Schizophrenia and serious violence: a clinical-profile analysis incorporating impulsivity and substance-use disorders

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.

Candidate symptomatic markers for predicting violence in schizophrenia: A cross-sectional study of 7711 patients in a Chinese population

OBJECTIVE

Violent behaviour is an alarming problem among schizophrenia patients. The effects of historical, clinical, and pathological risk factors for violence have been investigated by multiple studies, but consensus has not been achieved. As psychotic symptoms are more direct and intuitive indicators for violence, identifying robustly associated symptoms is a crucial part of the future prediction and precise management of violent patients in clinics. This study aims to identify the psychotic symptoms correlated with violence among schizophrenia patients in a Chinese population.

METHODS

In this cross-sectional study, the medical records of 7711 schizophrenia patients (4711 in the discovery set and 3000 in the validation set) were collected from 1998 to 2010. Their psychotic symptoms were extracted, and the patients were divided into violent and non-violent groups. Multivariate logistic analysis was applied to identify symptoms associated with violence in the discovery set.

RESULTS

Eight psychotic symptoms were found to be significantly correlated with violence in schizophrenia. "Destruction of property", "verbal aggression" and "insomnia" increased the risk of violence, while "flat affect", "delusion of persecution", "auditory hallucination", "vagueness of thought" and "poverty of thought" decreased the risk of violence. The regression model was evaluated by receiver operating characteristic (ROC) analysis for its discriminatory performance, achieving area under curve (AUC) values of 0.887 in the discovery sample set and 0.824 in the validation sample set.

CONCLUSIONS

The correlated symptoms identified by this study can serve as future candidate predictors for violence in schizophrenia, paving the way for precise management of schizophrenia patients in clinics.

One-year randomized trial comparing virtual reality-assisted therapy to cognitive-behavioral therapy for patients with treatment-resistant schizophrenia

The gold-standard cognitive-behavioral therapy (CBT) for psychosis offers at best modest effects. With advances in technology, virtual reality (VR) therapies for auditory verbal hallucinations (AVH), such as AVATAR therapy (AT) and VR-assisted therapy (VRT), are amid a new wave of relational approaches that may heighten effects. Prior trials have shown greater effects of these therapies on AVH up to a 24-week follow-up. However, no trial has compared them to a recommended active treatment with a 1-year follow-up. We performed a pilot randomized comparative trial evaluating the short- and long-term efficacy of VRT over CBT for patients with treatment-resistant schizophrenia. Patients were randomized to VRT (n = 37) or CBT (n = 37). Clinical assessments were administered before and after each intervention and at follow-up periods up to 12 months. Between and within-group changes in psychiatric symptoms were assessed using linear mixed-effects models. Short-term findings showed that both interventions produced significant improvements in AVH severity and depressive symptoms. Although results did not show a statistically significant superiority of VRT over CBT for AVH, VRT did achieve larger effects particularly on overall AVH (d = 1.080 for VRT and d = 0.555 for CBT). Furthermore, results suggested a superiority of VRT over CBT on affective symptoms. VRT also showed significant results on persecutory beliefs and quality of life. Effects were maintained up to the 1-year follow-up. VRT highlights the future of patient-tailored approaches that may show benefits over generic CBT for voices. A fully powered single-blind randomized controlled trial comparing VRT to CBT is underway.

Exploring the Benefits of Virtual Reality-Assisted Therapy Following Cognitive-Behavioral Therapy for Auditory Hallucinations in Patients with Treatment-Resistant Schizophrenia: A Proof of Concept

BACKGROUND

Combining cognitive behavioral therapy (CBT) for psychosis with another psychosocial intervention comprising virtual reality (VR)-assisted therapy (VRT) may improve targeted outcomes in treatment-resistant schizophrenia patients.

METHODS

Ten participants having followed CBT were part of our comparative clinical trial comparing VRT to CBT and were selected at the end of the study as they desired to continue to achieve improvements with VRT (CBT + VRT). Clinical assessments were administered before/after treatments and at follow-ups. Changes in outcomes were examined using linear mixed-effects models. To gain a more in depth understanding on CBT + VRT, therapists' notes, and open interviews on a sub-group of patients were qualitatively analyzed.

RESULTS

Findings showed that the sequence of both interventions was appreciated by all patients. Several significant improvements were found throughout time points on auditory verbal hallucinations, beliefs about voices, depressive symptoms, symptoms of schizophrenia and quality of life. Although most of these improvements were in similar range to those observed in our comparative trial, effects of CBT + VRT on depressive symptoms and symptoms of schizophrenia were larger than those found for either intervention alone.

CONCLUSION

This proof of concept is the first to merge gold-standard CBT with VRT for treatment refractory voices and to suggest a certain synergistic effect.

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.

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

Background

Violent behaviour (VB) occurs in first episode of schizophrenia and can have devastating impact both on victims and patients themselves. A better knowledge of the underlying mechanisms of VB may pave the way to preventive treatments.

Objectives

1) To explore the nature of the link between impulsivity and VB in early psychosis (EP) patients; 2) To explore the interactions between impulsivity and substance abuse, insight, and positive symptoms, the main dynamic risk factors of VB described to date.

Design and methods

Post hoc analysis of data acquired in the frame of a 36-months EP cohort study. A total of 265 EP patients, aged 18 to 35, treated at TIPP (Treatment and early Intervention in Psychosis Program), at the Department of Psychiatry in Lausanne, Switzerland, were included in the study. Logistic regression analyzes were performed as well as mediation analysis and interaction analysis

Results

Our data suggest that impulsivity is a predictor of VB when analyzed independently and as part of a multi-factorial model. Impulsivity continues to differentiate violent patients from non-violent ones at the end of the program. In addition, the relationship between impulsivity and VB is not mediated by substance abuse. Finally, the effect of impulsivity on the probability of VB is potentiated by the interaction of different levels of insight and positive symptoms.

Conclusions

Early intervention strategies in psychotic disorders should include evaluation of impulsivity considering it is linked to increased risk of VB and may respond to treatment.

Temperament and character in homicidal patients with schizophrenia

Background: Understanding the etiology of violence in patients with schizophrenia is an issue of great clinical and public importance. Although personality traits are an important aspect in determining complex behaviors of schizophrenia patients, there is a lack of research on the relationship between personality traits and violence, especially homicidal behavior, in this population. Aim: We aimed to compare temperament and character dimensions between homicidal and other mostly violent forensic patients with schizophrenia, and to determine which temperament and character dimensions are associated with homicidal behavior in these patients. Methods: We recruited 71 male forensic schizophrenia patients without concomitant substance dependence and antisocial personality disorder. The patients were divided into two groups according to trial documentation as: (1) Homicide and attempted homicide group (N 30; 42%), and (2) Other offenses group (N 41; 58%). Patients were assessed by means of the Temperament and Character Inventory and the Positive and Negative Syndrome Scale. Differences between groups were tested with t-test. Results: The two groups of patients were similar in their PANSS scores, but the homicidal men were significantly more likely to show higher harm avoidance (HA) scores than the less violent comparison men (t = 2,876, df-69, p = 0.005). Conclusions: Our results indicate that forensic schizophrenic patients with higher HA scores would show a greater risk of homicidal violence. Improved understanding of personality traits associated with such behavior is needed in order to prevent homicidal behavior. Importance of these results suggests that further study is needed.

Factors influencing decisions of mental health professionals to release service users from seclusion: A qualitative study

AIM

This study aims to explore and understand factors influencing the decisions of mental health professionals releasing service users from seclusion.

BACKGROUND

Seclusion should only be used as a last resort and for the minimum possible duration. Current evidence outlines which service users are more likely to be secluded, why and what influences professionals' decision to seclude. Little is known about factors professionals consider when releasing service users.

DESIGN

A qualitative study was undertaken to explore factors which influence decision-making of mental health professionals when terminating episodes of seclusion.

METHODS

Semi-structured face-to-face interviews with 21 professionals were undertaken between May 2017-January 2018. Framework analysis was used to systematically manage, analyse, and identify themes, while maintaining links to primary data and providing a transparent audit trail.

RESULTS

Six themes were identified where professionals looked for service users to demonstrate cooperation and compliance before they would be released. Decisions were subjective, being influenced by the experience and composition of the review team, the availability of resources plus the emotional tone and physical environment of the ward. Release could be delayed by policy and protocol.

CONCLUSION

Professionals should have greater awareness of factors that hinder or facilitate decisions to release service from seclusion and an understanding of how service user views and involves in decisions regarding seclusion should be explored.

IMPACT

Senior staff should be available to facilitate release at the earliest opportunity. Staff should ensure that policy and procedures do not prolong the time service users remain secluded.

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.

[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.

Comparative study of aggression - Dangerousness on patients with paranoid schizophrenia: Focus on demographic data, PANSS, drug use and aggressiveness

This cross sectional study aimed to compare the differences in psychopathology of Greek homicide and homicide attempters, patients with schizophrenia, with non violent individuals, suffering from schizophrenia. The study compared three Groups of 220 men, diagnosed with schizophrenia: (a) Group Α (Schizophrenia - No violence, (b) Group Β (Schizophrenia - with violence or violent crime), (c) Group C (Schizophrenia - not guilty by reason of insanity - violent crime). Several psychometric tools were used, such as M.I.N·I (Mini-International Neuropsychiatric Interview), PANSS scale (Positive and Negative Symptoms Scale). Most subjects suffered from paranoid schizophrenia. On factors such as demographic characteristics (i.e. current occupational status, living status), statistically significant findings were shown for Groups B and C vs Group A. Predisposing psychosocial factors, such as family conflicts and aggressiveness against family, were found to be statistically significant in differentiating violent versus nonviolent individuals with psychosis. They differed significantly in factors like history of juvenile delinquency, but also in the type of aggressiveness in general. These differences were confirmed on PANSS scale. In conclusion, the longer the history of aggressiveness is presented, the greater the chances are of individuals falling into Group C and it is possible to spend several years from the onset of the disease until the moment of crime.

Comparison of long-acting and oral antipsychotic treatment effects in patients with schizophrenia, comorbid substance abuse, and a history of recent incarceration: An exploratory analysis of the PRIDE study

INTRODUCTION

Comorbid substance abuse is known to blunt response to treatment for underlying psychiatric disorders, but it has not been investigated in schizophrenia when comparing the effects of long-acting injectable antipsychotics with those of oral antipsychotics.

METHODS

This exploratory analysis compared once-monthly paliperidone palmitate (PP1M) with daily oral antipsychotics on time to treatment failure in patients with schizophrenia and a history of incarceration. Subjects were stratified into substance abuse (reported substance or alcohol misuse in the past 30days on the baseline Addiction Severity Index-Lite Version and/or met criteria for a current MINI diagnosis of a substance abuse disorder) and nonabuse cohorts.

RESULTS

In the substance abuse cohort, treatment failure was observed in 56.2% (73/130) and 64.2% (86/134) of subjects in the PP1M and oral antipsychotic groups, respectively. For the nonabuse cohort, treatment failure was observed in 36.5% (35/96) and 53.6% (45/84) of subjects in the PP1M and oral antipsychotic groups, respectively. Median (95% confidence interval [CI]) time to first treatment failure was 291 (179-428) days and 186 (94-296) days in the PP1M and oral antipsychotic groups, respectively. Median (95% CI) time to first treatment failure was >450 and 284 (147 to >450) days in the respective treatment groups.

CONCLUSION

Greater treatment effects were evident with PP1M compared with oral antipsychotics in both cohorts. The observed beneficial effect of PP1M was attenuated in the substance-abuse cohort, further reinforcing both the need for and value of continued research to optimize patient care in these complex patient populations.

Distinct pathological profiles of inmates showcasing cluster B personality traits, mental disorders and substance use regarding violent behaviors

High rates of violence are found amid offenders with severe mental illnesses (SMI), substance use disorders (SUDs) and Cluster B personality disorders. Elevated rates of comorbidity lead to inconsistencies when it comes to this relationship. Furthermore, overlapping Cluster B personality traits have been associated with violence. Using multiple correspondence analysis and cluster analysis, this study was designed to differentiate profiles of 728 male inmates from penitentiary and psychiatric settings marked by personality traits, SMI and SUDs following different violent patterns. Six significantly differing clusters emerged. Cluster 1, "Sensation seekers", presented recklessness with SUDs and low prevalence's of SMI and auto-aggression. Two clusters committed more sexual offenses. While Cluster 2, "Opportunistic-sexual offenders", had more antisocial lifestyles and SUDs, Cluster 6, "Emotional-sexual offenders", displayed more emotional disturbances with SMI and violence. Clusters 3 and 4, representing "Life-course-persistent offenders", shared early signs of persistent antisocial conduct and severe violence. Cluster 3, "Early-onset violent delinquents", emerged as more severely antisocial with SUDs. Cluster 4, "Early-onset unstable-mentally ill delinquents", were more emotionally driven, with SMI and auto-aggression. Cluster 5, "Late-start offenders", was less severely violent, and emotionally driven with antisocial behavior beginning later. This study suggests the presence of specific psychopathological organizations in violent inmates.

[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.

Predictors of criminal justice system trajectories of homeless adults living with mental illness

OBJECTIVES

This study examines whether baseline profiles of criminal justice involvement are independently associated with 24-month trajectories of arrests in a sample of homeless adults living with mental illness.

METHODS

Interviews with justice-involved participants from the At Home/Chez soi project, a multisite trial of Housing First in Canada, yielded information related to arrests, as well as demographic, clinical, and contextual predictors of criminal justice system involvement. All potential predictors were entered into logistic and negative binomial regression models to assess their effect on re-arrest.

RESULTS

Of the 584 individuals involved with the criminal justice system at baseline, and for whom follow-up data was obtained, 347 (59%) were re-arrested within two years. Of those, 283 (82%) had an episodic pattern of re-arrest and 64 (18%) had a continuous trajectory of re-arrest. Results indicate that participants involved with the legal system for minor (mostly theft and public order) offenses at baseline were most likely to be repeatedly arrested. Gender, Aboriginal status, and recent victimization were also independently associated with re-arrest.

CONCLUSIONS

These findings have implications for the delivery of police and clinical services alike, as well as for policies that aim to divert vulnerable individuals who commit minor crimes from a long-term trajectory of justice involvement.

Neonatal handling causes impulsive behavior and decreased pharmacological response to methylphenidate in male adult wistar rats

Neonatal handling has an impact on adult behavior of experimental animals and is associated with rapid and increased palatable food ingestion, impaired behavioral flexibility, and fearless behavior to novel environments. These symptoms are characteristic features of impulsive trait, being controlled by the medial prefrontal cortex (mPFC). Impulsive behavior is a key component of many psychiatric disorders such as attention deficit hyperactivity disorder (ADHD), manic behavior, and schizophrenia. Others have reported a methylphenidate (MPH)-induced enhancement of mPFC functioning and improvements in behavioral core symptoms of ADHD patients. The aims of the present study were: (i) to find in vivo evidence for an association between neonatal handling and the development of impulsive behavior in adult Wistar rats and (ii) to test whether neonatal handling could have an impact on monoamine levels in the mPFC and the pharmacological response to MPH in vivo. Therefore, experimental animals (litters) were classified as: "non-handled" and "handled" (10[Formula: see text]min/day, postnatal days 1-10). After puberty, they were exposed to either a larger and delayed or smaller and immediate reward (tolerance to delay of reward task). Acute MPH (3[Formula: see text]mg/Kg. i.p.) was used to suppress and/or regulate impulsive behavior. Our results show that only neonatally handled male adult Wistar rats exhibit impulsive behavior with no significant differences in monoamine levels in the medial prefrontal cortex, together with a decreased response to MPH. On this basis, we postulate that early life interventions may have long-term effects on inhibitory control mechanisms and affect the later response to pharmacological agents during adulthood.

Schizophrénie et violence : données actuelles et controverse

L’association entre schizophrénie et violence a longtemps été controversée, mais les données issues des études les plus récentes établissent un lien clair entre schizophrénie et risque de violence. Néanmoins, tous les patients schizophrènes ne présentent pas un risque égal de passage à l’acte violent. Différents facteurs de risque ont ainsi pu être identifiés, tels l’intensité de la symptomatologie psychotique, l’impulsivité ou les comorbidités addictives. Récemment, différents auteurs ont émis l’hypothèse de différents sous-groupes de patients schizophrènes à risque de comportements violents : la majorité des actes commis par les patients schizophrènes représenteraient des gestes de violence mineure alors que les actes de violence majeure ne seraient commis que par une faible proportion de ces patients. Pour l’ensemble de ces patients, des difficultés persistent dans l’établissement de leur responsabilité pénale. Le code pénal français prévoit l’irresponsabilité pénale pour les personnes atteintes, au moment des faits, d’un trouble psychique ou neuropsychique ayant aboli leur discernement ou le contrôle de leurs actes. Pour autant, la reconnaissance de la responsabilité pénale des personnes atteintes de troubles mentaux semble en augmentation, augmentant ainsi le nombre de patients schizophrènes en détention. Une première partie aura pour objectif d’approfondir l’étude des facteurs de risque des comportements violents, en intégrant l’hétérogénéité des gestes de violence, à partir d’une étude descriptive de patients schizophrènes incarcérés. Une attention particulière sera portée sur les liens existant entre troubles de la familiarité et passages à l’acte violents. Une deuxième partie s’intéressera aux facteurs neurobiologiques des comportements violents des patients schizophrènes, grâce à l’étude du lien entre impulsivité et violence en imagerie par résonance magnétique fonctionnelle (IRMf). Enfin, une troisième partie abordera la question de la responsabilité de ces patients souffrant de troubles mentaux et présentant des comportements violents, et s’intéressera notamment aux nouvelles techniques d’approches expertales de la responsabilité.

Clinical profiles of stigma experiences, self-esteem and social relationships among people with schizophrenia, depressive, and bipolar disorders

Some mental illnesses and certain mental health care environments can be severely stigmatizing, which seems to be related to decreased self-esteem and a deterioration of the quality of social relationships for people with mental illness. This study aims to identify clinical profiles characterized by clinical diagnoses more strongly associated with the treatment settings and related to internalized stigma, self-esteem and satisfaction with social relationships. It also aimed to analyze associations between clinical profiles and socio-demographic indicators. Multiple correspondence analysis and cluster analysis were performed on a sample of 261 individuals with schizophrenia and mood disorders, from hospital-based and community-based facilities. MCA showed four distinct clinical profiles allowing a differentiation among levels of: internalized stigma, social relationship satisfaction and self-esteem. Overall, results revealed that internalized stigma remains a pervasive problem for some people with schizophrenia and mood disorders. Particularly, internalized stigma and social relationships dissatisfaction and associated socio-demographic indicators appear to be a risk factor for social isolation for individuals with schizophrenia, which may worsen the course of the disorder. Our findings highlight the importance to develop structured interventions aimed to reduce internalized stigma, and exclusion of those who suffer the loss of their social roles and networks.

Psychose et toxicomanie : le cimetière des évidences

L’objectif de cet article est d’évaluer la qualité des évidences produites par les 25 méta-analyses publiées dans le domaine de la comorbidité entre la psychose et la toxicomanie. L’évidence suggère que le cannabis serait un facteur de risque dans le développement de la psychose. Cette relation est toutefois faible, et ses implications demeurent équivoques. La prévalence de la consommation de tabac, d’alcool et de cannabis est élevée dans la psychose, mais elle semble surestimée, puisqu’inférée à partir d’études cliniques et non pas populationnelles. La toxicomanie est associée à une exacerbation des symptômes positifs et dépressifs de la schizophrénie, mais cette observation est basée sur des études transversales, et non pas longitudinales. Une forte association existe entre la toxicomanie et la violence dans la psychose, mais celle-ci n’est pas pondérée en fonction de divers facteurs confondants. Les effets de la toxicomanie sur la cognition dans la schizophrénie sont hétérogènes. Le bupropion et la varénicline augmentent les taux de cessation tabagique dans la schizophrénie, mais cette observation est basée sur un petit nombre d’études. Enfin, les traitements intégrés ne semblent pas supérieurs aux traitements habituels offerts à cette population comorbide. Le champ de la comorbidité demeure certainement un immense défi pour la médecine fondée sur les évidences.

Unique aspects of impulsive traits in substance use and overeating: specific contributions of common assessments of impulsivity

Abstract Background: Impulsivity is a complex trait often studied in substance abuse and overeating disorders, but the exact nature of impulsivity traits and their contribution to these disorders are still debated. Thus, understanding how to measure impulsivity is essential for comprehending addictive behaviors.

OBJECTIVES

Identify unique impulsivity traits specific to substance use and overeating.

METHODS

Impulsive Sensation Seeking (ImpSS) and Barratt's Impulsivity scales (BIS) Scales were analyzed with a non-parametric factor analytic technique (discriminant correspondence analysis) to identify group-specific traits on 297 individuals from five groups: Marijuana (n = 88), Nicotine (n = 82), Overeaters (n = 27), Marijuauna + Nicotine (n = 63), and CONTROLs (n = 37).

RESULTS

A significant overall factor structure revealed three components of impulsivity that explained respectively 50.19% (pperm < 0.0005), 24.18% (pperm < 0.0005), and 15.98% (pperm < 0.0005) of the variance. All groups were significantly different from one another. When analyzed together, the BIS and ImpSS produce a multi-factorial structure that identified the impulsivity traits specific to these groups. The group specific traits are (1) CONTROL: low impulse, avoids thrill-seeking behaviors; (2) Marijuana: seeks mild sensation, is focused and attentive; (3) Marijuana + Nicotine: pursues thrill-seeking, lacks focus and attention; (4) Nicotine: lacks focus and planning; (5) Overeating: lacks focus, but plans (short and long term).

CONCLUSIONS

Our results reveal impulsivity traits specific to each group. This may provide better criteria to define spectrums and trajectories - instead of categories - of symptoms for substance use and eating disorders. Defining symptomatic spectrums could be an important step forward in diagnostic strategies.

Male inmate profiles and their biological correlates

OBJECTIVE

Borderline and antisocial personality disorders (PDs) share common clinical features (impulsivity, aggressiveness, substance use disorders [SUDs], and suicidal behaviours) that are greatly overrepresented in prison populations. These disorders have been associated biologically with testosterone and cortisol levels. However, the associations are ambiguous and the subject of controversy, perhaps because these heterogeneous disorders have been addressed as unitary constructs. A consideration of profiles of people, rather than of exclusive diagnoses, might yield clearer relationships.

METHODS

In our study, multiple correspondence analysis and cluster analysis were employed to identify subgroups among 545 newly convicted inmates. The groups were then compared in terms of clinical features and biological markers, including levels of cortisol, testosterone, estradiol, progesterone, and sulfoconjugated dehydroepiandrosterone (DHEA-S).

RESULTS

Four clusters with differing psychiatric, criminal, and biological profiles emerged. Clinically, one group had intermediate scores for each of the tested clinical features. Another group comprised people with little comorbidity. Two others displayed severe impulsivity, PD, and SUD. Biologically, cortisol levels were lowest in the last 2 groups and highest in the group with less comorbidity. In keeping with previous findings reported in the literature, testosterone was higher in a younger population with severe psychiatric symptoms. However, some apparently comparable behavioural outcomes were found to be related to distinct biological profiles. No differences were observed for estradiol, progesterone, or DHEA-S levels.

CONCLUSIONS

The results not only confirm the importance of biological markers in the study of personality features but also demonstrate the need to consider the role of comorbidities and steroid coregulation.

Neurocognitive vulnerability: suicidal and homicidal behaviours in patients with schizophrenia

OBJECTIVE

Schizophrenia is associated with an increase in the risk of both homicide and suicide. The objectives of this study were to systematically review all published articles that examined the relation between neurocognitive deficits and suicidal or homicidal behaviours in schizophrenia, and to identify vulnerabilities in suicidal and homicidal behaviour that may share a common pathway in schizophrenia.

METHODS

A systematic review of the literature was performed using MEDLINE to include all studies published up to August 31, 2012.

RESULTS

Among the 1760 studies, 7 neuropsychological and 12 brain imaging studies met the selection criteria and were included in the final analysis. The neuropsychological and functional neuroimaging studies were inconclusive. The structural imaging studies reported various alterations in patients with schizophrenia and a history of homicidal behaviour, including: reduced inferior frontal and temporal cortices, increased mediodorsal white matter, and increased amygdala volumes. Patients with a history of suicidal acts showed volumetric reductions in left orbitofrontal and superior temporal cortices, while right amygdala volume was increased, though, these findings have rarely been replicated. Finally, no study has directly compared neurocognitive markers of suicidal and homicidal risk.

CONCLUSION

These results suggest that brain alterations, in addition to those associated with schizophrenia, may predispose some patients to a higher risk of homicide or suicide in particular circumstances. Moreover, some of these alterations may be shared between homicidal and suicidal patients. However, owing to several limitations, including the small number of available studies, no firm conclusions can be drawn and further investigations are necessary.

Comorbidity of schizotypy and psychopathy: skin conductance to affective pictures

Prior research indicates a relationship between psychopathy and schizophrenia, elucidating a specific trajectory toward violence. Recent research has suggested that this relationship exists at the nonclinical trait level of schizotypy; however, this finding has not been examined objectively. To explore this relationship using both subjective and objective measures, 54 undergraduates (50% male; mean age 20.41) who endorsed a wide range of schizotypy on the Schizotypal Personality Questionnaire (SPQ) completed a laboratory-based protocol. Participants viewed 15 pictures (five neutral, five threatening, and five of others in distress) from the International Affective Pictures System while electrodermal activity was recorded. As expected, all participants exhibited increased skin conductance levels (SCL) to threat and distress pictures compared to neutral pictures; however, no difference in SCL was found between threat and distress pictures. A unique relationship between psychopathy and schizotypy was found (i.e., schizotypy was related to higher Self-Centered Impulsivity and lower Fearless Dominance); however, schizotypy was related to increased SCL in response to emotional and neutral pictures. Although results do not support autonomic hyporesponsiveness often found in clinical psychopathy, a positive relationship was found between schizotypy and self-reported physical aggression. Findings highlight the need to examine other trajectories of violence within the schizophrenia spectrum disorders.

Reflection impulsivity and response inhibition in first-episode psychosis: relationship to cannabis use

BACKGROUND

People with psychosis demonstrate impaired response inhibition on the Stop Signal Task (SST). It is less clear if this impairment extends to reflection impulsivity, a form of impulsivity that has been linked to substance use in non-psychotic samples.

METHOD

We compared 49 patients with first-episode psychosis (FEP) and 30 healthy control participants on two forms of impulsivity measured using the Information Sampling Test (IST) and the SST, along with clinical and IQ assessments. We also compared those patients who used cannabis with those who had either given up or never used.

RESULTS

Patients with FEP had significantly greater impairment in response inhibition but not in reflection impulsivity compared with healthy controls. By contrast, patients who reported current cannabis use demonstrated greater reflection impulsivity than those that had either given up or never used, whereas there were no differences in response inhibition.

CONCLUSIONS

These data suggest that abnormal reflection impulsivity is associated with substance use in psychosis but not psychosis itself ; the opposite relationship may hold for response inhibition.

[Homicide, schizophrenia and substance abuse: a complex interaction]

BACKGROUND AND AIM

The prevalence of homicide perpetrators with a diagnosis of schizophrenia is 6% in Western countries populations. The relationship between schizophrenia and homicide is complex and cannot be reduced to a simple causal link. The aim of this systematic review was to clarify the role of substance abuse in the commission of murder in people suffering from schizophrenia.

METHODS

A systematic English-French Medline and EMBASE literature search of cohort studies, case-control studies and transversal studies published between January 2001 and December 2011 was performed, combining the MeSH terms "schizophrenia", "psychotic disorders", "homicide", "violence", "substance use disorder", and the TIAB term "alcohol". Abstract selection was based on the STROBE and PRISMA checklist for observational studies and systematic and meta-analysis studies, respectively.

RESULTS

Of the 471 selected studies, eight prospective studies and six systematic reviews and meta-analysis studies met the selection criteria and were included in the final analysis. Homicide committed by a schizophrenic person is associated with socio-demographic (young age, male gender, low socioeconomic status), historical (history of violence against others), contextual (a stressful event in the year prior to the homicide), and clinical risk factors (severe psychotic symptoms, long duration of untreated psychosis, poor adherence to medication). In comparison to the general population, the risk of homicide is increased 8-fold in schizophrenics with a substance abuse disorder (mainly alcohol abuse) and 2-fold in schizophrenics without any comorbidities. A co-diagnosis of substance abuse allows us to divide the violent schizophrenics into "early-starters" and "late-starters" according to the age of onset of their antisocial and violent behavior. The violence of the "early-starters" is unplanned, usually affects an acquaintance and is not necessarily associated with the schizophrenic symptoms. Substance abuse is frequent and plays an important role in the homicide commission. In addition, the risk of reoffending is high. In the "late-starters", the violence is linked to the psychotic symptoms and is directed to a member of the family. The reoffence risk is low and it depends on the pursuit of care or not.

CONCLUSION

Defining subgroups of violent schizophrenic patients would avoid stigmatization and would help to prevent the risk of homicide by offering a multidisciplinary care which would take into account any substance abuse.