C. Assessment of Dangerousness To Self Or Others

RECOMMENDATION

1. All patients with ASD/PTSD should be assessed for safety and dangerousness including current risk to self or others, as well as historical patterns of risk:
   • Suicidal or homicidal ideation, intent (plan), means (e.g., weapon, excess medications), history (e.g. violence or suicide attempts), behaviors (e.g., aggression, impulsivity), comorbidities (substance abuse, medical conditions)
   • Family and social environment – including risks to the family
   • Ongoing health risks or risk-taking behavior
   • Medical/psychiatric comorbidities or unstable medical conditions.
   • Consider potential to jeopardize mission in operational environment.

DISCUSSION

It is crucial to assess for safety and dangerousness in persons with PTSD, including current risk to self or others, as well as historical patterns of risk. Assessment of dangerousness should begin with building rapport and need to take place in a safe and secure environment. If the patient has thoughts of self-harm, identify whether they have had suicidal ideation or intent or a history of a suicide attempt. Any history of suicidal attempts or a family history of a completed suicide should be taken seriously. Pay careful attention to patients with behaviors that may signal dangerousness (e.g., agitation, intimidation, paranoia, or threatening). Access to weapons or other means of harm should also be taken seriously. Assess for domestic or family violence. Assessment of medical, psychiatric, and social/environmental risks is also warranted.

Assessment of dangerousness can include questions such as:

• You sound like you've been having a very tough time and are quite distressed. Has life ever seemed not worth living?
• Have you ever thought about acting on those feelings?
• Sometimes, when people get really upset or angry, they feel like doing harm to other people. Have you had any thoughts about harming others, recently?
• How would I know you are angry or upset? How do you express your feelings?
• Are there times you are afraid to go home?

Dangerousness to Self
Suicidality - Persons with PTSD, including sub-threshold PTSD, are at high-risk for suicidal ideation (Marshall et al., 2001) and, for women, suicide attempts (Breslau, 2000; Ferrada-Noli et al., 1998; Kaslow et al., 2000; Prigerson & Slimack, 1999). Suicidal behavior is best assessed with the following criteria: presence of active depression or psychosis, presence of substance abuse, past history of suicidal acts, formulation of plan, a stated intent to carry out the plan, feeling that the world would be better off if the patient were dead, availability of means for suicide (e.g., firearms and pills), disruption of an important personal relationship, and failure at an important personal endeavor (Simon, 1992). The presence of these factors often constitutes a psychiatric emergency and must always be taken seriously. Among young adults, aggressive symptoms may be predictive of suicidality in men and elevated symptoms of PTSD and/or depression may be more predictive in women (Prigerson & Slimack, 1999). Other predictors of completed suicide in general include history of suicide attempts, family history of suicide, access to weapons, male gender and Caucasian race. Rates of suicidal ideation in treatment-seeking Vietnam veterans have been 70 to 80 percent (Kramer et al., 1994). Among veterans with PTSD, intensive combat-related guilt has been linked to suicidality (Hendin & Haas, 1991). These findings point to the need for greater clinical attention to the role of guilt in the evaluation and treatment of suicidal veterans with PTSD. Additionally, Vietnam veterans with diagnosed PTSD have an increased risk of death due to suicide as compared to those without PTSD (Bullman & Kang, 1994).

Those with severe childhood trauma (e.g., sexual abuse) may present with complex PTSD symptoms and parasuicidal behaviors, (e.g., self mutilation, medication overdoses) (Roth et al., 1997). Further, limited cognitive coping styles in PTSD have been linked to a heightened suicide risk (Amir et al., 1999). Fostering competence and social support may reduce this risk (Kotler et al., 2001). Comorbid substance use disorders may increase the risk of suicidality. Additionally, persons with PTSD may also be at personal risk of danger through ongoing or future victimization in relationships (e.g. domestic violence/battering, or rape).

Dangerousness to Others
Some individuals with PTSD may be at risk for violence toward others (Swanson et al., 2002). Explosivity, anger problems, and past history of violence are associated with increased risk for violent behavior. Violence often emerges as a response to perceived threat or marked frustration by the patient stemming from their inability to meet goals by nonviolent means. The specific factors that contribute to violent behavior may include psychiatric, medical, environmental and situational/social engagements. Often, it is a combination of these factors that precipitates and aggravates the potential for violence, which may quickly escalate to frank agitation or the carrying out of violent impulses. Whatever the cause, the following situations may serve as warning signs pointing towards a very real threat of violence:

• Ideation and/or intent to harm others
• Past history of violent behaviors
• Severely agitated, aggressive, threatening or hostile
• Actively psychotic

Special attention to the risk of domestic violence is warranted. Careful attention to the home environment and relationships is essential. If there are children, an assessment of parenting skills, anger management, caregiver burden, and discipline style is crucial. Advising high-risk patients and their families on gun removal and safe storage practices has been recommended to decrease violence risk (Seng, 2002). PTSD is a predictor of violence in persons with severe mental illness (Swanson et al., 2002). Substance use disorders are highly comorbid in PTSD and can also predict violence. Immediate attention and intervention may be required in order to ward off the potential for escalation of agitation or violent impulses.

Health Risks
Persons with PTSD may have high rates of health risk behaviors, health problems, and medical conditions. Thus, an assessment of health and behavioral risks in individuals with PTSD is warranted. In addition to alcohol and drug use, persons with PTSD are at high-risk for cigarette smoking (Acierno et al., 1996). PTSD is a predictor of several HIV-risk behaviors as well as risk factors for related blood-borne infections, such as hepatitis B and C (Hutton et al., 2001). Other potentially dangerous comorbid medical conditions are intoxication or withdrawal syndromes requiring medical detoxification (e.g., alcohol, benzodiazepine, barbiturates, and possibly opiates). Medical conditions that can present a danger to others include the risk of transmission of blood-borne pathogens such as HIV, HCV/HBV, thus risk assessment and serotesting is warranted.

Psychiatric conditions:

1. Delirium - (also known as organic brain syndrome, organic psychosis, acute confusional state, acute brain syndrome and various other names) is a disorder of cognition and consciousness with abrupt onset that is frequently overlooked. This is common in the elderly and medically ill (Farrell & Ganzini, 1995).
2. Acute or marked psychosis - "Psychosis" in and of itself, is not a disorder. Rather, psychosis is a symptom, which may present in a variety of conditions. Psychotic patients have an impaired sense of reality, which may manifest in several forms (hallucinations, delusions, mental confusion or disorganization). Acute psychosis represents a medical emergency.
3. Severe debilitating depression (e.g., catatonia, malnourishment, severe disability) - While many mild to moderate illnesses may not necessarily present situations mandating immediate attention, the presence of severe depressive symptoms may represent a medical emergency, even in the absence of suicidal ideation.

Medical conditions:

1. Urgent conditions - Any condition immediately threatening to life, limb, eyesight, or requiring emergency medical care requires immediate attention.
2. Chronic diseases - Patients who have PTSD and other chronic medical diseases may find that their medical conditions are worsened by PTSD. Some medical conditions can be acutely dangerous in the presence of PTSD such as bronchial asthma, peptic ulcer disease, GI bleed and hypertension, if malignant (Davidson et al., 1991). PTSD has also been linked to cardiovascular disease, anemia, arthritis, asthma, back pain, diabetes, eczema, kidney disease, lung disease, and ulcers (Weisberg et al., 2002).

Operational Risk (Combat or Ongoing Military Operation)
Because reexposure to trauma may exacerbate or trigger PTSD symptoms, special consideration must be given when including patients with a history of PTSD symptoms in mission critical operations.

See VA/DoD Clinical Practice Guideline for Major Depression Disorder (MDD): Appendix 2, Unstable and High-Risk Conditions and Appendix 3, Suicidality.