Practical Risk Assessment - David Kan, M.D.

Practical Risk Assessment - David Kan, M.D.

Violence Risk Assessment Presented 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 hospital Civilly committed at end of sentence

Left in prison hospital because state hospital didnt 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 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. 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 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 Violence Risk Assessment "When a therapist determinesthat 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 Violence Risk Assessment What is the best predictor of violence? Criminal Record b. Presence of Intoxication c. Past History of Violence d. Perception of Self as a Victim e.

All of the Above f. None of the Above Correct Answer: F. None of the Above Violence is impossible to predict. However, RISK can be assessed. a. 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 Violence Risk Assessment In assessment, psychiatrists look for mental disorders Connection is debatable Most violence is committed by

people WITHOUT psychiatric diagnosis Violence Risk Assessment Violence = Specific Individual + Specific Situation Violence Risk Assessment Past History is the best predictor

What is the most violent thing theyve 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) Violence Risk Assessment Specific threat towards an

individual is another serious risk factor Specific threat + Past History exponentially increases risk. Violence Risk Assessment People at high risk do not always commit violent acts People who commit violent acts may not be considered high risk

Violence Risk Assessment Psychiatrists accurately predict longterm 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) 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 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% 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 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 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 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 Violence Risk Assessment Drugs and Alcohol

Psychiatric patients 5x increased rate Non-patients, 3x increased rate Steadman et al., 1998 Violence by peopl d/cd 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 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. Violence Risk Assessment Vietnam Combat Vets and PTSD VN combat vets with PTSD > prevalence of violent

behavior than VN vets without PTSD Lasko et al. Compr Psychiatry 1994 Sep-Oct;35(5):373-81 Hospitalized combat vets with PTSD > than nonhospitalized 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 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 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 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 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

Violence Risk Assessment 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 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 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): 164169 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

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 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) Violence Risk Assessment Affect Angry and lacking empathy Perception as victim

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 Violence Risk Assessment Interventions Pharmacotherapy

Substance Abuse treatment Psychosocial intervention Removal of available weapons Increased supervision 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 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. 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?

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. Assessment: Records

Review Existing medical records Past medical records How do I fulfill this duty? 1. Document informed consent on the limits of privacy 2. Render & Document a violence risk assessment 3. Seek consultation 4. Develop a plan 5. Implement treatment plan INCLUDING

FOLLOW-UP 6. Document the facts and your reasoning Develop a Plan . . . Incapacitation: -hospitalizing the patient -transferring inpatients to more secure ward -sedating the patient into an oblivious stupor Develop a Plan . . . Target Hardening: -warning the victim and

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

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

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. 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 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 Risk Assessment Summary Assessment does not = prediction Consider Risk Factors Risk assessment is like predicting weather Better for proximal events Needs to be updated frequently Practical Risk Assessment

Question s and Comment s Psychopathy Checklist 2 factors: Interpersonal/Affective and Impulsive/Deviant lifestyle 1.Glibness/superficial charm - I/A 2.Grandiose sense of self-worth - I/A 3.Need for stimulation/proneness to

boredom - Imp/Dev 4.Pathological lying - I/A 5.Conning/manipulative - I/A 6.Lack of remorse or guilt - I/A 7.Shallow affect - I/A 8.Callous/lack of empathy - I/A 9.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/Dev 15.Irresponsibility - Imp/Dev 16.Failure to accept responsibility for own actions - I/A 17.Many short-term relationships ------18.Juvenile delinquency - Imp/Dev 19.Revocation of conditional release - Imp/Dev 20.Criminal versatility --------

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