Schizophrenia, Delusional Symptoms, and Violence: The Threat/Control-Override Concept Reexamined

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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                                                                  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:

Schizophrenia 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).

Table 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-                                                                                               £
 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
                    Retrospective                 Retrospective                  Retrospective (TMHS           Retrospective                                                                                  Prospective                                      E.
                                                                                  partly prospective)
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
                                                                                  ECA: DIS                                                                                                                     Impulsiveness Scale (research                   s;
                                                                                                                                                                                                               interviewers, consultant                        o_
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
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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

Schizophrenia, 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
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.
   Prestige of the profession of patients1 fathers according to Kieining and Moore (1968).
* p < 0.05; " p < 0.01; *** p < 0.001

Schizophrenia 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
                                                            Model 1                  Model 2                    Model 3
                                                          Social origin         + Substance-related         + TCO symptoms
                                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)
                               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

Schizophrenia, 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
                                                        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.
  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.
  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.
   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

Schizophrenia 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
                                  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
Schizophrenia, 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 +
                                                                               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
                                                     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.
  Models 1 and 2 are Identical to those in table 7.
  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-

Schizophrenia 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

Schizophrenia, 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.

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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.
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