Decision-making processes and institutional antisocial behaviour among forensic psychiatric inpatients: a systematic review

The present study is a systematic review with a potential meta-analysis that investigates the relationship between decision-making processes and institutional antisocial behaviour among inpatients in forensic psychiatric settings. Institutional antisocial behaviour within secure psychiatric units—such as aggression, violence, rule violations, and disciplinary incidents—constitutes a clinically significant indicator of psychopathology, behavioural dysregulation, treatment response, and risk level. Concurrently, contemporary research in cognitive and clinical psychology has demonstrated that core decision-making mechanisms (e.g., impulsivity, risky choice, executive functioning deficits, reduced cognitive control) are associated with aggressive and antisocial behaviour across general and clinical populations. However, the synthesis of empirical findings specifically concerning forensic psychiatric inpatients remains fragmented. Aim of the Study The primary objectives of this review are: To identify and systematically synthesise empirical findings concerning decision-making processes among forensic psychiatric inpatients. To examine whether, and through which mechanisms, these cognitive and psychological processes are associated with institutional antisocial behaviour within secure psychiatric settings. To explore potential moderating factors (e.g., age, sex, psychiatric diagnosis, level of security). To evaluate the methodological quality of the available studies and the overall strength of the evidence. Scientific Framework This study is situated at the interdisciplinary intersection of: Cognitive neuropsychology, Forensic psychiatry, Theories of self-regulation and behavioural control, and Violence risk assessment models. The working hypothesis is that impairments in core decision-making mechanisms—particularly response inhibition, reward/punishment processing, and cognitive control—will be consistently associated with increased rates of aggressive or rule-violating incidents within institutional settings. Methodological Approach The review will follow the PRISMA 2020 guidelines. Empirical studies (quantitative, qualitative, and mixed-methods) published between 2005 and 2026 will be included. The review process will involve: Systematic searches across international databases Independent dual screening of eligibility Standardised data extraction Risk of bias assessment using the Mixed-Methods Appraisal Tool (MMAT, 2018) Structured narrative synthesis Meta-analysis where sufficient methodological and clinical homogeneity is identified Expected Results It is anticipated that: Impulsivity and executive functioning deficits will demonstrate a consistent positive association with institutional aggression. Studies will exhibit methodological heterogeneity, particularly regarding assessment tools and operational definitions. A need will emerge for more ecologically valid neuropsychological assessments within forensic psychiatric environments. Diagnostic differences (e.g., psychotic disorders versus personality disorders) may influence the nature and strength of the observed associations. Expected Contribution This review aims to: Advance theoretical understanding of the cognitive mechanisms underlying antisocial behaviour in institutional contexts. Inform the development of targeted cognitive and behavioural interventions. Support structured violence risk assessment and treatment planning in forensic psychiatric settings. Provide methodological recommendations for future high-quality empirical research.