You are on page 1of 6

International Journal of Law and Psychiatry 33 (2010) 171176

Contents lists available at ScienceDirect

International Journal of Law and Psychiatry

Early psychosis and aggression: Predictors and prevalence of violent behaviour amongst individuals with early onset psychosis
Alicia Spidel a,, Tania Lecomte b, Caroline Greaves c, Kimberly Sahlstrom d, John C. Yuille a
a

The University of British Columbia, Canada University of Montral, Canada Simon Fraser University, Canada d Forensic Psychiatric Hospital, Canada
b c

a r t i c l e
Keywords: Psychosis Violence Substance abuse Psychopathy

i n f o

a b s t r a c t
Studies in the area of psychosis and violence to date suggest that those who suffer from psychosis are at higher risk for perpetration of such aggressive behaviours. In fact, it has been suggested that variables such as substance use and personality may mediate this relationship. Other variables, such as childhood physical abuse, might also be implicated in the etiology. In the current study, a sample of one hundred and eighteen participants with a primary diagnosis of psychosis were interviewed and prevalence rates for aggressive experiences were as follows: history of trouble with the law (45%), history of emotional abuse (9.6%), physical abuse (38.8%), and sexual abuse (60.2%). With regard to perpetration, 69.6% reported verbal or physical aggression (69.6%), and further, 61% reported problems with substances. Logistic regression procedures were used with a number of the variables under study and relationships were evidenced between psychopathy scores, history of abuse, and regular drug use. History of child abuse was related to violence history, with those who were victims of child abuse being more likely to be violent in later life. In addition higher scores on the psychopathy measure were linked with violence history. This study was a rst step towards identifying persons suffering from a mental illness who may be at risk for violence by identifying who, among rst episode clients, may be more likely to perpetrate violent behaviours. Targeted interventions and strategies may be further rened so that individuals receiving mental health services may be better served. 2010 Published by Elsevier Ltd.

1. Introduction The relationship between mental disorder and violence has been argued about and researched for decades. It has been suggested that individuals who have, or will develop, schizophrenia are at increased risk for violent offending (Appelbaum, 2006; Brennan, Mednick, & Hodgins, 2000; Naudts & Hodgins, 2006; Swanson, 1994; Swanson et al., 2006; Vevera, Hubbard, Vesely, & Papezov, 2005; Wallace, Mullen, & Burgess, 2004). This nding has been shown in various studies across different countries and samples (for a review see Naudts & Hodgins, 2006). In a study by Taylor and Gunn (1984), which is cited as being one of the most methodologically robust (Mullen, 2006) the researchers found that 11% of homicide offenders and 9% of those found guilty of non-fatal violence had schizophrenia. Although there is a signicant association between psychosis and violence, it is not clear why some patients with psychosis behave violently and others do not. Comorbid substance misuse signicantly
Corresponding author. Department of Psychology, The University of British Columbia, 2136 West Mall, Vancouver, B.C., Canada. E-mail address: aspidel@interchange.ubc.ca (A. Spidel). 0160-2527/$ see front matter 2010 Published by Elsevier Ltd. doi:10.1016/j.ijlp.2010.03.007

increases this risk (Walsh et al., 2001), and other factors suggested as being important include specic symptoms (Taylor, 1998) and nonadherence to medication (Swartz et al., 1998). A signicant association has been demonstrated between psychopathy, as assessed by Hare's (1991) criteria, and violence in patients with schizophrenia (Nolan, Volavka, Mohr, & Czobor, 1999; Tengstrom, Grann, Langstrom et al., 2000). As a result of these unclear ndings there is a great deal of controversy in the mental health eld about how to interpret the association between psychosis and violence (Buchanan, 2008; Elbogen & Johnson, 2009). Despite this debate, very few studies have examined this phenomenon and the associated variables specically in those who have recently experienced psychosis. Most of the research to date has instead focused on chronic patient samples (Lecomte et al., 2008). However, by extending investigations to individuals in the early phases of the illness, it should be easier to tease apart the contribution of numerous inuences on subsequent violent behaviour. Although a few studies have indeed included similar variables (i.e., substance misuse and aggression) in early psychosis samples (Foley et al., 2005; Milton et al., 2001), the present study is a rst investigation of this kind in a Canadian sample, and in addition, a rst to compare the inuence of violence concurrent with

172

A. Spidel et al. / International Journal of Law and Psychiatry 33 (2010) 171176

childhood abuse history, psychopathy, and substance abuse. Accordingly, the current study focused on violence history in an early psychosis sample, along with factors such as child abuse, personality traits, and substance use. 1.1. History of childhood abuse Childhood abuse has rarely been investigated in early psychosis clients. However, Grilo, Sanislow, Fehon, Martino, and McGlashan (1999) investigated the psychological and behavioural functioning of 322 psychiatrically hospitalized adolescents and found that those in their high childhood abuse group reported higher levels of violence and substance use problems (amongst other variables) than did those in their low abuse group. Other adolescent studies with those in a community drug treatment program, have in fact shown negative correlations between psychiatric disorders and violent behaviour with childhood abuse history (Hawke, Jainchill, & De Leon, 2003). In addition research has found a strong association between childhood abuse, subsequent violence perpetration, and substance use problems (see Hawke et al., 2003), which necessitates continued empirical investigation. 1.2. Personality disorder: Psychopathy The investigation of personality disorder as an additional factor in psychiatric illness and violence has received little attention in the literature, particularly in those presenting a rst episode of psychosis. It has, however, been found that individuals with psychiatric disorders and co-occurring antisocial personality disorders are also more likely to be arrested (Brown, Ridgely, Pepper, Levine, & Ryglewicz, 1989). An antisocial personality disorder diagnosis, however, does not always indicate criminal behaviour. By contrast, psychopathic traits are strongly predictive of criminal behaviour and violent recidivism for Caucasian males residing in the community (Cunningham, Reidy, & Sorensen, 2008). There is now good evidence that personality factors mediate criminality in schizophrenia (Nolan et al., 1999; Tengstrm et al., 2004). In individuals with early psychosis, personality features have not received empirical attention regarding their links with violence. This is despite the existence of a body of studies reporting psychopathy to be a robust predictor of violence and recidivism across various samples (Hare, 2006). Due to its strong link with violence, personality traits, in particular, psychopathy, were central features considered in the current investigation. 1.3. Substance use An often cited criticism in the psychiatric literature is that substance abuse has not, until quite recently, received consideration as a contributing factor to subsequent expressions of violence (Smith & Hucker, 1994; Swanson, 1994). Swanson (1994) noted the dearth in general population data examining the relationship between severe mental illness, violence, and substance abuse. Of interest to the present investigation is the nding that more than 50% of individuals with severe mental illness are known to have substance abuse problems, with the prevalence being closer to 70% in rst episode samples (Linszen et al., 1997). In addition, comorbid substance disorders are associated with a variety of negative outcomes including: increased psychotic symptoms, poorer treatment adherence, housing instability and homelessness, and a preponderance of medical problems (Soyka, 2000). Swartz et al. (1998) looked at the joint effect of substance abuse and medication noncompliance on the greater risk of serious violence among persons with severe mental illness in 331 inpatients. The authors found that the combination of medication noncompliance and alcohol or substance abuse problems was signicantly associated with serious violent acts in the community, even after sociodemographic

and clinical characteristics were controlled. The authors concluded that alcohol or other drug abuse problems, combined with poor adherence to medication, may signal a higher risk of violent behaviour among persons with severe mental illness. Although the statistical association of substance use and criminal behaviour has been established (e.g., Lindqvist, 1986), this has not been evaluated sufciently within the early psychosis population. In order to begin to address some of the aforementioned shortcomings in the literature to date, the current study's objectives were: 1) to investigate the prevalence of childhood abuse, violence, psychopathic traits, and substance abuse in a sample of rst episode individuals, and 2) to determine the best predictors of violent behaviour in a sample of early psychosis individuals, amongst childhood abuse, psychopathic traits, and substance abuse. 2. Method 2.1. Participants The sample consisted of 118 individuals with early psychosis dened as having consulted a medical professional for psychotic symptoms (namely hallucinations and/or delusions) for the rst time less than two years prior to entering the study. Their diagnoses included schizophrenia spectrum psychosis, bipolar disorder, and major depressive disorder with psychotic features. Eligible clients were 18 years of age or older, receiving case-management services or having regular contacts with a primary mental health clinician, capable of consenting to the study, and, residing in the community. Exclusion criteria were delineated as those with a mental handicap (IQ b 70), an organic disorder, or a drug-induced psychosis diagnosis. A diagnosis of drug-induced psychosis was determined from their chart and they were not invited to participate in the study. As some of the participants had incomplete data only the ones with complete data for all the variables were included in the study. Participants were recruited from the South Fraser Early Psychosis Intervention (EPI) Program, the Vancouver EPI Program, the University of British Columbia Day Program, and St. Paul's Hospital Outpatient Clinic. All the clients who were seen at these clinics were asked by their caseworkers or psychiatrists if they were willing to hear about the study. The participants in the study had a mean age of 25.14 (SD= 6.8) and 64.1% were male (n = 75). In terms of ethnicity 61% of the sample was Caucasian (n = 70), 16% Asian (n = 18), and 3% First Nations (n = 3), or other. A large majority (92.1%, n = 105) were single/never married. Average number of years of education was reported as 12.5 (SD= 2.3). Diagnostic information obtained through chart review revealed that 56% (n = 66) of this sample had a diagnosis of schizophrenia, 22% (n = 27) schizoaffective disorder, 11% (n = 13) bipolar disorder and 10% (n = 12) psychosis NOS, or, were simply identied as early psychosis. All were prescribed atypical antipsychotics, with many receiving various combinations of antipsychotics and mood stabilizers. 2.2. Measures As part of a larger study on treatment adherence in early psychosis (Lecomte et al., 2008), in the present cross-sectional study participants met with a trained interviewer once for 2 h. Participants completed self-report questionnaires on experiences with child abuse, violence perpetration, and substance abuse, and also completed a personality questionnaire. 2.2.1. Violence Violence was measured using the Modied Overt Aggression Scale (MOAS; Kay, Wolkenfeld, & Murrill, 1988) which assesses three types of self-reported violence in the last 12 months: 1) physical aggression,

A. Spidel et al. / International Journal of Law and Psychiatry 33 (2010) 171176

173

2) verbal aggression and 3) property aggression. Lifetime arrest for violent offences was measured via self-report which asked whether the participant had even been arrested as well as other sociodemographic information such as ethnicity, marital status, and education level attained. Unfortunately the researchers had no access to ofcial records, which would be of interest in future studies. The MOAS was developed for clinical purposes, focuses exclusively on aggressive behaviour (Bowers, 1999), provides clear behavioural anchors, requires no formal training, and has a high (0.850.94) interrater reliability (Kay et al., 1988; Steinert et al., 2000). It has been used with psychiatric populations (Crocker et al., 2005). Inter-rater reliability of MOAS scores was evaluated using an intra-class correlation coefcient (ICC), as was the joint reliability of the raters in the study with an expert rater. The ICC between the raters in the present study was .96, and .98 between the raters and expert rater. Results suggest that this measure can be utilized in rater assessment and that raters administering the MOAS in this model of rater reliability assessment demonstrate a high level of consistency and reliability. For the purpose of this study groups were constructed for those with and without a history of violence (i.e. verbal, physical and any violence verbal and physical combined) using scores on the MOAS. 2.2.2. History of child abuse Childhood trauma was assessed using the Childhood Trauma Questionnaire (CTQ; Bernstein et al., 1994). The Childhood Trauma Questionnaire is a 28-item self-report inventory that provides brief, reliable, and valid screening for histories of abuse and neglect. It inquires about ve types of maltreatment emotional, physical, and sexual abuse, as well as emotional and physical neglect. Also included is a 3-item Minimization/Denial Scale for detecting false-negative trauma reports. It has been found to be a reliable and valid (Bernstein, Ahluvalia, Pogge, & Handelsman, 1997) measure of childhood trauma and abuse. In the context of this investigation, means and prevalence of emotional, physical, and sexual abuse were reported, and further, the total score was used to look at the relationships between the history of child abuse and the other variables. 2.2.3. Personality disorder: Psychopathy Psychopathic traits were assessed using the Self-Report Psychopathy Scale (SRP-II; Hare, 1991; Hare, Harpur, & Hemphill, 1989). The SRP-II is a 60-item self-report measure of psychopathy, with items scored on a 7-point scale ranging from 1 (not true) to 7 (very true). The SRP-II is modeled after the PCL-R (Psychopathy Checklist-Revised; Hare, 2003), and is intended to assess the prototypical psychopath as described by Hart, Hare, and Forth (1994), involving a cluster of personality traits and socially deviant behaviours. The SRP-II has two factors, a personality-based factor and a behaviour- based factor. Information concerning the reliability and validity of the SRP-II is limited, although Widiger, Frances, Pincus, and Davis (1991) reported that the SRP-II correlated from 0.24 to 0.56 (M = 0.35) with the DSMIII-R (American Psychiatric Association, 1994) diagnosis of antisocial personality disorder, from 0.13 to 0.50 (M = 0.29) with ICD-10 (World Health Organization, 1990) with diagnoses of dissocial personality disorder, and from 0.23 to 0.68 (M = 0.38) with a 10-item psychopathy set derived from the PCL-R (Zagon & Jackson, 1994). In this study the SRP-II total score was used. 2.2.4. Substance use Substance use was assessed using the drug and alcohol scales of the Addiction Severity Index (Zanis, McLellan, & Corse, 1997). The ASI is administered as a semi-structured interview and assesses current and past use of alcohol, as well as various types of drugs. Using a 10point scale from 0 to 9, interviewer severity ratings indicate the degree of patient problems in each of the alcohol or drug domain. For the purpose of analyses in this study, substance use was restricted to a

yes or no history of drug abuse or history of alcohol abuse. Due to power issues, each drug was not analyzed separately in this dataset. In addition, past overdoses on any type of drug or alcohol were recorded. The ASI has been validated in multiple studies, including individuals with severe mental illness. In fact, all measures except the SRP-II, have previously been validated with individuals with severe mental illness. Though the SRP-II is still being validated with this population, it has been used with individuals with severe mental illness in other studies (Crocker et al., 2005) and will be interpreted with caution. 3. Results 3.1. Objective 1 3.1.1. Violence In terms of violence, the MOAS detected that 42.7% (n = 50) of the sample had a history of physical aggression, and 61.5% (n = 72) had a history of verbal aggression. For this analysis property violence was not included. Overall, combining verbal and physical violence 67.5% (n = 79) of the sample had a history of one or both of these types of violence. Unfortunately there is no normative data for the MOAS. Forty-six percent (n = 52) of the sample reported having been in trouble with the law at some point in their lives, 42.9% (n = 48) had been arrested and 35.1% (n = 39) had spent at least one night in jail. 3.1.2. History of childhood abuse The study found that there was a high degree of childhood abuse history in this sample (M = 114.2; SD = 22.4). The CTQ total score mean for this sample falls in the severe to extreme range. The means and standard deviations for the CTQ subscales are as follows: emotional abuse (M = 11.6; SD = 1.01); physical abuse (M = 8.40; SD = 0.88); sexual abuse (M = 7.80; SD = 0.97) and are all in the severe to extreme range. In a comparison undergraduate sample the means and standard deviations for the CTQ subscales are as follows: emotional abuse (M = 7.3; SD = 3.27); physical abuse (M = 6.51; SD = 2.47); and sexual abuse (M = 5.53; SD = 2.14). The means in the current sample were higher in each subsample than in the undergraduate sample. In terms of prevalence, 90.4% of the sample reported a history of emotional abuse; 61.2% reported having been physically abused; and 39.8% reported a history of sexual abuse. 3.1.3. Personality disorder: Psychopathy The sample means on the SRP-II was 4.11 for males, and 3.81 for females. These scores appear elevated compared to SRP-II item norms based on a sample of undergraduates (2.81 for males, and 2.53 for females; Williams & Paulhus, 2004). 3.1.4. Substance use Substance use for the last 30 days was assessed using the ASI. In this sample, marijuana was the most commonly used substance 55.7% (n = 64) of the sample reported marijuana use, 47.4% (n = 55) reported alcohol use, 26.1% (n = 30) had used cocaine, 21.7% (n = 25) had used amphetamines, 11.3% (n = 13) had used ecstasy, 9.6% (n = 9) had used hallucinogens, and 9.6% (n = 9) reported heroin use. In addition, 17.5% (n = 20) of the sample reported that they had overdosed in the past on some type of drug or alcohol. The results here are descriptive and normative data is not appropriate for these variables. 3.2. Objective 2 First, correlations were performed in order to examine the nature of the relationships between the various variables. Pearson correlations were performed in most cases (i.e., where either variable was continuous or one variable was dichotomous and one continuous) and Phi correlations were performed in the cases where both variables

174

A. Spidel et al. / International Journal of Law and Psychiatry 33 (2010) 171176 Table 2 Odds ratios (with condence intervals) for predicting violence across childhood history of abuse, psychopathy, and any regular alcohol/drug use. Physical CTQ-total SRP-II Regular alcohol use Regular drug use p b .05. 1.02 1.67 2.65 1.16 (1.001.05) (.833.36) (.5712.30) (.343.78) Verbal 1.04 1.46 2.92 3.51 (1.011.07) (.711.07) (.2830.71) (.7815.71)

were dichotomous. Interestingly, both physical and verbal violence were correlated with the other variables. Physical violence was correlated with psychopathy scores (r = .21, p b .05), with history of abuse (r = .31, p b .01), with alcohol abuse (r = .21, p b .05), and with drug abuse (r = .18, p b .05). Verbal violence was similarly correlated with psychopathy scores (r = .21, p b .05), with history of abuse (r = .33, p b .001), with alcohol abuse (r = .24, p b .01) and with drug abuse (r = .28, p b .01; see Table 1 for all correlations). The primary intent of the second objective was to determine the extent that the variables could predict violent behaviour. All potential dependent variables were entered in logistic regressions. Logistic regression revealed that a higher level of physical violence was most strongly predicted by a history of childhood abuse (odds ratio = 1.02, p b .05), and higher scores on the SRP-II (odds ratio = 1.67, p = .15), above all other variables. In terms of verbal violence history, logistic regression revealed higher scores on a history of childhood abuse (odds ratio = 1.04, p b .05) and drug abuse (odds ratio = 3.51, p = .10) more strongly predicted verbal violence compared with the other variables (see Table 2 for the complete list of scores). 4. Discussion The current study was intended as a preliminary investigation of violence in an early psychosis community sample, specically examining the history of childhood abuse, psychopathy, and substance misuse. Findings suggest that the perpetration of violent behaviours, either verbal or physical, is indeed an issue in a community sample of those presenting with early psychosis. These ndings are consistent with previous research which showed that one in three rst episode patients displayed violence when presenting with psychotic symptoms, and that one in 14 displayed violence that either could have or did cause injury to another person (Foley et al., 2005). Close to 70% of the current sample reported perpetrating at least one physical and/or verbal violent act during the course of the previous 12 months. Several explanations could be suggested in light of this nding. For instance, young adults, and particularly young males going through difcult times are more prone to expressing anger verbally or physically. The participants in this sample were predominantly male, which could explain this higher tendency toward violence. The study also found that many of the participants had a childhood abuse history in the severe to extreme range. In accordance with other studies, the results of this study suggest that individuals who were abused as children are also more likely to perpetrate violence, whether verbal or physical in nature (Williams & Chang, 2000). In addition researchers have found a strong link between childhood abuse and psychosis (Read, van Os, Morrison, & Ross, 2005) and a recent study that found this association in individuals experiencing a rst episode of psychosis (Lecomte et al., 2008). These researchers suggest that a reason for this may be that child abuse increases individuals' feelings of vulnerability and in turn their perceptions of the world as a treacherous place (Morrison, Frame, & Larkin, 2003). Both of these feelings have been linked to paranoia and psychosis (Morrison, 2001). Some researchers have

Table 1 Correlations for childhood history of abuse, violence, psychopathy, and any regular alcohol/drug use. SRP-II CTQ SRP-II CTQ-total MOAS-physical MOAS-verbal Regular alcohol use Regular drug use MOAS- MOAS- Regular Regular drug physical verbal alcohol use use .21* .33*** .43*** .67 .23* .21* .24** .16 .23* .18* .28** .58***

.25** .21* .31**

*p b .05, ** p b .01, and ***p b .001.

suggested that there is a distinct subtype of psychosis that is traumainduced (Ellason & Ross, 1997; Kingdon & Turkington, 1999). Others suggest that it is possible that a vicious circle can develop where traumatic events could precipitate a psychotic episode, which in turn could cause PTSD in relation to the psychotic symptoms, which may further exacerbate psychosis (this is similar to the interactive model proposed by Mueser, Rosenberg, Goodman, & Trumbetta, 2002). Regardless of the cause this is an important issue for the study with this population in the future. Another issue that appeared to be prevalent in this early psychosis sample was reported substance use, with more than 61% mentioning a problem in the past month consistent with previous studies in rst episodes (see Addington & Addington, 2006). Even though the substance with the most reported usage in the past 30 days (over half of the sample) was marijuana, a drug not typically linked with violence, it was followed closely by alcohol at just under half of the sample reporting usage. Furthermore, a substantial proportion reported using hard drugs: over one-quarter used cocaine and onefth used amphetamines. These results suggest that addressing substance use issues in early psychosis is not only an important target for health or symptomatic reasons, but could also have an inuence on violent behaviours. In fact, the majority of this sample had co-occurrences of substance abuse and violence, though the interaction did not reach signicance. There was a signicant correlation linking violence history and psychopathy scores, however it did not signicantly predict violence. This is an interesting area for further exploration. Theoretical and clinical research on psychopathy has found a strong and consistent link between violence and psychopathy (Porter & Woodworth, 2006). In addition psychopathy scores in offenders have been found to be one of the most signicant predictors of whether an individual would be violent in the future (Hemphill, Hare, & Wong, 1998). Although scores on the SRP-II in this sample were not found to predict violence this may be a function of the sample (i.e., community rather than incarcerated) and warrants further study. It is also important to consider that the SRP-II has not yet been validated with this population, limiting the interpretation of these results. It may be that this measure does not accurately measure psychopathy in this population; more information is needed on the instrument's convergent and construct validity. Violent behaviour by individuals with psychosis is a result of many factors (Krakowski, Volavka, & Brizer, 1986; Monahan, 1981; Mulvey & Lidz, 1984). This study is limited by the fact that only a few of these factors have been considered. Additional factors that should be addressed in future studies include socioeconomic factors, illness factors such as diagnosis (Krakowski et al., 1986; Rossi, Roncone, Allegro, & Palmieri, 1986; Swanson, Holzer, Ganju, & Jono, 1990), acute symptomatology (Beck, White, & Gage, 1991; Lowenstein, Binder, & McNiel, 1990), and family history (e.g., of violence, of substance abuse; Monahan, 1981). It was also limited by the cross-sectional design indeed, it is unclear as to whether the psychosis preceded or followed the presentation of violence in these individuals. Furthermore, in this study, it was not possible to specically link the type or severity of the violent behaviours with the other variables studied. A more in-depth qualitative interview could generate such information.

A. Spidel et al. / International Journal of Law and Psychiatry 33 (2010) 171176

175

The fact that the current research relied on self-report and clinical interviews may not be a limitation, since care was taken to ensure that the participants understood their reports were anonymous and condential. In addition, studies of illicit drug use regularly employ self-reports, and the literature shows respectable reliability and validity of self-reported behaviours when compared to biomarkers, criminal records and collateral interviews (Darke, 1998; Hamid, Deren, Beardsley, & Tortu, 1999; Stasiewicz, Bradizza, & Connors, 1997; Stasiewicz & Stalker, 1999; Wolford et al., 1999). When looking at drug and alcohol use, it may be of interest in future research to investigate drug use separately across substances. This was not done here as the power for the groups would have been too low. It would be interesting to examine these potential differences with a larger sample in future studies particularly as research with cannabis has shown that it plays an important role in the development of schizophrenia (Wheatley, 1998) and its high prevalence in the current study. Another area for future research would be to look at how specic symptoms of psychosis inuence violence. For example, grandiosity and paranoia have been investigated as predisposing patients toward medication noncompliance (Kelly, Maimon, & Scott, 1987; Pan & Tantam, 1989), which may result in more violence. Marder et al. (1983) found more severe psychopathology, including disorganization, hostility, and suspiciousness, was associated with inpatient drug refusal. It may then be that looking at specic symptoms instead of psychosis as a whole would be more telling when looking at violence prediction. In the area of mental illness and violence, the question of generalizability of ndings across settings is of importance. The situational precipitants of assaultive behaviour in the community differ from those in the hospital, and violent behaviour during hospitalization has not been shown to be a good predictor of violence in the community after release (Steadman, 1981; Steinert, 2002). The present study employed a relatively generalizable sample due to its focus on violence in community residents, albeit early psychosis individuals, rather than in hospitalized or incarcerated individuals. It is also important to remember that this study looked at the history of violence not just over the time since they were experiencing symptoms of psychosis or treatment for the symptoms. It would be of interest in future studies then to look at violence history prior to symptoms of psychosis and after the symptoms develop. The current study's results provide some insight on prevalence and predictors of violence among individuals with early psychosis residing in the community. It is important to remain mindful that these results do not apply to reasons why an individual is violent. As such, future studies are certainly warranted to uncover further associations and perhaps to determine causal relationships between these factors. As the literature in this area grows, targeted interventions may be developed and existing strategies rened so that individuals receiving mental health services are better served. Violence represents immense and various costs, both to the individual and to society; therefore, the more information gathered concerning individuals who commit violence, the better society can tailor prevention, management, and treatment strategies according to the needs of the specic population. References
Addington, D., & Addington, J. (2006). Early intervention for psychosis: Who refers? Schizophrenia Research, 84, 176177. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders, 4th ed. Washington, D.C.: APA. Appelbaum, P. S. (2006). Violence and mental disorders: Data and public policy. American Journal of Psychiatry, 163, 13191321. Beck, J. C., White, K. A., & Gage, B. (1991). Emergency psychiatric assessment of violence. American Journal of Psychiatry, 148, 15621565. Bernstein, D. P., Ahluvalia, T., Pogge, D., & Handelsman, L. (1997). Validity of the childhood trauma questionnaire in an adolescent psychiatric population. Journal of the American Academy of Child & Adolescent Psychiatry, 36, 340348. Bernstein, D., Fink, L., Handlesman, L., Foote, J., Lovejoy, M., Wenzel, K., et al. (1994). Initial reliability and validity of a new retrospective measure of child abuse and neglect. American Journal of Psychiatry, 151, 11321136.

Bowers, L. (1999). A critical appraisal of violent incident measures. Journal of Mental Health, 8, 339349. Brennan, P. A., Mednick, S. A., & Hodgins, S. (2000). Major mental disorders and criminal violence in a Danish birth cohort. Archives of General Psychiatry, 57, 494500. Brown, V. B., Ridgely, M. S., Pepper, B., Levine, I. S., & Ryglewicz, H. (1989). The dual crisis: Mental illness and substance abuse: Present and future directions. American Psychologist, 44, 656659. Buchanan, A. (2008). Risk of violence by psychiatric patients: beyond the actuarial versus clinical assessment debate. Psychiatric Services, 59, 184190. Crocker, A. G., Mueser, K. T., Drake, R. E., Clark, R. E., McHugo, G. J., Ackerson, T. H., et al. (2005). Antisocial personality, psychopathy, and violence in persons with dual disorders. Criminal Justice and Behavior, 32, 452476. Cunningham, M. D., Reidy, T. J., & Sorensen, J. R. (2008). Assertions of future dangerousness at federal capital sentencing: Rates and correlates of subsequent prison misconduct and violence. Law and Human Behavior, 32, 4663. Darke, S. (1998). Self-report among injecting drug users: A review. Drug and Alcohol Dependence, 51, 253263. 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. Archives of General Psychiatry, 66(2), 152161. Ellason, J., & Ross, C. (1997). Childhood trauma and psychiatric symptoms. Psychological Reports, 80, 447450. Foley, S. R., Kelly, B. D., Clarke, M., McTigue, O., Gervin, M., Kamali, M., et al. (2005). Incidence and clinical correlates of aggression and violence at presentation in patients with rst episode psychosis. Schizophrenia Research, 72, 161168. Grilo, C. M., Sanislow, C., Fehon, D. C., Martino, S., & McGlashan, T. H. (1999). Psychological and behavioral functioning in adolescent psychiatric inpatients who report histories of childhood abuse. American Journal of Psychiatry, 154, 538543. Hamid, R., Deren, S., Beardsley, M., & Tortu, S. (1999). Agreement between urinalysis and self-reported drug use. Substance Use & Misuse, 34, 15851592. Hare, R. D. (2003). Manual for the revised psychopathy checklist, 2nd ed. Toronto, ON, Canada: Multi-Health Systems. Hare, R. D. (2006). Psychopathy: A clinical and forensic overview. Psychiatric Clinics of North America, 29, 709724. Hare, R. D. (1991). The Hare Psychopathy Checklist-Revised Toronto, Ontario: MultiHealth Systems. Hare, R.D., Harpur, T.J., & Hemphill, J.F. (1989). Scoring pamphlet for the Self-Report Psychopathy scale: SRP-II. Unpublished document, Simon Fraser University, Vancouver, Canada. Hart, S. D., Hare, R. D., & Forth, A. E. (1994). Psychopathy as a risk marker for violence: Development and validation of a screening version of the Revised Psychopathy Checklist. In J. Monahan & H. Steadman (Eds.), Violence and mental disorder: Developments in risk assessment (pp. 8198). Chicago, IL: University of Chicago Press. Hawke, J. M., Jainchill, N., & De Leon, G. (2003). Posttreatment victimization and violence among adolescents following residential drug treatment. Child Maltreatment, 8, 5871. Hemphill, J. F., Hare, R. D., & Wong, S. (1998). Psychopathy and recidivism: A review. Legal and Criminological Psychology, 3, 139170. Kay, S. R., Wolkenfeld, F., & Murrill, L. M. (1988). Proles of aggression among psychiatric patients: I. Nature and prevalence. Journal of Nervous & Mental Disease, 176, 539546. Kelly, G., Maimon, J., & Scott, J. (1987). Utility of the health belief model in examining medication compliance among psychiatric outpatients. Social Science and Medicine, 25, 12051211. Kingdon, D. G., & Turkington, D. (1999). Cognitivebehavioural therapy of schizophrenia. In T. Wykes, N. Tarrier, & S. Lewis (Eds.), Outcome and innovation in the psychological treatment of schizophrenia (pp. 5979). London: Wiley. Krakowski, M., Volavka, J., & Brizer, D. (1986). Psychopathology and violence: A review of literature. Comprehensive Psychiatry, 27, 131148. Lecomte, T., Spidel, A., Leclerc, C., Greaves, C., Bentall, R. P., & MacEwan, G. W. (2008). Predictors and proles of treatment non-adherence and engagement in services problems in early psychosis. Schizophrenia Research, 102, 295302. Linszen, D. H., Dingemans, P. M. A. J., Nugter, M. A., Van der Does, A. J. W., Scholte, W. F., & Lenior, M. A. (1997). Patient attributes and expressed emotion as risk factors for psychosis relapse. Schizophrenia Bulletin, 23, 119130. Lindqvist, L. (1986). Barndomspsykoser: Arv eller miljoe? [Childhood psychoses: Heredity or environment?] Psykisk-Haelsa, 27, 192199. Lowenstein, M., Binder, R. L., & McNiel, D. E. (1990). The relationship between admission symptoms and hospital assaults. Hospital and Community Psychiatry, 41, 311313. Marder, S. R., Mebane, A., Chien, C. P., Winslade, W. J., Swann, E., & Van Putten, T. (1983). A comparison of patients who refuse and consent to neuroleptic treatment. American Journal of Psychiatry, 140, 470472. Milton, J., Amin, S., Singh, S. P., Harrison, G., Jones, P., Croudace, T., et al. (2001). Aggressive incidents in rst-episode psychosis. The British Journal of Psychiatry, 178, 433440. Monahan, J. (1981). The clinical prediction of violent behavior. Crime and Delinquency Issues: A Monograph Series, ADM, 81921, 134. Morrison, A. P. (2001). The interpretation of intrusions in psychosis: An integrative cognitive approach to hallucinations and delusions. Behavioral Cognition Psychotherapy, 29, 257276. Morrison, A. P., Frame, L., & Larkin, W. (2003). Relationships between trauma and psychosis: A review and integration. British Journal of Clinical Psychology, 42, 331353. Mueser, K. T., Rosenberg, S. D., Goodman, L. A., & Trumbetta, S. L. (2002). Trauma, PTSD and the course of severe mental illness: An interactive model. Schizophrenia Research, 53, 123143.

176

A. Spidel et al. / International Journal of Law and Psychiatry 33 (2010) 171176 Swartz, M. S., Swanson, J. W., Hiday, V. A., Borum, R., Wagner, H. R., & Murns, B. J. (1998). Violence and severe mental illness: The effects of substance abuse and nonadherence to medication. American Journal of Psychiatry, 155, 226231. Taylor, P. J. (1998). When symptoms of psychosis drive serious violence. Social Psychiatry and Psychiatric Epidemiology, 33, 4754. Taylor, P. J., & Gunn, J. (1984). Violence and psychosis. I. Risk of violence among psychotic men. British Medical Journal (Clinical Research Edition), 288, 19451949. Tengstrom, A., Grann, M., Langstrom, N., & Kullgren, G. (2000). Psychopathy (PCL-R) as a predictor of violent recidivism among criminal offenders with schizophrenia. Law and Human Behaviour, 24, 4558. Tengstrm, A., Hodgins, S., Grann, M., Langstrm, N., & Kullgren, G. (2004). Schizophrenia and criminal offending: The role of psychopathy and substance use disorders. Criminal Justice and Behavior, 31, 367391. Vevera, J., Hubbard, A., Vesely, A., & Papezov, H. (2005). Violent behaviour in schizophrenia: Retrospective study of four independent samples from Prague, 1949 to 2000. British Journal of Psychiatry, 187, 426430. Wallace, C., Mullen, P. E., & Burgess, P. (2004). Criminal offending in schizophrenia over a 25 year period marked by deinstitutionalization and increasing prevalence of comorbid substance use disorders. American Journal of Psychiatry, 161, 716727. Walsh, E., Gilvarry, C., Samele, C., Harvey, K., Manley, C., Creed, F., et al. (2001). Reducing violence in severe mental illness: Randomised controlled trial of intensive case management compared with standard care. BMJ, 323, 10931096. Wheatley, M. (1998). The prevalence and relevance of substance use in detained schizophrenic patients. Journal of Forensic Psychiatry, 9, 114129. Widiger, T. A., Frances, A. J., Pincus, H. A., & Davis, W. W. (1991). Toward an empirical classication for the DSM-IV. Journal of Abnormal Psychology, 100(3), 280288 Special issue: Diagnoses, dimensions, and DSM-IV: The science of classication. Williams, R. J., & Chang, S. Y. (2000). A comprehensive and comparative review of adolescent substance abuse treatment outcome. Clinical Psychology: Science and Practice, 7, 138166. Williams, K. M., & Paulhus, D. L. (2004). Factor structure of the Self-Report Psychopathy Scale (SRP-II) in non-forensic samples. Personality and Individual Differences, 37, 765778. Wolford, G. L., Rosenberg, S. D., Drake, R. E., Mueser, K. T., Oxman, T. E., Hoffman, D., et al. (1999). Evaluation of methods for detecting substance use disorder in persons with severe mental illness. Psychology of Addictive Behaviors, 13, 313326. World Health Organization (1990). World Health Organization, vi, 52 Albany, NY, US. Zagon, I. K., & Jackson, H. J. (1994). Construct validity of a psychopathy measure. Personality and Individual Differences, 17, 125135. Zanis, D. A., McLellan, A., & Corse, S. (1997). Is the Addiction Severity Index a reliable and valid assessment instrument among clients with severe and persistent mental illness and substance abuse disorders? Community Mental Health Journal, 33, 213227.

Mullen, P. E. (2006). Schizophrenia and violence: From correlations to preventive strategies. Advances in Psychiatric Treatment, 12, 239248. Mulvey, E. P., & Lidz, C. W. (1984). Clinical considerations in the prediction of dangerousness in mental patients. Clinical Psychology Review, 4, 379401. Naudts, K., & Hodgins, S. (2006). Neurobiological correlates of violent behavior among persons with schizophrenia. Schizophrenia Bulletin, 32, 562572. Nolan, K. A., Volavka, J., Mohr, P., & Czobor, P. (1999). Psychopathy and violent behavior among patients with schizophrenia or schizoaffective disorder. Psychiatric Services, 50, 787792. Pan, P. C., & Tantam, D. (1989). Clinical characteristics, health beliefs and compliance with maintenance treatment: A comparison between regular and irregular attenders at a depot clinic. Acta Psychiatrica Scandinavica, 79, 564570. Porter, S., & Woodworth, M. (2006). Psychopathy and aggression. In C. Patrick (Ed.), Handbook of psychopathy (pp. 481494). New York: Guilford. Read, J., van Os, J., Morrison, A. P., & Ross, C. A. (2005). Childhood trauma, psychosis and schizophrenia: A literature review with theoretical and clinical implications. Acta Psychiatrica Scandinavica, 112, 330350. Rossi, A., Roncone, R., Allegro, A., & Palmieri, G. (1986). L'indagine con TAC (Tomograa Assiale Computerizzata) nei disturbi schizofrenici [Research with computerized axial tomography (CAT) in schizophrenic disturbances]. Rivista Sperimentale di Freniatria e Medicina Legale delle Alienazioni Mentali, 110(6, Suppl), 12011208. Smith, J., & Hucker, S. (1994). Schizophrenia and substance abuse. British Journal of Psychiatry, 165, 1321. Soyka, M. (2000). Substance misuse, psychiatric disorder and violent and disturbed behaviour. The British Journal of Psychiatry, 176, 345350. Stasiewicz, P. R., Bradizza, C. M., & Connors, G. J. (1997). Subject-collateral reports of drinking in inpatient alcoholics with comorbid mental disorders. Alcoholism, Clinical and Experimental Research, 21, 530536. Stasiewicz, P. R., & Stalker, R. G. (1999). Subject-collateral reports of drinking in inpatient alcoholics with comorbid cocaine dependence. American Journal of Drug and Alcohol Abuse, 25, 319329. Steadman, H. J. (1981). Critically reassessing the accuracy of public perceptions of the dangerousness of the mentally ill. Journal of Health and Social Behavior, 22, 310316. Steinert, T. (2002). Prediction of inpatient violence. Acta Psychiatrica Scandinavica, 412 (suppl), 133141. Steinert, T., Sippach, T., & Gebhardt, R. P. (2000). How common is violence in schizophrenia despite neuroleptic treatment? Pharmacopsychiatry, 33, 98102. Swanson, J. W. (1994). Mental disorder, substance abuse and community violence. In J. Monahan & H. J. Steadman (Eds.), Violence and Mental Disorder (pp. 183203). Chicago: Chicago University Press. Swanson, J. W., Holzer, C. E., Ganju, V. K., & Jono, R. T. (1990). Violence and psychiatric disorder in the community: Evidence from the Epidemiological Catchment Area surveys. Hospital and Community Psychiatry, 41, 761770. Swanson, J. W., Swartz, M. S., Van Dorn, R. A., Wagner, H. R., Stroup, T. S., Lieberman, J. A., et al. (2006). A national study of violent behavior in persons with schizophrenia. Archives of General Psychiatry, 63, 490499.

You might also like