Is lack of insight associated with physically aggressive behavior among people with schizophrenia living in the community?

Receptor-Independent Therapies for Forensic Detainees with Schizophrenia-Dementia Comorbidity

Forensic institutions throughout the world house patients with severe psychiatric illness and history of criminal violations. Improved medical care, hygiene, psychiatric treatment, and nutrition led to an unmatched longevity in this population, which previously lived, on average, 15 to 20 years shorter than the public at large. On the other hand, longevity has contributed to increased prevalence of age-related diseases, including neurodegenerative disorders, which complicate clinical management, increasing healthcare expenditures. Forensic institutions, originally intended for the treatment of younger individuals, are ill-equipped for the growing number of older offenders. Moreover, as antipsychotic drugs became available in 1950s and 1960s, we are observing the first generation of forensic detainees who have aged on dopamine-blocking agents. Although the consequences of long-term treatment with these agents are unclear, schizophrenia-associated gray matter loss may contribute to the development of early dementia. Taken together, increased lifespan and the subsequent cognitive deficit observed in long-term forensic institutions raise questions and dilemmas unencountered by the previous generations of clinicians. These include: does the presence of neurocognitive dysfunction justify antipsychotic dose reduction or discontinuation despite a lifelong history of schizophrenia and violent behavior? Should neurolipidomic interventions become the standard of care in elderly individuals with lifelong schizophrenia and dementia? Can patients with schizophrenia and dementia meet the Dusky standard to stand trial? Should neurocognitive disorders in the elderly with lifelong schizophrenia be treated differently than age-related neurodegeneration? In this article, we hypothesize that gray matter loss is the core symptom of schizophrenia which leads to dementia. We hypothesize further that strategies to delay or stop gray matter depletion would not only improve the schizophrenia sustained recovery, but also avert the development of major neurocognitive disorders in people living with schizophrenia. Based on this hypothesis, we suggest utilization of both receptor-dependent and independent therapeutics for chronic psychosis.

The effect of functional remission and cognitive insight on criminal behavior in patients with schizophrenia

OBJECTıVE: This study was planned to determine the relationship of functional remission with a criminal history and determine its effect on criminal behavior in patients with schizophrenia.

METHODS

This cross-sectional study was conducted with 132 patients with schizophrenia (66 with and 66 without a criminal history). Data were collected between November 2020 and April 2021 using a personal information form, the Functional Remission of General Schizophrenia (FROGS), the Taylor Crime Violence Rating Scale, the Beck Cognitive Insight Scale, and the Positive and Negative Syndrome Scale (PANSS) was used to collect data.

RESULTS

In terms of all scale variables, there were significant differences between the groups with and without a criminal history (p < 0.05). These differences were mostly clearly observed in the FROGS-social functionality (effect size: 16.79), PANSS-positive (effect size: 2.62) and FROGS-health and treatment (effect size: 2) subscales.

CONCLUSIONS

In this study, it was determined that as the symptoms of the illness increased in schizophrenia, the patients' functional remission and insight decreased, and their tendency to commit crimes increased. Psychiatric nurses can plan therapeutic interventions to increase the functionality and insight levels of patients with schizophrenia.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Associations Between Clinical Insight and History of Severe Violence in Patients With Psychosis

Background and Hypothesis

Violence is more prevalent in patients with psychotic disorders compared to the general population. Hence, adequate violence risk assessment is of high clinical importance. Impaired insight is suggested as a risk factor for violence in psychosis, but studies have yielded conflicting results. We hypothesized that impaired insight was associated with a history of severe violence in patients with psychotic disorders.

Study Design

Clinical insight was assessed both using the Birchwood Insight Scale (BIS) and the Positive and Negative Symptom Scale (PANSS) item G12 (lack of judgment and insight). The degree of impaired clinical insight was compared between psychosis patients with (N = 51) and without (N = 178) a history of severe violence. Multiple linear regression analyses were performed to investigate the effects of putative confounders.

Study Results

We found that a history of severe violence was significantly associated with lower insight in one of the three BIS components (the relabeling of symptoms) (P = .03, R2 = 0.02) and the PANSS item G12 (P = .03, R2 = 0.02) also after controlling for putative confounders.

Conclusions

The results suggest there is an association between impaired insight and severe violence in psychosis patients. We propose that examination of insight by validated instruments comprising different components may add useful information to clinical violence risk assessment in psychosis patients.

Identifying subgroups based on self-assessment of ability in patients with schizophrenia and its relationship with vocational outcomes

Background/Objectives

People with schizophrenia have defective self-assessment of ability (i.e., loss of introspective accuracy [IA]). Although previous studies grouped people according to the degree of IA, the clinical features of these subgroups have not been clarified. Additionally, the determinants of outcomes depending on self-assessment remain unknown. We aimed to identify the clinical features that can help distinguish these subgroups and whether the determinants of vocational outcomes differed between the groups.

Methods

The self-assessment ability of 100 people with schizophrenia was examined and categorized as accurate, over-, or under-estimators. Multiple discriminant analysis was also performed. After demonstrating statistical validity, the relative effects of positive and negative symptoms, cognitive function, and level of IA on vocational outcomes were also examined for each subgroup.

Results

The symptoms that particularly explained the differences between these subgroups were positive and negative (expressing factors) symptoms: p < .001. Using the determinants of vocational outcomes in each subgroup, the over-estimator subgroup was characterized by positive symptoms: p = .025, the under-estimator group, by the underestimation of their own ability: p = .042, and the accurate estimator group, by cognitive function: p = .006.

Conclusion

Reduced IA can be a core mediator of various symptoms. Thus, tailoring the target and strategy of interventions for vocational outcomes according to the accuracy and quality of IA is important in clinical settings.

The Multiple Dimensions of Insight in Schizophrenia-Spectrum Disorders

The concept of insight is used to indicate the propensity of patients with schizophrenia and other severe mental disorders to recognize their illness and engage in treatment. Thus, insight may have notable consequences for the ill individual: Those who lack insight are at higher risk of nonadherence to treatments, negative clinical outcomes, and worse community functioning. Although insight is an intuitive concept, its essence remains difficult to capture. However, many rating scales are available to aid assessment, both for clinical and research purposes. Insight cannot be reduced to a symptom, a psychological mechanism, or a neuropsychological function. It is likely to have dynamic relationships with all these dimensions and with responses to personal events and contextual factors. In particular, social consequences of mental illness and explanatory models that are alternative to the medical model may fundamentally shape insight and treatment choice. Moreover, the cultural or individual stigmatization of mental illness may turn the acquisition of insight into a painful event and increase the risk of depression. Clinicians need to carefully evaluate and promote insight through a personalized approach to aid patient process of care and personal growth.

A review of factors associated with severe violence in schizophrenia

BACKGROUND

There is a modest but consistent association between violence and schizophrenia. The consequences of serious violence could be catastrophic for the victims, as well as the patients themselves and the community. Any knowledge that would help to prevent acts of serious violence would be of considerable value for the individual and the society.

AIM

To identify external and clinical risk factors for serious violence in schizophrenia, in addition to considering the strength of the association between the factors assessed and severe violence.

METHODS

This was accomplished by a literature survey. One-hundred and two relevant papers were identified that were published during the past 20 years. Forty-four papers were assessed for eligibility. In all, 27 studies including clinical or cognitive variables were reviewed systematically. An effect size was reported where an odds ratio (OR) could be identified or calculated from available data. Five external factors and six clinical domains were evaluated.

RESULTS

Substance abuse is robustly linking schizophrenia and violence. Among the clinical factors, insight, impulsivity, psychopathy, motor speed and a global measure of cognition are the factors with the strongest empirical evidence for an association with severe violence.

CONCLUSION

This is the first systematic review of risk factors for severe violence in schizophrenia, in which a great number of clinical and external factors have been evaluated. Most of the clinical factors have been compared on effect size. The identified factors that represent an increased risk of violence in patients with schizophrenia should be included in risk assessments.

[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.

[Insight and psychiatric dangerousness: A review of the literature]

INTRODUCTION

Violence committed by individuals with severe mental illness has become an increasing focus of concern among clinicians, policy makers, and the general public, often as the result of tragic events. Research has shown in the past two decades an increased risk of violence among patients with mental disorder. Nevertheless, of those suffering from mental illness, perpetrators of other directed violence form a minority subgroup. The means by which there is this association between mental illness and violence has remained controversial. Factors such as positive psychotic symptoms, medication non-adherence, alcohol or psychoactive substance abuse and antisocial personality were found to be predictive of violence. Overall, literature provides support to the assertion that violent behavior of mentally ill patients is a heterogeneous phenomenon that is driven by multiple inter-related and independent factors. Furthermore, psychiatrists are often asked to predict an individual's future dangerousness, in a medical or a legal context. In the process of risk assessment of dangerousness, more focus has been placed on dynamic risk factor. In this context, lack of insight has established itself both as a part of violence risk models and as a clinical item in structured approaches to measure dangerousness. However, few studies have tested these associations. The main purpose of this paper is to review the literature concerning the relationship between insight and dangerousness and discuss the contributions of the insight in the assessment of dangerousness in patients with mental illness. We included twenty studies that evaluated the association between insight and variable such as physical or verbal violence, aggressiveness, hostility or sexual aggression.

RESULTS

According to the findings of this review, the strength and specific nature of this relationship remain unclear due to considerable methodological and conceptual shortcomings, including heterogeneity in the definition and assessment of violence, a minority of prospective studies and the lack of systematic consideration of possible confounding variables. However, the ability of the patient to perceive their illness is an important element to be considered in assessing the dangerousness both medically and legally. Higher belief flexibility and lower confidentiality of individual judgment, which reflect greater cognitive insight, may be associated with a lower incidence of violence, in particular in schizophrenia by decreasing the degree of confidence related to psychotic symptoms.

CONCLUSION

In the growing efforts to reduce stigma associated with mental illness, it is important to identify a subgroup of patients at risk of violence and provide them with targeted treatment. In this sense, it seems important in the future to continue in this field of research to determine if the lack of insight is a covariate of a worsened condition or a specific violence risk factor per se.

Medication and aggressiveness in real-world schizophrenia. Results from the FACE-SZ dataset

INTRODUCTION

The primary objective of this study was to determine if second-generation antipsychotic (SGA) administration was associated with lower aggressiveness scores compared to first-generation (FGA) in schizophrenia (SZ). The secondary objective was to determine if antidepressants, mood stabilizers, and benzodiazepines administration were respectively associated with lower aggressiveness scores compared to patients who were not administered these medications.

METHODS

Three hundred thirty-one patients with schizophrenia (N = 255) or schizoaffective disorder (N = 76) (mean age = 32.5 years, 75.5 % male gender) were systematically included in the network of FondaMental Expert Center for Schizophrenia and assessed with the structured clinical interview for DSM-IV Axis I disorders and validated scales for psychotic symptomatology, insight, and compliance. Aggressiveness was measured by the Buss-Perry Aggression Questionnaire (BPAQ) score. Ongoing psychotropic treatment was recorded.

RESULTS

Patients who received SGA had lower BPAQ scores than patients who did not (p = 0.01). More specifically, these patients had lower physical and verbal aggression scores. On the contrary, patients who received benzodiazepines had higher BPAQ scores than patients who did not (p = 0.04). No significant difference was found between BPAQ scores of patients respectively being administered mood stabilizers (including valproate), antidepressant, and the patients who were not. These results were found independently of socio-demographical variables, psychotic symptomatology, insight, compliance into treatment, daily-administered antipsychotic dose, the way of antipsychotic administration (oral vs long acting), current alcohol disorder, and daily cannabis consumption.

CONCLUSION

The results of the present study are in favor of the choice of SGA in SZ patients with aggressiveness, but these results need further investigation in longitudinal studies. Given the potent side effects of benzodiazepines (especially dependency and cognitive impairment) and the results of the present study, their long-term prescription is not recommended in patients with schizophrenia and aggressive behavior.

Psychosocial functioning in schizophrenia: are some symptoms or demographic characteristics predictors across the functioning domains?

This study aimed to examine symptoms/demographic characteristics as predictors for psychosocial functioning among individuals with schizophrenia. The Personal and Social Performance (PSP) scale was used to assess psychosocial functioning. Other measures of interest included were the Clinical Global Impression, Severity scale, and the Marder's five-factor model of the Positive and Negative Syndrome Scale. This study included 199 participants with non-acute stage schizophrenia. Spearman correlation coefficients and stepwise multiple linear regression analyses were applied to determine the correlates and predictors of PSP domain/total scores. Younger age, earlier age of schizophrenia onset, severe illness, positive symptoms, negative symptoms, disorganized thought, hostility/excitement, and anxiety/depression were found to significantly correlate with poor functioning. Severe illness and negative symptoms are the main predictors of greater impairment of socially useful activities, personal and social relationships, and self-care. Further prospective studies in other settings, which would include an increased number of variables such as neurocognitive function and social support, are warranted.

Aggression in Psychoses

Most individuals diagnosed with a mental illness are not violent, but some mentally ill patients commit violent acts. PubMed database was searched for articles published between 1980 and November 2013 using the combination of key words “schizophrenia” or “bipolar disorder” with “aggression” or “violence.” In comparison with the general population, there is approximately a twofold increase of risk of violence in schizophrenia without substance abuse comorbidity and ninefold with such comorbidity. The risk in bipolar disorder is at least as high as in schizophrenia. Most of the violence in bipolar disorder occurs during the manic phase. Violence among adults with schizophrenia may follow two distinct pathways: one associated with antisocial conduct and another associated with the acute psychopathology, particularly anger and delusions. Clozapine is the most effective treatment of aggressive behavior in schizophrenia. Emerging evidence suggests that olanzapine may be the second most effective treatment. Treatment nonadherence greatly increases the risk of violent behavior, and poor insight as well as hostility is associated with nonadherence. Nonpharmacological methods of treatment of aggression in schizophrenia and bipolar disorder are increasingly important. Cognitive behavioral approaches appear to be effective in cases where pharmacotherapy alone is not sufficient.

Poor insight into schizophrenia: contributing factors, consequences and emerging treatment approaches

Poor insight or unawareness of illness has been commonly observed in schizophrenia and has been long recognized as a potent barrier to treatment adherence and a risk factor for a range of poorer outcomes. Paradoxically, the achievement of insight often poses a different set of problems including depression and low self-esteem. One barrier to the treatment of poor insight has been a lack of understanding of the phenomenon, which causes poor insight to develop and persist over time. Without knowing what promotes poor insight, treatment to date has had little to offer beyond the supportive provision of information. To explore these issues, this article reviews emerging literature on the correlates of poor insight in schizophrenia, and newly developing ways of conceptualizing insight. It then details a number of innovative integrative group and individual treatment approaches in the early stages of development, which take into account some of the potential causal forces behind poor insight, including deficits in neurocognition, social cognition, metacognition and heightened self-stigma. A plan for further research is presented to develop a model of the factors whose interaction influences insight, and to refine and test integrative treatments.

Association between insight, cognitive insight, positive symptoms and violence in patients with schizophrenia

BACKGROUND

Violence is a significant clinical and public concern and is a frequent occurrence in patients with schizophrenia. The relationship between insight and violence remains controversial. In addition, there is a lack of research on insight, cognitive insight, demographic and psychopathologic variables in violent versus nonviolent schizophrenia patients.

AIM

We aimed to compare insight, cognitive insight, psychopathological and demographic variables in violent and nonviolent subjects suffering from schizophrenia. In addition, we aimed to determine the demographic and clinical predictors of violent behaviour in patients with schizophrenia.

METHOD

We recruited 133 schizophrenic patients without concomitant substance abuse or axis II disorder. Diagnoses were based on the SCID-I and SCID-II. Violent behaviours were assessed using the Overt Aggression Scale. Insight and cognitive insight were assessed with the Scale to Assess Unawareness of Mental Disorder and the Beck Cognitive Insight Scale, respectively.

RESULTS

We compared 47 patients with violent schizophrenia with 86 nonviolent patients. Non-violent patients had more severe depression, lower scores on positive symptoms, better clinical insight, more self-reflectivity and higher R-C index scores than did violent patients. In addition, history of violence, lower self-reflectiveness, worse clinical insight and delusion severity were significant predictors of violence in schizophrenia.

CONCLUSION

The present study suggests that the inclusion of insight and cognitive insight may increase the prediction of violence in this population. In addition, clinicians should consider using non-pharmacological techniques that are based on cognitive behaviour therapy and enhance insight, particularly cognitive insight, among patients with schizophrenia who exhibit violent behaviour.

Structured assessment of violence risk in schizophrenia and other psychiatric disorders: a systematic review of the validity, reliability, and item content of 10 available instruments

OBJECTIVES

To undertake a systematic review on structured violence risk assessment tools in individuals with schizophrenia.

METHODS

A systematic search was conducted from 1990 to 2011 to identify violence risk assessment tools and studies examining their predictive validity. Item content of the identified instruments was analyzed, and areas under the curve (AUC) from the studies were extracted. In addition, an 11-item checklist was developed to assess the utility and psychometric properties of these tools.

RESULTS

Ten risk assessment tools designed to predict community violence in psychiatric patients were identified, but only 2 studies reporting predictive validity estimates in patients with schizophrenia were found (median AUC = 0.69; interquartile range = 0.60-0.77). When inclusion criteria was broadened to include studies measuring accuracy for any diagnostic group, mixed evidence of predictive validity was found, with median AUCs ranging from 0.62 to 0.85 depending on the population. Item content included mostly clinical, sociodemographic, and criminal history factors. As only 1 tool included a neurobiological item, a structured review of brain-based and cognitive risk factors for violence was included, and 3 clusters (neurocognitive ability, neurocognitive awareness, and attitudinal cognition) were identified.

CONCLUSIONS

While a number of violence risk assessment tools exist that can be used to predict the likelihood of community violence in psychiatric patients, there is currently little direct evidence for their utility in individuals with schizophrenia. In addition, there is large variation in item content between instruments, and further research is necessary to determine whether the inclusion of alternative factors could improve risk assessment.

Criminal offending and distinguishing features of offenders among persons experiencing a first episode of psychosis

AIMS

Persons with severe mental illness (SMI) are at increased risk of criminal offending, particularly violent offending, as compared with the general population. Most offenders with SMI acquire convictions prior to contact with mental health services. This study examined offending among 301 individuals experiencing their first episode of psychosis.

METHODS

Patients provided information on sociodemographic and clinical variables and completed a neurological soft sign examination and neuropsychological tests. Additional information was extracted from clinical files and official criminal records.

RESULTS

The results show that 33.9% of the men and 10.0% of the women had a record of criminal convictions, and 19.9% of the men and 4.6% of the women had been convicted of at least one violent crime. Proportionately more male and female patients than men and women in the general UK population had prior convictions for violent crimes. In a multivariate model including background and clinical variables, only one variable distinguished the male offenders. African-Caribbean ethnicity was associated with a threefold increase in the odds of offending (odds ratio=3.84, 95% confidence interval 1.03-14.37). Offenders, as compared with non-offenders, obtained significantly lower premorbid and current intelligence quotient scores and similar scores on tests of neurological soft signs, working memory and executive functions.

CONCLUSIONS

At contact with mental health services for a first episode of psychosis, significant numbers of patients have records of criminal convictions and thereby a high risk for future violent behaviour. These patients require specific interventions, in addition to medication, to reduce offending and aggressive behaviour.

Violent behavior in acute psychiatric inpatient facilities: a national survey in Italy

Violence committed by acute psychiatric inpatients represents an important and challenging problem in clinical practice. Sociodemographic, clinical, and treatment information were collected for 1324 patients (677 men and 647 women) admitted to Italian public and private acute psychiatric inpatient facilities during an index period in 2004, and the sample divided into 3 groups: nonhostile patients (no episodes of violent behavior during hospitalization), hostile patients (verbal aggression or violent acts against objects), and violent patients (authors of physical assault). Ten percent (N = 129) of patients showed hostile behavior during hospitalization and 3% (N = 37) physically assaulted other patients or staff members. Variables associated with violent behavior were: male gender, <24 years of age, unmarried status, receiving a disability pension, having a secondary school degree, compulsory admission, hostile attitude at admission, and a diagnosis of schizophrenia, bipolar disorder, personality disorder, mental retardation, organic brain disorder or substance/alcohol abuse. Violent behavior during hospitalization was a predictive factor for higher Brief Psychiatric Rating Scale scores and for lower Personal and Social Performance scale scores at discharge. Despite the low percentage of violent and hostile behavior observed in Italian acute inpatient units, this study shed light on a need for the careful assessment of clinical and treatment variables, and greater effort aimed at improving specific prevention and treatment programs of violent behavior.