587745 research-article2015
ANP0010.1177/0004867415587745ANZJP ArticlesSimpson et al.
Research
Developmental typologies of serious mental illness and violence: Evidence from a forensic psychiatric setting
Australian & New Zealand Journal of Psychiatry 1–12 DOI: 10.1177/0004867415587745 © The Royal Australian and New Zealand College of Psychiatrists 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
Alexander I Simpson1,2, Teresa Grimbos1, Christine Chan3 and Stephanie R Penney1,2
Abstract Objective: To identify subgroups of forensic psychiatric patients based on the age onset of serious mental illness and offending and assess the external validity of the subgroups with theoretically based sociodemographic, clinical, legal and risk-related variables. Method: The age onset of serious mental illness and criminal contact was ascertained for a sample of 232 patients. A range of sociodemographic, clinical, legal and risk-related variables were coded to assess whether age onset subgroups differed in a manner consistent with the literature on typologies of mentally ill offenders. Results: One-quarter of the sample was classified as early starters (patients whose first offense occurred before becoming mentally ill), while two-thirds were late starters (where first offense occurred following illness onset). A small percentage (8%) of patients were deemed late late starters, defined as late starters who had experienced 10+ years of illness and were >37 years upon first arrest. A larger proportion of early starters had a substance use disorder, antisocial personality disorder and a greater number of static/historical risk factors for violence. Early starters were younger upon first arrest and had more previous criminal contacts compared to late starters and late late starters. Mental illness was found to start later in life for late late starters; this group was also more likely to have been married and to have a spouse as victim in the index offense. Conclusion: We found support for distinct subgroups of mentally ill offenders based on the age onset of illness and criminal contact. Compared to late starters, offenses committed by early starters may be motivated more frequently by antisocial lifestyle and attitudes, as well as more instrumental behaviors related to substance abuse. In addition, late late starters may represent a distinct third subgroup within late starters, characterized by relatively higher levels of functioning and social stability; future work should replicate. Findings suggest different rehabilitation needs of the subgroups. Keywords Typologies, age onset, serious mental illness, offending, violence
Introduction Evidence suggests that individuals with serious mental illness (SMI) are at elevated risk of violence (Brennan et al., 2000; Douglas et al., 2009), including homicide (RichardDevantoy et al., 2009; Simpson et al., 2004; Taylor and Gunn, 1999; Wallace et al., 1998). However, people with SMI may behave violently for a variety of motivations (Nestor, 2002), including as a direct result of positive symptoms of psychosis or when symptoms result in heightened stress or exposure to provocation (Hiday, 1997). Other ‘conventional’ risk factors are relevant to the violence committed by those with SMI: neurocognitive impairments, early behavioral problems, substance misuse and antisocial
personality are more common in people with schizophrenia (Andrews et al., 2006) and may partly explain the increased 1Complex
Mental Illness Program (Forensic Division), Centre for Addiction and Mental Health, Toronto, ON, Canada 2Department of Psychiatry, University of Toronto, Toronto, ON, Canada 3Department of Public Health, University of Liverpool, Liverpool, UK Corresponding author: Alexander I Simpson, Complex Mental Illness Program (Forensic Division), Centre for Addiction and Mental Health, 1001 Queen St West, Toronto, ON M6J 1H4, Canada. Email: [email protected]
Australian & New Zealand Journal of Psychiatry
Downloaded from anp.sagepub.com at University of Birmingham on June 1, 2015
2 prevalence of violence in SMI (Hodgins, 2008). In addition, varying developmental trajectories to violence are well documented: in particular, Moffitt’s taxonomy differentiating life course persistent (LCP) and adolescent-limited (AL) offenders has shown that early and severe childhood behavior problems are associated with violence and criminality, as well as significant mental and physical health problems that persist into adulthood (Moffitt, 1993; Moffitt et al., 2002; Piquero et al., 2010; Satterfield et al., 2007). A similar distinction has been made for individuals with psychotic illnesses who offend. Hodgins (Hodgins, 2008; Hodgins et al., 2014) proposed that the age at which antisocial behaviors emerge is a key variable to identify those whose offending is the result of illness as opposed to other criminogenic risk factors. She posited three trajectories to violence among individuals with SMI: (1) Type I offenders (‘early starters’, or ES), who exhibit antisocial behavior that begins in childhood or adolescence, prior to illness onset, and persists into adulthood; (2) Type II offenders (‘late starters’, or LS), who exhibit no antisociality prior to becoming mentally ill, but who are repeatedly violent following the onset of illness; and (3) Type III offenders (‘late late starters’, or LLS), who suffer from a chronic SMI, but who exhibit no aggression until one or two decades after illness onset, when they commit a single and serious violent offense often against someone caring for them. Whereas the violence witnessed in Type I offenders is thought to be influenced by specific genes conferring vulnerability for both early conduct problems and SMI, Type II and III offenders may be more influenced by post-illness neurological changes, including those caused by illness, substance misuse and psychotropic medication (Hodgins et al., 2014). A small number of studies have investigated ES and LS subgroups on a number of dimensions (see Table 1), lending support to the existence of distinct subgroups showing varying trajectories to violence. Unfortunately, ES and LS groups have not been consistently operationalized across studies, and just one study (Van Dongen et al., 2014, 2015) has investigated the LLS group. One approach has been to define the groups on the basis of whether the first incident of offending occurred before (ES) or after (LS) 18 years of age (Hodgins and Janson, 2002; Laajasalo and Hakkanen, 2005; Pedersen et al., 2010b; Tengström et al., 2001) or whether or not they had a diagnosis of conduct disorder prior to age 15 (Mathieu and Côté, 2009; Sánchez-SanSegundo et al., 2014). A second approach defines ES as those with an age of first arrest or violence which is less than the age onset of their SMI, and vice versa for the LS (Jones et al., 2010; Kooyman et al., 2012; Taylor, 1993; Van Dongen, 2014, 2015). This latter approach is arguably more developmentally meaningful, being sensitive to the interrelationship between the age onset of illness and offending. Van Dongen et al. (2014, 2015) studied the LLS group in a sample of forensic inpatients based on the timing of their first offense vis-à-vis the onset of psychosis (ES = offending
ANZJP Articles before onset; LS and LLS = offending only after onset), as well as age (LS 34 years old). Each group was compared with civil psychiatric non-offenders within the same community. The authors found that LLS comprised a small proportion of their sample (7%) and that substance misuse was significantly less likely among LLS compared to ES and non-offenders with schizophrenia. Although still evident in both ES and LS, persecutory delusions were most strongly associated with membership in the LLS group, while the ES group had more antisocial personality traits, conduct problems in adolescence and substance use problems (Van Dongen et al., 2014). LS were not compared to LLS on these latter dimensions. The authors concluded that there are more similarities than differences between LS and LLS and inferred that offending in these two groups is associated with positive symptoms (particularly delusions) but not with antisocial traits as in ES. Taken together, the research in Table 1 has established that ES, as compared to LS, show earlier behavioral problems and greater adversity in childhood, greater criminal involvement and higher rates of antisocial personality disorder (ASPD) and substance misuse. They are more likely to be male and less educated than LS. Differences in the onset and severity of psychiatric problems are less clear; it may be that LS developed psychiatric problems at an earlier age and had more severe psychiatric issues as evidenced by more frequent hospitalizations. Research regarding whether LLS exists as a third subgroup is limited, as well as how this group may differ from ES and LS.
Aims of the study This study investigates whether discrete subgroups of forensic psychiatric patients exist based on the age onset of SMI and offending. Subgroups were constructed based on the relative timing of SMI and criminal contact, and we investigated whether evidence of a third subgroup of SMI offenders, the LLS, appears in this sample. Building on existing research and theory, we conducted direct comparisons on specified sociodemographic, clinical, legal, offense- and risk-related variables between the three subgroups. We hypothesize that the ES group will have more offenses, although not necessarily more serious offending, and are likely to show more antisocial personality traits and have higher rates of substance misuse than both the LS and LLS groups. We hypothesize that the LLS group will have more social stability but a higher severity of offending than the ES and LS groups and will be more likely to offend against a caregiver or family member.
Method Study design and participants Data were drawn from the forensic program at the Centre for Addiction and Mental Health (CAMH) in Toronto,
Australian & New Zealand Journal of Psychiatry Downloaded from anp.sagepub.com at University of Birmingham on June 1, 2015
Community psychiatric
Kooyman et al. (2012)
Hodgins and Janson (2002)
Forensic
Civil (birth cohort study)
Study
Jones et al. (2010)
Study population setting
ES: first conviction prior to development of illness LS: first conviction during or subsequent to illness onset
ES: one or more court appearance(s) prior to first psychiatric admission LS: court appearance after psychiatric admission
ES: offender + major mental disorder + first offense
ANP0010.1177/0004867415587745ANZJP ArticlesSimpson et al.
Research
Developmental typologies of serious mental illness and violence: Evidence from a forensic psychiatric setting
Australian & New Zealand Journal of Psychiatry 1–12 DOI: 10.1177/0004867415587745 © The Royal Australian and New Zealand College of Psychiatrists 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
Alexander I Simpson1,2, Teresa Grimbos1, Christine Chan3 and Stephanie R Penney1,2
Abstract Objective: To identify subgroups of forensic psychiatric patients based on the age onset of serious mental illness and offending and assess the external validity of the subgroups with theoretically based sociodemographic, clinical, legal and risk-related variables. Method: The age onset of serious mental illness and criminal contact was ascertained for a sample of 232 patients. A range of sociodemographic, clinical, legal and risk-related variables were coded to assess whether age onset subgroups differed in a manner consistent with the literature on typologies of mentally ill offenders. Results: One-quarter of the sample was classified as early starters (patients whose first offense occurred before becoming mentally ill), while two-thirds were late starters (where first offense occurred following illness onset). A small percentage (8%) of patients were deemed late late starters, defined as late starters who had experienced 10+ years of illness and were >37 years upon first arrest. A larger proportion of early starters had a substance use disorder, antisocial personality disorder and a greater number of static/historical risk factors for violence. Early starters were younger upon first arrest and had more previous criminal contacts compared to late starters and late late starters. Mental illness was found to start later in life for late late starters; this group was also more likely to have been married and to have a spouse as victim in the index offense. Conclusion: We found support for distinct subgroups of mentally ill offenders based on the age onset of illness and criminal contact. Compared to late starters, offenses committed by early starters may be motivated more frequently by antisocial lifestyle and attitudes, as well as more instrumental behaviors related to substance abuse. In addition, late late starters may represent a distinct third subgroup within late starters, characterized by relatively higher levels of functioning and social stability; future work should replicate. Findings suggest different rehabilitation needs of the subgroups. Keywords Typologies, age onset, serious mental illness, offending, violence
Introduction Evidence suggests that individuals with serious mental illness (SMI) are at elevated risk of violence (Brennan et al., 2000; Douglas et al., 2009), including homicide (RichardDevantoy et al., 2009; Simpson et al., 2004; Taylor and Gunn, 1999; Wallace et al., 1998). However, people with SMI may behave violently for a variety of motivations (Nestor, 2002), including as a direct result of positive symptoms of psychosis or when symptoms result in heightened stress or exposure to provocation (Hiday, 1997). Other ‘conventional’ risk factors are relevant to the violence committed by those with SMI: neurocognitive impairments, early behavioral problems, substance misuse and antisocial
personality are more common in people with schizophrenia (Andrews et al., 2006) and may partly explain the increased 1Complex
Mental Illness Program (Forensic Division), Centre for Addiction and Mental Health, Toronto, ON, Canada 2Department of Psychiatry, University of Toronto, Toronto, ON, Canada 3Department of Public Health, University of Liverpool, Liverpool, UK Corresponding author: Alexander I Simpson, Complex Mental Illness Program (Forensic Division), Centre for Addiction and Mental Health, 1001 Queen St West, Toronto, ON M6J 1H4, Canada. Email: [email protected]
Australian & New Zealand Journal of Psychiatry
Downloaded from anp.sagepub.com at University of Birmingham on June 1, 2015
2 prevalence of violence in SMI (Hodgins, 2008). In addition, varying developmental trajectories to violence are well documented: in particular, Moffitt’s taxonomy differentiating life course persistent (LCP) and adolescent-limited (AL) offenders has shown that early and severe childhood behavior problems are associated with violence and criminality, as well as significant mental and physical health problems that persist into adulthood (Moffitt, 1993; Moffitt et al., 2002; Piquero et al., 2010; Satterfield et al., 2007). A similar distinction has been made for individuals with psychotic illnesses who offend. Hodgins (Hodgins, 2008; Hodgins et al., 2014) proposed that the age at which antisocial behaviors emerge is a key variable to identify those whose offending is the result of illness as opposed to other criminogenic risk factors. She posited three trajectories to violence among individuals with SMI: (1) Type I offenders (‘early starters’, or ES), who exhibit antisocial behavior that begins in childhood or adolescence, prior to illness onset, and persists into adulthood; (2) Type II offenders (‘late starters’, or LS), who exhibit no antisociality prior to becoming mentally ill, but who are repeatedly violent following the onset of illness; and (3) Type III offenders (‘late late starters’, or LLS), who suffer from a chronic SMI, but who exhibit no aggression until one or two decades after illness onset, when they commit a single and serious violent offense often against someone caring for them. Whereas the violence witnessed in Type I offenders is thought to be influenced by specific genes conferring vulnerability for both early conduct problems and SMI, Type II and III offenders may be more influenced by post-illness neurological changes, including those caused by illness, substance misuse and psychotropic medication (Hodgins et al., 2014). A small number of studies have investigated ES and LS subgroups on a number of dimensions (see Table 1), lending support to the existence of distinct subgroups showing varying trajectories to violence. Unfortunately, ES and LS groups have not been consistently operationalized across studies, and just one study (Van Dongen et al., 2014, 2015) has investigated the LLS group. One approach has been to define the groups on the basis of whether the first incident of offending occurred before (ES) or after (LS) 18 years of age (Hodgins and Janson, 2002; Laajasalo and Hakkanen, 2005; Pedersen et al., 2010b; Tengström et al., 2001) or whether or not they had a diagnosis of conduct disorder prior to age 15 (Mathieu and Côté, 2009; Sánchez-SanSegundo et al., 2014). A second approach defines ES as those with an age of first arrest or violence which is less than the age onset of their SMI, and vice versa for the LS (Jones et al., 2010; Kooyman et al., 2012; Taylor, 1993; Van Dongen, 2014, 2015). This latter approach is arguably more developmentally meaningful, being sensitive to the interrelationship between the age onset of illness and offending. Van Dongen et al. (2014, 2015) studied the LLS group in a sample of forensic inpatients based on the timing of their first offense vis-à-vis the onset of psychosis (ES = offending
ANZJP Articles before onset; LS and LLS = offending only after onset), as well as age (LS 34 years old). Each group was compared with civil psychiatric non-offenders within the same community. The authors found that LLS comprised a small proportion of their sample (7%) and that substance misuse was significantly less likely among LLS compared to ES and non-offenders with schizophrenia. Although still evident in both ES and LS, persecutory delusions were most strongly associated with membership in the LLS group, while the ES group had more antisocial personality traits, conduct problems in adolescence and substance use problems (Van Dongen et al., 2014). LS were not compared to LLS on these latter dimensions. The authors concluded that there are more similarities than differences between LS and LLS and inferred that offending in these two groups is associated with positive symptoms (particularly delusions) but not with antisocial traits as in ES. Taken together, the research in Table 1 has established that ES, as compared to LS, show earlier behavioral problems and greater adversity in childhood, greater criminal involvement and higher rates of antisocial personality disorder (ASPD) and substance misuse. They are more likely to be male and less educated than LS. Differences in the onset and severity of psychiatric problems are less clear; it may be that LS developed psychiatric problems at an earlier age and had more severe psychiatric issues as evidenced by more frequent hospitalizations. Research regarding whether LLS exists as a third subgroup is limited, as well as how this group may differ from ES and LS.
Aims of the study This study investigates whether discrete subgroups of forensic psychiatric patients exist based on the age onset of SMI and offending. Subgroups were constructed based on the relative timing of SMI and criminal contact, and we investigated whether evidence of a third subgroup of SMI offenders, the LLS, appears in this sample. Building on existing research and theory, we conducted direct comparisons on specified sociodemographic, clinical, legal, offense- and risk-related variables between the three subgroups. We hypothesize that the ES group will have more offenses, although not necessarily more serious offending, and are likely to show more antisocial personality traits and have higher rates of substance misuse than both the LS and LLS groups. We hypothesize that the LLS group will have more social stability but a higher severity of offending than the ES and LS groups and will be more likely to offend against a caregiver or family member.
Method Study design and participants Data were drawn from the forensic program at the Centre for Addiction and Mental Health (CAMH) in Toronto,
Australian & New Zealand Journal of Psychiatry Downloaded from anp.sagepub.com at University of Birmingham on June 1, 2015
Community psychiatric
Kooyman et al. (2012)
Hodgins and Janson (2002)
Forensic
Civil (birth cohort study)
Study
Jones et al. (2010)
Study population setting
ES: first conviction prior to development of illness LS: first conviction during or subsequent to illness onset
ES: one or more court appearance(s) prior to first psychiatric admission LS: court appearance after psychiatric admission
ES: offender + major mental disorder + first offense
