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Threats to harm others

Specialties > Mental health

Differential Diagnosis Schema 🧠

Psychiatric Disorders

  • Schizophrenia: May present with persecutory delusions or command hallucinations that lead to violent thoughts or behaviors.
  • Bipolar disorder (manic phase): Grandiosity, impulsivity, and irritability may lead to aggressive behaviors and threats.
  • Personality disorders: Antisocial and borderline personality disorders are particularly associated with impulsive and aggressive behaviors.
  • Paranoid delusional disorder: Delusions of persecution or threat may lead to preemptive aggression as a perceived form of self-defense.
  • Substance-induced psychosis: Intoxication with or withdrawal from substances (e.g., alcohol, stimulants) can lead to paranoia, aggression, and threats of harm.
  • Depression with psychotic features: Suicidal ideation can sometimes be coupled with homicidal thoughts, particularly in severe cases with psychotic features.
  • Intermittent explosive disorder: Characterized by sudden episodes of impulsive, aggressive, violent behavior or angry verbal outbursts.
  • Post-traumatic stress disorder (PTSD): Hypervigilance, irritability, and anger may manifest as threats or aggressive behavior.

Organic Causes

  • Delirium: Acute confusion due to infection, metabolic disturbances, or drug toxicity can present with aggression and threats.
  • Dementia: Frontal lobe involvement may lead to disinhibition, aggression, and threats to harm others.
  • Traumatic brain injury: Damage to frontal or temporal lobes can result in impulsivity, aggression, and violent thoughts.
  • Epilepsy: Post-ictal states, particularly after complex partial seizures, can lead to confusion, aggression, and threats.
  • Endocrine disorders: Conditions like hyperthyroidism or hypoglycemia may cause agitation, irritability, and aggression.
  • Cerebral neoplasms: Tumors affecting the frontal or temporal lobes may cause personality changes, aggression, and threatening behavior.
  • Infections: Encephalitis, particularly herpes simplex virus (HSV) encephalitis, may lead to aggressive behavior and threats due to brain involvement.

Key Points in History 🥼

History of Presenting Complaint

  • Nature of the threat: Determine the specific nature of the threat, including any detailed plans, targets, or stated reasons for the threat.
  • Triggering factors: Identify any recent events or stressors that may have precipitated the threatening behavior (e.g., loss, perceived insult).
  • History of violence: Previous episodes of aggression, violence, or threats, and the context in which these occurred.
  • Mental state changes: Recent changes in mood, behavior, or thought patterns, including the presence of hallucinations, delusions, or paranoia.
  • Substance use: Current or past use of alcohol, drugs, or other substances that may contribute to impulsivity or aggression.
  • Sleep disturbances: Insomnia or other sleep issues, which may exacerbate irritability and aggressive behavior.
  • Access to weapons: Determine if the patient has access to firearms, knives, or other weapons that could be used to carry out the threat.
  • Risk to others: Assess the risk to specific individuals or the general public, including the likelihood of the patient acting on their threats.
  • Protective factors: Explore any factors that might reduce the likelihood of the patient acting on their threats, such as supportive relationships, responsibilities, or treatment engagement.

Background

  • Mental health history: Previous psychiatric diagnoses, hospitalizations, and treatments, particularly for conditions associated with aggression or violence.
  • Substance use history: Detailed history of alcohol, illicit drugs, and prescription medication use, including periods of dependence, withdrawal, and intoxication.
  • Medical history: Chronic conditions, neurological disorders, or history of head injury that could contribute to behavioral changes.
  • Family history: History of psychiatric disorders, substance misuse, or violence in first-degree relatives.
  • Social history: Current living situation, relationships, employment status, and any recent stressors, such as loss of job or relationship breakdown.
  • Criminal history: Any history of criminal behavior, particularly violent offenses or breaches of legal orders.
  • Medication adherence: Whether the patient is taking prescribed medications as directed, and any recent changes in treatment.
  • Support network: Availability and involvement of family, friends, or community resources that may help mitigate risk.
  • Childhood history: Any history of childhood trauma, abuse, or neglect that might influence adult behavior.

Possible Investigations 🌡️

Psychiatric Assessment

  • Mental state examination: Assess appearance, behavior, speech, mood, affect, thought process, thought content (including delusions and hallucinations), cognition, insight, and judgment.
  • Risk assessment: Structured tools such as the HCR-20 (Historical, Clinical, Risk Management-20) or the Violence Risk Appraisal Guide (VRAG) may be used to assess risk.
  • Cognitive assessment: Screen for cognitive impairment using tools like the Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA).
  • Substance use assessment: Use standardized tools like AUDIT for alcohol use or DAST for drug use to assess the impact of substance misuse on behavior.
  • Neuropsychological testing: In cases where organic brain conditions are suspected, detailed cognitive testing may be warranted.
  • Collateral history: Obtain information from family members, carers, or other healthcare professionals to better understand the patient’s behavior and risk factors.

Laboratory and Imaging Tests

  • Full blood count (FBC): To check for infections, anemia, or other systemic conditions that might affect behavior.
  • Electrolytes and renal function: To rule out metabolic imbalances that could contribute to confusion or agitation.
  • Liver function tests: Particularly in the context of alcohol misuse, to assess for hepatic encephalopathy.
  • Thyroid function tests: To exclude hyperthyroidism as a cause of agitation or aggression.
  • Toxicology screen: Urine or blood tests to detect the presence of alcohol, illicit drugs, or medications that could influence behavior.
  • CT/MRI brain: Indicated if there is suspicion of intracranial pathology, such as a tumor, hemorrhage, or stroke.
  • EEG: To rule out epilepsy or other seizure disorders, particularly in patients with episodic aggression or altered consciousness.
  • Infectious disease screening: In cases where encephalitis or other infections are suspected, appropriate microbiological tests should be conducted.
  • Glucose levels: To exclude hypoglycemia as a cause of confusion or aggression.
  • Vitamin B12 and folate levels: Deficiencies can contribute to cognitive impairment and behavioral changes.
  • Neuroimaging: CT or MRI of the head may be warranted if there is suspicion of an organic brain cause for the behavior, such as a tumor, stroke, or traumatic injury.
  • Lumbar puncture: If there is a suspicion of CNS infection or inflammation, such as encephalitis or meningitis.
  • HIV and syphilis serology: If there is a possibility of neurosyphilis or HIV-associated neurocognitive disorder.

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Mental health