Schizophrenia, Delusional Symptoms, and Violence: The Threat/Control-Override Concept Reexamined
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Schizophrenia, Delusional Symptoms, and
Violence: The Threat/Control-Override
Concept Reexamined
by Thomas Stompe, Qerhard Ortwein'Swoboda, and Hans Schanda
and Link 1997; Tiihonen et al. 1997; RasSnen et al. 1998;
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Abstract
Brennan et al. 2000a, 2000fc; Mullen et al. 2000jTAn
In 1994 Link and Stueve identified a number of symp- overrepresentation of schizophrenia patients is repeatedly
toms—called threat/control-override (TCO) symp- reported mainly among the most severe forms of violence
toms—that were significantly more than others related (Petursson and Gudjonsson 1981; Lindqvist 1986;
to violence. This was confirmed by some, but not all, Gottlieb et al. 1987; Eronen et al. 1996a, 1996*, 1996c,
following studies. The contradictory results could be 1997; Wallace et al. 1998), confirming the prejudices of
due to remarkable differences in sample compositions, the general population against these patients. The search
sources used, and definitions and periods of recorded for reliable predictive factors for future violence is a mat-
violence, but they are mainly due to problems defining ter of special interest (Steadman et al. 1993; Monahan and
the TCO symptoms. To reexamine the validity of the Steadman 1994; Monahan and Appelbaum 2000;
TCO concept from an exclusively psychopathological Steadman and Silver 2000).
position, we compared in a retrospective design a sam- Clinical diagnoses as more or less stable (actuarial)
ple of male offenders with schizophrenia not guilty by predictors can in fact provide (at least partly) statistically
reason of insanity (n = 119) with a matched sample of significant results, yet they suffer from a lack of speci-
nonoffending schizophrenia patients (n = 105). We ficity. Dynamic psychopathological factors such as delu-
could find no significant differences regarding the sional/psychotic symptoms seem to have a higher predic-
prevalence of TCO symptoms hi the two groups dur- tive value and have always been associated with violent
ing the course of illness. The only statistically signifi- behavior (B6ker and Hafner 1973; Taylor 1985;
cant discriminating factors were social origin and sub- Krakowski et al. 1986; Link et al. 1992). Some years ago,
stance abuse. Yet, taking into account the severity of Link and Stueve identified among the range of delusional
offenses, TCO symptoms emerged as being associated symptoms a few that were significantly more frequently
with severe violence. This effect is primarily attribut- than others related to violence. As these symptoms
able to the comparatively unspecific threat symptoms. describe a patient's feeling of being "gravely threatened
Control-override, to be seen as more or less typical for by someone who intends to cause harm" (p. 143) and of
schizophrenia, showed no significant association with an override of self-control through external forces, they
the severity of violent behavior. were called threat/control-override (TCO) symptoms
Keywords: Schizophrenia, violence, threat/con- (Link and Stueve 1994). These findings were corroborated
trol-override symptoms. in general by several other studies (Swanson et al. 1996,
Schizophrenia Bulletin, 30(l):31^44, 2004. 1997; Link et al. 1998), and meanwhile the TCO concept
has found its way into the literature dealing with risk
assessment and risk management (e.g., Bjtfrkly 2000;
Regardless of the much more important influence of gen- Cooke 2000).
eral criminogenic factors such as (antisocial) personality
However, scepticism was expressed by Mullen
disorders and substance abuse, newer studies with differ-
(1997) regarding the rates of thought insertion and feel-
ent designs are confirming a modest but significant link
ings of external control in the nonpsychotic Link and
between mental illness and criminal/violent behavior
(Lindqvist and Allebeck 1990; Swanson et al. 1990;
Hodgins 1992; Link et al. 1992; Wessely et al. 1994; Send reprint requests to Dr. T. Stompe, Justizanstalt GSllersdorf,
Hodgins et al. 1996; Modestin and Ammann 1996; Stueve Gflllersdorf 17, 2013 Austria; e-mail: thomas.stompe@chello.at.
31Schizophrenia Bulletin, Vol. 30, No. 1, 2004 T. Stompe et al.
Stueve community sample (1994). He pointed out that Stueve (1994) definition for the Triangle Mental Health
"whatever is being measured it is unlikely to be the rela- Survey (TMHS) subsample using the corresponding items
tively uncommon passivity phenomena, at least not in the from the PERI, and the Swanson et al. (1996) definition
form traditionally recognised" (Mullen 1997, p. 7). for the Epidemiologic Catchment Area (ECA) subsample.
And, in fact, the first prospective investigation based Probably the most precise definition of psychopathology
on data from five face-to-face interviews within 1 year in was that of Appelbaum et al. (2000), who used the
more than 1,000 patients (MacArthur Violence Risk MacArthur-Maudsley Delusions Assessment Schedule, an
Assessment Study) (Appelbaum et al. 2000) was not able adaptation of the Maudsley Assessment of Delusions
to confirm the earlier positive results. Moreover, Schedule as an expert rating (Appelbaum et al. 1999) and,
Appelbaum et al. found that "body/mind control delusions additionally, patients' self-reports.
. . . displayed a negative relationship to the incidence of Given that (in concordance with DSM definitions)
violence" (2000, p. 568), at least during the first two fol- especially "transitivistic" passivity phenomena are pri-
lowup assessments in their sample. Their effort to dupli- marily found in patients with schizophrenia and related
cate the designs of the earlier studies (retrospective self- disorders, we tried to reexamine the validity of the TCO
reports) as closely as possible initially led to significant concept from an exclusively clinical/psychopathological
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results, but these were eliminated after controlling for standpoint, comparing a sample of offenders with schizo-
anger and impulsivity measures. phrenia found to be not guilty by reason of insanity
These contradictory results may be caused not least by (NGRI) with a matched sample of nonoffending schizo-
methodological problems. Table 1 shows that—apart from phrenia patients regarding the frequency of TCO symp-
the differences in the sample compositions—the instru- toms and their possible association with violent behavior.
ments used, the definitions of violence and TCO symptoms,
and the periods and procedures of recording were remark-
ably divergent: the lay-administered Psychiatric Methods
Epidemiology Research Interview (PERI) and the
Diagnostic Interview Schedule (Link and Stueve 1994; According to Austrian law, persons who have committed a
Swanson et al. 1996, 1997; Link et al. 1998), DSM-1II-R severe offense (i.e., under threat of a penalty of more than
diagnoses based on hospital charts and mental health center 1 year of imprisonment) in causal connection with a men-
records (Swanson et al. 1997) or face-to-face interviews by tal disorder and who are found NGRI by the courts are
clinically trained research staff (Appelbaum et al. 2000), exculpated and have to be treated under restriction order
the psychiatrist-administered Schedule for Affective for an indefinite period of time, most of them in the
Disorders and Schizophrenia (SADS) (Link et al. 1998), Justizanstalt Gollersdorf, Austria's central high-security
and expert-administered special instruments such as the institution for male mentally ill offenders (Schanda et al.
MacArthur-Maudsley Delusions Assessment Schedule, the 2000).
Novaco Anger Scale, and the Barratt Impulsiveness Scale Patients of the Justizanstalt Gollersdorf with a clini-
(Appelbaum et al. 2000). The periods of several compo- cal diagnosis of schizophrenia who had been delusional at
nents of recorded violence were past month, past year, and any time during their illness were interviewed by means
past 5 years (Link and Stueve 1994); past year and whole of the SADS: Lifetime Version (SADS-L) (Spitzer and
adult life period (Swanson et al. 1996) and—additionally— Endicott 1977). Those who met DSM-IV criteria for
past 5 years and following 18 months (Swanson et al. schizophrenia (American Psychiatric Association 1994) (n
1997); past 5 years (Link et al. 1998); and—in the only = 119) were included in the study and further checked
prospective study—during several followup intervals (10 with the SADS-L as to substance abuse. Additionally, the
weeks each) (Appelbaum et al. 2000). All but Appelbaum delusional symptomatology was documented by means of
et al. (and partly Swanson et al. 1997) were dealing with a semistructured questionnaire (Fragebogen zur Erfassung
self-reported aggression. psychotischer Symptome [FPS]), developed for transcul-
The periods of recorded TCO symptoms were past tural studies on the psychotic symptomatology of schizo-
month/past year (Link and Stueve 1994), past year and phrenia patients (Stompe and Ortwein-Swoboda, unpub-
adult life period (Swanson et al. 1996), past year (Link et lished manuscript, 1999).
al. 1998), and every 10 weeks (Appelbaum et al. 2000). As the earlier studies on TCO symptoms primarily
From the position of a clinical psychiatrist, the sev- investigated violent behavior in general without reference
eral definitions of the TCO symptoms are of special inter- to legal categories, we decided to use for reason of better
est. In Link and Stueve (1994), thought withdrawal and comparability the classification according to Taylor
movement control were not counted as TCO symptoms— (1985) targeting primarily the severity of the violent acts
unlike in Swanson et al. (1996). In Swanson et al. (1997), (in our case, the index offenses leading to detention in the
two different formulations were applied—the Link and high-security institution).
32Table 1. Sample characteristics, study designs, diagnostic instruments, definitions, and periods of recorded violence and TCO
symptoms In previous studies on TCO symptoms o
Link and Stueve Swanson et al. Swanson et al. Link et al. Appelbaum et al.
(1994) (1996) (1997) (1998) (2000)
Sample 232 patients (various 10,066 community residents TMHS (n= 169) plus ECA Community sample (n •= 2,678) 1,136 discharged hospital in- £
E.
characteristics, diagnoses), 521 community (ECAdata) (n = 129) pooled sample of patients, various diagnoses, 5 P
study design residents persons with psychiatric followup evaluations during 1 yr
disorders (various
diagnoses) o
a
Retrospective Retrospective Retrospective (TMHS Retrospective Prospective E.
partly prospective)
•a
Relevant PERI (lay administered) DIS (lay administered) TMHS: DSM-llt-R PERI (lay administered) DSM-ill-R checklist, o
diagnostic (hospital charts, mental SADS (psychiatrist MacArthur-Maudsley Delusions
instruments health center records) administered) Assessment Schedule, Novaco
PERI Anger Scale, Barratt
I
ECA: DIS Impulsiveness Scale (research s;
interviewers, consultant o_
psychiatrists)
Aggression Self-reported Self-reported Self-reported (TMHS also Self-reported Self-reported, collaterals,
(sources, hospital charts, court arrest records
period of records)
recording) Hitting (past mo, past yr) Hitting, injuring partner or TMHS: any violent acts Physical fight, weapon use Batteries resulting in physical
Fighting (past 5 yrs) child, physical fight weapon toward others (following 18 injury or involving use of a
Weapon use (past 5 yrs) use, physical fight while mos, past 5 yrs) weapon, sexual assaults, threats
drinking ECA: see Swanson et al. made with a weapon in hand
(1996)
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Past yr, adult life period Past 5 yrs During each followup period
(10 wkseach)
TCO 1. Thought/mind control 1. Thought/movement control TMHS: see Link and 1. Thought/mind control 1. Belief of being under external
symptoms 2. Thought insertion 2. Thought Stueve (1994) (period of 2. Thought insertion control (actions, thoughts)
(definition, 3. Feeling that other people insertion/withdrawal recording unknown) 3. Feeling that others wish to 2. Thought insertion
period of wish to do harm 3. Belief that others are ECA: see Swanson et al. do harm 3. Thought withdrawal
recording) plotting, trying to hurt (1996) 4. Persecutory delusions 4. Belief of being hypnotized,
or poison 5. Delusions of control being under magic perform-
4. Belief that others are ance, or being hit by X-rays
following or laser beams
5. Belief that people are spying
6. Belief that people are following
7. Belief of being secretly
tested, experimented on
8. Belief that someone is plot-
ing, trying to hurt, poison
Past mo, past yr (50% Past yr, adult life period Past yr During each followup period
of sample each)
Note.—OIS •» Diagnostic Interview Schedule; ECA = Epidemiologic Catchment Area; PERI = Psychiatric Epidemiology Research Interview; SADS = Schedule for Affective Disorders and
Schizophrenia; TCO >= threat/control-override; TMHS - Triangle Mental Health Survey.Schizophrenia Bulletin, Vol. 30, No. 1, 2004 T. Stompe et al.
Taylor defines "minimal" (la—verbally aggressive, groups, arranged in three major classes (upper, middle,
lb—carrying a weapon which was not used, lc—minimal lower). The scale has often been used in epidemiologic
damage to property when this was accidental) and "mod- and clinical investigations (e.g., Schepank 1990; Stompe
erate" violence (2a—actual bodily harm, 2b—sexual et al. 2000).
offense under force, 2c—using an offensive weapon but The control sample was drawn from the consecutive
without causing injury, 2d—damage to property when this admissions to the Psychiatric University Clinic of Vienna
was the main intent) as "low violence"; "moderately seri- and an affiliated rehabilitation center for chronic schizo-
ous" (3a—grievous bodily harm, 3b>—damage to property phrenia patients. Patients with previous convictions were
when this was extensive and could have threatened life) excluded. The files of all (also former) inpatient treat-
and "serious" violence (4a—victim died, 4b—life actually ments were checked for every clue of violence not offi-
endangered and victim detained in hospital more than 24 cially prosecuted. Moreover, the patients were asked for
hours) as "high violence." former violent behavior, although not as systematically as
As a certain degree of dangerousness is the legal pre- in the investigations cited in table 1. If there was a clear
requisite for the detention of a mentally ill offender (see indication of (usually minor) forms of violence in the
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above), Taylor's categories lb, lc, and 2a did not apply to descriptions of the admission procedures or in the collat-
our sample. So we equated our legal categories severe eral reports documented in the files, the patient was
threat and compulsion with Taylor's item "verbally excluded from the study. Finally, our control sample con-
aggressive" (la), sexual offenses without physical injury sisted of 105 male schizophrenia patients matched within
of the victim with "sexual offense under force" (2b), rob- certain ranges for age, duration of illness, and schizophre-
bery and severe compulsion using a weapon with "using nia subtypes. The diagnostic assessment of the control
an offensive weapon but without causing injury" (2c), and group was identical with that of the offender group.
severe damage to property (including a part of the cases The SADS-L and FPS ratings were carried out by
of arson) with "damage to property when this was the two experienced psychiatrists (T.S. and G.O.-S.) and were
main intent" (2d) and classified them as "low violence." based on face-to-face interviews and the files from previ-
Severe bodily injury was equated with "grievous bodily ous hospitalizations. This allowed the documentation of
harm" (3a), arson under certain (especially dangerous) TCO symptoms present at any time during the illness. The
circumstances with "damage to property when this was period of recruitment for both groups was 1994 to 1998.
extensive and could have threatened life" (3b), and mur- Following the psychopathologically oriented German
der and attempted murder with Taylor's categories serious tradition (Kraepelin 1909-1915; Jaspers 1913; Schneider
violence with (4a) and without (4b) death of the victim, 1939), the FPS is subdivided into three sections (delu-
all classified as "high violence." sions, Schneiderian first rank symptoms, hallucinations).
Without a doubt, objections could be raised to clas- So our definition of TCO symptoms is—in contrast to the
sify sexual offenses under force as equal to, for example, definitions used by Link and Stueve (1994), Link et al.
severe verbal aggressiveness or actual bodily harm. But (1998), and Swanson et al. (1996, 1997)—reduced to
the ranking of Taylor is committed not to legal or moral clear persecutory delusions and to the typical (schizo-
standards as criteria for severity but only to the amount of phrenic) "passivity phenomena" (Jaspers 1913) addressed
violence. Even so, if a sexual assault included the bodily by Mullen (1997).
injury of the victim, it had to be rated as high violence. As Appendix 1 shows the translation of those FPS items
our sample included only four cases of sexual assault, corresponding with the TCO symptoms. By threat we
none of them with severe bodily injury, we decided to fol- understand the delusional belief of imminent danger
low the Taylor classification (1985). caused by others. In concordance with Swanson et al.
Forty-seven offenders had committed low-severity (1997) we discriminate between the delusional idea of
offenses, and 68 high-severity offenses; in four cases a being vitally threatened by physical aggression or poison-
definite classification was not possible because of the ing and the delusion of being followed by one or more
incompatibility with our legal definitions. persons. By control-override we understand the loss of
The social levels of origin were documented by control over one's own thoughts, feelings, movements,
means of the Soziale Selbsteinstufung, a scale measuring and actions in connection with the belief that an external
the prestige of the patients' fathers' professions (Kleining power has taken control over these functions. We fol-
and Moore 1968). This scale is based on a survey in a rep- lowed Kurt Schneider's definition insofar as the psychotic
resentative sample of 48,312 persons in Germany who influence on volition has to be experienced directly by the
were asked to choose one of 36 options to identify their patient Under "made volition," Schneider (1939) summa-
professions and their fathers' professions. The ratings rized the first rank symptoms of made motion, made
were validated by sociologists and placed in nine sub- action, made thoughts, and made emotions. He described
34Schizophrenia, Delusional Symptoms, and Violence Schizophrenia Bulletin, Vol. 30, No. 1, 2004
thought insertion and thought withdrawal as belonging to stance-related disorders, and models 3 and 4 TCO symp-
the experiences of being influenced. We ascertained them toms, controlling for the prior variables, thus leading from
separately and then united both under the term "thought the general to the particular. The results are presented as
shifting." So, control-override consists of the two symp- odds ratios. All data analyses were carried out with the
tom clusters "made volition" and "thought shifting." To SPSS version 6.1 for Windows (Buhl and Zofel 1995).
scrutinize the interrater reliability for the TCO symptoms,
the interviews of 48 patients were rated independently by
the two psychiatrists (T.S. and G.O.-S.). In these cases
Results
Cohen's kappa for the single items was 0.75 to 0.98 with Table 2 shows the sociodemographic and basic clinical
the exception of made emotions. For the diagnosis of data of both offender and nonoffender groups. There are
schizophrenia according to the SADS-L, Cohen's kappa no significant differences regarding age, age at onset,
was 0.96. duration of illness, and schizophrenia subtypes (DSM-IV).
In a first step we assessed the possible association of However, the overrepresentation of schizophrenia patients
substance abuse, social origin, and TCO symptoms with with substance-related disorders (with the exception of
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violence by means of univariate statistics (2-tailed chi- nonalcohol substance abuse, dependence) is highly signif-
square test). Subsequently, stepwise forward logistic icant in the offender group, which also originates more
regression was used to examine the risk of violence with often from lower social levels.
and without TCO symptoms and the generally accepted Table 3 displays the prevalence of TCO symptoms in
criminogenic variables social level of origin and sub- the two groups. One can see that TCO symptoms could be
stance-related disorders. Model 1 is based on the single registered very frequently in a 7-year course. Threat (feel-
independent variable social origin, model 2 adds sub- ing of being poisoned, hurt, or followed) was rated far
Table 2. Age, age at onset, duration of Illness, schizophrenia subtypes, substance-related disorders
(DSM-tV), and social class of origin In offending and nonoffending male schizophrenia patients
Offenders Nonoffenders
(n = 119) (n=105) Significance
Mean ± SD Mean ± SD
Age 29.9 ± 9.2 29.318.7 ns1
Age at onset 22.5 ± 6.5 22.2 1 6.2 ns1
Duration of illness 7.416.8 7.2 1 6.2 ns1
n(%) n(%) Chi-square
Schizophrenia subtypes
Disorganized 6 (5.0) 6 (5.7) 0.05
Catatonic 11 (9.2) 8 (7.6) 0.19
Paranoid 88 (73.9) 82(78.1) 0.52
Residual 11 (9.2) 7 (6.7) 0.50
Undifferentiated 3 (2.5) 2(1.9) 0.09
Additional substance-related disorders 64 (53.8) 29 (27.6) 15.72"*
Alcohol abuse, dependence 21 (17.6) 8 (7.6) 4.98*
Nonalcohol abuse, dependence 21 (17.6) 20(19.0) 0.07
Polysubstance-related disorder 22(18.5) 1 (1.0) 18.62***
Social class of origin2
Upper 3 (2.5) 13(12.4) 8.18"
Middle 56(47.1) 54(51.4) 0.43
Lower 60 (50.4) 38 (36.2) 4.59*
Note.—ns " nonsignificant; SD =• standard deviation.
1
ftest.
2
Prestige of the profession of patients1 fathers according to Kieining and Moore (1968).
* p < 0.05; " p < 0.01; *** p < 0.001
35Schizophrenia Bulletin, Vol. 30, No. 1, 2004 T. Stompe et al.
more often than was control-override. Within the control- A completely different situation emerges when high-
override cluster, those symptoms summarized under and low-violence offenders are compared. Table 5 shows
thought shifting occurred more often than experiences of that the general criminogenic factors (substance-related
external influence on volition. Neither on the level of sin- disorders and social class of origin) have no impact on the
gle symptoms nor on that of symptom clusters could we discrimination between high and low violence. But, in
find any differences between offenders and nonoffenders. contrast, residual and disorganized schizophrenia sub-
These results were confirmed by a multivariate proce- types are overrepresented in low, paranoid subtype in
dure (table 4): A stepwise forward logistic regression high-violence offenders, although the statistical signifi-
model based on only the social class of origin (model 1) cances are not as pronounced as in the differences regard-
led to a statistically significant result. Adding substance- ing substance abuse in the comparison of offenders and
related disorders (model 2) improved the statistical signif- nonoffenders (table 2).
icance, while the inclusion of TCO symptoms (model 3) Also, regarding TCO symptoms there were differ-
was not able to ameliorate the statistical significance of ences between the two offender groups (table 6). Again,
the model chi-square. threat was the symptom cluster registered most frequently.
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Table 3. Prevalence of TCO symptoms during entire course of illness in offending and nonoffending
male schizophrenia patients
Offenders Nonoffenders
(n = 119) (n = 105)
n(%) n(%) Chl-square
Threat 100(84.0) 81 (77.1) 1.71
Being poisoned, hurt 59 (49.6) 48 (45.7) 0.33
Being followed 70 (58.8) 62 (59.0) 0.00
Control override 50 (42.0) 51 (48.6) 0.97
Made volition 28 (23.5) 27 (25.7) 0.14
Made motions 17(14.3) 17(16.2) 0.16
Made actions 19(16.0) 15(14.3) 0.12
Made thoughts 7 (5.9) 9 (8.6) 0.61
Made emotions 9 (7.6) 4 (3.8) 1.44
Thought shifting 42 (35.3) 40(38.1) 0.20
Thought insertion 40 (33.6) 37 (35.2) 0.07
Thought withdrawal 9 (7.6) 14(13.3) 0.16
Threat and/or control-override symptoms 105(88.2) 95 (90.5) 0.29
Table 4. Stepwise forward logistic regression models for risk of violence In male schizophrenia
patients
Model 1 Model 2 Model 3
Social origin + Substance-related + TCO symptoms
disorders
Risk factors OR (95% Cl) OR (95% Cl) OR (95% Cl)
Offenders (n= 119) vs. Social origin 1.93" (1.24-3.02) 1.83*(1.15-2.89) 1.83* (1.15-2.89)
nonoffenders (n = 105) Substance-related 2.94"* (1.65-5.25) 2.94*** (1.65-5.25)
disorders
TCO Symptoms
Model chi-square 8.74" 22.66"" 22.66****
Note.—Cl - confidence interval; OR •= odds ratio; TCO = threat/control-override. Parameter significance tests based on WakJ chi-square
testwfthc#= 1.
* p < 0.05; " p < 0.01; *** p < 0.001; *"* p < 0.0001
36Schizophrenia, Delusional Symptoms, and Violence Schizophrenia Bulletin, Vol. 30, No. 1,2004
Table 5. Age, age at onset, duration of Illness, schizophrenia subtypes, substance-related disorders
(DSM-iV), and social class of origin In high- and low-violence male schizophrenia offenders1
High violence Low violence
(n = 68) (n = 47) Significance
II
Mean ± SD Mean ± SD
Age 30.2 ±8.1 29.4 ± 7.8 m?
Age at onset 23.1 ±6.3 21.7 ±6.8 m?
Duration of illness 7.1 ±7.1 7.3 ± 7.0 ns>
n(%) n(%) Chl-square
Schizophrenia subtypes
Disorganized 1 (1.5) 5(10.6) 4.72*
Catatonic 9(13.2) 2 (4.3) 2.59
Paranoid 55 (80.9) 30 (63.8) 4.19*
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Residual 3 (4.4) 8(17.0) 5.11*
Undifferentiated 2 (4.3) 2.94
Additional substance-related disorders 34 (50.0) 27 (57.4) 0.62
Alcohol abuse, dependence 10(14.7) 10(21.3) 0.84
Nonalcohol abuse, dependence 14(20.6) 7 (14.9) 0.60
Polysubstance-related disorder 10(14.7) 10(21.3) 0.84
Social class of origin 3
Upper 1(1.5) 2 (4.3) 0.85
Middle 33 (48.5) 23 (48.9) 0.00
Lower 34 50.0 22 (46.8) 0.11
Note.—ns = nonsignificant.
1
Severity of offense rated according to Taylor (1985), total n = 115, In 4 cases definite classifications not possible because of incompati-
bility wtth legal definitions.
2
nest
3
Prestige of the profession of patients' fathers according to Kieining and Moore (1968).
* p < 0.05
Table 6. Prevalence of TCO symptoms during entire course of illness in high- and low-violence male
schizophrenia offenders1
High violence Low violence
(n = 68),n(%) (n = 47),n(%) Chl-square
Threat 64(94.1) 33 (70.2) 12.03*"
Being poisoned, hurt 39 (57.4) 19(40.4) 3.19
Being followed 42(61.8) 25 (53.2) 0.84
Control override 30(44.1) 19(40.4) 0.16
Made volition 17(25.0) 10(21.3) 0.21
Made motions 9(13.2) 7 (14.9) 0.06
Made actions 11 (16.2) 7 (14.9) 0.04
Made thoughts 4 (5.9) 3 (6.4) 0.01
Made emotions 9(13.2) 4 (8.5) 1.44
Thought shifting 27 (39.7) 14(29.8) 1.19
Thought insertion 26 (38.2) 13(27.7) 1.39
Thought withdrawal 6 (8.8) 3 (6.4) 0.23
Threat and/or control- 66(97.1) 36 (76.6) 11.61"*
override symptoms
Note.—TCO = threat/control-override.
1
Severity of offense rated according to Taylor (1985), total n = 115, in 4 cases definite classification not possible because of incompatibil-
ity wtth legal definitions.
*"p< 0.001
37Schizophrenia Bulletin, Vol. 30, No. 1, 2004 T. Stompe ct al.
But despite the fact that also 70.2 percent of the low-vio- Apart from general criminogenic factors, delusional
lence offenders exhibited threat symptoms during their ill- symptomatology has always been considered a major trig-
ness, the differences between the low- and the high-vio- ger of violent behavior (B5ker and Hafner 1973; Rofrnan
lence groups reached statistical significance (p < 0.001). et al. 1980; Taylor 1985). So the TCO concept introduced
In contrast, control-override symptoms, taken separately by Link and Stueve (1994) appeared to be plausible at
or as a group, showed no association with the severity of first glance in concordance with common clinical knowl-
the offense. edge and was seen as an important step forward in the
In a stepwise forward logistic regression analysis, improvement of risk assessment in mental patients. The
neither social origin (model 1) nor substance-related dis- results of Link and Stueve (1994) were confirmed by a
orders (model 2) were able to separate the high- from the number of studies (Swanson et al. 1996, 1997; Link et al.
low-violence group (table 7). Only the inclusion of TCO 1998), with the exception of the only prospective one
symptoms in the logistic regression (model 3) led to a sta- (Appelbaum et al. 2000) in which Mullen's (1997) princi-
tistically significant result. TCO symptoms were signifi- pal objections regarding the definitions of TCO symptoms
cantly related to high violence. most likely have been taken into account (table 1).
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In another series of stepwise forward logistic regres- Therefore, it seemed necessary to reinvestigate the
sion procedures, the influence of threat and control-over- position of the TCO symptoms (in a strict and narrow
ride symptoms was analyzed separately (table 8). As the psychopathological definition; appendix 1) in schizophre-
models 1 and 2 are identical with those in table 7, only the nia patients who committed a violent act leading to long-
new models 3 (+ control-override symptoms) and 4 (+ term treatment in a forensic institution by comparison
threat symptoms) are presented. One can see that the asso- with a control group of schizophrenia patients without a
ciation between TCO symptoms and high violence in history of aggressive behavior.
table 7 has to be ascribed primarily to the threat compo- The offender and the nonoffender groups did not dif-
nent, while control-override has no statistically significant fer in age, age at onset, duration of illness, and schizo-
effect. phrenia subtypes (table 2). Yet, as was to be expected,
general criminogenic factors such as lower social class of
Discussion origin (see Edwards et al. 1988; Farrington 1990; Wessely
and Taylor 1991; Farrington and West 1993; Heads and
The search for reliable predictor variables for future vio- Taylor 1997; Hiday 1997; Stueve and Link 1997; Swartz
lence of mentally ill subjects is one of the most important et al. 1998; Kennedy et al. 1999) and substance-related
topics of forensic psychiatry, not only because of the spe- disorders (see Eronen et al. 1996a; Monahan 1997;
cial public interest, and the prejudices against and the RasSnen et al. 1998; Scott et al. 1998; Swartz et al. 1998;
stigmatization of psychiatric patients, but also because of Wallace et al. 1998; Citrome and Volavka 1999; George
the consequences on general mental health care (e.g., civil and Krystal 2000; Mullen et al. 2000) could be found
commitment laws) (Miller 1993; Beck 1996; Beck and more frequently in the offender group, confirming the
Wencel 1998; Schanda 1999, 2001). knowledge of an association between low social class of
Table 7. Stepwise forward logistic regression models for risk of high-violence offending In male
schizophrenia offenders
Model 1 Model 2 Model 3
Social origin + Substance-related + TCO symptoms
disorders
Risk factors OR (95% Cl) OR (95% Cl) OR (95% Cl)
High- (n = 68) vs. low- Social origin
violence (n » 47) Substance-related
offenders1 disorders
TCO symptoms 10.08" (2.18-48.00)
Model chi-square 0.33 1.07 11.96*"
Note.—Cl = confidence interval; OR = odds ratio; TCO = threat/corttroJ-override. Parameter significance tests based on WakJ chi-square
testwtthSchizophrenia, Delusional Symptoms, and Violence Schizophrenia Bulletin, Vol. 30, No. 1, 2004
Table 8. Step wise forward logistic regression models for risk of high-violence offending In male
schizophrenia offenders with separate Inclusion of threat and control-override symptoms
Model 3 1
Social origin +
Substance-related
disorders + control-override Model 4 1
symptoms + Threat symptoms
Risk factors OR (95% Cl) OR (95% Cl)
High- (n = 68) vs. low- Social origin
violence (n = 47) Substance-related
offenders2 disorders
Control-override
symptoms
Threat symptoms 6.78" (2.07-22.27)
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Model chi-square 1.37 12.11*"
Atore.—Cl = confidence Interval; OR - odds ratio. Parameter significance tests based on WakJ chi-square test with df= 1.
1
Models 1 and 2 are Identical to those in table 7.
2
Seventy of offense rated according to Taylor (1985), total n - 115, In 4 cases definite classification not possible because of incompatibility
with legal definitions.
** p < 0.01 ;*" p < 0.001
origin and violent/criminal behavior—the latter in concor- Hodgins et al. 1996 vs. Gottlieb et al. 1987; Eronen et al.
dance with sociological theories regarding the suppression 1996a, 1996*, 1996c; see also Wallace et al. 1998), we
of aggressive behavior by education in higher social subdivided our offender sample into those with high- and
classes (Elias 1976; Bourdieu 1988). low-severity offenses according to Taylor (1985). And, in
In table 3, one can see that TCO symptoms could be fact, the paranoid subtype is moderately but significantly
registered in both groups very frequently during a 7-year overrepresented in the high-violence group, confirming
course. Link and Stueve (1994), Link et al. (1998), and the aforementioned general knowledge (Bdker and Hafner
Swanson et al. (1996, 1997) do not offer any information 1973; Eronen et al. 1996c), while the disorganized and the
about the occurrence of TCO symptoms within the several residual subtypes showed an association with low vio-
diagnostic subgroups. This is also the case in Appelbaum et lence (table 5). Sociodemographic factors and substance
al. (2000). But, after combining the original sample descrip- abuse were not able to differentiate between the high- and
tion (Steadman et al. 1998) with the number of TCO symp- the low-violence groups.
toms at the time of index hospitalization (Appelbaum et al. In contrast to the lack of significance regarding the
1999), one can draw the conclusion that in the MacArthur differentiation of offenders and nonoffenders, TCO symp-
sample 84.1 percent of the schizophrenia patients with sus- toms showed a statistically significant association with
pected delusions (or 51.1% of all schizophrenia patients) high violence (table 6). While control-override symptoms
had persecutory delusions in the weeks before index admis- were not able to discriminate between the high-and the
sion; the rates for body/mind control were 75.4 percent and low-violence groups, threat symptoms were registered
45.8 percent, respectively. So, the frequency of TCO symp- significantly more often in the severely violent group.
toms is comparable to that in our sample despite the differ- This was confirmed by multivariate statistics (table
ent periods of registration (mean more than 7 years vs. 10 7). Only the inclusion of TCO symptoms (model 3) was
weeks). However, there were no significant differences in able to ameliorate the model chi-square and to define the
the occurrence of TCO symptoms in the offender and the high-violence group. Nevertheless, it must be kept in
nonoffender groups (88.2% vs. 90.5%). mind that TCO symptoms were present also in 76.6 per-
This is confirmed by a multivariate procedure that cent of the low-violence offenders (table 6), thus indicat-
showed the importance of sociodemographic factors and ing a high false-positive rate.
substance abuse for the discrimination between offenders The remarkably different frequencies of threat and
and nonoffenders (table 4). control-override symptoms and the fact that only threat
As it is known from the literature that the severity of symptoms but not control-override symptoms were signif-
a violent act is positively correlated with the increasing icantly overrepresented in the high-violence offender
influence of illness-related factors (see Lindqvist and group (table 6) suggest that there should be a separate
Allebeck 1990; Swanson et al. 1990; Link et al. 1992; investigation of the influence of threat and control-over-
39Schizophrenia Bulletin, Vol. 30, No. 1, 2004 T. Stompe et al.
ride (table 8)—by all means in concordance with Link et patients), which points to the principal problem of data
al. (1998). But, while Link et al. (1998) found both threat collection. Appelbaum et al. (2000) concluded that the
and control-override to be independently associated with "reliance on subject self-reports of delusional symptoms
violent behavior, our data confirmed such an effect for may result in mislabelling as delusions other phenomena
only the threat component. that can contribute to violence" (p. 566), but it is an inves-
However, the significance of our data is limited tigator's job to make the best possible attribution of a phe-
because of a number of methodological limitations, which nomenon. The "unbiased" registration of a "symptom"
also apply to the studies presented in table 1, with the suggests an increase in reliability but introduces a new
exception of Appelbaum et al. (2000). First, the study bias that leads to a decrease in validity by neglecting the
design is retrospective, which in general means a reduc- central problem: whether the patient and the investigator
tion of validity. But one has to take into account that understand the question the same way (see also the results
prospective studies on violent behavior over longer peri- of Klosterkotter et al. 1994). In the case of lay interviews,
ods of time with repeated patient interviews suffer from the problem may be increased by deficits in the interview-
the unavoidable bias that the investigation of the problem ers' knowledge of subtle psychopathological phenomena
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per se is changing the outcome (Schanda and Taylor such as feelings of external control. So, especially for the
2001). assessment of CO symptoms, it is necessary to assess
Second, the longer the periods of registration of vio- their presence more precisely by asking additional ques-
lence and TCO symptoms, the more questionable the tions (appendix 1).
causal connection between symptoms and violence (see This problem is illustrated by Link et al. (1998). From
Taylor and Hodgins 1994). their data one can calculate that comparable items were
Third, as proven by Steadman et al. (1998), agency registered in the same sample with remarkably different
records represent only part of the total amount of violent frequencies depending on whether the SADS or the PERI
behavior. Like all other studies on TCO symptoms, with was used: SADS "persecutory delusions" 0.4 percent vs.
the exception of Appelbaum et al. (2000) and partly PERI "people wished to do harm very/fairly often" 7.3
Swanson et al. (1997), our study did not include a per- percent (plus "sometimes/almost never" 53.8%); SADS
sonal interview of collaterals. Despite the fact that our "delusions of control" 1.4 percent vs. PERI "mind domi-
control patients were asked about violent behavior in a nated by external forces very/fairly often" 2.2 percent
nonstandardized way and all hospital files were checked (plus "sometimes/almost never" 16.8%), adding to the lat-
for any indication of violence not officially prosecuted, ter the PERI item "thoughts put in head that were not the
we cannot be certain that our "nonviolent" controls have patient's own" 4 percent ("very/fairly often") and 35.3 per-
not been violent in the past. But one has to remember that cent ("sometimes/almost never"). Obviously, the lay-
Europe's crime rates, cases solved, and nonalcohol sub- administered PERI is documenting—in contrast to the psy-
stance abuse are quite different from those of the United chiatrist-administered SADS—the perception of a hostile
States—especially regarding more severe forms of vio- environment in general without the obligatory presence of
lence. The U.S. homicide rate, for instance, is four times severe psychopathology. This confirms the statement of
that of the United Kingdom (Eronen et al. 19966)- The Appelbaum et al. (2000), who were able to replicate earlier
same holds true for the number of cases solved (Eronen et findings "only by including a large number of presump-
al. 1996*, 1997) and the extent of illicit substance abuse tively nondelusional symptoms under the threat/control-
(Eronen et al. 1996c). So the possibility of a major bias override rubric" (p. 571). Taking all this into account, one
seems rather low in our sample. has to doubt whether the meanings of the TCO symptom
Fourth, the role of impulsivity was not sufficiently definitions in the Link and Swanson papers are really com-
considerea1—quite apart from the fact that impulsivity in parable with those in the Appelbaum paper (table 1) or
connection with acute psychotic symptomatology cannot with our own. In any case, it seems necessary to question a
be automatically equalized with personality-based impul- positive as well as a negative answer of a patient, to ask
sivity (Stompe and Ortwein-Swoboda 2000). for examples, and to insist on precise descriptions (appen-
Fifth, the varying influence of the level of social dix 1).
functioning of a patient on symptom-caused violence Regarding the insinuated "exceptional dangerous-
(Swanson et al. 1998) and the role of social networks ness" of schizophrenia patients, we have concluded that
(Estroff et al. 1994) have not been taken into account. control-override symptoms—if seen in concordance
But, apart from all the methodological problems, the with the definitions for schizophrenia disorders and
crucial question for the assessment of the validity of the affective disorders with mood-incongruent features in
TCO symptoms for the prediction of violent behavior DSM-IV (APA 1994, pp. 275, 378, 381)—are not an
seems to be their different meanings (for investigators and outstanding source of violence. Moreover, from the
40Schizophrenia, Delusional Symptoms, and Violence Schizophrenia Bulletin, Vol. 30, No. 1, 2004
position of a clinical psychiatrist, one has to consider tion of violence on psychiatric wards. In: Hodgins, S., ed.
that these symptoms are often rather volatile and brief Violence Among the Mentally III. Dordrecht, The
and can be experienced by the patient also as neutral or Netherlands: Kluwer, 2000. pp. 237-250.
positive (Stompe and Ortwein-Swoboda 2000). In con- Boker, W., and Hafher, H. Gewalttaten Geistesgestdrter.
trast, delusional threat is for a patient an exclusively New York, NY: Springer, 1973.
negative (ominous, dangerous) phenomenon. But threat
Bourdieu, P. Die feinen Unterschiede. Kritik der
is, compared to control-override, relatively unspecific
gesellschaftlichen Urteilskraft. 2nd ed. Frankfurt/Main,
and occurs—not only as "a generally suspicious attitude
Germany: Suhrkamp, 1988.
toward others" (Appelbaum et al. 2000, p. 571) but also
as a clear delusional symptom—in schizophrenia as Brennan, P.; Grekin, E.; and Vanman, E. Major mental
well as in affective, organic, substance-related, and per- disorders and crime in the community. A focus on patient
sonality disorders. populations and cohort investigations. In: Hodgins, S., ed.
Violence Among the Mentally 111. Dordrecht, The
Netherlands: Kluwer, 2000a. pp. 3-18.
Conclusion
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Brennan, P.A.; Mednick, S.A.; and Hodgins, S. Major
Our results confirm the importance of general factors such mental disorders and criminal violence in a Danish birth
as substance abuse and social origin for the violent behav- cohort. Archives of General Psychiatry, 57:494-500,
ior of schizophrenia patients. The TCO symptoms in a
narrow, clinical definition were not associated with vio- BOhl, A. and Zofel, P. SPSSfUr Windows. Version 6.1. 2nd
lence in general, yet they turned out to be an indicator of ed. Bonn, Germany: Addison-Wesley, 1995. pp. 328-335.
the severity of an offense. This effect is primarily due to Citrome, L., and Volavka, J. Schizophrenia: Violence and
the comparatively unspecific threat symptoms, whereas comorbidity. Current Opinion in Psychiatry, 12:47-51,
control-override symptoms—at least in our definition typ- 1999.
ical for schizophrenia—showed no significant association
Cooke, D.J. Major mental disorder and violence in correc-
with severe violence. Future research is needed to investi-
tional settings. Size, specificity, and implications for prac-
gate the complex interactions between psychotic symp-
tice. In: Hodgins, S., ed. Violence Among the Mentally III.
toms, underlying affect, impulsivity, social level of func-
Dordrecht, The Netherlands: Kluwer, 2000. pp. 291-311.
tioning, social networks, and violence.
Edwards, J.G.; Jones, D.; Reid, W.H.; and Chu, Ch.-Ch.
Physical assaults in a psychiatric unit of a general hospital.
References American Journal of Psychiatry, 145:1568-1571, 1988.
American Psychiatric Association. DSM-FV: Diagnostic Elias, N. Ober den Prozess der Zivilisation:
and Statistical Manual of Mental Disorders. 4th ed. Soziogenetische und psychogenetische Unterschiede.
Washington, DC: APA, 1994. Frankfurt/Main, Germany: Suhrkamp, 1976.
Appelbaum, P.S.; Clark Robbins, P.; and Monahan, J. Eronen, M.; Hakola, P.; and Tiihonen, J. Factors associ-
Violence and delusion: Data from the MacArthur ated with homicide recidivism in a 13-year sample of
Violence Risk Assessment Study. American Journal of homicide offenders in Finland. Psychiatric Services,
Psychiatry, 157:566-572, 2000. 47:403-406, 1996a.
Appelbaum, P.S.; Clark Robbins, P.; and Roth, L.H. Eronen, M.; Hakola, P.; and Tiihonen, J. Mental disorders
Dimensional approach to delusions: Comparison across and homicidal behavior in Finland. Archives of General
types and diagnoses. American Journal of Psychiatry, Psychiatry, 53:497-501,1996fc.
156:1938-1943, 1999. Eronen, M.; Tiihonen, J.; and Hakola, P. Schizophrenia
Beck, J.C. Forensic psychiatry in the USA and U.K.: A and homicidal behavior. Schizophrenia Bulletin,
clinician's review. Criminal Behaviour and Mental 22(l):83-89, 1996c.
Health, 6:11-27, 1996. Eronen, M.; Tiihonen, J.; and Hakola, P. Psychiatric disor-
Beck, J.C, and Wencel, H. Violent crime and axis I psy- ders and violent behavior. International Journal of
chopathology. In: Skodol, A., ed. Psychopathology and Psychiatry in Clinical Practice, 1:179-188, 1997.
Violent Crime. Washington, DC: American Psychiatric Estroff, S.E.; Zimmer, C ; Lachicotte, W.S.; and Benoit, J.
Press, 1998. pp. 1-27. The influence of social networks and social support on
Bjorkly, S. High-risk factors for violence. Emerging evi- violence by persons with serious mental illness. Hospital
dence and its relevance to effective treatment and preven- and Community Psychiatry, 45:669-679, 1994.
41Schizophrenia Bulletin, Vol. 30, No. 1, 2004 T. Stompe et al.
Farrington, D. Implications of criminal career research for Lindqvist, P., and Allebeck, P. Schizophrenia and crime. A
the prevention of offending. Journal of Adolescence, longitudinal follow-up of 644 schizophrenics in
13:95-113, 1990. Stockholm. British Journal of Psychiatry, 157:345-350,
Farrington, D., and West, D. Criminal, penal and life his- 1990.
tories of chronic offenders: Risk and protective factors Link, B.; Andrews, H.; and Cullen, F.T. The violent and
and early identification. Criminal Behaviour and Mental illegal behavior of mental patients reconsidered.
Health, 3:492-523, 1993. American Sociological Review, 57:275-292, 1992.
George, T.P., and Krystal, J.H. Comorbidity of psychiatric Link, B., and Stueve, A. Psychotic symptoms and the vio-
and substance abuse disorders. Current Opinion in lent/illegal behavior of mental patients compared to the
Psychiatry, 13:327-331,2000. community. In: Monahan, J., and Steadman, H., eds.
Gottlieb, P.; Gabrielsen, G.; and Kramp, P. Psychotic Violence and Mental Disorder: Development in Risk
homicide in Copenhagen from 1959 to 1983. Acta Assessment. Chicago, IL: University of Chicago Press,
Psychiatrica Scandinavica, 76:285-292, 1987. 1994. pp. 137-158.
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ by guest on May 13, 2015
Heads, T.C., and Taylor, P.J. Childhood experiences of Link, B.G.; Stueve, A.; and Phelan, A. Psychotic symp-
patients with schizophrenia and a history of violence: A toms and violent behaviors: Probing the components of
special hospital sample. Criminal Behaviour and Mental "threat/control-override" symptoms. Social Psychiatry
Health, 7:117-130, 1997. and Psychiatric Epidemiology, 33:S55-S60, 1998.
Hiday, V. Understanding the connection between mental Miller, R.D. The criminalisation of the mentally ill: Does
illness and violence. International Journal of Law and dangerousness take precedence over need for treatment?
Psychiatry, 20:399-417, 1997. Criminal Behaviour and Mental Health, 3:241-250, 1993.
Hodgins, S. Mental disorder, intellectual deficiency, and Modestin, J., and Ammann, R. Mental disorders and crim-
crime. Archives of General Psychiatry, 49:476-483, 1992. inality: Male schizophrenia. Schizophrenia Bulletin,
Hodgins, S.; Mednick, S.A.; Brennan, P.A.; Schulsinger, 22(l):69-82, 1996.
F.; and Engberg, M. Mental disorder and crime: Evidence Monahan, J. Clinical and actuarial predictions of violence.
from a Danish birth cohort. Archives of General In: Faigman, D.; Kaye, D.; Saks, M.; and Sanders, J., eds.
Psychiatry, 53:486-496, 1996. Modern Scientific Evidence: The Law and Science of
Jaspers, K. General Psychopathology. (1913) Translated Expert Testimony. Vol. 1. St. Paul, MN: West Publishing
by Hoenig, J., and Hamilton, M.W. London, U.K.: Johns Company, 1997. pp. 300-318.
Hopkins University Press, 1997. Monahan, J., and Appelbaum, PS. Reducing violence
Kennedy, H.G.; Iverson, R.C.Y.; and Hill, O. Violence, risk: Diagnostically based clues from the MacArthur
homicide and suicide: Strong correlation and wide varia- Violence Risk Assessment Study. In: Hodgins, S., ed.
tion across districts. British Journal of Psychiatry, Violence Among the Mentally III. Dordrecht, The
175:462-466, 1999. Netherlands: Kluwer, 2000. pp. 19-34.
Kleining, G., and Moore, H. Soziale Selbsteinstufung Monahan, J., and Steadman, H. Toward a rejuvenation of
(SSE). Kdlner Zeitschrift filr Soziologie und risk assessment research. In: Monahan, J., and Steadman,
Sozialpsychologie, 20:502-552, 1968. H., eds. Violence and Mental Disorder: Developments in
KlosterkOtter, J.; Albers, M.; Steinmeyer, E.M.; Hensen, Risk Assessment. Chicago, IL: University of Chicago
A.; and Sass, H. Positive oder negative Symptome: Was Press, 1994. pp. 1-17.
ist brauchbarer filr die Diagnose Schizophrenic? Mullen, P.E. A reassessment of the link between mental
Nervenant, 65:444-453, 1994. disorder and violent behaviour, and its implications for
Kraepelin, E. Psychiatrie. Ein Lehrbuch fur Studierende clinical practice. Australian and New Zealand Journal of
und Ante. 8th ed. Leipzig, Germany: Johann Ambrosius Psychiatry, 31:3-11, 1997.
Barth, 1908-1915. Mullen, P.E.; Burgess, P.; Wallace, C ; Palmer, S.; and
Krakowski, M.; Volavka, J.; and Brizer, D. Ruschena, D. Community care and criminal offending in
Psychopathology and violence: A review of the literature. schizophrenia. Lancet, 355:614-617, 2000.
Comprehensive Psychiatry, 27:113-148, 1986. Petursson, H., and Gudjonsson, G.H. Psychiatric aspects
Lindqvist, P. Criminal homicide in northern Sweden of homicide. Acta Psychiatrica Scandinavica,
1970-1981: Alcohol intoxication, alcohol abuse and men- 64:363-372, 1981.
tal disease. International Journal of Law and Psychiatry, RasSnen, P.; Tiihonen, J.; Isohanni, M.; Rantakallio, P.;
8:19-37, 1986. Lehtonen, J.; and Moring, J. Schizophrenia, alcohol
42Schizophrenia, Delusional Symptoms, and Violence Schizophrenia Bulletin, Vol. 30, No. 1, 2004
abuse, and violent behavior: A 26-year followup study of situational perspective. In: Hodgins, S., ed. Violence
an unselected birth cohort. Schizophrenia Bulletin, Among the Mentally III. Dordrecht, The Netherlands:
24(3):437-441, 1998. Kluwer, 2000. pp. 35-48.
Rofman, E.S.; Askinazi, C ; and Fant, E. The prediction of Stompe, T., and Ortwein-Swoboda, G. "Fragebogen zur
dangerous behaviour in emergency civil commitment. Erfassung Psychotischer Symptome (FPS)." Unpublished
American Journal of Psychiatry, 137:1061-1064, 1980. manuscript, 1999.
Schanda, H. The Ashenputtel principle in modern mental Stompe, T, and Ortwein-Swoboda, G. Leonhard's classi-
health care. Criminal Behaviour and Mental Health, fication and affectivity among mentally ill offenders. In:
9:199-204, 1999. Franzek, E.; Ungvari, G.S.; Rtither, E.; and Beckmann,
Schanda, H. Die Versorgung psychisch Kranker zur H., eds. Progress in Differentiated Psychopathology.
Jahrtausendwende—ein Weg in die Zwei-Klassen- Wtirzburg, Germany: International Wernicke-Kleist-
Psychiatrie? Fortschritte der Neurologie, Psychiatrie und Leonhard Society, 2000. pp. 298-306.
ihrer Grenzgebiete, 69:195-202, 2001. Stompe, T.; Ortwein-Swoboda, G.; Strobl, R.; and
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ by guest on May 13, 2015
Schanda, H.; Ortwein-Swoboda, G.; Knecht, G.; and Friedmann, A. The age of onset of schizophrenia and the
Gruber, K. The situation of forensic psychiatry in Austria: theory of anticipation. Psychiatry Research, 93:125-134,
Setback or progress? International Journal of Law and 2000.
Psychiatry, 23:481^*92, 2000. Stueve, A., and Link, B.G. Violence and psychiatric dis-
Schanda, H., and Taylor, P. Aggressives Verhalten psy- orders: Results from an epidemiological study of young
chisch Kranker im stationSren Bereich: Haufigkeit, adults in Israel. Psychiatric Quarterly, 68:327-342,
Risikofaktoren, Prevention. Fortschritte der Neurologie, 1997.
Psychiatrie und ihrer Grenzgebiete, 69:443-452, 2001. Swanson, J.; Borum, R.; Swartz, M.S.; and Monahan, J.
Schepank, H. Methodik und empirische Basis. In: Psychiatric symptoms and disorders and the risk of vio-
Schepank, H., ed. Verldufe. Seelische Gesundheit undpsy- lent behaviour in the community. Criminal Behaviour and
chogene Erkrankungen heute. Berlin, Germany: Springer, Mental Health, 6:309-329, 1996.
1990. pp. 9-29. Swanson, J.; Estroff, S.; Swartz, M.; Borum, R.;
Schneider, K. (1939) Klinische Psychopathologie. 10th Lachicotte, W.; Zimmer, C; and Wagner, R. Violence and
ed. Stuttgart, Germany: Thieme, 1973. severe mental disorder in clinical and community popula-
tions: The effects of psychotic symptoms, comorbidity
Scott, H.; Johnson, S.; Menezes, P.; Thornicroft, G.;
and lack of treatment. Psychiatry, 60:1-22, 1997.
Marshall, J.; Bindman, J.; Bebbington, P; and Kuipers, E.
Substance misuse and risk of aggression and offending Swanson, J.; Holzer, C ; Ganju, V.; and Jono, R. Violence
among the severely mentally ill. British Journal of and psychiatric disorder in the community: Evidence from
Psychiatry, 172:345-350, 1998. the Epidemiologic Catchment Area Surveys. Hospital and
Community Psychiatry, 41:761-770, 1990.
Spitzer, R.L., and Endicott, C. Schedule for Affective
Disorders and Schizophrenia: Lifetime Version (SADS-L). Swanson, J.; Swartz, M.; Estroff, S.; Borum, R.; Wagner,
3rd ed. New York, NY: New York State Psychiatric R.; and Hiday, V. Psychiatric impairment, social contacts
Institute, 1977. and violent behavior. Social Psychiatry and Psychiatric
Epidemiology, 33:586-594, 1998.
Steadman, H.J.; Monahan, J.; Robbins, P C ; Appelbaum,
P.; Grisso, T.; Klassen, D.; Mulvey, E.P.; and Roth, L. Swartz, M.S.; Swanson, J.W.; Hiday, V.A.; Borum, R.;
From dangerousness to risk assessment: Implications for Wagner, H.R.; and Burns, B.J. Violence and severe mental
appropriate research strategies. In: Hodgins, S., ed. illness: The effects of substance abuse and nonadherence
Mental Disorder and Crime. Newbury Park, CA: Sage, to medication. American Journal of Psychiatry,
1993. pp. 39-62. 155:226-231, 1998.
Steadman, H.J.; Mulvey, E.P.; Monahan, J.; Clark Taylor, P.J. Motives for offending among violent and psy-
Robbins, P.; Appelbaum, P.S.; Grisso, T.; Roth, L.; and chotic men. British Journal of Psychiatry, 147:491-498,
Silver, E. Violence by people discharged from acute psy- 1985.
chiatric inpatient facilities and by others in the same Taylor, P.J., and Hodgins, S. Violence and psychosis:
neighborhoods. Archives of General Psychiatry, Critical timings. Criminal Behaviour and Mental Health,
55:393-401, 1998. 4:267-289, 1994.
Steadman, H.J., and Silver, E. Immediate precursors of Tiihonen, J.; Isohanni, M.; RSsanen, P.; Koiranen, M.; and
violence among persons with mental illness: A return to a Moring, J. Specific mental disorders and criminality: A
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