E4.2

Violence Risk Assessment

Predicting violence is imprecise. Structured judgment combining history, current symptoms, target specificity, and access to means.

Encounter card

Setting

When patient endorses homicidal ideation, has history of violence, presents with paranoid psychosis with persecutory delusions, or context suggests risk (acute mania, intoxication, command hallucinations).

Opening move

Ask directly about violent ideation, specific targets, plans, access to means, prior violence. Integrate with mental status, intoxication, and current symptoms.

Sample language

"Have you been having thoughts of hurting anyone?"
"Is there a specific person you've been thinking about?"
"How would you do it? Do you have access to weapons?"
"Have you ever hurt anyone in the past?"

Listen for

Specific identified target (highest risk). Plan and means access. History of violence (single best predictor of future violence). Acute psychosis with persecutory content directed at identified persons. Intoxication. Command hallucinations to harm. Antisocial features. IPV history.

Common pitfalls

Discounting "I want to kill him" as venting without further assessment. Missing IPV risk. Overpathologizing nonspecific anger statements. Failing to act on credible threats (Tarasoff duty).

Red flags / escalate: Specific identified target + plan + access + recent provocation = imminent threat (Tarasoff duty). Active command hallucinations to harm. Intoxicated patient with weapon access. IPV history with current escalation.

Documentation

Document the assessment process. If duty to warn/protect triggered (Tarasoff), document the threat, the target, the action taken (warning, hospitalization, police contact).

Real-world reality: Means restriction conversations — particularly firearm access — require time, sensitivity, and follow-through. The 10-minute conversation that produces an actual change in access can prevent a suicide.

Violence prediction is imprecise. The structured assessment + clinical judgment is the standard of care — not perfect prediction.

Warm grey-tinted clinical notebook page, burnt orange accent. Violence risk factor categories — history (best predictor), current psychosis with persecutory content, command hallucinations, intoxication, antisocial features, IPV history. Margin clusters.

Violence risk assessment in psychiatry is structured judgment integrating history, current symptoms, target specificity, and access to means. Pure prediction of violence is imprecise; the goal is identifying who is at meaningfully elevated acute risk and acting on that information appropriately.

History is the strongest predictor. Past violence — particularly recent violence, severity, and frequency — predicts future violence more reliably than any current presentation. The patient with prior assaults is at higher baseline risk than the patient with similar current symptoms but no history. Document the history specifically.

Current symptoms that elevate risk: active psychosis with persecutory delusions (especially involving identified persons), command hallucinations to harm specific people, acute mania, severe substance intoxication, antisocial features producing premeditation. The patient with paranoid delusions about a specific neighbor who is "planning to hurt me first" is in different territory than the patient with general paranoid ideation.

Target specificity matters substantially for both clinical risk and legal duty. The patient threatening violence against an identifiable person — with means access and credible intent — is in the highest-acute-risk territory and triggers Tarasoff duty (in jurisdictions where it applies). Generic anger statements without specific targets are different from named-target threats.

Tarasoff duty — the legal duty to warn or protect identifiable third parties from credible threats — varies by jurisdiction. Most states require either warning the target, hospitalizing the patient, or contacting law enforcement, or some combination. Consult your institutional policy and state law. When triggered, document the threat specifically, the basis for the duty assessment, and the action taken.

Intimate partner violence screening is part of violence risk assessment, both for the patient as victim and for the patient as potential perpetrator. Screen privately. Document specifically. Safety planning if active. IPV history elevates risk of future severe violence, including homicide of the partner.

Hospitalize, treat, document, consult. The patient with credible imminent threats may meet criteria for involuntary hospitalization in addition to or instead of Tarasoff actions. Treatment may rapidly reduce risk (acute psychosis often improves substantially with rapid pharmacologic intervention). Document carefully — these decisions are often reviewed. Consult colleagues and risk management when the risk picture is acute or unclear.

When duty to warn/protect is triggered — identifiable target + credible threat + capacity to act. Options: warn target, hospitalize patient, contact police. Margin notes on legal framework.

The anchor

Violence risk assessment uses structured judgment — history, current symptoms, target specificity, and access to means. The Tarasoff duty triggers when an identifiable target faces a credible imminent threat.

Screening for intimate partner violence as part of violence risk and patient safety. Margin clusters on screening questions and safety planning.

Prove it

A patient with schizophrenia tells you he's been hearing voices telling him to harm his neighbor, who he believes is poisoning his food. He has thought about getting a knife but doesn't have one yet. How do you assess and act?

This connects to

E4.1

Suicide Risk

The parallel structured assessment.

E4.5

Involuntary Hold

The legal response.

Locked concepts unlock as you reach them on the path.