Facial emotion recognition in people with schizophrenia and a history of violence: a mediation analysis.

Evidence for an association between impaired facial emotion recognition and violence in people with schizophrenia is inconclusive. In particular, the role of misidentification patterns involving specific emotions such as anger and the influence of clinical characteristics on this association remain unclear. In this study, we compared facial emotion recognition performance in age- and gender-matched schizophrenia spectrum disorders subjects with (N = 52) and without (N = 52) a history of violence. Data on current symptom severity, Cluster B personality status, past victimization, and alcohol and substance misuse were also collected. Compared to those without, subjects with a history of violence showed worse facial emotion recognition performances, involving anger, fear, disgust, sadness, and happiness. When formally testing the reporting of angry faces, evidence of enhanced sensitivity to anger was not supported. Finally, when the impact of current symptoms was assessed, higher severity of activation symptoms, including motor hyperactivity, elevated mood, excitement and distractibility, mediated the relationship between history of violence and poor facial emotion recognition performance. As a whole, our findings seem to support the role of perceptual deficits involving different emotions as well as of a mediation played by activation symptoms. Facial emotion recognition deficits associated with the propensity to violence, as well certain symptoms mediating their relationship, should be targeted by specific treatment approaches.

Substance use disorders and violent behaviour in patients with severe mental disorders: A prospective, multicentre study.

OBJECTIVE: The relationship between alcohol and substance use and the risk of violence exhibited by patients with mental disorders is under-researched. This prospective cohort study aims to compare patients with severe mental disorders and with different substance use behaviors in terms of sociodemographic and clinical characteristics, hostility, impulsivity and aggressive behaviors. Furthermore, this study aims to assess differences in violent behaviors during a 1-year monitoring follow-up. METHODS: A total of 378 participants with severe mental disorders from Italian residential facilities and from four Departments of Mental Health (244 outpatients and 134 residential patients) were enrolled. Participants were categorized as Persons with Current Substance Use, Persons with Former Substance Use and Persons with Non-Substance Use. All these patients underwent a complex multidimensional assessment, including the lifetime and current substance use; a subsample of outpatients was also assessed with a laboratory substance assay including the testing for specific substances. We assessed the differences among these three groups in hostility, impulsivity and aggressive behaviors. RESULTS: The results of the close 1-year monitoring show a significantly higher risk of violence for patients with severe mental disorders Persons with Current Substance Use compared to Persons with Former Substance Use and Persons with Non-Substance Use. Persons with Current Substance Use showed significantly higher scores for irritability, negativism and verbal assault compared to Persons with Non-Substance Use. Persons with Former Substance Use showed significantly higher scores for lifetime history of aggressive behaviors compared with patients with Persons with Non-Substance Use. CONCLUSION: These findings suggest that patients with comorbid mental illness and substance use disorders should be referred for specific interventions to reduce aggressive behavior and ensure patient well-being and community safety.

Aggressive behavior and metacognitive functions: a longitudinal study on patients with mental disorders.

BACKGROUND: Metacognitive functions play a key role in understanding which psychological variables underlying the personality might lead a person with a severe mental disorder to commit violent acts against others. The aims of this study were to: (a) investigate the differences between patients with poor metacognitive functioning (PM group) and patients with good metacognitive functioning (GM group) in relation to a history of violence; (b) investigate the differences between the two groups in relation to aggressive behavior during a 1-year follow-up; and (c) analyze the predictors of aggressive behavior. METHODS: In a prospective cohort study, patients with severe mental disorders with and without a lifetime history of serious violence were assessed with a large set of standardized instruments and were evaluated bi-monthly with MOAS in order to monitor any aggressive behavior. The total sample included 180 patients: 56% outpatients and 44% inpatients, and the majority were male (75%) with a mean age of 44 (± 9.8) years, and half of them had a history of violence. The sample was split into two groups: poor metacognition (PM) group and good metacognition (GM) group, according to MAI evaluation scores. RESULTS: The PM patients reported a history of violence more frequently than GM patients, during the 1-year follow-up, but no differences between groups in aggressive and violent behavior were found. The strongest predictors of aggressive behavior were: borderline and passive-aggressive personality traits and a history of violence, anger, and hostility. The metacognitive functions alone did not predict aggressive behavior, but metacognitive functions interacted with hostility and angry reactions in predicting aggressive behavior. CONCLUSIONS: This study led to some important conclusions: (a) some aspects closely related to violence are predictive of aggressive behavior only in patients with poor metacognition, thus good metacognition is a protective factor; (b) poor metacognition is associated with a history of violence, which in turn increases the risk of committing aggressive behavior.

Patient personality and psychotherapist reactions in individual psychotherapy setting: a systematic review.

Despite the importance of psychotherapists' subjective experiencse working with patients with mental issues, little is known about the relationship between therapists' emotional reactions and patients' personality problems. The present study is a systematic review of quantitative research on the association between patients' personality pathology and psychotherapists' emotional, cognitive and behavioural reactions in individual psychotherapy setting. A systematic database search (from January 1980 to August 2019) supplemented by manual searches of references and citations identified seven relevant studies. Significant and consistent relationships were found between therapist reactions and specific personality traits or disorders. In general, odd and eccentric patients tend to evoke feelings of distance and disconnection; emotionally dysregulated patients tend to evoke anxiety and incompetence, and anxious and withdrawn patients tend to evoke sympathy and concern. However, the relatively small sample of studies and methodological inconsistencies across studies limit firm conclusions and suggest the need for more systematic research. Findings from this review indicate that patients who share the same personality disorder or symptoms tend to evoke specific and similar cognitive, emotional and behavioural reactions in their therapists. This suggests that therapists overall reactions toward patients may be source of valuable diagnostic information.

Personality, Schizophrenia, and Violence: A Longitudinal Study: The Second Wave of the VIORMED Project.

This study investigated the association between maladaptive personality traits, personality disorders (PDs), schizophrenia, and the risk of aggressive behavior. Ninety-four patients with a history of violence and 92 patients with no history of violence underwent a multidimensional baseline assessment. Aggressive behavior was monitored during a 1-year follow-up through the Modified Overt Aggression Scale. The Violent group scored significantly higher than the Control group on the Millon Clinical Multiaxial Inventory (MCMI-III) Antisocial, Sadistic, Borderline, and Paranoid personality scales. Irrespective of any history of violence, patients with PD as a primary diagnosis displayed more aggressive behaviors than those with a primary diagnosis of schizophrenia during the follow-up. Furthermore, the most significant predictor of aggressive behaviors over time was endorsing a primary diagnosis of PD. Identifying the crucial risk factors for violent recidivism would contribute to reducing aggressive behavior in this population.

Self-harm behaviour and externally-directed aggression In psychiatric outpatients: a multicentre, prospective study (viormed-2 study).

The aim of the project was to investigate differences between outpatients with Severe Mental Disorders (SMDs) with and without a history of Self-Harm behaviour (SHb) and/or Violent behaviour against other people (Vb) in relation to: (a) socio-demographic and clinical characteristics, (b) violent behaviour during a 1-year FU, (c) predictors of SHb and Vb during the FU. Outpatients with SMDs, with and without a history of Vb were enrolled. They were divided in four groups: patients with lifetime Vb (V), patients with both Vb and SHb (V-SH), patients with only SHb (SH) and patients with no history of SHb and Vb (control group, CONT). The frequency and severity of SHb and Vb during the FU were assessed every two weeks by the MOAS. Overall 246 patients were enrolled. BPRS-E Depression item, the SLOF Social acceptability, the BDHI Indirect Aggression, the BIS Motor Impulsiveness and the STAXI-2 Control-Out showed significant correlations with all the four groups (p < 0.030). V and V-SH patient groups reached higher scores in all MOAS sub-scales. Age among the SH group and BPRS-E affect-anxiety subscale among the V group significantly predicted aggression against people. In people with SMDs a history of SHb or Vb is associated with different medium-term outcomes.

Violence risk and mental disorders (VIORMED-2): A prospective multicenter study in Italy.

BACKGROUND: The management of mentally ill offenders in the community is one of the great challenges imposed on community psychiatry. AIM: The aim of this study was to analyze the association between sociodemographic, clinical, and psychosocial factors and violent behavior in a sample of outpatients with severe mental disorders. METHOD: This was a prospective cohort study with a baseline cross-sectional design used to provide a detailed analysis of patients' profiles, followed by a longitudinal design to measure aggressive and violent behavior during a 1-year follow-up. Patients with severe mental disorders, with or without a history of violence, were enrolled in four Italian Departments of Mental Health and underwent a comprehensive multidimensional assessment. RESULTS: The sample included 247 outpatients, for a total of 126 cases and 121 controls. Compared to controls, patients with a history of violence had a greater frequency of lifetime domestic violence, a greater lifetime propensity to misuse substances, and a higher number of compulsory admissions. The forthnightly monitoring during the 1-year follow-up did show statistically significant differences in aggressive and violent behavior rates between the two groups. Verbal aggression was significantly associated with aggression against objects and physical aggression. Moreover, outpatients with an history of violence showed statistically significant higher MOAS scores compared to both residential patients with an history of violence, assessed in the first wave of this project, and all controls. CONCLUSIONS: Patients with a history of violence had specific characteristics and showed a greater occurrence of additional community violence during a 1-year observation period. Our results may assist clinicians in implementing standardized methods of patient assessment and violence monitoring in outpatient mental health services and may prompt improved collaboration between different community services.

Publisher Correction: Self-harm behaviour and externally-directed aggression in psychiatric outpatients: a multicentre, prospective study (viormed-2 study).

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Barriers to and Facilitators of Engagement With mHealth Technology for Remote Measurement and Management of Depression: Qualitative Analysis.

BACKGROUND: Mobile technology has the potential to provide accurate, impactful data on the symptoms of depression, which could improve health management or assist in early detection of relapse. However, for this potential to be achieved, it is essential that patients engage with the technology. Although many barriers to and facilitators of the use of this technology are common across therapeutic areas and technology types, many may be specific to cultural and health contexts. OBJECTIVE: This study aimed to determine the potential barriers to and facilitators of engagement with mobile health (mHealth) technology for remote measurement and management of depression across three Western European countries. METHODS: Participants (N=25; 4:1 ratio of women to men; age range, 25-73 years) who experienced depression participated in five focus groups held in three countries (two in the United Kingdom, two in Spain, and one in Italy). The focus groups investigated the potential barriers to and facilitators of the use of mHealth technology. A systematic thematic analysis was used to extract themes and subthemes. RESULTS: Facilitators and barriers were categorized as health-related factors, user-related factors, and technology-related factors. A total of 58 subthemes of specific barriers and facilitators or moderators emerged. A core group of themes including motivation, potential impact on mood and anxiety, aspects of inconvenience, and ease of use was noted across all countries. CONCLUSIONS: Similarities in the barriers to and facilitators of the use of mHealth technology have been observed across Spain, Italy, and the United Kingdom. These themes provide guidance on ways to promote the design of feasible and acceptable cross-cultural mHealth tools.

More anxious than depressed: prevalence and correlates in a 15-nation study of anxiety disorders in people with type 2 diabetes mellitus.

BACKGROUND: Anxiety disorder, one of the highly disabling, prevalent and common mental disorders, is known to be more prevalent in persons with type 2 diabetes mellitus (T2DM) than the general population, and the comorbid presence of anxiety disorders is known to have an impact on the diabetes outcome and the quality of life. However, the information on the type of anxiety disorder and its prevalence in persons with T2DM is limited. AIMS: To assess the prevalence and correlates of anxiety disorder in people with type 2 diabetes in different countries. METHODS: People aged 18-65 years with diabetes and treated in outpatient settings were recruited in 15 countries and underwent a psychiatric interview with the Mini-International Neuropsychiatric Interview. Demographic and medical record data were collected. RESULTS: A total of 3170 people with type 2 diabetes (56.2% women; with mean (SD) duration of diabetes 10.01 (7.0) years) participated. The overall prevalence of anxiety disorders in type 2 diabetic persons was 18%; however, 2.8% of the study population had more than one type of anxiety disorder. The most prevalent anxiety disorders were generalised anxiety disorder (8.1%) and panic disorder (5.1%). Female gender, presence of diabetic complications, longer duration of diabetes and poorer glycaemic control (HbA1c levels) were significantly associated with comorbid anxiety disorder. A higher prevalence of anxiety disorders was observed in Ukraine, Saudi Arabia and Argentina with a lower prevalence in Bangladesh and India. CONCLUSIONS: Our international study shows that people with type 2 diabetes have a high prevalence of anxiety disorders, especially women, those with diabetic complications, those with a longer duration of diabetes and poorer glycaemic control. Early identification and appropriate timely care of psychiatric problems of people with type 2 diabetes is warranted.

Personality, Schizophrenia, and Violence: A Longitudinal Study.

The aims of this study were (a) to investigate the presence of clinically significant personality traits and personality disorders (PD) in patients living in residential facilities, with or without a history of violence (69 and 46, respectively); and (b) to investigate any associations between clinically significant personality traits and PDs, aggression, impulsivity, hostility, and violent behavior during a 1-year follow-up. The most frequent primary diagnoses were schizophrenia (58.3%) and PD (20.9%). Those with a history of violence demonstrated more antisocial and alcohol dependence features and lower depressive PD symptoms than the control group. Hostility levels, antisocial symptoms, and drug dependence, as well as a Structured Clinical Interview for DSM-IV Axis II diagnosis of PD, predicted aggressive and violent behavior during follow-up. The study confirms the relevance of assessing PDs both to evaluate the risk of violent behavior and to plan appropriate preventive and treatment intervention.

Clinical and neuropsychological features of violence in schizophrenia: A prospective cohort study.

The increased risk of violence in schizophrenia has been linked to several environmental, clinical and neuropsychological factors, including executive dysfunction. However, data about the nature of these effects are mixed and controversial. The main aim of this study was to investigate the relationship between clinical and neuropsychological factors with violence risk in patients with schizophrenia, taking into account current psychopathology and lifetime alcohol use. We compared a sample of patients living in Residential Facilities (RFs) with schizophrenia and a past history of interpersonal violence (vSZ, N=50) to patients with schizophrenia matched on age, gender and alcohol abuse/dependence but with no violence history (nvSZ, N=37). We then established the association between the clinical and neuropsychological factors that predicted violence over a 1year follow-up period. The results revealed that vSZ patients living in RFs were characterized by greater compulsory hospital admissions, higher anger and less negative symptoms as compared to nvSZ patients. vSZ patients performed better on executive and motor tasks than nvSZ; however, these differences appeared to be explained by the lower negative psychotic symptom in the vSZ group. Both groups were involved in episodes of violence during the follow-up period; among the two, the vSZ patients were more likely to be violent. Negative symptoms predicted less verbal aggression at 1year follow-up. Overall, these findings support a key role of negative rather than positive symptoms in driving violence risk among SZ patients living in RFs, in a manner that negative symptoms are linked to a lower risk of violence.

Moderate efficiency of clinicians' predictions decreased for blurred clinical conditions and benefits from the use of BRASS index. A longitudinal study on geriatric patients' outcomes.

OBJECTIVES: Accurate prognosis is an essential aspect of good clinical practice and efficient health services, particularly for chronic and disabling diseases, as in geriatric populations. This study aims to examine the accuracy of clinical prognostic predictions and to devise prediction models combining clinical variables and clinicians' prognosis for a geriatric patient sample. STUDY DESIGN AND SETTING: In a sample of 329 consecutive older patients admitted to 10 geriatric units, we evaluated the accuracy of clinicians' prognosis regarding three outcomes at discharge: global functioning, length of stay (LoS) in hospital, and destination at discharge (DD). A comprehensive set of sociodemographic, clinical, and treatment-related information were also collected. RESULTS: Moderate predictive performance was found for all three outcomes: area under receiver operating characteristic curve of 0.79 and 0.78 for functioning and LoS, respectively, and moderate concordance, Cohen's K = 0.45, between predicted and observed DD. Predictive models found the Blaylock Risk Assessment Screening Score together with clinicians' judgment relevant to improve predictions for all outcomes (absolute improvement in adjusted and pseudo-R(2) up to 19%). CONCLUSION: Although the clinicians' estimates were important factors in predicting global functioning, LoS, and DD, more research is needed regarding both methodological aspects and clinical measurements, to improve prognostic clinical indices.

Monitoring and predicting the risk of violence in residential facilities. No difference between patients with history or with no history of violence.

BACKGROUND: Most people with mental disorders are not violent. However, the lack of specific studies in this area and recent radical changes in Italy, including the closure of six Forensic Mental Hospitals, has prompted a more detailed investigation of patients with aggressive behaviour. AIMS: To compare socio-demographic, clinical and treatment-related characteristics of long-term inpatients with a lifetime history of serious violence with controls; to identify predictors of verbal and physical aggressive behaviour during 1-year follow-up. METHODS: In a prospective cohort study, patients living in Residential Facilities (RFs) with a lifetime history of serious violence were assessed with a large set of standardized instruments and compared to patients with no violent history. Patients were evaluated bi-monthly with MOAS in order to monitor any aggressive behaviour. RESULTS: The sample included 139 inpatients, 82 violent and 57 control subjects; most patients were male. The bi-monthly monitoring during the 1-year follow-up did not show any statistically significant differences in aggressive behaviour rates between the two groups. The subscale explaining most of the MOAS total score was aggression against objects, although verbal aggression was the most common pattern. Furthermore, verbal aggression was significantly associated with aggression against objects and physical aggression. CONCLUSIONS: Patients with a history of violence in RFs, where treatment and clinical supervision are available, do not show higher rates of aggressiveness compared to patients with no lifetime history of violence. Since verbal aggression is associated with more severe forms of aggression, prompt intervention is warranted to reduce the risk of escalation.