Environmental Influence on Violent Psychotics, Part II

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With the help of one of the authors of the study I cited yesterday, Jeffrey Swanson of Duke, and a psychiatrist friend who teaches at a major university and has treated patients with psychosis for close to 20 years, I have tracked down some other articles on the subject of environmental influence on people with violent psychosis.

First, though, let me restate the caveat with which I opened part one of this discussion yesterday. We know very little about Loughner—is he mentally ill, what drugs if any was he currently taking or abusing last weekend, what is his personal history of exposure to violence—so asserting a direct cause and effect between the political environment and his alleged attack at this early stage is as wrongheaded as completely dismissing the possibility of a link between the two.

Let me also say that the following articles do not show or attempt to show or even suggest that political factors definitively contribute to violence. As I wrote yesterday, the relationship between environment and violence in the mentally ill is poorly understood. These studies attempt to show only that cultural influences can affect the content of delusions in patients, and perhaps violence in those patients.

And lastly, the debate over the relationship between political environment and violent psychosis has brought into play at least two other important issues that I think are worth addressing. First, the question of free speech and whether any political speech should be limited even if it could be proven that it increases the likelihood of violence in people with psychosis. The simple answer to that is obviously not. No one is advocating formal limits on speech. The question is what society can agree on as acceptable rhetoric in our public discourse and what reasonable people should condemn or discourage. If it was found that violent political rhetoric could be a contributing factor in a case like Rep. Giffords’ shooting, many people might agree to publicly disapprove of violent rhetoric in political discourse.

Second, Joe raises here the question of posing increased but unspecified limits on the mentally ill. Providing treatment for people with mental illness is important, but I would argue that in the current environment the danger of discrimination against people with mental illness is greater than the danger of violence from them. The universe of people with mental illness is large. The study I cited yesterday indicates how few people with mental illness commit seriously violent acts. Furthermore, another study by the same authors found that absent three factors–violent surroundings, drug abuse or a history of being a victim of violence–the mentally ill are no more prone to violence than those without mental illness. When combined with mental illness those factors can produce extreme violence, which may get to the Loughner question. But the vast majority of violence is committed by people without mental illness and associating mental illness generally with violence is “a source of discrimination, it’s unfair and it’s counterproductive,” says Prof. Jeffrey Swanson of Duke, one of the study’s authors.

Now to the studies on environmental influence on people with violent psychosis:

The first study from the University Hospital of Vienna, Austria, compared delusions among schizophrenics in Austria and Pakistan. Its purpose was to try and identify core elements of schizophrenia by finding what elements of the disease seemed merely the result of cultural influences. For the purposes of our discussion, they discover that delusions of grandeur, guilt and religious delusions are apparently fueled by environment and they conclude, “cultural factors seem to have a decisive influence on shaping the contents of delusion.”

The second study by the Tokyo Metropolitan College of Allied Medical Sciences compares schizophrenic delusions among patients in Tokyo, Vienna and Tübingen and finds the European patients tended toward delusions of poisoning and religious themes of guilt and sin, while the Japanese had more amorphous delusions of “reference” such as being “slandered,” which the authors surmise “may derive from the group-oriented self in Japanese ‘shame culture.’”

The third study from the GKT School of Medicine and Institute of Psychiatry, King’s College, London, UK, argues that “religious rituals and expectations of the family play a major role in the genesis and maintenance of delusions” and concludes that “The real clinical significance of religious delusions varies from violence to others to self-harm.” In other words, it concludes that religious rituals can contribute to violent delusions in schizophrenics.

The last study, in the American Journal of Public Health, by Swanson, Swartz et al. (the authors of yesterday’s study) looks at the “socio-environmental context of violent behavior in persons treated for severe mental illness.” It finds that in schizophrenics “Variables found to be associated with violent behavior in the previous year included homelessness, experiencing or witnessing violence in the surrounding environment, substance abuse, mood disorder, PTSD,” and other factors.

If one supposes that political discourse can play as much of a role as religious rituals or other environmental factors in the content of delusions, then together these articles would suggest that the national political environment could have played a role in Loughner’s violence. Greg Sargeant interviews one of the authors of the study I cited yesterday and he supports this idea. Swanson, the lead author on one of the studies discussed, says, “We’re talking about people with disordered thoughts, so they could blow a distortion or caricature way out of proportion.”

However, I’m still very ambivalent about drawing any conclusions at this point. I think it is perfectly possible that Loughner could have been influenced by the political environment, but I don’t know if he was. And even if he was influenced by it, it seems to me likely that the political content was a narrow, possibly negligible, part of a big psychiatric problem. Swanson likewise stresses that there are numerous influences, as noted above, that can lead to violence in the mentally ill.

That said, if there’s a chance that violent rhetoric could contribute to the delusions of violent psychotics, I don’t see why reasonable people wouldn’t want to discourage violent rhetoric in politics—or on this blog for that matter. Everyone is responsible for his or her language and now is as good a time as any for everyone to think about the tone and content of their speech. I think political discussions generally, and on this blog in particular, while admirably lively and heartfelt, would benefit from less anger and less rhetorical references to violence.