Take Caution: Look for Disturbed Behaviors When You Assess Violence Risk (2014)

Acommon misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relationship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symptoms (1).' Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical decision making. The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when identifying persons who are more likely to commit acts of violence. (2) Demographics. Young age, male sex, cognitive deficits, less formal education, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person's living environment and ongoing social circumstances are important considerations when assessing violence risk. Inimpulsivity. Persons who display impulsive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or borderline personality disorder. Impulsivity often can be treated with medication, behavioral therapy, and other psychotherapeutic modalities. Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of violence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with violence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic steroids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances. Threats. Persons who express a threat are more likely to behave violently (3); those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as possible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement. Untreated psychosis. Be aware of patients who have untreated or undertreated symptoms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a violent act. (4), (5) Repeat violence. The best predictor of violence is a history of violence. The severity of the violent acts is an important consideration. Even a person who has only a single (known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk. Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punching a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. …