1. Sabella, Donna PhD, MEd, MSN, CRNP, PMHNP-BC


How can nurses identify and address signs of potential violence in their patients?


Article Content

Violence is a recognized public health problem in the United States. In a study comparing U.S. homicide rates with those in 22 other high-income countries, results showed that our overall homicide rate is almost seven times higher.1 Even more alarming is the finding that our firearm homicide rates are almost 20 times higher than those in Italy, Japan, Portugal, Austria, France, and Germany. What role, if any, does mental illness play in this disturbing state of affairs?


News headlines have been reporting, with alarming frequency, stories of mass violence committed by people with serious mental illness. Indeed, based on these headlines, it is small wonder that the public believes that mental illness causes violence. But, according to Richard Friedman, MD, "most who are violent are not mentally ill and most people who are mentally ill are not violent."2 This article will examine the stories behind some of the recent tragic headlines, review the research connecting mental illness and violence, and describe how all nurses-including those who are not mental health nurses-can identify and address signs and symptoms of potential violence in their patients.



On April 20, 1999, 18-year-old Eric Harris and 17-year-old Dylan Klebold drove to Columbine High School in Jefferson County, Colorado, heavily armed. By the end of their deadly rampage, 12 students and one teacher were dead, 23 others were wounded, and both Harris and Klebold had committed suicide.3 Harris has since been characterized as a psychopath,4 while Klebold has been described as becoming withdrawn and moody during his teenage years (he reportedly wrote a paper about a man in a trench coat who murdered nine people that alarmed his English teacher). After Klebold's death, his journal entries, which were filled with dark thoughts and feelings and mentions of death, were examined by professionals who viewed them as clear indications of depression and suicidal ideation.5

Figure. Photographs ... - Click to enlarge in new windowFigure. Photographs of Eric Harris and Dylan Klebold taken from the 1999 Columbine High School yearbook, before the shootings in which Harris and Klebold killed 13 people and wounded 23 others before committing suicide. Photos by Ho New / Reuters.

Fast forward eight years to Seung-Hui Cho and Virginia Tech.6 On April 16, 2007, Cho opened fire in a dormitory and classroom building on the Virginia Tech campus in Blacksburg, Virginia. Before turning the gun on himself, he had killed 32 people. His is considered the deadliest mass shooting in U.S. history.7 On January 8, 2011, in Tucson, Arizona, Jared Lee Loughner killed six people and injured 13, includ-ing U.S. congresswoman Gabrielle Giffords.8 In the early morning hours of Friday, July 20, 2012, James Eagan Holmes, a 24-year-old former student in the Department of Neuroscience at the University of Colorado, Denver, entered a movie theater in Aurora, Colorado. His murderous rampage left 12 dead and 58 injured.9, 10 And later that same year, our nation mourned the murders of 20 schoolchildren and six adults at Sandy Hook Elementary School in Newtown, Connecticut. On Friday, December 14, 2012, 20-year-old Adam Lanza, armed with several semiautomatic weapons, forced his way into the school after murdering his own mother while she slept in the house they shared, and proceeded to fatally shoot children and adults at the school, eventually taking his own life.11


Prior indications of mental illness. Records show that before the shootings, there were indications of mental health problems and concerns for Cho, Loughner, Holmes, and Lanza. Concerns about his behavior and emotional health surfaced early for Cho; as a toddler he was medically fragile and prone to crying. His family moved from Korea to the United States in 1992 when Cho was eight years old. At that time, his parents worried that he was isolated and socially withdrawn. Elementary and secondary school teachers expressed concern about a number of his behaviors, and an eighth-grade art teacher questioned him about suicidal and homicidal ideation based on what she had observed in his artwork. And in a 1999 paper for his English class, Cho expressed a desire to repeat the events of Columbine.12 Although he was in and out of therapy during those years, Cho's problems continued into college. Referred to mental health services by a professor at Virginia Tech because of his behavior, Cho made contact by phone and in person with mental health professionals at the university during the winter of 2005. On December 14, 2005, he was hospitalized overnight on a psychiatric unit when he threatened to take his own life.13


Although Jared Loughner had never been deemed violent and had no history of involvement with the police, his behavior while enrolled at Pima Community College warranted enough concern on the part of campus security, professors, and other students that he was told to undergo a mental health evaluation if he wished to continue his studies.14, 15 According to authorities, there are no records that Loughner ever sought such assessment or treatment.15 Diagnosed with schizophrenia after the Tucson shootings, he was sentenced to life in prison without parole and will undoubtedly undergo long-term treatment.16

Figure. On January 8... - Click to enlarge in new windowFigure. On January 8, 2011, Jared Lee Loughner killed six people and injured 13, including U.S. congresswoman Gabrielle Giffords, in Tucson, Arizona. Photo (C) U.S. Marshals Service / Reuters.

Unlike Cho and Loughner, who had academic difficulties, James Eagan Holmes did well in school, rising to the rank of doctoral student at the University of Colorado, Denver. Having been awarded a federal grant, he was in the first year of a neuroscience program dedicated to studying how the brain works.17 Based on media reports, Holmes had been seeing a psychiatrist while a student at the university, although he had no prior criminal record, displayed no clear signs of mental illness,18 and had no signs or a history of mental health problems in childhood.19 However, after threatening a professor, Holmes was barred from the university; soon after he went on his deadly shooting rampage.20

Figure. James Holmes... - Click to enlarge in new windowFigure. James Holmes, a 24-year-old former doctoral student at the University of Colorado, Denver, entered a movie theater in Aurora, Colorado, on July 20, 2012, and killed 12 people and injured 58 others. Photo (C) Associated Press.

Although not much information has been released about Adam Lanza's state of mind prior to the events at Newtown, what has been reported indicates that there were serious concerns about his mental health and general behavior; one news report indicated that at the time of the shootings, Adam was refusing to leave the house and his mother was considering having him committed.21 Although few specific details exist about Lanza's mental health history, we do know that until the time of his rampage he had no known criminal record or evidence of violent behavior.



Unlike people with medical illnesses or conditions, those diagnosed with or even perceived to have a mental illness are often viewed by the public not only as having the potential to become violent but also as posing a significant risk of violence.22-24 There is a generally held view that the public needs to be protected from these people, a view influenced by the belief that mental disorders can cause people to self-harm or harm others.22, 25 A longitudinal study regarding Americans' attitudes toward mental health between 1950 and 1996 found that during this time the number of Americans who associated mental illness with violence and danger had nearly doubled.26, 27 More recently, the President's New Freedom Commission on Mental Health reported that 61% of Americans associate schizophrenia with behavior that is dangerous to others.28 Finally, in a recent review of the literature, Markowitz found that while public understanding of the causes of mental illness has grown "somewhat more sophisticated," there has also been an increase in "the proportion of persons who associate mental illness with dangerousness, violence, and unpredictability."25



Is the public correct? Are people with mental illness violent and dangerous? And are they significantly more so than the general population? While the relationship between violence and mental illness has been studied for decades, these questions, as of yet, have no definitive answers. Comparisons between those with mental illness and those without are often given in imprecise terms. For example, in a recent study using data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), those with severe mental illness were determined to be significantly more violent than those with no mental illness or no history of substance abuse; however, the meaning of "significantly more violent" was vague and undefined.29 When comparing groups with various disorders, however, the researchers found that those with severe mental illness and alcohol and drug abuse and/or dependence had the highest rate of violence (9.41%). The rate of violence for those with severe mental illness alone was 2.88% and for those with alcohol and drug abuse and/or dependence alone it was 2.49%. It's important to note that the authors cautioned readers to be aware of premorbid conditions and other clinical factors when examining violence outcomes.


While evidence supports that those suffering from a mental disorder are capable of violence or criminal behavior (and this is particularly true of those with serious mental illness such as psychosis),30-33 many argue that this is the exception and the risk is modest.25, 34-38 In fact, one study noted that severe mental illness alone was not a valid predictor of future violence, proposing that it's necessary to take additional factors into account, including past violence, a history of juvenile detention, substance use, age, gender, and income.39 Of note are the results of the MacArthur Violence Risk Assessment Study. In this landmark study, researchers identified a stronger relationship between mental illness and violence in those with a co-occurring substance abuse disorder.40 This was also found to be the case in a number of studies of those with serious mental health issues, including the NESARC study cited above.29, 41-43


However, the majority of people living with a mental health disorder are believed to be no more prone to violence than the general population.37 Furthermore, according to research by the American Psychiatric Association, the majority of people who are violent do not suffer from mental illness.30 Indeed, numerous sources assert that the majority of people with mental illness are not violent at all, especially to others, and present only a modest risk of becoming violent and engaging in criminal behavior.25, 44 In fact, they are more likely to inflict harm upon themselves or to be victimized by others than to cause harm to someone else.37, 45, 46


In her overview of violence and mental illness, Stuart47 stated that


* mental disorders are "neither necessary, nor sufficient causes of violence"; the major determinants of violence are sociodemographic and socioeconomic factors.


* the public is overly afraid that people with mental illness will commit violent acts.


* substance abuse plays a role in violence among those with and without other behavioral issues.


* more attention needs to be paid to the context of and situation that leads up to any violence.




In the events described above, the level of destruction was well beyond what most of us can imagine. Such horrific events blindside us all. We are left wondering what might have been done to prevent events from having gone this far. How can we tell when someone is crossing the line[forms light horizontal]beginning to develop emotional and behavioral problems that could lead to violence? How do we recognize "the enemy" of mental illness when the enemy is so cleverly disguised as us?


As nurses, we rely on laboratory values and overt signs and measurements to indicate physical and medical distress. But what can we rely on to give us clear indications that someone is poised to commit acts of unspeakable violence? Unfortunately there is no crystal ball. But that should not keep us from paying attention, learning what to look for, and taking steps to intervene when appropriate. One does not need to be clinically trained in mental health to be part of the solution (see Otto48 for a detailed discussion of assessing and managing risk). All nurses can be aware of and alert to the possible risk factors for violence among those with mental health issues:


* male


* younger than 40 years


* a history of violence


* a history of involvement with the juvenile justice system


* a co-occurring substance abuse disorder


* the belief that one's thoughts and behaviors are being controlled


* the belief that one is being threatened or persecuted


* a personality disorder


* access to weapons



Nurses can also watch for the following signs and symptoms that a person may be in mental or emotional distress:


* changes in sleeping or eating patterns


* feelings of hopelessness


* use of drugs and/or alcohol or an increase in use


* feeling sad and unable to enjoy life


* lack of motivation


* experiencing delusions and hallucinations


* change for the worse in personal hygiene


* irrational fears and concerns


* feelings of persecution and paranoia and being suspicious of others


* alternating high and low moods


* isolating oneself from others


* persistent feelings of anger and hostility


* limited emotional range


* persistent feelings of anxiety


* expressing odd thoughts


* feelings of wanting to harm or kill oneself or someone else


* rapid and unexplained change in behavior and personality


* cognitive difficulties and trouble paying attention and staying focused


* speech disturbances such as making up words, inability to stay on topic, and disorganized or confused thoughts



It's important to remember, however, that these signs and symptoms do not guarantee that a person will become violent. Nor do they mean that a person will ultimately be diagnosed with a mental illness. If there is no history of mental illness, it's good practice to clear the person medically and to provide support-such as a referral to expert psychiatric help-to a person experiencing any of these symptoms.


When a person expresses hostile or violent ideas, speaks of getting even, feels that she or he is being persecuted, makes statements such as, "They'll be sorry," or makes you feel uncomfortable, take such talk and behavior seriously. Don't assume that it's "just a phase." Avoid invading the physical space of someone who is feeling paranoid or threatened. Consider notifying the authorities if a person has made threats or spoken of wanting to harm her- or himself or others, and alert family members of the need to do the same. Suggest that family members remove weapons from the home. Most importantly, help the person to seek professional treatment. Remain positive by sharing information about effective medications and treatments, and enlist trusted family or friends to steer the patient in the direction of receiving help. If the patient refuses, consider requesting an involuntary commitment. And, as with other health issues, the sooner mental health issues are treated, the better the outcome. When properly treated, people with mental illness have the same risk of violence as the general population.36



Although much of our present debate focuses on gun control and the mentally ill, it's wrong to assume that these two are intrinsically linked; many people who are not mentally ill commit crimes with guns. Adam Lanza used guns he took from his mother, a law-abiding citizen who had every legal right to own the weapons she had in her home. Extending background checks, while a good idea, would not have kept guns out of his reach.


It may be equally, if not more, important to increase accessibility to mental health treatment and to decrease the stigma of mental illness by communicating that mental illness and violent behavior do not necessarily go hand in hand. Making care more accessible, affordable, and available-and helping us all to be more aware when friends, family, and loved ones are in need of treatment-is crucial to preventing the next Sandy Hook and to keeping those we care for from crossing the line.




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