Violence in psychosis: conceptualizing its causal relationship with risk factors

Background: While statistically robust, the association between psychosis and violence remains causally unexplained. Objective: To provide an overview of possible causal pathways between risk factors and violence in psychosis. Methods: A structured narrative review of relevant studies published between 1990 and 2013, found via online databases and bibliographies. Both reviews and empirical studies were included. No restrictions were applied to language, study design, sample characteristics and measurement of psychosis and violence. Case reports and studies about self-harm were excluded. A final sample of 69 studies was used. Findings: The lack of knowledge regarding the causal relationship between psychosis and violence is partially due to methodological aspects of research. These aspects include study design, sampling, operationalization and confounding variables. Moreover, violence is the potential outcome of several interrelated risk factors: demographics, social factors, persecutory delusions, command hallucinations, comorbid antisocial personality pathology, substance use, inadequate insight, treatment non-adherence and physiological factors. Forty-one possible causal pathways between these risk factors and violence are presented. Conclusions: This study stimulates research by providing a theoretical framework, avenues for future investigation and methodological recommendations. Understanding violence in psychosis enhances its prevention and treatment, decreases stigma associated with psychosis and improves the patient’s legal position

Investigating the prevalence of problematic substance use and mental disorders in a large sample of prisoners with mental illness: network analysis

Background The relationship between psychopathology and criminal offending has been the subject of many studies. Co-occurring substance use seems to increase the risk of offending in those with mental illness. Aims To present data on the prevalence of mental disorders and demographics of prisoners with mental illness, and investigate associations between diagnoses and substance use from a network perspective. Method Data used in this study are part of a cohort study within the four penitentiary psychiatric centres in The Netherlands. It includes data of 4956 incarcerated male patients. Prevalence rates of mental disorders and demographic variables were compared between individuals with and without problematic substance use. A network of diagnoses, including three categories of substance use, was constructed with regression coefficients. Results Most patients showed prior problematic substance use (72.2%) in more than one category of substances (58.7%). Problematic substance use was associated with diagnoses of schizophrenia spectrum disorders (χ2(1) = 37.52, P < 0.001, V = 0.09) and cluster B personality disorders (χ2(1) = 56.39, P < 0.001, V = 0.11). Three major findings of the network are discussed in detail: the role of antisocial personality disorder, impulsivity and psychotic disorders in combination with problematic substance use. Conclusions Problematic substance use is highly prevalent among prisoners with mental illness, and should always be taken into account in research on this topic. Treatment should target substance use to reduce the risk of recidivism. Further differentiation in categories of substances is needed for the development of risk profiles

Preventing crime in cooperation with the mental health care profession

Although major mental disorders do not have a central position in many criminological theories, there seems to be an evident relationship between these disorders and criminal behavior. In daily practice police officers and mental health care workers work jointly to prevent nuisance and crime and to keep the city livable. Examining the situations where the criminal justice system and mental health institutes are jointly involved to prevent crime, some pitfalls emerge that seem to threaten successful cooperation. There appear to be unrealistic expectations of the possibility to reduce the risk of reoffending by means of treatment and of the possibility to predict which offender poses a risk to society. Another complexity is the fact that both parties work from different backgrounds and pursue different goals. The way society and the criminal justice system deal with persons who are assumed to be a risk to the community because of a mental disorder demands a further investigation from a criminological perspective

Peri-operative red blood cell transfusion in neonates and infants: NEonate and Children audiT of Anaesthesia pRactice IN Europe: A prospective European multicentre observational study

BACKGROUND: Little is known about current clinical practice concerning peri-operative red blood cell transfusion in neonates and small infants. Guidelines suggest transfusions based on haemoglobin thresholds ranging from 8.5 to 12 g dl-1, distinguishing between children from birth to day 7 (week 1), from day 8 to day 14 (week 2) or from day 15 (≥week 3) onwards. OBJECTIVE: To observe peri-operative red blood cell transfusion practice according to guidelines in relation to patient outcome. DESIGN: A multicentre observational study. SETTING: The NEonate-Children sTudy of Anaesthesia pRactice IN Europe (NECTARINE) trial recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. PATIENTS: The data included 5609 patients undergoing 6542 procedures. Inclusion criteria was a peri-operative red blood cell transfusion. MAIN OUTCOME MEASURES: The primary endpoint was the haemoglobin level triggering a transfusion for neonates in week 1, week 2 and week 3. Secondary endpoints were transfusion volumes, 'delta haemoglobin' (preprocedure - transfusion-triggering) and 30-day and 90-day morbidity and mortality. RESULTS: Peri-operative red blood cell transfusions were recorded during 447 procedures (6.9%). The median haemoglobin levels triggering a transfusion were 9.6 [IQR 8.7 to 10.9] g dl-1 for neonates in week 1, 9.6 [7.7 to 10.4] g dl-1 in week 2 and 8.0 [7.3 to 9.0] g dl-1 in week 3. The median transfusion volume was 17.1 [11.1 to 26.4] ml kg-1 with a median delta haemoglobin of 1.8 [0.0 to 3.6] g dl-1. Thirty-day morbidity was 47.8% with an overall mortality of 11.3%. CONCLUSIONS: Results indicate lower transfusion-triggering haemoglobin thresholds in clinical practice than suggested by current guidelines. The high morbidity and mortality of this NECTARINE sub-cohort calls for investigative action and evidence-based guidelines addressing peri-operative red blood cell transfusions strategies. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02350348

Prison brain? Executive dysfunction in prisoners

A better understanding of the functioning of the brain, particularly executive functions, of the prison population could aid in reducing crime rates through the reduction of recidivism rates. Indeed, reoffending appears to be related to executive dysfunction and it is known that executive functions are crucial for self-regulation. In the current paper, studies to executive functions in regular prisoners compared to non-offender controls were reviewed. Seven studies were found. Specific executive functions were found to be impaired in the general prison population, i.e. attention and set-shifting, as well as in separate subgroups of violent (i.e. set-shifting and working memory) and non-violent offenders (i.e. inhibition, working memory and problem solving). We conclude that the limited number of studies is remarkable, considering the high impact of this population on society and elaborate on the implications of these specific impairments that were found. The current findings call for further research

Aggressive Incidents by Incarcerated People With Psychiatric Illness and Their Relationship With Psychiatric Symptoms

Aim A prospective design was used to investigate the relationship of current psychiatric symptoms of incarcerated people with serious mental illness (SMI) and aggressive behavior on a penitentiary ward for crisis intervention. Methods One hundred sixty detainees with SMI, detained in a high-security penitentiary psychiatric facility, were screened every 2 weeks with the Brief Psychiatric Rating Scale-Extended (BPRS-E) by trained clinicians, to ensure that the data on psychiatric symptoms were up-to-date. Aggressive behavior was registered with the Staff Observation Aggression Scale–Revised. A binary logistic regression analysis was performed to examine the relationships between factor scores of the BPRS-E and aggressive behavior. Results Significant relationships between the BPRS-E factor hostility, antisocial traits, and aggressive incidents were found, but not between the positive symptoms or manic factor scores and aggressive incidents. Discussion Symptoms of SMI measured with the BPRS-E did not help to explain the occurrence of aggressive behavior. This is not in line with what is commonly found. The implication is that it can be expected that this population will display aggressive behavior but that symptoms do not help in predicting when this will occur. In addition, hostility and antisocial traits were related to aggressive behavior. For this specific population, an interactional approach might be more effective in the management of aggression than treatment of symptoms of SMI

Men and women with borderline personality disorder resident in Dutch special psychiatric units in prisons:A descriptive and comparative study

Background: The overall prevalence of borderline personality disorder is well known, but characteristics of offender patients with the condition are less clear, especially among men. Aim: Describe characteristics of men and women with borderline personality disorder in special psychiatric units in Dutch prisons on three domains: prevalence of child abuse, comorbidity of borderline personality disorder with other disorders, and clinical symptoms. Methods: One hundred and sixty-seven people were assigned to this study based on a Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) diagnoses retrieved from records. Other DSM-5 diagnoses were also recorded. Two scales, the Dutch Historisch, Klinisch, Toekomst—Revisie and the international Brief Psychiatric Rating Scale—Expanded (BPRS-E) were used to record child abuse and clinical symptoms, respectively. Results: Prevalence rates of child abuse were high, but the men and women did not differ in this respect. The male offender patients were more likely than the women to have a comorbid substance use disorder, whereas the women were more likely to have a comorbid anxiety disorder. Intellectual disability was the most common comorbid Axis II disorder. The women were more likely than the men to have committed a fatal/nearly fatal index offence and showed higher rates of distress or behavioural disturbance on all five BPRS-E factors. Conclusions: This study provides evidence of the importance of in-depth knowledge of presentations with borderline personality disorder specific to setting. Although we were unable to make direct comparisons with other samples, our figures suggest clinically relevant differences among offender patients from the more widely reported general samples. We also shed light on a sometimes underexposed group of men with borderline personality disorder and their clinical needs. More population-specific intervention and follow-up studies are now indicated