Schizophrenia and Other Psychotic Disorders 539
Suicide
People with schizophrenia have a higher risk of dying by suicide than do other
people: As Table 12.4 shows, 10–15% of people with schizophrenia commit suicide
(Caldwell & Gottesman, 1990; Siris, 2001). Those with the paranoid subtype are at
the highest risk for suicide. Perhaps paradoxically, patients at risk for committing
suicide are those who are most likely to be aware of their symptoms: They have rel-
atively few negative symptoms but pronounced positive symptoms; they are highly
intelligent with career goals, are aware of their deterioration, and have a pattern of
relapsing and then getting better, with many episodes; and—like other people who
die by suicide—they are more likely to be male (Fenton, 2000; Funahashi et al.,
2000; Moussaoui et al., 1999; Siris, 2001). Ironically, some of these factors—a high
level of premorbid functioning, few negative symptoms, and an awareness of the
symptoms and their effects—are associated with a better prognosis (see Table 12.6).
As researchers have identifi ed these risk factors, they have used them to focus suicide
prevention efforts.
Violence
Suicide is often the result of some form of self-infl icted violence, but this does not
imply that patients with schizophrenia are generally violent. Although the affl icted
individual may threaten to become violent during an episode of schizophrenia, con-
trary to sensational headlines, these patients rarely actually engage in violent be-
havior. Risk factors associated with violent behavior include being male, having
comorbid substance abuse, not taking medication, and having engaged in criminal
behavior or having had psychopathic tendencies before schizophrenia developed
(Hunt et al., 2006; Monahan et al., 2001; Skeem & Mulvey, 2001; Tengström,
Hodgins, & Kullren, 2001). Only one of these factors pertains to schizophrenia
directly; rather, it is the comorbid disorders that increase the risk of violent behavior
(Angermeyer, 2000; Erkiran et al., 2006; Swanson et al., 2006). Note that less than
10% of violent acts reported to the police are caused by people with schizophrenia,
and most of these offenders are people with schizophrenia who also abuse alcohol
or drugs (Walsh, Buchanan, & Fahy, 2002).
Rather than being perpetrators of violence, people with schizophrenia have amuch greater likelihood of being victims of violence. One survey found that almost
20% of people with a psychotic disorder had been victims of violence in the previ-
ous 12 months. Those who were more disorganized and functioned less well were
more likely to have been victimized (Chapple et al., 2004), perhaps because their
impaired functioning made them easier “marks” for perpetrators.
People with schizophrenia who signifi cantly improve often have one or more of the following
characteristics:- They functioned at a relatively high level before their fi rst episode.
- The symptoms had a sudden onset.
- They developed symptoms later in life.
- They have a family history of mood disorders, not schizophrenia.
- They have the paranoid subtype (in the DSM-IV-TR categorization) or the nondefi cit subtype,
with relatively good cognitive functioning. - They have fewer negative symptoms.
- They are aware of their symptoms and recognize that the symptoms are caused by an illness.
- They are women (whose symptoms also respond better to medication).
Sources: Amador et al., 1991; Fenton & McGlashan, 1994; Green, 2001.
Table 12.6 • Factors Associated With a Better Prognosis for Individuals
With Schizophrenia