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Original Investigation |

Pathways to Violent Behavior During First-Episode Psychosis:  A Report From the UK National EDEN Study

Catherine Winsper, PhD1; Swaran P. Singh, MBBS, MD, DM, FRCPsych1; Steven Marwaha, PhD1; Tim Amos, MB, BS, MRCPsych2; Helen Lester, MB, BCH, MD3; Linda Everard, BSc4; Peter Jones, MB, BS, PhD5; David Fowler, PhD6; Max Marshall, MB, BS, PhD7; Shon Lewis, MB, BS, PhD7; Vimal Sharma, PhD, FRCPsych8; Nick Freemantle, PhD9; Max Birchwood, BSc, PhD, DSc, CPsychol, FBPsS10
[+] Author Affiliations
1Warwick Medical School, University of Warwick, Coventry, England
2Academic Unit of Psychiatry, Oakfield House, Oakfield Grove, Bristol, England
3Schools of Health and Population Sciences, Primary Care Clinical Sciences Building, University of Birmingham, Birmingham, England
4The Early Intervention Service, Birmingham, England
5Department of Psychiatry, University of Cambridge and CAMEO, Cambridge and Peterborough NHS Foundation Trust, Cambridge, England
6University of East Anglia, Norwich Research Park, Norwich, England
7Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, England
8Cheshire and Wirral Partnership, NHS Foundation Trust, Early Intervention Service, Cherry Bank Resource Centre, Cheshire, England
9Department of Primary Care and Population Health, University College London Medical School, London, England
10School of Psychology, University of Birmingham, Birmingham, England
JAMA Psychiatry. 2013;70(12):1287-1293. doi:10.1001/jamapsychiatry.2013.2445.
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Importance  Although many studies have explored the correlates of violence during first-episode psychosis (FEP), most have simply compared violent psychotic individuals with nonviolent psychotic individuals. Accumulating evidence suggests there may be subgroups within psychosis, differing in terms of developmental processes and proximal factors associated with violent behavior.

Objective  To determine whether there are subgroups of psychotic individuals characterized by different developmental trajectories to violent behavior.

Design, Setting, and Participants  The National EDEN (Evaluating the Development and Impact of Early Intervention Services in the West Midlands) Study longitudinal cohort assessed premorbid delinquency (premorbid adjustment adaptation subscale across childhood and adolescence), age at illness onset, duration of untreated psychosis, past drug use, positive symptoms, and violent behavior. Group trajectories of premorbid delinquency were estimated using latent class growth analysis, and associations with violent behavior were quantified. This study included 6 early intervention services in 5 geographical locations across England, with violent behavior information available for 670 first-episode psychosis cases.

Main Outcomes and Measures  Violent behavior at 6 or 12 months following early intervention services entry.

Results  Four groups of premorbid delinquency were identified: stable low, adolescent-onset high to moderate, stable moderate, and stable high. Logistic regression analysis, with stable low delinquency as the reference group, demonstrated that moderate (odds ratio, 1.97; 95% CI, 1.12-3.46) and high (odds ratio, 3.53; 95% CI, 1.85-6.73) premorbid delinquency trajectories increased the risk for violent behavior during FEP. After controlling for confounders, path analysis demonstrated that the increased risk for violence in the moderate delinquency group was indirect (ie, partially mediated by positive symptoms) (probit coefficient [β] = 0.12; P = .002); while stable high delinquency directly increased the risk for violence (β = 0.38; P = .05).

Conclusions and Relevance  There appear to be diverse pathways to violent behavior during FEP. Stable high premorbid delinquency from childhood onwards appears to directly increase the risk for violent behavior, independent of psychosis-related risk factors. In addition to tackling illness-related risks, treatments should directly address antisocial traits as a potent risk for violence during FEP.

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Figure 1.
Path Model Showing the Estimated Direct Paths Within the Final Model

Indirect (mediated) paths (not shown) were modeled via age at onset, duration of untreated psychosis (DUP), past drug use, and positive symptoms. Fit indices: χ2 = 6.46; P = .09; root mean square error of approximation = 0.04; Comparative Fit Index = 0.98. EIS indicates early intervention service.aStable low delinquency as the reference group.

Graphic Jump Location
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Figure 2.
Growth Trajectories of Delinquency From Childhood to Late Adolescence (Controlling for Sex)

There were 4 distinct trajectories of delinquency from childhood to late adolescence.

Graphic Jump Location




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