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Clinical experiences with Version 2 and 3 of the HCR-20 in the SAFE pilot project

Clinical experiences with Version 2 and 3 of the HCR-20 in the SAFE pilot project. Stål Bjørkly, Molde University College. Gunnar Eidhammer and Lars Erik Selmer, Clinic of Addiction and Psychiatry , Vestre Viken Trust.

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Clinical experiences with Version 2 and 3 of the HCR-20 in the SAFE pilot project

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  1. Clinicalexperienceswith Version 2 and 3 ofthe HCR-20 in the SAFE pilot project Stål Bjørkly, Molde University College. Gunnar Eidhammer and Lars Erik Selmer, ClinicofAddiction and Psychiatry, Vestre Viken Trust. Johnny Wærp,Section for Medium Security, Gaustad, Oslo University Hospital. Alexander R. Flaata and Marthe Kjerstad, Section for Maximum Security, Dikemark, Oslo University Hospital. Centre for Forensic Psychiatry, Oslo University Hospital, Oslo, Norway www.forensic-psychiatry.no

  2. Main researchobjectives - Risk assessment - Risk management - Prospective follow-up - Naturalistic design

  3. Setting and sample One maximumsecurityunit and three medium security units + Forensic patient + Major mental illness + Seriousviolencetowardsothers + Dischargewithin 6-12 months

  4. Sample characteristics (n= 22) • Mean age: 32 • Gender: 19 male • Relationshipwith partner: No:17 • Highesteducation:Compulsoryschool (8/2 failed), High school (11/10), University (3/2) • Employment/Income: Social support • Ethnicity:17 native Caucasian Norwegians www.forensic-psychiatry.no

  5. Sample characteristicscont. • Previouspsychiatrictreatment: • 1 – 12 months: 7 • 1 – 2 years: 3 • Over 2 years: 12 • Primary diagnoses: • Paranoid Schizophrenia 14 • HebephrenicSchizophrenia: 4 • Personalitydisorders: 4 www.forensic-psychiatry.no

  6. Repeatdynamic risk assessment • Hallucinations (PSYRATS-A) • Delusions (PSYRATS-B) • TCO (PERI) • Hopelesness (The HopelesnessScale) • Dissociation (DES-II) • Insight (SAI-E) • Warningsigns (SWAB, FESAI, ERM) • Situationalvulnerability(REFA)

  7. Focus in thispresentation • To compareHCR-20 version 2 and 3 • Clinical risk factors and risk management www.forensic-psychiatry.no

  8. Internalconsistency and clinicalutility Gunnar Eidhammer, Lars Erik Selmer and Stål Bjørkly www.forensic-psychiatry.no

  9. Participants and setting • Setting • Raters • Assessment of 20 forensic mental health patients • All patients were male www.forensic-psychiatry.no

  10. Sample (n = 20) www.forensic-psychiatry.no

  11. Internalconsistency • ICC: Two-way mixed effects model (rater effects random and measures effects fixed) Cronbach's alpha (95%CI) H-items .854 (.726 - .940) C-items .586 (.256 - .809) R-items .812 (.662 - .913) All items of HCR-20 and V3 .842 (.708 - .935) C-items: p < .001; Other items: p < .000 • Significant differences for H-items (t=-2.797, df=19, p<.012) and C-items (t=-4.040, df,=19, p<.001), but not for R-items (t=.218, df=19, p<.830). www.forensic-psychiatry.no

  12. Clinicalutility: coding • Change from 0, 1, 2, omit (V2) to y, p, n, o (V3) makes the V3 more adapted to clinical practice. • Mitigates the risk of importing an actuarial approach into the use of the V3 • Protects against misuse of numbers in decision making processes • The new structure reduces the risk of empirically unfounded conclusions www.forensic-psychiatry.no

  13. Clinical utility: Presence / Relevance • Presence: • The principalcommon risk factors • Evidence-/knowledge-based • Relevance: • The principalindividual risk factors • Person-specific www.forensic-psychiatry.no

  14. Clinical utility: Risk formulations • Risk formulationsinform and enhanceclinicalpractisethroughindividualized risk management strategies • An example: CombiningtheEarly Recognition Method (ERM) and R item analysis to develop risk management strategies www.forensic-psychiatry.no

  15. Concluding remarks • The 7-step structure 1. Gather and document basic case information 2. Identify presence 3. Assess relevance 4.Integrate information into case formulation 5. Identify risk scenarios 6. Recommend risk management strategies 7. Risk judgment documentation • V3 = A more systematic, comprehensive and individualizedviolence risk analysis • “Risk analysis” = assessment + management www.forensic-psychiatry.no

  16. Changes in repeated HCR-20 measurement Johnny Wærp www.forensic-psychiatry.no

  17. Clinical Comparison HCR-20 V2-V3 Clinical items V2 Clinical items V3 C1 Insight C2 Violent ideation or intent C3 Symptoms of major mental disorder C4 Instability C5 Treatment supervision response • C1 Lack of insight • C2 Negative attitudes • C3 Active symptoms of major mental disorder • C4 Impulsivity • C5 Unresponsive to treatment

  18. Rihanna • Diagnosis F 60.3 Emotionallyunstablepersonalitydisorder (DSM:Borderline) • Single, 34 yrs • Historyof: • sexualabuse • psychiatrichospitalisations (last 10 years) • violencetowardsothers • self harm and suicidal behaviour

  19. Repeated Measurements HCR-20 V2

  20. Changes in repeatedmeasurement

  21. Perceivedthreat and controloverride symptoms (TCO) • Monitoredweekly for TCO- symptoms for 18 months. • At T3 a risk management plan wasformulated: - focuson TCO- symptoms - associatedwithirregularmenstruation. • Presenceof TCO- symptoms: • Risk factor and, • Warningsign (SWAB) • For vilolencetowardself/others • Patientacknowledgedthisrelationship • Medicationwithbirthpills.

  22. Changes in repeatedmeasurementsof TCO

  23. C3 Formulation in V2 vs. in V3 V2 Formulation V3 Formualtion C3 Active symptoms of major mental disorder Sub-item: Psychotic disorders Does not meet ICD- criteria for schizophrenia. Not present and not relevant,but Shows active TCO symptoms in relevant pattern recorded on SWAB and REFA (short term) Sub-item: Major mood disorders Meets criteria for major mood disorder in remission Not present, but relevant for long term risk Sub-item: Intellect/executive/ social NP tests show some memory problems Present and moderately relevant C3 Active symptoms of major mental disorder T1: 1, T2: 1, T3: 0 • Psyrats A No score (T1, T2, T3) • Psyrats B No score (T1, T2, T3 ) • Peri - TCO Scores present at T1 and T2, not present at T3. TCO weekly monitoring still shows pattern related to irregular menstruation

  24. Conclusion • Sub-itemsstructurejudgement • Presence and relevancehelpdefineformulations • Specificationof time frame and priorityof case enhancestructureof risk mangementprocedure • Formulationbecomes more specific and useful for nextleveloftreatment

  25. A single-case illustration from a highsecurityward Alexander R. Flaata Marthe Kjerstad www.forensic-psychiatry.no

  26. Method • Two independent raters • One patient: Justin, in his late twenties • Raters completed HCR-20 (V2/V3) together with hospital staff • Outcome of violence risk assessment, violence risk management plan, and clinical utility was discussed

  27. Justin • Alcoholabuse: 12 yearsold • Drugabuse (cannabis, amphetamine and heroine) • Age at first psychiatricadmission: 21 • 19 hospitalisations • F20.0 Paranoid Schizophrenia • Transferred from medium to highsecurityward : 24 yearsold • Numerous severe physicalassaultsagainst mental healthprofessionals

  28. Dynamics ofviolence in highsecurityward. • Paranoid delusions: • Controlled by thepersonnel (by a device in his brain) • Ownthoughtsbroadcasted • Emotionaldistress: Psychoticanxiety • Somaticdelusions: • Body changes (penis and face) • Emotionaldistress: Dysmorphophobicanxiety • He felt to be in urgentneedofmedicalexamination • Realityorientation: increased risk ofviolence. • Antisocial (instrumental) violence: • Persistent demandof sedatives, violent movies, discharge… • Verbal threats, and physicalviolence to getwhathewanted.

  29. Comparisonofclinicalutility • V2 • Less support in theassessmentprocess • More broad and general risk management planning • V3 • Clear structure for assessmentprocedure • Requires more spesificinquiryintohow risk factorscontribute to present risk ofviolence • Method for identifyingsignificantindividual risk factors

  30. Clinicalutility (II) • V3 • Systematicapproach to developrealisticscenarios • Relevance scores enhance risk assessmentaccuracy • Assessmentof Justin: • Splitting factor: Itemswithlowrelevance • This contributedto different outcomes: v2: moderat v3: low to moderate,

  31. Conclusion • Bothversions have significantclinicalutility in formulatingviolence risk and management • V3 provides a betterstructureoftheassessmentprocess • V3 is more comprehensiveregardingthewholeprocessofviolence risk assessment • V3 is more time-consuming

  32. Contact information Stål Bjørkly stal.bjorkly@kompetanse-senteret.no Centre for Forensic Psychiatry, Oslo University Hospital, Oslo, Norway www.forensic-psychiatry.no

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