Moral cognition, the missing link between psychotic symptoms and acts of violence: a cross-sectional national forensic cohort study.

BACKGROUND: People with schizophrenia are ten times more likely to commit homicide than a member of the general population. The relationship between symptoms of schizophrenia and acts of violence is unclear. There has also been limited research on what determines the seriousness and form of violence, such as reactive or instrumental violence. Moral cognition may play a paradoxical role in acts of violence for people with schizophrenia. Thoughts which have moral content arising from psychotic symptoms may be a cause of serious violence. METHOD: We investigated if psychotic symptoms and moral cognitions at the time of a violent act were associated with acts of violence using a cross-sectional national forensic cohort (n = 55). We examined whether moral cognitions were associated with violence when controlling for neurocognition and violence proneness. We explored the association between all psychotic symptoms present at the time of the violent act, psychotic symptoms judged relevant to the violent act and moral cognitions present at that time. Using mediation analysis, we examined whether moral cognitions were the missing link between symptoms and the relevance of symptoms for violence. We also investigated if specific moral cognitions mediated the relationship between specific psychotic symptoms, the seriousness of violence (including homicide), and the form of violence. RESULTS: Psychotic symptoms generally were not associated with the seriousness or form of violence. However, specific moral cognitions were associated with the seriousness and form of violence even when controlling for neurocognition and violence proneness. Specific moral cognitions were associated with specific psychotic symptoms present and relevant to violence. Moral cognitions mediated the relationship between the presence of specific psychotic symptoms and their relevance for violence, homicide, seriousness of violence, and the form of violence. CONCLUSIONS: Moral cognitions including the need to reduce suffering, responding to an act of injustice or betrayal, the desire to comply with authority, or the wish to punish impure or disgusting behaviour, may be a key mediator explaining the relationship between psychotic symptoms and acts of violence. Our findings may have important implications for risk assessment, treatment and violence prevention.

A randomized controlled trial of cognitive remediation for a national cohort of forensic patients with schizophrenia or schizoaffective disorder.

BACKGROUND: Evidence is accumulating that Cognitive Remediation Training (CRT) is effective for ameliorating cognitive deficits experienced by patients with schizophrenia and accompanying functional impairment. There has been no randomized controlled trial of CRT using a nationally representative population of forensic patients, despite the significant cognitive deficits frequently present within this group. METHODS: Sixty-five patients with schizophrenia or schizoaffective disorder were enrolled in a single blind randomized controlled trial of CRT versus treatment as usual (TAU); representing 94% of those eligible within a national forensic cohort. The primary outcome measure was the composite score of the MATRICS Consensus Cognitive Battery (MCCB). Secondary outcome measures included neurocognitive and social cognitive domains, symptoms, and 'real world' functioning. Patient satisfaction was examined using an exit interview. Participants were reassessed at 8 months follow up. All data were analyzed using an intention to treat design (ITT). RESULTS: For the primary outcome measure, the MCCB composite score, there were significant differences between those who participated in CRT and those receiving TAU at both end of treatment and 8 months follow up (Cohen's d = 0.34. Significant improvements were observed in visual and working memory. Mediation analysis found that those who cognitively benefited from CRT had corresponding improved functioning, and more net positive therapeutic moves i.e. moves to units with lower security within the hospital. Ninety-six percent believed their cognitive gains positively affected their daily lives. CONCLUSIONS: CRT may be an acceptable and efficacious intervention for forensic patients with schizophrenia or schizoaffective disorder. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02360813 . Trial registered Feb 4th 2015, last updated May 1st 2015.

SEQUenCE: a service user-centred quality of care instrument for mental health services.

OBJECTIVE: To develop a quality of care instrument that is grounded in the service user perspective and validate it in a mental health service. DESIGN: The instrument (SEQUenCE (SErvice user QUality of CarE)) was developed through analysis of focus group data and clinical practice guidelines, and refined through field-testing and psychometric analyses. SETTING: All participants were attending an independent mental health service in Ireland. PARTICIPANTS: Participants had a diagnosis of bipolar affective disorder (BPAD) or a psychotic disorder. INTERVENTIONS: Twenty-nine service users participated in six focus group interviews. Seventy-one service users participated in field-testing: 10 judged the face validity of an initial 61-item instrument; 28 completed a revised 52-item instrument from which 12 items were removed following test-retest and convergent validity analyses; 33 completed the resulting 40-item instrument. MAIN OUTCOME MEASURES: Test-retest reliability, internal consistency and convergent validity of the instrument. RESULTS: The final instrument showed acceptable test-retest reliability at 5-7 days (r = 0.65; P < 0.001), good convergent validity with the Verona Service Satisfaction Scale (r = 0.84, P < 0.001) and good internal consistency (Cronbach's alpha = 0.87). CONCLUSIONS: SEQUenCE is a valid, reliable scale that is grounded in the service user perspective and suitable for routine use. It may serve as a useful tool in individual care planning, service evaluation and research. The instrument was developed and validated with service users with a diagnosis of either BPAD or a psychotic disorder; it does not yet have established external validity for other diagnostic groups.

Heterosexual men's ratings of sexual attractiveness of pubescent girls: Effects of labeling the target as under or over the age of sexual consent.

The study aimed to identify implicit and explicit processes involved in reporting the sexual attractiveness of photographs of the same pubescent girls labeled as either under or within the age of sexual consent in the UK, women, and men. In two studies, 53 and 70 heterosexual men (M age 25.2 and 31.0 years) rated the sexual attractiveness of photographs in each category presented via computer [seeing target photographs of girls labeled as either under- (14-15 years) or within the age of consent (16-17 years)], using a 7-point response box. Ratings in Study 1 were in response to a question asking participants to rate how sexually attractive the person in each photograph was. In Study 2, participants rated how sexually attractive they personally found the target. Response times were also recorded. Several findings were replicated in both studies (although the strength of findings differed). Mean ratings of the sexual attractiveness of the underage girls were lower than those of overage girls and women. In addition, correlations revealed significantly longer responding times when "underage" girls (and men) were rated as more highly sexually attractive. No such relationship emerged with the same girls labeled within the age of consent or women. Overall, these data suggest that men find pubescent girls identified as being under the age of consent sexually attractive, but inhibit their willingness to report this; the greater the attraction, the greater the inhibition.

How do delirium motor subtypes differ in phenomenology and contributory aetiology? a cross-sectional, multisite study of liaison psychiatry and palliative care patients.

OBJECTIVES: To investigate whether delirium motor subtypes differ in terms of phenomenology and contributory aetiology. DESIGN: Cross-sectional study. SETTING: International study incorporating data from Ireland and India across palliative care, old age liaison psychiatry and general adult liaison psychiatry settings. PARTICIPANTS: 1757 patients diagnosed with delirium using criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM IV). PRIMARY AND SECONDARY OUTCOME MEASURES: Hyperactive, mixed and hypoactive delirium subtypes were identified using the abbreviated version of the Delirium Motor Subtype Scale. Phenomenology was assessed using the Delirium Rating Scale Revised. Contributory aetiologies were assessed using the Delirium Aetiology Checklist (DEC), with a score >2 indicating that the aetiology was likely or definitely contributory. RESULTS: Hypoactive delirium was associated with dementia, cerebrovascular and systemic infection aetiologies (p<0.001) and had a lower overall burden of delirium symptoms than the other motor subtypes. Hyperactive delirium was associated with younger age, drug withdrawal and the DEC category other systemic aetiologies (p<0.001). Mixed delirium showed the greatest symptom burden and was more often associated with drug intoxication and metabolic disturbance (p<0.001). All three delirium motor subtypes had similar levels of impairment in attention and visuospatial functioning but differed significantly when compared with no subtype (p<0.001). CONCLUSIONS: This study indicates a pattern of aetiology and symptomatology of delirium motor subtypes across a large international sample that had previously been lacking. It serves to improve our understanding of this complex condition and has implications in terms of early detection and management of delirium.