Schizophrenia disorders, substance abuse and prior offending in a sequential series of 435 homicides.

OBJECTIVE: To examine the relationship between committing homicide, the presence of schizophrenia, substance misuse and past criminality. METHOD: The study employed a data linkage design, using contacts recorded on two statewide databases, one of which recorded public mental health services contacts and the second of which recorded contacts with the police. The estimated rates of schizophrenia disorders, substance abuse and criminal convictions found among a population of 435 homicide offenders were contrasted with estimated rates in two composite comparison samples. RESULTS: Of the 435 offenders, 38 (8.7%) had been diagnosed with a schizophrenia disorder, which was RR 13.11 (95% CI 9.14-18.80) times more likely than a comparison sample. Rates of known substance abuse between homicide offenders with and without schizophrenia and community-dwelling residents with schizophrenia did not differ significantly. However, these rates were higher than those found in the general community. A similar pattern emerged for comparisons regarding offending histories between these same groups. CONCLUSION: The association between homicidal violence and having a schizophrenia disorder cannot be explained away simply on the basis of either comorbid substance abuse or prior criminal offending.

Stalkers and harassers of royalty: the role of mental illness and motivation.

BACKGROUND: Public figures are at increased risk of attracting unwanted attention in the form of intrusions, stalking and, occasionally, attack. Whereas the potential threat to the British Royal Family from terrorists and organized groups is clearly defined, there is a dearth of knowledge about that from individual harassers and stalkers. This paper reports findings from the first systematic study of this group. METHOD: A retrospective study was conducted of a randomly selected stratified sample (n=275) of 8001 files compiled by the Metropolitan Police Service's Royalty Protection Unit over 15 years on inappropriate communications or approaches to members of the British Royal Family. Cases were split into behavioural types. Evidence of major mental illness was recorded from the files. Cases were classified according to a motivational typology. An analysis was undertaken of associations between motivation, type of behaviour and mental illness. RESULTS: Of the study sample, 83.6% were suffering from serious mental illness. Different forms of behaviour were associated with different patterns of symptomatology. Cases could be separated into eight motivational groups, which also showed significant differences in mental state. Marked differences in the intrusiveness of behaviour were found between motivational groups. CONCLUSIONS: The high prevalence of mental illness indicates the relevance of psychiatric intervention. This would serve the health interests of psychotic individuals and alleviate protection concerns without the necessity of attempting large numbers of individual risk predictions. The finding that some motivations are more likely to drive intrusive behaviours than others may help focus both health and protection interventions.

Violence in stalking situations.

BACKGROUND: Stalking is often viewed as a precursor to violence, but determining which stalkers might attack is a difficult task. This study overcomes shortfalls in previous investigations by adopting a pseudo-prospective design and examining potential risk factors for different types of stalker. METHOD: Demographic, behavioural and diagnostic information was collected from stalkers referred to a community forensic mental health service (n=211). Potential risk factors for stalking violence were identified using odds ratios and chi2 tests, and entered into logistic regression models. Model utility was assessed using receiver operating characteristic curves. RESULTS: Amongst Rejected ex-intimate stalkers, violence was best predicted by previous violence, making threats and being employed (area under the curve=0.75), while for stalkers with other motives and relationships to the victim, being aged less than 30 years, substance use at the time of stalking and prior violence best predicted stalking violence (area under the curve=0.80). CONCLUSIONS: Stalkers at increased risk of violence can be accurately identified by examining motivational and relationship type in conjunction with specific relevant risk factors. Previous violence is a particularly important risk factor, as are threats amongst ex-intimate stalkers. Approach behaviours and psychosis were shown to be less useful in predicting violence.

Threats to kill: a follow-up study.

BACKGROUND: Mental health clinicians are frequently asked to assess the risks presented by patients making threats to kill, but there are almost no data to guide such an evaluation. METHOD: This data linkage study examined serious violence following making threats to kill and the potential role of mental disorder. A total of 613 individuals convicted of threats to kill had their prior contact with public mental health services established at the time of the index offence. The group's subsequent criminal convictions were established 10 years later using the police database. Death from suicidal or homicidal violence was also established. RESULTS: Within 10 years, 44% of threateners were convicted of further violent offending, including 19 (3%) homicides. Those with histories of psychiatric contact (40%) had a higher rate (58%) of subsequent violence. The highest risks were in substance misusers, mentally disordered, young, and those without prior criminal convictions. Homicidal violence was most frequent among threateners with a schizophrenic illness. Sixteen threateners (2.6%) killed themselves, and three were murdered. CONCLUSIONS: In contrast to the claims in the literature that threats are not predictive of subsequent violence, this study revealed high rates of assault and even homicide following threats to kill. The mentally disordered were over-represented among threat offenders and among those at high risk of subsequent violence. The mentally disordered threateners at highest risk of violence were young, substance abusing, but not necessarily with prior convictions. Those who threaten others were also found to be at greater risk of killing themselves or being killed.

The role of mental disorder in attacks on European politicians 1990-2004.

OBJECTIVE: The only systematic studies of attacks on public figures come from the USA. These studies de-emphasize the role of mental illness and suggest threats are of no predictive value. This study re-examines these questions through a study of attacks on European politicians. METHOD: All non-terrorist attacks on elected politicians in Western Europe between 1990 and 2004 were analysed. RESULTS: Twenty-four attacks were identified, including five involving fatalities, and eight serious injuries. Ten attackers were psychotic, four drunk, nine politically motivated and one unclassifiable. Eleven attackers evidenced warning behaviours. The mentally disordered, most of whom gave warnings, were responsible for most of the fatal and seriously injurious attacks. CONCLUSION: A greater awareness of the link between delusional fixations on public figures and subsequent attacks could aid prevention. Equally importantly, recognition would encourage earlier intervention in people who, irrespective of whether they eventually attack, have delusional preoccupations which ruin their lives.

Choking deaths: the role of antipsychotic medication.

BACKGROUND: An increased risk of choking associated with antipsychotic medication has been repeatedly postulated. AIMS: To examine this association in a large number of cases of choking deaths. METHOD: Cases of individuals who had died because of choking were linked with a case register recording contacts with public mental health services. The actual and expected rates of psychiatric disorder and the presence of psychotropic medication in post-mortem blood samples were compared. RESULTS: The 70 people who had choked to death were over 20 times more likely to have been treated previously for schizophrenia. They were also more likely to have had a prior organic psychiatric syndrome. The risk for those receiving thioridazine or lithium was, respectively, 92 times and 30 times greater than expected. Other antipsychotic and psychotropic drugs were not over-represented. CONCLUSIONS: The increased risk of death in people with schizophrenia may be a combination of inherent predispositions and the use of specific antipsychotic drugs. The increased risk of choking in those with organic psychiatric syndromes is consistent with the consequences of compromised neurological competence.

A study of women who stalk.

OBJECTIVE: The authors examined whether female stalkers differ from their male counterparts in psychopathology, motivation, behavior, and propensity for violence. METHOD: Female (N=40) and male (N=150) stalkers referred to a forensic mental health clinic were compared. RESULTS: In this cohort, female stalkers were outnumbered by male stalkers by approximately four to one. The demographic characteristics of the groups did not differ, although more male stalkers reported a history of criminal offenses. Higher rates of substance abuse were also noted among the male stalkers, but the psychiatric status of the groups did not otherwise differ. The duration of stalking and the frequency of associated violence were equivalent between groups. The nature of the prior relationship with the victim differed, with female stalkers more likely to target professional contacts and less likely to harass strangers. Female stalkers were also more likely than male stalkers to pursue victims of the same gender. The majority of female stalkers were motivated by the desire to establish intimacy with their victim, whereas men showed a broader range of motivations. CONCLUSIONS: Female and male stalkers vary according to the motivation for their pursuit and their choice of victim. A female stalker typically seeks to attain a close intimacy with her victim, who usually is someone previously known and frequently is a person cast in the professional role of helper. While the contexts for stalking may differ by gender, the intrusiveness of the behaviors and potential for harm does not.

Child sexual abuse and later disordered eating: a New Zealand epidemiological study.

OBJECTIVE: This community-based study examined how some women who have experienced childhood sexual abuse (CSA) develop an eating disorder (ED), whereas others develop depression and anxiety, and others show no adverse psychological sequelae. METHODS: A two-stage random community sampling strategy was used to select two groups of women: (1) women with CSA prior to age 16 years and (2) a comparison group of women reporting no abuse. Both groups completed the Parental Bonding Instrument (PBI), the Present State Examination, and additional ICD-10 eating disorders questions. Information on the nature and frequency of the CSA was obtained at interview. CSA women with ED (CSA+ED) were compared with CSA women without ED (CSA-noED) and with CSA women with anxiety and/or depression (psychiatric comparison group). RESULTS: Higher rates of EDs in women who have experienced CSA were confirmed in this study. Belonging to a younger age cohort, experiencing menarche at an early age, and high paternal overcontrol on the PBI independently increased the risk of developing an ED in women who had experienced CSA. Low maternal care was specifically associated with the development of anorexia nervosa, whereas early age of menarche differentiated women with bulimia nervosa. Younger age and early age of menarche also differentiated the CSA+ED women from the psychiatric comparison group. DISCUSSION: Early maturation and paternal overcontrol emerged as risk factors for ED development in women with CSA. Although these variables are also risk factors in the general population, women with CSA may be vulnerable to ED development because these risk factors are particular domains of concern that emanate from experiences of CSA.

Stalking: new constructions of human behaviour.

OBJECTIVE: In the last decade stalking has emerged as a significant social problem, which now constitutes a specific form of criminal offence in most English-speaking nations. This paper examines why stalking has become a major social problem and why it should be of particular concern to mental health professionals. METHOD: Using the extant literature, the history of the emergence of stalking as social, legal and behavioural science discourses is presented. An attempt is made to understand the social and cultural forces which shaped our current understanding of the phenomenon of stalking. RESULTS: Stalking flourishes in a variety of contexts; the social conditions conducive to such behaviour include greater instability in intimate relationships, a culture of blame and entitlement and a growing social anxiety that emphasizes vulnerability to crime and suspicion regarding the intentions of strangers. Stalking is now an established category whose utility is in directing social, legal and health energies to support victims and relieve stalkers of their burden of pursuit. CONCLUSIONS: Stalking is a curious construction born of a range of tensions in contemporary culture but has proved to be a useful label and a useful concept. In part due to the emergence of the concept of stalking, laws are now available to protect, and services increasingly geared to support, the victims of persistent harassment.

Same-gender stalking.

Although stalkers most commonly target victims of the opposite gender, the results of larger and less selective studies suggest that same-gender stalking occurs with greater frequency than formerly thought. This study reviews the exiguous literature on same-gender stalking and presents the findings from a clinical study of 29 same-gender stalking cases that were referred to a forensic psychiatry center. The demographic characteristics, behavior, motivations, and psychopathology of same-gender stalkers are compared with a sample of 134 opposite-gender stalkers. The two groups were similar in many respects, with some discrepancies evident in the prior relationship between victim and stalker, harassment methods, and stalking motives. The impact of same-gender stalking on its victims is examined, and the implications of these findings are discussed.

Reactive psychoses revisited.

OBJECTIVE AND METHOD: This paper describes the overlap between reactive (psychogenic) psychosis and other brief psychotic episodes, and explores the gradual disappearance of reactive psychoses as a distinct nosological entity from international classifications. Clinical and conceptual issues concerning reactive psychosis are examined on the basis of a critical review of major classical and modern papers. A brief illustrative case history is also provided. RESULTS: Reactive psychoses are conceptualised as severe disturbances of mental state, on occasion chameleon-like in their shifting form and content, arising in response to a stressful event or life situation. Reactive psychoses have an abrupt onset and usually run their course to complete resolution in a matter of days or weeks. Precipitants include overwhelming fear, threat of imminent destruction, social isolation (as can occur with imprisonment, immigration or deafness), bereavement and intense sexual or interpersonal conflicts. The emergence of a reactive psychosis usually occurs against the background of a predisposing vulnerability in terms of personality disorder, organic impairment, or a history of sensitising experiences, occasionally operating in combination. CONCLUSIONS: The increasing failure to recognise reactive psychoses diminishes clinical psychiatry because it removes an important opportunity for understanding mental disorder in terms of an integration, and totalisation, of developmental history, psychological makeup, social context and current realities, and in so doing lessens our awareness of the links between psychosis and our common humanity.

Mass homicide: the civil massacre.

Seven cases of mass homicide in Australia, New Zealand, and Britain between 1987 and 1996 are presented. These cases add to the world literature on these rare crimes and balance previous, mostly North American reports. These acts were committed by socially unsuccessful, self-absorbed, and resentful individuals. Lengthy fantasy comprising identification, modeling, and rehearsal preceded the incidents, even where the final acts had impulsive elements. Most had a long-standing fascination with firearms fueling their fantasies and providing the means for mass killing. Their targets were mostly unprotected strangers. Overt suicidal intent or a preparedness to die while committing the homicides was invariable. Ethological theories of status acquisition may provide a useful understanding of mass homicide.

Community care and criminal offending in schizophrenia.

BACKGROUND: The introduction of community care in psychiatry is widely thought to have resulted in more offending among the seriously mentally ill. This view affects public policy towards and public perceptions of such people. We investigated the association between the introduction of community care and the pattern of offending in patients with schizophrenia in Victoria, Australia. METHODS: We established patterns of offending from criminal records in two groups of patients with schizophrenia over their lifetime to date and in the 10 years after their first hospital admission. One group was first admitted in 1975 before major deinstitutionalisation in Victoria, the second group in 1985 when community care was becoming the norm. Each patient was matched to a control, by age, sex, and place of residence to allow for changing patterns of offending over time in the wider community. FINDINGS: Compared with controls, significantly more of those with schizophrenia were convicted at least once for all categories of criminal offending except sexual offences (relative risk of offending in 1975=3.5 [95% CI 2.0-5.5), p=0.001, in 1985=3.0 [1.9-4.9], p=0.001). Among men, more offences were committed in the 1985 group than the 1975 group, but this was matched by a similar increase in convictions among the community controls. Those with schizophrenia who had also received treatment for substance abuse accounted for a disproportionate amount of offending. Analysis of admission data for the patients and the total population of admissions with schizophrenia showed that although there had been an increase of 74 days per annum spent in the community for each of the study population as a whole, first admissions spent only 1 more day in the community in 1985 compared with 1975. INTERPRETATION: Increased rates in criminal conviction for those with schizophrenia over the last 20 years are consistent with change in the pattern of offending in the general community. Deinstitutionalisation does not adequately explain such change. Mental-health services should aim to reduce the raised rates of criminal offending associated with schizophrenia, but turning the clock back on community care is unlikely to contribute towards any positive outcome.

Study of stalkers.

OBJECTIVE: This clinical study ws devised to elucidate the behaviors, motivations, and psychopathology of stalkers. METHOD: It concerned 145 stalkers referred to a forensic psychiatry center for treatment. RESULTS: Most of the stalkers were men (79%, N = 114), and many were unemployed (39%, N = 56); 52% (N = 75) had never had an intimate relationship. Victims included ex-partners (30%, N = 44), professional (23%, N = 34) or work (11%, N = 16) contacts, and strangers (14%, N = 20). Five types of stalkers were recognized: rejected, intimacy seeking, incompetent, resentful, and predatory. Delusional disorders were common (30%, N = 43), particularly among intimacy-seeking stalkers, although those with personality disorders predominated among rejected stalkers. The duration of stalking was from 4 weeks to 20 years (mean = 12 months), longer for rejected and intimacy-seeking stalkers. Sixty-three percent of the stalkers (N = 84) made threats, and 36% (N = 52) were assaultive. Threats and property damage were more frequent with resentful stalkers, but rejected and predatory stalkers committed more assaults. Committing assault was also predicted by previous convictions, substance-related disorders, and previous threats. CONCLUSIONS: Stalkers have a range of motivations, from reasserting power over a partner who rejected them to the quest for a loving relationship. Most stalkers are lonely and socially incompetent, but all have the capacity to frighten and distress their victims. Bringing stalking to an end requires a mixture of appropriate legal sanctions and therapeutic interventions.

Stalking: false claims of victimisation.

BACKGROUND: False allegations of victimisation although uncommon are important to recognise. This paper examines those who falsely claim to have been the victims of stalking. AIMS: To highlight the phenomenon of false victims of stalking. METHOD: Twelve individuals who falsely claimed to be victims of stalking were compared with a group of 100 true stalking victims. RESULTS: False stalking victims presented for help earlier than real victims and were less likely to claim harassment via letters. They reported equivalent levels of violence directed at themselves but seldom claimed others were attacked. Five types of false claimants were recognisable. False victims consumed more medical services than genuine stalking victims and they were more likely to be embroiled in legal action. They reported similar levels of distress with suicidal ruminations in over 40%. CONCLUSIONS: The current interest in stalking is promoting false claims of being stalked. Early identification of these cases and appropriate intervention are essential to both minimising abuses of resources available to true victims and equally to ensure appropriate care for those who express their own disordered state in false claims of victimisation.

The long-term impact of childhood sexual abuse in Australian women.

OBJECTIVE: The aim of this study was to examine the association between childhood sexual abuse (CSA) and a range of adverse adult outcomes in a community sample of women using multivariate analysis which accounted for a number of potential confounding effects. METHOD: Retrospective study of cross-sectional data on the long-term impact of CSA, collected as part of a larger two-stage case-control study of the possible relationship between CSA and alcohol abuse. Data were appropriately weighted to adjust for the different selection probabilities of cases and controls. RESULTS: Significant associations were found between reporting CSA and experiencing domestic violence, rape, sexual problems, mental health problems, low self-esteem, and problems with intimate relationships even after taking into account a range of family background factors. Women who had experienced abuse involving intercourse were the most vulnerable to these negative outcomes. CONCLUSIONS: The findings indicate that the influence of CSA on adverse long-term effects is mediated and influenced both by the severity of the abuse experiences and by a range of family and social background factors.

Sudden death in psychiatric patients.

BACKGROUND: The present study investigated histories of prior psychiatric treatment in cases of sudden death reported to the coroner. METHODS: A matching survey linked the register of deaths reported to the coroner with a comprehensive statewide psychiatric case register covering both in-patient and community-based services. RESULTS: Sudden death was five times higher in people with histories of psychiatric contact. Suicide accounted for part of this excess mortality but deaths from natural causes and accidents were also elevated. Schizophrenic and affective disorders had similar suicide rates. Comorbid substance misuse doubled the risk of sudden death in affective and schizophrenic disorders. CONCLUSIONS: The rates of sudden death are sufficiently elevated to raise questions about current priorities in mental health care. There is a need both for greater attention to suicide risk, most notably among young people with schizophrenia, to the early detection of cardiovascular disorders and to the vigorous management of comorbid substance misuse.