Violence Risk Assessment

1. Presented By: David Kan, MD Violence Risk Assessment

2. Violence Risk Assessment Why are Psychiatrists & Psychologists involved in predicting violence?

3. 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 didn’t 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

4. 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.

5. 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

6. 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

7. Violence Risk Assessment "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

8. 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.

9. 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

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

11. Violence Risk Assessment • Violence = Specific Individual + Specific Situation

12. Violence Risk Assessment • 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)

13. Violence Risk Assessment • Specific threat towards an individual is another serious risk factor • Specific threat + Past History exponentially increases risk.

14. Violence Risk Assessment • People at high risk do not always commit violent acts • People who commit violent acts may not be considered high risk

15. 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 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)

16. 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

17. 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% • >65  <1%

18. 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

19. 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

20. 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 265:48-54 • 1 in 3 households have a gun • 20% are unlocked • Inquire about recent weapon movement

21. 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

22. Violence Risk Assessment • Drugs and Alcohol • Psychiatric patients 5x increased rate • Non-patients, 3x increased rate Steadman 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

23. 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 > than Mental Illness Monahan, 1997 Actuarial support for the clinical assessment of violence risk. International Review of psychiatry 176:312-319.

24. 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

25. Violence Risk Assessment • 1st break schizophrenia • 52/253 violent in 1992 study • 36 violent in preceding year • 16 > 1 year after admission Humphreys, et al (1992) Dangerous behavior preceding first admissions for schizophrenia Br J Schiz 161:501-505

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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)

34. Violence Risk Assessment • Affect • Angry and lacking empathy • Perception as victim

35. 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

36. Violence Risk Assessment • Interventions • Pharmacotherapy • Substance Abuse treatment • Psychosocial intervention • Removal of available weapons • Increased supervision

37. 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

38. You may have a duty to protect when… • You are in a ‘special relationship.’ • The intended victim is ‘identifiable’ • The risk of violence is significant. • The risk of violence is imminent. • The laws or case law where you practice say that there is, or may be, a duty.

39. Structured Threat Assessment Screening Questions* • Are you the sort of person who has trouble controlling your temper? • Have you found yourself hitting people or damaging things when you are angry? • What is the most violent thing you have ever done?

40. More Routine Threat Assessment Screening Questions • What is the closest you have ever come to being violent? • Do you ever worry that you might physically hurt somebody? *Monahan, John. Limiting therapist Exposure to Tarasoff Liability. American Psychologist, Mar 1993, p 242.

41. Structured Threat Assessment: Records Review • Existing medical records • Past medical records

42. How do I fulfill this duty? • Document informed consent on the limits of privacy • Render & Document a violence risk assessment • Seek consultation • Develop a plan • Implement treatment plan INCLUDING FOLLOW-UP • Document the facts and your reasoning

43. Develop a Plan . . . • Incapacitation: -hospitalizing the patient -transferring inpatients to more secure ward -sedating the patient into an oblivious stupor

44. Develop a Plan . . . • Target Hardening: -warning the victim and encouraging action

45. Develop a Plan . . . • Treatment Intensification: Increase visits, change Rx, convene joint session with victim and/or others, remove weapons, align with pt’s health (“ I want to help you stay out of that kind of trouble and I know you do too.”)

46. 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

47. Mass Shooters • Dietz – Media Saturation leads to at least one copycat within 2 weeks • Shooters are: • Male • Depressed & Suicidal • Blame others • See act as revenge • Rarely caught – most kill selves • Rarely psychotic

48. HIV, Hep C, other Infections, and Duties Toward 3rd Parties APA Position: Disclosure should occur only when these 4 conditions are present: 1. The third party is identifiable. 2. The third party is at significant risk. 3. The third party is unaware. 4. The patient is unwilling to inform.

49. Effect on the Tx Relationship when a third party is warned James Beck (‘82): 26 cases of warning -Psychiatrists judged that effect was -Positive in 2 cases -Neutral in 13 cases -Negative in 4 cases -Indeterminate in 7 cases -Informed Consent + Warranted = + or neutral therapeutic outcome

50. Effect cont. • Binder and McNiel (1996) had similar findings to Beck 13 yrs before • Warnings are quite common • Most intended victims are grateful but already know • When advised after a warning, most patients maintain attachment