Perinatal and childhood risk factors for later criminality and violence in schizophrenia. Longitudinal, population-based study

Correlates of Future Violence in People Being Treated for Schizophrenia

OBJECTIVE

Violent behavior is infrequent among individuals with schizophrenia but is clinically important. The purpose of this study was to provide data on the correlates of violence, which may allow better risk assessment and care.

METHODS

A total of 1,435 individuals with schizophrenia who participated in the National Institute of Mental Health's Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study and were followed for 18 months were examined. The dependent variables were self-reported injurious and noninjurious violence during follow-up. The independent variables, assessed at study entry, comprised participants' recent injurious and noninjurious violence, demographic and background variables, childhood risk factors, clinical condition, current circumstances, and recent contact with hospitals and prisons. Proportional hazards models of time to first injurious violence were used to generate bivariable and multivariable hazard ratios for all participants and, separately, for participants with no injurious violence at study entry.

RESULTS

Seventy-seven participants (5.4%) reported engaging in injurious violence during follow-up, and 119 (8.3%) reported engaging in exclusively noninjurious violence. In the multivariable analysis, baseline injurious violence (hazard ratio=4.02), recent violent victimization (hazard ratio=3.52), severity of drug use (hazard ratio=2.93), baseline noninjurious violence (hazard ratio=2.72), childhood sexual abuse (hazard ratio=1.85), and medication nonadherence (hazard ratio=1.39) were associated with future injurious violence. For participants with no history of injurious violence at study entry, baseline noninjurious violence was the strongest predictor (hazard ratio=3.02). Recent violent victimization was no longer a significant correlate. The remaining correlates and the strength of their association with future injurious violence were similar to those for all participants.

CONCLUSIONS

This is the first longitudinal multivariable analysis of predictors of injurious violence in a large cohort of patients with schizophrenia followed over 18 months. The results revealed simultaneous strong effects of baseline injurious violence and recent violent victimization on future injurious violent behavior. Among clinical variables, poor medication adherence, but not baseline symptoms of psychosis or depression, significantly predicted injurious violence. Treatment strategies to reduce risk should emphasize medication adherence.

New Clinically Relevant Findings about Violence by People with Schizophrenia

OBJECTIVE

To review findings with clinical relevance that add to knowledge about antisocial and aggressive behaviour among persons with schizophrenia.

METHOD

Nonsystematic literature review.

RESULTS

Recent evidence shows that individuals who develop schizophrenia present cognitive deficits, psychotic-like experiences, and internalizing and externalizing problems from childhood onwards. Many of their relatives present not only schizophrenia-related disorders but also antisocial behaviour. While the increased risk of aggressive behaviour among persons with schizophrenia has been robustly established, recent findings show that by first contact with clinical services for psychosis, most people with schizophrenia who will engage in aggressive behaviour may be identified. At first episode, 2 distinct types are distinguishable: those who present a history of antisocial and aggressive behaviour since childhood and those who began engaging in aggressive behaviour as illness onsets. Antipsychotic medications and other treatments shown to be effective for schizophrenia are needed by both types of patients. Additionally, those with a history of antisocial and aggressive behaviour since childhood require cognitive-behavioural programs aimed at reducing these behaviours and promoting prosocial behaviour. Reducing physical victimisation and cannabis use will likely reduce aggressive behaviour. Evidence suggests that threats to hurt others often precede assaults.

CONCLUSIONS

At first contact with services, patients with schizophrenia who have engaged in aggressive behaviour should be identified and treated for schizophrenia and for aggression. Research is needed to identify interactions between genotypes and environmental factors, from conception onwards, that promote and that protect against the development of aggressive behaviour among persons with schizophrenia.

The poly(I:C)-induced maternal immune activation model in preclinical neuropsychiatric drug discovery

Increasing epidemiological and experimental evidence implicates gestational infections as one important factor involved in the pathogenesis of several neuropsychiatric disorders. Corresponding preclinical model systems based upon maternal immune activation (MIA) by treatment of the pregnant female have been developed. These MIA animal model systems have been successfully used in basic and translational research approaches, contributing to the investigation of the underlying pathophysiological mechanisms at the molecular, cellular and behavioral levels. The present article focuses on the application of a specific MIA rodent paradigm, based upon treatment of the gestating dam with the viral mimic polyinosinic-polycytidilic acid (Poly(I:C)), a synthetic analog of double-stranded RNA (dsRNA) which activates the Toll-like receptor 3 (TLR3) pathway. Important advantages and constraints of this animal model will be discussed, specifically in light of gestational infection as one vulnerability factor contributing to the complex etiology of mood and psychotic disorders, which are likely the result of intricate multi-level gene×environment interactions. Improving our currently incomplete understanding of the molecular pathomechanistic principles underlying these disorders is a prerequisite for the development of alternative therapeutic approaches which are critically needed in light of the important drawbacks and limitations of currently available pharmacological treatment options regarding efficacy and side effects. The particular relevance of the Poly(I:C) MIA model for the discovery of novel drug targets for symptomatic and preventive therapeutic strategies in mood and psychotic disorders is highlighted in this review article.

Environmental and familial risk factors for psychotic and non-psychotic severe depression

BACKGROUND

Severe unipolar depression can be classified as either psychotic depression (PD) or non-psychotic depression (non-PD). A number of biological and clinical differences have been detected between PD and non-PD, but it remains unknown whether risk factors for the two subtypes also differ. The aim of the present study was therefore to investigate whether a number of potential risk factors influenced the risk of developing PD and non-PD to different extents.

METHODS

This is a register-based historical prospective cohort study following all 2.4 million individuals born in Denmark between 1955 and 1990. During follow-up 2183 and 9101 individuals were registered in the Danish Psychiatric Central Research Register with PD and non-PD respectively. The association between risk factors and the development of PD and non-PD was estimated by survival analysis (Poisson regression) and expressed as incidence rate ratios (IRR).

RESULTS

The most consistent finding of the study was that of a general overlap in familial and environmental risk factors for PD and non-PD. However, a parental history of bipolar disorder was a risk factor for PD (mother, IRR=1.66, p=0.003. Father, IRR=1.56, p=0.040) and not for non-PD (mother, IRR=0.92, p=0.430. Father, IRR=1.08, p=0.552). Conversely, a positive family history of schizophrenia was associated with neither PD nor non-PD LIMITATIONS: Diagnoses were assigned as part of routine clinical practice.

CONCLUSION

Our findings justify the distinction between PD and non-PD in the current diagnostic manuals. Furthermore, the fact that parental bipolar disorder and not schizophrenia was a risk factor for PD supports the Kraepelinian dichotomy.

Aggressive behaviour and psychosis in a clinically referred child and adolescent sample

BACKGROUND

Despite evidence of an increased risk of violence among adults suffering from psychosis, very little is currently known about the relationship between early onset psychosis and aggressive behaviour. We aimed to identify and examine overlaps between aggressive behaviour and psychosis in a referred child and adolescent sample to assess whether potential risk factors and other associated features of this co-occurring pattern can be identified at a young age.

METHODS

Standardised item sheet data on young people referred to the Child and Adolescent Department of the Maudsley Hospital between 1973 and 2004 were used to contrast three groups: (1) aggressive-only (n = 1,346), (2) psychosis-only (n = 173), and (3) co-occurring aggression and psychosis (n = 39) on a range of comorbid symptoms and potential risk factors.

RESULTS

Co-occurring cases presented with elevated rates of depersonalisation/derealisation, intrusive thoughts and restlessness, and were more likely to have received past treatment compared with both psychosis-only and aggressive-only cases. Although co-occurring cases resembled the psychosis-only group in many domains, including socio-demographic background and rates of emotional symptoms, they differed from 'pure' psychosis cases in having high levels of special educational needs, irritability, non-aggressive antisocial behaviours, as well as being more likely to be from a low social class and have increased contact with police and child care authorities.

CONCLUSIONS

Our findings suggest that it is possible to identify early risk factors for aggression in individuals with psychosis.

Perinatal risk factors in offenders with severe personality disorder: a population-based investigation

Although perinatal factors are associated with the development of several psychiatric disorders, it is unknown whether these factors are linked with personality disorder. Cases of personality disorder were drawn from a national registry of all forensic psychiatric evaluations (n = 150). Two control groups were used: (1) A sample of forensic evaluations without any psychiatric disorder (n = 97) allowing for a nested case-control investigation; and (2) A population-based sample matched by age and gender with no history of psychiatric hospitalization (n = 1498). Prematurity (<37 weeks of completed gestation) was significantly associated with a diagnosis of personality disorder, both in the nested and the population-based case-control comparisons with adjusted odds ratios (OR) for this risk factor ranging from 2 to 4. Asphyxia (adjusted OR = 2.4, 95% CI: 1.4-4.1) and complicated delivery (adjusted OR = 1.5, 1.0-2.1) were associated with personality disorder in the population-based study, and the former remained significant in multivariate models. Overall, perinatal complications were found to be associated with a later diagnosis of personality disorder in this selected sample. As with other psychiatric disorders where such associations have been demonstrated, changes during the perinatal period may lead to abnormal brain development and function.

A novel approach to determining violence risk in schizophrenia: developing a stepped strategy in 13,806 discharged patients

Clinical guidelines recommend that violence risk be assessed in schizophrenia. Current approaches are resource-intensive as they employ detailed clinical assessments of dangerousness for most patients. An alternative approach would be to first screen out patients at very low risk of future violence prior to more costly and time-consuming assessments. In order to implement such a stepped strategy, we developed a simple tool to screen out individuals with schizophrenia at very low risk of violent offending. We merged high quality Swedish national registers containing information on psychiatric diagnoses, socio-demographic factors, and violent crime. A cohort of 13,806 individuals with hospital discharge diagnoses of schizophrenia was identified and followed for up to 33 years for violent crime. Cox regression was used to determine risk factors for violent crime and construct the screening tool, the predictive validity of which was measured using four outcome statistics. The instrument was calibrated on 6,903 participants and cross-validated using three independent replication samples of 2,301 participants each. Regression analyses resulted in a tool composed of five items: male sex, previous criminal conviction, young age at assessment, comorbid alcohol abuse, and comorbid drug abuse. At 5 years after discharge, the instrument had a negative predictive value of 0.99 (95% CI = 0.98-0.99), meaning that very few individuals who the tool screened out (n = 2,359 out of original sample of 6,903) were subsequently convicted of a violent offence. Screening out patients who are at very low risk of violence prior to more detailed clinical assessment may assist the risk assessment process in schizophrenia.

Prevalence of criminal behaviors in an internal-medicine-resident clinic population

OBJECTIVE

Few, if any, US studies have examined rates of criminal behaviors among patients in clinical samples. According to findings from non-US studies, mostly in psychiatric samples, rates of criminal behavior are higher than in the general population. In this study, we examined the prevalence of criminal behaviors in an internal medicine outpatient sample from a resident-provider clinic.

METHOD

In a consecutive sample of internal medicine outpatients, 380 participants were surveyed in October of 2010 regarding 27 criminal offenses as delineated by the crime categorization schema used by the Federal Bureau of Investigation.

RESULTS

In this sample, 22.1% reported at least one criminal charge. The most commonly self- reported criminal charge was driving under the influence of alcohol or drugs (10.3%), followed by disorderly conduct (7.1%), drug abuse violations (5.8%), simple assault (5.3%), drunkenness (4.5%), and aggravated assault (3.2%).

CONCLUSIONS

Like previous non-US studies among psychiatric samples, there appears to be a higher prevalence of criminal behavior among outpatients in an internal medicine training clinic than in the general population. These behaviors may be inter-related through alcohol/substance-use disorders.

Early risk factors for criminal offending in schizophrenia: a 35-year longitudinal cohort study

BACKGROUND

Recent evidence suggests that factors predicting offending among individuals with no mental disorder may also predict offending among individuals with schizophrenia.

AIMS

The aims of the study were (1) to explore the prevalence of risk factors for criminal offending reported at age 18 among males later diagnosed with schizophrenia, (2) to explore the associations between risk factors reported at age 18 and lifetime criminal offending, (3) to predict lifetime serious violent offending based on risk factors reported at age 18, and (4) to compare the findings with those in males with no later diagnosis of schizophrenia.

METHODS

The study was a prospective, longitudinal study of a birth cohort followed up through registers after 35 years. The cohort consisted of 49,398 males conscripted into the Swedish Army in 1969-1970, of whom 377 were later diagnosed with schizophrenia.

RESULTS

Among the subjects later diagnosed with schizophrenia, strong associations were found between four of the items reported at age 18 and lifetime criminal offending: (1) low marks for conduct in school, (2) contact with the police or child care authorities, (3) crowded living conditions, and (4) arrest for public drinking. Three of these four risk factors were found to double the risk of offending among males with no later diagnosis of schizophrenia.

CONCLUSIONS

Criminality in individuals with schizophrenia may at least partly be understood as a phenomenon similar to criminality in individuals in the general population.

Violence among persons diagnosed with schizophrenia: how pharmacists can help

Violence among those diagnosed with schizophrenia has been reported but is not a diagnostic component of the disorder. The position of the courts regarding fulfillment of the requisite intent to commit violent acts has not been extensively reported. This article discusses the impact of a diagnosis of schizophrenia in an individual and how the pharmacist can help integrate information into the health care system. The recent Supreme Court case of Clark versus Arizona and the older case of Patterson versus Cockrell are discussed with respect to the concept of intent (to commit the act) and the implications this has on an individual in the midst of a psychotic episode. Quality of life, the perception of the stigma associated with a diagnosis of schizophrenia, and pharmacotherapy are briefly discussed. The origin of schizophrenia is multifactorial. Persons with schizophrenia are not innately violent, but alteration in perception may precipitate aggressive acts. Given the complex and diverse nature of schizophrenia and the fact that even with successful pharmacological treatment residual symptoms may still be present, there is a need to provide information to health care practitioners and the court.

Perinatal risk factors in the development of aggression and violence

Over the past several decades, the relative contribution of both environmental and genetic influences in the development of aggression and violence has been explored extensively. Only fairly recently, however, has it become increasingly evident that early perinatal life events may substantially increase the vulnerability toward the development of violent and aggressive behaviors in offspring across the lifespan. Early life risk factors, such as pregnancy and birth complications and intrauterine exposure to environmental toxins, appear to have a profound and enduring impact on the neuroregulatory systems mediating violence and aggression, yet the emergence of later adverse behavioral outcomes appears to be both complex and multidimensional. The present chapter reviews available experimental and clinical findings to provide a framework on perinatal risk factors that are associated with altered developmental trajectories leading to violence and aggression, and also highlights the genetic contributions in the expression of these behaviors.

Paternal age and mortality in nonaffective psychosis

INTRODUCTION

Advanced paternal age (APA) is associated with an increased mortality in the general population, and is a risk factor for schizophrenia. We aimed to test if APA is associated with increased mortality in people with nonaffective psychosis.

METHODS

Subjects with nonaffective psychosis who were born in Helsinki, Finland, between 1951 and 1960 (n=529) were followed until June 2006 (age 46 to 55). Hazard ratios were calculated, adjusting for subject age, age of the other parent, and gender.

RESULTS

In females but not males, there was a significant increase in all-causes mortality (HR=7.04, 95% CI 1.60-31.04, p=0.01) and natural deaths (HR=7.64, 95% CI 1.20-48.66, p=0.03) in offspring of fathers age > or =40, after adjustment for potential confounders. In males but not females, there was a significant decrease in suicides (HR=0.89, 95% CI 0.81-0.97, p=0.01) with increasing maternal age (as a continuous variable). In the entire sample, there was also a trend for decreased all-cause mortality (HR=0.96, 95% CI 0.92-1.01, p=0.08) with increasing maternal age (as a continuous variable).

DISCUSSION

Both paternal and maternal age may affect mortality risk in offspring with psychosis. The specific disorders and pathway(s) associated with the increase in natural cause mortality remain to be determined.

Factor structures of the neurocognitive assessments and familial analysis in first-episode schizophrenia patients, their relatives and controls

OBJECTIVES

Schizophrenia patients have a wide range of cognitive deficits. To explore the structure of these deficits and index their psychometric properties in order to define the major separable factors, exploratory factor analysis (EFA) was performed on a series of neuropsychological test results in a sample of Han Chinese first-episode schizophrenia patients, their relatives and controls without mental illness.

METHODS

The factors derived from the composite sample were tested with confirmatory factor analysis (CFA) in each of the subsamples. The heritability of each factor was estimated by using the mixed linear model in order to determine whether the common factor scores describe the familiarity of the data.

RESULTS

A six-factor model of general mental activity, sort and shift, attention and anti-interference, logical memory, reasoning and problem-solving/executive function, and visual reproduction were extracted and confirmed on EFA and CFA. There was a hierarchy in cognitive performance deficits in relatives depending on their relatedness to probands. Patients performed more poorly than siblings/offspring in general mental activity, sort and shift, attention and anti-interference, logical memory, planning and problem-solving, but not in visual reproduction. The logical memory domain was found to be significantly heritable (h(2)=0.34), and reasoning and problem-solving had a marginal heritability of around 0.19.

CONCLUSIONS

Generalized cognitive deficit accounts for the majority of the overall variance of cognitive deficits in schizophrenia. Estimates of heritability were modest. The present results also support the hypothesis that neurocognitive deficits of schizophrenia are familial and could serve as endophenotypes, especially logical memory, which is the most heritable.

White matter integrity and prediction of social and role functioning in subjects at ultra-high risk for psychosis

BACKGROUND

White matter microstructural disruptions have been observed in patients with schizophrenia. However, whether changes exist prior to disease onset or in high-risk individuals is unclear. Here, we investigated white matter integrity, as assessed by diffusion tensor imaging (DTI), in individuals at ultra-high risk for psychosis (UHR) relative to healthy control subjects (HC) and the relationship between baseline DTI measures and functional outcome over time.

METHODS

Thirty-six UHR participants and 25 HCs completed baseline DTI scans. Subjects also completed clinical follow-up assessments approximately 6 months (26 subjects) and 15 months (13 subjects) later. We used a rigorous registration approach (Tract-Based Spatial Statistics [TBSS]) to examine fractional anisotropy (FA) in six major white matter tracts.

RESULTS

Relative to the HC group, UHR subjects showed lower baseline FA in the superior longitudinal fasciculus, the major frontoparietal white matter connection. Cross-sectional analyses demonstrated that UHR youth failed to show the same age-associated increases in FA in the medial temporal lobe (MTL) and inferior longitudinal fasciculus as HCs. Finally, lower baseline FA in the MTL and inferior longitudinal fasciculus predicted deterioration in social and role functioning in UHR participants at 15-month follow-up.

CONCLUSIONS

This is the first investigation of white matter microstructural alterations in a clinical high-risk sample. Our findings indicate that white matter development may be altered in youth at risk for psychosis, possibly due to disrupted developmental mechanisms, and further, that white matter integrity may be predictive of functional outcome.

Schizophrenia and violence: systematic review and meta-analysis

BACKGROUND

Although expert opinion has asserted that there is an increased risk of violence in individuals with schizophrenia and other psychoses, there is substantial heterogeneity between studies reporting risk of violence, and uncertainty over the causes of this heterogeneity. We undertook a systematic review of studies that report on associations between violence and schizophrenia and other psychoses. In addition, we conducted a systematic review of investigations that reported on risk of homicide in individuals with schizophrenia and other psychoses.

METHODS AND FINDINGS

Bibliographic databases and reference lists were searched from 1970 to February 2009 for studies that reported on risks of interpersonal violence and/or violent criminality in individuals with schizophrenia and other psychoses compared with general population samples. These data were meta-analysed and odds ratios (ORs) were pooled using random-effects models. Ten demographic and clinical variables were extracted from each study to test for any observed heterogeneity in the risk estimates. We identified 20 individual studies reporting data from 18,423 individuals with schizophrenia and other psychoses. In men, ORs for the comparison of violence in those with schizophrenia and other psychoses with those without mental disorders varied from 1 to 7 with substantial heterogeneity (I(2) = 86%). In women, ORs ranged from 4 to 29 with substantial heterogeneity (I(2) = 85%). The effect of comorbid substance abuse was marked with the random-effects ORs of 2.1 (95% confidence interval [CI] 1.7-2.7) without comorbidity, and an OR of 8.9 (95% CI 5.4-14.7) with comorbidity (p<0.001 on metaregression). Risk estimates of violence in individuals with substance abuse (but without psychosis) were similar to those in individuals with psychosis with substance abuse comorbidity, and higher than all studies with psychosis irrespective of comorbidity. Choice of outcome measure, whether the sample was diagnosed with schizophrenia or with nonschizophrenic psychoses, study location, or study period were not significantly associated with risk estimates on subgroup or metaregression analysis. Further research is necessary to establish whether longitudinal designs were associated with lower risk estimates. The risk for homicide was increased in individuals with psychosis (with and without comorbid substance abuse) compared with general population controls (random-effects OR = 19.5, 95% CI 14.7-25.8).

CONCLUSIONS

Schizophrenia and other psychoses are associated with violence and violent offending, particularly homicide. However, most of the excess risk appears to be mediated by substance abuse comorbidity. The risk in these patients with comorbidity is similar to that for substance abuse without psychosis. Public health strategies for violence reduction could consider focusing on the primary and secondary prevention of substance abuse. Please see later in the article for Editors' Summary.

Behaviour problems in childhood and adolescence in psychotic offenders: an exploratory study

BACKGROUND

Several studies have shown that adults who develop schizophrenia and commit a criminal offence may already have shown behaviour problems in childhood or adolescence. It is less clear whether such problems follow a particular pattern in such patients.

AIMS

To examine the utility of the Child Behavior Checklist (CBCL) among offenders, to test whether externalizing behaviour problems, as measured by the CBCL, are more frequent in psychotic offenders than in non-offenders with psychosis, and to investigate relationships between early behavioural problems and adult personality disorder in psychotic offenders.

METHODS

Three groups of violent offenders detained under the Dutch Entrustment Act (TBS-detainees)(n = 78) and one group of psychotic patients in general psychiatry (n = 16) were rated from case records on the CBCL.

RESULTS

There was a significant difference between psychotic offenders with a personality disorder (n = 25) and the non-offender patients with psychosis (n = 16) on the 'delinquent behavior' scale, but no such difference between psychotic offenders with (n = 25) and without (n = 21) personality disorder. A hierarchic cluster analysis revealed significantly higher scores for externalizing behaviour in all TBS-detainees with a personality disorder. Those starting to offend early had higher scores for externalizing behaviour than late starters.

CONCLUSIONS

Psychotic and non-psychotic offenders with personality disorder resemble one another in their early childhood behaviour problems; psychotic offenders without a personality disorder differ from these two groups but resemble non-offenders with psychosis. In contrast to findings in non-forensic populations, there were no differences on other problem scales of the CBCL. Given the small sample sizes, replication is needed, but the findings lend weight to treatment models which focus on the psychosis in the latter two groups but extend also to personality disorder in the former.

The validity of schizophrenia diagnosis in the Finnish Hospital Discharge Register: findings from a 10-year birth cohort sample

The purpose of this study was to investigate the diagnostic validity of schizophrenia in the Finnish Hospital Discharge Register (FHDR) with a large, epidemiologically representative sample using a multidiagnostic approach (DSM-III-R, DSM-IV, ICD-10), and to find additional criteria that could be used to improve the validity of schizophrenia diagnosis in future register-based research that utilizes the FHDR. The study population consisted of all individuals (n=877) who were born in Helsinki, Finland, between 1 January 1951 and 31 December 1960, and who had had at least one diagnosis of schizophrenia, schizophreniform disorder or schizoaffective disorder in the FHDR. All their available hospital case notes were collected. The total number of subjects for whom case notes were obtained was 806. We used the OPCRIT system (version 3.4) to produce diagnoses according to ICD-10, DSM-III-R and DSM-IV criteria based on the information extracted from the hospital case notes. We examined the distribution of the DSM-III-R, DSM-IV and ICD-10 diagnoses generated by the OPCRIT and calculated the proportion of individuals who received the same diagnosis in the FHDR and in the OPCRIT assessment. The proportion of subjects who received a core schizophrenia spectrum diagnosis (schizophrenia, schizoaffective disorder or schizophreniform disorder) in both the FHDR and OPCRIT assessment varied between 75% (DSM-III-R criteria) and 78% (ICD-10 criteria). Of the subjects with a narrow schizophrenia diagnosis in the FHDR, between 74% (DSM-IV) and 78% (ICD-10) received a diagnosis of schizophrenia in the reassessment depending on the diagnostic criteria applied. Eighty per cent of those who had received a core schizophrenia spectrum FHDR diagnosis after 1982 (vs. 56% of those who had received their last schizophrenia diagnosis in 1982 or before) received a DSM-IV diagnosis of core schizophrenia spectrum disorder. Of the 58 subjects in the sample who had been given at various times diagnoses of both core schizophrenia diagnosis and bipolar I diagnosis in FHDR, 43% received a core schizophrenia spectrum diagnosis according to DSM-IV criteria. The validity of the FHDR schizophrenia diagnosis is acceptable for large-scale register studies and comparable with that of other Nordic registers. Diagnostic validity can be further improved by selecting subjects who have core schizophrenia spectrum disorder as the latest diagnosis, by omitting cases diagnosed before 1982, and by excluding cases with a register diagnoses of both a core schizophrenia spectrum and bipolar I disorder.

Effectiveness of comprehensive supports for schizophrenic women during pregnancy and puerperium: preliminary study

The risks of deteriorated psychiatric symptoms/daily life functioning should be warned of in schizophrenic women during pregnancy and puerperium. The purpose of the present paper was to prospectively monitor mental status and functioning of pregnant women with schizophrenia, and investigate the effects of various supports. Subjects were 20 schizophrenic women who visited a clinic providing care and support for pregnant women with psychiatric diseases, consisting of 12 patients with psychotic deterioration (deterioration group) and eight remitted stable patients (stable group). Psychiatric assessments were performed using Positive and Negative Syndrome Scale (PANSS) and Global Assessment of Functioning (GAF) at three time-points: at the first examination, after fixed prescription during pregnancy, and after delivery. The types/doses of drugs and other non-drug-related supports (13 items) were recorded during the study period. Although a higher total PANSS score at the first examination (P = 0.004) and lower GAF scores at the first examination and even after fixed prescription (P = 0.0003) were observed in the deterioration group, those after delivery finally caught up with the levels in the stable group. Doses of antipsychotic drugs were gradually increased in the deterioration group although no significant differences in chlorpromazine equivalent doses were found between the two groups after fixed prescription. There was a positive correlation between the number of non-drug-related supports and amelioration score in PANSS (r(s) = 0.553, P = 0.012). These findings suggest that comprehensive intervention is a requisite in pregnant schizophrenic women, especially with psychotic deterioration, and that non-drug-related supports may also contribute to maintenance of good and stable mental status in these patients.

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.

Evaluating the effects of birth complications on low self-control in a sample of twins

Gottfredson and Hirschi's general theory has generated an abundance of research examining the effects of low self-control on crime and analogous behaviors. Less research, however, has focused on the factors that contribute to the development of low self-control. Gottfredson and Hirschi maintain that ineffective parents are the sole cause for the emergence of low self-control. At the same time, they disregard the possibility that low self-control has a biological or genetic component. This article extends prior research and examines the effects of birth complications and parental involvement on low self-control. Using a sample of twin children, the authors find that parental involvement is only weakly and inconsistently related to low self-control. On the other hand, although most of the birth complications had no appreciable effect on low self-control, anoxia (oxygen starvation) emerged as the strongest and most consistent predictor of low self-control.

Predicting violence in schizophrenia: a prospective study

BACKGROUND

People with schizophrenia are more violent than the general population, but this increased risk is attributable to the actions of a small subgroup. Identifying those at risk has become an essential part of clinical practice.

AIMS

To estimate the risk factors for assault in patients with schizophrenia.

METHODS

Two hundred seventy-one patients with schizophrenia were interviewed using an extensive battery of instruments. Assault was measured from multiple data sources over the next 2 years and criminal records were obtained. Multiple sociodemographic and clinical variables measured at baseline were examined as possible predictors of assault during follow-up.

RESULTS

Sixty-nine (25%) patients committed assault during the 2-year follow-up. The model that best predicted assault included a history of recent assault (OR 2.33, 95% CI 1.17-4.61), a previous violent conviction (OR 2.02, 95% CI 1.04-3.87), having received special education (OR 2.76, 95% CI 1.22-6.26) and alcohol abuse (OR 3.55, 95% CI 1.24-10.2).

CONCLUSIONS

Previously established risk factors including a history of violence and alcohol abuse are replicated in this study. Although low premorbid IQ did not predict violence, a need for special education did.

Childhood origins of violent behaviour in adults with schizophreniform disorder

BACKGROUND

People with psychosis have an elevated risk of violence.

AIMS

To examine whether violent behaviour in adults with psychosis can be accounted for by psychotic symptoms or physical aggression in childhood.

METHOD

We used data from a prospective longitudinal study of a complete birth cohort born in New Zealand. When cohort members were 26 years old, information was obtained on past-year psychiatric diagnosis of schizophreniform disorder and on violent behaviour. Childhood psychotic symptoms were measured at age 11 years using a diagnostic interview, and childhood physical aggression was assessed by teachers when cohort members were aged 7, 9 and 11 years.

RESULTS

Participants with schizophreniform disorder were more likely to be violent than participants without, even after controlling for sociodemographic variables and concurrent substance dependence disorders. Childhood psychotic symptoms were a strong risk factor for violence in adults with schizophreniform disorder, as was childhood physical aggression, although to a lesser extent.

CONCLUSIONS

Violence by individuals with schizophreniform disorder could be prevented by monitoring early signs of psychotic symptoms and by controlling childhood physical aggression.