Dissertation committee:
Παπαγεωργίου Χαράλαμπος, Καθηγητής, Ιατρική, ΕΚΠΑ
Δουζένης Αθανάσιος, Καθηγητής, Ιατρική, ΕΚΠΑ
Ρίζος Εμμανουήλ, Αν. Καθηγητής, Ιατρική, ΕΚΠΑ
Μιχόπουλος Ιωάννης, Αν. Καθηγητής, Ιατρική, ΕΚΠΑ
Κόλλιας Κωνσταντίνος, Αν. Καθηγητής, Ιατρική, ΕΚΠΑ
Οικονόμου Μαρίνα , Αν. Καθηγήτρια, Ιατρική, ΕΚΠΑ
Φερεντίνος Παναγιώτης , Επ. Καθηγητής, Ιατρική, ΕΚΠΑ
Summary:
Schizophrenia is a serious chronic mental disorder, with disordered thinking, delusional ideas, hallucinations, marked anxiety, bizarre behavior and suicidal tendencies. Its causes are unknown, but hereditary factors and neurobiological imbalances in brain chemistry can increase the person's vulnerability or predisposition to trigger psychotic episodes. Existing studies on schizophrenia from the fields of psychiatry and forensic psychiatry suggest that schizophrenia is an important risk factor for violence or for crime commission. Its association with crime has been underlined in Greek, but mainly in foreign scientific literature, indicating a strong association with unmarried men, who have poor compliance with medication, co-morbidity and long duration of the disease.
The present Greek study aimed at highlighting the particular characteristics of personality and mental disorders of Greek patients with schizophrenia, who exhibit aggressive/ violent behavior and commit violent crimes such as homicide and attempted homicide. At the same time, efforts are made to analyze how these characteristics and violence are differentiated in relation to other schizophrenic individuals who are not violent. The importance of this study lies in the fact that in our country to date there is little evidence on this subject, while stereotypical and stigmatizing perceptions still dominate those who experience mental health problems and suffer from major mental disorders, such as schizophrenia. There is a need to conduct studies on the aggressiveness and risk of patients with schizophrenia as their de-institutionalization and social reintegration are under way. Methodologically, it is a cross-sectional study of a sample of 220 men who met DSM-IV-TR diagnostic criteria for schizophrenia. It was carried out from January 2011 to November 2015 in patients who were involuntarily hospitalized in the “Dafni” State Psychiatric Hospital of Attica or who were hospitalized after being judged not guilty by reason of insanity or detained in the Psychiatric Prison of Korydallos (PPK). The study has correlated three groups of patients: a) Group Α (Schizophrenia - No violence): 74 patients with a diagnosis of schizophrenia and related disorders (DSM-IV-TR) with no history of violence, who were involuntarily hospitalized in departments of the “Dafni” State Psychiatric Hospital of Attica, b) Group Β (Schizophrenia - with violence or violent crime): 74 patients with a diagnosis of schizophrenia and related disorders (DSM-IV-TR), with a history of serious violence, who were hospitalized, involuntarily in departments of the “Dafni” State Psychiatric Hospital of Attica (N=43) or detained in the Psychiatric Prison of Korydallos in Athens (N=31), and c) Group C (Schizophrenia - not guilty by reason of insanity – violent crime): 72 patients with a diagnosis of schizophrenia and related disorders (DSM-IV-TR), who were treated according to article 69 of the Penal Code (not guilty by reason of insanity) and confined by the courts to the “Dafni” State Psychiatric Hospital of Attica.Also, comparisons were made (with univariate and multivariate logistic regression model) of a) PPK patients with Group’s B “Dafni” patients, b) Group C with Group’ B PPK patients, c) Group C with Group’s B “Dafni” patients, d) Group C with Group B in a subset of patients with commanding hallucinations, to determine the probability of individuals of belonging to a higher severity group, considering that the level from the lowest to the highest severity is: “Dafni” patients – Group B, PPK – Group B and Group C. Patient data were obtained through interviews and structured /semi-structured diagnostic processes and psychometric tools. The clinical assessment and diagnosis was made according to DSM-IV-TR.
The main findings of the study indicate that our sample consisted mostly of patients with paranoid schizophrenia, mostly unmarried, with very limited emotional ties and without recent emotional ties. They had low to moderate living status, low to moderate academic performance and limited professional activity. Most patients have shown poor compliance with their medication. The most serious psychosocial, predisposing factors that emerged above all for the "violent" groups were poor parenting, parents' early divorce, peers influence in terms of gang membership or " bad companies ", the history of juvenile delinquency and the absence of a supportive environment. It seemed that they occasionally used substances, mainly cannabis and alcohol. Most patients had a history of violence prior to disease onset and before adulthood, such as juvenile delinquency, verbal aggression, family conflicts, vandalism and arrests.Also, most patients (75%) did not exhibit history of commanding auditory hallucinations, though those who exhibited, they belonged to the “violent” groups. Clearly, however, Group B and C recorded the highest levels of violence. The severity of history of violence or aggressive behavior /criminality in relation to the disease onset, especially for the "violent" groups, is evident from verbal aggression before admission for hospitalization or during hospitalization, from violence against people and objects before admission. The study demonstrated the differences between the three groups in relation to violence, which were confirmed by the positive and negative subscales of the PANSS scale.
From further subgroups’ comparison it appeared that the results of the Group C vs. Group B were maintained, even in the subgroups of patients with schizophrenia in PPK and Group’ B “Dafni” patients. Specifically, the finding of negative correlation between the duration of cannabis use and the probability of belonging to Group C, appears to be clearly confirmed, when the comparison focuses on the Subgroup of Group B, patients who were hospitalized in “Dafni”. For Group’s B subgroup, PPK patients, the correlation was less robust and not statistically significant. The findings regarding the positive relationship of alcohol and group C is confirmed when the comparison focuses on the subgroup of Group B, patients who were hospitalized in “Dafni”, while for PPK patients was not statistically significant. The negative correlation of juvenile delinquency and the probability of the patient that belongs to Group C appears to be almost the same in the two additional comparisons (Group C vs B-“Dafni” patients and Group C vs. B-PPK).
The same applies to the positive correlation between the long intervals between disease onset and crime of Group C and the negative correlation between moderate or poor health (based on the psychometric tool, SF36) and the probability of belonging to Group C. Positive correlations with the subscale P1 (delusional ideas) and N6 (lack of spontaneity and flow of conversation) of the PANSS scale, the scores of the PCL-SV scale for psychopathy and psychosocial predisposing factors, which indicate the probability of belonging to Group C, seem to be maintained at least towards the correlation direction (that is to say, correlations are maintained positive) and to the additional comparisons of Subgroups PPK and “Dafni” patients, with Group C, while retained their statistical significance on several occasions. Accordingly, the P7 subscale (hostility) of the PANSS scale had negative correlation with the patient’s probability of belonging to Group C. This negative correlation with the P7 subscale (hostility), as estimated in the overall comparison of Group C with Group B, remains nearly unchanged and statistically significant in the comparisons of subgroups PPK and “Dafni” patients, with Group C.
In general, it can be said that the study of violence about people suffering from severe mental disorders, such as schizophrenia, offers a knowledge wealth for deeper understanding of the mechanisms underlying violent and aggressive behavior but is also important in order to develop preventive and therapeutic interventions, for the provision of more helpful risk assessments, and reduce violent behaviors and relapses in this type of patients.
