Psychosis and Violence: The Case for a Content Analysis of Psychotic Experience

Transcription

1 VOL. 22, NO. 1, 1996 Psychosis and Violence: The Case for a Content Analysis of Psychotic Experience 91 by John Junginger Abstract There has been a great deal of debate about the dangers psychiatric patients pose to the general population. Recent studies appear to confirm a moderate but reliable association between mental illness and violence. The nature of this association, however, is unresolved. Considerable evidence suggests that much of the violent behavior observed in the mentally ill is not random but is motivated and directed by psychotic symptoms. In many cases, the behavior appears to be a predictable and in some ways rational response to irrational beliefs (delusions) and perceptions (hallucinations). The content and themes of a psychotic patient's delusion or hallucination often imply a specific course of violent action. Unlike studies of associations between violence and broad categories of subject characteristics (e.g., mental illness), an analysis of the association between violence and the content and themes of psychotic symptoms could be much more informative. Conceivably, such an analysis could identify not only psychiatric patients at risk for committing violence but also those individuals who are at risk for becoming targets of their violence. Schizophrenia Bulletin, 22(1): , Mental Illness and Violence There has been considerable debate about the dangers psychiatric patients pose to the general population. Guze et al. (1974), relying on patients' uncorroborated selfreports, concluded that people with schizophrenia were not often involved in serious crimes. This conclusion was challenged by Zitrin et al. (1976), who examined arrest records of 867 psychiatric patients admitted to New York's Bellevue Hospital from the hospital's catchment area. These researchers found that the frequency of arrests for five major crimes murder, rape, robbery, aggravated assault, and burglary was considerably higher for the patient sample than for urban areas of the United States as a whole. Furthermore, except for murder and robbery, the arrest rate for patients was higher than the rate for the hospital's catchment area. The latter finding suggested that mental illness exerted an influence on violent crime independent of whatever demographic factors persons in the community shared. The influence of demographic factors on violent behavior has been the major confound in studies of the association between mental illness and violence. The failure to control for these factors has called into question findings that link mental illness and violence, such as those reported by Giovannoni and Gurel (1967) and Sosowsky (1978). Monahan and Steadman (1983) reviewed over 200 studies on crime and mental illness and concluded that the association between the two tends to "disappear" when factors such as age, sex, race, and social class are controlled. Steadman and Felson (1984), for example, found that 22 percent of former psychiatric patients reported at least one inci- Reprint requests should be sent to Dr. J. Junginger, Dept. of Psychology, SUNY-Binghamton, Binghamton, NY

2 92 SCHIZOPHRENIA BULLETIN dent of striking someone in the previous year, compared with 15 percent of a random community sample. Furthermore, 8 percent of the former patients, compared with "only" 2 percent of the community sample, reported using a weapon. However, these differences between former patients and community residents were no longer significant when demographic factors were statistically controlled. Previous or current hospitalization is another factor that can confound the apparent association between mental illness and violence. Monahan (1992) noted that because of the widespread acceptance of dangerousness as a criterion for civil commitment (Monahan and Shah 1989), studies of the link between mental illness and violence that use currently or previously hospitalized patients introduce a prominent selection bias. That is, psychiatric patients with a history of hospitalization often owe their hospitalization to violent behavior and therefore have a higher incidence of violence than their never-hospitalized psychiatric counterparts. More recent studies of the association between mental illness and violence have taken many of the above concerns into account. The findings of these studies have caused even influential skeptics such as Monahan to reevaluate their position that mental illness is unrelated to violence. (Monahan 1992). For example, Swanson (1994) reviewed findings of the National Institute of Mental Health (NIMH) Epidemiologic Catchment Area (ECA) study (Robins and Regier 1991), which used the Diagnostic Interview Schedule (DIS; Robins et al. 1981) to assign DSM-III (American Psychiatric Association 1980) diagnoses to about 10,000 residents of three cities. Items on the DIS inquiring about incidents of hitting or throwing things at someone, and of using weapons in a fight, were used to assess violent behavior. Swanson (1994) found that when psychiatric and demographic variables were entered into a logistic regression, the presence of a major mental disorder such as schizophrenia was a significant predictor of violence. (It should also be noted, however, that substance abuse had an even stronger association with violence.) The finding of a link between mental illness and violence in the ECA data is particularly relevant not only because demographic variables were statistically controlled but because the subject sample was not biased by exclusive sampling from currently or formerly hospitalized patients (cf. Monahan 1992). In that way, the ECA data more closely approximated the true rates of crime and mental disorder in the general population than previous studies of exclusively clinical samples (cf. Monahan and Steadman 1983). Psychosis and Violence Now that an association between mental illness and violence has been fairly well established the nature of this association must be resolved. Considerable evidence suggests that a significant amount of the violence observed in the mentally ill is associated with specific psychotic symptoms. What this evidence often seems to indicate is that it is not simply the presence of mental illness that induces violence, but rather the specific presence of delusions and hallucinations. For example, Bartels et al. (1991) found that hallucinations or delusions were significant predictors of hostility in 133 outpatients with schizophrenia. A series of similar findings seemed to implicate the specific role of persecutory delusions in violence: Krakowski and Czobor (1994) found a significant association between "paranoid" symptoms and transient ward violence in a group of 38 psychiatric patients consecutively admitted to a secure care unit. Straznickas et al. (1993) reported that seven of 24 (29%) assaults by psychiatric patients against their spouses were preceded by persecutory delusions. Shore et al. (1988) found that persecutory delusions were associated with later violence in a subgroup of the "White House Cases" nonforensic psychiatric patients hospitalized for acting on delusions or hallucinations that led them to approach a major government office (this particular subgroup had only nonviolent prior arrests). Deutsch et al. (1991) concluded that the presence of delusions, mainly persecutory, was a significant predictor of physical aggression in 181 patients with probable Alzheimer's disease. D'Orban and O'Connor (1989) noted a possible homicidal risk associated with persecutory and hypochondriacal delusions in 14 matricides and 3 patricides committed by women. In perhaps the most compelling demonstration of the association between psychotic symptoms and violence, Link et al. (1992) compared arrest rates and self-reported violence in several patient groups and a sample of 400 adults who had never received psychiatric services. Even after controlling for

3 VOL 22, NO. 1, a number of demographic factors, including age, sex, race, education, marital status/family composition, and homicide rate of the local community, Link et al. found that the patient groups were almost always more violent than the community sample. Even more informative was the finding that every difference in rates of recent violent behavior between patient and community gtoups became nonsignificant when current psychotic symptoms were statistically controlled. Furthermore, current psychotic symptoms predicted recent violence not only in the patient group, but also in the community gtoup. Thus, the association between psychotic symptoms and violence inferred from previous studies of clinical samples (see above) also was evident in this epidemiological sample (Link et al. 1992). "Psychotic Action" The association between psychotic symptoms and violence that has sometimes been observed suggests that the violent behavior of psychiatric patients is not unpredictable. What often appears obvious is that this violence is consistent with the content and themes of concurrent delusions or hallucinations. In many cases, the violent behavior of the mentally ill appears to be a predictable and in some ways rational response to irrational beliefs and perceptions. (See also, e.g., Link and Stueve's [1994] principle of rationality-within-irrationality.) The content and themes of a psychotic patient's delusion or hallucination often imply, and sometimes even command, a specific course of action. As reported by UOrban and O'Connor (1989) and by Straznickas et al. (1993), for example, patients with persecutory delusions may resort to violence or even homicide, presumably to "protect" themselves. This type of behavior could be thought of as a psychotic form of "self-defense." In a similar manner, patients' hallucinated voices may command a specific course of violent action. Unlike studies of associations between violence and broad categories of subject characteristics (e.g., mental illness), an analysis of the association between violence and the content and themes of psychotic symptoms could be much more informative. Conceivably, such an analysis could identify not only psychiatric patients at risk for committing violence but also those individuals who are at risk for becoming targets of their violence. Occasionally, as in cases of delusional guilt or command hallucinations of suicide, the patients themselves may be the ones at risk. There have been surprisingly few studies of the extent to which behavior is consistent with the content and themes of concurrent delusions or hallucinations a phenomenon referred to here as "psychotic action." In one notable study, Taylor (1985) interviewed 121 psychotic prisoners and found that 112 (93%) had active psychotic symptoms when they committed their crimes. When asked why they had committed the crime, 23 (21%) described motives judged to be "definitely" influenced by psychotic symptoms; an additional 29 (26%) described motives that were "probably" influenced by psychotic symptoms. Of the 52 psychotic prisoners who were definitely or probably influenced by their psychotic symptoms, 47 (90%) were influenced by delusions and 5 (10%) by hallucinations. Taylor concluded that psychotic patients who commit criminal offenses tend to do so because of their psychotic symptoms. Taylor also noted that behavior "definitely" influenced by delusions appeared significantly more dangerous than that influenced by hallucinations. Violent psychotic action also has been found in other, more limited forensic samples. Martell and Dietz (1992), for example, reviewed the State forensic mental health records of 20 persons referred for psychiatric evaluation after pushing strangers onto subway tracks in New York City. All but one of the offenders had a history of psychiatric hospitalization, and all but one were psychotic at the time of the offense. More relevant to the present discussion was the finding that 7 of the 20 (35%) were specifically influenced by delusional beliefs, and that 3 (15%) claimed to have committed the offense in response to command hallucinations. In a similar finding reported by Kennedy et al. (1992), 12 of 15 (80%) patients who were admitted to a forensic psychiatric unit following assaultive or threatening behavior, and who met DSM-I11-R (American Psychiatric Association 1987) criteria for delusional disorder, had incorporated their victims into their persecutory delusions (see above) before the offense. In a more systematic study of the specific influence of psychotic symptoms on behavior, Wessely et al. (1993) retrospectively examined the association between delusions and psychotic action in 83 delusional patients consecutively admitted to one of three British hospitals. These researchers assessed the

4 94 SCHIZOPHRENIA BULLETIN full range of each patient's delusional beliefs and identified a "principal delusion." Patients were then asked whether any action, not just violence, had occurred as a result of this principal delusion. In addition, informants were located who could provide information about the patients' behavior in the month before admission to the hospital. Wessely et al. (1993) found that 60 percent of the patients reported at least one incident of behavior specifically motivated by the principal delusion; 20 percent described three or more incidents. Judges' ratings of the probability that informant-reported behavior was related to the principal delusion indicated that 48 percent of the patients "probably" or "definitely" acted on their principal delusion in the month before admission. This percentage rose to 77 percent if behavior in response to any delusion (i.e., not just the principal delusion) was included. The authors concluded that actions associated with delusional beliefs are more common than is generally thought. It is important to note that violence was not uncommon in the sample of inpatients described by Wessely et al. (1993), especially considering the limited time period assessed. Of the 59 patients for whom informant information was available, 17 (29%) displayed minor violent behavior, and 2 (3%) serious violent behavior in the month before admission to the hospital. (It also should be noted, however, that the extent to which this violence was motivated by delusions apparently was unclear.) Fifteen of 83 patients (18%) claimed to have "broken" something in reaction to their principal delusion, and 14 (17%) claimed to have "hit" someone for that reason, all in the month before admission. The extent to which hallucinations induce violent psychotic action is less clear. Recall that Taylor (1985) believed that psychotic prisoners were more likely to act violently in response to delusions than to hallucinarions, and that a similar pattern of influence was found in the New York City subway offenders described by Martell and Dietz (1992). McNiel (1994) reviewed several "quantitative" studies of hallucinations and violence and concluded that there was, in fact, a significant association between the two. Unfortunately, he overlooked the issue of whether the violence induced by hallucinations was symptom-consistent, although he did dismiss evidence for a specific link between command hallucinations and violence. McNiel (1994) claimed that studies using "systematic sampling techniques" suggested that patients rarely complied with violent hallucinated commands. If this were true, and the association between hallucinations and violence noted by McNiel was mostly unrelated to compliance with command hallucinations, then the extent to which hallucinations induce violent psychotic action would be more difficult to determine. That is, few examples of symptomconsistent violence are as obvious as compliance with command hallucinations. Two studies by Junginger (1990, 1995) appear to refute claims that command hallucinarions pose little, if any, danger (Goodwin et al. 1971; Hellerstein et al. 1987; McNiel 1994). Junginger (1990) assessed the most recent command hallucination of 51 psychiatric inpatients and outpatients. These patients were asked to describe the command and whether they complied. Assessment was limited to the most recent hallucination to aid recall and minimize sampling issues, most of which concerned the great variability in hallucinatory experience reported by some patients (e.g., some patients reported hearing different voices issuing different commands on different occasions, and so on). Therefore, the rate of compliance with the most recent command hallucination across patients was thought to be a better estimate of base rate compliance with any single command. Junginger (1990) found that 20 of the 51 patients (39%) reported that they had complied with their most recent command hallucination. Twenty-four patients (47%) reported that they did not comply, and 7 (14%) claimed not to recall. Commands to engage in dangerous or violent behavior comprised a significant percentage (39%) of the patients' most recent command hallucinations. In fact, this percentage actually was considerably lower than the 69 percent reported by Hellerstein et al. (1987), who relied on a review of hospital charts, which presumably were more likely to note dangerous commands than harmless ones. Of the 44 patients who could recall whether or not they had complied, 12 of 24 patients (50%) experiencing harmless commands reported compliance, compared with 8 of 20 (40%) experiencing dangerous commands. All 8 reports of dangerous compliance subsequently were verified by secondary sources. In a followup study, Junginger

5 VOL 22, NO. 1, (1995) assessed the most recent command hallucination of 93 psychiatric inpatients. Junginger (1990) slightly modified his earlier method by having an independent judge estimate both the dangerousness of the command and the level of reported compliance on 3-point scales, not as dichotomous (yes/no) variables. This modification allowed these variables to better reflect the intermediate level of danger and compliance that was sometimes described by patients. Obvious examples of "very" dangerous commands included those to shoot or stab someone. Examples of commands judged "somewhat" dangerous included those to simply grab or hit someone and to throw a TV across the room. An example of behavior judged to be "partial" compliance was loading a gun and driving to the house but not shooting anyone following a command to "kill everyone in the house!" Junginger (1995) found that 52 patients (56%) reported what was judged to be at least partial compliance with their most recent command hallucination; 40 (43%) reported full compliance. This latter percentage of full compliance was similar to that found for a dichotomous measure of compliance in a previous study 0unginger 1990). Once again, reported compliance with dangerous commands was not uncommon: 27 of 59 patients (46%) reported at least partial compliance with commands that were judged somewhat or very dangerous, and 11 of 47 (23%) reported full compliance with very dangerous commands. In all but two cases, reports of full compliance with very dangerous commands were independently verified by hospital records. Symptom Attributes, Prior History, Characteristics of Illness, and Psychotic Action Studies that have found an association between psychosis and violence and, more specifically, between the content of psychotic symptoms and violence, have several methodological limitations. Violence has been quantified a number of different ways, and, with the notable exception of Link et al. (1992), sample sizes have been small and drawn from a variety of clinical populations. Consequently, the strength and specific nature of the relationship between psychosis and violence remain unclear. At the same time, it can also be said that these studies clearly indicate that the delusions and hallucinations of psychotic patients sometimes induce violent psychotic action. Accordingly, awareness of the content and themes of a patient's psychotic symptoms may be useful for estimating risk and for identifying potential targets of violence. Furthermore, even though the specific risk posed by delusions and hallucinations has not been determined, other preliminary findings suggest that certain characteristics of illness and symptom attributes increase the likelihood of psychotic action. These other findings may indicate that accurately identifying patients at risk for violence requires not only an awareness of the content of their symptoms, but also an understanding of the characteristics and history of their illness. For example, Wessely et al. (1993) tried to identify the types of delusions associated with informant-reported psychotic action. It should come as no surprise, based on clinical lore and on several studies cited earlier, that persecutory delusions were significantly more likely to be acted on than any other type of principal delusion. Thus, die presence of a persecutory theme seems to increase the risk of psychotic action. In the case of command hallucinations, Junginger (1990) identified two symptom attributes that had independent and significant associations with compliance: patient identification of hallucinated voices (HVs) as fairly specific persons or entities, and so-called hallucinationrelated delusions. Potentially more important for the prediction of violent or dangerous behavior was the finding that five of eight patients (63%) reporting compliance with dangerous commands could identify their HVs and had hallucination-related delusions. On the other hand, the presence of both of these symptom attributes was found in only 1 of 12 patients (8%) who did not comply with dangerous commands. In a followup study (Junginger 1995), analyses again indicated that being able to identify the HV was significantly associated with reported compliance: 42 of 64 patients (66%) who identified their HV reported at least "partial" compliance with its commands, compared with only 10 of 29 patients (34%) who could not identify their HV. In the case of the most dangerous behavior reported in that sample full compliance with very dangerous commands 9 of 28 patients (32%) who identified their HV reported full compliance with very dangerous commands, compared with only 2 of 19 patients (11%) who could not identify their HV. The meaning of this apparent

6 96 SCHIZOPHRENIA BULLETIN association between identifying the HV and complying with its commands may be difficult to determine. One speculation is that patients are more inclined to psychotic action as questions about psychotic experiences (e.g., "Who's talking to me?") are resolved (Junginger 1990). In this sense, identifying the HV may be one aspect of a more systematized distortion of reality in which symptom-consistent behavior is more likely to fit. A previous finding of an association between hallucination-related delusions and compliance (Junginger 1990) could be thought of in a similar manner. Hafner and Boker (1982) provided some support for the notion that systematized distortions of reality may lead to violent psychotic action. They found that "systematic" delusions, that is, delusional beliefs that were logically elaborate, were far more common in a group of 344 delusional violent offenders (75%) than in a group of 245 delusional nonoffenders (41%). Hafner and Boker (1982) concluded that the presence of systematic delusions seems to increase the risk of violent crime. On the other hand, Buchanan et al. (1993) found no such association between systematized delusions identified by the Present State Exam (PSE; Wing et al. 1974) and informant-reported or selfreported psychotic action in a group of 78 delusional inpatients. Without dismissing this negative finding, it should be noted that Buchanan et al. (1993) assessed behavior only in the month immediately before admission to the hospital. Wessely et al. (1993), reporting different analyses on the same sample of patients, qualified some of their own conclusions in consideration of the brief period assessed. In any case, the intriguing findings reported by Hafner and Boker (1982), and the presumably related findings of Junginger (1990, 1995), at least suggest that measures of the degree to which a patient's distorted sense of reality is systematized may be useful for predicting violence. The presence of systematized delusions indicates this type of distortion most clearly. Although several researchers have identified systematization as an important dimension of delusions (Kendler et al. 1983; Taylor et al. 1994), its assessment has lagged well behind its assigned importance. The degree to which a delusion is systematized, that is, logically elaborated around a central theme, typically has been measured as a dichotomy (e.g., Hafner and Boker 1982 and DSM-1II-R) or indirectly (and only somewhat less crudely) on the 3-point scale of the PSE the method adopted for the Maudsley Assessment of Delusions Schedule (MADS; Wessely et al. 1993). At Indiana University, we have been working with a method in which systematization is represented by the actual number of logical elaborations around the delusion's central theme, a much more sensitive measure of this dimension. In a trial of the method's reliability, the author and an independent judge rated 28 narratives of actual delusions taken from Junginger et al. (1992) according to the following instructions and examples: Count the number of logical elaborations of the central theme of the delusion. Logical elaborations add detail to the central theme, such as what happened or followed, or what was the status of some detail; also how, where, when, why, and who was involved. For example: SWM, 41, believes a dentist (who) put a microphone (what) in his tooth (where) during his last visit to have his teeth cleaned (when). The microphone allows the local authorities (who) to keep track of him (why) so they can pick him up when they need to (why). The dentist works for the FBI (who) and was brought in when federal agencies were asked for help by the local authorities (what). The local authorities want to prevent him from succeeding at his mission (why), which is secret (what). The local authorities are under the control of unnamed "conspirators" (who) 12 logical elaborations. This may be easier in some cases if you first imagine the delusion with little or no elaboration, and then count the extra details that are present. For example: SWM, 41, believes something was placed somewhere (what? by whom? where? when?) so others can keep track of him (why, but who? and why keep track?)... and so on. In spite of what appears to be a fairly difficult task, intraclass correlational coefficients (ICCs; Shrout and Fleiss 1979) for the trial judges were excellent: 0.98 for single raters, and 0.99 for the mean of two raters on which analyses often are based. Furthermore, the mean of the trial judges' ratings and the mean of the independent ratings of a psychiatrist and a clinical psychologist, made in reference to a 3-point scale adapted from the DSM-1II-R definition of systematization, correlated highly (r ). This indicated that, in fact, the new method was measuring the traditional dimension of systematization, although in a much more sensitive manner. Persecutory theme is another dimension of delusions that typically

7 VOL 22, NO. 1, is measured as a dichotomy; delusions usually are described as either having or not having a persecutory theme (e.g., American Psychiatric Association 1987; Wessely et al. 1993). In light of what appears to be a general consensus among clinicians and researchers that perceived persecution may lead directly to violence (Krakowski and Czobor 1994) or to threats of violence (Estroff et al. 1994), it is surprising that assessment of this dimension has not been given more consideration. It seems reasonable to propose that persecutory theme also can be measured along some limited continuum to better represent, for example, an intermediate level of persecution described by some patients. In a trial of one such method at Indiana University, the author and an independent judge rated the same 28 narratives of delusions as above according to the following descriptions: 0 = None. No evidence of persecutory content or even implied persecution. 1 = Moderate. Some evidence of persecutory content or implied persecution, but the persecutory content is not the predominant theme of the delusion. 2 - High. Clear evidence of persecutory content that dominates the theme of the delusion. That is, the core belief is that the person is being harmed, attacked, harassed, cheated, conspired against, influenced, or in any way persecuted. Once again, ICCs for the trial judges were excellent: 0.83 for single raters, and 0.91 for the mean of two raters on which analyses often are based. In addition to the presumed benefits of more sensitive measures (cf. Strauss 1969), a further advantage of estimating persecution and systematizan'on along continua is that an interaction variable can be created by multiplying the two estimates together, for example. Such a variable could be useful for investigating the intuitive notion that it is not just the level of persecution (Wessely et al. 1993) or systematization (Hafner and Boker 1982) that induces psychotic action, but also and especially the level of systematized persecution. There is evidence that other factors also may function as catalysts for patients' acting on the content and themes of their delusions and hallucinations. For example, Shore et al. (1990), in their summary of the White House Case studies, concluded that men with schizophrenia and a history of psychotic action may be at relatively greater risk for future violence. In what seems a related finding, Buchanan et al. (1993) reported that patients who actively sought information to confirm or refute a delusional belief were more likely to report subsequent psychotic action. In his review of studies of hallucinations and violence, McNiel (1994) claimed that the risk for assault is "obviously higher" for a patient with a history of behaving violently in response to hallucinations. Thus, a history of actions based on delusions or hallucinations may predispose a patient to violent psychotic action in the future, a notion entirely consistent with classic conceptualizations of human behavior (Mischel 1968). Certain characteristics of psychiatric illness also seem to be a stimulus for psychotic action. Kennedy et al. (1992), for example, found that fear or anger preceded the threatening or assaultive behavior of 15 patients diagnosed with delusional disorder; as noted earlier, 12 of these patients exhibited symptom-consistent violence. (Interestingly, in three cases the patients apparently had not incorporated their victims into their persecutory delusions more about that later.) Buchanan et al. (1993) found that psychotic action was associated with feeling frightened, sad, or anxious. They proposed that their finding was consistent with Bidder's (1924) claim that psychotic action is mostly a consequence of "affectivity." Bleuler's notion seems to suggest that disturbed mood "activates" the violent behavior implied by the content and themes of psychotic symptoms. Presumably, in the absence of delusions or hallucinations, the targets of mood-induced violence, if not random, would be far less predictable. Researchers also have speculated about an association between psychotic action and acute symptomatology. McNiel (1994), for example, reviewed a number of "personal variables" thought to affect the relationship between hallucinations and violence. He expressed the possibility that hallucinations are more likely to induce violence during episodes of acute exacerbation of the patient's illness. This view is consistent with Krakowski et al.'s (1988) finding that the psychotic symptoms of 44 psychiatric inpatients were significantly associated with violence during the early part of their stay on a forensic unit, but not later when their symptoms were less acute. Thus, as with disturbed mood (Bleuler 1924), acute psychosis may serve to activate symptom-consistent violence. In summary, the content and themes of a patient's psychotic symptoms can be thought of as a

8 98 SCHIZOPHRENIA BULLETIN blueprint for action. Whether a patient acts on this blueprint, however, apparently is determined by a number of other factors (cf. McNiel 1994). A Limited Model of Effects on Violence A comprehensive model of the various effects on violence probably would be so complex as to defy interpretation (see, e.g., Monahan 1981; Monahan and Steadman 1994). However, a limited model focused on the symptom attributes and characteristics of illness described here might be useful not only as a descriptive device but also as a guide for identifying potentially important areas for study. One such model is shown in figure 1. Psychiatric hospitalization has been added to the model both as a consequence of the other components and as an environmental factor that affects these other components, as will be seen. The major hypothesis proposed here is that delusions and hallucinations can directly induce violence consistent with the content or themes of these psychotic symptoms. This hypothesis is Figure 1. A limited model of enhancing and suppressing effects on violence enhancing or inducing effect suppressing or modifying effect Delusions & Hallucinations CO Characteristics of Illness Psychiatric Hospitalization o

9 VOL 22, NO. 1, based mainly on the findings of Taylor (1985), Junginger (1990, 1995), and Wessely et al. (1993) but also draws on the findings cited earlier that indicate the occurrence of violent psychotic action (Kennedy et al. 1992; Martell and Dietz 1992). As can be seen, other characteristics of illness also are proposed to have a direct effect on violence. These include anger and impulsiveness, which have been found to induce violence independent of delusions and hallucinations (Barratt 1994; Novaco 1994). Violence directly induced by such characteristics of illness would not be symptom-consistent, however, and its parameters therefore would be more difficult to predict. Characteristics of illness also can have an indirect effect on violence through delusions and hallucinations. As described earlier, disturbed moods such as fear, anger, sadness, and anxiety apparently can activate violent psychotic action (Kennedy et al. 1992; Buchanan et al. 1993). Accordingly, as shown in figure 1, the indirect path from characteristics of illness to violence leads through delusions and hallucinations and results in symptom-consistent violence. Figure 1 indicates that delusions and hallucinations also can have an indirect effect on violence through characteristics of illness. For example, Kennedy et al. (1992) found that patients' disturbed moods appeared to be a consequence of their delusions. In the usual case, these disturbed moods led to violent psychotic action, presumably in the manner just described and depicted in figure 1. As already noted, however, in a few cases disturbed mood led to violence that apparently was not symptom-consistent. Thus, violence apparently can be induced directly from characteristics of illness resulting from psychotic symptoms. Again, such violence would not be symptom-consistent because the indirect path from delusions and hallucinations to violence leads through characteristics of illness, which exert a direct effect. The effects of characteristics of illness, psychotic symptoms, and violence on psychiatric hospitalization are relatively well known. Mezzich et al. (1984), for example, found that violent behavior was a major determinant of hospitalization for a large sample of patients presenting in a psychiatric emergency room over a 6-month period. In a review of recent developments in U.S. mental health laws, Monahan and Shah (1989) chronicled the increasing acceptance of "tangible violence" as the standard for civil commitment. The association of psychotic symptoms with hospitalization also is well established. Hillard et al. (1988) found that the presence of delusions was one of the variables that best predicted psychiatric hospitalization for adult patients; Mezzich et al. (1984) and Beck et al. (1991) reported similar findings for both delusions and hallucinations. In the case of characteristics of illness, both the actual number of psychiatric symptoms and the overall severity of illness as indicated by the Global Assessment Scale (Endicott et al. 1976) have been found to predict hospitalization (Feigelson et al. 1978; Mezzich et al. 1984; McNiel et al. 1992). Furthermore, as can be seen in figure 1, characteristics of illness and psychotic symptoms may have additional, indirect effects on hospitalization through their direct effects on other components. The effects of psychiatric hospitalization on violence, psychotic symptoms, and characteristics of illness are more complex. Hospitalization has a direct suppressing effect on violence probably due to pharmacological treatment, and to an environment that provides fewer weapons, targets, and opportunities for violence (cf. Krakowski et al. 1986). The pharmacological treatment component of psychiatric hospitalization also has a welldocumented direct suppressing effect on psychotic symptoms and other characteristics of illness, such as disturbed mood. As shown in figure 1, by directly suppressing other components, hospitalization also may indirectly suppress delusions and hallucinations, violence, and characteristics of illness. An issue that has not been given much consideration, however, is the degree to which an environment may alter the patient's actual psychotic experience. In an assessment relevant to this issue, Junginger (1995) compared the hallucinatory experiences of psychiatric inpatients who were either in the hospital (n = 25) or outside the hospital (n - 68) at the time of their most recent command hallucination. His findings again appeared to show the direct suppressing effect of the restrictive hospital environment on violence: only 1 of 7 patients (14%) reported "full" compliance with a "very" dangerous command experienced in the hospital, compared with 10 of 40 (25%) who experienced a very dangerous command outside the hospital. Also, when the command's level of dangerousness was statistically controlled, it was found that hospitalized patients reported significantly lower levels of

10 100 SCHIZOPHRENIA BULLETIN overall compliance. What was more intriguing, however, was that patients in the hospital at the time of their most recent command hallucination reported significantly less dangerous commands than patients experiencing their commands outside the hospital. Related to this finding was the observation that commands experienced in the hospital either tended to be specific to the hospital environment (e.g., "Don't talk to that nurse!"), or could be complied with in the hospital as easily as outside the hospital; that is, there were no reports of commands such as "Shoot (someone)!" experienced in the hospital. Although preliminary, these findings suggest that violence in psychotic patients is a product not only of the interaction between the usual characteristics of a person and the opportunities provided by a particular environment, but also of the adaptation of psychotic experience to a particular environment. Even as a limited model, figure 1 suggests numerous areas for study. As discussed earlier, characteristics of illness such as acute symptomatology (Krakowski et al. 1988) and disturbed mood (Kennedy et al. 1992; Buchanan et al. 1993) already have been implicated as catalysts for psychotic action. Alcohol or drug abuse would seem to be another likely candidate, although currently there is no dear evidence for a true interaction effect of the dual diagnosis of mental illness and substance abuse on violence (Swanson and Holzer 1991). In any case, it seems clear that characteristics of the patienf s psychiatric illness are implicated in the occurrence of violent psychotic action and that research should continue to try to identify the specific characteristics important to this association. Systematization and persecutory theme are the dimensions of delusions most dearly assodated with violent psychotic action (Hamer and Boker 1982; Kennedy et al. 1992). Consistent with this view, systematized persecutory themes would seem to pose a particularly strong risk for violent psychotic action and therefore should be investigated, possibly with some type of interaction measure such as proposed earlier. Furthermore, researchers (Kendler et al. 1983; Harrow et al. 1988; Wessely et al. 1993) seem to agree on the clinical significance of two other dimensions of delusions: conviction and a dimension representing aspects of a patient's "emotional commitment" to a delusion. It is conceivable that these two dimensions also are assodated with patients' acting on their delusions, and therefore probably should be evaluated as predictors of violent psychotic action. In the spedal case of command halludnations, being able to identify the HV has been found to be reliably assodated with reported compliance, at least in the small, relatively chronic samples studied thus far flunginger 1990, 1995). Disregarding, for the moment, the ultimate meaning of this assodation, this simple attribute of hallucinatory experience could be useful for identifying patients at somewhat greater risk for complying with violent commands. Of the various other attributes of hallurinatory experience (see McNiel 1994), the frequency or persistence of halludnations, espedally of command halludnations, intuitively seems to be one that might be considered an instigator of violent psychotic action (cf. Hellerstein et al. 1987). The finding by Junginger (1995) that a patient's psychotic experience actually may adapt to the more restrictive hospital environment raises several interesting possibilities. One is that the suppressing effect of the hospital environment on violence may be due in part to a more benign adaptation of psychotic experience in other words, an indirect suppressing effect of hospitalization on violence through delusions and hallucinations. This, in turn, may suggest that environments outside the hospital could be modified to "encourage" development of these more benign psychotic states. The flip side of this effect, of course, is that some environments may actually favor the development of more dangerous elements of psychotic experience. Several researchers have noted, for example, that the availability of weapons increases the risk of violence (Berkowitz and Page 1967; Monahan 1981). In psychotic patients, the availability of weapons also could lead to the integration of these weapons into the patients' psychotic experience. For example, one of the patients in the sample studied by Junginger (1995) reported experiencing hallucinations outside the hospital commanding her to get her father's gun and shoot her husband. After being admitted to the hospital, she reported that a voice instructed her to get the blunt-point, plastic sdssors used in art dass and stab one of the ward personnel. Apparently, as the availability of weapons became more restricted, her psychotic experience became at least somewhat more benign.

11 VOL. 22, NO. 1, These preliminary findings and speculations suggest a potentially productive area for research. A final consideration is whether a history of psychotic action affects the various associations between violence and the elements of psychotic experience outlined here. It may be that these associations become less meaningful with repeated occurrences of psychotic action; that is, patients may begin to act on their delusions or hallucinations simply because they have acted on them in the past. One of the more difficult goals for research will be to determine the relative importance of the associations between violence and various elements of psychotic experience. As with a host of other human behaviors (Mischel 1968), prior violent psychotic action may prove to be the best predictor of its future occurrence. Conclusions There is increasing acceptance of findings indicating that violence is more common in the mentally ill than in the general population. A great deal of the violence observed in the mentally ill appears to be consistent with the content or themes of concurrent delusions or hallucinations. I am proposing routine estimates of the degree to which violence in the mentally ill is symptom-consistent (Taylor 1985; Junginger 1990, 1995; Wessely et al. 1993). These estimates will give us a better idea of both the incidence of violent psychotic action and the conditions under which it occurs. Without these routine estimates, we will be unable to differentiate violent psychotic action from the indirect effects of psychotic symptoms on violence. Ironically, it is the reality of psychotic action that will allow better identification of patients at risk for committing violence and of those individuals who are at risk for becoming targets of their violence. This is true because delusions and hallucinations are more salient and their content and themes provide more useful information than the often obscure motives for other forms of violence. The irony, of course, is that the very symptoms that increase the risk for violence in psychiatric patients also allow prediction of some of its parameters. The content and themes of a patient's psychotic symptoms often imply, and may even dictate, a specific course of violent action. Patients with disturbed mood, acute symptomatology, systematized distortions of reality, persecutory themes, and a prior history of acting on their delusions and hallucinations appear more likely to engage in this violent action. However, the true incidence of violent psychotic action cannot be determined by retrospective studies such as those reviewed here; only prospective studies can do that. The incidence of symptom-consistent violence in patients previously determined to be at risk according to the criteria outlined here, relative to patients previously determined to be less at risk, should finally resolve the issue of the danger posed by delusions and hallucinations. References American Psychiatric Association. DSM-HI: Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, DC: The Association, American Psychiatric Association. DSM-III-R: Diagnostic and Statistical Manual of Mental Disorders. 3rd ed., revised. Washington, DC: The Association, Barratt, E. Impulsiveness and aggression. In: Monahan, J., and Steadman, H., eds. Violence and Mental Disorder: Developments in Risk Assessment. Chicago, IL: University of Chicago Press, pp Bartels, S.J.; Drake, R.E.; Wallach, M.A.; and Freeman, D.H. Characteristic hostility in schizophrenic outpatients. Schizophrenia Bulletin, 17(1): , Beck, J.; White, K.; and Gage, B. Emergency psychiatric assessment of violence. American Journal of Psychiatry, 148: , Berkowitz, L., and Page, A. Weapons as aggression-eliciting stimuli. Journal of Personality and Social Psychology, 7: , Bleuler, E. Textbook of Psychiatry, 4th German ed. Translated by A.A. Brill. New York, NY: Macmillan Press, Buchanan, A.; Reed, A.; Wessely, S.; Garety, P.; Taylor, P.; Grubin, D.; and Dunn, G. Acting on delusions: n. The phenomenological correlates of acting on delusions. British Journal of Psychiatry, 163:77-81, Deutsch, L.; Bylsma, F.; Rovner, B.; and Steele, C. Psychosis and physical aggression in probable Alzheimer's disease. American Journal of Psychiatry, 148: , D'Orban, P., and O'Connor, A. Women who kill their parents.

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