FIG1 On the big screen,
murderers are often portrayed as psychotic maniacs who cannot be deterred from
harming their targets. The reality is somewhat less dramatic but more
reassuring: some people who kill or commit violent acts exhibit symptoms of
mental illness that can be mitigated with medication and psychotherapy.
Renée Sorrentino, M.D., tells psychiatrists that they have the
ability to reduce the risk of future violence among violent offenders by
treating certain symptoms such as emotional dysregulation.
Three forensic psychiatrists scoured the data to learn more about the
relationship between mental illness and violent crime and discovered a
relatively high prevalence of certain personality traits and behaviors among
violent offenders. They discussed their findings at APA's 2006 annual meeting
in Toronto in May.
"Homicide is not specifically associated with one psychiatric
disorder," said Renée Sorrentino, M.D., director of forensic
psychiatry at the Erich Lindemann Mental Health Center and an instructor at
Harvard Medical School.
Sorrentino presented data from a study conducted by Jenny Shaw, Ph.D., of
1,594 people convicted of homicide in the United kingdom that found that 34
percent had been diagnosed with a mental disorder during their lives, but only
10 percent of them were experiencing symptoms at the time of the offense.
In another study by the same researcher, 44 percent of those convicted of
homicide in the United kingdom had been diagnosed with a mental disorder. Of
those, 11 percent had a mood disorder, 9 percent a personality disorder, and 6
percent schizophrenia. More than 63 percent had been out of contact with the
mental health system at the time of the crime, she pointed out.
Sorrentino also cited a 2004 study in which Seena Fazel, M.D., and
colleagues examined the records of all individuals convicted of homicide and
attempted homicide in Sweden from 1988 to 2001. The presence or absence of
psychiatric diagnoses was ascertained for 1,625 (81 percent) of the homicide
offenders; of these, 1,464 (90 percent) had a psychiatric diagnosis, including
20 percent with a psychotic illness. Fifty-four percent of a subgroup of 1,091
offenders about whom there was information on secondary diagnoses had a
personality disorder. Only 10 percent of the offenders for whom psychiatric
diagnostic information was available had no psychiatric diagnosis.
Other studies have linked homicide with certain symptoms or behaviors that
can be managed when treated by a psychiatrist, Sorrentino noted.
"Some of the risk we can attenuate, such as paranoid delusions,
command hallucinations, and suicidality," she said, adding that some
suicidal people may be at risk for violence "because they feel they have
nothing to lose."
She cited data from a study of 48 people who committed homicide in which
there was a clear sexual component that found they were more likely than
nonhomicidal incest offenders to have been removed from their homes during
childhood. Homicidal sexual offenders were also more likely to score higher on
psychopathic and antisocial personality scales and have neuropsychological
Other studies have found that people who commit homicides that are sexual
in nature were more likely than nonhomicidal sexual offenders to belong to
gangs, have a history of being cruel to animals, collect pornography, abuse
drugs, and exhibit sadism, fetishism, or voyeurism.
According to Joy Stankowski, M.D., "the strongest predictor of
violence is not an Axis I disorder, but personality disorders and substance
use disorders." She is a senior instructor in psychiatry at Case Western
Reserve University in Cleveland.
She noted that studies of jail detainees have found high rates of
antisocial personality disorder and substance abuse.
Violent individuals may benefit from targeted forms of treatment depending
on their personality traits, Stankowski said. For instance, people with
emotional dysregulation, a common symptom of borderline personality disorder,
may benefit from dialectical-behavioral therapy if they engage in an
impulsive, reactive type of violence, Stankowski noted.
However, such treatment may not work for those with antisocial traits who
plan a violent act in a "calculating" manner, she said.
Even violent offenders with mental illness and a history of medication
noncompliance can benefit from treatment, according to information presented
at the workshop.
To help attendees better understand how violent patients may be treated on
an inpatient unit, Susan Hatters-Friedman, M.D., a senior instructor in
psychiatry at Case Western Reserve University in Cleveland, presented the case
of "Billy," a 30-year-old patient with schizoaffective disorder,
borderline personality disorder, and mild mental retardation.
At a young age, he was raped by a family member and as an adult was
convicted of rape. Soon after admission to an inpatient unit, Billy grabbed a
female nurse and tried to pull down her pants, Hatters-Friedman said, in
response to auditory hallucinations to rape her.
Clinicians treated Billy one symptom at a time, according to Stankowski.
They administered IM injections of a long-acting antipsychotic medication due
to his lack of insight and poor medication compliance. In addition, he
received IM injections of hormones to decrease his libido. To help his
symptoms of borderline personality disorder, Billy received
dialectical-behavioral therapy, Stankowski noted.
"Until he learned new ways to cope with his emotions" through
therapy, clinicians helped him better control his emotions through
pharmacotherapy, she said.
In some cases, remarked Sorrentino, "violence is predictable and