MacArthur Violence Risk Assessment Study Research Articles

Lifetime Cannabis Use Disorder Is Not Associated With Lifetime Impulsive Behavior and Severe Violence in Patients With Schizophrenia Spectrum Disorders From a High-Security Hospital.

The link between substances of abuse, impulsivity, and violence in psychotic patients remains unclear. This study aims at unraveling whether cannabis use disorder is associated with violent and/or psychotic behavior in patients who are hospitalized in a high-security hospital. We conducted a cross-sectional retrospective study in 124 patients with schizophrenia spectrum disorders admitted to a high-security hospital. Lifetime violent behavior was assessed using the History of Aggressive Behavior Form-Subject of the MacArthur Violence Risk Assessment Study and impulsivity using the Psychopathy Checklist-Revised (considering items: "proneness to boredom," "lack of self-control," and "impulsive thoughtless gestures"). Substance use disorder was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria. Positive and Negative Syndrome Scale was also administered. Violent and nonviolent psychotic patients showed similar prevalence of cannabis use disorder. Alcohol and cocaine use disorders were more prevalent among violent psychotic patients. Cannabis use disorder was not associated with any dimension of impulsivity, whereas alcohol use disorder was positively correlated to impulsive thoughtless gestures (standardized β = 0.213, P = 0.027) and cocaine use disorder with proneness to boredom (standardized β = 0.290, P = 0.002). Finally, logistic regression analysis revealed that, unlike cannabis and cocaine use disorders, alcohol use disorder (odds ratio, 3.964; 95% confidence interval, 1.729-9.087; P = 0.001) was a factor associated with violence. These findings show that cannabis and alcohol are largely abused and coabused by psychotic patients with a propsensity for violence, but only alcohol is associated with impulsive and violent behavior. Therefore, especially alcohol abuse should be seriously considered by practitioners when evaluating the dangerousness of patients with schizophrenia spectrum disorders.

Assessing Violence Risk in Adolescents in the Pediatric Emergency Department: Systematic Review and Clinical Guidance.

IntroductionViolence risk assessment is one of the most frequent reasons for child and adolescent psychiatry consultation with adolescents in the pediatric emergency department (ED). Here we provide a systematic review of risk factors for violence in adolescents using the risk factor categories from the MacArthur Violence Risk Assessment study. Further, we provide clinical guidance for assessing adolescent violence risk in the pediatric ED.MethodsFor this systematic review, we used the preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2009 checklist. We searched PubMed and PsycINFO databases (1966–July 1, 2020) for studies that reported risk factors for violence in adolescents.ResultsRisk factors for adolescent violence can be organized by MacArthur risk factor categories. Personal characteristics include male gender, younger age, no religious affiliation, lower IQ, and Black, Hispanic, or multiracial race. Historical characteristics include a younger age at first offense, higher number of previous criminal offenses, criminal history in one parent, physical abuse, experiencing poor child-rearing, and low parental education level. Among contextual characteristics, high peer delinquency or violent peer-group membership, low grade point average and poor academic performance, low connectedness to school, truancy, and school failure, along with victimization, are risk factors. Also, firearm access is a risk factor for violence in children and adolescents. Clinical characteristics include substance use, depressive mood, attention deficit hyperactivity disorder, antisocial traits, callous/unemotional traits, grandiosity, and justification of violence.ConclusionUsing MacArthur risk factor categories as organizing principles, this systematic review recommends the Structured Assessment of Violence Risk in Youth (SAVRY) risk- assessment tool for assessing adolescent violence risk in the pediatric ED.

Disentangling compliance with command hallucinations: Heterogeneity of voice intents and their clinical correlates

BackgroundEarlier studies suggested that perceptions of voice intents (benevolence, malevolence) are associated with different psychological and behavioral responses including compliance with command hallucinations (CH). However, to our knowledge, no studies have examined the clinical differences between subgroups of clients with different perceptions of the intents of their CH. In order to better understand the risk for compliance with CH, our objectives were 1) to compare sociodemographic and clinical profiles of subgroups of clients (based on perceptions of CH intents); and 2) to investigate their specific associated risk factors for compliance with CH. MethodWe analyzed the MacArthur Violence Risk Assessment Study, focusing on 181 participants with psychosis reporting CH. Group comparisons and within-group ordinal logistic regression analyses were performed using sociodemographic and clinical measures such as the BPRS, BIS-11 and NAS-PI. ResultsOf the 181 participants, 102 (56.4%) reported having only malevolent voices, 14 (7.7%) rated them as benevolent only, 58 (32.03%) as benevolent and malevolent, and only 7 (3.86%) as neutral only. Results showed that individuals with malevolent voices had more emotional disturbance while those with benevolent CH had more severe positive psychotic symptoms and were more certain that they would comply in the future. Moreover, childhood physical abuse, belief about having to obey as well as psychotic symptoms significantly predict compliance with malevolent CH in a multivariate model. ConclusionsOur results suggest that researchers and clinicians should consider perceptions of voice intents when both assessing risk of compliance with CH and developing relevant intervention targets.

Perceived Coercion During Admission Into Psychiatric Hospitalization Increases Risk of Suicide Attempts After Discharge.

There is an elevated risk for suicide in the year following psychiatric hospitalization. The present study examined whether perceived coercion during admission into psychiatric hospitalization increases risk for postdischarge suicide attempts. Participants were 905 psychiatric inpatients from the MacArthur Violence Risk Assessment Study that were assessed every 10weeks during the year following discharge. Perceived coercion during admission was assessed while hospitalized, and suicide attempts were assessed following discharge. Analyses adjusted for nonrandom assignment of groups via propensity score weighting and for established correlates of postdischarge suicidal behavior. Of 905 participants, 67% endorsed perception of coercion into psychiatric hospitalization, and 168 (19%) made a postdischarge suicide attempt. Patients who perceived coercion during hospitalization admission were more likely to make a suicide attempt after discharge than those who did not, even after adjusting for established covariates (OR=1.29, |z|=2.87, p=.004, 95% CI=1.08, 1.54). There was no interaction between recent self-harm or suicidal ideation at time of admission and perceived coercion on postdischarge suicide attempts. Patients' perception of the context in which they were hospitalized is associated with a small but significant increase in their likelihood of postdischarge suicide attempts.

Trajectories of Dynamic Risk Factors as Predictors of Violence and Criminality in Patients Discharged From Mental Health Services: A Longitudinal Study Using Growth Mixture Modeling.

Background: Individuals with severe mental illnesses are at greater risk of offenses and violence, though the relationship remains unclear due to the interplay of static and dynamic risk factors. Static factors have generally been emphasized, leaving little room for temporal changes in risk. Hence, this longitudinal study aims to identify subgroups of psychiatric populations at risk of violence and criminality by taking into account the dynamic changes of symptomatology and substance use. Method: A total of 825 patients from the MacArthur Violence Risk Assessment Study having completed five postdischarge follow-ups were analyzed. Individuals were classified into outcome trajectories (violence and criminality). Trajectories were computed for each substance (cannabis, alcohol, and cocaine, alone or combined) and for symptomatology and inputted as dynamic factors, along with other demographic and psychiatric static factors, into binary logistic regressions for predicting violence and criminality. Best predictors were then identified using backward elimination, and receiver operator characteristic (ROC) curves were calculated for both models. Results: Two trajectories were found for violence (low versus high violence). Best predictors for belonging in the high-violence group were low verbal intelligence (baseline), higher psychopathy (baseline) and anger (mean) scores, persistent cannabis use (alone), and persistent moderate affective symptoms. The model’s area under the curve (AUC) was 0.773. Two trajectories were also chosen as being optimal for criminality. The final model to predict high criminality yielded an AUC of 0.788, retaining as predictors male sex, lower educational level, higher score of psychopathy (baseline), persistent polysubstance use (cannabis, cocaine, and alcohol), and persistent cannabis use (alone). Both models were moderately predictive of outcomes. Conclusion: Static factors identified as predictors are consistent with previously published literature. Concerning dynamic factors, unexpectedly, cannabis alone was an independent co-occurring variable, as well as affective symptoms, in the violence model. For criminality, our results are novel, as there are very few studies on criminal behaviors in nonforensic psychiatric populations. In conclusion, these results emphasize the need to further study the predictors of crime, separately from violence and the impact of longitudinal patterns of specific substance use and high affective symptoms.

Impulsivity, Painful and Provocative Events, and Suicide Intent: Testing the Interpersonal Theory of Suicide.

The Interpersonal Theory of Suicide (IPTS; Joiner, 2005. Why People Die by Suicide. Cambridge, MA: Harvard University Press) hypothesizes that repeated exposure to painful and provocative events (PPE) increases capability for suicide (CS), therefore facilitating the development of suicidal intent, and that impulsive individuals are more likely to experience these painful and provocative events, creating an indirect relationship between impulsivity and CS. Research to date largely supports this hypothesis but has not translated this theory to actual suicidal intent. The present study used data from the MacArthur Violence Risk Assessment Study to examine the relationship between PPE and intent, and the indirect relationship between impulsivity and intent among a sample of 245 recent suicide attempters, using the clinician-rated Suicide Intent Scale as an objective measure of intent. Results supported the hypothesized direct relationship between PPE and intent, and the indirect relationship between impulsivity and intent through PPE. There was no direct relationship between impulsivity and intent, suggesting that the relationship between impulsivity and intent occurs entirely through exposure to PPE. These findings suggest that assessing exposure to painful and provocative events is critical in evaluating risk of suicide, and that impulsivity itself does not confer an increased risk of lethal or nearly lethal attempts.

Characteristics of a suicide attempt predict who makes another attempt after hospital discharge: A decision-tree investigation

The year following discharge from psychiatric hospitalization is a high-risk period for suicidal behavior, particularly among patients initially hospitalized after a suicide attempt. Demographic and clinical correlates have been identified; however, characteristics of the initial attempt may provide insight into risk for subsequent attempts as well. This investigation examined whether individual or a combination of suicide attempt characteristics predicted future attempts. Two hundred and eighteen psychiatric inpatients from the MacArthur Violence Risk Assessment Study with a recent suicide attempt were administered items from the Suicide Intent Scale and followed one year after discharge. Sixty-nine (31.65%) made a subsequent attempt. Data were analyzed by a stepwise logistic regression, followed by an iterative receiver operator curve (IROC) analysis, a recursive partitioning classification tree. The cross-validated IROC, but not logistic regression, predicted subsequent suicide attempts. Furthermore, the IROC found that participants who made definite plans and underwent extensive preparation were at highest risk for subsequent attempts. These findings suggest that suicide attempt characteristics preceding psychiatric hospitalization can help identify patients at elevated risk for another attempt post-discharge.

The Lack of Cross-Validation Can Lead to Inflated Results and Spurious Conclusions: A Re-Analysis of the MacArthur Violence Risk Assessment Study

Cross-validation is an important evaluation strategy in behavioral predictive modeling; without it, a predictive model is likely to be overly optimistic. Statistical methods have been developed that allow researchers to straightforwardly cross-validate predictive models by using the same data employed to construct the model. In the present study, cross-validation techniques were used to construct several decision-tree models with data from the MacArthur Violence Risk Assessment Study (Monahan et al., 2001). The models were then compared with the original (non-cross-validated) Classification of Violence Risk assessment tool. The results show that the measures of predictive model accuracy (AUC, misclassification error, sensitivity, specificity, positive and negative predictive values) degrade considerably when applied to a testing sample, compared with the training sample used to fit the model initially. In addition, unless false negatives (that is, incorrectly predicting individuals to be nonviolent) are considered more costly than false positives (that is, incorrectly predicting individuals to be violent), the models generally make few predictions of violence. The results suggest that employing cross-validation when constructing models can make an important contribution to increasing the reliability and replicability of psychological research.

Psychopathic Traits and Recurring Victimization: An Examination Using a Community and Clinical Sample

Few studies have identified specific characteristics of recurrent victims that distinguish them from single victims. One such characteristic that may do so is possessing psychopathic traits, given that persons with psychopathic traits are generally risk-seeking, callous, short-tempered, and lack behavioral controls. To examine this possibility, we use data from both the National Longitudinal Study of Adolescent to Adult Health (Add Health) and the MacArthur Violence Risk Assessment Study (MacRisk). We find that in both samples, psychopathic traits are able to distinguish between nonvictims and recurring victims as well as single-wave victims and recurring victims. This finding holds great promise for identifying who may be at risk of experiencing recurring victimization, ways to reduce victimization risk, as well as potential additional avenues for research in this area.

Severe mental illness and firearm access: Is violence really the danger?

In response to a spate of mass shootings, national debate over the root of America's gun violence epidemic has centered on mental illness. Consequently, calls have been made to legislatively restrict firearm access among individuals with mental illness to reduce gun violence. While there is a link between mental illness and suicide, a dearth of empirical evidence exists to inform public policy on the link between firearm access and mental illness. The current study addresses this gap by exploring the nature of firearm-related risk among disordered individuals as compared to others from the same communities. We examined a subsample of the MacArthur Violence Risk Assessment Study, including 255 recently discharged psychiatric patients and 490 census-matched community residents. We conducted binomial logistic regressions to explore the impact of firearm access and patient status on violence and suicidality. In total, 15.3% reported firearm access, 23.5% violence, and 21.5% suicidality. Multivariate analyses revealed that, in the context of firearm access, patients were no more likely to perpetrate violence (OR=0.588; 95% CI=0.196–1.764) but were significantly more likely to report suicidality (OR=4.690; 95% CI=1.147–19.172). These results indicate that firearms constitute a serious risk factor for suicide, not violence, for disordered individuals. Thus, legislative efforts to reduce firearm-related risk among disordered individuals should focus on self-harm, not violence. Moreover, claims that mental illness is a principal cause of gun violence may reduce help-seeking among individuals at high risk for suicide. Researchers should devote further attention to addressing these claims empirically.

The Prediction of Repeated Violence Among Individuals With Serious Mental Disorders: Situational Versus Dispositional Factors.

The question we attempt to answer in this study is why some individuals with serious mental illness engage in repeated violence, while others do not. There appear to be two perspectives that may explain repeated violence: one that emphasizes situational factors and one that emphasizes dispositional factors. Situational factors are those that are constantly changing within one's life, whereas dispositional factors are those that remain relatively stable over time. Therefore, dispositional factors would theoretically put individuals with serious mental illness at stable risk for repeated violence because these factors remain relatively stable over time. In fact, perhaps individuals with mental illness repeatedly engage in violence because they have a dispositional trait (like impulsivity, for example) that puts them at stable risk for repeated violence. Conversely, situational factors would theoretically explain why individuals do not engage in repeated violence because they are transient and constantly changing. Therefore, perhaps one desists from violence because some situational factors changed in that individual's life. Using data from the MacArthur Violence Risk Assessment Study (i.e., MacRisk), a longitudinal study of people with serious mental illness, repeated violence was evaluated across waves. A multilevel logistic regression model was employed. Results indicate that both situational and dispositional factors are significantly associated with repeated violence. Specifically, situational factors such as marital status, drug use, perceived stress, and time away from the psychiatric hospital and dispositional factors such as personality traits including agreeableness, conscientiousness, openness, and extraversion are all significantly associated with repeated violence. These findings have important policy implications regarding criminal justice intervention and clinical practice.

Violence to Others, Violent Self-Victimization, and Violent Victimization by Others Among Persons With a Mental Illness.

This research examined the frequency of and characteristics associated with three forms of violence among persons with mental illness-violence directed at others, self-directed violence, and violence directed at them by others. Previously unreported data from a follow-up sample of 951 patients from the MacArthur Violence Risk Assessment Study were analyzed to characterize involvement in violence directed at others, self-directed violence, and violence directed at them by others. Most patients (58%) experienced at least one form of violence, 28% experienced at least two forms, and 7% experienced all three forms. Several diagnostic, social, and historical variables distinguished the groups. Given the substantial overlap among the three forms of violence, clinicians should routinely screen patients who report one form for the occurrence of the other two. Co-occurrence of several forms of violence may require a package of interventions with components geared to each.

Characteristics of Sexual Abuse Among Individuals With Serious Mental Illnesses.

The deleterious effects of sexual abuse (SA) are well documented, as many studies have found that SA can increase the risk for psychiatric disorders. While SA has been examined in multiple samples, no studies have examined the characteristics of SA in individuals with severe mental illnesses (SMI). This study examined the prevalence rate and characterized the nature of SA among individuals with SMI who were under psychiatric care in three different inpatient facilities. Utilizing data from the MacArthur Violence Risk Assessment Study, 1,136 individuals with SMI were assessed for SA histories, psychiatric diagnoses, and other demographics. Nearly half of this sample ( n = 511) identified SA histories, with almost half indicating that the person was a stranger or someone outside of the family unit. One third reported SA occurred "too many times to count," and approximately a third indicated the abuse consisted of intercourse, occurring at a mean age of 11.22 years. Results found that individuals with SA histories were often never married, Caucasian, female, had children, described themselves as psychologically unwell, and were commonly voluntary psychiatric admissions. Those with SA histories had significantly higher psychopathology and lower functioning, and were more likely to be diagnosed with depression but less likely to be substance dependent. Identifying SA characteristics in individuals with SMI is a critical component to successful treatment. Thorough screening and assessment of this common problem can help clinicians identify accompanying issues that may exacerbate SMI symptomology, and improve the prognosis for long-term outcomes.

Does Sense of Control Predict Depression Among Individuals After Psychiatric Hospital Discharge?

Sense of control is known to be related to depression. Yet, few studies have examined the role of sense of control as related to depression for discharged psychiatric patients. In this study the longitudinal relationship between sense of control and depressive mood was examined using the MacArthur Violence Risk Assessment Study, a 6-wave, 1-year study of 948 ethnically diverse postdischarge psychiatric patients. Sense of control was decomposed into 2 components (i.e., a time-invariant as well as a time-varying component) and so as to examine which component of sense of control would more accurately explain this relationship. Results demonstrated that time-varying sense of control significantly predicted changes in depressive mood during the transition to community environment. Time-invariant sense of control, however, was not significantly related to changes in depressive mood. Findings of this study hold important implications for intervention practice with people before or after psychiatric discharge, including the need for incorporation of therapeutic and psychoeducational efforts that bolster sense of control.

Rater differences in psychopathy measure scoring and predictive validity.

Although field studies reveal that some forensic evaluators tend to assign higher psychopathy measure scores to sexual offenders than others, the extent to which these findings apply to psychopathy measure scoring in other contexts is unclear. And no study has examined the impact of evaluator differences in scoring on predictive validity. We used data from the MacArthur Violence Risk Assessment Study to examine whether there were rater differences in psychopathy measure scoring and predictive effects among trained raters in a rigorous research context. The proportion of variance in Psychopathy Checklist: Screening Version (Hart, Cox, & Hare, 1995) scores attributable to raters was larger for Part 1 (14%) than Part 2 (4%) scores. The association between Facet 4 scores and future violence was stronger among evaluators who assigned higher and more variable Facet 4 scores, but there were no similar effects for other PCL:SV scores. Although there was only limited evidence for an association between PCL:SV scoring tendencies and predictive validity, findings show that mean differences in scoring have implications for score interpretation, with the cut score that indicates a high level of risk being lower when it comes from a rater who assigns relatively low scores compared to a rater who assigns relatively high scores. These findings suggest that evaluators should carefully consider their own psychopathy measure scoring tendencies across cases and the extent to which these tendencies are consistent with the normative sample scores that form the basis of their psychopathy measure score interpretations.

Gun Violence and Victimization of Strangers by Persons With a Mental Illness: Data From the MacArthur Violence Risk Assessment Study.

Highly publicized incidents in which people with apparent mental illnesses use guns to victimize strangers have important implications for public views of people with mental illnesses and the formation of mental health and gun policy. The study aimed to provide more data about this topic. MacArthur Violence Risk Assessment Study data were analyzed to determine the prevalence of violence by 951 patients after discharge from a psychiatric hospital, including gun violence, violence toward strangers, and gun violence toward strangers. Two percent of patients committed a violent act involving a gun, 6% committed a violent act involving a stranger, and 1% committed a violent act involving both a gun and a stranger. When public perceptions and policies regarding mental illness are shaped by highly publicized but infrequent instances of gun violence toward strangers, they are unlikely to help people with mental illnesses or to improve public safety.

Psychosis Uncommonly and Inconsistently Precedes Violence Among High-Risk Individuals

A small group of individuals with mental illness is repeatedly involved in violence. Little is known about how often and how consistently these high-risk individuals experience delusions or hallucinations just before a violent incident. To address these questions, data from the MacArthur Violence Risk Assessment Study were used to identify 305 violent incidents associated with 100 former inpatients with repeated violence (representing 50% of incidents and 9% of participants) and test whether psychosis-preceded incidents cluster within individuals. Results indicated that (a) psychosis immediately preceded 12% of incidents, (b) individuals were “fairly” consistent in their violence type (ICC = .42), and (c) those with exclusively “non-psychosis-preceded” violence (80%) could be distinguished from a small group who also had some psychosis-preceded violence (20%). These findings suggest that psychosis sometimes foreshadows violence for a fraction of high-risk individuals, but violence prevention efforts should also target factors like anger and social deviance.

A predictive model of criminality in civil psychiatric populations

Purpose – The purpose of this paper is to develop a predictive model of criminal risk in civil psychiatric populations, by determining the relative impacts of psychopathy, drug use, impulsivity and intelligence on levels of criminality. Design/methodology/approach – The sample consisted of 871 civil psychiatric patients, selected from the MacArthur Violence Risk Assessment Study, who had been diagnosed with a mental illness or personality disorder, and hospitalised less than 21 days. Each participant was administered the Hare Psychopathy Checklist Screening Version (PCL:SV), Barratt Impulsiveness Scale (BIS-11) and the Wechsler Adult Intelligence Scale (WAIS-R). In addition, information on background demographics, drug use and criminality was obtained via a self-report questionnaire. Findings – Pearson correlations identified significant positive relationships between past arrests, psychopathy, impulsivity and drug use. Intelligence was negatively related to past arrests. Multiple regressions identified a significant main effect for Factor 2 psychopathy on past arrests when controlling for all covariates, but not for Factor 1 psychopathy, intelligence or impulsivity. Drug use and gender had small univariate effects. Research limitations/implications – It is suggested that future research investigates the influence of specific mental disorders on different types of offending. Originality/value – By investigating predictors of criminal behaviour in civil psychiatric patients, the present study makes valuable contributions to the research literature, enhancing our theoretical understanding of the relationships between psychopathy and criminality/recidivism. It also has notable implications in applied practice, for example in the development and refinement of risk assessment methods.

A new condition for assessing the clinical efficiency of a diagnostic test.

When prediction using a diagnostic test outperforms simple prediction using base rates, the test is said to be "clinically efficient," a term first introduced into the literature by Meehl and Rosen (1955) in Psychological Bulletin. This article provides three equivalent conditions for determining the clinical efficiency of a diagnostic test: (a) Meehl-Rosen (Meehl & Rosen, 1955); (b) Dawes (Dawes, 1962); and (c) the Bokhari-Hubert condition, introduced here for the first time. Clinical efficiency is then generalized to situations where misclassification costs are considered unequal (for example, false negatives are more costly than false positives). As an illustration, the clinical efficiency of an actuarial device for predicting violent and dangerous behavior is examined that was developed as part of the MacArthur Violence Risk Assessment Study.

Delusions, Anger, and Serious Violence: New Findings From the MacArthur Violence Risk Assessment Study

Recent research on the association between delusions and violence has suggested complex and differing pathways. Furthermore, it has been emphasized that temporal proximity is fundamental when investigating these relationships. We reanalyzed data from the MacArthur Violence Risk Assessment Study utilizing a different methodological approach to investigate associations between specific delusions and violence. Longitudinal study of 1136 male and female civil psychiatric inpatients after discharge. Delusions, affect due to delusions, and violence were measured at baseline and in 5 follow-up assessments. Serious violence was established using the MacArthur Community Violence Interview. Logistic mixed-effect models for repeated measures were performed. A "prospective" model confirmed previous findings that delusions do not predict later violence. However, reanalysis, considering temporal proximity, indicated a relationship between specific delusions and outcome including: being spied upon (adjusted OR [AOR] = 1.62, 95% CI = 1.06-2.47, P = .027), being followed (AOR = 1.90, 95% CI = 1.29-2.80, P = .001), being plotted against (AOR = 1.70, 95% CI = 1.14-2.52, P = .009), being under control of person/force (AOR = 1.92, 95% CI = 1.24-2.97, P = .003), thought insertion (AOR = 1.63, 95% CI = 1.00-2.66, P = .048), and having special gifts/powers (AOR = 1.95, 95% CI = 1.31-2.92, P = .001). All these delusions were associated with angry affect (P < .05). Inclusion of anger in the model significantly attenuated the main effects (except grandiose delusions), indicating an indirect pathway. Temporal proximity is crucial when investigating relationships between delusions and violence. Anger due to delusions is the key factor in this pathway. Our findings have important implications for identification of psychotic patients at risk for violent behavior and, most importantly, management of their risk.