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from "Talk Back," Clinical Psychiatry News, November 2000....

Various Factors Determine Mentally Ill Patients’ Potential for Danger

 How dangerous are mentally ill patients, in terms of risk to themselves or to others?

 

Respondents to this Talk Back question agreed that research and clinical experience show that all mentally ill patients should not be considered dangerous.

“There are millions of Americans who have a mental illness and are not dangerous,” said Dr. Jeffrey T. Peterson of the University of Southern California Institute of Psychiatry and Law in Los Angeles. “All mentally ill patients should not be considered dangerous, just as all criminals should not be considered mentally ill.”

Nonetheless, every mentally ill inpatient and outpatient should be considered potentially dangerous and dealt with most carefully at each contact for the safety of all, said Dr. Paul Chellappa, a forensic psychiatrist in Middletown, N.Y.

Several factors—such as treatment compliance, treatment setting, and type of mental illness—need to be considered when determining the potential for danger in mentally ill patients, according to the respondents.

The issue of dangerousness is different for inpatients and outpatients, said Dr. Chellappa, who is also an attending psychiatrist in the psychiatric emergency department at Arden Hill Medical Center in Goshen, N.Y. Inpatients are closely observed and contained; prompt crisis intervention is available.

Outpatients, on the other hand, are more difficult in that they live in the community and have limited coping skills. These patients often fall through the cracks and can exhibit dangerous behaviors when their support systems fail, he said.

Dr. Diane Schetky, a forensic psychiatrist in Rockport, Maine, said it was once thought that people who had command hallucinations were more violent than the general population, but recent data suggest that is not necessarily true. Many people who have these hallucinations for a long time learn to ignore them.

Whether hallucinations cause a person to become dangerous also depends on who the hallucinations are coming from, whether it’s the voice of someone they know or a stranger’s voice. They’re not going to do something that a stranger tells them to do, she said.

Dr. Schetky also raised the question of social isolation. A schizophrenic is less likely to be violent if he or she is isolated—treated or untreated.

Dr. Mark Levy of the University of California, San Francisco, said that chronic schizophrenics were traditionally considered less dangerous than the general population. There are now some data that say this is not necessarily true and that subsets need to be considered.

There are some paranoid schizophrenics who are quietly delusional and hallucinate without posing a danger. There are also highly dangerous paranoid schizophrenics who have very systematic delusions or command hallucinations that instruct them to kill someone.

Dr. Levy said there are also subsets within people with depression. The psychotically depressed are the shooters in public places and mass murderers. These people tend to have a classic history of progressive depression.

At some point in their past, they were very functional with no visible signs or symptoms of mental illness. They tend to be men in their late 20s to 50s, loners, and people who have suffered a series of losses. In the face of mounting losses, they become more and more reclusive and withdrawn. What makes them unique and uniquely dangerous is that they focus more and more on fantasies of revenge. They brood over these fantasies for months and start acquiring weapons. These people are like time bombs, Dr. Levy said.

It is not possible to predict if and when someone will become a danger to themselves or others, but an assessment of the factors suggesting dangerousness can be undertaken, said Dr. Peterson, who is also a consultant to the Los Angeles County Mental Health Court.

Dr. Levy referred to the landmark California Supreme Court case, Tarasoff v. Regents of the University of California, which said that clinicians have a duty to warn third parties about a potentially dangerous person. The law, which has been replicated in all 50 states, protects the clinician against breach of confidentiality.

However, care needs to be taken when crossing the barrier between no danger to danger, Dr. Levy said.

He gave an example of using good judgment in determining a patient’s potential for danger. In the course of intensive psychotherapy, emotions become strong and the patient can say, “I’m going to kill my boss.” But it doesn’t mean that they’re actually going to kill their boss, he said. The situation needs to be evaluated in a fashion similar to evaluating suicide.

What are their thoughts about it? Do they have a plan? Have they acquired a weapon? Do they have a time or means? “Then you make a judgment on the data as to whether they actually present a threat or whether this is a passing thought,” Dr. Levy said. “You don’t have a duty to warn about a passing thought.”

Similar evaluations should be conducted with regard to suicidal thoughts and intentions. “A patient who says, ‘I’d rather be dead’ is different from one who says, ‘I’m going to jump off a bridge.’ ”

In mentally ill individuals who have demonstrated dangerous behaviors in the past, attempts to prevent future dangerousness should be made, Dr. Chellappa said. Interventions such as hospitalization, medication, therapy, family involvement, and case management can be implemented.