Mark R. Serper

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.

Practice-related improvement in information processing with novel antipsychotic treatment

BACKGROUND Attentional deficits are prominent in schizophrenia, and skill learning is impaired. Novel antipsychotic treatment has been reported to improve certain cognitive skills in schizophrenic patients, but no information is yet available about the effect of newer medications on skill learning. METHODS Clinically stable patients with schizophrenia (n=16) and chronically hospitalized inpatients (n=8) were recruited while receiving conventional antipsychotic treatment. Subjects were tested at baseline on a visual continuous performance test (CPT), performed alone and simultaneously with an auditory CPT. Normal controls (n=8) were also tested at baseline. The inpatients and half of the outpatients were switched to treatment with risperidone. All patients then performed the visual CPT on a daily basis and performed the dual tasks once per week, for 4weeks. RESULTS Patients who remained on conventional medications did not improve in their performance despite the extensive practice on the test. Both chronic and stable patients receiving risperidone treatment manifested a statistically significant (P<0.05) improvement from baseline on both single and dual-task visual CPT. Stable outpatients performed significantly better at the end of the protocol than the normal controls performance at baseline (P<0.05). IMPLICATIONS These results suggest that practice-related improvements in the performance of information processing tests are enhanced by novel antipsychotic medications. Although the specific biological mechanism of this effect is not yet known, the results may suggest that use of newer medications will enhance skill development and perhaps facilitate rehabilitation of patients with schizophrenia.

Medication may be required for the development of automatic information processing in schizophrenia.

Medicated and unmedicated schizophrenic patients and normal subjects (ns = 4) were examined on the extent to which their information-processing performance became automated over time, as reflected by increased competence in dual task performance. The central task was a computerized version of the Continuous Performance Test, and the secondary task was a word-list shadowing task. Normal subjects and medicated schizophrenic patients became much more efficient at performing both tasks simultaneously with practice, with unmedicated patients showing no improvement over time.

Linguistic and cognitive failures in schizophrenia. A multivariate analysis.

Schizophrenic (N = 38), manic (N = 30), and normal (N = 25) subjects were examined with laboratory tasks measuring serial recall and encoding, distractibility, and reality monitoring. In addition, the psychiatric patients were examined with three measures of verbal communication disorder, including positive thought disorder, negative thought disorder, and frequency of reference failures. It was found that positive thought disorder and reference failures in schizophrenics were best predicted by measures of distractibility and reality monitoring, with communication disorder in mania, although common and severe, not predicted by these cognitive performance measures. Furthermore, negative thought disorder in schizophrenics was not predicted by the cognitive measures. These results are discussed in terms of their implications regarding the differences in potential determinants of positive and negative thought disorders.

Factorial structure of the hallucinatory experience: continuity of experience in psychotic and normal individuals.

Examination of the distribution of the hallucinatory experience may aide in the determination of their continuity and the psychological mechanisms that mediate their occurrence. Past investigators have found that hallucinatory experiences are not limited to disordered individuals and can be induced in the laboratory and occur naturally in the general population. Few reports to date, however, have directly investigated the continuity of the experience by comparing hallucinatory behavior of psychotic patients with a nonclinical sample. In the present study, we examined the architecture of the hallucinatory experience by comparing the factorial structure of the Launay-Slade Hallucination Scale using psychotic patients with active hallucinations, psychotic inpatients without hallucinations, and a group of university students. In support of the continuum model of psychosis, a very similar factor-analytic solution was obtained for all three groups. Discriminant function analysis, however, revealed that all groups achieved a high classified rate by their item responses. These results are consistent with the notion that expression of hallucinatory behavior exists along a continuum, but at a certain level of symptom severity beyond a critical threshold, the behavior becomes discontinuous and dysfunctional.

Empirical assessment of the factorial structure of clinical symptoms in schizophrenic patients: Formal thought disorder

Male schizophrenic patients (n = 142) were examined with a clinical assessment of their language dysfunctions with the Scale for the Assessment of Thought, Language, and Communication (TLC). Confirmatory factor analyses were conducted to test the relative fit of several differential theoretical models of the factorial structure of thought disorders. The models examined were positive-negative thought disorder, a three-factor model based on the results of an earlier exploratory factor analysis, and a simpler verbal productivity-disconnection model that can be extracted from other exploratory analyses and empirical studies. The positive-negative thought disorder model failed to fit the data, while the three-factor model fit the data, but no better than the simpler verbal productivity-disconnection model.

Neurocognitive Functioning in Recently Abstinent, Cocaine-Abusing Schizophrenic Patients

PURPOSE This report examined a broad range of cognitive functioning in a group of recently abstinent, cocaine-abusing schizophrenic patients (CA + SZ). METHODS Measures of selective and sustained attention, learning and memory, and executive functioning were administered to CA + SZ patients within 72 h of last cocaine use. A comparison group of non-substance-abusing schizophrenic patients (SZ) presenting for inpatient psychiatric treatment were also examined in an identical time frame. We hypothesized that the neurobiological impact of cocaine abuse and acute abstinence would cause CA + SZ to manifest deficits in all domains of cognitive functioning relative to non-abusing SZ patients. RESULTS Results revealed that CA + SZ displayed significant memory impairment relative to their non-abuser SZ counterparts. No group differences, however, were detected on any other neurocognitive measure. CA + SZ were able to selectively process digit strings during the presence and absence of distracting stimuli, sustain attention, and perform executive functions at performance levels equal to their non-abuser SZ counterparts. IMPLICATIONS These results are consistent with many past studies that have found CA + SZ patients to manifest memory impairment but have relatively well preserved functioning in other cognitive domains. The results are discussed in terms of the biological concomitants of cocaine abuse and acute abstinence in schizophrenia.

Predictors of aggression on the psychiatric inpatient service: Self-esteem, narcissism, and theory of mind deficits

Aggressive behavior committed by inpatients has significant negative effects on patients, clinical staff, the therapeutic milieu, and inpatient community as whole. Past research examining nonpsychiatric patient groups has suggested that elevated self-esteem and narcissism levels as well as self-serving theory of mind (ToM) biases may be robust predictors of aggressive behavior. In the present study, we examined whether these constructs were useful in predicting aggressive acts committed by psychiatric inpatients. Severity of psychiatric symptoms, demographic variables and patients’ anger, and hostility severity were also examined. We found patients who committed acts of aggression were differentiated from their nonaggressive counterparts by exhibiting significantly higher levels of self-esteem and narcissistic superiority. In addition, aggressors demonstrated self-serving ToM biases, attributing more positive attributes to themselves, relative to their perceptions of how others viewed them. Aggressors also showed increased psychosis, fewer depressive symptoms, and had significantly fewer years of formal education than their nonaggressive peers. These results support and extend the view that in addition to clinical variables, specific personality traits and self-serving attributions are linked to aggressive behavior in acutely ill psychiatric patients.

Increased susceptibility to auditory conditioning in hallucinating schizophrenic patients: a preliminary investigation.

Auditory hallucinations have been elicited in the laboratory after repeated pairings of a tone (unconditioned stimulus) with a light (conditioned stimulus), until the presentation of the light alone resulted in subjects hearing the tone. This auditory sensory-conditioning phenomenon was first reported in normal subjects over a half-century ago. But the model remains, to date, untested in actively hallucinating patients. If sensory-conditioning mechanisms actually mediate the occurrence of clinical hallucinations, one would expect that hallucinating patients would more readily acquire and be more resistant to extinguish a conditioned hallucination than nonhallucinating psychotic patients. The present study examined the susceptibility of 15 hallucinating and 15 nonhallucinating acute schizophrenic inpatients to acquire and maintain a sensory-conditioned hallucination response. Consistent with the auditory sensory-conditioning model, evidence suggests that hallucinating patients acquire and maintain sensory-conditioned hallucinations more quickly than their nonhallucinating counterparts. Results are discussed in terms of hallucinators’ susceptibility to sensory conditioning and suggestibility as important factors underlying hallucinatory behavior. The findings are interpreted with respect to the behavioral mechanisms underlying psychotic symptom formation.

Development and Preliminary Validation of a Questionnaire Assessment of Expressed Emotion

A questionnaire for measurement of expressed emotion was constructed. It consisted of two scales, criticism and emotional overinvolvement. The questionnaire and the Camberwell Family Interview were then administered to relatives of schizophrenics, and preliminary assessments of scale reliabilities and concurrent validities were done. Both questionnaire scales were reliable. With respect to validity, the criticism scale correctly classified 88% of the subjects relative to the criticism scale of the interview. The emotional overinvolvement scale was less satisfactory (67%) but still assisted in classification of over-all expressed emotion. Expressed emotion, classification by the questionnaire, correctly identified 84% of the subjects with respect to the interview.