violence risk assessment presented by: david kan, md

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


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.


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


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


"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


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.


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


In assessment, psychiatrists look for mental disordersConnection is debatableMost violence is committed by people WITHOUT psychiatric diagnosis


Violence = Specific Individual + Specific Situation


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)


Specific threat towards an individual is another serious risk factorSpecific threat + Past History exponentially increases risk.


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


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)


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


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%


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


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


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


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


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 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


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


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


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


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


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


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


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


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


Affect Angry and lacking empathy Perception as victim


Approach Distinguish static from dynamic risk

factors. Static

Demographic and past history Unchangeable

Dynamic Access to weapons, psychotic symptoms Active substance abuse, living conditions


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


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


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

Questions and

Comments

violence risk assessment presented by: david kan, md

Documents