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Nibbio G, Bertoni L, Calzavara-Pinton I, Necchini N, Paolini S, Baglioni A, Zardini D, Poddighe L, Bulgari V, Lisoni J, Deste G, Barlati S, Vita A. The Relationship between Cognitive Impairment and Violent Behavior in People Living with Schizophrenia Spectrum Disorders: A Critical Review and Treatment Considerations. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1261. [PMID: 39202542 PMCID: PMC11356552 DOI: 10.3390/medicina60081261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Revised: 08/01/2024] [Accepted: 08/02/2024] [Indexed: 09/03/2024]
Abstract
Cognitive impairment is a core feature of schizophrenia spectrum disorders (SSD). Violent and aggressive behavior represents a complex issue in psychiatry, and people with SSD have been shown to be at risk of being both victims and perpetrators of violence. In this review, the complex relationship between cognitive impairment and violent behavior is explored, also considering the usefulness of treating cognitive impairment to improve violence-related outcomes. Several studies report that cognitive impairment is linked to violent behavior, but significant differences between domains and conflicting results are also present, leaving the identification of specific cognitive profiles predicting violent behavior in SSD as an important aim for future research. Evidence regarding the effectiveness of treating cognitive impairment to improve violent behavior, while heterogeneous, provides more consistent results: cognition-targeting interventions appear to provide significant benefits also in the prevention of aggression in people living with SSD, and preliminary evidence shows cognition-focused interventions targeting violent behavior improve both cognition- and violence-related outcomes. Implementing these interventions in clinical practice could be of great usefulness, particularly in forensic contexts. Physical exercise, which improves cognitive performance and psychosocial functioning in SSD, appears to reduce violent behavior in healthy individuals, but requires further studies in clinical samples.
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Affiliation(s)
- Gabriele Nibbio
- Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy; (G.N.); (L.B.); (N.N.); (S.P.); (A.B.); (D.Z.); (V.B.); (G.D.); (A.V.)
| | - Lorenzo Bertoni
- Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy; (G.N.); (L.B.); (N.N.); (S.P.); (A.B.); (D.Z.); (V.B.); (G.D.); (A.V.)
| | - Irene Calzavara-Pinton
- Department of Mental Health and Addiction Services, ASST Spedali Civili of Brescia, 25123 Brescia, Italy; (I.C.-P.); (L.P.); (J.L.)
| | - Nicola Necchini
- Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy; (G.N.); (L.B.); (N.N.); (S.P.); (A.B.); (D.Z.); (V.B.); (G.D.); (A.V.)
| | - Stefano Paolini
- Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy; (G.N.); (L.B.); (N.N.); (S.P.); (A.B.); (D.Z.); (V.B.); (G.D.); (A.V.)
| | - Antonio Baglioni
- Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy; (G.N.); (L.B.); (N.N.); (S.P.); (A.B.); (D.Z.); (V.B.); (G.D.); (A.V.)
| | - Daniela Zardini
- Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy; (G.N.); (L.B.); (N.N.); (S.P.); (A.B.); (D.Z.); (V.B.); (G.D.); (A.V.)
| | - Laura Poddighe
- Department of Mental Health and Addiction Services, ASST Spedali Civili of Brescia, 25123 Brescia, Italy; (I.C.-P.); (L.P.); (J.L.)
| | - Viola Bulgari
- Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy; (G.N.); (L.B.); (N.N.); (S.P.); (A.B.); (D.Z.); (V.B.); (G.D.); (A.V.)
| | - Jacopo Lisoni
- Department of Mental Health and Addiction Services, ASST Spedali Civili of Brescia, 25123 Brescia, Italy; (I.C.-P.); (L.P.); (J.L.)
| | - Giacomo Deste
- Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy; (G.N.); (L.B.); (N.N.); (S.P.); (A.B.); (D.Z.); (V.B.); (G.D.); (A.V.)
- Department of Mental Health, ASST Valcamonica, 25123 Brescia, Italy
| | - Stefano Barlati
- Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy; (G.N.); (L.B.); (N.N.); (S.P.); (A.B.); (D.Z.); (V.B.); (G.D.); (A.V.)
- Department of Mental Health and Addiction Services, ASST Spedali Civili of Brescia, 25123 Brescia, Italy; (I.C.-P.); (L.P.); (J.L.)
| | - Antonio Vita
- Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy; (G.N.); (L.B.); (N.N.); (S.P.); (A.B.); (D.Z.); (V.B.); (G.D.); (A.V.)
- Department of Mental Health and Addiction Services, ASST Spedali Civili of Brescia, 25123 Brescia, Italy; (I.C.-P.); (L.P.); (J.L.)
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Lau S, Habermeyer E, Hill A, Günther MP, Machetanz LA, Kirchebner J, Huber D. Differentiating Between Sexual Offending and Violent Non-sexual Offending in Men With Schizophrenia Spectrum Disorders Using Machine Learning. SEXUAL ABUSE : A JOURNAL OF RESEARCH AND TREATMENT 2023:10790632231200838. [PMID: 37695940 DOI: 10.1177/10790632231200838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
Forensic psychiatric populations commonly contain a subset of persons with schizophrenia spectrum disorders (SSD) who have committed sex offenses. A comprehensive delineation of the features that distinguish persons with SSD who have committed sex offenses from persons with SSD who have committed violent non-sex offenses could be relevant to the development of differentiated risk assessment, risk management and treatment approaches. This analysis included the patient records of 296 men with SSD convicted of at least one sex and/or violent offense who were admitted to the Centre for Inpatient Forensic Therapy at the University Hospital of Psychiatry Zurich between 1982 and 2016. Using supervised machine learning, data on 461 variables retrospectively collected from the records were compared with respect to their relative importance in differentiating between men who had committed sex offenses and men who had committed violent non-sex offenses. The final machine learning model was able to differentiate between the two types of offenders with a balanced accuracy of 71.5% (95% CI = [60.7, 82.1]) and an AUC of .80 (95% CI = [.67, .93]). The main distinguishing features included sexual behaviours and interests, psychopathological symptoms and characteristics of the index offense. Results suggest that when assessing and treating persons with SSD who have committed sex offenses, it appears to be relevant to not only address the core symptoms of the disorder, but to also take into account general risk factors for sexual recidivism, such as atypical sexual interests and sexual preoccupation.
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Affiliation(s)
- Steffen Lau
- University Hospital of Psychiatry Zurich, University of Zurich, Zurich, Switzerland
| | - Elmar Habermeyer
- University Hospital of Psychiatry Zurich, University of Zurich, Zurich, Switzerland
| | - Andreas Hill
- University Hospital of Psychiatry Zurich, University of Zurich, Zurich, Switzerland
| | - Moritz P Günther
- University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Lena A Machetanz
- University Hospital of Psychiatry Zurich, University of Zurich, Zurich, Switzerland
| | - Johannes Kirchebner
- University Hospital of Psychiatry Zurich, University of Zurich, Zurich, Switzerland
| | - David Huber
- University Hospital of Psychiatry Zurich, University of Zurich, Zurich, Switzerland
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Buizza C, Strozza C, Sbravati G, de Girolamo G, Ferrari C, Iozzino L, Macis A, Kennedy HG, Candini V. Positive and negative syndrome scale in forensic patients with schizophrenia spectrum disorders: a systematic review and meta-analysis. Ann Gen Psychiatry 2022; 21:36. [PMID: 36088451 PMCID: PMC9463849 DOI: 10.1186/s12991-022-00413-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 06/19/2022] [Indexed: 01/10/2023] Open
Abstract
Among forensic patients with schizophrenia spectrum disorders, the association between symptomatology and violence is still not entirely clear in literature, especially because symptoms shift both during the acute phase of the illness and after. The aims were to investigate the level of symptomatology in forensic patients and to evaluate if there are differences in the level of symptoms between forensic and non-forensic patients. According to PRISMA guidelines, a systematic search was performed in PubMed, Web of Science, and ProQuest, using the following key words: "forensic" AND "Positive and Negative Syndrome Scale" OR "PANSS". A total of 27 studies were included in the systematic review, while only 23 studies in the meta-analysis. The overall sample included a total of 1702 participants, most commonly male and inpatients in forensic settings. We found that studies with an entirely male sample had significantly lower Positive PANSS ratings than studies with mixed samples. Although both forensic and non-forensic patients were affected by mild psychopathological symptoms, forensic patients presented higher ratings in all four PANSS scales. This meta-analysis shows that forensic patients reported a mild level of symptomatology, as assessed with the PANSS, and therefore might be considered as patients in partial remission. Among patients with schizophrenia, the association between symptoms and violence is very complex: many factors might be considered as key mediators and thus should be taken into account to explain this association. Further studies are needed.Trial registration all materials and data can be found on the OSF framework: https://osf.io/5ceja (date of registration: 8 September 2021).
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Affiliation(s)
- Chiara Buizza
- Psychiatric Epidemiology and Evaluation Unit, IRCCS Istituto Centro San Giovanni Di Dio Fatebenefratelli, Via Pilastroni 4, 25125, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Viale Europa 11, 25123, Brescia, Italy
| | - Cosmo Strozza
- Interdisciplinary Centre On Population Dynamics, University of Southern Denmark, 5000, Odense, Denmark
| | - Giulio Sbravati
- Psychiatric Epidemiology and Evaluation Unit, IRCCS Istituto Centro San Giovanni Di Dio Fatebenefratelli, Via Pilastroni 4, 25125, Brescia, Italy
| | - Giovanni de Girolamo
- Psychiatric Epidemiology and Evaluation Unit, IRCCS Istituto Centro San Giovanni Di Dio Fatebenefratelli, Via Pilastroni 4, 25125, Brescia, Italy
| | - Clarissa Ferrari
- Service of Statistics, IRCCS Istituto Centro San Giovanni Di Dio Fatebenefratelli, Via Pilastroni 4, Brescia, Italy
| | - Laura Iozzino
- Psychiatric Epidemiology and Evaluation Unit, IRCCS Istituto Centro San Giovanni Di Dio Fatebenefratelli, Via Pilastroni 4, 25125, Brescia, Italy
| | - Ambra Macis
- Service of Statistics, IRCCS Istituto Centro San Giovanni Di Dio Fatebenefratelli, Via Pilastroni 4, Brescia, Italy
| | - Harry G Kennedy
- The National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland.,Academic Department of Psychiatry, Trinity College Dublin, Dublin, Ireland
| | - Valentina Candini
- Psychiatric Epidemiology and Evaluation Unit, IRCCS Istituto Centro San Giovanni Di Dio Fatebenefratelli, Via Pilastroni 4, 25125, Brescia, Italy.
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Hsu MC, Ouyang WC. Effects of Integrated Moral Reasoning Development Intervention for Management of Violence in Schizophrenia: A Randomized Controlled Trial. J Clin Med 2022; 11:jcm11051169. [PMID: 35268258 PMCID: PMC8911519 DOI: 10.3390/jcm11051169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/03/2022] [Accepted: 02/18/2022] [Indexed: 02/06/2023] Open
Abstract
Moral cognition is an important and multidimensional, but often overlooked, determinant of violence. Very few interventions have systematically examined the role of moral reasoning, anger management and problem-solving together in violence. A randomized controlled trial was conducted to comprehensively evaluate the sustained effects of an integrated Moral Reasoning Development Intervention (MRDI) in the management of repetitive violence in schizophrenia. This study placed special emphasis on essential components related to moral reasoning and violence in patients with schizophrenia. Evaluations, including measures of violence, moral reasoning, ethical valuation and judgement, decision-making, conflict management style, and personality traits, were performed at baseline, end of intervention, and 1-month follow-up after intervention. We found that MRDI was superior to treatment-as-usual, in improving moral reasoning and related variables and violence outcomes (p < 0.05). In comparison with the treatment-as-usual group (n = 22), patients in the MRDI group (n = 21) showed improved levels of moral reasoning, with decreased levels of violent behaviors. The MRDI participants also experienced significantly greater improvements or changes (p < 0.05) in their ethical valuation and judgement, decision-making style and preferences, and conflict management style. Our findings provide important implications for risk assessment and violence management and prevention.
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Affiliation(s)
- Mei-Chi Hsu
- Department of Nursing, I-Shou University, Kaohsiung City 82445, Taiwan;
| | - Wen-Chen Ouyang
- Department of Geriatric Psychiatry, Jianan Psychiatric Center, Ministry of Health and Welfare, Tainan City 71742, Taiwan
- Department of Nursing, Shu-Zen Junior College of Medicine and Management, Kaohsiung City 82144, Taiwan
- Department of Psychiatry, College of Medicine, Kaohsiung Medical University, Kaohsiung City 80708, Taiwan
- Correspondence: ; Tel.: +886-6-2795019
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Gou N, Xiang Y, Zhou J, Zhang S, Zhong S, Lu J, Liang X, Liu J, Wang X. Identification of violent patients with schizophrenia using a hybrid machine learning approach at the individual level. Psychiatry Res 2021; 306:114294. [PMID: 34823086 DOI: 10.1016/j.psychres.2021.114294] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/24/2021] [Accepted: 11/14/2021] [Indexed: 12/14/2022]
Abstract
Despite numerous risk factors associated with violence in patients with schizophrenia, predicting and preventing violent behavior is still a challenge. At present, machine learning (ML) has become a promising strategy for guiding individualized assessment. To build an effective model to predict the risk of violence in patients with schizophrenia, we proposed a hybrid ML method to improve the prediction capability in 42 violent offenders with schizophrenia and 33 non-violent patients with schizophrenia. The results revealed that the final model, which combined multimodal data, achieved the highest prediction performance with an accuracy of 90.67%. Specifically, the model, which fused three modalities of neuroimaging data, achieved a better accuracy than other fused models. In addition, the msot discriminative neuroimaging features involved in the prefrontal-temporal cognitive circuit and striatum reward system, indicating that dysfunction in cortical-subcortical circuits might be associated with high risk of violence in patients with schizophrenia. This study provides the first evidence supporting that the combination of specific multimodal neuroimaging and clinical data in ML analysis can effectively identify violent patients with schizophrenia. Furthermore, this work is crucial for the development of neuro-prediction models that could facilitate individualized treatment and interventions for violent behaviors in patients with schizophrenia.
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Affiliation(s)
- Ningzhi Gou
- National Clinical Research Center for Mental Disorders, and Department of Psychiatry, The Second Xiangya Hospital of Central South University, 139 Middle Renmin Road, Changsha, Hunan 410011, China
| | - Yizhen Xiang
- Hunan Provincial Key Lab on Bioinformatics, School of Computer Science and Engineering, Central South University, Changsha, Hunan 410083, China
| | - Jiansong Zhou
- National Clinical Research Center for Mental Disorders, and Department of Psychiatry, The Second Xiangya Hospital of Central South University, 139 Middle Renmin Road, Changsha, Hunan 410011, China
| | - Simei Zhang
- Shenzhen Mental Health Center, Shenzhen Kangning Hospital, Shenzhen 518020, China
| | - Shaoling Zhong
- National Clinical Research Center for Mental Disorders, and Department of Psychiatry, The Second Xiangya Hospital of Central South University, 139 Middle Renmin Road, Changsha, Hunan 410011, China
| | - Juntao Lu
- National Clinical Research Center for Mental Disorders, and Department of Psychiatry, The Second Xiangya Hospital of Central South University, 139 Middle Renmin Road, Changsha, Hunan 410011, China
| | - Xiaoxi Liang
- National Clinical Research Center for Mental Disorders, and Department of Psychiatry, The Second Xiangya Hospital of Central South University, 139 Middle Renmin Road, Changsha, Hunan 410011, China
| | - Jin Liu
- Hunan Provincial Key Lab on Bioinformatics, School of Computer Science and Engineering, Central South University, Changsha, Hunan 410083, China.
| | - Xiaoping Wang
- National Clinical Research Center for Mental Disorders, and Department of Psychiatry, The Second Xiangya Hospital of Central South University, 139 Middle Renmin Road, Changsha, Hunan 410011, China.
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6
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Candidate symptomatic markers for predicting violence in schizophrenia: A cross-sectional study of 7711 patients in a Chinese population. Asian J Psychiatr 2021; 59:102645. [PMID: 33845298 DOI: 10.1016/j.ajp.2021.102645] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 04/04/2021] [Accepted: 04/05/2021] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Violent behaviour is an alarming problem among schizophrenia patients. The effects of historical, clinical, and pathological risk factors for violence have been investigated by multiple studies, but consensus has not been achieved. As psychotic symptoms are more direct and intuitive indicators for violence, identifying robustly associated symptoms is a crucial part of the future prediction and precise management of violent patients in clinics. This study aims to identify the psychotic symptoms correlated with violence among schizophrenia patients in a Chinese population. METHODS In this cross-sectional study, the medical records of 7711 schizophrenia patients (4711 in the discovery set and 3000 in the validation set) were collected from 1998 to 2010. Their psychotic symptoms were extracted, and the patients were divided into violent and non-violent groups. Multivariate logistic analysis was applied to identify symptoms associated with violence in the discovery set. RESULTS Eight psychotic symptoms were found to be significantly correlated with violence in schizophrenia. "Destruction of property", "verbal aggression" and "insomnia" increased the risk of violence, while "flat affect", "delusion of persecution", "auditory hallucination", "vagueness of thought" and "poverty of thought" decreased the risk of violence. The regression model was evaluated by receiver operating characteristic (ROC) analysis for its discriminatory performance, achieving area under curve (AUC) values of 0.887 in the discovery sample set and 0.824 in the validation sample set. CONCLUSIONS The correlated symptoms identified by this study can serve as future candidate predictors for violence in schizophrenia, paving the way for precise management of schizophrenia patients in clinics.
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Kennedy HG, Mullaney R, McKenna P, Thompson J, Timmons D, Gill P, O’Sullivan OP, Braham P, Duffy D, Kearns A, Linehan S, Mohan D, Monks S, McLoughlin L, O’Connell P, O’Neill C, Wright B, O’Reilly K, Davoren M. A tool to evaluate proportionality and necessity in the use of restrictive practices in forensic mental health settings: the DRILL tool (Dundrum restriction, intrusion and liberty ladders). BMC Psychiatry 2020; 20:515. [PMID: 33097036 PMCID: PMC7583300 DOI: 10.1186/s12888-020-02912-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 10/11/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Prevention of violence due to severe mental disorders in psychiatric hospitals may require intrusive, restrictive and coercive therapeutic practices. Research concerning appropriate use of such interventions is limited by lack of a system for description and measurement. We set out to devise and validate a tool for clinicians and secure hospitals to assess necessity and proportionality between imminent violence and restrictive practices including de-escalation, seclusion, restraint, forced medication and others. METHODS In this retrospective observational cohort study, 28 patients on a 12 bed male admissions unit in a secure psychiatric hospital were assessed daily for six months. Data on adverse incidents were collected from case notes, incident registers and legal registers. Using the functional assessment sequence of antecedents, behaviours and consequences (A, B, C) we devised and applied a multivariate framework of structured professional assessment tools, common adverse incidents and preventive clinical interventions to develop a tool to analyse clinical practice. We validated by testing assumptions regarding the use of restrictive and intrusive practices in the prevention of violence in hospital. We aimed to provide a system for measuring contextual and individual factors contributing to adverse events and to assess whether the measured seriousness of threating and violent behaviours is proportionate to the degree of restrictive interventions used. General Estimating Equations tested preliminary models of contexts, decisions and pathways to interventions. RESULTS A system for measuring adverse behaviours and restrictive, intrusive interventions for prevention had good internal consistency. Interventions were proportionate to seriousness of harmful behaviours. A 'Pareto' group of patients (5/28) were responsible for the majority (80%) of adverse events, outcomes and interventions. The seriousness of the precipitating events correlated with the degree of restrictions utilised to safely manage or treat such behaviours. CONCLUSION Observational scales can be used for restrictive, intrusive or coercive practices in psychiatry even though these involve interrelated complex sequences of interactions. The DRILL tool has been validated to assess the necessity and demonstrate proportionality of restrictive practices. This tool will be of benefit to services when reviewing practices internally, for mandatory external reviewing bodies and for future clinical research paradigms.
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Affiliation(s)
- Harry G. Kennedy
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland ,grid.8217.c0000 0004 1936 9705DUNDRUM Centre for Forensic Excellence, Department of Psychiatry, Trinity College Dublin, Dublin 2, Ireland
| | - Ronan Mullaney
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland
| | - Paul McKenna
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland
| | - John Thompson
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland
| | - David Timmons
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland
| | - Pauline Gill
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland
| | - Owen P. O’Sullivan
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland ,grid.451052.70000 0004 0581 2008Camlet Lodge Medium Secure Unit, North London Forensic Service, Chase Farm Hospital, Barnet Enfield and Haringey NHS MHT, London, UK
| | - Paul Braham
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland
| | - Dearbhla Duffy
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland
| | - Anthony Kearns
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland ,grid.8217.c0000 0004 1936 9705DUNDRUM Centre for Forensic Excellence, Department of Psychiatry, Trinity College Dublin, Dublin 2, Ireland
| | - Sally Linehan
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland
| | - Damian Mohan
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland ,grid.8217.c0000 0004 1936 9705DUNDRUM Centre for Forensic Excellence, Department of Psychiatry, Trinity College Dublin, Dublin 2, Ireland
| | - Stephen Monks
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland ,grid.8217.c0000 0004 1936 9705DUNDRUM Centre for Forensic Excellence, Department of Psychiatry, Trinity College Dublin, Dublin 2, Ireland
| | - Lisa McLoughlin
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland
| | - Paul O’Connell
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland ,grid.8217.c0000 0004 1936 9705DUNDRUM Centre for Forensic Excellence, Department of Psychiatry, Trinity College Dublin, Dublin 2, Ireland
| | - Conor O’Neill
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland ,grid.8217.c0000 0004 1936 9705DUNDRUM Centre for Forensic Excellence, Department of Psychiatry, Trinity College Dublin, Dublin 2, Ireland
| | - Brenda Wright
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland
| | - Ken O’Reilly
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland ,grid.8217.c0000 0004 1936 9705DUNDRUM Centre for Forensic Excellence, Department of Psychiatry, Trinity College Dublin, Dublin 2, Ireland
| | - Mary Davoren
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland ,grid.8217.c0000 0004 1936 9705DUNDRUM Centre for Forensic Excellence, Department of Psychiatry, Trinity College Dublin, Dublin 2, Ireland ,Broadmoor High Security Hospital, Berkshire, UK
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