Who Is Most Likely To Become Violent?

Educational Objectives

The goal of this lecture is to improve risk assessment for violence. After hearing and assimilating this lecture, the clinician will be better able to:

1. Predict risk for violence in patients with mental illness.

2. Recognize symptoms of schizophrenia that are associated with increased risk for violence.

3. Distinguish affective violence from predatory violence.

4. List dynamic and static risk factors for violence.

5. Develop a violence risk prevention plan.

Summary

Paranoia and risk for violence: key points — 1) building crescendo of paranoid fear creates risk; as intensity of fear escalates, risk of individual striking out in misperceived need for self-defense increases; 2) clinicians should not surrender professional judgment to family members; clinicians have ability to make reasoned decisions without personal involvement because they have more experience and detached empathy; 3) individuals who pose threats must be distinguished from those who make threats

Mental illness and risk for violence: in any given year, 2% of general population without psychiatric diagnosis commits violent act; individuals with bipolar disorder or schizophrenia ≈5 times more likely to commit violence; alcohol and substance abusers more likely than persons with major mental illness to commit violence

Errors in clinical judgment: underestimating capacity of women and attractive patients to commit violence; overestimating commission of violence by minority members; after witnessing details of crime (eg, harm done to victim), overestimating capacity of individual to commit violence

Comorbidity of substance abuse: present in >40% of individuals with schizophrenia, >80% of individuals with antisocial personality disorder, and 60% of individuals with bipolar disorder I; combination of schizophrenia and substance abuse associated with 17-fold increase in likelihood of violence; comorbid substance abuse and history of violence increase likelihood of violence in mentally ill patients

Commitment statutes: many based on determination of whether individual poses “substantial risk of dangerous conduct or physical harm”; substantial risk — denotes strong possibility rather than probability (ie, 51% chance or better); “the greater the magnitude, the less the likelihood has to be” (eg, 1 in 10 chance of teacher slapping student not sufficient for civil commitment, but 1 in 100 chance of killing student sufficient for commitment)

Risk assessment: standardized instruments — Psychopathy Checklist-Revised (PCL-R); Violence Risk Appraisal Guide (VRAG; actuarial instrument [ie, cannot use any clinical factors]); Historical Clinical Risk Management-20 (HCR-20) based on structured professional judgment (“equal to actuarial factors”); Classification of Violence Risk (COVR) uses software algorithm; self-perception of risk for violence — individual’s subjective opinion about how concerned therapist should be about patient being violent in next 2 mo; slightly more accurate than use of 2 different instruments; accuracy — actuarial risk assessment more accurate than clinical judgment based on stability of historical factors; however, clinical judgment must be used when deciding which patients from emergency department require admittance to hospital; actuarial instrument more useful when detailed history provided

Violence in psychosis: Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) — followed >1000 patients with schizophrenia; assessed positive symptoms (eg, hallucinations, delusions, disorganized thoughts) and negative symptoms (eg, blunted emotions, apathy, inability to “get going”) of schizophrenia; patients with most positive factors and least negative factors pose greatest risk; whereas positive factors may be acted on, negative emotions often indicate lack of energy or wherewithal to act in violent manner; paranoid psychotics — often plan violence against misperceived persecutor; sufficiently organized to obtain lethal weapon

Hallucinations: compared with delusions, associated with lower incidence of violence; hallucinations that evoke negative emotions and command hallucinations more likely to evoke violence; command hallucinations — one-third of all hallucinations; instruction to carry out order (suicide most common order); relatively small number involve physically harming or killing another person; violence more likely to be carried out when delusion related to hallucination, familiar voice heard in hallucination, and when hallucinator may benefit or feel personally superior; commands from, eg, religious leader, not more likely to be obeyed (no evidence supports association between likelihood of violence being carried out and attribution of voice to “good” vs “evil” personage)

Delusions: persecutory delusions — more likely to result in violence than misidentification, grandiose, or erotomanic delusions; these include “threat and control override delusions” (perceived as domination of mind by forces beyond individuals’ control, with thoughts “being put in their heads”, and belief that others wish them harm); nonviolent delusions — may manifest as belief that one is dead or that thoughts are being broadcast; response to threats — men tend to experience fight-or-flight response or become aggressive; women may become aggressive but have greater tendency to “tend and befriend”, and seek protector; systematized persecutory delusions — individual believes threat coming from particular person or entity; danger heightened because potential target more clear; violence among severely mentally ill — most associated with delusions (some stem from delusion-related hallucination; small proportion related to hallucinations that have no relationship with delusion)

Mania: associated with high incidence of substance abuse; manic substance abusers twice as likely to be violent, compared with general population; manic individuals without substance abuse disorder not more likely to be violent than general population; manic patients most likely to be violent when limits set (eg, “Don’t get out of that chair”)

Homosexual panic: occurs among men who perceive themselves to be heterosexual but have occasional stray thoughts of being attracted to another man; theory of paranoia — suggested by Freud; individual loves another man, individual hates other man, and other man hates individual; perceived need to “protect one’s manhood” may spur paranoid individual to commit violence

Personality traits associated with violence: impulsivity; poor tolerance of criticism or frustration; self-centeredness; projection of blame; violence most often occurs in patients with antisocial or borderline personality disorder

Delayed gratification: Marshmallow experiment — 200 boys 4 yr of age told that they could receive 1 marshmallow now or 2 marshmallows in 15 min; some children chose to receive 1 marshmallow while others could wait to get 2 marshmallows; in follow-up of >25 yr, those capable of delaying gratification scored 210 points higher on college entrance examinations, had higher incomes, and showed lower likelihood of going to prison, being evicted, being obese, or being divorced

Childhood antecedents of adult violence: being brutalized by parent or caretaker; when older, boys tend to brutalize more vulnerable individuals; girls more likely to replicate victimization (eg, history of sexual victimization during girlhood 27 times more common among prostitutes, compared with other women); childhood bullies more likely to be violent as adults; victims of bullies more likely to have anxiety and depression in adulthood; juvenile delinquency and gang membership correlated with adult violence; speaker recommends examining tattoos of patients to gain insight into psyche (eg, 26% of tattoos on adult men read, “Mom” or “Mother,” which may suggest individual has passive dependent needs)

Patterns of violence: affective violence — associated with strong arousal of autonomic nervous system and impulsive action; involves grievance, emotion, and attack; predatory violence — planned action; involves intermediate steps of research, planning, and preparation; anger and fear most often precede violence; anger in absence of empathy particularly concerning; capacity for affect can be determined early in life and has important consequences (absence may indicate, eg, autistic spectrum disorder, antisocial personality disorder); behaviors most often exhibited 5 min before inpatient assault include yelling, swearing, and standing uncomfortably close

Threats: more likely to be carried out when relationship between threatener and victim intimate (eg, threats toward spouse most likely to be carried out, compared with threats toward, eg, political figure); 70% of men who killed their female partner made threats beforehand

Risk factors for violence: dynamic — can be changed by intervention; include living setting, access to weapons, and acute psychosis; static — age; sex; history of violence; antisocial traits

Violence prevention plan: list each dynamic risk factor, intervention, and status (eg, individual with alcohol abuse disorder not receptive to treatment)

Example: man with history of 4 violent events (fired gun at mother 3 times; on one occasion, assaulted police officer who attempted to protect perpetrator’s mother); on each occasion, man under influence of alcohol and cocaine and had been noncompliant with antipsychotic agents for prescribed paranoid schizophrenia; dynamic risk factors and interventions — acute psychosis (intervention, long-acting antipsychotic drugs); substance abuse (intervention, treatment program; drug screening can be made condition of probation); living with mother (intervention, relocation outside of mother’s home; men with psychosis more likely to assault or kill own mother than any other individual); access to guns should be barred

Tarasoff duty: duty of clinician to take reasonable steps to protect intended victim from foreseeable violence of patient

Risk factors: young age (eg, 20-30 yr); male sex; persecutory delusions; hallucinations or powerful thoughts; access to weapon; history of violence; substance abuse; acting out as planned; feeling ready to die, or undeterred by expectation of dying, while carrying out violence; separation from spouse (strong support system reduces suicide and homicide); lack of insight (correlated with noncompliance with medications) typical of schizophrenics who commit violence; proximity to victim; veteran (more likely to succeed in killing with lethal weapon than nonveteran); impulsivity; anger; lack of empathy; history of violence; egosyntonic (“comfortable” with violence as method of resolving problems); work-related provocations; persistent thoughts

Interventions: alcohol treatment program; removal of weapons; conference with coworkers and supervisor; marital therapy; management of impulsivity

Conclusions: consider obtaining formal history of violence; building crescendo of paranoid fear concerning; writing formal violence risk plan important

Questions and answers: reasons for underestimation of risk for violence in women — in general society, men 10 times more violent than women; risk for violence increases 5-fold among men with schizophrenia but 22-fold among women with schizophrenia; increase in risk for violence among psychotic women greater than that among psychotic men; risk factors — past history of violence more predictive of future violence than substance abuse or psychopathy; duty to warn — assess whether individual likely to carry out threat on identifiable victim; assessment instruments (eg, HCR-20) do not apply; actuarial and structured instruments apply to violence in general; with specific threat toward individual, duty to take reasonable steps to protect applies; Capgras delusion — belief that, eg, friend, spouse, has been replaced by imposter; increases risk for violence (but not to extent seen in individuals with persecutory delusions); terminating relationship with patient — allowed for physicians in private practice (agencies may have different rules); patient must be provided with 30 days notice and referral information

Readings

Bucci S et al: Predicting compliance with command hallucinations: anger, impulsivity and appraisals of voices’ power and intent. Schizophr Res. 2013 Jun;147(1):163-8; Da Silva S et al: 2D:4D digit ratio predicts delay of gratification in preschoolers. PLoS One. 2014 Dec 9;9(12):e114394; Edlinger M et al: Risk of violence of inpatients with severe mental illness — do patients with schizophrenia pose harm to others? Psychiatry Res. 2014 Nov 30;219(3):450-6; Flynn S et al: Serious violence by people with mental illness: national clinical survey. J Interpers Violence. 2014 May;29(8):1438-58; Glied S, Frank RG: Mental illness and violence: lessons from the evidence. Am J Public Health. 2014 Feb;104(2):e5-6; Hermes ED et al: Minimum clinically important difference in the Positive and Negative Syndrome Scale with data from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE). J Clin Psychiatry. 2012 Apr;73(4):526-32; Hodgins S: Among untreated violent offenders with schizophrenia, persecutory delusions are associated with violent recidivism. Evid Based Ment Health. 2014 Aug;17(3):75; Ranney ML et al: Gender-specific research on mental illness in the emergency department: current knowledge and future directions. Acad Emerg Med. 2014 Dec;21(12):1395-402; Ten Have M et al: The association between common mental disorders and violence: to what extent is it influenced by prior victimization, negative life events and low levels of social support? Psychol Med. 2014 May;44(7):1485-98.

Disclosures

For this lecture, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Resnick was recorded in Fort Lauderdale, FL, at the American Academy of Psychiatry and the Law’s Forensic Psychiatry Review Course, presented October 19-21, 2015. For information about upcoming meetings from the American Academy of Psychiatry and the Law, please visit www.aapl.org/aapl-meetings.htm. The Audio Digest Foundation thanks Dr. Resnick and the American Academy of Psychiatry and the Law for their cooperation in the production of this lecture.

CME/CE INFO

Accreditation:

Lecture ID:

PG050601

Qualifies for:

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.