Schizophrenia and Violence: Myths, Realities, and Treatments

Schizophrenia and Violence:
Myths, Realities, and Treatments
Steven M. Silverstein, Ph.D.
Executive Director
Violence Institute of New Jersey
Rutgers University Behavioral Health Care
Overview
• Is violence increased in schizophrenia?
– Who, when, where
• Reducing violence in treatment settings
Typical Statements About Violence and
Schizophrenia – Advocate Groups
• After controlling for factors such as substance
abuse, schizophrenia is not associated with an
increased risk of violence...
• People with schizophrenia are more likely to be
victims of violence than perpetrators of it
• The perception that people with schizophrenia are
violent is a major contributor to stigma and
rejection
• Over-estimation of violence can lead to bad
treatment decisions, and other negative
consequences
MacArthur Violence Risk Assessment Study
Monahan, J., et al. (2001). Rethinking Risk Assessment: The MacArthur Study of Mental
Disorder and Violence. New York: Oxford University Press.
• Population:
– 1,136 psychiatric short-term (~9 days) inpatients
• English-speaking patients between 18 and 40
• White, African American, or Hispanic
• Chart diagnosis: psychotic, mood, substance-use, or Axis II disorder
• Sources of information:
– Interviews with patients, collateral individuals, and official
sources of information (arrest and hospital records)
– During hospitalization (pts) and at 10 & 20 week follow-ups
– Violence defined as acts that resulted in physical injury; sexual
assaults; assaults or threats that involved a weapon
MacArthur Study Findings:
Major Violence Risk Factors
PRIOR ARRESTS
DEMOGRAPHIC
Seriousness
Frequency
Age (-)
Male
Unemployed
Disadvantaged neighborhood
CHILD ABUSE
DIAGNOSIS
Seriousness
Frequency
Antisocial PD*
Schizophrenia (-)
FATHER
OTHER CLINICAL ISSUES
Used drugs
Home until age 15 (-)
Substance abuse
Poor anger control
Violent fantasies
Loss of consciousness
Involuntary status in hospital
Data from 205 Inpatients
(Hodgins et al., 2007, Br. J, Psychiatry)
Behavior
Men
Women
Lifetime serious assault
41.7%
21.2%
Violent crime conviction
46.7%
16.5%
Assault, past 6 months
49.2%
38.8%
Life-threatening, past 6 months
21.7%
18.8%
Where Is The Truth?
• Violent acts committed by people with
schizophrenia account for only a small portion of
overall violence, and far less than that attributed
to substance abuse • BUT, for people who have schizophrenia, there
is a significant risk for violence
• AND, the consequences of violence can be
serious
• So, it is important to understand the facts (i.e.,
who, when, where) for advances in research,
prevention, and treatment
Why?
• 77.4% of carer-relatives of people with a psychotic
disorder reported moderate-severe levels of aggression,
and 52% of them reported symptoms of PTSD (Loughland et
al., 2009, Soc Psychiatry Psychiatr Epidemiol)
• Most MH services do not assess/manage risk of
violence, or provide treatments for violence reduction
(Hodgins et al., 2009, Eur. Psychiatry)
• Many patients in forensic psychiatric settings/jail/prison
• Self-reports of violent behavior are not exaggerated;
they underestimate rates of violence compared to those
of informants (Steadman et al., 1998, Arch. Gen Psych)
• Most violent acts associated with schizophrenia are
committed by patients who are not receiving treatment
Criticisms of the MacArthur Violence
Risk Assessment Study
• Rehospitalization may account for low rates of violence
among schizophrenia patients at follow-up
• The study did not include patients in forensic hospitals, jails
or prisons, or who were homeless—all would be expected to
have a high prevalence of violent behavior.
• Violence in schizophrenia is related to paranoia and anger,
and patients with these are unlikely to participate in research
• A published report 1 year later reported that the refusal-toparticipate rate for individuals with schizophrenia was
43.7%, which was much higher than for other diagnoses
What Do Other Studies Say?
JAMA, 2009
Schizophrenia, Substance Abuse, and
Violent Crime - 1 (Fazel et al., 2009, JAMA)
• Cross referenced all hospital admissions and convictions (for
homicide, assault, robbery, arson, a sexual offense, illegal
threats, or intimidation) in Sweden from 1973-2006
• 8,003 people with schizophrenia compared to 80,025 people
without schizophrenia
• 13.2% of people with schizophrenia had at least 1 violent
offense compared with 5.3% of general population controls
• 27.6% of patients with comorbid substance abuse were
convicted for a violent act vs. 8.5% of patients without
substance abuse
• Are these underestimates? Many violent acts do not lead to
convictions.
Schizophrenia, Substance Abuse, and
Violent Crime - 2 (Fazel et al., 2009, PLoS Medicine)
• Meta-analysis of studies from 1970 to 2009
– 20 studies, 18,423 individuals
• Odds ratios for violence compared to general population:
– 2.1 without substance abuse comorbidity (2.8 in men, 19.9 in women)
– 8.9 with substance abuse comorbidity (12.2 in men, 74.8 in women)
– 8.9 OR is similar to that in substance abuse without psychosis
• Risk for homicide is higher regardless of substance abuse
status (0.3% vs. 0.02% in general population)
• Conclusion: Both conditions increase risk for violence, with
substance abuse contributing more, in stable patients
Epidemiologic Catchment Area (ECA) Study
N=10,059; examined self-reported violent behavior in past year
(Swanson, Holzer, Ganju, & Jono, 1990, Hospital and Community Psychiatry)
DIAGNOSIS
WEIGHTED N
No Disorder
8066
2.05
One Diagnostic Group
Anxiety disorder
Affective disorder
Schizophrenia
Substance abuse
1160
142
26
533
2.37
3.45
8.36
21.30
Two Diagnostic Groups
Schizophrenia and anxiety
Affective and anxiety
Substance abuse and anxiety
Schizophrenia and affective
Affective and substance abuse
Schizophrenia and substance abuse
36
99
119
10
29
3
4.29
11.09
20.25
21.09
29.19
30.33
23
24
12
15.22
16.71
17.09
Three Diagnostic Groups
Schizophrenia, substance abuse, anxiety
Affective, substance abuse, anxiety
Schizophrenia, affective, anxiety
% VIOLENT
Overall Conclusions from
Major Studies
• Schizophrenia is associated with an increased
risk for violence
• Substance abuse increases this risk
significantly
• So does having a mood disorder
• Can risk prediction be advanced beyond this?
• What about other state and trait factors (e.g.,
symptoms, personality, treatment status)?
NIMH Clinical Antipsychotic Trials of
Intervention Effectiveness (CATIE study)
• 1,410 schizophrenia patients interviewed
about violent behavior in the past 6 months
• 2 types of violence coded
– minor violence = simple assault without injury
or weapon use;
– serious violence = assault resulting in injury or
involving use of a lethal weapon, threat with a
lethal weapon in hand, or sexual assault
– A composite measure of any violence was also
analyzed
CATIE – Results
• 6-month prevalence of any violence was 19.1%
– 3.6% reported serious violent behavior
• Positive (psychotic) symptoms, such as persecutory
ideation, increased the risk of minor and serious
violence
• Negative symptoms (e.g., social withdrawal)
lowered the risk of serious violence
• Minor violence was associated with co-occurring
substance abuse and interpersonal and social factors
• Serious violence was associated with psychotic and
depressive symptoms, childhood conduct problems,
and victimization
CATIE
State vs Trait
• In acutely ill patients, predictors include:
– Positive symptoms, especially paranoia
– Anger, agitation
• In stabilizing or stable patients, predictors include:
– History of conduct disorder or antisocial personality
disorder
– Prior violent behavior
– Substance abuse
• 62.8% of discharged patients who committed a violent
act within 1 year after discharge did so within 20 weeks
(Steadman et al., 1998, Arch Gen Psychiatry)
Schizophrenia and Psychopathy
Violence, Schizophrenia, Psychopathy
• Hostility, suspiciousness, and uncooperativeness were
related to aggressive behavior in schizophrenia patients,
but only in those low in psychopathy
• Patients high in psychopathy had high probability of
aggressive behavior regardless of symptoms (Abushua’leh & buAkel, 2006, Psychiatry Research)
• In patients with < 3 positive symptoms (16% violent in
past 6 mo.), violence related to younger age, male
gender, depression, child CD, and drug use (Hodgins & Riaz,
2011, European Psychiatry)
• In the CATIE study, treatment adherence was strongly
related to extent of violence reduction, but only for
patients without history of conduct problems (Swanson et al.,
2008, Br. J. Psychiatry)
3 Types of Violent Offenders with Schizophrenia?
(Hodgins, 2008, Phil. Trans. R. Soc. B.)
1. Early-start offenders
– History of conduct disorder and aggressive behavior in
childhood and adolescence (~40%)
– Compared to non-violent patients: Better cognitive
flexibility and verbal skills; but poorer attention, more
impulsivity, and a tendency to misinterpret faces as angry
2. Aggression starts after psychosis onset
– May be related to substance abuse
– More likely to kill (23.9%) than Type-1 patients (10.4%)
3. Older men with no history of violence or
antisocial behavior who kill, usually caretaker
First Episode of Psychosis
A Critical Risk Factor for Violence
• 38.5% of the homicides committed by people with a
psychotic illness occur before treatment
• ~ 1 in 700 people with psychosis commit a homicide
before treatment
• Each year, ~1 in 10,000 patients with psychosis who have
received treatment will commit a homicide
• The rate of homicide in psychosis before treatment is
approximately 15 times higher than the annual rate after
treatment
Percentage of First Episode Cases
Among Psychotic Patients who Engage
in Impulsive Behaviors
(Nielssen et al., 2012, J. Clin. Psychiatry)
Behavior
% of Schizophrenia Patients
Violent suicide attempts
49%
Major self-mutilation
54%
Homicide
39%
Assault resulting in serious injury
38%
Victimization and Violence
• People with schizophrenia are more likely
than people in the general population to be
victims of crime, especially victims of
physical assaults (Hodgins, et al., 2007b; Maniglio, 2009)
• But, their own aggressive behavior is the
strongest predictor of victimization (Hodgins et
al., 2007; Walsh et al., 2003; Silver et al., 2005)
• Reducing rate of violent behavior should
reduce rate of victimization
But, schizophrenia is rare.
Subclinical Psychosis and Violence
Violence in People with Attenuated Psychosis
• ~5.5% of the adult population reports occasional psychotic
experiences (Stefanis et al., 2002, Psychological Medicine)
• Psychotic-like experiences associated with a 5-fold increase in
risk for assaulting another person, and with increased rates
(1.4x to 15.2x) of problems with the police, and imprisonment
(Rössler et al., 2007, Schizophr Res; Mojtabai, 2006, Soc.Psychiatry & Psychiatr. Epidemiol)
• Highest 10% of scorers on the Schizotypal Personality
Questionnaire (SPQ) report higher scores on self-reported
measures of crime and violence (Raine, 1991, Schizophrenia Bulletin)
• Children with high SPQ scores also score high on measures of
reactive aggression (Raine et al., 2011, Schizophrenia Bulletin)
• Victimization mediates the relationship in children: Schizotypal
children are picked on because they are odd, shy, or different,
and then they are more likely than others to react aggressively
Summary: Primary Risk Factors
for Violence in Schizophrenia
•
•
•
•
•
•
•
•
•
•
Male gender
Young age
Substance abuse
Low SES, in socially disadvantaged neighborhood
Past conviction for a violent offense
Mood disturbance
1st psychotic episode
Lack of treatment
Past victimization
Psychopathy, antisocial or conduct disorder
Other Risk Factors for Violence in Schizophrenia
• Poor self-care skills (Flannery et al., 1998)
• Delusions of being spied on, persecution, or conspiracy
(Cold et al., 2013, JAMA Psychiatry)
• Hostility, suspiciousness, agitation or excitement
(Cheung et al.,
1997, Schizophrenia Research; Flannery et al., 1998)
• Past suicidal threats and attempts increased risk of
violence in male (3.8x, 2.8x) and female (9.4x, 4.4x)
patients; Suicidal ideation did not raise risk (Witt et al., 2014,
Schiz Res)
• Rigid thinking, poor executive functioning Krakowski & Czobor,
2011, J Clin Psychiatry; Silverstein et al., 1998, Psychiatric Quarterly)
• Poorer facial emotion recognition, or reduced ability to
discriminate intensities of facial emotions (Demiburga et al., 2013,
Scz Res; Silver et al., 2005 J Clin Psychiatry)
Reducing Violence Associated
with Schizophrenia
in Treatment Settings
Violence in Psychiatric Settings
• The risk of injury in public hospitals is greater
than injury rates for agriculture, mining,
manufacturing, transportation, and construction
combined (Dinwiddei & Briska, 2004, Int J Law & Psychiatry)
• Violence and aggression is one of the most
significant challenges facing mental health
workers (Bjorkly, 1999, Scandinavian Journal of Psychology)
• The prevalence of violence in inpatient settings
may be increasing (Daffern & Howells, 2004, Int J Forensic Ment Health)
• Violence and aggression is one of the primary
reasons for psychiatric admission
Effects of Negative Staff Behavior
• External observers coding staff-patient interactions
find that poor quality interactions are the primary
antecedent of aggressive/violent events (Bowers, et al., 2011)
• 82% of assaults on staff members were immediately
preceded by an aversive stimulus presented to the
patient by the assaulted nurse (Wykes & Whittington, 1998)
• Limit setting, activity demands and denial of patient
requests were antecedents to over 60% of aggressive
and violent incidents (Marth, 2009)
Examples of Inappropriate
Comments by Staff to Patients
(made in the presence of an observer)
•When I tell you to do something, you do it.
•Shut up.
•You stink.
•Leave. The dining room is closed.
•If you can’t lower your voice like a normal
person, you’ll have to get a time out.
•Those are the rules and that is all there is to it.
Effects of Positive Staff Behavior
• When staff responses were perceived as
collaborative, validating and useful by patients,
violence and aggression towards staff decreased
(Marth, 2009)
• As staff competence improves, seclusion,
restraint, and staff injury decline (Donat, 2002).
• The amount of positive comments that patients
receive from staff is a strong predictor of overall
inpatient program success, and community tenure
after discharge (Coleman & Paul, 2001)
Recommendations to Reduce Violence In
Inpatient Settings
(Bowers et al., 2011, Inpatient violence and aggression : a literature review; A Report from the
Conflict and Containment Reduction Research Programme)
1. Enhance the therapeutic relationship of
staff and patients
2. Better manage patient requests
3. Increase technical mastery of seclusion and
restraint procedures
Description of Training Components
• 8 hours of didactic instruction about
schizophrenia, behavior therapy, psychiatric
rehabilitation, and communication skills in
specific situations (including interactive
role-plays)
• Written assessment
• In-vivo dynamic assessment
Example of Therapeutic Communication:
The 3-Step Procedure
1) Validate feelings
2) Set limits, reality test
3) Suggest an appropriate alternative behavior
Patient – I want to go outside and smoke now!
Staff – I can see that you really want to smoke, but the next
break time isn’t for another hour.
Patient: I can’t make it that long.
Staff – I can see that you are getting really frustrated, but since
causing a commotion would lead to losing points, let’s
see if we can think of something else you can do for the
next hour that you will enjoy and that will help you earn
points. What are some things you like to do here?
Patient: Watch TV...
Mean percent (%) rating scores and standard
deviations (SD) on the 7 behavior categories from
the SRIFS for all staff at Time 1 (before training)
and Time 3 (after all staff completed training)
Positive
Behavior
Negative
Behavior
Neutral
Behavior
Therapeutic
Behavior
Instruct
Behavior
Time 1
24%***
(10)
6**
(08)
7%
(08)
11%*
(10)
Time 3
38%***
(11)
2%**
(0)
4%
(05)
15%*
(10)
*p<.05
**p<.01
***p<.001
26%
(13)
NonInteractive
Behavior
08%
(18)
Paperwork/
Staff-Staff
Conversation
20%**
(20)
25%
(09)
04%
(07)
11%**
(15)
Message: The complete training program
improved staff behavior on several
important dimensions.
Effects of Staff Training on
Patient Behavior Domains
BEHAVIOR
Verbal Aggression
CHANGE AFTER
STAFF TRAINING
Down 31%
Physical Aggression Down 64%
Bizarre Behavior
Down 60%
Presence in Milieu
Up 50%
Conclusions
• People with a diagnosis of schizophrenia are at an
increased risk for violence
• Risk is increased by several factors, including:
substance abuse, untreated 1st psychotic episode,
history of antisocial personality traits, significant
anger, persecutory ideation, mood symptoms, poor
social skills, low SES, and history of being abused
• Treatment can reduce rates of violence
– Clozapine, behavior therapy, targeted cognitive
interventions, substance abuse treatment, CBT (?)
• Stigma may be reduced when violence is reduced
Treatment Implications - 1
• Assess
– Standard violence assessment (+/-)
– Functional assessment
– Symptom assessment: each increase of 1 on PANSS
Hostility item raises odds of serious aggression by 1.65
(Swanson et al., 2006, Arch. Gen. Psychiatry)
– Substance abuse
– History of victimization
•
•
•
•
Reduce substance abuse
Reduce psychotic symptoms
Increase conceptual flexibility via cognitive remediation
Assisted Outpatient Treatment for non-adherent people
Treatment Implications - 2
• During an acute psychotic episode, medication and
behavior therapy can reduce violence
• After the acute episode, medication, and a focus on
psychosis are insufficient to reduce violence, especially
in patients with a history of conduct disorder
– Psychopathy assessment should be standard in such cases
• ACT teams and ICM teams do not reduce incarceration
rates, nor are services and treatments adjusted based on
violence risk. This needs to change (Hodgins et al., 2009, Eur Psych)
• FACT teams, that focus on reducing antisocial
behavior may be able to reduce rehospitalization,
arrests and time in jail (Cuddeback et al., 2008, Psych Services; Hodgins et al.,
2007, Int J Forensic Mental Health)
Acknowledgments
• Rutgers – UBHC
• The Violence Institute of New Jersey faculty and
staff
• Matthew Roché
• Chia-Cherng Cheng
• Jill Del Pozzo
• NY Presbyterian Hospital – The Second Chance
Program