A history of violence

The enduring and controversial link with schizophrenia (warning: discussion of the 2023 Nottingham attacks)

This is Daniel M’Naghten. He was born, most likely in Glasgow, in 1813. He probably spelled his name as the more recognisable ‘McNaughtan’ - but the misspelling in now enshrined in psychiatric and legal canon.

Despite lacking formal education, he taught himself French and enjoyed reading philosophy. He was well travelled, spending time in France and London. He attended debates and lectures in anatomy. He had a brief career as an actor and engaged in chartism, a radical political movement.

By the age of 30, he reported that the ruling Tory party was persecuting him because he voted against their candidate. He purchased pistols, telling his landlady that they were for shooting birds. He went to London and was seen lurking around Whitehall. Then, on January 1843 near Downing Street, M’Naghten shot the civil servant Edward Drummond in the back from point blank range. Drummond later died from his injury, while M’Naghten made no effort to escape, waiting to be arrested.

It is widely accepted that he mistook Drummond for the real target, sitting Tory Prime Minister Robert Peel. He gave the following statement to the police:

The Tories in my native city have compelled me to do this. They follow and persecute me wherever I go and have entirely destroyed my peace of mind. They followed me to France, into Scotland, and all over England; in fact, they follow me wherever I go. I cannot sleep nor get no rest from them…. I believe they have driven me into a consumption. I am sure I shall never be the man I was. I used to have good health and strength, but I have not now. They have accused me of crimes of which I am not guilty; in fact, they wish to murder me. It can be proved by evidence. That’s all I have to say.

The subsequent trial is part of legal history. Both the defence and prosecution agreed that M’Naghten suffered from persecutory delusions. He appeared otherwise ‘generally sane’, with relatively high day-to-day functioning. The defence argued that his soundness of mind in other aspects of life was irrelevant, the killing of Drummond was in response to a delusion, so he should be considered insane. The jury duly returned a verdict of not guilty, on the grounds of insanity.

M’Naghten was detained in the criminal wing of Bethlem Hospital, where he remained until transfer to the newly opened Broadmoor Asylum in 1864. He died a year later from renal and cardiovascular complications.

The verdict caused a furore, particularly as Queen Victoria was herself the target of assassination attempts, most notably by Edward Oxford (also found not guilty by reason of insanity). The Queen wrote to the Prime Minister to voice her displeasure. On instruction of the Government, the House of Lords put questions to a panel of judges. Their response became known as the M’Naghten rules:

• Every man is presumed to be sane unless the contrary is proved

• To establish the defence of insanity it must be proved that at the time of committing the act the defendant was labouring under a defect of reason from a disease of the mind

• So as not to know the nature and quality of the act he was doing

• Or if he did know it that he did not know that what he was doing was wrong

These rules became the standard in England and were widely adopted abroad. The defence of insanity and treatment in secure hospitals like Broadmoor has thus been part of the justice system for hundreds of years. Despite this, the link between violence and mental illness continues to provoke controversy, in both academic and public spheres.

An academic debate

Last month, Professor Seena Fazel, a forensic psychiatrist¹ posted a thread on X describing an ongoing debate across academic journals. It centres on a meta-analysis of violence and schizophrenia published by Fazel and others in 2021. They examined rates of violent acts perpetrated by people with schizophrenia spectrum disorders, compared with general population controls. Risk of violence, including homicide, was increased in schizophrenia, with a pooled odds ratio of 4.5 (95% CI 3.6-6.8) in men. The association was consistent across time, across countries, and across a range of violent acts. The authors emphasised that most people with schizophrenia are not violent, less than 1 in 4 men engaged in violence over a 35 year time period.

The study received two responses; one made some valid statistical criticisms, while the other, led by Professor Paolo Fusar-Poli², was harsher:

We believe the methods and their interpretations are flawed, and their uncritical dissemination risks fuelling misunderstandings and stigmatisation, potentially leading to violence against people with psychosis, as feared by our coauthor with lived experience of psychosis…

We call for an open debate rebutting these findings to ensure that the headline messages are not used to undo decades of work by human rights advocates and anti-stigma campaigners.

They criticised the analysis for including low quality studies, with imprecise diagnoses and inconsistent measures of violence. They suggested the result could have been confounded by social class or other adversities associated with schizophrenia.

While some methodological criticisms are valid, a bulk of evidence still points towards an association with schizophrenia. Furthermore, the association is consistent across study designs, some of which have lower risk of bias. A meta-analysis of randomised controlled trials, showed that antipsychotics reduce violence in schizophrenia. The risk of violent crime is higher during periods when patients are not prescribed antipsychotics. Finally, addressing the confounding effect of social class, people with schizophrenia have an increased risk of violence compared with unaffected siblings.

This fits with the risk of violence being related to schizophrenia itself and points to the risk being reduced with appropriate treatment. Unperturbed, Fusar-Poli published an editorial in World Psychiatry criticising the meta-analysis and claiming it would expose people with schizophrenia to further discrimination.

While the academic debate will likely continue, anyone who has worked in acute psychiatric settings will have their own experience of how psychosis can result in violence. Unfortunately this is a reality of severe mental illness.

The reality of mental illness

At their first placement in a psychiatric hospital I like to ask medical students about their initial impressions. They often notice that the nurses are wearing casual clothes rather than uniforms or that the doors are more secure. Another observation is staff members carrying alarms. Students will be advised which patients can be approached and which should be seen with a member of staff.

When starting a job in psychiatry, everyone has to go through training in ‘disengagement’ or ‘breakaway’ skills - how to deescalate and avoid violence. Most doctors have witnessed violence on a psychiatric ward, usually between two patients. All patient encounters involve some assessment of risk.

This risk is not uniform across mental disorders; people suffering from severe anorexia are seldom a risk to anyone but themselves. Every psychiatrist, though, will know patients with severe schizophrenia who have hurt others in direct response to their illness. The patient may buy weapons to protect themselves against enemies they hear plotting. Like M’Naghten, they may believe malign agencies pursue and persecute them, no matter where they go.

We also see these people get better. After being admitted to hospital for the protection of others, preoccupied by delusional beliefs that they are under attack, they then start antipsychotic medication, improve and are discharged back into the community.

Holding two ideas at once

In the early hours of the 13th of June 2023, Valdo Calocane stabbed to death two university students and a school caretaker in Nottingham, before injuring several others with a stolen van. The victims were Grace O’Malley-Kumar, a medical student, her friend Barnaby Webber, and Ian Coates, who was only five months away from retirement. This terrible, senseless loss of life shook the city of Nottingham and has reverberated across the country.

Calocane was known to mental health services with a diagnosis of paranoid schizophrenia. He did not believe he was unwell and did not take his prescribed antipsychotic medication. He heard threatening voices and believed he was being spied on. He even travelled to MI5 headquarters in London, in an attempt to stop the voices.

At the time of the attacks, Calocane believed he was being controlled by an advanced AI and that his family was in grave danger. At his trial, five consultant psychiatrists provided written evidence. They unanimously concluded that, if not for his illness, Calocane would not have killed those innocent people.

Calocane pled guilty to manslaughter by reason of diminished responsibility and was sentenced to a hospital order, to be detained at Ashworth High Security Hospital. The Judge’s sentencing remarks are worth reading in full.

I will not link to the media reaction, but it was predictable. Calocane was described as a ‘monster’, ‘the most evil person on the planet’, who ‘got away with murder’. Much of this sentiment was an understandable release of grief and anger from the victims’ families. However, there was little balance in the coverage, even by respected broadcasters like the BBC. The public (or Twitter-public) reaction was uglier, with the focus on Calocane’s race (he is Black) and immigration status (he was settled in the UK through his Portuguese citizenship).

Like M’Naghten, Calocane had purchased his weapon beforehand, like M’Naghten, he was described by witnesses as calm. This led some to describe the attack as premeditated. In both cases, the medical evidence was in agreement and the judicial verdict caused uproar. The similarity of the responses to these cases, almost two hundred years apart, is striking.

We have established legal and medical systems which treat people who have committed acts of violence in response to mental illness not as criminals but as unwell people in need of help. The high security hospitals in which they are detained are places of treatment and rehabilitation, not punishment. In 2024, just as in 1843, there are criticisms of this system - though I hope many will accept that it is the correct societal response.

Perhaps the issue of violence in schizophrenia is so vexed because we have to hold two seemingly opposite ideas at once. We have to accept that while the majority of people with schizophrenia will never pose a risk to others, violence can occur as an inherent part of the illness. We have to acknowledge the horror of the Nottingham attacks, while accepting the defendant’s mental state meant he was not wholly responsible.

Finally we must realise that anti-stigma campaigns and mental health awareness cannot change the reality that severe illnesses like schizophrenia can be frightening, unpredictable, and occasionally violent.

1. Conflict of interest - I am currently based in the same department

2. Conflict of interest - a previous supervisor and coauthor