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Association of Violence With Emergence of Persecutory Delusions in Untreated Schizophrenia
Robert Keers, Ph.D.; Simone Ullrich, Ph.D.; Bianca L. DeStavola, Ph.D.; Jeremy W. Coid, M.D.
Am J Psychiatry 2014;171:332-339. doi:10.1176/appi.ajp.2013.13010134
View Author and Article Information

The authors report no financial relationships with commercial interests.

This article presents independent research commissioned by the U.K. National Institute for Health Research under its Program Grants for Applied Research funding scheme (RP-PG-0407-10500).

The views expressed in this article are those of the authors and not necessarily those of the U.K. National Health System, the U.K. National Institute for Health Research, or the U.K. Department of Health.

From the Forensic Psychiatry Research Unit, Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London; and the Centre for Statistical Methodology, London School of Hygiene and Tropical Medicine.

Address correspondence to Dr. Keers (r.keers@qmul.ac.uk).

Copyright © 2014 by the American Psychiatric Association

Received January 30, 2013; Revised July 01, 2013; Accepted September 09, 2013.

Abstract

Objective  Psychosis is considered an important risk factor for violence, but studies show inconsistent results. The mechanism through which psychotic disorders influence violence also remains uncertain. The authors investigated whether psychosis increased the risk of violent behavior among released prisoners and whether treatment reduced this risk. They also explored whether active symptoms of psychosis at the time of violent behavior explained associations between untreated psychosis and violence.

Method  The U.K. Prisoner Cohort Study is a prospective longitudinal study of prisoners followed up in the community after release. Adult male and female offenders serving sentences of 2 or more years for a sexual or violent offense were classified into four groups: no psychosis (N=742), schizophrenia (N=94), delusional disorder (N=29), and drug-induced psychosis (N=102). Symptoms of psychosis, including hallucinations, thought insertion, strange experiences, and delusions of persecution, were measured before and after release. Information on violence between release and follow-up was collected through self-report and police records.

Results  Schizophrenia was associated with violence but only in the absence of treatment (odds ratio=3.76, 95% CI=1.39–10.19). Untreated schizophrenia was associated with the emergence of persecutory delusions at follow-up (odds ratio=3.52, 95% CI=1.18–10.52), which were associated with violence (odds ratio=3.68, 95% CI=2.44–5.55). The mediating effects of persecutory delusions were confirmed in mediation analyses (β=0.02, 95% CI=0.01–0.04).

Conclusions  The results indicate that the emergence of persecutory delusions in untreated schizophrenia explains violent behavior. Maintaining psychiatric treatment after release can substantially reduce violent recidivism among prisoners with schizophrenia. Better screening and treatment of prisoners is therefore essential to prevent violence.

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TABLE 1.Comparison of the Occurrence of Violent Re-Offenses Among Prisoners With No Psychosis and Those With Lifetime Schizophrenia, Delusional Disorder, or Drug-Induced Psychosis
Table Footer Note

a Estimates were obtained by fitting logistic regression models with adjustment for gender, age (years), major depression, drug dependence, alcohol dependence, psychopathy, and time at risk (which accounted for prison sentences occurring between release and violent re-offense).

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TABLE 2.Violent Re-Offending Among Prisoners With a Lifetime Diagnosis of Psychotic Disorders Receiving No Treatment, Treatment During Prison, or Continued Treatment Compared With Those With No Psychosis
Table Footer Note

a Estimates were obtained by fitting logistic regression models with adjustment for gender, age (years), major depression, drug dependence, alcohol dependence, psychopathy, and time at risk (which accounted for prison sentences occurring between release and violent re-offense).

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TABLE 3.Effects of the Emergence of Symptoms of Psychosis on Violence During the Follow-Up Period
Table Footer Note

a Estimates were obtained by fitting logistic regression models with adjustment for gender, age (years), major depression, drug dependence, alcohol dependence, psychopathy, and time at risk (which accounted for prison sentences occurring between release and violent re-offense).

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