Members of the public tend to associate more than in the past mental illness and violence. Such beliefs are fuelled by media reports which emphazise a link between violence and mental illness. The essay aims at examining the evidence, if any, of such correlation, by focusing on one mental illness, schizophrenia and a personality disorder, psychopathy. It addresses methodological issues, such as the control of confounding variables, definitions and diagnoses and the need to consider a variety of approaches when trying to disentangle issues of risks and causality. Finally, the relevance of an association between mental illness and crime is addressed.
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People with mental illness tend to be portrayed by the media as violent, unpredictable and dangerous (BiliÄ‡ and Georgaca, 2007) and the public fear violence which is random, senseless and unpredictable, which they associate with mental illness (Stuart, 2003). The perception by the general public of the link between mental illness and violence has fed the stigma of mental illness, reinforcing discrimination and victimization among the mentally ill. Experiments have shown a direct link between exposure to negative television portrayals and the development of negative attitudes towards mental health issues, affecting viewers’ beliefs about their level of safety (Diefenbach and West, 2007). The fear of crime may also be exacerbated by the deinstitutionalisation of the mentally ill who are cared instead by health services within the community (Wallace, Mullen and Burgess, 2004).
Prior to 1980, research studies tended not to show any relationship between mental illness and violent crime. Since then, as definition of psychiatric disorders changed to incorporate more violence as a diagnosis characteristic (Turner, Brace, Motzkau, Briggs and Pike, 2009), research findings highlighted more often such relationship.
Taylor (2004) argues that while a statistical relationship between violence and mental disorders is not contested, it has to be interpreted with caution. For instance, there is substantial heterogeneity between studies that have reported an increased risk of violence in individuals with schizophrenia, and uncertainty over the causes of this heterogeneity. Fazel, Gulati, Linsell, Geddes and Grann (2009) reviewed studies that have compared risks of interpersonal violence in individuals with schizophrenia with the general population samples. They concluded that schizophrenia and other psychoses are associated with violence, particularly homicide. However, most of the excess risks seem to be mediated by substance abuse comorbidity, which has dramatically escalated. Deinstitutionalisation has been linked to a supposed increase in violence in this population, which in turn has been related to the inadequate care and support in the community (Wallace and al., 2004). By analysing the pattern of convictions in persons with schizophrenia over a 25-year period, marked by deinstitutionalisation and increased rates of substance abuse problems among that population, and comparing criminal records of patients who had been admitted for schizophrenia in the Australian state of Victoria at various periods, with matching community subjects, Wallace and al. (2004) concluded that “a clear association emerged between having schizophrenia and higher rates of conviction for a wide range of criminal offenses, including violent offenses”. Higher rates of criminal conviction were found for patients with substance abuse problems than those without those problems. However, the mediating factor of substances abuse as single marker of an increased risk of offending for people with schizophrenia has been challenged in the study from Wallace and al. (2004) where it was found that while the rate of substance abuse among patients with schizophrenia escalated over a 25 years period, the rate of criminal convictions increased at much the same rate as in the general population. Moreover, it was argued that schizophrenia has an association with higher rates of criminal offending that is independent of substance abuse in that patients may have a predisposition to offending and prone to abuse substances.
Uncertainties regarding the link between schizophrenia and violent crime remain, as there are wide variations in risk estimates across studies, ranging from 7-fold increases in violent offenses in schizophrenia compared with general population controls, to no association. (Fazel, Långström, Hjern, Grann, Lichtenstein, 2009). Different models postulate contrasting associations between mental illness and violence. A symptom approach to schizophrenia focuses on psychopatholic symptoms such as delusions and hallucinations which cause violent behaviour. A risk factor approach for violence concentrates on the comorbid substance use, of which the association with schizophrenia is attenuated by adjustment for substance abuse, suggesting a mediating effect. An alternative model is that schizophrenia and violent behaviour co-occur because of familial factors that are related to both (i.e. poor anger management). The results from the study from Fazel and al. (2009) showed that the risk of violent crime was mostly confined to patients with substance abuse comorbidity whereas the risk increase was small in schizophrenia patients without substance abuse comorbidity. Besides, the risk increase among those with substance abuse comorbidity was significantly less pronounced when unaffected siblings were used as controls, suggesting a familial confounding factor in the association between schizophrenia and violence. Similarly, Silver and Teasdale (2005) argued that when stressful life events and impaired social support are controlled, the association between mental disorder and violence is substantially reduced.
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There are strong limitations in research findings to ascertain a cause-effect relationship between mental illness and violence. A major problem is the ‘circularity’ effect whereby it is impossible to distinguish the direction of the association. For instance, genetic susceptibility to substance abuse may lead to schizophrenia, which in turn increases the likelihood of violent behaviour. One of the difficulties for researchers is to identify variables which are confounding and difficult to control, for instance those of a situational nature, such as socio-economic and environmental factors. Other major limitations relate to the methodological approaches used to establish a link between mental illnesses and violence. For instance, Walsh, Buchanan and Fahy (2002) argued that cross-sectional studies taking violence as main selection criteria for admission, committed before and during hospitalisation are of limited usefulness because they would overestimate any association. For example, discharged patients are considered less at risk of threat than those retained in hospitals. They added that while the rates of violence were found to be lower in those with schizophrenia than in those with other diagnoses, it should not be concluded that the illness is a protective factor against violence and that while schizophrenia is less of a violence risk than substance misuse, there is still an increased risk of violent behaviour in persons with mental illness in comparison with the general population.
The relationship between a personality disorder such as psychopathy, and criminal behaviour, is even more arguable than for mental illnesses, as the issue of circularity applies to the definition of psychopathy: when psychopathy is defined on the basis of particular behaviours, those are in turn explained as being a result of the disorder. Hence, psychopathy incorporate the constructs of ‘criminal offending’ or ‘antisocial behaviour’, which, as a result, has ‘obscured its relationship to the broader class of personality disorders” (Blackburn in Turner and al., 2009). As such, if labelled under ‘antisocial personality’, the assumption then is that psychopathy is linked to criminality, rather than an ‘abnormal personality’. This was reinforced by the merging of abnormal personality traits with criminal criteria in the revised Hare Psychopathy Checklist (PCL-R). Blackburn (2009) argued that the reference to the ‘criminal psychopath’ came from the psychopathy being defined in terms of social deviance, which “confounds the dependent with the independent variable and precludes any understanding of the relationship”. In Cleckley’s original criteria of psychopathy (Turner et al., 2009), psychopathy was not associated with criminality but related instead to the distress caused to others rather than on social rule-breaking as a core feature.