Theory of mind function, motor empathy,emotional empathy and schizophrenia:A single case study

KAREN ADDY1, KAREN SHANNON2, &

KEVIN BROOKFIELD3

1North West Wales NHS Trust, UK, 2Mersey Care NHS Trust, UK, and3University of Liverpool, UK

AbstractIt has been proposed that theory of mind dysfunction contributes to thedevelopment of paranoid schizophrenia. The inability to represent others’ thoughtsand feelings has implications for the type of behaviour expressed by people withdelusional beliefs. Evidence has shown that a diagnosis of paranoid schizophrenia isassociated with an increased risk of violence. This case study explores the role oftheory of mind and emotional processing in the violent index offence of a 33-year-old man (SB) with a diagnosis of paranoid schizophrenia. Neuropsychological andtheory of mind assessment measures were administered during SB’s admission tomedium secure services. SB was found to be within the average range onstandardised neuropsychological assessment measures but was found to besignificantly impaired on measures examining theory of mind and various aspectsof emotional functioning. The implications of SB’s emotional deficits within thecontext of his index offence are discussed.

Keywords: Violence, theory of mind, schizophrenia, paranoid delusional beliefs

Introduction

Blair (1995) argues that violent behaviour is inhibited by a cognitive

mechanism, which is activated by non-verbal signals communicating

distress in another. Blair suggests that humans are predisposed to withdraw

from a violent attack in response to cues of distress in the potential victim.

The violence inhibition mechanism depends upon the ability to infer the

Correspondence: Karen Addy, Psychology Department, Heulwen Unit, North West Wales NHS Trust,

Ysbyty Gwynedd, Bangor LL57 2PW, UK. E-mail: karen.addy@nww-tr.wales.nhs.uk

The Journal of Forensic Psychiatry & Psychology,

September 2007; 18(3): 293 – 306

ISSN 1478-9949 print/ISSN 1478-9957 online ª 2007 Taylor & Francis

DOI: 10.1080/09670870701292746

meaning of a potential victim’s behaviour in terms of the inner emotional

and cognitive states that their behaviour reflects.

In order to infer the meaning behind a victim’s behaviour, one requires

the ability to represent their thoughts and feelings – to have an empathic

awareness of others one must have theory of mind abilities. Indeed, studies

exploring empathy in individuals with theory of mind deficits due to

developmental disorders such as autism suggest that empathy and theory of

mind abilities are linked (e.g., Baron-Cohen & Wheelwrights, 2004; Dyck,

Ferguson, & Shochet, 2001).

When exploring the role of empathy it is important to clarify what is

meant by the term. Blair (2005) argues that empathy, rather than being a

single construct, comprises three dissociable neurocognitive processes.

Blair (2005) defines empathy in cognitive, motor, and emotional terms.

When describing empathy Blair (2005) refers to Feschbach (1978, 1987),

who viewed empathy as a function of three processes: the ability to

discriminate affective cues in others, the ability to assume a perspective

based on these cues, and the ability to feel an emotional response to these

cues (the ability to experience emotions).

Feschbach’s view highlights the requirement for theory of mind ability in

order to process an emotional response affectively. Blair (2005) describes

this process as cognitive empathy, and postulates that cognitive empathy is

related to theory of mind functioning in that individuals who cannot

represent the mental states of others should not be able to respond to others

empathetically. Blair (2005) goes on to describe motor empathy, which is

defined as the ability to mimic and synchronise with another person’s facial

expressions, which has been described as the most primitive form of

sympathy (Smith, 1966). Third, Blair (2005) describes emotional empathy;

this type of empathic awareness relies on the ability to recognise facial

expressions as signals of an internal emotion in the other. Blair (1995,

2003) argues that this type of empathy acts as a modulator of behavioural

responses. For example, recognition of a fearful expression as indicating

another is scared elicits an emotional response, which then shapes

behaviour. Indeed, studies have shown that fearful faces act as aversive

stimuli and condition an avoidance response (Mineka & Cook, 1993). In

addition, studies have demonstrated that angry expressions trigger a

behavioural change in the observer (Blair, 2003; Blair & Cipolotti, 2000;

Keltner & Anderson, 2000). Blair (2005) therefore argues that when

considering whether a particular psychiatric population is associated with

empathic dysfunction, it is essential to consider the form of empathy

assessed in order to interpret any results meaningfully.

The two main psychiatric populations that have been associated with

impairments in empathy are those with autistic spectrum disorders and

those with psychopathy. Within the literature there are a number of

distinctions between these two groups in terms of types of impairment.

294 K. Addy et al.

Evidence demonstrates that people with autistic spectrum disorders

(including Asperger’s syndrome) have impairments in theory of mind

function (Baron-Cohen, 1995; Baron-Cohen, Leslie, & Frith, 1985; Hill &

Frith, 2003). In addition, the evidence suggests that these individuals have

impairments in motor empathy, with numerous studies demonstrating

deficits in facial imitation (Smith & Bryson, 1994; Williams, Whiten, &

Singh, 2004). On the other hand, there is no consistent evidence to suggest

that people with autism have difficulties with emotional empathy (Blair,

2005), suggesting that individuals with autistic spectrum disorders are able

to feel emotional reactions in response to others’ distress cues. This finding

appears to differentiate individuals with autism from those diagnosed with

psychopathic disorders.

Within the literature there is evidence to indicate that psychopathic

individuals demonstrate reduced emotional empathy, leading to blunted

internal emotional reactions to others’ distress (Blair, 2005). However,

there is no consistent evidence to indicate that psychopathic individuals

have deficits in theory of mind function (cognitive empathy) or motor

empathy (Blair, 2005).

It may be this difference in emotional processing deficits that accounts for

the variation in behaviour seen between these population groups. Individuals

with psychopathic tendencies, by definition, are significantly more likely to act

in violent ways or inflict serious harm on others (Hare, 1991). On the other

hand, there is little evidence from research to indicate an association between

autistic spectrum disorders and increased risk of violence.

Within the literature there is a great deal of evidence that individuals with

a diagnosis of schizophrenia also demonstrate theory of mind impairments.

Furthermore, a wealth of evidence suggests an increased risk of violent

behaviour in this group, particularly among those with paranoid delusions

(for a comprehensive review see Walsh, Buchanan, & Fahy, 2001; see also

Mullen, 1997). Frith (1992) proposes a neuropsychological model of

schizophrenia, and argues that specific clusters of symptoms found in

people diagnosed with schizophrenia can all be understood in terms of a

general cognitive mechanism involved in the ability mentally to represent

thoughts and feelings. Within the realm of paranoid delusions, Frith’s

(1992) model focuses upon a person’s ability to represent others’ mental

states. Frith (1992) argues that paranoid delusions occur when the wrong

inference is made about other people’s mental states, leading individuals to

assume that others are threatening towards them, or intend to harm them.

In support of this model, a number of studies demonstrate symptom-

specific cognitive deficits in theory of mind functioning (for a review, see

Harrington, Siegert, & McClure, 2005). Frith’s (1992) model has

important implications for the treatment and management of people with

a diagnosis of schizophrenia that have theory of mind dysfunction. It also

has important implications for public protection and the risk management

Case study 295

of the violent behaviour of such people; within the literature there is

consistent evidence that people with a diagnosis of paranoid schizophrenia

are more likely to commit violent crimes than any other group diagnosed

with a mental illness (Mullen, 1997; Walsh, Buchanan, & Fahy, 2001). For

example, Link, Andrews, and Cullen (1992) interviewed 375 psychiatric

patients and reported that patients with current psychotic symptoms, and

most significantly those with paranoid delusions, had elevated rates of

violent behaviour compared to non-clinical control groups. Taylor et al.

(1998) reviewed the hospital and government records of 1015 patients

within high security hospitals. They found that a diagnosis of schizophrenia

was strongly associated with violence in this group: 75% of those with a

diagnosis of schizophrenia had incidents of violence recorded, which they

reported were driven by paranoid delusional belief systems. Taylor et al.

found that in the absence of delusions, hallucinatory experiences did not

have this effect. However, these studies have looked specifically at paranoid

delusions as a predictor of violent behaviour within groups diagnosed with

schizophrenia without considering possible causal mechanisms.

In a recent study, Abu-Akel and Abushu’leh (2004) explored the role of

theory of mind functioning and empathy in violent and non-violent patients

with a diagnosis of paranoid schizophrenia. They found that violence within

this group was associated with good theory of mind abilities and poor

empathy. The authors argued that, within the context of hostility towards

others, paranoid patients with poor empathic reasoning and good theory of

mind abilities were more likely to have committed violent crimes. However,

there are a number of difficulties involved in interpreting the results of this

study. First, the authors failed to define empathic reasoning: it is unclear

whether Abu-Akel and Abushu’leh (2004) are referring to emotional

empathy as defined by Blair (2005). If this is the case, then it is possible that

within their study the violent individuals assessed were actually individuals

with psychopathic traits. In addition, the authors failed to distinguish

between the types of violent crime committed – that is, whether these

crimes were pre-planned or impulsive. This is an important distinction, as

previous research has highlighted differences in cortical activation, as

measured by neurotransmitter activation, between destructive planned

violence such as arson or familiar murder (Lindberg, Asberd, & Sundqvist-

Stensman, 1984; Virkkunen et al., 1994) and impulsive instrumental

violence (Castellanos et al., 1994; Coccaro, Kavoussi, Cooper, & Hauger,

1997).

Abu-Akel and Abushu’leh (2004) concluded that good theory of mind

functioning allowed the perpetrator to ‘manipulate and deceive their

victims’ (p. 52), hence enabling them to commit the violent crime. Further

highlighting psychopathic tendencies in their participants, Abu-Akel and

Abushu’leh (2004) argue that ‘violent patients with paranoid schizophrenia

have a profile resembling psychopaths’ (p. 52). Again, this could suggest

296 K. Addy et al.

that their sample consisted of psychopathic individuals rather than

individuals without psychopathic traits but suffering from a schizophrenic

illness. This leads to significant difficulties with interpreting their findings:

as previously discussed, individuals with psychopathic tendencies have a

profile of empathic dysfunction affecting emotional empathy but not

cognitive empathy (theory of mind; Blair, 2005). On the other hand, those

suffering from schizophrenia have symptom-specific cognitive deficits in

theory of mind functioning (for a review, see Harrington et al., 2005).

Furthermore, Abu-Akel and Abushu’leh (2004) do not take into account

Frith’s (1992) model of schizophrenia, in which it is argued that paranoid

delusions occur because the individual makes incorrect inferences about

others’ intentions, leading him/her to feel under threat from others. Taking

this model into account, an alternative explanation can be offered for Abu-

Akel and Abushu’leh’s findings. It can be argued that violent behaviours

within the context of paranoid schizophrenia may be motivated by the

paranoid delusional beliefs the individual holds. These beliefs, combined

with lack of empathy with a potential victim, allow the use of violence as a

way to defend oneself from perceived threat, possibly through lack of

activation of the violence inhibition mechanism due to poor cognitive

emotional processing (Blair, 2005). The fact that the individuals had good

theory of mind abilities is also accounted for, as Frith’s model suggests that

theory of mind abilities would be present but impaired, leading the

individuals to make incorrect assumptions about others’ intentions and as

such perhaps providing the motivation for violence rather than reflecting

psychopathic tendencies as Abu-Akel and Abushu’leh (2004) suggest.

In the light of Blair’s (1995, 2005) work it may be, then, the type of

empathic dysfunction that determines whether someone with a diagnosis of

paranoid schizophrenia may commit a violent act. The research appears to

suggest that impairments in emotional empathy may be associated with

violence in psychopathic individuals where theory of mind functioning

(cognitive empathy) is not impaired. However, within the literature there is

still a lack of understanding of how deficits in theory of mind functioning,

motor empathy, and emotional empathy may have an impact upon

behavioural regulation and propensity for violence in individuals with

other psychiatric illnesses, especially paranoid schizophrenia.

The current study explores theory of mind functioning, motor empathy,

and emotional empathy in a single case – a 33-year-old man (SB) with a

diagnosis of paranoid schizophrenia. Within the context of this diagnosis

SB attacked his parents, killing his father and seriously wounding his

mother. Following his admission to a medium secure unit it became

apparent that SB had significant social difficulties, which after assessment

were found to be due to a specific theory of mind impairment. In addition,

there was evidence of specific impairment in emotional empathy but not in

motor empathy. Although, as this is a single case study, these findings are

Case study 297

limited, they suggest that there may be a specific profile of empathic

impairments in individuals with paranoid schizophrenia that differs from

the profile identified in autistic spectrum disorders and psychopathy, thus

highlighting an area for further research.

Method

Participant SB

SB’s informed consent was obtained, prior to completing the assessment, for

the information obtained during the assessment to be used. Some personal

details have been omitted to protect SB’s identity. SB was admitted to a

medium secure unit following the manslaughter of his father. Prior to this

admission he was not known to psychiatric services. He had no prior history of

violence and until his index offence had lived with his parents. SB was in full-

time employment until an accident six months prior to his offence rendered

him unable to work. There was no reported personal or family history of

serious mental illness or drug or alcohol abuse, and no history of violence.

Family reports indicated that SB had difficulties with social interactions

from an early age. It was reported that he did not like attending school as he

found it difficult to mix with the other children, and would go home at

lunchtimes to eat alone. Throughout his life he had no lasting friendships or

relationships other than with his family and, despite being 33 years of age,

he lived at home with his parents until his index offence. Educationally SB

was reported to be average, and after leaving school he began working in a

structured job that required minimal social interaction. SB’s main hobbies

were solitary – mainly running alone or going for long drives in his car. In

discussions, SB reported that he would have liked to have had friends but

found it difficult to interact with others and therefore tended to retreat on

his own.

Prior to his index offence SB was involved in a minor car accident. He did

not sustain any injury but was unable to work afterwards; he lost his car, and his

superficial contact with others outside his family ceased. This accident appears

to have been the catalyst for SB’s mental health deterioration. He withdrew

from his family, isolating himself in his bedroom for long periods. He then

became preoccupied with his neighbours, believing that they were spying on

him. In the days immediately prior to his offence he was psychiatrically

assessed at home and diagnosed with paranoid schizophrenia (DSM-IV). It

was felt that he required hospitalisation, but he was not at that time eligible for

a section order. SB found this stressful and refused to be admitted. Over the

following few days his parents became increasingly concerned about him and

encouraged him to be admitted.

The day before his index offence SB asked his parents to withdraw money

they were keeping for him. He gave away all of his belongings and went to

298 K. Addy et al.

an associate’s house. Giving the associate his money, SB asked the associate

to hide him as an alternative to hospital admission. However, the associate

returned him to his parents’ home and gave his father the money.

On the day of his index offence, SB asked his father to return his money.

They argued and SB began smashing items in the home, which prompted

his father to state that he would deduct the cost of the items from SB’s

money. His father continued to state that SB would need to go to hospital

and at this point SB picked up a weapon, with which he attacked and killed

his father. Following this, his mother attempted to enter the scene and SB

attacked her, seriously injuring her. He made no attempt to escape from the

scene and was arrested in the family home.

Following his arrest SB was admitted to medium secure psychiatric

services on account of his paranoid delusional beliefs regarding his

neighbours and the hospital admission. On admission SB was able to

discuss the circumstances leading to the offence. He reported that he had

been angry that his father would not return his money. He continued to

express delusional beliefs about his neighbours, believing they were

conspiring to admit him into hospital. However, he did not express any

delusional beliefs about his parents. Psychiatric assessment on admission

indicated that SB met DSM-IV criteria for schizophrenia; there was no

evidence of any other Axis I or Axis II disorder at this time.

Assessment measures and procedure

Following admission a full clinical psychological assessment of SB took

place. It was noted that he had no emotional connection with his offence.

He was sorry that his father had died, but lacked any awareness or

understanding of the impact of his behaviour, either on his father or on the

rest of his family. In addition, he reported that once he was discharged from

the unit he would return to live with his mother. This stark lack of

emotional awareness, combined with his apparent longstanding difficulties

with social interaction, gave rise to considerations of possible develop-

mental disorders such as Asperger’s syndrome. However, consultation and

assessment with the specialist Asperger’s syndrome assessment service

indicated that SB did not meet DSM-IV criteria for Asperger’s syndrome.

This lead to exploration of the hypothesis that SB had difficulties with

theory of mind and emotional processing. As a consequence, a full

neuropsychological and theory of mind assessment was conducted.

To ensure that SB did not have learning difficulties or executive

impairments that could account for his presentation, a range of

neuropsychological assessments were performed. He completed the

Wechsler Adult Intelligence Scale III (WAIS III; Wechsler, 1997), the

Controlled Oral Word Association task – FAS Version (COWA; Benton &

Hamsher, 1989), the Hayling and Brixton test (Burgess & Shallice, 1996),

Case study 299

and the Rivermead Behavioural Memory Test (RBMT; Wilson, Cockburn,

& Baddley, 1985). In addition, an assessment of SB’s theory of mind

abilities and empathic awareness was completed.

The ‘Reading the Mind in the Eyes Test’ Revised Version. This test (Baron-

Cohen, Jolliffe, Mortimore, & Robertson, 1997) identifies subtle impairments

in social intelligence and social understanding. It comprises 36 photographs

depicting only the eye area of famous actresses and actors; the individual is

required to use motor empathy processes to identify the emotion being

conveyed. The participant selects from a choice of four words the word that

describes the emotion displayed, and is also provided with a glossary of all

terms used, in order to look up words whose meaning may be unfamiliar.

Previous studies have demonstrated that individuals with known motor

empathy impairments due to autistic spectrum disorders perform poorly on

this task (Baron-Cohen, Wheelwrights, Hill, Raste, & Plumb, 2001).

Social script stories, logical sequence stories, and false belief stories. All of these

tasks are picture sequencing tasks devised and used by Langdon and

Coltheart (1997, 1999) to assess theory of mind functioning in people with

a diagnosis of schizophrenia. In this case these tasks were used in a

qualitative manner, by asking SB to describe the content of the story after

he had completed each task.

The logical sequence task and the social script stories task are both

picture sequencing tasks that are used to ensure that a participant is able to

sequence events correctly. The social scripts involve day-to-day activities

such as hand washing, shopping, etc. The logical sequence tasks involve

ordering picture sequences depicting physical cause and effect: for example,

a ball rolls off a table, hits a cup, and knocks it over.

The false belief stories task is used to explore participants’ ability to infer

false beliefs and correctly predict that others will act on the basis of false

beliefs. Each story depicts a character who, unaware of an event occurring

earlier in the story, acts on a false belief of the situation. The false belief task

has been described as the ‘litmus test of intact mentalising ability’

(Pylyshyn, 1978): participants have to be aware of the mental state of

others and understand that the story character is acting upon a false belief,

in order to complete the task correctly. Thus the false belief stories task

provides a measure of theory of mind metarepresentational abilities.

Story task. This task comprises 12 passages each followed by a series of

questions, as used by Corcoran and Frith (1996). Each of these stories

reflects aspects of theory of mind functioning, double bluffs, false beliefs,

and white lies. The stories were read out to SB and he had access to read

them. The stories were followed by a series of questions that assessed the

factual content of the story to ensure that SB had understood it. There were

300 K. Addy et al.

also inference questions that required knowledge of the characters’

mental states, first order false belief questions, and second order

false belief questions. In this case these stories were used in a qualitative

manner to explore SB’s understanding and knowledge of others’ mental

states. In addition, further emotional empathy questions were added to

explore SB’s understanding of the impact of such false beliefs and

deception, hence providing a qualitative assessment of SB’s emotional

empathetic awareness.

Results

Neuropsychological assessment measures

SB’s verbal and non-verbal WAIS III scores were within the average range

(VIQ 95%, CI 95 – 110; PIQ 95%, CI 92 – 106). In addition, he performed

within the normal ranges for the RBMT, the COWA, and the Hayling and

Brixton tests.

Theory of mind assessment measures

The ‘Reading the Mind in the Eyes Test’ Revised Version. SB recorded a score

of 18/36, which is only slightly above the chance score of 13. A recent study

by Richell et al. (2003) demonstrated that the average score on this measure

for normal controls is 23.3 (SD¼ 4.3). This suggests SB had significant

difficulties with identifying the emotional meaning in eye expressions, and

implies that SB had difficulties with motor empathy similar to individuals

with autistic spectrum disorders.

Logical sequence stories. SB was able to sequence all of these picture cards

correctly and provided socially and culturally appropriate stories to

rationalise his decision-making. This indicates that SB was able to apply

logic and problem-solving effectively to work out the natural sequence of

concrete situations, and thus there was no evidence that he struggled with

ordering and planning.

Social script cards. These cards are similar to the logical sequencing cards,

but depict people interacting in common social situations, such as entering

a shop, selecting items, and paying for them. These are slightly more

advanced, as they require some knowledge of appropriate behaviour and

typical interactions in social settings. Problems with correctly ordering

these cards could be attributed to sequential problems, such as disorganised

symptoms of schizophrenia or severe frontal lobe problems that impact on

organisation, or a lack of general social knowledge. SB was able to complete

all of these stories correctly and again provided appropriate rationales each

Case study 301

time. This suggests that SB was aware of social order and had knowledge of

socially and culturally acceptable behaviours.

False belief cards. SB was unable to complete any of these stories correctly. It

was apparent that he attempted to use logic to solve the task, by identifying and

attending to ambiguous clues, without recognising the mental states of the

characters involved. This strategy enabled SB to place the cards in an order,

but when asked to provide a story to explain his sequencing he struggled to do

so, or offered an unusual or bizarre explanation to justify his decision-making.

For example, one of the cards depicts a woman baking cakes while a dog

lies under the table While her back is turned another character steals the

cakes. When she sees the cakes are gone, believing that the dog ate them she

shouts at the dog and tells it, ‘Get out.’ SB reported that the women had left

the cakes for a man, who must have been tidying her garden, and could not

explain why she shouted at the dog.

Throughout the assessment SB was confused about the correct order for

the cards, and tended to base his decisions upon misperceptions of the

character’s actions or attempts to apply logical explanations that did not

take into account the characters’ false beliefs, thus highlighting a problem

with cognitive empathy.

Story task. SB was able to give information about the facts in the stories,

indicating that he had understood and retained the information presented.

However, he was unable to make inferences based on the stories and

struggled to understand the false belief content. He consistently made

errors based on the assumption that the other characters in the story had all

the information available to them that was available to him, and was unable

to infer the mental state of the characters involved.

For example, in a story involving one character deceiving another but

then being caught out, SB was able to express that the character had lied

but was unable to understand why. In addition he was unable to explain

how the character who was lied to may feel upon finding out the lie,

reporting, ‘They wouldn’t mind.’ This suggests that SB was able to make

inferences based on an understanding of social rules (such as telling lies)

but was unable to use this information to generate the mental states of the

characters involved or to empathise with an individual. SB seemed to have

difficulties with emotional empathy, as he was unable to express any

emotional thoughts in relation to the characters involved, and was unable to

generate any feeling towards them.

Discussion

The assessment suggested that SB had difficulties with inferring the mental

states of others, implying an impairment in cognitive empathy. In addition, it

302 K. Addy et al.

appeared that he was unable to generate emotional understanding of others

based upon these inferences, thus indicating impairment in emotional

empathy. Furthermore, SB struggled with the motor empathy task. It is not

clear, however, whether this was a longstanding problem that contributed to

his development of schizophrenia, as Frith’s (1992) model would suggest, or

whether this difficulty was a result of his schizophrenia. The state or trait nature

of theory of mind deficits within schizophrenia has been widely debated in the

literature, and remains a source of debate (Harrington et al., 2005). However,

in this case the reported early childhood experiences of being unable to interact

with others, eating alone rather than being at school, and consistently having

no longstanding relationships with anyone other than his family members prior

to his illness appears to suggest the former.

The finding that SB was impaired on theory of mind functioning

(cognitive empathy) is consistent with previous studies exploring theory of

mind dysfunction within schizophrenia (Corcoran, Cahill, & Frith, 1997;

Corcoran & Frith, 1996; Corcoran, Mercer, & Frith, 1995; Frith &

Corcoran, 1996; Langdon & Coltheart, 1997). However, in addition to this

impairment, there were further impairments in SB’s motor empathy and

emotional empathy.

This profile of impairment in each of the three areas of emotional

processing that Blair (2005) discusses differs from previous accounts of

empathic impairments in individuals with a diagnosis of autistic spectrum

disorders: the literature indicates impairments in cognitive and motor

empathy but not emotional empathy (Baron-Cohen, 1995; Baron-Cohen

et al., 1985; Hill & Frith, 2003; Smith & Bryson, 1994; Williams et al.,

2004). Furthermore, the profile of empathic impairments demonstrated in

SB’s case also differs from that of individuals with psychopathic disorders,

where impairments in emotional empathy but not motor or cognitive

empathy have been demonstrated (Blair, 1995, 2005). SB’s difficulties

could not be accounted for by a general learning disability, executive

impairment, or a diagnosable developmental disorder.

With reference to discussions about theory of mind as a factor in violent

behaviour within the context of schizophrenia, this study appears in part

to support Abu-Akel and Abushu’leh’s (2004) findings. SB was able

to understand deception, as in the previous study, but was unable to

understand its emotional consequences. In addition, SB struggled with

more complex mentalising tasks such as second order and faux pas tasks

(those which require the ability to understand that anothers actions are

based upon their false belief of the situation), which is not consistent with

Abu-Akel and Abushu’leh’s findings. This may be due to the lack of clarity

about the type of violence (i.e., planned or spontaneous) explored by Abu-

Akel and Abushu’leh, and the type of emotional disturbance they assessed,

which, as previously discussed, has implications for the conclusions that can

be drawn.

Case study 303

The contribution of SB’s emotional impairments to the manslaughter

of his father and attempted murder of his mother is not clear. It seems

reasonable to suggest that SB’s impairments in empathic functioning

contributed towards enabling him to perpetrate an act of extreme violence.

It may be that one of the key factors involved in the expression of violence

in individuals with a diagnosis of schizophrenia is similar to that involved

in psychopathy: individuals are unable to empathise with victims due to

impaired emotional empathy. It may be this impairment that separates

individuals diagnosed with schizophrenia from those with autistic spectrum

disorders when considering the risk of violence. However, the role of motor

empathy and cognitive empathy impairments in the likelihood of violence

within the schizophrenic population requires further research, as this case

study demonstrates impairments in both of these areas.

Clearly this is a single case study and as such has limitations. However, it

highlights an area for further research to explore the differing aspects of

emotional processing in people with schizophrenia, with implications for

assessing risk of violence and its management within this group.

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