NIMH's Insel:"Our failure to talk about the risk [of violence] has lead to a loss of credibility..."
SRF: I just noticed a new paper from the CATIE study showing that violence in schizophrenia has roots in pre-disease conduct problems (Swanson et al., 2007). It seemed like a fitting bookend, if you will, for a year that saw the death of Wayne Fenton and the killings at Virginia Tech, and so I wonder if we should be cautiously optimistic that a study like this could have some positive impact on efforts to combat stigma and perhaps focus research on root causes of violence and things like that. Any thoughts about that?
TI: Yes, it's a really interesting question; I like the way you posed it. In the past, my own sense of the community is that there's been an avoidance of talking about violence in schizophrenia because of a concern that it would increase the stigma. In fact, the data support the proposition that people with schizophrenia are more likely to be involved in violence either toward others or toward themselves unless they're treated. So there's every reason to treat people with this illness to reduce violence. But we also shouldn't avoid discussing the risk of violence in those who are not treated. Our failure to talk about the risk has led to loss of credibility in some of our attempts to reduce stigma. People with this illness, or with bipolar illness during the manic phase, are more likely to be violent than the general population by several-fold. Some people estimate that 50 percent of manic episodes involve violence, sometimes self-directed but other times not. What's interesting about this new study is that it breaks down the problem here; at least it clarifies that we may be talking about two quite different things. On the one hand, people who have a history of conduct disorder and who are at a greater risk for violence towards others, and for whom schizophrenia in some ways disinhibits them, exacerbates violent tendencies that they've had in the past. And that appears very different from people who are schizophrenic and are acting out a delusional fantasy.
As to the Wayne Fenton murder, in recent newspaper coverage of that, this young man said that he had a particular delusion about Dr. Fenton and he was trying to liberate Dr. Fenton's soul as a way of cleansing it. That's not sociopathy.