Clinical risk management in psychiatry.

Psychiatric disorder and dangerousness Psychiatric disorder, especially schizophrenia, is associated with a significant risk of violence before admission to hospital.2 Patients with schizophrenia in a recent large scale Swedish longitudinal study committed four times as many violent offences as the general population.3 Among inpatients, those with schizophrenia are also disproportionately more likely to be violent.4 Taylor found that the vast majority of the psychotic offenders on remand at Brixton Prison whom she examined had symptoms at the time of the index offence. Schizophrenia is also overrepresented among men remanded for homicide: 11% in Taylor's series.5 Recent cross sectional surveys show an association between self reported violent behaviour and either a diagnosis of schizophrenia or current psychotic symptoms.6 Thus violence is most likely to occur when patients have active symptoms of psychosis, and the risk significantly diminishes after treatment.7 The risk of violence in mental illness is greatest when the patient has delusions and passivity experiences,8 and there is a well recognised association of violence with delusional belief, as in the "pathologies of passion" such as morbid jealousy and erotomania.5