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Violence and Mental Illness
Research: Violence & Mental
Illness
• MacArthur Foundation Violence Risk
Assessment Study (1998)
• significant under-reporting of violence
perpetrated by discharged mentally ill
• immediate family members most often
targeted; such violence most likely to occur
within the home
Research: Violence & Mental
Illness (cont.)
• MacArthur Foundation Violence Risk
Assessment Study (1998)
Diagnosis
% Violence
None
Major Mental Illness
Major Mental Illness
& Substance Abuse
Other Mental Disorder
& Substance Abuse
4.6
17.9
31.1
43.0
Research: Violence & Mental
Illness (cont.)
• specific symptoms, such as command
hallucinations to perpetrate violence,
predicted violence (Monahan et al., 2001),
as did comorbid MMI and substance use
disorders (Steadman et al., 1998).
• MMI, including psychotic disorders, played
a very small role in the violence of patients.
Elbogen and Johnson (2009)
• analyzed a two-wave epidemiological data
set of 34,653 persons residing in the
community in the United States. The
authors reported that MMI, did not predict
violence
• However, comorbid MMI and substance use
disorders did predict later violence, more so
than substance use disorders alone,
suggesting an interaction between MMI and
substance use disorders.
Elbogen & Johnson (cont.)
• Although the odds of future violence among
those with schizophrenia alone were about
double the odds of future violence among
persons without schizophrenia, this
association was not statistically significant
Additional Research
• MMI remains predictive of violence in the
presence of other risk factors that have been
entered into multivariate analyses (Swanson
et al., 2006) or after adjusting for population
parameters
Douglas, Guy & Hart (2009)
• Meta-analytic study of research on the
association between psychosis and violence
analyzing effect sizes from 204 studies.
• The median of the effect sizes indicated that
psychosis was significantly associated with a
49%–68% increase in the odds of violence.
• psychosis measured as a diagnosis of
schizophrenia or measured at symptom level
more predictive
USCP Data re: Mentally Ill Subjects
• Overall, nearly 40% of the USCP threat
assessment caseload involves persons who display
symptoms of obvious/serious mental illness
• Substantially more likely to approach
• Substantially more likely to use multiple methods
of contact
• Less likely to threat before approach—but when
make threats, risk of approach is substantial
• More likely to be driven by personal or delusiondriven motives when approach
Implications for Threat
Assessment
• Focus upon symptoms, not diagnosis
• Nature of threat inherent in symptom to
subject and target
• Nature of grievance inherent in symptom
• Personalized nature of grievance
• Context—why now? Current stressors?
Factors Associated with
Violent Recidivism
Clinical Factors
• Prior Hospitalizations
• Treatment compliance
• Hx of Therapeutic Alliance
• Substance Abuse
• Personality Disorder (particularly Antisocial
Personality Disorder)
Hallucinations
• False or distorted sensory experiences that
appear to be real perceptions.
• These sensory impressions are generated by
the mind rather than by any external stimuli,
and may be seen, heard, felt, and even
smelled or tasted.
Delusions
• A false belief that is firmly held despite
logical and confirming evidence to the
contrary.
• Different types, for example:
• Grandeur
• Paranoia/Persecutory
Factors Associated with
Violent Recidivism
Clinical Factors
• Principle of “rationality within
irrationality”
• Particular symptoms:
• Delusions
• Hallucinations
• Symptom Severity
• Violent Fantasies
Psychotic Symptoms
Indicative of Risk
Threat/control override symptoms
• command hallucinations
• hallucination related to delusion
• source of voice is identifiable to patient
• delusion indicates immediate physical harm
• thought insertion/broadcasting delusions
• perceived loss of bodily control
Interview Issues: Mental
Illness
•
•
•
•
•
•
Principle of “rationality within irrationality”
Do not argue with delusions
mental illness not equal limited intelligence
Have subject educate regarding issues involved
Careful use of confrontation
Direct questions regarding dangerousness not
always useful-- use of indirect or third party
perspective questions
Interview Issues: Mental
Illness
• “What if…” questions
• Role of external stressors as triggers
• Exceptions to when not acted on
hallucinations/delusions or other symptoms
• Do not neglect role of alcohol
• Recognize need for future contacts
Contact Information
Mario Scalora
[email protected]
402-472-3126