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RUNNING

HEAD: MINDFULNESS, ANXIETY, AND PSYCHOSIS

Mindfulness Based Therapy as it relates to Anxiety Reduction in Acute In-Patient Care with

Individuals Who Experience Psychosis

Students Name

CNS 6529 Research and Evaluation

June 5, 201

Dan Lawther, PhD

South University

MINDFULNESS, ANXIETY, AND PSYCHOSIS

Abstract

Mindfulness is described as “paying attention in a particular way: on purpose, in the present

moment, and non-judgmentally” (Chadwick, Taylor, and Abba p 351, 2005). This study

purposes that mindfulness based training will have a greater effect in reducing anxiety in patients

that are in acute inpatient facilities who are experiencing psychosis better than the facilities

standard training which is rational behavior therapy based. Thirty participants will be asked to

join the study in which fifteen of the participants shall receive mindfulness training while the

other fifteen participants will receive the standard hospital therapy. The participants will be

asked to rate their anxiety levels using State-Trait Anxiety Inventory (STAI) and Beck’s Anxiety

Inventory (BAI) prior to their first group and after their last group has been administered. It is

expected that the mindfulness group will experience greater reduction in anxiety symptoms as

reported by BAI and STAI. This study can help influence future directions in therapy in acute

inpatient facilities.

MINDFULNESS, ANXIETY, AND PSYCHOSIS

Introduction

Davis, Strasburger, and Brown (2007) used mindfulness training to see if there would be

a reduction in anxiety as it relates to patients who were diagnosed with the DSM IV-TR

definition of schizophrenia. They found that mindfulness training helped to reduce anxiety in

participants with schizophrenia in comparison to intensive therapy (Davis, Stasburger, and

Brown 2007). Mindfulness is defined as “purposefully paying attention in each moment to all

life experiences, regardless of how ordinary” (Davis, Strasburger, and Brown p. 24, 2007).

Although, numerous studies have looked into mindfulness as a way to cope with both

psychological and non-psychological distress, many fail to see how mindfulness can improve the

quality of life in those with psychosis in acute inpatient facilities (Carmody and Baer 2008).This

study seeks to explore mindfulness training and its effects on reduction of anxiety in acute

inpatient, patients that are experiencing psychosis. It is expected that mindfulness training will

help reduce anxiety and increase mindfulness in those participants that are given mindfulness

training.

MINDFULNESS, ANXIETY, AND PSYCHOSIS

Review of Literature

More holistic approaches have been taken in recent years to improve the quality of life in

those experiencing psychosis (Lukoff, Wallace, Liberman, and Burke 1986). Holistic approaches

tend to involve more than just psychoeducational therapy. The idea is to continue the already

existing continuation of mind and body. Lukoff and colleagues (1986) used a holistic approach

to see if there was a significant reduction in stress, in individuals with schizophrenia. The

comparison group of social skills training and holistic approach to stress reduction showed no

difference in prevention of relapse back into a hospital setting.

From holistic approach, the idea of positive psychology arose as a method to enhance

well-being, both psychological and physical. Positive psychotherapy (PPT) was developed to

increase positive emotion, engagement and meaning (Seligman, Rashid, and Parks 2006).

Positive psychotherapy has been used in various clinical settings and parallels mindfulness in

that it teaches the individual to focus on their well-being and engagement with their body.

Positive psychology interventions are effective in enhancement of subjective well-being,

psychological well-being and reduction of depressive symptoms (Bolier et al 2013). Thus, a

focus on well-being will be beneficial for individuals with psychosis.

It is also important to consider how holistic approaches can be used to prevent

hospitalization. In research conducted by Drvaric, Gerristen, Rashid, Bagby, and Mizrahi (2015)

defined resilience as the ability to adapt to stress and adversity. The study shows that

interventions addressing well-being as it relates to resilience can help people at clinical high risk

for developing psychosis. Well-being is important focus for psychosocial interventions. Thus, it

is important to begin prevention mechanisms in those that are more likely to experience

MINDFULNESS, ANXIETY, AND PSYCHOSIS

psychosis. Prevention mechanisms like mindfulness may be used to help the individual increase

their well-being and reaction to stress, so resilience to stressful situations can reduce an

individual likelihood of experiencing psychosis and becoming hospitalized.

The inclusion of the mind and the body into therapeutic treatment is thought to help

reduce distress. With reduction of distress, people with psychosis may be able to have a higher

functioning life, in which they may be able to even work. Davis and colleagues, (2015) used

mindfulness training to see if individuals with schizophrenia will have better job performance.

Their Mindfulness Intervention for Rehabilitation and Recovery in Schizophrenia (MIRRORS)

program helped increase job performance and job attendance than an intensive support group.

Although, this study used mindfulness in an outpatient setting with participants in stable phase of

schizophrenia it still shows that mindfulness is an effective therapy.

Laithwaite and associates (2009) use compassionate focused therapy in a high security

setting to promote help seeking and to develop compassion towards oneself. It used inpatient

facility to improve the well-being of participants by having them focus on themselves, similarly

to meditation. As Penn and colleagues (2004) have shown, schizophrenia and therapeutic

progress is increased with some type of therapy than with medication alone.

Therefore, mindfulness should be taken into great consideration when working with

populations experiencing psychosis. Kuyken and fellow researchers (2008) used mindfulness

based cognitive therapy (MBCT) to prevent relapse into hospitals. Although, their targeted

population was those with recurrent depression they still found that relapse in those with

medication and MBCT was less than those that just had anti-depressant and standard therapy

(Kuyken et al 2008).

6
MINDFULNESS, ANXIETY, AND PSYCHOSIS

In their 2005 study, Chadwick, Taylor and Abba, used mindfulness training to see if

individuals with psychosis could better deal with their psychotic episodes and understand what it

means to be mindful. Although, it was a pilot study they found that the participants seem to have

greater awareness of their psychosis and through mindfulness were able to cope better and not be

distressed by their hallucinations. They were able to maintain their well-being and use their

awareness of their senses to recognize external stimuli from their internal stimuli.

Holistic approaches have been beneficial in continuing the connection between the mind

and body. Mindfulness focuses on this connection in greater detail than other holistic

approaches. Through mindfulness based training, greater awareness to psychosis and dealing

with internal stimuli has been found (Chadwick, Taylor, and Abba 2005). Although, many

studies have found a link between mindfulness and improvement of quality of life they have

neglected to include an environment that many who experience psychosis tend to get counseling

and treatment from, an inpatient facility. Therefore, purpose of this study is to evaluate whether

mindfulness training will reduce anxiety in individuals experiencing psychosis in an acute

inpatient facility.

MINDFULNESS, ANXIETY, AND PSYCHOSIS

Method

Participants

Thirty participants will be chosen from G. Werber Bryan Psychiatric Hospital (BPH)

from two separate acute in patient lodges; with fifteen participants on each lodge, respectively.

The participants anticipated age range would be from 18 years of age to 59 years of age with an

anticipated average of 32 years of age. The expected gender makeup of the participants would be

twenty-eight men and two women. The participants will be of different ethnicities, but mainly

African American and European American descent. The participants will be chosen based on the

following criteria: at least two weeks of stay at BPH prior to beginning of research with at least

two weeks of stay at BPH before discharge, and the diagnosis of schizophrenia, schizoaffective

disorder, or bipolar one with psychosis as defined by the DSM V. Participants that meet these

requirements will further be eliminated based on their level of cognitive functioning with the

mental status examination.

After selection. The fifteen participants on lodge 1 and lodge 2 will then be randomly

assigned to either Group A, the mindfulness training or Group B, the standard training of BPH.

Both of the groups will be conducted on the participants’ lodges so they did not have to meet

outside of their lodge. On lodge 1, eight participants will be assigned to Group A, while seven

participants will be assigned to Group B. On lodge 2, seven participants will be assigned to

Group A, while eight participants will be assigned to Group B. All participants are anticipated to

stay throughout the intended study time of two weeks.

Materials

MINDFULNESS, ANXIETY, AND PSYCHOSIS

The Mental Health Status Examination (MHSE) will be used to assess cognitive ability

and memory retention for participants to participate. The inter-rater validity is strong and the

external validity is shown through the wide use in mental health settings.

The State Trait Anxiety Inventory (STAI) will be used prior to first group meeting and

after the last group meeting. This tool is to assess how much the participants’ anxiety levels

decrease. It has validity in the range of 0.69 to 0.89 with test-retest (APA 2016).

The Beck’s Anxiety Inventory (BAI) will be used prior to the first group meeting and

after the last group meeting to make sure that the mindfulness addresses physical attributes of

anxiety. It is a 21-item self-report inventory with a high internal consistency (alpha=0.92) and a

high test-retest reliability of 0.75 over one-week period (Beck, Epstein, Brown, and Steer 1988).

The Cognitive and Affective Mindfulness Scale-Revised (CAMS-R) is a 12-item self-

report inventory that will be used to see if participants understand mindfulness. It has an

acceptable internal consistency and will only be given to only participants in Group A during the

first group and after the last group has been administered. [Feldman, Hayes, Kumar, Greeson,

and Laureanceau 2007]

Design

This study will be a between-subjects, experimental design. The independent variables

are the two following groups: mindfulness training and standard BPH training. The dependent

variable is the amount of anxiety reduction experienced by the participants. By having two

groups a day one in the morning and one in the afternoon, it will help control for participants that

may not be “morning” people.

MINDFULNESS, ANXIETY, AND PSYCHOSIS

Procedures

After getting permission from Bryan G. Werber Psyhiatric Hospital Institutional Review

Board and South Carolina Department of Mental Health Institutional Review Board,

respectively, participants will be chosen with help of treatment team members on each acute

lodge. The patients will then be asked to participate in the study with the knowledge of getting a

credit at the canteen for two items three days a week for the two-week time period the groups are

administered. The participants will be given the informed consent and will be given the option to

participate in the study.

After all consents are signed. The participants will be randomly assigned into either

mindfulness training group, Group A, or standard training group, Group B. The groups will meet

twice a day on Monday-Friday and once a day on Saturday, for a two-week time period.

Group A: Mindfulness Training

This group training was modeled from Chadwick, Hughes, Russell, Russell, and Dagnan

(2009), mindfulness groups and will be conducted by the author of this paper. The groups will

meet twice a day: in the morning, focus will be on the body and the sensations that are a part of

it; and in the afternoon, focus will be on the participants’ psychosis and how to change their

reaction to their internal stimuli. Each group will be 45 minutes in length, with 15 minutes

dedicated to reflection of the content of group. At least one time a week, if weather permits the

groups will be held outside. Homework to continue body scans and observations of senses will

be given to the participants at the end of both groups.

Group B: Standard Training

MINDFULNESS, ANXIETY, AND PSYCHOSIS

Like Group A, this group will meet twice a day and will continue to focus on the rational

behavior therapy that BPH teaches. This group will continue to be taught by the same clinical

counselor who has facilitated groups there prior to start of this study to maintain consistency

between both lodges.

MINDFULNESS, ANXIETY, AND PSYCHOSIS

Expected Results

Based on prior research, I expect to see some improvement in anxiety as it relates to

psychosis in the individuals that are in Group A. I expect to use a two-way ANOVA analysis in

excel to compare the before and after of STAI with both groups. I will also use ANOVA to

compare before and after BAI results. I also expect to use a t-test to compare CAMS-R from

before and after mindfulness groups are administered. I expect to see a larger decrease in anxiety

with individuals in Group A than in individuals in Group B. I also expect to see an increase in

mindfulness after the groups have been administered than before in participants of Group A. I

expect to see a very small p-value (0.05 or smaller) to support that training in mindfulness does

reduce anxiety in participants in that population so my null hypothesis of no change between

groups in reduction anxiety can be rejected with confidence. I also expect to see that the t-value

for my t-test will be 0.05 or smaller to show significance difference of knowledge of

mindfulness.

MINDFULNESS, ANXIETY, AND PSYCHOSIS

Discussion

Although, this study has not been actively conducted, it is believed it will serve as a great

contribution to the hospital setting. Many patients experiencing psychosis, do not get a holistic

approach to their treatment. The symptoms are treated, but the mind and body are not allowed to

be connected together for better health and well-being in patients. If anxiety is reduced when this

study is actually conducted, another factor that can be added to better enhance future studies is

the amount of time for relapse. If relapse back into the hospital is reduced due to patients’ ability

to use mindfulness training outside of inpatient facilities, it would be a better investment and

could lead to lower costs for insurance companies in the long run. It will also be crucial to try

and include more women and diversity into these future inpatient facilities study. This study can

also be changed for the purpose of not including psychosis and looking into mindfulness training

for other patients who are in psychiatric inpatient facilities.

MINDFULNESS, ANXIETY, AND PSYCHOSIS

References

American Psychological Association. 2016. The State Trait Anxiety Inventory. American

Psychological Association. Retrieved 29 Feb 2016.

Beck AT, Epstein N, Brown G, Steer RA. (1988). An Inventory for Measuring Clinical Anxiety:

Psychometric Properties. Journal of Consulting and Clinical Psychology. 56(6). 893-897.

Bolier L, Haverman M, Westerhof GJ, Riper H, Smit F, and Bohlmeiher E. (2013). Positive

Psychology Interventions: A Meta-analysis of Randomized Controlled Studies. BMC

Public Health. 13(119).

Carmody J and Baer RA. (2008). Relationships Between Mindfulness Practice and Levels of

Mindfulness, Medical and Psychological Symptoms and Well-being in a Mindfulness-

Based Stress Reduction Program. J Behav Med. 31. 23-33.

Chadwick P, Taylor KN, and Abba N. (2005). Mindfulness groups for people with psychosis.

Behavioral and Cognitive Psychotherapy. 33. 351-359.

Chadwick P, Hughes S, Russell D, Russell I, and Dagnan D. (2009). Mindfulness Groups for

Distressing Voices and Paranoia: A Replication and Randomized Feasibility Trial.

Behavioural and Cognitive Psychotherapy. 37.403-412.

Davis LW, Strasburger AM, and Brown LF. (2007).

MINDFULNESS, ANXIETY, AND PSYCHOSIS

Mindfulness: An Intervention for Anxiety in Schizophrenia. Journal of Psychosocial

Nursing. 45(11). 23-29.

Davis LW, Lysaker PH, Kristeller JL, Salyers MP, Kovach AC, and Woller S. (2015). Effect of

Mindfulness on Vocational Rehabilitation Outcomes in Stable Phase Schizophrenia.

Psychological Services. (12):33. 303-312.

Drvaric L, Gerristen C, Rashid T, Bagby RM, and Mizrahi R. (2015). High Stress, Low

Resilience in People at Clinical High Risk for Psychosis: Should we Consider a Strengths-

Based Approach. Canadian Psychology. 56:3. 332-347.

Feldman G, Hayes A, Kumar S, Greeson J, and Laurenceau JP. (2007). Mindfulness and

Emotion Regulation: The Development an Initial Validation of the Cognitive and Affective

Mindfulness Scale-Revised (CAMS-R). J Pysholopathol Behav Assess. 29. 177-190.

Laithwaite H, O’Hanlon M, Collins P, Doyle P, Abraham L, Porter S, and Gumley A. (2009).

Recovery After Psychosis (RAP): A Compassion Focused Programme for Individuals

Residing in High Security Settings. Behavioural and Cognitive Psychotherapy. 37. 511-526.

Lukoff D., Wallace C. J., Liberman R.P., and Burke K. (1986). A Holistic Program for Chronic

Schizophrenic Patients. Schizophrenia Bulletin. 12(2). 274-282.

Kuyken W, Taylor RS, Barrett B, Evans A, Byford S, Watkins E, Holden E, White K, Byng R,

Mulla E, and Teasdale JD. (2008). Mindfulness-Based Cognitive Therapy to Prevent Relapse

in Recurrent Depression. Journal of Consulting and Clinical Psychology. 76(6). 966-978.

MINDFULNESS, ANXIETY, AND PSYCHOSIS

Penn DL, Mueser KT, Tarrier N, Gloege A, Cather C, Serrano D, and Otto MW. (2004).

Supportive Therapy for Schizophrenia: Possible Mechanisms and Implications for

Adjunctive Psychosocial Treatments. Schizophrenia Bulletin. 30(1). 101-112.

Seligman MEP, Rashid T, and Parks AC. (2006). Positive Psychology. American Psychologist.

774-788.

ResearchPaper Rubric

Name: ___________________________ Date: ___________________ Score: __________________

Category Exceeds Standard Meets Standard Nearly Meets Standard Does not meet standard

Title Page Running Head, Title, Your
name, Course Name, Date,
Instructor’s name,
Institution
Title includes variables and
some indication of
relations (e.g. “difference
between”, effects of x on
y). APA style is completely
correct.

All relevant parts of the
title page are included.
Title/RH is appropriate but
is not be very concise

Title/RH does not
effectively convey all the
variables in the study.
Some needed elements
are missing.

Title page is either missing
or contains inaccuracies.
Title page does not follow
APA style.

Abstract Abstract includes research
question, variables,
number and type of
participants and
anticipated results

Focus of research is
unclear. Participant
information and
anticipated results not
stated.

Introduction Clearly and concisely
describes topic and its
importance, why the topic
was chosen, and questions
to be answered.

Describes topic and its
importance; fails to
describe key questions

Introduction describes the
topic and its importance
ambiguously.

Introduction is incomplete
and/or nonfocused. Does
not adequately convey
topic.

Review of Literature Succinctly summarizes
literature without
reproducing it. Good use
of paraphrase and
summaries of main ideas.
Focus is on the research,
rather than the
researchers. Relationship
of studies to each other
and to present study is
apparent.

Studies are generally
described in enough detail
so that relationships
between studies can be
understood. The review
contains unnecessary
quotations, or poor
paraphrases of the original
articles.

Some of the reviewed
literature seems to be
inappropriate or not well-
linked to the topic.
Review contains many
lengthy quotes. Review is
basically a reproduction of
the literature.

Review consists of a
description of several
articles with no attempts
to link findings to each
other or to the paper.
Review is unfocused or
material is inappropriate.

Organizational
Structural Development
of Ideas

Ideas are logical and
sequenced. Paragraphs
are well organized;
effective use of transitions
to facilitate flow

Paragraph development
present but not perfected

Logical organization; ideas
not fully developed

Little evidence of structure
or organization

Conclusion Engaging; summarizes key
findings, indicates points
of comparison and
contrast in research,
answers initial questions,
highlights own position on
topic. Advances argument
for conducting current
study

Summarizes key findings
and answers initial
questions. Suggests
avenues for future
research

Summarizes key findings. Summary merely a
restatement of research.
No contrasts or
comparisons; no attempt
to answer initial questions.
Author’s own position if
included appears
confused.

Methods Section:
Participants

Sample is appropriate
given the nature of the
study. Participant
information includes
number and all necessary
characteristics. Any
recruitment criteria are
noted.

Sample size is appropriate.
Generally adequate
description of participants.
Some important
characteristics omitted

Participant information is
presented in a manner
that is unclear and
unfocused. Sample size
may be too small given the
nature of the study.

Participants are
inadequately described.
Sample size is too small
given the nature of the
study. Replication would
not be possible.

Methods Section:
Measures and Materials

Measures and materials
are accurately described
with enough detail that a
reader could replicate the
study. Materials are
appropriate given the
hypothesis. If materials
are self-created, method
of assuring validity and
reliability should be
included.

Materials are appropriate,
but description is not
complete. More detail is
needed.

Materials are incomplete
and/or not appropriate
given the hypothesis.
Description is lacking in
details

Measures and materials
are poorly selected; have
little validity for the
purpose for which used.
No description of methods
or materials.

Hypotheses Hypotheses are all clearly
stated, and directional
predictions are made
based on previous
literature. Hypotheses are
testable. It is clear what
the experimental groups
will be and what will be
measured.

Main hypotheses are
stated clearly and
directional predictions are
made, but it is somewhat
unclear what the
experimental groups will
be or what will be
measured.

Variables in main
hypothesis are stated, but
no directional prediction
about the relation
between the variables is
specifically stated. It is
unclear what the
experimental groups will
be and what will be
measured.

Hypotheses are not stated
or the direction does not
follow from the literature
presented.

Methods Section:
Design

The design of the study is
clear and complete and
appropriate to test
hypothesis. Variables are
appropriate and
operationalized properly.
Independent and
Dependent variables are
correctly identified.

Design is complete and
appropriate but not clearly
described. Variables are
appropriately
operationalized.

Design is not complete or
the operationalization of
the variables is not clear.
Measured variables may
not be appropriate.

Design is not appropriate
for hypothesis. Variables
are not operationalized or
not valid. Independent
and dependent variables
misidentified.

Methods Section:
Procedure

Procedure is appropriate
and ethical. Procedures
are described, in order,
with enough detail that a
reader could replicate the
study; instructions and
protocols are included.
Condition assignments are
clear; randomization and
counterbalancing are
explained as necessary.

Procedure is appropriate
and ethical. The
description is primarily
complete but some minor
details may be missing, or
some procedural aspects
could be explained more
clearly.

Procedure is appropriate
and ethical. The
description is not in order
or is difficult to follow.
Some details appear
absent.

Procedure is not
appropriate or not ethical.
The description is unclear,
or many major details are
omitted.

Summary/Anticipated
Results

Summary clearly restates
research issue/problem;
provides a rationale for

Research issue/problem is
restated but purpose of
the study, rationale, or

Summary muddled.
Problem and rationale for
study are unclear. No

No restatement of
issue/problem. Rationale
and purpose of the study

examining the issue;
reviews the purpose of the
study; discusses
anticipated results

anticipated results are
missing.

discussion of anticipated
results.

not discussed. No
discussion of possible
outcomes

Reference Section Reference page includes
all and only cited articles.
The articles are
appropriately scholarly
and appropriate to the
topic. Reference section is
in APA format, double
spaced with hanging
indent. Contains more
than the required number
of references.

Reference page may leave
out a cited article or
include one that is not
cited. The references are
scholarly. The page is in
APA style with only minor
errors. Contains the
required number of
references

Some references appear
inappropriate for paper.
Key references are clearly
cited from other sources
and not likely read by the
student. Reference page
is generally in APA style
but with many errors.
Reference page contains
hyperlinks.

Reference list is more like
a bibliography. Fewer
than 8 references or
several reverences that
are not scholarly or
references included that
are from the internet.
Many format errors.

Format Times New Roman 12
Font; double spaced;
appropriate headings;
appropriate margins

Format does not meet
South standards and
guidelines

Mechanics No errors in punctuation,
capitalization, and spelling

Few errors in punctuation,
capitalization, and spelling

Many errors in
punctuation, capitalization
and spelling interfere with
the reading of the paper

Numerous distracting
errors make reading and
comprehension difficult.
Writing ability is well
below that which is
expected from a graduate
level student

Usage Excellent word choice.
No errors in sentence
structure or word usage.

Almost no errors in
sentence structure and
word usage. Periodic
incomplete sentences,
problems with
subject/verb agreement,
or run on sentences, but

Distracting errors in
sentence structure and
word usage. Incomplete
sentences, lack of
subject/verb agreement,
or run on sentences
obscure the meaning of

The number of errors in
grammar, usage, and
sentence syntax
suggests writing which is
well below that
expected from a
graduate level student.

not to the point of being
distracting from the
overall focus of the
paper.

some sentences or
paragraphs.

Paraphrase and Quotes Uses paraphrasing and
gives appropriate credit
for ideas. Uses
quotations only when
they are essential to the
understanding of an
idea or concept or when
it is essential to “hear”
the words of the original
author. Quotations
contain appropriate
citations and include
page or paragraph
numbers.

Some use of direct
quotations. Quotations
generally contain the
appropriate citation.
Quotations over 40
words are placed in a
free-standing block,
indented without
quotation marks.

Paper contains many
direct quotations where
use of paraphrasing
would be appropriate.
Direct quotations are in
the appropriate format
and generally correctly
cited.

Paper is generally a
linking of multiple direct
quotations. Many
quotations lack citation
or are incorrectly cited.
In many instances,
information from other
sources is used without
giving appropriate
credit.

Citations All cited works are done
in correct format with
no errors (APA style
manual, 6th edition)

Majority of cited works
are done in correct
format. Some
inconsistencies are
evident.

Few works are cited,
but format is correct

Citations are incorrectly
formatted or absent.

2/3/202

Your Research Paper

• Use 8 ½ by 11” white paper, with margins
of 1” (or 1 ¼”)

• Double space EVERYTHING

• Font should be pica 10 pitch or Times
Roman 12 pitch

• Single spaces between sentences

• Page numbers in upper right hand corners

How to set up your paper in APA

2/3/2022

•

Title Page

•

Abstract

•

Introduction

•

Review of Literature

•

Method

– Participants

– Apparatus and Measures
–

Design

–

Procedures

• Expected Results
• Reference Section

Key Elements

Title Page

2/3/2022

• One paragraph

• 150 – 250 words

• Format
– Purpose of Study

– Participants

– Methods and

Materials

– Anticipated results

Abstract

2/3/2022

• Sets the stage for the project
• Creates reader interest in the topic
• Establishes the issues or concerns that

leads to the study
• Conveys information about the problem
• Places the study within the larger context
• Reaches out to a specific audience

Introduction

• The primary purpose of a review of
literature is to demonstrate why your study
is necessary.

• What research has been performed by
others that relates to your topic

Review of Literature

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• Review
– Setting
– Population

– Methods
– Outcomes

• Evaluate
– Relations

– Contradictions
– Gaps

– Inconsistencies

Review and Evaluate

• Corrigan, Rowan, Green, Lundin, River, Uphoff-
Wasowski, White and Kubiak (2002) conducted
two studies examining the causal processes in
contact, fear and rejection. Corrigan et al. posited
two models to account for stigmatizing reactions.
In the first model, labeled personal responsibility,
beliefs about personality responsibility influences
both the level of pity and anger displayed toward
mental patients. Additionally, the variables of pity
and anger influence helping behavior. In the
second model, labeled dangerousness, perceived
dangerousness influences fear of mental patients,
which in turn influences the avoidance of the
mentally ill.

An Excerpt from a Review of Literature

2/3/2022

• Taken as a whole, it appears that exposing
these myths as myths increases the
acceptance of the mentally ill and that staged
contact with a mentally person to expose
myths has an even more powerful effect.
Caution must be advised, though; Martin et
al.’s (2002) and Alexander and Link’s (2003)
studies and the first study of Corrigan et al.
(2002) were based upon paper and pencil
methodologies. And while Corrigan et al.’s
(2002) second study involved staged Myths
of violence 6 presentations, it was conducted
in a college setting with a college sample.

Another Excerpt from the Same Review

• Participants
– Who will be in your study?

– What population did you use?

– Were there any restrictions in the nature of
your participant pool?

Method

2/3/2022

• Total number of participants and the number
assigned to each condition

• Major demographic characteristics of the
participants (age, sex, etc.)

• Way the participants were selected
• Was the selection restricted in some way?

– All counseling majors
– Only women
– Only deaf

• How were the participants assigned?

Participant Information

Twenty-seven students from South
University (12 women and 15 men) ranging
in age from 17 to 43 years old, voluntarily
participated in this experiment. There were
9 participants randomly assigned to each of
the three conditions. Informed consent was
obtained from all participants.

Example:

2/3/2022

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Published

Criminal Behavior and Repeat
Violent Trauma

A Case–Control Study

John T. Nanney, PhD, Erich J. Conrad, MD, Michael McCloskey, PhD, Joseph I. Constans, PhD

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Introduction

: Repeat violent injury is common among young urban men and is increasingly a focus
of trauma center–based injury prevention efforts. Though understanding risk factors for repeat
violent injury may be critical in designing such interventions, this knowledge is limited. This study
aims to determine which criminal behaviors, both before and after the initial trauma, predict repeat
violent trauma. Gun, violent, and drug crimes are expected to increase risk of subsequent violent
injury among victims of violence.

Methods: A case–control design examined trauma registry and publicly available criminal data for
all male patients aged o40 years presenting for violent trauma between April 2006 and December
2011 (N¼1,142) to the sole Level 1 trauma center in a city with high rates of violence. Logistic
regression was used to determine criminal behaviors predictive of repeat violent injury. Data were
obtained and analyzed between January 2013 and June 2014.

Results: Regarding crimes committed before the first injury, only drug crime (OR¼5.32) predicted
repeat violent trauma. With respect to crimes committed after the initial injury, illegal gun
possession (OR¼2.70) predicted repeat victimization. Initiating gun (OR¼3.53) or drug crime
(OR¼5.12) was associated with increased risk.
Conclusions: Prior drug involvement may identify young male victims of violence as at high risk of
repeat violent injury. Gun carrying and initiating drug involvement after the initial injury may
increase risk of repeat injury and may be important targets for interventions aimed at preventing
repeat violent trauma.
(Am J Prev Med 2015;49(3):395–401) Published by

Elsevier Inc. on behalf of American Journal of Preventiv

e
Medicine

Introduction

V
iolent trauma plagues young men in many
urban, typically African American, commun-
ities.1–4 Violence is the leading cause of death for

African American men aged 18–35 years and remains a

theastern Louisiana Veterans Healthcare System (Nanney,
epartment of Psychiatry (Nanney, Conrad, Constans),
e University School of Medicine; South Central Veterans
Illness Research, Education, and Clinical Center (Nanney,

partment of Psychology (Constans), Tulane University, New
siana; Department of Psychological Sciences (Nanney),
issouri-Saint Louis, Saint Louis, Missouri; and the Depart-

chology (McCloskey), Temple University, Philadelphia,

rrespondence to: John T. Nanney, PhD, University of
Louis, Department of Psychological Sciences, 1 University

adler Hall Room 236, Saint Louis MO 63121. E-mail:
.edu.
$36.00
i.org/10.1016/j.amepre.2015.02.021

Elsevier Inc. on behalf of American Journal of Preventiv

leading cause of death through age 40 years.3,4 For
victims of violence, repeat injury is common,5–9 and
trauma center–based interventions to reduce repeat
violent trauma have recently emerged.10–15 Such inter-
ventions have yielded only mixed results, possibly
because most interventions focus on enrolling patients
in general outpatient case management services rather
than changing specific risk behaviors.16 Interventions
targeted at specific behaviors known to increase risk of
later violence/violence injury may have greater chances
of success.17

Certain criminal behaviors—specifically violent, gun,
and drug offenses—may be strong candidate risk factors
for repeat violent trauma.2,5,7 Violent behavior invites
violent retaliation. Assaults are more likely to involve
more-severe gunshot injuries if assailants expect the
target to be similarly armed.18 Violence also permeates
illicit drug economies, as disputes cannot be settled

e Medicine Am J Prev Med 2015;49(3):395–401 395

http://crossmark.crossref.org/dialog/?doi=10.1016/j.amepre.2015.02.021&domain=pdf

mailto:nanneyj@umsl.edu

http://dx.doi.org/10.1016/j.amepre.2015.02.021

Nanney et al / Am J Prev Med 2015;49(3):395–401396

legally.19 Other forms of crime, like unarmed, non-
confrontational property crime (e.g., auto theft) may be
less likely to provoke retaliatory violence and may be less
associated with repeat injury risk. Empirical studies
focused on crime and trauma recidivism are generally
consistent with this pattern, but methodologic limita-
tions preclude definitive conclusions. One study5 found
that violent, gun, and drug crimes were more common
among repeat victims of violence than among patients
injured accidentally. This study, however, did not com-
pare repeat to single episode victims of violence and it
relied exclusively on survey methods to assess criminal-
ity. A second study7 found that gun, drug, and violent
crime, but not property crime or crime in general, were
more common among repeat than single-episode trauma
patients. Nonetheless, this study7 combined violent and
accidental trauma patients, so it is not clear if these
findings hold for those who specifically experience
violent trauma.
Extant literature also has not differentiated between

crimes committed before and those committed after first
injury. This issue is important for the development of
trauma center–based interventions. Understanding
which behaviors occurring prior to the first trauma are
associated with rehospitalization is useful in identifying
those initial trauma victims most at risk of future violent
trauma. However, this information may be less relevant
for intervention development because these historic
risk factors may be static or unchangeable through
intervention. By contrast, understanding the risk behav-
iors that occur after the initial hospitalization is critical
for development of hospital-based interventions,17 as
these are the behaviors such interventions can influence
most directly. For example, the experience of trauma
may lead to new risk behaviors (e.g., regular gun
carrying or drug involvement).2,20,21 Whether such
changes increase risk of repeat trauma, making them
potential targets for intervention, has not been examined
directly.
The present case–control study aims to identify differ-

ences in criminal behavior between repeat and single-
episode victims of violence. To address limitations of
previous studies, administrative hospital and criminal
data are examined, and criminal behaviors occurring
prior to the initial trauma are coded separately from
those occurring after first injury. It is hypothesized that
violent crime, gun possession, gun use, and drug crime,
both prior to and following initial trauma, would predict
repeat violent trauma, but that property crime, both
before and after, would not. Finally, as a stronger
demonstration that risk behaviors may be useful targets
of intervention, it is examined whether those who do not
engage in specific criminal behaviors prior to the first

trauma but begin engaging in that crime afterwards have
higher chances of repeat violent injury than those who
continue to abstain. It is expected that initiating gun
possession, gun use, and violent or drug crime following
a violent trauma would increase risk of repeat violent
injury, but that initiating property crime would not.

Methods
Study Population

The study was approved and a waiver of informed consent was
granted by the IRB of the Louisiana State University Health
Sciences Center, New Orleans. A study population consisting of
all adult male patients aged r40 years from Orleans Parish who
were admitted to the Spirit of Charity Level 1 Trauma Center
(SOCTC) with a violent injury between April 2006 and December
2011 and who survived their initial injury was identified from the
trauma center trauma registry (N=1,243). The SOCTC is the only
Level 1 trauma center in New Orleans and thus treats all severe
violent injuries (e.g., gunshot wounds) that occur in the metro-
politan area. From Hurricane Katrina in August 2005 until the
Trauma Center’s reopening in April 2006, there is an 8-month gap
in the trauma registry. For this reason, only data after April 2006
were examined.

Violent trauma was operationalized as hospital presentations
with an ICD-9 e-code of 960–969, specifically indicating inten-
tional violent injury. Cases of violent trauma recidivism were
identified by linking trauma center presentations according to
patient name, Social Security Number (SSN), and birth date.
Patients who presented with a violent trauma between April 2006
and December 2011 and then presented with at least one
additional violent trauma between April 2006 and December
2012 were classified as violent trauma repeaters (n=93). The
control group consisted of patients who presented to the trauma
center with a violent trauma between April 2006 and December
2011 but no additional violent traumas from April 2006 to
December 2012 (n=1,150). All databases with patient identifiers
were destroyed following the linking of hospital and criminal
databases.

Data Sources

The trauma registry contains demographic, medical, and patient
outcome data on patients for whom the hospital trauma activation
protocol is initiated. Demographic data included date of injury;
name; birth date; SSN; gender; race (self-report or if necessary as
determined by medical staff); age; and ZIP code of residence.
Cause of injury data included the ICD-9 e-code identifying the
mechanism (e.g., gun or knife) and apparent intent (i.e., inten-
tional versus accidental) of injuries. Criminal data were retrieved
from the Orleans Parish Criminal District Court docket master.
Patients were linked to criminal records by their name and date of
birth. Dates and nature of all criminal convictions were recorded.
Criminal behavior was classified according to five categories: gun
possession, gun use, drug crime, violent crime, and property crime.
Gun possession crimes were defined as convictions that only
involved the illegal possession or use of a firearm, without any use
or threat of use against another person. Gun use crimes required

www.ajpmonline.org

Nanney et al / Am J Prev Med 2015;49(3):395–401 397

firearm use or threat of use against others. Violent crimes were
defined as all those involving interpersonal aggression or violence.
Drug crimes were defined as those that included the possession or
distribution of illicit substances. Property crimes were defined as
those that require the unlawful entry or unlawful taking, pos-
session, or destruction of another person’s property.
Criminal behavior categories, with the exception of gun

possession, were not mutually exclusive, so each criminal act
could count toward multiple categories (e.g., shooting a person
would count as a violent crime and a gun use crime). To better
isolate the impact of mere gun possession, gun possession and gun
use were coded to be mutually exclusive. That is, if an individual
used a gun in a crime at any point during a given time period (i.e.,
before or after initial injury) they could not be coded positive for
gun possession during that time period. Separate variables were
created for crimes committed before and crimes committed after
the initial injury. For those with multiple violent injuries, crime
after the first trauma included only those crimes that occurred
before the last violent injury in order to focus only on crimes that
could logically contribute to repeat trauma risk. Trained research
assistants conducted the crime ratings. Inter-rater reliability was
assessed by having independent raters separately code criminal
history for 20% of patients. Inter-rater reliability was excellent
(κ=0.90).

Statistical Analysis

Data were analyzed in April–June 2014 using SPSS, version 21.0. A
multivariate logistic regression model was used to examine the
independent contribution of crimes in predicting repeat trauma.
Criminal behaviors occurring prior to the initial injury were
entered at Step 1. Criminal behaviors occurring after the initial
trauma were then entered at Step 2.
To examine how behavior change following initial trauma may

impact repeat injury risk, patients who did not engage in a given

Table 1. Demographics and Injury Characteristics

Total
(n¼1,243)

Repea
(n¼93

Age (years), M (SD) 26.55 (6.12) 23.70 (5

18–25 622 (50.1) 67 (7

26–32 377 (30.3) 16 (1

33–40 244 (19.6) 10 (1

Race

Black 1089 (82.8) 90 (9

White 79 (6.4) 2 (2

Asian 11 (0.9) 0 (0

Other 124 (10.0) 1 (1

Time to second injury (years), M (SD) 1.68 (1

First injury gunshot 860 (69.2) 77 (8

Second injury gunshot 77 (8

Note: Boldface indicates statistical significance (po0.01) Values are n (%) u

September 2015

form of crime prior to the initial trauma were coded dichoto-
mously as to whether they either (1) continued to abstain from that
type of crime or (2) began engaging in that type of crime. For each
type of crime, a separate logistic regression was conducted with
repeat victimization as the dependent variable and this crime
initiation variable as the independent variable. History of other
types of crime was controlled.
A potential study confounder is time following initial injury in

which crime can be observed. For those without re-injury, there
was no repeat injury to signal end of observation, which then
continued until the end of the study (December 2012). The
observation period was thus considerably longer among those
without later injury compared with repeat victims (F=135.39,
po0.001), potentially biasing results. Observation time after the
first injury was thus controlled in all analyses. Race was controlled
in all analyses because African Americans may be disproportion-
ately likely to receive certain criminal convictions22 and be
assaulted with a weapon.18

Results
Demographics and injury characteristics appear in
Table 1. Repeat victims of violent trauma (n¼93)
comprised 7.5% of the overall sample (N¼1,243). Repeat
violent trauma victims were significantly younger than
those with only a single violent injury and were more
likely to have initially presented with a gunshot injury
than single-episode victims. Though African Americans
predominated in the overall population of violently
injured young men (82.8%), repeat victims of trauma
were almost exclusively black. Rates of criminal con-
viction, both before and after the first injury, are included

t
)

Single episode
(n¼1,150) χ2 F p-value

.29) 26.78 (6.13) 22.20 o0.001
2.0) 556 (48.3)

7.2) 360 (31.3)

0.8) 234 (20.3)

6.8) 939 (81.7) 13.81 o0.001

.2) 77 (6.7) 2.99 0.08

) 11 (1.0) 0.90 0.34

.1) 123 (10.7) 8.87 0.003

.37)

2.8) 783 (68.1) 8.73 0.003

2.8)

nless otherwise noted.

Table 3. Multivariate Logistic Regression of Crime and
Trauma Recidivism

Crime Wald OR (95% CI)

Before only

Race (black/not black) 7.77** 5.32 (1.64, 17.25)

Gun possession before 0.04 1.11 (0.54, 2.21)

Gun use before 0.13 0.75 (0.16, 3.54)

Violence before 0.71 1.36 (0.70, 2.46)

Drug crime before 5.43** 1.71 (1.09, 2.69)

Property crime before 0.17 0.88 (0.47, 1.63)

Table 2. Frequency of Crime

Number (%) with
conviction before

first injury

Number (%) with
conviction after

first injury

Gun
possession

105 (8.4) 72 (5.8)

Gun use 25 (2.0) 19 (1.5)

Violence 148 (11.9) 121 (9.8)

Drug 478 (38.5) 193 (15.5)

Property 172 (13.8) 77 (6.2)

Nanney et al / Am J Prev Med 2015;49(3):395–401398

in Table 2. Drug crime was most common and gun
crimes the least common, both before and after initial
injury.
Results of the multivariate logistic regression (Table 3)

indicate that when considering only crimes prior to the
initial trauma (Step 1), only pre-injury drug crime
significantly predicted repeat trauma (p¼0.01). When
crimes committed after the initial trauma were consid-
ered (Step 2), illegal gun possession after the initial injury
significantly predicted repeat violent trauma (p¼0.03)
and drug crime committed after the first injury trended
toward significance (p¼0.054). Drug crime before the
initial injury remained a significant predictor (p¼0.02).
A series of logistic regressions examining how crime

initiation following the first trauma related to risk of
repeat trauma (Table 4) found that initiating illegal gun
possession (p¼0.01) and drug crime (p¼0.01) signifi-
cantly predicted repeat trauma. Initiating gun use,
violence, and property crime did not.

Before and aftera,b

Race (black/not black) 4.45** 3.56 (1.10, 12.18)

Time after first injury 82.26** 0.91 (0.90, 0.93)

Gun possession before 0.02 1.06 (0.50, 2.24)

Gun use before 0.08 0.77 (0.13, 4.53)

Violence before 0.61 0.76 (0.39, 1.51)

Drug crime before 5.19** 1.80 (1.09, 2.97)

Property crime before 0.01 0.97 (0.49, 1.89)

Gun possession after 4.95* 2.70 (1.13, 6.48)

Gun use after 0.68 0.37 (0.03, 3.97)

Violence after 0.17 1.33 (0.52, 3.40)

Drug crime after 3.70 1.93 (0.99, 3.76)

Property crime after 0.26 0.76 (0.27, 2.14)

Note: Boldface indicates statistical significance (*po0.05; **po0.01).
aORs are adjusted by including in Step 2 the span of time covered when
evaluating criminal behavior after the first injury.

bHosmer-Lemeshow model goodness of fit χ2(8)¼9.78, p¼0.28.

Discussion
Gun and drug crimes, as expected, predict repeat violent
trauma. The relationship of these criminal behaviors to
repeat trauma appears to be more complex than pre-
viously recognized, however. At the time of the initial
injury, only a history of drug crime predicts repeat
victimization. This risk continues even when controlling
for subsequent criminal behavior. Once one becomes
involved and identified with the illicit drug market, it may
be difficult to extricate oneself from the violent social
milieu and intergroup conflict that surround it.19 Initia-
tion of drug crime following first injury is associated with
increased risk. Victims of trauma may turn to substances
in order to self-medicate,2,23 increasing their vulnerability
due to exposure to this violent market. Surprisingly,
overall drug crime following first trauma is only margin-
ally significant. Perhaps, for those already involved in the
drug market, additional drug crime confers only small

incremental risk. History of gun crime at first injury is not
associated with increased risk. Only after initial injury
does gun crime emerge as a predictor of later victim-
ization, and this is only for gun possession, not gun use.
For the emblematic patient at highest risk for repeat
violent trauma, an initial injury may enhance recognition
of the violence associated with the illicit drug market
leading to an increase in weapon carrying as a means of
protection.2,20,21 The present results underscore the grave
risks that may be associated with this, as it appears that
initiating gun possession following the initial injury is an
important determinant of an individual’s risk for repeat
violent injury. It is unclear why weapon carrying is a risk
factor after, but not before, the initial injury. Perhaps after
an initial injury, individuals may display weapons more
openly to deter possible assailants. Being known to carry a
weapon increases the likelihood that, when conflict does
occur, the other party will arm themselves similarly,

www.ajpmonline.org

Table 4. ORs for Initiation of Crime After Initial Trauma Predicting Trauma Recidivism

Crime initiateda n Unadjusted OR (95% CI) Wald AORa (95% CI)

Gun possession 1,116 2.15 (0.98, 4.69) 7.45 3.53 (1.43, 8.73)

Gun use 1,218 0.73 (0.10, 5.51) 0.36 0.59 (0.06, 4.62)

Violence 1,092 0.70 (0.27, 1.77) 0.08 0.87 (0.32, 2.38)

Drug crime 764 2.08 (0.89, 4.89) 9.03 5.12 (1.77, 14.84)

Property crime 1,070 1.38 (0.53, 3.57) 0.24 1.30 (0.45, 3.74)

Note: Boldface indicates statistical significance (po0.01).
aORs are adjusted for criminal history prior to the initial trauma, race, and individual differences in the span of time covered when evaluating criminal
behavior after the first injury.

Nanney et al / Am J Prev Med 2015;49(3):395–401 399

leading to higher chances of severe injury.18 Surprisingly,
the actual use of a gun in a crime and violence more
generally do not predict repeat violent injury. Such crimes
carry higher chances of lengthy prison terms, such that
some individuals engaging in them may be protected
from repeat violent trauma because of their incarceration.
Some convicted of gun possession may also have been
preparing to use the weapon absent legal intervention.
Finally, it is noteworthy that African American race is
associated with repeat injury even controlling for other
factors. Although it is possible that SES could in part
explain this relationship, this finding is consistent with
literature suggesting that a bias in perceiving African
American men as dangerous makes them more likely to
be targets of more severe, armed assaults when conflicts
emerge.18

Differentiating between risk behaviors that occur
before and those that occur after the initial trauma allows
us to provide more nuanced clinical guidance than prior
research. A history of drug crime at first injury marks
violent trauma patients as higher risk for violent re-
injury. Trauma centers may thus benefit from routinely
screening for drug involvement and targeting interven-
tions to this higher-risk group. Primary substance abuse
prevention models24 may help reduce repeat violence by
preventing involvement in the violent drug market in the
first place. The methods used in the present study allow
us to conclude with greater confidence that certain
behaviors occurring after the initial injury, particularly
gun carrying and drug involvement, may be appropriate
targets for trauma center–based interventions. Fortu-
nately, such interventions for both are developing. A
trauma center–based intervention directly targeting gun-
carrying adolescents was recently found to reduce
chances of continued firearm carrying at 1 year of
follow-up.25 Though replications with adults are
required, this finding—in combination with the present
findings—suggests that direct behavioral intervention
regarding gun carrying may have the potential to reduce
repeat violent trauma. Such interventions likely should

September 2015

not be limited to those who already have a history of
carrying guns. Indeed, many of those at risk may not yet
have begun engaging in significant gun carrying at the
time of the injury.2,20,21 Clinicians may anticipate that
patients without histories of gun use may be considering
arming themselves in the wake of their trauma. Develop-
ment of preventive interventions that directly inquire
about plans for gun use after the injury and attempt to
guide this decision-making process may be needed. With
respect to drug involvement, general substance abuse
prevention strategies are widely available20,26 and trauma
center–based interventions for illicit drug use are
developing.27

Limitations
Criminal data include only illegal behaviors that warrant
criminal prosecution and conviction. Such data cannot
determine if purely legal gun possession confers risk of
violent injury, though a relationship between legal gun
possession and violent injury has been suggested.28–31

Results also may not extend to less severe illegal
behaviors that do not lead to arrest, prosecution, and
conviction (e.g., occasional recreational drug use).
Whether risk of repeat injury from drug crime is a
function of drug use or drug distribution cannot be
determined given that both often may yield similar
convictions for drug possession.32 The trauma registry
contains only the most critical injuries that require
treatment at a Level I trauma center. Results thus may
not extend to the majority of violent injuries that do not
require this level of care.
Our study is limited to a single metropolitan area, New

Orleans, at a unique period in its history (i.e., the
aftermath of Hurricane Katrina). Owing to the high rates
of migration during this period, some participants in this
study may have been injured or may have engaged in
crime in another location. Even participants who resided
in New Orleans throughout the duration of the study
may have been injured or committed crimes while
outside of the area. Additional research using a broader

Nanney et al / Am J Prev Med 2015;49(3):395–401400

geographic region would thus be needed to confirm the
present findings. Also, given the gap in trauma registry
data owing to Hurricane Katrina, this study is com-
pressed into a relatively narrow time frame. The time
between first and second injury in our study suggests that
about 90% of patients who will return with repeat violent
injuries from the 2006–2011 population are captured in
these data, but that about 10% of the repeat victims of
violence in this population are likely “incorrectly”
classified as single-episode victims of violence because
they have not yet returned with their second violent
injury. Likewise, it is possible that an unknown number
of patients experienced violent injuries prior to the
beginning of the study data in 2006 such that they too
are incorrectly classified as single-episode victims. Anal-
ysis of a narrower cohort (2006–2008) for which 99% of
repeat trauma victims are likely captured produced
results substantively similar to the larger population,
increasing the confidence that the present findings would
persist if the database were extended in both the past and
future.

Conclusions
Though repeat violent injury is a public health priority
for young urban men and increasingly a focus of
intervention, research examining risk factors for
repeat trauma remains sparse. The present results
confirm previous scholarship suggesting that gun and
drug crimes predict repeat violent injury. Analysis of
timing of these crimes in relation to the initial injury
indicates that drug crime before and gun possession
after predict repeat trauma. Initiating gun or drug
crime after injury also predicts later violent injury.
Trauma center–based interventions targeting gun
carrying and drug involvement may thus have prom-
ise in reducing the violence that continues to plague
many urban neighborhoods.

The authors would like to acknowledge the assistance of Erin
Reuther, PhD for supervision of research assistants and for her
comments regarding the manuscript. The authors also
acknowledge the assistance of Samia Lalani, Christie Andolena,
BS, April Hartman, BS, Ian Comnick, BA, Elena Pueraro, and
Catherine Rochefort, BS, in collecting, entering, and managing
data. Without their diligent work, this project would not have
been possible.

The contents of this report do not represent the views of the
Department of Veterans Affairs or the U.S. Government.

JTN, EJC, and JIC contributed to the conception and
design of the study; the acquisition, analysis, and interpre-
tation of data; the drafting and revision of the manuscript;
and statistical analysis. JTN contributed to the supervision

of research assistants. EJC contributed to administrative
support. And MM contributed to the interpretation of the
data and the drafting and revision of the manuscript. JTN
had full access to all the data in the study and takes
responsibility for the integrity of the data and the accuracy
of the data analysis.
No financial disclosures were reported by the authors of

this paper.

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Criminal Behavior and Repeat Violent Trauma

Introduction
Methods
Study Population
Data Sources
Statistical Analysis
Results
Discussion
Limitations
Conclusions
References

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