Metacognition as a Framework to Understanding the Occurrence of Aggression and Violence in Patients with Schizophrenia

Patients with schizophrenia engage in more violence and delinquent behavior compared with the normal population. Research has presented comorbid factors such as psychoses (and specifically first-episode psychoses), drug and alcohol abuse, personality disorders, and psychopathy as the major culprits in precipitating increased violent behavior in patients with schizophrenia. Over the last few years, it has become increasingly clear that the ability to comprehend the mental states of self and other, also termed metacognition, is a useful measure to understanding the psychopathology and social functioning in patients with schizophrenia. Characterizing the metacognitive profile in patients with schizophrenia can thus contribute to explaining the occurrence of violence and aggression in these patients.In this chapter, we present evidence supporting the viability and utility of metacognition as a framework to understanding the occurrence of violent behavior in patients with schizophrenia. First, we begin with a brief description of schizophrenia and a summary of the commonly held views about its association with impairment in social functioning, including violence and aggression. Next, we provide a definition of aggression and violence, and how these concepts are linked and conceptualized in this chapter. Here, we introduce a distinction between two subtypes of aggression and violence, namely impulsive and premeditated aggression/violence. This is followed by a section describing the nature of metacognitive impairments in schizophrenia and its association with the occurrence of violence and aggression, with a special emphasis on its association with impulsive and premeditated violence/aggression. Finally, we present a putative model describing the association of violence and these two types of violence with specific metacognitive profiles, and propose potential therapeutic interventions aiming at reducing violence and aggression in schizophrenia.