Social Cognitive and Affective Neuroscience, 2017, 111

doi: 10.1093/scan/nsw164
Original article

Socio-neuro risk factors for suicidal behavior in

criminal offenders with psychotic disorders
Carla L. Harenski,1 Michael Brook,2 David S. Kosson,3 Juan R. Bustillo,4
Keith A. Harenski,1 Michael F. Caldwell,5 Gregory J. Van Rybroek,5
Michael Koenigs,6 Jean Decety,7 David M. Thornton,8 Vince D. Calhoun,1,9
and Kent A. Kiehl1,10
1

The Mind Research Network and Lovelace Biomedical and Environmental Research Institute, Albuquerque,
NM, USA, 2Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of
Medicine, Chicago, IL, 3Department of Psychology, Rosalind Franklin University, Chicago, IL, 4Department of
Psychiatry, University of New Mexico, Albuquerque, NM, 5Mendota Mental Health Institute, Madison, WI,
6
Department of Psychiatry, University of Wisconsin Madison, Madison, WI, 7Departments of Psychology and
Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, 8Sand Ridge Secure Treatment
Center, Mauston, WI, USA, 9Department of Electrical and Computer Engineering, University of New Mexico,
Albuquerque, NM and 10Department of Psychology, University of New Mexico, Albuquerque, NM
Correspondence should be addressed to Carla L. Harenski, The Mind Research Network, 1101 Yale Blvd NE, Albuquerque, NM 87106, USA.
E-mail: [email protected]

Abstract
Relative to the general population, individuals with psychotic disorders have a higher risk of suicide. Suicide risk is also
elevated in criminal offenders. Thus, psychotic-disordered individuals with antisocial tendencies may form an especially
high-risk group. We built upon prior risk analyses by examining whether neurobehavioral correlates of social cognition
were associated with suicidal behavior in criminal offenders with psychotic disorders. We assessed empathic accuracy and
brain structure in four groups: (i) incarcerated offenders with psychotic disorders and past suicide attempts, (ii) incarcerated
offenders with psychotic disorders and no suicide attempts, (iii) incarcerated offenders without psychotic disorders and (iv)
community non-offenders without psychotic disorders. Established suicide risk variables were examined along with empathic accuracy and gray matter in brain regions implicated in social cognition. Relative to the other groups, offenders with
psychotic disorders and suicide attempts had lower empathic accuracy and smaller temporal pole volumes. Empathic accuracy and temporal pole volumes were significantly associated with suicide attempts independent of other risk variables. The
results indicate that brain and behavioral correlates of social cognition may add incremental value to models of suicide risk.
Key words: empathic accuracy; temporal poles; suicide; psychosis

Received: 10 March 2016; Revised: 14 September 2016; Accepted: 31 October 2016

C The Author (201~7). Published by Oxford University Press. For Permissions, please email: [email protected]
V

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/
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| Social Cognitive and Affective Neuroscience, 2017, Vol. 0, No. 0

Introduction
Psychotic disorders, such as schizophrenia and bipolar disorder with psychotic features, are associated with an 8- to
12-fold risk of suicide compared with the general population
(Roy, 1986; Caldwell and Gottesman, 1990; Breier et al., 1991;
Harris and Barraclough, 1997; Dutta et al., 2010; Nordentoft et al.,
2011). It is difficult to assess which psychotic individuals are at
higher risk than others, though certain risk variables have been
identified (e.g. comorbid psychiatric disorders, substance abuse,
family history of suicide, medication discontinuation, insight
into illness) (Potkin et al., 2003; Hawton et al., 2005a,b; Hor and
Taylor, 2010). While some of these variables contribute to suicide risk assessment, they may be difficult to predict (e.g. medication discontinuation) or may represent static variables that
cannot be modified (e.g. family history). There is thus a need for
research to characterize dynamic risk variables that can be
identified early and modified with treatment.
Disturbances in social behavior are a core feature of psychotic disorders. Underlying these disturbances are impairments
in the production and interpretation of appropriate social signals such as facial and vocal emotion recognition (Getz et al.,
2003; Kohler et al., 2010), emotional and mental state attribution
(Brune, 2005; Olley et al., 2005; Langdon et al., 2006; Leitman
et al., 2006), and empathic accuracy (Derntl et al., 2009; ShamayTsoory et al., 2009; Lee et al., 2011b; Smith et al., 2015). Patients
with schizophrenia tend to show greater deficits compared
those with bipolar disorder (Lee et al., 2013). These deficits are
associated with poor outcomes (Fett et al., 2011) including impaired interpersonal skills and social functioning (Hooker and
Park, 2002; Pinkham and Penn, 2006), and mediate the relationship between neurocognitive impairment and overall functioning (Green and Horan, 2010; Couture et al., 2011; Horan et al.,
2012; Schmidt et al., 2011). They may also affect family and peer
relationships, causing feelings of social disconnection.
Although lack of social connectedness is an often-cited risk factor for suicide (Durkheim, 1897; Shneidman, 1998; Joiner et al.,
2009; Van Orden et al., 2010; OConnor, 2011), to date there has
been little direct examination of the association between social
cognitive impairment and suicidal behavior.
The neuroanatomical underpinnings of social cognition have
been well established (Cacioppo and Decety, 2011). For example,
mental state attribution, or mentalizing, reliably engages the
medial prefrontal cortex (mPFC), posterior superior temporal
cortex (posterior ST) and temporal poles (Frith and Frith, 2003;
Amodio and Frith, 2006; Olson et al., 2007; Assaf et al., 2009).
Individuals with psychotic disorders show aberrant functional
responses in these regions when performing social cognitive
tasks, which are related to overall social functioning (BrunetGouet and Decety, 2006; Malhi et al., 2008; Benedetti et al., 2009;
Kim et al., 2009; Dodell-Feder et al., 2014). Furthermore, anatomical MRI studies have reported gray matter volume reductions in
some of these regions, most consistently posterior ST, among
psychotic-disordered individuals with a history of suicide attempts (Aguilar et al., 2008; van Heeringen et al., 2011;
Giakoumatos et al., 2013). This finding has been attributed to
altered social perception (inferred perceptions of oneself by
others which lead to negative affect) (Giakoumatos et al., 2013).
Most of the patient research summarized above has been
conducted in psychotic-disordered individuals who reside in the
community. Another group of individuals at high risk for suicide
is prisoners. Individuals who become imprisoned at some point
show increased suicidal thoughts and behaviors throughout
their lives, with a rate of almost six times the general

population among males (Fruehwald et al., 2004; Jenkins et al.,

2005). Thus, criminal offenders with psychotic disorders may
represent an especially high-risk group (Baillargeon et al., 2009;
Haglund et al., 2014). It is challenging to conduct neuroimaging
studies of criminal offenders due to incarceration and the practical challenges associated with bringing imaging capabilities to
prisons (or transporting prisoners to outside imaging facilities,
which is often not possible or permissible). In this study, we
used a mobile MRI scanner that was situated on prison grounds,
enabling us to recruit and scan psychotic-disordered offenders.
The goal of this study was to compare the behavioral and
brain correlates of social cognition in psychotic offenders with
and without a history of suicide attempts. Although not all suicide attempters go on to complete suicide, past attempts are
among the strongest predictors of future suicide (Gunnell and
Lewis, 2005). We chose to examine empathic accuracy, defined
here as the ability to infer others emotions in social contexts.
The empathic accuracy task we used presented video clips to
study participants in which people (not actors) described autobiographical events, and participants indicated which types of
emotions the people most likely experienced during the event
(Ickes, 1997; Brook and Kosson, 2013). This task was chosen for
its interpersonal and dynamic features, which resembles the
types of social cognitive abilities that individuals use in real-life
social interactions. Additionally, difficulty inferring specific
types of emotions in others could be expected to escalate interpersonal conflict and feelings of social alienation (for example,
misinterpreting nervousness or shyness as irritation or anger).
We compared task performance and brain structure between
psychotic offenders with and without a history of suicide attempt/s, and also compared performance with nonpsychotic
offenders and community non-offenders. The community
non-offender group was used to provide standard measures of
empathic accuracy and brain structure. However, because this
group was likely to differ from the psychotic offenders on characteristics other than psychosis or suicidal behavior (e.g. substance abuse, criminal behavior, impoverished environments),
we also included a non-psychotic offender comparison group.
We hypothesized that psychotic offenders with a history of suicide attempts would show lower empathic accuracy and smaller
posterior superior temporal (posterior ST) gray matter volume.
Although the posterior ST was our primary region of interest, we
also included the temporal poles and mPFC, which have been
implicated in studies of mental state attribution in schizophrenia and bipolar disorder (Benedetti et al., 2009; Kim et al., 2009;
Lee et al., 2010; Lee et al., 2011a; Dodell-Feder et al., 2014). We
hypothesized that empathic accuracy and gray matter volumes
would add incremental value to the discrimination of psychotic
offenders with and without past suicide attempts, independent
of other established risk variables for suicide (e.g. depression).

Method
Participants
The total sample included 126 participants: (a) male criminal offenders (n 41) who met DSM-IV criteria for schizophrenia
(n 19), schizoaffective disorder (n 11), bipolar disorder with
psychotic features (n 9), major depressive disorder with psychotic features (n 1) or psychotic disorder not otherwise specified
(n 1); (b) male criminal offenders with no history of a psychotic
disorder (n 59) and (c) male community non-offenders (n 26).
Incarcerated offenders were recruited from state psychiatric/
treatment and prison facilities in Wisconsin and New Mexico.

C. L. Harenski et al.

Table 1. Demographic and clinical characteristics of study groups

Age
IQ estimate
PCL-R
Illness duration
Olanzapine equiv.
PANSS positive
PANSS negative
PANSS general
BIS
Race (CA:AA:OT)
Handedness (R:L:B)
Psychotic disorder (SZ:SZA:BP:OT)
Anxiety disorder
Early adverse experiences
Serious violence

Community
non-offender
(n 5 26)

Non-psychotic
offender (n 5 59)

Psychotic no
suicide attempt
(n 5 25)

Psychotic suicide
attempt (n 5 18)

M (s.d.)
32.5 (11.16)
114.8 (14.69)

M (s.d.)
33.0 (9.49)
98.1 (13.22)
22.5 (7.65)

M (s.d.)
40.2 (10.23)
94.9 (14.45)
21.4 (7.30)

M (s.d.)
38.9 (11.73)
93.8 (18.61)
21.1 (6.26)

%
61.5:11.5:27
73:8:19

%
47:47:5
88:5:7

87a

15.8 (12.33)
19.8 (14.76)
15.0 (5.86)
12.6 (5.07)
26.0 (9.70)
60.6 (12.06)
%
60:32:8
88:8:4
40:32:24:4
16
44
57.7

17.8 (13.36)
23.4 (16.34)
14.7 (5.99)
12.7 (5.78)
28.35 (5.60)
60.6 (12.95)
%
50:39:11
78:17:5
61:17:17:5
17
47
76.5

Post hoc

F
4.23
10.66
0.34
t
0.50
0.74
0.16
0.02
0.90
0.00
v2
20.3
7.45
2.24
0.00
0.04
1.85

P
0.01
< .001
0.71
P
0.62
0.47
0.88
0.98
0.38
1.00
P
0.06
0.28
0.52
0.95
0.98
0.17

CN/NO < PN/PS

CN > NO/PN/PS

IQ, intelligence quotient estimate from the vocabulary and matrix reasoning subtests of the WAIS; PCL-R, psychopathy checklist-revised; PANSS, positive and negative
symptom scale; BIS, Barratt impulsiveness scale; CA, Caucasian; AA, African American; OT, other; R, right; L, left; B, both (no dominant hand); SZ, schizophrenia; SZA,
Schizoaffective disorder; BP, bipolar disorder; OT, other psychotic disorder.
a
Five participants were excluded from this analysis due to insufficient detail available regarding the degree of injury or use of weapons related to assault.

Non-offenders were recruited from the NM community. All participants were scanned using the same mobile MRI scanner.
Inclusion criteria for the psychotic offender group were: (i) age
between 18 and 60, (ii) native English speaker, (iii) reading level
fourth grade or higher, (iv) no history of epilepsy or seizures, (v)
no history of serious head injury with loss of consciousness longer than 1 h, (vi) no history of mental retardation or developmental disability. These criteria were also applied to both
control groups, in addition to: (i) no lifetime psychotic disorder
in self or first-degree relative or recurrent major mood Axis I
disorder, (ii) no history of paranoid, schizotypal or schizoid Axis
II disorder. Community non-offenders were additionally
required to have no history of drug use or alcohol use disorder
and no criminal offenses. Written informed consent was obtained from all participants at the initial study session after a
complete description of the study procedures, which were
approved by the University of New Mexico Institutional Review
Board. Participants were paid at a rate commensurate to work
assignments at their facility. No prior studies have reported on
the psychotic or non-offender participants. A subset of the nonpsychotic offender group has been included in prior studies
(Motzkin et al., 2011; Ly et al., 2012; Motzkin et al., 2014; Pujara
et al., 2013; Philippi et al., 2015; Wolf et al., 2015).
Of the 41 psychotic offenders, 18 had a history of suicide attempt/s and 23 did not. Psychotic offenders were consecutively
enrolled in the study (rather than being selected based on history of suicidal behavior). Classification of suicide attempts was
based on criteria outlined in the Colombia Suicide Severity
Rating Scale (C-SSRS) (Posner et al., 2011): a potentially selfinjurious act committed with at least some wish to die as a result of the act. Relevant life history details were obtained via
interviews and file review. Specifically, we reviewed participant
institutional files that contained medical records with annual
psychiatry reports, psychosocial history summaries dating back
to childhood and interval reports regarding adjustment to the

facility and treatment progress. Usually, these were sufficient to

determine whether the individual had a history of a suicide attempt. In rare cases where file content was insufficient, information was obtained from the Structured Clinical Interview for
DSM-IV Disorders (SCID-IV) and/or Hare Psychopathy ChecklistRevised (PCL-R) interviews (see below). Demographic and clinical characteristics of the four groups are provided in Table 1.

Assessments
Past and present DSM-IV Axis I and II disorders were evaluated
in all participants using the research version of the Structured
Clinical Interview for DSM-IV Disorders (SCID-IV) (First et al.,
1997). Psychotic disorder diagnoses in incarcerated offenders
were confirmed with additional file reviews of previous evaluations by facility psychologists or physicians. Current symptoms were evaluated in psychotic offenders using the Positive
and Negative Symptom Scale (Kay et al., 1987). All except six
psychotic offenders were taking antipsychotic medications at
the time of the study. Medication dosages were converted to
daily olanzapine equivalents (Gardner et al., 2010) (see
Supplementary data for additional information). Intelligence
was assessed with the vocabulary and matrix reasoning subtests of the Wechsler Adult Intelligence Scale (WAIS) (Wechsler,
1997; Ryan et al., 1999). Psychopathy, which is more prevalent
among offenders (Hare, 2003) and associated with lower empathic accuracy (Brook and Kosson, 2013), was assessed using
the Hare Psychopathy Checklist-Revised (PCL-R) (Hare, 2003).
Established risk variables for suicide in psychotic individuals
(Potkin et al., 2003; Hawton et al., 2005a; Hor and Taylor, 2010)
were examined. Positive and negative symptoms, as well as insight, were scored from relevant PANSS items. Because studies
have found that high levels of positive symptoms and low levels
of negative symptoms are associated with the highest risk for suicide (Hor and Taylor, 2010), we separated participants into groups
based on whether their positive and negative symptom scores

| Social Cognitive and Affective Neuroscience, 2017, Vol. 0, No. 0

were above or below the group median (i.e. High Positive High
Negative, High Positive Low Negative, Low Positive High
Negative and Low Positive Low Negative), and created a binary
measure (HP LN vs other groups). Participants with a symptom
score equal to the median (n 13) were excluded from analysis
with this variable. Depression was defined as having a history of
at least one major depressive episode. Relevant clinical information was obtained from the SCID and file review. Information regarding substance use disorders was obtained from the SCID
(see Supplementary data for additional information).
We also evaluated variables associated with increased suicide risk in the general population: impulsivity, anxiety, aggression and early adverse experiences (e.g. physical and/or or
sexual abuse) (Sareen et al., 2005; Nock and Kessler, 2006; Stein
et al., 2010; Swann et al., 2005). Impulsivity was measured using
the Barratt Impulsiveness Scale (Patton et al., 1995). History of
anxiety disorder was evaluated with the SCID. Early abuse was
assessed using a modified version of the Traumatic Life Events
Questionnaire (Kubany et al., 2000; http://www.bhevolution.org).
For aggression, we assessed the individuals history of violent
acts. Participants were assigned to one of the two categories: no
violence or minor violence (e.g. assault without injury or
weapon use) and serious violence (e.g. sexual offense, homicide)
(Swanson et al., 2006). Violence information was obtained via an
interview in which participants were asked if they had ever
committed each of several different classes of crime (e.g. robbery, homicide, DUI, minor assault). Self-report was checked
against file/criminal records. None of these variables significantly differed between psychotic offenders with and without
past suicide attempts (Table 1).

Empathic accuracy task

Participants viewed 13 brief video clips in which the target individual described an affectively laden social situation they had
previously experienced. The target was a volunteer relating an
event they had actually experienced (not an actor). Target volunteers were diverse in age, race and ethnicity and included
both males and females. The target was situated/angled in the
video to simulate an interpersonal interaction with the participant. Following each clip the participant completed an answer
sheet which listed 25 emotions comprising the tripartite hierarchical inventory of emotion words (Parrott, 2001). They were
instructed to select which emotions they believed the target
had experienced, and to rank the selected emotions in order (#1
being the most relevant). Empathic accuracy was operationalized as the degree of correspondence (02 Likert scale) between
the participant rating of the most salient emotion (i.e. the emotion ranked #1) and the target rating of the most salient emotion. The total possible score was 26/26 (i.e. score of 2 for each of
the 13 scenarios), thus a range of 0100% accuracy. The task has
shown high construct validity with other empathic accuracy
measures (Brook and Kosson, 2013).

Mapping software (SPM12; http://www.fil.ion.ucl.ac.uk/spm). T1

images were manually inspected by an operator blind to subject
identity and realigned to ensure proper spatial normalization.
Data were then spatially normalized into the standard Montreal
Neurological Institute space, resampled to 2  2  2 mm voxels
and segmented into white matter, gray matter and cerebrospinal fluid. The segmented maps were modulated to preserve
total cerebral volume (Ashburner and Friston, 2005) and voxels
with values <0.15 were removed. The segmented images were
then smoothed using a Gaussian kernel with a full-width at
half-maximum of 10 mm. Five psychotic offenders (three from
the non-suicide attempt group) did not complete the MRI scan
due to MRI incompatibility (n 3), withdrawing from the study
prior to the MRI scan (n 1), or being unavailable while the MRI
scanner was stationed at the facility (n 1).

MRI analysis
Regional gray matter volumes in a priori regions of interest were
calculated in SPM12 for each participant. Mean GMVs were extracted from anatomical image masks defining the posterior superior temporal cortex [Brodmann Area (BA) 22], temporal poles
(BA 38) and mPFC (BA 9). Image masks were obtained from the
Wake Forest University Pick Atlas Toolbox in SPM12 based on
automated anatomical labeling (aal) defined regions. Group differences in each region were then analyzed using ANCOVA in
SPSS 20.0 (www.spss.com) with planned t-tests comparing the
suicide attempt group to the no suicide attempt, non-psychotic
offender and non-offender groups. Alpha was set to P < 0.05
(two-tailed) for all analyses. Additionally, we conducted a
whole-brain analysis to investigate whether regions other than
those hypothesized differed between groups. A Monte Carlo
simulation conducted using
ClustSim (Forman et al., 1995) determined that an 831 voxel
extent at P < 0.001 uncorrected yielded a corrected threshold of
P < 0.05, accounting for spatial correlations between GMVs in
neighboring voxels. Total brain volume (GMV WMV), age and
IQ estimate were included as covariates in all of the above
analyses.

Behavioral data analysis

All analyses were conducted using SPSS. Empathic accuracy
performance across groups was analyzed using one-way analysis of variance. Age and IQ estimate, which were negatively
and positively correlated with empathic accuracy scores, respectively [r(124) 0.22, P 0.017; r(122) 0.25, P 0.005], were
included as covariates. None of the other variables in Table 1
were significantly correlated with empathic accuracy. One-way
ANCOVA was conducted across groups with planned follow-up
t-tests to compare performance between the suicide attempt
group and the no suicide attempt, nonpsychotic offender and
non-offender comparison groups. Alpha was set to P < 0.05
(two-tailed) for all analyses.

MRI acquisition

Suicide group analysis

High-resolution T1-weighted structural MRI scans were collected on a Siemens 1.5T Avanto mobile scanner, stationed at
the correctional facility, using an MPRAGE pulse sequence on a
32-channel head coil (repetition time 2400 ms, echo times 2.41 ms, inversion time 1000 ms, flip angle 8 , slice thickness 1.2 mm, matrix size 240  240) yielding 160 sagittal
slices with an in-plane resolution of 1.3 mm  1.3 mm. Data
were preprocessed and analyzed using the Statistical Parametric

We used logistic regression to examine the effects of established suicide risk variables for psychotic disorders (depression,
positive negative symptoms, substance use disorder, insight),
empathic accuracy and brain volumes on suicide attempt group
status (yes/no) of psychotic offenders. In order to retain the participants that did not complete MRI scans (thus keeping the participant group consistent across regressions), GMV values for
these participants were generated using iterative Markov chain

C. L. Harenski et al.

The effect in the left temporal pole was explained by reduced

volume in the psychoticsuicide attempt group relative to nonpsychotic offenders (x 46, y 18, z 15; P < 0.001; k 7384)
and non-offenders (x 46, y 21, z 18; P < 0.001; k 27 964).

Association between empathic accuracy, brain volumes

and suicide attempts

Fig. 1. Target (% accuracy) scores across groups. PS, psychotic offenders with suicide attempts; PN, psychotic offenders without suicide attempts; NO, nonpsychotic offenders; CN, community non-offenders. *P < 0.05, **P < 0.005.

Monte Carlo fully conditional specification imputation in SPSS,

which is appropriate for arbitrary pattern missing data (all results remained significant when the analysis was repeated
without these subjects.).

Results
Group differences in empathic accuracy
Participants showed moderate empathic accuracy performance
(% accuracy M 44.3, s.d. 14.64), consistent with prior research
in criminal offenders (Brook and Kosson, 2013). Psychotic offenders with a history of suicide attempts had lower empathic
accuracy compared with psychotic offenders without suicide attempts (P 0.032), nonpsychotic offenders (P 0.001) and community non-offenders (P 0.036); main effect of group
[F(3,122) 3.67, P 0.014; Figure 1]. There were no significant differences among the three comparison groups on empathic accuracy [F(2,104) 0.48, ns].

Group differences in brain volume

Psychotic offenders with a history of suicide attempts had lower
right and left temporal pole volumes compared with psychotic
offenders without suicide attempts (right: P .004; left:
P 0.005), nonpsychotic offenders (right: P 0.015; left: P 0.017)
and community non-offenders (right: P 0.009; left: P 0.004);
main effect of group [right: F(3,119) 3.33, P 0.022; left:
F(3,119) 3.63, P .015; Figure 2]. There were no significant group
effects in the mPFC [F(3,119) 0.54, P 0.65], or posterior ST [right:
F(3,119) 0.91, P 0.44; left: F(3,119) 2.04, P 0.11]. There were no
significant differences among the three comparison groups
(psychotic offenderno suicide attempt, non-psychotic offender, healthy control) in any region of interest (all Ps > 0.30).
The results of the whole-brain analysis revealed a main effect of group in right primary auditory cortex (BA 41; x 44,
y 15, z 8; F(3,115) 10.56; k 4700) and left temporal pole (BA
38; x 45, y 21, z 18; F(3,115) 9.50; k 3915). Betweengroup comparisons indicated that the group effect in primary
auditory cortex was explained by reduced volume in both
psychotic offender groups relative to nonpsychotic offenders
(suicide attempters: x 44, y 15, z 9, P < 0.0001, k 102,
non-attempters: x 44, y 16, z 9, P < 0.001, k 270) and nonoffenders (suicide attempters: x 44, y 14, z 8, P < 0.00001,
k 15; non-attempters: x 45, y 9, z 2, P < 0.001, k 3664),

We used logistic regression to examine the effects of established suicide risk variables for psychotic disorders (depression,
positive negative symptoms, substance use disorder, insight),
empathic accuracy and brain volumes on suicide attempt group
status (yes/no) of psychotic offenders. Zero-order regressions
with each variable are presented in Table 2. Depression and
positive negative symptom groups were significant predictors
of past suicide attempt/s, while substance use disorder and insight were not. Examining alcohol and drug use disorders separately also did not yield significant results.
We retained all variables for the hierarchical logistic regression with three steps: (1) Established risk variables, (2) Empathic
accuracy, (3) Left or right temporal pole volume, except for the
positive negative symptom variable so that the 13 participants
that did not meet criteria for 1 of the positive negative symptom groups could be included. There were no significant differences in empathic accuracy or left and right temporal pole
volumes between the psychotic symptom groups (P 0.52,
P 0.35, P 0.39, respectively). A separate hierarchical logistic
regression analysis without the 13 participants and including
the positive negative symptom variable, the results of which
were substantively the same with regard to the significance of
empathic accuracy and brain volumes in predicting suicide attempt group, is provided in Supplementary data, Table S1.
Results revealed that lower empathic accuracy was associated with an increased likelihood of a past suicide attempt,
above and beyond the effects of the other risk variables (depression, substance use, insight) [v2(1) 8.84, P < 0.05] (Table 3).
Additionally, reduced left and right temporal pole volumes were
associated with an increased likelihood of a past suicide attempt, above and beyond the effects of the other risk variables
(depression, substance use, insight) and empathic accuracy
[left: v2(1) 15.99, P < 0.001; right v2(1) 12.57, P < 0.001] (Table 3).
The inclusion of empathic accuracy increased the amount of
variance explained from 0.29 to 0.50, and the additional inclusion of left or right temporal pole volumes increased the variance to 0.78 and 0.73, respectively. While the addition of
empathic accuracy to established risk variables did not increase
the percent of correctly classified cases (74.4% in both steps),
the addition of left or right temporal pole volumes increased
correct classification to 89.7 and 87.2%, respectively.

Associations with psychopathy

Because psychopathic traits exist at clinical levels in incarcerated populations (Hare, 2003), and have been associated with
lower empathic accuracy (Brook and Kosson, 2013), we examined associations between psychopathy and relevant variables
in the current study. Psychopathy scores did not significantly
differ between any of the incarcerated groups, including suicide
attempters vs non-attempters (Table 1). There were no significant correlations between psychopathy scores and empathic accuracy among all incarcerated participants [r(98) 0.02,
P 0.83], nonpsychotic offenders [r(59) 0.02, P 0.91] or psychotic offenders [r(39) 0.16, P 0.34]. There were also no significant correlations between psychopathy scores and right

| Social Cognitive and Affective Neuroscience, 2017, Vol. 0, No. 0

Fig. 2. (A) Anatomical image mask defining the temporal pole ROI. (B) Group differences in bilateral temporal lobe volumes. Bars represent standard error. Means adjusted for age, IQ estimate and TBV. PS, psychotic offenders with suicide attempts; PN, psychotic offenders without suicide attempts; NO, nonpsychotic offenders; CN,
community non-offenders. *P < 0.05, **P < 0.005.

Table 2. Logistic regression analysis evaluating suicide attempt history (yes/no) in psychotic offenders based on established risk variables, empathic accuracy and temporal pole volumes
Risk variable
Depression
Positive negative
symptoms
Substance use disorder
Insight
Empathic accuracy
Left temporal pole
Right temporal pole

SE (b)

P value

1.52
2.30

0.71
1.19

0.03
0.05

4.55 (1.1418.15)
10.00 (0.97102.87)

0.62
0.05
0.72
1.10
0.89

0.72
0.33
0.38
0.43
0.39

0.38
0.89
0.06
0.01
0.02

1.87 (0.467.60)
0.96 (0.501.81)
0.49 (0.231.02)
0.33 (0.140.78)
0.41 (0.190.88)

OR (95% CI)

temporal pole volumes [r(98) 0.16, P 0.13, r(59) 0.17,

P 0.20, r(39) 0.22, P 0.18], left temporal pole volumes
[r(98) 0.19, P 0.06, r(59) 0.20, P 0.12, r(39) 0.25,
P 0.12], mPFC volumes [r(98) 0.15, P 0.16, r(59) 0.15,
P 0.25, r(39) 0.23, P 0.19], left posterior ST volumes
[r(98) 0.14, P 0.19, r(59) 0.19, P 0.15, r(39) 0.16,
P 0.34] or right posterior ST volumes [r(98) 0.14, P 0.19,
r(59) 0.22, P 0.10, r(39) 0.12, P 0.48].

Discussion
Psychotic disorders are associated with increased suicide risk,
social cognitive impairments and aberrant brain volumes in regions that are integral components of social cognitive networks.
We explored the hypothesis that lower empathic accuracy and
smaller brain volumes in regions implicated in social cognition
would be related to past suicide attempts in a psychoticdisordered offender population. We found that psychotic offenders with a history of suicide attempts had lower empathic
accuracy and reduced gray matter in bilateral temporal poles.
These results were significant above and beyond the effects of
other suicide risk variables (depression, substance abuse, insight). The inclusion of empathic accuracy with other risk variables increased the amount of variance explained from 29% to
50%, while the inclusion of temporal pole volumes further
increased this to 7378%. Thus, empathic accuracy and temporal pole volumes contributed substantially to the discrimination of psychotic offenders with and without past suicide
attempts.

The higher incidence of a past depressive episode among individuals with psychotic disorders and past suicide attempt/s is
consistent with prior research, as is the finding of higher positive and lower negative PANSS symptom scores (Potkin et al.,
2003; Hawton et al., 2005a,b; Hor and Taylor, 2010). We did not
observe group differences in alcohol or drug use, contrary to
prior findings. This is likely because prior studies have been
conducted in community non-offenders. Criminal offenders
have higher rates of substance use than non-offenders (Kessler
et al., 1994; Compton et al., 2005). Thus there may have been less
variability among offenders and consequently fewer group differences. We also did not observe group differences in insight,
which could be related to our measurement of this variable
with the PANSS. Prior studies that found higher insight among
suicidal psychotic individuals used measures that focused on
insight into illness (Kim et al., 2003; Schwartz and Smith, 2004;
Crumlish et al., 2005). The PANSS combines insight into illness
and need for treatment, the latter of which is not related to suicidal behavior (Crumlish et al., 2005). It is also important to note
that the PANSS was not administered near the time of a suicide
attempt, and participants were undergoing continual treatment
and supervision, which could impact current insight levels and
other characteristics.
Psychotic offenders with past suicide attempts were impaired in empathic accuracy relative to all comparison groups.
This suggests a reduced ability to identify emotions in social
context. While in line with prior studies showing impaired social cognition in schizophrenia (Green et al., 2015), we found
that impairment was specific to those with suicide attempts.
Those without attempts were generally unimpaired relative to
non-psychotic offenders or community controls. There are several possible explanations for this result, which are also the reasons why we did not hypothesize psychotic vs nonpsychotic
group differences. First, most prior studies have focused on
schizophrenia, whereas we included individuals with any
psychotic disorder. Second, some types of social cognitive abilities may be generally impaired in psychotic disorders while
other social cognitive impairments are associated with suicide
risk. For example, whether non-affective (e.g. cognitive perspective taking/theory of mind) social cognitive abilities known to be
impaired in psychotic disorders are associated with suicide risk
has not been studied. Even within the domain of empathic accuracy, differences in assessment methods could affect the association with functional outcomes. Some prior studies

C. L. Harenski et al.

Table 3. Hierarchical logistic regression analysis evaluating suicide attempt history (yes/no) based on established risk variables, empathic accuracy and temporal pole volumes
Step and variable
Step 1
Depression
Substance use disorder
Insight
Step 2
Empathic accuracy
Step 3a
Left temporal pole
Step 3b
Right temporal pole

SE (b)

2.28
0.86
0.31
1.48
3.17
2.16

Wald

0.86
0.83
0.40
0.60
1.28
0.86

6.93
1.08
0.59
6.10
6.17
6.39

OR (95% CI)

v2

R2

v2(3) 9.37*

0.29

v2(1) 8.84***

0.50

v2(1) 15.99****

0.78

v2(1) 12.57****

0.73

9.72 (1.7952.88)**
2.37 (0.4712.09)
1.36 (0.622.97)
0.23 (0.070.74)*
0.04 (0.0030.51)*
0.65 (0.460.91)*

*P < 0.05. ** P < 0.01. *** P < 0.005. **** P < 0.001.

examining empathic accuracy in schizophrenia used a task in

which participants rated the degree of positive or negative emotion that a person was experiencing during an autobiographical
event (Zaki et al., 2009; Lee et al., 2011b; Harvey et al., 2013). We
asked participants to select specific emotions that the person
experienced during an autobiographical event. These tasks may
engage different cognitive and affective processes such as semantic knowledge (e.g. social-emotional terms and concepts). It
seems plausible that misinterpreting levels of positive or negative emotion in others could lead to interpersonal conflict, and
consequently feelings of social isolation and suicidal ideation/
behavior. However, until suicidal behavior is studied in relation
to a variety of social cognitive abilities and their measurement,
such suggestions are speculative. Third, it is possible that certain social cognitive impairments are uniquely related to suicide attempt history in offender populations. It is important to
identify which types of social cognition predict suicide risk in
which populations, so that interventions can be tailored
appropriately.
Psychotic offenders with suicide attempts had smaller bilateral temporal pole volumes relative to the comparison groups.
The critical involvement of the temporal poles in social and
emotional processing has been demonstrated in lesion and neuroimaging studies of humans and non-human primates (Olson
et al., 2007). Damage to this region impairs the ability to recognize and produce appropriate social signals (e.g. facial expressions) and causes changes in personality including social
withdrawal. Functional imaging studies have shown that tasks
involving thinking about other peoples thoughts and emotions
consistently engage the temporal poles (Olson et al., 2007). The
temporal poles also support multi-sensory integration and topdown modulation of sensory regions during social cognitive
processing (Pehrs et al., 2015, Cerebral Cortex). Prior neuroimaging studies of suicidal behavior in schizophrenia and other
psychotic disorders have not typically implicated the temporal
poles, but instead posterior superior temporal cortexparticularly within the left hemisphere (Aguilar et al., 2008;
Giakoumatos et al., 2013). We did observe reduced left posterior
ST volumes in attempters, but the result fell short of significance. It is also possible that temporal pole volumes are
uniquely related to suicide attempts in offender populations. A
recent study found that youth homicide offenders had smaller
temporal pole volumes relative to youth offenders who had not

committed homicide (Cope et al., 2014). Thus, the temporal

poles may be associated with risk of harm to self and others.
However, there is some evidence of temporal pole involvement
in suicide in non-forensic, non-psychotic populations. Reduced
norepinephrine receptor binding in the temporal poles has been
found in depressed suicide victims (De Paermentier et al., 1990,
1991).
These results also highlight biobehavioral markers that
could be targeted for treatment intervention. Social cognitive
abilities are being increasingly viewed as treatment targets in
schizophrenia and related psychotic disorders. Recent studies
have implemented techniques such as social cognitive skills
training, oxytocin administration, and transcranial direct current stimulation to enhance social cognition in schizophrenia
(Kurtz and Richardson, 2012; Pedersen et al., 2011; Davis et al.,
2013; Fischer-Shofty et al., 2013; Lindenmayer et al., 2013;
Guastella et al., 2015; Rassovsky et al., 2015). The results suggest
that, depending on the technique used, improvements are specific to certain types of social cognition. For example, enhancing
effects of oxytocin are usually observed for higher-order social
cognitive abilities, such as mentalizing and empathy. Given the
substantial variability among types of higher-order social cognitive abilities, as discussed earlier, it will be important to identify
which are related to suicidal behavior and can be modified by
specific interventions. It is also possible that certain interventions have observable effects on brain structure or function but
not behavior.
There are some limitations to this study. First, our prediction
of suicide attempts group was retrospective. While studies have
shown that that suicide risk is measurable up to 37 years after
the initial attempt (Dahlgren, 1977; Suominen et al., 2004; Angst
et al., 2005; Bradvik et al., 2008), prospective studies in which social cognitive variables are recorded at baseline (prior to suicidal
behavior) will provide a more stringent test of their applicability
as risk variables. Second, although having a history of suicide
attempts is a strong indicator of future suicide, many attempters will not go on to complete. Prospective studies are needed
to determine whether the current results extend to suicide completion. Third, we did not include a comparison group of nonpsychotic offenders with past suicide attempts. As such, the
question of whether the current results are generalizable to
non-psychotic populations cannot be addressed. Additionally,
because there have been no prior studies of social cognition and

| Social Cognitive and Affective Neuroscience, 2017, Vol. 0, No. 0

suicide in psychotic disorders (to our knowledge), and no prior

studies of empathic accuracy in psychotic disorders using our
specific task, whether the results are generalizable to psychosis
and/or suicidal behavior in non-forensic (i.e. community)
psychotic samples remains to be determined. We did, however,
assess a number of variables which tend to be elevated in forensic populations and have been associated with reduced empathic accuracy and/or frontal and temporal brain volumes (e.g.
psychopathy, aggression, impulsivity) to ensure that our results
were not attributable to these factors. Fourth, we did not have a
large enough sample to compare the results across different
diagnostic groups (e.g. schizophrenia vs bipolar disorder).
Finally, all participants were taking an antipsychotic or other
psychotropic medication. Although there were no significant
differences in the number of participants who were currently
using these medications in the suicide attempt and no-attempt
groups, other potential influences (e.g. effects of long-term
medication use) cannot be ruled out.
The current results also do not demonstrate causality between impaired empathic accuracy and suicidal behavior. The
results identify one type of social cognitive skill that is related
to suicide behavior in psychotic criminal offenders, as well as
demonstrating reduced brain volume in a region implicated in
social cognition. They also lend support to theories of suicide
that posit thwarted belongingness and social disaffiliation as
major risk factors (Joiner et al., 2009), and the notion that accuracy measures of social cognition are important for evaluating
functional outcomes in general (Zaki and Ochsner, 2011).
Although replication is needed, the current results are of clinical
interest in demonstrating the incremental value of social cognition to the cumulative evaluation of suicide risk and in identifying a potential neurobehavioral target for treatment and risk
management.

Supplementary data
Supplementary data are available at SCAN online.

Acknowledgements
We thank Elizabeth Krusemark, Christopher Lee, Michael
Miller, Miranda Sitney, and Simone Viljoen for assistance
with data collection.

Funding
This work was supported by a grant from the National
Institutes of Health (grant number P20GM103472).

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