Violence among people with schizophrenia: phenotypes and neurobiology.

People with schizophrenia are at increased risk, as compared to the general population, to acquire convictions for violent crimes and homicide. They also show elevated levels of aggressive behaviour. While psychotic symptoms explain aggressive behaviour that is common during acute episodes, they do not explain such behaviour at other stages of illness or prior to illness onset. Three distinct phenotypes have been identified: individuals with a childhood onset of conduct disorder who display antisocial and aggressive behaviour both before and after schizophrenia onset; individuals with no history of conduct problems who begin engaging in aggressive behaviour as illness onsets; and individuals who after many years of illness engage in a severe physical assault. Little is known about the aetiology of the three types of offenders and about the neural mechanisms that initiate and maintain these behaviours. We hypothesize that schizophrenia preceded by conduct disorder is associated with a combination of genes conferring vulnerability for both disorders and altering the effects of environmental factors on the brain, and thereby, with a distinct pattern of neural development. Some evidence is available to support this hypothesis. By contrast, offending among adults with schizophrenia who have no history of such behaviour prior to illness may result from the changes in the brain that occur as illness onsets, and that are further altered by comorbid conditions such as substance misuse, or by the progressive changes in the brain through adulthood that may result from the illness and from the use of antipsychotic medications.