Chest radiograph
Medication levels
Thyroid function tests
Lipoprotein levels
B12 levels
Arterial blood gases
Static risk factors.
Much of the literature on violence in psychiatric practice has been devoted to determining static and dynamic risk factors. Static risk factors are patient characteristics of the patient that cannot be changed with clinical intervention, such as demographics, diagnoses, personality characteristics, and prior history. Even though risk factors represent associations with outcomes, they do not imply overt causation. 60
The most replicated and affirmed static variable associated with the prediction of future violence is a history of past violence. 4 , 12 , 43 , 61 , 62 The risk of future violence increases linearly with the number of past violent acts. 12 Persons who have acted aggressively because of their delusions in the past are likely to do so in the future. 54 Janofsky 63 found that violent behavior before admission to the hospital is correlated with violence as an inpatient in a psychiatric facility. A history of impulsivity is also related to future violence, as Asnis and colleagues 8 showed that 91 percent of patients who attempted homicide also had attempted suicide during their lifetimes.
Other static risk factors include male sex, younger adult age, lower intelligence, history of head trauma or neurological impairment, dissociative states, history of military service, weapons training, and diagnoses of major mental illnesses. 12 In a review of literature, Bonta, et al., found that younger age, male sex, single marital status, and having antisocial peers were associated with violent recidivism. Most evidence shows that race and social class are unrelated to recurrence of violence. 11 Poor work adjustment can be an additional static risk factor in a patient’s social history; other static variables include a dysfunctional family of origin and a history of abuse as a child. 12
Using the National Comorbidity Study data collected from 1990 to 1992, Corrigan and colleagues demonstrated that participants who reported more than three psychiatric diagnoses were 2 to 4.5 times more likely to also report violent behaviors, as opposed to participants who reported only one diagnosis. 64 Major mental illnesses are a static risk factor, but active symptoms or the presence of a relapse may be more exact predictors of violence risk, and are considered dynamic variables that are likely amenable to treatment. 10 Thus, the association between mental illness and violence is best viewed in a longitudinal perspective, with increased risk at different points throughout a patient’s lifetime. Compared to other sociodemographic and historical factors, the contribution of mental illness to the overall risk of violence in society as a whole is relatively small. 60 In fact, demographic variables, particularly gender, are far better predictors of violence than psychiatric diagnoses of either substance abuse or nonsubstance abuse disorders; thus, stress on the connection between violence and psychiatric illness may be unnecessarily propagating stigma about mental illness. 64
Dynamic risk factors are variables in a patient’s presentation that can potentially be improved with clinical intervention. 65 They are often closely related to or even the same as those clinical symptoms that bring patients to acute care settings. 60 Perhaps the most frequently cited dynamic risk factor is substance abuse or dependence. 10 Other dynamic risk factors include persecutory delusions, command hallucinations, nonadherence with treatment, impulsivity, low Global Assessment of Functioning (GAF) score, homicidality, depression, hopelessness, suicidality, feasibility of homicidal plan, access to weapons, and recent move of a weapon out of storage. 12
Untreated psychotic symptoms represent significant risk factors for violent behavior, especially psychotic symptoms that threaten the patient, or that involve losing control to outside forces. 8 Among inpatients with schizophrenia, the most predictive variables for violence are suspiciousness and hostility, more severe hallucinations, poor insight into delusions and the overall illness, and greater disorganization of thought processes. 12 Delusions alone are not associated with violence except when delusions are persecutory in nature or involve conscious thoughts of committing violence. 54
Recent estimates suggest that up to 80 percent of patients are nonadherent to treatment recommendations at some point during their illnesses. 62 Nonadherence may be associated with violence and can be addressed through psychoeducation, cognitive-behavioral and supportive therapy, outpatient commitment, and intensive case management, as well as through focus on the therapeutic alliance. Bonta, et al., note that poor living situation and limited social support are risk factors for violence, but these can be altered by placing the patient in a supervised setting, providing family therapy, and involving the patient in positive community activities. 11
JB was a 45-year-old married man who was involuntarily committed to the state hospital for severe depression, worsening over the previous several months, with multiple suicide attempts. The patient’s most recent suicide attempt involved jumping off the roof of his two-story home. In addition to severe neurovegetative symptoms, the patient exhibited some psychotic features, including delusions that his wife and children were destitute and starving. During the transfer to the state facility, the patient became aggressive and attacked the police officer escorting him in an attempt to obtain the officer’s gun and commit suicide.
The patient arrived on multiple medications from his stay at the community hospital, including a nortriptyline 50mg at bedtime, citalopram 20mg daily, benztropine 2mg twice daily, lorazepam 1mg twice daily, zolpidem 10mg at bedtime, and quetiapine 200mg at bedtime. In addition to a 25-year history of depression, the patient’s medical history was significant for mild hypertension and acid reflux. A computed tomography (CT) scan of his brain several months before this admission revealed mild cortical atrophy in the frontal regions.
There was no evidence from collateral sources that the patient engaged in any current or past substance abuse: His last drink was two months prior to this admission. The patient did endorse a significant family history of depression, which included his mother receiving electroconvulsive therapy in the remote past and two cousins committing suicide.
After two days on the acute unit in the state facility, while continued on most of his medications, JB began to exhibit aggressive behavior; he approached other male patients and pinched or punched them without provocation. When questioned by staff about these incidents, the patient stated, “People are out to get me.” He indicated that he intended to take preemptive action against those that he believed were targeting him on the unit. He was alert and oriented in all spheres during and immediately following these episodes. He did, however, repeat questions about irrelevant topics while being restrained for attacking other patients and staff.
The violent incidents continued at various times throughout the day, and multiple emergency medications were tried without much effect. The patient appeared very anxious, and he was only responsive to staff reassurance and redirection for several minutes before becoming aggressive again. A thorough review of his medication regimen uncovered multiple agents with possible deleterious effects on his cognition. Unnecessary medications, such as anticholinergics, benzodiazepines, sleep aids, sedating antidepressants, and antipsychotics were stopped or tapered off. The patient unfortunately ended up in restraints after several of these attacks, as he did not respond to redirection or doses of calming medications.
Modifying a patient’s environment to prevent or decrease aggression is mainly of concern to inpatient facilities, although similar adjustments in a person’s home situation by outpatient clinicians may also have benefits. Studies have shown that most violent incidents occur earlier in the mornings and evenings, particularly when patients are gathered together in small areas. A study of 118 psychiatric inpatients with psychotic and/or substance use disorders admitted within two weeks to an urban hospital showed that patients who were involuntarily hospitalized exhibited more aggression. The authors also demonstrated that patients with an uncomplicated substance use disorder trended toward more total aggression than psychotic patients and patients with comorbid psychosis and substance abuse. 66 Warning signs that may precede violence include pacing, psychomotor agitation, combative posturing, guardedness, paranoid or threatening remarks, low frustration tolerance, emotional lability, and irritability. Environmental control can aid in containing violence, and it is essential to catch the patient in these earlier stages leading up to aggression and provide some measure of control to de-escalate building violence ( Table 3 ). 12
Environmental modifications to help control aggression
EMPLOY: |
Adapted from: Buckley P et al. Treatment of the psychotic patient who is violent. 2003;26:231–272. |
Calm, soothing tone of voice |
Positive and friendly attitude of helpfulness |
Expressing concern for patient’s wellbeing |
Offering of food or drink |
Allowing phone calls to trusted support person |
Decreasing waiting times |
Distraction with a more positive activity |
Removal of potentially dangerous items from area |
Verbal redirection and limit-setting |
Relaxation techniques |
Close observation or one-to-one sitter |
Quiet time or open seclusion |
AVOID: |
---|
Overcrowding patients |
Unpleasant or polluted surroundings |
Loud and irritating noises |
Intimidating direct eye contact |
Unnecessary invasion of personal space |
Direct confrontative stance with crossed arms |
Hands concealed in pockets |
Having sufficient numbers of staff present as well as avoiding overcrowding of patients decreases violent acts. Staff members should be well trained to pick up cues that signal mounting aggression. They must be able to maintain calm, comforting demeanors and refrain from using direct confrontation and intruding on a patient’s personal space. Beneficial techniques include verbal redirection, implementation of relaxation techniques, close observation, distraction of the patient’s attention away from triggers of aggression, and the use of quiet time or open seclusion in areas of the unit with decreased stimuli. Unpleasant surroundings and loud, irritating noises also increase the likelihood of violence. 12 The longer aggressive patterns of behavior have been in place, the less likely it is that they will be modified by changes in the environment alone. 20
Seemingly simple interventions can have a tremendous impact on violent outcomes. These include offering something to drink or eat, decreasing wait times, maintaining a positive and friendly attitude toward the patient, avoiding intimidating direct eye contact, and removing potentially dangerous objects from the area. Since a staff member’s body language can contribute significantly to triggering violence, uncrossing arms and displaying empty hands can be less threatening. Remaining empathetic, making soothing statements, and expressing concern for the patient’s wellbeing reinforces the idea that everyone is present to ensure the patient’s safety and access to treatment. Positive reinforcement for peaceful choices in behavior and for behavior that preserves the treatment community’s order and boundaries can be useful. Consistency in setting limits on behavior and suggesting alternatives to violence, such as talking to staff or making a phone call, are important de-escalation techniques. 12
The governing principle of managing violent psychiatric patients is the doctrine of least restrictive alternatives. This necessitates managing aggressive patients with the least restrictive yet effective means possible. Restraints or locked seclusion are the final resort in dealing with imminent danger in an emergency or inpatient setting. In implementing restraints, the staff should identify a team leader and complete the procedure in a standard and calm manner. 12 Each inpatient psychiatric facility maintains policies and guidelines for the application of restraints and seclusion to which staff must adhere.
Patients with more frequent visits to their mental health centers have a reduced likelihood of threatening violence or committing violent acts against family members. 67 The psychotherapeutic relationship can be healing and restorative in and of itself, but specific techniques certainly contribute the curative element of the treatment. Alpert and Spillman 68 completed a review on psychotherapeutic treatments for violent patients, emphasizing that all therapists need to maintain a safe therapeutic environment for themselves and the patient, complete sufficient training on the management of violent patients, and have access to consultation and supervision. 68
Countertransference is an intriguing consideration in the treatment of aggressive patients. The therapist’s countertransference reactions may influence the progress of treatment, including under- or overestimating risk and becoming overinvolved with or neglectful of the patient. In trying to build a therapeutic alliance with a violent patient, the therapist may ignore feelings of fear or disgust, which could have disastrous consequences. Alternately, the clinician may find it difficult to relate and empathize with an aggressive patient, especially if such acts are chronic. Without self-monitoring, the therapist may find it difficult to maintain a supportive, nonjudgmental stance and avoid inappropriate reactions. 68
Various modalities of therapy could apply to the violent patient. Therapists with a behavioral focus would be more concerned with prior triggers, violent behaviors, and consequences for actions. Many institutions employ these behavioral techniques in the form of levels of privileges that the patient can earn. Social skills training promotes more acceptable assertive behaviors and reinforces self-control mechanisms. Cognitive approaches focus on incorrect automatic thoughts that precede anger reactions in the context of larger faulty belief systems that direct an individual’s perceptions of external events. Filtering experiences through these inaccurate cognitive schema results in distortions of situations, with subsequent unnecessary feelings of anger and inappropriate responsive behaviors. 68
Group therapy creates a microcosm of real-world relationships and interpersonal difficulties for patients. Group therapy can be less intense for potentially violent patients and their therapists in terms of transference and countertransference reactions. Interactions with other group members through a course of therapy can be a source of modeling for aggressive patients. Groups also provide supportive confrontations and conflict resolution. Family and couples therapy can be more problematic if the victim and the perpetrator are treated together, as it can be difficult to assign responsibility for the violence appropriately. The perpetrator will tend to rationalize the aggression in the family as an appropriate response to instigation. Continuing violence in the relationship during treatment is another obstacle to overcome. 68 Early detection of abuse and domestic violence, combined with proper therapeutic methods, can be important in decreasing the chance for future violence in children and adolescents. 23
After JB’s medication regimen was simplified, medication used to address the violent behavior was limited to only haloperidol 5mg up to every four hours as needed for agitation. Staff observed that he responded well to positive and consoling statements by female nurses and attendants. He began requesting to be able to lie quietly in the seclusion room with a staff member watching him, while the door remained open and unlocked. These environmental accommodations were made, and the patient’s aggressive incidents and time spent in restraints began to decline. He was able to be involved in group activities on the unit and receive visits from supportive family members. His depression was persistent, however. In view of the refractory nature of his symptoms, he underwent a course of electroconvulsive therapy.
Acute violent behavior.
In addition to environmental modifications and psychotherapy, pharmacotherapy certainly has a place in treating and controlling violent behavior. Many of the practices in medicating acute aggression are based in and developed from clinical experience and personal observation. There is limited empirical data regarding appropriate pharmacologic choices.
Pharmacological considerations involve more than just the choice of medication; it also includes the clinician’s presentation of options to the patient and the route of medication administration. When possible, it is best to offer the patient a choice as to which type or route of medication will be used to help him or her regain self control. The act of the patient making this choice facilitates good judgment and control, potentially heading off further frustration and agitation while preserving dignity for all involved. 4 Since oral administration of most of these agents is generally as effective as parenteral dosing, taking the medication by mouth offers an opportunity for the patient to regain some self efficacy in treatment. However, violent patients may summarily refuse treatment with medications. In this emergency setting (with impending harm to self and/or others), this treatment refusal is usually overruled, and medication is administered against the patient’s will, for the safety of the treatment community.
High-potency first-generation neuroleptics have been the agents of first choice for the treatment of acute aggression since their inception, especially when such aggressive behavior seems to be motivated or aggravated by psychotic symptoms. These medications, such as haloperidol and fluphenazine, are used alone or in combination with a quick-acting benzodiazepine, such as lorazepam, for added sedation. Reasonable doses of these medications—5mg for the neuroleptics and 2 to 3mg for the benzodiazepine—can be given orally or intramuscularly and repeated every 1 to 2 hours until the patient’s aggression has ceased. 62 Haloperidol, in particular, has been shown repeatedly in the literature to be safe in patients, even if their medical histories are unknown. In particular, haloperidol has minimal effects on cardiac status and seizure threshold. 4 Markedly higher doses of these neuroleptics, a more common practice in past decades, can actually worsen aggression, largely due to dose-related side effects, especially akathisia and dystonias. 62 When more sedation as well as antipsychotic properties are desired, chlorpromazine in oral doses of 100 to 200mg can quiet aggressive behaviors quickly, with cautious observation for anticholinergic and orthostatic side effects. 12 Monotherapy with benzodiazepines can also be useful in treating aggression, especially those agents with quicker onsets of action. 4 Lorazepam is commonly chosen, perhaps because of its reliable intramuscular administration. Benzodiazepines carry a small but real risk of disinhibition and paradoxical aggression.
Preliminary data on new intramuscular and rapidly dissolving formulations of several second-generation antipsychotics, including risperidone, olanzapine, and ziprasidone, suggest that they are comparable in efficacy to haloperidol for managing acute aggression. These formulations may facilitate the eventual transition over to chronic maintenance with their oral counterparts. Data also suggest these newer medications may demonstrate more favorable side effect profiles in emergency situations. 69 However, manufacturers of each agent detail specific warnings in the package inserts of these new preparations, including concern for corrected QT prolongation with ziprasidone and excessive sedation and cardiorespiratory depression if olanzapine is combined with benzodiazepines intramuscularly.
The risk of violence decreases when psychiatric symptoms are treated successfully; this concept underscores the importance of accurate diagnosis and comprehensive treatment of chronically aggressive patients. Some targeted pharmacotherapy may help control violent behaviors in psychiatric patients when treatment of the underlying disorder is not enough to prevent hostile incidents. This directed therapy can assist chronic patients in living more successfully in a community environment.
Available evidence maintains that second-generation antipsychotics should be considered the treatment of choice for chronic aggression, given their efficacy and favorable tolerability in the long term. 62 In particular, clozapine is recommended for persistent violence in the setting of psychosis, especially refractory conditions. Several studies have shown that clozapine is effective in controlling aggression and reduces the use of restraint and seclusion in state hospital settings. 72 Volavka and colleagues showed that clozapine lessened hostility, separate from improving psychosis. 71 Other second-generation antipsychotics, such as risperidone, olanzapine, and quetiapine, have shown equal efficacy in psychiatric patients with chronic violent behavior as compared to traditional neuroleptics. They have also shown benefit in aggression associated with autism or dementia. 12
Lithium has displayed effectiveness for aggression in mentally retarded populations, with serum concentrations of 0.6 to 1.4mEq/L reducing violent incidents by 50 to 73 percent in separate samples. 72 Lithium has also repeatedly been shown to reduce irritability and incidents of aggression in patients diagnosed with bipolar disorder. Valproate has been shown to promote significant reductions in aggression, across multiple diagnostic categories, including organic syndromes, dementia, mental retardation, and bipolar disorder. 73 In addition, carbamazepine decreases agitation in brain-injured patients. 74
Selective serotonin reuptake inhibitors have established efficacy in decreasing aggression in populations with various psychiatric diagnoses, including Alzheimer’s disease, autism, mental retardation, psychosis, posttraumatic stress disorder, and personality disorders. 72 A three-month, double-blind study of 21 patients with borderline personality disorder showed a decrease in anger after receiving therapeutic dosages of fluoxetine, apart from changes in their depressive symptoms. 75 One multicenter trial found that citalopram was more effective than placebo in controlling aggression and irritability in patients with Alzheimer’s-type dementia. 72
B-blockers have been tried as an adjuvant treatment to help control violent incidents in patients with a variety of symptoms. In patients recently hospitalized for traumatic brain injury, propranolol (up to 420mg/day) was found to be more effective than placebo in reducing agitation in 21 subjects. 72 Ratey and colleagues examined 41 chronic inpatients with psychosis and found that nadolol (40–120mg/day) combined with other psychotropics, resulted in significant improvements in aggression and hostility scores as compared with placebo. 78
Violence has serious implications for society and psychiatric practice, directly and indirectly affecting the quality of life of patients, their families, the community, and mental health workers. The specter of violence in psychiatric practice demands risk stratification and management as part of the complete patient assessment. Any modifiable risk factor must be addressed by psychiatrists while working with inpatient and outpatient treatment teams. Psychotherapy and pharmacotherapy are used both in the emergent circumstance and throughout the course of illness.
This review of the available literature on violence and aggression supports this notion that such symptoms are often a consideration in providing care psychiatric patients. We can conclude from the information in this review that individuals with mental illness, when appropriately treated, do not pose any increased risk of violence over the general population. Violence may be more of an issue in patients diagnosed with personality disorders and substance dependence. The overall impact of mental illness as a factor in the violence that occurs in society as a whole appears to be overemphasized, possibly intensifying the stigma already surrounding psychiatric disorders. Violence and mental illness are not without connection, however, as they share many biologic and psychosocial aspects.
In the future, research may focus on discovering useful factors in the development of aggression, which would shed light on preferred treatment methods. Understanding factors contributing to violence and appropriately developing a risk management plan to address those factors will hopefully contribute to further eliminating stigma and other obstacles confronting psychiatric patients, helping them to achieve a good quality of life and independence in the community.
IMAGES
VIDEO
COMMENTS
Research is helping to tease apart why some people with serious mental illness are prone to violence while others are not, and how clinicians and others can help through improved treatment and informed myth-busting.
On the other hand, people with mental health conditions appear to be at increased risk for being victims of interpersonal violence. A major limitation to researching mental health and violence is that only approximately half of those with a mental illness have a formal diagnosis.
Members of the public exaggerate both the strength of the association between mental illness and violence and their own personal risk. Finally, too little is known about the social contextual determinants of violence, but research supports the view the mentally ill are more often victims than perpetrators of violence.
The debate about addressing mental illness and violence often ignores key facts. Many people experience mental illnesses, so having had a diagnosed illness is not a very specific predictor of violent behavior. This means that many proposed policy approaches, ...
This special issue of the Harvard Review of Psychiatry addresses the vexing topic of violence and mental illness with a set of reviews and essays written from diverse intellectual and practice perspectives; the articles reflect both the multifaceted nature of the problem and the importance of interdisciplinary research to inform effective interventions and policies to try to solve it. The ...
That said, mental health professionals play a critical role in assessing their patients for violence risk, counseling about firearm safety, and guiding the creation of rational and evidence-based public policy that can be effective in mitigating violence risk without unnecessarily stigmatizing people with mental illness.
This essay addresses the complex intersection of injurious behavior with mental illness and access to firearms. It explores what more can be done to stop gun violence while respecting the rights of lawful gun owners, preserving the dignity of persons with mental illnesses, and promoting racial equity.
Gun violence in the United States causes traumatic responses in those who are directly exposed and contaminates the consciousness of young people, particularly those with serious mental health prob...
Violence and abuse are endemic worldwide and are frequently experienced by people with mental health problems. However, although violence and abuse are recognised as important in understanding how mental health problems develop, there has been little research focused on the commonest form of abuse—domestic abuse—or sexual abuse in adulthood and their relationship with mental health. We are ...
This chapter reviews previous empirical research results investigating the associationAssociation between mental illnessMental illness and violenceViolence . Over the last several decades, the USA has suffered from a large number of mass shootingsMass shooting ,...
Surveys reveal that the public associates mental illness with violent crime - Claudia Hammond says the evidence suggests otherwise.
Violence and Mental Illness Swanson, Jeffrey W. PhD; Special Issue Editor Author Information Harvard Review of Psychiatry 29 (1):p 1-5, 1/2 2021. | DOI: 10.1097/HRP.0000000000000281 Buy Metrics
Many health service psychologists will, at some point in their careers, evaluate, treat, or study the relatively small number of people with serious mental illness who have committed or have the potential to commit violence toward others. Most often they see these individuals in psychiatric inpatient or forensic settings, but occasionally in private practice as well. Many more psychologists ...
Biological Mechanisms Of The Health Effects Of Violence Exposure The physical injuries that stem from violence have been studied more extensively than have the mental health effects, with work on ...
In public perception, mental illness and violence remain inextricably intertwined, and much of the stigma associated with mental illness may be due to a tendency to conflate mental illness with the concept of dangerousness. This perception is further augmented by the media which sensationalises violent crimes committed by persons with mental illness, particularly mass shootings, and focuses on ...
Violence against women is widely recognised as a violation of human rights and a public health problem. In this Series paper, we argue that violence against women is also a prominent public mental health problem, and that mental health professionals should be identifying, preventing, and responding to violence against women more effectively. The most common forms of violence against women are ...
How can mental health research change the dominant narratives surrounding mass shootings and multiple-victim homicides, and thus broaden debates about the community effects of gun violence?
The relationship between mental illness and violence has long been a subject of debate and a general course of concern within the mental health profession, the public, correctional systems, and the criminal justice systems. As a result this has led to an increase in research being focused on the reasons why mentally ill people commit crimes. Debate about the need for, the nature of and care of ...
Introduction. The analysis of criminality and people's mental health contains not only the effect of inflicted harm on one's mental stability but also the potential predisposition of people with mental illnesses towards violent behaviour. The recent portrayals of violent crimes against small or large groups of people have often mentioned ...
Key words: Global mental health, interpersonal violence, mental health, social justice In 2017, this journal published a call for papers for a special series on the topic of interpersonal violence and mental health. The invitation was received with much interest: from 2017 to 2019, 24 papers were published reporting on data from 31 countries.
Through life story interviews with victims of psychological abuse, we offer new empirical evidence for a tactic of coercive control: mental health weaponization.Shaped by structural vulnerabilities, mental health weaponization involves three key features: gendered accusations that victims are "crazy" and emotionally unstable; leveraging victims' past traumas against them, particularly that ...
Across the U.S., youth mental health challenges have led to crippling consequences for individuals, families and communities. In Michigan, Michigan State University Extension is working to improve outcomes for youth facing these challenges, thanks in part to a three-year, $1.55 million grant from the U.S. Office of Juvenile Justice and Delinquency Prevention.
Violence against women is a prominent public health problem and a violation of human rights, which impairs, in particular, women's rights to life, to freedom from torture and other cruel, inhuman, or degrading treatments or punishments, and to the highest attainable standards of physical and mental health.1,2 International and national ...
Exposure to violence contributes to the genesis of, and exacerbates, mental health conditions, and existing mental health problems increase vulnerability to partner violence. A recently described phenomenon is when male violence against females occurs within intimate relationships during youth, and it is termed adolescent or teen dating violence.
The incidence of mental ill-health among young men in particular, started rising in 2008 with the onset of the Great Recession and for young women around 2012. The age profile of mental ill-health shifts to the left, over time, such that the peak of depression shifts from mid-life, when people are in their late 40s and early 50s, around the ...
Violence attracts attention in the news media, in the entertainment business, in world politics, and in countless other settings. Violence in the context of mental illness can be especially sensationalized, which only deepens the stigma that already permeates our patients' lives. Are violence and mental illness synonymous, connected, or just ...