The criminal and personality profile of patients with schizophrenia and comorbid psychopathic traits

Personality and Individual Differences 40 (2006) 1591–1602 www.elsevier.com/locate/paid

The criminal and personality profile of patients with schizophrenia and comorbid psychopathic traits Rachael Fullam *, Mairead Dolan University of Manchester, Edenfield Centre, Bolton Salford Trafford Mental Health NHS Trust, Manchester M25 3BL, UK Received 23 May 2005; received in revised form 30 November 2005; accepted 9 January 2006 Available online 10 March 2006

Abstract Sixty-one male forensic patients who met the DSM-IV criteria for schizophrenia were categorised into high and low psychopathic trait groups using the Psychopathy Checklist: Screening Version. The groups were compared on their criminal history, symptom profile, personality style, risk scores and subsequent institutional violence. Patients with high scores on the PCL:SV had a greater number of previous convictions and were more likely to have a family history of criminality. The high psychopathy-scoring group had higher levels of Positive and Negative Syndrome Scale grandiose and hostile symptomatology, and higher scores on trait impulsivity and aggression. They also had a more coercive, less compliant interpersonal style than the low-psychopathy scoring group. The high-psychopathy scoring group were more likely to be involved in institutional aggression and had higher levels of risk for violence. Patients with schizophrenia and high levels of comorbid psychopathy have a distinctive interpersonal style that may contribute to their greater risk of disruptive institutional behaviour. Ó 2006 Elsevier Ltd. All rights reserved. Keywords: Schizophrenia; Psychopathy; Institutional aggression; Violence; Personality

*

Corresponding author. Tel.: +44 1617723855; fax: +44 1617723446. E-mail address: [email protected] (R. Fullam).

0191-8869/$ - see front matter Ó 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.paid.2006.01.003

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1. Introduction There is significant comorbidity between schizophrenia and personality disorders in general (Taylor et al., 1998), and between schizophrenia and antisocial personality disorders (ASPD) in incarcerated offenders [21–63%] (Coˆte´ & Hodgins, 1990; Hodgins, Hiscoke, & Freese, 2003; Hodgins, Toupin, & Coˆte´, 1996). Existing studies of patients with psychosis report that those with comorbid personality disorders are more likely to commit a violent assault following discharge (Moran et al., 2003). More specifically, studies examining comorbid ASPD and schizophrenia suggest an association with aggression and violence prior to admission (Rasmussen, Levander, & Sletvold, 1995), and following discharge (Hodgins et al., 2003). Work by Hodgins et al. (1996) suggests that patients with comorbid ASPD have poorer social skills, a younger mean age at first conviction, a greater number of overall convictions and a greater number of non-violent convictions than those with schizophrenia alone. DSM-IV ASPD has been criticised for its over reliance on social deviance (Hare, 1996), so many researchers assess co morbidity using the Psychopathy Checklist Revised (PCL-R, Hare, 1991) because of its greater emphasis on the interpersonal (callous unemotional) aspects of antisocial behaviour. One recent British study suggests that 23% of patients with major mental illness in High Security have co-morbid psychopathy (Blackburn, Logan, Donnelly, & Renwick, 2003). Others (e.g. Rasmussen & Levander, 1996; Tengstro¨m, Hodgins, Grann, La˚ngstro¨m, & Kullgren, 2004) report psychopathy comorbidity rates of 29% and 33% respectively in samples of violent patients with schizophrenia. Although psychopathy as a primary diagnosis has been shown to be associated with an increased risk of violent crime (Hare & Hart, 1993), violent recidivism (Hart, Kropp, & Hare, 1988) and institutional violence (Hare & McPherson, 1984; Valliant, Gristey, Pottier, & Kosmyna, 1999), there have been few studies looking at the impact of comorbid psychopathy in patients with schizophrenia. Available studies suggest that violent patients with schizophrenia have higher psychopathy scores than those who are not violent (Rasmussen et al., 1995; Nolan, Volavka, Mohr, & Czobor, 1999), patients with high psychopathy scores have a greater number of criminal convictions (Tengstro¨m et al., 2004), and that psychopathy is a robust predictor of violent recidivism in patients with schizophrenia (Rice & Harris, 1992; Tengstro¨m, Grann, La˚ngstro¨m, & Kullgren, 2000). Although all of these studies suggest a relationship between psychopathy and violence in patients with schizophrenia, none studies include more detailed dimensional measures of personality and interpersonal style, risk scores, or assessments of symptom profile so that relationships between these variables can be examined. Furthermore, there have been few specifically looking at the validity of the psychopathy construct in patients with schizophrenia. We hypothesised that among patients with schizophrenia, the high scoring psychopathy group would be more criminal and have higher trait impulsivity and aggression scores on psychometric measures suggesting that the psychopathy construct has reasonable concurrent validity in this sample. Based on our recent findings in PD samples (Dolan & Blackburn, 2006) we predicted that the high psychopathy scorers would have a more dominant and coercive interpersonal style and would be more aggressive when within an institution than those who score in the lower end of the psychopathy spectrum.

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2. Methods 2.1. Participants Sixty-one male patients who met the DSM-IV criteria for schizophrenia (Structured Clinical Interview for DSM-IV: SCID-II; First, Spitzer, Gibbon, & Wiliams, 1997) were recruited from medium and maximum secure forensic psychiatric hospitals in the North of England. Ninetytwo percent were classified as having paranoid schizophrenia and the remainder as the disorganised type. Ten participants had also been given a clinical diagnosis of antisocial personality disorder, one a diagnosis of schizoid personality disorder and one a diagnosis of schizoid and dependant personality disorder. The mean age of the patient group was 37.79 years (SD = 8.52 years) and mean IQ, as measured by the Welschler Abbreviated Scale of Intelligence (WASI, The Psychological Corporation, 1999) was 91.43 (SD = 17.77). The mean Psychopathy Checklist-Screening Version (Hart, Cox, & Hare, 1995) score was 12.5 (SD = 5.37) and mean duration of illness was 11.46 years (SD = 8.70). 2.2. Procedure The study was approved by the North West Regional Ethics committee and written consent was attained from all subjects. Case files were reviewed to assess the presence or absence of a history of drug/alcohol abuse, sexual abuse, physical abuse, family criminality, and family mental illness. Information on criminal history was also coded dichotomously as presence or absence of juvenile and adult offending (inter-rater agreement Kappa 0.98). Number of offences, type of offences and age of first offence were recorded from the official conviction records reported within the case files. Trained researchers completed the psychopathy, risk and symptom related assessments based on file review and interview where appropriate. Nursing staff rated the assessment of interpersonal style, and a researcher blind to baseline assessment score completed the collection of institutional violence outcome data. 2.3. Assessments 2.3.1. Assessment of symptomatology Symptoms were assessed using the positive and negative subscales of the Positive and Negative Syndrome Scale (PANSS, Kay, Fiszbein, & Opler, 1987). The mean positive symptom score in the whole sample was 12.30 (SD = 5.43) and the mean negative symptom score was 14.90 (SD = 6.51). 2.3.2. Assessment of psychopathy and background variables The Psychopathy Checklist: Screening Version (PCL:SV, Hart et al., 1995) was rated based on file review and interview. Inter-rater reliability using Intraclass correlations on total score in 10 cases was high at 0.93. PCL:SV factor 1 reflects affective and interpersonal traits and factor 2 reflects behavioural or social deviance components of psychopathy. As it has been shown that PCL-R scores are lower

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in UK compared to US forensic populations (Cooke, Miche, Hart, & Clark, 2005), and there are no established metric equivalence studies on the cross cultural cut-off scores using the PCL:SV in UK populations, we categorised the sample as psychopathic patients with schizophrenia (PS) and non-psychopathic patients with schizophrenia (NPS) based on a score above or below the 75th percentile on the PCL:SV (16 or above). We have adopted this system in a previously published study in schizophrenia (Dolan & Blackburn, 2006). 2.3.3. Assessment of personality and interpersonal style Participants completed the Antisocial Personality Questionnaire (APQ, Blackburn & Fawcett, 1999) a self-report inventory, which measures cognitive, affective and behavioural dispositions of relevance to offenders and other socially deviant groups. The APQ has 8 primary factor scales as follows; Self-Control (SC), Self-Esteem (SE), Avoidance (AV), Paranoid Suspicion (PA), Resentment (RE), Aggression (AG), Deviance (DE), and Extraversion (EX), and two higher order factor scales, Impulsivity (I) and Withdrawal (W). Nursing staff rated interpersonal style using the Chart of Interpersonal Reactions in Closed Living Environments (CIRCLE, Blackburn & Renwick, 1996). This 49-item instrument rates the interpersonal behaviour of inpatients based on observations made over the past month. Items are assigned to scales measuring the octants of Leary (1957) interpersonal circle; Dominant, Coercive, Hostile, Withdrawn, Submissive, Compliant, Nurturant and Gregarious. This measure has good inter-rater reliability (range 0.55–0.68, n = 210) and test retest reliability (0.83–0.92, n = 102) (see Blackburn & Renwick, 1996). 2.3.4. Assessment of violence risk and institutional aggression An independent researcher (blind to baseline assessment scores) reviewed the computerised official incident reports to record data on all aggressive incidents from admission to the point of assessment. An incident was considered aggressive if the patient was the clear instigator or coaggressor, and if the incident involved verbal or physical aggression to staff, patients or property. The time in months, from date of admission to the date of the first aggressive incident, was also recorded for each participant. The Historical, Clinical, Risk 20 item scale (HCR-20, Webster, Douglas, Eaves, & Hart, 1997) was completed for each participant. The HCR-20 is a structured clinical checklist, which contains ten Historical items, five Clinical items, and five Risk related items. The HCR-20 has satisfactory psychometric properties and has been shown to be a robust predictor of institutional and community violence (Webster et al., 1997). All 20 items are coded using a ‘‘0’’ rating for absence of an item, ‘‘1’’ for possible presence of the item and ‘‘2’’ for definite evidence for this item. The data were analysed with and without the H7 psychopathy and H9 personality disorder items due to criterion predictor overlap. 2.4. Statistical analyses Data were analysed using SPSS version 11.5 (Chicago Illinois, Inc.). Group differences were examined using parametric and non-parametric analysis where appropriate. A logistic regression analysis was conducted to investigate which of the psychometric measures that had univariate sig-

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nificance contributed most to the PS and NPS group categorisation. A total of 57 cases were included. The Hosmer and Lesmeshow Test indicated reasonable goodness of fit (v2 = 4.38, df 8, p = 0.82). The Nagelkerle R square was 0.68. Receiver Operator Characteristics (ROCs, see Mossman, 1994) were used to assess the accuracy of the variables that contributed most to group classification. Kaplan Meier Survival analyses were used to statistically compare group differences (using time in months) in survival rates to the first adverse institutional event following admission.

3. Results 3.1. General and background characteristics of the sample Overall, the PS group had a significantly higher mean number of previous offences than the NPS group. No other significant group differences were found in terms of age, IQ, length of current admission, illness duration or medication status. There was a non-significant trend towards a younger mean age of first offence in the PS group (see Table 1). The PS group were significantly more likely to have a history of family criminality and an offence in adulthood than the NPS group (see Table 2). There were no significant group differences in the rates of drug/alcohol abuse, familial mental illness, sexual/physical abuse, juvenile delinquency or previous violence.

Table 1 General characteristics of the sample Non-psychopathic patients with schizophrenia (NPS), n = 42

Psychopathic patients with schizophrenia (PS), n = 19

Mean

Mean

SD

Mean rank

SD

Mann Whitney U

Mean rank

Age Years in education WASI-IQ Length of current admission years (min 0.17, max 25.80)

35.69 11.45 93.54a 4.97

8.74 1.92 17.36 5.28

30.75 31.48 32.52 29.49

36.00 11.21 86.90 6.85

8.25 1.62 18.26 7.31

31.55 29.95 26.95 34.34

388.00 379.00 306.50 335.50

Illness duration in years since first psychiatric admission Medication (standard chlorpromazine units) Age of first offence Number of previous offences

11.55

9.14

30.99

11.26

7.88

31.03

398.50

552.11a

390.96

32.22

475.38

449.09

26.79

319.00

19.39c 9.17b

6.40 14.02

31.38 26.77

16.11 14.84

3.48 16.10

23.83 36.79

258.00 251.00**

< 0.05; **p < 0.01; n = 41. b n = 40. c n = 39.

*p

a

***p

< 0.001.

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Table 2 Background history of the sample History of drug abuse History of alcohol abuse Family mental illness Family criminality History of sexual abuse History of physical abuse Juvenile offence history Adult offence history Previous violent offences *p

< 0.05; **p < 0.01; n = 41. b n = 40.

***p

NPS, n = 42

PS, n = 19

v2

70.7% 28.6% 46.3%a 12.5%b 19.0% 17.1%a 52.4% 68.3%a 69.0%

89.5% 31.6% 42.1% 36.8% 21.1% 26.3% 73.7% 94.7% 84.2%

2.55 0.06 0.09 4.71* 0.03 0.69 2.46 5.08* 2.82

< 0.001.

a

3.2. PANSS symptomatology On the positive PANSS scale, the PS group had significantly higher scores on Grandiosity and Hostility than the NPS group. There were no significant group differences on the remaining positive and negative symptom scales (see Table 3).

Table 3 PANSS positive and negative symptom scores PANSS variable

NP, n = 42

PS, n = 19

Mean SD

Mean rank Mean SD

Mean rank

28.71 29.70 31.36 29.87 30.43 28.20 28.39 27.74 31.65 33.30 31.07 31.62 30.26

14.21 2.57 1.37 2.11 1.47 2.18 2.42 2.21 14.21 2.11 2.11 1.89 2.63

36.05 33.87 30.21 33.50 32.26 37.18 36.76 38.21 29.55 25.92 30.84 29.63 32.63

1.23 30.70 1.52 33.12

2.21 1.74

1.13 31.66 1.33 26.32

386.50 310.00

1.07 31.62

1.53

0.84 29.63

373.00

Positive scale total 11.43 Positive–delusions 2.24 Positive–conceptual disorganisation 1.50 Positive–hallucinatory behaviour 1.64 Positive–excitement 1.40 Positive–grandiosity 1.52 Positive–suspiciousness/persecution 1.79 Positive–hostility 1.29 Negative scale total 15.21 Negative–blunted affect 2.62 Negative–emotional withdrawal 2.12 Negative–poor rapport 1.98 Negative–passive/apathetic 2.33 social withdrawal Negative–difficulty in abstract thinking 2.19 Negative–lack of spontaneity and 2.31 conversation flow Negative–difficulty in 1.69 stereotyped thinking *p

< 0.05;

**p

< 0.01;

***p

< 0.001.

4.90 1.66 0.86 1.08 0.89 1.19 1.05 0.67 6.75 1.36 1.25 1.32 1.39

6.15 1.68 0.36 1.56 0.90 1.35 1.35 1.51 6.07 1.20 1.29 1.41 1.74

Mann Whitney U 303.00 344.50 384.00 351.50 375.00 281.50* 289.50 262.00** 371.50 302.50 396.00 373.00 368.00

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3.3. Personality and interpersonal style 3.3.1. Antisocial Personality Questionnaire On the APQ the PS group had significantly higher mean scores than the NPS group on the Resentment, Aggression and Deviance subscales and on the Impulsivity higher order factor (see Table 4). The NPS group had a significantly higher mean Self-Control score than the PS group. There were no significant group differences on the APQ: Self-Esteem, Avoidance, Paranoid suspicion, Extraversion scales or on the Withdrawal higher order factor. 3.3.2. Chart of Interpersonal Reactions in Closed Living Environment On the CIRCLE the PS group had a significantly higher mean score on the Coercive and Hostile subscales, and a significantly lower score on the Compliance subscale than the NPS group. No

Table 4 Mean scores for Antisocial Personality Questionnaire subscales APQ variable (min–max possible score)

NPS, n = 39 Mean

SD

Mean

SD

Self-control (0–20) Self-esteem (0–18) Avoidance (0–19) Paranoid suspicion (0–17)a Resentment (0–19) Aggression (0–20) Deviance (0–20) Extraversion (0–20) Impulsivity (0–33) Withdrawal (0–24)

11.46 6.54 6.74 5.39 7.61 6.56 10.31 11.85 13.64 9.15

4.72 5.18 4.16 5.16 4.68 4.20 4.71 3.77 7.72 5.40

7.42 6.44 6.89 6.53 10.47 11.95 13.05 10.42 19.16 11.00

4.23 3.65 3.37 3.86 4.75 4.18 2.57 3.70 7.65 5.10

*p a

PS, n =19

t-Statistic (df 57) 3.16** 0.07 0.14 1.45 (df 46.49) 2.17* 4.58*** 2.36* 1.41 2.50* 1.22

< 0.05; **p < 0.01; ***p < 0.001. Analysis with transformed data.

Table 5 Mean CIRCLE subscale scores for each grouplabel CIRCLE variable (min–max possible score) Dominant (0–15) Coercive (0–24)a Hostile (0–24) Withdrawn (0–12) Submissive (0–12) Compliance (0–15) Nurturant (0–27) Gregarious (0–15) *p a

< 0.05; **p < 0.01; ***p < 0.001. Analysis with transformed data.

NPS, n = 40

PS, n = 19

t-Statistic (df 57)

Mean

SD

Mean

SD

7.25 7.05 7.40 10.15 11.90 25.95 26.95 15.30

5.82 7.51 5.62 4.69 4.39 3.99 11.90 6.35

9.68 14.84 10.63 10.42 12.32 21.05 23.79 15.16

7.03 9.93 5.93 4.87 4.14 5.42 9.90 6.54

1.40 3.62** 2.03* 2.05 3.50 3.90*** 1.00 0.08

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significant differences were found between groups on the Dominant, Withdrawn, Submissive, Nurturant or Gregarious subscales (see Table 5). 3.4. Violence risk, institutional aggression 3.4.1. HCR-20 On the full item HCR-20 the PS group had a higher mean total HCR-20 score (M = 25.61, SD = 5.38) than the NPS group (M = 19.29, SD = 5.49), (t(57) = 4.09, p < 0.001). The PS group also had significantly higher mean scores on the Historical scale (M = 15.7, SD = 1.87), (t(57) = 5.09, p < 0.001). Analysis of the adjusted total and Historical scores after removal of items 7 and 9 confirmed that the PS group had higher total (t(57) = 3.05, p < 0.01), and Historical (t(57) = 2.52, p < 0.05). The PS group had significantly higher Clinical (M = 5.44, SD = 2.48) scores than the NPS group (M = 3.90, SD = 2.69), [t(57) = 2.07, p < 0.05]. There were no significant group differences in Risk subscale scores (NPS M = 3.49, SD = 2.20 vs. PS M = 4.44, SD = 2.91), (t(57) = 1.39, N.S). 3.4.2. Institutional aggression The PS group were more likely to have engaged in an episode of institutional aggression (PS 13 [72%] vs. NPS 13 [34.2%]; v2 = 7.1, p < 0.01) between admission and time of assessment. They also had a significantly higher mean number of aggressive incidents in the first year of admission than the NPS group (NPS M = 0.18 [SD 2.18]; mean rank NPS, 28.51; PS M = 2.74 [SD 4.92]; mean rank of PS, 36.5; Mann Whitney U = 294.5, p < 0.05).

1.0

Cum survival

0.8

0.6 Group PS

0.4

NPS 0.2 0

20 40 60 80 100 120 Inc - time period till first incident post admission in months

Fig. 1. Kaplan Meier survival analysis for aggressive incidents post-admission.

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Table 6 Logistic regression for the prediction of psychopathic status Wald Number previous offences PANSS hostility PANSS grandiosity APQ self-control APQ resentment APQ aggression APQ deviance CIRCLE coercion CIRCLE hostility CIRCLE compliance

0.69 0.00 0.28 0.22 3.45 5.61 0.27 1.04 0.66 1.69

Significance 0.41 0.98 0.60 0.64 0.06 0.02 0.60 0.31 0.42 0.19

Exp(B) 1.02 0.98 0.85 0.91 0.70 1.76 1.11 1.11 0.91 0.80

95.0% C.I. for EXP(B) Lower

Upper

0.97 0.32 0.47 0.65 0.48 1.10 0.75 0.91 0.73 0.57

1.07 3.02 1.54 1.31 1.02 2.81 1.65 1.36 1.14 1.12

There was a significant difference between the NPS and PS survival curves for time in months following admission to first aggressive incident (Kaplan Meier, Log rank statistic [df 1] = 7.64, p < 0.01), (PS M = 17.17 months, SD = 31.68; NPS = 28.48 months, SD = 42.24) (see Fig. 1). 3.5. Predictive accuracy for PS /NPS status A logistic regression (LR) analysis was conducted using the enter method with psychopathy group as the dependent variable. The dependent variables were the variables that were significantly different in the univariate analysis. The model was significant (v2 = 36.6, df 10, p = 0.001) overall correct classification was 88.9%. As can be seen in Table 6 the APQ aggression score contributed most significantly to equation. A repeat LR with APQ aggression alone was also significant (v2 = 16.9, df 1, p = 0.001) with 77.6% overall accuracy. The ROC AUC for APQ aggression was 0.82, p < 0.001.

4. Discussion We compared the clinical, criminal and personality characteristics of a well matched sample of patients with schizophrenia who were categorised into high /low psychopathy groups based on the PCL:SV. Generally, the findings fit with previous studies that report associations between psychopathy score and violence risk and criminality in general (Hart et al., 1988) but also in patients with schizophrenia (Nolan et al., 1999; Rasmussen et al., 1995; Rice & Harris, 1992; Tengstro¨m et al., 2000, 2004). Although there were no significant differences in age of onset of offending, the PS showed a trend towards a younger age of onset in line with previous studies in ASPD and nonASPD comparisons in patients with schizophrenia (Hodgins et al., 1996). Our finding that the groups did not differ in the presence or absence of a history of violence reflects the forensic nature of the sample, but we confirmed the notion that patients with comorbid psychopathic traits engage in more frequent offending and more frequent institutional aggression as well as a shorter time to first violent incident (Dolan & Khawaja, 2004).

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Our finding that patients with comorbid psychopathy had a family history of criminality is consistent with the literature suggesting a high rate of heritability for psychopathy, ASPD and criminality (see Dolan, 1994 for a review). Although previous studies have reported associations between psychopathy and substance misuse in PD samples (Blackburn & Coid, 1999) we did not observe this, and the prevalence of substance misuse was similar in both groups. Although there have been are no previous reports on the relationship between schizophrenia symptoms and psychopathy, our findings that psychopathy was associated with higher PANSS grandiosity and hostility scores suggests that some of the symptoms normally attributed to schizophrenia may also be rooted in personality pathology. Despite concerns about the use of self-report measures of personality pathology in forensic samples (e.g. Hare, 1996) we were able to confirm the notion that patients with high psychopathy scores had less self-control and a more aggressive, deviant and impulsive personality style. Indeed the APQ aggression score made a notable contribution to the prediction of high psychopathy score status. We were also able to show that key workers rated the more psychopathic group as significantly more coercive, less compliant and showed a trend towards a hostile interpersonal style. This work is compatible with studies in non-psychotic samples (Blackburn, 1998; Blackburn & Renwick, 1996; Dolan & Blackburn, 2006), and suggests that self-report and staff-rated measures of personality may be useful in both identifying those who require more in-depth interview-based personality/psychopathy assessments, and also in determining those who may need targeted psychological interventions to improve compliance and to reduce the impact of their coercive or dominant behaviours in ward settings. In the UK there has been a general reticence in assessing comorbid psychopathy in patients with schizophrenia due to concerns about the reliability and validity of this construct in patients with major mental illness. The findings from this study suggest psychopathy assessments in patients with schizophrenia showed reasonable interrater reliability and concurrent validity. Psychopathy assessment may also have clinical utility as high scores have previously been shown to be a significant treatment/outcome moderator in PD samples (Shine & Hobson, 2000). Our research findings also add to literature detailing the link between psychopathy, and institutional aggression of mentally disordered samples (Heilbrun et al., 1998). Our finding of an association between psychopathy and poor self-control as well as a coercive/less compliant interpersonal style suggests that this personality profile may well relate to the observed greater frequency of aggressive incidents in more psychopathic patients in institutional settings. Assessing personality functioning, including interpersonal style, may help in developing appropriate treatment interventions to lessen the impact that such personality pathology has on maladaptive behaviours including poor compliance and institutional aggression. Staff awareness of the contribution of antisocial and psychopathic traits to non-compliant and acting out behaviours in patients with schizophrenia may also help them manage and cope with such behaviour in a more constructive way, thereby reducing the reported levels of stress noted in frontline staff in secure settings (Coffey & Coleman, 2001). There are some limitations in the current study including small sample size, the cross sectional nature of the design and the focus on patients in secure care. Future studies need to determine whether our findings are supported in larger scale studies and in civil psychiatric samples. Although the MacArthur Violence Risk Assessment study reported that the PCL:SV was a robust predictor of community violence post-discharge (Steadman, Roth, Grisso, Mulvey, & Banks, 2001), it would be useful to examine the predictive validity of self-report and staff rated measures

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of personality traits related to antisocial behaviour in both institutional and community settings in patients with schizophrenia.

Acknowledgements Funded by grants from the National Forensic Mental Health R&D Programme, National Alliance for Research into Schizophrenia and Merseycare NHS Trust.

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