HOJAS DE TARIFA

The risk assessments of patients who are judged, after careful consideration of the differential diagnoses, to most likely have a disorder other than a primary psychotic disorder are addressed in the chapters appropriate to their underly-ing diagnoses. In this section, we focus on the evidence-based risk assessment of patients who are thought to have a primary psychotic disorder, although many of the risk factors for this population can be extrapolated to other pop-ulations who experience psychotic symptoms in the context of other dis-orders. This is certainly not an exhaustive listing of all of the risk factors for suicide and violence; this discussion is meant to highlight those factors that are most relevant to the emergency psychiatric assessment.

Risk Factors for Violence

The public perception that patients with psychosis are at elevated risk of vio-lence has sparked a debate in the psychiatric literature that is still far from be-ing resolved, despite the existence of several large-scale studies on the topic (Torrey et al. 2008). Although the jury is still out on this larger question, it is clear from the literature that several factors can predict violence in this popu-lation. As might be expected, past history of violence and criminal behavior is one of the strongest predictors of future violence and, if present, should be weighted heavily in the risk assessment of any patient. The risk assessment cannot, however, rely exclusively on past behavior as a predictor of future vi-olent behavior, because doing so ends up being both overinclusive and under-inclusive. On the one hand, if past behavior were the only factor considered, the risk assessment would fail to identify patients with no such history who go on to become first-time perpetrators of violence (Buchanan 2008). On the other hand, a history of violence is always present in patients who have en-gaged in that behavior, and so a focus on history fails to consider the patient’s acute risks and current symptoms.

Comorbid substance abuse may be one of the largest contributors to vio-lence among patients with a primary psychotic illness (Monahan et al. 2001).

However, some authors have found that it is not the substance abuse itself but other factors associated with substance abuse (e.g., childhood conduct

disor-der and current psychotic symptoms) that are most predictive of violence (Swanson et al. 2006). Intoxication certainly raises the risk of violence due to its disinhibiting effects, but it is an easily modifiable risk factor in that the pa-tient’s risk can be significantly reduced just by retaining the patient until he or she is no longer intoxicated. Akathisia can similarly increase risk of violent acting-out due to the physical discomfort that it causes, and it can be easily modified by changing the psychopharmacological regimen to address this symptom.

Positive psychotic symptoms, including hallucinations and delusions (par-ticularly hallucinations of a command nature and delusions of a persecutory nature), are associated with higher rates of violence, whereas negative symp-toms may actually lower the risk of serious violence (Swanson et al. 2006).

Command auditory hallucinations to harm others are particularly concerning if the patient has any history of acting on command auditory hallucinations in the past. Given the important role of antipsychotics in preventing positive symptoms, noncompliance with antipsychotics increases the risk of violence.

Recent violent threats and behavior leading up to presentation in the psychi-atric emergency setting must be given significant weight in the risk assessment, particularly if the patient has a past history of violence or arrest. Homicidal ideation, even if it has been communicated as violent fantasies shared only with the assessing clinician, rather than as threats toward a target, will also in-crease the acute risk of violence. Even when violent ideation or behavior is ab-sent from the current preab-sentation, the risk of repeated violence if the patient has a history of violent behavior when experiencing similar symptoms can be serious enough to justify the classification of the patient as at elevated acute risk.

Risk Factors for Suicide

As with violence, past history is strongly predictive of future behavior when assessing suicide risk, and a history of past suicide attempts will chronically el-evate a patient’s risk for future suicide attempts. Unlike with violence, patients with schizophrenia and other psychotic illnesses are at elevated lifetime risk for completed suicide, with estimates ranging between 5% and 15%. The risk is generally thought to be highest early in the course of the illness, highlight-ing the importance of engaghighlight-ing psychotic patients early in the course of their

symptoms (Melle et al. 2006). Comorbidities with depressive symptoms and with substance abuse are thought to increase the risk of suicide attempts among psychotic patients, as is the presence of command auditory hallucinations to harm oneself (particularly when the patient has a history of acting on com-mand auditory hallucinations). Current suicidal ideation, particularly if there is evidence of planning, should be weighed seriously in the risk assessment.

However, the presence of contingency to this suicidal ideation (e.g., “If you don’t admit me, I will kill myself ”) is less predictive than noncontingent cidal ideation (Lambert 2002). Social isolation likely also contributes to sui-cide risk, whereas the presence of good social and treatment supports may serve as a protective factor. Akathisia may also worsen suicide risk and should be given particular attention because this is a modifiable risk factor. As with all psychiatric patients, access to weapons will elevate concern about suicide risk.

Other Risk Factors for Harm to Self

A risk assessment also must include a consideration of the potential danger to a patient from inability to care for self. Much of this assessment can be ascer-tained from the first contact with the patient: if the patient is disheveled, suf-fering from parasite infestation, or sufsuf-fering from visible consequences of untreated medical illness that on evaluation appear to be related to the pa-tient’s psychotic symptoms, then the patient clearly is unable to care for him-self or herhim-self. For example, diabetes-related leg ulcers may turn out to have been caused by the patient not taking prescribed insulin, under the delusion that he or she is cured of diabetes.

If the individual’s inability to care for self is not obvious, the clinician must ask questions—often subtle questions—to assess a patient’s ability to care for self. For instance, a patient who is afraid to stay in her apartment due to per-secutory delusions might choose instead to stay in a shelter. Does this indicate the patient’s inability to care for self? The answer to that question hinges on several subsidiary questions about whether the behavior (staying in the shel-ter) results in adverse consequences for the patient that can lead to potential worsening of her physical or mental health. Appropriate questions might in-clude the following: Does she have access to her psychiatric medications in the shelter? Is she still able to attend her outpatient treatment? Does she still have

access to her family and social supports? Has similar behavior led to harm in the past? The availability of support services may alter decisions about whether such a patient needs inpatient psychiatric hospitalization or can be maintained in the community with greater oversight.