Aggression in Schizophrenia: mediators of agression

Substance Abuse

A great many people, especially in the USA, believe that the main stimulant of crime and violence in individuals, both with and without mental illness, is substance abuse . Epidemiological data on schizophrenia confirm the correlation between substance abuse and criminal activity (Swanson et al , 1990; Steadman et al , 1998; Soyka, 2000; Steele et al , 2003; Wallace et al , 2004).

Individuals with schizophrenia who abuse alcohol and other psychoactive substances are currently responsible for the majority of offenses, and data from some studies suggest that the incidence of violence among individuals with schizophrenia, but without problems associated with the use of psychoactive substances, is not higher. than in control population samples ( Monahan et al , 2001). The authors of the influential MacArthur study even believed that schizophrenia without concomitant substance abuse is a protective factor against aggressive behavior ( Steadman et al , 1998).

Given the authority of Steadman and his co-authors, this judgment has become generally accepted. However, as mentioned, amending the mediating factor actually amends the effect of schizophrenia. Moreover, you can conclude that the very substance abuse is a causative factor only after excluding the possibility that violence, and substance abuse are mediated – wholly or partly – a common third factor torus.

The most likely candidates for such a third factor are personality traits. and / or social conditions.

The McArthur study concluded that individuals with schizophrenia who did not abuse psychoactive substances were no more aggressive than other members of society, was refuted by research results that explored larger groups of individuals who did not abuse psychoactive substances (Vevera et al , 2005).

For example, a study of 2,861 individuals with schizophrenia, consistent with the population control group and first hospitalized over a 25-year period, showed that although during these years the incidence of known cases of substance abuse among patients increased from 8 to 27%, the conviction rate for violence increased only moderately (from 6 to 10%), which corresponds to an increase in the control group (from 1 to 3%) ( Wallace et al , 2004). In this article, it has been suggested that over the past 30 years, more and more people with schizophrenia who are prone to violence have begun to abuse psychoactive substances, and not that the incidence of violence manifested by schizophrenic patients has increased in accordance with the increase in the level of substance abuse . This explanation is supported by the results of a study conducted by two groups: Tengström and his colleagues. (2004), as well as Vevera and his colleagues (2005).

Reducing the incidence of substance abuse among individuals with schizophrenia is an important therapeutic goal, essential for improving both the control of symptoms of the disease and the quality of life. Although this will almost certainly contribute to reducing the number of cases of antisocial behavior, this is far from a panacea for violent inclinations.


If you believe the popular press and some politicians, the root of the problem of crime among people with severe mental disorders is in deinstitutionalization and in the insolvency of community health care. In a single study that examined the problem of crime among individuals with schizophrenia during the period of deinstitutionalization and the introduction of community health care, there was no evidence for an increase in the number of offenses compared to their frequency in the general population ( Mullen et al , 2000; Wallace et al , 2004). True, it must be admitted that this took place in the locality in which adequate funding was provided for the transition period, and during the study it remained an integrated service rationally provided with sufficient resources. Studying a less organized and worse funded deinstitutionalization process could have other results. However, this illustrates only that ineffective assistance – at the place of residence or in a psychiatric hospital – gives unfavorable results. There is currently no scientific basis for attributing to the deinstitutionalization any increase in crime. Those of us who have worked in large psychiatric hospitals know that their strong point was the strict formation of institutionalized groups and not representing the risk of incapacitated, rather than antisocial and aggressive patients, who then, as now, often ended up in prison.

Active psychopathological symptoms

Considerable clinical experience and numerous literature data confirm the link between active psychopathological symptoms and antisocial behavior, although not all studies support the role of such specific manifestations as delusions and hallucinations ( Hafner & Boker , 1982; Taylor , 1985; Appelbaum et al , 2000; Arsenault et al , 2000). Negative symptoms can perform the protection function even hydrochloric (Swanson et al , 2006).

The assessment of the role of active psychopathology in the manifestation of violence in individuals with schizophrenia, in my opinion, is overstated, but the fact that it plays a certain role is beyond doubt. For example, evidence of a link between jealous rage and assaults against a partner is fully proven, and persecutory delirium, hallucinations, and nonspecific psychotic arousal sometimes provoke violence ( Mullen , 1996; Foley et al , 2005).

A model of two types of violence in schizophrenia is gaining increasing support ( Steinert et al , 1998; Gje et al , 2003). Individuals who demonstrate the first type of violence usually have a systematized nonsense associated with violence, they do not have clear anamnestic data on behavior disorder or offenses during the period of adulthood, they usually commit the first violent crime after admission to treatment, almost always attack a person who assists them or cares for them, or for a friend, and – perhaps most importantly – they are “similar ” to the sick.

Individuals with the second type of violence usually have disorganized clinical syndromes, a history of behavioral disorder, early onset of substance abuse , and, as a rule, they commit violent and non-violent offenses before diagnosing mental disorder, resorting to violence in the family and outside the home and “Similar” to criminal offenders. Most cases of violence among individuals with schizophrenia can be attributed to the second type, although it is possible that the first type of violence is over-represented among the killers.

Consequences of psychopathological symptoms in schizophrenia

Some disorders that make up the schizophrenic syndrome are found from an early age. Schizophrenia can affect the risk of aggressive behavior through three types of vulnerability.

  • the types of vulnerability that precede the development of active psychopathological symptoms;
  • types of vulnerability acquired due to the active course of the disease;
  • types of vulnerability imposed by the results of ongoing treatment and management.

Of the examples listed in Box 1, attention should be paid to the early onset of substance abuse , since one of the most common clinical errors is the diagnosis of psychosis caused by these substances in individuals with schizophrenia, in whom the abuse was preceded by the appearance of overt psychotic symptoms.

Development factors

Violent individuals with schizophrenia are more likely to develop than those who do not manifest themselves and those in the general population.

As a result, in childhood and younger adolescence, the former are at a disadvantage. They are more likely to come from disadvantaged with e- Mei, which have been deprived of parental care, they observed growth retardation, there were problems in school and poor peer relationships in childhood and adolescence, criminal histories from family members (Schanda et al , 1992; Tiihonen et al , 1997; Fresan et al , 2004).

Childhood disorder (according to anamnesis), which probably partly reflects the sequence of such factors, is much more often diagnosed in people with schizophrenia who will be violent, and serves as a powerful predictor of such behavior ( Hodgins et al , 2005). Yet such a strong connection seems to be that it uses both ways: individuals with a behavioral disorder and delinquency of juveniles have a history of increased risk of developing schizophrenia in later life ( Gosden et al , 2005).

Box 1. Vulnerabilities that can predispose to violence in schizophrenia

The types of vulnerability that precede the development of active psychopathological symptoms:

  • developmental disorders;
  • asocial traits of character;
  • insufficient education;
  • increased frequency of behavior disorder;
  • non-socialized delinquency ;
  • early onset of substance abuse .

Types of vulnerability acquired due to the active course of the disease:

  • active psychopathological symptoms;
  • degradation of the individual;
  • change in social status;
  • substance abuse ;
  • unemployment.

Vulnerabilities caused by:

  • side effects of drugs, especially akathisia and neuroleptic deficiency syndrome;
  • excessive insulation;
  • loss of social skills;
  • imprisonment.

Current social context

Individuals with schizophrenia often do not form the working skills and social roles of an adult individual even before diagnosing their disorder. Once established, schizophrenia is associated with unemployment, which usually leads to a precarious financial situation and a decline in social status. This usually leads to marginal existence, characterized by poor living conditions, if not homelessness, in socially disorganized neighborhoods where substance abuse, interpersonal conflicts and crimes are common. The risk of violence in individuals with severe mental disorders appears to increase dramatically in those who are discharged from hospital to areas with a high crime rate (Silver, 2000; Logdberg et al, 2004).

Personal factors

Currently, strong evidence has been obtained that personality traits serve as mediating factors for criminal activities in schizophrenia (Moran et al, 2003; Nolan et al, 1999; Moran & Hodgins, 2004; Tengström et al, 2004). In part, the connection is incomprehensible because of the terminology used to describe the weaknesses of the personality of individuals with schizophrenia, unlike those of offenders.

The psychopathic traits of a repeat offender-offender are vividly described as follows: lack of remorse and remorse, search for novelty, impulsivity and heartlessness. On the contrary, to describe the personality disorders observed in schizophrenia, the following expressions are used: flattened affect, lack of empathy, lack of realistic long-term goals, irresponsibility, excessively high self-esteem and hypersensitivity.

In fact, representatives of both groups show irritability, tendency to asocial actions, indifference (or blindness) to the feelings and interests of other people, suspicion and negativity, express ideas of greatness, unrealistic beliefs about their rights and inability to learn from experience. The main thing for the emergence of manifestations of violence are both the type of personality, against which the psychosis manifests, and the negative effects of the schizophrenic process on the person.

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