Validity of PAI Suicide and Violence Indices in Outpatient Psychiatric Sample

The Suicide (SPI) and Violence Potential Indices (VPI)
from the Personality Assessment Inventory: A Preliminary
Exploration of Validity in an Outpatient Psychiatric Sample
Samuel Justin Sinclair & Iruma Bello & Maren Nyer &
Jenelle Slavin-Mulford & Michelle B. Stein &
Megan Renna & Daniel Antonius & Mark A. Blais
Published online: 9 February 2012
# Springer Science+Business Media, LLC 2012
Abstract Assessing risk of harm to self and others is an
important component of psychological assessment, although
methods for risk assessment vary considerably. The Person-
ality Assessment Inventory (PAI) is frequently administered
to evaluate general psychological functioning, as well as to
provide information about suicide and violence risk. The
purpose of this study was to evaluate the construct validity
of the PAI Suicide (SPI) and Violence Potential (VPI) indi-
ces in a sample of 158 psychiatric outpatients referred for
psychological and neuropsychological assessment within a
large northeastern academic medical center between 2007
and 2011. Results generally supported the convergent and
divergent validity of both SPI and VPI when evaluating
groups with and without a history of suicide and violence
risk, and effect sizes were moderate to large even after
controlling for other covariates. SPI and VPI scores were
also found to vary significantly across different psychiatric
groups in ways that would be expected. Finally, we explored
the relationship between SPI and VPI, and executive
functioning impairment—a neuropsychological variable

found to be associated with impulsive self and other-
harming behaviors. Consistent with prior research, SPI and
VPI were found to be significantly elevated in groups dem-
onstrating executive dysfunction. The implications of these
findings and specifically the utility of using SPI and VPI in
the assessment of risk are discussed.
Keywords Personality assessment inventory. Risk
assessment . Suicide potential . Violence potential
Psychologists and other healthcare providers are increasingly
being asked to provide clinical judgments regarding a person’s
level of risk of harm to self and others in both clinical and non-
clinical settings. As some have noted previously, current
frameworks for evaluating risk are varied and often imprecise,
which when coupled with low base rates of suicide and
aggression in the general population results in prediction
models that are frequently unreliable (Monahan et al. 2001;
Wenzel, et al. 2011). Further, research over the last decade has
demonstrated that factors underlying risk for suicide and
aggression are themselves complex, and include a wide array
of affective, neuropsychological, biological, demographic,
and contextual variables (Dougherty, et al. 2004; Jollant et
al. 2005; Keilp, et al. 2001; Monahan et al. 2001; Monahan
and Steadman 1994; Soloff, et al. 2000; van Heering and
Marusic 2003; Wenzel et al. 2011). As a result, accurately
predicting the near-term risk of suicidal and violent behaviors
can prove to be challenging.
Despite these complexities, both suicide and violence con-
tinue to be prominent public health issues. For example, The
National Institute of Mental Health (NIMH) reported in 2007
that suicide was the tenth leading cause of death within the
United States overall and the third leading cause of death for
An earlier version of this paper was presented at the annual

meeting of
the Society for Personality Assessment, Boston, MA, March
2011.
S. J. Sinclair (*) : I. Bello : M. Nyer : J. Slavin-Mulford :
M. B. Stein : M. Renna: M. A. Blais
Department of Psychiatry,
Massachusetts General Hospital and Harvard Medical School,
One Bowdoin Square, 7th Floor,
Boston, MA 02114, USA
e-mail: [email protected]
D. Antonius
University at Buffalo, State University of New York,
Buffalo, NY, USA
D. Antonius
New York University School of Medicine,
New York, NY, USA
J Psychopathol Behav Assess (2012) 34:423–431
DOI 10.1007/s10862-012-9277-6
people ages 15 to 24, accounting for roughly 34,598 fatalities
overall (NIMH 2011). Further, suicide rates have also been
found to vary significantly across groups differing in terms of
age, gender, and race/ethnicity. Men, those in adolescence and
older age groups, and American Indians and Non-Hispanic
Whites are disproportionately more likely to die by suicide.
Those with mental illness (and primary affective/mood disor-
ders specifically) and substance abuse disorders are also con-
sidered to be at elevated risk (NIMH 2011).
With respect to the issue of violence, the US Federal
Bureau of Investigation (FBI) reported 1,318,398 violent

crimes in the United States in 2009, or 492.4 crimes per
100,000 citizens; the most frequent of these crimes was
aggravated assault (FBI 2011). Within psychiatric popula-
tions specifically, Monahan et al. (2001) found that those with
substance abuse and prior violence histories, male gender, and
psychopathy were risk factors for prospective violence direct-
ed at others. Interestingly, Monahan et al. (2001) reported that
major mental illness and especially psychotic illness were
associated with lower rates of violence, although other re-
search on this has been inconsistent.
While studies on this have been somewhat mixed, other
cognitive/neuropsychological variables have also been found
to be associated with both suicidal and violent behavior. For
example, Voracek (2004, 2009) found a significant, positive
correlation between intellectual functioning and rates of sui-
cide in both men and women in an international study of 85
countries. Voracek discussed this relationship in the context of
evolutionary theory, and specifically “that a threshold intelli-
gence is necessary for suicidality” (Voracek 2004, p. 544). In
contrast, other research has generally supported an inverse
relationship between cognitive functioning on the one hand,
and behavioral disinhibition and antisocial behaviors on the
other hand (Farrington 2006; Neumann and Hare 2008). Some
have argued that this relationship is accounted for by more
focal neuropsychological deficits within the executive function
domain, which has also been associated with both suicidal and
violent behaviors (Harkavy-Friedman et al. 2006; Jollant et al.
2005; Marzuk, et al. 2005; Morgan and Lilienfeld 2000;
Westheide et al. 2008). Although “Executive Function” refers
to an array of cognitive abilities which implicate a network of
cortical and sub-cortical structures in the brain, these findings
have typically been explained in terms of how executive
dysfunction specifically may predispose people to greater
levels of disinhibition, impulsivity, cognitive rigidity, and re-
duced capacity for complexity and effective decision-making.

Risk Assessment with the Personality Assessment
Inventory
Although a myriad of risk assessment paradigms exist today,
the Personality Assessment Inventory (PAI; Morey 1991,
2007) has been increasingly used to evaluate common forms
of psychopathology and interpersonal style, as well as factors
that impact the course of treatment and are associated with risk
(e.g., aggressiveness, suicidal ideation). The PAI has been
utilized in forensic settings to facilitate the assessment of
dangerousness to self and others, treatment amenability, and
classifying offenders (Edens, et al. 2001; Morey and Quigley
2002). Similarly, the PAI has also demonstrated predictive
utility for determining risk of recidivism in inmates released
from custody (Walters and Duncan 2005) and disciplinary
issues during incarceration (Walters, et al. 2003).
Specifically, the PAI is a 344-item self report instrument
assessing general psychological functioning and interper-
sonal style (Morey 1991, 2007). Research has demonstrated
its psychometric adequacy across a wide variety of clinical
and non-clinical settings (Boone 1998; Braxton, et al. 2007;
Deisinger 1995; Holden 2000; Morey 1991; Morey 2007;
Siefert, et al. 2009; Sinclair et al. 2009; 2010). Its four
validity scales have also been found to be effective in
detecting invalid and inconsistent response styles (Sellbom
and Bagby 2008). The PAI was developed to assess multiple
relevant domains of psychopathology including: Somatic
Complaints (SOM), Anxiety (ANX), Anxiety-Related
Disorders (ARD), Depression (DEP), Mania (MAN), Paranoia
(PAR), Schizophrenia (SCZ), Borderline Features (BOR),
Antisocial Features (ANT), Alcohol Problems (ALC) and Drug
Problems (DRG) (Morey 2007).

In addition to these self-report scales, a number of sup-
plemental indices were also developed by Morey (1996) to
assess for other clinical factors, including suicide and vio-
lence potential specifically. The Suicide Potential Index
(SPI) was constructed by identifying the 20 features of the
PAI profile that have been found in the literature to be most
associated with completed suicide. These include factors
such as elevated affective distress, alcohol and drug abuse,
mistrust, social withdrawal, insomnia, impulsivity, anger,
mood fluctuations, among others. The SPI is scored by
summing these 20 indicators and converting them into
corresponding T-scores. Preliminary research by Morey
(1996) suggests that SPI has been found to be associated
with whether someone is on suicide precautions, has attemp-
ted suicide in the past, and level of care. More recently,
Breshears, et al. (2010) additionally reported that the SPI
was a strong predictor of suicidal behavior among veterans
with head injuries.
Similarly, the PAI Violence Potential Index (VPI) was
developed by taking the 20 features of PAI profile that have
been found to be most associated with violence and danger-
ousness. These include variables such as anger, hostile control
in relationships, sensation-seeking, impulsivity, agitation, an-
tisocial behavior, grandiosity, and alcohol and drug abuse,
among others. The VPI is scored by summing these 20 indi-
cators and deriving corresponding T-scores, and has been
424 J Psychopathol Behav Assess (2012) 34:423–431
found to be associated with whether someone has a
history of assault, has been convicted of violent crime,
or is on assault precautions (Morey 1996). Similarly,
research has shown small to moderate-sized effects for

VPI in predicting violent nonsexual recidivism, nonvio-
lent recidivism, and sex offender registry violations
(Boccaccini, et al. 2010). That being said, other research
has shown limited incremental validity for the VPI in
differentiating those who reported interpersonal violence
in the last year when compared to the Aggression scale,
which performed somewhat better in terms of its effect
(Crawford, et al. 2007).
A more recent study by Hopwood, et al. (2008) evaluated
the construct validity of SPI and VPI (among other PAI
scales) in a large sample of people who were court-
mandated to attend a substance abuse treatment program in
the United States. Of note, they found that while average
VPI scores were not significantly different across groups
with and without a history of assault or major rule infrac-
tions within the treatment facility, mean SPI scores were
significantly elevated in groups with a history of prior
suicide attempts versus those without. However, the highly
specific nature of the sample and possible other confounds
(e.g., effects of demographic and other clinical variables)
limit the extent to which these findings generalize to other
clinical and non-clinical populations.
Study Purpose
Despite an emerging body of research on the validity and
reliability of the PAI, the vast majority of this work has
focused almost exclusively on the clinical scales, and much
less is known regarding the properties of the supplemental
indices including the SPI and VPI. Given the unique manner
in which these indices were developed and potential added
clinical utility in terms of evaluating for risk of harm to self
and others, the specific purpose of this study was to inves-
tigate the convergent and divergent validity of the SPI and
VPI indices across groups varying in terms of their risk

histories (i.e., those with histories of suicide attempts, vio-
lence histories, etc). It was hypothesized that the SPI would
yield greater effect sizes in differentiating groups with and
without a history of suicidal ideation, suicide attempts, and
inpatient psychiatric hospitalizations, whereas the VPI
would better differentiate those with and without a history
of violence and arrests.
In light of research that has also found varying rates of
suicidal behaviors and violence across different psychiatric
groups, the second purpose of this study was to evaluate
whether SPI and VPI scores varied as a function of psychi-
atric history. Although many forms of psychiatric diagnoses
have been found to be associated with elevated risk of self-
harm and violence directed at others, primary mood (depres-
sive, bipolar) disorders have been found to be strong pre-
dictors of suicidal behaviors and primary substance abuse
disorders have been found to be related to elevated rates of
violence specifically (Dougherty et al. 2004; Jollant et al.
2005; Keilp et al. 2001; Monahan et al. 2001; Monahan and
Steadman 1994; Soloff et al. 2000; van Heering and Marusic
2003; Wenzel et al. 2011). Given this literature, it was
hypothesized here that SPI would yield larger effect sizes
in differentiating those with and without primary mood
disorders, while VPI would be more sensitive to those with
and without a history of alcohol and drug abuse. Because
the literature has been somewhat inconsistent with respect to
the relationship between psychotic disorders and propensity
for suicide and violence (Monahan et al. 2001; Monahan
and Steadman 1994), it was expected that both SPI and VPI
would yield small effect sizes in differentiating those with
and without histories of psychotic symptoms.
Finally, given the multiple studies that have shown a
relationship between executive dysfunction and elevated

rates of impulsivity (including suicidal and violent
behaviors), this study sought to test whether SPI and
VPI scores varied across groups with and without exec-
utive functioning impairment. In light of this research, it
was hypothesized that SPI and VPI would both be sen-
sitive in differentiating groups with and without execu-
tive dysfunction.
Method
Participants
Study participants were 158 psychiatric outpatients referred
for psychological and neuropsychological assessment within a
large northeastern academic medical center between 2007 and
2011. The mean age for the sample was 42.0 years (SD014.6;
range019 to 82 years). The majority of the sample was
Caucasian (91%), male (55%), and right-handed (85%); and
the average education in years was 14.3 (SD03.0). Just over
one-quarter of the sample (29%) indicated they were married
at the time of the assessment, while the majority reported
never being married (57%). Roughly half of the sample was
unemployed (53%); 42% reported they were working; 5%
said they were retired; and 12% noted they were enrolled in
an educational program of some kind.
All participants were engaged in psychiatric care at
the time of the assessment, and were referred by their
mental health providers for psychological and neuropsy-
chological testing with the goal of providing greater
diagnostic clarity and recommendations for treatment.
As part of the evaluation process, diagnostic information
was collected from the referring provider and medical
J Psychopathol Behav Assess (2012) 34:423–431 425

record prior to the evaluation (i.e., diagnoses made by referring
providers) and the breakdown is as follows: Major Depressive
Disorder (44%), Bipolar Disorder (22%), Anxiety Disorders
(14%), Cognitive Disorders such as ADHD (7.2%), Psychotic
Disorders (2%), Substance Abuse Disorders (4.6%), Somato-
form Disorders (0.7%), Adjustment Disorders (0.7%), and
other Axis I Disorders (4.8%).
Procedure
All assessments were conducted by licensed clinical psy-
chologists in the clinic, or psychology post-doctoral fellows
or pre-doctoral interns under their supervision. Assessment
data from the clinic were entered into a de-identified data
repository approved by the hospital’s Institutional Review
Board (IRB). Included in the data repository are basic de-
mographic information about the patients; clinical and diag-
nostic information that was collected from the medical
record, clinical interview with the patient, and interviews
with other sources (e.g., spouses, friends, family members);
and all psychological and neuropsychological test scores. The
PAI and other clinical data reported in this study were drawn
from this IRB-approved data repository.
Measures
The Personality Assessment Inventory The PAI is a 344-
item self report measure of general psychological function-
ing, which was developed to screen for various psychiatric
disorders, alcohol and drug abuse, factors associated with
treatment amenability, and interpersonal style (Morey 1991,
2007). The instrument contains 4 validity scales, 11 clinical
scales (assessing constructs such as depression, anxiety,
mania, schizophrenia, etc.), 5 treatment consideration scales

(measuring factors such as lack of social support, amenabil-
ity to treatment), and 2 interpersonal scales assessing dom-
inance/assertiveness and warmth/affiliation. All items are
rated along a 4-point Likert scale (False, Slightly True,
Mainly True, Very True). In addition to these specific scales,
a number of supplemental indices were also developed by
Morey (1996) to assess for suicide and violence potential,
among other factors. As noted above, the SPI and VPI
indices were constructed using the 20 features of the profile
that have been found to be most associated with suicidal and
violent behavior (e.g., substance abuse, impulsivity, affec-
tive dysregulation, etc.), and are scored by summing these
indicators and deriving corresponding T-scores. Normative
data were collected by the test developers to assist with
interpretation using a US-census matched community sam-
ple (N01,000) and a clinical sample (N01,246).
The Wechsler Abbreviated Scale of Intelligence (WASI) The
WASI was developed in 1999 for purposes of providing a
brief yet reliable method for evaluating intelligence in pop-
ulations ranging in age from 6 to 89 (The Psychological
Corporation 1999). Similar to the longer Wechsler Adult
Intelligence Scale (WAIS-III), the WASI derives estimates
for Full-Scale IQ, Verbal IQ, and Performance IQ. The
WASI consists of the four subtests from the WAIS-III which
have been shown to load the strongest on g, or general
intellectual functioning, as well as their relative relation-
ships to both verbal and performance-based cognitive abil-
ities: Vocabulary, Block Design, Similarities, and Matrix
Reasoning (Wechsler 1997). The WASI takes approximately
30 min to administer.
Executive Functioning Measures In the present study, exec-
utive functioning was evaluated using three commonly
administered instruments: The Wisconsin Card Sorting Test

(WCST; Heaton, et al. 1993), the Trail Making Test Part B
(Reitan and Wolfson 1985), and the Stroop Neuropsycholog-
ical Screening Test (Trenerry, et al. 1989). The WCST specif-
ically requires examinees to sort cards according to the color,
shape, and number of the objects represented, while also
changing the sort criteria over the course of the test—which
necessitates a capacity for set-shifting and cognitive flexibil-
ity. In the current study, the number of sets established, as well
as the number of total and perseverative errors were aggregat-
ed (averaged) into a single WCST index score. Similarly, the
Trail Making Test Part B requires examinees to draw lines
through numbers and letters in alternating and ascending
fashion, and is considered a test of cognitive flexibility
and set-shifting. The total time to complete the task was
used for purposes of deriving an overall score. Finally,
the Stroop Neuropsychological Screening Test requires
an individual to initially read 112 words written in
different ink colors, and then on a second list of words
they are asked to inhibit the natural reading response
and give a dissonant response (name the color of the
ink) instead. The number of correct responses within the
2-minute time limit was used to derive the score for the
test. Patients’ scores on all three of these tests were
converted into standard scores using existing normative
data for each instrument to have a mean of 100 and
standard deviation of 15.
Data Analyses
The construct validity of the PAI Suicide (SPI) and Violence
Potential Indices (VPI) was evaluated in several different
ways. First, mean SPI and VPI scores were estimated across
groups with and without (i.e., dichotomous groups) a history
of suicidal ideation, suicide attempts, inpatient psychiatric
hospitalization, violence/assaultive behavior directed at
others, and any form of arrest (including assault and other

violent offenses).
Second, average SPI and VPI scores were estimated across
different psychiatric groups, as defined by the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV-TR, Amer-
ican Psychiatric Association 2000). Groups included those
with and without a history of a major depressive episode,
manic episode, primary psychotic episode (e.g., hallucina-
tions, delusions, paranoid ideation), alcohol abuse, and drug
abuse. These groups were defined based on both a thorough
review of the patient’s medical record prior to the clinical
assessment, as well as a semi-structured clinical interview by
the assessment psychologist to evaluate whether the patient
had ever met DSM-IV criteria for any of these psychiatric
conditions in the past. Dichotomous groups were again con-
structed based on these criteria.
Finally, mean SPI and VPI scores were calculated for
groups exhibiting any form of executive dysfunction versus
those with no impairment. Dichotomous groups were created
based on whether or not patients exhibited cognitive impair-
ment on any of the three measures of executive function
detailed above (i.e., the Wisconsin Card Sorting Test, Trail
Making Test Part B, or the Stroop Neuropsychological
Screening Test). For purposes of this study, impairment was
defined as a standard score below 70, which is similar to how
other studies have categorized cognitive deficit (e.g., see
Harvey, et al. 2009). Such a score falls two standard deviations
below the normative mean and is traditionally accepted as the
definition of impairment (Lezak, et al. 2004). Subjects with
any executive functioning score below a standard score of 70
were assigned to the executive dysfunction group (N047).

Univariate tests (i.e., independent samples t tests and
Pearson correlations) were first conducted to evaluate the
relationships between SPI and VPI, and other model
variables (e.g., age, FSIQ, gender, race, and executive
dysfunction). Second, least-squared adjusted means and
effect sizes (i.e., Cohen’s d’s) were estimated for each
of these group comparisons using the General Linear
Modeling procedure in SPSS Version 16. Because re-
search has demonstrated varying effects of gender, age,
race, intellectual functioning, and other socioeconomic
indicators on the potential for suicide and violence risk
(detailed above), all Analysis of Covariance (ANCOVA)
models were constructed to control for the effects of age,
gender, education (dichotomized as a high school educa-
tion or greater versus those with less than high school
education), race (white versus non-white), and full scale
IQ (derived from the WASI). Adjusted mean SPI and
VPI scores and cohen’s d estimates were then estimated
after accounting for these covariates to determine whether
differences across groups were statistically significant,
as well as to assess the magnitude of the effect. Cohen
(1988) suggested d values of 0.2 as indicating a small
effect, 0.5 as a moderate effect, and 0.8 and greater as a
large effect.
Results
Descriptive analyses were first conducted to evaluate the
linear relationships between SPI and VPI, and other varia-
bles included in the models (presented below). First, SPI
and VPI were found to correlate significantly (r00.740; p0
0.001). Second, both SPI (r0−0.239; p00.002) and VPI
(r0−0.280; p<0.001) were found to be significantly corre-
lated with Full Scale IQ, and VPI was significantly related to
age (r0−0.221; p00.005) while SPI was not. Finally, inde-

pendent samples t tests indicated that while mean SPI and
VPI were not associated with gender or race, both were
associated with education level and executive dysfunction.
Specifically, mean SPI (M071.2; SD015.8) and VPI
(M065.1; SD017.7) scores were both significantly (i.e., at
the p<0.05 level) elevated in groups with a high school
education or less, as compared to those who achieved higher
levels of education (M062.5; SD013.4 & M054.8; SD0
Table 1 Adjusted Mean (SE)a PAI Suicide (SPI) & Violence
Potential
(VPI) index scores across groups with and without histories of
suicide
and violence risk
History of Suicide Attempt
Yes No F (df) p d
N 29 129
SPI 72.1 (2.7) 64.2 (1.3) 6.5 (1,151) 0.011 0.53
VPI 62.9 (2.8) 57.6 (1.3) 2.9 (1,151) 0.092 0.34
History of Suicidal Ideation
Yes No
N 69 89
SPI 71.6 (1.6) 61.1 (1.4) 23.9 (1,151) 0.001 0.70
VPI 61.6 (1.7) 56.2 (1.5) 5.3 (1,151) 0.022 0.34
History of Psych

Hospitalization
Yes No
N 68 90
SPI 69.5 (1.8) 62.8 (1.5) 7.5 (1,151) 0.007 0.45
VPI 60.2 (1.8) 57.3 (1.6) 1.3 (1,151) 0.258 0.18
History of Violence/Assault
Yes No
N 24 134
SPI 70.6 (3.1) 64.8 (1.2) 2.9 (1,151) 0.091 0.39
VPI 66.6 (3.1) 57.1 (1.2) 7.7 (1,151) 0.006 0.61
History of Arrests
Yes No
N 32 126
SPI 75.3 (3.1) 64.1 (1.2) 10.6 (1,151) 0.001 0.75
VPI 69.5 (3.2) 56.8 (1.2) 13.3 (1,151) 0.001 0.81
a Adjusted Mean SPI and VPI (Standard Errors [SE]) scores
after
controlling for Age, Gender, Education, Race, and Full Scale IQ

13.0, respectively). Similarly, both mean SPI (M072.3;
SD015.8) and VPI (M065.9; SD019.4) scores were signif-
icantly elevated in groups demonstrating some form
of executive functioning impairment, as compared to those
groups without impairment (M 062.9; SD 013.6 &
M055.4; SD012.6, respectively).
Table 1 presents adjusted mean SPI and VPI scores
across groups with and without a history of suicidal idea-
tion, suicide attempts, inpatient psychiatric hospitalization,
violence/assaultive behavior directed at others, and arrests.
As hypothesized, differences in SPI were found to be sta-
tistically significant at the p<0.05 level when comparing
those with and without a history of suicidal ideation
(F(1,151)023.9, p00.001), suicide attempts (F(1,151)0
6.5, p00.011), and inpatient psychiatric hospitalization
(F(1,151)07.5, p00.007) after controlling for age, gender,
race, education, and full-scale IQ. Similarly, VPI scores
were also found to be statistically significant when compar-
ing those with and without a history of violence/assault
(F(1,151)07.7, p00.006) and arrests (F(1,151)013.3,
p00.001).
The pattern of effect sizes also supported the convergent
and divergent validity of SPI and VPI. Specifically, SPI was
found to be more sensitive in differentiating groups with and
without a history of suicidal ideation, suicide attempts, and
inpatient psychiatric hospitalization (range of Cohen’s d’s0
0.45 to 0.70), as compared to VPI (range of Cohen’s d’s0
0.18 to 0.34). In contrast, VPI was found to better differen-
tiate those with and without a history of violence towards
others and arrests (range of Cohen’s d’s00.61 to 0.81), as
compared to SPI (range of Cohen’s d’s00.39 to 0.75).

Table 2 presents adjusted mean SPI and VPI scores
across groups with and without a history of a major depres-
sive episode, manic episode, psychotic episode, alcohol
abuse, and drug abuse. As hypothesized, SPI scores were
found to be significantly higher among those with a history of
a major depressive episode (F(1,151)043.5, p00.001), manic
episode (F(1,151)08.7, p00.004), alcohol abuse (F(1,151)0
16.5, p00.001), and drug abuse (F(1,151)038.6, p00.001).
No significant differences in SPI were found between groups
with and without a history of psychosis. Similarly, VPI scores
were also significantly different between groups with and
without a history of a major depressive episode (F(1,151)0
10.2, p00.002), manic episode (F(1,151)08.7, p00.004),
alcohol abuse (F(1,151)020.8, p00.001), and drug abuse
(F(1,151)021.8, p00.001). VPI differences were not found
to be statistically significant across groups with and without a
history of psychosis. Of note, while SPI was more sensitive
than VPI in differentiating groups with and without a history
of a major depressive episode (Cohen’s d’s01.28 and 0.66,
respectively) and drug abuse (Cohen’s d’s00.95 and 0.73,
respectively), both were comparable in terms of differentiating
those with and without a history of mania (Cohen’s d’s00.52
and 0.48, respectively), psychosis (Cohen’s d’s00.00 and
0.08, respectively) and alcohol abuse (Cohen’s d’s00.61 and
0.66, respectively).
Finally, Table 3 presents adjusted mean SPI and VPI scores
across groups with and without executive functioning
Potential
(VPI) index scores across psychiatric groups
History of Depression

Yes No F (df) p d
N 132 26
SPI 68.6 (1.1) 49.5 (2.7) 43.5 (1,151) 0.001 1.28
VPI 60.2 (1.2) 49.8 (3.0) 10.2 (1,151) 0.002 0.66
History of Mania
Yes No
N 45 113
SPI 70.9 (2.2) 63.2 (1.2) 8.7 (1,151) 0.004 0.52
VPI 63.6 (2.2) 56.0 (1.3) 8.7 (1,151) 0.004 0.48
History of Psychosis
Yes No
N 29 129
SPI 65.7 (2.8) 65.7 (1.3) 0.00 (1,151) 0.987 0.00
VPI 59.6 (2.9) 58.3 (1.3) 0.16 (1,151) 0.688 0.08
History of Alcohol Abuse
Yes No
N 67 91
SPI 70.9 (1.7) 61.8 (1.4) 16.5 (1,151) 0.001 0.61

VPI 64.5 (1.7) 54.2 (1.5) 20.8 (1,151) 0.001 0.66
History of Drug Abuse
Yes No
N 51 107
SPI 75.3 (1.9) 61.1 (1.3) 38.6 (1,151) 0.001 0.95
VPI 66.3 (2.0) 54.9 (1.3) 21.8 (1,151) 0.001 0.73
after
Potential
(VPI) index scores across groups with and without executive
function-
ing impairment
Executive Functioning
Impairment
Yes No F (df) p d
N 47 111
SPI 71.0 (2.4) 63.4 (1.4) 6.3 (1,151) 0.013 0.48
VPI 63.2 (2.4) 56.6 (1.5) 4.7 (1,151) 0.032 0.44
after

impairment. As hypothesized, both SPI (F(1,151)06.3, p0
0.013) and VPI (F(1,151)04.7, p00.032) scores were found
to be significantly higher among those demonstrating impair-
ment on at least one measure of executive function after
controlling for age, gender, race, education, and full-scale
IQ. Further, both were comparable in terms of their sensitivity
in differentiating these groups, as is evidenced by their similar
effect size estimates (Cohen’s d’s 00.48 and 0.44,
respectively).
Discussion
Evaluating risk of harm to self and others is often an impor-
tant component of psychological assessment, and psychol-
ogists and other health care providers are increasingly being
asked to provide clinical judgments regarding a person’s
level of risk across a variety of clinical and non-clinical
(e.g., occupational, screening, etc.) contexts. Despite much
research in this area, existing methods for assessing risk are
varied (e.g., self-report psychometric instruments, actuarial
tools, patient interviews, using collateral information, etc.)
and often imprecise. Given this and the low base rates of
suicidal and violent behaviors in the general population,
making these determinations can be challenging.
The Personality Assessment Inventory (PAI) specifically
has seen increased use in clinical, forensic, and non-clinical
settings as a means of assessing risk of harm to self and
others (Boone 1998; Braxton, et al. 2007; Deisinger 1995;
Holden 2000; Morey 1991; Morey 2007). However, despite
a growing body of research focusing on the clinical and

treatment consideration scales of the PAI, less is known
regarding the PAI supplemental indices, particularly those
assessing Suicide (SPI) and Violence Potential (VPI). The
specific purpose of this study was to evaluate the construct
validity of SPI and VPI in a sample of 158 psychiatric
outpatients
referred for psychological and neuropsychological assessment
within a large northeastern academic medical center between
2007 and 2011.
Overall, results generally supported the convergent and
divergent validity of both SPI and VPI. SPI was specifically
found to be significantly elevated in populations with a
history of suicidal ideation, suicide attempts, and inpatient
psychiatric hospitalization as compared to those without.
Further, these differences were observed even after control-
ling for other factors known to be associated with each.
While the former two are intuitively obvious, the latter is
also expected given that the vast majority of these psychi-
atric admissions are accounted for by people who were
admitted in the context of primary mood difficulties (often
with secondary suicidal ideation), as well as some following
an actual suicide attempt. Only a small minority of these
admissions are accounted for by people expressing ideation
about hurting others.
These findings are consistent with the study by Hopwood
et al. (2008), who reported similar effect sizes for SPI across
groups with and without a history of suicidal behaviors, and
also extends this research in several important ways. First, the
current study generalizes these findings further using a differ-
ent sample of psychiatric outpatients, while also utilizing a
more complex array of criterion variables to assess construct
validity (e.g., history of suicidal ideation, inpatient hospitali-
zation, executive functioning impairment, etc.). Second, the

current study also controlled for a variety of other factors that
have been known to be associated with suicidal behaviors,
providing for more robust evidence of this relationship.
Similarly, VPI was found to be significantly elevated in
groups with a history of violence towards others and arrests
as compared to those without. Although history of arrests was
used here as a global category, these patterns also make intu-
itive sense given that many of these people were arrested for
violent crimes, the most common of which was assault. Inter-
estingly, these results contradict the findings by Hopwood et al.
(2008), who found no significant differences in VPI across
groups with and without a history of assault, and provide
preliminary support for the use of the index in outpatient
psychiatric settings.
SPI and VPI scores were also found to vary significantly
across different psychiatric groups in ways that would be
expected. Specifically, while SPI better differentiated those
with and without a history of a major depressive episode,
both SPI and VPI were comparable in terms of discriminat-
ing those with and without a history of mania. This finding
is generally consistent with the literature, and specifically
the effects of affective instability and mood lability on the
potential for impulsive behaviors that are destructive in
quality (Dougherty et al. 2004; Jollant et al. 2005; Keilp et
al. 2001; Monahan et al. 2001; Monahan and Steadman
1994; Soloff et al. 2000; van Heering and Marusic 2003;
Wenzel et al. 2011).
While both SPI and VPI were also found to be compara-
ble in differentiating those with and without a history of
alcohol abuse, SPI was slightly more sensitive in discrimi-
nating between groups with and without a history of drug
abuse, despite both effect sizes being large in magnitude.
Overall, these findings also make intuitive sense given that

both alcohol and drug overuse are variables used in deriving
both SPI and VPI. This also generally fits with the literature,
which has suggested a relationship between substance abuse
and elevated risk of harm to self and others (Monahan et al.
2001; Monahan and Steadman 1994; NIMH 2011).
Neither SPI nor VPI were found to differentiate between
groups with and without a history of psychotic symptoms.
Given that the literature has been somewhat inconsistent with
respect to the relationship between psychotic experience and
propensity for suicide and violence (Junginger 1996;
Monahan et al. 2001; Monahan and Steadman 1994), this
finding is not surprising. Within the context of the current
study, it may also be explained by the fact that most of the
patients being assessed were not psychotic at the time of the
assessment, and only 3 out of the 129 were diagnosed with
primary psychotic disorders. Future research is necessary to
better examine the relationship between SPI/VPI and primary
psychotic disorders.
Finally, both SPI and VPI scores were found to be ele-
vated in groups manifesting impairment on at least one of
the three executive functioning measures administered as
part of the assessment process. This finding is also generally
consistent with the literature, which has demonstrated a
relationship between executive dysfunction and propensity
for suicidal and violent behaviors (Harkavy-Friedman et al.
2006; Jollant et al. 2005; Marzuk, et al. 2005; Morgan and
Lilienfeld 2000; Westheide et al. 2008). Perhaps most sig-
nificant, effect sizes were still in the moderate range after
accounting for general intellectual functioning (full-scale

IQ), which provides additional evidence for the unique
contribution of executive functioning impairment specifically
(as opposed to more global cognitive functioning) on the
potential for impulsive behaviors that are destructive in qual-
ity. These findings have typically been explained in terms of
how executive deficits may predispose people to greater levels
of disinhibition and impulsivity, which may increase the risk
of harm to self and/or others.
Overall, these results are promising in terms of the con-
vergent and divergent validity of SPI and VPI in evaluating
risk of harm to self and others, and contribute to the litera-
ture in several ways. Perhaps most importantly, the current
study extends the current research on SPI and VPI (e.g.,
Hopwood et al. 2008) by using multiple criterion variables
for each index (i.e., not just a history of suicide attempts or
violence), including psychiatric diagnoses and neuropsy-
chological variables which may be hypothesized to yield
different kinds of relationships. Following on this point, all
analyses controlled for other demographic and clinical var-
iables that have also been shown to relate to risk, providing
further evidence for the validity of both indices. Finally, the
current study also extends prior research that has often used
highly specific samples (e.g., forensic patients, incarcerated
populations, etc.) through the use of a more generalized
outpatient psychiatric sample.
Given the unique manner in which both SPI and VPI
were developed (i.e., using multiple indicators from the PAI
profile found to be associated with each), these findings
would suggest that both may be useful ancillary measures
for evaluating the potential for suicidal and violent behavior.
Of course, such interpretation should be conducted within
the context of a thorough clinical interview and review of
the person’s history, as well as utilizing other corroborating

sources for evaluating prospective threat. However, using
measures such as SPI and VPI may provide health care
providers with additional, methodologically varied techni-
ques to be used within a larger risk assessment context.
Limitations and Future Directions
Despite these promising results, there are a number of issues
with respect to the current study design that should be
addressed in future research. First, the retrospective nature
of this study (i.e., evaluating SPI and VPI in relation to past
behaviors) provides more limited data in terms of prospec-
tive risk. It will be important for future research to further
explore the predictive utility of SPI and VPI in determining
risk of harm to self and others, particularly given that this is
what psychological evaluators are frequently being asked to
do in their work. Second, while the overall sample used in
this study was moderate, some of the specific group cells
were smaller than hoped, which renders the models more
unstable. Additional research on larger samples would allow
for more covariates to be used, and greater stability in the
score estimates. Finally, the psychiatric conditions coded in
this study were historical and not all patients met criteria for
these conditions at the time of assessment. Future research
should evaluate SPI and VPI in relation to current psychiatric
conditions to determine whether these patterns change. This is
particularly true of psychotic experiences, given the small
effects observed in the current study.
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