Skip to main content

Mental disorder and violence: is there a relationship beyond substance use?

Social Psychiatry and Psychiatric Epidemiology volume 47, pages 487–503 (2012)Cite this article

Abstract

Purpose

A general consensus exists that severe mental illness (SMI) increases violence risk. However, a recent report claimed that SMI “alone was not statistically related to future violence in bivariate or multivariate analyses.” We reanalyze the data used to make this claim with a focus on causal relationships between SMI and violence, rather than the statistical prediction of violence.

Methods

Data are from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a two-wave study (N = 34,653: Wave 1: 2001–2003; Wave 2: 2004–2005). Indicators of mental disorder in the year prior to Wave 1 were used to examine violence between Waves 1 and 2.

Results

Those with SMI, irrespective of substance abuse status, were significantly more likely to be violent than those with no mental or substance use disorders. This finding held in both bivariate and multivariable models. Those with comorbid mental and substance use disorders had the highest risk of violence. Historical and current conditions were also associated with violence, including childhood abuse and neglect, household antisocial behavior, binge drinking and stressful life events.

Conclusions

These results, in contrast to a recently published report, show that the NESARC data are consistent with the consensus view on mental disorder and violence: there is a statistically significant, yet modest relationship between SMI (within 12 months) and violence, and a stronger relationship between SMI with substance use disorder and violence. These results also highlight the importance of premorbid conditions, and other contemporaneous clinical factors, in violent behavior.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2

Notes

  1. Given the wording of the NESARC interview question for “schizophrenia”, it is more accurate to refer to this cluster of mental disorders as “psychotic disorders” [41]. However, we will use the term “schizophrenia” in order to maintain a consistent reference point to the prior authors’ work.

  2. The NESARC data are no longer available for independent analysis due to concerns regarding data confidentiality. Consequently, the NESARC data are now housed at the U.S. Census Bureau. All analyses were conducted by the third author of this paper, an employee of that agency, in constant consultation with the lead-author.

  3. Data from the MacArthur Violence Risk Assessment study showed that patients without alcohol or drug symptoms, as assessed by the MAST and DAST, were not significantly more violent than comparison group subjects without alcohol or drug symptoms (4.7 vs. 3.3%). However, it is also important to note that the MacArthur study used a patient sample (i.e., recently discharge from the hospital), which differs from the NESARC sample.

References

  1. Monahan J, Steadman H, Silver E, Appelbaum P (2001) Rethinking risk assessment: The macarthur study of mental disorder and violence. Oxford University Press, New York

    Google Scholar 

  2. Monahan J, Steadman HJ, Appelbaum PS, Robbins PC, Mulvey EP, Silver E, Roth LH, Grisso T (2000) Developing a clinically useful actuarial tool for assessing violence risk. Br J Psychiatry 176:312–319

    Article  PubMed  CAS  Google Scholar 

  3. Steadman HJ, Silver E, Monahan J, Appelbaum PS, Robbins PC, Mulvey EP, Grisso T, Roth LH, Banks S (2000) A classification tree approach to the development of actuarial violence risk assessment tools. Law Hum Behav 24(1):83–100

    Article  PubMed  CAS  Google Scholar 

  4. Appelbaum PS, Robbins PC, Monahan J (2000) Violence and delusions: data from the macarthur violence risk assessment study. Am J Psychiatry 157(4):566–572

    Article  PubMed  CAS  Google Scholar 

  5. Steadman HJ, Mulvey EP, Monahan J, Robbins PC, Appelbaum PS, Grisso T, Roth LH, Silver E (1998) Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Arch Gen Psychiatry 55(5):393–401

    Article  PubMed  CAS  Google Scholar 

  6. Swanson J, Estroff S, Swartz M, Borum R, Lachicotte W, Zimmer C, Wagner R (1997) Violence and severe mental disorder in clinical and community populations: The effects of psychotic symptoms, comorbidity, and lack of treatment. Psychiatry 60(1):1–22

    PubMed  CAS  Google Scholar 

  7. Swanson JW, Swartz MS, Van Dorn RA, Elbogen EB, Wagner HR, Rosenheck R, Stroup S, Lieberman J (2006) A national study of violent behavior in persons with schizophrenia. Arch Gen Psychiatry 63:490–499

    Article  PubMed  Google Scholar 

  8. Swartz MS, Swanson JW, Hiday VA, Borum R, Wagner HR, Burns BJ (1998) Violence and severe mental illness: the effects of substance abuse and nonadherence to medication. Am J Psychiatry 155(2):226–231

    PubMed  CAS  Google Scholar 

  9. Elbogen EB, Johnson SC (2009) The intricate link between violence and mental disorder: results from the national epidemiologic survey on alcohol and related conditions. Arch Gen Psychiatry 66(2):152–161. doi:10.1001/archgenpsychiatry.2008.537

    Article  PubMed  Google Scholar 

  10. Fazel S, Langstrom N, Hjern A, Grann M, Lichtenstein P (2009) Schizophrenia, substance abuse, and violent crime. JAMA 301:2016–2023

    Article  PubMed  CAS  Google Scholar 

  11. Walsh E, Gilvarry C, Samele C, Harvey K, Manley C, Tattan T, Tyrer P, Creed F, Murray R, Fahy T (2004) Predicting violence in schizophrenia: a prospective study. Schizophr Res 67(2–3):247–252

    Article  PubMed  Google Scholar 

  12. Swanson JW, Van Dorn RA, Swartz MS, Smith A, Elbogen EB, Monahan J (2008) Alternative pathways to violence in persons with schizophrenia: the role of childhood antisocial behavior problems. Law Hum Behav 32(3):228–240. doi:10.1007/s10979-007-9095-7

    Article  PubMed  Google Scholar 

  13. Fazel S, Grann M, Carlstrom E, Lichtenstein P, Langstrom N (2009) Risk factors for violent crime in schizophrenia: a national cohort study of 13, 806 patients. J Clin Psychiatry 70:362–369

    Article  PubMed  Google Scholar 

  14. Soyka M, Graz C, Bottlender R, Dirschedl P, Schoech H (2007) Clinical correlates of later violence and criminal offences in schizophrenia. Schizophr Res 94:89–98

    Article  PubMed  Google Scholar 

  15. Haggård-Grann U, Hallqvist J, Långström N, Möller J (2006) Short-term effects of psychiatric symptoms and interpersonal stressors on criminal violence. Soc Psychiatry Psychiatr Epidemiol 41(7):532–540. doi:10.1007/s00127-006-0056-0

    Article  PubMed  Google Scholar 

  16. Swanson JW, Swartz MS, Van Dorn RA, Volavka J, Monahan J, Stroup TS, McEvoy JP, Wagner HR, Elbogen EB, Lieberman J (2008) A comparison of antipsychotic drugs for reducing violence in persons with schizophrenia. Br J Psychiatry 193:37–43

    Article  PubMed  Google Scholar 

  17. Angermeyer MC, Matschinger H (1996) The effect of violent attacks by schizophrenic persons on the attitude of the public towards the mentally ill. Soc Sci Med 43(12):1721–1728

    Article  PubMed  CAS  Google Scholar 

  18. Link BG, Phelan JC, Bresnahan M, Stueve A, Pescosolido BA (1999) Public conceptions of mental illness: labels, causes, dangerousness, and social distance. Am J Public Health 89(9):1328–1333

    Article  PubMed  CAS  Google Scholar 

  19. Pescosolido BA, Monahan J, Link BG, Stueve A, Kikuzawa S (1999) The public’s view of the competence, dangerousness, and need for legal coercion of persons with mental health problems. Am J Public Health 89(9):1339–1345

    Article  PubMed  CAS  Google Scholar 

  20. Van Dorn RA, Swanson JW, Elbogen EB, Swartz MS (2005) A comparison of stigmatizing attitudes toward persons with schizophrenia in four stakeholder groups: perceived likelihood of violence and desire for social distance. Psychiatry: Interpersonal and Biological Processes 68(2):152–163

    Article  Google Scholar 

  21. Angermeyer MC, Cooper B, Link BG (1998) Mental disorder and violence: results of epidemiological studies in the era of de-institutionalization. Soc Psychiatry Psychiatr Epidemiol 33:S1–S6. doi:10.1007/s001270050203

    Article  PubMed  Google Scholar 

  22. Huguelet P, Perroud N (2010) Is there a link between mental disorder and violence? Reply. Arch Gen Psychiatry 67:540

    Article  PubMed  Google Scholar 

  23. Arseneault L, Moffitt TE, Caspi A, Taylor PJ, Silva PA (2000) Mental disorders and violence in a total birth cohort: results from the dunedin study. Arch Gen Psychiatry 57(10):979–986. doi:10.1001/archpsyc.57.10.979

    Article  PubMed  CAS  Google Scholar 

  24. Hodgins S, Tiihonen J, Ross D (2005) The consequences of conduct disorder for males who develop schizophrenia: associations with criminality, aggressive behavior, substance use, and psychiatric services. Schizophr Res 78:323–335

    Article  PubMed  Google Scholar 

  25. Mueser KT, Rosenberg SD, Drake RE, Miles KM, Wolford G, Vidaver R, Carrieri K (1999) Conduct disorder, antisocial personality disorder and substance use disorders in schizophrenia and major affective disorders. J Stud Alcohol 60(2):278–284

    PubMed  CAS  Google Scholar 

  26. Robins LN, Price RK (1991) Adult disorders predicted by childhood conduct problems: results from the nimh epidemiologic catchment area project. Psychiatry 54(2):116–132

    PubMed  CAS  Google Scholar 

  27. Eriksson Å, Romelsjö A, Stenbacka M, Tengström (2010) A Early risk factors for criminal offending in schizophrenia: a 35-year longitudinal cohort study. Soc Psychiatry Psychiatr Epidemiol:1–8. doi:10.1007/s00127-010-0262-7

  28. Swanson JW, Swartz MS, Elbogen EB (2004) Effectiveness of atypical antipsychotic medications in reducing violent behavior among persons with schizophrenia in community-based treatment. Schizophr Bull 30:3–20

    Article  PubMed  Google Scholar 

  29. Swanson JW, Swartz MS, Elbogen EB, Van Dorn RA (2004) Reducing violence risk in persons with schizophrenia: Olanzapine vs. Risperidone. J Clin Psychiatry 65:1666–1673

    Article  PubMed  CAS  Google Scholar 

  30. Volavka J (1999) The effects of clozapine on aggression and substance abuse in schizophrenic patients. J Clin Psychiatry 60:43–46

    PubMed  CAS  Google Scholar 

  31. Volavka J (2002) Neurobiology of violence, 2nd edn edn. American Psychiatric Publishing, Inc, Washington

    Google Scholar 

  32. Volavka J, Citrome L (1999) Atypical antipsychotics in the treatment of the persistently aggressive psychotic patient: methodological concerns. 35:S23–S33

    Google Scholar 

  33. Volavka J, Czobor P, Nolan K, Sheitman B, Lindenmayer JP, Citrome L, McEvoy JP, Cooper TB, Lieberman JA (2004) Overt aggression and psychotic symptoms in patients with schizophrenia treated with clozapine, olanzapine, risperidone, or haloperidol. J Clin Psychopharmacol 24:225–228

    Article  PubMed  CAS  Google Scholar 

  34. Volavka J, Czobor P, Sheitman B, Lindenmayer JP, Citrome L, McEvoy JP, Cooper TB, Chakos M, Lieberman JA (2002) Clozapine, olanzapine, risperidone, and haloperidol in the treatment of patients with chronic schizophrenia and schizoaffective disorder. Am J Psychiatry 159(2):255–262

    Article  PubMed  Google Scholar 

  35. Skeem JL, Monahan J, Mulvey EP (2002) Psychopathy, treatment involvement, and subsequent violence among civil psychiatric patients. Law Hum Behav 26(6):577–603

    Article  PubMed  Google Scholar 

  36. Stueve A, Link BG (1998) Gender differences in the relationship between mental illness and violence: evidence from a community-based epidemiological study in Israel. Soc Psychiatry Psychiatr Epidemiol 33:S61–S67. doi:10.1007/s001270050211

    Article  PubMed  Google Scholar 

  37. Torrey EF (2006) Violence and schizophrenia. Schizophr Res 88(1–3):3–4

    Article  PubMed  Google Scholar 

  38. Swanson JW, Van Dorn RA, Monahan J, Swartz MS (2006) Violence and leveraged community treatment for persons with mental disorder. Am J Psychiatry 163:1404–1411

    Article  PubMed  Google Scholar 

  39. Grant B, Kaplan K (2005) Source and accuracy statement for the wave 2 national epidemiologic survey on alcohol and related conditions (nesarc). National Institute on Alcohol Abuse and Alcoholism, Rockville

  40. Grant BF, Moore TC, Shepard J, Kaplan K (2003) Source and accuracy statement: Wave 1 national epidemiologic survey on alcohol and related conditions (nesarc). National Institute on Alcohol Abuse and Alcoholism, Bethesda

  41. Mojtabai R (2006) Psychotic-like experiences and interpersonal violence in the general population. Soc Psychiatry Psychiatr Epidemiol 41(3):183–190. doi:10.1007/s00127-005-0020-4

    Article  PubMed  Google Scholar 

  42. Fleiss JL, Levin B, Paik MC (2003) Statistical methods for rates and proportions. Wiley, New York

    Book  Google Scholar 

  43. Swanson JW, Holzer CE, Ganju VK, Jono RT (1990) Violence and psychiatric disorder in the community: evidence from the epidemiologic catchment area surveys. Hosp Community Psychiatr 41(7):761–770

    CAS  Google Scholar 

  44. Compton WM, Thomas YF, Stinson FS, Grant BF (2007) Prevalence, correlates, disability, and comorbidity of dsm-iv drug abuse and dependence in the United States: results from the national epidemiologic survey on alcohol and related conditions. Arch Gen Psychiatry 64(5):566–576. doi:10.1001/archpsyc.64.5.566

    Article  PubMed  Google Scholar 

  45. Hasin DS, Goodwin RD, Stinson FS, Grant BF (2005) Epidemiology of major depressive disorder: results from the national epidemiologic survey on alcoholism and related conditions. Arch Gen Psychiatry 62(10):1097–1106. doi:10.1001/archpsyc.62.10.1097

    Article  PubMed  Google Scholar 

  46. Hasin DS, Stinson FS, Ogburn E, Grant BF (2007) Prevalence, correlates, disability, and comorbidity of dsm-iv alcohol abuse and dependence in the United States: results from the national epidemiologic survey on alcohol and related conditions. Arch Gen Psychiatry 64(7):830–842. doi:10.1001/archpsyc.64.7.830

    Article  PubMed  Google Scholar 

  47. Robins LN, Regier DA (1991) Psychiatric disorders in America: the epidemiologic catchment area study. The Free Press, New York

    Google Scholar 

  48. Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, Wittchen HU, Kendler KS (1994) Lifetime and 12-month prevalence of dsm-iii-r psychiatric disorders in the United States. Arch Gen Psychiatry 51:8–19

    Article  PubMed  CAS  Google Scholar 

  49. Sobel ME (1995) Causal inference in the social and behavioral sciences. In: Arminger G, Clogg CC, Sobel ME (eds) Handbook of statistical modeling for the social and behavioral sciences. Plenum Press, New York, pp 1–38

    Google Scholar 

  50. Hill AB (1965) The environment and disease: association or causation. Pro R Soc Med 58:295–300

    CAS  Google Scholar 

  51. Stueve A, Link BG (1997) Violence and psychiatric disorders: results from an epidemiological study of young adults in Israel. Psychiatr Q 68(4):327–342

    Article  PubMed  CAS  Google Scholar 

  52. Eronen M, Angermeyer MC, Schulze B (1998) The psychiatric epidemiology of violent behaviour. Soc Psychiatry Psychiatr Epidemiol 33:S13–S23

    Article  PubMed  Google Scholar 

  53. Corrigan PW, Watson AC (2005) Findings from the national comorbidity survey on the frequency of violent behavior in individuals with psychiatric disorders. Psychiatry Res 136(2–3):153–162

    Article  PubMed  Google Scholar 

  54. Coid J, Yang M, Roberts A, Ullrich S, Moran P, Bebbington P, Brugha T, Jenkins R, Farrell M, Lewis G, Singleton N (2006) Violence and psychiatric morbidity in the national household population of Britain: public health implications. Br J Psychiatry 189(1):12–19. doi:10.1192/bjp.189.1.12

    Article  PubMed  Google Scholar 

  55. Cook TD, Campbell DT (1979) Quasi-experimentation: design & analysis issues for field settings. Houghton Mifflin, Boston

    Google Scholar 

  56. Shadish WR, Cook TD, Campbell DT (2002) Experimental and quasi-experimental designs for generalized causal inference. Houghton Mifflin, Boston

    Google Scholar 

  57. Arboleda-Flórez J, Holley H, Crisanti A (1998) Understanding causal paths between mental illness and violence. Soc Psychiatry Psychiatr Epidemiol 33(Suppl 1):S38–S46

    Article  PubMed  Google Scholar 

  58. Hill KG, White HR, Chung I-J, Hawkins JD, Catalano RF (2000) Early adult outcomes of adolescent binge drinking: Person- and variable-centered analyses of binge drinking trajectories. Alcohol Clin Exp Res 24(6):892–901

    Article  PubMed  CAS  Google Scholar 

  59. Yang M, Coid J (2007) Gender differences in psychiatric morbidity and violent behaviour among a household population in great britain. Soc Psychiatry Psychiatr Epidemiol 42(8):599–605. doi:10.1007/s00127-007-0226-8

    Article  PubMed  Google Scholar 

  60. Williams JH, Van Dorn RA, Bright CL, Jonson-Reid M, Nebbitt VE (2010) Child maltreatment and delinquency onset among African American adolescent males. Res Soc Work Pract 20:253–259

    Article  Google Scholar 

  61. Kosterman R, Graham JW, Hawkins JD, Catalano RF, Herrenkohl TI (2001) Childhood risk factors for persistence of violence in the transition to adulthood: a social development perspective. Violence Vict 16(4):351–354

    Google Scholar 

  62. Van Dorn RA, Williams JH, Del-Colle M, Hawkins JD (2009) The co-occurrence of substance use, mental illness and violence among young adults. J Behav Health Serv Res 36(4):465–477

    Article  PubMed  Google Scholar 

  63. Williams JH, Van Dorn RA, Hawkins JD, Abbott R, Catalano RF (2001) Correlates contributing to involvement in violent behaviors among young adults. Violence Vict 16(4):371–388

    PubMed  CAS  Google Scholar 

  64. Barry D, Petry N (2008) Gender differences in associations between stressful life events and body mass index. Prev Med 47(5):498–503

    Article  PubMed  Google Scholar 

  65. Fazel S, Gulati G, Linsell L, Geddes JR, Grann M (2009) Schizophrenia and violence: systematic review and meta-analysis. PLoS Med 6(8):1–15

    Article  Google Scholar 

  66. Volavka J, Swanson JW (2010) Violent behavior in mental illness: the role of substance abuse. JAMA 304:563–564

    Article  PubMed  CAS  Google Scholar 

  67. Swanson JW, Swartz MS, Essock SM, Osher FC, Wagner HR, Goodman LA, Rosenberg SD, Meador KG (2002) The social-environmental context of violent behavior in persons treated for severe mental illness. Am J Public Health 92(9):1523–1531

    Article  PubMed  Google Scholar 

  68. Mericle A, Havassy B (2008) Characteristics of recent violence among entrants to acute mental health and substance abuse services. Soc Psychiatry Psychiatr Epidemiol 43(5):392–402. doi:10.1007/s00127-008-0322-4

    Article  PubMed  CAS  Google Scholar 

  69. Honkonen T, Henriksson M, Koivisto AM, Stengård E, Salokangas RKR (2004) Violent victimization in schizophrenia. Soc Psychiatry Psychiatr Epidemiol 39(8):606–612. doi:10.1007/s00127-004-0805-x

    Article  PubMed  Google Scholar 

  70. Link BG, Stueve A (1998) New evidence on the violence risk posed by people with mental illness: on the importance of specifying the timing and the targets of violence. Arch Gen Psychiatry 55(5):403–404. doi:10.1001/archpsyc.55.5.403

    Article  PubMed  CAS  Google Scholar 

  71. Sobell LC, Sobell MB (1992) Timeline follow-back: a technique for assessing self-reported alcohol consumption. In: Litten RZ, Allen J (eds) Measuring alcohol consumption: psychosocial and biological methods. Humana Press, Totowa, pp 41–72

    Chapter  Google Scholar 

  72. Davidson L, Roe D (2007) Recovery from versus recovery in serious mental illness: one strategy for lessening confusion plaguing recovery. J Ment Health 16(4):459–470

    Article  Google Scholar 

  73. Nolan KA, Volavka J, Czobor P, Sheitman B, Lindenmayer J-P, Citrome LL, McEvoy J, Lieberman JA (2005) Aggression and psychopathology in treatment-resistant inpatients with schizophrenia and schizoaffective disorder. J Psychiatr Res 39(1):109–115

    Article  PubMed  Google Scholar 

  74. Fazel S, Lichtenstein P, Grann M, Goodwin GM, Langstrom N (2010) Bipolar disorder and violent crime: new evidence from population-based longitudinal studies and systematic review. Arch Gen Psychiatry 67:931–938

    Article  PubMed  Google Scholar 

  75. Látalová K (2009) Bipolar disorder and aggression. Int J Clin Pract 63(6):889–899

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

The authors would like to thank Dr. Randy Borum for his helpful comments on an earlier draft of the manuscript.

Conflict of interest

The authors declare that they have no conflict of interest.

Author information

Authors and Affiliations

  1. University of South Florida, Tampa, USA

    Richard Van Dorn

  2. Department of Psychiatry, New York University School of Medicine, New York, NY, USA

    Jan Volavka

  3. U. S. Census Bureau, Washington, DC, USA

    Norman Johnson

Authors
  1. Richard Van Dorn
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jan Volavka
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Norman Johnson
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Richard Van Dorn.

Additional information

This paper is released to inform interested parties of research and to encourage discussion. Any views expressed on statistical, methodological, or technical issues are those of the author(s) and not necessarily those of the U.S. Census Bureau.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Van Dorn, R., Volavka, J. & Johnson, N. Mental disorder and violence: is there a relationship beyond substance use?. Soc Psychiatry Psychiatr Epidemiol 47, 487–503 (2012). https://doi.org/10.1007/s00127-011-0356-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00127-011-0356-x

Keywords

  • Violence
  • Severe mental illness
  • Epidemiology
  • Causality versus statistical prediction