The role of cognition in understanding the sleep- aggression relationship in a forensic psychiatric sample

This PhD program of work focused on the role of cognition in the sleep-aggression relationship relating to both aggression towards others and towards the self (i.e. self-injury). The research aimed to develop a preliminary model to explain the potential contribution of cognition in this complex relationship. Research methodology included a systematic literature review, qualitative interviews, a cross-sectional study and an intervention study comparing Mindfulness, Sleep Hygiene Education, and Treatment as Usual (control). The empirical studies were conducted with high secure psychiatric patients. Findings indicate that cognition is multifaceted in the relationship between sleep and aggression. Interventions to improve sleep should be tailored to individual needs and consider the cognitive factors contributing to both sleep and aggression. The preliminary model outlined acknowledges the contribution of a range of cognitions

Evaluation of a cognitive skills programme for male prisoners – exploring treatment effectiveness

Aim: The current study provides an evaluation of a cognitive skills programme (Enhanced Thinking Skills) with adult prisoners. Method: A pre and post treatment-only design with 171 male prisoners, using self-report psychometric measures. Results: Significant differences were found in the direction expected. Clinical recovery using stringent methods was not indicated, although improvement/partial response was across a number of domains. Originality: This study represents the first prison study to distinguish between levels of positive change. It questions previous interpretations of treatment outcome. Implications for practice: Expectations for treatment outcome for short term interventions should be more realistic; Cognitive skills programmes may be best considered as precursors to longer term therapies; Treatment outcome should focus on improvement and not recovery

Understanding the sleep-aggression relationship in a forensic mental health sample

The contribution of cognition to the sleep-aggression relationship is explored via three connected studies, involving adult male forensic patients detained in a high secure hospital. Study 1 included 31 patients, interviewed to examine their experiences of specific sleep problems. In Study 2, 42 patients completed a series of measures examining sleep dysfunction, aggression, and cognition, while Study 3 was designed to impact on sleep via a cognitive approach. In the latter, 48 patients were randomly assigned as part of a feasibility trial to one of three conditions: mindfulness (cognitive approach), sleep education, and treatment as usual. Collectively, the studies demonstrated the multifaceted nature of cognition in the sleep-aggression relationship, with a need to account fully for cognitive factors. A preliminary conceptual model is outlined - the Cognitive Sleep Model for Aggression and Self Harm (CoSMASH), as a direction for future research to consider

Victim empathy-based content in aggression treatment: Exploring impact within a secure forensic hospital

This study explores the impact of inclusion of victim empathy-based content in offender treatment. It presents first a systematic review of 20 papers, before proceeding to consider a qualitative interviews with therapists (n= 7), and forensic patients (n= 5), who had completed a long-term violence therapy (Life Minus Violence – Enhanced, LMV-E©). The research explored perceptions of forensic patients and treatment facilitators when completing victim empathy work, and explored any negative effects this may have. Findings from the systematic review indicated five themes: (1) Interventions incorporating victim empathy can be effective; (2) There are positive risk-understanding consequences from completing victim empathy work; (3) Offenders perceive victim empathy positively; (4) The emotional impact of victim empathy work on offenders’ is poorly explored and, (5) Completing victim empathy in treatment groups receives mixed evaluations from offenders. The systematic review was used to inform the interview themes for the resulting qualitative study with facilitators and forensic patients. This study indicated six themes: (1) Victim empathy content facilitates change; (2) Victim empathy content can be difficult for patients; (3) Victim empathy content can lead to an emotional response; (4) Victim empathy content can be beneficial, with the process important; (5) Victim empathy content can help understand risk, and (6) Patients’ experience of treatment begins before attending sessions. The results are discussed with attention to similarity in perceptions and experiences between staff and patients, with suggestions made for clinical implications and future research

Impacting on factors promoting intra-group aggression in secure psychiatric settings

Three preliminary and linked studies investigate the impact of making alterations to factors considered relevant to engaging in and experiencing intra-group aggression (bullying) among adult male patients detained in a single secure forensic hospital. Study one (n = 44) outlines the institutional factors, attitudes towards bullying and environmental factors that increase the likelihood of engaging in bullying and or being victimised. Study two (n = 56 patients and 113 staff) assesses the effect of three variations of intervention that aimed to reduce intra-group aggression through direct alteration of the physical and psychosocial environment, using data from both patients and staff. Study three (n = 414) looks at the effects of two variations of the intervention used in study two, which offered patients’ participation in individual and communal activities. It was predicted that changes to the physical and social environment would produce a reduction in the factors shown to predict intra-group aggression. Attitudes supportive of bullying and the presence of social hierarchies each increased the likelihood of engaging in bullying. Indirect changes to the social environment on the wards had more positive effects than those incorporating direct alterations to the physical and social environment. The differences in effectiveness of the two approaches are discussed in relation to the established predictors of intra-group aggression. The research concludes by noting the preliminary nature of the research and outlining potential directions for future research and interventions

Effect of remote ischaemic conditioning on clinical outcomes in patients with acute myocardial infarction (CONDI-2/ERIC-PPCI): a single-blind randomised controlled trial.

BACKGROUND: Remote ischaemic conditioning with transient ischaemia and reperfusion applied to the arm has been shown to reduce myocardial infarct size in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). We investigated whether remote ischaemic conditioning could reduce the incidence of cardiac death and hospitalisation for heart failure at 12 months. METHODS: We did an international investigator-initiated, prospective, single-blind, randomised controlled trial (CONDI-2/ERIC-PPCI) at 33 centres across the UK, Denmark, Spain, and Serbia. Patients (age >18 years) with suspected STEMI and who were eligible for PPCI were randomly allocated (1:1, stratified by centre with a permuted block method) to receive standard treatment (including a sham simulated remote ischaemic conditioning intervention at UK sites only) or remote ischaemic conditioning treatment (intermittent ischaemia and reperfusion applied to the arm through four cycles of 5-min inflation and 5-min deflation of an automated cuff device) before PPCI. Investigators responsible for data collection and outcome assessment were masked to treatment allocation. The primary combined endpoint was cardiac death or hospitalisation for heart failure at 12 months in the intention-to-treat population. This trial is registered with ClinicalTrials.gov (NCT02342522) and is completed. FINDINGS: Between Nov 6, 2013, and March 31, 2018, 5401 patients were randomly allocated to either the control group (n=2701) or the remote ischaemic conditioning group (n=2700). After exclusion of patients upon hospital arrival or loss to follow-up, 2569 patients in the control group and 2546 in the intervention group were included in the intention-to-treat analysis. At 12 months post-PPCI, the Kaplan-Meier-estimated frequencies of cardiac death or hospitalisation for heart failure (the primary endpoint) were 220 (8·6%) patients in the control group and 239 (9·4%) in the remote ischaemic conditioning group (hazard ratio 1·10 [95% CI 0·91-1·32], p=0·32 for intervention versus control). No important unexpected adverse events or side effects of remote ischaemic conditioning were observed. INTERPRETATION: Remote ischaemic conditioning does not improve clinical outcomes (cardiac death or hospitalisation for heart failure) at 12 months in patients with STEMI undergoing PPCI. FUNDING: British Heart Foundation, University College London Hospitals/University College London Biomedical Research Centre, Danish Innovation Foundation, Novo Nordisk Foundation, TrygFonden

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

Introduction: The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures. Methods: In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025. Findings: Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2–6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5–5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4–10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32–4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23–11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation. Interpretation: After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification

From night owl to angry bird: Investigating the association between chronotype and aggression

Recent attempts to understand the sleep-aggression relationship highlight the importance of the role of cognition. A related but separate concept of sleep, chronotype (i.e., sleep timings) has also been suggested to contribute to levels of aggression. The current study explores the relationship between chronotype, sleep quality, hostility, aggression, and intimate partner violence (IPV). Two hundred and eight participants completed online questionnaires to explore the contribution of hostility and sleep quality as mediators of the chronotype-aggression relationship. Findings indicate that chronotype was associated with levels of aggression, with those with later chronotypes reporting higher levels of aggression. Two mediation models revealed that this relationship was mediated by hostile cognitions (i.e., hostile attribution biases), and partially mediated by sleep quality. The chronotype-IPV relationship was explored, but the association was not significant. Findings indicate that those with late chronotypes may be more susceptible to hostile cognitions which leads to aggressive outcomes. However, there may be additional factors contributing to this relationship when considering violence in relationships. Aggression-focused interventions may benefit from dissecting an individual’s sleep patterns to reduce hostile cognitions and future research would benefit from objective measures of both chronotype and aggression

Childhood emotional abuse and depression: The mediating roles of emotion regulation and resilience

Childhood adverse experiences are associated with an increased susceptibility to low psychopathology. Childhood emotional abuse (CEA) is a widespread adversity, known to be associated with depression. Yet, the underlying mechanisms contributing to the relationship remain unclear. The present study aimed to explore the association between CEA and depression and identify potential mediating factors, focusing specifically on emotion regulation and resilience. Participants (N = 110) completed an online survey assessing experiences of CEA, depression levels, emotional regulation strategies, and resilience levels. A mediation analysis found that CEA has a direct influence on the onset of depression. Interestingly, only the expressive suppression emotional regulation strategy and resilience were found to mediate the relationship between CEA and depression. Cognitive reappraisal was not a mediator. The results add to the growing literature emphasising the association between CEA and depression. The implications for clinicians would be to explore the emotional regulation strategies and resilience in clients with known CEA. In the future, when assessing the outcome of CEA, it is critical to consider all aspects of the effects of CEA. Rather than primarily focusing on the presence of depression, clinicians should consider the fact that CEA often hinders one’s social, cognitive, and emotional development

Risk and protective factors in risk assessment: Predicting inpatient aggression in adult males detained in a forensic mental health setting

Background: Structured clinical risk assessments represent a preferred means of assessing levels of aggression risk at different times and in different individuals. Increasing attention has been given to capturing protective factors, with sound risk assessment critical to high-secure forensic mental health care. Aim: To assess the predictive value of the HCR-20v3 for aggression risk and the long-term care version of the SAPROF (the SAPROF-LC-pilot) in a high-secure forensic mental health inpatient population. To determine the incremental value of protective over risk factors. Method: Participants were adult males detained in a high secure forensic mental health service, with a primary diagnosis of schizophrenia and/or personality disorder. The focus was on examining hospital based aggression (self- and other-directed) at two time points; up to six months (T1) and between seven and 12 months (T2). Results: The HCR-20V3 and SAPROF-LC-pilot demonstrated good predictive validity but with variability across subscales and aggression types/periods. Historical factors of the HCR-20V3 and External factors of the SAPROF-LC-pilot failed to predict, aside from a medium effect at T1 for verbal aggression and self-harm, for Historical factors. There was evidence for protective factors adding to prediction over risk factors alone, with the integration of protective and risk factors into a risk judgement particularly helpful in improving prediction accuracy. Conclusions: Protective factors contribute to risk estimates and particularly if integrated with risk factors. Combining risk and protective factors has clear predictive advantages, ensuring that protective factors are not supplementary but important to the aggression assessment process