A preoccupation with psychosis

The evidence discussed by Mullen (2006) in the pages of this journal clearly shows that the correlation between schizophrenia and violence is not just statistically significant but is clinically and socially so. This increased rate of violence is mediated by a wide variety of cofactors, particularly substance misuse and personality disorder, but even after controlling for such factors a small increased risk remains. This consensus position has emerged after some 30 years of debate and previous denial, which was founded on ideology as much as evidence. It is an important consensus, offering the hope of improved public education and awareness, better service provision and a better collaboration between the multitude of professions, disciplines and services concerned with these issues. The opinion-dominated literature has less often acknowledged that even if there were no demonstrable statistically significant increase in the rate of violence in people with schizophrenia as a group, psychiatry might still have an important public protection role to play for individual patients in whom the two co-exist. Authors such as Mossman (2000) and Hart et al (2007) have eloquently explicated the problems that arise from basing individual risk management on group-derived associations. Most societal violence is not mediated by psychosis, being more often associated with anger or other extreme affective states, often interacting with disinhibitors such as intoxication. So it might be thought that mood disorders, with their prominent symptoms of dysphoria, irritability and anger, and their intrinsic tendency to weaken internal inhibitions, would be associated with violence at least as much as schizophrenia. But received wisdom tells us that this is not the case, that violence in mood disorders is unusual.