V i o l e n c e a n d Su i c i d e R i s k

A s s e s s m e n t in Yo u t h w i t h
P s y c h o t i c D i s o rd e r s
Practical Considerations for Community
Clinicians

Charles L. Scott, MD*, Anne B. McBride, MD

KEYWORDS
 Violence  Suicide  Risk  Psychosis  Early psychosis  Adolescent  Teenager

KEY POINTS
 Although most youth with psychosis do not exhibit violence, psychosis is a significant in-
dependent risk factor for violent and suicidal behaviors and warrants special
consideration.
 Specific psychotic symptoms (eg, command hallucinations, delusions, paranoia) can be
identified and should be considered when assessing violence and suicide risk.
 Youth with psychotic disorders exhibit higher levels of suicidal behaviors than nonpsy-
chotic peers, and earlier onset of psychosis is associated with increased suicidal thinking
and behavior.

INTRODUCTION

Although the majority of youth with psychotic symptoms do not experience

an increased risk of violence, psychosis is a significant risk factor for violence
and suicidal behavior in children and adolescents. Mental health providers play
an important role in the identification of psychotic symptoms in youth because early
treatment improves long-term outcome and can lower the risk of harm to self or
others. This article provides a practical overview for clinicians and forensic evalua-
tors on risk factors for future violence and suicidal behavior uniquely associated
with psychotic symptoms.

Disclosure Statement: The authors have nothing to disclose.

Department of Psychiatry and Behavioral Sciences, University of California, Davis Medical
Center, 2230 Stockton Boulevard, Sacramento, CA 95817, USA
* Corresponding author.
E-mail address: clscott@ucdavis.edu

Child Adolesc Psychiatric Clin N Am 29 (2020) 43–55

https://doi.org/10.1016/j.chc.2019.08.015 childpsych.theclinics.com
1056-4993/20/ª 2019 Elsevier Inc. All rights reserved.
44 Scott & McBride

Abbreviations
FEP first episode psychosis
SAVRY structured assessment of violence risk in youth
TCO threat/control override

PSYCHOSIS AND VIOLENCE RISK ASSESSMENT

Case Vignette
Jason is a 16-year-old boy referred to your outpatient clinic by his school counselor.
He was suspended from school because he brought a hunting knife on campus, which
was discovered when it accidently fell out of his backpack during gym class. In sev-
enth grade, Jason associated with peers who were involved in using alcohol and
drugs. He was later caught by his science teacher using marijuana in the school bath-
room. Although Jason was adjudicated delinquent for vandalism and shoplifting when
he was in the eighth grade, he successfully completed his supervisory aftercare
requirements. He has no other prior mental health or treatment history.
Jason’s mother, a single parent owing to his father’s incarceration, reports she is
concerned that Jason may have relapsed on marijuana despite his denials and started
to “act strange.” She describes that he no longer socializes with anyone, isolates in his
room after school, spends “hours” on the computer, and rarely showers.
During your evaluation, Jason seems to be extremely guarded. When asked, he tells
you that he hears “his coach’s voice” calling him “a fag” and saying that “other stu-
dents hate you and want to kill you.” He describes that this “voice” makes him angry
and he feels sad that his peers wish him harm. He reports that the coach’s voice is
“strong” and “may be telling me I have to kill or be killed.” When asked, he states
that he brought the hunting knife to school to “protect myself.” His urine drug screen
is negative for all tested substances, including marijuana. Jason refuses all treatment
and wants to go home so he can “be safe in my room.” His mother relates that after he
shuts his bedroom door, he barricades himself in his room. She adds that she found
more than 20 knives hidden underneath his bed.
You are concerned that Jason may be developing a psychotic illness. How would
you assess the relationship of a possible psychotic illness to his risk of future violence
or aggression?

Psychosis and Future Violence Risk Overview

Although most individuals with a psychotic disorder are not violent, psychotic symp-
toms are important to explore when assessing a youth’s future violence risk.1
Large and Nielssen2 conducted a systematic review of violence occurring in first
episode psychosis (FEP). Serious violence was defined as an assault that caused
an injury, any use of a weapon, or any sexual assault. Severe violence was defined
as violence that resulted in physical harm to the victim or required hospital treatment.
These authors found that 34.5% of patients experiencing their first-episode of psycho-
sis exhibited some form of violent behavior before treatment and 16.6% had exhibited
serious violence. Box 1 summarizes those risk factors that were associated with
violence of any severity in this population.
The primary risk factors associated with serious violence were a history of prior
violence or convictions, the duration of untreated psychosis, and total symptom
scores.
Risk factors for future violence have also been identified in those individuals at risk
to develop psychosis or who have some symptoms of psychosis, but do not yet meet
diagnostic criteria for a psychotic disorder. For example, Hutton and colleagues3
 Violence and Suicide Risk Assessment 45

Box 1
Risk factors associated with any form of violence in individuals with FEP

 Involuntary treatment
 History of prior violence or any criminal convictions
 Hostile affect
 Symptoms of mania
 Illicit substance use
 Lower levels of education
 Younger age
 Male sex
 Duration of untreated psychosis

Data from Large MM, Nielssen O. Violence in first-episode psychosis: a systematic review and
meta-analysis. Schizophr Res 2011;125(2–3):209–220.

looked specifically at violence risk factors present in 34 people at ultra-high risk of

developing psychosis and found the following risk factors present: convictions for
violence, current thoughts or plans, violent past, concerns expressed by others
regarding violence, jealousy, suspiciousness, impulsiveness, persecutory beliefs,
anger, and irritability.

Specific Psychotic Symptoms and Violence

Because most individuals diagnosed with a psychotic disorder are not violent, are
there particular psychotic symptoms that are noted to increase a person’s risk
to act aggressively? Most of the research evaluating the relationship of specific psy-
chotic symptoms to violence derives from the adult literature1 and should be consid-
ered when evaluating children and adolescents. Paranoia, delusions, and auditory
hallucinations are 3 of the most common psychotic symptoms that have shown a
unique relationship to future violence risk.

Paranoia and future violence

In the MacArthur Study of Mental Disorder and Violence, adults experiencing nondelu-
sional suspiciousness, such as misperceiving others’ behavior as indicating hostile
intent, were at an increased risk of violence when followed prospectively after psychi-
atric hospital release.4 In their meta-analysis from 7 UK general population surveys
(including >23,000 adults), Coid5 found that paranoid ideation was associated with
violence, severity, and frequency independent of other psychotic-like symptoms.
Paranoid individuals also described more incidents involving the police. These asso-
ciations were independent of comorbid substance abuse or other psychiatric
comorbidity.

Delusions and violence

Threat/control override (TCO) type delusions are characterized by the presence of be-
liefs that one is being threatened (eg, being followed or poisoned) or that one is losing
control to an external source (eg, one’s mind is dominated by forces beyond the per-
son’s control).6 Swanson and colleagues,7 using data from the Epidemiologic Catch-
ment Area surveys, found that people who reported TCO symptoms were about twice
as likely to engage in assaultive behavior as those with other psychotic symptoms. In
46 Scott & McBride

contrast, results from the MacArthur Study of Mental Disorder and Violence5 showed
that the presence of delusions did not predict higher rates of violence among recently
discharged psychiatric patients. In particular, a relationship between the presence of
TCO delusions and violent behavior was not found. Similarly, in their study of 224
detained male adolescents (ages 12–17), Colins and colleagues8 found detained youth
with paranoid delusions or TCO delusions did not have a higher rate of violent future
crimes when compared with detained youth without TCO delusions.
Nederlof and associates9 conducted a cross-sectional multicenter study to further
examine whether the experience of TCO symptoms is related to aggressive behavior.
The investigators determined that TCO symptoms were a significant correlate of
aggression in their study sample. When the 2 domains of TCO symptoms were eval-
uated separately, only threat symptoms made a significant contribution to aggressive
behavior. In their attempt to reconcile conflicting findings from earlier research
regarding the relationship of TCO symptoms to aggressive behavior, the authors sug-
gested that various methods of measuring TCO symptoms may underlie the seemingly
contradictory findings among various studies.10 These authors findings, however,
suggest that inquiring as to specific threat delusions remain an important aspect of
evaluating psychotic symptoms and future dangerousness.
In addition to research examining the potential relationship of delusional content to
aggression, Appelbaum and coworkers10 used the MacArthur-Maudsley Delusions
Assessment Schedule to examine the contribution of non–content-related delusional
material to violence. The 7 dimensions covered by the MacArthur-Maudsley Delusions
Assessment Schedule (with brief definitions) are:
1. Conviction: The degree of certainty about the delusional belief.
2. Negative affect: Whether the delusional belief makes the individual unhappy, fright-
ened, anxious, or angry.
3. Action: The extent to which the individual’s actions are motivated by the delusional
belief.
4. Inaction: Whether the individual has refrained from any action as a result of the
delusional belief.
5. Preoccupation: The extent to which the individual indicates that their thoughts
focus exclusively on the delusion.
6. Pervasiveness: The degree to which the delusional belief penetrates all aspects of
the individual’s experiences.
7. Fluidity: The degree to which the delusional belief changed frequently during the
interview.
These authors found that individuals with persecutory delusions had significantly
higher scores on the dimensions of “action” and “negative affect,” indicating that
persons with persecutory delusions may be more likely to react in response to
the dysphoric aspects of their symptoms.11 Other research has demonstrated
that individuals suffering from persecutory delusions and negative affect are
more likely to act on their delusions11 and to act violently.12 When evaluating a pa-
tient with persecutory delusions, the clinician should also inquire if the patient has
used safety actions. Safety actions are specific behaviors (such as avoidance of a
perceived persecutor or an escape from a fearful situation) that the individual has
used with the intention of minimizing a misperceived threat. In a study of 100
patients with current persecutory delusions, more than 95% reported using safety
behaviors in the past month.13 Box 2 provides sample questions to further investi-
gate potential delusions and risk of further violence based on the research
summarized elsewhere in this article.
 Violence and Suicide Risk Assessment 47

Box 2
Sample questions to evaluate possible delusions associated with violence

 Do you worry that any one wishes you harm?

 What ways do you believe that others are attempting to harm you?
 Do you ever worry you are being spied on? Is it possible that you are being followed?
 Do you believe others are plotting against you?
 Have you had the experience that others can insert thought in your head?
 Have you had any concerns that you are under the external control of another power?
 How certain are you that this is happening?
 Is there anything that could convince you that this was not true?
 How does this belief make you feel (eg, unhappy, frightened, anxious, or angry)?
 Have you thought about any actions to take as a result of these beliefs? If so, what?
 Have you taken any actions as a result of your beliefs? If so, what specific actions?
 Have you stopped doing something you would normally have done based on these beliefs?
 How much time do you spend thinking about this?
 In what ways have these beliefs impacted your life?

Command hallucinations and violence

Auditory hallucinations that command the patient to do something are experienced by
approximately one-half of psychiatric patients who experience auditory hallucina-
tions.14 The majority of command hallucinations are nonviolent in nature and patients
are more likely to obey nonviolent instructions than violent commands.15 However, be-
tween 30% and 65% of individuals comply with the command to harm others.14,16
Research establishing specific factors associated with a person acting on harm-
other command hallucinations has been mixed. In a review of 7 controlled studies
examining the relationship between command hallucinations and violence, no study
demonstrated a positive relationship between command hallucinations and violence,
and one found an inverse relationship.17 In contrast, McNiel and associates18 found in
their study of 103 civil psychiatric inpatients that 33% of patients reported having had
command hallucinations to harm others during the prior year and 22% of the patients
reported that they complied with such commands. The authors concluded that
patients in their study who experienced command hallucinations to harm others
were more than twice as likely to be violent than those without such commands.
Four factors have been described as increasing a person’s willingness to comply
with harm-other command hallucinations. First, persons are more likely to act on audi-
tory hallucinations to harm others when they perceive the voice they hear as power-
ful.14,16 Birchwood and Chadwick19 noted that persons who perceive a voice as
powerful experience a subjective loss of control over the voice with associated feel-
ings of powerlessness and helplessness. Evaluators should ask the individual what
he or she believes would be the consequence for failing to obey the voice with
more dire perceived outcomes increasing compliance.20 Second, if the person be-
lieves that following the directive of the command hallucination will benefit them,
they are more likely to comply.14 Third, persons are more likely to follow harmful com-
mand hallucinations when they are associated with a congruent delusion.15 As an
example, an adolescent who hears a voice to kill his mother is more likely to act on
this command if he has the delusional belief that his mother has been invaded by
48 Scott & McBride

an evil alien who is preparing to kill him. Finally, Cheung and colleagues12 noted in their
study of patients with schizophrenia that those whose hallucinations generated nega-
tive emotions (eg, anger, anxiety, and sadness) were more likely to act violently than
those individuals with voices that generated a positive emotion. Box 3 provides sam-
ple questions to further investigate auditory hallucinations and their potential risk of
further violence based on the research summarized elsewhere in this article.

General Violence Risk Assessment in Youth with Psychosis or Psychotic-Like

Symptoms
Clinical risk factors
In addition to understanding risk factors uniquely associated with psychotic symp-
toms and aggression, the clinician should also evaluate nonpsychotic risk factors
for future violence. Bushman and colleagues21 outline personal and environmental
risk factors for youth violence and these are summarized in Box 4.

Structured instruments in assessing youth’s violence risk

In addition to a clinical assessment of violence risk, a variety of structured assess-
ments to evaluate a youth’s risk of future violence have also been developed. Most
of these instruments, however, do not include risk factors specific to psychotic symp-
toms and their relationship to aggression. One of the most well-studied and empiri-
cally supported structured assessments for youth violence is the Structured
Assessment of Violence Risk in Youth (SAVRY).22 The SAVRY is based on the struc-
tured professional judgment model and can be used in youth between ages 12 and
18. The SAVRY has been found to have strong predictive validity for violent recidivism
in juvenile offenders specifically, across gender and ethnicity.23,24 However, because
the SAVRY does not include a rating specific to psychosis, the evaluator should be
aware that use of this instrument may augment their evaluation but cannot substitute
for evaluation of those risks uniquely associated with youth with psychotic symptoms.
Case vignette review
As an evaluator, you note that Jason has numerous risk factors for future violence spe-
cific to his psychotic symptoms. These include general paranoia, a threat delusion that
other students wish to kill him, fear and sadness related to this belief, powerful
auditory command hallucinations that he has acted on by obtaining knives for his pro-
tection, safety behaviors to protect himself (eg, barricading himself in the room and
collecting knives), treatment refusal, and social isolation. He also has numerous

Box 3
Sample questions to evaluate auditory hallucinations associated with risk of future violence

 What are the voices saying?

 Is the voice of someone you know or are familiar with?
 How confident are you that the voices are real?
 Do you believe that the voices are well-meaning?
 What coping strategies do you have to deal with the voices?
 Do you feel you can resist doing what the voices are telling you to do?
 Do you feel the voice is powerful?
 Do you benefit in any way from acting on the voices?
 How do these voices make you feel?
 Violence and Suicide Risk Assessment 49

Box 4
General risk factors for youth violence

Environmental risk factors

 Easy access to guns
 Social exclusion and isolation
 Family and neighborhood difficulties (eg, abuse, poverty, violent neighborhood, parental
aggression)
 Exposure to violent media
 Substance use
 Stressful events
 School characteristics (eg, large class size and high student-to-teacher ratio)
Personal risk factors
 Male sex
 Aggressive behavior in early childhood
 Problems with emotional regulation (eg, poor anger regulation)
 Dark personality traits (eg, narcissism, psychopathy, Machiavellianism, and sadism)
 Obsession with weapons or death

From Bushman BJ, Coyne SM, Anderson CA, et al. Risk factors for youth violence: youth violence
commission, International Society for Research on Aggression (ISRA). Aggress Behav
2018;44(4):331-336; with permission.

general risk factors, independent of psychosis, for potential violence that include a
prior history of juvenile delinquency, marijuana use, antisocial peer group, and family
disruption because his father is incarcerated. Although he has numerous readily iden-
tified risk factors for future violence, the evaluator should attempt to review other
known risk factors as outlined to better estimate the level of his future risk. Jason
should have treatment initiated as soon as possible because early treatment can
make a meaningful impact on lowering his violence risk. For example, in a 10-year pro-
spective follow-up study of individuals with FEP, Langeveld and colleagues25 found
that once treatment was initiated, the prevalence of violence in psychotic individuals
declined gradually to approach base rates of violence in the general population. How-
ever, persistent substance use remained a risk factor for violence even after treatment
initiation, indicating the need for Jason to have ongoing substance use monitoring and
treatment independent of treatment for his psychotic symptoms.

PSYCHOSIS AND SUICIDE RISK ASSESSMENT

Case Vignette
Terry is a 13-year-old girl who has been diagnosed with depression and is being
treated in your outpatient clinic. She was initially brought to you when her mother
found her cutting on her wrists and thighs in her bedroom when she was 12 years
old. She has become increasingly isolated and completely alienated from her friends
owing to her odd appearance. A former honor student, she is now failing all her clas-
ses. Her teachers describe that she stares ahead without moving for the entire hour of
every class and, when questioned, her answers seem unrelated to the classroom ma-
terial presented. She is admitted to the inpatient psychiatric unit to evaluate for a
potential psychotic depressive disorder.
During her hospitalization, she confides to her therapist that she started having a
visual hallucination at age 8 of her grandmother after she died from a heart attack.
She reports a belief that her grandmother died because she did not complete the
meal that she had cooked for her granddaughter on the night before her death. She
describes extreme guilt and believes that she must be punished for “killing Nana.”
50 Scott & McBride

She states that she hears her voice telling her to “join Nana in heaven” so that they
both can be “at peace.” She acknowledges that during the week after her grand-
mother’s death, she attempted to hang herself in the room with her belt, but the closet
rod holding the belt noose broke. When asked, she states that she first heard her
grandmother’s voice at age 9 and she began hearing her voice again about 3 months
before her hospital admission.
You are concerned about Terry’s risk for suicide based on her apparently psychotic
presentation and wonder if antipsychotic medications should be initiated. What spe-
cific factors should you consider regarding her psychotic symptoms that may increase
her risk of suicide?

Suicide in Youth with Psychotic Symptoms

Psychosis represents a significant risk factor for suicidal behaviors (ie, ideation, at-
tempts, or completed suicide) in children and adolescents. Youth with psychotic dis-
orders exhibit significantly higher levels of suicidal behaviors than their typically
developing peers.26 In addition, research indicates that individuals with onset of psy-
chosis before entering adulthood report suicidal ideation and attempts at increased
rates compared with individuals whose psychosis begins in adulthood.27 In their pro-
spective cohort study of 1112 adolescents (aged 13–16 years), Kelleher and
colleagues28 found that those youth who reported psychotic symptoms at baseline
had a nearly 70-fold increased odds of acute suicide attempts compared with youth
without psychotic symptoms.
In their study of clinical high-risk and psychotic disorder children ages 7 to 13 years,
Sinclair-McBride and colleagues29 likewise found an elevated risk of suicidal thoughts
and behaviors, although many of these young children had never expressed their sui-
cidal plant or intent. In addition, the severity of the suicidal thoughts and behaviors
was significantly correlated with reported social anhedonia (a lack of close friends,
preferring to spend time alone) and odd behavior or appearance in this young
subpopulation.
Various researchers have attempted to examine additional factors that may pose a
particular risk for suicidal behaviors in youth with psychotic symptoms. In their review
of 110 youth (ages 9–17 years) with positive psychotic symptoms of less than 6 months
duration, Sanchez-Gistau and colleagues30 noted that participants were more likely to
be classified as a high suicide risk if they had attempted suicide before the current
psychotic episode, had severe depressive symptoms, and were taking antidepres-
sants. Neither the subtype of psychosis (ie, affective or nonaffective psychosis) or
positive versus negative Positive and Negative Syndrome Scale scores differentiated
attempters from nonattempters in this sample. Bjorkenstam and colleagues31
reviewed cases of more than 2800 individuals (ages 15–30 years) diagnosed with their
FEP and discharged from a psychiatric facility. The 2 strongest risk factors in this sam-
ple for a suicide after a FEP hospital discharge were a history of self-harm or a convic-
tion for a violent crime.
In their systematic review and meta-analysis of controlled studies, Challis and col-
leagues32 examined factors associated with suicide attempts or deliberate self-injury
(referred to as deliberate self-harm), in individuals before and after treatment for FEP.
These researchers noted that substance abuse and depressed mood were associated
with deliberate self-harm, but positive psychotic symptoms were not. In addition, in-
dividuals with a longer duration of untreated psychosis before FEP treatment had
higher rates of deliberate self-harm before and after treatment. Coentre and col-
leagues33 noted that, in those with FEP, suicidal behavior was particularly high in
the first years after FEP. In this study, suicidal behavior was associated with a previous
 Violence and Suicide Risk Assessment 51

suicide attempt, sexual abuse, comorbid polysubstance use, lower baseline func-
tioning, a longer time in treatment, recent negative events, older patients, a longer
duration of untreated psychosis, higher positive and negative psychotic symptoms,
family history of severe mental disorder, substance use, depressive symptoms, and
cannabis use.

Specific Psychotic Symptoms and Suicidality in Youth

Hallucinations and suicide risk
As with research studying the relationship of specific psychotic symptoms to violence,
most research examining the relationship of specific psychotic symptoms to suicide
and/or suicidal behavior derives from the adult literature. In their study of 148 adult in-
patients with a psychotic spectrum disorder, Wong and colleagues34 noted that the
presence of command auditory hallucinations was significantly associated with active
suicidal ideation and a greater percentage of patients with command auditory halluci-
nations endorsed a recent suicide attempt. Individuals in this study who experienced
noncommand auditory hallucinations did not demonstrate an increase in suicide idea-
tion. In contrast, Harkavy-Friedman and colleagues35 found that, in 100 individuals
diagnosed with schizophrenia or schizoaffective disorder and experiencing command
hallucinations, only those who had a past suicide attempt were at an increased risk for
a future suicide attempt.
In one of the few studies examining the presence of auditory hallucinations in youth,
Connell and colleagues36 noted that most adolescents who experience hallucinations
do not have an increased rate of mental disorder as an adult. However, those youth
who experience hallucinations at more than 1 point in time (between ages 14 and
21 in this study) had an increased risk of developing a psychotic illness and an
increased risk of suicidal behavior. Therefore, evaluators assessing hallucinations
should evaluate whether the youth has experienced hallucinations at a prior point in
time to help assess suicide risk.
Younger children’s risk of suicide related to hallucinations may be unique when
compared with adolescents. For example, Livingston and Bracha37 found that psy-
chotic children did not have an increased risk owing to auditory hallucinations;
instead, their risk of suicide was elevated if they experienced visual hallucinations of
dead relatives.
Delusions and suicide risk
Various studies have substantiated that delusions represent an independent risk factor
for suicidal behaviors in certain populations. For example, individuals with psychotic
(delusional) depression have a 2-fold higher risk of committing a suicidal attempt than
patient with nonpsychotic depression.38 Guilt delusions in youth may increase the risk
of suicidal ideation. For example, in their study of children and adolescents diagnosed
with bipolar 1 disorder (aged 6–15 years), Duffy and colleagues39 noted that the delu-
sions of guilt were uniquely associated with increased odds of suicidal ideation.
Delusional-like experiences in the general population are common. Saha and col-
leagues40 evaluated the relationship of delusional-like experiences to suicidal idea-
tion, suicide plan, and suicide attempts in 8841 Australian adults drawn from a
national survey of mental health. In this study, 3 questions (with subsequent probes
for affirmative responses) were asked to screen for delusional-like experiences:
1. Have you ever felt that your thoughts were being directly interfered with or
controlled by another person?
2. Have you ever had a feeling that people were too interested in you?
3. Do you ever have any special powers that most people lack?
52 Scott & McBride

Box 5
Risk factors for suicide in youth with psychosis

 Severe depression
 Prior suicide attempts
 History of self-harm
 Violent crime convictions
 Substance abuse (particularly cannabis)
 Longer duration of untreated psychosis
 Command auditory hallucinations to kill combined with past suicide attempt
 Hallucinations at more than 1 point in time
 Visual hallucinations of dead relatives (in younger children)
 Delusions of guilt (particularly in bipolar 1 disorder)

These researchers found that participants endorsing one or more delusional-like

experiences were approximately 2 to four times as likely to report suicidal ideation,
plans, or attempts.
Box 5 summarizes key factors that evaluators should investigate when assessing a
youth with psychotic symptoms and their risk for future violence.

General Factors Associated with Suicide Risk

In addition to evaluating for psychotic symptoms that may specifically increase a
youth’s risk for suicidal behavior, the clinical should also be familiar with general

Box 6
Key risk factors for suicide in youth

 Mental disorders with the most common being

 Affective disorder
 Substance abuse
 Personality disorder
 Previous suicide attempts
 Specific personality characteristics
 Impulsivity
 Poorer problem-solving skills
 Family structure and process risk factors
 History of mental disorder in a first-degree relative (particularly depression and substance
abuse)
 Family history of suicide
 Violence in the home
 Specific life events traits
 Interpersonal losses
 School problems and academic stress
 Acute conflicts with parental figures
 Exposure to inspiring models who have committed suicide
 Availability of means to commit suicide

Data from Bilsen J. Suicide and youth: risk factors. Front Psychiatry 2018;9:540.
 Violence and Suicide Risk Assessment 53

risk factors for suicide in children and adolescents, independent of psychosis. Bilsen41
reviewed the most important risk factors for suicide in late school age-children and ad-
olescents based on his review of the scientific literature. Box 6 summarizes these key
factors that are important in assessing general suicide risk factors in this population.

Case Vignette Review

Terry has numerous specific factors related to her psychotic symptoms that increase
her suicide risk. These include her comorbid depression, history of self-harm, auditory
hallucinations at separate points in her life, visual hallucinations of her dead grand-
mother, delusions of guilt, social anhedonia, odd appearance, long period of untreated
psychosis, and command hallucinations combined with a prior suicide attempt. Terry
is at high risk to attempt suicide and a thorough review of other general risk factors
described in Box 6 is warranted. In addition, the treatment providers should carefully
consider the initiation of appropriate pharmacotherapy to manage her psychotic
depression as soon as possible.

SUMMARY

Although most youth with psychosis are not a danger to self or others, the presence of
psychotic symptoms carries unique risk for aggression and suicidal behaviors. Key
points regarding this relationship are as follows:
 Although most youth with psychosis do not exhibit violence, psychosis is a sig-
nificant independent risk factor for violent and suicidal behaviors and warrants
special consideration.
 Specific psychotic symptoms (eg, command hallucinations, delusions, paranoia)
can be identified and should be considered when assessing violence and suicide
risk.
 Youth with psychotic disorders exhibit higher levels of suicidal behaviors than
nonpsychotic peers, and earlier onset of psychosis is associated with increased
suicidal thinking and behavior.

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