Psychotic Symptoms and Violent Behaviors: Probing the Components of ‘Threat/Control-Override’ Symptoms
Evidence for an association between mental illness and violence has grown in recent years, leading many to ask why such an association exists. One hypothesis links elevated rates of violence among people with mental illness to a small set of psychotic symptoms--so called threat/control-override (TCO) symptoms. Several studies have supported this hypothesis, but none has examined which of the components, threat or control-override--if either--predominates in explaining violence. To explore this issue we used data from a two-stage epidemiological study (n = 2741) conducted in Israel. Data on TCO symptoms were collected using two methods--fixed-format self-report questions from the first stage and psychiatrists' ratings based on interviews using the Schedule for Affective Disorders and Schizophrenia (SADS) from the second. Results show that both a measure of threat and a measure of control-override are independently associated with violent behaviors. Results also show that neither method--neither fixed-format questions nor psychiatrist rating--predominates in explaining violence. In sum, these results indicate that both the threat and the control-override components of the TCO concept are useful in predicting violent behaviors and that a better measurement of the TCO concept is achieved using a multimethod approach.
Available from: Seena Fazel
- "Specifically, when an acutely psychotic individual harbors delusional beliefs that others are threatening to harm him, this may kindle extreme irrational anger toward the object of the imagined malevolence, leading in turn to aggressive or violent behavior, as the normal cognitive controls are impaired. The findings of Coid and associates are not inconsistent with Link's theory of " rationality within irrationality " and " threat/control-override " as an explanation of violence in some persons with psychotic symptoms . A complex picture of the violence-psychosis link emerged in the mid-2000s in findings from the National Institute of Mental Health Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) . "
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This article describes epidemiological evidence concerning risk of gun violence and suicide linked to psychiatric disorders, in contrast to media-fueled public perceptions of the dangerousness of mentally ill individuals, and evaluates effectiveness of policies and laws designed to prevent firearms injury and mortality associated with serious mental illnesses and substance use disorders.
Research concerning public attitudes towards persons with mental illness is reviewed and juxtaposed with evidence from benchmark epidemiological and clinical studies of violence and mental illness and of the accuracy of psychiatrists’ risk assessments. Selected policies and laws designed to reduce gun violence in relation to mental illness are critically evaluated; evidence-based policy recommendations are presented.
Media accounts of mass shootings by disturbed individuals galvanize public attention and reinforce popular belief that mental illness often results in violence. Epidemiological studies show that the large majority of people with serious mental illnesses are never violent. However, mental illness is strongly associated with increased risk of suicide, which accounts for over half of US firearms-related fatalities.
Policymaking at the interface of gun violence prevention and mental illness should be based on epidemiological data concerning risk, to improve the effectiveness, feasibility, and fairness of policy initiatives.
Available from: Aymeric Petit
- "Among psychotic patients, Link et al. (6) reported that severity of delusion and hallucinations was significantly related to aggressive behavior (7). Schizophrenics are more likely to be violent if their hallucinations generate negative emotions (anger, anxiety, sadness) and if they have not developed successful strategies to cope with their voices (8, 9). "
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ABSTRACT: Aim of the study: This study tried to identify risk factors of aggressive behavior in a population of schizophrenic inpatients. We tested the association between aggressive behavior and socio-demographic characteristics, addictive disorders, history of suicide attempt, and sexual violence, impulsivity, and sensation seeking.
Methods: All consecutive schizophrenic inpatients (100) were assessed during 6 months. Aggressive behavior was quantified with a standardized scale, the Overt Aggression Scale (OAS). We studied socio-demographic characteristics and the history of suicide attempt and sexual violence with a specific standardized questionnaire. Addictive disorders were identified with the Fagerström and CAGE questionnaires and with the DSM-IV-R diagnostic criteria for nicotine, alcohol, cannabis opiates, and cocaine abuse and dependence disorders. Lastly, we studied sensation seeking with the Zuckerman scale and impulsivity with the Barratt scale.
Results: Linear regression identified four factors associated with aggressive behavior: male gender (odd ratio = 12.8), history of sexual violence (odd ratio = 3.6), Fagerström score (odd ratio = 1.3), number of cigarettes smoked each day (odd ratio = 1.16). Patients with nicotine use or dependence had significantly higher levels of OAS scores. This difference was not observed between patients with or without alcohol dependence. OAS scores were correlated to the number of cigarettes smoked each day and to Fagerström scores. Patients with a higher level of sensation seeking and impulsivity also had higher OAS scores.
Conclusion: A typical schizophrenic patient at risk of showing aggressive behavior is a man, who smokes and presents a history of sexual violence.
Available from: Roland M Jones
- "Subsequent studies whilst invoking substance misuse as an important mediator, have offered yet further support (Elbogen and Johnson, 2009; Fazel et al., 2009). In addition, there is a growing body of literature showing a relationship between certain psychotic symptoms and violence (Taylor et al., 1998; Mojtabai, 2006), whilst threat/control override (TCO) symptoms have been linked to violence (Link et al., 1998; Swanson et al., 2006). Nevertheless, only a minority of patients who have schizophrenia or other psychoses with such symptoms engage in violent acts and not all violence by people with schizophrenia can be directly linked to such symptoms (Taylor, 2008). "
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ABSTRACT: A small but significant relationship between schizophrenia and violence is well established, but not yet fully explained. Research has highlighted anger as an important factor in precipitating actual violence in general and psychiatric populations. However, anger has not been extensively studied as a risk factor for violence in people with schizophrenia and related psychoses. We evaluated published evidence on the relationship between anger and violence in patients with schizophrenia and related psychoses by means of a systematic review of the literature. A search of main online databases from inception till January 2012 was performed and supplemented with correspondence with authors and data available online. 11 studies which measured angry affect in patients with schizophrenia who had been violent were included in the review. 5 studies with a total of 510 individuals had anger data that were suitable to be pooled in a meta-analysis in form of standardised mean difference values comparing the anger scores of the non-violent groups with violent groups. All the studies included showed significantly higher scores for anger in the violent group compared with the non-violent group with the pooled result expressed as standardised mean difference of 0.74 95% CI (0.53, 0.94) and the Z value for overall effect=7.01. The studies not included in the meta-analysis which looked at 610 individuals, were analysed descriptively and all of them reported higher scores for anger for individuals with schizophrenia who acted violently. There is a consistency of significant association between angry affect and violent behaviour in the context of psychotic illness across various study designs, settings and populations. Theoretical support already exists for this relationship and this review lends further support to explore this relationship further.
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