Schizophrenia and Violence: from correlations to preventive strategies Paul E Mullen Monash University and Victorian Institute of Forensic Mental Health

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Schizophrenia and Violence from correlations to
preventive strategiesPaul E Mullen Monash
University and Victorian Institute of Forensic
Mental Health
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Improved Management of High Risk Groups with
Schizophrenia Could

• Reduce seriously violent crime by 2-4.
• Reduce incarceration rates (prison and forensic
  hospitals) of those with schizophrenia by 30 -
  50.
• Improve quality of life for the most disturbed
  and disadvantaged among those with schizophrenia.

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SCHIZOPHRENIA

• Clinically Significant Socially Significant

VIOLENCE
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• Schizophrenia Among Violent Offenders

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Homicides and Schizophrenia
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Homicides and Schizophrenia
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OR for Schizophrenia and Homicide
Highest probable ascertainment
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• Violent Offending in those with Schizophrenia

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Violent Offending in Schizophrenia(2861)
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• Violence and Homicide in 1,705 patients with
  Schizophrenia. Soyka et al 2004
• 7-12 years post discharge
• Any conviction 224 (13.1)
• Violent convictions 45 (2.6)
• Homicide/attempted homicide 5 cases (0.3)

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SCHIZOPHRENIA

• Clinically Significant Socially Significant

VIOLENCE
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WHY HAS IT NOT BEEN OBVIOUS TO CLINICIANS
RESEARCHERS ?
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CLINICAL RISKS COMMUNITY RISKS AN APARENT
PARADOX

• 5 10 of violent crime including homicide is
  attributable to the 0.5 to 0.6 of the population
  with schizophrenia

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CLINICAL RISKS COMMUNITY RISKS AN APARENT
PARADOX

• BUT in schizophrenia the risks for individuals
  are-
• Homicide 1 in 10000 per year For
  males 1 in 2000
  per year
• Convictions serious violence 1 in 500 per year
  
• Any violent convictions 1 in 180 per year
• for violence
• For males 1 in 100
  per year
• Violent incidents 5-10 in 100 per year

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Violence in Schizophrenia
DELUSIONALLY DRIVEN

• l
• Older Younger
• Organised Delusions Disorganised
• Domestic Domestic and non domestic
• Psychopathic Traits
• Not Antisocial Conduct
  Disorder
• Substance Abusing
• (look like patients) (look like criminals)

MULTIFACTORIAL
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• Schizophrenia
• Developmental Difficulties
  Active Symptoms
• Personality Vulnerabilities
• Education Failure
• 
  
  Unemployment Social Dislocation Substan
  ce Abuse
• 
  
  
  Criminal Peer Group
  Rejection by Services
• 
  Violent
  Behaviours

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Substance Abuse ?
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Explaining The Association Between Schizophrenia,
Substance Abuse and Offending

• Substance abuse causes the offending
• Those with schizophrenia with a propensity for
  offending behaviours also having a propensity to
  abuse substances when they are available
• A mixture of the above

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OFFENDING AMONG THE MENTALLY DISORDERED
1,136 public inpatients
Schizophrenia Protective Factor
Steadman et al (1998, 2000)
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Substance Abuse and Schizophrenia

• Far higher rates of alcohol and drug abuse are
  found in those with schizophrenia particularly
  younger males.
• (Soyka 2000)

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Reminder

• If you control for a variable which is itself
  significantly associated with schizophrenia then
  you are controlling in part for the disorder
  itself and risk obscuring causal as well as
  statistical associations.

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Lifetime Convictions in the Schizophrenia
Cohorts
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Lifetime Convictions in the Schizophrenia
Cohorts
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Schizophrenia S.A.

• Comorbid S.A. is associated with increased
  offending
• This is in part because S.A. in almost anyone
  increases the risks of offending
• This is in part because those with a
  predisposition to offending have a particular
  avidity for substance abuse
• S.A. may explain part but by no means all of the
  correlation.

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Manage Substance Abuse
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• Do active symptoms mediate offending in
  schizophrenia?
• Yes Link Stuve 1994-1998 Taylor 1985-1998
  Arsenault 2000
• Probably not MacArthur Studies 1998-

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• Clear emergence of schizophrenia before the
  onset of significant violence does suggest that
  in some way the illness may have a direct role in
  the violence
• Taylor Estroff (2002)
• Do the criminal careers differ between those with
  and those without schizophrenia?
• Yes Hafner Boker 1973 Taylor 1993 Wessley et
  al 1994 Taylor Hodgins 1994

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Temporal patterns of convictions 8,791
convictions in cases - 1,119 convictions in
controls
72.7 convicted for first time prior to first
admission
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The Role of Symptoms in Violent Behaviour

• Apparently undeniable in individual cases.
• Clear increased rates predate and continue
  independent of obvious symptoms in many.
• An important but not the major mediator in
  populations.

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ACTIVE SYMPTOMS

• Improved Symptom Control.
• Stabilisation in I.P. context using compulsory
  powers and extended admissions if indicated.
• (Forensic services as primary preventative
  services not just containing services)

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• Current social conditions and dislocation does
  mediate the correlation to some extent
• Silver et al (2000)

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• Social Conditions
• Avoid discharging to disorganised accommodation
  in high crime neighbourhoods.
• Provide appropriate level of support and
  supervision.
• Ensure opportunity for meaningful activity and
  recreation within structured programs or work
  environment.
• Address peer groups which support substance abuse
  and offending.

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Developmental Histories

• Those with schizophrenia who show violent and
  criminal proclivities more frequently-
• come from deprived and disadvantaged backgrounds
• have family histories of criminality
• have had poor peer relationships through
  childhood and adolescents
• had conduct disorder
• failed educationally.
• (Schanda et al 1992 Tihonen et al 1997 Fresán
  et al 2004 Cannon 2002)

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Early Intervention

• Target children from disadvantaged backgrounds
  for school enhancement programmes
• Intervene early in educational failure
• Develop active management of conduct disorder

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• Personality Vulnerabilities in Schizophrenia
  explain part of the Association with Offending

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• Genetic Vulnerability
• Schizophrenia CD ASPD

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• Genetic Vulnerability
• Schizophrenia CD ASPD
• Socially Disadvantaged Childhood

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Mean Number of Registered Total Criminal Offences
per Year at Risk from Age 15 to Index Offence for
Six Offender Groups Subjected to Forensic
Psychiatric Assessment
Source Tengstrom, Grann, Langstrom, Hodgins
Kullgren, 2000
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CBT Psychotherapies for Personality
Vulnerabilities

• ASPD (Psychopathic) traits
• Callousness and insensitivity
• Suspiciousness
• external locus of control
• Novelty seeking
• Impulsiveness (fecklessness)
• Antagonism/negativity
• Poor insight
• Plus cognitive deficits

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WHAT IS TO BE DONE

• Give high risk patients high priority

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• BUT
• How do you recognise high risk groups?

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• Keep it simple.
• Keep it focused
• Keep it clinical
• Make it Systematic
• Make it multidisciplinary
• Keep it management focused

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WHAT IS TO BE DONE

• Give high risk patients high priority
• Improve the social conditions under which those
  with schizophrenia live
• Ensure employment
• Address the criminogenic personality factors
• Manage substance abuse
• Improve symptom control
• Improve risk management

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Breaking the Links

• Schizophrenia
• Early Intervention Vigorous Management of
• Active Illness
• CBT for Personality Manage
• Vulnerabilities Substance Abuse
• Education Enhancement Compulsory I.P.
  Management if indicated
• Social Skills Training
• Placement in Supported
• Works Skills Training Accommodation in low
• crime neighbourhoods

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Improved Management of High Risk Groups with
Schizophrenia Could

• Reduce seriously violent crime by 2-4.
• Reduce incarceration rates (prison and forensic
  hospitals) of those with schizophrenia by 30 -
  50.
• Improve quality of life for the most disturbed
  and disadvantaged among those with schizophrenia.

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• Are the associations between schizophrenia and
  offending an artifact of differential detection
  and conviction rates?

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• Rates in crimes with a very high clear up rates
  (e.g. homicides) are greater than those with low
  clear up rates (e.g. theft)
• Probability that police are more reluctant to
  proceed to charge obviously mentally disordered
  individuals

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Lifetime violent convictions
Offending in a Population of People with
Schizophrenia(2861)(Wallace, Mullen, Burgess,
2003)
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Lifetime violent convictions
Offending in a Population of People with
Schizophrenia(Wallace, Mullen, Burgess, 2003)
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Lifetime violent convictions
Offending in a Population of People with
Schizophrenia(Wallace, Mullen, Burgess, 2003)
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• Address known mediators (risk factors)
• Some evidence for two broad types among
  schizophrenics who are violent
• With psychopathic traits
• Without such traits ( ? Symptom driven )

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What is to be Done?
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• Keep it simple.
• eg. Male, young, substance abusing, histories of
  conduct disorder and/or offending behaviours,
  antagonistic, poorly compliant.
• Keep it clinical
• e.g. Angry and Threatening, Delusional Jealousy,
  Feckless, Poor insight, Frightened and
  Suspicious.
• Make it Systematic
• e.g. use HCR 20, or other structured clinical
  judgement approaches.

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• Is there a significant correlation between having
  schizophrenia and violent offending?
• Is the correlation socially clinically
  important?
• If so what might explain that correlation?
• What is to be done?

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Conclusions

• There is an association between schizophrenia and
  violent offending.

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• Is the correlation explained by
  deinstitutionalization ?
• It is hard not to see de-institutionalisation as
  a major factor in the increasing number of crimes
  committed by schizophrenic patients
• Kramp (2005 )

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• Is the Correlation explained by Active Symptoms?

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Deinstitutionalisation in Victoria

• Mental Hospital Beds in 1965 200 per
  100,000
• Deinstitutionalization begins in 1980
• 1st asylum closed 1985
• Last asylum closed 1993
• Beds in general and forensic hospital in 2000
• 40 per 100,000

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Lifetime Convictions in the Schizophrenia
Cohorts
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Lifetime Convictions in the Schizophrenia
Cohorts
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Schizophrenia Cohorts1975-1995

• Do not differ significantly from controls in age
  of onset of offending or in subsequent temporal
  patterns of offending
• Majority of offending careers start before
  diagnosis of schizophrenia

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Victimisation for genders combined
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Victimisation for genders combined
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Reported Victimisation for Males
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Reported Victimisation for Females
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Conclusions

• Why there is an association could include
• The direct influence of active symptoms
• The influence of comorbid substance abuse
• The social and economic conditions imposed by
  chronic disability
• Personality traits

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MENTAL DISORDERS IN OFFENDERS

• Wallace Mullen Burgess et al (1998)
• Sample 3,838 men and 315 women convicted in
  higher courts 1993-1995
• Ascertainment Linkage with state wide register
  of psychiatric contacts established 1961

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Offending in a Population of People with
Schizophrenia(Wallace, Mullen, Burgess, 2000
2004)

• 5 cohorts of patients with Schizophrenia in
  Victorian public mental health registry (1975,
  1980, 1985, 1990, 1995)
• Total 2861 (1689 males, 1172 females)
• Matched control group (, age, gender)
• Linked to criminal convictions

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Scale Structure of the PCL-R 2nd Ed. (Hare, 2003)
Psychopathy
Factor 1 Interpersonal/Affective
Factor 2 Social Deviance

• Promiscuous sexual behaviour
• Many short-term marital relationships

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Scale Structure of the PCL-R 2nd Ed. (Hare, 2003)
Psychopathy
Factor 1 Interpersonal/Affective
Factor 2 Social Deviance
Facet 1 Interpersonal
Facet 2 Affective
Facet 3 Lifestyle
Facet 4 Antisocial

• Glibness/Super.
• Charm
• Grandiose self-
• worth
• Pathological
• Lying
• Conning/
• Maniupulative

• Poor behavioural
• controls
• Early behavioural
• problems
• Juvenile delinq.
• Revocation of
• condition. release
• Criminal versatility

• Lack of remorse
• or guilt
• Shallow Affect
• Callous/Lack of
• Empathy
• Failure to accept
• responsibility
• for actions

• Need for stimul.
• prone. to boredom
• Parasitic lifestyle
• Lack of realistic,
• long-term goals
• Impulsivity
• Irresponsibility

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IN SCHIZOPHRENIA
Psychopathic Traits
Factor 1 Interpersonal/Affective
Factor 2 Social Deviance
Facet 1 Interpersonal
Facet 2 Affective
Facet 3 Lifestyle
Facet 4 Antisocial

• Grandiose self-
• worth
• Insensitivity
• Suspiciousness

• Poor behavioural
• controls
• Early behavioural
• problems
• Juvenile delinq.

• Lack of remorse
• Shallow Affect
• Callous/Lack of
• Empathy
• Failure to accept
• responsibility

• Prone to boredom
• Dependent lifestyle
• Lack of realistic,
• long-term goals
• Irresponsibility

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Conceptual Overlap Among DSM-IV Personality
Disorders and Psychopathy
Histrionic
Histrionic
Antisocial
Borderline
Psychopathy
Narcissistic
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Risk Management

• Two basic approaches
• Identify whether the individual is in a high risk
  group and either incapacitate them or attempt to
  otherwise manage their risk.
• Identify the risk factors operative in the
  population from which the individual comes and
  attempt to reduce those risk factors in that
  population.

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The Appeal of the Individual Approach

• We are confronted clinically and forensically
  with individuals about whom we have to make
  decisions, not with groups.
• Management in practice is about what is to be
  done about this particular individual not about
  populations which may include them.

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Problems with the Individual Approach

• The established risk factors which inform
  decisions are based on group data. The
  individual approach depends on treating someone
  not according to their individual characteristics
  but as a function of the group to which certain,
  but not all, of those characteristics assigns
  them.

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Problems with the Individual Approach

• Assigning individuals to a level of risk is
  usually (?always) accompanied with a claim of a
  percentage probability for that person of
  committing a further violent/sexual/whatever act.
• In reality someone is or is not violent you
  cannot be 70, 30 or less than 5 violent. Thus
  some individuals (at least with the
  incapacitation approach) will always be
  disadvantaged unfairly.

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• ROC 80 true positives 20 false positives
• 20 violence identify 16 false positives 16
• 10 violence identify 8 false positives 18
• 5 violence identify 4 false positives 19
• 0.5 violence identify 1 false positives 40
• 0.05 violence identify 1
  false positives 500

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Problems with the Individual Approach

• 3. Low risk groups, or low scoring individuals,
  are usually far more numerous than the high.
  Thus the low risk individuals usually make a
  larger contribution to the behaviour you wish to
  avoid (70 of 100 people is less than 10 of
  1,000).
• Identifying significant, or better still
  necessary but not sufficient risk factors, and
  managing them in the whole group will therefore
  usually be more effective than searching out the
  high risk individual and managing them.

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How to Resolve Some of the Problems
Moving from data (group based risk factors) to
evaluation (of individuals) and action (usually
directed at individuals) you can either

• Assume individual has the characteristics and
  risk level of group to which they are assigned
  and act on that basis.
• Identify presence or absence of mutable risk
  factors in the particular individual and manage
  those variable.
• Combine (1) to assign priority and (2) to direct
  action.

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What does this mean in practice for mental health
professionals?

• For Assessment
• Focus is on the presence or absence of specific
  risk factors not on individuals supposed level
  of risk.
• Level of overall risk in this individual is
  about, and only about, assigning priority for
  treatment (compulsory versus voluntary treatment
  is not about level of risk but about capacity and
  competence to refuse such treatment).

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What does this mean in practice for mental health
professionals

• For Management
• Managing risk factors in individuals and/or
  groups not risky individuals.
• Identifying what mediates risk factors even of
  the fixed variety (child abuse, prior
  imprisonment, impulsivity, callousness etc) and
  manage those intervening influences.

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Risk Curves by age
Probability of Violence
High
Low
15 20 25 30 35 40
45 50
Age
From Tony Florio
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Therefore Prevention Must Primarily Target High
Risk Groups Not High Risk Individuals
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IN SCHIZOPHRENIA
Psychopathic Traits
Factor 1 Interpersonal/Affective
Factor 2 Social Deviance
Facet 1 Interpersonal
Facet 2 Affective
Facet 3 Lifestyle
Facet 4 Antisocial

• Grandiose self-
• worth
• Insensitivity
• Suspiciousness

• Poor behavioural
• controls
• Early behavioural
• problems
• Juvenile delinq.

• Lack of remorse
• Shallow Affect
• Callous/Lack of
• Empathy
• Failure to accept
• responsibility

• Prone to boredom
• Dependent lifestyle
• Lack of realistic,
• long-term goals
• Irresponsibility

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Schizophrenia Among 1998 Males Convicted of
Serious Violent Offences 1993-1995 (Wallace et
al 1998)
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Victorian Prisoner Health StudyMental Health
Screening Results
116 (26) of prisoners met the criteria for at
least one of the diagnostic categories
Schizophrenia - 32 (7), Major depression - 47
(20), Manic depression - 35 (8).
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Prevalence Rates of Mental Disorders Victorian
Prisoner Health Study

• Mental Illness Victorian PMHS
• Been told by Dr they have an MI 28
• Schizophrenic Disorders 7
• Major Depression 20
• Manic Depression (Bipolar Disorder) 8
• Substance Use
• Alcohol abuse and dependence 40
• Used illegal drugs 66
• Injected illegal drugs 49
• Sought help for drug abuse 25
• Sources Ogloff, Barry-Walsh, Davis (2003)

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SCHIZOPHRENIA IN 2153 OFFENDERS (OR)
Odd Ratio plt 0.001
Wallace et al (1998)
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Proposition 1

• If there is no relationship between mental
  illness and crime
• THEN
• mental health services have no role in managing
  criminal behaviour.

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Proposition 2

• If the symptoms of mental illness (delusions,
  hallucinations, confusion, obsessions) have no
  relationship to crime
• THEN
• mental health services have no role in managing
  criminal behaviour.

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Proposition 3

• If substance abuse mediates the criminal
  behavior in the mentally disordered
• THEN
• mental health services have no role in managing
  criminal behaviour.

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Proposition 4

• If it is the personality traits (disorders)
  which are responsible for criminal behaviour, not
  the psychosis
• THEN
• mental health services have no role in managing
  criminal behaviour.

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Proposition 5

• If it is unemployment, living in a disorganised
  neighbourhood and associating with lawless and
  antisocial groups which leads to crime
• THEN
• mental health services have no role in managing
  criminal behaviour.

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BUT

• Although these five propositions are believed by
  many mental health professionals, and there is
  considerable truth in all but the first
• mental health services DO have a role and a
  responsibility to manage criminal behaviour.
• WHY?

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SCHIZOPHRENIA
VIOLENCE
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PREVALENCE OF AUSTRALIAN PRISONERS WITH A MENTAL
ILLNESS

• Major mental disorder 8 m. 15 f.
• (psychosis)
• Schizophrenias 5 m. 6 f.
• Personality disorders 39 m. 49 f.

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PREVALENCE OF AUSTRALIAN PRISONERS WITH A MENTAL
ILLNESS

• Substance Abuse
• Alcohol 55 m. 33 f.
• - hazardous drinking levels I community
• Regular community use in 12 months prior to
  imprisonment
• Cannabis 55 m. 33 f.
• Opiates 27 m. 50 f.
• Cocaine 21 m. 26 f.
• Amphetamines 21 m. 20 f.

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BIRTH COHORT STUDIES
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Finland Birth Cohort (12,058 subjects (Tiihonen
et al 1997)

• By age 26 years
• Schizophrenia 51 cases
• 13.7 violent offences OR 7.0 (3.1-15.9)
• SES interacts lowest SES more than doubles risk
  of a conviction compared to highest SES

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COMMUNITY STUDY IIBirth Cohort 173,668 men
162,322 women
RELATIVE RISKS
Hodgins et al 1996
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Risks for Violent Behaviours in the 12 Months
Before 21 Years of Age (961 persons)
Arseneault et al 2000
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SCHIZOPHRENIA IN OFFENDERS (OR)
Odd Ratio plt 0.001
Wallace et al (1998)
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SCHIZOPHRENIA IN OFFENDERS (OR)
Odd Ratio plt 0.001
Wallace et al (1998)
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Odds Ratios for Homicide Schizophrenia and
Substance Abuse in Males
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Lifetime Convictions in the Schizophrenia
Cohorts
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Prior Offending ?

• The increased rates of offending among patients
  can be explained by their previous arrest records
  
• (Monahan 1981, Cohen 1980).
• Even among the mentally ill past criminality
  remains a robust predictor of future criminality
• (Bonta et al 1998 Hodgins Muller Isberner
  2004)

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• Is the correlation explained by prior offending
  histories?

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OFFENDING AMONG THE MENTALLY DISORDERED

• In 63 males and 55 of females offending
  preceded first psychiatric contact. Mean age at
  first offence did not differ from controls.
  Offending increased in two years prior and
  subsequent to first contact.
• Mullen et al 2000

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SCHIZOPHRENIA AMONG VIOLENT OFFENDERS

• Taylor Gunn (1984)
• Sample 1,241 men on remand
• Ascertainment PSE
• Schizophrenia - expected rate 0.6
• - non fatal violence 9
• - homicide 11

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• Is there an association
  between
  schizophrenia criminal violence ?

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SCHIZOPHRENIA IN SERIOUS OFFENDERS in 3838 males
(1993-1995)
Wallace et al (1998)
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Potential Mediators (Confounders) of the
Relationship I

• Substance Abuse
• Prior Offending
• Early Development
• Personality Traits

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Potential Mediators (Confounders) of the
Relationship II

• Social Conditions
• Assumed differential arrest and conviction rates

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Homicide Offences in 2861 Patients with
Schizophrenia

• 9 cases were charged with murder. 4 convicted, 1
  adjudicated insane, 3 convicted of lesser
  offences and one acquitted.
• Homicide/attempted homicide 8 (0.2)
• No controls were charged with, or convicted of,
  murder.
• Homicide Rate
• 1975-2000 1 - 1.5 per 100,000 per year
• 14 year risk 14 - 21 per 100,000
• Chances for 3,000 over 14 yr 0.42 - 0.63 (0.01
  - 0.02)

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Consequences of Psychopathology of Schizophrenia

• Pre-existing Vulnerabilities
• Developmental Difficulties, Conduct Disorder,
  Dissocial, Educational Failure, Psychopathic
  Traits, Substance Abuse
• Acquired Vulnerabilities
• Active Symptoms, Personality Changes, Social
  Dislocation, Substance Abuse
• Imposed Vulnerabilities
• Drug Side Effects, Increased Isolation,
  Incarceration eroding social skills and
  employment prospects.

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• There is a correlation between having
  schizophrenia and violent offending.
• Is this due to confounding influences ?
• If not
• What might explain this correlation?

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What mediates that increase?

• In some, the illness itself
• In some, personality vulnerabilities
• In some, associated substance abuse
• In some, the social dislocation associated with
  the illness
• In some, a disrupted personal and social
  development
• In many, some or all of the above.

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