Mental Illness and Violence How Can Nurses Identify and Address Signs of Potential Violence in Their Patients?

MENTAL HEALTH MATTERS By Donna Sabella, PhD, MEd, MSN, CRNP, PMHNP-BC

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

iolence is a recognized public health problem Tech campus in Blacksburg, Virginia. Before turn- in the United States. In a study comparing ing the gun on himself, he had killed 32 people. His U.S. homicide rates with those in 22 other is considered the deadliest mass shooting in U.S. V 7 high-income countries, results showed that our over- history. On January 8, 2011, in Tucson, Arizona, all homicide rate is almost seven times higher.1 Even Jared Lee Loughner killed six people and injured 13, more alarming is the finding that our firearm homi- including U.S. congresswoman Gabrielle Giffords.8 cide rates are almost 20 times higher than those in In the early morning hours of Friday, July 20, 2012, Italy, Japan, Portugal, Austria, France, and Germany. James Eagan Holmes, a 24-year-old former student in What role, if any, does mental illness play in this dis- the Department of Neuroscience at the University of turbing state of affairs? Colorado, Denver, entered a movie theater in Aurora, News headlines have been reporting, with alarming Colorado. His murderous rampage left 12 dead and frequency, stories of mass violence committed by peo- 58 injured.9, 10 And later that same year, our nation ple with serious mental illness. Indeed, based on these mourned the murders of 20 schoolchildren and six headlines, it is small wonder that the public believes adults at Sandy Hook Elementary School in New- that mental illness causes violence. But, according to town, Connecticut. On Friday, December 14, 2012, Richard Friedman, MD, “most who are violent are 20-year-old Adam Lanza, armed with several semiau- not mentally ill and most people who are mentally ill tomatic weapons, forced his way into the school af- are not violent.”2 This article will examine the stories ter murdering his own mother while she slept in the behind some of the recent tragic headlines, review the house they shared, and proceeded to fatally shoot research connecting mental illness and violence, and children and adults at the school, eventually taking describe how all nurses—including those who are not his own life.11 mental health nurses—can identify and address signs Prior indications of mental illness. Records and symptoms of potential violence in their patients. show that before the shootings, there were indications of mental health problems and concerns for MENTAL ILLNESS AND VIOLENCE IN THE NEWS Cho, Loughner, Holmes, and Lanza. Concerns about On April 20, 1999, 18-year-old Eric Harris and his behavior and emotional health surfaced early 17-year-old Dylan Klebold drove to Columbine for Cho; as a toddler he was medically fragile and High School in Jefferson County, Colorado, heavily prone to crying. His family moved from Korea to the 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 ide- 5 ation. Photographs of Eric Harris and Dylan Klebold taken from the Fast forward eight years to Seung-Hui Cho and 1999 Columbine High School yearbook, before the shootings Virginia Tech.6 On April 16, 2007, Cho opened fire in which Harris and Klebold killed 13 people and wounded 23 in a dormitory and classroom building on the Virginia others before committing suicide. Photos by Ho New / Reuters. [email protected] AJN ▼ January 2014 ▼ Vol. 114, No. 1 49 MENTAL HEALTH MATTERS

United States in 1992 when Cho was eight years old. Although not much information has been released At that time, his parents worried that he was isolated about Adam Lanza’s state of mind prior to the events and socially withdrawn. Elementary and secondary at Newtown, what has been reported indicates that school teachers expressed concern about a number of there were serious concerns about his mental health his behaviors, and an eighth-grade art teacher ques- and general behavior; one news report indicated that tioned him about suicidal and homicidal ideation at the time of the shootings, Adam was refusing to based on what she had observed in his artwork. And leave the house and his mother was considering hav- in a 1999 paper for his English class, Cho expressed ing him committed.21 Although few specific details a desire to repeat the events of Columbine.12 Although exist about Lanza’s mental health history, we do know he was in and out of therapy during those years, Cho’s that until the time of his rampage he had no known problems continued into college. Referred to mental criminal record or evidence of violent behavior. health services by a professor at Virginia Tech because of his behavior, Cho made contact by phone and in WHAT THE PUBLIC BELIEVES person with mental health professionals at the univer- Unlike people with medical illnesses or conditions, sity during the winter of 2005. On December 14, those diagnosed with or even perceived to have a 2005, he was hospitalized overnight on a psychiatric mental illness are often viewed by the public not only unit when he threatened to take his own life.13 as having the potential to become violent but also Although Jared Loughner had never been deemed as posing a significant risk of violence.22-24 There is a violent and had no history of involvement with the generally held view that the public needs to be pro- police, his behavior while enrolled at Pima Commu- tected from these people, a view influenced by the nity College warranted enough concern on the part belief that mental disorders can cause people to self- of campus security, professors, and other students harm or harm others.22, 25 A longitudinal study re- that he was told to undergo a mental health evalua- garding Americans’ attitudes toward mental health tion if he wished to continue his studies.14, 15 Accord- between 1950 and 1996 found that during this time ing to authorities, there are no records that Loughner the number of Americans who associated mental ill- ever sought such assessment or treatment.15 Diag- ness with violence and danger had nearly doubled.26, 27 nosed with schizophrenia after the Tucson shoot- More recently, the President’s New Freedom Com- ings, he was sentenced to life in prison without mission on Mental Health reported that 61% of parole and will undoubtedly undergo long-term Americans associate schizophrenia with behavior treatment.16 that is dangerous to others.28 Finally, in a recent re- Unlike Cho and Loughner, who had academic dif- view of the literature, Markowitz found that while ficulties, James Eagan Holmes did well in school, ris- public understanding of the causes of mental illness ing to the rank of doctoral student at the University has grown “somewhat more sophisticated,” there of Colorado, Denver. Having been awarded a fed- has also been an increase in “the proportion of per- eral grant, he was in the first year of a neuroscience sons who associate mental illness with dangerous- program dedicated to ness, violence, and unpredictability.”25 studying how the brain works.17 Based on me- WHAT THE LITERATURE REVEALS dia reports, Holmes had Is the public correct? Are people with mental ill- been seeing a psychia- ness violent and dangerous? And are they signifi- trist while a student at cantly more so than the general population? While the university, although the relationship between violence and mental illness he had no prior criminal has been studied for decades, these questions, as of record, displayed no yet, have no definitive answers. Comparisons be- clear signs of mental ill- tween those with mental illness and those without ness,18 and had no signs are often given in imprecise terms. For example, in or a history of mental a recent study using data from the National Epide- health problems in miologic Survey on Alcohol and Related Conditions childhood.19 However, (NESARC), those with severe mental illness were de- after threatening a pro- On January 8, 2011, Jared Lee termined to be significantly more violent than those Loughner killed six people fessor, Holmes was and injured 13, including U.S. with no mental illness or no history of substance barred from the univer- congresswoman Gabrielle abuse; however, the meaning of “significantly more 29 sity; soon after he went Giffords, in Tucson, Arizona. violent” was vague and undefined. When compar- on his deadly shooting Photo © U.S. Marshals Service / ing groups with various disorders, however, the re- rampage.20 Reuters. searchers found that those with severe mental illness

50 AJN ▼ January 2014 ▼ Vol. 114, No. 1 ajnonline.com and alcohol and drug abuse and/or dependence had Such horrific events the highest rate of violence (9.41%). The rate of vi- blindside us all. We are olence for those with severe mental illness alone was left wondering what 2.88% and for those with alcohol and drug abuse might have been done and/or dependence alone it was 2.49%. It’s impor- to prevent events from tant to note that the authors cautioned readers to having gone this far. be aware of premorbid conditions and other clinical How can we tell when factors when examining violence outcomes. someone is crossing the While evidence supports that those suffering from line―beginning to de- a mental disorder are capable of violence or crimi- velop emotional and be- nal behavior (and this is particularly true of those havioral problems that with serious mental illness such as psychosis),30-33 could lead to violence? many argue that this is the exception and the risk is How do we recognize 25, 34-38 James Holmes, a 24-year-old modest. In fact, one study noted that severe “the enemy” of mental former doctoral student at mental illness alone was not a valid predictor of fu- illness when the enemy is the University of Colorado, ture violence, proposing that it’s necessary to take so cleverly disguised as Denver, entered a movie additional factors into account, including past vio- us? theater in Aurora, Colorado, lence, a history of juvenile detention, substance use, As nurses, we rely on on July 20, 2012, and killed 12 age, gender, and income.39 Of note are the results of laboratory values and people and injured 58 others. the MacArthur Violence Risk Assessment Study. In overt signs and measure- Photo © Associated Press. this landmark study, researchers identified a stron- ments to indicate physi- ger relationship between mental illness and violence cal and medical distress. But what can we rely on in those with a co-occurring substance abuse disor- to give us clear indications that someone is poised der.40 This was also found to be the case in a number to commit acts of unspeakable violence? Unfortu- of studies of those with serious mental health issues, nately there is no crystal ball. But that should not including the NESARC study cited above.29, 41-43 keep us from paying attention, learning what to However, the majority of people living with a men- look for, and taking steps to intervene when appro- tal health disorder are believed to be no more prone priate. One does not need to be clinically trained in to violence than the general population.37 Further- mental health to be part of the solution (see Otto48 more, according to research by the American Psy- for a detailed discussion of assessing and managing chiatric Association, the majority of people who are risk). All nurses can be aware of and alert to the violent do not suffer from mental illness.30 Indeed, possible risk factors for violence among those with numerous sources assert that the majority of people mental health issues: with mental illness are not violent at all, especially • male to others, and present only a modest risk of becom- • younger than 40 years ing violent and engaging in criminal behavior.25, 44 In • a history of violence fact, they are more likely to inflict harm upon them- • a history of involvement with the juvenile justice selves or to be victimized by others than to cause system harm to someone else.37, 45, 46 • a co-occurring substance abuse disorder In her overview of violence and mental illness, • the belief that one’s thoughts and behaviors are Stuart47 stated that being controlled • mental disorders are “neither necessary, nor suf- • the belief that one is being threatened or perse- ficient causes of violence”; the major determinants cuted of violence are sociodemographic and socioeco- • a personality disorder nomic factors. • access to weapons • the public is overly afraid that people with men- Nurses can also watch for the following signs tal illness will commit violent acts. and symptoms that a person may be in mental or • substance abuse plays a role in violence among emotional distress: those with and without other behavioral issues. • changes in sleeping or eating patterns • more attention needs to be paid to the context • feelings of hopelessness of and situation that leads up to any violence. • use of drugs and/or alcohol or an increase in use • feeling sad and unable to enjoy life ASSESSING FOR VIOLENCE RISK • lack of motivation In the events described above, the level of destruc- • experiencing delusions and hallucinations tion was well beyond what most of us can imagine. • change for the worse in personal hygiene [email protected] AJN ▼ January 2014 ▼ Vol. 114, No. 1 51 MENTAL HEALTH MATTERS

• irrational fears and concerns a law-abiding citizen who had every legal right to • feelings of persecution and paranoia and being own the weapons she had in her home. Extending suspicious of others background checks, while a good idea, would not • alternating high and low moods have kept guns out of his reach. • isolating oneself from others It may be equally, if not more, important to in- • persistent feelings of anger and hostility crease accessibility to mental health treatment and • limited emotional range to decrease the stigma of mental illness by commu- • persistent feelings of anxiety nicating that mental illness and violent behavior do • expressing odd thoughts not necessarily go hand in hand. Making care more • feelings of wanting to harm or kill oneself or accessible, affordable, and available—and helping someone else us all to be more aware when friends, family, and • rapid and unexplained change in behavior and loved ones are in need of treatment—is crucial to personality preventing the next Sandy Hook and to keeping • cognitive difficulties and trouble paying atten- those we care for from crossing the line. ▼ tion and staying focused • speech disturbances such as making up words, Donna Sabella is a mental health nurse and assistant clinical inability to stay on topic, and disorganized or professor and director of global studies at the Drexel Univer- confused thoughts sity College of Nursing and Health Professions in Philadelphia. It’s important to remember, however, that these She also coordinates Mental Health Matters: ds842@drexel. edu. The author has disclosed no potential conflicts of interest, signs and symptoms do not guarantee that a person financial or otherwise. will become violent. Nor do they mean that a person will ultimately be diagnosed with a mental illness. If REFERENCES there is no history of mental illness, it’s good practice 1. Richardson EG, Hemenway D. Homicide, suicide, and unin- to clear the person medically and to provide support— tentional firearm fatality: comparing the United States with such as a referral to expert psychiatric help—to a per- other high-income countries, 2003. J Trauma 2011;70(1): son experiencing any of these symptoms. 238-43. 2. Friedman RA. Violence and mental illness—how strong is When a person expresses hostile or violent ideas, the link? N Engl J Med 2006;355(20):2064-6. speaks of getting even, feels that she or he is being 3. Kohn D. What really happened at Columbine? CBSNews persecuted, makes statements such as, “They’ll be 2009 Apr 29. http://www.cbsnews.com/2100-500164_162- sorry,” or makes you feel uncomfortable, take such 286144.html. 4. Stenson J. Destined as a psychopath? Experts seek clues. talk and behavior seriously. Don’t assume that it’s “just NBCNews.com 2009 Apr 20. http://www.nbcnews.com/ a phase.” Avoid invading the physical space of some- id/30267075/ns/health-mental_health/t/destined-psychopath- one who is feeling paranoid or threatened. Consider experts-seek-clues/#.UhKZ2JLVC80. 5. Klebold S. I will never know why. O, The Oprah notifying the authorities if a person has made threats Magazine 2009. http://www.oprah.com/world/Susan- or spoken of wanting to harm her- or himself or oth- Klebolds-O-Magazine-Essay-I-Will-Never-Know-Why. ers, and alert family members of the need to do the 6. Kaufman G, Aswad J. Cho history raises question: where is the line between strange and dangerous behavior? Many of same. Suggest that family members remove weap- the gunman’s warning signs are very common. MTV.com ons from the home. Most importantly, help the per- 2007 Apr 20. http://www.mtv.com/news/articles/1557628/ son to seek professional treatment. Remain positive when-someone-dangerous-not-just-strange.jhtml. by sharing information about effective medications 7. Times Topics. Seung-Hui Cho: news about Seung-Hui Cho, including commentary and archival articles published in the and treatments, and enlist trusted family or friends New York Times. n.d. http://topics.nytimes.com/top/refer- to steer the patient in the direction of receiving help. ence/timestopics/people/c/cho_seunghui/index.html. If the patient refuses, consider requesting an invol- 8. [no author.] With shooter put away, let’s turn to lessons of Jan. 8 [editorial]. Arizona Daily Star 2012 http://azstarnet. untary commitment. And, as with other health is- com/news/opinion/editorial/with-shooter-put-away-let-s-turn- sues, the sooner mental health issues are treated, the to-lessons-of/article_176bde12-4040-53a1-a0b3-894713333 better the outcome. When properly treated, people 5b4.html. 9. Banda PS. Cinemark to reopen Aurora shooting theater in with mental illness have the same risk of violence as 2013. Associated Press 2012 Sep 21. http://bigstory.ap.org/ the general population.36 article/cinemark-reopen-aurora-shooting-theater-2013. 10. Elam J. James Eagen Holmes joins roster of mass murderers, CONCLUSION why? Washington Times 2012 Jul 21. http://communities. washingtontimes.com/neighborhood/heart-without-compro- Although much of our present debate focuses on mise-children-and-children-wit/2012/jul/21/john-eagen-holmes- gun control and the mentally ill, it’s wrong to assume joins-roster-serial-killers-whil. that these two are intrinsically linked; many people 11. Barron J. Nation reels after gunman massacres 20 children at school in Connecticut. New York Times 2012 Dec who are not mentally ill commit crimes with guns. 14. http://www.nytimes.com/2012/12/15/nyregion/shooting- Adam Lanza used guns he took from his mother, reported-at-connecticut-elementary-school.html.

52 AJN ▼ January 2014 ▼ Vol. 114, No. 1 ajnonline.com 12. Virginia Tech Review Panel. Mental health history of Seung 28. The President’s New Freedom Commission on Mental Hui Cho. In: Mass shootings at Virginia Tech, April 16, 2007. Health. Achieving the promise: transforming mental health Report of the Virignia Tech Review Panel presented to Timothy care in America. Final report. Rockville, MD: Substance M. Kaine, Governor, Commonwealth of Virginia. Richmond, Abuse and Mental Health Services Administration; 2003 Jul. VA; 2007. p. 31-62. http://www.governor.virginia.gov/temp- DHHS pub. no. SMA 03-3832. http://govinfo.library.unt. content/techPanelReport-docs/8%20CHAPTER%20IV%20 edu/mentalhealthcommission/reports/FinalReport/downloads/ LIFE%20AND%20MENTAL%20HEALTH%20HISTORY downloads.html. %20OF%20CHOpdf.pdf. 29. Van Dorn R, et al. Mental disorder and violence: is there a 13. Friedman E. VA. tech shooter Seung-Hui Cho’s mental health relationship beyond substance use? Soc Psychiatry Psychiatr records released. ABCNews 2009 Aug 19. http://abcnews. Epidemiol 2012;47(3):487-503. go.com/US/seung-hui-chos-mental-health-records-released/ story?id=8278195. 30. American Psychiatric Association. Fact sheet: violence and 14. Flaccus G. How Jared Loughner fell through the mental mental illness. Washington, DC; 1994. http://bipolarworld. health cracks. Huffington Post 2011 Jan 12. http://www. net/pdf/violence.pdf. huffingtonpost.com/2011/01/12/jared-loughner-fell-through- 31. Krakowski MI, Czobor P. Clinical symptoms, neurological mental-_n_808194.html. impairment, and prediction of violence in psychiatric inpa- 15. Berger J. Mental health warnings preceded rampage, as tients. Hosp Community Psychiatry 1994;45(7):700-5. Arizona gunman likely went untreated. FoxNews.com 2011 32. Swanson JW, et al. Psychotic symptoms and disorders and Jan 10. http://www.foxnews.com/us/2011/01/10/mental- the risk of violent behaviour in the community. Crim Behav health-warnings-preceded-arizona-rampage-evidence- Ment Health 1996;6(4):309-29. gunman-sought. 33. Swanson JW, et al. A national study of violent behavior in 16. Muskal M. Gabby Giffords stared down Jared Lee Loughner, persons with schizophrenia. Arch Gen Psychiatry 2006; husband says. Los Angeles Times 2012 Nov 9. http://articles. 63(5):490-9. latimes.com/2012/nov/09/nation/la-na-nn-gabby-giffords- loughner-sentence-20121109. 34. Institute of Medicine Committee on Crossing the Quality 17. Wyatt K, Riccardi N. Brain experts who studied with James Chasm: Adaptation to Mental Health and Addictive Disorders, Eagan Holmes won’t say if they saw warning signs. Huffington Board on Health Care Services. Improving the quality of Post 2011 Jul 24. http://www.huffingtonpost.com/2012/07/24/ health care for mental and substance-use conditions. james-eagan-holmes-brain-experts_n_1700164.html. Washington, DC: National Academies Press; 2006. Quality 18. HuffPost Healthy Living. James Holmes, Colorado shooting chasm series. suspect, saw psychiatrist who specializes in schizephrenia: 35. Mulvey EP. Assessing the evidence of a link between mental what is it? Huffington Post 2012 Jul 30. http://www.huffing- illness and violence. Hosp Community Psychiatry 1994; tonpost.com/2012/07/30/james-holmes-schizophrenia-mental- 45(7):663-8. health_n_1720163.html. 36. Rueve ME, Welton RS. Violence and mental illness. Psychiatry 19. Gann C. James Holmes gave no indication of violent delu- (Edgmont) 2008;5(5):34-48. sions. ABCNews 2012 Jul 23. http://abcnews.go.com/blogs/ 37. SANE Australia. SANE factsheet: mental illness and violence. health/2012/07/23/james-holmes-gave-no-indication-of- 2012. http://www.sane.org/images/stories/information/fact violent-delusions. sheets/1205_info_fs5violence.pdf. 20. Associated Press. Colorado massacre prosecutors: James Holmes threatened professor before shooting. CBSNews.com 38. Substance Abuse and Mental Health Services Administration. 2012. http://www.cbsnews.com/8301-201_162-57522294/ Understanding mental illness: factsheet. n.d. http://www. colo-massacre-prosecutors-james-holmes-threatened-professor- samhsa.gov/mentalhealth/understanding_Mentalllness_ before-shooting. Factsheet.aspx. 21. HuffPost Crime. Adam Lanza’s motive: did fear of being 39. Elbogen EB, Johnson SC. The intricate link between violence committed lead to Sandy Hook Elementary shooting? (update). and mental disorder: results from the National Epidemiologic Huffington Post 2012 Dec 21. http://www.huffingtonpost. Survey on Alcohol and Related Conditions. Arch Gen com/2012/12/19/adam-lanza-motive_n_2329508.html. Psychiatry 2009;66(2):152-61. 22. Corrigan PW, et al. Challenging two mental illness stigmas: 40. Monahan J, et al. Rethinking risk assessment: the MacArthur personal responsibility and dangerousness. Schizophr Bull study of mental disorder and violence. New York: Oxford 2002;28(2):293-309. University Press; 2001. 23. Link BG, Stueve A. New evidence on the violence risk posed 41. Bo S, et al. Risk factors for violence among patients with by people with mental illness: on the importance of specify- schizophrenia. Clin Psychol Rev 2011;31(5):711-26. ing the timing and the targets of violence. Arch Gen Psychiatry 1998;55(5):403-4. 42. Fazel S, et al. Schizophrenia and violence: systematic review and meta-analysis. PLoS Med 2009;6(8):e1000120. 24. Monahan J. Mental disorder and violent behavior: percep- tions and evidence. Am Psychol 1992;47(4):511-21. 43. Steadman HJ, et al. Violence by people discharged from acute 25. Markowitz FE. Mental illness, crime, and violence: risk, psychiatric inpatient facilities and by others in the same neigh- context, and social control. Aggress Violent Behav 2011; borhoods. Arch Gen Psychiatry 1998;55(5):393-401. 16(1):36-44. 44. Stuart HL, Arboleda-Flórez JE. A public health perspec- 26. Pescosolido BA, et al. Americans’ views of mental health and tive on violent offenses among persons with mental illness. illness at century’s end: continuity and change. Public report Psychiatr Serv 2001;52(5):654-9. on the MacArthur mental health module, 1996 general so- 45. Hiday VA, et al. Criminal victimization of persons with se- cial survey. Bloomington, IN: Indiana Consortium of Mental vere mental illness. Psychiatr Serv 1999;50(1):62-8. Health Services Research, Indiana University; the Joseph P. 46. Hiroeh U, et al. Death by homicide, suicide, and other un- Mailman School of Public Health, Columbia University; 2000. natural causes in people with mental illness: a population- http://www.indiana.edu/~icmhsr/docs/Americans’%20 Views%20of%20Mental%20Health.pdf. based study. Lancet 2001;358(9299):2110-2. 27. Pescosolido BA, et al. The public’s view of the competence, 47. Stuart H. Violence and mental illness: an overview. World dangerousness, and need for legal coercion of persons with Psychiatry 2003;2(2):121-4. mental health problems. Am J Public Health 1999;89(9): 48. Otto RK. Assessing and managing violence risk in outpa- 1339-45. tient settings. J Clin Psychol 2000;56(10):1239-62. [email protected] AJN ▼ January 2014 ▼ Vol. 114, No. 1 53