Substance abuse amplifies the risk for violence in schizophrenia spectrum disorder

Mentalizing mediates the relationship between psychopathy and premeditated criminal offending in schizophrenia: a 6-year follow-up study

PURPOSE

Research has shown that schizophrenia augments the risk for criminal behaviour and variables both defining- and related to schizophrenia, increase criminal offending. Premeditated criminal offending is considered a severe form of criminal offending, however, very little is known about what predicts future premeditated criminal offending in schizophrenia.

METHOD AND MATERIALS

In this 6-year follow-up study we explored which factors underlie future premeditated criminal behaviour in a sample of patients diagnosed with schizophrenia (N = 116). We also investigated if a specific mentalizing profile underlie part of the variance of premeditated criminal offending.

RESULTS

Results showed that psychopathy underlie future premeditated crime in schizophrenia, and that a specific mentalizing profile, comprised of a dysfunctional emotional and intact cognitive mentalizing profile in relation to others, mediated parts of the relation between psychopathy and premeditated criminal offending. Finally, our results indicated that patients with schizophrenia with a specific mentalizing profile (see above) engaged in premeditated criminal behaviour earlier during the 6-year follow-up period compared to patients with other mentalizing profiles.

CONCLUSIONS

Our findings suggest that mentalization should carefully be inspected in patients with schizophrenia in relation to future premeditated offending.

Violence in relation to cognitive deficits and symptom severity in a sample of Egyptian patients with schizophrenia

BACKGROUND

Patient with schizophrenia are significantly more likely to be violent than general population; and the consequences of this violence risk are often very serious for the patients, their caregivers, and the entire community.

AIM

To assess the risk of violence in patients with schizophrenia and its correlation with severity of symptoms and cognitive functions.

METHODS

A cross-sectional comparative study conducted in Okasha institute of psychiatry including 50 patients with schizophrenia compared to 50 healthy control group regarding violence risk as assessed by Historical, Clinical, and Risk Management-20 (HCR-20), case group was assessed using Structured Clinical Interview for DSM-IV (SCID-I), Positive and Negative Syndrome Scale (PANSS), cognitive functions were assessed by Wechsler Adult Intelligence Scale (WAIS), Trail Making Test (TMT) Part A and B, the Wisconsin Card Sorting Test (WCST), and the Wechsler Memory Scale (WMS).

RESULTS

There was a statistically significant difference between case and control groups regarding risk of violence where 58% of the case group were found to have risk of violence compared to only 18% in the control group. There was a significant correlation between this risk of violence and period of untreated psychosis, no of episodes, and history of substance use; also was significantly correlated with PANSS and Wisconsin card sorting test subscales. Regarding logistic regression analysis for factors affecting violence risk; total PANSS score and history of substance use were significant independent factors that increase violence risk.

CONCLUSION

Violence risk in patient with schizophrenia is a cardinal factor that may affect life of the patients, their family, and society; this risk can be affected by different factors including severity of symptoms, no of episodes, history of substance use, and cognitive function of the patients.

Alcohol, Aggression, and Violence: From Public Health to Neuroscience

Alcohol has been associated with violent crimes and domestic violence across many nations. Various etiological factors were linked to chronic alcohol use and violence including psychiatric comorbidities of perpetrators such as personality disorders, mood disorders, and intermittent explosive disorders. Aggression is the precursor of violence and individuals prone to aggressive behaviors are more likely to commit impulsive violent crimes, especially under the influence of alcohol. Findings from brain studies indicate long-term alcohol consumption induced morphological changes in brain regions involved in self-control, decision-making, and emotional processing. In line with this, the inherent dopaminergic and serotonergic anomalies seen in aggressive individuals increase their susceptibility to commit violent crimes when alcohol present in their system. In relation to this, this article intends to investigate the influence of alcohol on aggression with sociopsychological and neuroscientific perspectives by looking into comorbidity of personality or mood disorders, state of the mind during alcohol consumption, types of beverages, environmental trigger, neurochemical changes, and gender differences that influence individual responses to alcohol intake and susceptibility to intoxicated aggression.

Aggression on the psychiatric ward: Prevalence and risk factors. A systematic review of the literature

INTRODUCTION

On psychiatric wards, aggressive behaviour displayed by patients is common and problematic. Understanding factors associated with the development of aggression offers possibilities for prevention and targeted interventions. This review discusses factors that contribute to the development of aggression on psychiatric wards.

METHOD

In Pubmed and Embase, a search was performed aimed at: prevalence data, ward characteristics, patient and staff factors that are associated with aggressive behaviour and from this search 146 studies were included.

RESULTS

The prevalence of aggressive behaviour on psychiatric wards varied (8-76%). Explanatory factors of aggressive behaviour were subdivided into patient, staff and ward factors. Patient risk factors were diagnosis of psychotic disorder or bipolar disorder, substance abuse, a history of aggression, younger age. Staff risk factors included male gender, unqualified or temporary staff, job strain, dissatisfaction with the job or management, burn-out and quality of the interaction between patients and staff. Staff protective factors were a good functioning team, good leadership and being involved in treatment decisions. Significant ward risk factors were a higher bed occupancy, busy places on the ward, walking rounds, an unsafe environment, a restrictive environment, lack of structure in the day, smoking and lack of privacy.

CONCLUSION

Despite a lack of prospective quantitative data, results did show that aggression arises from a combination of patient factors, staff factors and ward factors. Patient factors were studied most often, however, besides treatment, offering the least possibilities in prevention of aggression development. Future studies should focus more on the earlier stages of aggression such as agitation and on factors that are better suited for preventing aggression such as ward and staff factors. Management and clinicians could adapt staffing and ward in line with these results.

Effects of comorbid alcohol use disorder on the clinical outcomes of first-episode schizophrenia: a nationwide population-based study

BACKGROUND

Alcohol use disorder (AUD) is a common psychiatric comorbidity in schizophrenia, associated with poor clinical outcomes and medication noncompliance. Most previous studies on the effect of alcohol use in patients with schizophrenia had limitations of small sample size or a cross-sectional design. Therefore, we used a nationwide population database to investigate the impact of AUD on clinical outcomes of schizophrenia.

METHODS

Data from the Health Insurance Review Agency database in South Korea from January 1, 2007 to December 31, 2016 were used. Among 64,442 patients with first-episode schizophrenia, 1598 patients with comorbid AUD were selected based on the diagnostic code F10. We performed between- and within-group analyses to compare the rates of psychiatric admissions and emergency room (ER) visits, and medication possession ratio (MPR) between the patients with comorbid AUD and control patients matched for the onset age, sex, and observation period.

RESULTS

The rates of psychiatric admissions and ER visits in both groups decreased after the time point of diagnosis of AUD; however, the decrease was significantly greater in the patients with comorbid AUD compared to the control patients. While the comorbid AUD group showed an increase in MPR after the diagnosis of AUD, MPR decreased in the control group. The rates of psychiatric admissions, ER visits, and MPR were worse in the comorbid AUD group both before and after the diagnosis of AUD.

CONCLUSIONS

The results emphasize an importance of psychiatric comorbidities, especially AUD, in first-episode schizophrenia and the necessity of further research for confirmative findings of the association of AUD with clinical outcomes of schizophrenia.

Predicting factors for non-suicidal self-injury in patients with schizophrenia spectrum disorders and the role of substance use

Non-suicidal self-injury (NSSI) has been shown as a characteristic feature in many clinical populations in recent years and schizophrenia is one of the most common psychiatric disorders which is associated with NSSI. In this study, we aimed to investigate predictors of NSSI in patients with schizophrenia spectrum disorders (SSD) and the role of lifetime substance use disorder (SUD). A sample of 165 patients with a diagnosis of SSD who were in remission participated in the study. Lifetime NSSI was assessed using the Inventory of Statements About Self-injury (ISAS). Lifetime SUD were evaluated. Logistic regression analysis was conducted to predict NSSI. SUD was found to be related to NSSI in patients with SSD, and it was associated with an approximately fourfold increase in the risk of NSSI. The rates of lifetime SUD in our sample and in the NSSI (+) group were 38.2 % and 55.6 %, respectively. The most commonly abused substances among patients with NSSI were cannabis and synthetic cannabinoids. The prevalence of NSSI was 43.6 % in our sample. 'Self-cutting' was the most common type and 'affect regulation' was the most common function of NSSI. One of the most significant risk factors for NSSI was a previous history of suicide attempts. SUD appears to be a significant predictor of NSSI in patients with SSD. Further investigation of treatable risk factors such as SUD which are related to NSSI is needed. It is also essential to screen SSD patients for NSSI due to the probable relation to high risk of suicide.

N-Methyl-d-aspartate receptor co-agonist availability affects behavioral and neurochemical responses to cocaine: insights into comorbid schizophrenia and substance abuse

Both schizophrenia (SZ) and substance abuse (SA) exhibit significant heritability. Moreover, N-methyl-d-aspartate receptors (NMDARs) have been implicated in the pathophysiology of both SZ and SA. We hypothesize that the high prevalence of comorbid SA in SZ is due to dysfunction of NMDARs caused by shared risk genes. We used transgenic mice with a null mutation of the gene encoding serine racemase (SR), the enzyme that synthesizes the NMDAR co-agonist d-serine and an established risk gene for SZ, to recreate the pathology of SZ. We determined the effect of NMDAR hypofunction resulting from the absence of d-serine on motivated behavior by using intracranial self-stimulation and neurotransmitter release in the nucleus accumbens by using in vivo microdialysis. Compared with wild-type mice, SR-/- mice exhibited similar baseline intracranial self-stimulation thresholds but were less sensitive to the threshold-lowering (rewarding) and the performance-elevating (stimulant) effects of cocaine. While basal dopamine (DA) and glutamate release were elevated in the nucleus accumbens of SR-/- mice, cocaine-induced increases in DA and glutamate release were blunted. γ-Amino-butyric acid efflux was unaffected in the SR-/- mice. Together, these findings suggest that the impaired NMDAR function and a consequent decrease in sensitivity to cocaine effects on behavior are mediated by blunted DA and glutamate responses normally triggered by the drug. Projected to humans, NMDAR hypofunction due to mutations in SR or other genes impacting glutamatergic function in SZ may render abused substances less potent and effective, thus requiring higher doses to achieve a hedonic response, resulting in elevated drug exposure and increased dependence/addiction.

Positive symptoms, substance use, and psychopathic traits as predictors of aggression in persons with a schizophrenia disorder

It is still not clear what the unique contribution of particular psychopathological factors is in explaining aggression in schizophrenia. The current study examined whether persecutory ideations, psychopathy and substance use are associated with different measures of aggressive behavior. We expected that persecutory ideations are associated with reactive aggression, and psychopathic traits are more associated with proactive aggression of inpatients. 59 inpatients with schizophrenia were included. Persecutory ideations we assessed using the Persecutory Ideation Questionnaire (PIQ), psychopathic traits with the revised version of Psychopathic Personality Inventory (PPI-R) and substance use was assessed using the Comprehensive Assessment of Symptoms and History (CASH). In addition, aggression was measured with the Reactive and Proactive Aggression Questionnaire (RPQ), in an experimental task using the Point Subtraction Aggression Paradigm (PSAP) and on the ward using the Social Dysfunction and Aggression Scale (SDAS). Results showed that psychopathy explains most of the variance in self-reported proactive and reactive aggression. In contrast, persecutory ideations explain most of the variance in observed aggression on the ward. Results implicate that it is important to acknowledge comorbid factors in patients with schizophrenia for more precise risk assessment and appropriate treatment for aggressive patients with schizophrenia.

Availability of N-Methyl-d-Aspartate Receptor Coagonists Affects Cocaine-Induced Conditioned Place Preference and Locomotor Sensitization: Implications for Comorbid Schizophrenia and Substance Abuse

Schizophrenia is associated with high prevalence of substance abuse. Recent research suggests that dysregulation of N-methyl-d-aspartate receptor (NMDAR) function may play a role in the pathophysiology of both schizophrenia and drug addiction, and thus, may account for this high comorbidity. Our laboratory has developed two transgenic mouse lines that exhibit contrasting NMDAR activity based on the availability of the glycine modulatory site (GMS) agonists d-serine and glycine. Glycine transporter 1 knockdowns (GlyT1(+/-)) exhibit NMDAR hyperfunction, whereas serine racemase knockouts (SR(-/-)) exhibit NMDAR hypofunction. We characterized the behavior of these lines in a cocaine-induced (20 mg/kg) conditioned place preference (CPP) and locomotor sensitization paradigm. Compared with wild-type mice, GlyT1(+/-) mice displayed hastened extinction of CPP and robust cocaine-induced reinstatement. SR(-/-) mice appeared to immediately "forget" the learned preference, because they did not exhibit cocaine-induced reinstatement and also displayed attenuated locomotor sensitization. Treatment of GlyT1(+/-) mice with gavestinel (10 mg/kg on day 1; 5 mg/kg on days 2-17), a GMS antagonist, attenuated cocaine-induced CPP and caused them to immediately "forget" the learned preference. Treatment of SR(-/-) mice with d-serine (300 mg/kg on day 1; 150 mg/kg on days 2-17) to normalize brain levels caused them to avoid the cocaine-paired side of the chamber during extinction. These results highlight NMDAR dysfunction as a possible neural mechanism underlying comorbid schizophrenia and substance abuse. Also, these findings suggest drugs that directly or indirectly activate the NMDAR GMS could be an effective treatment of cocaine abuse.

The influence of treatment attendance on subsequent aggression among severely mentally ill substance abusers

The interrelationships between severe mental illness, substance use, and aggression are of longstanding importance with implications for community treatment programs, treatment research and public policy. Through the analysis of longitudinal data collected from 278 patients over a 6-month period following admission to an outpatient dual diagnosis treatment program, this study examined the association between dual diagnosis treatment attendance and subsequent aggression among individuals diagnosed with both a severe mental illness and a substance use disorder. We also tested substance use and psychiatric symptoms as mediators of this treatment-aggression relationship. The results of structural equation modeling analyses indicated that dual diagnosis treatment was associated with lower levels of subsequent aggression. Mediational analyses indicated that greater treatment involvement was associated with reduced substance use, which was associated with lower levels of aggression; thus, substance use was found to mediate the relationship between dual diagnosis treatment and aggression. Surprisingly, severity of psychiatric symptoms did not predict later aggression. These findings suggest that targeting substance use reduction in treatment may have the additional benefit of reducing the risk of later aggression among dual diagnosis patients.

Comorbidity of schizotypy and psychopathy: skin conductance to affective pictures

Prior research indicates a relationship between psychopathy and schizophrenia, elucidating a specific trajectory toward violence. Recent research has suggested that this relationship exists at the nonclinical trait level of schizotypy; however, this finding has not been examined objectively. To explore this relationship using both subjective and objective measures, 54 undergraduates (50% male; mean age 20.41) who endorsed a wide range of schizotypy on the Schizotypal Personality Questionnaire (SPQ) completed a laboratory-based protocol. Participants viewed 15 pictures (five neutral, five threatening, and five of others in distress) from the International Affective Pictures System while electrodermal activity was recorded. As expected, all participants exhibited increased skin conductance levels (SCL) to threat and distress pictures compared to neutral pictures; however, no difference in SCL was found between threat and distress pictures. A unique relationship between psychopathy and schizotypy was found (i.e., schizotypy was related to higher Self-Centered Impulsivity and lower Fearless Dominance); however, schizotypy was related to increased SCL in response to emotional and neutral pictures. Although results do not support autonomic hyporesponsiveness often found in clinical psychopathy, a positive relationship was found between schizotypy and self-reported physical aggression. Findings highlight the need to examine other trajectories of violence within the schizophrenia spectrum disorders.

Psychotic symptoms, self-harm and violence in individuals with schizophrenia and substance misuse problems

When schizophrenia is combined with substance misuse, rates are consistently higher. However research findings on the relationship between violence, self-harm and schizophrenia are inconclusive. This study aimed to examine links between specific psychotic symptoms, substance misuse and violence in people dually diagnosed with schizophrenia and substance misuse. Presence and frequency of violence to self and others were examined in relation to the type and severity of psychotic symptoms and level of substance use over a 24 month period in 327 people with schizophrenia and substance misuse problems. 32.3% had an incident of violence to others during the study period and 28.6% had a self-harm/suicide incident. 39 (11.9%) participants reported command hallucinations (CH) and 157 (48.0%) had threat control override symptoms (TCOS). Presence of TCOS and presence of CH were not associated with violence to others but were both associated with self-harm. Different command hallucination sub-types were associated with different types of violence. Delusional and hallucination severity and distress were mainly associated with self-harm. These findings suggest that specific symptoms are related to different outcomes, particularly in relation to self-harm, and these effects remain even after substance use is controlled for. This has important implications for assessment and treatment of this group.

Relationships between dimensional factors of psychopathy and schizotypy

Existing research has suggested that comorbid psychopathy may explain one trajectory of violent behavior in a subset of individuals with schizophrenia. However, it remains unclear which specific traits and symptoms are responsible for this relationship and whether it is limited to clinical and/or forensic categories, or if it reflects a dimensional relationship found in the general population. Therefore, the aim of this study was to examine differential relationships between specific factors of psychopathy and schizotypy in a non-psychiatric and non-forensic sample. Two hundred and twelve undergraduate students (50% female) completed the Schizotypal Personality Questionnaire (SPQ) and the Psychopathic Personality Inventory-Revised (PPI-R). After controlling for age and sex, regressions showed that the total SPQ score was positively related to the total PPI-R score and the Self-Centered Impulsivity factor, and negatively related to the Fearless Dominance factor. Self-Centered Impulsivity was positively related to all three SPQ factor scores, with the strongest relationship found with the Cognitive-Perceptual factor. In contrast, Fearless Dominance was negatively related to only the Interpersonal and Disorganized factors of the SPQ, with the strongest relationship found with the Interpersonal factor. Findings suggest that the comorbidity of schizotypy and the self-centered impulsivity aspect of psychopathy is not limited to extreme discrete populations, but exists in a more dimensional manner within a non-psychiatric sample. In addition, it appears that schizotypy is negatively related to the fearless dominance aspect of psychopathy, which appears to be a novel finding. Results provide preliminary findings that may have implications for developing appropriate prediction, assessment, and treatment techniques for violent behavior in schizophrenia-spectrum disorders.

The magnocellular visual pathway and facial emotion misattribution errors in schizophrenia

Many individuals with schizophrenia show impairment in labeling the emotion depicted by faces, and tend to ascribe anger or fear to neutral expressions. Preliminary research has linked some of these difficulties to dysfunction in the magnocellular (M) visual pathway, which has direct projections to subcortical emotion processing regions. The current study attempted to clarify these relationships using a novel paradigm that included a red background. Diffuse red light is known to suppress the M-pathway in nonpsychiatric adults, and there is preliminary evidence that it may have the opposite (stimulating) effect in schizophrenia-spectrum disorders (SSDs). Twenty-five individuals with SSDs were compared with 31 nonpsychiatric controls using a facial emotion identification task depicting happy, angry, fearful, and sad emotions on red, green, and gray backgrounds. There was a robust interaction of group by change in errors to the red (vs. green) background for misattributing fear expressions as depicting anger (p=.001, ή(2)=.18). Specifically, controls showed a significant decrease in this type of error with the red background (p=.003, d=0.77), while the SSD group tended to increase this type of error (p=.07, d=0.54). These findings suggest that the well-established M-pathway abnormalities in SSDs may contribute to the heightened misperception of other emotions such as anger, which in turn may cause social misperceptions in the environment and elicit symptoms such as paranoia and social withdrawal. As the ventral striatum plays a primary role in identifying anger and receives efferent input from the M-pathway, it may serve as the neuroanatomical substrate in the perception of anger.

[Homicide, schizophrenia and substance abuse: a complex interaction]

BACKGROUND AND AIM

The prevalence of homicide perpetrators with a diagnosis of schizophrenia is 6% in Western countries populations. The relationship between schizophrenia and homicide is complex and cannot be reduced to a simple causal link. The aim of this systematic review was to clarify the role of substance abuse in the commission of murder in people suffering from schizophrenia.

METHODS

A systematic English-French Medline and EMBASE literature search of cohort studies, case-control studies and transversal studies published between January 2001 and December 2011 was performed, combining the MeSH terms "schizophrenia", "psychotic disorders", "homicide", "violence", "substance use disorder", and the TIAB term "alcohol". Abstract selection was based on the STROBE and PRISMA checklist for observational studies and systematic and meta-analysis studies, respectively.

RESULTS

Of the 471 selected studies, eight prospective studies and six systematic reviews and meta-analysis studies met the selection criteria and were included in the final analysis. Homicide committed by a schizophrenic person is associated with socio-demographic (young age, male gender, low socioeconomic status), historical (history of violence against others), contextual (a stressful event in the year prior to the homicide), and clinical risk factors (severe psychotic symptoms, long duration of untreated psychosis, poor adherence to medication). In comparison to the general population, the risk of homicide is increased 8-fold in schizophrenics with a substance abuse disorder (mainly alcohol abuse) and 2-fold in schizophrenics without any comorbidities. A co-diagnosis of substance abuse allows us to divide the violent schizophrenics into "early-starters" and "late-starters" according to the age of onset of their antisocial and violent behavior. The violence of the "early-starters" is unplanned, usually affects an acquaintance and is not necessarily associated with the schizophrenic symptoms. Substance abuse is frequent and plays an important role in the homicide commission. In addition, the risk of reoffending is high. In the "late-starters", the violence is linked to the psychotic symptoms and is directed to a member of the family. The reoffence risk is low and it depends on the pursuit of care or not.

CONCLUSION

Defining subgroups of violent schizophrenic patients would avoid stigmatization and would help to prevent the risk of homicide by offering a multidisciplinary care which would take into account any substance abuse.

Violence in childhood-onset schizophrenia

Violence is elevated in older adolescents and adults with schizophrenia; however, little is known about younger children. This report focuses on rates of violence in younger children with schizophrenic-spectrum illnesses. A retrospective review of structured diagnostic interviews from a case series of 81 children, ages 4-15 years of age, with childhood onset of schizophrenic-spectrum illness is reported. Seventy-two percent of children had a history of violent behavior, including 25 children (31%) with a history of severe violence. Of those with a history of violence, 60% had a least one episode of violence that did not appear to be in response to an external stimulus (internally driven violence). There was no significant impact of age or gender. For many children, these internally driven violent episodes were rare and unpredictable, but severe. Similar to what is found in adolescents and adults, violence is common in children with schizophrenic-spectrum illnesses. General violence prevention strategies combined with early identification and treatment of childhood psychotic illnesses may decrease the morbidity associated with childhood psychotic violence.

Prevalence of delusional jealousy in psychiatric disorders

Delusional jealousy is a known risk factor for violence and homicide, but little is known about its prevalence in psychiatric disorders. We therefore reviewed retrospectively the psychopathological symptoms at admission and discharge, assessed with the AMDP system, of all patients admitted to the Psychiatric Hospital, University of Munich, Germany, from January 2000 through December 2008 (n=14,309). We identified 72 cases of delusional jealousy (0.5% of the whole sample). The prevalence was highest in schizophrenia and other psychoses (1.3%), and more of the patients with delusional jealousy were men (43 of 72, 59.7%). One-fifth (15 of 72, 20.8%) of the patients with delusional jealousy were aggressive at admission (vs. 6.2% of the total sample). We conclude that delusional jealousy is a comparatively rare phenomenon that is most frequent in schizophrenia and related psychoses. Quite a number of affected patients are aggressive, which may indicate a risk of future violence.

Association for methodology and documentation in psychiatry profiles predict later risk for criminal behavior and violent crimes in former inpatients with affective disorder

Few studies have investigated criminal and violent behavior in patients with affective disorders. We reviewed the national crime register for records of criminal offenses committed by 1561 patients with affective disorders and studied the predictive value of certain psychopathological symptoms assessed with the Association for Methodology and Documentation in Psychiatry (AMDP) system concerning future criminal behavior. Sixty-five (4.2%) patients had been convicted in the 7-12 years after discharge (307 cases). Patients with the AMDP syndrome mania had a significantly higher risk for later criminal behavior. The combination with the hostility syndrome further increased the risk. These findings are in line with previous data indicating a higher risk for later criminal behavior in patients with a manic/bipolar disorder compared to depressive disorder. As previously demonstrated in another sample of schizophrenic patients, the AMDP syndromes mania (and hostility) is associated with a higher risk of later criminal behavior.

Criminal behaviour and violent crimes in former inpatients with affective disorder

BACKGROUND

Several studies have reported criminal and violent behaviour in people with schizophrenia but few have investigated the association between affective disorders and violent behaviour.

METHODS

We reviewed the national crime register for records of criminal offences committed by 1561 patients with affective disorders treated between 1990 and 1995 in the Psychiatric Hospital of the University of Munich. The sample was divided into patients with bipolar I disorder, manic disorder and major depressive disorder. Sociodemographic and other risk factors for non-violent and violent criminal behaviour were analysed.

RESULTS

Sixty-five (4.16%) patients had been convicted in the 7 to 12 years after discharge (307 cases). The rate of criminal behaviour and violent crimes was highest in the manic disorder group: 15.7% (14 of 89) were listed in the national crime register and 5.6% (5 of 89) were convicted of physical injury offences. Violence and criminality were comparatively rare in patients with major depressive disorder: only 1.42% (10 of 702) committed violent crimes. Male gender was a substantial risk factor for non-violent and especially violent behaviour: the rate of violent crimes was six times higher than in females. Marital status appeared to influence the prevalence of later delinquency: separated, divorced and widowed patients committed offences more frequently. A history of substance use problems before clinical treatment was reported by 21.2% (329 of 1561) of the sample. A wide range of different crimes were committed, with defalcation, theft and fraud being the most frequent. Twenty-one cases of physical assault and one case of later homicide were recorded. In contrast to other forensic studies, we did not find a significant effect of substance abuse on the risk of later delinquent behaviour.

CONCLUSION

The frequency of criminal behaviour and violent crimes in individuals with affective disorder depends on much more than just the diagnosis. This study may stimulate further research to identify psychopathological predictors for future violent and criminal behaviour.

An exploration of criminal thinking styles among civil psychiatric patients

BACKGROUND

Several studies have found a relationship between psychiatric illness and criminal behaviour. Despite this, few studies have examined the presence of criminal thinking among civil psychiatric patients.

AIMS

The aim of this study is to explore the patterns and correlates of criminal thinking, using the Psychological Inventory of Criminal Thinking Styles (PICTS), in a sample of civil psychiatric patients.

METHOD

The PICTS (Layperson Edition) and the Brief Psychiatric Rating Scale (Anchored Version; BPRS) were administered to 76 civil psychiatric patients. PICTS scores were compared with those of offenders from a previously published study. Bivariate tests were conducted between selected PICTS scales, BPRS factors, demographic and criminal history variables. Stepwise multiple regressions were performed to assess those variables that predicted the general criminal thinking, proactive and reactive composite scales of the PICTS.

RESULTS

Independent samples t-tests revealed that five PICTS thinking styles were significantly higher in the psychiatric sample compared with the comparison sample of criminal offenders. Bivariate correlations revealed that the PICTS proactive composite scale was significantly related to and predicted by substance abuse and arrest history. CONCLUSIONS/CLINICAL IMPLICATIONS: Thinking styles which are typically associated with criminality were found in this sample of civil psychiatric patients. Cognitive remediation strategies targeting these may help to prevent criminal activity in psychiatric patients.

Psychosis and violence: stories, fears, and reality

Individuals with psychosis are often feared. In fact, they are themselves likely to be victims of violence; however, the main aim of this review is to provide an overview of the evidence on relations between psychosis and violence to others. The terms psychosis and violence were used in a literature search limited to the Cochrane Library and PubMed, a manual search of 8 journals, and a follow-up of additional references in the articles found. The overview draws on new empirical data and major reviews. Almost all sound epidemiologic data on psychosis and violence dates from 1990. There is consistency on a small but significant relation between schizophrenia and violent acts. Since then there has also been movement toward understanding the nature of associations and progress on strategies for managing individuals who have psychosis and are violent. Public fears about individuals with psychotic illnesses are largely unfounded, although there would be benefit in greater attention to the safety of those in their close social circle. The task for the next 10 years must be the development and application of knowledge to improve specific treatments-that is, interventions that go beyond holding and caring to bring about substantial change.

Clinical correlates of later violence and criminal offences in schizophrenia

BACKGROUND

Violence and criminality in patients with schizophrenia has been described in several studies but prediction of later criminal behavior is difficult.

METHODS

We reviewed the national crime register for records of criminal offences committed by 1662 patients with schizophrenia treated between 1990 and 1995 in the Psychiatric Hospital of the University of Munich. Analyses were performed to determine predictors of later criminal behavior, and the psychopathological syndrome scales in the Association for Methodology and Documentation in Psychiatry (AMDP) system were used to establish possible psychopathological characteristics for such behavior.

RESULTS

One hundred and sixty nine (10.2%) of the 1662 patients had been convicted in the 7-12 years after discharge, whereby male patients (117 of 685, 17.1%) outnumbered female patients ( 52 of 977, 5.3%) by more than 3 to 1. The rate of violent crimes was especially high: 62 (3.7%) patients were convicted for physical injury offences. Five cases of manslaughter or murder were recorded. AMDP syndrome scales were found to be predictive for later criminal offences. Significantly higher rates of criminal conviction and recidivism were found for patients with lack of insight at discharge. Analyses also showed a significantly higher risk of non-violent and violent crimes in patients with a hostility syndrome at admission and discharge. There was a significantly lower incidence of criminal behavior in subjects with a depressive syndrome.

CONCLUSION

Data indicate a significant rate of minor and serious physical injury offences in former inpatients with schizophrenia. Moreover, results identify risk factors for future non-violent and violent criminal behavior in patients with schizophrenia.