Acting on delusions: the role of negative affect in the pathway towards serious violence

ABSTRACT

Acting violently on delusions is a significant clinical problem. Recent research has identified state anger as key component in the pathway from persecutory/threat delusions to serious violence. To determine the magnitude of the effect of delusional anger and to investigate a dose-response relationship we carried out a prospective follow-up study of forensic in-patients discharged into the community. Men and women (n = 409) were assessed before/after discharge at 6 and 12 months (Positive and Negative Syndrome Scale, MacArthur Community Violence Interview). No association was found with a content un-specific measure of delusions, thought disorder, hallucinations, grandiosity and violence. Suspiciousness/persecution was significantly associated with both violence and anger. Anger was also associated with violence. Mediation analyses suggested that 84% of the association between suspiciousness/persecution and violence was explained by anger. Key target of interventions should primarily be the anger; treatment of delusional beliefs plays a secondary role in the management of risk.

KEYWORDS:

• Paranoid delusions
• angry affect
• violence
• indirect pathway
• dose-response

Acknowledgement

This study was funded by the U.K. National Institute for Health Research (NIHR) under its Program Grants for Applied Research funding scheme (RP-PG-0407-10500). The views expressed in this manuscript are those of the authors and not necessarily those of the U.K. National Health System (NHS), the NIHR or the U.K. Department of Health. There was no editorial direction or censorship from the funders.