Impulsivity in early psychosis: A complex link with violent behaviour and a target for intervention

Impulsivity across severe mental disorders: a cross-sectional study of immune markers and psychopharmacotherapy

BACKGROUND

Impulsivity is a transdiagnostic feature linked to severe clinical expression and a potential target for psychopharmacological strategies. Biological underpinnings are largely unknown, but involvement of immune dysregulation has been indicated, and the effects of psychopharmacological agents vary. We investigated if impulsivity was associated with circulating immune marker levels and with a range of psychopharmacological treatment regimens in severe mental disorders.

METHODS

Impulsivity was assessed in a sample (N = 657) of patients with schizophrenia or schizophreniform disorder (SCZ) (N = 116) or bipolar disorder (BD) (N = 159) and healthy participants (N = 382) using the Barratt Impulsiveness Scale (BIS-11) questionnaire. Plasma levels of systemic immune markers (RANTES, IL-1RA, IL-18, IL-18BP, sTNFR-1) were measured by enzyme immunoassays. Patients underwent thorough clinical assessment, including evaluation of psychotropic medication. Associations were assessed using linear regressions.

RESULTS

Impulsivity  was positively associated with SCZ (p < 0.001) and BD (p < 0.001) diagnosis and negatively associated with age (p < 0.05), but not significantly associated with any of the circulating immune markers independently of diagnostic status. Among patients, impulsivity was negatively associated with lithium treatment (p = 0.003) and positively associated with antidepressant treatment (p = 0.011) after controlling for diagnosis, psychotropic co-medications, manic symptoms, and depressive symptoms.

CONCLUSIONS

We report elevated impulsivity across SCZ and BD but no associations to systemic immune dysregulation based on the current immune marker selection. The present study reveals associations between impulsivity in severe mental disorders and treatment with lithium and antidepressants, with opposite directions. Future studies are warranted to determine the causal directionality of the observed associations with psychopharmacotherapy.

Evolution of impulsivity levels in relation to early cannabis use in violent patients in the early phase of psychosis

BACKGROUND

Prevention of violent behaviors (VB) in the early phase of psychosis (EPP) is a real challenge. Impulsivity was shown to be strongly related to VB, and different evolutions of impulsivity were noticed along treatments. One possible variable involved in the relationship between VB and the evolution of impulsivity is cannabis use (CU). The high prevalence of CU in EPP and its relationship with VB led us to investigate: 1/the impact of CU and 2/the impact of early CU on the evolution of impulsivity levels during a 3-year program, in violent and non-violent EPP patients.

METHODS

178 non-violent and 62 violent patients (VPs) were followed-up over a 3 year period. Age of onset of CU was assessed at program entry and impulsivity was assessed seven times during the program. The evolution of impulsivity level during the program, as a function of the violent and non-violent groups of patients and CU precocity were analyzed with linear mixed-effects models.

RESULTS

Over the treatment period, impulsivity level did not evolve as a function of the interaction between group and CU (coef. = 0.02, p = 0.425). However, when including precocity of CU, impulsivity was shown to increase significantly only in VPs who start consuming before 15 years of age (coef. = 0.06, p = 0.008).

CONCLUSION

The precocity of CU in VPs seems to be a key variable of the negative evolution of impulsivity during follow-up and should be closely monitored in EPP patients entering care since they have a higher risk of showing VB.

Cannabis use among patients presenting to the emergency department for psychosis: Associations with restraint use, medication administration, psychiatric hospitalization, and repeat visits

Cannabis use is associated with increased severity of psychotic symptoms and the risk of acute agitation and aggressive behavior in inpatient (IP) and outpatient settings. Whether or not cannabis use is associated with increased acuity of psychosis-related ED presentations and risk of repeat ED visits for psychosis is unclear. In this retrospective study of 2,134 ED visits for acute psychosis, we investigated the risk of physical restraint, parenteral medication administration, psychiatric hospitalization, and recurrent ED visits. We examined ED visits between March 1, 2019 and February 28, 2021 based on urinary Tetrahydrocannabinol (THC) screen status (positive vs negative vs no screen). The risk of physical restraint, parenteral antipsychotic, and benzodiazepine administration was significantly greater in ED visits with a positive THC screen compared to those with a negative or no THC screen. We did not find an association between a positive urinary THC screen and IP hospitalization or the risk of recurrent ED presentation for psychosis within 90 days. These findings suggest that positive urinary THC may predict acute agitation or acuity of symptoms in ED settings and underscores the importance of screening for THC during ED presentations for psychosis.

Aggressive behaviour in antipsychotic-naive first-episode schizophrenia patients, their unaffected siblings and healthy controls

AIM

While patients with schizophrenia are more likely to be victims rather than perpetrators of aggressive behaviour, prior research has shown increased rates of aggressive behaviours in these patients that appear very early in the course of illness. We aimed to assess aggression in antipsychotic-naive first-episode schizophrenia patients, their healthy siblings, and controls; and to investigate correlates of aggression in the patients group.

METHODS

Patients (N = 55), siblings (N = 55) and healthy controls (N = 71) were evaluated on Buss and Perry Aggression Questionnaire (AQ), Life History of Aggression (LHA), Barratt Impulsiveness Scale, and Levenson Self-Report Psychopathy Scale. Age, gender and substance use were regarded as covariates, and differences between the three groups were evaluated using analysis of covariance. Hierarchical regression was performed to determine which variables were associated with aggression level in the patients group.

RESULTS

The Tukey multiple comparison test showed that both patients (p < .001) and siblings (p = .023) scored higher on the LHA Aggression than controls. Siblings scored higher than controls (p = .010) for the Anger subscale of the AQ. Patients scored significantly higher than controls in the three impulsiveness dimensions; whereas siblings scored higher than controls in the motor (p = .023) and non-planning (p = .004) dimensions. Multivariate analyses showed that, after controlling for confounders, only attentional impulsiveness (β = .446, p = .0244) and psychopathy traits (β = .359, p = .010) helped predict AQ total scores among patients.

CONCLUSION

Aggression and some of its risk factors including impulsiveness are likely to be trait variables that might provide important vulnerability markers for people at heightened risk of developing psychosis.

Correlation Between Aggressive Behavior and Impulsive and Aggressive Personality Traits in Stable Patients with Schizophrenia

Purpose

To explore the correlation between aggressive behavior and impulsive and aggressive personality traits in inpatients with schizophrenia.

Methods

In total, 367 inpatients with schizophrenia were divided into two groups: the aggressive group and the non-aggressive group. We assessed inpatients' psychotic symptoms as well as their aggressive and impulsive personality traits using the Positive and Negative Symptom Scale, the Barratt Impulsiveness Scale, and the Buss-Perry Aggression Questionnaire.

Results

Compared with the scores of inpatients in the non-aggressive group, the total Buss-Perry Aggression Questionnaire, subscale, and Barratt Impulsiveness Scale behavioral factor scores in those in the aggressive group were higher (p < 0.05). The results of logistic regression analysis suggested that a high Positive and Negative Symptom Scale positive factor score (odds ratio = 1.07) and a high Buss-Perry Aggression Questionnaire physical aggression score (odds ratio = 1.02) were risk factors for aggressive behavior.

Conclusion

Hospitalized patients with schizophrenia with more severe positive symptoms and aggressive traits may be more prone to aggressive behavior.

Does cannabis use predict aggressive or violent behavior in psychiatric populations? A systematic review

Background: Despite an increase in information evaluating the therapeutic and adverse effects of cannabinoids, many potentially important clinical correlates, including violence or aggression, have not been adequately investigated.Objectives: In this systematic review, we examine the published evidence for the relationship between cannabis and aggression or violence in individuals with psychiatric disorders.Methods: Following PRISMA guidelines, articles in English were searched on PubMed, Google Scholar, MEDLINE, and PsycINFO from database inception to January 2022. Data for aggression and violence in people with psychiatric diagnoses were identified during the searches.Results: Of 391 papers identified within the initial search, 15 studies met inclusion criteria. Cross-sectional associations between cannabis use and aggression or violence in samples with post-traumatic stress disorder (PTSD) were found. Moreover, a longitudinal association between cannabis use and violence and aggression was observed in psychotic-spectrum disorders. However, the presence of uncontrolled confounding factors in the majority of included studies precludes any causal conclusions.Conclusion: Although cannabis use is associated with aggression or violence in individuals with PTSD or psychotic-spectrum disorders, causal conclusions cannot be drawn due to methodological limitations observed in the current literature. Well-controlled, longitudinal studies are needed to ascertain whether cannabis plays a causal role on subsequent violence or aggression in mental health disorders.

Feasibility and Utility of Different Approaches to Violence Risk Assessment for Young Adults Receiving Treatment for Early Psychosis

This pilot study examined violence risk assessment among a sample of young adults receiving treatment for early psychosis. In this study, thirty participants were assessed for violence risk at baseline. Participants completed follow-up assessments at 3, 6, 9 and 12 months to ascertain prevalence of violent behavior. Individuals were on average 24.1 years old (SD = 3.3 years) and predominantly male (n = 24, 80%). In this sample, six people (20%) reported engaging in violence during the study period. Individuals who engaged in violence had higher levels of negative urgency (t(28) = 2.21, p = 0.035) This study sought to establish the feasibility, acceptability, and clinical utility of violence risk assessment for clients in treatment for early psychosis. Overall, this study found that most individuals with early psychosis in this study (who are in treatment) were not at risk of violence. Findings suggest that violent behavior among young adults with early psychosis is associated with increased negative urgency.

Searching for bridges between psychopathology and real-world functioning in first-episode psychosis: A network analysis from the OPTiMiSE trial

Background

Network analysis has been used to explore the interplay between psychopathology and functioning in psychosis, but no study has used dedicated statistical techniques to focus on the bridge symptoms connecting these domains. The current study aims to estimate the network of depressive, negative, and positive symptoms, general psychopathology, and real-world functioning in people with first-episode schizophrenia or schizophreniform disorder, focusing on bridge nodes.

Methods

Baseline data from the OPTiMiSE trial were analyzed. The sample included 446 participants (age 40.0 ± 10.9 years, 70% males). The network was estimated with a Gaussian graphical model, using scores on individual items of the positive and negative syndrome scale (PANSS), the Calgary depression scale for schizophrenia, and the personal and social performance scale. Stability, strength centrality, expected influence (EI), predictability, and bridge centrality statistics were computed. The top 20% scoring nodes on bridge strength were selected as bridge nodes.

Results

Nodes from different rating scales assessing similar psychopathological and functioning constructs tended to cluster together in the estimated network. The most central nodes (EI) were Delusions, Emotional Withdrawal, Depression, and Depressed Mood. Bridge nodes included Depression, Conceptual Disorganization, Active Social Avoidance, Delusions, Stereotyped Thinking, Poor Impulse Control, Guilty Feelings, Unusual Thought Content, and Hostility. Most of the bridge nodes belonged to the general psychopathology subscale of the PANSS. Depression (G6) was the bridge node with the highest value.

Conclusions

The current study provides novel insights for understanding the complex phenotype of psychotic disorders and the mechanisms underlying the development and maintenance of comorbidity and functional impairment after psychosis onset.

The factor structure of the Barratt Impulsiveness Scale (BIS-11) and correlates of impulsivity among outpatients with schizophrenia and other psychotic disorders in Singapore

BACKGROUND

Impulsivity has been linked to risky behaviours amongst patients with schizophrenia or other psychotic disorders. However, there is a dearth of studies examining impulsivity amongst this population in Singapore. Moreover, to date, scales to measure impulsivity have not been validated in this population. The present study seeks to examine the underlying factor structure of the Barratt Impulsiveness Scale (BIS-11) and explore sociodemographic and clinical correlates of impulsivity within this group.

METHODS

Confirmatory factor analyses (CFA) were conducted to test factor structures of the BIS-11 proposed in extant literature. However, due to poor fit statistics, the sample (n = 397) was split into two groups, with Exploratory Factor Analyses (EFA) conducted in the first subgroup (n = 200). The final model of the EFA was then tested within the second subgroup (n = 197) with CFA. Multivariable linear regressions were conducted to examine sociodemographic and clinical correlates of each underlying factor.

RESULTS

CFA indicated a three-factor structure amongst 16-items of the BIS-11 with acceptable fit: i) Non-planning impulsivity (5-items; α = 0.94), ii) Motor impulsiveness (6-items α = 0.84), and iii) Lack of self-control (5-items, α = 0.85). Lower education was associated with higher non-planning impulsivity. While age, ethnicity, marital status, and general psychiatric symptom severity were significant correlates of motor impulsiveness, problematic alcohol use and general psychiatric symptom severity were related to a greater lack of self-control.

CONCLUSION

Factor structures of the BIS-11 suggested by extant literature were not applicable, and we propose an alternative factor structure for BIS-11. Significant correlates of impulsivity are highlighted, and avenues for future research are suggested.

Effects of substance use on monetary delay discounting among people who use stimulants with and without HIV: An ecological momentary assessment study

Exploration of the real-time relationship between substance use and delay discounting may reveal potential mechanisms driving high-risk behaviors. We conducted an ecological momentary assessment (EMA) study to investigate the effects of substance use on delay discounting in a sample of people who use stimulants (HIV+: 30; HIV-: 34). Participants completed multiple EMAs throughout the day for 28 days. The EMAs collected data on delay discounting and substance use (time since last substance use and level of intoxication). Delay discounting was assessed using a brief Monetary Choice Questionnaire (MCQ). Analyses were conducted using linear mixed effects modeling. Most participants (99.1%) used cocaine as their primary stimulant. Among participants without HIV, MCQ score remained relatively stable during the first 2 hr after stimulant use, followed by an increase during 2-6 hr (p < .05), before decreasing again. For alcohol and marijuana, the MCQ score was stable during the first 4 hr after use, with a sharp increase at 4-6 hr (p < .05), before decreasing again. Among participants with HIV, there were no changes in MCQ score as a function of time since recent substance use. These findings provide evidence of a plausible connection between delay discounting and acute withdrawal that may have relevance for risky behaviors. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Violence, neurocognitive function and clinical correlates in patients with schizophrenia

BACKGROUND

Schizophrenia patients with violent behavior are a severe public health concern, but the correlates of this violent behavior are unknown. Additionally, the relationship between neurocognitive function and violent behavior in Chinese patients with schizophrenia has not yet been investigated.

METHODS

A total of 337 schizophrenia inpatients were recruited. The Positive and Negative Syndrome Scale (PANSS) was used to assess psychopathological symptoms. Neurocognitive functioning was evaluated using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS).

RESULTS

The percentage of violent behavior was 10.4% in patients with schizophrenia. Patients with violent behavior had higher PANSS-positive, excited, and total subscale scores than patients who did not show violent behavior. Patients with violent behavior also had lower RBANS language, semantic fluency, and total subscale scores. Gender (OR = 0.066∼0.819, p = 0.023), illness duration (OR = 0.876∼0.971, p = 0.002), smoking (OR = 1.127∼2.950, p = 0.014), the PANSS positive subscale (OR = 1.050∼1.197, p = 0.001), and the RBANS language subscale (OR = 0.927∼0.987, p = 0.005) significantly contributed to the development of violent behavior in schizophrenia patients.

CONCLUSION

Our findings revealed that cognitive and clinical assessments should be considered in comprehensive assessments of future risks of violence in schizophrenia patients.

The Link Between Cannabis Use and Violent Behavior in the Early Phase of Psychosis: The Potential Role of Impulsivity

INTRODUCTION

Recently, the literature has shown that Cannabis Use (CU) was a risk factor for Violent Behavior (VB) in patients with psychosis, and those in the early phase of psychosis (EPP). These findings are relevant because of the high prevalence of CU in this EPP, and the potential for prevention during this phase of illness. However, there is still a lack of clear explanations, supported by empirical evidence, about what underlies the link between CU and VB against other.

METHOD

This viewpoint reviews the scientific literature on the link between CU and VB, and the involvement of impulsivity in this relationship. This last point will be addressed at clinical and neurobiological levels.

RESULTS

Recent studies confirmed that CU is particularly high in the EPP, and is a risk factor for VB in the EPP and schizophrenia. Studies have also shown that impulsivity is a risk factor for VB in psychosis, is associated with CU, and may mediate the link between CU and VB. Research suggests a neurobiological mechanism, as CU affects the structures and function of frontal areas, known to play a role in impulsive behavior.

CONCLUSION

Scientific evidence support the hypothesis of an involvement of impulsivity as a variable that could mediate the link between CU and aggression, particularly, when CU has an early onset. However, this hypothesis should be confirmed with longitudinal studies and by taking into account confounding factors. The studies highlight the relevance of early prevention in the EPP, in addition to interventions focusing on psychotic disorders.

[Individual and contextual factors associated with violent behaviours during psychiatric hospitalizations]

BACKGROUND

The prevention of Physical Violent Behavior (VB) toward others during psychiatric hospitalization is a major concern of clinicians. These VBs can have a deleterious impact on the victims, inpatients or caregivers, as well as on the therapeutic milieu. Such violence can also have negative consequences for the assailant patients, such as repeatedly being hospitalized under restraint, stigmatization, and difficulties reintegrating into the community.

OBJECTIVES

This study explored individual (age, gender, marital status, living status, diagnostic) and institutional (type of admission, length of stay, number of previous hospitalizations) risk factors, and how their interactions could increase the risk of VB during psychiatric hospitalizations.

METHOD

The study was carried out over a period of four years in the psychiatry department of the Lausanne University Hospital, on the 15 wards (219 beds) specialized in acute psychiatric care for adults. All the patients admitted to one of these wards during this period (n=4518), aged between 18 and 65 years, were included in the study. The sample was divided in two groups: non-violent patients (NVPs) and violent patients (VPs). VBs, defined as physical aggressions against another person, were assessed by the Staff Observation Aggression Scale - Revised (SOAS - R). Only physical assaults, associated or not with other types of violence, involving hospitalized patients were analyzed. Personal and institutional factors were extracted from the hospital database. Chi² independence tests were used to assess differences between groups. Logistic regression models were used to identify the links between each factor and the VB. Classification and regression trees were used to study the hierarchical effect of factors, and combinations of factors, on VBs.

RESULTS

During the study period, 414 VBs were reported involving 199 patients (4.40 % of all patients). VPs were significantly younger, male, more likely to be unmarried and living in sheltered housing before hospitalization. In this group, the proportion of patients with diagnoses of schizophrenia, and/or schizophrenia with comorbid substance abuse and cognitive impairment, were higher compared to NVPs. VPs were more frequently admitted involuntarily, had a longer average length of stay and a greater number of previous hospitalizations. The logistic regression model performed on individual factors have shown a significant link between age (OR=0.99; CI: 0.97-1.00; P-value=0.024), living in sheltered housing before admission (OR=2.46; CI: 1.61-3.75; P-value<0.000), schizophrenic disorders (OR=2.18; CI: 1.35-3.57; P-value=0.001), schizophrenic disorders with substance abuse comorbidity (OR=2.00; CI: 1.16-3.37; P-value=0.016), cognitive impairment (OR=3.41; CI: 1,21-8.25; P-value=0.010), and VBs. The logistic regression model on institutional factors have shown a significant link between involuntary hospitalization (OR=4.38; CI: 3.20-6.08; P-value<0.000), length of previous stay (OR=1.01; CI: 1.00-1.01; P-value<0.000), number of previous hospitalizations (OR=1.06; CI: 1.00-1.12; P-value=0.031), and VBs. The logistic regression model on individual and institutional factors have shown a significant link between age (OR=0.99; CI: 0.97-1.00; P-value=0.008), living in sheltered housing before admission (OR=2.46: CI: 1.61-3.75; P-value=0.034), cognitive impairment (OR=3.41; CI: 1.21-8.25; P-value=0.074), involuntary hospitalization (OR=3.46; CI: 2.48-4.87; P-value<0.000), length of previous stay (OR=1.01; CI: 1.00-1.01; P-value<0.000), and VBs. The classification and regression trees have shown that the relationship between long length of stay and repeated hospitalizations mainly potentiate the risk of violence.

CONCLUSION

The results of this study have shown the existence of a small group of vulnerable patients who accumulate constrained hospital stays during which violence occurs. Exploring the clinical profiles and institutional pathways of patients could help to better identify these patients and promote a more appropriate mode of support, such as intensive clinical case management. This model could facilitate the development of a clinical network and the links between the structures and partners caring for a patient. This would create a continuous support, avoiding or limiting the lack of continuity of care and care disruption.

Factors associated with repetitive violent behavior of psychiatric inpatients

A small number of psychiatric inpatients displays a large proportion of Violent Behaviors (VB). These can have a major impact on both victims and patients themselves. This study explored personal, situational and institutional risk factors and their combined effects, which could lead to repetitive VB (three or more assaults). Data from 4518 patients, aged 18 to 65, admitted to an acute psychiatric care facility, were included in the analysis. VB, defined as physical aggressions against another person, were assessed by the Staff Observation Aggression Scale-Revised. 414 VB were reported during the study period, involving 199 patients. 0.75 % of all patients were repetitively violent and committed 43% of all VB. Factors that were linked to repetitive VB were living in sheltered housing before hospitalization, suffering from schizophrenia with substance abuse comorbidity, cumulating hospitalization days and some situational factors, like the fact of being in nursing offices and pharmacies. When all personal, situational and institutional factors were considered together, the combined effects of length of stay and living in sheltered housing increased the risk of repetitive VB. We have identified a small group of vulnerable patients for whom new modalities of inter-institutional networking should be developed to prevent repetitive VB.

Rate and predictors of disengagement in an early psychosis program with time limited intensification of treatment

BACKGROUND

Service disengagement is a frequent problem in early intervention in psychosis. The goal of this study was to evaluate the rate and variables associated with service disengagement in a three year specialized program that allows treatment intensification on a case to case basis.

METHODS

328 early psychosis patients were assessed at baseline on a large set of socio-demographic and clinical variables and were followed-up over 36 months. Patients who left the program for reasons related to engagement with care were compared to patients who completed the program.

RESULTS

Rates of disengagement were low (6.3%). Patients with lower socio-economic status, who committed offences during the program or with a diagnosis of Schizophreniform/brief psychotic disorder were more likely to disengage from the program.

CONCLUSIONS

The engagement strategies implemented in the context of our early intervention programs have allowed to keep disengagements to a relatively low level. In this context, only 3 variables emerged to guide adaptation of the intervention in order to improve this already good engagement rate.

Hostility and aggressive behaviour in first episode psychosis: Results from the OPTiMiSE trial

AIM

The aim of this paper is to determine clinical factors related to hostility and disturbing and aggressive behaviour and to examine the effect of medication on these behaviours in FEP.

METHODS

Data from phase I and II of the OPTiMiSE trial are used. Outcome measures are the hostility item of the Positive and Negative Syndrome Scale (PANSS P7) and the disturbing and aggressive behaviour domain of the Personal and Social Performance scale (PSP-D).

RESULTS

Moderate, severe or extreme hostility (PANSS P7 > 3) was present in 42 patients (9.4%). The PANSS P7 and PSP-D were low to moderate but significantly associated with the selected PANSS items: delusions, hallucinatory behaviour, excitement, tension, uncooperativeness, unusual thought content, impulsivity, and lack of judgement and insight. In a subsample of 185 patients (41.5%) with baseline PANSS P7 > 1, the PANSS P7 and PSP-D scores improved in the first 4 weeks of amisulpride treatment. This effect remained significant after controlling for baseline positive symptoms (PANSS P1-P6). No significant differences were found between olanzapine and amisulpride in the second phase of the trial.

CONCLUSION

Clinical risk factors such as poor impulse control, uncooperativeness and excitement could help clinicians in detecting and treating hostile and aggressive behaviour in FEP. Amisulpride could be an effective antipsychotic choice in the treatment of FEP patients who express hostile or aggressive behaviour. Future research is needed to compare the effects of amisulpride and olanzapine on hostility in FEP during the first weeks of treatment.

Early onset of cannabis use and violent behavior in psychosis

BACKGROUND

Although evidence from psychosis patients demonstrates the adverse effects of cannabis use (CU) at a young age and that the rate of CU is high in subgroups of young violent patients with psychotic disorders, little is known about the possible effect of the age of onset of CU on later violent behaviors (VB). So, we aimed to explore the impact of age at onset of CU on the risk of displaying VB in a cohort of early psychosis patients.

METHOD

Data were collected prospectively over a 36-month period in the context of an early psychosis cohort study. A total of 265 patients, aged 18-35 years, were included in the study. Logistic regression was performed to assess the link between age of onset of substance use and VB.

RESULTS

Among the 265 patients, 72 had displayed VB and 193 had not. While violent patients began using cannabis on average at age 15.29 (0.45), nonviolent patients had started on average at age 16.97 (0.35) (p = 0.004). Early-onset CU (up to age 15) was a risk factor for VB (odds ratio = 4.47, confidence interval [CI]: 1.13-20.06) when the model was adjusted for age group, other types of substance use, being a user or a nonuser and various violence risk factors and covariates. History of violence and early CU (until 15) were the two main risk factors for VB.

CONCLUSIONS

Our results suggest that early-onset CU may play a role in the emergence of VB in early psychosis.

Frontal cortical thickness correlates positively with impulsivity in early psychosis male patients

AIM

Impulsive behaviours, which are frequent in young people suffering from psychosis have been linked to risky and violent behaviours and participate to the burden of psychotic illness. Given that morphological brain correlates of impulsivity in schizophrenia have been poorly investigated especially in young adults, the aim of this study was to investigate the relationship between impulsivity and cortical thickness in early psychosis (EP) patients.

METHOD

A total of 17 male subjects in the early phase of psychosis were recruited. Impulsivity was assessed with the Lecrubier Impulsivity Rating Scale. Mean cortical thickness was extracted from magnetic resonance imaging brain scans, using surface-based methods.

RESULTS

Mean cortical thickness in the frontal lobe correlated positively with mean impulsivity in EP male patients.

CONCLUSION

Our results suggest that psychotic subjects exhibiting higher impulsivity have larger frontal cortical thickness, which may pave the way towards the identification of patients with a higher risk to display impulsive behaviours.

Violent behaviour in early psychosis patients: Can we identify clinical risk profiles?

AIMS

The objective of this study is to explore, within a sample of early psychosis patients (EPP), if subgroups regarding rate of violent behaviour (VB) against others can be identified on the basis of dynamic risk factors (treatment modifiable characteristics).

METHODS

In a sample of 265 EPP, treated at the Treatment and Early Intervention in Psychosis Program in Lausanne, we conducted a latent-class analysis on the basis of the main dynamic VB risk factors (substance use disorder [SUD], positive symptoms, insight, and impulsivity). VB were restricted to "serious violence" and were assessed through patients self-report, interview with relatives or forensic services and with a standardized instrument.

RESULTS

The analysis confirmed the heterogeneity of the sample regarding rate of VB. Patients could be stratified within 4 subgroups, 3 of which were at increased risk of VB. The two groups with the highest rates of VB displayed specific clinical profiles. The first one was characterized by high levels of impulsivity, hostility, positive symptoms and SUD, and the second, by low level of insight and low social functioning. These patterns suggest that significant difficulties in social interaction may contribute to the emergence of aggressive reactions against others.

CONCLUSIONS

Identification of EPP at increased risk of VB seems possible on the basis of dynamic risk factors. If confirmed prospectively, this could pave the way to the development of preventive strategies and specific interventions.

Aggressive Behavior, Hostility, and Associated Care Needs in Patients With Psychotic Disorders: A 6-Year Follow-Up Study

Background: Hostility and aggressive behavior in patients with psychotic disorders are associated with demographic and clinical risk factors, as well as with childhood adversity and neglect. Care needs are an essential concept in clinical practice; care needs in the domain of safety for others reflect the actual problem the patient has. Hostility, aggressive behavior, and associated care needs, however, are often studied in retrospect. Method: In a sample of 1,119 patients with non-affective psychotic disorders, who were interviewed three times over a period of 6 years, we calculated the incidence of hostility, self-reported maltreatment to others and care needs associated with safety for other people (safety-to-others). Regression analysis was used to analyze the association between these outcomes and risk factors. The population attributable fraction (PAF) was used to calculate the proportion of the outcome that could potentially be prevented if previous expressions of adverse behavior were eliminated. Results: The yearly incidence of hostility was 2.8%, for safety-to-others 0.8% and for maltreatment this was 1.8%. Safety-to-others was associated with previous hostility and vice versa, but, assuming causality, only 18% of the safety-to-others needs was attributable to previous hostility while 26% was attributable to impulsivity. Hostility, maltreatment and safety-to-others were all associated with number of unmet needs, suicidal ideation and male sex. Hostility and maltreatment, but not safety-to-others, were associated with childhood adversity. Neither safety-to-others, maltreatment nor hostility were associated with premorbid adjustment problems. Conclusion: The incidence of hostility, self-reported aggressive behaviors, and associated care needs is low and linked to childhood adversity. Known risk factors for prevalence also apply to incidence and for care needs associated with safety for other people. Clinical symptoms can index aggressive behaviors years later, providing clinicians with some opportunity for preventing future incidents.

[Three clinical risk profiles of violent behavior in a cohort of early psychosis patients]

OBJECTIVE

This study aims to determine whether it is possible to identify clinical profiles at risk of violent behaviors (VB) in the early phase of psychotic disorders, on the basis of the main dynamic psychopathological risk factors and describe characteristics of the groups with highest levels of violent behaviors.

METHOD

A total of 265 patients, aged 18 to 35, treated at the Treatment and early Intervention in Psychosis Program (TIPP-Lausanne), a specialized early psychosis program, were included in this study. We conducted a latent-class analysis and a discriminative analysis on the basis of the main dynamic VB risk factors: substance use disorder, impulsivity, positive symptoms, insight, aggression, hostility, anger, emotional instability and adherence to treatment. These factors were evaluated by specialized scales and on the basis of the Positive and Negative Syndrome Scale (PANSS). VB were restricted to physical aggression against people, defined as "serious violence". They were assessed on the basis of a questionnaire listing violent offenses (Swiss Criminal Code) and VB such as assault and battery, information through the forensic psychiatric services and on the basis of the Staff Observation Aggression Scale (SOAS-R scale) during inpatient treatment phase.

RESULTS

Four heterogeneous subgroups were identified with respect to the studied clinical characteristics, including two groups with high rates of VB. The first group, comprising 46% of patients with VB, is distinguished by the prevalence of a range of dimensions related to hostility, impulsivity and emotional instability, associated with high levels of substance abuse and positive symptoms. These clinical dimensions are very significant at the statistical level, since they explain 70% of the construction of subgroups (discriminant analysis). The second group with 37% of patients with VB, is characterized by a lack of insight, lack of adherence to treatment and substance use. These two clinical profiles could increase the impairment of cognitive, functional and relational abilities and contribute to the development of VB in this early phase of psychosis. The third subgroup, with a violent behaviors rate of 28.6%, is distinguished by its high proportion of diagnoses of substance abuse (100%) and women (54%). A last subgroup of patients, the largest quantitatively, has a low proportion of VB (15%) and the lowest levels on the studied factors, suggesting that the majority of patients with this profile commit few VB.

CONCLUSION

Our results show that it is possible to identify groups at risk of violent behaviors during the early phase of psychosis on the basis of clinical characteristics that may evolve and therefore be the focus of preventive care. These results highlight the need to target substance use, impulsivity and lack of insight at follow-up in order to prevent VB.

[Insight and Violent Behavior in a Cohort of Early Psychosis Patients]

OBJECTIVES:

An important proportion of patients with first episode psychosis behave in a violent, hetero-aggressive manner. This study aims to explore the association between insight and violent behavior (VB), and insight evolution in the follow-up period.

METHOD:

The study was carried out with a prospective cohort of 265 patients recruited from the early treatment and intervention for psychotic disorders program, and followed for a 3-year period. Insight assessing is based on a 3-item scale and the insight item in Positive and Negative Syndrome Scale (PANSS). VBs were evaluated by case managers, information from forensic services and through a record of VBs noted during hospitalization. Univariate and multivariate logistic regression analyses, t-tests and correlations were conducted.

RESULTS:

The significant effect of insight as a factor associated with VBs that was found in univariate analyses disappears after controlling for the effect of positive symptoms, substance addiction diagnosis, impulsivity and treatment compliance.

CONCLUSION:

If patient insight in their illness develops positively during treatment, our results suggest that the risk of VBs occurring is not influenced by insight level. On the other hand, it is significantly linked to substance abuse and impulsivity, which might implicate focusing on these 2 dimensions in preventive strategies. Insight impact on VB should be further explored in more focused prospective analyses.

Cannabis, a Significant Risk Factor for Violent Behavior in the Early Phase Psychosis. Two Patterns of Interaction of Factors Increase the Risk of Violent Behavior: Cannabis Use Disorder and Impulsivity; Cannabis Use Disorder, Lack of Insight and Treatment Adherence

Background: Previous literature suggests that prevalence of cannabis use in the early phase of psychosis is high, and that early psychosis patients are at high-risk for violent behavior. However, the link between cannabis use and violent behavior in early psychosis patients is unclear. We carried out a study on a sample of early psychosis patients, in order to explore the impact of cannabis use on the risk of violent behavior (VB), while taking into account (1) potential confounding factors and, (2) interactions with other dynamic risk factors of VB. Method: In a sample of 265 early psychosis patients, treated at the Treatment and Early Intervention in Psychosis Program (TIPP) in Lausanne, we used logistic regression models to explore the link between various dynamic risk factors of VB [positive symptoms, substance use disorder (drugs including cannabis, alcohol and others drugs), insight, impulsivity, affective instability, and treatment adherence], and VB occurring during treatment. In order to understand hierarchical effects attributable to the combinations of risk factors on VB we conducted a Classification and Regression Tree (CART). Results: Our results show that cannabis use disorder is a risk factor for VB. The associations among risk factors suggest the presence of two patient profiles with an increased rate of VB: the first is composed of patients with cannabis use disorder and impulsivity, and the second of patients combining cannabis use disorder, absence of insight and non-adherence to treatment. The results also show the moderating role of insight and adherence to treatment on the rate of VB in patients with cannabis use disorder. Conclusion: This study suggests that cannabis use disorder is a significant risk factor for VB amongst early psychosis patients, particularly when combined with either impulsivity, lack of insight and non-adherence to treatment. These results suggest that preventive strategies could be developed on the basis of such patient profiles.

Two-Year Clinical and Functional Outcomes of an Asian Cohort at Ultra-High Risk of Psychosis

Background: To determine the 2-year clinical and functional outcomes of an Asian cohort at ultra-high risk (UHR) of psychosis. Method: This was a longitudinal study with a follow-up period of 2 years on 255 help-seeking adolescents and young adults at UHR of psychosis managed by a multi-disciplinary mental health team in Singapore. Clients received case management, psychosocial, and pharmacological treatment as appropriate. Data comprising symptom and functional outcomes were collected over the observation period by trained clinicians and psychiatrists. Results: The 2-year psychosis transition rate was 16.9%, with a median time to transition of 168 days. After 2 years, 14.5% of the subjects had persistent at-risk symptoms while 7.5% developed other non-psychotic psychiatric disorders. 38.4% of the cohort had recovered and was discharged from mental health services. The entire cohort's functioning improved as reflected by an increase in the score of the Social and Occupational Functioning Assessment Scale during the follow-up period. Predictors to psychosis transition included low education level, baseline unemployment, a history of violence, and brief limited intermittent psychotic symptoms, while male gender predicted the persistence of UHR state, or the development of non-psychotic disorders. Conclusion: Use of the current UHR criteria allows us to identify individuals who are at imminent risk of developing not just psychosis, but also those who may develop other mental health disorders. Future research should include identifying the needs of those who do not transition to psychosis, while continuing to refine on ways to improve the UHR prediction algorithm for psychosis.