Empathy, schizophrenia and violence: a systematic review

A small but significant association between schizophrenia and violence is open to a number of explanations. Impaired empathy has been associated with schizophrenia, and with violence in the general population. Our aim was to conduct a systematic review of any research into relationships between schizophrenia, empathy and violence.

The electronic databases Medline, Psychinfo, Embase, Cochrane and DARE were searched using combinations of terms for schizophrenia, empathy and violence, as were selected journals and reference lists of relevant articles. Selection of studies and data extraction was done by each of us, blind to the other.

Six studies were identified, but sample selection, research procedures and empathy, illness and violence measures differed sufficiently between them that only descriptive analysis was possible. Apart from one single case study, sample sizes were between 24 (12 violent) and 116 (35 violent). A component of emotional empathy (emotion recognition) was measured in three of the studies, all of which showed some specific dysfunctional recognition related to violence. Cognitive empathy was measured in three studies, two linking impairments to violence and one not. Emotional responsiveness was measured in one study and no association with violence was found.

Although evidence is inconclusive on empathy impairment as a mediator of violence by people with chronic psychosis, it's likely relevance is most apparent in the better controlled studies. Larger scale studies are indicated with rigorous control for comorbidities.