Anger mediates delusion link to violence in psychotic patients
medwireNews: Anger due to delusions appears to be a key factor explaining violent behavior in patients with acute psychosis, findings from the East London First Episode Psychosis Study show.
The population-attributable risk percentage of anger related to delusions was 30.8% for minor violence and 55.9% for serious violence, after taking into account gender, ethnicity, age, comorbid antisocial personality disorder, drug use, mania symptoms, and trait anger.
"The association was stronger for serious violence than for minor violence and the high attributable risk of anger due to delusions... has implications for preventive intervention and treatment," say Simone Ulrich (Queen Mary University of London, UK) and colleagues.
"If anger due to delusions could be identified and treated, a substantial number of violent incidents could potentially be prevented."
They used the Schedules for Clinical Assessment in Neuropsychiatry and Maudsley Assessment of Delusions Schedule to assess 458 individuals aged 18 to 64 years with first-episode psychosis.
There was a 38% prevalence of violence, with 12% of patients engaging in serious violence, defined as assault resulting in injury or involving use of a lethal weapon, threat with a lethal weapon, or sexual assault.
After taking into account demographic characteristics and comorbid psychopathology typically associated with violence in the general population, anger was the only affect due to delusions that was positively associated with violence, both minor and serious.
There were six delusions and one delusional characteristic that were significantly associated with anger, including being spied on, familiar people impersonated, persecution, conspiracy, threat/control override, and misidentification.
Of these, three highly prevalent delusions - persecution, being spied on, and conspiracy - were significantly associated with anger that led to serious violence specifically, while the association between minor violence and the delusion that familiar people are being impersonated was significantly, but only partially, mediated by anger.
The researchers note in JAMA Psychiatry that in addition to the mediating affect of anger, there was also evidence of a direct affect of delusions on minor violence, namely for bizarre delusions associated with smell, preoccupation with previous experiences, and hypochondriacal delusions. But these delusions were relatively uncommon.
Ulrich et al comment on the importance of being able to differentiate between "anger due to a delusion and anger as part of the delusion itself" in preventing future violence among deluded patients.
"If the anger is reactive to the delusional belief, it may be modifiable by treatment that specifically targets the anger," they explain.
"However, if it is part of the delusion itself, this would imply that treatment must simultaneously target the delusion and the associated anger."
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By Lucy Piper, Senior medwireNews Reporter