Forensic psychiatric inpatients and aggression: An exploration of incidence,prevalence, severity,and interventions by gender

BackgroundPrevious investigations suggest that women judged to be not criminally responsible on account of mental disorder (NCR-MD) differ markedly from their male counterparts in important ways, underscoring the necessity of subsequent study.ObjectiveThe goal of the present study was to inform our understanding of the presenting profile of female forensic psychiatric patients and contrast their risk of inpatient aggression with their male counterparts.MethodThe population of patients assessed and/or treated at a secure Canadian forensic psychiatric hospital were available for study. In total, 527 patients had complete data and were part of intensive retrospective file reviews; inpatient aggression was evaluated using the Overt Aggression Scale.ResultsWomen were no less likely than men to have a violent index offence and to perpetrate inpatient aggression. Examining the range of aggressive behaviours and severity levels did little to increase the relevance of gender to inpatient risk.DiscussionFemale forensic patients represent a highly selected subgroup of women with exceptional clinical and behavioural challenges and associated treatment needs.     

Are they different? A comparison of risk in Dangerous and Severe Personality Disordered and Personality Disordered hospitalized populations

Abstract

There has been considerable interest internationally in the assessment and treatment of individuals who have a severe personality disorder and who might pose a high risk of future recidivism. In the UK, the Dangerous and Severe Personality Disorder (DSPD) programme was initiated to deal with just this group. It is unclear, yet, whether those admitted to these services are different from those admitted to conventional personality disorder (PD) services. In the present study, 60 patients admitted to DSPD services, under DSPD criteria, were compared with 44 patients admitted to personality disordered (non-DSPD) services within the same high secure psychiatric hospital, on risk measures, including (1) an index of predicted future violence, (2) previous offending behaviour and (3) ‘pre-treatment’ levels of institutional risk-related behaviour. Results indicated that DSPD patients do pose a greater clinical and management risk, have a higher number of ‘pre-treatment’ risk-related behaviour, and have a greater number of convictions and imprisonments after age 18, relative to PD patients. The implications and limitations of these results are discussed.     

Understanding motives for aggression in forensic psychiatric patients: a preliminary study

The primary aim of this study was to explore motivations underpinning aggression among men detained within conditions of high security. Thirty men residing at a high secure psychiatric hospital completed self-report measures, including the Aggression Motivation Questionnaire, Revised EXPAGG and Barratt Impulsiveness Scale-IIr. The Historical items of the Historical, Clinical and Risk-Management (HCR-20) and the Psychopathy Checklist-Screening Version were rated. A subsample of participants agreed to complete a functional assessment on an aggressive incident that had occurred during their placement (n = 9). Increased psychopathy and impulsivity, and the presence of historical risk items were predicted to associate with higher levels of both aggression motivation and beliefs supportive of aggression. Young age at first violent incident and personality disorder related positively to aggression motivation. Thematic analysis conducted on the functional assessments identified social recognition, emotion regulation, communication and protection as functions underpinning aggression. Results are discussed with regards to their implication for violence treatment and assessment, with a focus on motivation recommended.     

Exploring the role of locus of control in sex offender treatment

Abstract

This study aims to investigate the concept of Locus of Control (LoC) and its relationship to risk, personality disorder and treatment outcome in sexual offenders. The sample was taken from referrals to a community treatment service for sexual offenders in south-east London. One hundred and eighty-five men completed a measure of LoC at the time of assessment, of whom 74 entered the treatment programme and 39 completed a post-treatment LoC measure. At assessment, child molesters and non-contact offenders had a significantly more external LoC than rapists, and LoC was also significantly associated with cluster A and C personality disorder traits, as well as the presence of traits in two or more personality disorder clusters. LoC was not associated with risk measures or compliance with treatment. Once outliers were removed, a significant change was seen in post-treatment LoC scores, with most change occurring in an increasingly internal direction.     

A multidimensional scaling analysis of the Hare PCL-R: Unfolding the structure of psychopathy

Abstract

Recent studies examining the Psychopathy Checklist – Revised (PCL-R) have argued for a range of factorial solutions to describe and explain the dimensions of psychopathy. This study details an empirical analysis of North American PCL-R data for 4630 male offenders, using multidimensional scaling (MDS) as a non-linear alternative to factor analysis. The emergent structure of Hare's psychopathy psychometric can be interpreted in more than one way and at different levels of specificity. The multidimensional scalograms reveal a set of facets consistent with the two- and four-factor solutions that emerge from the same data. Equally the structure of the PCL-R can be interpreted through personality theory as a set of core traits and behavioural manifestations, consistent with an evolutionary basis for psychopathic tendencies. These analyses provide support for a multidimensional structure within the PCL-R, and suggest that psychopathy can be viewed as an extreme variant of multiple dimensions of personality.     

Antisocial personality disorder comorbid with borderline pathology and psychopathy is associated with severe violence in a forensic sample

Background: Evidence suggests the relationship between personality disorder (PD) and violence in offenders might be clarified by considering sub-groups of PD offenders defined by patterns of PD comorbidity. Aim: to identify patterns of PD comorbidity associated with severe violence, defined by its severity, quantity and age of onset (Violence Index: VI) in a forensic sample of 100 PD offenders. Methods: Correlations were first computed between VI and a range of personality and criminological variables; next, patients with antisocial/borderline comorbidity were compared with other PD patients; finally, regression analysis was conducted to identify unique predictors of VI. Results: The antisocial deviance factor of psychopathy and antisocial/borderline comorbidity were each significantly and independently associated with severe violence. Patients showing both a high psychopathy score and antisocial/borderline comorbidity had a significantly greater VI than those without these characteristics. Conclusion: PD patients with high psychopathy co-occurring with borderline and antisocial PDs show a criminal profile characterised by a high degree of serious violence.     

Relation of Antisocial and Psychopathic Traits to Suicide-related Behavior Among Offenders

Offenders with antisocial traits are relatively likely to attempt suicide, largely because they are more likely to have high negative emotionality and low constraint. Among 682 male offenders, we tested whether negative emotionality, low constraint, and also substance use problems mediated any relationship between antisocial personality disorder (ASPD) and psychopathy on the one hand, and suicide-related behavior (SRB) and ideation on the other. ASPD and the impulsivity/lifestyle features of psychopathy weakly predicted SRB. High negative emotionality and low constraint (but not substance use) mediated the relation between ASPD and SRB. Impulsivity/lifestyle features of psychopathy retained an independent predictive effect. Self-report psychopathy measures added unique predictive variance to the Psychopathy Checklist—Revised. We discuss implications for suicide risk assessment and prevention.

Are There Ethnic Differences in Levels of Psychopathy? A Meta-Analysis

Although considerable research on psychopathy has been conducted over the past 30 years, relatively few studies have examined key issues related to potential ethnic differences in this constellation of socially maladaptive personality traits. Given recent sociopolitical and scientific developments, an issue of considerable debate is whether Black individuals possess "more" traits of psychopathy than do Whites. To address this issue, a meta-analysis of differences between these groups' scores on the Psychopathy Checklist--Revised (PCL-R; Hare, 1991) was performed, using 21 studies (N = 8,890) of correctional, substance abuse, and psychiatric samples. Blacks exceeded Whites by an average of less than 1 point on the PCL-R total score. Effect sizes for core interpersonal and affective traits of psychopathy (Factor 1) were sufficiently homogeneous to clearly interpret, although other features manifested statistically significant heterogeneity. Our finding that Blacks and Whites do not meaningfully differ in their levels of core psychopathic traits is consistent with community-based findings for self-report measures of psychopathy and clinical diagnoses of antisocial personality disorder.     

Domestically and generally violent forensic psychiatric outpatients: personality traits and behavior

A group of 63 domestically violent patients and a group of 103 generally violent patients at a Dutch forensic psychiatric outpatient clinic are examined with regard to personality traits and problem behaviors to develop treatment programs for domestically violent patients. The domestically violent patients are more unstable from a psychological viewpoint but not more inclined to anger than the average Dutch male. They report less anxiety in situations in which criticism can be given but more anxiety in situations in which someone can be given a compliment. When comparing domestically violent patients with generally violent patients, domestically violent patients score lower on anger as disposition and on aggressive behavior than the generally violent patients do. However, both groups do not differ from each other in their score on the dimension of psychopathy.     

Behind closed doors: the effect of pretrial publicity on jury deliberations

Abstract

Effective treatment of aggressive behaviour and accurate release decision making are necessary components of adequate clinical practice in forensic psychiatric units. Unfortunately, methods to identify treatment targets and ameliorate aggressive behaviour have developed at a slower pace than risk assessment technologies. Recent progress on the identification of offence paralleling or functionally equivalent behaviour offers a framework for individually tailored treatment and idiographic release decision making, although empirical scrutiny of this approach is inadequate. This paper describes an examination of the relationship between aggressive behaviour prior to admission with aggression during inpatient psychiatric treatment, and reconviction for violent offending following discharge. Results showed a relationship between pre- and post-admission aggression but no relationship between aggression during inpatient psychiatric treatment with either pre-admission aggressive behaviour or violent recidivism. These findings indicate the importance of state psychological variables, specifically those states affected by symptoms of psychiatric illness, as well as environmental activators and inhibitors of violence that operate within the hospital. These require inclusion in an adequate functional analysis of aggressive behaviour for forensic psychiatric patients.     

Behavior on the ward of personality-disordered inpatients and chronically psychotic inpatients during a three-year stay in a Dutch forensic psychiatric hospital

To gain insight into the behavior of a group of personality-disordered patients and a group of chronically psychotic patients during their stay in a Dutch forensic psychiatric hospital, data on these patients were collected biannually for seven years. Three aspects of the patients’ behavior were examined: the prediction of institutional behavior shortly after admission, changes in the patients’ behavior on the ward during their stay in hospital, and the prediction of these changes. In the personality-disordered patients, observed irritation/anger and aggressive behavior on the ward turned out to be positively related to psychopathy, the PCL-R lifestyle and antisocial facets, and the neuroticism domain. A positive relationship was also found between aggressive behavior on the ward and trait anger. In the chronically psychotic patients, a positive relationship was found between irritation/anger and the PCL-R interpersonal and lifestyle facet. During a stay of three years, the aggressive behavior of both patient subgroups, which was already low at the start, did not decrease further, but their prosocial behavior increased. In the personality-disordered patients, relatively high scores on the antisocial facet of the PCL-R indicated an increase in prosocial behavior, whereas in the chronically psychotic patients no relationship was found between any PCL-R facet and behavior change. Effect studies on treatment programs for forensic psychiatric inpatients have to contend with the problem of a low base rate of institutional aggression. Therefore, we advise that such studies focus not only on a decrease in negative behaviors but also on an increase in positive behaviors.     

Sexual fantasies and sensation seeking among psychopathic sexual offenders

Abstract

This study investigated the relationship between psychopathy, sensation seeking behavior and sexual fantasies in a sample of 199 participants from a maximum security forensic hospital. Psychopathy, measured by the Psychopathy Checklist – Revised (PCL-R), and several sensation seeking and sexual fantasy measures were utilized. Results indicated that, in agreement with previous research, sexually deviant psychopaths are more likely to offend against adults than children. Likewise, psychopaths showed some tendency to score significantly higher on sexual sensation seeking measures than nonpsychopathic sexual offenders. Furthermore, a relationship between psychopathy and overall sexual fantasies existed but there were not specific patterns among psychopaths and nonpsychopaths with regard to specific categories of sexual fantasies.     

Psychological profile of sex offenders using weapons in their crimes

Abstract

A sample of 1533 sex offenders was examined for clinical characteristics associated with weapon use in their crimes. A total of 24.9% used weapons, most often knives (50.1%), with 13.6% using multiple weapons. Weapon-users were a very disturbed group, who showed a significantly higher prevalence than non-users of psychoses, suicide attempts, alcoholism, drug addiction and abuse, personality disorders, psychopathy, attention deficit hyperactivity disorder, cognitive impairment and violent criminal histories. The weapon-users recidivated more often than non-users and appeared in court on 8.7 separate occasions compared to 2.9 for non-users in an average follow-up of 21.5 years. The best predictors of weapon use were total violent offence convictions, sadism diagnoses and adult versus child victims. The importance of examining weapon use in assessing sex offenders is discussed.     

Psychopathic traits and change on indicators of dynamic risk factors during inpatient forensic psychiatric treatment

The main objective of the present study was to investigate the impact of treatment on forensic psychiatric inpatients, examining changes on 22 indicators of five dynamic risk factors for violence (i.e., egocentrism, hostility, impulsivity, lack of insight, and negative distrustful attitudes), and to relate these potential changes to level of psychopathy assessed with the Hare Psychopathy Checklist - Revised (PCL-R). Also, we studied the relationship between psychopathy and treatment compliance, as indicated by the attendance rate of therapeutic activities. Eighty-seven male patients (due to missing data on at least one measure, sample size varies from 58 to 87; 42 patients have complete datasets) were administered a standardized psychological assessment battery (self-report inventories, performance-based personality test, observer ratings) upon admission (T1) and after on average 20 months of treatment (T2). Upon admission, psychopathy (median split, PCL-R score≥22) was significantly related to a higher score on five of the 22 indicators of dynamic risk. The analyses showed no significant differences between psychopathic and non-psychopathic patients on the indicators of dynamic risk factors during 20 months of inpatient forensic psychiatric treatment. However, psychopaths showed the expected pattern of treatment noncompliance, compared to non-psychopaths. The clinical and research implications of these findings are discussed.     

Exploratory trial of schema-focussed therapy in a forensic personality disordered population

The management of needs and risks in personality disordered offender populations has become a focus for health and criminal justice services in the UK. Recent studies demonstrate the effectiveness of schema focussed therapy (SFT) for patients with borderline personality disorder. This study was an exploratory trial of the feasibility of implementing SFT in a population of patients with personality disorder in a high secure hospital in England. Preliminary evaluations of the effects of SFT were conducted to investigate whether those receiving SFT demonstrated significant improvements on measures of anger, impulsiveness, schemata and interpersonal style. No significant effects were evident although there was a significant increase in defectiveness/shame schema in the SFT group. Lack of effectiveness of SFT is likely due to the preliminary nature of this study. Future trials of SFT need to ensure comprehensive therapist preparation, control of TAU, bigger samples, address attrition and provide more intensive therapy.     

Reconciling psychopathy and low self-control

Although both reflect a self-centered, antisocial personality, psychopathy and low self-control have seldom been examined together. This study created scales reflecting both common and unique elements of both constructs, investigated their factor structure, and explained variance in delinquency. Four alternative hypotheses were tested: that low self-control and psychopathy constitute a single construct, that they constitute primary and secondary psychopathy or interpersonal and intrapersonal traits, or that they constitute Antisociality—the tendency to perform antisocial acts—and (low) Self-Direction—the tendency to act in one's long-term beneft. Models containing Antisociality and Self-Direction fit better than alternatives and accounted for substantial variance in offending.     

Self-deception and other-deception among admissions to a maximum security hospital and a medium secure unit

Abstract

Other-deception and self-deception are important variables to consider when conducting a forensic psychological evaluation. The main aim of the present study was to investigate the effects of setting on other-deception and self-deception scores. It was hypothesised that patients at a maximum security hospital (Broadmoor) would score lower on an other-deception questionnaire than similar patients at a medium secure unit (Denis Hill Unit). All the patients completed the other-deception (ODQ) and self-deception (SDQ) questionnaires of Sackeim and Gur (1979) on admission to the two security hospitals. The Broadmoor patients (N = 46) obtained significantly lower ODQ score than the Denis Hill Unit (N = 52) patients, after controlling for differences in ethnic background and diagnosis among the two populations. No significant difference in setting was found for the SDQ score. The ODQ and SDQ scores were significantly associated with the type of diagnosis and the ethnic background of the patient, with patients diagnosed as mentally ill scoring higher than those with a diagnosis of personality disorder, and ethnic minority patients scoring higher than Caucasian patients.     

Seasonal variation of seclusion incidents from violent and suicidal acts in forensic psychiatric patients

BackgroundA seasonal variation in violence and suicidal behaviour has been reported in several studies with partially congruent results. Most of forensic psychiatric patients have a history of severe violent behaviour that often continues in spite of regular treatment. In the forensic psychiatric hospital environment aggressive and suicidal acts are often sudden and unpredictable. For reasons of safety, rapid and intensive coercive measures, such as seclusion and restraint, are necessary in the treatment of such patients.ObjectiveTo examine whether these involuntary seclusions have a seasonal pattern, possibly similar than the reported seasonal variation in violence and suicidal behaviour. By investigating the possibility of a seasonal variation of seclusion incidents from violent and suicidal acts, it may become possible to improve the management of forensic psychiatric patients.MethodsThe hospital files of all secluded patients at Niuvanniemi Hospital from 1 January 1996 to 31 December 2002 were examined. In total, 385 patients (324 male and 61 female) were identified as being secluded at least once in 1930 different incidents (1476 from male and 454 from female patients). Seasonal decomposition and linear regression with dummy month variables were used to examine the possibility of annual variations for seclusions.ResultsThe seasonal variation of involuntary seclusion incidents was statistically significant. According to the linear regression model, most of the seclusion incidents, affecting many different patients, began in July and August, and were concentrated throughout the fall until November. The sum of all seclusion days was lowest in January and highest between July and November (difference + 31% to + 37%).ConclusionsThese findings are mainly in agreement with results from other studies on seasonal variation and violent behaviour. The allocation of staff for late summer and fall might enhance the management of forensic psychiatric patients, thus leading to possible decreases in seclusion incidents. The factors affecting violent, aggressive and suicidal behaviours are complex and more investigation is needed to understand, identify, intervene and effectively reduce such behaviours.     

Psychopathy,Conduct Disorder,and Stigma: Does Diagnostic Labeling Influence Juvenile Probation Officer Recommendations?

This study investigated the potential influence of labeling a juvenile as psychopathic. Juvenile probation officers (JPOs; N = 260) rendered hypothetical recommendations based on eight mock psychological evaluations. The evaluations varied the presence of two diagnostic criteria (antisocial behavioral history and psychopathic personality traits) and diagnostic labels (psychopathy, conduct disorder, no diagnosis) in order to distinguish criterion effects from labeling effects. The diagnostic criteria of antisocial behavior had a substantial effect on JPO recommendations (effect sizes .50–.79), while the diagnostic criteria of psychopathic personality traits had a more limited effect. Surprisingly, diagnostic labels had little effect, and there were no appreciable differences between conduct disorder and psychopathy diagnoses. These findings illustrate the importance of distinguishing diagnostic criterion effects from diagnostic labeling effects.