Cognitive remediation and social cognitive training for violence in schizophrenia: a systematic review

Domain-specific associations between social cognition and aggression in schizophrenia spectrum disorders

Aggression in schizophrenia spectrum disorders (SSD) is rare but elevated relative to the general population. Existing studies have not identified reliable personal predictors of aggression in SSD. In line with social information processing models suggesting that difficulties interpreting social cues and others' intentions may lead to aggression, we evaluated whether social cognitive domains or global social cognition could be modifiable risk factors in SSD. We examined aggression and social cognition in 59 participants with SSD and 43 healthy volunteers (HV). Self-reported aggression was measured via the Reactive-Proactive Aggression Questionnaire (RPAQ). Social cognition was assessed using five tasks measuring emotion processing, theory of mind, and social perception. Group differences were analyzed using Mann-Whitney-Wilcoxon tests. Multiple regressions examined effects of social cognition on aggression, controlling for demographic and clinical covariates. Supplemental mediation analyses tested whether impairments in emotion processing, theory of mind, or overall social cognition explained the relationship between SSD diagnosis and increased aggression. Reported aggression was higher in the SSD group, and social cognitive abilities were impaired across domains (p < .001). Better emotion processing (β = -0.35, p = .03) and theory of mind (β = -0.32, p = .03) predicted lower aggression in SSD, even when accounting for demographic and neurocognitive variables. Exploratory models adjusting for overall psychiatric symptom severity showed that theory of mind remained significant, while emotion processing attenuated. However, social cognition did not mediate the relationship between diagnosis and aggression. Future studies should examine other social processing factors, such as attributional bias.

The study on agitation and structure of orbitofrontal cortex subregion in first-episode drug-naïve patients with schizophrenia

Agitation is one of the core symptoms of schizophrenia. The occurrence of agitation may be related to orbitofrontal cortex dysfunction. However, due to methodological heterogeneity, the relationship between agitation and orbitofrontal cortex subregions remains unclear. Based on the multi-dimensional structure of the orbitofrontal cortex subregion, this study aims to explore the relationship between orbitofrontal cortex structure and agitation in first-episode drug-naïve patients with schizophrenia. The study subjects included 50 first-episode drug-naïve patients with schizophrenia and 29 healthy controls. All participants underwent structure magnetic resonance imaging scanning. The patients' clinical symptoms were assessed using the Positive and Negative Syndrome Scale, and the agitation were evaluated using the Brief Agitation Rating Scale. SPSS 26.0 was used to compare the differences in the orbitofrontal cortex subregion between the two groups in different structure dimensions and then conduct a Pearson's partial correlations analysis to observe the relationship between orbitofrontal cortex subregion structure and agitation. There were no significant differences in demographic factors between the two groups. Our results show the folding index of the orbitofrontal cortex subregion in patients with schizophrenia were significantly smaller compared to the healthy controls. The surface area in the orbitofrontal cortex subregion is significantly negatively correlated with agitation in first-episode drug-naïve schizophrenia patients. These results suggest that structure alterations in the orbitofrontal cortex subregion may be involved in schizophrenia agitation.

Examining the impact of a group treatment using cognitive and social cognition remediation for young offenders: The justice health NSW school-link advantage pilot study

AIM

Young offenders experience higher rates of neurodevelopmental and mental health disorders than the general population, and significant access barriers to health treatment. Treatment combining Cognitive Remediation Therapy (CRT) and Social Cognition Remediation Therapy (SCRT) has demonstrated benefits for functional improvements and social development. However, there is limited information regarding group treatment programs in custodial settings for young offenders. This pilot study explores the effectiveness and feasibility of a group treatment program for youth offenders with cognitive deficits and mental health concerns in youth detention.

METHODS

The School-Link Advantage pilot study designed and tested a 10-week group treatment program combining CRT and SCRT for young offenders in custody. The closed groups incorporated interactive activities focussed on emotional recognition and regulation skills, optimizing executive functioning, understanding values, exploring belief systems, improving relationships, and safety planning.

RESULTS

Of the 22 male participants recruited in an Australian Youth Justice Centre, 12 completed all aspects of the treatment program, reflecting a 54.5% completion rate in a typically challenging to engage population cohort. Results demonstrated significant improvements in the ability to store and retrieve information, recognize information, and control emotions. Planning and organizing skills also showed considerable development.

CONCLUSIONS

This pilot study suggests that a combined CRT and SCRT group treatment program has the potential to effectively target cognitive challenges associated with mental health disorders in young offenders in custody. These promising outcomes suggest exploring randomized controlled trials with increased cultural sensitivity for diverse populations.

The Relationship between Cognitive Impairment and Violent Behavior in People Living with Schizophrenia Spectrum Disorders: A Critical Review and Treatment Considerations

Cognitive impairment is a core feature of schizophrenia spectrum disorders (SSD). Violent and aggressive behavior represents a complex issue in psychiatry, and people with SSD have been shown to be at risk of being both victims and perpetrators of violence. In this review, the complex relationship between cognitive impairment and violent behavior is explored, also considering the usefulness of treating cognitive impairment to improve violence-related outcomes. Several studies report that cognitive impairment is linked to violent behavior, but significant differences between domains and conflicting results are also present, leaving the identification of specific cognitive profiles predicting violent behavior in SSD as an important aim for future research. Evidence regarding the effectiveness of treating cognitive impairment to improve violent behavior, while heterogeneous, provides more consistent results: cognition-targeting interventions appear to provide significant benefits also in the prevention of aggression in people living with SSD, and preliminary evidence shows cognition-focused interventions targeting violent behavior improve both cognition- and violence-related outcomes. Implementing these interventions in clinical practice could be of great usefulness, particularly in forensic contexts. Physical exercise, which improves cognitive performance and psychosocial functioning in SSD, appears to reduce violent behavior in healthy individuals, but requires further studies in clinical samples.

Predictors of psychosocial functioning in people diagnosed with schizophrenia spectrum disorders that committed violent offences and in those that did not: Results of the Recoviwel study

Psychosocial functioning represents a core treatment target of Schizophrenia Spectrum Disorders (SSD), and several clinical and cognitive factors contribute to its impairment. However, determinants of psychosocial functioning in people living with SSD that committed violent offences remain to be more thoroughly explored. This study aims to separately assess and compare predictors of psychosocial functioning in people with SSD that did and that did not commit violent offences considering several clinical, cognitive and violence-related parameters. Fifty inmates convicted for violent crimes in a forensic psychiatry setting diagnosed with SSD (OP group) and fifty participants matched for age, gender, education, and diagnosis (Non-OP group) were included in the study. A higher risk of violent relapse as measured by HCR-20 clinical subscale scores (p < 0.002) and greater global clinical severity as measured by CGI-S scores (p = 0.023) emerged as individual predictors of worse psychosocial functioning, as measured by PSP scores, in the OP group. Greater global clinical severity (p < 0.001), worse performance in the processing speed domain as measured by the BACS Symbol Coding (p = 0.002) and TMT-A tests (p = 0.016) and higher levels of non-planning impulsivity as measured by BIS-11 scores (p < 0.001) emerged as individual predictors of worse psychosocial functioning in the Non-OP group. These results confirm that clinical severity impacts psychosocial functioning in all individuals diagnosed with SSD and suggest that while cognitive impairment clearly represents a determinant of worse functional outcomes in most patients, the risk of violent relapse is a specific predictor of worse psychosocial functioning in people with SSD that committed criminal offences.

Effects of cognitive training and behavior modification on aggressive behavior and sleep quality in schizophrenia

Background

Schizophrenia (SCZ) is linked to a heightened risk of impulsive aggression and disturbances in sleep patterns. Cognitive and social cognitive impairments have been connected to aggression, with social cognitive deficits appearing to play a more immediate role. In this investigation, we conducted a retrospective analysis of the impact of cognitive training and sleep interventions on aggressive behavior and the quality of sleep among individuals with SCZ who were hospitalized.

Methods

This study divided 80 hospitalized patients into two groups according to medical advice, namely the normal group and the study group. The control group received routine drug treatment and education; The research group implemented cognitive training and sleep intervention based on the normal group. Collect basic clinical data, aggressive behavior indicators, and sleep quality indicators.

Results

There is no difference in the basic information statistics between the two groups. Both groups can reduce aggressive behavior and improve sleep quality. In the study group, there was a notable decrease in aggressive behavior compared to the control group. Furthermore, the sleep quality in the study group exhibited significant improvement when compared to the control group.

Conclusion

Cognitive training and sleep intervention have been proven to be effective nonpharmacological treatments, effectively reducing aggressive behavior and improving sleep quality.

Construction and verification of aggressive behavior risk prediction model in stable patients with schizophrenia

BACKGROUND

Among all types of mental disorders, individuals with schizophrenia exhibit the highest frequency of aggressive behavior. This disrupts the healthcare environment and poses threats to family life and social harmony. Present approaches fail to identify individuals with schizophrenia who are predisposed to aggressive behavior. In this study, we aimed to construct a risk prediction model for aggressive behavior in stable patients with schizophrenia, which may facilitate early identification of patients who are predisposed to aggression by assessing relevant factors, enabling the management of high-risk groups to mitigate and prevent aggressive behavior.

METHODS

A convenience sample of stable inpatients with schizophrenia were selected from Daqing Municipal Third Hospital and Chifeng Municipal Anding Hospital from March 2021 to July 2023. A total of 429 patients with stable schizophrenia who met the inclusion criteria were included. A survey was conducted with them using a questionnaire consisting of general information questionnaire, Positive and Negative Symptom Scale, Childhood Trauma Questionnaire-Short Form, Connor-Davidson Resilience Scale and Self-esteem Scale. Patients enrolled in this study were divided into aggressive and non-aggressive groups based on whether there was at least one obvious and recorded personal attack episode (including obvious wounding and self-injurious behavior) following diagnosis. Binary Logistic regression was used to determine the influencing factors, and R software was used to establish a nomogram model for predicting the risk of aggressive behavior. Bootstrap method was used for internal validation of the model, and the validation group was used for external validation. C statistic and calibration curve were used to evaluate the prediction performance of the model.

RESULTS

The model variables included Age, Duration of disease, Positive symptom, Childhood Trauma, Self-esteem and Resilience. The AUROC of the model was 0.790 (95% CI:0.729-0.851), the best cutoff value was 0.308; the sensitivity was 70.0%; the specificity was 81.4%; The C statistics of internal and external validation were 0.759 (95%CI:0.725-0.814) and 0.819 (95%CI:0.733-0.904), respectively; calibration curve and Brier score showed good fit.

CONCLUSIONS

The prediction model has a good degree of discrimination and calibration, which can intuitively and easily screen the high risk of aggressive behavior in stable patients with schizophrenia, and provide references for early screening and intervention.

The "zipper model of empathy" applied to violence in schizophrenia: A search for social cognitive underpinnings of lack of empathic behavior

BACKGROUND

The "zipper model of empathy" has been proposed for psychopathy. It postulates that empathic behavior may fail to arise due to impaired facial emotion recognition. In this study, we examined if the model may be of relevance for schizophrenia.

METHODS

In a sample of participants with schizophrenia and a history of severe interpersonal violence, associations between measures of social cognition (emotion recognition, theory of mind) and aspects of psychopathy (lack of empathy, lack of remorse) were investigated. A non-violent sample experiencing schizophrenia served as a control group.

RESULTS

Correlation analyses revealed a specific and statistically significant association between facial emotion recognition and lack of empathy in the violent sample. Follow-up analyses identified that neutral emotions were of particular importance. Logistic regression analyses confirmed that impairments in facial emotion recognition predicted levels of empathy in the violent sample experiencing schizophrenia.

CONCLUSIONS

Our results suggest that the "zipper model of empathy" may be relevant for schizophrenia. The findings further point to the potential benefit of including social cognitive training in the treatment of persons with schizophrenia and a history of interpersonal aggression.

Empathy deficit in male patients with schizophrenia and its relationships with impulsivity and premeditated violence

Objective

To explore the pattern of empathy characteristics in male patients with schizophrenia (SCH) and to examine whether empathy deficit is associated with impulsivity and premeditated violence.

Methods

One hundred and fourteen male SCH patients were enrolled in this study. The demographic data of all patients were collected and the subjects were divided into two groups, namely, the violent group, including 60 cases, and the non-violent group, comprising 54 cases, according to the Modified Overt Aggression Scale (MOAS). The Chinese version of the Interpersonal Reactivity Index-C (IRI-C) was used to evaluate empathy and the Impulsive/Predicted Aggression Scales (IPAS) was employed to assess the characteristics of aggression.

Results

Among the 60 patients in the violent group, 44 patients had impulsive aggression (IA) and 16 patients had premeditated aggression (PM) according to the IPAS scale. In the violent group, the scores of the four subfactors of the IRI-C, i.e., perspective taking (PT), fantasy (FS), personal distress (PD), and empathy concern (EC), were significantly lower than in the non-violent group. Stepwise logistic regression showed that PM was independent influencing factor for violent behaviors in SCH patients. Correlation analysis revealed that EC of affective empathy was positively correlated with PM but not with IA.

Conclusion

SCH patients with violent behavior had more extensive empathy deficits compared with non-violent SCH patients. EC, IA and PM are independent risk factors of violence in SCH patients. Empathy concern is an important index to predict PM in male patients with SCH.

Computerized cognitive and social cognition training in schizophrenia for impulsive aggression

BACKGROUND

Schizophrenia is associated with an elevated risk for impulsive aggression for which there are few psychosocial treatment options. Neurocognitive and social cognitive deficits have been associated with aggression with social cognitive deficits seemingly a more proximal contributor. The current study examined the effects of combining cognitive and social cognition treatment on impulsive aggression among inpatients with chronic schizophrenia and schizoaffective disorder and a history of aggression compared to cognitive remediation treatment alone.

METHODS

The two-center study randomized 130 participants to receive 36 sessions of either a combination of cognitive remediation and social cognition treatment or cognitive remediation plus a computer-based control. Participants had at least one aggressive incident within the past year or a Life History of Aggression (LHA) score of 5 or more. Participants completed measures of neurocognition, social cognition, symptom severity, and aggression at baseline and endpoint.

RESULTS

Study participants were mostly male (84.5 %), had a mean age 34.9 years, and 11.5 years of education. Both Cognitive Remediation Training (CRT) plus Social Cognition Training (SCT) and CRT plus control groups were associated with significant reductions in aggression measures with no group differences except on a block of the Taylor Aggression Paradigm (TAP), a behavioral task of aggression which favored the CRT plus SCT group. Both groups showed significant improvements in neurocognition and social cognition measures with CRT plus SCT being associated with greater improvements.

CONCLUSION

CRT proved to be an effective non-pharmacological treatment in reducing impulsive aggression in schizophrenia inpatient participants with a history of aggressive episodes. The addition of social cognitive training did not enhance this anti-aggression treatment effect but did augment the CRT effect on cognitive functions, on emotion recognition and on mentalizing capacity of our participants.

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.

Violence in relation to cognitive deficits and symptom severity in a sample of Egyptian patients with schizophrenia

BACKGROUND

Patient with schizophrenia are significantly more likely to be violent than general population; and the consequences of this violence risk are often very serious for the patients, their caregivers, and the entire community.

AIM

To assess the risk of violence in patients with schizophrenia and its correlation with severity of symptoms and cognitive functions.

METHODS

A cross-sectional comparative study conducted in Okasha institute of psychiatry including 50 patients with schizophrenia compared to 50 healthy control group regarding violence risk as assessed by Historical, Clinical, and Risk Management-20 (HCR-20), case group was assessed using Structured Clinical Interview for DSM-IV (SCID-I), Positive and Negative Syndrome Scale (PANSS), cognitive functions were assessed by Wechsler Adult Intelligence Scale (WAIS), Trail Making Test (TMT) Part A and B, the Wisconsin Card Sorting Test (WCST), and the Wechsler Memory Scale (WMS).

RESULTS

There was a statistically significant difference between case and control groups regarding risk of violence where 58% of the case group were found to have risk of violence compared to only 18% in the control group. There was a significant correlation between this risk of violence and period of untreated psychosis, no of episodes, and history of substance use; also was significantly correlated with PANSS and Wisconsin card sorting test subscales. Regarding logistic regression analysis for factors affecting violence risk; total PANSS score and history of substance use were significant independent factors that increase violence risk.

CONCLUSION

Violence risk in patient with schizophrenia is a cardinal factor that may affect life of the patients, their family, and society; this risk can be affected by different factors including severity of symptoms, no of episodes, history of substance use, and cognitive function of the patients.

Aggression, Alexithymia and Sense of Coherence in a Sample of Schizophrenic Outpatients

Schizophrenia elevates the risk for aggressive behavior, and there is a need to better understand the associated variables predicting aggression for treatment and prevention purposes. The aim of the present study is to determine the relationship between alexithymia, sense of coherence and aggressive behavior in a sample of schizophrenic outpatients. Using a correlational research design, standardized self-report questionnaires assessed aggression (brief aggression questionnaire—BAQ), alexithymia (Toronto Alexithymia Scale—TAS) and sense of coherence (sense of coherence questionnaire—SOC) in a sample of 100 schizophrenic outpatients in clinical remission. Participants reported high levels of aggression and alexithymia along with reduced sense of coherence. Significant negative correlations were evidenced among scores on the SOC scale (p < 0.001) with both the TAS as well as with the BAQ scales. However, a positive correlation (p < 0.001) was observed between the TAS and BAQ scales. Regression indicated that 27% of the variation in the BAQ rating was explained by the TAS, while an additional 17.8% was explained by the sense of coherence. The difficulty identifying feelings of alexithymia and the comprehensibility and manageability components of sense of coherence significantly predicted anger, hostility and physical aggression. Sense of coherence mediated the relationship between alexithymia and aggression. From the path analysis, comprehensibility emerged as the key factor counterbalancing alexithymic traits and aggressive behaviors, and manageability effectuated higher anger control. The findings hold practical implications for the treatment and rehabilitation of schizophrenic patients.

Substance Abuse Associated with Aggressive/Violent Behaviors in Psychiatric Outpatients and Related Psychotropic Prescription

Psychiatric disorders with substance abuse are considered the leading causes of most violent and aggressive behaviors in the general population. This study was aimed to assess the impact of substance abuse and the therapeutic approaches adopted by psychiatrists in aggressive vs non-aggressive outpatients (n = 400) attending community-based psychiatric services and recruited over a 3-year period. Clinical and therapeutic variables were collected from medical records and the Modified Overt Aggression Scale (MOAS) was used to assess any aggressive/violent behavior. Violent behaviors were significantly higher in alcohol and substance abusers compared to non-abusers (p < 0.01), except for heroin abusers. Mean weighted MOAS score was significantly higher in patients taking antipsychotics (p < 0.005). The administration of Haloperidol, Zuclopenthixol, and Clozapine was more frequent in aggressive than in non-aggressive patients. The most frequently administered drug in these patients was Haloperidol (23.91%), with a higher mean daily dosage in violent vs non-violent patients. Our results confirm the well-established relationship between substance abuse and violent behaviors in psychiatric inpatients also within outpatient community services. Observed rates of most frequently prescribed antipsychotics to aggressive patients did not show any preference for newer generation compounds, with clinicians operating in the community setting likely being in need for further evidence and specific training to support their treatment choice.

Neurocognitive features, personality traits, and social function in patients with schizophrenia with a history of violence

Recent literature examining associations between cognitive function, clinical features, and violence in patients with schizophrenia has been growing; however, the results are inconsistent. Reports on social function and personality are limited. These studies are yet to be reflected in risk assessment tools and management plans. The aim of this study is to provide a resource for risk assessment and intervention studies by conducting multifaceted well-established assessments in a large population. Data from 355 patients with schizophrenia (112 patients with a history of violence; 243 patients without a history of violence) and 1265 healthy subjects were extracted from a large database of individuals with mental disorders in a general psychiatric population in Japan. The associations between violence in patients with schizophrenia and intellectual function, cognitive function (memory function, executive function, attentional function, verbal learning, processing speed, social cognition), clinical variables, personality traits, social function, and quality of life (QOL) were analyzed. Compared with healthy subjects, the schizophrenia group had broadly impaired cognitive function and social cognition, and their personality traits showed similar differences as those reported previously. Patients with schizophrenia with a history of violence showed significantly more impaired visual memory function (P = 1.9 × 10^-5, Cohen's d = 0.34), longer hospitalization (P = 5.9 × 10^-4, Cohen's d = 0.38), more severe excited factor on Positive and Negative Syndrome Scale (P = 1.6 × 10^-4, Cohen's d = 0.47), higher self-transcendence personality construct on the Temperament and Character Inventory (P = 1.8 × 10^-4, Cohen's d = 0.46), and shorter total working hours per week (P = 4.8 × 10^-4, Cohen's d = 0.53) than those with schizophrenia without a history of violence. New findings, including impaired visual memory, a high self-transcendence personality trait, and shorter total working hours, could be focused on in future interventional research.

Mistakes in interpersonal perceptions: Social cognition in aggressive forensic psychiatry patients

BACKGROUND

While there is an established link between untreated psychosis and aggression, an enhanced understanding of the role of social cognition is still needed.

AIMS

To examine social cognitive functioning among patients in a specialist forensic mental health service who had been deemed not criminally responsible for acts of violence due to a psychotic disorder. It was hypothesised, first, that such patients would show reduced social cognitive functioning compared with healthy, nonviolent comparison participants and, second, that those who continued to be aggressive while inpatients would demonstrate significant reductions compared to the now nonaggressive group.

METHODS

The study samples were of 10 recently aggressive and 15 not-recently aggressive patients and 20 healthy, nonviolent comparison participants. Each completed the Toronto Empathy Questionnaire (TEQ), the Reading the Mind in the Eyes Test-Revised (RMET) and the Interpersonal Perception Task-15 (IPT-15).

RESULTS

There was no significance between group differences on the RMET and TEQ. The patient group as a whole, however, showed significant interpersonal misperceptions, with specific misperceptions on IPT-15 deception and kinship subscales, while at the same time lacking self-awareness of their errors. Misperceptions on the IPT-15 competition subscale were unique to recently aggressive patients.

CONCLUSIONS

Select aspects of reduced social cognitive functioning were found among not criminally responsible patients with psychosis who had committed violent acts and who continued to act aggressively while forensic inpatients. These findings enhance our understanding of the role of social cognition in predisposing toward violence and the potential importance of incorporating interventions which improve social cognition directly. We suggest also the potential for future research using virtual reality technologies in treatment.

Family Conflict and Violence by Persons with Serious Mental Illness: How Clinicians Can Intervene During the COVID-19 Pandemic and Beyond

Although most persons living with serious mental illness (SMI) do not act violently, this population is at a modestly increased risk of engaging in violence, with family members being the most common victims. Consequently, evidence suggests that a sizable minority of family members-many of whom are caregivers-have experienced violence by their relative with SMI. The risk of conflict and violence in families of persons with SMI is likely currently heightened due to a range of challenges resulting from the COVID-19 pandemic (e.g., interruption in treatment services and the occurrence of arguments while sheltering in place together). As such, during the pandemic, it is particularly important that clinicians intervene with these populations to prevent conflict and violence and strengthen their relationships with each other. Based on available evidence, we recommend that clinical interventions aiming to do so address the following topics with family members and/or persons with SMI: mutual understanding; positive communication; effective problem-solving; symptoms and psychiatric crises; triggers to, and early warning signs of, anger and conflict; and strategies for de-escalating conflict and managing violent behavior. We offer suggestions for how clinicians can address these topics and recommend established clinical resources providing more guidance in this area.

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 Effects of Cognitive Behavior Therapy and Social Skill Training among Schizophrenia with Risk of Violent Behavior

BACKGROUND: Schizophrenia is a condition in which people suffer from impaired ability to think, perceive, and show emotional responses and interact socially. Patients with schizophrenia can experience the risk of violent behavior (RVB). Psychotherapy is needed to deal with the problem. AIM: This study aimed to investigate the effects of cognitive behavior therapy (CBT) and social skill training (SST) on signs and symptoms of risks of violent behavior (RVB). METHODOLOGY: This study employed a quasi-experimental without a control group. The research samples used purposive sampling were 30 patients with symptoms of risks of violent behavior. Meanwhile, the measurement used the sign and symptom questioners of risks of violent behavior (Z = 0.791). RESULT: This study revealed that signs and symptoms decreased significantly (p < 0.05) from 10.45 to 5.41 after the respondents had obtained the CBT. Moreover, after the respondents had received CBT and SST, the sign and symptoms decreased significantly (p < 0.05) from 5.41 to 0.52. CONCLUSION: This study recommends that the combination of CBT and SST be administered to patients with schizophrenia with risks of violent behavior.

Neurocognition and social cognition in patients with schizophrenia spectrum disorders with and without a history of violence: results of a multinational European study

OBJECTIVE

Neurocognitive impairment has been extensively studied in people with schizophrenia spectrum disorders and seems to be one of the major determinants of functional outcome in this clinical population. Data exploring the link between neuropsychological deficits and the risk of violence in schizophrenia has been more inconsistent. In this study, we analyse the differential predictive potential of neurocognition and social cognition to discriminate patients with schizophrenia spectrum disorders with and without a history of severe violence.

METHODS

Overall, 398 (221 cases and 177 controls) patients were recruited in forensic and general psychiatric settings across five European countries and assessed using a standardized battery.

RESULTS

Education and processing speed were the strongest discriminators between forensic and non-forensic patients, followed by emotion recognition. In particular, increased accuracy for anger recognition was the most distinctive feature of the forensic group.

CONCLUSIONS

These results may have important clinical implications, suggesting potential enhancements of the assessment and treatment of patients with schizophrenia spectrum disorders with a history of violence, who may benefit from consideration of socio-cognitive skills commonly neglected in ordinary clinical practice.

Cognitive Flexibility and Reaction Time Improvements After Cognitive Training Designed for Men Perpetrators of Intimate Partner Violence: Results of a Pilot Randomized Controlled Trial

Purpose Current interventions for intimate partner violence (IPV) perpetrators are designed to reduce IPV recidivism by treating risk factors and increasing protective factors. However, these interventions pay less attention to cognitive functioning in IPV perpetrators and how these variables interfere with the future risk of recidivism. Therefore, the main objective of this research was to compare the effectiveness of Standard Intervention Programs for men who perpetrate IPV [SIP] + cognitive training vs SIP + placebo training in promoting cognitive improvements and reducing recidivism. Furthermore, we also aimed to assess whether changes in the risk of recidivism would be related to cognitive changes after the intervention. Method IPV perpetrators who agreed to participate were randomly allocated to receive SIP + cognitive training or SIP + placebo training. Several cognitive variables were assessed before and after the interventions with a complete battery of neuropsychological tests assessing processing speed, memory, attention, executive functions, and emotion decoding abilities. Moreover, we also assessed the risk of recidivism. Results Our data pointed out that only the IPV perpetrators who received the SIP + cognitive training improved their processing speed and cognitive flexibility after this intervention. Furthermore, these participants presented the lowest risk of recidivism after the intervention. Nonetheless, cognitive improvements and reductions in the risk of recidivism after the intervention were unrelated. Conclusions Our study reinforces the importance of implementing cognitive training to reduce risk of recidivism after SIP. Hence, these results might encourage professionals to incorporate neuropsychological variables in IPV intervention programs.

[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.

A Systematic Review of Non-pharmacological Strategies to Reduce the Risk of Violence in Patients With Schizophrenia Spectrum Disorders in Forensic Settings

Background: The purpose of this systematic review is to systematically investigate which non-pharmacological interventions are effective in reducing violence risk among patients with schizophrenia spectrum disorders (SSD) in forensic settings. Methods: Six electronic data bases were searched. Two researchers independently screened 6,003 abstracts resulting in 143 potential papers. These were analyzed in detail by two independent researchers yielding 10 articles that could be used. Results: Of the 10 articles, four were non-randomized controlled trials, three were pre-post studies without controls, and one was observational. Only two studies applied a randomized controlled trial design. Cognitive behavioral treatment programs were investigated in three studies. A broad range of other interventions were studied. Often outcome measures were specific to each study and sample sizes were small. Frequently, important methodological information was missing from the papers. It was not possible to carry out a meta-analysis due to the heterogeneity of the study designs and outcome measures. Conclusion: Because of methodological limitations it is difficult to draw firm conclusions about the effectiveness of non-pharmacological interventions to reduce the risk of violence in patents with SSD in forensic psychiatry settings. Studies applying better methods in terms of study design, sample sizes and outcome measures are urgently needed.

Non-pharmacological strategies for self-directed and interpersonal violence in people with severe mental illness: a rapid overview of systematic reviews

INTRODUCTION

Self-directed and interpersonal violence among people with severe mental illness has become a health priority. Though non-pharmacological interventions have been investigated, to our knowledge, no summary of all systematic reviews on this topic has been reported. We will conduct a rapid overview of reviews to synthesise evidence available by identifying systematic reviews on non-pharmacological interventions for self-directed or interpersonal violence in people with severe mental illness.

METHODS AND ANALYSIS

This is a protocol for a rapid overview of reviews. The overview will include any systematic reviews (with or without meta-analyses) of randomised controlled trials (RCTs) or cluster RCTs that examine the effect of non-pharmacological interventions on self-directed or interpersonal violence in people with severe mental illness. This protocol applies the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Protocols, the criteria for conducting overviews of reviews in the Cochrane Handbook of Systematic Reviews of Interventions and the criteria for the Cochrane Rapid Reviews. To identify studies, a search will be performed in the following databases: PubMed, EMBASE, PsycINFO, CINAHL, LILACS, SciELO, Web of Science, Scopus, ProQuest, the Cochrane Database of Systematic Reviews through the Cochrane Library and the Epistemonikos database of systematic reviews. The searches date from inception to September 2020. The study selection process will be described using a PRISMA flow diagram, we will assess the quality of evidence in systematic reviews included and the quality of the systematic reviews themselves and the main results will be summarised in categories to provide a map of the evidence available.

ETHICS AND DISSEMINATION

No patients or other participants will be involved in this study. The results will be presented at mental health conferences and for publication in a peer-reviewed journal.

REGISTRATION DETAILS

The protocol was registered on the Open Science Framework (https://osf.io/myzd9/).

Aggressiveness is associated with excitement on the five-factor model of the positive and negative syndrome scale and prefrontal function in patients with stable schizophrenia

Aggressiveness is a clinical concern in the stable phase of schizophrenia, as well as in the acute phase. The factors that affect aggressiveness during the stable phase remain unclear. This study investigated factors associated with aggressiveness in patients with stable schizophrenia. Sixty-six patients with schizophrenia who were in the stable phase without acute exacerbation were assessed for aggressiveness using the Buss-Perry Aggression Questionnaire; impulsivity using the Barratt Impulsiveness Scale Version 11, psychotic symptoms using the five-factor model of the Positive and Negative Syndrome Scale (PANSS) including positive symptoms, negative symptoms, disorganization, excitement, and emotional distress; and prefrontal hemodynamic responses using near-infrared spectroscopy. Multivariate regression analyses showed that the excitement factor of the PANSS five-factor model, which comprised four PANSS items (poor impulse control, hyperactivity, hostility, and uncooperativeness), and delayed prefrontal hemodynamic responses were associated with elevated aggressiveness. These findings suggest that in patients with stable schizophrenia, excitement symptoms and prefrontal dysfunction are associated with elevated aggressiveness. Furthermore, the impact of impulsive traits on aggressiveness is less relevant. Our results shed light on a specific aspect of aggressiveness in patients with stable schizophrenia and may indicate factors to consider in the clinical setting.

Staging and profiling for schizophrenia spectrum disorders: Inter-rater reliability after a short training course

OBJECTIVE

Clinical staging and profiling have been proposed as a new approach in order to refine the diagnostic assessment of schizophrenia spectrum disorders. However, only limited evidence is available for the inter-rater reliability of the clinical staging and profiling model. The aim of the present study was therefore to determine the inter-rater reliability of the clinical staging and profiling model for schizophrenia spectrum disorders, and to investigate whether a short course can improve inter-rater reliability.

METHODS

Consecutively recruited inpatients with schizophrenia spectrum disorders were included between January 2015 and January 2016 (study 1), and between March 2018 and October 2018 (study 2). By contrast with the assessors in study 1, all the assessors in study 2 were trained in clinical staging and profiling. We used the clinical staging model proposed by McGorry and identified profile characteristics. Inter-rater reliability was measured using the Intraclass Correlation Coefficient (ICC).

RESULTS

The ICC score for clinical staging in study 1 was moderate (0.578). It improved considerably in study 2 (0.757). In general, the ICC scores for the profile characteristics in studies 1 and 2 ranged from poor to sufficient (0.123-0.781).

CONCLUSION

This study demonstrated that inter-rater reliability in clinical staging was sufficient after training. However, inter-rater reliability for clinical profile characteristics was highly variable. The general implementation of the clinical staging model for schizophrenia spectrum disorders is therefore feasible but clinical profile characteristics should be used with caution.

Breaking down long-term chronic aggression within a forensic hospital system

OBJECTIVE

Historically, patients with multiple acts of aggression, or chronic aggressors, have been studied as one large group. It was our objective to subdivide this group into those patients who engage in physical aggression consistently over multiple years and see if common characteristics of chronic aggressors could classify patients into an aggressive or nonaggressive group.

METHOD

Within a forensic hospital system, patients who had committed 5 acts of physical aggression, per year, for 3 years (2010 and 2015) were reviewed. Data was collected on clinical and demographic characteristics that have shown to be associated with chronically aggressive patients and compared to nonaggressive matched controls. Data collection and analysis were completed to determine if the variables could classify patients into an aggressive or nonaggressive group.

RESULTS

Analysis showed that 2 variables, the presence of a cognitive disorder and a history of suicidal behaviors were significant in the univariate and multivariate analyses. The 2 variables were able to correctly classify 76.7% of the cases.

CONCLUSION

A cognitive disorder, a history of suicidal behavior, and increased age were factors associated with this subgroup of aggressive patients. Clinicians may want to explore treatment programs aimed at these clinical factors including cognitive rehabilitation and social cognition treatments, which have been shown to reduce aggression in cognitively impaired populations.

Neurocognition and social cognition training as treatments for violence and aggression in people with severe mental illness

Aggressive and violent behavior, including both verbal and physical aggression, have considerable adverse consequences for people with schizophrenia. There are several potential causes of violent behavior on the part of people with severe mental illness, which include intellectual impairments, cognitive and social-cognitive deficits, skills deficits, substance abuse, antisocial features, and specific psychotic features. This review explores the interventions that have been tested to this date. Computerized Cognitive Training (CCT) or Computerized Social-Cognitive Training (CSCT) have been associated with reductions in violence. Combined CCT and CSCT have been found to improve social cognition and neurocognition, as well as everyday functioning when combined with rehabilitation interventions. These interventions have been shown to reduce violence in schizophrenia patients across multiple environments, including forensic settings. The reductions in violence and aggression have manifested in various ways, including reduced violent thinking and behavior, reduced physical and violent assaults, and reduced disruptive and aggressive behaviors. Effects of cognitive training may be associated with improvements in problem-solving and the increased ability to deploy alternative strategies. The effect of social cognition training on violence reduction appears to be direct, with improvements in violence related to the extent of improvement in social cognition. There are still remaining issues to be addressed in the use of CCT and CSCT, and the benefits should not be overstated; however, the results of these interventions are very promising.

Gambling and Social Cognition: a Systematic Review

Purpose of Review

The aim of this article was to review current research regarding social cognition (SC) in gambling disorder (GD), to (i) compile and synthetize the current state of existing literature on this topic, and (ii) propose cognitive remediation therapy approaches focused on SC for clinicians.

Recent Findings

It is well known that disordered gamblers show impairment regarding non-social cognitive functions such as inhibition, attention, and decision-making. Furthermore, patients with substance use disorders also present certain deficits regarding social information processing which are difficult to differentiate from the intrinsic toxic effects linked to drugs or alcohol consumption.

Summary

To date, relatively little research has been undertaken to explore SC in gambling disorder (GD) with neuropsychological tasks. Preliminary results suggest impaired non-verbal emotion processing, but only one study has directly measured SC in GD. As a consequence, future research on this framework should propose diverse measures of SC, while controlling for other factors such as personality traits and subtypes of disordered gamblers.

Comprehensive review on virtual reality for the treatment of violence: implications for youth with schizophrenia

Youth violence is a complex and multifactorial issue that has severe health and social consequences. While treatment options exist to treat/reduce violence in at-risk populations such as schizophrenia, there remains limitations in the efficacy of current interventions. Virtual reality (VR) appears to be a unique possibility to expose offenders and to train coping skills in virtual situations that are capable of eliciting aggression-relevant behavior without threatening others. The focus of this paper is to provide a comprehensive review of studies using VR to manage violence across several at-risk populations, with a particular emphasis on youth with schizophrenia. Despite the encouraging success of VR applications for the treatment of different mental health problems, no studies have explored the usability of VR to specifically treat violence in patients with schizophrenia. A limited number of studies have focused on violence risk factors in other mental health problems (i.e., emotion regulation in individual suffering from post-traumatic disorders) that may be targeted in treatments to reduce the risk of violence. The preliminary studies using VR as a therapeutic element have shown reductions in anger, improvements in conflict-resolution skills as well as in empathy levels, and decreases in aggression. Possible applications of these interventions in youth with schizophrenia will be discussed.

The importance of impulsivity and attention switching deficits in perpetrators convicted for intimate partner violence

It has been stated that Attention deficit hyperactivity disorder (ADHD) increases the likelihood of risky behavior such as intimate partner violence (IPV), but the cognitive mechanisms that facilitate or underlie these types of behavior remain unexplained. In this regard, several authors have established that impulsivity and inattentive symptoms might affect basic processes such as emotional decoding and set-shifting abilities, which are important processes for emotional and behavioral regulation. Hence, these symptoms entail a reduction in sensitivity to key contextual stimuli. Accordingly, the main aim of this study was to examine the involvement of impulsivity (assessed by self-reports) and attention switching impairments (assessed with the Attention Switching Task; AST), as well as the associations between these cognitive processes in facial emotion decoding (assessed by the eyes test) and cognitive flexibility impairments (measured by the Wisconsin Card Sorting Test, WCST) in a sample of IPV perpetrators (n = 89; mean age = 40) and a control group matched on socio-demographic characteristics (n = 39; mean age = 41). IPV perpetrators had higher trait impulsivity and greater attention switching costs than controls. Moreover, differences were also found between groups in facial expression decoding and WCST performance, with IPV perpetrators showing lower Eyes Test and WCST scores. Mainly, we observed that the ability to recognize facial expressions was poorer when individuals showed high impulsivity in both groups, but this association was only explained by deficits in attention switching in IPV perpetrators. Our research reinforces the importance of impulsivity and inattentive symptoms as targets for specific cognitive rehabilitation interventions designed to prevent the long-term IPV risk of recidivism.

Victimización y perpetración de la violencia de pareja adolescente: Un modelo predictivo

Resumen La evidencia ha mostrado un incremento de la violencia en las relaciones de pareja, lo cual amerita identificar los factores que la predicen. El objetivo fue establecer un modelo predictivo de las características sociodemográficas, psicopatológicas y del consumo de alcohol sobre la victimización y la perpetración de la violencia de pareja adolescente. La muestra fue de 599 participantes, entre 13 y 19 años, de instituciones educativas públicas y privadas de Bogotá, Colombia. 327 eran del sexo femenino (M = 16.9; DE = 1.45) y 272 del sexo masculino (M = 17.35; DE = 1.35). Se aplicó el Cuestionario de Autoinforme de Variables Psicológicas, el Inventario de Síntomas, el Cuestionario de Identificación de los Trastornos debidos al Consumo de Alcohol, y el Inventario de Conflicto en las Relaciones en el Noviazgo Adolescente. El consumo de alcohol y los síntomas psicopatológicos predicen en el sexo femenino la victimización, y en el sexo masculino la perpetración de la violencia de pareja.

Mentalization and empathy as predictors of violence in schizophrenic patients: Comparison with nonviolent schizophrenic patients, violent controls and nonviolent controls

There are conflicting results concerning risk of violence in schizophrenia. Empathy and mentalization deficits are associated both with schizophrenia and violence, however, there are only a few studies with equivocal results concerning their relationship. 88 violent and nonviolent paranoid schizophrenic and violent and nonviolent control males in psychiatric, forensic psychiatric and correctional institutions completed the Ekman 60 Faces test, Faux Pas Recognition Test, Eysenck IVE test, Interpersonal Reactivity Index, and the Spielberger Anger Expression Scale. Data were analysed with ANOVA and logistic regression models. Significant group differences with a characteristic pattern were detected in mentalization, facial affect recognition, fear and anger recognition, interpersonal distress, and frequency of direction of anger expression. Predictors of violent behaviour were different in the schizophrenic and non-schizophrenic groups. Lack of major differences in empathy and mentalization between violent and nonviolent schizophrenia patients suggests that such deficits are core features of schizophrenia but do not determine emerging violence in this illness. Our results emphasise the importance of distinguishing between violence related to core positive symptoms of schizophrenia and that emerging from independent comorbid antisocial personality traits in order to identify targets for screening, detection, prevention and management of violence risk in different subpopulations of schizophrenia patients.

Characteristics of International Assaultive Psychiatric Patients: Review of Published Findings, 2013-2017

Since the 1960s, empirical research has worked toward a better understanding of the characteristics of assaultive psychiatric patients. International research through 2012 indicated that male and female patients with schizophrenia and other diagnoses presented the greatest risk for assault. This present review of studies that presented raw assault sought to assess the latest research findings on assaultive patients for the most recent 5 year period, 2013-2017. It was hypothesized that male patients with schizophrenia would present the greatest risk. The findings indicated a sharp increase in the total number of reported assault incidents over the proceeding decade. These assaults were committed largely by male patients with a diagnosis of schizophrenia. Explanations for these findings and an updated methodological inquiry are presented.

Do cognitive deficits predict negative emotionality and aggression in schizophrenia?

Schizophrenia is associated with an elevated risk of aggression. Cognitive deficits have been associated with inpatient aggression and future violence. The relationship between cognitive deficits and violent behavior has however been inconsistent across studies. In addition, studies have failed to inform how cognitive deficits may contribute to aggression in schizophrenia. The current study examined the association of cognitive deficits with schizophrenia-related aggression and violent offending. It also explored the putative mediating role of negative emotionality on the impact of cognitive deficits on aggression. People with schizophrenia and schizoaffective disorder (N = 78) were recruited from a state hospital. Participants were classified based on their history of violent offending. Participants completed measures of cognition, symptoms, and aggression. Deficits in working memory, reasoning/problem-solving, and verbal learning were the most prioritized for the prediction of violent offender status. Violent offenders demonstrated greater impairments in most cognitive domains especially working memory and verbal learning. Offenders also demonstrated greater negative emotionality, excitement/agitation, and incidents of verbal and physical aggression. Negative emotionality and excitement/agitation fully transmitted the effect of cognitive deficits on impulsive aggression in meditational models. Cognitive deficits increase the risk of impulsive aggression in schizophrenia via inefficient regulation of negative affective states.

Attitudes of Chinese community members and psychiatrists towards forensic psychiatric assessments

The aim of this study was to investigate the attitudes of Chinese community members and psychiatrists towards forensic psychiatric assessments. A questionnaire designed to record attitudes toward the current forensic psychiatric assessment procedures and the disposal of mentally ill offenders was developed and distributed via a mobile App. A total of 134 community members and 132 psychiatrists voluntarily completed the questionnaire. Most of responders agreed that the department of public-security has the right to apply for a forensic psychiatric assessment but should not be held solely by that department. Community members were less significantly confident in the validation of forensic psychiatric opinions than were the psychiatrists. A significantly higher proportion of community members than psychiatrists considered that offenders judged Not Criminally Responsible on Account of Mental Disorder (NCRMD) should be punished as would be sane people. In addition, only a minority of responders supported that NCRMD should not be held criminally responsible. Our results indicate that both groups have comments on the current distribution of right of startup of forensic psychiatric assessments. Compared to psychiatrists, community members have lower confidence in the validation of forensic psychiatric assessment and have stricter attitudes toward the disposal of offenders with psychiatric disorders.

[Preventing violence in schizophrenia with cognitive remediation]

OBJECTIVES

The association between schizophrenia and violence represents an important issue in psychiatry. Often highly publicized, violent acts raise the question of their detection, prevention, management and treatment. There is no single, direct and exclusive link between aggressiveness and the underlying psychiatric disorder. On the contrary, the processes underlying this violence are multiple and interlinked. In addition to static and dynamic risk factors, cognitive deficits play an important role in the genesis and maintenance of violent and aggressive behavior.

METHODS

Using recent data from the international literature and the main databases, we first clarify the role played by cognitive deficits in the violence of patients with schizophrenia. We then evaluate the place of psychosocial interventions such as cognitive remediation and social cognitive training in managing the violent and aggressive behavior of these patients.

RESULTS

Executive functions and working memory are the most studied neurocognitive functions in the field of violence in schizophrenia. Impulsivity, lack of cognitive flexibility, lack of adaptation and inhibition of automatic motor responses, and altered anger regulation may explain this relationship. Three main components of social cognition are associated with violent behaviors in schizophrenia: (1) the recognition of facial emotions through the inoperability of systems of "emotional monitoring", violent inhibition and recognition of informative facial zones; (2) the theory of the mind through the erroneous interpretation of the intentions of others; (3) the attributional style through the preferentially aggressive over interpretation of social situations and weak capacities of introspection. Overall, cognitive biases inhibit response in a socially acceptable manner and increase the risk of responding impulsively and aggressively to a stressful or provocative situation. In this context, we studied the place held by psychosocial interventions in the management of the violent and aggressive behaviors of these patients. Various cognitive remediation programs have shown their feasibility in people with schizophrenia and neurocognitive deficits with a history of violence as well as their effectiveness in reducing violence, mainly by reducing impulsivity. Similarly, specific programs dedicated to social cognitive training such as Social Cognition and Interaction Training (SCIT), Reasoning and Rehabilitation Mental Health Program (R&R2 MHP) and Metacognitive Training (MCT) have shown their positive impact on the control and reduction of global aggressive attitudes and on the numbers of physical and verbal aggressive incidents in schizophrenia. The improvement of social cognition would be achieved through the amendment of interpersonal relationships and social functioning. These interventions are effective at different stages of disease progression, in patients with varied profiles, on violent attitudes in general and on the number of verbal and physical attacks, whether for in-patients or out-patients. Beneficial effects can last up to 12months after termination of the study program. The interest of these interventions is preventive if the subject never entered in a violent register or curative in case of a personal history of violence. This type of care can be considered from a symptomatic point of view by limiting downstream the heavy consequences of such acts, but also etiologically by acting on one of the causes of violent behavior. Compliance with the eligibility criteria, carrying out a prior functional analysis and confirmation of the major impulsive part of the patient's violence are prerequisites for the use of these programs. Similarly, the early introduction of such therapies, their repetition over time and the integration of the patient into a comprehensive process of psychosocial rehabilitation will ensure the best chance of success.

CONCLUSIONS

Some cognitive impairments appear to have their place in the genesis, progression and maintenance of violent acts of individuals with schizophrenia. Their management thus opens new therapeutic perspectives such as cognitive remediation, still rarely used in this aim, to complement the action of the traditional care tools. However, further therapeutic trials are needed before considering cognitive remediation and social cognitive training as central care modalities in the therapeutic control of violence in schizophrenia.

Treatment Modifications and Suggestions to Address Visual Abnormalities in Body Dysmorphic Disorder

Recent psychophysical and neurocognitive findings implicate abnormal visual processing for a range of stimuli in body dysmorphic disorder (BDD); such abnormalities differentiate BDD from other mental health disorders. Current treatments most commonly involve cognitive behavior therapy with or without accompanying antidepressant medications. These are moderately successful yet appear to overlook the core phenomenological aspect of abnormal perception in BDD. The following text summarizes the current literature of perceptual abnormalities within BDD and how these findings may be applied and incorporated into treatment options. Possible modifications of cognitive behavioral therapy (CBT) based on the widespread visual abnormalities within BDD include making perceptual mirror retraining a compulsory component of therapy and implementing self-exposure tasks within exposure and response prevention. Alternative options such as a visual training program to remediate visual abnormalities across a range of visual stimuli are also explored, which may be included as an adjunctive treatment alongside CBT.