Legally Mandated, Formally Pressured, or Voluntary Anger Treatment: Associations With Treatment Recommendations, Refusal, and Completion.

Legally mandated treatment is common in the criminal justice system, for example, for anger management, substance misuse, and intimate partner violence. Past studies have compared voluntary and legally mandated treatment participants but have not distinguished a third, in-between group that is formally pressured to participate in treatment, but not mandated by the criminal justice system. The current study aimed to assess differences on individual characteristics (e.g., sociodemographic and psychiatric) and baseline measures of psychopathology (e.g., anger, aggression, and depression) across three levels of voluntariness and to determine whether voluntariness was associated with treatment recommendation, refusal, and completion at an outpatient anger treatment clinic. Data were retrospectively gathered from the clinical charts of 405 participants. Referrals were classified as voluntary (e.g., self-referred, 61%), formally pressured (e.g., required by work, 14%), or legally mandated (e.g., court order, 25%). Legally mandated participants were younger, more likely to have substance use disorder, less likely to be women, to have a high school education, or to be on psychiatric medications compared to the other two groups. Voluntary participants scored higher on measures of self-reported anger, depression, and stress than the legally mandated participants. Legally mandated participants in particular presented with non-clinical levels of anger and aggression. Level of voluntariness did not affect the decision to recommend individual or group therapy after an intake assessment, but legally mandated participants were significantly more likely (OR = 2.30) than voluntary participants to refuse recommended treatment. Level of voluntariness did not have a significant association with treatment completion. Findings support our distinction between legally mandated and formally pressured participants, but do not support previous research that suggests legally mandated individuals have lower attrition rates in similar treatment programs. The study has implications for the criminal justice system and for anger treatment programs who admit participants with varying levels of voluntariness.

Short-term clinical risk assessment and management: Comparing the Brockville Risk Checklist and Hamilton Anatomy of Risk Management.

The current article aims to examine the performance of two brief, dynamic risk measures - the Brockville Risk Checklist (BRC4) and one of two versions of the Hamilton Anatomy of Risk Management [HARM-FV and electronic HARM-FV (eHARM-FV)] - scored at regular clinical case conferences for forensic psychiatric patients in two different settings. The eHARM represents a first-in-class dynamic risk assessment tool using data analytics. Two studies are presented from two forensic psychiatric hospitals in Ontario, Canada. The first study compared the HARM-FV, scored by trained research staff, with the BRC4, scored concurrently by clinical teams, on 36 forensic inpatients. In the second study, trained research staff scored both the BRC4 and the eHARM-FV on 55 forensic inpatients. Both studies demonstrated that the BRC4 and both HARM-FV tools were moderately and positively correlated with each other, with higher agreement for similar domains and items. In both samples, the risk measures performed better at identifying individuals who engaged in repeated or more serious problematic behavior. The HARM-FV and eHARM-FV produced higher area under the curve values for subsequent behavior compared with the BRC4. All three tools were effective at detecting future aggression and adverse incidents. We did not directly compare the HARM-FV and eHARM-FV.

Reliability and validity of the DSM-IV-TR and proposed DSM-5 criteria for pedophilia: Implications for the ICD-11 and the next DSM.

We tested the inter-rater reliability and criterion-related validity of the DSM-IV-TR pedophilia diagnosis and proposed DSM-5 pedohebephilia diagnosis in a sample of 79 men who had committed child pornography offenses, contact sexual offenses against children, or who were referred because of concerns about whether they had a sexual interest in children. Participants were evaluated by two independent psychiatrists with an interview and questionnaire regarding demographic characteristics, sexual history, and self-reported sexual interests; they also completed phallometric and visual reaction time testing. Kappa was .59 for ever meeting DSM-IV-TR criteria for pedophilia and .52 for ever meeting the proposed DSM-5 criteria for pedohebephilia. Ever meeting DSM-IV-TR diagnosis was significantly related to self-reported index of sexual interest in children (highest AUC=.81, 95% CI=.70-.91, p<.001) and to indices of sexual interest in children from phallometric testing (AUC=.70; 95% CI=.52-.89; p<.05) or a computerized assessment based on visual reaction time and self-report (AUC=.75; 95% CI=.62-.88; p<.005). Ever meeting the proposed DSM-5 "diagnosis" was similarly related to self-report (AUC=.84, 95% CI=.74-.94, p<.001) and to the two objective indices, with AUCs of .69 (95% CI=.53-.85; p<.05) and .77 (95% CI=.64-.89; p<.001), respectively. Because the pDSM-5 criteria did not produce significantly better reliability or validity results and users are more familiar with the current DSM-5 criteria, we believe these results suggest the revision of DSM-5 and development of ICD-11 could benefit from drawing on the current DSM-5 criteria, which are essentially the same as DSM-IV-TR except for a distinction between having a paraphilia (the interest) and a paraphilic disorder (the paraphilia plus clinically significant distress or impairment).

The role of central and peripheral hormones in sexual and violent recidivism in sex offenders.

Hormonal factors are important in multifactorial theories of sexual offending. The relationship between hormones and aggression in nonhumans is well established, but the putative effect in humans is more complex, and the direction of the effect is usually unclear. In this study, a large sample (N = 771) of adult male sex offenders was assessed between 1982 and 1996. Gonadotrophic (follicle-stimulating hormone and luteinizing hormone) and androgen hormone (total and free testosterone; T) levels were assessed at Time 1, along with indicators of sex drive and hostility. Individuals were observed up to 20 years in the community, with an average time at risk of 10.9 years (SD 4.6). Gonadotrophic hormones correlated positively with self-reported hostility and were better predictors of recidivism than was T (area under the curve (AUC), 0.58-0.63). Self-reported hostility emerged as a partial mediator of this relationship between gonadotrophic hormones and recidivism. These results point to a potentially new area of investigation for hormones and sexual aggression.

A pilot study of electrocortical activity in dysfunctional anger: decreased frontocortical activation, impaired attention control, and diminished behavioral inhibition.

Dysfunctional anger, though not a primary clinical diagnosis per se, does present clinically as a pathological mood for which treatment is sought. Few studies have probed the neurocortical correlates of dysfunctional anger or assessed if cognitive processes, such as attention, are altered in dysfunctional anger. Though dysfunctional and high trait anger appears to be associated with biased processing of anger-eliciting information, few studies have examined if dysfunctional anger modulates attention more generally. This is a notable gap as volitional attention control is associated with effective emotive regulation, which is impaired in dysfunctional anger and in associated acts of aggression. In this pilot study, we examined performance and electroencephalographic (EEG) profiles during a 12-min continuous performance task (CPT) of sustained attention in 15 adults with dysfunctional anger (Anger group) and 14 controls (control group). The Anger group had fewer hits at the end of the CPT, which correlated with decreased frontocortical activation, suggesting decreased engagement of frontal circuits when attention is taxed. The Anger group had more false alarms overall indicating impaired response inhibition. Increased right cortical activation during the initial portion of CPT existed in the Anger group, perhaps reflecting greater engagement of frontal circuits (i.e. effort) during initial stages of the task compared to controls. Finally, increased overall beta1 power, suggesting increased cortical activation, was noted in the Anger group. These EEG patterns suggest a hypervigilant state in dysfunctional anger, which may interfere with effective attention control and decrease inhibition. Such impairments likely extend beyond the laboratory setting, and may associate with aggressive acts in real life.

Developing a clinical typology of dysfunctional anger.

BACKGROUND: This study attempted to validate a clinical typology of dysfunctional anger proposed by DiGiuseppe and Tafrate (2007) using assessment data obtained from 197 participants assessed at an outpatient clinic for anger problems. METHODS: Several self-report scales assessing anger, hostility, impulsivity and aggression, as well as a structured interview regarding anger experience and expression, were administered; Axis I and II comorbidity were assessed using clinical assessment and the SCID-II PQ. RESULTS: We found support for four of the proposed eight types described by DiGiuseppe and Tafrate - Pervasive Dysfunctional Anger, Impulsive Type; Pervasive Dysfunctional Anger, Mixed Type; Impulsive Aggressive Dysfunctional Anger; and Suppressed Dysfunctional Anger - with significant, predicted group differences on self-report measures of anger, aggression, and impulsivity, as well as differences in Axis I and II diagnoses. LIMITATIONS: Patients were rarely assigned to the other four dysfunctional anger types and thus we could not examine the validity of these types. We relied heavily on self-report data. CONCLUSIONS: Anger is a common symptom in outpatient psychiatry clinics. It is associated with both mood and anxiety disorder diagnoses, and often co-occurs with substance use problems. Different types of angry patients will likely require different assessment and treatment approaches.