A Psycho-Demographic Study in a Sample of Schizophrenic Versus Non-Schizophrenic Offenders

Abdullah Gholoum et al. A Psycho-Demographic Study in a Sample of Schizophrenic Versus Non-Schizophrenic Offenders Abdullah Gholoum 1, Mohamed AbuZeid 2, Hesham Ahmed Rami 2, Mohamed El-Dardiri 1 Department of Neuropsychiatry, Psychological Medicine Hospital, Kuwait 1 ; Ain Shams University 2 ABSTRACT Objective: To examine the assumption that puts schizophrenia as a major risk factor for homicide and crime, by describing demographic clinical and social characteristics of crimes committed by a sample of offenders suffering from schizophrenia. Method: 25 schizophrenic offenders and 21 non-mentally disordered offenders were compared as regards the type of crime, victim data and psychiatric comorbidity. Results: Violence and murdering of a close relative was a significant finding among the schizophrenic group and not among controls. Paranoid-type schizophrenia was the most violent type among cases and delusions of persecution followed by delusions of infidelity were markedly present just prior to the offence. (Egypt J. Neurol. Psychiat. Neurosurg., 2007, 44(1): 399-406). INTRODUCTION A question was raised by Wallace et al. 1 as to whether characteristics of homicides committed by mentally disordered offenders differ from those committed by other non-mentally disordered offenders, given that the prevalence of mental disorders among homicide offenders appears to be no greater than that of the general population. Several researchers have concluded that schizophrenia increases the risk of violence in general and of homicide in particular. 2 Although an association between schizophrenia and increased risk of violence was demonstrated repeatedly, the timing of violent act within the course of the illness is often not reported. 3 Previous reports have linked positive psychiatric symptoms with violence that often occurs around the time of hospital admission. 4 In the process of analyzing crime there must be an attempt to identify crime pattern (motive and behavior), the choice of victim and place of crime, the geographic profile and the offender s profile. 5 Research studies fall short of providing useful predictive or explanatory models of violence in schizophrenia. In part this can be due to lack of analytical study of crime. Thus unpredictability is a theme of schizophrenic behavior and, without a doubt, is a theme of crime. By interrelating both, some light can be shed on the expectation of violence and homicide intentions. Aim of the Work 1. To study, in an analytical view, the difference found in homicide pattern between schizophrenic and non-schizophrenic, free-ofmental-disorder, homicide offenders as regards motive, crime scene, and offenders characteristics. 2. To identify how different types of schizophrenia can affect crime type. 3. To monitor substance use as a comorbid condition in schizophrenia during homicide. METHOD We studied a group of 25 cases of murderers diagnosed after the act with schizophrenia (all types) in a random manner. We collected various demographic clinical and event-related variables for homicide offenders diagnosed with schizophrenia (Using DSM IV structured clinical interview, APP 1994), and for another group of 399

Egypt J. Neurol. Psychiat. Neurosurg. Vol. 44 (1) - Jan 2007 21 murderers free of schizophrenia or other mental disorder apart from substance use. The two groups were recruited to the forensic psychiatry unit of the psychological medicine hospital in the State of Kuwait. Crime data were collected from both groups as regards site and type of crime, whether a violent one with marked aggression toward the victim or nonviolent, also data regarding the type of weapon used (sharp object, a gun, or a rifle). Data on the offender s behavior (escape, surrender, try to hide crime evidence, or not known) before, during and after the offence were collected, and the motive was investigated whether it was known or not. Data on the victim also considered gender, age, and relation of the victim to the offender. The clinical data did search for the presence or absence of schizophrenia, any comorbid condition and whether schizophrenia was diagnosed before the offence or just after, and to which type of schizophrenia the offender belongs. Also any previous 6-months contact with psychiatric service (outpatient, inpatient, or no contact to the service at all) was recorded. RESULTS Table and figure (1) show a comparison between the type of crime, whether violent or nonviolent, among cases versus control. Violent crimes were significantly more prevalent among the schizophrenic group as compared to the nonschizophrenic one. Table (2) shows a comparison between the crime motive, whether known or unknown, among cases versus control. A known motive was significantly more prevalent among the control group as compared to the schizophrenic one, whereas the latter group prevailed in the unknown motive crimes. Table (3) shows a comparison between the types of social behavior after crime whether the subject ran away or surrendered or the behavior was unknown among cases versus control. Running away was significantly more prevalent among the control group as compared to the schizophrenic one whereas surrendering was more prevalent among schizophrenic offenders. Table (4) and figure (2) show a comparison between the relation of the victim to the offender, whether a family member or non-family member, among cases versus control. Offenders in the schizophrenic group were more likely to kill their own family members as compared to the nonschizophrenic ones. Table (5) shows a comparison between the type of crime, whether violent or non-violent, among different types of schizophrenia. Violence was significantly more prevalent among the paranoid group as compared to other subtypes of schizophrenia. This work showed the delusions immediately prior to or during the offence of homicide in the schizophrenic group to be found in 22 out of 25 offenders, which is about 88%. The nature of delusions was as in the table (6). It was found also that hallucination immediately prior to or during the killing was present in 11 out of 25 offenders of the schizophrenic group, which represents 44%. Hallucination was mainly of the auditory type (about 81% of all hallucination types). Table 1. Type of crime in cases versus control. Type of crime Controls Cases Total Violent 8 17 25 Non-violent 13 8 21 Total 21 25 46 Chi square significance 0.041 400

Count Abdullah Gholoum et al. Bar Chart 20 filter control cases 15 10 5 0 1 2 type of crime-1-viol-2-non Fig. (1): Type of crime in cases versus control. Table 2. Motive in cases versus control. Control Cases Total Motive Known 15 8 23 Unknown 6 17 23 Total 21 25 46 Chi square significance 0.008 401

Count Egypt J. Neurol. Psychiat. Neurosurg. Vol. 44 (1) - Jan 2007 Table 3. Social behavior after crime in cases versus control. Control Cases Total Run away 14 7 21 Social behavior after offence Surrender 3 12 15 Unknown 4 6 10 Total 21 25 46 Chi square significance 0.02 Table 4. Relation to the victim in cases versus control. Family Member Non-member Total Filter Control 4 17 21 Cases 18 7 25 Total 22 24 46 Chi square significance 0.000 Bar Chart 20 family member non member 15 10 5 0 0 1 control cases Fig. (2) 402

Abdullah Gholoum et al. Table 5. Violence among types of schizophrenia. Type of schizophrenia undifferentiated schizoaffective paranoid residual disorganized Total Violence 3 0 9 4 1 17 Non-violence 0 4 2 0 2 8 Total 3 4 11 4 3 25 Chi square significance 0.006 Table 6. Nature of delusions in schizophrenic offenders. Nature of delusion No. Percentage Persecutory 22 88% Jealousy or infidelity 10 40% Bizarre 8 32% Grandiose 5 20% Reference 5 20% Religious 4 16% Control 3 12% Somatic 1 4% Sexual 1 4% Sample Characteristics The cases reviewed here represent a cohort of 18 men and 7 women who were referred to our unit for a forensic psychiatric examination by our team of experienced forensic psychiatrists. All of the 25 individuals were charged with homicide. DSM IV diagnostic criteria were used to diagnose all the individuals with schizophrenia. Most of the persons in the cases reviewed here had been diagnosed before the homicide event and only 4 cases were diagnosed after the homicide event. Moreover, in most of the cases the index of suspicion of schizophrenia or dangerousness was not high until it was too late to intervene preventively. Demographic clinical and homicide event-related variables were noted for the 18 men and 7 women in the cohort. As to personal data, 12 were single, 5 were married and 8 were separated or divorced. Unemployment was found in 13 individuals and all the others were having regular jobs. It was seen in the study that all individuals in the cohort did have symptoms of schizophrenia prior to the offence. The comorbidity of substance abuse was very significant among schizophrenic offenders compared to non-schizophrenic ones. It was found in 13 male and 2 female schizophrenic offenders whereas it was found in only 7 males and 1 female in the control group, which means that it was found in 60% of the schizophrenia offenders group and in only 38% in the non-mental disorder group. Sample of Case Reports Case I A twenty-seven-year old male with a diagnosis of undifferentiated schizophrenia killed his nephew child by stabbing him repeatedly and then cutting his neck, separating the head from the body. The act followed a delusion by the offender that the child was pushing his aunts to take the 403

Egypt J. Neurol. Psychiat. Neurosurg. Vol. 44 (1) - Jan 2007 offender s organs out of his body and to torture him physically then kill him. Case II A forty-five-year old male suffering from schizophreniform psychosis killed 5 of his children and failed to kill himself and another 4 of his children by drinking organo-phosphorus poison put in orange juice. He had delusions of infidelity towards his wife and falsely believed that she took all his money and was going to kill him and give the children to a shelter. Case III A forty-five-year old male diagnosed with paranoid schizophrenia killed his daughter by cutting her throat with a knife upon returning from pilgrimage to Mecca after having developed delusions of infidelity towards his wife and a false belief that the victim was not his daughter, so he decided to kill her for the purpose of her salvation. Case IV A twenty-nine-year old Asian woman working as a servant killed her employer, who was a young woman, as she developed a sudden delusion that the employer was conspiring with one of her friends to force the offender to indulge in prostitution. The Asian woman stabbed the victim 4 times then left the crime scene and escaped. Case V A thirty-nine-year old paranoid schizophrenic male who had been admitted once to our hospital killed his two sisters by stabbing them vigorously one after the other, rendering them both dead. He then went to the police station and surrendered. He had delusions that both his sisters were having sexual relations with men from the same building. Case VI A thirty-nine-year old male patient diagnosed with undifferentiated schizophrenia killed his driver after having had a fight with him outside the bank, where he shot him dead with his gun. Case VII A twenty-nine-year old male diagnosed with paranoid schizophrenia killed his father, shooting him with a rifle, as he had developed a delusion that his father was the devil himself and that by killing him he would save humanity. Case VIII A thirty-five-year old male, who was diagnosed as undifferentiated schizophrenia, shot his wife repeatedly after having delusions that she was having an affair with his own father and his brother. DISCUSSION Evidence suggests that among the potential modified risk factors for violent crime is severe mental illness. Also psychiatric case registers in Australia and the United Kingdom and registers of discharged psychiatric patients in the USA have indicated that psychosis is a modest risk factor for offending in homicide. Palmer et al.6 studied the risk of an individual with psychosis committing violent homicide or any offense compared to the general population in the same age and found it to be 2 to 6 times for men and 2 to 8 times for women. The results reached in this study agree with former results as it was significant that the violent type of crime is related to schizophrenic case group. Also it was found in the results that paranoid schizophrenia, regardless of the offender s age or sex, was in particular significantly related to violent homicide. In addition, it was clearly significant that paranoid schizophrenia offenders murder one family member of the opposite sex. These results can be explained in light of other findings reached which concern the type of delusions. It was significantly clear that delusions of jealousy or infidelity are the second most encountered delusions among schizophrenics, in particular the paranoid group, which may give a clue as to why a paranoid schizophrenic murders violently a family member who may be a wife or husband (opposite sex). Also results showed clearly that persecutory delusions are the leading delusion among the schizophrenic group 404

Abdullah Gholoum et al. and among paranoid schizophrenia which was mainly also toward a family member, a day-to-day related one. Confidently enough, the results of this study go with a study by Badcock 7 where for 50% of the cases in which schizophrenic offenders act violently, violence can be traced back to some delusional experience. Moreover, a study conducted by Okasha et al. 8 (in which one of the authors of this paper participated) showed that schizophrenia was the lowest diagnosis in prison. Hence it is clear that homicide is not more among schizophrenics, rather it is violence that marks a schizophrenia offender. The diagnosis of schizophrenia carries a 75% possibility of the offence to be driven by delusions. 9 Again a blood relative was more likely to be the victim of choice in schizophrenic offenders in one homicide study in Finland in 2006. 10 As mentioned earlier in the results of this study that showed paranoid schizophrenics to be significantly the most violent during a homicide act, we find previous reports such as that by Junginger 11 which showed violence is linked to a more restricted set of symptoms such as hostility or suspiciousness, or it may involve more specific and organized persecutory delusions that are often focused on specific persons. Muzinic 12 emphasized the forensic importance of psychotic jealousy in a recent retrospective study of 200 persons who had committed or attempted homicide. He found that jealousy in the diagnostic category of paranoid schizophrenia and paranoid psychosis was associated with the highest degree of danger and that the time span from the first manifestation of jealousy was shortest in schizophrenia. A very important and significant finding that was discovered during this study was the substance abuse comorbidity to the diagnosis of schizophrenia among homicide offenders (15, 60% of schizophrenia group). Substance abuse was found to increase violence significantly in the schizophrenic offender group. This study came to a statistically significant result that cases are more likely to surrender after homicide as compared to other non-schizophrenic offenders. Though this could not be analyzed in the context of this paper, it goes with a study done by Steyru & Choinski that arresting at the crime scene was one characteristic frequently found among psychotic homicide offenders. 13 Conclusion In a medico-legal context, a forensic psychiatrist examining individuals involves gathering all pertinent information on the person s symptoms and clinical signs to make a clinical judgment; and only then a question should be raised: could the murderous behavior represent an expression of the illness? Needless to say, not all homicides result from a psychopathology, however, various psychotic symptoms such as delusions, hallucinations or disorganization of thinking and behavior may be associated with pathological homicide. We can now accept that people with schizophrenia are significantly more likely to be violent and that comorbid substance abuse considerably increases the risk of homicide and violence. Additionally, in the instances where homicide targeted family members, schizophrenic offenders had the greatest share. So if homicidal behavior is an expression of illness, experts need to include it in their diagnostic analysis to increase objectivity in their medico-legal report. We think that further exploration of the timing of violent events of homicide within the illness course will be useful to provide deeper insights in prediction of violence and homicide intentions in individuals with schizophrenia. It will also likely influence the forensic disposition of these patients. REEFRENCES 1. Wallace C, Mullen P, Burgess P, Palmer S, Ruschena D, and Browne C, 1998, Serious criminal offending and mental disorder, British Journal of Psychiatry, vol. 172, pp.477-84. 405

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