Adrienne Saxton, MD Assistant Professor Department of Psychiatry Case Western Reserve University School of Medicine Cleveland, Ohio
Phillip Resnick, MD Forensic Psychiatry Section Editor Current Psychiatry Professor Department of Psychiatry Case Western Reserve University School of Medicine Cleveland, Ohio
Stephen Noffsinger, MD Associate Professor Department of Psychiatry Case Western Reserve University School of Medicine Cleveland, Ohio
Disclosures The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
In their 1999 article, Borum et al30 discussed threat assessment strategies utilized by the U.S. Secret Service and recommended investigating “pathways of ideas and behaviors that may lead to violent action.” Borum et al30 summarized 3 fundamental principles of threat assessment (Table 130).
What to do when violence risk is not due to mental illness
Based on the information in Mr. F’s case scenario, it is likely that his homicidal ideation is not due to mental illness. Despite this, several risk factors for violence are present. Where do we go from here?
Scott and Resnick17 recommend considering the concept of dangerousness as 5 components (Table 217). When this model of dangerousness is applied to Mr. F’s case, one can see that the magnitude of the harm is great because of threatened homicide. With regard to the imminence of the harm, it would help to clarify whether Mr. F plans to kill Ms. S immediately after discharge, or sometime in the next few months. Is his threat contingent on further provocations by Ms. S? Alternatively, does he intend to kill her for past grievances, regardless of further perceived insults?
Next, the frequency of a behavior relates to how often Mr. F has been aggressive in the past. The severity of his past aggression is also important. What is the most violent act he has ever done? Situational factors in this case include Mr. F’s access to weapons, financial problems, housing problems, and access to drugs and alcohol.17 Mr. F should be asked about what situations previously provoked his violent behavior. Consider how similar the present conditions are to past conditions to which Mr. F responded violently.5 The likelihood that a homicide will occur should take into account Mr. F’s risk factors for violence, as well as the seriousness of his intent to cause harm.
