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Violence Risk Assessment

Overview | Clinical Scenarios | Additional Tips | References
By Phillip Resnick, MD

OVERVIEW

Definition

Violence has a range of definitions. Only serious physical violence and homicide will be addressed in this section.

General Principles of Violence Risk Assessment

The single greatest risk factor for future violence is past violence1,2. Other static risk factors for violence include :

  • Previous arrests
  • Male gender
  • Age between 15 and 24 years, and
  • A history of adverse childhood experiences, such as parental separation, witnessing domestic violence and being the victim of abuse.

Dynamic risk factors for violence include substance use and active psychiatric symptoms. The majority of people who commit violent crimes are under the influence of alcohol during their violent offense (1). Individuals with paranoia are at risk of killing persons that they misperceive as persecutors. Command hallucinations, especially when associated with a delusion, also elevate the risk of violence3.

Tarasoff duties to protect intended victims from patient violence vary greatly from state to state. Some states adhere to the Tarasoff principle that when a clinician knows, or should know, that his patient presents a substantial danger to another, he incurs an obligation to take reasonable steps to protect the intended victim. Malpractice liability may also arise if the clinician does not follow these steps. Over 35 states have passed Tarasoff statutes which provide immunity from liability in the absence of an explicit threat toward an identifiable victim (See Duties to Protect Section).

CLINICAL SCENARIOS

Scenario #1: In the emergency room, a 23-year-old man with a history of schizophrenia is brought in by the police after he barricaded himself in his basement. He refused to open the door because he believed that someone was trying to insert an electronic tracking device into his body. He has a history of prior violence in misperceived acts of self-defense because of paranoid delusions. He insists on keeping a handgun in his home for self-protection.

  • This patient is mentally ill and at risk of again attacking a misperceived persecutor. Paranoid delusions are more likely to cause violence toward others than any other single psychiatric symptom.
  • Hospitalization of this patient is required due to his active delusions and possession of a lethal weapon. If the patient does not agree to voluntary hospitalization, he would be eligible for civil commitment because of the acute danger to others due to his paranoia. If the emergency room doctor failed to admit him, she would be at high risk of a malpractice suit if the patient killed a perceived “persecutor.”

Scenario #2: A female psychiatric inpatient with a history of addiction to benzodiazepines demands alprazolam for “anxiety.” A nurse explains to the patient that no order is written, but states that she will check with the patient’s doctor. The patient puts her face close to the nurse’s face and yells that she will not be able to control herself if she does not receive alprazolam “now!”

  • This patient is at high risk of violence toward a staff member. Female inpatients are slightly more likely to be assaultive than male patients.
  • The most common behaviors preceding a psychiatric inpatient assault against a staff member is yelling, swearing, and standing uncomfortably close. The nurse should consult with the physician on call about prescribing a non-benzodiazepine sedative.

Scenario #3: A psychiatric outpatient being treated for depression announces that he has just received irrefutable proof that his wife has been unfaithful. The patient has a history of domestic abuse, impulse control problems, and antisocial personality traits. The patient announces that he ordered a handgun, but he will not be able to pick it up until the next day.

  • This patient is at high risk of shooting his unfaithful wife.
  • Depending upon the state statute, depression may not be a sufficient mental illness to commit the patient unless it caused a distortion of reality related to his wife’s infidelity.
  • If he did not have a mental illness which is necessary for civil commitment, involuntary hospitalization may not be a choice.
  • However, the doctor still has a Tarasoff duty to take reasonable steps to protect the patient’s endangered wife. Depending on the state, appropriate steps may include notifying the patient’s wife, law enforcement, and/or taking other reasonable steps to reduce the risk of violence.

ADDITIONAL TIPS

In the case of potentially violent patients the best way to reduce the likelihood of a malpractice lawsuit is good documentation. For example, in scenario 3, it would be important to explain the reasoning for the failure to admit the patient after documenting a violence risk assessment. Efforts to modify dynamic risk factors should be specified. Documentation should include firearms inquiry, efforts to contact family members, and the rationale for the level of care selected.

REFERENCES

  1. Resnick P, Saxton A. Malpractice Liability Due to Patient Violence. Focus. 2019 Oct;17(4):343-348. Available from: https://focus.psychiatryonline.org/doi/10.1176/appi.focus.20190022
  2. Bonta J, Law M, Hanson K. The prediction of criminal and violent recidivism among mentally disordered offenders: a meta-analysis. Psychol Bull. 1998 Mar;123(2):123-42. Available from: https://content.apa.org/doiLanding?doi=10.1037%2F0033-2909.123.2.123
    3. Scott C, Resnick P. Clinical Assessment of Aggression and Violence in Principles and Practice of Forensic Psychiatry, 3rd ed. Rosner R, Scott C (eds) Boca Raton: CRC Press; 2017.

Additional Reading

  1. Resnick PJ. From Paranoid Fear to Completed Homicide, in Pearls, Current Psychiatry. 2016;15(2):24.
  2. Saxton AM, Resnick PJ, Noffsinger, SG. Chief Complaint: Homicidal – Assessment Violence Risk. Current Psychiatry, 2018;17(5):27-35.
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