The Long-Term Changes in Dynamic Risk and Protective Factors Over Time in a Nationwide Sample of Dutch Forensic Psychiatric Patients

The long-term changes of dynamic risk and protective factors have rarely been studied in forensic psychiatric patients. We utilized a latent growth curve analysis to investigate trajectories of risk and protective factors over time in all 722 male forensic psychiatric patients who were unconditionally released between 2004 and 2014 from any of 12 Dutch forensic psychiatric centers (FPCs). The study covered the period from juridical observation until unconditional release. Moreover, we investigated whether these trajectories differ between patients depending on their psychiatric diagnosis namely substance use disorders (SUD), psychotic disorders, and cluster B personality disorders (PDs). In addition, we also investigated whether SUD may influence changes in risk and protective factors in a group of psychotic and cluster B PDs patients, respectively. Overall, findings suggest that all changes in dynamic risk and protective factors could be depicted by two phases of patients' stay in the FPCs. Specifically, most changes on dynamic risk and protective factors occurred at the beginning of treatment, that is, from the time of juridical assessment up to the time of unguided leave. Moreover, the moment of unguided leave could be considered the ‘turning point’ in the treatment of offenders. We also found that SUD and psychotic patients changed the most in the first phase of their stay, while cluster B PDs patients changed the most in the second phase. However, SUD did not modify changes in risk and protective factors in psychotic and cluster B PDs patients. These findings may help improve offender treatment and crime prevention strategies.

The influence of therapy alliance and treatment motivation in patients with Cluster B personality disorders on incidents in forensic hospitals

Purpose Nonspecific factors such as therapy alliance and treatment motivation have been shown to be predictive of therapy outcome. However, research investigating these factors among patients with personality disorders, or studies in the context of mandated treatment showed mixed results. A new theory furthermore speculates there may be differences between early formed therapeutic alliance (trait-like) versus alliance formed on the longer term (state-like). This paper aims to investigate the effects of therapy alliance and treatment motivation in 103 Dutch male forensic psychiatric patients with Cluster B personality disorders. Design/methodology/approach The authors used incidents as a measure of treatment outcome. They studied the effect of nonspecific factors on incidents in two phases, namely, 0 – 18 months and 18 – 36 months, along with known predictors of incidents (age, Historical items of the HCR-20 and psychopathy) as covariates. Findings Regression models predicting incidents in the first 18 months of treatment were nonsignificant. Incidents in the second 18 months were significantly predicted by models including alliance and motivation measured at the start of treatment, but not measures at 18 months and covariates. Predictors, except for age, were all nonsignificant. Practical implications These findings lend tentative support for the trait-like vs state-like theory of change through nonspecific factors. However, it may also be that other factors are more important in predicting therapy outcome in forensic psychiatric patients with Cluster B personality disorders. Originality/value The current study represents the first effort to study the effects of non-specific factors on therapeutic discourse in hospitalized offenders with Cluster B personality disorders.

Emotion Regulation and Self-Harm Among Forensic Psychiatric Patients

Emotion regulation has been specifically linked to both non-suicidal self-injury (NSSI) and attempted suicide. It is also known that self-harm is disproportionally higher (30–68.4%) in forensic samples than in the general population, yet knowledge about the association between emotion regulation and self-harm in forensic settings is scarce. The purpose of this study was to describe emotion regulation in a sample of forensic psychiatric patients, to explore dimensions and levels of emotion regulation between forensic psychiatric patients with and without self-harm, and to explore associations between forensic psychiatric patients’ self-reported emotion regulation and self-reported functions of NSSI. A cohort of forensic psychiatric inpatients (N=98) was consecutively recruited during 2016–2020 from a high-security forensic psychiatric clinic in Sweden. Data were collected through the self-report measures Difficulties in Emotion Regulation Scale (DERS) and Inventory of Statements About Self-injury (ISAS). In relation to the first aim, median total and subscales scores for DERS were reported. Results showed a statistically significant difference in emotion regulation between participants with and without self-harm (p=0.004), with a medium effect size (Cohen’s d=0.65) for the DERS total scale. The DERS subscales returned large differences for Impulse (p=0.001, d=0.86), Goals (p=0.014, d=0.58), and Strategies (p=0.012, d=0.54) between participants with and without self-harm. Finally, DERS scores were correlated with both the interpersonal (rs=0.531, p<0.001, n=43) and intrapersonal factors (rs=0.503, p<0.001, n=43) of NSSI as reported on the ISAS. Participants with self-harm (NSSI and/or suicide attempts) demonstrated significantly more difficulties with emotion regulation than those without self-harm. Emotion dysregulation was associated with both interpersonal and intrapersonal functions of NSSI in the participants. We suggest further studies on forensic psychiatric patients’ maladaptive behaviors that focus on substance abuse, self-harm, and aggressive behaviors in relation to the regulation and expression of emotion.

“Trapped in their Shame”: A Qualitative Investigation of Moral Injury in Forensic Psychiatry Patients

Individuals who engage in criminal behavior for which they are found not criminally responsible (NCR) may be at increased vulnerability to experience moral pain and, in extreme circumstances, moral injury after regaining insight into the consequences of their behavior. Yet, almost no research exists characterizing the nature, severity, or impact of moral pain in this population. Semi-structured interviews were conducted with nine forensic psychiatric patients and 21 of their care providers. Narratives were explored using thematic analysis. Findings demonstrate that NCR patients endorse symptoms consistent with moral injury, including feelings of guilt toward victims, shame for one’s behavior, and a loss of trust in one’s morality. Moral pain is a strong driver of behavior and must be understood as part of a constellation of factors influencing criminality, risk, and recovery. Future research must develop adequate tools to measure and characterize offense-related moral injury to understand its impact on this population.

Gender-Specific Differences in Depressive Behavior Among Forensic Psychiatric Patients

BackgroundWomen are almost twice as likely to develop depression than men, but men commit suicide more often. One explanation for this paradox is that current depression inventories do not fully capture typical male symptoms of depression. Several studies showed that most depression symptoms in men are masked by externalizing behaviors, such as aggressiveness, addiction, and risky behavior. Here, we explored the differences in depression symptoms between men and women in a forensic psychiatric sample.MethodsWe screened 182 forensic psychiatric patients and selected a matched sample (21 women and 21 men). External symptoms of depression were assessed with the Gender-Sensitive Depression Screening (GSDS) and internal symptoms with the Beck Depression Inventory Revision.ResultsAlthough externalizing behaviors were similar in both groups, we found a significant relationship between external and internal depression symptoms only in men. In addition, male forensic patients with a history of suicide had higher scores in the GSDS, whereas female patients with a history of suicide had higher scores in the Beck Depression Inventory Revision.DiscussionThe finding that the GSDS detected depression symptoms in men indicates that this instrument might be useful for developing assessments to prevent suicide in forensic practice.

Clinical Characteristics and Self-Harm in Forensic Psychiatric Patients

Self-harm, comprising non-suicidal self-injury, and suicide attempts, is a serious and potentially life-threatening behavior that has been associated with poor life quality and an increased risk of suicide. In forensic populations, increased rates of self-harm have been reported, and suicide is one of the leading causes of death. Aside from associations between self-harm and mental disorders, knowledge on self-harm in forensic psychiatric populations is limited. The purpose of this study was to characterize the clinical needs of a cohort of forensic psychiatric patients, including self-harm and possible risk factors thereof. Participants (N = 98) were consecutively recruited from a cohort of forensic psychiatric patients in Sweden from 2016 to 2020. Data were collected through file information, self-reports, and complemented with semi-structured interviews. Results showed that self-harm was common among the participants, more than half (68.4%) of whom had at some point engaged in self-harm. The most common methods of non-suicidal self-injury were banging one's head or fist against a wall or other solid surface and cutting, and the most common method of suicide attempt was hanging. The most prominent functions of non-suicidal self-injury among the participants were intrapersonal functions such as affect regulation, self-punishment, and marking distress. Self-harm in general was associated to neurodevelopmental disorders (p = 0.014, CI = 1.23–8.02, OR = 3.14) and disruptive impulse-control and conduct disorders (p = 0.012, CI = 1.19–74.6, OR = 9.41), with reservation to very wide confidence intervals. Conclusions drawn from this study are that self-harm was highly prevalent in this sample and seems to have similar function in this group of individuals as in other studied clinical and non-clinical groups.

Childhood Trauma, the Combination of MAO-A and COMT Genetic Polymorphisms and the Joy of Being Aggressive in Forensic Psychiatric Patients

Aggression and violent offenses are common amongst forensic psychiatric patients. Notably, research distinguishes two motivationally distinct dimension of aggression–instrumental and reactive aggression. Instrumental aggression comprises of appetitive, goal-directed aggressive acts, whereas reactive aggression consists of affective, defensive violence with both their biological basis remaining largely unknown. Childhood trauma and functional genetic polymorphisms in catecholamines converting enzymes, such as mono-amino-oxidase A (MAO-A) and catechol-o-methyltransferase (COMT) have been suggested to augment an aggressive behavioral response in adulthood. However, it warrants clarification if these factors influence one or both types of aggression. Furthermore, it remains elusive, if having a combination of unfavorable enzyme genotypes and childhood maltreatment further increases violent behavior. Hence, we set out to address these questions in the current study. First, analysis revealed an overall marginally increased frequency of the unfavorable MAO-A genotype in the test population. Second, each gene polymorphisms together with a traumatic childhood significantly increased the AFAS (Appetitive and Facilitative Aggression Scale) scores for both reactive and appetitive aggression. Third, having a combination of both disadvantageous genotypes and a negative childhood served as a minor positive predictor for increased reactive aggression, but had a strong influence on the joy of being aggressive.

A Latent Class Analysis of Forensic Psychiatric Patients in Relation to Risk and Protective Factors

Forensic psychiatric patients form a very heterogeneous population regarding psychopathology, criminal history, and risk factors for reoffending. Therefore, the present study aimed to investigate whether there are more homogeneous classes of forensic patients based on DSM-IV-TR Axis I and II diagnoses and previously committed offenses, by means of explorative latent class analysis (LCA). It was also investigated which risk and protective factors are significantly more prevalent in one class compared to other classes. The study sample contained 722 male forensic psychiatric patients who were unconditionally released between 2004 and 2014 from high-security forensic clinics. Data were retrospectively derived from electronic patient files. Five distinctive patient classes emerged: class with only Axis II diagnosis, class with multiple problems, antisocial class, psychotic class, and intellectually disabled class. These classes differed significantly in risk and protective factors. This study contributes to the understanding of patient classes and provides directions for future, class-tailored interventions.