Lack of awareness of mental illness (anosognosia) increases violence

(Edited by Dr. E. Fuller Torrey)

Unawareness of illness (anosognosia) is found in approximately half of all individuals with serious mental illnesses. It increases the likelihood that such individuals may become aggressive and violent. Unawareness of illness increases the chances that such individuals will not take medication, which therefore increases the person’s symptoms and chances of becoming violent. The most important way to decrease violent behavior in individuals with serious mental illnesses is to make certain that they are being treated


  •   In a four-country study in Canada, Germany, Finland, and Sweden, 216 patients with schizophrenia in forensic hospitals were followed for two years after discharge. Those patients with little or no insight had significantly more aggressive behavior compared to those with good insight. However, as predictors of aggressive behavior, the patients’ positive symptom score (e.g., delusions and hallucinations) and their level of psychopathy (sociopathy) were better predictors than was their level of insight. (Lincoln TM, Hodgins S. Is lack of insight associated with physically aggressive behavior among people with schizophrenia living in the community? Journal of Nervous and Mental Disease 2008;196:62–66.
  • In Germany, the criminal records of 1,662 individuals with schizophrenia who had been discharged from psychiatric hospitals were assessed. According to the authors: —Significantly higher rates of criminal conviction and recidivism were found for patients with lack of insight at discharge. (Soyka M, Graz C, Bottlender R et al. Clinical correlates of later violence and criminal offences in schizophrenia. Schizophrenia Research 2007;94:89–98).
  • In the United States (New York), 60 male patients with psychosis who had been charged with a violent crime were assessed. Severity of community violence was strongly associated with poor insight, medication nonadherence, and substance abuse. (Alia-Klein N, O’Rourke TM, Goldstein RZ et al. Insight into illness and adherence to psychotropic medications are separately associated with violence severity in a forensic sample. Aggressive Behavior 2007;33:86–96.)
  • In the United States (five sites), 1,011 outpatients with severe psychiatric disorders were assessed for medication adherence and physically assaultive behavior over six months. Those who became physically assaultive were significantly more likely to have treatment nonadherence (p<0.001), to be sicker, to be a substance abuser, and to have a personality disorder. Elbogen EB, Van Dorn RA, Swanson JW et al. Treatment engagement and violence risk in mental disorders. British Journal of Psychiatry 2006;189:354–360.
  • In the United States (multi-site study), 1,906 individuals with schizophrenia and related disorders were prospectively followed and assessed for three years. Medication nonadherence was significantly associated with being violent, arrested, and victimized (all significant at a level of p<0.001). Ascher-Svanum H, Faries DE, Zhu B et al. Medication adherence and long-term functional outcomes in the treatment of schizophrenia in usual care. Journal of Clinical Psychiatry 2006;67:453–460.
  • In Ireland, 157 individuals with first-episode psychosis were assessed for violent behavior. The strongest predictors of violent behavior in the week following admission were poor insight (odds ratio 2.97) and a past history of violence (odds ratio 3.82). Foley SR, Kelly BD, Clarke M et al. Incidence and clinical correlates of aggression and violence at presentation in patients with first episode psychosis. Schizophrenia Research 2005;72:161–168.
  • In England, 44 male inpatients in a forensic psychiatric hospital were assessed for violent behavior. It was found that —a previous diagnosis of mental illness, lack of insight, and active signs of mental illness were the most predictive of inpatient violence. Grevatt M, Thomas-Peter B, Hughes G. Violence, mental disorder and risk assessment: can structured clinical assessments predict the short-term risk of inpatient violence? Journal of Forensic Psychiatry and Psychology 2004;15:278–292.
  • In the United States (Ohio), 115 individuals with schizophrenia who had committed violent acts for which legal charges were incurred were compared to 111 individuals with schizophrenia who had no history of violent acts. The violent individuals had —marked deficits in insight? and were much more symptomatic. Compared to the nonviolent individuals, those who had been violent scored significantly lower (p<0.001) on awareness of mental disorder, awareness of achieved effect of medications, and awareness of social consequences of mental disorders. Buckley PF, Hrouda DR, Friedman L, et al. Insight and its relationship to violent behavior in patients with schizophrenia. American Journal of Psychiatry 2004;161:1712–1714.
  • In Sweden, 40 —mentally disordered? individuals with a history of —violent criminality were discharged from two forensic hospitals and followed for between 3 and 12 years. Twenty-two of them committed additional violent crimes, and 18 did not. Among the strongest predictors of those who committed additional violent crimes were lack of insight and —noncompliance with remediation attempts. Strand S, Belfrage H, Fransson G et al. Clinical and risk management factors in risk prediction of mentally disordered offenders—more important than historical data? Legal and Criminological Psychology 1999;4:67–76.
  • In Spain, 63 individuals with a diagnosis of schizophrenia or schizoaffective disorder were assessed for violent behavior during their brief hospitalizations. The strongest predictors of violent behavior were insight into symptoms (especially delusions), being sicker, and past history of violence. Arango C, Calcedo Barba A, González-Salvador T et al. Violence in inpatients with schizophrenia: a prospective study. Schizophrenia Bulletin 1999;25:493–503.
  • In the United States (North Carolina), 331 —severely mentally ill? individuals who had been involuntarily admitted to a psychiatric disorder were assessed for their history of assaultive and violent behavior. The findings indicated —that substance abuse problems, medication noncompliance, and low insight into illness operate together to increase violence risk. Swartz MS, Swanson JW, Hiday VA et al. Violence and severe mental illness: the effects of substance abuse and nonadherence to medication. American Journal of Psychiatry 1998;155:226–231.
  • In the United States (Massachusetts), 133 outpatients with schizophrenia were assessed for violent behavior over six months. During that period, —13 percent of the study group were characteristically violent,? and this was associated with medication nonadherence. —Seventy-one percent of the violent patients had problems with medication compliance, compared with only 17 percent of those without hostile behaviors. Bartels SJ, Drake RE, Wallach MA et al. Characteristic hostility in schizophrenic patients. Schizophrenia Bulletin 1991;17:163–171.