Executive function and in-patient violence in forensic patients with schizophrenia

Mentalizing mediates the relationship between psychopathy and premeditated criminal offending in schizophrenia: a 6-year follow-up study

PURPOSE

Research has shown that schizophrenia augments the risk for criminal behaviour and variables both defining- and related to schizophrenia, increase criminal offending. Premeditated criminal offending is considered a severe form of criminal offending, however, very little is known about what predicts future premeditated criminal offending in schizophrenia.

METHOD AND MATERIALS

In this 6-year follow-up study we explored which factors underlie future premeditated criminal behaviour in a sample of patients diagnosed with schizophrenia (N = 116). We also investigated if a specific mentalizing profile underlie part of the variance of premeditated criminal offending.

RESULTS

Results showed that psychopathy underlie future premeditated crime in schizophrenia, and that a specific mentalizing profile, comprised of a dysfunctional emotional and intact cognitive mentalizing profile in relation to others, mediated parts of the relation between psychopathy and premeditated criminal offending. Finally, our results indicated that patients with schizophrenia with a specific mentalizing profile (see above) engaged in premeditated criminal behaviour earlier during the 6-year follow-up period compared to patients with other mentalizing profiles.

CONCLUSIONS

Our findings suggest that mentalization should carefully be inspected in patients with schizophrenia in relation to future premeditated offending.

Identifying Predictors of Inpatient Verbal Aggression in a Forensic Psychiatric Setting Using a Tree-based Modeling Approach

Inpatient violence poses a great risk to the health and well-being of other patients and members of staff. Previous research has shown that prevalence rates of violent behavior are particularly high in forensic psychiatric settings. Thus, the reliable identification of forensic inpatients who are particularly at risk for violent behavior is an important aspect of risk management. In the present study, we analyzed clinicians' assessments of N = 504 male and female inpatients of German forensic mental health institutions in order to identify risk factors for verbal institutional violence. Using a tree-based modeling approach, we found the following variables to be predictors of verbal aggression: gender, insight into the illness, number of prior admissions to psychiatric hospitals, and insight into the iniquity of the offence. A high number of prior admissions to psychiatric hospitals seems to be a risk factor for verbal aggression amongst men whereas it showed the opposite effect amongst women. Our results highlight the importance of dynamic risk factors, such as poor insight into the own illness, in the prediction of violent incidents. With regard to future research, we argue for a stronger emphasis on nonparametric models as well as on potential interaction effects of risk and protective factors.

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

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

Neuropsychological features in patients with severe mental disorders and risk of violence: A prospective multicenter study in Italy

In Severe Mental Disorders (SMDs) the most important cognitive deficits involve the Executive Functions (EFs). In this study we examined the association between EFs and aggressive behaviour in outpatients with SMDs. We included a total of 247 outpatients divided into two groups: 'cases', patients with a history of violence (N=126) and 'non-violent' (N=121). We compared their EFs score and then categorized the participants into four groups (Pathological Non-Violent comparison group; Non-Pathological Non-Violent comparison group; Pathological Violent cases and Non-Pathological Violent cases), based on the scores of a subtest assessing processing speed (i.e., Symbol-coding task) of the Brief Assessment of Cognition in Schizophrenia (BACS). We followed the 4 groups during a 1-year follow-up (FU) monitoring violent behaviour with the Modified Overt Aggression Scale (MOAS). According to the classification based on the BACS-Symbol Coding Task we found no statistically significant differences between subgroups in MOAS scores. We only found that the trend curve for PV was almost consistently over the other group curves in the MOAS 'aggression against people'. Our results suggested a worse performance in the violent compared to non-violent group in EFs. Despite this evidence, the score on the processing speed task was not associated with aggressive behaviour during FU.

Increased prevalence of psychopathy and childhood trauma in homicide offenders with schizophrenia compared to nonviolent individuals with schizophrenia

Purpose: Schizophrenia is associated with an increased homicide risk. Personality pathology, particularly antisocial personality disorder and psychopathic traits, has been associated with increased violence risk in schizophrenia. Childhood trauma, more specifically physical abuse, has been associated with violence risk in healthy populations and in individuals with mental illness. It is, however, unclear how childhood trauma relates to homicide in schizophrenia. This is, to our knowledge, the first study to concurrently examine personality pathology and childhood trauma in a group consisting solely of homicide offenders with schizophrenia (HOS). HOS is compared to nonviolent participants with the same diagnosis (non-HOS). Additionally, currently assessed demographical and clinical characteristics of a Norwegian sample of HOS are reported. Materials and methods: Two groups of participants with schizophrenia were recruited in collaboration with in and outpatient clinics across Norway, HOS (n= 26) and non-HOS (n= 28). Assessments of personality pathology and childhood trauma were conducted, and information about clinical and demographical characteristics was registered. Results: HOS participants had significantly higher psychopathy scores, and more frequently reported moderate to severe childhood physical abuse than non-HOS participants. When simultaneously added to a logistic regression model, only psychopathy uniquely contributed to explaining group membership. Conclusions: Psychopathy and physical abuse was more prevalent among HOS participants compared to non-HOS, but only psychopathy independently predicted homicidal status. These results confirm the importance of including an evaluation of psychopathic traits in violence risk assessments of individuals with schizophrenia.

Cognition and violent behavior in psychotic disorders: A nationwide case-control study

Background

The excess risk of violence in psychotic disorders may partly be explained by impairments in executive functions (EFs) and theory of mind (ToM). However, previous studies have been limited by composite measures of EFs and small samples of inpatients.

Methods

Data were collected for the research project Genetic Risk and Outcome of Psychosis (GROUP). Patients with psychotic disorders (N = 891) were recruited from various care settings in the Netherlands. The following neuropsychological tests were administered (targeted cognitive function in parentheses): (i) Continuous Performance Test-HQ (inhibition); (ii) Response Shifting Task (cognitive flexibility); (iii) Wechsler Adult Intelligence Scale, Third Edition (WAIS-III) Block Design subtest (fluid intelligence); (iv) Neuropsychological Assessment Battery (NAB) Mazes Test (planning); (v) Degraded Facial Affect Recognition Task (affective ToM); and (vi) Hinting Task (cognitive ToM). Lifetime violence was ascertained from medical records and patient interviews. We used analysis of covariance to compare the mean scores of violent and nonviolent patients on each test, adjusting for age and sex.

Results

Violent patients performed significantly worse than nonviolent patients on the WAIS-III Block Design subtest (F [1, 847] = 5.12, p = .024), NAB Mazes Test (F [1, 499] = 5.32, p = .022) and Hinting Task (F [1, 839] = 9.38, p = .002). For the other tests, the between-group differences were nonsignificant. Violent behavior explained no more than 1% of the variance in performance on each test.

Conclusion

Impairments in EFs and ToM are unlikely to provide useful targets for risk assessment and interventions.

A multi-dimensional approach to the relationship between insight and aggressiveness in schizophrenia: Findings from the FACE-SZ cohort

BACKGROUND

Aggressiveness is a stigma frequently associated with schizophrenia. The role of insight as a risk factor of aggressiveness remains contradictory; mainly because single measures of these states mask their complexity and heterogeneity.

METHODS

This study was conducted on 666 patients aged 15 and above with a DSM-IV-TR diagnosis of schizophrenia spectrum disorder, drawn from the French national network of schizophrenia expert center database. Collected data comprised socio-demographics and standardized psychiatric assessments. Aggressiveness was evaluated using the Buss-Perry Aggression Questionnaire and insight using the Scale to assess Unawareness of Mental Disorder (SUMD) and Birchwood Insight Scale (BIS).

RESULTS

Hostility was the aggressiveness dimension the most strongly associated with SUMD insight dimensions. Patients aware of their illness were nearly twice as likely to show hostility than those seriously unaware (OR = 1.95, 95% CI.: 1.08-3.5), but not when further adjusting for depression. Similarly, those aware of the consequences of their illness and of their symptoms were more hostile. Patients moderately aware of illness consequences had a higher risk of both anger and physical aggressiveness than those unaware (OR = 2.63, 95% CI.: 1.42-4.86, OR = 2.47, 95% CI.: 1.33-4.60, respectively), even when adjusting for depression for anger.

CONCLUSION

Our study confirms that a multi-dimensional approach to insight and aggressiveness is essential to understand the types of links between these clinical states. Insight may trigger the expression of an underlying hostile tendency, maybe via depression and self-stigmatisation. This should be taken into account in therapeutic approaches to improve insight.

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.

Impaired neuropsychological profile in homicide offenders with schizophrenia

BACKGROUND

Our ability to predict and prevent homicides committed by individuals with schizophrenia is limited. Cognitive impairments are associated with poorer functional outcome in schizophrenia, possibly also homicide. The aim of the current study was to investigate global and specific cognition among homicide offenders with schizophrenia (HOS).

METHODS

Twenty-six HOS were compared to 28 individuals with schizophrenia and no history of violence (non-HOS), and a group of healthy controls (HC, n = 151). HOS and non-HOS participants were recruited from in- and outpatient units across Norway. An extensive neuropsychological test battery was administered.

RESULTS

HOS participants performed significantly weaker than HC in all cognitive domains. Further, statistically significant differences between HOS and non-HOS participants were found for IQ (d = 0.52) and verbal learning (d = 0.82), with larger impairments in the HOS compared to the non-HOS group.

CONCLUSIONS

Our results indicate that HOS participants show clinically significant impairments in global and specific cognition.

Differences in Neuropsychological Functioning Between Homicidal and Nonviolent Schizophrenia Samples

Few studies have compared performance on neurocognitive measures between violent and nonviolent schizophrenia samples. A better understanding of neurocognitive dysfunction in violent individuals with schizophrenia could increase the efficacy of violence reduction strategies and aid in risk assessment and adjudication processes. This study aimed to compare neuropsychological performance between 25 homicide offenders with schizophrenia and 25 nonviolent schizophrenia controls. The groups were matched for age, race, sex, and handedness. Independent t-tests and Mann-Whitney U-tests were used to compare the schizophrenia groups' performance on measures of cognition, including composite scores assessing domain level functioning and individual neuropsychological tests. Results indicated the violent schizophrenia group performed worse on measures of memory and executive functioning, and the Intellectual Functioning composite score, when compared to the nonviolent schizophrenia sample. These findings replicate previous research documenting neuropsychological deficits specific to violent individuals with schizophrenia and support research implicating fronto-limbic dysfunction among violent offenders with schizophrenia.

Do cognitive deficits predict negative emotionality and aggression in schizophrenia?

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

Neuropsychology and emotion processing in violent individuals with antisocial personality disorder or schizophrenia: The same or different? A systematic review and meta-analysis

OBJECTIVES

To assess whether there are shared or divergent (a) cognitive and (b) emotion processing characteristics among violent individuals with antisocial personality disorder and/or schizophrenia, diagnoses which are commonly encountered at the interface of mental disorder and violence. Cognition and emotion processing are incorporated into models of violence, and thus an understanding of these characteristics within and between disorder groups may help inform future models and therapeutic targets.

METHODS

Relevant databases (OVID, Embase, PsycINFO) were searched to identify suitable literature. Meta-analyses comparing cognitive function in violent schizophrenia and antisocial personality disorder to healthy controls were conducted. Neuropsychological studies not comparing these groups to healthy controls, and emotion processing studies, were evaluated qualitatively.

RESULTS

Meta-analyses indicated lower IQ, memory and executive function in both violent schizophrenia and antisocial personality disorder groups compared to healthy controls. The degree of deficit was consistently larger in violent schizophrenia. Both antisocial personality disorder and violent schizophrenia groups had difficulties in aspects of facial affect recognition, although theory of mind results were less conclusive. Psychopathic traits related positively to experiential emotion deficits across the two disorders. Very few studies explored comorbid violent schizophrenia and antisocial personality disorder despite this being common in clinical practice.

CONCLUSION

There are qualitatively similar, but quantitatively different, neuropsychological and emotion processing deficits in violent individuals with schizophrenia and antisocial personality disorder which could be developed into transdiagnostic treatment targets for violent behaviour. Future research should aim to characterise specific subgroups of violent offenders, including those with comorbid diagnoses.

Objective predictors of outcome in forensic mental health services-a systematic review

This systematic review aimed to examine whether neurobiological methods, or other methods independent of clinical judgment, have been investigated to assist decision making in forensic mental health services and, if so, whether this may be a useful strategy for predicting outcomes. OVID-Medline, Embase, and PsychInfo (inception-January 2015) were searched, limiting to English and human studies, using terms relating to "predict," "outcome," "psychiatry," and "forensic" to identify primary research articles reporting on predictors of outcome in forensic mental health services not reliant on clinical judgment/self-report. Fifty studies investigating demographic, neuropsychological/neurophysiological, and biological predictors were identified, reporting on 3 broad outcomes: (i) inpatient violence, (ii) length of stay, (iii) reoffending. Factors associated positively, negatively, and showing no relationship with each outcome were extracted and compiled across studies. Of various demographic predictors examined, the most consistent associations were between previous psychiatric admissions and inpatient violence; a more "severe" offense and a longer length of stay; and young age and reoffending. Poor performance on tests of cognitive control and social cognition predicted inpatient violence while a neurophysiological measure of impulsivity showed utility predicting reoffending. Serum cholesterol and creatine kinase emerged as biological factors with potential to predict future inpatient violence. Research in this field is in its infancy, but investigations conducted to date indicate that using objective markers is a promising strategy to predict clinically significant outcomes.

A randomized study of cognitive remediation for forensic and mental health patients with schizophrenia

Cognitive remediation has proven efficacy for improving neurocognition in people with schizophrenia. The current study evaluated the benefits of cognitive remediation on neurocognition, functioning, psychotic symptoms, and aggression in a sample of forensic and mental health patients. Care recipients with schizophrenia or schizoaffective disorder (N = 78) receiving services in the forensic and mental health units of a state hospital were randomized to participate in cognitive remediation versus computer games control activities. Participants' neurocognition, functional capacity, experiential recovery, psychotic symptoms, and aggression incidents were assessed at baseline and posttreatment. Cognitive remediation was associated with improvements in several neurocognitive domains and circumscribed domains of functional capacity. People assigned to cognitive remediation experiences greater reductions in negative symptoms, agitation/excitement, and verbal and physical aggression. In addition to improving neurocognition in long-term hospitalized forensic and mental health patients, cognitive remediation may enhance efforts at reducing negative symptoms, emotion dysregulation, and aggression incidents. Forensic settings may represent a new frontier for the clinical dissemination of cognitive remediation.

Audit study of the new hospitalization for assessment scheme for forensic mental health in Japan

AIM: To clarify the components of hospitalization for assessment (HfA) and the management changes from the beginning of the scheme to the present.

METHODS: This study is composed of two surveys. In 2013 survey, we created two paper questionnaires (facility and case questionnaires) for psychiatrists working in psychiatric hospitals accepting HfA patients. Questionnaires were sent to 205 hospitals that were identified as accepting the HfA cases, and responses were requested via mail. The facility questionnaire was designed to clarify the following specifications and characteristics of each facility: the facility organizer (public sector or private hospital), and the number of beds, psychiatrists, psychiatric nurses, occupational therapists, psychiatric social workers, psychotherapists, public health nurses, and patients treated through HfA during the survey period. The case questionnaire was then used to collect data of the patients under HfA based on the Medical Treatment and Supervision (MTS) Act who were discharged between July 1, 2012 and June 30, 2013. Gathered information included: legal information of each case, demographic data, past history of the offenders, issued offense and the relationship to the victim, information regarding past psychiatric testimonies, psychiatric diagnoses, contents of the treatment during HfA, information regarding seclusion and restraint during the HfA, the verdict of the District Court panel, and so forth. Next, we compared those results with relevant data obtained in 2007. The 2007 survey comprised data of HfA patients from July 15, 2005 (the date the MTS Act was enforced) to January 15, 2007.

RESULTS: We obtained 171 cases, approximately a half of whole contemporary cases of HfA, from 134 facilities, of which 46 were national, prefectural, or semi-official hospitals, and 88 were private hospitals, in 2013 survey. The majority of subjects were male, schizophrenic, and experienced previous psychiatric treatment. The most frequent type of the offense was injury, followed by arson. Most of the subjects were medicated, and a few cases took psychotropic injection during the HfA. The frequency of injection was decreased in 2013 (χ² = 7.54, df = 1, P = 0.006) than in 2007. Psychiatric testimony was more likely to be conducted in 2013 (χ² = 8.56, df = 1, P = 0.004). The examiner psychiatrist was more likely to belong to the HfA facility to which the patient was hospitalized (χ² = 5.32, df = 1, P = 0.02). Hospitalization orders were more frequently selected in 2013 (χ² = 19.76, df = 3, P < 0.001), although the characteristics of the subjects had not changed.

CONCLUSION: Although the management of HfA has improved in recent years, structural problems remain.

The four-factor model of the Psychopathy Checklist--Revised: validation in a Dutch forensic inpatient sample

In The Netherlands, the Ministry of Security and Justice requires the assessment of the Psychopathy Checklist-Revised (PCL-R; Hare, 1991; Hare, 2003) in all forensic psychiatric inpatients. To examine the four-factor structure of the Psychopathy Checklist-Revised, confirmatory factor analysis (CFA) was conducted using a Dutch sample of forensic psychiatric inpatients (N=411) and the results indicated acceptable fit. Also, using multiple group CFA, the four-factor model provided an acceptable fit in both patients with a personality disorder and patients with a psychotic disorder, and there was reasonably good evidence of measurement invariance between these two subgroups. Furthermore, correlations with external measures of aggression and personality traits provided additional support for the validity of the four-factor model in patients with a personality disorder. In patients with a psychotic disorder fewer significant correlations with external measures were found. Taken together, the results support the use of the four-factor structure in Dutch offenders who are detained under hospital order.

Neurocognitive features in male patients with schizophrenia exhibiting serious violence: a case control study

BACKGROUND

The relationship between violence and neurocognitive function in schizophrenia is unclear. We examined the backgrounds and neurocognitive functions of violent and nonviolent patients with schizophrenia to identify factors associated with serious violence.

METHODS

Thirty male patients with schizophrenia who were hospitalized after committing serious violent acts were compared with 24 hospitalized male patients with schizophrenia and no history of violence. We evaluated psychiatric symptoms using the Positive and Negative Syndrome Scale (PANSS) and neurocognitive functions using the Brief Assessment of Cognition in Schizophrenia (BACS)-Japanese version.

RESULTS

Repeated-measures analyses of variance on BACS subcomponents z-scores showed that the violent and control groups had different neuropsychological profiles at trend level (p = 0.095). Post hoc analyses of variance indicated that the violent group had significantly better working memory and executive function than the control group. In post hoc ANOVAs also controlling for the effect of the presence of substance abuse on cognitive function, violent or nonviolent group had a significant main effect on executive function but not on working memory.

CONCLUSIONS

Patient with violent or non-violent schizophrenia have distinct neuropsychological profiles. These results may help develop improved psychosocial treatments.

Assessment and determinants of aggression in a forensic psychiatric institution in Hong Kong, China

Institutional aggression in forensic psychiatric setting is an under-researched subject, despite the magnitude of the problem. No studies have been conducted on the assessment of risk and the examination of predictors of aggression among the Chinese forensic psychiatric population. Our study aimed to examine the determinants of aggression in the only forensic psychiatric institution in Hong Kong, and to test the psychometric properties of a risk-assessment instrument, the Dynamic Appraisal of Situational Aggression (DASA). We recruited a representative sample of 530 consecutively admitted detainees. Qualified nurses completed two risk-assessment instruments, the DASA and the Brøset Violence Checklist (BVC), once daily during the participants׳ first 14 days of admission. Aggressive incidents were recorded using the revised Staff Observation Aggression Scale (SOAS-R), and participants׳ data were collected for multivariate analyses. We showed that female gender, diagnoses of personality disorder and substance-related disorder, and admission at other correctional institutions were associated with institutional aggression. Aggression was perpetrated by 17.7% of the participants, and the DASA was demonstrated to have good psychometric properties in assessing and predicting aggressive incidents. Our findings preliminarily support the use of daily in-patient risk-assessment and affirm the role of dynamic factors in institutional aggression.

Factors associated with violence among Japanese patients with schizophrenia prior to psychiatric emergency hospitalization: a case-controlled study

BACKGROUND

Numerous studies have examined a wide range of risk factors associated with violence among patients with schizophrenia. However, risk factors linked to different socio-cultural backgrounds remain unclear.

OBJECTIVE

The objectives were to investigate factors associated with violence among Japanese patients with schizophrenia prior to emergency hospitalizations and to compare them with factors found in studies on other populations.

METHODS

We recruited 420 Japanese patients with schizophrenia who had committed violent acts immediately prior to emergency admission to a psychiatric hospital in Tokyo, during the period 1986 to 2005. Cases were compared with controls (non violent hospitalized patients with schizophrenia) matched for gender, age and admission year. All medical records were reviewed retrospectively. Inter-rater reliability tests of assessment were performed. Conditional logistic regression analysis was used to identify factors associated with violence.

RESULTS

The symptoms of gross excitement, prior violence, auditory hallucinations, systematization of delusions, incoherence of speech, delusions of reference, TCO symptoms, living with others and long duration of illness were found to be associated with violence. In contrast, antisocial traits such as substance abuse and antisocial episodes were not recognized as significant violence-associated factors.

CONCLUSION

Violence among Japanese patients with schizophrenia was strongly associated with elements of schizophrenia itself, rather than antisocial traits. This study highlighted associated factors for violence among Japanese patients with schizophrenia which differ distinctly from associated factors in other countries. This result demonstrates that future studies assessing the risk of violence among patients with schizophrenia need to consider cultural and racial differences in cohorts.

Comorbid personality disorders and violent behavior in psychotic patients

Schizophrenia without any comorbidity confers a modest, but statistically significant elevation of the risk for violence. That risk is considerably increased by comorbid antisocial personality disorder or psychopathy as well as by comorbid substance use disorders. These comorbidities are frequent. Conduct disorder and conduct disorder symptoms elevate the risk for aggressive behavior in patients with schizophrenia. Violence among adults with schizophrenia may follow at least two distinct pathways-one associated with premorbid conditions, including antisocial conduct, and another associated with the acute psychopathology of schizophrenia. Aggressive behavior in bipolar disorder occurs mainly during manic episodes, but it remains elevated in euthymic patients in comparison with controls. The risk of violent behavior is increased by comorbidity with borderline personality disorder, antisocial personality disorder, and substance use disorders. These comorbidities are frequent. Borderline personality disorder and bipolar disorder are related in their phenomenology and response to medication. These two disorders share a tendency to impulsiveness, and impulsive behavior, including impulsive aggression, is particularly expressed when they co-occur.

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.

Mentalizing mediates the relationship between psychopathy and type of aggression in schizophrenia

Convincing evidence demonstrates that psychopathy is associated with premeditated aggression. However, studies have failed to explain why this association exists and whether socio-cognitive functions, such as mentalizing, could explain the relation. This cross-sectional study investigates, in 108 patients with schizophrenia, the association of psychopathy and mentalizing abilities with premeditated and impulsive aggression and probes the nature of their influence on these specific aggression patterns. Patients' engagement in premeditated aggression was associated with diminishing mentalizing and increasing psychopathic tendencies. Moreover, mediation analyses reveal that the ability to attribute mental states to others mediates the relation between psychopathy and type of aggression. This mediation is facilitated by a specific mentalizing profile characterized by the presence of intact cognitive and deficient emotional mentalizing capacities. This study is the first to report a mediating effect of mentalizing on the relationship between psychopathy and type of aggression in schizophrenia. Implications of these results are discussed.

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.

Relationships between dimensional factors of psychopathy and schizotypy

Existing research has suggested that comorbid psychopathy may explain one trajectory of violent behavior in a subset of individuals with schizophrenia. However, it remains unclear which specific traits and symptoms are responsible for this relationship and whether it is limited to clinical and/or forensic categories, or if it reflects a dimensional relationship found in the general population. Therefore, the aim of this study was to examine differential relationships between specific factors of psychopathy and schizotypy in a non-psychiatric and non-forensic sample. Two hundred and twelve undergraduate students (50% female) completed the Schizotypal Personality Questionnaire (SPQ) and the Psychopathic Personality Inventory-Revised (PPI-R). After controlling for age and sex, regressions showed that the total SPQ score was positively related to the total PPI-R score and the Self-Centered Impulsivity factor, and negatively related to the Fearless Dominance factor. Self-Centered Impulsivity was positively related to all three SPQ factor scores, with the strongest relationship found with the Cognitive-Perceptual factor. In contrast, Fearless Dominance was negatively related to only the Interpersonal and Disorganized factors of the SPQ, with the strongest relationship found with the Interpersonal factor. Findings suggest that the comorbidity of schizotypy and the self-centered impulsivity aspect of psychopathy is not limited to extreme discrete populations, but exists in a more dimensional manner within a non-psychiatric sample. In addition, it appears that schizotypy is negatively related to the fearless dominance aspect of psychopathy, which appears to be a novel finding. Results provide preliminary findings that may have implications for developing appropriate prediction, assessment, and treatment techniques for violent behavior in schizophrenia-spectrum disorders.

Subtypes of aggression in patients with schizophrenia: the role of personality disorders

BACKGROUND

Research has repeatedly demonstrated that schizophrenia has a small but significant association with violence. It is further recognised that a subgroup of people with such links also have personality disorders, but the extent to which type of violence or aggression varies according to subgroup is less clear.

AIM

This study aimed to investigate, among co-morbid cases, if the number or type of personality disorders predicts type of aggression.

METHODS

In a cross-sectional study, 108 patients with schizophrenia were assessed for personality disorder, Axis-I diagnosis, verbal IQ, social functioning and type of aggression.

RESULTS

Logistic regression revealed that the more personality disorders identified (Cluster B personality disorders compared with Clusters A and C) and anti-social personality disorder compared with other Cluster B disorders significantly predicted premeditated aggression.

CONCLUSIONS

These findings suggest that detailed personality assessment should be a routine part of comprehensive assessment of patients with schizophrenia. Improved knowledge of the presence and type of personality disorders may help detect and manage the risk of some types of aggression.

A review and meta-analysis of the patient factors associated with psychiatric in-patient aggression

OBJECTIVE

To combine the results of earlier comparison studies of in-patient aggression to quantitatively assess the strength of the association between patient factors and i) aggressive behaviour,ii) repetitive aggressive behaviour.

METHOD

A systematic review and meta-analysis of empirical articles and reports of comparison studies of aggression and non-aggression within adult psychiatric in-patient settings.

RESULTS

Factors that were significantly associated with in-patient aggression included being younger, male, involuntary admissions, not being married, a diagnosis of schizophrenia, a greater number of previous admissions, a history of violence, a history of self-destructive behaviour and a history of substance abuse. The only factors associated with repeated in-patient aggression were not being male, a history of violence and a history of substance abuse.

CONCLUSION

By comparing aggressive with non-aggressive patients, important differences between the two populations may be highlighted. These differences may help staff improve predictions of which patients might become aggressive and enable steps to be taken to reduce an aggressive incident occurring using actuarial judgements. However, the associations found between these actuarial factors and aggression were small. It is therefore important for staff to consider dynamic factors such as a patient's current state and the context to reduce in-patient aggression.

Neuroimaging and neurocognitive correlates of aggression and violence in schizophrenia

Individuals diagnosed with major mental disorders such as schizophrenia are more likely to have engaged in violent behavior than mentally healthy members of the same communities. Although aggressive acts can have numerous causes, research about the underlying neurobiology of violence and aggression in schizophrenia can lead to a better understanding of the heterogeneous nature of that behavior and can assist in developing new treatment strategies. The purpose of this paper is to review the recent literature and discuss some of the neurobiological correlates of aggression and violence. The focus will be on schizophrenia, and the results of neuroimaging and neuropsychological studies that have directly investigated brain functioning and/or structure in aggressive and violent samples will be discussed as well as other domains that might predispose to aggression and violence such as deficits in responding to the emotional expressions of others, impulsivity, and psychopathological symptoms. Finally gender differences regarding aggression and violence are discussed. In this context several methodological and conceptional issues that limited the comparison of these studies will be addressed.

Schizophrenia spectrum disorders, substance misuse, and the four-facet model of psychopathy: the relationship to violence

OBJECTIVE

To investigate the relationship between the four-facet model of PCL-R psychopathy and violence in a community-based sample of Australian men with schizophrenia-spectrum disorders.

METHOD

A community sample of 94 males with schizophrenia-spectrum disorders was recruited from mental health services within Victoria, Australia. Psychopathy was measured using the PCL-R. Measures of substance misuse and lifetime violence were also administered.

RESULTS

PCL-R-total, Facets 2, 3, and 4 scores and substance misuse (DAST) scores were predictive of Violent versus Non-Violent group membership. The regression equation indicated that the predictive validity of PCL-R scores remained significant after controlling for substance misuse. An additional regression indicated that only Facets 3 and 4 were significant in predicting violence group membership.

CONCLUSION

Psychopathy (particularly the antisocial and behavioural components) was associated with lifetime violence, even after controlling for substance misuse. These findings have implications for the assessment, treatment, and management of health clients with schizophrenia-spectrum disorders.

Reduced hippocampal and parahippocampal volumes in murderers with schizophrenia

Evidence has accumulated to suggest that individuals with schizophrenia are at increased risk for violent offending. Furthermore, converging evidence suggests that abnormalities in the fronto-limbic system, including the prefrontal cortex, the hippocampus, and the parahippocampal gyrus, may contribute towards both neuropsychological disturbances in schizophrenia and violent behavior. Since the behavioral and clinical consequences of disturbed fronto-limbic circuitry appear to differ in schizophrenia and violence, it may be argued that patients with schizophrenia who exhibit violent behavior would demonstrate different structural abnormalities compared to their non-violent counterparts. However, the neurobiological basis underlying homicide offenders with schizophrenia remains unclear and little is known regarding the cross-cultural applicability of the findings. Using a 2 x 2 factorial design on a total Chinese sample of 92 males and females, we found reduced gray matter volume in the hippocampus and parahippocampal gyrus in murderers with schizophrenia, in the parahippocampal gyrus in murderers without schizophrenia, and in the prefrontal cortex in non-violent schizophrenia compared to normal controls. Results provide initial evidence demonstrating cross-cultural generalizability of prior fronto-limbic findings on violent schizophrenia. Future studies examining subtle morphological changes in frontal and limbic structures in association with clinical and behavioral characteristics may help further clarify the neurobiological basis of violent behavior.