Risk management : The role of clinical factors in violent behaviour

Sammanfattning: Background: The relationship between clinical factors and reoffending in psychiatric and correctional populations is unclear, with a lot of contradictory results and some clinical areas lacking in research. The overall aim of this thesis was to add to this knowledge-base within the framework of risk assessment and management. Paper I investegated the association between self-assessed personality disorder and reoffending. Paper II investigated the association between clinical factors and aggressive behaviour in patients in psychiatric after-care. Paper III described the development of a structured method for risk management, SORM, the instrument used to collect data on dynamic risk and protective factors and reoffending, presented in papers IV and V. Methods: Paper I was a prospective follow-up of 168 offenders who underwent court-ordered pre-sentencing psychiatric evaluation in Sweden. The DIP-Q self-assessment instrument was used, and mean time-at-risk in the community at follow-up was 3 years. Paper II was prospective follow-up of 128 psychiatric inpatients one year into their after-care. Clinical factors were assessed at discharge and after six months in the community. Paper III described the development of a protocol for monotoring and managing risk in the community; SORM. Paper IV was a prospective, once-per month, two year follow-up of discharged forensic psychiatric patients using the SORM. Paper V was a retrospective case-control study of rapidly recidivating violent offenders who had been in the community less than two years before charged with a new violent offences. Results: An association was found between self-assessed antisocial and schizoid personality disorder and re-offending (paper I), and between ASPD, and positive psychotic symptoms, especially so called TCO symptoms, and aggressive behaviour for psychiatric patients in after-care (paper II). The clinical factors of the SORM were the ones that best predicted the outcome criteria of reoffending or risk situations (paper IV) and reoffending among violent offenders (paper V). Conclusions: The results from the four clinical follow-up studies I-II, IV-V examined the relationship over time between clinical factors and offending from different viewpoints, all of which underlined the relative importance of clinical factors for the risk of recidivism. The need for new research approaches to build on risk prediction research and develop structured comprehensive risk management aids that focus more on dynamic, clinical factors is discussed.