Clinical Case Conference

Am J Psychiatry 167:3, March 2010 ajp.psychiatryonline.org 253

From New York University School of Medicine
This article is featured in this months AJP Audio.
(Am J Psychiatry 2010; 167:253259)
the relevance of risk assessment for treatment consider-
ations and future management. We also discuss current
practices for preventing violence in psychiatric settings
and the multilevel issues that inuence whether clini-
cians report assaults and how they process the experience
of assaults.
Case Presentation
Mr. J is an 18-year-old man with a history of multiple
prior psychiatric hospitalizations and residential place-
ments, recurrent threatening and aggressive behavior,
gang involvement, and legal problems. He was admitted
to the hospital for a court-ordered psychiatric evaluation
after he violated the terms of his probation by having a
violent outburst at home and skipping school.
His long psychiatric history began at age 3, with recur-
rent episodes of re setting. Since then, as a child and
young adult, he has been hospitalized multiple times,
including at state and forensic psychiatric facilities.
Mr. J has endorsed various psychiatric symptoms from
a wide range of diagnostic clusters, including psychotic
symptoms, which he later claimed he made to obtain
entitlements. Mr. J has a history of alcohol and cannabis
abuse and self-injurious behavior, including supercial
cutting, medication overdoses, and hanging attempts.
His prior diagnoses include bipolar disorder, depression,
posttraumatic stress disorder (PTSD), paranoid schizo-
Although their overall contribution to violence in
society is relatively small (1, 2), individuals with severe
mental illness are more likely to engage in aggressive and
assaultive behavior than people in the general population
(39). Thus, violence among the mentally ill constitutes
a serious public safety concern. Particularly vulnerable
are the mental health treatment providers who work with
these violent patients. Among clinicians, violence toward
psychiatrists is common and is an important issue (10
12); more than a third of psychiatrists have been assaulted
by a patient at least once (10, 13). The risk of violent vic-
timization is greater in clinicians with less experience (11).
Reports estimate that 72% to 96% of psychiatric residents
have been verbally threatened (12, 1416), and 36% to 56%
have experienced physical assaults (12, 1418).
We present the case of a young adult inpatient with a
long history of assaultive behavior, who after several ag-
gressive outbursts on an inpatient ward ultimately at-
tacked and injured a psychiatric resident. This individual
belongs to a particularly dangerous subgroup of psychi-
atric patients: the antisocial individual with a concurrent
diagnosis of a major mental disorder. This case illustrates
the diagnostic complexities related to violent psychiatric
patients, the importance of assessing violence potential
and identifying aggressive tendencies at admission, and
Daniel Antonius, Ph.D.
Lara Fuchs, M.D.
Farah Herbert, M.D.
Joe Kwon, M.D.
Joanna L. Fried, M.D.
Paul R.S. Burton, M.D.
Tara Straka, M.D.
Zeev Levin, M.D.
Eve Caligor, M.D.
Dolores Malaspina, M.D.
Aggressive patients often target psychia-
trists and psychiatric residents, yet most
clinicians are insufciently trained in vio-
lence risk assessment and management.
Consequently, many clinicians are reluc-
tant to diagnose and treat aggressive and
assaultive features in psychiatric patients
and instead focus attention on other
axis I mental disorders with proven phar-
macological treatment in the hope that
this approach will reduce the aggressive
behavior. Unclear or nonexistent report-
ing policies or feelings of self-blame may
impede clinicians from reporting assaults,
thus limiting our knowledge of the im-
pact of, and best response to, aggression
in psychiatric patients. The authors pre-
sent the case of a young adult inpatient
with a long history of antisocial and as-
saultive behavior who struck and injured
a psychiatric resident. With this case in
mind, the authors discuss the diagnostic
complexities related to violent patients,
the importance of assessing violence risk
when initially evaluating a patient, and
the relevance of risk assessment for treat-
ment considerations and future manage-
ment. This report illustrates common
deciencies in the prevention of violence
on inpatient psychiatric units and in the
reporting and response to an assault, and
has implications for residency and clini-
cian training.
Psychiatric Assessment of Aggressive Patients:
A Violent Attack on a Resident
CLINICAL CASE CONFERENCE
254 ajp.psychiatryonline.org Am J Psychiatry 167:3, March 2010
quickly began to manifest poor frustration tolerance and
limited self-control, and he stated that he preferred to
be rearrested and returned to jail. He began fashioning
weapons, which he turned over to staff. On hospital day
45, he became physically threatening and brandished a
toothbrush at a housekeeper whose work was prevent-
ing Mr. J from using the telephone. Staff also discovered
that Mr. J had defaced the walls of his room with gang-
related grafti and homicidal threats. Two days later
he received unscheduled antipsychotic medication for
threatening behavior and attempting to assault another
patient who reportedly made insulting comments. The
following day, while discussing his feelings with the at-
tending psychiatrist, he ran across
the room and repeatedly struck the
same patient without warning or
provocation. When staff members
approached, he stopped the assault
and accepted sedating medications
but refused to engage in discussion
about the incident.
Clinical reassessment focused on
Mr. Js past trauma, and uoxetine
was added to his medication regi-
men. Over the following weeks, he
was able to identify appropriate
strategies for coping with frustra-
tion, and although he was not able
to use them consistently, his behav-
ior improved enough that he no
longer required one-on-one moni-
toring. Nonetheless, on day 75 of
his admission, when a tentative treatment plan to re-
lease him before the holidays was reconsidered because
of suicidal threats and provocative behavior, he punched
a wall. Over the next 3 days, after he learned that his
mother had been to the emergency department with a
fever, he became extremely distraught and began seek-
ing reassurance from the staff.
With the planned departure of the psychiatric resident
with whom he had been working, Mr. J began persever-
ating on his own discharge issues, and at treatment team
meetings he would shout demands at the staff. After one
of these meetings, Mr. J was noted to be talking loudly
on the pay phone. A psychiatric resident who was not in-
volved in his care walked past the pay phone, and for no
apparent reason, Mr. J suddenly rushed after the resident
and struck him on the side of the head with a closed st.
Mr. J was quickly restrained to prevent further assault,
but he remained verbally threatening and attempted to
lunge at staff again. He received multiple doses of se-
dating antipsychotic medications and remained in wrist
and ankle restraints for several hours afterward because
of extreme agitation and threatening behavior. He was
then arrested and transferred to a forensic unit for ongo-
ing stabilization.
Discussion
Diagnostic Challenges: Focus on Aggressive,
Assaultive, and Antisocial Behavior
The range of diagnoses and variety of psychotropic
medications given to Mr. J during his history of psychiatric
treatment illustrate some of the diagnostic and therapeutic
phrenia, schizoaffective disorder, attention decit hy-
peractivity disorder, mood disorder not otherwise speci-
ed, learning disorder not otherwise specied, speech
and articulation problems, and mixed personality dis-
order, for which he has been prescribed a variety of an-
tipsychotics (olanzapine, quetiapine, risperidone, and
chlorpromazine) and mood stabilizers (lithium carbon-
ate and valproic acid) as well as benzodiazepines and
antidepressants.
His criminal record consists of several juvenile of-
fenses, and his mother has contacted the police on nu-
merous occasions in response to his threatening and ag-
gressive behavior. During a period of incarceration, he
joined a gang, with which he is still
involved.
His current admission was occa-
sioned when he allegedly caused
property damage to an apartment
and threatened his mother with
a butcher knife. He was admitted
for further psychiatric evaluation
because of concerns for his safety
and that of others, self-injurious
behavior, increased mood lability,
and noncompliance with his cur-
rent medications (valproic acid and
risperidone). During the admission
interview, he expressed hopeless-
ness about the future and reported
insomnia due to nightmares, which
he attributed to a previously undis-
closed sexual assault that occurred
during a past incarceration. He denied suicidality, psy-
chotic symptoms, and substance use. However, he re-
vealed that he sometimes denies symptoms when speak-
ing to treatment providers because he is concerned that
these comments will be reported to court ofcials. At
the time of admission, his symptoms were considered
consistent with an axis I diagnosis of mood disorder not
otherwise specied, and clinicians planned to rule out
diagnoses of bipolar disorder not otherwise specied
and PTSD.
Hospital Course
Over the course of hospitalization, Mr. J made frequent
verbal threats to staff and other patients, and he particu-
larly targeted and frightened a vulnerable patient in the
unit. Three weeks into his hospitalization, he was denied
discharge after a court hearing. This resulted in increased
agitation, and he began making gang-related threats to
staff and peers. He also started refusing and cheeking
medications. Several days later, he entered the nursing
station and destroyed a fax machine after he allegedly
misinterpreted a statement made by a staff member. He
required physical restraint, and in the course of being
medicated, he kicked a nurse. Subsequently, additional
antipsychotic medication was prescribed on an as-need-
ed basis. Mr. J minimized the incident, reporting that he
intended to kick the medication away and not to hurt
anyone. In light of this incident and mounting threats to
the vulnerable patient on the oor, he was transferred to
another psychiatric unit.
On the new unit, Mr. J was initially managed on one-
on-one observation for his and others safety, and he
was able to maintain behavioral control. However, he
This case is not unique,
and it may reect an
unfortunate reluctance on
the part of many clinicians
to properly diagnose
assaultive behavior in
adolescents and young
adults, particularly when
these patients meet criteria
for axis I mental disorders.
CLINICAL CASE CONFERENCE
Am J Psychiatry 167:3, March 2010 ajp.psychiatryonline.org 255
search has demonstrated that adolescents with severe
mental illness and conduct disorder have a greater risk
for aggressive behavior than other severely mentally ill
patients (29). Mr. Js troublesome behavior continued into
early adulthood, and his present hospitalization was char-
acterized by an inability to follow directions and unit rules,
weapon making, impulsivity, irritability, threatening and
assaultive conduct, and manipulative behavior aimed at
inuencing decisions about his treatment and discharge.
These behaviors are consistent with a diagnosis of antiso-
cial personality disorder (28). Mr. J also exhibited features
of psychopathy, such as shallowness, lack of empathy,
callousness, failure to accept responsibilityfeatures fre-
quently associated with DSM-IV-TR antisocial personality
disorder but not recognized in the current DSM diagnostic
criteria. Some clinicians argue for psychopathy as a sepa-
rate DSM diagnosis, and some use the term to describe a
more severe form of antisocial personality disorder (30)
associated with extremely high rates of violent recidivism
(31). (For more information on psychopathic traits, see
reference 32.)
Diagnostically establishing that Mr. J belongs to a
dangerous and violent subgroup of axis I psychiatric pa-
tients who have comorbid antisocial (and psychopathic)
personality traits is exceedingly important for interven-
tion and treatment considerations. The increased risk of
aggressive and assaultive behavior (21, 27, 33) may have
severe consequences, such as short-term and long-term
physical and psychological damage to both the aggressor
and the victims (e.g., clinical staff and peers in psychiat-
ric settings). Moreover, treatment planning must account
for the mixture of axis I symptoms and violent personal-
ity traits as well as the inefcacy of standard antipsychotic
medications in reducing violence risk in these patients
(34). In fact, in some patients the antisocial personality
disorder may rst emerge after antipsychotic medication
has proven effective. Early implementation of interven-
tions in a treatment milieu is essential if antisocial behav-
ior is to be managed in a psychiatric setting. It is critical
that all unit personnel are involved in the interventions in
order to maintain a safe treatment environment for staff
and other patients.
In the absence of clinical attention to aggressive behav-
ior, the antisocial patient with a diagnosis of severe mental
illness may continue to be violent toward others, imped-
ing treatment of other psychiatric symptoms and worsen-
ing long-term prognosis.
Regrettably, there is a dearth of treatment programs that
specically target antisocial behavior in patients with se-
vere mental illness, and the research on such programs
is similarly sparse. Promising results have been reported
for the use of cognitive-behavioral therapy techniques
in addition to treatment as usual for severely mentally ill
patients with histories of violence (35, 36). There is also
evidence that increased frequency of treatment sessions
may in itself reduce the risk of violence in psychopathic
complexities that routinely confront psychiatric residents
and other mental health professionals. In the case of Mr. J,
the presence of an axis I diagnosis of mental illness is rela-
tively obvious. Perhaps more striking, however, is the ab-
sence of diagnoses or treatment considerations that reect
his lifelong pattern of behavioral and emotional problems.
These are severe problems that have signicantly impaired
Mr. Js functioning in many domains and are associated
with a long history of unlawful and socially unacceptable
conduct, including the assault on the resident.
This case is not unique, and it may reect an unfortu-
nate reluctance on the part of many clinicians to properly
diagnose assaultive behavior in adolescents and young
adults, particularly when these patients meet criteria for
axis I mental disorders. Instead, as in the case of Mr. J,
clinicians frequently demonstrate a preference for focus-
ing clinical attention on other psychiatric symptoms in
the hope that these efforts will indirectly reduce aggres-
sive behavior. This preference may be rooted in part in the
availability of pharmacological treatments with demon-
strated efcacy for many axis I psychiatric disorders, while
comparable pharmacological options or clear therapeutic
guidelines for the treatment of violent behavior are lack-
ing. Heterogeneity among violence-prone individuals
with severe mental illness further complicates interven-
tion and treatment planning. Although the displayed be-
havior (violence) might be similar across severely ill psy-
chiatric patients, this behavior may result from several
different pathways, and the context and circumstances for
aggression and assaults may differ according to subgroup
(substance abuse or dependence additionally raises the
risk of violence [19, 20]). For example, the escalation of vi-
olent behavior may be related to acute psychotic behavior,
which may de-escalate with treatment with antipsychotic
medication (21). Neurological impairment may also trig-
ger and increase violent behavior in a subgroup of psychi-
atric patients (22) in whom the aggressive behavior does
not respond to regular pharmacological treatment (23).
Recently, research has begun examining a particularly
challenging subgroup of violent psychiatric patients: the
antisocial patient with co-occurring major mental dis-
orders (24). These patients differ neurobiologically from
other violence-prone severely mentally ill populations (25,
26). They also are more likely to engage in violent behavior
(21, 27), tend to have an earlier age at rst hospitalization,
and have longer hospital stays (27), thereby contributing
signicantly to the enormous nancial costs of psychiatric
illness to the public.
The case of Mr. J exemplies this latter subgroup. Al-
ready as a young child, he began displaying behavioral
problems (e.g., repeated re setting), and his troubles
continued throughout his adolescent years with manipu-
lative, truant, threatening, and aggressive behavior; gang
involvement; and episodes of incarceration and forensic
institutionalization. All of these behaviors are consistent
with a diagnosis of conduct disorder (28). Notably, re-
CLINICAL CASE CONFERENCE
256 ajp.psychiatryonline.org Am J Psychiatry 167:3, March 2010
deal has been published on the topic, and interview guide-
lines and empirically tested assessment instruments are
widely available for mental health professionals (for re-
cent books on risk assessment, see references 44 and 45).
While risk assessment is invaluable in the evaluation
and treatment of violent behavior in patients with psy-
chiatric diagnoses, the potential for violence in mental
health care settings remains. Therefore, it is important
that mental health staff also possess general skills in dif-
fusing potentially violent situations. Few studies have
empirically investigated techniques that clinicians can
use to diffuse threats of violence. A study of 101 surveyed
clinicians distilled three elements of effective responses
to violent behavior: biological (physical or chemical re-
straints), psychological (verbal methods of deescalation
of the situation), and social (use of institutional, family,
or peer inuence) (10). Another study highlighted the im-
portance of training in nonviolent self-defense, restraint
and seclusion procedures, alternatives to restraint and
seclusion, identication of high-risk patients, improved
security, and postincident crisis counseling (46). Other
methods that have been suggested in deescalating threats
of violence are searching patients before interviews or
interventions are conducted (15), implementing social
norms against violence within the patient/staff com-
munity that are maintained through periodic meetings
(47), increasing staff awareness and adherence to exist-
ing policies for the management of violent patients (15),
increasing staff recognition of countertransferential feel-
ings related to assaultive patients (47), teaching trainees
about the psychodynamics of aggression (16), and plac-
ing written guidelines regarding safety issues in patients
charts where they can be followed up on by staff supervi-
sors (15).
In an attempt to address recommendations put forth
by APA (41), Schwartz and Park (14) outlined a complete
training program specically designed for psychiatric res-
idents to improve their ability to evaluate and treat vio-
lent patients. The program consists of 10 hours of training
in the rst year of residency, during which time trainees
attend didactic seminars on the assessment and manage-
ment of violent patients, receive training in diagnosing
and evaluating these individuals, and learn about phar-
macological interventions, seclusion and restraint meth-
ods, environmental safety, and forensic issues. Schwartz
and Park also underline the importance of training in self-
defense techniques to defend against and escape assaul-
tive behavior. The didactic seminars are followed by prac-
tical training in simulated situations. In the second phase
of the program, the trainees attend 2-hour seminars in
each of the following years of residency. These seminars
provide an opportunity for reviewing skills learned during
the rst year.
Despite limited empirical research on the efcacy of
specically designed training programs and methods for
the management and treatment of violent psychiatric pa-
civil psychiatric patients (37), despite the common per-
ception that psychopathic individuals are difcult to treat
and manage (38). Nonetheless, to further advance the
eld, research studies designed to examine the efcacy of
intervention and treatment programs across subgroups
of violent psychiatric patients (e.g., the acutely psychotic
patient, the neurologically impaired patient, and the anti-
social psychiatric patient) are warranted.
Psychiatric Practices: Risk Assessment and Violence
Prevention
A question often raised in the aftermath of an assault is
whether the incident could have been prevented. Would
a thorough and accurate assessment of violence risk have
changed the outcome in the case of Mr. J given the pres-
ence of numerous risk factors (e.g., comorbidity of sub-
stance abuse, multiple previous psychiatric diagnoses,
history of violence and arrests, and antisocial behavior)?
Currently, little formal risk assessment training occurs in
psychiatric settings. A study in Oregon found that only
40% of surveyed psychiatrists had received some form of
violence-management training (39). Results from a larger
study, which used a national representative sample, found
that one-third of psychiatric residents had received inade-
quate training in dealing with violent patients and assess-
ing potential violence; moreover, two-thirds of residents
felt they would benet from a training seminar specically
on the management of violent patients (14). These num-
bers are concerning given that clinicians with less expe-
rience are more likely to be victimized (11). Additionally,
lack of training may affect staff attitudes toward the man-
agement and treatment of violent psychiatric patients,
thereby creating a less-than-optimal therapeutic envi-
ronment for these difcult individuals (40). Thus, proper
training in dealing with violent patients in order to effec-
tively assess, treat, and cope with this population should
be implemented in training programs for mental health
professionals. This view is shared by both APA (41) and the
American Psychological Association (42).
Risk assessment to evaluate violence potential may be
a crucial rst step in predicting and preventing aggressive
and assaultive behavior in patients; it should also be an
important element of treatment and management con-
siderations. Risk assessment may serve to enhance staffs
ability to safely manage violent patients and decrease the
likelihood of staff assaults. Research by McNiel et al. (43)
indicates that formal training in the evaluation of poten-
tially violent patients can enhance clinicians rationale
for risk assessment and management plans. McNiel et al.
assessed a 5-hour training program in violence risk as-
sessment given to psychiatric residents and psychology
interns; trainees attended didactic presentations on as-
sessment, documentation, and management of violence
risk factors and discussed case vignettes in which violence
risk factors were identied. Although there is no standard
format for conducting risk assessment interviews, a great
CLINICAL CASE CONFERENCE
Am J Psychiatry 167:3, March 2010 ajp.psychiatryonline.org 257
Conclusions
This case serves to illustrate several important issues
related to the management of potentially violent pa-
tients. Assaultive behavior toward psychiatric residents,
psychiatrists, and other clinicians is a serious concern,
yet there is a paucity of training for most residents and
clinicians in the area of risk assessment and manage-
ment of violent patients. Clinicians are often reluctant
to diagnose and treat aggressive and assaultive features
in adolescents and young adults with psychiatric prob-
lems, instead focusing treatment on other axis I mental
disorders in the hope that this will also reduce aggres-
sive behavior. Interventions and treatment of violent
psychiatric patients may be further hampered by the
assumption that violent psychiatric patients belong to
a homogeneous group, whereas there are actually sev-
eral subgroups of violence-prone patients whose behav-
ior is rooted in dissimilar underlying mechanisms. This
oversight is unfortunate given that proper risk assess-
ment of violence characteristics can guide differential
treatment and management considerations and help in
the prevention of assaultive behavior in patients deter-
mined to be potentially violent. Another concern is that
unclear or nonexistent reporting policies or feelings of
self-reproach may prevent residents and clinicians from
reporting assaultive behavior. This limits our under-
standing of the prevalence of violence by psychiatric pa-
tients and prevents us from providing the resources nec-
essary to address the problem. We should emphasize the
fact that despite the strong association between severe
mental illness and violence, the majority of individuals
suffering from psychiatric problems do not have aggres-
sive tendencies and will not act out violently (50). In fact,
the severely mentally ill are signicantly more likely to be
victims of violence than they are to be perpetrators (5).
Furthermore, because mental illness is relatively rare, the
contribution of mentally ill individuals to overall rates of
violence in our society is comparatively small (1, 2).
Received Jan. 14, 2009; revisions received July 30 and Aug. 31, 2009;
accepted Sept. 4, 2009 (doi: 10.1176/appi.ajp.2009.09010063). From
New York University School of Medicine. Address correspondence
and reprint requests to Dr. Antonius, New York University School of
Medicine, Department of Psychiatry, 550 First Ave., NBV 22N10, New
York, NY 10016; [email protected] (e-mail).
All authors report no nancial relationships with commercial in-
terests.
References
1. Friedman RA: Violence and mental illness: how strong is the
link? N Engl J Med 2006; 355:20642066
2. Walsh E, Fahy T: Violence in society. BMJ 2002; 325:507508
3. Swanson JW, Holzer CE 3rd, Ganju VK, Jono RT: Violence and
psychiatric disorder in the community: evidence from the Epi-
demiologic Catchment Area surveys. Hosp Community Psychi-
atry 1990; 41:761770
tients, the research described above clearly underlines the
importance of properly training inexperienced clinicians
to prepare them for situations in which they interact with
potentially aggressive patients.
Psychiatric Practices: When an Assault Occurs
Because mental health professionals often are on the
front line when an assault occurs, it is important that they
be equipped to handle the aftermath of an incident, in-
cluding being aware of institutional procedures related
to reporting acts of violence. In the case we report, the at-
tending psychiatrist, the residency training director, the
assistant training director, the hospital police, and the resi-
dents other colleagues were all notied after Mr. Js assault
on the resident, and they all responded in an appropriate
and supportive manner. Unfortunately, the notication
procedures followed in this case are rare in many settings.
One study (14) found that among physically assaulted resi-
dents, 69% reported the incident to a supervisor, 24% con-
tacted the medical or residency training director, and 17%
reported the occurrence to law enforcement. Only 43% had
a debrieng session with a supervisor following the assault,
and 33% experienced supportive counseling from a super-
visor or colleague (14). These ndings suggest a tendency
to underreport assaultive incidents, which is concerning
given the physical and psychological impact of a violent
assault. Surveys of practicing psychiatrists suggest that the
tendency not to report assaultive behavior continues after
residency training has been completed (11, 39).
Underreporting may be related to lack of training, but it
may also be partially explained by research ndings sug-
gesting that 16% to 26% of assaulted residents feel they
were partially to blame for the incident (14, 17) and 12%
believe that being assaulted by patients is inherent to the
psychiatric profession (14). Residents may think that it is
easier to just move on after an assault without taking
into account violent patients high rate of recidivism; the
same patient who attacked the resident will likely attack
another staff member or patient unless action is taken
and proper treatment and management are implemented.
Nevertheless, many residents and medical students report
that they have no knowledge of a clear policy or protocol
for handling and reporting violent attacks (14, 48).
The prevalence of underreporting violent attacks also
raises the question of whether residency training pro-
grams and hospital administrations have accurate statis-
tics on physical attacks on residents and other staff. If the
administration is unaware of the extent to which violent
behavior among patients is a problem, administrators
may be reluctant to fully support legal action against pa-
tients who act out or to transfer them to forensic settings.
Research emphasizes the necessity of training in formal
incident reporting guidelines (48). It has also been sug-
gested that medical student training directors knowledge
about the response to assaults toward trainees and report-
ing policies should be investigated (49).
CLINICAL CASE CONFERENCE
258 ajp.psychiatryonline.org Am J Psychiatry 167:3, March 2010
26. Dolan MC, Fullam RS: Psychopathy and functional magnetic
resonance imaging blood oxygenation level-dependent re-
sponses to emotional faces in violent patients with schizophre-
nia. Biol Psychiatry 2009; 66:570577
27. Hodgins S, Tiihonen J, Ross D: The consequences of conduct
disorder for males who develop schizophrenia: associations
with criminality, aggressive behavior, substance use, and psy-
chiatric services. Schizophr Res 2005; 78:323335
28. American Psychiatric Association: Diagnostic and Statistical
Manual of Mental Disorders, 4th ed, Text Revision (DSM-IV-TR).
Washington, DC, American Psychiatric Association, 2000
29. Hodgins S, Cree A, Alderton J, Mak T: From conduct disorder to
severe mental illness: associations with aggressive behaviour,
crime, and victimization. Psychol Med 2008; 38:975987
30. Blair RJ: Neurocognitive models of aggression, the antisocial
personality disorders, and psychopathy. J Neurol Neurosurg
Psychiatry 2001; 71:727731
31. Hemphill JF, Hare RD, Wong S: Psychopathy and recidivism: a
review. Legal and Criminological Psychology 1998; 3:139170
32. Hare RD: The Hare Psychopathy ChecklistRevised. North
Tonowanda, NY, Multi-Health Systems, 1991
33. Skeem JL, Mulvey EP: Psychopathy and community violence
among civil psychiatric patients: results from the MacArthur
Violence Risk Assessment Study. J Consult Clin Psychol 2001;
69:358374
34. Swanson JW, Swartz MS, Van Dorn RA, Volavka J, Monahan J,
Stroup TS, McEvoy JP, Wagner HR, Elbogen EB, Lieberman JA;
CATIE Investigators: comparison of antipsychotic medication
effects on reducing violence in people with schizophrenia. Br J
Psychiatry 2008; 193:3743
35. Haddock G, Barrowclough C, Shaw JJ, Dunn G, Novaco RW,
Tarrier N: Cognitive-behavioural therapy v social activity
therapy for people with psychosis and a history of violence:
randomised controlled trial. Br J Psychiatry 2009; 194:152
157
36. Yates K, Kunz M, Czobor P, Rabinowitz S, Lindenmayer JP, Volav-
ka J: A cognitive, behaviorally based program for patients with
persistent mental illness and a history of aggression, crime, or
both: structure and correlates of completers of the program. J
Am Acad Psychiatry Law 2005; 33:214222
37. Skeem JL, Monahan J, Mulvey EP: Psychopathy, treatment in-
volvement, and subsequent violence among civil psychiatric
patients. Law Hum Behav 2002; 26:577603
38. Kernberg O: The psychotherapeutic management of psycho-
pathic, narcissistic, and paranoid transferences, in Psychopa-
thy: Antisocial, Criminal, and Violent Behavior. Edited by
Millon T, Simonsen E, Birket-Smith M, Davis RD. New York, Guil-
ford, 1998, pp 372382
39. Faulkner LR, Grimm NR, McFarland BH, Bloom JD: Threats and
assaults against psychiatrists. Bull Am Acad Psychiatry Law
1990; 18:3746
40. Volavka J: Neurobiology of Violence, 2nd ed. Washington, DC,
American Psychiatric Publishing, Inc, 2002
41. Dubin W, Lion J (eds): Clinician Safety: Report of the American
Psychiatric Association Task Force on Clinician Safety. Washing-
ton, DC, American Psychiatric Press, 1993
42. American Psychological Association, Society of Clinical Psy-
chology, Section on Clinical Emergencies and Crises, Task Force
on Education and Training: Report on Education and Train-
ing in Behavioral Emergencies. Washington, DC, American
Psychological Association, Feb 10, 2000. http://www.apa.org/
divisions/div12/sections/section7/tfreport.html
43. McNiel DE, Chamberlain JR, Weaver CM, Hall SE, Fordwood SR,
Binder RL: Impact of clinical training on violence risk assess-
ment. Am J Psychiatry 2008; 165:195200
44. Webster CD, Hucker SJ: Violence risk assessment and manage-
ment. Chichester, UK, John Wiley & Sons, 2007
4. Walsh E, Buchanan A, Fahy T: Violence and schizophrenia: ex-
amining the evidence. Br J Psychiatry 2002; 180:490495
5. Teplin LA, McClelland GM, Abram KM, Weiner DA: Crime victim-
ization in adults with severe mental illness: comparison with
the National Crime Victimization Survey. Arch Gen Psychiatry
2005; 62:911921
6. Tiihonen J, Isohanni M, Rsnen P, Koiranen M, Moring J: Spe-
cic major mental disorders and criminality: a 26-year pro-
spective study of the 1966 northern Finland birth cohort. Am J
Psychiatry 1997; 154:840845
7. Hodgins S, Alderton J, Cree A, Aboud A, Mak T: Aggressive be-
haviour, victimization, and crime among severely mentally
ill patients requiring hospitalisation. Br J Psychiatry 2007;
191:343350
8. Fazel S, Langstrom N, Hjern A, Grann M, Lichtenstein P: Schizo-
phrenia, substance abuse, and violent crime. JAMA 2009;
301:20162023
9. Arseneault L, Moftt TE, Caspi A, Taylor PJ, Silva PA: Mental
disorders and violence in a total birth cohort: results from the
Dunedin study. Arch Gen Psychiatry 2000; 57:979986
10. Whitman RM, Armao BB, Dent OB: Assault on the therapist.
Am J Psychiatry 1976; 133:426429
11. Bernstein HA: Survey of threats and assaults directed toward
psychotherapists. Am J Psychother 1981; 35:542549
12. Coverdale J, Gale C, Weeks S, Turbott S: A survey of threats and
violent acts by patients against training physicians. Med Educ
2001; 35:154159
13. Madden DJ, Lion JR, Penna MW: Assaults on psychiatrists by
patients. Am J Psychiatry 1976; 133:422425
14. Schwartz TL, Park TL: Assaults by patients on psychiatric resi-
dents: a survey and training recommendations. Psychiatr Serv
1999; 50:381383
15. Black KJ, Compton WM, Wetzel M, Minchin S, Farber NB, Rasto-
gi-Cruz D: Assaults by patients on psychiatric residents at three
training sites. Hosp Community Psychiatry 1994; 45:706710
16. Pieters G, Speybrouck E, de Gucht V, Joos S: Assaults by patients
on psychiatric trainees: frequency and training issues. Psychi-
atr Bull R Coll Psychiatr 2005; 29:168170
17. Gray GE: Assaults by patients against psychiatric residents at
a public psychiatric hospital. Acad Psychiatry 1969; 13:8185
18. Ruben I, Wolkon G, Yamamoto J: Physical attacks on psychiat-
ric residents by patients. J Nerv Ment Dis 1980; 168:243245
19. Swanson JW: Mental disorder, substance abuse, and commu-
nity violence: an epidemiological approach, in Violence and
Mental Disorder: Developments in Risk Assessment. Edited by
Monahan J, Steadman HJ. Chicago, University of Chicago Press,
1994, pp 101136
20. Putkonen A, Kotilainen I, Joyal CC, Tiihonen J: Comorbid per-
sonality disorders and substance use disorders of mentally ill
homicide offenders: a structured clinical study on dual and
triple diagnoses. Schizophr Bull 2004; 30:5972
21. Swanson JW, Van Dorn RA, Swartz MS, Smith A, Elbogen EB,
Monahan J: Alternative pathways to violence in persons with
schizophrenia: the role of childhood antisocial behavior prob-
lems. Law Hum Behav 2008; 32:228240
22. Krakowski M: Schizophrenia with aggressive and violent be-
haviors. Psychiatr Ann 2005; 35:4549
23. Krakowski M, Czobor P, Chou JC: Course of violence in pa-
tients with schizophrenia: relationship to clinical symptoms.
Schizophr Bull 1999; 25:505517
24. Hodgins S: Violent behaviour among people with schizophre-
nia: a framework for investigations of causes, and effective
treatment, and prevention. Philos Trans R Soc Lond B Biol Sci
2008; 363:25052518
25. Naudts K, Hodgins S: Neurobiological correlates of violent
behavior among persons with schizophrenia. Schizophr Bull
2006; 32:562572
CLINICAL CASE CONFERENCE
Am J Psychiatry 167:3, March 2010 ajp.psychiatryonline.org 259
48. Waddell AE, Katz MR, Lofchy J, Bradley J: A pilot survey of
patient-initiated assaults on medical students during clinical
clerkship. Acad Psychiatry 2005; 29:350353
49. Coverdale JH, Louie AK, Roberts LW: Protecting the safety of med-
ical students and residents. Acad Psychiatry 2005; 29:329331
50. Stuart H: Violence and mental illness: an overview. World Psy-
chiatry 2003; 2:121124
45. Maden A: Treating Violence: A Guide to Risk Management in
Mental Health. Oxford, UK, Oxford University Press, 2007
46. Flannery RB Jr: Characteristics of staff victims of psychiatric pa-
tient assaults: updated review of ndings, 19952001. Am J
Alzheimers Dis Other Demen 2004; 19:3538
47. Felthous AR: Preventing assaults on a psychiatric inpatient
ward. Hosp Community Psychiatry 1984; 35:12231226