Pamela Jane Taylor

Violence and psychosis. I. Risk of violence among psychotic men.

A survey of the records of 1241 men remanded in prison on criminal charges over four months yielded a high prevalence of psychiatric disorder. Of the total prison intake of 2743 men over the same period, 246 (9.0%) showed major symptoms of psychiatric illness and a further 237 (8.6%) symptoms of withdrawal from drugs or alcohol. Symptoms of neurotic disorders were underrecorded, so in terms of diagnosis 237 men (8.7%) were considered to be psychotic. Of these, 166 (70%) were schizophrenic. The influence of affective psychosis was small. The risk of violence among men with schizophrenia was high. Twenty five (9%) non-fatal personal assaults and 24 (21%) offences of damage to property were committed by men with schizophrenia. The presence of mental illness probably influences the decision to remand in custody for some of these offences, but this is unlikely to explain the substantially higher prevalence of schizophrenia among men convicted of homicide (five (11%) ) and arson (six (30%) ) than would be expected in the general population of Greater London (0.1-0.4%). The prevalence of schizophrenia among men convicted of homicide may even be an underestimate, as may the prevalence of affective psychosis and possibly of other psychiatric abnormalities, given the substantial incidence of concurrent suicide in such men.

Volumetric structural brain abnormalities in men with schizophrenia or antisocial personality disorder

Brain abnormalities are found in association with antisocial personality disorder and schizophrenia, the two mental disorders most implicated in violent behaviour. Structural magnetic resonance imaging was used to investigate the whole brain, cerebellum, temporal lobe, lateral ventricles, caudate nucleus, putamen, thalamus, hippocampus, amygdala and the prefrontal, pre-motor, sensorimotor, occipito-parietal regions in 13 men with antisocial personality disorder, 13 men with schizophrenia and a history of violence, 15 men with schizophrenia without violent history and 15 healthy non-violent men. Compared to controls, the antisocial personality disorder group displayed reductions in whole brain volume and temporal lobe as well as increases in putamen volume. Both schizophrenia groups regardless of violence history exhibited increased lateral ventricle volume, while the schizophrenia group with violent history showed further abnormalities including reduced whole brain and hippocampal volumes and increased putamen size. The findings suggest that individuals with antisocial personality disorder as well as those with schizophrenia and a history of violence have common neural abnormalities, but also show neuro-anatomical differences. The processes by which they came to apparently common ground may, however, differ. The finding of temporal lobe reductions prevalent among those with antisocial personality disorder and hippocampal reduction in the violent men with schizophrenia contributes support for the importance of this region in mediating violent behaviour.

Risk Factors for Homelessness: Evidence From a Population-Based Study

OBJECTIVE This study examined factors associated with lifetime experience of homelessness among young adults. METHODS Data were analyzed for 14,888 young adults (mean+/-SD age 21.97+/-1.77; 7,037 men and 7,851 women) who participated in the National Longitudinal Study of Adolescent Health (Add Health), a U.S. nationally representative, population-based sample. Data were collected from young adults through computer-assisted interviews six years after they had enrolled in the study as adolescents. Variables that have been associated with lifetime homelessness in at least one service sample were mapped to Add Health survey items. Data were analyzed by logistic regression. RESULTS A total of 682 respondents (4.6%) were classified as ever being homeless. Several factors related to childhood experiences of poor family functioning, socioeconomic disadvantage, and separation from parents or caregivers were independently associated with ever being homeless. Other significant independent factors included current socioeconomic difficulty, mental health problems, and addiction problems. Indicators of involvement in crime and addiction problems with gambling and alcohol were not independently associated with homelessness. CONCLUSIONS The findings underscore the relationship between specific indicators of adversity in childhood and risk of homelessness and point to the importance of early intervention efforts. Consistent with the extant research literature, mental health problems also appear to be associated with homelessness, highlighting the potentially complex service needs of this population.

ECT for schizophrenia.

Electroconvulsive therapy (ECT) in the treatment of schizophrenia was evaluated in a double-blind trial; the clinical change after ECT was compared with that after a treatment procedure identical to it but for two exceptions--no electricity was used and no convulsion was induced. All patients had paranoid schizophrenia according to Present State Examination criteria and all received standard doses of neuroleptics for at least 2 weeks before random assignment to the two groups. 20 patients completed the trial: 10 had ECT and 10 were in the control group. Treatment was given three times a week, with a minimum of eight treatments and a maximum of twelve. Clinical change was assessed by the Comprehensive Psychiatric Rating Scale. Both groups improved but the improvement of patients receiving ECT was significantly greater than that of controls both after six treatments (p=0.02) and at the end of treatment (p=0.004). Thus the group receiving ECT gained a clear and early advantage compared with the control group, although by 16 weeks there was little difference between the two groups. Possible reasons for this are discussed.

A neuropsychological investigation into violence and mental illness

Previous research has reported cognitive impairment in patients with schizophrenia and antisocial personality disorder (APD), the two psychiatric illnesses most implicated in violent behaviour. Previous studies have focused on either group exclusively, and have been criticized for procedural inadequacies and sample heterogeneity. The authors investigated and compared neuropsychological profiles of individuals with APD and violent and nonviolent individuals with schizophrenia in a single investigation. The study involved four groups of subjects: (i) individuals with a history of serious violence and a diagnosis of APD, (ii) individuals with a history of violence and schizophrenia, (iii) individuals with schizophrenia without a history of violent behaviour and (iv) healthy control subjects. All study groups were compared on a neuropsychological battery designed to assess general intellectual function, executive function, attention, and processing speed. Cognitive deficits were more widespread among individuals with schizophrenia regardless of history of violence, compared with those with APD. Significant impairment in patients with APD was limited to processing speed. Violent individuals with schizophrenia demonstrated poorer performance than their nonviolent schizophrenia peers on a measure of executive function. Different cognitive impairments are manifested by individuals with APD and schizophrenia with violent behaviours, suggesting differences in underlying pathology. Furthermore, cognitive impairment appears to be more a feature of schizophrenia than of violent behaviour, although there is evidence that a combination of schizophrenia and violent behaviour is associated with greater cognitive deficits.

When symptoms of psychosis drive serious violence

Abstract Three studies are briefly reviewed as contributions to the epidemiology of violence and mental disorder. The samples were severally drawn from a then substantial regional pre-trial prison, a national high security hospital service and a general psychiatric hospital with a mainly local clientele. Delusions emerged consistently as having an important role in the precipitation of a violent act by a person with a psychotic illness; the more serious the act, the more delusions appear to have had a direct role. Nevertheless, given that delusions are very common symptoms of psychosis, but serious violence by someone with psychosis is unusual, other mediating factors must be operating. There is some support each for an interactional effect with other symptoms of the psychotic process, an influential effect on further symptom, – particularly affective symptom – development and at least two social relationship mechanisms. This augurs well for a shift from hitherto primarily observational work to hypothesis-generated research.

Amnesia for criminal offences

Nearly 10% of a sample of men charged with a variety of offences claimed amnesia for their offence. The amnesia occurred only among those who had committed violence and was most frequent following homicide. All the amnesics had a psychiatric disorder, four having a primary depressive illness and the remainder being almost equally divided between schizophrenia and alcohol abuse. None of the amnesias had any legal implications. The circumstances of the offences suggested a variety of mechanisms to account for the amnesia, including repression, dissociation and alcoholic black-outs. Psychological defence mechanisms were probably of some importance, even when alcohol was an important factor.

Dysfunctional, but not functional, impulsivity is associated with a history of seriously violent behaviour and reduced orbitofrontal and hippocampal volumes in schizophrenia

Aggression and violent acts have been linked with impulsive responding. We investigated whether impulsive personality trait, especially suggestive of dysfunctional impulsivity (i.e. fast and inaccurate responding where this is non-optimal), is associated with a history of seriously violent behaviour and specific brain deficits in schizophrenia. Twenty-four male participants with schizophrenia, of whom 10 had a history of serious physical violence, and 14 healthy male participants were assessed on impulsiveness (dysfunctional impulsivity), venturesomeness (functional impulsivity), and empathy. All participants underwent magnetic resonance imaging. The results revealed that participants with schizophrenia and a history of violence showed elevated impulsiveness but had comparable scores on venturesomeness and empathy dimensions. Impulsiveness scores correlated negatively with reduced orbitofrontal grey matter volume in both the patient and healthy control groups, and with hippocampal volume in the patient group. Our findings suggest that dysfunctional, but not functional, impulsivity is elevated in patients with schizophrenia with a propensity for repetitive violence, and this in turn appears to be associated with reduce volumes of both the orbitofrontal cortex grey matter and the hippocampus. Violence risk prediction and management strategies in schizophrenia may benefit from including specific measures of dysfunctional impulsive traits.

Sub-syndromes of tardive dyskinesia.

A reliable method for recording the site and duration of purposeless movements was devised. With this method 267 subjects were studied, 182 of whom had been exposed to neuroleptics. The results were submitted to a principal components analysis and 3 movement dimensions emerged. One group of movements resembled a parkinsonian syndrome. The other 2 groups of movements both conformed to the generally accepted criteria for tardive dyskinesia. These groups were: (1) head and neck movements and (2) trunk and limb movements. The possibility of the second and third groups representing clinically relevant sub-syndromes of tardive dyskinesia is discussed.

Efficacy of mood stabilisers in the treatment of impulsive or repetitive aggression: systematic review and meta-analysis

BACKGROUND Individuals with repetitive or impulsive aggression in the absence of other disorders may be diagnosed with intermittent explosive disorder according to DSM-IV, but no such diagnostic category exists in ICD-10. Mood stabilisers are often used off-license for the treatment of aggression associated with a variety of psychiatric conditions, but their efficacy in these and in idiopathic aggression is not known. AIMS To summarise and evaluate the evidence for the efficacy of mood stabilisers (anticonvulsants/lithium) in the treatment of impulsive or repetitive aggression in adults. METHOD A meta-analysis of randomised controlled trials that compared a mood stabiliser with placebo in adults without intellectual disability, organic brain disorder or psychotic illness, identified as exhibiting repetitive or impulsive aggression. RESULTS Ten eligible trials (489 participants) were identified A pooled analysis showed an overall significant reduction in the frequency/severity of aggressive behaviour (standardised mean difference (SMD) = -1.02, 95% CI -1.54 to -0.50), although heterogeneity was high (I(2) = 84.7%). When analysed by drug type, significant effects were found in the pooled analysis of three phenytoin trials (SMD = -1.34, 95% CI -2.16 to -0.52), one lithium trial (SMD = -0.81, 95% CI -1.35 to -0.28), and two oxcarbazepine/carbamazepine trials (SMD = -1.20, 95% CI -1.83 to -0.56). However, when the results of only those studies that had a low risk of bias were pooled (347 participants), there was no significant reduction in aggression (SMD = -0.28, 95% CI -0.73 to 0.17, I(2) = 71.4%). CONCLUSIONS There is evidence that mood stabilisers as a group are significantly better than placebo in reducing aggressive behaviour, but not all mood stabilisers appear to share this effect. There is evidence of efficacy for carbamazepine/oxcarbazepine, phenytoin and lithium. Many studies, however, were at risk of bias and so further randomised controlled trials are recommended.