Psychiatric Risk Assessment and ManagementDr Sarah FosterGPST2 Havering VTS

Definitions

• Risk: the likelihood of an adverse event.

• Risk management: Organised attempt to minimise the likelihood of adverse events. Defining the seriousness of the potential harm, the probability that it will occur and its imminence.

Risk Assessment

• Risk to assessor / ensuring personal safety

• Violence / Harm to others• Suicide• DSH• Self-neglect/vulnerability• Others: risk of

abuse/exploitation, risk to children, sexual offences

Personal Safety

• Personal privacy• Personal attack alarms/alarm

in room present and accessible

• Staff nearby• Exits from room are clear• Seat yourself close to the

door• Observation panels in door

• Remove potential missiles or weapons. But if armed call police urgently.

• Policy guidance on prevention and management of violent behaviour within the work place (CG001)

• Breakaway training• Reporting violent incidents• Familiarize yourself with the

details of the case prior to consultation

Risk of violence

HIGH RISK (Any of the following)

• History of violence (particularly recent)

• Stated threat of violence/ overt hostility

• Immediate availability of a weapon/carrying a weapon

• Social alienation/reduced support• Alcohol/ substance abuse• Active symptoms of psychosis

especially delusions of violence• Agitated/excited/suspicious

Other predictors of violence

• Impulsive/Explosive/Antisocial personality traits

• Lack of collaboration with suggested treatment

• Active symptoms of mania

N.B. Assume self referrals are high risk

Delusions associated with violence

• Delusions focused on one individual

• Preoccupation with violence• Delusions of control i.e.

being under threat, controlled by another person or an external force

• Intense emotions: fearful, suspicious, angry, perplexed

• Depression with belief other family members better off dead

• Lack of conviction as to the truth of a delusion should NOT be seen as reassuring as acting on false beliefs is more likely if shakily held than firmly held!

Case example 1

“Stalker shoots his former lover in Harvey Nichols murder-suicide”

Pech, a former Slovakian soldier, was high on cocaine when he walked into Harvey Nichols and shot Miss Bernal in the back of the head before taking his own life. The Metro, September 2007

What if any were the signs of high risk?• Substance abuse• Verbal threats of violence and death “If

you report me, I will kill you”• Physically aggressive• Delusions focused on one person and

issues of control. Stated that if he could not have her noone else would.

• Initially hung around perfume department of store when banned and then broke terms of bail by continuing to approach her repeatedly.

• No insight• Previously in the Slovakian Army so had

knowledge and experience of using guns

Case example 2

“Bartelio Maxie a 29 year-old, schizophrenic gentleman walked off the unfenced grounds of Creedmoor Psychiatric Center on April 16, 1991.”

“Four months later Maxie cut the throat of Frances Andral, 50, a close family friend with whom he had been living in Jamaica, Queens, after moving here from his native Haiti, police said.”

“Maxie told police that he believed Andral was trying to put a voodoo curse on him. He also said that voices in his head were telling him to kill her before she killed him.”

New York Newsday, Friday August 20, 1999

Signs of high risk

• Delusion of control• Delusion that he was himself

threatened

OVERALL: To accurately establish risk related to a delusion takes very detailed investigation of the delusion.

Limited time in GP so if in doubt refer.

Tips for the interview• Allow personal space• Avoid prolonged eye contact• Avoid raising your voice; appear

calm and self-controlled.• Ask for facts about the problem,

encourage reasoning.• Avoid note taking if patient

suspicious• TERMINATE the interview if you

feel afraid/threatened. Do not persist if situation deteriorating.

• If weapon is produced ask for it to be put down (not handed over)

• Never say “calm down”

Community Visits

• Always ensure someone know where you are and expected time of return.

• If high risk do not go alone.

“The Bare Minimum” History

• History of violence• Thoughts of violence• Very important to to get a

collateral history (to ask about these again)

Suicide Risk• Do not assess when drowsy after

OD• What were intentions?

(Asking about suicide does not make it more likely)

• Evidence of planning? • Now intend to die?• Triggers/ current problems? (Must

be addressed and resolved to prevent future attempts)

• Psychiatric disorder ? (Psychiatric History and MSE)

• Social support network and coping strategies

Prediction of suicide risk

1. Hopelessness2. Depressive illness3. Male over 454. Unemployed/retired5. Living alone6. Alcohol or drug addiction7. Poor physical health8. Violent methods in previous

attempts (hanging, gun)9. Suicide note especially those

done in isolation10. Previous attempts11. Regret surviving

The “SAD PERSONS” scale• S Sex is male• A Age >45 yrs or <19 yrs• D Depression• P Previous attempts• E Ethanol abuse• R Rational thinking loss

(particularly psychosis)• S Social support is lacking• O Organised plan• N No spouse

Score > or equal to 5 admission is advised

DSH

HIGH RISK if:

1. Repeat offender

2. Mentally ill

3. Socially isolated

N.B. Risk can never be excluded completely

Self neglect/ Vulnerability

Assess:• Physically capable • Mentally capable (AMT)• Finances• Social network• Being victimised by another

individual?

At risk groups: children, elderly, dementia, learning disabilities, severe depression, personality traits e.g. dependent, substance and alcohol abuse

THE END

References

1. Goldberg, D. The Maudsley Handbook of Practical Psychiatry Oxford University Press. 2003

2. Semple, D. Oxford Handbook of Psychiatry

Oxford University Press. 2006