Dr adrian keller psychosis and violence vietnam conference presentation final version

VIOLENCE AND MENTAL ILLNESS – RISK ASSESSMENT AND MANAGEMENT Dr Adrian KellerForensic PsychiatristJustice Health, NSW... Psychosis and violence –o Comorbid substance abuse substantially

VIOLENCE AND

MENTAL ILLNESS – RISK ASSESSMENT AND MANAGEMENT

Dr Adrian KellerForensic PsychiatristJustice Health, NSW

and violence

in persons with psychosis

with psychosis

“Most people who are

violent are not mentally ill…and most people

who are mentally ill are not violent.”

Cycle of Violence

Psychosis and violence –

o Comorbid substance abuse substantially

increases the risk (4 x greater than for persons with psychosis and no substance abuse)

o However, the risk of violence in persons with both psychosis AND substance abuse is no

higher than for substance abuse alone

o Homicide rates for persons with psychosis are strongly

correlated with the total homicide rates within the general community of that country

– a range of non-specific risk factors, which vary in proportion from country to country, mediate the risk of homicide

amongst persons with psychosis These include:

- Substance abuse

- History of childhood conduct disorder

- Lower socioeconomic status

- Being a victim of violence

‘Negative symptoms’ (e.g amotivation and blunted affect)

appear to be a protective factor against violence in persons with psychosis

Hallucinations and violence: 17 studies reviewed

 No evidence that auditory command hallucinations increase violence risk

 Several studies found a link between command hallucinations that contain violent content, and violence

 No evidence that co-occurrence of hallucinations and delusions

increases risk for violence

Delusions and violence: 20 studies reviewed

 Most studies find a link between delusions and violence

 13 out of 14 studies found that persecutory delusions increase risk for violence

 3 of 4 studies found that threat/control-override symptoms (TCO) are associated with violence

 5 out of 7 studies found that “delusional distress” ( delusions

accompanied by anger, fear/anxiety or suspiciousness/hostility) was associated with increased risk for violence

Psychotic Symptoms and

Violence: Recent Findings

o Relative risk of homicide in person with

psychosis is high (15 – 20 x general

population), although ‘absolute risk’ is low

(0.3% vs 0.02% in general population)

o Rates of homicide have not changed

appreciably before and after

‘deinstitutionalisation’

o Shifting focus from the ‘relative’ to the

‘absolute’ risk of violence posed to the

community may reduce the stigma associated with a diagnosis of psychosis

 Homicide and other forms of violence are

far more common in persons with psychosis who are not receiving adequate treatment

 Those patients who have “never received treatment” appear to be at higher risk than patients who “have a record of poor

adherence to medication despite previous treatment”

 The DUP (duration of untreated psychosis) also seems to be correlated with violence

Victims of homicide committed by

persons with psychosis

 Random attacks on strangers is uncommon

 Most common victims are close family (e.g parents, spouse, child)

 Next most common are close associates

and friends

 For those patients in hospital or custody,

proximity of victim is important factor (e.g mental health professionals; other patients

or other prisoners)

Understanding Risk

 RISK: The probability of an outcome

 RISK FACTOR: A factor that has an association with a risk

 RISK ASSESSMENT: The process of evaluating the risk

 RISK PREDICTION: A statement of the probability of an outcome

 RISK MANAGEMENT: The process through which risk is contained

The Nature of Risk

Important principles to consider in relation to the nature

of risk:

 Risk changes continually A person’s risk can change

rapidly and over the course of a short period of time, as well as over a longer period of time.

 Risk cannot be eliminated Risk can be managed when

mental health professionals engage in ‘responsible risk taking’.

 Risk management begins with assessment and

identification of empirically known and idiosyncratic risk factors – and ends with a plan to manage those risk factors

Risk Over Time

Factors Correlated With Risk for

Violence in the Mentally Ill

(MacArther 2000)

GENDER

women

misuse

APPROACHES TO RISK ASSESSMENT

Why Have an Approach

reliability

assessment may reduce the probability of a

hazard occurring in an individual patient

management plan establishes an understandable rationale for the decision taken, and provides the assessor with a defensible position when a hazard does occur (as, over time, it inevitably will)

Approaches to Risk Assessment

The 2 Extremes – Flexible & Rigid

 Unstructured Clinical Judgment (no factors and no structure)

 Actuarial Approach(specific factors and rigid structure)

Unstructured Clinical Judgment

 Most common method

used by mental health

professionals

 Minimal cost

 Minimal time required

 Nạve , impressionistic, subjective, intuitive

 The “in my experience” approach

 Akin to making a diagnosis without knowledge of the signs and symptoms that are associated with the condition

Actuarial Approach

 Use of an equation, graph,

table to provide a

probability estimate of risk

for a particular risk group

 Factors are mostly static and

do not account for other risk reducing factors and

circumstances

 Based on outcomes in context

of strict research conditions

 Tells you the risk group and less about the individual

 Becomes the focus at expense

of clinical experience

 Does not assist in management

 Too specific: X% in B population over T time

Structured Professional Guidelines

 Utilizes a list of empirically

based risk factors vetted by a

experts

 Operationalises these risk

factors

 Provides a fixed scoring guide

 Provides guidance for decision

making

 Assists in risk categorization

 Makes the assumption that

ultimately clinical discretion

 Some focus on risks and weaknesses, not

 Focus on forensic populations

DISADVANTAGES

HCR 20

Historical Factors

 Static

 Tell you the base level of risk

 The best you can do

 Future Issues to consider

 What need to be done in the future

The HCR-20: a Structured Clinical Rating Scale for Risk for Future

Violence (Webster et al., 1997)

(5) Substance use problems

(6) Major mental illness

(4) Impulsivity (5) Unresponsive to treatment Risk management items:

(1) Plans lack feasibility (2) Exposure to destabilizers (3) Lack of personal support (4) Non-compliance with remediation attempts (5) Stress

THE “HOLY GRAIL”

(a) identification of causal, dynamic/

variable risk factors

(b) that are amenable to treatment

The KEY QUESTION remains:

Having regard to the risk factors

relevant in this case, can this person be safely managed in the expected

environment? (e.g

community)

Remember: Low Risk DOES NOT = No Risk

TAKE HOME MESSAGES

 The presence of psychosis increases a person’s risk of violence – but remember: whilst relative risk is high, absolute risk is low

 Violence is a complex, multi-factorial

phenomenon and most risk factors are common

to persons with/without psychosis The most

important of these is substance misuse

 The highest risk of violence associated with

psychosis may be in the first episode of illness, prior to the commencement of treatment

 The most rigorous and clinically appropriate

approach to violence risk management is the use of structured professional guidelines