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

Abstract

BackgroundPeople 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.MethodWe 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.ResultsPsychotic 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.ConclusionsMoral 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 tool to evaluate proportionality and necessity in the use of restrictive practices in forensic mental health settings: the DRILL tool (Dundrum restriction, intrusion and liberty ladders)

“…The authors concluded that little is known about a) how to provide effective treatment or reduce the risk of assault carried out by these prolific, high risk patients and b) little is known about their motivations for carrying out the assaults which in some cases may be instrumental rather than expressive e.g. patients wishing to separate from other patients and staff due to a belief that that they will be harmed [ 8 ], or because of moralistic attitudes or cognitions [ 9 , 10 ]. Or reactive violence related to impaired neurocognition and social cognition [ 11 ].…”

Effects of Integrated Moral Reasoning Development Intervention for Management of Violence in Schizophrenia: A Randomized Controlled Trial

“…Patients with schizophrenia are, in general, not violent. However, there is an increase in violent behavior in schizophrenia [ 1 ], and with violent offenses [ 2 ], in particular, homicide [ 3 , 4 , 5 ]. A study has reported that the five-year incidence of violent conviction after first being diagnosed with schizophrenia was 11% in men and 3% in women [ 6 ].…”

“…Repetitive violence is often a multifactorial construct that involves biological, psychosocial, emotional, and pathophysiological factors and contextual, environmental, family-oriented, and situational features, alone or in combination [ 10 , 11 , 12 , 13 , 14 ]. Disorder-specific determinants, such as psychotic symptoms, are not always the sole factor involved in violence [ 5 ].…”

“…Moral reasoning has received relatively little attention in the research of looking into violence and violence-prone contexts in schizophrenia literature [ 2 , 5 , 21 , 22 ]. Moral reasoning is not simply associated with violence, but also to its level of maturity.…”

“…Moral reasoning, which includes moral and ethical components, is a process that guides decision-making [ 25 ]. It involves moral judgments and behaviors, and also includes reasons given for the behavior, causal relation and responsibility attribution [ 5 , 21 ]. Most judgments or moral decision-making involve information processing, such as rational or experiential thinking styles [ 26 ].…”