Heterogeneity of violence in schizophrenia and implications for long-term treatment.
OBJECTIVE
Most patients with schizophrenia are not violent. However, persistent violent behaviour in a minority of patients presents a therapeutic challenge. Published treatment guidelines and most pharmacological and epidemiological literature on violence in schizophrenia treat overt physical aggression as a homogeneous phenomenon. The aim of this review is to address the subtyping of violent behaviour in schizophrenia, and to relate the subtypes to treatment.


METHODS
Literature describing subtypes of violence in schizophrenia and the treatment of this problem was reviewed. 'Schizophrenia', 'violence', 'aggression', 'hostility' and 'personality disorders' were the principal search terms describing behaviours. Generic names of individual atypical antipsychotics and mood stabilisers were used in treatment searches.


RESULTS
There are at least three aetiological subtypes of violence in schizophrenia (i) that related directly to positive psychotic symptoms, (ii) impulsive violence and (iii) violence stemming from comorbidity with personality disorders, particularly psychopathy. Current treatment of violence in schizophrenia relies on antipsychotics and mood stabilisers. The evidence of effectiveness is relatively strong for clozapine, but inconsistent for other treatments. No systematic recommendations relating the treatment to aetiological subtypes of violence were found.


CONCLUSIONS
The inconsistent effectiveness of the current treatments of violent behaviour in schizophrenia is due, at least in part, to the aetiological heterogeneity of that behaviour. We should not expect that any given pharmacological treatment will be equally effective in reducing violent behaviour caused by psychosis, impaired impulse control or personality disorder.


CONCLUSIONS
Violence in schizophrenia is aetiologically heterogeneous. This heterogeneity has therapeutic implications that impact clinical practice today and should be further explored in future studies.
Department of Psychiatry, New York University School of Medicine, New York, NY, USA. janvolavka@gmail.com
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Volavka
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Citrome
D000374:Aggression / Q000187:drug effects / Q000523:psychology; D000927:Anticonvulsants / Q000627:therapeutic use*; D014150:Antipsychotic Agents / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D018020:Lithium Compounds / Q000627:therapeutic use; D008134:Long-Term Care; D008297:Male; D010554:Personality Disorders / Q000150:complications / Q000188:drug therapy*; D012559:Schizophrenia / Q000150:complications / Q000188:drug therapy*; D012565:Schizophrenic Psychology; D014754:Violence / Q000517:prevention & control* / Q000523:psychology
D000927:Anticonvulsants; D014150:Antipsychotic Agents; D018020:Lithium Compounds