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Aggression and Violent Behavior 19 (2014) 235–241

Contents lists available at ScienceDirect

Aggression and Violent Behavior

A systematic review of the association between attributional


bias/interpersonal style, and violence in schizophrenia/psychosis
Stephanie T. Harris ⁎, Clare Oakley, Marco M. Picchioni
Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, King's College London, De Crespigny Park, SE5 8AF, UK
St Andrew's Academic Centre, Institute of Psychiatry, King's College London, St Andrew's Healthcare, Northampton, NN1 5DG, UK
St Andrew's Academic Centre, St Andrew's Healthcare, Northampton, NN1 5DG, UK

a r t i c l e i n f o a b s t r a c t

Article history: Despite the widely recognized link between schizophrenia and violence, the illness-specific factors underlying
Received 23 September 2013 that association remain unclear. A body of work has implicated deficits in social cognition, consistently seen in
Received in revised form 11 April 2014 schizophrenia, that may mediate the risk of violence. Two specific areas of interest are attributional bias and in-
Accepted 14 April 2014
terpersonal style. We conducted a systematic literature search using EMBASE, Scopus, Ovid Medline, PsycINFO
Available online 21 April 2014
and Science Direct databases with search terms relating to attributional bias, interpersonal style and violence/
Keywords:
aggression in schizophrenia. Eleven studies were identified, six related specifically to attributional bias and
Attribution bias five to interpersonal style. Results suggest an association between hostile and externalizing attribution biases,
Interpersonal style and violence in schizophrenia. Furthermore, hostile, dominant, and coercive interpersonal styles are also fre-
Social cognition quently associated with violence in schizophrenia. An interaction between cognitive impairments and underly-
Schizophrenia ing personality traits, as well as other co-morbid or illness factors, is proposed to likely underpin associations
Violence with violence in schizophrenia. Conclusions are limited by methodological constraints. The field would benefit
Aggression from consistent definitions of violence, and a more systematic approach to cognitive assessment. Furthermore,
studies with more homogeneous samples; and longitudinal designs are warranted in order to gain a better un-
derstanding of causation with regard to illness factors specific to schizophrenia.
© 2014 Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
1.1. Social cognition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
1.2. Attributional style and bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
1.3. Interpersonal style . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
2. Material and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
3.1. Attributional bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
3.2. Interpersonal style . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
4.1. Attribution bias and aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
4.2. Interpersonal style and aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
5. Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
6. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
Appendix A. Example of electronic search strategy—Scopus (interpersonal style) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240

⁎ Corresponding author at: St Andrew's Academic Centre, St Andrew's Healthcare, Northampton, NN1 5DG, UK. Tel.: +44 1604 616858; fax: +44 1604 616265.
E-mail address: Stephanie.1.harris@kcl.ac.uk (S.T. Harris).

http://dx.doi.org/10.1016/j.avb.2014.04.009
1359-1789/© 2014 Elsevier Ltd. All rights reserved.
236 S.T. Harris et al. / Aggression and Violent Behavior 19 (2014) 235–241

1. Introduction interpreted as hostile, this is known as a ‘hostile’ attribution bias.


These are demonstrated in patient populations, particularly among
Epidemiological and birth cohort studies have provided robust evi- paranoid patients (Blackwood et al., 2001). While this effect may be
dence for an increased risk of violence in schizophrenia (Arsenault, more pronounced in patients with greater persecutory delusions
Moffitt, Caspi, Taylor, & Silva, 2000; Fazel, Långström, Hjern, Grann, & (Martin & Penn, 2002), Lysaker, Lancaster, Nees, and Davis (2004)
Lichtenstein, 2009; Swanson et al., 2006; Walsh, Buchanan, & Fahy, found no association between attributions and social dysfunction, nor
2002). Despite this, reviews examining causal factors have yielded in- any relationship with symptoms. Broader reasoning biases, for example,
consistent findings, and present a complex association with violence. jumping to conclusions (JTC) (Dudley, John, Young, & Over, 1997) and
The most robustly evidenced of these factors linking schizophrenia and poorer mentalizing abilities (Koelkebeck et al., 2010; Pickup & Frith,
violence are substance abuse (Elbogen & Johnson, 2009; Eriksson, 2001) are also evident in patients with schizophrenia, contributing to
Romelsjö, Stenbacka, & Tengström, 2011; Fazel, Gulati, Linsell, Geddes, incorrect attributions and overconfidence in decision making.
& Grann, 2009; Fazel, Långström, Hjern, Grann, & Lichtenstein, 2009;
Short, Thomas, Mullen, & Ogloff, 2013; Swanson, Holzer, Ganju, & Jono, 1.3. Interpersonal style
1990) and co-morbid personality factors, in particular, antisocial person-
ality disorder and psychopathy (Nolan, Volavka, Mohr, & Czobor, 1999; Kiesler's (1987) interpersonal circle theory hypothesizes that when
Tengström, Hodgins, Grann, Långström, & Kullgren, 2004). interacting with others (interpersonal behavior), we are inherently
Given the inconsistencies of findings, an interaction between differ- predisposed to establish a relationship that reinforces our conceptuali-
ent factors seems more likely to explain the association. Reviews of the zation of the self, through the reactions of others. In short, the ‘aim’ is
literature have provided evidence for different underlying neurobiolog- to elicit in others a reaction that will compliment interactions with
ical mechanisms in violence research, presenting violence in schizo- that person on two dimensions: affiliation (hostile to friendly) and con-
phrenia as a very complex multidimensional problem (Hoptman & trol (dominance to submission). Classically, this can occur in two ways.
Antonius, 2011). Other factors that appear to contribute to the complex First, the reactions may be corresponding (i.e., matching across the affil-
link with violence include positive psychotic symptoms (Link & Stueve, iation dimension, but opposing on the control dimension), for example,
1994; Swanson et al., 2006), particularly in the early phase of the illness a friendly interpersonal style met with equal friendliness, or dominance
(Large & Nielssen, 2011). met with a submissive response. Alternatively, a contradictory response
may be elicited. In that case, responses only correspond along one or
1.1. Social cognition neither dimension, and include hostility elicited by an attempt to
exert dominance. Limited experimental data suggest that contradictory
Patients with schizophrenia exhibit cognitive deficits in a variety of responses are associated with lower self-esteem in patients (BjØrkvik,
domains (Andreasen, 1997; Fioravanti, Carlone, Vitale, Cinti, & Clare, Biringer, Eikeland, & Nielsen, 2009). Lower self-esteem can, in turn, be
2005). Such deficits predict poorer functional outcome (Liddle, 2000); linked with increased frustration that can manifest as an over reliance
and may deteriorate over time (Pinkham, Penn, Perkins, & Lieberman, on maladaptive behaviors, such as becoming overly dominant and rare-
2003). Among the multiple cognitive domains, deficits in social cogni- ly submissive (BjØrkvik et al., 2009). Previous work with offenders sug-
tion may contribute directly to social functioning deficits observed in gests that hostile/dominant personality styles, in particular, are strong
schizophrenia (Brüne, 2005; Couture, Penn, & Roberts, 2006; Green & predictors of aggression (Dolan & Blackburn, 2006).
Horan, 2010). Successful social functioning depends upon appropriately The aim of this review will be to consider the evidence for roles for
attending to relevant social data, inferential processing and making de- abnormalities in attributional and interpersonal styles as determinants
cisions based on that information (Penn, Sanna, & Roberts, 2008). There of the risk of aggression or violence in schizophrenia.
is evidence that patients with schizophrenia show impaired processing
of social cues. For instance, impairments in facial emotion recognition 2. Material and methods
have been consistently reported, particularly for negative emotions
(Kohler, Walker, Martin, Healey, & Moberg, 2010; Kohler et al., 2003). We conducted a literature search and manual cross referencing of
Poor recognition of negative facial emotions has, in turn, been associat- English language empirical studies relating to attributional bias and in-
ed with increased aggression and violence in schizophrenia (Harris & terpersonal style in patients with schizophrenia and psychosis, who had
Picchioni, 2013; Weiss et al., 2006). One review (Blackwood, Howard, been violent or aggressive. We searched the databases EMBASE,
Bentall, & Murray, 2001) suggested that the cognitive deficits observed SCOPUS, PsycINFO, Science Direct and Ovid Medline (Jan2013). Search
in schizophrenia may result in biases in inferential processing of social terms comprised the following: “attribution”, “cognitive”, “interpersonal”,
information, leading to inappropriate interpersonal interactions and in- “interactional”, “bias”, “style”, “schizophreni*”, “psychosis”, “psychotic”,
correct causal attributions. “delusion*”, “violen*”, and “aggressi*” (Appendix A).
Two areas of social cognition that may, therefore, contribute to vio- Studies were included if they assessed patients with schizophrenia or
lence in schizophrenia are those of attributional bias and interpersonal another psychotic disorder and either attentional bias or interpersonal
style. style in relation to violence. Violence/aggression must have been system-
atically assessed, using either standardized tools or other objective means.
1.2. Attributional style and bias We identified 12 studies; six examined attributional bias and vio-
lence in schizophrenia (Table 1) and the remaining six, interpersonal
Attributional style refers to the manner in which an individual style (Table 2). In the main, the studies were conducted in inpatient set-
causally interprets the intentions of others or the events that occur tings and violence/aggression was assessed using self-report measures
around them. It is proposed that patients with schizophrenia have and patient records.
“self-serving” attribution biases, more so than healthy subjects. This re-
fers to a greater than normal tendency both to attribute the causes of 3. Results
positive events to themselves; and also to attribute the causes of nega-
tive events to external factors, which is, in turn, known as an “external- 3.1. Attributional bias
izing bias” (Blackwood et al., 2001; Candido & Romney, 1990; Kaney &
Bentall, 1989). Patients may also demonstrate stronger personalizing Three studies identified an association between violence and a hos-
biases. A “personalizing bias” refers to the active attribution of intent tile attribution style. McNiel, Eisner, and Binder (2003) examined attri-
in another person for negative events. Where this negative intent is butional biases using the External Hostile Attribution Scale in 110 in-
S.T. Harris et al. / Aggression and Violent Behavior 19 (2014) 235–241 237

Table 1
Studies of attributional bias in violent populations with psychotic illness.

Year Author Participants Violence/aggression Measures Main findings Limitations

2003 McNiel 110 short-term psychiatric Physical aggression against External Hostile Violence positively correlated with all Retrospective
et al. inpatients others or threatening others Attribution Scale (EHAS) indicators of attributional style
with a lethal weapon ▪ 20 item self-report
Range of diagnoses: 45% reported violence in the measure High external hostile attributions Self-selection bias—
schizophrenic disorders (20%), 2 months prior to hospital predicted violence excluding the most
other psychotic disorders (13%), admission violent patients
Novaco Anger Scale—A Interpersonal factors add to the Self-report measures
(NAS-A) prediction of violence over other
Barratt Impulsiveness variables
Scale (BIS-11)
Minnesota Multiphasic
Personality Inventory—2
(MMPI-2)
2005 Waldheter 29 inpatients from a state Modified Overt Aggression Internal, Personal and Positive correlation between: Heterogeneous group
et al. psychiatric hospital Scale (MOAS) Situational Attributions ▪ post-test violence, and personalizing
▪ Frequency of violent acts Questionnaire (IPSAQ) and hostile attribution biases for
Severe mental illness including (3 months pre and post-test) Ambiguous Intentions accidental situations Relatively low base
schizophrenia spectrum ▪ Severity of violent acts Hostility Questionnaire ▪ hostile attribution bias for levels of violence
disorders (3 months pre and post-test) (AIHQ) ambiguous situations and post-test Did not distinguish
violence violence type
Social cognitive variables have
incremental predictive utility for
predicting violence severity
2007 Goldberg 76 inpatients in acute psychiatric Retrospective Overt Theory of Mind task Aggressive patients had: Retrospective
et al. care Aggression Scale (ROAS) ▪ Positive and negative ▪ Greater self-serving biases
Schizophrenic or mood disorder ▪ Cut off score of 5 or more ▪ higher self-esteem scores Cross-sectional
(with Divided into 2 groups Rosenberg Self-Esteem Did not examine phase
and without substance use ▪ Aggressive (n = 20) Scale of illness
disorder) ▪ Non-aggressive (n = 56) Narcissistic Personality
Inventory (NPI)
2010 Papava 40 paranoid delusional patients Rosenzweig Picture Attribution Style Both groups attribute negative events No objective measure of
et al. Frustration Study (PFS) Questionnaire (ASQ) externally violence or aggression
2 groups ▪ Measures Extra/Intra Rosenzweig Picture Delusional patients with depression Very specific sample
▪ persistent delusional disorder punitive responses or with/ Frustration Study (PFS) respond with outward aggression in group
patients—depressive signs without punishment ▪ 24 pictures of ambiguous frustrating situations
(n = 20) situations
▪ persistent delusional disorder—
no depressive signs (n = 20)
Excluded substance misuse
2011 Tolfrey 45 male inpatients in medium The majority of index offenses Gudjonsson Blame Positive correlation between mental Male patients only
et al. and low were violent Attribution Inventory— blame and number of previous
UK psychiatric care ▪ Included sexual offenses and Revised (GBAI-R) offenses
Diagnoses of paranoid arson Beliefs about Substance Maladaptive beliefs about substance
schizophrenia (62.2%), other Use Scale (BSU) use associated with higher
psychotic disorders (8.9%) externalization of blamex
All with prior substance misuse Externalization of blame may
represent a lack of responsibility and
increased risk of reoffending
2012 Edwards & 62 male mentally disordered Mostly violent index offenses Social Information Patients score highly for hostile Male patients only
Bond offenders from one UK regional ▪ Physical violence (62%) Processing-Attribution attributions
and one secure unit Emotion Questionnaire ▪ Comparable with personality
(SIP-AEQ) disorder
Diagnosis of schizophrenia (74%) Computerised Stories Task Low “self-concept clarity” and high
Narcissistic Personality narcissism predicted increased
Inventory (NPI) hostile attribution
Responses indicating physical
aggression associated with more
hostile attributions

patients with a variety of mental health diagnoses including schizophre- personalizing and hostile attribution biases for responses to stimuli
nia (20%) and other psychotic disorders (13%). Self-reported violence depicting accidental and ambiguous situations. The design of the study
was predicted by high hostile external attributions across the diagnostic and its analysis, however, left it unable to point to attributional bias as
categories, even after controlling for diagnostic/demographic variables. a direct risk factor for aggression. Edwards and Bond (2012) identified
The authors concluded that this, therefore, independently added to the that mentally disordered patients (74% with schizophrenia), with a his-
statistical prediction of violence. Waldheter, Jones, Johnson, and Penn tory of violent offending had a greater hostile attributional bias than
(2005) used the Internal, Personal and Situational Attributions Ques- controls. Patients with such biases were also more likely to indicate a
tionnaire and the Ambiguous Intentions Hostility Questionnaire to iden- pro-aggressive response in relation to presented social scripts. Aggres-
tify links between hostile attribution biases in accidental (no specific sive responses to stories containing physical aggression were associated
intent) and ambiguous situations, and violence in 29 psychiatric inpa- with hostile attributions. Furthermore, violent patients with serious
tients (41% with schizophrenia). The results revealed a positive correla- mental illness (74% had schizophrenia) performed similarly to those
tion between violence in the three months after testing, and both with personality disorder who had been violent.
238 S.T. Harris et al. / Aggression and Violent Behavior 19 (2014) 235–241

Table 2
Studies of interpersonal style in violent populations with psychotic illness.

Year Author Participants Violence/aggression Measures Main findings Limitations

1992 Morrison 156 US psychiatric patients Violence Scale (VS) Interpersonal Control Scale Traits of intimidation and control Reliance on self-report
(ICS) in aggressive patients
Diagnoses of schizophrenia 2 types of violence Intimidation Scale (IS) Coercion was the strongest Does not differentiate
(n = 69) ▪ Others predictor of aggression between type of aggression
▪ Property Social Desirability Scale (SDS) Aggression in schizophrenia may
Frequency of violent relate to a coercive interpersonal
ideation prior to admission style
2006 Doyle & 100 UK forensic inpatients Modified Overt Aggression Chart of Interpersonal Violence linked to coercive, Mixed gender sample
Dolan Scale (MOAS) Reactions in Closed Living dominant and hostile
▪ 12 weeks following Environments (CIRCLE) interpersonal styles
Major mental disorder (90.4%) baseline Ward Angers Rating Scale High coercion score predicted Low base rate for physical
▪ schizophrenia spectrum (WARS) violence violence
disorders Actual, threatened or Novaco Anger Scale (NAS) Compliant interpersonal style Relatively small sample
▪ delusional disorder attempted physical harm protected against violence
to others
2006 Fullam & 61 male UK medium/high secure Institutional aggression Chart of Interpersonal Schizophrenia patients with Small sample size
Dolan patients with schizophrenia data Reactions in Closed Living psychopathy had higher coercive
▪ 92% paranoid schizophrenia Environments (CIRCLE) and hostile styles
▪ 8% disorganized type Historical, Clinical, Risk— ▪ Rated by nursing staff ▪ Higher aggression than the non- Staff rated measures
▪ Psychopathy and non- 20 item scale (HCR-20) psychopathy group
psychopathy groups (cut off Antisocial Personality No significant differences for Cross sectional
score 16 on PCL:SV) Questionnaire (APQ) dominant or submissive subscales No measure of type of
violence
2007 Fresán 102 outpatients with Overt Aggression Scale Temperament and Character Violent patients had lower Only violence in the week
et al. schizophrenia (OAS) Inventory (TCI) cooperativeness prior to assessment was
▪ Violent and non-violent groups ▪ Violent group cut-off ▪ May relate to a paranoid recorded
score of 7 interpersonal style provoking Only one measure of
violence personality
Trend towards lower reward High proportion of patients
dependence and violence with paranoid schizophrenia
2010 Daffern 152 inpatients at Australian Overt Aggression Scale Impact Message Inventory— Dominant and hostile–dominant Inpatients only
et al. acute psychiatric/forensic unit (OAS) Circumplex (IMI-C) interpersonal styles associated
▪ Verbal aggression with violence
Most diagnosed with a psychotic (51.3%) A hostile interpersonal style Self-selection bias
disorder (83.7%) ▪ Physical aggression 11.8% accounted for high variance in
violent behavior
2012 Cookson 79 acute psychiatric patients Overt aggression Scale Impact Message Inventory— Aggression related to higher Acute inpatients setting
et al. (OAS) Circumplex (IMI-C) dominance and hostility scores
Combined hostile–dominant scale Do not differentiate
did not predict aggression diagnoses
Low threshold for violence/
aggression

The remaining three studies linked attenuated self-serving and exter- Morrison (1992) noted that coercive tendencies could exist without
nalizing biases with violence risk. Goldberg et al. (2007) assessed aggres- overt displays of aggression, although a coercive interpersonal style was
sive and non-aggressive in-patients with schizophrenia, using the a very strong predictor of aggression in mentally disordered patients.
Retrospective Overt Aggression Scale to define past aggression. Aggres- Schizophrenia interestingly, was related to coercion, while bipolar dis-
sive patients manifested more self-serving attribution biases than their order was not. Doyle and Dolan (2006) assessed interpersonal style in
non-aggressive counterparts, and with higher self-esteem scores. The 100 UK inpatients, with serious mental illness, including schizophrenia.
authors hypothesized that patients engaged in self-serving biases in Violent patients displayed more coercive, dominant, and hostile inter-
order to preserve or bolster their self-esteem when threatened. Consis- personal styles. Consistent with Morrison's findings, higher coercion
tent with this, Tolfrey, Fox, and Jeffcote (2011) explored risk factors for scores were predictive of violence. There was also a significant link
criminal offending in 45 male inpatients in UK medium and low secure with the frequency of violence. Similarly, Daffern et al. (2010) observed
hospitals. Most patients (80%) had a psychotic disorder at the time of greater dominant and hostile interpersonal styles in a sample of 152 in-
their offense, which was typically violent. Maladaptive beliefs about patients, of whom, over 80% had a psychotic disorder. A hostile interper-
substance misuse were associated with a higher externalizing bias, sug- sonal style accounted for a greater proportion of the variance in
gesting that such externalization was associated with less acceptance of frequency of violent behavior than all other interpersonal styles, but
personal responsibility and an increased risk of violent reoffending. also more so than psychiatric factors such as psychotic symptoms.
Papava et al. (2010) examined two groups of patients with paranoid Cookson et al. (2012) found that patients who had been aggressive
delusional beliefs, divided according to depressive symptoms on the scored higher on hostility and dominance scales of the Impact Message
Brief Psychiatric Rating Scale. Both groups attributed an external cause Inventory—Circumplex; though the combined hostile-dominant scale
to negative events; however, the deluded patients with depressive did not predict aggression.
symptoms endorsed a greater propensity to aggression in response to Fullam and Dolan (2006) assessed 61 male patients with schizo-
frustration. phrenia in medium secure care, divided into high and low psychopathy,
using the Psychopathy Check List-Screening Version (Hart, Cox, & Hare,
3.2. Interpersonal style 1995). Those with both schizophrenia and psychopathy had more coer-
cive and hostile interpersonal styles, and were more likely to have
Of six studies, five associated coercive, hostile, or dominant interper- engaged in institutional aggression than their ‘non-psychopathic’ coun-
sonal styles with aggression. terparts. No significant differences were found however between the
S.T. Harris et al. / Aggression and Violent Behavior 19 (2014) 235–241 239

groups on dominant or submissive subscales. Fresán, Apiquian, Nicolini, Furthermore, antisocial personality disorder, psychopathic traits and
and Cervantes (2007) divided over 100 patients with schizophrenia on psychopathy, co-morbid with schizophrenia were specifically associat-
the Overt Aggression Scale on the basis of recent violence. Patients with ed with a coercive interpersonal style and an increased risk of aggres-
schizophrenia who had been violent showed a significantly less cooper- sion (Fullam & Dolan, 2006; Vitale, Newman, Serin, & Bolt, 2005). That
ative interpersonal style than the non-violent patients. finding appears superficially consistent with data from other personali-
ty disordered populations linking self-serving narcissistic and hostile at-
4. Discussion titudes to the concept of psychopathy and aggression (Dolan &
Blackburn, 2006; Goldberg et al., 2007). In contrast however, Daffern,
4.1. Attribution bias and aggression Duggan, Huband, and Thomas (2008) observed that hostility scores
were not significantly related to overt displays of aggression in patients
Current evidence suggests that a history of violence and aggression with personality disorder (predominantly antisocial and borderline).
in individuals with psychotic disorders including schizophrenia is asso- Such personality disorders are over-represented in schizophrenia com-
ciated with hostile, externalizing attribution biases (Edwards & Bond, pared to the general population (Newton-Howes, Tyrer, North, & Yang,
2012; McNiel et al., 2003; Waldheter et al., 2005). Furthermore, person- 2008). Based on this, and better replicated associations between these
alizing biases in general are linked to aggression in these patients interpersonal styles and personality disorders, personality factors
(Waldheter et al., 2005). These data suggest that a tendency to attribute would seem to play a role in the relationship to violence, although
blame for negative events and/or hostile intent towards others may be other factors must also be relevant. Interactions between underlying
linked with an increased tendency to violent and aggressive behavior. personality styles and psychotic symptoms may predispose predisposes
In schizophrenia, attribution biases can occur in ambiguous and ac- towards violence (Arsenault et al., 2000). The increasingly robust evi-
cidental situations (Waldheter et al., 2005). People both with and with- dence for a substantial link between substance misuse, schizophrenia,
out mental health problems who are aggressive, over-attribute hostility and violence (Fazel, Gulati, Linsell, Geddes and Grann, 2009; Fazel,
and hostile intent to others in ambiguous situations, compared with Långström, Hjern, Grann and Lichtenstein, 2009) cannot be ignored, de-
non-aggressive individuals. They may also ruminate more on these spite early evidence to the contrary (Morrison, 1992). This is, however,
interactions (Epps & Kendall, 1995; Wilkowski & Robinson, 2010). Com- more likely linked to the disinhibiting and direct aggression enhancing
bined with the robustly established cognitive impairments in schizo- effects of drugs. The diagnostic heterogeneity within many of these
phrenia (Rund, 1998; Sponheim et al., 2010), it follows that patients studies makes comparisons across studies difficult. Poor characteriza-
may hypothetically over-attribute hostility in ambiguous and neutral tion of sample groups makes it impossible to account for co-morbid fac-
situations, by selectively attending to potentially hostile cues in the en- tors, such as substance use and personality disorder, despite their own
vironment. This is consistent with the aberrant salience hypothesis clear independent associations with violence.
(Kapur, 2003) that may be a risk factor for, or underpin some psychotic It is also well documented that cognitive impairments exist in
symptoms. Evidence suggests that patients with schizophrenia are schizophrenia; however, these were rarely comprehensively assessed.
more likely to attribute meaning to a stimulus where there is none, While social cognitive impairments may be related to violence in psy-
with this effect exaggerated in patients with delusions (Roiser et al., chosis, there may be a role for cognition generally. For example impair-
2009). Poorer executive functioning may further contribute to hostile ments in executive functioning, in particular, may predispose patients
attribution biases through a misinterpretation of real cues and an inabil- to aggression (Krakowski & Czobor, 2012b) and social naivety, increas-
ity to update and modify cognitions accordingly (Krakowski & Czobor, ing the risk of provoking hostility from others (Fresán et al., 2007). It
2012a,b). These are then combined with cognitive distortions, such as should be noted, however, that this marked cognitive impairment
jumping to conclusions, reasoning biases, and greater cognitive, emo- alone cannot explain the presence of hostile attribution biases or inter-
tional and behavioral impulsivity. personal styles in those without schizophrenia.
Some data support the proposal that these kinds of attribution biases Based on the available evidence, it seems very unlikely that factors
predict the risk of aggression and violence more than demographic or specific to schizophrenia alone underpin the observed association be-
clinical variables (McNiel et al., 2003). That study also lent support to tween attributional biases, interpersonal style, and violence. Rather,
the association between Threat Control/Override (TCO) symptoms, par- these in combination with underlying personality traits and other co-
ticularly delusions, and violence, though this has not been consistently morbid or illness specific factors may be more likely to mediate that
replicated (Appelbaum, Robbins, & Monahan, 2000; Link & Stueve, relationship.
1994). It remains unclear whether patients, or perhaps only violent pa-
tients, have a greater tendency to make negative attributions that then 5. Limitations
link to the risk of violence, almost irrespective of their psychotic symp-
toms. Several lines of enquiry continue to suggest that other factors, The majority of studies were conducted in inpatient settings pre-
some linked with illness, but others intimately related to developmental senting a problem with the generalizabiliy of results. Studies in this
background and adult personality, influence the complicated relation- area are generally cross-sectional in terms of their design. As none had
ships between schizophrenia, attributional style, and violence. Anger, a longitudinal component, it is almost impossible to determine how def-
excitement, impulsiveness, narcissism, and low depression scores icits in social cognition may shift with illness severity and influence the
have all been associated with a hostile attributional style in schizophre- link with violence. Almost universally small sample sizes may give rise
nia (Edwards & Bond, 2012; Goldberg et al., 2007). Others have sug- to Type-2 errors, and limit interpretation further.
gested that a fragile self-image/perception may evoke aggressive Few studies took account of vital social and demographic variables.
attribution biases (Edwards & Bond, 2012). Although, there is some ev- Furthermore, the diagnostic heterogeneity found in many of the studies
idence that certain people may tend towards aggression in order to de- is likely to have introduced both noise and variance into the data. There
fend or preserve their self-esteem (Donnellan, Trzesniewski, Robins, was often also a failure to assess contributory co-morbidities, such as
Moffitt, & Caspi, 2005), studies have not always supported this relation- childhood conduct disorder and personality disorder, in schizophrenia
ship (Baumeister, Bushman, & Campbell, 2000). samples.
An almost universal problem is the inconsistent definition and quan-
4.2. Interpersonal style and aggression tification of aggression and violent behavior. Although violence is a
highly complex behavioral response, few studies incorporated indices
Dominant, coercive and hostile interpersonal styles are, unsurpris- of severity, frequency, outcome and intent. These studies lacked consis-
ingly, associated with aggression in a spectrum of mental disorders. tency in their assessment methods, making comparison between
240 S.T. Harris et al. / Aggression and Violent Behavior 19 (2014) 235–241

investigations difficult. Only one assessed cognitive ability more widely, Blackwood, M. A., Howard, R. J., Bentall, R. P., & Murray, R. M. (2001). Cognitive neuropsy-
chiatric models of persecutory delusions. American Journal of Psychiatry, 158, 527–539.
despite evidence that this may independently moderate risk of violence Brüne, M. (2005). Emotion recognition, ‘theory of mind’, and social behavior in schizo-
in schizophrenia (Barkataki et al., 2005; Kumari et al., 2006; Schug & phrenia. Psychiatry Research, 133(2), 135–147.
Raine, 2009). Candido, C. L., & Romney, D. M. (1990). Attributional style in paranoid vs. depressed pa-
tients. British Journal of Medical Psychology, 63(4), 355–363. http://dx.doi.org/10.
1111/j.2044-8341.1990.tb01630.x.
6. Conclusions Cookson, A., Daffern, M., & Foley, F. (2012). Relationship between aggression, interperson-
al style, and therapeutic alliance during short-term psychiatric hospitalization.
International Journal of Mental Health Nursing, 21(1), 20–29.
Both attributional and interpersonal styles may play roles in the link Couture, S. M., Penn, D. L., & Roberts, D. L. (2006). The functional significance of social cog-
between violence and schizophrenia. Specifically, externalizing, hostile nition in schizophrenia: A review. Schizophrenia Bulletin, 32(Suppl. 1), S44–S63.
http://dx.doi.org/10.1093/schbul/sbl029.
attributional biases, and dominant and hostile interpersonal styles
Daffern, M., Duggan, C., Huband, N., & Thomas, S. (2008). The impact of interpersonal
seem robustly linked with aggression and violence. Available evidence style on aggression and treatment non-completion in patients with personality disor-
implicates underlying personality traits alongside a role for the cogni- der admitted to a medium secure psychiatric unit. Psychology, Crime & Law, 14(6),
tive impairments widely observed in schizophrenia. The underlying 481–492. http://dx.doi.org/10.1080/10683160801948717.
Daffern, M., Thomas, S., Ferguson, M., Podubinski, T., Hollander, Y., Kulkhani, J., et al.
mechanisms are unclear, however, and caution should still be exercised (2010). The impact of psychiatric symptoms, interpersonal style, and coercion on ag-
when interpreting these data due to the small number of methodologi- gression and self-harm during psychiatric hospitalization. Psychiatry: Interpersonal
cally inconsistent studies. and Biological Processes, 73(4), 365–381.
Dolan, M., & Blackburn, R. (2006). Interpersonal factors as predictors of disciplinary in-
Future research must be more methodologically sound, with more fractions in incarcerated personality disordered offenders. Personality and Individual
homogeneous, better defined samples. Definitions and quantification Differences, 40(5), 897–907. http://dx.doi.org/10.1016/j.paid.2005.10.003.
of aggression and violence must also be optimized. Longitudinal studies Donnellan, M. B., Trzesniewski, K. H., Robins, R. W., Moffitt, T. E., & Caspi, A. (2005). Low self-
esteem is related to aggression, antisocial behavior, and delinquency. Psychological
incorporating first episode psychosis samples are warranted to improve Science, 16(4), 328–335. http://dx.doi.org/10.1111/j.0956-7976.2005.01535.x.
our understanding of causal relationships with illness severity. Cogni- Doyle, M., & Dolan, M. (2006). Evaluating the validity of anger regulation problems, inter-
tive ability should also be established. By addressing these failures, we personal style, and disturbed mental state for predicting inpatient violence.
Behavioral Sciences & the Law, 24(6), 783–798.
will improve our understanding of the nature of the link between
Dudley, R. E. J., John, C. H., Young, A. W., & Over, D. E. (1997). Normal and abnormal rea-
schizophrenia and aggression and violence. We will then be in a better soning in people with delusions. British Journal of Clinical Psychology, 36(2), 243–258.
position to target finite clinical resources to more effectively assess http://dx.doi.org/10.1111/j.2044-8260.1997.tb01410.x.
Edwards, R., & Bond, A. J. (2012). Narcissism, self-concept clarity and aggressive cog-
and manage that risk, with substantial benefits for patients and society.
nitive bias amongst mentally disordered offenders. Journal of Forensic Psychiatry
& Psychology, 23(5–6), 620–634. http://dx.doi.org/10.1080/14789949.2012.
Acknowledgments 715180.
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disorder: Results from the national epidemiologic survey on alcohol and related con-
The authors would like to thank Sandrine Harris and Laura O'Shea ditions. Archives of General Psychiatry, 66(2), 152–161. http://dx.doi.org/10.1001/
for their help in the preparation and proof reading of the manuscript. archgenpsychiatry.2008.537.
Epps, J., & Kendall, P. (1995). Hostile attributional bias in adults. Cognitive Therapy and
Research, 19(2), 159–178. http://dx.doi.org/10.1007/bf02229692.
Appendix A. Example of electronic search strategy—Scopus Eriksson, Å., Romelsjö, A., Stenbacka, M., & Tengström, A. (2011). Early risk factors for
criminal offending in schizophrenia: A 35-year longitudinal cohort study. Social
(interpersonal style) Psychiatry and Psychiatric Epidemiology, 46(9), 925–932. http://dx.doi.org/10.1007/
s00127-010-0262-7.
Fazel, S., Gulati, G., Linsell, L., Geddes, J. R., & Grann, M. (2009a). Schizophrenia and vio-
1) interpersonal 140,193 lence: Systematic review and meta-analysis. PLoS Medicine, 6(8), 1–14.
2) interactional 514 Fazel, S., Långström, N., Hjern, A., Grann, M., & Lichtenstein, P. (2009b). Schizophrenia,
3) style 53,675 substance abuse and violent crime. Journal of the American Medical Association,
4) 1 OR 2 140,665 301(19), 2016–2023.
5) 3 AND 4 1468 Fioravanti, M., Carlone, O., Vitale, B., Cinti, M., & Clare, L. (2005). A meta-analysis of cogni-
tive deficits in adults with a diagnosis of schizophrenia. Neuropsychology Review,
6) schizophreni* 127,831
15(2), 73–95. http://dx.doi.org/10.1007/s11065-005-6254-9.
7) psychosis 77,718
Fresán, A., Apiquian, R., Nicolini, H., & Cervantes, J. J. (2007). Temperament and character
8) psychotic 31,884
in violent schizophrenia patients. Schizophrenia Research, 94, 74–80.
9) delusion* 13,771 Fullam, R., & Dolan, M. (2006). The criminal and personality profile of patients
10) 6 OR 7 OR 8 OR 9 190,229 with schizophrenia and comorbid psychopathic traits. Personality and Individual
11) violen* 58,370 Differences, 40, 1591–1602.
12) aggressi* 53,466 Goldberg, B. R., Serper, M. R., Sheets, M., Beech, D., Dill, C., & Duffy, K. G. (2007). Predictors
13) 11 OR 12 105,162 of aggression on the psychiatric inpatient service: Self esteem, narcissism, and theory
14) 5 AND 10 AND 13 203 of mind deficits. The Journal of Nervous and Mental Disease, 195(5), 436–442.
Green, M. F., & Horan, W. P. (2010). Social cognition in schizophrenia. Current Directions in
Psychological Science, 19, 243–248.
Harris, S. T., & Picchioni, M. M. (2013). A review of the role of empathy in violence risk in
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