Assessment and Management of The Risk of Violence in Schizophrenia

Scenario

A 21-year-old lady with the diagnosis of schizophrenia informs you she will kill her neighbour tomorrow as she has ruined her life. She tells not to disclose this to anyone.

How will you assess the homicidal risk in this patient?
What treatment and follow up recommendations will you make in this case?

Clinical Assessment

Listen to the patient and develop a therapeutic relationship.

begin the assessment and enquire about her demographics.

Enquire about the issue that she brought up—she will kill her neighbour.

Elaborate on how she thinks her neighbour has ruined her life.

Explore her thoughts and whether the patient may have persecutory delusions

Assess how much resentment she feels?

Follow up with inquiry about her mood, esp. about irritability and depression

How she plans to commit the act

Has she threatened the person?

Whether she has done so in the past

If so, what provoked such an incident

Whether the provoking factor is still present

Whether she possesses a weapon.

How easily she can access her

Whether she uses alcohol or substance

Psychiatric history and mental state

Whether she has other psychotic symptoms, e.g., commanding hallucinations

Negative symptoms (reduced likelihood)

Elicit relevant personal history

Especially whether she is single, divorced or separated

Who she lives with?

Her socioeconomic circumstances

Any stressful circumstances she might be passing through

Tools to Assess the Risk of Violence

Buss-Durkee Hostility Inventory

• 75 (true/false)-item questionnaire

• Used to assess cynicism and distrust

Hostility and Direction of Hostility Questionnaire

The 51-item self-report questionnaire with 5 subscales.

Used to assess the range of manifestations of aggression, hostility, and punitiveness; distinguishes hostility as they direct it either externally (extra-punitive: psychopathic, paranoid, hysterical) or internally (internal-punitive: guilt, self-criticism)

Aggression Risk Profile

• 39-item rating scale

• Identifies the characteristics of chronically aggressive patients, to foresee future manifestations of violent behaviour

Suicide and Aggression Survey

• Semi-structured clinician-administered interview and research tool; divided into 5 parts

• Elicits a brief medical history, recent and lifetime suicidality, and tendency to social violence; measures recent and past aggressiveness expressed by suicidal acts and thoughts

Management

Clozapine for schizophrenia, which also reduces the risk of violence (Farooq and Taylor 2011)
Address the modifiable risk factors identified
Inform the potential victim as a precautionary measure (which is also a legal/ethical responsibility)
If community services are available, we should consider assertive outreach.
If the patient is violent, we can also consider ECT.
Family therapy, CBT and other psychosocial interventions for schizophrenia.

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