Risk Assessment In

Psychiatry
 Objectives
 To understand the nature and
purpose of risk assessment in
psychiatry
 To understand factors contributing to
risk in psychiatry
 To be able to demonstrate its
application in history taking and
examination.
 Risk assessment in
psychiatry :
1) risk of self harm/suicide
2) risk of violence/homicide
 Risk of Self-harm /suicide
Introduction

 Suicide risk assessment is a complex

difficult and challenging clinical task
 Suicide usually results from the
interplay of multidimensional factors
 Suicide itself cannot be predicted-
only suicide risk can be assessed
based on suicide risk factors
 Is a process, not an event
 Should be carried out at important
junctures in the patient’s course- and
when clinically indicated
 Identify demographic features and
psychological characteristics
associated with the risk.
 What can clinicians do?
 Good patient-centred clinical care is
always the best for risk management
 Includes clinician self-awareness of
counter-transference issues
 Documentation is important
 Who Needs an Assessment?
 Individuals who have
- made a suicide attempt
- engaged in self-harm behavior
irrespective of motivation
 Who Needs an Assessment?
 Individuals who
- express suicidal thoughts
- express hopelessness
- have psychotic symptoms
- have a psychiatric illness
- diagnosed with serious medical
illness (life threatening,
disfigurement, severe pain or loss of
functioning) accompanied by
psychiatric symptoms.
How do we assess self
harm/suicide risk?

A) Identifying data
Demographic:
Age - increase risk in late adolescence
& early adulthood ( 15-24 years),
Increase again in older age group
( after age 70)
Marital status- increase risk in
widowed, divorced and single
Gender - completed suicide higher in
men. Deliberate self harm ( suicide
attempts) higher in women
Unemployment, financial difficulties
and economic recession
Socially isolated at higher risk
B i) History of presenting illness

Circumstances surrounding the self harm:-

Before the self-harm
- psychosocial stressors – unemployment, break-
up, death
Degree of preparation:-
- Planning – planned vs impulsive act
- Suicide note

- Last acts – making will / giving away possessions

During the self-harm

- Lethality of method (overdose,sf laceration is

non-lethal)
- Expectations by self-harm - death

- Precautions against discovery

Alone
Intervention unlikely – nobody returning home
for hours / days
Locking door / closing the curtains
- Associated use of alcohol/illicit substance
After the self-harm
 Help seeking behaviour – telephone –
ambulance/friend OR not taking any action &
waiting to die
 Desire to undertake further self-harm in order to

die
 Regret to be alive
B ii) Psychiatric symptoms
 Assess for depressive symptoms

- depressed mood, loss of interest,

decreased energy, fatigue,
pessimistic thoughts, ideas of self
harm
 Assess for psychotic symptoms
- hallucinations, command auditory
hallucination, delusions
 Assess for anxiety symptoms

- excessive worry , fear, apprehension

that is persistent, or related too
specific situation or circumstances.
Note:
If patient needs suicide risk
assessment following self harm then
do Bi) followed by Bii) in the HOPI

If patient needs a suicide risk

assessment but no current self harm
then do Bii) in the HOPI
C)
 Past psychiatric history & history of self
harm
 Personal history
- Family history of suicide/ psychiatric
disorders
-Childhood history of neglect/ abuse
- Medical history – chronic illness causing
functional impairment , pain ,
dependence on others, disfigurement
 - Drug & alcohol history
- Psychosocial history – isolation,
unemployment, recent life events
- Personality disorder –boderline
and antisocial personality disorder.
Personality factors- impulsivity and
poor problem solving skills

Note:
Past suicidal behaviors are a major
risk factor.50% who die by suicide
have history of previous attempt
50% of people who die by suicide
suffer from MDD. Presence of
hopelessness – pessimism &
negative expectations of the future
Note:
Psychosis presents with 10% of suicides
About 50% schizophrenia – may attempt
suicide at some point of the illness
 Schizophrenia – suicide attempts are

precipitated by
- depression
- psychosocial stressors
- psychotic symptoms
command hallucination – telling patient
to harm themselves or to harm others.
Note:
Alcohol & Substance use disorders.
Lifetime risk for suicide up to 15%
Chronic abuse has impact on the social life
and health with comorbid depression or
anxiety

Anxiety disorders –15-20% of suicides

Higher risk with comorbid depression or
substance abuse.
Note:
Borderline & antisocial personality
disorder. 5% of suicides .
Associated with hostile & impulsive
personality traits
D)
 Current suicidality

Mental state examination :-

Mood- depressed
Perceptual disturbances – commanding
auditory hallucinations
Content of thought- suicidal thoughts,
intent and plan, delusions
Note:
Suicidal ideation:
Refers to thoughts, ruminations & preoccupations
about death and self-harm
Suicidal Intent:
Refers to the patient’s expectation & commitment
to die by suicide.
This is reflected by the subjective belief in the
lethality of the chosen method
Suicidal Plan:
 How detailed & specific the plan
 Chosen method of harm – lethality

 Chosen time & setting of the event

 Protective factors for suicide
 Absence of mental disorder
 Sense of responsbilty to family
 Children at home
 Employment
 Positive coping skills
 Strong religious belief
 Good social support
 Initiating the suicide assessment
 Establish rapport
 Calm, patient, non-judgmental &
empathic approach. This creates safe
& comfortable atmosphere.
 Empathic statement
I can see how difficult things have
been for you lately ……….

It seems that things have been hard

for you & that it has been difficult to
cope ……..

You seem to be having a hard time

…….
 Gentle Inquiry
I wonder if you would help me
understand how this has been for you?

Can you share your concerns with me?

Can you tell me about what has been

happening?

How have things been for you lately?

 What not to do
 Avoid rushing the patient or asking
leading questions such as:

‘You don’t have any ideas about

suicide, do you’?
 What not to do
 Do not interrogate the patient or force the
patient to defend her action

‘Why would you do such a thing’?

‘Why would you even consider suicide’?

‘What is wrong with you’?

‘What is so bad in your life’?

 What not to do
 Do not minimize the patient’s distress

‘Oh, you are fine’

‘It’s not such a big thing is it’?

‘Lots of people go through these kinds of

things & are fine’
 What not to do
 Do not undercut the seriousness of the
suicidal thoughts or behavior

‘Come on… your are not really going to do

anything’

‘If you really wanted to die you would be

dead by now’

‘You’ll feel better after a good night’s rest’

‘Get over it….you are fine’

 Asking about suicidal ideation
 Always start general then become more specific

Do you ever feel that life is not worth living?

Do you ever have thoughts about not wanting to

live anymore?

Is death something that you have thought about

recently?

Do you ever think about ending your life?

 Management
 No suicidal risk
- patient can be treated outpatient
with good social support .
- Follow up review – offer
psychological management and treat
any underlying psychiatric disorders
 Suicidal risk
- Hospitalize patient under suicide
caution
- Treat underlying psychiatric
disorders. ECT indicated for severe
depression with high suicide risk
- Psychological management – coping
skills, counseling, supportive
psychotherapy, group therapy,
family therapy
Risk of Violence/ homicide
 Introduction
 Generally mentally ill are not violent
 Violent behavior in mentally ill is due
to their symptoms or poor impulse
control.
 Assessing & managing the risk of
violence, which may cause harm to
another person is part of psychiatric
practice.
 Common reasons
Fear
1. Command or frightening
hallucinations
2. Delusions – persecutory &
threatening
3. Impaired cognition – delirium or
dementia
 Common reasons
Anger
1. Poor impulse control with limited avenue
to let out anger
- mania (irritable)
- Personality disorders – borderline,
paranoid
- Drug/alcohol dependents
- Schizophrenia
Doctor factors
- Lack of experience
- Lack of knowledge regarding patho-
physiology of violence

Staff factors
-Understaffing
-Lack of experience & knowledge
-Lack of coordinated plan of action
 Violent Episodes
 Violent incidents – happen in public,
home & wards
 Ward – times of high activity.
- Overcrowded, noisy & lack of
privacy
- Poor ventilation & lighting
- Lack of structured activities
- Lack of communication
- Inadequate sedation
Predictors of Risk of Violence

-Past history of violence – most reliable

predictor of potential violence
- Positive symptoms with command
auditory hallucinations and paranoid
delusions
- Antisocial personality traits with history of
criminal record
-Abuse of alcohol or other drugs
 Warning Signs
Clues of impending violence
- loud speech & verbal threats
- increased muscle tension – sitting
on the edge of the chair, gripping
the arm
- Increased and prolonged
restlessness
- slamming doors, breaking things
- reporting of hallucination or
delusions with violent content
 Techniques in interviewing a
potentially violent patient
Setting
1. Get as much information as possible from other
sources. Avoid causing delays
2. Ensure members of staff are in the vicinity of
interview room
3. Exit must be clear from the area of interview
4. Interviewer sits with the patient and table in
between
5. Invite the patient to sit down
6. During interview, keep a reasonable distance
away from the patient.
7. Speak softly & non authoritative way
8. Avoid sudden movements
 Interview

1. Show concern for the patient

2. Develop rapport .Use verbal methods of
persuasion
3. Patient’s request – handled in an honest,
straightforward manner. Allow choices
4. Use open ended questions and enquire about
the violence.
5. Do not make promises that cannot be carried
out.
7. Pay attention to patient’s speech & motor activity
8. Inform staff to intervene when needed . Staff
should be well versed in emergency procedures
of handling violence
9. Medico-legal implications: important to have a
proper documentation of information & findings
 History taking
Mode of referral
1. Who brought the patient? Police?
Relatives?
Why was he brought?
- fear of becoming violent?
- planning violence?
- currently violent ?
- Has violence already occurred?
2) History of presenting illness
- assess for psychotic symptoms and
the need to act on the psychotic
symptoms
- - assess for manic symptoms

- - assess for evidence of delirium

- - substance withdrawal or
intoxication
3)Past history – history of violence,
antisocial personality disorder,
substance abuse, impulsivity
4)Mental State Examination

1. Determine the level of consciousness &

orientation
2. Presence of command hallucinations and
paranoid delusions and the need to act on
this symptoms that leads to violence
3. Assess the degree of impulse control &
judgment
 Template for risk of violence
 Current Mental State
 Mood:
 Clarifies current mood
 Thinking/perception
 Elicits paranoid delusions
 Asks about other kinds of delusions
(e.g., TI)
 Ideation of harm to others
 Asks if ideas to harm self
 Assesses for perceptual
abnormalities
 Auditory Hallucinations
 external space
 clarifies if 2nd and/or 3rd person
 command
 Other hallucinations in any
modalities
 Impulse Control:
 Difficulty controlling urges to
violence
 Concentration difficulties
 Insight
 Does he think he has a mental
illness?
 Willing to accept psychiatric
treatment?
 Willing to be admitted voluntarily?
 Past History
 Psychiatric disorder
 Non-compliance (psychiatric
recommendations)
 Substance misuse
 Aggression towards peers/authority
figures
 Criminal record
 Management
 Determine primary psychiatry diagnosis.
All medical staff working at emergency
and psychiatry unit should have training in
relation to the short-term management of
disturbed/violent behavior.
 Rapid tranquilization should only be
considered once de-escalation ( verbal
techniques)have failed to calm the patient.
 De –escalation
- Non confrontational verbal approach in a
safe setting
- -Engage the patient in conversation.
Listen and show empathy by
acknowledging concerns. Ask open ended
questions.
 Rapid tranquilization
Antipsychotics IM Haloperidol 5-10mg to
be administered and repeated when
necessary.
 Monitoring of vital signs is essential