psychotic illness

University Degree Subjects allied to Medicine

Are people with psychotic illnesses dangerous?

Psychotic illnesses can be defined as:

“Conditions caused by any one of a group of illnesses that are known, or thought, to affect the brain causing changes in; thinking, emotion and behaviour”

These illnesses include depression and schizophrenia and according to Nazroo (1997) one person in 250 suffers from a psychotic disorder like schizophrenia in which they experience delusions and hallucinations that may impair thought processes.

When assessing whether people with psychotic illnesses are dangerous-The concise Oxford dictionary (1985) defines danger as “liability or exposure to harm, risk or peril.”-dangerousness is most often but not exclusively associated with anti-social or psychopathic disorder and also schizophrenia. People diagnosed with borderline or paranoid personality disorder may be at higher risk of self-harm and/or suicide than other people. Schizophrenia is the condition most often associated with the term “madness” and contrary to popular belief it is not a split personality but it is a group of psychotic disorders that are characterised by a loss of contact with reality-symptoms are mainly disturbances of thought processes, but also extend to disturbances of emotion and behaviour. Both positive symptoms i.e. Hallucinations and delusions along with negative i.e. Apathy and withdrawal are characteristic. Its prevalence varies from 0.2% to 2% of the population according to DSM IV (1994).

During an episode of any psychotic illness, people perceive their world differently from normal, they may develop delusions i.e. False beliefs of persecution, guilt or grandeur - what they see, hear and feel is real to them but people around them do not share these experiences. These symptoms can have such an impact that they can lead to murder and other violent acts for example Peter Sutcliffe (the Yorkshire Ripper) –he told police that in 1967, at the age of twenty, he had heard the voice of God speak to him as he worked at Bingley cemetery. He would claim that he had first heard that voice while digging a grave. He stated that the voice had led him to a cross-shaped headstone upon which were written the Polish words JEGO, WEHBY and ECHO. It was this same voice that had ordered him to kill prostitutes. Police officials were satisfied that Peter Sutcliffe was mentally ill, suffering from paranoid schizophrenia, and should be incarcerated in an institution for the insane. It is impossible to know if Peter Sutcliffe would have carried out these murders had he not been suffering from schizophrenia, even so these episodes can be threatening and perplexing to others even if they pose no danger hence it is difficult to know if the association between mental illness and dangerous behaviour stems from this “fear of the unknown” or if there is at least an element of truth.

Reference: Peter Sutcliffe. Available at www.crimelibrary.com, accessed 04/12/2003

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Reference: Peter Sutcliffe. Available at www.crimelibrary.com, accessed 04/12/2003

Dr. John Monahan claims that “ there is no question that some of the violence in society can be attributed to mental disorder” however he goes on to say “only 4% of violence can be attributed to mental disorders… and if mental disorder could be magically cured tomorrow 96% of violence in society would still be there.” Despite this, for some, the association between mental illness and dangerousness is automatic, perhaps because behaviours themselves are often defined as specific mental disorders. Media portals of mental illness give rise to beliefs that the sole conditions necessary for violence towards others by a person are mental illness and the individual’s liberty. This belief is further reinforced by sensationalised reporting on occasions when someone with a diagnosed mental illness does commit a violent act (levey and Howells, 1995). On these occasions any history of contact with mental health professionals is taken as evidence that the person must have been “sick” at the time of the act, hence such expressions as “ he much have been ill” in response to hearing of a particularly brutal physical or sexual assault. This type of statement is a reflection of how entrenched medicine has become in our daily lives. Conrad and Shneider (1980) point out that it is a relatively recent phenomenon that problems such as violence and addiction have been defined as medical problems. As a result of such beliefs, Harris and colleague Dr. Marnie Rice studied people with mental illnesses and tried to discover if it was, in itself a risk factor and whether people released from maximum security settings – including people with mental illness – wind up behind bars, they found that: offenders with schizophrenia were less likely that a matched control group of offenders to commit further criminal and violent offences. They went on to comment that:

“Substance abuse and anti-social personality disorder confer a much greater risk”(September 1997, issue of psychiatric services”

In summary his findings in researching schizophrenia showed a negative risk factor-among those released form institutions, people with schizophrenia are least likely to be violent.

Reference: Violence. Available at accessed 15/12/2003

This work however focused only on a very specific population: offenders who were already at the maximum-secure centre for committing serious offences. Therefore The MacArther Violence Risk Assessment Study was designed to study 951 acute psychotic patients in 3 American cities for a year after discharge – in this way it was trying to eliminate the flaws of previous work which had been unable to be generalised. In one of the locations, Pittsburgh, more than 500 non-patients living in the same neighbourhood were also evaluated for violence. These people were to be the control group. The results of this study found that patients who were not abusing alcohol or other drugs were no more violent than other people living in their neighbourhoods, however when substance abuse enters the picture – the scene changes. Alcohol and drugs appear to be the key catalyst for violent behaviour – and patients abusing them were more violent than other people in their neighbourhoods. In fact, the study found alcohol or substance abuse was a dramatic factor in violence among both patients and non-patients. It tripled the rate of violence among non-patients in the community, and increased the rate of violence by discharged patients by up to five times. The nature of this violence usually involved hitting and the victims were most often family members. These findings clearly indicate that public fears of violence on the street by discharged patients who are strangers to them are misdirected.

Swanson et al (1990) found further support for this notion that drug and alcohol abuse leads to more violent acts than psychotic illness. Using the National Institute of Mental Health’s Epidemiological Catchment Area Surveys which involved close to 10,000 surveys Swanson found that 2.1% of those who did not meet DSM - III criteria for mental disorder reported committing a violent act in the last year. This compares with 12.7% for those who met criteria for schizophrenia, 11.7% for major depression, 11% for mania or bipolar, 24.6% for alcohol abuse/dependence and 34.7% for drug abuse/dependence. “Violence was most likely to occur among young, lower class men, among those with substance abuse diagnosis, and among those with a diagnosis of major mental disorder” (Monahan, 1992)

Reference: Out of mind. Available at accessed 15/12/2003

Despite these findings the results cannot be completely generalised – capgras syndrome is a delusional disorder which leads people to believe that a close relative or friend has been replaced by an impostor, an exact double, despite recognition of familiarity in appearance and behaviour. The “impostor” is a key figure for the patient at time of onset of symptoms; if married, always the husband or wife accordingly. The patient may also see himself as his own double. As a variant of this syndrome the patient believes that inanimate objects, such as furniture, a letter, a watch, spectacles, have been replaced by an exact double. A man suffering from these delusions thought his wife was a robot and In order to test his hypothesis he cut her head off – clearly this man was dangerous because he so firmly believed these convictions - however does this make him as much of a menace to society as Myra Hindley and Ian Brady? Neither of the pair was ever diagnosed with a psychotic illness.

Adults suffering from depression and those suffering from depressive bipolar symptoms are very rarely violent, however they could still be classified as dangerous people, as they pose a risk to themselves, people with depressive symptoms suffer from apathy, feelings of guilt and worthlessness etc. and this is very distressing and up to 15% of these people choose to take their own lives in order to put an end to their suffering and quite often the immense suffering of those around them. Depression in children does not usually amount to such drastic ends however its frequently results in anti-social behaviour and this may be just as dangerous according to the definition, as someone taking their own life – this self-directed death leads to the tragic end of a life however anti-social behaviour can amount to: arson, theft, violence and a host of other potentially dangerous actions.

When we think of dangerous people most of us would fail to recognise people who take their own lives as dangerous – however these people are exposing themselves to danger and harm hence must be considered and included in data. These people are not a menace to society however they suffer so badly in there own world from feelings of worthlessness and guilt that they feel no one would care if they even noticed the sufferer was dead. Therefore these are included in publicised data and this contributes to the sensationalised reports of “mad” people carrying out dangerous acts. If these people could be somehow categorised slightly differently then some of the stigma and stereotypes, which come with psychotic illness, could perhaps be eradicated. Despite this, people with mental illnesses have in the past and will continue to carry out dangerous acts, this may be partly due to non compliance with medication however the symptoms of these illness are the most likely reason - the figures may suffer from some slight distortion as it has been known that people pose as mentally ill in an attempt to get a reduced jail sentences. Delusions can be terrifying for the sufferer and they believe that what they see and feel is real, and in some cases – for example Peter Sutcliffe, the results can be horrific. As a result of these isolated incidents it would be impossible to reject the hypothesis that people with psychotic illnesses are dangerous; however the majority of studies find that alcohol and substance abuse are the single most influential factors when considering violent activity hence a direct correlation between psychotic illness and dangerousness cannot be cited. Dangerousness has been displayed in many different types of people, many of whom do not suffer from psychotic disorders – therefore it seems fair to say that mental illness can lead to dangerousness however it is certainly not the only factor, nor can we assume that all people with psychotic illnesses are dangerous.