However, a literature search on measurement of patients’ structured self-reported assessment of future risk of violent, suicidal or self mutilating behaviour failed to disclose any published empirical research. The risk of self-harm and violent behaviour by psychiatric patients is an important clinical research topic. Therefore it is recommended to actively treat these comorbid conditions. This spontaneous decrease can be delayed by comorbidity such as other personality disorder, substance use disorder, psychosis and attention deficit disorders. Antisocial personality traits diminish over time. But, bensodiazepines seem to increase the risk of violent behaviour among patients with personality disorders. Evidence for pharmacological treatment of repetitive aggressive behaviour is weak. Cognitive behaviour treatment focused on violent behaviour has some effect in criminal populations, but the antisocial personality traits are resistant to treatment.
During diagnostic assessment of personality disorders, violence risk screening is recommended. Especially antisocial personality disorder and antisocial personality traits are linked to violence. Personality disorders, violence and criminal behaviour The importance of personality disorders for violent and criminal behaviour is illustrated by their high prevalence in prison populations. From an ethical viewpoint, prediction of violence and restraining psychiatric patients into more custodial care is not only useless for society but bears extremely high costs for those many patients falsely predicted to become violent. If the consequences for the patients who are positively predicted to be violent include some kind of extended incarceration the question of prediction becomes a moral issue since those interventions made would be not for the benefit of the patient but rather a precaution for society. Given the same predictive accuracy and Trieman et al's annual rate of violent patients discharged of 0.4%,2 the ratio of correct to false positive predictions of assault would be about 1 in 30. If we assume that the psychiatric profession succeeded in predicting with 90% sensitivity and 90% specificity (a very high accuracy) our Swedish sample showed that for every correct prediction of violence after discharge from an institution, 11 patients would be falsely predicted to commit serious violence. The ability to make a correct prediction depends not only on the accuracy of the classification of future offenders (sensitivity) but also on the correct identification of all future non-offenders (specificity). When discussing the possibility of preventing these serious acts of violence the possibility of predicting statistically rare events must be taken into account.4 Beck showed in 1985 why the psychiatric profession fails in predicting violence after discharge from an institution.5 The reason is not lack of knowledge of risk factors important for future violence but rather a statistical impossibility. Trieman et al estimated that 2% of their population of discharged patients committed serious violent acts within the five years after discharge (that is, 0.4% a year).2 In 1987 Wistedt and I studied the possibility of using a prediction of the likelihood of violence, assessed at discharge from involuntary psychiatric care, as a means of reducing rates of violence in Swedish society.3 Our calculations showed that, at most, 100 serious assaults a year in Sweden were committed by patients who had been discharged during the previous year from involuntary psychiatric treatment-that is, less than 1% of all patients discharged. This is sometimes held as a reason for more custodial, institutionalised treatment. Editor-The debate about the dangerousness of discharged psychiatric patients is interesting.1,2 In public debate (and sometimes also among professionals) it is often claimed that discharged patients are responsible for a substantial number of violent assaults in society.
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