Violence Assessment and Management
Violence Assessment and Management
Violence Assessment and Management
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Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Paul S. Appelbaum, M.D.
Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi
Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xxiii
I
ASSESSMENT PRINCIPLES
5 Mood Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Rif S. El-Mallakh, M.D.
R. Jeannie Roberts, M.D.
Peggy L. El-Mallakh, Ph.D.
III
TREATM ENT S ET TINGS
IV
TREATM ENT AND MANAGEMENT
V
SPECIAL POPULATIONS
VI
S P E C I A L TO P I C S
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .567
Contributors
xi
xii ❘ Textbook of Violence Assessment and Management
How is it that clinicians in the mental health system have come to have
responsibility for the assessment and management of violence? The an-
swer lies deep in the history of our field. People with serious mental dis-
orders have long been feared for the oddness of their behavior, and in
some cases for the occasional acts of violence that may punctuate their
lives. Indeed, funding for the first hospital in the colonial United States,
the Pennsylvania Hospital in Philadelphia, which opened in 1751, was
obtained in part by the promise of having a place to contain the mentally
ill, thus diminishing the perceived threat they posed to the populace.
From its inception, then, the mental health system has been intimately
linked with the prediction and prevention of violence.
One cannot proceed further without noting that the relationship be-
tween mental illnesses and violence has been much exaggerated over
the years. Epidemiologic and cohort studies taken as a whole suggest
some increased risk of violence in persons with major mental disorders.
But not all studies support this conclusion, and in any event the contri-
bution of serious mental disorders is dwarfed by the effects of substance
abuse (especially alcohol abuse) and personality traits such as psycho-
pathy. The best available estimate suggests that only 3%–5% of the risk
for violence in the United States is attributable to mental illnesses, and
it has long been clear that people with serious mental illnesses are much
more likely to be the victims of violence than its perpetrators.
Nonetheless, mental illness is sometimes causally linked with vio-
lence, as when patients act on command hallucinations to harm other
people or strike out in fear against imagined persecutors. Manic pa-
tients in their irritability or depressed patients in their hopelessness
may also cause harm to others. All of these conditions and others are ex-
acerbated by the simultaneous use of alcohol and other disinhibiting
substances, the abuse of which is more common among people with
mental disorders.
As a result, nearly every phase of the mental health evaluation and
treatment process may involve the assessment of violence risk and de-
cisions about its management. This includes outpatient screening and
xvii
xviii ❘ Textbook of Violence Assessment and Management
If the promised land is not yet in sight, there is still no question that
this is an exciting time for the science and practice of violence risk as-
sessment. Clinicians and researchers are experimenting with ways of
combining actuarial and clinical approaches, in the hope of achieving
levels of accuracy unattainable with either alone. Behavioral geneticists
have begun to identify gene variants that may be implicated in violence
risk and have begun to develop initial models of the interactions of these
variants with environmental variables. Functional magnetic resonance
imaging, positron emission tomography, and other brain scanning tech-
niques are being used to identify neural circuits that may inhibit or
facilitate violent acts. With the knowledge being gained, it seems likely
that violence risk prediction in the next generation will look very differ-
ent than it does today.
The same can be said with regard to the present relatively primitive
level of management and treatment of violence risk. When violence ap-
pears to be causally linked to the symptoms of mental illnesses, our
contemporary interventions typically focus on symptom control. Rela-
tively few interventions—anger management programs are one—target
the propensity to violence per se. This situation may also improve in the
future as advances in the science of violence causation promote the de-
velopment of more specific interventions. Indeed, we may some day
legitimately be able to speak of prevention of violent propensities,
rather than management of risk, as clinicians’ primary task.
However promising the future, clinicians must address the needs of
patients and the demands of society today. Thus the importance of this
book, which summarizes in an accessible format the state of the art of vi-
olence assessment and management for mental health clinicians. Here,
clinical and actuarial approaches to risk assessment are reviewed, the
association of violence with specific psychiatric disorders is addressed,
and management of violence is considered in depth. The important set-
tings of the home, workplace, school, and healthcare facility are consid-
ered, as are the legal and risk management issues of which all clinicians
should be aware. As a guide to dealing with violence today this volume
is unparalleled, and I commend it to your thoughtful attention.
xxi
xxii ❘ Textbook of Violence Assessment and Management
T his textbook could not have been published without the committed
efforts of many individuals. We want to express our gratitude to all the
authors for the time and effort they devoted to researching and writing
chapters of such high quality. It is their book as much as ours.
We also want to thank Robert E. Hales, M.D., M.B.A., Editor-in-
Chief of American Psychiatric Publishing, Inc., and John McDuffie, Ed-
itorial Director, for their vision and support for a textbook on violence
assessment and management.
Many thanks go to Ms. Tina Coltri-Marshall for her outstanding
work in the difficult task of coordinating the entire textbook project
among the editors, numerous authors, and American Psychiatric Pub-
lishing staff. Special appreciation goes to Ms. Carol A. Westrick for her
competence and undaunted work ethic.
This work was funded, in part, by grant DA06534 from the National
Institute on Drug Abuse.
—R.I.S., K.T.
xxiii
xxiv ❘ Textbook of Violence Assessment and Management
Disclosure of Interests
The contributors have declared all forms of support received within the 12 months prior
to manuscript submittal that may represent a competing interest in relation to their
work published in this volume, as follows:
Carl C. Bell, M.D.: Consultant, AstraZeneca
John M. Bradford, M.D.: Grant support, Canadian Institute Health Research,
Janssen-Ortho; Speakers’ bureau, Janssen-Ortho, Pfizer
Leslie Citrome, M.D., M.P.H.: Consultancy, honoraria, or clinical research support,
Abbott Laboratories, AstraZeneca, Barr Laboratories, Bristol-Myers Squibb,
Eli Lilly and Company, GlaxoSmithKline, Janssen Pharmaceutica, Jazz Phar-
maceuticals, Pfizer
William R. Dubin, M.D.: Speakers’ bureau, AstraZeneca, Pfizer
The following contributors stated that they had no competing interests during the year
preceding manuscript submittal:
Thomas Ala, M.D.; Peter Ash, M.D.; James C. Beck, M.D.; Martha Crowner, M.D.;
Peggy L. El-Mallakh, Ph.D., R.N.; Rif S. El-Mallakh, M.D.; Paul Fedoroff, M.D.;
Alan R. Felthouse, M.D.; Philip Firestone, Ph.D.; Susan Hatters Friedman, M.D.;
Thomas A. Grieger, M.D., D.F.A.P.A.; Anzalee Khan, M.S.; Jean-Pierre Linden-
mayer, M.D.; John R. Lion, M.D.; Barbara E. McDermott, Ph.D.; John Monahan,
Ph.D.; Autumn Ning, M.D.; Cameron D. Quanbeck, M.D.; William H. Reid, M.D.,
M.P.H.; R. Jeannie Roberts, M.D.; Charles L. Scott, M.D.; Daniel W. Shuman, J.D.;
Jonathan M. Silver, M.D.; Robert I. Simon, M.D.; Kenneth Tardiff, M.D.; Robert L.
Trestman, Ph.D., M.D.; Sara T. Wakai, Ph.D.
P A R T I
Assessment Principles
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C H A P T E R 1
T his chapter presents a clinical model for the short-term risk assess-
ment of violence. Assessment of the risk of violence by patients is ex-
pected of all clinicians who have a relationship with a patient for eval-
uation or treatment: psychiatrists, other physicians, psychologists,
nurses, social workers, activity therapists, and all other staff members
who have responsibilities for patients. The responsibility to assess the
risk of violence exists when clinicians evaluate a patient in the emer-
gency department and decide whether to discharge or admit; see a pa-
tient in an office setting for the first time and between outpatient visits;
admit a patient to a hospital and order a level of observation; and pro-
vide other immediate treatment as the patient enters the hospital. It ex-
ists during in-hospital diagnosis and treatment, including monitoring
the patient and deciding whether seclusion or restraint should be used.
It exists in the decision to discharge the patient and in the planning and
implementation of care after discharge.
The focus of this chapter is to describe clinical methods to evaluate
the risk of violence in the short term (within days or a week), because
an increased risk of violence should result, as soon as possible, in pre-
ventive clinical actions such as change in medication, monitoring, and
admitting to or discharge from a hospital. Unlike clinical methods of
assessing the risk of violence, actuarial methods of assessing the risk of
violence use structured instruments with items that are selected to
3
4 ❘ Textbook of Violence Assessment and Management
and review old charts for previous episodes of violence, police and ar-
rest reports, and other available records such as judicial proceedings.
Intent
If a patient has thoughts of harming someone, it is important to explore
whether he or she really intends to do something or is just having
thoughts of violence. This disclosure may arise during an outpatient
treatment session, as an offhand comment on the inpatient unit, or dur-
ing any other contact with the patient. The patient’s mere thought of vi-
olence may not be sufficient for the clinician to take actions such as
warning someone, changing medication, or hospitalizing the patient.
For some patients these thoughts of violence may seem intrusive, alien,
and disturbing, and they will say that they do not intend to do anything
to carry them out.
Available Means
The availability of a means of inflicting injury or death is important in
the assessment of violence potential. If the patient is thinking about get-
ting a gun or already has one, the clinician should obviously take a
threat of violence more seriously. The clinician always should ask a po-
tentially violent patient if he or she has or has ready access to a gun. Vig-
orous efforts should be made to have the patient get rid of the gun or to
have it taken from the patient by family members or others. Removal of
the gun must be verified by a callback by staff. When guns are removed,
Clinical Risk Assessment of Violence ❘ 7
the potential for homicide is reduced; however, that does not necessar-
ily preclude the patient’s attacking the victim in other, less lethal ways.
“Available means” also applies to the physical availability of the po-
tential victim. How easily accessible is he or she to the patient? Does the
potential victim live in a secluded place or in a city building without a
doorman? Geography is another aspect of availability. A schizophrenic
patient who threatens his or her father may be more of an immediate
threat if actually living with the father as opposed to living in a different
city or state at a distance from him.
Verbal aggression
____ Makes loud noises, shouts angrily
____ Yells mild personal insults (e.g., “You’re stupid”)
____ Curses viciously, uses foul language in anger, makes moderate threats to
others or self
____ Makes clear threats of violence toward other or self (e.g., “I’m going to
kill you”) or requests help to control self.
Physical aggression against objects
____ Slams door, scatters clothing, makes a mess
____ Throws objects down, kicks furniture without breaking it, marks the wall
____ Breaks objects, smashes windows
____ Sets fires, throws objects dangerously
Physical aggression against self
____ Picks or scratches skin, hits self, pulls hair (with no or minor head injury
only)
____ Bangs head, hits fist into objects, throws self onto floor or into objects
(hurts self without serious injury)
____ Small cuts or bruises, minor burns
____ Mutilates self, makes deep cuts, bites that bleed, internal injury, fracture,
loss of consciousness, loss of teeth
Physical aggression against other people
____ Makes threatening gestures, swings at people, grabs at clothes
____ Strikes, kicks, pushes, pulls hair (without injury to them)
____ Attacks others, causing mild or moderate physical injury (bruises, sprain,
welts)
____ Attacks others, causing severe physical injury (broken bones, deep
lacerations, internal injury)
Psychosis
Psychosis is not a diagnosis, but it is a symptom that can be found in a
number of disorders, including schizophrenia, delusional disorder,
neurological and medical disorders, substance abuse disorders, and
mood disorders, especially with mania. These disorders are discussed
elsewhere in this book. When psychosis is present, regardless of the dis-
order, it increases the risk of violence (Anderson and Silver 1999).
Schizophrenic patients can be delusional and can have ideas of per-
secution. Patients may believe that people are trying to harm them; that
the police, the FBI, or other organizations are spying on them; that some
unknown mechanism is controlling their minds; or that the therapist is
harming them (e.g., through medication). Patients with paranoid delu-
sions in schizophrenia may react to these persecutory delusions by re-
taliating against the presumed source of the persecution. Patients with
other types of schizophrenia may attempt to kill other persons because
of some form of psychotic identification with the victim. Hallucinations
associated with schizophrenia have been known to result in violent be-
havior and homicide (Andreasen et al. 1995; Dixon et al. 1991; Modestin
and Ammann 1996).
Other aspects of schizophrenia, apart from psychotic processes, can
also result in violence. Sudden, unpredictable changes in affect may be
associated with anger, aggression, and violent behavior. Some schizo-
phrenic patients are violent because of generalized disorganization of
thought and a lack of impulse control accompanied by purposeless ex-
cited psychomotor activity (akathisia), or they may inadvertently come
into physical contact with other patients, which may lead to fights.
Schizophrenic patients also may use violence to attain what they want,
to express anger, or to deliberately hurt others.
The psychotic paranoid patient, regardless of diagnosis, poses a
problem because his or her delusions may not be obvious or the patient
may attempt to hide them. Therefore, the evaluator must listen for sub-
tle clues and should follow up regarding the assessment of violence
toward others but must be careful not to confront the patient with insis-
tent questioning about the presence of paranoid delusions (Taylor and
Felthous 2006).
A manic patient may become violent as a result of delusional think-
ing in which the patient believes he or she is being persecuted because
of some special attribute. Manic patients usually put all their impulses,
including violent ones, into action. A typical situation in which manic
patients erupt with violence is when they feel contained and not free to
do what they want to do (McElroy et al. 1992).
Clinical Risk Assessment of Violence ❘ 11
Personality Disorders
Violence by persons with antisocial personality disorder is often vicious
and persistent. They will continue punching, or hitting with objects, be-
yond what is needed to subdue the other person and win the fight.
These patients have no remorse for their actions, and the victim is per-
ceived as deserving the beating. The person with borderline personality
disorder can be violent and make suicidal gestures when rejected or
feeling rejected by others. The violence and suicide attempts are part of
a broader picture of impulsivity and instability of interpersonal rela-
tionships. Persons with narcissistic personality can be violent occasion-
ally when angry, such as when they are not given something they think
they deserve. The person with paranoid personality rarely attacks those
seen as persecutors, but when violence does occur it can be severe, even
taking the form of mass murder. The person with intermittent explosive
disorder is violent during circumscribed episodes, often with little ap-
parent precipitating cause or out of proportion to any identifiable cause
(Bernstein et al. 1993; Gunderson et al. 1991; Hare et al. 1991; Herpertz
et al. 1997; Kemperman et al. 1997).
Demographic Characteristics
Demographic characteristics of patients should be considered in the as-
sessment of violence potential. Young persons and men have been
found to be at increased risk of violence, as are persons from environ-
ments of poverty, familial disruption, or decreased social control in
which violence is considered an acceptable means of attaining a goal in
12 ❘ Textbook of Violence Assessment and Management
Case Examples
Case Example 1
The patient was a 25-year-old single white man with a history of para-
noid schizophrenia who was discharged from the military in the 1970s
because he developed delusions that he was a spy for the government
and had killed people. He was sent to a Veterans Administration (VA)
hospital for treatment and was discharged to the clinic for outpatient
treatment.
After discharge from the hospital, he still voiced paranoid ideation
and the delusion that he was a spy. He was not certain that he had killed
people and stated that there was no history of violence. He denied any
suicidal or violent ideation when first seen in the clinic. An in-depth,
comprehensive assessment of his short-term violence potential was per-
formed at that time. He was given oral haloperidol and continued to
attend the clinic on a monthly basis. He was compliant with the medi-
cation for years and was seen by a psychiatric resident who updated the
initial evaluation of violence and suicide potential monthly under the
supervision of an attending psychiatrist.
The patient continued to be delusional about being a spy but denied
any suicidal or violent ideation or intent. He lived alone and worked
part-time installing carpet for a small business. One day, he slashed and
killed his employer with a carpet knife. A lawsuit resulting from this act
was filed against the VA.
It was determined that the murder was not predictable and that the
patient had been monitored consistently, had received adequate treat-
ment, and had been compliant with medication; the judge consequently
ruled in favor of the VA. Although it was not admissible in the court,
I read the patient’s diary, and he had made no mention of thoughts or
intent to kill anyone, including his employer.
Case Example 2
The patient was a 36-year-old single, biracial man with a history of
schizoaffective disorder and polysubstance abuse, including cocaine
and alcohol. He was brought into the psychiatric emergency depart-
ment by the police after a physical altercation with a staff member at his
residence. He had become verbally aggressive for several weeks and
had stopped taking his valproic acid and olanzapine. On the day of the
violent episode, he had run into the street, was brought back to the res-
idence, and then threw a chair at a staff member. He had a history of two
suicide attempts and had been psychotic on a number of occasions. In
the emergency department he de-escalated considerably but made fre-
Clinical Risk Assessment of Violence ❘ 13
Conclusion
This chapter has described violence by patients with a number of psy-
chiatric disorders. Violence differs among psychiatric disorders in
terms of frequency, the manner in which it is expressed, and the psycho-
pathology and dynamics that produce it. Violence is seen more fre-
quently by clinicians and is more problematic in antisocial personality,
borderline personality, and intermittent explosive disorders; schizo-
phrenia and other psychotic disorders; mania; and alcohol and drug
abuse.
A model has been presented here for assessing the potential for vio-
lence among patients in the short term (days or a week). This time
period is of great relevance in clinical decisions regarding a patient’s
admission to a hospital, monitoring and treatment in the hospital, and
discharge from the hospital; the development of an aftercare plan; and
outpatient monitoring of the patient’s potential for violence between of-
fice visits. The clinician assessing violence potential must rely on as
many sources of data as possible, including interviews with the patient,
friends and family, police, current and former treaters, and past clinical
and other types of records.
14 ❘ Textbook of Violence Assessment and Management
Key Points
■ Ten factors involved in evaluating a patient’s potential for violence
are outlined in Table 1–1. In brief, they include appearance, idea-
tion and planning, intent, means and access, past history, alcohol
and drug use, presence of psychosis, presence of personality disor-
der, history of treatment noncompliance, and demographic and
socioeconomic characteristics.
■ All ten of the factors are weighed by the clinician in the final
assessment of whether the patient poses a short-term risk of
violence to others.
■ If the patient poses a short-term risk of violence, some action is
necessary on the part of the evaluator. Action may include chang-
ing the treatment plan, hospitalizing the patient, warning the
intended victim and/or the police, and other creative maneuvers
to prevent the imminent violence by the patient.
■ All of the data used to determine whether a patient is at risk for
violence must be documented in writing; the thinking process by
which the decision was made also must be evident in the written
documentation.
■ Reassessment of violence potential should be made at short inter-
vals (e.g., from visit to visit or every few days) if the patient is to
continue to be treated outside the hospital or other institution.
■ In the hospital and emergency department, safety and monitoring
of a potentially violent patient are essential, and treatment after
discharge must be detailed in writing and arranged in a timely
manner.
References
Anderson KE, Silver JM: Neurological and medical diseases and violence, in
Medical Management of the Violent Patient: Clinical Assessment and Ther-
apy. Edited by Tardiff K. New York, Marcel Dekker, 1999, pp 87–124
Andreasen NC, Arndt S, Alliger R, et al: Symptoms of schizophrenia: methods,
meanings, and mechanisms. Arch Gen Psychiatry 52:341–351,1995
Bernstein DP, Useda D, Siever LJ: Paranoid personality disorder: a review of its
current status. J Personal Disord 7:53–62, 1993
Bushman BJ: Effects of alcohol on human aggression: validity of proposed ex-
planation. Recent Dev Alcohol 13:227–304, 1997
Choi PYL, Parrott AC, Cowan D: High dose anabolic steroids in strength ath-
letes: effects upon hostility and aggression. J Psychopharmacol 3:102–113,
1989
Clinical Risk Assessment of Violence ❘ 15
Convit A, Nemes ZC, Volavka J: History of phencyclidine use and repeated as-
saults in newly admitted young schizophrenic men. Am J Psychiatry
154:1176–1183, 1988
Denison ME, Paredes A, Booth JB: Alcohol and cocaine interactions and aggres-
sive behaviors. Recent Dev Alcohol 13:283–291, 1997
Dixon L, Haas G, Weiden PH, et al: Drug abuse in schizophrenic patients: clin-
ical correlates and reasons for use. Am J Psychiatry 148:224–230, 1991
Gunderson JG, Ronningstam E, Smith LE: Narcissistic personality disorder: a
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1991
Hare RD, Hart SD, Harper TJ: Psychopathy and the DSM-IV criteria for antiso-
cial personality disorder. J Abnorm Psychol 100:391–398, 1991
Harris GT, Rice ME, Camilleri JA: Applying a forensic actuarial assessment (the
Violence Risk Appraisal Guide) to nonforensic patients. J Interpers Vio-
lence 19:1063–1074, 2004
Herpertz S, Gretzer EM, Steinmeyer V, et al: Affective instability and impulsiv-
ity in personality disorder. J Affect Disord 44:31–37, 1997
Kemperman I, Russ MJ, Shearin E: Self-injurious behavior and mood regulation
in borderline patients. J Personal Disord 11:146–157, 1997
Kroner DG, Mills JF, Reddon JR: A coffee can, factor analysis and prediction of
antisocial behavior: the structure of criminal risk. Int J Law Psychiatry
28:360–374, 2005
Kumar S, Simpson AI: Application of risk assessment for violence methods to
general adult psychiatry: a selective review of the literature. Aust NZ J Psy-
chiatry 39:328–335, 2005
Langevin R, Ben-Aron G, Wortzman R, et al: Brain damage, diagnosis, and sub-
stance abuse among violent offenders. Behav Sci Law 5:77–86, 1987
Linaker OM: Assaultiveness among institutionalized adults with mental retar-
dation. Br J Psychiatry 164:62–78, 1994
McCormick RA, Smith M: Aggression and hostility in the substance abuser: the
relationship to abuse patterns, coping style, and relapse trigger. Addict Be-
hav 20:555–564, 1995
McElroy SL, Keck PE, Pope HG, et al: Clinical and research implications of the
diagnosis of dysphoric or mixed mania or hypomania. Am J Psychiatry
149:1633–1644, 1992
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Research Monographs 94:68–79, 1989
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Modestin T, Ammann R: Mental disorders and criminality: male schizophrenia.
Schizophr Bull 22:69–82, 1996
Pope HG, Katz DL: Psychiatric and medical effects of anabolic-androgenic ste-
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386, 1994
Tardiff K, Leone AC, Marzuk PM: Suicide risk measures, in Handbook of Psy-
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16 ❘ Textbook of Violence Assessment and Management
Case examples reprinted from Monahan J, Steadman HJ, Appelbaum PS, et al.:
Classification of Violence Risk Professional Manual. Lutz, FL, Psychological Assess-
ment Resources, 2005, pp. 12 and 18. Used with permission.
17
18 ❘ Textbook of Violence Assessment and Management
The HCR-20
The “HCR-20,” first published in 1995 and revised in 1997, consists of a
series of 20 ratings addressing Historical, Clinical, and Risk manage-
ment factors (Webster et al. 1997). In one study, the HCR-20 was com-
pleted for civilly committed patients who were followed for approxi-
mately two years after discharge into the community. When the scores
were divided into five categories, 11% of the patients scoring in the low-
est category were found to have committed or threatened a physically
violent act, compared with 40% of the patients in the middle category
and 75% of the patients in the highest category (Douglas et al. 1999; see
also Douglas et al. 2005).
22 ❘ Textbook of Violence Assessment and Management
For clinical purposes, it makes little sense to sum the number of risk fac-
tors present in a given case, and then use fixed, arbitrary cutoffs to clas-
sify the individual as low, moderate, or high risk… [It] is both possible
and reasonable for an assessor to conclude that an assessee is at high risk
for violence based on the presence of a single risk factor—if, for exam-
ple, that risk factor is “Active Symptoms of Major Mental Illness” and
reflects the assessee’s stated intent to commit a homicide…. In sum, at
present it may be neither possible nor desirable to develop cutoff scores
for the determination of summary or final risk judgments in clinical
settings.
1
Note that the author of this chapter is one of the owners of COVR.
24 ❘ Textbook of Violence Assessment and Management
Unstructured 0 No No No
HCR-20 1 Yes No No
COVR 2 Yes Yes No
VRAG 3 Yes Yes Yes
Note. COVR=Classification of Violence Risk; HCR=Historical, Clinical, and Risk
Management; VRAG=Violence Risk Appraisal Guide.
Conclusion
In unstructured risk assessment, neither the selection nor the measure-
ment of the risk factors used in the assessment is specified in advance.
Therefore, there are no risk factor “scores” that can be combined to yield
a quantitative estimate of risk and no need for a clinical review of such
an estimate. The three forms of structured risk assessment described
here all specify in advance at least which risk factors are to be addressed
and how those risk factors are to be measured. The HCR-20 structures
only the choice and measurement of risk factors. The COVR goes on to
also structure the manner in which the risk factors are combined to yield
an estimate of risk, but the COVR allows the clinician to review this es-
timate in the context of other (unstructured) available information be-
fore issuing a final risk estimate. The VRAG, in contrast, is a completely
structured (i.e., actuarial) risk assessment tool. No clinical review is al-
lowed: the structured risk estimate that is produced when the risk fac-
tors are combined is the final product of the risk assessment process.
Although the three specific structured risk assessment tools consid-
ered here are the most frequently discussed in the literature, it should be
emphasized that they are merely illustrative of a larger group of instru-
ments that—like the HCR-20—structure only the choice and measure-
ment of risk factors (e.g., Kropp and Hart 2000), or—like the COVR—
also structure the manner in which the risk factors are combined to yield
an overall estimate of risk but allow the clinician to review this struc-
tured estimate in the context of other available information (e.g., Han-
son 1997), or—like the VRAG—stipulate that the structured risk esti-
mate that is available when the risk factors are combined is the final
product of the risk assessment process (Harris et al. 2003).
If structured violence risk assessment is superior to unstructured vi-
olence risk assessment, which specific form of structured risk assess-
ment has the highest predictive validity? Should the clinician structure
only one component of the risk assessment process (as the HCR-20
does), two components (as the COVR does), or all three components (as
the VRAG does)? On this issue, perhaps because some of these instru-
ments are so new, there are many strong opinions but no widespread
acceptance of a single view among either researchers or practitioners.
Finally, although structured violence risk assessment—of whatever
form—appears to be demonstrably superior to unstructured violence
risk assessment, and despite the increasing receptivity of courts and
legislatures to the use of structured violence risk assessment, only a mi-
nority—perhaps only a small minority—of practicing mental health
professionals in the United States routinely employ any form of struc-
Structured Risk Assessment of Violence ❘ 31
tured violence risk assessment at the latter end of the first decade of the
twenty-first century.
Key Points
■ To improve the predictive validity of violence risk assessment, the
assessment process can fruitfully be disaggregated into its three
components: 1) selecting and measuring risk factors, 2) combin-
ing risk factors, and 3) generating a final estimate of risk.
■ Violence risk assessment instruments recently have been created
that structure one, two, or all three of these component parts of
the risk assessment process.
■ All forms of structured violence risk assessment appear to have
greater predictive validity than unstructured (“clinical”) violence
risk assessment.
■ Consensus has not yet been achieved as to which form of struc-
tured violence risk assessment has the greatest predictive validity.
■ Courts and legislatures are increasingly open to the use of struc-
tured violence risk assessment.
■ At the present time, relatively few practicing mental health profes-
sionals employ any form of structured violence risk assessment.
References
Aegisdottir S, White M, Spengler P, et al: The Meta-Analysis of Clinical Judg-
ment Project: fifty-six years of accumulated research on clinical versus sta-
tistical prediction. Couns Psychol 34:341–382, 2006
Appelbaum P, Robbins P, Monahan J: Violence and delusions: data from the
MacArthur Violence Risk Assessment Study. Am J Psychiatry 157:566–572,
2000
Banks S, Robbins P, Silver E, et al: A multiple-models approach to violence risk
assessment among people with mental disorder. Crim Justice Behav
31:324–340, 2004
Douglas K, Ogloff J, Nicholls T, et al: Assessing risk for violence among psychi-
atric patients: the HCR-20 violence risk assessment scheme and the Psy-
chopathy Checklist: Screening Version. J Consult Clin Psychol 67:917–930,
1999
Douglas K, Yeomans M, Boer D: Comparative validity analysis of multiple mea-
sures of violence risk in a sample of criminal offenders. Crim Justice Behav
32:479–510, 2005
Elbogen E, Mercado C, Scalora M, et al: Perceived relevance of factors for vio-
lence risk assessment: a survey of clinicians. International Journal of Foren-
sic Mental Health 1:37–47, 2002
32 ❘ Textbook of Violence Assessment and Management
Cultural Competence in
Violence Risk Assessment
Russell F. Lim, M.D.
Carl C. Bell, M.D.
35
36 ❘ Textbook of Violence Assessment and Management
der stemming from domestic or romantic conflict are the chief forms of
violence in the European-American community (Petee et al. 1997). Serial
killing has been stereotypically linked to European Americans; how-
ever, a recent article by Walsh (2005) showed that this type of homicide
by African Americans has been underreported. Thus, being a minor-
ity—with the exception of being Asian American—was associated with
being a victim of a violent attack. The distinction must be made that be-
ing associated with something does not necessarily predict it, hence the
distinction of a risk marker not being a risk factor because there has been
no causal link proven. Furthermore, although it is true that there are ra-
cial and ethnic differences in homicide rates, these differences drop out
when variables of socioeconomic status are controlled (Bell 2002). Socio-
economic inequality, not race, facilitates higher rates of violence among
ethnic minority groups (Johnson 2000).
Demographic factors associated with increased risk for violence in
adults are race and ethnicity; however, because these risk factors “tend
to dissipate when other factors are taken into account statistically”
(Hucker 2004), it is likely that in adults, race and ethnicity are also actu-
ally risk markers and not risk factors, as was seen in adolescents. This
finding is supported by the MacArthur Violence Risk Assessment
Study (Steadman et al. 1998), which found that although there was an
overall association between race and violence, African Americans and
European Americans who lived in comparably disadvantaged neigh-
borhoods had the same rates of violence.
A common stereotype is that people of color (e.g., African Ameri-
cans) are more dangerous than people without color (i.e., perceived Eu-
ropean Americans). Another variation of this effect is the finding that mi-
nority children are more frequently evaluated and reported as victims of
child abuse, according to Lane et al. (2002), which shows a reporting bias
and does not necessarily indicate that minorities are more likely to be
abusive toward their children. Clinician biases are also seen in increased
rates of seclusion and restraint of African Americans compared with
whites in the psychiatric inpatient ward (Flaherty and Meagher 1980)
and in the more and larger doses of oral and injectable antipsychotic
medications given to African American patients than to similar white
patients by psychiatric clinicians in psychiatric emergency and inpatient
services (Primm 2006). Flaherty and Meagher (1980) speculated that “the
stereotype of the black male made the staff feel and act as if blacks were
more dangerous, prompting more restrictive measures” (p. 681). Fla-
herty and Meagher’s study also found that black patients were less likely
to be referred to recreational and occupational therapy, whereas these
services were routinely ordered for whites on the unit. The physicians on
Cultural Competence in Violence Risk Assessment ❘ 39
the unit reported that they ordered these therapies routinely unless a pa-
tient was too dangerous or psychotic to participate.
The reasons for the overdetermination of dangerousness in people
of color have been poorly studied, and the few studies examining this
issue tend to be dated. Flaherty and Meagher (1980) found that all-
white inpatient treatment teams spent less time discussing black patient
issues compared with white patient issues. Adebimpe (1981) and others
(Gross et al. 1969) have observed similar low allocations of time on
black patient issues and attribute part of this problem to the social and
cultural distance between the patient and clinician. Adebimpe (1981)
cited differences in vocabulary, modes of communication, value sys-
tems, and expression of distress and a breakdown in rapport as factors
that increase diagnostic errors. Jones and Gray (1985) stated that “white
psychiatrists seem to have more difficulty relating to black male pa-
tients than to [black] female patients” (p. 25) and hypothesized that this
may be because white psychiatrists expect black men to be threatening
(i.e., they adhere to a common societal negative stereotype of black men).
Although these important studies are classic, they are from a time when
experimental design and statistical methodology were less sophisti-
cated, and modern studies should be performed to expand upon and
update these findings.
The following two cases illustrate how an individual’s or clinician’s
cultural experiences and assumptions can influence violent behavior
and the risk assessment of violent behavior.
Case Example 1:
Racism and Oppression in a Hawaiian Man
A 35-year-old biracial Caucasian and Hawaiian man was imprisoned af-
ter being convicted of killing his ex-wife’s father, a Portuguese Ameri-
can man who had disapproved of his daughter’s marrying someone
who was not Portuguese. The patient had murdered the victim by
punching him to death. The patient was an amateur boxer and at the
time of the killing was using cocaine and complaining that he was in
danger from others. He was eventually released after the completion of
his prison sentence and placed in a board and care for persons with
mental disorders and substance abuse disorders. He lived there with
other men belonging to various ethnic groups and would get into fights
when a roommate would call him by a racial slur.
Case Example 2:
Racism, Transference, and Countertransference
A male Caucasian patient was to be evaluated at a prison for a psychi-
atric disorder. He was 6 feet tall, heavy, and muscular. His voice was
loud, and he spoke with a heavy Southern accent. He glared angrily at
anyone who came near. His psychiatrist, a thin, 5-foot-tall African
American wearing glasses, began to question the patient, but he refused
to answer, saying, “Not to you!” The patient was a devout Christian and
read the Bible daily. He had been convicted of murdering an elderly
Caucasian woman by tackling her, lifting her up in the air, and dropping
her on the sidewalk. He was convinced that she meant him harm and
felt no remorse for his actions. He also believed that the correctional of-
ficers meant him harm.
Interpersonal Violence
Interpersonal violence is defined as a pattern of assaultive and coercive
behaviors, including physical, sexual, and psychological attacks as well
as economic coercion. The assessment of IPV is somewhat different
from risk assessments done in psychiatric hospitals, clinics, and prisons.
The person being evaluated is usually the victim and may or may not
volunteer that he or she is being abused. Culture and religion also affect
the assessment and management of this potentially violent situation.
Intimate partner violence (IPV) is a form of interpersonal violence be-
tween two people who are intimate, including spouses, couples, and
partners. The term was developed to replace wife abuse or spousal abuse
in order to include gay partners. Within the women’s movement, IPV
usually refers to violence toward women; the term is also used in refer-
ence to gay female relationships.
IPV is pervasive, with one in four women in the United States expe-
riencing abuse during their lifetime (Tjaden and Thoennes 2000). In
2002, the World Health Organization identified domestic violence as a
serious public health problem, with victims experiencing more opera-
tive procedures, visits to doctors, and hospital stays than nonvictims.
Domestic violence not only causes acute injuries but also has been
linked to serious health consequences such as chronic pain, abdominal
complaints, sexually transmitted infections, unwanted pregnancies, de-
pression, posttraumatic stress disorder, miscarriages, and premature la-
bor (Krug et al. 2002). Unfortunately, many victims suffer in silence and
receive no assistance for their abusive situation. Healthcare and mental
healthcare professionals play a crucial role in identifying victims be-
cause these professionals have regular opportunities to ask their pa-
tients about domestic violence, regardless of the reason for the medical
visit. Patients should be routinely screened for domestic violence by di-
rectly asking about domestic violence, regardless of symptoms, injuries,
or reason for the visit (Mayor’s Office to Combat Domestic Violence
2003). In the latter part of this chapter, we discuss some culturally spe-
cific information useful in the assessment and prevention of IPV.
Case Example 3:
Domestic Violence in a Puerto Rican Woman
Ms. A, a 30-year-old Puerto Rican woman from New York, married an
Argentinean man she met in college. She was a second-generation
42 ❘ Textbook of Violence Assessment and Management
Critical Concepts:
Culturally Appropriate Assessment
Culture can be defined as a set of meanings, norms, beliefs, and values
shared by a group of people. These beliefs and values are taught, rein-
forced, and reproduced to the next generation. Culture refers to a sys-
tem of meanings in which words, behaviors, events, and symbols have
attached meanings that are agreed upon by the members within the cul-
tural group. Thus, an individual’s culture shapes how he or she makes
sense of the social and natural world. Finally, culture includes both the
subjective components of human behavior (the shared ideas and mean-
ings that exist within the minds of individuals within a group) as well
as the objective components (the observable behaviors and interactions
of these individuals).
One’s culture shapes what symptoms one expresses and how they
are expressed (Mezzich et al. 2000), and it influences the meaning that
one attributes to symptoms and how one interacts with the healthcare
system. Culture also influences what a society regards as appropriate or
inappropriate behavior, and it thus exerts a powerful influence on an in-
dividual’s potentially violent behavior. War, with its sociocultural
Cultural Competence in Violence Risk Assessment ❘ 43
violent behavior, this question would relate to the reasons behind and
justification for such behavior. Part three of the formulation concerns
stressors and supports and includes an extended family assessment re-
garding the family’s influence on the patient as well as the role that re-
ligion plays in the patient’s life. Part four is an examination done by the
clinician to assess what role the clinician’s and patient’s ethnicities are
playing in the interaction. (As in Case 2 above, there could be transfer-
ence on the patient’s part and countertransference from the evaluator’s
perspective, leading to fear on the evaluator’s part and to aggression
from the patient.) Part five assembles the previous four parts to make a
formulation that informs treatment, such as the cultural history in Case
1 above, leading to a culturally appropriate treatment plan.
DSM-IV-TR also includes culture-bound syndromes, such as amok,
boufée delirante, pibloktoq, and zar. Although these can provide an explana-
tion of violent behavior, they are seen in cultures not often encountered
in daily clinical practice. These syndromes are included in Table 3–2 for
reference. Using the DSM-IV-TR OCF in concert with a cultural consult-
ant or someone familiar with a particular culture’s beliefs, values, and
norms to help understand individuals’ beliefs about their behavior, their
family relationships, and their religious beliefs will yield much more use-
ful information for the assessment and management of violence.
Case Example 4:
A Pregnant Pakistani Adolescent
Sheryl comes in for her first visit to a psychiatrist. She is 17 years old and
has been married to her 19-year-old husband for 3 months. He answers
most of the questions for her and states that she is depressed and does
nothing around the house. The husband refuses to leave the room when
asked to do so. Nevertheless, the psychiatrist insists, and the husband
leaves the room. Sheryl never makes eye contact with the physician.
When the psychiatrist assesses her for IPV, she denies it. When asked if
her husband controls what she does, she states, “Of course he does. He
is my husband.”
Knowing nothing further about the patient than the stated case, we
would be alarmed by the overly controlling partner and the patient’s
lack of eye contact. We know, however, that she emigrated from Paki-
stan and is Muslim. The culturally specific information that we would
find helpful in this situation is that generally, Muslim women expect to
be married and expect that the marriage will be arranged. A study by
Hassouneh-Phillips (2001) showed that American Muslim women view
marriage as a means to achieving personal and spiritual happiness.
They also believe that good wives are obedient, because the Qur’an
states that men have more strength so their duty is to protect and sup-
port their women (Mayor’s Office to Combat Domestic Violence 2003).
As mentioned earlier, culture influences how people view and per-
ceive abuse; whether they seek help, how they communicate their expe-
riences; and from whom they are likely to seek assistance. Cultural fac-
tors may serve as barriers to treatment, such as an extended family
structure in which a family elder supports the abuse, or a church leader
who advises the woman to go back to her husband. The clinician should
communicate with each patient as an individual, without expecting
generalized reactions from their respective cultural groups.
48 ❘ Textbook of Violence Assessment and Management
Somalis
Pan et al. (2006) conducted interviews in San Diego, California, with
members of the Somali, Latino, and Vietnamese communities. They
found that Somali community members felt that physical violence was
an unacceptable means of conflict resolution. However, IPV is viewed as
an acceptable means of maintaining the patriarchal structure of the So-
mali family. The major sources of conflict within the family were changes
in gender roles and responsibilities since resettling in the United States.
The power dynamic in the family was reversed when families came to the
United States because government aid checks were issued to the Somali
women, not the men. Thus, Somali men reported feelings of helplessness
and uselessness because they have lost their role as the breadwinner for
the family, and many try to regain control through violence.
Somali women are responsible for maintaining harmony within the
family by supporting their husband, obeying his wishes, and not upset-
ting or angering him. IPV perpetrated by the husband can be justified in
situations in which the wife defied the husband’s wishes. Somali men
view this as the husband’s right to “teach his wife a lesson.” Interestingly
enough, there is no term for IPV in the Somali language. Both genders
report that it is a commonly held belief among women that if a husband
does not beat his wife, it means he does not love her. Most Somalis are
Cultural Competence in Violence Risk Assessment ❘ 49
Asian Americans
In assessing any Asian culture, it may be useful to know that Asians
value the importance of the family over the individual. They believe in
conflict avoidance and that personal problems such as marital issues
should remain private so as not to shame and dishonor the family and
50 ❘ Textbook of Violence Assessment and Management
cause a loss of face. Before marriage, a woman follows and obeys her fa-
ther; after marriage, she follows and obeys the husband; and after the
death of her husband, she follows and obeys the son (Xu et al. 2001).
Yoshioka and Dang (2000) did a survey of Asian American families
about their attitudes toward family violence. The men had the highest
score in support of male privilege. They believed that a man has the
right to discipline his wife, that he should be able to have sex whenever
he wants it, that he is the ruler of his home, and that some wives deserve
beatings. It is a sign of weakness to ask for help, and family members
would discourage the disclosure of problems and would make excuses
for the abuser. Asian Americans’ respect for their elders would result in
pressure not to report (see Table 3–4 for a list of barriers to reporting
IPV). Violence was justified if the wife had an extramarital affair, lost
emotional control, or made a financial decision without consulting the
husband. Older respondents and men were more tolerant toward the
use of force to resolve family conflict (Yick and Agbayani-Siewart 1997).
Vietnamese
The Vietnamese community in San Diego (Pan et al. 2006), as do many
non-Western ethnic communities, sees domestic violence as a family
matter. Sharing information about the family with outsiders is viewed
as inappropriate. Violence, ignoring problems, and seeking outside as-
sistance (court, counselors, police) are cited as unacceptable ways of re-
solving conflict, which creates a trap, because the victim cannot involve
outsiders to resolve his or her problems with violence. Shame is a major
barrier to accessing services. The responsibility for maintaining peace
and family harmony falls on the woman, who accomplishes this task by
obeying her husband’s wishes and attending to the needs of her hus-
band, much like what was seen in Somali families. Strong family ties
and respect for family members are cited as ways of promoting har-
mony in the family. Acceptable strategies for conflict resolution include
soliciting and listening to the advice of parents and elders or discussing
problems in a peaceful manner. The primary stressors for IPV were eco-
nomic. Bui and Morash (1999) stated that “for Vietnamese Americans,
women’s economic contributions could not reduce husbands’ domi-
nant positions and violence, but economic hardship could prevent
abused women from leaving an abusive relationship ” (p. 790). Viet-
namese participants reported that sending money to family members in
Vietnam or sponsoring family members to the United States are major
sources of tension. In addition, they repeatedly identified excessive
gambling as a cause of tension within the family. Both men and women
Cultural Competence in Violence Risk Assessment ❘ 51
gamble, and many spend their families’ income either in the casinos or
in underground gambling rings.
Cambodians
Weil and Lee (2004) described cultural factors that increase the risk of
IPV for Cambodian women. The cultural expectations of the wife are
52 ❘ Textbook of Violence Assessment and Management
that she will obey and respect the husband, not be sexually promiscu-
ous before or after marriage, and accept the problems of the marriage.
Women are blamed for problems regardless of fault, and in fact, the cul-
tural belief is that the woman must have done something wrong to de-
serve such punishment. A contributing factor is that most women were
physically abused by their parents before their marriages. Women do
not have the right to divorce or leave a husband who is hitting them and
cannot have their husbands arrested for violent acts against the family.
Latinos
In the Latino community, family harmony is supported by following
family traditions and celebrations and helping each other. Physical vio-
lence and verbal aggression are considered unacceptable ways of re-
solving conflict. Open communication between family members and
leaving potentially volatile situations are viewed as acceptable ways of
resolving conflict. Gender roles in this community appear to be slowly
changing as families adjust to living in the United States; men are start-
ing to recognize that women may have more to contribute to the family
than the domestic tasks of cooking, house cleaning, and childcare.
Latina women are asking for more equitable distribution of labor
and decision making in the household; however, they are still responsi-
ble for the vast majority of housework and childcare. Adolescent girls
reported frustration about the amount of responsibility they held in the
household compared with their brothers. The frequently mentioned
causes of tension in the family were economics, immigration status, and
substance use. Women from the Latino community reported that the
threat of deportation due to their undocumented status is often used as
a means of controlling them and ensuring that they do not leave abu-
sive situations. For example, women reported that men often say that if
their wives call the police, they will be deported. When compared with
the Somali and Vietnamese communities, the Latino community ap-
pears to be more aware of the availability of domestic violence interven-
tion services but has a limited understanding of how to use the services
and how to work with service providers. Significant barriers to access
are language and cultural differences, fear of deportation, and the in-
ability to effectively use identified services (Pan et al. 2006).
African Americans
African American families have a legacy of racism and stereotypes that
works against both members of the married couple. Black men, like
most men, may experience entitlement dysfunction when they see that
Cultural Competence in Violence Risk Assessment ❘ 53
they are being fitted into a gender role stereotype. They are often seen
as menacing, so they have been legitimized by this stereotype to be in-
timidating and controlling. African American women have an image of
having much sexual, social, physical, and economic power. They can
also be seen as invulnerable, insensitive, stoic, and in need of domesti-
cation and control. Victims of IPV feel shame about their inability to
have a perfect family. Those who have darker complexions, tall phy-
siques, are overweight, fight back, or have a mental illness are thought
to deserve abuse (Bell and Mattis 2000). Some African American adoles-
cent women are coerced into intimate relationships with older African
American males and may be labeled as morally suspect or hypersexual.
Financial pressures may make leaving an abusive relationship seem-
ingly impossible, because the single mother and her children would
end up homeless (Bell and Mattis 2000). Finally, Richie (1996) noted that
many African American women who are being battered by their part-
ners or sons are reluctant to report violence out of fear of contributing
to the victimization of African American men.
Potter (2007) found that many African American women seek sup-
port from religious leaders when trying to deal with IPV, and many are
not supported for reporting the violence or for wanting to leave their
husbands. The victim is often sent back to the perpetrator with the man-
date that they “should work things out” because Ephesians 5:21–33
states “submit yourselves unto your own husbands, as unto the Lord.
For the husband is the head of the wife, even as Christ is the head of the
church…. Therefore as the church is subject unto Christ, so let the wives
be to their own husbands in everything.”
Key Points
■ The culturally appropriate assessment of the risk of violence is
vital in developing effective interventions that are culturally con-
gruent.
■ As the United States becomes more ethnically diverse every year,
the likelihood increases that our patients will be from cultures
with which we are unfamiliar.
■ A violence risk assessment of culturally diverse patients requires
the clinician to become familiar with basic norms about violence,
coping strategies and behaviors, gender roles, and the roles of spir-
ituality and religion in the patient’s culture.
54 ❘ Textbook of Violence Assessment and Management
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C H A P T E R 4
Psychological Testing in
Violence Risk Assessment
Barry Rosenfeld, Ph.D., A.B.P.P.
Ekaterina Pivovarova, M.A.
59
60 ❘ Textbook of Violence Assessment and Management
Case Example
Assessing Violence Risk in a Criminal Defendant
For the past several months, Shawn, a 23-year-old medical student, had
been dating one of his medical school classmates, Veronica. As the rela-
tionship evolved, Shawn became increasingly jealous, accusing Veron-
ica of flirting with one of their professors and eventually demanding
that she confess to her infidelity. Veronica ended the relationship shortly
after this confrontation, but Shawn continued to initiate contact with
Veronica after class despite her repeated insistence that they had noth-
ing more to discuss. One day Shawn arrived at Veronica’s apartment un-
announced, demanding she let him in to talk about their relationship.
Veronica refused to allow him into the apartment and told Shawn she
would call the police if he continued to harass her. Soon afterward
Veronica began receiving telephone calls in the night; the caller typically
would hang up without speaking, but occasionally she heard a man’s
voice on the phone calling her insulting names. Several days later
Veronica thought she saw Shawn sitting in a car parked across the street
from her apartment. She telephoned the police, who confronted Shawn
and, on searching his car, discovered a camera, a stun gun, a large knife,
and a pair of handcuffs. However, because Shawn had not actually as-
saulted Veronica, the charges of harassment and stalking carried a rela-
tively modest penalty. Nevertheless, the court referred Shawn for a
mental health evaluation, requesting an evaluation of his mental state
and violence risk as well as recommendations for what treatment, if any,
was necessary.
Psychological Testing in Violence Risk Assessment ❘ 61
Psychopathy
Psychopathy is probably the most well established and widely known
risk factor for future violence, cutting across most contexts and popula-
tions. The term psychopathy has been used to describe the subset of indi-
viduals who engage in violent and criminal behavior, show no remorse
for their actions or empathy for their victims, and yet maintain a super-
ficial veneer of sociability and poise. A thorough review of the psych-
opathy literature could easily fill several volumes. For the purpose of
violence risk assessment, it is probably sufficient to note that this con-
struct comprises a central element of both clinical and actuarial (as well
as structured professional judgment) approaches to risk assessment.
62 ❘ Textbook of Violence Assessment and Management
The central “measure” of psychopathy for the past two decades has
been Hare’s Psychopathy Checklist (PCL) and its subsequent revision
(PCL-R; Hare 1991). The PCL was developed to measure the core con-
cepts of psychopathy and has been extensively validated in forensic
mental health research. Not only is the PCL-R considered by many to be
a critical element of any violence risk assessment, it is also incorporated
into many of the empirically supported actuarial risk assessment mea-
sures (e.g., the HCR-20 [Historical, Clinical, and Risk Management] and
Violence Risk Appraisal Guide). However, the PCL-R is not a psycho-
logical “test,” per se, but rather a clinical rating scale. The measure con-
sists of 20 items that are evaluated by a trained clinician on the basis of
clinical interview, official records, and third-party information. Each
item is scored on a scale of 0–2, with 0 indicating that the item does not
apply, 1 indicating that the item applies “somewhat,” and 2 indicating
that the item clearly applies to the individual. Scores are typically eval-
uated against published normative data, either by identifying the indi-
vidual’s level of psychopathy (e.g., percentile relative to typical crimi-
nal offenders or forensic psychiatric patients) or by identifying those
individuals who score above the threshold used to identify “psycho-
pathy” (i.e., greater than 30). Although considerable research has fo-
cused on elucidating a factor structure for this measure, most clinicians
rely on the total score for evaluating violence risk.
However, despite its importance in violence risk assessment, the
PCL-R has a number of limitations that are rarely acknowledged by
mental health evaluators. For example, although research studies typi-
cally demonstrate a high degree of interrater reliability across different
clinicians, individual evaluators may not have received comparable
training. Thus, the accuracy of PCL-R ratings will vary considerably
across clinicians, and contradictory PCL estimates are not uncommon.
In addition, mental health evaluators may be confused about the
different versions of the PCL that exist, at times using measures incor-
rectly. For example, Hare and Hart developed a screening version of the
PCL for use in research settings where identification of “probable” psy-
chopaths may be useful (Hart et al. 1995). Yet many clinicians utilize
this briefer instrument in clinical evaluations, seemingly unaware of the
different purpose and validation data that pertain to the screening ver-
sion (e.g., a higher rate of “false positives”: incorrect classifications of
nonpsychopathic offenders as psychopathic). Likewise, the PCL has
been adapted for adolescents (the PCL-YV, or Youth Version; Forth et al.
2003), although the validity of this measure for violence risk assessment
is far less convincing than for the PCL-R.
Psychological Testing in Violence Risk Assessment ❘ 63
The utility of the PCL for evaluating violence risk in women is also
far less clear than its utility in men, because the construct of psycho-
pathy has been less often explored in women offenders. The few studies
that have examined the use of the PCL-R in women have failed to clar-
ify whether this instrument is equally useful in women. Finally, cross-
cultural research on the construct and measurement of psychopathy is
still in a relatively nascent stage. Although a growing number of studies
have supported the utility of the PCL in other countries and settings,
and considerable research has analyzed the cross-racial validity of the
PCL in North American offenders (e.g., comparing Caucasian and Afri-
can American samples), this research has largely been restricted to
Western, highly developed countries (e.g., Sweden, the Netherlands,
the United Kingdom). In fact, little evidence exists to support (or con-
tradict) the utility of the PCL as an aid for evaluating violence risk in
non-Western cultures. Hence, considerable caution is warranted when
utilizing this measure in violence risk assessment with individuals who
fall outside the primary validation sample (North American males in
prison). In the vignette described earlier, for example, the PCL-R would
likely lead to an unrealistically low estimate of violence risk, largely
because of Shawn’s high-achieving background and lack of childhood
behavior problems or other serious antisocial behaviors.
bility that the individual being evaluated has not been honest in report-
ing his or her history, symptoms, behaviors, or thoughts. Hence, a thor-
ough assessment of test-taking style is typically critical to any violence
risk assessment, particularly when the individual’s self-report will make
up a significant component of the evaluation (which is often, but not
necessarily, the case). Although several instruments (e.g., MMPI-2,
MCMI-III, PAI) include scales that assess defensiveness, there is little
dispute that the MMPI-2 is the best-validated measure for evaluating
test-taking style. Of course, the presence of defensiveness does not cor-
respond to an elevated risk of violence, but it does suggest that the indi-
vidual’s denial, lack of insight or awareness, or deliberate minimization
of symptoms likely results in inaccurate (unrealistic) test results and self-
report. It is worth noting that although these instruments also include
multiple scales and indices to evaluate symptom exaggeration (malin-
gering), this pattern is rarely observed in the evaluation of violence risk
because little motive exists for exaggerating the severity of one’s symp-
toms. Furthermore, for the sake of brevity, the discussion that follows fo-
cuses primarily on the MMPI-2, with the acknowledgement that similar
scales and interpretations may be available from other measures.
Assuming that the individual has responded honestly to the MMPI-
2, interpretation of the Clinical and Supplementary scales of the instru-
ment can be helpful in identifying general aggressive tendencies. It
should, of course, be noted that the presence of a “profile” that is linked
to an elevated risk of violence is by no means sufficient to conclude that
an individual is at high risk for violence. Nevertheless, a personality
style associated with an elevated risk of violence may provide one indi-
cator of possible violence risk. Likewise, evidence of a psychotic disor-
der, which in itself may not correspond to an elevated risk of violence,
could provide important data in cases where the individual’s history or
clinical presentation suggests delusional beliefs of a threatening or
paranoid nature, as in the vignette previously described.
The scenario of paranoid delusions notwithstanding, the MMPI-2
profile most commonly associated with violence is the 3–4/4–3 profile.
This profile has been described as indicative of poorly controlled anger
and hostility, although more recent research on these scales and this
code type has been equivocal. In addition, the Overcontrolled Hostility
Scale, which was developed to identify individuals who engaged in se-
vere acts of violence that seemed disproportionate to the provocation,
has also been used to explain seemingly extreme violent incidents by in-
dividuals who had little prior history of violence, although most au-
thors caution against using this scale as a predictive measure because it
was developed using retrospective analyses (Greene 2000).
Psychological Testing in Violence Risk Assessment ❘ 65
A number of other MMPI-2 subscales exist that are both less contro-
versial and less widely studied than the Overcontrolled Hostility Scale.
For example, a number of subscales have been developed specifically
for the Psychopathic Deviance Scale (Scale 4) that break down eleva-
tions on this clinical scale into smaller, content-based subdivisions. The
five subscales developed by Harris and Lingoes are Familial Discord,
Authority Conflict, Social Imperturbability, Social Alienation, and Self
Alienation (Harris R, Lingoes J: Subscales for the Minnesota Multipha-
sic Personality Inventory. San Francisco, CA, The Langley Porter Clinic,
unpublished manuscript, 1955). Although some of these subscales (e.g.,
Social and Self Alienation) are less intuitively relevant to violence risk,
Osberg and Poland (2001) found modest correlations (r= 0.36) between
Authority Conflict and Self Alienation and future criminal behavior
among a sample of inmates who were eventually released. In fact, these
subscales provided considerable incremental validity beyond the larger
scale. Thus, although relatively little research has applied these sub-
scales to violence risk assessment, particularly in prospective studies,
they may provide a useful element of MMPI-2 interpretation in risk as-
sessment settings.
The PAI, another widely used, multi-scale, objective personality in-
ventory, has also been used in violence risk assessment. The PAI not
only includes several scales intended to measure aggressive tendencies
(Aggressive Attitude, Verbal Aggression, and Physical Aggression), but
also includes a summary index intended to quantify violence potential.
Unfortunately, despite this scale’s potential, relatively little research has
supported its use as a risk assessment tool (Morey and Quigley 2002).
Likewise, the PAI Correctional Report includes an “Institutional Risk
Circumplex” intended to help evaluate the offender’s likelihood of en-
gaging in violent behavior within a prison setting, although at present
this index too has little empirical support for its utility (Edens and Ruiz
2005).
Finally, the MCMI-III includes subscales for Antisocial Personality
Disorder along with scales tapping Sadistic and Negativistic (opposi-
tional) personality traits (Millon 1994). Although elevations on these
scales, either in isolation or in combination with other scales, are often
interpreted as indicating aggressive tendencies, relatively little research
has addressed—let alone supported—these interpretations. In short, al-
though multi-scale inventories such as the MMPI-2, PAI, and MCMI-III
have considerable potential and are frequently utilized in violence risk
assessment, empirical support for many of the indices and interpreta-
tions is extremely limited, and the need for caution in making any con-
clusions regarding violence risk cannot be overemphasized.
66 ❘ Textbook of Violence Assessment and Management
ment, the MacArthur Risk Assessment Study found strong evidence for
the predictive validity of the measure in identifying psychiatric patients
at elevated risk of future violence. Thus, although still relatively under-
studied, this measure of impulsivity may have some utility in violence
risk assessment.
arousal patterns. However, despite its frequent use in sex offender treat-
ment settings, this technique has a number of significant limitations, in-
cluding the relatively modest research literature supporting its predic-
tive validity. Questions also exist regarding the potential impact of
anxiety, sexual abstinence, and conscious repression of arousal on the
relative arousal ratio on the PPG. Furthermore, clinicians are likely to
encounter privacy and ethical issues in using this highly intrusive in-
strument, particularly when the risk assessment has been mandated
and true consent is not obtained.
In response to the limitations of the PPG, Gene Abel, one of the lead-
ing researchers on treatment of sexual offenders, developed an alterna-
tive approach to evaluating deviant sexual arousal, the Abel Assess-
ment of Sexual Interest (AASI; Abel et al. 1998). The AASI, designed to
be a less invasive measure than the PPG, is composed of three parts: the
individual’s subjective rating of sexual interest, a measure of Visual Re-
action Time (VRT) in response to sexual stimuli, and a questionnaire de-
signed to elicit attitudes and cognitions thought to correspond to sexual
offending. However, the key component of the AASI is the measure of
VRT, which records the amount of time the individual examines visual
stimuli presented on the computer screen. This measure hinges on the
assumption that sexual offenders who spend relatively more time view-
ing images that depict sexually deviant material are likely to have
greater arousal to these stimuli and are therefore more likely to re-
offend than individuals who spend relatively little time viewing sexu-
ally deviant images. In addition, by comparing viewing patterns for
multiple possible types of paraphilic interest, the AASI may help differ-
entiate the specific nature of an individual’s deviant arousal, helping
guide treatment and risk management strategies.
However, relatively little research has examined either the AASI in
general or the VRT in particular. Abel et al. (2004) found some support
for the utility of the VRT in identifying child molesters, but virtually no
research has addressed the validity of this measure in other populations
of sex offenders. Moreover, the effectiveness of the VRT in differentiat-
ing different subgroups of sex offenders (e.g., pedophiles versus adult
rapists) or identifying offenders with a high likelihood of re-offending
is not clear. As discussed earlier, the self-report sections of the AASI are
also clearly vulnerable to the biased responding that occurs so often in
violence risk assessment (and even more so among sex offender evalu-
ations, given the negative ramifications of admitting deviant sexual
arousal). However, despite the limited research on its validity, the AASI
holds some promise as a potential aid to violence risk assessment for
sexual offenders. That said, at present it is clear that the AASI does not
72 ❘ Textbook of Violence Assessment and Management
Conclusion
The importance of accurate violence risk assessment cannot be over-
stated, because the potential ramifications of errors can be devastating.
Fortunately, a growing number of psychological tests and techniques
can assist the clinician performing such evaluations. In the case example
presented earlier, psychological testing might help to illuminate many
potentially critical violence risk factors such as psychosis, impulsivity,
and anger management issues and substance abuse. For example, a Ror-
schach Inkblot test might be useful to evaluate the possibility of an un-
derlying psychosis that might account for Shawn’s jealousy. In addition,
personality tests such as the MMPI and SASSI could provide useful in-
formation regarding the extent of Shawn’s substance abuse that might
help explain his increasingly problematic behavior (which, given his
status as a medical student, likely reflects a significant change from his
baseline) and provide an alternative avenue for intervention. In addi-
tion, such measures would provide information regarding the validity
of Shawn’s self-report through an evaluation of his response style (i.e.,
the presence or absence of defensiveness). Finally, evaluating impulsiv-
ity and anger through either self-report (e.g., the Barratt or Novaco
scales) or clinical ratings (as elicited by the PCL) would help clarify the
extent to which Shawn’s recent behavior actually reflects a change in,
rather than a continuation of, long-standing personality characteristics.
A finding of changed behavior might support the hypothesis that
Shawn’s behavior is the result of an emerging mental disorder that is
potentially (likely) treatable, with specific treatment recommendations
being guided by the nature of the disorder. A determination that
Shawn’s behavior is a manifestation of long-standing personality char-
acteristics would highlight the need to more closely examine his past
behavior as an indication of his current violence risk (which may be less
relevant in the context of an emerging mental disorder).
This chapter outlines a number of different psychological assess-
ment techniques that may be useful supplements to a clinical evalua-
tion of violence risk. Whether the clinician uses an actuarial approach,
a structured professional judgment approach, or an unstructured clini-
cal evaluation, accurate determination of violence risk requires careful
assessment of the risk factors that have been identified in the research
literature. Although the scope and comprehensiveness of the measures
described in this chapter vary widely—as does their validity in risk as-
Psychological Testing in Violence Risk Assessment ❘ 73
Key Points
■ Psychological testing can be a valuable supplement to any risk
assessment approach.
■ Evaluating defensiveness is critical, particularly when self-report
is relied on.
■ Assessing underlying psychosis, sexual deviance, or substance
abuse can help identify important risk-enhancing symptoms.
■ Formal assessment of psychopathy can bolster any risk assess-
ment method.
■ Limitations exist regarding validity of assessment in populations
other than Western, English-speaking adults.
References
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P A R T I I
Mood Disorders
Rif S. El-Mallakh, M.D.
R. Jeannie Roberts, M.D.
Peggy L. El-Mallakh, Ph.D.
Passive Exposure
Witness to Domestic Violence
Early life experiences can affect both the biology and behavior of an in-
dividual. For example, abuse or neglect of young individuals will influ-
ence the development of mood disorders and problem behaviors later
77
78 ❘ Textbook of Violence Assessment and Management
wards et al. 2006; Hanson et al. 2006; Peiponen et al. 2006; Sher et al.
2005; Whitaker et al. 2006).
Physical Abuse
Physical abuse may be a major contributing factor in the development
of violence in later life (Huizinga et al. 2006). Physical abuse is also piv-
otal in the development of depression in youth and on into adulthood
(Cukor and McGinn 2006; Reigstad et al. 2006; Widom et al. 2007;
Wright et al. 2004). Physical abuse may occur in either the home envi-
ronment or in school. Bullying is a form of verbal and physical violence
that can have major impact on development. The odds of experiencing
social problems and depression with suicidal ideation and attempts are
3.9 times higher among victims of bullying compared with nonvictims
(Brunstein Klomek et al. 2007; Kim et al. 2006). Furthermore, bullying
behaviors have been linked to mood disturbances. The odds of bullies
developing social problems, depression, and suicidality are 1.8 times
higher compared with people who are not bullies, and bullies who are
also targets of other bullies are 4.9 times as likely to develop social prob-
lems (Brunstein Klomek et al. 2007; Kim et al. 2006). High-profile school
shooters such as those at Columbine High School or Virginia Tech had
been bullied by classmates.
Sexual Abuse
Sexual abuse of children is associated with a wide variety of physical
and psychological sequelae, many of which are lifelong. Early sexual
80 ❘ Textbook of Violence Assessment and Management
Adult Assault
After personality development is complete, adult assaults (sexual or
physical) can increase the likelihood of the development of mood dis-
turbances (Johansen et al. 2006). Consequences of being a victim of as-
sault include depression, anxiety disorders, and substance abuse; these
can persist for decades (Acierno et al. 2007).
tion in women who have experienced IPV is 17.5 times higher com-
pared with women who have not experienced IPV. However, depres-
sion frequently predates the episodes of IPV, and the presence of
depression in young women actually increases the likelihood of dating-
violence (Foshee et al. 2004; Rivera-Rivera et al. 2006). African Ameri-
can women may be at particular risk for mood disturbances due to high
rates of IPV; 18% also abuse alcohol, which can worsen prognosis
(Paranjape et al. 2007). Women in abusive relationships have a great
need for emotional support (Theran et al. 2006), and African American
women appear to obtain much support through spirituality and affilia-
tion with religious institutions (Mitchell et al. 2006; Watlington and
Murphy 2006).
Treatment Approaches
Pharmacological approaches to treatment are geared toward treating
the depression and PTSD that may be associated with past or current
exposure to violence. In addition, researchers have investigated the
82 ❘ Textbook of Violence Assessment and Management
Case Example 1
Ms. A is a 36-year-old woman who presented to the emergency psychi-
atric service with a complaint of worsening depression and suicidal ide-
ation. She had a previous psychiatric history of recurrent major depres-
sion since adolescence, PTSD, and prescription benzodiazepine abuse.
She was not currently in treatment but had been treated in the past with
psychotherapy and a variety of antidepressant, anxiolytic, and antipsy-
chotic medications. She had had three previous hospitalizations, all as-
sociated with suicide attempts. The current episode began when her
boyfriend, with whom she lived, had become more abusive. He had at-
tempted to strangle her and had then raped her after an argument about
his alcohol abuse. She reported a remote history of childhood emotional
abuse by an alcoholic father prior to her parents’ divorce and sexual mo-
lestation by her mother’s boyfriend when she was 13 years old.
Ms. A was admitted to a crisis stabilization unit for 10 days, started on
an antidepressant (sertraline, 100 mg/day), and engaged in supportive
and insight-oriented psychotherapy. After discharge she engaged in out-
patient psychotherapy and pharmacotherapy. She continued to complain
of anxiety, and due to her history of benzodiazepine abuse, gabapentin
was started and increased to 1,200 mg three times daily. She reconciled
with her abusive boyfriend after he stopped using alcohol. However, the
Mood Disorders ❘ 83
Summary
Aggression and depression are intimately related. Early exposure to ag-
gression, either as a witness or as a victim, increases the likelihood of
depression, the chronicity of depression, and the likelihood of becom-
ing a perpetrator of future aggression. Similarly, early abuse increases
the risk of subsequent victimization and chronic depression.
Case Example 2
Mr. B was a 34-year-old white man with a history of bipolar disorder. He
reported that he experienced frequent “mood swings.” He described
these as brief periods (minutes to hours) in which he quickly lost his
temper. During these periods, he could become aggressive toward
strangers or toward significant others to whom he was emotionally at-
tached. He reported frequent fights and previous arrests for assault. Mr.
B also had a history of significant alcohol and marijuana abuse, which
he minimized. He denied that his marijuana use was a problem and
stated that it helped him calm down. He also did not view his alcohol
abuse as a problem because he did not “drink every day” and main-
tained that he could quit “at any time.” On questioning, he reported ep-
isodes of reduced sleep, reduced need for sleep, increased irritability, in-
creased rapid thoughts and distractibility, and increased involvement in
multiple problematic behaviors. These periods lasted 4–5 days and oc-
curred three or four times annually. He also reported periods of depres-
sion that were generally brief, lasting only 2 weeks, during which he
also manifested irritability, loss of interest, loss of pleasure, low self-
esteem, increased frustration, and suicidal ideation. He reported that he
had used both alcohol and marijuana during these episodes. He had no
periods of significant sobriety. A tentative diagnosis of type II bipolar
disorder was made, along with intermittent explosive disorder and al-
cohol and marijuana abuse. Mr. B was offered treatment with dival-
proex and psychotherapy and was encouraged to attend treatment for
substance abuse. He never sought out substance abuse treatment and
never stopped using marijuana, but he had brief periods in which he
stopped using alcohol. These periods of abstinence from alcohol gener-
ally lasted less than 1 month. His compliance with divalproex and psy-
chotherapy was very poor. He continued to have periods of depression
and impulsive rage, and he continued to abuse alcohol and marijuana.
Two years after his initial presentation, Mr. B committed suicide with a
self-inflicted gunshot wound.
Summary
Aggression is common in individuals who are experiencing an episode
of mania, and there may be a subtype of mania in which aggression is
the core feature. Aggression may also be common in unipolar major de-
pression. The effect of antidepressants on aggression is unclear. If there
is an anti-aggression effect of these agents, it is weak. Most commonly,
the mood-stabilizing antiepileptic medications and antipsychotic med-
ications are used to treat aggression, but their anti-aggression effect ap-
pears to be weak.
Only 37% had a major depressive illness at the time of the DSH assess-
ment, but 21% of the males had no psychiatric diagnoses at the time of
the DSH (Lamprecht et al. 2005).
In young adults, the lack of depression in subjects with DSH has also
been noted. Among 1,986 high-functioning military recruits (62%
male), only 10% of those with a history of DSH reported depressive
symptoms on the Beck Depression Inventory (Klonsky et al. 2003).
Peers viewed self-harmers as having strange and intense emotions and
a heightened sensitivity to interpersonal rejection (Klonsky et al. 2003).
Given that DSH may not necessarily be associated with depression,
why does it occur? Tzemou and Birchwood (2007) examined dysfunc-
tional thinking patterns and intrusive memories in patients diagnosed
with both unipolar depressive and bipolar mood disorders. They re-
cruited 49 participants diagnosed with major depression or manic or
hypomanic episodes. Twenty healthy control subjects were also re-
cruited from the same areas in Central England. Compared with the
healthy controls, dysfunctional attitudes were abnormal in the mood-
disordered groups when ill (Tzemou and Birchwood 2007). Interest-
ingly, whereas dysfunctional attitudes resolved in bipolar subjects as
they became euthymic, they persisted into euthymia for those diag-
nosed with unipolar major depression (Tzemou and Birchwood 2007).
der (Jamison 1993). On Christmas Eve in 1888, van Gogh cut off his own
earlobe with a razor blade as he was apparently attempting to attack an
acquaintance. Following this episode of self-harm, van Gogh exhibited
alternating states of “madness and lucidity” and received treatment in
an asylum in Saint-Remy. Two months after his discharge from the asy-
lum, he committed suicide by shooting himself “for the good of all”
(Van Gogh Gallery 2007).
1999; Henriksson et al. 1993). The fraction of adolescent suicides that in-
volve depression may be slightly higher, at 43% (Brent et al. 1993).
Comorbid psychiatric conditions may additionally increase the risk
for suicide. Paramount among these is co-occurring substance use,
which accounts for some 45% of completed suicides (Rich et al. 1986).
Additionally, aggression (Dervic et al. 2006; Keilp et al. 2006) and Clus-
ter B personality disorders (Dervic et al. 2006) are associated with sui-
cide attempts in depressed individuals with a history of childhood sex-
ual abuse.
A decline in depression and hopelessness was associated with a de-
cline in suicidal ideation in 198 people diagnosed with major depres-
sion (Sokero et al. 2006). There is a close correlation between the in-
creased use of antidepressants and an observed decline in overall
suicide rate (Gibbons et al. 2006; Korkeila et al. 2007), but this trend may
have begun prior to the introduction of antidepressants (Safer and Zito
2007). Antidepressants may have no effect on suicide ideation (Ham-
mad et al. 2006) or may actually increase the risk of suicide attempts
among depressed adults (Tiihonen et al. 2006) and suicide ideation
among adolescents (Bridge et al. 2007; Dubicka et al. 2006), but they
may reduce completed suicides (Tiihonen et al. 2006). The U.S. Food
and Drug Administration has placed a warning on all antidepressants
that they may increase suicidal ideation in adolescents (Kuehn 2007).
Although lithium is rarely used in major depressive disorder, it appears
to have an antisuicide effect similar to that seen in bipolar illness (Guz-
zetta et al. 2007).
Case Example 3
Mr. C was a 66-year-old married white man with a lifelong history of al-
cohol abuse and depression. He had been treated intermittently with an-
tidepressants but never persisted in psychiatric treatment for more than
3 months. He had had a chaotic relationship with his wife of 44 years
and had been verbally and physically abusive. For unknown reasons, in
the setting of ongoing alcohol abuse, he shot and killed his wife and
then killed himself.
Suicide and homicide are ultimately two sides of the same coin.
Individuals who commit suicide are more likely to have a history of
92 ❘ Textbook of Violence Assessment and Management
Summary
DSH behaviors frequently occur independently of suicide and should
be considered separate phenomena. However, individuals who engage
in DSH are at a higher risk of subsequent suicide. Subjects who engage
in DSH behavior have generally experienced early abuse. Both major
depression and bipolar illness are significant risk factors for completed
suicides. Bipolar disorder carries a much higher risk for completed sui-
cide than does major depression. Comorbid disorders, particularly sub-
stance abuse, increase the suicide risk. Antidepressants may increase
suicide ideation but do not appear to increase completed suicides and
may reduce the severity of suicide attempts. Lithium has a clear antisui-
cide effect in both bipolar illness and unipolar major depression.
Key Points
■ Early exposure to aggression, either as a witness or as a victim,
increases the likelihood of future depression, the severity and
chronicity of future depressions, and the likelihood of perpetrat-
ing future aggression.
94 ❘ Textbook of Violence Assessment and Management
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C H A P T E R 6
Schizophrenia and
Delusional Disorder
Martha L. Crowner, M.D.
Violence Assessment
The first step in assessing a violent incident is to find out exactly what
happened. Ask who did what to whom. The term violent, like aggression,
agitation, and assaultiveness, is often used quite loosely and imprecisely,
105
106 ❘ Textbook of Violence Assessment and Management
abused cannabis, 19%, and for those who abused alcohol, 25%. Trained
nonclinicians administered the Diagnostic Interview Schedule, based
on DSM-III (American Psychiatric Association 1980), to arrive at Axis I
diagnoses. When a person met criteria for more than one diagnosis, he
or she was counted in both categories. Those with more diagnoses were
more likely to be violent. In logistic regression analysis, male gender,
youth, poverty, substance abuse, and major mental illness all predicted
violence, as did the interaction between substance abuse and major
mental illness.
Other investigators have had similar findings: a low base rate of vi-
olence and a moderate rate in adults with psychotic illness. A large Is-
raeli survey (Stueve and Link 1997) found a 7% rate of violence in the
previous 5 years in adults ages 24–33 without identified psychiatric ill-
ness and a 21% rate in adults with psychotic or bipolar disorders. They
also found higher rates in those with comorbid substance abuse (39%)
and very high rates (93%) in those with psychotic or bipolar disorders
comorbid with antisocial personality, with or without substance abuse.
The relationship between violence and psychotic and bipolar disorders
was significant after controlling for substance abuse, antisocial person-
ality disorder, and demographic characteristics. Investigators asked if
respondents had been in a physical fight within the previous 5 years or
had a weapon in hand during a fight.
Diagnoses of psychosis obtained in large community samples such as
these may agree poorly with clinical diagnoses, but these studies give a
general idea of comparative rates of violence across diagnoses and with
comorbidity. Community samples have the advantage of avoiding the
sampling bias that can occur in studies of hospitalized patients (i.e., that
many of these subjects are hospitalized because they have been violent).
and crudely classed into these two groups. Reactive events are impul-
sive, affective, or explosive, whereas instrumental events are coercive,
predatory, or psychopathic (Eichelman 1990). This dichotomy is an
oversimplification, because motives are often mixed, but it can be use-
ful in treatment planning for mentally ill people. Investigators believe
that reactive aggression is more treatable than instrumental aggression
(Campbell et al. 1978, 1982, 1984, 1995; Sheard et al. 1976).
In reactive fights, assailants react out of strong emotion. For exam-
ple, in a study in which we asked assailants to explain their behavior
(Crowner et al. 1995), one said, “I couldn’t help it. She made me lose
face. She keeps insulting me in front of others. I just did it.” Another
said, “I was upset. She just ticked me off when she hit me with the ping-
pong racket. I’m going to kill her if she hits me again.” Another said, “I
was so angry with him, the way he plays games before he takes his
medication. We always have to suffer because he plays those games. We
can’t get our cigarettes on time. I pushed him to one side so I could get
my medication. I didn’t think he’d fall.”
Instrumental assaults have a concrete goal. For example, a patient-
assailant explained, “He didn’t want me to have any of his food or
candy. He just has to do what I say.” Another said, “He sat on my chair
[the chair where this man habitually sat] after I stood up to take my
medication. I asked him to get up from my chair but he pretended not
to hear me, so I lifted up my chair.”
Assailants express reasons that have both reactive and instrumental
aspects when they say they assaulted someone to make him or her stop
a noxious behavior. One said, “He started it. He was bothering me and
bothering me. I just have to hit him to make him stop. He instigated it.
It’s not my fault. I think I broke his nose, but it was not my fault.” An-
other said, “He’s always cursing and harassing me. I woke up one
morning and just couldn’t take it anymore. I just wanted to make him
stop, let him know I was in a bad mood that day.” A third patient said,
“I wanted him to stop bothering the patients. He was bothering another
patient. I just wanted to help. I am a fair guy, and I don’t like others be-
ing bullied.”
Violence Management
General Principles
Inpatient management of violent patients is truly a team effort, requir-
ing consensus and collaboration with all disciplines, particularly—but
not exclusively—nursing. Psychiatrists have a legal and professional re-
sponsibility to lead this team by managing group dynamics and by
guiding treatment decisions. Assaultive patients very often stir up in-
tensely emotional conflicts within groups of staff members and be-
tween patient and professionals. Management decisions should be
guided by data, an empathetic engagement with the patient, and calm.
Staff are obliged to make all possible efforts to preserve patient dignity
and protect patient safety. To balance our obligations to patients with
our obligations to the safety of staff demands astute judgment and un-
usual skill.
The treatment team should have established guidelines for identify-
ing potentially dangerous situations and for choosing interventions to
prevent escalation of threatening behaviors. Criteria for intramuscular
medication given without patient consent and for seclusion and re-
straint should be clear, concrete, and accepted by the entire ward staff.
Management strategies vary according to local custom; staff will
usually turn to what they have done before and what seems to have
worked. However, interventions should be the least restrictive neces-
sary to ensure safety and should be based on available data. Restraint
and seclusion should be interventions of last resort, because patients
find them traumatic and humiliating and because these interventions
often lead to injuries of patients and staff. Use of restraint and seclusion
114 ❘ Textbook of Violence Assessment and Management
is reviewed in this volume (Chapter 17) and also by Bernay and Elver-
son (2000).
Pharmacological management of violent adults with schizophrenia
is discussed at length elsewhere in this volume (see Chapter 15). I only
mention briefly a few points here. Medication adherence is often key.
The physician must attempt to establish an alliance with the patient,
however tenuous, and delicately balance adverse and beneficial effects.
Court-ordered treatment may be necessary. When it is clear that the pa-
tient is taking medication, and it is not effective after an adequate trial,
clozapine can be helpful. Many have documented clozapine’s benefits
for violent patients, but Krakowski et al. (2006) completed a study di-
rectly comparing haloperidol, olanzapine, and clozapine in the treat-
ment of assaultive patients with schizophrenia and schizoaffective dis-
order. They found that clozapine was more efficacious than olanzapine,
and olanzapine was more efficacious than haloperidol. The antiaggres-
sive effects seemed to be above and beyond the antipsychotic and sed-
ative effects of the medications.
easily thrown and blood pressure cuffs set in heavy metal posts on
wheels. Eliminate places where weapons can be hidden, such as
dropped ceilings made of fiberboard squares that can easily be lifted.
Safeguard individual patient privacy with barriers in bathrooms, show-
ers, and bedrooms so personal intrusions and reactive, paranoid as-
saults are less likely. Safeguard personal possessions to decrease thefts.
Patients should have secure lockers with functional locks. Valuables
such as cash and cigarettes may be best held by staff.
Physical closeness and threats can predict assault. This has practical
significance for management of space between patients, for example in
lines, elevators, dining rooms, and dayrooms. Avoid crowding, bump-
ing, shoving, and pushing. Do not require patients to wait in lines for
medications or meals. In a large psychiatric hospital, patients were
escorted daily to off-ward programming. So that escorts could make
fewer trips, patients were packed shoulder to shoulder and elbow to
belly into elevators; in this setting, angry shouts and shoving were com-
mon. Shouts and shoving could easily lead to fistfights in a small en-
closed space. This is an excellent example of what not to do.
Case Examples
The following is an example of a very serious assault; this type of assault
is rare and is not part of the studies discussed earlier, except perhaps
Taylor’s (1985). It illustrates that psychotic factors, particularly delu-
sional thinking, can be forgotten, suppressed, or repressed while non-
psychotic motivations are expressed.
Case Example 1
Mr. A was 48 years old when he was released on parole and committed
to a psychiatric hospital after serving a 12-year sentence for killing his
common-law wife with a kitchen knife. He related that she started a
fight with him over a coat, which she said he did not hang up properly.
As she came at him with a large fork, he stabbed her. “She got like that,”
he said. He denied he was drinking or using illicit substances at the time
of the crime. After the crime, he turned himself in at the local precinct.
As he lay in bed in prison, he would occasionally see and hear his
wife and long for her. “Don’t cry over spilt milk? I still cry over spilt
milk,” he said. “That saying is wrong.”
Records of a psychiatric admission 4 years before the crime revealed
that he had gone to his wife’s workplace with a knife because he wanted
to break the spell he believed she had cast over him. He also believed
she was controlling his mind. Of this admission Mr. A had few memo-
ries. He could only recall, “They say I was hearing voices.” When re-
minded of the documented circumstances of his previous admission, he
became visibly disturbed and said at that time he was acting a fool and
was ill.
Case Example 2
Mr. B was a man in his twenties with a diagnosis of chronic schizophre-
nia and mild mental retardation. He had been continuously hospitalized
for at least 5 years. On the ward he was constantly irritable and paranoid,
especially about the food he was served, believing it was deliberately
contaminated with crack cocaine or cyanide. He also worried that he was
losing weight and that his body was changing in various ways.
Mr. B was seen daily, and he frequently would present a complaint.
He asked to see an ophthalmologist for poor near vision and a podiatrist
for burning feet and dry skin. He asked to sleep in an open seclusion
room because his room was too hot. He refused breakfast, saying he had
a cold that he could feel in his chest and head. He asked for cough syrup
and to stay in bed. He said he did not get his oral antipsychotic medica-
tion and that he could not live without it. Later the same day he com-
plained his mind was exploding because of medication, asked for a de-
creased dose, and said he needed none.
This patient could be mollified or put off sometimes, but never con-
vinced or brought around. He wanted to explain that all the violent in-
cidents he had been involved in were not his fault. After a few weeks of
such complaints, he punched another patient in the head because, as he
related, he was upset that he had not received a kosher diet. Fifteen min-
utes later while passing in the hall, his victim hit Mr. B, and Mr. B be-
came enraged. Staff members tried at length to calm him down, but he
hit one in the face.
After it became clear that Mr. B was ingesting little of his medication
consistently, a court order for fluphenazine decanoate was obtained. As
a result he had increased attention span, better ability to express himself
verbally, fewer paranoid and somatic complaints, and much less as-
saultiveness.
Case Example 3
Mr. C was sent to a hospital emergency department after he punched
another man at the shelter where he was living. The other man, who was
118 ❘ Textbook of Violence Assessment and Management
Key Points
■ Large community surveys find rates of violent behavior in adults
with schizophrenia are somewhat higher than in adults with no
diagnosed psychiatric illness but are lower than in groups with
substance abuse disorders.
■ Serious violence in a large group of patients with schizophrenia
has been associated with hostility, suspiciousness, persecutory
delusions, hallucinations, grandiosity, and excitement.
■ Negative symptoms were associated with a decreased risk of
serious violence in this same large group. High levels of positive
symptoms with high levels of negative symptoms were not linked
to increased risk of serious violence, but high levels of positive
symptoms with low levels of negative symptoms were.
Schizophrenia and Delusional Disorder ❘ 119
References
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Disorders, 3rd Edition. Washington, DC, American Psychiatric Associa-
tion, 1980
120 ❘ Textbook of Violence Assessment and Management
Arseneault L, Moffitt TE, Caspi A, et al: Mental disorders and violence in a total
birth cohort. Arch Gen Psychiatry 57:979–986, 2000
Bernay LJ, Elverson DJ: Managing acutely violent inpatients, in Understanding
and Treating Violent Psychiatric Patients. Edited by Crowner ML. Wash-
ington, DC, American Psychiatric Press, 2000, pp 49–68
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dangerous behavior: a critique of the major findings in the last decade. Clin
Psychol Rev 24:513–528, 2004
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child and adolescent psychiatry. J Am Acad Child Psychiatry 17:717–720,
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Eichelman BS: Neurochemical and psychopharmacologic aspects of aggressive
behavior. Annu Rev Med 41:149–158, 1990
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olence in the social networks of people with serious psychiatric disorders.
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phrenia: relationship to clinical symptoms. Schizophr Bull 25:505–517, 1999
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treatment of violent patients with schizophrenia and schizoaffective disor-
der. Arch Gen Psychiatry 63:622–629, 2006
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ing the components of “threat/control-override” symptoms. Soc Psychia-
try Psychiatr Epidemiol 33:S55–S60, 1998
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arthur Study of Mental Disorder and Violence. New York, Oxford Univer-
sity Press, 2001
Nolan KA, Czobor, P, Biman R, et al: Characteristics of assaultive behavior
among psychiatric inpatients. Psychiatr Serv 54:1012–1016, 2003
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committed by chronically assaultive state hospital patients. Psychiatr Serv
58:521–528, 2007
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gressive behavior in man. Am J Psychiatry 133:1409–1413, 1976
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ological study of young adults in Israel. Psychiatr Q 68:327–342, 1997
Swanson JW, Holzer CE, Ganju VK, et al: Violence and psychiatric disorder in
the community: evidence from the Epidemiologic Catchment Area sur-
veys. Hosp Community Psychiatry 41:761–770, 1990
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ior in persons with schizophrenia. Arch Gen Psychiatry 63:490–499, 2006
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atry 147:491–498, 1985
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C H A P T E R 7
Posttraumatic Stress
Disorder
Thomas A. Grieger, M.D., D.F.A.P.A.
David M. Benedek, M.D., D.F.A.P.A.
Robert J. Ursano, M.D., D.F.A.P.A.
123
124 ❘ Textbook of Violence Assessment and Management
symptoms associated with PTSD, but not required for the diagnosis, in-
clude impaired interpersonal relationships, impaired affect modula-
tion, self-destructive and impulsive behaviors, feelings of constant
threat, and changes in personality characteristics. The American Psy-
chiatric Association’s practice guidelines note that some individuals
with PTSD have an increased expectation of danger that results in an
“anticipatory bias” in their perception of their environment and in-
creased readiness for “flight, fight, or freeze” responses (Ursano et al.
2004). This increased readiness for aggression may take the form of a re-
duced ability to tolerate mild or moderate slights, resulting in acts that
are disproportionate to the degree of provocation. Other psychiatric
conditions commonly comorbid with PTSD include major depression,
substance abuse disorders, and other anxiety disorders (American Psy-
chiatric Association 2000).
Almost all studies of aggression and violence in patients with PTSD
have been conducted among combat veterans from the Vietnam era. Vi-
olence in patients who develop PTSD in response to sexual assaults,
physical assaults, motor vehicle crashes, acts of terrorism, or exposure
to natural and manmade disasters has not been well studied. In contrast
to other patients with PTSD (e.g., those whose PTSD results from a mo-
tor vehicle accident or an isolated sexual assault), war veterans during
combat will have experienced extended periods of heightened vigilance
and arousal lasting weeks to months and extreme and repeated inter-
personal violence. Exposures include being shot at by enemy forces,
killing enemy forces, and sometimes being responsible for the wound-
ing or death of noncombatants. Under certain wartime conditions,
some may also witness or participate in repeated non-warfare acts of
abusive violence or killing of prisoners or civilians (Laufer et al. 1984).
Some civilian law enforcement officers may also have similar, but less
repeated, exposures.
Veterans with PTSD demonstrate higher levels of anger, problems
with anger regulation, increased levels of criminality, increased levels of
violence, and greater potential for serious acts of violence when com-
pared with other patient populations. Domains of anger problems in-
clude inaccurate perception and processing of environmental cues,
heightened physiological and emotional activation, and behavioral in-
clinations to act in antagonistic or confrontational ways (Chemtob et al.
1997). Patients with regulatory deficits in all three domains display an-
ger and aggression that has been labeled a “ball of rage” (Chemtob et al.
1997).
Although the literature on violence and PTSD is extensive, findings
between studies have shown multiple possible explanations for this
Posttraumatic Stress Disorder ❘ 125
association and leave open many questions. Are those exposed to serious
personal threat more likely to have come from troubled backgrounds
prior to the trauma? Does exposure to violence lead to future acts of vi-
olence directly, or is it mediated through the development of PTSD?
What is the role of comorbid substance use and violence?
Perhaps due to the complex number of pathways to violence, mod-
els to predict future acts of violence among veterans with PTSD have
not shown useful predictive value. Among one group of veterans with
PTSD, demographic variables, exposure to atrocities, severity of PTSD
symptoms, severity of drug and alcohol problems, past violent behav-
iors, past suicidal behaviors, and prior treatment information were
used in an attempt to develop such a model (Hartl et al. 2005). Only
prior violence history was useful in predicting postdischarge violence;
PTSD and depression severity were both poor predictors of high- and
low-risk group membership.
Although no precise model exists for predicting violence among pa-
tients with PTSD, there are identified risk factors for future violence
that can be the focus for management and treatment. Research during
the past three decades has examined multiple risk factors in an effort to
determine which seem most strongly associated with the violence in pa-
tients with PTSD.
homicide, rape, or assault and were 6.75 times more likely to have been
arrested for violence within the past year. Among those who did not
meet full criteria for PTSD, the presence of each additional symptom of
PTSD increased risk of current incarceration for a violent crime (odds
ratio [OR] 1.22) and for arrest for violence in the past year (OR 1.26). Of
those arrested for a violent crime who endorsed at least one symptom
of PTSD (N=80), most reported the PTSD symptoms began 1 or more
years prior to the arrest. This suggested that the presence of the symp-
toms may have contributed to the commission of the crime.
Family Violence
Patients with PTSD may direct aggression toward intimate partners. On
the Standard Family Violence Index (throwing something at someone,
pushing, grabbing, shoving, slapping, kicking, biting, hitting, beating
up, threatening with a gun or knife, or using a gun or knife on some-
one), veterans with PTSD endorsed an average of 22 such acts in the
past year (Beckham et al. 1997). In contrast, combat veterans without
PTSD endorsed an average of 0.2 such acts in the past year. Socioeco-
nomic status, aggressive responding, and PTSD severity were associ-
ated with increased violence. Yet another study found that presence of
PTSD may mediate the effect of combat exposure on later intimate part-
ner violence (Orcutt et al. 2003). Among multiple studies of Vietnam-
era veterans, past-year partner violence rates range from 13% to 58%,
with higher rates generally seen among inpatients with substance de-
pendence, PTSD, or other psychiatric disorders (Marshall et al. 2005).
PTSD severity was also correlated with partner abuse severity. Partner
physical abuse has also been associated with interactions of alcohol
consumption (frequency and amounts) and severity of hyperarousal
symptoms (Savarese et al. 2001). Higher rates of depression and drug
abuse are seen in veterans who had engaged in partner violence (Taft et
al. 2005).
In a study of veterans with either PTSD or depression, but not both
conditions, those in each group endorsed similar rates of partner vio-
lence (roughly 80%) and severe partner violence (roughly 40%) during
the past year (Sherman et al. 2006). Compared with control couples in
which the veteran did not currently meet criteria for a serious psychiat-
ric illness, those with either depression or PTSD were twice as likely to
endorse any act of partner violence and four times as likely to endorse
an act of severe partner violence. The study did not include veterans
with comorbid depression and PTSD, so it did not assess the relation-
ship of comorbid illness and partner violence.
128 ❘ Textbook of Violence Assessment and Management
Suicide
Patients with PTSD are also at increased risk of suicide or suicide at-
tempts. Comorbidity of PTSD and other psychiatric conditions is com-
mon, and a substantial portion of patients with PTSD are diagnosed with
three or more other conditions (Brady et al. 2000a). The most commonly
comorbid conditions are depressive disorders, substance use disorders,
and other anxiety disorders, all of which are associated with an increased
risk of suicide. In one study, patients with comorbid depression and
PTSD were at increased risk of suicide attempts compared with patients
with only depression (Oquendo et al. 2003). In a second study, the pres-
ence of Cluster B personality disorders (paranoid, narcissistic, border-
line, or antisocial personality) in addition to PTSD and depression fur-
ther increased the risk of suicide attempts (Oquendo et al. 2005). In both
of these studies, the majority of subjects were non-veteran women.
Subthreshold PTSD can also develop after exposure to traumatic
events. Individuals not meeting full diagnostic criteria for the disorder
experience comparable levels of impairment and suicidality when com-
pared with patients who meet full criteria for the disorder (Zlotnick et
Posttraumatic Stress Disorder ❘ 129
al. 2002). In one large national screening study, roughly one in four sub-
jects reported at least one PTSD symptom of at least 1 month’s duration
(Marshall et al. 2001b). Functional impairment, number of comorbid
disorders, presence of a depressive disorder, and current suicidal ide-
ation increased linearly and statistically with each increasing additional
PTSD symptom. Individuals with subthreshold PTSD were at greater
risk of suicidal ideation even after controlling for the presence of a de-
pressive disorder. These studies highlight the importance of screening
all patients with a history of trauma for presence of PTSD symptoms
that may increase risk of suicide or suicide attempts.
Are there specific settings or events that cause you to become irritable or
“on guard”?
Have you been involved in a physical altercation within the past 6 months?
Case Example 1
A 39-year-old Drug Enforcement Agency (DEA) officer was medically
retired 2 years ago after he had been shot in the face at close range dur-
ing a drug raid. During his 15 years with the agency he had seen
multiple shootings and had observed fellow officers killed in the line of
duty. During covert assignment in South America he had seen drug
smugglers torture, kill, and mutilate the bodies of rival gangs. In the
past 5 years he had had frequent nightmares with themes of killing and
pervasive danger, from which he awakened sweating and shaking. He
became progressively withdrawn, ultimately divorced his wife of
10 years, and no longer visited or spoke with family members. He was
constantly vigilant of his environment and startled at the sound of loud
noises. He presently has frequent suicidal ideation but relates no history
of acts of self-harm. He has a concealed weapons permit and carries a
concealed handgun on his person whenever he leaves his apartment. He
experienced some improvement in his depressed mood, lack of plea-
sure, and poor sleep after being started on sertraline by his primary care
physician 4 months ago. He has nightmares nearly every night and has
gradually increased his alcohol use to a pint of vodka per night, con-
suming it between 4:00 and 11:00 P.M. Some mornings he has little
recollection of his activities the prior evening. He was referred to an out-
patient practice by his primary care physician.
ered to reduce the frequency and severity of nightmares, and his sertra-
line dosage may need to be titrated to ensure optimal response. Cogni-
tive-behavioral therapy should be initiated to examine the accuracy of
his perception of threats, establish future goals and direction, identify
“triggers” for possible aggressive acts and develop alternative response
choices, and reestablish communication and social supports. To assist
with abstinence from alcohol and to establish lifestyle changes, referral
to a self-help group such as Alcoholics Anonymous may be useful.
Case Example 2
A 42-year-old career law enforcement officer was referred by his em-
ployee assistance program provider for an evaluation of possible PTSD
and medication treatment. During his career, the officer had seen multi-
ple partners wounded in the line of duty and had been shot at on three
occasions. One of these shootings resulted in a minor wound. He had re-
cently been reprimanded for excessive use of physical force during an
arrest, when he repeatedly struck a suspected drug dealer with his ba-
ton in response to verbally abusive statements. He has loud, verbally
abusive fights with his wife, but these have not escalated to physical vi-
olence. On his screening questionnaire, he reported “sleep problems”
and “anger control issues” as his primary concerns. He is on no medica-
tions and has no prior psychiatric treatment.
Case Example 3
A 26-year-old married National Guard sergeant had completed two
tours in Iraq (20 months total) and had just been released from active
duty to resume his civilian employment. He was self-referred to an out-
patient clinic with symptoms of intrusion, avoidance, emotional numb-
ing, hypervigilance, and arousal. Like many of his friends from the war,
he carries a loaded pistol in his car and sometimes on his person, “be-
cause I feel naked and vulnerable without it.” He does not hold a con-
cealed weapons permit. The patient’s wife is concerned that whenever
the patient is around persons who appear to be of Western Asian origin
he becomes notably agitated and overly reactive to any movement on
their part. At times she has feared that he would draw his pistol and use
it. This behavior is worse on days following nightmares with themes
pertaining to the war. The patient drank heavily when he first returned
from deployment but cut back when his wife threatened to leave him.
Case Example 4
A 23-year-old active-duty Army sergeant presented to the clinic at the
urging of his wife. She has requested a divorce—and then recanted her
136 ❘ Textbook of Violence Assessment and Management
request—on three occasions since his return from a year-long tour in Af-
ghanistan 3 weeks ago. The sergeant notes that he believes his wife “fell
in with the wrong crowd” while he was deployed and “stayed out late
partying and messing with drugs.” She has acknowledged being un-
faithful on one occasion. She told the sergeant she quickly broke things
off with the man (whom the sergeant knows), but she continues to
makes excuses to spend time away from home. The sergeant believes
she is either continuing to see this man or is using drugs with her new
friends. She usually leaves the house after an argument about household
responsibilities. The sergeant reports he has been excessively irritable
and angry because she “isn’t keeping the house up like she did before I
left. She’s more concerned about her friends than about me.” He further
reports that he becomes filled with desperation when he thinks of his
wife leaving him. He acknowledges that he has punched walls and
kicked a door after her abrupt departures, but he has neither threatened
nor assaulted his wife. He explains that she is the “only girl that ever
loved me, so I could never hurt her,” but he acknowledges that when he
thinks of her with that other guy he gets so angry he sees “flashes of me
just choking him—or maybe her, and I can’t get those out of my head for
10 or 20 minutes until I turn the radio up loud and smoke a cigarette.”
He reports initial insomnia and restlessness, particularly when his
wife rejects his sexual advances. His sleep is further interrupted by
nightmares related to his experience in Afghanistan. He has become so-
cially withdrawn, noting that “I don’t want to go out with my wife’s
friends because they all know what she’s been up to while I’ve been
away—and they don’t know what I’ve been through anyway.” He de-
nies appetite, weight, energy, or concentration changes or any suicidal
thoughts. He notes “I was depressed [at age 11] when my parents di-
vorced. I talked to a counselor every week for 6 months back then, and
I took Prozac—but I don’t feel that way now.” He was raised by his
mother after she divorced his physically abusive father. He had very
few friends (no close friends and no girlfriends) and preferred to be
alone. There is no history of alcohol or illicit substance use. He joined the
military immediately after high school and had been successful in spe-
cial operations training. He married his wife in a courthouse ceremony
after a brief courtship, “mostly so that she could get away from her par-
ents and get benefits while I was deployed.” During deployment he
thought frequently about the life they would have together upon his re-
turn. Now he becomes “just so angry inside” when he recognizes that
these dreams may not be realized.
Key Points
■ In contrast to patients who developed PTSD after a single-event
trauma, PTSD patients who underwent repeated threats to life
from multiple sources and observed repeated acts of violence
toward others over long periods are more likely to show height-
ened vigilance and possibly aggressive or violent behavior in
future settings.
■ Further research is clearly necessary on therapeutic interventions
targeting combat-related PTSD and PTSD-related violence and
aggression. The recommended treatments for PTSD, though sup-
ported by reasonable evidence in general, have not been well
validated in combat veteran populations—those most likely to
feel aggression and display violence as a result of their experi-
ences and illness. Furthermore, no controlled studies exist on the
effects of treatments on reducing aggression or violence in
patients with PTSD.
■ For combat veterans with PTSD, present knowledge and clinical
experience suggest that assessment and management of aggres-
sion and violence should include the use of pharmacological and
psychotherapeutic treatments with demonstrated efficacy in
other (i.e., noncombat) PTSD patients.
■ Effective management also requires treatment of other comorbid
conditions and the development of a hierarchy of problems and
interventions.
138 ❘ Textbook of Violence Assessment and Management
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140 ❘ Textbook of Violence Assessment and Management
F rom Biblical times through the present, we have known that alcohol
is often associated with out-of-control behavior and violence. Alone
among abused chemicals, only alcohol directly and commonly in-
creases aggression (Roth 1994). With illegal drugs, in contrast, the asso-
ciated violence is more often due to drug commerce: conflicts between
distributors, arguments and robberies between buyers and sellers, or
stealing to raise drug money (Roth 1994). Alcohol sedates the frontal re-
gions of the brain, the regions necessary for more judicious, thoughtful
decisions. Almost one-third of American adults drink at levels that in-
crease their risk for physical, mental health, or social problems (Na-
tional Institute on Alcohol Abuse and Alcoholism [NIAAA] 2004).
Most instances of substance-related violence happen at times and
places with no physician in attendance (homes, the street, bars, clubs, dis-
cos) (Macdonald et al 1999; Steadman et al 1998). Yet we as clinicians can
141
142 ❘ Textbook of Violence Assessment and Management
Case Example 2
Bert and his wife were arguing about their financial problems. Because of
his angry, intoxicated outburst, his wife called the police, who came and
left. His wife then left the house, taking their child with her. Bert drank
Substance Abuse Disorders ❘ 143
through that night. The next day he called his boss, saying he did not feel
well, and he continued to drink. That evening the police pounded on his
door to serve a warrant. He called 911, telling the operator that he did not
know what was going on, but that he had a gun and he was defending
his home. The police placed a cordon around the house.
Case Example 3
Many years after the event, late in therapy, Carla shared her most pain-
ful, secret guilt. She had never told anyone this before. As a young
mother deserted by her husband, she felt overwhelmed by the needs of
their infant. While drinking and intoxicated, when bathing the child,
she had knocked a radio from the edge of the tub into the water, think-
ing it might electrocute the child. The child was not harmed.
The World Health Organization (WHO) has found a strong link be-
tween child maltreatment and alcohol abuse. Thirty-five percent of pa-
rental child abusers had consumed alcohol or drugs at the time of the
incident (U.S. Department of Justice 2001). Risk factors include being
young, poor, unemployed, and socially isolated (Krug et al. 2002).
WHO suggests a range of prevention strategies, including family sup-
port, parenting training, screening for child maltreatment, and services
for victims (World Health Organization, n.d.).
“Shush, be still, be still, no breath. Off just shut off. Find the ceiling’s cor-
ner and hide in it.”
“There’s no fucking safe place no matter what they say. Don’t matter
what ‘they’ say.”
“How long do I have to be 5 years old anyway.”
“Be still, be gone, hold onto the quiet numb solitude.”
“Thought I had killed my mother. I went outside. She was peeing in the
bushes. She came in. I hit her in the head, I was so angry. She was passed
out upstairs. I put a feather in front of her nose. She was still breathing.”
Substance Abuse Disorders ❘ 145
Case Example 4
For 10 years, Dan was hypomanic and very successful. “People were
patting me on the back, telling me how amazing I was.” Sometimes he
felt an “electric buzz” that he would try to force down with alcohol.
Then he began to have financial losses, depression, and conflicts with
his wife. “All the brain power I had when I was manic turned against
me. I couldn't come up with a good reason not to kill myself.” He waited
until 11:00 P.M. so that there wouldn’t be any children on the road, then
got drunk at a local bar and drove his car into a tree at high speed. He
survived, with mild, persistent brain injury.
Case Example 5
Evan was a young man with a strong sense of right and wrong who had
intense feelings about justice and injustice. He bitterly criticized himself
for various deficiencies, including having failed several college courses.
He found a reason to live in a several-years’ relationship with a young
woman who was also troubled and struggling, but then she left and be-
gan sending him e-mails accusing him of sexual insensitivity in their re-
lationship. He purchased a .38 revolver, got drunk, and killed himself.
First he left money for his roommates for the month’s rent, and he left a
message on his therapist’s answering machine, thanking her for trying
to help him. Evan feared he didn’t have the courage to kill himself. With
alcoholic intoxication, he found the courage.
Substance Abuse Disorders ❘ 147
Case Example 6
The sister of one of my patients phoned me, saying she was concerned
that her own husband “might have a little problem with cocaine.” As we
spoke, this woman’s husband was standing in their living room, shot-
gun at his side, peering through the blinds.
Case Example 7
I saw a young man in the hospital who had a bullet in his right arm.
When trying to buy cocaine from a drug dealer, he had folded over a $10
bill, trying to fool the dealer into thinking he was paying two $10 bills.
Addiction
Dackis and O’Brien (2005) have characterized addiction as “a disease of
brain reward centers that ensure the survival of organisms and spe-
cies.” They describe the mechanism as follows:
Given their function, reward centers have evolved the ability to grip at-
tention, dominate motivation and compel behavior directed toward sur-
vival goals, even in the presence of danger and despite our belief that we
are generally rational beings. By activating and dysregulating endoge-
nous reward centers, addictive drugs essentially hijack brain circuits
that exert considerable dominance over rational thought, leading to pro-
150 ❘ Textbook of Violence Assessment and Management
gressive loss of control over drug intake in the face of medical, interper-
sonal, occupational and legal hazards. There is even evidence that de-
nial, once thought to be purely “psychological,” may be associated with
drug-induced dysfunction of the prefrontal cortex. (Dackis and O’Brien
2005, p. 1431)
Case Example 8
Frank was a talented physician who could often get a year or two of re-
covery from his addiction to opiates. That was enough stability to per-
mit him to work and use his medical skills, although not in patient care.
In relapse, he returned to the place where he customarily bought drugs,
even though he had been robbed there with a knife at his throat only the
night before. Several months later, he died alone in a motel room in an-
other state, probably of an overdose.
Case Example 9
Geoff, always falling far short of the expectations of his successful fa-
ther, began using marijuana in early adolescence and later began using
cocaine. Geoff’s father understood these drug use–related failures as
willful misbehavior and tried to discipline him, sometimes physically.
Geoff cooperated superficially with the treatment program his parents
had tricked him into attending. “Bunch of crap, just sit down and talk.
Didn’t get anything out of it. Just listen to people’s problems.” He
planned to “get my life sorted out. Just become a social user. Not com-
pletely stop.” He continued to smoke marijuana while in the treatment
program.
After his completion of that treatment program, Geoff’s plans to be
a “social user” of cocaine quickly and disastrously crashed. He took his
second treatment program much more seriously, understanding that he
could not safely use marijuana, either. Modafinil seemed to free him of
craving for cocaine and probably also helped his attention-deficit/
hyperactivity disorder.
Substance Abuse Disorders ❘ 151
Identifying Addiction
For many years, literature and Hollywood have dramatized (some-
times accurately) the lives of alcoholics and drug addicts. The “Decade
of the Brain” has now flowered into a moving, scientifically based mass
media production, Home Box Office’s series Addiction (sponsored by
the Robert Wood Johnson Foundation, the National Institute on Alcohol
Abuse and Alcoholism, and the National Institute on Drug Abuse),
which began March 15, 2007. A superb collection of resources can be ac-
cessed, and a DVD of the series can be purchased, at the series Web site
(http://www.hbo.com/addiction).
Only 10% of patients with alcoholism receive assessment and refer-
ral to treatment from their primary care physicians (McGlynn et al.
2003). For physicians, the National Institute on Alcohol Abuse and Al-
coholism (NIAAA, 2005) has released an updated version of Helping Pa-
tients Who Drink Too Much: A Clinician’s Guide. “Too much” is defined as
five or more drinks in a day for a man, four or more drinks in a day for
a woman. (A standard drink is equivalent to 12 ounces of beer, 5 ounces
of wine, or 1.5 ounces of 80-proof spirits.)
The single question “How often in the past year have you had five
or more drinks [four for a woman] in a day?” can serve to screen for al-
cohol-related problems (Dawson et al. 2005). As an alternative to the
single question during the clinical interview, the guide suggests screen-
ing by the written self-report AUDIT—the Alcohol Use Disorders Iden-
tification Test.
For persons who screen positive for alcohol-related problems, the
next step is to assess the severity and extent of the problems, using a list
of symptoms derived from DSM-IV-TR (American Psychiatric Associa-
tion 2000). The NIAAA’s guide provides additional resources and treat-
ment templates.
About 30% of the U.S. population have what is called “at-risk drink-
ing” (National Institute on Alcohol Abuse and Alcoholism 2005),
“heavy drinking,” or “unhealthy alcohol use” (Saitz 2005). These levels
of use do not meet criteria for substance abuse (a substance-related fail-
ure to perform obligations at work, school, or home; use in hazardous
situations; or recurrent legal or social problems—often associated with
antisocial personality disorder). Nor do they meet criteria for substance
dependence (a loss of control of use of the substance; a life focused on
getting and using the substance).
Often, “at-risk” heavy drinkers who do not meet the criteria for
abuse or dependence can voluntarily reduce their alcohol consumption
and can benefit from learning that their consumption is greatly above
152 ❘ Textbook of Violence Assessment and Management
the norm. Habitually they associate with other people who drink
heavily, and they conclude, incorrectly, that such a level of consumption
is common. The NIAAA guide Helping Patients Who Drink Too Much
provides a useful comparison and a template for strategies for cutting
down.
Treating Addiction
For many years, 12-Step recovery groups have counseled separating
from “people, places, and things” associated with drug or alcohol use.
Science has now shown that even years into recovery, environmental
cues can powerfully induce relapse (Grusser et al. 2004).
“Evidence-Based” strategies to help patients reduce the risk of re-
lapse (Witkiewitz and Marlatt 2007) include the following:
Case Example 10
Helen has 50 years of happy marriage, a graduate degree, and a close re-
lationship with her adult children. However, more than once, she was
intoxicated when she arrived to provide transportation for her grand-
children. Understandably fearful, Helen’s children would not let her
take the grandchildren, even when she was sober. Acamprosate seemed
to make her recovery more comfortable. (She was also taking anti-
depressant medication.) Although three times daily is the suggested
dosing schedule, Helen had loose stools if she took acamprosate more
than twice a day. With participation in 12-Step recovery, she stayed
sober and regained the trust of her children.
ingested. For example, the reaction from the small amount of alcohol
that may be ingested from a vinegar salad dressing (or absorbed from
hair spray or deodorant) is not severe. Some persons with robust acetal-
dehyde dehydrogenase require an increased disulfiram dose.
In 1986, R.K. Fuller and colleagues, in a carefully done, controlled,
blinded study, concluded that disulfiram “may help reduce drinking
frequency after relapse” but “does not enhance counseling in aiding al-
coholic patients to sustain continuous abstinence or delay the resump-
tion of drinking” (Fuller et al. 1986, p. 1449).
Disulfiram can be useful for those patients who, although commit-
ted to not drinking, cannot trust themselves to abstain, especially early
in recovery. Because acetaldehyde dehydrogenase requires as long as
2 weeks to regenerate after cessation of disulfiram, taking disulfiram
once daily settles for that day the internal discussion, “Will I drink to-
day?” Disulfiram can be used episodically for protection during busi-
ness trips or vacation.
Case Example 11
Jerome is a distinguished professional, respected by his colleagues,
elected by them to chair an organization representing their interests.
However, at a lecture, he appeared intoxicated on stage. He could go for
weeks without drinking, but if he had a break in his schedule on a nice
day, he might step outside for a bit, and his favorite bar was just down
the block, across the street. Seldom could he pass it without going in.
Disulfiram gave him long-term sobriety.
of our patients. We are a social species. Meeting with other people who
also are recovering from addiction, people who have had similar expe-
riences, people who come to know us and are not angry at us (as fami-
lies often are at the addicted person), people who seem to be decent
people other than the aberration of their alcohol- and drug-related be-
haviors, people who are succeeding at recovery—all this powerfully en-
courages and motivates. Learning that addiction is a disease, with pow-
erful genetic and environmental antecedents, not simply a hopeless
moral failing, can lift demoralizing guilt and lend credibility to strate-
gies for managing the disease, as we do with other chronic diseases. Pa-
tients learn these strategies from other recovering people, from counse-
lors, and from therapists. Although it is not the focus of this chapter,
treating comorbid psychiatric illness, and influencing destructive life
circumstances, can be vitally important.
Project MATCH disappointed many high hopes by not confirming
10 hypothesized treatment-effective “matches” between treatment type
and type of patient with alcoholism. The one “match” was between pa-
tients with low psychiatric severity and 12-Step facilitation therapy.
NIAAA Director Enoch Gordis remarked that these findings “challenge
the notion that patient–treatment matching is necessary in alcoholism
treatment” (National Institute on Alcohol Abuse and Alcoholism 1996).
Although it is hard to study 12-Step programs in a rigorous scientific
manner, clinicians who treat addiction have long respected 12-Step re-
covery. Dr. George E. Vaillant made a major scientific contribution, pub-
lishing in 1983 (with a revised edition in 1995) The Natural History of Al-
coholism, a prospective study of more than 700 individuals followed for
more than 40 years. Vaillant wrote that “multiple studies that collec-
tively involved a thousand or more individuals, suggest that good clin-
ical outcomes are significantly correlated with frequency of attendance
at Alcoholics Anonymous (AA) meetings, with having a sponsor, with
engaging in Twelve-Step work and with chairing meetings” (Vaillant
2005, p. 433, citing Emrick 1993). Dr. Vaillant (2005) observes that
Project MATCH found, during its first year, that AA alone was as ef-
fective as the two most effective professional alternatives: cognitive-
behavioral and motivational enhancement therapies.
156 ❘ Textbook of Violence Assessment and Management
Key Points
■ Alcohol and other drugs of addiction, interacting with personality
and circumstances, often increase the likelihood of violence.
■ Alcohol is the most widely used of addictive chemicals, and it is the
chemical most likely to induce aggression; therefore it has the
largest role in violence.
■ Patients often do not volunteer information about their drinking
or drug use. Every patient should be asked at least the single
screening question: How often in the past year have you had five
or more drinks in a day? (four or more drinks for a woman). Even a
single such day is reason for further evaluation.
■ Addictions treatment is effective. It should be tailored to each
patient, using supportive therapies (12-Step meetings, individual
therapy), counseling and cognitive-behavioral therapies, and
pharmacotherapy.
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Substance Abuse Disorders ❘ 159
Personality Disorders
William H. Reid, M.D., M.P.H.
Stephen A. Thorne, Ph.D.
161
162 ❘ Textbook of Violence Assessment and Management
tency, and intensity of their symptoms. Costello (1996) noted that the
“use in research of such complex polythetic categories of personality
disorder made up of heterogeneous sets of experiences and behaviors
makes it very difficult to interpret research findings” (p. 1). In addition,
despite the definition and conceptualization of personality disorders as
an enduring pattern of inner experience and behavior that is inflexible,
pervasive, stable, and of long duration, some have argued against a
blanket position that all personality disorders are always stable (Coid
2003; Rogers and Shuman 2005).
Understanding the heterogeneous nature of violence is imperative
for clinicians and researchers attempting to develop effective manage-
ment and treatment approaches and for readers who review their find-
ings. Both ordinary experience and clinical and research findings lead
one to view violence itself as a multifaceted construct varying widely in
quality, severity, purpose, duration, and frequency. Even very specific
forms of violence can have a variety of causes (see Widiger and Trull
1994, p. 212). Swanson et al. (2006) commented on that heterogeneity in
their recent study of violence rates among schizophrenics, noting that
“[v]iolent behavior occurs within a social-ecological system, involving
a whole person with a particular life history and a state of health or dis-
ease, interacting with a particular social surround” (pp. 490–491). Each
individual’s risk level varies with the degree to which his or her person-
ality characteristics and dimensions may or may not be exposed to var-
ious environmental variables (Nestor 2002). In general, what accounts
for violent behavior in one individual with a given personality disorder
does not necessarily portend violent behavior in others with the same
diagnosis.
Case Example 1
A man who met diagnostic criteria for antisocial personality ap-
proached an elderly man in an isolated area of a park and demanded
money. When the robbery victim resisted giving up his valuables, the
perpetrator hit him repeatedly in order to force him to comply. After the
victim had been subdued, the perpetrator took his wallet and ran away.
Case Example 2
An injured worker suing his employer for millions of dollars lost his
lawsuit because of a somewhat technical judicial decision. His attorney
noted that the worker was very upset over the loss, and he referred the
client to a psychologist. During a brief course of treatment, the therapist
uncovered long-standing signs of paranoia but no frankly delusional
material. Believing the sessions to be completely confidential, the pa-
tient/plaintiff eventually admitted that since losing the lawsuit, he had
rehearsed sabotaging the defense attorney’s car, had actually entered
the lawyer’s property and examined the engine and brake lines, and
had a plan to murder the judge.
Case Example 3
A patient with borderline personality was distraught about the possibil-
ity of losing custody of her children during a divorce. She told her psy-
chiatrist that her estranged husband had beaten her in front of the
children and that she was afraid he would harm them as well. She of-
fered bruises on her neck and arms as evidence. The psychiatrist helped
her to contact police and obtain a restraining order prohibiting her hus-
band from visiting her or the children.
As the police and the state child protective agency investigated the
matter, attention began to shift to the patient herself. It eventually be-
came clear that she inflicted her own bruises, then invited her husband
to her house, started an argument in front of the children, and began hit-
ting him. When he did not hit back and began to leave, she dramatically
fell screaming to the floor and loudly proclaimed “Daddy hit me!
Daddy’s hurting me! Run, or he’ll hurt you, too!”
Personality Disorders ❘ 169
Risk Assessment
An experienced evaluator of antisocial, paranoid, or borderline persons
should recognize the presence of some risk, but the level of risk and the
probability of violence may be difficult to ascertain, even in patients
with substantial aberrant personality traits. Those with histories of vio-
lent behavior, paranoid or mildly psychotic thinking in a context of pos-
sible gain, and/or marked lack of empathy should raise additional
concern.
Case Example 4
A man who met diagnostic criteria for antisocial personality but not for
any Axis I disorder broke into a home and stole several items while the
occupants were asleep. He then set fire to the house in order to hide his
crime, deflect blame from himself, and destroy evidence that might
have incriminated him. The occupants were awakened by a smoke
alarm and escaped, but they could easily have been injured or killed.
After his arrest several days later, the robber described setting the
fire as necessary to avoid being caught. He denied wanting to harm the
occupants, describing the fire as simply a means of avoiding arrest. It
was “nothing personal,” just “something I had to do whether they [the
occupants] were there or not.” Warning or awakening them so that they
could escape had not crossed his mind.
Case Example 5
A young man with a long history of relatively minor antisocial acts en-
gaged in a drag race on a city street. As he neared the end of the race, he
realized he was about to run a red light. Nevertheless, he continued to
accelerate, ran the red light, and struck another car. The driver of the
other car was killed. When testifying about his reckless behavior, he de-
scribed it entirely in terms of his taking a thrilling chance with his own
life, seeming oblivious to any responsibility for others’ safety. He under-
stood the chance of an accident, and the chance that someone might be
hurt or killed, but he described the danger of racing purely in terms of
a focus on himself, saying “I can live with those odds.”
Risk Assessment
This form of violence is overrepresented in those with substantial anti-
social and asocial character traits. In addition to lack of empathy or rec-
ognition of other’s needs and feelings (a common thread in many kinds
of violence), the risk of purposeful but noninstrumental violence may
be heralded by a potential perpetrator’s wish for pleasure or need for
stimulation that overshadows his judgment, impulse control, and ap-
preciation of future consequences.
Treatment/Management
When symptoms are recognizable and treatable, the general treatment
principles described in the last section apply (e.g., treatment for sub-
stance abuse or mood instability).
Case Example 6
Frequent arguments between a middle-aged man and his wife, often in-
volving intoxication with alcohol, routinely led to his threatening or as-
saulting her, her threatening or briefly leaving him, and then his
successfully begging her to stay. Eventually, the wife resolved to ignore
his entreaties and promises and filed for divorce. He did not believe she
would go through with the divorce, but when he came home one night,
she had locked him out. He stayed with a friend for a few days, calling
her often and thinking she would change her mind.
After several days, he was served with the divorce papers. He drove
to her place of work and once again pleaded with her to reconsider. She
refused, adding (in front of her coworkers) that he had never been much
of a husband and had never satisfied her sexually. He returned to his car,
took a shotgun out of the trunk, went back into the building, killed her,
and then waited for police to arrive.
Risk Assessment
Characterological paranoia is among the most dangerous personality
traits. It is associated with both domestic and general violence. Many
people with paranoid personality routinely imagine and rehearse (men-
tally or literally) violent “solutions” to paranoia-created scenarios.
Truly delusional persons with Axis I disorders are much more likely to
be seen by a mental health professional than are those with paranoid
personality alone. Passive, dependent, or avoidant people do not antic-
ipate violence but may become dangerous when trapped or restrained
and unable to escape emotional pressure. However, they usually can
adjust their environments to decrease their anxiety (and concomitantly
172 ❘ Textbook of Violence Assessment and Management
Treatment/Management
Characterologically paranoid people, who go through life with an over-
determined expectation of trouble, are very difficult to manage (and
sometimes to recognize) unless or until their public behavior raises con-
cerns. Persons whose personality traits lead them to avoid confronta-
tion and anxiety can usually be relied on to avoid triggering situations
if they have the choice to do so. Once such a person is in a setting that over-
whelms even resilient characterological defenses, such as a perceived
inescapable threat or restraint, the best management approaches in-
volve quickly defusing the situation, isolating or containing the poten-
tially violent person, or removing potential victims.
Case Example 7
Dr. X, an otherwise competent abdominal surgeon, was known for both
his skill and his irritable, narcissistic manner. He led a regimented life,
with little warmth for family or friends, the barest superficial acknowl-
edgment of the roles of others in his cases and other achievements, and
Personality Disorders ❘ 173
Case Example 8
Mr. S was known as a nice, quiet fellow, the adult son of a very aggres-
sive, poorly liked father whose bullying controlled most people close to
him. Mr. S behaved in an almost opposite manner, passive and appear-
ing dependent on his father for income and a place to live. In over a de-
cade of adulthood, he had traveled and interacted socially with others
but had never held a meaningful job for more than a few weeks, had
never married, and had never lived away from his father. Privately,
Mr. S dreaded the thought of being like his father, who had abused him
during childhood and as an adult.
One night while both were intoxicated, his father began once again
to bully and humiliate Mr. S. At some point, the combination of physical
and emotional humiliation reached an intolerable level; Mr. S grabbed
his father’s arms to restrain them. The father laughed derisively, break-
ing the son’s hold, slapped him repeatedly in the face, and called him
“my little bitch.” Mr. S exploded, pummeled his father to the ground,
and finally shot him in the chest with a shotgun kept nearby in case of
intruders.
174 ❘ Textbook of Violence Assessment and Management
When his father lay obviously dead, Mr. S wrapped him in a bed-
sheet and bound the body with duct tape, then retreated to his bedroom,
locked the door, and went to bed. The next day, he called an attorney
and gave himself up to police. Asked later about what he did to the
body, Mr. S replied that although he knew his father was dead, he could
not feel truly secure until he had wrapped and bound him and locked
the bedroom door.
Risk Assessment
Many violent acts of this type occur when an external event threatens
poorly defended fears of inadequacy or abandonment. Some people
with severely dependent, paranoid, narcissistic, schizotypal, or obses-
sive-compulsive traits—characteristics that decrease one’s ability to
marshal and rely upon more efficient internal defenses when trapped in
emotionally intractable situations from which one cannot escape—can
be very dangerous. Such conditions, particularly inability to escape an
intolerable and anxiety-producing situation, increase the likelihood of a
violent reaction designed to stop the pain and escape the threat. When
conditions are extremely stressful, even schizoid and avoidant persons
may revert to primitive, violent actions to defend their egos. Intoxica-
tion is a substantial risk factor, as are some kinds of emotional attacks
and idiosyncratic emotional triggers (e.g., repeated, inescapable de-
meaning or “in your face” challenges during arguments with a spouse
or competitor).
Treatment/Management
“Treatment” of the characterologic vulnerability, when motivation and
resources are present, is described elsewhere. See also the general de-
fusing, separation, and containment principles described above, as well
as treatments for coexisting substance abuse, mood instability, and
other noncharacterologic factors mentioned earlier in this chapter.
Case Example 9
Ms. T was a 43-year-old woman with borderline personality disorder
and very primitive attachment needs. She and her 24-year-old daughter
had an extraordinarily hostile-dependent relationship that was often
characterized by rather obvious manipulations designed to keep the
daughter physically and emotionally bound to the mother. The daugh-
ter had tried to move away on several occasions, but each time she had
changed her plans to meet her mother’s needs and continued to live on
her mother’s property. At one point, the daughter approached her
mother once again—by telephone, to avoid a personal confrontation—
to tell her she was moving in with a boyfriend who lived some distance
away. She called from her place of work.
The telephone conversation soon deteriorated into a volatile event.
Ms. T alternated among superficially rational “suggestions” that the
daughter reconsider and have her boyfriend move into the daughter’s
trailer on the mother’s property, pleas that the daughter consider the
mother’s health conditions (which were not particularly serious), sar-
castic comments that the boyfriend would probably leave her, and,
eventually, angry threats to rent the daughter’s house to someone else
so that she could never “come home.”
The daughter would not budge. She repeatedly told her mother that
she was indeed going to move away and parried each of the manipula-
tive comments and threats with sarcasm and threats of her own (such as
“You’ll never see your grandchildren” and “You’ve been sick for years;
let me know when it gets really serious”). The daughter finally hung up
in the middle of her mother’s tirade.
Ms. T got into her car to drive to the daughter’s workplace, shaking
with anger and anxiety. On the way, she drove very recklessly, failed to
yield at an intersection, and hit another car, injuring several people.
Case Example 10
A woman with severe borderline and paranoid traits was being told that
she had lost custody of her children. A social worker and a trainee were
trying to treat her as gently as possible while making it clear that she would
only be allowed to see her children, who had been removed from the
home, in a supervised setting. The woman listened for a moment, then be-
gan screaming that none of the things they were saying about her was true,
that she was a good mother, and that she refused to listen to their lies.
The social work trainee raised her voice and somewhat assertively
tried to confront the woman, recounting her past abusive acts in order
to make her understand why her parental rights were being terminated.
The woman only became more agitated, screamed louder, and bolted
from the room, pushing the senior social worker away from the door
and into an aquarium, which fell and broke, cutting her arm and neck.
176 ❘ Textbook of Violence Assessment and Management
Risk Assessment
This level of fragility and potential for decompensation is not typical of
most people with personality disorders and may suggest an Axis I dis-
order. Those prone to such reactions have marginal egos that are inade-
quately protected by sometimes superficially resilient, but inwardly
brittle, defenses. Their personalities may have substantial, poorly inte-
grated borderline, schizotypal, dependent, obsessive-compulsive, and/
or avoidant features. They often seem outwardly stable but have inner
worlds kept artificially free of mental controversy that might threaten
their emotional lives. They may show stilted or even ritualistic behav-
iors in order to control the impact of the external environment on those
inner lives, or they may simply choose isolation and other defenses as
means of avoiding stressors.
Careful examination of such persons’ lives may reveal reaction for-
mation, an extraordinary need to defend desperately against discovering
in oneself some frighteningly destructive core emotion or self-reviled de-
pendency. For some, that veneer can become dangerously weak under
stressful (often idiosyncratic) circumstances such as intoxication, loss, or
inescapable humiliation.
Treatment/Management
In case example 10 above, the trainee’s confrontational manner in-
creased the pressure on the woman’s already assaulted, fragile ego. A
less confrontive approach would likely have prevented the accidental
injury to her colleague.
Case Example 11
Two men decided to play a deadly “urban war game” in which they as-
sumed the roles of assassins. They outfitted a small van in such a way
that one of them could drive to an “assassination” location and park the
truck while the other sat in the back with a high-powered rifle. The rifle
was equipped with a telescopic sight so that shots could be taken from
some distance. The driver would spot a faraway victim, chosen at ran-
dom according to opportunity, and give the shooter a signal. The
shooter would then open a side window, fire, and quickly close the win-
dow, after which the van would drive away.
The pair were caught after killing several people. Upon evaluation,
neither met criteria for any significant psychiatric diagnosis except per-
sonality disorder with antisocial and (in one) paranoid traits.
Risk Assessment
As in the case of several other conditions described in this chapter, a his-
tory of this kind of violence, in reality or in substantial fantasy (e.g.,
with “rehearsing” behavior), increases risk of future violence. Those
with disorders whose hallmark is a lack of empathy, responsibility,
and/or impulse control, such as antisocial, narcissistic, or paranoid per-
sonality, are of most concern.
Treatment/Management
Management of persons in this group is generally practical and societal
(e.g., judicial, correctional) rather than psychiatric. For those rare cases
in which a treatable disorder such as mood instability or substance
abuse is relevant, see the treatment comments found earlier in this
chapter and elsewhere in the broader treatment literature.
Case Example 12
A man and a woman had a 4-month dating relationship that fluctuated
between superficial intimacy and loud arguments. The man, who
treated the relationship primarily as one of sexual convenience, grew
tired of the woman’s volatile emotions and demands for proof of his
love. The woman clung to the hope that the relationship would lead to
a fairy tale marriage. Finally, he stopped calling her and began dating
someone else.
The woman was hurt and angry at being abandoned and at losing
what she had viewed as a lasting future of love and security. Over time,
the loss became less and less tolerable. Her anger grew. She saw no life
for herself without (her fantasy of) the ex-boyfriend and convinced her-
self that their relationship would have a chance if his new girlfriend
were gone.
One night, when driving by her ex-boyfriend’s house, she noticed
the girlfriend’s car in the driveway. She stopped and smashed the wind-
shield with a hammer, then drove away. The ex-boyfriend suspected she
had broken the windshield and called to confront her. She denied it but
took the call as an opportunity to rekindle the relationship and as evi-
dence that she was still in his thoughts. He told her the police had been
called and hung up. He continued to date the new girlfriend.
Two weeks later, the woman saw the ex-boyfriend and his new girl-
friend in a bar. When they noticed her, they got up to leave. She yelled
at them to stop and began to berate the girlfriend. The couple again
started to leave, and the woman, who was somewhat intoxicated, at-
tacked the girlfriend. She was restrained and later arrested.
Psychiatric evaluation of the woman revealed these facts as well as
a history of significant abuse by a stepfather, very unstable adult rela-
tionships, and episodes of depression and self-injury associated with
relatively minor losses. No frankly delusional material was evident.
Risk Assessment
People with flagrant manifestations of borderline coping should be
viewed with concern. Those with paranoid personality disorder are rel-
atively common perpetrators as well. Severely dependent character
traits in the absence of borderline features should raise consideration
for violence in some settings and contexts, albeit to a lesser extent. Chil-
dren with markedly borderline or paranoid parents are especially at
risk of either direct abuse or exposure to violent moods and unstable
parenting.
Treatment/Management
Treatment of ancillary symptoms of anxiety, mood instability, and occa-
sional psychotic thinking is relatively straightforward and often suc-
cessful with cooperative patients. Psychotherapy should be designed to
Personality Disorders ❘ 179
Case Example 13
Mr. H was a Vietnam veteran with a stable but childless marriage to a
Vietnamese woman whom he had brought to the United States. He was
generally domineering, expecting her to be a submissive wife. Once in
the United States, she pursued an education, getting a graduate degree
and becoming a college teacher, while he remained relatively unedu-
cated and generally unsuccessful in his small business. At home, his
wife tried to tolerate his dominating style, dislike for socializing, and
noticeable paranoid traits.
One of Mr. H’s few hobbies was working with his several dogs, pit
bulls who required a large pen and considerable care. He was quite gen-
tle with them, and although he was reclusive and suspicious and had a
history of severe childhood beatings from his father, there was no evi-
dence that he had ever physically abused his wife.
As his business failed, Mr. H spent more and more time working on
an elaborate backyard structure, the walls of which were created from
thick metal plates salvaged from a construction site. He described the
structure as a shelter for his dogs. Police would later describe it as a
“bunker,” but there was no other evidence that he was preparing for
some fantasized attack, and he had no known association with antigov-
ernment or “survivalist” groups.
180 ❘ Textbook of Violence Assessment and Management
Risk Assessment
Those with paranoid personality, especially, warrant concern and mon-
itoring, particularly when there is a history of violence or threat. Chil-
dren in the family are at risk of both direct abuse and exposure to
violent moods and cold or unstable parenting. Severe narcissistic and
schizotypal traits suggest increased risk as well.
Personality Disorders ❘ 181
Treatment/Management
There is no specific treatment for patients with histories similar to that
of Mr. H. The pain of depression may cause them to seek treatment, but
compliance is a difficult issue, and antidepressant approaches do not
address the paranoid or other personality traits (although they may al-
leviate paranoia that stems from a mood disorder). Antidepressant
treatment may also contribute to a switch to manic or hypomanic be-
havior, which, in the context of paranoia or other aberrant personality
traits, can be quite dangerous. Adequate monitoring is important. Al-
though one cannot be certain, alleviation of Mr. H’s depression might
have changed the outcome.
Conclusion
With a few exceptions (e.g., antisocial personality), the potential rela-
tionships between personality disorders and violent behavior are
poorly studied. We encourage clinicians to view personality disorder as
a heterogeneous construct. That heterogeneity raises diagnostic and
methodological concerns about the reliability and generalizability of
much of the available research. Individual consideration, including un-
derstanding setting and context, is vital to improving risk assessment.
It follows that recognizing increased risk can allow clinicians to match
the problems and needs of individuals to available treatment when ap-
propriate and, perhaps more often, to recommend practical manage-
ment approaches.
Mental health professionals working with personality-disordered
individuals should review critically the better studies of violence risk,
particularly those pertaining to personality disorders, then extend that
focus beyond diagnosis. The case examples in this chapter highlight
characterologic vulnerability but also feature environmental factors re-
lated to increased risk. Clinicians who understand the importance of
setting and context, and their relationship to the internal vulnerability
associated with different personality traits, will have an easier time rec-
ognizing and assessing risk than many of their colleagues and will be in
a better position to help manage that risk.
182 ❘ Textbook of Violence Assessment and Management
Key Points
■ Although personality disorders are associated with a guarded or
poor prognosis for change, they should not be lumped into a
single, global construct. They are heterogeneous, with a variety
of symptoms and behaviors within each diagnosis.
■ Personality disorders are rarely ego dystonic. Most people with
personality disorders or aberrant character traits who seek profes-
sional help have coexisting disorders or conditions.
■ This chapter focuses on understanding and managing some
aspects of violence risk. It does not address “prediction” or “cure.”
■ The presence of a personality disorder diagnosis does not imply
that everyone with that diagnosis has the same risk of violence.
■ The diagnoses and situations discussed in this chapter do not gen-
erally imply lack of responsibility for one's actions. They are rarely
associated with exoneration from blame for criminal acts.
■ Violence and risk of violence, with or without a personality disor-
der, is often associated with intoxication of some kind.
■ The authors present a new, eight-category typology of character-
ologic violence, not intended to be mutually exclusive, whose
common thread is violence, not diagnosis per se.
1. Purposeful, instrumental violence
2. Purposeful, noninstrumental violence
3. Purposeful, targeted, defensive violence
4. Targeted, impulsive violence
5. Nontargeted, impulsive violence incidental to emotional
escape
6. Random but purposeful violence
7. Violence related to perceived/feared loss or abandonment
8. Violence related to chronic paranoia or consequent
misconception
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C H A P T E R 1 0
Violent behavior has long been associated with focal brain lesions as
well as with diffuse damage to the central nervous system (CNS). Any
condition producing psychosis or mania may have aggression as a con-
comitant symptom. Medical conditions that do not directly affect the
brain can also be a cause of aggressive behavior due to diffuse effects on
CNS function. Irritability and aggression are a major source of morbid-
ity for many neurological and medical patients and increase the burden
on their families and other caregivers. In this chapter, we discuss com-
mon neurological and medical etiologies of aggressive behavior (see
Table 10–1). Identification and treatment of the underlying cause is of-
ten the first step in treatment of violence related to a neurological or
medical disorder.
Dementia
Dementia, a progressive decline in function across multiple cognitive
domains, is common, affecting 5%–8% of those over age 65 and nearly
50% of those over 85 (Small et al. 1997). Behavioral disturbances are
common in people with many types of dementia. Rabins et al.’s (1982)
survey of family and primary caregivers found that the most serious
problem reported was aggressive behavior. Families are able to tolerate
185
186 ❘ Textbook of Violence Assessment and Management
Stroke
Cerebrovascular accidents are an extremely common condition. Despite
some decline in cases of stroke due to treatment of hypertension, stroke
continues to be a major source of morbidity and mortality, especially in
Neurological and Medical Disorders ❘ 189
Inpatients
Ghaziuddin and Ghaziuddin (1992) studied violent behavior in intel-
lectually impaired persons during 1 year at a 100-bed unit at a univer-
sity hospital. Of the 106 patients admitted to the unit during the study,
35% were involved in 145 violent incidents. Twelve patients who had
associated psychiatric diagnoses were responsible for 86% of the inci-
dents. Sigafoos et al. (1994) studied a population of 2,412 people with
intellectual disability in Queensland, Australia. Of the sample, 48%
were severely to profoundly mentally retarded, 24% were moderately
impaired, and 9.6% were mildly impaired. Most individuals (59%) were
190 ❘ Textbook of Violence Assessment and Management
male, and 16% of this population lived in institutions. Of the group liv-
ing in institutions, 35% exhibited aggressive behavior. For those living
in group homes, 17% were aggressive. Persons who were identified as
aggressive had more profound levels of retardation and lower verbal
abilities. Much of the aggressive behavior in this study was directed to-
ward other patients or at other patients and staff.
Outpatients
Variable rates of aggression are reported among mentally handicapped
people in outpatient settings. Bouras and Drummond (1992) conducted
a study in southeast London, England, of 318 people (190 men, 128
women) with intellectual deficiencies who live in a community setting
and were referred to the psychiatry department of a mental handicap
service. Most of the patients in the study (54.4%) had a mild mental
handicap, 28.6% had moderate mental handicap, and 17% had severe
mental handicap. Almost one-third of the patients demonstrated ag-
gression toward others, and 13% engaged in self-injurious behavior.
Those people with severe intellectual impairment were more severely
and frequently aggressive.
Davidson et al. (1994) studied 199 individuals who were referred to
an outpatient crisis intervention program during a 2.5-year period and
had an IQ below 70 and concomitant adaptive behavior deficits. All peo-
ple in the study had at least one severe behavior disorder, and all had be-
havioral problems that were severe enough to threaten their ability to
stay in an outpatient community setting. Half lived with family mem-
bers, 22% in community residences, and 9% in intermediate community-
based facilities for intellectually disabled persons. The remainder of
those studied were either in family care or living independently or semi-
independently. Intake evaluations, historical data from agency records,
and medical records were reviewed as a source of data on aggressive be-
havior. At the time of the study, 131 individuals were classified as ag-
gressive. This study found that aggressive and nonaggressive patients
had similar neurological histories and medical status. CNS disorders, in-
cluding seizures, were seen with a similar prevalence in both groups.
The study concluded that current aggressive behavior was best pre-
dicted by past aggressive behavior when found in males with lower cog-
nitive functioning who might have been previously institutionalized.
Epilepsy
Epilepsy has long been felt to be a cause of, or at least a contributor to,
acts of violence. However, the literature is far from clear in establishing
Neurological and Medical Disorders ❘ 191
Ictal Aggression
Ictal aggression occurs most often when persons attempting to assist
the patient during a seizure restrain the patient and the patient resists.
Treiman (1986) gives several examples of “resistive violence” in re-
sponse to restraint at the end of a generalized tonic-clonic seizure. Re-
sistive violence has also been observed in animal seizure models. Ictal
aggression is rarely directed and does not show elements of planning or
premeditation.
Postictal Aggression
Postictal aggression involves violent acts that occur when a patient is
still confused following a seizure. Usually, postictal aggression is seen
after a general tonic-clonic seizure. It can occur less commonly after a
complex partial seizure. Attempts at restraint are the most common
cause of aggression during this time. Postictal psychosis is another
likely cause of much postictal aggression, especially if the patient expe-
riences frightening hallucinations or feels paranoid during that time
(Devinsky and Bear 1984).
Interictal Aggression
Aggressive behavior between seizures is more controversial than ictal
or postictal aggression because there is no direct relationship between
the aggression and the seizure event. Most epileptologists agree that the
majority of patients with epilepsy are psychologically normal between
seizures. It is still unclear whether a small subset of persons with epi-
lepsy behave differently between seizures as a result of brain alterations
caused by the ictal events. Devinsky et al. (1994) studied 61 adult pa-
tients with epilepsy (46 patients with temporal lobe epilepsy, 15 with
absence epilepsy) and compared this group with 17 neurologically
normal control subjects. This study found no pattern of aggressive or
hostile behavior among persons with epilepsy. However, the author
did find increased suspiciousness in patients with left temporal lobe
192 ❘ Textbook of Violence Assessment and Management
Encephalitis Lethargica
Encephalitis lethargica was first described in detail by Constantine von
Economo in 1917 (von Economo 1937). Besides producing physical
symptoms of an acute CNS infection, encephalitis lethargica could, at
times, progress to coma or death. Survivors were sometimes afflicted
with parkinsonism or bizarre behavioral disturbances. The agent that
causes encephalitis lethargica has not yet been isolated. Some sur-
vivors, mostly adolescents, experienced pseudopsychopathic states.
Sporadic cases of encephalitis lethargica are still seen infrequently
throughout the world.
Movement Disorders
Movement disorders may result in behavioral changes. Increased irrita-
bility and angry outbursts are reported in many movement disorders.
Psychotic symptoms, which exacerbate underlying aggression, are also
Neurological and Medical Disorders ❘ 195
Parkinson’s Disease
Although aggression may not be a common manifestation of Parkin-
son’s disease, per se, it may develop as a result of treatment of motor
symptoms with dopaminergic medications, especially if psychosis is a
side effect. Patients who develop impulse control disorders—“hedon-
istic dopaminergic dysregulations” that are at times related to use of
dopaminergic medications to treat motor symptoms—may be agitated
or impulsive.
Wilson’s Disease
Wilson’s disease, or hepatolenticular degeneration, is an autosomal re-
cessive disorder involving dysregulation of copper metabolism by the
liver. Neurological, renal, and hepatic abnormalities are the usual find-
ings in the disease. In a study of 42 patients with Wilson’s disease, Akil
et al. (1991) noted that 24 of the patients had psychiatric symptoms as
the presenting complaint. Personality changes, including aggression
and irritability, were the most common presenting psychiatric com-
plaint. Dening and Berrios (1989) assessed multiple neuropsychiatric
symptoms in 195 patients with Wilson’s disease. Aggression was defi-
nitely present in 17 patients and assessed as possibly present in 11 indi-
viduals.
Huntington’s Disease
Huntington’s disease is an autosomal dominant movement disorder. It
typically features choreiform movements and/or psychiatric symp-
toms. Burns et al. (1990) assessed 26 patients with Huntington’s disease
and found that 59% of the patients scored significantly on an aggression
scale. Aggression and irritability were not correlated with apathy or
with each other. Marder et al. (2000) found in a large study of patients
at various stages of the disease that aggression was reported by more
than half of patients or caregivers.
Medical Disorders
Numerous medical conditions may result in diffuse brain dysfunction
and subsequent aggression. Several authors have discussed the fre-
quency of “minimal brain dysfunction” or poorly characterized “neu-
rological soft signs” in aggressive individuals (e.g., Elliot 1992; Monroe
1978). The most commonly seen disorders are described here; it is well
worth pursuing a complete medical workup in any patient who devel-
ops aggression suddenly or without a prior history of violent behavior.
Neurological and Medical Disorders ❘ 197
Delirium
Delirium, or acute confusional state, is a transient global disorder of cog-
nition; it is a syndrome, not a disease, with multiple causes (see Table
10–2). The condition is a medical emergency associated with increased
morbidity and mortality. Decreased attention span and a waxing and
waning type of confusion are important features (American Psychiatric
Association 2000).
Agitated or violent behavior has been reported in delirium due to
many causes, including postoperative confusion (Lepouse et al. 2006).
Several conditions associated with delirium are discussed in the follow-
ing sections.
Toxins
Toxin exposure can produce various neurobehavioral changes, the most
common of which are sedation and memory deficits. Toxins that are as-
sociated with aggression include alkyltin, arsenic, lead (in adults), man-
ganese, and mercury. Solvents generally cause lethargy and confusion,
although toluene exposure may produce excitation and disinhibition.
Gas exposure, such as carbon monoxide, causes lethargy and impaired
cognition and may cause delirium. Nitrous oxide use is associated with
delusions and agitation (Bleecker 1994; Bolla and Roca 1994).
Rheumatic Diseases
Systemic lupus erythematosus is the autoimmune disorder most closely
associated with neuropsychiatric symptoms, including aggression. Be-
havioral effects of lupus can be due to either direct CNS involvement or
effects on other organ systems, such as uremia due to renal impairment,
leading to confusion and delirium. Other rheumatological disorders,
such as the vasculitides, Sjögren’s syndrome, and sarcoidosis, can all
produce dementia and psychosis, leading to aggressive behavior
(Ovsiew and Utset 1997). As noted earlier, steroids, which are com-
monly used to treat rheumatological diseases, may cause psychosis and
agitation.
Sleep Disorders
There have been a few reports of aggressive behavior during parasom-
nias, including violent attacks by patients with rapid eye movement be-
havior disorder (Mahowald et al. 2007). Recognition of this disorder is
particularly important due to its association with several other condi-
tions, including Parkinson’s disease, Lewy body dementia, and multi-
system atrophy. Sleep deprivation can, of course, worsen irritability in
many conditions, leading to exacerbation of underlying behavioral
problems.
Hypoglycemia
A series of studies conducted by Virkkunen et al. (2007) in Finland
has examined biological correlates of aggression in a group of violent
prisoners. One consistent finding has been that this group is prone to
hypoglycemia and that they have in increase in irritability during these
episodes.
Neurological and Medical Disorders ❘ 199
Treatment
Assessment and Quantification of Aggressive Episodes
Before therapeutic intervention to treat violent behavior is initiated, cli-
nicians should document the baseline frequency and severity of the oc-
currences. It is essential to establish a treatment plan that uses objective
documentation of aggressive episodes to monitor the efficacy of inter-
ventions for both acute and chronic aggression. The Overt Aggression
Scale is an instrument of proven reliability and validity that can be used
easily and effectively to rate aggressive behavior in patients with a wide
range of medical or neurological disorders (Silver and Yudofsky 1991;
Yudofsky et al. 1986). The scale comprises items that assess verbal ag-
gression, physical aggression against objects, physical aggression
against self, and physical aggression against others. Behavior can be
monitored by staff or by family members utilizing this instrument.
Pharmacotherapy
Although no drug is approved by the U.S. Food and Drug Administra-
tion specifically for the management of acute or chronic aggression,
medications are widely used, and often misused, for this purpose. The
use of pharmacological interventions can be considered in two catego-
ries: 1) use of the sedating effects of medications, as required in acute
situations, so that the patient does not harm him- or herself or others,
and 2) use of nonsedating antiaggressive medications to treat for
chronic aggression when necessary. Some patients may not respond to
just one medication but may require combination treatment. There are
few double-blind, placebo-controlled trials conducted in this area to
guide the use of medication to treat aggressive behavior (Neurobehav-
ioral Guidelines Working Group et al. 2006). We suggest using the
guidelines published by the Expert Consensus Panel for Agitation in
Dementia (Alexopolous et al. 1998) as a framework for the assessment
and management of agitation and aggression in medical and neurolog-
ical illness.
Chronic Aggression
If a patient continues to exhibit periods of agitation or aggression be-
yond several weeks, the use of specific antiaggressive medications
should be initiated to prevent future episodes. The choice of medication
may be guided by the underlying hypothesized mechanism of action
(i.e., effects on serotonin system, adrenergic system, kindling) or in con-
sideration of the predominant clinical features. Since no medication has
been approved for the treatment of aggression, the clinician must use
medications that have been approved for other uses (i.e., for seizure dis-
orders, depression, anxiety, mood stabilization, hypertension).
Table 10–3 summarizes our recommendations for the utilization of
various classes of drugs in the treatment of aggressive disorders. In
treating aggression, the clinician, when possible, should diagnose and
treat underlying disorders and use antiaggressive agents specific for
those disorders. When there is a partial response after a therapeutic trial
with a specific medication, adjunctive treatment with a medication with
a different mechanism of action should be instituted. For example, a pa-
tient with a partial response to β-blockers may show further improve-
ment with the addition of an anticonvulsant or a serotonergic antide-
pressant. Side effects may limit dosing, as in any patient population;
patients with disease affecting the brain are often more sensitive to
medication side effects. Among the more important side effects, akathi-
sia may occur, with concomitant restlessness and irritability, in patients
who are being treated with neuroleptics for suppression of chorea or for
psychiatric symptoms. This can potentially worsen aggression if not
recognized.
Clinicians should be aware of recent U.S. Food and Drug Adminis-
tration warnings that the use of atypical antipsychotics was associated
with an increased risk of death in a review of data from 5,106 elderly de-
mented patients in randomized, controlled clinical trials (see Kuehn
2005 for an excellent commentary on the “black box” warnings). A mor-
tality rate of 4.5% was seen in those elders receiving atypical agents
compared with a rate of 2.6% in those who were given placebo. Deaths
were predominantly due to cardiovascular and infectious illnesses. A
“black box” warning has been added to labeling of all atypical neuro-
Neurological and Medical Disorders ❘ 201
leptics. As discussed earlier, many of the patients who are most in need
of treatment for aggression are elderly and may have memory loss; they
may thus be at higher risk of mortality associated with atypical neuro-
leptic use. Conversely, agitation and violence are associated with signif-
icant risk of increased morbidity and mortality. Clinicians should weigh
carefully the small possibility of increased mortality associated with
atypical antipsychotic use versus the many complications inherent in
leaving aggressive symptoms untreated in these patients.
Behavioral Treatment
It is clear that aggression can be caused and influenced by a combination
of environmental and biological factors. Because of the unpredictable
nature of aggression in neurological and medical disease, caregivers and
staff in institutional settings may overreact to aggression when it occurs.
Behavioral treatments have been shown to be highly effective in treating
patients with organic aggression and may be useful when combined
with pharmacotherapy. Behavioral strategies—including a token econ-
omy, aggression replacement strategies, and decelerative techniques—
may reduce aggression in the inpatient setting and can be combined ef-
fectively with pharmacological treatment.
Because irritability is often directed toward individuals known to the
patients, education of caregivers in how to identify and avoid situations
that trigger irritability and how to minimize its effects if it does occur is
crucial. Behavioral interventions may prove helpful in prevention of ag-
gression by removing precipitating factors. This includes adherence to a
schedule to avoid surprising the patient and provoking an outburst
(Moskowitz and Marder 2001). Caregivers should be advised to stop an
activity, such as assistance with ADLs, if aggressive behavior begins to
escalate. They should also be counseled not to argue with patients if the
behavior begins to escalate. If threats of physical aggression occur, they
should quickly remove themselves and other family members from the
area where the patient is and contact emergency medical services for as-
sistance. Any ammunition and weapons should be removed from the
home. The patient should be prevented from accessing alcohol and illicit
drugs because use of these substances, even in small quantities, may
contribute greatly to disinhibition in patients with neurological and
medical illness. If there is a history of severe aggression against persons
or property, law enforcement agencies may need to intervene to prevent
injury to the patient or caregivers. Evaluation by a medical professional
to rule out medical illness, delirium, medication toxicity, or physical dis-
comfort should be conducted, especially in patients who have not been
202
TABLE 10–3. Psychopharmacological treatment of chronic aggression
Examples of agents
❘
Class of agent used (dosing range) Potential side effects Overall comments
Selective serotonin Escitalopram (10–20 mg) Initially may cause Preferable to start with an SSRI, then add a neuroleptic if
reuptake inhibitors anxiety or agitation needed. However, in cases of acute or extreme
(SSRIs) aggression, a neuroleptic should be started first. SSRIs
❘
203
204 ❘ Textbook of Violence Assessment and Management
Discussion
Aggressive behavior in the presence of medical illness is common and
can be highly disabling. Neuroanatomical, neurochemical, and neuro-
physiological factors may have an etiological or mediating role in the
production of violence. The vignettes that follow illustrate some com-
mon clinical features of violence in the medical setting.
this way to fairly minor provocations and expressed regret that he had
behaved in such a manner. Mr. H has never been evaluated for Hunting-
ton’s symptoms clinically and has no wish to know if he has the gene.
Key Points
■ Explosive and violent behavior has long been associated with both
focal brain lesions and diffuse damage to the CNS.
■ Irritability and/or aggression is a major source of morbidity for in-
dividuals with neurological or medical disease and a source of ad-
ditional stress to their caregivers and families.
■ Presence of aggression is often a primary factor when the decision
is made to place patients in an institution rather than provide care
in a home setting.
■ Low frustration tolerance and explosive behavior can be set off by
minimal provocation or occur without warning. It is essential that
all clinicians be aware of aggression and its assessment and treat-
ment in order to provide effective care to patients with this condi-
tion.
■ After appropriate evaluation and assessment of possible etiolo-
gies, treatment begins with the documentation of the aggressive
episodes. Psychopharmacological strategies may be divided into
those intended to treat acute aggression and those intended to
prevent episodes in the patient with chronic aggression.
■ The treatment of acute aggression involves the judicious use of se-
dation; the treatment of chronic aggression is guided by underly-
ing diagnoses and symptoms.
■ Behavioral strategies, including caregiver reassurance and educa-
tion, remain an important component in the comprehensive
treatment of aggression.
206 ❘ Textbook of Violence Assessment and Management
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C H A P T E R 1 1
211
212 ❘ Textbook of Violence Assessment and Management
Prenatal Development
Prenatal risk factors such as maternal use of alcohol, tobacco, or cocaine
and pregnancy/birth complications have been linked to developmental
delays and behavioral problems in children and to antisocial behavior
214 ❘ Textbook of Violence Assessment and Management
and violent offending in adults (Raine 2002). Exposure to these risk fac-
tors may directly or indirectly affect the structure and function of the
developing fetal brain, leading to long-term damage to central nervous
system neurotransmitter pathways (Ernst et al. 2001). For example, chil-
dren of mothers who smoked were found to be twice as likely to have a
criminal record by age 22 (Räsänen et al. 1999). In addition, 6- or 7-year-
old girls who had been exposed to cocaine in utero were significantly
more likely to score in the abnormal range on the Aggression subscale
of the Child Behavioral Checklist than control subjects (Sood et al.
2005). However, these risk factors are rarely found independent of other
psychosocial complications such as poverty, poor parenting skills, and
limited access to medical care and educational opportunities.
Childhood Trauma
Childhood trauma has been associated with impulsive and aggressive
behaviors, including self-destruction and suicidal behavior in later
years (Briere and Runtz 1990). Brodsky et al. (2001) examined 136 adults
with major depression and found that participants with a history of
physical or sexual abuse were more likely to have made a suicide at-
tempt and had higher levels of impulsivity, aggression, and comorbid
borderline personality disorder than participants with no abuse history.
The researchers assert that childhood trauma may constitute an envi-
ronmental risk factor that leads to the development of both suicidality
and impulsivity. Similarly, Roy (2005) studied 268 abstinent drug-
dependent patients and found a significant positive correlation between
impulsivity and risk-taking scores on the Barratt Impulsivity Scale and
scores of abuse and neglect on the Childhood Trauma Questionnaire.
in brain imaging studies (Raine et al. 1997). Grafman et al. (1996) stud-
ied Vietnam veterans who had penetrating head injuries and found
they had higher verbal aggression scores than control subjects and
patients with lesions in other areas of the brain. A study evaluating
89 patients with traumatic brain injury found that those who scored
high on the Overt Aggression Scale had a preinjury history of mood dis-
order, alcohol and drug abuse, and aggressive behaviors (Tateno et al.
2003). These findings indicate that postinjury behavior may be reflec-
tive of preexisting impulsive and aggressive tendencies.
Neurochemistry
Neurotransmitters are chemicals that send information between neurons
in the brain and help to regulate mood, thinking, and behaviors (Ber-
man and Coccaro 1998). Among the many known neurotransmitters,
the most studied in relation to aggression and impulsivity are seroto-
nin, norepinephrine, dopamine, and γ-aminobutyric acid (GABA). The
majority of the studies suggest that GABAergic and serotonergic sys-
tems inhibit predatory aggression, and the noradrenergic and dopa-
minergic systems stimulate affective aggression (Eichelman 1988). Low
levels of serotonin have been associated with increased rates of aggres-
sion, impulsivity, depression, and suicidality. Coccaro (1996) found
lower serotonin levels in suicide victims, particularly those who used a
violent suicide method, when compared with accident victims. In addi-
tion, Coccaro and Kavoussi (1997) examined 40 patients with person-
ality disorders and a history of impulsive aggression and found that
fluoxetine, a selective serotonin reuptake inhibitor, reduced scores of
aggression and irritability on the Overt Aggression Scale.
The noradrenergic system affects attention to stimuli, arousal levels,
and responses to stressors (Berridge and Waterhouse 2003) and is one
of the fastest-responding neurochemical systems (Haller et al. 1998).
Norepinephrine is involved in the fight-or-flight response and has been
linked to aggressive behavior (Haden and Scarpa 2007). In a study mea-
suring aggressive behavior and norepinephrine levels, Gerra et al.
(1997) experimentally induced aggression using a free-operant proce-
dure in 15 males with “low normal” and 15 males with “high normal”
basal aggressivity (based on scores on the Buss-Durkee Hostility Inven-
tory and other measures). They found no differences between the
groups in base rate plasma norepinephrine levels. However, during the
task, norepinephrine levels were significantly higher in the high group
than the low group. These findings suggest that high-aggressive indi-
viduals respond more intensely, and their norepinephrine increases
216 ❘ Textbook of Violence Assessment and Management
Discussion
Intermittent Explosive Disorder
Case Example 1
J.W. is a 30-year-old man with a long history of fights and assaultive be-
havior. He was referred by a judge for anger management classes several
years ago. J.W. was walking down the street when he inadvertently
bumped into a stranger. The stranger said, “Why don’t you watch where
you’re going!” Infuriated, J.W. turned on the stranger and started pum-
meling him into unconsciousness. Minutes later, when onlookers pulled
him off of his victim, J.W. was upset and remorseful over his behavior.
Pyromania
Case Example 2
R.J. is 23 years old and has had a fascination with fires since early child-
hood. In the past he has set many small, contained fires and enjoyed
watching the resultant blazes. Tonight, he is sitting in his room fondling
218 ❘ Textbook of Violence Assessment and Management
Case Example 3
W.P. is a 35-year-old woman with moderate intellectual disability deriv-
ing from fetal alcohol syndrome. She was recently placed in a group
home after the death of her parents several months ago. She has never
needed psychiatric care in the past. She does well at her job placement
until it is time to leave. At that point, on a fairly consistent basis over the
past few weeks, this normally pleasant woman hits anyone who at-
tempts to persuade her to board her minivan for the ride back to her
group home.
Case Example 4
M.R. is 28 years old and has been in psychiatric care throughout his life.
He is currently on a trial of a new anticonvulsant. He sits quietly rocking
back and forth, chewing on his already bleeding left wrist. When Jim,
his caregiver, attempts to intervene, this startles him. M.R. then furi-
ously swings his arms, hitting Jim repeatedly.
The term autism, derived from the Greek word for “self,” was coined
by Leo Kanner (1943), a child psychiatrist, to describe the extreme
aloneness he viewed as the central trait of the disorder. Autism spec-
trum disorder (ASD), as it is now called, is currently recognized as a
neurodevelopmental disorder (Aicardi 1998). According to DSM-IV-
TR, to be diagnosed with autistic disorder an individual must exhibit 6
or more of the 12 identified behaviors, with at least two from the social
interaction domain and one each from the communication, repetitive,
and stereotyped patterns domains. In addition, delays in social interac-
tion, language, or symbolic or imaginative play must be evident before
the age of 3 years.
Prevalence rates of ASD range from 0.7 to 72.6 per 10,000, depend-
ing on the diagnostic criteria used in the studies (Williams et al. 2006).
Fombonne (1999) reviewed 23 studies on autism and found that preva-
lence rates significantly increased with publication year, indicating im-
proved diagnostic criteria and methods along with greater availability
of services. For example, Croen and Grether (2003) found that 75% of in-
dividuals with autism had some level of intellectual disability and pro-
posed that the increase in the prevalence of autism may be attributable
to the reclassification of some individuals’ diagnoses from intellectual
disability to autism. Fombonne (2003) also found a higher rate of boys
222 ❘ Textbook of Violence Assessment and Management
Impulsive Suicide
Case Example 5
After 65 years of life, K.T. has coped with several serious illnesses and
repeated bouts of depression. He has been treated by a psychiatrist for
the past few years, with only modest symptomatic improvement. The
past 3 months have been filled with unremitting depression. K.T. feels
hopeless and has intermittently considered ending his life. The three
drinks he just had seem to make the decision easier. He hits the car’s ac-
celerator and aims head on for the gap in the guard rail, with the river
100 feet below.
Suicide ranks among the top 10 causes of death for individuals in all
age groups in several Western countries (World Health Organization
2006). Suicide attempts have been defined as “potentially self-injurious
behavior with a nonfatal outcome, for which there is evidence (either
implicit or explicit) that the person intended at some (nonzero) level to
kill himself/herself” (O’Carroll et al. 1996, p. 247). Terms such as para-
suicide, deliberate self-harm, and suicidal gestures are considered SIBs that
may have the appearance of a suicide attempt but may not have the as-
sociated intention of ending one’s life. Using data from the National Co-
morbidity Survey of 5,877 respondents, Nock and Kessler (2006) found
Impulsivity and Aggression ❘ 223
4.6% of the sample had made a suicide attempt, 2.7% reported doing so
with the intent to die, and 1.9% committed the act as a way to commu-
nicate distress to others with no intent to die.
To date, a prior suicide attempt is among the best predictors of even-
tual death by suicide (Goldstein et al. 1991). In a 5-year follow-up of
1,573 suicide attempters, Nordstrom et al. (1995) found the risk of recur-
rent suicidal behavior to be 11% for attempted suicide and 6% for ulti-
mately completed suicide. Rates were highest among young men.
Johnsson-Fridell et al. (1996) reported a 13% suicide completion rate
among inpatients within 5 years of attempted suicide. In a study exam-
ining lifetime history of suicide attempts and methods of 1,397 suicides
in Finland, Isometsä and Lonnqvist (1998) found that 56% of fatal sui-
cides occurred on the first attempt (62% of males and 38% of females),
and the risk of suicide completion was highest during the first year after
a suicide attempt. With such high fatality figures, particularly for men,
using previous suicide attempt as a predictor of suicide completion has
limited preventive value.
Risk factors associated with suicidal behavior include male gender,
fewer years of education, being young, and residence in the southern or
western regions of the United States (Nock and Kessler 2006). Based on
psychological autopsies, a 6-month prevalence rate of an Axis I diagno-
sis has been found in 88% of suicide completers (Lesage et al. 1994). Spe-
cifically, depressive (major depressive episode and mania), impulsive
(drug abuse and dependence), and aggressive (conduct disorder and
antisocial personality disorder) behaviors and psychiatric comorbidity
increase the risk of suicide attempts (Nock and Kessler 2006), with ma-
jor depression being the most common psychiatric disorder associated
with suicide and attempted suicide (Henriksson et al. 1993). Childhood
trauma has been associated with self-destruction and suicidal behavior
in later years (Briere and Runtz 1990) and contributes to a younger age
of onset of suicidal behaviors, often beginning in childhood or adoles-
cence (Brodsky et al. 2001).
Impulsivity has been conceptualized as action without planning or
reflection; it differs from premeditated behavior by having a short re-
sponse time, lack of reflection, and a dissociation between action and
consequence (Barratt et al. 1999). Impulsivity, along with other disin-
hibiting moderators such as substance use or significant current dis-
tress, is strongly associated with self-destructive behaviors, including
suicidal behavior (Dumais et al. 2005). Impulsive suicidal behavior has
been defined as a suicide attempt with less than 5 minutes of premedi-
tation (Simon et al. 2001). Using this definition of impulsive suicidality,
prevalence rates range from 24% for nearly lethal suicide attempts by
224 ❘ Textbook of Violence Assessment and Management
individuals 13–34 years old (Simon et al. 2001) to 40% for hospital pa-
tients treated for self-injury (Williams et al. 1980).
Individuals who engage in impulsive suicidal behavior tend to use
more violent methods, such as firearms, hanging, cutting, and jumping
(Simon et al. 2001), than their nonimpulsive counterparts. At the same
time, impulsive suicide attempters have lower expectations of dying
from their actions (Swann et al. 2005). Despite the impulsive attempters’
lower expectations of dying than nonimpulsive attempters, the destruc-
tive outcomes are comparable in terms of severity of injuries, reversibil-
ity of condition, and admission into intensive care (Simon et al. 2001).
The incongruous thought process involved in these attempts is consis-
tent with a defining construct of impulsivity: the disconnect between
action and intention (Swann et al. 2005).
Impulsivity does not appear to increase the risk of suicide inde-
pendently. Simon et al. (2001) suggested that suicidal behavior may be
associated with the inability to control aggression-related impulsive
behavior rather than with impulsivity in general. For example, the re-
searchers examined indicators of impulsive behavior such as prior ar-
rests, quitting a job without a source of income, having multiple sex
partners, and alcohol use within 3 hours of the suicide attempt and
found no relationship to impulsive suicidal behavior. However, being
in a physical fight in the past year was associated with impulsive sui-
cide attempts. Zouk et al. (2006) examined the psychiatric records of
164 suicide cases using the Barratt Impulsivity Scale. Individuals who
scored 75 or higher (which was the 70th percentile for the group) were
labeled impulsive and scored significantly higher on the Buss-Durkee
Hostility Inventory than their nonimpulsive peers (defined by a score
equal to or below the 30th percentile on the Barratt scale), suggesting
that aggression is a serious risk factor for impulsive suicidal behavior.
Dumais et al. (2005) found impulsive and aggressive behaviors to be as-
sociated with suicidality in 104 males diagnosed with major depression.
However, they asserted that the relation of aggressive and impulsive
behaviors and suicide may be better explained by Cluster B personality
disorder and alcohol/drug abuse.
Self-Injurious Behaviors
Case Example 6
B.D. has been in psychiatric care for a decade. Her problems have in-
cluded an eating disorder, emotional instability, intense unstable rela-
tionships, and SIBs. Finding a space on her inner thigh not already
scarred, the 25-year-old cuts herself. As she watches the blood flow, the
Impulsivity and Aggression ❘ 225
intense roiling emotions she had felt moments before give way to a
sense of relaxation and peace.
SIB involves deliberate and often repetitive harm to one’s own body
without suicidal intent (Favazza 1998). A typical pattern for SIB begins
with an overwhelming psychological distress such as anger, anxiety,
tension, fear, or a sense of loss. An individual often responds to the
overwhelming emotion by isolating and dissociating. In carrying out
SIB, there is an absence of suicidal intent and often a lack of pain. The
precipitating tension is relieved by the SIB, and individuals report feel-
ing a sense of calm, often followed by disgust and/or guilt (Suyemoto
1998).
SIBs can be very diverse in terms of specific behaviors, severity, and
frequency. Simeon and Favazza (2001) proposed four classifications of
SIBs—major, stereotypic, compulsive, and impulsive—as a way to help
understand and treat the disorder. Major SIBs tend to be severe, poten-
tially lethal, and irreversible, such as castration, eye enucleation, and
amputation of extremities. This category of SIB is relatively rare and is
associated with schizophrenia, intoxication, neurological conditions,
bipolar disorder, and severe personality disorders. The impetus for ma-
jor SIB is often associated with sin, religious delusions, sexual tempta-
tion, punishment, and salvation (DeMuth et al. 1983). Stereotypic SIBs
tend to be repetitive and lack symbolism or affect. The behaviors can be
occasional or chronic, such as head banging, eyeball pressing, and fin-
ger biting (Favazza and Simeon 1995). These types of SIBs are common
in individuals with mental retardation (Griffin et al. 1986), autism
(Christie et al. 1982), and Tourette’s syndrome (Robertson et al. 1989).
Compulsive SIBs are ritualistic and repetitive behaviors such as trichotil-
lomania, nail biting, skin picking, and skin scratching (Simeon 2006).
Individuals with this type of behavior often report that the behaviors
occur unintentionally. The behaviors are typically associated with
mounting anxiety followed by relief. Impulsive SIBs include skin cut-
ting, skin burning, poisoning, and self-hitting. These behaviors tend to
provide short-term relief from unbearable psychological states (Simeon
2006).
The prevalence of any SIB in the general public has been estimated
to be 4% (Briere and Gil 1998). However, prevalence rates vary greatly
based on selected populations. For example, in a study of 15- and 16-
year-old students in England, researchers (Hawton et al. 2002) found
that 6.9% of their sample had engaged in at least one act of deliberate
self-harm in the previous year. The primary method of harm was cut-
ting (two-thirds) and poisoning (less than one-third). Multiple acts of
226 ❘ Textbook of Violence Assessment and Management
Key Points
■ Impulsivity and aggression may be useful or destructive behav-
iors, depending on the context. They are characteristic of a range
of disorders and of symptoms of mental illness that may result in
significant functional impairment, morbidity, and mortality.
■ Intermittent explosive disorder (IED), an impulse-control disorder,
is the only DSM-IV-TR diagnosis with recurrent aggressive acts as
the primary symptom. People with IED describe “a need to attack,”
“an adrenaline rush,” “a need to defend oneself,” and “an urge to
kill.” Episodes may be infrequent and brief but can have devastat-
ing results such as destruction of property, serious assault, or even
homicide. People with IED have difficulties maintaining employ-
ment, financial stability, and meaningful relationships.
■ Pyromania is the repeated failure to resist the impulse to set
motiveless fires. Risk factors associated with pyromania are male
gender, unemployment, living alone, and a keen interest in fires.
■ For people with intellectual disabilities, aggressive behavior can
have a severe negative impact on residential, education, and
employment opportunities. Acts of aggression tend to increase
with severity of disability, but higher-functioning individuals tend
to act aggressively toward others and lower-functioning individu-
als to engage in self-injurious behavior (SIB). Skill deficits in atten-
tion span, impulse control, memory, neurological functioning,
communication skills, and social skills may be present and may
increase the probability of aggression.
■ In individuals with autism, aggression is common and may include
impulsivity, aggression toward others, SIB, destruction of property,
disruptiveness, stereotypy, and other socially unacceptable behav-
iors, not necessarily with malicious intent. Impairments com-
monly found in autism may reduce the capacity for social interac-
tion, communication, and ability to alter behavior and emotional
states in response to another’s action or perceived feelings.
■ Suicide is a major public health concern and is a leading cause of
death in several Western countries. A prior suicide attempt is one
of the best predictors for eventual death by suicide; however, the
preventive value of this is limited because more than half of fatal
suicides occur on the first attempt. Those who engage in impul-
sive suicide (with less than 5 minutes of premeditation) use more
violent methods, have lower expectations of dying from their
actions, and have comparable destructive outcomes to their non-
impulsive counterparts.
228 ❘ Textbook of Violence Assessment and Management
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Impulsivity and Aggression ❘ 231
Treatment Settings
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C H A P T E R 1 2
Outpatient Settings
James C. Beck, M.D., Ph.D.
General Principles
There is no substitute for clinical judgment in assessing the risk
of violence and in making the many decisions involved in treatment.
237
238 ❘ Textbook of Violence Assessment and Management
possibly getting revenge on her and her new boyfriend? Or is this a fan-
tasy with little or no affective charge of any kind? It is essential to attend
to the affect associated with the answers to these questions and not only
to the content of the answer.
B=f(P,E)
Expanded, it means that behavior (B) is a function of the person (P) and
the environment (E). Too often, clinical training focuses on the individual
person, P, ignoring or giving too little attention to the facts of the per-
son’s situation or environment, E. The description of a patient as a “vi-
olent person” is common but not terribly helpful. It is true that some
people are more likely to be violent than others, but the likelihood of vi-
olence depends to a substantial extent on the person’s environment or
situation, and the clinician should not neglect gathering the relevant
facts about the person’s situation. This conceptual framework is useful
not only for assessment, but also for treatment, as in this case example.
Case Example
Mr. A, a 37-year-old single white male, was first diagnosed with para-
noid schizophrenia at age 19. He receives disability payments and lives
with his mother, whom he believes is poisoning his food. He gives as his
reason that his food tastes funny. He adds that when he complains, his
mother tells him there is nothing wrong with the food—there must be
something wrong with him.
He tells his clinician that he is frightened and that he has begun to
think about killing his mother. He denies that he has any concrete idea
of how to kill her or any plan for what he might do, but he acknowledges
that this thought does not cause him any anxiety. He denies being angry
at anyone else, and he has no known history of violence. He denies any
substance abuse. He says that he is taking his medication and attending
outpatient treatment and a drop-in center regularly. His health is good.
His past history shows that he was a quiet child with few friends.
His chart contains no mention of fighting, truancy, or oppositional be-
havior. He had one brief romantic relationship at age 19, and he has a
long history of unemployment—he last worked 15 years ago, part time,
bagging groceries. In the past he has taken his medication inconsis-
tently, and when he has stopped his medicine he has also stopped com-
ing to outpatient appointments.
240 ❘ Textbook of Violence Assessment and Management
What is to be done for this patient? As a first step in assessing risk, the
clinician might review one of the published methods of risk assessment.
The HCR-20, a 20-item instrument, is a good choice (Webster 1997). It
serves as a reminder-checklist for things we need to know in weighing
risk. The authors of the HCR-20 suggest that each item be rated absent
(0), possibly present (1), or definitely present (2). The authors wrote, “Put
simply, it is reasonable for assessors to conclude that the more factors
present in a given case, the higher the risk for violence” (Webster 1997,
p. 22). But, they added, “Even here, though, assessors must be cautious”
(p. 22), implying that they recognized that a simple quantitative ap-
proach is not an adequate basis on which to assess risk. Published stud-
ies show correlations of about 0.30 between scores on the HCR-20 and fu-
ture violence (Webster 1997). This means that the HCR-20 predicts less
than 10% of the variance in future violence. It is useful for helping us
gather the data we need, but it is not a substitute for clinical judgment.
There are three scales in the HCR-20: 10 historical items (H), 5 clini-
cal items (C), and 5 risk items (R). Rating the H items for the patient in
the case example, we have the following:
1
This illustrates that so-called objective rating scales often require clinical judgments in
making the ratings. However, since the inconsistent response is rated “possible” as a
risk-management factor as well, rating it as possible here may be double counting. Thus
“negative” is more accurate.
Outpatient Settings ❘ 241
Rating the five risk-management items for Mr. A, we find that he has
• No positive indicators
• One negative: No feasible plan
• One possible: Variable past compliance with treatment
• Three items we have not evaluated: Exposure to destabilizers, lack of
personal support, and current stress
This exercise reveals that evaluation to this point has focused almost
exclusively on P (person) items in attempting to assess B—that is, future
violent behavior—and has almost totally ignored E (environment). In
the HCR-20, three of the five risk-management items refer to environ-
mental variables: exposure to destabilizers, lack of personal support,
and stress. At this point, these have not been adequately assessed.
This analysis points in the appropriate direction. The clinician can
either re-interview Mr. A or, if she will agree, interview his mother. Note
here I did not say to interview the mother if Mr. A agrees. Interview the
mother regardless of whether he agrees. Why? Because, as a general
rule, safety issues override confidentiality issues. When the clinician is
seriously concerned about the potential for harm to either the patient or
anyone else, he or she should attempt to gather whatever data is rele-
vant to the assessment of risk. Here, the mother is likely to provide use-
ful information, and the concern is about a potential killing, so the cli-
nician must interview her.
Too often, when a senior clinician consults about a patient’s poten-
tial for suicide or for violence toward others and asks what the family
says, the answer is, “Oh, we haven’t talked with the family. The patient
wouldn’t give us permission.” This occurs most often on inpatient units.
This is wrong. Safety is more basic than confidentiality. This does not
mean that the clinician has carte blanche to violate confidentiality. It does
mean that when the clinician has done a thorough assessment with the
patient and safety remains an important issue, the clinician must look
further to whatever other sources of information may be accessible.
To add one clinical note to this aside, the clinician should almost al-
ways, except in the most unusual circumstances (e.g., a delirious pa-
tient), explain to the patient what he or she is going to do and why.
There are data showing that therapy is disrupted not when the clinician
breaches confidentiality to seek additional sources of information but
rather when the clinician fails to inform the patient of what he or she is
doing (Beck 1981). When the clinician goes behind the patient’s back to
breach confidentiality, the patient feels betrayed. The result is that the
patient distrusts the clinician, will end the contact if possible, and is
242 ❘ Textbook of Violence Assessment and Management
likely to avoid the mental health system in the future (Beck 1981; Tara-
soff v. Regents of the University of California 1976).
Returning to Mr. A, and recalling the missing information, here are
two alternative scenarios.
In the first scenario, Mr. A and his mother live alone with no immediate
family nearby. Mr. A is not sure whether his mother is angry with him
or not. When the clinician interviews the mother, she says that she is
quite annoyed with her son—she cannot understand why he is com-
plaining about her cooking, and she is quite unsympathetic. She says,
“With all I do for him, he is really ungrateful. I tell him if he doesn’t like
the food here he should ‘go to another hotel.’ ” Mr. A is worried about
his situation at home. He wonders if his mother means he should leave.
Asked about outside social supports, Mr. A says his only regular contact
is the drop-in center and that he has recently had an argument with one
of the other patients and has not been back for several weeks.
In the alternate scenario, the clinician learns Mr. A’s divorced sister lives
downstairs with her 10-year-old son and Mr. A has a good relationship
with them. He often eats there, especially if there has been an argument
at home. Mother (or sister) says that Mr. A has been talking for years
about his fear of being poisoned but that his sister is able to reassure
him, and the family takes all this in stride as part of Mr. A’s illness. Mr.
A has no close friends, but he does have coffee almost every day at the
local Dunkin’ Donuts, and he is doing fine in his drop-in center.
acceptable level. At the present time, when managed care dictates brief
hospitalizations, very little if anything is likely to have changed be-
tween pre-admission and discharge except that a week has passed since
the patient was removed from his or her environment to the hospital.
Now the hospital is proposing to discharge the patient to outpatient
care. If the outpatient clinician is part of an organizational network car-
ing for such patients, she or he may have something to say about
whether enough has changed that this patient is safe for outpatient
treatment. The value of B=f(P,E) in this situation is that it helps the cli-
nician ask a broad range of questions and consider a range of poten-
tially useful interventions or changes that may reduce the risk.2
2 Although the focus of this analysis is on danger to others, it is equally useful in assess-
ing risk of self-harmful behavior. For example, a man who worked in the same office
with his girlfriend became suicidally depressed after she dumped him. This patient
improved significantly after he changed his job situation. Not seeing the ex-girlfriend
every day gave the patient and the clinician time to provide treatment addressing the
person’s vulnerability to loss and related depression. Changing E-related risk reduced
the risk of self-harmful B and gave the psychiatrist the freedom to work on enduring P
variables with her patient.
Outpatient Settings ❘ 245
Threats to Patients
The focus of this chapter is on assessing risk of possible violence that the
patient may commit in the future, and how to assess that. Much of the
relevant data is elicited from the patient in the clinical interview. This
section addresses risk assessment when the patient is worried about
being a victim of violence, for example if she is being stalked. For an
248 ❘ Textbook of Violence Assessment and Management
With a paranoid patient the question of who sits nearer the door
may be important. If the clinician is not worried about violence toward
him- or herself, it may be best to let the patient have a clear path to the
door, so that the patient can leave without going through the clinician if
he or she becomes frightened. On the other hand, if the clinician is con-
cerned about violence, there may be greater risk to placing the patient
between the door and the clinician.
When in doubt about your own physical safety, ask the patient. That
is, raise a concern about the patient’s current volatility and your own
safety in the patient’s presence and try to negotiate an agreement on
how to further conduct the interview. This could mean leaving the door
open. In extreme cases it could mean arranging to meet in an emergency
department or other hospital setting. The point is that the clinician
should never meet with a patient in a situation in which the clinician
feels unsafe.
This last point leads to another critical assessment—namely, the cli-
nician’s assessment of his or her own comfort in dealing with potential
violence. Clinicians vary widely in how tolerant they are of dealing
with patients with histories of serious violence and in how comfortable
they are working in settings such as emergency services or prisons in
which potentially violent patients are a significant part of the caseload.
It is important to know one’s own level of comfort or discomfort with
the issue of violence and to try to arrange a professional life in which
the expected level of assessment of potential violence is within a zone
of comfort.
Again, no physical location is safe if no one else is present. It is es-
sential when seeing patients identified as potentially violent that other
people are within earshot and that they are aware of the issue. If the cli-
nician is worried, he or she can arrange to keep the office door partly
open if this is the best that can be done in a particular setting. Clinics can
install “panic buttons” that the clinician can use to alert staff to difficul-
ties. A clinician once interviewed a patient in a prison setting in which
the guards placed a small tower-shaped buzzer on the desk. “If this gets
knocked down,” they said, “40 people will come running in.” In emer-
gency services, weapons checks or metal detectors may be appropriate.
The recent tragic death of a senior psychiatrist—killed by a patient
whom he saw in a physically isolated office on a Sunday morning—
illustrates the potential dangers of seeing patients in isolation. It is not
good for patients to be violent, and it is certainly not good for therapists
to be victims. Commitment to patients is good, but professional services
should be provided only in a context that keeps the clinician safe.
250 ❘ Textbook of Violence Assessment and Management
tory of one or more violent offenses. Similar but less dramatic results
held for patients who had a comorbid conduct disorder.
Hodgins et al. (1999) also reported that antisocial personality was as-
sociated with violence among patients with schizophrenia, but in contrast
to Mueser et al. (2006), Hodgins’s group did not find that antisocial per-
sonality was associated with violence among patients with bipolar disor-
der. For the bipolar patients, substance abuse was associated with vio-
lence, and compliance with treatment decreased the risk of violence.
Recent data establish quite clearly that the violence associated with
schizophrenia is strongly related to the presence of comorbid conduct
disorder or antisocial personality disorder (Hodgins et al. 2005). In a
sample of 248 men with schizophrenia or schizoaffective disorder, ap-
proximately 20% had comorbid conduct disorder, and almost all men
with conduct disorder also met criteria for antisocial personality disor-
der. “In childhood and adolescence, conduct disorder was associated
with poor academic performance, physical abuse, substance misuse, in-
stitutionalization, and being raised in a family characterized by crimi-
nality and substance misuse” (Hodgins et al. 2005, p. 323). Conduct dis-
order was associated with an increased risk of violent crime such that
for each additional symptom of conduct disorder, the risk of violent
crime increased by 1.2. This was true after controlling for diagnoses of
drug or alcohol misuse. Notably, there was no association between vio-
lence and positive or negative symptom level in this sample, and cur-
rent substance abuse was equally common in conduct disorder patients
and others. The clinical implication of these findings is clear: the clini-
cian should routinely assess for a history of symptoms of conduct dis-
order or antisocial personality.
A body of work exists showing that delusions of threat (paranoia) or
control-override (delusions of thought insertion, or that one’s behavior
is controlled by outside forces) are associated with violence (Hodgins et
al. 2003; Link et al. 1992, 1998). These symptoms are associated with vi-
olence after controlling for gender, age, ethnicity, antisocial personality
disorder, and years of education. This association is another example of
the general principle that violence is associated with anger. It seems
likely that most people would be angry if they thought someone was
trying to harm them or was inserting thoughts into their mind.
Inquiring about the emotional charge associated with delusions is
critical (Buchanan et al. 1993). Buchanan et al. (1993) studied delusional
patients with the aim of better understanding why patients acted on de-
lusions. They found that patients were more likely to act on delusions
when feeling sad, anxious, or frightened as a result of the delusion. The
252 ❘ Textbook of Violence Assessment and Management
authors noted that Bleuler, in 1924, had already found affect to be an im-
portant determinant of delusionally driven action.
In a multisite/multinational study of 128 men with schizophrenia
discharged from the hospital and followed up for 2 years, Hodgins et al.
(2003, 2005) found that aggressive behavior was associated with severe
positive symptoms and in particular with threat or control-override
symptoms. This relationship held true when psychopathy and sub-
stance abuse were held constant. Depot medication did not reduce the
risk of violence for these patients. Again, the clinical implication is
clear: inquire about threat or control-override symptoms with care in
patients who show evidence of a psychotic disorder.
Fava and Rosenbaum (1999; Fava et al. 1993) studied anger attacks
as a symptom of depressive disorders. More than one-third of depressed
outpatients reported anger attacks, and 30% of those said that they
threw things or destroyed property. Personality disorders were more
common in patients with anger attacks than in those without. A small
study of women with psychosis in the community (Dean et al. 2006)
found more Cluster B personality disorders (impulsive, dissocial, histri-
onic, and borderline) in violent compared with nonviolent patients.
These data show that clinicians should not imagine that patients are too
depressed to be violent. They reinforce also the importance of assessing
personality characteristics as risk factors for violence.
What to conclude from all this? First, that the risk of violence asso-
ciated with schizophrenia in the absence of antisocial personality or
conduct disorder or substance abuse is probably not much higher than
the risk for persons without mental disorder—an informed guess is that
the risk is perhaps doubled. Risk for future violence is greater when, in
addition to schizophrenia, there is evidence for antisocial personality
disorder, conduct disorder, substance abuse, symptoms of threat or con-
trol override, past history of victimization, or exposure to violence in
the current environment. These are variables that are critical to evaluate
when assessing any patient for risk of future violence.
Environmental Variables
Swanson et al. (2002) reported on the relationship between environ-
mental variables and violence in a study of 802 inpatients and outpa-
tients with psychotic or major mood disorders. They found that 1-year
rates of serious violence were related to three variables: 1) substance
abuse, 2) past history of victimization, and 3) exposure to violence in the
current environment. When all three were present, 30% of patients re-
ported serious violence; when none were present, almost no patients re-
ported serious violence. When one of these factors was present, 2%
reported violence, and when two were present, 8%–10%.
Treatment Variables
As a general principle, there is no specific treatment for aggression. One
exception to this may be the treatment of impulsive aggression. Barratt
et al. (1997) showed that in a prison sample, phenytoin decreased im-
pulsive aggression but not planned aggression. Medications that reduce
affect dysregulation may reduce the likelihood of aggression. Examples
of these medications include oxcarbazepine, gabapentin, lamotrigine,
and other medications initially developed to treat seizure disorders.
Although there is no treatment for violence per se, there is treatment
for mental disorders, and to the extent that aggression is associated
with active symptoms of mental disorder, successful treatment of the
mental disorder may reduce the risk of violence. Clozapine has been
shown to reduce the risk of violent behavior among inpatients, when
254 ❘ Textbook of Violence Assessment and Management
Key Points
■ Risk assessment is first and foremost a process of clinical assess-
ment. Applying an algorithm or using a rating scale may be a use-
ful part of the process, but in the end it is the clinician’s assess-
ment of the unique facts that characterize this person in this
situation that will determine the recommended course of action.
■ The clinician should always, always, always attend to his or her
own safety. Never work in isolation with patients about whom
there are any safety concerns.
■ Assessing the person is important, but it is not the whole story—
behavior (B) is a function of the person (P) and the environment (E).
Outpatient Settings ❘ 255
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C H A P T E R 1 3
Inpatient Settings
Cameron D. Quanbeck, M.D.
Barbara E. McDermott, Ph.D.
259
260 ❘ Textbook of Violence Assessment and Management
Case Example 1
Ms. Smith is a 23-year-old woman with borderline personality disorder.
She was brought by police into an acute psychiatric hospital after cut-
ting her wrists in an apparent suicide attempt. Ms. Smith had become
distraught after discovering her boyfriend was involved with another
woman. On the unit, she exhibits agitated behavior. She is seen pacing
rapidly though the hallways of the unit, her emotions ranging from in-
tense anger to hysterical crying. She exclaims repeatedly, “How could
he do this to me?!” Suddenly, she approaches the nursing station and
demands to use the phone so she can call her boyfriend. The nurse on
duty sternly responds, “No! Calling him right now is not a good idea,
you just need to go to your room right now and calm down!” Ms. Smith,
not pleased with the nurse’s response, becomes more hostile and yells,
“Give me your phone! I need to call him right now! I’m gonna kill you,
bitch!” The nurse, attempting to control the situation, stands up and
barks out an order: “Go to your room immediately!” Ms. Smith then
jumps over the desk and begins to strike the nurse repeatedly in the
head and face.
❘
Impulsive Organized Psychotic
Precipitant Spontaneous reaction to Opportunity arises to use Paranoia peaks in intensity and
interpersonal provocation violence to advantage assailant feels compelled to act
Behaviors preceding assault Psychomotor agitation, hostile Distinct lack of emotional Paranoid delusions accompanied
experience, and less formal training are the most likely to be assaulted
(Flannery et al. 2001; Ray and Subich 1998). Furthermore, when asked
about the underlying reasons for staff assaults, patients cite as precipi-
tants poor communication with staff or the perception that staff are too
controlling (Duxbury 2002).
Research has shown that if psychiatric clinicians learn the clinical
skills needed to “de-escalate” emotion in patients who are agitated,
staff assaults can be reduced (Forster et al. 1999). A key component of
this technique is the ability to recognize early signs that indicate a pa-
tient is “escalating” in a process that may ultimately result in physical
violence (Maier 1996). The escalating process has been characterized as
follows: 1) tension in minor muscles; 2) verbal abuse, verbal threats, and
hostility; 3) tension in major muscles; 4) physical violence; and, finally,
5) relaxation and exhaustion. Experienced nurses viewed as experts in
de-escalation techniques cite the importance of intervening in the first
two stages of the process in order to avert an attack (Johnson and
Hauser 2001). Effective de-escalation techniques are summarized in
Table 13–3. Interventions clinicians can use to help gain control of a
patient’s dangerous behavior are outlined in Table 13–4. (For a more
detailed discussion of seclusion and restraints, see Chapter 17.) If de-
escalation fails and a staff assault occurs, it is important to engage the
clinicians involved in a debriefing session (Secker et al. 2004). The goals
of this debriefing session should be to 1) determine what triggered the
assault; 2) review the interventions taken and why they failed; and
3) examine what was learned and what can be done differently next
time. Finally, the physical and psychological impact on the involved
staff should be evaluated; a significant decline in rates of assault has
been noted after psychiatric facilities implement a program that pro-
vides psychological support for staff who have been assaulted (Flan-
nery et al. 1998).
Case Example 2
Mr. Jones is a 34-year-old man with schizophrenia, paranoid type. He
was transferred from an acute facility to a psychiatric state hospital for
long-term treatment. The first several months of his stay were unevent-
ful. Nursing staff then began to note deterioration in his clinical condi-
tion. Mr. Jones began to complain that other patients were saying nega-
tive things about him behind his back. He began to isolate himself in his
room throughout the day and was often observed talking to himself. He
accused nursing staff of putting poison in his medications and occasion-
ally refused to take his scheduled antipsychotic. While waiting in line
for medications a few weeks later, he became very angry and agitated
and exclaimed, “Stop giving out drugs and syringes to kids; it’s illegal!”
266 ❘ Textbook of Violence Assessment and Management
He then threw his medications at nursing staff. A few days later, he fran-
tically dialed 911 and demanded an ambulance be sent to get him be-
cause his life was in jeopardy. Early the next day, he approached the unit
psychiatrist from behind and struck him in the head while yelling, “You
poured kerosene on me last night!”
Case Example 3
Mr. Green is a 28-year-old man who was admitted to a Veterans Affairs
psychiatric hospital after going to the emergency department and re-
porting that voices were telling him to kill himself and others. His urine
toxicology screening was positive for cocaine. His preliminary diagnosis
was psychotic disorder not otherwise specified. On the unit, Mr. Green
frequently came to the nursing station complaining of anxiety and re-
ceived several doses of lorazepam (Ativan) as needed. Several days
later, Mr. Jackson (another patient on the unit) approached the charge
nurse and reported that Mr. Green was threatening to harm patients un-
less they “cheek” their benzodiazepines and give them to him. The
nurse notified the unit psychiatrist, and Mr. Green’s order for lorazepam
was discontinued based on the suspicion that he was abusing it.
Later in the day, Mr. Green approached the nursing station com-
plaining of agitation and requested lorazepam. The nurse on duty in-
formed Mr. Green that his lorazepam had been discontinued by the psy-
chiatrist. When Mr. Green asked why it was stopped, the nurse replied,
“I don’t know, you’ll have to ask the doctor tomorrow during rounds.”
Visibly irritated, Mr. Green walked away and entered his room. He re-
turned to the nursing station 1 hour later and calmly told the nurse,
“You have a really pretty face, I’d hate to see it get all cut up, but you
never know what could happen around here. Now, I want you to work
on getting my Ativan reordered.” Later, on the night shift, nurses
rushed to Mr. Jackson’s room after hearing a lot of commotion and yell-
ing. They found Mr. Jackson (the patient who had reported Mr. Green’s
extortion scheme to nursing staff) with a bloodied and broken nose. Mr.
Jackson immediately exclaimed, “He hit me when I was sleeping!” and
pointed to Mr. Green standing in the hallway. Mr. Green smiled at the
nursing staff and said, “The voices made me do it.”
serves to increase the level of control the patient holds over the clini-
cian. To deal with these threats, psychiatric units can maintain a “threat
book” in which staff can document threats received that day. At the end
of the shift, staff meet as a group to assess the clinical meaning of the
threat in the context of the patient’s clinical condition. Two staff mem-
bers then later confront the patient who made the threat, attempt to get
him or her to accept responsibility for making the threat, and suggest
more effective ways of getting what the patient wants. Clinicians work-
ing in long-term and forensic settings must develop approaches to this
type of aggression because, unlike in short-term community settings,
immediate discharge is not an option.
A controversial approach to inpatient assaults is criminal prosecu-
tion (Appelbaum and Appelbaum 1991). Filing criminal charges against
violent inpatients is a recent phenomenon, with the first case report ap-
pearing in the literature in 1978 (Schwarz and Greenfield 1978). In the
past, prosecution has not been considered a viable option because of the
prevailing belief that hospitalized psychiatric patients are, by virtue of
their situation, not responsible for their actions (Norko et al. 1991). Fur-
thermore, taking an action that moves a patient out of a therapeutic mi-
lieu and into the punitive atmosphere of a jail or prison creates an ethi-
cal dilemma. Mental health professionals are expected to act in patients’
best interests and respect their autonomy, and physicians have a duty
to “do no harm” (Appelbaum and Appelbaum 1991).
Over recent years, however, the number of inpatients prosecuted for
assaults has increased on the basis of several countervailing ethical
viewpoints (Dinwiddie and Briska 2004):
Key Points
■ Inpatient aggression is an important problem because it has
damaging psychological and physical effects on both psychiatric
patients and staff.
■ A small minority of psychiatric inpatients are responsible for the
majority of inpatient assaults, including the most serious as-
saults; this subset of repetitively assaultive patients warrants
greater attention in the form of systematic study.
■ The most robust long-term risk factor for inpatient violence is a
history of inpatient assaults or violent crime.
■ Certain psychiatric symptoms and behaviors indicate an inpatient
is at increased risk for assault in the short term; recognizing these
clinical risk factors and making appropriate interventions can
help prevent aggression.
■ The clinical management of an aggressive inpatient should be
guided by the type of violence in which a patient engages. It is im-
portant to characterize the primary factor motivating aggressive
behavior.
■ Impulsively aggressive inpatients should be observed for signs of
escalation so that measures can be taken to de-escalate patients
early in the process. Because most impulsive assaults are precipi-
tated by an aversive interpersonal interaction, clinicians should
critically examine how they approach patients.
■ In inpatients with a history of assaults motivated by psychosis,
increased assault risk is indicated by paranoid or persecutory
delusions (with or without commanding auditory hallucinations)
and accompanying anger, fear, or sadness.
■ Among inpatients whose aggression is motivated by antisocial or
self-serving interests, it is important to confront the behavior and
to attempt to get the patient to assume responsibility for his or
her actions. Criminal prosecution may be ethically justified in
managing this type of patient.
■ When a clinician is assuming care of an inpatient with a history of
violence, time spent investigating past motivations for aggressive
behavior through record review and clinical interview can be valu-
able. Knowing the precipitants, situations, and symptoms that
have led to violence in the past can be useful in preventing future
assaults. After an inpatient assault, a debriefing session can yield
critical information that can be used to develop different ap-
proaches effective in preventing subsequent violence.
Inpatient Settings ❘ 273
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in the community: evidence from the Epidemiologic Catchment Area sur-
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in patients with schizophrenia treated with clozapine, olanzapine, risperi-
done, or haloperidol. J Clin Psychopharmacol 24:225–228, 2004
Weinshenker N, Siegel A: Bimodal classification of aggression: affective defense
and predatory attack. Aggression and Violent Behavior 7:237–250, 2002
Whittington R, Patterson P: Verbal and non-verbal behavior immediately prior
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C H A P T E R 1 4
Emergency Services
Jean-Pierre Lindenmayer, M.D.
Anzalee Khan, M.S.
277
278 ❘ Textbook of Violence Assessment and Management
Case Example 1:
An Agitated Patient and the
Delivery of Emergency Psychiatric Care
Initial evaluation. A 24-year-old male is brought by the local police and
ambulance to an emergency psychiatric facility within a medical emer-
gency setting for bizarre and uncontrolled behavior at home. His
mother had contacted the police because she was afraid for her life and
that of her son. She reported that he had not slept for the past 3 nights,
was not eating, and was pacing the apartment “damning people to hell”
and stating “God is here.” He had begun to throw plates, glasses, and
furniture around the apartment. The patient also admitted to visual hal-
lucinations of seeing God in the shape of a white male. Both mother and
patient denied any drug use. The patient had no prior medical history,
was not on any medications, and had no allergies. He was initially eval-
uated by the emergency psychiatric nurse, who also interviewed the
mother. The nurse reported that the patient did not have any significant
past psychotic episodes or hospitalizations, and she referred him to be
seen by the medical doctor and the psychiatrist.
Medical evaluation. The patient’s physical examination results
were within normal limits, as was his laboratory workup.
Psychiatric evaluation. The patient was examined by the psychia-
trist and psychiatric resident. The psychiatric assessment resulted in the
diagnosis of acute schizophrenic episode. Following the diagnosis, the
patient was referred to a social worker and case manager on staff for fur-
ther evaluation of available support structures and past history, which
he refused, saying, “The people here are going to kill me.” One staff
280 ❘ Textbook of Violence Assessment and Management
member with whom he had bonded convinced the patient that no harm
would come to him. However, the patient refused to be further exam-
ined and instead paced up and down the hallway outside yelling, “God
is here, come and get me.” The emergency department psychiatrist rec-
ommended that the patient be admitted to the inpatient psychiatric fa-
cility for observation because he was thought to present a risk of harm
to himself or others. A short-acting intramuscular antipsychotic for his
agitated behavior was prescribed. The patient eventually agreed to take
the medication and to go to the inpatient psychiatric unit.
life safety equipment. The surrounding area is often very busy, filled
with patients with a wide range of psychiatric problems. Many will re-
quire further investigation and possible admission. Patients who are
not in need of immediate treatment are sent to a different area to await
disposition or discharge.
Generally, a PES within a hospital should be designed to increase
overall efficiency while providing a calming, open setting that mini-
mizes the crowded environment and resulting anxiety that often char-
acterize emergency visits. Emergency rooms should be focused on max-
imum patient privacy and optimum comfort because these features are
essential for an emergency psychiatric patient. This can be enhanced by
aesthetically pleasing design features throughout the emergency room,
such as an interior glass wall between waiting and patient registration
areas to provide a sense of security to the staff and a monitoring capa-
bility of the entire emergency area.
An efficient emergency room layout is important to the rapid ad-
ministration of services. The following design features should be avail-
able: 1) separate entrances for life-threatening emergencies, such as
threats of suicide and self-harm; 2) entry/registration/waiting/triage
functions located in close proximity to one another to decrease distance;
and 3) entrances to patient interview rooms that allow maximum access
by psychiatric and medical staff for patients to be taken directly to the
treatment areas. It is very important to note that all doors should have
locks but that doors are usually kept open to avoid creating a sense of
crowding for paranoid patients. All sharp objects should be out of the
reach of patients and their families. Articles of furniture should be in-
stalled so as to prevent them from being used as a weapon. Additional
comfort is provided by appropriate reading materials, televisions, and
availability of telephones. Televisions and telephones should be se-
cured to their respective structures, and the television should be out of
the reach of patients.
There also needs to be an area where safety personnel, usually local
police officers, can wait while the paperwork for patients whom they
have brought to the emergency room is being processed. A cardinal rule
is that no loaded weapons can be brought in by law enforcement offi-
cers. Most emergency departments also have their own safety officer
supervising the waiting and examination areas.
Staff
Most large emergency rooms include a number of psychiatrists (M.D.s)
and at times psychiatric residents, registered nurses (R.N.s), psycholo-
gists (Ph.D.s), social workers (M.S.W.s), psychiatric technicians (e.g.,
hospital orderlies), clerical staff, and security officers. PES staff should
be trained in making thorough assessments of patients’ problems and
in identifying appropriate dispositions and referrals. To conduct these
assessments, Summers and Happell (2002) argued that the psychiatric
nurses may be a core service provider in the emergency room. Similarly,
Osborne (2003) and McDonough et al. (2004) reported that the use of a
mental health triage nurse reduced lengthy waiting times and crowd-
ing in waiting rooms. In addition, studies found that the use of psychi-
atric triage scales contributed to reduced wait times, more efficient and
effective treatment of mental health patients, and improved referral to
appropriate resources (Broadbent et al. 2004; Happell et al. 2002).
A key focus of PES staff is the safe management of the psychiatric
and behavioral emergencies. Staff should be trained in emergency pro-
cedures, including seclusion and physical restraint. Trained safety offic-
ers should also be present and should be under the supervision of the
psychiatrist and medical and nursing personnel.
The psychiatric emergency team is led by the psychiatrist. This lead-
ership position is built on the specific medical-psychiatric diagnostic
background and the psychopharmacological expertise of the psychia-
trist. However, many psychiatric emergency rooms, particularly those
that do not offer comprehensive services, cannot provide continuous
coverage by a psychiatrist (Allen 1999). Consequently, psychiatric nurses,
social workers, and at times trained psychologists will provide crisis in-
tervention and emergency psychotherapy, if necessary.
Most psychiatric emergency rooms also have a physician available to
evaluate psychiatric emergencies with a medical component. This is
particularly important in medical emergencies that may have been mis-
Emergency Services ❘ 283
Extended Services
Research on PES delivery systems has documented persistent growth in
demand, with concomitant increased pressure on psychiatric emer-
gency room operations and personnel. Factors contributing to this de-
mand are the shift to the community mental health service delivery
model and the reduction of available long-term inpatient beds in state
psychiatric facilities; insufficient community mental health supports;
and recidivism among people with persistent mental illness identified
as socially disadvantaged (Ellison and Blum 1986; Smart et al. 1999; So-
lomon and Davis 1985). The delineation of these factors provides the
arena in which to test new PES delivery strategies, such as the introduc-
tion of Assertive Community Treatment teams and Intensive Case Man-
agement models, liaison with community agencies (Sundheim and
Ryan 1999), and utilization of psychiatric nurses to create an integrated
care pathway (Wynaden et al. 2003).
Case Example 2:
Psychiatric Evaluation in an Emergency Setting
Initial symptoms. A day after his prison release, Mr. A became agitated
at home and began staring at others and not communicating. Upon reg-
istration at the PES, and after initial review by the nurse, he was seen by
the psychiatric resident. He reported that other people could read his
mind and broadcast his thoughts. He also reported that he heard voices
outside his window at home telling him that he was “not a good man”
and would “not succeed.” Mr. A also reported that he heard his neigh-
bors talking about him. He had threatened and confronted some indi-
viduals, which resulted in an altercation.
Past history. Mr. A had no history of psychiatric symptoms or legal
problems until his early 40s, when he was incarcerated for a nonviolent
offense for 6 months. During the incarceration, his mental status deteri-
orated. He began exhibiting depression, ideas of hopelessness, and
paranoid delusions. He was hospitalized in the prison infirmary and
treated with venlafaxine and haloperidol, with subsequent stabilization.
He was released after serving his full sentence.
Initial examination. Mr. A was noted to be staring blankly without
looking at the interviewer. His speech was monosyllabic. He showed
marked psychomotor retardation, and he made negativistic statements
Emergency Services ❘ 285
criterion for such short-term PES units is that the patient be cooperative
and voluntary. Involuntary admission can only be done to an acute in-
patient admissions unit. The main emphasis of such units is on main-
taining patients’ functioning in and ties to the community. Herz et al.
(1979), in a series of papers, developed the idea that the results of brief
hospitalization can be comparable with standard hospitalization, with
the advantage of fostering less regression and better maintenance of
community survival skills.
Observations
Several different models exist for short-term observation assessment
and stabilization units, including the 23-hour observation bed, the crisis
stabilization unit, and the 72-hour observation bed. Such units are usu-
ally in close proximity to PESs.
• Crisis intervention/stabilization
• Psychiatric nursing assessment
• Physical assessments
• Medication/somatic services
• 24-hour observation
• Individual and group counseling
• Linkage and referrals to longer-term services
• Education for safe return to the community
Crisis Residence
A crisis residence offers a supervised residential setting for persons re-
quiring extended stabilization during a mental health crisis. The ex-
pected length of stay could be up to 21 days. Crisis beds are usually
linked to local psychiatric emergency rooms and acute inpatient pro-
grams. Follow-up care is provided after discharge by community re-
sources and supports. The major goal of crisis residences is to stabilize
the situation and return the patient to his or her home quickly, rather
than to provide long-term care. Emphasis is on maintaining the rela-
tionships the patient has in the community, with family, the referral
agency, and with those resources that have provided services previ-
ously. Services that can be provided in the community will not be du-
plicated in the residence. Each program provides a highly structured,
individually designed intervention for each resident in accordance with
the needs of patients.
Crisis Respite
Crisis respite is the lowest level of treatment intensity in the crisis resi-
dence program. The crisis respite programs serve patients with housing
problems. Sledge et al. (1996) described an arrangement linking respite
with day hospitalization programs designed for the severely and per-
sistently mentally ill. The respite component provides housing for up to
four clients, using mental health workers and Master’s-level program
directors.
Restraints
The implementation of restraints is a difficult procedure, but an impor-
tant option, generally reserved for those situations in which there is the
potential for imminent harm to patient or staff through patients’ behav-
ior and where other interventions of a lesser degree of intensity and re-
strictiveness have been unsuccessful. The specific definition by the Joint
Commission for the Accreditation of Healthcare Organizations (JCAHO;
2002, p. 123) for use of restraint is “a direct application of force without
permission to restrict freedom of movement.”
Once the decision to use restraint is made, the overriding principle
is that it be done swiftly and humanely and that the patient be reassured
that it is done in his or her best interest. As is the case for seclusion, only
staff members trained in applying restraints are allowed to use them.
The implementation of physical restraints is a dangerous procedure,
both for staff and patient. It should never be attempted unless there is
sufficient staff present to ensure that it can be done with a minimum of
struggle. Using at least five staff members is recommended, one for each
limb and an extra person as team leader. The presence of a critical group
of staff may also assist in calming the patient, thus aborting the need for
restraints. Once the decision is made to proceed, implementation must
be completed and negotiations temporarily suspended. The team
leader, just as in team resuscitation, oversees the staff and ensures safety.
It is usually best that the physician avoid physical participation in sub-
duing a combative patient because this may interfere with the therapeu-
tic relationship. The same time limitations are placed on restraints as
they are on seclusion. During restraints, staff is required to conduct 15-
minute checks to assess vital signs, any signs of injury, and the patient’s
psychological state and readiness to discontinue seclusion or restraints.
Emergency Services ❘ 293
Case Example 4:
Seclusion in Emergency Psychiatric Services
Initial assessment. A 31-year-old male university graduate was es-
corted by police officers involuntarily because of delusional thinking
and aggressive behavior during the previous 24 hours. The patient vio-
lated a restraining order from his ex-wife, whom he had harassed and
threatened to physically assault. He had bizarre and rigid thinking that
was sexually inappropriate; he was noted to walk 10–25 miles daily ex-
posing himself to others. The initial screening evaluation completed by
the emergency room triage nurse indicated that he was disheveled and
showed grandiose delusions.
Medical evaluation. The patient did not have any significant medi-
cal history, and he had not been in psychiatric treatment. The neurolog-
ical examination was normal. There was no history of alcohol or illicit
drug use. Blood and urine tests were normal.
Psychiatric assessment. Mental status examination showed the pa-
tient to be disheveled and to have marked flight of ideas and belliger-
ence. The most striking features were grandiose delusional thinking and
significant paranoia centering on the police in his community. His affect
was inappropriate during the interview; at times he would laugh when
asked a serious question and at times he would cry. He was fully ori-
ented but would not cooperate with formal mental status testing. The
initial diagnosis was acute mania with psychosis.
Patient behavior. Upon admission to the emergency room, the pa-
tient was extremely uncooperative, verbally threatening staff members
and other patients and making sexually explicit remarks to a female
nurse, with occasional verbal outbursts. During the time of his out-
bursts, less restrictive methods of modifying the patient’s behavior,
such as “talking him down,” had failed. The doctrine of “the least
294 ❘ Textbook of Violence Assessment and Management
Suicidal Risk
Suicide and suicide attempts are among the most serious outcomes of
psychiatric illness, and the most extreme intervention (e.g., involuntary
hospitalization) may have to be used if these events are at high risk. The
national rate of suicide has remained fairly consistent at 1.1%–1.4%.
Suicidal ideation and behavior are the most common presenting com-
plaints of patients seeking treatment at psychiatric emergency facilities,
and these patients are at a considerable risk of subsequent suicide
(Dhossche 2000). Substance use disorders have been consistently recog-
nized as chronic risk factors for suicide (Pages et al. 1997). Patients pre-
senting to the emergency room with complaints of suicidal ideation or
suicidal command hallucinations, or presenting after a suicide attempt,
have to be carefully evaluated. Both state-related risk factors, such as
ideas of hopelessness or worthlessness, and trait-related risk factors,
such as age or a previous serious suicide attempt, need to be fully as-
sessed. The intensity of current suicidal ideation should be explored,
and the presence of protective factors against suicidal acting out should
also be assessed. The result of this in-depth evaluation will dictate the
final treatment decision.
Case Example 5:
Use of Restraints for Suicidal Ideation
in Emergency Service Settings
Initial assessment. Mr. R is a 50-year-old man with a long history of re-
current depressions and multiple hospitalizations dating back to age 19.
The patient had been discharged from an inpatient psychiatric facility
3 months earlier and voluntarily presented himself to the hospital emer-
gency room indicating that his medication was not helping him and that
he was having frequent thoughts of wanting to hurt himself. The patient
Emergency Services ❘ 295
Key Points
■ Psychiatric emergency services (PESs) comprise a large spectrum
of acute psychiatric service delivery systems that are available for
the assessment, acute stabilization, and initial treatment of
mental health emergencies.
■ PESs usually function on a 24-hour-a-day basis and provide
extremely important clinical services.
■ The psychiatric emergency room is traditionally the main venue
for the delivery of emergency services; however, PESs cover exten-
sive and comprehensive mental health delivery systems and do
not function in isolation.
■ Such delivery systems are critical to prevent unnecessary hospital-
izations that might, in turn, foster chronicity and dependence on
institutional care.
■ The crisis situation leading up to an emergency presentation by
a patient is rarely completely resolved after evaluation and treat-
ment in the PES.
296 ❘ Textbook of Violence Assessment and Management
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P A R T I V
Treatment
and Management
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C H A P T E R 1 5
Psychopharmacology and
Electroconvulsive Therapy
Leslie Citrome, M.D., M.P.H.
301
302 ❘ Textbook of Violence Assessment and Management
Case Example
John is a 40-year-old white male, diagnosed at different times as having
schizophrenia, bipolar disorder, or schizoaffective disorder. His first
psychiatric hospitalization was at age 18 when he was brought to the
hospital emergency department in an acute psychotic state with para-
noid delusions. He has had several known hospitalizations since then,
the most recent after he was arrested for assault. In the emergency de-
partment he was acutely agitated and required intramuscular medica-
tion to control his behavior. He was given an intramuscular injection of
haloperidol 5 mg combined with lorazepam 2 mg in the same syringe.
After 45 minutes he appeared calmer, but he complained of stiffness in
his neck and tongue and was drooling. He received diphenhydramine
50 mg intramuscularly for this dystonic reaction, followed by oral benz-
tropine 2 mg. Toxicology screen in the emergency department came
back positive for cocaine and cannabis.
John was admitted to the psychiatric inpatient unit and refused all
oral medications, saying he was “allergic to Haldol” and that “nothing
really works.” On the second day of hospitalization he asked to smoke
a cigarette, and when told the unit was now “smoke free,” he began
shouting at the staff, threatened to sue them, and made a fist. Because
Psychopharmacology and Electroconvulsive Therapy ❘ 303
he was not taking any oral medications, a decision was made to give
him a “stat” dose of ziprasidone 20 mg intramuscular. After the injec-
tion, John was substantially calmer. He was able to articulate that he felt
less anxious, and he acknowledged he did not feel any restlessness or
stiffness that he usually felt after receiving intramuscular haloperidol.
He agreed to continue taking the “new” medication.
Despite the initial success with ziprasidone, John continued to feel
paranoid and uncomfortable. He was unable to sleep. He was subse-
quently prescribed a number of different other antipsychotics, includ-
ing quetiapine and olanzapine. Although he was free of any extrapyra-
midal side effects, symptom relief was incomplete and he continued to
be intermittently agitated, often with little provocation. John was ulti-
mately placed on clozapine, which did decrease the frequency of his
outbursts. John’s aggression became exclusively verbal, never physical,
and he was more easily reassured. Adjunctive valproate and adjunctive
lamotrigine treatment were also attempted but did not make a substan-
tial difference in his impulsivity.
❘
Agent Dose, mg nonelderly adults, h Comments
Lorazepam 0.5–2.0 10–20 The only benzodiazepine that is reliably absorbed intramuscularly.
Useful for symptoms of alcohol withdrawal.
Haloperidol 5–10 12–36 The most commonly used anti-agitation intramuscular antipsychotic,
❘
Reference Agent and indication N Study arms (N) placebo equivalent
Lesem et al. 2001 Ziprasidone; 117 Ziprasidone 2 mg (54), 10 mg (63) 10 mg superior on Behavioral Activity
schizophrenia Rating Scale at 0–2 hours, but not by
Clinical Global Impression–Severity
❘
307
308 ❘ Textbook of Violence Assessment and Management
effects compared with the older antipsychotics and are discussed in the
following paragraphs.
Ziprasidone
Ziprasidone mesylate was approved in 2002 by the U.S. Food and Drug
Administration (FDA) for the indication of acute agitation in patients
with schizophrenia, on the basis of two 1-day, double-blind trials
(Daniel et al. 2001; Lesem et al. 2001) of agitated hospitalized subjects
with a primary diagnosis of schizophrenia, schizoaffective disorder, bi-
polar disorder with psychotic features, delusional disorder, or psy-
chotic disorder not otherwise specified (DSM-IV-TR; American Psychi-
atric Association 2000). Approximately 80% of the subjects had
schizophrenia or schizoaffective disorder. Doses tested were ziprasi-
done 10 mg versus 2 mg (Lesem et al. 2001) and 20 mg versus 2 mg
(Daniel et al. 2001). There was no placebo arm, per se, nor were active
comparators such as haloperidol or lorazepam used. The 2-mg dose of
ziprasidone can be considered as a placebo-equivalent. The 20-mg dose
yields a higher percentage of responders and a greater degree of re-
sponse in terms of reduction of agitation than the 10-mg dose; however,
product labeling recommends the range of 10–20 mg per injection.
Safety concerns specific to intramuscular ziprasidone, as noted in
product labeling, include caution in patients with impaired renal func-
tion because the cyclodextrin excipient is cleared by renal filtration. Be-
cause of ziprasidone’s dose-related prolongation of the QT interval and
the known association of fatal arrhythmias with QT prolongation by
some other drugs, ziprasidone is contraindicated in patients with a
known history of QT prolongation (including congenital long QT syn-
drome), recent acute myocardial infarction, or uncompensated heart
failure. However, more than 5 years of clinical availability has not re-
sulted in evidence that ziprasidone by itself poses a substantial clinical
problem in this regard (Zimbroff et al. 2005). Comparative intramuscu-
lar antipsychotic data on QTc are available; the product information
(Pfizer 2005) includes details of a study evaluating the QTc-prolonging
effect of intramuscular ziprasidone, with intramuscular haloperidol as a
control, and reveals a mean increase in QTc from baseline for ziprasi-
done of 4.6 msec following the first injection and 12.8 msec following the
second injection, compared with 6.0 msec and 14.7 msec for haloperidol,
and with no patients having had a QTc interval exceeding 500 msec.
The patient in the case example did not have any history of cardiac
conduction problems. When the need developed for an intramuscular
injection of an anti-agitation medication, ziprasidone was selected over
Psychopharmacology and Electroconvulsive Therapy ❘ 309
Olanzapine
Olanzapine was approved in 2004 by the FDA for the indication of agi-
tation associated with schizophrenia and bipolar I mania, on the basis
of three 1-day, placebo-controlled inpatient trials with active compara-
tors (Breier et al. 2002; Meehan et al. 2001; Wright et al. 2001). A fourth
pivotal trial was done in patients age 55 or older with agitation asso-
ciated with dementia, though regulatory approval was not pursued
(Meehan et al. 2002). Superior onset of efficacy for intramuscular olan-
zapine 10 mg was demonstrated compared with intramuscular halo-
peridol 7.5 mg in patients with schizophrenia (Wright et al. 2001) and
intramuscular lorazepam 2 mg in patients with bipolar mania (Meehan
et al. 2001). In the bipolar trial, olanzapine was superior to lorazepam at
all time points up to and including 2 hours postinjection. In the schizo-
phrenia trial examining olanzapine 10 mg (Wright et al. 2001), olanza-
pine was superior to haloperidol at 15, 30, and 45 minutes postinjection.
In the study comparing multiple fixed doses of intramuscular olanza-
pine with intramuscular haloperidol 7.5 mg (Breier et al. 2002), patients
treated with 5.0, 7.5, or 10.0 mg of olanzapine had greater mean im-
provement in agitation than those given placebo at all time points, but
the groups given 2.5 mg of olanzapine or haloperidol did not show
greater mean improvement compared with those given placebo until
60 minutes after the first injection. In the pivotal trials, no adverse event
was significantly more frequent for intramuscular olanzapine com-
pared with intramuscular haloperidol or intramuscular lorazepam. The
recommended dose in product labeling is 10 mg (with lower doses of
2.5–5.0 mg for vulnerable patients such as the elderly or medically in-
firm) (Eli Lilly 2006).
Safety concerns specific to intramuscular olanzapine, as noted in
product labeling, include hypotension, bradycardia with or without hy-
potension, tachycardia, and syncope as reported during the clinical tri-
als. As per the product label, patients should remain recumbent if
drowsy or dizzy after injection until examination has indicated that
they are not experiencing postural hypotension, bradycardia, and/or
hypoventilation. Simultaneous injection of olanzapine intramuscular
and parenteral benzodiazepines is not recommended. Data from the
310 ❘ Textbook of Violence Assessment and Management
Aripiprazole
Aripiprazole intramuscular was approved by the FDA in late 2006 for
the indication of agitation associated with schizophrenia or bipolar ma-
nia, on the basis of three 1-day, placebo-controlled inpatient trials with
active comparators (Andrezina et al. 2006a; Tran-Johnson et al. 2007;
Zimbroff et al. 2007). The schizophrenia studies utilized haloperidol in-
tramuscular as an active comparator, with mixed results in terms of rel-
ative efficacy. In the study comparing intramuscular aripiprazole
9.75 mg with intramuscular haloperidol 6.5 mg (Andrezina et al. 2006a),
analysis according to the non-inferiority hypothesis indicated that ari-
piprazole was non-inferior to haloperidol. However, for the aripiprazole
group, decrease in agitation differed significantly from placebo at 1 hour
after the first injection, whereas a significant difference was achieved at
45 minutes in the haloperidol group. There was no significant difference
in the improvement in the agitation scores between the aripiprazole and
haloperidol groups at these time points, nor at 30 minutes or 2 hours;
however, the difference at 90 minutes was significant in favor of halo-
peridol (P = 0.022). Aripiprazole performed somewhat better in the
study that compared multiple fixed doses of intramuscular aripiprazole
with intramuscular haloperidol 7.5 mg (Tran-Johnson et al. 2007). In that
study, changes in agitation scores were statistically significant as early as
45 minutes for the aripiprazole 9.75-mg group, whereas a significant dif-
ference between haloperidol and placebo was first seen at 105 minutes.
In the study comparing aripiprazole versus lorazepam and placebo in
agitated patients with bipolar disorder, lorazepam evidenced superior-
ity over placebo as early as 45 minutes after injection and aripiprazole at
60 minutes (Zimbroff et al. 2007). In product labeling, the usual recom-
mended dose is 9.75 mg (Bristol-Myers Squibb 2006).
Safety concerns specific to intramuscular aripiprazole, as noted in
product labeling, include greater sedation and orthostatic hypotension
with the combination of lorazepam and aripiprazole as compared with
that observed with aripiprazole alone.
The pivotal registration trials of the intramuscular formulations of
the second-generation antipsychotics suffer from the limitation that the
Psychopharmacology and Electroconvulsive Therapy ❘ 311
Antipsychotics
In the United States several second-generation antipsychotics are avail-
able: clozapine, risperidone, olanzapine, quetiapine, ziprasidone, ari-
piprazole, and paliperidone. All seven are approved by the FDA for the
treatment of schizophrenia, and all, except for clozapine and paliperi-
done, are also approved for the treatment of bipolar mania. Second-
generation antipsychotics have also been used off-label for a variety of
conditions (Tremeau and Citrome 2006). Of special interest is the possi-
bility that these agents have specific anti-hostility effects, with cloza-
pine having the strongest evidence supporting this.
Clozapine’s usefulness for patients with aggressive behavior was
initially suggested by case series and retrospective studies in which a
reduction in the number of violent incidents and/or a decrease in the
use of seclusion or restraint was observed among inpatients once they
Psychopharmacology and Electroconvulsive Therapy ❘ 313
Anticonvulsants
Mood stabilizers such as lithium and anticonvulsants are extensively
used, including off-label use among patients with a diagnosis of schizo-
phrenia (Citrome et al. 2002). There is an expectation that adjunctive
mood stabilizers can reduce aggressive and impulsive behavior (Cit-
rome 1995). There are expert consensus guidelines suggesting the use of
adjunctive mood stabilizers in those with schizophrenia with agitation,
excitement, aggression, or violence (McEvoy et al. 1999), but the sup-
porting evidence for this indication is based almost entirely on uncon-
trolled studies and case reports. The most commonly used mood stabi-
lizer is valproate (Citrome et al. 2000, 2002). Our case patient had a trial
of adjunctive valproate, but it did not have a substantial impact on his
psychopathology or degree of impulsivity. A review of the use of val-
proate in violence and aggressive behaviors in a variety of diagnoses
(Lindenmayer and Kotsaftis 2000) did reveal a 77.1% response rate (de-
fined by a 50% reduction in target behavior) based on 17 reports (164
patients, approximately one-half with dementia). Double-blind con-
trolled studies that tested and support this are few in number but do in-
clude a varied array of diagnoses, including borderline personality dis-
order (Hollander et al. 2001, 2005), Cluster B personality disorders as a
group (Hollander et al. 2003), and children and adolescents with explo-
sive temper and mood lability (Donovan et al. 2000).
Positive symptoms were reduced with adjunctive valproate in a 28-
day double-blind, randomized study with olanzapine and risperidone
among 249 patients with an acute episode of schizophrenia (Casey et al.
2003). A post hoc secondary analysis from this study found that combi-
nation therapy with divalproex had significantly greater anti-hostility
effect at 3 days and at 7 days than antipsychotic monotherapy (P< 0.05),
as measured by the PANSS hostility item (Citrome et al. 2004a). The ef-
fect on hostility was statistically independent of antipsychotic effect on
other PANSS items that reflect delusional thinking, a formal thought
Psychopharmacology and Electroconvulsive Therapy ❘ 315
Key Points
■ Attempts to manage violent behavior by using medication geared
to the primary diagnosis may fail if the violent behavior is due to
an unidentified comorbid psychiatric or medical disorder.
■ Medication options for management of an acute episode of agita-
tion have expanded to include several different rapid-acting for-
mulations of second-generation antipsychotics. These agents are
less likely than first-generation antipsychotics to cause extrapyra-
midal side effects. Extrapyramidal symptoms especially relevant
in the emergency setting are akathisia (introduces an iatrogenic
cause for worsening of agitation) and acute dystonia (complicates
treatment course and impairs the therapeutic alliance).
■ Long-term treatment requires addressing all comorbidities. For
patients with schizophrenia, use of clozapine appears to be the
best option to decrease aggressivity. The evidence base for the
other second-generation antipsychotics is not as compelling as
that for clozapine. Adjunctive use of anticonvulsants, β-adrenergic
blockers, and serotonin-specific reuptake inhibitors can be consid-
ered, as can electroconvulsive therapy. The long-term use of ben-
zodiazepines is discouraged.
■ Psychotherapeutic approaches remain an important part of man-
aging patients with impulsive aggressive behavior, particularly for
outpatients with personality disorders, although the use of cer-
tain agents such as valproate and serotonin-specific reuptake
inhibitors shows promise in controlled clinical trials.
References
Abbott Laboratories: ABT-711 M02–547 clinical study report. Available at http://
www.clinicalstudyresults.org/documents/company-study_782_0.pdf. Ac-
cessed March 19, 2007
American Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiat-
ric Association, 2000
Andrezina R, Josiassen RC, Marcus RN, et al: Intramuscular aripiprazole for the
treatment of acute agitation in patients with schizophrenia or schizoaffec-
tive disorder: a double-blind, placebo-controlled comparison with intra-
muscular haloperidol. Psychopharmacology (Berl) 188:281–292, 2006a
Andrezina R, Marcus RN, Oren DA, et al: Intramuscular aripiprazole or halo-
peridol and transition to oral therapy in patients with agitation associated
with schizophrenia: sub-analysis of a double-blind study. Curr Med Res
Opin 22:2209–2219, 2006b
Psychopharmacology and Electroconvulsive Therapy ❘ 319
Volavka J, Czobor P, Nolan KA, et al: Overt aggression and psychotic symptoms
in patients with schizophrenia treated with clozapine, olanzapine, risperi-
done, or haloperidol. J Clin Psychopharmacol 24:225–228, 2004
Volavka J, Czobor P, Citrome L, et al: Efficacy of aripiprazole against hostility in
schizophrenia and schizoaffective disorder: data from 5 double-blind stud-
ies. J Clin Psychiatry 66:1362–1366, 2005
Wright P, Birkett M, David SR, et al: Double-blind, placebo-controlled compar-
ison of intramuscular olanzapine and intramuscular haloperidol in the
treatment of acute agitation in schizophrenia. Am J Psychiatry 158:1149–
1151, 2001
Wright P, Meehan K, Birkett M, et al: A comparison of the efficacy and safety of
olanzapine versus haloperidol during transition from intramuscular to oral
therapy. Clin Ther 25:1420–1428, 2003
Zimbroff DL, Allen MH, Battaglia J, et al: Best clinical practice with ziprasidone
IM: update after 2 years of experience. CNS Spectr 10(suppl):1–15, 2005
Zimbroff DL, Marcus RN, Manos G, et al: Management of acute agitation in pa-
tients with bipolar disorder: efficacy and safety of intramuscular aripipra-
zole. J Clin Psychopharmacol 27:171–176, 2007
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C H A P T E R 1 6
Psychotherapeutic
Interventions
John R. Lion, M.D.
325
326 ❘ Textbook of Violence Assessment and Management
Clinical Inexperience
A word should be said about aggression as a “stepchild” entity in clin-
ical psychiatry. Despite its commonplace occurrence in society and its
frequent occurrence in hospital inpatient settings, violence largely re-
mains a behavior of the criminal realm and a subject of interest to soci-
ologists or students of law enforcement. Indeed, few clinicians enter the
field of psychiatry anticipating that the patients they treat will be vio-
lent or dangerous; the discipline is, after all, a “talking” specialty with
verbal interventions. A resident’s early exposure to the emergency de-
partment may correct some of this distortion, but denial is still possible,
particularly because most aggressive patients are managed by nursing
staff and technicians. Restraint and seclusion, although medical inter-
ventions, are not routinely taught to physicians. Indeed, in residency
training programs little formal education is provided about the man-
agement of violent patients when compared with teachings about the
psychotherapy of anxiety or depression or the pharmacological treat-
ment of the schizophrenias (Dubin and Lion 1992). The elective of fo-
rensic psychiatry delves into the subject of violence, but few psychiatric
residencies have formal links with jails or prisons.
A therapist thus can easily emerge from training with limited
awareness of the world of antisocial conduct. Many psychiatrists have
never examined a rapist or a murderer, let alone treated one. This inex-
perience often leads the beginning therapist to avoid confrontation with
the patient’s aggressiveness. The therapist may not properly delve into
past behaviors or may avoid probing subjects or feelings that evoke an-
ger; a false delicacy may descend on the therapy. It is recommended
that clinicians who undertake work with violent patients peruse the
journals of the forensic sciences and criminology. Psychiatrists rarely
see these periodicals and should be acquainted with the vocabularies
and concepts of this entirely different clinical world.
The phenomenology of violence leads to further complexity. Unless
the patient is still in the throes of a manic illness or has otherwise dem-
onstrated frequent outbursts on a hospital unit, he or she generally is
not violent when seen by the clinician. For example, jails and prisons
house men and women who have been very violent. However, that vi-
olence is over; when seen by the clinician, they are typically nonviolent.
This is not the case with a depressed patient who enters treatment in the
midst of an observable melancholic state. Not viewing the pathological
or deviant behavior makes it difficult for a clinician to appreciate the
gravity of a patient’s case or his or her dangerousness. Because violent
patients easily disclaim their violent propensities even when confronted
Psychotherapeutic Interventions ❘ 327
Case Example 1
A therapist was sent to a local prison to review the case of a child mo-
lester. The patient presented as a mild-mannered man who rejected any
idea that he was guilty of multiple assaults on children and who insisted
that he had been falsely incarcerated. The therapist easily believed him
until such time as he began to read a very thick chart filled with ac-
counts of violent paraphiliac behavior.
Spouse abusers also often insist that they are no longer violent and
that they love those whom they have hurt and would never harm them
again. One-time murderers may describe a rich circumstantiality that
absolves them of their actions. A therapist, faced with such disavowal
of violent tendencies, may dismiss the act as a “one-time” event and ex-
cuse future propensities. Thus it is vital to review the violent act. If a po-
lice report exists, an attempt should be made to procure it and read it. If
the patient committed murder, the autopsy report of the victim should
be studied. These efforts bring home the seriousness of the behavior.
Another common reaction on the part of unseasoned therapists is to
boast about the patient’s violent deeds, as if they were treating individ-
uals of distinction (e.g., “He’s the one who brutally murdered all those
children…”). Such a statement converts fear into awe, diminishes re-
pugnance, and rationalizes the clinician’s involvement in a case that
other colleagues might view as belonging in the sphere of antisocial be-
havior and more fittingly dealt with by a prison psychologist than by
someone in a suburban practice.
risk of death by suicide parallels the risk involved in treating any inher-
ently fatal disease. However, in the case of outwardly directed aggres-
sion, the patient can hurt or kill others; the violence thus moves beyond
the boundaries of therapy and can affect more or less innocent bystand-
ers. Liability, always on the mind of today’s clinician, has the potential
to escalate dramatically. The average psychotherapy patient talks about
becoming violent or dreams of violence but does not act on those urges.
The violent patient, in contrast, has “crossed the line” from contempla-
tion to response. Therapists must worry about things going very wrong.
They must concern themselves with the safety of potential victims, with
weaponry, with Tarasoff issues, with liability, and with the patient’s use
of alcohol or other disinhibitory or stimulant substances.
Vectors of Violence
A common misconception is that the violent patient is exempt from sui-
cide and vice versa. However, violent patients can hurt others and
themselves as well; they can commit both homicide and suicide. The
disorder of unregulated aggression, then, is a disease unto itself, and
there is some evidence that it reflects central nervous system serotonin
deficits (Markowitz and Coccaro 1995). It is the vector, then, that often
becomes a focus of treatment. The psychological burden of treating vi-
olent patients, whether they be suicidal or homicidal, is significant, and
the therapist must worry about patients’ inwardly and outwardly di-
rected aggression. No homicidal patient is ever immune from commit-
ting suicide, just as no suicidal patient with violent tendencies is ex-
empt from channeling anger outwardly. Vectors of aggression can shift
abruptly, depending on the availability of the victim or of a weapon
such as a handgun.
Case Example 2
A man who was being treated for an ear infection became delusional
and thought that his doctor was poisoning him. He decided to kill him-
self in front of the doctor in order to illustrate his plight. He brought a
loaded pistol to his appointment, took it out, and pointed it at his head,
but at the last moment he turned the muzzle toward the doctor and shot
and killed him.
Case Example 3
A young adolescent girl stabbed and killed her abusive mother during an
argument. The court mandated inpatient psychiatric treatment, and the
girl remained on a university teaching unit for more than a year. Because
her case was an unusual one, she became the subject of intensive psycho-
therapy. Upon her release, she continued outpatient treatment but became
increasingly depressed and ultimately committed suicide by hanging.
Case Example 4
An investment broker entered treatment after erupting in rage at a coun-
try club wedding and loudly calling his girlfriend a whore. In the past,
he had once begun to choke her. It became apparent that a recurring
330 ❘ Textbook of Violence Assessment and Management
stressor was abandonment; at the country club, she had left his side to
interact with other family members, and he recalled feeling isolated and
becoming furious.
Case Example 5
A schoolteacher stabbed her husband during an argument. He later
died, and she adamantly maintained that she had not intended to kill
him. Indeed, when the police arrived, she was administering cardiopul-
monary resuscitation to him. She presented as a demure woman and
was much prone to intellectualize. It was only after the therapist ex-
plored her history of violence for some 9 hours that she admitted,
sheepishly, that she disliked ants in her house and would pour flamma-
ble fluids on them and light them on fire. In time, she also related that
she had burned herself on the ankle with cigarettes, something she hid
with ankle bracelets.
Deranged Transferences
Assuming that the violent person becomes a willing patient and mean-
ingfully partakes in treatment, the transference must be carefully mon-
itored. Physical rage usually reflects the most desperate helplessness,
and it can easily be rekindled, particularly within the nurturing process
of psychotherapy. Patients with primitive character structures can be-
gin to relate to a therapist in the same way they responded to parents or
authority figures. Small prohibitions on the part of the therapist may
become magnified; for example, the clinician who will not renew a ben-
zodiazepine drug may be perceived as very cruel and withholding. Per-
haps the greatest danger stems from the vicissitudes of intimacy. As the
violent patient comes to feel closer to the therapist, an intolerable yearn-
ing may arise that is frustrated by the constraints of treatment. Loss of
the therapist may arise as a risk. The simple dependency of the patient
on the therapist can become overwhelming. These dynamics must be
regularly explored, as must the specific fantasies that the patient has
about the therapist.
Case Example 6
A social worker treated a woman with a borderline personality disorder
in a public clinic setting. The patient was demanding and often para-
noid but came regularly to sessions and developed a clear dependency
on the therapist. In time, this dependency changed into wishes to be
with the therapist outside of the hour. These urges were not fully ex-
plored. One evening, the patient appeared outside the therapist’s home
wielding a loaded handgun. She fired a shot that missed the therapist,
at which time the therapist tackled her and subdued her until the police
arrived.
Countertransference Issues
It can happen that a therapist becomes irrationally fearful of a violent
patient, as the following case illustrates.
Case Example 7
A psychiatrist sought consultation because he found himself frightened
of a violent patient without good cause. No threat had been made, nor
was the patient menacing or otherwise intimidating. As he discussed
the case and the consultant asked him about his own experiences with
Psychotherapeutic Interventions ❘ 333
violence, the clinician stated that he once had gone on vacation and
parked at an overlook atop a mountain. Another car drove up and a
man got out of the car, walked toward the psychiatrist, took out a re-
volver, and aimed it at him. He managed to push the man over the
ledge in self-defense and called for the police. The man was found and
returned to a prison from which he had escaped. The psychiatrist had
actually not remembered this upsetting event, and talking about it re-
solved his uneasiness with the patient who had obviously kindled the
recollection.
Such an event is rare in the lives of most clinicians, but less dramatic
instances of violence may be evoked during treatment, leading to skews
in the perception of the patient (Lion 1998). For certain therapists, sex-
ual deviance such as that shown by a child molester is so repulsive that
no meaningful treatment can be undertaken. Clinicians must make an
inner appraisal of their own experiences with aggression as they labor
with the patient before them.
Victims
Treating a violent patient without consideration of an existing victim is
an error. In spouse abusers, for example, the therapist must monitor
how the patient is behaving at home, and this can only be done by ask-
ing the wife about the patient. A useful strategy with identified victims
is to invite them into an evaluative session with the patient present. This
minimizes any breach of confidentiality while allowing the therapist to
observe how the two parties interact. It is sometimes the case that the
would-be victim’s behaviors are so provocative that treatment is indi-
cated. In cases where the patient has been violent toward children or an-
imals, a corroborating source of information should be sought, such as
a case worker or relative. Again, the therapy of the violent patient is
conducted with less privacy than that operative in more traditional in-
dividual treatment. In some sense, it is like the treatment of an actively
suicidal patient, in which the therapist comes to rely on the family for
feedback and participation.
Warning victims about incipient violence is now a standard of care
under most Tarasoff-based state statutes. Although imminence of a
threat prevails as the qualifier for warning, there should be some con-
cept of reasonableness in the mind of the treating clinician. Certainly, a
patient who wishes to harm a non–family member presents a dire situ-
ation in which warning may be indicated. More frequently, however,
the patient is already enmeshed in a troubled relationship with a clearly
identified other such as a lover or spouse. If a threat is made, the clini-
334 ❘ Textbook of Violence Assessment and Management
cian should seek, whenever possible, to invite the spouse or lover into
a treatment session. This is far superior to issuing a sudden formal
warning by phone or letter. Such a warning is a clearly alienating event
and leads to little or no possibility of therapeutic resolution. In general,
it makes little clinical sense to wait until a major interpersonal crisis oc-
curs before intervening; the therapist must engage in prophylactic work
and introduce the potential victim into the treatment setting early on.
Otherwise, that person is distanced from the treatment and cannot eas-
ily enter into it to inform the therapist about the patient’s behavior.
Controversy about warning has recently arisen in the case of college
students whose suicidal or homicidal thoughts come to the attention of
administrators. However, institutions can come to see their role as a pri-
vate one, and misguided notions of confidentiality can prevail, leading
the college to withhold notification of a patient’s violent urges at possi-
ble risk to the public or to the patient him- or herself. Very few patients
are “imminently” homicidal (or even suicidal) to the point of equipping
themselves with a loaded weapon. Rather, they talk first about emerg-
ing thoughts, much as any patient describes angry feelings about some-
one else. Unchallenged, the thoughts escalate. The point here is that the
clinician should adopt a lower threshold for “warning” a victim or no-
tifying family so that preventive action can be taken.
that the patient keeps in his or her wallet and uses when the anger starts
building up. Perhaps the only exception to the nonspecificity of treat-
ment is the use of antiandrogens or hormonal agents to treat the height-
ened drive state seen among pedophiles or rapists.
Assessing the efficacy of a drug is often difficult. A patient may
claim that he or she is no longer violent when the spouse reports other-
wise, and a dosage adjustment may be necessary. This is another reason
why it is useful to periodically (once a month, for example) solicit infor-
mation from a victim. One matter to be cognizant of is a reduction in
alertness resulting from too high a dosage of medication. Because vio-
lent patients are often hypervigilant, they may be noncompliant with
any drug that makes them feel vulnerable to the world around them.
Small dosages, titrated upward, is the rule of thumb. Patients can be
told that the initial amount of medication given may be ineffective and
that the clinician will slowly increase it.
Supervision
Psychiatry tends to be practiced in isolation. With violent patients, it is
useful to talk things over with another clinician, provided that the latter
has some experience in the management of aggression.
Case Example 8
A resident treated a paranoid patient who became threatening to her,
threw a pillow at her during a session, and ultimately made a homicidal
threat. The resident had been reporting this to her supervisor, a psycho-
analyst. The latter was dismissive of the danger involved and suggested
that the resident was both unconsciously eliciting the threats and mag-
nifying the risk of them. The resident sought consultation with a foren-
sic psychiatrist, who became appropriately alarmed. He recommended
that the resident notify the police of the threat and helped the resident
hospitalize the woman and halt therapy with her.
Case Example 9
A young man prone to temper smoked marijuana frequently. He lived
by himself but was pressured by his family to find a stable job and get
married. Arguments often erupted between the patient and his father,
336 ❘ Textbook of Violence Assessment and Management
It is clear that there may come a time when limits with a patient are
reached and it becomes prudent to relinquish treatment. Assuming that
the situation does not reflect a countertransference element as described
earlier, the clinician should shift care to another setting. This is not sim-
ple to accomplish, because a truthful revelation of what occurred will
deter many prospective therapists from taking on the case. It is useful
in these instances to hospitalize the patient and meet on several occa-
sions with the treatment team and the future therapist. It is important
to explain to the patient why transfer is taking place—that is, to admit
to the patient directly that he or she has become too frightening. Pa-
tients are often surprised to hear this, but the comment has clear thera-
peutic value, particularly in a critical situation when physical confron-
tation by the patient occurs. If a patient becomes threatening, not
revealing the impact of the threat can lead the patient to become more
menacing because he or she senses no response. This advice seems
counterintuitive to security and law enforcement personnel who would
never admit to others that they are fearful. However, in the clinical
realm, the message can halt dangerous behavior.
Key Points
■ Many therapists lack experience with aggressive patients. It is rec-
ommended that clinicians who undertake work with violent
patients peruse the journals of the forensic sciences and
criminology.
■ Violent behavior typically is not on display during therapy, and
this can make it difficult for a clinician to appreciate a patient’s
dangerousness. Thus it is important to review the patient’s past
violent acts.
Psychotherapeutic Interventions ❘ 337
References
Coldren JR: Patuxent Institutions: An American Experiment in Corrections.
New York, Peter Lang Publishing Group, 2004
Dubin WR, Lion JR (eds): Clinician Safety. Task Force Report No 33. Washing-
ton, DC, American Psychiatric Press, 1992
Gellerman DM, Suddath R: Violent fantasy, dangerousness, and the duty to
warn and protect. J Am Acad Psychiatry Law 33:484–495, 2007
Lion JR: Countertransference in the treatment of the antisocial patient, in Coun-
tertransference Issues in Psychiatric Treatment. Edited by Gabbard GO (Re-
view of Psychiatry Series, Vol 18; Oldham JM and Riba MB, series eds).
Washington, DC, American Psychiatric Press, 1998, pp 73–84
Lion JR, Herschler JA: The stalking of clinicians by their patients, in The Psy-
chology of Stalking: Clinical and Forensic Perspectives. Edited by Meloy
JR. San Diego, CA, Academic Press, 1998, pp 165–172
Lion JR, Dubin WR, Futrell DE (eds): Creating a Secure Workplace. Chicago, IL,
American Hospital Publishing, 1996
Markowitz PH, Coccaro PI: Biological studies of impulsivity, aggression, and
suicidal behavior, in Impulsivity and Aggression. Edited by Hollander E,
Stein DJ. Chichester, UK, Wiley, 1995, pp 71–90
McGlashan TH, Carpenter WT: Postpsychotic depression in schizophrenia.
Arch Gen Psychiatry 33:231–239, 1976
338 ❘ Textbook of Violence Assessment and Management
339
340 ❘ Textbook of Violence Assessment and Management
and definitions. Unfortunately, the fact that these two institutions have
differing standards has made the subject of restraint and seclusion more
confusing. Added to this complexity is the fact that states vary in which
regulations they follow. Thus the clinician must know the written
guidelines applicable to the state in which he or she practices.
Observation
During the period of time the patient is in restraints or seclusion, obser-
vations regarding behavior should be made every 15 minutes by appro-
priately trained nursing staff. For those patients in four-point restraints
or in lesser degrees of restraint in combination with seclusion, observa-
tions must be continuous. In the first edition of its report, the APA task
force considered 15-minute observations as satisfied by visual checks
and recommended in-person evaluation every 2 hours minimally.
JCAHO mandates 15-minute checks and allows seclusion monitoring to
be done by video camera, whereas CMS makes no comment on tech-
nique or frequency of observations, deferring to parameters spelled out
in hospital policy. The APA task force adheres to the 15-minute observa-
tion rule, although it recommends more frequent monitoring if clinically
indicated, for example, in instances of self-destructiveness that may in-
volve headbanging. The task force recognizes that continuous television
monitoring of patients in seclusion is common, and it approves such
methods of observation provided that appropriate use is made of the
monitor. The screen itself should be placed in an area of the nursing sta-
tion conducive to privacy. Visual observation checks (as opposed to in-
person assessments) should comment on the patient’s behavior while as-
certaining that the patient is not injuring him- or herself. Observations
should also determine that the patient is not at risk for physical exhaus-
tion or hyperpyrexia due to exertion while taking psychotropic drugs.
Patients should be seen in person every 2 hours—more often if clin-
ically indicated, such as if the patient is banging his or her head. If agi-
tated patients are to be approached in the seclusion room, the same
Seclusion and Restraint ❘ 349
number of staff should enter the room as were required in the first in-
stance to subdue the patient (e.g., one for each extremity). Once a pa-
tient is quiet, direct observation with the seclusion room door open
should be made so that the state of the patient and a description of ver-
bal interchange can be documented on the patient’s chart. If the patient
is in restraints, the pulse, blood pressure, and range of motion of ex-
tremities should be assessed. Table 17–1 summarizes times regarding
orders and observations.
Emergency Medication
Confusing definitions and recommendations regarding medication
have been put forth by CMS and JCAHO. CMS allows medications to
be used “as part of an approved treatment plan for the patient’s diagno-
sis.” If, however, a medication is not so used, the intervention becomes
a “chemical restraint” and is thus viewed the same as a physical re-
straint and subject to CMS regulations. JCAHO considers the use of
medication to restrict a patient’s freedom of movement to be improper.
The APA task force believes that psychotropic medication may or may
not restrict movement but that it can be a powerful aid to patients who
are struggling to control behavior. The task force does not endorse the
term chemical restraint because it is both a misnomer and pejorative. The
use of medication obviously depends on the nature of the patient’s con-
dition, the degree of agitation, and the qualitative nature of the aggres-
siveness. If the patient is flagrantly psychotic or in an extremely agitated
manic state, medication may be indicated. Medication, if rationally
used, may shorten the length of stay in seclusion by helping the patient
to gain mastery over aggressive urges. One hazard, however, of medi-
cating assaultive patients is that the patient may be rendered so lethar-
gic that he or she becomes disorganized and combative as a function of
organic impairment. Thus clinicians need to navigate between under-
and over-medication and document specific target symptoms that re-
spond to psychotropic agents.
Some patients in restraint and seclusion can be offered medication
orally, a tactic more conducive to dignity than other routes. On the other
hand, it is well known that there are some patients so flagrantly ill that
a parenteral injection is needed. Parenteral medication is rarely curative
of an underlying psychosis but is used basically to induce symptomatic
improvement. Further and more vigorous treatment must ensue before
the core symptoms such as delusions and hallucinations abate.
“As-needed” dosing of drugs should be avoided. If drugs are used
during the restraint and seclusion process, the goals of administration
should be spelled out in specific orders, for example, “Haldol 5 mg po
q4h until belligerence and aggressiveness abates.” Clinicians who are
involved in the care of violent patients should be familiar with a variety
352 ❘ Textbook of Violence Assessment and Management
Unique Restraints
It is possible to use various restraint devices in a creative fashion that
allows the patient to mingle with others on a ward or within the room.
The use of garments that restrain extremities or that bind older patients
to a wheelchair may allow the individual to participate in group meet-
ings and receive milieu enrichment that would not occur in a seclusion
room. The use of PADS (Protective Aggression Devices) allows a belt-
like device to be applied to the waist and wrists or to the ankles but in
a manner that permits some range of motion, including ambulation
(Van Rybroek et al. 1987). An advantage of these devices is that they en-
able the patient to take part in ward activities while still restricting po-
tentially dangerous arm or leg movements. There is flexibility in the use
of PADS, so that the nondominant hand can even be released from the
belt line as a function of improved behavior.
Key Points
■ Seclusion and physical restraint are techniques to manage violent
patients in hospitals that are regulated by governmental agencies
and the psychiatric profession.
■ Seclusion and restraint are used in emergencies to prevent immi-
nent harm to other persons, as well as to the patient, and to pre-
vent serious disruption of the treatment environment.
■ Seclusion or restraint may be contraindicated on the basis of the
patient's clinical condition and should not be used as a punitive
response or for the convenience of the staff.
■ Seclusion and restraint must be ordered by a physician or, in some
situations, by another licensed independent practitioner who
must see the patient face to face within one hour after initiation
of seclusion or restraint.
■ The duration of seclusion or restraint is limited on the basis of the
patient’s age.
■ Clinicians must know and adhere to the policies of the hospital in
which they practice in regard to other parameters such as tech-
niques of using and renewing seclusion and restraint.
■ The patient in seclusion or restraint must be observed properly
and receive adequate nursing care and medical care, including the
use of medication.
■ Patients may be released from seclusion or restraint when the
patient's behavior is under control and no longer poses a threat to
self or others or a further disruption of the treatment environ-
ment.
References
Ahmed MB, Lepnurm M: Seclusion practice in a Canadian forensic psychiatric
hospital. J Am Acad Psychiatry Law 29:303–309, 2001
American Psychiatric Association: Seclusion and Restraint: Report No 22 of the
American Psychiatric Association Task Force on Seclusion and Restraint.
Washington, DC, American Psychiatric Association, 1985
American Psychiatric Association Task Force on Seclusion and Restraint: Seclu-
sion and Restraint: Report of the American Psychiatric Association Task
Force on Seclusion and Restraint (unpublished). Submitted to the Ameri-
can Psychiatric Association, 2006
Binder RL: The use of seclusion on an inpatient crisis intervention unit. Hosp
Community Psychiatry 30:266–269, 1979
Busch A, Shore MF: Seclusion and restraint: a review of the recent literature.
Harv Rev Psychiatry 8:261–270, 2000
Seclusion and Restraint ❘ 355
Special Populations
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C H A P T E R 1 8
359
360 ❘ Textbook of Violence Assessment and Management
Epidemiology
Aggression is a common behavior in a child’s development. A high per-
centage of an 18-month-old’s peer interactions involve aggression, of-
ten in reaction to frustration or wanting something another child has.
By age 2½, after the child has developed more social skills and lan-
guage, the frequency of physical peer aggression drops significantly,
and it continues to decrease until age 6 as most children shift to verbal
types of aggression. Most of the preschool child’s aggression is directed
at peers. Much of how a child learns to handle aggression is mediated
by parenting, so children who deviate from normal development and
are identified early can often be helped by parental interventions.
Aggression remains common in elementary school children. Data from
a large-scale longitudinal survey of Canadian children indicated that par-
ents rated as “sometimes” or “often true” that more than one-third of boys
and about 30% of girls ages 4–11 get into many fights and about 20% of
boys and 10% of girls physically attack people (Offord et al. 2001). Of the
15 DSM-IV-TR criteria for conduct disorder, seven code for physical ag-
gression (American Psychiatric Association 2000), so rates of conduct dis-
order give some indication of the frequency of rates of maladaptive aggres-
sion in elementary school–aged children. Epidemiological studies report
rates of conduct disorder in elementary school–aged boys as approxi-
mately 3%–7% (Loeber et al. 2000), with considerably lower rates in girls.
Violence is common throughout adolescence: in the United States,
about 30% of 12-year-old boys and 25% of 17-year-old boys surveyed in
a large-scale study in 2005 reported having gotten into a serious fight in
the past year (U.S. Department of Health and Human Services 2006). For
girls, the rates were only about one-third lower. In the same study, about
Children and Adolescents ❘ 361
10% of adolescent boys and 3%–4% of girls reported that in the past year
they attacked someone with intent to seriously hurt the victim. Bullying
is a common middle school variant of violent behavior, practiced by
about 13% of sixth to tenth graders (Nansel et al. 2001). Adolescent dat-
ing violence also occurs with high frequency. In a nationally representa-
tive sample of high school students, about 9% of both girls and boys re-
ported being physically hit by a boyfriend or girlfriend in the previous
year (Centers for Disease Control and Prevention 2006). Interestingly, the
362 ❘ Textbook of Violence Assessment and Management
rates of dating violence were not significantly different for boys and
girls, unlike most other forms of violent behavior. Dating violence was
most strongly associated with the risk factors of being sexually active
and having attempted suicide. The cumulative prevalence of committing
a serious violent offense by age 17 is estimated at 30%–40% for boys and
16%–32% for girls. Although African American youth are arrested at
much higher rates than white youth, the self-report data cited above
show much smaller racial differences. The peak age for the onset of vio-
lent behavior occurs in adolescence, around age 16 for boys (Elliott 1994).
These rates of violence appear to have been fairly stable over the
past several decades (U.S. Department Health and Human Services
2001). However, adolescent homicide rates have been quite variable:
rates for white males tripled from 1964 to 1991 and then over the ensu-
ing 10 years fell back to the rates of the 1970s (National Center for
Health Statistics 2004). Thus, although the frequency of violence has re-
mained fairly constant, the lethality of that violence has varied consider-
ably. Both the increase and decrease of adolescent homicide rates were
linked to changing rates of using firearms by adolescents (Snyder and
Sickmund 2006). The involvement of youth in the crack trade and in-
creased gang activity led to an increase in youth homicide. Despite the
fact that possession of a handgun by an adolescent is illegal, fear on the
street led more youth to carry handguns for protection, which led to
more homicides and a spiraling cycle of yet more fear (Blumstein 2002).
In the mid-1990s, one study showed almost all incarcerated male delin-
quents owned a handgun (Ash et al. 1996). Possession of a handgun
markedly raises the potential lethality of a violent confrontation. After
the mid-1990s youth (and, to a lesser extent, adult) violent crime rates
dropped markedly. The reasons for the crime drop remain controversial
but appear related to increases in the prison population, increases in the
number of police, the decline of crack, and legalized abortion (Levitt
2004). The cycle of fear went into reverse, and firearm carrying by youth
decreased. The central role of guns in the lethality of youth violence ob-
viously has major implications for intervention.
Developmental Trajectories
Much of what we know about the development of violence has been
learned from longitudinal studies of youth. The majority of researchers
recognize at least two main patterns: an early-onset trajectory in which
the youth engages in serious violence before puberty, and a late-onset
group who do not engage in serious violence until adolescence (Moffitt
1993; National Institutes of Health 2004; U.S. Department of Health and
Children and Adolescents ❘ 363
Risk Factors
The high rates of violence in adolescents, compared with the general pop-
ulation, indicate that adolescence itself is a risk factor. The considerable
literature on risk factors for youth violence demonstrates numerous risk
factors at the levels of individual, family, and community (Connor 2002;
Hann 2002; Hawkins et al. 2000). The risk factor literature is complex for
several reasons. First, violence is a heterogeneous group of behaviors, and
risk factors differ for different types of violence. Second, not only are there
numerous risk factors in different domains, but given the dynamic nature
of development, different risk factors become salient at different ages. For
example, having a delinquent peer group is a potent risk factor for ado-
lescents but not for preadolescents. Third, risk factors may interact: for ex-
ample, there is considerable evidence from twin and adoption studies
that some genetic risk factors, such as having an antisocial biological par-
ent or having the low–monoamine oxidase A allele, are much more likely
to be expressed in violent behavior when an adopted child is raised in an
adverse home environment (Caspi et al. 2002; Foley et al. 2004). Finally, as
with suicidality, no combination of risk factors can predict with much
Children and Adolescents ❘ 365
Case Examples
Case 1: Early-Onset Course
Bruce, age 13, was referred for treatment as a condition of probation for
carrying a handgun while “on duty” as a lookout for a drug seller. He
presented as an irritable teenager who initially resented having to come,
but he was quite talkative in the initial evaluation session. He had been
in foster care for 3 years beginning at age 4 when his mother was sent to
prison on a drug charge, but he was returned to her care when he was 7.
His father was unknown. His mother reported oppositional behavior at
home after age 7 and theft from other youths at school. Despite this his-
tory, he had obtained a C average in school. When he was 9, he got mad
and killed a dog with a baseball bat, and a year later, he got angry dur-
ing a baseball game and hit another player with a bat. The school re-
ported he was a bully and hung out with a peer group that harassed
other students. He had recently joined a gang and proudly showed the
evaluator the gang tattoo on his shoulder.
Assessment
Violence, both prospective and completed, encompasses a wide range
of behaviors that call for differing approaches to assessment and inter-
vention. Violent youth are involved in multiple systems, and depend-
ing on the referral, a clinician may take one of a variety of roles, such as
366 ❘ Textbook of Violence Assessment and Management
are present that can be used as weapons, and where others are rapidly
available in the case of an impending assault from the patient.
History of Violence
Overall, the best predictor of whether a behavior will occur in the future
is whether it is occurring in the present or has occurred in the recent
past (Tremblay and LeMarquand 2001). Therefore, a history of violence
is key. The clinician needs to obtain both chronological detail (such as
when violent behavior began and with what frequency it continued)
and detailed knowledge of violent events (e.g., precipitants, emotional
state during the assault, nature of the assault, feelings after). Less struc-
tured interviewing may obtain details missed by structured question-
ing. One useful approach for discussing a violent event with a child or
adolescent is to say, “Let’s suppose I was going to make a movie of what
happened. Could you describe what happened in enough detail so I
could do that?” Follow up with questions about the event and what led
up to it, and then, once the external nature of the event is clear, go back
and ask about feeling states at key points, for example, “Tell me what
was in your mind when he said [or did]….”
Children and Adolescents ❘ 369
Diagnosis
The most common psychiatric diagnosis applied to youth with histories
of violence is conduct disorder, the main criterion of which is “a repeti-
tive and persistent pattern of behavior in which the basic rights of oth-
ers or major age-appropriate societal norms or rules are violated, as
manifested by the presence of three (or more) [of the listed behavioral
criteria that include bullying, getting into fights, using weapons, and
robbery]” (American Psychiatric Association 2000). Conduct disorder is
thus a phenomenological diagnosis encompassing a wide range of an-
tisocial behaviors. Children with the disorder typically have a history of
previous ODD, a diagnosis characterized by a pattern of negativistic,
hostile, and defiant behavior, but ODD does not have aggressive behav-
ior as a criterion. The American Academy of Child and Adolescent Psy-
chiatry has published practice parameters for the evaluation and treat-
ment of conduct disorder (American Academy of Child and Adolescent
Psychiatry 1997) and ODD (American Academy of Child and Adoles-
cent Psychiatry 2007). Antisocial personality disorder can only be diag-
nosed in adults and has as one criterion that there was evidence of con-
duct disorder prior to age 15. ODD and conduct disorder are Axis I
disorders, but when they progress to antisocial personality disorder, the
condition is classified as an Axis II disorder. For intervention purposes,
the construct of psychopathy, which is not included in DSM, may be
useful. Psychopathy encompasses the lack of remorse and the lack of
empathy components of antisocial personality but does not include the
more behavioral components. The most common metric for psycho-
pathy, the Hare Psychopathy Checklist, does have an adolescent ver-
sion, the Psychopathy Checklist–Youth Version (PCL-YV; Forth et al.
2003; see discussion of rating scales later). Personality disorder has been
associated with recidivism in delinquents (Steiner et al. 1999).
A comprehensive psychiatric diagnostic assessment is useful to
delineate disorders that may be contributing to violence risk. Violence
can be a symptom of many diagnoses in addition to conduct disorder,
including pervasive developmental disorder and bipolar disorder.
Conduct disorder has a very high comorbidity with attention-deficit/
hyperactivity disorder (ADHD). Many violent youth give histories of
exposure to violence, either as a victim or as a witness, and may meet
criteria for posttraumatic stress disorder. Substance abuse is a signifi-
370 ❘ Textbook of Violence Assessment and Management
Predatory Violence
It is clinically useful to distinguish between aggression that is impul-
sive, reactive, hostile, and affective and aggression that is predatory, in-
strumental, proactive, and controlled (Jensen et al. 2007; Vitiello and
Stoff 1997), although many youth exhibit both. There is some evidence
Children and Adolescents ❘ 371
that different neural pathways are involved (Blair 2004). The assess-
ment of the child in the first case example, in which there is a clear his-
tory of past impulsive participation in group violence, will be different
from the assessment of the child in the second case, for whom the key
issue is the risk of an individual’s acting alone in a cold-blooded, pred-
atory manner. A youth planning predatory violence is more likely to
conceal his thinking than is a youth who acts impulsively. Therefore,
more indirect information is necessary. Although psychiatrists who
work with youth are experienced in obtaining collateral information
from parents, they are less likely to be experienced in obtaining infor-
mation from peers. Yet the evaluee’s friends are the most likely—more
so than parents—to have heard the youth express threats, even if the
friends did not take the threat seriously. One commonality in the mass
school shootings by adolescents is that in each case the shooter had ex-
pressed threats toward others prior to the event (Verlinden et al. 2000).
Depending on the level of risk suggested by other indicators, a youth’s
friends can be telephoned (with the permission of the patient) or,
in higher-risk situations, questioned by law enforcement personnel.
Whenever risk of predatory violence by an adolescent is a serious con-
sideration, if at all possible some friends should be talked to.
The second key principle in assessing risk of predatory violence is to
think in terms of a pathway toward violence (Borum et al. 1999). This
threat assessment approach, first developed for the U.S. Secret Service
(Fein and Vossekuil 1998) and later adapted to school threat assess-
ments (O’Toole 1999; Vossekuil et al. 2002), advocates focusing less on
the profile of the subject and more on whether the subject is taking steps
toward targeted violence. The path begins with fantasizing about kill-
ing, progresses to beginning planning, which might involve increased
interest in weapons or learning about how others have conducted mass
shootings by reading on the Internet, and then moves on to more de-
tailed preparation, such as obtaining weapons, scouting out sites, and
following potential victims. The farther along this path a person is, the
more risk he or she poses. It is not necessary for a person to make a threat
in order to be a threat. Because an interviewee may deny intent to harm,
when interviewing a potential attacker, one also looks for “leakage,”
such as interest in weapons and interest in other attacks, that may indi-
cate moving on a path toward violence. It is also important to explore
the motivation for the behavior that brought the subject to attention. In
the case of the potential school shooter described earlier, it would be im-
portant to explore what he had in mind when he wrote the “Hit List.”
For cases that seem to pose medium to high threat, a team of investiga-
tors may be necessary to search for possible physical evidence or inter-
372 ❘ Textbook of Violence Assessment and Management
Weapons
Because of the close link between weapon carrying and the lethality of
violence, a weapon assessment should be part of the evaluation of any
youth being assessed for violence. In one study, the rate of firearm own-
ership by boys who have been in detention approaches 100%, and for
girls it is about half that (Ash et al. 1996). The assessment should in-
clude a history of how and when the youth first obtained a gun, subse-
quently obtained weapons, and has access to non-owned guns in the
home or from peers. For impulsive aggression, the issue is less one of
access, because most youths can obtain a gun if they really want one,
than of how frequently, for what reasons, and under what conditions
the youth carries a weapon and how often and under what conditions
he or she has fired at a person and demonstrates an intent to use (Ash
2002; Pittel 1998).
Management
We have come a long way from the 1970s, when the predominant think-
ing was that “nothing works” in dealing with violent youth, although
violent behavior remains a challenge to treat. Because violence is the
product of multiple factors, the most effective treatments utilize several
modalities aimed at different sources of dysfunction. These modalities
vary widely depending on the nature of the clinical situation: a 4-year-
old who was expelled from preschool for hitting other children will re-
Children and Adolescents ❘ 373
ceive different services than the adolescent in the first case example
who has a long history of antisocial behavior.
Medication
There is growing consensus that medication should first be used to treat
any underlying disorder, such as ADHD, depression, or bipolar disor-
der (Connor et al. 2006; Pappadopulos et al. 2003; Schur et al. 2003). One
area in which practice varies widely is the extent to which irritability in
adolescents is perceived as justifying a diagnosis of possible bipolar dis-
order and thus the utilization of a mood stabilizer. After treating any
underlying disorder, the second step is to use psychosocial approaches
to manage aggressive behavior, such as cognitive-behavioral treat-
ments, parent management training, and increasing environmental
structure. Only after those approaches have failed should medication
be considered for the target symptom of aggressive behavior.
In 2006, the U.S. Food and Drug Administration approved an indi-
cation for risperidone for the symptomatic treatment of irritability in
autistic children and adolescents. No medications have demonstrated
consistent efficacy in reducing aggression in other conditions. The most
widely utilized medications are mood stabilizers and atypical antipsy-
chotics, which appear more effective for impulsive/reactive aggression
than for predatory aggression (Connor et al. 2006). Among the mood
stabilizers, lithium and divalproex sodium have received the most re-
search support. Among the atypical antipsychotics, risperidone is the
best studied, and other antipsychotics have not yet been studied in ran-
Children and Adolescents ❘ 375
Environmental Interventions
Because association with delinquent peers and gangs is so central in ad-
olescent violence, interventions that reduce peer effects or utilize them
proactively have proved useful. For example, from 1991 to 1995, Boston,
Massachusetts, averaged 44 street homicides of youth per year. After a
community intervention beginning in 1996, that number was reduced
by 63% (Kennedy et al. 2001), the so-called “Boston Miracle.” Although
the intervention was multipronged, the basic idea was that although in
most cases the police did not know the shooter, they did know to which
gang the shooter belonged, and law enforcement came down hard on
all that gang’s members. First, there was a community outreach effort
educating gangs to the fact that following a shooting, all gang members
of the presumptive shooter’s gang would be prosecuted for any offense
to the fullest extent possible. Police resources from the city were then
concentrated on the area in which the shooter’s gang operated. Law en-
forcement and the judiciary bought into the program, and maximum
penalties were then given to that gang’s members for any offense, from
public drinking to assault. Those who violated probation in any man-
ner, including such probation requirements as going to school, had their
probation revoked. Because all of the gang suffered for a shooting, peer
pressure rapidly began discouraging shootings.
Other interventions that strive for deterrence have been less success-
ful. For example, after the crime wave of the early 1990s, concern for
public safety led to more punitive approaches toward youth. Following
the “adult crime, adult time” mantra, almost all states expanded their
criteria for waiving juveniles to adult court (Sickmund 2004). The weight
of the evidence now suggests that punishing juveniles as adults in-
creases recidivism (Fagan 1996; McGowan et al. 2007). The American
Psychiatric Association (2005) has called for reform of policies that pun-
ish large numbers of adolescents as adults.
Consultation
Aggression and violence in children and adolescents are among the
most difficult conditions to assess and treat in child and adolescent psy-
chiatry. Working with such youth also raises strong countertransference
issues, and the imprecision of risk assessment in the context of others’
lives being potentially at stake can generate considerable anxiety in the
clinician. Many child psychiatrists have little experience with this pop-
376 ❘ Textbook of Violence Assessment and Management
Key Points
■ The onset of serious violence is typically an adolescent phenome-
non. Those whose violence begins in preadolescence have a signif-
icantly worse prognosis.
■ Serious violent offending is common in high school students,
but most do not continue their violent careers into adulthood.
■ Many risk factors for violence have been identified, but no
constellation of risk factors allows for accurate predictions of
future dangerousness.
■ Effective treatments for violent youth are multimodal and inter-
vene at multiple levels. Most effective treatments include parent
interventions. For adolescents, also intervening to change the
patient’s relationship to a delinquent peer group is important.
■ The best-established use of psychopharmacology is to treat
comorbid psychopathology such as ADHD or a mood disorder. No
medications specifically target aggression, but mood stabilizers
and atypical antipsychotics are sometimes utilized when available
psychosocial treatments have not proved effective.
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C H A P T E R 1 9
The Elderly
Robert Weinstock, M.D.
Stephen Read, M.D.
Gregory B. Leong, M.D.
J. Arturo Silva, M.D.
381
382 ❘ Textbook of Violence Assessment and Management
Assessment
Violent acts attract attention. One common setting in which this be-
comes relevant is in a general hospital. A patient can be profoundly de-
pressed or even confused without attracting attention until the person
threatens suicide—or throws a bedpan in frustration at a nurse’s aide.
The psychiatric attention that was being left until discharge suddenly
becomes an emergency. Implicit in this scenario are two principles: that
actual or threatened violence remains one of the more reliable routes to
psychiatric evaluation, and that the act itself commonly occurs—and is
interpreted as “crazy”—in its perceived inappropriateness in context.
A consequence of this scenario is that the referral for evaluation is
likely to emphasize the act and its consequences—that is, how upset the
victim (or potential target) is or the danger to others—more than the
context. In the communicated need to “do something” urgently, the
evaluator may have difficulty gaining information about the contextual
issues, information that would substantially guide the “prescription”—
the course of recommended response and treatment. In many circum-
stances the psychiatric consultant in a general hospital may not be able
to perform a complete assessment (Devanand 2005; Silver and Herr-
mann 2004), especially in urgent circumstances. Many similar problems
arise in the outpatient setting. Assessment of the problem is essential to
provide appropriate management and treatment. Because any of the el-
ements of a complete evaluation may provide the critical key to the
problem, we first review the relevant portions of a complete assessment.
Chief Complaint
The patient may or may not have a “complaint”—the incident that led
to the referral may have been forgotten—or the patient’s complaint may
be the result of the response of others: “Why is everyone mad at [afraid
of] me?” Eliciting the patient’s recall provides a valuable key to mem-
ory, insight, and lability of mood and may actually reveal the precipi-
tant for the patient’s action. In addition, in this inquiry, the consultant
384 ❘ Textbook of Violence Assessment and Management
Case Example 1
Mr. M was a 74-year-old man who had retired from the U.S. Postal Ser-
vice after 43 years of delivering the mail in the small town where he
lived. He had married, relatively late in life, a widow he had met on his
rounds whose mother had urged her daughter to pursue him. Mr. M
therefore became stepfather to the widow’s two children as well as a
“solid citizen” who knew everyone by name and was most proud of be-
ing the greeter every Sunday prior to church services.
The police were startled one morning by his phone call: “I think I
have just killed my wife.” They arrived within a few minutes to find Mr.
M, hammer in hand, standing by the kitchen table where his wife was
slumped, clearly dead. Mr. M said, “I don’t know why I did it.” After his
arrest and jailing, he was given a psychiatric evaluation. His psychiatric
history, which he corroborated, included being hospitalized three times
for severe depression. Each time, his depression had responded to anti-
depressant medicine, principally sertraline, with modest dosages of
(different) antipsychotic medicines. His first hospitalization occurred
after age 50, and the most recent had been 18 months prior to his lethal
assault. This last hospitalization was precipitated by Mr. M’s having ap-
peared at the door of the police station with an axe, shouting threats and
challenging the police to shoot him. Observers had agreed that Mr. M
had returned to his quiet, well-behaved self after discharge. However,
The Elderly ❘ 385
understanding of the events (sadly, of course, much too late). Note that
this information, although in some sense applicable to the “chief com-
plaint,” appeared only late in the interview, after rapport had been es-
tablished and following a gradual approach to the fraught circum-
stances of the event.
Past History
Medical/Surgical
Confusion is the term most commonly used in referrals when the diag-
nosis of delirium eventuates. In the elderly, in fact, delirium may com-
monly herald the onset of an illness such as myocardial infarction that
in younger people is announced by more specific symptoms. Because of
the high frequency with which mental functions abruptly decline in the
elderly due to delirium related to some recent physiological challenge,
the medical history is a high priority in the evaluation of the violent ge-
riatric patient. In addition, knowledge about medical status will be vital
to the choice of treatment.
The consultant should seek recent laboratory studies. Asking about
recent acute illnesses or changes in the patient’s status may identify, for
example, a bladder infection that in an older person is associated with
“confusion” more than with identifiable physical discomfort. Recent
medication changes and their effects, such as the anticholinergic effects
of amitriptyline commonly given to alleviate neuropathic pain, may
precipitate delirium, especially in individuals with dementia. Identify-
ing a physiological abnormality not only may lead to a specific and
sometimes prompt resolution of mental derangement but also can be vi-
tal to preserving brain function.
Case Example 2
Mrs. J was a high-functioning 72-year-old woman with no personal or
family history of major mental disorder who slowly became increas-
ingly agitated over a several-week period, to the dismay of her family.
Eventually, psychiatric consultation was sought, which led to voluntary
psychiatric hospitalization. However, her hospital stay became involun-
tary after she assaulted a staff member when her husband could not be
reached by phone. She was diagnosed with acute mania and started on
quetiapine and lithium. She became alternately sedated and agitated as
well as somewhat confused; in response to needed care interactions, she
frequently responded by hitting attendants, and more than once struck
other patients in a fit of irritability. At these times, she would typically
be given intramuscular lorazepam and confined to the “quiet room” or
restrained in her bed for several hours. She was noted to sweat pro-
The Elderly ❘ 387
This case illustrates the need for careful medical analysis and collab-
oration. Late-onset mania is rare. Hyperthyroidism cannot be expected
to respond to “psychiatric” treatment, even when it presents “psychiat-
ric” symptoms. A more disturbing feature of this case is that in this
same time frame, after the return of euthyroid state, Mrs. J was noted to
have memory impairment of which there had been no sign prior to her
hospitalization, and she went on to have full-blown dementia due to
Alzheimer’s disease.
Alternatively, the inquiry into the mental and physical condition
prior to the violent incident may lead to the identification of an emer-
gent, not-yet-recognized dementia. A brief example is a consultation in
a lovely elderly woman who lived alone. Her family stopped by to pick
her up for church and found all the drawers in her kitchen had been
emptied on the floor and everything scattered. After it was ascertained
that this was not a break-in or robbery, she was evaluated for delirium
or dementia. She presented very articulately—she was in a book club,
for example—but oddly could not recall the titles of any recent books.
This observation led to the demonstration of impaired short-term mem-
ory, and a history emerged of episodes of accumulating impairment
during a 2-year period—and a diagnosis of Alzheimer’s disease.
Case Example 3
Mr. T was a 67-year-old veteran admitted to the acute psychiatric unit
from an emergency department. He had a history of depression that had
been treated with fluoxetine and of very mild early dementia. He had
abused crack cocaine in the past, with episodes of delusions and paranoia
treated with olanzapine. His most recent hospitalization had been for pul-
monary insufficiency. He was a longtime smoker and had emphysema.
388 ❘ Textbook of Violence Assessment and Management
Psychiatric
Psychiatric history information may be most elusive in the elderly. For
example, the patient may have suppressed personal recall related to the
stigma of such experiences, and family members (children) may never
have been told. In addition, the patient may be delirious or demented,
and hospital or nursing home staff may have no real information about
prior history. Misidentification delusions in the elderly can result in vi-
olence. Substance abuse histories may also be vital but are subject to de-
liberate concealment or ignorance about the extent of alcohol intake, for
example, which may contribute to the clinician’s overlooking delirium
tremens or drug-induced psychosis or affective disorder. Another cau-
tion is that a condition that today would be recognized as a major de-
pressive episode may have been diagnosed in the early adult life of an
85-year-old as “neurosis,” “schizophrenia” or other psychosis, or sim-
ply a “nervous breakdown” in older nomenclature. Elicitation of psy-
chiatric history is usefully done in conjunction with the medical history.
However, a history of prior psychiatric disorder can be critical for iden-
tifying the precipitating episode of a reemergence. As discussed above,
in emergency department and medical settings, confusion and agitation
The Elderly ❘ 389
Psychosocial
Inquiry into psychosocial factors provides background information
that is valuable for rapport and for identifying sources of stress (and for
observing the patient’s resilience and capacity to understand and ap-
preciate such forces). Such inquiry may also reveal clues to a family ill-
ness or to an event relevant to the patient’s actions. A serious issue
involving a close family member, a recent bereavement, or a major fi-
nancial or social decision may dominate the patient’s thinking and have
a greater meaning than one would expect. In addition to the direct
physical and physiological effects of the patient’s condition, his or her
awareness of it may be a critical stressor. Whether the concern is “heart
attack,” “cancer,” or care consequences (e.g., a lap belt used on a patient
with dementia to prevent forgetful attempts to stand after hip replace-
ment surgery), it may be experienced directly by the patient as an exac-
erbation of vulnerability—a perception of threat that can lead to a vio-
lent reaction to a stimulus that otherwise would not be threatening.
Attentional Problems
Attentional problems are the core symptoms of delirium. The first issue
is whether the patient is paying attention—that is, is able to listen to and
respond appropriately to questions or requests from caregivers. Is the
patient easily distracted? Can the patient reorient to the previous ques-
tion after an interruption? On the other hand, can he or she then turn
390 ❘ Textbook of Violence Assessment and Management
Case Example 4
Dr. F, a former surgeon and community leader, had been living at home
with his wife and attending day care. He had support from his out-of-
town children as well. He had been functioning as a surgeon until his
memory problems became apparent. He had been cared for at home for
several years after diagnosis of dementia due to Alzheimer’s disease
(which itself followed several years of declining short-term memory
and risky financial decisions), and this home stay was supplemented by
his attending adult day care. He was evaluated for nursing home place-
ment after an emergency call about his being “agitated.” Some restless-
ness and “agitation” had been mitigated with low-dose risperidone.
However, near the end of the day care schedule, in fact within several
minutes of 2:30 P.M. every day, Dr. F would suddenly transition from a
relatively affable, cooperative, good-humored man into a restless, agi-
tated, active and impatient man. He would typically claim he “needed
to go [somewhere],” and he would try to push his way out toward the
parking lot. Day care staff had worked out somewhat elaborate at-
tempts to divert him, but on the day in question, he had been unde-
terred and had struck a staff person who finally tried to block his way
physically. His wife had arrived shortly thereafter, and she also (for the
first time) feared that he would be “violent.”
The 2:30 P.M. transition time endured in the nursing setting. Dr. F
was bright, confident, helpful, and cooperative in the morning but be-
came impatient, demanding, and urgent from before 3:00 P.M. until past
dinnertime. If staff were unable to distract or redirect him, he could be-
come very forceful. Although this was generally limited to pushing or
392 ❘ Textbook of Violence Assessment and Management
shoving obstructions out of his way (including staff persons or, occa-
sionally, another patient who was unable to recognize the situation), at
least the threat of more focused aggression existed. Containing his ag-
gressive impulses was difficult—doors were “secure,” but Dr. F’s athlet-
icism enabled him to get through several barriers and even to climb over
the six-foot-high perimeter wall. Once out, he was also able to move
very quickly.
As staff came to know him, their interventions became more effec-
tive. Organizationally, because his behavioral change was timed close to
change of shift, administrative team intervention was required to ensure
a continued high level of observation (instead of the distraction of com-
pleting mandated charting) and to manage the relative confusion atten-
dant on staff comings and goings. These efforts alone remained insuffi-
cient. His behavior worsened at every attempt to reduce antipsychotic
dosage, and he required doses of risperidone 2–3 mg daily, most given
after lunch to maximize mid-afternoon effect and thus mute the impulse
and contain the risk of aggression.
Dr. F’s dementia was moderately severe at nursing home admission
(e.g., MMSE score was 14/30) and continued to progress over the next
5 years. He was started on donepezil with some mild improvement. Al-
though the diurnal pattern was unchanged, management became easier
as his capabilities diminished. After surgery to repair an intertrochan-
teric (hip) fracture, he experienced delirium and, after recovery, was not
only less mobile but also had a substantial incremental worsening of his
dementia. He was also more passive, and at that point the diurnal agi-
tation became much less marked, allowing for the tapering and discon-
tinuation of risperidone.
Thought Processing
The presence of hallucinations, delusions, preoccupations, or other ab-
normalities may be indicative of impaired brain function and may also
directly contribute to the aggressive impulse.
uals. The hyperactive, driven, grandiose manic patient may also react
violently to what would otherwise be mild provocation or frustration.
Attentional and cognitive deficits, as well as delusions, can be associ-
ated with both poles of mood disorder and further compromise the
patient’s impulse control. Because apathy can be an early sign of de-
mentia, sometimes it is difficult to distinguish from depression in the
elderly.
Case Example 5
Mrs. L was a 78-year-old woman who had been a social leader of her
community and who had been married nearly 50 years to a man who
continued to adore her. His devotion led him to seek assistance from ev-
ery source he could find when she developed a persistent, savagely anx-
ious depressive syndrome—and to seek an alternative if success were
not promptly forthcoming.
Mrs. L had acted at nearly hysterical levels for a substantial part of
every day for more than 3 years. She would throw herself into walls at
times, although there was no clear attempt to commit suicide. She had
torrents of tears and refused to be comforted and would at times strike
at or claw at anyone who presumed to get close, including her husband
and the caregivers he hired. Sleep, appetite, energy, and mental focus
were all grossly deficient, and she had lost over 40 pounds in the year
preceding evaluation. Although a diagnosis of depression had been
made (several times), treatment had never been consistently pursued
because of her own hopelessness and resistance and her husband’s great
concern every time someone mentioned the possibility of side effects.
Evaluation confirmed a diagnosis of severe recurrent major depres-
sion. Consultation with an internist and laboratory studies revealed no
medical cause; in fact, Mrs. L remained in good health. Mr. L was in-
volved in all phases of the assessment—with an emphasis on his accept-
ing that the primary diagnosis was psychiatric. Once that was estab-
lished, it was possible to provide realistic information about treatment
options and the course of improvement that could be expected. Accord-
ingly, Mrs. L was started on venlafaxine. Treatment response began at a
dosage of 75 mg daily, with additional improvement and real symptom-
atic relief evident at a dosage of 150 mg daily. Each improvement, how-
ever small, was strongly reinforced both with Mrs. L and her husband.
Some level of distress, agitation, and anxiety persisted with optimal
doses of venlafaxine, but further improvement was achieved with the
addition of small doses of risperidone and then antianxiety medication.
Mrs. L eventually returned to her primary care doctor for follow-up.
Twice in 4 years she was reevaluated when symptoms returned—both
times after an attempt to “stop medicine because I was better.” The third
relapse differed. At this point, overt difficulty with memory was seen at
evaluation, and this proved to be the early finding in her developing
dementia due to Alzheimer’s disease. Donepezil was started, but with
little effect. As her dementia progressed, she became more impaired.
394 ❘ Textbook of Violence Assessment and Management
Treatment
Consider Acute/Emergent Treatment
At times the consultant must consider initiating treatment of violent be-
havior before the full evaluation process can be completed. A rapid
medical response, such as restraining a patient in a bed, may be neces-
sary to ensure the safety of the patient and others or to limit the morbid-
ity of other responses. Two groups of medications remain the mainstays
of acute calming of aggressive and violent behavior: benzodiazepines
and neuroleptics. Both require careful titration and close observation
but have a high safety profile in short-term use, especially when com-
pared with the potential for injury from agitated or aggressive behavior.
“Close observation” should include frequent visualization, prefera-
bly with the patient in constant line of sight. In addition to monitoring
level of agitation and aggression (i.e., the response of target symptoms),
observations should include vital signs, color, any appearance of phys-
ical distress, urine output, and level of awareness. Regular notes should
be made (and retained) and a supervisor and/or physician should be
notified promptly of any deterioration in any parameter.
Despite the Clinical Antipsychotic Trials in Intervention Effective-
ness–Alzheimer’s Disease (CATIE-AD; Schneider et al. 2006) studies and
recent concerns about neuroleptic medications in the elderly, most au-
thorities continue to prefer the use of these agents in the elderly due to
the greater likelihood of aggravating cognitive impairment and the risks
of unsteady gait with benzodiazepines. Benzodiazepines often can also
be disinhibiting. Neuroleptics may be given orally, intramuscularly, or
intravenously (e.g., in an intensive care setting with established venous
access), but the availability of liquid (elixir) and fast-dissolving oral prep-
arations has greatly reduced the need for parenteral administration.
At the time of this writing there is controversy about the meaning of
the CATIE-AD studies regarding the use of atypical antipsychotics in
The Elderly ❘ 395
the elderly to treat agitation and aggression. It appears that these med-
ications are effective, but this effectiveness can be negated by side ef-
fects (Schneider et al. 2006). The U.S. Food and Drug Administration
(FDA) has not approved these medications for the treatment of demen-
tia-related psychosis because of increased danger of death (Karlawich
2006). There may be a small increased risk of death (Schneider et al.
2005), but there are contradictory findings and interpretations, and
many think these agents have a place and that the danger has been
overblown (Barak et al. 2007; Raivio et al. 2007).
sleep cycle, hallucinations, and irritability and other mood changes (de
Jonghe et al. 2007) allows for mitigating their effects. These importantly
include diminished immediate safety, negative impact on the patient,
and the fact that prolonged delirium is associated with poor outcomes,
including death and permanent brain damage. For example, in case ex-
ample 2, Mrs. J’s prolonged thyrotoxicosis left her with permanent mem-
ory loss, and she subsequently developed progressive dementia.
Because brain function is a sensitive marker of decompensation in
the function of any major organ system—cardiac, pulmonary, hepatic,
or renal—identifying the presence and cause of such dysfunction is crit-
ical. Asthma, incipient pneumonia, congestive heart failure, and elec-
trolyte imbalance are other common illnesses for which the typical
symptoms in the elderly may be “confusion” rather than specific text-
book medical symptoms. An especially common cause is a bladder in-
fection, which reliably causes confusion and abrupt decompensation in
the patient with moderate to severe dementia. Delirium tremens may
appear in the covertly alcoholic person. For these reasons, the consult-
ant is urged not to dismiss the observation “she’s just not herself” from
a credible caregiver who knows the patient well (whether a family
member, home health aide, or certified nursing assistant or nurse), be-
cause those who work closely with the patient over time will be the
most sensitive to these changes.
Case Example 6
Mrs. A was a wealthy, divorced 84-year-old woman originally seen in
the context of a bitter and complex family struggle over property issues.
In fact, this complicated situation was largely explained by Mrs. A’s
early dementia, which had been unrecognized. Resolution of the de-
mentia led to conservatorship, with a commitment that she be cared for
400 ❘ Textbook of Violence Assessment and Management
Case Example 7
An 86-year-old widow was seen for psychosis and agitation associated
with the episodic delusion that the house where she lived was “not my
home.” This delusion appeared reliably every afternoon at 4 P.M., at
which time this sweet, docile woman who enjoyed many activities be-
came angry, anxious, and distressed and would strike out at her care-
giver or anyone else who tried to reassure or correct her misperception.
In fact she had run away from home twice, and consideration was being
given to placing her in a care facility.
Evaluation revealed an articulate and opinionated woman with
moderately severe dementia (MMSE score 14/30) fully consistent with
Alzheimer’s disease, as confirmed by positron emission tomography
scan. The initial intervention was family education, informing them that
the patient was unable to understand what was happening and did not
intend her actions and that this was fully typical for midstage Alz-
heimer’s disease, including the afternoon emergence. As a result, they
arranged for a home health aide (who fortunately established good rap-
port with the patient). Cholinesterase inhibitor therapy was started
(donepezil, titrated to 10 mg daily), together with memantine.
On this program, the patient’s cognition improved modestly
(MMSE rose to 17/30), and, although the afternoon psychosis contin-
ued, she was less adamant and responded better to attempts to demon-
strate that the house really was her home. However, after several
months, cognition again declined, and the distress and agitation and at-
tempts to elope continued. She even threatened one evening to hit her
The Elderly ❘ 403
caregiver, whom at other times she had come to call her “new daugh-
ter.” At this point it was decided to add low-dose atypical antipsychotic
medication, specifically quetiapine. Dosing was started at 25 mg daily
at 2 P.M. and 6 P.M. She was seen 1 month later, and review of daily logs
indicated there were no physical changes and that although the inten-
sity of symptoms was less, distress still emerged in late afternoon. Dos-
age was slowly increased in 25-mg increments. At 100 mg twice daily,
there were no reported incidents and the patient remained free of par-
kinsonian or metabolic side effects. She continued on this dosage with-
out apparent adverse effects.
Key Points
■ Geriatric patients can be violent for the same reasons as younger
individuals.
■ Violence resulting from dementia and delirium with resultant
confusion is more common in the elderly.
■ Treatment of the underlying condition may be essential to control
of violence.
■ Frailness in many elderly persons may require special caution and
considerations.
■ Nonetheless, violence in the elderly can be serious and requires
active intervention.
References
Almvik R, Rasmussen K, Woods P: Challenging behavior in the elderly moni-
toring violent incidents. Int J Geriatr Psychiatry 21:368–374, 2006
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http://www.amda.com/managementtools/index.cfm.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiat-
ric Association, 2000
Aradt S, Turvey CL, Flaum M: Older offenders, substance abuse, and treatment.
Am J Geriatr Psychiatry 10:733–739, 2002
Aupperle PM, Koumaras B, Chen M, et al: Long-term effects of rivastigmine
treatment on neuropsychiatric and behavioral disturbances in nursing
home residents with moderate to severe Alzheimer’s disease: results of a
52-week open-label study. Curr Med Res Opin 20:1605–1612, 2004
Avalon L, Gum AM, Feliciano L, et al: Effectiveness of nonpharmacological in-
terventions for the management of neuropsychiatric symptoms in patients
with dementia. Arch Intern Med 166:2182–2188, 2006
Bogousslavsky J, Cummings JL: Behavior and Mood Disorders in Focal Brain
Lesions. New York, Cambridge University Press, 2000
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Royall DR, Mahurin RK, Gray KF: Bedside assessment of executive cognitive
impairment: the executive interview. J Am Geriatr Soc 40:1221–1226, 1992
Schneider LS, Dagerman KS, Insel P: Risk of death with atypical antipsychotic
drug treatment for dementia: meta-analysis of randomized placebo-
controlled trials. JAMA 294:1934–1943, 2005
Schneider LS, Tariot PN, Dagerman KS, et al: Effectiveness of atypical antipsy-
chotic drugs in patients with Alzheimer’s disease. N Engl J Med 355:1525–
1538, 2006
Silver IL, Herrmann N: Comprehensive psychiatric evaluation, in Comprehen-
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vik LF, Grossberg GT, et al. New York, WW Norton, 2004, pp 253–279
Sink KM, Holden KF, Yaffe K: Pharmacological treatment of neuropsychiatric
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Szwabo PA, Grossberg GT: Problem Behaviors in Long-Term Care: Recognition,
Diagnosis, and Treatment. New York, Springer, 1993
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P A R T V I
Special Topics
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C H A P T E R 2 0
Forensic Issues
Charles L. Scott, M.D.
409
410 ❘ Textbook of Violence Assessment and Management
Case Example 1
Jill is a 47-year-old woman who has recently separated from her hus-
band Jack after a volatile 10-year marriage. Jack has been arrested in the
past for driving under the influence and has physically assaulted Jill
during the course of their marriage. After Jill files for divorce, she dis-
covers notes on her car from Jack that say she will “always be his,” and
he leaves numerous threatening phone calls that include both pleas to
reunite and veiled threats to kill her. Jill becomes afraid and seeks out
mental health counseling for advice.
Stalking
Stalking is a serious problem in the United States. All 50 states, the fed-
eral government, and the District of Columbia classify stalking as a
crime. Although precise statutory definitions vary, most stalking stat-
utes incorporate the following elements:
❘
Intimate Previous relationship: Most dangerous group, with history of violence Intense probation/parole
marriage, cohabiting, Quickly escalates supervision
dating/sexual Abuses alcohol and stimulants Intervene to decrease risk of
> 50% physically assault victim domestic violence before and
One-third use or threaten use of weapon after separation
Rapists
Although the specific definition of rape varies according to jurisdiction,
common legal elements of rape include the penetration of a human or-
ifice by another person’s body part or object. According to the National
Crime Victimization Survey, there were more than 190,000 victims of
rape or sexual assault in the United States during 1995 (Catalano 2006).
The majority of rapes and sexual assaults are committed by men against
women.
Groth and Birnbaum (1979) classified rapists into four main types.
Two of the categories emphasize the use of sexual aggression to satisfy
the rapist’s need for power and the other two categories highlight the
use of sexual aggression to express anger. Characteristics of each rapist
subtype in this typology are outlined in Table 20–4.
A more recent typology developed by Knight and Prentky (1990),
classifying rapists according to their primary motivation, includes the
following four types:
416 ❘ Textbook of Violence Assessment and Management
Case Example 2
Joe is a 48-year-old man with a long-standing history of impulsive, an-
gry outbursts. He is extremely narcissistic and becomes aggressive
whenever criticized. Because of Joe’s personality, he has been unable to
sustain any long-term relationships and is socially isolated. He spends
a great deal of his time reading weapons magazines and fantasizes
about dying while shooting others in a “blaze of glory.” Because of his
temper problems, he was terminated from work. He blamed his super-
visor for all of his problems and decided to go to his workplace and
“take out anyone and everyone.”
Suicide By Cop
The phrase suicide by cop refers to behaviors by an individual intended
to provoke a law enforcement officer to use lethal force that will result
in the person’s death. In a study of more than 430 exchanges of fire be-
tween police and a suspect over a 10-year period in Los Angeles
County, California, researchers classified 10.5% of the cases as suicide-
by-cop situations (Hutson et al. 1998). In their review of 15 deaths of sui-
cidal persons who provoked law enforcement officers into killing them,
researchers (Wilson et al. 1998) described 10 characteristics of these in-
dividuals, which are summarized in Table 20–6.
In their review of the literature, Mohandie and Meloy (2000) out-
lined both verbal and behavioral clues indicating risk for suicide-by-
cop that may be helpful when conducting a psychological autopsy.
Twelve verbal clues associated with a suicide-by-cop situation included
suspects demanding authorities kill them, setting a deadline for author-
ities to kill them, threatening to kill or harm others, wanting to “go out
in a blaze of glory,” giving a verbal will, telling hostages or others they
want to die, looking for a “macho” way out, offering to surrender to
person in charge, indicating elaborate plans of their own death, express-
ing feelings of hopelessness/helplessness, emphasizing that jail is not
an option, and making biblical references, particularly to resurrection
and to the Book of Revelations.
Behavioral clues to suicide-by-cop risk include being demonstrative
with a weapon, pointing a weapon at police, clearing a threshold in a
Forensic Issues ❘ 421
Murder-Suicide
Murder-suicide occurs when an individual commits suicide after taking
the life of another person. In the National Violent Death Reporting Sys-
tem (Bossarte et al. 2006), only suicides that occur within 24 hours after
a murder qualify the deaths as murder-suicide, whereas other authors
extend this period to up to one week (Marzuk et al. 1992). Various labels
have been used to describe the phenomenon of a murderer who subse-
quently takes his or her own life, including “homicide-suicide,” “dyadic
death,” “doubly violent aggression,” and “despondent killers.”
Because there is no national surveillance system for murder-suicide
in the United States, the exact prevalence is difficult to determine. In the
majority of studies, murder-suicide rates have been reported to range
from 0.2 to 0.3 per 100,000 persons (Coid 1983; Marzuk et al. 1992;
422 ❘ Textbook of Violence Assessment and Management
Milroy 1995), although rates as high as 0.4 to 0.5 per 100,000 persons
have also been noted (Hannah et al. 1998; Hanzlick and Koponen 1994).
Hanzlick and Koponen (1994) identified common precipitants for mur-
der-suicide, as outlined in Table 20–7.
In addition to the motivators just noted, Bossarte et al. (2006), in
their study of 65 murder-suicide incidents, found that a legal problem
was the most common associated circumstance, experienced by one of
every four perpetrators.
Marzuk et al. (1992) proposed a murder-suicide typology based on
the relationship between the perpetrator and the victim. The proposed
categories of murder-suicide are 1) spousal/consortial, 2) familial, and
3) extrafamilial.
Spousal/Consortial Murder-Suicides
Numerous studies indicate that the majority of murder-suicides involve
male perpetrators who kill spouses or intimates (Aderibigbe 1997; Felt-
hous and Hempel 1995; Malphurs and Cohen 2002; Marzuk et al. 1992;
Milroy et al. 1997; Palermo et al. 1997) with a handgun (Malphurs and Co-
hen 2002). Nearly one-third of men who kill their spouse or partner will
commit suicide, a statistical phenomenon not matched by females who kill
intimate partners (Bossarte et al. 2006). Common psychiatric diagnoses in
perpetrators of couple murder-suicides include depression (Rosenbaum
1990) and alcohol intoxication or abuse (Comstock et al. 2005).
• What do you believe will happen to your child if you die or commit
suicide?
• Do you have any fears or concerns that your child may be harmed
by others?
• Do you have any worries regarding your child’s health or unneces-
sary suffering?
• Are you having any thoughts about harming your child?
• Have you taken any steps to harm your child?
• If you have had thoughts of harming your child, what has kept you
from doing so thus far?
Extrafamilial Murder-Suicides
Suicides after the murder of a person who is not a family member or in-
timate partner are relatively rare. Murder-suicides outside the family
have occurred in the workplace, school settings, and public environ-
ments such as shopping malls or tourist locations. The perpetrators also
have been referred to as “mass killers” or “rampage killers.” Mullen
(2004) proposed a classification scheme for separating types of mass
killers that is defined by the relationship between the killers’ intentions
and their victims. This typology is described in Table 20–8.
The perpetrator of an autogenic (i.e., self-initiated) mass murder
typically involves a heavily armed male who randomly shoots individ-
uals before turning the gun on himself. The murderer may target for his
Forensic Issues ❘ 425
1. Male
2. Younger than 40 years of age
3. Socially isolated without close relationships
4. Unemployed or minimally employed
5. Bullied and/or isolated as a child
6. Fascinated with weapons
7. Collector of weapons
Key Points
Forensic evaluations of dangerousness are performed in a wide variety
of situations that may involve a known, unknown, or even deceased
offender. Regardless of the circumstance, forensic examiners should:
■ Conduct a detailed psychiatric examination to search for the pres-
ence of mental illness, substance use disorder, and/or personality
disorder
■ Carefully review collateral records
■ Interview individuals familiar with the offender
■ Understand unique characteristics of both the offender and the
potential victims when organizing a violence-prevention plan
■ Be familiar with key typologies to understand underlying motiva-
tions and risk factors
References
Aderibigbe YA: Violence in America: a survey of suicide linked to homicide.
J Forensic Sci 42:662–665, 1997
American Academy of Psychiatry and the Law: Ethical guidelines for the prac-
tice of forensic psychiatry, adopted May 2005. Available at http://aapl.org/
pdf/ETHICSGDLNS.pdf. Accessed March 20, 2007
Biffl E: Psychological autopsies: do they belong in the courtroom? Am J Crim
Law 1:123–146, 1996
Bossarte RM, Simon TR, Barker L: Homicide-suicide: characteristics of homi-
cide followed by suicide incidents in multiple states, 2003–04. Inj Prev
12(suppl):33–38, 2006
Byard RW, Knight D, James RA, et al: Murder-suicides involving children: a 29-
year study. Am J Forensic Med Pathol 20:323–327, 1999
Canter DV, Alison LJ, Alison E, et al: The organized/disorganized typology of
serial murder: myth or model? Psychol Public Policy Law 10:293–320, 2004
Catalano SM: National Crime Victimization Survey: Criminal Victimization
2005 (BJS Bulletin, NCJ 214644). Washington, DC, Office of Justice Statistics,
U.S. Department of Justice, 2006
Cohen D, Llorente M, Eisdorfer C: Homicide-suicide in older persons. Am J
Psychiatry 155:390–396, 1998
Coid J: The epidemiology of abnormal homicide and murder followed by sui-
cide. Psychol Med 13:855–860, 1983
Comstock RD, Mallonee S, Kruger E, et al: Epidemiology of homicide-suicide
events, Oklahoma, 1994–2001. Am J Forensic Med Pathol 26:229–235, 2005
De Becker G: The Gift of Fear: Survival Signals That Protect us from Violence.
London, Bloomsbury, 1997, pp 200–214
Dietz PE: Mass, serial, and sensational homicides. Bull NY Acad Med 62:477–
491, 1986
Forensic Issues ❘ 427
L ike the gift from the gods in numerous Greek myths (e.g., Midas, Pan-
dora, Icarus), psychiatry and psychology’s acquisition of the capacity to
assess the risk of violence comes with burdens that may overshadow
the gift. One burden of acumen in assessing risk of violence, with con-
sequences as tragic as any visited by the mythological Greek gods, is
that when violence occurs, psychiatrists and psychologists are often
transformed, with the aid of the legal process, from heroes to villains for
not having used their gift to prevent the violence from happening. An-
other burden is that when violence is legally relevant, the law expects
to receive accurate prophecies from psychiatrists and psychologists,
even at the expense of confidentiality and cautious science. Accord-
ingly, a comprehensive treatment of violence necessitates a hard look at
legal rules that bear on the assessment of violence. This chapter intro-
duces those contexts and the issues they raise.
The first section of this chapter addresses an all too common legal
dilemma for psychiatrists and psychologists: the impact of acumen in
violence assessment and management on the rules governing thera-
pist–patient confidentiality. Most states either recognize a statutory
duty of confidentiality for psychotherapists or incorporate a profes-
sional ethics code containing a duty of confidentiality into state licens-
ing law. If psychiatrists or psychologists have unique insights about a
429
430 ❘ Textbook of Violence Assessment and Management
The Supreme Court rejected the prisoner’s argument that the U.S. Con-
stitution prohibits imposition of the death penalty based on clinical pre-
dictions regarded as unreliable by the American Psychiatric Association,
among others, which filed an amicus brief in the case. Acknowledging
problems with the accuracy of clinically based predictions, the Court re-
fused to permit a private organization to frustrate imposition of the
death penalty it had approved.
Barefoot v. Estelle (1983) presented a question of constitutional mini-
mums—does a death sentence that rests on a clinical prediction violate
due process, thus requiring a fundamental change in the criteria for the
imposition of capital punishment? Because it was a state court trial and
conviction, it did not specify what the Federal Rules of Evidence might
demand of an expert in these circumstances above the constitutional
minimums. That part of the puzzle was revealed a decade later, when
the Supreme Court decided Daubert v. Merrell Dow Pharmaceuticals, Inc.
(1993). Daubert was a toxic tort case, filed in California state court and
removed to federal court on diversity of citizenship grounds. The plain-
tiff alleged that Bendectin, an anti-nausea drug manufactured by Mer-
rell Dow Pharmaceuticals, caused limb reduction birth defects. The de-
fendant’s Motion for Summary Judgment asserted that epidemiology
was the generally accepted standard for evaluating a drug’s toxicity
and that no published epidemiological study found a significant rela-
tionship between Bendectin and limb reduction birth defects. When the
plaintiff’s experts, all well-qualified research scientists with impressive
credentials, offered another approach to analyzing the data, the court
rejected their expert testimony, relying on Frye, which it assumed to be
the standard applied under the Federal Rules of Evidence, and granted
the defendant’s motion for summary judgment.
The case made its way to the Ninth Circuit and eventually to the Su-
preme Court. The Court granted review to resolve the test for expert ev-
idence under the Federal Rules of Evidence, unresolved since the rules
were enacted in 1975. Examining the text of the rules, the court con-
cluded that because nowhere in the rules was Frye mentioned, it could
not have been intended to be the test for scientific evidence under the
Federal Rules of Evidence. Instead, relying on falsifiability as the hall-
mark of science, the court adopted a pragmatic approach to relevance
and reliability, taking into account whether the underlying methods
and procedures were testable and had been tested; whether they had
been subjected to peer review and publication, and if so what was the
error rate and could it be controlled; and finally a rebirth of Frye’s gen-
eral acceptance test. Two other related decisions followed (General Elec-
tric v. Joiner [1997] and Kumho Tire Co. v. Carmichael [1999]) that made
Legal Issues of Prediction, Protection, and Expertise ❘ 437
Key Points
■ Psychiatrists are expected by their patients and their profession
to make accurate violence assessments in their clinical practice.
■ Psychiatrists are expected by their patients and their profession
to know what is required of them to meet their obligations to
patients, those whom the patient may endanger, and society.
■ Psychiatrists will be held accountable by their patients, those
whom the patients harm, and society for harm that results from
the failure to engage in state-of-the-art, evidence-based assess-
ments of violence.
References
Barefoot v. Estelle, 403 U.S. 880 (1983)
Boynton v. Burglass, 590 So. 2d 446 (Fla. App 1991)
Cal. Civ. Code § 43.92(b) (West 2006)
Cal. Civ. Code § 43.92(b) (West 2007)
Daubert v. Merrell Dow Pharmaceuticals, Inc., 509 U.S. 579 (1993)
16 Del. C. § 5402 (2007)
Evans v. United States, 883 F.Supp. 124 (S.D. Miss. 1995)
Fla. Stat. § 491.0147 (2006)
Frye v. United States, 293 F. 1013 (D.C. Cir. 1923)
General Electric v. Joiner, 522 U.S. 136 (1997)
Green v. Ross, 691 So. 2d 542 (Fla. App. 1997)
405 Ill. Comp. Stat. 5/3–807 (2007)
In re commitment of R.S., 801 A.2d 219 (N.J. 2004)
In re detention of Thorell, 72 P.3d 708 (Wash. 2000), cert. denied 541 U.S. 990 (2004)
Johnson v. Cockrell, 306 F.3d 249 (5th Cir. 2002)
Kumho Tire Co. v. Carmichael, 526 U.S. 137 (1999)
Miss. Code Ann. § 41–21–97 (2006)
Nenno v. State, 970 S.W.2d 549 (Tex. Crim. App. 1998)
N.J. Stat. § 2A:62A–16 (2007)
O’Connor v. Donaldson, 422 U.S. 563 (1975)
Rev. Code Wash. (ARCW) § 71.05.120 (2007)
R.I. Gen. Laws § 40.1–5–2(7)(4) (2007)
State for Interest of P.W., 801 S.W.2d 1 (Tex. App. 1990)
Tarasoff v. Regents of the University of California, 17 Cal. 3d 425, 131 Cal. Rptr. 14,
551 P.2d 334 (1976)
Tex. Code Crim. Proc. Art. 17.15(5) (2006)
Tex. Code Crim. Proc. Art. 7.071(2)(b)(1) (2006)
Texas Health and Safety Code § 611.004(a)(2) (2006)
Thapar v. Zezulka, 494 S.W. 2d 635 (Tex. 1999)
C H A P T E R 2 2
441
442 ❘ Textbook of Violence Assessment and Management
how they have been applied. At least one study of experienced forensic
psychiatrists found that sexual sadism as a diagnosis was not being ap-
plied in Canadian correctional facilities as defined in DSM-IV-TR. The
kappa coefficient for reliability across diagnoses was only 0.14, which is
extremely poor (Marshall et al. 2002). Without reviewing all the details
of this particular study, it is clear that confusion about this very signifi-
cant diagnosis is evident. Confusion about the clinical aspects of sexual
violence occurs even among experienced forensic psychiatrists, in part
due to difficulties related to the “coercive paraphilic disorders.” There
was a recommendation by the Subcommittee on Sexual Disorders to in-
clude this group of paraphilias in the DSM-III-R diagnostic schema
(Abel 1989; American Psychiatric Association 1987). Although there was
strong empirical evidence for a diagnostic grouping of the “coercive
paraphilic disorders,” there was also considerable concern that the in-
clusion could lead to forensic psychiatric misuse of such a diagnostic
classification (Abel 1989). This debate has left a gap in the diagnostic
classification for males who meet the criteria for the paraphilias as well
as established clinical criteria for the paraphilias (e.g., typical natural
history of the paraphilias) and who are offenders against adult females.
Some of these men commit rape and show a sexual preference for rape
over consensual sex with adult females. The lack of an official diagnosis
has led to some of these men being diagnosed as having sexual sadism
and others as having paraphilia not otherwise specified. Neither of these
diagnostic classifications accommodates this type of paraphilic male
very well, leading to diagnostic confusion as well as forensic misuse in
sexually violent predator cases in the United States.
Clinical studies of sexually sadistic homicide perpetrators are rare,
mostly because this is a small group of individuals infrequently seen
even in forensic psychiatric settings (Swigert et al. 1976). Two studies
have looked at the offender and offense characteristics, including crime
scene behavior and other factors related to sexually sadistic homicide
(Dietz et al. 1990; Gratzer and Bradford 1995). Both of these studies had
to review a large number of homicide perpetrators and sexual offenders
before finding a relatively small number of males that met the diagnos-
tic criteria. Dietz et al. (1990) completed an uncontrolled descriptive
study of 30 sexually sadistic homicide or attempted homicide perpetra-
tors. Intentional torture for sexual arousal was the common characteris-
tic of this group of males. It was also clear that careful planning, includ-
ing stranger victim selection, most commonly occurred. Bondage,
beating, and homicide by strangulation were common offense charac-
teristics. Gratzer and Bradford (1995) compared the Dietz et al. sample
with another sample of sexually sadistic homicide and attempted homi-
Sexual Violence and the Clinician ❘ 447
and control (Groth et al. 1977). Crime scene examinations usually show
evidence of a sexual motivation. Myers and colleagues (2006) believe
that serial sexual murderers should be considered sexual offenders.
They also suggest the modification of DSM criteria to accommodate
this. They believe that these individuals mostly have paraphilic disor-
ders in the sadistic spectrum and that a diagnostic classification of “sex-
ual sadism, homicidal type” should be included as a subtype of sexual
sadism (Myers 2002; Myers et al. 2006).
If sexually sadistic homicide perpetrators do have a sexual motiva-
tion, then it should be measurable by physiological methods. Sexual
arousal can be measured by penile tumescence techniques known as
phallometry. There is evidence both for and against the capability of
this technique to discriminate between nonoffender and offender
populations or between different types of offenders (Marshall and
Fernandez 2000). Nonetheless, it is useful in differentiating groups of
men convicted of child molesting offenses, particularly extrafamilial
child sexual abuse, and in a meta-analysis on sexual offender recidi-
vism, phallometry was found to be one of the most reliable predictors
of recidivism for child molesters (Hanson and Bussiere 1998). There are
several ways to measure sexual arousal, although the one favored by
the lead author of this chapter (J.M.W.B.) is the use of indices reflecting
relative sexual arousal or sexual preference. A calculation is made
based on responses to audiotape descriptions of sex with children
where the arousal to children (the numerator) is divided by the arousal
to mutually consenting sex with adults (the denominator) and an index
is calculated by the ratio. This means an index greater than 1 means a
sexual preference in the direction of pedophilia. Indices can also be
used for sexual preference in a sadistic direction. In a study of 27 child
molesters who had committed or who had attempted a sexually moti-
vated homicide, 189 nonhomicidal child molesters, and 47 community
control subjects, there were clear differences between the three groups
based on phallometric measures (Firestone et al. 2000a). Significantly
more homicidal and nonhomicidal child molesters had pedophile indi-
ces greater than 1 compared with nonoffenders. The homicidal and
nonhomicidal child molesters did not differ from each other on pedo-
phile indices. This is not surprising, because both groups were pedo-
philes. However, when it came to assault indices, which measured
arousal to nonsexual violence (a measurement of sadistic sexual prefer-
ence), significantly more homicidal child molesters had assault indices
of 1 or greater or a sexual preference for nonsexual violence, compared
with the other two groups. The nonoffenders and nonhomicidal child
molesters did not differ from each other on this measure (Firestone et
450 ❘ Textbook of Violence Assessment and Management
Recidivism
Understanding recidivism is fundamental to understanding sexual vio-
lence. There is a large body of scientific literature on sexual offender re-
cidivism that covers different types of sexual offenders, and there is con-
siderable consistency in the research findings even in studies from
different countries. Recidivism studies provide information to predict
subsequent risk of reoffense as well as information about treatment out-
come. There are well-established and significant differences in the recid-
ivism rates of different types of sexual offenders. The results of a task
force report from the American Psychiatric Association (1999) showed
that sexual assaulters of adult females (“rapists”) have the highest recid-
ivism rates, followed by extrafamilial child molesters; intrafamilial child
molesters (“incest” perpetrators) have the lowest rates of recidivism.
There is still evidence that recidivism rates are reflections of sexual of-
fenses that are underreported. In order to compensate for underreport-
ing, most recent studies include conviction rates and rearrest rates.
Arguably the most accurate reflection would be a combination of con-
viction rates, rearrest rates, and self-reported rates of sexual offenses.
Most recent studies involve a survival analysis technique. In general
terms, the longer the follow-up period, the higher the reported rates of
recidivism. In general, a follow-up period of at least 5 years while of-
fenders are at risk in the community is necessary for a valid study.
A number of meta-analyses have been completed on sexual offender
recidivism studies, the most significant being a study by Furby et al.
(1989), followed by two by Hanson (Hanson and Broom 2005; Hanson
and Thornton 1999) and a treatment outcome study meta-analysis by
Alexander (1999; Furby et al. 1989; Hanson and Broom 2005; Hanson
Sexual Violence and the Clinician ❘ 451
and Bussiere 1998). The Furby et al. (1989) study was generally re-
garded as a pessimistic one that was highly critical of the methodology
in existing recidivism studies, but at the same time it played an impor-
tant role in ensuring that future recidivism studies had improved meth-
odology. The Hanson and Bussiere (1998) meta-analysis comprised
more than 28,000 sexual offenders with a median follow-up period of
approximately 4 years and included 87 studies from six different coun-
tries. The meta-analysis documented the specific factors associated
with a high risk of sexual offense recidivism. The strongest predictors
of sexual offender recidivism were related to sexual deviance. Phallo-
metric measures of pedophilic sexual preference were highly correlated
with the risk of future sexual offense recidivism (r=0.32). Prior sexual
offenses (r= 0.19); age (r= 0.13); early onset of sexual offending (r= 0.12);
any prior offenses (r= 0.13); and never having been married (r= 0.11)
were also strongly correlated with sexual offender recidivism. The over-
all recidivism rate for sexual offenses was 13.4% (Hanson and Bussiere
1998). Alexander (1999) reviewed 79 treatment outcome studies includ-
ing more than 11,000 subjects. She showed that all the psychological
treatments included in the study resulted in lower recidivism rates
compared with an untreated group for both adults and adolescents. She
also showed that mandatory treatment appeared to have a positive ef-
fect on treatment outcome compared with voluntary treatment of sex-
ual offenders. Hanson and Broom (2005), in a follow-up meta-analysis,
used different analytical techniques to examine the trends in recidivism.
Sexual offender recidivism studies have been a focus of our own re-
search. We have completed recidivism studies of rapists, extrafamilial
child molesters, incest perpetrators, and exhibitionists (Firestone et al.
1998, 1999, 2000c; Greenberg et al. 2002). The mean follow-up period for
the studies was approximately 7 years, and all exceeded 5 years. The
studies included phallometric data and Hare Psychopathy Checklist
(PCL) scores as well as many other variables and used rearrest rates and
conviction rates as a measure of recidivism taken from the Canadian Po-
lice Information Computer, a national database of arrest and conviction
rates. Phallometric measures of deviant sexual preference and scores
were important predictors of sexual offense recidivism, and the PCL
scores were also strong predictors of violent and general recidivism. We
have completed other recidivism studies as well that looked more
closely at other factors related to recidivism, such as hostility (Firestone
et al. 2000b, 2005b, 2006; Greenberg et al. 2000). Incest perpetrators have
generally been regarded as a homogeneous group having the lowest risk
of recidivism for child molesters. Some differences in recidivism risk
based on victim age had been reported, and this was felt to be an impor-
452 ❘ Textbook of Violence Assessment and Management
tant factor for future risk assessment. A study of 119 incest perpetrators
consisted of a group of men (n = 48) who had victims younger than 6
years of age compared with another group of men (n=71) whose victims
were adolescents and more typical of incest perpetrators. Both groups
showed deviant sexual preference; however, the group with the young
victims had significantly more psychopathology, including substance
abuse (Firestone et al. 2005a). There are also important differences in the
recidivism risk for incest perpetrators whose victims are their biological
daughters compared with those whose victims are stepdaughters
(Greenberg et al. 2005). Deviant sexual preference was significantly
lower in men who molest their biological daughters, and this crime
therefore carries a lower risk of future sexual offense recidivism.
Sexual offense recidivism risk can be easily estimated by using the
Static-99, developed by the Research Division of the Solicitor General of
Canada (Hanson and Bussiere 1998). The ability to identify high-risk
sexual offenders provides the criminal justice system with a mechanism
to prevent further harm to the general public as well as a basis for sen-
tencing of these individuals or dealing with them through civil commit-
ment. These statistical instruments are considerable improvements
over the use of unstructured clinical judgment (Hanson and Bussiere
1998). The Static-99 is scored using easily obtained information with
limited training and yet provides significant accuracy in the prediction
of sexual offense recidivism (Hanson and Thornton 2000; Nunes et al.
2002). It also classifies sexual offender risk levels based on scoring of the
instrument as low, medium-low, medium-high, and high for sexual of-
fense recidivism based on the potential risk. It also gives the percentage
risk of future violent recidivism. This useful instrument can be utilized
by the forensic or general psychiatrist not trained in specialized forensic
sexology, thus providing a valid measure of future risk for sexual vio-
lence or violence in general that is considerably more accurate than un-
structured clinical evaluation.
Treatment
In recent years the focus of psychological treatments has been on the
cognitive-behavioral treatment spectrum. These treatments help the
person with a paraphilia block or reduce thoughts of or fantasies about
deviant behaviors such as child molesting. The treatments can be given
on an individual basis, but in most specialized treatment programs it is
performed in a group treatment setting. This not only improves the
cost-effectiveness of treatment but also has a therapeutic advantage be-
cause other individuals in the group with a similar paraphilia both
Sexual Violence and the Clinician ❘ 453
Key Points
■ Sexual violence involves any sexual act with a nonconsenting
partner and also includes physical violence associated with a
paraphilia or sexual deviation.
■ Various studies have shown that between 10% and 16% of males
and between 20% and 27% of females have been victims of
childhood sexual abuse.
■ In recent years the Internet has become a vehicle for sexual
offenses, usually child pornography. Studies have defined
different types of Internet offenders.
■ Clinical studies of sexually sadistic homicide perpetrators are rare,
mostly because this condition only rarely occurs. Clinical features
have been defined and an association has been found between
sexual sadism and brain abnormalities.
■ Sexual arousal has been shown to be one of the most reliable
predictors of sexual offense recidivism. It has also been shown
to discriminate between sexual offenders and nonoffenders,
particularly in relation to pedophilia, and to discriminate
between pedophilic homicidal perpetrators and nonhomicidal
perpetrators.
456 ❘ Textbook of Violence Assessment and Management
References
Abel GG: Paraphilias, in Comprehensive Textbook of Psychiatry, 5th Edition.
Edited by Kaplan HI, Sadock BJ. Baltimore, MD, Williams & Wilkins, 1989,
pp 1069–1085
Abel GG, Mittelman M, Becker JV, et al: Predicting child molesters’ response to
treatment. Ann N Y Acad Sci 528:223–234, 1988
Alexander MA: Sexual offender treatment efficacy revisited. Sex Abuse 11:101–
116, 1999
Alexy EM, Burgess AW, Baker T: Internet offenders: traders, travelers, and com-
bination trader-travelers. J Interpers Violence 20:804–812, 2005
American Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders, 3rd Edition, Revised. Washington, DC, American Psychiatric
Association, 1987
American Psychiatric Association: Dangerous Sex Offenders: A Task Force Re-
port of the American Psychiatric Association. Washington, DC, American
Psychiatric Association, 1999
American Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiat-
ric Association, 2000
Bradford JM: Treatment of men with paraphilia. N Engl J Med 338:464–465, 1998
Bradford JM: The treatment of sexual deviation using a pharmacological ap-
proach. J Sex Res 37:248–257, 2000
Bradford JM: The neurobiology, neuropharmacology, and pharmacological
treatment of the paraphilias and compulsive sexual behaviour. Can J Psy-
chiatry 46:26–34, 2001
Bradford JM: On sexual violence. Curr Opin Psychiatry 19:527–532, 2006
Sexual Violence and the Clinician ❘ 457
461
462 ❘ Textbook of Violence Assessment and Management
Case Examples
Case Example 1:
Violence in the Psychiatric Emergency Service
Mr. A, a 30-year-old man, was brought to the psychiatric emergency ser-
vice by police at his own request after he told them he was depressed
and suicidal and wanted to go to the hospital. He was using $200 worth
of cocaine per day and reported symptoms of major depression. He
stated, “I am hopeless and feel like I might hurt myself or others.” Mr.
A had presented a month earlier with a similar complaint and had been
referred to outpatient treatment. The managed care company reported
the patient had a long history of drug and psychiatric treatment related
to his drug use. He had never followed up with outpatient treatment,
even with a case manager.
In the psychiatric emergency service the patient was labile and eas-
ily agitated and could only with effort be redirected. He was tempo-
rarily placed in an open seclusion room in view of the nurses’ station
Violence Toward Mental Health Professionals ❘ 463
This patient had a known history of drug use, was labile, easily agi-
tated, and was seen pacing in the seclusion room. The resident chose to
confront the patient and, in essence, called the patient a liar, violating
the dynamic of violence by humiliating this already labile patient.
Rather than focusing on affect management, the resident chose to give
a rational explanation to the patient about the documented history of
drug treatment and his history of noncompliance. The resident instead
should have addressed the affect, considered medication, and, most im-
portantly, had additional staff present with him during the interview.
Case Example 2:
Failure of a Risk Assessment in an Outpatient Office
Mr. B, in his early 30s, held his psychiatrist hostage for 90 minutes,
threatening to beat him up and to destroy the property in the psychia-
trist’s private home office. When the patient had initially called for an
appointment, the psychiatrist learned that Mr. B had a history of violent
episodes and paranoid responses to psychiatrists. Mr. B stated on the
phone that he was an impossible case but that his initial response to this
psychiatrist was positive. During the first four treatment sessions, Mr. B
had continually pressed the psychiatrist to demonstrate an interest in
him. After the fourth session he had called the psychiatrist at 11 P.M. and
asked to meet with him to discuss a crisis. The psychiatrist responded
that he could not meet him and that he would see him at the next sched-
uled time. At the next appointment Mr. B walked into the office, locked
the door, and began his threatening behavior. Mr. B screamed and ver-
bally abused the psychiatrist for 90 minutes, pushing him around and
knocking diplomas off the wall. Although angry and fearful, the psychi-
atrist talked to the patient in a calming manner. The psychiatrist did not
challenge Mr. B but calmly pointed out possible repercussions. The pa-
tient finally left the office and never returned or contacted the psychia-
trist. The psychiatrist acknowledged his own sense of grandiosity and
vanity had been enhanced when the patient made positive comments
about him on the phone and that this further strengthened his denial of
the risk of aggression that this patient posed.
464 ❘ Textbook of Violence Assessment and Management
This patient had a risk profile that suggested he was at risk for vio-
lence—that is, a history of violence and conflicts with previous psychia-
trists. The psychological defense of denial resulted in the psychiatrist’s
minimizing the risk and treating the patient in his home office. The psy-
chiatrist should have either treated this patient in a more secure setting or
declined to take this patient into treatment at the initial phone interview.
Because of the patient’s size and possibly her gender, this psychia-
trist used denial and minimized the risk by failing to set limits with the
patient after the first aggressive incident. After that first episode the
psychiatrist also should have reevaluated the safety of treating this pa-
tient in his home office. Grabbing the patient’s wrist to take away the
knife was a questionable strategy and risked possible injury to the psy-
chiatrist or the patient. It would have been preferable to continue the
talk-down strategy.
Dynamics of Violence
The successful management of violence is predicated on an understand-
ing of its dynamics. Violence is a reaction to feelings of passivity and
helplessness. A patient’s threatening behavior is commonly an overre-
action to feelings of impotence, helplessness, and perceived or actual
feelings of humiliation. A clinician who encounters a threatening pa-
tient should avoid becoming verbally or physically aggressive toward
the patient. Psychiatrists who respond to threatening patients with
physical or verbal aggression are significantly more likely to be injured
or have property destroyed than those who acknowledge their fear but
also express a desire to help the patient (Dubin et al. 1988). The strategy
of a nonthreatening offer to provide help is reassuring to the patient and
is the centerpiece for intervention with a potentially violent patient.
Affect Management
The main strategy for de-escalating a potentially violent patient is affect
management. Patients who are affectively aroused will need to ventilate
their history, and the clinician should not overly intrude into the in-
terview (Eichelman 1995). Often the patient who is overwhelmed with
468 ❘ Textbook of Violence Assessment and Management
angry affect intimidates the clinician, who then responds with logical and
rational explanations. This type of intervention only inflames the patient.
Affect management involves acknowledging the patient’s affect, validat-
ing the affect when appropriate, and encouraging the patient to talk about
his or her feelings. For instance, the clinician might say, “I can see how an-
gry this makes you. If I were given medication against my will I would be
as angry as you are. Let’s talk more about your feelings.” Phrases such as
“ventilate,” “talking it out,” “getting it off your chest,” or “catharsis” are
colloquialisms that refer to the process of allowing a person to discharge
his or her affect. Addressing the affect serves several purposes. It teaches
the patient to reduce his or her internal state of tension by verbalizing feel-
ings and teaches that it is not necessary to hit someone or destroy furni-
ture to feel better. Giving the patient the opportunity to ventilate affect of-
ten defuses an escalating patient and averts a more violent confrontation.
arm crosses the chest, the opposite elbow rests on it with the index fin-
ger touching the cheek or chin).
Limit Setting
At times clinicians react to escalating or agitated behavior with punitive
threats, in an attempt to set limits. A threatening intervention, however,
is contrary to the dynamics of violence because it evokes feeling of im-
potence or humiliation in the patient and increases the risk of violence.
Overt anger or hostility should never be expressed toward an agitated
patient (Petit 2005). Limit setting can be therapeutic and avert violent
behavior. Green et al. (1988) described the basic philosophy behind
limit setting, which is to contain and counteract maladaptive behavior
that interferes with therapy and threatens the safety of the clinician.
Green et al. (1988) further note that effective limit setting involves clear
identification of the specific behaviors that need to be altered and pre-
cise articulation of the consequences that will follow if the inappropri-
ate behavior persists. If the therapist lacks clarity in his or her thinking
or communications to the patient concerning inappropriate behavior,
the intervention may confuse and disorganize the patient. Whenever
possible, interpretive interventions should precede the imposition of
limits, because this affords the patient greater flexibility in exercising
his or her own autonomy and discretion.
Successful limit setting is most effective when this sequence is fol-
lowed (Green et al. 1988):
For example, a clinician can say to a patient, “You cannot yell, curse,
or threaten other patients in the day room. They are afraid of you, and
they think that you will harm them. Therefore, you can go to your room
and listen to the radio until you feel calmer, or we can walk to the se-
clusion room and I will give you some medication.” Given several op-
tions, the patient will usually accept whichever is preferred. If given a
choice, the patient will pause to consider the options, and each pause
decreases the amount of energy behind the anger. As this process con-
tinues, the patient will slowly regain self-control (Maier 1996). Offering
only one option invites the patient to argue and negotiate, which leads
to further escalation and frequently culminates in an assault against the
clinician or restraint of the patient.
470 ❘ Textbook of Violence Assessment and Management
Threat Management
Overview
A neglected area in clinician safety is threat management. Unfortunately,
there is a paucity of research in this area. There are no data detailing the
clinical context in which most threats occur or of the outcome of threats.
Threats can take many forms. They can be verbal, written, by phone, or re-
layed by a third party. Patients can threaten the clinician in an impulsive,
emotional outburst; by a calm, serious statement; in a joking, flippant
manner; or through vague innuendos (Tardiff 1996). Threats can be in the
form of property damage, visits to a therapist’s home, or loitering around
a therapist’s office on days when there is no appointment (Jenkins 1989).
The sending of love letters, pornographic materials, or vacation pictures
can represent threats (Jenkins 1989). Threats can also take the form of
veiled comments that show a patient is involved in the clinician’s personal
life (Maier 1996). Such comments might include knowledge of the clini-
cian’s car or home address or the names of the clinician’s children. These
statements are made as a way of showing interest in the clinician but are
usually out of proportion to the therapeutic relationship (Maier 1996).
Threats to clinicians can occur in a variety of settings, including clin-
ical settings such as the emergency department, inpatient unit, outpa-
tient clinic, or private office. They can occur in custody hearings, dis-
ability evaluations and hearings, forensic evaluations and hearings,
competency hearings, and in nonpsychiatric medical settings, or they
may come from spouses of patients.
Dynamics of a Threat
Threats are a means by which a patient tries to gain control of others
through manipulation (Maier 1996). When patients make manipulative
comments, they are often of such a nature that the clinician is not en-
couraged to share them with his or her peers. For instance, a patient
may ask a female clinician if she is pregnant or has her period. He may
tell a male clinician that he looks hung over or make some comment
about the clinician’s sexual identity. The interplay between positive
comments and personal judgments can provide for effective manipula-
tion, resulting in the clinician’s behavior becoming predictable and thus
usable by the patient against the clinician at some future time. In this
process, the patient establishes a secret relationship with the clinician,
binding the clinician to the patient, governing the clinician’s conduct,
and distorting his or her judgment (Maier 1996). Sharing the secret with
a colleague is the first step in managing this process.
472 ❘ Textbook of Violence Assessment and Management
Types of Threats
Brown et al. (1996) described two types of threat situations: situational
and transferential threats. A situational threat occurs when a psychiatrist
acts as an administrator, usually on an inpatient unit or emergency de-
partment. For example, a psychiatrist frustrated a patient’s wish by de-
nying a request to go out on a pass to get more medication. The patient
threatened the psychiatrist, an emergency code was called, the patient
was restrained or escorted from the hospital, and the threat situation
ended with no psychiatrist being injured.
A transference threat occurs within the context of ongoing psycho-
therapy. The threats to therapists described by Brown et al. (1996) were
often insidious and in several instances continued for many years. Al-
though no psychiatrists who were the targets of transference threats
were physically injured, the threats were very disruptive, both to the
psychiatrists and to their families. The treating psychiatrist who ini-
tially viewed the threat as an issue to be resolved in therapy often toler-
ated transference threats. The threat situation often continued for many
months before the psychiatrist recognized the inherent danger. Rather
than diluting the transference by disengaging from the patient, many of
the therapists intensified the transference by increasing the frequency of
treatment sessions. Therapists often have difficulty disengaging from a
patient. Such situations may be compared with the problem of marital
separation when two parties are locked in a pathological relationship
(Lion 1995). By the time the treating psychiatrist in this example sought
consultation from a colleague, the clinician was so enmeshed in the pa-
tient’s distorted or psychotic transference that the resolution of the
threat situation was complicated, if not impossible. When a clinician is
threatened or perceives a threat, he or she should initially seek expert
consultation.
Monitoring Threats
Psychiatrists must pay close attention to any changes in either transfer-
ence or countertransference feelings as they arise in the therapy situa-
tion. Any changes in behavior or affect, either by the therapist or the pa-
tient, should alert the clinician to a potential change in the therapeutic
relationship. Such behavior might include patient requests for more
therapy sessions, frequent phone calls or messages on the answering
machine, notes or gifts between sessions, increased and frequent flat-
tery, or increased anger, hostility, or withdrawal. Therapists who treat
more primitive character disorders or paranoid or psychotic patients
Violence Toward Mental Health Professionals ❘ 473
run a certain risk as closeness develops (Lion 1995). This is a risk that
must be continuously assessed and dealt with. Often, subtle actions,
such as the patient’s moving back his or her chair, defensive posturing,
or tardiness late in the course of therapy, should alert a clinician to a
problem in the transference (Lion 1995). In such situations, immediately
reviewing the case with a colleague is a prudent first step toward un-
derstanding the change in the therapeutic relationship, assessing
whether a threat exists, and if one does exist, the level of risk. Similarly,
a clinician should also monitor his or her countertransference. Feelings
of increasing attraction, dread, anxiety, or anger toward a patient might
signal the beginning of a distorted transference.
Stalking
There are various definitions of stalking (Meloy 1998). From a clinical
perspective, stalking is obsessional pursuit, harassment, and intimida-
tion by a person who has a significant personal relationship (or believes
Violence Toward Mental Health Professionals ❘ 475
one to exist) with the object of the unwanted attention (Miller 2001).
Stalking of clinicians is a behavior representative of a pathological
attachment or deranged transference, or it may be the result of a dissat-
isfying outcome (Lion and Herschler 1998). Eight percent of adult
American women and 2% of adult American men have been stalked
sometime in their lives (Meloy 1998). At least half of stalkers may ex-
plicitly threaten their victims, and the frequency of violence toward
their objects ranges from 25% to 35% (Meloy 1998). The homicide rate
among victims of stalking is less than 2% (Meloy 1998). Physicians and
mental healthcare staff are at even greater risk of being stalked than the
general population, particularly by their patients. Recent studies have
found that 11% of mental health professionals responding to a survey
had been stalked, with psychologists and psychiatrists more likely to
experience longer periods of stalking (Galeazzi et al. 2005). Sandburg et
al. (2002) reported that 53% of inpatient clinical staff were stalked,
threatened, or harassed at some point during their career. Gentile et al.
(2002) found that 10% of psychologists had been stalked at least one
time, and Ashmore et al. (2006) found that 50% of responding mental
health nurses had been stalked.
Although violence is obviously the most disturbing potential out-
come of stalking, this phenomenon also deserves close attention be-
cause most victims of stalking experience major life disruptions and
psychological disturbance, including anxiety, depression, or symptoms
of trauma (Meloy 1998). Lion and Herschler (1998) presented cases of
psychiatrists who have been threatened or stalked and spent enormous
amounts of time and money on protective measures and legal fees;
some had to relocate their families and practices to other parts of the
country.
Immediate management of stalking is imperative and does not dif-
fer significantly from the management of threats. Meloy (1997) recom-
mended 10 guidelines for the clinical management of stalking, covering
the following points: a team approach, personal responsibility for
safety, documentation and recording, no initiated contact, protection
orders, law enforcement and prosecution, treatment if indicated, segre-
gation and incarceration, periodic violence risk assessment, and the
importance of dramatic moments, which are events that shame or hu-
miliate the perpetrator. Lion and Herschler (1998) further suggested be-
ing attuned to early inappropriate behaviors and boundary violations
and considering the risk that such violations will escalate over time to
the point of physical danger. Clinicians should seek legal and forensic
consultation early—preferably prior to an intervention.
476 ❘ Textbook of Violence Assessment and Management
Office Safety
The most problematic issue is the individual clinician who practices
alone. Office safety requires planning and persistence, and clinicians
should be cognizant of safety issues. Ideally, offices should have two
doors, one into the reception room and another locked door that leads
into the actual treatment office. This second door should have a peep-
hole so that the clinician can see who is in the outer office. Ideally, a cli-
nician may wish to have two entrances to his or her office so that if a
threatening patient comes into the reception area, there is another
means of exit. If a clinician does not have a receptionist, he or she
should consider a panic alarm or buzzer system to notify either build-
ing security or police in the event of a threatening or aggressive patient.
Institutional outpatient sites should be constructed so that there is a
physical and personal buffer for the clinician. Offices in outpatient clin-
ics should have panic buttons or an organized strategy to notify a recep-
tionist, other staff, or even the police of a threatening situation. A pro-
tocol should be developed to train office staff to recognize patients who
Violence Toward Mental Health Professionals ❘ 477
are at risk for violence. Strategies should be put in place so that the of-
fice staff can notify the clinical staff or, if necessary, the police without
alarming the patient when he or she begins to escalate or presents to the
office in a threatening manner. For instance, a simple code such as “Dr.
Smith, can you see Mr. Jones immediately?” may be a signal that Mr.
Jones is demonstrating behavior that puts him at risk for violence. This
nonthreatening phone call then allows the clinician to implement other
strategies, such as calling the police or mobilizing other clinic staff to
help contain the patient. A different code should be developed to alert
staff that an armed patient is in the waiting area. Such an alarm should
be simple and not threatening, for example, “Is room 22 available?” Di-
rect alarm systems to the police should also be considered, especially
for the situation in which a patient has a weapon or is suspected of hav-
ing a weapon. Such a system should be inconspicuous so as not to alert
the patient that an alarm is being sounded.
There are certain architectural features that can further enhance
safety. An office should be decorated in a manner consistent with the
type of patient that the clinician is treating. If a clinician is treating psy-
chotic patients or patients with a history of aggression, or if he or she
frequently evaluates new patients, there are specific office safety issues
that should be considered. Safe offices will have heavy furniture that
cannot be lifted or used as a weapon. Offices, especially in emergency
departments or inpatient units, should not have hard, sharp objects
such as small ashtrays, artwork, lamps, or other decorations that can be
thrown or used as weapons. All office doors should swing out into a
hall and not into an office. This prevents a patient inside the office from
blocking the therapist’s egress by leaning against the door. Berg et al.
(2000) recommended several strategies for enhancing safety in emer-
gency departments and clinics. Having windows in the doors of the ex-
amining rooms allows privacy while lending a sense of the possibility
of being monitored for unacceptable behavior. Security cameras also
provide a sense that behavior is being monitored, and posting rules
makes it clear that violence will not be tolerated and has consequences.
478 ❘ Textbook of Violence Assessment and Management
Key Points
Managing aggressive, violent patients is a clinical challenge. However,
if the clinician periodically reviews the key points of clinical manage-
ment, most encounters with a violent patient can have a satisfactory
outcome. The fundamental management strategies include:
■ Performing a risk assessment on all new patients.
■ Not evaluating or treating patients at risk for violence alone or in
an isolated office.
■ Remembering that violence is a response to feelings of helpless-
ness, passivity, and perceived or actual feelings of humiliation.
■ Using nonthreatening talk-down strategies and using affect
management as the centerpiece of the intervention.
■ Setting limits by offering the patient two options, with one being
the preferred option.
■ Being cognizant of the different manifestations of a threat,
because threats take many forms.
■ Monitoring transference and countertransference and evaluating
any change in the context of a developing threat situation.
■ Immediately seeking consultation if a threat is perceived or if the
clinician questions whether a patient’s behavior is a threat.
■ Immediately initiating threat management strategies without
hesitation or ambivalence.
■ Anticipating the potential for stalking and immediate and early
consultation with a forensic expert.
■ Responding in a nonthreatening manner to an armed patient and
offering help and understanding.
■ Periodically evaluating offices and patient areas and implement-
ing changes that will enhance safety.
References
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ences of stalking. J Psychiatr Ment Health Nurs 13:562–569, 2006
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tients. New Dir Ment Health Serv 86:9–29, 2000
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Dietz PE: Defenses against dangerous people when arrest and commitment fail,
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Dubin WR: Assaults with weapons, in Patient Violence and the Clinician. Ed-
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1996, pp 3–14
Dubin WR, Wilson SJ, Mercer C: Assaults against psychiatrists in outpatient set-
tings. J Clin Psychiatry 49:338–345, 1988
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Fink DL, Shoyer B, Dubin WR: A study of assaults against psychiatric residents.
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Violence Toward Mental Health Professionals ❘ 481
Intimate partner violence (IPV) can take any of several forms, includ-
ing emotional, physical, and/or sexual abuse. This chapter focuses spe-
cifically on the physical and sexual abuse inflicted by one individual
against his or her intimate partner, who may be a spouse, a live-in part-
ner, or a date of the opposite or same sex. It should be recognized, how-
ever, that emotional abuse and physical violence are often related. The
physical violence may take numerous forms, including battering or
beating, rape, murder, or forced suicide; may be effected through the
use of fists, feet, sexual organs, poisoning, drowning, hanging, fire, elec-
trical shocks, knives, guns, and/or other weapons (Loue 2001b); and
can occur in a variety of settings, not just the home. The violence may
be perpetrated for various proffered reasons, including economic pres-
sures and dissatisfaction with the partner’s attitudes or behavior.
Incidents of physical abuse may occur only intermittently, but an
abusive partner may use emotional abuse to gain and retain control
during the interim periods (Dutton and Golant 1995). This “cycle of
483
484 ❘ Textbook of Violence Assessment and Management
violence,” as it has been referred to, consists of three phases. The first, or
tension-building, phase is characterized by verbal, emotional, and
sometimes physical abuse of lesser severity. Often the victim will at-
tempt to alleviate the situation by placating the batterer. The second, or
acute battering, phase represents the discharge of built-up tension. Al-
though the victim may be blamed for “triggering” the abuse, the actual
cause of the violence is often a stressor external to the relationship (such
as difficulties at work) or internal to the abuser. Acute battering episodes
are often unpredictable. During the third, or “honeymoon,” phase, the
abuser attempts to apologize for his or her actions through apologies,
gifts, helpfulness, and increased emotional closeness with the victim. It
is during this phase that the bond between the abuser and his or her vic-
tim is intensified, because the victim now experiences the positive as-
pects of the relationship and comes to believe in the partner’s voiced
commitment to the relationship. This intensified emotional closeness
and commitment increases the difficulty of leaving the abusive relation-
ship (Walker 2000).
In the United States, the lifetime prevalence of physical assault by an
intimate partner against women in a population not defined by mental
illness has been found to range from 9% to 30% (Bureau of Justice Statis-
tics 1998; Tjaden and Thoennes 2000), and the prevalence of rape by an
intimate is approximately 8% (Tjaden and Thoennes 2000). The range of
estimates is due, in part, to variations across studies in the methods used
to collect data (e.g., personal interviews, telephone interviews, written
surveys); the sampling methods used (e.g., hospital patients, general
population, clinic outpatients); and definitions of partner violence.
Previous research has identified the following risk factors for part-
ner violence in the United States: younger age, urban residence, lower
levels of education, and lower income (Sorenson et al. 1996). Prior his-
tory of abuse, including childhood abuse (Friedman and Loue 2007),
may also increase risk. Female victims of IPV have been found to be
more likely to use multiple substances (alcohol, cigarettes, and illegal
drugs) than are nonvictims (Martin et al. 1996). Pregnancy has also been
established as a risk factor for IPV victimization (Miller and Finnerty
1996). Pregnant women especially at risk for battering during their
pregnancies are those who have been battered prior to pregnancy (Mc-
Farlane et al. 1992). Homicide is a leading cause of death during preg-
nancy (Frye 2001). Research indicates that homicide is more likely to oc-
cur among couples of lower socioeconomic status and those in which
the wife is significantly younger than the husband (Chimbos 1998). It
has been hypothesized that the homicide may be related to partner con-
cerns about paternity or changing role expectations.
Intimate Partner Violence and the Clinician ❘ 485
Case Example
Marta [all names used in the case example are fictitious] is a Hispanic
woman in her mid-30s who was diagnosed with major depression some
years ago. Marta moved from Puerto Rico to the mainland United States
at a relatively young age. Both her brother and an uncle repeatedly
486
TABLE 24–1. Theories of causation of intimate partner violence
Theory Description
❘
Why the violence occurs
Culture of violence Subcultures develop norms that permit the use of physical force or violence.
(Wolfgang and Ferracuti 1967)
Ecological theory (Belsky 1980) Risk of assault is a function of the interplay between factors at the macrosystemic,
❘
487
488 ❘ Textbook of Violence Assessment and Management
sexually abused her as a young child. Marta was raised in the Roman
Catholic faith and more recently became a member of the religious com-
munity known as Mita y Aaron, founded by a Puerto Rican woman. Al-
though Marta has been involved in several relationships, she has never
married and has no children.
Marta has not used any substances for approximately 7 years, but
during her prior relationship with Jorge, she was dependent on alcohol
and heroin. Jorge was physically abusive, but Marta believed that, as a
good woman, she was responsible for her partner’s happiness. She de-
scribed his abuse thus:
Marta explained why she tolerated the abuse, which included rape:
One day he got crazy, and he kicked me out of the apartment be-
cause his sister was telling him bad things about me. He took me
close and threw me down the steps. For a day I slept in the hall-
way. Then [he] said he called the cops and the cops told me I
needed to leave his place. I could not say anything because the
apartment was under his name only…. He would tell me what
I was thinking, and he was right. It was my job to sexually sat-
isfy him, so he continued to have anal sex with me.
Assessment
Assessing Abuse
Partner victimization is more common than many of the symptoms that
are routinely brought up during psychiatric visits, and yet it is infre-
490 ❘ Textbook of Violence Assessment and Management
Legal Issues
Protection and the Reporting of
Intimate Partner Violence
In some instances in which the healthcare provider believes that a pa-
tient may be a danger to his or her intimate partner, the provider may
Intimate Partner Violence and the Clinician ❘ 493
guarantee safety; CPOs are violated approximately 40% of the time and
may even elevate the woman’s risk (Spitzberg 2002). Considerations re-
garding the seeking of CPOs include offender’s employment or social
standing, severity and persistence of the violence, length of relation-
ship, presence of children, and living situation (Jordan 2004).
Key Points
■ Intimate partner violence (IPV) can be perpetrated by men
against women, by women against men, or by same-sex
partners.
■ Severely mentally ill women may be at increased risk of IPV.
■ IPV may exacerbate existing symptoms of mental illness.
■ Patients may not disclose IPV to their care providers out of
fear, shame, and embarrassment.
■ Responses to IPV may mimic symptoms of mental illness.
For instance, a woman may appear to be disorganized and
paranoid when she may actually be living in fear of severe
injury.
■ Psychiatrists and other health professionals may perform an
assessment to determine if their patient fears for his or her
safety because of IPV or if the patient may be likely to
perpetrate violence against a partner.
■ Healthcare providers may be required by law to warn the
potential victim if they believe that a patient is likely to
perpetrate IPV and/or to report to designated authorities
the occurrence of IPV.
496 ❘ Textbook of Violence Assessment and Management
References
Bergman B, Ericsson E: Family violence among psychiatric inpatients as measured
by the Conflict Tactics Scale (CTS). Acta Psychiatr Scand 94:168–174, 1996
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39:213–223, 1998
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survivors of intimate partner violence: the role of risk and protective factors.
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among public mental health consumers with chronic and severe mental ill-
ness. Community Ment Health J 42:487–500, 2006
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DeNiro DA: Perceived alienation in individuals with residual-type schizophre-
nia. Issues Ment Health Nurs 16:185–200, 1995
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Dobash RE, Dobash R: Violence Against Wives. New York, Free Press, 1979
Dutton DG, Painter SL: Traumatic bonding: the development of emotional at-
tachments in battered women and other relationships of intermittent
abuse. Victimology 1:139–155, 1981
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Dutton MA: Intimate partner violence: 25 years of expert testimony. Presenta-
tion at the annual meeting of the American Academy of Psychiatry and the
Law, Chicago, IL, October 2006
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Books, 1995
El-Bassel N, Gilbert L, Witte S, et al: Intimate partner violence and substance
abuse among minority women receiving care from an inner city emergency
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Ferris LE, Norton PG, Dunn EV, et al: Guidelines for managing domestic abuse
when male and female partners are patients of the same physician. JAMA
278:851–857, 1997
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and against women with severe mental illness: a review. J Womens Health
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JAMA 285:1510–1511, 2001
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Abusive Relationships. New York, Simon and Schuster, 1998
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Kaplan ML, Asnis GM, Lipschitz DS, et al: Suicidal behavior and abuse in psy-
chiatric outpatients. Comp Psychiatry 36:229–235, 1995
Khan FI, Welch TL, Zillmer EA: MMPI-2 profiles of battered women in transi-
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Loue S: Elder abuse and neglect in medicine and law: the need for reform. J Leg
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sponses. New York, Plenum, 2001b
Martin SL, English KT, Clark KA, et al: Violence and substance use among
North Carolina pregnant women. Am J Public Health 86:991–998, 1996
498 ❘ Textbook of Violence Assessment and Management
Workplace Violence
and the Clinician
Ronald Schouten, M.D., J.D.
Workplace violence has been a major concern for the American work-
place and public in recent decades. Although international terrorism has
been the focus of foreign policy and the media, workplace violence has
continued to be a leading concern of employers (Pinkerton Consulting
and Investigations 2003). The term workplace violence conjures up images
of disgruntled, armed employees wreaking havoc, killing and injuring
coworkers, and in most cases killing themselves or being killed in the
process of apprehension by police. Contrary to public perception and
media portrayals, such stereotypical workplace violence episodes have
decreased in frequency since 1994 (Bureau of Labor Statistics 2006a), as
has the overall rate of violent crime in the United States. Much more com-
mon is an array of behaviors that are justifiably included under a broad
definition of workplace violence or aggression: nonfatal assaults, bully-
ing, harassment (both sexual and nonsexual), verbal abuse, threats from
both known and anonymous sources, and hoaxes. Acts of terrorism with
conventional or chemical, biological, radiological, or nuclear weapons
can also be included as incidents of workplace violence, given that work-
places are common targets of terror attacks (Schouten et al. 2004).
The need to understand and manage acts of violence in the work-
place has given rise to multiple theories, proposed methods for iden-
tifying potentially violent employees, and prevention measures. Al-
though some, but by no means all, acts of workplace violence are
501
502 ❘ Textbook of Violence Assessment and Management
Case Example
ABCD Corporation, based in the northeastern United States, is a manu-
facturer and distributor of consumer electronics. Over the past 5 years,
ABCD has been gradually outsourcing its manufacturing operations,
service centers, and distribution networks. As a result, its U.S.-based
workforce has shrunk by 30% over 2 years, with rumors of additional
cuts in the near future. Most recently, plans were announced to move the
entire customer service operation to Bangalore, India, over the next year.
The U.S. customer service representatives have been offered the option
of transferring to ABCD’s manufacturing plant in Arkansas, taking an
early retirement package, or working until such time as the U.S. opera-
tion is closed.
Six weeks after the announcement that the customer service opera-
tion would be outsourced, a large envelope bearing excess postage and
addressed to the Chief Executive Officer (CEO) arrived in the mail.
ABCD’s corporate security director took possession of the envelope and
turned it over to the local hazardous materials team for screening prior
to opening. The envelope was opened when no indication of toxic sub-
stances was found. Inside were digital photographs of the CEO’s wife
and children leaving their home on the way to school. Appropriate se-
curity measures were put in place and a full-scale investigation was
opened by law enforcement. No suspicious behavior was observed near
the CEO’s home, and the investigation turned up no useful leads that
could tie the mailing to anyone in the community or at ABCD.
Word of the mailing spread quickly among ABCD employees. Em-
ployees began wondering what might happen next and speculated who
among them might have done this. Some commented that they were
certain something else would happen, given how the company had
“screwed all of us.” Several commented that the CEO was getting what
he deserved and that although they did not want to see anyone hurt, he
had a good scare coming to him, given the terror he was causing the em-
ployees by sending their jobs overseas.
Three weeks after the mailing, graffiti began appearing in the men’s
restroom. Obscene and graphic, and written in an awkward hand, the
Workplace Violence and the Clinician ❘ 503
graffiti made direct threats of violence toward the CEO and ABCD. Po-
lice investigation, including interviews with a number of employees
who used that restroom, yielded little. Through the interviews, police
and ABCD security learned that fear among employees, as well as anger
at ABCD for the downsizing and for failing to deal with the threats, was
growing. There was discussion of installing video cameras in the men’s
room and the hall leading to it, but corporate counsel advised that these
were prohibited by state privacy laws. Employees’ concerns increased
when they began to discover pieces of office equipment inexplicably
broken.
The list of suspects who might possibly be responsible for the letter,
graffiti, and sabotage was long. No one at ABCD was happy about the
employment situation. The economy was poor, good jobs were scarce in
the region, and most of the employees had families with young children.
Among the employees, the gossip was that James Wilson was a
likely suspect. James, a programmer in the information services divi-
sion, was slated to have his job eliminated when the outsourcing began.
Thirty years of age, James was regarded as a loner, did not socialize with
coworkers, and lived with his elderly parents. He took advantage of the
company flextime policy, often coming to work late and staying until
the early morning hours. James’s sole known recreational activity was
computer fantasy games, with which he was rumored to be “obsessed.”
An employee with whom James had attended high school told col-
leagues that James had owned a handgun in high school.
Gossip about James preoccupied the plant, much to the detriment of
productivity. The gossip increased when another letter arrived with a
note threatening that “If I go down, you all go down.” James was inter-
viewed by police and corporate security and denied involvement in any
of the events. As rumors about James continued, and employees began
complaining to human resources that he seemed “odd” and they were
afraid of him, a decision was made to send him for a fitness-for-duty
evaluation, even though his job performance had remained good. The
psychiatrist retained to perform the evaluation, Dr. Anderson, was told
that James was being referred because he “fit the profile” of someone
who might commit an act of workplace violence.
Dr. Anderson found James to be an anxious young man with symp-
toms of obsessive-compulsive and avoidant personality disorders.
There was no indication of psychosis, mood disorder, or other mental
disorders, nor was there any indication of hostility toward ABCD or his
coworkers. Interviews with James’s supervisor revealed that he was
quiet and diligent, was irritable at times and avoided other employees,
but had never been threatening or violent. His personnel record was un-
remarkable; his criminal background check was clean. The expressions
of concern from coworkers were vague, unsubstantiated, and based on
their perception that he was “odd” and had a history of mental illness.
The psychiatrist concluded that James did not pose a risk of harm to
ABCD or its employees and found him fit for duty. Upon his return, a
number of coworkers complained to Human Resources that they did not
care what the evaluator said, they were still concerned. Several threat-
504 ❘ Textbook of Violence Assessment and Management
place environment (Baron and Neuman 1996), low work group har-
mony (Cole et al. 1997), and failure to discipline aggressive employees
(Allen and Lucero 1998). Again, some of these are found in the case ex-
ample. Karl and Hancock (1999) proposed that organizations are at in-
creased risk of workplace aggression if they conduct terminations with
more than one supervisor present or on a Monday or Tuesday.
a beneficial impact on all parties involved, but the goal is not to diagnose
and provide treatment, or even a treatment referral, for the evaluee. The
goal is to determine the level of risk to which the referring party is ex-
posed and to assist in managing that risk. Although clinicians have a
duty to behave in an ethical manner no matter what their role, the fidu-
ciary duty that arises from the doctor–patient relationship to act only in
the best interests of the patient is owed not to the evaluee but to the
party requesting the assessment (Schouten 1993; Strasburger et al. 1997).
The evaluating clinician has a duty to the evaluee to disclose informa-
tion to the employer only with consent (American Academy of Psychi-
atry and the Law 2005), although the employer may make participation
in the evaluations and release of information a contingency of any fu-
ture employment. Even so, the evaluating clinician should only disclose
information on a need-to-know basis and should be aware of the extent
to which Health Insurance Portability and Accountability Act privacy
requirements apply to these evaluations (Gold and Metzner 2006).
The databases available in workplace violence consultations and
clinical evaluations differ, with each more limited and more complete in
certain ways. Clinical evaluations occur in person, whereas the work-
place violence consultant may never meet the subject face to face. On
the other hand, the consultant will ideally have more comprehensive in-
formation from a wider range of sources than is available to the average
clinical evaluator. In clinical settings, the primary sources of informa-
tion are generally limited to the patient him- or herself and perhaps
family members. Time and location permitting, the outpatient evalua-
tor may have access to the evaluee’s medical records. In contrast, the
workplace violence consultant will often make the risk determination
on the basis of background information, interviews with collateral
sources, review of documents and other communications, and often
comprehensive background checks, which can provide the basis for a
structured assessment based on actuarial risk factors.
It is also important to keep in mind that in workplace violence risk
assessments, only a small proportion of subjects will have identifiable
Axis I or even Axis II disorders. Thus, options available to the clinical
evaluator may not be accessible to the consultant. For example, volun-
tary or involuntary hospitalization may be available for an individual
who is engaging in threatening behavior as a result of a mental illness.
In the absence of such an illness, or sufficient risk of harm to justify in-
voluntary commitment, alternative solutions to maintaining safety
must be found. This may require a decision as to whether the matter
should be referred to law enforcement or if a legal action, such as a re-
straining order, should be pursued.
514 ❘ Textbook of Violence Assessment and Management
Smith will be a business decision that takes into consideration not only
risk issues but also the impact of retaining Mr. Smith when his behavior
is known to other employees. From a violence risk management stand-
point, however, all parties may be best served by a mandatory medical
leave, possible short-term disability, and ongoing provision of health
insurance benefits. In the event that Mr. Smith is to be discharged, a sev-
erance package that includes severance pay and ongoing health bene-
fits can decrease the stress of termination, especially in a situation like
his where family health issues constitute an ongoing stressor.
Key Points
■ Workplace violence is a subject that has captured the imagination
of the public and the media due to the human drama and tragedy
involved.
■ Because this type of violence is about abnormal behavior, psychia-
trists and other mental health professionals will continue to be
called upon to provide risk assessments, develop prevention
strategies, and suggest methods to mitigate risks.
■ As mental health professionals, we have much to offer in terms of
workplace risk assessment, prevention, and mitigation. Individu-
als who choose to pursue this rewarding professional activity can
do so effectively so long as they undertake the proper training,
understand the tasks ahead of them, and stay within the bound-
aries of knowledge, skill, and professional ethics.
References
Allen R, Lucero M: Subordinate aggression against managers: empirical analy-
ses of published arbitration abstracts. The International Journal of Conflict
Management 9:234–257, 1998
Ambrose ML, Seabright MA, Schminke M: Sabotage in the workplace: the role of
organizational injustice. Organ Behav Hum Decis Process 89:947–965, 2002
American Academy of Psychiatry and the Law: Ethics Guidelines for the Prac-
tice of Forensic Psychiatry. Bloomington, CT, American Academy of Psy-
chiatry and the Law, 2005
American Society of Industrial Security: Workplace Violence Prevention and
Response Guideline. Alexandria, VA, American Society of Industrial Secu-
rity, 2005
Americans With Disabilities Act, 42 U.S.C. § 12113(b) (1990)
Aquino K, Bradfield M: Perceived victimization in the workplace: the role of sit-
uational factors and victim characteristics. Organization Science 11:525–
537, 2000
Workplace Violence and the Clinician ❘ 517
Palmer v. Circuit Court of Cook County, 351 F.3d 117 (7th Cir. 1997) cert denied, 522
U.S. 1096 (1998)
Pastor LH: Initial assessment and intervention strategies to reduce workplace
violence. Am Fam Physician 52:1169–1174, 1995
Penney LM, Spector PE: Job stress, incivility, and counterproductive work be-
havior (CWB): the moderating role of negative affectivity. Journal of Orga-
nizational Behavior 26:777–796, 2005
Pettus v. Cole, 57 Cal.Rptr.2d 46 (Calif. Court Appeals 1996)
Philipse MWG, Koeter MWJ, van der Staak CPF, et al: Static and dynamic pa-
tient characteristics as predictors of criminal recidivism: a prospective
study in a Dutch forensic psychiatric sample. Law Hum Behav 30:309–327,
2006
Pinkerton Consulting and Investigations: Top Security Threats and Manage-
ment Issues Facing Corporate America. Parsippany, NJ, Pinkerton Consult-
ing and Investigations, 2003
Rosen A: Detection of suicidal patients: an example of some limitations in the
prediction of infrequent events. J Consult Psychol 18:397–403, 1954
Scalora MJ, Washington DO, Casady T, et al: Nonfatal workplace violence risk
factors: data from a police contact sample. J Interpers Violence 18:310–327,
2003
Schouten R: Pitfalls of clinical practice: the treating clinician as expert witness.
Harv Rev Psychiatry 1:64–65, 1993
Schouten R: Violence in the workplace, in Mental Health and Productivity in the
Workplace. Edited by Kahn JP, Langlieb AM. San Francisco, CA, Jossey-
Bass, 2003, pp 314–328
Schouten R: Workplace violence: an overview for practicing clinicians. Psychi-
atr Ann 36:790–797, 2006
Schouten R, Callahan MV, Bryant S: Community response to disaster: the role
of the workplace. Harv Rev Psychiatry 12:229–237, 2004
Sen P, Gordon H, Adshead G, et al: Ethical dilemmas in forensic psychiatry: two
illustrative cases. J Med Ethics 33:337–341, 2007
Simister J, Cooper C: Thermal stress in the USA: effects on violence and on em-
ployee behaviour. Stress and Health 21:3–15, 2005
Skarlicki D, Folger R: Retaliation in the workplace: the roles of distributive, pro-
cedural, and interactional justice. J Appl Psychol 82:434–443, 1997
Storms P, Spector P: Relationships of organizational frustration with reported
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Occupational Psychology 60:227–234, 1987
Strasburger LH, Gutheil TG, Brodsky A: On wearing two hats: role conflict in
serving as both psychotherapist and expert witness. Am J Psychiatry
154:448–456, 1997
Swanson JW, Swartz MS, Van Dorn RA, et al: A national study of violent behav-
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University of Iowa Injury Prevention Research Center: Workplace Violence: A
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search Center, 2001
Vossekuil B, Reddy M, Fein R: Safe School Initiative: An Interim Report on the
Prevention of Targeted Violence in School. Washington, DC, U.S. Secret
Service, 2000
520 ❘ Textbook of Violence Assessment and Management
Vehicular Crashes
and the Role of
Mental Health Clinicians
Alan R. Felthous, M.D.
Thomas M. Meuser, Ph.D.
Thomas Ala, M.D.
521
522 ❘ Textbook of Violence Assessment and Management
1
In this discussion the term accident is used selectively, not generically, because not all
crashes are unintended.
Vehicular Crashes and the Role of Mental Health Clinicians ❘ 523
Mental Disorders
Psychosis and Schizophrenia
A literature review conducted by the National Highway Traffic Safety
Administration (Dobbs 2005) concluded that individuals with un-
treated psychotic disorders and, overall, those with schizophrenia, de-
pressive or anxiety disorders, alcoholism, and personality disorders are
at greatest risk for motor vehicular crashes. Studies of schizophrenic
drivers show a relationship to crash rates if correction is made for expo-
sure to driving. (Those with serious mental impairments spend less
time driving than their unafflicted counterparts.) There is general
agreement that one should not drive during the acute phase of a psy-
chotic illness (American Psychiatric Association 1995; Austroads 1998;
Canadian Medical Association 2000).
Little is written, however, on how to determine when a condition is
sufficiently acutely psychotic that driving should be restricted. This is
presumably because current psychotropic medications have shortened
the duration of acute psychotic exacerbations—and therefore of periods
when driving should be restricted. Moreover, the customary standard
of practice is to hospitalize the individual who is acutely psychotic, thus
minimizing for that period that individual’s exposure to driving and
potential for causing a crash.
524 ❘ Textbook of Violence Assessment and Management
Case Example 1
Mr. Hilton Putney had been hospitalized numerous times, had failed to
take prescribed medication in the community, had attempted suicide on
several occasions, and had deliberately crashed his car on two occa-
sions. Immediately after he was discharged from Delaware State Hospi-
tal, Mr. Putney stopped taking medication and did not keep his outpa-
tient appointment. He deliberately crashed his car into another, killing
the other driver, Mr. George Laird. Mr. Putney was charged with man-
slaughter and found not guilty by reason of insanity. The lawsuit against
Dr. Naidu and other hospital psychiatrists resulted in a $1.4 million ver-
dict. The Supreme Court of Delaware, referring to the Tarasoff duty of
therapists to protect third persons from foreseeable harm caused by
their patients, upheld the cause of action.
Depression
Most authorities would agree that depressed individuals may drive if
their mood is stable and any medications are regulated (American Psy-
chiatric Association 1995; Austroads 1998). Austroads (1998) advised
against driving while medications are being adjusted, whereas the
American Psychiatric Association (1995) recommended that the physi-
cian warn the patient that any newly prescribed medication can affect
Vehicular Crashes and the Role of Mental Health Clinicians ❘ 525
driving ability. There is general agreement that individuals who are pro-
foundly depressed with impaired concentration should not drive
(American Psychiatric Association 1995; Austroads 1998; Canadian
Medical Association 2000). Although controversy exists over the num-
ber of crashes caused by suicidal drivers (Dobbs 2005), practiced mental
health clinicians are familiar with individual patients who have thought
of making a suicidal crash while driving or have actually attempted
this.
Case Example 2
Mr. Tony Marconi,2 a 60-year-old retired fireman, reported at the hospi-
tal emergency department that he was thinking of committing suicide
by drug overdose or vehicular crash. Diagnoses included major depres-
sive disorder and cocaine dependence. Although he took antidepressant
medication as prescribed, he still felt depressed, so he tried to self-
augment with cocaine. Even this extra measure did not assuage his
depression. When interviewed the day after admission to the hospital
inpatient psychiatric service, Mr. Marconi denied having had a specific
method of suicide in mind: he stated that he came to the hospital only to
obtain help with depression and said he was thinking of suicide but
without a method or plan in mind. When asked specifically about drug
overdose, he acknowledged having attempted suicide by drug overdose
several years ago but denied that this was a recent consideration.
When asked about suicide by vehicular crash, Mr. Marconi said this
had occurred to him just before a prior hospitalization about 3 weeks
earlier. While he was driving on a busy interstate highway and feeling
hopeless about his unrelenting depression and insuperable cocaine ad-
diction, it suddenly occurred to him that he could at that very moment
steer his car into another vehicle and end his misery once and for all in
a fatal crash. When asked if he had concern about the other driver, Mr.
Marconi said this did occur to him as a secondary consideration. The
thought of harming another person importantly constrained him from a
disastrous turn of the steering wheel and impelled him to drive straight
to the hospital to obtain help.
2
For this and the subsequent case examples, information is altered to obscure identifica-
tion and resemblance to any particular individual.
526 ❘ Textbook of Violence Assessment and Management
Case Example 3
Ms. Lilian Quen is a 35-year-old woman who was admitted to the hos-
pital with major depressive disorder. She had been feeling hopeless and
having suicidal thoughts of killing her children as well as herself. Al-
though not psychotic, she could not bear the thought of her children not
being raised and cared for by herself. Two methods occurred to her:
poisoning by overdosing with medicine and driving her car with both
children inside into a river. She seriously thought of the latter method
recurrently over several years. Several times she made initial prepara-
tions by placing her children in the car and driving to a riverbank. No-
ticing that she was distraught, her children asked what was the matter,
gave solace to their mother, and in so doing interrupted Ms. Quen’s fa-
tal intentions.
This would have been a crash of another kind, driving the car into
the river in a combined homicide-filicide. It serves as another example
of the importance of assessing suicide and homicide risk by obtaining a
detailed history of prior thoughts, preparatory acts, and attempts and
by asking the details of the method(s) considered in addition to asking
about desperate thoughts. The suicide-homicide prevention plan in-
volves the child protective authorities, aggressive treatment of depres-
sion, careful discharge planning before hospital release, and close mon-
itoring afterward. Extended restriction of driving should be a part of the
prevention plan.
Vehicular Crashes and the Role of Mental Health Clinicians ❘ 527
Dementia
For patients diagnosed with a progressive dementia such as Alzhei-
mer’s disease, it is not a matter of if retirement from driving will be
necessary but when. Alzheimer’s disease differs from other conditions
reviewed in this chapter because current treatments cannot restore driv-
ing fitness in those already impaired. Whereas patients with early, mild
forgetfulness and a safe driving record may retain sufficient ability to
drive for a time, those with more advanced impairment (i.e., deficits in
divided attention, visuospatial skills, and/or executive functioning) are
likely to pose a hazard on the road (Carr et al. 2006). The American Psy-
chiatric Association (1997) recommends that patients with moderate
dementia be required to stop driving for reasons of individual and pub-
lic safety. The American Academy of Neurology argues that even those
at the mild stage have sufficient deficits to warrant driving cessation
(Dubinsky et al. 2000).
In a landmark study by Linda Hunt and colleagues at Washington
University (Hunt et al. 1997), patients evaluated as clinically normal and
as being in the early stages of dementia were administered a detailed
on-road performance evaluation. Patients were characterized as either
very mildly demented or mildly demented by use of the Clinical De-
mentia Rating (CDR; Morris 1993), 0.5 and 1 levels, respectively. Overall
ratings of “safe,” “marginal,” or “unsafe” were assigned to each older
driver. The majority (97%) of those judged to be clinically normal (CDR
0) were found to be safe or marginal drivers. This number dropped to
81% for very mildly demented (CDR 0.5) drivers and 59% for mildly de-
mented (CDR 1) drivers. As many CDR 1 drivers were found to be un-
safe as safe—41% in both cases. Subsequent testing over time revealed
that the majority of these demented drivers moved from safe/marginal
to unsafe categories over a 2-year period, with mildly demented (CDR
1) individuals showing the steepest decline (Duchek et al. 2003).
Based on these and other findings, it is reasonable to consider the
transition from CDR 0.5 to CDR 1 stages of dementia (i.e., very mild to
mild) as the critical period for driving-related assessment, discussion of
driving retirement, and implementation of a cessation and alternative
transportation plan (Meuser et al. 2006). Primary care and specialist
physicians, including psychiatrists, can play important evaluative and
counseling roles in this process, according to the American Medical As-
sociation’s Older Drivers Project (American Medical Association 2003;
Wang and Carr 2004). In-office interview and screening procedures
are sufficient, in many cases, to “risk stratify” patients into likely safe
or unsafe categories. Advancing impairment and evidence of on-road
528 ❘ Textbook of Violence Assessment and Management
Case Example 4
Mrs. Burns has very mild Alzheimer’s disease (CDR 0.5) and lives by
herself in a rural area. Her closest family member lives an hour away
and visits weekly to check on her well-being. Her family handles all of
her finances and housekeeping and sets up her weekly pillbox to assist
with medication administration. Mrs. Burns and her family report that
her driving ability remains unimpaired. Her daily routine is to drive
into town 3 miles to socialize and to have her main meal of the day. Her
friends do not drive, and visiting them requires her to operate a motor
vehicle. In addition, she is reluctant to leave the home she has enjoyed
for the past 30 years.
Case Example 5
Mr. Young has moderate Alzheimer’s disease (CDR 2) and lives with his
wife in a suburban area. Mrs. Young has never driven. They go out reg-
ularly to run errands, shop, go to restaurants, and visit friends and fam-
ily. Mrs. Young has vetoed all recommendations that Mr. Young have a
driving performance test, because they would then be isolated if he
should fail. She states that he drives well, but she does add that she has
to tell him where to turn and when to stop.
down his ignition key or disabling the car so that it is inoperable. Just
having a car in the driveway may satisfy some patients, especially those
with more advanced memory loss. The vehicle could also be sold.
Disturbances in Consciousness
Two neurological conditions involving sudden, unpredictable loss of
consciousness are seizures and narcolepsy. Other conditions with loss
of consciousness, such as syncope and sleep apnea, create similar con-
cerns about driver safety, but this discussion is limited to neuropsychi-
atric conditions. A seizure can occur once in a lifetime or it can be recur-
rent, depending on the etiology. An underlying neurological disorder as
well as electroencephalographic abnormalities predicts seizure recur-
rence (Berg and Shinnar 1991). Epilepsy by definition involves recur-
rent loss of consciousness and the function of other faculties, depending
on the nature of the disorder. Most states in the United States withhold
or withdraw the epileptic person’s license until a specific period of time
has elapsed without a seizure. The length of this seizure-free period
varies between states and ranges from 3 months to 2 years (Dobbs
2005). While the epileptic is at risk for a seizure, other activities to be
avoided include operating heavy machinery, swimming, being in the
immediate vicinity of an open fire or a body of deep water, and other
obviously perilous situations.
Falling asleep behind the wheel is thought to be a common cause of
vehicular accidents. Narcolepsy and sleep apnea are of special concern
because sudden attacks of drowsiness and sleep are not easily con-
trolled by those afflicted. Narcolepsy symptoms include catalepsy, hal-
lucinations, and sleep paralysis. Emotions can induce a spontaneous
loss of muscle strength known as catalepsy, which, in addition to “sleep
attacks,” puts the narcoleptic driver at risk. A narcoleptic individual
should not drive as long as the risk of sudden sleep remains. The Cana-
dian Medical Association (2000) recommends no vehicular driving if a
cataleptic episode has occurred within the past 12 months.
cians, even for harm inflicted on third persons, if the physician should
have taken some reasonable preventive measure (Felthous 1989a).
This liability is more likely to occur if the patient/offending driver
had been hospitalized and then released or discharged with incomplete
symptom control. In Tarasoff-like jurisprudence, such cases can be clas-
sified as involving the “foreseeable rule,” where the crash can reason-
ably be anticipated even if the other specific individual victims cannot
be identified in advance (see Felthous 1989b).
In Schuster v. Altenberg (1988) the Supreme Court of Wisconsin up-
held a claim wherein the driver, Edith Schuster, was a psychiatric out-
patient with manic-depressive illness. She was killed in the accident,
and her daughter was left with both legs paralyzed. Causes of action in-
cluded negligent diagnosis and treatment, failure to seek civil commit-
ment, and “failure to warn the patient’s family of her condition and its
dangerous implications” (p. 4). In dicta, the court equated warning the
patient with treating the patient: “Warning a patient of risks associated
with a condition and advising the patient as to appropriate conduct
constitutes treatment as to which the physician must exercise ordinary
care” (p. 6). The court’s approach to this case raises the question of
which disorders would require such a warning (Felthous 1989b). Today,
despite the Schuster decision, it is not likely that the standard of practice
would be to warn bipolar patients generally of the risk of driving once
they are deemed safe enough to be treated as outpatients.
Clinicians have a duty to inform their patients about material side
effects of the medicines they prescribe. This can include the potential
side effect of drowsiness and a warning not to drive or operate heavy
machinery until the patient becomes accustomed to the drug and aware
of its effects. If the patient is not so informed, takes the prescribed sedat-
ing or otherwise mind-altering drug, and then, because of the drug’s
side effect, loses control of his or her vehicle, resulting in an accident,
the physician can be held liable for injuries that the patient sustained
from the accident or, in some jurisdictions, injuries inflicted on others.
An oft-cited case example of this type of liability with correspond-
ing legal duty of the clinician to inform the patient is Gooden v. Tips
(1983). The plaintiff, who was struck and injured, argued that the phy-
sician who prescribed Quaalude was negligent for failing to warn her
against driving while taking this medicine. The holding for the Court of
Appeals of Texas found the petition to be sufficient. Likewise, in Kirk v.
Michael Reese Hospital and Medical Center (1985), an Illinois court found
that such a duty to warn a patient of adverse effects of a medication can
“extend to cover members of the public who may be injured as a prox-
imate cause of the failure to adequately warn” (p. 911).
Vehicular Crashes and the Role of Mental Health Clinicians ❘ 533
If the patient already knows of the risk, however, liability may not
necessarily extend to a prescribing physician who did not give such a
warning. A psychiatrist and psychologist in Connecticut were sued
with the claim that they failed to warn a patient not to drive her vehicle
while she was taking medication that altered her sleep cycle (Weigold v.
Patel 2004). The medication caused her to fall asleep at the wheel, it was
claimed, and to strike another car, resulting in the death of the other
driver. Because the driver/patient knew that her driving was impaired,
she, not her treaters, created the proximate cause by driving anyway.
The clinicians could not control the patient’s behavior, and therefore
their failure to warn the patient not to drive was not the proximate
cause of the victim’s death. The court concluded that the psychiatrist
and psychologist had no duty to warn the patient not to drive.
Regardless of what jurisdictional law requires in the way of informing
patients of the side effects of medication and the risk of driving when se-
dated, such information is reasonable to convey. By the same token, the
benefits of a medicine should also be shared with patients, including the
likelihood that a medication or combination of medicines can improve
driving performance. Psychotically disorganized patients can be expected
to be at greater risk for an automobile accident because of their mental dis-
order. Antipsychotic medicines improve symptoms of psychosis and dis-
organized thinking, and thus driving competence should also be restored.
Anticipating the sedative potential of antidepressant medications, phar-
maceutical companies include warnings of driving risk in the package in-
serts of many such agents. Yet empirical evidence demonstrates that when
depressed patients are treated with antidepressant medication, their driv-
ing competence and safety parameters improve (Ärzte-Zeitung 2007).
Clinicians have also been held liable for failing to diagnose a condi-
tion that could risk a vehicular crash and for not informing the patient
of the risk. In Iowa, a driver lost control of a vehicle during a seizure and
ran into a pedestrian. The injured pedestrian sued the driver’s physi-
cian, claiming failure to diagnose the seizure, to determine its cause, to
advise the patient not to drive, and to warn the patient of the risk asso-
ciated with driving. Moreover, it was claimed that the physician negli-
gently assured the driver that he could drive. On appeal, the Supreme
Court of Iowa held that the plaintiff’s petition with the above claims
stated a cause of action against the physician (Freeze v. Lennon 1973).
Conclusion
It is impossible to estimate the number of vehicular crashes attributable
to a mental or neurological disorder. Crashes are generically and collo-
534 ❘ Textbook of Violence Assessment and Management
Key Points
■ Medications are double-edged swords: they can impair or improve
driving competence, depending on how they are used.
■ Risk assessment interviews should be informed by the possibility
of suicide or homicide by vehicular crash.
■ For patients with Alzheimer’s disease, it is not a matter of if retire-
ment from driving should occur but when.
■ Laws or protective duties for clinicians regarding the risk of vehic-
ular crashes are variable and jurisdiction-specific.
References
American Medical Association: Physician’s Guide to Assessing and Counseling
Older Drivers. Chicago, IL, American Medical Association, 2003
American Psychiatric Association: Role of the Psychiatrist in Assessing Driving Abil-
ity: Position Statement (APA Document Reference No. 930004). Approved by
the Board of Trustees, December 1993, Approved by the Assembly, November
1993. Washington, DC, American Psychiatric Association, 1993
American Psychiatric Association: Position statement on the role of psychia-
trists in assessing driving ability. Am J Psychiatry 152:819, 1995
American Psychiatric Association: Practice guidelines in the treatment of
Alzheimer’s disease. Am J Psychiatry 154(suppl):1–39, 1997
Ärzte-Zeitung: Autofahren Klappt bei Depressiven mit Antidepressiva besser als
ohne, 2007. Available at http://www.aerztezeitung.de/docs/2006/02/03/
020a0401.asp?cat=/medizin/depression-65K-. Accessed January 24, 2006
Austroads: Assessing Fitness to Drive. Austroads Guidelines for Health Profes-
sionals and Their Legal Obligations. Sydney, Australia, Superline Printing,
1998
Bacon D, Fisher RS, Morris JC, et al: American Academy of Neurology position
statement on physician reporting of medical conditions that may affect
driving competence. Neurology 68:1174–1177, 2007
Berg AT, Shinnar S: The risk of seizure recurrence following a first unprovoked
seizure: a quantitative review. Neurology 41:965–972, 1991
Brown LB, Ott BR: Driving and dementia: a review of the literature. J Geriatr
Psychiatry Neurol 17:232–240, 2004
California Department of Motor Vehicles Health and Safety Code, Section
103900. Available at http://www.dmv.ca.gov/pubs/vctop/appndxa/hlthsaf/
hs103900.htm. Accessed January 23, 2008
Canadian Medical Association: Determining Medical Fitness to Drive: A Guide
for Physicians. Ottawa, Canada, Canadian Medical Association, 2000
Carr D, Duchek J, Meuser T, et al: The older driver with cognitive impairment.
Am Fam Physician 73:1029–1034, 2006
536 ❘ Textbook of Violence Assessment and Management
Dobbs BM: Medical Conditions and Driving: A Review of the Literature (1960–
2000). Washington, DC, National Highway Traffic Safety Administration,
2005
Dubinsky RM, Stein AC, Lyons K: Practice parameter: risk of driving and
Alzheimer’s disease (an evidence-based review). Report of the Quality
Standards Subcommittee of the American Academy of Neurology. Neurol-
ogy 54:2205–2211, 2000
Duchek JM, Carr DB, Hunt LA, et al: Longitudinal driving performance in early
stage dementia of the Alzheimer type. J Am Geriatr Soc 51:1342–1347, 2003
Felthous AR: The duty to warn or protect to prevent automobile accidents, in
Review of Clinical Psychiatry and the Law, Vol 1. Edited by Simon RI.
Washington, DC, American Psychiatric Press, 1989a, pp 221–238
Felthous AR: The Psychotherapist’s Duty to Warn or Protect. Springfield, IL,
Charles C Thomas, 1989b
Felthous AR: Personal violence, in Forensic Psychiatry. Edited by Simon RI,
Gold L. Washington, DC, American Psychiatric Publishing, 2006, pp 471–
500
Freeze v. Lennon, 210 NW.2d 576 (1973)
Gooden v. Tips, 651 SW.2d 364 (Tex. App. 1983)
Hunt LA, Murphy CF, Carr D, et al: Environmental cueing may effect perfor-
mance on a road test for drivers with dementia of the Alzheimer type.
Alzheimer Dis Assoc Disord 11(suppl):13–16, 1997
Kirk v. Michael Reese Hospital and Medical Center, 483 NE.2d 906 (Ill. App. 1 Dist.
1985)
Meuser TM, Carr DB, Berg-Weger M, et al: Driving and dementia in older
adults: implementation and evaluation of a continuing education project.
Gerontologist 46:680–687, 2006
Morris JC: The Clinical Dementia Rating (CDR): current version and scoring
rules. Neurology 43:2412–2414, 1993
Naidu v. Laird, 539 A.2d 1064 (1988)
Schuster v. Altenberg, Wisconsin Supreme Court, No. 87–0115, 1988
Wang C, Carr D: Older driver safety: a report from the Older Drivers Project.
J Am Geriatr Soc 52:143–149, 2004
Weigold v. Patel, 840 A.2d 19 (Conn. App. 2004)
Recommended Readings
Felthous AR: The duty to warn or protect to prevent automobile acci-
dents, in Review of Clinical Psychiatry and the Law, Vol 1. Edited
by Simon RI. Washington, DC, American Psychiatric Press, 1989, pp
221–238
Meuser TM, Carr DB, Berg-Weger M, et al: Driving and dementia in old-
er adults: implementation and evaluation of a continuing education
project. Gerontologist 46:680–687, 2006
C H A P T E R 2 7
School Violence
Carl P. Malmquist, M.D., M.S.
537
538 ❘ Textbook of Violence Assessment and Management
such data to protect the image of school districts. The National Research
Council and Institute of Medicine (2003) used the following criteria for
lethal school violence: taking place in or associated with schools, com-
mitted by students of the school, and resulting in multiple victimiza-
tions in a single incident. Note that this approach is narrowed to stu-
dents committing lethal acts, but it does not specify which level of
schools (such as colleges or lower grades), and the incident can be either
in or “associated with” schools.
Current Situation
In 1977 the federal government published a revealing study on school
crime (National Institute of Education 1977). It found that although
teenagers spend only 25% of their time in school, 40% of robberies and
School Violence ❘ 539
associated with 109 homicide events, from July 1999 through June 2006.
Seventy-eight percent of the homicides occurred on school campuses. A
reported 65% included gunshot wounds, 27% included stabbings or
cuttings, and 12% included beatings, indicating some overlap. The re-
port noted that although homicide is the second leading cause of death
among those ages 5–18 years in the United States, school-associated ho-
micides represent less than 1% of all homicides of school-age children.
A major limitation of the SAVD study is that the cases were identified
from news media reports, which would result in underestimation.
Bullying
Bullying is cited so often as a link to school violence, if not shootings,
that it merits a detailed discussion. Some go so far as to argue that if bul-
lying were dealt with, school violence would be dealt with as well.
Given the American school system, this is not likely to happen. A prob-
lem is that bullying encompasses a large number of students, which in-
cludes many acquiescent observers. The “Indicators” report defined
victimization by bullying as including 1) being made fun of, called
names, or insulted; 2) being subjected to rumors; 3) being threatened
with harm; 4) being pushed, shoved, tripped, or spit on; 5) being made
to do things one does not want to do; 6) being excluded from activities
or a group on purpose; and 7) purposeful destruction of property. Some
would restrict its meaning to repeated, negative acts by a child or group
against another. Although the acts may be physical, the usage encom-
passes verbal taunts or manipulative behavior to exclude others. Im-
plicit is a power game that is played out with different scenarios.
Surveys of students reveal that 16% of children say they have been
bullied during a current school term, and about 30% of sixth- through
tenth-graders say they have been involved as a bully or a target (Nansel
et al. 2001). Adverse consequences of such behavior, reported on both
sides, include more physical and psychological problems, persistence in
the role of victim, a shift from victim to perpetrator, and problems with
self-esteem and depression (Van der Wal et al. 2003). The causal relation-
ship between school bullying and psychopathological behavior has been
debated in terms of which comes first. Psychopathological behavior,
such as social problems, aggression, and externalizing behavior prob-
lems, may be the consequence of bullying experiences rather than the
cause (Kim et al. 2006). Explanations for bullying are also being sought
from neuroscience research involving limbic activation, varying levels of
autonomic arousal, and temperamental variations from integrity of pre-
frontal/executive regulatory capacities (Sugden et al. 2006).
School Violence ❘ 541
that they were outcast Goths. The fact is that they were out to have the
highest possible body count, and no one was specifically targeted.
The shootings were not impulsive, nor did they appear to be an act
of revenge against students and teachers per se, except in the sense that
the victims were now under their control, vulnerable and helpless. In-
vestigation revealed that the boys resented the possibility that they
might later be seen as “petty school shooters.” To avert this, the goal
was to amass the largest possible number of deaths, and if the bombs
had been wired correctly, about 600 deaths would have occurred. In
terms of personality characteristics, the two were quite different. Kle-
bold was hotheaded, depressed, and suicidal. Harris had more psycho-
pathic traits—“nice” on the surface but actually cold, calculating, and
homicidal. He was described as someone who took pleasure in lying
and was contemptuous of others. Without Harris, it is doubtful that
Klebold alone could have carried out such a mission.
Jonesboro, Arkansas
In a quite different type of case, Andrew Golden, age 11 and in sixth
grade, and Mitchell Johnson, age 13 and in seventh grade, carried out a
partnership shooting at Andrews Middle School on March 24, 1998.
Much of the background material on this event is taken from the case
study by the National Research Council and Institute of Medicine (2003).
The outcome was four students and one teacher dead and nine students
and one teacher wounded. Just after recess, Andrew was seen by other
students pulling the handle on the fire alarm and exiting the school. Stu-
dents responded to the alarm and marched outside to the playground.
On a hillside 100 yards away, the two boys, dressed in camouflage
shirts, opened fire. Police arriving at the top of the hill 10 minutes later
were stunned by how young the shooters were. When apprehended,
the boys had 11 guns (Remington rifles, Smith and Wesson pistols, der-
ringers, and semiautomatics) and several hundred shells that belonged
to Andrew’s father and grandfather. The shooting clearly had been
planned, because they had a van full of provisions, including sleeping
bags and pillows, a load of junk food, and a map to a remote hunting
area where they planned to hide.
The boys had driven to the school area in Mitchell’s stepfather ’s
van, which Mitchell barely knew how to handle. Nine weeks earlier
they had planned what to do if it was raining and students did not come
out to the playground if there was a fire alarm drill. Ballistics reports re-
vealed that Mitchell killed at least one but probably two people and
wounded at least three. Andrew, a more skilled shot, fired 25 shots, kill-
School Violence ❘ 545
ing three and wounding at least two others in the course of 5 minutes.
Although all but one of the victims shot were female, it remains conjec-
tural whether anyone was specifically targeted.
Many students did not know that the two boys knew each other
beyond a casual level. Mitchell had arrived in Arkansas only 2 years
earlier after being raised in Minnesota, where his parents had gone
through a heated divorce. His mother was a correctional officer, and af-
ter the divorce she first took a job in a federal prison in Kentucky. Two
sons were born in the marriage: Mitchell and a younger brother. Prior
to the divorce Mitchell’s father was described as a hard drinker, a disci-
plinarian, mean-tempered, and explosive. In addition, when Mitchell
was 8 years old, an older boy had begun to rape him, and later his
younger brother, repeatedly. The mother married again for a third time
to a man who had served prison time on a drug charge, but they had
settled down and the family was living in a trailer camp.
Mitchell presented a mixed picture. Some saw him adjusting well as
a new student, being polite and singing in a church choir. However, his
dark side was seen in belligerent, boastful, and bullying behavior. A
few weeks before the shooting he had been disciplined for wearing a
baseball cap in school. He was both furious about this and unrepentant.
He wrote a paper stating he had some squirrels he wanted to kill, which
led the teacher to give the paper to the school principal. Although
adults saw Mitchell as a troubled boy, his peer group saw him as a
moody boy with a temper who was seeking some place in the social
pecking order.
Andrew Golden was younger, but about half of the people inter-
viewed saw him as the leader. He came from a gun-owning family, the
guns used were from his family, and he was a marksman. An only child,
he was seen by others as belligerent, although his parents saw him as
doing no wrong. School behavior was erratic, varying from class clown
to “chip off the old block,” similar to the way his father had been at the
same school as a boy.
Psychiatric reports on the two boys described Andrew as the more
troubled, and in contrast to Mitchell, he never spoke to anyone about
the incident, nor did his family. Observations in the juvenile facility
where the boys resided for several years after the trial reflect wide dif-
ferences. Mitchell was cooperative, repentant, and liked by staff; An-
drew remained silent and kept to himself. An insanity defense was
raised for Andrew, but the court ruled a juvenile was not entitled to
such a defense, a decision upheld by the Arkansas Supreme Court. Be-
cause the boys were not yet 14 years of age, they could be detained only
until they reached 21, which left many in the community incredulous.
546 ❘ Textbook of Violence Assessment and Management
Virginia Tech
There have been earlier notable cases of lethal violence at a college level
that are sometimes ignored in discussions of “school shootings” (Simon
1996). Charles Whitman at the University of Texas in 1966 killed his
wife and mother and then, from a tower on the campus, shot 13 people
to death and wounded 31 others before he committed suicide. Gan Lu,
an astrophysicist at the University of Iowa, shot and killed a physics
professor and a rival who won an award Lu had hoped to receive; he
then killed five other faculty members and wounded another person
before committing suicide. In 1993 Wayne Lo, an 18-year-old student at
Simon’s Rock College in Massachusetts, used a high-powered assault
rifle to kill a professor in his car and a student in the library and then
wounded four others. Perhaps it is stretching school shootings to in-
clude Ted Kaczynski, the Unabomber, but he was a one-time college
professor who sent bombs through the mail that killed 3 persons and
wounded 23 others over 17 years. The victims were either university
professors or worked in technology.
The mass killing at Blacksburg, Virginia, on April 16, 2007, by a 23-
year-old college student is a recent picture of a troubled young male
who stumbled along until the fatal day. Seung-Hui Cho murdered
32 people and wounded 17 and then committed suicide, in the worst
peacetime shooting in American history. Many factors remain elusive.
That morning he went to a dormitory and killed a male and female stu-
dent whose selection remains a puzzle. Cho then mailed off a manifesto
to NBC News with pictures of himself posing with guns and video clips
and making a rambling verbal attack on wealthy people. In an essay
found in his room, he blamed practically everyone except himself for
what he was doing—women, religion, the wealthy, debauchery, and
“deceitful charlatans” (“The Virginia Tech Massacre” 2007).
Almost a 2-hour gap occurred before Cho then appeared in a class-
room building half a mile away. He locked the doors with chains so that
those inside could not escape and proceeded into various classrooms,
trying to kill everyone in them with two semiautomatics: a Glock 9 mm
and a Walther P22. Those who survived said he was silent as he went
about shooting students and faculty at close range, putting two or three
bullets in each to make sure they died. When police burst into the build-
ing, he shot himself.
Before any name was released by officials, some classmates guessed
that the shooter was Cho. He had rarely spoken to anyone, referred to
himself as “Question Mark,” hid behind sunglasses, and was seen as in-
timidating. In a creative writing class, the themes of his papers involved
School Violence ❘ 547
money, fury, sex, religion, and overbearing adults. In 2005, two female
students complained to police that Cho was stalking them but did not
press charges. At that time a district court found him “mentally ill and
an imminent danger to self and others,” but he never received any treat-
ment. His situation later exposed the flaws in a labyrinthine mental
health system (Schulte and Jenkins 2007). A court had committed him
for “involuntary outpatient commitment,” which exists in many states
as a category of civil commitment. The problem is in the follow-up and
the lack of clarity as to who assumes responsibility for ensuring that the
individual receives treatment. Is it the court system, some agency, or the
individual himself? In Cho’s case, no one assumed responsibility.
Discussion
There is a distinction between the pervasive problem of “school vio-
lence” and lethal school (rampage) shootings. The former is closer to the
problems of juveniles with ongoing conduct problems and is the more
classic picture of juvenile offenders in which a subset become violent.
Social and family disorganization are relevant. Lethal school shootings
present a different set of problems. Attempts are often made to create
profiles from these rampage killers’ characteristics, such as being a
loner and avoiding people, or to propose psychiatric diagnoses in retro-
spect. A major limitation is that such profiles include a great many
youths with personality characteristics and social difficulties similar to
those of the few who carry out such acts.
Consider the contrasting personalities of Golden and Johnson in
their joint act at Andrews Middle School in Arkansas, or contrast them
with that of Cho at Virginia Tech. A major obstacle to knowledge about
school killers is the lack of psychiatric and psychological data on the
perpetrators, either because they have committed suicide or because
such data are kept private. Hence, our knowledge is often based on
newspaper reports or police statements. One approach tried to system-
atize such offenders within four operant styles: adaptive, conservative,
integrative, and expressive (Fritzon and Brun 2005). The adaptive of-
fender targets specific individuals; the conservative is affected by an ex-
ternal trigger in which self-esteem is threatened; the integrative targets
others whom he identifies with his internal conflicts, and then commits
suicide; and the expressive is randomly violent.
The U.S. Secret Service developed a profile of 41 school shooters
from 37 school incidents (Vossekuil et al. 2000). The most frequent mo-
tive was revenge, with about three-fourths of the perpetrators threaten-
ing suicide before an attack. Although the report concluded there was
548 ❘ Textbook of Violence Assessment and Management
no evidence the shootings were the result of a mental disorder, the per-
petrators were described as feeling extremely depressed or desperate.
Two-thirds felt persecuted, and three-fourths were dealing with a major
change in a relationship or a loss of status.
This profile was consistent with a report by Meloy et al. (2001) of ad-
olescent mass murderers (not all in schools) in which a precipitating
event of personal loss or status threat had occurred. In 75% of the cases,
the shooters had communicated threats beforehand. The report empha-
sized bullying and the frequent motive of revenge. McGee and De-
Bernardo (1999) described 12 shooting incidents in middle and high
schools of “classroom avengers.” Again it was stated the shooters did
not show overt signs of a mental disorder, yet had a significantly de-
pressed mood. On reviewing these reports, the depression theme recurs
often enough to raise the question of whether those in contact with ad-
olescents are sufficiently adept at detecting depressive states.
An FBI report focused on the “myths” connected to school shootings
(O’Toole 2000). Among the myths examined were links to revenge, an-
ger about being bullied, unresolved anger about other matters, gun
availability in the homes of the perpetrators, the impact of violent video
games, and being a loner. The study argued against the idea that the
shooters shared these attributes. The debate as to whether the shooters
were mentally ill or had “mental problems” continued to intrude in all
these studies. Although the brooding ruminations of Cho suggest a se-
rious mental illness, other shooters may simply be referred to as having
a prominence of strong emotions whose ascendancy takes over their de-
cision making.
The FBI focus was on threat assessment, and they employed the con-
cept of “leakage.” The student intentionally or unintentionally “leaks”
a cry for help by way of feelings, thoughts, fantasies, or intentions about
an impending violent act. The clues may be subtle threats, boasting, in-
nuendoes, or predictions that can appear in stories, diaries, essays, let-
ters, and drawings. The leakage may involve “jokes” about violence or
destruction that are then retracted with “I was just joking.” At times
there are efforts to get friends or classmates to help with preparations
for a violent act.
A troublesome question deals with unshared information that was
available in the communities before such shootings. If such suspicions
are shared, a question arises as to how wide the sharing should be. A
retrospective study of 253 school-associated violent deaths in the
United States found more than half the perpetrators had signaled the
future event by notes, threats, or journal entries (Anderson et al. 2001).
However, unless we opt for a society with a norm of routinely inform-
School Violence ❘ 549
Prevention
None of the measures proposed in this section will eliminate the occa-
sional rampage homicidal shooting in schools. However, it is possible
that intervention at earlier stages might head off problems that could
eventuate in serious school violence. Such primary prevention of shoot-
ings could operate silently if intervention is successful. Two overriding
policy questions arise with increased preventive efforts. One is whether
families and children are willing to lose some liberties by greater in-
trusions into their lives when the payoff may be low. The second is
whether the public is willing to assume the additional costs that such
measures require.
A striking feature of writings on prevention of “school violence” is
the contrasting emphasis by those in clinical fields compared with those
in education. Clinically oriented writers focus on serious assaultive ep-
isodes, whereas educators are more concerned about the daily preva-
lence of various types of violence that intrude on educational processes.
550 ❘ Textbook of Violence Assessment and Management
Conclusion
Those who work with adolescents and families have knowledge of
what may prevent some violence in schools. To what extent various risk
factors are dealt with so that some future act of violence is thwarted
may never be known. It is often a matter of trying to intervene with a
focus on risk factors (MacNeil 2002). An important area of potential risk
is the adolescent’s social environment, such as income level, availability
of drugs and alcohol, and family disorganization. A second area is the
psychological and neuropsychiatric aspects of an individual in terms of
impulse control, beginning conduct problems, and possible psychiatric
disorders. A third area of risk focuses on the psychological milieu of the
adolescent. This includes family conflict, inconsistent or overly harsh
punishments, and failing or changing educational performance.
The key is connecting with those adolescents most in need of inter-
vention and then taking action and involving people with sufficient ex-
pertise. In cases like Columbine, Jonesboro, and Virginia Tech, the trou-
ble was in either no one detecting the individual or too many people
ignoring what they saw and heard. An approach of trying to predict
who might engage in a mass shooting is wasteful because it bypasses
approaches that may thwart such a later outcome. It may be helpful to
zero in on high-risk students for intervention, first through implement-
ing better sharing of records and ideas within school systems and
among teachers, then by extending this to clinicians and the juvenile
justice system. As noted, this approach necessitates caution about vio-
lations of privacy and also requires a sensitive person in charge to exer-
cise wise judgment in sharing information about students.
Key Points
The following preventive measures are recommended to lessen the
likelihood of school violence:
■ Increased security measures—more security officers, metal
detectors, electronic devices, and photographic devices in and
around schools
■ Greater sensitivity to signs and symptoms that indicate a troubled
student, or one communicating harm, such as by “leakage.” This
is superior to attempts to profile “school shooters.”
552 ❘ Textbook of Violence Assessment and Management
References
Anderson M, Kaufman J, Simon TR, et al: School-associated violent deaths in
the United States, 1994–1999. JAMA 286:2695–2702, 2001
Beavan K: School violence on the increase. New York Times Educational Sup-
plement, February 12, 1970, p 16
Centers for Disease Control and Prevention: School-associated homicides—
United States, 1992–2006. MMWR Morb Mortal Wkly Rep MMWR 57(2):
33–36, January 18, 2008
Crews GA, Counts MR: The Evolution of School Violence in America. Westport,
CT, Praeger, 1997
Cullen D: The depressive and the psychopath: at last we know why the Colum-
bine killers did it. Slate, April 20, 2004. Available at http://slate.msn.com/
id/2099203. Accessed April 20, 2004
Dinkes R, Cataldi EF, Kena G, et al: Indicators of School Crime and Safety: 2006.
U.S. Departments of Education and Justice. Washington, DC, U.S. Govern-
ment Printing Office, 2006
Fritzon K, Brun A: Beyond Columbine: a faceted model of school-associated ho-
micide. Psychology, Crime and Law 11:53–71, 2005
Hunter L, MacNeil G, Elias M: School violence: prevalence, policies, and pre-
vention, in Juvenile Justice Sourcebook. Edited by Roberts AR. New York,
Oxford University Press, 2004, pp 101–125
Kaufman P, Chen X, Choy S, et al: Indicators of School Crime and Safety, 2001.
Washington, DC, U.S. Government Printing Office, 2001
School Violence ❘ 553
Kim YS, Leventhal BL, Koh Y, et al: School bullying and youth violence. Arch
Gen Psychiatry 63:1035–1041, 2006
MacNeil G: School bullying: an overview, in Handbook of Violence. Edited by
Rapp-Paglicci I, Roberts AR, Wodarski J. New York, Wiley, 2002, pp 247–
261
Malmquist CP: Homicide: A Psychiatric Perspective. Washington, DC, Ameri-
can Psychiatric Publishing, 2006
McGee JP, DeBernardo CR: The classroom avenger: a behavioral profile of
school based shootings. The Forensic Examiner 8:16–18, 1999
Meloy JR, Hempel AG, Mohandie K, et al: Offender and offense characteristics
of a nonrandom sample of adolescent mass murderers. J Am Acad Child
Adolesc Psychiatry 40:719–728, 2001
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Schools: Cross-National and Cross-Cultural Perspectives. Edited by Den-
mark F, Krauss HA, Wesner RC, et al. New York, Springer, 2005, pp 37–57
Nansel T, Overpeck M, Pilla R: Bullying behavior among U.S. youth: preva-
lence and association with psychosocial adjustment. JAMA 285:2094–
3100, 2001
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Study Report to the Congress, Vol 1. Washington, DC, U.S. Government
Printing Office, 1977
National Research Council and Institute of Medicine: Deadly Lessons: Under-
standing Lethal School Violence. Edited by Moore MH, Petrie CV, Braga
AA, et al. Washington, DC, National Academies Press, 2003
Newman KS: Rampage: The Social Roots of School Shootings. New York, Basic
Books, 2004
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Palinkas LA, Prussing E, Landsverk J, et al: Youth-violence prevention in the af-
termath of the San Diego East County school shootings: a qualitative as-
sessment of community explanatory models. Ambul Pediatr 3:246–252,
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tims and offenders of direct and indirect bullying. Pediatrics 111:1312–1317,
2003
The Virginia Tech massacre. The Economist, April 21, 2007, pp 27–29
Vossekuil B, Reddy M, Fein R, et al: Safe School Initiative: An Interim Report on
the Prevention of Targeted Violence in Schools. Washington, DC, U.S. Se-
cret Service, 2000
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C H A P T E R 2 8
Clinically-Based Risk
Management of Potentially
Violent Patients
Robert I. Simon, M.D.
555
556 ❘ Textbook of Violence Assessment and Management
Case Example
Dan, a 36-year-old married man, enters treatment with a psychiatrist for
depression, insomnia, and anxiety. His symptoms arise from long-
standing marital strife. The psychiatrist agrees to see the patient once a
week for psychotherapy and medication management. Within a month
after beginning treatment, Dan begins to suspect that his wife is having
an affair. He finds “racy” e-mails sent to his wife by a coworker. A near-
violent confrontation occurs. She adamantly denies having an affair. He
leaves the home, goes to a hotel, and calls his psychiatrist.
The patient’s psychiatric condition rapidly worsens over the next
week. He is unable to sleep. He ruminates about killing his wife. He ad-
mits to having guns at home. The psychiatrist sees the patient more fre-
quently, adjusts medications, and explores Dan’s potential for violence
toward his wife. Dan has a history of violent rages, although he has
never harmed his wife or anyone else. He intends to break into his
house, get his guns, and threaten to kill his wife.
The psychiatrist informs the patient that psychiatric hospitalization
is necessary. The patient refuses. The psychiatrist performs and docu-
ments a careful violence risk assessment, which indicates that Dan is at
acute, high risk for violence. If he does not enter the hospital voluntarily,
the psychiatrist will be forced to involuntarily hospitalize him. Dan re-
luctantly agrees to hospitalization. With his permission and in his pres-
ence, the psychiatrist calls Dan’s wife and informs her of the violent
threats by her husband. She is not surprised. She is told that Dan is go-
ing directly to the hospital. The locks on her house are changed. A secu-
rity system is installed after she speaks with the police.
Clinically-Based Risk Management ❘ 557
The psychiatrist tells Dan’s wife to remove all guns and ammunition
from the home and secure them in a place unknown to the patient. She
is asked whether guns might be kept in a car, at work, or anywhere else.
The psychiatrist asks for a callback from the patient’s wife once the guns
and ammunition are removed, which he receives within an agreed-
upon time.
Dan shows rapid improvement while on the psychiatric unit. He is
seen daily by his psychiatrist. His medications are adjusted. The treatment
team provides valuable input regarding the patient’s behaviors. No vio-
lent outbursts or threats occur. Depression and agitation moderate.
With the patient’s approval, the psychiatrist arranges for a meeting
with the patient and his wife together on the inpatient unit. With the
psychiatrist present, Dan is able to express his anger appropriately and
safely. His wife openly expresses her disappointments with the mar-
riage, stating that she has had the entire burden of caring for their three
children. The meeting is very emotional but frank and productive. The
psychiatrist recommends marital counseling, which both accept. They
continue to talk by phone.
After performing and documenting a careful violence risk assess-
ment, the psychiatrist determines that Dan’s risk of violence is now low.
As agreed upon during the inpatient meeting, the doctor and the patient
will inform the patient’s wife about the date and time of discharge. Dan
agrees to enter the hospital’s partial hospitalization program on the day
after his discharge. The couple remains separated.
Initially, the psychiatrist sees Dan three times a week to ensure sta-
bilization of his condition. Dan and his wife continue marital therapy.
By mutual agreement, the couple have no other direct contact with each
other. The patient is grateful for the psychiatrist’s care during the crisis.
The therapeutic alliance is strengthened.
The Tarasoff court did not use the phrase “imminent danger.” “Immi-
nent” appears frequently in the mental health literature. It is common par-
lance among clinicians. It is also a legal term of art found in civil commit-
ment statutes; in duty to warn and protect statutes and case law, usually
under the rubric of dangerousness; and in seclusion and restraint policies.
“Imminence” of violence is another word for the short-term prediction of
violence, for which no standard of care exists. “Imminent” violence
should not be a substitute for comprehensive violence risk assessment. It
is a myth firmly entrenched in both psychiatry and the law (Simon 2006).
Clinicians have found that the duty to protect provides more lati-
tude for treatment interventions than the original duty-to-warn doc-
trine. Except in states with immunity statutes limiting the responsibility
of therapists for the patients’ violent acts, no hard-and-fast rules have
been created requiring clinicians to employ specific interventions to
warn and protect endangered third parties. In jurisdictions where no
duty to warn or protect currently exists, case law from other states may
be applied in deciding suits that allege such a duty.
Generally, courts have held that the therapist’s control over an out-
patient is not sufficient to establish a duty to protect without a foresee-
able victim. In treatment of an outpatient, the Tarasoff duty applies
when there is evidence, through either threats or acts, that the patient is
potentially violent to a specific, foreseeable victim. The dangers must be
substantial, involving serious bodily harm or death. If no threats or vi-
olent acts are uncovered after careful clinical evaluation, liability is un-
likely even if violence should occur.
The duty to warn does not obviate implementing other clinical in-
terventions that may be more effective. Simply warning an endangered
third party is rarely sufficient by itself. Other clinical interventions are
usually required—for example, seeing the patient more frequently, ad-
justing medication, or hospitalization.
When the clinician decides to issue a warning, the warning should
take place, if possible, in the presence of the patient and with the pa-
tient’s consent. In an emergency, however, the clinician does not need the
patient’s consent. With few exceptions, a legal problem arising in psychi-
atric treatment can be successfully addressed through good clinical prac-
tice and a clear understanding of the relevant legal requirements. Thus,
warning should be used after other clinical interventions have been tried
and failed or in conjunction with other clinical interventions.
Generally, if the clinician decides to warn, an interview may be ar-
ranged or a phone call made so that the potential victim can ask ques-
tions. Language difficulties between the clinician and the endangered
person may contribute to tragic consequences unless detected and
Clinically-Based Risk Management ❘ 559
Inpatient Discharge
Although the Tarasoff duty was originally applied to the outpatient set-
ting, the same legal duty to protect individuals and society from harm
by mental patients arises for the release of violent inpatients. Generally,
the duty to warn is of narrower scope than the duty not to discharge a
violent patient. In outpatient cases that involve failure to warn and pro-
tect an endangered third party, the threat of violence is serious, violence
is foreseeable, and usually the victim is identifiable. The duty not to dis-
charge a violent inpatient has a broader scope because the patient may
not express specific threats toward persons or groups, thus posing a
threat to the general public. In hospital discharge cases, the clinician’s
duty extends beyond that owed to readily identifiable victims. Psychi-
atrists face greater liability exposure for the release of potentially vio-
lent hospital patients than in outpatient cases alleging a Tarasoff duty
(Simon 1992).
In inpatient release cases, the courts have held that there is a duty to
control, with or without a foreseeable victim. The duty to evaluate the
560 ❘ Textbook of Violence Assessment and Management
Documentation
Documentation is an essential part of good patient care. It encourages
the clinician to sharpen clinical focus and to clarify decision-making ra-
tionale (Simon 2004). The record is an active clinical tool, not just an in-
ert document. The clinician treats the patient, not the chart. Documen-
tation is a risk management measure that also supports good clinical
care.
For patients at risk for violence, it is necessary to document clinical
interventions and the rationale for clinical decisions. Documentation
should specifically address what was done, the reason(s) for doing it,
and the rationale for rejecting alternative interventions and treatment
(Slovenko 2002). Violence risk assessment should be contemporane-
ously documented. If a malpractice claim is made against the psychia-
trist, contemporaneous documentation assists the court in considering
the many clinical complexities and ambiguities that exist in the assess-
ment, treatment, and management of patients at risk for violence.
Clinically-Based Risk Management ❘ 563
Key Points
■ Clinically-based risk management principles are patient centered,
supporting the treatment process and the therapeutic alliance.
Unduly defensive risk management practices based on the clini-
cian’s fear of being sued or the need to provide a legal defense if
sued may subvert good patient care and invite a lawsuit.
■ Risk management principles usually represent ideal or best prac-
tices. The legal standard of care requires only the provision of ordi-
nary or reasonable care.
■ No standard of care exists for the prediction of violence. There is
no research that supports the ability of the clinician to predict who
will or will not be violent. The purpose of violence risk assessment
is to identify treatable and modifiable risk and protective factors
that will inform the clinician’s treatment and management of the
patient.
■ The clinician’s treatment and management of the potentially vio-
lent patient often requires a team approach that includes signifi-
cant others, as well as consultation with other mental health pro-
fessionals, inpatient staff, lawyers, law enforcement officials, and
the judicial system. Never worry alone.
■ The duty to protect endangered third parties from patient vio-
lence should be considered a national standard of care for all men-
tal health professionals.
■ A working knowledge of the legal regulation of psychiatry assists
the practitioner in managing the clinical-legal dilemmas that
often arise in treating and managing potentially violent patients,
while also preserving the doctor-patient relationship.
■ Active case management of a potentially violent patient should
not be attempted by e-mail or video conference.
■ Documentation is an essential aspect of good patient care and
clinically-based risk management.
Clinically-Based Risk Management ❘ 565
References
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death in the home: findings from a national study. Am J Epidemiol 160:929–
936, 2004
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Green v. Ross, 691 502d.542 (Fla. App. 1997)
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American Psychiatric Press, 1992
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Based Risk Management. Washington, DC, American Psychiatric Publish-
ing, 2004
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Acad Psychiatry and Law 33:8–11, 2005
Simon RI: The myth of “imminent” violence in psychiatry and the law. Univ
Cincinnati Law Rev 75:631–644, 2006
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Threat Behav 37:518–526, 2007
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Routledge, 2002
Tarasoff v. Regents of the University of California, 17 Cal. 3d 425, 131 Cal. Rptr. 14,
551 P.2d 334 (1976)
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Index
Page numbers printed in boldface type refer to tables or figures.
567
568 ❘ Textbook of Violence Assessment and Management
Discharge from inpatient facilities, 13, Drug abuse. See Alcohol use/abuse;
14, 559–560, 561 Substance abuse disorders
Classification of Violence Risk for, Drug Enforcement Agency (DEA), 133
25–26 Drug Screening Test, 445
Discrimination, racial, 36 DSH. See Deliberate self-harm
Disorganized and organized crime DSM-IV-TR. See Diagnostic and
scenes, FBI profiling of, 417–418, Statistical Manual of Mental
418 Disorders
Disorientation, in elderly persons, 381 Dusky v. U.S., 410
Dissociation, in culture-bound Duty to warn and protect potential
syndromes, 45 victims, 246, 247, 269, 333–334,
Disturbances in consciousness, driving 373, 430–434, 524, 557–559
safety and, 531 best practices for, 434, 558
Disulfiram inpatient discharge and, 559–560
for alcoholism, 153–154 from intimate partner violence,
for cocaine dependence, 154 492–494
Divalproex. See Valproate issuing a warning, 558–559
Documentation, 562 language barriers and use of
Domestic violence, 41–42. See also translator, 558–559
Intimate partner violence risk management steps for, 559, 560
childhood mood disorders state allowances for therapist
associated with passive discretion in, 433–434
exposure to, 77–78 vs. therapist–patient confidentiality,
escalating pattern of, 7 246, 247, 429–430
parental substance abuse and, 78 Dynamics of violence, 467
screening for, 41 Dysarthria, 6
Donepezil, for Alzheimer’s disease,
392, 393, 399, 402 Eating disorders, self-injurious
Dopamine, 215 behaviors and, 224, 226
Dopamine-β-hydroxylase (DBH), 154 Ecological theory of intimate partner
Driving safety, 7, 521–535 violence, 486
dementia and, 527–531 ECT (electroconvulsive therapy), 316
depression and, 524–526 Elderly persons, 381–404
disturbances of consciousness and, alcohol-related abuse of, 145
531 assessment in, 383–394
intoxication and, 522 chief complaint, 383–386
legal duties of clinicians to prevent in inpatient setting, 383
vehicular crashes, 531–534 mental status examination, 389–
Physician’s Guide to Assessing and 394
Counseling Older Drivers, 528– attentional problems, 389–
530 390
psychosis, schizophrenia and, 523– cognitive and memory
524 impairment, 390–392
suicidal drivers, 522, 524–526 disorders of mood and
warning patients about medication affective regulation,
effects on, 522–523, 532–533 392–394
Droperidol, intramuscular, 304 thought processing, 392
Index ❘ 583
RRASOR (Rapid Risk Assessment for Schizophrenia, 4, 13, 27, 105–119, 301
Sexual Offender Recidivism), 29, antisocial personality disorder and,
437 250–251
availability of potential victim to
Sadism, 330. See also Sexual sadism patient with, 7
Safety causes of violence in, 10
of aggressive elderly persons and clinical violence risk assessment in, 12
their caregivers, 395 command hallucinations in, 108–
of clinician, 248–249, 254, 332, 461– 109, 267, 267–268
478 conduct disorder and, 250–251
of clinician’s office, 248–249, 332, delusions in, 10, 12, 265–266
463–464, 465–466, 476–477 diagnosed in emergency setting, 279
vs. confidentiality, 241, 247 driving safety and, 523–524
driving, 521–535 escalating pattern of violence in, 7
duty of clinicians to warn and inpatient management of violent
protect potential victims, 246, patients, 113–118
247, 269, 333–334, 373, 430–434, case examples of, 116–118
524, 557–559, 560 intimate partner violence and, 485
in emergency settings, 13, 14, 281, motivations for assault in patients
282, 291, 462–463, 470 with, 109, 113
gun safety management, 6, 372, 373, pharmacotherapy for aggression/
557, 562, 563 agitation in, 113, 114, 302–303
management of armed patient, 476 prevalence of violence in, 250–252
of patient in restraints, 347 psychosis in, 10
protecting victims and reporting of pyromania and, 219
intimate partner violence, 492– reversible risk factors for violence
494 in, 106
seclusion room design for, 350 self-injurious behaviors in, 225
weapons checks for, 46, 249, 332, 462 substance abuse and, 250
of workplace, 507 violence and positive symptoms of,
Sarcoidosis, 198 252
SASSI (Substance Abuse Subtle violence assessment in, 105–113
Screening Inventory), 69, 72 association with symptoms of
Satiation (masturbatory), for mental illness, 107–109
paraphilias, 453 classification of assaults, 109–111
SAVD (School-Associated Violent research on classification of
Death) study, 539 assaults, 110–111
SAVRY (Structured Assessment of videotape recording of inpatient
Violence Risk in Youth), 370 assaults, 111–112
Scheduling appointment for violence Schizotypal personality disorder, 174,
risk assessment, 466 176, 179–180
Schizoaffective disorder, 12, 251, 302 Schneidman, E.S., 418–419
Schizoid personality disorder School threat assessments, 371–372
purposeful, targeted, defensive School violence, 79, 359, 365, 371, 537–
violence and, 171 552
targeted, impulsive violence and, background of, 538
174 bullying, 540–541
Index ❘ 605