News reports about individuals with schizophrenia engaging in violent behavior often lead many people to develop negative stigma toward this severe mental disorder.

However, according to the latest evidence-based reviews, the belief that all people with schizophrenia are dangerous or prone to violence is a myth that needs to be corrected.

The Facts

• Most people with schizophrenia never engage in violent behavior.
• In fact, they are more likely to become victims of violence, discrimination, neglect, and exploitation.
• The risk of violence increases only in specific groups with additional risk factors.

“Schizophrenia is not synonymous with violence. What is dangerous is not the diagnosis itself, but the risk factors that go unrecognized and untreated.”

How Great Is the Risk of Violence in Schizophrenia?

Recent meta-analyses show that the risk of violent behavior among people with schizophrenia is indeed higher than in the general population. However, this increased risk does not apply to all patients. The highest risk is found during the early stage of illness, particularly during First Episode Psychosis (FEP).

Several studies indicate that:

• The risk of violence is approximately 4–6 times higher than in the general population.
• The highest risk occurs during the first psychotic episode.
• With adequate treatment, the risk usually decreases significantly.

Why Can Violence Occur?

Violent behavior in schizophrenia is multifactorial.

1. Persecutory Delusions

Patients may believe that they are:

• Being followed
• Being monitored
• Being poisoned
• About to be killed
• Being targeted by someone intending harm

Because they feel threatened, patients may act aggressively as a form of self-defense.

Example:

“I hit him first because I was convinced he was going to kill me.”

This is one of the most commonly identified clinical factors.

2. Command Hallucinations

Patients hear voices instructing them to:

• Attack others
• Set fire to a house
• Harm themselves
• Injure other people

Not all patients follow these commands, but the risk increases when:

• The patient strongly believes the voices.
• The patient has poor insight.
• The patient is not receiving treatment.

3. Substance Abuse

This is the most consistently identified risk factor across studies.

Particularly:

• Alcohol
• Cannabis
• Methamphetamine
• Multiple substance use

Several studies suggest that substance abuse contributes more to violent behavior than schizophrenia itself.

“In many cases, what makes a patient dangerous is not schizophrenia, but alcohol and drug use.”

4. Medication Non-Adherence

The risk increases when patients:

• Stop medication on their own
• Fail to attend follow-up appointments
• Refuse treatment

Consequences include:

• Relapse of psychotic symptoms
• Worsening delusions and hallucinations
• Reduced impulse control

5. Impulsivity and Poor Self-Control

Some patients experience:

• Difficulty regulating emotions
• Increased irritability
• Frequent anger outbursts

Impulsivity has been shown to be an important predictor of aggressive behavior in early psychosis.

6. Lack of Insight

Patients may not recognize that they are ill.

As a result, they may:

• Refuse medication
• Refuse treatment
• Reject family support

Poor insight is associated with an increased risk of aggressive behavior.

Risk Factors That Require Attention

High-Risk Factors

• Previous history of violence
• Criminal history
• Alcohol or drug abuse
• Severe persecutory delusions
• Command hallucinations
• Medication non-adherence
• High impulsivity
• Poor insight
• Treatment discontinuation
• First Episode Psychosis (FEP)

Early Warning Signs of Violent Behavior

Families, nurses, and healthcare professionals should recognize the following stages:

Stage 1: Mild Agitation

• Restlessness
• Pacing
• Inability to sit still
• Intense staring

Stage 2: Escalation

• Loud speech
• Irritability
• Clenched fists
• Kicking objects

Stage 3: Threats

• Verbal threats
• Swearing
• Pointing aggressively

Stage 4: Physical Violence

• Hitting
• Kicking
• Choking
• Property destruction

Protective Factors

Research has identified several factors that reduce the risk of violence.

1. Medication Adherence

The strongest protective factor.

2. Family Support

Families who:

• Accept the patient
• Provide support
• Encourage medication adherence

have been shown to improve patient outcomes.

3. Psychosocial Rehabilitation

Including:

• Social skills training
• Occupational therapy
• Vocational training
• Community support

4. Psychotherapy

Particularly:

• Cognitive Behavioral Therapy for Psychosis (CBTp)
• Assertiveness Training
• Anger Management

These interventions have been shown to reduce aggression.

5. Freedom from Alcohol and Drugs

An extremely important protective factor.

Principles of Managing Violent Behavior

When Risk Is Low

• Use de-escalation techniques
• Speak calmly
• Avoid arguing with delusions
• Maintain a safe distance
• Offer choices

Example:

Less helpful:

“You are wrong. Nobody is trying to kill you.”

More helpful:

“I understand that you feel afraid. Let’s sit down and talk.”

When Risk Is Moderate

• Reduce environmental stimulation
• Move the patient to a calmer setting
• Involve family members
• Assess medication adherence

When Risk Is High

• Prioritize safety
• Contact mental health professionals
• Consider hospitalization
• Provide pharmacological interventions when indicated

Important Message for Families

Do not only ask:

“Does he or she have schizophrenia?”

Also ask:

• Is the person currently relapsing?
• Is the person taking medication regularly?
• Is there alcohol or drug use?
• Are there persecutory delusions or command hallucinations?

These are the factors that most strongly determine the risk of violence.

Conclusion

• The majority of people with schizophrenia are not violent.
• The risk of violence increases primarily in the presence of severe persecutory delusions, command hallucinations, substance abuse, medication non-adherence, a history of violence, high impulsivity, and poor insight.

Regular treatment, family support, psychosocial rehabilitation, and freedom from substance abuse are the key elements in preventing violent behavior among people with schizophrenia.

What should concern us is not people with schizophrenia, but schizophrenia that remains untreated. With appropriate treatment, recovery is possible. Stigma, however, only worsens the situation.

References:

1. Lagerberg TV, Whiting D, Lichtenstein P, Fazel S. Systematic review of risk factors for violence in psychosis: 10-year update. Br J Psychiatry. 2025;226(4):e75. doi:10.1192/bjp.2025.15. Cambridge University Press & Assessment
2. Youn S, Large M, Nielssen O, Cotton SM, Killackey E, Allott K. Rates of violence during first-episode psychosis (FEP): a systematic review and meta-analysis. Schizophr Bull. 2024;50(4):757-769. doi:10.1093/schbul/sbae026. 
3. Youn S, Large M, Nielssen O, Cotton SM, Killackey E, Allott K. Risk factors of violence during first-episode psychosis: a systematic review. Trauma Violence Abuse. 2026;27(1):1-18. doi:10.1177/15248380241309297.
4. Whiting D, Fazel S. Violence in schizophrenia: triangulating the evidence on causes and prevention. World Psychiatry. 2024;23(2):233-245. doi:10.1002/wps.21171. 
5. VanDercar AH, Resnick PJ. Violence risk factors in psychiatric populations. Focus (Am Psychiatr Publ). 2026;24(1):2-9. doi:10.1176/appi.focus.20250028.