Assessing potential for harm: Would your patient injure himself or others?

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Antisocial personality disorder (APD). Violence by those with APD often is motivated by revenge or occurs during a period of heavy drinking. Violent behavior by these persons frequently is cold, calculated, and lacks emotionality.¹⁹

In addition to DSM-IV-TR personality disorders, be familiar with the psychological construct known as psychopathy. Cleckley²⁰ used the term psychopath to describe a person who is superficially charming, lacks close relationships, is impulsive, and is primarily concerned with self-gratification. Hare et al²¹ developed the Psychopathy Checklist-Revised as a validated measure of psychopathy in adults. Psychopathy is a strong predictor of criminal behavior and violence among adults.²²

Affect. Individuals who are angry and lack empathy for others are at increased risk for violent behavior.²³ Also observe the patient for physical signs and symptoms of changes indicating incipient violence. Berg et al²⁴ noted that signs of imminent violence can include:

• chanting
  
• clenched jaw
  
• flared nostrils
  
• flushed face
  
• darting eyes
  
• close proximity to the clinician
  
• clenched or gripping hands.
  

Asking patients if they are experiencing homicidal ideations may not always elicit important information regarding a patient’s potential thoughts about harming others. For example, in persons who report feeling persecuted, ask what they would do if they came face-to-face with the individual they fear. Some patients may report that they would attempt to avoid all contact to minimize their personal risk. Others might feel a need to make a preemptive strike for protective purposes. In neither situation would the patient have reported experiencing homicidal thoughts.

Static vs dynamic factors. When organizing strategies to decrease risk factors for violence, distinguish static from dynamic factors. Static factors include demographic information and history of violence. Dynamic factors, which are subject to change with intervention, include access to weapons, psychotic symptoms, active substance use, and a person’s living situation.

Organizing a chart that outlines known risk factors, interventions to address dynamic risk factors, and the status of each risk factor/intervention may be helpful. Table 4 provides an example of such a chart for Mr. J. This approach can help you develop a violence prevention plan that addresses each patient’s combination of risk factors.

Table 4

Sample violence risk management chart for Mr. J

Risk factor	Intervention	Status
Paranoia	Antipsychotic medication	Admitted to inpatient psychiatric facility; antipsychotic medications ordered with continued assessments of mental status
Antipsychotic medication nonadherence	Depot form of antipsychotic	Mr. J agreed to depot medication
Gun at home	Remove guns	His mother removed all guns from home
Alcohol and methamphetamine abuse	Evaluate for potential alcohol detox; urine drug screen on admission	Mr. J refused group substance treatment in the hospital; substance use treatment in the community to be arranged prior to discharge

Finally, be familiar with jurisdictional requirements that govern duties to warn or protect third parties your patient may have threatened.

Related resource

• Simon RI, Hales RE, eds. The American Psychiatric Publishing textbook of suicide assessment and management. Arlington, VA: American Psychiatric Publishing, Inc; 2006.
  
• Simon RI, Tardiff K, eds. Textbook of violence assessment and management. Arlington, VA: American Psychiatric Publishing, Inc; 2008.
  

Drug brand names

• Risperidone • Risperdal
  

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.