Pathways for VA and community stakeholder management of military veterans with sexual offenses: Sexual and nonsexual recidivism rates and risk factors in military veterans released from California sexually violent predator (SVP) commitment.

Military veterans with sexual offenses committed after discharge are often eligible for Veterans Affairs (VA) services including health care. There are few, if any, studies of sexual recidivism among military veterans with sexual offense histories to guide clinical management. This study examined diagnostic and postrelease sexual and nonsexual recidivism among military sexual offenders released from California sexually violent predator (SVP) commitment. The sample consisted of 363 males; 131 were identified as military veterans and 232 as civilians. The rates of recidivism were assessed for two follow-up periods: a fixed 5-year and a total 21-year follow-up. Recidivism was operationalized as any new sexual, violent, or general criminal arrest or conviction occurring after discharge to the community in California. We found a low risk for sexual reoffense for both groups. Specific to veterans, the rates for sexual and nonsexual violent recidivism were under 7% for both follow-up periods. Diagnostically, veterans had a significantly higher rate of pedophilic disorder and lower rate of antisocial personality disorder than civilians; neither were predictive of sexual recidivism or any other recidivism. On average, veterans were 61 years old at discharge; and older age at discharge was associated with a significantly lower likelihood of recidivism of any type. A relatively high proportion of veterans had a history of childhood sexual abuse and head trauma. Trauma-informed care may be a particularly valuable treatment approach for veterans with sexual offenses. These data may aid the VA and other providers in forming evidence-based decisions regarding the management of veterans with sexual offenses. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Inpatient residential treatment program for combat-related posttraumatic stress disorder (PTSD): Results from the 2020 Artsakh (Nagorno-Karabakh) War.

Inpatient residential treatment programs to evaluate active military service members for potential return to service or discharge are considered an integral component of rehabilitation for trauma related conditions. This retrospective study was conducted on combat-exposed military service members who were admitted to an inpatient residential treatment program for evaluation of fitness to serve and treatment of trauma related conditions. The PTSD Checklist for DSM-5 (PCL-5) was used to screen for PTSD, determine symptom severity, and monitor symptom change. At the time of admission, 54.3% of the service members met the provisional PTSD diagnosis, whereas at the time of discharge, 16.28% of the service members met the provisional diagnostic criteria. The most common symptoms rated moderately or higher were sleep troubles, followed by super alert, disturbing memories, feeling upset, disturbing dreams, physical reactions, avoiding memories, and negative feelings. Paired t-test results comparing the PCL-5 five Subscales and Total Score at the time of admission and discharge showed significant reductions. The five symptoms that improved the least were sleep troubles, feeling upset, avoiding memories, difficulty concentrating, and trouble remembering. The successful creation and implementation of an Armenian version of the PCL-5 was realized and, when put to the test, aided in screening, diagnosing, and monitoring PTSD symptoms among Armenian Army Service members. The results suggest that PTSD symptoms in an inpatient residential treatment program decreased over time. The symptoms that bothered the service members at most during the time of admission, however, improved the least at the time of discharge.

Reset for systematic action: Removing VA barriers to housing and treatment for military veterans with sexual offenses.

Though the U.S. Department of Veterans Affairs (VA) provides housing, residential treatment, and mental health care to justice involved veterans, those with sexual offenses face daunting obstacles to securing such services, including exclusion from housing programs, and lack of mental health services to treat sexual deviancy disorders. The VA's strategy to date may reflect a large system's caution in systematically addressing a problem that involves a population with an even higher degree of stigma than homelessness. Failure to develop strategies to address this problem reflects the need for a VA system-wide, consistent, and effective approach across relevant domains that incorporate the current state of knowledge and practice. Since 2006, the VA's program serving justice system veterans has been highly effective in serving the reentry veteran population. The challenge of serving veterans with sex offenses can and must be met with a similar level of effectiveness. In this commentary, we propose that the VA, beginning with the Secretary, adopt a "reset" policy and programmatic action agenda to enhance access to housing and treatment for sexual deviancy disorders. We offer specific pathways for implementation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Vaccine breakthrough infections with SARS-CoV-2: Why older adults need booster vaccinations.

Objectives: COVID-19 vaccinations are highly efficacious in preventing severe illness that can lead to hospitalizations and death, but incidents of vaccine breakthrough (VBT) infections persist. We examined VBT infections within a congregate setting to help guide public health practices. Study design: This is a retrospective cohort study of VBT infections identified via polymerase chain reaction (PCR) testing between 2/1/2021-11/1/2021. Methods: A VBT infection was defined as the detection of SARS-CoV-2 collected from a person ≥14 days after all recommended doses of a COVID-19 vaccine. VBT infections were examined in five California psychiatric inpatient hospitals with a workforce of more than 10,000 hospital staff and approximately 5500 patients. Results: 415 VBT infections out of 14,101 fully vaccinated individuals within our system (2.9%) were identified. Days since final vaccine date ranged from 16 to 291 days. Kruskal-Wallis nonparametric test revealed a statistically significant difference in age between individuals with VBT infections versus all other vaccinated individuals [U = 6.47, p = .01]. A chi-square test of independence revealed no significant sex differences between individuals with VBT infections (58.8% male and 41.2% female) versus all other vaccinated individuals (59.6% male and 40.4% female; X2 (3, N = 14101) = 5.059, p = .167). Out of 415 VBT cases, 65.1% received the Moderna vaccine, 33.2% received Pfizer, and 1.7% received J&J; and 38.1% were asymptomatic at time of VBT infection, 24.1% were symptomatic, while 37.8% were missing symptom data. Conclusions: Vaccination campaigns, including boosters and continued surveillance, are important complimentary strategies for reducing the proliferation of COVID-19 VBT cases and severity of symptoms associated with COVID-19.

A descriptive study of adverse childhood experiences (ACEs) among female patients with sexual dysfunctions in Armenia.

BACKGROUND: Adverse childhood experiences (ACEs) are associated with increased risk for a wide range of negative health outcomes, including sexual dysfunctions. There is a growing interest to advance the science of ACEs to improve the lives of children and families worldwide. PARTICIPANTS AND PROCEDURE: The purpose of the present study was to explore the extent to which ACEs occur in patients with sexual dysfunctions in Armenia. To this end, the ACE questionnaire was used to assess the presence of adverse experiences from 85 female patients with sexual dysfunctions and 155 sex- and age-adjusted controls. RESULTS: More than two-thirds of the patients (74.1%) had been exposed to one or more ACEs and 27.2% had been exposed to four or more ACEs. In the control group, these numbers were 56.1% and 18.1% respectively. Patients had significantly higher ACE scores (M = 2.06, SD = 1.95) than the control group (M = 1.65, SD = 2.50). Parental divorce and witnessing mother being abused (treated violently) were the most prevalent adversities in the patients. CONCLUSIONS: The presence of multiple adverse childhood experiences in the patient group suggests that psychogenic factors are likely involved in sexual dysfunctions. ACEs Aware initiatives in Armenia aimed at screening for childhood adversities can improve the treatment of sexual dysfunctions and ultimately improve health and wellbeing.

A Preliminary Analysis of Sexual Recidivism and Predictive Validity of the Static-99R in Men Discharged From State Hospitals Pursuant to California's Sexually Violent Predator Act.

We examined the recidivism rates and the predictive validity of the Static-99R in 335 men who were detained or civilly committed and released from California State Hospitals pursuant to the Sexually Violent Predator (SVP) Act, and followed up for approximately 21 years from date of hospital admission. In all, 8.7% were arrested or convicted for a new sexual offense during the total follow-up (N = 335) and 7.8% over a fixed 5-year follow-up (n = 205). The Static-99R demonstrated small in magnitude discrimination for sexual, violent, and general recidivism (area under the curve [AUC]/C = .56 to .63). Calibration analyses, conducted through expected/observed (E/O) index, demonstrated that the Static-99R overpredicted sexual recidivism, irrespective of whether the Routine or High Risk/Need norms were used. Observed recidivism rates were lower than predicted by Static-99R scores and may be the result of the sample's older age at release, lengthy hospitalization, or other factors.

A Comparison of Risk Factors Among Discharged Military Veterans and Civilians Involuntarily Hospitalized Under California's Sexually Violent Predator Act.

While military veterans have a lower overall rate of incarceration for criminal offenses than civilians, they have a higher rate of incarceration for violent sexual offenses. Despite military veteran overrepresentation among individuals adjudicated for violent sexual offenses, little is known about their risk factors for sexual offending. This study compared military veterans and civilians who had been involuntarily hospitalized and discharged pursuant to California's Sexually Violent Predator Act. Pedophilic disorder appeared nearly twice as often among veterans than civilians (62.7% vs. 38.7%), whereas antisocial personality disorder was twice as common among civilians compared to veterans (48.1% vs. 23.9%). Consistent with the result for pedophilic disorder, veterans were more likely to target male victims age 13 and below, while civilians tended to target female victims over the age of 13. The results suggest different risk profiles for veterans compared to civilians who have been convicted of sexually violent offenses.

Applying Collaborative Justice to Sexually Violent Predator Civil Commitment.

Sexually violent predator (SVP) statutes are unique in that these laws allow for the indefinite civil psychiatric commitment of sex offenders after their criminal sentences have been served. In addition to the high cost of psychiatric hospitalization, recently observed low base rates of sexual recidivism of sex offenders released from custody suggest that, in select SVP cases, a collaborative justice model of outpatient placement may be feasible in lieu of lengthy and costly placement in state hospitals. Given its position as one of the states with a large number of SVP commitments, California offers an opportunity to implement a collaborative justice model for adult sex offenders found to meet SVP criteria. In this article, a template for such a model is suggested. Admittedly, this model faces multiple obstacles, both within the judicial system and in the public arena. Nonetheless, public concerns may be mitigated through high-control parole plus additional treatment and controls, interim halfway house placement, and community prosocial support systems.

Length of stay for inpatient incompetent to stand trial patients: importance of clinical and demographic variables.

OBJECTIVE: We investigated clinical and demographic variables to better understand their relationship to hospital length of stay for patients involuntarily committed to California state psychiatric hospitals under the state's incompetent to stand trial (IST) statutes. Additionally, we determined the most important variables in the model that influenced patient length of stay. METHODS: We retrospectively studied all patients admitted as IST to California state psychiatric hospitals during the period January 1, 2010 through June 30, 2018 (N = 20 041). Primary diagnosis, total number of violent acts while hospitalized, age at admission, treating hospital, level of functioning at admission, ethnicity, sex, and having had a previous state hospital admission were evaluated using a parametric survival model. RESULTS: The analysis showed that the most important variables related to length of stay were (1) diagnosis, (2) number of violent acts while hospitalized, and (3) age of admission. Specifically, longer length of stay was associated with (1) having a diagnosis of schizophrenia or neurocognitive disorder, (2) one or more violent acts, and (3) older age at admission. The other variables studied were also statistically significant, but not as influential in the model. CONCLUSIONS: We found significant relations between length of stay and the variables studied, with the most important variables being (1) diagnosis, (2) number of physically violent acts, and (3) age at admission. These findings emphasize the need for treatments to target cognitive issues in the seriously mentally ill as well as treatment of violence and early identification of violence risk factors.

Associations between MMPI-2-RF Scale scores and institutional violence among patients detained under sexually violent predator laws.

Sexually violent predator (SVP) laws allow the postprison civil commitment of sex offenders to a secure psychiatric hospital because of mental abnormality and posing a serious risk to public safety. Research on predictors of future institutional violence in this population is lacking because adequately sized samples are difficult to obtain. In the current study, we examined psychological predictors of future institutional violence in a sample of 171 psychiatrically hospitalized males detained or civilly committed under an SVP laws. Using the Minnesota Multiphasic-Personality Inventory-2-Restructured Form (Ben-Porath & Tellegen, 2008/2011), we found that scales assessing thought dysfunction, emotional dysregulation, and externalizing behaviors were associated with future physical violence at the hospital. Relative risk ratio analyses indicated that SVPs producing elevations on these scales were at 1.5-2.5 times greater risk of future physical violence than those without elevations. Overall, the results suggest the Minnesota Multiphasic-Personality Inventory-2-Restructured Form is associated with future institutional violence among SVPs. Implications and limitations of these findings are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Linking Mental Disorder and Risk in Sexually Violent Person Assessments.

A common criticism of sexually violent person (SVP) laws is that psychiatric commitment has been co-opted to continue the incarceration of dangerous criminals, not dangerous individuals with mental illness. This opinion may have credence because some forensic clinicians use a "silo" approach (i.e., diagnosing based on historical criminal behavior rather than current symptomatology, and formulating risk for future sexual violence based on actuarial scores rather than characteristics and features of the mental condition). A silo process fosters a missing link; namely, the absence of a nexus between the mental condition and risk. This approach violates the necessary predicate for involuntary civil commitment, that the symptoms of an individual's current mental disorder be linked to and support a present sexual danger to others. In this article, we provide a brief overview of SVP statutes; describe how the silo approach compromises accurate diagnosis and identification of relevant risk factors; and present actual and fictitious cases illustrating the presence and absence of the missing link.

Predictive validity of HCR-20, START, and static-99R assessments in predicting institutional aggression among sexual offenders.

Sexual offenders are at greater risk of nonsexual than sexual violence. Yet, only a handful of studies have examined the validity of risk assessments in predicting general, nonsexual violence in this population. This study examined the predictive validity of assessments completed using the Historical-Clinical-Risk Managment-20 Version 2 (HCR-20; Webster, Douglas, Eaves, & Hart, 1997), Short-Term Assessment of Risk and Treatability (START; Webster, Martin, Brink, Nicholls, & Desmarais, 2009), and Static-99R (Hanson & Thornton, 1999) in predicting institutional (nonsexual) aggression among 152 sexual offenders in a large secure forensic state hospital. Aggression data were gathered from institutional records over 90-day and 180-day follow-up periods. Results support the predictive validity of HCR-20 and START, and to a lesser extent, Static-99R assessments in predicting institutional aggression among patients detained or civilly committed pursuant to the sexually violent predator (SVP) law. In general, HCR-20 and START assessments demonstrated greater predictive validity-specifically, the HCR-20 Clinical subscale scores and START Vulnerability total scores-than Static-99R assessments across types of aggression and follow-up periods. (PsycINFO Database Record

Cognitional Impairment: Is There a Role for Cognitive Assessment in the Treatment of Individuals Civilly Committed Pursuant to the Sexually Violent Predator Act?

Sexually Violent Predator statutes allow the involuntary treatment of individuals who are found to pose a threat to public safety. Most sex offender treatment programs rely on cognitive interventions to reduce the risk of recidivism. The purpose of this study was to examine (a) whether individuals with paraphilia diagnoses have cognitive deficits compared with the general population; (b) whether individuals diagnosed with pedophilia differed on cognitive performance when compared with individuals diagnosed with paraphilia not otherwise specified (NOS), nonconsent; and (c) whether individuals with paraphilia plus antisocial personality disorder (ASPD) differed in cognitive performance when compared with individuals with a paraphilia diagnosis only. The sample consisted of 170 males (M age = 50.21; SD = 10.22) diagnosed with pedophilia or paraphilia NOS, nonconsent, who were detained or civilly committed to a forensic psychiatric hospital. Assessments included Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), Wechsler Abbreviated Scale of Intelligence (WASI), and Wide Range Achievement Test 4 (WRAT4). Individuals diagnosed with pedophilia and paraphilia NOS, nonconsent, obtained lower scores than matched controls based on the RBANS Immediate Memory, Visuospatial/Constructional, Delayed Memory indices and Total Score. In comparison with individuals with paraphilia NOS, nonconsent, those with pedophilia diagnosis had lower scores on the RBANS Delayed Memory. Individuals diagnosed with a paraphilia disorder combined with ASPD demonstrated trends toward lower IQ scores than those with a paraphilia diagnosis only. Treatment programs can improve their chance of success by assessment of cognitive processes, and offer therapy in a style that is consistent with the cognitive abilities of their clients.

Prevalence of physical violence in a forensic psychiatric hospital system during 2011-2013: Patient assaults, staff assaults, and repeatedly violent patients.

UNLABELLED: Introduction We examined physical violence in a large, multihospital state psychiatric system during 2011-2013, and associated demographic and clinical characteristics of violent patients to better understand issues of patient and staff safety. METHOD: Acts of physical violence committed by patients against other patients (n=10,958) or against staff (n=8429) during 2011-2013 were collected and analyzed for all hospitalized patients during the same time period to derive prevalence rates and associated odds ratios. RESULTS: Overall, 31.4% of patients committed at least 1 violent assault during their hospitalization. Differential risk factor patterns were noted across patient and staff assault. Younger age was associated with a higher prevalence of both patient and staff assault, as was nonforensic legal status. Females had a higher prevalence of staff assault than patient assault. Ethnic groups varied on rates of patient assault, but had no significant differences for staff assault. Schizoaffective disorder was associated with higher prevalence and odds of patient (OR 1.244, 95% CI 1.131 to 1.370) and staff (OR 1.346, 95% CI 1.202 to 1.507) assault when compared to patients diagnosed with schizophrenia. Most personality disorder diagnoses also had a higher prevalence and odds of physical violence. One percent of patients accounted for 28.7% of all assaults. Additionally, violent patients had a significantly longer length of hospitalization. Discussion Implications of these findings to enhance patient safety and inform future violence reduction efforts, including the need for new treatments in conjunction with the use of violence risk assessments, are discussed.

California State Hospital Violence Assessment and Treatment (Cal-VAT) guideline.

Here we provide comprehensive guidelines for the assessment and treatment of violence and aggression of various etiologies, including psychotic aggression and impulsive aggression due to schizophrenia, mood disorders, ADHD, or trauma, and predatory aggression due to psychopathy and other personality disorders. These guidelines have been developed from a collection of prescribing recommendations, clinical trial results, and years of clinical experience in treating patients who are persistently violent or aggressive in the California Department of State Hospital System. Many of the recommendations provided in these guidelines employ off-label prescribing practices; thus, sound clinical judgment based on individual patient needs and according to institution formularies must be considered when applying these guidelines in clinical practice.

California State Hospital Violence Assessment and Treatment (Cal-VAT) guidelines.

Here we provide comprehensive guidelines for the assessment and treatment of violence and aggression of various etiologies, including psychotic aggression and impulsive aggression due to schizophrenia, mood disorders, ADHD, or trauma, and predatory aggression due to psychopathy and other personality disorders. These guidelines have been developed from a collection of prescribing recommendations, clinical trial results, and years of clinical experience in treating patients who are persistently violent or aggressive in the California Department of State Hospital System. Many of the recommendations provided in these guidelines employ off-label prescribing practices; thus, sound clinical judgment based on individual patient needs and according to institution formularies must be considered when applying these guidelines in clinical practice.

Clinical validity of the Repeatable Battery for the Assessment of Neuropsychological Status among patients with schizophrenia in the Republic of Armenia.

There is considerable interest in Armenia toward advancing research and applying evidence-based practice in the treatment of schizophrenia. An area of research that has made little progress is the standardization of reliable and valid tests to measure cognitive functions. The aim of the present study was twofold. The first goal was to adapt the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) into Armenian. The second purpose was to examine the clinical validity of the Armenian-language RBANS in patients diagnosed with schizophrenia and healthy comparison controls. Seventy-seven patients with DSM IV TR diagnosis of schizophrenia or schizoaffective disorder, and 77 healthy individuals participated in the study. The cognitive performance of patients was compared with that of healthy controls and U.S. normative data. The Armenian-language RBANS demonstrated acceptable psychometric properties in terms of test validity and reliability. Relative to healthy controls, patients with schizophrenia exhibited impaired performance in all RBANS Index and Subtest tasks. Patients and comparison controls performed below the U.S. data with the greatest differences found in language and attention tasks. The present findings support that the Armenian-language RBANS is a good test for measuring cognitive functions in patients with schizophrenia and the general population. The performance differences between Armenian and U.S. samples highlight the limitation in using English-standardized normative data for cross-cultural studies. The results merit further investigation to disentangle cultural variations from cognitive disturbances.

Smoking reduces conflict-related anterior cingulate activity in abstinent cigarette smokers performing a Stroop task.

Prior research suggests that abrupt initiation of abstinence from cigarette smoking reduces neural cognitive efficiency. When cognitive efficiency is high, processing speed and accuracy are maximized with minimal allocation of cognitive resources. The study presented here tested the effects of resumption of smoking on cognitive response conflict after overnight abstinence from smoking, hypothesizing that smoking would enhance cognitive efficiency. Twenty paid research volunteers who were chronic cigarette smokers abstained from smoking overnight (>12 h) before undergoing fMRI while performing a color-word Stroop task during two separate test sessions: one that did not include smoking before testing and another one that did. Statistical analyses were performed by modeling the Stroop effect (incongruent >congruent) BOLD response within a collection of a priori regions of interest that have consistently been associated with cognitive control. Behavioral assessment alone did not reveal any significant differences in the Stroop effect between the two sessions. BOLD activations, however, indicated that in the right anterior cingulate cortex (ACC), smokers had significantly less task-related activity following smoking (p<0.02). In contrast, the right middle frontal gyrus exhibited significantly greater activity after smoking as compared to the no-smoking session (p<0.003). Exaggerated neural activity in the ACC during nicotine withdrawal may reflect a compensatory mechanism by which cognitive control networks expend excessive energy to support selective attention processes. Resumption of smoking may enhance cognitive control in smokers, involving a reduction in ACC response conflict activity together with improvement in conflict resolution involving the dorsolateral prefrontal cortex.

Magnetic resonance imaging studies of cigarette smoking.

This chapter reviews studies that have applied magnetic resonance imaging (MRI) toward a better understanding of the neurobiological correlates and consequences of cigarette smoking and nicotine dependence. The findings demonstrate that smokers differ from nonsmokers in regional brain structure and neurochemistry, as well as in activation in response to smoking-related stimuli and during the execution of cognitive tasks. We also review functional neuroimaging studies on the effects of nicotine administration on brain activity, both at rest and during the execution of cognitive tasks, independent of issues related to nicotine withdrawal and craving. Although chronic cigarette smoking is associated with poor cognitive performance, acute nicotine administration appears to enhance cognitive performance and increase neural efficiency in smokers.

Gender effects on mood and cigarette craving during early abstinence and resumption of smoking.

Women are more likely than men to relapse after initiating abstinence from cigarette smoking. The reasons for this phenomenon are unclear but may relate to negative mood, cigarette craving, or other symptoms of nicotine withdrawal. We addressed this issue in a study of 26 female and 38 male smokers. The Profile of Mood States, Shiffman-Jarvik Withdrawal Scale, and Urge to Smoke Scale were administered twice in each of two test sessions on different days. One session began within 1 hr after smoking ad libitum and the other followed overnight abstinence (>13 hr). On each test day, the two assessment blocks were separated by a 5-10-min break, during which each participant smoked one cigarette. In the first test block, both men and women reported higher scores after >13 hr abstinence than after <1 hr abstinence on the tension-anxiety and anger-hostility subscales of the Profile of Mood States, and for the craving and psychological symptoms of the Shiffman-Jarvik Withdrawal Scale. Scores of female subjects showed significantly larger differences between sessions on the tension-anxiety subscale and a trend toward significance (p = .050) on the anger-hostility subscale of Profile of Mood States than those of males. Moreover, on the tension-anxiety subscale, women also reported a greater reduction than men from smoking one cigarette after overnight abstinence. The findings indicate that overnight abstinence produces more negative mood symptoms and cigarette craving in female smokers than in males, and that resumption of smoking produces greater relief from these symptoms in female smokers. These differences may contribute to the greater likelihood of relapse when women try to quit smoking.