I Criminal and antisocial behaviours

and schizophrenia: a neglected topic

SHEILAGH HODGINS
Institute of Psychiatry, King's College, University of London, UK

I Introduction

This chapter reviews current findings of antisocial and violent behaviour

among persons who develop schizophrenia. Initially, the evidence indicating
that persons who develop schizophrenia are at increased risk for both non-
violent and violent crime is briefly reviewed. Next, the current understanding
of criminality in the general population is presented demonstrating the impor-
tance of studying sub-groups of offenders defined by age of onset of criminal
activities. Part 3 of the chapter presents data describing a sample of 224 men
with schizophrenia, 58 non-offenders and 116 offenders divided by age at first
crime. Part 4 synthesises what is known about possible aetiological factors
contributing to antisocial behaviour in persons who develop schizophrenia.
The final section of the chapter concludes by suggesting that research aimed
at identifying the aetiology of schizophrenia will be enriched, and perhaps
moved closer towards its goal, by taking account of antisocial behaviour
among those who develop schizophrenia and their relatives.

I Part 1: Criminality of persons who develop schizophrenia

In the last decade, several epidemiological studies of large unbiased birth co-
horts and population cohorts conducted in a number of different countries have
compared the criminality of individuals with schizophrenia to that of the general
population. All have found that persons with schizophrenia are at increased risk
for nonviolent offending and at even higher risk for violent offending (Ar-
seneault et al. 2000; Brennan et al. 2000; Mullen et al. 2000; Swanson et al.
1990; Tiihonen et al. 1997). These investigations likely underestimate the crim-
inality of persons with, or who will develop, schizophrenia. All but one (Ar-
seneault et al. 2000) examined treated cases, thereby underestimating the preva-
lence of schizophrenia, and official criminality, thereby underestimating antiso-
cial and aggressive behaviours that have not led to criminal convictions.
Further, studies in jurisdictions in which all persons accused of homicide un-
dergo a psychiatric assessment have found that persons with schizophrenia, as
compared to the general population, are at increased risk to commit homicide.
These studies indicate that persons with schizophrenia are responsible for any-
where between 6% and 28% of homicides (for reviews see Erb et al. 2001).

W. F. Gattaz et al (eds.) Search for the Causes of Schizophrenia

© Steinkopff Verlag Darmstadt 2004
316 I S.

Consistent with these findings are the results of studies reporting that per-
sons with schizophrenia living in the community are convicted for more non-
violent and violent offences than their non-disordered neighbours (Belfrage
1998; Lindqvist 1986). Diagnostic studies of representative samples of con-
victed offenders have documented rates of schizophrenia between 2 and 7
times higher than those for age- and gender-matched samples of the general
population (see for example, Brinded et al. 1999; Brink et al. 2001; Gunn 2000;
Hodgins and Cote 1995). The proportion of persons with, or who will develop
schizophrenia, that are convicted of crimes vary from one country to another
and parallel the rates of criminality in the general population (see for exam-
ple, Hodgins and Janson 2002; Mullen et al. 2000).
While the increase in the risks of nonviolent offending and particularly of
violent offending for persons with schizophrenia reported in various studies
are similar (Hodgins 1998), the proportions of persons with this disorder who
offend differ. These differences result from many factors including the crime
rate in the region being studied, the rate of resolution of criminal offences,
the era under study, and the age of the subjects when the criminal data were
obtained. For example, the criminality of a Danish cohort that included more
than 358000 persons was examined in 1991 when the cohort members were in
their forties. Men with schizophrenia were found to be 4.6 times (95% confi-
dence interval 3.8-5.6) more likely to be convicted of a violent offence than
the men who had never been admitted to a psychiatric ward. The women with
schizophrenia were 23.2 times (95% confidence interval 14.4-37.4) more likely
to have a conviction for a violent offence than women with no psychiatric ad-
missions (Brennan et al. 2000). However, only 11.3% of the men and 2.3% of
the women who developed schizophrenia committed violent offences. In the
1953 Stockholm birth cohort, when cohort members were aged 30, 50% of the
men and 19% of the women with a major mental disorder had been convicted
of at least one offence (Hodgins 1992). In the Dunedin birth cohort, 15.4% of
the cohort members with a schizophrenia spectrum disorder had at least one
criminal conviction between their 20 th and 21 st birthdays (Arseneault et al.
2000). Among the patients with schizophrenia in the state of Victoria, Austra-
lia, 26.3% were reported to have a record of criminal convictions as compared
to 8.6% of the matched control subjects (Mullen et al. 2000). With compelling
evidence demonstrating that some persons who develop schizophrenia are at
increased risk to engage in serious criminal activities, the challenge now is to
understand how the offenders with schizophrenia differ from those with the
same disorder who do not offend.

I Part 2: Adescription of criminal offenders with schizophrenia

In order to understand the criminality of persons who develop schizophrenia,
it is helpful to briefly review what is known about criminality among persons
without this disorder.