Violence in Civil Psychiatric Patients: Mad, Bad, or Both?

Violence in Civil Psychiatric Patients: Mad, Bad, or Both?

This study examined the relationship between thinking styles and violence/aggression among civil psychiatric patients. The results reflect that a higher rate of aggressive incidents was predicted by a higher Psychological Inventory of Criminal Thinking Styles (PICTS) score Denial of Harm, higher Brief Psychiatric Rating Scale (BPRS) Hostile Suspiciousness cores, and lower educational attainment. In addition, violence was predicted by higher BPRS Hostile Suspiciousness, lower education, and younger age. These results reinforce the importance of symptom-driven hostility in predicting inpatient aggression and violence. This is the bottom line of a recently published article in The International Journal of Forensic Mental Health. Below is a summary of the research and findings as well as a translation of this research into practice.

Featured Article | International Journal of Forensic Mental Health | 2020, Vol. 18, No. 4, 389-299

Criminal Thinking as a Risk Factor for Psychiatric Inpatient Aggression


W. Armory Carr; Psychology, University of New Haven, West Haven, Connecticut, USA
Barry Rosenfeld; Psychology, Fordham University, Bronx, New York, USA
Merrill Rotter; Department of Psychiatry, Albert Einstein College of Medicine, New York, New York, USA


Thinking styles that predispose offenders to antisocial behavior have been shown to predict violence and aggression among inmates. This study explored this relationship among civil psychiatric inpatients. Medical records of N ¼ 74 discharged patients were reviewed for inpatient incidents using the Overt Aggression Scale (OAS), occurring subsequent to the administration of several measures including the Psychological Inventory of Criminal Thinking Styles (PICTS), and Brief Psychiatric Rating Scale (BPRS). Univariate negative binomial regression models demonstrated that a higher rate of aggressive incidents was predicted by higher PICTS Denial of Harm, higher BPRS Hostile Suspiciousness scores, and lower educational attainment. Violence (i.e., physical aggression towards others) was predicted by higher BPRS Hostile Suspiciousness, lower education, and younger age in univariate analyses. In multivariate negative binomial regression models using the above independent predictors, higher BPRS-Hostile Suspiciousness scores and lower educational
attainment significantly predicted both outcomes. This study’s results reinforce the importance of symptom-driven hostility to predicting inpatient aggression and violence, while highlighting the relatively minor role of specific criminal thinking styles in aggressive behavior among institutionalized psychiatric patients.


Violence; psychiatric patients; psychological inventory of criminal thinking styles; criminal thinking

Summary of the Research

“Inpatient violence is a common and destructive phenomenon in psychiatric settings…In this article, we investigate the application of a construct typically used in offender settings (i.e., criminal thinking styles) to understand violence risk among civil psychiatric inpatients…Several studies have also examined criminal cognitions among individual with mental illness. [Prior authors] found significantly higher levels of five out of the eight criminal thinking styles…among civil psychiatric patients compared to published normative data from a sample of non-mentally ill offenders…In the present study, we examine the effects of psychiatric symptoms and criminal thinking styles on the prediction of violent and aggressive behavior among a sample of civil psychiatric patients. Consistent with previous studies on offenders, we anticipate that general criminal thinking and reactive criminal thinking will significantly predict future aggressive and violent behavior” (p.389-391).

“This study used a pseudo-prospective design in that research staff examined the medical records of discharged psychiatric patients who had completed a battery of assessment measures as part of a previous study on the effects of incarceration on the mentally ill…[The] analyses revealed mixed results for the PICTS [Psychological Inventory of Criminal Thinking Styles], but confirmed the importance of the BPRS [Brief Psychiatric Rating Scale] Hostile Suspiciousness scale in predicting both aggression and violence. Higher PICTS Denial of Harm predicted an increased rate of aggressive incidents in univariate models, but was rendered insignificant in a multivariate model which included symptomatic hostility and paranoia as well as lower education” (p.395).

“[The] findings were unexpected, in that General criminal thinking was unrelated to violence or aggression. This stands in contrast to previous studies using the same or similar outcomes with offender samples, which have typically demonstrated a significant association…Furthermore, we were unable to find a relationship with higher-order criminal thinking style composite scales of Proactive and Reactive criminal thinking, contradicting studies linking these scales to previous violent arrests…Our findings suggest that, despite apparently strong criminal cognitive patterns, these particular cognitions do not contribute to the prediction of violence or aggression beyond that explained by psychiatric symptomatology, and impoverished education. However, as stated in the introduction, more violence-specific attitudes, attributional styles and beliefs may play a greater role in the development of violent and aggressive behavior” (p.396).

“The importance of the role of psychiatric symptoms as a risk factor for aggression and violence among civil psychiatric inpatients was clearly supported by this study. The results also concur with previous research using the BPRS, in which the scores on the Hostile Suspiciousness factor scale were significantly higher at intake for short-term civil psychiatric patients who later engaged in physical aggression during their hospital stay…Given that our study was conducted at a long-term care facility, our results suggest that the importance of hostility extends beyond the short-term prediction of violence. Lower education level was one of our control variables and was significant in both final models…As a demographic variable, there are likely several specific mechanisms of actions to explain this relationship such as deficits in socio-cognitive perspective-taking” (p.396).

Translating Research into Practice

“As a commonly assessed and targeted dynamic risk factor within offender samples, criminal thinking has begun to be investigated among non-offender samples. At this very early stage of research, replication of findings with a larger sample would help extend these results. However, in terms of immediate clinical relevance, the importance of symptoms from the Hostile Suspiciousness factor for the prediction of violence and aggressive behavior among the severely mentally ill cannot be overstated” (p.397).

Other Interesting Tidbits for Researchers and Clinicians

“Beyond acute psychiatric symptoms, personality dysfunction is also an important risk variable to consider in assessing the risk of violence. Probably the most frequently studied construct with regard to violence is psychopathy. Although there has been much debate about the composition of the construct…psychopathy has consistently been shown to be important in evaluating the risk of violence among community samples of psychiatric patients…However, studies have indicated some variability of the performance of the construct in institutional settings…The reasons for this may include the nature of violence in inpatient settings being more impulsive than predatory…Indeed, one prospective study found that ratings of psychiatric symptoms and anger were better than scores on the Psychopathy Checklist-Revised (PCL-R; Hare, 1991) scores as predictors of staff and patient directed aggression…” (p.391).

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