Schizophrenia and Violence: from correlations to preventive strategies Paul E Mullen Monash University and Victorian

1. Schizophrenia and Violence: from correlations to preventive strategiesPaul E Mullen Monash University and Victorian Institute of Forensic Mental Health

2. Improved Management of High Risk Groups with Schizophrenia Could • Reduce seriously violent crime by 2-4%. • Reduce incarceration rates (prison and forensic hospitals) of those with schizophrenia by 30% - 50%. • Improve quality of life for the most disturbed and disadvantaged among those with schizophrenia.

3. SCHIZOPHRENIA Clinically Significant Socially Significant VIOLENCE

4. Schizophrenia Among Violent Offenders

5. Homicides and Schizophrenia

6. Homicides and Schizophrenia

7. OR for Schizophrenia and Homicide * Highest probable ascertainment

8. Violent Offending in those with Schizophrenia

9. Violent Offending in Schizophrenia(2861)

10. Violence and Homicide in 1,705 patients with Schizophrenia. Soyka et al 2004 • 7-12 years post discharge: • Any conviction: 224 (13.1%) • Violent convictions: 45 (2.6%) • Homicide/attempted homicide: 5 cases (0.3%)

11. SCHIZOPHRENIA Clinically Significant Socially Significant VIOLENCE

12. WHY HAS IT NOT BEEN OBVIOUS TO CLINICIANS & RESEARCHERS ?

13. CLINICAL RISKS & COMMUNITY RISKS AN APARENT PARADOX • 5 – 10% of violent crime including homicide is attributable to the 0.5 to 0.6% of the population with schizophrenia

14. CLINICAL RISKS & COMMUNITY RISKS AN APARENT PARADOX BUT in schizophrenia the risks for individuals are:- • Homicide 1 in 10000 per year For males 1 in 2000 per year • Convictions serious violence 1 in 500 per year • Any violent convictions 1 in 180 per year for violence For males 1 in 100 per year • Violent incidents 5-10 in 100 per year

15. Violence in Schizophrenia DELUSIONALLY DRIVEN MULTIFACTORIAL l Older Younger Organised Delusions Disorganised Domestic Domestic and non domestic Psychopathic Traits Not Antisocial Conduct Disorder Substance Abusing (look like patients) (look like criminals)

16. Schizophrenia Developmental Difficulties Active Symptoms Personality Vulnerabilities Education Failure Unemployment Social Dislocation Substance Abuse Criminal Peer Group Rejection by Services Violent Behaviours

17. Substance Abuse ?

18. Explaining The Association Between Schizophrenia, Substance Abuse and Offending Substance abuse causes the offending Those with schizophrenia with a propensity for offending behaviours also having a propensity to abuse substances when they are available A mixture of the above

19. OFFENDING AMONG THE MENTALLY DISORDERED 1,136 public inpatients Schizophrenia Protective Factor Steadman et al (1998, 2000)

20. Substance Abuse and Schizophrenia Far higher rates of alcohol and drug abuse are found in those with schizophrenia particularly younger males. (Soyka 2000)

21. Reminder If you control for a variable which is itself significantly associated with schizophrenia then you are controlling in part for the disorder itself and risk obscuring causal as well as statistical associations.

22. Lifetime Convictions in the Schizophrenia Cohorts

23. Lifetime Convictions in the Schizophrenia Cohorts

24. Schizophrenia & S.A. • Comorbid S.A. is associated with increased offending • This is in part because S.A. in almost anyone increases the risks of offending • This is in part because those with a predisposition to offending have a particular avidity for substance abuse • S.A. may explain part but by no means all of the correlation.

25. Manage Substance Abuse

26. Do active symptoms mediate offending in schizophrenia? • Yes: Link & Stuve 1994-1998; Taylor 1985-1998; Arsenault 2000 • Probably not: MacArthur Studies 1998-

27. “Clear emergence of schizophrenia before the onset of significant violence does suggest that in some way the illness may have a direct role in the violence” Taylor & Estroff (2002) • Do the criminal careers differ between those with and those without schizophrenia? • Yes: Hafner & Boker 1973; Taylor 1993; Wessley et al 1994; Taylor & Hodgins 1994

28. Temporal patterns of convictions 8,791 convictions in cases - 1,119 convictions in controls 72.7% convicted for first time prior to first admission

29. The Role of Symptoms in Violent Behaviour • Apparently undeniable in individual cases. • Clear increased rates predate and continue independent of obvious symptoms in many. • An important but not the major mediator in populations.

30. ACTIVE SYMPTOMS Improved Symptom Control. Stabilisation in I.P. context using compulsory powers and extended admissions if indicated. (Forensic services as primary preventative services not just containing services)

31. Current social conditions and dislocation does mediate the correlation to some extent Silver et al (2000)

32. Social Conditions • Avoid discharging to disorganised accommodation in high crime neighbourhoods. • Provide appropriate level of support and supervision. • Ensure opportunity for meaningful activity and recreation within structured programs or work environment. • Address peer groups which support substance abuse and offending.

33. Developmental Histories Those with schizophrenia who show violent and criminal proclivities more frequently:- • come from deprived and disadvantaged backgrounds; • have family histories of criminality; • have had poor peer relationships through childhood and adolescents; • had conduct disorder; • failed educationally. (Schanda et al 1992; Tihonen et al 1997; Fresán et al 2004; Cannon 2002)

34. Early Intervention • Target children from disadvantaged backgrounds for school enhancement programmes • Intervene early in educational failure • Develop active management of conduct disorder

35. Personality Vulnerabilities in Schizophrenia explain part of the Association with Offending

36. Genetic Vulnerability Schizophrenia CD & ASPD

37. Genetic Vulnerability Schizophrenia CD & ASPD Socially Disadvantaged Childhood

38. Mean Number of Registered Total Criminal Offences per Year at Risk from Age 15 to Index Offence for Six Offender Groups Subjected to Forensic Psychiatric Assessment Source: Tengstrom, Grann, Langstrom, Hodgins & Kullgren, 2000

39. CBT & Psychotherapies for Personality Vulnerabilities ASPD (Psychopathic) traits • Callousness and insensitivity • Suspiciousness } • external locus of control } • Novelty seeking } • Impulsiveness (fecklessness) } • Antagonism/negativity • Poor insight Plus cognitive deficits

40. WHAT IS TO BE DONE • Give high risk patients high priority

41. BUT How do you recognise high risk groups?

42. Keep it simple. • Keep it focused • Keep it clinical • Make it Systematic • Make it multidisciplinary • Keep it management focused

43. WHAT IS TO BE DONE • Give high risk patients high priority • Improve the social conditions under which those with schizophrenia live • Ensure employment • Address the criminogenic ‘personality’ factors • Manage substance abuse • Improve symptom control • Improve risk management

44. Breaking the Links Schizophrenia Early Intervention Vigorous Management of Active Illness CBT for Personality Manage Vulnerabilities Substance Abuse Education Enhancement Compulsory I.P. Management if indicated Social Skills Training Placement in Supported Works Skills Training Accommodation in low crime neighbourhoods

45. Improved Management of High Risk Groups with Schizophrenia Could • Reduce seriously violent crime by 2-4%. • Reduce incarceration rates (prison and forensic hospitals) of those with schizophrenia by 30% - 50%. • Improve quality of life for the most disturbed and disadvantaged among those with schizophrenia.

47. Are the associations between schizophrenia and offending an artifact of differential detection and conviction rates?

48. Rates in crimes with a very high clear up rates (e.g. homicides) are greater than those with low clear up rates (e.g. theft) • Probability that police are more reluctant to proceed to charge obviously mentally disordered individuals

49. Lifetime violent convictions Offending in a Population of People with Schizophrenia(2861)(Wallace, Mullen, & Burgess, 2003)

50. Lifetime violent convictions Offending in a Population of People with Schizophrenia(Wallace, Mullen, & Burgess, 2003)