Will this patient turn violent?” Psychiatrists face this tough question every day. Although predicting a complex behavior such as violence is nearly impossible, we can prepare for dangerous behavior and improve our safety by:
- knowing the risk factors for patient violence
- assessing individuals for violence potential before clinical encounters
- controlling situations to reduce injury risk.
In one study, more than 50% of psychiatrists and 75% of mental health nurses reported an act or threat of violence from patients within the past year.1 To help you avoid becoming a statistic, this article provides a 5-step procedure (Box) to quickly assess and respond to risk of violence in a psychiatric patient.
5 steps to assess and reduce the risk of patient violence
1 Seek patient history of violence; if positive, obtain details of violent behavior
2 Evaluate the context, including the patient’s psychosocial stressors, recent behavior
3 Identify arousal states such as fear, anger, confusion, or humiliation that are risk factors for violence
4 Structure the interview for safety, with attention to the treatment environment
5 Evaluate the patient in a structured clinical encounter
Step 1: Seek Patient History
A careful review of past events and those immediately preceding the clinical encounter is the best tool for assessing potential for violence. The more you can learn from the patient chart and other sources before you see the patient, the better (Table 1). Valuable clues can be obtained from interviews with family members, outpatient providers, police officers, and others who have had pertinent social contact with the patient.
Table 1
Will this patient become violent?
Questions to consider before a clinical encounter
| Long-term behavior What violent acts has this patient committed? Were conditions similar with each episode? Any unprovoked acts? Was violence associated with alcohol or drug use? How has the patient behaved with health care providers in the hospital? In outpatient settings? |
| Immediate situation What are the patient’s immediate stressors? Did he or she arrive with family or in police custody? How did the patient behave while en route? |
A minority of patients account for most aggressive acts in clinical encounters. One study showed that recidivists committed 53% of all violent behaviors in a health care setting.4 A patient’s history of violence should be flagged in the chart and verbally passed on to staff to alert providers of increased risk.
However, not having a violent history does not guarantee that a patient will not become dangerous during a clinical encounter. All patients with a violent past had an initial violent episode, and that first time can occur in a practice setting.
Psychotic states by themselves appear to increase the risk of violence, although the literature is mixed.5,6 Clearly, however, psychotic states associated with arousal or agitation do predispose patients to violence, especially if the psychosis involves active paranoid delusions or hallucinations associated with negative affect (anger, sadness, anxiety).7
Increased rates of violence have also been reported in psychiatric patients with:
- acute manic states associated with arousal or agitation8
- nonspecific neurologic abnormalities such as abnormal EEGs, localizing neurologic signs, or “soft signs” (impaired face-hand test, graphesthesia, stereognosis).9
Psychiatric diagnoses associated with increased risk of violence include schizophrenia, bipolar mania, alcohol and other substance abuse, and personality disorders.11-13 In clinical practice, however, I find psychiatric diagnoses less useful in predicting violence than the patient’s arousal state and the other risk factors discussed above.
Step 2: Evaluate the Context
In addition to evidence-supported risk factors (Table 2), context—or the broader situation in which a patient is embedded at the time of psychiatric evaluation—plays a prominent role in potentially violent situations. For example, if “divorce” is listed as a presenting factor:
- Is the patient recently divorced, or did it occur years ago?
- Does he hate all women or just his ex-wife?
- Was she having an affair, and did he just learn about this?