Paranoia and Violence

Educational Objectives

The goal of this program is to improve assessment of potential for paranoid violence. After hearing and assimilating this program, the clinician will be better able to:

1. Assess need for hospitalization in patients exhibiting paranoia.

2. Identify factors that increase risk for violence among patients with mental illness.

3. Distinguish between delusions that are likely to lead to violence and those that do not typically result in aggression.

4. Use an appropriate approach to a patient exhibiting querulous paranoia.

5. Characterize threats in terms of the likelihood that they will be carried out.

Summary

Case example: after arguing with a coworker, a steelworker developed delusions about being killed by other employees at the steel plant; his paranoia then expanded to, eg, his family, members of the medical community; on a Sunday morning, he was taken to the hospital emergency department; the psychiatrist who evaluated the steelworker diagnosed acute paranoid schizophrenia and recommended hospitalization to initiate antipsychotic medication; the patient adamantly refused, voicing his fears that he would be killed in the hospital; the patient a

Case example: after arguing with a coworker, a steelworker developed delusions about being killed by other employees at the steel plant; his paranoia then expanded to, eg, his family, members of the medical community; on a Sunday morning, he was taken to the hospital emergency department; the psychiatrist who evaluated the steelworker diagnosed acute paranoid schizophrenia and recommended hospitalization to initiate antipsychotic medication; the patient adamantly refused, voicing his fears that he would be killed in the hospital; the patient agreed to take antipsychotic medication at home, after which the psychiatrist relented and allowed the patient to be discharged to his wife’s care; the patient had no history of past violence and had made no explicit threats; that night, he refused to take his medication (claiming that it was poisoned); during lovemaking with his wife, he stabbed her 7 times in the chest with scissors, causing her death; in the morning, his 11-yr-old daughter discovered the scene and eventually succeeded in contacting the police; a SWAT team was summoned when the steelworker refused to allow the police to enter the house; the steelworker was arrested without further incident

Meeting the standard of care: the steelworker declined voluntary admission; therefore, hospitalization was possible only if he met criteria for involuntary commitment (which required that the patient represent a substantial risk for physical harm to others); considerations — 1) escalating paranoia is in itself a serious situation that may signal considerable risk for violence; as delusions intensify, the patient becomes increasingly fearful and the likelihood of violence against the perceived persecutor escalates; 2) in part, the psychiatrist agreed to allow the steelworker to go home because of his wife’s comfort in assuming his care; although input from the family is important, psychiatrists should not surrender their clinical judgment to family members; judgments made by the wife and the psychiatrist differ based on, eg, their disparate levels of experience with paranoia, professional detachment vs loving empathy; 3) although the patient did not make any threats, the psychiatrist should have perceived that he posed a threat

Violence in the United States: levels are similar to those in other countries, with the exception of homicide by firearms; television dramas create the perception that mentally ill people are dangerous; in reality, they are only slightly more dangerous than members of the general population (account for only 3% of violent crime); most mentally ill people are not violent (in fact, they are more likely to be victims than aggressors); over the last 50 yr, there has been a shift in perception, such that mentally ill persons are seen as having a brain disease rather than being “weak willed”; unfortunately, this change in perception includes seeing mentally ill persons as dangerous; as a result, employers are less likely to hire them and landlords are less willing to rent to them

Frequency of violence in mentally ill persons: study — >10,000 people were interviewed and asked whether they had committed any act of violence in the last year; findings showed that only 2% of persons who had no mental disorder reported committing a violent act; among those with schizophrenia or bipolar disease, the frequency of violence was 5-fold greater; in individuals who had substance abuse issues coupled with schizophrenia, the rate of violence was 17 times higher than in the general population

CATIE study: evaluated which medications are most useful for schizophrenia and which persons with schizophrenia are most likely to commit serious violence; the results show that the most dangerous people with schizophrenia are those with predominance of positive symptoms (eg, delusions) and few negative symptoms; conversely, predominance of negative symptoms reduces the likelihood of violence (ie, those with extreme apathy lack the will to leave home and do harm to someone else)

Delusions: twice as likely as hallucinations to lead to violence; when people define situations as “real,” real consequences are likely to follow; however, not all delusions are equally dangerous

Erotomania: affected individuals have a delusional belief that another person is intensely in love with them; if the individual feels betrayed by the object of this delusion, he or she might harm that person or another who is perceived to be an obstacle to the relationship

Delusional misidentification (Capgras syndrome): affected individuals believe that others have been replaced by physical duplicates or imposters; violence is most likely to occur when the delusional individual perceives an increased threat from the imposter

Threat/control-override delusions: characterized by a belief that one’s mind is being controlled by forces beyond one’s control; may include a belief that others wish them harm (ie, paranoid delusions; associated with an increased risk for violence)

Serious delusions not associated with aggression: include delusions that one is dead or does not exist, that one’s thoughts are being broadcast, or that one’s thoughts are being removed by an external force

Risk for paranoid delusions: delusions in which a person believes that someone or something is trying to harm him or her are quite common (occur in >50% of people with schizophrenia, 44% of patients with psychotic depression, 31% of those with dementia, and 28% of those with mania); in persons who have a history of feeling threatened (eg, have experienced a burglary or arrest), the likelihood of developing paranoia is increased 20 fold; such individuals develop excessive sensitivity to the negative emotions of others (pay selective attention to threat-related stimuli and “jump to conclusions” based on little data)

Risk of committing violence: compared with other psychiatric diagnoses, paranoid schizophrenia has a stronger association with violence, both in the community and in the psychiatric hospital; in patients with paranoia, violence tends to be well planned and in line with their delusions, and most often directed at the specific persons seen as their persecutors; in ≈90% of cases, the violence is self-protective (striking out purely in anger occurs in only 10% of instances); compared with other schizophrenic patients, those with paranoia are more likely to commit serious crimes because they are well organized and therefore able to gain access to weapons; in some cases, homicide may be the person’s first violent act

Sex-based differences: men respond to a perceived threat with a “fight-or-flight” response and are more likely to become aggressive; women usually respond without violence (tend to befriend the individual and seek out relationships for protection)

Factors that increase risk for violence: specific rather than vague beliefs about the source of persecution; high levels of anxiety and distress; fear and anger are the emotions that most often precede violence (in psychotic as well as nonpsychotic individuals)

Querulous paranoia: characterized by persistent, self-damaging pursuit of a grievance; affected persons are also known as “vexatious litigants” or “injustice collectors”; they may bring lawsuits for grievances that are based on persecutory delusions; threats made by such individuals should not be ignored, as they may precede serious violence; a team approach is recommended so that the affected individual is unable to focus on one person as the perceived source of persecution

Paranoid motives for violence: divided into 4 categories

Misperceived self-defense: exemplified by the case of the steelworker who attacked his wife

Defense of one’s manhood: homosexual panic occurs in some men when they experience a psychotic decompensation; Freud’s hypothesis — the individual thinks, “I love you,” when he is attracted to a man; this belief then becomes reversed (ie, “this man loves me); that belief is also threatening to his manhood, so the delusion changes again, such that he believes, “this man hates me”; the individual may strike out against the other man because his delusions involve being harmed by him

Defense of one’s children: example — a highly religious woman developed paranoid beliefs that cars were circling her block, and that these were being driven by individuals who were going to kidnap her children, sexually abuse them, and force them into child pornography; she stabbed her children to death, believing that she was “saving their souls”; after killing the children, the woman stabbed herself repeatedly so that she could “join her children in heaven”; she survived, stood trial, and was found legally insane

Defense of the world: example — a woman delusionally believed that her father was Satan; the formal term for this type of belief is “cacodemonomania”; this patient believed that she could bring about world peace and free the world of evil by killing “Satan” and his family; she was found legally insane after she gruesomely killed her grandmother and her aunt’s boyfriend

Perspective of the person with paranoia: one study found that 96% of persons with paranoia engage in some “safety behaviors” (eg, avoidance of certain activities, leaving home only when accompanied by a certain trusted individual, reducing perceived vulnerability by decreasing their visibility, enhanced vigilance); people with paranoid beliefs often engage in nonviolent behaviors before they resort to violent behaviors, such as moving out of their homes because they believe neighbors are plotting against them, taking a long journey to evade a persecutor, barricading themselves in a room, carrying weapons for protection, or seeking protection against a perceived persecutor from the police; preemptive violence by a person with paranoia can be viewed as an extreme safety measure; when someone is fearful, in addition to locking doors and windows, other measures may be taken to reduce feelings of vulnerability (eg, taking lessons in self-defense)

Assessing potential for violence in a patient with paranoia

1) Establish a therapeutic alliance: do not expect the patient’s trust in return; allow the patient to tell their detailed “paranoid theory” without correcting their delusional beliefs (such corrections could cause the patient to feel humiliated or attacked); this approach may allow the clinician to discover whether there is an idiosyncratic trigger for violence (eg, a belief that, when an individual rolls her eyes, she is “being controlled by the devil”) and intervene at an appropriate time

2) Maintain physical and emotional distance: avoid making any sudden or unexpected movements

3) Maintain a respectful, nonjudgmental attitude: a recent study shows that residents in psychiatry are 54% more likely to be physically assaulted by patients during their residency than are residents in other specialties; the more arrogant and insensitive the psychiatry residents were, the more likely they were to be attacked; plastic surgeons are more likely to be murdered by a disgruntled patient than are physicians in any other specialty (owing to the unrealistic expectations from plastic surgery of patients who have body dysmorphic disorder)

Assessment questions: with most patients, the clinician may plainly ask about homicidal ideation; when dealing with paranoia, it is better to ask what the patient would do if confronted with the perceived persecutor; although the patient with paranoia may truthfully answer, “no,” when asked, “do you have any thoughts of killing anyone?,” he or she might respond differently to a situation of misperceived threat; perceived intentionality — ask how the patient would react to, eg, having someone bump into him when passing by; this allows assessment of whether the patient would overattribute incidental events and perceive them as intentional slights or violence

Substance use: in a paranoid individual, the use of alcohol and drugs is associated with increased risk for violence; a study shows that, during the commission of violent crimes in the United States, 41% of perpetrators were intoxicated with alcohol and 36% had taken illegal drugs; stimulants (eg, amphetamines, methamphetamine, cocaine) diminish control and increase violence by 3 different mechanisms (ie, by causing paranoia, grandiosity, and disinhibition)

Weapons history: for patients with paranoia, this should not be limited to asking whether they currently own a gun; in addition, ask whether they have ever owned a gun, whether they have ever threatened to injure someone with a weapon, and whether they recently moved their weapon (bringing the weapon physically closer may indicate escalating fear); firearms should be removed from individuals who have potential to become paranoid

Evaluation of threats: all threats should be taken seriously; attempts should be made to elucidate the details; the more intimate the relationship between the threatener and the victim, the more likely the threat is to be carried out; for example, among threats made against a spouse, the patient’s psychotherapist, and the governor of the state, risk for violence against the spouse is greatest because of the availability of that individual and the existence of an intimate relationship with the threatener; “face-to-face” threats, those that are specific, and threats introduced late in a controversy (ie, after the “heat of the argument” has passed) are more likely to be carried out (whereas, if a threat is made anonymously, the risk is reduced)

Assessment after the commission of a violent act: may be necessary for persons found not guilty by reason of insanity or who inflicted minor injury and were not charged with a crime; a psychological test, such as the Historical Clinical Risk Management-20 (HCRM-20), may be used in deciding when release from the hospital is appropriate; the clinician should carefully evaluate the behaviors that preceded paranoid violence (eg, lack of sleep, stalking, making threats); if a patient who has a history of paranoid violence discontinues therapy, it is foreseeable that she might stop taking her antipsychotic medications, at which point paranoia may recur and place the patient at risk of carrying out paranoid violence; in that circumstance, the clinician has an affirmative duty to contact a case manager who is responsible for reaching out to that patient or contacting a family member

Identifying persistent potential for violence: for a patient with a history of paranoid violence, be wary of “superficial insight” (ie, knowledge of appropriate answers to give when being assessed for paranoia); be sure to ask, eg, “what would you do if you truly believed someone was trying to kill you?”; assess the rapidity with which the commission of violence followed the onset of paranoia in the past

Conclusions: the likelihood of homicide in first-episode psychosis is 15-fold greater than that after a period of treatment; when assessing the patient with paranoia, it is essential to determine whether there has been an escalation of self-protective behaviors; threats do not always precede paranoid violence; making a threat is not the same as posing a threat

greed to take antipsychotic medication at home, after which the psychiatrist relented and allowed the patient to be discharged to his wife’s care; the patient had no history of past violence and had made no explicit threats; that night, he refused to take his medication (claiming that it was poisoned); during lovemaking with his wife, he stabbed her 7 times in the chest with scissors, causing her death; in the morning, his 11-yr-old daughter discovered the scene and eventually succeeded in contacting the police; a SWAT team was summoned when the steelworker refused to allow the police to enter the house; the steelworker was arrested without further incident

Meeting the standard of care: the steelworker declined voluntary admission; therefore, hospitalization was possible only if he met criteria for involuntary commitment (which required that the patient represent a substantial risk for physical harm to others); considerations — 1) escalating paranoia is in itself a serious situation that may signal considerable risk for violence; as delusions intensify, the patient becomes increasingly fearful and the likelihood of violence against the perceived persecutor escalates; 2) in part, the psychiatrist agreed to allow the steelworker to go home because of his wife’s comfort in assuming his care; although input from the family is important, psychiatrists should not surrender their clinical judgment to family members; judgments made by the wife and the psychiatrist differ based on, eg, their disparate levels of experience with paranoia, professional detachment vs loving empathy; 3) although the patient did not make any threats, the psychiatrist should have perceived that he posed a threat

Violence in the United States: levels are similar to those in other countries, with the exception of homicide by firearms; television dramas create the perception that mentally ill people are dangerous; in reality, they are only slightly more dangerous than members of the general population (account for only 3% of violent crime); most mentally ill people are not violent (in fact, they are more likely to be victims than aggressors); over the last 50 yr, there has been a shift in perception, such that mentally ill persons are seen as having a brain disease rather than being “weak willed”; unfortunately, this change in perception includes seeing mentally ill persons as dangerous; as a result, employers are less likely to hire them and landlords are less willing to rent to them

Frequency of violence in mentally ill persons: study — >10,000 people were interviewed and asked whether they had committed any act of violence in the last year; findings showed that only 2% of persons who had no mental disorder reported committing a violent act; among those with schizophrenia or bipolar disease, the frequency of violence was 5-fold greater; in individuals who had substance abuse issues coupled with schizophrenia, the rate of violence was 17 times higher than in the general population

CATIE study: evaluated which medications are most useful for schizophrenia and which persons with schizophrenia are most likely to commit serious violence; the results show that the most dangerous people with schizophrenia are those with predominance of positive symptoms (eg, delusions) and few negative symptoms; conversely, predominance of negative symptoms reduces the likelihood of violence (ie, those with extreme apathy lack the will to leave home and do harm to someone else)

Delusions: twice as likely as hallucinations to lead to violence; when people define situations as “real,” real consequences are likely to follow; however, not all delusions are equally dangerous

Erotomania: affected individuals have a delusional belief that another person is intensely in love with them; if the individual feels betrayed by the object of this delusion, he or she might harm that person or another who is perceived to be an obstacle to the relationship

Delusional misidentification (Capgras syndrome): affected individuals believe that others have been replaced by physical duplicates or imposters; violence is most likely to occur when the delusional individual perceives an increased threat from the imposter

Threat/control-override delusions: characterized by a belief that one’s mind is being controlled by forces beyond one’s control; may include a belief that others wish them harm (ie, paranoid delusions; associated with an increased risk for violence)

Serious delusions not associated with aggression: include delusions that one is dead or does not exist, that one’s thoughts are being broadcast, or that one’s thoughts are being removed by an external force

Risk for paranoid delusions: delusions in which a person believes that someone or something is trying to harm him or her are quite common (occur in >50% of people with schizophrenia, 44% of patients with psychotic depression, 31% of those with dementia, and 28% of those with mania); in persons who have a history of feeling threatened (eg, have experienced a burglary or arrest), the likelihood of developing paranoia is increased 20 fold; such individuals develop excessive sensitivity to the negative emotions of others (pay selective attention to threat-related stimuli and “jump to conclusions” based on little data)

Risk of committing violence: compared with other psychiatric diagnoses, paranoid schizophrenia has a stronger association with violence, both in the community and in the psychiatric hospital; in patients with paranoia, violence tends to be well planned and in line with their delusions, and most often directed at the specific persons seen as their persecutors; in ≈90% of cases, the violence is self-protective (striking out purely in anger occurs in only 10% of instances); compared with other schizophrenic patients, those with paranoia are more likely to commit serious crimes because they are well organized and therefore able to gain access to weapons; in some cases, homicide may be the person’s first violent act

Sex-based differences: men respond to a perceived threat with a “fight-or-flight” response and are more likely to become aggressive; women usually respond without violence (tend to befriend the individual and seek out relationships for protection)

Factors that increase risk for violence: specific rather than vague beliefs about the source of persecution; high levels of anxiety and distress; fear and anger are the emotions that most often precede violence (in psychotic as well as nonpsychotic individuals)

Querulous paranoia: characterized by persistent, self-damaging pursuit of a grievance; affected persons are also known as “vexatious litigants” or “injustice collectors”; they may bring lawsuits for grievances that are based on persecutory delusions; threats made by such individuals should not be ignored, as they may precede serious violence; a team approach is recommended so that the affected individual is unable to focus on one person as the perceived source of persecution

Paranoid motives for violence: divided into 4 categories

Misperceived self-defense: exemplified by the case of the steelworker who attacked his wife

Defense of one’s manhood: homosexual panic occurs in some men when they experience a psychotic decompensation; Freud’s hypothesis — the individual thinks, “I love you,” when he is attracted to a man; this belief then becomes reversed (ie, “this man loves me); that belief is also threatening to his manhood, so the delusion changes again, such that he believes, “this man hates me”; the individual may strike out against the other man because his delusions involve being harmed by him

Defense of one’s children: example — a highly religious woman developed paranoid beliefs that cars were circling her block, and that these were being driven by individuals who were going to kidnap her children, sexually abuse them, and force them into child pornography; she stabbed her children to death, believing that she was “saving their souls”; after killing the children, the woman stabbed herself repeatedly so that she could “join her children in heaven”; she survived, stood trial, and was found legally insane

Defense of the world: example — a woman delusionally believed that her father was Satan; the formal term for this type of belief is “cacodemonomania”; this patient believed that she could bring about world peace and free the world of evil by killing “Satan” and his family; she was found legally insane after she gruesomely killed her grandmother and her aunt’s boyfriend

Perspective of the person with paranoia: one study found that 96% of persons with paranoia engage in some “safety behaviors” (eg, avoidance of certain activities, leaving home only when accompanied by a certain trusted individual, reducing perceived vulnerability by decreasing their visibility, enhanced vigilance); people with paranoid beliefs often engage in nonviolent behaviors before they resort to violent behaviors, such as moving out of their homes because they believe neighbors are plotting against them, taking a long journey to evade a persecutor, barricading themselves in a room, carrying weapons for protection, or seeking protection against a perceived persecutor from the police; preemptive violence by a person with paranoia can be viewed as an extreme safety measure; when someone is fearful, in addition to locking doors and windows, other measures may be taken to reduce feelings of vulnerability (eg, taking lessons in self-defense)

Assessing potential for violence in a patient with paranoia

1) Establish a therapeutic alliance: do not expect the patient’s trust in return; allow the patient to tell their detailed “paranoid theory” without correcting their delusional beliefs (such corrections could cause the patient to feel humiliated or attacked); this approach may allow the clinician to discover whether there is an idiosyncratic trigger for violence (eg, a belief that, when an individual rolls her eyes, she is “being controlled by the devil”) and intervene at an appropriate time

2) Maintain physical and emotional distance: avoid making any sudden or unexpected movements

3) Maintain a respectful, nonjudgmental attitude: a recent study shows that residents in psychiatry are 54% more likely to be physically assaulted by patients during their residency than are residents in other specialties; the more arrogant and insensitive the psychiatry residents were, the more likely they were to be attacked; plastic surgeons are more likely to be murdered by a disgruntled patient than are physicians in any other specialty (owing to the unrealistic expectations from plastic surgery of patients who have body dysmorphic disorder)

Assessment questions: with most patients, the clinician may plainly ask about homicidal ideation; when dealing with paranoia, it is better to ask what the patient would do if confronted with the perceived persecutor; although the patient with paranoia may truthfully answer, “no,” when asked, “do you have any thoughts of killing anyone?,” he or she might respond differently to a situation of misperceived threat; perceived intentionality — ask how the patient would react to, eg, having someone bump into him when passing by; this allows assessment of whether the patient would overattribute incidental events and perceive them as intentional slights or violence

Substance use: in a paranoid individual, the use of alcohol and drugs is associated with increased risk for violence; a study shows that, during the commission of violent crimes in the United States, 41% of perpetrators were intoxicated with alcohol and 36% had taken illegal drugs; stimulants (eg, amphetamines, methamphetamine, cocaine) diminish control and increase violence by 3 different mechanisms (ie, by causing paranoia, grandiosity, and disinhibition)

Weapons history: for patients with paranoia, this should not be limited to asking whether they currently own a gun; in addition, ask whether they have ever owned a gun, whether they have ever threatened to injure someone with a weapon, and whether they recently moved their weapon (bringing the weapon physically closer may indicate escalating fear); firearms should be removed from individuals who have potential to become paranoid

Evaluation of threats: all threats should be taken seriously; attempts should be made to elucidate the details; the more intimate the relationship between the threatener and the victim, the more likely the threat is to be carried out; for example, among threats made against a spouse, the patient’s psychotherapist, and the governor of the state, risk for violence against the spouse is greatest because of the availability of that individual and the existence of an intimate relationship with the threatener; “face-to-face” threats, those that are specific, and threats introduced late in a controversy (ie, after the “heat of the argument” has passed) are more likely to be carried out (whereas, if a threat is made anonymously, the risk is reduced)

Assessment after the commission of a violent act: may be necessary for persons found not guilty by reason of insanity or who inflicted minor injury and were not charged with a crime; a psychological test, such as the Historical Clinical Risk Management-20 (HCRM-20), may be used in deciding when release from the hospital is appropriate; the clinician should carefully evaluate the behaviors that preceded paranoid violence (eg, lack of sleep, stalking, making threats); if a patient who has a history of paranoid violence discontinues therapy, it is foreseeable that she might stop taking her antipsychotic medications, at which point paranoia may recur and place the patient at risk of carrying out paranoid violence; in that circumstance, the clinician has an affirmative duty to contact a case manager who is responsible for reaching out to that patient or contacting a family member

Identifying persistent potential for violence: for a patient with a history of paranoid violence, be wary of “superficial insight” (ie, knowledge of appropriate answers to give when being assessed for paranoia); be sure to ask, eg, “what would you do if you truly believed someone was trying to kill you?”; assess the rapidity with which the commission of violence followed the onset of paranoia in the past

Conclusions: the likelihood of homicide in first-episode psychosis is 15-fold greater than that after a period of treatment; when assessing the patient with paranoia, it is essential to determine whether there has been an escalation of self-protective behaviors; threats do not always precede paranoid violence; making a threat is not the same as posing a threat

Suggested Readings

Barrelle A et al. Capgras syndrome and other delusional misidentification syndromes. Front Neurol Neurosci. 2018;42:35-43; doi:10.1159/000475680; Bebbington P, Freeman D. Transdiagnostic extension of delusions: schizophrenia and beyond. Schizophr Bull. 2017;43:273-282; doi:10.1093/schbul/sbw191; Beck JC. Delusions, substance abuse, and serious violence. J Am Acad Psychiatry Law 2004;32:169-172; Biswas J et al. Treatment delayed is treatment denied. J Am Acad Psychiatry Law. 2018;46(4):447-453. doi:10.29158/JAAPL.003786-18; Lee R. Mistrustful and misunderstood: a review of paranoid personality disorder. Curr Behav Neurosci Rep. 2017;4:151-165; doi:10.1007/s40473-017-0116-7; Li Q et al. Delusion, excitement, violence, and suicide history are risk factors for aggressive behavior in general inpatients with serious mental illnesses: A multicenter study in China. Psychiatry Res. 2019;272:130-134; doi:10.1016/j.psychres.2018.12.071; Mullen PE, Lester G. Vexatious litigants and unusually persistent complainants and petitioners: from querulous paranoia to querulous behaviour. Behav Sci Law. 2006;24:333-349; doi:10.1002/bsl.671; Swanson JW et al. Violence and psychiatric disorder in the community: evidence from the Epidemiologic Catchment Area surveys [published correction appears in Hosp Community Psychiatry 1991 Sep;42(9):954-5]. Hosp Community Psychiatry. 1990;41:761-770; doi:10.1176/ps.41.7.761; Tone EB, Davis JS. Paranoid thinking, suspicion, and risk for aggression: a neurodevelopmental perspective. Dev Psychopathol. 2012;24(3):1031-1046. doi:10.1017/S0954579412000521; Witt K et al. Risk factors for violence in psychosis: systematic review and meta-regression analysis of 110 studies [published correction appears in PLoS One. 2013;8(9). doi:10.1371/annotation/f4abfc20-5a38-4dec-aa46-7d28018bbe38]. PLoS One. 2013;8(2):e55942. doi:10.1371/journal.pone.0055942.

Acknowledgments

Dr. Resnick was recorded exclusively for Audio Digest using teleconferencing software, in compliance with current social-distancing guidelines during the COVID-19 pandemic. Audio Digest thanks Dr. Resnick for his cooperation in the production of this program.

Readings

Barrelle A et al. Capgras syndrome and other delusional misidentification syndromes. Front Neurol Neurosci. 2018;42:35-43; doi:10.1159/000475680; Bebbington P, Freeman D. Transdiagnostic extension of delusions: schizophrenia and beyond. Schizophr Bull. 2017;43:273-282; doi:10.1093/schbul/sbw191; Beck JC. Delusions, substance abuse, and serious violence. J Am Acad Psychiatry Law 2004;32:169-172; Biswas J et al. Treatment delayed is treatment denied. J Am Acad Psychiatry Law. 2018;46(4):447-453. doi:10.29158/JAAPL.003786-18; Lee R. Mistrustful and misunderstood: a review of paranoid personality disorder. Curr Behav Neurosci Rep. 2017;4:151-165; doi:10.1007/s40473-017-0116-7; Li Q et al. Delusion, excitement, violence, and suicide history are risk factors for aggressive behavior in general inpatients with serious mental illnesses: A multicenter study in China. Psychiatry Res. 2019;272:130-134; doi:10.1016/j.psychres.2018.12.071; Mullen PE, Lester G. Vexatious litigants and unusually persistent complainants and petitioners: from querulous paranoia to querulous behaviour. Behav Sci Law. 2006;24:333-349; doi:10.1002/bsl.671; Swanson JW et al. Violence and psychiatric disorder in the community: evidence from the Epidemiologic Catchment Area surveys [published correction appears in Hosp Community Psychiatry 1991 Sep;42(9):954-5]. Hosp Community Psychiatry. 1990;41:761-770; doi:10.1176/ps.41.7.761; Tone EB, Davis JS. Paranoid thinking, suspicion, and risk for aggression: a neurodevelopmental perspective. Dev Psychopathol. 2012;24(3):1031-1046. doi:10.1017/S0954579412000521; Witt K et al. Risk factors for violence in psychosis: systematic review and meta-regression analysis of 110 studies [published correction appears in PLoS One. 2013;8(9). doi:10.1371/annotation/f4abfc20-5a38-4dec-aa46-7d28018bbe38]. PLoS One. 2013;8(2):e55942. doi:10.1371/journal.pone.0055942.

Disclosures

For this program, Dr. Resnick and the planning committee reported nothing to disclose.

Acknowledgements

Dr. Resnick was recorded exclusively for Audio Digest using teleconferencing software, in compliance with current social-distancing guidelines during the COVID-19 pandemic. Audio Digest thanks Dr. Resnick for his cooperation in the production of this program.

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