Download Violence Risk Assessment Management Tool Kit

Violence Risk
Assessment & Management
Information Toolkit
Dr Gregory Darryl /
Dr Waldron Gerard
Structure
• Epidemiology of violence and mental illness
• Risk Assessment:
– Clinical
– Actuarial
– Structured clinical
• Risk Management
• Further Study
Epidemiology of
Violence and Mental Illness
Is it this bad?
Crime
• There are various ways of measuring
crime:
• Household survey (e.g. British Crime
Survey)
• Arrest statistics
• Rates of convictions
British Crime Survey
2012/13
http://www.ons.gov.uk/ons/dcp171778_349849.pdf
• 8.0 million crimes in past one year
• c.f. police report 3.7 million offences
• 21.5% chance of being a victim (39.7% in
1995)
BCS- Types of Offences
24%
27%
Violence
Burglary
9%
Vehicle related
theft
Other thefts
Vandalism
25%
15%
Trends in Violent Offences
source: Crime Survey for England and Wales, Office for
National Statistics
BCS- Violent offences
http://www.ons.gov.uk/ons/dcp171778_298904.pdf
• Levels of violent crime estimated by the CSEW showed a
statistically significant decrease of 13%
in the year ending September 2013 compared with the previous
year. This follows on from large
falls seen in the CSEW between 1995 and 2004/05, with current
estimates at less than half the level
seen at the highest level reported, in 1995
• Highest perpetrator group- single men, 16-24 (86% violent
offenders men; 52% aged between 16 and 24)
• Highest victim group- see above
• 2.3% risk of violence (3.8% men, 2.1% women, 11% gp above)
• Men most likely victim violence from stranger (75%)
• Women most likely victim of domestic violence (71%)
• 47% of perpetrators alcohol; 23% drugs
Types of Violent Offences(2011/12)
source:
Focus on: Violent Crime and Sexual
Offences, 2011/12
http://www.ons.gov.uk/ons/dcp171778_298904.pdf
Why drop in crime?
• Various theories e.g.
• Post World War 2 baby boom- large numbers of young
men during 1960s and 1970s who are now older
• Removal of lead from petrol
• Repopulation of inner cities
• Hotspot policing
• Technology, making acquisitive offending harder
• Better trauma care, meaning fewer deaths from violence
• For review see 'The International Crime Drop’, van Dijk,
J et al, Palgrave Macmillan, London, 2012
Is there a link between
psychosis and violence?
Research Base
• Before 1990s there was a lack of evidence
on the link between mental illness and
violence
• During the 1990s and 2000s a large
number of different studies were
undertaken, driven, in part by public
anxiety
Bias
• Studies in this area are difficult. Information biases are
particularly problematic, concerning:
• Psychiatric factors e.g.
• Diagnosis
• Definition of psychiatric patient
• And offending / violence e.g.
• Recording of crime
• Selection bias (are people who are psychotic more likely
to be arrested?)
• Arrest statistics
Types of studies
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Prison Surveys
Cross-Sectional Studies
Cohort studies
Discharge Follow-up
Meta-analysis
Prison Surveys
• Prisons are a good place to look for those
who’ve been violent!
• These were the first studies to look at the
link between violence and mental illness
e.g.
• Maden, Taylor, Brooke et al (1995); Taylor
& Gunn (1984)
Gunn, Maden & Swinton (1991)
• 5% of all convicted male prisoners in
E&W; n=1796
• 45% psychiatric diagnosis
• 90%= substance abuse, PD, sexual
deviance, neurosis
• 2% psychotic
• 3% needed transfer to hospital
Cross-sectional Studies
• Prison surveys gave some information but
looked at an unusual group
• Cross sectional studies aimed to measure
mental illness and criminality at using data
obtained at one moment in time e.g.
• Epidemiological Catchment Area SurveySwanson et al (1990)
Epidemiological Catchment Area
Survey- Swanson et al (1990)
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Method:
10,000 people
3 metropolitan areas in USA
DSM-III diagnosis
Epidemiological Catchment Area
Survey- Swanson et al (1990)
• Measures of violence (1 or more needed in past year):
• “Did you ever hit or throw things at your partner?”
• “Have you ever spanked or hit a child hard enough that
he/she has bruises or had to stay in bed or had to see a
doctor?”
• “Since the age of 18, have you been in more than 1 fight
that came to swapping blows, other than fights with your
partner?”
• “Have you ever used a weapon like a stick, knife or gun
in a fight since you were 18?”
• Have you ever gotten into physical fights while drinking?”
ECA- Results
• Usual demographic correlates of violence e.g.
young socially disadvantaged men had highest
rate of violence
• Rates of violence:
• 2% in those with no disorder
• 8% ‘pure schizophrenia’
• 25% alcoholism + no diagnosis
• 35% alcoholism + another psychiatric diagnosis
ECA- Comments
• No selection bias
• Blunt measure of violence
• Cross-sectional i.e. impossible to answer
questions about causation
Cohort Studies
• Looked at groups of individuals at different
periods of time, often using large case registries
and matching these with arrest or conviction
data e.g. Linquist & Allbeck
• Results gave some indication about causality
• Large numbers of participants but possibility of
selection bias (e.g. doesn’t consider those not
arrested/ convicted, depending on data set
used)
Lindqvist & Allbeck (1990)
• 644 patients with schizophrenia
• All patients discharged from hospital in
Stockholm during 1971
• Followed up to 15 years on police registry
• No difference in overall offending
• 4x higher rate of violent offences among
males with schizophrenia
Follow-up studies
• Concentrated on patients discharged from
psychiatric hospitals e.g.
• Hodgins et al (1992)
• Monahan et al (2002): MacArthur Violence
Risk Assessment Study
Monahan et al (2002): MacArthur
Violence Risk Assessment Study
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Method:
1,130 recently discharged patients
Follow up for 1 year
3 urban centres in USA
Controls- community controls
Comprehensive measure of violenceinterviewed discharge and 10 weekly; subject,
collateral; and official records
Monahan et al (2002): MacArthur
Violence Risk Assessment Study
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Results: rate of violence in first 20 weeksschizophrenia 9%
Bipolar disorder 15%
PD 25%
Substance misuse 29%
PCL-SV (measure of psychopathy) score was
best predictor
• Demographic factors, previous violence
important
Monahan et al (2002): MacArthur
Violence Risk Assessment Study
• Comments:
• Very good measure of violence
• Managed care model in USA- symptoms
remained at discharge?
• Very large proportion of substance misuse
• Risky patients (with delusions?) not
discharged
MacArthur Violence Risk
Assessment Study
• Main findings (not to be taken at face value …)
- Violence is common in mental health populations
- Substance misuse is more important than mental illness
as cause of violence (delusions do not predict higher
rates of violence)
- Psychopathy is a useful predictor of violence in general
mental health populations
- Violence in mental health populations is related to many
of the same factors as in the general population
Meta-analyses
• Putting the results of different studies
together e.g. Fazel at al
Fazel et al (2009)
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Violence: arrests; convictions; self report
Schizophrenia / psychosis v general population
20 studies; 18,400 subjects
OR of being violent in schizophrenia group 4.7
(1 -7) for men & 8.2 (4- 29) for women
• Co-morbid substance use +/- schizophrenia
considerably increased risk
• No difference: Nordic v US; outcome measure
used
Fazel et al (2009)
• Few longitudinal studies found when literature
searched
• Substance abuse & SCZ- “unlikely to be a
simple additive relationship”
• It was noted that over the previous 25 years:
increase SU in schizophrenia but no increase
violence (Wallace et al, 2004)
• Suggested that violence highest in a ‘sub-group:
PD, social problems + schizophrenia’
So, evidence of some link
between psychosis and violence
• Individual patient with schizophrenia likely
to convicted of a violent offence once
every 100 years- (Lindqvist et al 1990)
• Risk of violence in SCZ less than that of
typical 16-24yr old lower social class man(Swanson et al 1990)
Maden, 2004
• But: association between psychotic illness
with PD/SUD and violence in the
community similar magnitude to smoking
and lung cancer (i.e. 20 x increase)
• The population attributable risk attributable
to schizophrenia is small:
• 5.2% (Fazel and Grann, 2006)
• Demographic factors more important than
psychosis
• Risk is highest to family members (60% of
victims family members; 10% strangers)
Overall, violence is unusual in
psychosis
• And needs to be seen in context:
• Patients with schizophrenia have a high risk of victimisation- 1535% suffer violence each year (Choe et al 2008)
• High risk of suicide- 18% of those who commit suicide suffer with
schizophrenia (NCISH, 2013)
http://www.hqip.org.uk/assets/NCAPOP-Library/NCAPOP-201314/NCISHAnnualReport201304July13.pdf
• Podcast: “The National Confidential Inquiry into Suicide and
Homicide by People with Mental Illness” by Professor Louis Appelby
http://www.psychiatrycpd.co.uk/default.aspx?page=16705
Why is there an association
between violence and psychosis?
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Common risk factors for both
Volavka et al (2008) suggest three major groups:
Those who act violently directly as a result of psychotic symptoms
Impulsive aggression due to impaired response inhibition
Aggression due to co-morbid personality disorder (often younger
age of first criminality, association with substance use)
• Individual formulation is key
• Podcast : “Violence and schizophrenia: a realistic look at the risks,
contributing factors and management” by Professor John Gunn
http://www.psychiatrycpd.co.uk/default.aspx?page=2138
Homicides in England and
Wales
What proportion of homicides are perpetrated
by people with mental disorder?
Homicide
• 542 homicides (circa 400 during 1960s)
(1 per 100000)
• 20-50 per year by those who are
considered to be mentally disordered at
the time of the offence
Victims of Homicide (England
and Wales)
Homicide offenders who are
mentally ill
• Family, not strangers, most likely victims
• 7% homicide-suicide (Large et al 2008)
Homicide in 1st episode psychosis:
Nielssen & Large, 2010
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Meta-analysis of 10 studies
38.5% homicides during 1st episode
1.59 per 1000 patients
0.11 per 1000 treated patients
15.5% increase rate in 1st episode patients
RCPsych CPD module link: ‘Psychiatric aspects of
homicide’
http://www.psychiatrycpd.co.uk/learningmodules/psychia
tricaspectsofhomicid.aspx
Fire-setting
• Mostly unrelated to
mental illness
• Highest rate in young
social disadvantaged
men
• Rix, 1994- fire setters
referred for
psychiatric report:
44
Arson & psychosis
Anwar et al, 2009
• Case control study, Sweden, 1690
convictions for arson
• OR in men 22.6 (14.8-34.4)
• OR in women 38.7 (20.4-73.5)
Symptoms of psychosis & violence
• What about the relationship between
specific psychotic symptoms and
violence?
Daniel McNaughten
Daniel McNaughten, 1843
• “The Tories in my native city have compelled me
to do this. They have accused me of crimes of
which I am not guilty; they do everything in their
power to harass and persecute me; in fact, they
wish to murder me”
• Killed Edward Drummond, private secretary to
the Prime Minister, leading to present day test of
legal insanity
Symptoms of psychosis & violence:
delusions
• But not everyone acts on their delusions!:
• Bleuler (1924):
• “They really do nothing to attain their goal:
the Emperor and the Pope manure the
fields; the Queen of Heaven irons the
patients’ shirts or besmears herself and
the table with saliva”
Delusions & violence
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Who acts on delusions?
Wessely et al, 1993
Method:
Retrospectively assessed
Patients admitted to psychiatric hospital
Variety of diagnoses
Actions- self report and informant
Link to delusion rated by expert
Delusions & violence:
Wessely et al 1993
• Results:
• 60% at least 1 delusional action
• 20% 3 or more
Delusions & violence:
Wessely et al 1993
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Most common:
28% not meeting friends
28% not listening to radio
14% hit someone
11% hurt self
Associated with:
Actively seeking evidence (“noticing”);
unhappiness; fear; anxiety
Specific delusional beliefs
• Data from the ECA suggested delusions of passivity and
persecution increased rate of violence x 2 compared to
other psychotic symptoms: ‘Threat control over-ride’
• (MacArthur: no increase. But- 25% of subjects misused
substances e.g. too many violent non-psychotic
subjects)
• Delusional jealousy
• Erotmania (Menzies et al 1995)
• Misidentification, risk especially if involves a family
member (Silva et al 1996)
Affect and delusions
• Association between delusional beliefs of persecution,
being spied upon, conspiracy and violence perhaps
mediated by affective response, specifically anger
• Should the treatment target treatment be anger rather
than the delusion?
• See: Coid, J et al (2013) The Relationship between
Delusions and Violence, JAMA Psychiatry, 70(5) 465-71:
http://www.ncbi.nlm.nih.gov/pubmed/23467760
Threats to Kill
• Relatively common but evidence suggests they
need to be taken seriously:
• Warren et al, 2008• Within 10 years, 44% of those convicted of
making threats to kill convicted of violent
offending; 58% of those with history of
psychiatric contact convicted
• Highest risk associated with young age,
substance use, absence of past criminality
Hallucinations
• Little evidence of a link between hallucinations
and violence
• Beliefs about ‘voices’ perhaps more important
than content e.g. ‘knowing’ the identity of the
voice (Barrowcliff et al, 2006)
• Command hallucinations important in impulsive
individuals? (Junginger et al, 2004)
Assessing Risk of Acting on Auditory
Hallucinations – Factors to Consider
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A detailed account of the content of the hallucinations;
Does the patient believe the voices to be powerful or of higher social status
than the patient?
Does the patient believe that the commands are justified or reasonable?
Does the patient seek engagement with the voices, or want to please the
voices?
Do they report any subjective compulsion, urge or drive to comply?
Can they identify the voices or do they identify with them? Are the voices
perceived as benevolent or malevolent?
What does the patient believe will be the consequences of complying or not
complying?
Have they ever complied with the voices before, either in a dangerous or
nondangerous way?
The Link between Psychosis & Violence
•
It is likely that at least two types of violent offending are seen within those
with psychotic disorders such as SCZ.
Type 1 violence:
- Associated with pre-morbid conditions (including antisocial conduct and
substance abuse prior to the onset of illness)
- Violent offences appear independent to active symptoms within this
group
Type 2 violence:
- Directly associated with the acute psychopathology of the illness (or
disinhibition by virtue of psychosis)
- Violence frequently targeted at caregivers or acquaintances.
• This means that identification of ongoing positive symptoms, particularly
command hallucinations and threat override symptoms will continue to be
important targets of treatment (Swanson et al, 2006, Lieberman, 2006, Appelbaum et al,
2000, Arsenault et al, 2000).
Protective factors
• Negative symptoms (Nilssen, 1988)
• Presence of insight, both into mental
illness and own risk
Other mental disorders &
Violence Risk
Bipolar Disorder & violence
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Fazel et al (2010)
Case control study, Sweden
3700 participants
8.4% violent crime (3.5% population controls; 6.2% in
unaffected full siblings)
• Risk increase : OR 1.3 (1.0- 1.5) in bipolar group; if
compared to unaffected sibs OR 1.1 (0.7-1.6)
• No difference by clinical subgroups
• Early environment; shared familial influences on BPAD,
SU & offending important
Depression
• Mixed data on relationship to violence.
• Some studies showed no association (e.g. Arsenault et
al 2000)
• But, MacArthur, rate of violence at 1 year:
Depression
28.5%
Bipolar
22%
Schizophrenia
14.8%
• High rate of depression in prisoners and patients in
secure hospitals (Fazel, 2012)
Mental disorder in prisoners:
Fazel et al, 2012
Variable
Psychosis, %
(95% CI)
Major depression, %
(95% CI)
Overall
3.7 (3.2-4.1)
11.4 (9.9-12.8)
Male
3.6 (3.1-4.2)
10.2 (8.8- 11.7)
Female
3.9 (2.7- 5.0)
14.1 (10.2-18.1)
Sentenced prisoners
3.7 (3.0- 4.2)
10.5 (8.8- 12.1)
Remand prisoners
(detainees)
3.5 (4.2- 6.8)
12.3 (9.5-15.1)
Low/middle income
5.5 (4.2-6.8)
22.5 (10.6-34.3)
High income
3.5 (3.0-3.9)
10.0 (8.7-11.2)
Gender of inmates
Prisoner status
Country
PD and violenceUK 700 Study
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Moran et al 2003
Method:
Psychosis
N= 708
28% rate of co-morbid pd
10% schizoid; 9% paranoid; 6% impulsive;
6% dissocial
• Violence- self report, carer, case file
UK 700 Study
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32% with comorbid pd ‘physical assault’
15% without pd
Odds Ratio= 1.7
Paranoid, impulsive, dissocial pd significantly associated
Other studies:
MacArthur: rate of violence correlated with PCL-R
scores; 73% rate of violence in 1 year if borderline pd
• Logan et al: women who commit serious acts of violence
4 x more likely to be diagnosed with borderline pd than
those who commit minor violence
Substance Use
• Various ways in which substance use can
lead to violence:
• Intoxication
• Withdrawal
• Acquisition
• Personality change
• Poor treatment compliance
Co-morbidity increases the risk of violence
• 25 x increase violence in patients with schizophrenia
who misuse alcohol; circa 3 x increase without alcohol
(Wallace et al, 2004)
• OR of violence in patients with schizophrenia 2.1 (1.72.7); with substance abuse OR 8.9 (5.4-14.7)- Fazel et
al, 2009
• Homicide- : odds ratios for ‘alcoholism’ of 11 for men and
38 for women- Eroneb et al, 1996
• “Substance abuse disorders represent by far the
strongest correlates of violence among all mental
disorders”- Nestor, 2002
Substance Misuse
Population
% Substance Misuse
General population
17
General psychiatric patients
39
Sentenced prisoners
50-63 (men); 33-39 (women)
Remand prisoners
58 (men); 36 (women)
Forensic patients
40
Learning Disability
• Offending more likely in mild & moderate than severe
LD: 6.5% prisoners IQ less than 70 (Mottram, 2007); 5%
of those attending day centres had contact with criminal
justice system (Holland, 2002)
• Offending more likely in association with family, social &
environmental disadvantage
• Some evidence for increased rates of sexual offending &
fire-raising, including in Aspergers syndrome- Enayati et
al 2008)
PTSD
• Limited evidence of link to violence
• Recent study linked PTSD and risk of
violence in British Army cohort• MacManus D, Dean K, Jones M, et al.
Violent offending by UK military personnel
deployed to Iraq and Afghanistan: a data
linkage cohort study. The Lancet
Dementia
• ‘Low grade’ physical aggression common,
especially in depressed patients Physical
Aggression in Dementia Patients and Its
Relationship to Depression (Lyketsos et al
1999)
• Criminality uncommon
Traumatic Brain Injury & Epilepsy
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Association with violence:
episodic dyscontrol
frontal lobe disinhibition
exacerbation of premorbid ‘antisociality’ (Miller
2010)
• No increase rate of violence in epilepsy, but rare
cases of unusual complex behaviours than can
involve violence
Violence Risk Assessment
Why Worry About Violence Risk
Assessment?
• Critical event in history of modern UK mental health services
• Case of Christopher Clunis – patient with SCZ who killed
Jonathan Zito (stranger) in Dec 1992 (stabbed him in face on
platform in broad daylight at Finsbury Park Tube Station)
• Led to development of CPA framework & mandatory homicide
inquiries
• Tenacity of victim’s widow (Jayne Zito) led to the subsequent
Ritchie Inquiry (1994) - a landmark inquiry which forced
mental health services to better consider violence risk
Clunis Case – Key Findings of Inquiry
• GP never received any correspondence from mental
health services
• Much of what he said was unreliable (e.g. married aged
2 years / schooled at Eton) – but no attempts to check
facts
• No attempts by services to involve family (who were
reportedly caring and supportive) even when detained
under MHA
• Often described as having drug-induced psychosis – but
no evidence of major drug use aside from his subjective
claims
Clunis Case – Key Findings of Inquiry
• Label of Personality Disorder also often applied – but seemingly had
normal personality prior to onset of Schizophrenia
• Discharged from hospital or evicted from hostels due to behavioural
problems related to his mental illness (but labelled otherwise)
• Did well when on regular depot injections – did badly when not
• Committed many violent offences in 4 years prior to the homicide
but not convicted
• Growing history of violence often not mentioned in reports
• Not homeless at first contact with mental health services – later
became homeless due to deteriorating mental state and failure of
services to help him
Case Against Violence Risk
Assessment
• Old fashioned fictional ethical argument – doctors duty to relieve
suffering of patient (assessment of risk to others low down priority
list)
• Can get you into trouble – e.g. case of Professor Roy Meadow –
struck off by GMC (later reversed) after giving inaccurate expert
evidence in Court that led to wrongful conviction of a woman for
killing her children
• Impossible task – “I know that half of my patients don’t need to be
here – unfortunately I don’t know which half …” (former Broadmoor
Medical Superintendent) – this view suggests that any violence by
patients occurs at random and cannot be predicted – hence get on
with trying to relieve suffering
Case Against Violence Risk
Assessment
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Capacity – some suggest this should be the focus instead
But …
Mentally ill may be considered to retain Capacity even when obviously
mentally unwell (e.g. despite delusions, they may be viewed as being able
to retain information about the proposed treatment / to be able to weigh
up pros and cons / communicate their view effectively)
We are not that experienced at assessing Capacity – and clinicians may
disagree
Capacity fluctuates over time (SCZ is a chronic fluctuating condition – with
mental state sometimes changing day-to-day or even by the hour)
Does Capacity serve interest of professionals more than patients at times
(e.g. “justifies” allowing a difficult patient to self-discharge – even when they
will inevitably stop their medication and relapse and put others at potential
risk
Case for Violence Risk Assessment
• Psychiatrists arguably in unique position when it comes
to dealing with risks to others
• SARS analogy (2003) – state had powers to detain
individuals who might spread the disease – Toronto
almost completely isolated for a period of time –
illustrates low tolerance of risk to others associated with
medical conditions – BSE in UK another example –
Ebola a very topical example (September 2014) – also
smoking now banned in public places in many countries
(due to potential harm to others)
Case for Violence Risk Assessment
• Assuming similar principles should apply to mental health (parity
argument) then if violence is occasionally caused by mental illness,
then mental health services must take that seriously
• Tarasoff case (1976) – Californian therapist deemed negligent for
failing to pass on information when they became aware of specific
risk to a 3rd party – Court concluded there was a duty to warn in
these circumstances overriding normal duty of confidentiality
• Most of us working in adult mental health know this of course – e.g.
we have experience of using MHA to detain patients where there is
risk to others or self
Case for Violence Risk Assessment
• Epidemiology – for many years (until 1980s)
traditional teaching was that there was NO link
between mental disorder and violence –- there is
now a huge literature on violence and mental
disorder (see earlier slides)
Case for Violence Risk Assessment
• Public expectations – we have no choice - far greater scrutiny on
doctors since scandals such as heart surgery death rates for
children in Bristol /Alder Hey Hospital organ retention / murders by
Harold Shipman (GP)
• Likewise – since high-profile homicide inquiries from 1990s onwards
(the tendency to explicitly name professionals in inquiry reports has
shifted over time – with professionals now typically more
anonymised – and with more of a focus on Root Cause Analysis as
opposed to targeting blame)
• Trusts have no choice – could face lawsuits and huge financial
penalties for perceived failings of care
• Good news – Structured Professional Judgment (SPJ) risk
assessment tools (e.g. HCR-20) are (arguably) user-friendly and
make sense to most interested professionals
Clinical Risk Assessment
Can Clinicians Predict Violence?
• Baxstrom case – Johnnie Baxstrom was sent to prison in
1959 after being convicted of assault – later diagnosed
as mentally ill and transferred to New York State
Hospital for the criminally insane – when sentence
expired in 1961 kept in hospital as considered to still be
mentally ill and dangerous – petitioned the Supreme
Court who ordered his release in 1966 – Court’s decision
based upon his constitutional rights – New York State
subsequently realised that 966 other detained patients
could potentially petition the Supreme Court and win on
the same grounds
Baxstrom Case
• Decision taken by New York State to transfer all 967 patients to civil
mental hospitals within the space of a few months
• Steadman and colleagues (1972, 1974) followed up the Baxstrom
patients for 4 years and found only 16 convictions (involving 9
patients) – only 2 were for felonies (one for assault / one for robbery)
– hence the secure hospitals appear to have been over-cautious in
previously recommending ongoing detention
• However, half of the patient group remained in hospital throughout
the 4 year follow-up period which is likely to have contributed to the
low rate of serious violence – also despite the low level of
convictions, 1 in 5 of the patients did act violently in this period (but
were not charged)
How Do We Identify High Risk
Patients?
• If you look at patients with SCZ who are violent, they
look more like a group of violent offenders than a group
of patients with SCZ who are not violent
• However, still need to explain increase in violent
behaviour in patients with SCZ
• Likely to be difference in vulnerability – those who will
develop SCZ more vulnerable during development to
adverse influences of neglect, abuse, educational failure,
substance misuse, etc
Static & Dynamic Risk Factors
• Static Risk Factors – e.g. male sex / age at first violent
offence / previous violence / history of conduct disorder /
early maladjustment / poor socio-economic background /
employment problems / relationship problems / diagnosis
of major mental illness / diagnosis of PD / history of
substance misuse
• Dynamic Risk Factors – e.g. active psychotic symptoms /
poor insight / impulsivity / negative attitudes (e.g. procriminal views) / active substance misuse
Static Risk Factors
• Factors that usually cannot be altered by
intervention
• Provide estimate of long term likelihood of
violent behaviour
• However, some static factors can be
dynamic factors and hence target for
interventions too (e.g. substance misuse)
Static Risk Factors
• Young males – unemployed – from low socio-economic
backgrounds – consistently over-represented in both
psychiatric and non-psychiatric violent populations
• Exposure to adverse childhood experiences &
attachment disruption – can lead to:
- Inability to relate to people appropriately (e.g. more likely
to react with anger or aggression)
- Later psychopathology
- In some individuals – development of mental disorders
and/or criminality
Conduct Disorder
• Men and Women with severe mental illness who
have history of conduct disorder – increased risk
for aggressive behaviour and violent crime
(Hodgins 2008 / Swanson 2008)
• Evidence that early conduct disorder (<15 years)
associated with later development of mental
illness including SCZ (Kim-Cohen 2003)
Previous Violence
• Remains one of the most powerful indicators of future violence
• The following need to be considered:
- Types of victims
- Environmental & Contextual issues
- Frequency of previous violence
- Exposure to or development of violence at young age
• Hence for previous violent offences, consider:
- The context
- The severity
- Possible contributing factors
Static Factors
• Issues to bear in mind:
- Generally cannot be the target for treatment
and therefore are considered less useful in
identifying clinical management strategies for
the future
- May contribute to the stigmatisation of
patients and may be (mis)used to reject
patients from treatment.
Dynamic Factors
• Dynamic variables, in contrast, are subject to change
over time and unlike static factors, can be a target for
treatment in clinical practice. They include:
•
•
•
•
•
•
Active psychotic symptoms
Substance abuse
Insight
Anger (impulsivity)
Social circumstances
Personality traits (less easy to modify of course)
Unstructured Clinical
Assessment
• The traditional clinical approach ideally involves
gathering information from a number of sources under
headings such as:
•
• Family History / Personal history / Substance Misuse
History / Forensic History / Past Medical History / Past
Psychiatric History / Usual (Pre-Morbid) Personality /
Mental State Examination
• i.e. taking a good quality history
Taking a Better Forensic History
• Traditional teaching – any charges or convictions ? (tip of the
iceberg …)
• Suggested approach (ideal – and may not be so doable for busy
Duty Doctor in A&E with lots of other patients to see):
• Charges / convictions – always ask about the actual context (i.e. tell
me what happened) - e.g. a patient who reported conviction for
Common Assault said he battered his step-father with a baseball bat
causing a fractured skull, but plea bargaining and witness
intimidation (he came from a notorious criminal family) watered
down the charge) – also ask about the sentence (e.g. if a very long
custodial sentence, their account of what happened might be
dubious)
Taking a Better Forensic History
• “Have you ever physically harmed anyone (the flip side
of asking if there is any history of DSH or suicide
attempts) – “what is the worst thing you have ever done
to someone ?” “why did you do it?”
• “Have you ever carried or used weapons?”
• “Have you ever set fires deliberately?”
• “have you ever been charged or convicted or accused of
a sexual offence?”
• “do you have any interest in the Occult, Nazism or Far
Right Organisations?”
Unstructured Clinical
Assessment
• Gunn’s framework for clinical assessment:
(1993)
•
•
•
•
•
•
•
Detailed Life History
Substance Abuse
Psychosexual Assessment
Description of previous offending/antisocial behaviour
Psychological assessments
Mental State Examination
Attitude to Treatment/Insight
Unstructured Clinical
Assessment
• The information is gathered incorporating detailed
descriptions of past violent episodes (anamnestic analyses),
such as:
- The context of the offence
- Its severity
- The nature of possible contributing factors e.g. mental
state, substance use, social support and compliance and
engagement with services in the past.
• The skilled clinician will weigh up the personal and situational
factors which may have contributed to prior offending and the
likelihood of such interactions occurring in the future.
Unstructured Clinical
Assessment
• Disadvantages of UCA:
-
No evidence base
Reliance on charismatic authority
Difficult to challenge or defend
Low reliability
Low validity
Susceptible to counter-transference
Susceptible to bias and prejudice (e.g. unreliable reliance on
anecdotes or personally remembered examples – although
sometimes such examples may lead to an accurate diagnosis or
view of risk)
Structured Risk Assessment
100
Actuarial Risk Assessment
101
Structured ApproachesActuarial Risk Assessment
• Actuarial risk assessment: the use of group data,
usually to assign a numerical risk to a group of
patients or to a patient who is a member of the
group
• Atheoretical- based on observed associations
with no attempt to understand cause
• Therefore ignore context, idiosyncratic/specifics
of patient
• But can identify high risk groups
Actuarial Risk Assessment
•
Actuarial risk assessment tools use statistical algorithms to estimate the
probability that a person will engage in violence in the future. They are
based on the same principles that apply to insurance policy evaluators.
•
During assessments with these tools, specific historical risk factors are
explored systematically.
•
Based on the presence or absence of these risk factors, an estimated
probability of risk of violence is given at the end.
Actuarial Risk Assessment
• The benefit of actuarial tools is that they can assist in highlighting a
number of background factors which can be used clinically as a
checklist for evaluating risk.
• This is similar to risk factors which are routinely assessed in those at
risk of cardiac illness (such as diabetes, smoking, family history,
high cholesterol). They can, therefore, help to identify high risk
groups.
• These tools can also be of use in assisting managerial decisions, for
example in the efficient allocation of resources to certain high risk
populations.
Actuarial Risk Assessment
• Consistent factors identified by these tools
include:
-
young age
male sex
history of substance abuse
presence of personality disorder
history of offending
Actuarial Risk Assessment Limitations
• Despite the benefits of using these instruments, they are
developed on specific samples, constituted in particular
places at particular times, and overlook uncommon but
critical factors.
• For example, morbid jealousy is a clinical variable
associated with an extremely high risk of violence but is
relatively uncommon, therefore it would not be identified
as a risk factor using these tools.
Actuarial Risk Assessment Limitations
• In addition, as they do not focus on potential modifiable
factors, they are less clinically useful when attempting to
develop strategies to facilitate management of risk.
• Also, an inventory of static variables alone does not
provide a clear picture of risk because these factors will
never change. However, the probability of the person's
risk can change with a wide variety of variables not
considered in the assessment tool.
Actuarial Risk Assessment Limitations
• Recent debate has highlighted that the majority of actuarial tools
currently available are based on data derived from relatively small
sample sizes. This significantly limits their generalisability and
introduces very large margins of error in risk estimates made from
test scores derived from these tools.
• In addition, because serious violence within populations with mental
illness such as schizophrenia remains a relatively rare event, this
makes prediction at an individual level prone to significant error.
• A recent assessment of precision of individual estimates in two
actuarial tools, VRAG and Static 99, confirmed that both tools could
not predict outcome at an individual level evidenced by large
margins of error (Hart et al, 2007).
Some Examples of Actuarial
Risk Assessment Tools
• VRAG
• PCL-R (PCL-SV)
• ICT
PCL-SV
•
•
•
•
•
•
•
•
•
•
•
•
Superficial
Grandiose
Manipulative
Lacks remorse
Lacks empathy
Does not accept responsibility
Impulsive
Poor behavioural controls
Lacks goals
Irresponsible
Adolescent antisocial behaviour
Adult antisocial behaviour
VRAG
•
•
•
•
•
•
•
•
•
•
•
•
PCL-SV score
Early school maladjustment
PD
Age at index offence
Lived with both parents to age 16
Failure on previous conditional discharge
Non-violent offence score
Marital status
Schizophrenia
Victim injury during index offence
Alcohol misuse
Female victim
Structured Clinical
Risk Assessment
112
Structured Professional
Judgement
• SPJ stands for ‘ Structured Professional Judgment’
approach. This is currently the most widely used
approach.
• It relies on known risk factors based on empirical
research and clinical practice
• It also relies on clinical judgement – but it structures this
• At it’s core is ‘formulation’ – i.e. understanding why
someone poses a specific risk (as opposed to simply
‘predicting’ that they do)
• The HCR-20 is one such example
What is the HCR-20?
• An organising framework to support decision
making about an individual’s risk of violence
• Conceptual framework that
Prompts understanding of any past violence
Helps to describe the future risk of violence
that an individual potentially poses to others
Attempts to describe what that violence might
look like
Aims to facilitate strategies for reducing that
risk
Cont.
• Based on empirically and clinically
supported risk factors - a shift towards
integrating research and clinical practice
• Professional guidelines, an aide memoire
(not ‘just’ a checklist, not a structured
interview)
• A structure that supports, rather than
replaces, clinical judgement
Based on some assumptions…
• Violence as a Choice: The proximal cause of
violence is a ‘decision’ to act violently
– This decision is influenced by a host of
neurobiological, psychological, and social factors
• All Violence is ‘Functional’
– Distance/safety, justice/retribution, gratification/gain,
agency/status, expression/communication,
compliance/control, excitement/stimulation
• There is no single adequate general ‘theory’ of
violence
• However, having a case specific theory (a
formulation!) is helpful
Not a panacea!
•
•
•
•
•
•
•
•
Needs training
Takes time and some experience
Is not useful for other outcomes e.g. suicide
Has one item which requires a PCL-V− hence needs a psychologist
or extra training to complete this item
May mislead clinicians into thinking HCR-20 = risk assessment,
rather than it being only a part of the process.
Potential for bias when completed by, for example, a treating
clinician
Misses some rarer but important risk factors such as history of
threats to harm/kill
But- can be helpful for ‘risky’ cases
Why use the HCR-20?
•
•
•
•
•
It has acceptable reliability
It has acceptable validity
It offers ‘value-add’
It’s clinically meaningful to use
It allows room for recording changes in
risk
• It can be used with men and women
HCR-20
HISTORICAL FACTORS
CLINICAL FACTORS
RISK MANAGEMENT
FACTORS
History of Problems with… Recent Problems with… Future problems
with…
H1 Violence
C1 Insight
H2 Other Antisocial
Behaviour
H3 Relationship
H4 Employment
H5 Substance use
H6 Major mental disorder
H7 Personality disorder
H8 Traumatic Experiences
H9 Violent Attitudes
H10 Treatment/
Supervision response
C2 Violent ideation or
intent
C3 Symptoms of major
mental disorder
C4 Instability
C5 Treatment/
Supervision
response
R1 Professional
services
R2 Living situation
R3 Personal support
R4 Treatment/
supervision
response
R5 Stress or coping
Conceptual Basis of the HCR-20
v3 – Risk Factors
Violence Risk
Historical ‘H items’
Past
Documented
(10 items)
Clinical ‘C items’
Present
Observed; 1-6 months
(5 items)
Risk Management
‘R items’
Future
Speculative/Projected
(5 items)
Conceptual Basis of the HCR-20
v3 – The Process
Risk Factors
Risk Formulations
Making Meaning
Risk Management
Risk Scenarios
Historical Factors
• Past aspects of the individual’s behaviour or experience
• Reflect psychosocial adjustment problems, as well as
history of antisocial behavior and violence
• Factors have strong empirical support as violence risk
factors
• Relatively fixed risk markers for violence
• But could change for the worse (or better?)
• ….so still need to be reviewed and updated
Clinical Factors
• Refers to the individual’s recent / current level of
functioning (consider last 6 months)
• Constructs that are, in theory, dynamic /
changeable and therefore responsive to
interventions and management strategies
• … because of this, clinical items need to be
assessed/updated on regular basis
Risk Management Factors
•
Refers to speculative/future factors
•
Decide on institutional or community setting
•
Consider the individual’s future situation and environment (whether in the
institution or community) and his/her likely adjustment to this and
implications for risk
•
Includes aspects of discharge planning, treatment, relational aspects of risk
management and the individual’s likely coping
•
Relevant for devising management and treatment plans – and for
assessing them
•
Changeable factors, therefore potentially amenable to
management/treatment and must be reviewed regularly
Formulation
• The key to risk assessment and the end-point of
the HCR-20
• ‘A hypothesis about the causes, precipitants and
maintaining influences of a person's
psychological, interpersonal and behavioural
problems’
• Needs to include both risk and protective factors
• Helps transparency & can be shared with patient
e.g.
•
•
‘Mr A is 23 years old and suffers with schizophrenia. He holds persecutory
type delusional ideas focussed on his mother and experiences distressing
auditory hallucinations which he believes to be his mother. He witnessed
violence as a child, seeing his father beat his mother. He was emotionally
neglected. He drinks heavily; in the past, when intoxicated he has
assaulted others. He is without employment but is in a stable relationship
with a partner in whom he can confide. His past violence includes an
assault on his mother when at secondary school, during an argument over
his use of cannabis…..
He likely poses a significant risk of violence to his mother when acutely
psychotic. The risk seems likely to be of punching and kicking, rather than
more serious violence. This risk will be increased at times when he is
intoxicated and could be reduced if contact with his mother takes place at
her house during the day….”
All Violence is ‘Functional’
•
•
•
•
•
•
•
Distance/safety
Justice/retribution
Gratification/gain
Agency/status
Expression/demonstration/communication
Compliance/control
Excitement/stimulation
• Understanding the function is key for
‘formulation’ and risk assessment!
Risk Management
128
Homicide Inquiries
• In 1994, the UK Government responded to the
publication of the Inquiry into the care and treatment of
Christopher Clunis by making it mandatory for health
services to hold an independent inquiry into all cases of
homicide by a patient who had been in recent contact
with specialist mental health services
• Most inquiry panels chaired by a Judge or senior lawyer,
along with a Consultant Psychiatrist and a third member
typically from Social Work or Nursing background
• Unpopular with clinicians from the outset and became
more unpopular over time
Homicide Inquiries
• Criticisms:
- Reliance on wisdom of hindsight
- Over-emphasis on individual rather than systemic
explanations
- Variable standards of reports and poor quality control
- Cost (very expensive)
- Highly stressful (for clinicians – also for some panel
members although sympathy for them may be limited …)
A Different Approach
• The UK National Confidential Inquiry into Suicide &
Homicide by People with Mental Illness (NCISH) was
established in 1996 – in an attempt to overcome some of
the problems associated with individual inquiries
• Particular strength is that it begins with a comprehensive
sample of all homicides in the country, so that the
findings on mental disorder are better placed in context
• Main output consists of reports designed to improve
clinical practice
12 Points to a Safer Service
(Appleby et al 2001)
1.
2.
3.
4.
5.
6.
Staff should receive training in risk management every 3 years
All patients with severe mental illness and a history of self-harm or
violence should receive the most intense level of care
Individual care plans should specify action to be taken if the patient
fails to attend or to comply with treatment
There should be prompt access to patients in crisis and for their
families
Assertive Outreach Teams should be used to prevent loss of
contact with vulnerable and high-risk patients
Atypical antipsychotic medication should be available to all
patients with severe mental illness who are non-compliant with
‘typical’ drugs because of side effects
12 Points to a Safer Service
(Appleby et al 2001)
7. There should be a strategy for dual diagnosis patients covering training on
the management of substance misuse, joint working with substance misuse
services, and staff with specific responsibility to develop the local service
8. Inpatient wards should remove or cover all likely ligature points
9. There should be follow-up within 7 days of discharge from hospital for
everyone with severe mental illness or a history of self-harm in the previous 3
months
10. Patients with a history of self-harm in the last 3 months should receive
supplies medication covering no more than 2 weeks
11. There should be local arrangements for sharing information with criminal
justice agencies
12. There should be a policy of post-incident multidisciplinary case review and
the information should be given to families of involved patients
Managing Risk - Interventions
•
As causes of violence are multi-factorial, treatment must be multifaceted and
targeting resources to those most in need, addressing the specific factors identified
by assessment.
•
Many high risk patients will be young, substance misusing, rejecting of treatment and
disorganised.
•
Extended hospital admissions in these cases may assist in ensuring an adequate
period of assessment to clarify the diagnosis.
•
They will also ensure a sufficient drug-free period to allow consideration of
interventions in reducing substance use
•
Insight should be addressed and attempts made to improve both the patient's and
family’s understanding of the impact of drug use and non-compliance with
medication.
General Principles of
Management
• In those cases considered at high risk of relapse
and consequent risk of violence, consideration
should be made of:
- Depot medication (or Clozapine)
- Community Treatment Orders (if not on
Section 37/41)
- Assertive Outreach Teams
- Supervised administration of medication
General Principles of
Management
• External motivators sometimes prove more realistic for
retaining high-risk patients in treatment. In such cases,
involvement of other agencies such as the following may
be more practical in ensuring compliance and
engagement with treatment:
-
Probation
Police
Multi-agency public protection panels (MAPPs)
General Principles of
Management
•
The likelihood of engagement with treatment will also be greater with:
- Improved accommodation
- Regular support from professionals with whom the patient has positive
relationships
- Links to programmes to improve social interaction, enhance work-related
skills and provide recreational and sporting activities
Referral to forensic services (e.g. F/AOS Team) should be made for those
individuals identified as having the highest level of risk, as they will need a
higher level of supervision than can be provided by routine clinical teams.
Substance Misuse
• The assessment and management of drug and alcohol misuse
among those with mental illness remains a major priority. Its
effective control is a prerequisite for any other management and
continues to be a particular challenge.
• Patients with substance misuse should be offered specialised
treatment. There should be a particular focus on psychosocial
interventions that involve addressing both:
-
Integrating mental health
Substance-misuse treatment interventions (effective for
ameliorating substance use disorder in schizophrenic patients).
Substance Misuse
• Treatments should be considered such as:
-
Group-based cognitive-behavioural treatment
Contingency management
Long-term residential treatment
Motivational interviewing
Family education and support
Engagement with non-governmental agencies.
Substance Misuse
•
•
•
•
While many or most patients may not desire to stop substance use,
treatment can be guided by their level of motivation with a focus on
education, harm minimisation and relapse prevention where appropriate.
In cases in which comorbid substance use interferes with antipsychotic
compliance, a depot antipsychotic should be considered.
Preliminary evidence has suggested that clozapine treatment is associated
with a reduction in substance use in those with schizophrenia spectrum
disorders and so may facilitate interventions aimed at comorbid substance
abuse.
Maintenance prescription for those addicted to heroin, especially if
combined with psychological treatment, should be considered (Brunette et
al, 2006).
Psychotropic Medication
• If the violent behaviour is related to positive symptoms then better
control of hallucinations and delusions will be necessary for
improvement.
• Clozapine has been shown to demonstrate an anti-aggressive
effect:
- Independent to its effect on other positive and negative
symptoms
- Independent to sedation
- Superior to that of both haloperidol, risperidone and olanzapine
in two randomised double blind trials (Citrome et al, 2001;
Volavka, 2004).
• Clozapine also has mood stabilising properties and can reduce
suicidality
Psychotropic Medication
•
Results of the Clinical Antipsychotic Trials of Intervention Effectiveness
(CATIE) indicated a significant reduction in violence in patients with
schizophrenia treated with either first generation (perphenazine) or second
generation antipsychotics (olanzapine, risperidone, quetiapine and
ziprasidone).
•
However, the second generation antipsychotics showed no significant
benefit over the first generation antipsychotics. In fact quetiapine was
observed to be less effective than perphenazine.
•
The violence was reduced only in those whose prior violence was linked to
psychotic symptoms. It was not the case for a subgroup with a history of
childhood conduct problems in whom violence was not strongly linked with
psychotic symptoms.
Psychotropic Medication
• Adjunctive Valproate has been relatively frequently prescribed to
reduce aggression in patients with:
-
Mental retardation
Organic brain syndromes
Dementia
Schizophrenia.
• However, only one small study has demonstrated a specific
antihostility effect of adjunctive valproate in patients with
schizophrenia when combined with risperidone or olanzapine.
Therefore more studies are required (Schwarz et al, 2008).
Psychotropic Medication
• Other proposed treatments include:
-
SSRIs
Beta-adrenergic blockers
Benzodiazepines (short-term use - caution as
withdrawal may paradoxically increase agitation or
aggression).
• However again limited research supports these
treatments (for review see Citrome, 2007).
Psychological Interventions
• Psychological interventions can specifically target domains such as:
-
Anger Management (e.g. Triple C Group);
Mental Health Awareness;
Interpersonal skills and effective self assertion;
Coping with Psychosis (CBT model utilised);
Sexual Risk (e.g. Better Relationships Group in East London).
Such resources tend to be more available in Forensic Services
Re-cap
• Epidemiology of violence and mental illness
• Risk Assessment:
– Clinical
– Actuarial
– Structured clinical
• Risk Management
• Further Study
Further Study for Psychiatrists
• Podcast: “Assessing and communicating
violence risk” by Dr Mike Doyle
http://www.psychiatrycpd.co.uk/default.aspx?pag
e=1990
• RCPsych CPD module link – ‘Risk
assessment and management of violence
in general adult psychiatry’ link:
http://www.psychiatrycpd.co.uk/learningmodules/
riskassessmentandmanagement.aspx
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•
•
•
•
•
•
•
•
•
•
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•
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