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1 RISK ASSESSMENT FOR VIOLENCE Phillip J. Resnick, M.D. vj I. Demographics of Violence in General A. Age - violence peaks in late teens and early 20s. B. Sex - males more than females. C. Social class - the lower, the more street violence. D. IQ - the lower, the more violence. E. History of substance abuse F. Less education G. Employment instability H. Residential instability II. Mental Illness and Violence Epidemiology A. An epidemiologic study by Swanson et al., (1990) provided a survey of over 10,000 persons in the community regarding self reported violence in the last year. Violent Behavior in the Last Year Diagnosis Percent No disorder 2 Obsessive-compulsive disorder 11 Panic disorder 12 Major depression 12 Mania or bipolar disorder 11 Schizophrenia 13 Cannabis abuse or dependence,19 Alcohol abuse or dependence ) 25 Other drug abuse or dependence The higher the number of psychiatric diagnoses, the greater the rate of violence. 2. The combination of substance abuse with other major psychopathology is more volatile than either alone.

2 3. Nearly a third of those with schizophrenia also met the criteria for alcohol or drug abuse and dependence. [. Components of Dangerousness A. Magnitude B. Likelihood C. Imminence D. Frequency. Psychosis and Violence A. Paranoid psychoses 1. Paranoid schizophrenics in the community are more violent than other diagnostic categories. However in hospitalized patients, more likely to be violent. non-paranoid patients are 2. In paranoid patients with delusions, their violence is usually well planned and in line with the delusion. The violence is directed at a specific person who is seen as persecuting the patient, often relatives or friends. 3. Paranoid patients are more likely to be dangerous because they often have recourse to weapons, since they are more likely to be in the community. 4. Paranoid schizophrenics are likely to commit the most serious crimes because of their ability to plan and their retention of some reality testing. B. Chronic disorganized psychotics 1. Chronic psychotic patients who remain more disorganized are more likely to be assaultive in hospitals. 2. In more disorganized psychotic states, less planned and less dangerous aggressive acts are likely to occur. C. Hallucinations, and Violence 1. Hallucinations that evoke negative emotions (anger, anxiety, sadness) generate more violence.

3 2. Violence is associated with having less successful strategies to cope with voices. 3. Command hallucinations are associated with violence. D. Compliance with command hallucinations: 1. Increased with a hallucination-related delusion. 2. Increased if the voice is familiar. 3. Dangerous commands are obeyed less often. 4. Increased with history of compliance. E. Delusions and violence: 1. More violence is due to delusions than hallucinations. 2. There is an increased risk of aggression with certain specific psychotic symptoms. 3. Risk of violence is increased by: (a) "Threat/control-override" symptoms associated with increased aggression include: (1) Mind feels dominated by forces beyond your control. (2) Feelings that thoughts are being put into your head. (3) Feelings that there are people that wish you harm. (b) Psychotic delusions not associated with increased aggression: (1) Feeling dead, dissolved, or not existing. (2) Feelings that your thoughts are broadcast. (3) Feelings that thoughts are taken by external force. 4. Violence is more likely if delusions are: (a) (b) (c) Persecutory. Systematized. Preceded by fear or anger.

4 4. (d) Acted on before. 5. Erotomania (a) (b) (c) More common in males than females. Less than 5% of erotomanics commit a violent act. The loved person is the most common object of violence. (d) The act is may also be committed against one who stands in the way of the loved person. V. Depression: A. Violence can result when the patient reacts in despair by striking out against other people. B. Parents may kill their children prior to a suicide, especially mothers of young children. VI. Mania: A. Manic patients show a high percentage of assaultive or threatening behavior but serious violence itself is rare. B. Manic patients show considerably less criminality of all kinds than schizophrenics. C. Manic patients are especially likely to be assaultive when limits are set. VII. Premenstrual tension syndrome is associated with violence by wives toward their husbands. A. Wives kill their husbands more often in the five days before their periods as they do the remainder of the month. B. Reduction of PMS has been seen with alprazolam, buspirone, and SSRIs, such as Prozac. ^ VIII. PTSD A. Veterans with PTSD have a higher incidence of violent crimes. B. Flashbacks may include threatening hallucinations.

5 5 C. Irritability D. High incidence of substance abuse to numb feelings. IX. Personality Traits Associated with Violence: A. Impulsivity (absence of reflective delay). B. Low frustration tolerance. C. Inability to tolerate criticism. D. Repetitive anti-social acts. E. Drive automobiles recklessly. F. Egocentricity and entitlement. G. Tendency to have superficial relationships and to dehumanize others. H. Mental status exam may show glibness, lack of introspection, and a tendency to project internal difficulties on to the environment. X. Childhood Factors Correlated with Later Violence: A. Brutality sustained by a child from a parent, particularly a brutal father. Boys become aggressive; become victims. girls are more likely to B. Parental seduction. C. Truancy, school failures. D. Delinquency as an adolescent. Tatooed persons show a higher likelihood of drug use, criminality, impulsivity, and masculine concerns. E. Arrest for prior assault. ) F. Childhood hyperactivity or serious inattention. G. First psychiatric hospitalization by age 18. H. One study documented a triad of enuresis, fire-setting and cruelty to animals.

6 C./Assessment of Risk of Future Violence A. Careful assessment of the patient's past use of violence. 1. Past violence is the single best predicter of future violence Patient s account of prior violence. (a) What is the most violent thing you have ever done? (b) (c) Frequency of violent acts. Assess each prior violent act. (1) Who said what? (2) Degree of injury? (3) Presence of alcohol or drugs? 3. Obtain collateral information. (a) Talk to family to gather information. (b) Victim's account of details of past violence. (c) Psychiatric records. <J B. Look for patterns of violence. 1. Violence may occur only in acute psychotic episodes. 2. Assess whether the past violence was precipitated by an interpersonal condition which diminished the patient's self-esteem. 3. Ego dystonic vs. ego syntonic attitudes toward violent impulses. Is there remorse for past violence? 4. Affective vs. predatory violence (a) Affective aggression is the result of external and internal threatening stimuli that evoke an intense and patterned activation of the autonomic.nervous system, accompanied by threatening vocalizations and attacking or defending postures.

7 (b) Predatory aggression is planned, purposeful, and goal directed. Unlike affective aggression, it is not reactive and requires emotional detachment. Predatory violence is the hallmark of the psychopathic character, and is exceedingly dangerous because there are no behaviors that foreshadow it. 5. Assess patients for overcontrol as well as undercontrol, since this sometimes leads to homicide. 6. Look for neurologic clues such as headache, altered consciousness, and repetitive behavior related to violence 7. Pattern of family violence, non-family violence or both. Violence directed only to the family tends to be less severe. 8. Panic attacks are associated with violence in some cases. C. Evaluate the use of drugs and alcohol. 1. Amphetamines, PCP and alcohol diminish controls. 2. Stimulants predispose to violence through disinhibition, grandiosity, and paranoia. D. Weapons History Assessment 1. Have you ever owned a weapon? 2. If so, what weapons have you owned? 3. Do you own a weapon now? 4. Did you ever threaten, injure or kill person with a weapon? 5. Have you moved your weapons closer in the recent past? (such as from the closet to under the bed). E. Criminal and court records should be evaluated. 1. The age at first arrest appears to be highly related to persistence of criminal offending. 2. The probability of a fifth arrest given four previous arrests is 80%.

8 F. Institutional history 1. Ten or more prior psychiatric admissions increases the likelihood of future violence. 2. A history of escape from any institution is associated with violence. G. Military history should note fighting, AWOL, drugs, Article XV1 s (non-judicial punishment), and type of discharge. H. Work history should explore frequency of jobs and reasons for termination. I. Sexual aggression history. An FBI study of serial rapists showed an 76% incidence of sexual abuse after detailed questioning. t. Current Assessment of Dangerousness. II. A. A lack of empathy for others, coupled with anger. B. Give credence to your subjective feelings in assessing dangerousness. C. Pre-assault behavior includes verbal abuse, raised voice, swearing, and standing uncomfortably close. D. You may offer food to the patient who is escalating. E. Take all threats seriously and elucidate the details. F. In paranoid patients, inquire about what the patient would do if confronted by a perceived persecutor. G. Appraisal of "perceived intentionality." H. Do a careful assessment of the future victim. Classification of Risk Factors A. Dynamic -- subject to change by intervention or treatment, or control of situation. Eg: Living setting, access to weapons, substance abuse, probationary supervision. B. Static -- not subject to change by intervention. Eg: Demographic information, history of violence, childhood

9 9 abuse, antisocial traits. XIV. Risk Assessment After a Violent Act A. It is useful to develop a plan for the prevention of aggression, especially after a violent act. B. A chart can be developed with three headings: 1. Risk factors 2. Management/treatment strategies 3. Status Violence Prevention Plan Example Risk Factor Management/Treatment Status 1. Psychosis 1. Depo antipsychotic Substance abuse 2. AA & urine screens Living with mother 3. Not live with mother Access to guns 4. Limit access to guns 4. XV. Tarasoff v. U.C. (1976) When a therapist determines, or should determine, that his patient presents a serious danger of violence to another, he incurs an obligation to use reasonable care to protect the intended victim from danger. XVI. Malpractice Risk Reduction: A. Stay current in your knowledge. B. Obtain all relevant data., C. Document your reasoning. D. Know your Tarasoff duty. E. Obtain consultation. XVII. Summary

10 10 A. Take a violence history. B. Be alert for escalating fear in a paranoid patient C. Formulate a formal violence reduction plan.

11 11 GENERAL REFERENCES 1. Appelbaum P.S., Robbins, P.C., Monahan, J.: "Violence and Delusions: Data from the MacArthur Violence Risk Assessment Study," Am J Psychiatry, 157: , Junginger, J., "Psychosis and Violence: The Case of a Content Analysis of Psychotic Experience," Schizophrenia Bulletin, 22:91-103, Kausch, O., Resnick, P.J., "Psychiatric Assessment of the Violent Offender," Handbook of Psychological Approaches with Violent Offenders: Contemporary Strategies and Issues, V.B. Van Hasselt & M. Herson (Eds.), Kluwer Academic/Plenum Publishers, New York, p , Kausch, O. and Resnick, P.: "Risk Assessment for Violence: A Clinical Approach, " Directions in Psychiatry, 23:55-63, Loza, W., Villeneuve, D.B., and Loza-Fanous, A.: "Predictive Validity of the Violence Risk Appraisal Guide: A Tool for Assessing Violent Offender's Recidivism," International Journal of Law and Psychiatry, 25:85-92, Monahan, J., Steadman, H.J., Silver, E., Appelbaum, P.S., Robbins, P.C., Mulvey, E.P., Roth, L.H., Grisso, T. and Banks, S. : Rethinking Risk Assessment: The MacArthur Study of Mental Disorder and Violence, New York: Oxford Press, Resnick, P.J., "Can Psychiatrists Predict Violence?" Harvard Mental Health Letter, 9(12):8, Resnick, P.J., Kausch, O., "Violence in the Workplace: Role of the Consultant," Consulting Psychology Journal: Practice and Research, 47: , Robbins, P.C., Monahan, J., and Silver, E. : "Mental Disorder, Violence, and Gender," Law and Human Behavior. 27: , Scott, C.L. : "Juvenile Violence," The Psychiatric Clinics of North America, 22:71-83, 1999., 11. Silver, E. and Miller, L.L. : "A Cautionary Note on the Use of Actuarial Risk Assessment Tools for Social Control," Crime and Delinquency, 48: , Swanson, J., Borum, R., Swartz, M., and Monahan, J. : "Psychotic Symptoms and Disorders and the Risk of Violent Behaviour in the Community, " Criminal Behaviour and Mental Health, 6: , 1996.

The Paranoid Patient: Perils and Pitfalls

The Paranoid Patient: Perils and Pitfalls Phillip J. Resnick, MD Professor of Psychiatry Case Western Reserve University Director of Forensic Psychiatry University Hospitals Case Medical Center Cleveland,