Schizophrenia and Violence

By Dr. Vjekoslav Peitl

Even today there is a noticeable stigma associated with psychiatric patients, especially patients with schizophrenia, as schizophrenia is the most stigmatised psychiatric disease. One of the theories on the development of the stigma is based on the existence of two kinds of threat, symbolic and tangible. The symbolic threats are those affecting beliefs, values, ideology or the way a group defines its social, political or spiritual norms, and we can agree that schizophrenia (as well as other psychiatric disorders) often does not comply with the mentioned norms. Tangible threats are those that may lead to direct physical damage and in this context the patient is perceived as unpredictable and dangerous, posing a threat to personal safety. Another reason for fear lies in the fact that the general population does not understand this group of patients or their illness. This misunderstanding is mostly due to ignorance. Misunderstanding and ignorance regarding any individual or group causes fear, a fear of the unknown, which often leads to isolation. Speaking of the stigmatisation of schizophrenia, one of the main reasons for exclusion of the affected individuals from society is another, related, fear – the fear of violence. Over the years this fear has also often been sustained by the media, featuring patients with schizophrenia usually in the context of a criminal act, usually a bizarre one. Out of sensationalism, the unaccountability of the affected person was often dismissed and unjustified. The fact that these people are often left on their own, on the outskirts of a a society that should be taking care of them, their regular treatment and medication, social support, etc. was usually ommitted from media coverage. Thus, dealing with the core of the patients’ problems was avoided and the problem ignored without searching for its solution. All of that while forming the opinion of the general public that most patients are dangerous and violent. Because of this fear through history psychiatric patients were sent to closed institutions away from civilization and to the margins of society (this attitude persists in some societies even today). However, the change of this process, with a significant deinstitutionalization of psychiatric patients ongoing from the nineteen-seventies to this day did not cause an increase of criminal acts in the population of patients with schizophrenia.

Although many cultural, religious, racial and similar differences have been overcome through understanding and education, this is not the case in patients with psychiatric disorders. As we have stressed earlier, this is especially evident in patients suffering from schizophrenia. These individuals are specific because an average person (layman) cannot completely understand a psychotic patient due to the fact that symptoms of the disorder tend to vary from one patient to another, as well as in the same patient during his or her lifetime. Other symptoms of the disease, such as negative symptoms (paucity of speech, autism, restricted emotional expression, social withdrawal, unkempt physical appearance etc.) may give out the impression that the person’s senses are impaired, resulting in hallucinations, even though this is often not the case. The truth is that psychosis as a group of symptoms often varies; it often remains undetected in its beginnings and in the case of distorted perception of reality (hallucinations) the future reactions of the patients to such distorted perception cannot be safely predicted. However, we must also stress that such moments are relatively rare and extremely well treated and controlled with available medication (antipsychotics and others). Furthermore, schizophrenia is a chronic illness. Despite this fact, patients do not chronically hallucinate their entire lives, nor are they chronically aggressive. Instead, they suffer from episodes of illness deterioration, which can be considered as fragments within the overall chronic and often uneventful disease course.

Many authors emphasize the negative impact of social stigmatization on confidence, social adaptation and regular taking of prescribed medication. Additionally, many people have tried to break the prejudices and declare these patients as less dangerous to society. From the nineteen-eighties until today it has been proclaimed that these patients are not more inclined to violent behavior than the general population, which has been statistically proven many times. Many associations that gather patients, family and friends of patients with schizophrenia, charity organizations (The Schizophrenia and Related Disorders Alliance of America, Sane Australia, etc.), as well as some scientists believe that there is no significant link between schizophrenia and violence.

But, is this really true?

The research conducted in the nineteen-eighties, and even some more recent, have not found a significant difference in tendencies towards violence between patients and general population. However, it was noticed that patients with severe psychological disorders are more likely to get arrested than the rest of the population. This is usually due to the patients’ often conspicuous or particular appearance, their clothes, unusual behavior and prejudice from the people arround them, prompting false reports due to lack of information on the actual perpetrator. Some research even suggests that patients with schizophrenia are more likely to become victims than commit acts of violence. Furthermore, only a small fragment of violent behavior in the population is attributed to psychological disorders. However, recent research indicates that patients with schizophrenia have an increased rate of violent behavior compared to the general population, with mostly autoaggressive acts, especially suicide attempts. According to some authors, 5 % of the patients are at risk from committing suicide in their lifetime. Just to compare numbers, the risk of committing homicide in the same population is estimated at 0.3 %, compared to less than 0.1 % in the general population. Increased tendency towards violent behavior is associated with many risk factors, primarily with the use of illegal psychoactive substances. Other factors that may contribute to violent behavior are young age, male sex, alcohol consumption, low socioeconomic status, unemployment, acute phases of the disease, irregular taking of medication, comorbidity of dissociative personality disorder (psychopathy), paranoid subtype of schizophrenia, earlier suicide attempts, recurring hospitalization and history of violent behavior. According to a recent meta-analysis, 38.5 % of all homicides committed by patients with schizophrenia occurred during their first psychotic episode, before the introduction of any kind of therapy. Thus, they occured when the disease was still unrecognized, undiagnosed and untreated.

We can conclude that only a small portion of patients with schizophrenia exhibit a tendency towards violent behavior. The risk of violent behavior in this population increases with the presence of comorbidity as well as a series of other risk factors. As most of the earlier mentioned risk factors can be prevented and/or treated, their recognition and early detection form the basis for preventing agitation, aggressive and violent behavior. As violent behavior in patients with schizophrenia mostly occurs before and during the first psychotic episode, i. e. prior to any treatment; early treatment of psychotic disorders (especially schizophrenia) is extremely important as a preventive measure. Furthermore, as schizophrenia is a chronic disorder, adequate and tailor made treatment (especially psychopharmacotherapy) forms the mainstay of a long-lasting patient-physician relationship and ensures an equally long-lasting remission, free of aggressive symptoms.

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