PsychOdyssey 380: Violence and Mental Illness

The recent (January 2011) shooting of Congresswoman Gabrielle Giffords by Jared Loughner in Tuscon, AZ, renews  the public debate about the association of violence and mental illness. While the absolute level of violence involving indivduals with mental illness is statistically small, the incidence of “rampage” violence like the Tuscon episode or the Virginia Tech massacre three years ago seems to involve individuals with mental illness to a higher degree. What is the truth? And what is the proper response by society? PsychOdyssey 380 provides a reading framework for better discernment.

Resource list:

Elbogen, E. B., & Johnson, S. C. (2009). The Intricate Link Between Violence and Mental Disorder: Results from the National Epidemiologic Survey on alcohol and related conditions. Arch Gen Psychiatry, 66(2), 152-161. doi: 10.1001/archgenpsychiatry.2008.537

Abstract: Because severe mental illness did not independently predict future violent behavior, these findings challenge perceptions that mental illness is a leading cause of violence in the general population. Still, people with mental illness did report violence more often, largely because they showed other factors associated with violence. Consequently, understanding the link between violent acts and mental disorder requires consideration of its association with other variables such as substance abuse, environmental stressors, and history of violence.

Fazel, S. (2011). The line between madness and mayhem. The Wall Street Journal, January 15-16, 2011, p. C3.

Luo, Michael (2011). Mixing Guns and Mental Illness. The New York Times, July 3, 2011, p. A1.

Mulvey, E. P. (1994). Assessing the evidence of a link between mental illness and violence. Hospital & Community Psychiatry, 45(7), 663-668.

Abstract: The relationship of mental illness and violence is an issue of longstanding clinical and policy importance, and recent research on this association has sparked renewed debate. The author formulates six statements on the association that seem warranted by recent investigations and reviews the research evidence. In general, contrary to findings of earlier research, an association does appear to exist between mental illness and the likelibood of being involved in violent incidents. A dual diagnosis of mental illness and substance abuse probably significantly increases the risk for violence, and the association between mental illness and violence is probably significant even when demographic characteristics are taken into account. Given the considerable limitations of current research, priorities for future research include attention to the strength oftbe association for individual subjects, inclusion of adequate comparison groups of non-mentally-ill persons and a broad range of variables, and intensive studies of repetitively violent individuals over time.

Rueve, M. E., & Welton, R. S. (2008). Violence and mental illness. Psychiatry, 5(5), 34-48.

Abstract: Violence attracts attention in the news media, in the entertainment business, in world politics, and in countless other settings. Violence in the context of mental illness can be especially sensationalized, which only deepens the stigma that already permeates our patients’ lives. Are violence and mental illness synonymous, connected, or just coincidental phenomena? This article reviews the literature available to address this fundamental question and to investigate other vital topics, including etiology, comorbidity, risk factor management, and treatment. A psychiatrist who is well versed in the recognition and management of violence can contribute to the appropriate management of dangerous behaviors and minimize risk to patients, their families, mental health workers, and the community as a whole.

Swanson, Jeffrey W., Swartz, Marvin S., Van Dorn, Richard A., Elbogen, Eric B., Wagner, H. Ryan, Rosenbeck, Robert A., Stroup, T. Scott, McEvoy, Joseph P., & Lieberman, Jeffrey A. (2006). A national study of violent behavior in persons with schizophrenia. Archives of General Psychiatry, 63(5), 490-499.

Abstract: Violent behavior is uncommon, yet problematic, among schizophrenia patients. The complex effects of clinical, interpersonal, and social-environmental risk factors for violence in this population are poorly understood. To examine the prevalence and correlates of violence among schizophrenia patients living in the community by developing multivariable statistical models to assess the net effects of psychotic symptoms and other risk factors for minor and serious violence. A total of 1410 schizophrenia patients were clinically assessed and interviewed about violent behavior in the past 6 months. Data comprise baseline assessments of patients enrolled in the National Institute of Mental Health Clinical Antipsychotic Trials of Intervention Effectiveness. Setting and Patients Adult patients diagnosed as having schizophrenia were enrolled from 56 sites in the United States, including academic medical centers and community providers. Violence was classified at 2 severity levels: minor violence, corresponding to simple assault without injury or weapon use; and serious violence, corresponding to 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. The 6-month prevalence of any violence was 19.1%, with 3.6% of participants reporting serious violent behavior. Distinct, but overlapping, sets of risk factors were associated with minor and serious violence. “Positive” psychotic symptoms, such as persecutory ideation, increased the risk of minor and serious violence, while “negative” psychotic symptoms, such as 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. Particular clusters of symptoms may increase or decrease violence risk in schizophrenia patients. Violence risk assessment and management in community-based treatment should focus on combinations of clinical and nonclinical risk factors.

Torrey, E. F. (2011). Stigma and violence: Isn’t time to connect the dots? Schizophrenia Bulletin. doi: 10.1093/schbul/sbr057

Abstract: Stigma against mentally ill persons is a major problem and has increased in incidence. Multiple studies have suggested that the perception of violent behavior by seriously mentally ill individuals is an important cause of stigma. It is also known that treating seriously mentally ill people decreases violent behavior. Therefore, the most effective way to decrease stigma is to make sure that patients receive adequate treatment.

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