Understanding aggression and treating forensic psychiatric inpatients with Virtual Reality

Many forensic psychiatric inpatients (in Dutch: TBS-patients) have difficulty controlling their aggression. For example, aggression can be aimed at fellow patients, staff, and / or objects. This not only has negative consequences for emotional and physical well-being, but also influences the progress of the treatment and the living environment in a TBS-clinic. The aim of the research in this dissertation was to investigate the effectiveness of a new treatment, but also to improve knowledge about aggressive behavior. TBS-patients relatively often have poor impulse control, and easily misinterpret social situations as hostile. Our systematic literature review showed that this tendency to interpret ambiguous social situations as hostile also occurs in non-aggressive TBS-patients and individuals in the general population. We also found that physical aggression from TBS-patients to staff or belongings is often preceded by non-physical aggression, so that structured monitoring of aggression can contribute to the reduction of incidents. Currently, there are few effective treatments for aggression problems. That is why we have developed a Virtual Reality aggression prevention therapy (VRAPT). This dissertation shows that the assessment, framing, monitoring and treatment of aggressive behavior in TBS-patients is a challenge, even with an innovative VR treatment. Unfortunately, the number of aggressive incidents did not decrease after VRAPT. However, the intervention studied was an important first step in the development of VR-treatments in forensic psychiatry. This dissertation shows that further steps are needed, fortunately the assessment of patients and therapists shows that there is support for this

Mapping aggressive behavior of forensic psychiatric inpatients with self-report and structured staff-monitoring

Structured assessment of aggressive behavior in forensic psychiatry is needed. This study investigated staffobserved and self-reported measures to map prevalence and characteristics of aggressive behavior in forensic inpatients and aimed to identify early signs of aggressive outbursts. In this longitudinal study, 120 forensic psychiatric inpatients with a history of aggression were included. Staff monitored aggressive behavior for 30 weeks using the Social Dysfunction and Aggression Scale (SDAS). Patients completed baseline self-report measures on aggression, anger, and impulsivity. Staff monitoring showed that most inpatients displayed moderate (86%) or severe (65%) aggressive behavior at least once, and 37.5% showed physical aggression. Inpatients with a least one physical aggression incident differed from others in self-reported anger, (reactive) aggression, nonplanning impulsivity, and sociodemographic and clinical characteristics (e.g., higher prevalence of cluster B personality disorders, and lower intelligence). Two-thirds of the physical aggression incidents were preceded by observations of increased non-physical aggression (SDAS). In forensic psychiatric inpatients with a history of aggression, more than a third of the patients demonstrated at least one occasion of physical aggression during 30 weeks of observation

The complex associations between early childhood adversity, heart rate variability, cluster B personality disorders, and aggression

Early childhood adversity can cause an imbalance in the autonomic function, which may in turn lead to the development of trauma-spectrum disorders and aggressive behavior later in life. In the present study, we investigated the complex associations between early adversity, heart rate variability (HRV), cluster B personality disorders, and self-reported aggressive behavior in a group of 50 male forensic inpatients (M age = 41.16; SD = 10.72). Structural Equation Modeling analysis revealed that patients with cluster B personality disorders were more likely to have adverse early childhood experiences and reduced sympathetic dominance in response to a threat than patients without cluster B personality disorders. In addition, HRV and cluster B personality disorders did not significantly mediate the association between early childhood adversity and self-reported aggressive behavior. These findings are important for clinical practice to facilitate specific treatment programs for those affected

New Developments in Virtual Reality-Assisted Treatment of Aggression in Forensic Settings:The Case of VRAPT

Aggression is a known problem in individuals being cared for in forensic settings, yet the evidence base for its treatment is scarce. Virtual Reality (VR) has been proposed as a promising addition to interventions in forensic settings, as it may increase the motivation among participants, bridge the gap between real life, therapeutic and laboratory experiences, and increase the ecological validity of psychological research. Recently, a new treatment for aggression using VR as the treatment environment, Virtual Reality Aggression Prevention Training (VRAPT) program, was developed to provide realistic and safe environments for participants to practice aggression management. In its current revised version, VRAPT is conceptualized as a form of cognitive behavioral therapy with its theoretical background in the General Aggression Model. Its purpose is to increase awareness of, and improve control over, one's own aggression and that of others through social interactions in individually tailored virtual environments. This manuscript describes how the lessons learned from the first randomized controlled trial of VRAPT have been applied to further develop the method and discusses challenges and future directions for VR-assisted treatment of aggression in forensic settings. VRAPT is a new psychological treatment for aggression and the coming years will provide expanded scientific evidence for further developments and adaptations

Virtual Reality Aggression Prevention Therapy (VRAPT) versus Waiting List Control for Forensic Psychiatric Inpatients:A Multicenter Randomized Controlled Trial

Many forensic psychiatric inpatients have difficulties regulating aggressive behavior. Evidence of effective aggression treatments is limited. We designed and investigated the effectiveness of a transdiagnostic application of a virtual reality aggression prevention training (VRAPT). In this randomized controlled trial at four Dutch forensic psychiatric centers, 128 inpatients with aggressive behavior were randomly assigned to VRAPT (N = 64) or waiting list control group (N = 64). VRAPT consisted of 16 one-hour individual treatment sessions twice a week. Assessments were done at baseline, post-treatment and at 3-month follow-up. Primary outcome measures were aggressive behavior observed by staff and self-reported aggressive behavior. Analysis was by intention to treat. This trial was registered in the Dutch Trial Register (NTR, TC = 6340). Participants were included between 1 March 2017, and 31 December 2018. Compared to waiting list, VRAPT did not significantly decrease in self-reported or observed aggressive behavior (primary outcomes). Hostility, anger control, and non-planning impulsiveness improved significantly in the VRAPT group compared to the control group at post-treatment. Improvements were not maintained at 3-month follow-up. Results suggest that VRAPT does not decrease aggressive behavior in forensic inpatients. However, there are indications that VRAPT temporarily influences anger control skills, impulsivity and hostility

Virtual reality aggression prevention treatment in a Dutch prison-based population: a pilot study

BackgroundTreating violent behavior in prisons comes with challenges, such as the inability to practice safely with triggering situations and motivational issues. A solution may be the use of Virtual Reality (VR). With VR, specific conditions or needs can be tailored for individual practice, it can enhance motivation and VR has proven to be a safe and effective tool in mental health treatment.ObjectiveA pilot study was conducted to test the acceptability, feasibility, and preliminary effects of VR Aggression Prevention Treatment (VRAPT) in a prison-based population.MethodsIn total 17 detainees with aggressive behavior were included in this single-group pilot study. Acceptability and feasibility were assessed using qualitative measures for participants and therapists. Preliminary treatment effects were measured with self-report and observational measures on aggression, anger, emotion regulation, and impulsiveness.ResultsParticipants and therapists were predominantly positive about VRAPT. Participants rated the sessions with an average satisfaction score of 9.2 out of 10 (SD = 0.3). Qualitative data showed that participants reported having learned to respond more adequately to aggressive behavior and gained insights into their own and others’ triggers and tension. The combination of VR and theory was experienced as a strength of the treatment, as well as the ability to trigger aggression in VR which provided insights into aggression. However, the theoretical framework was found to be too complex, and more aggressive and personal scenarios should be incorporated into the sessions. Self-reported aggression, anger, provocation, emotion regulation, and observed verbal aggression decreased and seemed to stabilize after the treatment ended, with small to medium effect sizes.ConclusionVRAPT proved feasible and acceptable for most participants and therapists. An adapted treatment protocol called Virtual Reality Treatment for Aggression Control (VR-TrAC), will be used in a future RCT to investigate the effects of the treatment in a prison-based population

Mapping aggressive behavior of forensic psychiatric inpatients with self-report and structured staff-monitoring

Structured assessment of aggressive behavior in forensic psychiatry is needed. This study investigated staff-observed and self-reported measures to map prevalence and characteristics of aggressive behavior in forensic inpatients and aimed to identify early signs of aggressive outbursts. In this longitudinal study, 120 forensic psychiatric inpatients with a history of aggression were included. Staff monitored aggressive behavior for 30 weeks using the Social Dysfunction and Aggression Scale (SDAS). Patients completed baseline self-report measures on aggression, anger, and impulsivity. Staff monitoring showed that most inpatients displayed moderate (86%) or severe (65%) aggressive behavior at least once, and 37.5% showed physical aggression. Inpatients with a least one physical aggression incident differed from others in self-reported anger, (reactive) aggression, non-planning impulsivity, and sociodemographic and clinical characteristics (e.g., higher prevalence of cluster B personality disorders, and lower intelligence). Two-thirds of the physical aggression incidents were preceded by observations of increased non-physical aggression (SDAS). In forensic psychiatric inpatients with a history of aggression, more than a third of the patients demonstrated at least one occasion of physical aggression during 30 weeks of observation

Hostile attribution bias and aggression in adults - a systematic review

Human aggression is highly prevalent and has a large impact on the lives of victims and society in general. Causes and mechanisms of aggression are manifold. One prominent component of aggression is the tendency to interpret ambiguous behavior of others as hostile, so called Hostile Attribution Bias (HAB). This systematic review investigated the association between HAB and aggression in adults. PsychInfo, Embase, PubMed and Web of Science databases were searched and 25 studies were included. These studies reported small to medium associations between HAB and aggression in adults. The association was present across different population samples, varying from students to forensic psychiatric patients. As most studies were cross-sectional and HAB measurements varied in quality, conclusions and implications for interventions are preliminary. This review provides an overview of existing research on HAB and aggression in adults, and highlights the importance of longitudinal studies and adequate HAB measurements for future research

Effect of virtual reality aggression prevention training for forensic psychiatric patients (VRAPT): Study protocol of a multi-center RCT

Background Many patients residing in forensic psychiatric centers have difficulties regulating their aggression in an adequate manner. Therefore, they are frequently involved in conflicts. Evidenced-based aggression therapies in forensic psychiatry are scarce, and due to the highly secured environment, it is hard to practice real-life provocations. We have developed a Virtual Reality aggression prevention training (VRAPT), providing safe virtual environments, in which patients can practice controlling their aggressive behaviors in an adequate way. The main objective of this study is to examine whether VRAPT is effective in reducing aggression among forensic psychiatric inpatients. Methods Four forensic psychiatric centers in the Netherlands are participating in this study. Participants will be randomly assigned to either VRAPT or a waiting list. The two groups will be compared at several different time points: baseline (12 weeks before intervention), pre-intervention, post-intervention and at 12 weeks follow-up. After follow-up measurements are completed, participants from the waiting list will also receive VRAPT. The primary outcome is level of aggressive behavior, consisting of staff-reported and self-reported measures. Secondary outcomes are self-report questionnaires on e.g., anger, impulsivity and aggression. Discussion To the best of our knowledge this is the first study to examine the effectiveness of a VR aggression prevention training in forensic psychiatric centers