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Schizophrenia, Criminality, and its Portrayal in the Media

Schizophrenia is a mental disorder classified as a psychotic disorder by the DSM; it is most commonly associated with delusions and hallucinations.[1] People with schizophrenia are characterized as out-of-touch with reality and engaging in a wide variety of atypical behaviors as a result of their illness. Symptoms of schizophrenia can be categorized into positive and negative: positive symptoms are abnormal behaviors or thought processes not experienced by healthy individuals, while negative symptoms are absences or reductions of normal behavior, such as affective flattening and social withdrawal.[2]

Popular culture and the media draw success and attention from overemphasizing flashy, unusual, and emotionally-provoking content. This leads to a general overemphasis of shocking or scary occurrences involving those with abnormal psychology. Particularly for schizophrenia, this has led to a significant exaggeration of positive symptoms over the negative, characterizing it with unnerving hallucinations and complete disconnection from reality. These natural tendencies of the media have ultimately led to the association of violence with schizophrenia. Individuals with schizophrenia are seen as more violent than the average population and more likely to engage in criminal activity. Schizophrenia has also developed an association with poverty and homelessness. Although some of the media characterizations are based on facts, they are often exaggerations and dramatic simplifications of the reality that most people with schizophrenia truly experience.

Crime

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The mental disorder of schizophrenia is commonly associated with criminality. Recent research that has examined this relationship between schizophrenia and criminality has revealed that the crimes committed by patients with schizophrenia are strongly associated with the male sex, being single, refusing to accept treatment, substance abuse, and duration of illness.[3] In a study conducted on untreated criminal offenders, persecutory delusions were present during the period in which violent crimes were committed[4]

Statistics

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People diagnosed with schizophrenia are reported to be 4 to 6 times more prone to resort to violence and criminality than mentally healthy individuals. Moreover, six percent of homicides in Western countries are said to be committed by individuals who suffer from schizophrenia.[3]

Based on a 2015 study conducted by Abolfazl Ghoreishi from the Department of Psychiatry at Zanjan University of Medical Sciences in Zanjan, Iran, the following rates across various factors were found amongst 358 participants with schizophrenia.[3]

Independent Variables No Crime (Non-Offenders) Committed Crime (Offenders)
Male 35.3% 64.7%
Female 50.8% 49.2%
16-45 years of age 28.4% 71.6%
Alcohol Abuse 27.2% 72.8%
Opium Abuse 37.6% 62.4%
Didn't finish high school 32% 68%

A closer look in the types of offense committed by those who were shown to have criminal behavior is as follows:[3]

Type of Offense Distribution patterns of the different types of offenses in

the sample (%)

Premeditated Homicide 0.8
Children Abuse 4.7
Child Abuse 24
Spouse Abuse 41.9
Damage to Property 26.8
Insult 8.4
Assault 9.8
Theft 3.6
Rape 0.3
Setting Fire 0.3

Substance Abuse

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Substance abuse is a disorder that has been found to be highly comorbid with schizophrenia.[5] Up to 50% of schizophrenia patients meet the criteria for a dual diagnosis of schizophrenia and substance abuse at some point in their lifetime.[6] These additional disorders often worsen prognosis and contribute to schizophrenia’s high suicide rate.[7] Aside from the less severe substances of tobacco and caffeine, alcohol, cannabis, and cocaine comprise the majority of substance abuse cases.[6] In a longitudinal study by Hanna Putkonen, PhD, MD, from the National Institute for Health and Welfare, Finland, over 8,000 individuals diagnosed with schizophrenia were tracked for 33 years, as well as their full siblings which served as the control. Schizophrenia was found to be correlated with an increase in violent crime in the study. However, although the risk of an individual with schizophrenia engaging in violent crime was drastically heightened, once individuals with a dual diagnosis of substance abuse were ignored, the difference in risk for violent crime between the control group and the participants with schizophrenia (and no substance abuse) was only slightly higher. [8] Substance abuse also makes patients with schizophrenia more likely to stop treatment/ not take their medications.[9]

The high rate of a dual-diagnosis of substance use disorder and schizophrenia is associated with an elevation in the risk of illness and injury. Not only does intoxication causes obvious impairments in cognitive functioning, but substance misuse is also correlated with worse outcomes in psychosis and higher rates of presentation to inpatient, and emergency services. [9]As discussed in the earlier section, there is high rate of criminality resulting in incarceration amongst individuals with a diagnosis of schizophrenia; however, most of these individuals have been found to of been actively abusing substances at the time. It is particularly these individuals with both a schizophrenia diagnosis and drug addiction problem that lack stable housing, and who are at a high risk of being incarcerated. Thus, comorbid substance abuse disorders in patients with schizophrenia have been shown to be a significant barrier to carrying out effective treatment. [9]

Cannabis

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Research has provided strong physiological and epidemiological evidence that supports the existence of a mechanistic link between cannabis use and schizophrenia. Tetrahydrocannabinol, which is the primary psychoactive component of cannabis, can trigger schizophrenia-like positive and negative symptoms. Prospective, longitudinal, and epidemiological studies have all consistently found an association between cannabis use (preceding psychosis) and schizophrenia.[10] Individuals who use cannabis heavily or frequently during their teenage years, start using young, or use of cannabis with high THC potency show a stronger link between cannabis use and chronic psychosis (including a schizophrenia diagnosis). These studies have revealed that every time cannabis is used, the risk of schizophrenia nearly doubles; this accounts for an 8% to 14% of all cases. Furthermore, using cannabis frequently or with high THC potency increases the risk of schizophrenia 6-fold. [10]

Cocaine

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It has been stressed that patients with schizophrenia who abuse cocaine are at an increased risk of suicide, are less compliant with treatment, and have a higher hospitalization rate than patients without cocaine abuse.[11] Based on the self-medication hypothesis, schizophrenic patients often use cocaine to counteract the negative side effects of anti-psychotic drug treatments prescribed for schizophrenia. Furthermore, cocaine may be used in order to overcome deficiencies in dopamine-mediated reward circuits. [9]

Nicotine

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The prevalence of cigarette smoking among schizophrenia patients is significantly higher than in the general population; this may reflect self-medication of symptoms and/or adverse effects of neuroleptics.[12] Nicotine interacts with multiple important pathways involved in schizophrenia, such as the dopaminergic and the glutamatergic pathways in the mesolimbic areas. Over 70% of patients with chronic schizophrenia are nicotine-dependent.[13] Nicotine uses are significantly more likely to be male, have an earlier age of onset of schizophrenia, and have a greater number of prior hospitalizations.In additions, smokers were reported to have received significantly higher doses of neuroleptics than nonsmokers.[9] In a 2004 study, more than 14,000 adolescents were investigated and followed over a period of 4 to 16 years, and found that adolescents who smoked over 10 cigarettes daily, at the time of their initial evaluation, were significantly more likely to be hospitalized for schizophrenia during the follow-up period. These results suggest that impaired nicotinic neurotransmission might be involved in the pathophysiology of schizophrenia.[12]

Violence and Homicide

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Prominent Cases

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Richard Chase was an American serial killer from Sacramento, California who violently murdered 6 people from 1977 to 1978. Known as "The Vampire of Sacramento" he was most notorious for drinking his victims' blood and cannibalizing their remains.[14] It is believed that he engaged in this behavior based on the notion that drinking fresh blood would prevent him from dying.[14] He was diagnosed with schizophrenia in 1976 when he was committed to a mental institution.[15] Chase was a known drug addict and most commonly abused marijuana, alcohol, and LSD.[14] He committed suicide by overdosing on antidepressants.[16] The disturbing nature of Chase's murders have inspired film adaptations, song lyrics, and popular crime TV shows.[17][18] In the Criminal Minds episode "Blood Hungry", the character Eddie Mays was heavily based on Richard Chase.[18] A CSI episode titled "Justice is Served" is also based on his crimes. Although the media emphasizes Chase’s schizophrenia in an attempt to draw an added shock factor, it is imperative to remember that the majority of individuals with schizophrenia who commit violent crimes have a dual diagnosis with substance abuse, which was definitely a significant factor of Chase’s life and criminality.[3][6]

David Berkowitz, known as the Son of Sam and the .44 Caliber Killer, was an American serial killer from New York City most infamous for his shooting sprees using a .44 caliber Bulldog revolver. He eventually killed 6 victims and wounded 8 and was incarcerated for second-degree murder and is currently serving six consecutive life sentences. Berkowitz's psychological profile created from the evidence law enforcement had collected on his killings included a description stating that the killer likely suffered from paranoid schizophrenia. Berkowitz’s schizophrenia certainly played a role in his justifications and behaviors, but the overall difference in the risk for violent crime between any patient with schizophrenia that does not have problems with substance abuse and an individual without a schizophrenia diagnosis is very small.[8] The prominence of his case and other similar criminals in the media unfortunately exaggerates the perceived correlation between schizophrenia and homicide.

Ed Gein, known as The Butcher of Plainfield, and gained widespread attention for his crimes which included murdering and "body snatching." He was diagnosed with schizophrenia in 1957, prior to the trial for one count of first-degree murder. He was declared mentally incompetent and pleaded not guilty by reason of insanity. Gein’s crimes inspired infamous fictional characters such as Norman Bates, Leatherface, and Buffalo Bill. Unfortunately this has caused the media to focus on the horrific and abnormal “trophies” that Gein kept from his victims, indirectly leading to the portrayal that individuals that have schizophrenia and other mental illnesses are disturbing and scary.

David Gonzalez, sometimes called the "Freddy Krueger Killer" due to the inspiration he drew from the movie A Nightmare on Elm Street, was a serial killer who murdered four people over two days in 2004 throughout England. Before the incident had occurred, his mother wrote Parliament a letter about the lack of availability of mental health resources for her son. Afterwards at his trial, he pled insanity but the judge declined this claim. Gonzalez went on this killing spree when he was under the influence of drugs. His mother noted that he struggled with drug abuse and that he even refused psychiatric treatment because he used cannabis. Again, Gonzalez’s struggle with substance abuse likely contributed significantly to his killing spree, especially considering that he was on drugs when it occurred. Substance abuse contributes significantly to the likelihood that an individual with schizophrenia will commit a violent crime.[3]

James Eagan Holmes, diagnosed with schizophrenia by 20 doctors[19], was responsible for the July 20, 2012 shooting at a movie theater in Colorado during a Batman premiere. He is currently serving 12 life sentences in prison without the possibility of parole for the murder of 12 people and the attempted murder of 70 others. When Holmes was taken into custody, he admitted to also having “booby-trapped” his apartment with explosives, which were later deactivated by authorities. 

Jared Lee Loughner was an American mass murderer who was diagnosed with paranoid schizophrenia after being arrested in 2012. In August of 2012, he was deemed incompetent to stand trial. Three months later he was judged competent to stand trial where he pled guilty to 19 counts of murder. Prior to this, Loughner attended Pima Community College (February - September 2010). Loughner had 5 interactions with campus police, and multiple professors complained to the administration about his behavior. On January 2011, he entered a Walmart in Tucson, AZ with a gun and killed 6 people. Loughner also had a history of extensive drug use including alcohol, cannabis, cocaine, psychedelic mushrooms, and LSD. Drug use has a significant effect on the risk of violence in individuals with schizophrenia.[6]

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An analysis of contemporary movies found that 83% of movie characters with schizophrenia exhibited dangerous or violent behavior towards others and 31% of these violent individuals engaged in homicidal behavior.[20] One such film is the 1987 film Rampage, loosely based on the killings of Richard Chase.[17] Because these films falsely illustrate that the majority of people with schizophrenia engage in violence, it exaggerates the rate of violence committed by individuals with schizophrenia.

Additionally, the unusual characteristics of some of the crimes committed by people with schizophrenia have gained infamy through their inspiration of fictional characters. Ed Gein in particular, who was known for the gruesome trophies he kept from his victims, was the inspiration for Norman Bates (Psycho), Leatherface (The Texas Chainsaw Massacre), and Buffalo Bill (The Silence of the Lambs).

Poverty and Homelessness

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The 2009 film The Soloist, based on the New York Times bestselling book of the same name, highlights the correlation between schizophrenia and poverty.[21][22] Nathaniel Ayers (played by Jamie Foxx) is a homeless Juilliard-dropout cellist who was diagnosed with schizophrenia. As journalist Steve Lopez (played by Robert Downey Jr.) chases a news story, he bonds with Nathaniel and is exposed to the struggles that those who are not only impoverished but also suffer from mental illness face on a daily basis. A notable point raised by the film is the difficulty and ethical implications of getting schizophrenia patients to take medication regularly.[21] Although antipsychotic medications have proven to be an effective treatment for many of schizophrenia's more serious symptoms, medication compliance is a prominent obstacle to their efficacy. It is estimated that schizophrenia outpatients taking oral and depot medications have a 1-month to 2-year noncompliance rate of 55%.[23] Additionally, 28% of patients who reduced or stopped taking medications reported financial burden to be the principal factor in their discontinuation.[23] Combined with general lack of access to adequate healthcare for most homeless individuals, it can be extremely difficult for those in poverty like the character of Nathaniel Ayers to get the medications they need.

Unlike stereotypes of violence and criminality, the portrayal of poverty and homelessness in contemporary movies tends to be fairly accurate. Almost half of schizophrenic movie characters are presented as being of low socioeconomic status, which is consistent with published research on the frequency of poverty among those with schizophrenia.[20]

Research

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Of all studies of schizophrenia ever conducted, less than one percent were concerned with poverty.[24] The research that has been published overwhelmingly supports the existence of a relationship between schizophrenia and poverty. The Epidemiologic Catchment Area study found that the risk of developing schizophrenia for people in the lowest quartile of socioeconomic status was almost 8 times greater than those in the highest quartile.[25] Additionally, about half of those who meet the criteria for schizophrenia are in the lowest socioeconomic group.[25]

The correlation between schizophrenia and poverty could be bidirectionally causal. Increased difficulty in maintaining employment and reliance on a support network for individuals with schizophrenia makes it more likely that schizophrenic individuals will end up homeless or in poverty. In addition, poverty itself may play a causal role in the development of schizophrenia. A study of the Dutch Hunger Winter in 1944 to 1945 illustrates that children born to mothers that experienced prenatal malnutrition had a significantly higher risk for developing schizophrenia and schizoid personality disorder in adulthood.[26] Additionally, lower occupational status of an individual's father and living in a poorer residential area are associated with significantly increased risk of developing schizophrenia.[27]

The manner in which schizophrenia is both diagnosed and treated suggests class bias, indicating that even mental health professionals can be influenced by the stereotypes and stigmas pushed in the media. Studies have found that psychiatrists generally tend to assign more severe diagnoses to poorer people than those that are wealthier despite having the same symptoms.[28] A survey of New Zealanders found that people with no education were 1.2 times as likely to receive any DSM diagnosis than those with education, but 1.8 times as likely to be diagnosed with a 'serious disorder' such as schizophrenia.[29] Poorer individuals with schizophrenia are also much more likely to be admitted to psychiatric facilities than those that are better off economically.[24] This may partially be attributed to the perception that lower economic status patients are seen as having a poorer prognosis and professionals are less interested in treating them.[30] Clinicians are people just like anyone else in the general population, and their internalized class bias may affect their diagnoses, treatments, and even the demographic of people diagnosed with schizophrenia at large.

References

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  1. ↑ American Psychiatric Association, ed (2013). Diagnostic and statistical manual of mental disorders : DSM-5. (5th ed.). Arlington, VA: American Psychiatric Association. ISBN 0890425558. OCLC 830807378. https://www.worldcat.org/oclc/830807378. 
  2. ↑ DSM-5 Clinical Cases. DSM Library. American Psychiatric Publishing. 2013-08-11. doi:10.1176/appi.books.9781585624836.jb02. ISBN 1585624632. http://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9781585624836.jb02. 
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Ghoreishi, Abolfazl; Kabootvand, Soleiman; Zangani, Ebrahim; Bazargan-Hejazi, Shahrzad; Ahmadi, Alireza; Khazaie, Habibolah (2014-05-14). "Prevalence and attributes of criminality in schizophrenic patients". Journal of Injury and Violence Research. 7 (1): 7–12. ISSN 2008-4072. doi:10.5249/jivr.v7i1.635
  4. ↑ Hodgins, Sheilagh (2014-08-01). "Among untreated violent offenders with schizophrenia, persecutory delusions are associated with violent recidivism". Evidence-Based Mental Health 17 (3): 75–75. doi:10.1136/eb-2014-101859. ISSN 1362-0347. PMID 25043431. http://ebmh.bmj.com/content/17/3/75. 
  5. ↑ Fazel, Seena; Gulati, Gautam; Linsell, Louise; Geddes, John R.; Grann, Martin (2009-08-11). "Schizophrenia and Violence: Systematic Review and Meta-Analysis". PLoS Medicine 6 (8). doi:10.1371/journal.pmed.1000120. ISSN 1549-1277. PMID 19668362. PMC PMC2718581. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2718581/. 
  6. ↑ 6.0 6.1 6.2 6.3 Thoma, Patrizia; Daum, Irene (2013-09-01). "Comorbid substance use disorder in schizophrenia: A selective overview of neurobiological and cognitive underpinnings". Psychiatry and Clinical Neurosciences. 67 (6): 367–383. ISSN 1440-1819. doi:10.1111/pcn.12072.
  7. ↑ Green, Alan I; Canuso, Carla M; Brenner, Mark J; Wojcik, Joanne D. "Detection and management of comorbidity in patients with schizophrenia". Psychiatric Clinics of North America 26 (1): 115–139. doi:10.1016/s0193-953x(02)00014-x. http://linkinghub.elsevier.com/retrieve/pii/S0193953X0200014X. 
  8. ↑ 8.0 8.1 BMJ Publishing Group Ltd, Royal College of Psychiatrists and British Psychological Society (2010-02-01). "Schizophrenia and comorbid substance abuse substantially increases risks of violent crime". Evidence-Based Mental Health. 13 (1): 31–31. ISSN 1362-0347. PMID 20164528. doi:10.1136/ebmh.13.1.31.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 Winklbaur, Bernadette; Ebner, Nina; Sachs, Gabriele; Thau, Kenneth; Fischer, Gabriele (2006-3). "Substance abuse in patients with schizophrenia". Dialogues in Clinical Neuroscience 8 (1): 37–43. ISSN 1294-8322. PMID 16640112. PMC PMC3181760. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181760/. 
  10. ↑ 10.0 10.1 Volkow, Nora D.; Swanson, James M.; Evins, A. Eden; DeLisi, Lynn E.; Meier, Madeline H.; Gonzalez, Raul; Bloomfield, Michael A. P.; Curran, H. Valerie et al. (2016-03-01). "Effects of Cannabis Use on Human Behavior, Including Cognition, Motivation, and Psychosis: A Review". JAMA Psychiatry 73 (3). doi:10.1001/jamapsychiatry.2015.3278. ISSN 2168-622X. http://archpsyc.jamanetwork.com/article.aspx?doi=10.1001/jamapsychiatry.2015.3278. 
  11. ↑ Sayers, Steven L.; Campbell, E. Cabrina; Kondrich, Janienne; Mann, Stephan C.; Cornish, James; O'Brien, Charles; Caroff, Stanley N. (June 2005). "Cocaine abuse in schizophrenic patients treated with olanzapine versus haloperidol". The Journal of Nervous and Mental Disease 193 (6): 379–386. ISSN 0022-3018. PMID 15920378. https://www.ncbi.nlm.nih.gov/pubmed/15920378. 
  12. ↑ 12.0 12.1 Weiser, Mark; Reichenberg, Abraham; Grotto, Itamar; Yasvitzky, Ross; Rabinowitz, Jonathan; Lubin, Gad; Nahon, Daniella; Knobler, Haim Y. et al. (2004-07-01). "Higher Rates of Cigarette Smoking in Male Adolescents Before the Onset of Schizophrenia: A Historical-Prospective Cohort Study". American Journal of Psychiatry 161 (7): 1219–1223. doi:10.1176/appi.ajp.161.7.1219. ISSN 0002-953X. https://ajp.psychiatryonline.org/doi/abs/10.1176/appi.ajp.161.7.1219. 
  13. ↑ Ziedonis, D. M.; Kosten, T. R.; Glazer, W. M.; Frances, R. J. (March 1994). "Nicotine dependence and schizophrenia". Hospital & Community Psychiatry 45 (3): 204–206. ISSN 0022-1597. PMID 7910577. https://www.ncbi.nlm.nih.gov/pubmed/7910577. 
  14. ↑ 14.0 14.1 14.2 Bovsun, Mara (January 2, 2010). "Just crazy for blood: Richard Trenton Chase, a.k.a. the Vampire of Sacramento". New York Daily News. Retrieved September 15, 2016.
  15. ↑ K., Ressler, Robert (1992). Whoever fights monsters. Shachtman, Tom, 1942- (1st ed.). New York: St. Martin's Press. ISBN 0312078838. OCLC 25245627. https://www.worldcat.org/oclc/25245627. 
  16. ↑ D., Keppel, Robert (2003). The psychology of serial killer investigations : the grisly business unit. Birnes, William J.. Amsterdam: Academic Press. ISBN 9780124042605. OCLC 57004815. https://www.worldcat.org/oclc/57004815. 
  17. ↑ 17.0 17.1 Friedkin, William (1992-10-30), Rampage, Michael Biehn, Alex McArthur, Nicholas Campbell, retrieved 2017-10-26
  18. ↑ 18.0 18.1 "Richard Chase". Criminal Minds Wikia.
  19. ↑ "Dangerous Minds: Mental Illnesses of Infamous Criminals". Forensics Colleges. Retrieved 2017-11-02.
  20. ↑ 20.0 20.1 Owen, Patricia R. (2012-07-01). "Portrayals of Schizophrenia by Entertainment Media: A Content Analysis of Contemporary Movies". Psychiatric Services. 63 (7): 655–659. ISSN 1075-2730. doi:10.1176/appi.ps.201100371.
  21. ↑ 21.0 21.1 Wright, Joe (2009-04-24), The Soloist, Jamie Foxx, Robert Downey Jr, Catherine Keener, retrieved 2017-10-12
  22. ↑ Steve., Lopez, (2008). The soloist : a lost dream, an unlikely friendship, and the redemptive power of music. New York: G.P. Putnam's Sons. ISBN 0399155066. OCLC 181424092.
  23. ↑ 23.0 23.1 Fenton, Wayne S.; Blyler, Crystal R.; Heinssen, Robert K. (1997-01-01). "Determinants of Medication Compliance in Schizophrenia: Empirical and Clinical Findings". Schizophrenia Bulletin. 23 (4): 637–651. ISSN 0586-7614. doi:10.1093/schbul/23.4.637.
  24. ↑ 24.0 24.1 Read, John (2010). “Can Poverty Drive You Mad? ‘Schizophrenia’, Socio-Economic Status and the Case for Primary Prevention”. New Zealand Journal of Psychology. 39: 7-19
  25. ↑ 25.0 25.1 Cohen, Carl I. (1993-10-01). "Poverty and the Course of Schizophrenia: Implications for Research and Policy". Psychiatric Services. 44 (10): 951–958. ISSN 1075-2730. doi:10.1176/ps.44.10.951.
  26. ↑ Susser, Ezra; Clair, David St.; He, Lin (2008-06-01). "Latent Effects of Prenatal Malnutrition on Adult Health". Annals of the New York Academy of Sciences. 1136 (1): 185–192. ISSN 1749-6632. doi:10.1196/annals.1425.024.
  27. ↑ Werner, Shirli; Malaspina, Dolores; Rabinowitz, Jonathan (2007-11-01). "Socioeconomic Status at Birth Is Associated With Risk of Schizophrenia: Population-Based Multilevel Study". Schizophrenia Bulletin. 33 (6): 1373–1378. ISSN 0586-7614. doi:10.1093/schbul/sbm032.
  28. ↑ Abramowitz, Christine V.; Dokecki, Paul R.. "The politics of clinical judgment: Early empirical returns.". Psychological Bulletin 84 (3): 460–476. doi:10.1037/0033-2909.84.3.460. http://content.apa.org/journals/bul/84/3/460. 
  29. ↑ Wells, Gary L.; Memon, Amina; Penrod, Steven D. (2016-06-23). "Eyewitness Evidence". Psychological Science in the Public Interest 7 (2): 45–75. doi:10.1111/j.1529-1006.2006.00027.x. http://journals.sagepub.com/doi/10.1111/j.1529-1006.2006.00027.x. 
  30. ↑ Lucy., Johnstone (2000). Users and abusers of psychiatry : a critical look at psychiatric practice (2nd ed.). London: Routledge. ISBN 0415211557. OCLC 48139555. https://www.worldcat.org/oclc/48139555. 
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