Ward Climate Within a High Secure Forensic Psychiatric Hospital: Perceptions of Patients and Nursing Staff and the Role of Patient Characteristics.

Within this study the relationship between patient characteristics (age, length of stay, risk, psychopathy) and individual perceived ward climate (n=83), and differences between staff's and patient perceptions of climate (n=185) was investigated within a high secure forensic hospital. Results show that therapeutic hold was rated higher among staff compared to patients, while patients held a more favorable view on patient cohesion and experienced safety. Furthermore, patient characteristics (age, risk and psychopathy) were found to be related with individual ratings of ward climate. The findings underline the importance of assessing ward climate among both patients and staff in clinical practice.

Quality of life in long-term forensic psychiatric care: comparison of self-report and proxy assessments.

OBJECTIVE: To compare quality of life (QoL) ratings of long term forensic psychiatric care patients with the ratings of psychiatric nurses, in which the nurses indicate how they think the patient would answer. METHODS: Agreement on QoL-scores according to the Forensic inpatient Quality of Life Questionnaire (FQL) was investigated for seventy- seven pairs of patients and psychiatric nurses from two forensic psychiatric long-care facilities where QoL is seen as an important treatment goal. This study also examined whether the amount of agreement was related to specific patient characteristics and characteristics of the patient- psychiatric nurse relationship. RESULTS: On group level, only small and mostly non-significant differences were found between patients' and psychiatric nurses' mean QoL scores. However, pairwise comparisons revealed poor agreement between patients' and nurses' QoL scores for half of the domains and moderate agreement on the other half of the domains, except for Leave, which was the only domain on which patients and their nurses had similar scores. Patient characteristics such as type of offence and type of psychopathology were negligibly related to the level of agreement. However, characteristics of the patient-nurse relationship such as age of the nurse and length of the patient-nurse relationship did influence the amount of consensus between patients' and proxies' QoL-scores significantly. CONCLUSIONS: Nurses were not sufficiently able to accurately estimate their patients' QoL experience and could probably benefit from a training aimed at assessing QoL of their patients and how to support their patients in optimizing their QoL themselves.

Staff's perception of Patients' affiliation and control in a Highly Secure Psychiatric Setting.

Effective interactions between patients and staff have been associated with positive ward climate and therapeutic effects, but also pose a challenge in high secure forensic psychiatric settings. The goal of this study was to gain more insight into i) the characteristics that play a role in how staff members perceive the interpersonal style of patients, and ii) whether these perceptions are related to patients' evaluation of ward climate and satisfaction with daily staff. Staff members (n = 69), rated the interpersonal style of 102 male patients. Satisfaction with daily staff and ward climate were rated by 45 patients. Results show that patient characteristics (primary diagnosis, patient age, disruptive behavior, recent problems with symptoms of major mental disorder and recent problems with treatment or supervision response) were related to how staff perceived the interpersonal style (i.e., affiliation and control) of patients. Furthermore, the level of affiliation was positively related to patients' satisfaction with daily staff. Patients that were seen as more controlling by staff were less satisfied with the safety on their ward (as a factor of ward climate). The results indicate that perception of patients' interpersonal style entails patient related information and can be relevant for staff to use in their work.

Testosterone Modulates Altered Prefrontal Control of Emotional Actions in Psychopathic Offenders(1,2,3).

Psychopathic individuals are notorious for their controlled goal-directed aggressive behavior. Yet, during social challenges, they often show uncontrolled emotional behavior. Healthy individuals can control their social emotional behavior through anterior prefrontal cortex (aPFC) downregulation of neural activity in the amygdala, with testosterone modulating aPFC-amygdala coupling. This study tests whether individual differences in this neuroendocrine system relate to the paradoxical lack of emotional control observed in human psychopathic offenders. Emotional control was operationalized with an fMRI-adapted approach-avoidance task requiring rule-driven control over rapid emotional responses. Fifteen psychopathic offenders and 19 matched healthy control subjects made approaching and avoiding movements in response to emotional faces. Control of social emotional behavior was required during affect-incongruent trials, when participants had to override affect-congruent, automatic action tendencies and select the opposite response. Psychopathic offenders showed less control-related aPFC activity and aPFC-amygdala coupling during trials requiring control of emotional actions, when compared with healthy control subjects. This pattern was particularly pronounced in psychopathic individuals with high endogenous testosterone levels. These findings suggest that reduced prefrontal coordination underlies reduced behavioral control in psychopathic offenders during emotionally provoking situations. Even though the modest sample size warrants replication, the modulatory role of endogenous testosterone on the aPFC-amygdala circuit suggests a neurobiological substrate of individual differences that is relevant for the advancement of treatment and the reduction of recidivism.

Neural connectivity during reward expectation dissociates psychopathic criminals from non-criminal individuals with high impulsive/antisocial psychopathic traits.

Criminal behaviour poses a big challenge for society. A thorough understanding of the neurobiological mechanisms underlying criminality could optimize its prevention and management. Specifically,elucidating the neural mechanisms underpinning reward expectation might be pivotal to understanding criminal behaviour. So far no study has assessed reward expectation and its mechanisms in a criminal sample. To fill this gap, we assessed reward expectation in incarcerated, psychopathic criminals. We compared this group to two groups of non-criminal individuals: one with high levels and another with low levels of impulsive/antisocial traits. Functional magnetic resonance imaging was used to quantify neural responses to reward expectancy. Psychophysiological interaction analyses were performed to examine differences in functional connectivity patterns of reward-related regions. The data suggest that overt criminality is characterized, not by abnormal reward expectation per se, but rather by enhanced communication between reward-related striatal regions and frontal brain regions. We establish that incarcerated psychopathic criminals can be dissociated from non-criminal individuals with comparable impulsive/antisocial personality tendencies based on the degree to which reward-related brain regions interact with brain regions that control behaviour. The present results help us understand why some people act according to their impulsive/antisocial personality while others are able to behave adaptively despite reward-related urges.

Psychopaths lack the automatic avoidance of social threat: relation to instrumental aggression.

Psychopathy (PP) is associated with marked abnormalities in social emotional behaviour, such as high instrumental aggression (IA). A crucial but largely ignored question is whether automatic social approach-avoidance tendencies may underlie this condition. We tested whether offenders with PP show lack of automatic avoidance tendencies, usually activated when (healthy) individuals are confronted with social threat stimuli (angry faces). We applied a computerized approach-avoidance task (AAT), where participants pushed or pulled pictures of emotional faces using a joystick, upon which the faces decreased or increased in size, respectively. Furthermore, participants completed an emotion recognition task which was used to control for differences in recognition of facial emotions. In contrast to healthy controls (HC), PP patients showed total absence of avoidance tendencies towards angry faces. Interestingly, those responses were related to levels of instrumental aggression and the (in)ability to experience personal distress (PD). These findings suggest that social performance in psychopaths is disturbed on a basic level of automatic action tendencies. The lack of implicit threat avoidance tendencies may underlie their aggressive behaviour.