Risk Assessment for Violence

Question 1

Violence Demographics (A/S+1/C/IQ+1)

Answer 1

A: Late teens/early 20s
Sex: Males in gen pop, but with MI, not significantly different
Class: Lower
IQ: Lower. But ID women 25x more likely, ID men 5x more likely

Question 2

Violence by Dx (4)

Answer 2

SUD > Schiz > BPAD > MDD

Question 3

5 Structured Instruments for Violence Risk Assessment

Answer 3

Psychopathy Checklist-Revised (PCL-R)
Hare Psychopathy Checklist-Revised
Violence Risk Appraisal Guide (VRAG)
Historical/Clinical/Risk Management 20 Item (HCR-20)
Classification of Violence Risk (COVR)

Question 4

Actuarial Risk Assessment Benefit

Answer 4

More accurate due to stability of historical factors

Question 5

Clinical Factors

Answer 5

More relevant in acutely psychotic pts

Question 6

Paranoid Psychosis Violence (3.3)

Answer 6

More violent in community (as opposed to hospital, where less violent); recourse to weapons
Violence well-planned
Target is misperceived persecutors (90% out of fear, 10% anger)

Question 7

Mean Time from Onset of Psychosis and Serious Violence

Answer 7

30d

Question 8

Schizophrenia General Symptom Type and Violence

Answer 8

Positive sx incr
Negative sx decr

Question 9

3 Hallucination Associations w/ Violence

Answer 9

• Hallucinations generate neg emotions (anger/anxiety/sadness)
• Less successful strategies to cope with AH
• cAH

Question 10

cAH Content % (5)

Answer 10

Suicide 52%
Homicide 5%
Injury self/others 12%
Non-violent acts 14%
Unspec 17%

Question 11

cAH Association

Answer 11

cAH to harm others 2x as likely to be violent than pts w/o such commands

Question 12

cAH Compliance % and Reducer

Answer 12

Overall 10-80%
Decr if command is dangerous

Question 13

4 Traits More Likely to Obey Harmful Command

Answer 13

Hallucination-related delusion
Familiar voice
Feelings of personal superiority
Benefit hallucinator

Question 14

3 Threat/Control-Override (TCO) Sx Associated w/ Increased Violence (& rate)

Answer 14

Mind feels dominated by external forces
Thoughts being put into head
Feeling that people wish you harm
(assault about 2x as likely as other psychotic sx)

Question 15

3 Non-Violent Delusions

Answer 15

Dead/dissolved/not existing
TB
Thoughts removed by external forces

Question 16

Male v. Female Difference w/ Threat Delusions

Answer 16

Men more likely to respond w/ violence (fight or flight vs. tend and befriend), so women seek out nurturing relationships

Question 17

5 Delusion Characteristics Associated w/ Violence

Answer 17

Persecutory
Systematized
Generate neg emotions (fear, anger)
Acted on before
Combined with SA

Question 18

2 Specific Associated w/ Violence

Answer 18

Poisoned
Infidelity

Question 19

Manic Violence (Type and Cause)

Answer 19

High percentage of assaultive/threatening behavior, but serious violence rare
Often respond violently to any form of limit setting

Question 20

Premenstrual Tension Syndrome

Answer 20

Violence by wives towards husband, as many killings in 5 PMS days than remainder of month

Question 21

PTSD (general association and other contribitor)

Answer 21

PTSD vets w/ higher incidence of violent crimes
Lots of SUD to numb pain which predisposes

Question 22

2 PDs Associated w/ Violence

Answer 22

BPD and ASPD

Question 23

10 Personality Traits Associated w/ Violence

Answer 23

1. Impulsivity (absence of reflective delay)
2. Low frustration tolerance
3. Inability tol criticism
4. Repetitive antisocial acts
5. Drive automobiles recklessly
6. Egocentricity/entitlement
7. Superficial relationships/dehumanize others
8. Paroxysmal, episodic quality
9. MSE glibness, lack of introspection, projection of internal difficulties onto environment
10. Suspicious about motives of others

Question 24

3 Schizophrenia Pt Caregiver Violence Rates

Answer 24

Parents: 68%
Siblings: 12%
Spouses: 7%

Question 25

4 Family Violence Risk Factors

Answer 25

1. Financial dependence on family 2. Family caregiver 3. Limit setting by family 4. Criticism/hostility by family

Question 26

4 Family Violence Risk Reducers

Answer 26

1. Professional representative payee 2. Education in de-escalation 3. ICM 4. Affordable non-family housing

Question 27

8 Childhood Factors Correlated with Violence

Answer 27

1. Brutality from parent, particularly father 2. Parental seduction 3. Truancy/school failures/low IQ 4. Being a bully (victims get depressed) 5. Adolescent delinquency 6. Arrest for prior assault 7. Childhood hyperactivity or severe inattention 8. First psyc hospital by age 18

Question 28

MacDonald Triad (3 and point)

Answer 28

Enuresis, fire-setting, cruelty to animals Later studies didn't confirm enuresis

Question 29

Best Predictor of Future Violence

Answer 29

Past violence

Question 30

4 Components of Dangerousness History

Answer 30

1. Past Violence 2. Substance Abuse 3. Weapons Hx 4. Criminal Arrests

Question 31

2 Types of Aggression (& comparison)

Answer 31

Affective aggression - result of threatening (int/ext) stimuli that evoke ANS response, accompanied by threatening vocalizations and attacking/defending postures Predatory aggression - planned, purposeful, goal-directed. Not reactive and requires emotional detachment

Question 32

Reason for Intense Dangerousness of Predatory Aggression

Answer 32

No foreshadowing behaviors

Question 33

Path to Affective Violence (3)

Answer 33

Grievance -> idea/emotion -> attack

Question 34

Path to Predatory Violence (5)

Answer 34

Grievance -> Idea -> Research/Planning -> Prep -> Attack

Question 35

Assessment of Dangerousness Acute Likelihood (3)

Answer 35

1. Lack of empathy (combined w/ anger) 2. Behavior: verbal abuse, standing close, swearing, loud, etc. 3. Threats/likelihood of being carried out

Question 36

5 Risk Factors for Threats Being Carried Out:

Answer 36

1. More intimate relationship b/w threat/threatened 2. Face-to-face 3. More specific 4. Signed name (as opposed to anonymous) 5. Introduced late in controversy instead of early (considered decision to use violence, instead of initial emotional response)

Question 37

2 Types of Risk Factors for Violence

Answer 37

Dynamic Static

Question 38

Dynamic Risk Factors (what they are, temporality, examples)

Answer 38

Subject to change by intervention/tx/situation control. Typically current E.g., living setting, weapon access, psychotic sx, med nonadherence

Question 39

Static Risk Factors (what they are, temporality, examples)

Answer 39

Not subject to change by intervention Typically historical E.g., demographic info, hx of violence, childhood abuse, antisocial traits, etc.

Question 40

3 Highest Recent Risk Factors for Violence

Answer 40

1. Current ETOH use 2. Recent violence 3. Recent victimization

Question 41

Components of Violence Prevention Plan (3)

Answer 41

Risk Factors -> Management/Treatment -> Status (implemented, attempted but unsuccessful, not attempted)