Male Forensic Patients Research Articles

Arts therapies and Schema Focused therapy: A pilot study

Abstract Arts therapies and Schema Focused therapy (SFT), use experiential techniques to help patients access and reprocess emotions. We conducted a randomized controlled pilot study to determine the effectiveness of these therapies at evoking emotional states (“schema modes”) in forensic patients, a group that is considered difficult to reach emotionally. Ten male forensic patients with Cluster B personality disorders who were enrolled in a randomized clinical trial of SFT versus usual forensic treatment (“treatment as usual,” TAU) participated in the study. We investigated the effect of Arts therapies versus verbal psychotherapy, and SFT versus TAU on modes. As hypothesized, patients showed significantly more healthier emotional states in their Arts therapy sessions than in their verbal psychotherapy sessions SFT evoked more childmodes than TAU, at a trend level of significance. Patients in the SFT and TAU conditions showed no differences in schema modes early in therapy, and were equivalent on all baseline characteristics. These findings, though requiring replication in a larger sample, suggest that Arts therapies and SFT have potential for evoking emotional states in difficult to reach patients.

Epilepsy at a large psychiatric hospital: survey and audit of its management

AbstractObjectives: Although epilepsy and psychiatric disorder are known to be associated, little is known about the nature of epilepsy in psychiatric inpatients and how well psychiatrists manage psychiatric patients with epilepsy. The aim of this study was to describe the nature of epilepsy in patients at a large specialist independent psychiatric hospital and to audit the management of epilepsy using patients' records.Method: Cross-sectional survey of inpatients and audit of clinical documents. Audit standards were derived from good clinical practice and UK guidelines.Results: In total, 83/488 (17%) patients had a life-time history of epileptic seizures and 67 (14%) were receiving anti-epileptic drugs. The prevalence of epilepsy was 37% among brain injury patients, compared with 10-11% in adult male and female forensic patients and in the elderly and 2% in adolescents. Generalised tonic-clonic seizures predominated. Common aetiological factors were: traumatic brain injury, antipsychotics, cerebral hypoxia, cerebrovascular disease and learning disability. In 53/67 (79%) cases the care plan stated the patient had epilepsy but in only 20 (30%) was the seizure type recorded. For 30 (45%) there was no history of how epilepsy had been diagnosed. Of those patients with a history of status epilepticus, 5/15 (33%) had a readily accessible emergency treatment plan. The patient's last seizure was incompletely documented in 29/44 (66%) cases, while for only 7/67 (10%) patients was there documented evidence of a review of epilepsy management within the past year.Conclusions: Epilepsy was common in this group of psychiatric inpatients. Documentation and management needed improvement and to be in line with national guidelines.

General and maladaptive traits and anger in a combined forensic psychiatric and general population sample

The present study examines the associations between anger and general and maladaptive traits in a combined forensic psychiatric and community sample of men. Thirty-four male forensic psychiatric patients and 219 men from the general population completed the Novaco Anger Scale (NAS; Novaco, 1994), the NEO-PI-R (Costa & McCrae, 1992), the ADP-IV (Schotte & De Doncker, 1994) and the VKP (Duijsens, Haringsma, & EurelingsBontekoe, 1999) at two measurement occasions with a one-year interval. The results of a series of multiple regression analyses showed that general and maladaptive traits accounted for a substantial amount of variance in anger scores. Neuroticism, Agreeableness and Externalizing traits were most prominent in the prediction of anger, while Conscientiousness was acting as a suppressor variable in the regression models. Strengths and limitations of the present study and implications for further research and clinical practice are discussed.

Do male and female forensic patients with learning disabilities differ on subscales of the Novaco Anger Scale and Provocation Inventory (NAS‐PI)?

PurposeHigh levels of anger have been associated with forensic learning disabled populations. The role of gender within the experience of anger is not clear. This study aims to start exploring the question “Do female forensic patients with learning disabilities have different needs in relation to anger?”Design/methodology/approachThis study used a between‐subjects design with one independent variable: gender. The Novaco Anger Scale and Provocation Inventory was applied. Scores obtained by 12 females were compared with those of 23 males within a forensic psychiatric service for learning disabled patients.FindingsSignificant differences were found between scores, suggesting female forensic patients with learning disabilities experience higher levels of anger than do males, particularly in the arousal domain, and demonstrate difficulties in regulating anger.Research limitations/implicationsThe use of a single measure of anger and the small, forensic nature of the sample limits this study. It is recommended that further research address these issues and extend the exploration of this issue to non‐forensic populations.Practical implicationsGender specific differences, and the potential influence of learning disabilities should be considered when assessing and treating anger difficulties. Female forensic patients with learning disabilities may benefit from a greater emphasis on anger arousal reduction work.Social implicationsThis study highlights how the impact of gender and learning disabilities on the experience of anger is currently insufficiently understood.Originality/valueThis study forms a preliminary study of anger in the under‐researched population of females with learning disabilities.

S26-02 - The effectiveness of schema focused therapy; Indirect, experimental measures of emotional change in forensic patients

According to recent literature, 50 to 90 percent of criminal offenders have personality disorders (PDs), with cluster B PDs being the most prevalent in forensic settings. The latter type of PD is associated with an increased risk of violence and recidivism. Among forensic patients with a cluster B diagnosis, psychopathic offenders are at particularly high risk for re-offending. Psychopaths are believed to be untreatable, but evidence for this view is weak.The current study aims at determining the effectiveness of Schema Focused Therapy (SFT) versus ‘treatment as usual’ in male forensic patients (including psychopaths) with Antisocial, Borderline, Narcissistic, and Paranoid PDs, within a 3-year multi-center randomized clinical trial. SFT is an integrative form of psychotherapy combining cognitive, behavioral, psychodynamic object relations, and humanistic/existential approaches, and was developed as a treatment for PDs and other longstanding problems. SFT aims at changing early maladaptive schema modes, thereby producing changes on a structural, emotional level.The goal of a second study that runs within the same project is to objectively determine the nature of the emotional deficiencies that are thought to be central to psychopathy. By administering forensic patients an extensive test battery that assesses various affective capacities (e.g., moral emotion, emotional expressive behavior, cognitive and emotional empathy), we aim at constructing an integrative picture of psychopaths’ emotional functioning. Within the SFT effectiveness study, patients are tested twice (with a one year interval), to see whether these affective capacities are subject to change in the context of therapy.

The Influence of Psychiatric Symptoms and Cognitive Abilities on Competence-Related Abilities

This study evaluated the influence of psychiatric symptoms (psychoticism, withdrawal, depression, hostility) and cognitive abilities (executive functioning, working memory, attention, processing speed) on competence-related abilities (understanding, reasoning, appreciation). Seventy-seven male forensic patients were administered the MacCAT-CA, the BPRS, and several cognitive measures. Results revealed that, when considered as a group, the cognitive abilities accounted for more variance in the scores for all three competence-related abilities than did the psychiatric symptoms although there was an additive effect when these groups of variables were considered collectively. Both the psychiatric symptoms and cognitive abilities accounted for a substantial portion of the variance in understanding and reasoning scores, but less so for appreciation. Psychoticism and attention were important factors across all aspects of competence, while working memory was associated with understanding and reasoning, but not appreciation. The presence of symptoms of psychosis had a moderating effect on all four cognitive variables with regard to reasoning, but not understanding or appreciation. The knowledge gained from these results can be used by practitioners to help improve the consistency and accuracy of competency evaluations.

Psychopathy and sexual sadism.

Psychopathic personality disorder and sexual sadism share several common characteristics, such as emotional detachment from the suffering of others or the preparedness to inflict pain or injuries. Based on a sample of 100 male forensic patients (all of them sex offenders, half of them sadistic), the concept of psychopathy and sexual sadism as a unified construct was tested empirically. Pooling indicator variables for psychopathic and sexually sadistic disorders showed that a two-factorial solution yielded a better fit than a single-factor model. The two factors identified psychopathy and sexual sadism as separate latent variables. More specifically, the data were compatible with a path model in which affective deficits and behavioral disinhibition of the psychopathy domain are precursors to sexually sadistic conduct.

PCL-R Psychopathy and its Relation to DSM Axis I and II Disoders in a Sample of Male Forensic Patients in a Belgian Security Hospital

The purpose of this study was to examine the relationship between the psychopathy, assessed using the PCL-R, and DSM Axis I and II disorders in a Belgian adult male forensic patients (N= 84). Regarding Axis I disorders, diagnoses of psychopathy were associated only with diagnoses of substance abuse/dependence. Regarding Axis II disorder, psychopathy diagnoses were associated with antisocial personality disorder. This relationship was asymmetrical, as psychopathy was highly predictive of antisocial personality disorder but not vice versa. Furthermore, there was a significant positive association between antisocial personality disorder and PCL-R total scores, Factor 1 and 2 scores, and Facet 1, 3, and 4 scores. There was also a significant positive correlation between narcissistic personality disorder and PCL-R Factor 1 and Facet 1 scores. These findings are congruent with the international research literature and have potential therapeutic relevance, as Cluster B disorders including antisocial personality disorders are associated with low treatment motivation and compliance (Widiger & Corbitt, 1997; Robins, Tipp, & Przybeck, 1991). Overall, diagnoses of psychopathy were rather specific and unrelated to most major mental disorders (psychoses, mood or anxiety disorders) and personality disorders (Clusters A and C).

A Cumulative Scale of Severe Sexual Sadism

The article assesses the scale properties of the criterion set for severe sexual sadism in a sample of male forensic patients (N = 100). Half of the sample consists of sexual sadists; the remainder is sampled at random from the general group of nonsadistic sex offenders. Eleven of 17 criteria (plus the additional item of inserting objects into the victim's bodily orifices) of Marshall, Kennedy, Yates, and Serran's list form a cumulative scale. More specifically, this scale comprises all the 5 core criteria that Marshall and his colleagues considered particularly relevant. The resulting 11-item scale of severe sexual sadism is highly reliable (r(tt) = .93) and represents a strong scale (H = .83) of the Guttman type (coefficient of reproducibility = .97). The 11-item scale distinguishes perfectly between sexual sadists and nonsadistic sex offenders in the sample.

Predicting short-term institutional aggression in forensic patients: A multi-trait method for understanding subtypes of aggression.

Accurately predicting inpatient aggression is an important endeavor. The current study investigated inpatient aggression over a six-month time period in a sample of 152 male forensic patients. We assessed constructs of psychopathy, anger, and active symptoms of mental illness and tested their ability to predict reactive and instrumental aggression. Across all levels of analyses, anger and active symptoms of mental illness predicted reactive aggression. Traits of psychopathy, which demonstrated no relationship to reactive aggression, were a robust predictor of instrumental aggression. This study (a) reestablishes psychopathy as a clinically useful construct in predicting inpatient instrumental aggression, (b) provides some validation for the reactive/instrumental aggression paradigm in forensic inpatients, and (c) makes recommendations for integrating risk assessment results into treatment interventions.

S18-04 Schema focused therapy for forensic patients with personality disorders: New research findings

Rationale:Schema Focused Therapy (SFT) has proven effective in outpatients with Borderline Personality Disorder (PD)(Giesen-Bloo et al., 2006). To test the effectiveness of SFT with forensic patients, we have begun a multi-center randomized clinical trial of SFT for male forensic patients with Antisocial, Borderline, Narcissistic, or Paranoid PDs.Methods:One hundred twenty patients will be enrolled from 7 high security forensic hospitals (“TBS clinics”) in The Netherlands. Patients are randomly assigned to receive either SFT or usual forensic treatment. Patients receive 3 years of therapy, and are assessed every 6 months for changes in PD symptoms, recidivism risk, and other outcomes. Following treatment completion, patients will be followed an additional 3 years to assess actual recidivism.Results:Since 2007, 39 patients (mean PCL-R score = 25.0, SD = 6.6) have been enrolled in the study, 22 have completed their 12-month assessments, and 11 their 18-month assessments. Only 3 have dropped out. Recruitment is ongoing, with expected completion of the project in 2012. Pilot data on a different sample of N = 18 forensic PD inpatients treated in SFT for a mean of 1.9 years (SD = 0.8) is encouraging. Nine of the 18 patients showed reliable improvement, and only one showed reliable deterioration (mean d-score = 0.84, SD = 0.95, p < .01).Conclusions:SFT appears to be a promising treatment for forensic patients with Antisocial and other Cluster B PDs.

Perception of Stigmatization in Forensic Patients With Schizophrenia

The literature about perceived stigmatization of forensic patients with schizophrenia is sparse. To examine relations between the perceived stigmatization of forensic patients with schizophrenia and the intensity of the symptoms, age, regular home visiting, kind of offence, perceived family support and duration of hospitalization. Sixty-two male forensic patients with schizophrenia were included. Perceived stigmatization was measured by the modified questions from the World Health Organization Disability Assessment Schedule II. Symptomatology was assessed with the Positive and Negative Syndrome Scale. Perception of family support was assessed with a visual-analogue scale. Due to different characteristics of offences and possibilities for home visiting, patients were divided into groups of those who had committed violent and non-violent offences, and those with and without the possibility of regular home visiting. Symptoms have an impact on the perception of stigma. The kind of offence committed does not have a significant role in the perception of discrimination. Age was negatively correlated with the perception of stigma. Results might have significance for a better understanding of social relations between forensic patients and their environment and provide us with information about institutionalized forms of stigma. Results might have implications for the treatment and the quality of life of these patients.

Construct validity, reliability and predictive validity of the dynamic risk assessment and management system (DRAMS) in offenders with intellectual disability

Background. There have been a number of developments in the assessment of dynamic risk in the criminological literature. The dynamic risk assessment and management system (DRAMS) has been developed to facilitate the measurement of dynamic factors of risk for offenders with intellectual disability.Method. The study was designed to assess the construct validity, reliability and predictive utility of the DRAMS in 23 male forensic patients in a high secure setting. Predictions were made against independently collected incident data. Concurrent validity was assessed against the Ward Anger Rating Scale (WARS).Results. A reformulation of the individual section variables according to convergent and discriminant correlational analysis revealed Cronbach's alpha levels of >.8 for all sections apart from mood (alpha .750) and items retained to facilitate clinical information (alpha −.017). Two hundred pairs of WARS and DRAMS assessments revealed orderly sectional correlations. The sections of mood, antisocial behaviour, and intolerance/agreeableness predicted incidents with a medium effect size as did total DRAMS score. There were highly significant differences between assessments taken 1 or 2 days prior to an incident and control assessments conducted at least 7 days from an incident.Conclusions. The reformulated DRAMS has good construct and concurrent validity. It appears to be a reliable assessment tool and informs on risk levels relating to stable and acute proximal factors. It appears as an important addition to the utility of risk assessments for this population.

Predicting violent reconvictions using the HCR-20

Risk assessment of future violent acts is of great importance for both public protection and care planning. Structured clinical assessments offer a method by which accurate assessments could be achieved. To test the efficacy of the Historical, Clinical and Risk Management Scales (HCR-20) structured risk assessment scheme on a large sample of male forensic psychiatric patients discharged from medium secure units in the UK. In a pseudo-prospective study, 887 male patients were followed for at least 2 years. The HCR-20 was completed using only pre-discharge information, and violent and other offending behaviour post-discharge was obtained from official records. The HCR-20 total score was a good predictor of both violent and other offences following discharge. The historical and risk sub-scales were both able to predict offences, but the clinical sub-scale did not produce significant predictions. The predictive efficacy was highest for short periods (under 1 year) and showed a modest fall in efficacy over longer periods (5 years). The results provide a strong evidence base that the HCR-20 is a good predictor of both violent and non-violent offending following release from medium secure units for male forensic psychiatric patients in the UK.

Anger and assaultiveness of male forensic patients with developmental disabilities: links to volatile parents

This study with 107 male forensic patients with developmental disabilities investigated whether exposure to parental anger and aggression was related to anger and assaultiveness in a hospital, controlling for background variables. Patient anger and aggression were assessed by self-report, staff-ratings, and archival records. Exposure to parental anger/aggression, assessed by a clinical interview, was significantly related to patient self-reported anger, staff-rated anger and aggression, and physical assaults in hospital, controlling for age, intelligence quotient, length of hospital stay, violent offense history, and childhood physical abuse. Results are consonant with previous findings concerning detrimental effects of witnessing parental violence and with the theory on acquisition of cognitive scripts for aggression. Implications for clinical assessment and cognitive restructuring in anger treatment are discussed.

Violence and Personality in Forensic Patients

Concerning the discussion about the connection of personality traits, personality disorders, and mental illness, this study focused on the personality profiles of male forensic patients, prison inmates, and young men without criminal reports. The main topic centered on group-specific personality profiles and identifying personality facets corresponding with mental illness. The authors therefore used the Rasch model-based Trier Integrated Personality Inventory. They individually tested 141 German forensic patients with different crime backgrounds, 122 prison inmates, and 111 soldiers of the German army. Within group differences they found that the individuals with mental retardation differ from patients with a personality disorder or psychosis. Patients with mental retardation displayed higher neurotic and/or paranoid personality accents and tended to be low organized and self-confident.

Gender Differences in Diagnoses of Mentally Disordered Offenders

We investigated differences in psychiatric diagnoses and medicolegal insanity decisions between female and male forensic psychiatric patients. Data on all offenders (N = 4396) subjected to a court-ordered forensic psychiatric inpatient evaluation were obtained for the years 1992–2000. A significantly higher proportion of female mentally disordered offenders were given a diagnosis of personality disorder while mentally disordered male offenders more often had a diagnosis of alcohol and/or drug dependence or sexual disorders. There was an increased likelihood that violent women would be declared legally insane even after controlling for a number of potential confounders. This may reflect an underlying difference in the severity of psychiatric morbidity not accounted for diagnostically or that a gender bias exists in the forensic psychiatric evaluation process.

Brain cell membrane motion-restricted phospholipids in patients with schizophrenia who have seriously and dangerously violently offended

This study directly assessed, for the first time, whether there was a change in brain cell motion-restricted membrane phospholipids in vivo in male forensic patients with schizophrenia who had seriously and violently offended (homicide, attempted murder, or wounding with intent to cause grievous bodily harm) while psychotic, by quantification of the broadband resonance signal from 31-phosphorus neurospectroscopy scans. Cerebral 31-phosphorus magnetic resonance spectroscopy was carried out in 15 such patients, who suffered from positive symptoms of schizophrenia, and in 12 age- and sex-matched normal control subjects. Spectra were obtained from 70 × 70 × 70 mm 3 voxels using an image-selected in vivo spectroscopy pulse sequence. There was no significant difference in the broad resonances between the two groups, with the mean (standard error) percentage broadband signal for the patients being 57.8 (5.6) and that for the control subjects 57.7 (6.0). The phosphomonoesters and phosphodiesters narrow signals also did not differ between the groups. These results suggest that patients with schizophrenia who have predominantly positive symptoms may not show neuroimaging-based signs compatible with the membrane phospholipid hypothesis of schizophrenia.

The criminal and personality profile of patients with schizophrenia and comorbid psychopathic traits

Sixty-one male forensic patients who met the DSM-IV criteria for schizophrenia were categorised into high and low psychopathic trait groups using the Psychopathy Checklist: Screening Version. The groups were compared on their criminal history, symptom profile, personality style, risk scores and subsequent institutional violence. Patients with high scores on the PCL:SV had a greater number of previous convictions and were more likely to have a family history of criminality. The high psychopathy-scoring group had higher levels of Positive and Negative Syndrome Scale grandiose and hostile symptomatology, and higher scores on trait impulsivity and aggression. They also had a more coercive, less compliant interpersonal style than the low-psychopathy scoring group. The high-psychopathy scoring group were more likely to be involved in institutional aggression and had higher levels of risk for violence. Patients with schizophrenia and high levels of comorbid psychopathy have a distinctive interpersonal style that may contribute to their greater risk of disruptive institutional behaviour.

Higher-Order Dimensions of Personality Disorder: Hierarchical Structure and Relationships with the Five-Factor Model, The Interpersonal Circle, and Psychopathy

Two studies examined the higher-order factor structure of DSM-IV personality disorders using the International Personality Disorder Examination in male forensic psychiatric patients. In Study 1 (N = 168), exploratory factor analysis at the level of individual personality disorder criteria indicated nine primary factors. Exploratory and confirmatory factor analyses of these first-order factors supported a hierarchical structure in which two of three second-order factors covaried to yield a third-order factor. The two resulting superordinate factors were labelled Anxious-Inhibited and Acting Out. In Study 2 (N = 160), we used exploratory and confirmatory factor analyses to test hypotheses of common dimensions underlying these superordinate factors of personality disorder and superordinate factors of the five-factor model of personality, dimensions of the interpersonal circle, and psychopathy. Of three common factors, one combined Anxious-Inhibited disorders, "neurotic introversion," and hostile-submission. The other two factors of Acting Out/ psychopathy and antagonism/hostile-dominance covaried to yield a superordinate factor. Possible substrates underlying two superordinate dimensions common to normal and abnormal personality were identified in the theoretical literature.