[Aggression regulation in eating disorders: evidence for a brief body and movement oriented intervention]

Individuals with eating disorders tend to internalise their anger and aggression excessively. However, an evidence-based intervention, targeted on this persistent issue, was missing until now. Therefore, a body and movement oriented intervention was developed, which supports patients to reframe and redirect anger and aggression against the destructive influence of the eating disorder.<br/> AIM: To study the effectiveness of the aggression regulation intervention.<br/> METHOD: The intervention was tested in a first randomised controlled trial (RCT) in an outpatient setting and in a two-center RCT in a multidisciplinary day hospital setting. Coping with anger was measured by the Self-Expression and Control Scale (SECS). Eating disorder pathology was measured by the Eating Disorder Examination Questionnaire (EDE-Q).<br/> RESULTS: Both RCTs delivered first evidence for the brief body and movement oriented intervention to reduce excessive anger internalisation in individuals with eating disorders. Moreover, in the outpatient trial the eating disorder pathology was significantly more reduced in the intervention group compared to the control group.<br/> CONCLUSION: There is first evidence for the effectiveness of a body and movement oriented approach of reducing excessive anger internalisation in individuals with eating disorders.

Force production parameters as behavioural measures for anger expression and control: The Method of Stamp Strike Shout

This study presents first test results of a new performance-based, psychomotor method to measure anger expression and control, based on voice expression and physical force production in directional movement of arms and legs, called the Method of Stamp Strike Shout (MSSS). Recorded are the standardized impact of stamping on a force plate, hitting a punching bag, and the amplitude of shouting in a microphone at various force levels. The premise is, that these body behaviours stand for the ‘urge to act or shout’ that belongs to anger-related emotions. The MSSS is meant to be applied in addition to potentially biased self-report questionnaires and has been designed for diagnostic as well as therapeutic purposes in clinical practice. First, this paper focusses on the instrumentation, internal structure and reliability of the MSSS. An explorative study in a student sample (n = 104) shows correlation patterns between increasing and decreasing levels of force production within each subtest (Stamp, Strike and Shout) and between the three subtests. We found excellent internal consistency of the three subtests and high test-retest reliability. The parameters of increasing and decreasing force levels form the slopes of what we call a force pyramid. To adjust for the clustering within persons, aggregated outcomes were calculated: sum scores per subtest as an indication of total force produced, two linear contrast scores to indicate the rate of increase / decrease, and two quadratic contrast scores as measures of the curvature of the slopes. On all subtests, all aggregated scores showed differences between men and women, also when controlled for weight. To test the validity of the MSSS, the second part of the paper examines the relationship between force parameters and anger coping style, measured by the Self-Expression and Control Scale (SECS). The results suggest that the Shout subtest was the most sensitive indicator for anger coping style, showing negative correlations with Anger In, for women as well as men. For women, higher amplitude was also associated with higher Anger Out and lower amplitude with higher Anger Control. The Stamp subtest showed weak positive correlations with the Anger In subscales, whereas no correlations were found on the Strike subtest. Further, a more robust comparison was made between two groups of participants who reported to have an internalizing versus an externalizing anger coping style. Results indicated that internalizing women as well as men used less force than externalizing participants on all three subtests, especially on the Shout subtest. This was confirmed by lower mean sum scores on the Shout subtest for internalizing women compared with externalizing women. No differences in linear contrast scores were shown between internalizing and externalizing participants. The quadratic contrast scores suggested differences of the curvation of the slopes between women with more or less anger control when stamping, and men with more or less anger control when striking. As this is an explorative study, findings should be interpreted with caution.

Risk assessment by client and case manager for shared decision making in outpatient forensic psychiatry

BACKGROUND

In outpatient forensic psychiatry, assessment of re-offending risk and treatment needs by case managers may be hampered by an incomplete view of client functioning. The client's appreciation of his own problem behaviour is not systematically used for these purposes. The current study tests whether using a new client self-appraisal risk assessment instrument, based on the Short Term Assessment of Risk and Treatability (START), improves the assessment of re-offending risk and can support shared decision making in care planning.

METHODS

In a sample of 201 outpatient forensic psychiatric clients, feasibility of client risk assessment, concordance with clinician assessment, and predictive validity of both assessments for violent or criminal behaviour were studied.

RESULTS

Almost all clients (98 %) were able to fill in the instrument. Agreement between client and case manager on the key risk and protective factors of the client was poor (mean kappa for selection as key factor was 0.15 and 0.09, respectively, and mean correlation on scoring -0.18 and 0.20). The optimal prediction model for violent or criminal behaviour consisted of the case manager's structured professional risk estimate for violence in combination with the client's self-appraisal on key risk and protective factors (AUC = 0.70; 95%CI: 0.60-0.80).

CONCLUSIONS

In outpatient forensic psychiatry, self-assessment of risk by the client is feasible and improves the prediction of re-offending. Clients and their case managers differ in their appraisal of key risk and protective factors. These differences should be addressed in shared care planning. The new Client Self-Appraisal based on START (CSA) risk assessment instrument can be a useful tool to facilitate such shared care planning in forensic psychiatry.

Predictive validity of the Short-Term Assessment of Risk and Treatability for violent behavior in outpatient forensic psychiatric patients

It remains unclear whether prediction of violence based on historical factors can be improved by adding dynamic risks, protective strengths, selection of person-specific key strengths or critical vulnerabilities, and structured professional judgment (SPJ). We examine this in outpatient forensic psychiatry with the Short-Term Assessment of Risk and Treatability (START) at 3 and 6 months follow-up. An incident occurred during 33 (13%) out of 252 3-month and 44 (21%) out of 211 6-month follow-up periods (n = 188 unique clients). Pearson correlations for all predictor variables were in the expected directions. Prediction of recidivism based on historical factor ratings (odds ratio [OR] = 1.10) could not be improved through the addition of dynamic risk, protective strength, or key or critical factor scores (all ORs ns). The addition of the SPJ improved the model to modest accuracy (area under the curve [AUC] = .64) but made no independent significant contribution (OR = 1.55, p = .21) for the 3-month follow-up. For the 6-month follow-up, SPJ scores also increased predictive accuracy to modest (AUC = .67) and made a significant independent contribution to the prediction of the outcome (OR = 1.98, p = .04). Multicollinearity limits were unviolated. Limitations apply, however, results are similar to those from clinical, researcher rated samples and are discussed in the light of setting specific characteristics. Although it is too early to advocate implementing risk assessment instruments in clinical practice, we can conclude that clinicians in a heterogeneous outpatient forensic psychiatric setting can achieve similar results with the START as clinicians and research staff in more homogeneous inpatient settings.

Risk assessment and shared care planning in out-patient forensic psychiatry: cluster randomised controlled trial

BACKGROUND

Forensic psychiatry aims to reduce recidivism and makes use of risk assessment tools to achieve this goal. Various studies have reported on the predictive qualities of these instruments, but it remains unclear whether their use is associated with actual prevention of recidivism in clinical care.

AIMS

To test whether an intervention combining risk assessment and shared care planning is associated with a reduction in violent and criminal behaviour.

METHOD

A cluster randomised controlled trial (Netherlands Trial Register number NTR1042) was conducted in three out-patient forensic psychiatric clinics. The intervention comprised risk assessment with the Short Term Assessment of Risk and Treatability (START) and a shared care planning protocol formulated according to shared decision-making principles. The control group received usual care. The outcome consisted of the proportion of clients with violent or criminal incidents at follow-up.

RESULTS

In total 58 case managers and 632 of their clients were included. In the intervention group (n = 310), 65% received the intervention at least once. Findings showed a general treatment effect (22% of clients with an incident at baseline v. 15% at follow-up, P<0.01) but no significant difference between the two treatment conditions (odds ratio (OR) = 1.46, 95% CI 0.89-2.44, P = 0.15).

CONCLUSIONS

Although risk assessment is common practice in forensic psychiatry, our results indicate that the primary goal of preventing recidivism was not reached through risk assessment embedded in shared decision-making.