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Updated 20 January 2011 E-mail discussion
Printable version

Forum Discussion: Schizophrenia and Violence, Case Not Closed

In response to the recent discourse in the general media about the mental health status of Jared Loughner, the man accused of killing six and injuring 12 in Arizona on 8 January 2011, the SRF editors have decided to open up a special forum discussion focusing on violence and the mentally ill. We have asked Paul Appelbaum of Columbia University to begin the discussion by posing some questions that can promote a deeper, more complex rendering of the issues that emerge whenever events likes these occur in our society. We welcome your thoughts, interpretations, suggestions, and citations where appropriate. The editors at SRF are grateful to Paul Appelbaum of Columbia University for his timely and succinct introduction.

For additional commentary and discussion, check out National Alliance on Mental Illness (NAMI) Medical Director Ken Duckworth's blog. Duckworth, along with Pete Earley, a NAMI member and author of Crazy: A Father's Search Through America's Mental Health Madness; Lisa Dixon, M.D., University of Maryland and NAMI scientific advisory council member, and E. Fuller Torrey, M.D., of the Treatment Advocacy Center and the Stanley Medical Research Institute, were featured on the Diane Rehm Show (NPR).

Also, here's a New York Times piece focusing on the challenges of seeking psychiatric help.

Lastly, a few CNN videos to reflect on:
Living With Schizophrenia
Examining Mental Illness in America
Federal Government Approach to Mental Health

View Comments By:
Jan Volavka — Posted 26 January 2011
Matthew Large — Posted 28 January 2011
Fuller Torrey — Posted 28 January 2011
Seena Fazel — Posted 31 January 2011
Paulo Negro — Posted 2 February 2011
Jan Golembiewski — Posted 3 February 2011
Anne Grasbeck — Posted 14 February 2011
David Shern, Steven Vetzner — Posted 14 February 2011
Sandeep Saluja — Posted 17 February 2011
Anne Grasbeck — Posted 17 February 2011
Jan Golembiewski — Posted 22 February 2011
Lennart Borgman — Posted 25 March 2011


Background Text
Paul S. Appelbaum, Elizabeth K. Dollard Professor of Psychiatry, Medicine and Law
Director, Division of Law, Ethics & Psychiatry, Department of Psychiatry, Columbia University College of Physicians and Surgeons/New York State Psychiatric Institute

The tragic shootings in Tucson have once again made the link between schizophrenia and violence a matter of considerable public concern. No one at this point can say with assurance whether Jared Loughner, the troubled young man behind the Glock semi-automatic pistol, has a mental disorder and, if so, what his diagnosis is. However, ignorance of his actual mental condition has not stopped confident assertions by a variety of commentators that he suffers from a mental illness, with schizophrenia by far the most popular choice.

Rapid acceptance by the public of these virtual diagnoses in part reflects deep-rooted preconceptions about the relationship between schizophrenia and violence. Although the weight of the literature suggests that schizophrenia and other psychotic disorders increase the risk of violent behavior, a substantial part of that link—in some studies, the entire differential risk—is accounted for by higher rates of substance abuse among people with psychotic illnesses (Elbogen and Johnson, 2009; Fazel et al., 2009). Data from the CATIE study indicated that positive symptoms increased violence risk, while negative symptoms had a protective effect (Swanson et al., 2006). Even accepting some increased risk associated with schizophrenia, though, it is clear that only a small percentage of violence in our society is due to serious mental illness, with the most frequently cited figure for attributable risk in the range of 3-5 percent (Swanson, 1994).

Nonetheless, the discussion has highlighted several issues regarding young people who may be experiencing early symptoms of a major mental disorder that are worth considering. How adequate are our mechanisms for detecting the onset of schizophrenia and intervening early in its course, and if they are lacking, what might improve our practices? Given that many young people resist accepting the diagnosis of a disorder, and even those who initiate treatment frequently abandon it, when should involuntary evaluation and treatment take place, and what are the longer-term consequences of these approaches? Should restrictions on access to weapons by people with mental illnesses be strengthened, or by focusing on this already stigmatized group, are we colluding in the denial of a broader problem of too-easy availability of guns in our country? And lastly, how can we better educate the public about the nature of schizophrenia and encourage adoption of reasonable policies to help people with the disorder?

Elbogen EB, Johnson SC. The intricate link between violence and mental disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry . 2009 Feb 1 ; 66(2):152-61. Abstract

Fazel S, Gulati G, Linsell L, Geddes JR, Grann M. Schizophrenia and violence: systematic review and meta-analysis. PLoS Med . 2009 Aug 1 ; 6(8):e1000120. Abstract

Swanson, 1994, In Monahan J and Steadman H (Eds.), Violence and Mental Disorder. Chicago: University of Chicago Press, 101-136.


Comments on Online Discussion
Comment by:  Jan Volavka
Submitted 24 January 2011 Posted 26 January 2011

A substantial part of the link between schizophrenia and violent behavior is indeed accounted for by higher rates of substance abuse. However, we should keep in mind other factors as well. It should be noted that the Elbogen and Johnson's 2009 analysis (Elbogen and Johnson, 2009) cited by Dr. Appelbaum included only 136 patients diagnosed with schizophrenia without substance abuse (seven of whom were violent). These numbers are too small to make any statements specific to schizophrenia with confidence. There are other problems with that analysis that will be discussed elsewhere in a detailed report.

Fazel et al. do report the odds ratio of 2.1 (CI 1.7-2.7) for risk estimate of violence in schizophrenia and other psychoses with no substance abuse comorbidity (Fazel et al., 2009). In addition to substance abuse, psychotic symptoms and comorbid personality disorders are also likely to be independent risk factors for violence in individuals with schizophrenia. The crucial role of...  Read more


View all comments by Jan Volavka

Comment by:  Matthew Large
Submitted 28 January 2011 Posted 28 January 2011

Professor Appelbaum makes a number of indisputable points about the stigma of violence associated with mental illness, the role of substance abuse in violence by mentally ill people, and the need for legislation limiting the availability of firearms in the United States. However, I’d like to focus on the danger of first-episode psychosis. In recent years, my colleagues and I have conducted a number of systematic reviews and meta-analyses with a focus on the association between violence and first-episode psychosis (Nielssen and Large, 2010; Large and Nielssen, 2011; Nielssen et al., 2009; Large and Nielssen, 2008). We found that one in three presentations of psychosis is associated with some degree of violence, one in six with more serious violence involving an assault causing some degree of injury, the use of a weapon, or more rarely a sexual assault (  Read more


View all comments by Matthew Large

Comment by:  Fuller Torrey
Submitted 28 January 2011 Posted 28 January 2011

The issue of the involuntary treatment of individuals with schizophrenia and other severe psychiatric disorders is a crucial one. The Treatment Advocacy Center was started 11 years ago specifically to deal with this issue and to promote treatment before such individuals become homeless, incarcerated, or homicidal. Forum members who have an interest in this issue may find the website useful.

View all comments by Fuller Torrey


Comment by:  Seena Fazel
Submitted 31 January 2011 Posted 31 January 2011

Professor Applebaum makes important observations about the need for better detection of schizophrenia, particularly early in its course, and the potential role of involuntary treatment in improving the patient outcomes. Three other areas may further assist clinically: identifying those at higher risk of violence, improving the management of violence risk, and better detection and treatment of detainees and prisoners with schizophrenia.

Understanding more about risk factors for violence in individuals with schizophrenia may assist in identifying those at higher risk (Fazel et al., 2009), although the predictive validity of any combination of risk factors may be poor (Large et al., 2011), particularly for rare outcomes such as homicide (Fazel et al., 2010). Even if risk is identified, the poor quality of the evidence-based treatments for violence in schizophrenia needs to be considered. In a recent review we conducted, only eight...  Read more


View all comments by Seena Fazel

Comment by:  Paulo Negro
Submitted 2 February 2011 Posted 2 February 2011

It's my understanding that the literature of risk assessment for violent re-offense of non-criminally responsible (NCR) defendants indicates that most of the variance is associated with non-mental illness characteristics such as personal background, psychopathic score, and addiction—variables related to the overall propensity to violence—not mental illness. The diagnosis of schizophrenia decreases the likelihood of re-offense, at least in the VRAG. (Violence Risk Appraisal Guide, Quinsey et al., Violent offenders: appraising and managing risk, 2nd edition. American Psychological Association, 2008)

This, in my view, brings into question how NCR is conceptualized—consistent with a more narrowly defined NCR. In other words, the strong actuarial connection between variables not directly stemming from formal psychopathology and violent behavior strengthens the argument for a conservative (cognitive-based) use of the NCR adjudication. I am not updated on how the use of classic (Jasperian) elaboration of the delusion concept has fared in court testimony (perhaps...  Read more


View all comments by Paulo Negro

Comment by:  Jan Golembiewski
Submitted 2 February 2011 Posted 3 February 2011

The discussion of violence in mental illness inevitably focuses on psychosis, mania, drug dependency disorders, and affective disorders. Among these illnesses, three themes re-occur: 1) paranoiac-defensive violence, 2) manic-delusional violence, and 3) cases involving mostly depression and bipolar disorder where the violence seems to be triggered by altruistic delusions (Large and Nielssen, 2011; Richard-Devantoy et al., 2008). This last case appears to fit the bill for the Tucson massacre, at least on evidence as presented by the media. We are told the suspect’s Internet babble contained claims that Giffords was responsible for brainwashing the American public (Wilmer, 2011).

But there is another condition that may lead to violence in psychiatric disorders that appears to be continually overlooked, though obviously not in the case of Loughner. It is the case for opportunistic violence. This is where violence occurs (to one’s self or another person or living thing) simply because...  Read more


View all comments by Jan Golembiewski

Comment by:  Anne Grasbeck
Submitted 14 February 2011 Posted 14 February 2011

Psychiatric symptoms including disinhibition with aggressiveness characterize frontotemporal dementia. The onset of this neurodegenerative disorder is usually around the ages of 55-60, but cases with onset at the ages of 20-30 have been described. In the early stages, frontotemporal dementia could be difficult to distinguish from affective disorders and schizophrenia.

References:

Brun A, Englund B, Gustafson L, Passant U, Mann DMA, Neary D, Snowden J. Clinical and neuropathological criteria for frontotemporal dementia. The Lund and Manchester Groups. J Neurol Neurosurg Psychiatry 1994;57: 416-8.

Horstmann V, Gräsbeck A. Occurrence of depression in families with frontotemporal dementia (FTD) – a family history study. Neuroepidemiology 2009;33:124-130. Abstract

Vanderzeypen, F., Bier, J. C., Genevrois, C., Mendlewicz, J. & Lotstra, F. (2003) [Frontal dementia or dementia praecox? A case report of a psychotic disorder with a severe decline]. Encephale, 29, 172-80. Abstract

View all comments by Anne Grasbeck


Comment by:  David Shern (Disclosure)Steven Vetzner
Submitted 14 February 2011 Posted 14 February 2011

The discussion surrounding the tragic shootings in Arizona has too often focused on statutory and regulatory changes that will either compel individuals into care as outpatients and/or create lists of persons who have been involuntarily treated for mental health conditions. Neither of these is evidence-based, and there are good reasons to believe that both have chilling effects on the help-seeking behaviors that we should be encouraging. From our perspective, they are "feel good" efforts that do no real good by themselves. This is particularly tragic since we have evidence-based prevention programs that have been shown to reduce the rate of antisocial behaviors, diagnosable mental illnesses, and substance use conditions. We need to place greater emphasis on public health initiatives that will prevent the development of behavioral problems, promote access to treatment, and benefit the greater good.

One example of the reflexive response is the recommendation that we should somehow change gun laws so that information on people like Loughner can be collected and their access to...  Read more


View all comments by David Shern
View all comments by Steven Vetzner

Comment by:  Sandeep Saluja
Submitted 17 February 2011 Posted 17 February 2011

May I please ask what specific drug therapies target aggression? I have patients who continue to display aggression despite receiving both antipsychotics and anticonvulsants.

View all comments by Sandeep Saluja

Comment by:  Anne Grasbeck
Submitted 17 February 2011 Posted 17 February 2011

In geriatric psychiatry, interviews with relatives are standard when investigating persons for dementia. This is because relatives are often the first to notice when the patient’s personality changes, and because it is possible to receive useful information from them (Barber et al., 1995).

Studies on violent acts and threats by persons with serious mental illness have shown that more than half of the targets of violence were the relatives of the mentally ill. Stranger homicide in psychosis was very uncommon (Estroff et al., 1994; Nielssen et al., 2009). Violence toward mothers was most common among patients with psychoses (Estroff et al., 1994; Liettu et al., 2009). Patients who were violent perceived their relatives as threatening but did not consider themselves as being threatening in return (  Read more


View all comments by Anne Grasbeck

Comment by:  Jan Golembiewski
Submitted 22 February 2011 Posted 22 February 2011

Anne Gräsbeck’s comment on 17 February seems to suggest that opportunistic violence is rare; however, violence due to Capgras delusion is much more common among those with psychiatric disorders (De Pauw and Szulecka, 1988; Richard-Devantoy et al., 2008). Capgras is a belief that friends and family have been replaced by someone else with bad intentions (see Gerrans, 2002). Thus, the murder of friends and family can be understood to be altruistic.

Although the case of the suspect Loughner is neither opportunistic, nor Capgras, the Tucson massacre (as I wrote in my last posting; Golembiewski, above) appeared to be motivated by altruism. The murderer appeared to be motivated by the interests of protecting society. The concern in Capgras is (presumably) for the safety of the self and those close relatives and friends who fail to see past the (victim’s) mask (and into the Capgras delusion). Is violence like the Tucson case motivated by delusions that are related to Capgras, but with...  Read more


View all comments by Jan Golembiewski

Comment by:  Lennart Borgman
Submitted 25 March 2011 Posted 25 March 2011

It is interesting to note that clozapine, the substance which seemed best to reduce violence in data by both Krakowski et al., 2006, and Topiwala and Fazel, 2010 (mentioned before in this discussion), also is associated with the lowest mortality rate according to Tiihonen et al., 2009 (approx one-quarter compared to haloperidol and one-half compared with olanzapine).

Could this perhaps be associated with less brain damage? Could the results from Amminger et al. be valuable here?

References:

Amminger, G. P., Schafer, M. R., Papageorgiou, K., Klier, C. M., Cotton, S. M., Harrigan, S. M., Mackinnon, A., et al. (2010). Long-Chain {omega}-3 Fatty Acids for Indicated Prevention of Psychotic Disorders: A Randomized, Placebo-Controlled Trial. Arch Gen Psychiatry, 67(2), 146-154. Abstract

Tiihonen, J., Lönnqvist, J., Wahlbeck, K., Klaukka, T., Niskanen, L., Tanskanen, A., Haukka, J. (2009). 11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study). Lancet, 374, 620-7. Abstract

View all comments by Lennart Borgman

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