Sally C. Johnson MD Professor UNC Department of Psychiatry Forensic Psychiatry Program and Clinic

1. Sally C. Johnson MDProfessorUNC Department of PsychiatryForensic Psychiatry Program and Clinic Dead Right, Dead Wrong, or the Jury is Still Out: The Complex Worlds of Violence and Mental Illness

2. Learning Objectives • Appreciate the complexity of the relationship between violence and mental illness • Understand the current state of risk assessment • Translate this understanding into a practical approach to risk management

3. 75% of people believe that people with mental illness are dangerous.

4. Literature:Mental illness and Violence From Nursery Rhymes….

5. Lizzie Borden took an axe and gave her mother forty whacks. When she saw what she had done she gave her father forty-one.

6. To recent best-sellers…

7. “These were the lovely bones that had grown around my absence…” Susie Salmon cutting through a cornfield after school is persuaded by George Harvey, a man in his mid-40s who lives alone and builds dollhouses for a living, to have a look at his underground den. He rapes and kills her, dismembers her body, puts the parts in a safe and dumps it into a sinkhole.

8. We are led to believe that “crazy” people do crazy and frightening things.

9. Film Portrayal: Mental Illness and Violence The idea of the insane killer….

10. Takes a real life story like that of Ed Gein

11. … and makes him into Norman Bates in Alfred Hitchcock’s “Psycho”

12. In the News:Mental Illness and Violence Whether it is the poor handyman in need of a job…

13. Bryan David Mitchell Elizabeth Smart Kidnapping

14. Or workplace violence that hits close to home…

15. The murder of an NIMH administrator while trying to help a psychotic patient sent shockwaves through the mental health community, forcing clinicians to remember the rare—but ever present—risk of violence. It is a rare scenario, the potential nightmare in the life of a psychiatrist: a patient becomes violent…while the psychiatrist and the patient are alone in the psychiatrist's office. Wayne Fenton, M.D. October 3, 2006

16. …or a psychiatrist (possible terrorist) turned mass murderer…

17. Nidal Malik Hasan Ft. Hood Killing Rampage

18. We are surrounded by possible links between violence and mental illness, and it’s frightening.

19. We are looking for a way to give names and faces to our fears…

20. …we want to know who is going to be violent and be able to stop them from being violent.

21. Cesare Lombroso’s “Atavism”: violent criminals were throwbacks to primitive humans / identifiable by physical characteristics / so could just permanently detain or execute them

22. What’s the message?

23. Physical Signs of Imminent Violence (Berg, Bell, and Tupin, 2000) • Chanting • Clenched Jaw • Flared Nostrils • Flushed face • Clenched or Gripping hands • Darting Eye Movements • Increased proximity of patient to Clinician • Inability of Patient to Comply with reasonable Limit setting

24. Core Issues to Consider Definitions Violence / Mental Illness Assessment What’s adequate? How often? Prediction Of what? For how long? Prevention Responsibility / Cost Liability / Blame

25. Violence: what does it mean? • Actual physical violence? • Potential for violent behavior? • Threat of violent behavior? • Breaking the law? • Psychological or emotional harm? • Risk to property? • Does it have to be a specific act or just a general propensity towards violence?

26. Does it have to be imminent? • Does frequency matter? • Does severity matter? • What about the setting? • Does it matter toward whom or what it is directed?

27. What about defining Mental Illness or Mental Disorder? Clinically… • ICD-10 : “the existence of a clinically recognizable set of symptoms or behavior associated … with … interference with personal functions”. • DSM-IV-TR : “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual …associated with present distress … disability … or a significantly increased risk of suffering death, pain, disability, or an important loss of freedom …

28. BUT… Within the legal/judicial system, mental illness or disorder is viewed as a legal, moral or policy judgment or definition- not a clinical one.

29. Our legal system has long connected mental illness and violence and looked to clinicians to predict likelihood of future violence:

30. Legal Areas of Violence Risk Prediction • Civil Commitment O’Connor v. Donaldson (1975) / Addington v. Texas (1979) • Civil Liability Tarasoff v. Regents of the University of CA (1976) • Death Penalty Cases Jurekv.Texas(1976) / Barefoot v. Estelle (1983) • Juveniles Shall v Martin (1984) • Preventive Detention U.S. v. Salerno (1987) • Sex Offender Commitment Statutes Kansas v. Hendricks (1997) / US v Comstock (2010) “

31. This legal dependence on clinical prediction of risk has persisted despite data suggesting that clinicians are often wrong in their predictions.

32. Natural experiments suggested clinicians were wrong more often than not: • Baxstrom v. Herald, (1966)-release or transfer of “dangerous” patients. In 4 yr. follow-up only 20% assaultive • Dixon v. Attorney General of Commonwealth of PA (1971/1979-review)-86% false positive rate among those originally predicted to be dangerous • 1976-Cocozza/ Steadman-257 incompetent felons released: 14% of those predicted as dangerous were rearrested; 16% of those not viewed as dangerous were rearrested! • 1977-Patients released from Patuxent Institute/ MD -58% false-positive rate in predictions of violence

33. In the wake of early legal decisions, research efforts increased with the aim to improve violence risk assessment in clinical practice and the criminal justice context by: • identifying empirically-validated risk factors • developing risk assessment instruments based on empirically-validated risk factors

34. Methodological problems in earlier studies were identified … • Large #s of patients were lost to follow-up • Many had been treated for years • Reviews relied on official criminal records which grossly under-estimated violence • Definition of violence was inconsistent • Original predictions had not all been clinical: many were administrative or legal • Turns out that Clinicians were actually right more often than not - but just barely

35. Review of History of Study of Relationship between Violence and Mental Illness • Pre-deinstitutionalization studies showed no increased risk of violence • Post-deinstitutionalization studies began to show increased risk • It appeared that increased risk might be more connected to active symptoms rather than to diagnoses • There was more and more evidence that the relationship between mental illness and violence was actually quite complex

36. MacArthur Violence Risk Assessment Study (1994) • Civil Admissions from inpatient psychiatric hospitals: Western Psychiatric/ Pittsburgh, PA; Western Missouri Mental Health Center/ Kansas City, MO; Worcester State hospital and University of Massachusetts Medical Center / Worcester, MA • Ages 18-40 • English Speaking / White or African-American (Hispanic at Worcester) • Chart Dx of Schizophrenia, schizophreniform, schizoaffective, depression, dysthymia, mania, brief reactive psychoses, delusional disorder, alcohol or drug abuse or dependence, or personality disorder. Research and clinician interviews in hospital; two research interviews of patient and collateral informant with next 20 weeks. Review of hospital, arrest and rehospitalization records

37. MacArthur Study-18.7 % of patients were involved in violent altercations: Significant Findings • Men no more likely to be violent than women; drinking , SA and medication non-compliance > in men / women directed violence against family and at home • All measures (self report, hospital and arrest records)- previous violence and criminalitystrongly related to future violence • Prior physical abuse, but not sexual abuse as child was associated with post-DC violence • Parents history of substance abuse or criminal behavior: strong relationship • All races in same disadvantaged neighborhood had same risk: crime rate of neighborhoods pts. are discharged into may be important factor • Personality disorder/ adjustment disorderhad greater risk than all other Dx; schizophrenia<depression or bipolar but > than non-disordered population

38. MacArthur Study Findings continued…. • Co-occurring Dx of Substance Abuse or Dependence strongly predictive • Psychopathy(the antisocial component) as measured by PCL predicted violence • Delusions were not predictive (even threat-control-over-ride) but suspiciousness was • Hallucinations/ command hallucinations were not predictive unless voices specifically commanding violent acts • Persistent violent thoughtsduring hospitalization and afterwards were predictive • Anger: high scores on Novaco Anger Scale at hospitalization were twice as likely to engage in violent acts post DC

39. : So where are we now, more than 25 years later?

40. National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) We employed a nationally representative, longitudinal dataset from this two wave, face-to-face survey conducted by the National Institute on Alcohol Abuse and Alcoholism. N= 34,653 subjects Wave 1 (2001-2002) Wave 2 (2004-2005). Our questions were: 1) Does severe mental illness (SMI) predict future violent behavior? 2) What risk factors prospectively predict violent behavior?

41. Multivariate Predictors of Violent Behavior Perpetrated Between Waves 1 and2 • Dispositional Factors: age, education, sex, race, income • Historical Factors: parental criminal history, witnessing parental fighting, history of any violence, history of juvenile detention • Clinical Factors: Schizophrenia, Bipolar Disorder, Major Depression, Substance abuse/Dependence, Schizophrenia+SA/D, Bipolar Disorder+SA/D, Depression+SA/D, Perceives hidden threats in others • Contextual Factors: Victimized in past year, family or friend died in past year, fired from job in past year, divorced or separated in past year, Unemployed for past year

42. Top Ten Predictors of Any Violent Behavior Between Waves 1 and2 • Age (younger) • History of any violent act • Male • Divorce or separation in the past year • History of physical abuse • Parental criminal history • Unemployment for the past year • Co-occurring severe mental illness and substance abuse • Victimization in the past year

43. SMI did not predict severe/serious violence, even when combined with substance use disorders. • SMI was significantly associated with physical abuse by parents, parental arrests, substance disorders, recent victimization, and unemployment. • 46% of those with SMI had co-morbid substance abuse/dependence. Violence risk was higher in this group than substance use without SMI. • People with SMI were more vulnerable to past histories that elevate violence risk and more prone to experience environmental stressors that also elevate violence risk.

44. Severe mental illness did NOT rank among the strongest predictors of violent behavior. • Severe mental illness alone was NOT statistically related to future violence, in bivariate or multivariate analyses. • People with any type of severe mental illness were NOT at increased risk of committing serious/severe violent acts.

45. Evolution from Violence Prediction to Risk (or threat) Assessment • Violence Prediction -focuses on the individual -portrays dangerousness as a state • Risk Assessment -focuses on person-situation interactions -portrays dangerousness as dynamic, contextual and continuous

46. We continue to be asked to assess risk of violence: • Need for admission/ suitability for discharge • ER evaluations • Civil Commitment/ Release • Workplace/ school threats • Juvenile justice management • Sentencing/ Parole/ Probation/ Early Release • Sex Offender Commitments • Specialty Court Treatment Plans

47. Approaches to Risk Assessment • Unstructured Clinical Judgment • Actuarial • Structured Professional Judgment • Anamestic

48. Clinical Judgment • More accurate than chance (Mossman 1994) AUC= .67 • Does facilitate aspects of data gathering and data interpretation

49. Actuarial • Formal / equation-formula-graph- table used to arrive at a probability of some outcome • Objective, mechanistic, reproducible combination of predictive factors, selected and validated through empirical research against known outcomes • BUT clinicians have not embraced this • Hard to go from the abstract to the individual

50. Structured Professional Judgment Presentation of specific risk factors derived from broad review of literature not specific data set- factors are well operationalized so their applicability can be coded: yes-possibly-no-/ multiple data sources/ evaluator draws conclusion weighing risk factors and intensity of management