Aggression and Violent Behavior 19 (2014) 235–241

Contents lists available at ScienceDirect

Aggression and Violent Behavior

A systematic review of the association between attributional

bias/interpersonal style, and violence in schizophrenia/psychosis
Stephanie T. Harris ⁎, Clare Oakley, Marco M. Picchioni
Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, King's College London, De Crespigny Park, SE5 8AF, UK
St Andrew's Academic Centre, Institute of Psychiatry, King's College London, St Andrew's Healthcare, Northampton, NN1 5DG, UK
St Andrew's Academic Centre, St Andrew's Healthcare, Northampton, NN1 5DG, UK

a r t i c l e i n f o a b s t r a c t

Article history: Despite the widely recognized link between schizophrenia and violence, the illness-specific factors underlying
Received 23 September 2013 that association remain unclear. A body of work has implicated deficits in social cognition, consistently seen in
Received in revised form 11 April 2014 schizophrenia, that may mediate the risk of violence. Two specific areas of interest are attributional bias and in-
Accepted 14 April 2014
terpersonal style. We conducted a systematic literature search using EMBASE, Scopus, Ovid Medline, PsycINFO
Available online 21 April 2014
and Science Direct databases with search terms relating to attributional bias, interpersonal style and violence/
Keywords:
aggression in schizophrenia. Eleven studies were identified, six related specifically to attributional bias and
Attribution bias five to interpersonal style. Results suggest an association between hostile and externalizing attribution biases,
Interpersonal style and violence in schizophrenia. Furthermore, hostile, dominant, and coercive interpersonal styles are also fre-
Social cognition quently associated with violence in schizophrenia. An interaction between cognitive impairments and underly-
Schizophrenia ing personality traits, as well as other co-morbid or illness factors, is proposed to likely underpin associations
Violence with violence in schizophrenia. Conclusions are limited by methodological constraints. The field would benefit
Aggression from consistent definitions of violence, and a more systematic approach to cognitive assessment. Furthermore,
studies with more homogeneous samples; and longitudinal designs are warranted in order to gain a better un-
derstanding of causation with regard to illness factors specific to schizophrenia.
© 2014 Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
1.1. Social cognition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
1.2. Attributional style and bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
1.3. Interpersonal style . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
2. Material and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
3.1. Attributional bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
3.2. Interpersonal style . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
4.1. Attribution bias and aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
4.2. Interpersonal style and aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
5. Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
6. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
Appendix A. Example of electronic search strategy—Scopus (interpersonal style) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240

⁎ Corresponding author at: St Andrew's Academic Centre, St Andrew's Healthcare, Northampton, NN1 5DG, UK. Tel.: +44 1604 616858; fax: +44 1604 616265.
E-mail address: Stephanie.1.harris@kcl.ac.uk (S.T. Harris).

http://dx.doi.org/10.1016/j.avb.2014.04.009
1359-1789/© 2014 Elsevier Ltd. All rights reserved.
236 S.T. Harris et al. / Aggression and Violent Behavior 19 (2014) 235–241
1. Introduction
Epidemiological and birth cohort studies have provided robust evi-
dence for an increased risk of violence in schizophrenia (Arsenault,
Moffitt, Caspi, Taylor, & Silva, 2000; Fazel, Långström, Hjern, Grann, &
Lichtenstein, 2009; Swanson et al., 2006; Walsh, Buchanan, & Fahy,
2002). Despite this, reviews examining causal factors have yielded in-
consistent findings, and present a complex association with violence.
The most robustly evidenced of these factors linking schizophrenia and
violence are substance abuse (Elbogen & Johnson, 2009; Eriksson,
Romelsjö, Stenbacka, & Tengström, 2011; Fazel, Gulati, Linsell, Geddes,
& Grann, 2009; Fazel, Långström, Hjern, Grann, & Lichtenstein, 2009;
Short, Thomas, Mullen, & Ogloff, 2013; Swanson, Holzer, Ganju, & Jono,
1990) and co-morbid personality factors, in particular, antisocial person-
ality disorder and psychopathy (Nolan, Volavka, Mohr, & Czobor, 1999;
Tengström, Hodgins, Grann, Långström, & Kullgren, 2004).
Given the inconsistencies of findings, an interaction between differ-
ent factors seems more likely to explain the association. Reviews of the
literature have provided evidence for different underlying neurobiolog-
ical mechanisms in violence research, presenting violence in schizo-
phrenia as a very complex multidimensional problem (Hoptman &
Antonius, 2011). Other factors that appear to contribute to the complex
link with violence include positive psychotic symptoms (Link & Stueve,
1994; Swanson et al., 2006), particularly in the early phase of the illness
(Large & Nielssen, 2011).
1.1. Social cognition
Patients with schizophrenia exhibit cognitive deficits in a variety of
domains (Andreasen, 1997; Fioravanti, Carlone, Vitale, Cinti, & Clare,
2005). Such deficits predict poorer functional outcome (Liddle, 2000);
and may deteriorate over time (Pinkham, Penn, Perkins, & Lieberman,
2003). Among the multiple cognitive domains, deficits in social cogni-
tion may contribute directly to social functioning deficits observed in
schizophrenia (Brüne, 2005; Couture, Penn, & Roberts, 2006; Green &
Horan, 2010). Successful social functioning depends upon appropriately
attending to relevant social data, inferential processing and making de-
cisions based on that information (Penn, Sanna, & Roberts, 2008). There
is evidence that patients with schizophrenia show impaired processing
of social cues. For instance, impairments in facial emotion recognition
have been consistently reported, particularly for negative emotions
(Kohler, Walker, Martin, Healey, & Moberg, 2010; Kohler et al., 2003).
Poor recognition of negative facial emotions has, in turn, been associat-
ed with increased aggression and violence in schizophrenia (Harris &
Picchioni, 2013; Weiss et al., 2006). One review (Blackwood, Howard,
Bentall, & Murray, 2001) suggested that the cognitive deficits observed
in schizophrenia may result in biases in inferential processing of social
information, leading to inappropriate interpersonal interactions and in-
correct causal attributions.
Two areas of social cognition that may, therefore, contribute to vio-
lence in schizophrenia are those of attributional bias and interpersonal
style.
1.2. Attributional style and bias
Attributional style refers to the manner in which an individual
causally interprets the intentions of others or the events that occur
around them. It is proposed that patients with schizophrenia have
“self-serving” attribution biases, more so than healthy subjects. This re-
fers to a greater than normal tendency both to attribute the causes of
positive events to themselves; and also to attribute the causes of nega-
tive events to external factors, which is, in turn, known as an “external-
izing bias” (Blackwood et al., 2001; Candido & Romney, 1990; Kaney &
Bentall, 1989). Patients may also demonstrate stronger personalizing
biases. A “personalizing bias” refers to the active attribution of intent
in another person for negative events. Where this negative intent is
interpreted as hostile, this is known as a ‘hostile’ attribution bias.
These are demonstrated in patient populations, particularly among
paranoid patients (Blackwood et al., 2001). While this effect may be
more pronounced in patients with greater persecutory delusions
(Martin & Penn, 2002), Lysaker, Lancaster, Nees, and Davis (2004)
found no association between attributions and social dysfunction, nor
any relationship with symptoms. Broader reasoning biases, for example,
jumping to conclusions (JTC) (Dudley, John, Young, & Over, 1997) and
poorer mentalizing abilities (Koelkebeck et al., 2010; Pickup & Frith,
2001) are also evident in patients with schizophrenia, contributing to
incorrect attributions and overconfidence in decision making.
1.3. Interpersonal style
Kiesler's (1987) interpersonal circle theory hypothesizes that when
interacting with others (interpersonal behavior), we are inherently
predisposed to establish a relationship that reinforces our conceptuali-
zation of the self, through the reactions of others. In short, the ‘aim’ is
to elicit in others a reaction that will compliment interactions with
that person on two dimensions: affiliation (hostile to friendly) and con-
trol (dominance to submission). Classically, this can occur in two ways.
First, the reactions may be corresponding (i.e., matching across the affil-
iation dimension, but opposing on the control dimension), for example,
a friendly interpersonal style met with equal friendliness, or dominance
met with a submissive response. Alternatively, a contradictory response
may be elicited. In that case, responses only correspond along one or
neither dimension, and include hostility elicited by an attempt to
exert dominance. Limited experimental data suggest that contradictory
responses are associated with lower self-esteem in patients (BjØrkvik,
Biringer, Eikeland, & Nielsen, 2009). Lower self-esteem can, in turn, be
linked with increased frustration that can manifest as an over reliance
on maladaptive behaviors, such as becoming overly dominant and rare-
ly submissive (BjØrkvik et al., 2009). Previous work with offenders sug-
gests that hostile/dominant personality styles, in particular, are strong
predictors of aggression (Dolan & Blackburn, 2006).
The aim of this review will be to consider the evidence for roles for
abnormalities in attributional and interpersonal styles as determinants
of the risk of aggression or violence in schizophrenia.
2. Material and methods
We conducted a literature search and manual cross referencing of
English language empirical studies relating to attributional bias and in-
terpersonal style in patients with schizophrenia and psychosis, who had
been violent or aggressive. We searched the databases EMBASE,
SCOPUS, PsycINFO, Science Direct and Ovid Medline (Jan2013). Search
terms comprised the following: “attribution”, “cognitive”, “interpersonal”,
“interactional”, “bias”, “style”, “schizophreni*”, “psychosis”, “psychotic”,
“delusion*”, “violen*”, and “aggressi*” (Appendix A).
Studies were included if they assessed patients with schizophrenia or
another psychotic disorder and either attentional bias or interpersonal
style in relation to violence. Violence/aggression must have been system-
atically assessed, using either standardized tools or other objective means.
We identified 12 studies; six examined attributional bias and vio-
lence in schizophrenia (Table 1) and the remaining six, interpersonal
style (Table 2). In the main, the studies were conducted in inpatient set-
tings and violence/aggression was assessed using self-report measures
and patient records.
3. Results
3.1. Attributional bias
Three studies identified an association between violence and a hos-
tile attribution style. McNiel, Eisner, and Binder (2003) examined attri-
butional biases using the External Hostile Attribution Scale in 110 in-
 S.T. Harris et al. / Aggression and Violent Behavior 19 (2014) 235–241 237

Table 1
Studies of attributional bias in violent populations with psychotic illness.

Year Author Participants Violence/aggression Measures Main findings Limitations

2003 McNiel 110 short-term psychiatric
et al. inpatients
Range of diagnoses:
schizophrenic disorders (20%),
other psychotic disorders (13%),
2005 Waldheter 29 inpatients from a state
et al. psychiatric hospital
Severe mental illness including
schizophrenia spectrum
disorders
2007 Goldberg 76 inpatients in acute psychiatric
et al. care
Schizophrenic or mood disorder
(with
and without substance use
disorder)
2010 Papava 40 paranoid delusional patients
et al.
2 groups
▪ persistent delusional disorder
patients—depressive signs
(n = 20)
▪ persistent delusional disorder—
no depressive signs (n = 20)
Excluded substance misuse
2011 Tolfrey 45 male inpatients in medium
et al. and low
UK psychiatric care
Diagnoses of paranoid
schizophrenia (62.2%), other
psychotic disorders (8.9%)
All with prior substance misuse
2012 Edwards & 62 male mentally disordered
Bond offenders from one UK regional
and one secure unit
Diagnosis of schizophrenia (74%)
Physical aggression against
others or threatening others
with a lethal weapon
45% reported violence in the
2 months prior to hospital
admission
Modified Overt Aggression
Scale (MOAS)
▪ Frequency of violent acts
(3 months pre and post-test)
▪ Severity of violent acts
(3 months pre and post-test)
Retrospective Overt
Aggression Scale (ROAS)
▪ Cut off score of 5 or more
Divided into 2 groups
▪ Aggressive (n = 20)
▪ Non-aggressive (n = 56)
Rosenzweig Picture
Frustration Study (PFS)
▪ Measures Extra/Intra
punitive responses or with/
without punishment
The majority of index offenses
were violent
▪ Included sexual offenses and
arson
Mostly violent index offenses
▪ Physical violence (62%)
External Hostile
Attribution Scale (EHAS)
▪ 20 item self-report
measure
Novaco Anger Scale—A
(NAS-A)
Barratt Impulsiveness
Scale (BIS-11)
Minnesota Multiphasic
Personality Inventory—2
(MMPI-2)
Internal, Personal and
Situational Attributions
Questionnaire (IPSAQ)
Ambiguous Intentions
Hostility Questionnaire
(AIHQ)
Theory of Mind task
▪ Positive and negative
Rosenberg Self-Esteem
Scale
Narcissistic Personality
Inventory (NPI)
Attribution Style
Questionnaire (ASQ)
Rosenzweig Picture
Frustration Study (PFS)
▪ 24 pictures of ambiguous
situations
Gudjonsson Blame
Attribution Inventory—
Revised (GBAI-R)
Beliefs about Substance
Use Scale (BSU)
Social Information
Processing-Attribution
Emotion Questionnaire
(SIP-AEQ)
Computerised Stories Task
Narcissistic Personality
Inventory (NPI)
Violence positively correlated with all Retrospective
indicators of attributional style
High external hostile attributions Self-selection bias—
predicted violence excluding the most
violent patients
Interpersonal factors add to the Self-report measures
prediction of violence over other
variables
Positive correlation between: Heterogeneous group
▪ post-test violence, and personalizing
and hostile attribution biases for
accidental situations Relatively low base
▪ hostile attribution bias for levels of violence
ambiguous situations and post-test Did not distinguish
violence violence type
Social cognitive variables have
incremental predictive utility for
predicting violence severity
Aggressive patients had: Retrospective
▪ Greater self-serving biases
▪ higher self-esteem scores Cross-sectional
Did not examine phase
of illness
Both groups attribute negative events No objective measure of
externally violence or aggression
Delusional patients with depression Very specific sample
respond with outward aggression in group
frustrating situations
Positive correlation between mental Male patients only
blame and number of previous
offenses
Maladaptive beliefs about substance
use associated with higher
externalization of blamex
Externalization of blame may
represent a lack of responsibility and
increased risk of reoffending
Patients score highly for hostile Male patients only
attributions
▪ Comparable with personality
disorder
Low “self-concept clarity” and high
narcissism predicted increased
hostile attribution
Responses indicating physical
aggression associated with more
hostile attributions

patients with a variety of mental health diagnoses including schizophre-
nia (20%) and other psychotic disorders (13%). Self-reported violence
was predicted by high hostile external attributions across the diagnostic
categories, even after controlling for diagnostic/demographic variables.
The authors concluded that this, therefore, independently added to the
statistical prediction of violence. Waldheter, Jones, Johnson, and Penn
(2005) used the Internal, Personal and Situational Attributions Ques-
tionnaire and the Ambiguous Intentions Hostility Questionnaire to iden-
tify links between hostile attribution biases in accidental (no specific
intent) and ambiguous situations, and violence in 29 psychiatric inpa-
tients (41% with schizophrenia). The results revealed a positive correla-
tion between violence in the three months after testing, and both
personalizing and hostile attribution biases for responses to stimuli
depicting accidental and ambiguous situations. The design of the study
and its analysis, however, left it unable to point to attributional bias as
a direct risk factor for aggression. Edwards and Bond (2012) identified
that mentally disordered patients (74% with schizophrenia), with a his-
tory of violent offending had a greater hostile attributional bias than
controls. Patients with such biases were also more likely to indicate a
pro-aggressive response in relation to presented social scripts. Aggres-
sive responses to stories containing physical aggression were associated
with hostile attributions. Furthermore, violent patients with serious
mental illness (74% had schizophrenia) performed similarly to those
with personality disorder who had been violent.
238 S.T. Harris et al. / Aggression and Violent Behavior 19 (2014) 235–241

Table 2
Studies of interpersonal style in violent populations with psychotic illness.

Year Author Participants Violence/aggression Measures Main findings Limitations

1992 Morrison 156 US psychiatric patients
Diagnoses of schizophrenia
(n = 69)
2006 Doyle & 100 UK forensic inpatients
Dolan
Major mental disorder (90.4%)
▪ schizophrenia spectrum
disorders
▪ delusional disorder
2006 Fullam & 61 male UK medium/high secure Institutional aggression
Dolan patients with schizophrenia
▪ 92% paranoid schizophrenia
▪ 8% disorganized type
▪ Psychopathy and non-
psychopathy groups (cut off
score 16 on PCL:SV)
2007 Fresán 102 outpatients with
et al. schizophrenia
▪ Violent and non-violent groups ▪ Violent group cut-off
2010 Daffern 152 inpatients at Australian
et al. acute psychiatric/forensic unit (OAS)
Most diagnosed with a psychotic (51.3%)
disorder (83.7%)
2012 Cookson 79 acute psychiatric patients
et al.
Violence Scale (VS)
2 types of violence
▪ Others
▪ Property
Frequency of violent
ideation prior to admission
Modified Overt Aggression
Scale (MOAS)
▪ 12 weeks following
baseline
Actual, threatened or
attempted physical harm
to others
data
Historical, Clinical, Risk—
20 item scale (HCR-20)
Overt Aggression Scale
(OAS)
score of 7
Overt Aggression Scale Impact Message Inventory—
Circumplex (IMI-C)
▪ Verbal aggression
▪ Physical aggression 11.8%
Overt aggression Scale
(OAS)
Interpersonal Control Scale
(ICS)
Intimidation Scale (IS)
Social Desirability Scale (SDS)
Chart of Interpersonal
Reactions in Closed Living
Environments (CIRCLE)
Ward Angers Rating Scale
(WARS)
Novaco Anger Scale (NAS)
Chart of Interpersonal
Reactions in Closed Living
Environments (CIRCLE)
▪ Rated by nursing staff
Antisocial Personality
Questionnaire (APQ)
Temperament and Character
Inventory (TCI)
Impact Message Inventory—
Circumplex (IMI-C)
Traits of intimidation and control
in aggressive patients
Coercion was the strongest
predictor of aggression
Aggression in schizophrenia may
relate to a coercive interpersonal
style
Violence linked to coercive,
dominant and hostile
interpersonal styles
High coercion score predicted
violence
Compliant interpersonal style
protected against violence
Schizophrenia patients with
psychopathy had higher coercive
and hostile styles
▪ Higher aggression than the non-
psychopathy group
No significant differences for
dominant or submissive subscales
Violent patients had lower
cooperativeness
▪ May relate to a paranoid
interpersonal style provoking
violence
Trend towards lower reward
dependence and violence
Dominant and hostile–dominant
interpersonal styles associated
with violence
A hostile interpersonal style
accounted for high variance in
violent behavior
Aggression related to higher
dominance and hostility scores
Combined hostile–dominant scale
did not predict aggression
Reliance on self-report
Does not differentiate
between type of aggression
Mixed gender sample
Low base rate for physical
violence
Relatively small sample
Small sample size
Staff rated measures
Cross sectional
No measure of type of
violence
Only violence in the week
prior to assessment was
recorded
Only one measure of
personality
High proportion of patients
with paranoid schizophrenia
Inpatients only
Self-selection bias
Acute inpatients setting
Do not differentiate
diagnoses
Low threshold for violence/
aggression

The remaining three studies linked attenuated self-serving and exter-
nalizing biases with violence risk. Goldberg et al. (2007) assessed aggres-
sive and non-aggressive in-patients with schizophrenia, using the
Retrospective Overt Aggression Scale to define past aggression. Aggres-
sive patients manifested more self-serving attribution biases than their
non-aggressive counterparts, and with higher self-esteem scores. The
authors hypothesized that patients engaged in self-serving biases in
order to preserve or bolster their self-esteem when threatened. Consis-
tent with this, Tolfrey, Fox, and Jeffcote (2011) explored risk factors for
criminal offending in 45 male inpatients in UK medium and low secure
hospitals. Most patients (80%) had a psychotic disorder at the time of
their offense, which was typically violent. Maladaptive beliefs about
substance misuse were associated with a higher externalizing bias, sug-
gesting that such externalization was associated with less acceptance of
personal responsibility and an increased risk of violent reoffending.
Papava et al. (2010) examined two groups of patients with paranoid
delusional beliefs, divided according to depressive symptoms on the
Brief Psychiatric Rating Scale. Both groups attributed an external cause
to negative events; however, the deluded patients with depressive
symptoms endorsed a greater propensity to aggression in response to
frustration.
3.2. Interpersonal style
Of six studies, five associated coercive, hostile, or dominant interper-
sonal styles with aggression.
Morrison (1992) noted that coercive tendencies could exist without
overt displays of aggression, although a coercive interpersonal style was
a very strong predictor of aggression in mentally disordered patients.
Schizophrenia interestingly, was related to coercion, while bipolar dis-
order was not. Doyle and Dolan (2006) assessed interpersonal style in
100 UK inpatients, with serious mental illness, including schizophrenia.
Violent patients displayed more coercive, dominant, and hostile inter-
personal styles. Consistent with Morrison's findings, higher coercion
scores were predictive of violence. There was also a significant link
with the frequency of violence. Similarly, Daffern et al. (2010) observed
greater dominant and hostile interpersonal styles in a sample of 152 in-
patients, of whom, over 80% had a psychotic disorder. A hostile interper-
sonal style accounted for a greater proportion of the variance in
frequency of violent behavior than all other interpersonal styles, but
also more so than psychiatric factors such as psychotic symptoms.
Cookson et al. (2012) found that patients who had been aggressive
scored higher on hostility and dominance scales of the Impact Message
Inventory—Circumplex; though the combined hostile-dominant scale
did not predict aggression.
Fullam and Dolan (2006) assessed 61 male patients with schizo-
phrenia in medium secure care, divided into high and low psychopathy,
using the Psychopathy Check List-Screening Version (Hart, Cox, & Hare,
1995). Those with both schizophrenia and psychopathy had more coer-
cive and hostile interpersonal styles, and were more likely to have
engaged in institutional aggression than their ‘non-psychopathic’ coun-
terparts. No significant differences were found however between the
 S.T. Harris et al. / Aggression and Violent Behavior 19 (2014) 235–241
groups on dominant or submissive subscales. Fresán, Apiquian, Nicolini,
and Cervantes (2007) divided over 100 patients with schizophrenia on
the Overt Aggression Scale on the basis of recent violence. Patients with
schizophrenia who had been violent showed a significantly less cooper-
ative interpersonal style than the non-violent patients.
4. Discussion
4.1. Attribution bias and aggression
Current evidence suggests that a history of violence and aggression
in individuals with psychotic disorders including schizophrenia is asso-
ciated with hostile, externalizing attribution biases (Edwards & Bond,
2012; McNiel et al., 2003; Waldheter et al., 2005). Furthermore, person-
alizing biases in general are linked to aggression in these patients
(Waldheter et al., 2005). These data suggest that a tendency to attribute
blame for negative events and/or hostile intent towards others may be
linked with an increased tendency to violent and aggressive behavior.
In schizophrenia, attribution biases can occur in ambiguous and ac-
cidental situations (Waldheter et al., 2005). People both with and with-
out mental health problems who are aggressive, over-attribute hostility
and hostile intent to others in ambiguous situations, compared with
non-aggressive individuals. They may also ruminate more on these
interactions (Epps & Kendall, 1995; Wilkowski & Robinson, 2010). Com-
bined with the robustly established cognitive impairments in schizo-
phrenia (Rund, 1998; Sponheim et al., 2010), it follows that patients
may hypothetically over-attribute hostility in ambiguous and neutral
situations, by selectively attending to potentially hostile cues in the en-
vironment. This is consistent with the aberrant salience hypothesis
(Kapur, 2003) that may be a risk factor for, or underpin some psychotic
symptoms. Evidence suggests that patients with schizophrenia are
more likely to attribute meaning to a stimulus where there is none,
with this effect exaggerated in patients with delusions (Roiser et al.,
2009). Poorer executive functioning may further contribute to hostile
attribution biases through a misinterpretation of real cues and an inabil-
ity to update and modify cognitions accordingly (Krakowski & Czobor,
2012a,b). These are then combined with cognitive distortions, such as
jumping to conclusions, reasoning biases, and greater cognitive, emo-
tional and behavioral impulsivity.
Some data support the proposal that these kinds of attribution biases
predict the risk of aggression and violence more than demographic or
clinical variables (McNiel et al., 2003). That study also lent support to
the association between Threat Control/Override (TCO) symptoms, par-
ticularly delusions, and violence, though this has not been consistently
replicated (Appelbaum, Robbins, & Monahan, 2000; Link & Stueve,
1994). It remains unclear whether patients, or perhaps only violent pa-
tients, have a greater tendency to make negative attributions that then
link to the risk of violence, almost irrespective of their psychotic symp-
toms. Several lines of enquiry continue to suggest that other factors,
some linked with illness, but others intimately related to developmental
background and adult personality, influence the complicated relation-
ships between schizophrenia, attributional style, and violence. Anger,
excitement, impulsiveness, narcissism, and low depression scores
have all been associated with a hostile attributional style in schizophre-
nia (Edwards & Bond, 2012; Goldberg et al., 2007). Others have sug-
gested that a fragile self-image/perception may evoke aggressive
attribution biases (Edwards & Bond, 2012). Although, there is some ev-
idence that certain people may tend towards aggression in order to de-
fend or preserve their self-esteem (Donnellan, Trzesniewski, Robins,
Moffitt, & Caspi, 2005), studies have not always supported this relation-
ship (Baumeister, Bushman, & Campbell, 2000).
4.2. Interpersonal style and aggression
Dominant, coercive and hostile interpersonal styles are, unsurpris-
ingly, associated with aggression in a spectrum of mental disorders.
239
Furthermore, antisocial personality disorder, psychopathic traits and
psychopathy, co-morbid with schizophrenia were specifically associat-
ed with a coercive interpersonal style and an increased risk of aggres-
sion (Fullam & Dolan, 2006; Vitale, Newman, Serin, & Bolt, 2005). That
finding appears superficially consistent with data from other personali-
ty disordered populations linking self-serving narcissistic and hostile at-
titudes to the concept of psychopathy and aggression (Dolan &
Blackburn, 2006; Goldberg et al., 2007). In contrast however, Daffern,
Duggan, Huband, and Thomas (2008) observed that hostility scores
were not significantly related to overt displays of aggression in patients
with personality disorder (predominantly antisocial and borderline).
Such personality disorders are over-represented in schizophrenia com-
pared to the general population (Newton-Howes, Tyrer, North, & Yang,
2008). Based on this, and better replicated associations between these
interpersonal styles and personality disorders, personality factors
would seem to play a role in the relationship to violence, although
other factors must also be relevant. Interactions between underlying
personality styles and psychotic symptoms may predispose predisposes
towards violence (Arsenault et al., 2000). The increasingly robust evi-
dence for a substantial link between substance misuse, schizophrenia,
and violence (Fazel, Gulati, Linsell, Geddes and Grann, 2009; Fazel,
Långström, Hjern, Grann and Lichtenstein, 2009) cannot be ignored, de-
spite early evidence to the contrary (Morrison, 1992). This is, however,
more likely linked to the disinhibiting and direct aggression enhancing
effects of drugs. The diagnostic heterogeneity within many of these
studies makes comparisons across studies difficult. Poor characteriza-
tion of sample groups makes it impossible to account for co-morbid fac-
tors, such as substance use and personality disorder, despite their own
clear independent associations with violence.
It is also well documented that cognitive impairments exist in
schizophrenia; however, these were rarely comprehensively assessed.
While social cognitive impairments may be related to violence in psy-
chosis, there may be a role for cognition generally. For example impair-
ments in executive functioning, in particular, may predispose patients
to aggression (Krakowski & Czobor, 2012b) and social naivety, increas-
ing the risk of provoking hostility from others (Fresán et al., 2007). It
should be noted, however, that this marked cognitive impairment
alone cannot explain the presence of hostile attribution biases or inter-
personal styles in those without schizophrenia.
Based on the available evidence, it seems very unlikely that factors
specific to schizophrenia alone underpin the observed association be-
tween attributional biases, interpersonal style, and violence. Rather,
these in combination with underlying personality traits and other co-
morbid or illness specific factors may be more likely to mediate that
relationship.
5. Limitations
The majority of studies were conducted in inpatient settings pre-
senting a problem with the generalizabiliy of results. Studies in this
area are generally cross-sectional in terms of their design. As none had
a longitudinal component, it is almost impossible to determine how def-
icits in social cognition may shift with illness severity and influence the
link with violence. Almost universally small sample sizes may give rise
to Type-2 errors, and limit interpretation further.
Few studies took account of vital social and demographic variables.
Furthermore, the diagnostic heterogeneity found in many of the studies
is likely to have introduced both noise and variance into the data. There
was often also a failure to assess contributory co-morbidities, such as
childhood conduct disorder and personality disorder, in schizophrenia
samples.
An almost universal problem is the inconsistent definition and quan-
tification of aggression and violent behavior. Although violence is a
highly complex behavioral response, few studies incorporated indices
of severity, frequency, outcome and intent. These studies lacked consis-
tency in their assessment methods, making comparison between
240 S.T. Harris et al. / Aggression and Violent Behavior 19 (2014) 235–241

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