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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    • "Public Health Service, 2001; Goldsmith et al., 2002). In schizophrenia, the risk for suicidal ideation, behavior and completed suicide is particularly high early in the illness course (Dutta et al., 2010; Pompili et al., 2011; Nielssen et al., 2012), though suicide risk remains elevated for many years after a single suicide attempt (Dutta et al., 2010). "
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    ABSTRACT: Background: Suicide is prevalent in schizophrenia (SZ), yet the neural system functions that confer suicide risk remain obscure. Circuits operated by the prefrontal cortex (PFC) are altered in SZ, including those that support reactive control, and PFC changes are observed in postmortem studies of heterogeneous suicide victims. Aims: We tested whether history of suicide attempt is associated with altered frontal motor cortex activity during reactive control processes. Method: We evaluated 17 patients with recent onset of DSM-IV-TR-defined SZ using the Columbia Suicide Severity Rating Scale and functional magnetic resonance imaging during Stroop task performance. Group-level regression models relating past suicidal behavior to frontal activation controlled for depression, psychosis, and impulsivity. Results: Past suicidal behavior was associated with relatively higher activation in the left-hemisphere supplementary motor area (SMA), pre-SMA, premotor cortex, and dorsolateral PFC, all ipsilateral to the active primary motor cortex. Conclusion: This study provides unique evidence that suicidal behavior in patients with recent-onset SZ directly relates to frontal motor cortex activity during reactive control, in a pattern reciprocal to the relationship with proactive control found previously. Further work should address how frontal-based control functions change with risk over time, and their potential utility as a biomarker for interventions to mitigate suicide risk in SZ.
    Full-text · Article · Sep 2015 · Crisis The Journal of Crisis Intervention and Suicide Prevention
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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.
    Full-text · Article · May 2015
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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.
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