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Executive function and in-patient violence in forensic patients with schizophrenia

  • Rachael S. Fullam (a1) and Mairead C. Dolan (a2)



The literature on the association between neuropsychological deficits and in-patient violence in schizophrenia is limited and the findings inconsistent.


To examine the role of executive function deficits in in-patient violence using measures of dorsolateral (DLPFC) and ventrolateral prefrontal cortical (VLPFC) function.


Thirty-three violent and forty-nine non-violent male forensic in-patients with schizophrenia were assessed using neuropsychological tasks probing DLPFC and VLPFC function and on measures of symptoms and psychopathy.


There were no significant group differences in neuropsychological task performance. Higher rates of violence were significantly associated with lower current IQ scores and higher excitement symptom scores. The ‘violent’ group had significantly higher interpersonal and antisocial domain psychopathy scores. In a logistic regression analysis, IQ and the interpersonal domain of psychopathy were significant discriminators of violent v. non-violent status.


Personality factors rather than symptoms and neuropsychological function may be important in understanding in-patient violence in forensic patients with schizophrenia.

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Corresponding author

Correspondence: Rachael Fullam, Centre for Forensic Behavioural Science, School of Psychology, Psychiatry and Psychological Medicine, Monash University, Victorian Institute for Forensic Mental Health, Locked Bag 10, Fairfield, VIC 3078, Australia. Email:


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Declaration of interest


Funding detailed in Acknowledgements.



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Executive function and in-patient violence in forensic patients with schizophrenia

  • Rachael S. Fullam (a1) and Mairead C. Dolan (a2)


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Executive function and in-patient violence in forensic patients with schizophrenia

  • Rachael S. Fullam (a1) and Mairead C. Dolan (a2)
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Author response to Abbott et al

Rachael Fullam, Adjunct Lecturer
17 April 2009

The e letter by Drs Abbott and Kirk reflects a basic misunderstandingof the issue under investigation and of the scientific principals used in the study. This was not a prevalence study examining the generic links between executive dysfunction and inpatient violence. We are aware of the findings regarding acquired or organically based brain damage and violence; however, this was not the focus of the study. The article describes a scientific research study designed to address a very specific issue, namely, the relationship between executive function, symptoms, psychopathy and inpatient violence in forensic patients with schizophrenia. Due to the fact that this was a research study we had to gain informed consent from participants. In addition, in order to scientifically investigate our hypotheses we introduced appropriate controls for confounding variables such as medication side effects. We also had to ensure that patients were stable enough to complete the neuropsychological assessment battery. However, regardless of these controls, our overall sample showed significant levels of executive dysfunction, producing similar scores on the neurocognitive tasks to thoseseen in other samples of patients with chronic schizophrenia and patients with frontal lobe damage.1,2 We have highlighted the limitations of the study in the article and point out that the findings are not necessarily generalisable to a more acute population.

1.Pantelis C, Barber FZ, Barnes TR, Nelson HE, Owen AM, Robbins TW. Comparison of set-shifting ability in patients with chronic schizophrenia and frontal lobe damage. Schizophr Res 1999; 37:251-70.2.Pantelis C, Barnes TR, Nelson HE, Tanner S, Weatherley L, Owen AM, Robbins TW. Frontal-striatal cognitive deficits in patients with chronic schizophrenia. Brain 1997; 12:1823-43.

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Executive function and inpatient violence in forensic patients with schizophrenia

Patricia Abbott, Consultant Rehabilitation Psychiatrist
06 November 2008

Fullam & Dolan?s finding that dysexecutive dysfunction was not a predictor of inpatient violence in a forensic population was surprising,, but may be explained by the selection criteria for inclusion in the study.These authors excluded subjects who were unable to give informed consent and only accepted individuals who were ?stable on medication?. These criteria would have excluded a significant number of individuals with the most severe forms of treatment-resistant schizophrenia who could not consent to participate in this study because of formal thought disorder orserious cognitive impairment. They would also have excluded those with more severe dysexecutive disorder who may exhibit ?organic impulsive aggression? (Yudovsky, 1990) and therefore not be considered sufficiently ?stable on medication? to be selected.

Participants selected for this study are likely to be those whose illnesses are reasonably responsive to treatment and who have relatively minor dysexecutive deficits with limited behavioural consequences, as indicated by the incident data in this paper. Relatively minor dysexecutive deficits may not be readily detectable in terms of behavioural change in the general population following brain injury even though they are critical in terms of functional outcome in this group (McCullagh & Feinstein, 2005).

In the Centre for Cognitive Rehabilitation at Ashworth Hospital, we provide a treatment programme for men in high secure services who have severe impulsive behaviour secondary to dysexecutive disorder, caused by acquired brain injury, treatment-resistant schizophrenia or other conditions. Almost all of our high dependency population would not have fulfilled the inclusion criteria for this study by virtue of high rates ofincidents (rendering them insufficiently ?stable?) or absence of capacity to consent. In our experience there is a similar sub-group in longer term medium secure settings who may also have been excluded for the same reasons.

In our view, by virtue of excluding the population in high secure services with the most severe forms of both treatment-resistant schizophrenia and dysexecutive disorder, Fullam & Dolan have effectively excluded the group most likely to exhibit high rates of violence. This is an area which should be investigated further before it is safe to conclude that psychopathy is a bigger factor than dysexecutive disorder in inpatient violence in people with schizophrenia.

1 Fullam RS & Dolan MC . Executive function and inpatient violence in forensic patients with schizophrenia, Br J Psychiatry 2008,193 , 247-253

2 McCullagh S & Feinstein A Cognitive Changes (chapter) in Textbook of Traumatic Brain Injury (eds Silver JM, McAllister TW &YudofskySC), 2005, American Psychiatric Publishing, Inc., Washington DC, London

2 Yudofsky SC, Silver JM, Hales RE Pharmacologic management of aggression in the elderly Journal of Clinical Psychiatry 1990, 51, suppl 10, 22-28.
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