Schizophrenia is a lifelong, severe psychotic condition. Ten percent of people will have at least one episode of schizophrenia during their lifetime with symptoms comprising of delusions, hallucinations and disorganized thinking. The causes of schizophrenia include among others genetic predisposition, obstetric complications, and illegal drug use. Individuals with schizophrenia are at an increased risk for violence due to specific psychotic symptoms leading to ramifications for those living with people with schizophrenia, their families and mental health care professionals.  Although some studies found little or no increased risk of violence among patients with schizophrenia compared with that of the general population, many others found a marked increase in violent offending in patients with the disease owing in large part to substance abuse comorbidity.

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 Schizophrenia is a chronic and severe mental disorder affecting how a person thinks, feels, and behaves and who may appear to have lost touch with reality. “Schizophrenia is the most chronic and debilitating of all psychological disorders” (Introduction, 2010).  It is also a progressive disease and when symptoms first materialize, can appear to be mild. The most common condition reported by 75% of the patients is auditory hallucinations and they can come in the form of imaginary voices that “curse them, comment on their behavior, order them to do things, or warn them of danger (Introduction, 2010).  According to Walsh & Yun (2013), there is an array of subtypes of schizophrenia categorized according to the symptoms exhibited. “Some individuals are unkempt, illogical, and frenetic (disorganized), some are rigid, unresponsive, slow moving and sometimes totally immobile (catatonic), and some are hostile and distrusting (paranoid).” It is the latter type that is most prone to overt physical aggression (Walsh & Yun, 2013) and it is also the latter subtype that is of concern when researching the link between schizophrenia, drug abuse and violence. 

 The World Health Organization defines violence as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, mal-development or self-harm and suicidal behavior” (“Violence”, 2016).  This applies to both the mentally ill and the non-mentally ill.  Even though those offenders with a mental illness such as schizophrenia have similar risk factors for criminal behavior as those free of mental illness, it does not signify that mental illness had nothing to do with it. Violence can occur with schizophrenic patients at almost any age but seems to frequently first appear in adolescence. “Psychosis typically develops during late adolescence and early childhood” (Peterson & Heinz, 2016).  It is during this time that patients are exploring relationships, maybe attending college and developing their identities. When schizophrenia symptoms begin their progression, unemployment, relationship difficulties and detrimental peer groups grow leading to criminal behavior in young people (Peterson & Heinz, 2016).  Schizophrenia and violence is not limited only to the young.  Overall, persons with schizophrenia are believed to commit violent crime four to six times the level of the general population without schizophrenia (Fazel, Långström, Hjern, Grann & Lichtenstein, 2016). Both men and women with schizophrenia are subject to non-violent as well as violent criminal behavior offenses.

 Research indicates that schizophrenia and violence can befall both sexes.  According to Hodgins (2008),  “There is now robust evidence demonstrating that both men and women with schizophreniaare at elevated risk when compared to the general population to be convicted of non-violent criminal offences, at higher risk to be convicted of violent criminal offences, and at even higher risk to be convicted of homicide.”  A study of a birth cohort constituting all of the 358,180 persons born in Denmark between 1944 and 1947 were followed until they reached their mid-forties excluding those who had either died or emigrated before the end of the follow up period (Hodgins, 2008).  Elevated risks were discovered especially for women. When “official criminal records of cohort members who had been admitted to a psychiatric ward at least once with a discharge diagnosis of schizophrenia were compared with those with no psychiatric admission…the risk of a violent crime was elevated 4.6 (3.8–5.6) times among the men and 23.2 (14.4–37.4) times among the women with schizophrenia when compared with those with no admissions to a psychiatric ward” (Hodgins, 2008). Also according to Hodgins (2008), similar results of elevations in risk were realized in other birth and populations cohorts, therefore not limiting data to one geographical area or timeframe.  Many studies have been conducted on the relationship of schizophrenia and violent offending and most prove similar results.

 Additional research also indicates a higher level of occurrence of violence in schizophrenia sufferers.  Fazel, Gulati, Linsell, Geddes, & Grann (2009) report that the results of 20 individual studies were identified and the total number of schizophrenia and other psychoses cases in the included studies was 18,423 with 1,832 or 9.9% as violent. They were then compared with 1,714,904 individuals in the general population, of whom only 27,185 or 1.6% were violent substantiating the higher level of violence found in the schizophrenia population. These publications were from 11 countries including the United States. “Violence was ascertained from register-based sources in 13 studies, by self-report and informants in five others, and in two investigations by both methods (Fazel & Gulati et al., 2009).  It is well established that there is a rise in violence in schizophrenia patients.  It is also well established that the abuse of drugs, alcohol, nicotine and cannabis increases the rates in both schizophrenia and violence.

 The connection between schizophrenia, violence and violent offending is elevated by substance abuse comorbidity.  Peterson & Heinz (2016) state that one of many pathways from symptoms to crime is through substance abuse where 50% of psychiatric inpatients had a co-occurring substance abuse disorder (SUD) especially for those living in poverty. The likelihood of having a substance abuse disorder is nearly two times higher among people with serious mental illness such as schizophrenia than in the general population according to Peterson & Heinz (2016) and national surveys. Research by Hambrecht and Häfner (1996) supports that “the onset and course of schizophrenia and substance abuse were retrospectively assessed in a representative first-episode sample of 232 schizophrenic patients. Information by relatives validated the patients’ reports”.  Those abusing alcohol prior to their first admission was 24% and drug abuse was 14%, which is two times the rates of the general population (Hambrecht & Häfner, 1996). A substantial number of schizophrenic patients develop substance abuse comorbidity in order to self-medicate hoping to alleviate some of their symptoms. Winklbaur, Ebner, Sachs, Thau, and Fischer (2006) report that “self-medication is primarily used in order to deal with negative symptoms, such as social withdrawal and apathy, dysphoria, and sleeping problems, as well as drug use, in an attempt, to decrease discomfort from the side effects of antipsychotic medication” while Peterson and Heinz (2016) state that self-medicating in schizophrenic individuals “can ultimately lead to criminal justice involvement.”  Additionally, Winklbaur et al. (2006) suggest that schizophrenic women with substance abuse difficulties are insufficiently identified prohibiting them from getting the treatment they need. Schizophrenic patients with substance abuse comorbidity are at a greater risk of committing violent crimes because it appears to exacerbate the problem. 

 Those with substance use disorders and schizophrenia tend to react to the use of common drugs (all drugs) and specific ones such as nicotine and marijuana in harmful ways. The study by Fazel & Gulati et al. (2009), demonstrates that there is an association between schizophrenia and violence, and shows that this association is greatly increased by drug and alcohol abuse. The study goes on to reveal that the rate of violent crime in individuals diagnosed as having schizophrenia and substance abuse comorbidity at 27.6% was significantly higher than in those without comorbidity at 8.5% (Fazel & Gulati et al., 2009), a difference of 19.1%.  Obviously it is nicotine that is the most prevalent drug abused by schizophrenia patients most likely due to its legal standing and ability to be easily attained as well as the “self-medicating” effect it has on the patients, but nicotine on its own is not likely to cause violent behavior.  However, it seems likely that nicotine use in schizophrenic patients would also accompany other drug use.  Cannabis is also frequently abused by schizophrenic patients worsening their clinical outcomes. “For example, a recent magnetic resonance imaging study concluded that the loss of gray matter, commonly seen in the brains of schizophrenic patients, proceeds nearly twice as fast in patients who also used cannabis over a 5-year follow-up” (Volkow, 2009).  Therefore it follows that cannabis use increases the likelihood of a person contracting schizophrenia so consequently those schizophrenic patients who have SUD comorbidity are more inclined to commit a violent act. It also follows that comorbid schizophrenia patients have two issues they need to deal with in order to lower the levels of schizophrenia, SUD comorbidity, and violence.

 Available evidence in the form of research and studies indicate that there is a relationship between schizophrenia and non-violent/violent crimes and that it increases with the addition of substance abuse comorbidity. The above three elements are found in a heterogeneous population and do not point to any one type of population.  However, results show that women having both schizophrenia and substance abuse comorbidity are less like to receive the diagnosis and treatment that they need. As with any mental illness, there does not seem to be enough understanding of each disease and without that, adequate treatments only seem to be waiting in the wings to be discovered and implemented.

 People with mental illness, especially those with schizophrenia, often are highly misunderstood and I am guilty of it myself.  It is said that “knowledge is power” and I have discovered Sir Francis Bacon’s statement to be true. With any illness, mental or physical, the problems need to be understood before diagnoses and effective intervention and treatment can be established.  If substance abuse comorbidity in a schizophrenic patient is not discovered, treating only the schizophrenia is treating only half the problem. Clinical treatment for drug abuse might not diagnose the schizophrenia while mental health professionals might fail to observe co-occurring substance abuse problems. Add to that the strong possibility that a comorbid schizophrenic individual will commit a violent crime, it is imperative that additional research be conducted because I believe that great numbers of law enforcement would not have the concern, consideration or understanding of the those with schizophrenia who commit a crime. Any infirmity weakens a patient, but one who has schizophrenia is especially vulnerable due to the mental disturbance and most likely having less understanding of one’s situation. This leaves them open to injury, more illness and in all probability homelessness not to mention incarceration all of which prevent them from treatment.  If mankind can view schizophrenia, not as a “mental disease” but rather a disease of the brain circuitry, there would be less sigma and more understanding associated with it.  As Andrei Lankov puts it:  To not have your suffering recognized is an almost unbearable form of violence.  

Works Cited

*Fazel, S., MD, Långström, N., MD, PhD, Hjern, A., PhD, Grann, M., PhD, & Lichtenstein, P., PhD. (2009). Schizophrenia, Substance Abuse, and Violent Crime. Journal of the American Medical Association, 301(19), 2016-2023. doi:doi: 10.1001/jama.2009.675

*Fazel S., Gulati G., Linsell L., Geddes JR., Grann M. (2009) Schizophrenia and Violence: Systematic Review and Meta-Analysis. PLoS Med6(8): e1000120. https://doi.org/10.1371/journal.pmed.1000120

*Hambrech, M., & Häfner, H. (1996). Substance abuse and the onset of schizophrenia. [Abstract]. Biological Psychiatry, 40(11), 1155-1163. doi:https://doi.org/10.1016/S0006-3223(95)00609-5

*Hodgins, S. (2008).Violent behaviour among people with schizophrenia: a framework for investigations of causes, and effective treatment, and prevention. Philosophical Transactions of the Royal Society B: Biological Sciences, 363(1503), 2505-2518. doi:10.1098/rstb.2008.0034

*Introduction to Psychology. (2010). University of Minnesota Libraries Publishing. doi:https://doi.org/10.24926/8668.1201

*Peterson, J., & Heinz, K. (2016). Understanding Offenders with Serious Mental Illness in the               Criminal Justice System. Mitchell Hamline Law Review, 42(2), 3rd article, 538-562. Retrieved October 19, 2017, from : http://open.mitchellhamline.edu/mhlr/vol42/iss2/3

*Varshney M., Mahapatra A., Krishnan V., Gupta R., Deb KS. Violence and mental illness: what               is the true story? Journal of Epidemiology and Community Health. 2016;70(3):223-225.               doi:10.1136/jech-2015-205546.

*Volkow ND. Substance Use Disorders in Schizophrenia—Clinical Implications of Comorbidity. Schizophrenia Bulletin. 2009;35(3):469-472. doi:10.1093/schbul/sbp016.

Violence. (2017). Retrieved October 18, 2017, from http://www.who.int/topics/violence/en/

*Walsh, A and Yun, I. (2013). “Schizophrenia: Causes, Crime, and Implications for Criminology and Criminal Justice”. International Journal of Law, Crime and Justice, 41(2), 188-202. http://dx.doi.org/10.1016/j.ijlcj.2013.04.003

*Winklbaur B, Ebner N, Sachs G, Thau K, Fischer G. Substance abuse in patients with schizophrenia. Dialogues in Clinical Neuroscience. 2006;8(1):37-43.