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teaching:violence [on April 30, 2020]
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psychdb [Primer]
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 ====== Violence and Mental Illness ====== ====== Violence and Mental Illness ======
 ===== Primer ===== ===== Primer =====
-The **relationship between violence and mental illness** is a challenging issue that clinicians face. The association between the two is commonly linked together in popular media and society, resulting in an exaggerated and misunderstood perception of mental illness. Clinicians are often asked to assess the risk that a patient could pose to the public, while also being asked by society/law to keep an individual'​s personal liberties in mind.+The **relationship between violence and mental illness** is a challenging issue that clinicians face. The association between the two is commonly linked together in popular media and society, resulting in an exaggerated and misunderstood perception of mental illness. Clinicians are often placed in a difficult position of being asked to assess the risk that a patient could pose to the public, while also being asked by society/law to keep an individual'​s personal liberties in mind (e.g. - involuntary admissions).
  
-== Are the mentally ill more violent ​on a population level? == +== Are the Mentally Ill More Violent ​on a Population Level? == 
-Large scale meta-analyses have shown that even categorizing individuals at "high risk" ​of violence had very little effects of predicting violence on a population level. One study demonstrated that to prevent one homicide, 35,​000 ​"high-risk" ​schizophrenia patients would need to be detained.[([[https://www.ncbi.nlm.nih.gov/pubmed/21250894|Large,​ MM., Ryan, CJ., Singh, S. P., Paton, M. B., & Nielssen, O. B. (2011). The predictive value of risk categorization ​in schizophrenia. ​Harvard review of psychiatry, ​19(1), 25-33.]])]+<alert type="info" ​icon="fa fa-book fa-lg fa-fw"
 +See also: 
 +  * **[[https://onlinelibrary.wiley.com/doi/10.1002/wps.21171|WhitingDet al. (2024). Violence ​in schizophrenia: triangulating the evidence on perpetration riskWorld psychiatry, ​23(1), 158.]]** 
 +  * **[[https://​rationalpsychiatry.substack.com/​p/​a-history-of-violence|Rational Psychiatry: A History of Violence]]** 
 +</​alert>​
  
-== Who is at higher risk? == +  * Large scale meta-analyses have shown that even categorizing individuals at "high risk" of violence had very little effects of predicting violence on a population level. One study demonstrated that to prevent one homicide, 35,000 "​high-risk"​ schizophrenia patients would need to be detained.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​21250894|Large,​ M. M., Ryan, C. J., Singh, S. P., Paton, M. B., & Nielssen, O. B. (2011). The predictive value of risk categorization in schizophrenia. Harvard review of psychiatry, 19(1), 25-33.]])] 
-Three factors are implicated in those who have a higher risk of violence compared with the general population: (1) //severe// mental illness, (2) substance abuse and/or dependence, and (3) a past history of violence. Individuals with //all// of these risk factors have a distinctly higher than average risk of violence (severe mental illness alone does not predict risk of violence).[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​19188537|Elbogen,​ E. B., & Johnson, S. C. (2009). The intricate link between violence and mental disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of general Psychiatry, 66(2), 152-161.]])] These individuals should have a more structured violence risk assessment done, such as with the HCR-20. In acute psychiatric settings, young age, male sex, history of psychiatric illness, comorbid substance abuse and positive symptoms of a psychotic disorder have also been shown to be predictors of violent behaviour.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4789812/​|Varshney,​ M., Mahapatra, A., Krishnan, V., Gupta, R., & Deb, K. S. (2016). Violence and mental illness: what is the true story?. J Epidemiol Community Health, 70(3), 223-225.]])]+ 
 +==== Risk Factors for Violence ==== 
 +  * Individuals with mental illness can be at higher risk for violence based on certain [[teaching:​biopsychosocial-case-formulation|biological,​ psychological,​ and social]] factors:​[(Andrews,​ D. A., & Bonta, J. (2006). The psychology of criminal conduct (4th ed.). Newark, NJ: LexisNexis.)] 
 +    * Biological factors include gender (male), temperament/​impulsivity,​ and a family history of violence 
 +    * Psychological factors include antisocial attitudes and poor problem solving approaches 
 +    * Social factors include poor parent-child relations, social learning or antisocial behaviour, and victimization in childhood. 
 +  * The top three factors ​that are implicated in those who have a higher risk of violence compared with the general population: (1) //severe// mental illness, (2) substance abuse and/or dependence, and (3) a past history of violence. 
 +    * Individuals with //all// of these risk factors have a distinctly higher than average risk of violence (severe mental illness alone does not predict risk of violence).[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​19188537|Elbogen,​ E. B., & Johnson, S. C. (2009). The intricate link between violence and mental disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of general Psychiatry, 66(2), 152-161.]])] 
 +  * These individuals should have a more structured violence risk assessment done, such as with the HCR-20. 
 +  * In acute psychiatric settings, young age, male sex, history of psychiatric illness, comorbid substance abuse and positive symptoms of a psychotic disorder have also been shown to be predictors of violent behaviour.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4789812/​|Varshney,​ M., Mahapatra, A., Krishnan, V., Gupta, R., & Deb, K. S. (2016). Violence and mental illness: what is the true story?. J Epidemiol Community Health, 70(3), 223-225.]])] 
 + 
 +<panel type="​info"​ title="​Static and Dynamic Risk Factors for Violence"​ subtitle=""​ no-body="​true"​ footer="">​ 
 +^ Static (Unmodifiable) Risk Factors ​                                                                                                                                                         ^ Dynamic (Modifiable) Risk Factors ​                                                                                                                                                                                                                                                                                                                  ^ 
 +| • Previous violence history\\ • Substance use history\\ • Age (young teens)\\ • Male gender \\ • Intelligence\\ • Young age of violence \\ • Low socioeconomic background \\ • Psychopathy ​ | • Current substance abuse, intoxication\\ • Recent triggers for agitation or assaultive behaviours\\ • Presence of supports\\ • Access to weapons (firearms)\\ • Stress \\ • Negative attitudes \\ • Insight\\ • Impulsivity\\ • Access to victims\\ • Comorbid mental health conditions (treated or untreated), such as active psychotic symptoms ​ | 
 +</​panel>​
  
 ===== Approach ===== ===== Approach =====
-See [[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC2686644/​|Rueve,​ M. E., & Welton, R. S. (2008). Violence and mental illness. Psychiatry (Edgmont), 5(5), 34.]] for an excellent review of approach to violence/​agitation in mental illness.+<alert type="​info"​ icon="​fa fa-book fa-lg fa-fw">​ 
 +See **[[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC2686644/​|Rueve,​ M. E., & Welton, R. S. (2008). Violence and mental illness. Psychiatry (Edgmont), 5(5), 34.]]** for an excellent review of approach to violence/​agitation in mental illness. 
 +</​alert>​
  
-==== DASA ==== +  * Unfortunately,​ research has consistently shown that psychiatrists cannot predict future violence with any significant degree ​of accuracy.[(SadockB. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock'​s synopsis of psychiatry: Behavioral sciences/​clinical psychiatry (Eleventh edition.). Philadelphia:​ Wolters Kluwer.)][([[https://​blogs.bmj.com/​bmj/​2020/​11/​17/​violence-risk-assessment-in-psychiatry-nobody-can-predict-the-future/​|BMJ Opinion: Violence ​risk assessment ​in psychiatry: nobody can predict the future]])] 
-The Dynamic Appraisal ​of Situational Aggression ​(DASA) is a brief7-item scoring instrument to aid health care professionals ​in identifying patients with an increased ​risk of violence, ​in order to enable focused preventative interventions to reduce ​risk of imminent violence.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4854232/|LanttaT., Kontio, R., Daffern, M., Adams, C. E., & Välimäki, M. (2016). Using the Dynamic Appraisal ​of situational Aggression with mental health inpatients: a feasibility study. Patient preference ​and adherence10691.]])]+  * Thus, the use of validated rating tools may be one way to at least systematically document ​risk. 
 +===== Neurobiology ===== 
 +<alert type="​info"​ icon="​fa fa-book fa-lg fa-fw">​ 
 +See also article: **[[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4176893/|SieverLJ. (2008). Neurobiology ​of aggression ​and violence. American Journal of Psychiatry165(4)429-442.]]** 
 +</​alert>​
  
 +  * The failure of higher control systems in the prefrontal cortex to modulate aggressive acts triggered by anger-provoking stimuli play a role in violence and aggression.[[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4176893/​|Siever,​ L. J. (2008). Neurobiology of aggression and violence. American Journal of Psychiatry, 165(4), 429-442.]] Imbalances between the prefrontal regulatory influences and hyper-responsivity of the amygdala and other limbic regions also play a role.
  
 +===== Risk Assessment =====
 +==== Actuarial ====
 +  * Actuarial tables can be used to estimate risk factors for violence. These estimates are usually based on static risk factors (using a specific algorithm that uses a combination of risk factor selection and weighting).
 +  * Examples of actuarial instruments for violence include the:
 +    * [[http://​www.vrag-r.org/​|Violence Risk Appraisal Guide (VRAG)]]
 +    * [[https://​psycnet.apa.org/​record/​2016-00698-021|Sex Offender Risk Appraisal Guide (SORAG)]].
 +  * Examples of actuarial instruments for sexual recidivism include the
 +    * [[http://​www.static99.org/​|STATIC-99R]]
 +  * Strengths of using these instruments is that they are transparent,​ strongly associated with violence, can be used by non-clinical decision makers, and generates a numerical probability and percentile rank of the risk.
 +  * However, disadvantages of these instruments is that the generalizability of the risk to a specific patient is limited.
 +
 +==== Structured Clinical Judgement ====
 +  * Structured clinical judgement tools like the Historical Clinical Risk Management-20 (HCR-20) allow clinicians to define static and dynamic risk factors for violence. The clinician combines these factors and arrives at a risk assessment. These tools are meant to promote flexibility in risk assessment, and allows for interprofessional input.
 +  * However, the use of these tools are also not perfect.[([[https://​pubmed.ncbi.nlm.nih.gov/​21255891/​|Singh,​ J. P., Grann, M., & Fazel, S. (2011). A comparative study of violence risk assessment tools: A systematic review and metaregression analysis of 68 studies involving 25,980 participants. Clinical psychology review, 31(3), 499-513.]])]
  
-===== Scales ===== 
-<panel title="​Scales for Violence Assessment"​ no-body="​true">​ 
-!^! Name                                               ^ Rater      ^ Description ​                                                                                                                                                                                  ^ Download ​ ^ 
-^ Historical Clinical Risk Management-20 (HCR-20) ​                   | Clinician ​   | 20-item, clinician-rated scale      | {{ :​teaching:​advanced:​hcr-20-v3-1-page.pdf |Download HCR-20 (1 page)}}, {{ :​teaching:​advanced:​hcr-20-v3-2-page.pdf |(2 page)}} ​        | 
-^ Classification of Violence Risk (COVR) ​                   | Clinician/​Patient ​   | An interactive software program that estimates the risk that a psychiatric inpatient will be violent to others. The software leads the clinician through a chart review and a brief interview with the patient. ​     | Not available ​        | 
-</​panel>​ 
 ==== HCR-20 ==== ==== HCR-20 ====
-The **Historical Clinical Risk Management-20 (HCR-20)**, is a validated violence risk assessment tool. It is the most commonly violence risk assessment instrument.[([[http://​http://​hcr-20.com|Douglas,​ K. S., Hart, S. D., Webster, C. D., & Belfrage, H. (2013). HCR-20V3: Assessing risk of violence – User guide. Burnaby, Canada: Mental Health, Law, and Policy Institute, Simon Fraser University.]])]+  * The **Historical Clinical Risk Management-20 (HCR-20)**, is a validated violence risk assessment tool for adults aged 18 and above who may pose a risk for future violence.. It is the most commonly ​used violence risk assessment instrument.[([[http://​http://​hcr-20.com|Douglas,​ K. S., Hart, S. D., Webster, C. D., & Belfrage, H. (2013). HCR-20V3: Assessing risk of violence – User guide. Burnaby, Canada: Mental Health, Law, and Policy Institute, Simon Fraser University.]])] 
 +  * The HCR-20 can be used in both general, civil, and forensic populations,​ and assesses the //future// risk for violence to others.[([[https://​pubmed.ncbi.nlm.nih.gov/​18450665/​|Gray,​ N. S., Taylor, J., & Snowden, R. J. (2008). Predicting violent reconvictions using the HCR-20. The British journal of psychiatry : the journal of mental science, 192(5), 384–387.]])] 
 + 
 +<panel title="​Structured Clinical Judgement for Violence Risk Assessment"​ no-body="​true">​ 
 +<​mobiletable 1> 
 +^ Name                                             ^ Rater              ^ Description ​                                                                                                                                                                                                     ^ Download ​                                                                                                                       ^ 
 +^ Historical Clinical Risk Management-20 (HCR-20) ​ | Clinician ​         | 20-item, clinician-rated scale, most commonly used as a violence risk assessment instrument. ​                                                                                                                    | {{ :​teaching:​advanced:​hcr-20-v3-1-page.pdf |Download HCR-20 (1 page)}}, {{ :​teaching:​advanced:​hcr-20-v3-2-page.pdf |(2 page)}} ​ | 
 +^ Classification of Violence Risk (COVR) ​          | Clinician/​Patient ​ | An interactive software program that estimates the risk that a psychiatric inpatient will be violent to others. The software leads the clinician through a chart review and a brief interview with the patient. ​ | Not available ​                                                                                                                  | 
 +</​mobiletable>​ 
 +</​panel>​ 
 + 
 +==== DASA ==== 
 +  * The **Dynamic Appraisal of Situational Aggression (DASA)** is a brief, 7-item scoring instrument to aid health care professionals in identifying patients with an increased risk of violence, in order to enable focused preventative interventions to reduce risk of imminent violence.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4854232/​|Lantta,​ T., Kontio, R., Daffern, M., Adams, C. E., & Välimäki, M. (2016). Using the Dynamic Appraisal of situational Aggression with mental health inpatients: a feasibility study. Patient preference and adherence, 10, 691.]])]
  
-===== Mass Violence ===== 
-  * [[https://​www.nytimes.com/​2018/​02/​20/​opinion/​mental-health-stopping-mass-shooters.html|The New York Times: The Mental Health System Can’t Stop Mass Shooters]] 
  
 ===== Resources ===== ===== Resources =====
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 ==== For Providers ==== ==== For Providers ====
 +  * [[https://​pubmed.ncbi.nlm.nih.gov/​22682575/​|Wong,​ L., Morgan, A., Wilkie, T., & Barbaree, H. (2012). Quality of resident violence risk assessments in psychiatric emergency settings. The Canadian Journal of Psychiatry, 57(6), 375-380.]]
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   * [[https://​beta.theglobeandmail.com/​opinion/​stop-using-mental-illness-to-explain-away-violence-its-not-that-simple/​article36521378/​|The Globe and Mail: Stop using mental illness to explain away violence. It’s not that simple (2017)]]   * [[https://​beta.theglobeandmail.com/​opinion/​stop-using-mental-illness-to-explain-away-violence-its-not-that-simple/​article36521378/​|The Globe and Mail: Stop using mental illness to explain away violence. It’s not that simple (2017)]]
   * [[https://​www.nytimes.com/​2017/​10/​11/​opinion/​psychiatrists-mass-killers.html|NYT:​ Psychiatrists Can’t Stop Mass Killers - Dr. Richard A. Friedman]]   * [[https://​www.nytimes.com/​2017/​10/​11/​opinion/​psychiatrists-mass-killers.html|NYT:​ Psychiatrists Can’t Stop Mass Killers - Dr. Richard A. Friedman]]
 +  * [[https://​www.nytimes.com/​2018/​02/​20/​opinion/​mental-health-stopping-mass-shooters.html|The New York Times: The Mental Health System Can’t Stop Mass Shooters]]
 +
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