Medical Management of the Violent Patient: Clinical Assessment and Therapy

This book is part of a series, Medical Psychiatry, edited by William A. Frosch, M.D., of Cornell University Medical College, New York. Dr. Frosch writes the series introduction, and Dr. Tardiff writes the volume preface.

This is a well-edited, well-written, and well-referenced book on violence in almost all its aspects, beginning with causes of violence, treatment of violent patients, multiple factors involved in violent behavior, victims of violence, legal aspects of violent behaviors, and preventing violence. The book is well divided into various sections, initially introducing the reader to the causes of violent behavior, including medical, psychiatric, organic, social, political, and other factors. The editor defines violent behavior as the intentional harm to another person or persons. It is good to restrict the discussion of violent behavior to that definition even though much violence may occur accidentally, by nature, or unintentionally. There is not much physicians can do about preventing or treating the accidental or unintentional behaviors that lead to violence. However, it is important for the physician and clinician to understand the causes leading to intentional violent or destructive behavior that can be predicted, managed or treated, and, one hopes, ultimately prevented.

The editor has selected excellent authors for the chapters, which are consistently well written and well edited. Many of the chapter authors are considered experts in the field in which they are writing. It is important to present violence in the multifactored manner in which the editor organizes this fine book. Inasmuch as the causes of violent behavior are seen as multiple and diverse, the assessment of the violent or potentially violent individual must include all known factors, including medical, psychiatric, social, and political.

Treatment or management of the violent patient must include consideration of all these factors to be successful. In his chapter on treatment of the psychiatric patient who becomes violent, the editor considers three different types of psychiatric patients: the psychotic, the organic, and the nonpsychotic and nonorganic. In my experience, the assessment of the psychotic patient or the organic patient may be more readily achieved than identification of the factors leading to violence in the nonpsychotic, nonorganic patient. We tend to consider such issues as antisocial personality disorder, drug abuse, and other social factors. Treatment of the nonpsychotic, nonorganic patient becomes less specific, inasmuch as there are fewer medications or treatments available to these patients.

The editor presents a nearly complete consideration of violence in our society. The one area that seems to be missing is the perpetration of violence in the geriatric population. Dr. Leah J. Dickstein, in her chapter on domestic violence, covers primarily spousal violence, although she does include a number of areas in her section on special issues. The chapter by the late Dr. Arthur H. Green, “Patterns of Violence Transmission in Physically and Sexually Abused Children,” is very important in view of the fact that a number of individuals later charged with violent behavior have had histories of physical and sexual abuse. In my practice, I have seen serial killers and mass murderers, all of whom have described serious sexual and physical abuse as youngsters.

The chapters on prediction of violence and prevention of violence are also quite important inasmuch as these are controversial areas that often become legal issues in malpractice cases in which psychiatrists line up on one side or the other regarding the prediction or prevention of violent behavior. Finally, the chapter by Dr. Peter M. Marzuk, “Violence and Suicidal Behavior: What Is the Link?” paves the way toward further understanding of the relationship between violent and self-destructive behavior, a link that needs to be explored more thoroughly.

In summary, this is an excellent book on a very important topic that covers the relevant issues as well as I have seen in one volume. It is essential reading for all psychiatrists working in the forensic field because it offers a wide range of understanding in a forensic psychiatric context. For all other psychiatrists, it is an important book to read to understand the risks involved in assessing and treating violent patients.