Rom J Leg Med [18] 289 294 [2010]

DOI: 10.4323/rjlm.2010.289
2010 Romanian Society of Legal Medicine

Assessement and management of violence risk in Forensic Psychiatry

Monica Moescu*1, Roxana Chiri2, Magdalena Dragu3, Vasile Chiri4

____________________________________________________________________________
Abstract: In an atempt to evaluate the accuracy of risk-assessment and risk-management of violence especially
for mentally ill persons, we performed a statistical analisys (crosstabulations, factor analysis) based on a retrospective
study of 176 clinical files of adult patients hospitalized during three years at SPMS Sapoca for forensic psychiatric
evaluation. Our study revealed that psychotic disorder didn't significantly associate with the violence of the offence even
when it is dually diagnosed with personality disorder but it was strongly associated with the lack of judgement. A positive
and significant correlation was demonstrated between judgement and the proposed safety measure.
Key words: forensic psychiatry, risk-assessment, risk-management

he psychiatric medico-legal examination, common land of legal medicine and psychiatry, is

the work of interdisciplinary and scientific research where the responsibility and ethical
consciousness of experts is committed to the highest degree [1]. V. Gheorghiu (2008) emphasizes: the
psychiatric medical legal expertise is primarily a scientific work, being developed by complying with
rigorous scientific standards, in accordance with national and international regulations of classification
of the diseases and of the methods of analyse and expert evaluation[2].
Forensic psychiatric assessment is considered to be a crucial element in the judicial process, influencing
all subsequent decisions on sentence, detention, placement or treatment of the person concerned [3].
There are a huge interest in the last years regarding relationship between mental disorders
(especially psychotic disorders) and violence. Not every mentally ill person is dangerous. And even if
he/she is part of a pathological class with high risk of aggression, how a psychiatrist can foresee an
aggressive act that would happen? [4]. There are a large consensus to accept good results of assesment
and management of violence risk so every medical-legal psychiatric examination should respect principles
of risk-assessment and risk-management. Violence, even that of the mentally ill person, is not purely a
psychiatric problem but also social and legal issue making the problem of danger a socio-criminological
and psychiatric complex problem [5].
This is a reason for what risk assessment considers clinical and historical data obtained from
patient, family or other official records. Risk assessment focused especially on prediction of violence of
mentally ill and this represents a form of primary prevention of violence. But risk assessment with his
clinical applications leads also to risk management which, pointedly, identifies risk factors and protective
factors for violence and build individual treatment strategies. This paper analyse a small sample of forensic
psychiatric examination looking for risk factors of violence focusing especially on relationship between
violence and psychotic disorders.
________________________

*!) Corresponding author, MD, PhD, Psychiatry and for Safety Measures Hospital Sapoca, Buzau,
E-mail: md_mosescu@yahoo.com, Phone: 0238 528146, fax: 0238528474;
2) Professor, MD, PhD, University of Medicine and Pharmacy Gr. T. Popa Iasi; Clinical Hospital of
Psychiatry Socola, Iasi;
3) MD, PhD, Chairperson, Medical - Legal Services, Buzau County;
4) Professor, MD, PhD, University of Medicine and Pharmacy Gr. T. Popa Iasi, Clinical Hospital of
Psychiatry Socola, Iasi
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Assessement and management of violence risk in Forensic Psychiatry

Material and Methods

The study is retrospective, passive, uncontrolled by documents (case report forms) of adults
hospitalized in order to be forensic psychiatric evaluated between 01.01.2006-31.12.2008 in SPMS
Sapoca. We followed 16 variables: age, sex, marital status, location, occupation, education, diagnosis (I
and II axis), co morbidity, psychiatric, criminal and forensic records, complementary investigation,
offence, judgement, proposed safety measure. The diagnoses were established according to ICD-10 criteria
(International Classification of Diseases ) and personality disorder was evaluated based on SCID-II
(Structured Clinical Interview for DSM axis II). After the recodifications there were obtained 15 variables,
each containing between two and five items (table no 1).We used Statistical Package for the Social
Sciences (SPSS) version 17.0 (for Windows Vista).
The final number of participants was N=176 (exclusion criteria: civil cases and cases with
incomplete information). It has been respected the ethical rules of the scientific research based on
documents, the work being approved by the Board of Ethics of SPMS Sapoca.
Working hypothesis: the demonstration of the importance of the psychiatric medical legal
examination in the assessment and risk management of violence. We mention that Buzau county is
characterized by the absence of significant variations from the national average regarding the facts
committed with great violence [6].
We calculated the frequencies, percentiles and a correlative bivariate analysis was performed.
Following the results of bivariate correlation it was performed cross tabulation on relations assessed as
significant. Depending on the main results obtained it was made a classification of the factors that may
interfere in assessment and risk management through hierarchical cluster and a dimensional factorial
reduction using the Variant method in 3 rotations.
Results and Discussions

Sample Characteristics
We noticed the dominance of men (86,4%) and the age group 26-45 years (51,1%) and of the rural
residence (67,3%). There were encountered extreme ages of 18 and respective 79 years and the average
age was 37.9 years. Data regarding the sex and age group corresponds with literature of speciality [5, 7, 8,
9, 10]. The repartition on origin depends on the characteristics of the country and of the county (Table 1).
Personality disorders (41,2%) was more diagnosed then psychotic disorders (15,3%). Psychotic
disorders had the same representation (13,5%) in both age groups 26-45 years and 46-64 years and there
were absent in the age group over 65 years. In our study there are different data obtained compared to
those at INML (National Institute of Legal Medicine) Bucuresti [7] and IML (Institute of Legal Medicine)
Iasi [5] regarding the psychotic disorders and schizophrenia in particular. The differences are mainly
caused by the method of selection of local judicial system on request of forensic assessment and of Buzau
county profile with a lower prevalence of psychotic disorder compared to the rest of the country.
Observation demonstrates the need for relevant multi-centre study of such data.
The offence provided by the Penal Code, as the reason for psychiatric medical legal
examination was theft in 23,6% of cases while offences with aggressive component represented
56,6% of all. Comparative to study from IML Iasi [5] there are no big differences regarding the theft
dominance but in the study from INML Bucuresti [7] the murder dominated with 16,2% from all,
because methodological through which at Bucuresti there are psychiatric medical-legal evaluated the
prisoners who committed murder from all country. In Sweden the most common offences for which
they were evaluated there were: violent crimes, sexual offences and arson [10]. The differences are
caused by the legal stipulations of each country on the offences for which it is requested the
psychiatric medical-legal examination.
In our sample patients diagnosed with psychotic disorders engaged in all types of crimes: from
murder to exhibitionism while 30% of patients with personality disorder and 43,7%.with organic
disorders committed theft. In cases of murder and attempted murder 55,5% of the cases were
diagnosed with personality disorder and 33,3% with psychotic disorders. The data from Iasi show a
low representation among those who have committed murders both for personality disorder (12,7%)
and schizophrenia (6,4%) [5]. Differences over some international studies [8, 9, 10, 11] is due to the
same legal stipulations for psychiatric medical-legal examination.
In our sample 67% had psychiatric history, 20% criminal and 16,5% forensic records
comparative to study from Bucuresti where 43,5% had a psychiatric history and 18,6% criminal
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Vol. XVIII, No 4 (2010)

records [7] In a report presented in Canada: 86% had a psychiatric history, 33% even psychiatric
hospitalization and 75% had a criminal record. [12] Therefore the difficulties related with primary
prevention are similar in many countries.
Table 1 Presentation Sample Population
no.
Variables
Items
1

Sex

Location

Age group

Psychiatric
history
Criminal
records
Forensic
history
Alcohol use

Epilepsy

Head trauma

5
6

10

Psychotics
disorders

11

Personality
disorders
Offense's
violence
Violence's
level

12
13

14

Judgement

15

Safety
measures

1 = male
2 = female
1= urban
2 = rural
1 = 18-24 years
2 = 25-44 years
3 = 45-64 years
4 = over 65 years
1= with
2 = without
1= with
2 = without
1= with prior forensic evaluation
2= prior forensic evaluation security measures
1= with
2 = without
1= with
2 = without
1= with
2 = without
1= absent
2= with psychotics disorders (including schizophrenia,
schizoaffective disorders, delusional disorders)
1 = absent
2 = present
1= without violence
2= with violence
1=high violence: murder, infanticide, attempt murder,
serious sexual crimes
2= low/medium violence: strike, aggression, destruction,
robbery, threat, arson, offences against public order,
breaking and entering, bodily harm
3= absence of violence
1 = preserved
2 = low
3 = absent
1= without
2= compulsory outpatient treatment (art. 113CP)
3= compulsory psychiatric hospitalization (art. 114CP)

Frequencies

Percentiles

152
24
61
115
30
90
48
8
120
56
35
151
146
29
76
100
10
166
17
159
147
29

86,4
13,6
34,7
65,3
17
51,1
27,3
4,5
68,2
31,8
19,9
80,1
83,5
16,5
43,2
56,8
5,7
94,3
9,7
90,3
83,5
16,5

100
76
76
100
23

56,8
43,2
43,2
56,8
13,1

75

42,6

78
129
23
24
128
28

44,3
73,3
13,1
13,6
72,7
15,9

29

11,4

A low or absent judgement was evaluated in the majority of those with psychotic disorders
(96,6%) and of those with organic disorders (75%). Safety measures have been proposed to 27,3%
like that: outpatient compulsory treatment at 15,9% (art.113 Penal Code) and compulsory
hospitalization (art.114 from Penal Code) at 11,4% from all cases. Psychotic disorders represented
80% of those who were proposed for compulsory hospitalization treatment and 30,4% of those who
were proposed the compulsory outpatient treatment. Organic disorders represented 43,4% from those
with proposal of compulsory outpatient treatment.
In conclusion our sample comply largely with characteristics shown by other scientific papers
from the field: predominance of men, rural residence, low education, single status, the average age
around 35 years, personality disorder were more frequently than psychotic disorders and the most
frequently act committed was theft. The most patients with psychotic disorders had low or absent
judgement in contrast to most of those diagnosed with personality disorder, alcohol-related disorders
or mental retardation which had present judgement. Safety measure of hospital treatment was
recommended more to people with psychotic disorders while compulsory outpatient treatment was
recommended, especially those with organic disorders
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Assessement and management of violence risk in Forensic Psychiatry

Bivariate Correlative Analysis Kendall's tau_b

Table 2 shows the results from the analysis of Kendall coefficient through bivariate correlation
method. We noticed that the most correlations certify the high level of reliability for psychiatric
medical-legal activity at Buzau Medical-Legal Unit (logic correlation in terms of psychopathology).
Table 2 - Bivariate Correlative Analyze Kendall's tau_b
No.
Variables correlated
Coef.
Coef.
Kendall
sigma
1
Psychotics disorders and:

psychiatric history
0,204
0.008

criminal records
0,183
0,016

judgement
0,722
0

safety measures
0,700
0
2
Personality disorder and:

criminal records
0,342
0

judgement
0,388
0

safety measures
0,405
0
3
Offense's violence - marital
0,231
0,02
status
4
Violence's level and:

psychiatric history
0,165
0,031

age group
0,171
0,016
5
Psychiatric history forensic
0,196
0,010
history
6
Judgement and:

psychiatric history
0,266
0

criminal records
0,261
0
7
Safety measures and:
0

criminal records
0,265
0

psychiatric history
0,277
0,027

forensic history
0,162
0

judgement
0, 975

Correlation

172
176
176
176
176
176
176

0,01
0,01
0,05
0,01
0,01
0.01
0,01

Negative
Positive
Negative
Negative

164

0,05

172
176
99

0,05
0,05

Negative
Positive
Positive

99
176
176
172
176
176

0,01
0,01
0,01
0.01
0,05
0,01

Positive
Negative
Negative
Positive
Positive
Positive

Negative
Positive
Positive
Negative

Also in table 2 it can be noticed that the male is not significantly correlated with violence, even
in association with psychotic disorders or personality disorder so it's rise the opportunity for discussion
about on the one hand, the trend to increase the anti-social behaviour of young age and female persons
and, on the other hand, multiple and classifiable conditioning of such behaviour.
Cross tabulation Analysis
For variables that were significantly correlated at bivariate correlative analyse we applied
crosstabulation analysis with chi-square test of association (table 3)
No
1
2
3
4
5
6
7
8
9

Table 3 - Crosstabulation Analysis

Variables correlated
Psychotics disorder Offense's violence
Psychotics disorder + Personality disorder
Offense's violence
Psychotics disorder absence judgement
Psychotics disorder safety measures proposed
Offense's violence psychiatric history
Psychotics disorder no criminal records
Low offense's violence low/absence
judgement
low/absence judgement safety measures
proposed
Presence judgement Personality disorder

2
0,543

df
2

3,659

NA

176
176
176
172
176

p
0,762
(>0,05)
0,056
(>0,05)
<0,001
<0,001
<0,05
<0.05
< 0.05

106 65
95 713
4,079
5,889
9,851

2
2
1
1
2

0,770
0,737
0,165
0,183
0,237

176

<0,001

0,914

176

<0,001

294
113
31 418

0,423

N valid
176
176

Cramer
NA

For our sample violent crime is not correlated with psychotic disorders or with coexisting psychotic
disorder-personality disorder what is differents toward majority of studies performed in last 25 years [13, 14,
15, 16, 17, 18]. But even in these studies the authors described factors predictivs for violence in people with
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Vol. XVIII, No 4 (2010)

psychotic illness like hallucinations and delusional, psychopatic traits or substance abuse [15]. We believe
that different observations are due to both, the varies designs of studies and varied cross-cultural and legal
conditions. In this respect our results do not differ from other studies, but it is a further proof for the
destigmatization of mental illness and, of course, of people with mental disorders that would significantly
improve the quality of psychiatric care within the family and community.
Significant results regarding relationship: psychotic disorders - absence of judgement - medical
safety measures proposed demonstrates the reliability of psychiatric medical legal examination, and through
high effect size, it argues the need for institutions that demand forensic assessment to keep in mind these
considerations.
The offenses committed without violence are significantly correlated with psychiatric history which
support the above results on relationship violence - psychotic disorders - psychiatric history and reveals the
importance of establishing of clear principles of risk management in scope to an efficent psycho-prophylaxis
of violence. There is a significant correlation (with a low Phi Cramer coefficient) between psychotic disorder
and the absence of criminal history that bring into discussion the theory of psychopathology of the medical
legal debuts and the significance of psycho-prophylaxis in vioence prevention.
The absence or low judgement correlated with low levels of violence raises psycho-prophylaxis
problem to avoid relapses and incite theoretical discussions about a possible gradual increase of aggressivity
to psychotic patients during evolution of disease.
Hierarchical cluster analysis
A first classification took into account ten variables that were grouped into three clusters as follows:
Cluster 1: psychotic disorders, personality disorder, sex, offence's violence, psychiatric history, criminal
record, forensic history
Cluster 2: judgement and safety measures
Cluster 3: age group.
A second cluster analysis consider only five variables grouped also into three clusters as follows:
Cluster 1: psychotic disorders and psychiatric history
Cluster 2: offence's violence and personality disorders
Cluster 3: judgement
This classification shows additional issues of the correlative analysis:
association on personality disorder - psychopathology - sex
the fact that the age group represents a single cluster which we have outlined previously above support
the movement of anti-social behaviour to young age
Analysis of factors reduction
By analysing of reducing factors through Varimax method, the psychotic disorder was the factor that
reduced correlated variables through Kendall method. Reported to psychotic disorders there are only two
components instead of three which proves that in relation to psychotic disorder in the analysis at level of
psychiatric medical-legal examination involve both psychiatric and medical-legal criteria (according to
current methodology for conducting forensic psychiatric expertise) and mixed criteria. The two components
are: 1) psychotic disorders, epilepsy, criminal records and 2) personality disorder, offence's violence, alcohol
use, psychiatric history, forensic history, judgement, safety measures, sex, age group.
By reducing factors we analysed the variables that were correlated by chi-square method and we
found also two components. Psychiatric history and judgement is one component which is logical because the
judgement is established for a time before examination and psychiatric analysis is a longitudinal type. The
second component includes three variables of which two are equal: offence's violence and personality
disorder and the third: psychotic disorders. This reduction factor is similar with the second cluster presented
above. The results obtained show the reliability of the methodology of psychiatric medical legal expertise
in our country.
Methodological Limitations
At SPMS Sapoca there are hospitalised mentally ill persons from eight counties and capital,
Bucuresti, who committed an offence according to Romanian Penal Code. These counties belongs to SouthEast Romania. There are no significant numerical differences between urban and rural population. The
medical-legal work is directly supervised by National Medical-Legal Institute (INML) Bucuresti
(methodological centre for all country) while psychiatric activity is supervised by Clinical Hospital of

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Assessement and management of violence risk in Forensic Psychiatry

Psychiatry Socola Iasi which have a long history of forensic psychiatry care. All these factors could
differentiate violent behaviour and principles of risk-management in other parts of the country.
Conclusions

Results obtained by analysing this sample demonstrate that that through the methodology of forensic
psychiatric examination it can be identified risk factors for violence: male gender, ages 26-45, personality
disorder, psychiatric and forensic history, criminal records, alcohol use, being un-employed. These risk
factors split into two categories: risk factors can be modified by applying safety measures (especially clinical)
and risk factors that can not be influenced by medical safety measures (especially historical). Assistance with
safety measures should address especially to those people with mental disorders for which risk factors for
violence can be influenced. A good risk assessment procedure should be predictive: must identify, assess
and prioritize legal psychiatric services, social services and interventions according to the patients'
violence risk. There is a general consensus to recognize that risk assessment should lead to risk
management so forensic psychiatric examination should include suggestions for reducing the
probability of violence through treatment. Some authors go even further claiming that risk assessment
is pointless if it incorporates directions for treatment and not focuses on the causes of violence [19].
Commission of forensic psychiatric examination, based on assessment of mental disorders and
historical variables, should guide the mentally ill person with medical safety measures (or forensic patient) to
medical institutions that provide forensic psychiatric services (hospitals, hospital units, extra-muros
structures) stratified according to risk assessed in forensic psychiatric examination: minimal, medium and
maximum risk. Allocating financial and human resources in forensic psychiatry is made according to
practical needs arising from risk assessment which helps to identify individuals with higher risk and need
more intensive services. Applications of principles of assessment and management of violence risk for every
medical-legal psychiatry examination can be achieved a planning and optimal efficiency of the resources and
for a long term a reduction in funds allocated to assist patients with medical safety measures.
In legal medicine, through excellence, truth is the conformity of ideas with the objective reality,
naked reality of subjectivity, which is why any medical-legal work must represent a real scientific research
based on scientific criteria, on the experiments and finally on scientific argument [20].
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