Assessment and Management of The Risk of Violence in Schizophrenia
- How will you assess the homicidal risk in this patient?
- What treatment and follow up recommendations will you make in this case?
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
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
- 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.