Violence and mental illness

Last night when I was on call, a new patient came to the child psychiatry unit. She had been threatening to kill her family and in fact had stabbed her teacher with a pencil. She is nine years old. When the resident and I went to the unit to write admission orders for her, I was curious: what does a homicidal nine year old look like? It was almost surprising to see that she looked, well, like a nine year old girl. She was tall for her age and thin; she wore a hospital gown that fell down to her feet, and she had wild, thick curly hair. She reminded me of a figure in a Pre-Raphaelite painting. She asked the nurse for a rubber band for her hair in a timid voice, and when the nurse asked her what kind of cereal she wanted, she said "I don't know" like any child who doesn't know what she is allowed to have. When I left, she was eating her cereal alone at a table in the darkened unit, lit only by a single ceiling light.

I've been thinking about violence and mental illness ever since I had a bipolar patient on internal medicine who would get very irritable and once started making very threatening moves as if he was going to harm me. On the psychiatric ward right now, we have a patient who spent 20 years in jail because she burned her house and her sister was killed in the fire. I spent some time looking for information about the link between mental illness and violence; it's a controversial issue and and it's difficult to find a consensus. This is just a blog post, so I'm not going to try to summarize everything I found, but there are some important points to make. While there is increased risk of violence in patients with mental illness who abuse substances, patients with mental illness who do not abuse substances have the same risk of violence as other people who live in their community. In addition, patients with mental illness who receive inpatient treatment are no more violent than people in their community after discharge from the hospital. In fact, it is more likely that patients with mental illness will be the victims of violence than commit violence themselves. And when people with mental illness do perform violent acts, the most likely targets are family members or friends, not strangers. For more information, check out these articles from the New England Journal of Medicine and World Psychiatry.

Mental illness already carries a huge stigma, and much of that stigma comes from exaggerated notions of the link between mental illness and violence. As one of the psychiatrists told us on the first day of the psychiatry rotation, "There is always the possibility that an encounter with a psychiatric patient will turn violent, but you'll find that most psychiatric patients are nice people." Indeed, the patients I'm working with are good people who have to live with a very difficult disease. I've mentioned Mr. E, who has schizophrenia; he's a kind, gentle person and one of my favorite patients I've had all year.

I've always been touched by reading about the relationship between British writer Charles Lamb and his sister Mary. From my longtime companion, the Norton Anthology:

When he was twenty-two his beloved sister, Mary, ten years his senior, broke down under the strain of caring for her invalid parents and stabbed her mother in the heart. Upon her recovery, Mary was released to the care of her brother, who devoted the rest of his life to her and to their common household. Mary's attacks recurred, briefly and periodically, and when the terribly familiar symptoms began to show themselves, Charles and Mary would walk arm in arm and weeping to the asylum, carrying a straitjacket with them.

Even in a short passage like this, it's clear how much love Charles had for Mary. I hope that in our society, we can learn to show the same kind of love to those with mental illness. After all, all of us will encounter mental illness, whether in ourselves, a loved one, or a coworker. I hope we all take the time to educate ourselves about mental illness so we can treat these people in a helpful and caring way.