Psychosis & Violence, Risk Assessment

8/19/2019 Psychosis & Violence, Risk Assessment

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Psychosis & Violence

Risk AssessmentDr. Luke Woon Sy-Cherng

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Violence

• Violence is " uni#ers"l $henomenon.• %ost e'nitions o( #iolence re(er to

$hysic"l #iolence) i.e. the *cont"ct+(orm o( #iolent ,eh"#iour e.g.*"ctu"l ,oily h"rm+ com$"re to*non-cont"ct+ (orms o( #iolent

,eh"#iour such "s *thre"ts to kill+.• here is " continuum o( #iolent

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heories o( Violence

• 0iologic"l $ers$ecti#e uni#ers"l instinct o("ggression Loren2 1

• Psychoyn"mic $ers$ecti#e e"th instinct

h"n"tos #s. li,iin"l instinct 4ros5reu 1!6

• Le"rning $ers$ecti#e (rustr"tion8"ggression hy$othesis Doll"r et "l. 13

• Soci"l cogniti#e $ers$ecti#e soci"lle"rning theory o( 0"nur" 193

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heories o( Violence

• Cogniti#e ,eh"#iour"l theoriesconscious ,eh"#iour"l choice ,"seon $ro,lem"tic ie"s "n erroneous,elie( systems

• Att"chment theory isru$tion o("tt"chment in e"rly chilhoo De

;uluet" !66) 0o


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• he $sychoses "re intrusi#e "n o(tenchronic e,ilit"ting illnesses.

• hey le"#e their su>erers ,oth #ulner",le

to #iolence & #ulner",le to ,eing #iolent.• ?n the @SA Crime Victimi2"tion Sur#ey) o#er

!= o( the $eo$le


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• ?n " re#ie< o( 31 @S em$iric"l stuiessince 16) Choe et "l. !669 (oun th"t)1!819 o( "ll $"tients


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• ?n 4ngl"n) links ,et


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4$iemiology

@S 4$iemiologic C"tchment Are" 4CA stuyS


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4$iemiology

he Dunein ,irth cohort Arsene"ult et "l.!666

• Community sur#ey ecte#iolence r"tes "t "ge !1 schi2o$hreni"s$ectrum isorer) "lcohol e$enency "nc"nn",is e$enency.

• =-(ol crimin"l con#ictions to E-(ol sel(-re$orte ele#"tion in #iolence r"tes "mongthose


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4$iemiology

he $ro$ortion o( homicides "ttri,ute to$eo$le


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4$iemiology

• ?t shoul ,e note th"t


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4$iemiology

SeJ o>ening• 5"2el et "l. !66E) using Sence


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4$iemiology

Arson

• An


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Psychosis to ViolenceP"th


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Psychosis to ViolenceP"thence signi'c"ntly less likely to h"#e

,een ri#en ,y $sychotic sym$toms

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Comor,i %ent"l Disorers

Person"lity isorer• %or"n et "l. !663 inter#ie


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• engstrNm et "l. !66: (oun th"t"mong !6! m"le o>eners ences th"t those $oint.

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Su,st"nce misuse• 4"rly stuies suggests "n in#erse

rel"tionshi$ ,et


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Su,st"nce misuse "n its role in incre"sing therisk o( #iolence "mong $eo$le


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Cont+• eJ$osure to "#erse soci"l en#ironments

le"s to su,st"nce use "n "ggressi#e

,eh"#iour• su,st"nce ",use eJ"cer,"tes $sychotic

"n other sym$toms

•

su,st"nce ",use reuces im$ulse control• su,st"nce ",use is " $roJy me"sure (or

$erson"lity isorer

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Clinic"l Ch"r"cteristics

Psychotic Sym$toms "n Violence• Psychotic sym$toms es$eci"lly

delusions h"#e ,een im$lic"te in "cts

o( #iolence.• A closely-rel"te conce$t is o(

thre"t/control-o#errie CK sym$toms.•

Link "n Stue#e 1: highlighte thiscluster "s " strong correl"te o( #iolence.

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CK consists o( three sym$toms• " (eeling th"t oneQs min is omin"te

,y (orces ,eyon oneQs control• " (eeling th"t thoughts "re ,eing $ut

into oneQs min th"t "re not oneQs o


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Psychotic Sym$toms "n Violence• Signi'c"nt rel"tionshi$ ,et


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Psychotic Sym$toms "n Violence• Violence in the conteJt o( $sychotic

illness is more likely to ,e irecteto


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Psychotic Sym$toms "n Violence

u"lities "ssoci"te


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Psychotic Sym$toms "n Violence• Hallucinations m"y occur in "ny sensory

mo"lity. here is some "t" on gust"tory"n/or ol("ctory h"llucin"tions in the conteJt o(elusions o( ,eing $oisone.

• %ost concern h"s ,een on "uitoryh"llucin"tions) $"rticul"rly comm"nh"llucin"tions.

• here is "n eJ$ect"tion th"t i( the comm"ns"re to o h"rm) then there is " risk th"t this


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Psychotic Sym$toms "n Violence

5"ctors "ssoci"te


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Psychotic Sym$toms "n Violence• Empathy Derntl et "l. !66 h"#e suggeste "

gener"l e'cit o( "ll em$"thic ",ilities in $eo$le


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4n#ironment"l 5"ctors

5"mily• he B"tion"l Con'enti"l ?nuiry into omicie

(or 4ngl"n "n W"les sho


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Clinic"l en#ironment• DiMculties in communic"tion

,et


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Community• A#"il",ility o( "lcohol "n other

rugs• Stigm" "n the high r"tes o(

community #ictimi2"tion• Stress(ul li(e e#ents e.g. ,ecoming

homeless• Violence in the surrouning

community3/11/1 3=


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%"n"gement & re"tment

Princi$les o( m"n"gement•


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Risk Assessment

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D"ngerousness/Risk

• *D"ngerousness+ re(ers to the risk o(serious h"rm to others.

• Clinici"ns "re eJ$ecte to ,e ",le to "ssess

risk o( serious h"rm ,y $eo$le ect on the rights o( the ini#iu"l.

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D"ngerousness/Risk

• he three m"in com$onents o("ngerousness B"tion"l Rese"rchCouncil) 19

1. the n"ture o( the $roGecte h"rm2. *risk ("ctors+ 8 the u"lities th"tinuence the ch"nces o( th"t h"rm

h"$$ening in re"lity3. *risk le#el+ 8 the $ro,",ility th"t theh"rm


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Risk Assessment

here "re ! m"in "$$ro"ches to risk"ssessment

• Actu"ri"l risk "ssessment

•

Clinic"l risk "ssessment

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Actu"ri"l Risk Assessment

• Risk ecision is m"e through " set o((ormul"e) or m"them"tic"l eJ$ressions.

• Actu"ri"l "ssessments o( risk h"#e ,een

e#elo$e ,y testing


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Clinic"l Risk Assessment

• A#"nt"ges o( the clinic"l "$$ro"chinclue its inter"cti#e n"ture o( "t"collection it "#ois im$osing

$reconcei#e ie"s onto the $erson ,eing"ssesse "n th"t it is "l


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Structure Fugment ools

• 3 m"in cl"sses o( stuy (or risk "ssessment tools• %"in e>ects "n"lysis 8"n"lysis o( " single) l"rge

"t" set. 4.g. he Violence Risk A$$r"is"l IuieVRAI.

• System"tic liter"ture re#ie< "n met"-"n"lysis.4.g. !6-item istoric"l) Clinic"l "n Risk%"n"gement Sc"le CR-!6. Tmore "s "n "i tostructure $ro(ession"l Gugment

• ?nter"ction e>ects "n"lysis 8 single "t" set) ,ut"llo


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Structure Fugment ools

• Violence Risk Assessment IuieVRAI

• istoric"l Clinic"l "n Risk%"n"gement Sc"le CR-!6

• Cl"ssi'c"tion o( Violence Risk CKVR

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A#"nt"ges

• 4nsuring th"t "ll in(orm"tion rele#"ntto #iolence "n other "ntisoci"l,eh"#iour is consiere.

• r"ns$"rency in metho "nrecoring o( the "ssessment.

• Ire"ter cl"rity in communic"ting

",out these issues.

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Violence Risk Assessment IuieVRAI

• he VRAI "rris et "l. 13


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Violence Risk Assessment IuieVRAI

• 5in"l VRAI score m"y r"nge (rom U!to O39.

• A series o( stuies (rom Borth Americ"

"n 4uro$e "re gener"lly in "greement",out the $reicti#e ",ility o( the VRAI)


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istoric"l Clinic"l "n Risk%"n"gement Sc"le CR-!6

• he CR-!6 is " structure clinic"l Gugmentinstrument We,ster et "l. 1E.

• De#elo$e (rom " system"tic re#ie< "n met"-"n"lysis concerning ("ctors th"t rel"te to#iolence.

• !6 #"ri",les "re coe on " 3-$oint sc"le*",sent+) *some


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• he rese"rch ,"se (or the CR-!6 isunri#"lle ,y th"t (or "ny otherinstrument in the 'el.

• %"ny stuies (rom Borth Americ""n throughout 4uro$e "re in"greement th"t the CR-!6 is "

use(ul instrument) returning A@Cs


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Cl"ssi'c"tion o( Violence RiskCKVR

• he CKVR %on"h"n et "l. !66=


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he %"cArthur Violence RiskAssessment Stuy

• he tool


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Cl"ssi'c"tion o( Violence RiskCKVR

• V"li"tion results (or CKVR outsiethe @SA "re gro


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Risk %"n"gement

“Positive risk management as part of a carefullyconstructed plan is a required competence forall mental health practitioners.”

De$"rtment o( e"lth in 4ngl"n !66E

Risk-rel"te ecision


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Risk %"n"gement

Princi$les o( risk m"n"gement %"en!66E

• #iolence is your ,usiness

• there is no "ltern"ti#e to risk m"n"gement• goo #iolence risk m"n"gement is goo

(or $"tients•

ho$e (or the ,est) ,ut $l"n (or the


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Risk %"n"gement

Princi$les o( risk m"n"gement %"en!66E

• not "ll #iolent "cts "re eu"l• st"n"ri2e "ssessments hel$

clinici"ns ,ut o not re$l"ce them• "s$ire to the ,est ,ut gi#e


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Conclusions

• Hno


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Conclusions

• he more commonly use n"me "is h"#eest",lishe reli",ility "n #"liity $ro'le.

• Risk "ssessment shoul ,e $"rt o( the


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Re(erences

Loren2 H 1 !n Aggression. Lonon %ethuen.5reu S 1!6) tr"nsl"te CF% u,,"ch) 1!! "eyond the Pleasure Principle. Lonon ?ntern"tion"l Psycho-"n"lytic"l Li,r"ry)

og"rth.Doll"r F) %iller B) Doo, L) %oening in men " c"se

control stuy ,"se on Sening. riminal 2ustice3/11/1 1


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Re(erences

(ner "n 0Nker W 1E3) tr"nsl"te %"rsh"ll) 19! rimes of (iolence by 1entally Abnormal !6enders. C"m,rige)@H C"m,rige @ni#ersity Press.

iihonen F "n Seners the e#elo$ment o( "

st"tistic"l $reiction instrument. riminal 2ustice and "ehaviour 20: 31=83=.We,ster CD) Dougl"s HS) 4"#es D) "n "rt SD 1E The H&789 +cheme$ Assessing &isk for (iolence' (ersion 8. 0urn",y)

C"n"" %ent"l e"lth) L"


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h"nk ou

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Psychosis & Violence, Risk Assessment