Fighting Fear

Confronting phobias and other fears

The Relationship Between Violence and Psychotic Disorders

They are both common—but occur together uncommonly.

Violence is extremely common, violent crimes occurring literally in the hundreds of thousands every year. Individuals assault each other impulsively, almost casually, even those whom they love. The causes of violence are, consequently, the subject of much attention—especially now, in the wake of a number of mass shootings. Every time someone commits a violent act so egregious that it comes to public notice, a dozen reasons are given for it and for all acts of violence. Poverty is blamed, or prejudice, or overcrowding. But the truth is that the causes of violence are innumerable.

Mental illness is commonly alleged to be a principal cause for violent behavior. For that reason many uninformed people are frightened of someone who is obviously disturbed emotionally. Yet mental illness, like most physical illness, tends to impair the individual’s ability to act, aggressively or in any other way. Only a few such conditions have a significant potential to precipitate a violent act. Among these is paranoid schizophrenia, which may affect the individual so that he comes to believe that people are persecuting him. He may then attack whomever he imagines his enemies to be. Certain drugs—for example, amphetamines—produce psychotic paranoid states which can be dangerous for the same reason. As everyone knows, alcoholic intoxication, because it lowers impulse control, causes some people to become violent; and if they are chronic alcoholics, they become violent over and over again.

Certain rare forms of epilepsy and other confusional states that sometimes occur as a complication of organic disease may cause the individual to strike out indiscriminately at whoever is nearby; but since these attacks are unpremeditated and uncoordinated, they do not often result in someone being injured. Occasionally, sexually deviant individuals become notorious by committing sadistic or murderous acts, but they too are unusual and represent the behavior of only a tiny fraction of those who arc sexually disturbed or deviant. There are in addition certain very dangerous, very strange, hysterical psychoses—such as amok—which stimulate the individual to sudden and usually short—lived bouts of murder, but these are exceedingly rare. And they occur mostly in islands of the South Pacific.


And there are still other people who are labeled with a psychiatric diagnosis, such as explosive personality, precisely because they are repeatedly violent irrationally and with little provocation. Such a term signifies nothing at all about them beyond the fact that they are indeed violent.  Certainly they are not psychotic, or mentally ill in any conventional sense. It is true, of course, that any psychotic or neurotic person can commit a violent act, but only because any person at all can commit such an act. The fact is that violence is an uncommon complication of mental illness.

Some attempts have been made to predict who will become violent, and who having once been violent, perhaps criminally violent, will become violent again. Not much success has been achieved. Psychiatrists, who are often charged legally with the responsibility for determining whether or not someone is dangerous, are often wrong, judging by subsequent events. What is not commonly appreciated is that these professionals are likely to exaggerate the danger rather than minimize it. They are more likely to hold patients indefinitely in a hospital on the sometimes arbitrary presumption of their dangerousness than they are to release homicidal persons into the community carelessly, as they are often accused of doing.

The indicators, such as they are, by which a person’s potential for violence is judged, are as follows:

  1. A previous history of violence. The more frequent and more vicious someone’s past violent acts, the more likely he is to be violent again. Often adults who have committed crimes of violence give a long history of other similar acts, dating back to their childhood. They may have had difficulty in school because of fighting. Or they may have exhibited an odd triad of symptoms: bed-wetting, fire-setting, and cruelty to animals. Probably any act of cruelty or wanton destructiveness is a sign of a defect of personality which may manifest itself at some point in the willful injury of others.
  2. Menacing behavior. Someone who threatens violence when he or she is angry, or who punches walls or breaks furniture, or who in some other way shows poor impulse control, is likely to strike out at someone when  particularly angry. Similarly, someone who nurses a grievance and constructs plans for revenge may undertake someday to consummate those plans. Threats are sometimes a prelude to an overt act. Threats can be expressed also nonverbally through the individual’s demeanor. Some people, before losing control, give warning by quarreling and shouting and by becoming agitated—in short, by appearing as if they are about to lose control.  And some people, of course, openly state their intention of committing a violent act.
  3. A pattern of engaging in activities where violent encounters are likely to occur. Certain social settings undermine the usual strictures against violence. For instance, someone in a rioting mob is capable of perpetrating a violent act even though ordinarily he is in good control of himself. Similarly, a person who frequents bars constantly or who associates with drug addicts places himself in a setting where violent behavior is tacitly encouraged because it is construed as a sign of manhood. Consequently, such a person may learn to be violent. Such learning occurs also in certain families so consumed by rage that their members repeatedly attack each other physically. Merely living with such a family is an incitement to violence.

As people become violent for different reasons, they are also violent in different ways:

One man became drunk regularly and punched his wife and children when he came home. On one occasion, his wife, presumably in a spirit of self-defense, stabbed him with a kitchen knife, precipitating the need for an emergency operation in order to save his life.

Another man, after a fight with his father, went to a park where he raped the first woman he saw. Another man, when he became angry at his wife, shot a rifle out of his window at passing cars.

A woman who had had no previous history of violent or abnormal behavior became so desperate upon delivering an illegitimate child that she killed it by throwing it into an incinerator.

A 12-year-old boy kicked his younger siblings at every opportunity and finally killed one of them with a hammer.

These examples could be multiplied endlessly. The variety of violence is extraordinary. The attendant risk to others depends on the strength and the intent of the violent impulse, the circumstances under which it arises, and the response those people who are immediately present.

Treatment
The violent person is usually violent again and again; therefore proper treatment must extend past the moment of violence itself and over a period of time. His therapist—who in this case may be almost anyone, a parole officer perhaps, or even a lawyer—must accomplish with this difficult patient the basic goals of any therapy. He must establish a trusting relationship between them in which the patient can express frustration verbally instead of by striking out. Indeed, they must be able to discuss openly not only the patient’s violence but all of his, or her, behavior.

Obviously the first principle of managing someone potentially violent is to see to it, as far as possible, that he does not in fact injure anyone, for his own sake as well as for everyone else’s. Even for a psychopath, the knowledge of having harmed another human is terrible.

Consequently, if it seems that there is a real risk of someone becoming violent, the police or other legal authorities should be involved promptly, at a time when they can prevent his actions rather than punish them. Some people, rather than call the police, play the role of victim over and over. Being so passive, perhaps masochistic, they may actually provoke attacks on themselves. No one should subject himself, or herself, to repeated physical assaults—or allow others to be subjected to them. Surprisingly, some people refuse to take the dangerousness of physical attack seriously, especially if they are not themselves the victim.

An army corporal was sent for psychiatric examination after he was found choking another soldier in the bathroom of his barracks. It was the third such assault he had committed that month, each time on a different person. Each time, the attack was interrupted fortuitously by other personnel who happened to walk into the room. The only explanation the corporal gave for these attacks was that these individuals “did not deserve to live;” and so he set out to kill them. There was no particular reason why they were undeserving of life. In fact when pressed, the corporal went so far as to admit that so far, at the age of 19, he had not yet come across anyone who in his judgment deserved to live.

His life before he entered the army was marked by one violent incident after another. When he was small, he tortured arid killed small animals, then larger animals when he was older. He committed petty larceny at an early age, then graduated to armed robber and assault with a deadly weapon. He attacked members of his own family, once with a wrench. From the time he was ten, his family refused to allow him in the house, and he lived thereafter in different foster homes and then different reformatories, one after another. Finally, when he was 18 years old, a judge who found him guilty of assault gave him the choice of serving a jail sentence or of enlisting in the army. He chose to enlist.

The psychiatrist contacted the corporal’s commanding officer and asked why the corporal, who was so obviously dangerous, had not been discharged from the service following the first of these three serious assaults. “Because he’s the best gunner I have,” replied the captain unabashedly. The fact that the United States happened to be at peace at the time made no difference. Taken aback, the psychiatrist asked the captain what it would take to convince him that the corporal was potentially homicidal. “Only if he killed someone,” the captain said. “Anyone who really wants to kill someone has no trouble doing it.”

The corporal was discharged from the service on psychiatric grounds before this provocative theory could be put to the test.

Violent behavior should never be overlooked, for it is an indicator of more violence to come. However, the present attention paid to psychiatric patients, although welcome for other reasons, is not likely to work as a way of preventing  mass shootings.  A murder can take place even when someone is being observed closely, just as suicide can. (c) Fredric Neuman Excerpted from "Caring: Home Guide for the Emotionally Disturbed." Follow Dr. Neuman's blog at fredricneumanmd.com/blog/ or ask advice at fredricneumanmd.com/blog/ask-dr-neuman-advice-column/

Fredric Neuman, M.D. is the Director of the Anxiety and Phobia Center at White Plains Hospital.

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