Thursday, February 21, 2013

How a Psychiatrist Predicts Violence



I am not a forensic psychiatrist.  I am a general adult psychiatrist, and ClinkShrink may have much more to add about such things. But with all this talk about potentially violent people and likely-to-be-violent people and legislation suggesting that psychiatrists should be the ones to determine if psychiatric patients are safe to own guns (no, no, please no...we treat mental illness, we don't certify people to use guns....) I thought I would try to demystify the process by which we determine if someone is dangerous.

For the routine, day-to-day shrink, we use two main measures of dangerousness:
~ History of violence
~ The patient's stated intent

If someone has never been violent and says they are not thinking about hurting themselves or anyone else, we assume they are not dangerous.

Are there other factors, or innuendo here? Of course, and other considerations may include:
~Substance abuse.  Substance abuse.  And substance abuse.  Substances dramatically increase the risk for violence.  Stay away from intoxicated people with weapons.
~The presence of factors that distort someone's ability to accurately assess reality, such as psychosis, dementia, or delirium. 
~ The patient says they have no thoughts about hurting anyone, but there are indicators that they are not being truthful about their intent.  Usually this is in the form of information presented by other people and we realize that the other party may be presenting information that has been misunderstood or distorted or meeting their own agenda, so we do our best.
~How well the evaluating psychiatrist knows the patient.  In an Emergency Room, there may be the tendency to err in favor of over-stating dangerousness because the doctor has no history with the patient and needs to make an admit vs. release decision fairly quickly and often with limited information.   They may decide to admit a patient and let an inpatient team observe the patient and gather more information.
~The patient's tendency to behave impulsively.
~Sometimes family history is considered, especially in patients with mood disorders and a family history of suicide.

The most common dilemma is that people will say they are having thoughts about hurting themselves (much more common then thoughts about hurting others) and they are uncertain about whether they will act on them.  If the psychiatrist knows the patient and knows that such thoughts are fairly common for this person, and that historically they have not acted on such thoughts, they may be more comfortable deciding the patient is probably not imminently dangerous than if the patient has a history of serious suicide attempts.

Is there magic?  No.  Are we right?  Sometimes.