Positron emission tomography in male violent offenders with schizophrenia

The FDG PET brain scans from 31 offenders with schizophrenia and schizoaffecive disorder from a maximum security mental hospital were compared with those of normal controls (N = 6) in terms of relative FDG uptake in a range of regions covering frontal and temporal regions. The patient sample was divided into those who had a history of repetitive violent offending (RVO, N = 17) and those without a repetitive violent history (NRVO, N = 14) according to the violence rating of their pre-admission convictions. Reduced FDG uptake was noted at both the right and left anterior inferior temporal (R and L AIT) regions in NRVOs but only at LAIT in RVOs. NRVOs had significantly lower FDG uptake at RAIT than RVOs. The findings suggest that metabolic changes at AIT may be related to different patterns of violent offending in patients with schizophrenia.     

Victim relations and victim gender in violent crimes committed by offenders with schizophrenia

BACKGROUND: Family members and friends appear to be most at risk of becoming victims of violence committed by offenders with major mental disorders. The aim of the present study is to examine, in a national sample, victim relation in violent crimes committed by male offenders with schizophrenia, with special reference to victim gender and the severity of violence. METHOD: We identified all violent offenders who were diagnosed with schizophrenia in forensic psychiatric evaluations during the years 1992-2000 and examined their court convictions. In total 588 victims were included, 327 men and 261 women, and distributed into three groups based on their relation to the offender: Family of origin (n = 77), Network (n = 183) and Unacquainted (n = 328). RESULTS: The majority of the victims were unacquainted with the offender, but the violence was less severe in this group. Among family members, e. g. parents, siblings and grandparents, there were more female than male victims (60 % vs 40 %), and victims in families, as well as males within the offender's network, were those most likely to be seriously or fatally injured. Female family victims, in particular mothers, were those most likely to die as victims of severe violence. CONCLUSIONS: The study highlights the risk for family members and the immediate network of becoming a target of violence. Mental health services together with community-based services have an important task in identifying risk situations and taking preventive measures.     

The predictive validity of subjective adherence measures in patients with schizophrenia

Despite frequent use of subjective adherence measures in patients with schizophrenia as well as other chronic conditions, there are several reports that question the validity of these instruments. Three well known, representative subjective measures are the Medication Adherence Questionnaire (MAQ), the Drug Attitude Inventory (DAI), and the Compliance Rating Scale (CRS). In this study we explored the predictive validity of these instruments in a European sample of 119 stabilized outpatients with schizophrenia. Clinical outcome variables were relapse and admission to a psychiatric hospital during a follow‐up period of 12 months. Results indicate that the predictive validity of all three measures was poor. The MAQ was the least problematic predictor for relapse (Nagelkerke R² = 0.09), and time to relapse (R² = 0.07) and had the best sensitivity for relapse (63.6%) as well as admission (87.5%). The MAQ and CRS were both moderate predictive for admission (Nagelkerke R² = 0.21, and R² = 0.29). We conclude that the validity of the instruments studied here is questionable and have limited clinical relevance. Given the feasibility and ease of most subjective instruments, researchers may be tempted to use them but should be aware of the serious drawbacks of these instruments. Copyright © 2011 John Wiley & Sons, Ltd.     

The predictive validity of common risk assessment tools in men with intellectual disabilities and problematic sexual behaviors

This CIHR-funded study examined whether certain current risk assessment tools were effective in appraising risk of recidivism in a sample of sex offenders with intellectual disabilities (ID). Fifty men with ID who had engaged in problematic sexual behavior (PSB) were followed for an average of 2.5 years. Recidivism was defined and measured as any illegal or problematic behavior, as well as any problematic but not necessarily illegal behavior. At the beginning of the study, each participant was rated on two risk assessment tools: the Violence Risk Appraisal Guide (VRAG) and the Sex Offender Risk Appraisal Guide (SORAG). During each month of follow-up, participants were also rated on the Short-Dynamic Risk Scale (SDRS), an assessment tool intended to measure the risk of future problematic behaviors. Data was analyzed using t-tests, Cohen’s d and area under the curve (AUC) to test predictive validity of the assessment tools. Using the AUC, results showed that the VRAG was predictive of sexual (AUC = 0.74), sexual and/or violent (AUC = 0.71) and of any criminally chargeable event (AUC = 0.69). The SORAG was only significantly predictive of sexual events (AUC = 0.70) and the SDRS was predictive of violent events (AUC = 0.71). The t-test and Cohen’s d analyses, which are less robust to deviations from the assumptions of normal and continuous distribution than AUC, did not yield significant results in each category, and therefore, while the results of this study suggest that the VRAG and the SORAG may be effective tools in measuring the short term risk of sexual recidivism; and the VRAG and SDRS may be effective tools in appraising long term risk of sexual and/or violent recidivism in this population, it should be used with caution. Regardless of the assessment tool used, risk assessments should take into account the differences between sex offenders with and without ID to ensure effective measurement.     

Revisiting the relapse predictive validity of prodromal symptoms in schizophrenia

After recovering from a first episode in schizophrenia, relapse prevention is a major objective and long-term treatment is indicated. Due to empirical findings regarding relapse preventive efficacy of antipsychotics, guidelines recommend maintenance neuroleptic treatment, which however is not feasible for all patients. Both under maintenance treatment and drug withdrawal, doctors and patients try to anticipate a reexacerbation by means of early signs of relapse in order to intervene as early as possible. Prodromal symptoms are supposed to be such early indicators, although empirical evidence is not uniform. In order to prepare a new research program, data from an earlier study were reanalyzed to examine the relapse predictive validity of prodromal symptoms. 339 outpatients observed prospectively for 2 years under different long-term treatment strategies were included in this analysis resulting in a total amount of 5861 observations/visits. Several prognostic parameters were computed regarding relationship between clinical state (relapse yes/no) and the occurrence of prodromal symptoms the immediate visit before. As to the results, none of the 22 single prodromal symptoms exceeded a sensitivity of 40%, with specificities ranging from 69% to 95%. An overall prodrome score led to a sensitivity of 72%, however specificity declined to 38%. The performed logistic regression analyses including other potential predictors (psychopathology, clinical change etc.) yielded other relevant 'early signs'. It is concluded that the relapse predictive validity of prodromal symptoms has to be enhanced e.g. by supplement of other clinical parameters with predictive potential or by closer monitoring.     

Concurrent and predictive validity of components of disordered thinking in schizophrenia

Although the various manifestations of disordered thought have played a central role in diagnostic and theoretical considerations of schizophrenia, such symptoms have not been found specific to schizophrenia, and at best have shown weak relations to outcome. As part of a 7-year followup study of a sample of young, acute, psychotic inpatients, we explored the hypothesis that despite these poor results there might be particular components of disordered thought that might have prognostic utility and be able to discriminate narrowly defined schizophrenics. Using extant symptom scales as our models, we constructed five internally consistent scales of disordered thought from behavioral ratings made using the Psychotic Inpatient Profile--Poverty of Speech, Attentional Impairment, Incoherence, Delusions, and Hallucinations. We tested the ability of these scales to predict various aspects of outcome adaptation including outcome diagnosis. In general, the Attentional Impairment scale demonstrated the best prognostic utility, predicting poorer outcome in several domains. Paradoxically, patients diagnosed by Research Diagnostic Criteria (RDC) as definite schizophrenic at outcome had been rated as showing less attentional impairment than probable and nonschizophrenics. An examination of the pattern of correlations between Attentional Impairment and performance on cognitive tasks suggested that attentional difficulties may be related to different underlying cognitive processes in those diagnosed schizophrenic and nonschizophrenic at outcome by RDC.     

Diagnostic validity of assessment scales for depression in patients with schizophrenia

The aim of this study was to examine the diagnostic validity of four commonly used assessment scales for depression in schizophrenia. The study population consisted of 84 inpatients meeting the DSM-IV criteria for schizophrenia. Depression in the study subjects was defined by the DSM-IV criteria for major depressive episode. The Positive and Negative Syndrome Scale (PANSS) and the Simpson-Angus Rating Scale (SARS) were used to differentiate depression from the negative and extrapyramidal symptom-related depressive phenomena in schizophrenia. The following four depression scales were assessed for their diagnostic validity as measures of depressive disorder in schizophrenia: the Calgary Depression Scale for Schizophrenia (CDSS), the Beck Depression Inventory (BDI), the Hamilton Rating Scale for Depression (HAM-D), and the depression subscale of the PANSS (PANSS-D). Of 84 patients with schizophrenia, 32 were diagnosed as having comorbid depressive disorder. The areas under the Receiver Operating Characteristic (ROC) curves of the CDSS, HAM-D, PANSS-D, and BDI were 0.94, 0.89, 0.90, and 0.81, respectively. The area under the ROC curve of the CDSS was significantly greater than that of the BDI and tended to be more favorable than those for the HAM-D and the PANSS-D. Our study suggests that the CDSS may provide the best assessment for depression in patients with schizophrenia.     

Structured assessment of violence risk in schizophrenia and other psychiatric disorders: a systematic review of the validity, reliability, and item content of 10 available instruments

Objectives: To undertake a systematic review on structured violence risk assessment tools in individuals with schizophrenia. Methods: A systematic search was conducted from 1990 to 2011 to identify violence risk assessment tools and studies examining their predictive validity. Item content of the identified instruments was analyzed, and areas under the curve (AUC) from the studies were extracted. In addition, an 11-item checklist was developed to assess the utility and psychometric properties of these tools. Results: Ten risk assessment tools designed to predict community violence in psychiatric patients were identified, but only 2 studies reporting predictive validity estimates in patients with schizophrenia were found (median AUC = 0.69; interquartile range = 0.60–0.77). When inclusion criteria was broadened to include studies measuring accuracy for any diagnostic group, mixed evidence of predictive validity was found, with median AUCs ranging from 0.62 to 0.85 depending on the population. Item content included mostly clinical, sociodemographic, and criminal history factors. As only 1 tool included a neurobiological item, a structured review of brain-based and cognitive risk factors for violence was included, and 3 clusters (neurocognitive ability, neurocognitive awareness, and attitudinal cognition) were identified. Conclusions: While a number of violence risk assessment tools exist that can be used to predict the likelihood of community violence in psychiatric patients, there is currently little direct evidence for their utility in individuals with schizophrenia. In addition, there is large variation in item content between instruments, and further research is necessary to determine whether the inclusion of alternative factors could improve risk assessment.     

精神分裂症患者凶杀行为多因素分析

目的探讨精神分裂症患者凶杀行为的影响因素。方法应用人口学资料、阳性与阴性症状量表（PANSS）、明尼苏达多相人格调查表（MMPI）、生活事件量表（LES）和社会支持评定量表（SSRs）等对31例具有凶杀行为的精神分裂症患者和50例无凶杀行为的患者进行对照研究。结果两组的PANSS量表阳性症状量表分、阴性症状量表分、MMPI的D（抑郁）、Hy（癔病）、Pd（人格偏移）,Mf（男性化和女性化）、Pa（偏执）、Pt（精神衰弱）、Sc（精神分裂症）、Si（社会内向性）量表分、负性事件刺激量、客观支持量表分等项目得分的差异,有统计学显著意义。多因素分析中,阴性症状,客观支持,D,Mf,Pt,sc进入回归方程。结论本研究提示负性事件、阴性症状、客观支持、D、Mf、Pt、Sc与精神分裂症患者凶杀行为有关联,可作为其预测因子。     

Investigating the predictive validity of Static-99/99R scores in a sample of older sexual offenders

There is limited information regarding the use of risk assessment tools with aging offender populations. It is known that the likelihood of offending behaviour decreases with age, a small group of men either continue or begin to offend sexually in the later decades of life. The current study investigated the predictive validity of the Static-99 and the Static-99R, in a sample of convicted Australian sex offenders aged 50 and older. A sample of 118 participants was identified, of which 17 (14.4%) re-offended within a follow-up period ranging from four months to 20 years (M = 9.07 years). There were seven recidivists (13.46%) above the age of 60 years (n = 52) and 10 aged 40 to 59.9 years (n = 66). Both the Static-99 and Static-99R demonstrated moderate predictive validity with both age groups. The limitations of this study are discussed as well as recommendations for future research.Key words: age correction, aged, aged sexual offenders, Australia, predictive validity, recidivism, risk assessment, sexual offenders, Static-99, Static-99R

Sexual offending is recognised as a significant social problem that can cause both short- and long-term harm to victims (Dworkin, Menon, Bystrynski, & Allen, 2017). As such, risk factors associated with repeated sexual offending have received considerable research attention in an attempt to guide efforts to prevent repeat sexual offending (e.g. Fazel, Sjostedt, Langstrom, & Grann, 2006; Hanson & Bussiere, 1998; Hanson & Morton-Bourgon, 2005; Mann, Hanson, & Thornton, 2010). The assessment of risk for sexual recidivism has been a focus of court decisions and treatment options for several decades. This has led to the development of a number of risk assessment tools. Some of these are mechanical in nature (i.e. actuarial instruments, e.g. Hanson, 2001), while others involve a degree of clinical discretion (i.e. structured professional judgment tools; see Davis & Ogloff, 2008). For these instruments to contribute to the legal process and treatment recommendations, their accuracy in different populations is important. One particular population that has seen little research regarding risk assessment tools is aged sex offenders.Age has been found to be a critical variable when assessing offender risk. As an offender ages, the risk of recidivism of all kinds generally decreases (Book, Starzyk, & Quinsey, 2001; Hanson, 2001; Hanson, Harris, Helmus, & Thornton, 2014; Rice & Harris, 2014). Being over the age of 50 years, in particular, is thought to be protective against non-sexual or sexual recidivism; as well as being protective against first-time sexual offending (Booth, 2016; Nicholaichuk, Olver, Gu, & Wong, 2014; Rettenberger, Haubner-Maclean, & Eher, 2013). It has been posited that this protective effect encompasses a range of issues such as reduced libido, restrictive ailments, frailty and greater likelihood of living in restrictive environments such as nursing homes (Bauer, Fetherstonhaugh, et al., 2013; Bauer, McAuliffe, Nay, & Chenco, 2013).Despite age generally appearing to be protective against offending, the number of older offenders in correctional systems continues to increase as the populations of most industrialised countries age. In Australia, for example, prisoners over the age of 50 years accounted for 12.8% of the total prison population in 2017, compared to 11.3% in 2010 and 8.5% in 2000 (Australian Bureau of Statistics, 2018). The increasing number of older Australian prisoners reflects a worldwide trend in prison populations, with sexual offenders projected to be a particularly common group among older prisoners (Chua, Cheung, Friedman, & Taylor, 2018). In Australia, the majority of prisoners over the age of 50 years are imprisoned due to sexual offending (Australian Bureau of Statistics, 2018; Chua et al., 2018). Given the increasing number of aged sexual offenders in prison and probation systems, it is essential that common risk assessment instruments that are used to determine security and rehabilitation programme placements, and even influence release decision making, can be shown to be valid with this group. The most commonly used actuarial instruments, both in Australia and worldwide, are the Static-99 family of instruments developed by Hanson and Thornton (2000).     

The concurrent and predictive validity of symptomatic remission criteria in first-episode schizophrenia

BackgroundSince the introduction of consensus criteria for symptomatic remission in 2005, most first-episode studies focused on cross-sectional relationship between remission status and functional outcome. Predictive validity of the proposed remission definition was under-studied. Relationship of remission with subjective quality of life (QoL) was inadequately addressed with inconsistent findings being observed.MethodOne hundred and four Hong Kong Chinese aged 18 to 55 years presenting with first-episode schizophrenia-spectrum disorder were studied. Socio-demographics, baseline clinical and functioning profiles were obtained. Psychopathological and functional reassessments were conducted at 6, 12 and 24 months. Subjective QoL was measured at 12 and 24 months. Symptomatic remission was operationally defined according to the consensus criteria developed by the Remission in Schizophrenia Working Group (RSWG), comprising both symptom-severity and 6-month duration components.ResultsAt 12 months, 59.6% of patients achieved symptomatic remission. Remitted patients had significantly lower symptom severity, more favorable psychosocial functioning and better subjective QoL at 12 months than non-remitted counterparts. Attainment of remission at 12 months was significantly associated with fewer positive, negative, depressive and disorganization symptoms, higher levels of functioning and subjective QoL at 24 months. Linear regression analysis indicated that remission status independently predicted functional outcome even when the effects of educational level, baseline functioning and negative symptom scores were controlled for.ConclusionThe operationally defined symptomatic remission formulated by the RSWG represented a clinically valid construct that was found to be closely related to both concurrent and longitudinal outcomes on psychopathology, functioning and subjective QoL in the early stage of schizophrenia.     

Parent-infant relationship global assessment scale: a study of its predictive validity

The Parent-Infant Relationship Global Assessment Scale (PIRGAS; Zero to Three, 1994) provides a continuously distributed scale of infant-parent relationship adaptation, raging from 'well-adapted' to 'dangerously impaired'. The present study examines the predictive validity of the PIRGAS in a high-risk sample by coding relationship adaptation level from a single sample of 10 min of unstructured free play between mothers and their 20-month-old infants and examining its relationship to subsequent interaction with mothers and behavior problems at 24 months. Relationship adaptation assessed reliably from observations of only 10 min of free play between mothers and their infants at 20 months of age using PIRGAS predicted subsequent mother- infant interaction in a laboratory based problem-solving paradigm (Crowell procedure) at 24 months and internalizing symptomatology of Child Behavior Checklist at age 24 months. These results contribute to the predictive validity of the PIRGAS as a measure of mother-infant relationship adaptation.     

Neural correlates of risk taking in violent criminal offenders characterized by emotional hypo- and hyper-reactivity

Recent approaches suggest that emotional reactivity can be used to differentiate between subgroups of individuals who are at risk for showing elevated levels of aggression and violence. In this study, we examined how emotion governs decision making within two subgroups of antisocial criminal offenders with either emotional hypo- or hyper-reactivity compared with healthy, noncriminal controls. Offenders were recruited from high-security forensic treatment facilities and penal institutions and underwent functional magnetic resonance imaging during a financial decision-making task. In this task, participants were required to choose between low-risk (bonds) and high-risk alternatives (stocks). Bonds were always the safe choice; stocks could win or lose, with a varying degree of uncertainty. We found that emotionally hypo-reactive offenders differed most from healthy controls by showing diminished neural activation in the rostral anterior cingulate cortex in response to uncertainty as well as decreased activity in the prefrontal cortex when trying to regulate their behavior accordingly (i.e., when consistently choosing “safe alternatives”). Hence, the data indicate that emotionally hypo-reactive offenders (with psychopathic traits) constitute a special subgroup within antisocial offenders characterized in particular by a limited capacity to emotionally represent uncertainty and to anticipate punishment.     

上海流浪精神分裂症患者心血管危险因素患病率的回顾性评估(英文)

背景:心血管疾病在中国日益增长,但是贫困精神病患者心血管疾病的危险因素患病率尚不明确。目标:评估无家可归的精神分裂症患者中心血管疾病四个主要危险因素的患病率-高血压,高血糖,高血脂及吸烟-并确定与这些危险因素相关的因素。方法:我们回顾了从2007年5月到2013年4月期间,在上海嘉定精神卫生中心住院的精神分裂症以及分裂样精神病患者病历,包括181名无家可归的患者和181非无家可归的患者。比较了两组间人口学特征和心血管事件的危险因素。使用逻辑回归模型确定了与四个风险因素中一种或多种存在关联的因素。结果:两组患者的高血压和高血脂症的患病率范围为19%到20%(男性和女性的患病率范围相同);这些比率和一般人群报道的相似。两组患者的高血糖患病率介于11%和15%之间(男性和女性的患病率范围相同)。在男性患者中吸烟是非常普遍的(无家可归男性吸烟率82%,非无家可归男性吸烟率78%),但是在中国女性患者吸烟远没有那么普遍(无家可归女性吸烟率7%,非无家可归女性吸烟率5%)。Logistic回归分析发现,男性,年龄,城市(与农村相比)与四大心血管危险因素中的一种或多种独立相关。无家可归与心血管危险因素的患病率不相关。结论:本研究是对中国流浪精神病患者的心血管危险因素的第一个研究报告。这项研究有几个重要因素没有评估(如抗精神病药物的类型、剂量和使用时间),尽管如此,该研究还是能表明在中国,流浪与精神疾病患者心血管疾病风险增高无关,与高等收入国家不同。对于中国不断增多的流浪者而言,还需要进一步的前瞻性研究来探索他们所需的最佳医疗服务模式。     

Feasibility and validity of computerized ecological momentary assessment in schizophrenia

BACKGROUND: Computerized Ecological Momentary Assessment (EMAc) techniques permit the assessment of daily life behaviors and experiences. The present investigation examined the feasibility and validity of this assessment methodology in outpatients with schizophrenia. METHODS: Outpatients with schizophrenia or schizoaffective disorder (n = 54) received a battery of standard laboratory clinical and functional outcome measures and then completed electronic questionnaires on a personal digital assistant (PDA) microcomputer 4 times per day for 1 week. RESULTS: Generally good compliance (87%) with EMAc was found, and participants rated their experience with the study positively. The data collected in daily life demonstrated expected patterns across the assessment week and were significantly associated with scores from standard laboratory instruments measuring similar constructs. CONCLUSIONS: EMAc is a feasible and valid approach to data collection in community-dwelling people with schizophrenia, and it may provide important information that is inaccessible via standard clinical and functional outcome measures administered in the laboratory.     

Early and late components of error monitoring in violent offenders with psychopathy

BACKGROUND: One of the most recognizable features of psychopathy is the reduced ability to successfully learn and adapt overt behavior. This might be due to deficient processing of error information indicating the need to adapt controlled behavior. METHODS: Event-related potentials (ERPs) and behavioral components of error-monitoring processes were investigated in 16 individuals with psychopathy and in 18 healthy subjects. A letter version of the Eriksen flanker task was used in two conditions. The first condition (normal condition) required participants to press one of two buttons depending on the identity of the target stimulus. The second condition (signaling condition) required them to signal each time they had committed an error by making a second press on a signaling button. Early stages of error monitoring were investigated by using the error-related negativity (ERN/Ne) and post-error slowing as indexes. Later stages were explored by examining the error positivity (Pe) and signaling rates. RESULTS: Both groups showed similar ERN amplitudes and amounts of post-error slowing. The psychopathic group exhibited both reduced Pe amplitudes and diminished error-signaling rates compared with the control group. CONCLUSIONS: Individuals with psychopathy show intact early error processing and automatic behavioral adaptation but have deficits in later stages of error processing and controlled behavioral adaptation. This is an indication that individuals with psychopathy are unable to effectively use error information to change their behavior adequately.