essay on mental illness and violence

The Association Between Mental Illness and Violence

• First Online: 04 May 2019

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• Lia Ahonen 2  

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This chapter reviews previous empirical research results investigating the association between mental illness and violence . Over the last several decades, the USA has suffered from a large number of mass shootings , and more often than not, mental illness is blamed. Mental illness can explain only a very small fraction of general violence , however, and even less specifically for gun violence . Only a few specific mental disorders can be associated with violence , most commonly first-episode psychosis, and schizophrenia with positive symptoms such as hallucinations and command delusions. The most common diagnosis in the USA, depression, is not associated with violence except in the rare cases in which psychosis is presented. The chapter concludes with a discussion about the duty to report, access to health care, and help-seeking.

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Ahonen, L. (2019). The Association Between Mental Illness and Violence. In: Violence and Mental Illness. SpringerBriefs in Criminology. Springer, Cham. https://doi.org/10.1007/978-3-030-18750-7_4

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Introduction

Violence and mental illness.

Swanson, Jeffrey W. PhD; Special Issue Editor

From the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, DUMC 3071, Durham, NC 27710. Email: [email protected] . The present work was supported by a grant to Duke University from the Elizabeth K. Dollard Charitable Trust.

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• http://orcid.org/0000-0002-6426-4051 Mohit Varshney ,
• Ananya Mahapatra ,
• Vijay Krishnan ,
• Rishab Gupta ,
• Koushik Sinha Deb
• Department of Psychiatry and National Drug-Dependence Treatment Centre (NDDTC) , All India Institute of Medical Sciences (AIIMS) , New Delhi , India
• Correspondence to Dr Mohit Varshney, Department of Psychiatry and National Drug-Dependence Treatment Centre (NDDTC), All India Institute of Medical Sciences (AIIMS), New Delhi 110029, India; drmohitvarshney23{at}hotmail.com

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• MENTAL HEALTH
• PUBLIC HEALTH

Introduction

In public perception, mental illness and violence remain inextricably intertwined, and much of the stigma associated with mental illness may be due to a tendency to conflate mental illness with the concept of dangerousness. This perception is further augmented by the media which sensationalises violent crimes committed by persons with mental illness, particularly mass shootings, and focuses on mental illness in such reports, ignoring the fact that most of the violence in society is caused by people without mental illness. This societal bias contributes to the stigma faced by those with a psychiatric diagnosis, which in turn contributes to non-disclosure of the mental illness and decreased treatment seeking, 1 and also leads to discrimination against them. The association of violence and mental illness has received extensive attention and publicity. Public perception of the association between mental illness and violence seems to have fuelled the arguments for coerced treatment of patients with severe mental illness. 2 , 3

Definition and magnitude of the problem

There are numerous ways of conceptualising the definition of violence, although at present there is no consensus as to which of these is the most appropriate. The WHO has defined violence as ‘the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, mal-development or deprivation’. 5 This definition includes threats, intimidation, neglect and abuse (whether physical, sexual or psychological), as well as acts of self-harm and suicidal behaviour. Although expansive and all-encompassing, it defines violence in terms of its outcomes on health and well-being rather than its characteristics as a construct that is socially or culturally determined.

Studies investigating the prevalence of violence in psychiatric patients show a wide variability, in accordance with the treatment setting in which they were conducted. The lowest prevalence rates of violence have been seen in outpatient settings (2.3–13%), and the highest in acute care settings (10–36%) and involuntarily committed patients (20–44%). 6 Around 10% of the patients with schizophrenia or other psychotic disorders behave violently, compared with less than 2% of the general public. 7 Although this suggests that mental illness does contribute to the risk of violence, it is important to note that the 1-year population-attributable risk (PAR) of violence associated with serious mental illness alone was found to be only 4% in the ECA (Epidemiologic Catchment Area) survey. 8 This implies that even if the elevated risk of violence in people with mental illness is reduced to the average risk in those without mental illness, an estimated 96% of the violence that currently occurs in the general population would continue to occur. Although a statistical relationship with violence has been demonstrated in certain severe mental disorders such as schizophrenia, however, only a small proportion of the societal violence can be attributed to persons suffering from mental disorders. 9

The dynamic interaction of social and contextual factors with the clinical variables plays an important role as a determinant of violence. However, these issues have not generated sufficient interest and the emphasis continues to be on the psychiatric diagnosis or clinical variables of the patient, while looking for causal factors of violence.

Violent victimisation of the mentally ill

Patients with severe mental illness constitute a high-risk group vulnerable to fall victims to violence in the community. Symptoms associated with severe mental illness, such as impaired reality testing, disorganised thought processes, impulsivity and poor planning and problem solving, can compromise one's ability to perceive risks and protect oneself and make them vulnerable to physical assault. 10 , 11

Violent victimisation of persons with severe mental illness presents obvious dangers of physical trauma and impairs the quality of patients’ lives. Past traumatic and victimisation experiences have been found to be significantly associated with patients’ symptom severity and illness course. 12 However, this issue has attracted much less attention than violent behaviour by the patients, in spite of the fact that violent victimisation of patients occurs more frequently than violent offending by the patient. 6 , 13 , 14

A recent review reported that the prevalence of violent victimisation ranges between 7.1% and 56%, although the issue of comparability among the studies exists. 15 Young age, comorbid substance use and homelessness were found to be the risk factors for victimisation. 15 A relationship between victimisation and violent behaviour by patients with severe mental illness has also been suggested in numerous studies. 16 However, it is not clear whether past victimisation predicts future violence, or past violence predicts future victimisation, or both.

Predictors of violent behaviour

The relationship between mental illness and violence has been shown to be more complex than initially suspected. From viewing mental illness as a causative agent, researchers after reanalysing the NESARC (National Epidemiologic Survey on Alcohol and Related Conditions) data have confirmed that mental illness and violence are related primarily through the accumulation of risk factors of various kinds, for example, historical (past violence, juvenile detention, physical abuse, parental arrest record), clinical (substance abuse, perceived threats), dispositional (age, sex, etc) and contextual (recent divorce, unemployment, victimisation) among the mentally ill. 17 In fact, for those with mental illness without substance use, the relationship with violence was modest at best. 7

With the growing repertoire of risk assessment tools, mental health professionals are often expected to predict and manage violent behaviour, especially in an acute care setting. Diagnostically, aggressive behaviour has been linked to schizophrenia, mania, alcohol abuse, organic brain syndrome, seizure disorder and personality disorders. 18 Among patients in acute psychiatric settings, young age, male sex, history of psychiatric illness, comorbid substance abuse and positive symptoms have been shown as consistent predictors of violent behaviour. Among these, the history of violence is often emphasised as the most significant predictor of future violence. 19 However, overall, the identified risk indicators of violent behaviour have poor predictive validity, in the short-term and the long-term. Large epidemiological studies like the ECA study also found a substantially increased risk of violent behaviour specifically within particular demographic subgroups of participants: younger individuals, males, those of lower socioeconomic status and those having problems involving alcohol or illicit drug use. 8 These risk factors were statistically predictive of violence in people with or without mental illness.

Role of substance abuse

A number of longitudinal studies have investigated the relationship between specific substance use disorders and criminal or violent outcomes and found general association between substance abuse, crime and violence. 20 – 22 More than half of the individuals with schizophrenia and bipolar disorder have diagnosable alcohol and drug dependence. 23 The risk of violent behaviour has been found to be greater in patients with substance abuse comorbidity. 24 Similarly, in patients with bipolar disorder who have been violent offenders, the risk has been found to be mostly confined to patients with substance abuse comorbidity. 25 Co-occurring mental illness and substance abuse has also been shown to predict violence in the community samples. 26

Substance abuse also increases the risk of criminal victimisation in people with mental illness. A study of 1839 largely homeless patients using mental health services showed a statistically significant relationship between the number of days they were intoxicated and being robbed, threatened with a weapon or beaten. 27 In an Australian study of 962 individuals with psychosis, the odds of being a victim were increased in those who had a lifetime history of substance abuse. 28

Evidence for available treatment options

It is now well established that adequate treatment, including management of comorbid substance use, leads to better outcomes for patients with severe mental illness. This improvement lowers the risk of violence, even up to that seen in the general population. However, there is little evidence that any of the available antipsychotics have specific ‘antiaggressive’ properties, although clozapine may be superior to other drugs in this regard. 29 Antiepileptics have shown benefit in reducing aggression in persons with intellectual disability and seizure disorder, but their effectiveness for this indication in severe mental disorders is unproven. 30 Thus, the best possible strategy seems to be to the reduction in psychopathology and functional deficits.

Research and public health challenges

The assessment of violence-specific risk prediction in the past studies presents several limitations: unclear definition of violence, use of non-standardised scales for the evaluation of aggressive behaviour, non-homogeneous samples, absence of control groups and of prospective design in the majority of the studies. 31 These limitations might explain the heterogeneity of conclusions drawn by various studies, and particularly the wide variations in risk ratios for mental illness as a contributor to the violence. An attempt to resolve this heterogeneity is important from a public health perspective as the association of violence with mental illness hampers community reintegration of people with schizophrenia.

Also, most studies have primarily examined the association between violence and severe mental illness, for example, schizophrenia, in terms of relative risk (ie, the amount of risk posed by those with schizophrenia relative to others). However, there is a dearth of literature on indices of greater public health significance, such as PAR %: the percentage of violence in the population that can be ascribed to schizophrenia and thus could be eliminated if schizophrenia was eliminated from the population. 32 A shift of research focus from relative to attributable risk will help provide a more balanced picture and prevent unnecessary stigmatisation of people suffering from severe mental illness. Another major issue is that, since causality between mental illness and violent behaviour cannot be definitively determined, these indices need to take into account the various social-related, contextual-related and comorbidity-related factors which would act as confounders. Better ways are required for presenting risk magnitudes in a comprehensive manner.

The public health importance of resolving these issues is, to a certain extent, in disassociating mental illness from the concept of dangerousness. Any attempt to resolve these issues must begin with an acceptable operational definition of violence, and clear distinctions between various types (towards self/others, verbal/physical, intended/actual, etc) for more consistent and reliable reporting.

Additionally, studies of violence among people with mental illness must go beyond linking various conditions or categories with rates or severity of violence, and instead include a careful examination of contextual and comorbid factors, so that the complex patterns of confounding may be unravelled. It is only with such an understanding that the appropriate intervention(s) might be formulated, and provided to patients at an appropriate time and setting.

Evidence regarding the effectiveness of psychotropic drugs on violent behaviour as one of the treatment outcomes is not yet adequately researched. Moreover, investigating the effectiveness of specific psychotropic drugs on violent behaviour as an outcome is also riddled with numerous challenges. Although pharmacoepidemiological studies provide an opportunity to assess the effectiveness of psychotropic drugs in reducing incidence of violent behaviour, they are subject to a number of confounding factors. These studies have often failed to look into the individual, social, economic and contextual factors responsible for variability in the risk of violence in these patients. Similarly, randomised controlled trials to investigate the efficacy of drugs to reduce violence in particular are also mired with feasibility issues.

Violent patients are often difficult to recruit and the attrition rates are also high in such studies. Also, since the outcome has a lower rate of occurrence, the sample size of studies needs to be high. 30 Moreover, conducting such studies will pose an ethical dilemma as violence in a psychiatric patient is considered as an acute emergency, warranting immediate intervention.

Conclusions

The relationship between mental illness and violent behaviour has serious implications from a public health perspective. Since current evidence is not adequate to suggest that severe mental illness can independently predict violent behaviour, public efforts are required to deal with the discriminatory attitude towards patients suffering from mental illness as potential violent offenders. The role of medication in controlling violent behaviour along with the target symptoms needs to be further clarified. Also, the role of individual and contextual factors in mediating violence remains to be explored further, and appropriate intervention strategies need to be formulated.

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Competing interests None declared.

Provenance and peer review Commissioned; externally peer reviewed.

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The Mental Illness and Gun Violence Analysis Essay

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Introduction

The issue and suggested connections, media coverage, findings on the prevalence of violent actions, mass shootings and terrorism, the influence of stigma on mental health care, gun control laws, crime patterns, and social implications.

The analysis of criminality and people’s mental health contains not only the effect of inflicted harm on one’s mental stability but also the potential predisposition of people with mental illnesses towards violent behaviour. The recent portrayals of violent crimes against small or large groups of people have often mentioned mental illness as a characteristic that is prevalent among offenders (McGinty, Kennedy-Hendricks, Choksy, & Barry, 2016). This framing of criminals is used by the advocates of specific gun regulations in some countries.

They argue that the creation of a particular mental background check will lead to the reduced rate of violent crimes as people who may supposedly endanger others will be restricted from accessing firearms (Corner & Gill, 2015).

In states where gun control laws are strict, the connection between mental illness and violence is debated as well – this discussion can be focused on acts of violence and terrorism by individuals and groups (Corner & Gill, 2015). In this case, similar aspects of the stigma surrounding mental illness persist, including such characteristics as the lack of control and one’s aggressive tendencies. However, the question of whether mental illness has a direct link to violent behaviours remains underexplored by the public.

Scholarly research suggests that the stigma surrounding mental health and its correlation with gun violence and other crimes cannot be supported by evidence (McGinty et al., 2014a). While mental illness affects a person’s perception of the world, it does not determine one’s probability of engaging in crimes and does not always indicate the increased prevalence of violent behaviours.

The main problem in the current representation of the correlation between mental illness and crime is the opinion that people with mental health problems are more likely than others to engage in illegal activities. This idea may be expressed by the public and exacerbated by media, advocates, and other influential speakers (Varshney, Mahapatra, Krishnan, Gupta, & Deb, 2016). The debate surrounding this concept often leads to people recollecting the incidents of gun violence, mass shootings, and lone-actor terrorist activity as situations that were initiated by people with mental illnesses.

The idea that one’s criminal behaviour can be reassessed based on their mental health also lies at the core of the crime-related legislation. Thus, when discussing the gun selling industry, some people suggest that a background check of a buyer’s mental health history can be used to allow or restrict gun usage (Swanson et al., 2016). In order to evaluate the arguments supporting and opposing this viewpoint, it is necessary to address the media representation of this problem, the public opinion and stigma related to mental health, as well as statistics and scholarly findings that consider the discussed links. The relationship between violent behaviours and mental illness traits can also be considered to provide a possible way of reforming the coverage of this problem.

The basis of the discussed connection between crimes and mental illnesses is apparent in media coverage of illegal activities and some specific types of incidents. The primary example in which mental illness is used as the leading characteristic of an offender is the use of guns for lone-actor shootings and terrorist acts. It should be noted that the majority of the discussed situations occurred in the United States, although some recent accidents also happened in Europe and other countries.

According to McGinty, Webster, Jarlenski, and Barry (2014c), the prevalence of the offender being described as having a serious mental issue was substantial in stories covering gun violence. Similarly, McGinty et al. (2016) find that the use of this characteristic has greatly increased in the last fifteen to ten years. Thus, the framing of shooters as people with mental health problems became more popular than before in the media.

The effect of this coverage significantly alters the way the public views persons with mental illnesses. The stigma that surrounds people with depression, bipolar disorder, schizophrenia, and other conditions is now strongly associated with violence and lack of personal control, as well as sociopathic tendencies and failure to understand intimate boundaries (Swanson, McGinty, Fazel, & Mays, 2015a). As a contrast, according to research findings, individuals with mental illnesses are more likely to become targets of violent behaviour than its initiators (Monahan, Vesselinov, Robbins, & Appelbaum, 2017). Nonetheless, the developed viewpoint of mental health affects people’s perceptions about crime.

Many researchers have considered the correlation between violent behaviour (with the focus on shootings) and people with mental illnesses. Metzl and MacLeish (2015) point out that the public shares four main assumptions about this issue – a diagnosis of a mental illness can predict crimes, mental problems cause crimes, only mentally ill persons commit mass shootings, and these incidents cannot be prevented by gun control laws. These statements are included in the basis of many scholars’ hypotheses for researching the topic.

The findings of the mentioned above studies, however, do not agree with the public’s opinion. For instance, Swanson et al. (2016) discover that people with mental illnesses with access to firearms do not endanger other people as much as healthy individuals. On the other hand, they are more likely to endanger themselves due to mental health issues often being accompanied by suicidal ideations (Swanson et al., 2016).

Wintemute (2015) also states that mental illness does not contribute to violence towards others but is a serious factor in people’s rates of self-harm. The author argues that firearm ownership is one of the most prevalent factors in homicide cases (Wintemute, 2015). Therefore, the portrayal of the so-called “dangerous people” expressed in the media is in direct opposition to the statistics and scholarly findings.

The incidents that involve multiple victims or end in the attacker committing suicide are also often perceived through the lens of mental illness. Corner and Gill (2015) analyse the possibility of lone and group terrorists to have a mental disorder. They find that while individuals committing a terrorist crime alone are more likely to have mental health disturbances than terrorist group members, they also reveal that lone terrorists often act because of outside influence, stress, and prejudice (Corner & Gill, 2015). Therefore, the connection between criminality and mental illness is not direct – people’s behaviour is heavily influenced by other factors which may be linked to stigma or unrelated problems.

Studies about mass shooters also disparage the idea that these persons commit violent crimes due to having a mental health issue. Baumann and Teasdale (2018) conclude that the focus on mental illness is incorrect because people with mental problems and access to firearms constitute a more significant danger to themselves rather than society. The scholars urge the need to reframe the debate around mental illness and centre the discussion on the protection of persons with severe mental illness from harming themselves (Baumann & Teasdale, 2018). Whether these individuals possess a firearm or not, they can endanger themselves by not receiving proper treatment.

The problem of social barriers to accessing mental health care can also be noted in this discussion. The stigma supported by the media and the public can contribute to the individuals being reluctant to interact with health providers. According to Corrigan, Druss, and Perlick (2014), the problematic depiction of people with mental health issues as violent offenders puts people at risk of leaving their conditions untreated. This lack of care can result in individuals losing control of their cognitive abilities, experiencing chronic stress, and being unable to function in society. Therefore, one can suggest that such negative portrayal not only fails to encourage positive change but also exacerbates the problem and exposes more people to dangerous behaviours and self-harm.

These assumptions also impact the treatment of offenders with mental health issues. Skeem, Winter, Kennealy, Louden, and Tatar (2014) find that individuals with mental illnesses are more likely than others to be “brought back to prison custody” after parole (p. 212).

Moreover, the lack of treatment for these individuals is strongly correlated with the probability of recidivism. The scholars note that general factors such as antisocial behaviours and the lack of impulse control should be the main focus of recidivism prevention initiatives (Skeem et al., 2014). This argument notes that psychiatric therapy is not that crucial for everybody because offenders without mental illnesses possess social problems as well.

As a result, the discussed stigma also removes any distinctions between mental illness and aggression, conflating the two concepts and uniting them under one idea of uncontrolled behaviour. Swanson et al. (2015b) state that people who can become angry easily own firearms more often than others. This connection is found by the authors to be more significant than that including people with mental illnesses.

Moreover, they establish that only a small proportion of people with severe mental illnesses (such as serious forms of bipolar disorder and schizophrenia) tend to be violent towards others, while more than 95% of these individuals do not engage in any harmful behaviour (Swanson et al., 2015b). Other factors, including social isolation and substance abuse, contribute to the problem heavily, having a tangible impact on people both with and without mental health issues (Swanson et al., 2015b). The correlation between anger and mental illness that strongly affects the public perspective is, therefore, not supported by evidence.

People with mental health problems become victims of abuse or self-harm more often than perpetrators of crime. Monahan et al. (2017) find that violent victimisation of such persons by other individuals occurs in 43% of investigated cases, while violent behaviour is expressed in 28% and self-victimisation in 23% (p. 517). Furthermore, approximately half of the study’s participants were involved at least in one type of violence. The scholars discover a strong correlation between violent behaviours and the history of abuse, stating that respondents were victimised as children by family members and other individuals (Monahan et al., 2017). Thus, it is possible to assume that the presence of mental illness is not the only contributing factor to violent behaviours.

The mentioned above idea that people with mental illnesses are the main perpetrators of crime in such incidents as mass shootings and violent attacks affects the ways in which some countries change their legislature. In the US, this is one of the common arguments for gun ownership proponents – this viewpoint distinguishes responsible firearms owners and supports limited possession of arms for certain groups of people, while not inflicting any changes on others.

McGinty, Webster, & Barry (2014b) disagree with this argument, basing their opposition on statistical findings and stating that gun ownership is a more impactful contributor to gun-related violence than mental illness. The idea that a background checking procedure is effective in reducing crimes directly challenges the research about mental health and abuse.

Other factors can affect the rate of crimes more effectively than people’s mental health. One of them is the concept of “contagion” – the spread of information about previous mass killings (Towers, Gomez-Lievano, Khan, MMubayi, & Castillo-Chavez, 2015). Social pressure and the combination of contagion and frequent exposure to violent events may contribute to a person’s urge to commit crimes. Other causes include the mentioned above possession of firearms, substance abuse, and prior history of violence.

Gun ownership is highlighted by Wintemute (2015) as the prevalent contributor to gun-related violence. It is also a factor that elevates the rates of suicide with the use of firearms (Towers et al., 2015). This link suggests that gun ownership endangers people with and without mental illnesses and poses a more significant threat than mental health problems.

The media portrayal of people with mental illnesses has a prevalence of negative characteristics, linking mental health disturbances with criminal activity. The main ideas that the public possesses correlate mental illnesses and crime, posing the concept of a “dangerous person” as the main reason for mass shootings and terrorist attacks. Scholarly research opposes this ideology and shows the lack of connection between violent crimes and mental health. In fact, some studies reveal that people with mental illnesses often become the target of abuse rather than its perpetrators. The existence of statistical findings refutes the argument that aims to approve mental health background checks as the sole barrier to purchasing firearms.

Moreover, this point of view fails to acknowledge other contributors to crime, some of which have a significant impact on criminal events. Gun ownership, whether legal or illegal, is a factor that affects the rate of shootings substantially. Other reasons include substance abuse and personality traits such as anger and aggressiveness. It should be noted that one’s personality should not be conflated with the existence of mental illness. The lack of social interaction and the inability to relate to other people’s emotions also should not viewed only as mental health problems.

The discrepancy in proposed viewpoints and scholarly findings suggests that mental illness remains to be stigmatised since it is linked to violence and lack of self-control. The debate about firearms in such countries as the US and the focus on mental illness as the main contributor to violent offences hinders the effectiveness of health care services and stops people from seeking professional assistance. More than that, it contributes to offenders with mental health issues having problems with receiving parole or asking for support after being freed. The connection between crime and mental health is indirect in cases where people with mental illnesses act as perpetrators.

Baumann, M. L., & Teasdale, B. (2018). Severe mental illness and firearm access: Is violence really the danger? International Journal of Law and Psychiatry , 56 , 44-49.

Corner, E., & Gill, P. (2015). A false dichotomy? Mental illness and lone-actor terrorism. Law and Human Behavior , 39 (1), 23-34.

Corrigan, P. W., Druss, B. G., & Perlick, D. A. (2014). The impact of mental illness stigma on seeking and participating in mental health care. Psychological Science in the Public Interest , 15 (2), 37-70.

McGinty, E. E., Frattaroli, S., Appelbaum, P. S., Bonnie, R. J., Grilley, A., Horwitz, J.,… Webster, D. W. (2014a). Using research evidence to reframe the policy debate around mental illness and guns: Process and recommendations. American Journal of Public Health , 104 (11), e22-e26.

McGinty, E. E., Kennedy-Hendricks, A., Choksy, S., & Barry, C. L. (2016). Trends in news media coverage of mental illness in the United States: 1995–2014. Health Affairs , 35 (6), 1121-1129.

McGinty, E. E., Webster, D. W., & Barry, C. L. (2014b). Gun policy and serious mental illness: Priorities for future research and policy. Psychiatric Services , 65 (1), 50-58.

McGinty, E. E., Webster, D. W., Jarlenski, M., & Barry, C. L. (2014c). News media framing of serious mental illness and gun violence in the United States, 1997-2012. American Journal of Public Health , 104 (3), 406-413.

Metzl, J. M., & MacLeish, K. T. (2015). Mental illness, mass shootings, and the politics of American firearms. American Journal of Public Health , 105 (2), 240-249.

Monahan, J., Vesselinov, R., Robbins, P. C., & Appelbaum, P. S. (2017). Violence to others, violent self-victimization, and violent victimization by others among persons with a mental illness. Psychiatric Services , 68 (5), 516-519.

Skeem, J. L., Winter, E., Kennealy, P. J., Louden, J. E., & Tatar, G. R., 2nd. (2014). Offenders with mental illness have criminogenic needs, too: Toward recidivism reduction. Law and Human Behavior , 38 (3), 212-224.

Swanson, J. W., Easter, M. M., Robertson, A. G., Swartz, M. S., Alanis-Hirsch, K., Moseley, D.,… Petrila, J. (2016). Gun violence, mental illness, and laws that prohibit gun possession: Evidence from two Florida counties. Health Affairs , 35 (6), 1067-1075.

Swanson, J. W., McGinty, E. E., Fazel, S., & Mays, V. M. (2015a). Mental illness and reduction of gun violence and suicide: Bringing epidemiologic research to policy. Annals of Epidemiology , 25 (5), 366-376.

Swanson, J. W., Sampson, N. A., Petukhova, M. V., Zaslavsky, A. M., Appelbaum, P. S., Swartz, M. S., & Kessler, R. C. (2015b). Guns, impulsive angry behavior, and mental disorders: Results from the National Comorbidity Survey Replication (NCS-R). Behavioral Sciences & the Law , 33 (2-3), 199-212.

Towers, S., Gomez-Lievano, A., Khan, M., Mubayi, A., & Castillo-Chavez, C. (2015). Contagion in mass killings and school shootings. PLoS One , 10 (7), e0117259.

Varshney, M., Mahapatra, A., Krishnan, V., Gupta, R., & Deb, K. S. (2016). Violence and mental illness: what is the true story? Journal of Epidemiology and Community Health , 70 (3), 223-225.

Wintemute, G. J. (2015). The epidemiology of firearm violence in the twenty-first century United States. Annual Review of Public Health , 36 , 5-19.

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IvyPanda. (2020, December 24). The Mental Illness and Gun Violence Analysis. https://ivypanda.com/essays/the-mental-illness-and-gun-violence-analysis/

"The Mental Illness and Gun Violence Analysis." IvyPanda , 24 Dec. 2020, ivypanda.com/essays/the-mental-illness-and-gun-violence-analysis/.

IvyPanda . (2020) 'The Mental Illness and Gun Violence Analysis'. 24 December.

IvyPanda . 2020. "The Mental Illness and Gun Violence Analysis." December 24, 2020. https://ivypanda.com/essays/the-mental-illness-and-gun-violence-analysis/.

1. IvyPanda . "The Mental Illness and Gun Violence Analysis." December 24, 2020. https://ivypanda.com/essays/the-mental-illness-and-gun-violence-analysis/.

Bibliography

IvyPanda . "The Mental Illness and Gun Violence Analysis." December 24, 2020. https://ivypanda.com/essays/the-mental-illness-and-gun-violence-analysis/.

MSU Extension 4-H Healthy Youth

Msu extension supports youth mental health while working to stop school violence.

Jamie Wilson <[email protected]> , Michigan State University Extension - September 04, 2024

MSU Extension is working to improve outcomes for youth facing mental health challenges, working with high schools and youth serving organizations in eight different counties to deliver mental health training to more than 620 individuals.

Across the U.S., youth mental health challenges have led to crippling consequences for individuals, families and communities. In Michigan, Michigan State University Extension is working to improve outcomes for youth facing these challenges, thanks in part to a three-year, $1.55 million grant from the U.S. Office of Juvenile Justice and Delinquency Prevention. Since launching the grant in 2023, MSU Extension has worked with high schools and youth serving organizations in eight different counties to deliver mental health training to more than 620 individuals.

“So many youth are struggling with mental health challenges, be that stress, anxiety, depression or something else” explained Frank Cox, MSU Extension 4-H youth educator based in Muskegon County and principle investigator on the grant. “Our goal is to equip youth and the adults that work with them with the skills they need to identify those in a mental health crisis and learn how to best support them.”

To achieve this, MSU Extension has partnered with the  National Center for School Safety  (NCSS) for  the Bringing Mental Health First Aid to Students, Teachers, and Officers Preventing (STOP) School Violence  grant. Located at the University of Michigan, NCSS seeks to improve school safety and prevent school violence. By teaching youth and educators how to help youth decompress and address mental health challenges, the grant seeks to achieve the long-term goal of reducing incidents of school violence.

“Not knowing how to effectively cope with feelings of anger, isolation, depression, substance misuse or mental health challenges can lead youth to contention and even devastating outcomes,” said Kea Norrell-Aitch, co-investigator on the grant and MSU Extension healthy living educator based in Macomb County. “Our program helps others learn how to identify teens on the verge of or in the midst of a crisis and connect them to the support that is needed.”

Through the STOP grant, MSU Extension and NCSS are working to build a statewide, community-based infrastructure of Mental Health First Aid responders. Mental Health First Aid  is an international, evidence-based training that teaches participants how to recognize the signs and symptoms of a mental health crisis and help someone who may be experiencing one. Grounded in messages of hope and recovery, this program helps break down the misinformation surrounding mental health and helps trainees understand how they can play a role in the “first response” to mental health challenges. As part of the grant, MSU Extension teaches Youth Mental Health First Aid to adults working with youth, as well as teen Mental Health First Aid to teens themselves.

“By training teenagers, as well as their teachers, school staff, and others in their daily lives how to recognize and support someone facing a mental health challenge, we are creating a first line of support for the mental health crisis,” said Darien Wilkerson, an MSU Extension 4-H healthy living educator based in Genesee County, who supports the grant. “These individuals can play a pivotal role in helping people in crisis and those just needing some extra support.”

In particular, Youth and teen Mental Health First Aid curricula introduces common mental health challenges for youth, reviews typical adolescent behavior, and teaches a five-step action plan for help to young people in crisis and non-crisis situations. The five-step plan uses the acronym ALGEE to help those in need:  A ssessing for risk of suicide or harm,  L istening nonjudgmentally,  G iving reassurance and information,  E ncouraging appropriate professional help, and  E ncouraging self-help and other support strategies. To date, MSU Extension has delivered Youth Mental Health First Aid to 118 individuals who serve youth audiences and teen Mental Health First Aid to 506 Michigan youth as part of the STOP grant.

“The impact that these Mental Health First Aid responders will have as a result of their training is really immeasurable,” said Cox. “They may help a student, a friend, a classmate or even themselves avoid hurting themselves or others and that is invaluable.”

The work of MSU Extension and NCSS is not over yet. They will continue to train additional professionals and peers across the state throughout the remainder of the grant, with a goal of serving 1,200 students. To inquire about bringing this program to your school or youth organization, contact Norrell-Aitch at [email protected] . Learn more about Mental Health First Aid at the program website . Visit the 4-H Healthy Youth website to learn more about 4-H healthy living programs for youth.

This article was published by Michigan State University Extension . For more information, visit https://extension.msu.edu . To have a digest of information delivered straight to your email inbox, visit https://extension.msu.edu/newsletters . To contact an expert in your area, visit https://extension.msu.edu/experts , or call 888-MSUE4MI (888-678-3464).

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The Declining Mental Health of the Young in the UK

We show the incidence of mental ill-health has been rising especially among the young in the years and especially so in Scotland. The incidence of mental ill-health among young men in particular, started rising in 2008 with the onset of the Great Recession and for young women around 2012. The age profile of mental ill-health shifts to the left, over time, such that the peak of depression shifts from mid-life, when people are in their late 40s and early 50s, around the time of the Great Recession, to one’s early to mid-20s in 2023. These trends are much more pronounced if one drops the large number of proxy respondents in the UK Labour Force Surveys, indicating fellow family members understate the poor mental health of respondents, especially if those respondents are young. We report consistent evidence from the Scottish Health Surveys and UK samples from Eurobarometer surveys. Our findings are consistent with those for the United States and suggest that, although smartphone technologies may be closely correlated with a decline in young people’s mental health, increases in mental ill-health in the UK from the late 1990s suggest other factors must also be at play.

David G. Blanchflower and Alex Bryson would like to thank the Human Development Report Office, United Nations Development Programme for support. The copyright for all research commissioned by the Human Development Report Office will be held by UNDP. We thank the ESRC Data Archive for access to the data. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.

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Violence and Mental Illness

Marie e. rueve.

Dr. Rueve is Staff Psychiatrist, Twin Valley Behavioral Healthcare and Assistant Clinical Professor, Wright State University, Boonshoft School of Medicine, Dayton, Ohio

Randon S. Welton

Dr. Welton is with Wright State University—Wright Patterson Medical Center, Dayton, Ohio.

Violence attracts attention in the news media, in the entertainment business, in world politics, and in countless other settings. Violence in the context of mental illness can be especially sensationalized, which only deepens the stigma that already permeates our patients’ lives. Are violence and mental illness synonymous, connected, or just coincidental phenomena? This article reviews the literature available to address this fundamental question and to investigate other vital topics, including etiology, comorbidity, risk factor management, and treatment. A psychiatrist who is well versed in the recognition and management of violence can contribute to the appropriate management of dangerous behaviors and minimize risk to patients, their families, mental health workers, and the community as a whole.

Introduction

In society today, mental illness and violence are often seen as inextricably linked, creating a harsh stigma for patients and, at times, an uncomfortable environment for psychiatrists. The perception carries serious consequences for psychiatric patients in the form of further discrimination and a sense of isolation from society. Violence has become of increasing concern in the practice of psychiatry. A large number of aggressive patients present to emergency departments, 1 and psychiatrists are often called on to assess and treat violent patients. Thousands of assaults occur in American hospitals each year, including psychiatric units and emergency rooms, resulting in the labeling of such workplaces by some as occupationally hazardous. 2 The literature suggests that psychiatrists have a 5- to 48-percent chance of experiencing a physical assault by a patient during their career, 3 and that 40 to 50 percent of psychiatry residents will be physically attacked by a patient during their four-year training program. 4 This type of patient implies specific challenges for the diagnosis and treatment of psychiatric disorders and their violent presentations, as the mental health provider is asked to identify potentially dangerous individuals and to intervene to reduce risk.

This article will help to clarify what, if any, link exists between mental illness and violence and to delineate the role of the mental health provider in addressing violent behavior.

Violence and Mental Illness: the Scope of the Problem

General population.

Swanson, et al., 5 noted that 3.7 percent of the general US population perpetrates one or more violent acts each year, and the lifetime prevalence of aggressive behavior in the community may be as high as 24 percent. According to the Centers for Disease Control (CDC), 17,357 homicides occurred in 2004, making it the 15th leading cause of death and yielding a death rate by violence for the year of 5.9 per 100,000. 6 Among women and men under 45 years of age, those in the lowest socioeconomic class were three times more likely to be violent than those in the highest socioeconomic class. Rates of violence also increased with lower education level, less social stability, and in regions with high rates of unemployment. 7

Mentally ill population

Most patients with stable mental illness do not present an increased risk of violence. Asnis, et al., 8 found that 21 of 517 outpatients (4%) in an urban setting reported a history of homicide attempts. Steadman and colleagues 9 followed several cohorts of recently discharged American psychiatric patients for one year and compared rates of violence with violence rates in a community sample in the same neighborhood. The mean number of violent acts among the discharged psychiatric patients was 1.6 acts per discharged patient per 10-week period; at 50 weeks, the average number of acts per patient was 2.12. The rate of violence among psychiatric patients was higher than the community sample only during the first 10 weeks after discharge. Steadman and colleagues concluded that rates of violence among mental health patients peak at time of admission to the hospital, and they remain high for a period after discharge when many patients still experience active psychiatric symptoms.

Mental illness may increase the likelihood of committing violence in some individuals, but only a small part of the violence in society can be ascribed to mental health patients. 10 Overall, those psychiatric patients who are violent have rates of repeated aggression somewhere between the general population and a criminal cohort. 11

Criminal population

Numerous studies have shown significant rates of mental illness in criminal populations. In 1998, 283,000 mentally ill persons were listed in the US penal system. In surveys, 16 percent of state prison inmates, 16 percent of local jail inmates, and seven percent of federal prisoners self-reported a previous mental health diagnosis or overnight stay in a psychiatric facility 12 Teplin 13 analyzed a random sample of 627 male arrestees and found the prevalence of mental illness to be almost three times that of the general population. Among the sample, the most common diagnoses were substance use disorders and personality disorders. Wallace 14 found that 36 percent of convicted Australian killers had participated in psychiatric treatment at some point before their offense, most of which again was for personality disorders and substance abuse.

These studies often are not, however, able to reliably determine that the mental illness is a preexisting factor that is directly responsible for the examined criminal behaviors. It is very likely, based on clinical experience, that mentally ill patients frequently encounter barriers to treatment, and that this inadequate treatment of their disorders results in patients being arrested for both violent and nonviolent crimes. Often such charges are based on behaviors that are direct manifestations of the patients’ then untreated symptoms, such as paranoia leading to trespassing or grandiosity resulting in breaking and entering. The crimes examined here may or may not be violent in nature. Experience also suggests that victims of crimes by mentally ill individuals are often known to the patient, unlike nonpsychiatrically ill criminals who may or may not violate strangers.

It is also unclear in this body of literature whether the crimes for which perpetrators are convicted involve illegal activities with drugs of abuse; crimes and diagnoses related to substance dependence exclusively may speak to a different issue than the link between violence and mental illness. On the other hand, in viewing comorbid substance dependence and mental illness as dually diagnosed disorders, drug-related crime may not require separate treatment. Substance dependence certainly impairs judgment further and increases the likelihood of violent activity, as discussed later.

Further highlighting such issues, Hodgkins, et al., 15 cross-referenced data on convictions and psychiatric hospitalizations among 350,000 persons from Scandinavian countries born between 1944 and 1947 and found that those with a previous psychiatric hospitalization were more likely to be convicted of a crime. In a review of 13 studies published between 1965 and 1989, Link, et al., 16 found that mental health patients were three times as likely to be arrested as the general population. Steadman and Cocozza, 17 in their review of violent behavior in criminally insane subjects, stated that virtually all violent offenses attributed to released psychiatric patients were committed by those who had criminal records preceding their hospitalization.

Studies have also examined the differences in psychiatric conditions between offenders who began committing crimes earlier versus later in life. Tengstrom 18 demonstrated that individuals who commenced criminal activity earlier in life also had earlier psychiatric admissions. Early offenders were convicted of more offenses, committed crimes of a more violent nature, showed higher rates of recidivism, and were more likely to have a substance use disorder and evidence of psychopathy. These investigations again do not differentiate between stable and unstable mental illnesses, and they do not address causation.

Etiology of Violence

Patients who are violent are not a homogenous group, and their violence reflects various biologic, psychodynamic, and social factors. Most researchers and clinicians agree that a combination of factors plays a role in violence and aggression, although there are differing opinions regarding the importance of individual factors.

Biologic factors

A family history of violence constitutes a major discriminator between violent and nonviolent individuals. 19 Violence is likely a polygenetic phenomenon, with many genes acting in a coordinated fashion to produce an aggressive phenotype. 20 There is no evidence that there is a specific genetic locus, and it is unknown whether a family history of violence signifies genetic transmission or learned behavior. Nielson, et al., 21 found preliminary evidence that a disturbance in coding for tryptophan hydroxylase, the rate-limiting enzyme in serotonin synthesis, was found in patients with impulsive aggressive behavior. More recently, a polymorphism in the catechol O-methyltransferase gene on chromosome 22q has been associated with significantly higher levels of hostility in schizophrenic patients. 22 Having a family history of antisocial personality disorder has been shown to increase the risk for development of conduct disorder, aggression, and antisocial behavior in children. 23 Eronen and colleagues 24 further noted that a family history positive for homicidal ideation and attempts was associated with extreme aggressive acts.

Twin studies have looked at the concordance rates for violence among twins as compared to the general population. Connor, et al., 25 studied bullying behavior in younger middle class children and discovered a concordance rate for monozygotic twins of 0.72 and for dizygotic twins of 0.42, indicating that 60 percent of the variance in bullying behavior is due to genetic variation.

Cadoret and colleagues 26 examined children who had a biological family history of antisocial personality disorder who were adopted into either stable or pathologic homes. They determined the highest incidence of aggression and conduct disorder occurred in children who had both the family history of antisocial behavior and were placed in disturbed adoptive homes, further confirming the suspicions among clinicians that violence has both genetic and environmental components.

Neurotransmitters

Researchers have focused on neurotransmitter involvement in a pathological model of aggression, directed by studies of suicidal patients and trials using different psychotropic medications in the treatment of violent patients. Investigators have determined that a low concentration of 5-hydroxyindoleacetic acid (5-HIAA), a metabolite of serotonin, in cerebrospinal fluid (CSF) is associated with an increased propensity for aggressive acts in psychiatric patients. 27 Brown and colleagues 28 also recognized this inverse correlation between 5-HIAA concentrations and a lifetime history of aggression, expressly in personality-disordered patients. Other studies repeated this finding in different populations, including impulsive murderers, arsonists, individuals who had committed infanticide, and suicidal patients. Stanley, et al., 29 examined 64 nonsuicidal patients with various diagnoses and classified them based on a six-item history of adult aggressive behavior (aggressive, n =35; nonaggressive, n =29). The authors demonstrated that the aggressive group had significantly lower 5-HIAA concentrations in CSF than the nonaggressive group. 29

Laboratory-based experiments have shown that neurochemical interventions decreasing central serotonin functioning are linked with an increase in aggressive behavior in animals. 30 Studies with mice that have the 5-HT1B receptor gene knocked out demonstrate aggressive behavior compared to wild type mice. 31 As human platelets and the human brain have identical serotonin transporters and receptors, platelet studies have shown that aggressive children with conduct disorder appear to have fewer 5-HT binding sites, suggestive of a reduced responsiveness of serotonin receptors in these children. 30

Depue and Spoont 32 noted that mesolimbic dopamine pathways affecting responses to the environment have a role in promoting aggression. They suggest that increasing dopamine in these pathways enhances irritability and subsequent aggression. 32 Subjects receiving drugs that increase norepinephrine activity in the central nervous system (CNS) showed increased aggression. Additionally, beta (β)-blockade in rats, decreasing norepinephrine availability, initially decreased fighting behaviors. As β receptors were up-regulated, fighting behaviors returned. Studies have also indicated that gamma-amino butyric acid (GABA) may have an inhibitory effect on aggressive behavior, although the evidence is inconclusive. 33

Neuroimaging

Advances in imaging of the brain have revealed preliminary data on regions and circuitry that may be involved in violence and aggression, both of impulsive and predatory types. 34 Prior to 2005, all 10 studies that investigated changes on single-photon emission computed tomography (SPECT) and positron emission tomography (PET) imaging in violent individuals found deficits in either prefrontal or frontal functioning, suggesting problems in executive functions and interpreting environmental stimuli as threatening or safe. 34 These reports examined both patients with various diagnoses and healthy controls. It must be noted, however, that frontal hypometabolism has been associated with a range of psychiatric conditions, including schizophrenia, without specification for violent patients. PET scanning in 41 subjects indicted for homicide found significantly lower levels of glucose metabolism in the prefrontal cortex and corpus callosum, as compared to matched controls, also suggesting that the ventral prefrontal cortex plays an important role in the control of impulsive urges, including aggression. 35 Other imaging studies focusing on the temporal lobe reported dysfunction in temporal lobe activity, particularly in subcortical structures such as the amygdala, hippocampus, and basal ganglia. 34 These regions are involved in fear and danger responsiveness, and they are dense in serotonin receptors, indicating that dysfunction in these regions may disrupt serotonin activity. 34

Narayan and colleagues studied 56 total subjects, including patients diagnosed with antisocial personality disorder or schizophrenia as well as a control group. With structural magnetic resonance imaging, they demonstrated that violent behavior was associated with thinning in various areas of the cortex, which differed in the schizophrenic and antisocial patients, as compared to the controls. 36 Other studies, focusing on personality-disordered patients, identified a significant decrease in glucose metabolism in the frontal cortex among those with aggressive tendencies. 33 Further evidence suggests that the limbic system is involved in the production of aggression. Specifically, stimulation of the amygdala in animals has resulted in rage attacks. 37

Psychophysiology

The association of physiologic markers and conditions such as aggression and antisocial personality disorder is an interesting area of study. Fourteen studies have examined the resting heart rate in young outpatients with antisocial personality disorder, and all found significantly lower resting heart rates in the antisocial cohorts, compared to controls. 38 Such findings are thought to propose a common under-arousal state among antisocial subjects. Investigators have found abnormalities on electroencephalography (EEG) in 25 to 50 percent of violent criminals studied. 39 Patrick and colleagues 40 conducted an examination of startle-blink measures, defined as muscle contraction around the eyes in response to a startling stimulus, in criminals with high versus low emotional detachment. They found that the high detachment group, which included antisocial individuals, displayed reduced startle-blink measurements, possibly representing decreased anxiety responses to stimuli. 40

Individual psychosocial factors

Because a biologic-environmental interaction is likely responsible for violence and aggression, careful attention must be paid to psychosocial factors that contribute to the development of violent behaviors. Psychodynamic theory proposes that aggression is a reaction to the blocking of libidinal impulses. It further asserts that aggression can result from the projection of self-destructive impulses, or death instinct, onto external objects. 37 Impulsive aggression may be a direct response to the individual’s perception of deprivation or punishment, and is often coupled with feelings of frustration, fear, injustice, and anger. 33 Beck 41 asserts that aggressive individuals develop a cognitive framework containing basic flaws in perceptions of social interactions, so that the individual sees others as responsible for all of his or her problems.

Social learning theory offers that violent behavior is a product of past experiences, which involved predisposing environmental conditions and reinforcing rewards. Pervasiveness of violent images in the media may desensitize viewers to violence. 37 Swanson and colleagues 42 identified multiple factors in the environment that were significantly associated with violence, including homeless and witnessing or experiencing violence.

That same desensitization and the importance of past experiences are displayed in a number of studies finding that a family history of violence is predictive of violent behavior. 43 Green and Kowalick 20 noted that variables such as parental hostility, maternal permissiveness, and absence of maternal affection could predict subsequent antisocial behaviors. Other psychosocial factors may include abuse as a child, poor parental modeling, limited social supports, and poor school experiences. 4 Conversely, increased family contact, especially if fraught with conflict, can prompt aggression and violent acts. Elbogen and colleagues assessed 245 severely mentally ill patients discharged on an outpatient commitment for one year and discovered that high family contact and family representative payeeship increased the predictive probability of family violence, after controlling for covariates such as violence history and substance abuse. 44

In examining violent youth, Steinburg and colleagues 45 suggest that, through violence, adolescents may be able to obtain financial reward, feel powerful, and protect themselves in threatening environments. Other contributing factors specific to hate crimes in youth include frustration, boredom, and erroneous learned ideas that certain victims are appropriate targets for violence. Another study examined physically assaultive adult inpatients ( n =238) diagnosed with major mental illnesses and discovered a higher prevalence of school truancy and foster home placement in the violent group, compared to a nonviolent control group. 46

Diagnoses Associated with Violence

Substance use disorders.

Substance use disorders have been proven to vastly increase the risk of a violent incident. Holcomb and Ahr 47 found that patients with alcohol or drug use had more arrests over their lifetime than patients with schizophrenia, personality disorders, or affective disorders. Eronen, et al., 24 discovered that the combination of alcoholism and antisocial personality disorder increased the odds of women committing homicide 40 to 50 fold, while the diagnosis of schizophrenia increased the risk only 5 to 6 fold. Steadman and colleagues 9 determined that patients with concomitant mental illness and substance abuse were 73 percent more likely to be aggressive than were nonsubstance abusers, with or without mental illness. Further, patients with primary diagnoses of substance use disorders and personality disorders were 240 percent more likely to commit violent acts than mentally ill patients without substance abuse issues. 9

Intoxication or withdrawal from various substances of abuse, including alcohol, sedatives, cocaine, amphetamines, and opiates, can promote violent behaviors, with or without comorbid mental illness ( Table 1 ). 48 In a study of 59 psychiatric inpatients, Blomhoff, et al., 43 determined that abuse of nonalcoholic psychoactive substances was one of only three significant demographic and clinical variables differentiating the violent group from the nonviolent group. Swanson and colleagues 5 noted that substance abuse was by far the most prevalent diagnosis among survey responders reporting past violent acts. Substance abuse was present in 42 percent of violent responders and in only five percent of nonviolent responders. In addition, female substance abusers were equally as violent as male substance abusers. In this study, substance abusers also demonstrated a greater propensity to assault more than one victim and to use a weapon during a violent incident. Of those who acknowledged alcoholism, 25 percent reported a history of violence. 5 Over and above these acute factors, chronic alcoholism is more predictive of violence than is immediate alcohol use. 4

Substances of abuse that promote violence

Substance abuse also plays a significant role in domestic violence. In their synopsis of this topic, Rudolph and Hughes 49 denoted that the strongest single predictor of injury to a victim of domestic assault is a history of alcohol abuse in the perpetrator. In addition, up to 45 percent of female alcoholics and 50 percent of female drug abusers have been battered. The most predictive factor for elder abuse was also found to be alcohol abuse in the caregiver. 49

Other psychiatric disorders

Psychiatric disorders associated with violence are wide-ranging, and can include psychotic disorders, affective disorders, Cluster B personality disorders, conduct and oppositional defiant disorders, delirium and dementia, dissociative and posttraumatic stress disorders, intermittent explosive disorder, sexual sadism, and premenstrual dysphoric disorder. 4 Steadman’s prospective study 9 on recently discharged patients indicated that the one-year prevalence rates for violent incidents was 18 percent for major mental illness without co-occurring substance abuse, 31 percent for major mental illness with comorbid substance abuse, and 43 percent for personality-disordered patients with comorbid substance abuse. The rate for mentally ill patients who didn’t abuse substances was roughly equal to that of patients who are not mentally ill and who did not abuse substance. 9

In a long-term study of schizophrenic patients, substance abuse increased conviction rates for violent crimes 16-fold among the schizophrenic group, and 30 percent of male subjects with both schizophrenia and substance abuse had been convicted of a violent crime. 50 Swanson, et al., 5 found that the rate of violence among those with a mental illness was twice that of those without a mental illness, but violence was not more prevalent in persons with schizophrenia than among those with other disorders. The study noted that 92 percent of schizophrenic patients were not violent by their own report. Swanson points out that the rate of violence increased linearly with the number of diagnoses, and they concluded that major mental illness was one risk factor for violence, among many others. 5

Approximately 20 percent of violent psychotic patients are motivated directly by their delusions or hallucinations. 51 Compliance with command hallucinations increased if that hallucination involved of a familiar voice and was associated with a delusion. 52 Patients who experience persecutory delusions may attack preemptively, believing that they are protecting themselves. Mentally ill patients with threatening, paranoid delusions are twice as likely to become aggressive compared with nonparanoid psychotic patients. 12 Link, et al., 16 hypothesized that the differences among comorbidity studies may reflect patients who were identified as carrying a psychotic diagnosis, but who were not actively experiencing symptoms at the time of the measurements. The authors also proposed that specific types of paranoid delusions made a violent response more likely. Their concept of “threat/control-override” delusions includes patient beliefs that people are seeking to harm them and that outside forces are in control of their minds. The authors showed that increases in the number and intensity of such delusions were associated with increases in violent behavior. 53 Other studies, however, have found this to be less significant when controlling for factors such as substance abuse and nonadherence with treatment. 54

Studies suggest that up to 30 percent of outpatients with Alzheimer’s disease exhibit violent behavior. 55 Manic and demented patients are the most likely types of patients to commit violent acts or display aggression on an inpatient unit. Their victims are usually random bystanders rather than predetermined targets. Patients with mental retardation often use violence to respond to or communicate about psychosocial stressors, as their deficits preclude them from developing more adaptive, nonviolent ways of responding. 12 Fava and colleagues 56 revealed that 55 of 126 (44%) depressed patients reported anger attacks as part of their symptoms; irritability associated with depression and anxiety could culminate in aggression. 56 Cases of depression that exhibited anger attacks had significantly higher rates of comorbid dependent, avoidant, narcissistic, borderline, and antisocial personality traits than patients with depression without such attacks. 57

Medical conditions

Certain medical conditions are associated with violent behavior and should be excluded first as sources of the presenting aggression. As many as 70 percent of patients with brain injury secondary to blunt trauma exhibit irritability and aggression. 58 Intracranial pathology, such as trauma, infections, neoplasms or malformations, cerebrovascular accidents, and varieties of degenerative diseases can manifest as delirious, affective, or psychotic syndromes involving violent behaviors. Metabolic conditions, such as thyroid storm, Cushing’s disease, or androgen or estrogen dysregulation have been associated with aggression. Systemic infections, environmental toxins, and aberrant effects of medications can result in violence. 4 Complex partial seizures in particular can result in aggressive symptomatology, and studies have shown that anticonvulsants treat aggression in patients with temporal lobe foci on abnormal EEGs. 59

Once safety has been assured, the emergency evaluation of a violent patient should include a complete history and physical examination to search for a medical cause of the behavior. Screening laboratory studies are also essential in effectively assessing and treating aggressive individuals ( Table 2 ). Violent patients should have their serum glucose level checked upon presentation, as aggression, confusion, and irritability can be a manifestation of hyper- or hypoglycemia. Other initial laboratory testing should include complete blood counts, comprehensive metabolic panels, calcium levels, creatinine phosphokinase, toxicology screen and blood alcohol level, and a brain CT or MRI. Other testing, such as chest radiograph, thyroid function, B12 and medication levels, lipoprotein levels, and arterial blood gases, should be employed as clinically indicated. 4

Laboratory testing in the work-up of the violent patient

Risk Factors For Violence

Static risk factors.

Much of the literature on violence in psychiatric practice has been devoted to determining static and dynamic risk factors. Static risk factors are patient characteristics of the patient that cannot be changed with clinical intervention, such as demographics, diagnoses, personality characteristics, and prior history. Even though risk factors represent associations with outcomes, they do not imply overt causation. 60

The most replicated and affirmed static variable associated with the prediction of future violence is a history of past violence. 4 , 12 , 43 , 61 , 62 The risk of future violence increases linearly with the number of past violent acts. 12 Persons who have acted aggressively because of their delusions in the past are likely to do so in the future. 54 Janofsky 63 found that violent behavior before admission to the hospital is correlated with violence as an inpatient in a psychiatric facility. A history of impulsivity is also related to future violence, as Asnis and colleagues 8 showed that 91 percent of patients who attempted homicide also had attempted suicide during their lifetimes.

Other static risk factors include male sex, younger adult age, lower intelligence, history of head trauma or neurological impairment, dissociative states, history of military service, weapons training, and diagnoses of major mental illnesses. 12 In a review of literature, Bonta, et al., found that younger age, male sex, single marital status, and having antisocial peers were associated with violent recidivism. Most evidence shows that race and social class are unrelated to recurrence of violence. 11 Poor work adjustment can be an additional static risk factor in a patient’s social history; other static variables include a dysfunctional family of origin and a history of abuse as a child. 12

Using the National Comorbidity Study data collected from 1990 to 1992, Corrigan and colleagues demonstrated that participants who reported more than three psychiatric diagnoses were 2 to 4.5 times more likely to also report violent behaviors, as opposed to participants who reported only one diagnosis. 64 Major mental illnesses are a static risk factor, but active symptoms or the presence of a relapse may be more exact predictors of violence risk, and are considered dynamic variables that are likely amenable to treatment. 10 Thus, the association between mental illness and violence is best viewed in a longitudinal perspective, with increased risk at different points throughout a patient’s lifetime. Compared to other sociodemographic and historical factors, the contribution of mental illness to the overall risk of violence in society as a whole is relatively small. 60 In fact, demographic variables, particularly gender, are far better predictors of violence than psychiatric diagnoses of either substance abuse or nonsubstance abuse disorders; thus, stress on the connection between violence and psychiatric illness may be unnecessarily propagating stigma about mental illness. 64

Dynamic risk factors

Dynamic risk factors are variables in a patient’s presentation that can potentially be improved with clinical intervention. 65 They are often closely related to or even the same as those clinical symptoms that bring patients to acute care settings. 60 Perhaps the most frequently cited dynamic risk factor is substance abuse or dependence. 10 Other dynamic risk factors include persecutory delusions, command hallucinations, nonadherence with treatment, impulsivity, low Global Assessment of Functioning (GAF) score, homicidality, depression, hopelessness, suicidality, feasibility of homicidal plan, access to weapons, and recent move of a weapon out of storage. 12

Untreated psychotic symptoms represent significant risk factors for violent behavior, especially psychotic symptoms that threaten the patient, or that involve losing control to outside forces. 8 Among inpatients with schizophrenia, the most predictive variables for violence are suspiciousness and hostility, more severe hallucinations, poor insight into delusions and the overall illness, and greater disorganization of thought processes. 12 Delusions alone are not associated with violence except when delusions are persecutory in nature or involve conscious thoughts of committing violence. 54

Recent estimates suggest that up to 80 percent of patients are nonadherent to treatment recommendations at some point during their illnesses. 62 Nonadherence may be associated with violence and can be addressed through psychoeducation, cognitive-behavioral and supportive therapy, outpatient commitment, and intensive case management, as well as through focus on the therapeutic alliance. Bonta, et al., note that poor living situation and limited social support are risk factors for violence, but these can be altered by placing the patient in a supervised setting, providing family therapy, and involving the patient in positive community activities. 11

Case Example

JB was a 45-year-old married man who was involuntarily committed to the state hospital for severe depression, worsening over the previous several months, with multiple suicide attempts. The patient’s most recent suicide attempt involved jumping off the roof of his two-story home. In addition to severe neurovegetative symptoms, the patient exhibited some psychotic features, including delusions that his wife and children were destitute and starving. During the transfer to the state facility, the patient became aggressive and attacked the police officer escorting him in an attempt to obtain the officer’s gun and commit suicide.

The patient arrived on multiple medications from his stay at the community hospital, including a nortriptyline 50mg at bedtime, citalopram 20mg daily, benztropine 2mg twice daily, lorazepam 1mg twice daily, zolpidem 10mg at bedtime, and quetiapine 200mg at bedtime. In addition to a 25-year history of depression, the patient’s medical history was significant for mild hypertension and acid reflux. A computed tomography (CT) scan of his brain several months before this admission revealed mild cortical atrophy in the frontal regions.

There was no evidence from collateral sources that the patient engaged in any current or past substance abuse: His last drink was two months prior to this admission. The patient did endorse a significant family history of depression, which included his mother receiving electroconvulsive therapy in the remote past and two cousins committing suicide.

After two days on the acute unit in the state facility, while continued on most of his medications, JB began to exhibit aggressive behavior; he approached other male patients and pinched or punched them without provocation. When questioned by staff about these incidents, the patient stated, “People are out to get me.” He indicated that he intended to take preemptive action against those that he believed were targeting him on the unit. He was alert and oriented in all spheres during and immediately following these episodes. He did, however, repeat questions about irrelevant topics while being restrained for attacking other patients and staff.

The violent incidents continued at various times throughout the day, and multiple emergency medications were tried without much effect. The patient appeared very anxious, and he was only responsive to staff reassurance and redirection for several minutes before becoming aggressive again. A thorough review of his medication regimen uncovered multiple agents with possible deleterious effects on his cognition. Unnecessary medications, such as anticholinergics, benzodiazepines, sleep aids, sedating antidepressants, and antipsychotics were stopped or tapered off. The patient unfortunately ended up in restraints after several of these attacks, as he did not respond to redirection or doses of calming medications.

Safety And Environmental Interventions

Modifying a patient’s environment to prevent or decrease aggression is mainly of concern to inpatient facilities, although similar adjustments in a person’s home situation by outpatient clinicians may also have benefits. Studies have shown that most violent incidents occur earlier in the mornings and evenings, particularly when patients are gathered together in small areas. A study of 118 psychiatric inpatients with psychotic and/or substance use disorders admitted within two weeks to an urban hospital showed that patients who were involuntarily hospitalized exhibited more aggression. The authors also demonstrated that patients with an uncomplicated substance use disorder trended toward more total aggression than psychotic patients and patients with comorbid psychosis and substance abuse. 66 Warning signs that may precede violence include pacing, psychomotor agitation, combative posturing, guardedness, paranoid or threatening remarks, low frustration tolerance, emotional lability, and irritability. Environmental control can aid in containing violence, and it is essential to catch the patient in these earlier stages leading up to aggression and provide some measure of control to de-escalate building violence ( Table 3 ). 12

Environmental modifications to help control aggression

Having sufficient numbers of staff present as well as avoiding overcrowding of patients decreases violent acts. Staff members should be well trained to pick up cues that signal mounting aggression. They must be able to maintain calm, comforting demeanors and refrain from using direct confrontation and intruding on a patient’s personal space. Beneficial techniques include verbal redirection, implementation of relaxation techniques, close observation, distraction of the patient’s attention away from triggers of aggression, and the use of quiet time or open seclusion in areas of the unit with decreased stimuli. Unpleasant surroundings and loud, irritating noises also increase the likelihood of violence. 12 The longer aggressive patterns of behavior have been in place, the less likely it is that they will be modified by changes in the environment alone. 20

Seemingly simple interventions can have a tremendous impact on violent outcomes. These include offering something to drink or eat, decreasing wait times, maintaining a positive and friendly attitude toward the patient, avoiding intimidating direct eye contact, and removing potentially dangerous objects from the area. Since a staff member’s body language can contribute significantly to triggering violence, uncrossing arms and displaying empty hands can be less threatening. Remaining empathetic, making soothing statements, and expressing concern for the patient’s wellbeing reinforces the idea that everyone is present to ensure the patient’s safety and access to treatment. Positive reinforcement for peaceful choices in behavior and for behavior that preserves the treatment community’s order and boundaries can be useful. Consistency in setting limits on behavior and suggesting alternatives to violence, such as talking to staff or making a phone call, are important de-escalation techniques. 12

The governing principle of managing violent psychiatric patients is the doctrine of least restrictive alternatives. This necessitates managing aggressive patients with the least restrictive yet effective means possible. Restraints or locked seclusion are the final resort in dealing with imminent danger in an emergency or inpatient setting. In implementing restraints, the staff should identify a team leader and complete the procedure in a standard and calm manner. 12 Each inpatient psychiatric facility maintains policies and guidelines for the application of restraints and seclusion to which staff must adhere.

Psychotherapy Interventions

Patients with more frequent visits to their mental health centers have a reduced likelihood of threatening violence or committing violent acts against family members. 67 The psychotherapeutic relationship can be healing and restorative in and of itself, but specific techniques certainly contribute the curative element of the treatment. Alpert and Spillman 68 completed a review on psychotherapeutic treatments for violent patients, emphasizing that all therapists need to maintain a safe therapeutic environment for themselves and the patient, complete sufficient training on the management of violent patients, and have access to consultation and supervision. 68

Countertransference is an intriguing consideration in the treatment of aggressive patients. The therapist’s countertransference reactions may influence the progress of treatment, including under- or overestimating risk and becoming overinvolved with or neglectful of the patient. In trying to build a therapeutic alliance with a violent patient, the therapist may ignore feelings of fear or disgust, which could have disastrous consequences. Alternately, the clinician may find it difficult to relate and empathize with an aggressive patient, especially if such acts are chronic. Without self-monitoring, the therapist may find it difficult to maintain a supportive, nonjudgmental stance and avoid inappropriate reactions. 68

Various modalities of therapy could apply to the violent patient. Therapists with a behavioral focus would be more concerned with prior triggers, violent behaviors, and consequences for actions. Many institutions employ these behavioral techniques in the form of levels of privileges that the patient can earn. Social skills training promotes more acceptable assertive behaviors and reinforces self-control mechanisms. Cognitive approaches focus on incorrect automatic thoughts that precede anger reactions in the context of larger faulty belief systems that direct an individual’s perceptions of external events. Filtering experiences through these inaccurate cognitive schema results in distortions of situations, with subsequent unnecessary feelings of anger and inappropriate responsive behaviors. 68

Group therapy creates a microcosm of real-world relationships and interpersonal difficulties for patients. Group therapy can be less intense for potentially violent patients and their therapists in terms of transference and countertransference reactions. Interactions with other group members through a course of therapy can be a source of modeling for aggressive patients. Groups also provide supportive confrontations and conflict resolution. Family and couples therapy can be more problematic if the victim and the perpetrator are treated together, as it can be difficult to assign responsibility for the violence appropriately. The perpetrator will tend to rationalize the aggression in the family as an appropriate response to instigation. Continuing violence in the relationship during treatment is another obstacle to overcome. 68 Early detection of abuse and domestic violence, combined with proper therapeutic methods, can be important in decreasing the chance for future violence in children and adolescents. 23

Case Example, Continued

After JB’s medication regimen was simplified, medication used to address the violent behavior was limited to only haloperidol 5mg up to every four hours as needed for agitation. Staff observed that he responded well to positive and consoling statements by female nurses and attendants. He began requesting to be able to lie quietly in the seclusion room with a staff member watching him, while the door remained open and unlocked. These environmental accommodations were made, and the patient’s aggressive incidents and time spent in restraints began to decline. He was able to be involved in group activities on the unit and receive visits from supportive family members. His depression was persistent, however. In view of the refractory nature of his symptoms, he underwent a course of electroconvulsive therapy.

Pharmacological Interventions

Acute violent behavior.

In addition to environmental modifications and psychotherapy, pharmacotherapy certainly has a place in treating and controlling violent behavior. Many of the practices in medicating acute aggression are based in and developed from clinical experience and personal observation. There is limited empirical data regarding appropriate pharmacologic choices.

Pharmacological considerations involve more than just the choice of medication; it also includes the clinician’s presentation of options to the patient and the route of medication administration. When possible, it is best to offer the patient a choice as to which type or route of medication will be used to help him or her regain self control. The act of the patient making this choice facilitates good judgment and control, potentially heading off further frustration and agitation while preserving dignity for all involved. 4 Since oral administration of most of these agents is generally as effective as parenteral dosing, taking the medication by mouth offers an opportunity for the patient to regain some self efficacy in treatment. However, violent patients may summarily refuse treatment with medications. In this emergency setting (with impending harm to self and/or others), this treatment refusal is usually overruled, and medication is administered against the patient’s will, for the safety of the treatment community.

High-potency first-generation neuroleptics have been the agents of first choice for the treatment of acute aggression since their inception, especially when such aggressive behavior seems to be motivated or aggravated by psychotic symptoms. These medications, such as haloperidol and fluphenazine, are used alone or in combination with a quick-acting benzodiazepine, such as lorazepam, for added sedation. Reasonable doses of these medications—5mg for the neuroleptics and 2 to 3mg for the benzodiazepine—can be given orally or intramuscularly and repeated every 1 to 2 hours until the patient’s aggression has ceased. 62 Haloperidol, in particular, has been shown repeatedly in the literature to be safe in patients, even if their medical histories are unknown. In particular, haloperidol has minimal effects on cardiac status and seizure threshold. 4 Markedly higher doses of these neuroleptics, a more common practice in past decades, can actually worsen aggression, largely due to dose-related side effects, especially akathisia and dystonias. 62 When more sedation as well as antipsychotic properties are desired, chlorpromazine in oral doses of 100 to 200mg can quiet aggressive behaviors quickly, with cautious observation for anticholinergic and orthostatic side effects. 12 Monotherapy with benzodiazepines can also be useful in treating aggression, especially those agents with quicker onsets of action. 4 Lorazepam is commonly chosen, perhaps because of its reliable intramuscular administration. Benzodiazepines carry a small but real risk of disinhibition and paradoxical aggression.

Preliminary data on new intramuscular and rapidly dissolving formulations of several second-generation antipsychotics, including risperidone, olanzapine, and ziprasidone, suggest that they are comparable in efficacy to haloperidol for managing acute aggression. These formulations may facilitate the eventual transition over to chronic maintenance with their oral counterparts. Data also suggest these newer medications may demonstrate more favorable side effect profiles in emergency situations. 69 However, manufacturers of each agent detail specific warnings in the package inserts of these new preparations, including concern for corrected QT prolongation with ziprasidone and excessive sedation and cardiorespiratory depression if olanzapine is combined with benzodiazepines intramuscularly.

Chronic aggression

The risk of violence decreases when psychiatric symptoms are treated successfully; this concept underscores the importance of accurate diagnosis and comprehensive treatment of chronically aggressive patients. Some targeted pharmacotherapy may help control violent behaviors in psychiatric patients when treatment of the underlying disorder is not enough to prevent hostile incidents. This directed therapy can assist chronic patients in living more successfully in a community environment.

Available evidence maintains that second-generation antipsychotics should be considered the treatment of choice for chronic aggression, given their efficacy and favorable tolerability in the long term. 62 In particular, clozapine is recommended for persistent violence in the setting of psychosis, especially refractory conditions. Several studies have shown that clozapine is effective in controlling aggression and reduces the use of restraint and seclusion in state hospital settings. 72 Volavka and colleagues showed that clozapine lessened hostility, separate from improving psychosis. 71 Other second-generation antipsychotics, such as risperidone, olanzapine, and quetiapine, have shown equal efficacy in psychiatric patients with chronic violent behavior as compared to traditional neuroleptics. They have also shown benefit in aggression associated with autism or dementia. 12

Lithium has displayed effectiveness for aggression in mentally retarded populations, with serum concentrations of 0.6 to 1.4mEq/L reducing violent incidents by 50 to 73 percent in separate samples. 72 Lithium has also repeatedly been shown to reduce irritability and incidents of aggression in patients diagnosed with bipolar disorder. Valproate has been shown to promote significant reductions in aggression, across multiple diagnostic categories, including organic syndromes, dementia, mental retardation, and bipolar disorder. 73 In addition, carbamazepine decreases agitation in brain-injured patients. 74

Selective serotonin reuptake inhibitors have established efficacy in decreasing aggression in populations with various psychiatric diagnoses, including Alzheimer’s disease, autism, mental retardation, psychosis, posttraumatic stress disorder, and personality disorders. 72 A three-month, double-blind study of 21 patients with borderline personality disorder showed a decrease in anger after receiving therapeutic dosages of fluoxetine, apart from changes in their depressive symptoms. 75 One multicenter trial found that citalopram was more effective than placebo in controlling aggression and irritability in patients with Alzheimer’s-type dementia. 72

B-blockers have been tried as an adjuvant treatment to help control violent incidents in patients with a variety of symptoms. In patients recently hospitalized for traumatic brain injury, propranolol (up to 420mg/day) was found to be more effective than placebo in reducing agitation in 21 subjects. 72 Ratey and colleagues examined 41 chronic inpatients with psychosis and found that nadolol (40–120mg/day) combined with other psychotropics, resulted in significant improvements in aggression and hostility scores as compared with placebo. 78

Violence has serious implications for society and psychiatric practice, directly and indirectly affecting the quality of life of patients, their families, the community, and mental health workers. The specter of violence in psychiatric practice demands risk stratification and management as part of the complete patient assessment. Any modifiable risk factor must be addressed by psychiatrists while working with inpatient and outpatient treatment teams. Psychotherapy and pharmacotherapy are used both in the emergent circumstance and throughout the course of illness.

This review of the available literature on violence and aggression supports this notion that such symptoms are often a consideration in providing care psychiatric patients. We can conclude from the information in this review that individuals with mental illness, when appropriately treated, do not pose any increased risk of violence over the general population. Violence may be more of an issue in patients diagnosed with personality disorders and substance dependence. The overall impact of mental illness as a factor in the violence that occurs in society as a whole appears to be overemphasized, possibly intensifying the stigma already surrounding psychiatric disorders. Violence and mental illness are not without connection, however, as they share many biologic and psychosocial aspects.

In the future, research may focus on discovering useful factors in the development of aggression, which would shed light on preferred treatment methods. Understanding factors contributing to violence and appropriately developing a risk management plan to address those factors will hopefully contribute to further eliminating stigma and other obstacles confronting psychiatric patients, helping them to achieve a good quality of life and independence in the community.