Characteristics and circumstances of homicidal acts committed by offenders with schizophrenia

BACKGROUND: While men with schizophrenia are at higher risk of displaying homicidal behaviours compared with the general population, very little is known about the circumstances related to the triggering of such violent acts among offenders with schizophrenia. The main goal of the present investigation was to describe the surrounding context, psychotic symptoms, target characteristics and other circumstantial factors associated with homicidal acts committed by men with schizophrenia, with or without an additional antisocial personality disorder (APD). METHOD: Comprehensive clinical and research interviews, as well as multiple sources of information including reports from social workers and police officers, criminal records, witness statements and questionnaires completed by friends, acquaintances and family members were used to determine specific characteristics surrounding the homicidal acts. RESULTS: Overall, a significant majority of homicides were considered as the consequence of psychotic symptoms; they mostly involved someone who knew the offender; and they usually occurred in a private residence. However, the subgroup of offenders with both schizophrenia and APD were less likely to be judged as responding to psychotic symptoms; they assaulted a non-relative more frequently, and they were more likely to have used alcohol and to be involved in an altercation with the victim prior to the incident than offenders without APD. CONCLUSION: Even for such extreme acts as homicides, the circumstances affecting the occurrence of violence among offenders with schizophrenia may differ when an additional APD diagnosis is present, which would have important implications for prevention and treatment programmes.     

Psychopathy and community violence among civil psychiatric patients: results from the MacArthur Violence Risk Assessment Study

Although psychopathy is recognized as a relatively strong risk factor for violence among inmates and mentally disordered offenders, few studies have examined the extent to which its predictive power generalizes to civil psychiatric samples. Using data on 1,136 patients from the MacArthur Violence Risk Assessment project, this study examined whether the 2 scales that underlie the Psychopathy Checklist: Screening Version (PCL:SV) measure a unique personality construct that predicts violence among civil patients. The results indicate that the PCL:SV is a relatively strong predictor of violence. The PCL:SV's predictive power is substantially reduced, but remains significant, after controlling for a host of covariates that reflect antisocial behavior and personality disorders other than psychopathy. However, the predictive power of the PCL:SV is not based on its assessment of the core traits of psychopathy, as traditionally construed. Implications for the 2-factor model that underlies the PCL measures and for risk assessment practice are discussed.     

Aggressive behaviour at first contact with services: findings from the AESOP First Episode Psychosis Study

BACKGROUND: Aggressive behaviour is increased among those with schizophrenia but less is known about those with affective psychoses. Similarly, little is known about aggressive behaviour occurring at the onset of illness. METHOD: The main reasons for presentation to services were examined among those recruited to a UK-based first episode psychosis study. The proportion of individuals presenting with aggressive behaviour was determined and these individuals were compared to those who were not aggressive on a range of variables including sociodemographic, clinical, criminal history, service contact, and symptom characteristics. Among the aggressive group, those who were physically violent were distinguished from those who were not violent but who were still perceived to present a risk of violence to others. RESULTS: Almost 40% (n=194) of the sample were aggressive at first contact with services; approximately half of these were physically violent (n=103). Younger age, African-Caribbean ethnicity and a history of previous violent offending were independently associated with aggression. Aggressive behaviour was associated with a diagnosis of mania and individual manic symptoms were also associated with aggression both for the whole sample and for those with schizophrenia. Factors differentiating violent from non-violent aggressive patients included male gender, lower social class and past violent offending. CONCLUSIONS: Aggressive behaviour is not an uncommon feature in those presenting with first episode psychosis. Sociodemographic and past offending factors are associated with aggression and further differentiate those presenting with more serious violence. A diagnosis of mania and the presence of manic symptoms are associated with aggression.     

Using a five-factor lens to explore the relation between personality traits and violence in psychiatric patients

Recent work suggests that predictors of violence are similar for individuals with and without mental illness. Although psychopathy is among the most potent of such predictors, the nature of its relation to violence is unclear. On the basis of a sample of 769 civil psychiatric patients, the authors explore the possibility that measures of psychopathy provide a glimpse of higher order personality traits that predispose individuals toward violence. Results indicate that general traits captured by a measure of the 5-factor model, particularly antagonism, were relatively strongly associated with violence and shared most of their violence-relevant variance with a leading measure of psychopathy. Because interpersonal and affective features of psychopathy are less important than basic traits of antagonism in postdicting violence, it may be appropriate to broaden focus in risk assessment to patients' basic personality traits.     

Criminal activities and substance use of patients with major affective disorders and schizophrenia: a 2-year follow-up

BACKGROUND: Compelling findings demonstrate that persons who develop major mental disorders, as compared to those who do not, are at increased risk to commit non-violent and violent crimes. This conclusion has recently been shown to apply to persons with major affective disorders. METHODS: Thirty males with major affective disorders and 74 with schizophrenia were followed for 2 years. At discharge, patients were intensively assessed including diagnoses using SADs and RDC. During follow-up, alcohol and drug use were measured, subjectively and objectively. At discharge, the two groups were similar as to secondary diagnoses of antisocial personality disorder, drug abuse/dependence, socio-demographic characteristics, and criminal history, but more of the patients with major affective disorders than those with schizophrenia had a history of alcohol abuse/dependence. During the follow-up period, the two groups were similar as to rehospitalization, treatment intensity, and substance use. RESULTS: By the end of the follow-up period, 33% of the patients with major affective disorders and only 15% of those with schizophrenia had committed crimes, most violent. Co-morbid antisocial personality disorder was associated with criminality among the patients with schizophrenia but not among those with major affective disorders. Among these latter patients, drug use and the intensity of out-patient care were associated with violent criminality. LIMITATIONS: The small number of subjects limited the conclusions. CONCLUSIONS: Violent behavior among patients with major affective disorders may not be uncommon and may be preventable by out-patient treatment which limits drug use.     

Alcohol abuse as the strongest risk factor for violent offending in patients with paranoid schizophrenia

Aim

To determine predictive risk factors for violent offending in patients with paranoid schizophrenia in Croatia.

Method

The cross-sectional study including male in-patients with paranoid schizophrenia with (N = 104) and without (N = 102) history of physical violence and violent offending was conducted simultaneously in several hospitals in Croatia during one-year period (2010-2011). Data on their sociodemographic characteristics, duration of untreated illness phase (DUP), alcohol abuse, suicidal behavior, personality features, and insight into illness were collected and compared between the groups. Binary logistic regression model was used to determine the predictors of violent offending.

Results

Predictors of violent offending were older age, DUP before first contact with psychiatric services, and alcohol abuse. Regression model showed that the strongest positive predictive factor was harmful alcohol use, as determined by AUDIT test (odds ratio 37.01; 95% confidence interval 5.20-263.24). Psychopathy, emotional stability, and conscientiousness were significant positive predictive factors, while extroversion, pleasantness, and intellect were significant negative predictive factors for violent offending.

Conclusion

This study found an association between alcohol abuse and the risk for violent offending in paranoid schizophrenia. We hope that this finding will help improve public and mental health prevention strategies in this vulnerable patient group.Individuals with schizophrenia have an increased risk of violence (1), but different studies report different risks (1,2). Anglo-American studies commonly report higher prevalence rates than European studies (3,4). These patients have also been reported to have up to 4-6 times higher violent behavior rate than the general population (3-5). Nonetheless, less than 0.2% patients suffering from schizophrenia commit homicide (in 20-year period) and less than 10% of commit a violent act (3). Also, patients with schizophrenia contribute to 6%-11% of all homicides and homicide attempts (3-5).In general, aggressiveness is usually associated with anti-social personality features, juvenile delinquency, and psychoactive substance abuse (6). In patients with schizophrenia violence and violent offending is associated with a great number of risk factors, such as premorbid affinity to violent behavior, alcohol abuse, younger age, lower socioeconomic status (6,7), deinstitutionalization, longer duration of untreated psychosis, later onset of first episode of psychosis (1,4,8), lower social status, broken families, asocial behavior of parents, loss of father at an early age, a new marriage partner in the family, and growing up in an orphanage (9).Several studies (10-12) looked at four basic personality dimensions and their role in violence in patients with schizophrenic illness spectrum: impulse control, affect regulation, narcissism, and paranoid cognition. Impulsivity and immature affect regulation were associated with most neuropsychiatric disorders, and were particularly predictive of affinity for addictive disorders, while paranoid cognition and narcissism were predictive of violence acts (10-12).The causes of schizophrenia may be genetic, early environmental, and epigenetic risk factors (13,14), which may further modulate the risk of violent offending among individuals with this disease (1,15). Until recently, very little has been reported about the predictive factors of violence and violent offending in the patient population in Croatia. The Croatian population has during the last two decades been exposed to environmental and socio-demographic changes (eg, Croatian War 1991-1995 and post-war period), which might have had an impact on predictive risk factors. Therefore, we conducted a cross-sectional study of in-patients with paranoid schizophrenia with or without history of physical violence and violent offending (inclusive of homicide) in several hospitals in Croatia during one-year period.     

A multivariate perspective on schizotypy and familial association with schizophrenia: a review

Although generally accepted that schizotypal personality disorder diagnosis is more prevalent among relatives of individuals with schizophrenia and may be associated with genetic liability to schizophrenia, it seems likely that this diagnosis is itself heterogeneous and thus perhaps not as useful in identifying genes that affect schizophrenia risk (i.e. endophenotypes) as it could be. In contrast, symptoms and dimensions of schizotypal personality disorder may be more etiologically homogeneous, and thus more useful in genetic studies. The current review evaluated and consolidated evidence to date regarding specific symptoms and dimensions of schizotypal personality disorder among non-psychotic relatives of schizophrenia patients. Comparisons were made with relatives of affective disorder patients and non-psychiatric controls. Findings indicate strong support for elevation of social-interpersonal schizotypal symptoms among relatives of schizophrenia patients versus other groups along with moderate specificity. Results suggest only a small elevation of cognitive-perceptual and disorganized symptoms in relatives of schizophrenia patients and results for disorganized symptoms were inconsistent across studies. Thus, evidence to date supports further investigation of genetic associations between symptoms of schizotypal personality disorder and schizophrenia, and suggests that social-interpersonal symptoms may be particularly promising in genetic analyses of schizophrenia.     

Neuroticism as a risk factor for schizophrenia

BACKGROUND: Neuroticism has been shown to increase the risk of depression whereas extraversion is associated with a reduction of risk. These personality traits play a central role in aetiological theories of affective disorder but their role in schizophrenia is unclear. In this study, the risk for schizophrenia associated with neuroticism and extraversion was examined and quantified. METHODS: Neuroticism and extraversion rated at the age of 16 years were examined in relation to adult schizophrenia in a national birth cohort of 5362 individuals. RESULTS: Neuroticism increased the risk of later schizophrenia independent of the level of affective symptoms in adult life (odds ratio over three levels: 1.93, 95% CI 1.09-3.43), whereas extraversion reduced the risk (OR: 044, 95% CI 0.23-0.84). CONCLUSIONS: Depression and schizophrenia may share personality risk-increasing and risk-reducing factors. Coping styles associated with particular personality traits may determine whether isolated symptoms progress to full-blown illness.     

Comorbid antisocial and borderline personality disorders: mentalization-based treatment

Mentalization is the process by which we implicitly and explicitly interpret the actions of ourselves and others as meaningful based on intentional mental states (e.g., desires, needs, feelings, beliefs, and reasons). This process is disrupted in individuals with comorbid antisocial (ASPD) and borderline personality disorder (BPD), who tend to misinterpret others' motives. Antisocial characteristics stabilize mentalizing by rigidifying relationships within prementalistic ways of functioning. However, loss of flexibility makes the person vulnerable to sudden collapse when the schematic representation is challenged. This exposes feelings of humiliation, which can only be avoided by violence and control of the other person. The common path to violence is via a momentary inhibition of the capacity for mentalization. In this article, the authors outline their current understanding of mentalizing and its relation to antisocial characteristics and violence. This is illustrated by a clinical account of mentalization-based treatment adapted for antisocial personality disorder. Treatment combines group and individual therapy. The focus is on helping patients maintain mentalizing about their own mental states when their personal integrity is challenged. A patient with ASPD does not have mental pain associated with another's state of mind; thus, to generate conflict in ASPD by thinking about the victim will typically be ineffective in inducing behavior change.     

具有暴力行为的女性偏执型分裂症患者MMPI对照研究

目的 研究具有暴力行为的女性精神分裂症患者的人格特征。方法 对31例具有暴力行为女性偏执型分裂症患者与41例无暴力行为的女性偏执型分裂症患者进行MMPI测查。结果 研究组与对照组在L、F、K、Pa有统计学差哥（P〈0．05）,Pd、Pt、Sc、Si两组具有明显差异（P〈0．01,P〈0．001）,两组剖析图相似呈F—Pa-Sc。结论 具有暴力行为的女性偏执型分裂症有特殊的人格特征,旨在对女性分裂症患者发生暴力行为加以预测。     

Assessing violence risk among youth

Despite recent declines in the reported rate of juvenile violence, there appears to be increasing public and professional concern about violent behavior among children and adolescents. Media accounts of school shootings and juvenile homicides have prompted a need to develop approaches for systematically assessing violence risk. This article describes the task of assessing general violence risk among youth, and argues that a somewhat different approach is required to assess cases where an identified or identifiable young person may pose a risk to a specifically identified or identifiable target (also referred to as "targeted violence"). Key risk factors for violent behavior among children and adolescents are identified, fundamental principles for conducting an assessment of violence potential in clinical and juvenile justice contexts are outlined, and an approach to assessment when an identified person engages in some communication or behavior of concern that brings him or her to official attention is briefly described.     

Violent injuries among women in an urban area

BACKGROUND: Although the rate of death from injuries due to violent acts is much higher among black women than among white women in the United States, little is known about the nature and correlates of violent injuries among black women living in urban areas. METHODS: In this case-control study conducted at three emergency departments in one inner-city community (in west Philadelphia), we studied 405 adolescent girls and women who had been intentionally injured and 520 adolescent girls and women (control subjects) who had health problems not related to violent injury. Data were collected by conducting standardized interviews with use of questionnaires and by screening urine for illicit drugs. Individual logistic-regression models were constructed to identify factors associated with violent injuries inflicted by partners and those inflicted by persons other than the partners of the victims. RESULTS: The male partners of the injured women were much more likely than the male partners of control subjects to use cocaine (odds ratio, 4.4; 95 percent confidence interval, 2.3 to 8.4) and to have been arrested in the past (odds ratio, 3.1; 95 percent confidence interval, 1.8 to 5.2). Fifty-three percent of violent injuries to the women had been perpetrated by persons other than their partners. Women's use of illicit drugs and alcohol abuse were factors associated with both violence on the part of partners and violence on the part of other persons. Neighborhood characteristics, including low median income, a high rate of change of residence, and poor education, were independently associated with the risk of violent injuries among women. CONCLUSIONS: Women in this urban, low-income community face violence from both partners and other persons. Substance abuse, particularly cocaine use, is a significant correlate of violent injuries. Standard Census data may help identify neighborhoods where women are at high risk for such violence and that would benefit from community-level interventions.     

精神分裂症暴力违法与无违法者MMPI测试比较分析

目的：探讨精神分裂症患者暴力违法的人格特征和精神病理。方法：比较31例司法鉴定诊断为精神分裂症的暴力违法者（被控故意杀人和伤害）与55例无违法记录的精神分裂症住院患者的MMPI量表分。结果：暴力违法的精神分裂症患者MMPI测试的Ha,D,Hy,Pa,Si量表分明显高于无违法者。结论：莫明的心理及躯体痛苦、消极沮丧、情绪化、敏感多疑、不安全感，可能是精神分裂症患者暴力违法的危险因素。     

Interpersonal violence and its correlates in Vietnam veterans with chronic posttraumatic stress disorder

Two studies were conducted to investigate interpersonal violence in Vietnam veterans with posttraumatic stress disorder (PTSD). In study one, combat veterans with PTSD reported significantly greater occurrence of violent behaviors over the past year (22 acts) versus combat veterans without PTSD (.2 acts). Combat exposure had an independent positive association with interpersonal violence. In study two, variables related to current interpersonal violent behavior in 118 PTSD combat veterans were evaluated. In rank order of importance, lower socioeconomic status, increased aggressive responding and increased PTSD severity were related to interpersonal violence. These results suggest that combat veterans with PTSD exhibit greater interpersonal violence than combat veterans without PTSD, and that there are multiple factors in this population which determine violent behavior. © 1997 John Wiley & Sons, Inc. J Clin Psychol 53: 859–869, 1997     

The relationship between aggressive attributional style and violence by psychiatric patients

The authors propose a new theoretical construct for understanding the risk of violent behavior by psychiatric patients: the aggressive attributional style. They propose that a cognitive style characterized by external hostile attributions increases the risk of violence by mentally ill persons. To evaluate this hypothesis, they administered several self-report measures relevant to the aggressive cognitive style, as well as measures of violent behavior in the community, to 110 psychiatric inpatients. Higher scores on several indicators of the aggressive attributional style were associated with violence. Multivariate logistic regression analyses showed that the relationship between attributional style and violence held up when demographic and diagnostic characteristics and impulsiveness were controlled. The authors discuss implications for development of cognitive interventions to reduce violence risk.     

诈骗犯、暴力犯的黑暗三人格与创造力及标新立异的关系

目的:探讨诈骗犯和暴力犯的黑暗三人格、创造力及标新立异的特点及差异,并探究黑暗三人格对创造性和标新立异的预测作用。方法:在北京市某监狱选取了108名成年男性诈骗犯和142名成年男性暴力犯,施测高夫创造力量表、短式黑暗三联征量表和标新立异量表。结果:(1)两类罪犯的马基雅维利主义、精神病态、自恋、黑暗三人格总分均与标新立异显著正相关(r=0.389,0.616,0.374,0.614;P0.01),马基雅维利主义、自恋、黑暗三人格总分与创造力显著正相关(r=0.151,0.398,0.251;P0.05或P0.01),创造力与标新立异显著正相关(r=0.137,P0.05);(2)回归分析表明,马基雅维利主义、精神病态、自恋显著正向预测标新立异(B=0.192,B=0.775,B=0.297;P0.001),仅自恋因子可以显著正向预测创造力(B=0.347,P0.001);(3)诈骗犯的创造力显著高于暴力犯(t=3.53,P0.001),精神病态(t=-1.86,P=0.064)和标新立异程度(t=-1.75,P=0.087)低于暴力犯,均达到边缘显著水平。结论:黑暗三人格与创造力和标新立异关系密切,不同犯罪类型的罪犯具有不同的人格和特质特点。     

Exploring Primary and Secondary Variants of Psychopathy in Adolescents in Detention and in the Community

The current study aims to ascertain how different variants of callous–unemotional traits differ in their psychopathology, exposure to aggression and violence, and aggressive and violent behavior. If secondary/distressed variants (high in callous–unemotional traits and high in anxiety) and primary/traditional variants (high in callous–unemotional traits and low in anxiety) differ along these dimensions, it may speak to their different etiologies, treatment needs (e.g., trauma focused), and responsiveness to treatment. The current sample consisted of 799 adolescents from high schools (n = 419) and juvenile detention centers (n = 380). Participants were interviewed regarding their callous–unemotional traits, psychopathology, exposure to aggression and violence, and aggressive and violent behavior. Parents/guardians and teachers/staff members also reported on participants’ callous–unemotional traits and aggressive and violent behavior. A model-based cluster analysis indicated that there were four clusters in the data set, based on callous–unemotional traits and anxiety: a nonvariant cluster, a primary/traditional callous–unemotional cluster, a secondary/distressed callous–unemotional cluster, and a “fearful” cluster. Secondary/distressed variants of psychopathy exhibited significantly greater symptoms of depression and psychoticism, more exposure to low level aggression and neighborhood violence, and more aggressive and violent behavior, as compared to the other clusters. Adolescents with callous–unemotional traits might not be a homogeneous group, but rather may differ in attitudes, behaviors, and exposure to risk, therefore differing in their treatment needs and responsiveness.     

Exposure to terrorism and violent behavior among adolescents in Israel

It is commonly assumed that exposure to terrorism may lead to violent behavior, but there is little empirical research on the relationship between these two variables. In the present paper, we examined the extent to which exposure to terrorism contributes to violent behavior among adolescents. In addition, we considered the role of environmental factors ( domestic and community violence) and personal and environmental resources (family and social support, mastery, hope, and life satisfaction). Two hundred and fifty‐four Israeli adolescents residing in areas with different levels of exposure to terrorism completed questionnaires. The findings confirm that exposure to terrorism contributes significantly to violent behavior. Exposure to domestic and community violence and mastery also contributed to explaining the variance in violent behavior, whereas the effects of hope and life satisfaction were indirect, and were expressed only in an interaction with variables of exposure to terrorism. The findings may be helpful in identifying groups at risk for violent behavior, as well as in guiding professionals to moderate and prevent such behavior. The findings also emphasize the impact of security‐related stress situations and prolonged exposure to terrorism on manifestations of violence. © 2007 Wiley Periodicals, Inc.     

Testing a four-factor model of psychopathy and its association with ethnicity, gender, intelligence, and violence

Although a 2-factor model has advanced research on the psychopathy construct, a 3-factor model was recently developed that emphasized pathological personality and eliminated antisocial behavior. However, dropping antisocial behavior from the psychopathy construct may not be advantageous. Using a large sample of psychiatric patients from the MacArthur Risk Assessment Study (J. Monahan & H. J. Steadman, 1994), the authors used confirmatory factor analysis to test a 4-factor model of psychopathy, which included interpersonal, affective, and behavioral impulsivity dimensions and an antisocial behavior dimension. Model fit was good for this 4-factor model, even when ethnicity, gender, and intelligence variables were included in the model. Structural equation modeling was used to compare the 3- and 4-factor models in predicting proximal (violence) and distal (intelligence) correlates of psychopathy.