Electronic Letters to:
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eLetters: Electronic letters published:
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Executive function and inpatient violence in forensic patients with schizophrenia
- Patricia Abbott, Czarina Kirk, Consultant Neuropsychiatrist (6 November 2008)
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Author response to Abbott et al
- Rachael Fullam, Professor Mairead Dolan (17 April 2009)
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Patricia Abbott, Consultant Rehabilitation Psychiatrist Mersey Care NHS Trust, Czarina Kirk, Consultant Neuropsychiatrist
Send letter to journal:
pat.abbott{at}merseycare.nhs.uk Patricia Abbott, et al.
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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 or serious 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 of incidents (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 &Yudofsky SC), 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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Rachael Fullam, Adjunct Lecturer Centre for Forensic Behavioural Science, Monash University and Forensicare, Professor Mairead Dolan
Send letter to journal:
rachael.fullam{at}forensicare.vic.gov.au Rachael Fullam, et al.
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The e letter by Drs Abbott and Kirk reflects a basic misunderstanding of 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 those seen 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. Declaration of interest: None |
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