IntroductionChildren’s development into healthy well-functioning adults can be negatively affected by adversity. Adverse childhood experiences (ACEs) have been shown to lead to a variety of poor life outcomes, ranging from mental health problems (e.g., anxiety or suicidality) through problematic health behaviors to serious physical diseases and even early death. ACEs can also make people more prone to aggressive behavior, criminality, and recidivism. In this study, we investigated the association between ACEs, specifically childhood maltreatment (CM), and forensically relevant factors; aggression, criminal risk factors, and treatment trajectories, as little is known about these associations in forensic psychiatric patients.MethodsThe study includes data derived from two studies in The Netherlands, of which the first study enrolled 128 patients residing in a Forensic Psychiatric Center (FPC) and the second study included 468 patients who were released unconditionally from FPCs between 2009 and 2013. We expected that more CM would be correlated with higher levels of aggression, higher clinical risk factor scores, and less decrease in clinical risk factor scores over time. To investigate this, we applied correlational analyses and linear growth curve modeling on risk assessment scores and self-report as well as staff report questionnaires on CM and aggression.ResultsConsistent with our first hypothesis, patients with higher CM scores also had higher aggression and risk assessment scores. The effect sizes were small to medium (0.12 to 0.34). Unexpectedly, CM did not influence the course of these treatment trajectories, however, we found that patients with histories of CM had a significantly longer length of stay in a forensic facility than patients without CM (respectively, 10.8 years and 9.3 years on average).DiscussionThis study underlines the importance of carefully examining the history of ACEs and CM in forensic psychiatric patients and considering this in forensic risk assessment and risk guided treatment. More research is needed to draw conclusions about whether and how histories of ACEs should be considered and targeted during treatment trajectories.

Purpose: To analyze and understand the zonular tension and distribution of forces in the presence of zonular disinsertion in a model simulation with and without a capsular tension ring (CTR). Methods: This study was conducted at Complejo Hospitalario Universitario Albacete, University of Castilla La Mancha, Spain. Twelve load cells were arranged in a circular fashion to simulate the 360 degrees of zonulae in the eye. An elastic band was prestretched in a uniform and radial manner in 12 directions. Force measurements were taken using 12 load cells, uniformly arranged at 30° spacing around the elastic band. Tension was measured at each cell, before and after the simulated zonulardisinsertion. Every clock hour of zonular disinsertion was cycled through all 12 load cells. The tension was evaluated for zonular disinsertion ranging from 0 to 5 clock hours (0° to 150°) with and without a CTR. Results: An increase in zonular tension was recorded in the load cells adjacent to the segments of zonular disinsertion. As the zonular disinsertion progressed, opposing forces could no longer cancel each other out, leading to a displacement of thecomplex. The use of a CTR redistributed the forces, providing better centration in the presence of zonulolysis. Conclusion: This study visualizes the distribution of forces and displacement of the capsular bag complex in the presence of zonular disinsertion and demonstrates a significant increase in zonular tension in the areas adjacent to the segment of zonular disinsertion. The use of a CTR managed to redistribute the tension over the remaining zonulae, maintaining better centration in the presence of zonulolysis. The knowledge of this behavior can help surgeons tackle clinically significant zonular disinsertion.

Violent criminal offenders with personality disorders (PD's) can cause immense harm, but are often deemed untreatable. This study aimed to conduct a randomized clinical trial to test the effectiveness of long-term psychotherapy for rehabilitating offenders with PDs. We compared schema therapy (ST), an evidence-based psychotherapy for PDs, to treatment-as-usual (TAU) at eight high-security forensic hospitals in the Netherlands. Patients in both conditions received multiple treatment modalities and differed only in the individual, study-specific therapy they received. One-hundred-three male offenders with antisocial, narcissistic, borderline, or paranoid PDs, or Cluster B PD-not-otherwise-specified, were assigned to 3 years of ST or TAU and assessed every 6 months. Primary outcomes were rehabilitation, involving gradual reintegration into the community, and PD symptoms. Patients in both conditions showed moderate to large improvements in outcomes. ST was superior to TAU on both primary outcomes - rehabilitation (i.e. attaining supervised and unsupervised leave) and PD symptoms - and six of nine secondary outcomes, with small to moderate advantages over TAU. ST patients moved more rapidly through rehabilitation (supervised leave, treatment*time: F(5308) = 9.40, p < 0.001; unsupervised leave, treatment*time: F(5472) = 3.45, p = 0.004), and showed faster improvements on PD scales (treatment*time: t(1387) = -2.85, p = 0.005). These findings contradict pessimistic views on the treatability of violent offenders with PDs, and support the effectiveness of long-term psychotherapy for rehabilitating these patients, facilitating their re-entry into the community.

People from all over the world pay for live streaming video images of minors, also called webcam child sex tourism (WCST). Although there is an increase in research about online sexual offending, relatively few studies have investigated the approaches used by people who have committed WCST offenses (PWCST). In addition, these studies describe these approaches as active-orientated without mentioning an avoidant pathway. The aim of the study was to investigate whether PWCST use similar pathways as the four offending pathways identified by Ward and Hudson. Using qualitative thematic analysis, 195 cases of online chat conversations between PWCST and operators posing as a minor were analyzed. The Ward and Hudson pathways model was partially replicable. Evidence was found for an approach and avoidant pathway. The data also suggest three other sub-pathways and a mixed pathway. Most PWCST in this study used an approach pathway to immediately approach minors for sex, which provides important insight into the diverse nature of sexual grooming.

Effective treatment interventions for criminal offenders are necessary to reduce risk of criminal recidivism. Evidence about deviant electroencephalographic (EEG)-frequencies underlying disorders found in criminal offenders is accumulating. Yet, treatment modalities, such as neurofeedback, are rarely applied in the forensic psychiatric domain. Since offenders usually have multiple disorders, difficulties adhering to long-term treatment modalities, and are highly vulnerable for psychiatric decompensation, more information about neurofeedback training protocols, number of sessions, and expected symptom reduction is necessary before it can be successfully used in offender populations. Studies were analyzed that used neurofeedback in adult criminal offenders, and in disorders these patients present with. Specifically aggression, violence, recidivism, offending, psychopathy, schizophrenia, attention-deficit hyperactivity disorder (ADHD), substance-use disorder (SUD), and cluster B personality disorders were included. Only studies that reported changes in EEG-frequencies posttreatment (increase/decrease/no change in EEG amplitude/power) were included. Databases Psychinfo and Pubmed were searched in the period 1990-2017 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, resulting in a total of 10 studies. Studies in which neurofeedback was applied in ADHD (N = 3), SUD (N = 3), schizophrenia (N = 3), and psychopathy (N = 1) could be identified. No studies could be identified for neurofeedback applied in cluster B personality disorders, aggression, violence, or recidivism in criminal offenders. For all treatment populations and neurofeedback protocols, number of sessions varied greatly. Changes in behavioral levels ranged from no improvements to significant symptom reduction after neurofeedback training. The results are also mixed concerning posttreatment changes in targeted EEG-frequency bands. Only three studies established criteria for EEG-learning. Implications of the results for the applicability of neurofeedback training in criminal offender populations are discussed. More research focusing on neurofeedback and learning of cortical activity regulation is needed in populations with externalizing behaviors associated with violence and criminal behavior, as well as multiple comorbidities. At this point, it is unclear whether standard neurofeedback training protocols can be applied in offender populations, or whether QEEG-guided neurofeedback is a better choice. Given the special context in which the studies are executed, clinical trials, as well as single-case experimental designs, might be more feasible than large double-blind randomized controls.

The likelihood of recidivism is considered to be the most important outcome measure in forensic psychiatry. Therefore, forensic psychiatric treatment focuses on the reduction of the risk of recidivism by treating dynamic risk and protective factors, aiming to reduce risk factors while enhancing protective factors during treatment.The goal of this study is to assess treatment progress with the Instrument for Forensic Treatment Evaluation (IFTE) in a Dutch forensic psychiatric centre (n=240). Latent Class Analysis was conducted to reconfirm previously found patient profiles. Patient profiles were based on risk factors, psychopathology, and offence type. Repeated measures ANOVAs were conducted to assess treatment progress for the whole patient group, for high and low risk patients, and for patients who had been in treatment for a period longer and shorter than one year.Latent Class Analysis has not reconfirmed the previously found profiles, therefore a repeated measures ANOVA was not conducted on profile level. On group-level, no significant progress was found. Though, patients with low protective behaviour, low resocialization scores, and high problem behaviour scores displayed significant treatment progress. Patients with low problematic behaviour showed a significant increase of problematic behaviour and patients with high protective behaviour a decrease of protective behaviour. Results indicated an interaction effect between time of admission and the factor resocialization skills, however this effect was not found for the other two factors.Results imply that higher risk patients can show more treatment progress than lower risk patients.

Abstract We present a program for violent forensic psychiatric inpatients and a program for sexually violent forensic psychiatric inpatients (child abusers and rapists) with Cluster B personality disorder as their primary diagnosis. Based on their dynamic criminogenic needs, heuristic behavioral models were formulated for violent and sexually violent behavior. With Goldstein, Glick, and Gibbs's Aggression Replacement Training as a starting point, two cognitive–behavioral programs were developed, one for violent and one for sexually violent inpatients. Assessment instruments and the first results of the two programs are described, followed by recommendations for further development and evaluation.

BackgroundDomestic Violence and Abuse (DVA) is associated with a range of psychosocial and mental health problems. Having a psychiatric illness increases likelihood of being a victim of DVA. Despite the evidence of a high risk for DVA and the serious effects of violent victimization in psychiatric patients, detection rates are low and responses are inadequate. The aim of the BRAVE (Better Reduction trough Assessment of Violence and Evaluation) study is to improve detection of and response to DVA in psychiatric patients. In this article, we present the protocol of the BRAVE study which follows the SPIRIT guidelines.MethodsThe BRAVE study is a cluster randomized controlled trial. We will include 24 community mental health teams from Rotterdam and The Hague. Twelve teams will provide care as usual and 12 teams will receive the intervention. The intervention consists of 1) a knowledge and skills training for mental health professionals about DVA, 2) a knowledge and skills training of DVA professionals about mental illness, 3) provision and implementation of a referral pathway between community mental health and DVA services. The follow up period is 12 months. Our primary outcome is the rate of detected cases of recent or any history of DVA in patients per team in 12 months. Detection rates are obtained through a systematic search in electronic patient files. Our secondary aims are to obtain information about the gain and sustainability of knowledge on DVA in mental health professionals, and to obtain insight into the feasibility, sustainability and acceptability of the intervention. Data on our secondary aims will be obtained through structured in depth interviews and a questionnaire on knowledge and attitudes on DVA.DiscussionThis study is the first cluster randomized controlled trial to target both male and female psychiatric patients that experience DVA, using an intervention that involves training of professionals. We expect the rate of detected cases of DVA to increase in the intervention teams. With early detection of victimization of DVA in psychiatric patients we hope to improve the mental health of psychiatric patients in the short and long term.Trial registrationISRCTN:14115257. Date of registration: 15th January 2015.

The present study investigated multivariate associations between attachment styles and personality disorders (PDs)—and the mediating role of trust—in a sample of child molesters (n = 84) and a matched control group from the general community (n = 80). Among child molesters, canonical correlation analysis revealed that two variates resembling avoidant and anxious attachment dimensions were associated with PD traits. Attachment avoidance was related to schizoid, schizotypal, and avoidant PDs, with a marginal contribution of antisocial PD. Attachment anxiety was related to borderline and histrionic PDs, with a marginal contribution of obsessive-compulsive PD. Paranoid and dependent PDs contributed to both variates. In the control group, a more general association between attachment insecurity and PDs emerged. Finally, mistrust significantly explained the associations between attachment and PDs in both samples. Future studies should examine whether treatment for PDs in child molesters could benefit from a focus on attachment and trust.

Despite the available literature on disclosure of child sexual abuse (CSA), little is known about how gender affects disclosure. This article aims to quantitatively examine whether gender differences exist in formal (to legal or child protection authorities) and informal (to a family member or friend) disclosure of CSA and, if so, to assess whether this relation is associated with abuse characteristics and attitudes toward gender roles. The study also aimed to examine whether gender differences exist in reasons not to disclose CSA. Data of a sample of 586 participants, who reported to have experienced CSA committed by a single person, have been used for the analyses. There were no gender differences for formal disclosure, but the informal disclosure rate of CSA was 2.4 times higher for women than men, and this effect remained significant after controlling for abuse characteristics and attitudes, even though the gender difference decreased slightly. Furthermore, women and men reported different reasons for not disclosing CSA in their personal network. Women were more worried than men that family and friends would discover the abuse and reported more insecurity of what to do in this situation. Professionals in the field of CSA should consider a gender perspective when developing guidelines. Men have rarely been the subject of studies of disclosure after CSA. Professionals should focus more on general mental health outcomes of men that are not related with CSA directly, but where the effects of CSA may exert more indirectly through associations with other problems in life.