Creatine kinase elevation and discontinuation of clozapine: fear-driven clinical practice in a forensic case with treatment-resistant schizophrenia and persistent violent behaviour.

In forensic settings, the most common indication for clozapine is treatment-resistant schizophrenia (TRS). Clozapine has also been shown to be effective in reducing hostility, aggression and violence in patients with schizophrenia and is of benefit in comorbid substance use disorders. The decision to initiate or to discontinue recently initiated clozapine can have a profound beneficial or detrimental influence on the lives and safety of patients and the staff caring for them. We present a case in which treatment with clozapine proved effective in spite of earlier repeated discontinuation of clozapine out of fear of neuroleptic malignant syndrome (NMS). Elevation of creatine kinase was deemed to be indicative of NMS in the absence of clinical signs of NMS. In somatic medicine, it is well known that creatine kinase elevation has many causes, most of them non-harmful. Collaboration with clinical chemistry was shown to be very useful, if not essential; research in the 1980s found replicated evidence for both sex and race differences in creatine kinase levels. In addition, substantial intra-individual variation has been found over time in healthy individuals. The creatine kinase levels of this patient of African descent were within normal limits for the African population. Baseline creatine kinase assessment and repetition of this assessment after 2 weeks with careful interpretation are recommended in all clozapine-treated patients. The authors advocate the introduction of evidence-based creatine kinase cut-off points that reflect the biological differences between the sexes and among races. More intensive contact between psychiatrists and clinical chemist can facilitate faster diagnosis and better treatment.

Virtual Reality Aggression Prevention Therapy (VRAPT) versus Waiting List Control for Forensic Psychiatric Inpatients: A Multicenter Randomized Controlled Trial.

Many forensic psychiatric inpatients have difficulties regulating aggressive behavior. Evidence of effective aggression treatments is limited. We designed and investigated the effectiveness of a transdiagnostic application of a virtual reality aggression prevention training (VRAPT). In this randomized controlled trial at four Dutch forensic psychiatric centers, 128 inpatients with aggressive behavior were randomly assigned to VRAPT (N = 64) or waiting list control group (N = 64). VRAPT consisted of 16 one-hour individual treatment sessions twice a week. Assessments were done at baseline, post-treatment and at 3-month follow-up. Primary outcome measures were aggressive behavior observed by staff and self-reported aggressive behavior. Analysis was by intention to treat. This trial was registered in the Dutch Trial Register (NTR, TC = 6340). Participants were included between 1 March 2017, and 31 December 2018. Compared to waiting list, VRAPT did not significantly decrease in self-reported or observed aggressive behavior (primary outcomes). Hostility, anger control, and non-planning impulsiveness improved significantly in the VRAPT group compared to the control group at post-treatment. Improvements were not maintained at 3-month follow-up. Results suggest that VRAPT does not decrease aggressive behavior in forensic inpatients. However, there are indications that VRAPT temporarily influences anger control skills, impulsivity and hostility.

Social-cognitive risk factors for violence in psychosis: A discriminant function analysis.

It has been proposed that mixed findings in studies investigating social cognition as a risk factor for violence in psychosis may be explained by utilizing a framework distinguishing between social-cognitive tests which measure relatively more basic operations (e.g. facial affect recognition) and measures of more complex operations (mentalizing, metacognition). The current study investigated which social cognitive and metacognitive processes are related to a violent history over and above illness-related deficits. Data from control participants (n = 33), patients with a psychotic disorder and no violent history (n = 27), and patients with a psychotic disorder in a forensic clinic (n = 23) were analyzed utilizing discriminant analysis. Metacognition and associative learning emerged as significant factors in predicting group membership between the three groups. In a follow-up analysis between only the patient groups, metacognitive Self-Reflectivity and Empathic Accuracy emerged as statistically significant predictors of group membership. The control group presented with higher levels of social cognitive and metacognitive capacity than patient groups, and the forensic patient group had lower levels than the non-forensic patient group. Our findings support previous research findings implying impaired metacognitive Self-Reflectivity in particular as a risk factor for violence.