Paul E. Mullen

Background: Despite high rates of self-reported crime victimisation, no study to date has compared official victimisation records of people with severe mental illness with a random community sample. Accordingly, this study sought to determine whether persons with schizophrenia-spectrum disorders have higher rates of recorded victimisation than the general population, and to explore whether there have been changes in rates of recorded victimisation over a period of deinstitutionalisation. Methods: The schizophrenia-spectrum cases were drawn from a state-wide public mental health register, comprising all persons first diagnosed with a schizophrenic illness in five year cohorts between 1975 – 2005. The criminal histories of 4,168 persons diagnosed with schizophrenic-spectrum disorders were compared to those of a randomly selected community sample of 4,641 individuals. Results: Compared to community controls, patients with schizophrenia-spectrum disorders were significantly more likely to have a record of violent (10.1% vs. 6.6%, odds ratio 1.4) and sexually violent victimisation (1.7% vs. 0.3%, odds ratio 2.77), but less likely to have an official record of victimisation overall (28.7% vs. 39.1%, odds ratio 0.5). Over the approximate period of deinstitutionalisation, the rate of recorded victimisation has more than doubled in schizophrenia-spectrum patients, but stayed relatively constant in the general community. Conclusions: People with schizophrenic-spectrum disorders are particularly vulnerable to violent crime victimisation; although co-morbid substance misuse and criminality both heighten the chances of victimisation, they cannot fully account for the increased rates. Deinstitutionalisation may have, in part, contributed to an unintended consequence of increasing rates of victimisation amongst the seriously mentally ill.

Study of risk factors for violence to prominent people is difficult because of low base rates. This study of harassers of the royal family examined factors suggested in the literature as proxies for violence—breaching security barriers, achieving proximity, approach with a weapon, and approach with homicidal ideation. A stratified sample of different types of approach behaviour was randomly extracted from 2,332 Royalty Protection Police files, which had been divided into behavioural types. The final sample size was 275. Significant differences in illness symptomatology and motivation were found for each proxy group. Querulants were significantly over-represented in three of the four groups. There was generally little overlap between the proxy groups. There is no evidence of the proxy items examined being part of a “pathway to violence”. Different motivations may be associated with different patterns of risk. Risk assessment must incorporate knowledge of the interactions between motivation, mental state, and behaviour. Copyright © 2010 John Wiley & Sons, Ltd.

PurposeTo illustrate the development of the interface between general and forensic mental health services in Victoria, Australia.MethodDeveloping effective cooperation between the general and forensic mental health services requires overcoming a number of barriers. The attitude of general services that antisocial behaviour was none of their business was tackled through ongoing workshops and education days over several years. The resistance to providing care to those disabled by severe personality disorders or substance abuse was reduced by presenting and promoting models of care developed in forensic community and inpatient services which prioritised these areas. The reluctance of general services to accept offenders was reduced by involving general services in court liaison clinics and in prisoner release plans. Cooperation was enhanced by the provision of risk assessments, the sharing of responsibility for troublesome patients, and a problem behaviours clinic to support general services in coping with stalkers, sex offenders and threateners.ConclusionsActive engagement with general services was promoted at the level of providing education, specialised assessments and a referral source for difficult patients. This generated a positive interface between forensic and general mental health services, which improved the quality of care delivered to mentally abnormal offenders.

Paul Mullen discusses Seena Fazel and colleagues' paper on the association between violent behavior and having been diagnosed with a schizophrenic disorder, and its implications for care of these individuals.

This paper considers the problem created by those who harbour unusually intense fixations on public figures. It examines the nature of such pathological fixations and how they differ from the wide range of normal concerns which lead people to communicate with, and even occasionally harass, politicians and other prominent persons. In those harbouring a pathological fixation, there often emerges a pattern of stalking-type behaviour, with repeated attempts at communication and/or contact which create concern. In a small number, the fixation either remains hidden or leads to attempts to communicate about, rather than to, the subject. Occasionally, such a fixation will come to attention with some dramatic approach, or even attack, on the individual with whom the fixated person has been preoccupied. Fixated people are of concern, not just because they create problems for public figures and their security systems, but because many are seriously mentally ill individuals in need of care, who in most cases cause harm only to their own lives and well-being.

Background: Mental health clinicians are frequently asked to assess the risks presented by patients making threats to kill, but there are almost no data to guide such an evaluation.Method: This data linkage study examined serious violence following making threats to kill and the potential role of mental disorder. A total of 613 individuals convicted of threats to kill had their prior contact with public mental health services established at the time of the index offence. The group's subsequent criminal convictions were established 10 years later using the police database. Death from suicidal or homicidal violence was also established.Results: Within 10 years, 44% of threateners were convicted of further violent offending, including 19 (3%) homicides. Those with histories of psychiatric contact (40%) had a higher rate (58%) of subsequent violence. The highest risks were in substance misusers, mentally disordered, young, and those without prior criminal convictions. Homicidal violence was most frequent among threateners with a schizophrenic illness. Sixteen threateners (2.6%) killed themselves, and three were murdered.Conclusions: In contrast to the claims in the literature that threats are not predictive of subsequent violence, this study revealed high rates of assault and even homicide following threats to kill. The mentally disordered were over-represented among threat offenders and among those at high risk of subsequent violence. The mentally disordered threateners at highest risk of violence were young, substance abusing, but not necessarily with prior convictions. Those who threaten others were also found to be at greater risk of killing themselves or being killed.

Objective:  The only systematic studies of attacks on public figures come from the USA. These studies de‐emphasize the role of mental illness and suggest threats are of no predictive value. This study re‐examines these questions through a study of attacks on European politicians.Method:  All non‐terrorist attacks on elected politicians in Western Europe between 1990 and 2004 were analysed.Results:  Twenty‐four attacks were identified, including five involving fatalities, and eight serious injuries. Ten attackers were psychotic, four drunk, nine politically motivated and one unclassifiable. Eleven attackers evidenced warning behaviours. The mentally disordered, most of whom gave warnings, were responsible for most of the fatal and seriously injurious attacks.Conclusion:  A greater awareness of the link between delusional fixations on public figures and subsequent attacks could aid prevention. Equally importantly, recognition would encourage earlier intervention in people who, irrespective of whether they eventually attack, have delusional preoccupations which ruin their lives.

In 1912, Karl Jaspers published an article entitled "The Phenomenological Approach to Psychopathology." This and his subsequent text, General Psychopathology, was to exert a profound influence on the development of psychiatry in general and psychiatric nosology in particular. The current Diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases both reflect, at least in part, that legacy. This article will argue that the descriptive psychopathology of Jaspers has been gradually transformed into a caricature which has substituted authority for enquiry and simplification for subtlety. We have been left with classificatory systems which impose reified categories increasingly at variance with clinical reality and increasingly divorced from the data generated by scientific enquiry. Returning to the phenomenological method, despite its contradictions, may open the way to clinical and research approaches which free us from the current straight jacket of orthodoxy which is impending our progress.