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A growing body of research suggests that an individual's willingness to fight and die for groups is rooted in the fusion of personal and group identities, especially when the group is threatened, violence is condoned, and the group's enemies are dehumanised or demonised. Here we consider whether the language used by extremists can help with early detection of these risk factors associated with violent extremism. We applied a new fusion-based linguistic violence risk assessment framework to a range of far-right extremist online groups from across the violence spectrum. We conducted an R-based NLP analysis to produce a Violence Risk Index, integrating statistically significant linguistic markers of terrorist manifestos as opposed to non-violent communiqués into one weighted risk assessment score for each group. The language-based violence risk scores for the far-right extremist groups were then compared to those of non-extremist control groups. We complemented our quantitative NLP analysis with qualitative insights that contextualise the violence markers detected in each group. Our results show that the fusion markers combined with several other variables identified across the different online datasets are indeed indicative of the real-world violence level associated with the relevant groups, pointing to new ways of detecting and preventing violent terrorism.

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OBJECTIVES: To explore the association between violent behaviors and emotions in individuals with mental disorders, to evaluate the application value of facial expression analysis technology in violence risk assessment of individuals with mental disorders in supervised settings, and to provide a reference for violence risk assessment. METHODS: Thirty-nine male individuals with mental disorders in supervised settings were selected, the participant risk of violence, cognitive function, psychiatric symptoms and severity were assessed using the Modified Overt Aggression Scale (MOAS), the Historical, Clinical, Risk Management-Chinese version(HCR-CV), the Positive and Negative Syndrome Scale (PANSS) and the Brief Psychiatric Rating Scale (BPRS). An emotional arousal was performed on the participants and the intensity of their emotions and facial expression action units was recorded before, during and after the arousal. One-way analysis of variance (ANOVA) was used to compare the differences in the intensity of emotions and facial expression action units before, during and after the arousal. Pearson correlation analysis was used to calculate the correlations between the intensity of the seven basic emotional facial expressions and the scores of the assessment scales. RESULTS: The intensity difference of sadness, surprise and fear in different time periods was statistically significant (P<0.05). The intensity of the left medial eyebrow lift action unit was found significantly different before and after the emotional arousal (P<0.05). The intensity of anger was positively correlated with the Modified Overt Aggression Scale score throughout the experiment (P<0.05). CONCLUSIONS: Eye action units such as eyebrow lifting, eyelid tightening and upper eyelid lifting can be used as effective action units to identify sadness, anger and other negative emotions associated with violent behaviors. Facial expression analysis technology can be used as an auxiliary tool to assess the potential risk of violence in individuals with mental disorders in supervised settings.

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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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Our knowledge of the severity and reoffending is limited for mentally disordered offenders, and studies generally evaluate without separation between different diagnostic groups. It was aimed to determine the general profile of mentally disordered offenders who are inpatients in a high secure psychiatry unit from Turkiye and to evaluate the factors associated with violence profiles among different diagnostic groups. According to the results the schizophrenia patients committed the most severe crimes, and intellectual disability patients had some different features from schizophrenia and bipolar disorder patients. History of substance misuse in the intellectual disability group (p = 0,045) and comorbid antisocial personality disorder in the bipolar disorder group (p = 0,015) were associated with increased crime severity. Substance misuse history, history of substance use during the crime, and the existence of comorbid antisocial personality disorder were associated with increased offenses in each of the three diagnosis groups. Living alone (p = 0,004) and having a suicide history (p= 0,052) were associated with the high number of offenses in the schizophrenia group. This study is the first study that compares three diagnostic groups to involve a large patient group. We believe that clinicians must evaluate these parameters for the violence risk assessment of patients.

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OBJECTIVE: The ability to assess a patient's risk of harm to self or others is a core competency for mental health clinicians which can have significant patient outcomes. With the growth of simulation in medical education, there is an opportunity to enhance education outcomes for psychiatric risk assessment. The purpose of this study was to determine how simulation is used to build competency in risk assessment and map its educational outcomes. METHODS: The authors conducted a systematic scoping review using the Arksey and O'Malley framework. Electronic database searches were conducted by an academic librarian. Studies published before August 2022 which described simulation activities aimed at training clinicians in suicide, self-harm, and/or violence risk assessment were screened for eligibility. RESULTS: Of the 21,814 articles identified, 58 studies were selected for inclusion. The majority described simulations teaching suicide risk assessment, and there was a notable gap for building competency in violence risk assessment. Simulation utility was demonstrated across emergency, inpatient, and outpatient settings involving adult and pediatric care. The most common simulation modality was patient actors. A smaller subset implemented technological approaches, such as automated virtual patient avatars. Outcomes included high learner satisfaction, and increases in psychiatric risk assessment knowledge, competency, and performance. CONCLUSION: Simulation as an adjuvant to existing medical curricula can be used to teach risk assessment in mental health. Based on the results of our review, the authors provide recommendations for medical educators looking to design and implement simulation in mental health education.

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Objectives: The study was aimed at measuring the impact of training on forensic case formulation in mental health and to provide more evidence on the reliability of the TEC-F. Method: Nine psychiatrists and six psychologists from various Latin American countries participated in a quasi-pedagogical experiment. The quality of formulations was independently and blindly measured pre- and post-intervention with the TEC-F and the assignment of two standard vignettes was also randomly manipulated. Quality mean differences and instrument reliability indicators were calculated. Results: The values of intraclass correlation coefficients were 0.92; 0.94; 0.83; 0.93 and 0.95 and the values of Cronbach's alpha coefficient were 0.83; 0.94; 0.63; 0.77 and 0.93, for the dimensions transparency, specificity, communication, reasoning and for the total TEC-F respectively. The results of the 19-day test-retest were excellent. The mean TEC-F total quality pre-course was 31.4 and the mean post-course, 38.4 (p = 0.003 and p = 0.001 for group test and paired test respectively). Conclusions: The pedagogical intervention produced a significant improvement in the quality of the expert's formulations. The study added evidence supporting the TEC-F reliability.

OBJETIVOS: El estudio se propuso medir el impacto de un entrenamiento sobre formulación pericial del caso forense en salud mental y extender evidencias relacionadas con la confiabilidad de la TEC-F. MÉTODO: Nueve psiquiatras y seis psicólogos de diversos países latinoamericanos participaron de un cuasi-experimento pedagógico. Se midió independientemente y a ciegas la calidad de las formulaciones con la TEC-F pre y post intervención y también se manipuló aleatoriamente la asignación de dos viñetas estándares. Se calcularon diferencias de medias e indicadores de confiabilidad del instrumento. RESULTADOS: Los valores de coeficientes de correlación intraclase fueron 0,92; 0,94; 0,83; 0,93 y 0,95 y los valores del coeficiente Alfa de Cronbach fueron 0,83; 0,94; 0,63; 0,77 y 0,93, para las dimensiones transparencia, especificidad, comunicación, fundamentación y para el total TEC-F respectivamente. Los resultados del test-retest a 19 días fueron excelentes. La media de calidad total TEC-F precurso fue 31,4 y la media post curso, 38,4 (p = 0,003 y p = 0,001 para prueba grupal y para prueba apareada respectivamente). CONCLUSIONES: La intervención pedagógica produjo una significativa mejoría en la calidad de las formulaciones periciales. El estudio adicionó evidencias sosteniendo la confiabilidad de la TEC-F.

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Introduction: Schizophrenia is associated with a heightened risk of violent behavior. However, conclusions on the nature of this relationship remain inconclusive. Equally, the empirical evidence on female patients with schizophrenia spectrum disorders (SSD) is strongly underrepresented. Methods: For this purpose, the first aim of the present retrospective follow-up study was to determine the risk factors of violence in a sample of 99 female SSD patients discharged from forensic psychiatric treatment between 2001 and 2017, using three different measures of violence at varying time points (i.e., violent index offense, inpatient violence, and violent recidivism). Potential risk factors were retrieved from the relevant literature on SSD as well as two violence risk assessment instruments (i.e., HCR-20 V3, FAM). Further, we aimed to assess the predictive validity of the HCR-20 V3 in terms of violent recidivism and evaluate the incremental validity of the FAM as a supplementary gender-responsive assessment. Results: The given results indicate strong heterogeneity between the assessed violence groups in terms of risk factors. Particularly, violence during the index offense was related to psychotic symptoms while inpatient violence was associated with affective and behavioral instability as well as violent ideation/intent, psychotic symptoms, and non-responsiveness to treatment. Lastly, violent recidivism was related to non-compliance, cognitive instability, lack of insight, childhood antisocial behavior, and poverty. Further, the application of the HCR-20 V3 resulted in moderate predictive accuracy (AUC = 0.695), while the supplementary assessment of the FAM did not add any incremental validity. Discussion: This article provides important insights into the risk factors of violence among female SSD patients while highlighting the importance of differentiating between various forms of violence. Equally, it substitutes the existing evidence on violence risk assessment in female offenders with SSD.

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INTRODUCTION: Workplace violence is a prevalent problem in health care, with mental health and emergency departments being the most at-risk settings. The aim of this evidence-based practice project was to pilot use of a violence risk assessment tool, the Broset Violence Checklist, to assess for risk of type II violence and record the interventions that nurses chose to implement to mitigate the situation. Additionally, reports made to the hospital reporting system were tracked and compared to previous reporting frequency. METHODS: Following staff education, nurses were instructed to complete checklists for all patients who have a score of 1 or higher, which indicates the presence of at least 1 high-risk behavior, and continue hourly scoring until the score returned to 0 or the patient was dispositioned. The number of incidents recorded, time of day, scores, interventions applied to mitigate violence, and change in scores after interventions were evaluated. The number of Broset Violence Checklist scoring sheets submitted and reports made via the hospital reporting system were compared. RESULTS: Incidents were most frequent from 11 am until 3 am. The highest scores occurred in the late evening and early morning hours. There were significantly more incidents captured with the use of the Broset Violence Checklist as compared to the hospital reporting system. Incidents significantly associated with higher scores included providing comfort measures, addressing concerns, and applying restraints. DISCUSSION: The Broset Violence Checklist was used successfully in the emergency department setting to identify behaviors associated with violence. Under-reporting to the hospital report system was identified in this project, consistent with reports in the literature. Specific interventions were not associated with a decrease in Broset Violence Checklist scores.

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Behavioral health professionals are charged with providing effective outpatient services while addressing patient and public safety, yet training in empirically-informed violence risk assessment strategies remains inaccessible. The authors developed and evaluated an online distance learning (ODL) course on clinical risk assessment targeting frontline providers and trainees in the United States. The ODL consisted of three modules: confidentiality, duty to third parties, and clinical assessment of violence risk. We evaluated the response characteristics and reach among different disciplines, as well as training satisfaction, change in knowledge, self-perceived competence, and self-reported impact on practice at six-week follow-up among 221 learners. Self-perceptions of competence and knowledge in the focal areas increased immediately after completing the training; self-perceived competence increased again by a significant margin at six-week follow-up. Participants reported a moderate-high positive impact of the training on practice.

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This study investigated item- and test-level functioning of the Structured Assessment of Violence Risk in Youth (SAVRY) and differential item functioning (DIF) across gender and race/ethnicity in justice-involved youth (JIY) using item response theory analysis. Participants were 868 JIY (23.7% female; 26.9% White, 50.9% Black, and 22.2% Hispanic) in pre-trial detention centers in Connecticut. Results obtained from the application of the graded response model showed that the SAVRY items were not equally discriminating JIY with varying levels of the latent trait, with "Poor compliance" as the most discriminating item and "History of self-harm or suicide attempts" as the least discriminating item. At the test level, the SAVRY provided precise (reliable) information about the latent trait for the majority of JIY whose latent trait between two standard deviations below and above the mean. Results of DIF revealed that six items operated inconsistently between White, Black, and Hispanic JIY, among which two items also functioned differentially across gender.

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We examined the long-term risk for stalking recidivism and the predictive validity of ratings made using the Guidelines for Stalking Assessment and Management (SAM) in 100 stalking offenders from a forensic clinic. Overall, 45 offenders were convicted of, charged with, or the subject of police investigation for stalking-related offenses during a potential time at risk that averaged 13.47 years. Survival analyses using the Cox proportional hazards model indicated that a composite score of the presence of SAM risk factors was significantly predictive of recidivism and had significant incremental validity relative to total scores on two scales commonly used in violence risk assessment, the Screening Version of the Hare Psychopathy Checklist-Revised (PCL:SV) and the Violence Risk Appraisal Guide (VRAG). Overall ratings of risk made using the SAM, however, were not significantly predictive of recidivism. We discuss the potential uses of the SAM in stalking risk assessment and provide recommendations for future research.

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A minority of psychiatric patients are unfit for general psychiatric care due to offensive behavior that renders them at risk of coming into contact with the criminal justice system. In the absence of criminal proceedings, these patients find themselves in the "gray zone" between general and forensic psychiatric care. To accommodate these patients, we established a "transforensic" ward. Instead of applying forensic treatment elements reactively (as part of a criminal sentence, after an offense has been committed), we applied it preventively (so as to avert offending behavior and resultant criminal sentences). Psychometric psychopathology and violence risk assessment scores were substantially lower at discharge than at admission (Cohen's ds = -0.3 to -0.6). These results offer ground for cautious optimism about the efficacy of transforensic care in serving as a safety net for psychiatric patients who are found to be unfit for general psychiatric care on account of their aggressive behavior.

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This study examined the discrimination and calibration properties of the Violence Risk Appraisal Guide-Revised (VRAG-R) within a large subset of the population of 574 individuals who had been found Not Criminally Responsible on Account of Mental Disorder (NCRMD) in Alberta. The VRAG-R was scored on all individuals identified via The Alberta NCR Project database from every file that contained sufficient relevant information and recidivism data were obtained via official criminal records. The VRAG-R demonstrated strong discrimination properties for general and violent recidivism over 5-year, 10-year, and global follow-ups. Calibration analyses, however, indicated that the VRAG-R substantially over estimated violence risk and that there was poor agreement between expected and observed recidivism rates for this population. When examined in the male subsample, these issues remained but to a lesser degree; examination of VRAG-R discrimination and calibration for females was not possible due to a lack of recidivists. Results indicated strong discrimination but poor calibration properties of the VRAG-R in this NCRMD population. Overall, the results support the use of the VRAG-R within a population of persons found NCRMD when employed in tandem with other measures as part of a comprehensive psychological risk assessment.

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Background: Violence Risk Screening Tool-10 (V-Risk-10) is one of the few instruments available for violence risk assessment in patients with a psychiatric diagnosis. The present study aimed to validate the Persian version of this instrument in patients admitted to the psychiatric ward. Materials and Methods: Eighty patients referred to a psychiatric hospital were enrolled in this cross-sectional methodological study. In the initial phase, seven senior psychiatry residents rated 20 cases independently at the time of their admission and total scale and subscale reliability were examined. Intraclass correlation coefficients were used to assess the inter-rater reliability. After initial confirmation of V-RISK-10 reliability, a senior psychiatry resident assessed 80 patients with V-RISK-10 in the emergency room. The incident of violent behaviors was recorded during the patients' admission period. The receiver operator characteristics curve (ROC-curve) analysis was used to measure the predictive accuracy of the instrument. The convergent validity was assessed by comparing V-RISK-10 scores between the three risk categories and the three outcome recommendations according to clinicians' overall clinical judgment. Results: A Cronbach's alpha coefficient was 0.99 for the total scale. During the research period, 47.5% of patients demonstrated various degrees of aggression and violent behavior. The ROC area under the curve was 0.89 (P < 0.001) with 87% sensitivity, 69% specificity, 72% positive predictive value, and 85% negative predictive value at the cutoff point of 8.5. Conclusion: Results indicate that the Persian version of V-Risk-10 is a reliable and valid screening tool for violence risk in patients who are admitted into psychiatric wards.

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Background: Little is known about people who are admitted to medium secure services (MSSs) from prison, including characteristics and factors that influence clinical pathways and subsequent discharge. We recently published the first study to establish the circumstances by which MSS "prison-transfer" patients are returned to prison. Of particular concern was the finding that a quarter of prison-transfer patients were returned to prison by Responsible Medical Officers (RMOs) because they were not engaging with treatment or were deemed too "high risk" to remain detained within the services, circumstances that would be unacceptable when considering discharge via a community care pathway. It is important to further explore the characteristics of people admitted to MSSs from prison, and to investigate how these may differ for individuals who are returned to prison, as compared to those discharged into the community. Aim: (a) To describe the characteristics of prison-transfers who receive an RMO directed discharge from MSSs; and (b) to compare these characteristics by discharge destination; prison return and community discharge. Methods: Prospective cohort comparative study: all prison-transfer patients discharged under the instruction of their RMO over a 6-month period, from 33 NHS medium secure units across England and Wales. Data on patient demographic, clinical and legal characteristics were extracted via full patient health record review and collateral information from clinicians was also obtained. This information was used to complete The Historical, Clinical and Risk--20 items (HCR-20v3) and The Structured Assessment of Protective Factors (SAPROF). Individuals who were returned to prison were compared with those who were discharged to the community. Results: Persons returned to prison represented a vulnerable group at time of discharge as compared to those discharged into the community and had a significantly shorter length of stay in MSSs. Over half of those returned to prison had a length of stay of <6 months. Individuals returned to prison displayed significantly more issues with psychological adjustment at time of discharge, and had a higher risk of future violence and a lower prevalence of protective factors that mitigate subsequent risks of relapse and reoffending. Discussion: MSs in England and Wales are returning vulnerable individuals to prison in lieu of adequate aftercare services. The role of and responsibilities of MSSs as regards admissions from prison needs to be reconsidered.

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This pilot study examined violence risk assessment among a sample of young adults receiving treatment for early psychosis. In this study, thirty participants were assessed for violence risk at baseline. Participants completed follow-up assessments at 3, 6, 9 and 12 months to ascertain prevalence of violent behavior. Individuals were on average 24.1 years old (SD = 3.3 years) and predominantly male (n = 24, 80%). In this sample, six people (20%) reported engaging in violence during the study period. Individuals who engaged in violence had higher levels of negative urgency (t(28) = 2.21, p = 0.035) This study sought to establish the feasibility, acceptability, and clinical utility of violence risk assessment for clients in treatment for early psychosis. Overall, this study found that most individuals with early psychosis in this study (who are in treatment) were not at risk of violence. Findings suggest that violent behavior among young adults with early psychosis is associated with increased negative urgency.

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Background: Adolescents are most at risk of engaging in violent interaction. Targeting violence risk and protective factors is essential for correctly understanding and assessing their role in potential violence. We aimed to use the Structured Assessment of Violence Risk in Youth (SAVRY) tool within the sample of adolescents to capture violence risk and protective factors and personality variables related to risk and protective factors. We further aimed to identify which violence risk and protective factors were positively or negatively related to violence within personal history and if any personality traits are typical for violent and non-violent adolescents. Identifying broader or underlying constructs within the SAVRY tool factor analysis can enable appropriate therapeutic targeting. Methods: We used the Czech standardized version of the SAVRY tool. The study sample comprised 175 men and 226 women aged 12-18 years divided into two categories according to the presence or absence of violence in their personal history. Mann-Whitney U test was used to compare numerical variables between the two groups. SAVRY factor analysis with varimax rotation was used to determine the item factors. We administered the High School Personality Questionnaire (HSPQ) to capture adolescents' personality characteristics. Results: In our sample, there were 151 participants with violence in their personal histories and 250 non-violent participants. Non-violent adolescents had higher values for all six SAVRY protective factors. The strongest protective factor was P3, Strong attachment and bonds across gender or a history of violence. Using factor analysis, we identified three SAVRY internal factors: social conduct, assimilation, and maladaptation. The SAVRY protective factors were significantly positively related to several factors in the HSPQ questionnaire. Conclusion: The results highlight the significance of protective factors and their relationship with violence prevalence. HSPQ diagnostics could be helpful in clinically targeting personality-based violence risks and protective factors. The therapeutic focus should be on tension, peer rejection, and anxiety. It is also essential to foster positive attitudes toward authority, prosocial behavior, and attitudes toward school. These strategies can help strengthen protective factors of the SAVRY.

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PURPOSE: To implement structured violence risk assessment (VRA) using the Dynamic Appraisal of Situational Aggression (DASA) on a 25-bed, adult, inpatient psychiatric unit. DESIGN AND METHODS: Inpatient DASA screening for 13 weeks with nursing communication orders (NCOs) to highlight patients at high risk for violence. Pre/posttests measured registered nurse (RN) knowledge and perceptions of the DASA. FINDINGS: DASA completion rate equaled 81.8% with an NCO issue rate of only 32.8%. RN perceptions of the DASA were positive, and knowledge of structured violence risk assessment increased. PRACTICE IMPLICATIONS: Structured violence risk assessment with the DASA is feasible and well-accepted on psychiatric units.

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BACKGROUND: In March 2020, the Norwegian government announced a COVID-19 lockdown in order to reduce the spread of the coronavirus. In Norway, lockdown measures included restricting people's ability to leave their home and the closing of social institutions, thus reducing the capacity for victims of intimate partner violence to alert someone outside of their home about violent incidents that occurred during lockdown. At the same time, the restrictive measures forced the victim and the perpetrator to stay together for prolonged periods within the home, and reduced the possibility for them to escape or leave the perpetrator. The aim of this study was to investigate how the frequency and character of intimate partner violence reported to the police changed during the period of lockdown in Norway. METHODS: All cases of intimate partner violence registered in police files before the pandemic (from January 2016-February 2020) and during lockdown in Norway (March-December 2020) were included in the study, representing a total of 974 cases. Differences in the number and severity of cases were calculated using χ2-tests and Wilcoxon's rank sum test. Differences in the characteristics of the reported violence was assessed with the Brief Spousal Assault form for the Evaluation of Risk (B-SAFER) and tested with Fischer's exact test with Bonferroni correction. Standardised Morbidity Rate (SMR) statistics were used to analyse the proportion of immigrants as compared to the general population. RESULTS: Reported intimate partner violence increased by 54% during the lockdown period in Norway. Between March-December 2020, the police assessed the cases as being at higher risk of imminent and severe violence. Our findings indicated an overrepresentation of immigrant perpetrators before and during lockdown (SMR = 1.814, 95% CI = 1.792-1.836 before, and SMR = 1.807, 95% CI = 1.742-1.872 during lockdown). Notably, while victims with an immigrant background were overrepresented before lockdown, we found significantly lower proportion of immigrant IPV victims during the lockdown period (SMR = 1.070, 95% CI = 1.052-1.087 before, and SMR = 0.835, CI 95% CI = 0.787-0.883 during lockdown). Also, there were significantly more female perpetrators and male victims reported to the police during the lockdown period. A higher proportion of the victims were assessed as having unsafe living conditions and personal problems during lockdown. Finally, during the lockdown period in Norway, a higher proportion of perpetrators had a history of intimate relationship problems. CONCLUSIONS: Intimate partner violence increased dramatically during the COVID-19 lockdown. A range of options for victims to escape from their perpetrators, particularly during times of crisis, should be developed in line with good practice, and with a special focus on the most vulnerable victims.

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