Studying Patients with Severe Mental Disorders Who Act Violently: Italian and European Projects

  • Giovanni de GirolamoEmail author
  • Giorgio Bianconi
  • Maria Elena Boero
  • Giuseppe Carrà
  • Massimo Clerici
  • Maria Teresa Ferla
  • Gian Marco Giobbio
  • Giovanni Battista Tura
  • Antonio Vita
  • Clarissa Ferrari
Part of the Comprehensive Approach to Psychiatry book series (CAP, volume 1)


Background: The management of mentally ill offenders in the community is one of the great challenges imposed on community psychiatry.

Aim: The aim of this study is to analyze the association between sociodemographic, clinical, and psychosocial factors and violent behavior in a sample of patients (both residential and outpatients) with severe mental disorders.

Method: This was a prospective cohort study with a baseline cross-sectional design used to provide a detailed analysis of patients’ profiles, followed by a longitudinal design to measure aggressive and violent behavior during a 1-year follow-up. Patients with severe mental disorders, with a history of violence (“cases”) or with no such history (controls), were enrolled in 22 residential facilities and in 4 Italian departments of mental health and underwent a comprehensive multidimensional assessment at baseline, and were then monitored with the Modified Overt Aggression Scale (MOAS) every 2 weeks for 1 year.

Results: The sample included 139 residential patients and 247 outpatients, for a total of 208 cases and 178 controls. Compared to controls, all patients with a history of violence had a higher number of compulsory admissions and a higher score at the Brown-Goodwin Lifetime History of Aggression (BGLHA); among residential patients many cases had been in a forensic mental hospital or in prison, while outpatient cases displayed a greater frequency of lifetime domestic violence and a greater lifetime propensity to misuse substances. The fortnightly monitoring during the 1-year follow-up did show statistically significant differences in aggressive and violent behavior rates between outpatient cases and all the rest of the sample, including residential cases. This shows that being in a residential setting, where treatment compliance is granted and substance-use disorders are prevented or controlled, is associated with a lower risk of aggressive and violent behavior. There was a continuum in aggression, with verbal aggression significantly associated with aggression against objects and the latter associated with physical aggression.

Conclusions: Outpatients with a history of violence had specific characteristics and showed a greater occurrence of additional community violence during a 1-year observation period. Our results may assist clinicians in implementing standardized methods of patient assessment and violence monitoring in outpatient mental health services and may prompt improved collaboration between different community services.


Violence Risk factors Substance use Self-harm 



The VIORMED-2 (Violence Risk and Mental Disorder 2) project was funded by the Health Authority of Regione Lombardia, Italy, grant CUP E42I14000280002 for “Disturbi mentali gravi e rischio di violenza: uno studio prospettico in Lombardia” with Decreto D.G. Salute N.6848, date16.7.2014.

The VIORMED-2 Group also includes Valentina Candini, PhD.; Cesare Cavalera, PhD.; Giovanni Conte, M.D.; Giulia Gamba, M.D.; Laura Iozzino, PhD.; Assunta Martinazzoli, M.D.; Giuliana Mina, M.D.; Alessandra Ornaghi, M.D.; Alberto Stefana, PhD.; and Bruno Travasso, M.D. The authors wish to thank the many clinicians, mental health staff, and family relatives who provided invaluable help for the realization of the project; the authors wish to particularly thank the patients who gave their time and their collaboration to the realization of the project.

Declaration of interest: All authors have no competing interests to disclose.


  1. 1.
    Large M, Smith G, Nielssen O. The relationship between the rate of homicide by those with schizophrenia and the overall homicide rate: a systematic review and meta-analysis. Schizophr Res. 2009;112:123–9.PubMedCrossRefGoogle Scholar
  2. 2.
    Large M, Smith G, Swinson N, Shaw J, Nielssen O. Homicide due to mental disorder in England and Wales over 50 years. Br J Psychiatry. 2008;193:130–3.PubMedCrossRefGoogle Scholar
  3. 3.
    Nielssen O, Large M. Penrose updated: deinstitutionalization of the mentally ill is not the reason for the increase in violent crime. Nord J Psychiatry. 2009;63:267. Scholar
  4. 4.
    Nielssen O, Large M. Rates of homicide during the first episode of psychosis and after treatment: a systematic review and meta-analysis. Schizophr Bull. 2010;36:702–12.PubMedCrossRefGoogle Scholar
  5. 5.
    Arboleda-Flórez J. Mental illness and violence. Curr Opin Psychiatry. 2009;22:475–6.PubMedCrossRefGoogle Scholar
  6. 6.
    de Girolamo G, Cozza M. The Italian psychiatric reform: a 20-year perspective. Int J Law Psychiatry. 2000;23:197–214.PubMedCrossRefGoogle Scholar
  7. 7.
    de Girolamo G, Bassi M, Neri G, Ruggeri M, Santone G, Picardi A. The current state of mental health care in Italy: problems, perspectives and lessons to learn. Eur Arch Psychiatry Clin Neurosci. 2007;257:83–91.PubMedCrossRefGoogle Scholar
  8. 8.
    Picardi A, Lega I, Candini V, Dagani J, Iozzino L, de Girolamo G. Monitoring and evaluating the Italian mental health system: the “Progetto Residenze” study and beyond. J Nerv Ment Dis. 2014;202:451–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Di Lorito C, Castelletti L, Lega I, Gualco B, Scarpa F, Vӧllm B. The closing of forensic psychiatric hospitals in Italy: determinants, current status and future perspectives. A scoping review. Int J Law Psychiatry. 2017;55:54–63.PubMedCrossRefGoogle Scholar
  10. 10.
    Ferracuti S, Pucci D, Trobia F, Alessi MC, Rapinesi C, Kotzalidis GD, Del Casale A. Evolution of forensic psychiatry in Italy over the past 40 years (1978–2018). Int J Law Psychiatry. 2019;62:45–9.PubMedCrossRefGoogle Scholar
  11. 11.
    Bulgari V, Iozzino L, Ferrari C, Picchioni M, Candini V, De Francesco A, Maggi P, Segalini B, de Girolamo G, VIORMED-1 Group. Clinical and neuropsychological features of violence in schizophrenia: a prospective cohort study. Schizophr Res. 2017;181:124–30.PubMedCrossRefGoogle Scholar
  12. 12.
    de Girolamo G, Buizza C, Sisti D, Ferrari C, Bulgari V, Iozzino L, Boero ME, Cristiano G, De Francesco A, Giobbio GM, Maggi P, Rossi G, Segalini B, Candini V, VIORMED-1 Group. Monitoring and predicting the risk of violence in residential facilities. No difference between patients with history or with no history of violence. J Psychiatr Res. 2016;80:5–13.PubMedCrossRefGoogle Scholar
  13. 13.
    Candini V, Ghisi M, Bottesi G, Ferrari C, Bulgari V, Iozzino L, Boero ME, De Francesco A, Maggi P, Segalini B, Zuccalli V, Giobbio GM, Rossi G, de Girolamo G. Personality, schizophrenia, and violence: a longitudinal study. J Pers Disord. 2017;31:1–17.CrossRefGoogle Scholar
  14. 14.
    Barlati S, Stefana A, Bartoli F, Bianconi G, Bulgari V, Candini V, Carrà G, Cavalera C, Clerici M, Cricelli M, Ferla MT, Ferrari C, Iozzino L, Macis A, Vita A, de Girolamo G, VIORMED-2 Group. Violence risk and mental disorders (VIORMED-2): a prospective multicenter study in Italy. PLoS One. 2019;14(4):e0214924. eCollection 2019. PubMed PMID: 30990814; PubMed Central PMCID: PMC6467378CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Bottesi G, Candini V, Ghisi M, Bava M, Bianconi G, Bulgari V, Carrà G, Cavalera C, Conte G, Cricelli M, Ferla MT, Iozzino L, Macis A, Stefana A, de Girolamo G, VIORMED-2 Group. Personality, schizophrenia, and violence: a longitudinal study: the second wave of the VIORMED Project. J Pers Disord. 2019;14:1–19.CrossRefGoogle Scholar
  16. 16.
    First MB, Gibbon M, Spitzer RL, Williams JBW, Benjamin S. Structured clinical interview for DSM-IV axis II personality disorders (SCID-II). Washington, D.C.: American Psychiatric Press, Inc.; 1997.Google Scholar
  17. 17.
    First MB, Spitzer RL, Gibbon M, Williams JBW. Structured clinical interview for DSM-IV-TR axis I disorders, research version, patient edition (SCID-I/P). Biometrics Research. New York State Psychiatric Institute: New York, NY; 2002.Google Scholar
  18. 18.
    Dazzi F, Shafer A, Lauriola M. Meta-analysis of the Brief Psychiatric Rating Scale-Expanded (BPRS-E) structure and arguments for a new version. J Psychiatr Res. 2016;81:140–51.PubMedCrossRefGoogle Scholar
  19. 19.
    Montemagni C, Rocca P, Mucci A, Galderisi S, Maj M. Italian version of the “Specific Level of Functioning”. J Psychopathol. 2015;21:287–96.Google Scholar
  20. 20.
    Brown GL, Goodwin FK, Ballenger JC, Goyer PF, Major LF. Aggression in humans correlates with cerebrospinal fluid amine metabolites. Psychiatry Res. 1979;1:131–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Buss AH, Durkee A. An inventory for assessing different kinds of hostility. J Consult Psychol. 1957;21:343–9.PubMedCrossRefGoogle Scholar
  22. 22.
    Barratt ES. Factor analysis of some psychometric measures of impulsiveness and anxiety. Psychol Rep. 1965;16:547–54.PubMedCrossRefGoogle Scholar
  23. 23.
    Spielberger CD, Johnson EH, Russell SF, Crane RJ, Jacobs GA, Worden TJ. The experience and expression of anger: construction and validation of an anger expression scale. In: Chesney MA, Rosenman RH, editors. Anger and hostility in cardiovascular and behavioral disorders. New York: Hemisphere/McGraw-Hill; 1985. p. 5–30.Google Scholar
  24. 24.
    Margari F, Matarazzo R, Cassacchia M, Roncone R, Dieci M, Safran S, et al. Italian validation of MOAS and NOSIE: a useful package for psychiatric assessment and monitoring of aggressive behaviours. Int J Methods Psychiatr Res. 2005;14:109–18.PubMedCrossRefGoogle Scholar
  25. 25.
    Millon T, Davis RD. The MCMI-III: present and future directions. J Pers Assess. 1997;68:69–85.PubMedCrossRefGoogle Scholar
  26. 26.
    Millon T, Davis RD, Millon C. Millon Clinical Multiaxial Inventory-III (MCMI-III) manual. 2nd ed. Minneapolis, MN: National Computer Systems; 1997.Google Scholar
  27. 27.
    Amore M, Tonti C, Esposito W, Baratta S, Berardi D, Menchetti M. Course and predictors of physical aggressive behaviour after discharge from a psychiatric inpatient unit: 1 year FU. Community Ment Health J. 2012;49:451–6.PubMedCrossRefGoogle Scholar
  28. 28.
    Appelbaum PS, Robbins PC, Monahan J. Violence and delusions: data from the MacArthur Violence Risk Assessment Study. Am J Psychiatry. 2000;157:566–72.PubMedCrossRefGoogle Scholar
  29. 29.
    Bobes J, Fillat O, Violence AC. Violence among schizophrenia outpatients compliant with medication: prevalence and associated factors. Acta Psychiatr Scand. 2009;119:218–25.PubMedCrossRefGoogle Scholar
  30. 30.
    Brucato G, Appelbaum PS, Lieberman JA, Wall MM, Feng T, Masucci MD, et al. A longitudinal study of violent behavior in a psychosis-risk cohort. Neuropsychopharmacology. 2018;43:264–71.PubMedCrossRefGoogle Scholar
  31. 31.
    Colasanti A, Natoli A, Moliterno D, Rossattini M, De Gaspari IF, Mauri MC. Psychiatric diagnosis and aggression before acute hospitalisation. Eur Psychiatry. 2008;23:441–8.PubMedCrossRefGoogle Scholar
  32. 32.
    Dean K, Walsh E, Morgan C, Demjaha A, Dazzan P, Morgan K, Lloyd T, Fearon P, Jones PB, Murray RM. Aggressive behaviour at first contact with services: findings from the AESOP First Episode Psychosis Study. Psychol Med. 2007;37:547–57.PubMedCrossRefGoogle Scholar
  33. 33.
    Ekinci O, Ekinci A. Association between insight, cognitive insight, positive symptoms and violence in patients with schizophrenia. Nord J Psychiatry. 2013;67:116–23.PubMedCrossRefGoogle Scholar
  34. 34.
    Keane S, Szigeti A, Fanning F, Clarke M. Are patterns of violence and aggression at presentation in patients with first-episode psychosis temporally stable? A comparison of 2 cohorts. Early Interv Psychiatry. 2018;13:888–94. [Epub ahead of print].CrossRefPubMedGoogle Scholar
  35. 35.
    Langeveld J, Bjørkly S, Auestad B, Barder H, Evensen J, ten Velden Hegelstad W, et al. Treatment and violent behavior in persons with first episode psychosis during a 10-year prospective FU study. Schizophr Res. 2014;156:272–6.PubMedCrossRefGoogle Scholar
  36. 36.
    Mauri MC, Cirnigliaro G, Di Pace C, Paletta S, Reggiori A, Altamura CA, Dell’Osso B. Aggressiveness and violence in psychiatric patients: a clinical or social paradigm? CNS Spectr. 2019;4:1–10. [Epub ahead of print].CrossRefGoogle Scholar
  37. 37.
    Pinna F, Tusconi M, Dessì C, Pittaluga G, Fiorillo A, Carpiniello B. Violence and mental disorders. A retrospective study of people in charge of a community mental health center. Int J Law Psychiatry. 2016;47:122–8.PubMedCrossRefGoogle Scholar
  38. 38.
    Steadman HJ, Mulvey EP, Monahan J, Robbins PC, Appelbaum PS, Grisso T, Roth LH, Silver E. Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Arch Gen Psychiatry. 1998;55:393–401.PubMedCrossRefGoogle Scholar
  39. 39.
    Swanson JW, Swartz MS, Van Dorn RA, Elbogen EB, Wagner HR, Rosenheck RA, Stroup TS, McEvoy JP, Lieberman JA. A national study of violent behavior in persons with schizophrenia. Arch Gen Psychiatry. 2006;63:490–9.PubMedCrossRefGoogle Scholar
  40. 40.
    Swanson JW, Swartz MS, Essock SM, Osher FC, Wagner HR, Goodman LA, et al. The social–environmental context of violent behavior in persons treated for severe mental illness. Am J Public Health. 2002;92:1523–31.PubMedPubMedCentralCrossRefGoogle Scholar
  41. 41.
    Swanson JW, Van Dorn RA, Monahan J, Swartz MS. Violence and leveraged community treatment for persons with mental disorders. Am J Psychiatry. 2006;163:1404–11.PubMedCrossRefGoogle Scholar
  42. 42.
    Tyrer P, Cooper S, Herbert E, Duggan C, Crawford M, Joyce E, Rutter D, Seivewright H, O’Sullivan S, Rao B, Cicchetti D, Maden T. The quantification of violence scale: a simple method of recording significant violence. Int J Soc Psychiatry. 2007;53:485–97.PubMedCrossRefGoogle Scholar
  43. 43.
    Tosato S, Bonetto C, Di Forti M, Collier D, Cristofalo D, Bertani M, Zanoni M, Marrella G, Lazzarotto L, Lasalvia A, De Gironcoli M, Tansella M, Dazzan P, Murray R, Ruggeri M. Effect of COMT genotype on aggressive behaviour in a community cohort of schizophrenic patients. Neurosci Lett. 2011;495:17–21.PubMedCrossRefGoogle Scholar
  44. 44.
    Winsper C, Ganapathy R, Marwaha S, Large M, Birchwood M, Singh SP. A systematic review and meta-regression analysis of aggression during the first episode of psychosis. Acta Psychiatr Scand. 2013;128:413–21.PubMedCrossRefGoogle Scholar
  45. 45.
    Winsper C, Singh SP, Marwaha S, Amos T, Lester H, Everard L, et al. Pathways to violent behavior during first-episode psychosis. JAMA Psychiat. 2013;70:1287.CrossRefGoogle Scholar
  46. 46.
    Zanarini MC, Temes CM, Ivey AM, Cohn DM, Conkey LC, Frankenburg FR, et al. The 10-year course of adult aggression toward others in patients with borderline personality disorder and axis II comparison subjects. Psychiatry Res. 2017;252:134–8.PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Giovanni de Girolamo
    • 1
    Email author
  • Giorgio Bianconi
    • 2
  • Maria Elena Boero
    • 3
  • Giuseppe Carrà
    • 4
  • Massimo Clerici
    • 4
    • 5
  • Maria Teresa Ferla
    • 6
  • Gian Marco Giobbio
    • 7
  • Giovanni Battista Tura
    • 8
  • Antonio Vita
    • 9
  • Clarissa Ferrari
    • 10
  1. 1.Unit of Epidemiological and Evaluation PsychiatryIRCCS Istituto Centro San Giovanni di Dio FatebenefratelliBresciaItaly
  2. 2.Department of Mental HealthASST Ovest MilaneseMilanItaly
  3. 3.Clin. Psychol.Rehabilitation Hospital Beata Vergine Della ConsolataTorinoItaly
  4. 4.Department of Medicine and SurgeryUniversity of Milano BicoccaMonzaItaly
  5. 5.Department of Mental HealthASST of MonzaMonzaItaly
  6. 6.Department of Mental HealthASST-Rhodense G. Salvini of GarbagnateMilanItaly
  7. 7.Villa Sant’Ambrogio Hospital, Sacro Cuore di Gesù Center, FatebenefratelliMilanItaly
  8. 8.IRCCS Istituto Centro San Giovanni di Dio FatebenefratelliBresciaItaly
  9. 9.Department of Clinical and Experimental SciencesUniversity of BresciaBresciaItaly
  10. 10.Unit of StatisticsIRCCS Istituto Centro San Giovanni di Dio FatebenefratelliBresciaItaly

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