Alcohol(Drug information on alcohol) is involved in many acts of violence. Cocaine can produce mood swings that look just like bipolar disorder, paranoid anxieties and reduced control over aggressive impulses. The drug PCP produces a disorganizing psychotic process with particularly nasty and often extremely violent, mutilating, murderous behavior. Hallucinogens such as LSD can lead to abiding or recurrent hallucinations and delusions; I have two young women in my current practice for whom it is questionable whether or not they would ever have developed their current chronic psychotic illnesses had they not used LSD. Heroin and other opioids rarely cause violence except when, during withdrawal, users feel impelled to violence to gain the wherewithal for their next fix.
Sometimes it is not the patient who is dangerous, but the dyadic relationship between the patient and the therapist. For example, a patient who acts seductively, combined with a therapist whose ability to set boundaries is diminished can result in doctor-patient sexual misconduct that can be ruinous to the two of them.
Active mental illness, especially with a strong affective component, raises the risk for danger. People who are quietly depressed or delusional are less likely candidates for violent acting-out. The Table outlines various clinical presentations that should raise a warning flag for clinicians.
We should also look for issues of revenge in people with personality disorders with antisocial features or a history of solving problems by resorting to physical assault or violence. Some families, as well as some social subgroups, habitually turn to violence as a way of problem-solving. Certainly, people who commit notorious acts of public violence have often consulted a mental health care professional at some point in their trajectory.
Not too long ago, the Washington, D.C., area was under assault as two serial snipers roamed the community killing 10 people with single rifle shots from long distance. What will prove to be their history of attempted mental health interventions, if any?
When our patients express intent to injure or kill others, we should ask about access to weapons--especially guns: Do they own guns or have access to them? Have they moved them lately? A gun collection, neatly disarmed or locked in a cabinet, with the bullets secured safely in a difference place, is one set of facts. A shotgun or pistol kept under the bed is another. As Scott and Resnick (2002) wrote:
Subjects should be asked whether they own or have ever owned a weapon. The recent movement of a weapon, such as transferring a gun from a closet to a nightstand, is particularly ominous in a paranoid person.