farlighetsvurdering v-risk-10
DESCRIPTION
En kort gjennomgang av momenter i en 10 punkts klinisk psykiatrisk farlighetsvurdering - V-Risk-10TRANSCRIPT
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Du vil huske 7 % av det jeg sier i dag
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Farlig?
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Tidligere og/eller aktuell
vold?
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Tidligere og/eller aktuelle trusler?
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Drept på sitt kontor
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Norge
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http://img294.imageshack.us/img294/9288/traispottinglt8.png
Rus
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Omfang av bruk av rusmidler i Norge
Representativt utvalg av personer over 15 år
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Psykiatrisk belastning blant stoffmisbrukere
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6 % psykisk upåfallende
Meta- undersøkelsen fra Cochrain
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65-85 % Personlighetsforstyrrelser
Meta- undersøkelsen fra Cochrain
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30-60% depresjon og angst
Meta- undersøkelsen fra Cochrain
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Psykoser 10-15 %
Meta- undersøkelsen fra Cochrain
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Hvorfor overopphopning av
rusproblematikk blant psykisk
syke ?
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RusmidlerNikotinAlkoholBenzodiazepinerCannabisAmfetamin og lignendeKokainMDMA (Ecstasy)LSD og andre
hallusinogener GHB og GLBHeroin og andre opiaterBarbituraterAnticholinergikaLøsemidler
Gir endret mental tilstandHar potensial for avhengighet
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Rusmiddlenes effekt
AffektmodulerendeAnxiolytikaHypnotika
Persepsjons-nedsettendeDemping av
sanseapparatet
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Akutte rusmiddeleffekterModifisert fra Jørg Mørland, Nfhi
Forskjellige hjernesystemer
Mesolimbisk-kortikaleDopaminerge systemer
Søvn
Ataxi
Sedering
Anxiolyse
Analgesi
Hypertermi
Autonome effekter BelønningEufori
”Behag”
SalienceMotivering
”Trang/ønske”
Substans-spesifikke
effekter
Felles effekter
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Affektmodulerende
Hadde alkohol vært oppført i felleskatalogen, hadde det stått under anxiolytica og hypnotika
De fleste rusmidlene har denne effekten
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Belønning
Symptomlindring
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Forverring?
Positive symptomer
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Økte symptomer
Løpe etter -> Doseøkning
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Problemer koblet til rusmiddelbruk hos pasienter med psykotisk lidelse
Forverring av
symptomer
Hyppigere
reinnleggelser
Øket suicidalitet (Drake og Wallach 1989, Linszen et al. 1994, Gupta et al. 1996, Dixon 1999, Salyers og Mueser 2001, Hunt et al. 2002).
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Oftere nødvendig å øke dosen av antipsykotika for å oppnå stabil fungering
Nikotin svekker effekten av antipsykotika
Påfølgende øket risiko for bivirkninger
(Zaretsky et al. 1993, Linszen et al.1994, Owen et al. 1996, Hunt et al. 2002).
Problemer koblet til rusmiddelbruk hos pasienter med psykotisk lidelse
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ÅRSAKSMODELLER
Rusutløst psykose (rus psykose)
Selvmedisineringsmodell (schiz. rus)
Sårbarhetsmodell (rus schiz.)
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”uhensiktsmessige måter å regulere følelser, atferd og forholdet til andre mennesker på…”
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Manglende innsikt
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Psykologisk forsvar
benektning
forskyvning split-ting
Dermed vanskelig å regulere senere atferd
http://slaine.deviantart.com/art/NEREIDA-806761
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Definisjon av aggresjon
Fysisk skadeIntensjonOffer vil unngå skade
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Definisjon av vold
”Aggressiv atferd innrettet på å påføre alvorlig fysisk skade”
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Prediksjon av Prediksjon av voldvold
Er det Er det mulig?mulig?
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Kliniske faktorer
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Dissosiert menneskesyn – mangel på empati
Andre mennesker er som kulisser – den følelsesmessig tilknytning blir borte.
Mennesker er enten ”Nyttige” eller ”Unyttige”
http://www.bymichaelo.com/crocodile.htm
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Finnes det en sammenheng mellom psykotiske symptomer og voldsatferd?
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Imperative
voldsfremmende
hørselshallusinasj
oner
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Emosjonelt ubehag ser ut til å øke risikoen for at pasienten skal handle i samsvar med forfølgelsesvrangforestillinger
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Innvasive, paranoide vrangforestillinger
49http://fc01.deviantart.com/fs22/f/2007/362/5/d/Deliverance_of_amity_by_alexiuss.jpg
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Redsel for tap av kontroll
andre har herredømme over deg
http://www.bymichaelo.com/plaything.htm50
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Misidentifikasjons-syndrom
en annen person har tatt
bolig i meg
Dobbeltgjenge
re
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Suicidal trusler
Suicidal forsøk
http://fc03.deviantart.com/fs15/f/2007/072/8/6/_by_mpedziwiatr.jpg
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Voldsrisiko hos psyk. pas.
Høyeste risiko: like før, under og like etter innleggelse
MVRAS: McArthur Violence Risk Assement Study
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Voldsrisiko hos psyk. pas.
Året etter avsluttet behandling:
Gradvis redusert risiko
MVRAS: McArthur Violence Risk Assement Study
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Voldsrisiko hos psyk. pas.
Over et år etter behandlingsslutt
= som i samfunnet for øvrig
MVRAS: McArthur Violence Risk Assement Study
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Voldsrisiko hos psyk. pas.
Offer: Familie & venner
(86%)
MVRAS: McArthur Violence Risk Assement Study
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Svikt i sosialt akseptabel selvhevdelse
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Resignasjon/apati i forhold til egen fremtid, særlig i kombinasjon med dødsangst
- fristilles i forhold til handlinger
http://fil.nrk.no/nyheter/kultur/1.4901142 59
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Voldsrisiko sjekkliste
V-RISK-10
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V-RISK-10
Tidligere og/eller aktuell vold
Tidligere og/eller aktuelle trusler (verbale/fysiske)
Tidligere og/eller aktuelt rusmisbruk
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V-RISK-10
Tidligere og/eller aktuell alvorlig psykisk lidelse
Personlighetsforstyrrelse
Mangler innsikt i sykdom og/eller atferd
Mistenksomhet
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V-RISK-10
Viser manglende innlevelse (empati)
Urealistisk planlegging
Fremtidige stressituasjoner
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Farlig -og hva så?
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Klarhet
Hvem er risikovurderingen gjort for?
Hvorfor gjøres denne vurderingen nå?
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Risiko for hva? Tidsperiode?
Vurder risiko for andre, for seg selv og risiko for manglende egenomsorg
Vurder risiko på kort sikt (dager til uker), middels sikt (uker til mnd) og lang sikt (mnd opp til 1 år)
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Prosess
Obs statistikk vs. Individuell vurdering
Minimum 1, 5 timer
Minimum 2 møter
Innhent komparenter
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Å formidle resultatet
Relevante risikofaktorerRisikoformuleringRisiko håndteringsplan
Dato for revurdering - ”bør brukes innen”
Hvilke risikofaktorer som skal vurderes neste gang
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Hvilke 7 % av det jeg sa skal du
huske?
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www.hare.org/
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www.slideshare.net/superdoc
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www.bymichaelo.com