Psychiatric Prediction of Violence

Introduction

Demographics of violence: people most likely to commit violence (especially street type) are most likely to be males in the late teens to early 20’s, of lower social class and IQ, have a history of substance abuse, less education as well as residential and employment instability.

Rank order of diagnosis based on self report survey of violent behavior in 1990(2%-35%): No disorder, OCD, Mania or bipolar disorder Panic disorder, Major depression, Schizophrenia, Cannabis abuse, EtOH abuse, Other drug abuse.

Components of Dangerousness:

Magnitude

Likelihood

Imminence

Frequency

Categories of violence-prone individuals

(1) Psychosis: In society, of all individuals who qualify for a diagnosis, Paranoid schizophrenics are the most violent due to their access to weapons and ability to plan and retention of some reality testing.

Paranoids overall are more likely to be violent, especially toward a person seen as persecuting the patient.

If with delusions, then likely to be well planned along the lines of the delusion.
Of the criminally insane, the paranoid are the most likely to commit murder.

In hospitalized patients, non-paranoid patients are more likely to be violent.

Command hallucinations compliance: is up to 80%, Ý when related to delusion or is a familiar voice, ß if dangerous.

Persecutory delusions are most likely to be acted upon.

Risk of violence if:

(1) patient fears imminent harm
(2) patient experiences external forces as overriding his personal control; Particularly delusions that these forces are dominating patient’s mind or thoughts are being put into patient’s head or people wish patient harm

(3) patient has systematized delusions involving anger fear

2/3 of Schizophrenics have hallucinations, but most are not command, and only the above type are dangerous.

Non-aggressive delusions: feeling dead, dissolved, not existing, thought broadcasting or that thought are being taken.

(2) Depression: Violence results if patient acts out in despair; Parents, especially mothers of young children take kid with them

Fathers will take the whole family.

(3) Mania: Exhibit high percentage of assaultive or threatening behavior but serious violence is rare.

much less criminality than schizophrenics due to a greater degree of impulse control.

Personality Traits of the violent

Impulsivity, low tolerance for frustration or criticism, recurring anti-social acts, reckless driving, egocentricity, entitlement, superficial relationships, tend to dehumanize others, paroxysmal and episodic quality to the violence

Mental Status Exam: glibness, lack of introspection, tendency to project internal conflict onto the environment.

Combination of low IQ and Anti-Social Personality are very strong predictors of violence

These traits don’t get people committed.

Factors correlated with violence later in life

Brutality sustained by a boy, particularly father. Girls tend to become victims. Cycle is broken with 70-90% of children.

Parental seduction, Truancy, school failures, lower IQ, Adolescent delinquency.

Tattooed persons are more likely to use drugs, be criminal and impulsive.

Arrest for prior assault, ADHD, psychiatric hospitalization prior to age 18.

Triad of enuresis, fire setting and cruelty to animals.

Assessment of risk of future violence: History Taking

Careful assessment of patient’s past use of violence; this is the single best predictor of future violence.

Explain limitations of confidentiality, then ask about: what is most violent act, frequency.

Assess each prior act in terms of source of info and degree of injury.

Obtain collateral information by asking "are you concerned that Mr. X may hurt someone" to victim and patient's family

Look for patterns, especially violence only during psychosis or insult evoked violence.

Has violence been precipitated by threat to patient’s self esteem, "he disrespected me"

Attitudes: are they ego syntonic or distonic (remorse)

Substance abuse of stimulants or EtOH: Mechanism: drugs Þ Disinhibition, Grandiosity, and Paranoia Þ Violence

Does he own a lethal weapon; the only difference between assault and homicide is the lethality of the weapon.

Evaluate criminal and court records: age of first arrest is predictor, by 4 arrests there is 80% chance of 5^th.

Institutional History: >9 Psych admits Ý risk of violence as does having escaped from an institution.

Military Hx: fighting AWOL, drugs, Articles XV’s (misdemeanors), type of discharge

Work Hx: reasons for termination (chronic unemployment or imminent termination may ;lead to mass murder)

Being laid off increases risk of violence by 8X.

Sexual Aggression Hx: ask about childhood experience without using words abused or molested.

86% of serial rapists were sexually abused as children

Current assessment of dangerousness

lack of empathy with anger is strong predictor

Your gut feeling; be careful not to let counter-transference feelings interfere with accurate assessment

Theme of helplessness on the part of the patient

Take all threats seriously and get the details; ask paranoids what they would do if confronted by a perceived persecutor

Appraisal "of perceived intentionality"; ask about a grudge list (revenge fantasies against potential target victims)

Do a careful assessment of future victim

Tarasoff vs. U.C.

If you determine patient present serious threat of violence to another, need to try to protect intended victim from violence. Notify police, victims etc.