The Dangerous Patient
David Mays, MD, PhD
dvmays@wisc.edu
Predicting Violence
• Risk assessment is a field of inquiry with a
growing literature over the last 20 years.
Predicting violence in potential offenders has
been the “Holy Grail” of forensic psychiatry.
• Unfortunately, mental health professionals are
only a little better than chance at predicting
who will be dangerous.
Actuarial Data
• .Various actuarial instruments have been
developed to try to assess violence risk (VRAG,
LSI-R, HCR-20, etc.) Their accuracy is better
than chance, but not good enough to be of
practical use in a clinical setting.
Data About Dangerousness
• The best data show that patients with the
most serious mental illnesses (schizophrenia,
major depression, and bipolar disorder) are 23x more likely to be assaultive as the general
population. (The lifetime prevalence of
violence among the mentally ill is 16%, vs. 7%
among the general population.)
• People who abuse alcohol and other drugs are
7x more likely to be assaultive.
Rates of Violence
(Fazel S, et al. JAMA May 20, 2009)
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
Gen pop
Schiz
Schiz + AODA
Violent Individuals in the General
Population
General Population
Violent
Nonviolent
Violent Individuals in the Mentally Ill
Population
Mentally Ill
Violent Individuals in the Substance
Abuse Population
Substance Abusers
Violent
Nonviolent
10 Static Risk Factors for Violence
Carlat Psychiatry Report March 2013
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History of violence
Male gender
Late teens, early 20’s
Below average IQ
Low socioeconomic status
Instability in housing or employment
History of property destruction
Substance abuse
Mental illness
Personality disorder (antisocial, borderline)
10 Dynamic Risk Factors for Violence
Carlat Psychiatry Report March 2013
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Intoxication
Withdrawal
Psychotic symptoms
Command hallucinations
Persecutory delusions
Paranoia
Physical agitation
Verbal aggression
Access to weapons
Anger (in response to narcissistic injury)
Screening Military Veterans
(Am J Psych Jul 2014)
• The following are related to risk for
subsequent violence, and are additive, i.e.
combinations of factors have more predictive
power. Subjects were followed for 1 year:
– Financial instability
– Combat experience (witnessing serious injury)
– Alcohol misuse
– History of noncombat violence or arrest for crime
– PTSD + past week irritability
A Risky Profile
• Young adults with severe mental illness, with
trauma and violence in the past, substance
abuse in the present, and no interest in
treatment in the future.
• (In one small study, patient’s own assessment
of their risk of becoming violent was a better
predictor than two other assessment tools.)
Gun Deaths in the USA
1000
12,000
18,000
Suicide
Homcide
Mass Killing
Homicide vs. Suicide
• Homicide rates have decreased by half (9.8 –
4.8/100,000) over the last 20 years. Suicide rates
have remained the same – 12/100,000.
• There are 38,000 suicides per year in the US.
There are 14,000 homicides.
• 32 college students were murdered at Virginia
Tech in 2007. 32 college students died of suicide
last week.
• 90% of suicides are mentally ill. <5% of murderers
are mentally ill.
Mental Illness + Guns = Suicide
• The strongest link between mental illness and
guns is suicide, not homicide.
• Homicide is more an urban phenomenon.
Suicide is more of a rural phenomenon.
• “Means restriction” works for suicide
prevention. Ironically, the strongest resistance
to means restriction (controlling guns) for
suicide is among rural populations. And rural
states have the highest suicide rates.
Gun Homicide and Mental Illness
• Even if we cured all mental illness overnight,
the rate of gun homicide would essentially
remain the same.
What About Mass Shootings?
• Mass shootings involve the killing of multiple
people, followed by the pre-planned suicide of
the shooter(s). Often the victims are strangers.
• More often than not, psychological autopsies
of these killers describe them as having a
mental illness.
• 35 states, including Wisconsin, have increased
mental health funding in an effort to prevent
mass shootings.
The $30 Million Wisconsin Plan to
Reduce Gun Violence
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Crisis Intervention team training
Child psychiatry consultation program
Grants to doctors in under-served areas
Peer-run respite centers
Treatment and diversion
Job placement and support
Mobile Crisis teams
New units at Mendota Mental Health Institute
Can We Identify a Potential Mass
Shooter?
• Possibly, in a few cases. But mass murder is a
multi-determined event with no simple
preventive solution. They are exceptionally
hard to anticipate and avert.
Can We Identify a Potential Mass
Shooter?
• The most likely profile is of a suicidal person
who is angry, paranoid, and delusional, with a
history of prior violence and substance abuse.
Common themes that arise in these
murderers is social persecution, envy, and a
desire for retribution and revenge. They often
seek a theatrical event, so they may videotape
themselves, alert an audience on the internet,
etc.
Anti-Stigma Alert:
• In all studies, mental illness is much weaker
predictor of violence than:
– A history of violence
– Substance abuse
Risk Factors for Violence
• In the early years, parenting factors are the most
important risk factor. For teenagers, peer
relationships are more important. Mental health
problems turn out to be rather poor predictors of
future violence.
• Conduct Disorder: Conduct disorder first appearing
at 6 years old doubles the risk of criminal adult
antisocial behavior (71%), compared to those
children who first develop conduct disorder at 12
years old.
Risk Factors for Violence
• Firearms are the single greatest risk factor. 28% of
families keep guns at home, 39% are unlocked or
loaded or both.
• Alcohol - 40% of all 15-24 year old homicide victims
are intoxicated.
• Bullying/Standby Behavior - 7-16% of schoolchildren
are bullied in any given semester. Bullying is worst in
rural schools. Bullies are 6x more likely to have a
criminal conviction by 24, as well as AODA problems.
Victims experience social and emotional isolation.
Risk Factors for Violence
• Mental illness: up to 60% are diagnosed. Also includes
violent preoccupation, chronic humiliation, grandiosity,
lack of empathy. ADHD is also linked to adult antisocial
personality disorder and substance abuse, although not
as strongly as conduct disorder. When combined with
conduct disorder, ADHD becomes a more ominous
predictor of bad outcome.
• Media: controversial, but especially influential in
vulnerable children
• Families who are dismissive and permissive: too much
privacy, parents are afraid of the child.
Risk Factors for Violence
• Exposure to abuse: 63% of children exposed to
domestic violence don’t do well. Violence is related
to emotional development (hypersensitivity to anger,
difficulties recognizing emotions or complex social
roles, less accurate attention to social cues, less
ability to generate competent solutions to
interpersonal problems), cognitive problems (lower
IQ, poor memory and concentration) and children
who end up blaming themselves for the violence.
Risk Factors for Violence
• Peer relationships: One of the most significant risk
factors for violence is association with peers whose
norms, values and practices are more permissive of
criminal behavior. Alternatively, attachment to
conventional others, involvement in conventional
activities, and belief in the central value system of
society hinders juveniles from engaging in delinquent
behavior.
Subtypes of CD
• Childhood onset
– Presence of 1 criteria before age 10
– Typically boys exhibiting high levels of aggression, may also
be diagnosed as ADHD.
– Problems tend to persist to adulthood (33% APD)
• Adolescent onset
– No criteria met before age 10
– Less aggressive, more normal relationships
– Most behaviors shown in conjunction with peers (e.g. gang
members)
– Less ADHD. Equal gender distribution.
– Much better prognosis
Limited Prosocial
• These youth are less likely to show empathy to
others in distress, although they are capable
of cognitively recognizing distress in others
(unlike some autism).
• They are less sensitive to punishment and
tend to be thrill-seeking and uninhibited.
• These youth are more likely to show both
“instrumental” and “reactive” aggression.
Reactive Aggression
• Reactive aggression is characterized by impulsive
defensive responses to perceived provocation.
Over-reaction to minor threats is also seen.
• Such children may selectively attend to negative
social cues, fail to consider alternative
explanations for behavior, fail to consider
alternative responses, and fail to consider the
consequences.
• Most reactive aggression is associated with
anxiety and depression.
Treatment of Reactive Aggression
• These youth generally are poorly socialized
and have difficulty with emotional
modulation:
– Deal with hostile-attributional biases and
hypervigilance to hostility
– Promote self-control mechanisms
– Work with managing intense anger
– Treat depression and anxiety
Instrumental Aggression
• In instrumental, or predatory, aggression,
violence is used as a means to an end. These
youth often show emotional detachment rather
than emotional dysregulation.
• They do not focus on the negative effects of their
behavior on others and resistant to punishment.
• Instrumental aggression in pre-adolescence
predicts delinquency, violence, disruptive
behavior during mid-adolescence, and criminal
behavior with psychopathy in adults.
• Instrumental aggression is very difficult to treat.
Violence and Mental Illness
• Very few mentally ill are violent, but studies have
demonstrated a small but increased risk of violence
for the mentally ill - notably, substance abuse, cluster
B personality disorders, psychotic disorders.
• Characteristics that are associated with violence:
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Impulse control
Affect regulation
Narcissism
Paranoid personality style
Violence and Mental Illness
• The most seriously violent 5% of psychiatric clients
account for half the violence.
• Violent and criminal acts attributable to mental
illness account for a very small proportion of overall
violence. Gender and age are more powerful
predictors. The mentally ill are more likely to be
victims than perpetrators - 11x higher than nonmentally ill. Their families are more likely to be the
targets than unrelated people in the community.
Schizophrenia – Actuarial Risk Factors
• Past history of violence (forensic release - 50x risk of
homicide)
• Substance abuse
– Risk of homicide is 10x general population
– Male schizophrenic AODA 17x
– Female schizophrenic AODA 80x
• Non-adherence with treatment
• Comorbid antisocial personality
• Homelessness - 40x violent, 60x attempted murder,
25x murder
Schizophrenia – Actuarial Risk Factors
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Paranoid cognitive style
Hostility and irritability
Command hallucinations in some clients
Delusions - persecutory, systematized, focused
on an individual
• The first year after diagnosis
Most Recent Study
Keers et al. Am J Psych March 2014
• In a longitudinal prospective study of 967
British prisoners incarcerated for a violent
offense, it was found that schizophrenia and
delusional disorder were not associated with
violence after release, unless the patients
were untreated. In the untreated group, it
appears that violence was associated with the
emergence of persecutory delusions.
Bipolar Disorder
• 25x general population, 49% lifetime prevalence
• Impulsivity is prominent, even when clients are
asymptomatic.
• Clients are often unpredictable: gregarious one
moment, hostile the next.
• The delusional grandiosity that is often seen in
mass murderers implies bipolar mania more than
schizophrenia. (Flagrant paranoia may likewise be
more the result of a delusional depression than
schizophrenia.)
Substance Abuse
• 12-16x general population
• These disorders have the highest correlates to violence,
more than all other disorders combined
• Impulse control and affect regulation are both impaired by
these disorders.
• Alcohol is involved in most murders. Drinking more than 5
drinks on any occasion increases the likelihood of violence,
either as a perpetrator or victim.
• Alcohol is present in >50% of domestic violence, violent
crimes, sexual assault, child abuse and neglect.
Personality Disorders
• Cluster B (borderline, narcissistic, histrionic, antisocial)
are the highest risk because of impulsivity and affect
dysregulation. Also, narcissistic injury may be an
important factor.
• Clients with antisocial personality disorder will use
violence to intimidate and control other people.
• About 75% of prison inmates meet the criteria of
antisocial personality disorder. Only 33% of these will
be psychopaths. They will have the highest number of
criminal charges per year, the most violent crime, be
responsible for the most violence in the prisons, and
be most likely to recidivate.
Boundaries and Personality Disorders
• Individuals with personality disorders will try various
ways to manipulate the therapist into giving them
what they want. Some therapists may be more
susceptible to trying to nurture a client who appears
needy, leading to boundary violations.
Treatment
• Results for all forms of treatment for APD are generally
dismal. Clients are not usually interested in treatment.
Their dishonesty, sensitivity to power issues, and
constant manipulating make them poor candidates for
therapy.
• There is no evidence for the efficacy of any
medications.
• Other treatments such as milieu, empathy, self-esteem
training, or anger management, are problematic or
have not shown any consistent benefit.
Treatment
• Treatment for borderline personality disorder
is structured psychotherapy.
• No treatments have been carefully studied for
narcissism or histrionic personality.
Organic Brain Disease
• 70% of brain injury clients have aggression and
irritability as symptoms.
• Frontal Lobe Syndrome
• Brief, unplanned, unsustained, ineffectual
• These aggressions are triggered by minor
episodes, no clear aims or goals, explosive,
remorse, long episodes of quiet.
• Epilepsy is rarely a cause of planned aggression.
Dementia
• Dementia invariably involves behavioral
disturbances. These may be categorized as
non-aggressive verbal (complaining,
negativism), non-aggressive non-verbal
(pacing, disrobing), aggressive verbal (threats,
cursing) or aggressive non-verbal (spitting,
kicking, hitting.) The most common
disturbances are apathy (36%), depression
(32%), and aggression (30%.)
Dementia
• The evidence for non-pharmacologic and
pharmacologic interventions is weak. Historically,
antipsychotics have been recommended, but side
effects limit their long-term use. Evidence is poor for
anticonvulsants or antidepressants. Cholinesterase
inhibitors produce conflicting results. Various
behavior therapies and environmental modifications
are promising, but difficult to implement by families
or in most care settings
Protecting Yourself
• Be alert at work, as when you are safely driving a car
• Get hands on training from an expert. Practice
screaming fire or 911
• Anticipate how you will react
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Freeze
Flight
Fight
Fright
Faint
Psychytachia, tunnel vision/auditory exclusion
Responding to
Verbal Aggression
• Hot Threats
• The goal is to talk down the client. Make sure escape route is
available, and client can hear and understand you. Overdose
with agreement. Don’t argue. Remember body buffer zones.
Divide attention by giving choices. Denial is a serious
impediment.
• Cold Threats
• If you feel threatened, it’s a threat. Clients can intimidate by
praise or threats. Share your feelings with the team. Meet
with the client and tell them how you feel, confront
delusions, and go to the police if appropriate. Ignoring
threats invites escalation.
Staying Safe
• Violence due to emotional arousal (anger) is
the most common kind in mental health
settings. It is easy to recognize anger, and
verbal threats are red flags to prepare for
violence. You must de-escalate the situation or
leave.
• When you get up to leave, tell the client what
you are doing so it will not be misinterpreted.
Don’t block the door.
Our Problematic Reactions
• Denial
– Common defense mechanism in response to fear,
even more common in mental health
professionals. (We usually turn down our sense of
alarm in order to do our jobs.)
• Countertransference
– Issues that are not well-integrated and are
aroused by the client’s behavior. The clinician may
act provocatively toward the client, over-control,
or ignore the client’s threats.
Managing a Crisis
MMHI Options Continuum
• Anxiety: client is pacing, ignoring others or
giving them inappropriate attention
– Staff response:
• Open, supportive stance at angle to client (feet apart,
knees slightly bent, open hands at waist length)
• Appropriate personal space with escape route (4-6 feet,
more for paranoid, be careful of geriatric client)
• Listen and paraphrase empathetically and calmly
• Avoid confrontational eye contact
• Find out how you can help
Managing a Crisis
MMHI Options Continuum
• Defensive Stage: client begins to act irrationally,
challenging authority, intimidating, threatening
• Staff response (at least two staff is necessary)
• Ready supportive stance (hands open at chest height)
• Appropriate distance with escape route (10 feet, 21 feet if client has a
weapon)
• Set clear, enforceable limits
• Remain professional - don’t get provoked
• Make sure there is no audience and allow client to vent
• Restate limits when client can listen
• Present positive options first
• If no movement, or client shows pre-attack behavior, disengage to
develop a plan.
Managing a Crisis
MMHI Options Continuum
• Aggressive Stage: client loses control and becomes
violent
• Immediate cues to aggression
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Posture
Manner
Appearance
Voice
Verbal abuse or threats
Impaired cognition
Approach/avoidance
“gut” reaction