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Original Investigation |

Triggers for Violent Criminality in Patients With Psychotic Disorders

Amir Sariaslan, PhD1; Paul Lichtenstein, PhD2; Henrik Larsson, PhD2,3; Seena Fazel, MD1
[+] Author Affiliations
1Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, United Kingdom
2Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
3Department of Medical Sciences, Örebro University, Örebro, Sweden
JAMA Psychiatry. 2016;73(8):796-803. doi:10.1001/jamapsychiatry.2016.1349.
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Importance  Absolute and relative risks of violence are increased in patients with psychotic disorders, but the contribution of triggers for violent acts to these risks is uncertain.

Objective  To examine whether a range of triggers for violent acts are associated with risks of violence in patients diagnosed with psychotic disorders and in individuals without a psychiatric diagnosis.

Design, Setting, and Participants  Using a sample of all individuals born in Sweden between 1958 and 1988 (N = 3 123 724), we identified patients in the National Patient Register who were diagnosed with schizophrenia spectrum disorders (n = 34 903) and bipolar disorder (n = 29 692), as well as unaffected controls (n = 2 763 012). We then identified, within each subsample, persons who had experienced any of the following triggers for violent acts between January 1, 2001, and December 15, 2013: exposure to violence, parental bereavement, self-harm, traumatic brain injury, unintentional injuries, and substance intoxication. By using within-individual models, we conducted conditional logistic regression to compare the risk of the individual engaging in violent acts in the week following the exposure to a trigger with the risk during earlier periods of equivalent length. All time-invariant confounders (eg, genetic and early environmental influences) were controlled for by this research design and we further adjusted for time-varying sociodemographic factors.

Main Outcomes and Measures  Adjusted odds ratios (aORs) of violent crime occurring in the week following the exposure to a trigger event compared with earlier periods.

Results  Among the sample of 2 827 607 individuals (1 492 186 male and 1 335 421 female), all of the examined trigger events were associated with increased risk of violent crime in the week following exposure. The largest 1-week absolute risk of violent crime was observed following exposure to violence (70-177 violent crimes per 10 000 persons). For most triggers, the relative risks did not vary significantly by diagnosis, including unintentional injuries (aOR range, 3.5-4.8), self-harm (aOR range, 3.9-4.2), and substance intoxication (aOR range, 3.0-4.0). Differences by diagnosis included parental bereavement, which was significantly higher in patients with schizophrenia spectrum disorders (aOR, 5.0; 95% CI, 3.0-8.1) compared with controls (aOR, 1.7; 95% CI, 1.3-2.2).

Conclusions and Relevance  In addition to identifying risk factors for violence, clarifying the timing of the triggers may provide opportunities to improve risk assessment and management in individuals with psychotic disorders.

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Figure.
Relative Risks of Violent Crime

Violent crime occurring in the week following exposure to a trigger compared with control periods across patients with psychotic disorders and controls. Within-individual estimates adjusted for age, calendar month, single status, low educational level, frequent residential relocations, low family income, residence in deprived neighborhoods, and being the recipient of unemployment benefits, social assistance, or disability pension benefits.

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