Violence in Schizophrenia

Answer

Violence in Schizophrenia

Mental illness and violence in today’s society are often considered to be inextricably linked. Consequently, this inextricable linkage between mental illness and violence has not only subjected patients with mental illness to a harsh stigma, but also at times induces an uncomfortable environment for psychiatrists. According to Papadopoulos et al. (2012), the perception about the connection between mental illness and violence carries serious consequences for people with mental illness in the form of furthering a sense of isolation and discrimination towards such patients by society. Papadopoulos et al. (2012) point out that violence has increasingly become a significant concern in psychiatry. Notably, emergency departments receive a large number of aggressive patients, often requiring the attention of psychiatrists to undertake assessments and provide treatments for such patients. According to Papadopoulos et al. (2012), hospitals experience thousands of assaults each year with greater incidences recorded in emergency rooms and psychiatric units thereby making such workplaces to be considered by some as occupationally hazardous. As noted by Papadopoulos et al. (2012), each psychiatrist within emergency rooms and psychiatric units has a probability of between five to forty-eight percent of being physically assaulted by a patient during his or her career, thereby leading to stigmatization of mental ill persons. Although majority of psychiatric patients are nonviolent, research studies point to the fact that severe mental illness such as schizophrenia increases the risk of violence. According to Volavka (2013), violent behavior of psychiatric patients presents obvious risks of injuries the victims. Evidently, a mentally ill patient with violent behaviors presents challenges during diagnosis and treatment of their condition. Volavka (2013) asserts that there are significant clinical challenges in caring for violent psychiatric patients, complicating the efforts of caregivers. Additionally, violence increases the cost of treatment by not only prompting regular hospitalization, but also potentially increasing the length of hospital stay. This paper presents a literature review on violence in schizophrenia.

Proposed Research Question

Does schizophrenia independently predict future violent behavior?

Relevant Themes

The themes relevant to the proposed research question include epidemiology of violent behavior in schizophrenia as well as its clinical features and treatment. As such, this review will examine the epidemiology of violent behavior in schizophrenia as well as its clinical features and treatment.

Epidemiology of Violent Behavior in Schizophrenia

Several studies have examined the factors associated with violence in schizophrenia. According to Nielssen (2015), some studies on this subject have been conducted based on the outcome of court cases. Such studies have been focused on the pattern of acute symptoms that were presenting during the commission of the violent act. For example, the inclusion criteria regarding the defense of mental illness saw 96 percent of subjects reporting delusional beliefs as a motivating factor towards the violent act. Nielssen (2015) points that there are other types of delusions associated with violence including the belief that something terrible had been committed by the victim, misidentification delusions, as well as delusions of jealousy. However, it is important to note that recent reviews involving examination of the diagnosis and offenses have noted a strong linkage between violence, diagnosis of schizophrenia and substance use. In fact, Nielssen (2015) emphasizes that substance use particularly triggers symptoms of schizophrenia besides being associated with poor adherence to treatment thereby inducing a disinhibiting effect in individuals whose frontal lobe function is already impaired.

The link between violence and schizophrenia was firmly established by a groundbreaking epidemiological study that determined a one-year prevalence of 8.4 percent of violent behavior in schizophrenia and only 2.1 percent among individuals without any mental illness (Volavka, 2013). According to the study conducted by Volavka (2013), the comorbid substance use disorders significantly increase the risk of violence. Notably, Volavka (2013) emphasizes that this finding is confirmed and supported by different epidemiological studies conducted in various countries. According to a study conducted by Van Dorn et al. (2012), severe mental illness such as schizophrenia cannot independently predict future violent behavior, but rather future violent behavior can be independently predicted by comorbid substance use disorder. Volavka (2013) emphasizes that individuals with severe mental illness such as schizophrenia are significantly more likely to exhibit violent behaviors, irrespective of substance abuse status than individuals without mental or substance use disorders. However, individuals with comorbid mental and substance use disorders demonstrate the highest risk of violence. Additionally, Van Dorn et al. (2012) further note that historical and current conditions including household antisocial behavior such as binge drinking and stressful life, childhood abuse and neglect are closely associated with violence. Although research evidence depicts such schizophrenia features as comorbid personality disorders and psychotic symptoms as likely independent risk factors for violence among patients with schizophrenia, it is evidently clear that substance abuse presents a significant risk factor for violence in schizophrenia.

Clinical Features of Violent Behavior in Schizophrenia

The origin and manifestations of violence in schizophrenia is heterogeneous in nature and can have a direct association with clinical symptoms. According to Volavka (2013), the elevated rates of violence among individuals with schizophrenia are closely linked to a set of delusional psychotic symptoms that are often referred to as threat-control-override symptoms. Volavka (2013) notes that the delusional psychotic symptoms are elicited by questions like "thoughts put into your head", “dominated by forces beyond you", as well as "people who wished you harm". However, Volavka (2013) opines that whereas violence can be precipitated by delusions in individual cases, delusions in themselves cannot increase the overall risk of violence in people with schizophrenia. Indeed, Volavka (2013) emphasizes that delusional motivation of violence is a very rare case. While acknowledging the fact that risk of violence may be increased by the command hallucinations to harm others, Volavka (2013) argues that there are varying levels of compliance with such commands. In general, it is important to note that increased risk of violence is potentially associated with positive symptoms of schizophrenia whereas negative symptoms exhibit reduced risk of violence. According to Ekinci and Ekinci (2013), there is consistent evidence linking violence to impaired insight. This finding is also supported by Lera et al. (2012). As pointed out by Czobor et al. (2015), this effect may occur indirectly whereby it gets mediated through reduced adherence to treatment related to poor insight. Importantly, much of the violence in individuals with schizophrenia is not directly related to psychotic symptoms, contrary to the belief of many clinicians. Indeed, recent evidence shows that violence among schizophrenia adult patients may follow at least two distinct pathways. The first possible pathway is associated with premorbid conditions such as antisocial conduct while the second possible pathway is associated with the acute psychopathology of schizophrenia. It is important to point out that the research study conducted by Volavka (2013) depicted that adherence to antipsychotic medication significantly reduce violent behavior among schizophrenia patients with no history of conduct problems. However, in the conduct problems group, the research findings do not show a significant difference in violence between those adherent to medications and the nonadherent individuals. Therefore, it can be undoubtedly inferred that there is a close association between reduced effectiveness of antipsychotics and a history of conduct disorder. Volavka (2013) notes the consistency of these findings with previous observations wherein only 20 percent of psychiatric ward assaults were found to be directly linked to psychotic symptoms such as hallucinations and delusions. Evidently, the other assaults constituting about 80 percent were attributed to a comorbid antisocial personality disorder, confusion, or impulsiveness. As a result, Volavka and Citrome (2011) assert that violence in schizophrenia has multiple pathways and as such, the etiological heterogeneity present potential implications for treatment.

Treatment of Violent Behavior in Schizophrenia

According to Nielssen (2015), past research evidence shows that earlier treatment of the first episode of schizophrenia can potentially reduce incidence of violence as well as both serious and less serious forms of self-harm in individuals with schizophrenia. Nielssen (2015) opines that there is a direct correlation between the duration of untreated psychosis and the proportion of homicides committed prior to treatment. Notably, about 16 percent of all individuals with schizophrenia have, prior to initial treatment, committed an act of physical violence, whereas 18 percent have self-harmed. As noted by Nielssen (2015), adequate evidence indicates that incidence of violence among people with schizophrenia can be significantly reduced by ensuring continued adherence to treatment.

 Treatment of violent behavior in schizophrenia involves both pharmacological treatment and non-pharmacological treatment. The pharmacological treatment of violent behavior in schizophrenia involves the use of atypical antipsychotics to provide long-term treatment of violent behavior in individuals with schizophrenia. According to Frogley et al. (2012), clozapine presents the gold standard for treating individuals with schizophrenia that exhibit violent behavior. Volavka (2012) emphasizes that although the anti-aggressive efficacy of clozapine is firmly established, this medication is not a panacea since many patients, probably over 50 percent, do not respond to it. However, Volavka (2013) notes that patients who fail to respond to this medication could be those with a history of conduct disorder. It is also important to note that this medication only display its full anti-aggressive effect upon reaching an effective dose. Furthermore, this medication may be discontinued by patients for various reasons including medical contraindications or adverse effects as well as the need for blood monitoring.

Another pharmacological treatment of violent behavior in schizophrenia involves the use of Olanzapine that has also demonstrated effective efficacy against overt physical aggression and hostility in individuals with schizophrenia. According to Volavka et al. (2011),  the anti-aggressive effects of Olanzapine, though not distinguishable from other atypical antipsychotics and weaker than those of clozapine, it has a more superior efficacy in reducing incidents of overt physical aggression and hostility in the first episode of schizophrenia than haloperidol, quetiapine, and amisulpride.

Risperidone is another pharmacological treatment for violent behavior in schizophrenia that reduces violent behavior and hostility. According to Volavka (2013), this medication demonstrates superiority over placebo in reducing hostility. Additionally, aripiprazole is another pharmacological treatment for violent behavior in schizophrenia that demonstrates more superiority than placebo and has no significant difference with haloperidol in efficacy to reduce hostility. This finding is based on the results of five randomized, double-blind studies comparing aripiprazole with placebo. Quetiapine is also a pharmacological treatment for violent behavior in schizophrenia whose effectiveness against hostility and aggression is supported by open studies (Volavka, 2013). Notably, the superiority of this medication over placebo was demonstrated by post-hoc analyses of randomized double-blind trials in terms of its effectiveness in reducing aggression among individuals with schizophrenia. However, Volavka (2013) notes that although the antiaggressive effects of quetiapine are weaker than those of perphenazine, they are similar to other atypical antipsychotics.  Similarly, ziprasidone is a pharmacological treatment for violent behavior in schizophrenia whose effectivity was confirmed by post-hoc analyses of the effects of the medication on hostility. As highlighted by Volavka (2013), these analyses involved data obtained from a randomized, open-label study that compared haloperidol with ziprasidone. The result of the analyses demonstrated that although both drugs reduced hostility, ziprasidone had a greater superiority than haloperidol whereas its anti-aggressive effect had no significant difference with other antipsychotics. According to Newman and McDermott (2011), other medications such as anticonvulsants and lithium can also be used for the adjunctive treatment of violent behavior in psychotic individuals. Although this treatment may be effective in some patients, it has no adequate support from empirical evidence and, therefore, must be closely monitored. Newman and McDermott (2011) noted that adrenergic beta-blockers demonstrate anti-aggressive effects in several case reports and studies and as such, provides a second- line treatment for violence in schizophrenia. However, beta-blockers potentially reduce pulse rate and blood pressure thereby inducing serious adverse effects on the user. Additionally, Singh et al. (2012) adduce that there is a link between violence in schizophrenia and the polymorphism of the catecholo-methyl transferase gene. Bhakta et al. (2012) also supported this finding.

Non-pharmacological treatment for violent behavior in schizophrenia is critical in addressing aggressive behavior in schizophrenia patients whenever such patients fail to respond adequately to pharmacological treatment. As noted above, comorbid antisocial personality disorder, and history of conduct disorder constitute other pathways to violence in such patients (Volavka, 2013). It is critical to reemphasize here that violent behavior in individuals with schizophrenia having these problems is not directly attributed to psychosis. Consequently, such individuals are less likely to respond adequately to antipsychotics. Moreover, some violent behavior in some patients does not respond to antipsychotics. Therefore, such patients become nonadherent to treatment and start substance abuse after discharge from the hospital. According to Volavka and Citrome (2011), substance abuse and nonadherence to pharmacological treatment significantly elevate the risk of violence in schizophrenia. Therefore, such patients require specialized, cognitive, behavioral treatment program such as Service for Treatment and Abatement of Interpersonal Risk (STAIR) program.  This non-pharmacological treatment program is focused on addressing factors associated with violent behavior in patients with schizophrenia. The curriculum of this program is completed by substance abuse programs while its core program is organized around Cognitive Skills Training course. As noted by Cullen et al. (2012), the STAIR program effectively reduced rates of hospitalization and arrests associated with violence besides improving adherence to treatment.

Various Research Methodologies used in Published Literature

The published research literature reviewed above were conducted using different methods including qualitative and quantitative research methods. For instance, the quantitative research methodology was employed by the literature examining the epidemiology of Violent Behavior in Schizophrenia. In this research methodology, the researchers sought to quantify behaviors of individuals with schizophrenia using a meta-analysis of 20 studies involving a comparison of risks of violence among 18,423 patients diagnosed with schizophrenia and the general population. During the research, the researchers developed an odd ratio (OR) to generate a statistical difference in risk of violence among different people (Volavka 2013). As a result, the research findings showed schizophrenia patients with an odds ratio of 2.1 and having no comorbidity had a modest and statistically significant increase of risk of violence. The use of the numbers to quantify the behavior of individuals clearly indicates employment of quantitative research methodology in the literature (Volavka, 2013). On the other hand, qualitative research methodology was used by another study in examining the epidemiology of Violent Behavior in Schizophrenia. In this study, data obtained from the National Epidemiologic Survey on Alcohol and Related Conditions was analyzed through a two-wave project during which violence between Waves 1 and 2 was examined using mental disorder in the year immediately before Wave 1. Similarly, qualitative research methodology was used in the research studies examining the treatment of violent behavior in schizophrenia whereby superiority of a number of treatments was compared based on their anti-aggressive efficacies. For instance, the anti-aggressive effects of clozapine were confirmed by two randomized controlled double-blind trials. The first trial compared risperidone, haloperidol, clozapine, and olanzapine in patients with schizophrenia. According to Volavka (2013), clozapine has demonstrated superior efficacy compared to risperidone and haloperidol when analyzed on the hostility item of the Positive and Negative Syndrome Scale. Moreover, additional analyses examined incidences of overt physical aggression and indicate the overall superiority of all three atypicals in anti-aggressive efficacy over haloperidol. A comparison of isperidoner, clozapine, and olanzapine was done in the second trial and involved schizophrenia patients considered to be violent. According to the findings of this study, clozapine demonstrated most superior efficacy in reducing incidents of overt physical aggression of all the three atypicals followed by olanzapine that also demonstrated superiority over haloperidol (Volavka 2013).

Justification for the Chosen Research Question

The chosen research question is central to understanding the underpinnings of the epidemiology of violent behavior in schizophrenia and its clinical features, thereby shedding light on the most effective ways of reducing violence in individuals with schizophrenia. Notably, understanding the epidemiology of violent behavior in schizophrenia is key to ensuring effective pharmacological and non-pharmacological treatment as it highlights the root cause of the problem. Therefore, the research question provides an opportunity to explore the root cause of the problem of violent behavior in schizophrenia hence ensuring effective remedial actions focused on reducing violence among those with schizophrenia including treatments.

In conclusion, mental illness and violence in today’s society are often considered to be inextricably linked thereby subjecting patients with mental illness to a harsh stigmatization and, at times, induces an uncomfortable environment for psychiatrists. Although majority of psychiatric patients are nonviolent, research studies point to the fact that severe mental illness such as schizophrenia increases the risk of violence. The link between violence and schizophrenia was firmly established by a groundbreaking epidemiological study that determined a one-year prevalence of 8.4 percent of violent behavior in schizophrenia and only 2.1 percent among individuals without any mental illness. According to past studies, severe mental illness such as schizophrenia cannot independently predict future violent behavior but rather, future violent behavior can be independently predicted by comorbid substance use disorder. The highest risk of violence occurs among individuals with comorbid mental and substance use disorders and those with historical and current conditions including household antisocial behavior, binge drinking and stressful life, childhood abuse, as well as neglect are closely associated with violence. Violent behavior in schizophrenia can be treated using both pharmacological treatment and non-pharmacological treatment.