Dorte Sestoft

A longitudinal study of prisoners on remand: psychiatric prevalence, incidence and psychopathology in solitary vs.non‐solitary confinement

Objective: To compare two levels of stress (solitary confinement (SC) and non‐SC) among remand prisoners as to incidence of psychiatric disorders in relation to prevalent disorders.

Psychopathy and psychopathological profiles in prisoners on remand.

A total of 178 Danish male remand prisoners were examined using comprehensive interviews and questionnaires on psychopathological, personality and social measures. and file data. These data were compared with scores on the Hare Psychopathy Checklist — Revised (PCL‐R). Subjects were divided into four groups according to quartile PCL‐R scores. In general there were high rates of psychiatric morbidity in all PCL‐K quartile groups. The medium‐high scorers represent a more vulnerable group with a high prevalence of dependence disorders, relatively high neuroticism score and relatively high prevalence of neurotic and stress‐related disorders. The high scorers were more psychosocially maladjusted, had more often made previous suicidal attempts, and had a higher psychoticism score. Chronic psychotic disorders did occur, mostly in the high‐scoring group. The population had lower scores on the PCL‐R than in most previous studies, suggesting a lower prevalence of psychopathic features among Danish criminals and possibly a lower cut‐off point when using the PCL‐R as a categorical measure. Both findings are consistent with the results of other European studies. Further studies on cross‐cultural differences with regard to PCL‐R psychopathic features and on psychic vulnerability related to PCL‐R scores and factor l/factor 2 of the PCL‐R are suggested.

Mechanical Restraint—Which Interventions Prevent Episodes of Mechanical Restraint?—A Systematic Review

PURPOSE To identify interventions preventing mechanical restraints. DESIGN AND METHODS Systematic review of international research papers dealing with mechanical restraint. The review combines qualitative and quantitative research in a new way, describing the quality of evidence and the effect of intervention. FINDINGS Implementation of cognitive milieu therapy, combined interventions, and patient-centered care were the three interventions most likely to reduce the number of mechanical restraints. PRACTICE IMPLICATIONS There is a lack of high-quality and effective intervention studies. This leaves patients and metal health professionals with uncertainty when choosing interventions in an attempt to prevent mechanical restraints.

Mechanical restraint in psychiatry: preventive factors in theory and practice. A Danish-Norwegian association study.

PURPOSE To examine how potential mechanical restraint preventive factors in hospitals are associated with the frequency of mechanical restraint episodes. DESIGN AND METHODS This study employed a retrospective association design, and linear regression was used to assess the associations. FINDINGS Three mechanical restraint preventive factors were significantly associated with low rates of mechanical restraint use: mandatory review (exp[B] = .36, p < .01), patient involvement (exp[B] = .42, p < .01), and no crowding (exp[B] = .54, p < .01). PRACTICE IMPLICATIONS None of the three mechanical restraint preventive factors presented any adverse effects; therefore, units should seriously consider implementing these measures.

Serotonin 1B Receptor Binding Is Associated With Trait Anger and Level of Psychopathy in Violent Offenders.

BACKGROUND The involvement of serotonin in aggression has traditionally been attributed to impaired prefrontal serotonergic inhibitory control of emotional reactions to provocations in antisocial individuals. However, it is unclear which specific serotonergic receptors are involved in the effects. A large body of preclinical research supports a specific role of serotonin 1B receptors (5-HT1BRs) in aggression and impulsivity, but this has never been evaluated in humans. METHODS Nineteen incarcerated violent offenders and 24 healthy control nonoffenders were included and examined with positron emission tomography, using the radioligand [11C]AZ10419369 for quantification of cerebral 5-HT1BR binding in three regions of interest: the anterior cingulate cortex, orbitofrontal cortex, and striatum. RESULTS Group status significantly moderated the association between striatal 5-HT1BRs and trait anger (difference in slopes, pcorrected = .04). In the violent offender group, striatal 5-HT1BR binding was positively correlated with self-reported trait anger (p = .0004), trait psychopathy (p = .008), and level of psychopathy according to the Psychopathy Checklist-Revised (p = .02). We found no group differences in 5-HT1BR binding. CONCLUSIONS Our data demonstrate for the first time in humans a specific involvement of 5-HT1BR binding in anger and psychopathy. 5-HT1BRs putatively represent a molecular target for development of pharmacologic antiaggressive treatments.

Ganser syndrome after solitary confinement in prison: A short review and a case report

A short review of the Ganser syndrome is given. The condition is a rare, probably dissociative, disorder with transient Vorbeireden as the central symptom. The case of a middle-aged man developing a transient Ganser syndrome after long-term solitary confinement in a remand prison is presented. Systematic investigation of 268 remand prisoners confirms the rarity of the syndrome, as only the case subject had this disorder.A short review of the Ganser syndrome is given. The condition is a rare, probably dissociative, disorder with transient Vorbeireden as the central symptom. The case of a middle-aged man developing a transient Ganser syndrome after long-term solitary confinement in a remand prison is presented. Systematic investigation of 268 remand prisoners confirms the rarity of the syndrome, as only the case subject had this disorder.

Heroin dependence: Consequences and precursors related to route of administration

Two random samples of Danish prisoners on remand (solitary confinement (SC) and non-SC)) were examined using semistructured and standardized psychiatric and social interviews, cognitive tests, and questionnaires. Heroin dependence was divided into injection heroin dependence (IHD) and smoke heroin dependence (SHD). Comparisons corrected for confounders were made with regard to IHD versus SHD and dependent versus non-dependent subjects. Thirty-two per cent of the sample had lifetime heroin dependence, and the IHD versus SHD ratio was 3:1. The IHD subjects were more severely strained than SHD with regard to somatic complications (blood-transferred infections), early social strain, psychiatric comorbidity (mood disorders), personality dimensions (introversion), and cognitive performance (low performance scale score). The IHD subjects were considered more vulnerable than SHD subjects, both premorbid and during the dependence. SHD subjects may be recruited from other groups than the traditional (that is, IHD) ...

Comparing the effect of non-medical mechanical restraint preventive factors between psychiatric units in Denmark and Norway.

Abstract Background: The use of mechanical restraint (MR) is controversial, and large differences regarding the use of MR are often found among countries. In an earlier study, we observed that MR was used twice as frequently in Denmark than Norway. Aims: To examine how presumed MR preventive factors of non-medical origin may explain the differing number of MR episodes between Denmark and Norway. Methods: This study is a cross-sectional survey of psychiatric units. Linear regression was used to assess the confounding effects of the MR preventive factors, i.e. whether a difference in the impact of these factors is evident between Denmark and Norway. Results: Six MR preventive factors confounded [∆exp(B)> 10%] the difference in MR use between Denmark and Norway, including staff education (− 51%), substitute staff (− 17%), acceptable work environment (− 15%), separation of acutely disturbed patients (13%), patient–staff ratio (− 11%), and the identification of the patients crisis triggers (− 10%). Conclusions: These six MR preventive factors might partially explain the difference in the frequency of MR episodes observed in the two countries, i.e. higher numbers in Denmark than Norway. One MR preventive factor was not supported by earlier research, the identification of the patients crisis triggers; therefore, more research on the mechanisms involved is needed. Clinical implications: None of the six MR preventive factors presents any adverse effects; therefore, units in Denmark and Norway may consider investigating the effect of implementing, the identification of the patients crisis triggers, an increased number of staff per patient, increased staff education, a better work environment and reduced use of substitute staff in practice.

Sensitivity and specificity of the Brøset Violence Checklist as predictor of violence in forensic psychiatry

Abstract Background: Violence and aggressive behavior within psychiatric facilities are serious work environment problems, which have negative consequences for both patients and staff. It is therefore of great importance to reduce both the number and the severity of these violent incidents to improve quality of care. Aims: To evaluate the specificity and sensitivity of the Brøset Violence Checklist (BVC) as a predictor of violent incidents for Danish forensic psychiatry patients. Method: A total of 156 patients were assessed three times daily with the BVC for 24 months. All aggressive or violent incidents were recorded using the Staff Observation Aggression Scale-Revised (SOAS-R). SOAS-R scores of 9 or more defined violent incidents. Data were analyzed using standard logistic regression models as well as models incorporating a random person effect. We used receiver operating curve (ROC) analysis to evaluate different BVC thresholds. Results: Of a total of 139,579 BVC registrations we found 1999 scores above 0 and 419 violent incidents. The BVC score was a strong predictor of violence. For the standard cut-off point of 3, specificity was 0.997 and sensitivity was 0.656. For the general risk of violence seen in this study, the risk of violence given a BVC score > 3 (positive predictive value) was 37.2%, and the risk of violence given a BVC score < 3 (negative predictive value) was 0.1%. Conclusion: The BVC showed satisfactory specificity and sensitivity as a predictor of the short-term risk of violence against staff and others by patients in a forensic setting.

Violent offenders respond to provocations with high amygdala and striatal reactivity.

Abstract The ability to successfully suppress impulses and angry affect is fundamental to control aggressive reactions following provocations. The aim of this study was to examine neural responses to provocations and aggression using a laboratory model of reactive aggression. We used a novel functional magnetic resonance imaging point-subtraction aggression paradigm in 44 men, of whom 18 were incarcerated violent offenders and 26 were control non-offenders. We measured brain activation following provocations (monetary subtractions), while the subjects had the possibility to behave aggressively or pursue monetary rewards. The violent offenders behaved more aggressively than controls (aggression frequency 150 vs 84, P = 0.03) and showed significantly higher brain reactivity to provocations within the amygdala and striatum, as well as reduced amygdala-prefrontal and striato-prefrontal connectivity. Amygdala reactivity to provocations was positively correlated with task-related behavior in the violent offenders. Across groups, striatal and prefrontal reactivity to provocations was positively associated with trait anger and trait aggression. These results suggest that violent individuals display abnormally high neural sensitivity to social provocations, a sensitivity related to aggressive behavior. These findings provide novel insight into the neural pathways that are sensitive to provocations, which is critical to more effectively shaped interventions that aim to reduce pathological aggressive behavior.