Mrigendra Das

Neuroticism and brain responses to anticipatory fear.

Personality is known to influence cognitive and affective functioning as well as the risk of psychiatric disorders. Exploration of the neurobiological correlates of personality traits has the potential to enhance understanding of their significance in development of related psychopathological states. The authors examined the association between individual differences in neuroticism and brain activity in response to threat of electric shocks. Fourteen right-handed healthy men underwent functional MRI during a 5-min experiment that involved repeated presentations of two 30-s alternating conditions. In 1 of these conditions, subjects were told to expect mild but painful electric shocks; there was no possibility of receiving shocks in the other condition. The results revealed that neuroticism correlated positively with the ratings of fear of shock and negatively (indicating suppression) with brain activity from safe to shock conditions in the anterior and posterior cingulate, superior/middle temporal gyrus extending to the hippocampus, precuneus, putamen, thalamus, and middle occipital gyrus. The observations support recent psychophysiological research that has demonstrated reduced processing of pain in subjects with higher levels of neuroticism, especially the anxiety component of this trait.

Clozapine: an effective treatment for seriously violent and psychopathic men with antisocial personality disorder in a UK high-security hospital

Objective A number of studies have demonstrated the anti-aggressive properties of clozapine in schizophrenia and its positive effect in borderline personality disorder. There is no published literature on the treatment of antisocial personality disorder (ASPD) with clozapine. We present a case series of 7 patients with primary ASPD and high psychopathic traits treated with clozapine, having a significant history of serious violence and currently detained in a UK based high-security hospital. Methods A retrospective review of case notes was carried out to formulate Clinical Global Impression (CGI) scores and record incidents of violence and aggression. Effect on specific symptom domains (cognitive-perceptual, impulsive-behavioural dyscontrol, affective dysregulation) was also noted. Metabolic parameters and serum clozapine levels were also sampled. Results All 7 patients showed significant improvement on clozapine. It was shown to benefit all symptom domains, especially impulsive behavioral dyscontrol and anger. The number of violent incidents committed by 6 of the 7 patients reduced significantly, and all patients’ risk of violence reduced. Clozapine serum levels for 6 of the 7 patients were in the range 150–350 ng/mL. Conclusion Clozapine is of benefit in reducing the clinical severity of ASPD. It improved all symptom domains, especially impulsive-behavioral dyscontrol and anger, and reduced levels of aggression and violence, especially at lower doses (serum levels <350 ng/m). To our knowledge, this is the first account of clozapine treatment in patients with ASPD and high psychopathy.

Augmentation of clozapine with amisulpride: an effective therapeutic strategy for violent treatment-resistant schizophrenia patients in a UK high-security hospital.

OBJECTIVE Clozapine is used in the management of treatment-resistant schizophrenia and is effective in reducing aggression; however a subgroup of patients is poorly responsive. For violent patients in this group, there is limited literature on the use of strategies to augment clozapine with other agents. Here we present a case series of 6 schizophrenia patients, within a high-security hospital, who have a history of serious violence and who were treated with clozapine augmented with amisulpride. METHODS We reviewed case notes and health records for evidence of violence/aggression and positive factors such as engagement in activities, and Clinical Global Impression (CGI) scores were formulated. We also examined metabolic parameters before and after augmentation. RESULTS All 6 of the patients showed clinical improvement in symptoms and a reduction in their risk of violence to others. Five patients had a reduction in number of violent/aggressive incidents, and all patients showed improvement in engagement in occupational, vocational, and/or psychological work. Metabolic parameters were largely unchanged except for 1 patient whose Body Mass Index (BMI) increased. Five patients reported side effects as unchanged or improved. CONCLUSION These schizophrenia patients with a history of violence showed clinical improvement and reduced aggression and violence with amisulpride augmentation of clozapine. To our knowledge, this is the first report of an antiaggressive benefit of this combination in forensic psychiatric patients. Further studies are warranted to establish the efficacy and anti-aggressive effects of amisulpride augmentation of clozapine.

An evaluation of the use of olanzapine pamoate depot injection in seriously violent men with schizophrenia in a UK high-security hospital

Background: Oral olanzapine is a well-established treatment for patients suffering from schizophrenia. Advantages of depot olanzapine may include improved compliance. However, it is expensive, causes metabolic side effects, and carries a risk of postinjection syndrome. Clinical trials have shown olanzapine pamoate to be effective, but further work is needed in this area. This study was a retrospective service evaluation, carried out in a high-security hospital, where the majority of patients have complex, treatment resistant schizophrenia spectrum disorder and a very high propensity for violence. Compliance is a significant problem, both in the high-security setting and on discharge. There has been no previous published work that the authors are aware of evaluating the effects of olanzapine pamoate in this subgroup of patients. Methods: The aim of the study was to evaluate the clinical efficacy of olanzapine pamoate, its effect on violence as well as its side effects, in a high-security setting for the first time. Anonymized patient records were used to identify the main outcome measure and clinical global improvement, and to ascertain secondary outcome measures which included seclusion hours, risk of violence and side effects. Metabolic parameters and number of incidents were also recorded. Eight patients were treated with olanzapine pamoate. Results: Six showed an improvement in symptoms, with an associated decrease in violence and number of incidents. Four showed an associated decrease in seclusion hours. Two showed an increase in body mass index and two showed an increase in glucose. Conclusions: The findings of this study are important in showing that all patients who responded to olanzapine pamoate also showed a decrease in violent behaviour. The potential anti-aggression effects of olanzapine pamoate may represent a very promising area for further work. A depot antipsychotic medication that reduces violence could have significant implications for management of high-security patients.

Measuring victim empathy among mentally disordered offenders: validating VERA-2.

There are very few, if any, valid and victim-specific situation empathy measures available at present for use with mentally disordered offenders. The aim of this study was to validate a modified version (VERA-2) of the Victim Empathy Response Assessment (VERA) tool which was developed earlier (Young et al., 2008) to enable victim-specific situation empathy measurement in offenders. A total of 55 mentally disordered in-patients residing in a maximum security hospital were assessed on VERA-2 as well as on measures of antisocial personality traits, global affective empathy, violent cognitions, and reported remorse for the index offence. The VERA-2 cognitive and affective empathy scales were negatively correlated with antisocial personality traits and violent cognitions, and positively related to remorse for the index offence. Global affective empathy was positively related to VERA-2 affective empathy. Participants with a history of sexual offending had significantly higher cognitive empathy than other offenders. Acceptance of violence and remorse for the index offence were the best predictors of both cognitive and affective empathy. The findings suggest that the VERA-2 is a valid instrument for measuring victim empathy among mentally disordered offenders, and may prove useful in the context of future risk assessment and outcomes in this population.

Risperidone Long‐acting Injection (RLAI) – real world outcomes from the United Kingdom high‐secure hospitals

Purpose – High‐secure hospital patients often have complex presentations that are marked by co‐morbidity, violence, histories of poor concordance with oral medication, and treatment resistance. The ability to give a long‐acting medication with a low propensity for extra pyramidal side effects is of potential value to clinicians treating these patients. Risperidone Long‐acting Injection (RLAI) is the first long‐acting atypical antipsychotic medication and may be potentially useful in this population. This paper aims to investigate this issue.Design/methodology/approach – This was a retrospective, naturalistic study to investigate the use and effectiveness, using hard outcome measures, of RLAI in the four UK high‐secure psychiatric hospitals. Hospital pharmacy databases at Ashworth, Broadmoor, Carstairs and Rampton hospitals were used to identify all patients who had been prescribed RLAI. Anonymised data were then obtained from the pharmacy databases and case notes which were then pooled.Findings – A total ...

Enrichment activities in the medical school psychiatry programme – could this be a key to engaging medical students in psychiatry? A study from a high secure forensic psychiatric UK hospital

BackgroundThe majority of research studies on medical student attitudes toward psychiatry focus on influencing factors and the medical school experience. This study evaluates the effectiveness of a one-day visit to a high secure forensic psychiatric unit on medical students’ attitudes towards psychiatry and also assesses career intentions and the factors influencing these.MethodChange in attitudes and career intention were measured by administering a questionnaire, which included the 30-item Attitudes Toward Psychiatry (ATP-30) survey, at the start (time 1) and end (time 2) of the one-day visit. Qualitative data on factors influencing career choice was also gathered.ResultsEvaluation of 284 responses revealed a significant increase in positive attitude towards psychiatry from time 1 to time 2 in the sample as a whole. The most influential factor on consideration of psychiatry as a career across all groups was the medical school clinical placement. For those that tended away from choosing psychiatry as a career, patient prognosis was important.ConclusionsPoor recruitment in psychiatry in the UK is already established which will doubtless be compounded by controversies surrounding the proposed new junior doctors’ contract. Now more than ever, the need to inspire and motivate those at medical school encountering psychiatry is crucial. Our findings add to the body of evidence that the medical school clinical attachment is fundamental in shaping attitudes. However, these results also show that a well-planned visit to a specialised psychiatric unit outside of traditional placements can have a significant impact on students’ attitudes toward psychiatry and mental illness in general. There is limited literature in the UK on enrichment activities within the psychiatry medical school curriculum. We propose that developing opportunities for enrichment activities within psychiatry could increase the scope of how we engage students in this fascinating field of medicine.

Effectiveness of a single day induction programme in changing medical students’ attitudes towards the speciality of forensic psychiatry

Objectives: We aimed to investigate the effectiveness of a day visit in changing attitudes towards a high-security forensic psychiatric hospital, with regard to the current recruitment difficulties in psychiatry. Methods: Broadmoor Hospital, a UK high-security psychiatric hospital, runs day visits for medical students, led by doctors. At the beginning and the end of the day students wrote their responses to the question, ‘What do you think of Broadmoor?’ Attitudes and themes were identified, and their prevalence was analysed. Results: The responses of 296 students were initially analysed; however, 19 responses had to be excluded because they were illegible or incomplete. Before the visit, 15 responses were rated as positive, 169 neutral and 93 negative. After the visit, 205 responses were positive, 69 neutral and three negative. The themes that changed markedly following the visit were those indicating a change to favourable attitude. Conclusions: A single day visit was shown to be effective in altering the attitudes of medical students towards forensic psychiatry within a high-security psychiatric hospital.

Work-related stress in forensic mental health professionals: a systematic review

Purpose The purpose of this paper is to investigate the prevalence of stress and burnout among forensic mental health (FMH) professionals. Design/methodology/approach A systematic review of the available literature accessed by relevant databases was conducted. Findings This study concluded that FMH suffer from moderate levels of both stress and burnout. There is insufficient evidence to establish that they suffer from higher levels of stress than their non-forensic colleagues. Interventions such as psychosocial intervention training have been reported to demonstrate an improvement in staff knowledge and attitudes towards patients, whilst reducing burnout. Practical implications Stress in FMH is a cause of concern. Conclusions drawn are applicable only to nursing staff as other professions were not adequately represented. As most studies used the burnout scores, results were directly comparable. Further research is needed to fully evaluate stress and burnout in professionals who work within FMH settings. Originality/value High levels of stress and burnout have negative effects on an individual’s ability to work and subsequently there is a financial and also moral incentive for the management of health service workforces to intervene. This study highlights that FMH, as a population, are at risk.

Substance misuse in personality disorder and schizophrenia: findings and clinical implications from a high secure hospital

Purpose Substance misuse (SMU) is widely prevalent in mentally disordered offenders and is linked with violence and offending behaviour. There is however, a scarcity of literature dedicated to investigating SMU and its clinical correlates in relation to patients detained within high secure hospital settings. The purpose of this paper is to investigate the extent and severity of SMU and corresponding treatment needs in patients with a primary diagnosis of personality disorder (PD) in comparison with mental illness (MI) in a high secure hospital. Design/methodology/approach The responsible clinicians of all patients (n=240) detained in a high secure hospital were asked to record information using a SMU screening questionnaire over a ten-month period. Details requested included substance type, history of past use and assessment and treatment needs. Data were recorded and then analysed: descriptive statistics were conducted to report historical use of substances, cross tabulations and χ2 analysis explored the relationship between SMU and treatment status and diagnosis and offending behaviour and a means comparison analysis was employed to explore length of stay and treatment of SMU. Findings A total of 230 questionnaires were returned (95 per cent of the patient population). A history of SMU was reported in 88.6 per cent of the sample, with alcohol and cannabis misuse being the most prevalent. At least one substance had been abused by 74.3 per cent of the sample. In two-thirds of the sample, SMU was linked with the onset of mental health problems and symptom exacerbation, including violence. Interestingly, patients with a diagnosis of MI as compared with PD were more likely to have used substances (93.3 per cent compared to 81.9 per cent) and were more likely to need treatment for SMU (64.3 per cent compared to 36.8 per cent). In those with an MI diagnosis, SMU was more likely to be linked with violence and index offence (74.3 per cent compared to 59.0 per cent). Practical implications SMU is significantly prevalent in high risk mentally disordered offenders and linked to onset of mental health problems and offending. Patients with schizophrenia have a higher prevalence of SMU than PD and are likely to be more in need of treatment. Violence and offending are more likely to be related to SMU in schizophrenia than in PD. Originality/value This study substantiates existing evidence that SMU contributes to mental health problems and criminogenic behaviour. Furthermore, the study reports new findings that characterize differences of the relationship of SMU to offending in schizophrenia and PD in forensic psychiatric patients presenting to a high secure hospital.