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Transgressive incidents directed at staff by forensic patients occur frequently, leading to detrimental psychological and physical harm, underscoring urgency of preventive measures. These incidents, emerging within therapeutic relationships, involve complex interactions between patient and staff behavior. This study aims to identify clusters of transgressive incidents based on incident characteristics such as impact, severity, (presumed) cause, type of aggression, and consequences, using latent class analysis (LCA). Additionally, variations in incident clusters based on staff, patient, and context characteristics were investigated. A total of 1,184 transgressive incidents, reported by staff and targeted at staff by patients between 2018-2022, were extracted from a digital incident reporting system at Fivoor, a Dutch forensic psychiatric healthcare organisation. Latent Class Analysis revealed six incident classes: 1) verbal aggression with low impact; 2) verbal aggression with medium impact; 3) physical aggression with medium impact; 4) verbal menacing/aggression with medium impact; 5) physical aggression with high impact; and 6) verbal and physical menacing/aggression with high impact. Significant differences in age and gender of both staff and patients, staff function, and patient diagnoses were observed among these classes. Incidents with higher impact were more prevalent in high security clinics, while lower-impact incidents were more common in clinics for patients with intellectual disabilities. Despite limitations like missing information, tailored prevention approaches are needed due to varying types of transgressive incidents across patients, staff, and units.

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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. The aim was to assess the predictive value of the HCR-20v3 for aggression risk and the long-term care pilot version of the SAPROF (the SAPROF-LC-pilot) in a high-secure forensic mental health inpatient population and to determine the incremental value of protective over risk factors. 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 6 months (T1) and between 7 and 12 months (T2). 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. Protective factors contributed 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.

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Since the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), identity impairment has become a diagnostic criterion for all personality disorders. The current study examined the occurrence of identity dimensions, clinically relevant identity impairments and personality pathology, and associations between these constructs in 92 forensic patients and 139 healthy controls. Patients showed higher levels of almost all identity dimensions, identity impairments, personality disorders, and almost all maladaptive personality traits than controls. Various identity dimensions were associated with consolidated identity as well as identity impairments in both groups. Both patients and controls with high ruminative exploration and identity malfunctioning showed more personality pathology. Different associations between identity functioning and particularly antisocial and borderline personality disorder showed to be stronger in patients than in controls. Our results highlight the importance of identity impairment as a crucial criterion to assess and treat personality pathology in forensic patients.

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Introduction: Comorbid substance use disorder (SUD) is linked to a higher risk of violence in patients with schizophrenia spectrum disorder (SSD). The objective of this study is to explore the most distinguishing factors between offending and non-offending patients diagnosed with SSD and comorbid SUD using supervised machine learning. Methods: A total of 269 offender patients and 184 non-offender patients, all diagnosed with SSD and SUD, were assessed using supervised machine learning algorithms. Results: Failures during opening, referring to rule violations during a permitted temporary leave from an inpatient ward or during the opening of an otherwise closed ward, was found to be the most influential distinguishing factor, closely followed by non-compliance with medication (in the psychiatric history). Following in succession were social isolation in the past, no antipsychotics prescribed (in the psychiatric history), and no outpatient psychiatric treatments before the current hospitalization. Discussion: This research identifies critical factors distinguishing offending patients from non-offending patients with SSD and SUD. Among various risk factors considered in prior research, this study emphasizes treatment-related differences between the groups, indicating the potential for improvement regarding access and maintenance of treatment in this particular population. Further research is warranted to explore the relationship between social isolation and delinquency in this patient population.

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This study investigates the relationship of delusional disorder and its subtypes to criminal and violent behavior by comparing the sociodemographic and clinical characteristics of patients with and without a criminal history and identifying predictors of crime. The records of 346 patients with a delusional disorder diagnosis were retrospectively evaluated using a sociodemographic data form, a crime violence rating scale and the Overt Aggression Scale (OAS). The results show that homicide and attempted homicide were committed more frequently by patients with jealous delusions, whereas verbal assault and crimes against the public were committed more frequently by patients with persecutory and other delusions. Patients with a criminal history had more hospital admissions and longer stays. Marital status, persecutory delusions, a high OAS score and older age were found to be associated with higher risk of crime. Clinical subtypes and sociodemographic characteristics seem to discriminate delusional disorder patients' risk of crime.

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Sensation seeking is a personality trait that manifests as a preference for change, variety and novelty. Sensation seeking has been positively associated with different externalising behaviours. However, its associations with psychopathic traits, impulsivity and aggression are unclear. These associations were examined via the psychometric properties of the Dutch version of the Brief Sensation Seeking Scale (BSSS) using individuals from the general population and forensic patients. The results show that the BSSS has good psychometric properties, including test-retest reliability and a four-factor structure. Additionally, the results support associations between sensation seeking and psychopathic traits, impulsivity and total scores of aggression but revealed no specific associations with different types of aggression (e.g. proactive and reactive). The Dutch BSSS is a valuable tool for assessing sensation seeking in both the general population and forensic patients. Future research should further examine its utility and explore the role of sensation seeking in antisocial conduct.

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Three studies examined the psychometric properties of a new scale, the Forensic Stigma Scale (FSS), designed to measure public stigma of forensic patients. In Study 1, the initial item pool was derived to measure three components of stigma (stereotypes, prejudice, discrimination). An EFA (n = 218) identified a two-factor model with 12 items. In Study 2, this two-factor solution was confirmed using CFA with a separate sample (n = 326) which had good-excellent fit indices. All 12 items loaded (> 0.40) on the two latent factors (Dangerousness/Unpredictability [7 items] and Responsibility/Blame [5 items]) identified in the EFA. In Study 3, using the combined samples from the previous two studies, the 12-item FSS showed promising internal consistency reliability (0.75-0.80) and demonstrated satisfactory-good criterion validity; the scale was moderately correlated with a similar construct and was able to differentiate individuals who did and did not have specific education on forensic psychology. IRT analyses demonstrated that both subscales had discrimination parameters in the moderate-high range (α = 1.03 to 2.54), though the threshold parameters (bi) on the Dangerousness/Unpredictability subscale showed better distribution across trait levels. Overall, the 12-item FSS demonstrates strong psychometric properties, especially the Dangerousness/Unpredictability subscale. The scale may provide clinical and empirical uses for measuring public stigma of forensic patients.

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BACKGROUND: Studies have shown that impairments in the ventromedial prefrontal cortex play a crucial role in violent behavior in forensic patients who also abuse cocaine and alcohol. Moreover, interventions that aimed to reduce violence risk in those patients are found not to be optimal. A promising intervention might be to modulate the ventromedial prefrontal cortex by high-definition (HD) transcranial direct current stimulation (tDCS). The current study aimed to examine HD-tDCS as an intervention to increase empathic abilities and reduce violent behavior in forensic substance dependent offenders. In addition, using electroencephalography, we examined the effects on the P3 and the late positive potential of the event-related potentials in reaction to situations that depict victims of aggression. METHODS: Fifty male forensic patients with a substance dependence were tested in a double-blind, placebo-controlled randomized study. The patients received HD-tDCS 2 times a day for 20 minutes for 5 consecutive days. Before and after the intervention, the patients completed self-reports and performed the Point Subtraction Aggression Paradigm, and electroencephalography was recorded while patients performed an empathy task. RESULTS: Results showed a decrease in aggressive responses on the Point Subtraction Aggression Paradigm and in self-reported reactive aggression in the active tDCS group. Additionally, we found a general increase in late positive potential amplitude after active tDCS. No effects on trait empathy and the P3 were found. CONCLUSIONS: Current findings are the first to find positive effects of HD-tDCS in reducing aggression and modulating electrophysiological responses in forensic patients, showing the potential of using tDCS as an intervention to reduce aggression in forensic mental health care.

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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.

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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.

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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.

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There are little published data on the characteristics or outcomes of offenders found unfit to stand trial who receive a 'qualified finding of guilt' in a Special Hearing in New South Wales (NSW) and are detained for a 'limiting term' (LT) under the supervision of the NSW Mental Health Review Tribunal (MHRT). We examined NSW MHRT records linked to re-offending data, to report on the characteristics and outcomes of 69 LT patients in a cohort spanning two decades. The most common diagnoses were schizophrenia (54%) and intellectual disability (33%). Patients were detained on average for 4.2 years, which is slightly shorter than the average maximum term imposed. Of the 55 people for whom criminal record data were available, 9.1% were charged with an offence during the first year post-release and 60% overall were charged for at least one post-release offence during a follow-up period ranging from 4.7 to 11.1 years.

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Aggressive incidents occur frequently in health care facilities, such as psychiatric care and forensic psychiatric hospitals. Previous research suggests that civil psychiatric inpatients may display more aggression than forensic inpatients. However, there is a lack of research comparing these groups on the incident severity, even though both frequency and severity of aggression influence the impact on staff members. The purpose of this study is to compare the frequency and severity of inpatient aggression caused by forensic and civil psychiatric inpatients in the same Dutch forensic psychiatric hospital. Data on aggressive incidents occurring between January 1, 2014, and December 31, 2017, were gathered from hospital files and analyzed using the Modified Overt Aggression Scale, including sexual aggression (MOAS+). Multilevel random intercept models were used to analyze differences between forensic and civil psychiatric patients in severity of aggressive incidents. In all, 3,603 aggressive incidents were recorded, caused by 344 different patients. Civil psychiatric patients caused more aggressive incidents than forensic patients and female patients caused more inpatient aggression compared with male patients. Female forensic patients were found to cause the most severe incidents, followed by female civil psychiatric patients. Male forensic patients caused the least severe incidents. The findings have important clinical implications, such as corroborating the need for an intensive treatment program for aggressive and disruptive civil psychiatric patients, as well as emphasizing the importance of gender-responsive treatment.

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Individuals with schizophrenia show deficits in recognition of emotions which may increase the risk of violence. This study explored how forensic patients with schizophrenia process spoken emotion by: (a) identifying emotions expressed in prosodic and semantic content separately, (b) selectively attending to one speech channel while ignoring the other, and (c) integrating the prosodic and the semantic channels, compared to non-clinical controls. Twenty-one forensic patients with schizophrenia and 21 matched controls listened to sentences conveying four emotions (anger, happiness, sadness, and neutrality) presented in semantic or prosodic channels, in different combinations. They were asked to rate how much they agreed that the sentences conveyed a predefined emotion, focusing on one channel or on the sentence as a whole. Forensic patients with schizophrenia performed with intact identification and integration of spoken emotions, but their ratings indicated reduced discrimination, larger failures of selective attention, and under-ratings of negative emotions, compared to controls. This finding doesn't support previous reports of an inclination to interpret social situations in a negative way among individuals with schizophrenia. Finally, current results may guide rehabilitation approaches matched to the pattern of auditory emotional processing presented by forensic patients with schizophrenia, improving social interactions and quality of life.

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BACKGROUND: Families of state patients experience challenges related to the patient's mental illness and history of criminal behaviour. Family members who act as guardians when patients are on leave of absence take responsibility for the patient's basic needs, activities of daily living and treatment regimen. They need to safeguard the patient from potential self-harm and harming others. Few studies have explored the burden these family members experience. AIM: The aim of this study was to explore and describe the challenges experienced by families caring for mental state patients who are on leave of absence. SETTING: An urban area in South Africa. METHODS: A qualitative approach was applied to answer the research question, 'what are the challenges experienced by families caring for mental state patients on leave of absence?' A purposive sample of nine participants who were caring for state patients on leave of absence was selected. Individual in-depth interviews were used to collect data. Data were analysed using thematic analysis. Ethical considerations and trustworthiness guided the study. RESULTS: Three themes illustrate the challenges experienced by family members, namely, challenges related to state patient's behaviour, emotional challenges and social challenges. A fourth theme focuses on the ways families used to cope with these challenges. CONCLUSION: Mental healthcare professionals may use the results of this study to design therapeutic interventions for family members of state patients who focus on empathetic understanding and the mobilisation of effective coping skills and social support.

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Scientific research shows that the likelihood of aggressive behaviour in people with mental disorders compared to healthy people is usually higher than among healthy people. Considering the social harmfulness of acts committed by persons suffering from schizophrenia, a thorough analysis of their conditions is recommended. The paper presents the results of research conducted by a team from the Forensic Psychiatry Clinic of the Institute of Psychiatry and Neurology (IPiN) in Warsaw regarding the psychological determinants of aggressive behaviour of people diagnosed with schizophrenia. The analysis covers selected demographic variables, personality traits as well as the level and type of aggression presented, including previously undertaken violent behaviour. This article includes the results of studies on patients diagnosed with schizophrenia, interned in the Forensic Psychiatry Clinic of IPiN, as well as patients with schizophrenia (addicted and non-addicted) staying in general psychiatric wards.

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Forensic-psychiatric patients reoffending or absconding during the leave granted to them (hereafter referred to as "granted leave") have gained increased attention by researchers and the general public. The patients' right to freedom on the one hand and the need for protection of the general public from serious harm on the other hand represent broadly discussed ethical issues. Thus, demands on quality regarding decisions on patients' granted leaves might be high. Despite such requirements, research on decision-making processes regarding granting leave in forensic psychiatry is very limited and focuses primarily on particular aspects. The present study aims at providing a first overview of the decision-making processes regarding granted leave in forensic psychiatry as a whole. Furthermore, the link between the particular steps of the process and absconding should be explored. In this way, the study results should contribute to provide a theoretical framework for the development of guidelines concerning granted leave in forensic psychiatry. A combination of qualitative and quantitative approaches will be used to collect data: information about risk assessment, decisions on granted leave, and documentation systems in forensic psychiatry will be collected via semi-structured interviews and quantified for further analyses using a checklist developed for this study; data on the implementation of risk assessment tools and documented patient information will be obtained via two self-constructed questionnaires; information about the absolute number of abscondences per hospital will be obtained from the Bavarian Authority for Forensic Commitment. The sample will include staff from all 13 forensic-psychiatric hospitals in Bavaria (Germany) comprising six professional groups: hospital directors, security officers, complementary therapists, psychiatrists, psychologists, social workers, and nursing staff. In each hospital, at least one member of each professional group should participate in the study. In total, 151 interviews will be held. As the study goals are descriptive, there are no pre-formulated hypotheses. Developing guidelines would be the first step towards further standardization of the granted leave decisional process in forensic psychiatry and to make it more transparent for patients, staff members, hospital directors, and the government.

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Risk of contact with the criminal justice system (CJS) is greater among those with mental illness, including severe mental illness-an observation that many argue reflects a process of "criminalizing" mental illness. Forensic patients represent a subgroup at one end of a spectrum of such criminalization, typically with histories of serious violence and psychotic illness. Strategies for decriminalizing mental illness in this context should consider a range of approaches, including intervening to prevent CJS contact in those with severe mental illness, particularly in the early or emerging stages of psychosis. However, it may be that even gold standard mental healthcare applied universally is insufficient to address CJS contact risks. While there is now an extensive literature documenting the relatively low rates of repeat CJS contact for forensic patients released from secure care, appropriate comparison groups are lacking and the key ingredients of any benefits of treatment are unknown. The CJS may well have something to learn from forensic mental health systems and services given the abject failure to stem rates of prison-release reoffending internationally. Understanding how to best identify risk and effectively intervene to prevent CJS contact in those with mental illness, whether early in the course of psychosis or following release from secure care, remains a priority for those seeking to address the criminalization of mentally illness in our communities.

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INTRODUCTION: In recent years mental health officials have reported a rise in the number of forensic patients present within their state psychiatric hospitals and the adverse impacts that these trends had on their hospitals. To date there have been no large-scale national studies conducted to determine if these trends are specific only to a few states or representative of a more global trend. The purpose of this study was to investigate these reported trends and their national prevalence. METHODS: The forensic directors of each state behavioral health agency (including the District of Columbia) were sent an Excel spreadsheet that had two components: a questionnaire and data tables with information collected between 1996 and 2014 from the State Profiling System maintained by the National Association of State Mental Health Program Directors Research Institute. They were asked to verify and update these data and respond to the questionnaire. RESULTS: Responses showed a 76% increase nationally in the number of forensic patients in state psychiatric hospitals between 1999 and 2014. The largest increase was for individuals who were court-committed after being found incompetent to stand trial and in need of inpatient restoration services. DISCUSSION: The data reviewed here indicate that increases in forensic referrals to state psychiatric hospitals, while not uniform across all states, are nonetheless substantial. CONCLUSION: More research is needed to determine whether this multi-state trend is merely a coincidence of differing local factors occurring in many states, or a product of larger systemic factors affecting mental health agencies and the courts.

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The Mental Health (Forensic Provisions) Act 1990 (NSW) was amended in 2013 to include section 54 A, enabling an application to be made for the extension of a forensic patient's status. Thirteen patients were subject to an extension order between 2014 and 30 June 2018. Shared characteristics of these forensic patients were considered with a view to identifying the types of patients involved in these applications and the gaps in service provision that this might reflect. Nine out of the 13 patients subject to an extension order had a background of sexual offences, and all patients had either an intellectual disability and/or complex comorbid disorders, such as severe personality disorder. The extension orders coincide with gaps in the service provision in relation to the management of certain complex mental disorders, intellectual disability and problematic behaviours that lead to justice system involvement. The authors discuss the potential implications that these findings have for future resource allocation, legislative reform and service provision.