Faculty Of Forensic Psychiatry Annual Conference

Transcription

Faculty of Forensic Psychiatry
Annual Conference
2nd – 4th February 2011
Radisson Blu Hotel, Berlin, Germany
Final Programme and abstracts
Front cover images courtesy of
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WEDNESDAY 2nd FEBRUARY
08.25-09.20
(Foyer)
Registration, coffee and exhibition viewing
09.25
Saphirs 1 & 2
Introductory remarks and welcome
Dr Janet Parrott
Clinical Director and Consultant Forensic Psychiatrist Bracton Clinic, Dartford, UK
SESSION 1: Keynote speech
Chair: Professor Jenny Shaw, University of Manchester, UK
09.30
Keynote Speech: Developments in Offender Health
Professor Louis Appleby
National Clinical Director for Health and Criminal Justice and Professor of Psychiatry at the University
of Manchester, UK
SESSION 2 – Commissioning Secure Services and Payment by results
Chair: Dr Paul Gilluley, West London Mental Health Trust, UK
10.15
The Medium Secure QIPP Challenge
Dr Elizabeth Allen , National Mental Health Development Unit, UK
10.45
PbR in Forensic Psychiatry: The Story So Far
Mr Nick Broughton, Medical Director, West London Mental Health Trust, UK
11.15-11.40
(Foyer)
Coffee and exhibition viewing
Saphirs 1 & 2
SESSION 3: Treatment of Sexual Offending
Chair: Professor Don Grubin, Newcastle University, UK
11.40
Sex Offender Treatment in Correctional Settings
Dr Ruth Mann , Rehabilitation Services Group National Offender Management Service HM Prison
Service, UK
12.20
Treatment of Sex Offenders
Professor Richard Krueger, Medical Director, Sexual Behaviour Clinic New York State Psychiatric
Institute & Columbia University Department of Psychiatry, USA
13.00-14.00
(Foyer)
Lunch and exhibition viewing
SESSION 4: UPDATE YOUR CLINICAL PRACTICE
Pick and mix parallel sessions-
14.00
Parallel session 1
Parallel session 2
Chair: Professor Philip Sugarman,
Chair: Dr Quazi Haque
St Andrew‘s Healthcare, UK
Priory Group and Institute of Psychiatry, UK
Saphir 1
Saphir 2
Self Harm and Suicide
Professor Nav Kapur
University of Manchester, UK
Offending Behaviour Programmes
Professor James McGuire
Liverpool University, UK
14.30
Depression Update
Professor Ian Anderson
University of Manchester, UK
Issues of good prescribing practice/new drug
developments
Professor David Taylor
Director of Pharmacy and Pathology South London
and Maudsley NHS Foundation Trust Pharmacy, UK
15.00
Misuse of “new” substances
Professor Mike Farrell
Institute of Psychiatry, UK
Metabolic Syndrome
Professor Christopher Byrne
The Institute of Developmental Sciences
University of Southampton, UK
15.30
Developments in offender health
Dr Andrew Forrester
South London & Maudsley, London, UK
Developing a Psychological Therapies
Programme for MSUs
Dr Tim Green
South London & Maudsley, London, UK
16.00-16.25
(Foyer)
Tea and exhibition viewing
16.30
Saphir 1& 2
SESSION 5: DISCUSSION: Moral Maze - Is Forensic Psychiatry Ethical?
Discussants include a panel of clinicians and lawyers
Chair: James Anderson
Bracton Centre, Oxleas NHS, UK
David James, Consultant Forensic Psychiatrist and Director, FTAC, UK
Jackie Craissati, Principal Clinical Psychologist and Clinical Director, Bracton Centre, UK
Adrian Grounds, Institute of Criminology, University of Cambridge, UK
Ashley Irons, Partner, Capsticks Solicitors, UK
17.40
Brief introduction to Bethlem Archive Art Exhibit
17.50
End of session
18.00-19.00
(Foyer)
Delegates from outside the UK and Ireland, Trainees and Medical Students are invited to
join us for a drinks reception at the Radisson Hotel
The Radisson Blu Berlin Aquarium: Have you zipped up and down in an elevator encased inside the
largest acrylic glass cylinder aquarium in the world?
THURSDAY 3rd FEBRUARY
08.30-09.10
(Foyer)
Saphirs 1 & 2
09.15
09.45
SESSION 6: Personality Disorder Masterclass
Chair: Professor Jeremy Coid, Barts & The London School of Medicine, UK
Biology of Personality Disorder
Professor Bill Deakin, University of Manchester, UK
Treatment of Borderline Personality Disorder
Professor Anthony Bateman, St Anns Hospital London, UK
10.15
The future of DSPD
Mr Nick Benefield and Mr Nick Joseph, Department of Health, London, UK
10.45
The Netherlands Experience
Professor Hjalmar Van Marle, University Medical Centre Rotterdam , Netherlands
11.20
Discussion
11.30-11.55
(Foyer)
Saphir 1 & 2
SESSION 7: Keynote Lecture
Chair: Professor Nigel Eastman, SGHMS, London, UK
12.00
Spree and Mass Killers: An Analysis of Extreme Violence
Professor Jack Levin, Northeastern University of Boston, USA
13.00-13.55
(Foyer)
SESSION 8: PARALLEL WORKSHOPS 14.00-15.30
Delegates are invited to ‘pick and mix’, changing between rooms during the sessions to make up their own
programme. Please note that attendance is on a first come first served basis on the day, subject to the room space
available
14.00
Saphir 1
Workshop 1
Adolescent and Young Adults Forensic Services
Paul Monks, Heidi Hales, Enys Delmage & Ash Roychowdhury
14.00
Saphir 2
Workshop 2
Relational Security
Paul Gilluley, Bradley Hillier and James Tighe
14.00
Rubin
Workshop 3
Substance misuse interventions in forensic services
Niamh Power, Julia O‘Connor and Alex Whale
14.00
Aquamarin
Workshop 4
Mentalization and group reflective practice in the management of forensic
personality-disordered patients;
Jessica Yakeley, Andrew Williams and Gill McGauley, Roberta Babb, John Canning, and
Cleo Van Velsen
14.00
Jade 1 & 2
Workshop 5
New versus old- Diminished Responsibility
Nigel Eastman, Sathana Gunasekaran and Nuwan Galappathie
14.00
Turmalin 1 & 2
Workshop 6
Trauma and criminal behaviour: assessment and treatment of post-traumatic syndromes in
forensic settings
Vittoria Ardino, Frances Maclennan, Piyal Sen and Andrew Forrester
15.30
(Foyer)
16.00
Turmalin 1 & 2
Tea and exhibition viewing
SESSION 9: PARALLEL WORKSHOPS
16.00-17.30
Delegates are invited to ‘pick and mix’, changing between rooms during the sessions to make up their
own programmes
Workshop 7
Forensic services and commissioning in the economic downturn
Dr Paul Gilluley, Dr Jeremy Kenney-Herbert, Dr Quazi Haque, Dr Mehdi Veisi, Mike Gatsi, Mrs Jill
Lockett, Dr Mary Whittle
16.00
Saphir 1
Workshop 8
Sex Offenders
Sodi Mann and Don Grubin
16.00
Saphir 2
Workshop 9
Avoiding Grief in Court
John Kent, David Reiss, Aideen O‘Halloran & Ashley Irons, partner at Capsticks Solicitors
16.00
Jade 1 & 2
Workshop 10
Service User Involvement in a Medium Secure Dangerous and Severe Personality Disorder
Unit
Caitriona Higgins Victoria Wasteney, Emma Chandler, Celia Taylor
16.00
Rubin
Workshop 11
Film Club - The Lives of Others (Director Florian Henckel von Donnersmarck,2006)
Cleo van Velsen
16.00
Aquamarin
Workshop 12
Managing Violent Personality Disordered Women in Psychologically Containing
Planned Environments – a strategy for the future
Mary DiLustro, Jay Sarkar
18.00
18.15
Additional Meeting: AFPSIG Business Meeting
Fun Run!
Walk, jog or sprint. Delegates are invited to burn of some calories on the streets of Berlin. Meet
outside the conference hotel. Route details will arranged by Dr Deirdre MacManus and her athletic
colleagues and will be confirmed at the conference. Delegates who wish to participate in the fun run
should sign on at the conference registration desk.
19.45
Drinks Reception and Conference Dinner–Radisson Blu Hotel
Exclusive booking! Enjoy a three course meal & panoramic city views
The conference dinner is not included in the whole conference fee. If you wish to attend contact the Conference Team
at the Registration Desk.
FRIDAY 4TH FEBRUARY
08.25-08.40
(Foyer)
08.45
Saphirs 1 & 2
FORENSIC FACULTY REPORT AND BUSINESS MEETING
9.30
SESSION 10: NEW RESEARCH PRIZE PRESENTATIONS
Judges: Professor Jeremy Coid, Prof Norbert Nedopil, Professor Phillip Sugarman
09.30
The prevalence and predictors of violent victimisation amongst male inpatients in six
English Regional Secure Units
Presenter: Dr Sophie Anhoury, UK
09.45
A simple screening tool for violence risk in schizophrenia
Presenter: Dr Seena Fazel, UK
10.00
Audit of the transfer of prisoners from HMP Isle of Wight to mental health hospitals
Presenter: Dr Tamsin Peachy, UK
10.15
Volumetric structural abnormalities of the Amygdala and Hippocampus in men with violent
antisocial personality disorder and schizophrenia
Presenter: Dr Elizabeth Zachariah, UK
10.30
An evaluation of the effectiveness of Enhanced Thinking Skills in improving the
functioning of offenders with antisocial personality disorder traits
Presenter: Dr Doyle, UK
10.45
The significance of protective factors in the assessment of risk
Presenter: Dr Lennox, UK
11.00-11.30
(Foyer)
Saphirs 1 & 2
11.30
11:30
12.00
13.00-13.45
(Foyer)
SESSION 11
Research on Community Treatment Orders
Chair: Prof Tom Fahy, Kings College London, Mrs Jill Locket, SLAM, London
Coffee
Evaluation of community treatment orders in the UK
Professor Tom Burns, University of Oxford, UK
Keynote Address - Involuntary Outpatient Commitment: The Data and the Controversy
Professor Marvin Swartz, Duke University School of Medicine, USA
Saphirs 1 & 2
13.45
14.15
SESSION 12:
Issues in GermanForensic Psychiatry
Chair: Dr Birgit Vollm, University of Nottingham, , UK
Pathways to care and forensic services in Germany
Professor Ruediger Mueller-Isberner, Medical Director, Haina Forensic Hospital
European Court Case on preventative detention
Professor Norbert Nedopil, Head of the Department of Forensic Psychiatry, University of Munich
SESSION 13:
A modern case of insanity
Chair: Dr John Crighton, Edinburgh, UK
14.45
Clinical Case Presentation
Dr Tim Exworthy, UK and discussants
16.00
Closing and valedictory remarks
Dr Janet Parrott, Chair of the Forensic Faculty
At the time of printing all information is accurate. We cannot be held responsible for any subsequent
changes.
PRESENTATION ABSTRACTS & BIOGRAPHIES (A-Z by presenter)
The following materials have been provided with kind permission of the presenters. We
hope you find the following speaker abstracts and biographies useful. Please feel free to
approach speakers for any handouts which are not included here.
Louis Appleby has recently been appointed as National Clinical Director for Health and Criminal Justice.
The aim of his new post is to reduce mental illness in prisons and improve collaboration between mental
health services and the criminal justice system. In his previous role as National Director for Mental Health
in England he played a central role in plans to reform mental health services, bringing in a range of new
services including home treatment, early intervention and assertive outreach teams, and mental health
legislation. He led numerous initiatives including to reduce suicides and improve the physical environment
of mental health wards.
Since 1996 he has been Professor of Psychiatry at the University of Manchester and since 1991 a consultant
psychiatrist in Manchester. He was awarded a CBE for services to medicine in 2006.
PBR IN FORENSIC PSYCHIATRY: THE STORY SO FAR
Dr Nick Broughton
Payment by Results will underpin the future funding of services provided by NHS Trusts. It was initially
introduced in the acute sector in 2003/4 and has now been extended to Mental Health Services. A 21 cluster
model has been developed for working age adults. Each of these clusters will form the basis of currencies
for commissioning services. Trusts are already allocating service users to these clusters, however, the
national tariffs for the currencies have yet to be agreed. Work in Forensic Services is less advanced. Both a
five cluster model developed by the London Programme Board and the 21 cluster model are currently being
piloted in a number of forensic services. Dr Broughton will provide an overview of the developments to date
and the likely next steps prior to the introduction of PbR in Forensic Mental Health services.
Dr Nick Broughton
Following graduating from Cambridge University, Dr Broughton completed his medical training at St
Thomas‘s Medical School in London. He joined the St Mary‘s Psychiatric Training Scheme after completing
house jobs before progressing to the West London Forensic Psychiatry Senior Training Scheme. He has
worked in West London as a Consultant in Forensic Psychiatry for over ten years in a wide variety of
settings, including prisons, a young offenders‘ institution, a specialist remand service and, most recently, a
women‘s enhanced medium secure service. He has a particular interest in service development and has
been involved in medical management for a number of years. He recently became Medical Director for West
London Mental Health NHS Trust.
Dr Broughton has sat on the Pan-London Service Line Reporting Programme Board since its inception in
2008 and last year joined the Department of Health‘s National Forensic & Challenging Behaviour Payment
by Results Product Review Group - as such he has been closely involved in the development of PbR in
forensic settings.
Christopher D Byrne FRCP FRCPath PhD
Professor Endocrinology & Metabolism
The Institute of Developmental Sciences (IDS Building) (University of Southampton), MP 887 Southampton
General Hospital Tremona Rd Southampton SO16 6YD
The importance of the metabolic syndrome, also known as Syndrome X or the insulin resistance syndrome,
was highlighted by Professor Reaven in the Banting Lecture at the American Diabetes Association annual
scientific conference of 1988. Although this description brought the syndrome to scientific and clinical
prominence, descriptions emphasising a clustering of inter-related cardio-metabolic risk factors can be
traced back to the 1920s. The metabolic syndorme is characterised by a cluster of related biochemical and
anthropometric features that include central obesity, glucose intolerance or diabetes, hypertension, and
dyslipidaemia.The epidemic of obesity is largely responsible for the increasing prevalence of metabolic
syndrome in the developed world. Since 2001 with the development of the National Cholesterol Education
Program guidelines for diagnosing metabolic syndrome, simple pragmatic criteria have been available that
can be applied in primary care across all continents. Although there is an on-going debate about the level of
thresholds that should be applied to individual features of the syndrome, it is likely that with further
research a consensus will be reached in the near future. These simple pragmatic criteria were revised in
2005 and again in 2009, with varying emphasis on the centrality of central obesity and the level of the
thresholds that should be applied to glucose concentrations. In 2011, it is now clear that metabolic
syndrome represents a condition of insulin resistance and ectopic fat accumulation associated with a
proinflammatory and procoagulant phenotype. The syndrome is also strongly associated with other diseases
such as non alcoholic fatty liver disease (NAFLD), polycystic ovary syndrome, type 2 diabetes and
cardiovascular disease and often the metabolic syndrome features are present in people who present
initially, with one of these diseases. The purpose of this presentation is to discuss the clinical and laboratory
diagnosis of the metabolic syndrome and the relationship between metabolic syndrome and obesity, type 2
diabetes and cardiovascular disease. The presentation will also discuss the newer evidence showing than
NAFLD is the key hepatic component of the metabolic syndrome and that NAFLD may be key to the
increased cardiometabolic risk that occurs with the syndrome.
Christopher D Byrne MB BCh PhD FRCP FRCPath
Professor Endocrinology & Metabolism & Consultant Diabetologist
University of Southampton & Southampton University Hospitals Trust
Christopher Byrne trained as a physician and clinical scientist at Cardiff, Cambridge and Stanford
Universities. After Medical Research Council clinical science fellowships he was appointed Professor of
Endocrinology & Metabolism in Southampton and inaugural Director of the Wellcome Trust Clinical Research
Facility. He was Director of the Clinical Research Facility for 5 years and is now a Principal Investigator
within the Southampton NIHR Biomedical Research Unit in Nutrition, Lifestyle and Obesity.
Christopher Byrne is an academic diabetologist with clinical and experimental research interests in the
metabolic syndrome and non alcoholic fatty liver disease. His research involves understanding the
developmental origins of metabolic syndrome and non alcoholic fatty liver disease, and the links between
metabolic syndrome, non alcoholic fatty liver disease, type 2 diabetes and cardiovascular disease. His
publications, include over a 150 peer reviewed authored papers and 2 books.
Handouts follow:
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Slide 1
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Metabolic syndrome:
linking diabetes,
cardiovascular disease and non
alcoholic fatty liver disease
Christopher D Byrne
University of Southampton
& Southampton University Hospitals Trust
www.metabolicsyndrome.org.uk
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Slide 2
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Content
• Definition in the context of type 2 dm
• Metabolic syndrome and type 2 dm
• Metabolic syndrome and morbidity and
mortality
• Insulin resistance and CV risk
• Physical activity
• NAFLD
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Slide 3
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Changing patterns of CVD risk factors
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1984
Cholesterol
Smoking
Hypertension
2011
Central obesity
Diabetes & MetS
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Slide 4
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What is type 2 diabetes?
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9/10
Insulin
resistant
Marked glucose
-cell
intolerance
dysfunction
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a progressive metabolic disorder –linked to
beta cell failure and/or insulin resistance
fpg>/= 7.0 mmol/l
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Slide 5
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What is metabolic syndrome?
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Insulin
resistance
+/- glucose
intolerance
+/- -cell
dysfunction
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Ectopic fat accumulation & insulin resistance
adversely affecting cardiometabolic risk factors
(to increase risk of type 2 diabetes,
cardiovascular disease and NAFLD)
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Slide 6
Portrait of Daniel Lambert by Benjamin Marshall,
19th Century
-so why do we need to decrease
weight in people with MetS?
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Denke M. N Engl J Med 2007;357:2526-2527
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Slide 7
Metabolic Syndrome
Features 2009
Metabolic Syndrome
 Triglyceride
Waist
BP
TG
Glucose
HDL
> 94/80 cm
 130/85
 1.7mmol/l
 5.6 mmol/l
< 1.0/1.3 mmol/l
 BP
 HDL
Cholesterol
Fatty liver
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OBESITY
Glucose intolerance
Vascular inflammation
& procoagulant
phenotype
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Slide 8
Criteria for Clinical Diagnosis of the
Metabolic Syndrome
Measure
Categorical cut points
Elevated waist circumference
Population- and countryspecific definitions
Elevated triglycerides (drug treatment for
elevated triglycerides is an alternate indicator)
>150 mg/dL
Reduced HDL cholesterol (drug treatment for
reduced HDL cholesterol is an alternate
indicator)
<40 mg/dL for males and
<50 mg/dL for
females
Elevated blood pressure (drug treatment for
elevated blood pressure is an alternate
indicator)
Systolic >130 mm Hg
and/or diastolic >85
mm Hg
Elevated fasting glucose (drug treatment for
elevated glucose is an alternate indicator)
>100 mg/dL
Consensus statement International Diabetes Federation (IDF), the National Heart, Lung, and Blood
Institute (NHLBI), the World Heart Federation, the International Atherosclerosis Society, and the
American Heart Association (AHA) Circulation 2009; 120:1640-1645
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Slide 9
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Risk factors for (central) obesity
•
•
•
•
•
•
•
•
•
Ageing but ? reason
Sex, men and post menopausal women
Ethnicity, South Asians – low lean body mass
Socio-economic status - deprivation
Low levels of physical activity – work/ leisure/ transport/
central heating
Excessive calorie intake
Secondary to e.g. hypothyroidism, glucocorticosteroids
Smoking cessation/ other lifestyle change / depression
Rarely genetics –commonest MCR-4R mutations (5% of
people BMI > 30 kg/m2 middle aged adults)
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Slide 10
Obesity, insulin resistance, type 2 diabetes
and metabolic syndrome
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Insulin
resistance
Type 2
diabetes
-cell
dysfunction
Metabolic syndrome: a disorder of ‘ectopic
fat’ accumulation, insulin resistance
(NAFLD) & cardio-metabolic risk
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Slide 11
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Diagnosis of diabetes 2010
• ADA for the first time said that HbA1c
levels >6.5% are sufficient for a diagnosis
of diabetes, while levels from 5.7% to
6.4% are a marker of "prediabetes" and
indicate increased risk of both incident
diabetes and cardiovascular disease
American Diabetes Association. Standards of medical care in diabetes-2010. Diabetes Care 2010; 33 (suppl 1):S11-S61
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Slide 12
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Slide 13
Association between the metabolic syndrome and
cardiovascular events and mortality:
meta-analyses of longitudinal studies
Covariates in risk model
Study
RR
95%
CI
McNeill
1.62
1.41
1.87
Sattar
1.41
1.05
1.90
Schillaci
1.73
1.25
2.38
Summary 1.54
1.32
1.79
MS Age Gender BP Lipids Glu Other
x x
x x
x x
0.2 0.5 1
2
x
x
x
x
x
x
x
x
x
x x
x
5
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Decreased risk Increased risk
All studies excluded people with prevalent cardiovascular disease, and 1 study (45) excluded women. "Other" covariates
included race (62), study site (in a multicenter study) (62), body mass index (45), C-reactive protein (45), creatinine (60),
left ventricular hypertrophy (60), and cigarette smoking (45,60,62). The boxes represent the relative risk (RR) for
individual studies and are proportional to their weight in the analysis, and the lines represent their 95% confidence
intervals (CIs). The diamond represents the pooled RR, and its width represents its 95% CI. BP = hypertension or
elevated systolic or diastolic blood pressure; Glu = fasting hyperglycemia;X = covariate included.
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Source: Gami et al J Am Coll Cardiol 2007;49:403-14
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Slide 14
Association between the MetS, CV events and
mortality: meta-analyses of longitudinal studies
Outcome
Studies (N)
RR
95%
CI
CV event
11
2.18
1.63-2.93
CHD event
18
1.65
1.37-1.99
CV death
10
1.91
1.47-2.49
CHD death
7
1.60
1.28-2.01
Death
12
1.60
1.37-1.92
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Decreased risk
1
2
5
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Increased risk
The diamonds represent the pooled relative risk (RR) and 95% confidence interval
(CI) for studies that assessed each outcome. Some studies assessed more than 1
outcome. CHD = coronary heart disease; CV = cardiovascular.
Source: Gami et al J Am Coll Cardiol 2007;49:403-14
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0.5
N=172,573 people
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Slide 15
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ULSAM: *Death and Major Cardiovascular Events
(HR, 95% CI) in the Different Groups
End
point
Normal weight
without
metabolic
syndrome
Normal weight
with metabolic
syndrome
Overweight
without
metabolic
syndrome
Overweight
with metabolic
syndrome
Obese
without
metabolic
syndrome
Obese with
metabolic
syndrome
Total
death
Referent
1.28 (0.90–1.82)
1.21 (1.03–1.40)
1.53 (1.19–
1.96)
1.65 (1.03–
2.66)
2.43 (1.81–
3.27)
CV
death
Referent
1.77 (1.11–2.83)
1.44 (1.14–1.83)
2.19 (1.57–
3.06)
1.20 (0.49–
2.93)
3.20 (2.12–
4.82)
Major
CV
events
Referent
1.63 (1.11–2.37)
1.52 (1.28–1.80)
1.74 (1.32–
2.30)
1.95 (1.14–
3.34)
2.55 (1.82–
3.58)
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Circulation, Jan 2010; 121: 230 - 236
*1758 middle-aged individuals without diabetes in the Uppsala Longitudinal Study
of Adult Men (ULSAM).
During a median follow-up of 30 years, 788 participants died and 681 developed cardiovascular disease.
Hazard models adjusted for age, smoking, and LDL cholesterol, metabolic syndrome
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Slide 16
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Diagnosis of diabetes 2010
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• ADA for the first time said that HbA1c
levels >6.5% are sufficient for a diagnosis
of diabetes, while levels from 5.7% to
6.4% are a marker of "prediabetes" and
indicate increased risk of both incident
diabetes and cardiovascular disease
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American Diabetes Association. Standards of medical care in diabetes-2010. Diabetes Care 2010; 33 (suppl 1):S11-S61
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Slide 17
Incidence of New Diabetes and Hazard Ratio (95% CI)
for Diabetes and Other Clinical Outcomes (14-Year
Median Follow-Up), by Baseline Glycated
Hemoglobin Level, in Nondiabetics
<5.0%
5.0% to
<5.5%c
5.5% to
<6.0%
6.0% to
<6.5%
>6.5%
Diabetes incidence
(%)
6
12
21
44
79
Diabetesb
0.52 (0.40–
0.69)
1.00
1.86 (1.67–
2.08)
4.48 (3.92–
5.13)
16.47 (14.22–
19.08)
CHD
0.96 (0.74–
1.24)
1.00
1.23 (1.07–
1.41)
1.78 (1.48–
2.15)
1.95 (1.53–
2.48)
Ischemic stroke
1.09 (0.67–
1.76
1.00
1.17 (0.89–
1.53)
2.22 (1.60–
3.08)
3.16 (2.15–4.64
Mortality
1.48 (1.21–
1.82)
1.00
1.18 (1.04–
1.35)
1.59 (1.34–
1.89)
1.65 (1.31–
2.08)
Parameter
a. Adjusted for age, sex, race, low-density and high-density cholesterol levels, triglyceride level, body-mass index,
waist-to-hip ratio, hypertension, family history of diabetes, education level, alcohol use, physical activity, and
smoking status
b. Defined as self-reported diagnosis of diabetes or use of antidiabetic medications
c. Reference for hazard ratios
Selvin E, Steffes MW, Zhu H, et al. Glycated hemoglobin, diabetes, and cardiovascular risk in nondiabetic adults. N Engl J Med 2010; 362:800-811
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
Slide 18
_________________________________
__
• What is the relationship between
insulin resistance and CV
outcome?
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 19
Measures of tissue insulin sensitivity
• 75g Oral Glucose Tolerance Test
-NEFA suppression – to derive a measure of
fat insulin sensitivity
Belfiore F et al. Insulin sensitivity indices calculated from basal and OGTT-induced
insulin, glucose, and FFA levels. Mol Genet Metab. 1998 Feb;63(2):134-41
• Euglycaemic Hyperinsulinaemic Clamp
-Whole body glucose uptake & suppression
of glucose production
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 20
Kaplan–Meier survival curves for subjects free from subsequent CHD
events during 10.4 years of follow-up, for a) tertiles of insulin sensitivity
index (Si), and b) tertiles of intact proinsulin at baseline.
_________________________________
__
_________________________________
__
_________________________________
__
Diabetologia (2005) 48: 862-867
_________________________________
__
_________________________________
__
_________________________________
__
Slide 21
How can we improve insulin
sensitivity?
• Which aspect of „insulin sensitivity‟ are we trying
to improve?
– regulation of glucose metabolism?
• Decrease hepatic glucose output, promote skm & adipose
glucose uptake
– regulation of vascular function?
• Increase vasodilatation?
• Increase microvascular nutrient exchange
_________________________________
__
_________________________________
__
_________________________________
– regulation of triglyceride metabolism?
• Decrease VLDL secretion
• Decrease lipolysis of adipose TG to release free fatty acids?
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 22
Tissue microvascular dysfunction
and metabolic syndrome
Obesity
Insulin Resistance
Hyperglycemia
Haemodynamics
Vasodilatation
↓NO/AA Metabolism
↑Myogenic
Response
Impaired Microvascular
Perfusion
Dyslipidemia
Inflammation
Endothelial Integrity
↓Microvascular
Density
Inflammation and
atherothrombosis
Cytoskeletal
Contraction
Junctional
Disorganisation
Impaired Microvascular
Solute/water Exchange
Clough et al Diabetes 2009
Turzyniecka et al Diabetic Med 2010
Turzyniecka et al J Appl Physiol 2010
Clough et al Microcirculation 2010
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 23
sensitivity?
• „Lifestyle‟ treatment
– What is it, how does it work & what exactly
should we be recommending?
• Drugs
– What drugs, how do they work & what should
we be recommending?
• Bariatric surgery
– What is it, how does it work and what should
we be recommending?
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
Slide 24
sensitivity?
• „Lifestyle‟ treatment
_________________________________
__
_________________________________
– Physical activity/exercise
– Diet & good nutrition
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 25
_________________________________
Energy balance
__
• 50 extra calories a day leads to 2.4kg
weight gain per year
_________________________________
• Losing 1kg requires a deficit of about 7000
calories
__
• Losing 0.5-1kg/week requires a deficit of
500-1000 calories/day
__
_________________________________
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 26
Definitions:
Physical activity/exercise
Aerobic fitness
Physical Activity
Exercise
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
_
Slide 27
We know that physical activity is beneficial but…………….
1 person on the stairs !
_________________________________
__
_________________________________
__
_________________________________
__
©2005. American College of Physicians. All Rights Reserved.
_________________________________
__
_________________________________
__
_________________________________
__
Slide 28
What is wrong with this picture – why are they not on the stairs?
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 29
_________________________________
Managing CV risk
• High absolute risk
– Aggressive CV risk reduction treatment
• LDLc treatment – statins targets QoF/NICE
• Bp treatment „ABCD‟ - targets
– Good nutrition – 5-10 fruits & veg
– Tackling obesity – consider bariatric surgery
– Improving PAEE – accumulation of 1 h „brisk
walking‟ daily
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
Slide 30
_________________________________
Where else to intervene to
reduce CV mortality?
__
• Try and prevent/slow the progression of Type 2DM.
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 31
Incidence of New Diabetes and Hazard Ratio (95% CI)
for Diabetes and Other Clinical Outcomes (14-Year
Median Follow-Up), by Baseline Glycated
Hemoglobin Level, in Nondiabetics
<5.0%
5.0% to <5.5%c
5.5% to <6.0%
6.0% to <6.5%
>6.5%
Diabetes incidence
(%)
6
12
21
44
79
Diabetesb
0.52 (0.40–
0.69)
1.00
1.86 (1.67–
2.08)
4.48 (3.92–
5.13)
16.47 (14.22–
19.08)
CHD
0.96 (0.74–
1.24)
1.00
1.23 (1.07–
1.41)
1.78 (1.48–
2.15)
1.95 (1.53–2.48)
Ischemic stroke
1.09 (0.67–1.76
1.00
1.17 (0.89–
1.53)
2.22 (1.60–
3.08)
3.16 (2.15–4.64
Mortality
1.48 (1.21–
1.82)
1.00
1.18 (1.04–
1.35)
1.59 (1.34–
1.89)
1.65 (1.31–2.08)
_________________________________
__
_________________________________
Parameter
a. Adjusted for age, sex, race, low-density and high-density cholesterol levels, triglyceride level, body-mass index,
waist-to-hip ratio, hypertension, family history of diabetes, education level, alcohol use, physical activity, and
smoking status
b. Defined as self-reported diagnosis of diabetes or use of antidiabetic medications
c. Reference for hazard ratios
Selvin E, Steffes MW, Zhu H, et al. Glycated hemoglobin, diabetes, and cardiovascular risk in nondiabetic adults. N Engl J Med 2010; 362:800-811
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 32
Glycaemic control and CV
Mortality
– Fasting glycaemic control reduces microvascular
complications, and does not appear to contribute
to reducing CV mortality.
– Metformin reduces CV mortality (by improving
endothelial function) and not by improving
glycaemic control.
– German Diabetes Intervention Study – the only
interventional study to show improved CVD and
all-cause mortality by controlling post-prandial
glycaemia.
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
Slide 33
Ectopic fat accumulation: a link between insulin
resistance, type 2 DM and vascular disease
Triglyceride:
obesity,
insulin resistance
and risk of
type 2 DM
Lipid metabolism:
NAFLD, insulin
resistance and
type 2 DM
Lipid metabolism
 NFB
 Foam cell
formation
 Neointimal proliferation
_________________________________
__
 NEFA oxidation
 Glucose
production
_________________________________
 Glucose uptake
__
 NEFA oxidation
 Insulin sensitivity
Triglyceride accumulation:
insulin resistance and
risk of type 2 DM
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 34
Non-alcoholic Fatty Liver Disease (NAFLD)
….significant lipid deposition in the hepatocytes of the liver
parenchyma in a patient without a history of excessive alcohol
consumption
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 35
_________________________________
__
_________________________________
__
VACUOLATED NUCLEI
_________________________________
__
H&E STAIN x 40
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 36
Non-alcoholic fatty liver disease
(NAFLD) definition
• Liver injury – fat accumulation
exceeding 5-10% by weight – fat laden
hepatocytes by light microscopy
• Similar to alcohol-induced liver injury
• NAFLD
•
•
•
•
Steatosis
Steatohepatitis (NASH)
NASH + extensive fibrosis
NASH-induced cirrhosis
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
_
Slide 37
_________________________________
NAFLD: Spectrum of disease
__
_________________________________
Non alcoholic
fatty liver
disease
__
Steatosis (fatty liver)
(20-30% of total)
Steatohepatitis
(NASH)
(fatty liver+
inflammation)
(2-3% of total)
Cirrhosis
Hepatocellular
carcinoma
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 38
_________________________________
What causes/contributes to NAFLD?
•
•
•
•
•
Age
Smoking
Diabetes
Met S/central obesity
Altered early development
(Bruce et al Hepatology 2009)
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 39
_________________________________
What is the relationship between physical
activity, hepatic insulin sensitivity and
hepatic fat?
__
Physical activity
_________________________________
r = 0.55, p = 0.01
Holt H et al.
Diabetologia 2006
49:141-148
__
Insulin sensitivity
_________________________________
Holt HB et al.
Diabetologia 2007;
50: 1698–1706;
__
r = -0.51, p = 0.05 (liver)
r = - 0.53, p=0.04 (muscle)
r = - 0.52, p=0.04 (fat)
Holt HB et al.
Diabetologia 2007;
50: 1024–1032.
Hepatic fat
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 40
_________________________________
Association between NAFLD and prevalent CVD in type 2
diabetic adults with and without NAFLD
UN-ADJUSTED O.R.
P < 0.001
AGE-, SEX-ADJUSTED
O.R.
P < 0.001
MULTIPLE*-ADJUSTED
O.R.
P < 0.001
METABOLIC SYNDROME
and MULTIPLE*ADJUSTED O.R.
(n=2,392)
0
__
_________________________________
__
P = 0.03
0,5
1
1,5
2
2,5
3
_________________________________
Logistic Regression; OR (95% CI)
Data are expressed as odds ratios ( 95% confidence intervals).
*The multiple adjustment reported in the third and fourth bars was as follows: age, sex, BMI, smoking status, diabetes
duration, HbA1c, LDL cholesterol and current use of medications
(hypoglycaemic, anti-hypertensive, lipid-lowering or anti-platelet drugs).
Targher et al Diabetes Care. 2007 Aug;30(8):2119-21.
__
_________________________________
__
_________________________________
__
_________________________________
Slide 41
_________________________________
Fatty acid exposures could affect:
__
• Insulin sensitivity
• Hepatic fat metabolism
(synthesis/oxidation) – via SREBP1c,
_________________________________
-> Fatty acids could affect the risk,
severity and progression of NAFLD
_________________________________
__
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 42
_________________________________
Saturated fatty acids appear to:
•
•
•
•
__
Insulin sensitivity
Hepatic fat synthesis
_________________________________
Hepatic inflammation
__
-> Saturated fatty acids could increase
the risk, severity and progression of NAFLD
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 43
_________________________________
__
Much recent interest in the possible
protective effects of omega-3
(w-3; n-3 ) fatty acids
_________________________________
‘fish oils’
_________________________________
__
__
_________________________________
__
_________________________________
__
_________________________________
Slide 44
Found in seafood, especially oily (fatty) fish,
fish oils, liver oils, algal oils,
pharmaceutical preparations (Omacor) .. …
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 45
_________________________________
„Fish oil fats‟……..these 2 fatty acids are present in „fish oil‟ and are present in
very high concentration in OMACOR
COOH
H3C
Eicosapentaenoic acid
EPA
__
_________________________________
20:5w-3
__
H3C
COOH
Docosahexaenoic acid
DHA 22:6w-3
NB. Fish oils may contain other unfavourable compounds e.g. mercury
Fish oils are not pure preparations but OMACOR is just EPA and DHA
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 46
Marine w-3 fatty acids
(contained in fish oils)
•
•
•
•
Insulin sensitivity (some studies only)
Hepatic TAG synthesis – via SREBP1c
Hepatic fatty acid oxidation – via PPAR-a
Systemic inflammation – via NFB and
PPAR-g (? Hepatic inflammation) –
also eicosanoid and resolvin
mediated effects
-> w-3 fatty acids could decrease the risk,
severity and progression of NAFLD
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 47
Wessex Evaluation of fatty Liver and Cardiovascular
markers in NAFLD with OMacor thErapy:
WELCOME study
funded by the National Institute for Health
Research (UK) and Diabetes UK
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 48
_________________________________
The WELCOME Study evaluates the
effects of purified w-3 fatty acids
(OMACOR 4 g/d) on serum biomarkers,
cardiovascular risk markers and liver
fat in a randomized placebo controlled
trial in patients with NAFLD
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 49
_________________________________
__
Schedule, visits and timescale
Visits 1 & 2
4
5
_________________________________
6 & 7 (+/- 8)
Purified w-3 fatty acid EEs 4 g
daily (n =50)
Placebo n=50
-4
0
4-6
10-12
15-18
Months
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
Slide 50
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 51
_________________________________
Acknowledgements
Southampton University
Magdalena Turzyniecka
King’s College London/
Edinburgh/Cambridge/
Surrey
Lucilla Poston, Josie McConnell
Kim Bruce
JJ Valletta & Andy Chipperfield Marco Argenton, Margot Umpleby,
Nick Wareham, Ulf Ekelund,
Lucinda England
Sarah H Wild
Mark Hanson
_________________________________
__
Felino Cagampang
Dyan Sellayah
_________________________________
Geraldine Clough
Priya Ethirajan
Graham Burdge
Mohamed Ahmed
Helen Holt, David Philips
__
__
Funding Bodies
51
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 52
The Welcome team
Christopher Byrne
Philip Calder
Geraldine Clough
Loke Bhatia
Debbie Smith
Norma Diaper
Gillian Wise
Sanchia Triggs
Bridget Clancy
Keith McCormick
Kate Nash
Nick Curzen
BRU Nutrition/Lifestyle staff
CRF staff
PIC centres in Bournemouth,
Poole, Winchester, IOW,
Basingstoke
Portsmouth,
Collaborators in Oxford:
Leanne Hodson and Keith Frayn
Collaborator in University of
Surrey:
Margaret Umpleby
Collaborator in University of
Nottingham
Neil Guha
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
________________________________
Mass and Spree Killers: An Anaylsis of Extreme Violence
Professor Jack Levin, Northeastern University
Most criminologists recognize three types of multiple homicide: mass murder, spree killing, and
serial murder. Thanks to sensationalized accounts of sadistic sexual attacks, the emphasis in
popular culture has been mainly on serial murder rather than the other two types. Yet the
distinctions among types of multiple homicide frequently break down, making them less than
useful for the purposes of research. Decades earlier, it was widely believed that only the body
count separated homicide from multiple homicide. We now know that mass and spree killers
differ from their single-victim counterparts in a number of important characteristics. Moreover,
unlike cases of murder generally (really, manslaughter), mass killers are methodical and
selective, usually planning their crimes far in advance. They almost always have mental health
and situational issues hardly found in other murderous perpetrators. The profile of a mass killer
may help to explain, but it hardly predicts. The false positive problem, frequently an obstacle to
predicting rare events, plagues the study of mass, spree, and serial killers. Our warning signs
apply not only to perpetrators of multiple homicide but also to numerous healthy and decent
people.
Professor Jack Levin is the Irving and Betty Brudnick Professor of Sociology and Criminology at
Northeastern University in Boston, where he co-directs its Center on Violence and Conflict. He has
published 30 books and numerous journal articles and newspaper columns, primarily in the areas of
multiple homicide (mass, spree, and serial) and hate crimes. Levin was recently the recipient of the
American Sociological Association‘s Award for the Public Understanding of Sociology. He has given
numerous keynote addresses to professional, academic, and community organizations in countries around
the world.
TREATMENT OF SEXUAL OFFENDING
Ruth E Mann, PhD, National Offender Management Service
This presentation will summarise recent literature about criminogenic and protective factors for sexual
offenders and how these might be identified. Dr Mann will suggest what the major targets for treatment
should be, and will consider why the targets of victim empathy and taking responsibility for offending may
need less attention in treatment than previously thought. She will compare the major offender rehabilitation
models and will offer suggestions for a fully bio-psycho-social approach to treatment, which expands
beyond the more traditional approach of psychologically-focused treatment. Dr Mann will also discuss the
importance of the wider residential, social and cultural context and how the attitudes of others can support
or derail treatment.
Dr Ruth Mann is a Consultant Forensic Psychologist who works for the National Offender Management
Service (NOMS), where she is responsible for the treatment of sexual offending across prison and probation
services. She is also responsible for NOMS‘ programme of rehabilitation research. Ruth has worked in the
field of sex offender treatment since 1987, originally as a practitioner and for the last 15 years in a
policy/administrative position. Ruth has published over 50 articles and book chapters on topics related to
sex offender assessment and treatment, is on the editorial board of Sexual Abuse: A Journal of Research
and Treatment, and in June 2010 won the British Psychological Society Division of Forensic Psychology
Senior Award for her contribution to forensic psychology in the UK.
Handouts follow
_________________________________
Slide 1
__
Treatment of Sexual Offending
Ruth E Mann, PhD
National Offender Management Service,
England & Wales
Faculty of Forensic Psychiatry Annual Meeting
Berlin, February 2011
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 2
_________________________________
Background
__
 National treatment in English & Welsh
prisons since 1992
 Followed by national treatment in
probation settings
 Creation & re-organisation of National
Offender Management Service
 National joint treatment planned for
2011
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 3
_________________________________
Major Rehabilitation Models
__
 Relapse
Prevention
_________________________________
 Marlatt, Laws
 Risk Need
Responsivity
Model
 Andrews & Bonta
 Good Lives Model
 Ward
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
_
Slide 4
_________________________________
Relapse Prevention Model
 Developed from clinical observation
 Offenders want to give up offending
but lack the skills to do so
 Recognition and Management of Risk
 Acknowledgement of motivation
 In practice, very avoidance focused
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 5
_________________________________
Risk Need Responsivity Model




Empirically based model
Risk principle
Need principle
Responsivity principle
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 6
_________________________________
Good Lives Model
 Theoretically developed
 Offending as an attempt to secure
life‘s goods
 E.g. intimacy, inner peace, sexual
satisfaction, autonomy, mastery
 Strong appeal to clinicians
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
_
Slide 7
_________________________________
Which model?
 RP was not designed to be avoidance
focused
 RNR appreciates the importance of
working positively with offenders
 GLM is experienced more positively
but RNR leads to better recognition of
risk factors
 RNR has strongest empirical base
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 8
Other characteristics of evidence
based programmes
 Have a printed manual
 Select and train staff carefully
 Staff understand and can articulate the
theoretical model of the program (the
―Model of Change‖).
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 9
_________________________________
__
Treatment Targets
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
_
Slide 10
_________________________________
Criminogenic needs
 Sexual
preoccupation
 Any deviant sexual
interest
 Offence supportive
attitudes
 Emotional
congruence with
children
 Lack of intimacy
 Lifestyle impulsivity
 Poor cognitive
problem solving
 Resistance to rules
 Grievance & hostility
 Negative social
influences
(Mann, Hanson & Thornton,
2010)
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 11
_________________________________
Protective factors
 Healthy sexuality
 Constructive
occupation
(including
employment)
 Motivation to desist
 Hope
 Agency
 Positive identity
 An intimate
relationship
 Healthy social
support (a place
within a group)
 Sobriety
 Being believed in
(Maruna, 2010)
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 12
_________________________________
Readiness targets?
 Denial?
__
_________________________________
 Resistance or low motivation
__
 Ability to handle groupwork
_________________________________
(Mann, Ware & Barnett, 2010)
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 13
Current practice (US) >80%
programmes (McGrath et al, 2010)
 Offense
responsibility
 Not criminogenic
 Victim empathy
 Intimacy skills
 Criminogenic
 Social skills
Slide 14
Current practice (Canada)
>80% of programs
 Intimacy skills
 Criminogenic
 Victim empathy
 Emotional
regulation
 Criminogenic
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 15
Current practice (England/Wales
prison)
 Attitude
reconstruction
 Victim empathy
 Self regulation
(emotional
regulation,
intimacy, problemsolving)
 Weakly
criminogenic
 Criminogenic
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 16
_________________________________
Not doing enough of…?
 Sexual self
regulation
 Sexual interests
 Offence supportive
attitudes
 Impulsivity
 Problem solving &
coping
 Grievance, hostility
and callousness
 Social support
 Intimacy support
 Employment or
constructive use of
time
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 17
_________________________________
Doing too much of…?
 Offense responsibility
 Victim empathy
 Social skills
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 18
_________________________________
Accepting Responsibility
 Often assumed to be equivalent to
making a full confession
 Need for a confession may be
intuitive or emotional rather than
rational
 Failure to confess = refusal to accept
sexual offender identity? May be
associated with desistance
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 19
An alternative to confessionoriented treatment
 Focus on taking responsibility for the
future
 More prevalent in desisting offenders
(Maruna, 2001)
_________________________________
__
_________________________________
__
_________________________________
(Ware & Mann, in preparation)
__
_________________________________
__
_________________________________
Slide 20
_________________________________
Victim empathy
__
 Rehabilitation, punishment or
correctional quackery?
_________________________________
 Rehabilitation – offenders report VE to
be important
 Punishment – offenders report VE to be
distressing
 Correctional Quackery – lack of coherent
rationale for VE; lack of VE not an
established risk factor
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 21
_________________________________
An alternative to Victim Empathy
__
 Enable offenders to overcome
obstacles to empathy
_________________________________





Ability to experience emotion
Perspective taking (theory of mind)
Menschenliebe
Situational factors
Management of personal distress,
shame, stress
(Mann & Barnett; Barnett & Mann; 2010)
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 22
_________________________________
__
Treatment Methods
For a bio-psycho-social programme
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 23
_________________________________
―Biological‖ methods
__
 Medication (anti-androgen, SSRI)
(Grubin, 2009)
 Treatment that is sympathetic to
neuropsychology of offenders (Creeden,
2009)
 Eyebrows-down approach (Visual, audio,
kinasthetic)
 Repetitive skills practice
 Real life integration
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 24
_________________________________
Case examples
 Mr A
 Experienced
persistent neglect
as a child
 Is impulsive, often
emotionally driven
and struggled at
school
 Finds it hard to
articulate his inner
world
 Suspicious of others
__
 Mr B
 Well educated
 Had a loving
childhood
 Likes to discuss,
analyse, read and
write.
 Enjoys
psychometric
testing sessions
 Easily trusts others
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 25
_________________________________
Cognitive-Behavioural Methods
 Standard CBT – adjusting thoughts as
a way of managing behaviour
 Attitude change – related to
attitudinal risk factors (offence
supportive attitudes, hostile attitudes,
beliefs that hamper intimacy and
trust).
 Skills practice, behavioural
experiments, etc.
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 26
_________________________________
Social methods
__
 Working positively with those engaged in
risk management
 Encouraging social protective factors
_________________________________
 Employment, accommodation, hobbies,
constructive daily & weekly routine
 Enhancing social support
 Improving relationship skills
 Filling gaps for those who lack support (COSA)
 Maintaining family ties
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 27
_________________________________
Case examples
 Mr C
 Employed
 Evenings spent with
brother, girlfriend
or mother
 One evening alone
per week ―me time‖
 Weekly schedule
indicated busy life,
constructive activity
and regular routine
__
 Mr D
 Unemployed
 Lack of social
contact
 Mainly watching TV
 Remained inside for
days at a time
 Irregular sleeping
and waking hours
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 28
_________________________________
Basic Therapist Competencies
__
 Understanding normative behaviours and
theoretical models of sexual deviance
 Socratic questioning
 Effective use of behavioural techniques such as
reinforcement, extinction and modelling
 Generalisation of alternative thinking and
behaviour outside the treatment environment
 Understanding and using group process
 Working with a co-therapist
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 29
_________________________________
Advanced Therapist Competencies







Expert therapeutic skills
Interpersonal skills
Understanding and accepting the client
Using positive language
Instilling hope for change
Working collaboratively with the client
Personal resilience
(Fernandez & Mann, 2009)
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 30
_________________________________
Four essential therapist skills




__
_________________________________
Reinforcing
Directive
Warm
Genuine
__
_________________________________
(Marshall, 2005)
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 31
_________________________________
__
Treatment Context
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 32
_________________________________
The social environment
__
 Offenders report that this affects their
decision to engage in treatment more
than other factors
_________________________________
 Views of family and friends
 Views of professionals
 Extent to which sex offenders are
stigmatised
(Mann, 2009)
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 33
_________________________________
The group environment
 Mixed group and individual sessions work
best (Schmucker & Losel, 2009; Ware et al, 2009).
 Effective group environment features:
 Cohesive, well organised
 Encouraged open expression of feelings
 Produced a sense of group responsibility
 Instilled hope in members
 Detrimental group environment features:
 Over controlling leaders
(Beech & Fordham, 1997)
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 34
_________________________________
Society
 Extent to which sex offenders are
stigmatised
 Extent to which communities take
responsibility for managing risk
(COSA)
 Extent to which policy makers seek
evidence to form or to justify policies
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 35
_________________________________
__
Conclusions
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 36
_________________________________
Treatment works?
__
 Overall, treatment seems to reduce
recidivism (Schmucker & Losel, 2010)
 RNR principles are upheld
_________________________________
(Hanson et al., 2009)
 Not all programmes work, and there are
few studies of high quality design
 Major RCT of sex offender treatment did
not show a treatment effect (highly
structured RP programme) (Marques et al, 2005)
 Treatment unlikely to work in isolation
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 37
The best chance for treatment to
work?
 When there is a clear model of
change
 When RNR is part of the model of
change
 When the aims of treatment are
understood and supported by people
other than the programme staff
 When evidence wins over intuition
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 38
_________________________________
__
Thank you for listening
[email protected]
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Forensic Psychotherapy in the Dutch TBS-provisions: effective by what means?
Hjalmar van Marle, MD PhD, psychiatrist, psycho-analyst.
Full Professor of Forensic Psychiatry
Erasmus University Medical Centre and School of Law Erasmus University,
Rotterdam, the Netherlands.
Psychotherapist/supervisor forensic psychiatric out-patient clinic Het Dok Rotterdam.
The Dutch TBS-detention measure, an Entrustment Act, has been implemented since 1928 for those
offenders who are held diminished responsible for their acts. In practice that means that TBS has been
sentenced most of the time for dangerous offenders with a personality disorder, which played a role in the
enactment of the often violent offences. The last two decades more and more mentally ill offenders have
become TBS-detainees as their aggressive behaviour was not to handle in the general psychiatric hospitals
anymore. Their presence now is about 20% of the total TBS-population. The TBS-hospitals work according
Programmes of Care, national established by the EFP (Centre of Expertise for Forensic Psychiatry in
Utrecht), but locally adjusted to the treatment philosophy of the hospital involved: for psychotic patients,
personality disordered patients, sex offenders, and long-stay patients.
Treatment in the TBS-hospital is originally the combination of socio-therapy and psychotherapy, as
the patient-staff relationships on the wards are the emotional engine for the psychotherapies, group and
individual. Individual psychotherapy is indicated when a patient is not able to profit from the group
psychodynamics only, which is often the case with narcissistic, psychopathic and paranoid personalities. The
results of psychotherapy then should be visible by the staff members on the ward, and could be further
developed towards diminishing the assessed risk factors. Best evidenced forensic psychotherapies are
Cognitive Behaviour Therapy, Dialectic Behaviour Therapy, Scheme Focussed Therapy, and Functional
Family Therapy for juvenile delinquents. Supervision regarding the therapeutic relationship remains
necessary. Non-specific treatment factors like support play an important role. Structured professional riskassessment (HCR-20 and the Dutch version HKT-30) is mandatory; it evaluates the broader scope of riskfactors, among them the more clinically relevant dynamic risk-factors.
Research on the effectiveness of the different kinds of psychotherapy is very difficult as they are
never given in an isolated position. Staff and psychotherapists are working with the same focus on high-risk
behaviour, and within the individual treatment program also other therapeutic activities will take place next
to the education of rehabilitating skills. Other severe confounders are the maximum security ‗high pressure‘
environment with the risk of apparent adaptation (by levelling all behaviour) and the safety-centered
interventions of the Ministry of Justice: huge (mediating or moderating) influences but hardly to measure.
An extra problem in forensic psychotherapy is that the primary focus is on personal functioning in the hereand-now situation, while the criterion: prevention of re-offending will be met only after years. Future
situations in the community cannot be taken into account, including substance abuse. The rate of recidivism
after TBS is 10 to 20 percent, more to 10 for violent offenders and more to 20 for the sexual offenders.
About 10 percent of the TBS-detainees will not leave the hospital, so called long-stay.
Marvin S. Swartz
Involuntary Outpatient Commitment: The Data and the Controversy
Abstract
Court-ordered community mental health treatment is among the most contested issues in mental health
treatment. While most United States jurisdictions have statutes nominally authorizing involuntary outpatient
commitment—a legal order to adhere to prescribed treatment in the community—until recently few US
states made substantial use of these laws. With the enactment of involuntary outpatient commitment (OPC)
statutes in New York in 1999, in California in 2003, and in Florida, Michigan, and West Virginia in 2005, and
the tragic deaths at Virginia Tech in the wake of a failed outpatient commitment order, policy interest in
OPC in the US has increased. In addition, interest in community treatment orders in the UK, Canada and
Europe has also grown. This presentation will review the data and controversy about these forms of courtordered treatment with a focus on a recently completed evaluation of New York State's Assisted Outpatient
Treatment program.
Marvin S. Swartz, M.D., is Professor and Head, Division of Social and Community Psychiatry and Executive
Vice Chair in the Department of Psychiatry and Behavioral Sciences at Duke University Medical Center. Dr.
Swartz's major research interest is in examining the effectiveness of services for severely mentally ill
individuals. He is former a Network Member in the MacArthur Foundation Research Network on Mandated
Community Treatment and Principal Iinvestigator of the NY State evaluation of Assisted Outpatient
Treatment in NY. He also serves as Co-PI of a study of the costs of mental health treatment in criminal
justice settings. He serves as Co-PI with Jeffrey Swanson of a NIMH study examining the effectiveness of
Psychiatric Advance Directives. Dr. Swartz is also Director of the National Resource Center on Psychiatric
Advance Directives.
WORKSHOP SUMMARIES & HANDOUTS
Workshop 1
Adolescent and Young Adults Forensic Services
Paul Monks, Heidi Hales, Enys Delmage & Ash Roychowdhury
“The Trouble with Teenagers…challenges of diagnosis and transitional care for mentally
disordered young offenders”
The workshop has the following educational goals:
1)
2)
3)
4)
5)
To give the audience an understanding of adolescent forensic services in the UK
To highlight the importance of effective transitions for a highly complex group
To discuss the challenges of effective transitional care from national to regional or local providers
To contemplate ways of managing these challenges via group discussion
To discuss and share ideas about what treatments should be provided and what outcomes should be
achieved for this age group
FORMAT:
The first 45 minutes of the workshop will be led by Drs. Monks, Delmage and Hales and will be focussed on
discussing the epidemiology to give the audience a representative description of the scale of needs. Trends
will be discussed regarding types of offending and common mental disorder presentations to services, and
the common pathways to secure hospital care. There will also be a discussion of the national picture in
terms of secure hospital service provision for those aged 13-18, in addition to a review of the areas of
currently unmet need.
The diagnostic challenges will make up part of the discussion, as well as consideration of the general
developmental milestones that young people go through, and how this can impact upon their mental health
management. There are specific issues related to the treatment of young people which hinge on these
milestones, namely funding arrangements which can radically alter when the young person reaches 18
years of age.
A further discussion will follow regarding the subdivisions within adolescent forensic populations of those 16
year olds who would benefit from placement in an adolescent forensic service until their early 20s and those
16 year olds who would benefit from a move to a transitional service at the age of 18.
Following this, the audience will be asked the following question to consider over a period of 20 minutes:
―What should a transitional service for adolescent mentally disordered offenders look like?‖
The audience will be tasked with considering the rationale, structure and philosophy of a transitional service
for young mentally disordered offenders (aged 18-26) and whether this group deserve special consideration
and a bespoke service to manage their specific needs. We will also consider outcome measures and national
guidance from New Horizons, the Care Quality Commission and the National Institute for Health and Clinical
Excellence, as well as the implications of the Bradley Report as applied to this population.
Dr. Roychowdhury will sum up in the final 25 minutes and will discuss common themes from the workshop,
and the challenges he sees transitional forensic services facing both now and in the future.
_________________________________
Slide 1
__
The Trouble With
Teenagers…
Challenges of Diagnosis and
Transitional Care for MDYOs
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 2
_________________________________
Learning Objectives
1
2
3
• To consider the service needs of adolescent
MDYOs when transitioning from C&A to Adult
services
• To consider different models of transition planning
• To discuss ways in which Adolescent and Adult
forensic services can work together to effect
smooth and successful transitions
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
Slide 3
Adolescent forensic services –
at the interface between CAMHS and adult forensic services, local
authority and juvenile criminal justice system
Community Adolescent Forensic
CAMHS
Adolescent
Forensic
Adult
Forensic
Services
_________________________________
__
Youth Offending Teams (United
Kingdom) / Young Person’s
Probation (Republic of Ireland)
_________________________________
NCG (NHS) adolescent forensic
inpatient units (in England and
Wales) or adolescent inpatient
units (Scotland and Ireland)
Independent secure inpatient
units
Voluntary sector services
__
Inreach into Secure Training
Centres or Youth Offender
Institutions (prisons for
juveniles)
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 4
_________________________________
Epidemiology
 Prevalence of mental health problems for young
people in contact with mental health services:
25-81% (increased if in custody)
 Conservative estimate: x3 higher than agematched controls
 62% of adolescent female serious offenders and
35% of adolescent male serious offenders have
histories of abuse, abandonment or neglect
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 5
_________________________________
Developmental needs of adolescents
Separation from their parents / care-givers
socially and emotionally – but ongoing need
for their support and guidance;
Parental involvement (positive or negative)
has great influence on their mental state
Development of own identity;
Development of capacity for intimacy;
Disruption of education / training may harm
future prospects.
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 6
_________________________________
Service needs of adolescents
 Young people are more impulsive and energetic than adults
 Young people require more containing care and adult input to
feel secure (attachment theory)
 Managing young people requires liaison with many agencies.
 Managing young people requires work with parents.
 Prodromal stage more commonly seen emerging in
adolescence.
 Medication used in adult patients may have increased risks in
young people.
 Family therapy has been shown to be a more effective in young
people than adult patient for certain disorders (eating disorder,
conduct disorder) whereas adult patients respond more to
individual therapy.
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 7
_________________________________
__
Why are transitions
important /
difficult?
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 8
_________________________________
Different systems ...
Adolescent
__
Adult
adult
adolescent
parents /
carers
school/
college
community
nuclear
family –
spouse /
children
work/ day
centres
community
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 9
_________________________________
Different Agencies
CAMHS
MAPPA
__
Paeds
_________________________________
CMHT
Education
MAPPA
Voluntary
Youth Work
Education
Welfare
Officer
Adolescent
Connexions
Back to Work
organisations
GP
Adult
Social
Services
Vulnerable
Adult Social
Services
YOI
YOT
Prison
Secure
Children‟s
Home
Probation
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 10
_________________________________
Different diagnoses
Child
Adult
Neurodevelopmental – ADHD
/ Autistic Spectrum
Autistic Spectrum
Disorder
Learning Disability
Learning Disability
Emotional Disorder
Affective Disorder
Psychotic Disorder
Psychotic Disorder
Adjustment Disorder
Complex PTSD
Emergent Personality
Disorder
PTSD
Personality Disorder
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 11
_________________________________
Diagnostic Issues
 Emergent Personality Disorder vs.
Conduct Disorder/Mixed Disorder of
Conduct and Emotions
 Conduct Disorder vs. Attachment Disorder
vs. ASD
 Mental Illness vs. Mental Disorder
 Psychosis vs. Acute Stress Reaction in
YOI
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 12
_________________________________
Many transitions across different ages
CAMHS
Adolescent
Forensic
General
Adult
Adult
Forensic
Child and
Family Social
Services
16-18
Leaving care
School
16
College
Home
varying
Independence
CAMHS
funding
18
Adult funding
YOi
21
Adult prison
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 13
_________________________________
Funding Issues
 Adolescent services are more expensive
than adult services
More staff
Education
Financial provision for adolescent
Safe Guarding
More agencies to liaise with
Family involvement
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 14
Case Example (1) –
 Who is the accepting team
Known to CAMHS
Admitted from LASCH / YOI
No specified address now
 Who is the local CMHT / Forensic Team to
transfer to
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
_________________________________
__
Slide 15
_________________________________
Case example (2)
 At what age should we transfer
18 year olds – settled in current unit
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 16
_________________________________
Case example (3)
 How do we effect a smooth transfer
Many have PD
Should have slow / planned transfer
However, beds come up suddenly
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 17
_________________________________
Meanings
• Transition can have several overlapping meanings:
• The social transition from adolescent roles to adult roles.
• The transition in presentation from adolescent mental
disorders to adult.
• The transitions from adolescent secure care and its approach
to adult secure services.
• Transition from adolescent criminal justice and legal
processes to adult equivalents.
• Transition as a reflection of ongoing emotional, social and
cognitive development in this age group.
• Due to the above, providing effective care to this age group
can be very challenging.
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
Slide 18
_________________________________
•
•
•
•
•
•
Why Young Adults?
Variable Maturity : many young adults exhibit developmental levels
more characteristic of far younger people. Brain development
continues into the mid to late 20s, affecting reason, judgement and
impulse control, and young people with the most troubled or
traumatic childhoods often take longer to mature.
A critical age for getting it right: the peak crime age is 19; young
adults are the most likely age group to desist from crime. (23)
Peak for onset of the major psychotic disorders such as
schizophrenia and bipolar illness in males, head injuries, the peak of
alcohol and drug abuse, and the peak association between drugs
use and violence all occur in this age group
Are adult forensic services able to deliver specialist assessments
(e.g. For ADHD, autism) and early intervention approaches to
psychosis, PD?
.
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 19
_________________________________
Social Context
•
•
•
•
•
•
•
•
Society has changed:
The age at which someone becomes a fully independent adult in society is
much later now than it was in earlier decades.
The criminal justice system‟s approach (and adult forensic?) to 18-24 year
olds is out of step with cultural and social norms of transitions to adulthood
Young Adults have complex needs:
Mentally disordered offenders frequently have few or no educational
qualifications, and no experience of work.
They also suffer from high levels of mental ill health, and alcohol and drug
problems.
In the transition to adulthood, support from care services, CAMHS, YOTs
and childrens services disappear.
How good are current adult forensic services at addressing social
exclusion?
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 21
_________________________________
Managing the Issue
• Other Departments are moving in the right
direction: the DWP has policies aimed specifically
at young people aged 18-24, on account of their
specific need and life stage, recognizing that there
is a complex tangle of benefits, support and
penalties throughout the transition to adulthood.
• Poor Transitions to Adulthood impact on the
next generation: at least ¼ of young men in
prison are fathers; most young women in prison
are mothers. Getting it right by maintaining family
relationships can help people move away from
crime
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 22
_________________________________
Workshop Question:
 “What should a transitional service for
adolescent mentally disordered offenders
look like?”
 Rationale
 Structure
 Philosophy
 Age range
 Arguments for and against
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
Slide 23
_________________________________
Common Themes from the Workshop
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Slide 24
Challenges from one who knows…
 Service development and internal
challenges to overcome
 External challenges
 The future, Big Society and GP
commissioners…
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
_________________________________
__
Workshop 2
Relational Security
Paul Gilluley, Bradley Hillier and James Tighe
The Department of Health issues ―See. Think. Act.‖ in 2010 to improve relational security within secure
mental health services. This workshop will discuss the background of why there was a need to improve
relational security within services.
The approach to improve relational security through, ―See. Think. Act.‖ Will be discussed.
The background to relational security will be explored and the development of standards within the Quality
Network..
Methods of measuring relational security will be discussed.
Objectives
1. To describes the background for the need for an improvement in relational security.
2. To understand relational security and ―See. Think. Act.‖
3. To get an idea of practical experience of how this has changed services approach to security.
4. To look at how we can measure relational security.
Presenters
-
Dr Paul Gilluley, Chair Advisory Group for the Quality Network
Dr Bradley Hillier, SpR in Forensic Psychiatry
Jim Tighe, Bracton Centre.
Format
Brief presentation of the background of the work and initial evaluation carried out.
Some time for audience to share how they have used programme within their service.
Discussion of high level indicators proposed for the measurement of relational security within services.
Workshop 3
Substance misuse interventions in forensic services
Niamh Power, Julia O‘Connor and Alex Whale
Summary not available at time of going to press.
Workshop 4
Mentalization* and group reflective practice** in the management of forensic personalitydisordered patients
*Jessica Yakeley and Andrew Williams: Portman Clinic, Tavistock and Portman NHS Foundation Trust: Gill
McGauley: Broadmoor Hospital, West London Mental Health Trust and St George‘s University of London.
**Roberta Babb, John Canning and Cleo Van Velsen: Millfields Unit. East London NHS Foundation Trust.
This workshop presents two linked treatment approaches to working with forensic personality-disordered
forensic patients. First, the findings, one year on, of a pilot project offering mentalization-based treatment
(MBT) to violent men with a diagnosis of antisocial personality disorder (ASPD) in an out-patient setting. It
is part of a multi-site research project co-ordinated by Anthony Bateman and Peter Fonagy aiming to
evaluate whether patients with ASPD can benefit from MBT.
Second, the use of a tool, the Interface of Meaning and Projection Formulation (impF), will be
demonstrated. The impF has been specifically designed for facilitating group reflective practice for clinical
teams working with forensic personality-disordered inpatients.
NICE guidelines on ASPD were welcomed for legitimizing treatment for this group of people who are often
both treatment-rejecting and treatment-resistant. However, the narrow range of treatment
recommendations for adults with ASPD highlighted the need for more research into effective treatments for
this complex and costly disorder. MBT is a psychoanalytically-based treatment approach that has been
developed by Bateman and Fonagy (2004) for patients with borderline personality disorder (BPD). Recently,
there has been increasing interest in the forensic field in the application of MBT to forensic patients with a
diagnosis of ASPD. Like BPD, ASPD can be understood as a disorder of attachment in which genetic
precursors interacting with early environmental adversity result in the abnormal development of mind in the
areas of affect regulation, impulse control and ability to mentalize.
In the first half of this workshop we will present research data showing that ASPD patients have both
disordered attachment patterns and an impaired capacity to mentalize, as measured by their Reflective
Function. We will then describe our treatment approach, the methodology and results to date of our pilot
project.
Treatment efficacy for personality disordered forensic patients is dependent upon the containment,
cohesiveness and the collective reflective function of the staff team. The second part of this workshop
demonstrates the fundamental need for group reflective practice for clinical teams working with personalitydisordered offenders.
The impF process allows the different emotional experiences of individuals/disciplines who work with
patients to be shared and become meaningful for the whole team. Without this, psychiatric teams can come
to resemble the fragmented mind of the patient, and differences between clinical team members can easily
slip into opposition, with individuals loosing their ‗psychological bearings‘ i.e. being caught up in a patient‘s
re-enactment of previous trauma.
The impF process creates a different reflective practice space which goes beyond the evacuating of
unpleasant feelings. Clinical examples will be presented which show the link between the impF and the
treatment resistant patient enhancing their own reflective function.
Learning objectives: After attending this workshop participants will be able to:
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Understand the concept of mentalization and its relevance to ASPD patients.
Describe the MBT treatment approach for ASPD and how it links to the aetiology of the disorder.
Understand the importance of group staff reflective practice within PD services.
Describe the impF process and how it links to treatment resistant PD.
Roberta Babb: Chartered Clinical Psychologist, Millfields Unit. East London NHS Foundation Trust.
John Canning: Modern Matron, Millfields Unit. East London NHS Foundation Trust.
Gill McGauley: Consultant Psychiatrist and Reader in Forensic Psychotherapy, Broadmoor Hospital, West
London Mental Health Trust and St George‘s University of London.
Cleo Van Velsen: Consultant Psychiatrist in Forensic Psychotherapy
Millfields Unit. East London NHS Foundation Trust.
Andrew Williams: Consultant Psychiatrist in Forensic Psychotherapy, Portman Clinic, Tavistock and Portman
NHS Foundation Trust
Jessica Yakeley: Consultant Psychiatrist in Forensic Psychotherapy, Portman Clinic and Director of Medical
Education and Associate Medical Director, Tavistock and Portman NHS Foundation Trust
Workshop 5
New Versus Old Diminished Responsibility
Nigel Eastman, Sathana Gunasekaran and Nuwan Galappathie
Description
The Coroners and Justice Act 2009 has replaced the partial defence to murder of ‗diminished responsibility‘,
as defined under the Homicide Act 1957, with a significantly different defence, applicable to killings
committed from 4 October 2010.
The workshop will compare ‗new‘ and ‗old‘ diminished responsibility, specifically from the perspective of the
medical expert. The changes introduced by the new Act will be explained, including uncertainties in terms of
how the Court of Appeal may interpret particular aspects of the new provisions. Such uncertainties relate
both to interpretation of the substantive defence and to the relative roles of expert and jury.
Four vignettes amounting to ‗paradigm cases‘ of potential diminished responsibility will then be provided to
participants, who will be asked to consider these under both the old and new provisions. The case vignettes
are based upon real cases, albeit not presented precisely as they occurred. Participants will consider
specifically how expert medical evidence may play out under ‗new diminished responsibility‘, in contrast to
the old provisions.
Participants in the workshop will be encouraged to describe their own experience and views as may be
relevant to operation of the new law.
Diminished Responsibility provision:

Section 2(1) of the Homicide Act 1957 provided:
"Where a person kills or is a party to the killing of another, he shall not be convicted of murder if he
was suffering from such abnormality of mind (whether arising from a condition of arrested or
retarded development of mind or any inherent causes or induced by disease or injury) as
substantially impaired his mental responsibility for his acts and omissions in doing or being a party
to the killing."

The Coroners and Justice Act 2009 (England and Wales) provides:
―(1) A person (―D‖) who kills or is a party to the killing of another is not to be convicted of murder
if D was suffering from an abnormality of mental functioning which,
(a) arose from a recognised medical condition,
(b) substantially impaired D‘s ability to do one or more of the things mentioned in
subsection (1A), and
(c) provides an explanation for D‘s acts and omissions in doing or being a party to the
killing.
(1A) Those things are—
(a) to understand the nature of D‘s conduct;
(b) to form a rational judgment;
(c) to exercise self-control.
(1B) For the purposes of subsection (1) (c), an abnormality of mental functioning provides an
explanation for D‘s conduct if it causes, or is a significant contributory factor in causing, D to carry
out that conduct.‖
Educational goals of the workshop
1. To provide participants with knowledge and understanding of the ‗new diminished responsibility‘
provisions.
2. To elucidate any uncertainties in how the new provisions may be interpreted by the Court of Appeal
and the implications for the giving of expert medical evidence of alternative interpretations.
3. To provide participants with a basis for determining their own technical and ethical approach to the
provision of expert evidence under the new provisions, however interpreted by the Court of Appeal.
4. Appeal.
Workshop 6
Trauma - recognition, management and treatment in custodial settings
Vittoria Ardino, Frances MacLennan, Piyal Sen, Andrew Forrester
This workshop is organised jointly by London Metropolitan University, St. Andrew‘s Hospital, South London
and Maudsley NHS Foundation Trust, HM Prison Brixton and the Institute of Psychiatry. The workshop will
be run by:
Vittoria Ardino - Senior Lecturer in Forensic Psychology, London Metropolitan University and Board
Member of the European Society of Traumatic Stress Studies
Frances MacLennan - Clinical Psychologist, South London and Maudsley NHS Foundation Trust at HM
Prison Brixton
Piyal Sen – Consultant Forensic Psychiatrist and Associate Medical director for CPD, St. Andrew’s
Healthcare, and Visiting Research Fellow, Institute of Psychiatry
Andrew Forrester - Consultant in Forensic Psychiatry, South London and Maudsley NHS Foundation Trust
at HM Prison Brixton, and Honorary Senior Lecturer, Institute of Psychiatry
The workshop will cover the prevalence, recognition and management of mental illness that is underlain by
trauma in custodial settings. This will include psychological and criminological issues underlying the
definition of post-traumatic stress disorder (PTSD), its measurement and treatment in forensic settings, and
an update on current research in the area.
Specific instruments for trauma assessment will be introduced and case material will be used to illustrate
the practical applications of research. This will include data from the research that the authors are currently
pursuing this area in HMP Brixton.
The implications for service delivery in custodial settings, which may, because of their very nature, re-ignite
or inflame earlier traumatic experiences, will be discussed and set alongside the development of prisonbased mental health in-reach services and the Improving Access to Psychological Therapies (IAPT) initiative
(through which talking therapies have been rolled out nationally, including within custodial settings). The
role of treatments in particularly vulnerable groups such as refugees and asylum-seekers, as well as
prisoners who are foreign nationals, will also be discussed.
At the end of the workshop, the participants will be updated on how to recognise trauma symptoms within
custodial settings, including for specific groups like foreign nationals, and how to treat such symptoms
within such settings.
Vittoria Ardino
Vittoria Ardino is a senior lecturer in Forensic Psychology at London Metropolitan University, UK, where she
lectures in the MSc in Forensic Psychology. She is the President of the Italian Society for the Study of
Traumatic Stress (SISST) and serves on the board of the European Society for Traumatic Stress Studies
(ESTSS). She is associated editor of the European Journal of Psychotraumatology and her research interests
and publications bridge clinical and forensic psychology with a focus upon the role of trauma in young and
adult offenders with post-traumatic symptoms. She also offers consultancy and workshops on trauma in
forensic settings.
Frances MacLennan
Frances MacLennan is a Clinical Psychologist with South London and Maudsley NHS Foundation Trust,
working currently at HM Prison Brixton. She has a particular interest in the Improving Access to
Psychological Therapy (IAPT) project and in the application of the trauma model to custodial settings.
Piyal Sen
Piyal Sen is a Consultant Forensic Psychiatrist with a special interest in the treatment of refugees and
foreign nationals. He is involved with a number of research projects within Brixton Prison on this area,
focused on the care pathway for foreign national prisoners and how trauma and criminality interact within
such a group. He also has a clinical and research interest in personality disorder and the role of trauma in
its development. He is the lead for personality disorder within St. Andrew‘s Healthcare and acts as a
reviewer for various journals like Medicine, Science and Law, Acta Neuropsychiatrica and Foundation years
Journal. He is also a member of the CPD Executive of the Royal College of Psychiatrists.
Andrew Forrester
Andrew Forrester is a Consultant and Honorary Senior Lecturer in Forensic Psychiatry, and Clinical Lead for
Offender Mental Health, with South London and Maudsley NHS Foundation Trust and the Institute of
Psychiatry, London. He has worked clinically in forensic mental health and prison services since 1998 and
has led the mental health in-reach team at HM Prison Brixton since 2005. He has worked clinically in
Edinburgh, London and Melbourne, and currently leads a clinical programme that focuses on severe and
enduring mental illness, and a research programme that focuses on offender mental health.
Workshop 7
Forensic services and commissioning in the economic downturn
Dr Paul Gilluley, Dr Jeremy Kenney-Herbert, Dr Quazi Haque, Dr Mehdi Veisi, Mike Gatsi
Moving Forward in Improving Quality : Economic Downturn and Forensic Mental Health Services
The National Health Service is about to undergo the biggest reform in its history. The Coalition
Government‘s Health White Paper, ‗Equity and excellence: Liberating the NHS‘ has set out the plan for this
reform. This workshop aims to keep clinicians up to date on how these reforms will have an impact on
forensic mental health services.
We will explore Commissioning for Quality and Innovation and how targets have been set nationally for
We will explore how the Quality, Innovation, Productivity and Prevention programme is having an effect on
This workshop will discuss the work completed by a multidisciplinary working party on addressing the
economic downturn and the effect on forensic mental health services. This working party was formed from
a workshop hosted by the Quality Network for Forensic Mental health Services in August 2010.
Objectives
1. To describes the effects of the economic downturn on forensic mental health services.
2. CQUINs and Quality standards.
3. Medium Secure QuIPP
4.
To explore the interface between prison and secure services
5. To explore the interface between secure services and the community.
Workshop 8
ASSESSMENT OF INTERNET OFFENDERS
Sodi Mann
Learning Objectives:
To better understand:
1.
2.
3.
4.
legal Issues associated with internet offending
types and profiles of internet offenders
risk assessment
approaches to treatment
There has been more than a 5 fold increase in convictions for indecent images of children (in E&W).
Internet offenders (IO) account for a third of total sexual convictions. English Case law (Bowden 2000 &
Jayson 2003) has led to a low threshold for conviction of ‗making‘ an indecent image. The courts have
adapted the COPINE scale to classify images.
Sullivan & Beech describe 3 motivational typologies. Research suggests IO‘s fall in 2 main clusters (using
the Ward & Siegert Model): Intimacy Deficits & Emotional Dysregulation.
Comparisons between IO & contact offenders reveal significant psychometric findings in terms of
psychological profile. The risk profile of these 2 groups is also significantly different, with the IO group
engaging better in treatment and engaging in fewer risk behaviours.
The internet treatment programme (iSOTP) has a different emphasis on modules used by the core
Programme. Psychometrics demonstrate an improvement in scores with iSOTP but no reconviction studies
yet published.
Final part of the presentation covers practical advice when assessing internet offenders. Particular focus
paid to complex issue of confidentiality, where the behaviour usually involves indirect victims & any breach
of confidentiality could jeopardise therapeutic engagement. A newly developed Confidentiality Guidance
Document will be made available to attendees to help any future decision making process (alongside, a new
Confidentiality Patient Contract)
Impact of Mandatory Polygraph Testing on Sex Offender Management (and its implications for
forensic psychiatry
Don Grubin
Learning objectives:
To better understand:
1.
2.
3.
4.
how polygraphy works
outcomes of polygraph testing in respect of supervision and treatment
whether mandatory testing disrupts therapeutic relationships
how the lessons of sex offender testing can be applied to the treatment of forensic patients
generally
Following a three year trial of sex offender polygraph testing in the probation service in which participation
was voluntary, legislation was passed to allow a trial of mandatory testing. This commenced in April 2009
in 2 probation regions in England. Although data are still being collected, much has been learned about the
similarities and differences between voluntary and mandatory testing.
The presentation will review the background to sex offender polygraph testing, including a discussion on
how polygraphy works. Data from the voluntary programme will be presented and considered in the
context of mandatory testing. The potential for use more generally in forensic psychiatry – to complement
court assessments, to improve risk assessment, to enhance treatment, and to improve supervision – will be
examined. The relevance of polygraph testing to internet offending will also be presented.
Workshop 9
Avoiding Grief in Court
John Kent, David Reiss, Aideen O‘Halloran, on behalf of FFEC with Ashley Irons
The workshop is targeted at specialty trainees and newly appointed consultants; however all are welcome to
attend. It will focus on generic transferable skills. Attendees from all jurisdictions will find it appropriate for
their training as the content will not focus on any particular legal system.
The aim of the workshop will be to promote excellence in courtroom practice. It will do this by providing a
forum for interactive learning using the expertise of a leading mental heath lawyer to guide us through the
key issues.
Writing reports for a myriad of courts is integral to our work as forensic psychiatrists. These include
tribunals (mental health), the various criminal courts, inquests, family courts and civil courts. For some it
appears to be plain sailing but for many it can be daunting: one bad experience can lead to significant
stress in respect of future appearances.
The learning objectives for the workshop include giving you knowledge and skills in preparing for an
impending court room appearance as an expert or professional witness, including how to reduce your
anxiety and avoid nasty surprises on the day. The session will provide an opportunity to improve your
competence as a witness in court; to reflect on the context of the court room and the role of the doctor
within it; and work through some of the challenges you may face in this setting.
The session will be informal, interactive, and audience participation will be welcome. Any examples of your
own experiences in court, good or bad, will help to add richness and spontaneity to the session.
Workshop 10
Service User Involvement in a Medium Secure Dangerous and Severe Personality Disorder Unit
Caitriona Higgins Victoria Wasteney, Emma Chandler, Celia Taylor
Summary not available by time of going to press
Workshop 11
Film Club - The Lives of Others (Director Florian Henckel von Donnersmarck,2006)
Cleo van Velsen
Summary not available by time of going to press
Workshop 12
Managing Violent Personality Disordered Women in Psychologically Containing Planned
Environments – a strategy for the future
Dr. Mary di Lustro – Clinical Lead and Consultant Forensic Psychiatrist, Women‘s Service, East Midlands
Centre for Forensic Mental health, Nottinghamshire Healthcare NHS Trust.
Dr. Jay Sarkar– Consultant Forensic Psychiatrist, Personality Disorder Service and Women‘s Service, East
Midlands Centre for Forensic Mental health, Nottinghamshire Healthcare NHS Trust.
DESCRIPTION OF WORKSHOP
Over the coming years the strategy for managing personality disordered offenders is going to change
substantially. The focus will shift from expensive individual and group treatments, for which substantial
evidence and expertise now exists, to developing ‗psychologically informed planned environments‘, also
called PIPES. Essentially, this strategy will ask service providers to create a safe, secure, responsive and
supportive environment within which patients/inmates can undergo treatment.
These environments are required not just within the prison estate and secure hospitals, but also in the
community. Implicit in this strategy is the notion of developing and enhancing staff skills to create and
maintain such environments by providing relational, as opposed to structural security. This requires
training for the workforce, meaningful structured days for inmates and patients, and opportunities to learn
effective interpersonal skills that can be translated onto life in the community.
Presenters will give a brief outline of the Models of Care used within their service with sufficient detail to
allow discussion and debate about whether Models of Care used within individual services take sufficient (or
any) account of the need to provide such environments. Presenters will consider how such environments
can be replicated in alternative settings, thereby facilitating the transition up or down the Secure Pathway.
FORMAT OF WORKSHOP:
The Workshop will include an interactive component. The facilitators of the Workshop will provide several
case vignettes (depending on the number of delegates attending the Workshop) for the delegates to review.
There will be debate about which elements of each patient‘s care would be most challenging and how this
could be accommodated within the ‗PIPES‘ framework.
During the interactive component delegates will be challenged by the facilitators referencing the research
evidence base on the management of women with Personality Disorder within in-patient settings, and
requested to consider how they might alter their own environments to function as a ‗PIPE‘.
EDUCATIONAL GOALS OF THE WORKSHOP
The Workshop will raise delegates‘ awareness and understanding of what ‗psychologically informed planned
environments‘ may look like.
Good practice will be shared with delegates derived from the effective running of such environments, with a
focus upon future planning.
Delegates can expect to develop a clear understanding of the function of psychologically improved
environments.
Delegates will develop an understanding of how current provision within some services results in ‗PIPES‘
and whether this might provide some solution to the lack of smooth transition between different levels of
security using conflicting models of care.
TARGET AUDIENCE:
Those developing services (managers, clinical directors), managing services (senior MDT staff) and running
services (middle-ranking & junior nursing and medical/psychiatric staff)
Handouts follow:
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Slide 1
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PIPES:
A STRATEGY FOR THE FUTURE
Mary diLustro
Jay Sarkar
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Slide 2
WHAT IS A PIPEs?
• Psychologically Informed Planned Environments
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National PD strategy
Treatments for individuals, groups one element
Focus to shift to therapeutic environment
Focus shifts to management in community
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Slide 3
BACK TO THE FUTURE
• Psychologically informed environment
– synonym: Therapeutic millieu
– Millieu: Awkward to spell and pronounce. What’s it?
•
•
•
•
A group living situation (ward, drop-in, day centres)
For children with emotional problems (adults with PDs)
Whose lives are full of crises (offenders, PDs in community)
Focussing on events that occur & processes that exist.
- Treischman et al 1969
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Slide 4
PIPE: A SECURE BASE
• “..actions of adults (carers) with children
(offenders) and the adults’ (carers’) control of the
environment can be coordinated to improve
children’s (offenders’) lives.” (Trieschman et al 69)
• Using the events & processes that exist in these
environments as effective tools to effect change
• Creating a secure base which offers safety in
relationships, predictable consequences to
actions, and oppurtunities to explore and learn
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Slide 5
PIPEs are Teaching environments
• Events
– What goes on daily among users and carers offer
opportunities for therapeutic education and reeducation of the users.
• Processes
– The rules, routines and practices within an
environment, their implementation, and management
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Slide 6
How people learn
• ‘A-ha’ learning: Insight/therapeutic learning
• ‘Me-too’ learning: Imitation/Identification
• ‘Stick-and-carrot’ learning: Reinforcment
• ‘Again-and-again’ learning: Repetitive events
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Slide 7
Events: Emotional (re)learning
• Events are a function of relational safety
– Interactions between users and users and carers
reveal ‘snippets’ into early home life
– Relationships reveal underlying attachment schemes
– every encounter offers opportunities for
psychological education
– Dependent upon capacity of group and carers to
support
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Slide 8
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Processes: Socio-emotional learning
• Rules of the environment (dos & donts)
• Policies and practice that are largely inflexible
and non-negotiable
–
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–
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‘Reasonable’ rules for daily running
‘Extreme’ rules necessary for safety of all
‘Reinforcement’ system for behavioural change
Privileges, access, leave, discharge
Every social group/society creates and enforces its
own rules
– Adaptive and flexible
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Slide 9
Processes of the space
1. Rules:
Group v Individual
Automatic v negotiated
•
•
•
•
Group automatic rules (Boundaries)
Individual automatic rules (assault  seclusion)
Group negotiated rules (exceptions)
Individual negotiated rules (tailored treatment)
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Slide 10
2. Routines
Planned sensible sequences of behaviour around
regular events of the day, week, year.
Routines around lunch, dinner, bedtimes
Daily negotiations, Community/Business meetings
Ward rounds requests, Self-report at CPAs/reviews
Viewing and processing reports
Routines for staff, MDT
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Slide 11
3. Programmes & Activities
Therapeutic tasks presented by daily events
Predictable vs Unpredictable
What does a situation demand
Capacity to bear frustration
Balance between autonomy v submission
Meaningful day events
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Slide 12
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4. Conversations
Psychotherapeutic conversations
Life-space conversations
One-line comments
Who does it? Nurses, Allied profs, Medics, RC
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Support & Guidance for Users
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Relationships with key individuals (shared ego)
Group mood & structure (group ego)
Institutional culture (external ego)
Individual’s own abilities (personal ego)
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Key Relationships
• Most crucial aspect of millieu
• Share/lend ego to users
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• Praise, share, support, etc
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• Fitness of attachment styles
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Critical elements of relationships
• Communication – good or bad
• Social reinforcement – approval or disapproval
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• Modelling behaviour – good or bad
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Group mood & structure
Structure
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Tightly knit
Clear leader
Multi-dimensional
‘Top dog’-’Black-sheep’
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Mood
Aroused
Relaxed
Antagonistic
Cooperative
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Institutional culture
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Traditions
Policies
Practices
User expectation of how organisation reacts
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Instituion as ‘secure base’
• Supportive millieu environment
• Avoiding repetition of bad experiences of past
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Millieu becomes the ‘secure base’
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Individual Capacities
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Emotional reactions
Ego strength – how regressed
Learning style
Motivational levels
Psychosocial stage of maturity
– Trust v mistrust (suspicious)
– Autonomy v shame, doubt (aggressive)
– Initiative v guilt (passive)
– Industry v inferiority (depressed)
– Identity v Ego diffusion (PD)
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Know your patient
• Emotional reactions: Impulsive-emotional v Withdrawnstrategising
• Ego strength: how regressed or child-like under stress
• Learning style: Relational, Group-based procedural
Reinforcement-orientate, Social learning
• Motivational levels: Motivators internal or external
• Psychosocial stage of maturity: Where is she at?
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POSTER ABSTRACTS (A-Z by presenter)
An audit into the prescription and use of sleeping tablets in East Sussex Forensic Psychiatry inpatients
Dr Shakil Alam, Foundation Doctor Year 2 Royal Free Hospital London, Dr Nikolas Gkampranis Staff Grade Forensic Psychiatrist,
East Sussex, Dr Peter Hayden-Smith Consultant Forensic Psychiatrist Hellingly Hospital East Sussex. East Sussex, Dr Richard
Noon Consultant Forensic Psychiatrist East Sussex
Aim: To monitor the use of sleeping tablets in the Forensic Psychiatric Services, looking specifically at length of stay, whether
the sleeping tablets had been prescribed regularly or as required, whether the patient was still experiencing insomnia symptoms
despite receiving a sleeping tablet and whether the medication was reviewed.
Introduction: A patient complaining of insomnia may describe one or more of the following symptoms: difficulty falling asleep,
frequent waking during the night, early-morning wakening, daytime sleepiness and a general loss of wellbeing through the
individual's perception of a bad night's sleep.
Method: The following hypnotic drugs were included in the study, as per Maudsley guidelines: Diazepam, Lormetazepam,
Oxazepam, Nitrazepam, Temazepam, Zaleplon, Zopiclone, Zolpidem, Promethazine and Chloral pd.
Data was collected through direct monitoring of medicine cards in the units, consultation of patient‘s case notes, discussion with
Nursing team and discussion with Ward Doctor when required. 39 patients from the Forensic Psychiatric services at Hellingly
Hospital were audited from July-August 2007.
Results
98% (38) of the sample had been inpatients for more than 4 weeks, 2% (1) had been inpatients for less than 4 weeks. 67% (27)
had been prescribed a hypnotic tablet. 31% (12) of the patients had been prescribed a sleeping tablet ‗as required‘. 28% (11)
had been prescribed a sleeping tablet regularly, and the remainder 72% (28) had been prescribed a hypnotic tablet both on the
regular and ‗as required‘ side. Worryingly 66% (26) of the treated group were still symptomatic with insomnia. 66% (26) of
patients on hypnotic medication had their medication reviewed on a monthly basis; however 18% (7) of the sample group
continued to experience insomnia symptoms and not have their medication reviewed.
Conclusion
The audit showed insomnia to be a common symptom amongst the Forensic Psychiatric inpatient sample used. Many had been
prescribed a sleeping tablet, mostly on an ‗as required‘ basis, although the results show that many patients continued to suffer
from insomnia despite medication therapy. Most of these patients were likely to be identified during monthly medication reviews,
however there remained a significant number of patients who continued to have insomnia symptoms inadequately treated,
receiving suboptimal medical therapy that was not reviewed.
Some of the difficulties in performing the audit arose from being unable to objectively assess the quality of the sleep (versus
subjective measures), whether there was a difference in the ways that ‗as required‘ medication was dispensed and being unable
to account for multiple comorbidities that could also be giving rise to insomnia. However, the audit did identify some ways in
which the service could be improved, such as by instituting weekly medication reviews for all inpatients, preferably before
weekends, monitoring of hypnotics by pharmacists, on call doctors to prescribe hypnotics as stat doses rather than as required,
sleeping tablets to be used only between certain hours during the night and only by senior members of the nursing team and a
full medication review before discharge.
Patients with Personality Disorders and Learning Disability- Closer to Learning Disability or Personality Disorder?
Dr R. Alexander FRCPsych, Consultant Psychiatrist & V Chester, Research Assistant, St John‘s House Hospital, PiC LD Services,
Diss, Norfolk IP22 1BA.
Introduction: Within secure hospital services for people with learning disability, the rate of personality disorders is around 50%.
This diagnosis shows a positive association with reconviction rates after discharge from such settings. There have been few
studies to systematically examine how patients with personality disorders and learning disability (the PD-LD group) differ from
either those with a learning disability alone (the LD group) or those with a personality disorder alone (the PD group). Such a
three way comparison would help to define these groups better and aid in appropriate service provision.
Aim: To examine how, among patients discharged from forensic services, those with personality disorders and learning disability
(the PD-LD group) differ from those with a learning disability alone (the LD group) or those with a personality disorder alone (the
PD group).
Method: Data was drawn from an ongoing long-term outcome study that has information on over 1000 discharges from forensic
mental health and learning disability services in the UK. The groups were compared on socio-demographic, clinical and forensic
variables as well as treatment-outcomes.
Results: There were 362 patients, spread over three groups- 48 in the PD-LD group, 97 in the LD group and 217 in the PD
group. Preliminary results suggest statistically significant differences on age at first conviction and the number and types of
previous convictions. The PD-LD group had the highest HCR-20 and PCL-SV scores and the longest duration of hospital stay. The
numbers of post-discharge convictions were significantly different with the PD group having the highest number while survival
without a reconviction was longest for the LD group.
Conclusions: In terms of past risk variables, the PD-LD group scores highest and may thus be closer to the PD group than the
LD group. Their rates of reconviction are lower than the PD group and in that respect they may be closer to the LD group. More
recently, there have been government initiatives to treat people with learning and developmental disabilities in mainstream
rather than specialist services. Implications of these findings on such a model of service provision are discussed.
(Acknowledgement: This study is part of the ongoing treatment outcome project led by Professors Robert Snowden and Nicola
Gray at Cardiff University).
Making the HCR-20 Easier to Use
Dr. James R Álvarez, Consultant Clinical and Forensic Psychologist; Dr. Ankur Agarwal, Consultant Forensic Psychiatrist; Dr. Amit
Nigam, Consultant Forensic Psychiatrist; Dr. Antoinette Kotzé; Specialty Doctor; Westminster Community Forensic Mental Health
(FoCuS) Team. Dr. Satinder Sahota, Consultant Forensic Psychiatrist; Dr. Dominic de Souza, Consultant Forensic Psychiatrist;
Kensington and Chelsea Community Forensic Mental Health (FoCuS) Team.
The HCR-20 is widely accepted as the gold standard violence risk assessment tool across a variety of settings. The current
consensus in the literature is that the structured professional judgment approach of the HCR-20 is best among the range of risk
assessment options available to help clinicians make decisions about patient care.
Though well researched in inpatient and correctional settings, there is relatively little in the literature about the HCR-20‘s
application, usefulness and ease of use in community settings.
The Westminster and Kensington & Chelsea Community Forensic Mental Health (FoCuS) Teams were set up to provide
community-based mental health services to mentally disordered offenders, to effectively assess and manage risk, to share this
risk with our colleagues in generic services and to implement strategies to reduce it. Referrals are received from community
mental health teams, general inpatient and secure units and the criminal justice system.
Regular use of the HCR-20 form now used by local inpatient services revealed it to be useful, but time-consuming. It quickly
became apparent that to achieve our team‘s aims efficiently and cost-effectively, it was necessary to make changes both to the
current HCR-20 form itself and to the organisational processes and procedures necessary to ensure that risks are identified and
communicated quickly in an actionable manner.
Following the principle that risk assessments are only as good as the time and effort spent communicating them, with the
author‘s consent, we redesigned and automated the HCR-20 form. Additionally, we re-engineered our organisational risk
assessment processes and procedures to more effectively communicate and develop risk management plans without
compromising their effectiveness for our team and referrers.
In this poster we report on the process of modifying the form to meet our needs, our experience of using the modified form and
describe the organisational and other issues encountered in using the tool. We also report how the modified version has fared in
our practice compared to the original and how referrers have experienced the new process.
We present the modified HCR-20 form and will encourage delegates to utilise this version and feedback to us their experience of
it in an iterative process aimed at adding to the literature on community risk assessment. This will also inform the current
revision of the HCR-20 now being undertaken by its original authors.
The prevalence and predictors of violent victimisation amongst male inpatients in six English Regional Secure Units
Dr Sophie Anhourya, Ms Alexis Cullenb, Professor Tom Fahyc, Dr Kimberlie Deand
a-d
Department of Forensic and Neurodevelopmental Science, Institute of Psychiatry, Kings College London, UK
Introduction
Individuals with severe mental illness are known to be at increased risk of violent victimisation relative to the general population.
To date much of the research in this field has focused upon individuals living in community settings. The prevalence, predictors
and persistence of violent victimisation over time have received comparatively little attention amongst inpatient populations, and
very little at all is known about the risks for those receiving treatment in forensic services.
Aims
To examine the prevalence and predictors of violent victimisation in a sample of male inpatients in six English Regional Secure
Units.
Method
This study utilised baseline data from 82 participants to establish prevalence and correlates of violent victimisation amongst a
male sample receiving inpatient treatment in conditions of medium security. Baseline variables relating to victimisation, violence,
substance misuse, inpatient behaviour, personality, symptom severity and demographic data were examined.
Results
In total 72% of the sample (n = 59) reported being subject to either verbal or physical victimisation over an average of 16
months follow-up, and 36.6% (n=30) reported physical victimisation alone. A total of 23.2% of the participants experienced
episodes of victimisation in two of the follow-up periods and 13.4% in one follow-up period. Those reporting physical victimisation
were significantly more likely at baseline to have experienced verbal victimisation, to have behaved aggressively towards others,
to have engaged in a greater number of acts of violence, to have engaged in antisocial behaviour, to have had hospital leave
withdrawn, to have misused substances, and to have high PCL-SV Factor 2 scores. Multivariate analysis showed previous
victimisation to be the strongest predictor of victimisation.
Conclusions
This study confirms that the experience of violent victimisation as a male Regional Secure Unit inpatient in England is a common
one. For many patients the experience of victimisation persists over time. The predictive factors we have identified share a
relationship with violence risk in this group. Future studies should focus on long term outcomes and the design and evaluation of
strategies aimed at reducing victimisation risk.
Long-term Care in Medium Secure Services
(London Mental Health Forensic Services)
Dr Doreen Attard MD MRCPsych, Specialist Registrar in Forensic Psychiatry, South West London and St George‘s NHS Trust
Forensic Services; Dr Bradley Hillier, Specialist Registrar in Forensic Psychiatry, Kent and Medway Partnership Trust; Dr Stephen
Attard, Locum Consultant Forensic Psychiatrist, Kent and Medway Partnership Trust; Dr Paul Gilluley MRCPsych, Consultant
Forensic Psychiatrist, West London NHS Trust Forensic Services; Dr Mari Harty MB BCH BAO MRCGP MRCPsych MSC DFP PhD,
Consultant Forensic Psychiatrist and Associate Medical Director, South West London and St George‘s NHS Trust Forensic Services
Aim:

To identify the characteristics, needs and prognosis of long-term medium secure patients (longer than four years)
Background review:
Clinical experience shows that the population cared for within conditions of medium security (MSU) has changed. Patients are
more challenging, have complex needs and require longer admissions.
Method:
South West London, West London and East London Mental Health Forensic Services participated in this study. Questionnaires
were designed and sent to responsible clinicians of male patients admitted for over four years in MSUs within these trusts.
Female patients and ‗long-stay‘ wards were excluded. The variables and opinions regarding appropriateness of security level,
prognosis and reasons for delay in discharge were then examined.
Results:
The study identified 105 men detained within these MSUs for over four years. 83% were found to have a diagnosis of paranoid
schizophrenia and 87% were on antipsychotic medication (30% on Clozapine). The majority of the index offences were series
violence to person (23%). During admission, the majority of these patients need regular support from staff for personal and
physical care, as well as to structure daytime activities (46%).
76% of the patient group were deemed to be at the appropriate secure levels. 25% were thought to require a less secure
environment. The majority of the patients were believed to be suitably placed in a hostel 5 years after the study (47%), whereas
28% were considered to be suitable for low secure units with behavioural modification facilities and 16% in long term low secure
services. It appeared that the main problems preventing progress was the severity of their mental health problems (67%).
Conclusions:
More patients than expected have been at this service for over five years. High rates of co-morbidity and complex needs were
noted. Should they be treated in more specialised units which better meet their needs?
The Point Prevalence of Metabolic Syndrome amongst patients on atypical antipsychotic medications in a secure
Forensic setting in rural East Sussex.
Daniel Howard Baker, 4th Year Medical Student, Brighton and Sussex Medical School, Dr Roderick Ley, Consultant Forensic
Psychiatrist, Sussex Partnership Foundation NHS Trust.
Background: There is increasing concern and recognition about the poor physical health of people with mental disorder. In
particular, the incidence of obesity and diabetes are rising which is reflected in the general population. While there have been
huge improvements in treatment such as in the development of atypical antipsychotic medications, this has come at a cost of
possible worsening physical health. The potential relationship between atypical antipsychotic medication and the Metabolic
Syndrome is well established. It has been reported that patients with severe mental illnesses such as Schizophrenia live 15 years
less than controls without mental illness. There are multiple definitions of Metabolic Syndrome. This in part is because there is
still yet to be an internationally agreed unifying factor. (1) (2) However it is generally agreed that Metabolic Syndrome is a
constellation of hyperinsulinaemia with insulin resistance and subsequent glucose intolerance, hypertension and dyslipidaemia
with hypercholesterolaemia and hypertriglyceridaemia. (3)
Aims: As such, our primary aim was to detect the point prevalence of Metabolic Syndrome amongst a group of psychiatric
patients detained in low and medium secure units who are currently taking atypical antipsychotics versus typical antipsychotics.
Our secondary aim was to identify the level of monitoring of patients on established and newly introduced atypical antipsychotic
regimes. We sought to highlight and make recommendations to Sussex Partnership Trust as to the current levels of monitoring
undertaken towards meeting the National Institute of Clinical Excellence (NICE) guidelines.
Methods: Patients were informed as to the potential of second generation antipsychotics to cause Metabolic Syndrome and
verbal consent was gained. Patients were systematically screened and underwent venepuncture for full blood count, urea and
creatinine, liver function tests, lipid profile including cholesterol and glycosylated haemoglobin (HbA1c) followed by height, weight
and waist circumference measurements. Blood pressure was obtained by calculating the mean from three readings for reasons of
accuracy.
Results: Data collection will conclude imminently. Once all data subsets are available systematic analysis will occur. Results
will be interpreted and patient‘s positive for Metabolic Syndrome identified. We have used the World Health Organisation (WHO)
1999 diagnostic criteria as opposed to the European Group for the study of Insulin Resistance (EGIR) or the National Cholesterol
Education Programme-Third Adult Treatment Panel (NECP-ATP III). (1) This was sufficiently more flexible in accommodating the
definition of obesity, allowing both waist circumference or body mass index. If a diagnosis of Metabolic Syndrome is made
patients will be counselled as to the potential consequences of this diagnosis and offered medical management in accordance with
NICE guidelines.
The “Forensicisation” of Challenging Behaviour:
The perils of people with Learning Disability and severe challenging behaviours becoming entrapped within Secure
Forensic Services
Dr Fergus Douds, Consultant Learning Disability Psychiatrist & Joint Associate Medical Director, The State Hospital, Carstairs,
Scotland
Dr Ashwin Bantwal, Specialty Registrar in Psychiatry of Learning Disability, South East Scotland Higher Training Scheme, The
State Hospital, Carstairs, Scotland
AIM:
To report concern about the referral of individuals with more significant levels of Learning Disability (at least moderate) and very
severe challenging behaviours to the high secure forensic service offered by The State Hospital, Carstairs, Scotland.
This is a patient group who historically were not regarded as ―mentally disordered offenders‖ or ―forensic‖ cases.
METHOD:
Referrals of individuals with more significant levels of Learning Disability presenting with ―severe challenging behaviours‖ to the
State Hospital‘s Forensic Learning Disability Service between August 2005 - July 2010 were reviewed. A total of 5 such referrals
were identified.
Common determinants were identified by reviewing each referral. These determinants were then thematically analysed.
RESULTS:
In terms of demographic details, all of the 5 individuals were male. The 5 individuals had no previous criminal convictions or
previous contact with the criminal justice system (other than police involvement for aggressive outbursts).
The identified determinants were broadly classifiable into psychiatric, environmental and staffing themes.
The common psychiatric determinants were: all 5 individuals suffered from Autistic Spectrum Disorder and functioned within the
moderate LD range. 3 of the individuals were felt to suffer from a co-morbid mental illness.
The common environmental determinants influencing the referral to the State Hospital included: robustness and design of the
referring ward; amount of available internal and external space; noise levels; heterogeneous patient groups and lack of
availability of suitable off ward/day services.
The common staffing determinants included: ―robustness‖ of the local team; staff numbers-both on the ward and on the campus;
staff training issues; competing service demands; low morale and high frustration/stress levels.
4 of the individuals were deemed unsuitable for admission to The State Hospital. One individual was admitted due to the need for
a very robust crisis placement to manage acute risk, with the caveat that a more appropriate placement had to be identified with
a degree of urgency.
All of the individuals are now being managed within specialist autism services, 4 in England and 1 in Scotland.
CONCLUSIONS:
It is a concern that following the hospital closure programme in Scotland, there is a dearth of very robust services for individuals
with severe challenging behaviours and Autism, leading to some individuals being referred, inappropriately in the view of the
authors, to forensic services.
Expensive out of area placements detract from the ability of local/regional Health Boards to develop specialist services. Key UK
Government policies in relation to commissioning of services locally for such individuals will be discussed.
Why we read with our Patients
Dr Celia Bell, Staff Grade Psychiatrist;
Dr Kathryn Naylor, Associate Specialist in Forensic Psychiatry
Dr David Fearnley, Medical Director
Ashworth Hospital, Mersey Care NHS Trust
Submission date 4/10/10
Mersey Care NHS Trust in partnership with ‗The Reader‘ organisation has been promoting Reading Groups within a wide range of
mental health facilities since 2007.
‗Get into reading‘ is a simple invention: group members meet weekly for an hour and two things happen, a facilitator or group
member reads aloud, the reading is broken up by discussion and response to the text Reading aloud can give immediate access
to complex writing that might otherwise be at the least daunting and at worst unavailable to a large section of the population
Reading Groups have been running within the Mental Health and Personality Disorder Units Ashworth High Secure Hospital since
2008. The facilitators are multidisciplinary; doctors, nurses, occupational therapists, senior management, librarians and
psychologists.
Two groups have received national recognition as runners up in the prestigious Orange Penguin Reading Group Award 2009.
The reading groups have been nominated for a Mersey Care ‗positive achievement award‘ in 2010. The groups are seen as part
of the Trust‘s strategy to promote well-being through culture and creativity.
The groups have read an enormous variety of novels, poem and short stories and the enthusiasm is infectious.
A literary festival held in October 2009 at the hospital was hugely successful, combining reading, poetry and music. The highlight
was an event lead by Brian Keenan reading from his latest book. A further event will be held in October 2010.
In our experience Reading Groups offer patients, increased confidence, improved communication skills, enhanced memory,
enjoyment and stimulation in what may be an austere, isolating long stay environment.
It is postulated that reading stimulates the brain‘s language areas, emotional centres, motor areas, and thoughts and may
prevent the onset of dementia.
As clinicians we see benefits for individual patients this view was supported by the SURE assessment (Service User research and
evaluation) in 2008 which recommended expansion of the programme.
Ashworth Hospital is the centre for the practical component of a PhD exploring Bibliotherapy which may provide more objective
evidence as to the benefits.
The Reader Organisation's ethos is that literature is not an aesthetic experience but practical help for being human.
As Samuel Johnson wrote:
‗The only end of writing is to enable the readers better to enjoy life or better to endure it‘
As we move to towards ‗Recovery‘ models of care it is important to recognise the role of holistic approaches that take minimal
resources but may have a big impact on improving patient experience of forensic care.
Fitness to Plead in England and Wales: Is the Law Fit for Purpose?
Dr Penelope Brown, MRCPsych LLM
Preparatory Clinician Scientist Fellow and Honorary ST4 Forensic Psychiatry,
Institute of Psychiatry,
Kings College London
The right to a fair trial is a fundamental human right, however mentally disordered defendants are often incapable of participating
effectively in trials which could result in an unjust verdict. The test for determining fitness to plead has developed since the
nineteenth century however it is viewed as outdated, especially as it does not embrace the principles of the Mental Capacity Act.
The Law Commission have recently reviewed the legislation.
Aims
The aim of this study is to assess whether the legislation relating to fitness to plead is fit for purpose in the twenty-first century
and to evaluate the potential impact of the changes proposed by the Law Commission on practice.
Methods
The history and development of the concept of fitness to plead will be summarised, and limitations in the legislation will be
identified using case law examples. The equivalent laws in the USA and Jersey will be outlined in order to examine how decisional
competence is considered when assessing fitness to plead in other jurisdictions. The role of the principles of the Mental Capacity
Act in determining fitness to plead and the recommendations of the Law Commission will be discussed.
Results
The concept of fitness to plead developed from seventeenth century principles, and the law relating to how this is determined
arose from the case of Pritchard who did not suffer mental illness per se. The criteria for determining fitness to plead include the
abilities
-
to
to
to
to
to
understand the nature of the
understand the meaning and
instruct a solicitor
understand the details of the
follow the proceedings of the
charge
consequences of entering a plea
evidence
trial so as to make a proper defence
Cases such as R v Robertson and R v Diamond have highlighted that significant mental illness does not necessarily lead to
unfitness to plead, and the law does not sit comfortably with modern psychiatric understanding. In the USA and Jersey, decisional
competence is important in determining fitness to plead and reduces the threshold for findings of unfitness. It has been proposed
that this should be incorporated into English law to better serve defendants‘ human rights.
Discussion
Incorporating the principles of the Mental Capacity Act into the test for fitness to plead could lead to significant changes in
practice, such as increasing the number of defendants needing diversion into the healthcare system which would impact
significantly on resources.
LEARNING MORE FROM LESS AT BROADMOOR HOSPITAL: AN AUDIT CYCLE OF INFORMATION DISSEMINATION
Dr Kaysi Thinn 1, Dr Pallavi Bujarbaruah 2, Dr Amalsha Vithanaarachchi 3,
Dr Girija Kottalgi 4, Dr Mrigendra Das 5
1 Specialist Registrar in Forensic Psychiatry
2, 3 Core Trainee in Psychiatry
4 Specialist Registrar in Forensic Psychiatry
5 Clinical Lead & Consultant in Forensic Psychiatry
Background: Winston Churchill once said about reports arising out of inquiries, ―This report, by its very length, defends itself
against the risk of being read.‖ We seem to be good at reporting and investigating incidents. However, part of the cycle that
seems to get the least attention is disseminating the lessons learned so mistakes do not recur. In Broadmoor Hospital we have
been examining how better to ensure that recommendations and learning points from inquiries into serious incidents are passed
down to frontline staff which is important for change in clinical practice. Thus, we audited how one could learn from incidents
within Broadmoor Hospital, and improve dissemination of post-incident recommendations to frontline staff.
Aims: The aims were that staff were to be familiar with the incident policy, be aware of serious incidents in clinical areas, their
corresponding inquiries, recommendations and changes to clinical practice.
Methods: Four wards were identified in which serious incidents had recently occurred (hostage-taking, a rooftop suicide,
attempted suicide serious self-harm). A questionnaire was compiled to assess awareness of the policy, knowledge of the incident
and incident review. Forty staff were randomly interviewed in July and December 2009 to identify changes over time.
Findings & Action Plan: The first audit revealed that most staff were aware of an incident policy. Half were aware of the
categories and review levels. Half were aware of the incident that had occurred but under a quarter had good knowledge of it
and had seen the incident report. Three-quarters were unaware of the recommendations arising from the incident review and
over half were unsure of whether practice had changed.
In order to improve awareness, we produced an A4 page summary of each of the four incidents which identified key learning
points with the headings: What happened? What did the investigation find? What can we learn from the incident? These
summaries were displayed in the wards and re-audited. The findings were positive with dramatic improvement in staff
knowledge. All were aware of the policy. Most were aware of the incident categories and review levels. Almost all knew and
were reasonably knowledgeable of the incidents.
Three-quarters had seen the incident review, were aware of the
recommendations and what practices had changed. Most preferred only a simplified version of the incident review.
Conclusions: We concluded that the best way to get the most vital information to the staff on the ground was to keep things
simple and easily accessible. As a result, all of our incident review reports now have an A4 size summary poster which is well
advertised across Broadmoor Hospital.
Oxleas NHS Foundation Trust court liaison and diversion: a service evaluation
Author
Dr Amit Chatterjee
Specialty Registrar in Forensic Psychiatry, The Bracton Centre
Co-authors
Dr Andrew Iles
Specialty Registrar in Forensic Psychiatry, HMP Brixton
Mrs Suzanne Ahlers
Forensic Community Psychiatric Nurse, The Bracton Centre
Mr Shaun Gallagher
Forensic Community Psychiatric Nurse, The Bracton Centre
Dr Ian Cumming
Consultant Forensic Psychiatrist, HMP Belmarsh
Dr Andrew Forrester
Consultant Forensic Psychiatrist, HMP Brixton
Dr Janet Parrott
Consultant Forensic Psychiatrist, The Bracton Centre
Aims
The Bradley Report identified approximately 100 court liaison and diversion schemes in the UK. The idea for these schemes was
supported by the Home Office in 1990 and further endorsed by the Reed Report in 1992. In his report, Lord Bradley highlighted
the inconsistency between these schemes. Oxleas NHS Foundation Trust has provided a court liaison and diversion service to a
range of magistrates‘ courts since 1992. We recognised a need to define our schemes and the population which they serve to
identify the needs in light of the Bradley Report. We chose Greenwich Magistrates‘ Court as the pilot scheme. By evaluating our
service we aim to improve our care of mentally disordered offenders.
Methods
Greenwich Magistrates‘ Court liaison and diversion scheme is staffed by a multi-disciplinary team of nursing and medical staff.
Social work input is provided by the duty AMHP service.
We collected data prospectively across a two year period (2008-2009). All data were collected anonymously. We captured the
following information: volume of referrals; source of referral; defendant demographics; diagnosis; nature of offence; and
assessment outcome, e.g. diversion to inpatient services, referral to community services, remand with view to further
assessment. The data were analysed using descriptive methodology.
Results
Analysis of the data revealed a total of 247 referrals for the two-year period (2008 and 2009). 79% of all defendants referred to
the service were male. The mean age of those seen was 34.1 years (range =18,68-years). 45% of defendants gave their ethnic
background as white British, whilst 19% stated their ethnicity as black African and 16% as black Caribbean. Common assault
was the most observed offence (22%), followed by theft/handling/receiving (11%). The remaining offences (affray/violent
disorder, criminal damage, possession of an offensive weapon and burglary) each formed less than 10% of the total caseload. In
those whom a diagnosis was made or known, schizophrenia was the most common (36%) followed by mood disorder (18%).
Personality disorder was the primary concern in less than 10% of cases and substance misuse in 11%. In terms of assessment
outcome, 13% of cases seen were diverted to inpatient services and 31% resulted in a referral to local community services.
Conclusions
In today‘s financial climate, budgetary cuts across the criminal justice and health sectors are inevitable and it is likely that
commissioners will seek out services with tangible outcomes. Our data demonstrate the value of court diversion and liaison
services in improving access to psychiatric services, in keeping with the vision set out by Lord Bradley. By evaluating our service
and the needs of its users, we now have a real opportunity to further develop our service in line with the needs of this vulnerable
and marginalised group of people.
Service Evaluation of the Mental Health Awareness Groups held at Ashworth Hospital
Dr Johannes Cronje who was working as an ST3 trainee in Psychiatry.
Aims
The purpose of the Mental Health Awareness group is to provide information regarding mental health difficulties, especially
schizophrenia. This is done through exploring the patient‘s understanding of their diagnosis and sharing their experiences of
having mental health difficulties.
The Stress Vulnerability Model is introduced, enabling patients to recognize the signs and
symptoms of potential relapse.
Different strategies are discussed that will enable patients to manage their symptoms more
effectively. They are also encouraged to access future support earlier.
The aim of the service evaluation was to compare the values of questionnaires completed by the patient‘s pre and post group to
see if there was any improvement in their knowledge about mental health difficulties, self-esteem and attitudes towards drugs.
Methods
Data was used from the Mental Health Awareness groups held at Ashworth Hospital, High secure hospital, gathered over a 3 year
period. This included a total of 31 male patients who completed the group. The following measures were administered for each
patient pre and post group.
1) General Knowledge of Illness Questionnaire (Smith and Birchwood 1987).
2) Culture Free Self Esteem Inventory (James Battle 1992).
3) Drug Attitude Inventory (DAI-3) (Hogan and Awad 1983).
For the service evaluation the mean values were compared, pre and post group.
Results
In summary the patients improved their knowledge and understanding of schizophrenia and mental illness.
a positive impact on their self-esteem and social skills.
The group also had
A description of factors associated with relapse and re-offending in patients discharged from medium secure units
to South London, Lewisham integrated community forensic team
C. Veasey-Connolly
Social Worker Southwark
York Clinic
Guys Hospital
Dr Rachel Daly
Consultant Forensic Psychiatrist
Bracton Centre
Provision of medium secure care and community resources upon discharge are an intensive commitment of services to mentally
disordered offenders yet there are few follow up studies of patients and it remains unclear whether specialist teams are more
effective than generic services.
Aim:
To examine a cohort of patients discharged from medium secure units into the community and to identify whether a specialist
team is more effective in addressing the needs of this group and preventing readmission and re-offending behaviour.
Method:
A cohort of 60 cases discharged into the community were followed up for a period of 2 years using data from electronic recording
and hospital notes.
Results:
Black patients are over-represented in the sample and more likely to be admitted to medium secure units for a first offence. Fifty
percent of patients did not relapse in the 2 year period. A re-offending rate of 18% of which 6.7% were violent appears positive
compared to other discharge follow-up studies at two years did not have all the patients in the community. There appears to have
been a successful outcome with patients who have a previous history of offending.
Conclusion:
Further research is needed with this vulnerable group. The use of this group of a dynamic clinical risk assessment to identify
improvements in clinical care is recommended. Specialist teams have much to offer in engagement skills, intense case
management and realistic risk assessment
A COMPARATIVE STUDY OF HEALTHCARE AND PLACEMENT NEEDS IN OLDER FORENSIC PATIENTS IN A HIGH
SECURE VERSUS MEDIUM/LOW SECURE HOSPITAL SETTING
Dr Kavita Das, Speciality Registrar, Yr 5 (1); Dr Kevin Murray, Consultant and Clinical Director (2); Dr Rick Driscoll, Medical
Director (3); Dr S.Rao Nimmagadda, Consultant Psychiatrist (3).
(1)Farnham Rd Hospital, Surrey and Borders Partnership NHS foundation Trust.
(2) Broadmoor Hospital, West London Mental Health Trust.
(3)Thornford Park Hospital.
Background
An area in health care provision which is under-researched and suffers from lack of adequate facilities in the UK are services for
older patients with history of serious offending.
Available research on older forensic patients in the UK has reported high psychiatric morbidity and physical health problems.
Similar studies on older offenders have concluded that they have more mental and physical health needs. Earlier studies on
similar populations in healthcare settings have methodological shortcomings. Recent studies however conclude that assessment
of healthcare and placement needs in older forensic patients is possible, using standardised needs assessment scales.
Aims, Objectives, Material and Methods
This is an exploratory study with an aim to compare healthcare and placement needs of older forensic patients (over 60 years)
from a High Secure Hospital and medium/low secure hospital. An additional objective was to assist in service planning for the
older forensic patients.
Fifteen patients each, from the High and Medium/low Secure Setting were examined using the Camberwell Assessment of Needs
(Forensic and Elderly version). Placement options were also compared. Socio-demographic and clinical data was collected from
the medical notes.
Results and Conclusions
This study supports the hypotheses that there are significant differences in healthcare and placement needs of the older forensic
patients in High Secure Hospital when compared to Medium/low Secure Hospital.
More than half of older patients in High Secure setting were transferred from prison compared to majority of the patients in
Medium/low Security Hospital were admitted from High Secure Hospital setting. Whilst, the older population was relatively
younger in High Secure, compared to the Medium/Low Secure Hospital they had more unmet needs in the areas of complex
physical health problems, and also reported more psychotic symptoms and treatment as unmet needs than the younger group.
The older group in Medium/Low Secure Hospital had more met needs than the older group in High Secure Hospital. The two
groups were significantly different in placement needs in that half of the older forensic patients in High Secure Hospital were
deemed not requiring continued high secure placements and actually needed other placements. The Older group in the
Medium/Low Secure Hospital, almost all needed low secure placement. In keeping with the significant findings, it is important to
train staff who look after older people in identifying and monitoring needs using standardised measures and the study highlights
the requirement for age specific services.
An evaluation of the effectiveness of Enhanced Thinking Skills in improving the functioning of offenders with
antisocial personality disorder traits
Dr. Tarun Khanna; University of Manchester
Dr. Michael Doyle; University of Manchester
Dr. Adrian Hayes; University of Manchester
Dr. Charlotte Lennox; University of Manchester
Lamiece Hassan; University of Manchester
Professor Jenny Shaw; University of Manchester
Background: Historically there has been significant therapeutic nihilism about effective interventions for patients with antisocial
personality disorder (ASPD) traits. Although, there is emerging evidence that cognitive skills interventions are effective in
reducing recidivism in these patients, there is a scarcity of research studies supporting the use of cognitive skills programmes to
improve functioning.
Aim: To look at the effectiveness of Enhanced Thinking Skills (ETS) in improving antisocial attitudes, anger regulation and social
problem solving skills in offenders with ASPD traits.
Method: The methodology is a non-randomised controlled trial comparing ETS (intervention; 70 participants) vs. treatment as
usual (TAU; 56 participants) in offenders with ASPD traits. Outcome measures were the Antisocial Personality Questionnaire, the
Novaco Anger Scale and the Social Problem Solving Inventory-Short Form.
Results: There were no significant differences between scores on baseline measures, demographic and criminal characteristics in
both groups. However there was a significant effect of allocation in the ETS group on all of the outcome measures, when
compared to TAU, indicating that ETS is likely to be of benefit.
Conclusions: This study shows that cognitive skills programmes based on ETS are likely to be effective in improving functioning in
offenders with traits of ASPD. However due to a number of limitations further research is required.
A simple screening tool for violence risk in schizophrenia
Jay P. Singh, Prof Martin Grann, Prof Paul Lichtenstein, Prof Niklas Långström, and Dr Seena Fazel
Aims: We aimed to develop a simple tool for screening violence risk in individuals diagnosed with schizophrenia.
Method: Information on 13,806 individuals with two or more hospital discharge diagnoses of schizophrenia between 1973 and
2004 was extracted from several high-quality Swedish registers. Logistic regression analyses were used to design a parsimonious
screening device, the predictive validity of which was measured using four outcome statistics. The instrument was calibrated on
6,903 participants and cross-validated using three independent replication samples of 2,301 participants each.
Results: Multivariate regression analyses resulted in a screening tool composed of five items. The instrument had a high
negative predictive value at 94%, meaning that of those patients who were deemed low risk, 94% were not subsequently
convicted of a violent offense after 32 years. The tool had a low positive predictive value, suggesting that it could not be used to
identify those patients who would go on to be convicted of a violent crime. There was no evidence for additive validity when the
items were weighted or three potential additional risk factors for violence were included: low level of education, parental violent
conviction, and parental alcohol abuse.
Conclusions: Focusing on screening out patients not at risk of violence may offer a more promising approach to risk assessment
in schizophrenia than the current practice that aims to identify high risk patients.
Examining the evidence for an authorship effect in forensic risk assessment: A subgroup analysis and
metaregression analysis
Dr Seena Fazel, Jay P. Singh, Prof Martin Grann
Aims: We undertook a systematic review and meta-analysis of nine commonly used risk assessment instruments to investigate
whether there is evidence for an authorship effect in the forensic risk assessment literature
Methods: We collected data from 75 studies based on 29,095 participants in 97 separate samples. For 61 of the samples, new
tabular data was provided directly by authors. We used four outcome statistics to assess rates of predictive validity, and analysed
sources of heterogeneity using subgroup analysis and metaregression. We examined whether the predictive validity of a study
was higher or lower if an author of that tool was also an author on a validation study. In addition, we explored whether there was
an effect when translators of tools were authors of validation studies. Finally, we investigated whether there was disclosure of
financial or non-financial benefits in investigations where a study author was also a tool author.
Results: There was some evidence for an authorship effect, and the paper will present the whether this was more marked in tools
employing structured clinical judgement or actuarial tools. We tested whether the authorship effect was mitigated by markers of
study fidelity, such as specific outcomes or the demographics of the study sample.
Conclusions: Several explanations for the authorship effect are given, its implications for risk assessment research findings
discussed, and methods for minimizing its effects are presented.
Clozapine therapy: Identifying patients at high-risk of developing diabetes mellitus and cardiovascular disease in
low secure and community forensic setting
Authors:
Dr Pujit Gandhi MBBS, MRCPsych
Dr Carlo Thomas MBBS, MRCPsych
Dr Pradeep Pasupuleti MBBS, MRCPsych
Dr Tom White BA, BSc (Hons), MB ChB, FRCPsych, Dip FM, MSc
Objectives:
1. To survey prevalence of cardiovascular risk factors and pro-diabetic states in patients on Clozapine therapy in all psychiatric
patients being cared for in forensic psychiatry setting in NHS Tayside
2.
To determine how the services in NHS Tayside compared to a similar study in NHS Glasgow and Clyde
Method:
1. All patients receiving clozapine therapy whilst inpatients or being followed up by forensic psychiatrists were identified.
2.
Age, sex, systolic blood pressure, smoking status, cholesterol, clozapine dose and frequency of clozapine related blood
monitoring was obtained from patients‘ case notes
3.
Glucose, cholesterol and frequency of clozapine related blood monitoring was obtained using Central Vision (online resource).
4.
Cardiovascular risk was calculated using the British National Formulary cardiovascular risk prediction charts.
5.
Data to be analysed using simple statistics and t-test.
Results:
This study is a work in progress, which we intend to finish by the end of October 2010. Data is being collected from 30 patients
(n=30) on Clozapine out of a total 67 patients presently being cared for in low secure and community forensic psychiatry setting
in NHS Tayside.
Clinical implications
The risk of diabetes mellitus and cardiovascular disease is significantly increased in patients receiving antipsychotic medication,
especially clozapine therapy. The risk is further increased in forensic population whose average duration of stay in the inpatient
setting is much longer than general adult cohort. Identifying the patients at risk of developing diabetes mellitus and
cardiovascular disease while they are in a pro-diabetic states and high cardiovascular disease risk states.
Narcissitic Personality Disorder: To Treat or Not to Treat?
Dr Dineka Gray (CT2), Dr Noir Thomas Consultant Forensic Psychiatrist.
Ashworth Hospital, Mersey Care NHS Trust, Liverpool, L31 1HW.
Aims
Department of Health Guidelines (2003) outlined the need for offenders with a diagnosis of personality disorder to receive
‗appropriate‘ care from forensic services and interventions designed to provide ‗treatment‘ as well as addressing offending
behaviour.1 Currently, in Ashworth Hospital, 11% of patients with personality disorder have a primary diagnosis of narcissistic
personality disorder. The average length of stay for these patients is 22.1 years (compared with a mean length of stay of 6.4
years for all patients with personality disorder). It costs approximately £250,000 per patient, per year within a high secure
setting, which corresponds to an average £5.5 million to ‗treat‘ an individual with narcissistic personality disorder.
Our aim was to consider whether this is clinically and cost effective by looking at the number of patients with narcissistic
personality disorder, their interventions and outcomes. This was particularly driven by the recent review and proposed
developments in service provisions for offenders with a diagnosis of personality disorder2.
Method
We conducted a file review to examine characteristics of patients with narcissistic personality disorder. Data was gathered
relating to demographics, PCL-R scores, length of stay, ‗treatment(s)‘, and other information pertaining to risk.
Results
The number of patients with a predominant personality disorder diagnosis at Ashworth Hospital is (n=72). Of these, 8 (11%)
have a diagnosis of narcissistic personality disorder. Their mean age is 52.2 years (range =34-73 years), and mean length of
stay; 22.1 years (median =26 years, range =2-40 years).
All 8 are classified White British, and fulfil criteria for Hare Psychopathy, as assessed by PCL-R.
None are prescribed psychotropic medication.
5 are detained under section 37/41 of the Mental Health Act 1983, 2 under section 37 (N) and 1 under section 47/49.
In reviewing treatment, 62.5% (n=5) had engaged in therapy focussing upon core personality pathology, (psychodynamic or
cognitive analytical therapy). 25% (n=2) refused all psychological intervention.
75% (n=6) had completed programmes specifically focussing upon offending and risk.
Conclusions
Our results indicate that these patients, often considered ‘impossible’ patients, do engage in therapy. This seems to have little
bearing upon discharge, given the mean length of stay. In the absence of any clear evidence base around treatment, it becomes
difficult to argue that this equates to ‗appropriate medical treatment‘.
Our review suggests that detention within this small group is likely to be protracted, with difficulties around engagement, a lack
of evidence base and clear outcome measures. This has massive financial, moral and ethical implications and indicates further
review.
Ethnic variation in juvenile delinquency
Dr Muhammad Gul –ST5 [SpR] Adolescent Forensic Service, Wells Unit West London Mental Health NHS Trust & Honorary Clinical
Research Fellow Imperial College London.
Ms Nicole Hickey –Imperial College London
Dr Matthew Hodes – Consultant Child & Adolescent Psychiatrist Central North West London NHS Foundation Trust & Senior
Lecturer Imperial College London.
Aim: The aim of this study was to examine ethnic variation in self-reported juvenile delinquency among a general population
sample of adolescents from an inner city urban population, and to explore some of the possible causes of any variation.
Method: N=327 adolescents (54% male) with a mean age of 15.1years (sd1.3) were recruited from a London secondary school
and divided into six ethnicity groups: White British, White Other, Middle East/Arab, Black, Bangladeshi & Pakistani, and Mixed.
Self-report questionnaires addressing family cohesion, family obligation, juvenile delinquency, religious affiliation and worship,
and the Strengths and Difficulties Questionnaire were completed. The juvenile delinquency scale produced a total score and was
further sub-categorized into six groups of delinquency: acquisitive, criminal damage, drug use, public drunkenness, other, and
conduct problems.
Results: The only measure of juvenile delinquency that showed significant ethnic variation was public drunkenness with the
White British group the most likely to have exhibited such behavior and the Bangladeshi & Pakistani and Middle East/Arab groups
the least likely. A similar, but non-significant, trend was also observed for drug use. The White British group also displayed the
greatest versatility in their delinquency i.e., they engaged in a variety of the different delinquent behaviors.
Exploring the possible causes of the ethnic variation it was found that the Bangladeshi & Pakistani and Middle East/Arab groups
were the most likely to come from stable two-parent families, and had the highest scores on the measure of family obligation
reflecting traditional family views. There was no main ethnicity effect for the measure of family cohesion, but the Bangladeshi &
Pakistani and Middle East/Arab groups were the most likely to report a religious affiliation, to regularly attend some form of
worship, & to adhere to religious food observance; the White British group were the least likely.
Conclusions: Significant ethnic variation in self-reported juvenile delinquency was only found for a measure of public
drunkenness, although there were non-significant group differences for other forms of delinquency. Ethnic group differences in
relation to family factors including parental marital stability, attitudes to traditional family life, and religiosity may help to explain
the reduced level of delinquency observed in the Bangladeshi & Pakistani and Middle East/Arab groups through the mechanism of
stronger ties to family and pro-social activities compared to the White British group.
Theory of Mind, Schizophrenia and Violence
Miss Stephanie Harris1,2, Dr Clare Oakley1,2, Dr Avi Reichenberg2, Professor Declan Murphy2, Dr Marco Picchioni1,2
1. King‘s College London, Institute of Psychiatry, St Andrew‘s Academic Centre
2. King‘s College London, Institute of Psychiatry, Department of Forensic and Neurodevelopmental Sciences
Background
There is a well recognised association between schizophrenia and violence. While substance misuse, especially in community
settings, is important, there is relatively little known about other illness specific factors that might drive this link. One factor to
consider is social functioning deficits.
Method
We conducted a literature database search and manual cross referencing, using combinations of the following terms:
schizophrenia, psychosis, antisocial, violence, aggression, forensic, theory of mind, emotion recognition and facial affect. All
identified studies were subsequently included in our review.
Results
It is widely accepted that theory of mind (ToM) deficits are found in individuals with schizophrenia; however few have attempted
to examine this in relation to violence in the disorder. Despite a modest number of studies and methodological inconsistency,
there is increasing evidence that patients with schizophrenia who are violent exhibit greater/better ToM abilities than those with
schizophrenia who are not. When compared with violent individuals with personality disorder, only more complex 2nd order ToM
is compromised in schizophrenia. However, violent patients with schizophrenia exhibit impaired ability to recognise facial
emotions in others, in particular fear and anger, compared to their non violent counterparts. This is consistent with findings in
non psychotic conduct disorder patients who also manifest marked impairments in facial recognition and non psychopathic
antisocial personality disorder subjects.
Conclusion
This data suggest that a proportion of violent schizophrenia patients, possibly those with premorbid conduct disorder or antisocial
personality traits, are likely to be characterised by a combination of good mentalising and poor empathetic inferencing abilities as
well as impaired inferencing of mental states. Although many of these studies are compromised by methodological
inconsistencies, there is increasing evidence that social functioning deficits such as ToM, emotion recognition and empathy may
play a significant role in informing our understanding of violence and aggression in schizophrenia. Future research should
concentrate on more detailed investigation of violence in schizophrenia, examining comorbid disorders in order to identify illness
specific aspects of social functioning focused on schizophrenia itself.
Role of a Community Forensic Learning Disability team
Dr Ragini Heeramun
ST4 Learning disability and Forensic Psychiatry, Severn Deanery
Dr Elizabeth O‘Mahoney
CT3, Severn Deanery
Dr Shamim Dinani
Consultant Psychiatrist in Learning Disabilities, South Bristol CLDT, Bristol
Wendy Goodman
Specialist Nurse, Avon Forensic community Learning Disability team, Bristol
Introduction
There has been a huge emphasis on expansion of wider community services for offenders with learning disability.The Avon
Forensic CLDT provides specialist multidisciplinary service to individuals with learning disability who are or have been in contact
with the Criminal Justice System.
Aim
1.
2.
To identify sources and reasons for referral and look at key interventions provided to those eligible for the service
To consider inappropriate referrals and needs of those not eligible for the service
Methodology
All referrals from July 2009 to June 2010 were considered and the referral letter and assessment details were accessed.
Results
There were 68 referrals to the team during this period comprising of 65 clients. The majority of the referrals were from
Community Learning Disability Teams closely followed by the CJS. More than half were referred for risk assessment and to access
adapted offending programs. A fifth of the referrals were for eligibility assessment. Sexual offences consisted of 37% of the
referrals, violent offences 30%, acquisitive 14% and arson 6%.
Services provided by the team included eligibility, cognitive and forensic risk assessments, adapted offender intervention
including individual work and groups (Good Thinking Skills and Sex Offender Treatment Program), monitoring of clients in out of
area secure placements and liaison with CJS and other services.
15 referrals were not eligible for the service. This included clients with cognitive impairment secondary to other mental health or
neurological problems. Half were from Probation services. The main reason for referral was to access adapted offending
interventions. Needs identified during assessment included housing and tenancy support, intervention around addiction and
offending behavior, mental health, vocational and literacy skills.
Conclusion
The Avon Forensic CLDT is a small specialist team working with adults with learning disabilities who have committed offences or
are at risk of offending. They provide a range of services such as risk assessments and specialist therapeutic work. They play a
key role in multiagency training and liaison with the CJS.
The majority of referrals were from CLDTs and CJS. The main purpose of referrals was for risk management and offender
interventions specific to those with learning disability. A key area of need identified is for adapted offender program in the
community for individuals with borderline learning disability and cognitive impairment secondary to other conditions. We would
recommend further development of offender management interventions for these clients via probation services or jointly by
probation and learning disability services.
Outcome measures used in forensic secure units for people with learning disability in England: a systematic review
Authors: Dr.Avinash Hiremath1
Dr.Regi Alexander2
1. Locum Consultant, Leicestershire Partnership NHS Trust
2. Department of Psychiatry, St John‘s House Hospital, PIC LD Services, Diss, Norfolk IP22 1BA and Honorary Visiting Clinical
Fellow, University of Leicester
Aims: Services are increasingly expected to demonstrate the success of their care pathways in the form of outcome measures.
There is, however, a lack of robust standardised outcome measures applied to patients with learning disability using secure
services. This paper systematically reviews literature for various outcome measures used in Learning Disability Secure Units in
England.
Methods: A detailed literature search was done on relevant databses using MeSH search terms. Studies were selected on the
basis of defined inclusion criteria. Data from the studies was extracted on a pre-designed form. As the variables extracted from
the studies are not homogenous, data has been presented in a narrative review.
Results: There are few studies describing outcome measures for people with learning disability in England. A variety of outcome
measures were used including recidivism, length of stay and discharge placement. Most studies described variables related to
their study population. Very few studies described care pathways and interventions, which made a valid comparison difficult.
Even fewer had a control group for interventions made. Within the comparisons made, it appeared that the length of stay
correlated with the level of security. As in mainstream forensic research, variables used to describe recidivism were the
commonest outcome measure. Therefore, there is not enough clarity on whether the measures are adequately descriptive,
standardised and reliably replicable. The merits and shortcomings of the measures used will be discussed and compared with
findings from the recent HTA systematic review of outcome measures used in forensic mental health research.( Health
Technology Assessment 2010; Vol. 14: No. 18)
Conclusion: In a time when outcome measures may be used to determine quality and guide commissioning, it is important for
services to use valid, reliable and user-friendly outcome measures. The measures must reflect the progress of patients through
the care pathways and must relate to the clinical, humanitarian, rehabilitation and public safety domains. More work is needed in
this area.
Treatment with Triptorelin in mentally disordered sex offenders: Case series from a High Secure Hospital.
Dr David K Ho 1, Dr Gillian Paterson1 , Dr Judith Harrison1, Dr Girija Kottalgi1, Dr Jose Romero-Urcelay1, Dr Mrigendra Das1
1. Broadmoor Hospital, West London Mental Health Trust, UK.
Introduction
The treatment of mentally disordered sex offenders includes a range of therapy from pharmacological agents to psychological
modalities. Treatment is often complicated by poor compliance due to undesirable side effect profiles of pharmacological agents
and patient motivation in psychological therapy. The evidence suggests that the best treatment involves a combination of both
modalities. This high secure hospital provides significant expertise in managing high risk sex offenders using combined modalities
which includes antilibidinal medication. Whilst historically Cyproterone Acetate was the first line treatment, more recently
Triptorelin, a gonadorelin analogue in the form of long acting depot injection is being used.
Method
We report our clinical experience of using Triptorelin in seven patients treated at Broadmoor Hospital. All patients provided
informed consent for this report. Treatment using Triptorelin was monitored through subjective and objective measures.
Subjective measures included interviews with patients to obtain self reported levels of sexual arousal and sexual fantasy profile.
The objective measures included the reported number of sexually related incidents, hormone levels (testosterone, leuteinizing
hormone and follicle stimulating hormone), clinical impression from the treating team and participation in psychological therapy.
Where available, penile plethysmography (PPG) recordings were also reported.
Findings
All patients reported a sustained decrease in sexual arousal, fantasy and masturbation since the commencement of Triptorelin.
Side effects such as hot flushes were tolerable and patients remained compliant. DEXA bone scans were performed to monitor the
development of osteoposoris, a known side effect. None of the patients experienced deterioration in bone density. In the
objective measures reported, all seven patients experienced a lowering of serum testosterone. Testosterone contributes to the
maintenance of sexually aggressive behaviour. There was also a decrease in the number of sexually related incidents reported.
In addition, the treating teams observed a sustained improvement in treatment adherence amongst these patients, including
increased participation in psychological therapy. There was also an improvement in temperament with decreased levels of
aggression. It was noted that being on Triptorelin treatment made Medium Secure Units more likely to accept these patients in
their care-pathway.
Conclusions
The use of Triptorelin in conjunction with psychological treatments should be considered for high risk mentally disordered sex
offenders. This case series demonstrates its benefits including contributing towards progression to lower dependency and
medium secure placements. Along with positive clinical outcomes of behavioural improvement and reduced sexually related
aggressive behaviour, treatment was well tolerated and compliance was good. This is crucial in the rehabilitation of this group of
patients who present a serious risk to society.
Legal Automatism: The only defence “open to an honest man”, or “the last refuge of a scoundrel”?
Dr Muzaffar Husain MBBS MA(Phil) MRCPsych, ST5 in Forensic Psychiatry, John Howard Centre, London, United Kingdom
Dr Asim N. Suddle MBBS MRCPsych, Consultant Forensic Psychiatrist, North London Forensic Service, London,
The legal defence of automatism refers to unconscious, involuntary behaviour. It remains established as a defence to criminal
liability in most jurisdictions derived from English common law. In nearly all such jurisdictions, the legal framework for analysing
automatism has been subsumed under the framework for allowing the insanity defence. In this article, we have defined the
defence of automatism, and briefly surveyed its history in criminal law. We have analysed the most recent judicial interpretations
of the defence, its limits and remit, in all English speaking jurisdictions. We have extracted the main legal guidelines for allowing
the defence in English courts. We have also reviewed and summarised what the courts have come to expect from medical expert
evidence in considering this defence. These legal expectations relate to the challenges inherent in medically assessing defendants
who claim automatism. Furthermore, clinically, automatism may derive from a range of medical causes which might require
medical treatment, not all of which can, or should, be provided in secure psychiatric treatment settings. We have enumerated
what these medical causes might be. These causes require treatment which creates unavoidable conflict in the existing legal
framework between the medical needs of the automatism acquittee and the need for public security. We conclude by proposing
an alternative framework which might resolve this conflict by separating the treatment needs of automatism acquittees from the
management of the risk they present to the public. We propose the increased involvement of the probation service for the latter
task. Such an enhanced partnership between the health service and the criminal justice system might deliver a better standard of
clinical care to such defendants, as well as address the legitimate needs of public safety.
The Dangerous and Severe Personality Disorder Programme - an outside critique
Dr Yasir Kasmi B.Sc. (Hons.) MBChB MMedSc MRCPsych, Consultant Forensic Psychiatrist, the Humber Centre
The Dangerous and Severe Personality Programme (DSPD) attempted to address the previous Government‘s frustration at
psychiatrists‘ unwillingness to deal with untreatable psychopaths, but also reflected tougher sentencing practices throughout the
1990s, high profile homicides, advances in risk assessment and psychological therapies and similar Dutch and Canadian
programmes.
The tone of successive Government papers and Mental Health Bills highlighted the public protection agenda and the erroneous
perception that changing law modifies practice. Almost a decade later, the amended Mental Health Act subtly altered definitions
of treatability and mental disorder, yet the DSPD programme had already started.
Treatment for mental disorder ranges from cure to containment. It is justified by therapeutic necessity and needs to be
convincingly shown. There is no Convention right to treatment derived from detention on the grounds of unsound mind, only that
detention should take place in hospital, so the debate on altering treatability was largely irrelevant.
The original subjective DSPD criteria have been largely replaced by the Psychopathy Check List, though false positives, training
and reliability are significant issues. The DSPD concept has been criticised as a misuse of psychiatry to advance the public
protection agenda by medicalising crime, where society‘s problems are increasingly attributed to mental disorder.
Creating new clinical conditions produces the illusion of knowledge and power and quells anxiety, yet expensive new services are
unlikely to be a panacea and if offending is attributed to the individual patient, we ignore wider socio-cultural causes. Sceptics
were concerned that doctors would be cast as agents of social control, breaking GMC ‗best interests‘ guidelines and even the
Hippocratic Oath.
Early evaluation has revealed that candidates spend time in non-assessment activities, are bored and have limited contact with
their clinical team and receive around an hour of therapy per week, with hospital places costing significantly more than a prison
place.
Other limitations include correct identification of suitable candidates, with only a third meeting the criteria in one sample 1, the
numbers needed to detain in order to prevent one DSPD offence and high prevalence within sentenced prisoners 2, the limitations
of extrapolating risk assessment tools to the individual, a lack of step down services, and how different philosophies exist within
the prison and hospital systems.
It is a costly service and if it fails, future investment is less likely. The system of indeterminate sentences for public protection is
likely to become its successor. A cautionary tale indeed.
References
1.
Tyrer P, Cooper S, Rutter D., et al. The assessment of dangerous and severe personality disorder: lessons from a
randomised controlled trial linked to qualitative analysis. The Journal of Forensic Psychiatry and Psychology 2009; 20:
132-146.
2.
Ullrich S, Yang M, Coid J. Dangerous and severe personality disorder: An investigation of the construct. International
Journal of Law and Psychiatry 2010;33: 84-88
Audit of Medical Clerking-In on In-Patient Admission to St Andrew‟s Healthcare, Birmingham (Independent Sector
Medium and Low Secure Unit)
Dr Sobia Tamim Khan
Rationale
All patients at time of admission to psychiatric in-patient care should have in-depth medical assessment and physical health
screening.
Aims
-To evaluate the quality of medical assessments including history and mental state examination at time of admission.
-To evaluate if physical examinations and investigations were carried out at the point of admission.
Objectives
To obtain and evaluate quantitative data to establish if standards are being met for the above identified aims of the audit.
Standards
Standards are devised from the following national guidelines.
GMC Good Medical Practice Guideline (Good Clinical Care)
NICE Guidelines
Research Evidence
CQC/CQUIN Standards
All patients at time of admission to St Andrew‘s Hospital Healthcare, Birmingham should have the following completed and
adequately documented in their electronic case notes.
-Psychiatric History including relevant psychological and social factors
-Mental State Examination
-Risk Factors
-Physical Examination
-Investigations
Method
This is a retrospective audit of medical assessments at time of admission. Information is collected using a specifically designed
data collection tool. The audit will collect data from first 50 admissions to the hospital since its opening in March 2009. The data
sources would include admissions department and RiO electronic notes.
All collected data will be evaluated and compared to standards by the auditors and results will be generated.
Dissemination of results
Results and recommendations from the audit will be discussed at the Multi-Disciplinary CPD Meeting. They will be passed on to
the Clinical Governance Committee. Further comments and final recommendations will be electronically circulated to all
department heads, ward managers and medical staff.
Re-audit
To re-audit in 6 months time after implementation of recommendations.
Time Line
Audit proposal approved- July 2010
Data collection- October 2010
Submission of initial report to audit meeting-November 2010
Development of Action Plan (following consultation)
Proposed re-audit date-6 months
Submission of final report (audit cycle completed) to audit meeting-2011
Publication-Following completed audit cycle
Audit cycle of admissions into The State Hospital Scotland
Dr Khuram Khan Higher Specialist Trainee in Forensic Psychiatry NHS Lothian
Dr Duncan Alcock Associate Medical Director The State Hospital
An audit was carried out in September 2010 to ascertain whether The State Hospital was complying with the current admission‘s
policy. This audit was part of an audit cycle originally carried out in March 2003.
The current guidelines and procedures for referral and admission to The State hospital 2005 states that ―there should be a
response to all referrals within 2 weeks and patients should not wait longer than 3 months for admission‖.
Aims



Ascertain the timeline between referral, assessment and admission
Determine where patients go on discharge from admission Ward
Identify and describe a range of patient characteristics in relation to the referral and admission
Method

All patients admitted between June 2008 and February 2010 (sample size = 37) were included in the study


An audit tool was developed
Data sources included medical files held in medical records and electronic data base through the medical records
manager
Results


76% of patients in 2010 as opposed to 84% in 2003 were seen within two weeks of referral





40% of patients stayed for 21 weeks or over in 2010 in admission ward as opposed to 7% in 2003

Homicide (30%) was the commonest index offences on admission in 2010 as compared to assault to severe injury and
breach of the peace (28% each) in 2003

Transfer for treatment direction (an order that is made by the Scottish Ministers under Section 136 of the new Act which
allows the transfer of a prisoner to hospital for treatment of a mental disorder) was the commonest section (32%),
patients were admitted under in 2010


The majority of patients in 2010 and 2003 were transferred from admission ward to other wards in State hospital
84% of patients were admitted within 12 weeks of assessment in 2010. An exact comparable figure was not available
from the 2003 audit but 82% of patients were admitted within three weeks as compared to 57% in 2010
35% of patients were admitted from courts in 2010 and 40% in 2003
35% of patients were admitted from prisons in 2010 and 26% in 2003
41% of patients had a primary diagnosis of schizophrenia on admission in 2010 as compared to 79% in 2003
In 2010 assessment of mental state was the commonest reason (14%) for admission. Violence towards others (74%)
and nature of index offence (84%) were the biggest reasons in 2003
The majority of patients in 2010 and 2003 came from Greater Glasgow health board
Conclusion
Results in 2010 could be explained on the basis of the following reasons:

A new law, the Mental Health (Care and Treatment) (Scotland) Act 2003 came into effect

Prolonged assessment process due to increased number of MDT members involved

Patients with more complex needs and serious offences are now being admitted in TSH.
Prevalence of co-morbid mental disorder and substance misuse in a Low Secure Forensic Service: Implications for
treatment and management.
Dr J P King1, Anna Williams2, Lydia Sudbury2, Kieran Lathan2 and H Y Leung2
1 Forensic Psychiatry Unit, Newsam Centre, Seacroft Hospital, Leeds
2 University of Leeds
Aims:
To determine the prevalence of co-morbid mental disorder and substance misuse in patients in the Leeds Low Secure service
because such patients are known to have poorer outcomes including treatment resistance, higher relapse rates, suicide and
recidivism. To identify the types of substances used to inform the likely treatment approaches required.
Method:
A substance use screening tool was developed and each patent‘s key worker was asked to complete it with the patient between
October 2009 and February 2010.
The tool captured information on demographics, diagnosis, index offence and substances
used currently or in the past. Of the 125 patients in the service (45 inpatients and 80 out-patients) 91 were interviewed giving a
response rate of 73%. All inpatients were interviewed.
Results:
65% (n=59) had a diagnosis of schizophrenia.
59% (n=54) had a past or current history of daily or regular use of illicit
substances and /or had a CAGE score of 2 or above. 36% had a current or past history of illicit substance misuse. Alcohol
(33%), Cannabis (25%) and Stimulants (21%) were the most commonly used substances.
Of the patients identifying
problematic substance use, 59% (n=13) had had treatment in the past but 41% (n=9) had not. Of those patients with a recorded
index offence and substance abuse, 48% thought their substance misuse was a factor in their offending. 66% of patients
smoked tobacco and interestingly 25% stated they wished to stop.
This study shows substance misuse is a significant problem in a low secure forensic population.
In line with Department of
Health guidance a strong argument can be made for integrated care (substance misuse interventions delivered by mental health
staff).
Needed interventions are likely to be non pharmacological as well as pharmacological.
This is because the most
commonly used illicit substances were Cannabis and Stimulants for which pharmacological intervention is not available or is of
limited value. The high prevalence of potentially harmful or hazardous alcohol consumption merits the service developing alcohol
education/reduction programmes. Patient friendly smoking cessation initiatives are required.
A survey of preference regarding the terms used to describe people who are resident in a secure mental health
service
Miss Amanda Langé, Mr Geoff Dickens, Dr Marco Picchioni
St Andrew‘s Academic Centre, Kings College London Institute of Psychiatry,
Northampton, NN1 5BW
Aims:
Language can stigmatize or empower people. Various terms are used to refer to users of forensic psychiatric services but, to
date, their preferences remain unexplored.
Methods:
Prospective, cross-sectional survey design with gender stratified random sampling. N=100 people resident in forensic mental
health services at St Andrew‘s Healthcare, UK were interviewed about their preferences. Four terms were presented; participants
selected one preferred term and ranked terms in preference order.
Results:
Participation rate was 45.9%. ―Patient‖ was preferred by the most respondents, but not by a majority (41%, 95% CI 33.9% –
48.1%). ―Client‖, ―Service User‖ and ―Consumer‖ were preferred by 21% (95% CI 15.1% - 26.9%), 16% (95% CI 10.7% 21.3%) and 3% (95% CI 0.5% - 5.5%) respectively. 19% (95% CI 13.3% - 24.7%) preferred another term or expressed no
preference. Distribution deviated significantly from chance (Χ2 = 37.4, df=4, P<0.0001).
―Patient‖ was ranked as one of the top two preferred terms by 67% (60.2% - 73.8%) of participants, ―Service User‖ by 54%
(46.8% - 61.2%), ―Client‖ by 50% (52.7% - 57.2%) and ―Consumer‖ by 12% (7.3% - 16.7%). Distribution was not random (Χ2
= 36.7.4, df=3, P<0.0001).
―Patient‖ was ranked the least preferred term by 11% (95% CI 6.5% - 15.5%) of participants, ―Service User‖ by 18% (95% CI
12.4% - 23.6%), ―Client‖ by 8% (95% CI 4.1% - 11.9%) and ―Consumer‖ by 52% (95% CI 44.8% - 59.2%). Distribution was
not random (Χ2 = 55.4.4, df=3, P<0.0001).
Conclusions:
‗Patient‘ was preferred by the most people, but not a majority. Most respondents ranked it their first or second choice, and it was
disliked by few. Client‘ and ‗service user‘ were acceptable to most and not widely disliked. ‗Consumer‘ was unpopular.
It remains unclear whether health care organisations will be able to accommodate these views in communication and literature.
The effect of prison on the mental health of young offenders
Dr Charlotte Lennox; University of Manchester
Professor Mairead Dolan; Monash University, Melbourne Australia
In recent years there have been improvements in the range of health services provided for young offenders while in prison.
However, prisons are still considered to be harsh environments. Few research studies have looked at the effect of prison
environment on prisoner‘s mental health in general or on those with pre-existing mental health problems. Studies that have,
have shown that mental health symptoms in prison generally improve over time and most prisoners, even those with mental
health problems, do not experience deterioration in their mental health whilst in custody.
Aim: This study aimed to assess how time spent in prison impacts on the mental health of young offenders with and without
mental health needs.
Methods: In this observational cohort study, a consecutive sample of young offenders, taken from the list of new receptions, were
approached for inclusion within three days of reception. 219 male young offenders were recruited, with a mean age of 16.56
years. Baseline assessments, including the Massachusetts Youth Screening Instrument [MAYSI-2]; The Salford Needs
Assessment Schedule for Adolescents [SNASA] and Kiddie Schedule for Affective Disorders and Schizophrenia [K-SADS] were
completed within two weeks of reception. Participants were then reassessed at three and six months post baseline on the same
assessments to document any change in mental ill health and need.
Results: MAYSI-2 baseline scores were used to assign prisoners into two groups, those with high level of mental health
symptoms (High MHS) and those with low level mental health symptoms (Low MHS). Repeated measures ANOVA‘s were used to
assess differences between the two groups over the three time points. During time in custody there were significant reductions
in MAYSI-2 scores and level of need on the SNASA; reductions on both assessments were seen at similar rates for both groups.
Clinical caseness was also assessed. Participants were tracked to see who was considered a case and not a case at each time
point on the SNASA and K-SADS. Of the 200 participants identified as not a case at baseline on the K-SADS, only two developed
mental illnesses severe enough to reach psychiatric diagnosis criteria while in prison.
Conclusions: This study found that there was a significant decline over time of mental health symptoms and very few develop
mental illnesses severe enough to reach psychiatric diagnosis criteria while in prison. Therefore it appears that in general, the
prison environment did not exacerbate psychiatric symptoms.
The significance of protective factors in the assessment of risk
Dr Charlotte Lennox; University of Manchester
Carlene King; University of Manchester
Lamiece Hassan; University of Manchester
Professor Mairead Dolan; Monash University, Melbourne Australia
Background: Identifying and predicting those who are at risk of violence is a key component of clinical practice in child and
adolescent psychiatry. There have been numerous prospective longitudinal birth-cohort studies identifying risk factors associated
with violence. However few studies have explored protective factors in the assessment of risk, despite acknowledgement that
protective factors may play an important role.
Aim: To examine the significance of protective factors in assessment of risk using the Structured Assessment of Violence Risk in
Youth (SAVRY).
Methods: The SAVRY was completed on 135 male adolescents in custody in the UK. Data on previous offending and childhood
psychopathology were collected. Participants were prospectively followed-up at 12 months using data from the Home Office
Police National Computer (HOPNC).
Results: Participants with protective factors were older when first arrested, were less prolific offenders, and had fewer
psychopathological problems. The number of protective factors present was significantly higher for participants who did not
reoffend during the follow-up. The total number of SAVRY protective factors significantly predicted desistance at follow-up and
resilient personality traits was the only significant individual protective factor.
Conclusion: Protective factors might buffer the effects of risk factors and a resilient personality may be crucial. Protective factors
should be an essential part of risk assessment and risk management. Interventions for high-risk adolescents also need to focus
on enhancing these protective factors.
Mail monitoring in a high secure hospital: a very peculiar practice
Dr John Milton, Consultant Forensic Psychiatrist, Rampton Hospital, Nottinghamshire Healthcare NHS Trust
Introduction
High secure hospitals are unusual as the hospital managers (and approved staff, sometimes known as ‗mail monitors‘ or ‗mail
censors‘) have the authority to review and potentially withhold a ‗postal packet‘ if requested by a recipient or if it is deemed to
potentially cause distress or harm to a patient or others. There are some exemptions to this and the overall process is monitored
by the Care Quality Commission (CQC). There has not been a published clinical review of this practice in recent years.
Aim
I undertook a retrospective survey of mail monitoring at Rampton High Security Hospital during 2008 with the aim of determining
the numbers of patients subject to formal monitoring, the patient characteristics and the number of mail items witheld and the
recorded reasons.
Method
This survey was part of a three phase project (later to include an audit of practice against policy guidelines and then a
questionnaire survey of Responsible Clinicians, RCs, for consensus on the threshold for monitoring). The survey involved
identifying, from the mail censors‘ records, all patients subject to formal mail monitoring (at the request of their RC) on a census
date in 2008, those patients whose mail was witheld during 2008, the number of mail items witheld during the year and the
reasons recorded for this. Some broad patient characteristics (such as gender, service location) were noted.
Results
There were 161 items of mail witheld during the study period, 56 items of in-coming mail, 97 items of out-going mail and in 8
cases the record was unclear. In addition 30 items of internal hospital mail were withheld. Three patients were responsible for 70
of the 161 items. Twenty seven percent of patients were subject to formal mail monitoring on the census date, over half of these
for monitoring outgoing mail. Almost half of the women patients were subject to mail monitoring compared to 16% of the male
mental illness patients. Almost 80% of outgoing mail items were withheld because the contents were deemed distressing whereas
there was a range of reasons for witholding incoming mail. There was a three-fold variation in RC practice in some directorates.
Few patients who had mail witheld appealed to the CQC.
Conclusion
Further study will audit the quality of the mail monitoring practice involving RCs and consider the apparent variation in RC
practice. Findings from Ashworth and Broadmoor Hospitals would be interesting for comparison.
ADMISSION TO HIGH SECURE HOSPITAL; CARE PATHWAYS, BED VACANCIES AND DELAYS
Presenting Authors:
Dr Kashmeera Naidoo, CT2 trainee, Ashworth Hospital, Merseycare NHS Trust
Dr Edward Silva, Consultant Forensic Psychiatrist, Ashworth Hospital, Merseycare
NHS Trust
Dr Birgit Völlm, Clinical Associate Professor, Institute of
Long waiting times and backlogs are recognised in most NHS services but it remains unclear whether lack of capacity is the main
cause of delays. Silvester et al. (2004) suggest a sophisticated analysis of organisational processes to better understand the
reasons for queuing, e. g. by applying insights from Erlang‘s queuing theory (Erlang, 1909) to NHS waiting lists.
In the Forensic setting, the Bradley report from DoH (2009) recommend a target of 14 days to transfer a prisoner with acute,
severe mental illness to an appropriate NHS healthcare setting
Aim:




To determine current waiting times for admission to Ashworth Hospital for PD and MI patients and assess these against
current standards
To determine reasons for delays considering patient and organisational factors ( referrer, the patient and Ashworth
Hospital)
To develop recommendations to improve current practice and reduce waiting times
This is a re-audit from 2004-05 (Völlm, Daley and Silva, 2009 )
Method
Referrals from April 2009 to April 2010 to Ashworth Hospital were considered and their progress tracked. Relevant documentation
was studied to obtain further information.
Results
During this period, 61 referrals were received, 52 were considered by the panel for admission and 36 were admitted to Ashworth
Hospital
There are no current national standards regarding admission times to high secure services, however, according to the national
standards set out by the Best Practice Guidance (DoH 2007) for medium secure units, a decision should be made within 6 weeks.
According to local Ashworth Hospital standards, a panel decision should be made within 3 weeks of referral.
In our audit all cases were reviewed by panel within 3 weeks which meets national and local standards. The source of referral,
distance of referral to Ashworth Hospital, diagnosis and eventual outcome did not have a significant effect on waiting times of the
various stages from referral to admission. According to Kaplan Meier analysis, 80% of referrals were admitted within 70 days, this
falls well within suggested national guidelines of 6 months (180 days) by 2005 (NHS plan DoH 2000). Overall, despite more
stringent local standards, absolute performance has improved from 2004-2005
Conclusion
It seems evident that delays in admission to Ashworth hospital are not a result of lack of capacity. Even with admission ward bed
shortages, available beds through the hospital are not being fully utilised. Factors such as time taken to assess the patient
should be given consideration.
An Audit of Psychiatric Referrals at a Secure Children‟s Home.
Mr. William Norton, 4th Year Medical Student, University of Leeds
Dr. Abdullah Kraam, Consultant Child and Adolescent Psychiatrist
There is significant evidence indicating a high incidence of psychiatric morbidity and mental health need for young persons (YPs)
held within secure accommodation. Standards developed from the Youth Justice Board and the Department of Health detail a
need for early and continual assessment of these needs, as well as access to comprehensive Child and Adolescent Mental Health
Services. This audit focused on a mental health clinic held at a Secure Children‘s Home (SCH) and compared its efficacy to these
standards.
A retrospective audit of 24 boys who attended a mental health clinic between October 2009 and May 2010 at a SCH was designed
and implemented. The audit tool was developed to analyse the assessment of a YPs mental health problems prior to arrival at the
home, the referral process to the clinic and the outcome shown in this clinic.
The YPs had an average age of 14 and 10 months, with 78% resident in the Yorkshire and Humber region. The admission
documentation indicated 50% have had previous CAMHS involvement with high levels of self harm and alcohol and cannabis
abuse. Initial assessments indicated 58% had a mental health problem recorded. At the clinic, 6 young persons had a confirmed
diagnosis of ADHD and 7 were defined as having no mental illness. Other impressions included conduct disorder, mood disorder
and behavioural difficulties.
The audit indicated there is an inconsistence approach to the assessment of YPs and supports the introduction of comprehensive
and quantifiable screening tools. There is a significant mental health need at this secure children‘s home which optimally should
be met with a comprehensive specialist multi-disciplinary mental health in-reach team. The high proportion of YPs from one
strategic health authority supports the development of specialised commissioning groups.
Violence in schizophrenia: imaging studies
Dr Clare Oakley1,2, Miss Stephanie Harris1,2, Professor Tom Fahy2, Professor Declan Murphy2, Dr Marco Picchioni1,2
1. King‘s College London, Institute of Psychiatry, St Andrew‘s Academic Centre
2. King‘s College London, Institute of Psychiatry, Department of Forensic and Neurodevelopmental Sciences
Background
There is firm evidence to support an independent association between schizophrenia and violence, though little indicating the
illness-specific factors that drive the association. There are an increasing number of structural and functional imaging studies that
attempt to identify the biological substrate for violent behaviour in schizophrenia.
Method
We conducted a database literature search using combinations of the terms schizophrenia, psychosis, imaging, MRI, antisocial,
aggression and violence. We included all MRI studies identified, nine structural, five functional and one diffusion tensor imaging.
Results
There are considerable methodological inconsistencies in the definitions of violence employed across studies and the inclusion of
patients with co-morbid antisocial personality disorder and substance misuse. Despite this, there is limited but consistent
evidence of reduced grey matter volume in the hippocampus and medial temporal lobe in patients with schizophrenia who are
violent. There is further evidence of probable grey matter volume loss and cortical thinning in the medial frontal lobe. The few
functional studies show reductions in frontal activity in response to working memory and an emotional face paradigm, but
increases in a response inhibition task. There is limited but consistent evidence of impaired structural and functional connectivity
between frontal and medial temporal lobes.
Conclusion
Despite the methodological challenges, there is emerging evidence that violent patients with schizophrenia are characterized by
medial temporal and probable frontal lobe deficits. These findings appear to overlap in part with the neurobiological
underpinnings of violent behaviour in antisocial personality disorder and psychopathy. More detailed investigation of violence in
patients with schizophrenia, with appropriate consideration of the relevant co-morbidities, is required to elucidate which deficits,
if any, are specific to violence in schizophrenia.
A Cruel and Unusual Punishment? -The Psychological Effects of Taser Use on Psychiatrically Vulnerable Adults
Dr Elizabeth O‟Mahony, Speciality Registrar, Severn Deanery
Dr Ragini Heeramun, ST4 Forensic and Learning Disability, Severn Deanery
Dr Mark Bolstridge, Speciality Registrar, Severn Deanery
Introduction
Tasers came into widespread use in the United Kingdom in December 2008. During the authors time working in a Regional
Secure Unit in the South West of England there have been several uses of Taser devices on inpatients. Taser use has been by
the Police and at the discretion of the Police and not the medical teams caring for the individuals involved. This has prompted a
project to examine Taser use in greater depth. Although information is available on the physical effects of Taser use we were
unaware of any work on the impact of Taser use on mental health. We feel that knowledge of the psychological implications is
vital for mental health practitioners encountering its use and working therapeutically with the individuals involved.
Aims and Method
The aim of this project was to review the accessible information on the psychological effects of Taser use. We searched online
databases including Embase, Medline, PsychINFO, CINAHL, and BNI. Search terms included Taser, electromuscular incapacitation
devise, stun gun, conducted electrical weapon, and non lethal weapons. We also searched for any police information in the public
domain and reviewed the material available on the manufacturers‘ website (www.2.taser.com).
Results
There were many papers on the physical effects of Taser use but there was scant information on the psychological implications of
its use. Many papers highlighted the lack of research in this area, and there has been a consistent call for more work exploring
the wider consequences particularly in the psychiatric population. However to date we could not find any substantial work in this
area completed.
Clinical Implication
The impact of Taser use on mental health is unknown and there is a lack of substantive research. In view of this we feel Tasers
should only be used as a last resort when all alternatives have been exhausted. A discussion also needs to occur about the
appropriateness of Taser use on psychiatrically vulnerable adults in the care of Mental Health Services and whether their
continued use without medical approval is acceptable.
Typifying the Historical, Clinical and Risk management factors in low secure forensic population
Authors:
Dr Pradeep Pasupuleti MBBS, MRCPsych
Dr Pujit Gandhi MBBS, MRCPsych
Dr Carlo Thomas MBBS, MRCPsych
Dr Tom White BA, BSc (Hons), MB ChB, FRCPsych, Dip FM, MSc
Objectives:
1.
2.
Method
1.
2.
3.
4.
Report on the total HCR scale and individual Historical, Clinical and Risk management subscales in a low secure forensic
population
Investigate whether there are differences in the C and R subscales between in and out patients and its relationship to
First minister‘s patients
Case note review of all patients in low sec forensic patients n=67
Background information will be obtained using a pro-forma to elicit background offence and diagnostic variables
Study results will be compared with data available from medium and high secure forensic population in Scotland.
Analysis of the data will be done using SPSS
Results
Preliminary data indicate that the historical factors do not vary amongst the three populations, i.e. low, medium and high secure
estates. However, there are some differences in the clinical and risk management items. We await full results by end of October
2010.
Clinical significance
This is one of the first studies on the disaggregated HCR-20 scores. HCR-20 had clinical utility in allowing a systematic
identification of substance misuse and personality factors. It is sensitive to change and could be used as a guide to security level.
How useful are Medical reports for Care Programme Approach (CPA) meetings in a medium secure hospital?
Dr.Prajakta Patil, ST4 (Forensic Psychiatry), South West London & St.George`s Training Scheme, London.
Dr.Rajesh Nadkarni, Consultant Forensic Psychiatrist, St.Nicholas` Hospital, Newcastle.
Background:
NICE(1) recommends that CPA(2) reviews for patients in secondary mental health services should ensure regular physical health
monitoring and documentation. This is especially significant in forensic services where patients have lengthy inpatient admissions.
Hutton Centre is the regional secure unit for the north-east of England, extending from Teesside to Cumbria, serving a population
of 14,74,843.It has 24 low and 55 medium secure forensic beds. Length of inpatient admission ranges from 18 months to 30
years.
Aims:
This service evaluation looked at the existing processes and quality of information recorded in the medical reports for care
coordination meetings. In stage 1, a standard medical CPA proforma (appendix1) was devised following multidisciplinary feedback
and piloted for three months. Stage 2 was performed 3 months after implementing changes to practice to evaluate the
satisfaction with the process.
Methods:
Feedback regarding medical reports was sought from 25 members of the multidisciplinary team involved in CPAs over the
previous 12 months at the Hutton Centre. This consisted of 2 psychologists, 1 social worker, 16 qualified staff nurses, 4
consultants, 3 specialty trainees in psychiatry. This identified wide variability between medical reports with inconsistent
documentation of medication side effects and physical health monitoring on occasions.
Based on this, a proforma for medical reports was devised and piloted in the same wards for three months. Stage 2 was
completed using a semi-structured questionnaire to evaluate satisfaction with the structured proforma and quality of physical
health documentation from the same 25 multidisciplinary staff.
Results:
Stage 1: Revealed variability in documenting medication, physical health monitoring, and duplication of information in reports
across disciplines.
Stage 2: 21 staff stated they were ‗very satisfied‘ and 4 were ‗satisfied‘ with the proforma. They reported that it had improved
communication between professionals. All felt that the proforma was effective in reducing duplication of information and
improving documentation of physical health.
Clinical implications:
Multidisciplinary staff valued a structured and consistent medical CPA proforma which clearly articulated medication and physical
health issues. In our view this is beneficial in reducing duplication of information, improving the quality of medical reports thereby
improving the quality of the service. This is particularly important when the focus over the next few years in the NHS is on
reducing waste and improving efficiency and quality of care within existing or reduced resources (3).
References:
1
2
3
4
NICE guidelines: ‗Core interventions in the treatment and management of
Schizophrenia in adults in primary and secondary care‘, March 2008.
Care Programme Approach: Department of Health(DoH)
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/DH_083650
NHS
Confederation:
―Budget
figures
reiterate
scale
of
NHS
challenge‖,
22June
2010
http://www.nhsconfed.org/Pages/home.aspx.Also,The Times, ―Emergency budget 2010: aggressive cuts will hit growth‖
22June 2010.Efficiency cuts ‗will hit NHS‘ 23 April 2009; bbc.co.uk, ‗How will recession hit the NHS‘ 10March 2009.
Standard proforma for Medical CPA report (appendix 1):
•
Personal details: Name, DOB
•
Admission Details:
–
DOA
–
Diagnosis
–
MHA Status
–
Consultant
–
Current medication
•
Background & Circumstances leading to admission (including index offence)-(for the first CPA
only)
•
Progress since last CPA:
–
Changes in MSE.
–
Medication changes since last CPA.
–
Significant changes in biological functioning.
–
Any other significant events (may include brief overview of OT, leaves, psychology)
•
Physical Health:
–
Side effects
–
General medical complaints/illnesses.
–
Monitoring for psycho tropics & serum drug levels (if any)-last done & due.
–
Drug interactions (if any).
•
Summary:
•
Points for discussion:
•
•
•
•
Attached:
As guidance on physical examination and medical history relevant in Psychiatry:
a) Garden, G.; ‗Physical examination in Psychiatric practice‘,
Advances in Psychiatric Treatment(2005)11:142-149;
b) Phelan, M; Blair G; ‗Medical history-taking in Psychiatry‘,
Advances in Psychiatric Treatment (2008) 14:229-234
Trust guidance on monitoring for high dose anti-psychotics
Note: Currently, the trust guidelines for monitoring of antipsychotics at all doses are the same as
above.
Reduction in repetition with structured proforma:
Effective documentation of physical monitoring/general
Medical illness:
25
30
20
25
20
15
yes
10
no
15
10
yes
no
5
5
possibly
0
0
yes
no possibly
yes
no
Looking Ahead: Community Forensic Services at Reaside Clinic, Birmingham
Dr Ramneesh Puri ST6 Forensic Psychiatry, Birmingham and Solihull NHS Foundation Trust; Dr Jeremy Kenney-Herbert,
Consultant Forensic Psychiatrist, Reaside Clinic, Birmingham; Dr Leela Sivaprasad, Consultant Forensic Psychiatrist, Reaside
Clinic, Birmingham.
Background: Reaside Clinic has provided community follow up services for mentally disordered male offenders, the majority
discharged on restriction orders, for 23 years. During this time adults of working age (AWA) services have undergone major
innovation and reorganisation and Reaside Clinic has developed strong but informal links with these services. In the current
health economic climate, with necessary increased focus on quality and efficiency, there is an effort to strengthen these links and
develop robust criteria and protocols for all stages of mentally disordered offenders‘ care pathways. This is in keeping with the
West Midlands Strategic Commissioning Group Secure Services Strategy 2010-2015.
Aim: We did a cross sectional survey of all patients being followed up in the community by Reaside Clinic to identify the number
of patients, their index offences, their legal statuses and any change in PCT over the years.
Results:
Numbers: Reaside Clinic had 109 community patients. 2 died of natural causes in weeks preceding this survey.
Legal Status: 64% (n=68) were on MOJ restriction orders (including Section 41 and CP(I)A but excluding Section 49 restrictions)
either currently or in the past. 13% (n=14) were on Supervised Community Treatment (CTOs) and 24% (n=26) were informal
(excluding 10 who were absolutely discharged from MOJ restrictions).
Index offences: 30% (n=32) had index offences of ABH, GBH or wounding. 25% (n=27) had murder, manslaughter or attempted
murder. 17 % ( n=19) had Sexual offences (including 13 with Rapes). Four had no index offence.
PCT; 38% (n=41) had a different responsible PCT from that at the time of admission to Reaside Clinic.
Discussion: The above data has already provoked interesting discussions around the question of whose responsibility these
complex patients should be and what specifications should the reorganised community services have? These issues are being
discussed by a joint working group including Forensic, AWA, Social care, service users and carers and other relevant stakeholders
with the aim of further developing the pathway for mentally disordered offenders to optimise care and safety.
Assessment of risk of violence; a clinical audit of community addiction service.
Dr Sobia Rafi –CT3 Trainee
Dr Mosun Fapohunda-Specialty Registrar
Dr Vijaya Murali-Consultant Psychiatrist
Azaadi Community Drug Team, Birmingham and Solihull Mental Health Foundation Trust.
Aims:
Illicit substance use is known to be associated with a variety of risks. This include risk to self, others and potential for
aggression/violence. Carrying out a thorough assessment of risk of violence in this client group, is not only an essential
component of good psychiatric practice, but also necessary in order to manage the risks appropriately.
The Royal College of Psychiatrists gives guidance about what is required in these assessments.
We aimed to establish current practice of assessment of risk of violence within our team, and make recommendations for
improvement.
Methods:
A retrospective review of case notes of 31 new referrals to our team between January-September 2010 was carried out to gather
the required information.
Results:
The recording of a risk assessment statement (i.e. low, medium and high) was documented in only 3/31 notes, though risk
management plan was seen in 30/31 notes. Forensic history was documented in 29/31 of the assessments. Psychiatric co
morbidity was seen in 25% of the sample.
Collateral information from other professionals was only available for 4 clients. 48% had spent time in prison for offences like
theft, assault and violence (25%).
Also noted was the neglect of attention to clinical enquiry regarding recent and ongoing violent thoughts. Aggressive ideation
regarding damage to property and interpersonal violence was also not recorded in any of the notes.
Conclusion:
Our results show that risk management plan was documented in almost all the notes, but details of the identified risks that
informed this management plans were scanty. The assessments could be made more comprehensive by adding a few salient
questions about the current violent thoughts and ideation which would be helpful in making the risk assessment more thorough.
We hope to train all staff working in our team on the assessment of risk of violence and carry out a future re-audit.
Audit cycle of Antidepressant prescribing at The State Hospital Scotland:
Dr Ayesha Raja, Speciality doctor
Dr Ian Dewar, Consultant Forensic psychiatrist
Sheila Smith, Clinical Effectiveness.
Introduction:
The State Hospital is a high secure hospital providing care and treatment to people who need to be detained under conditions of
special security. It is situated in Scotland and covers Scotland and Northern Ireland population, currently housing 140 patients.
An audit was carried out in 2009 looking into the prescribing of antidepressants at The State Hospital.
This was part of the audit cycle originally carried out in 2006.
Aim:
1.
2.
Compliance with prescribing standards - Lothian Joint formulary
Looking at the documented reasons for prescribing antidepressants
Standards

No more than one antidepressant should be prescribed to a patient at any one time.

Dose should not exceed BNF maximum dose.

SSRI‘s should be used as first line therapy in accordance with the NICE guidelines.
Method:
Sample included all the patients (16) on antidepressant therapy in October 2009.
The audit tool was developed looking into prescribed antidepressants, dosages, frequency, total daily dose, commencing date,
reason for prescribing Antidepressant and other medications used.
Results were compared with the audit in 2006.
Results and Recommendations
1. Percentage of patients prescribed antidepressants in 2009 had fallen in comparison to 2006 (11% as opposed to
14%). This is in accordance with national target set by Scottish government.
2. No patient was prescribed more than one antidepressant in 2009 or 2006 audit
3. No patients exceeded the recommended British National Formulary guidelines dosages in 2009 or 2006 audit
4. SSRI‘s was the most commonly prescribed antidepressant medication in both the audits (81% in 2009 and 76% in
2006)
5. Citalopram was the commonest SSRI in both 2009 and 2006 (45% and 31%)
6. Reasons for prescribing Antidepressants:
Explicit reasons were documented for 67% of patients in 2009. This was an improvement since the audit in 2006
when 52% of patients had explicit diagnosis given.
73% of patients were prescribed antidepressant for depression and 18% for anxiety in 2009.
72% of patients were prescribed antidepressant for depression and 24% for anxiety in 2006.
Within the hospital it is policy to review patient‘s mental state and medication at a regular interval. Implementation
of this as a part of treatment plan will ensure a more structured format for documenting explicit reasons.
An Inclusive Community Service for Mentally Disordered Offenders – Scoping Exercise
Author:
Dr. Lakshmanan Ramachandran, MRCPsych, StR6, Forensic Psychiatry, Mersey Care NHS Trust, Liverpool
Co-authors:
Dr. Claire Brabbins, MRCPsych, Consultant Psychiatrist,
Mersey Care NHS Trust, Liverpool
Introduction:
Treatment needs of mentally disordered offenders within secure care are complex. Secure NHS inpatient beds
are few. Private Sector Secure inpatient beds are often used, even if out of area (Out of Area Treatments /
‗OATs‘). The above services remain variously cost effective but, in general, are accepted as expensive. With
focus now on reducing costs and maximising savings there is scope for setting up innovative cost effective
services within the NHS for this subgroup of service users.
Aims:
Explore possibility of setting up an inclusive / integrated community mental health service for mentally
disordered male and female adult service users, currently within secure inpatient units, in Northwest England.
Method:
Focus group was held to clarify the structure, priorities, functions and financial implications of the intended
service. Electronic patient records serve as sampling frame as well as database for this exercise. All service
users from the NHS trust‘s catchment area, currently placed in ‗out-of-area‘ low secure units (OATs) were
identified. Case summary of each service user identified was examined. Data was extracted to identify
treatment needs [medication; psychology; nursing; social support; special needs (deafness; acquired brain
injury etc); public protection / security], legal status, risk profile and Offending behaviour.
Results
Of the 40 (N) service users (31M; 9F) 22 were admitted under secure units for mentally ill; 10 under specialist
personality disorder units; and 8 under specialist learning disability units. 2 service users are deaf; 5 have
acquired brain Injury (ABI) and none have a diagnosis of Autistic Spectrum Disorders. A number of them have
significant physical health problems ranging from disabling cardio respiratory illness to metabolic syndromes.
Work is now underway to elucidate the offending profile and risk profile of the individual patients and the
exercise will be completed by November 2010.
Conclusions:
There are likely to be significant financial and practical challenges in setting up this community service.
Physical health needs, nursing needs; risk management needs in general as well as in specific offences (for
e.g. sexual offending) appear significant in this respect, hitherto. A seamless interface between this inclusive
community service, other local specialised community mental health services and criminal justice system is
required but may be harder to achieve.
Nature and Prevalence of Various Organic Mental Disorders in a Medium and Low Secure Neurorehabilitation Service
Dr Vishwanath Byregowda Ramakrishna, MBBS MRCPsych LLM, Consultant Forensic Psychiatrist, St. Mary‘s Hospital, Warrington
Introduction
Some patients with Organic Mental Disorders require compulsory care and treatment in specialist secure/forensic settings due to
their risk history and specific neurorehabilitation needs. Such patients are usually diverted from courts or admitted from other
psychiatric or Brain Injury rehabilitation services. There is a paucity of research regarding the type of patients who require such
specialist secure services which are mostly available in the independent sector. Such information is important for effective
service provision within existing NHS/Independent Sector facilities or development of new specialist services.
Aim
To determine the nature and prevalence of various Organic Mental Disorders within a Secure Neurorehabilitation Hospital.
Method
This was a point prevalence study including all inpatients in the Medium and Low Secure Neurorehabilitation Units of an
Independent Secure Hospital located in the Northwest of England. Demographic details, MHA section, and ICD-10 primary
diagnoses of all patients was collated from medical records and analysed.
Results
A total of 39 patients were detained in the Medium (41%) and Low Secure (59%) Units under various sections of the Mental
Health Act 1983 (amended 2007) (s3: 51 %, s37/41:18%, s37:18%; s 48/49 and s38:5%) and Section 5(2) of the Criminal
Procedure (Insanity) Act 1964 (amended 2004) (8%). The age range of patients was 23 to 64 years (Mean: 40.7 yrs).
The primary diagnoses of patients included Organic Personality Disorder (44%); Organic Personality Disorder with Organic
Delusional Disorder (13%); Organic Personality Disorder with Organic Amnesic Disorder (5%);Organic Personality Disorder with
co-morbid mental illness (Paranoid Schizophrenia/Bipolar Affective Disorder 8%); Dementia in Huntington‘s Disease
(5%);Frontotemporal Dementia and Paranoid Schizophrenia (2.5%); Paranoid Schizophrenia with Frontal Lobe impairment (8%);
Other specified or unspecified mental disorder due to brain damage and dysfunction and to physical disease (Hydrocephalus,
epileptic psychosis 8%); and Alcohol Induced Dementia (2.5%). Two patients were recently admitted and were still undergoing
assessment and a formal ICD10 diagnosis was yet to be made.
Conclusion
The most prevalent disorder was Organic Personality Disorder (70%) either present on its own (44%) or with other co-morbid
conditions (26%). This included individuals with no previous psychiatric history (62%) or those with pre-existing mental illnesses
(8%). Challenging/offending behaviours in patients with neurological/neurodegenerative diseases, dementia (including alcohol
induced), and chronic mental illness with executive dysfunction had necessitated admission to this secure specialist service in the
rest (30%) of the cases.
Service User Satisfaction in a Regional Forensic Medium and Low Secure Service
Dr Steve Ramplin and Dr Phillip Brown
Introduction
There is evidence that satisfaction with care delivery leads to an improvement in health status. Levels of user involvement and
satisfaction are central to Government policy in health service provision and user satisfaction is recognized as a valuable measure
in evaluating the performance of NHS services. The few studies completed on user satisfaction in secure forensic settings contain
limited qualitative data. However, results of previous studies suggest patients detained in a medium secure unit are able to report
on satisfaction with their care.
Aims
This project aimed to audit user satisfaction across a regional forensic medium and low secure service. A questionnaire was
designed to anonymously capture demographic information and patients' views about their psychiatrist, meetings, care and
treatment.
Methods
After ethical approval was received a presentation about the project was given to ward managers and service user
representatives for dissemination to the patient population. The questionnaire was then piloted with service user representatives.
In March 2010 it was distributed to 93 inpatients with the assistance of the Patient Advice and Liaison Service, who facilitated
completion of surveys upon request. Completed surveys were posted into collection boxes on each ward.
Results
Forty-nine patients (51.6%) returned completed surveys. 85.4% were male, 89.6% were white and 43.9% were detained on a
civil section. Age appeared normally distributed. A primary psychotic diagnosis was reported by 57.1% and a primary diagnosis of
either personality or mood disorder by 14.3%. Current mental health was rated 'Very Good' or 'Excellent' by 56.3%. Patients
were generally satisfied with their psychiatrist, although 59.6% felt they had insufficient time to discuss their care, a concern
echoed in qualitative comments. 78.7% of patients were usually invited to their CPA meetings, with most feeling able to
participate. Qualitative data highlighted concerns about too many attendees and patient involvement appearing tokenistic. All
respondents took medication. A majority (55.8%) understood its role but only 28.9% felt side effects had been adequately
explained. Psychological interventions and physical health care were generally well received. 60% were not interested in
preparing an Advance Statement. 41.9% felt their Mental Health Act rights had been completely explained. The results are
comparable with equivalent data in the Mental Health Acute Inpatient Service Users Survey 2009, although performance was
poorer in the 'enough time to discuss condition and treatment' domain and better in terms of explaining the role of medication
and physical health management.
A Case Report of Body Integrity Identity Disorder in a forensic inpatient
Primary Author: James B. Reynolds, M.D., F.A.P.A., Medical Director and Chief Forensic Psychiatrist, Northwest Missouri
Psychiatric Rehabilitation Center, Missouri Department of Mental Health, St. Joseph, Missouri, U.S.A.
Second Author: Roxanne C. Keynejad, B.A. (Hons), 3rd year GPEP MBBS Student, King‘s College London, U.K.
Body Integrity Identity Disorder, or Amputee Identity Disorder, is a rare syndrome characterised by the persistent and intense
desire to have an apparently functional body part amputated, usually an arm or leg. Similar ideations are seen in Body
Dysmorphic Disorder, Somatophrenia, and Apotemnophilia. This case report discusses a 41 year old right-handed Caucasian
male, Mr G, who is detained in a low secure forensic facility in Northwest Missouri under Not Guilty by Reason of Mental Illness
status for a sexual offence. The patient recently disclosed the desire to have his functional right arm amputated. Mr G suffers
from osteogenesis imperfecta resulting in a moderately bowed and slightly shortened, but fully functional, right forearm. The arm
is not dramatically misshapen, and appears essentially normal unless closely inspected. After a four year admission
unremarkable for right arm complaints, the patient confided to the hospital chaplain that he had wished his arm to be amputated
since a traumatic event eight years ago when his house burned down. He now refrains from using his right arm in order to
―practise‖ for being an amputee. Mr G‘s primary diagnosis is Schizophrenia, Paranoid Type, but his ideations about his arm are
unrelated to his psychotic illness, which is apparently well controlled on Risperidone and Sertraline, with no evident delusions
about his arm. Mr G‘s chief complaint is that he feels ―less of a man‖ with his right arm and believes his self-esteem will be
greatly enhanced by being ―made whole‖ when it is cut off. The authors are unaware of any documented cases of this syndrome
in a forensic patient and the research base is sparse. The authors explore the existing literature, compare this case with the
diagnostic criteria proposed for this disorder and discuss the ethics of treatment for this condition by elective amputation of a
functional and generally healthy limb.
Parental Representations in a Forensic Personality-Disordered Population
Dr Lucinda Richards
CT1 Psychiatry Trainee, South London and Maudsley NHS Trust.
Dr Gill McGauley
(Supervisor) Consultant and Reader in Forensic Psychotherapy, Broadmoor Hospital; West London Mental Health
Trust and St George‟s University of London
Introduction
Research shows that adverse parenting affects child development and contributes to the development of psychopathology such as
personality disorder in adulthood. In particular, perceptions of early parental attachment figures, in part, determine the nature of
adult interpersonal relationships. Forensic, personality-disordered patients have frequently experienced early adverse parenting
and their personality disorder manifests itself, most often, in disordered adult relationships with staff and other patients which
can interfere with their treatment and progress. The parental attachment representations of this group are under-investigated.
Aims
This research investigated parental representations in a sample of personality-disordered forensic patients in Broadmoor High
Secure Hospital to determine whether, and if so how, these representations differed from those in other populations.
Methodology
Analysis of self-report questionnaire data and comparative literature review. Data from the Parental Bonding Instrument (PBI)
was analysed from 66 patients with a research diagnosis of personality-disorder. Means and standard deviations for each of the 2
PBI dimensions (parental care and control) were extracted from representative studies from the literature review. Differences in
means, between studies and Broadmoor patients, were calculated using independent t-tests.
Results
The literature review yielded 110 papers. Compared to both the non-clinical and the clinical groups, the Broadmoor patients
scored significantly lower for both maternal and paternal care indicating that the Broadmoor patients perceived their relationship
with both parents as lacking in care compared to other psychiatric patient groups.
Interestingly, the forensic patients perceived their parental care as significantly poorer than their non-forensic personalitydisordered counterparts (p ≤ 0.05). The study group scored significantly higher with respect to both maternal and paternal
control compared to all normal groups (p ≤ 0.001) but not compared to the other clinical groups.
Conclusion
Compared to non-clinical individuals the Broadmoor patients perceived their parenting as falling into the most adverse domain;
lacking in care and highly controlling. Despite similar psychopathology, perceived experience of care appeared to discriminate
between the forensic, personality-disordered patients and non-forensic patients.
This further supports the clinical observation that forensic, personality-disordered patients have experienced early adverse
parenting and suggest that it is perceived experiences of poor care that may be particularly relevant in forensic personalitydisordered patients, rendering the child susceptible to later developmental psychopathology. Knowledge of the parental
representations of forensic personality-disordered patients may provide professionals with a handle on understanding how these
can contribute to their adult interpersonal interactions during treatment and ultimately inform therapeutic interventions.
AUDIT OF THE TRANSFER OF PRISONERS FROM HMP ISLE OF WIGHT TO MENTAL HEALTH HOSPITALS
Dr Tamsin Peachey, Forensic Psychiatry trainee (ST5) & Dr Luke Birmingham, Consultant Forensic Psychiatrist, Ravenswood
House, Fareham, Hampshire
Objectives:
1. Review time taken to transfer mentally disordered prisoners to hospital.
2. Identify where and why delays are occuring locally.
3. Recommend changes to practice to reduce delays.
Background:
A prison is not equipped to deal with acutely unwell people and the Mental Health Act (2007) does not apply in prison. It is,
therefore, vital that mentally disordered prisoners be transferred, without delay, to a mental health hospital with an appropriate
level of security. In a recent report (Prison Reform Trust), a large number of prison boards reported significant delays in this
process. The Bradley Report, an independent review, suggests the process should be complete within 14 days.
Methodology:
A database has been compiled by the Community Mental Health Team (CMHT) at HMP Isle of Wight on all prisoners referred for
transfer to a mental health hospital. As data did not follow a normal distribution, median values provide a better description of
the data. Medians with lower and upper interquartile ranges are given (within which 75% of the sample and 25% of the sample
fall, respectively).
Results:
Between November 2005 and October 2009, 121 prisoners were referred for transfer to hospital due to their mental state. Of
these, 77% were accepted for admission. The median transfer time from referral to admission (n = 70) was 140.5 days (IQR +/62.5 - 200). The median time between 1) initial request by prison/CHMT to assessment by prison psychiatrist (n = 96) was 5
days (IQR +/- 1 - 7); 2) referral to assessment by hospital (n = 81) was 49 days (IQR +/- 21 - 79); 3) assessment to acceptance
by hospital (n= 50) was 13.5 days (IQR +/- 3.5 - 32) and 4) acceptance to admission (n = 47) was 24 days (IQR +/- 10 - 57).
The number of prisoners meeting Bradley‘s recommendation of 14 days is one.
Conclusions:
Preliminary analysis of the database has confirmed that we are falling short, by a large margin, of the 14 day transfer time
suggested by Bradley. Unacceptable delays occur at each stage, the largest being time between referral and assessment. We
need to assess what accounts for such delays and what factors (eg, diagnosis, level of security, catchment area) have a bearing
on transfer times. This will inform practice to address and reduce delay.
Evaluation of court diversion scheme at NHS Forth Valley by Forensic Community Mental Health Team
Roy MBBS MRCPsych;Dr. Rhona Morrison MBChB ,MRCPsych.
Dr.Peeyush
Aim: To evaluate the activity of court diversion scheme of NHS Forth Valley performed by Forensic Community Mental Health
Team.
Method: A retrospective analysis of data collated over period of last three years, looking at characteristics of referrals, diagnosis
and their outcomes. The Forensic Community Mental Health Team covers a general population of approximately 300,000 and
provides court liaison service to three Sheriff Court in that region.
Results: A total of 139 referrals were received from 2007 to 2009. Significant higher proportion were male within the age range
of 20 -29 and were homeless. The single most common offence was of public order i.e. Breach of Peace followed by violent
assaults. Over the three years there is gradual increase in referrals. Alcohol was frequently associated with the index offence
accounting for 29.6 %
(2009), 42.2 %( 2008) and 52.5 %( 2007). Assessment of Fitness to plead was the most common
reason for referring the defendants, which accounted for 55.5% (2009), 71.1 %( 2008) and 52.5 %
(2007).The second
commonest reason was for ―bizarre behaviour‖. Most common Diagnosis at the time of assessments alcohol related behavioural
and mental disorders followed by Personality Disorder. Following majority of assessments there was ―No Recommendation‖ made,
50 %( 2009), 46 %( 2008) and 40 %( 2007).Formal admission was recommended on average of 12% of all referrals each year.
In terms of final outcome significant numbers were granted bail, 37 %( 2009), 51.1 %( 2008) and 40 %( 2007).
Recent report Diversion: a better way for criminal justice and mental health suggested that although diversion can reduce the risk
of unnecessary imprisonment and reoffending, only 20% of people with mental health problem can avail these schemes. The
above study reinforces the evidence that diversion works especially well for people who have committed relatively minor offences
from serving short prison sentences. There is a provision to consider improvement in these services in future to prevent mentally
ill offenders getting entrapped within the criminal justice system.
ELDERLY HOMICIDES- CALL FOR A NATIONAL DATABASE IN UNITED KINGDOM: A Literature Review and Case series
Dr.Sabarigirivasan Muthukrishnan MRCPsych; Prof.Graeme Yorston MRCPsych; Dr.Suchitra Sabarigirivasan MRCPsych
AIM
The aim of the research is to understand the psychiatric and psychosocial aspects of elderly homicide offenders with a view to
develop risk assessment tools, risk prediction tools and risk management strategies.
METHODS
A: Review of medical literature on Elderly Homicides in UK and other countries.
B: Review of medical literature and relevant home office published literature to understand the various national databases in UK,
where the homicides are recorded and also to understand how murders committed by elderly and elderly mentally unwell
offenders are recorded
C: A case series which studied the psychiatric and psychosocial aspects of 12 elderly psychiatric patients who committed murder
and have been either admitted to a low secure elderly men and women unit in UK or referred for opinion.
RESULTS
In UK, the research is not very promising in relation to Elderly Homicides. There are many studies from US but due to various
factors the results of those studies are not applicable in UK .There is less promising recording of the details of Elderly Homicides
in UK national databases which record homicides. The current existing databases in UK do not separately delineate the
characteristics of elderly homicide offenders which can be a challenge to interested researchers.
The case series of 12 patients in the low secure facility for elderly men and women, showed that there is room for improvement
in the way elderly homicide data on offenders and victims are collected and shared among different agencies. The literature
review and case series showed that Dementia, Depression and Psychosis were the common diagnosis implicated in Elderly
Homicides.
We couldn‘t come up with the risk assessment tools, risk prediction tools and risk management strategies with the literature
review and study of the various databases. We were able to identify the most relevant psychosocial characteristics of elderly
homicide offenders and the common psychiatric diagnosis implicated. We are able to recommend the way forward for research in
this patient group to come up with the risk assessment/prediction tools and management strategies.
RECOMMENDATION
The research on elderly homicide can be done effectively if there is a separate national database which records the details of
Elderly Homicide offenders and victims. Alternatively, the current national databases on homicides can record effectively the
details of elderly homicides. This will help the health care agencies, social care agencies, criminal justice service and other
voluntary agencies involved with elderly homicide offenders and their families.
An Exploration of Physical Health in a Forensic Rehabilitation Setting
Mr Rishi Sen, Mr Jaison Patel (medical students) and Dr Elizabeth van Horn (Consultant in Forensic Rehabilitation)
Introduction
Numerous studies have shown that the physical health of forensic mental health patients is generally poor. The long stay patient
group has even higher rates of morbidity and mortality. There are many possible factors contributing to this, such as poor
awareness of physical health issues within the care team. This is an area that has received greater attention over recent years.
Our aim was to examine the physical health care of one patient group.
Method
An audit was carried out based on the ―Physical Healthcare Guidelines‖ provided by the East London and the City Mental Health
Foundation Trust‖. This was introduced earlier this year. This recommended recording the blood pressure, pulse, weight, waist
circumference, lipids, U&E, fasting blood sugar, HBA1c, FBC, LFT, TFT,ECG , prolactin and therapeutic drug monitoring within a
set interval period for each. We assessed how closely these guidelines were followed e.g. ECG done annually. We hoped that this
would be a good indicator of whether the patient's medical needs were being met. Clinical notes were audited and the results fed
back to the care team. Six weeks later a repeat audit was carried out. We then ran a focus group for the staff to identify areas
of improvement.
Results
The initial audit showed that less than 30% of the criteria were met within the set time period. The most recorded were ECG,
blood pressure, pulse and weight, and the worst recorded where HBA1c, liver-function-tests, thyroid-function-tests and prolactin.
The repeat audit showed a higher level of met need. Staff had used a variety of innovative and creative methods to enlist
patients in their physical health care.
Conclusion
We concluded that a large proportion of the physical health criteria were not met, despite the best intentions of the team. We
also noted that some investigations had been carried out but had not been recorded in the clinical notes and felt that this
reflected problems in shared care with local GPs. The focus group identified a number of factors which increased the quality of
care provided. This included close Consultant supervision of Junior Doctors. In addition staff had been able to use their
considerable expertise to motivate patients to take responsibility for their health.
Use of Granulocyte Colony Stimulating Factor in Clozapine induced Neutropenia
Dr Jake Harvey, Speciality Registrar in Forensic Psychiatry
Dr Al Aditya Khan, Speciality Registrar in Forensic Psychiatry
Dr Samrat Sengupta, Consultant Forensic Psychiatrist, Broadmoor Hospital
Background
Neutropenia and Agranulocytosis are known side effects of Clozapine treatment. Several studies have reported the use of
Granulocyte Colony Stimulating Factors (G-CSF) in haematological, oncological and transplant disorders. However, reports on the
use of G-CSF in cases of Clozapine induced neutropenia are somewhat limited.
Aim
This is a case series report on three patients, all with a history of Clozapine-associated neutropenia, managed with G-CSF and
continued treatment with Clozapine with a significant reduction of violence towards others.
Method
The cases in this study are male patients with a diagnosis of paranoid schizophrenia detained in a maximum security psychiatric
hospital with a history of poor response to first-line antipsychotic medications. Furthermore all had previously responded well to
Clozapine thereby significantly reducing their risk of harm to others. However, all experienced neutropenic reactions leading to
discontinuation of Clozapine. Two patients also had a history of idiopathic cyclical neutropenia, in the absence of Clozapine. They
were given doses of G-CSF prior to Clozapine re-challenge, due to low baseline neutrophil counts. Clozapine was subsequently
restarted following return of normal Neutrophil count, with enhanced blood monitoring. The third patient with a normal baseline
neutrophil level received G-CSF following a low neutrophil count.
Results
All three patients have experienced reduction in symptoms with a significant reduction of violence towards others, and
improvements in quality of life. Furthermore none has experienced adverse drug reactions related to G-CSF.
Conclusion
This study demonstrates the clinical utility of an alternative approach to discontinuation of treatment following Clozapineassociated neutropenia in patients with treatment resistance intractable Schizophrenia, whose risk of violence to others had been
related to their psychotic symptoms. While this approach is not recommended as first-line, it highlights a potential avenue for
patients associated with significant risk profiles.
Testing an innovative way of information dissemination in a secure hospital: Awareness Roadshows
Dr Amit Sharda CT2, Dr Potoula Sykioti CT3, Dr Kunal Choudhary CT2, Ruth Neilson (Occupational Therapist), Dr Mrigendra Das
Consultant Forensic Psychiatrist, Broadmoor Hospital, Crowthorne, Berkshire, UK
Background
Broadmoor Hospital has been subject to two recent major inquiries. The CQC inquiry was following concerns the Trust were not
learning from serious incidents. The PB-RL inquiry followed the inpatient homicide of a patient by another patient at Broadmoor
Hospital. These inquiries revealed a number of findings leading to a series of recommendations that needed implementing. The
hospital underwent a programme of changes aiming to improve standards of patient care. To carry out these changes effectively
it was felt to be crucial that ward staff were actually aware of these the post-inquiry recommendations.
Aims
To find out whether staff knowledge and awareness surrounding these inquiries was sufficient.
If staff knowledge was deficient, to implement an effective way to improve knowledge and awareness.
Method
A questionnaire was designed to assess staff awareness, and knowledge of findings, recommendations, and changes implemented
in the hospital following these inquiries. Staff opinion was also sought surrounding confidence of role, their perception of change
occurring, and morale, as well as space for comments. We interviewed 45 ward based staff.
Staff knowledge was found to be deficient in most areas. Qualitative analysis also fed back that there was not enough face to face
contact surrounding these, and that too much information was contained in the reports.
In light of these findings, an intervention was planned. Feedback showed it had to be succinct and relevant to the ward staff.
Time and cost were also important factors. Information from the inquiries was summarised and grouped under relevant headings.
This information was then put into an ―awareness roadshow‖ presentation lasting 10 minutes and consisting of eight slides with
handout.
Three junior doctors then went to the same three wards and ran the roadshows during nursing handovers and MDT meetings. The
same questionnaire was then repeated to 45 staff who attended the roadshows to complete the audit cycle.
Results
Staff knowledge and awareness increased appreciably following the roadshows. Awareness of the CQC and PBRL inquiries jumped
from 44% and 82% respectively to 93% and 100%. At least partial knowledge of recommendations increased from 40% to 98%
and partial knowledge of changes increased from 43% to 95%.
Conclusions
A simplified, succinct, face to face, time effective intervention (Awareness Roadshows) was successful in information
dissemination. Every staff member interviewed felt the roadshows were useful and that they should be used to disseminate
similar pieces of information in the future. This method can be adapted in other parts of the NHS and particularly by High
Reliability Organisations where failures of standards are unacceptable.
Smoking restrictions in secure psychiatric units – The medium secure experience
Dr Suraj K Shenoy, MB BS, MD, MRCPsych; ST5 in Forensic Psychiatry;
Humber Centre for Forensic Psychiatry, Willerby, Hull, HU10 6ED
[email protected]
Dr John H Kent MB BCh, FRCPsych
Consultant Forensic Psychiatrist
Newton Lodge, Yorkshire Centre for Forensic Psychiatry, Ouchthorpe lane, Wakefield, WF1 3SP
Mr John Wiggins
Clinical Security Manager
Newton Lodge, Yorkshire Centre for Forensic Psychiatry, Ouchthorpe lane, Wakefield, WF1 3SP
Aim
The restrictions on smoking in health services within England and Wales, both for NHS and independent providers, including
secure psychiatric units has been in force since July 2008. The introduction of these restrictions led to considerable debate within
our medium secure hospital on the practical issues of implementing a smoking ban. We surveyed all the NHS and Independent
sector medium secure units in England & Wales to find out their experiences of the introduction of these restrictions.
Method
We attempted to contact every medium secure unit within NHS and the independent sector in England and Wales to ascertain the
person best placed to respond to our survey. The survey was set up on a specialist survey website. A request to participate in the
survey along with a link to the user friendly survey was sent by email to the relevant person identified.
Results
39 medium secure units responded to the survey. The analysis of the responses shows that there has been considerable variation
in the extent to which the smoking restrictions have been implemented. The results highlight some major adverse consequences
caused by the practical implications of introducing restrictions on smoking as opposed to a total ban on smoking.
Conclusions
Implementing a smoking ban requires considerable planning and has resource implications to manage potential serious adverse
consequences.
CLINICAL PROFILE OF FOREIGN NATIONAL AND BRITISH PRISONERS AT HM PRISON BRIXTON: A COMPARATIVE
STUDY
Main author
Dr Jagmohan Singh
Specialty Doctor in Forensic Psychiatry
HM Prison Brixton, London
Co-authors
Dr Andrew Iles
Specialty Registrar in Forensic Psychiatry
HM Prison Brixton, London
Miss Manuela Jarrett
Researcher
Institute of Psychiatry, King's College London
Dr Piyal Sen
Consultant Forensic Psychiatrist and Associate Medical Director
St Andrews Healthcare, Visiting Research Fellow, Institute of Psychiatry, UK
Dr Andrew Forrester
Consultant and Honorary Senior Lecturer in Forensic Psychiatry
HM Prison Brixton and Institute of Psychiatry, King‘s College London
Background
The prevalence of mental disorder amongst the prison population is high: previous surveys have reported a two-fold to four-fold
excess of psychotic illness and major depression and about a ten-fold excess of personality disorder compared to the general
population. Despite evidence that immigration origin is a risk factor for psychological morbidity and suicide in prisons, the clinical
profile of the foreign national population has not been studied properly.
Aims
To describe and compare the clinical profile of foreign national and local prisoners referred to mental health team at a busy
London remand (pre-trial) prison.
Methods
We used a mixed prospective and retrospective data collection method. We surveyed each consecutive referral to the prison inreach team using a template designed to capture the following data: demographics, index offence(s), status (remand, sentenced
etc), forensic history, psychiatric history, medical history, co morbid substance misuse, location in prison, source and reason for
referral and outcome of the referral.
We gathered the data during the initial assessment interview and from collateral sources including: the referrer, the in-reach
referrals‘ register, the prison medical records, and the prison custody office. We corrected inconsistencies between self-reports
and collateral information.
Results
109 referrals were received over a 4-month period. 20 of these were foreign nationals. We found that foreign nationals were
under represented in the in-reach referral pool in comparison to their proportion within the normal prison population (18
(n=20/109) vs 40 (HMP Brixton, 2006 statistics)). A greater proportion of the foreign national group had an affective disorder
(n=4/20) and a disorder due to substance misuse (n=4/20) compared to the British group (n=11/89; n=13/89 respectively).
Proportionately, fewer of the foreign national group were known to community services (n=7/20 vs n=61/89).
Conclusions and implications
Research on foreign national prisoners is still in its infancy worldwide. This group has significant under-recognised treatment
needs. The study findings reflect this problem. Barriers to treatment include: cultural attitudes to mental illness, access to
language interpretation services, lack of cultural awareness within prisons, immigration status and possible institutionalized
discrimination. We believe that the provision of adequate interpreting services, cultural awareness and mental health education
programmes for prison staff would provide the opportunity for earlier detection of mental illness and identification of associated
treatment needs. Follow-up studies should also include interviews with foreign national prisoners for a qualitative assessment of
their own experience.
A service evaluation of the provision of care by ethnicity at Ashworth Hospital, a high-secure hospital
Dr Victoria Sullivan (CT3), Dr Edward Silva (Consultant Forensic Psychiatrist) Dr Inti Qurashi (Consultant Forensic Psychiatrist)
Background
Ashworth Hospital is one of the three High Secure Hospitals serving England and Wales with approximately 210 inpatients. In
recent decades deaths within forensic settings have attracted suggestions of institutional racism, and have been a particular
concern within the High Secure Hospitals.
An audit carried out in 2006 at Ashworth Hospital found that patients from a non-white background perceived that their cultural
needs were inadequately assessed and met. The Race Relations Act requires of NHS Trusts that they allow all patients the same
access to services and information, regardless of ethnicity.
Aims
The service evaluation aimed to assess if there were any differences in the each of the following aspects of care for different
ethnic groups;

Admissions and referrals

Length of hospital stay

Discharge and trial-leave rate

Number of incidents

Use of seclusion

Access to psychological therapies
Method
Any person who was an in-patient at Ashworth Hospital at any point between 1st April 2008 and 31st March 2009 was included.
Ethnicity was taken as the patient‘s self-ascribed ethnicity and was coded according to national ethnicity codes. Further
information was taken from PACIS; the electronic notes system, DATIX; the incident-reporting system, the seclusion monitoring
group and the psychology department.
Results were analysed using PASW version 18.
Results
228 patients were included in this evaluation, 24.6% of whom were from an ethnic minority background. 17% referrals and 22%
admissions to the hospital were for patients from a non-white background. Patients from a black background had the longest
average length of stay at 8.15 years, with the average for all patients being 7.39 years (p=0.674). 13.5% white patients
compared to 5.6% non-white patients were discharged from the hospital, but the results were not statistically significant Leave
rates were comparable at 7.6% and 7.4% respectively. For all types of incident, white patients were more commonly the
perpetrator, but seclusion rates were highest in non-white patients (37% vs. 26.3%) (p=0.8). Patients from an Asian background
had less access to some psychological therapies (p=0.55).
Discussion
Ashworth hospital has a higher proportion of ethnic-minority background patients than the national average. There is no
significant evidence that patients from ethnic-minority backgrounds have different access to services at Ashworth, however there
are some differences in length of stay, rate of discharge, rates of seclusion and access to psychological services. Further study
with higher numbers of patients is recommended.
Prescribing of antipsychotic medication in a regional secure unit-Results of a repeated audit cycle
Dr Mujahid Ali Syed, Speciality Trainee, Dr Thomas Elliott, Associate Specialist,
Dr Paul Chesterman, Consultant Forensic Psychiatry, North Wales Forensic Services
Aim
This annual Audit, now in its third year was repeated in Ty Llywelyn Medium Secure Unit to examine the extent to which
prescribing of these drugs reflects current evidence of clinical practice, to encourage the development of best practice guidelines
and to stimulate a discussion of the relevance and desirability of agreed clinical protocols.
Method
A point prevalence of prescribing practices within Ty Llywelyn was performed on 14th of August 2009. This was the third repeat
collection of prescribing data, collecting the same data as previous audits. Data was collected for all prescriptions of psychotropic
drugs. Medication prescribed on as required basis was not taken into account.
Results
Out of 22 patients only 14 were receiving antipsychotic medication (64%) on a regular basis. Between them they were prescribed
a total of 17 regular antipsychotic drug prescriptions. Many of the residents were prescribed only one antipsychotic drug, 11 of 14
(78.6%).Three patients were receiving more than one antipsychotic drug and all three of them were on combination of oral and
depot antipsychotics. No patient was receiving regular treatment with more than two different preparations. The majority of
patients, 11 of 14 (78.6%), were receiving depot preparation and none of them was receiving a dose below the recommended
lower limits thus reflecting maintenance regimes. A minority, 3 of 14 (22%) were on oral preparation alone and none of them
were on a lower dose than the recommended minimum. Olanzapine was the most frequently prescribed among atypicals and also
the only oral medication being used in conjunction with a depot.
Conclusion
Atypical antipsychotics were prescribed to 7 of 14 patients (50%), this is almost similar to previous audit in 2006 where 10 of 18
patients (55%) were prescribed atypicals. Only 2 of 14 patients (compared to one in 2006) were on Clozapine. We have generally
adhered to BNF recommendation in both audits with regards to prescribing more than one antipsychotic at the same time.
Following Nice guidelines only 2 of 14 (14%) patients were prescribed a combination of atypical and typical antipsychotics. No
patient was receiving treatment above BNF or Maudsley limits, this is an improvement from previous audit. In accordance with
The Royal College of Psychiatrists Consensus Statement no patient had ―mega doses‖ of antipsychotics in either of the audits.
Analysis of Incidents in low secure forensic services pre and post reconfiguration
Dr Anand Vemula, Staff Grade Psychiatrist, 5 Boroughs Partnership NHS Foundation Trust, Dr Ros Tavernor, Consultant Forensic
Psychiatrist, 5 Boroughs Partnership NHS Foundation Trust, Ian Stirton-Cook, Forensic Operational Business Manager, 5 Boroughs
Partnership NHS Foundation Trust.
Aims:
Previous research has highlighted ward environment change as a destabilising factor in patients. It was observed that when
Chesterton Unit, a low secure rehabilitation unit at Hollins Park Hospital was reconfigured as an all female unit that there was an
increase in incidents in both the male patients who moved to a new 10 bedded male unit and the female patients who remained
on the Chesterton unit. The reasons for this are not clear. The aims were to try to identify what factors were associated with the
increase in incidents and what interventions may have prevented or reduced this phenomenon. An awareness of the nature and
distribution of incidents may improve proactive targeted interventions to minimise risk in future service reconfiguration.
Method:
The total number of incidents per month was recorded as part of incident reporting for the 6 months before and 6 months after
the reconfiguration. To try to establish why the observed increase occurred the incidents were analysed and any generalisations
or lessons to be learned for service reconfiguration in the future were identified.
Results:
Incidents were subdivided into:
1 behavioural disturbance includes - sexual disinhibition, intimidation, threats
2 breach of security – absconding, smoking in non-designated areas, fire risks
3 Physical health problems
4 other recorded events including e.g. medication errors
In the 6 months prior to the move the baseline incidents were collected on Chesterton (mixed Unit) and in the 6 months after the
number of incidents increased almost fourfold on the Chesterton and trebled on Marlowe unit when the average per patient was
measured. The number of incidents for the 10 male patents and the original 10 female patients can be directly compared pre and
post reconfiguration. Reasons for the increase and service development and risk management issues will be discussed in the
poster presentation.
The extent of personality services in the East Midlands region of England
Dr Amanda Tetley
a
*, Miss Mary Jinks
a
Nick Huband
a
b
, Professor Kevin Howells
a
b
a
, Professor Conor Duggan
c
a
, Professor Mary McMurran
, Dr Steve Geelan , Dr John Milton* , & Dr Adarsh Kaul
a
, Dr
d
Institute of Mental Health, University of Nottingham, Nottinghamshire, UK
Arnold Lodge, Nottinghamshire Healthcare NHS Trust, Nottinghamshire, UK
c
Rampton Hospital, Nottinghamshire Healthcare NHS Trust, Nottinghamshire, UK
d
Wells Road Centre, Nottinghamshire Healthcare NHS Trust, Nottinghamshire, UK
*denotes presenting author
Personality disorder is a disabling and complex condition that affects a person‘s thoughts, feelings, perceptions, and relationships
with others, often causing subjective distress. It has been estimated that 4.4% of the general population (Coid et al., 2006) and
65% of prisoners (Fazel & Danesh, 2002) attract this diagnosis. In 2003, the National Institute for Mental Health in England
(NIMHE) highlighted the absence of service provision for people with personality disorder in both forensic and non-forensic
services and subsequently emphasised the need for greater service provision for this client group. Although some dedicated
forensic and non-forensic personality disorder services have since been piloted by the Department of Health since 2003, it unclear
what other dedicated services for people with personality disorder have been developed. Accordingly, this poster reports on
investigation of the level of dedicated forensic and non-forensic service provision for this client group in one region of England,
namely Nottinghamshire, Lincolnshire, and Derbyshire. Searches were conducted to identify all dedicated NHS and independent
services, and senior clinicians within each identified service were asked to complete a survey about their facility. Our findings
revealed that dedicated service capacity within this region appears to be severely inadequate to meet the needs of offenders and
non-offenders with personality disorder. They also revealed disparity in the level of community service provision across the three
counties, with the provision in some counties more limited than in others. Based on these findings, it is concluded that there is
insufficient dedicated service provision in this region for those with personality disorder and that variation in service provision
across the region is likely to produce geographical inequalities in the receipt of treatment. It is likely that these same
observations are true throughout England.
Characteristics of patients in three low secure forensic wards in the country
Dr Pratish Thakkar, Consultant Forensic Psychiatrist (Tees Esk and Wear Valley NHS Foundation Trust)
Dr Ipsita Ray Speciality Doctor (Tees Esk and Wear Valley NHS Foundation Trust)
Dr Ramneesh Puri, ST-6 Forensic Psychiatry, (Birmingham and Solihull Mental Health NHS Foundation Trust)
Dr Deepak Tokas Speciality Doctor-(East London NHS Foundation Trust)
Introduction
Low Secure Psychiatric Care, along with regional and high secure services has been a developing speciality in the UK over the
past 25 years However, little is known of the provision, roles and patients cared for by such units. In the literature we found
survey looking at provision in the non forensic low secure ward and PICU.
The forensic Low Secure ward is a developing area with quite diverse populations. In this study we have analysed data from three
low secure forensic wards across the country (North, Midlands and London).
Methods
The study is a cross sectional study designed to collect data on the same day across the 3 units. We designed a questionnaire
looking at the following areas: age, diagnosis, ethnicity, MHA section, source of admission, Index offence (If any), medication (if
of high dose antipsychotics) forensic history and history of substance misuse. The data was anonymised as the data was
collected by the three co-authors and analysed by the presenting author.
Results
We are planning to compare the findings from the three units and look if there are any statistical differences. We still await the
final data from one of the units and this and other exact figures will be presented at the conference. The following are the major
findings:






The most common diagnosis of the patient was Schizophrenia or schizotypal illness.
Majority of the patients were detained under the Part 3(Forensic Section) of the mental health act and were under restriction
from the ministry of justice.
Having a forensic history was common in the patients and violence against a person was the most common offence.
Majority of the patients had a need to address their substance misuse problems but were not high dose antipsychotic
treatment.
The source of admission was roughly equal from Medium secure unit, other low secure. Some were admitted directly from
prison and others were PICU
Due to the location of the three units the ethnicity varied greatly between them.
Conclusions
We feel that low secure forensic wards are a diverse population. More research in needed to gain knowledge about the patients
being treated in them. A quality network similar to that for Medium secure unit needs to be developed for low secure forensic
wards.
]
Impact of Smoking Cessation on Rates of Adverse Incidents
Author:
Dr. Deepu Thomas, MRCPsych, StR 5, Forensic Psychiatry
Co-authors:
Dr. Lakshmanan Ramachandran, MRCPsych, StR 6, Forensic Psychiatry
Dr. Jennie McCarthy, MRCPsych, Consultant Forensic Psychiatrist
(All employed by Mersey Care NHS Trust, Liverpool)
Introduction:
Smoking affects pharmacokinetics of psychotropic medications. This is significant in treating mentally ill
offenders who often present with severe and/or treatment resistant psychosis, and frequently with poor
compliance with treatment. Smoking cessation can potentially reduce the therapeutic dose needed; improve
response to treatment, and consequently, compliance as well as general wellbeing.
Aims:
Identify impact of smoking cessation, implemented on 03 July 2008, on adverse incidents for adult male and
female offenders in an NHS medium secure unit in Northwest of England.
Objectives:
Identification of changes in frequency of different categories of adverse incidents before and after
implementation.
Methods
The unit‘s medical records for the period July 2007 to July 2009 served as the sampling frame while providing
the demographic data. The sample (N=43) included all those who were an inpatient in the unit on 3 July 2008.
DATIX, the electronic adverse incident database, provided the adverse incident data. To explore clustering of
incidents surrounding implementation, rates of different categories of incident were examined (i) 6 months
before and 6 months after the implementation and (ii) 1 year before and 1 year after the implementation.
Results
Of the 43 patients 39 smoked cigarettes. Following cessation of smoking, number of incidents under the
category of ‗Aggressive Behaviour‘ decreased from 132 to 52; number of ‗Self Harm‘ incidents decreased from
43 to 10; ‗Alcohol Use‘ on the ward decreased from seven to three incidents; ‗Fire alarm‘ related incidents
increased from two to seven and ‗Sexual Assault‘ incidents decreased from seven to two.
Eight incidents directly related to smoking and six incidents of trading in contraband following the smoking
cessation implementation were recorded in the year following the smoking cessation whereas none were
recorded before.
Limitation:
Inconsistencies amongst professionals reporting incidents (for e.g. similar incidents categorised differently etc)
affected the accuracy of the adverse incident data.
Conclusions:
In our survey there were clearly issues related to accuracy of incident reporting process. There were, however,
some notable changes in frequencies of incidents that involved harm to others. These changes will need
further systematic exploration before these are attributed to smoking cessation.
Antipsychotic Use in a Cohort of Patients Admitted to Ashworth Hospital between June 2004 and May 2005
Dr P F Xavier (Specialty Registrar in Forensic Psychiatry), Dr E Silva (Consultant Forensic Psychiatrist) Ashworth Hospital,
Parkbourn, Maghull, Liverpool L31 1HW
email:[email protected]
INTRODUCTION:
Literature on the type of antipsychotic medications that are prescribed in High Secure Forensic Psychiatry Hospitals is limited. In
this service evaluation, we set out to identify antipsychotics that were being prescribed for patients in Ashworth High Secure
Forensic Psychiatric Hospital in Liverpool, who had a diagnosis of either Schizophrenia or Schizoaffective disorder. The evaluation
was part of an attempt to understand prescribing practices in this cohort of patients.
AIM:
To study practices related to the prescription of anti-psychotic medications and to evaluate duration of treatment as a quasi
outcome measure of effectiveness in patients with Schizophrenia or Schizoaffective disorder admitted to Ashworth Hospital
between June 2004 and May 2005.
METHODOLOGY:
A list of patients admitted in the given period was obtained. Patients with a diagnosis of either Schizophrenia or Schizoaffective
disorder were included in the study. Information on basic demographic details, diagnoses and antipsychotic medications
prescribed was obtained from PACIS (electronic hospital records) and this was collated for the six year period from June 2004 till
May 2010 and analysed. The antipsychotic medications were categorised based on nature i.e. typical or atypical, and route of
administration i.e. oral or intramuscular depot.
FINDINGS:
A total of 33 patients were admitted in that year. Of these patients only 27 fulfilled the study criteria based on diagnosis. 13 of
these patients were transferred out in the next 6 years and this included 2 deaths. The average duration of stay in Ashworth
Hospital for this cohort of patients was 236 weeks (4.5 years).
Clozapine was the antipsychotic that was prescribed for the longest duration followed by Olanzapine.
At the time of transfer, no patient was on a typical oral antipsychotic. An equal number of patients were on Olanzapine or
Clozapine. One patient was on Flupentixol depot and two patients were not on any antipsychotic medications.
SUMMARY:
The findings of this service evaluation give an insight into the prescribing practices of antipsychotic medications in Asworth High
Secure Forensic Psychiatric hospital.
Clozapine and Olanzapine were unsurprisingly found to be the two longest prescribed antipsychotics in this cohort of patients and
the antipsychotics that patients were most likely to be prescribed when they are transferred out of Ashworth Hospital.
Volumetric structural abnormalities of the Amygdala and Hippocampus in men with violent antisocial personality
disorder and schizophrenia
Dr Elizabeth Zachariah a, Prof Pamela Taylor b, Prof Veena Kumari C
a
Department of Forensic & Neurodevelopmental Science, Institute of Psychiatry, Kings College London, London, UK
b
c
Department of Psychological Medicine, School of Medicine, Cardiff University, Cardiff, UK
Department of Psychology,
Institute of Psychiatry, King’s College London, London, UK
Introduction
Antisocial personality disorder and schizophrenia are both associated with an increased risk of violence. Previous studies have
reported prefrontal-temporo-limbic abnormalities in association with violence in mental illness. Studies exploring the temporolimbic structures have found structural abnormalities of the amygdala and hippocampus in personality disorder, psychopathy and
schizophrenia.
Aim
This study compared whole brain, amygdala and hippocampus volumes using structural magnetic resonance imaging in four
groups of men.
Methods
Group 1 had men with a diagnosis of personality disorder (N=30), Group 2 had men with schizophrenia/delusional disorder
(N=32), Group 3 had patients with a dual diagnosis of personality disorder and schizophrenia (30) and Group 4 consisted of men
without a history of violence or mental illness (n=21). All subjects within the patient group had committed homicide/near-fatal
assault. T1-weighted scans were acquired using a 1-Tesla MRI scanner. Raters blind to the subject status measured whole brain,
amygdala and hippocampus volumes. Socio-demographic data and details of clinical history were recorded for all participants.
Clinical assessments consisted of National Adult Reading Test, Wechsler Adult Intelligence Scale, Comprehensive Psychiatric
Rating Scale, and the Positive and Negative Syndrome Scale. Assessment of violence was measured using ratings developed
from the criminal profile of Gunn and Robertson.
Differences in whole brain volume were analyzed using one-way analysis of variance (ANOVA) with groups as a between-subjects
factor. Differences in amygdala and hippocampus volumes were analysed using two-way 2 x 4 analysis of co-variance (ANOVA)
with hemisphere (left and right) as a within-subjects factor, groups as a between-subjects factor and whole brain volume as a
covariate. One-way analysis of variance (ANOVA) was used to examine differences in age and clinical variables. Chi-square
analyses were used to examine group differences in categorical variables for ethnicity, socio-economic status and level of
education.
Results
The findings showed that the different groups have differential as well as shared abnormalities in relation to violence. Compared
to normal controls both the personality disorder group and the psychotic group had reduced amygdalar volumes. There was only
a trend for smaller amygdala in the dual diagnosis group relative to the control group. The psychotic group had reduced
hippocampal volumes in addition to amygdalar abnormality. The dual diagnosis group had reduced whole brain volume in
comparison to normal controls and the personality disorder group but did not differ from the psychotic group. The results suggest
that volumetric reductions of the whole brain, amygdala and hippocampus are related to specific diagnostic group.
Case report & literature review: Essential considerations from a patient presenting to forensic service with a Muslim
cultural understanding of „Black Magic & Supernatural Possession.‟ and paranoid delusions.
Dr Nuruz Zaman, Dr Rekha Soni & Dr Owen Samuel
Robin Pinto Unit, South Essex Partnership Trust, Calnwood Road, Luton, Bedfordshire LU4 0LU
Aim: To review current literature on cultural understanding of black magic and supernatural possession, in evaluating a Muslim
patient reporting black magic as causative agent in index offence of possession with intent to harm. Particular focus is given to
insight development.
Method: Patient case report is presented and a PubMED search was conducted to identify research of significance on this topic.
Result: Development of insight in such patients remains particularly intractable. Current research is scarce and in the clinical
setting, the determination of religious delusions can be challenging at times. This continues to have implications for psychiatric
practice in increasingly multi cultural societies.
EXHIBITION/SUPPORT
The College would like to thank the following companies for their valuable support of this
meeting.
Alpha Hospitals
Bethlem Archive Art Exhibit
Cygnet Health Care
John Wiley & Sons
Partnerships in Care
South London & Maudsley NHS Foundation Trust
St Andrew‟s Healthcare
St Magnus Hospital
The presence of an exhibitor is not an endorsement of its products and exhibitors do not
influence the content of the meeting.
CONFERENCE ORGANISERS
Royal College Faculty of Forensic Psychiatry Conference Executive Organisers
Professor Tom Fahy- Co-Programme Organiser
Professor Jenny Shaw - Co-Programme Organiser
Dr Josanne Holloway – Faculty Finance Officer
Royal College Faculty Conference Office Organisers:
Michelle Braithwaite – Conference Manager
Dela Goka-Conference Administrator
Future events calendar-http://www.rcpsych.ac.uk/events/collegediary.aspxCONFEREN
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Back Cover Images:
‗Tree‘ By kind permission of artist John McKie
‗Shapes‘ By kind permission of artist Leon
‗Totem‘ By kind permission of artist Roy
Images from the Bethlem Gallery (http://www.bethlemgallery.com)

Faculty Of Forensic Psychiatry Annual Conference

Transcription

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