Marike Lancel

Poor sleep as a potential causal factor in aggression and violence

Clinical observations suggest that sleep problems may be a causal factor in the development of reactive aggression and violence. In this review we give an overview of existing literature on the relation between poor sleep and aggression, irritability, and hostility. Correlational studies are supporting such a relationship. Although limited in number, some studies suggest that treatment of sleep disturbances reduces aggressiveness and problematic behavior. In line with this is the finding that sleep deprivation actually increases aggressive behavior in animals and angriness, short-temperedness, and the outward expression of aggressive impulses in humans. In most people poor sleep will not evoke actual physical aggression, but certain individuals, such as forensic psychiatric patients, may be particularly vulnerable to the emotional dysregulating effects of sleep disturbances. The relation between sleep problems and aggression may be mediated by the negative effect of sleep loss on prefrontal cortical functioning. This most likely contributes to loss of control over emotions, including loss of the regulation of aggressive impulses to context-appropriate behavior. Other potential contributing mechanisms connecting sleep problems to aggression and violence are most likely found within the central serotonergic and the hypothalamic-pituitary-adrenal-axis. Individual variation within these neurobiological systems may be responsible for amplified aggressive responses induced by sleep loss in certain individuals. It is of great importance to identify the individuals at risk, since recognition and adequate treatment of their sleep problems may reduce aggressive and violent incidents.

The relation between poor sleep, impulsivity and aggression in forensic psychiatric patients.

Psychiatric disorders are often associated with disturbed sleep. Poor sleep can attenuate emotional control, including the regulation of aggression, and thus, may increase the risk of impulsive, aggressive acts. This cross-sectional study aimed to investigate the potential contribution of sleep problems to subjective and objective aggressiveness and impulsivity in a forensic psychiatric population. Questionnaires on sleep quality (Pittsburgh Sleep Quality Index), chronic severe insomnia (Sleep Diagnosis List), aggressiveness (Aggression Questionnaire) and impulsivity (Barratt Impulsiveness Scale-11) were completed by 96 forensic psychiatric inpatients, admitted to two forensic facilities in the Netherlands. To obtain more objective measurements of aggression and impulsivity, observational scores on a professional instrument to assess the risk of future aggression (Historical Clinical Future-30) and reported aggressive incidents were collected from files. Results showed that a worse sleep quality and higher insomnia scores were significantly associated with self-reported aggression and impulsivity, clinician-rated hostility and involvement in aggressive incidents within the facility. Whether a participant was professionally judged as impulsive could not be predicted by sleep quality or the insomnia score. To a large extent the results of this study support the hypothesis that poor sleep is related to impulsive, aggressive behavior in forensic psychiatric patients. It is worthwhile to examine the protective effect of treatment of sleep difficulties on aggressive reactivity in (forensic) psychiatric populations.

Violent women: a multicentre study into gender differences in forensic psychiatric patients

Abstract To gain insight into the relatively small, but increasing group of women in forensic psychiatry, a retrospective multicentre study was started gathering information from the files of 275 female patients of four Dutch forensic psychiatric hospitals on characteristics and violence risk factors. Overall, a picture emerged of severely traumatized women with complex psychopathology with multiple previous treatment failures and many incidents during treatment. The present study investigates specific psychiatric and criminal characteristics of female patients by comparing their data to those of 275 male forensic psychiatric patients. Various prominent differences were found, for example, women had more complex histories of victimization, were more often diagnosed with borderline personality disorder, were more likely to commit homicide and arson and less likely to commit sexual offenses, and were more often involved in inpatient aggression than their male counterparts. Several recommendations for gender-responsive treatment and directions for future research are provided.

Sleep disturbances in a clinical forensic psychiatric population

OBJECTIVEnPoor sleep is known to cause detrimental effects on the course of diverse psychiatric disorders and is a putative risk factor for hostility and aggression. Thus, sleep may be crucial in forensic psychiatric practice. However, little is known about the prevalence of sleep disturbances in these complex psychiatric patients.nnnMETHODSnIn this study we investigated the presence of sleep disorders and subjective sleep quality using the Sleep Diagnosis List (SDL), the Pittsburgh Sleep Quality Index (PSQI), interviews addressing the causes of sleep complaints, and file information on sleep medications in 110 patients admitted to a forensic psychiatric hospital.nnnRESULTSnAlmost 30% of the participants suffered from one or more sleep disorders, especially insomnia. An even larger proportion of the participants (49.1%) experienced poor sleep quality. Interestingly, patients with an antisocial personality disorder or traits were particularly dissatisfied with their sleep. The most common causes of sleep problems were suboptimal sleep hygiene, stress or ruminating, negative sleep conditioning, and side effects of psychotropic medication. Of the poor sleepers, 40.7% received a hypnotic drug.nnnCONCLUSIONnDespite intensive clinical treatment, sleep problems are experienced by a large number of forensic psychiatric patients. It would be worthwhile to examine the effects of pharmacological and non-pharmacological sleep interventions on both psychiatric symptoms and reactive aggressive behavior in forensic patients.

Deep sleep after social stress: NREM sleep slow-wave activity is enhanced in both winners and losers of a conflict

Sleep is considered to be a recovery process of prior wakefulness. Not only duration of the waking period affects sleep architecture and sleep EEG, the quality of wakefulness is also highly important. Studies in rats have shown that social defeat stress, in which experimental animals are attacked and defeated by a dominant conspecific, is followed by an acute increase in NREM sleep EEG slow wave activity (SWA). However, it is not known whether this effect is specific for the stress of social defeat or a result of the conflict per se. In the present experiment, we examined how sleep is affected in both the winners and losers of a social conflict. Sleep-wake patterns and sleep EEG were recorded in male wild-type Groningen rats that were subjected to 1h of social conflict in the middle of the light phase. All animals were confronted with a conspecific of similar aggression level and the conflict took place in a neutral arena where both individuals had an equal chance to either win or lose the conflict. NREM sleep SWA was significantly increased after the social conflict compared to baseline values and a gentle stimulation control condition. REM sleep was significantly suppressed in the first hours after the conflict. Winners and losers did not differ significantly in NREM sleep time, NREM sleep SWA and REM sleep time immediately after the conflict. Losers tended to have slightly more NREM sleep later in the recovery period. This study shows that in rats a social conflict with an unpredictable outcome has quantitatively and qualitatively largely similar acute effects on subsequent sleep in winners and losers.

Gender Differences in the Assessment and Manifestation of Psychopathy: Results From a Multicenter Study in Forensic Psychiatric Patients

abstract Gender differences were explored in PCL-R codings and the manifestation of psychopathy in 197 female and 197 male patients admitted between 1984 and 2013 to one of four Dutch forensic psychiatric hospitals. Four groups were compared with respect to criminological characteristics, historical violence risk factors and psychiatric characteristics including incidents during treatment. The lowered PCL-R cut-off score of 23 as applied in the Female Additional Manual (FAM; de Vogel, de Vries Robbé, van Kalmthout, & Place, 2012) was used to define women with psychopathy. The four groups were: (1) women without psychopathy (PCL-R < 23), (2) women with psychopathy (PCL-R ≥ 23), (3) men without psychopathy (PCL-R < 30), and (4) men with psychopathy (PCL-R ≥ 30). Overall, it was found that women and men with psychopathy show multiple similarities in their personal and criminal histories, but there were also several gender differences. Women with psychopathy compared to men with psychopathy committed more fraud, offended more often out of relational frustration, were more often diagnosed with the Borderline Personality Disorder, and showed less physical violence, but more manipulative and self-destructive behavior during treatment. Overall, women obtained lower scores on the PCL-R than men. Predictive validity of the PCL-R for physical violence during treatment was good for men and moderate for women. When verbal violence was included in the definition of violence, the predictive validity of the PCL-R was good for both the female and male sample. Implications of this study for forensic practice are discussed and several directions for future research are provided.

Low doses of mirtazapine or quetiapine for transient insomnia : A randomised, double-blind, cross-over, placebo-controlled trial

Low doses of the antidepressant mirtazapine or the neuroleptic quetiapine are often prescribed off-label for insomnia. However, studies on the effects on sleep and hangover effects the following day are scarce. In this randomised, double-blind, cross-over, placebo-controlled trial, the influence of 7.5 mg mirtazapine and 50 mg quetiapine on both normal sleep and sleep disturbed by acoustic stress (traffic noise) as a model for transient insomnia was assessed. Additionally, hangover effects on next-day alertness and cognitive functioning were examined. A total of 19 healthy men without sleep complaints completed three treatment sessions, each session consisting of three consecutive nights in one of the mirtazapine, quetiapine or placebo conditions. Sleep was assessed using polysomnography and the Leeds Sleep Evaluation Questionnaire. Daytime sleepiness and cognitive functioning were assessed using the Leeds Sleep Evaluation Questionnaire, Karolinska Sleepiness Scale, Digit Symbol Substitution Task, Psychomotor Vigilance Task and an addition task. Under acoustic stress, both mirtazapine and quetiapine increased total sleep time by half an hour and reduced the number of awakenings by 35–40% compared to placebo. While quetiapine specifically increased the duration of non-rapid eye movement sleep, stage N2, mirtazapine mainly increased deep sleep stage N3. Subjects reported that both mirtazapine and quetiapine eased getting to sleep and improved sleep quality. Both drugs caused daytime sleepiness and lessened sustained attention. These findings support the use of low doses of mirtazapine and quetiapine for the treatment of insomnia. Further prospective studies on the long-term effects regarding effectiveness and adverse effects are needed.

Off-Label Prescriptions of Low-Dose Quetiapine and Mirtazapine for Insomnia in The Netherlands

To the Editors: H ypnotics, such as benzodiazepines, are widely used to treat insomnia but have serious disadvantages, such as hangover effects on the next day, rapid development of tolerance, rebound insomnia upon drug discontinuation, and a high risk of misuse and abuse. Therefore, they should be used only for short time intervals. In The Netherlands, since 2009, benzodiazepines for the treatment of insomnia are no longer reimbursed in an attempt to reduce their use and lower health care costs. If prescribed, patients have to cover the cost of the medicines themselves. Possibly in search of an alternative, the prescription rate of low doses of other psychotropic medication with sedative effects seems to increase. In particular, quetiapine and mirtazapine are used “off-label” (OL), thus without regulatory approval, to treat sleep difficulties, but little is known about prescribing patterns. For quetiapine, an antipsychotic drug on the market since 1997, the recommended dose range for the licensed indications is 150 to 800 mg/d. Yet, 54% of the total quetiapine prescriptions in 2010 in England were for the 25 mg tablet. There are only limited data supporting the use of low doses of quetiapine in patients suffering from insomnia. One study in healthy volunteers and 2 in patients with insomnia found shortened sleep latency and increased total sleep time. Mirtazapine, on the market since 1994, is used to treat depression in a recommended dose range between 30 and 45 mg/d. In clinical practice, doses of 15 mg or less are used to improve sleep. Of the prescriptions for insomnia in the United States, 45% concerned OL antidepressants, frequently mirtazapine. Studies of mirtazapine in doses between 15 and 60 mg in insomniacs showed increased total sleep time and improved sleep efficiency. Adverse effects of the chronic use of low doses of quetiapine and mirtazapine have been reported, although this has not been thoroughly investigated. Both drugs have been associated with daytime sleepiness and weight gain in clinical studies. Case reports describe restless legs syndrome, akathisia, and hepatotoxicity for low-dose quetiapine and

Specific Risk Factors of Arsonists in a Forensic Psychiatric Hospital

Arsonists are often treated in forensic settings. However, high recidivism rates indicate that treatment is not yet optimal for these offenders. The aim of this case series study is to identify arsonist specific dynamic risk factors that can be targeted during treatment. For this study, we used patient files of and interviews with all patients that were currently housed at a forensic psychiatric hospital in the Netherlands (14 arsonists, 59 non-arsonists). To delineate differences in risk factors between arsonists and non-arsonists, scores on the risk assessment instrument the Historical Clinical Future–30 (HKT-30; completed for 11 arsonists and 35 non-arsonists), an instrument similar to the Historical Clinical Risk Management–20 (HCR-20), were compared. The groups did not differ on demographic factors and psychopathology. Concerning dynamic risk factors, arsonists had significantly poorer social and relational skills and were more hostile. Although this study needs replication, these findings suggest that the treatment of people involved in firesetting should particularly target these risk factors.

Characteristics and offences of women with borderline personality disorder in forensic psychiatry: a multicentre study

ABSTRACT Although female forensic patients diagnosed with borderline personality disorder (BPD) are generally considered taxing in clinical practice, little is known about their specific characteristics or offences. In this study, 156 female forensic psychiatric patients diagnosed with BPD were compared to 113 diagnosed otherwise. Information on demographic and psychiatric characteristics, victimization, index offences, and incidents during treatment was gathered from patient files. Risk factors for recidivism were assessed using the PCL-R and historical items of the HCR-20, including items from the new Female Additional Manual (FAM). Compared to non-BPD women, BPD women were more likely to have been abused as children and to have a history of outpatient treatment. While less likely to be convicted for (attempted) homicide, a higher percentage of BPD women was convicted for arson. Comorbid substance abuse was more frequent in the BPD group and incidents towards others and themselves were more violent in nature. The PCL-R and the H-scale of the HCR-20/FAM indicated several risk factors especially important for BPD women, such as poor behavioural control, impulsivity, and irresponsibility. The results support the clinical impression that women diagnosed with BPD are a subgroup within the female forensic psychiatric population, with specific focus points for treatment and management.