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Violence and Mental Disorders

2012-12-20

In my opinion, those who look to greater legal restrictions on firearm ownership for protection from homicidal rampages by disturbed individuals are looking in the wrong direction. Instead of passing more laws, we should look to early and aggressive intervention with psychiatric treatment for individuals who are at risk of committing violent acts, as being a more cost-effective approach to reducing violence.  It is important to remember that laws do not eliminate bad behavior, they only make it illegal–to reduce a behavior we abhor, it is better to address it directly.
I advocate the development of a mental health treatment system which is vastly more comprehensive than our current system. In this system, persons who express a need for psychiatric help would be only a part of the client base. Persons who show indications that they might have mental disturbances that lead to violent behavior will be identified by case-finding at points where they come into contact with police, medical providers, and even their neighbors. Persons who are identified can refuse treatment, but once identified, they can be restricted from firearm and weapon ownership unless they cooperate with mental health providers.
Under this type of system, if it were working properly, the Newtown killer would have been identified a long time ago as an at-risk individual. His mother would have been warned and advised to keep her firearms carefully locked up (or else have them removed from the house.) If there were issues in his life that were causing mental disturbances or leading to long-term resentment or anger, these might have been addressed if he was willing to accept treatment. In any case, he would have been removed from access to firearms of any kind, not just military-grade weapons.

Here are a couple of abstracts that deal with the issue of violence and mental illness. Despite what we are told in the media and by pundits/media experts, there is an association between mental illness and violence. Sociopathy, antisocial personality disorder, and alcohol abuse are the disorders most commonly found to exhibit violent behavior, but schizophrenia with paranoid ideation is also a major risk. Affective disorders such as depression, bipolar disorder, and dysthymia are not considered a high risk for other-directed violence.
In addition, there is an association of autism and Asperger’s syndrome with violence, but it is very different from the type of violence of which these abstracts speak. The violent behavior that occurs in patients with severe developmental disabilities like autism is typically poorly directed, episodic, and ineffectual. An important paper I found tried to distinguish “temper tantrums” and nonspecific behavior problems from actually violent behavior. It describes “an occasional aggressive outburst or behavioral disturbance” as questionable justification for applying a label of “violent” to a patient.
This paper states that, of reports reviewed and found methodologically sound, only 3 of 132 patients were considered clearly violent. If all reports of any quality were included, only 11 of 197 patients could be considered violent. The author goes on to note the incidence of violence in the USA among young people 12-24 years old is approximately 6 to 7 percent per year (in 1987.) The author concludes that there is no evidence for an increased risk of violence in Asperger’s syndrome.  When violence occurs in a patient with this diagnosis, it is probably due to some co-morbid disorder.
This paper was published in the Journal of Autism and Developmental Disorders, Vol. 21, No. 3, 1991 by M Ghaziuddin, Luke Tsai, and N Ghaziuddin.
The kind of violent behavior seen in patients with Asperger’s syndrome is thought to be related to their difficulties with empathy. “Agitation and aggressive outbursts” are typically described in the few patients who show signs of violence. Some caregivers to these patients describe a syndrome of “meltdown” in which the patient becomes extremely agitated and may react violently if disturbed. In these cases, the patient seems to be in a hypersensitive state and probably cannot distinguish individuals in his/her environment, much less demonstrate empathy for the suffering they inflict on others.
This brings us back to the killings that occurred on Friday, December 14, in Newtown, Connecticut. The killer was believed to have Asperger’s syndrome and was living at home with his mother after leaving high school, apparently without graduating. There are no details available now about his condition after he left school or his reasons for not continuing. There is talk in the media to the effect that he was left alone in his mother’s large house, possibly for long periods of time. There is also a statement that he was obsessed with “Call of Duty”, a video game that simulates the activities of soldiers in WW II.
His mother, who was alone with him for the last four years since her divorce, is dead, so our main source of information about his recent activities is cut off. His father is said to have given his wife a generous settlement of nearly a quarter million dollars a year in alimony as well as a 1.6 million dollar house. He is not talking but in any case lost contact with the younger Lanza four years ago. Clearly, the family was extremely well to do both before and after the divorce.
It is possible that one reason for his mother’s ownership of several “sporting” (military grade) firearms was “self-protection” since she was so well off. Since the family lived in an affluent section of Newtown, it is likely that they felt anxious about intruders. A weapon such as a Glock ten mm pistol with fifteen rounds in the magazine, kept at the bedside, is a common household appliance in wealthy homes, and imparts a distinct feeling of security.
Unfortunately, the young Lanza appears to have developed a homicidal rage on or before December 14. What may have occurred between the young man and his mother is unknown, but I suspect that she angered him by some apparently inconsequential behavior or remark. Prior to that incident, he must have developed a resentment or feeling of anger at some consistent feature of his environment that may have gradually become an obsession.
It is possible that the incident that set off the young Lanza may have been dissipated relatively harmlessly in an object-destroying tantrum if he had not had firearms available. It is also possible that a firearm that is not self-loading (semi-automatic) and has ten or fewer cartridges in its magazine may have greatly impaired him in his homicidal rampage; such firearms are often referred to as “hunting” weapons, such as bolt-action rifles and shotguns.
However, it is also possible that, if he had only a hunting firearm, he would have been able to kill an equal number of people if he was able to reload fast enough. A single shot from a 12 gauge shotgun is much more likely to be lethal than a single shot from a Bushmaster .223, especially at close range.
The real point is that it is not the weapon, but the homicidal intent of the weapon’s holder, that causes homicidal violence. While a baseball bat is less effective than a Bushmaster, it is still fairly easy to kill someone by hitting them on the side of the head with a bat just once.
Since we cannot eliminate weapons and potential weapons from the environment (especially because there are said to be 300 million firearms in the USA), it would be more effective to reduce the impulse to homicide by detecting and treating the potential aggressor.

 

Psychiatr Clin North Am. 1997 Jun;20(2):405-25.
Violence and homicidal behaviors in psychiatric disorders.
Asnis GM, Kaplan ML, Hundorfean G, Saeed W.
Source
Department of Psychiatry, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA.
Abstract
Our review evaluating the relationship between violent/homicidal behaviors and mental illness/psychiatric disorders used many different data including that assessing the prevalence of violent/homicidal behaviors in former psychiatric inpatients (just before hospitalization, during hospitalization, and after discharge) as outpatients and in community samples as well as evaluating the prevalence rate of psychiatric disorders in people who actually engaged in violent/homicidal disorders (jail detainees, prison inmates, and community samples). Irrespective of which line of investigation, there was convincing evidence that violent/ homicidal behavior was associated significantly with mental illness. Although earlier investigations failed to control for important variables, such as age and sociodemographics, most studies reviewed in this article did control for these items, further underlining the association of violence and mental illness. The question of whether specific psychiatric diagnostic categories are associated with violent/homicidal behavior is less definite across the various studies reviewed. The presence of substance abuse and dependence and alcohol abuse and dependence as well as antisocial personality disorder are particularly associated with an increased risk of violent/homicidal behaviors. The risk for these latter behaviors in schizophrenia, mood disorders, and anxiety disorders may appear somewhat greater than that for a general population but are not of the same magnitude of that for substance abuse or antisocial personality disorder. Interestingly, our outpatient study found that homicidal behaviors were not associated with any specific psychiatric diagnosis. Although understanding whether specific psychiatric diagnostic categories are more prone to violent behaviors may be of importance, most studies have been shortsighted regarding this evaluation. All the studies presented in this article except the ECA project, presented diagnostic data where either the presence of one psychiatric disorder did not preclude the diagnosis of another or assigned subjects/patients into the severest disorder of a predetermined hierarchy of diagnoses or only selected their principal/primary diagnosis. Thus, the effect of having a solitary psychiatric disorder (only one disorder present) as well as the effect of comorbidity per se on the relationship of psychiatric disorders and violent/homicidal behaviors were unexplored. Only the ECA study by Swanson and colleagues reported on the effect of comorbidity. As reviewed earlier in the article, Swanson et al found that comorbidity of psychiatric diagnostic categories further increased the risk of violent/ homicidal behaviors. In most cases, it was many more times than simply adding the rates of either diagnosis alone. Because more than 54% of respondents of the National Comorbidity Survey study who had one DSM-III-R diagnosis also had at least a second Axis I diagnosis, the association of violent/homicidal behaviors to mental illness may even be stronger than originally believed. Within the relationship of violent/homicidal behaviors and mental illness, this article suggests a number of particular risk factors. As just reviewed, substance/alcohol abuse and antisocial personality disorder as well as the presence of comorbid psychiatric disorders are significant risk factors. Which particular comorbid illness increases the risk still needs further elaboration. Studies must continue to try to define and understand the relationship of violent/homicidal behaviors in mental illness. Although mental disorders per se are significantly associated with violent/homicidal behaviors, it is reasonable to believe that targeting certain subgroups of patients should be helpful. Probably the presence of psychotic symptoms is a significant risk factor in violent/ homicidal behaviors in the mentally ill. Only one of the studies reviewed in this article evaluated this issue. (ABSTRACT TRUNCATED)
PMID: 9196922 [PubMed – indexed for MEDLINE]

Encephale. 2009 Dec;35(6):521-30. doi: 10.1016/j.encep.2008.10.009.
[Risk of homicide and major mental disorders: a critical review].
[Article in French]
Richard-Devantoy S, Olie JP, Gourevitch R.
Source
Département de psychiatrie et psychologie médicale, CHU d’Angers, 4, rue Larrey, 49933 Angers cedex 9, France. richarddevantoy@orange.fr
Abstract
INTRODUCTION:
Tragic and high profile killings by people with mental illness have been used to suggest that the community care model for mental health services has failed. It is also generally thought that schizophrenia predisposes subjects to homicidal behaviour.
OBJECTIVE:
The aim of the present paper was to estimate the rate of mental disorder in people convicted of homicide and to examine the relationship between definitions. We investigated the links between homicide and major mental disorders.
METHODS:
This paper reviews studies on the epidemiology of homicide committed by mentally disordered people, taken from recent international academic literature. The studies included were identified as part of a wider systematic review of the epidemiology of offending combined with mental disorder. The main databases searched were Medline. A comprehensive search was made for studies published since 1990.
RESULTS:
There is an association of homicide with mental disorder, most particularly with certain manifestations of schizophrenia, antisocial personality disorder and drug or alcohol abuse. However, it is not clear why some patients behave violently and others do not. Studies of people convicted of homicide have used different definitions of mental disorder. According to the definition of Hodgins, only 15% of murderers have a major mental disorder (schizophrenia, paranoia, melancholia). Mental disorder increases the risk of homicidal violence by two-fold in men and six-fold in women. Schizophrenia increases the risk of violence by six to 10-fold in men and eight to 10-fold in women. Schizophrenia without alcoholism increased the odds ratio more than seven-fold; schizophrenia with coexisting alcoholism more than 17-fold in men. We wish to emphasize that all patients with schizophrenia should not be considered to be violent, although there are minor subgroups of schizophrenic patients in whom the risk of violence may be remarkably high. According to studies, we estimated that this increase in risk could be associated with a paranoid form of schizophrenia and coexisting substance abuse. The prevalence of schizophrenia in the homicide offenders is around 6%. Despite this, the prevalence of personality disorder or of alcohol abuse/dependence is higher: 10% to 38% respectively. The disorders with the most substantially higher odds ratios were alcohol abuse/dependence and antisocial personality disorder. Antisocial personality disorder increases the risk over 10-fold in men and over 50-fold in women. Affective disorders, anxiety disorders, dysthymia and mental retardation do not elevate the risk. Hence, according to the DMS-IV, 30 to 70% of murderers have a mental disorder of grade I or a personality disorder of grade II. However, many studies have suffered from methodological weaknesses notably since obtaining comprehensive study groups of homicide offenders has been difficult.
CONCLUSIONS:
There is an association of homicide with mental disorder, particularly with certain manifestations of schizophrenia, antisocial personality disorder and drug or alcohol abuse. Most perpetrators with a history of mental disorder were not acutely ill or under mental healthcare at the time of the offence. Homicidal behaviour in a country with a relatively low crime rate appears to be statistically associated with some specific mental disorders, classified according to the DSM-IV-TR classifications.
PMID: 20004282 [PubMed – indexed for MEDLINE]

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