Course of violence in patients with schizophrenia: relationship to clinical symptoms

To understand the heterogeneity of violent behaviors in patients with schizophrenia, one must consider underlying clinical symptoms of the illness and their change over time. The purpose of this study was to examine persistence and resolution of violence in relation to psychotic symptoms, ward behaviors, and neurological impairment. Psychiatric symptoms and ward behaviors were assessed in violent inpatients with schizophrenia or schizoaffective disorder and in nonviolent controls on entry into the study. Patients were followed for 4 weeks; those who showed resolution of assaults over this time were classified as transiently violent, and those who remained assaultive were categorized as persistently violent. At the end of the 4 weeks, psychiatric symptoms, ward behaviors, and neurological impairment were assessed. Overall, the two violent groups presented with more severe psychiatric symptoms and were judged to be more irritable than the nonviolent control subjects, but the transiently violent patients showed improvement in symptoms over time. At the end of 4 weeks, the persistently violent patients had evidence of more severe neurological impairment, hostility, suspiciousness, and irritability than the other two groups. Canonical discriminant analyses identified two significant dimensions differentiated the groups. The first, characterized by positive psychotic symptoms, differentiated the violent patients from the control subjects; the second, characterized by neurological impairment and high endpoint score for negative symptoms, differentiated the transiently from the persistently violent patients. Identification of certain symptoms associated with different forms of violence has important implications for the prediction and differential treatment of violent behavior in patients with schizophrenia.