Psychotic Motivation and the Paradox of Current Research on Serious Mental Illness and Rates of Violence

Abstract

Persuasive empirical support exists for a positive association between serious mental illness (SMI) and rates of violence; a great deal of support is also present for the clinical impression that psychotic symptoms sometimes motivate "symptom-consistent" violence. We propose that the issue of the motivation for violence in the SMI population can be considered independently of the issue of the association between SMI and violence rates. We review much of the current literature on the association between SMI and violence in a framework that emphasizes motivational influences unique to the SMI population. We conclude that the contribution of psychotic motivation to rates of violence in the SMI population is a major research issue. Furthermore, we believe that recognition of the independence of motivational influences and violence rates, and consideration of the impact of treatment on violence, may help explain the paradox of current research: Delusions and hallucinations may motivate violent behavior, but this psychotic motivation may not be reflected in the actual rate of violence.

Perpetration of Violence, Violent Victimization, and Severe Mental Illness: Balancing Public Health Concerns

“…For decades, researchers have investigated violence perpetrated by persons with severe mental illness (1)(2)(3)(4)(5)(6). This research has, in part, been driven by a common perception that persons with mental illness are dangerous (7)(8)(9)(10).…”

Predictors of violent behavior among acute psychiatric patients: Clinical study

“…Much of the literature suggests that it is not a specific diagnosis in itself that is a risk factor for violence, but rather more specific symptomatological dimensions of the disorder such as thought disturbances, delusions and hallucinations. [3][4][5] A history of violence is the most significant predictor of future violence. 6 Other factors with predictive value include a history of incarceration, 2 drug or alcohol abuse and being a victim of child abuse.…”

“Stereotypic” delusional offending

“…However, what does appear different about the violence committed by persons with SMI is that it often seems to have a psychotic or ''unconventional'' motivation. As we have noted previously ( Junginger & McGuire, 2004), it is this potential to respond violently to a reality different from the objective or consensual reality-sensationalized by the popular media-that probably lies at the heart of the public's well documented fear of persons with SMI (see, e.g., Link, Phelan, Bresnahan, Stueve, & Pescosolido, 1999). Perhaps ironically, this same potential for psychotic motivation also may be the key to understanding the violence committed by persons with SMI and successfully managing it.…”

“…The most compelling evidence for the association between SMI and violence is provided by studies of unbiased subject samples ''unselected'' for either their mental illness or criminal justice histories ( Junginger & McGuire, 2004). Arseneault, Moffitt, Caspi, Taylor, and Silva (2000), for example, followed up on a 12-month, totalcity birth cohort in Dunedin, New Zealand, with psychiatric and violence history interviews at 21 years of age.…”

“…In two studies of patients with mostly schizophrenic (58%) and mood (29%) disorders, I found that that being able to assign an identity to the hallucinated voice-presumably a reliable indicator of a delusional context for the hallucination-was associated with compliance with both dangerous and harmless commands ( Junginger, 1990( Junginger, , 1995. Figure 1 is a tentative representation of the motivational influences for violence on the general and SMI populations based on current research ( Junginger & McGuire, 2004). In this representation, violence rates motivated by conventional means are assumed to be equal.…”