,Violence Risk Assessment HCR-20

Clinical View, Management, &

Reduction

AHMAD DOBEA M.D.

WWW.AHMADDOBEA.COM
 WHY WE FOCUS ON RISK AND
VIOLENCE
• TO MINIMIZE IT
• PROTECT YOURSELF
• DETAIN PATIENT
• DISCHRGE PATIENT
• SECLUDE
• PROTECT PATIENTS
• PROTECT SOCIETY
• SOLVE PROBLEMS IN HOSPITAL STRUCTURE
.Anxiety, Apprehension, Agitation, Aggression, Hostility, Violence, Excitement, Assault
 The “SAD PERSONS” scale
• S Sex is male
• A Age >45 yrs or <19 yrs
• D Depression
• P Previous attempts
• E Ethanol abuse
• R Rational thinking loss (particularly psychosis)
• S Social support is lacking
• O Organized plan
• N No spouse

Score > or equal to 5 admission is advised

 SUICIDE: A MULTI-FACTORIAL EVENT
Psychiatric Illness
Co-morbidity
Personality Neurobiology
Disorder/Traits
Impulsiveness
Substance
Use/Abuse
Hopelessness
Suicide
Severe Medical
Illness Family History

Access To Weapons /Psychodynamics

Psychological Vulnerability

Life Stressors Suicidal

Behavior
 MEYHODS
OF
ASSESSMENT
 ?Definition of Violence
• Actual, attempted, or threatened physical
harm that is deliberate and non-consenting
– Includes violence against victims who cannot
give full, informed consent
– Includes fear-inducing behavior, where threats
may be implicit or directed at third parties
– Violence can be:
• Verbal
• Written
• Physical
 Goals of Violence Risk Prediction
• Prevention of Present and Future Violence
• Protection of Public Safety
• Guide Intervention and Treatment of the Consumer
– Who owns the violence?
• Treatment Team
• Both Need to Address the Issue of Violence
– Understand Behavior
– Take Steps to Reduce the Behavior
» Hold Consumer Accountable for Actions
– Learn Alternatives to Violence
 HCR-20
• Structured Clinical Guide
• Involves both Clinical and Actuarial Components
• Items have a statistical relationship to violence
– Can be scored in an actuarial manner
• Designed to assess risk for general violence of
individuals with Mental or Personality
Disorders
• 20 Items
– 10 Historical; 5 Clinical; 5 Risk Management
 HCR-20
• Each Item is Coded
– 0 Absent
– 1 Probably or Partially Present
– 2 Present
• Overall Judgment of Risk for Violence
– Low
– Moderate
– High
• Dr. Bieda’s Opinion
– Don’t be lulled to sleep by a Low or Moderate risk level
– The context in which a consumer is violent is critical
 Information Used in HCR-20
• Information is Collected from Various Sources.
• Time Frame for Completion Varies
• May Include Some or All of the Following:
– Interview with Consumer
– Interview with Family Members
– Interview with Treatment Team Members
– Interview with trial Officer
– Collateral Material
• Probation Officer’s File
• Hospital Records
• Treatment Records
 Historical Scale
• 10 Static (Fixed) Risk Markers for Violence
• Spans a Number of Areas
– Past Violence
– Mental Illness
– Childhood Experiences
• Items Have Strong Empirical Support as
Risk Markers for Violence
 Historical Items
1. • Previous Violence
2. • Young Age at First Violence
3. • Relationship Instability
4. • Employment Problems
5. • Substance Use Problems
6. • Major Mental Illness
7. • Psychopathy
8. • Early Maladjustment
9. • Personality Disorder
10.• Prior Supervision Failure
 Risk Items
1.Plans Lack Feasibility
2.Exposure to De-stabilizers
3.Lack of Personal Support
4.Non-Compliance with Remediation Attempts
5.Stress
Anxiety, Apprehension, Agitation, Aggression,
Hostility, Violence, Excitement, Assault.
• Definition
– Excessive verbal and/or motor behavior
• Escalation
– Verbal Violence
– Physical Violence
– Written Violence
• Signs of agitation
– Pacing
– Irritable
– Affective liability
– Verbal outbursts
– Clenching fists or jaws
– Threatening or destructive behavior
– Slamming or banging objects
Anxiety, Apprehension, Agitation, Aggression,
Hostility, Violence, Excitement, Assault.
• Anxiety: tense, termers,
• Apprehension:
• Agitation: Pacing, Irritable, Affective liability, Verbal outbursts.
Clenching fists or jaws,Threatening or destructive
behavior,Slamming or banging objects
• Aggression: +ve or -ve
• Hostility: -ve
• Violence: directed, exaggerated.
• Excitement: nondirected
• Assault: directed, reasoned
 Prevalence
• Psychiatric patients in US
– 4.3 million ED US visits per year
– 5.4% of ED patients
• Incidence of violence in US
– 50% of healthcare providers in their
career
– 51% of MDs and 67% of nurses in ED
were physically assaulted in the last 6
months
• Drug and alcohol intoxication
or withdrawal
• Medical
Etiology Schizophrenia
Mania
Agitated Depression
Substance intoxication or Withdrawal
– Hypoglycemia Akathisia
Personality Disorder-Antisocial

– Hyperthyroidism
– Delirium
– Dementia
– Head Trauma Psychiatric

– Temporal Lobe Epilepsy

• Psychiatric
– Schizophrenia Medical

– Mania
– Agitated depression
– Personality
disorder – Antisocial, Delirium

borderline Dementia
Hyperthyroidism
Head Trauma

– PTSD Temporal Lobe Epilepsy

Clear Reduced Awareness

Normal Fluctuates Alertness

Impaired Impaired Orientation

Impaired Impaired Memory

Intact Hallucinations Perception

Vague Disorganized Thinking

Word finding Slow Language

difficulty
characteristics illness
Inflation, mood, religious, responsive mania
Sudden, sever, blind, furious, animal rage catatonic
Bizarre, related to,hall-del. Manegable. schizophrenia
Fear-persecution, or grandiose, religios, paranoids
political
Agitation, anxiety, apprehesion, del of ---- depression
Showy, relational, hysterical
Gains.marks. psychopathy
Sudden onset,offset epileptic
 Treatment
• Treat medical condition
• Reduce stimulation
• Verbal de-escalation - “Take him down”
• Alternatives to restraints
• Restrain
– Physical
– Chemical
– Combination
• Seclusion
 Prevent Violence

• Identify violent patients

• Search patients for weapons
• Use a comprehensive, collaborative approach
to the patient
• Strategies
– Administrative
– Behavioral
– Environmental
Prevent Violence-Strategies
– Administrative
• Gangs involvement
• Evacuation plan
• Staff training
– Behavioral
• Be direct, polite and respectful
• Keep close to open exit
• Listen to patient
• Use non-threatening speech and behavior
– Environmental
• Monitor rooms
• Well trained security presence – Clinical training programs
• Panic alerts
 Clinical Risk Assessment
• Psychiatrists and psychologists are accurate in no more
than 1 out of 3 predictions of violent behavior over a
several year period among institutionalized populations
that had both committed violence in the past and who
were diagnosed as mentally ill (Monahan, 1981 pp. 47-49).

• Relies on informal impressionistic, subjective

conclusion , reached by human clinical
evaluation

• Focused on dichotomous statement

– Either Dangerous or Not Dangerous
 Actuarial Risk Assessment
• Based on statistical over clinical risk variables.
• Base Rates: Involves a formal algorithmic
objective procedure or equation to reach the decision.
• MacArthur Violence Risk Assessment Study
(Monahan et al., 2001)
– Largest study of its kind and reviewed a large
sample of male and female acute civil patients
at several facilities on a wide variety of variables
believed to be related to the occurrence of violence.
 Risk Variables Found in MacArthur
Study (2001)
• Prior Violence and Criminality
• Diagnosis
– Co-occurring diagnosis = key factor for violence
– Schizophrenia associated with lower rates of
violence than diagnosis of Depression or Bipolar
disorder
– Personality Disorders
• Childhood Experiences of Violence
• Psychopathy
– PCL-R
 Risk Variables Found in MacArthur
Study (2001)
• Neighborhood Context
– Take into account individual and community
influences that increase prevalence of violence
• Sex
– Men no more likely to be violent than women
over the course of the 1 year follow up.
– Men more likely to substance abusing and less
likely to adhere to prescribed medications
– Women more likely to target family members
and to be violent at home
 Risk Variables Found in MacArthur
Study (2001)
• Delusions
– Did not predict higher rates of violence among recently
discharged psychiatric patients.
– Having a tendency toward misperception of others’
behavior as indicating hostile intent = linked to violence
• Hallucinations
– Command Hallucinations increased likelihood of
violence
• Violent Thoughts
– Violent thoughts while hospitalized = greater risk of
violence after discharge within 20 weeks of d/c
• Anger
 Construct of Violence Risk Assessment
• Nature
– What kinds of violence might occur?
• Severity
– How serious might the violence be?
• Frequency
– How often might the violence occur?
• Imminence
– How soon might the violence occur?
• Likelihood
– What is the probability that violence might occur?
 Clinical Items
1.Lack of Insight
2.Negative Attitudes
3.Active Symptoms of a Major Mental Illness
4.Impulsivity
5.Unresponsive to Treatment
 HCR20
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