The "zipper model of empathy" applied to violence in schizophrenia: A search for social cognitive underpinnings of lack of empathic behavior.

BACKGROUND: The "zipper model of empathy" has been proposed for psychopathy. It postulates that empathic behavior may fail to arise due to impaired facial emotion recognition. In this study, we examined if the model may be of relevance for schizophrenia. METHODS: In a sample of participants with schizophrenia and a history of severe interpersonal violence, associations between measures of social cognition (emotion recognition, theory of mind) and aspects of psychopathy (lack of empathy, lack of remorse) were investigated. A non-violent sample experiencing schizophrenia served as a control group. RESULTS: Correlation analyses revealed a specific and statistically significant association between facial emotion recognition and lack of empathy in the violent sample. Follow-up analyses identified that neutral emotions were of particular importance. Logistic regression analyses confirmed that impairments in facial emotion recognition predicted levels of empathy in the violent sample experiencing schizophrenia. CONCLUSIONS: Our results suggest that the "zipper model of empathy" may be relevant for schizophrenia. The findings further point to the potential benefit of including social cognitive training in the treatment of persons with schizophrenia and a history of interpersonal aggression.

Increased prevalence of psychopathy and childhood trauma in homicide offenders with schizophrenia compared to nonviolent individuals with schizophrenia.

Purpose: Schizophrenia is associated with an increased homicide risk. Personality pathology, particularly antisocial personality disorder and psychopathic traits, has been associated with increased violence risk in schizophrenia. Childhood trauma, more specifically physical abuse, has been associated with violence risk in healthy populations and in individuals with mental illness. It is, however, unclear how childhood trauma relates to homicide in schizophrenia. This is, to our knowledge, the first study to concurrently examine personality pathology and childhood trauma in a group consisting solely of homicide offenders with schizophrenia (HOS). HOS is compared to nonviolent participants with the same diagnosis (non-HOS). Additionally, currently assessed demographical and clinical characteristics of a Norwegian sample of HOS are reported. Materials and methods: Two groups of participants with schizophrenia were recruited in collaboration with in and outpatient clinics across Norway, HOS (n= 26) and non-HOS (n= 28). Assessments of personality pathology and childhood trauma were conducted, and information about clinical and demographical characteristics was registered. Results: HOS participants had significantly higher psychopathy scores, and more frequently reported moderate to severe childhood physical abuse than non-HOS participants. When simultaneously added to a logistic regression model, only psychopathy uniquely contributed to explaining group membership. Conclusions: Psychopathy and physical abuse was more prevalent among HOS participants compared to non-HOS, but only psychopathy independently predicted homicidal status. These results confirm the importance of including an evaluation of psychopathic traits in violence risk assessments of individuals with schizophrenia.

Impaired neuropsychological profile in homicide offenders with schizophrenia.

BACKGROUND: Our ability to predict and prevent homicides committed by individuals with schizophrenia is limited. Cognitive impairments are associated with poorer functional outcome in schizophrenia, possibly also homicide. The aim of the current study was to investigate global and specific cognition among homicide offenders with schizophrenia (HOS). METHODS: Twenty-six HOS were compared to 28 individuals with schizophrenia and no history of violence (non-HOS), and a group of healthy controls (HC, n = 151). HOS and non-HOS participants were recruited from in- and outpatient units across Norway. An extensive neuropsychological test battery was administered. RESULTS: HOS participants performed significantly weaker than HC in all cognitive domains. Further, statistically significant differences between HOS and non-HOS participants were found for IQ (d = 0.52) and verbal learning (d = 0.82), with larger impairments in the HOS compared to the non-HOS group. CONCLUSIONS: Our results indicate that HOS participants show clinically significant impairments in global and specific cognition.

Season of birth bias and anorexia nervosa: results from an international collaboration.

OBJECTIVE: Based on inconsistent findings in the literature, this study tested the hypothesis that "there is a season of birth bias for females with anorexia nervosa (AN)." METHOD: Females with AN, born in 1975 to 1996, were compared to females born in the same years and geographical regions by chi-square test for contingency tables with known population parameter testing for monthly deviations. Five groups were based on a priori power calculation and geographical location: Iceland, Norway and Sweden (N = 847), United Kingdom (N = 706), Oregon, USA (N = 394), Argentina and Brazil (N = 486), and Australia (N = 381). RESULTS: The hypothesis was not supported in any of the groups. The associations (Cramér's V) between month of birth and the differences in distributions of births ranged from 0.05 to 0.08, none of which were statistically significant. DISCUSSION: The main implication of these findings is that season of birth may not play a significant part in the aetiology of AN.

Object relations, reality testing, and social withdrawal in schizophrenia and bipolar disorder.

In this study, we investigated the relationships between observed social withdrawal (Positive and Negative Syndrome Scale [PANSS] Passive Social Withdrawal and PANSS Active Social Avoidance), subjectively experienced social withdrawal (Social Functioning Scale [SFS] Withdrawal and SFS Interpersonal Behavior), and their associations to the underlying psychological patterns of Object Relations and Reality Testing. Patients with schizophrenia (n = 55) and bipolar disorder (n = 51) from the ongoing Thematically Organized Psychosis project, Oslo University Hospital, Norway, were evaluated using the Bell Object Relations and Reality Testing Inventory, the PANSS, and the SFS. Object relations and reality testing subscales related differentially to PANSS Passive Social Withdrawal and PANSS Active Social Avoidance. These two measures, together with the level of alienation, explained a significant amount of variance in self-experienced social dysfunction. Findings reveal the multidimensional nature of social dysfunction in severe mental disorders.

Season of birth bias and bulimia nervosa--results from a multi-centre collaboration.

BACKGROUND: Season of birth bias has been observed for people with a number of disorders, including women with bulimia nervosa. However, inconsistent results and methodological weaknesses render previous conclusions about such bias uncertain. With an enhanced methodology, this study aims to test whether there is a season of birth bias for women with bulimia nervosa. METHOD: Women with bulimia nervosa at five secondary and tertiary services in Norway, born between 1966 and 1988 (n = 549), were compared with women in the general population in a chi-square test for contingency tables, with known population parameters testing monthly deviations. RESULTS: There was no statistically significant association between month of birth and the distribution of births in the two groups (Cramer's V = .09). CONCLUSION: There appears not to be any season of birth bias in women with bulimia nervosa in Norway.

A ten-year longitudinal repeated assessment study of cognitive improvement in patients with first-episode schizophrenia and healthy controls: The Oslo Schizophrenia Recovery (OSR) study.

The mapping of cognitive trajectories after a first episode of schizophrenia has been the aim in several studies, but the longitudinal course of cognitive impairments remains an important question. Due to methodological limitations, it has been challenging to pinpoint specific periods of improvement or stability in cognitive functioning over time. The objective of this study is to further clarify the longitudinal course of cognitive change after a first episode of schizophrenia through frequent repeated measurement. A total of 56 persons participated in the study (28 first episode patients and 28 healthy pairwise matched controls) with 79 % of patients retained at the 10-year follow-up. The Oslo Schizophrenia Recovery study has a repeated measurement design and includes data from nine cognitive assessments over 10 years. Cognition was assessed with the MATRICS Consensus Cognitive Battery, which is well suited for repeated measurements. Data were analyzed with linear multilevel models. The results challenge some of the views about the course of cognitive impairment in first-episode schizophrenia patients. Using quadratic time effects in our analyses and balancing the patient group with regards to the most relevant confounding demographic variables such as age, gender, and education, we showed that cognitive deficits change and improve more than in healthy individuals until year 6, when both groups stabilize. The patient group improved on some of the most important cognitive domains associated with functional outcome with 63.5 % full recovery at 10-year follow-up.

Object relations and reality testing in schizophrenia, bipolar disorders, and healthy controls: differences in profiles and clinical correlates.

OBJECTIVE: Deficits in object relations (OR) and reality testing (RT) functions are found in schizophrenia but have never been investigated in bipolar disorder. In the current study, we examine if there are OR and RT differences in schizophrenia and bipolar disorder compared to healthy controls and to what extent differences in clinical characteristics mediates the putative effect of diagnosis. METHODS: We used the Bell Object Relation and Reality Testing Inventory (BORRTI) to measure OR and RT in schizophrenia (n = 55), bipolar disorder (n = 51) and healthy controls (n = 158). Diagnoses and the life time presence of psychotic symptoms were evaluated based on the Structured Clinical Interview for DSM-IV. We used the Positive And Negative Symptom Scale to measure current symptoms. RESULTS: Analyses of variance with post hoc tests showed statistically significant differences in OR and RT between the Schizophrenia (SCZ), Bipolar Disorder (BD), and Healthy Control (HC) groups. Multiple regression analyses indicated that a lifetime history of psychotic symptoms contributed significantly to the variance in one BORRTI subscale (Social Incompetence) while Positive And Negative Symptom Scale components (either the positive component and emotional discomfort component) contributed significantly to the variance in all BORRTI subscales except one (Uncertainty of Perception). CONCLUSIONS: OR and RT deficits are present both in SCZ and BD, but differences appears to be mediated by differences in current positive and depressive symptoms.

Childhood trauma, social cognition and schizophrenia: Specific association between physical neglect and cognitive theory of mind in homicide offenders.

Schizophrenia is associated with a small, but increased risk of violent behavior, including homicide. Violent individuals with schizophrenia have elevated rates of childhood trauma and substantial social cognitive impairments. The aim of this study was to examine if childhood trauma is related to social cognition in homicide offenders with schizophrenia. We recruited 26 individuals with schizophrenia sentenced to compulsory mental care for homicide/attempted homicide and 28 non-violent schizophrenia controls. They filled out the Childhood Trauma Questionnaire (CTQ), providing scores for physical abuse, sexual abuse, emotional abuse, physical neglect and emotional neglect. Social cognition was assessed with two measures of emotion processing (Emotion in Biological Motion, Pictures of Facial Affect) and two theory of mind (ToM) tests (Hinting Task, Movie for the Assessment of Social Cognition: MASC). Spearman's rho correlation coefficients were computed, and significant results followed up with partial correlation analyses controlling for IQ. Three associations were statistically significant, all in the homicide group; between CTQ physical neglect and cognitive ToM assessed with Hinting Task and with MASC, and between CTQ emotional neglect and Hinting Task. Only the first remained significant after controlling for IQ, indicating a specific association between physical neglect and cognitive ToM in homicide offenders with schizophrenia.

Passive/apathetic social withdrawal and active social avoidance in schizophrenia: difference in underlying psychological processes.

OBJECTIVE: Social withdrawal, a core feature of negative symptoms, is differentiated into passive social withdrawal (PSW) and active social avoidance (ASA). We examined whether this differentiation was related to differences in underlying psychological processes of object relations and reality testing. METHOD: Two hundred seventy-two outpatients with schizophrenia and schizoaffective disorders from VA Connecticut Healthcare System/Connecticut Mental Health Center were evaluated using the Bell Object Relations and Reality Testing Inventory (BORRTI) and the Positive And Negative Symptoms Scale. RESULTS: Distinct patterns were found; PSW was associated with object relation subscales explaining 5% of the variance, ASA was associated with object relations and all reality testing subscales explaining 12% of the variance. CONCLUSIONS: Findings suggest differences in the underlying mechanisms behind PSW and ASA, confirming that PSW is a primary negative symptom, while ASA is related more to positive symptoms.

Cognitive, Work and Social Outcomes in Fully Recovered First-Episode Schizophrenia: On and Off Antipsychotic Medication.

OBJECTIVE: This study examined the development in cognition, work, and social functioning in a group of fully recovered first-episode schizophrenia (FES) patients across six-eight years and inspected whether changes in outcome were similar when individuals were off medication as when they were on medication. METHOD: Ten out of 28 participants were identified as fully recovered by the eighth follow-up. Assessments were conducted yearly, apart from the first year, when assessments were conducted every six months. Cognition was assessed with MATRICS Consensus Cognitive Battery. Functional outcomes were obtained through Global functioning: Social and Global functioning: Role. Information from semistructured interviews were also gathered. Data were analyzed with linear multilevel models. RESULTS: There were steady improvements in cognition, social, and role functioning among the patients, but the changes were significantly larger when individuals were off antipsychotic medications than on medications for processing speed and work functioning. T-tests showed that unmedicated participants were not healthier than medicated participants at baseline. The most common reason for discontinuing medication treatment was negative side effects. Instead, many of the participants highlighted the use of active coping mechanisms for maintaining recovery. CONCLUSIONS: The findings challenge some of the views about medication treatment of FES patients. For a subgroup of FES patients, continuous medication treatment is not necessary for maintaining low levels of symptoms. These patients show sustained good functioning once fully recovered. Due to a small sample size, these results may not be generalized to the general FES population and need to be replicated with studies of larger sample sizes.

Large social cognitive impairments characterize homicide offenders with schizophrenia.

Schizophrenia is associated with an increased violence risk, particularly homicide. One possible, but scarcely explored, contributor to the increased violence risk is social cognitive impairment. Individuals with schizophrenia show impairments in social cognition that are associated with poor functional outcome. This study examined social cognition among homicide offenders with schizophrenia (HOS), applying validated measures of emotion perception and theory of mind (ToM). Two groups of individuals with schizophrenia were compared, one had committed homicide (HOS, n = 26), and the other had no violence history (non-HOS, n = 28). Healthy controls (HC, n = 71) were included as reference group for one measure. Emotion perception was indexed by the Emotion in Biological Motion (Emotion) and Pictures of Facial Affect (PFA) tests. ToM was assessed with the Hinting Task and Movie for the Assessment of Social Cognition (MASC). The results showed that HOS participants had significantly poorer performance than non-HOS in both emotion perception and ToM. For the MASC test, HOS participants showed large deficits compared to HC (-4 standard deviations). Particularly, HOS participants made a substantial number of undermentalizing errors. The results suggest that emotion perception deficits and a tendency to undermentalize may be important for understanding homicide in schizophrenia.

Cognitive improvement in first-episode schizophrenia and healthy controls: A 6-year multi-assessment follow-up study.

The development of individual cognitive domains over time is not yet fully examined in first-episode schizophrenia (FES). This study's objective was to explore the cognitive trajectories of FES-patients (n = 28) and compare them to a pairwise matched healthy control group (n = 28, total n = 56). This study has a multi-assessment design, and includes patient data from seven assessments over six years. Healthy controls were assessed at baseline, after two years and after six years. Cognition was assessed with the MATRICS Consensus Cognitive Battery. Data were analyzed with linear multilevel models. FES-patients scored significantly lower than the control group across all cognitive domains at baseline. Over six years, improvements were seen in attention, verbal learning, processing speed, reasoning/ problem solving, working memory and social cognition. The overall trend points toward a similar cognitive change in both groups. The patient group's improvement in reasoning/ problem solving was significantly larger that the control group, but improvement in working memory was smaller. Cognitive improvements were seen under and after the initial psychosis episode and throughout the recovery process with 45.5% of the patients fully recovered by 6-year follow-up. Cognitive improvements were seen in almost every cognitive domain that is consistently impaired in FES.

Details of attention and learning change in first-episode schizophrenia.

Impaired attention and learning functions are common in schizophrenia. The details of this impairment, and how these change across time, are not well known. We aimed to compare the parameters of well-known attention and learning neuropsychological tests in first-episode schizophrenia (FES) patients and healthy controls in a 2-year follow-up period. The performance of 28-25 FES patients and pairwise matched healthy controls on the Continuous Performance Test-Identical Pairs, the revised Hopkins Verbal Learning Test, and the revised Brief Visuospatial Memory Test was compared at baseline and 2 years later. The attention dysfunction of the FES group was driven by slow reaction time and a comparative failure to identify correct hits. The reaction time was reduced somewhat across time in the patient group. Regarding the learning tasks, both groups increased their number of correct answers across trials. However, at each trial, the patient group exhibited lower scores, with a trend towards better visual learning performance across time. In summary, the FES patients were impaired in most of the parameters of the attention and learning tasks. Across time, modest improvements in reaction time and visual learning were displayed in the FES group. However, this group never caught up with the control group.

Resilience trajectories to full recovery in first-episode schizophrenia.

BACKGROUND: Resilience is successful adaptation despite adversity. This personality trait has the potential to add new knowledge to how to achieve a successful outcome, but resilience has been understudied in schizophrenia. The objective of the present study is to investigate if there are significant differences in resilience development among fully recovered and non-recovered patients with first episode schizophrenia (FES). METHODS: In the ongoing Oslo Schizophrenia Recovery Study spanning 10 years, 28 first-episode patients are interviewed and assessed yearly with comprehensive criteria of full recovery, a measure of social and role functioning and resilience, the Connor-Davidson Resilience Scale. The present study includes data from six follow-ups over four years. Working or studying, having symptoms that are stably mild or absent for two years or more, having contact with friends and/or dating, participating in leisure activities and living independently define full recovery. RESULTS: At the four-year follow-up, 55% were sustained full/partly recovered. Ten percent of those fully recovered were no longer in treatment. Choosing the overall best linear mixed model, we found a significantly larger increase in resilience score among the fully recovered than among those not recovered. CONCLUSIONS: Based on the theoretical rationale that resilience is activated differently in persons who experience adversity, the significant increase in resilience in the fully recovered group indicates that this psychological trait is present to a higher degree in fully recovered. These results highlight resilience as a factor associated with increased recovery in FES adding to the small literature on improvement among these patients and thus have important clinical implications.

Comparing effects: a reanalysis of two studies on season of birth bias in anorexia nervosa.

BACKGROUND: Outcomes from studies on season of birth bias in eating disorders have been inconsistent. This inconsistency has been explained by differences in methodologies resulting in different types of effect sizes. The aim of the current study was to facilitate comparison by using the same methodology on samples from two studies with differing conclusions. METHODS: The statistical analyses used in each study were applied to the samples from the other study and the resulting effect sizes, Cramêr's V and odds ratio (OR), were compared and discussed. RESULTS: For both studies, the Cramêr's Vs ranged between 0.03 and 0.08 and the OR ranged between 0.85 and 1.31. According to common conventions, Cramêr's Vs below 0.10 and ORs below 1.44 are considered small. CONCLUSION: As a marker of one or more potential risk factors, the observed effects are considered to be small. When reanalysed allowing for direct comparisons, studies with contrasting conclusions converge towards an absence of support for a season of birth bias for patients with AN.

The relationship between level of cognitive impairments and functional outcome trajectories in first-episode schizophrenia.

Although cognitive impairments are consistently linked to functional outcome in chronic schizophrenia, the relationship remains unclear for patients with first-episode schizophrenia. The objective of this present study was to determine whether there are distinct developmental trajectories for functional outcome in patients with different levels of baseline cognition. The present study has a multi-follow-up design, and includes data from six follow-ups over four years. Assessments were conducted yearly, apart from the first year where assessments were conducted every six months. A total of 28 patients with first-episode schizophrenia participated in the study, with 79% of patients retained at the 4-year follow-up. Cognition was assessed with MATRICS Consensus Cognitive Battery. Functional outcomes were obtained through Global functioning: Social and Global functioning: Role. Data were analyzed with linear multilevel models. Results suggest steady improvements in social and role functioning among the patients across the four year period. Baseline attention, verbal learning, and verbal working memory were significantly associated with social outcome. Role functioning was significantly associated with attention, verbal working memory, and reasoning/problem solving. Furthermore, the rate of change in social outcome varies among patients depending on their baseline level of attention and verbal working memory, with the lowest scoring group showing the least improvement over the years. The subgroup of patients with the largest cognitive impairments at the onset of the disorder shows limited improvements in social functioning compared to higher functioning groups.

Relationship between neurocognition and functional recovery in first-episode schizophrenia: Results from the second year of the Oslo multi-follow-up study.

Lack of control of confounding variables, high attrition rate, and too few neurocognitive domains completed at each assessment point are some of the limitations identified in studies of the relationship between cognition and functional outcome in schizophrenia. In the ongoing Oslo multi-follow-up study 28 first episode schizophrenia patients and a pairwise matched control group (N=28) are assessed with the MATRICS Consensus Cognitive Battery (MCCB), a clinical interview, an inventory on social and role functioning and criteria of remission and recovery at several follow-up points. The current paper describes the rate of remission and full recovery, and investigates the relationship between neurocognition and functional outcome. At 2-year follow-up, 80.0% of the patients were in remission and 16.0% of them fulfilled the criteria for full recovery. The attrition rate was very low. In the follow-up period, there was a statistically significant decline in Verbal Learning and a significant improvement on Reasoning/Problem Solving and Social Cognition in the schizophrenia group, but not in the control group. This indicates a differentiated neurocognitive course. In the schizophrenia group, Attention/Vigilance and years of education at baseline were significant predictors of social and role functioning 2 years later.

Neurocognitive predictors of remission of symptoms and social and role functioning in the early course of first-episode schizophrenia.

In a Norwegian ongoing longitudinal study, we investigate the neurocognitive development in first-episode schizophrenia patients, and the influence of neurocognition on remission and real life functioning. In the present study, results from the early course of illness are reported. The sample includes 28 schizophrenia spectrum patients and 28 pairwise matched healthy controls. The patients were recruited from mental health service institutions and data on psychosocial functioning, remission and neurocognition were obtained through a clinical interview, an inventory on social and role functioning, operational criteria of remission, and a standardized neurocognitive test battery, the MATRICS Consensus Cognitive Battery (MCCB). Large effect size differences between patients and controls were observed at baseline on every cognitive domain, as well as statistically significant improvements on overall cognitive function at follow-up for the patient group. A remission rate of 61% was found. The neurocognitive baseline measure of Attention significantly predicted remission status at follow-up, whereas Attention and Working Memory at baseline predicted levels of social and role functioning. In the early course of the illness, more than half of the group of first-episode patients were in remission, and neurocognitive functions are significantly associated with both remission of symptoms and social and role functioning.

Sustaining full recovery in schizophrenia after 15 years: does resilience matter?

The main purpose of this study was to follow up a group of persons who, fifteen years ago were considered to be fully recovered from schizophrenia, in order to examine how many have sustained their recovery and to investigate the role of resilience in recovery. A semi-structured interview was designed for this 15-year follow-up study based on previous research related to the course and prognosis of schizophrenia. In addition to the interview, measures of psychosocial functioning and the degree of positive and negative symptoms were used. Remission and recovery were evaluated by consensus-based criteria. The Connor-Davidson Resilience Scale was chosen to assess resilience. The results show a significant correlation between resilience and present psychosocial functioning. There is also a significant difference between fully recovered subjects and those in remission regarding their resilience score. These results show that the majority of the subjects had maintained their recovery, and that subjects who are still fully recovered have not used medication for seventeen years and are more resilient. Thus, a sustained, full recovery without medication seems possible for a subgroup of schizophrenia patients characterized by high resilience.