Secondary Logo

Journal Logo

Review article

Risk factors for violence among forensic psychiatric inpatients

Soliman, Alaa; Sadek, Hisham; Azzam, Hanan; Elkholy, Hussien

Author Information
Middle East Current Psychiatry: January 2013 - Volume 20 - Issue 1 - p 1-5
doi: 10.1097/01.XME.0000423000.04392.04
  • Free



Forensic evaluation differs from mental health evaluation for clinical or treatment purposes in several aspects. Clinical evaluations aim at serving the healthcare needs of the individual, whereas forensic evaluators have legal goals that serve other parties 1.

Crime prevention effectiveness has always been one of the most important issues in the area of correctional and forensic psychiatric treatment. Politicians, media, and the public frequently discuss the issue, and clinicians and researchers in the field are often asked for answers. Recently, there have been important developments in the accuracy of assessments of risk for violence among individuals with mental disorders 2–7.

Most countries subject both psychiatrists and other medical practitioners in the field to special obligations for assessing the danger that individual patients pose to themselves and others. The ultimate purpose of such assessments is not prediction, but prevention. Prevention is of utmost importance as many studies suggest that although mental illness constitutes a risk factor for violent crime, a mentally ill individual has only a moderate risk of being prosecuted for such an offense 8.

Individuals with mental disorders are not similar to other groups in terms of the risk factors for violence. The strongest predictors are criminal history and personal demographic variables. Other established risk factors for violence in individuals with psychosis are comorbid substance misuse, active psychotic symptoms, noncompliance with medication, and comorbid personality disorder, particularly antisocial personality disorder 9–13.

Conceptualization of violence

There are different definitions of violence. One definition is that violence is actual, attempted, or threatened harm to an individual or individuals. A behavior that would be fear-inducing to the average individual may be counted as violence. Violence is a description of the act itself, not the damage to a victim. Examples of acts of violence include hitting, punching, kicking, etc. Less clear examples of violence may include kidnapping, arson, and reckless driving because of the threat of harming others 13.

All sexual assaults should be considered violent behavior. Boer et al.14 defined sexual violence as actual or attempted sexual contact with an individual who does not provide consent or who is unable to provide consent.

Sex difference and violence

When assessment techniques of the risk of violence are applied to women, there are particular concerns because of well-established sex differences in the quality, frequency, intensity, and etiology of violence 10,15–18. For example, the construct of psychopathy, which is consistently considered as an integral part of assessment of risk of violence, is different for men and women 19,20. Nonetheless, studies evaluating violence risk assessment measures typically either ignore sex or include male sex as a risk factor for violence 21.

The HCR-20 Violence Risk Assessment Scheme is one of the most frequently used and widely researched violence risk assessment tools 13. Research has shown that the HCR-20 has moderate to strong predictive accuracy in men across different populations and settings 22; however, the utility of the HCR-20 has not been conclusively established or even adequately investigated in women 23, with much of the support for this measure coming from a single research team 24.

A study of the predictive accuracy of HCR-20 has indicated that a number of significant differences were observed for individual items between men and women. These sex differences indicate that the individual risk factors for violence may differ in terms of their frequency, and hence may have a different impact on the process of violence risk assessments. Interestingly, there were no sex differences in the individual items with respect to predictive utility, suggesting that, when present, the same risk factors apply equally to men and women 25.

Violence in psychiatry

Violence and psychosis

In the 1980s, expert opinion suggested that there was no increased risk for violence in individuals with schizophrenia and other psychoses 26. However, with the publication of large population-based studies over the last two decades, it is now believed that there is a modest association between violence and schizophrenia and other psychoses 27. This view is not shared by many mental health clinicians 28 or public advocacy groups. In factsheets, the Schizophrenia and Related Disorders Alliance of America states that individuals with schizophrenia are no more likely to be violent than their neighbors 29, and SANE Australia states that individuals with mental illness who receive treatment are no more violent than others 30.

The issue remains topical because it is believed to have contributed toward policy and legal developments for psychiatric patients 31 and the stigma associated with mental illness 32, which is considered to be the most significant obstacle to the development of mental health services 33.

Although a number of studies have examined the relationship between psychoses and violent outcomes, wide variations in risk ratios have been reported, with estimates ranging from seven-fold increases in violent offending in schizophrenia compared with general population controls 34,35 to no association in a highly influential prospective investigation 36.

Four main findings were obtained by a systematic review of the risk of violence in schizophrenia and other psychoses that identified 20 studies including 18 423 individuals with these disorders. The first finding was that the risk of violent outcomes was increased in individuals with schizophrenia and other psychoses. A second finding was that comorbidity with substance use disorders increased this risk considerably. Although there was considerable variation in this estimate between studies, the pooled estimate was around four times higher compared with individuals without comorbidity. Third, the study found no significant differences in risk estimates for a number of study design characteristics for which there has been uncertainty. These included whether the diagnosis was schizophrenia versus other psychoses, whether the outcome measure was register-based arrests and convictions versus self-report, and whether the study location was the USA or Nordic countries compared with other countries. Finally, the increased risk of violence in schizophrenia and psychoses comorbid with substance abuse was not different from the risk of violence in individuals with diagnoses of substance use disorders. In other words, schizophrenia and other psychoses did not appear to add any additional risk to that conferred by the substance abuse alone 37.

The relationship between comorbid substance abuse and violence in schizophrenia may be mediated by personality features and/or social problems, and is unlikely to be a simple additive effect 38.

The relationship with medication adherence may also mediate the association with violent outcomes, particularly if it precedes substance abuse on the causal pathway to violence.

Other findings suggest that individuals with substance use disorders may be more dangerous than individuals with schizophrenia and other psychoses, and that psychoses comorbid with substance abuse may confer no additional risk over and above the risk associated with the substance abuse. As substance use disorders are three to four times more common than psychoses 39,40, public health strategies to reduce violence in society could focus on the prevention and treatment of substance abuse at individual, community, and societal levels 37.

Violence and mood disorders

Any association between mood disorders and violence has been comparatively overlooked. It appears that there may be more evidence relating mood disorders and violence than many clinicians realize. Most societal violence is not mediated by psychosis, being more often associated with anger or other extreme affective states, often interacting with disinhibitors such as intoxication. Therefore, it might be considered that mood disorders, with their prominent symptoms of dysphoria, irritability, and anger, and their intrinsic tendency to weaken internal inhibitions, would be associated with violence at least as much as schizophrenia. However, clinical experience may indicate that this is not the case, that violence in mood disorder is unusual 41.

Homicide–suicide describes the situation when an individual kills someone (often a spouse or a relative) and then takes their own life. In England and Wales, it is estimated that homicide–suicide accounts for 1% of all homicides 42. Homicide–suicide has been commonly associated with depression, and one case series found that 75% of perpetrators were depressed at the time 43.

Infanticide is the killing of a child by the mother before the first birthday, very commonly in the context of pos-partum depression 44. It may be distinguished from neonaticide (a baby being killed within the first day of life) and filicide (the killing of a child on or after its first birthday). Two motivational profiles have been identified: mothers who committed neonaticide were mostly troubled by psychosis and social problems and mothers who committed filicide were defined as severely depressed, with a history of self-directed violence and a high rate of suicide attempts following the filicidal offence 45.

In general, affective states, particularly anger and irritability, play a role in aggressive behavior and are influenced by serotonergic mechanisms. Extensive literature has suggested a link between decreased serotonin function and aggression, probably mediated through impulse control, affect regulation, and social functioning 46. The evidence relating to a clinical association between mood disorders and violence may consider the rate of violence in relation to inpatient treatment of depression, the rate of depression in violent or offender populations, and the rates of co-occurring depression and violence in the community. Most individuals with mental illness are not admitted to hospital and most individuals who behave violently are not convicted of a crime or put in prison. Therefore, research using inpatients and convicted offenders underestimates the rate of mental illness and violent behavior in the general population and potentially biases any findings about an association between mental illness and violence. For this reason, studies in the community are very helpful in elucidating any association 41.

The relationship between mood disorders and violence has been relatively overlooked compared with schizophrenia. It may be that comorbid substance misuse has a more significant impact on the risk of violence in mood disorders than in schizophrenia, which explains why in some studies the association between mood disorders and violence did not remain when comorbidity was controlled for. However, comorbidity is almost ever present in day-to-day clinical practice. It might not be appropriate to consider diagnoses in isolation, as is the case in research 41.

Personality pathology and violence

Research indicates a higher prevalence of personality disorder diagnoses in forensic psychiatric and correctional samples compared with samples from community settings 47. Personality disorder diagnoses made using validated assessment measures have been detected between 42 and 78% of adult male and female prisoners 48,49. Also utilizing validated assessment methods, research into mentally disordered offenders, many of whom have a history of violence, suggests that 66% of men 50 and 80% of women 51 have one or more personality disorder diagnoses.

Personality pathology is a critical factor in the risk of harm presented by some individuals. Yet, although multiple studies verify the co-occurrence of violence and personality disorder, the mechanism of this link is not well understood. Consequently, the role of personality pathology in explaining violence may be inadequately addressed – if at all – in the risk formulations that should generate the risk management plans that follow. Understanding personality pathology may improve the way in which past violence is understood and the potential for future violence explored and, as a consequence, more appropriate recommendations for risk management may be made 52.

Prediction of violence

Danger to others is in certain ways more complex and more emotionally charged than suicidality, because the danger threatens to involve innocent bystanders. This situation exerts a significant influence on the degree of risk the clinician can accept. Nevertheless, prediction of dangerousness is fundamentally an unreliable endeavor. Forensic psychiatrists are constantly challenged to balance the individual patient’s rights and freedoms against the safety of the society 53.

Prediction of violence has been shown repeatedly to be a difficult clinical task, and its accuracy has usually been deemed to be poor. Some researchers have proposed that actuarial methods, risk assessment on the basis of statistical data, can enhance clinical assessments of potential for violence, which have traditionally been based on reviews by multidisciplinary staff 54.

In other words, risk assessments can be carried out in a number of different ways. Two traditional methods for making decisions – clinical and actuarial models – have been discussed in the medical and behavioral science literatures and have been applied to violence risk assessment. The clinical method has been described as an ‘informal, ‘in the head,’ impressionistic, subjective conclusion, reached (somehow) by a human clinical judge’. In contrast, the actuarial method has been described as ‘a formal method’ that ‘uses an equation, a formula, a graph, or an actuarial table to arrive at a probability, or expected value, of some outcome’ 55.

Recent work has suggested that the influence of risk assessment tools appears to be growing in both general and forensic settings. For example, violence risk assessment is now recommended in clinical guidelines for the treatment of schizophrenia in the USA and the UK 56,57. In the USA, risk assessment tools are used routinely in the mental healthcare systems of the majority of the 17 states that have civil commitment laws 58.

Originally, only clinical, unstructured assessments were carried out, and then instruments and structured methods became increasingly popular in the 1970s. The use of a combination of instruments and structured interviews is now on the rise. This could be justified by the fact that actuarial predictions of future violence on the basis of static nonpsychiatric characteristics result in greater statistical accuracy than purely clinical methods, but the former are insensitive to the effects of treatment and do not inform clinical intervention in an established way 59.

Risk assessment tools aid in the identification and management of individuals at risk of harmful behavior. Because of the potential utility of such tools, researchers have developed many risk assessment instruments, the manuals for which promise high rates of construct and predictive validity 60. To date, no single risk assessment tool has been consistently shown to have superior ability to predict offending 61.

However, a recent meta-analysis found that the predictive validity of commonly used risk assessment measures varies widely. The findings suggest that the closer the demographic characteristics of the tested sample are to the original validation sample of the tool, the higher the rate of predictive validity. The meta-analysis also indicated that tools designed for more specific populations were more accurate in detecting individuals’ risk of future offending. Risk assessment tools were found to produce more valid risk predictions for older White individuals and possibly women 62.

Because of the wide variation in the predictive validity of risk assessment measures, and the difficult clinical challenge imposed, further review of risk assessment procedures in the light of the current clinical and legal system is mandatory.


Conflicts of interest

There are no conflicts of interest.


1. Heilburn K Principles of forensic mental health assessment. 2001 New York, USA Springer
2. Douglas KS, Ogloff JRP, Nicholls TL, Grant I. Assessing risk for violence among psychiatric patients: the HCR-20 violence risk assessment scheme and the psychopathy checklist: screening version. J Consult Clin Psychol. 1999;67:917–930
3. McNiel DE, Binder RL. Screening for risk of inpatient violence: validation of an actuarial tool. Law Hum Behav. 1994;18:579–586
4. Monahan J, Steadman HJ, Appelbaum PS, Robbins PC, Mulvey EP, Silver E, et al. Developing a clinically useful actuarial tool for assessing violence risk. Br J Psychiatry. 2000;176:312–319
5. Monahan J, Steadman HJ, Silver E, Appelbaum PS, Robbins PC, Mulvey EP, et al. Rethinking risk assessment: the MacArthur study of mental disorder and violence. 2001 New York Oxford University Press
6. Quinsey VL, Harris GT, Rice GT, Cormier CA. Violent offenders: appraising and managing risk. 1998 Washington, DC American Psychological Association
7. Steadman HJ, Silver E, Monahan J, Appelbaum PS, Robbins PC, Mulvey EP, et al. A classification tree approach to the development of actuarial violence risk assessment tools. Law Hum Behav. 2000;24:83–100
8. Grann M, Langstrom N, Yourstone J, Freij I, Kullgren G, Forsman A, et al. Psychiatric risk assessment methods: are violent acts predictable? A systematic review The Swedish Council on Health Technology Assessment (SBU). SBU yellow report no. 175;. 2005
9. Bonta J, Law M, Hanson K. The prediction of criminal and violent recidivism among mentally disordered offenders: a meta-analysis. Psychol Bull. 1997;123:123–142
10. Link BG, Stueve A, Phelan J. Psychotic symptoms and violent behaviors: probing the components of ‘threat/control-override’ symptoms. Soc Psychiatry Psychiatr Epidemiol. 1998;33(Suppl 1):S55–S60
11. Swanson JW, Holzer CE III, Ganju VK, Jono RT. Violence and psychiatric disorder in the community: evidence from the epidemiologic catchment area surveys. Hosp Community Psychiatry. 1990;41:761–770
12. Swartz MS, Swanson JW, Hiday VA, Borum R, Ryan Wagner H, Burns BJ. Violence and severe mental illness: the effects of substance abuse and nonadherence to medication. Am J Psychiatry. 1998;155:226–231
13. Webster CD, Douglas KS, Eaves D, Hart SD HCR-20: assessing risk for violence. Version 2. 1997 Vancouver Mental Health Law & Policy Institute, Simon Fraser University
14. Boer DP, Hart SD, Kropp PR, Webster CD Manual for the sexual violence Risk-20. Professional guidelines for assessing risk of sexual violence. 1997 Burnaby, BC Mental Health, Law, and Policy Institute, Simon Fraser University
15. Dutton DG, Nicholls TL. A critical review of the gender paradigm in domestic violence research and theory: part I-theory and data. Aggress Violent Behav. 2005;10:680–714
16. Moffitt TE, Caspi A, Rutter M, Silva PA Sex differences in antisocial behaviour: conduct disorder, delinquency, and violence in the Dunedin longitudinal study. 2001 Cambridge, UK Cambridge University Press
17. Odgers CL, Moretti MM, Reppucci ND. Examining the science and practice of violence risk assessment with female adolescents. Law Hum Behav. 2005;29:7–27
18. Teasdale B, Silver E, Monahan J. Gender, threat/control-override delusions and violence. Law Hum Behav. 2006;30:649–658
19. Forth AE, Brown SL, Hart SD, Hare RD. The assessment of psychopathy in male and female noncriminals: reliability and validity. Pers Indiv Differ. 1996;20:531–543
20. Salekin RT, Rogers R, Sewell KW. Construct validity of psychopathy in a female offender sample: a multitrait-multimethod evaluation. J Abnorm Psychol. 1997;106:576–585
21. Funk SJ. Risk assessment for juveniles on probation: a focus on gender. Crim Justice Behav. 1999;26:44–68
22. Belfrage H, Douglas KS. Treatment effects on forensic psychiatric patients measured with the HCR-20 violence risk assessment scheme. Int J Forensic Ment Health. 2002;1:25–36
23. Garcia-Mansilla A, Rosenfeld B, Nicholls T. Risk assessment: are current methods applicable to women? Int J Forensic Ment Health. 2009;8:50–61
24. Nicholls TL, Ogloff JRP, Douglas KS. Assessing Risk for violence among male and female civil psychiatric patients: the HCR-20, PCL: SV, and VSC. Behav Sci Law. 2004;22:127–158
25. Garcia-Mansilla A, Rosenfeld B, Cruise KR. Violence risk assessment and women: predictive accuracy of the HCR-20 in a civil psychiatric sample. Behav Sci Law. 2011;29:623–633
26. Monahan J, Steadman HTonry M, Morris N. Crime and mental disorder: an epidemiological approach. Crime and justice: an annual review of research. 1983 Chicago Chicago University Press
27. Kooyman I, Dean K, Harvey S, Walsh E. Outcomes of public concern in schizophrenia. Br J Psychiatry. 2007;191(Suppl 50):s29–s36
28. Van Dorn RA, Swanson JW, Elbogen EB, Swartz MS. A comparison of stigmatizing attitudes toward persons with schizophrenia in four stakeholder groups: perceived likelihood of violence and desire for social distance. Psychiatry. 2005;68:152–163
29. Schizophrenia: the truth. 2008 Houston, Texas Schizophrenia and Related Disorders Alliance of America Available at: [Accessed 9 April 2009]
30. Violence and mental illness, SANE factsheet 5. 2008 Victoria, Australia SANE Available at: [Accessed 9 April 2009]
31. Farnham FR, James DV. ‘Dangerousness’ and dangerous law. Lancet. 2001;358:1926
32. James A. Stigma of mental illness. Foreword. Lancet. 1998;352:1048
33. Sartorius N. Stigma: What can psychiatrists do about it? Lancet. 1998;352:1058–1059
34. Tiihonen J, Isohanni M, Räsänen P, Koiranen M, Moring J. Specific major mental disorders and criminality: a 26-year prospective study of the 1966 Northern Finland birth cohort. Am J Psychiatry. 1997;154:840–845
35. Mullen PE, Burgess P, Wallace C, Palmer S, Ruschena D. Community care and criminal offending in schizophrenia. Lancet. 2000;355:614–617
36. Steadman HJ, Mulvey EP, Monahan J, Robbins PC, Appelbaum PS, Grisso T, et al. Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Arch Gen Psychiatry. 1998;55:393–401
37. Fazel S, Gulati G, Linsell L, Geddes JR, Grann M. Schizophrenia and violence: systematic review and meta-analysis. PLoS Med. 2009;6:e1000120
38. Mullen PE. Schizophrenia and violence: from correlations to preventive strategies. Adv Psychiatr Treat. 2006;12:239–248
39. Kessler RC, Wai TC, Demler O, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:617–627
40. Saha S, Chant D, Welham J, McGrath J. A systematic review of the prevalence of schizophrenia. PLoS Med. 2005;2:0413–0433
41. Oakley C, Hynes F, Clark T. Mood disorders and violence: a new focus. Adv Psychiatr Treat. 2009;15:263–270
42. Barraclough B, Harris EC. Suicide preceded by murder: the epidemiology of homicide–suicide in England and Wales 1988–92. Psychol Med. 2002;32:577–584
43. Rosenbaum M. The role of depression in couples involved in murder–suicide and homicide. Am J Psychiatry. 1990;147:1036–1039
44. Taguchi H. Maternal filicide in Japan: analyses of 96 cases and future directions for prevention. Seishin Shinkeigaku Zasshi. 2007;109:110–127
45. Krischer MK, Stone MH, Sevecke K, Steinmeyer EM. Motives for maternal filicide: results from a study with female forensic patients. Int J Law Psychiatry. 2007;30:191–200
46. Krakowski M. Violence and serotonin: influence of impulse control, affect regulation, and social functioning. J Neuropsychiatry Clin Neurosci. 2003;15:294–305
47. Understanding personality disorder: a report by the British Psychological Society. 2006 Leicester, England The British Psychological Society
48. Fazel S, Danesh J. Serious mental disorder in 23 000 prisoners: a systematic review of 62 surveys. Lancet. 2002;359:545–550
49. Singleton N, Meltzer H, Gatward R Psychiatric morbidity among prisoners in England and Wales. 1998 London The stationary Office
50. Blackburn R, Logan C, Donnelly J, Renwick S. Personality disorders, psychopathy and other mental disorders: co-morbidity among patients at English and Scottish high-security hospitals. J Forens Psychiatry Psychol. 2003;14:111–137
51. Logan C, Blackburn R. Mental disorder in violent women in secure settings: potential relevance to risk for future violence. Int J Law Psychiatry. 2009;32:31–38
52. Logan C, Johnstone L. Personality disorder and violence: making the link through risk formulation. J Personal Disord. 2010;24:610–633
53. Appelbaum PS, Gutheil TGAppelbaum PS, Gutheil TG. Legal issues in emergency psychiatry, Chapter 2. Clinical handbook of psychiatry and the law. 20074th ed. USA Lippincott Williams and Wilkins
54. AED Soliman, Reza H. Risk factors and correlates of violence among acutely ill adult psychiatric inpatients. Psychiatr Serv. 2001;52:75–80
55. Douglas KS, Ogloff JRP, Hart SD. Evaluation of a model of violence risk assessment among forensic psychiatric patients. Psychiatr Serv. 2003;54:1372–1379
56. Practice guideline for the treatment of patients with schizophrenia. 2004 Arlington, VA American Psychiatric Association
57. Schizophrenia: core interventions in the treatment and management of schizophrenia in primary and secondary care. 2009 London National Institute for Health and Clinical Excellence
58. Mercado CC, Ogloff JRP. Risk and the preventive detention of sex offenders in Australia and the United States. Int J Law Psychiatry. 2007;30:49–59
59. Norko MA, Baranoski MV. The prediction of violence; detection of dangerousness. Brief Treat Crisis Intervent. 2008;8:73–91
60. Bonta J. Offender risk assessment: guidelines for selection and use. Crim Justice Behav. 2002;29:355–379
61. Campbell M, French S, Gendreau P Assessing the utility of risk assessment tools and personality measures in the prediction of violent recidivism for adult offenders. 2007 Public Safety Canada
62. Singh JP, Grann M, Fazel S. A comparative study of violence risk assessment tools: a systematic review and metaregression analysis of 68 studies involving 25 980 participants. Clin Psychol Rev. 2011;31:499–513

forensic; psychiatric inpatients; risk factors; violence

© 2013 Institute of Psychiatry, Ain Shams University