Promotie M. Jankovic

This dissertation aimed to provide a better understanding of the factors contributing to aggression and violent recidivism. To this end, six empirical studies were conducted, with the first five studies focusing on mentally ill offenders from high-security forensic psychiatric institutions, while the sixth study involved a community sample. This knowledge can help in diminishing aggression, identifying crucial treatment targets, reducing violent recidivism, and ensuring that forensic psychiatric treatment aligns with patients' responsiveness. Factors such as adverse childhood experiences (ACEs), inpatient aggression, intellectual ability, and psychopathology were considered. 

• First, we found that improvement in dynamic risk and protective factors associated with recidivism was more pronounced in the first phase of patients’ stay in a forensic psychiatric institution, that is, from the moment of juridical assessment to unguided leave than in the second phase, from unguided leave to unconditional release. This emphasizes the importance of enhancing the second phase of forensic treatment. 
   
• Second, in a heterogeneous sample of forensic patients, it was possible to distinguish five patient classes based on their psychopathology, risk and protective factors, and criminal history. These findings can guide future interventions tailored to individual needs. 
   
• Third, although intelligence did not moderate the association of dynamic risk and protective factors with violent recidivism, specific risk and protective factors like addiction or social skills were found to distinctly contribute to five-year violent recidivism, serving as valuable treatment targets in forensic treatment. 
   
• Fourth, ACEs were not found to moderate the association of the dynamic risk and protective factors with diminished intellectual functioning or directly influence intellectual functioning. Nonetheless, diminished intellectual functioning was associated with lower self-reliance and poorer social skills, which are valuable aspects to address patient treatment. 
   
• Fifth, heart rate variability and a diagnosis of cluster B personality disorders (PDs) were not significant mechanisms underlying the association between ACEs and self-reported aggressive behavior. However, patients with cluster B PDs had blunted sympathetic activity in response to threat, indicating potential psychopathology and externalizing problems. 
   
• Sixth, in a community sample, ACEs were positively associated with both reactive and proactive aggression, suggesting that targeting specific impulsivity traits in individuals with ACEs could help mitigate reactive and proactive aggression. Finally, sports involvement in individuals with ACEs may help in preventing the development of the impulsivity trait known as a lack of premeditation. 
   

To conclude, this dissertation has made valuable contributions to our understanding of risk assessment, setting treatment goals, and delivering treatment to forensic psychiatric patients.