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Tanzer T, Pham B, Warren N, Barras M, Kisely S, Siskind D. Overcoming clozapine's adverse events: a narrative review of systematic reviews and meta-analyses. Expert Opin Drug Saf 2024; 23:811-831. [PMID: 38814794 DOI: 10.1080/14740338.2024.2362796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 05/29/2024] [Indexed: 06/01/2024]
Abstract
INTRODUCTION Clozapine is the gold standard treatment for treatment-resistant schizophrenia, however adverse events remain a clinical challenge. AREAS COVERED This review presents a narrative synthesis of systematic reviews and meta-analyses that have reported the onset, incidence, prevalence, and management of clozapine's adverse events. We conducted a systematic literature search using PubMed, Embase, PsycINFO, OvidMEDLINE, CINAHL, and the Cochrane Database of Systematic Reviews from inception to April 2024. EXPERT OPINION Effective management of clozapine's adverse events necessitates multi-faceted, individualized, and shared-decision strategies. Despite a lack of high-quality systematic evidence, expert inter-disciplinary solutions are provided to help address a critical need for clinical guidance. This 35-year update offers an evidence-based framework to assist clinicians, patients, and caregivers navigate the adverse events associated with clozapine therapy.
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Affiliation(s)
- Timothy Tanzer
- Princess Alexandra Hospital, Department of Pharmacy, Brisbane, Australia
- Medicine, University of Queensland, Brisbane, Australia
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | - Betty Pham
- Department of Pharmacy, Metro South Community and Oral Health, Brisbane, Australia
| | - Nicola Warren
- Medicine, University of Queensland, Brisbane, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Michael Barras
- Princess Alexandra Hospital, Department of Pharmacy, Brisbane, Australia
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | - Steve Kisely
- Medicine, University of Queensland, Brisbane, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Dan Siskind
- Medicine, University of Queensland, Brisbane, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Australia
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Sales CP, Forrester A, Tully J. Delays in transferring patients from prisons to secure psychiatric hospitals: An international systematic review. CRIMINAL BEHAVIOUR AND MENTAL HEALTH : CBMH 2023; 33:371-385. [PMID: 37667423 DOI: 10.1002/cbm.2309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 08/12/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Transfer to a psychiatric hospital of prisoners who need inpatient treatment for a mental disorder is an important part of prison healthcare in the UK. It is an essential factor in ensuring the principle of equivalence in the treatment of prisoners. In England and Wales, delays in transferring unwell prisoners to hospital were identified by the 2009 Bradley Report. There has been no subsequent systematic review of progress in so doing nor a corresponding appraisal of transfer arrangements in other parts of the world. AIM To conduct a systematic review of international literature about transfers of mentally unwell individuals from prison to hospital for the treatment of mental disorder since 2009. METHOD Eight databases were searched for data-based publications using terms for prison and transfer to hospital from 1 January 2009 to 4 August 2022. Inclusion criteria limited transfer to arrangements for pre-trial and sentenced prisoners going to a health service hospital, excluding hospital orders made on the conclusion of criminal hearing. RESULTS In England, four articles were identified, all showing that transfer times remain considerably longer than the national targets of 14 days (range, 14 days to >9 months); one study from Scotland found shorter mean transfer times, but more patients had been transferred to psychiatric intensive care units than to secure forensic hospitals. There were only two studies that investigated prison to hospital transfers for mental disorder from outside the UK and only one reported time-to-transfer data. CONCLUSIONS Findings from this literature review highlight failures to resolve transfer delays in England and provide little evidence about the problem elsewhere. Given the lack of data, it is unclear whether other countries do not have this problem or simply that there has been no research interest in it. A possible confounding factor here is that, in some countries, all treatment for prisoners' mental disorders occurs in prison. However, the principle that prisons are not hospitals seems important when people need inpatient care. Prospective, longitudinal cohort studies are urgently needed to map transfer times and outcomes.
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Affiliation(s)
| | - Andrew Forrester
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - John Tully
- Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
- Academic Unit of Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
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Ross C, Page R. Prison-based democratic therapeutic communities, medication, and the power to exclude. MEDICINE, SCIENCE, AND THE LAW 2023; 63:248-252. [PMID: 36214212 DOI: 10.1177/00258024221131451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
In 1962, the first custodial Democratic Therapeutic Community (DTC) was established in the English prison estate at HMP Grendon. Today, the Category B male prison estate in England and Wales has three DTCs and three 'TC+' units for prisoners with learning disabilities. There is one DTC in the female estate at HMP Send. The services fall under the remit of the Offender Personality Disorder Pathway, a jointly commissioned initiative that aims to provide a pathway of psychologically informed services for a highly complex and challenging group of prisoners who are likely to have a severe personality disorder. Several of these units make clear that prisoners prescribed psychotropic medicines are specifically excluded from entry and participation in the available therapy. This analysis paper explores whether an evidence-based rationale exists for this practice and examines the impact on those whose care pathways may comprise hospitals and prisons.
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Affiliation(s)
- Callum Ross
- Broadmoor Hospital, West London NHS Trust, UK
| | - Ruairi Page
- Midlands Partnership NHS Foundation Trust, UK
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Sesso G, Masi G. Pharmacological strategies for the management of the antisocial personality disorder. Expert Rev Clin Pharmacol 2023; 16:181-194. [PMID: 36787887 DOI: 10.1080/17512433.2023.2181159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 02/09/2023] [Indexed: 02/16/2023]
Abstract
INTRODUCTION Antisocial personality disorder (AsPD) is a pervasive pattern of violation of others' rights, related to the concept of psychopathy. AsPD is stable over time from adolescence, with evidence of conduct disorder (CD) before 15 years. DSM-5 included a specifier 'with limited prosocial emotions' (LPE), which characterizes adolescents with higher developmental vulnerability to develop AsPD. Despite being relatively frequent with considerable societal impact, AsPD is a difficult-to-treat condition with high comorbidity rates and poor evidence for effective pharmacological interventions. AREAS COVERED We conducted a narrative review and searched PubMed up to September 2022. We included RCTs and naturalistic studies evaluating pharmacological interventions on AsPD in adults, including those with comorbid substance use disorder or psychopathic traits. Evidence in youths with CD, callous-unemotional (CU) traits and aggression were also reviewed, exploring the role of CU traits as moderators of response. EXPERT OPINION Psychosocial interventions are the first option, with possible improvement of CU traits, beyond behavioral and affective symptoms, particularly if implemented early during development. Limited information, based on low-quality studies, supports the pharmacological options. Second-generation antipsychotics, lithium, anti-epileptic drugs, and stimulants are first-line medications, according to different target symptoms. Developmental pathways including ADHD suggest a specific role of psychostimulants.
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Affiliation(s)
- Gianluca Sesso
- Social and Affective Neuroscience Group, Molecular Mind Lab, IMT School for Advanced Studies Lucca, Lucca, Italy
- Department of Child and Adolescent Psychiatry and Psychopharmacology, IRCCS Stella Maris Foundation, Pisa, Italy
| | - Gabriele Masi
- Department of Child and Adolescent Psychiatry and Psychopharmacology, IRCCS Stella Maris Foundation, Pisa, Italy
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Drug-Associated Liver Injury Related to Antipsychotics: Exploratory Analysis of Pharmacovigilance Data. J Clin Psychopharmacol 2022; 42:440-444. [PMID: 35730552 DOI: 10.1097/jcp.0000000000001576] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Drug-associated liver injury is one of the most common causes for acute liver failure and market withdrawal of approved drugs. In addition, the potential for hepatotoxicity related to specific substances has to be considered in psychopharmacotherapy. However, systematic evaluations of hepatotoxicity related to antipsychotics are limited. METHODS We conducted an exploratory case/non-case study and evaluated pharmacovigilance data from VigiBase related to 30 antipsychotics marketed in the European Union. Reporting odds ratios were calculated for antipsychotics associated with the Standardized Medical Dictionary of Regulatory Activities queries "Drug-related hepatic disorders-comprehensive search" (DRHD-CS) and "Drug-related hepatic disorders-severe events only" (DRHD-SEO). RESULTS We found several signals for drug-associated liver injury including signals for severe events: 17 of 30 antipsychotics were associated with DRHD-CS and 10 of 30 antipsychotics with DRHD-SEO. Amisulpride, fluphenazine, levomepromazine, loxapine, olanzapine, perazine, perphenazine, pipamperone, sulpiride, and thioridazine were associated with both, DRHD-CS and DRHD-SEO. No association with fatal outcomes was detected. CONCLUSIONS Several common antipsychotics are associated with hepatotoxicity, partly also with severe hepatotoxicity. Our data do not allow to account for patient-related risk factors for drug-associated liver injury. This should be addressed in further studies.
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Felthous AR, McCoy B, Nassif JB, Duggirala R, Kim E, Carabellese F, Stanford MS. Pharmacotherapy of Primary Impulsive Aggression in Violent Criminal Offenders. Front Psychol 2022; 12:744061. [PMID: 34975633 PMCID: PMC8716452 DOI: 10.3389/fpsyg.2021.744061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 11/02/2021] [Indexed: 01/11/2023] Open
Abstract
Primary impulsive aggression (PIA) can be implicated as a common factor that results in an arrest, disciplinary, and restraint measures during confinement, and criminal recidivism after release. Evidence suggests that anti-impulsive aggression agents (AIAAs) can diminish or prevent impulsive aggression even when occurring with personality pathology such as borderline or antisocial personality disorder (ASPD), common conditions in offender populations. A previous review identified agents that have been subjected to controlled drug trials of sufficient quality, and subsequently, a decisional algorithm was developed for selecting an AIAA for individuals with IA. This selection process began with the five agents that showed efficacy in two or more quality studies from the earlier review. Today, 8 years after the quality review study, the present authors undertook this follow-up literature review. The aims of the present review were to survey the literature to identify and assess: (1) drug trials of comparable quality published since the 2013 review, including trials of the previously identified AIAAs as well as trials of agents not included in the earlier review; (2) severity of aggressive outbursts; (3) the materiality of risks or side-effects that are associated with individual AIAAs as well as antipsychotic agents commonly used to control clinical aggression; (4) efficacy of these agents in special populations (e.g., females); and (5) cost and convenience of each agent. Improved pharmacotherapy of PIA by addressing risks, side effects and practicality as well as the efficacy of AIAAs, should promote the rehabilitation and reintegration of some pathologically aggressive offenders back into the community.
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Affiliation(s)
- Alan R Felthous
- Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, Saint Louis, MO, United States
| | - Bridget McCoy
- Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, Saint Louis, MO, United States
| | - Jose Bou Nassif
- Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, Saint Louis, MO, United States
| | - Rajat Duggirala
- Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, Saint Louis, MO, United States
| | - Ellen Kim
- Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, Saint Louis, MO, United States
| | - Fulvio Carabellese
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
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Andreea T, Petru I, Miron AA, Paula-Simina P, Lorena D. Clozapine for Treatment-Refractory Aggressive Behavior. Psychiatr Q 2021; 92:721-733. [PMID: 32918660 DOI: 10.1007/s11126-020-09839-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2020] [Indexed: 01/17/2023]
Abstract
Emergency psychiatry has the main role of resolving suicidal behavior and aggression. These severe psychiatric symptoms can be found in many psychiatric disorders such as schizophrenia, bipolar disorder, major depression, personality disorders, cognitive disorders, intellectual disability and substance abuse. Although indications for the use of antipsychotics are limited to a specific group of diseases, they are frequently used as rescue medication in high-risk or nonresponsive cases. Clozapine, the gold standard for TRS (treatment resistant schizophrenia) is effective in controlling aggression. The aim of the research was to identify the use of clozapine for treatment-refractory aggressive behavior in psychiatric emergency. A retrospective study based on the paper files of patients admitted between 2010 and 2019 in the Clinical Hospital of Psychiatry and Neurology of Brasov, Romania. Were included all the patients admitted as a psychiatric emergency and treated with clozapine for aggressive behavior. The hospital is an academic institution with 150 beds for acute patients, serving an area of over 600,000 inhabitants. It is the main public institution where patients with psychiatric emergencies are hospitalized. Off 19,000 patients admitted during the study period, 504 patients (2,4%) with a diagnosis other than schizophrenia or schizoaffective disorder received clozapine for aggressiveness (89.5%). The first four diagnoses identified were bipolar disorder (n = 172), intellectual disability (n = 128), cognitive impairment (n = 112), and personality disorder (n = 92). Other disorders identified but with a smaller number of cases were major depressive disorder (n = 3), adjustment disorders (n = 2), delusional disorder (n = 2), obsessive compulsive disorder (n = 2) and postpartum psychosis (n = 1). Clozapine was used as 3rd or 4th choice. The dose was greater for manic patients (350.29 ± 98.01 mg/day) compared with all the other diagnoses. Clozapine was effective and safe in cases of patients with treatment-refractory aggressive behavior.
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Affiliation(s)
- Teodorescu Andreea
- 1st and 3rd Clinical Departments, Clinical Hospital of Psychiatry and Neurology of Brasov, Brasov, Romania
| | - Ifteni Petru
- 1st and 3rd Clinical Departments, Clinical Hospital of Psychiatry and Neurology of Brasov, Brasov, Romania.
| | - Ana Aliana Miron
- 1st and 3rd Clinical Departments, Clinical Hospital of Psychiatry and Neurology of Brasov, Brasov, Romania
| | - Petric Paula-Simina
- 1st and 3rd Clinical Departments, Clinical Hospital of Psychiatry and Neurology of Brasov, Brasov, Romania
| | - Dima Lorena
- Faculty of Medicine, Transilvania University of Brasov, 56 Nicolae Bălcescu Str., 500019, Brasov, Romania
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Carthy E, Ross C, Murphy D. Psychotropic medication prescribing in people with autism spectrum disorders with and without psychiatric comorbidity. BJPSYCH ADVANCES 2021. [DOI: 10.1192/bja.2021.32] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
SUMMARY
Autism spectrum disorders (ASDs) are a group of lifelong neurodevelopmental disorders characterised by difficulties in social interactions and social communication, and restricted and repetitive behaviours. Relative to the general population, individuals with ASDs are likely to be overrepresented in secure psychiatric care and custodial settings. Outcomes vary and can be problematic in the context of co-occurring intellectual disability, psychiatric disorder and challenging behaviours. To date, there is little in the way of specialised clinical guidance on the prescription of psychotropic medicines for individuals with ASDs, particularly information on any differences in efficacy and/or tolerability of specific medications. This review summarises the key research to date on the prescription of psychotropic medication in ASD with and without comorbid psychiatric or neurodevelopmental disorders, within the context of the existing clinical guidance. Some critical analysis is provided to aid clinicians in following a safe, effective and individualised approach to prescribing for people with ASDs.
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Silva E, Higgins M, Hammer B, Stephenson P. Clozapine re-challenge and initiation following neutropenia: a review and case series of 14 patients in a high-secure forensic hospital. Ther Adv Psychopharmacol 2021; 11:20451253211015070. [PMID: 34221348 PMCID: PMC8221694 DOI: 10.1177/20451253211015070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 04/16/2021] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Clozapine remains the most effective intervention for treatment resistant schizophrenia; however, its use is prohibited following neutropenias. We review neutrophil biology as applied to clozapine and describe the strategies to initiate clozapine following neutropenia used in a case series of 14 consecutive patients rechallenged in a United Kingdom (UK) high-secure psychiatric hospital. We examine outcomes including the use of seclusion and transfer. METHODS A case series of 14 male patients with treatment resistant schizophrenia treated with clozapine despite previous episodes of neutropenia between 2006 and 2015 is presented. Data were collected during 2015 and 2019. Using this routinely collected clinical data, we describe the patient characteristics, causes of neutropenia, the strategies used for rechallenging with clozapine and clinical outcomes. RESULTS Previous neutropenias were the result of benign ethnic neutropenia, clozapine, other medications and autoimmune-related. Our risk mitigation strategies included: granulocyte-colony stimulating factor (G-CSF), lithium and watch-and-wait. There were no serious adverse events; at follow up half of the patient's had improved sufficiently to transfer them to conditions of lesser security. There were dramatic reductions in the use of seclusion. CONCLUSION Even in this extreme group, clozapine can be safely and effectively re/initiated following neutropenias, resulting in marked benefits for patients. This requires careful planning based on an understanding of neutrophil biology and the aetiology of the specific episode of neutropenia.
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Affiliation(s)
- Edward Silva
- Rathbone Low Secure Unit, Mersey Care NHS Foundation Trust, Rathbone Hospital, Mill Lane, Liverpool, L13 4AW, UK
| | - Melanie Higgins
- Ashworth Hospital, Mersey Care NHS Foundation Trust, Liverpool, UK
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Ostinelli EG, Zangani C, Solmi M. Clozapine for persistent aggressive behaviour or agitation in people with schizophrenia. Hippokratia 2019. [DOI: 10.1002/14651858.cd013493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Edoardo G Ostinelli
- Università degli Studi di Milano; Department of Health Sciences; Via Antonio di Rudinì 8 Milan Italy 20142
| | - Caroline Zangani
- Università degli Studi di Milano; Department of Health Sciences; Via Antonio di Rudinì 8 Milan Italy 20142
| | - Marco Solmi
- University of Padua; Neurosciences Department; Padova PAdova Italy 35100
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Fuertes-Saiz A, Benito A, Mateu C, Carratalá S, Almodóvar I, Baquero A, Haro G. Sensorimotor Gating in Cocaine-Related Disorder with Comorbid Schizophrenia or Antisocial Personality Disorder. J Dual Diagn 2019; 15:243-253. [PMID: 31287382 DOI: 10.1080/15504263.2019.1633489] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: Schizophrenia, cocaine-related disorder, antisocial personality disorder, and psychopathy share biological bases, but few studies discriminate between these disorders by means of prepulse inhibition. This work studies the phenotype of patients with cocaine-related disorders who are vulnerable to presenting a dual diagnosis of schizophrenia or antisocial personality disorder, by evaluating their prepulse inhibition, impulsivity and psychopathy personality traits. Methods: The sample (n = 38) was divided into three groups: (1) cocaine-related disorder (8 individuals diagnosed with cocaine-related disorder who did not present any other mental disorder), (2) cocaine-related disorder and schizophrenia (n = 14), and (3) cocaine-related disorder and antisocial personality disorder (n = 16). Results: The prepulse inhibition in the two groups with dual diagnosis was lower than that in the cocaine-related disorder group, F(2, 35) = 6.52, p = .004, while there was no significant differences between the two dual-diagnosis groups. Psychopathy was evaluated with the revised Hare Psychopathy Checklist and showed no correlation with the prepulse inhibition. Secondary psychopathy (impulsivity and poor behavior control), as evaluated with Levenson Self-Report Psychopathy Scale, was related to the prepulse inhibition. Two discriminating functions were obtained that allowed prediction of patient inclusion in the groups using the prepulse inhibition and the revised Hare Psychopathy Checklist with a success rate of 81.6% (cocaine-related disorder = 62.5%; cocaine-related disorder and schizophrenia = 78.6%; cocaine-related disorder and antisocial personality disorder = 93.8%). These results are discussed in regard to the neurobiological implications of prepulse inhibition in dual diagnosis. Conclusions: The results suggest that the prepulse inhibition is a promising dual-diagnosis vulnerability marker in individuals with cocaine addiction, because prepulse inhibition deficits are related both to schizophrenia and antisocial personality disorder. In addition, prepulse inhibition, which is considered a good endophenotype for studies on the genetic and neurobiological basis of cocaine-related disorder and schizophrenia, could be used in the same way in studies on antisocial personality disorder.
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Affiliation(s)
- Alejandro Fuertes-Saiz
- TXP Research Group, Medicine Department, Universidad Cardenal Herrera-CEU, CEU Universities, Castelló, Spain.,Psychiatry Department, Hospital Provincial de Castelló, Castelló, Spain
| | - Ana Benito
- TXP Research Group, Medicine Department, Universidad Cardenal Herrera-CEU, CEU Universities, Castelló, Spain.,Torrente Mental Health Center, Hospital General Universitario, Valencia, Spain
| | - César Mateu
- TXP Research Group, Medicine Department, Universidad Cardenal Herrera-CEU, CEU Universities, Castelló, Spain.,Psychiatry Department, Hospital Arnau de Vilanova, Valencia, Spain
| | - Sonia Carratalá
- TXP Research Group, Medicine Department, Universidad Cardenal Herrera-CEU, CEU Universities, Castelló, Spain.,Neurophysiology Department, Hospital General de Castelló, Castelló, Spain
| | - Isabel Almodóvar
- TXP Research Group, Medicine Department, Universidad Cardenal Herrera-CEU, CEU Universities, Castelló, Spain.,Psychiatry Department, Hospital Provincial de Castelló, Castelló, Spain
| | - Abel Baquero
- TXP Research Group, Medicine Department, Universidad Cardenal Herrera-CEU, CEU Universities, Castelló, Spain.,Proyecto Amigó Foundation, Castelló, Spain
| | - Gonzalo Haro
- TXP Research Group, Medicine Department, Universidad Cardenal Herrera-CEU, CEU Universities, Castelló, Spain.,Psychiatry Department, Hospital Provincial de Castelló, Castelló, Spain
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Illness and drug modifiable factors associated with violent behavior in homeless people with severe mental illness: results from the French Housing First (FHF) program. Prog Neuropsychopharmacol Biol Psychiatry 2019; 90:92-96. [PMID: 30423419 DOI: 10.1016/j.pnpbp.2018.11.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/31/2018] [Accepted: 11/05/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the factors associated with violent behavior in a large multicenter sample of Homeless Schizophrenia (SZ) and Bipolar Disorder (BD) (HSB) subjects. METHODS This multicenter study was conducted in 4 French cities: Lille, Marseille, Paris and Toulouse. Violent behavior was defined by at least one episode of verbal or physical violence in the last 6 months. RESULTS Overall, 675 HSB patients, mean aged 38 years and 82.5% men were included, 458 SZ (68.4%) and 212 BD (31.6%). During the 6 months before evaluation, 213 (34.3%) committed at least one physical or verbal violence. In multivariate analysis, violence has been associated with younger age (aOR = 0.96[0.94-0.99], p = .001), number of nights in the street (aOR = 1.01[1.01-1.01]), BD diagnosis (aOR = 1.63[1.01-2.65], p = .04), higher current illness severity (CGI score) (aOR = 1.32[1.07-1.64], p = .01), higher rates of current manic episode (aOR = 2.24[1.32-3.81], p = .002), current alcohol use disorder (aOR = 2.05 [1.33-3.15], p = .001), antisocial personality disorder (aOR = 2.51[1.55-4.07], p < .001) and with antidepressant consumption (aOR = 2.01[1.01-4.04], p = .04). No specific antipsychotic or mood stabilizer has been associated with decreased rates of violent behavior, however clozapine, lithium and carbamazepine remained poorly prescribed. CONCLUSION In case of violent behavior in HSB subjects, clinicians should focus in priority on the treatment of mania, antidepressant iatrogenic effect and alcohol use disorder by pharmacological and non-pharmacological treatments. Clozapine, lithium and carbamazepine should be chosen as the treatments of reference in this population but may be hard to manage in some cases. The current clinical trial number is NCT01570712.
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Juárez-Treviño M, Esquivel AC, Isida LML, Delgado DÁG, de la O Cavazos ME, Ocañas LG, Sepúlveda RS. Clozapine in the Treatment of Aggression in Conduct Disorder in Children and Adolescents: A Randomized, Double-blind, Controlled Trial. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2019; 17:43-53. [PMID: 30690939 PMCID: PMC6361039 DOI: 10.9758/cpn.2019.17.1.43] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 03/22/2018] [Accepted: 03/23/2018] [Indexed: 01/06/2023]
Abstract
Objective This study was conducted to compare the efficacy of clozapine vs. risperidone in the treatment of aggression in conduct disorder in children and adolescents. Methods Twenty-four children with conduct disorder aged 6 to 16 years were randomized in a prospective, double-blind trial into two groups to receive clozapine or risperidone for 16 weeks. The Modified Overt Aggression Scale score was used as the primary outcome of the study. Secondary outcomes were Child Behavior Checklist (CBCL) externalization (CBCL-E) and internalization factors; Aggression, Hyperactivity and Delinquency subscales of CBCL-E, Child Global Assessment Scale (CGAS), Barnes Akathisia Rating Scale, and Simpson-Angus Scale. Results Both antipsychotics were similarly effective in the primary outcome and in most of the secondary ones. Clozapine was more effective in CBCL-E, the delinquency subscale and the CGAS scores than risperidone (p =0.039, 0.010, and 0.021). Two subjects from the clozapine group were excluded due to a low neutrophil count at week four. Conclusion Clozapine and risperidone are effective for short-term treatment of aggression in children and adolescents with conduct disorder. Clozapine was more effective than risperidone in conduct externalization factors, delinquency trait and global functioning in children and adolescents. Stronger efficacy of clozapine should be investigated in larger sample sizes using pharmacogenomic studies. White blood cell counts need to be monitored when prescribing clozapine.
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Affiliation(s)
- Myrthala Juárez-Treviño
- Department of Psychiatry, Hospital Universitario, Universidad Autónoma de Nuevo León, Mexico
| | | | - Lilia Marytza Leal Isida
- Department of Psychiatry, Instituto Tecnológicoy de Estudios Superiores de Monterrey ITESM, Escuela de Medicina, NL, Mexico
| | | | | | - Lourdes Garza Ocañas
- Department of Pharmacology, Hospital Universitario, Universidad Autónoma de Nuevo León, Mexico
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[Standards for treatment in forensic committment according to § 63 and § 64 of the German criminal code : Interdisciplinary task force of the DGPPN]. DER NERVENARZT 2019; 88:1-29. [PMID: 28776213 DOI: 10.1007/s00115-017-0382-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
People who have been convicted of a crime due to a severe mental disorder and continue to be dangerous as a result of this disorder may be placed in a forensic psychiatric facility for improvement and safeguarding according to § 63 and § 64 of the German Criminal Code (StGB). In Germany, approximately 9000 patients are treated in clinics for forensic psychiatry and psychotherapy on the basis of § 63 of the StGB and in withdrawal centers on the basis of § 64 StGB. The laws for treatment of patients in forensic commitment are passed by the individual States, with the result that even the basic conditions differ in the individual States. While minimum requirements have already been published for the preparation of expert opinions on liability and legal prognosis, consensus standards for the treatment in forensic psychiatry have not yet been published. Against this background, in 2014 the German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology (DGPPN) commissioned an interdisciplinary task force to develop professional standards for treatment in forensic psychiatry. Legal, ethical, structural, therapeutic and prognostic standards for forensic psychiatric treatment should be described according to the current state of science. After 3 years of work the results of the interdisciplinary working group were presented in early 2017 and approved by the board of the DGPPN. The standards for the treatment in the forensic psychiatric commitment aim to initiate a discussion in order to standardize the treatment conditions and to establish evidence-based recommendations.
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Abstract
Studies on antisocial personality disorder (ASPD) subjects focus on brain functional alterations in relation to antisocial behaviors. Neuroimaging research has identified a number of focal brain regions with abnormal structures or functions in ASPD. However, little is known about the connections among brain regions in terms of inter-regional whole-brain networks in ASPD patients, as well as possible alterations of brain functional topological organization. In this study, we employ resting-state functional magnetic resonance imaging (R-fMRI) to examine functional connectome of 32 ASPD patients and 35 normal controls by using a variety of network properties, including small-worldness, modularity, and connectivity. The small-world analysis reveals that ASPD patients have increased path length and decreased network efficiency, which implies a reduced ability of global integration of whole-brain functions. Modularity analysis suggests ASPD patients have decreased overall modularity, merged network modules, and reduced intra- and inter-module connectivities related to frontal regions. Also, network-based statistics show that an internal sub-network, composed of 16 nodes and 16 edges, is significantly affected in ASPD patients, where brain regions are mostly located in the fronto-parietal control network. These results suggest that ASPD is associated with both reduced brain integration and segregation in topological organization of functional brain networks, particularly in the fronto-parietal control network. These disruptions may contribute to disturbances in behavior and cognition in patients with ASPD. Our findings may provide insights into a deeper understanding of functional brain networks of ASPD.
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Müller JL, Saimeh N, Briken P, Eucker S, Hoffmann K, Koller M, Wolf T, Dudeck M, Hartl C, Jakovljevic AK, Klein V, Knecht G, Müller-Isberner R, Muysers J, Schiltz K, Seifert D, Simon A, Steinböck H, Stuckmann W, Weissbeck W, Wiesemann C, Zeidler R. Standards für die Behandlung im Maßregelvollzug nach §§ 63 und 64 StGB. FORENSISCHE PSYCHIATRIE, PSYCHOLOGIE, KRIMINOLOGIE 2018. [DOI: 10.1007/s11757-017-0445-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Sedgwick O, Young S, Baumeister D, Greer B, Das M, Kumari V. Neuropsychology and emotion processing in violent individuals with antisocial personality disorder or schizophrenia: The same or different? A systematic review and meta-analysis. Aust N Z J Psychiatry 2017; 51:1178-1197. [PMID: 28992741 DOI: 10.1177/0004867417731525] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To assess whether there are shared or divergent (a) cognitive and (b) emotion processing characteristics among violent individuals with antisocial personality disorder and/or schizophrenia, diagnoses which are commonly encountered at the interface of mental disorder and violence. Cognition and emotion processing are incorporated into models of violence, and thus an understanding of these characteristics within and between disorder groups may help inform future models and therapeutic targets. METHODS Relevant databases (OVID, Embase, PsycINFO) were searched to identify suitable literature. Meta-analyses comparing cognitive function in violent schizophrenia and antisocial personality disorder to healthy controls were conducted. Neuropsychological studies not comparing these groups to healthy controls, and emotion processing studies, were evaluated qualitatively. RESULTS Meta-analyses indicated lower IQ, memory and executive function in both violent schizophrenia and antisocial personality disorder groups compared to healthy controls. The degree of deficit was consistently larger in violent schizophrenia. Both antisocial personality disorder and violent schizophrenia groups had difficulties in aspects of facial affect recognition, although theory of mind results were less conclusive. Psychopathic traits related positively to experiential emotion deficits across the two disorders. Very few studies explored comorbid violent schizophrenia and antisocial personality disorder despite this being common in clinical practice. CONCLUSION There are qualitatively similar, but quantitatively different, neuropsychological and emotion processing deficits in violent individuals with schizophrenia and antisocial personality disorder which could be developed into transdiagnostic treatment targets for violent behaviour. Future research should aim to characterise specific subgroups of violent offenders, including those with comorbid diagnoses.
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Affiliation(s)
- Ottilie Sedgwick
- 1 Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,2 Broadmoor Hospital, West London Mental Health Trust, Crowthorne, UK
| | - Susan Young
- 2 Broadmoor Hospital, West London Mental Health Trust, Crowthorne, UK.,3 Centre for Mental Health, Department of Medicine, Imperial College London, London, UK
| | - David Baumeister
- 1 Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Ben Greer
- 2 Broadmoor Hospital, West London Mental Health Trust, Crowthorne, UK
| | - Mrigendra Das
- 2 Broadmoor Hospital, West London Mental Health Trust, Crowthorne, UK
| | - Veena Kumari
- 4 Research and Development, Sovereign Health Group, San Clemente, CA, USA
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Bozzatello P, Ghirardini C, Uscinska M, Rocca P, Bellino S. Pharmacotherapy of personality disorders: what we know and what we have to search for. FUTURE NEUROLOGY 2017. [DOI: 10.2217/fnl-2017-0010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Pharmacotherapy for personality disorders is in the early stage of development because the evidence base for effective drug treatment is insufficient, biased toward borderline personality disorder and rampant with methodological issues. In this paper, we reviewed randomized, placebo-controlled trials of drugs efficacy in patients with personality disorders published between 1990 and 2016. Overwhelming majority of studies focused on borderline personality disorder, and the accumulation of evidence resulted in seven meta-analyses, which are interpreted into better strategies for evidence-based practice. Little research attention was given to schizotypal and antisocial personality disorders, with only indirect treatment efficacy evidence for the obsessive–compulsive and avoidant personality disorders. Some avenues for future efficacy research are indicated.
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Affiliation(s)
- Paola Bozzatello
- Centre or Personality Disorders, Department of Neuroscience, University of Turin, via Cherasco 11, 10126, Turin, Italy
| | - Camilla Ghirardini
- Centre or Personality Disorders, Department of Neuroscience, University of Turin, via Cherasco 11, 10126, Turin, Italy
| | - Maria Uscinska
- Centre or Personality Disorders, Department of Neuroscience, University of Turin, via Cherasco 11, 10126, Turin, Italy
| | - Paola Rocca
- Department of Neuroscience, University of Turin, via Cherasco 11,10126, Turin, Italy
| | - Silvio Bellino
- Centre or Personality Disorders, Department of Neuroscience, University of Turin, via Cherasco 11, 10126, Turin, Italy
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Mortlock AM, Larkin F, Ross CC, Gupta N, Sengupta S, Das M. Effectiveness of paliperidone depot injection in seriously violent men with comorbid schizophrenia and dissocial personality disorder in a UK high-security hospital. Ther Adv Psychopharmacol 2017; 7:169-179. [PMID: 28540038 PMCID: PMC5431400 DOI: 10.1177/2045125317693513] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 05/05/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND High-security hospital patients are often complex in presentation and are characterized by treatment resistance, medication nonadherence and history of violence. Paliperidone is licensed both as an oral and depot antipsychotic medication in the treatment of schizophrenia. Clinical trials have shown that paliperidone depot is well tolerated with similar efficacy to risperidone depot but with additional practical advantages. Whilst data exist for the effectiveness of paliperidone palmitate (PP), there are no studies involving patients in forensic settings or those with comorbid personality disorder. Our aim was to evaluate the effectiveness of PP on violence, aggression and personality disorder symptoms. METHODS This project was a retrospective service evaluation involving 11 patients, carried out in a high-security hospital. A combination of patient records and interviews with the treating consultant psychiatrist were used to ascertain a Clinical Global Impression (CGI) score, the effect of PP on specific personality disorder symptom domains (cognitive-perceptual, impulsive-behavioural dyscontrol and affective dysregulation) and incidents of violence and aggression. Engagement with occupational and psychological therapies was also evaluated. Metabolic parameters were reviewed. RESULTS A total of 6 out of 11 patients continued on PP, most of whom had schizophrenia and dissocial personality disorder with histories of violence. All showed improvement in the CGI score with associated benefits in the three personality symptom domains. Overall, two patients demonstrated a reduction in the risk of violence. There was improvement in engagement with occupational therapy and psychological work. No significant effects on metabolic parameters were noted although hyperprolactinaemia, albeit asymptomatic, was consistently recorded. CONCLUSIONS This pragmatic service evaluation of a small but complex patient group demonstrated, for the first time, that PP was effective in reducing violence as well as improving personality pathology across all dimensions: a finding which could have significant implications for management of such high-security patients.
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Affiliation(s)
- Anna-Marie Mortlock
- Specialist Registrar Forensic Psychiatry, Broadmoor Hospital, West London Mental Health Trust, Crowthorne, UK
| | - Fintan Larkin
- Consultant Forensic Psychiatrist, Broadmoor Hospital, West London Mental Health Trust, Crowthorne, UK
| | - Callum C. Ross
- Consultant Forensic Psychiatrist, Broadmoor Hospital, West London Mental Health Trust, Crowthorne, UK
| | - Nitin Gupta
- Professor, Department of Psychiatry, Government Medical College, Chandigarh, India
| | - Samrat Sengupta
- Consultant Forensic Psychiatrist, Broadmoor Hospital, West London Mental Health Trust, Crowthorne, UK
| | - Mrigendra Das
- Consultant Forensic Psychiatrist, Top End Mental Health Service, PO Box 140, Parap, NT 0804, Australia
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Meyer JM, Cummings MA, Proctor G, Stahl SM. Psychopharmacology of Persistent Violence and Aggression. Psychiatr Clin North Am 2016; 39:541-556. [PMID: 27836150 DOI: 10.1016/j.psc.2016.07.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Persistent violence not due to acute psychosis or mania can be managed only after appropriate characterization of the aggressive episodes (psychotic, impulsive, or predatory/planned/instrumental). The type of violence combined with the psychiatric diagnosis dictates the evidence-based pharmacologic approaches for psychotically motivated and impulsive aggression, whereas instrumental violence mandates forensic/behavioral strategies. For nonacute inpatients, schizophrenia spectrum disorders, traumatic brain injury, and dementia comprise the majority of individuals who are persistently aggressive, with impulsive actions the most common form of violence across all diagnoses. Neurobiological considerations combined with empirical data provide a comprehensive framework for systematic medication trials to manage persistently aggressive patients.
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Affiliation(s)
- Jonathan M Meyer
- California Department of State Hospitals (DSH), Psychopharmacology Resource Network, DSH-Patton, 3102 East Highland Avenue, Patton, CA 92369, USA; Department of Psychiatry, University of California, San Diego; 9500 Gilman Drive, MC 0603, La Jolla, CA 92093-0603, USA.
| | - Michael A Cummings
- California Department of State Hospitals (DSH), Psychopharmacology Resource Network, DSH-Patton, 3102 East Highland Avenue, Patton, CA 92369, USA
| | - George Proctor
- California Department of State Hospitals (DSH), Psychopharmacology Resource Network, DSH-Patton, 3102 East Highland Avenue, Patton, CA 92369, USA
| | - Stephen M Stahl
- Department of Psychiatry, University of California, San Diego; 9500 Gilman Drive, MC 0603, La Jolla, CA 92093-0603, USA; California Department of State Hospitals (DSH), Bateson Building, 1600 9th Street, Room 400, Sacramento, CA 95814, USA
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Psychotropic prescribing in seriously violent men with schizophrenia or personality disorder in a UK high security hospital. CNS Spectr 2016; 21:60-9. [PMID: 26726766 DOI: 10.1017/s1092852915000784] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To analyze antipsychotic prescribing patterns in a UK high security hospital (HSH) that treats seriously violent men with either schizophrenia or personality disorder and examine how different groups consented to treatment and prescribing for metabolic conditions. We hypothesized that there would be high prevalence of antipsychotic polypharmacy, and high-dose antipsychotic and clozapine prescribing. BACKGROUND HSHs treat seriously violent, mentally disordered offenders, and the extant literature on prescribing patterns in forensic settings is sparse. METHODS Prescribing and clinical data on all 189 patients in a UK HSH were collected from the hospital's databases. Data were analyzed using SPSS. RESULTS The population was split into the following groups: schizophrenia spectrum disorder (SSD-only), personality disorder (PD-only), and comorbid schizophrenia spectrum disorder and PD. The majority (93.7%) of all patients were prescribed at least one antipsychotic, and (27.5%) were on clozapine. Polypharmacy was prevalent in 22.2% and high-dose antipsychotic in 27.5%. Patients on clozapine were more likely to be prescribed antidiabetic, statins, or antihypertensive medication. Patients in the PD-only group were more likely to be deemed to have the capacity to consent to treatment and be prescribed clozapine in contrast to the SSD-only group. CONCLUSIONS Rates of clozapine and high-dose antipsychotic prescribing were higher than in other psychiatric settings, while polypharmacy prescribing rates were lower. Higher clozapine prescribing rates may be a function of a treatment-resistant and aggressive population. A higher proportion of PD-only patients consented to treatment and received clozapine compared with in-house SSD-only as well as other psychiatric settings. Implications of the findings are discussed.
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Thibaut F, Bradford JMW, Briken P, De La Barra F, Häßler F, Cosyns P. The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the treatment of adolescent sexual offenders with paraphilic disorders. World J Biol Psychiatry 2015; 17:2-38. [PMID: 26595752 PMCID: PMC4743592 DOI: 10.3109/15622975.2015.1085598] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 08/18/2015] [Indexed: 01/12/2023]
Abstract
The primary aim of these guidelines was to evaluate the role of pharmacological agents in the treatment of adolescents with paraphilic disorders who are also sexual offenders or at-risk of sexual offending. Psychotherapeutic and psychosocial treatments were also reviewed. Adolescents with paraphilic disorders specifically present a different therapeutic challenge as compared to adults. In part, the challenge relates to adolescents being in various stages of puberty and development, which may limit the use of certain pharmacological agents due to their potential side effects. In addition, most of the published treatment programmes have used cognitive behavioural interventions, family therapies and psychoeducational interventions. Psychological treatment is predicated in adolescents on the notion that sexually deviant behaviour can be controlled by the offender, and that more adaptive behaviours can be learned. The main purposes of these guidelines are to improve the quality of care and to aid physicians in their clinical decisions. These guidelines brought together different expert views and involved an extensive literature research. Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for efficacy, safety, tolerability and feasibility. An algorithm is proposed for the treatment of paraphilic disorders in adolescent sexual offenders or those who are at risk.
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Affiliation(s)
- Florence Thibaut
- University Hospital Cochin, Faculty of Medicine Paris Descartes, INSERM U 894 CPN,
Paris,
France
| | - John M. W. Bradford
- University of Ottawa, Institute of Mental Health Research, Division of Forensic Psychiatry, Queen’s University, Clinical Director, Forensic Treatment Unit, Brockville Mental Health Centre, Royal Ottawa Health Care Group,
Brockville,
Ontario,
Canada
| | - Peer Briken
- Institute for Sex Research and Forensic Psychiatry, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf,
Hamburg,
Germany
| | - Flora De La Barra
- East Psychiatry and Mental Health Department, University of Chile,
Clinica Las Condes,
Chile
| | - Frank Häßler
- Clinic for Child and Adolescent Psychiatry, University of Medicine of Rostock,
Rostock,
Germany
| | - Paul Cosyns
- University Forensic Centre (University Hospital of Antwerp),
Belgium
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Yildirim BO, Derksen JJL. Mesocorticolimbic dopamine functioning in primary psychopathy: A source of within-group heterogeneity. Psychiatry Res 2015; 229:633-77. [PMID: 26277034 DOI: 10.1016/j.psychres.2015.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 04/08/2015] [Accepted: 07/05/2015] [Indexed: 01/17/2023]
Abstract
Despite similar emotional deficiencies, primary psychopathic individuals can be situated on a continuum that spans from controlled to disinhibited. The constructs on which primary psychopaths are found to diverge, such as self-control, cognitive flexibility, and executive functioning, are crucially regulated by dopamine (DA). As such, the goal of this review is to examine which specific alterations in the meso-cortico-limbic DA system and corresponding genes (e.g., TH, DAT, COMT, DRD2, DRD4) might bias development towards a more controlled or disinhibited expression of primary psychopathy. Based on empirical data, it is argued that primary psychopathy is generally related to a higher tonic and population activity of striatal DA neurons and lower levels of D2-type DA receptors in meso-cortico-limbic projections, which may boost motivational drive towards incentive-laden goals, dampen punishment sensitivity, and increase future reward-expectancy. However, increasingly higher levels of DA activity in the striatum (moderate versus pathological elevations), lower levels of DA functionality in the prefrontal cortex, and higher D1-to-D2-type receptor ratios in meso-cortico-limbic projections may lead to increasingly disinhibited and impetuous phenotypes of primary psychopathy. Finally, in order to provide a more coherent view on etiological mechanisms, we discuss interactions between DA and serotonin that are relevant for primary psychopathy.
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Affiliation(s)
- Bariş O Yildirim
- Department of Clinical Psychology, Radboud University Nijmegen, De Kluyskamp 1002, 6545 JD Nijmegen, The Netherlands.
| | - Jan J L Derksen
- Department of Clinical Psychology, Room: A.07.04B, Radboud University Nijmegen, Montessorilaan 3, 6525 HR Nijmegen, The Netherlands.
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Illustrative cases to support the Cal-VAT guidelines. CNS Spectr 2015; 20:311-8. [PMID: 25817927 DOI: 10.1017/s1092852915000127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
There is increasing interest in developing more nuanced methods for managing aggression and violence in long-term psychiatric inpatient settings. However, the dearth of controlled studies has, at times, hampered presentation of viable options. Following the publication of guidelines developed in the California State Hospital forensic system, the authors present a group of 7 cases illustrating different approaches to violence management, including pharmacological, psychotherapeutic, and environmental interventions.
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Abstract
Psychopathic individuals account for substantial predatory and impulsive violence. To the present, the principal intervention used to decrease the harm inflicted by psychopaths has been confinement. Nevertheless, most confined psychopathic persons return to the community. Recent advances in the understanding of the neurobiology of psychopathy hold promise for new research directions and more effective treatments. In this article, we will explore recent advances in genetics, electrophysiology, brain imaging, and psychopharmacology, as well as, in brief, their implications for new directions in research and treatment.
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Silverstein SM, Del Pozzo J, Roché M, Boyle D, Miskimen T. Schizophrenia and violence: realities and recommendations. ACTA ACUST UNITED AC 2015. [DOI: 10.1080/23744006.2015.1033154] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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