For a lot of psychiatrists, the question of what constitutes mental disorders is often simplified by defining it solely as those disorders which are believed to respond routinely to psychotropic medication (Blumenthal et al, 2001, p. 4). Relationship between Mental Disorder and Violence Prins (1990) adequately established that the relationship between mental disorder and criminality is a vague one, concluding, ‘Most psychiatric disorders are only very occasionally associated with criminality’.
Prins also illustrates the complexity of establishing cause and effect in this uncertain area: ‘We are trying to make connections between very different phenomena, and these phenomena are the subject of much debate concerning both substance and definition’. Most research, until recently, focused on the rates of violence among inpatients with mental illness or, on the other hand, the rates of mental illness among individuals who have been arrested, convicted, or incarcerated for violent crimes (Monahan J. 1992, 511-521).
For instance, one national survey revealed that the lifetime threat of schizophrenia was 5% among people convicted of homicide, signifying a connection between schizophrenia and homicide conviction (Shaw, Hunt, Flynn, et. al. , 2006, 143-147). These results, in my view, are inaccurate since the studies conducted are restricted by selection bias: subjects who are detained, imprisoned, or hospitalized are more likely to be violent or very ill and therefore cannot be an accurate representation of psychiatric patients in the broader population.
A more precise and less biased evaluation of the risk of violence by the mentally ill comes from epidemiologic studies of societal samples. The best known is the NIMH’s ECA Study, or the Epidemiologic Catchment Area (ECA) study, which studied the rates of a variety of psychiatric disorders in a sample of 17,803 subjects in five U. S. communities. Statistics on violence were gathered for about 7000 of the subjects (Swanson, 1994, p. 101 – 136).
Violence was defined as having used a weapon like a knife or gun and having become involved in more than one fight that came to blows. The study revealed that patients with serious mental illness (schizophrenia, major depression, or bipolar disorder) were 2-3 times more likely as people without such disorders to be violent. In absolute terms, the lifetime frequency of violence among individuals with serious mental illness was 16%, as compared with 7% among people without mental disorders.
It was also found that not all types of psychiatric illness are linked to violence; anxiety disorders, for instance, do not seem to augment the risk, and although most individuals with schizophrenia, bipolar disorder or major depression, do not commit acts of violence, the presence of such a disorder is considerably associated with a greater risk of violence.
Serious mental illness is quite uncommon however, so it actually plays a very small factor in the overall rate of violence in the society; the attributable risk has been predicted to be 3 to 5% — much less than that linked with substance abuse. People with no mental disorders, who abuse drugs or alcohol, are nearly 7 times as likely as those without substance abuse to resort to violent behavior. But substance abuse by the mentally ill multiplies the increased risk of violence.
A study involving 802 adults with a major mood disorder revealed that violence was autonomously connected with numerous risk factors, which includes substance abuse, a history of violence, homelessness, and poor medical health (Swanson, Swartz, Essock, et al. , 2002, 1523 – 1531). The 1-year rate of violence for subjects with none or only 1 of these factors was 2%. Thus, violent behavior in individuals with serious mental illness almost certainly is a consequence of several risk factors in many domains.
Research reveals a higher than average number of violent acts committed by some individuals with certain diagnoses, in particular antisocial or psychopathic personality disorders, but conflicting findings about specific symptoms (for instance, links between psychosis and violence in the community) – but the mediating factors of such acts are more consistently found to be mainly socio-demographic and socio-economic factors such as being young, male, of lower socio-economic status, and in particular, substance abuse (including alcohol) (Stuart, 2003, 121-124).
Another study conducted to determine the link between violence and mental disorders used representatives of the US population to clarify whether mental illnesses like schizophrenia, major depression or bipolar disorder led to violent behavior. Analyses revealed that the incidence of violence was higher among people with severe mental illness, but only marginally higher for those with co-occurring substance abuse and/or dependence.
It was further revealed that severe mental illness alone did not predict future violence; it was associated instead with historical (past violence, juvenile detention, physical abuse, parental arrest record), clinical (substance abuse, perceived threats), dispositional (age, sex, income), and contextual (recent divorce, unemployment, victimization) factors. Most of these factors were more prevalent in subjects with severe mental illness (Elbogen & Johnson, 2009, p. 152 – 161).
The belief that mental disorder predisposes people to behave violently is widely held and enduring, resulting in discriminatory practices and attitudes towards those with mental disorders. As Rubin notes: Certain mental disorders are characterized by some kind of confused, bizarre, agitated, threatening, frightened, panicked, paranoid or impulsive behavior. That and the view that impulse (i. e. ideation) and action are interchangeable support the belief that all mental disorder must of necessity lead to inappropriate, anti social or dangerous actions (Rubin, 1972, p. 398).
A fear of erratic acts of violence with mentally ill patients is common among the general population. In a US survey conducted about the perception of mental health patients, a high percentage of Americans rated people displaying characteristics of mental disorders as “likely to do something violent to others” (Pescosolido & Monahan & Link & Stueve & Kikuzawa, 1999, p. 1339 – 1345) . Americans are reported to demonstrate greater concern when exposed to people who have alcohol or drug problems instead of those who have mental health issues.
Conclusion From the various studies conducted in attempting to determine the link between mental disorders and violence, it is concluded that severe mental disorders do not independently predict violence, but these findings challenge perceptions that mental illness is a leading cause of violence in the general population. People with mental illness, however, do report violence more often, mostly because they show other factors associated with violence.
Consequently, determining the link between violence and mental disorder requires consideration of its association with other variables, such as substance abuse, environmental stressors and a history of violence. The challenge for law-enforcement agencies, medical practitioners and the general population is to be aware that although some psychiatric patients could pose a risk of violence, but to also keep in mind that most people who commit acts of violence are not mentally ill, and most people who have mental disorders are not violent.
References
Blumenthal, Stephen & Lavender, Anthony & Lavender, Tony, Trust, Zito. (2005). Violence And Mental Disorder. London: Jessica Kingsley Publishers. Cooper, Rachel. (2005). Classifying Madness: A Philosophical Examination of the Diagnostic and Statistical Manual of Mental Disorders. New York: Springer. De Zulueta, F. (1993). From Pain to Violence. London: Whurr Publishers. Elbogen, EB. & Johnson, SC. (2009). The Intricate Link Between Violence and Mental Disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2009 Feb; 66(2):152-61.