Understanding violence in psychosis: identifying key factors to target in treatment

Journal article

Background and hypothesis
Cognitions about violence are an understudied but likely contributor to violence in psychosis, particularly when they occur alongside other risk factors. To guide future treatment development, the aim in this study was to identify key cognitions and other modifiable risk factors for violence in psychosis.

Study Design
860 adult men with a diagnosis of psychosis from mental health services in England and Wales participated in this cross-sectional study. Violent incidents within the previous six-months were identified through clinical records and selfreport. Participants completed assessments of cognitions, paranoia, voices, emotion-dysregulation, anger, childhood adverse experiences, and substance use. Factor analysis was used to determine the structure of violence-related cognitions. Structural equation modelling (SEM) and network analysis were used to test relationships between cognitions, other risk factors, and violent behaviour.

Study Results
Factor analysis identified six types of violence-activating cognitions and two types of cognitions about the negative consequences of violence. The model comprised of five variables significantly associated with recent physical violence(R2=0.31): violence-activating cognitions (OR=1.92), anger (OR=1.60), current drug use (OR=2.47), distress from voice hearing (OR=1.13), and age (OR=0.98). Network analysis identified both direct and indirect pathways to violence.

Conclusions
Violence may be most likely to occur when there are a range of violenceactivating cognitions and less inhibition of acting on these cognitions due to factors such as anger, psychotic experiences, and drug use. Targeting in intervention the cognitions and disinhibiting factors identified could provide 2 both a test of causal connections with violence and evidence for new treatment routes.

Authors: Lambe, SP; Diamond, R; Hudson, F; Sheng Loe, B; Fazel, S

• Publication status: Accepted
• Peer review status: Peer reviewed
• Publisher: Oxford University Press
• Journal: Schizophrenia Bulletin
• Acceptance date: 2026-09-07
• EISSN: 1745-1701
• ISSN: 0586-7614
• Language: English