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

Brain structural alterations associated with impulsiveness in male violent patients with schizophrenia

BACKGROUND

Violence in schizophrenia (SCZ) is a phenomenon associated with neurobiological factors. However, the neural mechanisms of violence in patients with SCZ are not yet sufficiently understood. Thus, this study aimed to explore the structural changes associated with the high risk of violence and its association with impulsiveness in patients with SCZ to reveal the possible neurobiological basis.

METHOD

The voxel-based morphometry approach and whole-brain analyses were used to measure the alteration of gray matter volume (GMV) for 45 schizophrenia patients with violence (VSC), 45 schizophrenia patients without violence (NSC), and 53 healthy controls (HC). Correlation analyses were used to examine the association of impulsiveness and brain regions associated with violence.

RESULTS

The results demonstrated reduced GMV in the right insula within the VSC group compared with the NSC group, and decreased GMV in the right temporal pole and left orbital part of superior frontal gyrus only in the VSC group compared to the HC group. Spearman correlation analyses further revealed a positive correlation between impulsiveness and GMV of the left superior temporal gyrus, bilateral insula and left medial orbital part of the superior frontal gyrus in the VSC group.

CONCLUSION

Our findings have provided further evidence for structural alterations in patients with SCZ who had engaged in severe violence, as well as the relationship between the specific brain alterations and impulsiveness. This work provides neural biomarkers and improves our insight into the neural underpinnings of violence in patients with SCZ.

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.

Symptom Profile of Psychiatric Patients With Psychosis or Psychotic Mood Disorder in Prison

There is evidence that psychiatric patients with psychotic or manic disorders who are incarcerated suffer from the same symptoms as psychiatric patients who are treated in the community. There are also indications that their symptoms might be more severe. The aim of this study was to examine the severity of psychotic and manic symptoms, as well as to collect information about the emotional functioning of patients admitted to a prison psychiatric ward. Incarcerated patients with a diagnosis of psychotic or a manic disorder were examined with the Brief Psychiatric Rating Scale-Expanded (BPRS-E). With the scores of 140 assessments, a symptom profile was created using the domains of the BPRS-E. This profile was compared with the clinical profile of three nonincarcerated patient groups described in literature with a diagnosis in the same spectrum. We found high scores on positive and manic psychotic symptoms and hostility, and low scores on guilt, depression, and negative symptoms. High scores on manic and psychotic symptoms are often accompanied by violent behavior. Low scores on guilt, depression, and negative symptoms could be indicative of externalizing coping skills. These characteristics could complicate treatment in the community and warrant further research along with clinical consideration.

Mentalization and empathy as predictors of violence in schizophrenic patients: Comparison with nonviolent schizophrenic patients, violent controls and nonviolent controls

There are conflicting results concerning risk of violence in schizophrenia. Empathy and mentalization deficits are associated both with schizophrenia and violence, however, there are only a few studies with equivocal results concerning their relationship. 88 violent and nonviolent paranoid schizophrenic and violent and nonviolent control males in psychiatric, forensic psychiatric and correctional institutions completed the Ekman 60 Faces test, Faux Pas Recognition Test, Eysenck IVE test, Interpersonal Reactivity Index, and the Spielberger Anger Expression Scale. Data were analysed with ANOVA and logistic regression models. Significant group differences with a characteristic pattern were detected in mentalization, facial affect recognition, fear and anger recognition, interpersonal distress, and frequency of direction of anger expression. Predictors of violent behaviour were different in the schizophrenic and non-schizophrenic groups. Lack of major differences in empathy and mentalization between violent and nonviolent schizophrenia patients suggests that such deficits are core features of schizophrenia but do not determine emerging violence in this illness. Our results emphasise the importance of distinguishing between violence related to core positive symptoms of schizophrenia and that emerging from independent comorbid antisocial personality traits in order to identify targets for screening, detection, prevention and management of violence risk in different subpopulations of schizophrenia patients.

Psychosis and homicide

PURPOSE OF REVIEW

The contribution of people with psychosis to homicide statistics is small, but there is a statistically significantly higher rate of homicide among them than in the general population. Legal authorities and the wider public call for more information. Our aim was a narrative synthesis of empirical literature generated by systematic searches for the five complete years 2013-2017.

RECENT FINDINGS

One article showed that people with psychosis are five times more likely to be homicide victims than those without, but focus remains on perpetrators. Consensus is that although psychotic symptoms contribute to homicidal acts, so do many of the variables that increase homicide risk more generally - including substance use, trauma histories and access to weapons; thus, both the epidemiology of homicide and some details, like method, may be country specific. In 2013-2017, variation in service provision as a risk factor for homicide has emerged more clearly but, overall, research made few homicide-specific advances.

SUMMARY

Criminal homicide is, fortunately, uncommon in most countries. Homicides by people with psychosis are so rare that they do not rate mention in the 2013 United Nations Global Survey of Homicide. This may account for the limitations to much research for this group. Despite some homicide-specific evidence of advantage for early intervention for psychosis, impact of improving treatment - the most promising way forward - will generally have to be inferred from the not entirely satisfactory surrogate of effects of treatment on violent offending more generally.

Analysis and comparison of domestic femicide cases in the cities of Diyarbakir & Tekirdag, Turkey: A preliminary study

Court decision files from 2007 to 2012 were examined retrospectively in the Criminal High Courts of Diyarbakir and Tekirdag to analyse and compare domestic femicides in Diyarbakir and Tekirdag, Turkey, according to different fundamental characteristics. In total, 58 assailants were convicted of 50 femicides during this period. There were no so-called 'honour killings' in Tekirdag, while 16 (37.2%) of the homicides were honour killings in Diyarbakir. Policies to prevent violence against women, extending the means of access to post-violence services and reinforcing the law, policies and action plans to end this type of violence could be effective in decreasing cases of domestic femicide.

Prospective cohort study of the relationship between neuro-cognition, social cognition and violence in forensic patients with schizophrenia and schizoaffective disorder

BACKGROUND

There is a broad literature suggesting that cognitive difficulties are associated with violence across a variety of groups. Although neurocognitive and social cognitive deficits are core features of schizophrenia, evidence of a relationship between cognitive impairments and violence within this patient population has been mixed.

METHODS

We prospectively examined whether neurocognition and social cognition predicted inpatient violence amongst patients with schizophrenia and schizoaffective disorder (n = 89; 10 violent) over a 12 month period. Neurocognition and social cognition were assessed using the MATRICS Consensus Cognitive Battery (MCCB).

RESULTS

Using multivariate analysis neurocognition and social cognition variables could account for 34 % of the variance in violent incidents after controlling for age and gender. Scores on a social cognitive reasoning task (MSCEIT) were significantly lower for the violent compared to nonviolent group and produced the largest effect size. Mediation analysis showed that the relationship between neurocognition and violence was completely mediated by each of the following variables independently: social cognition (MSCEIT), symptoms (PANSS Total Score), social functioning (SOFAS) and violence proneness (HCR-20 Total Score). There was no evidence of a serial pathway between neurocognition and multiple mediators and violence, and only social cognition and violence proneness operated in parallel as significant mediators accounting for 46 % of the variance in violent incidents. There was also no evidence that neurocogniton mediated the relationship between any of these variables and violence.

CONCLUSIONS

Of all the predictors examined, neurocognition was the only variable whose effects on violence consistently showed evidence of mediation. Neurocognition operates as a distal risk factor mediated through more proximal factors. Social cognition in contrast has a direct effect on violence independent of neurocognition, violence proneness and symptom severity. The neurocognitive impairment experienced by patients with schizophrenia spectrum disorders may create the foundation for the emergence of a range of risk factors for violence including deficits in social reasoning, symptoms, social functioning, and HCR-20 risk items, which in turn are causally related to violence.

Prevention of homicidal behaviour in men with psychiatric disorders

OBJECTIVES

Homicide is overwhelmingly committed by men compared to women. Conservative estimates suggest that more than a third of these individuals have a treatable psychiatric disorder. These data present an opportunity to mental health clinicians to assist in the prevention of homicide by improving men's mental health.

METHODS

We review the current literature on men's mental health with a focus on assessing and reducing homicide risk in men with psychiatric conditions.

RESULTS

Bipolar disorder and schizophrenia appear to share a neural endophenotype that is a risk factor for homicide. Dual disorders, or the presence of a substance use disorder with other major mental illness, are a major risk factor for homicide in males. Dual diagnosis disorders, personality disorders and pathological traits and male depression share emotion dysregulation, irritability, and reactive aggression. Promoting physician education, addressing firearm safety, reducing the reluctance of men relative to women to engage in help-seeking behaviour, and using targeted risk interviews which integrate these data are all currently recommended.

CONCLUSIONS

The main focus in prevention of homicidal behaviour in males with psychiatric disorders should be to identify high risk groups, to provide adequate treatment, and to facilitate compliance with long-term treatment while considering male specific problems and needs.

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.