Evidence-Based Reviews

Assessing potential for harm: Would your patient injure himself or others?

Current Psychiatry. 2009 July;8(7):24-33

References

1. El-Mallakh RS, Roberts RJ, El-Mallakh RL. Mood disorders. In: Simon RI, Tardiff K, eds. Textbook of violence assessment and management. Arlington, VA: American Psychiatric Publishing, Inc; 2008:86–92.

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3. American Psychiatric Association. Practice guideline for the assessment and treatment of patients with suicidal behaviors. 2nd ed. In: Practice guidelines for the treatment of psychiatric disorders compendium. Arlington, VA: American Psychiatric Publishing, Inc; 2004:835–1027.

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7. Goldstein PJ, Bellucci PA, Spunt BJ, et al. Frequency of cocaine use and violence: a comparison between men and women. In: Scholber S, Schade C, eds. The epidemiology of cocaine use and abuse. Research monograph 110. Rockville, MD: National Institute on Drug Abuse; 1991:113–138.

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She adds that Mr. J now believes his family is working with the FBI to have him placed in a “secret detention camp.” Mr. J’s mother found a loaded pistol in his room and is “scared of what might happen.” During your psychiatric interview, Mr. J appears frightened and paranoid and provides only minimal answers to your questions. He clenches his teeth while staring intently at you.

Evaluating danger to others

There is good reason to be concerned that Mr. J might behave violently, and you likely have sufficient information to hospitalize him. When creating a long-term violence risk prevention plan, divide the concept of dangerousness into 5 components:

magnitude of potential harm
likelihood that harm will occur
imminence of harm
frequency of dangerous behavior
situational variables that promote or protect against aggressive behavior.

Review a patient’s history of violence because this is the single best predictor of future violent behavior.⁴ Criminal and court records are particularly useful in evaluating the person’s history of violence. Table 3 provides sample questions for eliciting information about a person’s history of violence when records are not readily available.

Clinical Point

A history of violence is the best predictor of future violent behavior

A person who has used weapons against others may pose a serious risk of future violence. Ask patients whether they own or have ever owned a weapon. In our experience, the recent movement of a weapon—such as transferring a gun from a closet to a nightstand—is particularly ominous in a paranoid person. The greater the psychotic fear, the more likely a paranoid person is to kill someone he misperceives as a persecutor.

Drugs and alcohol are strongly associated with violent behavior.⁵ Most persons involved in violent crimes are under the influence of alcohol or drugs at the time of their aggression.⁶ Stimulants such as cocaine, crack, amphetamines, and phencyclidine are of special concern. These drugs often are associated with feelings of disinhibition, a sense of power, and paranoia. The violence linked with cocaine use differs by gender: men are more likely to perpetrate violent crimes, whereas women are more likely to be the victims of violence.⁷

Table 3

10 questions to ask patients about a history of violence

What is the most violent thing you have ever done?
What types of violent behavior have you engaged in?
What is your understanding of why this violence occurred?
Who was involved in prior violent incidents?
Have you ever been arrested for any type of violent act?
Have you ever been intoxicated at the time you were violent?
Were you experiencing mental health symptoms when violent?
What is the greatest degree of injury you inflicted on someone else?
What weapons have you used when violent?
Have you ever been a victim of violence?

Mental illness and violence

Studies examining whether individuals with mental illness are more violent than the non-mentally ill have yielded mixed results.^8,9 In a study of civilly committed psychiatric patients released into the community, most mentally ill individuals were not violent.¹⁰ Although researchers noted a weak relationship between mental illness and violence, violent conduct was greater only when the person was experiencing acute psychiatric symptoms. Subsequent research suggests that individuals with schizophrenia may have increased rates of violence even when not experiencing active signs of their illness.¹¹

Psychosis. In paranoid psychotic patients, violence often is well planned and in line with their false beliefs.¹² These patients usually direct the violence at a specific person they perceive as a persecutor. Paranoid individuals often target relatives or friends. In addition, community-dwelling paranoid persons are more likely to be dangerous because they have greater access to weapons than institutionalized patients.¹²

Carefully inquire about hallucinations—particularly auditory ones—to determine whether their presence increases the person’s risk to commit a violent act. Patients with schizophrenia are more likely to be violent if their auditory hallucinations generate negative emotions (anger, anxiety, or sadness) and if the patients have not developed successful coping strategies.¹³ Although most patients ignore violent command hallucinations to harm others, the presence of command hallucinations may increase the likelihood of behaving violently,¹⁴ particularly if:

the voice is familiar to the person,¹⁵ and
the person has delusional beliefs associated with the hallucinations.¹⁶

Depression. Individuals who are depressed may strike out against others in despair. After committing a violent act, a depressed person may attempt suicide. Depression is the most common psychiatric diagnosis in murder-suicides.¹⁷ Patients with mania often engage in assaultive or threatening behavior, but serious physical violence is rare.¹² Patients with mania most commonly exhibit violent behavior when they are restrained or have limits set on their behavior.