Angry affect and violence in the context of a psychotic illness: a systematic review and meta-analysis of the literature

The ethics of coercion in mental healthcare: the role of structural racism

In mental health ethics, it is generally assumed that coercive measures are sometimes justified when persons with mental illness endanger themselves or others. Coercive measures are regarded as ethically justified only when certain criteria are fulfilled: for example, the intervention must be proportional in relation to the potential harm. In this paper, we demonstrate shortcomings of this established ethical framework in cases where people with mental illness experience structural racism. By drawing on a case example from mental healthcare, we first demonstrate that biases in assessing whether the coercive intervention is proportional are likely, for example, due to an overestimation of dangerousness. We then show that even if proportionality is assessed correctly, and the specific coercive intervention would thus be regarded as ethically justified according to the standard framework, coercion may still be ethically problematic. This is because the standard framework does not consider how situations in which coercive measures are applied arise. If structural racism causally contributes to such situations, the use of coercion can compound the prior injustice of racist discrimination. We conclude that the ethical analysis of coercion in mental healthcare should consider the possibility of discriminatory biases and practices and systematically take the influence of structural discrimination into account.

Dysconnectivity between the anterior insula and the dorsal anterior cingulate cortex during an emotion go/nogo paradigm is associated with aggressive behaviors in male schizophrenia patients

This study aimed to investigate the association between past-reported violent/aggressive behaviors and brain functional connectivity in male patients suffering from schizophrenia using a task modeling the interaction between negative emotion processing and response inhibition. Forty-four male patients with schizophrenia and twenty-two healthy male controls performed an emotional go/no-go task using angry and neutral faces during a functional magnetic resonance imaging session. Generalized psycho-physiological interaction was conducted to explore task-based functional connectivity and a negative binomial regression was used to evaluate the relationship between neural alterations and violent/aggressive behaviors. Regions involved in response inhibition and emotion regulation, such as the anterior insula, dorsal anterior cingulate cortex (dACC) and dorsolateral prefrontal cortex (DLPFC), were used as seed regions. During emotion-related response inhibition, patients with schizophrenia displayed altered connectivity between the anterior insula and amygdala, the DLPFC and lateral orbitofrontal cortex (OFC), as well as the anterior insula and the dACC when compared to healthy individuals. The latter was negatively associated with aggressive behaviors in participants with schizophrenia (Wald χ² = 9.51; p < 0.05, p-FDR corrected). Our results highlight alterations in functional connectivity in brain regions involved in cognitive control and emotion processing which are associated with aggressive behaviors in schizophrenia.

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.

The Relationship Between the Big Five Personality Factors, Anger-hostility, and Alcohol and Violence in Men and Women: A Nationally Representative Cohort of 15,701 Young Adults

Alcohol consumption is known to have a disinhibiting effect and is associated with a higher likelihood of aggressive behavior, especially among men. People with certain personality traits maybe more likely to behave aggressively when intoxicated, and there may also be variation by gender. We aimed to investigate whether the reason why men and women with certain personality traits are more likely to engage in violence may be because of their alcohol use.The Big Five personality traits and anger-hostility, alcohol consumption, and violence were measured by questionnaire in 15,701 nationally representative participants in the United States. We tested the extent to which alcohol mediates the relationship between personality factors and violence in men and women.We found that agreeableness was inversely associated with violence in both genders. Alcohol mediated approximately 11% of the effect in males, but there was no evidence of an effect in females. Anger-hostility was associated with violence in both sexes, but alcohol mediated the effect only in males. We also found that Extraversion was associated with violence and alcohol use in males and females. Alcohol accounted for 15% of the effect of extraversion on violence in males and 29% in females.The mechanism by which personality traits relate to violence may be different in men and women. Agreeableness and anger-hostility underpin the relationship between alcohol and violence in men, but not in women. Reducing alcohol consumption in men with disagreeable and angry/hostile traits would have a small but significant effect in reducing violence, whereas in women, reducing alcohol consumption among the extraverted, would have a greater effect.

Using citation network analysis to enhance scholarship in psychological science: A case study of the human aggression literature

Researchers cannot keep up with the volume of articles being published each year. In order to develop adequate expertise in a given field of study, students and early career scientists must be strategic in what they decide to read. Here we propose using citation network analysis to characterize the literature topology of a given area. We used the human aggression literature as our example. Our citation network analysis identified 15 research communities on aggression. The five largest communities were: “media and video games”, “stress, traits and aggression”, “rumination and displaced aggression”, “role of testosterone”, and “social aggression”. We examined the growth of these research communities over time, and we used graph theoretic approaches to identify the most influential papers within each community and the “bridging” articles that linked distinct communities to one another. Finally, we also examined whether our citation network analysis would help mitigate gender bias relative to focusing on total citation counts. The percentage of articles with women first authors doubled when identifying influential articles by community structure versus citation count. Our approach of characterizing literature topologies using citation network analysis may provide a valuable resource for psychological scientists by outlining research communities and their growth over time, identifying influential papers within each community (including bridging papers), and providing opportunities to increase gender equity in the field.

Anger rumination and imagined violence as related to violent behavior before and after psychiatric hospitalization

OBJECTIVE

Anger rumination and imagined violence, in the context of anger/aggression proclivity, are examined for their direct and conjoint associations with violent behavior by psychiatric patients.

METHOD

A secondary analysis of data from the MacArthur Violence Risk Study was conducted with 1136 acute civil commitment patients, assessed during hospitalization and after hospital discharge. Anger/aggression proclivity was assessed with the Brief Psychiatric Rating Scale hostility subscale, anger rumination was indexed using items from the Novaco Anger Scale, and imagined violence was measured with Grisso's Schedule of Imagined Violence. Violence, prehospitalization and posthospitalization, was indexed by the MacArthur project measure.

RESULTS

Correlational analyses, mediation analyses, and moderated mediation analyses were conducted. Anger rumination significantly predicted pre- and posthospitalization violence, when controlling for age, sex, race, childhood physical abuse, and anger/aggression proclivity; and it partially mediated the relation between anger/aggression proclivity and violence. Imagined violence and anger rumination were highly inter-related. When imagined violence was added to the regression model, it was a significant predictor of prehospitalization violence; however, it did not moderate the association of anger rumination with pre- or posthospitalization violence.

CONCLUSION

Anger rumination may be a mechanism through which anger activates violent behavior, which has important implications for psychotherapeutic intervention targeting. Future research should investigate the association between anger rumination and imagined violence, with attention given to revenge planning as a link.

Aberrant Functional Connectivity of the Orbitofrontal Cortex Is Associated With Excited Symptoms in First-Episode Drug-Naïve Patients With Schizophrenia

BACKGROUND

Schizophrenia (SZ) is associated with the highest disability rate among serious mental disorders. Excited symptoms are the core symptoms of SZ, which appear in the early stage, followed by other stages of the disease subsequently. These symptoms are destructive and more prone to violent attacks, posing a serious economic burden to the society. Abnormal spontaneous activity in the orbitofrontal cortex had been reported to be associated with excited symptoms in patients with SZ. However, whether the abnormality appears in first-episode drug-naïve patients with SZ has still remained elusive.

METHODS

A total of 56 first-episode drug-naïve patients with SZ and 27 healthy controls underwent resting-state functional magnetic resonance imaging (rs-fMRI) and positive and negative syndrome scale (PANSS). First, differences in fractional amplitude of low-frequency fluctuations (fALFF) between first-episode drug-naïve patients with SZ and healthy controls were examined to identify cerebral regions exhibiting abnormal local spontaneous activity. Based on the fALFF results, the resting-state functional connectivity analysis was performed to determine changes in cerebral regions exhibiting abnormal local spontaneous activity. Finally, the correlation between abnormal functional connectivity and exciting symptoms was analyzed.

RESULTS

Compared with the healthy controls, first-episode drug-naïve patients with SZ showed a significant decrease in intrinsic activity in the bilateral precentral gyrus, bilateral postcentral gyrus, and the left orbitofrontal cortex. In addition, first-episode drug-naïve patients with SZ had significantly reduced functional connectivity values between the left orbitofrontal cortex and several cerebral regions, which were mainly distributed in the bilateral postcentral gyrus, the right middle frontal gyrus, bilateral paracentral lobules, the left precentral gyrus, and the right median cingulate. Further analyses showed that the functional connectivity between the left orbitofrontal cortex and the left postcentral gyrus, as well as bilateral paracentral lobules, was negatively correlated with excited symptoms in first-episode drug-naïve patients with SZ.

CONCLUSION

Our results indicated the important role of the left orbitofrontal cortex in first-episode drug-naïve patients with SZ and suggested that the abnormal spontaneous activity of the orbitofrontal cortex may be valuable to predict the occurrence of excited symptoms. These results may provide a new direction to explore the excited symptoms of SZ.

The Safe pilot study: A prospective naturalistic study with repeated measures design to test the psychosis - violence link in and after discharge from forensic facilities

The research evidence is very strong for high recidivism rates of violence after discharge from forensic facilities. Big data research has found that a substantial proportion of the forensic population with relapse into violence has a psychosis diagnosis and a criminal record. However, more research on the association between psychotic symptoms and violence may inform and enhance risk assessment, prevention, and treatment. We conducted a prospective naturalistic study with a repeated measures design in a sample of 22 psychotic patients during follow-up after discharge from forensic mental health facilities. We had three aims: to test the predictive validity of three psychotic symptom scales for violence, to analyze main and interaction effects between psychotic symptoms and previous criminal conviction, and to explore the feasibility and potential benefit of the repeated measures design for prospective follow-up research. Interpreted within the limitation of the small sample size, the results were promising for all scales, particularly for adjusted effects without interaction. Two scales remained significant when their interaction with criminal conviction was adjusted. This indicates that risk judgment of psychotic patients with criminal conviction can be improved by adding measurement of fluctuations in psychotic symptoms. The repeated measures design was instrumental in this research.

Pathways to aggression and violence in psychosis without longstanding antisocial behavior: A review and proposed psychosocial model for integrative clinical interventions

There is a need for a clearer understanding of the factors associated with increased risk of aggression and violence (AV) among people with psychosis and other severe mental illness (SMI) to guide effective prevention and intervention. The current article (1) reviews the literature regarding psychosocial factors associated with AV among individuals with psychosis and other SMI who do not have longstanding antisocial behaviors, (2) proposes an integrative psychosocial model of AV that can be practically applied, and (3) proposes appropriate evidence-based clinical interventions to reduce AV and facilitate recovery. We propose that increased risk for AV among people with psychosis is driven by anger, which is affected by a range of factors including victimization and situational stressors, social rejection or experiences of discrimination, anxious arousal, and hostile attribution bias related to psychosis. The cumulative effect of these systems is exacerbated by co-occurring substance misuse and increased impulsivity, particularly negative urgency. In consideration of the current psychosocial model and existing evidence-based interventions for AV in individuals with psychosis, we propose that trauma-informed interventions that integrate skills training in emotion regulation, social and interpersonal situations, cognitive restructuring and remediation, and modified prolonged exposure may demonstrate the most promise for this population.

Pylons ablaze: Examining the role of 5G COVID-19 conspiracy beliefs and support for violence

Amid increased acts of violence against telecommunication engineers and property, this pre‐registered study (N = 601 Britons) investigated the association between beliefs in 5G COVID‐19 conspiracy theories and the justification and willingness to use violence. Findings revealed that belief in 5G COVID‐19 conspiracy theories was positively correlated with state anger, which in turn, was associated with a greater justification of real‐life and hypothetical violence in response to an alleged link between 5G mobile technology and COVID‐19, alongside a greater intent to engage in similar behaviours in the future. Moreover, these associations were strongest for those highest in paranoia. Furthermore, we show that these patterns are not specific to 5G conspiratorial beliefs: General conspiracy mentality was positively associated with justification and willingness for general violence, an effect mediated by heightened state anger, especially for those most paranoid in the case of justification of violence. Such research provides novel evidence on why and when conspiracy beliefs may justify the use of violence.

Persistent cannabis use as an independent risk factor for violent behaviors in patients with schizophrenia

Although recent studies have shown a moderately strong association between cannabis use and violence among people with severe mental disorders, the direction of this association has not been investigated prospectively in a population with schizophrenia. Therefore, this study aims to determine, using cross-lag models, whether a temporal relationship between cumulative cannabis use and violence exists in a population with schizophrenia. The authors reported findings covering an 18-month period from a randomized, double-blind clinical trial of antipsychotic medications for schizophrenia treatment. Among the 1460 patients enrolled in the trial, 965 were followed longitudinally. Although persistent cannabis use predicted subsequent violence, violence did not predict cannabis use. The relationship was therefore unidirectional and persisted when controlling for stimulants and alcohol use. Finally, a significant body of evidence suggests a link between persistent cannabis use and violence among people with mental illnesses. Studies to further investigate the mechanisms underlying this association should be conducted.

Violent Behavior Is Associated With Emotion Salience Network Dysconnectivity in Schizophrenia

Background: Despite individuals with schizophrenia being at an elevated risk of violence compared to the general population, limited efforts have been invested in investigating the neurobiological etiology explaining the increase. Among the few studies examining functional disruptions pertaining to violent schizophrenia patients using fMRI, only one study has considered functional connectivity. The current state of knowledge does not allow to infer deficits in functional connectivity specific to distinct cognitive/emotional states that have been associated with the emergence of violence in schizophrenia, such as negative emotion processing. This study sought to identify disrupted connectivity among men with schizophrenia and a history of violence (SCZ+V), compared to men with schizophrenia without a history of violence (SCZ-V) and healthy controls, during negative emotion processing using fMRI. Methods: Twenty SCZ+V, 19 SCZ-V, and 21 healthy men were scanned while viewing negative images. Results: Negative images elicited an increased connectivity between the dorsal anterior cingulate cortex (dACC) and the bilateral rostral prefrontal cortex (rPFC), as well as a decreased functional connectivity between the frontal regions (bilateral rPFC and dACC) and the putamen and hippocampus in SCZ+V men as compared to SCZ-V men and healthy controls. Concurrently, the centrality of the dACC within the network was reduced in SCV+V subjects. Conclusions: These results suggest an inefficient integration of the information by the dACC between frontal and limbic regions in SCZ+V men during negative emotion processing and highlight the importance of the ACC in the neurobiological bases of violent behavior in schizophrenia.

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.

Psychobiological response to an anger induction task in schizophrenia: The key role of anxiety

In this study an anger induction laboratory task was applied to men with schizophrenia, and resulted in significant changes in different psychophysiological parameters that were measured in a pre-post design. We observed a significantly greater self-reported anger mood and negative affection, lower self-reported positive affection, an increase in cardiovascular reactivity (with blood pressure in deeper affection compared to controls), higher salivary testosterone levels, lower salivary cortisol levels, and an increase in right ear items reported in dichotic listening. Furthermore, clinical risk factors related to anger in our patients were analyzed by Stepwise Regression analyses. Trait anger was significantly associated with a higher level of delusional pathology and impulsivity. Regarding the resulted state of anger as an output of the induction, the most relevant finding was that anxiety consistently and significantly predicted the increasing in anger feelings, and, remarkably, it predicted also the increasing in T levels and the cardiovascular reactivity of the patients.

Shifts in positive and negative psychotic symptoms and anger: effects on violence

BACKGROUND

Changes in positive and negative symptom profiles during acute psychotic episodes may be key drivers in the pathway to violence. Acute episodes are often preceded by fluctuations in affect before psychotic symptoms appear and affective symptoms may play a more important role in the pathway than previously recognised.

METHODS

We carried out a prospective cohort study of 409 male and female patients discharged from medium secure services in England and Wales to the community. Measures were taken at baseline (pre-discharge), 6 and 12 months post-discharge using the Positive and Negative Syndrome Scale. Information on violence was obtained using the McArthur Community Violence Instrument and Police National Computer.

RESULTS

The larger the shift in positive symptoms the more likely violence occurred in each 6-month period. However, shifts in angry affect were the main driving factor for positive symptom shifts associated with violence. Shifts in negative symptoms co-occurred with positive and conveyed protective effects, but these were overcome by co-occurring shifts in anger. Severe but stable delusions were independently associated with violence.

CONCLUSIONS

Intensification of angry affect during acute episodes of psychosis indicates the need for interventions to prevent violence and is a key driver of associated positive symptoms in the pathway to violence. Protective effects against violence exerted by negative symptoms are not clinically observable during symptom shifts because they are overcome by co-occurring anger.

Reduced dorsolateral prefrontal cortex activation during affective Go/NoGo in violent schizophrenia patients: An fMRI study

We investigated the influence of anger processing on cognitive control in male schizophrenia patients presenting violent behaviors. We recruited 23 patients without and 24 patients with (SCZ+V) a history of violent behaviors, as well as 22 healthy non-violent men. Participants were administered an affective (angry-neutral faces) Go/NoGo task while undergoing functional magnetic resonance imaging. We found a reduced activation in the dorsolateral prefrontal cortex in SCZ+V patients specifically when inhibiting a response while viewing angry faces. These results show an inability of SCZ+V to recruit a core region of the (inhibitory) cognitive control network in the context of anger.

The Violent Content in Attenuated Psychotic Symptoms

The relationship between psychosis and violence has typically focused on factors likely to predict who will commit violent acts. One unexplored area is violence in the content of subthreshold positive symptoms. The current aim was to conduct an exploratory analysis of violent content in the attenuated psychotic symptoms (APS) of those at clinical high risk of psychosis (CHR) who met criteria for attenuated psychotic symptom syndrome (APSS). The APS of 442 CHR individuals, determined by the Structured Interview for Prodromal Syndromes, were described in comprehensive vignettes. The content of these symptoms were coded using the Content of Attenuated Positive Symptoms Codebook. Other measures included clinical symptoms, functioning, beliefs and trauma. Individuals with violent content had significantly higher APS, greater negative beliefs about the self and others, and increased bullying. The same findings and higher ratings on anxiety symptoms were present when participants with self-directed violence were compared to participants with no violent content. Individuals reporting violent content differ in their clinical presentation compared to those who do not experience violent content. Adverse life events, like bullying, may impact the presence of violent content in APS symptoms. Future studies should explore violent content in relation to actual behavior.

Anterior cingulate hyperactivations during negative emotion processing among men with schizophrenia and a history of violent behavior

BACKGROUND

Evidence suggests a 2.1-4.6 times increase in the risk of violent behavior in schizophrenia compared to the general population. Current theories propose that the processing of negative emotions is defective in violent individuals and that dysfunctions within the neural circuits involved in emotion processing are implicated in violence. Although schizophrenia patients show enhanced sensitivity to negative stimuli, there are only few functional neuroimaging studies that have examined emotion processing among men with schizophrenia and a history of violence.

OBJECTIVE

The present study aimed to identify the brain regions with greater neurofunctional alterations, as detected by functional magnetic resonance imaging during an emotion processing task, of men with schizophrenia who had engaged in violent behavior compared with those who had not.

METHODS

Sixty men were studied; 20 with schizophrenia and a history of violence, 19 with schizophrenia and no violence, and 21 healthy men were scanned while viewing positive, negative, and neutral images.

RESULTS

Negative images elicited hyperactivations in the anterior cingulate cortex (ACC), left and right lingual gyrus, and the left precentral gyrus in violent men with schizophrenia, compared to nonviolent men with schizophrenia and healthy men. Neutral images elicited hyperactivations in the right and left middle occipital gyrus, left lingual gyrus, and the left fusiform gyrus in violent men with schizophrenia, compared to the other two groups.

DISCUSSION

Violent men with schizophrenia displayed specific increases in ACC in response to negative images. Given the role of the ACC in information integration, these results indicate a specific dysfunction in the processing of negative emotions that may trigger violent behavior in men with schizophrenia.

A cross sectional study of prevalence and correlates of current and past risks in schizophrenia

BACKGROUND

The growing burden of chronic often untreated mental illness has increased the importance of risk assessment in people suffering from major mental disorders.

AIMS

The present study was undertaken to obtain prevalence of various risks and predictive factors for self-harm, violence and various other risks among randomly recruited schizophrenia subjects (N=270) on the basis of past history of their disorder.

METHOD

Using a rigorous translation, back translation and acceptability process, a specially constructed semi-structured assessment interview, based on a prior NHS Trust risk assessment interview along with the Diagnostic Interview for Genetic Studies (DIGS), detailed information was obtained for various risks.

RESULTS

Risk of violence (historical) was reported among 65.55%, and risk of self-neglect among 53.33%, risk to others (47.41%), risk of coming to harm (24.07%), self-harm (22.59%), risk from others (11.85%), fire risk (2.96%). Risk of violence (historical) and risk to others was related to 'ever' having emotions related to harm and self-harm, 'current' emotions related to violence and poor compliance to treatment.

CONCLUSION

Regular risk assessment is essential to assess emotions related to violence and non-adherence to treatment. Assessment of risk helps clinicians predict the risks involved in management and in timely intervention.