DISCUSSION
We performed a forensic psychiatric assessment of a sample of 28
patients that were institutionalized in a forensic psychiatric facility
(custodial hospital) in Rio de Janeiro, Brazil, for offenses involving
violent behavior. Many of these women had little education and were
single (57%), were not working (32%), and had low family income at the
time of the crime. The main psychiatric diagnosis was schizophrenia
(n=13; 46%). Our findings corroborate the results reported in the
literature, which has identified schizophrenia as the main mental
disorder associated with aggressive behavior in both
developed17-19 and developing
countries20,21.
Few studies in Latin America have addressed aggressive behavior in
individuals with schizophrenia. One study22 included
253 stable outpatients. Prevalence of aggressive behavior in the sample
was 3.5% in Chile, 14.6% in Peru, and 55.4% in Bolivia. Aggressive
behavior was associated with the severity of psychotic symptoms, low
family income, young age at onset of the illness, and more
hospitalizations. Most of these variables were present in our sample.
Analysis of the means and standard deviations for positive and negative
symptom scores in our sample using the Positive and Negative Syndrome
Scale (PANSS)16 showed lower scores for positive
symptoms (12 ± 8.92) than for negative symptoms (38.5 ± 10.91), which
may be related to the evolution of this severe mental disorder, with
predominantly negative symptoms 23,24.
A history of previous violence has been considered consistently as
predictive of subsequent violence in various patient
populations25-27. Six patients (21%) in our sample
had a history of aggressive behavior, two of whom had been involved in
three criminal cases (with diagnoses of schizoaffective disorder and
bipolar disorder, respectively) and one patient had been involved in
five criminal cases (her diagnosis was schizophrenia).
The relationship between severe mental disorders and crime is more
complex than simple causality. Factors such as age, gender,
socioeconomic status, and prior crime are important, as are other
potentially treatable factors such as substance abuse, personality
disorders, and regular use of medications. Comorbidity with substance
abuse increases the risk of aggressive behavior in individuals with
severe mental disorders 28-33. According to Jaffeet al .34, individuals with substance use
disorders and comorbidity with mental disorders show lower success with
addiction treatment and more involvement in the criminal justice system.
It is highly important to track substance use disorders in order to
prevent aggressive behavior in these individuals.
On this issue, 10 patients (35.7%) in our sample reported alcohol
and/or psychoactive substance use on the day of the offense. Curiously,
all three patients with involvement in more than one criminal case
reported such use. The association between mental disorders and violence
can definitely be affected by various factors, including comorbidity
with substance use, negative life events, and low social support. Public
health strategies to reduce violence in individuals with and without
mental disorders should focus on substance abuse prevention.
Fourteen patients (50%) in the total sample (n=28) presented psychotic
symptoms at the time of the initial forensic psychiatric assessment
resulting in involuntary hospitalization. Auditory hallucinations (n=8
cases) and persecutory delusions (n=6 cases) were the most common
psychotic symptoms. These data illustrate the relevance of psychotic
symptoms prior to manifestation of the violent behavior. Another key
finding was that only four patients (14.3%) in the sample were in
psychiatric treatment or in use of psychiatric medication on the days
preceding the offense. We believe that the lack of treatment may have
contributed to perpetration of the violent behavior.
Homicide and unusual forms of aggression often result from symptoms
leading persons with mental disorders to believe they are in danger. A
study by Taylor35 found a strong association between
psychotic symptoms and recent aggressive behavior, since 93% of the
sample displayed psychotic symptoms when they committed these offenses,
and 47% were “definitely” or “probably” motivated by these
symptoms. Other studies have found an association between auditory
hallucinations and persecutory delusions and motivation to commit
homicide36-40. More severe paranoia is associated with
greater aggressiveness, even when controlling for such factors as
impulsiveness, command hallucinations, treatment with antipsychotics,
substance abuse, age, and gender41. Many homicide
cases definitely involve individuals with personality disorders rather
than other forms of mental illness42.
In this study’s sample, violent behavior was largely targeted to family
members. Of the 30 victims of violent behavior, 14 (47%) were the
patients’ family members, including a grandmother, mother, brother,
husbands, and children. One patient had tried to drown her three
children, who fortunately managed to survive. The most frequent means
for committing the violent behavior was cold steel weapons (n=9, or 32%
of the sample). A systematic review by Minero et
al. 43 also found that cold steel weapons (knives,
scissors, etc.) were the most frequent means used by individuals with
psychotic disorders to commit homicide.
Severe mental illness has been associated with certain cases of
familicidal behavior, with an emphasis on psychotic motivations. Other
purportedly associated factors are: loss of family control; revenge for
loss of the female partner; fear of abandonment; narcissistic rage;
financial difficulties; altruistic urges to defend the family from real
or imaginary catastrophes; and instrumental
violence44-45. One patient in our sample poisoned and
killed her two-year child as revenge for her male partner having left
her for another woman. We recently published case reports of
parricide46 and fratricide47 by
individuals with psychotic disorders.
Various studies have provided evidence that the risk of aggressive
behavior can increase in patients with affective
disorders48-51. However, estimates of the risk of
violence associated with bipolar disorder have not differed
statistically from those associated with psychotic depression in many
studies, often limited by the sample sizes. Manic symptoms such as
impulsiveness, grandiose delusions, impaired judgment, and psychosis can
also contribute to aggressive behavior in these
patients52. Our study found only two cases of bipolar
disorder. We believe that this finding may reflect the relatively small
sample size.
A wide variety of mental disorders have been described in association
with matricide, including schizophrenia53,54,
depression53,55 personality
disorders53,55, and alcohol and psychoactive substance
abuse55,56. Our sample included one case of matricide
and another of assault with a deadly weapon against the mother. The
first patient had bipolar disorder and the second schizophrenia. We
published a case report on the patient with bipolar disorder who killed
her mother57. It should be noted that many cases of
matricide are not associated with mental disorders58.
Five patients in the sample (18%) had committed or attempted filicide.
Three of the five patients presented diagnoses of schizophrenia. The
other two patients had diagnoses of mental retardation and borderline
personality disorder (the latter being considered partially responsible
to stand trial, thus her confinement to a forensic facility). Two of
these five patients had a history of alcohol abuse. The fact that there
was only one case of personality disorder may have been due to the fact
the it was a sample of patients with more severe mental disorders, under
more rigorous security. However, studies have found aggressive behavior
against intimate partners59,60 and
children61 in individuals with borderline personality
disorder. Another study found that filicidal mothers, compared to
fathers, were more subject to compulsory psychiatric hospitalization
than to incarceration62. We published a report of two
cases of filicide and attempted filicide, both with diagnosis of
schizophrenia63.
Various studies have found a persistent pattern of interrupted contact
with mental health services, while in others, the aggressive behavior
appears to occur right after the onset of the mental disorder, before
the offender has made contact with these services64.
In our study, 21 of 28 patients (75%) had a history of psychiatric
treatment. However, only four of the 28 patients (14.3%) were in
psychiatric treatment shortly before the crime, and the same percentage
were on psychoactive medication. The findings illustrate the fact that
these patients with aggressive behavior were not in regular psychiatric
treatment before they displayed this behavior. According to a cohort
study65, persons with schizophrenia show lower risk of
committing violent crimes when they are on antipsychotic medication,
compared to periods when they fail to receive such treatment.
Psychiatric patients with a criminal history would benefit from
treatment programs which nevertheless frequently exclude them. The
presence of criminal history should be an indicator of increased need
for integrative approaches, as opposed to exclusion from treatment.
Mental health services should strive to prevent patients’ loss to
follow-up and nonadherence to treatment, which often precede the
aggressive behavior committed by persons with severe mental disorders.
It is also essential for society and government authorities to mitigate
barriers to psychiatric and psychosocial treatment.
Although the statistical and empirical evidences point to a direct
relationship between serious mental disorders and aggressive behavior,
this certainly represents a small proportion of the violence occurring
in the community. In countries like Brazil with high rates of violence,
and where violence and crime show a strong association with precarious
socioeconomic conditions, the percentage of violent crimes such as
homicides associated with mental disorders may be even smaller. The aim
of studies on the association between violence and mental disorders is
not to stigmatize, but to better understand the factors contributing to
this association, as well as to propose mental health policies and
therapeutic interventions for patients with mental disorders and
aggressive behavior.
Current mental health policies and clinical practices have failed to
recognize that aggressive behavior and victimization are problems for
many patients with severe mental disorders. Thus, treatment services
have not provided sufficient services to treat these problems,
increasing the number of patients transferred to forensic services.
The media coverage on violence committed by individuals with serious
mental disorders increases the alarm and stigma towards these
individuals. They rarely commit violence, and they are actually the
victims66,67 more often than the perpetrators of
violence. Some studies have found that patients with mental illness were
more prone to dying from homicide than persons in the general
population68,69.
One limitation to our study was the small sample size (n=28). Our sample
is definitely not adequate for obtaining epidemiological data on a
potential association between mental illness and aggressive behavior in
women. Our sample consisted of court referrals on aggressive behavior in
women in a forensic facility and is thus not representative of the
overall population of women with aggressive behavior. However, the
sample included all the female patients that were committed to
psychiatric hospitalization for violent behavior in the state Rio de
Janeiro at the time of the study.
Another limitation was the use of retrospective data, although all the
participating patients were interviewed during the study itself. Further
studies are definitely necessary to explore the risk of violence in
women with mental disorders from various populations and to assess the
benefits of the therapeutic intervention in these factors, in reducing
the risk of violence.
Although our study cannot be considered representative of all the women
that committed homicide, we believe it can contribute to understanding
the relationship between homicide and mental disorders in women. The
study of motivating factors for violent behavior can provide knowledge
for establishing therapeutic interventions in women with mental
disorders that present risk of violent behaviors.