VIOLENCE RISK ASSESSMENT

Lee, Ruby Jade B.

 AR, 21/male, single, unemployed, RC from
Muntinlupa City

CC: “may mga bumubulong” – px; “nagwawala”

– mother
• 1 week PTC, patient noted auditory hallucinations
described as multiple voices of demons saying “wala ng
pag-asa gumaling yan”. The voices also commanded
him to hurt his family. He became irritable and verbally
hostile to his family. No consult done.
• 1 day PTC, px still had auditory hallucinations telling
him to hurt his family. He prayed the voices will stop.
He could also hear Jesus telling him not to hurt his
family. Despite this, the patient was seen hurting his
nephew. When his family tried to stop him, he
threatened to kill them. He demanded them to go
outside the house. He locked the doors and windows
and turned off the lights. He was later brought to the
Barangay outpost to contain his violent behavior.
• Several hours PTC, px was brought to ER PGH
 ER Psychiatry
• Provide a fundamental service
– Maintain safety of the patient
– Protect the patient from harm (self-inflicted or
otherwise)
 Violence and Mental Illness
• Culture of violence in US
– Violent acts are directly related to low social class, low
IQ and education levels, employment and residential
instability
• Only 3-5% of risk for violence in US can be
attributed to mental illness (Appelbaum, 2008)
• One series of surveys found that selective media
reporting reinforced public’s stereotypes linking
violence and mental illness, and encouraged
people to distance themselves from those with
mental disorders. (Satcher, 1999)
 Violence and Mental Illness
• The portrayal of persons with mental
illness on tv and in film
– may influence the treatment of persons
with mental illness
• Media portrayals
– influence the decisions of practitioners
regarding the clinical treatment of
persons with mental illness
• Homeless persons with mental illness
commit 35 times more crimes than
persons with mental illnesses who are
not homeless (Martell et al. 1995)
 Violence and Mental Illness
• Command auditory hallucinations
–perhaps the most common
• Disturbing visual hallucination
• Irritability secondary to mania
• Hopelessness secondary to
depression
• Symptoms are exacerbated by the
disinhibiting effects of substance
abuse
 Clinical Assessment: Risk Factors
Dyanamic Static
• Patient’s past use of violence • Ownership of weapons
• Patterns of past violence • Social supports
• Patterns of family violence • Living situation
• Substance use history • Current psychiatric
• Institutional history symptoms
• Military history • Noncompliance with
• Work history medication
• Sexual aggression history
• Demographics
 Static Risk Factors for Violence
• A history of violence
– patient’s self-report
– family and/or other mental health
clinicians
– Ask: why it occurred, how he or she felt,
the degree of physical injury inflicted
• Patterns of past violence
– If it occurred during psychotic states,
manic states, depressed states, or
intoxicated states
– whether the violence was predatory (i.e.,
planned, purposeful, and goal directed)
 Static Risk Factors for Violence
• Violence within the family of origin
– whether the patient experienced early violence in
his or her family
• Detailed substance use history
– stronger risk factor for violence than any psychotic
or affective diagnosis
 Static Risk Factors for Violence
• Institutional history
– once a person exceeds 10 psychiatric hospitalizations, the
likelihood of future violence is increased
• Military history
– Involved in combat and what type of discharge he or she
received
• Work history
– Patient’s previous job terminations & imminent loss of a
current job
– Persons who are unemployed after being laid off are six
times more likely to be violent than their employed peers
 Static Risk Factors for Violence
• History of sexual aggression
– Deviant sexual or violent fantasies
are related to the commission of
sexual and violent offenses
• Demographics
– The younger the person is at the
time of the first known violence,
the greater the likelihood of
subsequent violent conduct
 Dynamic Risk Factors for
Violence
• Weapons
• Social supports
– Presence of patient, tolerant, and encouraging
family members or peers can be of great
assistance in maintaining a risk management plan
• Housing/Living Situation
– Difficulty in achieving basic social needs (such as
housing, finances, and food) is a predictor of
violence
 Dynamic Risk Factors for Violence
• Current psychiatric symptoms
– Increased risk
• psychotic symptoms that override one’s sense of self-
control
• positive symptoms of schizophrenia
• one’s mental illness
• negative attitudes toward other people, social
agencies/institutions, and authority
 Dynamic Risk Factors for Violence
• Medication nonadherence
– Lack of insight into mental ilness
– Negative attitudes toward treatment
 Structured Risk Assessment
• Historical, Clinical, and Risk Management–20
• Classification of Violence Risk
• Violence Risk Appraisal Guide

– assessment of long-term risk of violence of

patients being discharged from inpatient units
THANK YOU