Context Psychopaths belong to a larger group of persons with antisocial personality disorder and are characterized by an inability to have emotional involvement and by the repeated violation of the rights of others. It was hypothesized that this behavior might be the consequence of deficient fear conditioning. Objective To study the cerebral, peripheral, and subjective correlates of fear conditioning in criminal psychopaths and healthy control subjects. Design An aversive differential pavlovian delay conditioning paradigm with slides of neutral faces serving as conditioned and painful pressure as unconditioned stimuli. Setting The Department of Medical Psychology at the University of Tubingen, Tubingen, Germany. Participants Ten male psychopaths as defined by the Hare Psychopathy Checklist–Revised and 10 age- and education-matched healthy male controls. The psychopaths were criminal offenders on bail and waiting for their trial or were on parole. The healthy controls were recruited from the community. Main Outcome Measures Brain activation based on functional magnetic resonance imaging, electrodermal responses, emotional valence, arousal, and contingency ratings. Results The healthy controls showed enhanced differential activation in the limbic-prefrontal circuit (amygdala, orbitofrontal cortex, insula, and anterior cingulate) during the acquisition of fear and successful verbal and autonomic conditioning. The psychopaths displayed no significant activity in this circuit and failed to show conditioned skin conductance and emotional valence ratings, although contingency and arousal ratings were normal. Conclusion This dissociation of emotional and cognitive processing may be the neural basis of the lack of anticipation of aversive events in criminal psychopaths.

https://jamanetwork.com/journals/jamapsychiatry/articlepdf/208744/yoa40213.pdf

Deficient Fear Conditioning in Psychopathy A Functional Magnetic Resonance Imaging Study

Background: Prison can be characterized as an impoverished environment encouraging a sedentary lifestyle with limited autonomy and social interaction, which may negatively affect self-control and executive function Here, we aim to study the effects of imprisonment on self-control and executive functions, and we report the change in neuropsychological outcome after 3 months of imprisonment Materials and Methods: Participants were 37 male inmates in a remand prison in Amsterdam, Netherlands, who completed six tests of a computerized neuropsychological test battery (the Cambridge Automated Neuropsychological Test Battery) in the first week of arrival Participants were retested after 3 months of imprisonment Change in performance was tested using the Wilcoxon Signed-Rank test Results: After 3 months of imprisonment, risk taking significantly increased (measured as an increase in the proportion of available points used for betting) and attention significantly deteriorated (measured as increased variability in reaction times on a sustained attention task), with large to medium effect sizes In contrast, planning significantly improved (measured with a task analog to the Tower of London) with a medium effect size Discussion: Our study suggests that 3 months of imprisonment in an impoverished environment may lead to reduced self-control, measured as increased risk taking and reduced attentional performance This is a significant and societally relevant finding, as released prisoners may be less capable of living a lawful life than they were prior to their imprisonment, and may be more prone to impulsive risk-taking behavior In other words, the impoverished environment may contribute to an enhanced risk of reoffending

/pdf/reduced-self-control-after-3-months-of-imprisonment-a-pilot-38dzsl4z8n.pdf

Reduced Self-Control after 3 Months of Imprisonment; A Pilot Study.

Objective The aim of this study was to identify quantitative data on the use of seclusion and restraint in different countries and on initiatives to reduce these interventions. Methods Combined literature review on initiatives to reduce seclusion and restraint, and epidemiological data on the frequency and means of use in the 21st century in different countries. Unpublished study was detected by contacting authors of conference presentations. Minimum requirements for the inclusion of data were reporting the incidence of coercive measures in complete hospital populations for defined periods and related to defined catchment areas. Results There are initiatives to gather data and to develop new clinical practice in several countries. However, data on the use of seclusion and restraint are scarcely available so far. Data fulfilling the inclusion criteria could be detected from 12 different countries, covering single or multiple hospitals in most counties and complete national figures for two countries (Norway, Finland). Both mechanical restraint and seclusion are forbidden in some countries for ethical reasons. Available data suggest that there are huge differences in the percentage of patients subject to and the duration of coercive interventions between countries. Conclusions Databases on the use of seclusion and restraint should be established using comparable key indicators. Comparisons between countries and different practices can help to overcome prejudice and improve clinical practice.

http://www.cfmhas.org.uk/assets/Lepping-2010-seclusion.pdf

Incidence of seclusion and restraint in psychiatric hospitals: a literature review and survey of international trends

Conflict (aggression, self-harm, suicide, absconding, substance/alcohol use and medication refusal) and containment (as required medication, coerced intramuscular medication, seclusion, manual restraint, special observation, etc.) place patients and staff at risk of serious harm. The frequency of these events varies between wards, but there are few explanations as to why this is so, and a coherent model is lacking. This paper proposes a comprehensive explanatory model of these differences, and sketches the implications on methods for reducing risk and coercion in inpatient wards. This Safewards Model depicts six domains of originating factors: the staff team, the physical environment, outside hospital, the patient community, patient characteristics and the regulatory framework. These domains give risk to flashpoints, which have the capacity to trigger conflict and/or containment. Staff interventions can modify these processes by reducing the conflict-originating factors, preventing flashpoints from arising, cutting the link between flashpoint and conflict, choosing not to use containment, and ensuring that containment use does not lead to further conflict. We describe this model systematically and in detail, and show how this can be used to devise strategies for promoting the safety of patients and staff.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/jpm.12129

Safewards: a new model of conflict and containment on psychiatric wards.

Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomised controlled trial

The Broset Violence Checklist (BVC) assesses confusion, irritability, boisterousness, verbal threats, physical threats, and attacks on objects as either present or absent. It is hypothesized that an individual displaying two or more of these behaviors is more likely to be violent in the next 24-hour period. All 109 consecutive referrals to four psychiatric inpatient acute units during a 2-month period were included in the study. Ratings were performed at the time of admission and three times a day for each patient—once for each working shift. Interrater reliability was adequate. Thirty-four separate incidences of violence occurred. Comparisons between ratings performed in the 24-hour interval before the incident and all other ratings suggested moderate sensitivity and good specificity of the instrument. It is concluded that the BVC is a useful instrument in predicting violence within the next 24-hour period and that the psychometric properties of the instrument are satisfactory.

The Brøset Violence Checklist Sensitivity, Specificity, and Interrater Reliability

Objective: Research on the prevalence and causes of in-patient aggression has been hindered by the use of different methods for measuring aggression. Since Palmstierna and Wistedt presented the Staff Observation Aggression Scale (SOAS) in 1987, this data collection method has been used in various studies, which may make comparisons more useful.



Method:  Studies with SOAS aggression data were compiled using MEDLINE, the Internet, and references from SOAS papers.



Results:  Reviews of studies on psychometric properties suggest fair to good inter-rater reliability and validity for SOAS assessments. The number of aggressive incidents per patient per year found on acute admissions wards (n = 38) considerably varied, with a range of 0.4–33.2 incidents (mean = 9.3).



Conclusion:  Although the aggression data included in the present review were obtained in highly comparable ways, substantial differences in aggression rates between wards were still found. Some countries (e.g. the Netherlands) appear to have a relatively high incidence of aggression on acute wards.

Fifteen years of research with the Staff Observation Aggression Scale: a review.

Objective: The Broset violence checklist (BVC) is a short-term violence prediction instrument assessing confusion, irritability, boisterousness, verbal threats, physical threats and attacks on objects as either present or absent. The aim of this paper is to describe the evolution and usefulness of the BVC.

Method:  This paper reviews studies on the BVC and discusses implications for further research.

Results:  Empirical research has shown that it has moderate sensitivity and high specificity with an adequate inter-rater reliability.

Conclusion:  The BVC is a useful instrument for predicting inpatient violence within the next 24-h period. The psychometric properties of the instrument are satisfactory. Results from ongoing studies will give important information on cultural differences, the validity of the BVC in less well staffed wards, the clinical use of the checklist and its ability to predict violence throughout all the hospital stay.

The Brøset violence checklist (BVC)

The Norwegian Broset-Violence-Checklist (BVC) is one of the few instruments that is suitable for short-term prediction of violence of psychiatric inpatients by nursing staff in routine care. The instrument assesses the presence or absence of six behaviours or states frequently observed before a violent incident. We conducted a study to elucidate whether the predictive properties of the BVC are retained in other psychiatric settings than the original north-Norwegian validation dataset. During their admission period, 219 consecutive patients admitted to six acute psychiatric wards were assessed as to the risk for attack using a German version of the BVC (BVC-G). Data on preventive measures were concurrently collected. Aggressive incidents were registered using an instrument equivalent to the Staff Observation of Aggression Scale (SOAS-R). Fourteen attacks towards staff were observed with incident severity ranging from 5 to 18 of a possible 22 points. BVC-G sensitivity was 64.3%, the specificity 93.9%, the positive predictive value 11.1%, and the area under the receiver operating characteristic curve 0.88. In some false positive cases intense preventive measures had been implemented. The predictive accuracy of the BVC-G proved consistent with the Norwegian original.

Predicting inpatient violence in acute psychiatric wards using the Brøset-Violence-Checklist: a multicentre prospective cohort study

Short- to medium-term risk assessment in psychiatric hospitals is a topic of clinical relevance that deserves attention from the research community. In this paper, the Short Term Assessment of Risk and Treatability, or START (Webster, Martin, Brink, Nicholls, & Middleton, 2004), a new structured instrument for judgment of dynamic risk and treatment factors is briefly described. Internal reliability properties are analyzed and the predictive validity for severe violence in a Norwegian high secure psychiatric hospital is investigated. The results indicate that the START has promise as a valid tool for short-term violence risk assessment. The authors make an argument for the importance and relevance of dynamic risk and strength factors in the short to medium term.

Predictive Validity and Other Psychometric Properties of the Short-Term Assessment of Risk and Treatability (START) in a Norwegian High Secure Hospital

Roger Almvik

Papers

The Brøset Violence Checklist Sensitivity, Specificity, and Interrater Reliability

Fifteen years of research with the Staff Observation Aggression Scale: a review.

The Brøset violence checklist (BVC)

Predicting inpatient violence in acute psychiatric wards using the Brøset-Violence-Checklist: a multicentre prospective cohort study

Predictive Validity and Other Psychometric Properties of the Short-Term Assessment of Risk and Treatability (START) in a Norwegian High Secure Hospital