ATAP:GP Meeting 2/17

• Please call 1-866-423-8755 and enter 553281 for audio

Violence and Mental Illness

Research: Violence & Mental Illness

• MacArthur Foundation Violence Risk Assessment Study (1998)

• significant under-reporting of violence perpetrated by discharged mentally ill

• immediate family members most often targeted; such violence most likely to occur within the home

Research: Violence & Mental Illness (cont.)

• MacArthur Foundation Violence Risk Assessment Study (1998)

Diagnosis % ViolenceNone 4.6

Major Mental Illness 17.9

Major Mental Illness

& Substance Abuse 31.1

Other Mental Disorder

& Substance Abuse 43.0

Research: Violence & Mental Illness (cont.)

• specific symptoms, such as command hallucinations to perpetrate violence, predicted violence (Monahan et al., 2001), as did comorbid MMI and substance use disorders (Steadman et al., 1998).

• MMI, including psychotic disorders, played a very small role in the violence of patients.

Elbogen and Johnson (2009)• analyzed a two-wave epidemiological data

set of 34,653 persons residing in the community in the United States. The authors reported that MMI, did not predict violence

• However, comorbid MMI and substance use disorders did predict later violence, more so than substance use disorders alone, suggesting an interaction between MMI and substance use disorders.

Elbogen & Johnson (cont.)

• Although the odds of future violence among those with schizophrenia alone were about double the odds of future violence among persons without schizophrenia, this association was not statistically significant

Additional Research

• MMI remains predictive of violence in the presence of other risk factors that have been entered into multivariate analyses (Swanson et al., 2006) or after adjusting for population parameters

Douglas, Guy & Hart (2009)

• Meta-analytic study of research on the association between psychosis and violence analyzing effect sizes from 204 studies.

• The median of the effect sizes indicated that psychosis was significantly associated with a 49%–68% increase in the odds of violence.

• psychosis measured as a diagnosis of schizophrenia or measured at symptom level more predictive

USCP Data re: Mentally Ill Subjects• Overall, nearly 40% of the USCP threat

assessment caseload involves persons who display symptoms of obvious/serious mental illness

• Substantially more likely to approach• Substantially more likely to use multiple methods

of contact• Less likely to threat before approach—but when

make threats, risk of approach is substantial• More likely to be driven by personal or delusion-

driven motives when approach

Implications for Threat Assessment

• Focus upon symptoms, not diagnosis• Nature of threat inherent in symptom to

subject and target• Nature of grievance inherent in symptom• Personalized nature of grievance• Context—why now? Current stressors?

Factors Associated with Violent Recidivism

Clinical Factors• Prior Hospitalizations• Treatment compliance• Hx of Therapeutic Alliance• Substance Abuse• Personality Disorder (particularly Antisocial

Personality Disorder)

Hallucinations

• False or distorted sensory experiences that appear to be real perceptions.

• These sensory impressions are generated by the mind rather than by any external stimuli, and may be seen, heard, felt, and even smelled or tasted.

Delusions

• A false belief that is firmly held despite logical and confirming evidence to the contrary.

• Different types, for example:• Grandeur• Paranoia/Persecutory

Factors Associated with Violent Recidivism

Clinical Factors• Principle of “rationality within

irrationality”• Particular symptoms:

• Delusions• Hallucinations• Symptom Severity• Violent Fantasies

Psychotic Symptoms Indicative of Risk

Threat/control override symptoms• command hallucinations• hallucination related to delusion • source of voice is identifiable to patient• delusion indicates immediate physical harm• thought insertion/broadcasting delusions• perceived loss of bodily control

Interview Issues: Mental Illness

• Principle of “rationality within irrationality”• Do not argue with delusions• mental illness not equal limited intelligence• Have subject educate regarding issues involved • Careful use of confrontation• Direct questions regarding dangerousness not

always useful-- use of indirect or third party perspective questions

Interview Issues: Mental Illness

• “What if…” questions • Role of external stressors as triggers • Exceptions to when not acted on

hallucinations/delusions or other symptoms • Do not neglect role of alcohol• Recognize need for future contacts

Contact Information

Mario Scaloramscalora1@unl.edu

402-472-3126