The Anatomy of Violence (41 page)

What’s also intriguing is that when we look at the biological factors that are related to schizophrenia, we find many of the same risk factors that we have seen earlier characterizing violence. Things like
frontal-lobe dysfunction, neurocognitive impairment, fetal maldevelopment, birth complications, blunted brain responses to stimuli we should normally pay attention to, and orienting abnormalities. To be sure, crime and schizophrenia are certainly not the same condition. They present very differently to the clinician. And there are risk factors like low resting heart rate that are unique to crime and unrelated to schizophrenia.
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Yet, at some causal level, there is a degree of common ground.

That common ground expresses itself most strongly when we look at the link between violence and schizophrenia. Large-scale epidemiological studies from many countries around the world now attest to the fact that schizophrenia patients are much more likely than normal controls to have a history of violent and criminal behavior. Turning the issue around, delinquent and criminal populations are more likely to show higher rates of psychotic disorders than the general population. This relationship between violence and schizophrenia is not weak. If you are a schizophrenic male, you are three times more likely to kill than someone of the same social background and marital status who is not schizophrenic. If you are a female schizophrenic, you are twenty-two times more likely to kill than a nonschizophrenic female.
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These are striking statistics, and we should be cautious in interpreting them. Many psychiatrists and families of schizophrenic patients do not want to hear this message.
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It’s hard enough for someone with schizophrenia to have to carry the burden of this debilitating illness, let alone to be labeled as violence-prone. It’s true that most schizophrenics are not dangerous and neither kill nor perpetrate violence.
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But the harsh reality is that the
neurodevelopmental ravages perpetrated
on the brains of schizophrenic patients during childhood and adolescence make them less able to regulate their emotions and hold back their anger as adults.
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You might accept that schizophrenia is a
neurobiologically based
mental disorder. You may even agree that schizophrenics are more likely than others to kill. But you could counter that schizophrenia is a rare mental illness, so surely it cannot account for much violence. And you’d have a point. What we next need to consider, therefore, is that there is a “watered-down”
version of schizophrenia with a higher base rate in the general population.

We have exactly that in a clinical condition called
schizotypal personality disorder.
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Instead of hearing
voices of nonexistent people, as schizophrenics do, schizotypals mistake an actual noise in the environment for someone speaking. It’s not entirely uncommon. I was in my hotel room at a conference in Tuscany washing and shaving in the bathroom sink when I heard a woman very close by, shrilly saying, “Well, hello.” Startled, I looked around. I looked in the bedroom. Nobody. How peculiar. I went back to washing, and heard the same thing again. It had to be outside in the corridor. I opened the door to my bedroom, but no one was standing out there. This was seeming more bizarre. Going back to washing and turning on the faucet, I realized that the squeaky female voice was none other than the squeaky tap. About every month or so I hear someone calling my name in the street, and look around to find myself mistaken again. Technically, the symptom is called “
unusual perceptual experiences”—you mistake sounds for voices and shadows for objects and people. But I’m all right, I tell myself.

Is it just me who’s got a tile loose? Not really. We can measure schizotypal personality quite well using simple self-report questionnaires. I created a measure for it back in 1991 (yes, psychologists really do study the problems they have). It’s called the “Schizotypal Personality Questionnaire.”
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It includes questions like this one: “When you look at a person, or yourself in a mirror, have you ever seen the face change right before your eyes”? We found in Los Angeles that 18 percent of supposedly high-functioning undergraduates said yes to this item. “Have you had experiences with astrology, seeing the future, UFOs ESP, or a sixth sense?” Forty-nine percent say they have. “I feel I have to be on my guard, even with friends” has 21 percent endorsement, while 31 percent agreed that “some people think that I am a very bizarre person.” When we brought in the students whose total score was in the
top 10 percent of the undergraduate population for a clinical interview, 55 percent of this group received a clinical diagnosis of
schizotypal personality disorder—equivalent to 5.5 percent of the total undergraduate population, much higher than the 1 percent base rate for schizophrenia.

Now, you could put this all down to the fact that it’s L.A. that we’re talking about—a safe haven for loonies from other locations to migrate to so they can fit in with all the other nutters and not seem so obviously bananas. And there might just be a smidgen of truth to that
West Coast stereotype. But at the same time, the reality is that psychosis has its manifestation at a dimensional level. There are shades of gray here, and there is a surprisingly large minority of people in the population with some characteristics similar to schizophrenia.

Are these individuals more likely to be violent and
antisocial? Yes, they are. Whether we look at undergraduates at universities—the privileged offenders—or just individuals in the community, those with higher scores on the “Schizotypal Personality Questionnaire” have higher scores on self-reported measures of crime and violence.
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They parallel what many others find in clinical populations of schizophrenics. Put together those with schizotypal personality and those with outright
schizophrenia and other psychoses, and you really do have a small but significant group at risk for crime and violence.

But why would schizophrenics be more likely to kill than others? One answer can be found at the surface level in the
symptoms of schizophrenia. For one thing, one common manifestation of schizophrenia is paranoia.
Paranoid schizophrenics are overly suspicious of other people’s intentions, and believe others are out to get them. If you believe that, then one reasonable defense is to get them before they get you. Other schizophrenics have delusions
of grandeur, which can give them a righteous sense of power and control over others, or a religious grandiosity that may make them feel they have the right to override the sanctity of life. Other schizophrenics have a
messianic vision—they are a prophet come to save the world from its debauchery and sins. One way of doing this, of course, is to kill as many prostitutes as you can, just as we saw with Peter Sutcliffe.

There are also features common to schizotypals and psychopaths. These two disorders may seem like chalk and cheese on the surface—the shy, retiring schizotypal versus the brash, confident psychopath. But there is a connection. Schizotypals have
constricted affect—meaning that their emotions are blunted and reduced. We similarly see in the
research literature on psychopaths repeated evidence of this emotional blunting. They just do not experience emotions in the same way that the rest of us do. Schizotypals also have no close friends outside of their family members, and in a similar fashion psychopaths form only very superficial, fleeting relationships, having an inability to form the deep and meaningful social affiliations that the rest of us do.

These superficial similarities partly explain why
schizophrenics are more
violent. In the same way that blunted emotions and a lack of social connectedness with other people nudge the psychopath into the perpetration of
violence, social disconnection and a lack of feeling can tip the schizophrenic into violence. And if you can’t bring yourself to imagine some violent offenders as having
schizophrenia-spectrum tendencies, then think again. How many
serial killers or murderers have you heard of who at some level were extraordinarily bizarre and acted out strange behaviors? Or had a “had to get them before they got to me”
paranoid rationalization for their
assaults? Or had really odd beliefs about the world and the people in it? Yes, mad murderers are not uncommon. Recall Ted
Kaczynski, the mail bomber, and
Peter Sutcliffe, the prostitute killer. Crime connects with schizophrenia—at least part of the time.

Plummeting to a deeper level of analysis, another reason for schizophrenics’ being more likely to perpetrate violence lies in the
brain. We have known since the 1970s, from the very first brain-imaging studies using
CT scans, that schizophrenics have enlarged
ventricles—large fluid-filled spaces in the deeper
areas of the brain that likely reflect brain atrophy. Since then thousands of brain-imaging studies have documented functional and structural impairments to many brain regions in both schizophrenics and schizotypals, particularly the
frontal and temporal lobes.
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These areas are particularly prevalent in violent offenders.
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Recall also in our prior discussion of brain imaging that schizophrenics who commit homicide are especially likely to have structural impairments to these brain areas. Consequently, one possible reason schizophrenics are more violent is that they have structural impairments to those brain areas that regulate aggression, as well as disturbances in the
limbic system, where emotion is generated.
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For some schizophrenics, then, it can boil down to an inability to regulate emotion and acting on the spur of the moment. Things just get a bit out of control sometimes. It’s not so much that they meticulously plan an attack or homicide in a cold-hearted fashion. It’s more
that their disorganized behavior and prefrontal dysfunction results in more
reactive forms of aggression—acting impulsively on a provocative stimulus. Indeed, schizophrenics are more likely to kill their own family members than to kill strangers. As many of us know, the home setting can be a tinderbox where what starts as an off-the-cuff comment becomes an out-of-control, blazing argument. Add paranoia and
delusions into the mix, and a spark can become a conflagration.

For kids, that spark may come at school. Together with
Annis Fung and
Bess Lam at City University in Hong Kong, we found that children with high scores on the child version of the
Schizotypal Personality Questionnaire had high scores on
reactive aggression.
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In this sample of 3,608 schoolchildren we also found that
victimization mediated—or explained—this relationship. Schizotypal kids are picked on because they are odd, shy, and different, and because of that, they reacted by lashing out in anger at others.

The spark igniting the violence tinderbox need not be physical in nature—it might be
ideological. Recall from
chapter 4
that Ted Kaczynski’s bombings were a reaction to industrialization and perceived scientific control over society. In other cases, homicide can be in reaction to social rejection and a sense of hopelessness. That might have been partly true for
Kip Kinkel, who was expelled from
Thurston High School and on the same day shot his parents before embarking on a
mass school
killing. Might
social isolation have partly triggered
Adam Lanza’s shooting his mother and then later killing schoolchildren at
Sandy Hook Elementary School?

Thus, poor mental health is a risk factor for violence in part because it reflects the type of brain dysfunction that can predispose people to violence. We certainly see a lot of evidence of mental-health disturbances in violent offenders. Not just in disorganized
murderers overcome by florid
symptoms of psychosis, but also in organized
serial killers who can exhibit more muted forms of
schizophrenia, as well as overt psychotic symptoms. Here’s an example of that muted form and the mix of schizotypal symptoms that include odd
beliefs, bizarre behavior, delusional thinking,
paranoid ideation, blunted affect, and no close friends.

I doubt any of you have ever heard of Leonard Lake. Though he killed at least twelve—and as many as twenty-five—men, women, and babies,
he is still considered a small fry in the bigger sea of serial killers. People like him slip from public attention, where there are so many other killers basking in an eerie limelight. Yet Lake’s case illustrates a mental-health point that is relatively underreported in the literature and needs to be recognized.

Lake had been diagnosed with
schizoid personality disorder when he was discharged from the
Marine Corps after service in
Vietnam. Although he went into psychotherapy, there is no known effective treatment for this personality disorder, one of the
schizophrenia-spectrum disorders. Lake was an
odd man in many ways. He was fascinated by medieval legends, paganism, and the Vikings. He was once observed to have a large pot on his stove in which he was cooking the head of a goat for soup.
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Odd beliefs and behavior like this are characteristic of those with
schizotypal personality disorder. One schizotypal I heard being described at a clinical case conference at UCLA wanted to sleep with a goat. Lake’s behavior and beliefs were no less bizarre. He had delusions
of grandeur and developed a
vision of running a survivalist compound in which only the strongest and bravest individuals would survive the apocalypse that was about to come. He believed the world would be destroyed in a nuclear war, but that he would rebuild the human race with his collection of young female sex slaves.
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Bizarre beliefs in those with schizophrenia-spectrum disorders don’t pop up from random neural misfiring in the brain. Instead, they have some foundation in the social environment. Lake’s delusions eerily mimic the main theme in
Stanley Kubrick’s classic film
Dr. Strangelove
, which was released in 1964. In the movie, the nuclear-arms race is getting out of control and paranoia is running rampant. Brigadier General Jack
Ripper initiates a B-52 nuclear attack against the Russians under the belief that a communist conspiracy lies behind the water fluoridation that is sapping his “precious bodily fluids.” The Russians have, unbeknownst to the West, developed a doomsday device that is programmed to wipe out the world in the event of an attack on Russia. The U.S. president, under the advice of Dr. Strangelove (a former Nazi weapons expert), develops a plan to occupy deep mine shafts. Selected men—who of course would include the president, Dr. Strangelove, and senior officials—will cohabit with many young women selected for their reproductive fitness and attractiveness so that the men may perform prodigious acts of unselfish reproduction to help repopulate the world.