Screening those at risk of psychosis may help prevent violence, reduce stigma

The article, "A Longitudinal Study of Violent Behavior in a Psychosis-Risk Cohort," by Gary Brucato, PhD, Ragy Girgis, MD and colleagues at Columbia University Medical Center, was published in Neuropsychopharmacology.

In the public imagination, individuals with psychosis are often identified with acts of violence. However, the reality is that persons with mental illness account for a very small proportion of violent crime in the U.S. But studies have shown that people with psychotic disorders are more prone to acts of mass violence involving strangers or intrafamily violence if they have not received effective treatment.

"It is important that we acknowledge that violence can be fueled by mental illness and that steps be taken to identify those people who might be prone and treat them accordingly. That is why these findings are so important as they demonstrate that screening people with sensitive instruments can detect which people in the incipient stages of mental disorders are at greatest risk of violence," noted Jeffrey A. Lieberman, MD, Lawrence C. Kolb professor and chair of psychiatry at Columbia University College of Physicians and Surgeons.

The study followed 200 individuals at high-risk of psychosis over a period of two years. Twelve (6%) of them reported acts of violent behavior in the six months before joining the study, fifty-six (28%) reported violent ideation at the time of entry into the study, and eight (4%) committed acts of violence during the two-year follow-up period. As a result of the study evaluation, the study staff provided treatment and took preemptive action for ten additional individuals whose thoughts had developed into plans for violent acts.

The results of the study showed that both thoughts of violence and recent violent behavior were associated with future incidents of violence, which occurred within an average of seven days of when the person developed psychotic symptoms.

Only information contained in the description of the person's symptoms predicted the violent behavior, and not direct questions of "whether you want to hurt anyone." The authors suggest that this is likely why prior studies of violence in mental illness did not predict violent behavior. The direct question "have you had thoughts of harming anyone else?," elicited zero responses of violent ideation from any of the 200 participants. However, the indirect question "have you felt that you are not in control of your own ideas or thoughts?" elicited reports of violent ideation from 56 individuals.

Also, the targets of the violent thoughts at the beginning of the study were not those that the person subsequently. This suggests that the attacks may have been impulsive and opportunistic rather than planned, and the result of the person's psychotic symptoms.

"These individuals feel that they themselves are not having violent fantasies, "said Dr. Gary Brucato, clinical psychologist and researcher in the department of psychiatry and first author on the paper. "They feel that the thoughts they are having are intrusive and not their own. Since they are not convinced that these thoughts are real, they tend not to report them or consider them meaningful."

A variety of factors, including alcohol and drug abuse, failure to take antipsychotic medications regularly, younger age, and psychotic symptoms such as delusions and hallucinations have been shown to have some effect on the risk of violence among people with psychosis. Earlier research has also indicated that the period around the time of a first psychotic episode is a time of high risk for violent behavior, and that violent behavior peaks at this time.

"These findings indicate that pre-symptomatic individuals at-risk for psychosis should be screened for violent ideation, and, importantly, demonstrate how to do the screening effectively," said Ragy Girgis, MD, assistant professor of psychiatry at Columbia University Medical Center and senior author on the paper. "We hope this finding and means of assessment will move the field to develop a more nuanced understanding of violent ideation in the context of psychotic symptoms. Much like suicidal ideation in depression, destigmatizing the experience of violent ideation in the attenuated phase of psychosis will allow patients to freely report it."