Week1
Darrel-Barry et al (2016) - The relationship between paranoia and
aggression in psychosis
Studies reviewed showed mixed support for an association between paranoia and
aggression in both inpatients and community settings, however the most methodologically
robust studies found a positive association.
Meta-analytic studies have illustrated an average four-fold (males) and eight-fold (females) increase
in violent crime for people with schizophrenia compared with the general population. For those who
are, violence and aggression are major contributors to poor treatment outcomes and as such are
detrimental to the well-being of those who receive a diagnosis. Violence and aggression in people
with schizophrenia most often occurs during periods of active or untreated psychosis.
Paranoia, inclusive of persecutory delusions, is a common symptom of schizophrenia and
represents the unsubstantiated, yet intense and tenacious, belief that one is at threat of harm or
persecution from others.
Strong studies:
When comparing aggressive and non-aggressive groups of inpatients with psychotic disorders, three
studies found evidence of a relationship between paranoia and physical aggression. Those in
aggressive groups were more likely to report persecutory delusions and greater levels of
suspiciousness. Physically aggressive patients were more hostile/suspicious than non-physically
aggressive patients, whilst persistently physically aggressive patients were more hostile/suspicious
than transiently physically aggressive and non-physically aggressive patients.
All three studies controlled for confounders, such as substance use, antipsychotic medication dose,
length of current admission, gender and age.
Of the nine studies providing correlational data, six demonstrated a significant positive correlation
between paranoia and aggression. Other studies found no correlation, but those had methodology
problems according to the authors, mainly not controlling for confounds. Another study only found a
correlation when the aggression was self-report.
There is mixed support for an association between paranoia and aggression in people with
schizophrenia in both inpatient and community settings, which likely reflect three important
methodological shortcomings in reviewing the literature:
o i) studies were largely methodologically heterogeneous;
o ii) studies were based on a diverse range of aggression and violence measures;
o iii) studies varied greatly in their operationalization of aggression.
Delusional distress was found to mediate the relationship between persecutory ideation and
aggression in an inpatient sample (Van Dongen et al., 2012).
Similarly, those scoring above the median on delusions and suspiciousness/persecution items
were almost three times more likely to be seriously aggressive than those scoring below the
median on both items.
Considering previous evidence, two potential explanations for the association between paranoia and
aggression are possible:
Aggression as a safety behaviour: paranoid individuals have attentional bias for threat cues,
increasing their motivation to eradicate the cause of the threat.
Aggression as a retaliatory response (retribution)
There were a bunch of limitations and future research should have more methodological rigour bla
bla.
, Lau et al (2019) - Latent class analysis identified phenotypes in
individuals with schizophrenia spectrum disorder who engage in
aggressive behaviour towards others
Results of the Latent Class Analysis (LCA) technique revealed that three of Hodgins' theoretically
postulated patient Schizophrenia Spectrum Disorders (SSD) typologies could be identified.
People with SSD have an elevated risk of being convicted of homicides and (non-)violent crimes.
However, the group of SSD patients seems to be very heterogeneous.
Hodgin's theoretical framework offers three different subtypes:
1. Early starters (S): conviction before disorder (comparing age at first criminal registry entry
with age of disorder)
a. More often experienced adverse childhood experiences or showed conduct
problems.
b. Anti-social personality characteristics start early in life
b. similar to the ‘life course persistent’ delinquent group defined by
Moffitt (1993),
2. Late starters (LS): disorder before conviction, but at age 34 or under.
a. Their criminal behaviour is more likely to be attributable to cognitive and perceptual
(positive) symptoms of their disorder.
2. Late late starters (LLS) or first offenders (FO): disorder before conviction, but at age 35 or
older.
a. Predominantly males in their late thirties with chronic schizophrenia but without any
prior history of antisocial behaviour. Typically engaged in homicide of those caring for
them.
Applicable to SSD (incl. psychosis) and other serious mental illnesses (SMI).
latent class analysis (LCA) was performed: a type of finite mixture model designed for analyzing
multivariate categorical data. It groups each observation probabilistically into an unobserved (=
latent) nominal class, while minimizing the confusion between different observed items.
The results of this study support the existence of three distinct subgroups (Objective 1), using
different operationalizations of Hodgins’ typology (Objective 2) and variables (Objective 4), while
using a more novel statistical methodology (Objective 3).
Operationalizing Hodgin's typology by means of using first inpatient treatment, or diagnosis,
has shortcomings: Offending may delay treatment of SSD, and whether women are diagnosed
separately or not influences their age of diagnosis.
In conclusion, using age at first criminal registry entry may serve as a fair differentiator of
offender patients into Hodgins’ subgroups.
o Age of first criminal registry entry was classified as a. <21, b. 21-35, c.>35.
Overall, it may be more important for prevention, early intervention, and treatment of offenders with
SMI or SSD to provide further details on subgroups—including psychopathological variables and
current treatment efficacy. Measuring the presence and extent of personality disorders and
psychopathy in addition to SSD could be a first step in that direction. This study considered
personality disorders diagnosed prior to forensic admission, but available data was insufficient on the
diagnosis of personality disorders after admission and (the relatively novel) psychopathy scores for a
sufficient number of patients, which may be due to forensic hospitalizations considered in this study
dating back as far as 1982.
