In this population of inmates in substance abuse treatment programs, thought insertion/control ideation and antisocial personality disorders were associated with increased risk for violent or disruptive behavior while in prison, while phobic-type symptoms were associated with a decreased risk. Violent behavior is associated with the combination of schizophrenia-spectrum and substance use disorders among community populations (Arseneault et al., 2000
; Swanson et al., 1990
), but might, in part, result from medication nonadherence associated with active substance use (Swartz et al., 1998
). Our findings suggest that these effects generalize to correctional settings, where medication adherence can be more controlled. Furthermore, consistent with prior literature on the relationships between violence and psychotic diagnoses, we could find no association between psychiatric diagnoses, as determined by screening instruments or the SCID, and the risk of violent or disruptive behavior while in prison.
Although the MacArthur Violence Risk Assessment Study, a large-scale cohort study of more than 1000 persons discharged from psychiatric hospitals, did not find that delusions increased the risk for violence (Appelbaum et al., 2000
), the current findings are consistent with studies of community-dwelling and hospitalized schizophrenic patients, which found that “positive” psychotic symptoms, which include control ideation, are associated with an increased risk of violence (Swanson et al., 2006
; Steinert, 2002
). Other research has shown that increased levels of violence are associated with persecutory delusions (Link et al., 1992
; Link & Stueve, 1995
; Swanson etal., 1990
; Wessely, 1993
), the misperception of hostile intent on the part of others (Monahan et al., 2001
; Scott & Resnick, 2006
), command hallucinations to commit violence (Monahan et al., 2001
), and hallucinations that gave rise to negative emotions such as anger (Cheung et al., 1997
). The focus on in-prison violence and the ability to separate control delusions as individual symptoms most likely explain why these findings differ from those of Duncan and colleagues (2008)
, which found no relationship between violence and hallucinations. However, even among psychotic persons, it remains likely that most aggressive behavior will result from “adverse interpersonal interactions,” such as arguments, rather than internal stimuli such as commanding auditory hallucinations (Quanbeck et al., 2007
Phobic-type symptoms appear to have reduced the likelihood of acting out. Phobic-type symptoms, though not restricted to psychotic persons, might function similarly to “negative” psychotic symptoms in that they constrict externalized actions. “Negative” psychotic symptoms such as social withdrawal reduce the risk of violence (Swanson et al., 2006
). Reported fearfulness might also reflect low status in the prison pecking order or a fear of reprisals for aggressive behavior. However, we could find no prior literature reporting a relationship between phobic symptoms and violence, so these findings should be considered exploratory pending confirmation in future investigations.
The present sample differs from community samples in significant ways. For example, psychopathy might be a weak predictor of violence in controlled settings such as psychiatric hospitals (Steinert, 2002
) and prisons (Guy et al., 2005
; Richards et al., 2003
) in which potential triggers such as family conflict are absent. The present study also reports on a selective sample that has committed crimes and might be more representative of individuals who lack the insight into their illness necessary to control their behavior (Buckley et al., 2004
) and coping mechanisms that would help them to moderate their hallucinations or delusional thinking (Cheung et al., 1997
). In these ways, the sample differs from patients discharged from psychiatric hospitals who were followed in the MacArthur study. Nevertheless, the current findings resonate with those of Swanson et al. (2006)
regarding positive and negative symptoms as risk factors for violence.
Like that by Duncan et al. (2008)
, the current study found an association between antisocial personality disorder and in-prison violence. Antisocial personality disorder is likely a risk for predatory aggression, defined as violent acts that are “planned, purposeful and goal directed” (Scott & Resnick, 2006
). In a meta-analysis of studies of violent recidivism among mentally ill offenders, antisocial personality disorder, younger age, and criminal history were among the strongest predictors (Bonta, Law, & Hanson, 1998
). It has been suggested that past violence predicts future violence (Monahan et al., 2001
), but variables characterizing persons with a high violence risk tend to lose their weight in studies utilizing high-risk samples (Steinert, 2002
). This phenomenon might explain why the current study found no effect of lifetime number of violent offenses, younger age, or male gender.
The limited relationship between prior type of substance use and violence is not surprising given the more limited access to substances inside the prison walls. In addition, drug convictions tend to be associated with less prison violence (Cunningham & Sorensen, 2006
). Substance use appears to function as a dynamic risk factor and a history of a substance use disorder has limited predictive ability as a static risk (Douglas & Skeem, 2005
). The disinhibiting effects of substance intoxication on aggression and its association with violence are well established (Steadman et al., 1998
; Swanson, 1994
). Supporting this assertion, possession or use of controlled substances or other contraband in prison had a strong, independent association with violent and disruptive behavior. This said, we cannot determine definitely whether substance use within prison itself causes the increased risk for violence, especially since others have suggested that active substance use does not fully explain violent behavior among persons with co-occurring disorders (Wallace, Mullen, & Burgess, 2004
). We also cannot discern whether the association between violence and failure to participate in assigned programs such as work, education, or vocational or substance abuse programming results from not receiving needed services in these domains. In both cases, it remains possible that these individuals’ disregard for authority itself explains any association with violent or disruptive behavior.
This study has several limitations. Correctional officers wrote the narratives for disciplinary actions, which are thus subject to reporting biases. Our study would be biased, for example, if correctional officers are more likely to charge or report infractions among prisoners with certain psychotic features, prior infractions for contraband, or antisocial traits. Differential reports along organizational, cultural, racial, and other lines might explain the almost twofold difference in the incidence of disciplinary reports between the two study sites. Other possible differences across sites might involve the number of prisoners housed in a facility, availability of services or the length of time over which infractions could be recorded. In this regard, we have no information about the time duration over which the infractions were recorded and whether they occurred before or after entry into substance abuse treatment or enrollment into the CODSI study. Thus, this study’s cross sectional design, examination of a single time point, and small number of sites limits causal inference about the relationship between disruptive behavior and its correlates. Finally, the findings derive from prisoners in prison substance use programs and might not generalize to other prison populations.
Despite these limitations, we conclude that prisoners with substance use disorders at risk for violence or disruptive behavior include those who suffer from a sense of being possessed or controlled, those with antisocial personality disorder, and those who possess or use controlled substances or other contraband in prison or fail to participate in assigned programs. Further study is needed with incarcerated and community “dual diagnosis” offender populations regarding the presence of command or control hallucinations, antisocial personality disorder, proneness to anger, and in-prison substance use, as well as insight and coping mechanisms to prevent the emergence of violent behavior. Future investigations should also determine whether and which targeted interventions might alleviate symptoms that increase the risk of violence, improve the safety and functioning of the prison system, and reduce recidivism.