Violence%20Risk%20Assessment

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Violence Risk Assessment
Presented By David Kan, MD
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Violence Risk Assessment

• Why are Psychiatrists Psychologists involved in
  predicting violence?

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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 hospital
• Civilly committed at end of sentence
• Left in prison hospital because state hospital
  didnt want him
• Writs were dismissed, transfer requests denied
• USSC Holdings
• Other civilly committed pts had right to hearing
• Commitment beyond term without judicial
  determination that he is dangerously mentally ill
  violates equal protection

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Violence Risk Assessment

• Tarasoff v. The regents of the University of
  California, 1976
• Facts
• Prosenjit Poddar and Tatiana Tarasoff
• Started dating
• Mr. Poddar unfamiliar with mores of America
  became depressed and saw psychologist, Dr. Moore.

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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

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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

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Violence Risk Assessment

• "When a therapist determinesthat 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

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Violence Risk Assessment

• What is the best predictor of violence?
• Criminal Record
• Presence of Intoxication
• Past History of Violence
• Perception of Self as a Victim
• All of the Above
• None of the Above
• Correct Answer F. None of the Above
• Violence is impossible to predict. However, RISK
  can be assessed.

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Violence Risk Assessment

• Assessing risk of violence
• Assessment 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

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Violence Risk Assessment

• In assessment, psychiatrists look for mental
  disorders
• Connection is debatable
• Most violence is committed by people WITHOUT
  psychiatric diagnosis

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Violence Risk Assessment

• Violence Specific Individual Specific
  Situation

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Violence Risk Assessment

• Past History is the best predictor
• What is the most violent thing theyve 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)

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Violence Risk Assessment

• Specific threat towards an individual is another
  serious risk factor
• Specific threat Past History exponentially
  increases risk.

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Violence Risk Assessment

• People at high risk do not always commit violent
  acts
• People who commit violent acts may not be
  considered high risk

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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
  4205-215 )
• 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)

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Violence Risk Assessment

• Psychiatrists tend to over predict violence out
  of concern for patients, 3rd party and ourselves
• Assessing dangerousness
• Vaguely defined
• USSC Logic if juries can do then psychiatrists
  must be better

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Violence Risk Assessment

• There is no single test or interview
• Structured approach critical
• Epidemiological Catchment Area study
• Violence is the province of the young
• 18 29 ? 7.34
• 30 44 ? 3.59
• 45 64 ? 1.22
• gt65 ? lt1

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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

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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

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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 26548-54
• 1 in 3 households have a gun
• 20 are unlocked
• Inquire about recent weapon movement

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Violence Risk Assessment

• 50-80 involved in violent crimes are under the
  influence of alcohol at the time of the offense
• Stimulant Drugs
• Cocaine, amphetamines, and PCP
• Disinhibition and paranoia
• Cocaine men commit crime, women victimized

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Violence Risk Assessment

• Drugs and Alcohol
• Psychiatric patients 5x increased rate
• Non-patients, 3x increased rate
• Steadman et al., 1998 Violence by peopl d/cd
  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

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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 gt than Mental Illness
• Monahan, 1997 Actuarial support for the clinical
  assessment of violence risk. International Review
  of psychiatry 176312-319.

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Violence Risk Assessment

• Vietnam Combat Vets and PTSD
• VN combat vets with PTSD gt prevalence of violent
  behavior than VN vets without PTSDLasko et al.
  Compr Psychiatry 1994 Sep-Oct35(5)373-81
• Hospitalized combat vets with PTSD gt 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
  Jul12(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 Dec53(8)859-69

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Violence Risk Assessment

• 1st break schizophrenia
• 52/253 violent in 1992 study
• 36 violent in preceding year
• 16 gt 1 year after admission
• Humphreys, et al (1992) Dangerous behavior
  preceding first admissions for schizophrenia Br J
  Schiz 161501-505

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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

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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 delusion
• Borum et al., 1996

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Violence Risk Assessment

• Hallucinations
• 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

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Violence Risk Assessment

• Depression
• May strike out in despair
• Depressed mothers whokill their children
• Most common diagnosis in murder-suicide
• Extension of suicide
• In couples, associated with feelings of
  jealousness and possessiveness
• Resnick (1969) Child murder by parents a
  psychiatric review of filicide. Am J Psych 126
  (3) 325-334
• Rosenbaum (1990) The role of depression in
  couples involved in murder-suicide and homicide.
  Am J Psych 147 (8) 1036-1039

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Violence Risk Assessment

• Mania
• High percentage of assaultive or threatening
  behavior
• Serious violence is rare
• Violence with restraints
• Violence with limit setting
• Tardiff (1980) Assault, suicide, and mental
  illness. Arch Gen Psych 37 (2) 164-169

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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 diagnosis
• Kalunian (1990) Violence by geriatric patients
  who need psychiatric hospitalization. J Clin
  Psych 51 (8) 340-343

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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

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Violence Risk Assessment

• Personality Traits
• Impulsivity
• Inability to tolerate criticism
• Repetitive antisocial behavior
• Reckless driving
• A sense of entitlement and superficiality
• Typical Violence paroxysmal, episodic
• Borum (1996)

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Violence Risk Assessment

• Affect
• Angry and lacking empathy
• Perception as victim

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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

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Violence Risk Assessment

• Interventions
• Pharmacotherapy
• Substance Abuse treatment
• Psychosocial intervention
• Removal of available weapons
• Increased supervision

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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

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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

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Psychopathy Checklist

• 2 factors Interpersonal/Affective and
  Impulsive/Deviant lifestyle
• 1.Glibness/superficial charm - I/A
• 2.Grandiose sense of self-worth - I/A
• 3.Need for stimulation/proneness to boredom -
  Imp/Dev
• 4.Pathological lying - I/A
• 5.Conning/manipulative - I/A
• 6.Lack of remorse or guilt - I/A
• 7.Shallow affect - I/A
• 8.Callous/lack of empathy - I/A
• 9.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/Dev
• 15.Irresponsibility - Imp/Dev
• 16.Failure to accept responsibility for own
  actions - I/A
• 17.Many short-term relationships  -------
• 18.Juvenile delinquency - Imp/Dev
• 19.Revocation of conditional release - Imp/Dev
• 20.Criminal versatility  --------

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Risk Assessment Summary

• Assessment does not prediction
• Consider Risk Factors
• Risk assessment is like predicting weather
• Better for proximal events
• Needs to be updated frequently

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Practical Risk Assessment

• Questions and Comments