The link between violence and mental health

There are many misconceptions about mental health conditions, including the perception that they often exhibit violent or dangerous behaviors. Violence occurs due to several factors and cannot be attributed solely to mental health issues. However, some individuals with mental health conditions may be more likely to behave violently than others.

Is violence a sign of mental health conditions?

Violence is not necessarily a sign of mental health conditions. People with and without mental illnesses cause violence. Although some people with psychiatric disorders can behave violently, this behavior cannot always be attributed to their mental health ^[1].

Studies show that only a small proportion of violence in the community is perpetrated by people with mental health conditions. Also, a higher proportion of people with mental health conditions are not violent than those who are ^[2][3].

Some mental illnesses can increase the risk of violent behavior, although this risk can vary significantly depending on the condition, symptom severity, and other factors. For example, two people with the same psychiatric diagnosis may experience different clinical symptoms and may have experienced different past and current circumstances, thereby causing a vast difference in their risk of violence.

Various factors influence the risk of violence, including a history of violence, past experiences of abuse, current lifestyle and circumstances, age, and gender. These key risk factors can dramatically impact an individual’s risk of violent behavior, regardless of their mental health ^[4][5].

Similarly, substance and alcohol misuse has also been found to significantly increase the risk of violence, both in individuals with mental illness and without ^[2][5].

Studies also show that individuals who have received appropriate and effective mental health treatment are almost equally as likely to behave violently as those without a mental illness. Most acts of violence caused by people with mental illnesses occurs when their condition is unstable due to inappropriate or discontinued treatment or other contributing factors ^[2][6].

Which mental health disorders include symptoms of violence?

Violence may be more likely in some mental health conditions than others and can vary depending on the context. For example, mental health patients in inpatient facilities whose conditions are not yet stabilized are more likely to be violent than individuals living in the community ^[2].

Schizophrenia

People with schizophrenia or other psychotic disorders may be up to five times more likely to be violent than the general population ^[3][6]. This risk varies depending on several factors, including the type of symptoms the individual experiences.

Persecutory or paranoid delusions can lead to an elevated risk of violence. People with these types of delusions may attack others due to fear or in an attempt to defend themselves from a perceived threat ^[2].

Additionally, substance or alcohol use, a history of violence, and a lack of appropriate treatment can cause an increased risk of violence in individuals with schizophrenia ^[6].

Studies show that violence occurs in around 10% of people with schizophrenia, indicating that most people with this condition do not display violent behaviors ^[3].

Personality disorders

Individuals with personality disorders, such as antisocial and borderline personality disorders, might exhibit violent behaviors. The risk of violence increases when these disorders occur alongside substance use disorders or psychotic symptoms ^[7].

People with borderline personality disorder typically experience symptoms such as emotion dysregulation and impulsivity, which may lead to violence in some instances ^[2][7].

Antisocial personality disorder can cause symptoms such as a lack of empathy, pursuing personal gain without concern for others, and an inability to regulate anger. This disorder is often associated with conduct disorder, aggressive behaviors, and exposure to physical abuse in childhood, all of which can lead to an increased risk of violence in adulthood ^[7][8].

Substance use disorders

Alcohol and substance use disorders dramatically increase the risk of violence both in individuals with comorbid mental illnesses and those without. Conditions such as schizophrenia and bipolar disorder, when combined with substance use disorder, cause a significant increase in the risk of violence ^[3][5].

Violent behaviors by those with substance use disorders can be attributed to the effects of alcohol and drugs. For example, intoxication or withdrawal from various substances can cause irritability, mania, impulsivity, paranoia, and agitation, potentially increasing the risk of violence ^[2].

Bipolar disorder

Occasionally, people with bipolar disorder behave violently. These behaviors may be related to symptoms of mania, such as grandiosity, impulsivity, an exaggerated sense of power, and an impaired ability to empathize ^[4].

Again, the risk of violence among people with bipolar disorder is significantly increased when combined with alcohol and substance abuse ^[2].

Dementia

Some individuals with dementia, such as Alzheimer’s disease, exhibit aggressive and violent behaviors. This is more likely to occur randomly than as a premeditated attack and is often due to confusion, fear, delusions, pain, or irritability ^[9].

Self-harming behaviors

It is also important to note that definitions of violence include harm to oneself. As such, there is a risk of self-violence occurring within the context of several mental health conditions in the form of self-harm or suicide ^[3].

People with conditions such as schizophrenia, depressive disorders, and trauma-related disorders are more likely to cause harm to themselves than to others ^[10].

The risk of attributing violence to mental health conditions

The way that mental health is portrayed in the news and media can influence how the public views mental illness. For example, news reports on mass shootings in the US often attribute these instances to mental illness. Similarly, movies and television shows often portray dangerous characters as people with mental health conditions ^[3][11].

These portrayals cause the public to believe that mental illness is the cause of violence. This contributes to stigma and discrimination faced by individuals with mental health conditions and can cause public fear and misunderstanding of mental illness ^[11].

Stigmatization of mental health leads to individuals feeling unsafe asking for support or professional help for fear of discrimination and judgment. It also causes people with mental health conditions to be vulnerable to being victims of violence. In fact, it is more likely for people with a mental illness to experience physical and psychological abuse than to perpetrate it ^[3].

Discrimination caused by misconceptions about mental illness can lead to trauma, social isolation, a lack of employment opportunities, and a lack of community support. This can potentially contribute to worsening symptom severity and an increased risk of suicide ^[10][11].

Treatment for violence and mental health

Treatment for someone with a mental health condition exhibiting signs of violence will depend on their condition, symptoms, and prior treatment plans. For example ^[2][3][4][6]:

• If they have a substance or alcohol use disorder, their risk of violence can be dramatically reduced by treating this first. This may require inpatient care, medication, and therapy to help with symptoms of detoxification and withdrawal.
• If the individual has been nonadherent with their mental health treatment, such as not taking their medication, this should bethe first recommendation to stabilize their symptoms.
• If treatment has not yet been provided, appropriate treatment should be implemented to reduce their symptoms and associated risk of violence. For example, an individual with psychotic symptoms can be prescribed antipsychotic medications.
• Psychosocial support can be put in place to help improve the individual’s functioning, relating to aspects such as employment, housing, and self-care, which have been shown to contribute to the risk of violence.
• Psychoeducation can help the individual better understand their condition and the importance of treatment adherence.
• Therapy, such as cognitive behavioral therapy (CBT), can be provided to help the individual manage their emotional distress and reduce harmful behaviors.
• Inpatient care can be provided to help stabilize severe mental illness and prevent harm to the individual and others.

How to deal with violent people

If you experience violence or a threat of violence from someone, the following may help you manage the situation ^[12]:

• Stay calm, use nonconfrontational language, tone, and behaviors to avoid escalating the situation.
• Try to stay at a safe distance from the violent individual, leaving the room or building if possible.
• Do not do anything that might put your safety at risk.
• Call for professional assistance, such as the police or mental health services.