1 International Journal of Forensic Mental Health 2003, Vol. 2, No. 2, pages Do Violent Offenders With Schizophrenia Who Attack Family Members Differ From Those With Other Victims? Annika Nordström and Gunnar Kullgren Do violent offenders with schizophrenia who attack family members differ from those with other victims? Data on individual background factors were collected on all male offenders of violent crimes who for their first time were subject to forensic psychiatric evaluation in Sweden between 1992 and 2000 and were diagnosed with schizophrenia. In addition to descriptive data for the whole sample, analyses were made in order to identify possible characteristic factors for offenders who targeted family members. In comparison to offenders with other victims, the findings indicate an earlier onset of mental illness, in terms of that they were more likely to have interrupted their schooling at an earlier stage, were more likely to have had psychiatric contacts in childhood, to be younger when first compulsorily admitted to psychiatric inpatient treatment, and they were also younger when they committed the index crime. The findings suggest the need to address the possibility of violent behavior within the family when managing patients with major mental disorders. Compared to the general population, individuals with schizophrenia have an increased risk of committing violent crime (Lindqvist & Allebeck, 1990; Eronen, Angermeyer, & Schulze, 1998; Hodgins, Mednick, Brennan, Schulsinger, & Engberg, 1996). In addition, a number of studies have focused on the risk of becoming a victim of violence committed by individuals with a major mental disorder, and on the setting for violence to occur. Family members and friends are found to be most at risk of becoming victims of violence (Steadman et al., 1998), particularly mothers living with their adult children. Financial dependency and co-occurring substance abuse increases this risk (Estroff, Swanson, Lachicotte, Swartz, & Bolduc, 1998). The present article aims to further explore background factors concerning offenders of violent crimes who have been diagnosed with schizophrenia, with special reference to victim relation. The focus has been on offenders who committed a violent crime against an immediate family member, such as a parent, sibling or grandparent, as compared to those with other victims. METHOD The legislation in Sweden is such that an offender who suffers from a severe mental disorder cannot be sentenced to prison. If there is any suspicion of severe mental disorder, the court can refer the offender for forensic psychiatric evaluation (FPE), and subsequently within a month an extensive report is presented to the court. A team consisting of a psychiatrist, psychologist, social worker and ward staff all contribute with their professional knowledge to the evaluation and the document. Evaluation and diagnostic assessment according to DSM are based on several weeks of inpatient observations and repeated clinical interviews. There are about 600 extended forensic psychiatric evaluations performed every year in Sweden, with an average of 100 (16%) resulting in a diagnosis of schizophrenia (RMV, 2001). This average includes both men and women with schizophrenia, all sorts of crimes and different forms of legal consequences, and who also might have been subject to a psychiatric evaluation before. Annika Nordström is a Doctoral Candidate, Division of Psychiatry, Department of Clinical Sciences, Umeå University, Sweden; Gunnar Kullgren is Professor, Division of Psychiatry, Department of Clinical Sciences, Umeå University, Sweden. The study was supported by grants from the Swedish Council for Social Research, the Söderströmska-Königska Foundation and the National Board of Forensic Medicine in Sweden. Correspondence should be sent to Annika Nordström, Division of Psychiatry, Department of Clinical Sciences, Umeå University, SE Umeå, Sweden ( International Association of Forensic Mental Health Services
2 196 Nordström & Kullgren The sample comprised 207 male offenders in Sweden, aged 18 years and over, who between 1992 and 2000 committed at least one violent crime and for the first time were subject to a forensic psychiatric evaluation where they received a diagnosis of schizophrenia according to DSM-III-R or DSM-IV (APA, 1987, 1994). Only those by court referred to forensic psychiatric treatment were included. Not included in this sample were individuals with foreign citizenship due to uncertainty regarding background data, and a few individuals where the relationship between the offender and the victim was unknown. Data were collected from forensic psychiatric evaluation reports, court convictions and the criminal register. Directives from the National Board of Forensic Medicine govern the contents of the evaluation protocols, which provide systematic information. In a previous study based on information collected from forensic psychiatric protocol in Sweden, the inter-rater reliability for variables used in the present study was found to be good in the range of kappa = 0.63 to 0.86, regarding the same variables that also have been used in the present study (Långström et al., 1999). Violent crimes were defined as those classified as actual or attempted murder or manslaughter, causing another s death, physical assault, attempted physical assault and violence against officials, according to Swedish legislation. Substance abuse was judged present either when it had been diagnosed or when it was reported in files from social authorities. The sample was divided into two groups (Family Victim group FV and Other Victim group OV ). When at least one of the victims was a family member, the offender was assigned to the FV group. Family member in this study includes parents, siblings and grandparents. Partners were not included as family members based on the assumption that the emotional relationship to parents, siblings and grandparents differs from that to a partner. There was missing information regarding acting out behavior at school 26% and parental alcohol or drug abuse in 24%. For the remaining variables missing data never exceeded 4%. RESULTS Most convictions involved only one victim of a violent crime according to the definition, but in 18% there were two victims and in 15% there were between three and eight victims. Of the 49 convictions involving family members, 87.8% involved family victims only. A total of 336 persons were victims of the crimes committed by the 207 male offenders (Table 1). There were significantly more female victims within the FV group than in the OV group, χ 2 (1, N = 336) = 4.24, p=.039. Mothers constituted the single largest victim group (n = 27). The severe injuries (fatal outcome or requiring hospital treatment) were also significantly more common among family victims than among other victims, χ 2 = 1, N = 336) 12.12, p = Schizophrenic disorder/paranoid type was the most frequent diagnosis with 40.6%, followed by 30.5% schizophrenic disorder/undifferentiated type, schizophreniform disorder 8.7%, schizoaffective disorder 7.7%, and others 13.5% (residual type, catatonic type and disorganized type). Mean age of the offenders by the time of the index crime was 32.1 (SD = 8.0, range = 19-51) for offenders in the FV group and 35.7 (SD = 9.4, range = 18-65) in the OV-group, t = 2.42, p =.016. Psychiatric history The vast majority of the 207 male offenders had a history of contact with psychiatric services. Before 18 years of age, 26.7% had been in contact with child- and adolescent psychiatric services, and 70.5% had as adults been subject to involuntarily general psychiatric inpatient care on at least one occasion. The mean age for the first involuntary treatment episode was 25.8 years (SD = 7.6). In 23.2% a previous suicide attempt was reported. There were no differences found between the FV and the OV group concerning experience of involuntary psychiatric treatment or suicide attempt. However, in relation to the OV group the offenders in the FV group had to a higher extent been in contact with child- and adolescent psychiatric services, and they were younger at their first compulsory admission to psychiatric treatment.
3 Violent Offenses Against Family Members 197 Table 1 Distribution of victim gender and victim injury between offenders targeting either any family victim or nonfamily victims, respectively Victim gender (N = 336) Family victim group Non-family victim group Female 55.2% (37) 41.3% (111) Male 44.8% (30) 58.7% (158) Victim injury Minor injury 56.7% (38) 77.7% (209) Severe injury or fatal outcome 43.3% (29) 22.3% (60) Table 2 Background factors of offenders with family victims in relation to offenders with other victims Family Victim Other Victim Statistics Group Group Psychiatric history Contact with child- and adolescence psychiatry 37.5% 23.4% χ 2 (1, n = 202) 3.72, p =.054 Involuntary psychiatric treatment 65.3% 72.2% χ 2 (1, N = 207) 0.84, p =.358 Mean age at first involuntary treatment (y) 23.4 SD = SD = 8.4 t = 2.05, p =.042* Suicide attempt 26.5% 22.5% χ 2 (1, N = 207) 0.40, p =.526 Childhood/school Not living with both parents < 16 years 50.0% 57.0% χ 2 (1, n = 206) 0.72, p =.395 Parental alcohol abuse 34.1% 35.4% χ 2 (1, n = 157) 0.02, p =.877 Acting out behavior in school 32.5% 26.5% χ 2 (1, n = 153) 0.52, p =.472 Placed in institution or foster-home 22.9% 21.7% χ 2 (1, n = 200) 0.03, p =.860 Continued to secondary school 58.3% 59.6% χ 2 (1, n = 204) 0.03, p =.874 Interrupted school during secondary school 57.1% 28.0% χ 2 (1, n = 121) 8.08, p =.004** Criminal history Earlier convictions of crime 63.3% 70.3% χ 2 (1, N = 207) 0.85, p =.357 Mean age first conviction any crime 21.4 SD = SD = 9.7 t = 1.91, p =.058 Earlier convictions of violent crime 34.7% 45.6% χ 2 (1, N = 207) 1.81, p =.179 Mean age first conviction -violent crime (years) 27.7 SD = SD =10.5 t = 1.58, p =.117 Earlier prison sentence 28.6% 24.1% χ 2 (1, N = 207) 0.41, p =.524 Alcohol/drug abuse Alcohol/drug abuse within 5 years 41.7% 56.0% χ 2 (1, n = 198) 2.99, p =.083 Social situation Partner relation > 1 year 20.4% 43.3% χ 2 (1, n = 206) 8.32, p =.004** Worked > 6 month 61.7% 65.1% χ 2 (1, n = 199) 0.18, p =.668 Homeless by the time of crime 8.3% 14.7% χ 2 (1, n = 204) 1.31, p =.252 Living with parents by the time of the crime 22.4% 8.9% χ 2 (1, N = 207) 6.50, p =.011* * p <.05, **p <.01
4 198 Nordström & Kullgren Childhood/school Nearly half of the 207 offenders (44.7%) had not lived with both parents up to the age of 16, in 64.4% this was due to parental separation. Parental alcohol or drug abuse was reported in 35.0% of the offenders, 28.1% of the offenders had a documented acting out behavior at school, and 22.0% had been placed in foster-home or institution outside their home as children. The majority of the individuals in the total group (68.6%) went on to secondary school but 34.7% of those who started dropped out from school before the three years were completed. The offenders in the FV group did not differ from the OV group in the variables concerning childhood except for education level, where more than half the offenders in the FV group who went on to secondary school, had interrupted their attendance at school before the end of the three years, compared to less than one third in the OV-group (Table 2). Criminality Prior to referral for forensic psychiatric evaluation, 42.9% had received a sentence for violent crime at a mean age of 30.2 year (SD = 9.99) and altogether 68.6% had been sentenced for some type of crime, mean age 24.1 (SD = 9.01). One quarter, 25.1%, of the individuals had received at least one prison sentence, with total terms ranging from 0.5 months to 9.8 years. Six offenders in the OV group and two in the FV group had earlier to the index offence committed violent crimes with family members as victims. Alcohol/drug abuse Out of all 207 offenders, 52.5% had documented alcohol and/or drug abuse in the five years prior to evaluation, and 38.8% had also received treatment for their alcohol or drug problem. The proportion of those with alcohol/drug abuse is lower in the FV group than in the OV group but the difference is not significant. Social factors About one-third (37.9%)of all 207 offenders had at least at some point in their lives lived in a relationship with a partner for one year or longer and 64.3% had been employed for a period of at least six months. By the time of the crime that led to the forensic psychiatric evaluation, however, 94.2% were living as singles, 90.2% had no work or ongoing studies and 13.2% were actually homeless. Within the FV group one out of five had experienced a relation with partner. More of the men in the FV group were living with their parents by the time of the index crime. Those living with their parents were significantly younger when committing the crime then other men in the FV group (26.8 versus 33.6 years, t = 2.62, p =.012). DISCUSSION The focus of the present study was on men who had committed violent crimes and who were diagnosed with schizophrenia at subsequent forensic psychiatric evaluation, in order to examine characteristic features among those who assaulted close family members in comparison to those with other victims. No previous study has reported on a national sample of offenders with major mental disorders and violent assaults of family members. Some researchers have reported on a non-forensic sample (Estroff et al., 1998; Vaddadi, Soosai, Gilleard, & Adlard, 1997) and others have not specifically looked into violence within the family (Steadman et al., 1998; Tengström, Hodgins, & Kullgren, 2001). Our sample overlaps to some degree with a sample from a previous study and shares less than one-third with that sample (Tengström et al., 2001). In our sample we included only those subject to forensic psychiatric evaluation from 1992, when criteria based diagnoses according to the DSM system were introduced. Furthermore, to increase the likelihood that all cases would be included, where a male individual with schizophrenia has committed a violent act, we have examined only cases where violence was physical and included only severe hands-on crimes. In the Swedish system it is highly probable that the combination of a severe violent act and a severe mental disorder will bring the offender to a forensic psychiatric evaluation. Out of all offenders, 43% had a previous conviction for a violent crime without referral to a forensic psychiatric evaluation. However, only 2% of the previous violent crimes that these offenders had
5 Violent Offenses Against Family Members 199 committed were as severe as those included in the present study. Even if about one-third of the offenders were reported to have lived in a relationship for more than one year, only 5.8% were involved in a relationship by the time of the index crime. We believe this sample to be representative of offenders with schizophrenia who commit severe violent crimes. The overall differences of background factors between the offenders with family victims and offenders with other victims were few. However, more of the offenders with family victims had been in contact with psychiatry as children and they had interrupted their attendance at secondary school to a greater extent. Both of these factors might indicate an earlier onset of the mental disorder. Those who assaulted family members were also younger at their first compulsory treatment episode. One of five offenders with family victims were actually still as adults living with their parents when they committed the violent crime, which is in line with findings from Estroff et al. (1998). The fact that family member victims were more severely injured than other victims might result from a higher threshold for reporting other violent acts within the family. An alternative explanation could be that disease-specific mechanisms and stronger emotional bonds result in more uncontrolled violence in close relationship. In summary, this study seems to indicate that individuals with schizophrenia who commit violent crimes have many features in common regardless of who their victims were. However, those who assaulted family members were younger and they seemed to have an earlier illness onset and possibly a more severe course of their illness as reflected by earlier referral to compulsory care. As suggested by Swanson and others (1998), it seems likely that a complex interaction between psychiatric impairment and social relationships is responsible for violent behavior rather than one single factor. Action must be taken to try to prevent violence in individuals with a major mental disorder even though their impact on the total level of criminality in society is low (Angermeyer, 2000; Stuart & Arboleda-Florez, 2001). Preventive measures on several levels are required. First, a range of measures on a general level is needed to increase awareness and to counteract stigmatization of mental illness in society. Second, management of mentally ill individuals at risk for violence must be improved. Third, steps must be taken towards improved and evidence-based treatment of already identified offenders with mental illness. REFERENCES American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev). Washington DC: Author. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington DC: Author. Angermeyer, M. C. (2000). Schizophrenia and violence. Acta Psychiatrica Scandinavica Suppl, 102, Eronen, M., Angermeyer, M. C., & Schulze, B. (1998). The psychiatric epidemiology of violent behaviour. Social Psychiatry and Psychiatric Epidemiology, 33, Suppl 1, Estroff, S. E., Swanson J. W., Lachicotte, W. S., Swartz, M., & Bolduc, M. (1998). Risk reconsidered: targets of violence in the social networks of people with serious psychiatric disorders. Social Psychiatry and Psychiatric Epidemiology, 33, Suppl 1, Hodgins, S., Mednick S. A., Brennan, P. A., Schulsinger, F., & Engberg, M. (1996). Mental disorder and crime. Evidence from a Danish birth cohort. Archive of General Psychiatry, 53, Långström, N., Grann, M., Tengstrom, A., Lindholm, N., Woodhouse, A., & Kullgren, G. (1999). Extracting data in file-based forensic psychiatric research: Some Methodological Considerations. Nordic Journal of Psychiatry, 53, Lindqvist, P., & Allebeck, P. (1990). Schizophrenia and crime: A longitudinal follow-up of 644 schizophrenics in Stockholm. British Journal of Psychiatry, 157, RMV-Rättsmedicinalverket, Statistisk årsbok 2001 (National Board of Forensic Medicine, Statistical yearbook 2001). Stockholm: Author. Steadman, H. J., Mulvey, E. P., Monahan, J., Robbins, P. C., Appelbaum, P. S., Grisso, T., Roth, L. H., & Silver, E. (1998). Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Archives of General Psychiatry, 55, Stuart, H. L., & Arboleda-Florez, J. E. (2001). A public health perspective on violent offences among persons with mental illness. Psychiatric Services, 52, Swanson, J., Swartz, M., Estroff, S., Borum, R., Wagner, R., & Hiday, V. (1998). Psychiatric impairment, social contact, and violent behavior: evidence from a study of outpatientcommitted persons with severe mental disorder. Social Psychiatry and Psychiatric Epidemiology, 33, Suppl 1,
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