Women, psychosis and violence
Introduction
Jane was never grateful for psychiatric services, but she kept returning to the same hospital. She was often abusive to staff and occasionally assaultive. When younger, Jane had been given an unequivocal diagnosis of schizophrenia. Now 38, she smelt of alcohol and unpleasant body odours. It was not clear how or where she was living. The clinical record now consistently said: ‘there is no evidence of psychosis.’ Regular formal risk assessments indicated that she was at high risk of being violent. Then Jane presented in distress because, she said, her mother had been kidnapped and was being held at a secret address. Staff checked and found Jane’s mother safe in her own home, but they wrote in Jane's record: ‘there is no evidence of psychosis’ and ‘no justification for having her in hospital’. Soon after, Jane killed a stranger she believed to be the kidnapper.
Psychosis may afflict people in pure form, but it is commonly complicated by other health and social problems. Comorbid substance misuse disorder rates may even be rising (e.g. McMahon, Butwell, & Taylor, 2003), perhaps due to easier availability of alcohol and/or illicit drugs in so many countries. Such complexity may create a sense of helplessness among clinicians, at the same time providing a formula for avoiding such patients. If someone presents with many problems, shifting definition of the main one may seem to justify denying a particular service. Multiple comorbidities and difficulties in accessing services are not unique to psychotic women who are violent, but such women may be particularly prone to them. Putkonen, Collander, Honkasalo, and Lönnqvist (1998), for example, found that of the 75% of female homicide offenders referred for forensic psychiatric examination in Finland between 1982 and 1992, most had multiple diagnoses (81, 61%). In New Zealand, Earthrowl and McCully (2002) found that one quarter of 150 women screened on entering prison met criteria for psychosis, but most had complex problems. Generally, unlike Jane, women with mental ill-health are especially challenging to violence risk assessments. Clinicians can predict violence among psychotic men quite well, but tend to underestimate its risk among women (Lidz, Mulvey, & Gardner, 1993).
Cases of women who were psychotic at the time of a serious violent act have long been recognised. Appignanesi (2008) starts her account of the treatment of women with mental ill-health with that of Mary Lamb, who, towards the end of the 18th century in England, killed her mother while in a psychotic state. Nevertheless, women have been excluded from much research in the field, or, when they are included, information about them is not provided separately, or their numbers are so small that their data are not analysed. In some studies of psychosis, large numbers of women have been recruited, but researchers have then ‘controlled for gender’ rather than treating women as interesting in their own right. Thus, although enthusiasm for gender specific service is commonly articulated, at least in the UK (e.g. Bartlett, 2007, Department of Health, 1999, Department of Health, 2002, Department of Health, 2003, Home Office, 2007), data directly pertinent to services for adult women with psychosis who are violent remain elusive.
Our review is of research published in English which includes such women or their treatment. We identified articles by entering the terms women, psychosis, violence into PubMed up to December 31st 2007, by drawing on previous ‘expert papers’ on psychosis and violence (Taylor, 2002, 2007), on UK government or government commissioned reports on specialist forensic mental health (fmh) services for women, and following up references in all articles identified. We thus identified over 400 articles, but were able to exclude nearly 75% because they were in fact not about violence and psychosis, about suicide, included no women, were single case histories, discursive and not data based or dealt only with the experience of violence by women with major mental illness. We both read the remaining articles and agreed on the following synthesis of the findings.
Section snippets
Women and violence
At first sight, it seems hardly surprising that women with psychosis who are violent are under-researched. All countries which regularly publish population and crime statistics show a slight excess of women in their general population, but men vastly outnumbering women in crime statistics overall, and for violent crimes in particular (e.g., Reiss & Roth, 1993/94). In terms of prison or specialist fmh service occupancy, men consistently outnumber women. In England and Wales, for example, in
Women and psychosis
Schizophrenia is the psychosis most commonly associated with violence (e.g. Arsenault et al., 2000, Brennan et al., 2000), so the next concern is relative community prevalence of schizophrenia between women and men. According to two systematic reviews of the incidence of schizophrenia over time (publication dates 1965–2001) and in many different countries, the weight of evidence is that this is lower in women than in men (Aleman et al., 2003, McGrath et al., 2004). Morbid risk for
Associations between psychosis and frequency of violence among women
Fazel and Grann (2006) extracted diagnostic data on everyone of 15 or over discharged from Swedish psychiatric hospitals over the 13 years 1988–2000 (15 is the age of criminal responsibility in Sweden). They linked these data to violence conviction data from the national crime register, using unique identification numbers. Over 98,000 patients, 56% women, with ‘severe mental illness’ (effectively psychosis) were identified, who, between them, had committed 21,119 violent crimes. The proportion
The violent offences of women with psychosis
No offending behaviour is exclusive to women, with or without psychosis. Nor does their sex fully protect them from any absolute distinction lies in legal technicalities—if it is specified that a particular offence can only be committed by a woman. In many countries ‘infanticide’ is defined in law as an offence of women, but infant homicide–killing a child of 12 months or less–is not. Are there, however, some violent offences to which women, in particular psychotic women, are especially prone?
The life-course of violence for women with psychosis
Two Swedish studies together suggest that women with psychosis have a shorter offending career than their male peers. The earlier one (Lindqvist & Allebeck, 1990) was of a 1971 Stockholm County discharge cohort of 330 men and 314 women with schizophrenia; the later (Hodgins, 1992) was of a 1953 Stockholm birth cohort of 15,117, yielding 79 women and 82 men in a broader category—‘major mental disorder’ (schizophrenia, major affective disorder, paranoid state or other psychosis). The later study
Explanations of violence by women with psychosis
Some violence by people with psychosis, particularly more serious violence, is directly driven by symptoms of the illness–especially delusions–but some violence is not. One indicator of the likelihood of delusional drive is the presence or absence of a personality disorder in addition to the psychosis (Taylor et al., 1998), its presence increasing the likelihood of substance misuse. A US study of case management of patients with psychosis found that women with psychosis are at least as likely
Gender specific services
In the UK it is government policy that there should be specialist mental health services exclusively for women, regardless of security level required (Department of Health, 1999, Department of Health, 2002, Department of Health, 2003). Many women had stated a preference for this, which may in itself be sufficient to justify segregation. There are also concerns that women needing residential services may not only be vulnerable to predatory male patients but also exceptionally likely to suffer
Longer term outcomes for women with psychosis who have been violent
Studies of outcome of offender patients after specialist fmh hospitalisation are consistent in suggesting that women do better than men, although it is difficult to link this directly to diagnosis. Overall, up to 75% of the men in a secure unit have an unequivocal psychotic illness, but only about half of the women. Maden et al. (2006) followed up all 116 women and 843 men discharged from medium security hospital units in England or Wales during the year from 1st April 1997. The women and men
Conclusions
In spite of growing interest in the likelihood that women with psychosis who are violent have special treatment needs, there is little research to guide service specificity. Almost all information has to be gleaned from studies which are mainly about men. This may be a factor in claims that current services are designed for men, and at best inappropriate for women, at worst actually damaging. The little information available to date, however, suggests only moderate differences from men. While
Acknowledgment
We are grateful to Ceri Allen for her immense help with the manuscript.
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