Violence and Mental Illness: Disseminating Fact and Dispelling Fiction

Introduction:

It is a tremendous pet peeve of mine when I read or hear others strongly associate mental illness with violence, mass shootings, and extremism. Not only are these accusations unfounded, but they continue to perpetuate stigmatization of those suffering from mental illness. In this post, I will counter the common myths and false claims perpetuated by the media, pop culture, and the public, and I will present a complete picture of the of the association between violence and mental illness.

Before reading on, it is important to understand the difference between violence and aggression. Aggression can be physical or verbal, but it is defined as any behavior that is intended to cause harm to another person, who does not desire to be harmed. Violence is defined by aggressive actions intended to cause significant physical harm, such as injury or death. [2]

What is considered Serious Mental Illness?

Serious mental illness (SMI) is typically categorized as individuals suffering from depression, bipolar disorder, PTSD, severe anxiety, and schizophrenia-spectrum disorders. [1] However, it is not limited to those specific diagnoses. The National Institute of Mental Health defines SMI as:

“A mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities. The burden of mental illnesses is particularly concentrated among those who experience disability due to SMI. [25]

         I often see claims in the media and on social media categorizing individuals with antisocial personality disorder (psychopathy, sociopathy) as individuals with severe mental illness. Many people may be confused by the idea that this would not be considered a SMI, but it is not typically categorized as such. Psychopathy and sociopathy (antisocial personality disorder) fall in the category of personality disorders.

            An important distinction in personality disorders is that there is no efficacious pharmacological treatment--personality disorders can be treated, but not effectively through medication management. [13] Medication can be used to treat symptoms of personality disorders, but there is no recognized or approved medication to treat personality disorders themselves. [13] However, there are effective means of treating personality disorders, such as Dialectical Behavioral Therapy (DBT). [13] I have witnessed DBT work wonders in treating Borderline Personality Disorder in my time as a caseworker.

           This does not mean that one cannot have comorbid SMI and antisocial personality disorder. For instance, I worked with a number of individuals who were diagnosed with antisocial personality disorder and schizophrenia-spectrum disorders.

Is there a Link between Serious Mental Illness and Violent Behavior?

The MacArthur Violence Risk Assessment Study found that by 20 weeks after discharge from inpatient psychiatric care, command hallucinations (i.e., auditory hallucinations/voices) instructing a participant to harm others and psychopathy (i.e., anti-social personality disorder) were the only clinical symptoms associated with violence. It is important to again point out that psychopathy/sociopathy (antisocial personality disorder) are not typically considered a serious mental illness (SMI). [1] When viewing the clinical symptoms of various SMI, the only symptom the study found to be associated with violence was command hallucinations of psychotic disorders, or disorders with psychotic features.

The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) conducted a survey of 34,653 people assessing violent acts over a period of 4 years, focusing on the following three groups: individuals diagnosed with a SMI, those with substance use/dependence, and those with a history of violence. [6] The following is a graphic representing their findings of predicted probability of violence:

As represented in the graphic, this study found that individuals diagnosed with SMI were no more likely to commit violence than individuals without a diagnosed mental illness. [6] When there are co-occurring diagnoses of SMI and substance use, we still do not see a significant rise in predicted violence. However, when a history of violence is combined with SMI or substance use, we see a sharp increase in predicted violence. When all three models overlap, we can see the most significant interaction predicting future violence. [6]

In contrast to the NESARC study’s focus on predicting future violence, another study used their data to instead focus on trying to establish a causal relationship between SMI and violent behavior. This study, by Social Psychiatry and Psychiatric Epidemiology, found that between 2 and 4 years after NESARC’s study’s baseline, 0.8% of individuals without a SMI had committed violent acts, compared to 2.9% of people with SMI, and 10% of people with SMI and co-occurring substance use disorder. [4] This is more in line with the general consensus view of SMI, co-occurring substance use disorder, and violent behavior.

It is still important to note that violent acts had only increased by 2.1% in the SMI group, versus a 9.2% increase in the population with co-occurring SMI and substance use disorder. [4] Is this a causal relationship in the SMI group, or is this indicative of underlying contextual factors posing as confounding variables?

Psychosocial Contextual Factors Influencing Violence:

       The MacArthur Violence Risk Assessment Study found that the participants who lived in impoverished, unsafe, and/or high crime neighborhoods did not have higher rates of violent behavior than their neighbors. [1] Additionally, there are higher rates of homelessness among the population with SMI, and mentally ill individuals are more likely to live in socially disorganized environments with higher crime rates and likelihood of victimization. [11]

           Paul Appelbaum, an author of the MacArthur Risk Assessment Study, stated that “a great deal of what is responsible for violence among people with mental illness may be the same factors that are responsible for violence among people without mental illness.” [11]

       The NESARC study specifically addressed contextual factors that influence this population and their possible propensity for violence. They found that while individuals diagnosed with a mental illness did report violence more often, it was largely because they displayed other factors associated with violence. [6] In other words, individuals with diagnosed mental illnesses were more likely than those without a mental illness to be experiencing contextual factors that influence violent behavior.

       The MacArthur Violence Risk Assessment Study found the following psychosocial contextual factors moderated violent behavior: [1]

History of prior violence
History of childhood abuse
Having a father who abused substances or was a criminal
Displaying antisocial behavior
Scoring high on anger measures

Substance Use, SMI, and Violent Behavior

           We can see from the study by Social Psychiatry and Psychiatric Epidemiology that the group possessing SMI and co-occurring substance use disorder were 7.1% more likely to have committed violent acts than individuals with SMI alone, and 9.2% more likely than those without a diagnosed mental illness. [4] It is very important to note the propensity for substance use to exacerbate the symptoms of SMI. [24]

         When we think back to the MacArthur Violence Risk Assessment Study, which found command hallucinations to be associated with violence [11], we can begin to imagine scenarios in which substance use combined with SMI can lead to an increased likelihood of violent behavior.

           For instance, substance use can cause or exacerbate psychotic symptoms in individuals diagnosed with schizophrenia-spectrum disorder or mood disorders with psychotic features. [27] This often includes command hallucinations, or psychotic voices which can demand the individual hurt or kill themselves or others. [11] Substance use combined with SMI yields a greater outcome of violence, and the substance use is destabilizing and likely to exacerbate symptoms of mental illness. [4] [24]

           Furthermore, substance use alone can lead to states of drug-induced psychosis, in which the individual is more likely to act violently. [7] Alcohol alone plays a significant role worldwide in increased aggression, crime, and violence. [21] Substance use is a far more serious contributing factor to violence than SMI alone.

Are there Mental Illnesses with a Stronger Association with Aggression and Violence?

Dementia and Alzheimer’s Disease:

           Among individuals diagnosed with some form of dementia or Alzheimer’s disease, 90% experience noncognitive symptoms. [5] Among them, the most concerning and frequent noncognitive symptom is aggression. [8] 50% of individuals diagnosed with dementia exhibit aggressive behavior, defined as "any physical or verbal behavior that has the effect of harming or repelling others, and includes behaviors such as hitting, kicking, and screaming.” [5]

           This increase in aggression in dementia/Alzheimer’s can be due to physical problems (e.g., constipation, UTI, and inability to communicate the need/problem), medication side effects, environmental factors, or the disease itself (i.e., confusion, fear). [19] [8]

         Two leading theories aimed at explaining mechanisms for aggression in dementia sufferers are need-driven dementia-compromised behavior (NDB) and progressively lowered stress threshold (PLST). [5] The PLST model focuses on the individual’s lowered tolerance of stress and discomfort. The NDB model encompasses the individual’s inability to articulate their physical, social, or environmental needs, which can result in aggression as a form of communicating that there are needs not being met. [5]

         Bathing is often a particularly challenging and distressing event, and often results in increased aggression among individuals diagnosed with dementia. [16] This is due to various factors, including sensory changes, fear, confusion, and pain; but it can be mitigated through empathetic and person-centered bathing practices. [16]

         Sundowners syndrome (or late-day confusion) is a group of symptoms individuals with dementia may experience, including changes in behavior, thinking, and mood; including fear, agitation, and irritability. [14] It is common for caretakers to be more on-guard around individuals who experience late-day confusion as the light begins to fade from the day. These symptoms can present during the day as well. [22]

Traumatic Brain Injuries:

         Traumatic brain injury (TBI) can result in significant changes to one’s cognitive abilities, motor control, emotions, ability to care for oneself, and even personality changes. [26] Studies determining the rates of aggressive behavior in individuals with a TBI vary significantly due to differences in operational definitions of aggression.

           One study which consisted of a well-controlled but relatively small sample (N=89), found that 33.7% of patients with a TBI exhibited significant aggressive behavior in the first 6 months following the traumatic episode. [23] They defined aggression in terms of the OAS (Overt Aggression Scale).

           It is imperative to remember the distinction between aggression and violence, as the vast majority of aggression displayed in those suffering from a TBI is verbal aggression, whereas physical aggression is much rarer. [17]

Anti-Social Personality Disorder:

The term sociopath is not an official diagnostic term, and instead refers to an individual diagnosed with anti-social personality disorder (ASPD). Likewise, the term psychopath is not an official diagnostic term. [9] There is debate over whether psychopathy and ASPD are separate conditions, or if psychopathy is a specific type of ASPD. There have also been studies arguing that psychopathy is a more violent version of ASPD. There is significant overlap between the two, and psychopathy is generally considered under the umbrella of ASPD. [9]

Individuals diagnosed with ASPD account for a significant number of crimes and are more likely to reoffend than other offenders. [15] Individuals with ASPD have a tendency to purposefully aggravate others, are very manipulative, and act without remorse or empathy. [9] The Mayo Clinic [12] lists the following risk factors for ASPD:

Diagnosis of childhood conduct disorder.
Family history of antisocial personality disorder or other personality disorders or mental health conditions.
Experiencing abuse or neglect during childhood.
Unstable or violent family life during childhood.

The Psychiatric Times states: “ASPD-related violence can be characterized as predominantly reactive (i.e., involving immediate, angry responses to provocations). Impulsive fighting and assaults toward acquaintances or family members are in fact common.” [15] Both a genetic predisposition as well as environmental factors influence the development of ASPD. [15]

Treatment for ASPD can be difficult, as individuals suffering from severe symptoms often do not believe there is a problem with their behavior and are often reluctant to receive treatment. However, treatment does exist in the form of psychotherapy such as Cognitive Behavioral Therapy (CBT) [12], and there is evidence to suggest that Dialectical Behavioral Therapy (DBT) may be advantageous in treating ASPD. [18] Like all other personality disorders, medication management can be used to treat symptoms of ASPD, but there is no medication approved for treating ASPD itself. [12]

Victimization of Individuals with Mental Illness

         The Substance Abuse and Mental Health Services Association (SAMHSA) asserts that: “Only 3%–5% of violent acts can be attributed to individuals living with a serious mental illness. In fact, people with severe mental illnesses are over 10 times more likely to be victims of a violent crime than the general population.” [20]

         To review, individuals with SMI are potentially only 2.1% more likely than those without a mental illness to be violent [4], but they are 10 times more likely to be victims of violence themselves. [20] Patients with SMI are more likely than any other community member to be the victim of a violent crime, and mentally ill individuals are more likely to live in socially disorganized environments with higher crime rates and likelihood of victimization. [11]

           The population suffering from mental illness continues to be victimized and further stigmatized every time claims are made falsely associating SMI with acts of violence, extremism, and mass killings. When people suffering from SMI read or hear remarks like this made by their friends, family, colleagues, media, etc., it makes them feel ashamed, fearful, and like they now must hide this aspect of their life. It makes people struggle in secret instead of being supported by family, friends, community, and peers.

Mass Shootings:

       It is one thing when the media and public speculate that mass shooters may have/had ASPD, as the reactive violence that can lead to mass shootings has an overlap with characteristics of ASPD. [15] However, it is important to remember that ASPD is not considered a severe mental illness (SMI). When the media and people on social media claim that mass shootings in general are due to SMI, they are both categorically incorrect and only serving to demonize and stigmatize those suffering from mental illness.

           Mass shootings are marked by components of anti-social behavior, social isolation, feelings of rejection, perceived victimization/threat, and a similar type of reactive violence displayed in those with ASPD. [15] These are the same components that contribute to the development of extremist ideologies and actions, such as those perpetrated by the “Incel” (meaning “involuntary celibacy”) community, who have been responsible for acts of violence, murder, and domestic terrorism, particularly focused on women and couples. [28]

           It is fair to say that a radicalized individual like this would most likely have severe behavioral dysfunction, but it is not accurate or honest to say that this is an individual suffering from a SMI. That is not how people are diagnosed. People become radicalized, and some risk factors may be genetic predisposition, situational factors, identity fusion to a group, and perceived threat to their group. [3]

          Some groups also form and radicalize through echo-chambers in online forums like 4 Chan and Reddit, such as the Incel community. What drives a person to commit such acts of violence and extremism is a very complicated matter, and to attribute it to SMI is inaccurate and harmful. It is also important to point out that less than 1% of radicalized individuals engage in a violent act. [3]

Summary:

Only 3-5% of violent acts can be attributed to those with SMI [20], co-occurring substance use plays the most pivotal role in violence [24], many psychosocial contextual factors influence violent acts [11], and while individuals with SMI are potentially 2.1% more likely than those without a mental illness to be violent [4], they are 10 times more likely to be victims of violence themselves. [20]

There does not exist a strong association between severe mental illness and violent behavior in general. Specific mental illnesses that do not fall into the category of SMI do have an association with aggression and violence, such as dementia/Alzheimer’s disease, traumatic brain injuries, and anti-social personality disorder. However, the notion that mentally ill individuals are violent is a harmful myth that only serves to further stigmatize an already disadvantaged population. This behavior is detrimental to the 26% of our (U.S.) population suffering from a diagnosed mental illness. [10] The false claims that individuals with SMI are dangerous and responsible for mass shootings and acts of extremism need to be called out for the harmful lies that they are.

References:

[1]. Appelbaum, P. S. (2023, September 7). The MacArthur Violence Risk Assessment Study. University of Virginia School of Law. https://www.law.virginia.edu/macarthur-violence-risk-assessment-study

[2]. Bushman, B. J. (2022). Aggression and violence. An Introduction to Social Psychology. https://opened.tesu.edu/introsocialpsychology/chapter/aggression-and-violence/

[3]. Cornell University. (n.d.). What we know about radicalization. Evidence Based Living. https://evidencebasedliving.human.cornell.edu/blog/what-we-know-about-radicalization/

[4]. DeAngelis, T. (2022, July 11). Mental illness and violence: Debunking myths, addressing realities. Monitor on Psychology. https://www.apa.org/monitor/2021/04/ce-mental-illness

[5]. Dettmore, D., Kolanowski, A., & Boustani, M. (2009a). Aggression in persons with dementia: Use of nursing theory to guide clinical practice. Geriatric nursing (New York, N.Y.). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3365866/

[6]. Elbogen, E. B. (2009, February 1). The Intricate Link between Violence and Mental Disorder. Archives of General Psychiatry. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/210191

[7]. Fiorentini, A., Cantù, F., Crisanti, C., Cereda, G., Oldani, L., & Brambilla, P. (2021, December 23). Substance-induced psychoses: An updated literature review. Frontiers in psychiatry. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8732862/

[8]. Gilmore, M. C., Chenoweth, L., Cohen-Mansfield, J., & et al. (2020, March 30). Development and treatment of aggression in individuals with dementia. Aggression and Violent Behavior. https://www.sciencedirect.com/science/article/abs/pii/S1359178920300781

[9]. Haghighi, A. S. (2021, July 6). Psychopath vs. sociopath: How do they differ?. Medical News Today. https://www.medicalnewstoday.com/articles/psychopath-vs-sociopath

[10]. Johns Hopkins Medicine. (2023, February 1). Mental health disorder statistics. https://www.hopkinsmedicine.org/health/wellness-and-prevention/mental-health-disorder-statistics

[11]. Latalova, K., Kamaradova, D., & Prasko, J. (2014, October 9). Violent victimization of adult patients with severe mental illness: A systematic review. Neuropsychiatric disease and treatment. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4200170/

[12]. Mayo Clinic. (2023a, February 24). Antisocial personality disorder. https://www.mayoclinic.org/diseases-conditions/antisocial-personality-disorder/diagnosis-treatment/drc-20353934

[13]. Mayo Foundation for Medical Education and Research. (2023c, July 14). Personality Disorders. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/personality-disorders/diagnosis-treatment/drc-20354468

[14]. Nall, R. (2021, June 30). Sundowner’s syndrome: Symptoms, causes, treatment tips, and more. Medical News Today. https://www.medicalnewstoday.com/articles/314685

[15]. Patrick, C. J., & Verona, E. (2015, March 25). Psychobiological aspects of antisocial personality disorder, psychopathy, and violence. Psychiatric Times. https://www.psychiatrictimes.com/view/psychobiological-aspects-antisocial-personality-disorder-psychopathy-and-violence

[16]. Rader, J., Barrick, A. L., Hoeffer, B., & et al. (2006, April). The bathing of older adults with dementia: Easing the... : Ajn the American Journal of Nursing. LWW. https://journals.lww.com/ajnonline/Fulltext/2006/04000/The_Bathing_Of_Older_Adults_with_Dementia__Easing.26.aspx

[17]. Rao, V., Rosenberg, P., Bertrand, M., & et al. (2009). Aggression after traumatic brain injury: Prevalence and correlates. The Journal of neuropsychiatry and clinical neurosciences. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2918269/

[18]. Rizvi, S. L., Search for more papers by this author, & Linehan, M. M. (2005, July 1). Dialectical behavior therapy for personality disorders. FOCUS. https://focus.psychiatryonline.org/doi/full/10.1176/foc.3.3.489

[19]. Roland, J. (2022, August 4). Alzheimer’s, violence and aggression: Causes, signs, management. Healthline. https://www.healthline.com/health/alzheimers/alzheimers-violence#management

[20]. SAMHSA. (2023, April 24). Mental health myths and facts. https://www.samhsa.gov/mental-health/myths-and-facts

[21]. Sontate, K. V., Rahim Kamaluddin, M., Naina Mohamed, I., Mohamed, R. M. P., Shaikh, M. F., Kamal, H., & Kumar, J. (2021, December 20). Alcohol, aggression, and violence: From public health to neuroscience. Frontiers in psychology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8729263/

[22]. Sundown Syndrome: Causes, treatment & symptoms. Cleveland Clinic. (2022, April 26). https://my.clevelandclinic.org/health/articles/22840-sundown-syndrome

[23]. Tateno, A., Search for more papers by this author, Jorge, R. E., & et al. (2003, May 1). Clinical correlates of aggressive behavior after traumatic brain injury. Psychiatry Online. https://neuro.psychiatryonline.org/doi/full/10.1176/jnp.15.2.155

[24]. Team, B. and S. (2023, October 6). Why substance misuse worsens mental health. Cleveland Clinic. https://health.clevelandclinic.org/dual-diagnosis-why-substance-abuse-worsens-your-mental-health/

[25]. U.S. Department of Health and Human Services. (n.d.). Mental Illness. National Institute of Mental Health. https://www.nimh.nih.gov/health/statistics/mental-illness

[26]. U.S. Department of Health and Human Services. (n.d.). Traumatic brain injury (TBI). National Institute of Neurological Disorders and Stroke. https://www.ninds.nih.gov/health-information/disorders/traumatic-brain-injury-tbi

[27]. Winklbaur, B., Ebner, N., Sachs, G., Thau, K., & Fischer, G. (2006). Substance abuse in patients with schizophrenia. Dialogues in clinical neuroscience. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181760/

[28]. Yang, M. (2022, March 16). “incels” are a rising threat in the US, Secret Service report finds. The Guardian. https://www.theguardian.com/us-news/2022/mar/16/involuntary-celibates-incels-threat-us-secret-service

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