International Journal of Mental Health Nursing (2004) 13, 39–52

FEATURE ARTICLE
New evidence or changing population? Reviewing
the evidence of a link between mental illness and
violence
Brodie Paterson, Peter Claughan and Sandy McComish
Department of Nursing and Midwifery, University of Stirling, Stirling, Scotland

ABSTRACT: There has been an apparent shift in majority opinion within psychiatry over the last
20 years on the nature of the relationship between mental illness and violence. Where once there was
perhaps widespread scepticism, research, while sometimes producing conflicting results, appears
ultimately to have led to the emergence of an almost universal consensus that there is a link. This
paper will review the nature of the evidence for such a link between mental illness and violence and
explore some of the newer suggestions about why mental illness may sometimes be related to violence
KEY WORDS: mental illness, research review, violence.

INTRODUCTION probability of their committing a violent crime then our

findings show that this does not exceed the dangerous-
Lionel Penrose in 1939 famously asserted that there was
ness of the legally responsible adult population as a
unequivocally a relationship between mental illness and
whole’. There was therefore widespread rejection of any
violence claiming that there was inverse relationship
link between mental illness and violence on the basis of
between the amount of violent crime in a number of
the available evidence and indeed of the relationship
European countries and the number of hospital beds that
between crime in general and mental disorder (Gunn
those countries devoted to the care of the mentally ill
1977).
(Conacher 1996). Such unsubstantiated claims notwith-
standing, expert opinion within psychiatry on the nature
of the relationship between mental illness and violence AIMS
would seem to have been largely to the contrary until
The relationship between mental illness and violence has
comparatively recently.
social and political dimensions as well as clinical implica-
Monahan and Steadman (1983; p. 211) concluding a
tions. There have, in particular, within the UK been
review of studies of patients discharged from psychiatric
concerns in respect of the influence the issue of violence
hospitals suggested that they showed no support for the
perpetrated by people experiencing mental illness and
premise that people with mental illness were more dan-
the role of media representations of the nature, extent
gerous than the general population when ‘matched for
and significance of such a relationship have had on social
demographic factors and prior criminal history’. Hafner
policy (Paterson & Stark 2001). There have also been
and Boker (1992; p. 89) reporting the results of a review
more recent concerns that proposals in England in rela-
of violent crime in Germany suggested that ‘if we define
tion to the management of Anti Social Personality Disor-
dangerousness of the mentally abnormal as the relative
der represent an unwelcome extension of the role of
psychiatry in respect of public safety (Pilgrim & Rogers
2003). This paper will however, restrict its focus to
Correspondence: Brodie Paterson, Department of Nursing and considering the nature and extent of the evidence which
Midwifery, University of Stirling, Stirling, Scotland FK9 4LA, United
Kingdom. Email: b.a.paterson@stir.ac.uk appears to have informed a new and different consensus
Brodie Paterson, MEd, BA(Hons), RMN, RNLD on the nature and degree of the relationship between
Peter Claughan, BN, RMN
Sandy McComish, MA, BSc, RMN, RNT mental illness and violence rather than the implications
Accepted November 2003. of such evidence for social policy.
40
BEFORE TARASOFF
Shah (1975) argued that research on the accuracy of
clinical predictions of dangerousness and thus an individ-
ual likelihood of committing a violent act cast ‘serious
doubt on the ability of clinicians to predict dangerous
behaviour at all’ (Lidz & Mulvey 1995; p. 43). This
opinion was endorsed by the American Psychiatric Asso-
ciation, which in 1973 took the seemingly extraordinary
step for a professional body of explicitly stating that their
members were not competent to make valid or useful
predictions of an individuals probability of engaging in
dangerous behaviour (Monahan & Walker 1994) Even
under best conditions ‘neither psychiatrists or behav-
ioural scientists can select persons who will become
dangerous’ (Steadman & Cocozza 1974; p. 188). It seems
ironic however, that at the same time psychiatry and
psychology were in broad agreement on the view that
there was not a relationship between mental illness and
violence and that by implication therefore, they could
have no particular expertise in predicting violent behav-
iour, that what should emerge but,
an increasing demand, and expectation that mental
health professionals should engage in activities predi-
cated both on the mentally disordered presenting a
threat to their fellow citizens and on a capacity to predict
that dangerousness (Mullen 1997; p. 4).
Almost contemporaneous with the American Psychi-
atric Associations disavowal of its members’ abilities to
make accurate judgements of an individual’s potential
dangerousness, a case was being heard in the Supreme
Court of California, Tarasoff v Regents 1976, which
continues to have a significant influence in this area.
Some brief background details of the case will be given to
place the judgement reached in context.
Tatania Tarasoff was a female graduate student at the
University of California in the Autumn of 1968 when she
met a fellow student Prosenjitt Poddar. They dated over
several weeks with Poddar apparently believing that the
relationship was serious. Tarasoff however, broke off the
relationship and by 1969 Poddar, tearful and depressed,
discontinued his studies and contacted the University
Health Service. He was initially evaluated by a psychi-
atrist who did not believe he required compulsory admis-
sion although he was prescribed a low dose antipsychotic
and referred to a psychologist for out-patient therapy.
During therapy Poddar reported fantasies of harming
and even killing a young girl, readily identifiable as
Tarasoff. The psychologist, aware in addition from a third
party, that Poddar had been considering purchasing a
firearm became concerned and contacted and discussed
his anxieties with the psychiatrist. They concluded that
commitment was necessary and the psychologist and the
B. PATERSON ET AL.
Campus police were then contacted and asked to contact
Poddar with a view to removing him to hospital. The
police visited his apartment on campus but found Podarr
apparently rational, he denied any threat to Tarasoff and
after warning him to stay away from her, the police
departed without taking him into care. The responsible
psychiatrist and psychologist then did nothing further to
pursue commitment and Poddar discontinued therapy.
Two months later Poddar went to Tarasoff’s home and
stabbed her to death. Tarasoff’s parents subsequently
filed a negligence suit against the University alleging that
its clinicians had been negligent in failing to detain
Poddar and in failing to warn Tarasoff of the threats
made against her. In an initial ruling (the case for
negligence was settled out of court), the California
Supreme Court found that:
once a therapist determines, or under applicable proce-
dures should have determined, that a patient poses a
serious danger of violence to others, he bears a duty to
exercise reasonable care to warn the foreseeable victim
of that danger (Tarasoff v Regents of the University of
California 551 P2d 555 (Cal 1974).
The establishment of what has become known as a
‘duty to warn’ caused considerable concern among
mental health professionals (Mason 1998). The Court
ruling was thus promptly challenged by the APA (1974)
who asserted that as psychiatrists and other mental health
professionals had no ability to predict violence, the
requirement to warn would result in many false positive
reports creating fear and alarm in potential victims when
there was no real danger and that the requirement to
warn would undermine the confidentiality of therapist
and patient unnecessarily (Anfang & Applebaum 1996).
The Supreme Court agreed to hear the case again and in
1976 (Tarasoff v Regents of California 551 P2d 333 Cal
1976) they issued a second opinion. In this instance the
Court again found that therapists have a duty to potential
victims but defined this as a ‘duty to protect’ rather than
a ‘duty to warn’. In their judgement if a therapist appre-
hends or should have apprehended, ‘that his patient
represents a serious danger of violence to another, he
incurs an obligation to use reasonable care to protect the
intended victim against such danger’ (Tarasoff v Regents
of California 551 P2d 333 Cal 1976). Actions necessary
might include warning the anticipated victim(s), alerting
others including the police and taking whatever reason-
able steps might be necessary to minimize the risk of
violence (Beck 1985).
The Court did not impose a duty for the therapist to
be either accurate or perfect in their prediction; rather
they argued that the practitioner should not be ‘negli-
gent’. Once a prediction was made, as in the case of
MENTAL ILLNESS AND VIOLENCE
Poddar, then ‘reasonable’ steps should be taken to warn
the intended victim or otherwise protect them, for
example warning the police or taking steps to have the
patient committed (Mason 1998). In the USA however,
Tarasoff and related rulings effectively served to create
the expectation, subsequently codified by statute in a
number of US States, that predictions of future danger-
ousness were integral to working in a professional capac-
ity with people experiencing mental illness (Carstenson
1994).
EVIDENCE FOR A NEW CONSENSUS?
One indirect result of the imposition of this responsibility
was to give impetus to research into the possible links
between mental illness and violence. The nature of the
research, which emerged over the last two decades, will
now be reviewed. Four broad categories of studies
appear to have dominated research into the general
relationship between mental illness and violence in the
period in question. Each of these will be examined and
explored in turn.
1. Studies that have examined the level of violent behav-
iour among those with mental illness. These include
studies of violence prior to admission to psychiatric
hospital, violence during hospitalization and violence
post discharge from hospital.
2. Studies which examine the frequency of mental illness
among those who have exhibited violent behaviour.
These include studies of prisoners on remand and
prisoners who have been convicted, both for general
criminal behaviour and for crimes of violence, includ-
ing homicide.
3. Community studies where the presence of mental
illness and the level of engagement in violent behav-
iour are established separately and the relationship
between the two then analysed.
4. Birth cohort studies where very large random popula-
tion samples, such as people born on the same day,
are studied over extended time periods and the rela-
tionships between such variables as diagnosis of schizo-
phrenia and the likelihood of committing a violent
offence are analysed.
Violence prior to admission
A series of studies have examined violent behaviour
involving people with a mental illness. These have
focused around hospital and highlight violence prior to
admission, violence by inpatients and violence by those
discharged from hospital. High rates of violent behaviour
have been reported prior to admission ranging from 12%
48 hours prior to admission (Rossi et al. 1986), 19% in
41
the month prior to a first admission (for schizophrenia)
(Johnston et al. 1986) and 26% in the 6 months preceding
admission (Binder & McNiel 1988). The studies how-
ever, have used different means of gathering data includ-
ing case note analysis, arrest records, and patient and
carer interviews, and therefore are not directly compar-
able. There remains the possibility that an unknown
proportion of violence may go undetected, particularly in
community samples (Lagos et al. 1977). If, for example,
arrest data are used, there may be incidents that are not
reported or that result in the perpetrator’s hospitalization
rather than arrest (Klassen & O’Connor 1988).
These results must of course be interpreted in the
context of mental health practice. Given the almost
universal adoption, of ‘dangerousness’ as perhaps the key
potential mental health admission criteria, people with a
perceived mental illness who have acted violently, or are
assessed by professionals as posing a high risk of acting
violently, are more likely to be seen as a priority for
admission. This has been described as ‘ascertainment
bias’ (Wessley & Taylor 1991). Retrospective samples
based on admission populations are thus irretrievably
flawed in terms of their lack of representativeness of the
incidence of violence across the whole population of
people with a mental illness (Monahan & Steadman
1994).
Violence by inpatients
Similar problems occur when violence by psychiatric
inpatients is considered. Only a small percentage of
people with severe mental illness are in hospital at any
given time and they tend to be those experiencing acute
episodes, those where drug compliance is poor or whose
symptoms are not well controlled. There have, however,
been a large number of studies on inpatient populations.
The immediate availability of a convenient sample
coupled with the fact that many hospitals have pre-
existing recording and reporting systems for violent
behaviours appears to have prompted much research.
Haller and Deluty (1988; p. 174) caution however, that
researchers ‘relying on formal incident reports of assaults
on staff very likely underestimate the actual incidence of
assaults’. Reporting systems may consistently under-
estimate the real frequency of incidents by as much as
60% (Daffern et al. 2003; Foust & Rhee 1993; Lion et al.
1991; Wenk et al. 1972) although the frequency and
reliability of reporting has been shown to increase in line
with the severity of injuries to the parties concerned
(Infantino & Musingo 1985).
It has also been suggested that violence in psychiatric
inpatient settings may not represent a relationship
between mental illness (or even specific symptoms) and
violence, as much as patients’ reactions to the experience
42
of admission, to the ward or service culture (Garnham
2001), to deliberate or unwitting provocation by other
patients or staff (Powell et al. 1994; Shepherd & Laven-
der 1999), to the lack of activities and staff patient
interactions (Sclafani 2000) or to the restrictions on
liberty which may accompany admission (Sheridan et al.
1990). Given differences in the nature of the units
studied which have ranged from maximum security
psychiatry (Larkin et al. 1988), through to locked obser-
vation wards (Cooper et al. 1983) to open admission areas
and units for elderly people experiencing dementia
(Fottrell 1980) as well as the inconsistencies in opera-
tional measures adopted, it is perhaps unsurprising that
research involving inpatient populations has failed to
produce consistent results.
Critics of studies of preadmission rates of violence and
the frequency of violence in inpatient populations have
suggested that both have failed to demonstrate that the
incidence and frequency of violence established differ
significantly from the base rates in the non-disordered
community population once appropriate socio-
demographic variables are controlled for (Monahan
1992). Comparing arrest rates for violence between
patients admitted to hospital or patients discharged from
hospital against notional community norms fails to ade-
quately reflect the preponderance of the poor, male,
single, alcoholic and black patients admitted and dis-
charged by most US public mental hospitals where much
of the research was conducted (Wessley 1997).
Violence by discharged patients
Criticisms can also be applied to a number of the studies
in which individuals hospitalized for treatment for mental
illness have been followed up on discharge (Asnis et al.
1997). Methodologically, with some minor variations,
these studies have compared the arrest rates of dis-
charged former patients with that of the general popula-
tion over periods of time ranging from 12 months to
5 years. A review of the literature by Link et al. (1992)
concluded that ex-psychiatric patient arrest rates were
300% greater than the average for the general popula-
tion. While arrests reflect a range of criminal behaviour
and not necessarily violence, the difference may be even
more marked when solely violent crimes were considered
(Rabkin 1979).
Lindqvist and Allebeck (1990) followed up 644 indi-
viduals, with a diagnosis of schizophrenia discharged
from hospital in Stockholm in 1971, over a 15-year
period. They found that the rate of recorded convictions
for violent offences was four times higher in the group
than the general population average. Of the 6% of the
sample who had been violent nearly half had an alcohol
misuse problem. Belfrage (1998) studied the conviction
B. PATERSON ET AL.
records over 10 years for patients discharged from four
Swedish psychiatric hospitals in 1986. Thirteen per cent
of the study group were convicted of a violent crime
during the 10 years of follow up with 1% of the study
group (11 people from 893) sentenced for murder,
attempted murder or manslaughter. A number of studies
have looked at specifically selected high risk groups and
found an even higher incidence of violence. Klassen and
O’Connor (1988) followed up 304 male patients identi-
fied as at risk for future violence for a year post-discharge
and found that 25% acted violently during that period.
Steadman et al. (1994), however, noted that literature
on violence by discharged patients must be interpreted
with considerable caution and make a number of criti-
cisms of the methodology employed. First, they suggest
that to rely solely on official arrest or conviction records,
records of re-hospitalization or self-reports by patients
without corroboration to determine the frequency and
severity of violence may result in inaccuracies. This may
lead to an effective inability to compare the violence by
‘ex-patients’ or people with mental health problems who
have not been admitted, to rates in the relevant commu-
nity. Second, they note that few studies have examined
the timing of violent acts and observe that this is ‘despite
the implications for intervention that timing may have’
(Steadman et al. 1998; p. 393). Monahan and Steadman
(1994) note that most samples of discharged patients are
unrepresentative of either the more general population of
people with a mental illness or of hospital populations in
that they exclude two groups of patients. The first consists
of those seen as posing a very high risk of violence who are
unlikely to be discharged and the second, comprising
those experiencing mental illness viewed as representing a
minimal risk but who were never admitted in the first
place. Excluding these two groups results again in the
problem of ascertainment bias.
One research study that addressed some of these
weaknesses is reported by Steadman et al. (1998). They
studied 1136 male and female patients across three
American sites for a year after discharge from hospital.
Diagnosis was confirmed by research interview using the
DSM III-R checklist (American Psychiatric Association
1987) and patients were followed up by interviews every
10 weeks post-discharge. Information from a collateral
respondent, usually a family member, was also obtained
weekly. Respondents were paid to participate in the
study and violence was established using self report and
the collateral information to establish; if and when the
individual had been violent, where the violence occurred,
what type of violence had been exhibited, how often had
this behaviour been displayed and who were the actual or
intended targets of the violence. This information was
then collated together with arrest and re-hospitalization
MENTAL ILLNESS AND VIOLENCE
records. There are some obvious weaknesses in this study
in that it did not employ a randomized sample using only
patients who volunteered to participate. However, at
1 year follow up the patient group identified as having a
major mental disorder (schizophrenia, schizophreniform
illness, schizoaffective disorder, depression, dysthymia,
mania, cyclothymia, mania or other psychotic disorder) in
conjunction with a substance misuse disorder were
reported to have a violence rate of 31.1%. The rate
reported for the group identified as having a major
mental disorder, but without substance misuse, was
17.9%.
Steadman et al. (1998) compared these rates with a
group of 519 community subjects matched carefully for
socio-demographic variables and noted that in one
sample area the rates for violence in the group with
major mental disorder (without comorbid substance
misuse) did not exceed the matched community sample.
Recent findings from The McArthur Community Risk
Study (Monahan 2002) have also suggested that the
prevalence of violence among people discharged from a
(psychiatric) hospital who do not have symptoms of
substance abuse is similar to the prevalence rates for
violence among other people living in the community not
diagnosed as substance abusers.
Mental illness in remand populations
In contrast to studies looking at the arrest records of
individuals with a diagnosis of mental illness a number of
studies have tried to ascertain the prevalence rate of
mental illness among populations of individuals detained
either on remand or in custody. Such studies are poten-
tially valuable because criminal behaviour in people with
mental illness, even when the illness is severe, may result
in remand or imprisonment rather than hospitalization.
Of note, however, is that most criminal justice systems
have procedures for treating those offenders who have a
serious mental illness at the time of arrest, or who
develop one during incarceration, which may involve
their transfer from prison to hospital. Reviews suggest
prevalence rates for all mental disorders ranging from 5%
to 16% with somewhat obviously, higher rates found in
prisoners referred for psychiatric examination in compar-
ison to random samples of the those detained (Malmquist
1995). Taylor and Gunn (1984) used a random sample of
consecutive admissions to study 1241 males remanded to
Brixton prison. They recorded the incidence of schizo-
phrenia at 6% in comparison to the estimated rate in the
South London population at that time of approximately
0.5% (Wessley 1997). Although women have been less
frequently studied, Teplin et al. (1996) reviewed a random
sample of 1272 female detainees in North America. DSM
III diagnosis was determined and compared to general
43
population statistics. Schizophrenia was not increased in
comparison to the estimated prevalence in the general
population but 70% were diagnosed as having a sub-
stance misuse problem, personality disorder and depres-
sion were also significantly higher than in the general
population.
Mental illness and violence in prison
The prevalence of mental illness in populations of
convicted offenders has also been studied. Monahan
(1993) in a Californian study estimated the incidence of
schizophrenia at 6%, more than three times the rate
estimated in the general US population (1.7%). Mania
and bipolar illness appear increased with 2.1% reported
in offenders in comparison to an estimated general
population frequency of 0.3%. Taylor and Gunn (1984)
in a British study followed up a group of detainees and
concluded that that 9% of those subsequently convicted
for non-violent crimes and 11% convicted for violent
crimes had schizophrenia. Only 8% were seen as being
symptom-free at the time of the offence (Taylor &
Gunn 1984).
Homicide
Homicide by people with mental illness has attracted
attention for study as a separate crime and has been the
subject of a number of studies in several countries.
Finland has a very high ‘clear up rate’ for homicide, with
the perpetrator identified, in over 95% of cases (in
comparison to the rate in the USA of approximately
66%). All offenders routinely receive a psychiatric evalu-
ation followed by an in depth examination by a specialist
forensic psychiatrist when the initial assessment has indi-
cated that this may be of benefit (Eronen et al. 1996a). In
a review of the forensic examinations carried out on 693
offenders, from a total of 994 offenders initially exam-
ined, Eronen et al. (1996a) found that 6.4% were diag-
nosed with schizophrenia or schizophrenic type
psychoses. This compares with an estimated prevalence
rate of schizophrenia of 1.7% in the Finnish population
(Eronen et al. 1996a). Other studies have reported an
even higher incidence of psychosis. Gottleib et al. (1987)
studied all 251 homicides in the Copenhagen area over a
25-year period and reported that 20% of the male and
44% of female perpetrators were psychotic.
In North Sweden of those convicted of homicide
between 1970 and 1980, 8% were reported to suffer
schizophrenia with a further 4% schizophreniform psy-
chosis (Lindqvist 1989). These figures are compatible
with a retrospective study by Petursson and Gudjonsson
(1981) of all homicides in Iceland between 1900 and
1979, which estimated that 15% of all homicides were
committed by people with schizophrenia.
44
Community studies: The key evidence?
Mullen (1997) suggests that the study which did most to
convince sceptics, particularly in the USA, of the exist-
ence of an association between mental illness and vio-
lence was a community study by Swanson et al. (1990).
This study involved the reanalyses of data gathered from
10 059 interviews carried out as part of the Epidemio-
logic Catchment Area Surveys (ECA). Subjects were
interviewed in three locations in the USA using the
Diagnostic Interview Schedule (DIS) to generate diagno-
sis established with reference to the Diagnostic and
Statistical Manual (3rd Edition) (DSM III) (American
Psychiatric Association 1987). The presence of any Axis 1
psychiatric diagnosis appeared to be associated with an
increased risk of violence in this sample. However, there
were significant effects resulting from comorbidity, the
presence of more than one disorder. This was particularly
true for depression when coexistent with substance
misuse. When categories were evaluated in the absence
of comorbidity, only schizophrenia and substance misuse
were significantly elevated in comparison to the non-
disordered community sample (Table 1). A more recent
community study by Steadman et al. (1998) of discharged
patients, has produced somewhat different results sug-
gesting that patients with a diagnosis of psychosis were
not more dangerous in comparison to other ‘non-
patients’ in their neighbourhood. However, the study did
confirm Swanson et al. (1990) findings that substance
abuse is an independent risk factor for violence and that
its effects are compounded in psychotic substance abus-
ers. There remains therefore some scope for different
interpretations of the literature (Pilgrim & Rogers 2003).
Cohort studies
There is, however, another valuable source of data which
support the contention that there is a link between
mental illness and violence. Hodgins (1994) reports that
a series of Scandinavian studies using unselected ‘birth
cohorts’, followed into adulthood have demonstrated that
TABLE 1: Diagnostic Interview Schedule Generated DSM III diagnosis and respondents reporting violence in preceding year (adapted from
Swanson et al. 1990)
Diagnosis
None (no disorder)
Phobia
Obsessive compulsive disorder
Panic disorder
Major depression
Major depression with grief
Mania of bipolar disorder
Schizophrenia of schizophreniform disorder
Cannabis abuse or dependence
Alcohol abuse of dependence
Other drug abuse or dependence
B. PATERSON ET AL.
subjects who develop schizophrenia and major affective
disorders including mania and bipolar illness appear
more likely to be convicted for violent crimes than non-
disordered subjects. Hodgins (1994) reports a study
involving a Danish cohort born between 1 January 1944
and 31 December 1947 (giving a sample once exclusions
for death and emigration were made of 158 799 women
and 164 602 men) who were followed up to age 43.
Hospital admission and diagnosis data were cross-
matched with data from the Danish National Police
database to determine convictions incurred by individ-
uals. For both males and females, psychiatric hospitali-
zation raised the risk of offending behaviour significantly,
including violent crime; the only exception was organic
disease. A Finnish study by Räsänen et al. (1998) exam-
ined a sample of 11 017 women in North Finland, up to
the age of 26 years, drawn from a potential group of
12 068, who gave birth to 12 058 (live) children in 1966.
Data on psychiatric hospitalizations were derived from
the Finnish Hospital Discharge Register up until 1993,
which contains all psychiatric diagnoses of patients
treated in either psychiatric or general hospital. A total of
561 subjects were identified and cross-referenced with
entries in the Finnish National Crime Register. In the 26
years follow up, 7.5% of the study group who had a
diagnosis of schizophrenia had been convicted of a
violent crime; this compared with 2.2% of non-
hospitalized men. In a Danish cohort study covering a
time period of 44 years, Brennan et al. (2000) found a
significant positive relationship between the mental dis-
orders that led to hospitalization and criminal violence.
Even where demographic factors and/or comorbid sub-
stance abuse were controlled for there was still a strong
effect.
COMORBIDITY
The issue of comorbidity is of interest due to the poten-
tial contribution it appears to make to the possibility of
Weighted no. respondents % reporting violence in preceding year
7870 2.05%
1323 4.97%
182 10.66%
90 11.56%
282 11.68%
308 10.70%
30 11.025
114 12.69%
191 19.25%
586 24.57%
99 34.74%
MENTAL ILLNESS AND VIOLENCE
violence. Results from a large-scale study of comorbidity
indicate that 54% of individuals diagnosed with one Axis
1 DSM III diagnosis had an additional Axis 11 DSM III
diagnosis (Kessler et al. 1994). Most research interest has
centred on schizophrenia comorbid with alcohol or other
substance misuse. The ECA study (Swanson 1994)
clearly supported earlier research linking alcoholism and
drug misuse to increased violence, although interactions
between substance misuse and violence have been
described as complex and multidimensional (Friedman
1998). The link between substance misuse, specifically
alcoholism, and violence has also been observed in hom-
icide. Eronen et al. (1996a) report that although schizo-
phrenia was found in perpetrators of homicide in Finland
more frequently than in the general population, alcohol
misuse was overwhelmingly the most frequently reported
mental disorder in those convicted of homicide with 40%
of male and 32% of female perpetrators diagnosed as
alcoholic. The potential effect of schizophrenia or other
major mental disorder with alcohol or substance misuse
appears therefore of particular concern. Eronen et al.
(1996b) report that comorbid alcoholism with schizo-
phrenia increased the risk of ‘all violence’ twofold in
comparison to a group with only schizophrenia. In
Räsänen et al.’s (1988) study comorbid alcoholism dra-
matically increased the likelihood of conviction for a
violent crime with 36% of individuals with schizophrenia
and a comorbid diagnosis of alcoholism being convicted
of a violent crime over a period in comparison to 7.5% of
those with schizophrenia alone.
HOW DOES MENTAL ILLNESS INCREASE
THE RISK OF VIOLENCE?
Even when the role of comorbid alcohol or substance
misuse is excluded there is strong evidence from both
community and cohort studies to support the hypothesis
that certain forms of severe mental illness, particularly
schizophrenia and schizophreniform psychoses, appear
to be associated with an increased risk of violence. This
has led to research seeking to explain why these diag-
noses may increase the risk of violence. Historically the
presumption has been that psychosis somehow removes
or inhibits an individual’s capacity for self control and in
so doing removes the psycho–dynamic barriers which
prevent violence (Gerbner et al. 1981). Interest to date
has focused on two particular subtypes of psychotic symp-
toms; first, ‘command hallucinations’ (Shawyer et al.,
2003) and second, the role of ‘delusions of persecution’
(Taylor et al. 1994). In command hallucinations, the indi-
vidual experiences direct instructions to carry out an act,
usually in the form of an auditory hallucination (Junginger
1996). There are claims that command hallucinations,
45
experienced by psychotic patients, instructing violence
pose little danger with the majority of patients not
responding to them (Cheung et al. 1997; Hellerstein
et al. 1987; McNiel & Binder 1994). Two studies by
Junginger (1990, 1995) cast doubt on this presumption,
indicating a high degree of general compliance with
command hallucinations (39% in the first study sample
and 43% in the second) by people suffering hallucina-
tions. In the second study by Junginger (1995) compli-
ance with ‘dangerous commands’ was investigated, 23%
reported that they had complied with a ‘very dangerous
command’, defined as involving a very serious threat to
another’s safety (Junginger 1996). A study by Taylor
(1985) of incarcerated prisoners with a diagnosis of
schizophrenia however, found that 90% of those whose
criminal behaviour was ‘definitely’ or ‘probably’ influ-
enced by their psychosis were influenced by delusional
beliefs rather than hallucinations. More recently, interest
has developed in whether there may be a ‘violence
escalating interaction between delusions and hallucina-
tions’ (Bjørkly 2002; p. 612) with suggestions that in the
absence of delusions hallucinations may only have a very
small violence triggering effect (Taylor et al. 1998).
Hiday (1997) asserts that it is not the presence of
specific psychotic symptoms, or even command hallu-
cinations that lead to violence, given that the majority of
these are not acted upon. One suggestion proposed is
that violence may be related to the severity of symptoms
the individual experiences. Link et al. (1992) in a com-
munity study in New York found psychiatric patients,
when compared to matched community residents, had
significantly higher rates of arrest on all indices of violent
behaviour. Link et al. (1992) then controlled for psy-
chotic symptoms using a 13-item scale and found the
differences in violence between the patient and commu-
nity sample were significantly reduced suggesting that
the greater the number and higher the severity of symp-
toms experienced, the greater the likelihood was that an
individual would be violent. Link and Stueve (1995) went
on, however, to hypothesize that it was not the presence
or severity of all symptoms which increased the risk of
violence but the presence of a particular constellation of
symptoms that produced feelings of personal threat or
involved the intrusion of thoughts which could ‘over ride’
the individual’s self control. This presumes, essentially,
that the internal constraints which function to restrict
violent behaviour in line with relevant social norms are
more likely to be over ridden when someone with psy-
chosis believed that they themselves are in danger from
an individual, group of persons or organization. Link and
Stueve (1995; p. 143) describe this as the ‘principle of
rationality – within irrationality’, if we accept that the
patient’s experience while delusional is experienced by
46 B. PATERSON ET AL.

them as ‘real’ then their actions are logically consistent
with their beliefs. Link et al. returned to this general
premise in 1999, suggesting that the relationship
between delusional ideation and the consequent actions
of a patient are examples of ‘The Thomas Theorem’:
Within sociology the Thomas Theorem has been closely
associated with a symbolic interactionist approach that
directs attention to the importance of understanding
peoples interpretations of situations for understanding
their behaviour (Link et al. 1999; p. 316)
In a 1995 study Link and Steuve investigated their
hypothesis of ‘rationality within irrationality’. The study
compared 232 patients (78 with a diagnosis of major
depression, 45 with schizophrenia, 24 with another psy-
chotic disorder, and 85 with diagnosis other than depres-
sion or psychosis) with a community sample of 521
matched for socio-demographic characteristics. The
presence of ‘threat control override’ symptoms was meas-
ured using a 13-item psychotic symptoms scale (Table 2)
in which symptoms were separated into those believed to
characterize this phenomena (1–3) and other symptoms
of psychosis believed to be unrelated to it (4–13). Each
scale item was measured on a 1–4 continuum from very
often (4) to never (1), each section was then summed to
give a maximum possible score for threat override of 12
and other psychotic symptoms of 40.
Link and Stueve (1995) found individuals who scored
highly on the threat control override scale (with a score of
6–12) were significantly over-represented in terms of
violence in comparison to those with low levels or who
had high scores on the other psychotic symptoms inven-
tory. These findings have been supported by subsequent
research by Swanson et al. (1996, 1997) on community
samples and inpatient populations showing evidence of
an association between high levels of ‘threat control over
ride’ (TCO) symptoms and violence. Cheung et al. (1997)
investigated the nature of delusional beliefs in a patient
sample with a DSM III-R diagnosis of schizophrenia.
They found that violent patients (defined as having one
violent incident or more per month) had a significantly
higher frequency of delusions of persecution than
patients categorized as ‘non- violent’, supporting the
premise that it is the nature of the delusional beliefs,
rather than simply the presence of delusional beliefs, that
may influence rates of violence.
Link and Stueve’s (1994) model of ‘threat control-
override’ causing violence by creating fear and anger and
impairing internal controls, is however, essentially an
intra-psychic one in which violence is mediated by factors
unique to the perpetrator. Hiday (1997) reminds us that
this is perhaps overly simplistic, asserting that both
interpersonal and social factors may play their part in the
promotion of violence. Hiday (1997; p. 400) has sug-
gested that the relationships between mental illness and
violence are mainly indirect and contingent rather than
linear and that both mental illness and violence must be
understood in terms of the ‘structural arrangements in
which individuals are embedded’. An individual experi-
encing high levels of symptoms may become involved in
tense situations where their delusional behaviour is prob-
lematic for others or where others attempts to remon-
strate with them or to encourage them to comply with
treatment create conflict (Hiday 1997). Novaco (1976)
has observed that anger as a form of arousal is a conse-
quence of interpretation of an event or incident as
provocative. His perspective views emotion largely as a
consequence of an internal mental process involving an
interaction between an individual’s interpretations of

TABLE 2: Psychotic Symptom Scale separated into threat/control – override and other psychotic symptom subscales
Psychotic Symptom Scale

Threat control – override symptoms

During the past year
1. How often have you felt that your mind was dominated by forces beyond your control?
2. How often have you felt that that thoughts were put into your head that were not your own?
3. How often have you felt that there were people who wished to do you harm?
Other psychotic symptoms
During the past year
1. How often have you felt that you did not exist at all, that you are dead, dissolved?
2. How often have you heard things that other people say they can’t hear?
3. How often have you felt your unspoken words were being broadcast?
4. How often have you thought that you were possessed by a spirit or the devil?
5. How often have you had visions or seen things that other people say they can’t see?
6. How often have you felt that you had special powers?
7. How often have you thought that something odd was going on?
8. How often have you felt your thoughts were being taken away from you by some external force
9. How often have you had ideas or thoughts that nobody else would understand if you talked about them
10. How often have you seemed to hear your thought spoken aloud – almost as if someone standing nearby could hear them?
MENTAL ILLNESS AND VIOLENCE
events. An individual labouring under persecutory delu-
sions, particularly if the delusion involves a threat to their
safety, according to Link and Stueve (1994) ‘rationality
within irrationality principal’ would be expected to expe-
rience a high level of arousal. The interaction between
arousal and anger has been described as ‘invidious’ with
high arousal levels increasing the likelihood of negative
attributions in respect of the actions of or intent of others
(Mueller 1983). The experience, or perceived experience,
of conflict with another may then be sufficient to increase
their arousal level to a point where their cognitive control
is overwhelmed (Breakwell & Rowett 1989). It remains
important to recognize that patients’ reported perceptions
may not always reflect paranoia but sometimes well
grounded and realistic fears of being a victim of violence
based on experience (Estroff & Zimmer 1994).
The likelihood of any given conflict situation resulting
in violence, will however be influenced by the predom-
inant beliefs within the participants’ cultures regarding
how conflict should be dealt with and thus the ‘legit-
imacy’ or otherwise of violence (Werner et al. 1983).
Hiday (1997) argues that beliefs supporting violence as a
means of conflict resolution may be more prevalent in
communities which have been disproportionately
affected by unemployment, where social disorganization
and poverty function as stressors, and individuals or
groups may become disassociated from the values of the
wider community. Growing up in such an environment is
likely to increase an individual’s risk of being a victim of
violence in comparison to more affluent areas (National
Research Council 1993) and may over time ‘foster mis-
trust and suspicion of others, an outlook that psychosis
exacerbates’ (Stueve & Link 1997; p. 329). Such influ-
ences may find expression in violence by patients. Silver
2001; p. 405) in a study involving some 270 discharged
patients found that environment functioned as an inde-
pendent risk factor for violence. Even when a range of
other variables including gender, diagnosis and level of
symptoms were controlled for, ‘patients discharged into
disadvantaged neighbourhoods were significantly more
likely to commit violent acts than patients discharged into
less disadvantaged neighbourhoods. Hiday (1997) argues
that social disorganization and poverty are found in
increased association with substance dependency creat-
ing an invidious combination. The role of alcohol and
substance misuse as precursors to violence is complex
and outside the scope of this review, but it has already
been noted that there is an association, and that comor-
bid alcohol or other substance misuse appears to signifi-
cantly increase the risk of violence in those with major
mental disorders. Hiday (1997) argues further that social
disorganization and poverty may increase the prevalence
of antisocial personality disorder in communities affected.
47
Anti-social personality disorder (ASP) is an Axis II diag-
nosis in DSM IV (American Psychiatric Association 1994)
the primary features of which are evident from childhood
and include persistent irresponsible behaviour, impuls-
ivity and aggression including violence. The concept of
personality disorder in its various forms and its use as a
diagnosis remain controversial, with critics asserting that
they are used to medicalize a range of deviant behaviour
(Hart et al. 1994). ASP has been linked to violence but
this link has been suggested to be ‘tautological’ in that an
individual who exhibits violent behaviour may attract the
diagnosis of ASP. If the individual then goes on to exhibit
further violence then the diagnosis of ASP is said to
predict violence (Hiday 1997). However, ASP is found
frequently in association with severe mental illness and
substance abuse, particularly it is suggested among those
who have a history of violence (Robbins 1993). Webster
et al. (1994) suggest that comorbid personality disorder
significantly increases the risk of future violence by
people with severe mental illness.
Hiday’s (1997) argument compellingly illustrates that
violence perpetrated by people experiencing mental
illness shares many characteristics with non-disordered
samples in terms of the structural factors which influence
it. However, there is another similarly of note, that likely
victims are overwhelmingly known to the perpetrator and
often intimates (i.e. family members) (Estroff & Zimmer
1994). Individuals experiencing severe mental illness may
on occasion kill someone they do not know but this is
highly unusual (Lindqvist & Allebeck 1989).
ALTERNATIVE EXPLANATIONS
It is tempting to observe that more sophisticated larger
scale and/or longitudinal studies were able to identify a
relationship between mental illness and violence where
earlier research either failed or was compromised by
methodological problems most notably ascertainment
bias. Monahan and Steadman (1983; p. 156) noted that:
in the four reports published before 1965 … released
mental patients were found to have rates of arrest lower
than those of the general population.
As is evident from this review such findings were
increasingly contradicted by research which began emerg-
ing in the US as early as the late 1960s (Rappeport &
Lassen 1965). Despite continuing problems with some of
this literature, such studies often found rates for crime
among discharged patients to be significantly higher than in
the general population, particularly for violent crimes. This
change cannot be readily attributed to methodological
improvements in discharge studies evident in some of the
more recent work but a highly plausible alternative
48
explanation exists. It proposes that rather than represent-
ing better experimental design the findings of such
studies reflected the gradual emergence of highly signifi-
cant changes in the nature of the psychiatric hospital
population in which de-institutionalization may have
played a major part. Psychiatric hospital bed numbers
have radically dropped in many countries across the
world over the last few decades (Thornicroft & Bebbing-
ton 1989). This downward trend commenced in the late
1950s in the US, continued steadily throughout the 1960s
and 1970s before rapidly accelerating, in the UK, in the
context of the ‘community care’ programmes of the
1990s. It has, however, been suggested that as alternative
to hospitals developed (albeit at differing rates in differ-
ent settings) newer community resources tended to
‘cream off’ those patients deemed more suitable for
discharge and/or community treatment. This, it is sug-
gested, has led some services to an overall increase in the
dependency of the hospital population. In the UK, even
in the midst of de-institutionalization, many patients
continued to be admitted to hospital, often those with
intractable psychoses and high levels of symptoms (Royal
Commission 1979). An inevitable corollary of a change in
the population admitted will be, over time, a change in
the nature of those discharged. If the number of patients
discharged experiencing psychoses increases as the pro-
portion of patients overall then, given the association
observed between schizophrenia and violence, we might
reasonably expect the proportion of patients arrested or
otherwise involved in violence to increase post-discharge
(Monahan & Steadman 1983). It has also been argued
that moves towards deinstitutionalization have unfortu-
nately occurred during a time period in which changes in
social attitudes towards drugs have led to much greater
use of illicit substances and with significant increases in
average alcohol consumption and consequently in alcohol
dependency and alcoholism both among the general
population and in people experiencing severe mental
illness (Regier et al. 1990). Given the invidious relation-
ship clearly demonstrated between severe mental illness,
substance abuse, alcoholism and violence we would
expect this to be reflected in admission data and this is
evident in a number of studies (Wheatley 1998). If the
population being admitted and discharged has signifi-
cantly altered, as seems evident in terms of both the
prevalence of psychoses and the increasing frequency of
comorbidity, it is perhaps unsurprising that the fre-
quency of violence reported has appeared to increase.
CONCLUSION
There remain significant problems with interpreting the
literature in this area; despite repeated calls for standard-
B. PATERSON ET AL.
ization there are continuing inconsistencies between
studies both in respect of how violence is defined and
how mental illness is ascertained that makes comparative
analysis extremely difficult (Mullen 1997). In addition,
data established from a study in one country or area may
be of little general significance if the magnitude of the
link between mental illness and violence is context spe-
cific and culturally mediated (Stueve & Link 1997). Even
although a potential link appears to have been estab-
lished between severe mental illness and violence it is
clear that a much smaller group with particular symp-
toms may present the greatest risk (Link & Stueve 1995).
The risk of violence arising in individuals appears to be
significantly increased when comorbid substance misuse
and/or ASP is present. Substance misuse increases the
risk of violence, independent of mental illness, even
where socio-demographic variables are carefully control-
led for (Monahan 2002). However, the literature on
violence by people with mental illness, including both
community studies and studies of convicted offenders,
strongly indicates that comorbid alcoholism and/or sub-
stance misuse appears to multiply their likelihood of
violence. Given the reliance of many studies on written
reports, arrest records or case records, the strength of the
link may in fact be underestimated as studies comparing
self reported incidents with case records suggest ‘vio-
lence and offending are under-reported in case-records’
(Wright et al. 2002; p. 49).
People experiencing severe mental illness emerge
from this selective review of the research as appearing to
account for only a small proportion of the violence in
society (Link & Stueve 1998). This proportion may vary
however, and homicides and other violence perpetrated
by people with mental illness may form a much greater
proportion of the overall total in societies where the
overall rate of violent crime is lower (Mullen 1997).
Violence by people experiencing mental illness, while
clearly not insignificant, makes it would appear only a
relatively modest contribution to overall rates of violence
in most societies in comparison to other factors such as
age, gender and alcohol. There is, however, now a
considerable literature indicating that the public percep-
tion of the nature and extent of the association between
violence and mental illness may be both distorted and
exaggerated which suggests that considerable work needs
to be done to inform the public more accurately (Crisp
2001).
It is also important to acknowledge despite the
conclusions of this review and others (Angermeyer
2000; Mullen 1997) that there remains a body of
opinion who consider that ‘the evidence that psychosis
predicts violence is contested’ (Pilgrim & Rogers 2003;
p. 8).
MENTAL ILLNESS AND VIOLENCE
ACKNOWLEDGEMENTS
The authors would like to thank Sandy McComish for
commenting on this review.
REFERENCES
American Psychiatric Association (1987). Diagnostic and Statis-
tical Manual of Mental Disorders. 3rd edn, revised. Wash-
ington DC: American Psychiatric Association.
American Psychiatric Association (1994). Diagnostic and Statis-
tical Manual of Mental Disorders II. Washington DC: Amer-
ican Psychiatric Association.
Anfang, S. A. & Applebaum, P. S. (1996). Twenty years after
Tarasoff: reviewing the duty to protect. Harvard Review of
Psychiatry, 4, 67–76.
Angermeyer, M. C. (2000). Schizophrenia and Violence. Acta
Psychiatrica Scandinavica, 102 (Suppl. 407), 63–67.
Asnis, G. M., Kaplan, M. L., Hundoerfean, G. & Saheed, W.
(1997). Violence and homicidal behaviours in psychiatric
disorders. Psychiatric Clinics of North America, 20,
405–425.
Beck, J. C., ed. (1985). The Potentially Violent Patient and the
Tarasoff Decision in Psychiatric Practice. New York: Ameri-
can Psychiatric Press.
Belfrage, H. (1998). A ten year follow-up of criminality in
Stockholm mental patients: new evidence for a relation
between violence and mental disorder and crime. British
Journal of Criminology, 38, 145–155.
Binder, R. L. & McNiel, D. E. (1988). Effects of diagnosis and
context on dangerousness, American Journal of Psychiatry,
145, 728–732.
Bjørkly, S. (2002). Psychotic symptoms and violence towards
others: a literature review of some preliminary findings.
Aggression and Violent Behaviour, 7, 602–605.
Breakwell, G. & Rowett, C. (1989). Violence in social work. In
K. Browne (Ed.). Human Aggression Naturalistic
Approaches. London: Routledge.
Brennan, P. A., Mednick, S. A. & Hodgins, S. (2000). Major
mental disorders and criminal violence in a Danish birth
cohort. Archives of General Psychiatry, 57, 494–500.
Carstenson, P. C. (1994). The evolving duty of mental health
professionals to third parties. International Journal of Law
and Psychiatry, 17, 1–42.
Cheung, P., Schweitzer, I., Crowley, K. & Tuckwell, V. (1997).
Violence in schizophrenia: role of hallucinations and delu-
sions. Schizophrenia Research, 26, 181–190.
Conacher, N. G. (1996). Psychiatric hospital downsizing and the
Penrose effect. The Journal of Nervous and Mental Diseases,
184, 708–710.
Cooper, S. J., Browne, F. W. A., McLean, K. J. & King, D. J.
(1983). Aggressive behaviour in a psychiatric observation
ward. Acta Psychiatrica Scandinavica, 68, 386–393.
Crisp, A. H., Gelder, M., Rix, S., Metzler, H. I. & Rowlands, O. J.
(2001). Stigmatisation of people with mental illness. British
Journal of Psychiatry, 177, 4–7.
49
Daffern, M., Mayer, M. M. & Martin, T. (2003). A preliminary
investigation into patterns of aggression in an Australian
forensic psychiatric hospital. Journal of Forensic Psychiatry
and Psychology, 14, 67–84.
Eronen, M., Panu, P. & Tiihonen, J. (1996a). Mental disorders
and homicidal behaviour in Finland. Archives of General
Psychiatry, 53, 497–501.
Eronen, M., Tiihonen, J. & Hakola, P. (1996b). Schizophrenia
and homicidal behaviour. Schizophrenia Bulletin, 22, 83–89.
Estroff, S. E. & Zimmer, C. (1994). Social networks, social sup-
ports and violence among persons experiencing severe and
persistent mental illness. In J. Monahan & H. Steadman
(Eds). Violence and Mental Disorder: Developments In Risk
Assessment. (pp. 81–98) Chicago: University of Chicago
Press.
Fottrell, E. (1980). A study among patients of violent behaviour
among patients in psychiatric hospitals. British Journal of
Psychiatry, 136, 216–221.
Foust, D. & Rhee, K. J. (1993). The incidence of battery in an
urban emergency department. Annals of Emergency Medi-
cine, 22, 583–585.
Friedman, A. S. (1998). Substance use/abuse as a predictor to
illegal and violent behaviour a review of the relevant liter-
ature. Aggression and Violent Behaviour, 3, 339–353.
Garnham, P. (2001). Understanding and dealing with anger,
aggression and violence. Nursing Standard, 16 (6), 37–42.
Gerbner, G., Gross, L., Morgan, M. & Signorelli, N. (1981).
Health and medicine on television. New England Journal of
Medicine, 305, 901–904.
Gottleib, P., Gabrielson, G. & Kramp, P. (1987). Increasing
homicides in Copenhagen from 1959 to 1983. Acta Psychiat-
rica Scandinavica, 77, 301–308.
Gunn, J. (1977). Criminal behaviour and mental disorder.
British Journal of Psychiatry, 130, 317–329.
Hafner, H. & Boker W. (1992). Crimes of Violence by Mentally
Abnormal Offenders. Cambridge: Cambridge University
Press.
Haller, R. M. & Deluty, R. H. (1988). Assaults on staff by
psychiatric in-patients: a critical review. British Journal of
Psychiatry, 152, 174–179.
Hart, S. D., Hare, R. D. & Forth, A. E. (1994). Psychopathy as a
risk marker for violence: Development and validation of a
screening version of the revised psychopathy checklist. In
J. Monahan & H. Steadman (Eds). Violence and Mental
Disorder: Developments In Risk Assessment (pp. 81–98)
Chicago: University of Chicago Press.
Hellerstein, D., Frosch, W. & Koeningsberg, H. (1987). The
clinical significance of command hallucinations. American
Journal of Psychiatry, 144, 219–221.
Hiday, V. A. (1997). Understanding the connection between
mental health and violence. International Journal of Law
and Psychiatry, 20, 399–417.
Hodgins, S. (1994). Schizophrenia and violence: are new mental
health policies needed? Journal of Forensic Psychiatry, 5,
473–477.
50
Infantino, J. & Musingo, S. Y. (1985). Assaults and injuries
among staff with and without training in aggression control
techniques. Journal of Hospital and Community Psychiatry,
36, 1312–1314.
Johnston, E., Crow, T., Johnson, A. & Macmillan, F. (1986).
The Northwick Park Study of first episodes of schizophrenia
1. Presentation of the illness and problems relating to admis-
sion. British Journal of Psychiatry, 149, 51–56.
Junginger, J. (1990). Predicting compliance with command hal-
lucinations. American Journal of Psychiatry, 147, 245–247.
Junginger, J. (1995). Command hallucinations and the predic-
tion of dangerousness. Psychiatric Services, 46, 911–914.
Junginger, J. (1996). Psychosis and violence: the case for a
content analysis of psychotic experience. Schizophrenia Bul-
letin, 22, 91–101.
Kessler, R. C., McGonagle, K. A. & Zhao, S. (1994). Lifetime
and twelve month prevalence of DSM III-R diagnosis in the
United States: Results From The National Comorbidity
Survey. Archives of General Psychiatry, 51, 8–19.
Klassen, D. & O’Connor, W. (1988). Crime, inpatient admis-
sions and violence among male hospital patients. Inter-
national Journal of Law and Psychiatry, 11, 305–312.
Lagos, J., Perlmutter, K. & Saxinger, H. (1977). Fear of the
mentally ill: empirical support for the common mans
response. American Journal of Psychiatry, 134, 1134–1137.
Larkin, E., Murtagh, S. & Jones, S. (1988). A preliminary study
of violent incidents in a special hospital. British Journal of
Psychiatry, 153, 226–231.
Lidz, C. W. & Mulvey, E. P. (1995). Dangerousness: from legal
definition to theoretical research. Law and Human Behav-
iour, 19, 41–48.
Lindqvist, P. (1989). Violence against the person: the role of
mental disorder and abuse. Umayer University Medical
Dissertations New Series, 254, Umea, Sweden.
Lindqvist, P. & Allebeck, P. (1990). Criminal homicide in North
West Sweden 1970–81. Alcohol intoxication, alcohol abuse
and mental disease. International Journal of Law and
Psychiatry, 8, 19–37.
Link, B. G., Andrews, H. & Cullen, F. T. (1992). The violent
and illegal behaviour of mental patients reconsidered. Amer-
ican Sociological Review, 57, 275–292.
Link, B. G., Monahan, J., Stueve, A. & Cullen, F. T. (1999).
Real in their consequences: a sociological approach to
understanding the association between psychotic symptoms
and violence. American Sociological Review, 64, 316–330.
Link, B. G. & Stueve, A. (1994). Psychotic symptoms and the
violent/illegal behaviour of mental patients compared to
community controls. In J. Monahan & H. Steadman (Eds).
Violence and Mental Disorder Developments in Risk Assess-
ment, (pp. 136–160). Chicago: University of Chicago Press.
Link, B. G. & Stueve, A. (1995). Evidence bearing on mental
illness as a possible cause of violent behaviour. Epidemio-
logical Reviews, 19, 1–19.
Link, B. G. & Stueve, A. (1998). New evidence on the violence
risk posed by people with mental illness. Archives of General
Psychiatry, 55, 403–404.
B. PATERSON ET AL.
Lion, J. R., Snyder, W. & Merril, G. (1991). Under reporting of
assaults on staff in a state hospital. Journal of Hospital and
Community Psychiatry, 34, 44–47.
Malmquist, C. P. (1995). Depression and homicidal violence.
International Journal of Law and Psychiatry, 18, 145–162.
Mason, T. (1998). Tarasoff liability: its impact for working with
patients who threaten others. International Journal of
Nursing Studies, 35, 109–114.
McNiel, D. E. & Binder, L. (1994) Relationship between acute
psychiatric symptoms, diagnosis and short-term risk of
violence. Hospital and Community Psychiatry, 45, 133–137.
Monahan, J. (1992). Mental disorder and violent behaviour:
perceptions and evidence. American Psychologist, 47,
511–521.
Monahan, J. (1993). Mental disorder and violence: another
look. In A. Hodgins (Ed.). Mental Disorder and Crime
(pp. 287–302). California: Sage.
Monahan, J. (2002). The Macarthur studies of violent risk.
Criminal Behaviour and Mental Health, 12, 567–572.
Monahan, J. & Steadman, H. (1983). Crime and mental illness:
an epidemiological approach. In N. Morris & M. Tonry
(Eds). Crime and Justice, Vol. 4 (pp. 145–189). Chicago:
University of Chicago Press.
Monahan, J. & Steadman, H. (1994). Toward a rejuvenation of
risk assessment research. In J. Monahan & H. Steadman
(Eds). Violence and Mental Disorder Developments in Risk
Assessment, (pp. 1–17) Chicago: University of Chicago
Press.
Monahan, J. & Walker, L. (1994). Social Sciences in Law, Cases
and Materials, 3rd edn. New York: Foundation Press.
Mueller, C. W. (1983). Environmental Stressors and Aggressive
behaviour. In R. G. Green & E. I. Donnerstein (Eds).
Aggression: Theoretical and Empirical Reviews, Vol. 2.
(pp. 135–162). New York: Academic Press.
Mullen, P. E. (1997). A reassessment of the link between
mental disorder and violent behaviour and its implications
for clinical practice. Australian and New Zealand Journal of
Psychiatry, 31 (3), 3–11.
National Research Council (1993). Understanding and Prevent-
ing Violence. Washington DC: National Academy Press.
Novaco, R. (1976). The function and regulation of the arousal of
anger. American Journal of Psychiatry, 133, 1124–1128.
Paterson, B. & Stark, C. (2001). Social policy and mental illness
in England in the 1990s: violence, moral panic and critical
discourse. Journal of Psychiatric and Mental Health Nurs-
ing, 8, 257–267.
Petursson, H. & Gudjonsson, G. H. (1981). Psychiatric
aspects of homicide. Acta Psychiatrica Scandinavica, 64,
363–372.
Pilgrim, D. & Rogers, A. (2003). Mental disorder and violence:
An empirical picture in Context. Journal of Mental Health,
12, 7–18.
Powell, G., Cann, W. & Crowe, M. (1994). What events
precede violent incidents in psychiatric hospitals? British
Journal of Psychiatry, 165, 107–112.
MENTAL ILLNESS AND VIOLENCE
Rabkin, J. (1979). Criminal behaviour of discharged mental
patients: a critical appraisal of the research. Psychological
Bulletin, 86, 1–29.
Rappeport, J. R. & Lassen, G. (1965). Dangerousness: arrest
rate comparison of discharged patients and the general pop-
ulation. American Journal of Psychiatry, 123, 413–419.
Räsänen, P., Tiihonen, J., Isohanni, M., Rantakallio, P., Lehto-
nen, J. & Moring, J. (1998). Schizophrenia, alcohol abuse
and violent behaviour: a 26-year follow up study. Schizo-
phrenia Bulletin, 24, 437–441.
Regier, D. A., Farmer, M. E., Rae, D. S. et al. (1990). Comor-
bidity of mental disorders with alcohol and other drug abuse:
results from the epidemiologic catchment area (ECA) study.
Journal of the American Medical Association, 264,
2511–2518.
Robbins, L. (1993). Childhood conduct problems, adult psycho-
pathology and crime. In S. Hodgins (Ed.). Mental Disorder
and Crime, (pp. 173–193). London: Sage.
Rossi, A. M., Jacobs, M. & Monteleone, M. (1986). Characteris-
tics of psychiatric patients who engage in assaultive behav-
iour and or other fear inducing behaviours. Journal of
Nervous and Mental Diseases, 174, 154–160.
Royal Commission On the National Health Service (1979).
London: HMSO.
Sclafani, M. J. (2000). Developing a clinical violence prevention
and intervention plan for psychiatric mental healthcare set-
tings. Journal of Health Care Quality, 22 (2), 8–12.
Shah, S. (1975). Dangerousness and civil commitment of the
mentally ill: some public policy considerations. American
Journal of Psychiatry, 132, 501–505.
Shawyer, F., Mackinnon, A., Farhall, J., Trauser, T. & Coplov, D.
(2003). Command hallucinations and violence. implications
for detention and treatment. Psychiatry, Psychology and the
Law, 10, 97–101.
Shepherd, M. & Lavender, T. (1999). Putting aggression into
context, an investigation into the contextual factors influenc-
ing the rate of aggressive incidents in a psychiatric hospital.
Journal of Mental Health, 8, 159–170.
Sheridan, M., Henrion, R., Robinson, L. & Baxter, V. (1990).
Precipitants of violence in a psychiatric inpatient setting.
Hospital and Community Psychiatry, 41, 776–780.
Silver, E. (2001). Neighbourhood social disorganisation as a
cofactor in violence among people with mental health
problems. International Journal of Offender Therapy and
Comparative Criminology, 45, 403–406.
Steadman, H. J. & Cocozza, J. J. (1974). Careers of the Crim-
inally Insane: Excessive Social Control of Deviance. Lexing-
ton MA: Lexington Books.
Steadman, H. J., Monahan, J., Applebaum, P. S. et al. (1994).
Developing a new generation of risk assessment research. In
J. Monahan & H. J. Steadman (Eds). Violence and Mental
Disorder: Developments in Risk Assessment (pp. 297–318).
Chicago: University of Chicago Press.
Steadman, H. J., Mulvey, E. P., Monahan, J. et al. (1998). Vio-
lence by people discharged from acute psychiatric inpatient
facilities and by others in the same neighbourhoods.
Archives of General Psychiatry, 55, 393–401.
51
Stueve, A. & Link, B. G. (1997). Violence and psychiatric disor-
ders results from an epidemiological study of young adults in
Israel. Psychiatric Quarterly, 68, 327–342.
Swanson, J. W. (1994). Mental disorder, substance abuse and
community violence: an epidemiological approach. In
J. Monahan & H. J. Steadman (Eds). Violence and Mental
Disorder: Developments in Risk Assessment (pp. 101–136).
Chicago: University of Chicago Press.
Swanson, J. W., Borum, R., Monahan, J. & Swartz, M. (1996).
Psychotic symptoms and the risk of violent behaviour:
evidence from the epidemiologic catchment area surveys.
Hospital and Community Psychiatry, 41, 317–338.
Swanson, J. W., Estroff, S., Swartz, M. et al. (1997). Violence
and severe mental disorder in clinical and community popu-
lations: The effects of psychotic symptoms, comorbidity and
lack of treatment. Psychiatry, 60, 1–22.
Swanson, J. W., Holzer, C., Ganja, V. & Jono, R. (1990). Vio-
lence and psychiatric disorder in the community: evidence
from the Epidemiologic Catchment Area Surveys. Hospital
and Community Psychiatry, 41, 761–770.
Taylor, P. J. (1985). Motives for offending among violent and
psychotic men. British Journal of Psychiatry, 147, 491–498.
Taylor, P. J., Garety, P., Buchanan, A. et al. (1994). Delusions
and Violence. In J. Monahan & H. J. Steadman (Eds).
Violence and Mental Disorder: Developments in Risk
Assessment (pp. 161–182). Chicago: University of Chicago
Press.
Taylor, P. J. & Gunn, J. (1984). Violence and psychosis, 1: risk
of violence amongst psychotic men. British Medical Journal,
288, 1945–1949.
Taylor, P. J., Leese, M., Williams, D., Butwell, M., Daly, R. &
Larkin, E. (1998). Mental disorder and violence: a special
(high security) hospital study. British Journal of Psychiatry,
172, 218–226.
Teplin, L. A., Abram, K. M. & McClelland, G. M., (1996). The
prevalence of psychiatric disorder among incarcerated
women 1: Pre-trial detainees. Archives of General Psychi-
atry, 53, 505–512.
Thornicroft, G. & Bebbington, P. (1989). Deinstitutionalisation
– from hospital closure to service development. British
Journal of Psychiatry, 155, 739–753.
Webster, D., Harris, G. T., Rice, M., Cormier, C. & Quinsay, V. L.
(1994). The Violence Prediction Scheme. Toronto: University
of Toronto.
Wenk, E., Robinson, J. O. & Smith, J. W. (1972). Can violence
be predicted. Crime and Delinquency, 18, 393–394.
Werner, P. D., Rose, T. K. & Yesavage, J. A. (1983). Reliability,
accuracy and decision making strategy in clinical predictions
of imminent dangerousness. Journal of Consulting Clinical
Psychology, 51, 812–825.
Wessley, S. (1997). The epidemiology of crime, violence and
schizophrenia. British Journal of Psychiatry, 170 (Suppl.
32), 8–11.
Wessley, S. & Taylor, P. (1991). Madness and crime: crimin-
ology vs psychiatry. Criminal Behaviour and Mental Health,
1, 193–228.
52 B. PATERSON ET AL.

Wheatley, M. (1998). The prevalence and relevance of sub- Wright, S., Gournay, K., Glorney, E. & Thornicroft, G. (2002).
stance use in detained schizophrenic patients. The Journal of Mental Illness substance abuse demographics: dual diag-
Forensic Psychiatry, 9, 114–129. nosis in the suburbs. Journal of Forensic Psychiatry, 13,
35–52.