[Risk of homicide and major mental disorders: a critical review]

The TCO concept in German forensic homicide offenders with schizophrenia spectrum disorders - new findings from a file-based, retrospective cross-sectional study

Introduction

There is evidence that there is a small group of people with schizophrenia spectrum disorders who are more likely to commit homicide than those in the general population. However, there is limited knowledge about the psychopathology that leads to homicide in this group. The aim of this study was to examine two commonly used definitions of the Threat/Control-Override (TCO) concept, which aims to identify a certain risk of serious violence in patients with schizophrenia spectrum disorders.

Methods

This is a sub analysis of a file-based, retrospective and exploratory cross-sectional study. All forensic homicide offenders with schizophrenia spectrum disorders who were detained at the Forensic Hospital Berlin as of 31 December 2014 were examined for the occurrence of TCO according to two commonly used definitions.

Results

Of a total of 419 forensic patients with schizophrenia spectrum disorders, 78 committed homicide (18.6%). The forensic homicide offenders with schizophrenia spectrum disorders were characterised by being male, unemployed, single and having committed (attempted) manslaughter. Irrespective of the definition used, the entire TCO complex was present in less than a third of the sample. In both definitions, Threat symptoms were slightly less frequent than Control-Override symptoms. While Threat symptoms occurred less frequently in Stompe et al.'s definition, Control-Override symptoms were the most common. With regard to Kröber's definition of Threat and Control-Override, the situation is exactly the opposite.

Discussion

Regarding the entire TCO complex, Kröber's definition seems a little more open and Stompe et al.'s more strict (38.5% vs. 35.9%). Since TCO only occurs in about one third of the subjects in both definitions, neither definition appears to be conclusive. A combination with proportions from both definitions could be a contribution to a future definition of TCO. The present study provides scarcely published primary data on psychopathology in homicide offenders with schizophrenia spectrum disorders, especially on the much discussed TCO concept in two definitions. In order to determine the most useful definition of TCO, to avoid false positives and to identify clear psychopathological risk symptoms, larger samples and comparative studies with offenders and non-offenders should be conducted in the future.

The effect of functional remission and cognitive insight on criminal behavior in patients with schizophrenia

OBJECTıVE: This study was planned to determine the relationship of functional remission with a criminal history and determine its effect on criminal behavior in patients with schizophrenia.

METHODS

This cross-sectional study was conducted with 132 patients with schizophrenia (66 with and 66 without a criminal history). Data were collected between November 2020 and April 2021 using a personal information form, the Functional Remission of General Schizophrenia (FROGS), the Taylor Crime Violence Rating Scale, the Beck Cognitive Insight Scale, and the Positive and Negative Syndrome Scale (PANSS) was used to collect data.

RESULTS

In terms of all scale variables, there were significant differences between the groups with and without a criminal history (p < 0.05). These differences were mostly clearly observed in the FROGS-social functionality (effect size: 16.79), PANSS-positive (effect size: 2.62) and FROGS-health and treatment (effect size: 2) subscales.

CONCLUSIONS

In this study, it was determined that as the symptoms of the illness increased in schizophrenia, the patients' functional remission and insight decreased, and their tendency to commit crimes increased. Psychiatric nurses can plan therapeutic interventions to increase the functionality and insight levels of patients with schizophrenia.

Homicides committed by women with mental disorders: A descriptive study conducted in a French secure unit

Women remain a small minority of homicide offenders and appear to be understudied in the scientific literature. Gender-specific characteristics are however identified by existing studies. The aim of the study was to explore homicides committed by women with mental disorders, by analyzing their sociodemographic, clinical features, and criminological circumstances of the homicide. We conducted a retrospective and descriptive study among all female homicide offenders with mental disorders hospitalized in a French high-secure unit over a 20-year period (n = 30). We found that the female patients we studied were a diverse group in terms of their clinical profiles, backgrounds, and criminological characteristics. Confirming previous studies, we observed an over-representation of young women, unemployed, with a destabilized family situation and history of adverse childhood experiences. Prior self- and hetero-aggressive behavior were frequent. We found a history of suicidal behavior in 40% of cases. Their homicidal acts often occurred impulsively at home, in the evening or at night and were mainly directed toward family members (60%), especially their child(ren) (46.7%), then acquaintances (36.7%), and rarely a stranger. We found symptomatic and diagnostic heterogeneity: schizophrenia (40%), schizoaffective disorder (10%), delusional disorder (6.7%), mood disorders (26.7%), and borderline personality disorder (16.7%). Mood disorders were exclusively unipolar or bipolar depressions, often with psychotic features. The majority of patients had received psychiatric care prior to the act. We identified four subgroups, according to psychopathology and criminal motives: delusional (46.7%), melancholic (20%), homicide-suicide dynamic (16.7%), and impulsive outbursts (16.7%). We consider that further studies are necessary.

Patient’s Experiences of Violence as Perpetrator: A Qualitative Study from Patients with Schizophrenia in Indonesia

BACKGROUND: Individuals with schizophrenia are at an increased risk for violence – limited study on exploring the experience of violence in patients with schizophrenia as a perpetrator. AIM: This research aimed to investigate the perception of violence as a perpetrator in Indonesia in patients with schizophrenia. METHODS: This study used phenomenology using a purposive sampling technique. A total of 40 patients were from the psychiatric ward of significant mental hospitals in West Java, Indonesia. The inclusion criteria for patients were the following: Age over 18 years old confirmed diagnosis with schizophrenia. Focus group discussion of patients comprised four groups. Each group consisted of tens of patients. RESULTS: The patient’s experiences as a perpetrator were categorized into six subthemes: Committing physical violence to family, quarreling with family, verbal abuse to family, a perpetrator of verbal violence to neighbors, expression of anger to object, and physical violence to nurse. CONCLUSION: The patient’s experiences of violence were not linear, but rather it was a complex experience of being a perpetrator, yet at the same time as of perpetrator violence. A staff training program to reduce patient violence is needed.

California's Mental Health Services Act and Mortality Due to Suicide, Homicide, and Acute Effects of Alcohol: A Synthetic Control Application

California's Mental Health Services Act (MHSA) substantially expanded funding of county mental health services through a state tax, and led to broad prevention efforts and intensive services for individuals experiencing serious mental disorders. We estimated the associations between MHSA and mortality due to suicide, homicide, and acute effects of alcohol. Using annual cause-specific mortality data for each US state and the District of Columbia from 1976-2015, we used a generalization of the quasi-experimental synthetic control method to predict California's mortality rate for each outcome in the absence of MHSA using a weighted combination of comparison states. We calculated the association between MHSA and each outcome as the absolute difference and percentage difference between California's observed and predicted average annual rates over the postintervention years (2007-2015). MHSA was associated with modest decreases in average annual rates of homicide (-0.81/100,000 persons, corresponding to a 13% reduction) and mortality from acute alcohol effects (-0.35/100,000 persons, corresponding to a 12% reduction). Placebo test inference suggested that the associations were unlikely to be due to chance. MHSA was not associated with suicide. Protective associations with mortality due to homicide and acute alcohol effects provide evidence for modest health benefits of MHSA at the population level.

Homicide committed by individuals with severe mental illnesses: A comparative study before and after the Tunisian revolution of January 14th, 2011

BACKGROUND

Many studies have established a correlation between the increase of homicide rates, and economic crises and rapid social changes following historical events. We propose to analyse the impact of the Tunisian Revolution on homicide rates in Tunisia in a clinical population.

METHODS

We conducted a retrospective comparative study of all individuals who commited an homicide and were admitted, at least once, to the forensic psychiatry unit in Razi Hospital between January 1st, 2004 and December 31st, 2018 after a decision of irresponsibility by reason of insanity.

RESULTS

The number of homicides committed by the individuals with mental illness included in our study was multiplied by a factor of 1.3 after the revolution, with a prevalence of 11.0% between 2004 and 2011, compared to a prevalence of 14.7% during the period 2011-2018. No significant difference was noted between the two groups regarding the socio-demographic characteristics or the characteristics of the act committed.

CONCLUSION

Our results highlighted that political and socio-economic crises following the Tunisian revolution significantly contributed to an increase of homicide rates in people with severe mental illness. Thus, macro-level socioeconomic determinants would be important to consider in homicide prevention strategies.

Psychopathy in Italian female murderers

Over the years, the number of homicides in Italy has progressively decreased, ultimately becoming one of the lowest rates in Europe (357 = 0.7 per 100,000 inhabitants in 2017, according to ISTAT). The number of homicides committed by women was about 9% of the total number of homicides during our study period. The percentage has increased in recent years because the total number of homicides has decreased without a proportionate decrease in the number of female homicides. Indeed, murder is an unusual type of crime for a woman and is often associated with a mental disorder, so when a woman committed a homicide, a psychiatric assessment was often performed. A forensic psychiatry expert was assigned to investigate the offender's psychopathology and mental state at the time of the offense. The root causes of the crime remained unexplained, however, due to the lack of a psychiatric precedent to justify this kind of assessment. The role of psychopathy in homicide has seldom been studied in female offenders, even though psychopathy has an important role in violent crimes. The investigators examined, clinically and historically, a sample of women who committed murder with different levels of criminal responsibility (female homicide offenders found not guilty by reason of insanity, having partial criminal responsibility, and convicted as criminally responsible and sentenced to prison) to identify the prevalence of the psychopathic dimension and its possible role in this sample. Prevalence and degree of psychopathic traits were examined in these female offenders using the Psychopathy Checklist-Revised. This study showed that females who had committed homicide were likely to suffer from mental illness; most of the homicidal acts were committed impulsively; and most female homicides occurred within the family, especially among women who were psychotic, but less so if they were psychopathic. Psychopathy tended to co-occur more with personality disorders than with psychotic psychopathology. Psychopathy was more evident among female homicide offenders who had been abused or traumatized. Psychopathic women who killed had high factor F1 scores and low antisocial component of factor F2.

The presence of alcohol consumption prior to homicide in Singapore

OBJECTIVE

To determine the prevalence of alcohol use disorders in people charged with homicide in Singapore. We also sought to determine which historical risk factors were associated with the use of alcohol 24 h prior to the homicide and with the presence of a severe mental illness at the material time of the offence.

METHODS

We extracted data from administrative records of all people charged with homicide in Singapore between 2007 and 2014. We used regression models to adjust for known confounding variables and explore the relationship between alcohol use and homicide.

RESULTS

Of 253 homicide offenders, 141 individuals (56%) meeting criteria for alcohol use disorders at the time of the offence. 121 offenders (48%) consumed alcohol within the 24 h preceding the homicide. Of the 149 that met criteria for a psychiatric diagnosis, 35 had a severe mental illness.

CONCLUSION

Alcohol use disorders are by far the most common disorder diagnosed in people charged with homicide in Singapore. Alcohol use is less common in homicide offenders with SMI.

[Paranoid personality disorder and criminal offense]

BACKGROUND

Currently, all of the studies that focus on the relationship between paranoia and criminal offenses exclusively concern subjects suffering from a delusional paranoid disorder. However, subjects with single paranoid personality disorder, without any associated delusional disorder, are not uncommon in forensic practice.

OBJECTIVES

This study aims to describe the offenses committed by subjects suffering from a single paranoid personality disorder and to compare them with the offenses committed by the subjects affected by a paranoid delusional disorder associated with paranoid personality disorder. Our initial hypothesis is that both populations have a comparable criminological profile.

METHODS

Based on a 17 year-long experience carried out in the framework of a forensic assessment, we have selected all subjects presenting a paranoid personality disorder, whether single or associated with paranoid delusional disorder. The selected individuals were divided into two groups according to whether they presented paranoid delusional disorder or not. The offenses were grouped into criminal categories. The alpha risk was fixed at 1%. Data analysis is done by SAS software version 9.4.

RESULTS

In a sample of 106 subjects presenting a paranoid personality disorder, including 4 women and 102 men, we found 79 subjects with a single paranoid personality and 27 with an associated paranoid delusional disorder. The average age at the time of the offense was 41 for those with single personality disorders and 49 for those with paranoid delusional disorders. Both groups had forensic antecedents (41%, 11/27 of paranoid delusional disorder and 51%, 40/79 of single paranoid personality disorder). Psychiatric history was more frequent in the paranoid delusional disorder group (59%, 16/27) than in the single paranoid personality disorder group (13%, 10/79). History of addiction was comparable in terms of alcohol abuse (26% in both groups) and other substances (7.5%, 2/27 of paranoid delusional disorder and 9%, 7/79 of single paranoid personality disorder). Comparison of the two groups highlighted significant differences in the type of criminal offenses committed (Fisher's exact test: P=0.0003, alpha risk <0.0001). The offenses committed by delusional authors essentially came down to verbal or physical violence, including homicide (44%, 12/27), and were usually focused on a designated persecutor. Sexual violence was rare. On the other hand, paranoid personality disorder was associated with a wider variety of offenses. Sexual offenses (including 28 rapes, 35%, 28/79) were thus almost as frequent as murder, and attempted murder (38%, 30/79). This diversity of committed offenses was found in their forensic antecedents. In these subjects, the logic of omnipotence may had over ruled the logic of revenge.

CONCLUSION

We conducted a retrospective study on 106 subjects with paranoid personality disorder, including 27 subjects with associated paranoid delusional disorder. The comparison of the two groups demonstrated significant differences in offenses. Verbal and physical but non-sexual violence, committed in a delusional logic, was found among delusional subjects, while the forms of violence were more multiform in the single paranoid personality disorder group, frequently including sexual violence. This is, as far as we know, the first study describing the medico-legal acting-out of paranoid personalities. These results, which will need to be confirmed by future studies, point out the importance of the criminological risk that may be associated with paranoid personality disorder, without any associated delusional disorder.

Association of Schizoid and Schizotypal Personality disorder with violent crimes and homicides in Greek prisons

BACKGROUND

Personality disorders (PDs) have been associated with both violent crimes and homicides in many studies. The proportion of PDs among prisoners reaches up to 80%. For male prisoners, the most common PD in the literature is antisocial PD. The aim of this study was to investigate the association between PDs and violent crimes/homicides of male prisoners in Greece.

METHODS

A sample of 308 subjects was randomly selected from a population of 1300 male prisoners incarcerated in two Greek prisons, one urban and one rural. The presence of PDs was assessed using the Mini International Neuropsychiatric Interview (MINI) and the Personality Diagnostic Questionnaire-4 (PDQ-4). Using logistic regression models PD types and PD "Clusters" (independent variables) were associated with "violent/non-violent crimes" and "homicides/non homicides" (dependent variables).

RESULTS

"Cluster A" PDs (Paranoid, Schizoid, and Schizotypal) were diagnosed in 16.2%, "Cluster B" (Antisocial, Borderline, Histrionic, Narcissistic) in 66.9% and "Cluster C" (Obsessive-Compulsive, Dependent, Avoidant) in 2.9% of the studied population. Violent crimes and homicides were found significantly associated with "Cluster A" PDs (p = 0.022, p = 0.020). The odds ratio of committing violent crimes was 2.86 times higher for patients with "Cluster A" PDs than the ones without PDs. In addition, the odds ratio of committing homicides was 4.25 times higher for patients with "Cluster A" PDs. In separate analyses, the commitment of violent crimes as well as homicides, was significantly associated with Schizoid (p = 0.043, p = 0.020) and Schizotypal PD (p = 0.017, p = 0.030).

CONCLUSIONS

The majority of prisoners was found to suffer from a PD, mainly the Antisocial "Cluster B", but the commitment of violent crimes and homicides was significantly associated only with "Cluster A" PDs and specifically with Schizoid and Schizotypal PD.

Method of homicide and severe mental illness: A systematic review

There is limited research that has examined offense characteristics in homicides committed by individuals with mental illness and with differing psychiatric diagnoses. The aim of this systematic review is to synthesize previous findings of studies analyzing homicide behavior by mentally ill individuals, and reporting any associations between mental illness and method of homicide. We searched four databases (MedLine, PsychINFO, Web of Science and Embase), and identified 52 relevant articles for analysis. Of these 52 articles, nine reported specific information on mental illness and method of homicide. Five out of nine articles revealed an association between schizophrenia/delusional disorder and the use of sharp instruments as a method of homicide. Four out of nine studies revealed an association between mood disorders (bipolar disorder/major depression) and strangulation/asphyxiation/suffocation/drowning. Our review confirms consistency across studies reporting a significant association between close contact methods and schizophrenia/mood disorders. Also identified as possible influential factors concerning weapon choice are illness duration, victim characteristics and planning/lack of planning of the homicide. Additionally, studies revealed up to 96% of severely mentally ill offenders experienced psychiatric symptoms at the time of the homicide. Future research may examine the presence of specific psychiatric symptoms when a mentally ill offender commits a homicide and whether these may be more influential in the method of homicide used than the psychiatric diagnosis of the offender.

Case-controlled Analysis of Patient-based Risk Factors for Assault in the Healthcare Workplace

Introduction

Violence against healthcare workers in the medical setting is common and associated with both physical and psychological adversity. The objective of this study was to identify features associated with assailants to allow early identification of patients at risk for committing an assault in the healthcare setting.

Methods

We used the hospital database for reporting assaults to identify cases from July 2011 through June 2013. Medical records were reviewed for the assailant’s (patient’s) past medical and social history, primary medical complaints, ED diagnoses, medications prescribed, presence of an involuntary psychiatric hold, prior assaultive behavior, history of reported illicit drug use, and frequency of visits to same hospital requesting prescription for pain medications. We selected matched controls at random for comparison. The primary outcome measure(s) reported are features of patients committing an assault while undergoing medical or psychiatric treatment within the medical center.

Results

We identified 92 novel visits associated with an assault. History of an involuntary psychiatric hold was noted in 52%, history of psychosis in 49%, a history of violence in the ED on a prior visit in 45%, aggression at index visit noted in the ED chart in 64%, an involuntary hold (or consideration of) for danger to others in 61%, repeat visits for pain medication in 9%, and history of illicit drug use in 33%. Compared with matched controls, all these factors were significantly different.

Conclusion

Patients with obvious risk factors for assault, such as history of assault, psychosis, and involuntary psychiatric holds, have a substantially greater chance of committing an assault in the healthcare setting. These risk factors can easily be identified and greater security attention given to the patient.

[Association between the violence in the community and the aggressive behaviors of psychotics during their hospitalizations]

BACKGROUND

Violence is a common issue in psychiatry and has multiple determiners. The aim of this study is to assess the psychotic inpatients' violence in association with the violence of the neighborhood from which the patients are drawn and to estimate the impact of this environmental factor with regard to other factors.

METHOD

A prospective multicenter study was led in nine French cities. Eligible patients were psychotic involuntary patients hospitalized in the cities' psychiatric wards. During their treatments, any kind of aggressive behavior by the patients has been reported by the Overt Aggression Scale (OAS).

RESULTS

From June 2010 to May 2011, 95 patients have been included. Seventy-nine per cent of the patients were violent during their hospitalizations. In a bivariate analysis, inpatient violence was significantly associated with different factors: male gender, patient violence history, substance abuse, manic or mixed disorder, the symptoms severity measured by the BPRS, the insight degree and the city crime rate. In a multivariate analysis, the only significant factors associated with the patients' violence were substance abuse, the symptoms severity and the crime rates from the different patients' cities.

CONCLUSION

These results suggest that violence within the psychotic patients' neighborhood could represent a risk of violence during their treatments.

Incidence and risk factors of workplace violence on psychiatric staff

BACKGROUND

A study by Hesketh et al. found that 20% of psychiatric nurses were physically assaulted, 43% were threatened with physical assault, and 55% were verbally assaulted at least once during the equivalent of a single work week. From 2005 through 2009, the U.S. Department of Justice reported that mental health occupations had the second highest average annual rate of workplace violence, 21 violent crimes per 1,000 employed persons aged 16 or older.

OBJECTIVE

An evaluation of risk factors associated with patient aggression towards nursing staff at eight locked psychiatric units.

PARTICIPANTS

Two-hundred eighty-four nurses in eight acute locked psychiatric units of the Veterans Health Administration throughout the United States between September 2007 and September 2010.

METHODS

Rates were calculated by dividing the number of incidents by the total number of hours worked by all nurses, then multiplying by 40 (units of incidents per nurse per 40-hour work week). Risk factors associated with these rates were analyzed using generalized estimating equations with a Poisson model.

RESULTS

Combining the data across all hospitals and weeks, the overall rate was 0.60 for verbal aggression incidents and 0.19 for physical aggression, per nurse per week. For physical incidents, the evening shift (3 pm - 11 pm) demonstrated a significantly higher rate of aggression than the day shift (7 am - 3 pm). Weeks that had a case-mix with a higher percentage of patients with personality disorders were significantly associated with a higher risk of verbal and physical aggression.

CONCLUSION

Healthcare workers in psychiatric settings are at high risk for aggression from patients.

[Impulsivity: What are the consequences on compliance to rehabilitation?]

INTRODUCTION

Impulsivity is a transnosographical dimension with major consequences on medical care with which psychiatrists are frequently confronted. Furthermore, compliance is a major variable that can affect the efficiency of therapeutics and hospitalizations in psychiatry. A study was carried out in three drug and alcohol rehabilitation hospitalization units to find out if impulsivity can have consequences on compliance.

METHOD

The studied population was composed of 85 patients aged from 18 to 70, hospitalized for one or more addiction disorders in a psychometric hospital in Vannes (France). Impulsivity was measured for all patients with the BIS-11 at the beginning of the rehabilitation program. Because no tool to evaluate a total rehab program compliance existed, a scale, used at the end of the hospitalization, was created to measure patient compliance. This score was composed of two simple numeric scales (one used by the nurses and one used by the patient's psychiatrist) and a coefficient of hospitalization duration that was the ratio of completed to planned days of hospitalization. Correlations were made between the different dimensions: impulsivity and compliance, impulsivity and hospitalization conditions, compliance and hospitalization conditions (voluntary or involuntary, planned by a psychiatrist or not, etc.).

RESULTS

The main statistically significant result of the study was a negative correlation existing between the motor dimension of impulsivity and compliance (r=-0.37 and P=0.001). The other dimensions of impulsivity showed no significant correlation with compliance score. The study revealed that the different hospitalization conditions showed no link with compliance or impulsivity.

CONCLUSION

These original results show that motor impulsive patients need an adaptation of the rehabilitation programs. Shorter programs might be more efficient.

Associations with violent and homicidal behaviour among men with schizophrenia

Objective We aimed to assess the risk factors associated with homicidal behaviour in male patients diagnosed with schizophrenia. Methods In a period of 1 year, male schizophrenia cases between 18-65 years of age (n = 210) were included. The clinical evaluation included the Positive and Negative Syndrome Scale (PANSS) and Overt Aggression Scale (OAS). The patients were divided into three groups in terms of violent behaviour history: (1) homicide group (n = 30), (2) a violent act resulting in serious injury (n = 71), (3) control group (patients without a history of a violent act) (n = 109). Results Lower level of education, rural residence, being unemployed and living alone were found to be significantly more common in patients who had committed a violent act compared to the schizophrenia patients in the control group. In order to explore the predictive value of several factors associated with violent behaviour, a logistic regression model was used, and variables (shorter duration of education, living alone, and lack of insight) significantly predicted the presence of violent behaviour (murder and/or injury) (χ(2)=31.78, df = 12, p = 0.001). Conclusions In order to be able to determine causality of homicidal acts in schizophrenia patients, our significant findings between homicidal violence, non-homicidal violence and the control group would merit further attention and exploration in further studies.

Developmental typologies of serious mental illness and violence: Evidence from a forensic psychiatric setting

OBJECTIVE

To identify subgroups of forensic psychiatric patients based on the age onset of serious mental illness and offending and assess the external validity of the subgroups with theoretically based sociodemographic, clinical, legal and risk-related variables.

METHOD

The age onset of serious mental illness and criminal contact was ascertained for a sample of 232 patients. A range of sociodemographic, clinical, legal and risk-related variables were coded to assess whether age onset subgroups differed in a manner consistent with the literature on typologies of mentally ill offenders.

RESULTS

One-quarter of the sample was classified as early starters (patients whose first offense occurred before becoming mentally ill), while two-thirds were late starters (where first offense occurred following illness onset). A small percentage (8%) of patients were deemed late late starters, defined as late starters who had experienced 10+ years of illness and were >37 years upon first arrest. A larger proportion of early starters had a substance use disorder, antisocial personality disorder and a greater number of static/historical risk factors for violence. Early starters were younger upon first arrest and had more previous criminal contacts compared to late starters and late late starters. Mental illness was found to start later in life for late late starters; this group was also more likely to have been married and to have a spouse as victim in the index offense.

CONCLUSION

We found support for distinct subgroups of mentally ill offenders based on the age onset of illness and criminal contact. Compared to late starters, offenses committed by early starters may be motivated more frequently by antisocial lifestyle and attitudes, as well as more instrumental behaviors related to substance abuse. In addition, late late starters may represent a distinct third subgroup within late starters, characterized by relatively higher levels of functioning and social stability; future work should replicate. Findings suggest different rehabilitation needs of the subgroups.

Prevalence and attributes of criminality in patients with schizophrenia

Background:

Existing research in law and psychiatry point to schizophrenia as a risk factor for violence and offense behaviors. The present study aims to: 1) report on the prevalence and types of offensive or criminal acts in patients with schizophrenia; 2) identify attributes of schizophrenic offenders; and 3) examine factors associated with offensive or criminal behaviors within a sample of schizophrenic offenders.

Methods:

This was a cross-sectional study of 358 patients with schizophrenia who were admitted to a psychiatric ward in Iran between 2004 and 2008. Study data was collected using patients’ medical, criminal records, as well as via personal interview with the family member. Study variables included criminality or offensive behavior, types of schizophrenia (paranoid vs. nonparanoid), experiencing hallucination, disease onset, and patients’ demographics.

Results:

Of the sample, 64.8% were male, 80.7% were 45 years old or younger, and 74.1% were either single or divorced. Slightly over 59 % were offenders with criminal status, of which, 9.8% were legal offenders and 48.6% were hidden offenders. The results of unadjusted logistic regression between these variables and criminality show, except for employment, marital status, and opium use, all other variables were statically associated with criminality.

Conclusions:

Methodological difficulties arising from this study, as well as, the role of mental health professionals, family, and legal system for prevention of violence in and by patients with schizophrenia are discussed.

[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.

Psychiatric disorders and aggression in the printed media: is there a link? A central European perspective

BACKGROUND

A content analysis was used to describe the association between psychiatric disorders and aggression in the printed media in the Czech Republic and Slovakia.

METHODS

Articles were chosen from the most widely read daily newspapers and magazines in both countries during five one-week periods in 2007. A coding manual was developed and a content analysis was performed. Aggressive behavior was assessed by two separate categories - the role of the mentally ill person in the violent act (perpetrator/victim) and the type of aggressive act (homicide, suicide).

RESULTS

A total of 375 articles were analyzed.

MAIN FINDINGS

1) The proportion of articles depicting psychiatric disorders together with either self- or other-directed aggressive behavior is 31.2%; 2) Homicide was most frequently mentioned in the context of psychotic disorders and schizophrenia, while affective disorders were most frequently associated with both completed suicides and homicides; 3) Eating disorders and anxiety disorders were seldom associated with any kind of aggressive behavior, including self-harm; 4) The vast majority of articles presented mentally ill people as perpetrators, and these articles were more often coded as stigmatizing. 5) Articles with aggressive behavior mentioned on the cover are roughly as frequent as those with aggressive behavior in the later sections of the media (36.7% vs. 30.7%).

CONCLUSIONS

The results are similar to the findings in countries with longer histories of consistent advocacy for improved depiction of mental illness in the media. However, we have shown that persons with mental illness are still over-portrayed as perpetrators of violent crimes, especially homicides.

Aggression in psychiatry wards: a systematic review

Although fairly frequent in psychiatric in-patient, episodes of aggression/violence are mainly limited to verbal aggression, but the level of general health is significantly lower in nurses who report 'frequent' exposure to violent incidents, and there is disagreement between patients and staff concerning predictors of these episodes. We searched the Pubmed, Embase and PsychInfo databases for English, Italian, French or German language papers published between 1 January 1990 and 31 March 2010 using the key words "aggress*" (aggression or aggressive) "violen*" (violence or violent) and "in-patient" or "psychiatric wards", and the inclusion criterion of an adult population (excluding all studies of selected samples such as a specific psychiatric diagnosis other than psychosis, adolescents or the elderly, men/women only, personality disorders and mental retardation). The variables that were most frequently associated with aggression or violence in the 66 identified studies of unselected psychiatric populations were the existence of previous episodes, the presence of impulsiveness/hostility, a longer period of hospitalisation, non-voluntary admission, and aggressor and victim of the same gender; weaker evidence indicated alcohol/drug misuse, a diagnosis of psychosis, a younger age and the risk of suicide. Alcohol/drug misuse, hostility, paranoid thoughts and acute psychosis were the factors most frequently involved in 12 studies of psychotic patients. Harmony among staff (a good working climate) seems to be more useful in preventing aggression than some of the other strategies used in psychiatric wards, such as the presence of male nurses.