[Increasing criminality in patients with schizophrenia: fiction, logical consequence or avoidable side effect of the mental health reforms?]. / Steigende Kriminalität schizophrener Patienten: Fiktion, logische Konsequenz oder vermeidbare Folge der Psychiatriereformen?

OBJECTIVE: The reforms of general mental health care aimed at a substantial improvement of the situation of the mentally ill. We examined the question of a possible association between the mental health reforms and the steady increase of the population of forensic mental hospitals becoming apparent since the introduction of community psychiatry. RESULTS: All recent publications report a moderate albeit statistically significantly increased risk of criminality in patients suffering from schizophrenia, which becomes more obvious in severe, violent offences. In homicide it comes up to the 10-fold of that of the general population. Comorbid substance abuse has a substantial impact on the extent of illegal behaviour, however, even under consideration of alcohol abuse the risk of homicide amounts to about the 7-fold of that of the general population. Nearly all European countries give account on a remarkable increase of the incidence and prevalence rates of mentally disordered offenders. Patients suffering from schizophrenia are disproportionately affected by this development. However, the substantially increased risk of homicide in schizophrenic patients, reported already in the pre-reform era, remained stable over time. Accordingly, the rate of patients admitted to forensic-psychiatric treatment because of offences of minor severity is on the rise. CONCLUSION: This development cannot be explained by single details of the mental health reforms, which show remarkable regional differences concerning numbers of mental hospital beds, ways of service provision, legal preconditions and rates of criminality and substance abuse. Rather, national and international data suggest changes of general societal attitudes to be the crucial factor. They have resulted in changes concerning the self-understanding of the representatives of modern mental healthcare. As aggressive behaviour is not integrated in the understanding of schizophrenia of present-day psychiatry, the objective needs of a subgroup of severely and chronically ill psychotic patients with high rates of comorbid substance abuse, lack of insight and compliance are increasingly neglected. The denial of these facts promotes the shift of 'difficult-to-treat patients' into forensic-psychiatric facilities and damages the reputation of psychiatry.

Family and social influences on offending in men with schizophrenia.

OBJECTIVE: Environmental influences have been reported to play a role in the genesis of both schizophrenia and violent behaviour. METHOD: We studied the central features of the family and social influences of 103 healthy non-offenders, 103 non-schizophrenic offenders, 103 schizophrenic non-offenders, and 103 schizophrenic offenders, using a semistructured instrument. RESULTS: Lower social class of origin, offending behaviour in the parental generation, loss of the father, a new partnership of the remaining parent, growing up in blended families, larger sibships and stays in foster homes during childhood and adolescence, promoted the development of offending behaviour in general. Schizophrenic patients were more likely to have relatives with schizophrenia, a finding which was more marked among offenders than non-offenders. CONCLUSIONS: We were able to identify characteristic unfavourable family and social influences which were associated in schizophrenic patients with a high risk of offending behaviour. This offers the prospect of early detection of those with schizophrenia who will go on to offend.

The impact of diagnostic criteria on the prevalence of schizophrenic subtypes.

The distribution of schizophrenic subtypes shows a high range of cross-cultural and historical variations. Our study aimed to investigate the effect of different diagnostic criteria on the prevalence of schizophrenic subtypes. A sample of 220 consecutively admitted schizophrenic patients from 3 different psychiatric institutions was classified according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, International Statistical Classification of Diseases, 10th Revision, and Bleuler's and Leonhard's criteria. Especially, the frequency of catatonic (10%-22%) and hebephrenic (5%-20%) subtypes of schizophrenia varied within a broad range depending on the diagnostic system applied. The comparison of International Statistical Classification of Diseases, 10th Revision and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition with "classical" criteria (Bleuler, Leonhard) for the different schizophrenic subtypes showed a reduction of typical symptoms and the introduction of criteria of prominence during the last century. These changes caused 2 trajectories ("paranoidization" and "shift into residual categories") explaining these cross-sectional variations.

Schizophrenia, delusional symptoms, and violence: the threat/control override concept reexamined.

In 1994 Link and Stueve identified a number of symptoms--called threat/control-override (TCO) symptoms--that were significantly more than others related to violence. This was confirmed by some, but not all, following studies. The contradictory results could be due to remarkable differences in sample compositions, sources used, and definitions and periods of recorded violence, but they are mainly due to problems defining the TCO symptoms. To reexamine the validity of the TCO concept from an exclusively psychopathological position, we compared in a retrospective design a sample of male offenders with schizophrenia not guilty by reason of insanity (n = 119) with a matched sample of nonoffending schizophrenia patients (n = 105). We could find no significant differences regarding the prevalence of TCO symptoms in the two groups during the course of illness. The only statistically significant discriminating factors were social origin and substance abuse. Yet, taking into account the severity of offenses, TCO symptoms emerged as being associated with severe violence. This effect is primarily attributable to the comparatively unspecific threat symptoms. Control-override, to be seen as more or less typical for schizophrenia, showed no significant association with the severity of violent behavior.

Anxiety and hostility in the manifest dreams of schizophrenic patients.

Aside from delusions, hallucinations, and thought disorders, affective disturbances belong to the most prominent symptoms of the schizophrenic process. However, nearly no empirical work has been done on the systematic investigation of the dream affects of patients with schizophrenia. We compared 96 dreams of 19 patients with schizophrenia and an equal number of dreams of 19 healthy controls collected over an 8-week period by means of the Gottschalk-Gleser Analysis Scales. Additionally, central psychopathological syndromes were measured by means of the AMDP-scales each day a patient reported a dream. Although cluster analyses showed general similarities in the organization of dream affects in the two groups, we found differences between patient and control groups in the frequency and intensity of anxious and hostile affects. As in delusions of persecution, patients experience themselves in their dreams more frequently as victims of hostility from outside, which corresponds well with a significantly higher intensity of threat anxieties (death, mutilation). On the other hand, value anxieties (guilt and separation) are found less frequently in the dreams of patients with schizophrenia pointing, together with a less differentiated organization of the dream affects, to the typical affective flattening of residual syndromes.