Poor Executive Functioning Associated with the Risk of Aggressive Behavior Recidivism in the Forensic Community in Schizophrenic Patients

Ibishi F. Nazmie, Musliu R. Nebi, PhD, Hundozi Zylfije, PhD, Haxhiu Bekim, PhD

University Clinical Center of Kosovo, Pristina, Kosovo
*Corresponding author:  Zylfije Hundozi, MD, PhD. University Clinical Center of Kosovo. Te rrethi. 10000, Pristina, Kosovo.  Phone: +37744521616. E-mail: zylhundozi@hotmail.com
Published: June 25, 2013


Objective: The aim of this study was to investigate the relationship between the risk of aggressive behavior recidivism and poor executive functioning in a forensic setting in schizophrenic patients.
Methods: The data were collected over a two-year time period. The subjects in the study included 65 male adults ≥18, with schizophrenia disorder using SCID based on the DSM-IVR criteria and evaluated using PANSS, HCR-20, PCL-R and neuropsychological testing of the cognitive domains MMSE, WAIS-R, Stroop Color and Word Test, TMT A and TMT B tests. After a two-year follow up for recidivism of aggressive behavior, the subjects of the recidivism group were compared with a group showing no recidivism in terms of executive functioning, risk assessment, psychopathic and clinical psychopathology.
Results: The recidivism group revealed significantly lower and poorer scores in Stroop Color, Stroop Word, Verbal IQ, TMT A and TMT B tests than those belonging to the non-recidivism group. Logistic regression analysis determined that the poor verbal IQ and executive functions measured using the Stroop Word test were the strongest predictors of violent recidivism rate even age at first violence, social status, PANSS, PCL and total IQ factor.
Conclusion: Poor executive functioning appears to be associated with a high risk of aggressive behavior recidivism during mandatory treatment among the forensic community in patients with schizophrenia disorder. Neuropsychological assessments of executive dysfunction might probably identify psychiatric inpatients that could be at high risk for aggressive behavior recidivism in forensic settings.

aggressive behavior; executive function; risk assessment; schizophrenia.

1. Sharma T, Antonova L. Cognitive function in Schizophrenia. Deficits, functional consequences, and future treatments. Psychiatr Clin North Am 2003; 26 (1):25-40.
2. GoldbergTE, Gold JM. Neurocognitive functioning in patients with schizophrenia: an overview. In: Bloom, F.E. and Kupfer, D.J. (eds). Psychopharmacology: The fourth generation of progress. New York: Raven Press, 1995.
3. Pantelis C, Barnes T, Nelson H, Tanner S, Weatherley L, Owen AM, et al. Frontal-striatal cognitive deficits in patients with chronic schizophrenia. Brain 1997; 120:1823-43.
4. Perlstein WM, Carter CS, Barch DM, Baird JW. The Stroop task and attention deficits in schizophrenia: a critical evaluation of card and single-trial Stroop methodologies. Neuropsychology 1998; 12(3):414–425. 
5. Morris RG, Rushe T,Woodruffe PW, Murray RM. Problem solving in schizophrenia: a specific deficit in planning ability. Schizophr Res 1995; 14(3): 235- 46.
6. Link BG, Stueve A, Phelan J. Psychotic symptoms and violent behaviors: probing the components of “threat/control-override” symptoms. Soc Psychiatry Psychiatric Epidemiol 1998; 33(Suppl 1):S55–60.
7. Swanson JW, Holzer CE 3rd, Ganju VK, JonoRT. Violence and psychiatric disorder in the community: evidence from the Epidemiologic Catchment Area surveys. Hosp Community Psychiatry 1990; 41(7):761–70.
8. Barkataki I, Kumari V, Das M, Hill M, Morris R, O'Connell P, et al. A neuropsychological investigation into violence and mental illness. Schizophr Res 2005; 74(1):1-13.
9. Paschall MJ, Fishbein DH. Executive cognitive functioning and aggression: a public health perspective. Aggression and Violent Behavior 2002; 17:215-235.
10. Krakowski M, Convit A, Jaeger J, Lin S, Volavka J. Neurological impairment in violent schizophrenic inpatients. Am J Psychiatry 1989; 146(7): 849-53.
11. Adams JJ, Meloy JR, Moritz S. Neuropsychological deficits and violent behavior in incarcerated schizophrenics. J Nerv Ment Dis 1990; 178(4):253-6.
12. Forster HG, Hillbrand M, Silverstein M. Neuropsychological deficit and aggressive behavior: a prospective study. Prog Neuropsychopharmacol Biol Psychiatry 1993; 17(6):939- 46.
13. Rasmussen K, Levander S, Sletvold H. Aggressive and non-aggressive schizophrenics: symptom profile and neuropsychological differences. Psychol Crime Law 1995; 2:119- 29.
14. Roy S, Herrera J, Parent M, Costa J. Violent and nonviolent schizophrenic patients: clinical and developmental characteristics. Psychol Rep 1987; 61(3):855- 61.
15. Lapierre D, Braun CM, Hodgins S, Toupin J, Leveillee S, Constantineau C. Neuropsychological correlates of violence in schizophrenia. Schizophr Bull 1995; 21(2):253-62.
16. Lafayette MD, Frankle WG, Pollock A, Dyer K, Goff DC. Clinical characteristics, cognitive functioning, and criminal histories of outpatients with schizophrenia. Psychiatr Serv 2003;54(12):1635-40.
17. Silver H, Goodman C, Knoll G, Isakov V, Modai I. Schizophrenia patients with a history of severe violence differ from nonviolent schizophrenia patients in perception of emotions but not cognitive function. J Clin Psychiatry 2005; 66(3):300-8.
18. Krakowski M, Czobor P, Libiger J,Kunz M, Papezova H, Parker BB. Violence in schizophrenic patients: the role of positive psychotic symptoms and frontal lobe impairment. Am J Forensic Psychiatry 1997; 18:39-50.
19. Wong TH, Lumsden J, Fenton GW, Fenwick PB. Neuroimaging in mentally abnormal offenders. Issues Crim Leg Psychol 1997; 27:49-58.
20. Friendship C, McClintock T, Rutter S, Maden A. Re-offending: patients discharged from a regional secure unit. Criminal Behaviour Mental Health 1999; 9:226-236.
21. Maden A, Scott F, Burnett R, Lewis GH, Skapinakis P. Offending in psychiatric patients after discharge from medium secure units: prospective national cohort study. BMJ 2004; 328(7455):1534.
22. Yoshikawa K, Taylor PJ, Yamagami A, Okada T, Ando K, Taruya T, et al. Violent recidivism among mentally disordered offenders in Japan. Crim Behav Ment Health 2007; 17(3):137–151.
23. Nilsson T, Wallinius M,  Gustavson C,  Anckarsäter H,  Kerekes N. Violent recidivism: a long-time follow-up study of mentally disordered offenders. PLoS One 2011; 6(10): e25768. doi: 10.1371/journal.pone.0025768. Epub 2011 Oct 11.
24. SteinertT. Prediction of inpatient violence. Acta Psychiatrica Scandinavica. 2003; Vol 106, Issue Suppl s412: 133–141.
25. Putkonen H,  Komulainen EJ,  Virkkunen M, Eronen M, Lönnqvist J. Risk of repeat offending among violent female offenders with psychotic and personality disorders. Am J Psychiatry 2003; 160(5):947-951.
26. Kondel TK, Mortimer AM, Leeson VC, Laws KR, Hirsch SR. Intellectual differences between schizophrenic patients and normal controls across the adult lifespan. J Clin Exp Neuropsychol 2003; 25(8):1045-1056.
27. Bowie CR, Reichenberg A, Patterson TL, Heaton RK, Harvey PD. Determinants of real-world functional performance in schizophrenia subjects: correlations with cognition, functional capacity, and symptoms. Am J Psychiatry 2006;163(3):418-25.
28. Fresa A, Apiquian R, de la Fuente-Sandovol C, Loyzaga C, Garcia-Anaya M, Meyenberg N, Nicolini H. Violent behavior in schizophrenia patients: Relationship with clinical symptoms. Aggress Behav 2005; 31: 511–20.
29. Cheung P, Schweitzer I, Crowley K, Tuckwell V. Violence in schizophrenia: role of hallucinations and delusions. Schizophr Res 1997; 26(2-3):181–90.
30. Arango C, Calcedo-Barba A, Gonzalez-Salvador T, Calcedo-Ordo A. Violence in inpatients with schizophrenia: a prospective study. Schizophr Bull 1999; 25(3):493–503.
31. Nolan KA, Volavka J, Czober P, Sheitman B, Lindenmayer JP, Citrome LL, McEvoy J, Lieberman JA. Aggression and psychopathology in treatment-resistant inpatients with schizophrenia and schizoaffective disorder. J Psychiatr Res 2005; 39(1):109–15.
32. Hare RD. Psychopathy: a clinical and forensic overview. Psychiatr Clin North Am 2006; 29(3):709–24.
33. Vitacco MJ, Neumann CS, Jackson RL. Testing a four-factor model of psychopathy and its association with ethnicity, gender, intelligence, and violence. J Consult Clin Psychol 2005; 73(3): 466–76.
34. Skeem JL. Mulvey EP. Psychopathy and community violence among civil psychiatric patients: results from the MacArthur Violence Risk Assessment Study. J Consult Clin Psychol 2001; 69(3):358–74.
35. Skeem JL, Mulvey EP, Grisso T. Applicability of traditional and revised models of psychopathy to the Psychopathy Checklist: screening version. Psychol Assess 2003; 15(1):41–55.
36. Skeem JL, Miller JD, Mulvey E, Tiemann J, Monahan J. Using a five-factor lens to explore the relation between personality traits and violence in psychiatric patients. J Consult Clin Psychol 2005; 73(3):454–65.
37. Seguin JR, Pihl RO, Harden PW, Tremblay RE, Boulerice B. Cognitive and neuropsychological characteristics of physically aggressive boys. J Abnorm Psychol 1995; 104(4):614-624.
38. Giancola PR, Mezzich AC, Tarter RE. Executive cognitive functioning, temperament, and antisocial behavior in conduct-disordered adolescent females. J Abnorm Psychol 1998; 107(4):629-641.
39. Serper M,  Beech DR,  Harvey PD,  Dill C. Neuropsychological and symptom predictors of aggression on the psychiatric inpatient service. J Clin Exp Neuropsychol 2008; 30(6):700-9.
40. Dolan M, Anderson IM. Executive and memory function and its relationship to trait impulsivity and aggression in personality disordered offenders. Journal of Forensic Psychiatry 2002; 13(3): 503-526(24).
41. Frith CD. The cognitive neuropsychology of Schizophrenia. Sussex UK: Lawrence Erlbaum,1992

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