PTSD: National Center for PTSD

Assessing Risk of Violence in Individuals with PTSD

Eric B. Elbogen, PhD, Sonya Norman, PhD, Paula P. Schnurr, PhD, and Rebecca A. Matteo, PhD

Although PTSD is associated with increased risk of violence, the majority of people with PTSD have no history of violent behavior. To understand a person's potential for violence, it is important to go beyond a diagnosis of PTSD and instead conduct a comprehensive review of risk and protective factors. For more information on the relationship between violence and PTSD, see Research Findings on PTSD and Violence.

A standardized, structured assessment that allows a provider to systematically review empirically supported risk and protective factors for violence can help increase accuracy when assessing a patient's risk for violent behavior. Providers can use information collected in the assessment to gauge risk and identify modifiable factors that can be targets of intervention.

Continuing Education Course

Assessing and Reducing Violence Risk in Veterans with PTSD

This PTSD 101 online course describes an evidence-based approach for improving clinical assessment and risk management of violence in Veterans with PTSD.

How Should a Provider Assess Risk?

Applying the science of what we know about risk and protective factors allows a provider to develop an effective safety plan to manage risk (1-3). Several principles can be applied:

• Approach assessment of violence risk factors in a systematic and consistent way so as not to overlook important variables.
• Investigate those risk factors that have been shown to have an empirical association with violence.
• Recognize that risk factors may concern not only the individual's characteristics but also his or her social environment.
• Understand that, in general, the more empirically supported risk factors endorsed for a person, the higher the likelihood of violence.
• Examine risk factors with respect to specific behaviors (e.g., domestic violence vs. general violence).

Clinicians should consider the use of validated violence risk assessment tools such as the Classification of Violence Risk (4) or Historical-Clinical Risk Management-20 (HCR-20) (2), although it should be noted that these have not yet been validated for PTSD or with Veterans. Several measures which are not risk assessment tools per se, but are relevant to risk assessment, have been used in Veteran populations. These include the Conflict Tactics Scale (5) where individuals endorse whether they have perpetrated specific types of intimate partner violence (e.g., sexual assault) and the Dimensions of Anger Reactions (DAR) Scale (6), which includes questions about aggressive urges when angry. The Violence Screening and Assessment of Needs (VIO-SCAN) is a 5-item screening tool for problems with violence validated with Veterans who served in Iraq and Afghanistan (7). The VIO-SCAN is not a comprehensive risk assessment, but can help clinicians identify Veterans in need of further evaluation for violence risk. Gathering information about violence from multiple sources in addition to the patient, such as collateral informants (e.g. close friends or family members), can help improve the quality of data used in risk assessment (1-4,7).

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How Should Providers Consider Risk and Protective Factors?

Risk factors indicate elevated potential for violence; protective factors indicate reduced potential of taking part in violent behavior. Non-PTSD risk factors that are related to increased risk of violence include alcohol and/or drug misuse, reporting co-occurring conditions, younger age, male gender, lower socio-economic status, and having housing or financial problems (1-3,7-9). Among Veterans, witnessing or committing crimes in childhood and higher levels of combat exposure have also been associated with increased risk of violence (7,9-11). Conversely, among Veterans, a number of protective factors associated with lower risk of violence have been identified, including perceived self-determination, reporting higher resilience, and indicating superior social support (10). Characteristics of risk and protective factors should be considered in the risk assessment process:

• Static versus dynamic factors: Risk and protective factors can be characterized as either static or dynamic (12). Static factors cannot be changed, even with treatment. Age and history of violence are examples of static factors. These are helpful in assessing risk because they are known risk factors but they cannot directly be targets for intervention. However, dynamic risk factors, such as PTSD or depressive symptoms, substance abuse, or high anger, can be modified through treatment (13).
• Individual versus contextual factors: Studies have shown that providers often base much of their decision making on individual-level factors such as past history of violence or current mental health problems (13). However, contextual factors such as social support, employment, meeting basic needs, and financial stability have been linked to violence risk as well (1,10,13).

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How Should a Provider Structure the Assessment?

A three-step process (13) that synthesizes the above principles can be used to assess someone's risk for perpetration of violence:

• Look at static, individual-level factors shown to empirically relate to violent behavior to establish a baseline estimate of risk. Although these variables (e.g., history of violence, young age) cannot be readily targeted for intervention, they can ground the evaluation by helping providers gauge a patient's level of risk based on these unchanging characteristics.
• Adjust this risk by evaluating dynamic, individual-level variables in the clinical domain. It may be that a patient who had been diagnosed with PTSD currently has no symptoms which may indicate that the patient's risk level can be adjusted downward. Conversely, if the patient is currently abusing substances, the risk level may need to be adjusted upward.
• Examine potential risk or protective factors in the patient's environment. If the patient has had a recent history of homelessness or living instability, he or she may be at increased risk of violence, even absent static or clinical risk factors. At the same time, there may be characteristics of a patient's environment, such as positive social support, that buffer against violence.

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How Can a Provider Help Reduce a Patient's Risk?

As of yet, there are no evidence-based PTSD treatments specifically designed to reduce the risk of violence directly. More research directly measuring changes in violent behavior before and after anger management is needed. However, given research showing correlations between anger and aggression in PTSD, cognitive behavioral anger management may be helpful to reduce some types of aggression including violence (14). One study showed that following group anger management, a sample of Vietnam Veterans reported reductions in both anger and physical assault (15).

When examining published research studies for ways to reduce violence risk, it is critically important to consider the comparison group and to look at the absolute values of pre to post change to determine if a treatment actually moves people into a range where they are at lower risk. Research suggests we can reduce someone's risk for violence by reducing dynamic risk factors and increasing protective factors. Tips for providers include:

• A thorough assessment will bring to light the patient's risk and protective factors that are modifiable. Providers can target modifiable factors in treatment to try to reduce someone's risk of violence.
• Attention should be paid to all modifiable risk factors. A treatment plan can include evidence based psychotherapy and pharmacotherapy for someone with mental health problems such as depression. Medical problems can also be addressed with ongoing treatment.
• PTSD is a treatable disorder. If PTSD is among the risk factors, evidence-based therapy and medications can reduce PTSD symptoms and diminish this risk factor. Intensive case management can be of help to someone with housing, employment, or financial problems.
• We can bolster the protective factors in a patient's environment by targeting physical and psychological health and social and occupational functioning in our treatments.
• Engaging the patient in treatment planning is important and risk assessment scholars have advocated for including clients in developing safety plans (16).

Using the tips above, we can comprehensively address the whole person in regard to social, physical, and psychological functioning to reduce risk of violence.\

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References

1. Monahan, J., & Steadman, H. J. (1994). Violence and mental disorder: Developments in risk assessment. Chicago, IL, US: University of Chicago Press, 324 pp.
2. Douglas, K.S., Hart, S.D., Webster, C.D., Belfrage, H. (2013). HCR-20V3: Assessing Risk of Violence: User Guide. Burnaby, Canada, Simon Fraser University, Mental Health, Law, and Policy Institute.
3. Heilbrun, K. (Ed.). (2009). Evaluation for risk of violence in adults. New York: Oxford University Press.
4. Monahan, J., Steadman, H. J., Robbins, P. C., Appelbaum, P., Banks, S., Grisso, T., Heilbrun, K., Mulvey, E. P., Roth, L., & Silver, E. (2005). An actuarial model of violence risk assessment for persons with mental disorders. Psychiatric Services, 56, 810-815. doi: 10.1023/A:1024851017947
5. Taft, C. T., Creech, S. K., & Kachadourain, L. (2012). Assessment and treatment of posttraumatic anger and aggression: A review. Journal of Rehabilitation Research & Development, 49, 777-788. doi: 10.1682/JRRD.2011.09.0156
6. Novaco, R., Swanson, R., Gonzalez, O, Gahm, G., & Reger, M. (2012). Anger and postcombat mental health: Validation of a brief anger measure with U.S. soldiers postdeployed from Iraq and Afghanistan. Psychological Assessment, 24, 661-675. doi: 10.1037/a0026636
7. 1. Elbogen, E. B., Cueva, M., Wagner, H. R., Sreenivasan, S., Brancu, M., Beckham, J. C., & Make, L. V. (2014). Screening for violence risk in military Veterans: Predictive validity of a brief clinical tool. American Journal of Psychiatry. Advance online publication. doi: 10.1176/appi.ajp.2014.13101316
8. Corrigan, P. W., & Watson, A. C. (2005). Findings from the National Comorbidity Survey on the frequency of violent behavior in individuals with psychiatric disorders. Psychiatry Research, 136, 153-162.
9. MacManus, D., Dean, K., Jones, M., Rona, R. J., Greenberg, N., Hull, L., Fahy, T., Wessely, S., & fear, N. T. (2013). Violent offending by UK military personnel deployed to Iraq and Afghanistan: a data linkage cohort study. Lancet, 381, 907-917. doi: 10.1016/S0140-6736(13)60354-2
10. Elbogen, E. B., Johnson, S. C., Wagner, H. R., Newton, V. M., Timko, C., Vasterling, J. J., & Beckham, J. C. (2012). Protective factors and risk modification of violence in Iraq and Afghanistan War Veterans. Journal of Clinical Psychiatry, 73, 767-73. doi: 10.4088/JCP.11m07593
11. Benedek, D. M., & Grieger, T. A. (2006). Post-deployment violence and antisocial behavior: The influence of pre-deployment factors, warzone experience, and posttraumatic stress disorder. Primary Psychiatry, 13, 51-56.
12. Douglas, K. S., & Skeem, J. L. (2005). Violence risk assessment: Getting specific about being dynamic. Psychology, Public Policy, and Law, 11(3), 347âˆ'383.
13. Elbogen, E. B., Fuller, S., Johnson, S. C., Brooks, S., Kinneer, P., Calhoun, P. S., & Beckham, J. C. (2010). Improving risk assessment of violence among military Veterans: An evidence-based approach for clinical decision-making. Clinical Psychology Review, 30, 595-607. doi: 10.1016/j.cpr.2010.03.009
14. Morland, L. A., Love, A. E., Mackintosh, M. A., Green, C. J., & Rosen, C. S. (2012). Treating anger and aggression in military populations: Research updates and clinical implications. Clinical Psychology: Science and Practice, 19, 305-322. doi: 10.1111/cpsp.12007
15. Marshall, A. D., Martin, E. K., Warfield, G. A., Doron-Lamarca, S., Niles, B. L., & Taft, C. T. (2010). The impact of antisocial personality characteristics on anger management treatment for Veterans with PTSD. Psychological Trauma: Theory, Research, Practice, and Policy, 2, 224-231. doi: 10.1037/a0019890
16. Heilbrun, K. (1997). Prediction versus management models relevant to risk assessment: The importance of legal decision-making context. Law and Human Behavior, 21, 347-359. doi: 10.1023/A:1024851017947

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