Violence: What We Know And What We Need To Know

Violence: What we know and what we need to know
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Violence is painfully once again in the headlines in this county. Orlando tragically adds to the list of mass shootings this year that demonstrates that the U.S., with 5 percent of the population of the globe, had 31 percent of its public mass shootings. The number of mass murders in this country in 2016 to date exceeds the days passed this year, which is to say at least one mass murder occurs, on average, every day.

How can we understand the types of individuals who perpetrate acts of violence? There are at least four prototypes of people who seek to harm other people. I described them in a video podcast recently (Mental illness and Violence -- 4 minutes) and write them here to help mitigate stigma about mental illness and violence. Each prototype is not exclusive of the others; in fact, the more categories a person conforms to the greater the risk of violence.

The four prototypes are:

  1. PSYCHOPATHS -- they don’t care about other people.

  2. THOSE WHO ARE ENRAGED AND AGGRIEVED -- they want to settle a score.

  3. THOSE WHO ARE ACTIVELY PSYCHOTIC PEOPLE -- their risk for violence is greater than the general public, but treatment reduces the risk they pose and improves the public safety.

  4. THOSE WHO ARE ACTIVELY USING ALCOHOL AND DRUGS -- these substances disinhibit individuals; they remove the brakes we have that prevent a thought from becoming an action. Active substance use and abuse creates the greatest risk of violence of all these groups.

Psychopaths are sometimes referred to as sociopaths or anti-social personalities. They lack empathy for others. Their principal, if not exclusive, concern is for themselves. Other people are a means toward their self-absorbed ends. By no means are all psychopaths violent, but some are, especially if another person represents a threat or a significant impediment to what they want. Think of the mafia or people from adolescence who hurt animals and people and who often do not leave their teenage years without a criminal record. So-called “white collar” criminals who exploit, extort and manipulate are often psychopaths but are not generally violent. If we can prevent youth from pursuing a psychopathic lifestyle we stand a chance, but once incarcerated they are often further socialized into a life of crime.

People who are enraged and aggrieved can escalate to violence. Their anger and wounded pride are powerful fuels for hateful action. These are people whose aim is to settle a score. But perhaps more importantly they need to restore their damaged self-esteem by destroying those whom they believe are responsible for their troubled station in life. Individuals who return to avenge where they lost a job or had a girl friend or spouse turn them away are examples of those who hurt or kill the people they blame. It is likely that some people who are radicalized have a foundation in these feelings. Murder coupled with suicide is yet another way these aggrieved and shamed souls take their revenge against others and themselves.

People with psychotic mental disorders, like schizophrenia, schizoaffective disorder and bipolar disorder, can be violent when under the sway of active delusions (e.g., fixed, false ideas especially paranoid delusions that cause them to be intensely fearful of others) and/or experience hallucinations (especially persecutory or command hallucinations that demean them or demand they take action against others). We can understand these people as responding to psychotic ideas that are responsive to good psychiatric treatment. When their illness is under control they are more or less at no greater risk for violence than the general public. But when actively psychotic they do present a risk -- both to people they know and strangers. The public safety is best served when their conditions are detected, properly diagnosed and effectively treated.

Individuals using and abusing substances like alcohol and drugs (of various sorts including synthetic marijuana -- Spice, K2, etc; crystal meth; PCP; and a host of other manufactured chemicals available today or en route for tomorrow’s ingestion are especially at risk for impulsive, suicidal and homicidal behaviors. Here too prevention starting in early adolescence, detection of individuals using in schools, primary care practices and work settings, and effective, comprehensive treatments offer communities the best chance of reducing self-destructive actions and behaviors dangerous to others.

Violence is ubiquitous, and has been so for millennia. But the rates of violence, including suicide, in the USA now far exceed other countries. To make a difference and reduce the epidemic of violence we need to start by not alleging that all violent acts are the result of mental illness. Then we need to serve each of these archetypes differently according to what will reduce their risks of harm and thereby improve the safety of communities.

More of the same exhortations, blaming and erroneous mixing of motives and prototypes has not been effective. We need to find a better course, what other choice do we have?


The opinions expressed herein are solely my own as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.

My book for families who have a member with a mental illness is The Family Guide to Mental Health Care (Foreword by Glenn Close) — is now available in paperback (

My new book, Four Secrets to Mental Health, will be available in December, 2016.

Follow me on Twitter: @askdrlloyd

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