FACTORS AFFECTING THE VALIDITY OF A VIOLENCE RISK SCREENING

TOOL WITH PSYCHIATRIC INPATIENTS

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BY
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Mélodie Foellmi
B. A., University of British Columbia, 06/19/2004
M. A., Fordham University, 08/31/2011
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DISSERTATION
SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN THE DEPARTMENT OF
PSYCHOLOGY AT FORDHAM UNIVERSITY

NEW YORK
06/25/2016

 
 ProQuest Number: 10182767

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This dissertation is dedicated to the past, present, and future patients of the Bronx
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Lebanon Hospital psychiatric inpatient service, as well as their loved ones.
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TABLE OF CONTENTS
Chapter I: Introduction ...................................................................................1
Thesis ............................................................................................... 1
Literature Review ............................................................................. 3
Violence and Mental Illness ................................................. 3
A Brief History of Violence Risk Assessment ................... 39
Violence Risk Screening and Triage .................................. 44
Purpose and Rationale .................................................................... 61
Conceptual Hypotheses .................................................................. 63
Chapter II: Method ..................................................................................... 68
Participants ..................................................................................... 68

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Instruments / Data Collection Methods ......................................... 69
Demographic, Clinical, and Contextual Variables ............ 69
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Fordham Risk Screening Tool (FRST) .............................. 70
Historical-Clinical-Risk 20 Assessment Scheme,
Version 3 (HCR-20V3)........................................................ 71
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Outcome Variables ............................................................ 73

Procedures ..................................................................................... 74
Informed Consent .............................................................. 78
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Operational Hypotheses ................................................................ 78

Data Analyses ................................................................................ 82
Descriptive Analyses ......................................................... 82
Inferential Analyses ........................................................... 82
Chapter III: Results .................................................................................... 85
Descriptive Analyses ...................................................................... 85
Sample Characteristics ....................................................... 85
Violence Risk Assessment Descriptive Data ..................... 90
Assumption Tests ............................................................... 93
Inferential Analyses ....................................................................... 94
Hypotheses ......................................................................... 94
Chapter IV: Discussion ............................................................................. 129

 
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Summary of Results ...................................................................... 129

Main Effects of Variables on Violence Risk Ratings ....... 133
Hypothesized Moderation Effects ..................................... 135
Clinical and Theoretical Implications ........................................... 137
Strengths and Limitations ............................................................. 145
Strengths ........................................................................... 145
Limitations ........................................................................ 147
Future Research ............................................................................ 151
Summary ...................................................................................... 155
References ................................................................................................ 156
Footnotes .................................................................................................. 182

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Appendix A .............................................................................................. 183

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TABLES

Table 1 ………………………………………………………………………. 85
Table 2 ………………………………………………………………………. 87
Table 3 ………………………………………………………………………. 88
Table 4 ………………………………………………………………………. 88
Table 5 ………………………………………………………………………. 90
Table 6 ………………………………………………………………………. 93
Table 7 ………………………………………………………………………. 95
Table 8 ………………………………………………………………………. 96
Table 9 ………………………………………………………………………. 97
Table 10 ……………………………………………………………………... 98
Table 11 ……………………………………………………………………... 99
Table 12 ……………………………………………………………………..101
Table 13 ……………………………………………………………………..104

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Table 14 ……………………………………………………………………..108
Table 15 ……………………………………………………………………..109
Table 16 ……………………………………………………………………..110
Table 17 ……………………………………………………………………..111
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Table 18 ……………………………………………………………………..115
Table 19 ……………………………………………………………………..118
Table 20 ……………………………………………………………………..120
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Table 21 ……………………………………………………………………..120
Table 22 ……………………………………………………………………..122
Table 23 ……………………………………………………………………..125
Table 24 ……………………………………………………………………..128
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FIGURES

Figure 1 ………………………………………………………………………..83
Figure 2 ………………………………………………………………………. 84
Figure 3 ………………………………………………………………………. 91
Figure 4 ………………………………………………………………………. 96
Figure 5 ………………………………………………………………………100
Figure 6 ………………………………………………………………………103
Figure 7 ………………………………………………………………………107
Figure 8 ………………………………………………………………………110
Figure 9 ………………………………………………………………………113
Figure 10 ……………………………………………………………………..117
Figure 11 ……………………………………………………………………..121
Figure 12 ……………………………………………………………………..124
Figure 13 ……………………………………………………………………..127

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Acknowledgments

First and foremost, I would like to thank my wonderful family: Hilmar Foellmi,
Josette Faure, and Flore-Anne Foellmi. Their unwavering love and support has kept me
afloat for years, and their own strength, tenacity, hard work, and good humor have given
me extra motivation when I needed it. For that I say thank you, merci, and danke schön! I
would also like to thank my husband Calvin Angell, who not only supported me in times
of perma-panic, but was also able to break through the graduate school force-field, make
me laugh, and remind me that there is more to life than work.

I am immensely greatful to Dr. Barry Rosenfeld for his mentorship, support,

encouragement, expertise, thoroughness, no-nonsense feedback, faith in me, and
friendship. I could not have hoped for a better ally or teacher throughout this process.

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The most heartfelt thank you to Julia Pottinger, Chris Seymour, Quinn Peters, and the
rest of the original Vancouver crowd, whose friendship means the world to me, and who
always seem to enjoy my work stories, no matter how terrifying they are. Joanna Will
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and Rachele Vogel - team JeRM – your energy and help during the last year of my degree
and dissertation were essential, and I wonder how I would have done it without you.
Thank you also to the rest of the fantastic Bellevue intern class of 2016.
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I would like to thank Dr. Ali Khadivi and Dr. Merrill Rotter for their support and
collaboration throughout the various stages of this project. I would also like to thank the
amazing graduate students and externs who contributed to data collection and data entry
for this project, with special thanks to Katharina Furjanic, Shana Grover, Alicia Nijdam-
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Jones, and Charity Wijetunga. This project would not have not come to life without your
hard work.

Since 2009, Fordham University has been my academic home, and I would like to thank
all of the faculty, staff, and students who made my time there as enriching and fun as it
was challenging. A big thank you to my dissertation committee members who provided
encouraging and constructive feedback. I would also like to thank the staff and
administrators at Bronx Lebanon Hospital who were present and helpful during the
duration of this project. I would like to send a big thank you to the patients of Bronx
Lebanon Hospital who participated in this project. Their experiences, suffering, and
resilience have made a mark that goes beyond simply completing a dissertation.

Last but not least, I would like to thank the National Institute of Justice for providing
funds for this project via the NIJ Graduate Research Fellowship Program in the Social
and Behavioral Sciences, CFDA 16.562.

 
  

CHAPTER I: INTRODUCTION

Thesis

Violence risk assessment and management are essential parts of psychiatric care,

and in recent decades several effective violence risk assessment instruments have been

developed and evaluated (Heilbrun, Yasuhara, & Shah, 2010). As a result, it is now

possible for clinicians to assess for risk of violence with a reasonable degree of accuracy

and consistency (Singh, Grann, & Fazel, 2011). However, a thorough violence risk

assessment requires considerable time and resources, both of which are in short supply in

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many psychiatric settings (Magen, Richards, & Ley, 2013; Thomas, Ellis, Konrad, Holzer,

& Morrissey, 2009). Given these limited resources, clinicians must screen hospital
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admissions to decide which patients are most in need of a thorough violence risk

assessment.
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To date, this screening process has been largely unstructured, untested, and

inconsistent, with considerable potential for error (Foellmi, Rosenfeld, Rotter, & Khadivi,
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2014; Heilbrun et al., 2010). Currently there are no well-validated violence risk

assessment screening tools to help clinicians decide which psychiatric patients are most

in need of more thorough violence risk assessment and management interventions.

Although no psychometrically sound violence screening tools currently exist, a

number of published instruments have been described as violence screening tools. Some

of these instruments are more accurately characterized as brief risk assessment measures

that predict short-term inpatient violence but do not identify patients in need of a

thorough violence risk assessment (e.g., Almvik & Woods, 1999; McNiel & Binder,

1994; Ogloff & Daffern, 2006). Other instruments have screening components, but have

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never been empirically evaluated with regard to their accuracy in identifying individuals

in need of further assessment (Watts et al., 2004). Still other brief instruments have been

designed to predict long-term community violence (Bjørkly, Hartvig, Heggen, Brauer, &

Mogen, 2009). Thus, it is inaccurate to label the existing brief instruments “screening

tools” as none have been designed and evaluated with regard to helping decide which

patients are most in need of a thorough violence risk assessment.

In response to the need for violence risk screening tools in psychiatric settings, a

team of mental health researchers created the Fordham Risk Screening Tool (FRST;

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Rosenfeld, Foellmi, Howe, & Rotter, 2013). The FRST is a brief flowchart intended to

help the clinician decide if a thorough violence risk assessment is needed. The FRST is
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not a violence risk assessment tool; it simply yields one of three recommendations:

Violence risk assessment needed, Uncertain, or Violence risk assessment not needed. The
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FRST has received preliminary empirical support in a pilot study of 65 psychiatric

inpatients at a large psychiatric hospital in the Bronx, New York. In this pilot study, the
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FRST significantly predicted violence risk estimates on the Historical Clinical Risk

Management-20 (HCR-20; Webster, Douglas, Eaves, & Hart, 1997), a widely used

violence risk assessment instrument.

The aim of the current study was to further examine the predictive validity of the

FRST. More specifically, the study aim was determine if clinical and demographic

variables impact the effectiveness of the FRST when screening individuals for

institutional and community violence risk in an adult psychiatric inpatient population.

This aim was accomplished by analyzing data from an ongoing violence risk screening

and assessment initiative at Bronx Lebanon Hospital (BLH). In this study, adult

 
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psychiatric inpatients were screened with the FRST at admission and then assessed with

version three of the HCR-20 (HCR-20V3; Douglas, Hart, Webster & Belfrage, 2013). The

FRST screening decisions were expected to significantly predict the HCR-20V3 results;

however, it was also expected that the predictive accuracy of the FRST would differ

based on a number of patient and contextual variables. Specifically, male gender, first

hospitalization at Bronx Lebanon Hospital, and lower education were expected to

increase the predictive accuracy of the FRST. From a clinical perspective, the presence of

a psychotic disorder, threat/control override symptoms, and individuals with mild

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psychiatric symptoms were expected to increase the predictive accuracy of the FRST.

With regard to contextual variables, police involvement in the initiation of hospitalization,

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an involuntary legal status, and having a residence at the time of admission were

expected to increase the predictive accuracy of the FRST. This study provides the first
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empirical examination of how demographic, clinical and contextual variables might

influence the effectiveness of risk screening in general and the FRST in particular.
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Knowledge regarding these moderator variables will help to guide the use and

implementation of the FRST in clinical practice.

Literature Review

Violence and Mental Illness

Violence and mental illness are continuously presented together in the popular

media. The perception that mentally ill individuals are prone to violence is highly

stigmatizing, and it oversimplifies a complex issue. Thus, it is important to disentangle

erroneous stereotypes from valid risk factors for violence that affect mentally ill

 
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individuals. To begin, it is necessary to take stock of some basic figures on violence in

general.

Problem of violence. Violent crime is a long-standing socio-political problem in

North America. In the United States, there were over seven million victims of violence in

2011 alone (U.S. Department of Commerce, 2011; U.S. Department of Justice, 2012a),

without counting the large “dark figure” of unreported violence (Coleman & Moynihan,

1996). Violent victimization also results in enormous economic losses (Waters et al.,

2004) and societal losses that can take a devastating toll on individuals and communities

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(U.S. Bureau of Justice Statistics, 1996). Violence can be defined as the actual, attempted,

or threatened infliction of bodily harm on another person (Webster, Douglas, Eaves, &
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Hart, 1997). However, research definitions of violence vary widely depending on the

study and the method of data collection. For example, broad definitions of violence can
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include acts directed at property and threats, while some definitions of violence include

only severe acts with severe consequences. Some studies measure violent outcomes based
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on victim reports, others on arrest records, and others use multiple methods. These

definitional and methodological differences can greatly impact reported outcomes. To

provide context for the results reported in this review, specific definitions of violence and

source of data will be included as much as possible.

Violence in the general population. According to the U.S. Federal Bureau of

Investigation’s most recent report on the National Crime Victimization Survey (United

States Department of Justice, 2013), there were 6,842,590 violent crimes (i.e., murder,

forcible rape, robbery, and aggravated assault) in 2012, and that year law enforcement

made over 500,000 arrests for violent crime (U. S. Department of Justice, 2012a, 2012b).

 
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Violent behavior varies greatly with respect to form, severity, and purpose, and it

is multiply determined: There is no one cause for violent behavior and violent offenders

are not a homogenous group (Otto & Douglas, 2010). Although researchers have found

many risk factors for violence in the general population, such as low socio-economic

status, male gender, and a history of victimization, the association between mental illness

and violence has been the subject of particular focus by popular media and researchers

alike. Unfortunately, not all media depictions of the relationship between mental illness

and violence are accurate. One challenge for psychologists and psychiatrists is to assess

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and manage the true risk of violence that is associated with mental illness without

propagating harmful stigma or misinformation about the risks posed by mentally ill
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individuals. In addition, the association between mental illness and crime is often

highlighted by the high prevalence of mental illness in criminal justice settings. Many
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researchers have addressed the issue of violence risk in community and offender

populations; however, the focus of the present review is exclusively on violence risk in
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psychiatric populations. This review will outline research on violence risk specifically as

it relates to psychiatric patients; however, it is noteworthy that many of the risk factors

for violence are similar in psychiatric, non-psychiatric, and offender populations (Metzl,

2011).

Violence in psychiatric populations. Despite decades of research and debate on

the relationship between mental illness and violence, the academic community has not

reached a full consensus on whether or not mental illness increases risk for violence.

Based on the data available to date, it seems that although most individuals with mental

illness do not engage in violence, there is a small but significant relationship between

 
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mental illness and violence such that individuals with mental illness are more likely to

engage in violence than those without mental illness (Monahan et al., 2001; Silver, 2006).

In other words, most individuals with a mental illness do not behave violently; however,

from a statistical perspective having a mental illness slightly increases the chances of

violent behavior compared with individuals who are not mentally ill. The causal

mechanisms underlying this relationship are unclear. The link between mental illness and

violence appears to be complicated by a host of intervening variables, which can be

broadly sorted into three categories: demographic and historical, clinical, and contextual .

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Of note, many of the variables that increase violence risk for individuals for mental

illness also increase violence risk for individuals without mental illness. This suggests
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that mentally ill individuals may simply be subjected to more of the conditions that foster

violent behavior, rather than there being a direct causal link between mental illness and
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violence.

Risk factors for violence in mentally ill populations. It is clear that the
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association between mental illness and violence cannot be explained by any one factor

alone. Rather, research studies have identified several specific factors that appear

empirically related to violence risk in mentally ill populations. These risk factors are

reviewed below. Though the intention in this review is to focus on studies conducted

specifically with mentally ill individuals, some of the research studies cited are larger

epidemiological studies that include individuals with and without mental illness.

Demographic and historical risk factors. Many studies have addressed the

relationship between demographic variables and violence in psychiatric patients, though

 
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findings have often been mixed. The following are some of the most relevant

demographic and historical factors that have been studied in relation to violence risk.

Gender. The strong relationship between gender and violence found in

community samples is less clear in psychiatric populations. In their meta-analysis of 64

studies on mentally disordered offenders, Bonta, Law, and Hanson (1998) found that

male gender significantly predicted violent recidivism (Zr = .11, p < .001). However, as

noted by Friedman and Loue (2007), many of the early studies examining the relationship

between gender and violence in psychiatric populations contained serious methodological

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flaws, including failing to include the definition of violence used, break down the

samples by diagnosis, or examine the context of the violence.

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However, since the publication of Bonta et al.’s (1998) meta-analysis, several

studies have found no significant relationship between gender and violence in psychiatric
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populations. For example, Hiday, Swartz, Swanson, Borum, and Wagner (1998) reported

that in a sample of 331 psychiatric patients who were court-ordered into outpatient
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treatment, males were twice as likely as females to use violence but only when the

researchers used a broad definition of violence that included threats and property damage.

Gender only predicted violence in a multivariate model including gender, age, race,

marital status, urban environment, and education at step one, and substance use and past

victimization at step two. Stueve and Link (1998) found that in an epidemiological study

of over 2,700 Israeli community members, psychiatric diagnosis significantly moderated

the relationship between gender and violence. Although males were four times as likely

to fight, and 15 times more likely to use guns than females, there was no gender

 
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difference in violence for those who had a psychiatric diagnosis of schizophrenia or

bipolar disorder.

In a more recent meta-analysis, Douglas, Guy, and Hart (2009) found that gender

had no moderating effect on the relationship between psychosis and violence. There was

no statistically significant difference in effect sizes per gender and results were

significantly different from chance for both males (median OR = 1.37, 95% CI [0.76,

3.22]) and females (median OR = 1.73, 95% CI [0.92 , 4.98]).

Age. Many studies have found that young age is significantly related to violent

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offending in psychiatric and community populations alike, though age categories differ

per study. Bonta et al.’s (1998) meta-analysis found a strong negative relationship
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between age and violent offending (Zr = .16), in studies with a mean follow-up length of

4.8 years (SD = 3.7). Since this meta-analysis, several other studies with psychiatric
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samples have also found that younger individuals are at higher risk for violent behavior.

For example in a retrospective study of over 1130 male offenders, Harris and Rice (2007)
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found that being 16 or younger at the time of the first violent offense significantly

predicted violent offending in the following 8.42 to 11.18 years, r(797) = -.22.

Race. Race is a controversial predictor of violence, both in the general community

and in psychiatric populations. Several studies have found that in psychiatric populations,

African-Americans and other racial minorities are more likely to commit violent crimes

than Caucasians (Bonta et al., 1998). Given the great potential for racial stigma based on

these findings, several researchers have made efforts to clarify this relationship and have

found that race alone does not in fact predict violence. Closer scrutiny has revealed that

once other factors such as socio-economic class and neighborhood are controlled for, race

 
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ceases to be a statistically significant predictor of violence (e.g., Silver, 2000). In fact,

although Bonta et al.’s (1998) meta-analysis reported individual studies that found race

differences in violence rates, there was no overall significant effect of race (Zr = 1.01, p

> .05).

Though beyond the scope of the current review, which focuses on adults, studies

of adolescents shed further light on some of the mediators and moderators of the race-

violence relationship. For example, neighborhood street culture (which is often

confounded with race) appears to be a determining factor in adolescent violence (Stewart

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& Simons, 2010). In a study of over 400 adolescents in juvenile detention, researchers

showed that violence risk ratings were in fact five times lower for African Americans
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when compared with Caucasians, but that African American youth were

disproportionately apprehended for violent crimes compared with Caucasian youth, χ2 (2,
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N = 482) = 21.26, p = .047 (Desai, Falzer, Chapman, & Borum, 2012). Most research on

race has compared African American and Caucasian individuals; therefore, less is known
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about the potential race-violence relationship (and any intervening mediators) for

individuals of other races or ethnicities. Few studies have examined international

differences in violence rates for psychiatric populations. However, in a meta-analysis by

Douglas et al. (2009), the relationship between psychosis and violence did not differ by

country, when comparing studies conducted in the United States (Median OR = 1.72 )

versus other countries (Median OR = 1.56).

In sum, young age is the only demographic characteristic that research has

consistently identified as a predictor of violence risk in mentally ill individuals. The male

gender-violence relationship that is seen in the general population does not apply to

 
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mentally ill populations, and race does not predict violence after statistically controlling

for other demographic factors.

Victimization. Transitioning to less visible, but equally important factors, past

victimization is a historical risk factor for violence that is especially relevant to

individuals with mental illness, because they have high rates of victimization compared

to the general population (Estroff & Zimmer, 1994; Maniglio, 2009). Violent

victimization in childhood or adolescence is related to violent behavior in adulthood

(Flannery, Singer, van Dulmen, Kretschmar, & Belliston, 2007). In addition, adulthood

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victimization is related to violence in mentally ill populations. Hiday, Swanson, Swartz,

Borum and Wagner (2001) studied victimization and violence in a sample of 331
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severely mentally ill individuals legally mandated to outpatient therapy via civil

commitment statutes. The rate of violent victimization in their sample was 2.5 times
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higher than that of the general population, and half of the sample engaged in violent

behavior during the follow-up period. They also found a significant association between
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victimization and violence perpetration; the odds of violence increased 1.76 times with

prior victimization. In a study of 802 adults with severe mental illness, Swanson et al.

(2002) found that substance abuse, violence in the environment, and past victimization

cumulatively predicted violent behavior. Thus, while victimization alone may increase an

individual’s risk for violence, it likely interacts with other violence risk factors that are

common among individuals with mental illness; together, these risk factors substantially

increase the likelihood of violence.

Legal involvement. Not only are mentally ill individuals more likely to be

victimized, they are also more likely to come into contact with the criminal justice system,

 
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perhaps in part due to their symptoms. An individual talking to him or herself, yelling,

staring, or moving erratically may alarm and frighten members of the general public, or

even mental health professionals (Link & Cullen, 1986; Meguid, Rabie & Bessim, 2010),

regardless of the individual’s true risk level (Hiday, 1995). Such stigma and

misunderstanding can increase violence risk in several potential ways, including

confrontation and escalation with members of the public, purposeful victimization due to

stigma, or perceived vulnerability (Peck, 2003).

Once police intervene, there is a higher likelihood of escalation to arrest or

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violence (Tucker, Van Hasselt & Russell, 2008). For example in a field study of 283

police officers, police were significantly more likely to arrest mentally individuals
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(46.7%) than individuals without a mental illness (27.9%) (Teplin, 2001). This bias is

especially prevalent when police officers are not trained to interact with mentally ill
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individuals (Lamb, Weinberger, & Gross, 2004; Ormston, 2010; Sadler, Corell, Park, &

Judd, 2012; Tucker et al., 2008; Watson & Angell, 2013). Individuals with mental illness
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are often less able to comply with police requests (Engel & Silver, 2001), which may

place them at higher risk for reprimands (Gillis v. Litscher, 2006; Holmes & Murray,

2011) and use of physical force during which they may feel the need to defend

themselves. When convicted and sentenced to prison, individuals with mental illness are

disproportionately victimized (Crisanti & Frueh, 2011; Wood & Buttaro, 2013), which in

turn increases violence risk. Finally, incarceration often leads to an increase in pre-

existing psychiatric symptoms, which may then further increase violence risk (Fedock,

Fries, & Kubiak, 2013; Felson, Silver, & Remster, 2012). Taken together, the effects of

criminal justice involvement on mentally ill individuals increases other risk factors for

 
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violence such as victimization, mental health symptoms, stress, and a number of

obstacles to reintegration (e.g., employment, living situation, reduced social support), all

of which also increase violence risk.

To summarize, empirical evidence links past victimization to increased violence

risk, and criminal justice involvement likely increases a variety of other risk factors for

violence. Next, the literature on specific disorders and symptoms is reviewed to identify

clinical correlates of violence.

Clinical risk factors. Demographic and historical variables tend to be the

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strongest statistical predictors of violent behavior (Corrigan & Watson, 2005; Heilbrun et

al., 2010). However, it is also important to examine clinical variables as predictors of

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violence in mentally ill populations, as different clinical factors may be more or less

pertinent to violence risk. The section below summarizes the mental disorders that have
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strongest empirical ties to violence risk.

Substance abuse. Based on research to date, the specific mental disorder with the
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strongest association to violence is substance abuse. Involvement with controlled

substances can lead to violence through a number of different pathways, many of which

have less to do with acute intoxication than with the lifestyle, social, and legal contexts

that surround substance use (Boles & Miotto, 2003). Elbogen and Johnson (2009)

analyzed data on almost 35,000 U.S. residents from the National Epidemiological Survey

on Alcohol and Related Conditions (NESARC), and found that severe mental illness in

the last 12 months predicted violent behavior only among individuals with alcohol or

substance abuse or dependence, χ2 (1, N = 34,653) = 71.42, p < .001. In contrast, Van

Dorn, Volavka, and Johnson (2012) reanalyzed this NESARC data and found that

 
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although alcohol and drug abuse moderated the relationship between serious mental

illness and violence, serious mental illness still increased the risk of violence in the

absence of substance abuse, OR = 1.60, 95% CI [1.17, 2.20], p < .01.

In a small retrospective study of 64 psychiatric patients, Fulwiler and Ruthazer

(1999) found that adolescents who began using alcohol or other substances before the age

of 15 and before the emergence of psychiatric symptoms were over six times more likely

to engage in violent behavior as adults, OR = 6.4, 95% CI [2.0, 20.2], p = .002. With a

sample of over 800 inpatient and outpatient psychiatric patients, Swanson et al. (2002)

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found that those who abused alcohol or controlled substances were more than five times

more likely to be violent than those who did not. Bonta et al.’s (1998) meta-analysis on
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violence in psychiatric populations demonstrated that any controlled substance use

increased the likelihood of violence (Zr = .11, p < .001). However, the relationship
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between substance use and violence may be exacerbated by other factors for mentally ill

individuals. For example Brunette et al. (2008) studied violence in psychiatric patients
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receiving treatment for substance abuse. They found that violence was more likely among

those patients who were referred to previous substance abuse treatment by a family

member, χ2 (1, N = 1774) = 6.0, p < .01, were victims of childhood physical abuse, χ2 (1,

N = 1774) = 10, p < .01, and were victims of childhood sexual abuse, χ2 (1, N = 1774) =

248, p < .01. Individuals who abused substances and were victims of childhood physical

or sexual abuse were over twice as likely to engage in violence compared with

psychiatric patients who used substances but had not been abused in childhood (Brunette

et al., 2008). Rates of violent offending may also differ depending on the type of

substance abused. For example alcohol-related violence may be due to the effects of

 
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acute intoxication, while illegal substance-related violence may be more strongly linked

to the activities that surround illegal substance use and trafficking, such as user-

perpetrated violence in order to procure substances, or dealer / trafficker-perpetrated

violence to resolve debts or deal with competition (Boles & Miotto, 2003). However,

these potentially different causal mechanisms have not been empirically investigated.

Psychosis. Aside from substance abuse, psychosis appears to be one of the most

robust clinical predictors of violence in psychiatric populations. A meta-analysis of 204

studies of psychosis and violence by Douglas et al. (2009) showed that the presence of

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psychotic symptoms increased the probability of violence from 49% to 68%. However,

not all psychotic symptoms seem to be equally associated with violence. Douglas et al.
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found that individuals who experienced positive symptoms such as hallucinations and

delusions (in particular threat/control override delusions1) were significantly more likely
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to be violent than those who did not have these symptoms (Median OR = 2.32, 95% CI

[1.23, 3.46]). A further meta-analysis and review of the literature by Reagu, Jones,
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Kumari, and Taylor (2013) showed that anger is significantly associated with violent

behavior in patients experiencing psychosis. In a study of over 450 patients with first-

episode psychosis, Coid et al. (2013) found a significant relationship between delusions

and violence, which was mediated by anger (z = 3.09, p = .002), feelings of being spied

on (z = 3.03, p = .002), and conspiracy delusions (z = 2.98, p = .002). A review of 20

empirical studies on psychosis and violence by Bjørkly (2002a) also showed that

persecutory delusions increased the risk of violent behavior, but only when combined

with negative emotionality. Results of a large epidemiological study indicate that

perceiving hidden threats from others in the context of psychosis increases the odds of

 
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violent behavior 1.45 times, even in the absence of substance use (Elbogen & Johnson,

2009). Bjørkly (2002b) also reviewed 17 studies on the relationship between

hallucinations and violence. He found that - contrary to popular belief - command

hallucinations alone do not increase violent behavior. Although less often studied, there is

some evidence that the disorganized symptoms found in psychosis may have a

destabilizing effect that indirectly increases risk for violence (Douglas et al., 2009);

however, further research is needed to test this hypothesis.

In summary, evidence for a direct relationship between psychotic symptoms are

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mixed, with some evidence that particular subtypes of symptoms (paranoid ideation,

command auditory hallucinations, threat control override symptoms) in combination with

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negative affect such as anger may be associated with increased violence. Further research

is necessary to better elucidate the connection between various psychotic symptoms and
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violence.

Specific psychotic disorders. Research studies on the association between

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psychosis and violence tend to focus on the presence or absence of acute psychotic

symptoms, rather than on the diagnosis more generally. Yet psychotic symptoms can

occur in a variety of different mental disorders, such as schizophrenia spectrum disorders,

major depressive disorder, and bipolar disorder. It is important to consider how violence

risk might differ depending on the diagnosis, not only in relation to acute psychotic

symptoms, but also to the other features of the disorder. The following paragraphs

discuss how specific psychotic disorders – including schizophrenia, depression, and

bipolar disorder – may be associated with violence for reasons other than the presence of

psychosis.

 
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Schizophrenia. Schizophrenia is the psychotic disorder most often associated with

violence. In a nationally representative U.S. sample of almost 7000 individuals with

mental illness drawn from the NESARC epidemiological study referenced above,

Elbogen and Johnson (2009) found that amongst individuals without substance use issues,

6% of those with schizophrenia engaged in violent behavior during a one-year follow-up,

compared to 4% of patients with bipolar disorder and 2% of patients with depression.

Although psychotic symptoms are the focus of most research on schizophrenia and

violence, individuals with schizophrenia-spectrum disorders display a host of symptoms

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aside from delusions, hallucinations, and disorganized speech and behavior. In fact, some

of the most compelling research on the functional impairment of individuals with

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schizophrenia concerns deficits in social cognition . Many studies have shown that

individuals with schizophrenia experience significant problems perceiving and

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responding to social cues, and show deficits in empathy (Hooley, 2009).

Whereas some scholars purport that increased violence rates in schizophrenia are
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attributable only to the acute psychotic symptoms in untreated individuals (Kuehn, 2012),

other researchers have posited that more stable deficits such as social cognition may also

increase risk for violence, even in the absence of acute primary symptoms. To test this

hypothesis, Bragado-Jimenez and Taylor (2012) reviewed six studies on empathy,

schizophrenia and violence, and found tentative evidence of an association between lack

of empathy and violence in schizophrenia. For example, the researchers found that the

relationship between schizophrenia and violence was moderated by misattribution of

sadness, OR = 1.31, p = 0.05, fear, OR = 1.26, p = 0.03, and anger, OR = 0.53, p = 0.001,

(Weiss et al., 2006).