Comparison of Impulsivity, Alexithymia and Facial Emotion Recognition in Schizophrenia Patients With and Without Criminal Records

INTRODUCTION: Criminal behaviour by people with schizophrenia has been attributed variously to direct effects of the illness, an interplay between clinical features and social circumstances or neither. A difficulty in the interpretation of the relevance of the illness may lie in the focus on the more clearly psychotic features and the relative neglect of emotional dysregulation or deficits in social cognition. We, therefore, aimed to examine whether psychological and social cognitive factors-such as alexithymia, impulsivity, aggression and facial emotion recognition-differ between individuals with schizophrenia who have a criminal history and those who do not. METHOD: Forty-seven patients with schizophrenia and a criminal record were recruited from consecutive admissions to a specialist forensic mental health inpatient unit and 73 patients with schizophrenia but no criminal record were recruited from a general psychiatry unit in the same hospital. All participants, aged 18-65 years, completed a battery of assessments, including the facial emotion recognition test, the Toronto Alexithymia Scale, the Barratt Impulsiveness Scale and the Buss-Perry Aggression Questionnaire, between October 2023 and June 2025. RESULTS: The offender-patients showed significantly higher average motor impulsivity scores, significantly higher alexithymia scores-particularly externally oriented thinking-and significantly higher anger scores, but significantly superior performance in facial emotion recognition tests, specifically identifying shame, fear, surprise and happiness more accurately than the noncriminal group. Clinically, individuals with a criminal history had a significantly later onset of disorder (30.78 vs. 23.42 years), shorter disorder duration (8.85 vs. 12.36 years) and fewer psychotic episodes (2.48 vs. 3.21) and were more prone to self-harm. The offender-patients appeared to have been less treatment-adherent; specifically, they were less likely to have sustained treatment with depot antipsychotic medication. These findings remained significant in regression analyses, with offending as the dependent variable and these other characteristics as independent variables. CONCLUSION: This study adds evidence on links between criminal behaviour and schizophrenia other than, or over and above, positive psychotic symptoms. Emotional dysregulation, substance use and poor treatment adherence were problematic, but facial emotion recognition was not. Thus, forensic risk assessments should include tests of emotion dysregulation to inform clinical interventions. Attention is also needed to improve treatment engagement and substance use management. Future research is needed to better understand the apparent disconnection between intact emotion recognition and criminal behaviour in this population.