violence risk assessment
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Violence Risk AssessmentPresented By: David Kan, MD
Violence Risk Assessment
Why are Psychiatrists & Psychologists involved in
predicting violence?
Practical Risk Assessment
Prior to 1966 little attention was paid to clinical risk assessment
1966 Johnnie K. BAXSTROM v. HEROLD 383 US 107 US SUPREME COURT NY
Baxstrom prisoner in prison psychiatric hospitalCivilly committed at end of sentenceLeft in prison hospital because state hospital didn’t want himWrits were dismissed, transfer requests deniedUSSC Holdings:
Other civilly committed pts had right to hearing Commitment beyond term without judicial determination
that he is dangerously mentally ill violates equal protection
Violence Risk Assessment
Tarasoff v. The regents of the University of California, 1976Facts:
Prosenjit Poddar and Tatiana Tarasoff
Started dating Mr. Poddar unfamiliar
with mores of America became depressed and saw psychologist, Dr. Moore.
Violence Risk Assessment
Facts: Mr. Poddar revealed intent to get gun
and kill Tatiana. Psychologist asked UCPD to hospitalize Poddar was discharged Moved into house Tatiana returned from vacation Then stalked and killed
Violence Risk Assessment
Facts: Lawsuit was filed for failure to warn Case dismissed by trial and appellate
court citing lack of duty to 3rd party California Supreme Court overturned
Violence Risk Assessment
"When a therapist determines…that his patient presents a serious danger of violence to another, he incurs an obligation to use reasonable care to protect the intended victim against such danger. The discharge of this duty may require the therapist to take one or more of various steps. Thus, it may call for him to warn the intended victim, to notify the police, or to take whatever steps are reasonably necessary under the circumstances.” – Tarasoff v. UC Regents
Violence Risk Assessment
What is the best predictor of violence?a. Criminal Recordb. Presence of Intoxicationc. Past History of Violenced. Perception of Self as a “Victim”e. All of the Abovef. None of the AboveCorrect Answer: F. None of the AboveViolence is impossible to predict. However,
RISK can be assessed.
Violence Risk Assessment
Assessing risk of violenceAssessment takes into account risk factors Here and Now Good for 24-48 hours or less Like weather forecasting
Needs to be updated, may not be right Pretty good for immediate future Not good for long term
Violence Risk Assessment
In assessment, psychiatrists look for mental disordersConnection is debatableMost violence is committed by people WITHOUT psychiatric diagnosis
Violence Risk Assessment
Violence = Specific Individual + Specific Situation
Violence Risk Assessment
Past History is the best predictor What is the most violent thing they’ve ever
done? Type of behavior, why it occurred, who was
involved, intoxication, degree of injury Criminal and Court records
Age at 1st arrest highly correlated with criminality Each prior episode increases risk Four previous arrests the probability of fifth is
80%(Borum et al., 1996)
Violence Risk Assessment
Specific threat towards an individual is another serious risk factorSpecific threat + Past History exponentially increases risk.
Violence Risk Assessment
People at high risk do not always commit violent actsPeople who commit violent acts may not be considered high risk
Violence Risk Assessment
Psychiatrists accurately predict long-term future violence 33% of the time in institutionalized patients who have previously committed a violent act.(Borum et al. – Assessing and managing violence risk in clinical practice. Journal of practical psychiatry and Behavioral Health 4:205-215 )
More accurate in assessing future violence when prediction is limited to briefer amount of time.(Lidz et al. The accuracy of predictions of violence to others.JAMA 269 (8):1007-1011)
Violence Risk Assessment
Psychiatrists tend to over predict violence out of concern for patients, 3rd party and ourselvesAssessing dangerousness Vaguely defined USSC Logic: if juries can do then
psychiatrists must be better
Violence Risk Assessment
There is no single test or interviewStructured approach criticalEpidemiological Catchment Area study Violence is the province of the young
18 – 29 7.34% 30 – 44 3.59% 45 – 64 1.22% >65 <1%
Violence Risk Assessment
Mental Disorders Rates of violence about equivalent
(Lidz et al., 1993)
Lower SES 3x as common in lower brackets
(Borum et al., 1996)
One study showed individual SES less predictive of violent behavior than concentrated poverty in neighborhood(Silver et al., 1999 – Assessing violence risk among discharged psychiatric patients: toward an ecological approach. Law and Human Behavior (2):237-55
Violence Risk Assessment
Increased risk with lower intelligence Mild mental retardation Men 5 x more likely to commit violent
offenses Women 25 x more likely Hodgins (1992) Arch of Gen Psych 49 (6):476-483
Less education increases risk
Violence Risk Assessment
Weapons Difference between assault and homicide is
the lethality of the weapon used
Assault with gun 5x more lethal than knife attack. Zimring (1991) Firearms, violence, and public policy. Scientific American 265:48-54
1 in 3 households have a gun 20% are unlocked Inquire about recent weapon movement
Violence Risk Assessment
50-80% involved in violent crimes are under the influence of alcohol at the time of the offenseStimulant Drugs Cocaine, amphetamines, and PCP Disinhibition and paranoia Cocaine – men commit crime,
women victimized
Violence Risk Assessment
Drugs and Alcohol Psychiatric patients 5x increased rate Non-patients, 3x increased rateSteadman et al., 1998 – Violence by peopl d/c’d from AIP and by others in the same
neighborhoods. Arch Gen Psych 55(5): 393-401
Military and Work history AWOL Frequent terminations Laid off 6x more likely to be violent then
employed
Violence Risk Assessment
Violence and Mental Illness Violence was greater only with acute
symptoms Schizophrenia lower rates of violence
than depression or Bipolar Disorder Substance Abuse > than Mental
IllnessMonahan, 1997 Actuarial support for the clinical assessment of
violence risk. International Review of psychiatry 176:312-319.
Violence Risk Assessment Vietnam Combat Vets and PTSD VN combat vets with PTSD > prevalence of violent
behavior than VN vets without PTSDLasko et al. Compr Psychiatry 1994 Sep-Oct;35(5):373-81
Hospitalized combat vets with PTSD > than non-hospitalized and VN general inpatient psychiatric population PTSD symptoms severity Substance abuse to a lesser degree
McFall et al, J Trauma Stress 1999 Jul;12(3):501-17
Vets with PTSD avg. 22 violent acts vs 0.2 for non-PTSD
Lower SES, increased aggressive responding and increased PTSD severity correlated
Beckham et alJ Clin Psychol 1997 Dec;53(8):859-69
Violence Risk Assessment
1st break schizophrenia 52/253 violent in 1992 study 36 violent in preceding year 16 > 1 year after admissionHumphreys, et al (1992) Dangerous behavior preceding first admissions for
schizophrenia Br J Schiz 161:501-505
Violence Risk Assessment
Paranoid psychotic patients Violence well-planned and in-line with
beliefs Relatives or friends are usual targets Paranoid in community more
dangerous than institutionalized given weapons access
Krakowski et al., (1986) Psychopathology and Violence: a review of the literature. Compr Psych 27 (2): 131-148
Violence Risk Assessment
Delusions – conflicting data Factors to consider
Threat/control override symptoms Non-delusional suspiciousness If delusions make people unhappy,
frightened or angry. Whether they have acted on previous
delusionBorum et al., 1996
Violence Risk AssessmentHallucinations In general, AVH not inherent risk Certain types increase risk
Hallucinations that generate negative emotions
If pts. have not developed coping strategies Command Hallucinations
7 studies that showed no relationship MacArthur study (2001) showed general
hallucinations were not associated but there was a relationship between command hallucinations to commit violence
Violence Risk Assessment
Depression May strike out in despair Depressed mothers who
kill their children Most common diagnosis
in murder-suicide Extension of suicide In couples, associated with feelings of
jealousness and possessivenessResnick (1969) Child murder by parents: a psychiatric review of filicide. Am J Psych
126 (3): 325-334Rosenbaum (1990) The role of depression in couples involved in murder-suicide
and homicide. Am J Psych 147 (8): 1036-1039
Violence Risk Assessment
Mania High percentage of
assaultive or threatening behavior
Serious violence is rare Violence with restraints Violence with limit settingTardiff (1980) Assault, suicide, and mental illness. Arch Gen Psych 37 (2): 164-
169
Violence Risk Assessment
Brain Injury Aggressive features:
Trivial triggering stimuli Impulsivity No clear aim or goals Explosive outbursts Concern and remorse following episode
Geriatric senile organic psychotic disease More assaultive than ANY other diagnosisKalunian (1990) Violence by geriatric patients who need psychiatric
hospitalization. J Clin Psych 51 (8): 340-343
Violence Risk Assessment
Personality Disorders Borderline somewhat associated Antisocial personal disorder most
common Violence is cold and calculated Motivated by revenge Occurs during periods
of heavy drinking Combined with low IQ
very ominous combination
Violence Risk Assessment
Personality Traits Impulsivity Inability to tolerate criticism Repetitive antisocial behavior Reckless driving A sense of entitlement and superficiality Typical Violence – paroxysmal, episodicBorum (1996)
Violence Risk Assessment
Affect Angry and lacking empathy Perception as victim
Violence Risk Assessment
Approach Distinguish static from dynamic risk
factors. Static
Demographic and past history Unchangeable
Dynamic Access to weapons, psychotic symptoms Active substance abuse, living conditions
Violence Risk Assessment
Interventions Pharmacotherapy Substance Abuse treatment Psychosocial intervention Removal of available weapons Increased supervision
Violence Risk Assessment
Approach Take all threats seriously Details – how act will be carried out
and anticipated consequences Potential grudge lists Investigation of fantasies of violence Also assess suicide risk Standardized instruments
Violence Risk Assessment
Actuarial Instruments Psychopathy Checklist (PCL-R)
20 items on a three point scale In North America cutoff is 30 or greater Problems if used as sole assessment
Does not capture protective or mediating factors
Overprediction of violence Several hours to administer
Psychopathy Checklist
2 factors: Interpersonal/Affective and Impulsive/Deviant lifestyle
1.Glibness/superficial charm - I/A2.Grandiose sense of self-worth - I/A3.Need for stimulation/proneness to
boredom - Imp/Dev4.Pathological lying - I/A5.Conning/manipulative - I/A6.Lack of remorse or guilt - I/A7.Shallow affect - I/A8.Callous/lack of empathy - I/A9.Parasitic lifestyle - Imp/Dev 10.Poor behavioural controls -
Imp/Dev
11.Promiscuous sexual behaviour ------
12.Early behaviour problems - Imp/Dev
13.Lack of realistic long-term goals - Imp/Dev
14.Impulsivity - Imp/Dev15.Irresponsibility - Imp/Dev16.Failure to accept responsibility
for own actions - I/A17.Many short-term relationships
-------18.Juvenile delinquency - Imp/Dev19.Revocation of conditional
release - Imp/Dev20.Criminal versatility --------
Risk Assessment Summary
Assessment does not = predictionConsider Risk FactorsRisk assessment is like predicting weather Better for proximal events Needs to be updated frequently
Practical Risk Assessment
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