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Aggression incidents are common in residential youth care, and impede treatment progress and the possibility of evolving into an independent healthy individual. Aggression incidents can lead to feelings of anxiety and unsafety in others, and can have major physical and/or traumatic impact for everyone involved. Current methods to prevent incidents are based on observations of increasing tension by professionals or adolescents themselves, however, they both might have difficulties recognizing these signals. A complementary and promising alternative might be the measurement of physiological reactivity to observe the stress response or increasing tension in adolescents. The present study used a wearable wireless device to examine patterns of physiological reactivity prior to aggression incidents in residential youth care. A total of 19 adolescents in residential youth care participated, who were involved in 87 aggression incidents during study participation. Participants wore a wearable wireless device to measure physiological stress response parameters (peaks per minute (PPM) , skin conductance (SCL), heart rate (HR)) during three, preferably consecutive, weeks, in which aggression incidents were accurately registered. Longitudinal multilevel models showed that PPM rose preceding incidents, but we failed to replicate previous SCL and HR findings in relation to incidents, as there was no significant effect for time, although both slopes did rise preceding aggression incidents. In sum, this study supports the idea that wearable devices measuring physiological stress reactivity might help in the prevention of aggression incidents. There is, however, high within-subject variation, which suggests that future studies should examine more personalized feedback and interventions to take this within-subject variation into account. To date, only a few tools adjusted the interface to this young (clinical) population, and store the data locally on the users’ phone.

Contains fulltext : 253265.pdf (Publisher’s version ) (Open Access) Listening to music can have a calming effect on people, but the natural “consumption” of music is generally not used in a goal-oriented way to reduce physiological arousal (i.e., heart rate and skin conductance) and tension, and to enhance mood. X-System is designed to predict the innate neurophysiological response to pieces of music and influence the arousal levels of users. We hypothesized that listening to a preferred genre of music has beneficial physiological and psychological effects and that X-System had an effect over and above the use of preferred music genres. A small-scale study (N = 38) was conducted in a medium secure forensic psychiatric facility to investigate the effects of passive music therapy on the arousal, tension, and mood of patients and their caregivers. Participants listened to a selection of songs of their preferred music genre for 2 days. On one of the 2 days, the music selection was played in an order established by X-System, with the aim to maximally reduce arousal, whereas on the other day the music selection was played in random order. In both conditions, physiological indices and self-reported tension decreased after listening to the preferred music. The hypothesized accelerated reduction in skin conductance for the X-System playlist was evident on visual inspection of the data, but the trend was non-significant (p = .065). The use of personalized music in forensic psychiatry might be a relatively effective, inexpensive way to benefit patients and staff members, especially patients that are hesitant to engage in the more traditional therapies. 18 p.

Nonsuicidal Self-Injury (NSSI) is a major public health problem. The present study covered three aspects of this behavior in an outpatient population with severe personality disorders. First, we compared a group that engaged in NSSI to a control group that did not. Second, we looked at the characteristics of the behavior. Third, we explored what the patients think are the reasons for NSSI. 50 (41%) of 121 patients had experienced NSSI during the seven-month data collection period. We found that the NSSI most often occurred in the evening (60%) and while being alone (82%). The most common forms of NSSI were the use of bodily force in some form (48%), followed by cutting (28%) and burning (10%). As triggers for NSSI, patients mentioned interaction with others and rising tension. Patients identified with both the ’distraction hypothesis’ and the ’self-punishment hypothesis’ as reasons for NSSI. They reported feeling less nervous and more relieved after NSSI, but also felt guilt about it. Although further research is necessary and the current findings should be interpreted with caution, weconclude based on our findings that it might be helpful for patients with severe personality disorders to be askedby their caregivers on a regular basis whether they use/ have used NSSI. We furthermore recommend consideringmaking an adequate crisis prevention plan with the patients who engage in NSSI.

Contains fulltext : 232097.pdf (Publisher’s version ) (Open Access) Background: Since the DSM‐5, adaptive functioning has taken a prominent place in the classification of intellectual disability (ID). The ADAPT was developed to assess adaptive skills in individuals with ID. Method: A total of 2,081 ADAPTs from clients with suspected ID or borderline intellectual functioning and 129 ADAPTs from people from the general population (non‐ID) were collected, along with background characteristics. Results: Internal consistency of the ADAPT was high (α = 0.98). ADAPT scores were positively associated with IQ, educational level and level of independent living. Furthermore, individuals without ID scored significantly higher than the clients on all of the 65 ADAPT items. Reference values were established for different IQ groups and living situations. Conclusion: Results suggest that the ADAPT is a valid instrument for measuring adaptive skills in individuals with ID. The reference values may be used for the purpose of estimating the level of ID and the needed intensity of support. 10 p.

Contains fulltext : 231148.pdf (Publisher’s version ) (Open Access) Impulsivity is strongly associated with aggression and antisocial conduct. Although self-report measures are a time-efficient means to assess impulsivity, they may be susceptible to socially desirable responding, particularly in forensic psychiatry. The current study aimed to investigate the predictive validity of three measures of impulsivity in predicting self- and informant-reported antisocial behavior: the Barratt Impulsiveness Scale, the Self-Centered Impulsivity scale of the Psychopathic Personality Inventory-Revised and the general Disinhibition factor of the Externalizing Spectrum Inventory. Next, the mediating role of a measure of self-deception, the Virtuous Responding scale, was examined in these associations. Participants (N = 94) were inpatients from addiction care and forensic psychiatry. Two regression analyses were conducted using self-reported antisocial behavior in the first, and informant-reported antisocial behavior in the second analysis as outcome variables. In addition, a mediated regression analysis was conducted, using the Virtuous Responding scale as a mediator. The impulsivity measures showed a substantially lower predictive validity when informant-reported behavior was predicted. The Virtuous Responding scale appeared to be unreliable in the current sample and showed no mediation effect. The results showed insufficient support for the predictive validity of the three measures of impulsivity. Alternative time-efficient assessments for impulsivity are needed, such as informant-based measures. 18 p.

Purpose Recent research on flexible assertive community treatment (FACT) for individuals with mild intellectual disabilities (MID) or borderline intellectual functioning (BIF) has shown positive results. This paper aims to identify which client variables are associated with treatment outcome of FACT. Design/methodology/approach Analyses were performed on assessments made during a six-year longitudinal study in The Netherlands. Data comprised assessments of 281 clients with at least 2 measurements. Treatment outcome was measured by the learning disability version of the Health of the Nation Outcomes Scales. Demographic variables and dynamic risk variables of the short version of the Dynamic Risk Outcome Scales were selected as potential predictor variables of outcome. Data were analysed using linear mixed models. Findings Limited awareness of the need for treatment, limited treatment motivation and cooperation, limited social skills, impulsivity and substance abuse were significantly associated with worse treatment outcome. None of the demographic variables influenced treatment outcome significantly, and neither did intelligence quotient or having a judicial or civil measure. Research limitations/implications Because of the observational design, no causal inferences can be drawn. Practical implications This study produces guidelines regarding nature and scope of the treatment supply and the competences of professionals working in FACT MID/BIF teams. Originality/value This paper encourages other countries to make assertive outreach available for people with MID/BIF on a larger scale, taking into account the acquired insights.

Contains fulltext : 240018.pdf (Publisher’s version ) (Closed access) The associations between physiological measures (i.e., heart rate and skin conductance) of autonomic nervous system (ANS) activity and severe antisocial spectrum behavior (AB) were meta-analyzed. We used an exhaustive partitioning of variables relevant to the ANS–AB association and investigated four highly relevant questions (on declining effect sizes, psychopathy subscales, moderators, and ANS measures) that are thought to be transformative for future research on AB. We investigated a broad spectrum of physiological measures (e.g., heart rate (variability), pre-ejection period) in relation to AB. The search date for the current meta-analysis was on January 1st, 2020, includes 101 studies and 769 effect sizes. Results indicate that effect sizes are heterogeneous and bidirectional. The careful partitioning of variables sheds light on the complex associations that were obscured in previous meta-analyses. Effects are largest for the most violent offenders and for psychopathy and are dependent on the experimental tasks used, parameters calculated, and analyses run. Understanding the specificity of physiological reactions may be expedient for differentiating between (and within) types of AB. 30 p.

Item does not contain fulltext Forensic psychiatric inpatients are frequently exposed to aggression from fellow patients during their treatment, but research on how this impacts patients' well-being and treatment progress is lacking. In this study, we interviewed nine patients on their experiences of victimization during mandatory psychiatric treatment. The interviews were analyzed using a Grounded Theory approach combined with elements from Consensual Qualitative Research and Interpretative Phenomenological Analysis. Three main themes emerged from the data, namely situational descriptives, intrapersonal and interpersonal consequences. Patients were not only exposed to both physical violence and verbal aggression by other patients, but also to a more ubiquitous flow of micro-aggressive comments. Options to escape these situations were limited. This means that victimization processes, which for most patients started much earlier in life, continue during forensic psychiatric treatment. Intrapersonal consequences include fear, hypervigilance, reactive aggression, flashbacks and avoidance and withdrawal. Interpersonal consequences include increased power differences between patients and adverse treatment consequences, such as difficulties with self-esteem. Victimization processes are not always timely noticed in an environment that focuses on risks and treatment of delinquent behavior. A higher level of trauma sensitivity in forensic mental health care is thus required. Recommendations for the implementation of trauma informed care are provided. 04 april 2022 22 p.

Item does not contain fulltext In high security forensic institutions, patients are sometimes placed on small-scale wards to be treated individually if their psychiatric condition and behaviour do not allow for them to live and interact more freely with other patients. On these so-called individual wards, there is little contact between patients and more security measures are in place, such as higher numbers of staff members per patient than on group wards. The present study investigated the experienced safety of staff members (n = 41) and patients (n = 21) of such individual wards, compared to staff members (n = 55) and patients (n = 55) of group wards with the Essen-CES. The mean item score on the scale experienced safety of the Essen-CES for the entire sample was 2.1 (SD = .9) with a range from 0 to 4 and higher scores reflecting a higher experienced safety. Staff on individual wards had a significantly lower experienced safety than patients on both ward types and staff on group wards. It is advised, therefore, to implement additional measures to support professionals who work on these individual wards. 7 p.

Contains fulltext : 217705.pdf (Publisher’s version ) (Open Access) Background: Attributions are cognitive variables that influence a person's behaviour. Although a large volume of research has been conducted on the attributions of support staff with regard to challenging behaviour (CB) exhibited by people with intellectual disabilities (ID), studies on patterns of attributional dimensions (i.e. attributional styles) are scarce. Method: Using semi-structured interviews, 19 support staff members were asked to describe incidents of aggressive, self-injurious and sexualized challenging behaviour. Data on attributions were analysed using the Leeds Attributional Coding System. Results: Four attributional styles differed significantly for aggressive, self-injurious and sexualized challenging behaviour. In addition, support staff members largely attributed these three types of CB to characteristics and behaviour of clients with ID. Conclusions: The results indicate that it is important to train support staff to recognize and understand the ways in which their attributions and behaviour influence the existence and maintenance of CB. 10 p.

Background:Little is known about the association between trauma and intellectual disability in SMI patients.Aim:To establish the prevalence of trauma and its association with intellectual functioning in SMI outpatients.Methods:A cross-sectional study was conducted in two mental health trusts in the Netherlands. We used the Trauma Screening Questionnaire (TSQ) to screen for trauma and PTSD, and the Screener for Intelligence and Learning disabilities (SCIL) for suspected MID/BIF. Chi-square andt-tests were used to test differences in outcome over patient characteristics. Post-hoc analysis was used to investigate gender differences between patients with and without MID/BIF on trauma and sexual trauma.Results:Any trauma was found in 86% of 570 patients and 42% were suspected for PTSD. The SCIL suggested that 40% had Borderline Intellectual Functioning (BIF), half of whom were suspected of having Mild Intellectual Disability (MID). These patients had more traumatic experiences (1.89 in BIF, 1.75 in MID, against 1.41 in SCIL-negative patients). Female MID/BIF patients (61%) had experienced significantly more sexual abuse than male MID/BIF patients (23%).Conclusions:Significantly more SMI outpatients who screened positive for MID/BIF reported having experienced traumatic events than those who screened negative. Rates of all trauma categories were significantly higher in the screen-positive group, who were also more likely to have PTSD. Sexual abuse occurred more in all females but the SCIL positive women are even more often victim. Clinical practice has to pay more attention to all of these issues, especially when they occur together in a single patient.

Individuals with mild intellectual disabilities (MID) or borderline intellectual functioning (BIF) and mental health problems or challenging behavior are difficult to reach by mainstream healthcare facilities and support organizations and frequently avoid the care they need. To improve the care for this client group in the Netherlands, the (Flexible) Assertive Community Treatment (ACT) model - originally developed for people with severe mental illness - was adapted and implemented by five organizations specialized in the care for people with MID/BIF and mental health problems or challenging behavior. After an introduction of the original ACT model and a description of the international state of the art of ACT for people with (M)ID/BIF, this paper describes the (Flexible) ACT‐MID/BIF model as developed and implemented in the Netherlands. Professionals' and clients' experiences with this new type of care are reported as well. Implications for clinical practice, policy and research are discussed.

Background The use of wearable biosensor devices for monitoring and coaching in forensic psychiatric settings yields high expectations for improved self-regulation of emotions and behavior in clients and staff members. More so, if clients have mild intellectual disabilities (IQ 50-85), they might benefit from these biosensors as they are easy to use in everyday life, which ensures that clients can practice with the devices in multiple stress and arousal-inducing situations. However, research on (continuous) use and acceptance of biosensors in forensic psychiatry for clients with mild intellectual disabilities and their caretakers is scarce. Although wearable biosensors show promise for health care, recent research showed that the acceptance and continuous use of wearable devices in consumers is not as was anticipated, probably due to low expectations. Objective The main goal of this study was to investigate the associations between and determinants of the expectation of usability, the actual experienced usability, and the intention for continuous use of biosensors. Methods A total of 77 participants (31 forensic clients with mild intellectual disabilities and 46 forensic staff members) participated in a 1-week trial. Preceding the study, we selected 4 devices thought to benefit the participants in domains of self-regulation, physical health, or sleep. Qualitative and quantitative questionnaires were used that explored the determinants of usability, acceptance, and continuous use of biosensors. Questionnaires consisted of the System Usability Scale, the Technology Acceptance Model questionnaire, and the extended expectation confirmation model questionnaire. Results Only the experienced usability of the devices was associated with intended continuous use. Forensic clients scored higher on acceptance and intention for continuous use than staff members. Moderate associations were found between usability with acceptance and continuous use. Staff members showed stronger associations between usability and acceptance (r=.80, P Conclusions Contrary to expectations, it was the actual perceived usability of wearing a biosensor that was associated with continuous use and to a much lesser extent the expectancy of usability. Clients scored higher on acceptance and intention for continuous use, but associations between usability and both acceptance and continuous use were markedly stronger in staff members. This study provides clear directions on how to further investigate these associations. For example, whether this is a true effect or due to a social desirability bias in the client group must be investigated. Clients with mild intellectual disabilities might benefit from the ease of use of these devices and their continuing monitoring and coaching apps. For these clients, it is especially important to develop easy-to-use biosensors with a minimum requirement on cognitive capacity to increase usability, acceptance, and continuous use.

BackgroundIt has been suggested that people with intellectual disabilities have a higher likelihood to develop psychiatric disorders, and that their treatment prognosis is relatively poor.AimsWe aimed to establish the prevalence of intellectual disability in different mental healthcare settings, and estimate percentage of cognitive decline. We hypothesised that the prevalence of intellectual disabilities increases with intensity of care.MethodA cross-sectional study was conducted in different settings in a mental healthcare trust in the Netherlands. We used the Screener for Intelligence and Learning Disabilities (SCIL) to identify suspected mild intellectual disability (MID) or borderline intellectual functioning (BIF). We identified patients with a high level of education and low SCIL score to estimate which patients may have had cognitive decline.ResultsWe included 1213 consecutive patients. Over all settings, 41.4% of participating patients were positive for MID/BIF and 20.2% were positive for MID only. Prevalence of suspected MID/BIF increased by setting, from 27.1% in out-patient settings to 41.9% in flexible assertive community treatment teams and admission wards, to 66.9% in long-stay wards. Only 85 (7.1%) of all patients were identified as possibly having cognitive decline. Of these, 25.9% were in long-stay wards and had a diagnosis of schizophrenia or substance use disorder.ConclusionsLow intellectual functioning is common in Dutch mental healthcare settings. Only a modest number of patients were identified as suffering from cognitive decline rather than suspected MID/BIF from birth. Therefore, we recommend improved screening of psychiatric patients for intellectual functioning at the start of treatment.

Contains fulltext : 233822.pdf (Publisher’s version ) (Closed access) Background: Trauma and intellectual disability are highly prevalent in the serious mental ill (SMI). Little is known of their impact on general functioning and quality of life. Aim: This study investigated the association of trauma and intellectual disability (ID) with general functioning and quality of life in SMI. Methods: Patient characteristics and diagnoses were extracted from electronic patient records. We used the Trauma Screening Questionnaire (TSQ), the Screener for Intelligence and Learning Disabilities (SCIL), the Health of the Nation Outcome Scale (HoNOS) and the Manchester Short Assessment of Quality of Life (MANSA) to asses trauma, intellectual impairment, general functioning and quality of life. Proportions on cut-off scores were analysed with cross-tabulations, questionnaire scores with t-tests. Multivariable associations were determined by logistic regression analysis. Results: 611 patients from an outpatient service were assessed. Trauma and ID were associated with each other (r = -0.207). Trauma was associated with worse general functioning and a lower quality of life. Mild intellectual disability (MID) or borderline intellectual functioning (BIF) were associated with worse general functioning. Conclusions: For patients with SMI, trauma and ID should be identified early in care to treat the lower general functioning and quality of life it caused. 9 p.

Background. While polypharmacy is common in long-term residential psychiatric patients, prescription combinations may, from an evidence-based perspective, be irrational. Potentially, many psychiatric patients are treated on the basis of a poor diagnosis. We therefore evaluated the DITSMI model (i.e., Diagnose, Indicate, and Treat Severe Mental Illness), an intervention that involves diagnosis (or re-diagnosis) and appropriate treatment for severely mentally ill long-term residential psychiatric patients. Our main objective was to determine whether DITSMI affected changes over time regarding diagnoses, pharmacological treatment, psychosocial functioning, and bed utilization. Methods. DITSMI was implemented in a consecutive patient sample of 94 long-term residential psychiatric patients during a longitudinal cohort study without a control group. The cohort was followed for three calendar years. Data were extracted from electronic medical charts. As well as diagnoses, medication use and current mental status, we assessed psychosocial functioning using the Health of the Nations Outcome Scale (HoNOS). Bed utilization was assessed according to length of stay (LOS). Change was analyzed by comparing proportions of these data and testing them with chi-square calculations. We compared the numbers of diagnoses and medication changes, the proportions of HoNOS scores below cut-off, and the proportions of LOS before and after provision of the protocol. Results. Implementation of the DITSMI model was followed by different diagnoses in 49% of patients, different medication in 67%, some improvement in psychosocial functioning, and a 40% decrease in bed utilization. Conclusions. Our results suggest that DITSMI can be recommended as an appropriate care for all long-term residential psychiatric patients.

Contains fulltext : 219929.pdf (Publisher’s version ) (Closed access) This study explores variables that predict physical violence in 614 (forensic) psychiatric inpatients. All violent incidents that occurred in a Dutch forensic psychiatric hospital between 2014 and 2019 (N = 3,713) were coded with the Modified Overt Aggression Scale+ based on daily hospital reports and patients' medical records. Binary logistic regression analyses examined which patient variables could differentiate between patients with and without physical violence during treatment and between patients with single and multiple incidents of physical violence. Variables included in the analyses were gender, legal status, borderline personality disorder, antisocial personality disorder, schizophrenia spectrum disorder, psychopathy (Psychopathy Checklist-Revised [PCL-R] score), self-harm during treatment, impulsivity, intellectual disability, and length of stay. A clear association was found between self-harm and inpatient physical violence on all outcome measures and in all analyses. Adequate monitoring of self-harm is advised as a strategy to early identify patients with a high risk to threaten ward safety. 19 p.

Contains fulltext : 216493.pdf (Publisher’s version ) (Open Access) 7 p.

Item does not contain fulltext The UPPS-P seems to be a promising instrument for measuring different domains of impulsivity in forensic psychiatric patients. Validation studies of the instrument however, have been conducted only in student groups. In this validation study, three groups completed the Dutch UPPS-P: healthy student (N = 94) and community (N = 134) samples and a forensic psychiatric sample (N = 73). The five-factor structure reported previously could only be substantiated in a confirmatory factor analysis over the combined groups but not in the subsamples. Subgroup sample sizes might be too small to allow such complex analyses. Internal consistency, as assessed by Cronbach’s alpha, was high on most subscale and sample combinations. In explaining aggression, especially the initial subscale negative urgency (NU) was related to elevated scores on self-reported aggression in the healthy samples (student and community). The current study is the second study that found a relationship between self-reported NU and aggression highlighting the importance of addressing this behavioural domain in aggression management therapy. 16 p.

Contains fulltext : 192696.pdf (Publisher’s version ) (Open Access) Introduction: People with intellectual disabilities and co-occurring psychopathology have a relatively high likelihood to engage in aggressive behavior. Nevertheless, structured clinical assessment of aggressive behavior, including when and where it occurs, is scarce in this population. Methods: On three wards specializing in the care for people with mild to borderline intellectual disability and co-occurring psychopathology, staff members completed the Staff Observation Aggression Scale-Revised adapted for people with intellectual disabilities (SOAS-R-ID) during a nine-month period, every time they witnessed aggressive behavior. Results: Based on 236 SOAS-R-ID forms, it was found that aggressive incidents were most common on Thursdays, and on two specific moments of the day (between 9-11 a.m. and 7-9 p.m.). The aggressive behavior was often exclusively of a verbal nature and was usually targeted against staff members (77.1% of the incidents). The Interclass (Pearson) Correlation Coefficient agreement between observers on the total score of the SOAS-R-ID was 0.72. Correlation between the judgment of the severity of aggressive behavior made by the staff members and the SOAS-R-ID severity scores was moderate (r = .40), but significant. Conclusions: Because aggressive behavior appeared to result often from interactions between the client and staff member or other clients, these interactions might be an important starting point for interventions. Structured clinical assessment of aggressive behavior can help to devise and test the effects of interventions. The SOAS-R-ID seems to be a clinically useful instrument and could therefore help to reduce the frequency of these incidents in the future. 19 p.

Item does not contain fulltext This study aims at detecting and categorizing early warning signs of aggressive behavior in child psychiatric units. We analyzed 575 violent incident report forms and developed a coding scheme consisting of 16 warning signs. From the 575 incident report forms, a total of 1087 signs were coded. Most common warning signs were 'restlessness' (21.2%), 'not listening' (15.2%) and 'anger' (9.8%). These were also the most prevalent warning signs for the severe incidents. Although warning signs differ for each individual child, this study indicates that there are common warning signs for imminent aggressive incidents in child psychiatric facilities. 5 p.

Contains fulltext : 167334.pdf (Publisher’s version ) (Open Access) Psychopathy is often described as a constellation of personality characteristics encompassing features such as impulsivity and antisociality, and a lack of empathy and guilt. Although the use of self-reports to assess psychopathy is still debated, there are distinct advantages to such measures and recent research suggests that they may not be as problematic as previously thought. This study further examined the reliability and validity of the Triarchic Psychopathy Measure (TriPM) in a community sample (N = 496) and forensic psychiatric patient sample (N = 217). Results indicated excellent internal consistencies. Additionally, the TriPM total and subscale scores related as expected to different subscales of the Psychopathic Personality Inventory –Revised (PPI-R) and to the Reactive and Proactive Aggression Questionnaire, reflecting good construct validity. Most importantly, ROC curve analyses showed that the TriPM evidenced better discrimination between the community sample and forensic psychiatric patients than the PPI-R. The current study extends the existent evidence demonstrating that the TriPM can be used as an efficient self-report instrument. 9 p.

BACKGROUND: Many clients in contact with social services and (mental) health care have mild to borderline intellectual disabilities (MBID). Yet, administering a full intelligence test may not be feasible.METHOD: In 318 adults and 305 juveniles, the scores on 14 questions that comprise the screener for intelligence and learning disabilities (SCIL) were analysed in relation to the IQs of the participants.RESULTS: The SCIL score had good predictive validity for detecting MBID in adults (AUC = 0.93). A cut-off score of 19 or lower is recommended to detect (a suspicion of) MBID. Test-retest reliability of the SCIL was 0.92. In juveniles, AUC values were 0.91 for 16- to 17-year-olds, 0.90 for 14- to 15-year-olds and 0.83 for 12- to 13-year-olds.CONCLUSIONS: The SCIL appears to be a time-efficient tool for screening for MBID in adults (18+) and juveniles of 14 years or older.

Item does not contain fulltext Background: The reliability and validity of the Screener for Intelligence and Learning Disabilities (SCIL) are unknown in a population of outpatients with severe mental illness. The prevalence of mild or borderline intellectual disabilities (MBID); an umbrella term for people with borderline intellectual functioning (BIF) and mild intellectual disability (MID) in this population is also unknown. Methods: A total of 625 patients were screened with the SCIL, 201 of which also had IQ test results. Results: Cronbach’s alpha of the SCIL was 0.73. The AUC value for detecting MBID was 0.81, and also 0.81 for detecting MID, with percentages of correctly classified subjects (when using the advised cut-off scores) being 73% and 79%, respectively. The SCIL results suggested that 40% of the patients were suspected of MBID and 20% of MID. Conclusion: The SCIL seems to be an appropriate screening tool for MBID. It is important to screen for MBID because a substantial proportion of outpatients with severe mental illness appear to be functioning at this level. It is necessary to adapt treatment for these patients. 7 p.

Contains fulltext : 205950.pdf (Publisher’s version ) (Open Access) Background: Assertive community treatment (ACT) and Flexible assertive community treatment (FACT) are organisation models for intensive assertive outreach that were originally developed for individuals with severe mental illness. The models are increasingly applied to people with mild intellectual disability (MID) or borderline intellectual functioning (BIF) and challenging behaviour or mental illness. Research on these types of care for this population is limited. To gain experience in FACT MID/BIF in the Netherlands and to obtain insight in its outcomes, four organisations specialised in the treatment of individuals with MID/BIF and challenging behaviour participated in a 6-year implementation and research project. Methods: A longitudinal study was set up to investigate outcomes over time. Outcome measures concerned admissions to (mental) health care, social and psychological functioning, (risk of) challenging and criminal behaviour, social participation and client satisfaction. Data were analysed using descriptive statistics and linear mixed models. Results: Over time, clients showed improvement in their social and psychiatric functioning and living circumstances. The number of admissions to (mental) health care diminished as well as the number of contacts with police and justice, the level of social disturbance and the risk factors for challenging and criminal behaviour. Problems related to finances, work and substance abuse remained unchanged. Conclusions: The results are encouraging and give rise to continued development of and broader research on FACT MID/BIF. 8 p.

Item does not contain fulltext Dynamic risk and protective factors serve to assess the violence risk level of (forensic) psychiatric patients and offer guidance to clinical interventions. Risk assessment scores on Historical Clinical Risk Management-20 (HCR-20) risk factors and Structured Assessment of Protective Factors for violence risk (SAPROF) protective factors at different treatment stages were compared with violent incidents during treatment for 399 multidisciplinary coded assessments on 185 male and female forensic psychiatric patients. At later stages of treatment, less risk factors and more protective factors were observed, and predictive validities were higher. The HCR-20 and SAPROF scores showed good overall predictive validity for inpatient violence. The combination of risk factors and protective factors was a good predictor of incidents of aggressive behavior for different groups of patients, such as patients with violent or sexual offending histories, patients with major mental illnesses or personality disorders, and patients with a high score on psychopathy. Implications of these findings and recommendations for future research are discussed. 22 p.

Contains fulltext : 200490.pdf (Publisher’s version ) (Open Access) Burnout in nursing staff is a major cause for turnover and absenteeism. Identifying risk and protective factors may be helpful in decreasing burnout symptoms. Moreover, research indicates that ambulatory assessments of the autonomic nervous system might be helpful in detecting long-term stress and burnout symptoms. One hundred and ten forensic nursing staff members completed questionnaires measuring experiences with aggressive behaviour, emotional intelligence, personality, and job stress during four waves of data collection across a 2-year period. Multilevel analyses were used to test the predicted associations and moderation effects with (the development of) burnout symptoms. Burnout was predicted by a combination of emotional intelligence, job stress, aggression, personality factors, and skin conductance, but no moderation effects over time were found. Over a period of 2 years, the model approximately predicts a change in one burnout category on the Maslach Burnout Inventory. The amount of burnout symptoms in nurses might be used as an indicator to predict turnover and absenteeism considering the increase in symptoms over time. Nursing staff who experience severe aggression and who have relatively low levels of emotional intelligence and altruism and high levels of neuroticism and job stress should be monitored and supported to decrease the risk of burnout. Staff members can be trained to increase their emotional intelligence and relieve stress to decrease their burnout symptoms and turnover and absenteeism on the long term. Ambulatory assessment might be helpful as a nonintrusive way to detect increasing levels of burnout. 12 p.

Contains fulltext : 194962.pdf (Publisher’s version ) (Open Access) Self-injurious behavior (SIB) is one of the most detrimental behaviors for the person showing it, as well as for their environment. Nevertheless, structured clinical assessments of SIB are scarce. Staff completed a Self-Harm Scale (SHS) every time they witnessed SIB in clients with an intellectual disability (ID) and co-occurring psychopathology (N= 33). Descriptive statistics were conducted to explore the nature of the incidents of SIB and the characteristics of the people involved in the incidents. In 41 weeks, 104 SIB incidents were reported for 8 out of 33 clients (24%). Incidents were most prevalent on Mondays (23%). As far as the methods of SIB concerned, cutting was the most used method (63%). Clients who showed SIB differed significantly from clients who did not on gender, having a personality disorder and communicative abilities. This study was one of the few that used an incident-based record form to report SIB by direct observation. It is hoped that the SHS helps to gain more information about SIB, to improve individualized interventions. Further research is necessary to determine the psychometric properties and clinical utility of the scale. 16 p.

Contains fulltext : 196481.pdf (Publisher’s version ) (Open Access) This systematic review examines the relationship between sympathetic and parasympathetic activity on the one hand and job stress and burnout on the other, and is registered at PROSPERO under CRD42016035918. Background: Previous research has shown that prolonged job stress may lead to burnout, and that differences in heart rate variability are apparent in people who have heightened job stress. Aims: In this systematic review, the associations between job stress or burnout and heart rate (variability) or skin conductance are studied. Besides, it was investigated which - if any - guidelines are available for ambulatory assessment and reporting of the results. Methods: We extracted data from relevant databases following the PRESS checklist and contacted authors for additional resources. Participants included the employed adult population comparing validated job stress and burnout questionnaires examining heart rate and electrodermal activity. Synthesis followed the PRISMA guidelines of reporting systematic reviews. Results: The results showed a positive association between job stress and heart rate, and a negative association between job stress and heart rate variability measures. No definite conclusion could be drawn with regard to burnout and psychophysiological measures. No studies on electrodermal activity could be included based on the inclusion criteria. Conclusions: High levels of job stress are associated with an increased heart rate, and decreased heart rate variability measures. Recommendations for ambulatory assessment and reporting (STROBE) are discussed in light of the findings. 24 p.

WHAT IS KNOWN ON THE SUBJECT?: Client aggression in forensic psychiatry is associated with burnout symptoms in nursing staff. It is unclear what mechanisms contribute to this relationship. The type and severity of aggression might be of importance in the association between client aggression and burnout symptoms, but also the personality characteristics and emotional intelligence of nursing staff. It is unknown whether wearable devices that measure arousal can be used to detect chronic stress and burnout symptoms. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: Especially, physical aggression as experienced by nursing staff is associated with staff's burnout symptoms (e.g., emotional exhaustion and depersonalization). Further research on the aggression questionnaire is necessary. The stress management skill of nursing staff is an important factor to consider in the association between burnout symptoms and client aggression. The wearable device was not useful for detecting burnout symptoms. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nursing staff who experience (physical) aggression should be carefully monitored and should receive social support from their management to aid their well-being. Contrary to intuition, nurses who reported a higher number of stress management skills might have to be monitored more closely if necessary. Abstract Introduction Aggressive behaviour of forensic clients is associated with burnout symptoms in nursing staff. The role of staff characteristics as moderators is unclear. Aim We explored the association between type and severity of aggressive behaviour as experienced by nursing staff and staff's burnout symptoms. In addition, the moderating roles of personality characteristics and emotional intelligence (EI) were studied. Moreover, the usefulness of ambulatory skin conductance assessments in detecting arousal related to burnout symptoms was studied. Method A total of 114 forensic nursing staff members filled out questionnaires and wore an ambulatory device. Results Experiencing physical aggression was positively associated with staff's burnout symptoms. Stress management skills, a subscale of EI, but not personality, moderated this relationship. Skin conductance was not associated with burnout symptoms. Remarkably, the association between aggression and burnout symptoms was highest for staff reporting a higher number of stress management skills. Discussion Longitudinal research is necessary to establish causality between client aggression and staff burnout symptoms. In addition, further research is necessary on the validity of the aggression measure used in the current study. Implication for practice Nursing staff who experience physical aggression frequently should receive social support for this, and staff who report high stress management skills should be monitored more carefully after having been confronted with aggression.

Contains fulltext : 155599.pdf (Publisher’s version ) (Closed access) The Externalizing Spectrum Inventory (ESI) was designed for assessing a broad spectrum of externalizing problems, including impulsive-aggressive behavior and substance abuse. After translation of the ESI into Dutch, a computerized version of the full Dutch ESI (ESI-NL) was administered to a mixed sample consisting of inpatients in forensic and addiction care (n=99) and non-psychiatric community participants (n=104). Internal consistencies, test-retest reliabilities, predictive' validity of the full and 160-item ESI-NL total scores and subscales were examined, along with the correlations between these two versions. The results indicated high reliability and predictive validity for both versions and a strong similarity between the two in direct comparisons. The 160-item Dutch ESI is recommended for clinical studies on violence proneness and externalizing problem behavior. 15 p.

BACKGROUND: Empirical knowledge of 'predictors' of physical inpatient aggression may provide staff with tools to prevent aggression or minimise its consequences. AIM: To test the value of a self-reported measure of impulsivity for predicting inpatient aggression. METHODS: Self-report measures of different domains of impulsivity were obtained using the Urgency, Premeditation, Perseverance, Sensation seeking, Positive urgency (UPPS-P) impulsive behaviour scale with all 74 forensic psychiatric inpatients in one low-security forensic hospital. Aggressive incidents were measured using the Social Dysfunction and Aggression Scale (SDAS). The relationship between UPPS-P subscales and the number of weeks in which violent behaviour was observed was investigated by Poisson regression. RESULTS: The impulsivity domain labelled 'negative urgency' (NU), in combination with having a personality disorder, predicted the number of weeks in which physical aggression was observed by psychiatric nurses. NU also predicted physical aggression within the first 12 weeks of admission. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The results indicate that NU, which represents a patient's inability to cope with rejection, disappointments or other undesired feelings, is associated with a higher likelihood of becoming violent while an inpatient. This specific coping deficit should perhaps be targeted more intensively in therapy. Self-reported NU may also serve as a useful adjunct to other risk assessment tools and as an indicator of change in violence risk. Copyright © 2015 John Wiley & Sons, Ltd. Language: en

Background: Earlier studies have suggested associations between diet-related blood parameters and both aggression and psychopathological symptoms, but little is known about this in forensic psychiatric inpatients. Aim: This article aims to explore the levels of diet-related blood parameters and their relationship to aggressive behaviour and/or psychopathology among Dutch forensic psychiatric inpatients. Methods: Minerals, vitamins, lead and fatty acid levels were measured in blood samples from 51 inpatients, well enough to consent and participate in the study, from a possible total of 99. Levels of aggression and psychopathology were assessed using questionnaires, observation instruments and clinical data. Associations between blood parameters and behavioural measures were calculated. Results: Low average levels of vitamin D3 and omega-3 fatty acids were found, with nearly two-thirds of the patients having below recommended levels of D3, while vitamin B6 levels were high. Magnesium, iron, zinc, copper and lead were overall within reference values, but copper/zinc ratios were high. Several significant associations between levels of fatty acid measures and both aggression and psychopathology were observed. Conclusion: In our sample of forensic psychiatric inpatients, fatty acids - but not mineral or vitamin levels - were associated with aggression and psychopathology. A potentially causal link between fatty acids and aggression could be tested in a randomised, placebo-controlled trial of fish oil supplements. General health of such patients might be improved by better vitamin D status (increased sun exposure and/or supplement use) and better omega-3 fatty acid status (oily fish or fish oil consumption), but discouraging unnecessary self-prescription of B vitamins where necessary.

Contains fulltext : 169048.pdf (Publisher’s version ) (Open Access) Background: Failure to detect psychiatric patients' intellectual disabilities may lead to inappropriate treatment and greater use of coercive measures. Aims: In this prospective dynamic cohort study we screened for intellectual disabilities in patients admitted to psychiatric wards, and investigated the use of coercive measures with these patients. Methods: We used the Screener for Intelligence and Learning disabilities (SCIL) to screen patients admitted to two acute psychiatric wards, and assessed patient characteristics and coercive measures during their stay and over the last 5 years. Results: Results on the SCIL suggested that 43.8% of the sample had Mild Intellectual Disability or Borderline Intellectual Functioning (MID/BIF). During their current stay and earlier stays in the previous 5 years, these patients had an increased risk of involuntary admission (OR 2.71; SD 1.28-5.70) and coercive measures (OR 3.95, SD 1.47-10.54). Conclusions: This study suggests that functioning on the level of MID/BIF is very prevalent in admitted psychiatric patients and requires specific attention from mental health care staff. 10 p.

Item does not contain fulltext Findings from an increasing number of studies suggest that incorporating systematic short-term risk assessments in treatment planning could lead to safer practice on psychiatric admissions wards. The aim of the present study was to investigate the associations between the scores of three structured observation tools – the Kennedy Axis V (K-Axis-V), the Brief Psychiatric Rating Scale (BPRS), and the Social Dysfunction and Aggression Scale (SDAS) - and seclusion. In total, 1840 weekly risk assessments with these observation scales were collected over 2342 admission weeks. These assessment scores related to 370 acutely-admitted psychiatric patients and were subjected to a multilevel analysis. It was found that several dynamic and static factors were related to seclusion. Dynamic factors included violent behaviour, current substance abuse, suspiciousness, and negativism. Static factors included ethnicity and having been diagnosed with a substance abuse disorder. The findings suggest that the incorporation of the Kennedy-Axis V, the BPRS, and the SDAS into standard practice might be helpful in identifying patients at high risk of seclusion, and could be supportive to treatment planning and clinical decision-making in the prevention of seclusion use in acute psychiatric settings. 14 p.

Background Aggression on haemodialysis units is a growing problem internationally that has received little research attention to date. Aggressive behaviour by patients or their relatives can compromise the safety and well-being of staff and other patients sharing a haemodialysis session. Objectives The objectives of the study were twofold: First, to identify the prevalance and nature of aggression on haemodialysis units; and second, to investigate factors that contribute to aggressive behaviour on haemodialysis units. Design and Methods A cross-sectional, sequential mixed method research design was adopted, with two research methods utilised. Incidents of aggressive behaviour were recorded over a 12-month period, using a renal version of the Staff Observation Aggression Scale. Six months after the incident data collection had commenced, semi-structured qualitative interviews were conducted with 29 multidisciplinary members of staff. Results Over 12 months, 74 aggressive incidents were recorded. The majority of incidents involved verbal aggression, and the perpetrators were a minority of patients, relatives and staff. Two patients were responsible for 38% of all incidents; both patients had mental health problems. Distinct temporal patterns to the aggressive behaviour were observed according to the day of the week and time of day. Conclusion This study demonstrates that aggression is a significant problem on haemodialysis units, with verbal aggression most prevalent. The temporal patterns to aggression observed are related to the uniqueness of the haemodialysis setting, with a distinctly different treatment environment compared with other healthcare settings.

Background A neurobiological perspective has become accepted as a valuable approach for understanding anti-social behaviour. There is literature to suggest that, in non-offending populations, psychological treatments affect both neurobiological measures and clinical presentation. A theoretical position to this effect has been adopted with respect to offender treatment, but there has been no systematic review of empirical literature on this point. Aims This study aimed to ascertain from published literature firstly whether there is evidence of change in neuropsychological or physiological measures after behavioural treatments/programmes for people with anti-social behaviour and secondly whether these neurobiological changes are associated with behavioural change. Method A systematic search strategy was formulated to include studies considering neurobiological factors', anti-social population', treatment' and treatment outcome'. The Maryland Scientific Methods Scale was used to select relevant studies of sufficient methodological quality. Results Eleven studies were found, only one with adults. Overall, the values of specific neurobiological risk factors, particularly of basal cortisol, become less abnormal following intervention. There was some evidence for a link between change in neurobiological functioning and behavioural improvement. Conclusions Findings, although provisional, may provide new insights into the underlying mechanisms of interventions for anti-social behaviour. Future studies that include pre-treatment neurobiological assessment could help reveal physical vulnerabilities that interventions should target to improve treatment efficacy, and provide for objective, independent corroboration of change.

ACCESSIBLE SUMMARY: In the previous paper we described a model explaining differences in rates of conflict and containment between wards, grouping causal factors into six domains: the staff team, the physical environment, outside hospital, the patient community, patient characteristics and the regulatory framework. This paper reviews and evaluates the evidence for the model from previously published research. The model is supported, but the evidence is not very strong. More research using more rigorous methods is required in order to confirm or improve this model. ABSTRACT: In a previous paper, we described a proposed model explaining differences in rates of conflict (aggression, absconding, self-harm, etc.) and containment (seclusion, special observation, manual restraint, etc.). The Safewards Model identified six originating domains as sources of conflict and containment: the patient community, patient characteristics, the regulatory framework, the staff team, the physical environment, and outside hospital. In this paper, we assemble the evidence underpinning the inclusion of these six domains, drawing upon a wide ranging review of the literature across all conflict and containment items; our own programme of research; and reasoned thinking. There is good evidence that the six domains are important in conflict and containment generation. Specific claims about single items within those domains are more difficult to support with convincing evidence, although the weight of evidence does vary between items and between different types of conflict behaviour or containment method. The Safewards Model is supported by the evidence, but that evidence is not particularly strong. There is a dearth of rigorous outcome studies and trials in this area, and an excess of descriptive studies. The model allows the generation of a number of different interventions in order to reduce rates of conflict and containment, and properly conducted trials are now needed to test its validity.

Research findings indicate that the symptoms and behaviour of acute psychiatric patients can fluctuate drastically within hours, and that structured daily risk assessments can reduce the risk of aggressive incidents and the duration of seclusion. The aim of this study was to investigate the validity of two structured observation tools, the Broset Violence Checklist (BVC) and the Kennedy Axis V), as an aid in seclusion-related clinical decision-making. In this study, 7403 day-to-day risk assessments were collected over 10 725 admission days (72% of the maximum number of structured assessments). A total of 7055 daily assessment scores from 301 acute psychiatric patients were used for the multilevel analysis. The sample demonstrated that dynamic and static factors were related to seclusion. Dynamic factors included dysfunctional scores on the item 'confusion' of the Broset Violence Checklist, and psychological impairment and impairment of social skills on the Kennedy Axis V. Static factors included non-Western descent, male sex, age less than 35 years, unmarried, and to some extent, a personality disorder. McFadden's pseudo R(2) value showed that most of the final model was related to the dynamic factors. We concluded that the incorporation of the BVC and the Kennedy Axis V into standard practice was helpful in identifying patients at high risk of seclusion.

Item does not contain fulltext This review focuses on the predictive value of neurobiological factors in relation to cognitive-behavioral therapy outcome among individuals with antisocial behavior. Ten relevant studies were found. Although the literature on this topic is scarce and diverse, it appears that specific neurobiological characteristics, such as physiological arousal levels, can predict treatment outcome. The predictive value of neurobiological factors is important as it could give more insight into the causes of variability in treatment outcome among individuals with antisocial behavior. Furthermore, results can contribute to improvement in current treatment selection procedures and to the development of alternative treatment options. 18 p.

Item does not contain fulltext Psychotropic drugs are a cornerstone in the treatment of psychopathology and/or behavioral problems in children with intellectual disability (ID), despite concerns about efficacy and safety. Studies on the prevalence of psychotropic drug use have mainly been focused on adults with ID or children without ID. Therefore the aim of this cross sectional study was to assess the prevalence and characteristics of psychotropic drug use in children with mild ID who were institutionalized in specialized inpatient treatment facilities in The Netherlands. Demographic data, psychiatric diagnoses, the nature of the behavioral problems, level of intellectual functioning, and medication data were extracted from medical records using a standardized data collection form. Adjusted relative risks (ARR) for the association between patient characteristics and psychotropic drug use were estimated with Cox regression analysis. Of the 472 included children, 29.4% (n=139) used any psychotropic drug, of which 15.3% (n=72) used antipsychotics (mainly risperidone), and 14.8% (n=70) used psychostimulants (mainly methylphenidate). Age, sex, and behavioral problems were associated with psychotropic drug use. Boys had a 1.7 (95%CI 1.1-2.4) higher probability of using psychotropic drugs, compared to girls adjusted for age and behavioral problems. Having any behavioral problem was associated with psychotropic drug use with an ARR of 2.1 (95%CI 1.3-3.3), adjusted for sex and age. The high prevalence of psychotropic drug use in children with ID is worrisome because of the lack of evidence of effectiveness (especially for behavioral problems) at this young age, and the potential of adverse drug reactions.

Contains fulltext : 102987.pdf (Publisher’s version ) (Closed access) Objectives Accurate observation of aggressive behavior among forensic psychiatric patients requires valid instruments. This study examines the validity and clinical utility of combining the social dysfunction and aggression scale (SDAS) and staff observation aggression scale revised (SOAS-R). Methods Nurses weekly obtained SDAS scores of 127 patients, resulting in 6.124 assessments. Aggressive incidents were documented by the SOAS-R. Internal consistency, subscale structure, interobserver reliability of the SDAS, and convergent validity with SOAS-R were analyzed. Conclusion A three-factor solution was found. Interobserver reliability was moderate, and good convergent validity was found. The SDAS, in conjunction with the SOAS-R, monitors changes in aggressiveness and may contribute to the prevention of aggressive behavior. 8 p.

Item does not contain fulltext This study investigates changes in neurobiological characteristics after a cognitive skills program for prisoners. It was hypothesized that prisoners who completed a cognitive skills training program would show improved neurocognitive functioning and changes in heart rate (HR) activity. In addition, it was expected that neurobiological changes were related to behavioral improvement. Male adult prisoners were included in the study and divided into two groups: the intervention groupprisoners participating in a cognitive skills training programand the control groupprisoners placed on a waitlist. Several neurocognitive skills and HR activity measures were assessed at pre- and posttest assessment. In addition, trainers, prison officers, and prisoners were requested to evaluate behavioral changes over time. Results did not confirm the hypotheses. The absence of both neurobiological and behavioral improvement is discussed in light of the measures used, the content and duration of the current intervention program, and the prison setting. 26 p.

SummaryA case history of a thirty-one year old schizophrenic female who was treated with olanzapine is described. Olanzapine is a relatively new atypical antipsychotic drug with a dopamine antagonistic as well as a potent serotonine antagonistic effect. Olanzapine was prescribed effectively after haloperidol, flupentixol chloride, and clozapine had not lead to (lasting) improvements of the psychiatric condition of the patient. Considering the efficacy and the limited risks of this relatively new antipsychotic medication the question arises as to whether olanzapine should be considered as the drug of first choice for patients who do not benefit from treatment with a typical neuroleptic drug.

To the Editor:Several studies have been performed on the effects of hormonal and surgical sex-reassignment therapy on the well-being of gender dysphoric patients. In this journal for instance, Gorin-Lazard et al. (2013) reported on differences in depression and self-esteem of gender dysphoric patien

Item does not contain fulltext Objective: In 2006, a goal of reducing seclusion in Dutch hospitals by at least 10% each year was set. More than 100 reduction projects in 55 hospitals have been conducted, with €35 million in funding. This study evaluated the results. Methods: Data (2008 to 2013) were from a national register. Multilevel logistic regression examined determinants of seclusion. Results: Hospital participation in the register ranged from eight in 2008 to 66 in 2013, and admissions ranged from 11,300 to 113,290. The average yearly nationwide reduction of secluded patients was about 9%. Reduction was achieved in half of the hospitals. Some hospitals saw increased rates. In some hospitals where seclusion decreased, use of forced medication increased. Higher seclusion rates were associated with psychotic and bipolar disorders, male gender, and several ward types. Conclusions: Seclusion decreased significantly, and forced medication increased. Rates varied widely between hospitals. For many hospitals, more efforts to reduce seclusion are needed. 7 p.

According to Dutch Law, patients committing severe crimes justifying imprisonment of four years or more who cannot be held (fully) accountable for these acts can be sentenced to compulsory hospitalization in a specialized TBS hospital in the Netherlands. In the current paper, the effects of TBS treatment will be addressed in terms of recidivism numbers after termination of TBS treatment, as well as in behavioral changes that are observed during admission to TBS hospitals. Although these results offer some indirect support suggesting that TBS is effective, no randomized controlled trials had been conducted up until now that could confirm this. In the current study, preliminary results are reported from a multicenter randomized clinical trial on the effectiveness of Schema Therapy (ST) for hospitalized TBS patients with Antisocial, Borderline, Narcissistic, or Paranoid Personality Disorders, including those with high levels of psychopathy. Patients at seven TBS clinics were randomly assigned to receive three years of either ST or Treatment As Usual (TAU), and are being assessed on several outcome variables, such as recidivism risk (HCR-20, START), personality disorder symptoms (SIDP-IV, SNAP), and successful re-integration into the community. A three-year follow-up study will examine actual recidivism. One hundred and two patients are participating in the study. The preliminary findings from the first 30 patients to complete the three-year study suggest that ST is yielding better outcomes than TAU with regard to reducing recidivism risk and promoting re-entry into the community. These findings are not yet statistically significant, and thus need to be interpreted with caution until confirmed in our complete sample and follow up. However, they suggest that ST may be a promising treatment for offenders with personality disorders, including some psychopathic ones.

Background: A well-known technique to assess (psychological) arousal is to measure the skin conductance level (SCL). Although widely used in experimental psychological research, this technique has not been used often in (locked) psychiatric admission settings on patients who are at a high risk of engaging in aggressive behaviour. One of the obvious reasons for this is that measuring skin conductance, until recently, required a substantial amount of equipment.Methods: As technology developed, it became possible to develop small wearable devices in the form of regular watches to measure the SCL as well as other psycho-physiological parameters. To illustrate the potential this may have for the prevention of aggressive behaviour, a case description is provided of a patient in crisis who became physically aggressive while wearing a skin conductance measurement device.Results: Interestingly, the SCL of the patient had been rising sharply before the first signs of aggressive behaviour were visible.Conclusion: Although it concerns an anecdotal case study, this finding suggests that measuring SCL on a continuous basis in patients who are at a high risk of becoming violent, without this procedure having to interfere with their daily life, may open new avenues for preventing aggression at an earlier stage. A large-scale empirical study in a substantial number of (potentially aggressive) patients is needed, however, to investigate the predictive validity of mobile skin conductance assessments on imminent inpatient aggression in a reliable way.

The aim of this study is to investigate factors associated with overall judgements of aggression severity as provided by ward nurses, using the Japanese-language version of the Staff Observation Aggression Scale - Revised (SOAS-R). Nurses who observed 326 aggressive incidents involving psychiatric inpatients at five mental health facilities in Japan provided their assessments of the incident severity both on the established rating scale, the SOAS-R, and on a visual analogue scale (VAS), a one-item scale to indicate overall aggression severity. To evaluate the factors influencing the VAS severity scores, a multiple regression analysis was performed, in which consumer, nurse and ward characteristics were added consecutively, along with SOAS-R severity scores as independent variables. SOAS-R scores explained 17.6% of the VAS severity scores. Independently from the SOAS-R scores, the gender and age of the aggressive consumers (adjusted R(2) = 10.0%), as well as the gender of the nurses who reported the aggression (adjusted R(2) = 4.1%), each explained VAS severity score to a significant degree. Apart from the SOAS-R scores, consumer and nurse characteristics appeared to influence the overall judgements of severity of aggressive incidents, which may be connected to decisions about the use of coercive measures, such as seclusion/restraint or forced medication.

Purpose: In many European countries, initiatives have emerged to reduce the use of seclusion and restraint in psychiatric institutions. To study the effects of these initiatives at a national and international level, consensus on definitions of coercive measures, assessment methods and calculation procedures of these coercive measures are required. The aim of this article is to identify problems in defining and recording coercive measures. The study contributes to the development of consistent comparable measurements definitions and provides recommendations for meaningful data-analyses illustrating the relevance of the proposed framework. Methods: Relevant literature was reviewed to identify various definitions and calculation modalities used to measure coercive measures in psychiatric inpatient care. Figures on the coercive measures and epidemiological ratios were calculated in a standardized way. To illustrate how research in clinical practice on coercive measures can be conducted, data from a large multicenter study on seclusion patterns in the Netherlands were used. Results: Twelve Dutch mental health institutes serving a population of 6.57 million inhabitants provided their comprehensive coercion measure data sets. In total 37 hospitals and 227 wards containing 6812 beds were included in the study. Overall seclusion and restraint data in a sample of 31,594 admissions in 20,934 patients were analyzed. Considerable variation in ward and patient characteristics was identified in this study. The chance to be exposed to seclusion per capita inhabitants of the institute's catchment areas varied between 0.31 and 1.6 per 100.000. Between mental health institutions, the duration in seclusion hours per 1000 inpatient hours varied from less than 1 up to 18 h. The number of seclusion incidents per 1000 admissions varied between 79 up to 745. The mean duration of seclusion incidents of nearly 184 h may be seen as high in an international perspective. Conclusion: Coercive measures can be reliably assessed in a standardized and comparable way under the condition of using clear joint definitions. Methodological consensus between researchers and mental health professionals on these definitions is necessary to allow comparisons of seclusion and restraint rates. The study contributes to the development of international standards on gathering coercion related data and the consistent calculation of relevant outcome parameters. (C) 2011 Elsevier Ltd. All rights reserved.