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The second contention is that the propensity to violence is linked not just to severity of personality disorder, but to overall level or severity of psychiatric morbidity. Details of such a typology, and its empirical support, are detailed under Heterogeneity of Violence below. The central argument in this paper is first, that consideration of the motivational heterogeneity of violence requires a typology of violence that can empirically account for the varieties of violence encountered in those deemed mentally disordered. This general psychopathology factor was suggested to represent overall severity of psychopathology. In this study, psychiatric disorders were initially explained by three higher-order factors, Internalising, Externalising and Thought Disorder, but were explained even better by one general psychopathology factor (p), with thought disorder symptoms at its pinnacle. In other words, which condition has causal primacy in determining the links between mental disorder and violent behaviour? Below it will be suggested that to understand the link between PD and violence, one needs to move beyond traditional diagnostic categories to a consideration of trans-diagnostic variables such those identified in a New Zealand birth cohort followed prospectively into adulthood. They ask: “Does one give precedence to a blow to the individual’s self-esteem (narcissism), or to a suspiciousness of the motives of others (paranoid traits), his or her substance abuse or the activation of PTSD symptoms in explaining his or her violent behaviour?” (p.25). In reviewing the functional link between PD and violence, Duggan and Howard gave the example of a patient who meets criteria for both narcissistic and paranoid PDs, has multiple (DSM-IV) Axis I conditions including substance use and post-traumatic stress disorder (PTSD) and is prone to violence. ![]() Moreover, violence has been found to be linked to a range of mental disorders in addition to PD, including schizophrenia (OR 7.4) ), bipolar disorder (OR 5.8) ), and depression (OR 3.0). Given the overwhelming co-occurrence of multiple disorders, particularly in forensic psychiatric patients, it becomes extremely difficult to specify what is responsible for the link with violence. Third, any attempt to infer a causal relationship between PD and violence is fraught with difficulties. Second, confusion exists over how best to classify violence, given its heterogeneity (see Heterogeneity of violence section below). First, confusion exists over how PDs should best be conceptualised and assessed, confusion that is exacerbated by the high degree of comorbidity that exists between different PDs, making their boundaries fuzzy (see Different perspectives on personality disorder: types or traits? section below). ![]() While the literature clearly indicates that PDs are linked to violence, an answer to the question “What is the link?” is obscured by several factors. This review aims to cast light on the relationship between personality disorders (PDs) and violence, in particular on the possible mechanisms that mediate the relationship. This view is consistent with the abandonment of personality disorder categories in the forthcoming eleventh edition of the International Classification of Diseases (ICD-11), where severity of personality disorder is defined in terms of the degree of harm to self and others. Evidence is reviewed suggesting that emotion dysregulation/impulsiveness, psychopathy, and delusional ideation conjointly contribute to the increased risk of violence shown by people with PD, and do so by contributing to a broad severity dimension of personality dysfunction. Here, a perspective on PD and violence is offered that views the relationship between them through the lenses of the Five Factor Model of personality and a quadripartite typology of violence. In particular, it remains unclear whether there is a causal relationship between PDs and violence, and what the psychological mechanisms might be that mediate such a relationship. Despite a well-documented association between personality disorders (PDs) and violence, the relationship between them is complicated by the high comorbidity of mental disorders, the heterogeneity of violence (particularly in regard to its motivation), and differing views regarding the way PDs are conceptualised and measured.
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