Psychopha opharm

Philip G. Janicak, MD, Editor

Volume 45 Number 10 October 2010

Timely Reports in Psychopharmacology and Device-Based Therapies

R E V I E W

Formerly Frank Ayds International Drug Therapy Newsletter

Violence Risk Assessment: Part I

Jonathan J. Howard, MD, and James L. Cavanaugh Jr, MD

L E A R N I N G

O B J E C T I V E S

After participating in this activity, the psychiatrist should be better able to:
Evaluate approaches to assessing the potential for violence. Identify risk factors, and combinations of factors, indicating potential for violence. Interpret the relationship between risk factors as markers.

This article is part I of a 2-part series.

hen performing a violence risk assessment, there are competing viewpoints as to which variables should be considered. Such variables are generally integrated into a theoretical model of the patients personality and behavior to either stratify the likelihood of becoming violent or inform treatment decisions. In the past, psychiatrists relied solely on unstructured clinical judgment, which was harshly described by Ennis and Litwack1 as having absolutely no expertise in predicting dangerous behavior and further marginalized by Lidz and colleagues2 in a case-controlled study. The introduction of actuarial methods (statistically oriented structured risk assessment), which identify and weigh various factors to minimize error-prone clinician subjectivity,
IN THIS ISSUE
Violence Risk Assessment: Part I . . . . . . . . . . . . . . . . . . 75 CME Quiz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

offers promise but remains underutilized by psychiatrists. This may be defensive posturing in response to statements such as Actuarial methods are too good and clinical judgment is too poor to risk contaminating the former with the latter. 3 In 1999, one-third of US psychiatric residents stated that they had no training in violence risk assessment, whereas another third described their training as inadequate.4 This was 4 years after the development of the Historical, Clinical, Risk Management 20-item (HCR-20) violence risk assessment scale,5 6 years after the publication of the Violence Risk Appraisal Guide (VRAG),3 and nearly 20 years after publication of the forerunner of the Psychopathy Checklist.6 Currently, there is no American Psychiatric Association practice guideline for violence risk assessment that resembles the established guideline for suicide risk assessment and treatment. Combining elements from the mental status examination and an actuarial instrument is referred to as structured professional judgment. Miller7 described this as identifying historical risk factors that characterize the context of an individuals aggressive behavior and risk factors
Dr. Howard is Attending Psychiatrist, Cermak Health Services of the Cook County Jail, 2800 S. California, Chicago, IL 60608, and in private practice, E-mail: [email protected]; and Dr. Cavanaugh is Professor, Department of Psychiatry, Rush University Medical College, Chicago, IL. All faculty and staff in a position to control the content of this CME activity and their spouses/life partners (if any) have disclosed that they have no financial relationships with, or financial interests in, any commercial organizations pertaining to this educational activity.

LWW.com

Lippincott Continuing Medical Education Institute, Inc. is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Lippincott Continuing Medical Education Institute, Inc., designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit. Physicians should only claim credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME article(s) and complete the quiz and evaluation assessment survey on the enclosed form, answering at least 80% of the quiz questions correctly. This activity expires on September 30, 2011.

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E d i t o r Philip G. Janicak, MD Professor of Psychiatry Medical Director, Psychiatric Clinical Research Center Rush University Medical Center, Chicago, IL

empirically correlated with dangerousness to formulate a clinical judgment of relative risk.

STATE OF THE ART IN VIOLENCE RISK ASSESSMENT

A PubMed search (key words: violence and psychiatry) returned 992 articles from all available documents on PubMed with no time period specified. Textbooks in the field and literature on topics commonly associated with violence in psychiatric patients (including traumatic brain injury [TBI], substance abuse, and personality disorders) were also reviewed. Dynamic risk factors are defined as malleable and more pertinent to managing violence risk as opposed to static variables that are not amenable to change (Table 1).8 Static (historical) and dynamic risk factors were identified throughout the literature and clinical approaches compared/ contrasted with actuarial instruments. The primary goal of this article is to identify common elements throughout these domains and the evidence-based variables vital in the process of violence risk assessment, so that clinicians can better clarify the risk of violence and implement strategies to prevent its occurrence. In part II, a second goal is to generate an algorithm that establishes relationships between these same variables to inform treatment decisions (eg, civil commitment, augmented supervision, consultation with a forensic specialist).

A s s o c i a t e

E d i t o r

Jeffrey T. Rado, MD Assistant Professor of Psychiatry Rush University Medical Center, Chicago, IL

E d i t o r i a l

A s s i s t a n t

Sandra M. Stugis, BS Rush University Medical Center, Chicago, IL

E d i t o r i a l Daniel J. Carlat, MD Assistant Clinical Professor of Psychiatry, Tufts University School of Medicine, Boston, MA James W. Jefferson, MD Clinical Professor of Psychiatry University of Wisconsin School of Medicine and Public Health Distinguished Senior Scientist Madison Institute of Medicine Madison, WI

B o a r d Christopher J. McDougle, MD Albert E. Sterne Professor and Chairman Department of Psychiatry Indiana University School of Medicine, Indianapolis, IN David N. Osser, MD Associate Professor of Psychiatry Harvard Medical School Taunton State Hospital Taunton, MA Rajiv Tandon, MD Adjunct Professor of Psychiatry University of Florida Chief of Psychiatry, Florida Office of Mental Health, Tallahassee, FL

STATIC RISK FACTORS

Psychopathy and Personality Disorders The text revision of the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR 2000) defines personality disorders as enduring subjective experiences and behavior, which deviate from cultural standards, are rigidly pervasive, have an onset in adolescence or early adulthood, are stable through time, and lead to unhappiness and impairment.9 Cleckley described the psychopathic personality as having traits of guiltlessness, superficial charm, egocentricity, and lack of remorse.10 This was incorporated into the DSM-I and, after much debate, subsequently reconfigured as antisocial personality disorder (ASPD) in 1980 with the publication of DSM-III.11 The current DSM emphasizes the behavioral aspects (failure to conform to social norms, deceitfulness, irresponsibility) of persons with ASPD rather than the personality characteristics themselves. Hare reflected upon the difficulty in reliably assessing personality traits by stating, it is easier to agree on the behaviors that typify a disorder than on the reasons why they occur.12 According to Hare, psychopathy is a multidimensional entity: Factor 1 entails the core personality traits of the psychopath (eg, aggressive narcissism), and is correlated with narcissistic and histrionic personality disorders; and

This continuing education activity is intended for psychiatrists and other health care professionals with an interest in psychotropic drug therapy. Psychopharm Review (ISSN 1936-9255) is published monthly by Lippincott Williams & Wilkins, 16522 Hunters Green Parkway, Hagerstown, MD 21740-2116. Customer Service: Phone (800) 638-3030, Fax (301) 223-2400, E-mail [email protected]. Visit our website at LWW.com. Copyright 2010 Lippincott Williams & Wilkins, Inc. All rights reserved. Priority postage paid at Hagerstown, MD, and at additional mailing offices. GST registration number: 895524239. POSTMASTER: Send address changes to Psychopharm Review Subscription Dept., Lippincott Williams & Wilkins, P.O. Box 1600, 16522 Hunters Green Parkway, Hagerstown, MD 21740-2116. Publisher: Terry Materese PAID SUBSCRIBERS: Current issue and archives (from 1999) are now available FREE online at www.lwwnewsletters.com. Subscription rates: Personal: $267.98 US, $360.58 Foreign; Institutional: $567.98 US, $629.58 Foreign; In-Training: $116.98 US, $134.58 Foreign. Single copy: $51. Send bulk pricing requests to publisher. COPYING: Contents of Psychopharm Review are protected by copyright. Reproduction, photocopying, and storage or transmission by magnetic or electronic means are strictly prohibited.Violation of copyright will result in legal action, including civil and/or criminal penalties. Permission to reproduce in any way must be secured in writing; e-mail [email protected]. Reprints: For commercial reprints and all quantities of 500 or more, e-mail [email protected]. For quantities of 500 or less, e-mail [email protected], call 1-866-903-6951, or fax 1-410-528-4434.

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Table 1. Violence Risk Assessment Variables

Static risk factors History of violence Best predictor for future violence
23

Female psychotic inpatients more violent in first 10 days48 Male assailants, substance abuse, property crime, school truancy48 Males violent with drug use, noncompliance, and history of serious violence48 Females more violent against family in home49 Males increased violence with threat delusions50 Family history of violence Parental violent crime correlated with violent convictions in children with schizophrenia30 Age Younger age associated with increased rates of major/minor violence in schizophrenia27 Young age at first violence is a risk factor for future violence in forensic populations3,5,18 Young age predictive of future violence in sex offenders33 Younger age significant covariate for serious violence in those with schizophrenia27 Traumatic brain injury TBI with LOC associated with persistently aggressive physical behavior29 TBI associated with violent victimization, frequent antisocial behavior, lifetime exposure to violent trauma45 TBI twice as likely in forensic psychiatric patients with psychopathy (30%)46 Dynamic risk factors Compliance Noncompliant substance-abusing patients twice as likely to be violent while with either problem alone no more violent than baseline37 Treatment adherence reduces violence in schizophrenia over 6 mo51 Perceived treatment need with perceived treatment benefit and compliance reduces violence8 Clinical symptoms Current agitation and immediate past violent behavior strong determinants of inpatient violence52 Patients with violent ideation more likely to be physically violent in first 24 hours as inpatients53 Elevated BPRS hostility-suspiciousness subscale predicted escalating violence (to physical) in inpatients, whereas those already physically aggressive with elevated thought disturbance continued physical violence29 PANSS elevated hostility subscale increases risk of serious violence in CATIE27 Threat control overrides risk factor in males50

Base rate violence, 2% vs 13% in mentally ill25 MacVRAS 18.7% violent @ 20 wks, CATIE 19.1%. individuals with schizophrenia violent @ 6 mo26,27 Arrest OR for future violence, 4.285.8527 Recent violence OR, 9 for future violence28 Recent physical aggression correlation with past violence29 92% of inpatient assailants have a history of violence24 Historical items of HCR-20 predict violence and homicides18 Psychopathy High narcissism and self-esteem associated with severe violence15 38% with psychopathy violent in 24 wks vs 16% below cutoff22 Externalizing problems and poor frustration tolerance lead to violence7 MacVRAS psychopathy, r 0.26 as highest correlate Psychopathy ROC strong17 Psychopathy increased in forensic psychiatric populations22 Substance abuse Epidemiologic surveys find 25% abusing alcohol and 35% abusing drugs are violent over 1 year25 Increased violence with long-term drug abuse due to CNS changes38 Increased with mental illness (31% for both vs 18% no substance). PD substance malinger 43% violent39 OR of violence 4 times with schizophrenia substance use. Also 27% of individuals with schizophrenia and substance abuse were violent, whereas only 18% of unaffected siblings were violent40 Without substance use, mental illness is actually protective (r 0.19)16 Victimization Increases future violence in males35 CATIE 4 times OR for violence with victimization within last 6 mo27 History of physical abuse and victimization within past years increases violence36 67% of assailants have past victimization (74% females)24 Serious child abuse and frequency of child abuse, r 0.14 MacVRAS16 Criminal victimization increases violence37 Sex Violence associated with male sex25
16

VRAG MacVRAS personality traits strongest cause of violence19

BPRS, Brief Psychiatric Rating Scale; CATIE, Clinical Antipsychotic Treatment Intervention Effectiveness; CNS, central nervous sytem; HCR-20, Historical, Clinical, Risk Management 20-item violence risk questionnaire; LOC, loss of consciousness; MacVRAS, MacArthur Violence Risk Assessment Study; OR, odds ratio; PANSS, Positive and Negative Syndrome Scale; PD, personality disorder; ROC, receiver operating characteristic; TBI, traumatic brain injury; VRAG, Violence Risk Appraisal Guide.

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Factor 2 is historically oriented, including presence of early behavior problems, socially deviant lifestyle, chronic instability; and is correlated with ASPD, criminality, impulsive violence, and reactive anger.13

Components of psychopathy are independently associated with violence.14 For example, both high narcissism scores (as measured on the Narcissistic Personality Inventory-21) and elevated self-esteem were associated with severe violence based on a multivariate analysis in a cross-sectional study of acute inpatients.15 Alternatively, Millers7 violence assessment model identifies associated personality characteristics: Low frustration tolerance; Vulnerability to criticism; Feelings of humiliation; Powerlessness; and A pattern of externalizing problems.7

Psychopathy is one of the 12 factors in the VRAG3 and 10 historical items in the HCR-20.5 These instruments use the Psychopathy Checklist (20-item PCL-Revised, 1991, or 12-item PCL-Screening Version [PCL-SV], 1995).13 An elevated score on the PCL-SV was strongly associated with violence, surpassing all other risk factors as a correlate (Pearson r 0.26) in the MacArthur Violence Risk Assessment Study.16 The PCL is also independently predictive of violence and is cross-validated with other actuarial instruments.17,18 Psychopathy is such a strong factor that the authors of the VRAG reinterpreted the data from the MacArthur study with a modified instrument and concluded that the fact that psychopathy is such a robust predictor of violence across populations suggests that personality traits associated with psychopathy must be among its most important causes.19 This point was ironically reinforced in a study comparing the VRAG with the PCL-SV. In a large sample of civil psychiatric patients, the VRAG did not improve the predictive validity of the PCL-SV alone, although the VRAG includes 11 additional variables apart from psychopathy.20 Psychopathic traits are distributed within the general population, with one study showing 1% to 2% of persons meeting the criteria (score 12 on the PCL-SV).21 A UK prospective study of forensic/nonforensic patients reported that 38% of those meeting criteria for psychopathy on the PCL-SV were violent within 24 weeks of discharge, compared with only 16% scoring less than the cutoff.22 History of Violence A history of violence is the single best predictor of future violence.23 Indeed, a large-scale, 10-year Massachusetts

study demonstrated a history of violence in 87% of outpatient and inpatient assailants.24 Another key factor is appreciating that base rates of violence are low for the general population but increased in those with mental illness. The National Epidemiological Catchment Area Survey showed that 2% of those with no mental disorder and 11% to 13% of those with mental illness were violent during a 1-year period.25 The MacArthur study demonstrated that 18.7% of psychiatric patients committed a violent act over a 20-week period after discharge from civil facilities.26 This is consistent with data from the Clinical Antipsychotic Treatment Intervention Effectiveness (CATIE) trial in which 19.1% of the 1410 schizophrenia patients reported any kind of violence with a subset of 3.6% reporting serious violence over 6 months. The leading bivariate association was arrested or picked up for a crime during the past 6 months and produced an odds ratio of 4.28 for minor violence and 5.85 for major violence.27 It should be noted that the CATIE and MacArthur studies used collateral history, which probably increased their accuracy over self-report epidemiologic efforts that document relatively low baseline rates of violence. Arrest history could be taken as an approximation for past violence. In the MacArthur study, 1136 patients were followed after discharge, and just below a high PCL-SV score (r 0.26) as the strongest bivariate of violence were seriousness of prior arrest (r 0.25) and frequency of adult arrest (r 0.24). This same study reported that recent violent behavior leading up to admission (r 0.14) was less strongly associated with violence at 20 weeks postdischarge, suggesting that an amplified quantity and quality of past violence is a particularly robust predictor of future violence.16 Without clarification, recent violence could be interpreted as another chapter in a history of violence; but in a prospective study, patients violent the week before admission were 9 times as likely to be violent in the 2 weeks after discharge than previously nonviolent patients.28 This association was also observed in a study where recent physical aggression was strongly correlated with a history of physical aggression, suggesting that these behaviors persist.29 An additional variable is a family history of violence. A link between parental violent crime and violent convictions in their children with schizophrenia was reported in a large-scale Swedish study. The authors concluded that familial (genetic or early environmental) factors play a role in the etiology of violence.30 Age Younger age is associated with increased rates of both minor and major violence in schizophrenia. This is consistent with Monahans overall observation that Violence peaks in early adulthood and decreases with age.31

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Young age at first violence is also identified in forensic psychiatric populations as a risk factor for future violence.3,5,18 For example, Quinsey and Maguire32 found young age, seriousness of first offense (index offense), and history of economic crime predictive of future violence in patients followed 11 years after release from a maximum-security facility. A study of 342 male sex offenders followed 5 years postrelease noted that a history of offense and young age were significantly predictive of sexual reoffending on other adults, and nonsexual violent and nonviolent offending.33 It should be appreciated that there is a convergence of variables in that younger age (whether at first offense, release, or as measured in the study) are all reflective of early offending. This association between early violence and later severe violence was also noted in the CATIE trial, with the 3 significant covariates for serious violence (ie, assault, threat with a lethal weapon, or sex offense) being younger age, childhood conduct problems, and arrest history.27 Victimization Victimization and mental illness were positively correlated in the National Co-morbidity Survey,34 and these victims themselves become perpetrators. This was reflected in a study in which victimization predicted future violence in psychiatric patients, with an especially strong link in men.35 In the CATIE Study, those with schizophrenia who experienced violent victimization were 4 times as likely to commit a violent act in the preceding 6 months as nonvictims.27 The National Epidemiological Survey on Alcohol and Related Conditions (NESARC) reported that a history of both physical abuse and victimization within the past year were robust predictors of violence.36 In the Massachusetts study, 67% of outpatient assailants reported a history of victimization.24 The MacArthur study also reported that suffering serious and frequent abuse as a child was a risk factor for future violence, with seriousness of abuse as important a predictor as recent violent behavior (Pearson r 0.14).16 In a retrospective study of involuntarily admitted patients, a bivariate analysis demonstrated an association between violence and being male or African American, substance abuse, and recent criminal victimization. African Americans, however, were no more likely than whites to commit violence unless recently victimized, and the authors proposed that higher rates of criminal victimization in African American neighborhoods may explain this association.37 Substance Abuse Alcohol and drug abuse can exacerbate psychopathology and may increase violence in persons with no psychiatric disorder. The Epidemiological Catchment Area Survey reported 25% of those abusing alcohol and 35% abusing drugs were violent over a 1-year period.25

Acute intoxication is associated with disinhibition, impulsivity, and emotional lability. Long-term use of substances episodically increases violence risk and may cause long-term CNS changes leading to psychiatric symptoms associated with violent behavior.38 In the MacArthur study, those with a major mental disorder and substance abuse had a 1-year violence rate of 31% compared with 17.9% of those with a major mental disorder and no substance abuse. In one cohort, the incidence of violence in psychiatric patients without substance abuse was statistically indistinguishable from matched controls without substance abuse.39 Of interest, this study categorized one group as other in that patients did not meet diagnostic criteria for a major mental disorder but rather endorsed substance abuse and some measure of adjustment or personality disorder, often with a chief complaint of suicidal. This group had the highest rate of violence (43%), suggesting some cluster of mental illness, psychopathy, and substance abuse as a particularly dangerous combination. A recent study compared 8000 patients with schizophrenia to unaffected siblings and general population controls. The investigators demonstrated the risk of violent crime in individuals with schizophrenia and substance abuse was 4-fold compared with the control group. But even though 27.6% of those with comorbid substance abuse were violent, 18% of their unaffected siblings were also violent, compared with the general population rate of 5.3%.40 Again, this suggests a shared genetic or environmental factor in the violent siblings. This increased rate of violence in substance-abusing schizophrenics was consistent with CATIE participants, where substance abuse increased the odds of serious violence by a factor of 4. Confounders such as psychotic symptoms and childhood conduct disorder, however, ultimately rendered the effect of substance abuse as insignificant. The authors attributed its effect to mediating or potentiating psychopathology and other factors.27 The NESARC study demonstrated that individuals with a co-occurring major psychiatric diagnosis and substance abuse have a significantly higher incidence of violent acts than subjects with substance abuse alone. In the final analysis, the authors concluded that a mentally ill person without substance abuse and a history of violence has the same chances of being violent within the next 3 years as the general population.36 It seems that the combination of mental illness and substance abuse is an exponential modifier for violence risk. This is problematic because in the NESARC Study, 46% with severe mental illness reported a lifetime history of substance use/dependence. This was consistent with 37.5% of CATIE participants endorsing substance

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use/dependence, and an additional 24.5% endorsing drug or alcohol use without impairment. Regardless of whether it is use, abuse, or impairment, the hazard lies in the fact that the majority (62.0%) of CATIE patients were using substances at some level.27 The MacArthur study went further in reporting the Pearson r coefficient for increased violence risk with comorbid substance abuse to be 0.19 for those with a major mental disorder, but having a major mental disorder without substance abuse was actually protective against future violence in the bivariate analysis with a Pearson r coefficient of 0.19.16 Head Trauma In the United States, 1.5 to 2 million individuals sustain a TBI each year, with 70,000 to 90,000 individuals experiencing substantial sequelae.41 Frontal lobe injury (with dysregulation of subcortical and limbic structures) is a possible mechanism leading to violent impulse-control disorders.42 This is further supported by a literature review linking prefrontal cortex disorders and increased rates of aggressive and antisocial behaviors.43 Complicating matters, several risk factors for TBI are also risk factors for a psychiatric condition, including being male, young adult age, substance abuse, and psychosocial disadvantage. A 2007 literature review reported that both a premorbid psychiatric disorder and lower socioeconomic status increase the risk for development of a post-TBI psychiatric syndrome.44 The relationship between head trauma, violence, and incarceration is complex, but clearly a subset of offenders (violent or not) has a history of TBI before incarceration. One study of incarcerated youth in Missouri reported that 18.3% had a history of serious TBI and in the bivariate analysis, past year violent victimization, frequency of antisocial behavior, and lifetime exposure to violent trauma were among the strongest correlates of TBI. This suggests that assault is a significant source of TBI in this population.45 Another study examined how forensic psychiatric patients with TBI differed from those without TBI. The authors reported that those with schizophrenia had a lower prevalence of TBI (42.7%) than those with alcohol or substance abuse/dependence (55%), whereas those diagnosed with ASPD/psychopathy were twice as likely to have TBI as those without.46 Causality is difficult to ascribe between TBI and violence because of confounders in poverty-ridden environments that have elevated base rates of TBI.47 A review of prevalence rates and causality concluded, TBI is more often a consequence than cause of substance abuse, with increased prevalence of substance abuse in TBI reflective of enduring, pre-morbid abuse patterns and coping strategies.44 In summary, the TBI literature shows a cluster of risk factors associated with violence (substance abuse, victim-

ization, and antisocial behavior/psychopathy) that is both apparent and repetitive, ultimately resembling a syndrome. Gender Epidemiologic studies report that violence is usually associated with younger age, low socioeconomic status, substance abuse, and male sex.25 Although gender is important, these studies fail to account for specific genderrelated differences in psychiatric patients. The Massachusetts study demonstrated nearly equal gender inpatient assault rates, but this trend did not hold in the community where nearly two-thirds of assailants were female.24 Inpatient assault rates by gender were similar in one prospective study, but women were more frequently verbally assaultive, with psychotic women showing increased rates of overall violence as a consequence of high arousal/excitation and higher rates of physical assaults within the first 10 days of hospitalization. Men had higher rates of community physical assaults and violence associated with substance abuse, and histories of nonviolent property crime and school truancy. The authors hypothesized that the higher incidence of community violence in men equated to more pervasive antisocial tendencies with acute psychotic symptoms enhancing a long-term predisposition toward violence.48 The MacArthur study reported that men were more likely to use street drugs or alcohol and less compliant with medications before committing violence than women. Furthermore, the quality of male violence was more serious. In contrast, women were more likely to target family members and be violent within the home.49 Based on the MacArthur study data, the authors concluded that gender has effects on stress coping, with men being significantly more likely than women to engage in violence while experiencing delusions of perceived threat.50

CONCLUSIONS
In part I of this article, we briefly describe various approaches to violence risk assessment before reviewing specific historical risk factors associated with future violence. In doing this, we culled data from large-scale studies that were representative of populations which a general psychiatrist would likely encounter. We specifically identified evidence-based historical variables including psychopathy, a history of violence, younger age, victimization, substance abuse, and head trauma and described how the respective genders situationally impact violence risk. Careful attention to these issues may help preclude violent behaviors. Part II of the article will review dynamic risk factors associated with violence and examine the underlying evidence supporting clinical versus actuarial approaches to violence risk assessment. In addition, we will discuss a proposed

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algorithm for clinicians conducting a violence risk assessment based on data shown in Table 1.

24. Flannery RB Jr, Fisher W, Walker A, et al. Characteristics of assaultive psychiatric inpatients: ten-year analysis of the assaulted staff action program ASAP. Psychiatr Q. 2002;73(1):59-69. 25. Swanson JW, Holzer CE III, Ganju VK, et al. Violence and psychiatric disorder in the community: evidence from the epidemiologic catchment area surveys. Hosp Community Psychiatry. 1990;41(7):761-770. 26. The MacArthur Violence Risk Assessment Study Executive Summary. http://www.macarthur.virginia.edu/risk.html. Accessed July 23, 2010. 27. Swanson J, Swartz MS, Van Dorn RA, et al. A national study of violent behavior in persons with schizophrenia. Arch Gen Psychiatry. 2006;63:490-499. 28. Tardiff K, Marzuk P, Leon AC, et al. A prospective study of violence by psychiatric patients after hospital discharge. Psychiatr Serv. 1997;48:678-681. 29. Amore M, Menchetti M, Tonti C, et al. Predictors of violent behavior among acute psychiatric patients: clinical study. Psychiatry Clin Neurosci. 2008;62:247-255. 30. Fazel S, Grann M, Carlstrom E, et al. Risk factors for violent crime in schizophrenia: a national cohort study of 13,806 patient. J Clin Psychiatry. 2009; 70(3):362-369. 31. Monahan J. The Clinical Prediction of Violent Behavior. Rockville, MD. NIMH; 1981. 32. Quinsey VL, Maguire A. Maximum security psychiatric patients: actuarial and clinical predictions of dangerousness. J Interpers Violence. 1986;1:143-171. 33. Hall GCN. Criminal behavior as a function of clinical and actuarial variables in a sexual offender population. J Consult Clin Psychol. 1988;56:773-775. 34. Kessler R, Molnar B, Feurer I, et al. Patterns and mental health predictors of domestic violence in the United States: results from the national comorbidity survey. Int J Law Psychiatry. 2001;24:487-508. 35. Carmen EH, Rieker PP, Mills T, et al. Victims of violence and psychiatric illness. Am J Psychiatry. 1984;141:378-383. 36. Elbogen EB, Johnson SC. The Intricate link between violence and mental disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2009;66(2):152-161. 37. Swartz MS, Swanson JW, Hiday VA, et al. Violence and severe mental illness: The effects of substance abuse and non-adherence to medication. Am J Psychiatry 1998;155(2):226-231. 38. Tardiff KJ, Wallace Z, Tracy M, et al. Drug and alcohol use as determinants of New York City homicide trends from 1990-1998. J Forensic Sci Soc. 2005;50:1-5. 39. Steadman HJ, Mulvey EP, Monahan J, et al. Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Arch Gen Psychiatry. 1998;55:393-401. 40. Fazel S, Langstrom N, Hjern A, et al. Schizophrenia, substance abuse, and violent crime. JAMA. 2009;301(19):2016-2023. 41. National Institutes of Health. Rehabilitation of persons with traumatic brain injury. JAMA 1991;282:974-983. 42. Grafman J, Schwab K Warden D, et al. Frontal lobe injuries, violence, and aggression: a report of the Vietnam head injury study. Neurology. 1996;46: 1231-1238. 43. Brower MC, Price BH. Neuropsychiatry of frontal lobe dysfunction in violent and criminal behavior: a critical review. J Neurol Neurosurg Psychiatr. 2001;71:720-726. 44. Rogers JM, Read CA. Psychiatric comorbidity following traumatic brain injury. Brain Inj. 2007;21(13/14):1321-1333.

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1. Ennis BJ, Litwack TR. Psychiatry and the presumption of expertise: flipping coins in the courtroom. Cal L Rev. 1974;62:693-752. 2. Lidz CW, Mulvey EP , Gardner W. Accuracy of predictions of violence to others. JAMA. 1993;269(8):1007-1011. 3. Quinsey V , Harris G, Rice M, et al. Violent Offenders: Appraising and Managing Risk, 2nd ed. Washington, DC: American Psychological Association, 2006. 4. Schwartz TL, Park TL. Assaults by patients on psychiatric residents: a survey and training recommendations. Psychiatr Serv. 1999;50(3):381-383. 5. Webster C, Douglas K, Eaves D, et al. HCR-20: Assessing Risk for Violence (Version 2). Vancouver, British Columbia, Canada: Simon Fraser University; 1997. 6. Hare RD. A research scale for the assessment of psychopathy in criminal populations. Pers Indiv Dif. 1980;1:111-121. 7. Miller MC. A model for the assessment of violence. Harv Rev Psychiatry. 2000;7:299-304. 8. Elbogen EB, van Dorn RA, Swanson JW, et al. Treatment engagement and violence risk in mental disorders. Br J Psychiatry. 2006;189:354-360. 9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Revision. Washington, DC: American Psychiatric Association; 2000. 10. Cleckley H. The Mask of Sanity. St. Louis: Mosby, 1941. 11. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, DC: American Psychiatric Association; 1980. 12. Hare RD. Psychopathy and antisocial personality disorder: a case of diagnostic confusion. Psychiatr Times. 1996;13(2):39-40. 13. Hare RD. The Psychopathy ChecklistRevised. 2nd ed. Toronto, Ontario, Canada: Multi-Health Systems; 2003. 14. Trestman RL. Clinical correlates and predictors of violence in patients with personality disorders. Psychiatr Ann. 1997;27:741-744. 15. Svindseth MF, Nottetad JA, Wallin J, et al. Narcissism in patients admitted to psychiatric acute wards: its relation to violence, suicidality, and other psychopathy. BMC Psychiatry. 2008;27(8):13. 16. Monahan J. Developing a clinically useful actuarial tool for assessing violence risk. Br J Psychiatry. 2000;176:312-319. 17. Buchanan A. Risk of violence by psychiatric patients: beyond the actuarial versus clinical assessment debate. Psychiatr Serv. 2008;59(2):184-190. 18. Claix A, Pham TH. Evaluation of the HCR-20 violence risk assessment scheme in a Belgian forensic population. Encephale. 2004;30(5):447453. 19. Harris GT, Rice ME, Camilleri JA, et al. Applying a forensic actuarial assessment (the violence risk appraisal guide) to non-forensic patients. J Interpers Violence 2004;19(9);1063-1074. 20. Edens JF, Skeem JL, Douglas KS. Incremental validity analyses of the violence risk appraisal guide and the psychopathy checklist: screening version in a civil psychiatric sample. Assessment. 2006;13(3):368-374. 21. Neuman CS, Hare RD. Psychopathic traits in a large community sample: links to violence, alcohol use, and intelligence. J Consult Clin Psychol. 2008;76(5):893-899. 22. Doyle M, Dolan M. Predicting community violence from patients discharged from mental health services. Br J Psychiatry. 2006;189:520526. 23. Klessen D, OConnor WA. A prospective study of predictors of violence in adult male mental health admissions. Law Hum Behav. 1988;12:143-158.

45. Perron BE, Howard MO. Prevalence and correlate of traumatic brain injury among delinquent youths. Crim Behav Ment Health. 2008;18:243-255. 46. Colantonio A, Stamenova V , Abramowitz C, et al. Brain injury in a forensic psychiatry population. Brain Inj. 2007;21(13/14):1353-1360. 47. Muscat JE. Characteristics of childhood homicide in Ohio 1974-84. Am J Public Health. 1988;78:822-824.

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48. Krakowski MK, Czobor P. Gender differences in violent behaviors: Relationship to clinical symptoms and psychosocial factors. Am J Psychiatry. 2004;161(3):459-465. 49. Robbins PC, Monahan J, Silver E. Mental disorder, violence, and gender. Law Hum Behav. 2003;27(6):561-571. 50. Teasdale B, Silver E, Monahan J. Gender, threat/control-override delusions and violence. Law Hum Behav. 2006;30(6):649-658.

51. Swanson J, Swartz M, Van Dorn RA, et al. Comparison of antipsychotic medication effect in reducing violence in people with schizophrenia. Br J Psychiatry 2008;19(1):37-43. 52. Beck JC, White KA, Gage B. Emergency psychiatric assessment of violence. Am J Psychiatry 1991;148(11):1562-1565. 53. McNiel DE, Binder RL. Predictive validity of judgments of dangerousness in emergency civil commitment. Am J Psychiatry 197;144(2):197-200.

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1. Certain historical risk factors have been identified as predictors for future violence. In the MacArthur Study, psychopathy (as measured through psychological testing) and arrest history (public record) were nearly equivalent in predicting future violence. A. True B. False 2. In US epidemiology studies, people with major mental illness had increased rates of violence. A. True B. False 3. Substance abuse has no effect on violent behaviors. A. True B. False 4. People with major mental illness and no substance abuse are no more likely than those without major mental illness and no substance abuse to be violent in the future. A. True B. False

5. A 48-eight-year-old man with schizoaffective disorder has been arrested approximately 20 times, incarcerated for 15 years (eg, conviction for sexual assault at age 15), and reports 3 suicide attempts. He began marijuana and alcohol use at age 14 and crack cocaine at age 20. Recently, the patient stopped taking medications and began drinking and using crack cocaine. He believed an acquaintance was plotting against him and subsequently murdered this person. He is delusional and experiencing apparent internal stimulation, with severe paranoid ideation. Which of the following statements describes a risk factor in this patient that predicts his violent behavior? A. Substance use at a young age B. Meets criteria for psychopathy C. Noncompliance and lack of a perceived need for treatment D. All of the above

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