Overview of Violence to Self and Others During the First Episode of Psychosis

St Vincent's Hospital, Darlinghurst, New South Wales, Australia.
The Journal of Clinical Psychiatry (Impact Factor: 5.5). 05/2012; 73(5):e580-7. DOI: 10.4088/JCP.11r07036
Source: PubMed


We aimed to review the evidence for an association between the first episode of psychosis and violence and to consider the possible explanations for this association and the implications for clinicians and service providers.
We searched for published studies in English describing an association between violence and first-episode psychosis using the subject headings, key words, abstracts, and titles in PubMed/MEDLINE from 1970 to 2010, using the terms first-episode schizophrenia OR first-episode psychosis OR early schizophrenia AND suicide OR self harm OR suicide attempt OR homicide OR violence.
We identified 20 studies reporting data on violent suicide attempts, self-mutilation, minor violence, severe nonlethal interpersonal violence, or homicide in first-episode and previously treated psychosis.
The number of people committing acts of violence prior to initial treatment for psychosis and after initial treatment was extracted from the relevant studies.
The proportion of people found to be in the first episode of psychosis at the time of an act of violence was compared to the expected ratio of first-episode to previously treated patients. A substantial proportion of psychotic patients examined after violent suicide attempts (49%), major self-mutilation (54%), homicide (39%), and assault resulting in serious injury (38%) are in their first episode of psychosis. Moreover, a substantial proportion of first-episode patients commit an act of less serious violence or attempt suicide prior to initial treatment.
The findings support the need for early intervention and community-wide programs to reduce the duration of untreated psychosis.

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Available from: Matthew Large, Aug 25, 2015
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    • "One factor related to this is the increased impulsivity that is present prior to treatment. In their review of 20 studies exploring the incidence of violence at different stages of psychosis, Nielssen et al. (2012) found that 49% of violent suicide attempts, 54% of the major self-mutilations, 39% of the homicides, and 38% of the nonfatal serious assaults were committed by people experiencing an untreated first episode of psychosis. "
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    ABSTRACT: Published findings on the relationship between schizophrenia and violence have been mixed, due to differences in study design and quality. In this review, we address the issue with an emphasis on characterizing who is most likely to be violent and when. We conclude that: (1) individuals with schizophrenia are at an increased risk for violence due to specific psychotic symptoms; (2) this risk is increased by brain abnormalities, psychiatric comorbidities, and demographic factors that are not specific to schizophrenia; (3) the majority of violent offenses committed by people with schizophrenia are indistinguishable from offenses committed by others; and (4) despite our knowledge of factors related to increased violence risk and the existence of effective treatments to mitigate this risk, valid risk assessment instruments for this population are lacking, and treatment strategies are rarely employed at any level of psychiatric care. In short, while most people with schizophrenia are not violent and violence committed by people with this condition accounts for only a small percentage of overall violent crime, there is nevertheless a significantly increased risk for violence among subgroups in this population. This has implications for people living with people with schizophrenia, mental health professionals, administrators of psychiatric care facilities, law enforcement personnel, the court system, and policymakers.
    05/2015; 1(1):21-42. DOI:10.1080/23744006.2015.1033154
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    • "A meta-analysis comparing homicide rates in treated and untreated persons with FEP concurs with this conclusion, i.e., even though homicide is extremely rare in FEP, the risk is 15.5 times higher in untreated FEP cases (Nielssen and Large, 2010) as compared to the normal population . Another study by the same group showed that between 40% and 60% of violent offenders with psychosis had never been treated (Nielssen et al., 2012). A recent review (Winsper et al., 2013), based on searches via MEDLINE, Embase and PsychINFO, concluded that rates of aggression in FEP remain high following initial contact with mental health services, and do not seem to alter following contact. "
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    ABSTRACT: Background: First episode psychosis (FEP) patients have an increased risk for violence and criminal activity prior to initial treatment. However, little is known about the prevalence of criminality and acts of violence many years after implementation of treatment for a first episode psychosis. Aim: To assess the prevalence of criminal and violent behaviors during a 10-year follow-up period after the debut of a first psychosis episode, and to identify early predictors and concomitant risk factors of violent behavior. Method: A prospective design was used with comprehensive assessments of criminal behavior, drug abuse, clinical, social and treatment variables at baseline, five, and 10-year follow-up. Additionally, threatening and violent behavior was assessed at 10-year follow-up. A clinical epidemiological sample of first-episode psychosis patients (n = 178) was studied. Results: During the 10-year follow-up period, 20% of subjects had been apprehended or incarcerated. At 10-year follow-up, 15% of subjects had exposed others to threats or violence during the year before assessment. Illegal drug use at baseline and five-year follow-up, and a longer duration of psychotic symptoms were found to be predictive of violent behavior during the year preceding the 10-year follow-up. Conclusion: After treatment initiation, the overall prevalence of violence in psychotic patients drops gradually to rates close to those of the general population. However, persistent illicit drug abuse is a serious risk factor for violent behavior, even long after the start of treatment. Achieving remission early and reducing substance abuse may contribute to a lower long-term risk for violent behavior in FEP patients.
    Schizophrenia Research 05/2014; 156(2). DOI:10.1016/j.schres.2014.04.010 · 3.92 Impact Factor
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    ABSTRACT: Patients with psychoses have an increased risk of becoming victims of violence. Previous studies have suggested that higher symptom levels are associated with a raised risk of becoming a victim of physical violence. There has been, however, no evidence on the type of symptoms that are linked with an increased risk of recent victimization. Data was taken from two studies on involuntarily admitted patients, one national study in England and an international one in six other European countries. In the week following admission, trained interviewers asked patients whether they had been victims of physical violence in the year prior to admission, and assessed symptoms on the Brief Psychiatric Rating Scale (BPRS). Only patients with a diagnosis of schizophrenia or related disorders (ICD-10 F20-29) were included in the analysis which was conducted separately for the two samples. Symptom levels assessed on the BPRS subscales were tested as predictors of victimization. Univariable and multivariable logistic regression models were fitted to estimate adjusted odds ratios. Data from 383 patients in the English sample and 543 patients in the European sample was analysed. Rates of victimization were 37.8% and 28.0% respectively. In multivariable models, the BPRS manic subscale was significantly associated with victimization in both samples. Higher levels of manic symptoms indicate a raised risk of being a victim of violence in involuntary patients with schizophrenia and related disorders. This might be explained by higher activity levels, impaired judgement or poorer self-control in patients with manic symptoms. Such symptoms should be specifically considered in risk assessments.
    PLoS ONE 03/2013; 8(3):e58142. DOI:10.1371/journal.pone.0058142 · 3.23 Impact Factor
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