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VIOLENCE AND SCHIZOPHRENIA: RISK FACTORS AND MEDIATORS
S30
Abstracts of the 4th Biennial Schizophrenia International Research Conference / Schizophrenia Research 153, Supplement 1 (2014) S1–S384
phate was greater in the HI group (18.7%) than in the control group (10.5%), reflecting greater DA release in the striatum in the HI group (F(1,36)=3.75, p=0.061, adjusted F(1,33)=4.57, p=0.040). HI subjects reported more social defeat, t(38)=−2.44, p=0.019, loneliness, t(37)=−3.33, p<0.01, and depression, t(38)=−2.20, p=0.034. However, none of these measures were substantially associated with DA release (range r=0.07–0.20). Discussion: These preliminary results provide some support for sensitization of the dopamine system in individuals experiencing chronic exclusion, but the results are not conclusive.
Symposium VIOLENCE AND SCHIZOPHRENIA: RISK FACTORS AND MEDIATORS Chairperson: Seena Fazel Discussant: John J. McGrath Monday, 7 April 2014 2:00 PM – 4:00 PM Overall Abstract: Violence perpetrated by patients with schizophrenia remains one of the most important adverse outcomes in such patients, and a robust body of work has concluded that the odds of violent outcomes in individuals with schizophrenia are around 4 times higher than general population controls. What remains uncertain, however, is what risk and protective factors moderate such risk. This symposium will present a series of new reviews examining risk and protective factors for violence in patients with schizophrenia. The first review is an overall examination of all risk factor research and a meta-epidemiological approach synthesizing information across similar factors. The second reviews the epidemiologic work on the relationship between delusions and violence, and discusses the implications of this research for psychiatric treatment and public mental health policy. The third is a systematic review of the prevalance and risk factors for violence among inpatients with schizophrenia-spectrum disorders. The final paper brings together research on protective factors and discuss interventions that might reduce the incidence of violence in schizophrenia.
DELUSIONS AND VIOLENCE Jeffrey Swanson Duke University School of Medicine This presentation will review and evaluate key evidence for the link between violent behavior and psychotic symptoms in general, and delusions in particular. The presenter will reexamine conflicting findings for the “threat/control-override” and “rationality-within-irrationality” hypotheses that emerged in the 1990s, focusing in detail on comparative evidence from the MacArthur Violence Risk Study and the more recent Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) from the USA. That delusions directly cause violence in schizophrenia has been widely assumed, yet remains contested in the literatures of psychiatry and its neighboring sciences. Populations with psychosis are heterogeneous, manifesting the full range of risk and protective factors for violence. For every threatening delusional patient, clinicians in nonforensic settings may see 9 who will not harm. Epidemiological studies describe violence in mental illness as a multi-factorial problem, with salient predictors including age, gender, substance abuse, social disadvantage, developmental history, victimization and trauma sequelae, and exposure to community violence. Clinical studies of aggression implicate other types of symptoms–such as explosive anger, impulsivity, dysregulated mood, psychoactive drug effects, and antisocial personality–that may combine with delusions to exacerbate or mediate their impact on violence risk. These other vectors of violence provide a context and a matrix within which to understand the role of delusions in precipitating aggressive and violent acts. Psychopathology may contribute to assaultive acts, but is rarely, if ever, the sufficient explanation for them. The lecture concludes with general implications for antipsychotic pharmacotherapy, involuntary treatment law, criminal justice, and policy in behavioral healthcare services delivery.
SYSTEMATIC REVIEW OF THE PREVALENCE AND RISK FACTORS FOR INTERPERSONAL VIOLENCE IN ACUTE PSYCHIATRIC UNITS Giovanni De Girolamo, Laura Liozzino IRCCS Fatebenefratelli
RISK FACTORS FOR VIOLENCE IN PSYCHOSIS: FINDINGS FROM A METAANALYSIS Seena Fazel 1 , Katrina Witt 1 , Richard Van Dorn 2 University of Oxford; 2 Research Triangle Insitute
1
Previous reviews on risk and protective factors for violence in psychosis have produced contrasting findings. Therefore we conducted a systematic review and meta-analysis of the direction and strength of association of risk and protective factors for violent outcomes in individuals with psychosis. We searched 6 databases for studies that reported factors associated with violence in adults diagnosed, using DSM or ICD criteria, with schizophrenia and other psychoses. Risk and protective factors were meta-analysed if reported in three or more primary studies. Meta-regression examined sources of heterogeneity. A novel meta-epidemiological approach was used to group similar risk factors into one of 10 domains. Sub-group analyses were then used to investigate whether risk domains differed for studies reporting severe violence (rather than aggression or hostility). There were 110 eligible studies reporting on 45,533 individuals, of whom 39,995 (87.8%) were diagnosed with schizophrenia. Dynamic (or modifiable) risk factors included hostile behaviour, recent drug misuse, non-adherence with psychological therapies (p values<0.001), higher poor impulse control scores, recent substance misuse, recent alcohol misuse (p values<0.01), and non-adherence with medication (p value <0.05). We also examined a number of static factors, the strongest of which were criminal history factors. When restricting outcomes to severe violence, these associations did not change materially. In conclusions, we found certain dynamic risk factors are strongly associated with increased violence risk in individuals with psychosis. Their role in risk assessment and management warrants further examination.
Using standard systematic reviewing methods, we have estimated the prevalence of patients admitted to acute psychiatric wards who have committed at least one violent act against persons (staff, other patients, visitors) during the hospitalization. Our aim is to study the socio-demographic, clinical characteristics of these patients, and to identify risk factors that can predict their violent behaviours. The study is ongoing and will be completed early in 2014. To date, we have identified over 50 studies for the review.
PREVENTING VIOLENCE IN SCHIZOPHRENIA Olav Nielssen St Vincents Hospital, Sydney Background: High rates of violence have been reported in clinical samples of patients with schizophrenia, especially of first episode psychosis, and there is an over-representation of people with schizophrenia among samples of violent offenders. Method: A review of case linkage studies, studies of violence and stage of illness, studies of factors associated with violence in schizophrenia, and outcome studies, to identify strategies that might reduce the incidence of violence by people with schizophrenia. Results: Case linkage studies show a peak in violent offending in the period before the diagnosis of schizophrenia. Studies of stage of illness and violence show that most serious violence is committed prior to initial treatment for schizophrenia, often after long period of untreated psychosis. The main factors associated with violence in schizophrenia are comorbid substance abuse and delusional beliefs in which the patient believes they are in danger or have been seriously wronged. Outcome studies suggest that long term supervision of treatment after committing an act of violence reduces the incidence of further violent offences. There were no studies showing that the routine use of any form of risk assessment was able to reduce rates of violence among people with schizophrenia.
Abstracts of the 4th Biennial Schizophrenia International Research Conference / Schizophrenia Research 153, Supplement 1 (2014) S1–S384
phate was greater in the HI group (18.7%) than in the control group (10.5%), reflecting greater DA release in the striatum in the HI group (F(1,36)=3.75, p=0.061, adjusted F(1,33)=4.57, p=0.040). HI subjects reported more social defeat, t(38)=−2.44, p=0.019, loneliness, t(37)=−3.33, p<0.01, and depression, t(38)=−2.20, p=0.034. However, none of these measures were substantially associated with DA release (range r=0.07–0.20). Discussion: These preliminary results provide some support for sensitization of the dopamine system in individuals experiencing chronic exclusion, but the results are not conclusive.
Symposium VIOLENCE AND SCHIZOPHRENIA: RISK FACTORS AND MEDIATORS Chairperson: Seena Fazel Discussant: John J. McGrath Monday, 7 April 2014 2:00 PM – 4:00 PM Overall Abstract: Violence perpetrated by patients with schizophrenia remains one of the most important adverse outcomes in such patients, and a robust body of work has concluded that the odds of violent outcomes in individuals with schizophrenia are around 4 times higher than general population controls. What remains uncertain, however, is what risk and protective factors moderate such risk. This symposium will present a series of new reviews examining risk and protective factors for violence in patients with schizophrenia. The first review is an overall examination of all risk factor research and a meta-epidemiological approach synthesizing information across similar factors. The second reviews the epidemiologic work on the relationship between delusions and violence, and discusses the implications of this research for psychiatric treatment and public mental health policy. The third is a systematic review of the prevalance and risk factors for violence among inpatients with schizophrenia-spectrum disorders. The final paper brings together research on protective factors and discuss interventions that might reduce the incidence of violence in schizophrenia.
DELUSIONS AND VIOLENCE Jeffrey Swanson Duke University School of Medicine This presentation will review and evaluate key evidence for the link between violent behavior and psychotic symptoms in general, and delusions in particular. The presenter will reexamine conflicting findings for the “threat/control-override” and “rationality-within-irrationality” hypotheses that emerged in the 1990s, focusing in detail on comparative evidence from the MacArthur Violence Risk Study and the more recent Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) from the USA. That delusions directly cause violence in schizophrenia has been widely assumed, yet remains contested in the literatures of psychiatry and its neighboring sciences. Populations with psychosis are heterogeneous, manifesting the full range of risk and protective factors for violence. For every threatening delusional patient, clinicians in nonforensic settings may see 9 who will not harm. Epidemiological studies describe violence in mental illness as a multi-factorial problem, with salient predictors including age, gender, substance abuse, social disadvantage, developmental history, victimization and trauma sequelae, and exposure to community violence. Clinical studies of aggression implicate other types of symptoms–such as explosive anger, impulsivity, dysregulated mood, psychoactive drug effects, and antisocial personality–that may combine with delusions to exacerbate or mediate their impact on violence risk. These other vectors of violence provide a context and a matrix within which to understand the role of delusions in precipitating aggressive and violent acts. Psychopathology may contribute to assaultive acts, but is rarely, if ever, the sufficient explanation for them. The lecture concludes with general implications for antipsychotic pharmacotherapy, involuntary treatment law, criminal justice, and policy in behavioral healthcare services delivery.
SYSTEMATIC REVIEW OF THE PREVALENCE AND RISK FACTORS FOR INTERPERSONAL VIOLENCE IN ACUTE PSYCHIATRIC UNITS Giovanni De Girolamo, Laura Liozzino IRCCS Fatebenefratelli
RISK FACTORS FOR VIOLENCE IN PSYCHOSIS: FINDINGS FROM A METAANALYSIS Seena Fazel 1 , Katrina Witt 1 , Richard Van Dorn 2 University of Oxford; 2 Research Triangle Insitute
1
Previous reviews on risk and protective factors for violence in psychosis have produced contrasting findings. Therefore we conducted a systematic review and meta-analysis of the direction and strength of association of risk and protective factors for violent outcomes in individuals with psychosis. We searched 6 databases for studies that reported factors associated with violence in adults diagnosed, using DSM or ICD criteria, with schizophrenia and other psychoses. Risk and protective factors were meta-analysed if reported in three or more primary studies. Meta-regression examined sources of heterogeneity. A novel meta-epidemiological approach was used to group similar risk factors into one of 10 domains. Sub-group analyses were then used to investigate whether risk domains differed for studies reporting severe violence (rather than aggression or hostility). There were 110 eligible studies reporting on 45,533 individuals, of whom 39,995 (87.8%) were diagnosed with schizophrenia. Dynamic (or modifiable) risk factors included hostile behaviour, recent drug misuse, non-adherence with psychological therapies (p values<0.001), higher poor impulse control scores, recent substance misuse, recent alcohol misuse (p values<0.01), and non-adherence with medication (p value <0.05). We also examined a number of static factors, the strongest of which were criminal history factors. When restricting outcomes to severe violence, these associations did not change materially. In conclusions, we found certain dynamic risk factors are strongly associated with increased violence risk in individuals with psychosis. Their role in risk assessment and management warrants further examination.
Using standard systematic reviewing methods, we have estimated the prevalence of patients admitted to acute psychiatric wards who have committed at least one violent act against persons (staff, other patients, visitors) during the hospitalization. Our aim is to study the socio-demographic, clinical characteristics of these patients, and to identify risk factors that can predict their violent behaviours. The study is ongoing and will be completed early in 2014. To date, we have identified over 50 studies for the review.
PREVENTING VIOLENCE IN SCHIZOPHRENIA Olav Nielssen St Vincents Hospital, Sydney Background: High rates of violence have been reported in clinical samples of patients with schizophrenia, especially of first episode psychosis, and there is an over-representation of people with schizophrenia among samples of violent offenders. Method: A review of case linkage studies, studies of violence and stage of illness, studies of factors associated with violence in schizophrenia, and outcome studies, to identify strategies that might reduce the incidence of violence by people with schizophrenia. Results: Case linkage studies show a peak in violent offending in the period before the diagnosis of schizophrenia. Studies of stage of illness and violence show that most serious violence is committed prior to initial treatment for schizophrenia, often after long period of untreated psychosis. The main factors associated with violence in schizophrenia are comorbid substance abuse and delusional beliefs in which the patient believes they are in danger or have been seriously wronged. Outcome studies suggest that long term supervision of treatment after committing an act of violence reduces the incidence of further violent offences. There were no studies showing that the routine use of any form of risk assessment was able to reduce rates of violence among people with schizophrenia.