8/19/2019 Psychosis & Violence, Risk Assessment
1/65
Psychosis & Violence
Risk AssessmentDr. Luke Woon Sy-Cherng
3/11/1 1
8/19/2019 Psychosis & Violence, Risk Assessment
2/65
Psychosis & Violence
3/11/1 !
8/19/2019 Psychosis & Violence, Risk Assessment
3/65
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
,eh"#iour.3/11/1 3
8/19/2019 Psychosis & Violence, Risk Assessment
4/65
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
3/11/1 :
8/19/2019 Psychosis & Violence, Risk Assessment
5/65
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
8/19/2019 Psychosis & Violence, Risk Assessment
6/65
Psychosis & Violence
• 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
8/19/2019 Psychosis & Violence, Risk Assessment
7/65
Psychosis & Violence
• ?n " re#ie< o( 31 @S em$iric"l stuiessince 16) Choe et "l. !669 (oun th"t)1!819 o( "ll $"tients
8/19/2019 Psychosis & Violence, Risk Assessment
8/65
Psychosis & Violence
• ?n 4ngl"n) links ,et
8/19/2019 Psychosis & Violence, Risk Assessment
9/65
Psychosis & Violence
3/11/1
8/19/2019 Psychosis & Violence, Risk Assessment
10/65
4$iemiology
@S 4$iemiologic C"tchment Are" 4CA stuyS
8/19/2019 Psychosis & Violence, Risk Assessment
11/65
4$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$orte ele#"tion in #iolence r"tes "mongthose
8/19/2019 Psychosis & Violence, Risk Assessment
12/65
4$iemiology
he $ro$ortion o( homicides "ttri,ute to$eo$le
8/19/2019 Psychosis & Violence, Risk Assessment
13/65
4$iemiology
• ?t shoul ,e note th"t
8/19/2019 Psychosis & Violence, Risk Assessment
14/65
4$iemiology
SeJ o>ening• 5"2el et "l. !66E) using Sence
8/19/2019 Psychosis & Violence, Risk Assessment
15/65
4$iemiology
Arson
• An
8/19/2019 Psychosis & Violence, Risk Assessment
16/65
Psychosis to ViolenceP"th
8/19/2019 Psychosis & Violence, Risk Assessment
17/65
Psychosis to ViolenceP"thence signi'c"ntly less likely to h"#e
,een ri#en ,y $sychotic sym$toms
3/11/1 1E
8/19/2019 Psychosis & Violence, Risk Assessment
18/65
Psychosis to ViolenceP"th
8/19/2019 Psychosis & Violence, Risk Assessment
19/65
Psychosis to ViolenceP"th
8/19/2019 Psychosis & Violence, Risk Assessment
20/65
Comor,i %ent"l Disorers
Person"lity isorer• %or"n et "l. !663 inter#ie
8/19/2019 Psychosis & Violence, Risk Assessment
21/65
Comor,i %ent"l Disorers
• engstrNm et "l. !66: (oun th"t"mong !6! m"le o>eners ences th"t those $oint.
3/11/1 !1
8/19/2019 Psychosis & Violence, Risk Assessment
22/65
Comor,i %ent"l Disorers
Su,st"nce misuse• 4"rly stuies suggests "n in#erse
rel"tionshi$ ,et
8/19/2019 Psychosis & Violence, Risk Assessment
23/65
Comor,i %ent"l Disorers
Su,st"nce misuse "n its role in incre"sing therisk o( #iolence "mong $eo$le
8/19/2019 Psychosis & Violence, Risk Assessment
24/65
Comor,i %ent"l Disorers
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
$erson"lity isorer
3/11/1 !:
8/19/2019 Psychosis & Violence, Risk Assessment
25/65
Clinic"l Ch"r"cteristics
Psychotic Sym$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$toms.•
Link "n Stue#e 1: highlighte thiscluster "s " strong correl"te o( #iolence.
3/11/1 !=
8/19/2019 Psychosis & Violence, Risk Assessment
26/65
Clinic"l Ch"r"cteristics
CK consists o( three sym$toms• " (eeling th"t oneQs min is omin"te
,y (orces ,eyon oneQs control• " (eeling th"t thoughts "re ,eing $ut
into oneQs min th"t "re not oneQs o
8/19/2019 Psychosis & Violence, Risk Assessment
27/65
Clinic"l Ch"r"cteristics
Psychotic Sym$toms "n Violence• Signi'c"nt rel"tionshi$ ,et
8/19/2019 Psychosis & Violence, Risk Assessment
28/65
Clinic"l Ch"r"cteristics
Psychotic Sym$toms "n Violence• Violence in the conteJt o( $sychotic
illness is more likely to ,e irecteto
8/19/2019 Psychosis & Violence, Risk Assessment
29/65
Clinic"l Ch"r"cteristics
Psychotic Sym$toms "n Violence
u"lities "ssoci"te
8/19/2019 Psychosis & Violence, Risk Assessment
30/65
Clinic"l Ch"r"cteristics
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
8/19/2019 Psychosis & Violence, Risk Assessment
31/65
Clinic"l Ch"r"cteristics
Psychotic Sym$toms "n Violence
5"ctors "ssoci"te
8/19/2019 Psychosis & Violence, Risk Assessment
32/65
Clinic"l Ch"r"cteristics
Psychotic Sym$toms "n Violence• Empathy Derntl et "l. !66 h"#e suggeste "
gener"l e'cit o( "ll em$"thic ",ilities in $eo$le
8/19/2019 Psychosis & Violence, Risk Assessment
33/65
4n#ironment"l 5"ctors
5"mily• he B"tion"l Con'enti"l ?nuiry into omicie
(or 4ngl"n "n W"les sho
8/19/2019 Psychosis & Violence, Risk Assessment
34/65
4n#ironment"l 5"ctors
Clinic"l en#ironment• DiMculties in communic"tion
,et
8/19/2019 Psychosis & Violence, Risk Assessment
35/65
4n#ironment"l 5"ctors
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=
8/19/2019 Psychosis & Violence, Risk Assessment
36/65
%"n"gement & re"tment
Princi$les o( m"n"gement•
8/19/2019 Psychosis & Violence, Risk Assessment
37/65
Risk Assessment
3/11/1 3E
8/19/2019 Psychosis & Violence, Risk Assessment
38/65
D"ngerousness/Risk
• *D"ngerousness+ re(ers to the risk o(serious h"rm to others.
• Clinici"ns "re eJ$ecte to ,e ",le to "ssess
risk o( serious h"rm ,y $eo$le ect on the rights o( the ini#iu"l.
3/11/1 39
8/19/2019 Psychosis & Violence, Risk Assessment
39/65
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"$$ening in re"lity3. *risk le#el+ 8 the $ro,",ility th"t theh"rm
8/19/2019 Psychosis & Violence, Risk Assessment
40/65
Risk Assessment
here "re ! m"in "$$ro"ches to risk"ssessment
• Actu"ri"l risk "ssessment
•
Clinic"l risk "ssessment
3/11/1 :6
8/19/2019 Psychosis & Violence, Risk Assessment
41/65
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
8/19/2019 Psychosis & Violence, Risk Assessment
42/65
Clinic"l Risk Assessment
• A#"nt"ges o( the clinic"l "$$ro"chinclue its inter"cti#e n"ture o( "t"collection it "#ois im$osing
$reconcei#e ie"s onto the $erson ,eing"ssesse "n th"t it is "l
8/19/2019 Psychosis & Violence, Risk Assessment
43/65
Structure Fugment ools
• 3 m"in cl"sses o( stuy (or risk "ssessment tools• %"in e>ects "n"lysis 8"n"lysis o( " single) l"rge
"t" set. 4.g. he Violence Risk A$$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 $ro(ession"l Gugment
• ?nter"ction e>ects "n"lysis 8 single "t" set) ,ut"llo
8/19/2019 Psychosis & Violence, Risk Assessment
44/65
Structure Fugment ools
• Violence Risk Assessment IuieVRAI
• istoric"l Clinic"l "n Risk%"n"gement Sc"le CR-!6
• Cl"ssi'c"tion o( Violence Risk CKVR
3/11/1 ::
8/19/2019 Psychosis & Violence, Risk Assessment
45/65
A#"nt"ges
• 4nsuring th"t "ll in(orm"tion rele#"ntto #iolence "n other "ntisoci"l,eh"#iour is consiere.
• r"ns$"rency in metho "nrecoring o( the "ssessment.
• Ire"ter cl"rity in communic"ting
",out these issues.
3/11/1 :=
8/19/2019 Psychosis & Violence, Risk Assessment
46/65
Violence Risk Assessment IuieVRAI
• he VRAI "rris et "l. 13
8/19/2019 Psychosis & Violence, Risk Assessment
47/65
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 $reicti#e ",ility o( the VRAI)
8/19/2019 Psychosis & Violence, Risk Assessment
48/65
istoric"l Clinic"l "n Risk%"n"gement Sc"le CR-!6
• he CR-!6 is " structure clinic"l Gugmentinstrument We,ster et "l. 1E.
• De#elo$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-$oint sc"le*",sent+) *some
8/19/2019 Psychosis & Violence, Risk Assessment
49/65
istoric"l Clinic"l "n Risk%"n"gement Sc"le CR-!6
3/11/1 :
8/19/2019 Psychosis & Violence, Risk Assessment
50/65
3/11/1 =6
8/19/2019 Psychosis & Violence, Risk Assessment
51/65
3/11/1 =1
8/19/2019 Psychosis & Violence, Risk Assessment
52/65
istoric"l Clinic"l "n Risk%"n"gement Sc"le CR-!6
• he rese"rch ,"se (or the CR-!6 isunri#"lle ,y th"t (or "ny otherinstrument in the 'el.
• %"ny stuies (rom Borth Americ""n throughout 4uro$e "re in"greement th"t the CR-!6 is "
use(ul instrument) returning A@Cs
8/19/2019 Psychosis & Violence, Risk Assessment
53/65
Cl"ssi'c"tion o( Violence RiskCKVR
• he CKVR %on"h"n et "l. !66=
8/19/2019 Psychosis & Violence, Risk Assessment
54/65
he %"cArthur Violence RiskAssessment Stuy
• he tool
8/19/2019 Psychosis & Violence, Risk Assessment
55/65
Cl"ssi'c"tion o( Violence RiskCKVR
• V"li"tion results (or CKVR outsiethe @SA "re gro
8/19/2019 Psychosis & Violence, Risk Assessment
56/65
Risk %"n"gement
“Positive risk management as part of a carefullyconstructed plan is a required competence forall mental health practitioners.”
De$"rtment o( e"lth in 4ngl"n !66E
Risk-rel"te ecision
8/19/2019 Psychosis & Violence, Risk Assessment
57/65
Risk %"n"gement
Princi$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 $l"n (or the
8/19/2019 Psychosis & Violence, Risk Assessment
58/65
Risk %"n"gement
Princi$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
8/19/2019 Psychosis & Violence, Risk Assessment
59/65
Conclusions
• Hno
8/19/2019 Psychosis & Violence, Risk Assessment
60/65
Conclusions
• he more commonly use n"me "is h"#eest",lishe reli",ility "n #"liity $ro'le.
• Risk "ssessment shoul ,e $"rt o( the
8/19/2019 Psychosis & Violence, Risk Assessment
61/65
Re(erences
Loren2 H 1 !n Aggression. Lonon %ethuen.5reu S 1!6) tr"nsl"te CF% u,,"ch) 1!! "eyond the Pleasure Principle. Lonon ?ntern"tion"l Psycho-"n"lytic"l Li,r"ry)
og"rth.Doll"r F) %iller B) Doo, L) %oening in men " c"se
control stuy ,"se on Sening. riminal 2ustice3/11/1 1
8/19/2019 Psychosis & Violence, Risk Assessment
62/65
Re(erences
(ner "n 0Nker W 1E3) tr"nsl"te %"rsh"ll) 19! rimes of (iolence by 1entally Abnormal !6enders. C"m,rige)@H C"m,rige @ni#ersity Press.
iihonen F "n Seners the e#elo$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"
8/19/2019 Psychosis & Violence, Risk Assessment
63/65
h"nk ou
3/11/1 3
8/19/2019 Psychosis & Violence, Risk Assessment
64/65
3/11/1 :
8/19/2019 Psychosis & Violence, Risk Assessment
65/65