1. - Violence – Clinical Risk Assessment & Management ELFT Training Packages for Primary Care - Violence – Clinical Risk Assessment & Management Responsible Clinician for contact: Frank Röhricht Associate Medical Director

2. Epidemiology of Violence and Mental Illness Is mental illness associated with an increased risk of violence?

3. Research Findings Before the 1990s there was a lack of evidence on the link between mental illness and violence During the 1990s and 2000s a large number of different studies were undertaken Studies of the rates of violence in those with mental illness & in those who have committed violent offences

4. Results Studies have consistently revealed an increased rate of violence within those with mental illness compared with the general population. First revealed by Swanson et al (1990) in data from Epidemiological Catchment Area Survey

5. Epidemiological Catchment Area Survey- Swanson et al. (1990) Method: 10,000 people 3 metropolitan areas in USA DSM-III diagnosis

6. ECA Survey- Swanson et al. Measures of violence (1 or more needed in past year): “Did you ever hit or throw things at your partner?” “Have you ever spanked or hit a child hard enough that he/she has bruises or had to stay in bed or had to see a doctor?” “Since the age of 18, have you been in more than 1 fight that came to swapping blows, other than fights with your partner?” “Have you ever used a weapon like a stick, knife or gun in a fight since you were 18?” Have you ever gotten into physical fights while drinking?”

7. ECA Results- Rates of Violence 2% in those with no disorder 8% in those with Schizophrenia 13% in those with Schizophrenia and co- morbid substance use 25% in alcoholism and no mental illness 35% alcoholism + another psychiatric diagnosis

8. These findings have since been confirmed in other samples in a variety of cultures and contexts

9. MacArthur Violence Risk Assessment study Investigated the rates of violence in discharged patients over 1 year follow-up at several sites across the USA 1,130 discharged patients At least one violent act was committed during the first 20 weeks post hospital discharge by 18.7% of patients

10. MacArthur Violence Risk Assessment study A diagnosis of substance misuse was associated with the highest prevalence of violence (29%) Followed by Personality Disorder (25%) Bipolar Affective Disorder 15% Schizophrenia 9%

11. Rates of mental illness within those who committed known violent crime Studies of prison populations have consistently shown an increased risk of mental illness Higher prevalence of schizophrenia in men convicted of homicide (11%) and arson (30%) than in general population(1%) ( Taylor & Gunn 1984)

12. Conclusion The evidence points to a clear association between mental illness and violence, especially psychosis and an even greater association in those with substance misuse and personality disorders such as psychopathy.

13. In context Homicide and Serious violence is rare Annual homicide rate in the UK is ~1 in 100,000 Annual risk of homicide in person with schizophrenia ~1 in 10,000 and serious violence 1 in 150 ( Mullen, 2006 )

14. Substance Use Various ways in which substance use can lead to violence: Intoxication Withdrawal Acquisition Personality change Poor treatment compliance

15. Co-morbidity increases the risk of violence 25 x increase violence in patients with schizophrenia who misuse alcohol; circa 3 x increase without alcohol (Wallace et al. 2004) OR of violence in patients with schizophrenia 2.1 (1.7- 2.7); with substance abuse OR 8.9 (5.4-14.7) (Fazel et al. 2009) Homicide- : odds ratios for ‘alcoholism’ of 11 for men and 38 for women (Eroneb et al. 1996) “Substance abuse disorders represent by far the strongest correlates of violence among all mental disorders” (Nestor 2002)

16. Co-Morbidity Learning Disability Post – Traumatic Stress Disorder Dementia – “Low-grade “physical aggression common Traumatic Brain Injury & Epilepsy - episodic dys- control, frontal lobe disinhibition and rare cases of unusual complex behaviours that can involve violence

17. RISK ASSESSMENT

18. Importance of Violence Risk Assessment Critical event in history of modern UK mental health services Case of Christopher Clunis – patient with schizophrenia who killed Jonathan Zito (stranger) in Dec 1992 (stabbed him in face on platform in broad daylight at Finsbury Park Tube Station) Led to development of CPA framework & mandatory homicide inquiries Tenacity of victim’s widow (Jayne Zito) led to the subsequent Ritchie Inquiry (1994) - landmark inquiry led to improvements in assessment of violence risk

19. Clunis Case- Key Findings of Inquiry GP never received any correspondence from mental health services Much of what patient said was unreliable (e.g. married aged 2 years / schooled at Eton) – but no attempts to check facts No attempts by services to involve family (who were reportedly caring and supportive) even when detained under MHA Often described as having drug-induced psychosis – but no evidence of major drug use (subjective claims only)

20. Clunis Case –Key Findings Label of Personality Disorder often applied – but patient seemingly had normal personality prior to onset of Schizophrenia Discharged from hospital or evicted from hostels due to behavioural problems related to his mental illness (but labelled otherwise) Did well when on regular depot injections – did badly when not Committed many violent offences in 4 years prior to the homicide but not convicted Growing history of violence often not mentioned in reports Not homeless at first contact with mental health services – later became homeless due to deteriorating mental state and failure of services to help him

21. How do we identify High Risk Patients? Static Risk Factors – risk factors that cannot be changed Dynamic Risk Factors – risk factors that can change over time and therefore can be considered a target for treatment

22. Static Risk Factors Male gender Age at first offence History of conduct disorder Adverse childhood experience/poor early attachment Previous History of violence Poor Socio-economic background

23. Past History of Violence Remains one of the most powerful indicators of future violence The following need to be considered: -Types of victims -Environmental & Contextual issues -Frequency of previous violence -Exposure to or development of violence at young age Hence for previous violent offences, consider: -The context -The severity -Possible contributing factors

24. Dynamic Risk Factors Active psychotic symptoms Substance abuse Insight Anger Social circumstances Personality Traits (e.g. impulsivity, way of relating to others)

25. Psychotic symptoms that increase risk Persecutory delusions especially those of being threatened by others or having one’s personal control overridden Delusional Jealousy Misidentification - especially if it involves a family member Command hallucinations

26. Risk of Acting on Auditory Hallucinations -A detailed account of the content of the hallucinations is necessary -Does the patient believe the voices to be powerful or of higher social status than the patient? -Does the patient believe that the commands are justified or reasonable? -Does the patient seek engagement with the voices, or want to please the voices? -Do they report any subjective compulsion, urge or drive to comply? -Can they identify the voices or do they identify with them? Are the voices perceived as benevolent or malevolent? -What does the patient believe will be the consequences of complying or not complying? -Have they ever acted upon the voices before, either in a dangerous or nondangerous way?

27. Threats to Kill Relatively common but evidence suggests they need to be taken seriously: Warren et al, 2008- Within 10 years, 44% of those convicted of making threats to kill convicted of violent offending; 58% of those with history of psychiatric contact convicted Highest risk associated with young age, substance use, absence of past criminality

28. Unstructured Clinical Assessment The traditional clinical approach ideally involves gathering information from a number of sources under headings such as: Family History / Personal history / Substance Misuse History / Forensic History / Past Medical History / Past Psychiatric History / Usual (Pre-Morbid) Personality / Mental State Examination i.e. taking a good quality history

29. Taking a better Forensic History May not be possible in a busy clinic Charges/convictions: actual content and length of sentence “Have you ever physically harmed anyone? “what is the worst thing you have ever done to someone ?” “why did you do it?” “Have you ever carried or used weapons?” “Have you ever set fires deliberately?” “have you ever been charged or convicted or accused of a sexual offence?” “do you have any interest in the Occult, Nazism or Far Right Organisations?”

30. Relevance of Risk Assessment Cannot predict outcome on an individual level Can weigh up personal and situational factor which may have contributed to past offending and the likelihood of such interactions occurring in the future Can use assessment to direct future management

31. Managing Risk- Interventions Many high risk patients will be young, substance misusing, rejecting of treatment and disorganised. Extended hospital admissions in these cases may assist in ensuring an adequate period of assessment to clarify the diagnosis. They will also ensure a sufficient drug-free period to allow consideration of interventions in reducing substance use Insight should be addressed, attempts made to improve both the patient's and family’s understanding of the impact of drug use and non-compliance with medication.

32. General Principles Assess Risk Factors Is Patient High/Moderate/Low Risk? Which Risk Factors are modifiable and how?

33. Cont…. Substance Use : education, harm minimisation, substitute prescribing, relapse prevention Treatment of Active Psychotic symptoms Psychological Interventions to target anger, interpersonal skills etc

34. Options Substance Misuse Services Crisis Team Period of Admission – informal or under MHA CMHT to reduce risk of relapse – consider depot or CTO Assertive Outreach Team / Forensic Services

35. Other Factors to Reduce Risk Improved Accommodation – better outcomes Positive relationships with professionals Programmes that provide meaningful structured activity, e.g. improve work related skills, recreational and sporting activities

36. DISCUSSION Questions?