Psychiatric Patients’ Assaults: A Worldwide Perspective, 2017-22

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Life is not fair in many circumstances. The serious mental illness of schizophrenia is one of those circumstances. No one likes being sick but the reality of schizophrenia is truly burdensome. Schizophrenia is a biologically rooted disease for which there are helpful treatments but no cure. One is born with this illness but it does not manifest until adolescence or early adulthood. The first time your brain fails to function normally, you realize that something strange is happening and it is frightening. It can actually traumatize the person. One’s thinking becomes unclear and disorganized. The person may begin hearing voices of people that are not present. These voices may direct the person to harm others. The individual may experience intense feelings of fear, anger, paranoia, excitement, and/or general confusion.

The individual’s life changes. The person may not go to college, get married, have children, or develop a career. Interactions with family and friends may be altered, especially if the individual fears these others are out to harm him or her. The frightened person may strike out and assault family members or friends. The person finds it hard to believe that he or she is doing this. He or she does not know why he or she did this. The person experiences shame and withdraws. For the person with schizophrenia, an immense, long loneliness begins. Worse, the intermittent assaulting does not stop. The medications do not stop all anger. As noted earlier, the person hits family members, or friends, but also strangers, the police, and the very healthcare providers trying to help. Many of these patients go on use alcohol and street-drugs to self-medicate this pain. The person learns that these outbursts may be at least in part biologically based beyond the person’s own abilities to control them. It may also be due to not following treatment requirements, hearing the voices, being restrained by staff, or being angry because your hospital weekend-pass with family was canceled. The person wants others to know that he or she often cannot control this urge to hit. That they do not want to strike out at others. That they are not mean. That they know this is not the way to live.

Certainly, not all persons with schizophrenia are assaultive. There are other serious mental illnesses, like bipolar disorder, wherein the patients also strike out. However, as I have noted in two prior blogs (January 16, 2015, and January 30, 2018) in the published literature from 2000-2017, patients with schizophrenia and co-occurring substance abuse have been the most frequent assailants toward other patients and healthcare staff, especially nursing personnel. For healthcare staff, it is a worldwide occupational hazard. In recent years, there have been advances in medicines, new psychosocial rehabilitation approaches, and, since many of these assaultive patients have themselves been victims of violence, trauma-informed care services. Have these new initiatives reduced patient violence? This present blog continues the earlier reviews in this series and examines the characteristics of patient assaults for the next five-year period, 2017-22. (1)

During these years, there were 20 studies worldwide of patients who were assaultive. There were 9,103 assaults from among 40,247 potentially assaultive patients. Most of the assaults were physical (68%) but there were other types of assaults as well (32%). Included here would be oral/verbal threats, racially derogatory statements, and damage to property. There were 22,329 male (55%) and 17,918 female (45%) patients. In the 18 studies reporting age of assailant, the average was 36.3 years. The most frequent primary diagnoses were schizophrenia (65%), affective disorders (60%), personality disorders (20%), and other diagnoses (20%). Of these assailants, 95% had histories of violence toward others, 25% had been victims of violence, and 85% had been diagnosed with histories of substance abuse. Again, nurses were the most common victims.

The results of this current five-year review are the same that they have been since 1990. Patients with schizophrenia and substance-use disorder are again most likely to be the assailants, with nursing personnel being the most frequent victims. The studies in this review did not indicate whether their facilities had utilized the newer advances in diagnosis and treatment, so we are not able to assess whether these new interventions would help reduce patient assaults.

The emergence of this consistent profile of the most likely assailant has spurred research into substance abuse, schizophrenia, and schizophrenia/substance abuse to better understand their etiologies. To date, the substance-abuse research has identified brain impairments in attention, impulse control, and emotional irritability. The schizophrenia research has also noted a variety of higher forms of cortical dysfunction and neurotransmitter issues, including dendritic-structural plasticity. (2) These important studies continue.

A second finding to emerge from this review is the importance of assessing any untreated psychological trauma/posttraumatic stress disorder (PTSD). One possible outcome of violence is later violence by the original victims. (3,4) This can include patient victims of violence who lash out at other patients or staff at some point. Psychiatry needs to pay more attention to possible PTSD in its seriously mentally ill patients. Treatment plans need to consider antipsychotic medications, substance-use interventions, psychosocial-rehabilitations approaches, and counseling for untreated PTSD, if indicated. Continuing research into these areas should result in better diagnoses and enhanced, efficacious treatment interventions.


1. Flannery, R. B. Jr., Flannery, G. J. “Characteristics of International Assaultive Psychiatric Patients: Review of Published Findings, 2017-2022.” Psychiatric Quarterly, 2023, 94: 559-68.

2. Forrest, M. P., Parnell, E., Penzes, P. “Dendritic Structural Plasticity and Neuropsychiatric Disease.” Nature Reviews Neuroscience, 2018, 17: 475-86.

3. Flannery, R. B. Jr. Posttraumatic Stress Disorder: The Victim’s Guide to Healing and Recovery. Second edition. Riverdale, NY: American Mental Health Fdn., 2012.

4. Flannery, R. B. Jr. Preventing Youth Violence Before It Begins. Riverdale, NY: American Mental Health Fdn., 2022.

Dr. Raymond B. Flannery Jr., Ph.D. FACLP, is an internationally recognized scholar and lecturer on the topics of violence, victimization, and stress management. Dr. Flannery is available for lectures and workshops for all types of groups and may be reached at The American Mental Health Foundation: elomke[at]

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