One of the most common and damaging stereotypes about mental illness is that mentally ill people are chronically dangerous and violence-prone (Corrigan & Watson, 2002). This stereotype is especially strongly linked to people with psychosis. Like many stereotypes, it’s not true in the vast majority of cases, but the general public may not realize that.
I wanted to write about this issue after coming across a CBC News article that appeared to be using “psychotic” to describe someone who had behaved violently, with no indication that the individual was experiencing a mental illness. Other sources reporting on the same story made no mention of mental illness, either.
What psychosis is
I’m not a fan of word policing, but knowing what words mean seems like a fundamental part of human communication. So let’s talk about what psychosis is.
Unlike terms like depression and anxiety, psychosis doesn’t have distinct medical and non-medical definitions. There’s just psychosis. Unlike misuse of terms like ADHD and OCD that tends to minimize the conditions, misuse of psychosis goes way off in the other direction of scary and violent.
Here are a couple of dictionary definitions for “psychosis”:
- “a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality” (Merriam-Webster Dictionary)
- “mental illness of a severe kind which can make people lose contact with reality” (Collins Dictionary)
What psychosis is not
Psychosis is sometimes confused with other words that sound similar but have different meanings.
- Psycho: the Merriam-Webster Dictionary defines this slang term as “a deranged or psychopathic person.”
- Psychopath (adjective: psychopathic): someone who lacks empathy, manipulates others, and is likely to engage in criminal behaviour. It’s not a psychiatric diagnosis, and the closest equivalent is antisocial personality disorder. In casual parlance, sometimes people will also use the word sociopath. Psychopathy has nothing whatsoever to do with psychosis. Yet people get this wrong all the time, including in a parody of American Psycho posted on Vogue’s Youtube channel titled Margot Robbie’s Beauty Routine Is Psychotically Perfect.
- Psychopathology: this refers to psychological disorders in general (psychosis is a form of psychopathology, as are bipolar and OCD), but it’s sometimes confused with psychopathy (having psychopathic traits).
Psychosis in a psychiatric sense is a little more specific than the dictionary sense. It’s characterized by delusions, hallucinations, and/or extremely disorganized thought process. Psychosis can happen in the context of multiple mental illnesses, including schizophrenia, schizoaffective disorder, delusional disorder, bipolar disorder, major depressive disorder, and OCD. People with borderline personality disorder sometimes experience “micropsychotic” episodes. Psychosis can also be triggered by various illicit substances as well as prescription medications, such as prednisone.
Are psychotic people violent?
Short answer: no more than anyone else.
Here’s some of what I’ve come across while working on my upcoming book about mental illness stigma.
In a given year, only 4% of violent acts can be attributed to mental illness (Swanson et al., 2016). Looking at violence risk across the broader population, being young, male, and of low socioeconomic class are the most significant contributing factors (Rosenberg et al., 2015). People with mental illness are actually more likely than the general population to be victims of violence (Teplin, 2005).
Most people with mental illness are not at increased risk for violence, with a few very specific exceptions. There is an increased risk for people who have a severe mental illness and a co-occurring substance use disorder, but there are often socioeconomic and other factors that also contribute to risk (Swanson et al., 2016). As in, it’s not just a matter of having a mental illness. There’s a buttload of people with mental illness, including illnesses with psychotic features, and they’re not going around hacking people to bits. I’m not, and this blog has multiple regular readers with psychotic illnesses who aren’t either.
MacArthur Violence Risk Assessment Study
The large MacArthur Violence Risk Assessment Study (MacArthur, 2005) looked at violent behaviour within the first 20 weeks of discharge from a forensic psychiatric hospital. The factors most strongly linked to violence were a history of prior violence and high scores on the Hare Psychopathy Checklist, a commonly used scale for assessing psychopathic traits. Looking at psychotic symptoms, there was no increased risk associated with delusions, nor was there an increased risk with hallucinations, with the specific exception of command auditory hallucinations to harm others, which are not common.
Despite the stereotypes, people with mental illness are less likely to commit gun violence than the national average. Between 2001 and 2010, less than 5% of 120,000 gun-related killings that occurred in the U.S. were done by people with a mental illness diagnosis (Metzl and MacLeish, 2015). A lot more than 5% of the population is mentally ill; if we crazy folk are going to be killing anyone, it’s most likely ourselves.
Why people overestimate risk
We’ve all been exposed over and over again to the “mentally ill = violent”, and particularly “psychotic = violent”, stereotypes. It’s hard to avoid, and it’s regularly reinforced in the media (Corrigan, 2016), which is why the news article I wrote about yesterday bugged me. Society Others those who break its rules, and it doesn’t get much more Other than psychosis.
That feeds right into the availability heuristic. We automatically give greater importance to what pops into our minds first, which is probably a gruesome story you heard on the news at some point. When I think of psychosis, I think of the hundreds of patients I had over the years.
Another cognitive bias is the just-world fallacy. We want the world to be fair, and when it isn’t, our minds try to rearrange things to establish fairness. If it’s crazy people who are violent, that upholds the just world fallacy because only “those people” would do something heinous.
It’s easier to Other groups of people when they’re at a distance and seem not quite human. Psychosis isn’t all that rare, but with the amount of stigma associated with it, who’s going to be motivated to “come out”? Would you disclose something about yourself if people were likely to react by fearing that you’ll get violent on their ass?
Let’s bring a little reality
This is a mental health blog. Quite a few people who hang out here have experienced psychosis, myself included, or continue to experience psychosis on an ongoing basis as part of their illness. We may not be what pops into mind with the availability heuristic, but we’re here, and we’re not scary. The psychosis = psycho/violent/psychopath thing isn’t accurate, and it’s not helpful.
And if ever people don’t know what psychosis or any other word associated with mental illness means, there’s a thing called a dictionary, and Google is happy to help with that. Ignorance is not bliss.
- Corrigan, P.W. (2016). Lessons learned from unintended consequences about erasing the stigma of mental illness. World Psychiatry, 15(1), 67-73.
- Corrigan, P.W., & Watson, A.C. (2002). The paradox of self-stigma and mental illness. Clinical Psychology: Science and Practice, 9(1), 35-53.
- MacArthur Research Network on Mental Health and the Law. (2005). The MacArthur Violence Risk Assessment Study.
- Metzl, J.M., & MacLeish, K.T. (2015). Mental illness, mass shootings, and the politics of American firearms. American Journal of Public Health, 105(2), 240-249.
- Rosenberg, J., Rosenberg, S., Ellefson, S., et al. (2015). Public mental health stigma and mass shootings. Scholarena.
- Swanson, J.W., McGinty, E.E., Fazel, S., et al. (2016). Mental illness and reduction of gun violence and suicide: Bringing epidemiologic research to policy. Annals of Epidemiology, 25(5), 366-376.
- Teplin, L.A., McClelland, G.M., Abram, K.M., et al. (2005). Crime victimization in adults with severe mental illness: Comparison with the National Crime Victimization Survey. Archives of General Psychiatry, 62(8), 911-921.