Social cognition and paranoia in forensic inpatients with schizophrenia: A cross-sectional study
Introduction
People with a diagnosis of schizophrenia are thought to have impairments in various domains of social cognition (Sprong et al., 2007), including their ability to accurately perceive and recognise emotions (‘emotion recognition’) and draw inferences about the thoughts, feelings and intentions of others – so-called ‘Theory of Mind’ skills (Frith, 1992, Zalla et al., 2006, Craig et al., 2004, Herold et al., 2002). Meta-analyses have found that the average scores of people with schizophrenia on tests of emotion recognition and ToM ability are between one half and one standard deviation below that of non-clinical participants (Kohler et al., 2009, Sprong et al., 2007). Such impairments are thought to have a negative effect on interpersonal and social interactions, and may have wide ranging consequences during the acute and recovery stages of schizophrenia (Couture et al., 2006).
Patients with schizophrenia who have engaged in violent offending present forensic mental healthcare services with particular challenges in relation to rehabilitation and recovery. In this population, impairments in social cognition may represent an unmet need which could be implicated in aggressive behaviour, future risk management, interpersonal relationships with staff and peers, and increased paranoia and persecutory delusions (Murphy, 2007, Salvatore et al., 2012, Waldheter et al., 2005). Indeed, persecutory delusions are one of the most frequently observed positive symptoms of schizophrenia. Although some authors have considered how they might be associated with an increased risk of committing a violent offence (e.g., Bentall and Taylor, 2006), a recent meta-analysis found that the empirical evidence remains surprisingly sparse and equivocal (Witt et al., 2013).
Of course paranoia is not confined to mental illness and is also present in the general population to varying degrees (Freeman, 2007). It can be thought of as dimensional in nature, ranging from frequently occurring yet easily dismissed thoughts to firmly held crystallized persecutory delusions (Couture et al., 2006, Savla et al., 2012, Freeman and Garety, 2014). As with other appraisals, paranoid appraisals represent an individual's attempt to make sense of their experiences, a process that is influenced by pre-existing beliefs, developmental and life experiences, as well as counterproductive behavioural responses (Morrison, 2001), which may include avoidance, hypervigilance and, in some cases, acts of hostility and aggression. Although making judgements about the hostile intentions of others can be an adaptive strategy for threat avoidance (Salvatore et al., 2012), it has also been linked to increased rates of aggression (Combs et al., 2009, Coid et al., 2016).
Although related, paranoia and aggression in schizophrenia may involve different patterns of strengths and impairments in social cognition. For example, whereas Harrington et al. (2005) found evidence of a specific relationship between ToM difficulties and symptoms of paranoia, Abu-Akel and Abushua'leh (2004) found that better ToM skills, albeit in the context of poorer empathy, were associated with greater hostility and violence in schizophrenia. Another study found reduced ToM impairments in patients with schizophrenia who had committed offences, in comparison to those who had not, although both groups displayed impairments when compared to a non-clinical population (Majorek et al., 2009). Indeed, whether ToM is actually associated with paranoia remains unclear. For instance, Greig et al. (2004) reported that greater ToM difficulties were related to symptoms of thought disorder and disorganisation, but not paranoia or persecutory delusions specifically. A recent review concluded that although ToM difficulties are consistently found in people with schizophrenia, the association with negative and disorganisation symptoms is stronger than that with persecutory delusions (Garety and Freeman, 2013).
The precise relationship between paranoia and emotion recognition in people with schizophrenia also remains unclear. Although a recent meta-analysis found that emotion recognition impairments are moderately associated with symptoms such as hallucinations and delusions (Ventura et al., 2013), other studies have reported either a negative relationship with paranoia (e.g., Williams et al., 2007), a positive relationship (e.g., Chan et al., 2008), and or no relationship at all (e.g., Pinkham et al., 2016). Pinkham et al. (2016) concluded that while paranoia is not associated with an impaired capacity to recognise emotions per se, it is associated with an increased bias to infer hostility or anger in others. Although Frommann et al. (2013) found that violent patients with psychosis were less likely than non-violent patients to accurately recognise either neutral or fearful facial expressions, whether these impairments also contribute to paranoia in this forensic group of patients has not been investigated. Given both social cognition and paranoia are linked to poorer outcomes and acts of aggression (Couture et al., 2006, Waldheter et al., 2005), this is a surprising omission. These patients have a number of characteristics, such as increased substance misuse, aggression, anger and symptoms of personality disorder (Ogloff et al., 2015), that make it unclear whether findings obtained from a non-forensic population can be easily applied to them.
The aim of the current study was to address this gap, and determine whether reduced social cognitive functioning is associated with increased paranoia in people with psychosis who have a history of violent offending and are receiving inpatient care for schizophrenia in a secure forensic setting. We set out to test the specific hypotheses that emotion recognition and theory of mind skills account for a significant portion of variance in indices of paranoia in this group, as assessed by self-reported paranoid thoughts and/or a hostile or blaming attributional bias.
Section snippets
Ethical approval
This study was given a favourable opinion by NHS Scotland's South East Scotland Research Ethics Committee.
Design
A within-group cross-sectional design was used to examine whether there was a relationship between social cognition and indices of paranoia. Self-report and observer-rated measures were used.
Participants
Participants were recruited from one high, and two medium secure forensic hospitals in Scotland which provide multi-disciplinary care for mentally ill offenders. In addition to psychotropic medications
Sample characteristics
As shown in Table 1, we recruited 27 participants (mean age 37.6 years, SD 11.16; range 22–55). Sixteen were recruited from a high-security hospital and 11 were recruited from two medium-secure units. All participants were male, all had a diagnosis of paranoid schizophrenia and all had a history of offending. The mean length of time since initial diagnosis of schizophrenia was 10.81 years (SD 5.88; range 1–24 years). Prior to admission, the majority (78%, N = 21) had used alcohol or drugs. A history
Discussion
Building on previous research (Frith and Corcoran, 1996, Sprong et al., 2007, Randall et al., 2003, Craig et al., 2004, Harrington et al., 2005, Mehl et al., 2010), the purpose of this study was to examine if difficulties in emotion recognition and theory of mind account for a significant proportion of variance in indices of paranoia in schizophrenia. Unlike previous studies, our participants were all forensic patients who had committed an offence (culpable homicide in almost half the sample),
Conflict of interest
The authors report no conflicts of interest.
Contributors
HB designed the study, carried out it out, analysed and interpreted the results, and prepared drafts of the final manuscript. SOR and LT contributed to the design of the study and supervised the procedures and SOR, LT and PH contributed to the analysis and interpretation of the results and prepared drafts of the final manuscript.
Role of the funding source
There was no funding for this work.
Acknowledgement
The authors would like to thank all the participants and staff who helped with this research.
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