Medications and Violence
May 26, 2015
So far, we have been to the Haunted House, visited the Zoo of the Brain, learned about Persuasive Words, and focused on the Symptoms of Schizophrenia. We now turn our attention to how Schizophrenia is treated (by Health Care Professionals), and the side effects. This chapter will finish discussing the associations between Schizophrenia and violence, and then there will be a short break before NCR.
The primary action of most antipsychotic medication is to block DOPAMINE receptors in the brain. This lowers the amount of dopamine exposure neurons receive, reducing their activity. There are many other factors involved, however, I have already said too much.
Blocking dopamine in the MESOLIMBIC area is great for reducing hallucinations and delusions in over 2/3 of people suffering. It can also be very helpful for much of the disorganization.
However, the same water that becomes milk in the cow; becomes venom in the snake. And, you should hopefully remember, that the brain is a zoo.
On top of the burden that people with Schizophrenia bear, many face very undesirable side effects from the most effective medications. Most used in treatment preferentially block dopamine (D2) receptors, throughout the major Dopamine systems in the brain.
Reduced Dopamine in the frontal lobe from Schizophrenia is associated with changes in personality, and blocking receptors further may equate to more negative features. Another minus is that newer antipsychotic medications have had only modest success in treating these vexing symptoms, which seem to insidiously subtract from your identity.
Blocking Dopamine in a specific part of the brain involved in movement, called the BASAL GANGLIA, can produce various movement disorders. Some of these movements resemble Parkinson’s Disorder (a condition where Dopamine producing neurons die). Interestingly, some people with Schizophrenia already have some of these same movement disorders before ever starting medication treatment.
One of the worst kinds is called TARDIVE DYSKINESIA, an irreversible side effect usually from the older antipsychotic medications; causing repetitive movements of many body parts, most classically, the lips, mouth, face, and tongue.
Other, frightening special side effects, can involve images from the Exorcist; a sudden wrenching of the muscles of the neck (TORTICOLLIS), a rolling back of the eyes (OCULOGYRIC CRISIS), or feelings of asphyxiation (PHARYNGEAL SPASMS), the limbs contorting in spastic postures (DYSTONIA). This scary scene of symptoms is called an Acute Dystonic Reaction, and it can be life threatening.
Many newer antipsychotics (‘atypicals’) were developed to avoid these nightmarish side effects in particular.
Some medications have other side effects as well, referred to as the METABOLIC SYNDROME. These complications may include: excessive weight gain, increased bad cholesterol and triglycerides, unstable blood sugars, as well as type 2 Diabetes.
Older antipsychotics (‘typicals’), and a few that are used widely today, block the action of Dopamine in the INFUNDIBULAR TRACT. This can result in elevated Prolactin, the hormone secreted when a mother is preparing to breastfeed. The Pro is for producing, the Lactin is for milk, and it does most bodies good.
For people with this side effect however, besides embarrassment from spontaneous wet T-shirt contests, the most serious result can be early bone thinning.
Ironically, one of the best medications in the world for Treatment Resistant Schizophrenia, CLOZAPINE, also has a rare, but deadly side effect of destroying most of one’s white blood cells (AGRANULOCYTOSIS).
It is like this version of Schizophrenia is the most malignant, and while most tolerate the chemotherapy, the blood work involved is almost as meticulous as in cnacer (spelled correctly). It also causes significant weight gain, but usually no other movement disorders. This ‘magic bullet’ is also the most effective antipsychotic in the world, for aggressive behaviour associated with Schizophrenia.
There are other side effects that I won’t cover, lest I sound like a Big Pharma ‘I don’t want to get sued’ infomercial. The other side effects are related to the fact that many antipsychotic medications affect many other receptors besides Dopamine, such as Serotonin.
Having said what I have said about medications and side effects, I want to be clear on a few things.
Antipsychotic medications are helpful in a majority of people who take them for symptoms of psychosis.
The challenge is finding the right balance between effectiveness, and tolerable side effects. Many people struggle to find this balance, and choose to stop taking these medications as prescribed.
My list of side effects should offer new perspective, and make it a bit easier, to imagine why someone would risk a psychotic episode, and ‘stop their meds’.
There are many other ways that people with Schizophrenia are helped, besides medications. Family Therapy and Education about the illness, what to expect, and ensuring there are appropriate supports for the family, is crucial. Cognitive Behavioural Therapy has good evidence as well, and helps strengthen the mind through nonjudgmental observation and Socratic logic, to correct distorted messages from the brain.
Since the early 2000’s, the scope of recovery has moved beyond merely a focus on treating hallucinations and delusions. The wider picture is on supporting people in creating a life worth living, despite their relapses, or incompletely treated symptoms. Psychosocial Rehabilitation is of vital importance to help people rebuild their goals and support their path along the way; so people can create self esteem through their own accomplishments.
Prior to the 90’s, it was commonly believed that those with mental illnesses were no more prone to violence than the general population. This is still generally true; however there are specific populations, within most mental illnesses, where the risk of violence is in fact higher than the average joe.
A fairly recent, selective review, published in the British Journal of Psychiatry indicated that the violence rates for people with Schizophrenia are anywhere between 2 -10 times greater than the general population.
This number is largely due to a small subgroup with several risk factors.
And please, try to remember, those who have Schizophrenia and commit violence, do not have violence because they committed Schizophrenia.
The overall proportion of societal violent crime, currently thought to be attributed to Schizophrenia is 2-8%. This may seem like a large number, but consider some other numbers gleaned from the following study.
In this one, the authors followed patients with various mental illnesses over 20 weeks after discharge from hospital. They monitored people for many variables, including violent episodes, and reported their findings. What they found was that roughly 9% of recently hospitalized people with Schizophrenia engaged in a violent act during that follow up. This may seem like a large number, but let’s compare it to the rates they found in other illnesses: Major Depressive Disorder (19%), Bipolar Affective Disorder (15%), Other Psychosis (17%), Substance Misuse (30%), Personality Disorder alone (25%).
Important risk factors that lead to violence during Schizophrenia’s course include: prior violence or antisocial conduct, abusing substances of abuse, not taking medications for whatever reason, and acute psychotic symptoms.
Luckily, at least 3 of these are modifiable, and you will read more about this in later chapters of Bloodbound Bus.
The only chemical that IS associated with aggression definitively is TESTOSTERONE.
The only genetic conditions that have been significantly associated with aggression are the XY (male) and XYY (supermale) conditions. With an extra Y chromosome comes an extra scoop of Testosterone.
There were apparently 3 or 4 supermales playing at one time, on a well known NFL team.
In summary, a statistical relationship does exist between Schizophrenia and violence; it is mostly related to a small subset of people with the illness.
The risk that you will be attacked by a person with Schizophrenia is significantly lower compared to humans with the combined risk factors of
And it gets much smaller, for those with Schizophrenia, if medications are taken as prescribed, and substance abuse is aggressively controlled.
For now, let us wrap up this chapter, and move into the courtroom of mental health and public opinion. See you in Part 6, where we discuss the NCR ‘controversy’.
Simon Trepel, MD
Simon Trepel, MD FRCPC, is a practicing Child and Adolescent Psychiatrist, in Winnipeg, Canada. He is an Assistant Professor, at the University Of Manitoba, in the Faculty of Medicine, and the Co-founder of the GDAAY Clinic. He is, more importantly, the proud Father of 2 beautiful Daughters. He writes in his spare time about things he knows something about, and occasionally about things he doesn’t; like Yoga, and Italian flavored coffees. He was not referring to coffee that tastes like an Italian person.
Check out his Blog, called Simon Says Psych Stuff, at