Virtual Reality Aggression Prevention Therapy (VRAPT) versus Waiting List Control for Forensic Psychiatric Inpatients: A Multicenter Randomized Controlled Trial
Abstract
:1. Introduction
- decreases both self-reported and staff-reported aggressive behavior;
- reduces determinants of aggressive behavior, including anger, impulsivity, and hostility.
2. Methods
2.1. Study Design and Participants
2.2. Randomization and Masking
2.3. Procedures
2.4. Intervention
2.5. Outcomes
2.5.1. Primary Outcome—Aggression
Social Dysfunction and Aggression Scale (SDAS)—Completed by Staff Members
Aggression Questionnaire (AVL)—Completed by Participants
2.5.2. Secondary Outcomes
2.5.3. Other Measures
2.6. Statistical Analyses
3. Results
4. Discussion
4.1. Strengths and Limitations
4.2. Implications and Future Research
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
References
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VRAPT Group (n = 64) | Waiting List (n = 64) | ||||||
---|---|---|---|---|---|---|---|
M (SD) or n % | M (SD) or n % | p | |||||
Age, in years | 39.4 | (10.6) | 38.0 | (10.0) | t (126) = 0.80 | 0.43 | |
Dutch origin | 47 | 73% | 51 | 80% | X2(1) = 0.70 | 0.40 | |
Highest completed education level | X2(5) = 4.28 | 0.51 | |||||
None | 4 | 6% | 6 | 9% | |||
Lower education | 45 | 70% | 36 | 56% | |||
Intermediate education | 7 | 11% | 7 | 11% | |||
Tertiary education | 2 | 3% | 2 | 3% | |||
Lower special education | 5 | 8% | 12 | 19% | |||
Missing | 1 | 2% | 1 | 2% | |||
DSM-5 diagnosis * | |||||||
Schizophrenia | 12 | 19% | 14 | 22% | |||
Schizoaffective disorder | 0 | 0% | 2 | 3% | |||
Delusional Disorder | 0 | 0% | 2 | 3% | |||
Psychotic disorder Not Otherwise Specified (NOS) | 6 | 10% | 4 | 6% | |||
Paranoid personality disorder | 0 | 0% | 1 | 2% | |||
Antisocial personality disorder | 22 | 35% | 26 | 41% | |||
Borderline personality disorder | 13 | 21% | 3 | 5% | |||
Narcissistic personality disorder | 4 | 6% | 3 | 5% | |||
Dependent personality disorder | 1 | 2% | 1 | 2% | |||
Personality disorder NOS | 25 | 40% | 27 | 43% | |||
Autism spectrum disorder | 5 | 8% | 12 | 19% | |||
Attention-deficit/hyperactivity disorder | 11 | 17% | 8 | 13% | |||
Pedophilia | 4 | 6% | 4 | 6% | |||
Other paraphilias | 3 | 5% | 2 | 3% | |||
First-offender | 4 | 6% | 5 | 8% | X2(1) = 0.12 | 0.73 | |
Age at first conviction, in years | 18.9 | (5.2) | 18.9 | (6.6) | t (116) = 0.02 | 0.99 | |
Type of first offense (n = 119) * | |||||||
(Attempted) homicide | 4 | 6% | 3 | 5% | |||
Sexual offense | 4 | 6% | 1 | 2% | |||
Violent offense | 26 | 41% | 26 | 41% | |||
Property offense | 28 | 44% | 29 | 45% | |||
Arson | 2 | 3% | 3 | 5% | |||
Other | 11 | 17% | 10 | 16% | |||
Age at index offense, in years | 31.3 | (9.8) | 29.5 | (9.2) | t (126) = 1.10 | 0.27 | |
Type of index offense * | |||||||
(Attempted) homicide | 31 | 49% | 23 | 36% | |||
Sexual offense | 16 | 25% | 20 | 31% | |||
Violent offense | 37 | 59% | 37 | 58% | |||
Property offense | 17 | 27% | 18 | 28% | |||
Arson | 4 | 6% | 3 | 5% | |||
Damage of index offense * | |||||||
No injury | 10 | 16% | 6 | 9% | |||
Physical injury | 34 | 53% | 40 | 63% | |||
Deadly injury | 11 | 17% | 8 | 13% | |||
Material damage | 15 | 23% | 15 | 23% | |||
Psychological neglect | 5 | 8% | 7 | 11% | |||
Missing | 5 | 8% | 4 | 6% | |||
Childhood trauma (CTQ-SF) | (N = 55) | (N = 57) | |||||
Childhood trauma total | 53.8 | (20.8) | 53.5 | (20.7) | U = 1502 | 0.95 | |
Emotional Abuse | 11.4 | (5.6) | 11.0 | (5.6) | U = 1508.5 | 0.55 | |
Emotional Neglect | 13.0 | (5.4) | 13.4 | (6.1) | U = 1584.5 | 0.79 | |
Psychical Abuse | 11.2 | (6.6) | 9.9 | (6.2) | U = 1376.5 | 0.32 | |
Psychical Neglect | 10.8 | (3.4) | 11.0 | (2.7) | U = 1787.5 | 0.26 | |
Sexual Abuse | 7.9 | (5.4) | 8.6 | (5.8) | U = 1681 | 0.45 |
VRAPT | Waiting List Control | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Pre | Post | Follow-up | Pre | Post | Follow-up | ||||||||
Instrument | M | SD | M | SD | M | SD | M | SD | M | SD | M | SD | |
Staff-rated | n = 64 | n = 63 | n = 62 | n = 64 | n = 64 | n = 62 | |||||||
Peak aggression (primary outcome) | SDAS | 6.9 | 6.4 | 6.9 | 6.7 | 6.9 | 6.7 | 6.2 | 6.9 | 6.6 | 7.0 | 6.2 | 6.6 |
General aggression | SDAS | 4.0 | 4.5 | 4.3 | 5.0 | 4.1 | 5.1 | 3.6 | 5.0 | 3.8 | 4.7 | 3.6 | 4.5 |
Aggression | n = 58 | n = 43 | n = 42 | n = 58 | n = 51 | n = 50 | |||||||
Aggression—total (primary outcome) | AVL | 81.0 | 18.0 | 73.5 | 19.1 | 70.8 | 18.1 | 83.1 | 19.1 | 76.7 | 20.8 | 69.7 | 21.2 |
Physical aggression | AVL | 27.6 | 8.6 | 24.0 | 8.8 | 22.0 | 8.5 | 28.0 | 8.3 | 24.2 | 9.0 | 21.5 | 8.7 |
Verbal aggression | AVL | 14.9 | 3.0 | 14.1 | 3.2 | 13.9 | 2.9 | 14.9 | 2.9 | 14.3 | 3.2 | 13.3 | 3.6 |
Anger | AVL | 18.1 | 5.1 | 16.3 | 5.0 | 15.7 | 5.1 | 18.3 | 5.5 | 17.5 | 5.6 | 16.4 | 5.8 |
Hostility | AVL | 20.6 | 5.9 | 19.0 | 6.1 | 19.2 | 6.4 | 21.9 | 7.0 | 20.7 | 7.4 | 18.5 | 7.1 |
Reactive and proactive aggression—total | RPQ | 18.8 | 9.4 | 11.5 | 10.1 | 10.0 | 11.4 | 18.9 | 9.5 | 12.5 | 10.7 | 11.8 | 10.7 |
Proactive aggression | RPQ | 7.6 | 5.6 | 4.4 | 5.3 | 3.7 | 6.0 | 7.8 | 5.4 | 5.3 | 6.3 | 4.8 | 5.9 |
Reactive aggression | RPQ | 11.3 | 4.6 | 7.1 | 5.6 | 6.3 | 5.9 | 11.2 | 5.1 | 7.3 | 5.2 | 7.0 | 5.5 |
Aggression and hostility—total | BDHI_D | 20.0 | 6.2 | 17.2 | 6.8 | 18.0 | 7.2 | 19.3 | 6.8 | 19.9 | 7.4 | 18.0 | 7.6 |
Direct aggression | BDHI_D | 10.1 | 3.9 | 7.9 | 4.4 | 8.4 | 4.5 | 9.3 | 3.9 | 8.9 | 4.0 | 8.5 | 4.1 |
Indirect aggression | BDHI_D | 8.0 | 4.2 | 6.7 | 4.4 | 7.1 | 4.5 | 8.0 | 4.4 | 8.7 | 5.0 | 7.2 | 5.1 |
Social desirability | BDHI_D | 2.0 | 1.3 | 2.5 | 1.4 | 2.5 | 1.3 | 2.0 | 1.3 | 2.3 | 1.4 | 2.2 | 1.3 |
Anger | |||||||||||||
State anger | STAXI-2 | 18.1 | 6.6 | 17.0 | 5.0 | 18.2 | 7.3 | 17.8 | 5.6 | 17.8 | 6.3 | 16.7 | 3.9 |
Trait anger | STAXI-2 | 18.0 | 5.2 | 16.4 | 4.9 | 16.5 | 6.0 | 17.5 | 5.5 | 17.2 | 6.3 | 15.8 | 5.6 |
Anger expression—Out | STAXI-2 | 17.0 | 4.6 | 15.5 | 3.8 | 15.7 | 4.4 | 16.0 | 4.6 | 16.0 | 4.5 | 15.7 | 4.7 |
Anger expression—In | STAXI-2 | 17.1 | 3.6 | 17.0 | 4.3 | 17.1 | 4.1 | 16.9 | 3.7 | 16.8 | 3.6 | 15.8 | 3.9 |
Anger control—Out | STAXI-2 | 21.2 | 5.1 | 23.1 | 5.5 | 22.8 | 5.3 | 21.0 | 5.3 | 20.9 | 5.0 | 21.5 | 5.2 |
Anger control—In | STAXI-2 | 22.0 | 4.9 | 23.6 | 5.5 | 23.9 | 5.5 | 22.5 | 5.7 | 22.3 | 5.2 | 22.6 | 5.7 |
Anger expression index | STAXI-2 | 38.6 | 12.8 | 33.7 | 13.8 | 34.4 | 15.2 | 37.4 | 13.9 | 37.6 | 12.7 | 35.4 | 13.6 |
Anger | NAS-PI | 86.9 | 15.8 | 80.9 | 16.1 | 80.1 | 17.8 | 86.9 | 15.9 | 84.0 | 16.7 | 79.8 | 17.7 |
Other | |||||||||||||
Provocation | NAS-PI | 51.4 | 11.8 | 48.3 | 14.0 | 50.0 | 15.9 | 51.0 | 13.2 | 49.7 | 14.0 | 48.2 | 13.6 |
Impulsivity—total | BIS-11 | 63.5 | 11.5 | 59.1 | 11.2 | 59.9 | 11.8 | 62.9 | 12.1 | 62.9 | 10.7 | 59.5 | 12.6 |
Motor | BIS-11 | 22.8 | 4.3 | 20.9 | 3.8 | 21.2 | 4.3 | 22.1 | 4.8 | 21.6 | 4.5 | 20.4 | 5.2 |
Cognition | BIS-11 | 15.7 | 3.6 | 14.9 | 4.1 | 15.1 | 3.6 | 15.9 | 4.4 | 16.1 | 3.8 | 15.4 | 4.4 |
Non-planning | BIS-11 | 25.0 | 5.6 | 23.3 | 5.3 | 23.6 | 5.3 | 24.8 | 5.3 | 25.1 | 5.1 | 23.9 | 5.2 |
Hostile interpretation bias | HIBT | 133.6 | 76.7 | 123.7 | 63.9 | 131.9 | 70.8 | 143.6 | 75.1 | 145.0 | 75.7 | 132.9 | 69.6 |
Pre-Post | Pre-Follow-up | ||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
b | t | df | p | 95% CI | Effect size | b | t | df | p | 95% CI | Effect size | ||||
Instrument | |||||||||||||||
Staff-rated | |||||||||||||||
Peak aggression (primary outcome) | SDAS | 0.15 | 0.27 | 127.3 | 0.79 | −0.98 | 1.29 | 0.05 | −0.01 | −0.02 | 125.1 | 0.98 | −0.60 | 0.59 | 0 |
General aggression | SDAS | −0.08 | −0.17 | 127.5 | 0.87 | −0.97 | 0.82 | 0.03 | −0.08 | −0.30 | 125.9 | 0.76 | −0.58 | 0.43 | 0.05 |
Aggression | |||||||||||||||
Aggression—total (primary outcome) | AVL | 0.18 | 0.06 | 99.8 | 0.95 | −5.63 | 5.99 | 0.02 | −1.70 | −1.10 | 98.9 | 0.27 | −4.77 | 1.37 | 0.19 |
Physical aggression | AVL | −0.77 | −0.55 | 103.1 | 0.58 | −3.55 | 2.01 | 0.11 | −0.63 | −0.80 | 104.0 | 0.42 | −2.18 | 0.92 | 0.15 |
Verbal aggression | AVL | 0.05 | 0.10 | 101.7 | 0.92 | −0.99 | 1.10 | 0.01 | −0.35 | −1.23 | 102.2 | 0.22 | −0.92 | 0.22 | 0.26 |
Anger | AVL | 0.52 | 0.67 | 100.8 | 0.51 | −1.03 | 2.08 | 0.12 | 0.13 | 0.34 | 98.9 | 0.73 | −0.63 | 0.89 | 0.07 |
Hostility | AVL | 0.50 | 0.42 | 99.6 | 0.67 | −1.85 | 2.85 | 0.12 | −0.86 | −1.57 | 97.7 | 0.12 | −1.94 | 0.23 | 0.28 |
Reactive and proactive aggression—total | RPQ | −0.23 | −0.12 | 102.7 | 0.90 | −3.96 | 3.50 | 0.37 | 0.40 | 0.42 | 102.2 | 0.68 | −1.49 | 2.28 | 0.05 |
Proactive aggression | RPQ | −0.12 | −0.12 | 100.3 | 0.91 | −2.15 | 1.92 | 0.09 | 0.14 | 0.28 | 99.9 | 0.78 | −0.85 | 1.14 | 0 |
Reactive aggression | RPQ | −0.08 | −0.08 | 105.3 | 0.93 | −2.02 | 1.86 | 0.03 | 0.30 | 0.59 | 104.5 | 0.56 | −0.70 | 1.30 | 0.12 |
Aggression and hostility—total | BDHI_D | 2.74 | 2.38 | 99.8 | 0.02 * | 0.45 | 5.02 | 0.44 | 0.12 | 0.22 | 96.2 | 0.83 | −0.97 | 1.20 | 0.02 |
Direct aggression | BDHI_D | 1.17 | 2.05 | 99.0 | 0.04 * | 0.04 | 2.31 | 0.38 | 0.30 | 1.04 | 97.5 | 0.30 | −0.27 | 0.87 | 0.18 |
Indirect aggression | BDHI_D | 1.66 | 1.94 | 102.5 | 0.06 | −0.04 | 3.36 | 0.32 | −0.08 | −0.21 | 96.2 | 0.83 | −0.82 | 0.66 | 0.08 |
Social desirability | BDHI_D | −0.09 | −0.34 | 102.8 | 0.74 | −0.61 | 0.43 | 0 | −0.11 | −0.83 | 99.5 | 0.41 | −0.36 | 0.15 | 0.12 |
Anger | |||||||||||||||
State anger | STAXI-2 | 1.13 | 0.81 | 98.0 | 0.42 | −1.64 | 3.90 | 0.16 | −0.59 | −0.78 | 104.1 | 0.44 | −2.09 | 0.91 | 0.10 |
Trait anger | STAXI-2 | 0.99 | 1.26 | 101.2 | 0.21 | −0.56 | 2.54 | 0.25 | −0.26 | −0.63 | 99.5 | 0.53 | −1.09 | 0.56 | 0.14 |
Anger expression—Out | STAXI-2 | 1.32 | 1.76 | 101.5 | 0.08 | −0.17 | 2.81 | 0.33 | 0.36 | 0.95 | 98.3 | 0.34 | −0.39 | 1.10 | 0.18 |
Anger expression—In | STAXI-2 | −0.11 | −0.17 | 101.8 | 0.86 | −1.37 | 1.15 | 0.03 | −0.54 | −1.54 | 100.5 | 0.13 | −1.23 | 0.15 | 0.28 |
Anger control—Out | STAXI-2 | −1.76 | −2.40 | 96.7 | 0.02 * | −3.22 | −0.30 | 0.48 | −0.40 | −0.91 | 94.8 | 0.36 | −1.26 | 0.47 | 0.16 |
Anger control—In | STAXI-2 | −1.38 | −1.46 | 102.8 | 0.15 | −3.26 | 0.50 | 0.25 | −0.67 | −1.40 | 100.3 | 0.16 | −1.61 | 0.28 | 0.23 |
Anger expression index | STAXI-2 | 4.41 | 2.21 | 98.1 | 0.03 * | 0.45 | 8.36 | 0.46 | 0.84 | 0.80 | 94.4 | 0.42 | −1.23 | 2.90 | 0.17 |
Anger | NAS-PI | 1.21 | 0.53 | 98.9 | 0.60 | −3.33 | 5.75 | 0.07 | −1.11 | −0.95 | 97.1 | 0.34 | −3.44 | 1.21 | 0.23 |
Other | |||||||||||||||
Provocation | NAS-PI | 1.85 | 1.06 | 98.3 | 0.29 | −1.60 | 5.31 | 0.23 | −0.88 | −0.99 | 96.1 | 0.33 | −2.65 | 0.89 | 0.20 |
Impulsivity—total | BIS-11 | 3.43 | 1.77 | 100.4 | 0.08 | −0.41 | 7.27 | 0.30 | −0.23 | −0.26 | 97.3 | 0.80 | −2.02 | 1.55 | 0.08 |
Motor | BIS-11 | 1.11 | 1.34 | 99.1 | 0.18 | −0.53 | 2.76 | 0.21 | −0.20 | −0.49 | 98.1 | 0.63 | −1.03 | 0.62 | 0.15 |
Cognition | BIS-11 | 0.73 | 0.96 | 103.0 | 0.34 | −0.77 | 2.23 | 0.14 | 0.02 | 0.05 | 99.3 | 0.96 | −0.66 | 0.69 | 0.01 |
Non-planning | BIS-11 | 1.59 | 2.07 | 99.3 | 0.04 * | 0.06 | 3.12 | 0.39 | 0.08 | 0.20 | 97.6 | 0.84 | −0.68 | 0.83 | 0.03 |
Hostile interpretation bias | HIBT | 10.93 | 0.93 | 76.3 | 0.36 | −12.57 | 34.43 | 0.18 | −5.99 | −0.88 | 73.2 | 0.38 | −19.62 | 7.64 | 0.27 |
Question | Answers | n (%) |
---|---|---|
Did you work on your learning goals? | Yes | 26 (68.4%) |
No, or not really | 7 (18.4%) | |
Don’t know | 5 (13.2%) | |
Do you notice a difference in your daily life? | Yes | 19 (50%) |
A little | 3 (7.9%) | |
No, or not really | 16 (42.1%) | |
Is this therapy an addition to other therapies? | Yes | 29 (76.3%) |
No, or not really | 4 (10.5%) | |
Not for me personally, but for other patients | 5 (13.2%) |
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Klein Tuente, S.; Bogaerts, S.; Bulten, E.; Keulen-de Vos, M.; Vos, M.; Bokern, H.; IJzendoorn, S.v.; Geraets, C.N.W.; Veling, W. Virtual Reality Aggression Prevention Therapy (VRAPT) versus Waiting List Control for Forensic Psychiatric Inpatients: A Multicenter Randomized Controlled Trial. J. Clin. Med. 2020, 9, 2258. https://doi.org/10.3390/jcm9072258
Klein Tuente S, Bogaerts S, Bulten E, Keulen-de Vos M, Vos M, Bokern H, IJzendoorn Sv, Geraets CNW, Veling W. Virtual Reality Aggression Prevention Therapy (VRAPT) versus Waiting List Control for Forensic Psychiatric Inpatients: A Multicenter Randomized Controlled Trial. Journal of Clinical Medicine. 2020; 9(7):2258. https://doi.org/10.3390/jcm9072258
Chicago/Turabian StyleKlein Tuente, Stéphanie, Stefan Bogaerts, Erik Bulten, Marije Keulen-de Vos, Maarten Vos, Hein Bokern, Sarah van IJzendoorn, Chris N. W. Geraets, and Wim Veling. 2020. "Virtual Reality Aggression Prevention Therapy (VRAPT) versus Waiting List Control for Forensic Psychiatric Inpatients: A Multicenter Randomized Controlled Trial" Journal of Clinical Medicine 9, no. 7: 2258. https://doi.org/10.3390/jcm9072258