The link between conduct disorder and adult antisocial behaviour is partially mediated by early onset alcohol abuse

This study sought to clarify the nature of the relationship between conduct disorder (CD), early-onset alcohol abuse (EOAA), some other externalizing-related constructs and adult violent antisociality (VA). It addressed two key questions: (i) whether EOAA mediated the link between CD and VA; and (ii) whether the effects of EOAA on VA were, in turn, mediated by impulsiveness, ventro-medial prefrontal cortex (vm-PFC) dysfunction and social deviance as measured by the Psychopathy Checklist-Revised (PCL-R). It tested the hypothesis that in the context of early disinhibitory psychopathology, e.g. CD, EOAA disrupts the neural substrates of self-regulation in vm-PFC during a critical neurodevelopmental period (i.e. before age 20). Consequently, on entry into adulthood the vm-PFC is functionally impaired and personality suffers maladaptive development which would then take the form of increased impulsiveness and social deviance, placing the individual at high risk of violent antisocial behaviour. Using a cross sectional design, DSM-IV Axis I and II disorders, psychopathy, impulsiveness, vm-PFC functioning, history of drug and alcohol use, and both amount and severity of violence were assessed in 100 patients with personality disorders detained in secure hospital settings. Patients identified as having a history of EOAA, compared with those with no alcohol abuse history, were more impulsive, scored higher on the social deviance factor of psychopathy (PCL-R F2), were more conduct disordered, and showed a higher level of VA. Regression analysis showed that CD, EOAA, impulsiveness and PCL-R F2 significantly predicted VA, although PCL-R F2 rendered the effects of CD insignificant when used conjointly in regression analysis. A multiple mediation model explaining about 20% of the variance in VA showed that EOAA partially mediated the effects of CD on VA, after controlling for age, cannabis misuse and ADHD. A separate multiple mediation model explaining 50% of the variance in VA showed that PCL-R F2 and impulsiveness partially mediated the effect of EOAA on VA. However, contrary to the prediction arising from the hypothesis, the effects of vm-PFC functioning on VA were insignificant. Although the study suffered from some limitations, results suggest that both impulsiveness and social deviance contribute importantly to a pathway leading from CD through adolescent alcohol abuse to maladaptive personality development and adult VA

The link between conduct disorder and adult antisocial behaviour is partially mediated by early onset alcohol abuse

This study sought to clarify the nature of the relationship between conduct disorder (CD), early-onset alcohol abuse (EOAA), some other externalizing-related constructs and adult violent antisociality (VA). It addressed two key questions: (i) whether EOAA mediated the link between CD and VA; and (ii) whether the effects of EOAA on VA were, in turn, mediated by impulsiveness, ventro-medial prefrontal cortex (vm-PFC) dysfunction and social deviance as measured by the Psychopathy Checklist-Revised (PCL-R). It tested the hypothesis that in the context of early disinhibitory psychopathology, e.g. CD, EOAA disrupts the neural substrates of self-regulation in vm-PFC during a critical neurodevelopmental period (i.e. before age 20). Consequently, on entry into adulthood the vm-PFC is functionally impaired and personality suffers maladaptive development which would then take the form of increased impulsiveness and social deviance, placing the individual at high risk of violent antisocial behaviour. Using a cross sectional design, DSM-IV Axis I and II disorders, psychopathy, impulsiveness, vm-PFC functioning, history of drug and alcohol use, and both amount and severity of violence were assessed in 100 patients with personality disorders detained in secure hospital settings. Patients identified as having a history of EOAA, compared with those with no alcohol abuse history, were more impulsive, scored higher on the social deviance factor of psychopathy (PCL-R F2), were more conduct disordered, and showed a higher level of VA. Regression analysis showed that CD, EOAA, impulsiveness and PCL-R F2 significantly predicted VA, although PCL-R F2 rendered the effects of CD insignificant when used conjointly in regression analysis. A multiple mediation model explaining about 20% of the variance in VA showed that EOAA partially mediated the effects of CD on VA, after controlling for age, cannabis misuse and ADHD. A separate multiple mediation model explaining 50% of the variance in VA showed that PCL-R F2 and impulsiveness partially mediated the effect of EOAA on VA. However, contrary to the prediction arising from the hypothesis, the effects of vm-PFC functioning on VA were insignificant. Although the study suffered from some limitations, results suggest that both impulsiveness and social deviance contribute importantly to a pathway leading from CD through adolescent alcohol abuse to maladaptive personality development and adult VA

A systematic review and meta-analysis of decision-making in offender populations with mental disorder

Decision-making has many different definitions, and is measured in varied ways using neuropsychological tasks. Offenders with mental disorder habitually make disadvantageous decisions, but no study has systematically appraised the literature. This review aimed to clarify the field by bringing together different neuropsychological measures of decision-making, and using meta-analysis and systematic review to explore the performance of offenders with mental disorders on neuropsychological tasks of decision-making. A structured search of Pubmed, Embase, PsycINFO, Medline, Cinahl was conducted with additional hand searching and grey literature consulted. Controlled studies of decision-making in offenders with evidence of any mental disorder, including a validated measure of decision-making were included. Total score on each relevant decision-making task was collated. Twenty-three studies met inclusion criteria (n=1,820), and 10 studies (with 15 experiments) were entered into the meta-analysis (n=841). All studies included in the meta-analysis used the Iowa Gambling Task (IGT) to measure decision-making. Systematic review findings from individual studies showed violent offenders made poorer decisions than matched offender groups or controls. An omnibus meta-analysis was computed to examine performance on IGT in offenders with mental disorder compared with controls. Additionally, two sub-group meta-analyses were computed for studies involving offenders with personality disorder and psychopathy, and recidivists who were convicted of Driving While Intoxicated (DWI). Individual studies not included in the meta-analysis partially supported the view that offenders make poorer decisions. However, the meta-analyses showed no significant differences in performance on IGT between the offender groups and controls. Further research is required to ascertain whether offenders with mental disorder have difficulty in making advantageous decisions. An analysis of cause and effect and various directions for future work are recommended to help understand the underpinning of these findings

Staff experience of harassment and stalking behaviour by patients

Staff from one National Health Service (NHS) Trust in England completed an online survey (N = 590) about their experience of intrusive behaviours from patients. These experiences were categorised into either stalking or harassment and compared in terms of staff and patient characteristics, types of intrusions, and aftermath. Overall, 150 were classified as being stalked (25.4%) and 172 harassed (29.2%). There were no differences in staff characteristics between the two groups. Staff from forensic services and nursing staff were particularly susceptible to these intrusions which took many forms. Respondents perceived a range of causes for the stalking and harassment, the most common being to gain power and control/to scare. It was rare for legal sanctions to be brought against the patient. Our findings reinforce the need for service providers to have policies supported with preventative measures, education and a robust process for addressing stalking so that these measures are embedded in practice in a way that supports staff working with patients. Furthermore, service providers should be challenged on what steps they have taken to prevent, and monitor, such behaviour

Barriers and facilitators to the implementation of individual placement and support (IPS) for patients with offending histories in the community: The United Kingdom experience

IntroductionWe aimed to identify the barriers and facilitators to the implementation of a high fidelity individual placement and support service in a community forensic mental health setting.MethodIn-depth interviews were conducted with clinical staff (n = 11), patients (n = 3), and employers (n = 5) to examine barriers and facilitators to implementation of a high fidelity individual placement and support service. Data was analysed using thematic analysis, and themes were mapped onto individual placement and support fidelity criteria.ResultsBarriers cited included competing interests between employment support and psychological therapies, perceptions of patients’ readiness for work, and concerns about the impact of returning to work on welfare benefits. Facilitators of implementation included clear communication of the benefits of individual placement and support, inter-disciplinary collaboration, and positive attitudes towards the support offered by the individual placement and support programme among stakeholders. Offences, rather than mental health history, were seen as a key issue from employers’ perspectives. Employers regarded disclosure of offending or mental health history as important to developing trust and to gauging their own capacity to offer support.ConclusionsImplementation of individual placement and support in a community mental health forensic setting is complex and requires robust planning. Future studies should address the barriers identified, and adaptations to the individual placement and support model are needed to address difficulties encountered in forensic settings

Is emotional impulsiveness (Urgency) a core feature of severe personality disorder?

Recent literature has focused on severity of personality disorder (PD) and a trait-based assessment of PDs in preference to assessment by specific sets of diagnostic criteria. Evidence suggests that emotional impulsiveness, also known as Urgency (Whiteside, & Lynam (2001). The five factor model and impulsivity: Using a structural model of personality to understand impulsivity. Personality and Individual Differences (30, 669–689), might contribute to a broad spectrum of PDs and to overall PD severity. In a sample of 100 forensic psychiatric patients, all men with confirmed PD and a history of serious offending, two hypotheses were tested: first that high Urgency scores would be associated with a broad spectrum of PDs, and with PD severity; and second, that in regression analysis Urgency would uniquely predict measures of PD severity. Results confirmed these hypotheses and are consistent with the idea that emotional impulsiveness/Urgency contributes importantly to overall severity of PD, and in so doing may explain, at least in part, the well-documented link between PD and violence

The use of telepsychiatry within forensic practice: a literature review on the use of videolink: a ten-year follow-up

In the last decade, telepsychiatry – the use of telecommunications technologies to deliver psychiatric services from a distance – has been increasingly utilised in many areas of mental health care. Since the review by Khalifa and colleagues in 2007 the body of literature relevant to the forensic applications of telepsychiatry has grown substantially, albeit not by much in the United Kingdom. In the current review, we aim to provide an update summary of the literature published since 2007 to determine the effectiveness and feasibility of increasing telepsychiatry utilisation in forensic practice. The literature reviewed provides some encouraging evidence that telepsychiatry is a reliable, effective and highly acceptable method for delivering mental health care in forensic settings. There are also a number of papers that indicate the use of telepsychiatry may be cost effective for health providers in the longer term. Further research is required to consider the potential legal and ethical implications of using telepsychiatry in forensic settings

Excitatory repetitive Transcranial Magnetic Stimulation applied to the right inferior frontal gyrus has no effect on motor or cognitive impulsivity in healthy adults

Background: Impulsivity is a multi-faceted concept. It is a crucial feature of many neuropsychiatric disorders. Three subtypes of impulsivity have been identified: motor, temporal, and cognitive impulsivity. Existing evidence suggests that the right inferior frontal gyrus (rIFG) plays a crucial role in impulsivity, and such a role has been elucidated using inhibitory repetitive transcranial magnetic stimulation (rTMS). There is a dearth of studies using excitatory rTMS at the rIFG, an important gap in the literature this study aimed to address. Methods: Twenty healthy male adults completed a single-blind sham-controlled randomised crossover study aimed at assessing the efficacy of rTMS in the neuromodulation of impulsivity. This involved delivering 10-Hz excitatory rTMS to the rIFG at the intensity of 100% motor threshold with 900 pulses per session. Trait impulsivity was measured at baseline using the Barrett Impulsiveness Scale and UPPS-P Impulsiveness Scale. The Stop Signal Task (SST) and Information Sampling Task (IST), administered before andafter rTMS sessions, were used as behavioural measures of impulsivity. Results: No significant changes on any measures from either SST or IST after active rTMS at the rIFG compared to the sham-controlled condition were found. Conclusions: Excitatory rTMS applied to the rIFG did not have a statistically significant effect on response inhibition and reflective/cognitive impulsivity. Further research is required before drawing firm conclusions. This may involve a larger sample of highly impulsive individuals, a different stimulation site or a different TMS modality such as theta burst stimulation