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The Assessment of Risk
Psychotic illness, particularly where hallucinations and delusions are acted upon, is well known to be associated with violence to the self or others. More in response to adverse media criticism than anything else, the UK Government advised its agencies, including the health service to behave with more rigour. Implicitly the notion was that if more rigour was employed by health, social services and other agencies there would be less violence to the self or others through psychotic illness, (and hence less adverse criticism of Government).
The argument rests on various assumptions, which would be difficult to research ethically or scientifically. Although the assumptions could be held to be reasonable ones, there is a general lack of data to justify them.
The whole affair has a whiff of anxiety about it, from politicians and administrators to doctors, nurses and carers. In reality the management of such potentially dangerous individuals can cause huge anxieties in the clinical team, and the team members can see the anxieties being passed about the team like a game of Pass the Parcel, except the newspaper-wrapped parcel contains unpredictable and unpleasant surprises.
In order to contain the anxiety there has been a glut of schedules and risk assessment forms; some with unknown or doubtful reliability or validity.
In this section we aim to build a repository of news, views, research, schedules and opinion on Risk Assessment.
The World Health Organisation published a guide to assessing potential risk of violence in 2000.
Latterly, there have been moves to analyse risk assessment schedules for psychopathy and suicide(Dolan & Doyle, 2000 and Cheng et al, 2000). Dolan & Doyle concluded that the Psychopathy Checklist (Hare 1991) appeared to be a key predictor of violent recidivism in a variety of settings.
PCL-R (Hare 1991)
|Grandiose sense of worth||1|
|Need for stimulation/proneness to boredom||2|
|Lack of remorse or guilt||1|
|Callous/lack of sympathy||1|
|Poor behavioural controls||2|
|Promiscuous sexual behaviour|
|Early behavioural problems||1|
|Lack of realistic long-term goals||2|
|Failure to accept responsibility|
|Many short term marital relationships|
|Revocation of conditional release||2|
* These are weighting factors.
Cheng et al (2000) performed a case control psychological autopsy study looking at both psychosocial and psychiatric reisk factors. They concluded that effective intervention and management for loss events and major depressive episodes in emotionally unstable individuals with a family tendency to suicidal behaviour (frequently comorbid with substance abuse) may prove to be effective. This view was based on the independent effects of five major risk factors:
- ICD-10 major depressive disorder (odds ratio if present =41.2)
- loss event (odds ratio if present = 6.1.)
- suicidal behaviour in first degree relative (odds ratio if present = 5.2)
- emotionally unstable personality disorder (odds ratio if present = 4.3)
- substance abuse(odds ratio if present = 3.2)
The following recommendations came from the Royal College in 1996:
|"The standard psychiatric assessment should include the following.
Are these risk factors stable or have any changed recently?
Does the patient have access to potential victims, particularly individuals identified in mental state abnormalities?
Evidence of any threat/control override symptoms: firmly held beliefs of persecution by others (persecutory delusions), or of mind or body being controlled or interfered with by external forces (delusions of passivity).
Emotions related to violence, for example irritability, anger, hostility, suspiciousness.
Specific threats made by the patient.
A formulation should be made based on these and all other items of history and mental state. The formulation should, so far as possible, specify factors likely to increase the risk of dangerous behaviour and those likely to decrease it. The formulation should aim to answer the following questions.
Special Working Party on Clinical Assessment and Management of Risk (1996) Assessment and clinical management of risk of harm to other people. Royal College of Psychiatrists, London.
The following table compares various standardised interviews specifically with regard to suicide risk assessement:
|Rating Scale||Suicide Risk|
|Beck Depression Inventory. Patient picks best answer.||3 = I would kill myself if I had the chance.
2 = I have definite plans about committing suicide.
1 = I feel I would be better off dead.
0 = I don't have any thoughts of harming myself
|Symptom Checklist. Patient rates on five point scale from not at all to extremely.||How much were you bothered by:
|Structured Clinical Interview for DSM-IV Semistructured interview. Rater selects: 1 = Absent or false 2 = Subthreshold 3 = Threshold or true
|Interviewer asks: Were things so bad that you were thinking a lot about death or that you would be better off dead? What about thinking of hurting yourself
Interviewer rates: Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide.
|Schedule for Affective Disorders and Schizophrenia. Semistructured interview. Rarer selects answers on six-point scale from not at all to extreme.||Interviewer asks: When people get upset or depressed or feel hopeless, they may think about dying or even killing themselves. Have you? (Have you thought how you would do it? Have you told anybody about suicidal thoughts? Have you actually done anything?)
Interviewer rates: Suicidal tendencies, including preoccupation with thoughts of death or suicide.
Further questions: Assess gestures, attempts, risk-rescue factors, medical lethality.
|Hamilton Depression Rating Scale. Rater selects best answer.||0= Thoughts of suicide absent.
1 = Feels life is not worth living.
2 = Wishes he or she were dead or any thoughts of possible death to self.
3 = Suicide ideas or gesture.
4 = Attempts at suicide (any serious attempt rates 4).
|Brief Psychiatric Rating Scale. Rater selects answer on seven-point scale where 1 = Not present 7 = Extremely severe|
|* Pocket Guide to Psychiatry, Edited by Tasman, Kay & Lieberman. Philadelphia, Saunders|
Violence to others is not usually associated with mental illness. It is however associated with youth, being male and with drug and alcohol mis-use. Risk assessment by psychiatrists therefore would have little to do with lowering violence in the general community. However, in helping assess dynamic risks in people with mental disorders there are risk factotrs that may be of use.
Demographically, young males, who are unemployed and of limited education are statistically more likely to be violent to others. A history of previous history of violence to self or others, especially where there has been severe violence is likely to suggest a likelihood of recurrence. A history of animal torture is ominous, as is a family history of criminal behaviour or violence. A history of being victim to physical or sexual abuse is associated.
Substance-related disorders predispose to violence, as does a diagnosis of dissocial personality disorder, or a past diagnosis of conduct disorder in childhood. Intermittent explosive disorder and impulse disorders in general bode ill.
Paranoid psychotic and acute organic psychoses are associated.
In terms of observable signs or reported symptoms on examination there are some which are of note:
- physical agitation and/or anger
- expressed intent to kill or take revenge
- identification of specific victim(s)
- psychotic symptoms, especially 2nd person command hallucinations to commit violence
- persecutory delusions
- disinhibition caused by traumatic brain injuries and other central nervous system dysfunctions
- current use of alcohol or other drug
Information from the subject or third parties which indicate the following should also ring alarm bells:
- living under circumstances of violence
- environmental access to guns or other lethal weapons
- membership of violent peer group
- behavioral Antisocial acts
- poor impulse control; risk taking or reckless behavior
- statements to others of intent to inflict harm
|Contributions to this section from official and unofficial sources are welcome.|
|Submitting Papers Guidelines for Authors|
Hare (1991) Manual for the Hare Psychopathy Checklist - Revised. Toronto, Canada: Multi-Health Systems
Doran M & Doyle (2000) Violence Risk Prediction. British Journal of Psychiatry, 177, 303-311.
Cheng, A T A, Chen T H H, Chen CC, & Jenkins R. (2000) Psychosocial and psychiaytric risk factors for suicide. British Journal of Psychiatry, 177, 360-365.