Delusions, Anger, and Serious Violence
Delusions, Anger, and Serious Violence
Introduction: Recent research on the association between delusions and violence has suggested complex and differing pathways. Furthermore, it has been emphasized that temporal proximity is fundamental when investigating these relationships. We reanalyzed data from the MacArthur Violence Risk Assessment Study utilizing a different methodological approach to investigate associations between specific delusions and violence.
Methods: Longitudinal study of 1136 male and female civil psychiatric inpatients after discharge. Delusions, affect due to delusions, and violence were measured at baseline and in 5 follow-up assessments. Serious violence was established using the MacArthur Community Violence Interview. Logistic mixed-effect models for repeated measures were performed.
Results: A "prospective" model confirmed previous findings that delusions do not predict later violence. However, reanalysis, considering temporal proximity, indicated a relationship between specific delusions and outcome including: being spied upon (adjusted OR [AOR] = 1.62, 95% CI = 1.06–2.47, P = .027), being followed (AOR = 1.90, 95% CI = 1.29–2.80, P = .001), being plotted against (AOR = 1.70, 95% CI = 1.14–2.52, P = .009), being under control of person/force (AOR = 1.92, 95% CI = 1.24–2.97, P = .003), thought insertion (AOR = 1.63, 95% CI = 1.00–2.66, P = .048), and having special gifts/powers (AOR = 1.95, 95% CI = 1.31–2.92, P = .001). All these delusions were associated with angry affect (P < .05). Inclusion of anger in the model significantly attenuated the main effects (except grandiose delusions), indicating an indirect pathway.
Conclusions: Temporal proximity is crucial when investigating relationships between delusions and violence. Anger due to delusions is the key factor in this pathway. Our findings have important implications for identification of psychotic patients at risk for violent behavior and, most importantly, management of their risk.
Key findings from the MacArthur Violence Risk Assessment Study (MVRAS), which showed that delusions do not predict violence among recently discharged psychiatric patients, had a profound impact on research in this field. Furthermore, several epidemiological surveys and case register studies found that, at the population level, psychosis showed little or no association with violence, which was explained almost entirely by comorbid substance misuse, or psychosocial adversity and environmental stressors more common in the lives of persons with severe mental illness.
More recently, researchers have reevaluated associations between violence and psychosis and observed contrasting findings according to whether the aim is to identify (statistical) predictors of violence or to establish relationships that allow consideration of causality. Reanalysis of data from the National Epidemiologic Survey of Alcohol and Related Conditions revealed a positive association between major mental illness and violence, demonstrating that temporal proximity between dependent and independent variables is crucial when investigating these relationships. Predictors derived from studies measuring symptoms or diagnoses at various points over the lifetime and comparing them with self-report or criminal records over extended periods cannot establish valid associations. Furthermore, because acute psychotic symptoms may present for relatively short periods, predictors which are identified over the lifespan may not be specific for psychosis and may apply equally to incidents of violence among the general (nonpsychotic) population.
Studies taking into consideration temporal proximity between exposure and outcome have confirmed associations between delusions and violence, albeit of a complex nature and involving more than 1 pathway. Findings from the Clinical Antipsychotic Trials of Interventions Effectiveness Study showed that hallucinations accompanied by delusional interpretations, and delusional thinking associated with suspiciousness and feelings of persecution, were related to serious violence among patients with schizophrenia. Anger due to delusional beliefs was the key factor explaining the association between first episode psychosis and violence in a UK study. Three highly prevalent delusions of persecution, being spied upon, and conspiracy demonstrated associations with serious violence, but only when the delusions made the patients angry. Anger is intrinsically and reciprocally related to threat perception and drives violent behavior in the absence of self-regulatory controls. Actively paranoid patients are more likely to misidentify neutral facial expressions as angry than those whose symptoms are not active. It appears that a subset of delusional beliefs lead to "tense situations," and that angry affect is an important component in a causal model of mental illness and violence.
When MVRAS was conducted, emphasis was placed on a "prospective" approach to overcome methodological shortcomings of previous research on the relationship between delusions and violence. To investigate direct pathways, delusional beliefs assessed in the past 10 weeks were modeled as predictors for serious violence in the following 10 weeks. However, based on the relevance of temporal proximity when studying these associations, there are compelling reasons to reexamine the MVRAS findings. Furthermore, confirmation is needed as to whether angry affect is an important mediator in the pathway between delusions and violence in a clinical sample with different diagnostic composition, and where only a minority of patients were in their first episode. We therefore carried out a statistical reanalysis of MVRAS data, utilizing a different approach, to examine associations between delusions and serious violence to investigate: whether there is a direct pathway; whether associations are confounded/mediated by diagnosis, trait anger, or affect due to delusional belief; and which delusional beliefs have the strongest effect on outcome (serious violence).
Abstract and Introduction
Abstract
Introduction: Recent research on the association between delusions and violence has suggested complex and differing pathways. Furthermore, it has been emphasized that temporal proximity is fundamental when investigating these relationships. We reanalyzed data from the MacArthur Violence Risk Assessment Study utilizing a different methodological approach to investigate associations between specific delusions and violence.
Methods: Longitudinal study of 1136 male and female civil psychiatric inpatients after discharge. Delusions, affect due to delusions, and violence were measured at baseline and in 5 follow-up assessments. Serious violence was established using the MacArthur Community Violence Interview. Logistic mixed-effect models for repeated measures were performed.
Results: A "prospective" model confirmed previous findings that delusions do not predict later violence. However, reanalysis, considering temporal proximity, indicated a relationship between specific delusions and outcome including: being spied upon (adjusted OR [AOR] = 1.62, 95% CI = 1.06–2.47, P = .027), being followed (AOR = 1.90, 95% CI = 1.29–2.80, P = .001), being plotted against (AOR = 1.70, 95% CI = 1.14–2.52, P = .009), being under control of person/force (AOR = 1.92, 95% CI = 1.24–2.97, P = .003), thought insertion (AOR = 1.63, 95% CI = 1.00–2.66, P = .048), and having special gifts/powers (AOR = 1.95, 95% CI = 1.31–2.92, P = .001). All these delusions were associated with angry affect (P < .05). Inclusion of anger in the model significantly attenuated the main effects (except grandiose delusions), indicating an indirect pathway.
Conclusions: Temporal proximity is crucial when investigating relationships between delusions and violence. Anger due to delusions is the key factor in this pathway. Our findings have important implications for identification of psychotic patients at risk for violent behavior and, most importantly, management of their risk.
Introduction
Key findings from the MacArthur Violence Risk Assessment Study (MVRAS), which showed that delusions do not predict violence among recently discharged psychiatric patients, had a profound impact on research in this field. Furthermore, several epidemiological surveys and case register studies found that, at the population level, psychosis showed little or no association with violence, which was explained almost entirely by comorbid substance misuse, or psychosocial adversity and environmental stressors more common in the lives of persons with severe mental illness.
More recently, researchers have reevaluated associations between violence and psychosis and observed contrasting findings according to whether the aim is to identify (statistical) predictors of violence or to establish relationships that allow consideration of causality. Reanalysis of data from the National Epidemiologic Survey of Alcohol and Related Conditions revealed a positive association between major mental illness and violence, demonstrating that temporal proximity between dependent and independent variables is crucial when investigating these relationships. Predictors derived from studies measuring symptoms or diagnoses at various points over the lifetime and comparing them with self-report or criminal records over extended periods cannot establish valid associations. Furthermore, because acute psychotic symptoms may present for relatively short periods, predictors which are identified over the lifespan may not be specific for psychosis and may apply equally to incidents of violence among the general (nonpsychotic) population.
Studies taking into consideration temporal proximity between exposure and outcome have confirmed associations between delusions and violence, albeit of a complex nature and involving more than 1 pathway. Findings from the Clinical Antipsychotic Trials of Interventions Effectiveness Study showed that hallucinations accompanied by delusional interpretations, and delusional thinking associated with suspiciousness and feelings of persecution, were related to serious violence among patients with schizophrenia. Anger due to delusional beliefs was the key factor explaining the association between first episode psychosis and violence in a UK study. Three highly prevalent delusions of persecution, being spied upon, and conspiracy demonstrated associations with serious violence, but only when the delusions made the patients angry. Anger is intrinsically and reciprocally related to threat perception and drives violent behavior in the absence of self-regulatory controls. Actively paranoid patients are more likely to misidentify neutral facial expressions as angry than those whose symptoms are not active. It appears that a subset of delusional beliefs lead to "tense situations," and that angry affect is an important component in a causal model of mental illness and violence.
When MVRAS was conducted, emphasis was placed on a "prospective" approach to overcome methodological shortcomings of previous research on the relationship between delusions and violence. To investigate direct pathways, delusional beliefs assessed in the past 10 weeks were modeled as predictors for serious violence in the following 10 weeks. However, based on the relevance of temporal proximity when studying these associations, there are compelling reasons to reexamine the MVRAS findings. Furthermore, confirmation is needed as to whether angry affect is an important mediator in the pathway between delusions and violence in a clinical sample with different diagnostic composition, and where only a minority of patients were in their first episode. We therefore carried out a statistical reanalysis of MVRAS data, utilizing a different approach, to examine associations between delusions and serious violence to investigate: whether there is a direct pathway; whether associations are confounded/mediated by diagnosis, trait anger, or affect due to delusional belief; and which delusional beliefs have the strongest effect on outcome (serious violence).
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