Scoring Clinical Vignettes (Self-Examination)—Violence 6–35

CLINICAL VIGNETTES

Violence
(Problem Area 3)
6–36 Mastering the Kennedy Axis V

Kennedy Axis V—Violence (Problem Area 3)

100 No evidence of violence to self or others; very satisfied with life; life’s problems never seem to lead to
any inappropriate anger, frustration, or conflicts. No symptoms.

90 No significant evidence of violence to self or others; generally satisfied with life, no more than
everyday problems or conflicts (e.g., an occasional argument with family members).

80 No more than slight problems with anger and irritability; if symptoms are present, they are transient
and expectable reactions to psychosocial stressors (e.g., occasional “blow up” with family members or friends; mild
anger after family argument); no suicidal ideation.

70 Mild symptoms (e.g., mild problems with anger and irritability; occasional thoughts of violent behavior;
thoughts that life may not be worth living); symptoms are not interfering significantly with his/her functioning;
severely assaulted others or serious suicidal attempt over 5 years ago; however, for years, has had no significant
problems with violence or self-harm.

60 Moderate difficulty with anger and irritability (e.g., moderate conflicts with peers or co-workers due
to anger and hostility; occasional threats of violent behavior); some evidence that self-destructive thoughts may be
present. Murdered someone over 10 years ago; however, for many years, has had no significant problems with
violence.

50 Serious problems with anger and irritability; moderate threats of violence; becomes verbally
threatening when needs/demands are not immediately met or when pushed to do something; occasionally hits
someone; occasional, relatively minor, sexual assault; occasional suicidal ideation; nonsuicidal self-abuse, such
as burning self with cigarettes or cutting self superficially; not felt to be in real danger of seriously hurting self or
others; however, some precautions including close observation may be indicated.

40 Major problems with anger and irritability; some real danger of hurting self or others; violent
outbursts toward family and neighbors; frequent threats of violence; hitting or biting someone is not unusual;
occasionally difficult to redirect from aggressive behavior; induces much fear of physical assault in others; single
suicidal gesture within the last month; moderate suicidal ideation; actively making plans to hurt self or others;
set a relatively minor fire within the last 3 months or is having fire-setting impulses with history of setting one or
two minor fires.

30 Often hitting or biting others; becomes physically aggressive when needs are not immediately met;
suicidal attempt without clear expectation of death during the last month; frequent suicidal preoccupation;
actively following through with plans to hurt self or others (e.g., obtaining a gun, pills, rope); at times close
observation or restraints may be necessary to prevent serious harm to self or others.

20 Frequently violent; very real danger of hurting self or others; serious thoughts of killing someone;
attempted to very violently harm or violently rape someone within the last month; constant suicidal
preoccupation; however, he/she is felt to have some control of the suicidal impulses; two or more suicidal
attempts without clear expectation of death within the last month; close observation to prevent harm to self or
others may be required 1 or 2 days a week.

10 Persistent danger of severely hurting self or others; attempted to kill someone within the last
month; attempted to very violently harm or violently rape a child within the last month; set a fire within the last
month with intent of hurting others; serious suicidal attempt within the last month with clear expectation of
death; little or no control of impulses to hurt self or others; expressing loss of control of command
hallucinations to hurt self or others; one-to-one, at-arms-length observation and/or physical restraint for
prevention of serious harm to self or others may be required 3 or more days a week; murdered someone within
the last 2 years.

NR Not rated
 Scoring Clinical Vignettes (Self-Examination)—Violence 6–37

Violence
NAME: Abbott, George
AGE: 35
Because of some financial difficulties, pt. occasionally gets into an argument with his wife; otherwise, he has
no significant evidence of violence. The arguments are generally relatively minor, of no real significance, and
end quickly. He has no current or past history of being threatening, assaultive, or suicidal.

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Ratings

Violence = 90
1) PSY = 100 2) SOC = 90 3) VIO = 90 4) ADL = 90 5) SAb = 80 6) MED = 90 7) ANC = 90
GAF Eq = 95
Dangerousness Level = 80

Explanation of Violence Rating

Occasional arguments with his wife = 90

No problems with being suicidal, threatening, or assaultive = 80 or better
6–38 Mastering the Kennedy Axis V

Violence
NAME: Caruso, Janice
AGE: 33
No significant evidence of violence. Pt. is not noted to be significantly irritable or angry. Pt. has no history of
being threatening or assaultive. During the interview, pt. was friendly and cooperative. Denies history of
suicide attempts or significant suicidal ideation. Pt. denies ever assaulting anyone.

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Ratings

Violence = 90
1) PSY = 65 2) SOC = 70 3) VIO = 90 4) ADL = 80 5) SAb = 80 6) MED = 80 7) ANC = 90
GAF Eq = 75
Dangerousness Level = 75

Explanation of Violence Rating

No significant evidence of violence = 90 or better

100 is not given because there are no statements about pt. being unusually free of interpersonal conflicts or
unusually satisfied with her life.
 Scoring Clinical Vignettes (Self-Examination)—Violence 6–39

Violence
NAME: Cross, Anthony
AGE: 24
Staff states that pt. occasionally threatens to sue staff; however, pt. does not make any threats of physical
violence to others. Staff states that pt. has mild to moderate problems with anger and irritability. Staff states
that at times he expresses suicidal ideation but seems fairly sure that he will not act on the ideation. At times,
pt. expresses a lot of hopelessness. Pt. states that at times he has suicidal thoughts; however, he states that
he would not act on the thoughts. During the interview, pt. seemed somewhat irritable.

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Ratings

Violence = 50
1) PSY = 45 2) SOC = 60 3) VIO = 50 4) ADL = 80 5) SAb = 95 6) MED = 70 7) ANC = 80
GAF Eq = 60
Dangerousness Level = 50

Explanation of Violence Rating

Mild to moderate problems with anger and irritability = 65

Somewhat irritable during the interview = 70
Occasional suicidal ideation = 50 (60 or better, if rater feels the suicidal ideation is not serious; 40 or worse, if
rater feels there is real danger the pt. will hurt himself)
6–40 Mastering the Kennedy Axis V

Violence
NAME: Davis, Richard
AGE: 45
Generally, pt. is friendly and cooperative. Pt. is at times impatient; however, he is easily redirectable. About
once every few weeks, pt. makes threatening remarks toward staff. There have been no recent problems with
his being irritable. There is no evidence of suicidal or self-abuse behavior. A couple of years ago, when doing
poorly, pt. had been very threatening and sexually assaultive. Pt. continues to be somewhat sexually
preoccupied. During the interview, pt. was pleasant and cooperative.

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Ratings

Violence = 50
1) PSY = 20 2) SOC = 35 3) VIO = 50 4) ADL = 25 5) SAb = 80 6) MED = 80 7) ANC = 70
GAF Eq = 35
Dangerousness Level = 35

Explanation of Violence Rating

Occasionally makes threatening remarks toward staff = 60

No recent assaults = 60 or better
A couple of years ago, when doing poorly, pt. had been very threatening and sexually assaultive. This history
of acting on threats moves the 60 to 50 because his history makes the threats more real.
 Scoring Clinical Vignettes (Self-Examination)—Violence 6–41

Violence
NAME: Griffin, Paul
AGE: 30
Staff states that generally pt. is uncooperative. Moderate problems with anger and irritability. Pt. is
threatening toward staff several times a week; however, it has been a few months since he was assaultive.
Pt.’s anger is not directed toward the other pts.; however, it is often directed at the staff or his family. In the
past, pt. has been actively threatening and assaultive toward his family, especially his mother. Staff states that
the threats and assaults are generally associated with his demands not being met or when staff members
attempt to pressure him into some activity. Staff states that there is no evidence of suicidal ideation. During
the interview, pt. was mildly irritable but cooperative.

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Ratings

Violence = 40
1) PSY = 40 2) SOC = 50 3) VIO = 40 4) ADL = 55 5) SAb = 30 6) MED = 70 7) ANC = 50
GAF Eq = 45
Dangerousness Level = 30

Explanation of Violence Rating

Moderate problems with anger and irritability = 60

Frequent threats of violence = 40
Significant past history of violence; assaultive a few months ago = 50 or worse
The vignette suggests that there is some real danger that he will hurt others = 40
6–42 Mastering the Kennedy Axis V

Violence
NAME: Palmer, Brenda
AGE: 37
Staff states that pt. tends to misinterpret verbal statements because of her delusional thinking and may
become very angry as a result of feeling that others are against her. Staff states that pt. has assaulted others
three times over the last 4 months. Pt. has been restricted from visiting home alone because she set a small
fire in her home 2 months ago when actively delusional. No previous history of setting fires. It did not appear
the pt. was trying to hurt anyone with the fire. She states that there has been no recent return of impulses to
set fires or the thoughts that she can control fires. Staff states that pt. often becomes very angry when any
limits are set on her use of cigarettes. Pt. was somewhat angry and irritable during the interview. Pt. has no
history of being suicidal.

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Ratings

Violence = 30
1) PSY = 30 2) SOC = 50 3) VIO = 30 4) ADL = 60 5) SAb = 70 6) MED = 80 7) ANC = 70
GAF Eq = 40
Dangerousness Level = 30

Explanation of Violence Rating

Has assaulted others three times over the last 4 months = 40 or worse
Paranoid and tends to misinterpret statements and become very angry and assaultive = 30
Set a fire 2 months ago and is delusional, angry, and irritable = 30 or worse
No history of being suicidal = 80 or better (this should have no effect on the rating)
 Scoring Clinical Vignettes (Self-Examination)—Violence 6–43

Violence
NAME: Powers, Jennifer
AGE: 35
Pt. has no current or past history of being suicidal or assaultive. Despite having a very busy life, she is very
satisfied with her life. She copes with various problems in a very healthy manner. Life’s problems never lead
to any inappropriate anger or frustration. She is seen as sensitive and able to compromise when handling
problems.

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Ratings

Violence = 100
1) PSY = 90 2) SOC = 100 3) VIO = 100 4) ADL = 100 5) SAb = 100 6) MED = 100 7) ANC = 100
GAF Eq = 100
Dangerousness Level = 90

Explanation of Violence Rating

No history of being suicidal or assaultive = 80 or better

Very satisfied with life and copes with problems in a very healthy way = 90 or better
Life’s problems never lead to any inappropriate anger or frustration = 100
Seen as sensitive and able to compromise when handling problems = 90 or better
6–44 Mastering the Kennedy Axis V

Violence
NAME: Renaldo, Alice
AGE: 24
Staff states that pt. self-induces vomiting three times a day; however, staff feels that pt. is not vomiting in any
attempt to hurt herself. No suicidal ideation. Staff states that generally pt. is not significantly angry or
irritable. Pt. denies having any thoughts of wanting to hurt herself; however, sometimes she feels that life is
not worth living.

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Ratings

Violence = 70
1) PSY = 50 2) SOC = 80 3) VIO = 70 4) ADL = 90 5) SAb = 90 6) MED = 70 7) ANC = 90
GAF Eq = 70
Dangerousness Level = 65

Explanation of Violence Rating

Sometimes feels that life is not worth living = 70

Not significantly angry or irritable = 90 or better
Factor out the dangerousness of vomiting. This is measured by the Psychological Impairment subscale.
 Scoring Clinical Vignettes (Self-Examination)—Violence 6–45

Violence
NAME: Robbins, Clyde
AGE: 48
Pt. was admitted from the county jail with charges of strangling a female resident to death 1 week ago at the
halfway house where they were living. He had resided at the halfway house for 3 years. While at the halfway
house, he had been hospitalized on several occasions. At times, he was reported to have been paranoid,
delusional, and threatening. Currently, pt. is actively paranoid and delusional. The alleged murder was done
in association with beliefs that if he did not kill someone, he would be killed as a religious martyr. He
reported that during his hospitalizations, he had no opportunity to kill anyone. At the halfway house, he had
not killed anyone earlier because he had diverted his need to kill someone into active involvement in religious
activities and writing. This stopped working following pt.’s being asked to leave the church because of his
hostile behavior. Pt. reportedly savagely beat the woman before strangling her. About 15 years earlier, pt.
attempted to kill four people because of a belief that it would cleanse his soul; however, he was successful
only one of the four times. This was an elderly man whose throat he cut with a knife. He was found not guilty
by reason of insanity. He has a long history of nonlethal attacks on other people. He shows callousness and
indifference toward people. He shows no remorse and casually talks about the murders. He is felt to be very
dangerous to others. He is observed constantly to prevent him from harming others.

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Ratings

Violence = 5
1) PSY = 30 2) SOC = 50 3) VIO = 5 4) ADL = 50 5) SAb = 80 6) MED = 80 7) ANC = 80
GAF Eq = 35
Dangerousness Level = 5

Explanation of Violence Rating

Murdered someone less than 1 month ago = 5

Continues to be paranoid and delusional (negative factor)
Recent murder was a second murder (extremely negative factor)
Savage nature of the murders (negative factor)
Shows no remorse and is unfeeling toward others (negative factor)
Ongoing problems with nonlethal assaultive behavior = 40 or worse
Felt to be very dangerous to others = 30 or worse
Observed constantly to prevent his harming others = 10 or worse
6–46 Mastering the Kennedy Axis V

Violence
NAME: Rosenthal, William
AGE: 51
Serious problems with anger and irritability; however, at times pt. appears to cycle through periods of being
almost pleasant. Frequent threats of violence. Often spontaneously explosive. When questioned, pt. rapidly
becomes angry and defensive. Despite his threats, he only occasionally actually strikes out at anyone. No
evidence of suicidal ideation. During the interview, pt. was unusually friendly and cooperative.

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Ratings

Violence = 45
1) PSY = 20 2) SOC = 10 3) VIO = 45 4) ADL = 20 5) SAb = 70 6) MED = 40 7) ANC = 70
GAF Eq = 25
Dangerousness Level = 15

Explanation of Violence Rating

Serious problems with anger and irritability = 50

Frequent threats of violence = 40
Often spontaneously explosive = 40
Only occasionally actually strikes out at anyone = 50
 Scoring Clinical Vignettes (Self-Examination)—Violence 6–47

Violence
NAME: Scott, David
AGE: 50
More than 20 years ago, pt. stabbed his mother and sister to death. He was overtly psychotic at the time. He
had paranoid delusions that he was “saving” them from torture by the Mafia. Before the murders, pt. was
preoccupied with the glory of being a hero. Pt. reported that at the time of the murders, he cared very much
for his mother and sister. About 10 years ago, pt. was released because there appeared to be no current
evidence of dangerousness, and he recognized the need for medication, was able to ignore auditory
hallucinations, and was not expressing paranoid delusions. However, periodically before and after his release,
the delusions would return, he would begin to lose insight into his illness, and at times the impulses to hurt
others would also return. There has been no subsequent evidence of his attempting to act on impulses to
harm others. Pt. acknowledges ongoing auditory hallucinations; however, these are generally not considered
dangerous until he experiences them as commands. About a year ago, there were concerns that pt. might
attempt to “help” protect a drug addict from the Mafia. Several months ago, he told people who were
confronting him about his delusions that they were going to die soon. However, he made no overt threats or
attempts to harm anyone. There has been no recent evidence of any thoughts or impulses to harm anyone.

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Ratings

Violence = 50
1) PSY = 40 2) SOC = 75 3) VIO = 50 4) ADL = 75 5) SAb = 60 6) MED = 70 7) ANC = 70
GAF Eq = 60
Dangerousness Level = 50

Explanation of Violence Rating

More than 20 years ago, he murdered two people; however, no further problems with violence = 60
Periodic delusional thoughts of “helping” people; in the past, “helping” people was by killing them = 50 or
worse
6–48 Mastering the Kennedy Axis V

Violence
NAME: Sellers, Mark
AGE: 63
Periodically, pt. is frequently assaultive to others. He is also self-abusive (hits himself in the head and bangs
his head). He is generally angry and verbally abusive. He requires frequent prn medication to control his
anger.

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Ratings

Violence = 40
1) PSY = 30 2) SOC = 45 3) VIO = 40 4) ADL = 30 5) SAb = 85 6) MED = 40 7) ANC = 80
GAF Eq = 35
Dangerousness Level = 40

Explanation of Violence Rating

Periodically, pt. is frequently assaultive = 40 or worse

Self-abusive = 50
Generally angry and verbally abusive = 50
Frequent prn medication to control anger = 50 or worse
 Scoring Clinical Vignettes (Self-Examination)—Violence 6–49

Violence
NAME: Woods, Gilbert
AGE: 28
Pt. is very angry and irritable; however, the explosive, loud, angry outbursts have decreased. With verbal
prompting, he is able to calm down. Pt. is fairly preoccupied with violence. Pt. has a long history of
assaultiveness, including seriously injuring at least one person. Pt. has not been assaultive for a long time.
Staff feels that his lack of assaultiveness is because of a combination of better control and the fact that he is
not pushed to do things. His anger is treated with prn medication, and he is directed to quiet areas when
agitated. Staff feels that if pushed, pt. would be in real danger of hurting others.

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Ratings

Violence = 35
1) PSY = 20 2) SOC = 35 3) VIO = 35 4) ADL = 30 5) SAb = 90 6) MED = 90 7) ANC = 70
GAF Eq = 30
Dangerousness Level = 35

Explanation of Violence Rating

Very angry and irritable = 40

Calms down with verbal prompting (this is a positive factor)
Explosive, loud, angry outbursts = 40
Preoccupied with violence (this is a negative factor)
Long history of violence (this is a negative factor)
No recent assaults (this is a positive factor)
Would be frequently assaultive if not handled very carefully by staff = 30
If pushed, would be a real danger to hurt others = 40 or worse
Notes