Temperament and character in homicidal patients with schizophrenia

Abstract

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.     

Temperament and character personality profile in relation to suicide attempts in patients with schizophrenia

Introduction

Schizophrenia is associated with a significant risk of suicide, and suicide still remains one of the main causes of death in schizophrenic patients. Beside classic risk factors for suicidality, temperament and character traits have been researched and considered as risk factors for suicidal behavior in recent years.

Method

Subjects were 94 patients with schizophrenia who were under treatment. All patients were in a stable phase of the illness. Patients with lifetime suicide attempt (n = 46) and without suicidal attempt (n = 48) were compared with each other in terms of temperament and character traits by using the Temperament and Character Inventory.

Results

Harm avoidance and persistence scores were higher in suicidal schizophrenic patients compared with nonsuicidal schizophrenic patients. The scores of self-directedness and cooperativeness were lower in suicidal schizophrenic patients compared with nonsuicidal schizophrenic patients. These 4 variables remained significant predictors of lifetime suicidal attempts in a logistic regression model.

Conclusion

To the best of our knowledge, the present study is the first that specifically compares schizophrenic patients with and without suicidal behavior by the Cloninger temperament and character model. Our data indicate that schizophrenic patients will show a greater risk for suicide according to certain personality configurations. However, to establish causal relationships between personality and suicidality in schizophrenia, longitudinal studies are warranted within a multifactorial interactive framework of biologic and clinical variables.     

Temperament and character in individuals at ultra-high risk for psychosis and with first-episode schizophrenia: Associations with psychopathology,psychosocial functioning,and aspects of psychological health

Objective

The psychobiological model of temperament and character indicates that personality traits are heritable and, during development, constantly influence one’s susceptibility to schizophrenia. Our objective was to evaluate temperament and character in subjects at ultra-high risk (UHR) for psychosis and individuals with first-episode schizophrenia.

Methods

UHR for psychosis subjects (n = 50), first-episode schizophrenia patients (n = 33), and normal controls (n = 120) were compared on temperament and character dimensions, and correlation analysis of each personality dimension with psychopathologies, global and social functioning, and self-esteem. General and social self-efficacy reports were conducted. UHR subjects were followed-up for 24 months and the baseline personality dimensions were compared between the converted and non-converted groups.

Results

Both clinical groups showed abnormal personality traits in terms of temperament (higher harm avoidance, lower reward dependence and persistence) and character (lower self-directedness and cooperativeness). Psychosocial functioning and psychological health components were found to be correlated with some personality dimensions. The conversion rate of overt psychotic disorder was 25.0% at the 24-month follow-up. Baseline cooperativeness dimension was a significant predictive dimension for conversion into overt psychosis in the UHR group during the follow-up period.

Conclusion

Patients with first episode schizophrenia have a pervasively altered personality profile from normal controls. More importantly, this altered personality profile already emerged in putative prodromal, UHR individuals. The present findings indicate that certain personality traits can play a protective or vulnerable role in developing schizophrenia.     

The structure of schizotypy: relationships between neurocognitive and personality disorder features in relatives of schizophrenic patients in the UCLA Family Study

Schizotypal personality features and certain neurocognitive deficits have been shown to aggregate in the relatives of schizophrenic patients, supporting the view that both are likely to reflect genetic contributions to liability to schizophrenia. Within the relatives of schizophrenic patients, however, the interrelationships between these potential indicators of liability to schizophrenia are not well known. Using data from the UCLA Family Study, we examine the interrelationships between personality disorder symptoms and neurocognitive functioning in nonpsychotic first-degree relatives of schizophrenic patients. Factor analyses indicate that several dimensions of schizotypy can be identified. A neurocognitive dysfunction dimension includes loadings from measures of sequential visual conceptual tracking, rapid perceptual encoding and search, and focused, sustained attention as well as the rating of odd and eccentric behavior from schizotypal personality disorder. Other aspects of schizotypal personality disorder form separate positive schizotypy and negative schizotypy dimensions. These analyses support the view that schizotypy is multidimensional in relatives of schizophrenic patients and indicate that neurocognitive deficits in perception and attention are associated with particular schizotypal personality features.     

Risk factors and correlates of violence among acutely ill adult psychiatric inpatients

OBJECTIVE: The purpose of the study was to identify risk factors and correlates of violence committed by patients in an acute adult psychiatric inpatient unit in a district general hospital of the United Kingdom's National Health Service. METHODS: Incidents of violence committed by inpatients over a one-year period in 1997-1998 were retrospectively analyzed. The clinical characteristics of 49 violent patients were compared with those of all patients admitted to the unit during the study period (N=474) and with a random sample of nonviolent patients (N=140). Logistic regression analysis was used to identify clinical variables that predicted violent behavior. RESULTS: Violence was not positively associated with schizophrenia or negatively associated with depression. Frequent medication change, high use of sedative drugs, past violent behavior, an ICD-10 diagnosis of dissocial personality disorder or emotionally unstable personality disorder (DSM-IV antisocial personality disorder or borderline personality disorder), and long hospitalization were the most powerful predictors of violence. Together these variables had a sensitivity of 76 percent, a specificity of 97 percent, and a positive predictive value of 90 percent in predicting which patients became violent. Compulsory (involuntary) admission, comorbid diagnoses, past self-harm, and nonalcohol drug abuse were also associated with violent behavior. CONCLUSIONS: Clinicians' judgment about an inpatient's potential for violence may be augmented by knowledge of the risk factors identified in this study. Medication variables could be especially useful predictors, particularly when information about other risk factors is not available. Factors other than mental illness per se may be crucial determinants of violence in acute inpatient settings.     

Characteristics of Violent Versus Nonviolent Patients with Schizophrenia

Recent research has demonstrated an associative link between some forms of mental illness and violence. While much of this violence is committed by persons with schizophrenia, the characteristics of violent versus nonviolent schizophrenic patients has received limited attention. Two studies with small sample sizes compared these groups on psychological dimensions in acute care settings, but there appears to be no study of continuing care inpatients. This study compared a statewide sample of violent and nonviolent inpatients with schizophrenia on several domains of social interpersonal behavior. In a between-group analysis, violent patients showed evidence of serious dysfunction in community self-care and community adjustment, whereas the nonviolent were more impaired in the areas of depression, restlessness, and internal confusion. A within-group analysis of patients with interpersonal violence and those with noninterpersonal violence yielded similar findings of serious community dysfunction versus internal confusion. The implications are discussed.     

Temperament and executive dysfunctions in schizophrenia

Recent studies suggest that both executive dysfunction and personality traits combine with symptoms to affect the social outcome of persons with schizophrenia. This study was designed to investigate how personality traits influence executive function in schizophrenia. Forty-four patients with schizophrenia and twenty-two healthy subjects were assessed for personality using the temperament and character inventory. Different aspects of executive function were assessed using the Auditory Digit Span (forward and backward) and the Wickens' test for proactive interference and release. The results showed that the influences of the various temperament dimensions on specific aspects of executive functions differ between patients and healthy subjects. On some dimensions, schizophrenia appears to reduce the cognitive differences related to temperament. On other dimensions, schizophrenia tends to reverse the cognitive differences related to temperament observed in healthy people. These results suggest that the temperamental profile of schizophrenia patients may well be of important prognostic value in the planning of cognitive enhancement therapy.     

Criminal and violent behavior in schizophrenic patients: An overview

Abstract  An overview of the most important older and newer results regarding the relationship between violent and criminal behavior on the one hand and schizophrenic illness on the other hand is presented. Four different methods are available to study this relationship: (i) study of the prevalence of mental illness in criminal/violent populations; (ii) study of criminality/violence rate in samples of psychiatric patients; (iii) study of criminality/violence in community samples comparing mental patients with non-patient community residents; and (iv) study of criminality/violence in birth cohorts prospectively. All these methods have been used; but samples composed of schizophrenic patients exclusively were only exceptionally studied. The results indicate that there is a modest but significant relationship between schizophrenia and violence and crime which persists even after controlling for demographic and socio-economic variables. The probability of schizophrenic patients to be criminal or violent depends on the acuity of their illness and is increased by their use of psychoactive substances. Generally, however, violent and criminal acts directly attributable to mental illness account only for a very small proportion of such acts in the society.     

Temperament and character dimensions of the relatives of schizophrenia patients and controls: the relationship between schizotypal features and personality.

PURPOSE: Previous findings indicated that schizophrenia patients might have a different personality structure from the general population on several dimensions of temperament and character. Some authors proposed that HA might be a marker of underlying genetic vulnerability to schizophrenia. Studies on high-risk subjects and first degree relatives of patients is essential to test the value of a measure as a marker of genetic vulnerability to a disease. Few studies tested the biopsychosocial model of personality on unaffected relatives of schizophrenia. SUBJECTS AND METHODS: We compared the Temperament and Character (TCI) profiles of 94 first degree relatives of schizophrenia and 75 controls. We also investigated the relationship between schizotypy and TCI dimensions in the study sample. RESULTS: The harm avoidance scores of the relatives of schizophrenia patients with schizotypal features were significantly higher. Self transcendence scores were also significantly higher among relatives with schizotypal features. In contrast, the relatives of the patients with schizophrenia who did not have schizotypal features had higher SD and C scores than the control group. DISCUSSION AND CONCLUSION: This finding is consistent with the previous findings which suggested harm avoidance as a vulnerability indicator of schizophrenia. Some character features like self transcendence might be also associated with schizotypal features.     

Effects of the label "schizophrenia" on causal attributions of violence.

We investigated the relation between the label of "schizophrenia" and causal attributions of violence. Undergraduates read 1 of 10 scenarios in which two variables were manipulated: a psychiatric label and environmental stress. The scenario described an employee who acted violently toward his boss. Subjects made causal attributions for the employee's behavior by completing an adapted version of the Causal Dimension Scale II. Subjects also completed a questionnaire designed to explore several issues concerning the effects of the schizophrenia label on perceptions of behavior. Contrary to the primary hypothesis, the schizophrenia label did not lead subjects to make significantly more personality causal attributions for violent behavior. With increasing environmental stress, subjects did make significantly fewer personality attributions. A follow-up study using practicing clinicians as subjects yielded similar findings. The results of these studies are discussed in light of perceived stereotypes of persons with schizophrenia and conceptual issues in attribution research.     

Schizotypal dimensions: continuity between schizophrenia and bipolar disorders

BACKGROUND: Family studies have suggested that schizophrenia and bipolar disorders share some susceptibility factors. Schizotypal personality disorder (SPD) may be an intermediate phenotype common both to schizophrenia and bipolar disorders. We explored the familiality of schizotypal dimensions by comparing the magnitude of schizotypal dimensions between schizophrenic and bipolar relatives. We also looked for intra-familial resemblance for these dimensions, and for an increased familial risk of schizophrenia and/or bipolar disorders associated with a particular schizotypal dimension. METHODS: We used the Schizotypal Personality Questionnaire (SPQ) to study the three schizotypal dimensions (disorganization, negative and positive) in a sample of unaffected first-degree relatives of schizophrenic (N=85), psychotic bipolar (N=63) and bipolar (N=32) probands. Differences between groups were tested using a two-tailed t-test or ANOVA for continuous variables and a chi-squared test for discrete variables. We used the intraclass correlation method to study the intra-familial correlation. Linear mixed models were used to measure the familial risk. RESULTS: The disorganization dimension appears to be common to relatives of both schizophrenia and psychotic bipolar disorders, but not in the relatives of non-psychotic bipolar probands. This dimension also increases the familial risk of these two disorders. The negative dimension shows intra-familial resemblance (R=0.29), we failed to observe the expected familiality for the disorganized dimension. CONCLUSIONS: The shared nature of the disorganization dimension shown by a similar familial risk for schizophrenia and psychotic bipolar disorders suggests that same genetic background may underlie psychotic disorders. Although, negative dimension is familial, it is not associated for an increased familial risk for both disorders.     

Mental disorder and violence: personality dimensions and clinical features

OBJECTIVE: This review examines the role of personality dimensions in the greater rates of violence that have now been established to accompany certain classes of mental disorders. METHOD: Empirical studies are reviewed that have often used objective measures of personality and epidemiological samples with low levels of subject selection biases. RESULTS: The risk of violence may be understood in terms of four fundamental personality dimensions: 1) impulse control, 2) affect regulation, 3) narcissism, and 4) paranoid cognitive personality style. Low impulse control and affect regulation increase the risk for violence across disorders, especially for primary and comorbid substance abuse disorders. By contrast, paranoid cognitive personality style and narcissistic injury increase the risk for violence, respectively, in persons with schizophrenia spectrum disorders and in samples of both college students and individuals with personality disorders. CONCLUSIONS: This review supports the hypothesis that these four fundamental personality dimensions operate jointly, and in varying degrees, as clinical risk factors for violence among groups with these classes of mental disorders.     

Psychopathy and violent behavior among patients with schizophrenia or schizoaffective disorder.

OBJECTIVE: Although a strong association between violence and psychopathy has been demonstrated in nonpsychotic forensic populations, the relationship between psychopathy and violence among patients with schizophrenia has not been thoroughly explored. Patients with and without a history of persistent violent behavior were compared for comorbidity of psychopathy and schizophrenia or schizoaffective disorder. METHODS: Violent and nonviolent patients were identified through reviews of hospital charts and records of arrests and convictions. The Psychopathy Checklist: Screening Version was administered to 51 patients, 26 violent patients and 25 matched nonviolent patients. Analysis of variance was used as the principal statistical method for comparing violent and nonviolent groups. RESULTS: Mean psychopathy scores were higher for violent patients than nonviolent patients. Five of the violent patients (19 percent) had scores exceeding the cutoff for psychopathy, and 13 (50 percent) scored in the possible psychopathic range. All of the nonviolent patients scored below the cutoff for possible psychopathy. Higher psychopathy scores were associated with earlier age of onset of illness and more arrests for both violent and nonviolent offenses. CONCLUSIONS: The comorbidity of schizophrenia and psychopathy was found to be higher among violent patients than among nonviolent patients. Violent patients with schizophrenia who score high on measures of psychopathy may have a personality disorder that precedes the emergence of psychotic symptoms, or they may constitute a previously unclassified subtype of schizophrenia, characterized by early symptoms of conduct disorder symptoms and persistent violent behavior.     

Schizophrenia and violence

OBJECTIVE: The relationship between schizophrenia and violence is studied from a psychiatric and a public health perspective. METHOD: All epidemiological studies which have been published since 1990 are reviewed. RESULTS: Despite differences in the methodological approaches chosen the studies reviewed concur in supporting the assumption that there is a moderate but significant association between schizophrenia (or more generally psychotic disorders) and violence. However, compared with the magnitude of risk associated with substance abuse and personality disorders, that associated with schizophrenia or other major mental disorders is small. In addition, the elevated risk to behave violently appears to be limited to particular symptom constellations. The evidence available so far suggests that the proportion of violent crimes committed by people suffering from a severe mental disorder is small. There is no unambiguous evidence of an increase of violent acts committed by severely mentally ill people in general and people suffering from schizophrenia in particular during recent years. Strangers appear to be at an even lower risk of being violently attacked by someone suffering from severe mental disorder than by someone who is mentally healthy. CONCLUSION: While the assessment of relative risk is of great interest for psychiatric researchers who are trying to identify factors which may increase or decrease the risk of violent behaviour among the mentally ill, which in turn may provide some clues as to how to intervene best in order to reduce the risk, the attributable risk is of special interest for the public since it informs about the risk of becoming victim of a violent act committed by someone who is suffering from a mental disorder.     

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.     

Temperament in schizophrenia: a study of the tridimensional personality questionnaire (TPQ).

PURPOSE: The aim of this study was to assess dimensions of temperament as defined by Cloninger's neurobiological model using the tridimensional personality questionnaire (TPQ) in a sample of consecutively recruited schizophrenic patients. SUBJECTS AND METHODS: We used the French version of the TPQ to compare 45 stable, euthymic schizophrenic patients with 126 controls with no personal or familial history of psychiatric disorder. After comparison of TPQ scores between groups, we also performed a multivariate analysis to avoid the confounding effects of age, gender, and alcohol and substance use disorder comorbidity. Results: Harm avoidance (HA) was higher in schizophrenic patients than in controls. DISCUSSION AND CONCLUSION: This replicates and extends the results of previous studies suggesting that schizophrenic patients have high HA and that HA might be a marker for underlying genetic vulnerability to schizophrenia.     

Personality in schizophrenia assessed with the Temperament and Character Inventory (TCI)

The Temperament and Character Inventory (TCI) is a well-established self-report questionnaire measuring four temperament and three character dimensions. However, surprisingly few studies have used it to examine the personality of patients with schizophrenia, and none in Japan. Moreover, possible gender differences in personality among patients with schizophrenia have not been well documented. We administered the TCI to 86 Japanese patients with schizophrenia and 115 age- and gender-matched healthy controls to characterize personality traits in patients with schizophrenia and to examine their relationships with clinical variables, particularly gender and symptoms. Compared with controls, patients demonstrated significantly lower novelty seeking, reward dependence, self-directedness and cooperativeness, and higher harm avoidance and self-transcendence. Male patients showed even more pronounced personality alteration than female patients when both of them were compared with healthy people. Personality dimensions were moderately correlated with symptom dimensions assessed by the Positive and Negative Syndrome Scale (PANSS). These results, together with prior findings in several other countries, suggest that schizophrenia patients have a unique personality profile which appears to be present across cultures and that the greater alteration of personality in schizophrenia males might be related to their poorer social and community functioning.     

Regional cortical thinning in subjects with violent antisocial personality disorder or schizophrenia

Violent behavior is associated with antisocial personality disorder and to a lesser extent with schizophrenia. Neuroimaging studies have suggested that several biological systems are disturbed in schizophrenia, and structural changes in frontal and temporal lobe regions are reported in both antisocial personality disorder and schizophrenia. The neural substrates that underlie violent behavior specifically and their structural analogs, however, remain poorly understood. Nor is it known whether a common biological basis exists for aggressive, impulsive, and violent behavior across these clinical populations. To explore the correlates of violence with brain structure in antisocial personality disorder and schizophrenia, the authors used magnetic resonance imaging data to investigate for the first time, to the authors' knowledge, regional differences in cortical thickness in violent and nonviolent individuals with schizophrenia and/or antisocial personality disorder and in healthy comparison subjects. Subject groups included right-handed men closely matched for demographic variables (total number of subjects=56). Violence was associated with cortical thinning in the medial inferior frontal and lateral sensory motor cortex, particularly in the right hemisphere, and surrounding association areas (Brodmann's areas 10, 11, 12, and 32). Only violent subjects with antisocial personality disorder exhibited cortical thinning in inferior mesial frontal cortices. The biological underpinnings of violent behavior may therefore vary between these two violent subject groups in which the medial frontal cortex is compromised in antisocial personality disorder exclusively, but laminar abnormalities in sensorimotor cortices may relate to violent behavior in both antisocial personality disorder and schizophrenia.     

A national study of violent behavior in persons with schizophrenia

CONTEXT: Violent behavior is uncommon, yet problematic, among schizophrenia patients. The complex effects of clinical, interpersonal, and social-environmental risk factors for violence in this population are poorly understood. OBJECTIVE: To examine the prevalence and correlates of violence among schizophrenia patients living in the community by developing multivariable statistical models to assess the net effects of psychotic symptoms and other risk factors for minor and serious violence. DESIGN: A total of 1410 schizophrenia patients were clinically assessed and interviewed about violent behavior in the past 6 months. Data comprise baseline assessments of patients enrolled in the National Institute of Mental Health Clinical Antipsychotic Trials of Intervention Effectiveness. SETTING AND PATIENTS: Adult patients diagnosed as having schizophrenia were enrolled from 56 sites in the United States, including academic medical centers and community providers. MAIN OUTCOME MEASURES: Violence was classified at 2 severity levels: minor violence, corresponding to simple assault without injury or weapon use; and serious violence, corresponding to assault resulting in injury or involving use of a lethal weapon, threat with a lethal weapon in hand, or sexual assault. A composite measure of any violence was also analyzed. RESULTS: The 6-month prevalence of any violence was 19.1%, with 3.6% of participants reporting serious violent behavior. Distinct, but overlapping, sets of risk factors were associated with minor and serious violence. "Positive" psychotic symptoms, such as persecutory ideation, increased the risk of minor and serious violence, while "negative" psychotic symptoms, such as social withdrawal, lowered the risk of serious violence. Minor violence was associated with co-occurring substance abuse and interpersonal and social factors. Serious violence was associated with psychotic and depressive symptoms, childhood conduct problems, and victimization. CONCLUSIONS: Particular clusters of symptoms may increase or decrease violence risk in schizophrenia patients. Violence risk assessment and management in community-based treatment should focus on combinations of clinical and nonclinical risk factors.     

Neurological impairment in violent schizophrenic inpatients

This study relates violent behavior of schizophrenic inpatients to demographic, historical, EEG, neurological, and neuropsychological variables. Patients were classified into high (N = 28), low (N = 27), or no (N = 34) violence groups. There were no significant differences among the groups on demographic or historical variables, except for prevalence of violent crime, which was higher in both violent groups than in nonviolent patients. Neurological and neuropsychological abnormalities differentiated the groups, with the high violence group evidencing more abnormalities than the other two groups in the area of integrative sensory and motor functions. The authors suggest that violence as well as neurological and neuropsychological deficits may characterize a more severe form of schizophrenia.