Correction: Neurobiological roots of psychopathy.

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

Neurobiological roots of psychopathy.

Psychopathy is an extreme form of antisocial behavior, with about 1% prevalence in the general population, and 10-30% among incarcerated criminal offenders. Although the heritability of severe antisocial behavior is up to 50%, the genetic background is unclear. The underlying molecular mechanisms have remained unknown but several previous studies suggest that abnormal glucose metabolism and opioidergic neurotransmission contribute to violent offending and psychopathy. Here we show using iPSC-derived cortical neurons and astrocytes from six incarcerated extremely antisocial and violent offenders, three nonpsychopathic individuals with substance abuse, and six healthy controls that there are robust alterations in the expression of several genes and immune response-related molecular pathways which were specific for psychopathy. In neurons, psychopathy was associated with marked upregulation of RPL10P9 and ZNF132, and downregulation of CDH5 and OPRD1. In astrocytes, RPL10P9 and MT-RNR2 were upregulated. Expression of aforementioned genes explained 30-92% of the variance of psychopathic symptoms. The gene expression findings were confirmed with qPCR. These genes may be relevant to the lack of empathy and emotional callousness seen in psychopathy, since several studies have linked these genes to autism and social interaction.

Use of coercion prevention tools in Finnish psychiatric wards.

Inpatient violence is a widespread problem in psychiatric wards and has often serious consequences. Literature indicates that de-escalation techniques are the recommended first-line intervention for managing violence, are widely used to reduce it, and restrictive practices in mental health settings. However, these techniques and models are not used at the optimum frequency and/or important factors are limiting their use and effectiveness. We aimed to determine what kind of de-escalation methods are used to reduce violence and coercion in Finnish psychiatric hospitals. Descriptive qualitative research using semi-structured questionnaires and Framework Analysis was used. The results of the study are reported in quantitative terms. A survey of psychiatric wards (N = 65) in Finland's hospital districts (n = 16) was conducted in the Autumn of 2019 to find out which de-escalation models are used. Finnish psychiatric wards use both the Safewards and Six Core Strategies models to reduce violence and the use of restrictive practices. Half of the hospitals used interventions and strategies from both models. Violence preventive methods are widely used in mental health settings in Finland. These interventions and models cover the organization, leadership, and patient perspectives to improve safety and decrease coercion actions in psychiatric wards.

Violence Factors and Debriefing in Psychiatric Inpatient Care: A Review.

The aim of the current review was to identify, analyze, and synthesize the available research on violence factors in psychiatric care and the potential of debriefing to reduce the incidence of violence necessitating coercive measures. A two-part electronic search was conducted using multiple databases. Part 1 focused on reviews and meta-analyses relating to violence factors published between 2007 and 2017. Part 2 focused on articles on debriefing published after 2000. Two hundred ninety-five articles on violence factors and debriefing were identified, from which 39 publications were selected for detailed analysis. Results indicate that patient characteristics, management, staff approaches, and the ward environment are influencers that may trigger violent incidents. Several violence factors in psychiatric care have been identified. Nursing communication, leadership, and debriefing are among the most effective ways of reducing violence in psychiatric care. [Journal of Psychosocial Nursing and Mental Health Services, 58(5), 39-49.].

Changes in patient safety culture: A patient safety intervention for Finnish forensic psychiatric hospital staff.

AIM: To evaluate how a 3-year patient safety intervention, more specifically, the implementation of a patient safety incident reporting system, influences patient safety culture. BACKGROUND: Positive patient safety culture improves both the quality of health care and patient safety. Nevertheless, nursing managers need tools that can help them develop and evaluate patient safety culture. METHODS: The Hospital Survey on Patient Safety Culture was used to evaluate patient safety culture at two Finnish forensic psychiatric hospitals (study and control) over two periods, baseline and follow-up. Data were analysed using Z-score and T test statistics. RESULTS: The follow-up results from the study hospital showed that five patient safety culture dimensions exhibited a significantly (p < 0.05) positive change in positive response rates over the 3-year period. Furthermore, nine out of twelve patient safety culture dimensions at the study hospital showed a significant improvement in mean score. At the control hospital, only the dimension of frequency of reporting events showed a significantly positive change (p < 0.05) in mean score. CONCLUSION: This research shows that the studied patient safety intervention (implementation of the patient safety incident reporting system) significantly influences patient safety culture. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing managers should utilize a variety of patient safety interventions to improve patient safety and focus on leveraging information from patient safety incidents to advance patient safety culture.

Opioid abuse and hospitalization rates in patients with schizophrenia.

BACKGROUND: Substance abuse worsens the course of schizophrenia, but it is not known whether or not there are differences between specific substances concerning their association with the hospitalizations of patients with schizophrenia. AIMS: The primary aims of this study were to examine the possible associations between amphetamine, cannabis, and opioid abuse, and the risk of hospitalizations among patients with schizophrenia. METHODS: The study population consisted of 146 patients with ICD-defined schizophrenia from two different geographical sites in Finland, and it included both inpatients and outpatients. Data were collected retrospectively from the patients' medical files. Substance abuse was defined as either harmful use or dependence according to ICD-10. RESULTS: The cumulative prevalence of substance abuse was 10.9% (16/146) for cannabis, 8.9% (13/146) for amphetamine, and 4.1% (6/146) for opioids. Among patients with schizophrenia and abuse of any substance, the number of hospitalizations was about 1.5-fold when compared to those without substance abuse. The incidence rate ratio for hospitalizations was 2.9 (95% CI 2.47-3.63) for opioids, 2.0 (1.71-2.41) for amphetamine, and 1.6 (1.33-1.84) for cannabis, when compared with no abuse of each substance. The risk of hospitalizations was significantly higher for opioids when compared with amphetamine (p < 0.001) or cannabis (p < 0.001). CONCLUSIONS: Harmful use or dependence of opioids among patients with schizophrenia is associated with significantly higher risk of hospitalizations than either harmful use or dependence of amphetamine or cannabis.

[Antisocial personality disorder]. / Epäsosiaalinen persoonallisuushäiriö.

Antisocial personality disorder (ASP), especially psychopathy as its extreme form, has provoked fear and excitement over thousands of years. Ruthless violence involved in the disorder has inspired scientists, too.The abundance of research results concerning epidemiology, physiology, neuroanatomy, heritability, and treatment interventions has made ASP one of the best documented disorders in psychiatry. Numerous interventions have been tested, but there is no current treatment algorithm. Biological and sociological parameters indicate the importance of early targeted interventions among the high risk children. Otherwise, as adults they cause the greatest harm. The use of medications or psychotherapy for adults needs careful consideration.

Exome sequencing followed by large-scale genotyping suggests a limited role for moderately rare risk factors of strong effect in schizophrenia.

Schizophrenia is a severe psychiatric disorder with strong heritability and marked heterogeneity in symptoms, course, and treatment response. There is strong interest in identifying genetic risk factors that can help to elucidate the pathophysiology and that might result in the development of improved treatments. Linkage and genome-wide association studies (GWASs) suggest that the genetic basis of schizophrenia is heterogeneous. However, it remains unclear whether the underlying genetic variants are mostly moderately rare and can be identified by the genotyping of variants observed in sequenced cases in large follow-up cohorts or whether they will typically be much rarer and therefore more effectively identified by gene-based methods that seek to combine candidate variants. Here, we consider 166 persons who have schizophrenia or schizoaffective disorder and who have had either their genomes or their exomes sequenced to high coverage. From these data, we selected 5,155 variants that were further evaluated in an independent cohort of 2,617 cases and 1,800 controls. No single variant showed a study-wide significant association in the initial or follow-up cohorts. However, we identified a number of case-specific variants, some of which might be real risk factors for schizophrenia, and these can be readily interrogated in other data sets. Our results indicate that schizophrenia risk is unlikely to be predominantly influenced by variants just outside the range detectable by GWASs. Rather, multiple rarer genetic variants must contribute substantially to the predisposition to schizophrenia, suggesting that both very large sample sizes and gene-based association tests will be required for securely identifying genetic risk factors.

[Managing aggression and violence associated with psychosis]. / Psykoottisen potilaan aggressio--ehkaisy ja hoito.

Risk for violence in psychosis is associated with the subject's history of early-onset antisocial behavior, substance abuse, suicidal ideation, lack of insight, and non-adherence to antipsychotic medication. These risk factors can be managed by effective treatment for psychosis, with the exception of predatory antisocial aggression. Generally, this group of patients is at considerable risk for untreated conditions. There is, however, no pharmacological treatment indicated solely for aggression. Physical violence can often be avoided by alertness and risk monitoring, and by attentive customer service skills. Safety at work is our shared responsibility.

Previous forensic mental examination is a useful marker indicating effective violence relapse prevention among psychotic patients.

BACKGROUND: Patients with schizophrenia have an increased risk of violent behavior. AIMS: The aim of this study was to find predictive indicators of high risk of violent behavior among outpatients with psychosis. METHODS: A total of 206 individuals were involuntarily ordered to hospital treatment as forensic patients after a forensic mental examination in Finland from 1995-1999. The information was collected from the registers of the National Authority for Medicolegal Affairs, and was obtained from 194 persons of which 184 had been accused of a violent crime. RESULTS: Twenty percent (22/110) of those forensic patients, who had received a psychosis diagnosis before the index crime, had previously undergone a forensic examination. This subgroup was 12% of the total study population (22/184), which is about 300 times higher than expected (i.e. if no risk increase assumed). Ten of the 22 persons in this subgroup had been committed in forensic psychiatric inpatient care and later discharged. The same number of persons had been sentenced to prison and subsequently released after the previous forensic mental examination. CONCLUSIONS: While primary prevention of crime for the larger population of all patients with psychosis is not feasible, secondary prevention (prevention of reoffending) might be possible by focusing on the small subgroup, which had undergone a previous forensic mental examination. Obligatory follow-up and treatment in outpatient care would probably decrease recidivistic offending among discharged forensic psychiatric patients and among those offenders found not guilty by reason of insanity but not considered to fulfill criteria for involuntary hospital treatment.

Metacognitive group training for forensic and dangerous non-forensic patients with schizophrenia: a randomised controlled feasibility trial.

BACKGROUND: In schizophrenia, the presence of certain cognitive biases has been established. Informed by this, metacognitive training (MCT) has been developed for schizophrenia. There is increasing evidence of its effectiveness with some patients, but its applicability to dangerous patients has not yet been demonstrated. AIMS: Our aim was to test the feasibility of a randomised controlled trial (RCT) of MCT for patients in a high-security hospital setting. METHODS: Twenty of 33 eligible and selected male in-patients with schizophrenia and a history of violence were randomised pairwise to eight sessions of MCT or treatment as usual. Symptom severity and reasoning, according to the jumping to conclusions paradigm, were measured before, immediately after treatment, and 3 and 6 months later. RESULTS: Men in both groups completed the trial, and those in the MCT arm, almost all of the group sessions. The MCT arm had a significant advantage in improvement of 'suspiciousness', greatest at 3 months, but then declining. No significant improvement in reasoning ability was achieved. CONCLUSIONS: Metacognitive training showed sufficient promise in this group for a full trial to be worthwhile, and the feasibility of an RCT methodology, even in a secure hospital, was established. The fact that the improvements faded during follow-up suggests that a useful modification to the treatment would be lengthening the protocol, repeating it, or both.

Efficacy and tolerability of antipsychotic polypharmacy for schizophrenia spectrum disorders. A systematic review and meta-analysis of individual patient data.

BACKGROUND: Antipsychotic polypharmacy (APP) is frequently prescribed for schizophrenia-spectrum disorders. Despite the inconsistent findings on efficacy, APP may be beneficial for subgroups of psychotic patients. This meta-analysis of individual patient data investigated moderators of efficacy and tolerability of APP in adult patients with schizophrenia-spectrum disorders. DESIGN: We searched PubMed, EMBASE, and the Cochrane Central Register of Randomized Trials until September 1, 2022, for randomized controlled trials comparing APP with antipsychotic monotherapy. We estimated the effects with a one-stage approach for patient-level moderators and a two-stage approach for study-level moderators, using (generalized) linear mixed-effects models. Primary outcome was treatment response, defined as a reduction of 25 % or more in the Positive and Negative Syndrome Scale (PANSS) score. Secondary outcomes were study discontinuation, and changes from baseline on the PANSS total score, its positive and negative symptom subscale scores, the Clinical Global Impressions Scale (CGI), and adverse effects. RESULTS: We obtained individual patient data from 10 studies (602 patients; 31 % of all possible patients) and included 599 patients in our analysis. A higher baseline PANSS total score increased the chance of a response to APP (OR = 1.41, 95 % CI 1.02; 1.94, p = 0.037 per 10-point increase in baseline PANSS total), mainly driven by baseline positive symptoms. The same applied to changes on the PANSS positive symptom subscale and the CGI severity scale. Extrapyramidal side effects increased significantly where first and second-generation antipsychotics were co-prescribed. Study discontinuation was comparable between both treatment arms. CONCLUSIONS: APP was effective in severely psychotic patients with high baseline PANSS total scores and predominantly positive symptoms. This effect must be weighed against potential adverse effects.

Cavum septum pellucidum and psychopathy.

The presence of cavum septum pellucidum (CSP) has been reported to be a neurodevelopmental marker of psychopathy. We scanned 26 violent offenders and 25 controls; 2 offenders and 2 controls had CSP (8% in both groups). Thus, the presence of CSP is not a common or a unique feature of antisocial personality disorder or psychopathy.

Patients' Perceptions of Safety and Debriefing in Forensic Mental Health Care in Finland.

BACKGROUND: Safety is of paramount importance to patients and staff in forensic mental health hospitals. Previous research has focused on organizational and nurses' perceptions of safety and violence in psychiatric wards. However, little is known about how patients view their safety. This study aimed to describe how patient debriefing can improve safety. METHODS: Qualitative research using thematic analysis was used. Data were collected by semistructured interviews and debriefing forms. Inpatient interviews ( n = 45) were conducted between June and July 2018, with debriefing forms ( n = 376) collected retrospectively. RESULTS: Forensic inpatient responses were divided into two main categories: psychological and physical security. Psychological safety included care culture and patient-related themes. Responses on care culture highlighted weaknesses in nurse-patient communication, whereas patient-related themes related to respondents' descriptions of the challenges posed by mental illness. Physical safety related to both the environment and patient-related themes, with various restrictions and environmental distractions seen by respondents as negatively affecting patient safety. CONCLUSIONS: Patients who participated in the study felt that care culture, especially communication with nurses, most significantly impacted their safety. Forensic hospitals should consider patients' perceptions of their care while systematically gathering information through debriefing, as these practices can contribute to the development of a safer care environment. The next step will be clarifying how changes in nursing practices and the care environment can be used to prevent violence in psychiatric wards.

The substance use among forensic psychiatric patients.

OBJECTIVES: The primary goal of this study was to examine the relative differences in the use of illegal substances (i.e., amphetamine, cannabis, opiates) among forensic patients who have committed a violent crime compared with the general population. The aim was also to find out if there were differences in substance use among forensic versus nonforensic patients with psychosis diagnosis. METHODS: The study population consisted of 190 persons, who were involuntarily ordered to hospital treatment as forensic patients in Finland. The information was compared with data from the national hospital discharge register. These results were also compared with national statistics from the general population. RESULTS: Among forensic patients, the lifetime prevalence of cannabis use was 2-fold, amphetamine use 40-fold, and opiate use over 60-fold higher than estimated from the general population in Finland. Cannabis use was 1.5-fold more common than amphetamine use among forensic patients and 1.3-fold more common among nonforensic patients. The prevalences of cannabis-related diagnoses were 4.7- and 3.7-fold more common than opiate use among forensic and nonforensic patients, respectively. CONCLUSIONS: Cannabis, amphetamine, and opiate use are associated with an increased risk of becoming a forensic psychiatric patient, but no substantial differences were observed among patients with psychosis diagnosis in the relative risk increase for cannabis versus amphetamine versus opiate use, indicating that none of these drugs are uniquely associated with violent offending among mentally ill.

[Restrictions during psychiatric hospitalization]. / Potilaan rajoittaminen psykiatrisessa sairaalahoidossa.

The Finnish Constitution affirms that everyone has the right to remain private and undisturbed. During the course of involuntary psychiatric treatment, only the exemptions stipulated in the Mental Health Act are allowed. The Act on the Status and Rights of Patients states that cooperation with the patient must also be attempted during involuntary treatment. The orders for restraints are different in psychiatric hospitals. For decades, restrictions were derived from early 19th century regulations, when all mentally ill individuals were considered to be incompetent. Nowadays, a patient's mental competence is based on functional disabilities, which should also apply to psychiatric treatment.

Voluntary patient safety incidents reporting in forensic psychiatry-What do the reports tell us?

WHAT IS KNOWN ON THE SUBJECT?: Patient safety incident reporting has been recognized as a key process for organizational learning and safety culture; however, there is limited knowledge about patient safety in forensic psychiatric care. There are distinct patient safety issues in psychiatric nursing, associated (inter alia) with the self-harm, violence, seclusion/restrain and restrictions. Many adverse events are preventable. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: No harm was caused to patients in less than half (51%) of all reported incidents (in a Finnish forensic psychiatric hospital during a six-year period) considered in this study. The most common location of violent incidents was corridors (31%), followed by day rooms (20%), and patient rooms (15%). The most common patient safety incidence type was violence against another patient (38%), which typically occurred in corridors (36%), dayrooms (25%) and patient rooms (15%), and was usually related to daily activities in the afternoon (1,400-1,600 hr) and evening (1,800-2,000 hr). Typically, recommendations for improving patient safety focus on human behaviours. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: There is a need to notify and report all patient safety incidents (following staff training), learn from previous incidents (also learn for success), prevent typical incidents, learn for success, promote patient participation in incident prevention, share development measures outside the ward to enable exploitation by others and strengthen safety culture. In forensic psychiatry, conversation with patients regarding safety measures is strongly recommended to prevent patient safety incidents related to violence. The perspective should be extended from patient-specific factors to general factors such as patient treatment and general comfort and privacy. ABSTRACT: INTRODUCTION: Patient safety incident reporting has been recognized as a key process for organizational learning and safety culture, but there is limited knowledge about patient safety in forensic psychiatric care. AIMS: To characterize the types and frequencies of incidents in forensic psychiatric care and assess the implications for practice. METHODS: Data were collected from a patient safety incident reporting system (PSiRS) database of one forensic psychiatry hospital in Finland and analysed using descriptive statistics. RESULTS: No harm was caused in more than half of the 2,521 reported incidents examined (51%, n = 1,260). The most frequently recorded incident type was violence (38%), which typically occurred in corridors (31%) or dayrooms (20%). The most frequently recommended action to prevent violent events was that potential risks should be discussed (77%). DISCUSSION: Patient safety incidents related to violence are common in forensic psychiatric hospitals. Although very few adverse events were classified as causing serious harm to patients, many cases of violence could be prevented by identifying potential circumstances that lead to violence. IMPLICATIONS FOR PRACTICE: Staff need encouragement and training to detect and report all patient safety incidents. Safety culture is strengthened by learning and sharing development measures to improve patient safety.

Female Psychopathy and Mortality.

The mortality of female psychopaths has scarcely been investigated. To estimate the association between psychopathy and mortality, data from subjects having been in forensic psychiatric assessments at Niuvanniemi Hospital during 1984-1993 were linked to the data from the National Death Registry. Sixteen psychopathic females scoring 25 points or higher in the PCL-R scale (psychopaths) were followed up for a median (IQR) 21 (17-25) years and 41 offenders scoring <25 on the PCL-R (non-psychopathic offenders) for 22 (17-25) years. In both psychopath and non-psychopath offender groups, the mortality was significantly higher (p < 0.01) than in the general population, being over 12-fold among psychopathic and over 6-fold among the non-psychopathic offenders.

Cortex and amygdala morphology in psychopathy.

Psychopathy is characterized by abnormal emotional processes, but only recent neuroimaging studies have investigated its cerebral correlates. The study aim was to map local differences of cortical and amygdalar morphology. Cortical pattern matching and radial distance mapping techniques were used to analyze the magnetic resonance images of 26 violent male offenders (age: 32±8) with psychopathy diagnosed using the Psychopathy Checklist-Revised (PCL-R) and no schizophrenia spectrum disorders, and in matched controls (age: 35± sp="0.12"/>11). The cortex displayed up to 20% reduction in the orbitofrontal and midline structures (corrected p<0.001 bilaterally). Up to 30% tissue reduction in the basolateral nucleus, and 10-30% enlargement effects in the central and lateral nuclei indicated abnormal structure of the amygdala (corrected p=0.05 on the right; and symmetrical pattern on the left). Psychopathy features specific morphology of the main cerebral structures involved in cognitive and emotional processing, consistent with clinical and functional data, and with a hypothesis of an alternative evolutionary brain development.

Group psychoeducation for long-term offender patients with schizophrenia: an exploratory randomised controlled trial.

BACKGROUND: Psychoeducation is now commonly provided in forensic settings, but its effectiveness among long-term offender patients with schizophrenia has not yet been established in randomised controlled trials (RCTs). AIM: To test the effects of a brief group psychoeducation programme for offenders with schizophrenia (n = 39) resident in a high-security hospital (Niuvanniemi Hospital, Finland). METHOD: High-security hospital patients were randomised into either eight sessions of group psychoeducation or 'treatment as usual' (TAU). Outcome measures, made at baseline, immediately post-treatment, and 3 months after that, included knowledge about illness, insight, compliance, attitudes towards medication, psychiatric symptoms and ward behaviour, self-esteem, health-related quality of life and perceived stigma. RESULTS: Three months after completing treatment, or an equivalent time under TAU, patients in the intervention group showed a positive treatment effect in terms of knowledge about illness, self-esteem and insight into the illness. The only possible adverse effect was a slight increase in irritability, but this did not translate into behaviour of concern to staff. CONCLUSIONS: Our sample size was small, and the findings must be regarded as preliminary, but the positive treatment effect of psychoeducation, and the absence of alarming side effects, suggests a full scale trial would be worthwhile. Most encouraging was that even the most severely ill patients were able to join the groups.