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 didn’t want him
Writs were dismissed, transfer requests denied
USSC Holdings:
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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:
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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:
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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:
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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 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
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
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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
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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)
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
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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
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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
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Rates of violence about equivalent
(Lidz et al., 1993)
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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
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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
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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
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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
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Cocaine, amphetamines, and PCP
Disinhibition and paranoia
Cocaine – men commit crime,
women victimized
Violence Risk Assessment
Drugs and Alcohol
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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
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AWOL
Frequent terminations
Laid off 6x more likely to be violent then employed
Violence Risk Assessment
Violence and Mental Illness
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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
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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
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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
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Vets with PTSD avg. 22 violent acts vs 0.2 for nonPTSD
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
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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
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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
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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
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In general, AVH not inherent risk
Certain types increase risk
 Hallucinations that generate negative emotions
 If pts. have not developed coping strategies
 Command Hallucinations
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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
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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
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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
Violence Risk Assessment
Brain Injury
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Aggressive features:
 Trivial triggering stimuli
 Impulsivity
 No clear aim or goals
 Explosive outbursts
 Concern and remorse following episode
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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
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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
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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
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Angry and lacking empathy
Perception as victim
Violence Risk Assessment
Approach
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Distinguish static from dynamic risk factors.
Static
 Demographic and past history
 Unchangeable
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Dynamic
 Access to weapons, psychotic symptoms
 Active substance abuse, living conditions
Violence Risk Assessment
Interventions
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Pharmacotherapy
Substance Abuse treatment
Psychosocial intervention
Removal of available weapons
Increased supervision
Violence Risk Assessment
Approach
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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
Violence Risk Assessment
Actuarial Instruments
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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
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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/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 --------
Risk Assessment Summary
Assessment does not = prediction
Consider Risk Factors
Risk assessment is like predicting
weather
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Better for proximal events
Needs to be updated frequently
Practical Risk Assessment
Questions
and
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