Violence in relation to cognitive deficits and symptom severity in a sample of Egyptian patients with schizophrenia

Abstract

Background:

Patient with schizophrenia are significantly more likely to be violent than general population; and the consequences of this violence risk are often very serious for the patients, their caregivers, and the entire community.

Aim:

To assess the risk of violence in patients with schizophrenia and its correlation with severity of symptoms and cognitive functions.

Methods:

A cross-sectional comparative study conducted in Okasha institute of psychiatry including 50 patients with schizophrenia compared to 50 healthy control group regarding violence risk as assessed by Historical, Clinical, and Risk Management-20 (HCR-20), case group was assessed using Structured Clinical Interview for DSM-IV (SCID-I), Positive and Negative Syndrome Scale (PANSS), cognitive functions were assessed by Wechsler Adult Intelligence Scale (WAIS), Trail Making Test (TMT) Part A and B, the Wisconsin Card Sorting Test (WCST), and the Wechsler Memory Scale (WMS).

Results:

There was a statistically significant difference between case and control groups regarding risk of violence where 58% of the case group were found to have risk of violence compared to only 18% in the control group. There was a significant correlation between this risk of violence and period of untreated psychosis, no of episodes, and history of substance use; also was significantly correlated with PANSS and Wisconsin card sorting test subscales. Regarding logistic regression analysis for factors affecting violence risk; total PANSS score and history of substance use were significant independent factors that increase violence risk.

Conclusion:

Keywords

Schizophrenia violence risk HCR 20 PANSS cognitive functions

Introduction

Schizophrenia is a severe form of mental illness that affects approximately 1% of the general population that frequently follows a chronic course, characterized by significant impairments in reality testing and alterations in behavior that broadly manifest in two types of symptoms: positive symptoms as delusions, hallucination, disorganized speech, and disorganized behavior; and negative symptoms in the form of blunted or flat affect, avolition, or apathy (Agarwal et al., 2015; World Health Organization, 2014); Making the disease burden in the Middle East being markedly greater than in developed countries and associated with a decline in social and occupational functioning (Alkhadhari et al., 2015; N. Meyer & MacCabe, 2016).

Regarding the violence risk in patients with schizophrenia; there is a controversy about the definite definition of violence where some studies use a restrictive definition of violence limiting their inclusion criteria based on history of a range of behaviors from destructive acts to severe physical violence such as assaults using a weapon resulting in injury to others or death while other studies use broader definitions that include threats and minor assaults; so violence can be defined as the expression of hostility and rage with the intent to injure or harm people or property through physical force (Chen et al., 2014; Large & Nielssen, 2008; VandenBos, 2007)

This risk of violence among patients with schizophrenia is dynamic and varies according to certain variables (environmental, clinical, and neuropsychological factors, including executive dysfunction) (Bo et al., 2011); and there are multiple factors affecting this risk including clinical characteristics of the patients as duration of untreated psychosis, number of episodes, current psychotic symptoms, and its severity, personality dimensions, cognitive abilities, childhood conduct problems, alcohol and substance misuse (Haddock et al., 2013; Imai et al., 2014).

One of the important factors affecting this risk of violence and considered an established predictor of disability is cognitive deficits; where recent evidence suggests that 50% to 70% of patients with schizophrenia have neuro-cognitive deficits across all stages of the illness (i.e. high risk, first episode, early and chronic phases) (Kadakia et al., 2022; Kelly et al., 2019) as cognitive impairment is an established feature of schizophrenia and is a strong predictor of eventual social and functional outcome which is largely responsible for the refractory nature of disability in schizophrenia (T. A. Okasha et al., 2020; Strassnig et al., 2018). These impairments are widespread and severely affecting attention, learning, memory, motor speed, verbal fluency, and executive functions to a magnitude corresponding to 1.5 or more S.D.s below normative standards (Harvey & Bowie, 2003; Jirsaraie et al., 2018), this global cognitive impairment and lack of insight appear to be significant risk predictors for aggression and future violence in schizophrenia (Darmedru et al., 2017) and deficits in executive functioning may be key components in the pathway that increases the propensity to violence in some patients with schizophrenia (Ahmed et al., 2018; Bulgari et al., 2017).

So one of the cardinal part in assessment of patient with schizophrenia is the accurate assessment of violence being the first step for effective prevention. So it is important to determine the predictors of violence among inpatients with schizophrenia for establishing effective prevention strategies (Erkiran et al., 2006).

Materials and methods

Participants

A comparative observational cross sectional study was conducted in Okasha Institute of Psychiatry, Faculty of Medicine, Ain Shams University Hospitals.

Using the PASS 11 program for sample size calculation, setting alpha error at 5% and power at 90%, results from previous study (L. F. Meyer et al., 2018) assuming prevalence of violence in patients with schizophrenia = 55% and in healthy controls = 20%, based on this the needed sample size consisted of at least 32 patients in case group and 32 participants in control group to detect this difference.

So our study included:

- The case-group: a convenient sample of 50 patients diagnosed with SCID I as schizophrenia according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; Bell, 1994) were recruited from the outpatient psychiatric clinics.

- The control-group: Fifty healthy subjects having no current or past psychiatric disorder were recruited from the relatives of the patients in internal medicine and surgical outpatient clinics.

In the two groups both male and female genders, age range from 18 to 50 years old were included after giving an informed written consent before enrollment in the study; with exclusion of patients diagnosed with other axis 1 psychiatric disorders, Patients with co-existing major central neurological disease, intellectual disability (Patients with IQ score below 90) or developmental disability, patients receiving electroconvulsive therapy sessions in the last 6 months before performing the cognitive function tests or participants who have refused to participate in the study were excluded.

Procedures

The researcher had interviewed the patients taking a full history then applied the following questionnaires to both the case and control groups:

Sociodemographic data: Sociodemographic data collection was done through a sheet designed by the researcher team.

Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I): is a widely used clinician-administered semi-structured interview intended to decide whether an individual meets criteria for any DSM disorder (First, 1997), in the current study it is administered to the case group by an experienced trained researcher using the Arabic version that was previously validated (Assad et al., 1992) to confirm diagnosis of schizophrenia and to exclude any comorbid neuropsychiatric disorders.

The General Health Questionnaire (GHQ): is a psychometric screening tool for identifying minor psychiatric disorders in the general population or non-psychiatric clinical settings (Goldberg & Hillier, 1979); the validated Arabic version of GHQ (A. Okasha et al., 1988) was administrated to the control group.

Positive and Negative Syndrome Scale (PANSS): is a semi structured clinical scale which is gold standard in assessing symptom severity of patients with schizophrenia (Kay et al., 1987), it was carried by a clinician for a considerable clinical judgment for the cases, it consists of 30 items covering three cardinal symptoms of schizophrenia (positive symptoms, negative symptoms, and general psychopathology).

Historical Clinical Risk Management-20: is a psychometric scale used for the assessment and management of violence risk (Douglas et al., 2013), HCR-20 is divided into three subscales: Historical (10 items), Clinical (5 items), and Risk Management (5 items) (L. F. Meyer et al., 2018). Although this scale does not have a cutoff point to identify violent behavior and the final score should be contextualized individually; some previous studies considered Participants to be violent according to clinical criteria and scoring ⩾21 on HCR-20 and Participants to be nonviolent according to clinical criteria and scoring ⩽20 on HCR-20 (L. F. Meyer et al., 2018; Telles et al., 2009).

Wechsler Adult Intelligence Scale (WAIS): is the most commonly administered general intelligence test for adults and is also viewed as a broad assessment of cognitive functions (Wechsler, 1981), in the current study we used the validated Arabic version by Melika (1996) that have been done by an expert clinical psychologist.

Wechsler Memory Scale (WMS): is one of the most widely used instruments to assess memory functions in adults (Wechsler, 1987(. The used version is the fourth edition (WMS-IV) done by an expert clinical psychologist in about 45 minutes to 1 hour .The WMS-IV Adult battery is made up of seven subtests: Spatial Addition, Symbol Span, Design Memory, General Cognitive Screener, Logical Memory (I and II), Verbal Paired Associates (I and II), and Visual Reproduction (I and II) (Hunsley & Lee, 2017).

Trail Making Test (TMT) Part A and B (Corrigan & Hinkeldey, 1987): is a neuropsychological test of visual attention and task switching. It consists of two parts applied by an expert clinical psychologist in which the subject is instructed to connect a set of 25 dots as quickly as possible while still maintaining accuracy. The test can provide information about visual search speed, scanning, speed of processing, mental flexibility, as well as executive functioning.

Wisconsin Card Sorting Test (The computerized version): WCST is probably the most paradigmatic test to assess prefrontal functioning and executive function as it allows the clinician to assess the following ‘frontal’ lobe functions: strategic planning, organized searching, utilizing environmental feedback to shift cognitive sets, directing behavior toward achieving a goal, and modulating impulsive responding (Grant & Berg, 1948; Monchi et al., 2001).

Statistical analysis

The collected data was revised, coded, tabulated and introduced to a PC using Statistical package for Social Science (SPSS 25). Data was presented and suitable analysis was done according to the type of data obtained for each parameter using Mean, Standard deviation, and range for parametric numerical data, while Median and Interquartile range (IQR) for non-parametric numerical data, Student T Test, Mann Whitney Test, ANOVA test, The Kruskal-Wallis, Post Hoc Test, Chi-Square test, Fisher’s exact test, Correlation analysis (using Spearman’s rho method), A p value less than .05 was considered statistically significant.

Results

The study sample consists of 100 participants distributed as 50 cases and 50 controls meeting the inclusion and exclusion criteria. This studied groups were matched regarding the age group, gender, educational level, and marital status with no significant differences among the two groups, where all participants were aged between 18 and 50 years with a Mean ± SD of 35.18 ± 8.39 years, 70% of them were males and 30% were females, with the majority of the case group being single (62%), unemployed (46%).

Comparative results between both groups

➢ Regarding the violence risk among the studied sample assessed using HCR 20; there was a highly statistically significant difference found between case group and control group regarding risk of violence where 58% of the case group were found to have risk of violence (Violent group) compared to only 18% of the control group only as shown in Table 1.

Table 1.

Comparison between case and control group regarding risk of violence using HCR-20.

	Group		Chi-Square test
	Case	Control	Chi-Square test
	N (%)	N (%)	χ²	p-Value	Sig.
Risk for future violence
No risk of violence	21 (42)	41 (82)	17.382	<.001	HS
Positive risk of violence	29 (58)	(18)	17.382	<.001	HS

Correlation of risk of violence to clinical characteristics of the case sample

➢ Regarding the bivariate analysis of violence risk and clinical characteristics of the case group; there was statistically significant relation found between violence risk and no of episodes, duration of untreated psychosis, relapse and presence of history of substance use with p-value .001, .047, >.001, and .002 respectively, also there was a highly statistically significant relation found between violence risk and severity of symptoms as regard positive symptoms, negative symptoms and total PANSS score with p-value >.001 for all of them as shown in Table 2.

Table 2.

Relation between violence risk and clinical characteristics of the case group.

		Risk for future violence		Test of significance
		Non violent	Violent	Test of significance
		Median (IQR)	Median (IQR)	Value	p-Value	Sig.
		N (Row %)	N (Row %)	Value	p-Value	Sig.
No of episodes	First episode	7 (100)	0 (0)	Fisher’s exact test	.001	S
No of episodes	Multiple episodes	14 (32.56)	29 (67.44)	Fisher’s exact test	.001	S
DUP (duration of untreated psychosis)	Less than 6 months	16 (53.33)	14 (46.67)	χ2 = 3.955	.047	S
DUP (duration of untreated psychosis)	6 months or more	5 (25)	15 (75)	χ2 = 3.955	.047	S
Relapse /Remission	In relapse	0 (0)	24 (100)	χ2 = 37.369	<.001	HS
	Partial remission	8 (61.54)	5 (38.46)
	Full remission	13 (100)	0 (0)
FH of psychiatric illness		6 (42.86)	8 (57.14)	χ2 = 0.006	.939	NS
History of substance use		3 (18.75)	13 (81.25)	χ2 = 5.221	.022	S
PANSS positive		12 (9–17)	28 (21–32)	z = −5.145	<.001	HS
PANSS negative		9 (8–12)	18 (12–24)	z = −3.993	<.001	HS
PANSS Gp		19 (17–25)	32 (25–45)	z = −4.123	<.001	HS
Total PANSS Score		38 (35–54)	76 (59–107)	z = −4.690	<.001	HS

Mann-Whitney test of significance (z). Chi-Square test of significance (χ²).

Correlation of risk of violence to cognitive functions

➢ There was no statistically significant relation found between violence risk and Trail Making part A and B and also all domains of Wechsler memory scale, Meanwhile there was a statistically significant relation found between violence risk and Wisconsin card sorting test as regard total correct score, % of conceptual level response, categories completed and trials to complete first category with p-value .002, .004, .003, and .023 respectively as shown in Table 3.

Table 3.

Relation between violence risk and cognitive functions.

	Risk for future violence		Mann-Whitney test
	Non violent	Violent	Mann-Whitney test
	Median (IQR)	Median (IQR)	z	p-Value	Sig.
Trial making Part A and B
Trail making part B	165 (126–190)	161 (120–195)	−0.059	.953	NS
Trail making part A	62 (46–71)	69 (55–80)	−1.534	.125	NS
Wechsler memory scale
WMS visual memory span total	12 (11–12)	11 (10–12)	−1.349	.177	NS
WMS visual memory span back	5 (4–6)	5 (4–5)	−0.683	.494	NS
WMS visual memory span forward	7 (6–7)	6 (5–7)	−1.328	.184	NS
WMS digit span total	10 (9–12)	10 (8–12)	−1.109	.267	NS
WMS digit span back	4 (4–6)	4 (3–5)	−1.03	.303	NS
WMS digit span forward	6 (5–7)	5 (5–6)	−1.317	.188	NS
WMS visual PA2	3 (2–5)	3 (2–4)	−0.802	.422	NS
WMS visual PA1	5 (4–6)	5 (4–6)	−0.59	.555	NS
WMS verbal PA2	5 (4–5)	5 (4–5)	−0.308	.758	NS
WMS verbal PA1	8 (7–10)	8 (6–8)	−1.185	.236	NS
WMS information	13 (12–14)	13 (13–14)	−0.138	.89	NS
Wisconsin card sorting test
WCST total correct	48 (42–52)	38 (28–45)	−3.148	.002	S
WCST total errors	16 (12–22)	26 (19–36)	−3.148	.002	S
WCST perseverative responses	19 (9–25)	15 (8–28)	−0.108	.914	NS
WCST perseverative errors	9 (7–16)	13 (8–22)	−1.122	.262	NS
WCST non perseverative errors	5 (3–7)	10 (8–15)	−4.106	<.001	HS
WCST conceptual level responses	44 (34–49)	27 (18–42)	−2.911	.004	S
WCST % conceptual level responses	69 (53–77)	42 (28–66)	−2.911	.004	S
WCST categories completed	4 (3–5)	2 (2–3)	−3.009	.003	S
WCST trials to complete first category	11 (6–16)	15 (12–20)	−2.265	.023	S
WCST failure to maintain set	0 (0–1)	0 (0–1)	−0.68	.496	NS

Logistic regression analysis for factors affecting violence risk among case group

➢ It was found that Total PANSS score and History of substance use were significant independent factors that increase the likelihood of being violent with p-value .001 and odds ratio with 95% CI of 1.08 [1.03–1.14] for total PANSS score and p-value .029 and odds ratio with 95% CI of 7.24 [1.23–42.61] for history of substance use as shown in Table 4 .

Table 4.

Logistic regression model for factors affecting violence risk among the studied case group.

		OR (95% CI)	B	p-Value	Sig.
Step 1	Total PANSS score	1.07 (1.02–1.13)	.070	.007	S
	WMS visual memory span total	0.63 (0.36–1.1)	−.457	.107	NS
	WCST % conceptual level responses	1.11 (0.81–1.53)	.103	.526	NS
	WCST total correct	0.81 (0.39–1.66)	−.214	.559	NS
	WCST categories completed	0.53 (0.19–1.52)	−.626	.239	NS
	History of substance use (1)	6.01 (0.86–42.02)	1.793	.071	NS
	PUP (period of untreated psychosis) (1)	2.01 (0.27–14.69)	.696	.493	NS
Step 2	Total PANSS score	1.08 (1.03–1.14)	.079	.001	S
Step 2	History of substance use (1)	7.24 (1.23–42.61)	1.980	.029	S

Note. Variable(s) entered on step 1: Total PANSS Score, WMS Visual Memory Span Total, WCST % conceptual level responses, WCST total correct, WCST categories completed, history of substance use, PUP (period of untreated psychosis).

Discussion

Violence risk either verbal or physical, causing minor or major assaults is one of the cardinal factors that affect the quality of life of patients with schizophrenia, their caregivers, and their society (Aubeeluck & Luximon-Ramma, 2020); so it is important to understand the factors that aggravate this risk of violence in order to prevent this risk and its consequences (Chen et al., 2014); our study have been designed to investigate violence risk in patient with schizophrenia and illustrate the correlation between this risk, clinical characteristics of patients, severity of schizophrenic symptoms, and cognitive functions.

Our results indicated that there was a highly statistically significant difference between case group and control group regarding risk of violence where 58% of the case group were found to have risk of violence (Violent group) compared to only 18% in the control group; These results were consistent with a study done by L. F. Meyer et al. (2018) in which 50% of the patients were violent and 50% were non-violent; this could be explained by the evidence of greater risk of violence among patients with schizophrenia compared to the general population as proven by recent researches especially in the presence of other risk factors as comorbid substance use (Bo et al., 2011).

Correlation between risk of violence and sociodemographic data

Regarding the age range; we have found that the mean age for the violent group being 36.79 ± 7.84 and mean age for nonviolent group being 32.95 ± 8.79; these results were partially in line with a study done by Wang et al. (2020) in which the mean age of violent patients was 44.82 ± 12.95; this age difference between violent and nonviolent groups could be explained by the fact that for some patients, the symptoms of schizophrenia may appear to worsen over time and become so severe that they engage in erratic or violent behavior (Whiting et al., 2022).

Also we have found that there was no statistically significant relation between risk of violence and gender; which could be explained by the point that despite men with schizophrenia are reported to commit severe acts of violence more frequently than women, less severe aggressive behaviors, such as verbal insults and threats, are seen more frequently among women (Elbogen & Johnson, 2009), but these results were in contrast with a study done by Fazel et al. (2009) in which almost 11% of men with schizophrenia and 3% of women were ever convicted of a violent offence; this could be explained by the presence of different clinical risk factors as comorbid substance use, impulsivity and personality traits which are more prevalent in men (Seeman, 2019).

As regard the relation between risk of violence and marital status we have found that there was no statistically significant relation between risk of violence and the marital status of the patient; there is a controversy regarding the relation between violence and marital status in different studies in different countries as this relation can be affected by different social and cultural factors; as in some studies they found that being unmarried can be a risk for violence and aggression due to few family members or caregivers and lack of emotional support in the social network of unmarried patients than married ones which is essential in the treatment and daily care of the patients (Ran et al., 2003; Van de Sande et al., 2013).

Correlation between risk of violence and clinical characteristics of the case group

Regarding the correlation between the violence risk in patient with schizophrenia and clinical characteristics of them we have found that there was a statistically significant relation between risk of violence and no of episodes of psychosis that the patients developed throughout their illness where 67.4% of the patients who developed multiple episodes of schizophrenia were within the violent group showing that the risk of violence proportionately increased by increasing number of episodes associated with increasing the severity of symptoms that the patients developed making them more vulnerable to engage in violent behavior; our finding were in agreement with the findings reported by Bobes et al. (2009) that showed that each relapse or acute episode occurring within the year increases the likelihood of occurrence of a violent episode. But our finding was inconsistent with the finding of Nielssen et al. (2012) that showed that most of the violent attempts done by psychotic patients are in their first episode of psychosis; this could be explained that the patient’s first hospitalization due to violence risk that have been considered the first episode of psychosis may not be the first time they have experienced a psychotic episode; and that their previous episodes have not been accompanied by violence risk (Adams & Yanos, 2020).

Similarly we have found that there was a statistically significant relation between risk of violence and duration of untreated psychosis as we found that 75% of patients who have DUP more than 6 months were within the violent group while only 46.6% of the patients with DUP less than 6 months were in the violent group; our results were in line with systemic reviews done by Large and Nielssen (2008), Látalová (2014), and Howes et al. (2021) that showed that longer duration of untreated psychosis (DUP) leads to poorer outcomes and was associated with a higher proportion of patients who committed homicide prior to receiving treatment.

This was also illustrated by a meta-analysis included a total of 48 publications that examined the association of DUP with symptom severity at first treatment contact and with treatment outcomes; showed that shorter DUP was associated with greater response to antipsychotic treatment, as measured by severity of global psychopathology, positive symptoms, negative symptoms, and functional outcomes. So similar to many other illnesses, early intervention may improve long-term outcomes of psychoses preventing this violence risk. Thus, DUP can be seen as a modifiable determinant of outcome (Látalová, 2014; Perkins et al., 2005).

On bivariate analysis of risk of violence and the current state of illness (in relapse/in remission); we have found that 100% of the patients who were in relapse (24 patients) had more violence risk than patients who were in remission as only 38.4% of patients in remission were in the violent group showing that relapse in patients with schizophrenia has devastating consequences, including worsening symptoms, impaired functioning, cognitive deterioration, and reduced quality of life and as a result violence risk will increase in those patients (Olivares et al., 2013), our findings were consistent with studies done by Volavka (2013), Hodgins et al. (2013), and Seidel et al. (2019) that showed increasing of violence risk in acute phase of schizophrenia.

Moreover our study has found that there was a statistically significant relation between the risk of violence and the presence of history of substance use in patients with schizophrenia where 81.2% of the patients who had positive history of substance use were within the violent group while only 18.7% of patients with negative history of substance use were within the violent group showing that comorbid substance abuse have a strong mediating role in aggravating violence risk. Our result were in agreement with multiple studies as Whiting et al. (2021), Brown et al. (2019), and Erkiran et al. (2006) and various other studies that all have showed the strong statistically correlation between violence risk in patient with schizophrenia and history of substance abuse or comorbidity with substance abuse as individuals with comorbid psychosis and substance misuse are roughly two to three times more likely to engage in serious violence than those who do not misuse substances as it can facilitate the expression of aggressive and violent behavior because substances reduce inhibitions in the pro-social expression of anger (Rampling et al., 2016).

There are several mechanisms by which co-occurring substance abuse may be implicated in violence risk in schizophrenia; acute pharmacological effects of alcohol and certain drugs may exacerbate psychiatric symptoms. Violence risk increases when substance abuse is added to the combinations of impaired impulse control and symptoms such as hostility, threat perception, grandiosity, and dysphoria. Substance use disorders are also associated with treatment non-adherence, which increases the risk for violence in patients with schizophrenia (Volavka & Citrome, 2011).

A similar finding was reported in a longitudinal study by Fazel et al. (2009) where the rates for violent crime among patients with schizophrenia with comorbid substance abuse were three times higher than for patients with schizophrenia, without substance abuse, so substance misuse is a consistent and significant factor in violent behavior among individuals with psychosis and can be a significant barrier to treatment adherence and success (Reagu et al., 2013).

Correlation of risk of violence to schizophrenia symptoms (PANSS)

Regarding bivariate analysis between violence risk and severity of symptoms; there was a strong statistically significant relation found between violence risk and severity of symptoms as regard positive symptoms, negative symptoms, and total PANSS score with p-value >.001 for all of them; this could be explained by the role that the psychotic symptoms may play a role in giving individuals a clear motivation for violence especially positive symptoms particularly those underlying persecutory ideations, where an association between violence in patients with mental illness and a certain constellation of symptoms referred to as ‘threat-control override’ has been observed where the occurrence of these ‘threat/control-override’ symptoms was significantly correlated with violent acts, as when an individual with mental illness feels threatened, and when his or her internal controls are compromised then violence becomes more likely as an understandable response, that is, when seen as a defense or retaliation against harmful and manipulative actions that the person believes to be directed against himself or herself (Carabellese et al., 2014).

Additionally negative symptoms may increase violence risk in specific circumstances; as in case of comorbid substance use or personality disorders that may give rise to motivations for violence, lack of inhibitions to act violently by impairing one’s ability to experience empathy, remorse, or anxiety. Also negative symptoms that result in depression or suicidality may increase violence risk, as morbid thoughts of self-harm may change or expand in focus to include others (Douglas et al., 2009).

Our finding were in line with studies done by Zhu et al. (2016) and Fresán et al. (2005) and met-analysis done by Douglas et al. (2009); that showed that Patients with exacerbation of psychotic symptomatology have an increased risk of violent behavior especially disturbances in thought, perception, and behavior, on the other hand, Our results were partially consistent with a study done by Volavka (2013) and study done by Swanson et al. (2006) in which 1,410 schizophrenia patients were clinically assessed and interviewed about violent behavior in the past 6 months and it was found that Positive psychotic symptoms increased the risk of violence, while negative psychotic symptoms lowered the risk of serious violence.

Correlation of risk of violence to cognitive functions

Regarding bivariate analysis between violence risk and cognitive functions; there was no statistically significant relation found between violence risk and Trail Making part A and B and also all domains of Wechsler memory scale, meanwhile there was a statistically significant relation found between violence risk and Wisconsin card sorting test as regard total correct score, % of conceptual level response, categories completed, and trials to complete first category; where WCST is probably the most paradigmatic test to assess prefrontal functioning and executive function as it allows the clinician to assess the ‘frontal’ lobe functions that proved to be affected as the abnormalities in fronto-temporal circuitry is a consistent feature of violence in schizophrenia (Hoptman & Antonius, 2011).

Moreover patients with executive dysfunction may not possess the needed amount of behavioral inhibition skills required to cope with the presence of symptoms and other stressful events that accompany acute psychosis therefor this aggravate the violence risk in those patients (Serper et al., 2008).

Our finding were in agreement with other studies as Bulgari et al. (2017) and O’Reilly et al. (2015), meta-analysis done by Reinharth et al. (2014) that all have showed the strong correlations between deficit in executive functions and violence risk in patient with schizophrenia. Also our study were consistent with a study done by Serper et al. (2008) that investigated the relationship of neuropsychological performance and aggressive inpatient behavior in 85 in patients diagnosed with schizophrenia/schizoaffective disorder (65%) or bipolar disorder (35%). Findings noted that executive functioning impairments significantly predicted aggressive behavior on the psychiatric unit.

Moreover our results were partially in line with a study done by Nazmie et al. (2013) done on 65 patients with schizophrenia that showed that Poor executive functioning appears to be associated with a high risk of aggressive behavior and also showed significant lower scores in Trail Making part A and B were used to evaluate cognitive processing speed, visual attention, and task switching abilities.

Regarding the logistic regression analysis for factors affecting violence risk among case group it was found that Total PANSS score and History of substance use were significant independent factors that increase the likelihood of being violent with p-value .001 and odds ratio with 95% CI of 1.08 [1.03–1.14] for total PANSS score and p-value .029 and odds ratio with 95% CI of 7.24 [1.23–42.61] for history of substance use; so the proper assessment for these factors and the proper plan of management to improve severity of symptoms are crucial factors to decrease the risk of violence in patients with schizophrenia.

Conclusions

Violence risk in patient with schizophrenia is a cardinal factor that may affect life of the patients, their family, and society; this risk can be affected by different factors including severity of symptoms, no of episodes, history of substance use, and cognitive function of the patients as proven by the results of our study; so our study recommends that proper comprehensive assessment of the violence risk in the routine psychiatric assessment is mandatory for rapid and better intervention to reduce this risk in order to decrease the burden of illness on the patients and mental health service.

Strengths

The strength of the current paper is that to the best of our knowledge, it is the first Egyptian study aiming at investigating the magnitude of risk of violence in a sample of Egyptian patients diagnosed with schizophrenia by applying Historical Clinical Risk Management-20 (HCR 20) to assess the violence risk and discuss its correlation with severity of symptoms that have been assessed clinically using Positive and Negative Syndrome Scale (PANSS) and cognitive dysfunction that have been measured using a cognitive battery including Wechsler Memory Scale (WMS), Trail Making Test (TMT) Part A and B, and Wisconsin Card Sorting Test.

As highlighting this different variables that affect risk of violence is an important factor for tailoring proper assessment and management plan to reduce this risk.

Limitations

The study was limited by the small sample size, even though it was based on a search from previous studies based on powerful calculation, so we recommended larger sample size in future researches, to ascertain the significance of some of the results and for proper generalization of these results.

Additionally the cross-sectional nature for this study does not allow follow up of the patients and lack the benefits of providing a better illustration of changes over time in subject population.

Also our study period included the era of COVID 19 pandemic that affect the flow of the patients to the outpatient clinics to complete the required the required sample size.

Footnotes

Acknowledgements

The authors want to thank all patients who participate in this study, also the authors are thankful to Dr. Adbdel Gawad Khalifa and his assistant Roba Ahmed for their participation in performing the cognitive battery assessment for the participants.

List of abbreviations

HCR 20: Historical Clinical Risk Management-20

PANSS: Positive and Negative Syndrome Scale

DSM: Diagnostic and Statistical Manual of Mental Disorders

IQ: Intelligent quotient

SCID-1: Structured Clinical Interview for DSM-IV Axis I Disorders

GHQ: The General Health Questionnaire

WAIS: Wechsler Adult Intelligence Scale

WMS: Wechsler Memory Scale

WCST: Wisconsin Card Sorting Test

TMT: Trail Making Test

SPSS 25: Statistical package for Social Science

Conflict of interest

The authors declare no conflict of interests.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical consideration

The study conformed to the standards of the Ethical Review Committee, Ain Shams University (FWA 000017585), and the scientific committee of neuropsychiatric department. Before enrollment in the study, a written informed consent was signed from study participants after adequately explaining the study aims and outcomes. The anonymity of the subjects was ensured, and all data were stored on a password protected computer in a locked office of the research team and access was strictly limited to study investigators.

ORCID iDs

Samar Serry

Eman S Rabie

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