1102799

research-article2022
IJOXXX10.1177/0306624X221102799International Journal of Offender Therapy and Comparative CriminologySonnweber et al.

Article
International Journal of

Exploring Characteristics of
Offender Therapy and
Comparative Criminology
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Homicide Offenders With © The Author(s) 2022

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DOI: 10.1177/0306624X221102799
https://doi.org/10.1177/0306624X221102799

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Martina Sonnweber1 , Steffen Lau1,

and Johannes Kirchebner1

Abstract
The link between schizophrenia and homicide has long been the subject of research
with significant impact on mental health policy, clinical practice, and public perception of
people with psychiatric disorders. The present study investigates factors contributing
to completed homicides committed by offenders diagnosed with schizophrenia
referred to a Swiss forensic institution, using machine learning algorithms. Data were
collected from 370 inpatients at the Centre for Inpatient Forensic Therapy at the
Zurich University Hospital of Psychiatry. A total of 519 variables were explored to
differentiate homicidal and other (violent and non-violent) offenders. The dataset
was split employing variable filtering, model building, and selection embedded in a
nested resampling approach. Ten factors regarding criminal and psychiatric history
and clinical factors were identified to be influential in differentiating between
homicidal and other offenders. Findings expand the research on influential factors
for completed homicide in patients with schizophrenia. Limitations, clinical relevance,
and future directions are discussed.

Keywords
schizophrenia, violence, offending, machine learning, forensic psychiatry

1University of Zürich, Switzerland

Corresponding Author:
Martina Sonnweber, Department of Forensic Psychiatry, University Hospital of Psychiatry, University of
Zürich, Alleestrasse 61A, 8462 Rheinau, Switzerland.
Email: martina.sonnweber@gmx.net
2 International Journal of Offender Therapy and Comparative Criminology 00(0)

Despite decades of research, it has not yet been conclusively clarified whether psy-
chotic disorders are more strongly associated with violence than other mental disor-
ders. Nevertheless, the link between schizophrenia spectrum disorders (SSD) and
homicide is well documented (Simpson et al., 2021; Whiting et al., 2021). According
to recent studies, the odds of homicidal offenses for individuals with SSD was higher
than for other violent offenses with a odds ratio of 19.5 [95% CI 14·7, 25·8] compared
to the general population (Whiting et al., 2020). Importantly, the incidence of SSD is
only 1.1%, indicating an actual overrepresentation of people with SSD committing
homicides. However, in general, homicide among persons with SSD remains rare,
with an annual rate of 0.02 to 0.36 per 100,000 persons (Large et al., 2009). About 1
out of 600 patients commits homicide before undergoing antipsychotic treatment,
implicating that the initial episode and the untreated symptomatology of the illness
itself poses a high risk for homicidal acts. However, it must be noted that the majority
of homicidal offenders do not suffer from SSD (Fazel, Gulati, et al., 2009) or engage
in violence generally (Buchanan et al., 2019).
In cases of severe violence and homicide committed by persons with SSD, rela-
tives, acquaintances, friends, or treating clinicians are more likely to be victims than
strangers (Abreu et al., 2017; Golenkov et al., 2011). Although it is generally rare for
people with SSD to exhibit extreme violence—including homicide—triggered by psy-
chosis (O. Nielssen & Large, 2010), certain types of psychotic symptoms are more
closely associated with violent behavior than others, such as paranoid delusions or
auditory command hallucinations (Pflueger et al., 2015; Swanson et al., 2006; Ullrich
et al., 2013). In addition, recent exposure to certain triggers, for example, intentional
or unintentional injury, victimization, bereavement, and substance intoxication were
found to be linked to a higher risk for violent offending (Sariaslan et al., 2016).
Therefore, a closer look at manifestations of symptoms and influencing factors associ-
ated with homicide would be useful in assessing the risk of homicidal offenses by
psychiatric patients.
The link between mental illness and homicidal behavior has considerable implica-
tions for mental health practice and policy, as it justifies allocation of (limited)
resources to mental health and criminal justice systems. The findings on this relation-
ship also provide the basis for detention measures to ensure public safety at the expense
of the autonomy and freedom of patients (Elbogen & Johnson, 2009; Kirchebner,
Günther, Sonnweber, et al., 2020). Focusing on the empirical association between
homicide and SSD may potentially increase the stigmatization of people with this
condition in the community. Nevertheless, the likelihood that some people with SSD
may commit homicides and other violent offenses represents a considerable risk that
lawmakers and practitioners are obliged to address. Hence, a more knowledgeable and
nuanced approach is needed to understand how, why, and when homicidal behavior
occurs in individuals with SSD and whether these individuals have certain character-
istics and experiences that distinguish them from other offenders with SSD, because
an accurate understanding of SSD-related violence may lead to improved treatment
and ultimately reduce stigmatization.
Sonnweber et al. 3

Our definition of “homicide/manslaughter” refers to serious acts of violence against

others with the intent to kill and only includes completed homicides and manslaughter.
Measuring the relative influence of different variables on homicides committed by
people with SSD poses a significant challenge in forensic psychiatry. Few studies have
distinguished different types of violent offending behavior, for example, minor and
severe offending (cf. Swanson et al., 2006). More often, all types of violent offending
are aggregated into a composite variable due to the limited statistical power to differ-
entiate between various forms of violence (Elbogen et al., 2006; Elbogen & Johnson,
2009). While these studies may have assumed that associations are the same irrespec-
tive of offense-severity, recent research has demonstrated that offenders accused of
different types of offenses also exhibit different mental characteristics and psycho-
pathological presentations (Fioritti et al., 2006; Hachtel et al., 2021; Matejkowski
et al., 2008). Thus, there may be features that distinguish offenders who commit com-
pleted homicidal acts from offenders who commit non-fatal violent or non-violent
offences. The present study aims to address this assumption exploratively using
machine learning (ML)—a statistical approach, which has recently been identified as
superior in comparison to classic statistical approaches in its sensitivity, specificity,
accuracy, and predictive validity (Bzdok & Meyer-Lindenberg, 2018; Hotzy et al.,
2018) and is increasingly being used in forensic psychiatry research (Gou et al., 2021;
K. Z. Wang et al., 2020).
Employing machine learning algorithms, the objectives of this exploratory study
were to investigate whether there exist any essential differences in characteristics
between offenders with SSD, who have committed homicide/manslaughter and those
who have engaged in other crimes. By incorporating an extensive set of variables
(including characteristics of childhood and adolescence, of the time before the index-
offense, and related to forensic psychiatric treatment) we aim to identify the most
influential of these variables in distinguishing offenders and to quantify a measure of
accuracy.

Method
Setting and Sample
This study is embedded in a large-scale project at The Centre for Inpatient Forensic
Therapy at the BLINDED University Hospital of Psychiatry in which basic research is
conducted on a homogeneous collective of offender patients with SSD. The Centre
provides treatment for mentally ill offenders. Patients are admitted either for manage-
ment of acute syndromes or for long-term detainment and treatment to reduce the risk
of recidivism due to their mental illness. They were admitted to the forensic psychiat-
ric institution for “treatment of a mental disorder” according to Article 59 of the Swiss
Penal Code, meaning that they had committed an offense that was related to a mental
disorder and that an expert evaluation had concluded that psychiatric treatment could
reduce the risk of future offenses.
4 International Journal of Offender Therapy and Comparative Criminology 00(0)

As part of this project, a database was created based on the patients’ extensive
forensic medical records. For this purpose, all 1,694 medical records of the patients
hospitalized in the clinic from 1982 to 2016 were screened. Individuals with a diagno-
sis of a SSD including schizophrenia, schizoaffective disorder, and delusional disorder
given by their psychiatrist at discharge according to the ICD-9 chapters 295.0 to 295.9
and ICD-10 chapters F20.0 to F25.9 (World Health Organization, 1978, 2016) were
identified and included into the study. The final population under investigation con-
sisted of 370 offender patients with SSD with the majority being recorded after the
year 2000 (296 cases). For full details on data collection and processing see Kirchebner,
Günther, and Lau (2020), Kirchebner, Günther, Sonnweber, et al. (2020), Kirchebner,
Sonnweber, et al. (2020), and Günther et al. (2020).
We conducted a retrospective content analysis of case records for all variables
using a structured protocol based on Seifert’s extended (Habermeyer et al., 2010;
Kutscher et al., 2009) list of criteria (Seifert & Leygraf, 1997). This is a coding proto-
col developed for the investigation of German offenders in the correctional system and
collects a variety of different domains from the enforcement records of the individuals.
These include: sociodemographic data, childhood/adolescent experiences, psychiatric
history, criminal history, social and sexual functioning, details of the offense leading
to forensic hospitalization, jail data, and specifics of the current hospitalization.
Psychopathological symptoms were assessed with a close adaptation of the Positive
and Negative Symptom Scale (PANSS; Kay et al., 1987) scoring the standard 30 items
on a three-point scale (0 = totally absent, 1 = discretely present, and 2 = substantially
present). In the process multidisciplinary patient records compiled during the patients’
hospitalization (these included forensic psychiatric reports, charge sheets, court judg-
ments, nursing reports, annual reports, risk assessment reports, discharge reports,
medication, etc.) were reviewed and coded by a trained physician. To evaluate inter-
rater reliability, a second trained independent rater coded a random subsample of 10%
of cases. Cohen’s kappa value (Brennan & Hays, 1992) was .78 and therefore substan-
tial (Lambert et al., 2004).
Finally, the coding protocol was digitized and transferred into a database with over
500 different variables. This database is the source for several exploratory research
questions. The present study aimed to exploratively investigate whether and how
offender patients with SSD who have committed a homicide differ from the rest of the
patients with respect to the 500 variables, and to identify the most important of these
variables. Details on the exact operationalization can be found in the next section.

Statistical Methods: Machine Learning

An in-depth description of ML can be found in BLINDED and was partially adopted
and extended here. An overview of the statistical steps can be seen in Figure 1 and are
further described in the following. All steps were performed using R version 3.6.3. and
the MLR package v2.171 (Bischl et al., 2016). CI calculations of the balanced accu-
racy were conducted using MATLAB R2019a (MATLAB and Statistics Toolbox
Release 2012b, The MathWorks, Inc., Natick, Massachusetts, United States) with the
add-on “computing the posterior balanced accuracy” v1.0 (Brodersen et al., 2010).
Sonnweber et al. 5

Figure 1.  Overview of statistical procedures.

Note. Step 1—Data Preparation: Multiple categorical variables were converted to binary code. Continuous
and ordinal variables were not manipulated. Outcome variable were defined (homicide/manslaughter
and all other offenses; homicide/manslaughter and violent offenses) and 519 predictor variables
were defined. Step 2—Data-splitting: Split into 70% training dataset and 30% validation dataset. Step
3 a, b, c, d, e—Model building and testing on training data I: Imputation by mean/mode; up-sampling of
outcome “homicide/manslaughter” 8×/7×; variable reduction via random forest; model building via ML
algorithms—logistic regression, trees, random forest, gradient boosting, KNN (k-nearest neighbor),
support vector machines (SVM), and naive Bayes; testing (selection) of best ML algorithm via ROC
parameters. Step 4—Model building and testing on training data II: Nested resampling with imputation,
up-sampling, variable reduction, and model building in inner loop and model testing on outer loop. Step
5a, b—Model building and testing on validation data I: Imputation with stored weights from Step 3a and
up-sampling of outcome “homicide/manslaughter” 8×/7×. Step 6—Model building and testing on validation
data II: Best model identified in Step 3e applied on imputed and balanced validation dataset and evaluated
via ROC parameters. Step7: Test for multicollinearity and ranking of variables by indicative power.

For the initial exploratory analysis (model 1), the outcome variable (type of index
offense) was dichotomized into (1) completed homicide/manslaughter and (2) all other
offenses (including violent and non-violent offenses). To examine the results of this
first analysis in more detail, we have decided to conduct a second analysis (model 2)
with (1) homicide/manslaughter and (3) other violent offenses as second outcome
6 International Journal of Offender Therapy and Comparative Criminology 00(0)

variables. The following offenses were considered as violent (based on Swiss law):
attempted homicide, assault, rape, robbery, arson, and child abuse. Non-violent
offenses included threat, theft, damage to property, minor sexual offenses (e.g., exhi-
bitionism), drug offenses, illegal gun possession, and other minor offenses (e.g., trig-
gering false alarms or emergency brakes). One patient showed missing data on his
index offense and was therefore excluded from the study. Of the remaining patients,
40 (10.8%) had committed homicide/manslaughter, 254 (68.8%) had committed a vio-
lent index offense and 75 (20.4%) had committed a non-violent index offense. In both
models, homicide/manslaughter was defined as the negative class, all other offenses
(model 1) and all other violent offenses (model 2) as the respective positive class. A
total of 519 dichotomous predictor variables remained. Next, the data set was divided
into a training subset (70% of patients) and a validation subset (30% of patients). This
was done to separate model building from model validation and reduce the risk of
overfitting.

Initial ML modeling: Nested resampling.  For model building only the training subset was
used. To reduce overfitting and to avoid final model selection to be influenced by data
processing, nested resampling (Moons et al., 2014; Studerus et al., 2017) was employed
for initial modeling: In an inner loop data processing and model training are performed
imbedded in fivefold-cross-validation and then in an outer loop the performance of
these models is tested—also embedded in fivefold-cross-validation. Cross-validation
is a technique to artificially create different subsamples of a data set (Browne, 2000).

Initial modeling: Data processing and model building.  This step was performed within the
inner loop of the nested resampling of the training subset. Because some ML algo-
rithms need complete data sets, missing values were imputed via mean and mode
algorithms implemented in the MLR package. Weights were stored and used in the
validation subset. Due to the imbalance in the distribution of the outcome variable (in
model 1 the distribution of homicide/manslaughter versus all other index offenses was
10.8% vs. 89.2% and in model 2 homicide/manslaughter versus violent index offenses
was 13.6% vs. 85.4%), the less frequent state of “homicide/manslaughter” was ran-
domly upsampled at a rate of 8 in model 1 and 7 in model 2, thus balancing the data
subset, as is recommended for optimal model building (Wei & Dunbrack, 2013). Since
the extraction of the most predictive variables without overfitting was a key objective
of the current study, a random forest algorithm (Ishwaran & Kogalur, 2022) was used
to filter the initial 519 variables. Hyperparameters were not tuned using the original
hyperparameters of the MLR package. Finally, discriminative model building was
applied with logistic regression, trees, random forest, gradient boosting, KNN (k-near-
est neighbor), support vector machines (SVM), and naïve Bayes, as an easily appli-
cable generative model (for a more detailed description see James et al., 2013).

Initial modeling: Model selection.  In the outer loop of the nested resampling procedure,
the final model was selected by assessing model performance of each model. Model
performance was evaluated in terms of balanced accuracy (i.e., the average of true
Sonnweber et al. 7

positive and true negative prediction rate, which is suggested for imbalanced data;
Brodersen et al., 2010) and goodness of fit (measured with the receiver operating char-
acteristic, balanced curve area under the curve method, and ROC balanced AUC).
Moreover, specificity, sensitivity, positive predictive value (PPV), and negative pre-
dictive value (NPV) were evaluated. As our training dataset was artificially balanced,
the model with the highest AUC was chosen for final model validation in the valida-
tion subset of the data (Campbell, 1994). The final set of identified predictor variables
was tested for multicollinearity to avoid dependencies between the variables.

Final model evaluation.  The validation subset of the original data set was not manipu-
lated except for the imputation of missing values via the stored weights from initial
model building (see above). The best performing final model was used and perfor-
mance measures were reassessed. The predictor variables of the outcome variable in
this final model were sorted by indicative power through means of a sensitivity analy-
sis using the gbm package (Cortez & Embrechts, 2013).

Results
The majority of the sample was male (91.6%, n = 339), with a mean age of 34.1 years
(SD = 10.2), single (80.8%, n = 299), unemployed (71.1%, n = 263), and not born in
Switzerland (54.6%, n = 202), 78.6% (n = 291) of the participants met criteria for
schizophrenia, 14.1% (n = 52) met criteria for persistent delusional disorder or an acute
and transient psychotic disorder, and 7.3% (n = 27) met criteria for schizoaffective
disorder. The patients’ most recent psychiatric placement (index offense) occurred for
a violent offense in 79.5% of cases (n = 294).
The performance measures of all trained models during the nested resampling pro-
cedure on the initial training dataset (70% of the total dataset) can be seen in Tables 1
and 2. Gradient Boosting was identified as the best performing algorithm for both
objectives with a balanced accuracy of 78.23% for the distinction between completed
homicide/manslaughter and all other offenses, and a balanced accuracy of 77.45% for
homicide/manslaughter versus violent offenses.
The 10 most indicative variables (code, description, and distribution) for each
objective, which were identified by random forest testing and subsequently used for
model building, can be seen in Tables 3 and 4.
For the first objective (homicide/manslaughter vs. all other offenses), the final gradi-
ent boosting model using these variables applied to the validation subset (30% of the
total data set) yielded a balanced accuracy of 62.17% and an AUC of 0.67 (see Table 5).
This model showed a sensitivity of 85.78%, reflecting its ability to correctly classify
other offenses and a lower specificity of 38.46%, indicating its ability to correctly iden-
tify the actual homicidal offenses.
For our second objective (homicide/manslaughter vs. other violent offenses), the
final gradient boosting model yielded a balanced accuracy of 70.21% and an AUC of
0.69 (see Table 6). This model showed a sensitivity of 78.87% (correctly identifying
violent offenses) and a specificity of 61.54% (correctly identifying actual homicides).
8 International Journal of Offender Therapy and Comparative Criminology 00(0)

Table 1.  Machine Learning Models and Performance in Nested Cross-Validation—

Homicide/Manslaughter vs. All Offenses.

Statistical Balanced Sensitivity Specificity PPV NPV

procedure accuracy (%) AUC (%) (%) (%) (%)
Logistic 68.79 0.7189 66.49 61.09 93.11 23.56
regression
Tree 73.51 0.7591 85.52 61.78 93.52 32.08
Random forest 59.86 0.7799 95.34 24.38 90.86 28.0
Gradient 78.23 0.8249 83.79 68.67 95.29 36.23
boosting
KNN 66.89 0.8021 87.55 46.24 92.79 30.29
SVM 61.64 0.7450 87.95 35.33 91.34 26.21
Naive Bayes 69.45 0.8023 75.13 63.78 93.56 23.11

Note. AUC = area under the curve (level of discrimination); PPV = positive predictive value;
NPV = negative predictive value; KNN = k-nearest neighbors; SVM = support vector machines.

Table 2.  Machine Learning Models and Performance in Nested Cross-Validation—

Homicide/Manslaughter vs. Violent Offenses.

Statistical Balanced Sensitivity Specificity PPV NPV

procedure accuracy (%) AUC (%) (%) (%) (%)
Logistic Regression 70.71 0.7973 74.98 66.43 94.45 28.50
Tree 57.71 0.6174 75.04 40.38 89.49 20.48
Random forest 64.68 0.7455 95.34 34.22 89.61 53.68
Gradient boosting 77.45 0.8257 84.33 70.57 93.38 39.67
KNN 75.63 0.8254 81.03 70.22 92.64 32.67
SVM 65.37 0.7703 83.57 47.17 90.79 36.95
Naive Bayes 69.86 0.8136 72.72 67.00 94.21 28.62

Note. AUC = area under the curve (level of discrimination); PPV = positive predictive value;
NPV = negative predictive value; KNN = k-nearest neighbors; SVM = support vector machine.

Testing for multicollinearity showed no dependencies between the variables. The

importance of each variable in the gradient boosting model can be seen in Figures 2
and 3.
Time spent in current forensic hospitalization (202.5 weeks for homicidal offend-
ers vs. 107 weeks for other offenders), the age of first diagnosis of SSD (30.8 years
vs. 27.8 years), and time spent in prison over 1 year (55.9% vs. 29.3%) were identi-
fied as the most indicative factors for the distinction between homicide/manslaugh-
ter and all other offenses. Olanzapine equivalent at discharge (18.2 vs. 19.4), age of
patient at index offense (32.5 years vs. 31.9 years), age at admission (36.9 years vs.
33.9 years), and age at first inpatient treatment (27.2 years vs. 24.7 years), PANSS
total score at admission (43.9 vs. 44.8) were also identified as factors influencing
Sonnweber et al. 9

Table 3.  Absolute and Relative Distribution of Indicative Variables—Homicide/Manslaughter

vs. All Offenses.

Homicide/
Variable code Variable description manslaughter Other offences
R22a (mean, SD) Time spent in current 202.49 (176.13) 106.98 (126.35)
forensic hospitalization
(in weeks)
PH1 (mean, SD) Age at schizophrenia 30.82 (7.74) 27.83 (9.53)
spectrum disorder
diagnosis
J1 (n/N, %) Time spent in prison 19/34 (55.88) 82/280 (29.29)
(before current
hospiatalzation >1 year)
R9e (mean, SD) Daily cumulative 18.23 (12.31) 19.39 (14.32)
olanzapine equivalent at
discharge
D6 (mean, SD) Age of patient at offence 32.53 (8.33) 31.94 (10.17)
PA_A (mean, SD) PANSS Score at admission 43.88 (24.44) 44.83 (20.32)
R28 (n/N, %) Future legal prognosis  
   Favorable 11/33 (33.3) 60/261 (23)
   Sufficient 13/33 (39.4) 60/261 (23)
   Doubtful 4/33 (12.1) 53/261 (20.3)
   Unfavorable 5/33 (15.2) 88/261 (33.7)
SD1 (mean, SD) Age at admission 36.90 (8.58) 33.90 (10.36)
PH14a (n/N, %) No drug abuse in patients’ 19/40 (47.5) 79/308 (25.6)
history
PH19b (mean, SD) Age of first inpatient 27.18 (7.08) 24.68 (8.78)
treatment

Note. SD = Standard deviation; PANSS = positive and negative syndrome scale (adapted measurements:
symptom completely absent = 0, symptom discretely present = 1, symptom substantially present = 2).

the model, as were no drug abuse (47.5% vs. 25.6%), and favorable legal prognosis
(33.3% vs. 23%).
The most influential variables for the distinction between homicide/manslaughter
and violent offenses were again time spent in current forensic hospitalization
(202.5 weeks for homicidal offenders vs. 124.7 weeks for violent offenders), the age of
first diagnosis of SSD (30.8 years vs. 27.5 years), time spent in prison over 1 year
(55.9% vs. 31.8%), and olanzapine equivalent at discharge (18.2 vs. 19.7). Furthermore,
the variables number of offenses leading to current forensic hospitalization (1.45 vs.
2.2), PANSS total score at admission (43.9 vs. 45.8), coercive treatment in patients’
history (28.6% vs. 57.4%), no drug abuse (47.5% vs. 24.6%), age at admission
(36.9 years vs. 33.8 years), and any legal complaint before current admission (8.3% vs.
28.4%) were also identified as being highly influential.
10 International Journal of Offender Therapy and Comparative Criminology 00(0)

Table 4.  Absolut and Relative Distribution of Indicative Variables—Homicide/Manslaughter

vs. Violent offenses.

Homicide/ Other violent

Variable code Variable description manslaughter offences

R22a (mean, SD) Time spent in current 202.49 (176.13) 124.68 (138.88)
forensic hospitalization
(in weeks)
PH1 (mean, SD) Age at schizophrenia 30.82 (7.74) 27.50 (9.64)
spectrum disorder
diagnosis
J1 (n/N, %) Time spent in prison 19/34 (55.88) 69/217 (31.79)
(before current
hospiatalzation >1 year)
R9e (mean, SD) Daily cumulative 18.23 (12.31) 19.66(13.09)
olanzapine equivalent at
discharge
D1 (mean, SD) Amount of offenses 1.45 (1.01) 2.16 (1.68)
leading to current
forensic hospitalization
PA_A (mean, SD) PANSS Score at admission 43.88 (24.44) 45.75 (20.88)
PH22a (n/N, %) Was the patient ever 10/35 (28.6) 120/209 (57.4)
forced to treatment?
SD1 (mean, SD) Age at admission 36.90 (8.58) 33.77 (10.56)
PH14a (n/N, %) No drug abuse in patients 19/40 (47.5) 59/140 (24.6)
history
PH27a (n/N, %) Were there any legal 3/36 (8.3) 62/218 (28.4)
complaints before
current offense?

Note. SD = standard deviation; PANSS = positive and negative syndrome scale (adapted measurements:
symptom completely absent = 0, symptom discretely present = 1, symptom substantially present = 2).

Table 5.  Final Gradient Boosting Model Performance Measures—Homicide/Manslaughter

vs. All Offenses.

Performance measures % 95% CI

Balanced accuracy 62.17 [56.03, 67.72]
AUC 0.6672 [0.5922, 0.7422]
Sensitivity 85.87 [76.69, 91.97]
Specificity 38.46 [29.24, 48.55]
PPV 55.24 [46.18, 63.49]
NPV 75.47 [61.42, 85.81]
Sonnweber et al. 11

Table 6.  Final Gradient Boosting Model Performance Measures—Homicide/Manslaughter

vs. Violent offenses.

Performance measures % 95% CI

Balanced Accuracy 70.21 [62.38, 76.57]
AUC 0.6912 [0.5341, 0.8483]
Sensitivity 78.87 [67.25, 87.31]
Specificity 61.54 [49.35, 65.68]
PPV 65.12 [54.00, 74.86]
NPV 76.19 [63.51, 85.64]

Figure 2.  Variable importance of final model homicide/manslaughter versus all other
offenses.

Discussion
The aim of our exploratory study was to identify factors that distinguish between
homicide/manslaughter and all other offenses committed by individuals with SSD in
12 International Journal of Offender Therapy and Comparative Criminology 00(0)

Figure 3.  Variable importance of final model—homicide/manslaughter versus violent

offenses.

order to provide an initial exploratory overview. By employing ML algorithms and a

unique database, we were able to build a model comprising 10 factors. To obtain an
even more detailed picture of individuals who committed homicide, a second analysis
was performed to distinguish between completed homicide/manslaughter and other
(non-fatal) violent crimes. Variables related to criminal and psychiatric history as well
as clinical factors have been identified to be highly influential and are described in
more detail below.
In both models, homicidal patients were older at diagnosis of SSD, at committing
the index offense, at admission to forensic treatment and at first inpatient treatment. In
comparison to other violent offender patients, homicidal patients were less likely to
have criminal records preceding their index offense. This finding supports previous
research on offenders suffering from SSD, which identified a subgroup characterized
by suddenly committing a very serious crime in their late 30’s and without any crimi-
nal history (“Type III” or “late late starters”; Hodgins et al., 2014; Simpson et al.,
2015). J. Wang et al. (2019) report similar results: only 6.5% of their examined homi-
cide offenders had committed offenses in the past and for most of them this was their
first offense. Other studies (Fioritti et al., 2006; Meehan et al., 2006; O. B. Nielssen
et al., 2007; O. Nielssen & Large, 2010) also found the average age to be over 30 years,
Sonnweber et al. 13

which is older than the average age at full expression of the illness in most studies on
SSD (Large et al., 2008) and also older than homicide offenders in the general popula-
tion (O. Nielssen & Large, 2010). Patients in the first episode of psychosis might have
a pattern of positive symptoms associated with violence (e.g., impulsivity, irritability,
and hallucinations). By contrast, negative symptoms in the later course of SSD might
decrease the occurrence of violence due to their drive-reducing effect. Furthermore, it
is possible that a course of treatment with antipsychotic medication might have a last-
ing neurobiological effect that decreases the probability of violent behavior (O.
Nielssen & Large, 2010).
In addition, a subgroup of offenders with SSD characterized by suddenly commit-
ting a very serious crime in their 30’s and without any criminal history was identified
in recent research (Hodgins et al., 2014; Simpson et al., 2015). J. Wang et al. (2019)
report similar results: only 6.5% of their examined homicide offenders had committed
offenses in the past and for most of them this was their first offense. Therefore, the risk
of homicide in patients with SSD without having committed any prior offenses should
not be disregarded.
Homicidal patients seemed to exhibit less severe illness-specific factors than all
other offender patients. They had lower PANNS scores at admission and required less
medication upon discharge. We suspect that non-violent offenders are more likely to
engage in inappropriate and bizarre social behavior that attracts negative attention and
tend to commit minor offenses more frequently, which may cause more regular
involvement with the legal system and a higher likelihood for coercive psychiatric
measures (which occurred twice as frequent among other violent offender patients
than among homicidal patients). This may also lead to further mandatory outpatient
psychiatric treatment (e.g., for probation) and regular follow-up visits so that minor
offenses might be identified more often. The fact that homicidal patients were older at
the time of committing the index offense and had less prior contact with the legal sys-
tem or mental health services than all other offenders could be an indication of a less
pronounced but chronic pathology and better pre-morbid social functioning and may
imply less severe neuropsychological impairments until the full clinical manifestation
of the disorder is evident. This would be in line with findings suggesting that patients
with SSD and a history of violence exhibit greater impairment of intellectual and exec-
utive functions than patients without such a history (Fioritti et al., 2006; Hodgins,
2017; Kumari et al., 2006). This could in turn indicate that acts involving serious
violence represent higher levels of psychosocial organization.
In addition, homicidal patients in our sample were considerably less likely to have
abused drugs in the past than all other offender patients, again suggesting less impaired
brain structures, especially in comparison to patients with chronic and multiple sub-
stance abuse (Tracy et al., 1995). Nonetheless, neurocognitive function should be con-
sidered along with other clinical and social variables when assessing violent individuals
with SSD, as previous studies found that neuroanatomical abnormalities and deficits
in neuronal activation contribute to violent behavior in individuals with SSD (Kumari
et al., 2006; Stratton et al., 2017). Clinicians should therefore be alert to a combination
of factors, namely impaired attention and executive function, auditory hallucinations,
14 International Journal of Offender Therapy and Comparative Criminology 00(0)

paranoid delusions, and criminal history, that may pose a risk for homicidal acts, as
suggested in previous research (Kumari et al., 2006; Stratton et al., 2017).
Furthermore, lifelong antisocial behavior, that is, frequently preceded by conduct
disorder in childhood, was found to be a major risk factor for violent offending in adult
life (Witt et al., 2013). However, that study did not provide a more detailed description
of the construct of violence used. Thus, it should be investigated whether this also
influences the incidence of homicides in individuals with SSD.
Homicidal patients remain longer in the legal system (prison, forensic psychia-
try)—despite better legal prognosis. This is in line with previous findings arguing that
the length of inpatient forensic treatment may be determined by factors that were
apparently unalterable by treatment efforts (Fioritti et al., 2006; Kirchebner, Günther,
Sonnweber, et al., 2020). Patients who have committed homicidal offenses may face
more difficult obstacles to release, than patients who have shown less severe criminal
behavior. Clinicians and courts may feel responsible for preventing similarly serious
crimes by all means, incorporating public safety policy considerations and the indi-
vidual views of clinical and public risk assessment decision-makers, and may discour-
age innovative treatment initiatives. Favorable therapeutic developments in offender
patients that would justify discharge from forensic inpatient treatment for less serious
crimes may be mistrusted in cases with serious index offenses. Whilst forensic psy-
chiatry should not base treatment decisions merely on the severity of the index offense,
but rather on risk evaluation and positive developments of offender patients, this
seems to be difficult in criminal cases involving a high degree of emotion due to the
severity of a crime.
No distal factors (such as childhood/adolescence and experiences of sexual or
physical abuse) or social (e.g., victimization) and environmental (e.g., socio-economic
status and ethnicity) factors could be identified, which is somewhat surprising, since
these factors were found to be increasing violence risk (O’Reilly et al., 2015; Witt
et al., 2013). Many of these difficulties are likely caused by cognitive impairment and
decline in patients with SSD (O’Reilly et al., 2015; Soyka, 2011). This again points
toward our consideration that homicidal patients show better cognitive performance
and less impairment. Explanations may include better premorbid functioning, later
onset of SSD and a shorter period of being untreated. Interestingly, the country of
origin did not play a central role although more than half of the patients were not born
in Switzerland. This is in line with the findings of a study on this specific population,
which identified social and therapeutic factors, rather than the severity of the offense,
as the decisive differences between Swiss and foreign individuals (Huber et al., 2020).
Regarding psychiatric co-diagnoses it is worth noting that neither personality dis-
orders (including antisocial and conduct disorder) nor substance abuse were found as
differentiating factors in this analysis. This is inconsistent with previous findings that
have linked personality disorders and substance abuse to a higher likelihood of vio-
lence in SSD patients (Baird et al., 2020; Fazel, Langström, et al., 2009; Hodgins
et al., 2005; Swanson et al., 2006; Walsh et al., 2002) and requires further clarification.
This could be due to the fact that only about 10% of the studied population had received
a co-diagnosis of personality disorder, which is due to the local diagnosis approach
Sonnweber et al. 15

that follows ICD-10, which specifies that no diagnosis should be assigned if the behav-
ior is due to another disorder, in this case SSD.
With the exception of factors regarding psychopathology (PANSS and medication),
all factors identified were static in nature and thus hardly or not alterable by therapy.
What can be changed though, is patients’ self-awareness through more individualized
therapeutic approaches and more resources in prevention and early detection.

Limitations
In the present analysis, data was collected retrospectively, and although the files used
in this study were of high quality, the possibility of distortions could not be completely
excluded, including the use of a PANSS-adapted scale for the content analysis of psy-
chopathological data, which in some cases were recorded before the publication of the
instrument.
While some of the influencing factors found in this study may represent associa-
tions with the outcomes, they do not imply causality, and further prospective studies
must be conducted before firm conclusions can be drawn about the influence of spe-
cific factors on homicidal behavior in patients with SSD.
In addition, due to the retrospective nature of the data, important variables that have
previously been considered critically important factors influencing homicides of indi-
viduals with SSD, such as the presence of psychopathy (Fox & DeLisi, 2019) and
adherence to (medication) therapy (Baird et al., 2020; Carabellese et al., 2021) at the
time of the offense, could not be examined. Another limitation is the small number of
homicidal patients compared to other violent or non-violent patients in our sample. To
compensate for this imbalance, up-sampling, and balancing methods were applied.
It should be noted that ML achieves particularly good results with large-scale data
sets, so that the 370 patients analyzed here represent a rather limited number in this
context and thus, despite cross-validation, overfitting remains a limitation to the inter-
pretive power of this study.

Future Research Directions

More attention should be paid to the measurement, operationalization, and context of
serious violence and homicidal behavior. Since the outcome variable “violence” was
not specified in more detail in many previous research studies (Kumari et al., 2006;
Stratton et al., 2017; Witt et al., 2013), the comparability between different studies is
limited. Consequently, the term “violence” should be clearly operationalized in future
studies. Relying solely on records or self-reports often excludes the measurement of
other characteristics of violence such as motivation, targets, or setting.

Clinical Implications
It is possible that the quality of mental health services provided and the lack of ade-
quate (individualized) services may influence the risk of homicide, for example, in
16 International Journal of Offender Therapy and Comparative Criminology 00(0)

terms of earlier recognition of SSD and treatment adherence and compliance. More
effective communication and education of professionals working in the (mental)
health care sector could enable earlier intervention in the case of previously unde-
tected risk factors for homicidal behavior in people suffering from SSD.
As SDD is one of the major causes of disease-related disability in the world (Świtaj
et al., 2012; Tandon et al., 2008) and is widely associated with dangerousness, a better
understanding of antecedents of homicides in individuals with SSD may be helpful in
developing viable preventive and therapeutic approaches targeting at high-risk patients
and could potentially reduce the prevalence of homicides.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship,
and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of
this article.

Ethical Approval
This study was reviewed and approved by the Ethics Committee Zurich [Kanton Zürich] (com-
mittee’s reference number: KEK-ZH-NR 2014-0480). The study complied with the Helsinki
Declaration of 1975, revised in 2008. This is a retrospective study. For this type of study formal
consent is not required.

ORCID iD
Martina Sonnweber https://orcid.org/0000-0002-9280-3286

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