Patient perceptions of schizophrenia in forensic and general adult psychiatry

This study explores the illness perceptions of patients with schizophrenia in forensic settings and contrasts their views with those of a general adult psychiatry sample. It was hypothesised that forensic psychiatric patients would have more negative illness beliefs than general adult patients. A cross-sectional survey was used. Forty forensic patients and 32 general adult patients with schizophrenia were recruited. They completed the Illness Perception Questionnaire for Schizophrenia (IPQS), a valid and reliable measure of illness perceptions in mental health problems. Forensic patients perceived their illness to be less chronic, less cyclical, and had a lower negative emotional response to illness. Our results did not support our original hypothesis and possible reasons are explored. Acknowledging patient’s views when formulating management plans could permit more effective individually tailored treatment.     

Arsonists Suffering From Schizophrenia—A Description in Comparison with Other Offenders with a Similar Diagnosis

This study aims to describe the small and distinct subgroup of arsonists diagnosed with schizophrenia, their motives, personal, and crime scene characteristics. While prior research identified significant differences to other criminals, firesetters in general, or mentally disordered offenders, there are no comparisons with other offender patients with schizophrenia so far. In a forensic institution in Switzerland, a group of 30 arsonists with schizophrenia spectrum disorder (SSD) was compared to 340 other offender patients with SSD using retrograde file analysis and multiple adapted Fisher´s exact tests. While symptoms of SSD were most defining of both groups, arsonists with SSD were more often single, unemployed, prescribed psychiatric medication at index offense, had a smaller variety of criminal motives, and acted out of anger or revenge in the context of a relationship. In conclusion, symptoms of SSD may be more defining and useful in guiding clinical practice than aspects specific to arsonists.     

Medication noncompliance in schizophrenia: codification and update

Risk of relapse and recidivism makes the failure to take antipsychotic medication as prescribed a significant issue in forensic psychiatry. This question may arise in such contexts as the setting of bail, plea bargaining, the insanity defense, and sentencing. We have reviewed the literature on medication noncompliance in schizophrenia and present here the results, organized by topics relevant for the work of forensic mental health experts. Reported rates of noncompliance vary widely, reflecting major differences in the populations studied and the methods used as well as the complexities involved in defining noncompliant behavior. A noncompliance rate of 50 percent has been attributed globally to chronic patients, both medical and psychiatric. The tendency of significant factors to interact precludes a simple typology of noncompliance. However, environmental security and supportiveness correlate positively with adherence; whereas anxiety, paranoia, grandiosity, depression, and side effects correlate negatively. Clinicians' assessments of whether medication is being taken have proven to be unreliable. Although monitoring by chemical measurement, particularly a radioreceptor assay for urine samples, can be useful, depot injection ensures that prescribed medication is being taken. Less invasive means of promoting compliance are described; psychodynamic and ethical issues to be considered in the monitoring and promotion of compliance over extended time periods are presented. We also probe the link between medication noncompliance and behavioral relapse. The time between default and relapse is most often measured in weeks. Whether due to medication withdrawal or not, the relapse pattern of each individual tends to repeat, allowing its recognition before recidivism occurs. Restarting medication at this stage, especially with a dosage increase, is usually effective. In sum, the forensic mental health expert can now readily use a large and diverse literature to assist with a variety of significant issues.     

American forensic psychiatrists who work in state institutions

The authors surveyed a sample of American forensic psychiatrists who work in state institutions. As a group, their respondents tended to be middle-aged, white men, who had little formal training in forensic psychiatry, felt somewhat alienated from their peers, yet who were Board certified in general psychiatry. They tended to be involved primarily in the direct treatment of patients, and most often expressed concerns about the care-and prominent lack of aftercare--received by forensic patients. They also perceived a sense of patient futility in the institutional forensic setting. The authors conclude by recommending that AAPL take a more active role in appealing to and representing such forensic psychiatrists.     

Management of forensic psychiatry patients who refuse medication--two scenarios

An Ohio federal court set Wyatt-type standards for treatment rights of forensic psychiatry patients and ordered legal due process-type hospital hearings to protect patients from what the court considers harmful clinical practices. Experience with this legal method for management of patients who refuse medication is examined for its impact on staff and patient care. Under legal pressure Ohio has built new regional forensic psychiatry hospitals. In one, spurred by legal activism, the prevalence of patients refusing medication has become pandemic. In its typical 16-bed ward, when 2 or more patients refuse medication, danger escalates rapidly for patients and staff. The method adopted to manage these situations is to assess the emergency of danger to patient or others, and if warranted to administer medication despite objections. This emergency management is dramatic in improving patient behavior and defusing milieu tensions. The psychiatrist ordering emergency management, however, faces challenges from several quarters--patient advocates, outside patients' rights legal advocates, and the commissioner of mental health. The clinically managed process contrasts markedly also with the legally imposed one in its impact on the personal and professional integrity of the responsible psychiatrist. Both scenarios illustrate the task yet remaining--integration of the clinical and legal concerns into a multisystem resolution of diverse interests, values, ethics, and rights.     

DBT in an outpatient forensic setting

Literature shows that effective treatment of borderline personality disorder (BPD) has become possible. However, borderline patients in forensic psychiatry do not seem to benefit from this development. In forensic psychiatry, prevention of criminal recidivism is the main focus of treatment, not core borderline problems like parasuicidal and self-destructive behavior. A dialectical behavioral treatment program for BPD was implemented in an outpatient forensic clinic in The Netherlands. Sociodemographic, clinical, and treatment data were collected from ten male, and nineteen female forensic BPD patients, and compared with corresponding data from fifty-eight non-forensic BPD patients. The results show that it is possible to implement dialectical behavior therapy in an outpatient forensic clinic. The data indicate that the exclusion of forensic patients, and especially female forensic patients, from evidence-based treatment is unjustified given the highly comparable clinical and etiological characteristics they share with female BPD patients from general mental health settings.     

Violent women: a multicentre study into gender differences in forensic psychiatric patients

To gain insight into the relatively small, but increasing group of women in forensic psychiatry, a retrospective multicentre study was started gathering information from the files of 275 female patients of four Dutch forensic psychiatric hospitals on characteristics and violence risk factors. Overall, a picture emerged of severely traumatized women with complex psychopathology with multiple previous treatment failures and many incidents during treatment. The present study investigates specific psychiatric and criminal characteristics of female patients by comparing their data to those of 275 male forensic psychiatric patients. Various prominent differences were found, for example, women had more complex histories of victimization, were more often diagnosed with borderline personality disorder, were more likely to commit homicide and arson and less likely to commit sexual offenses, and were more often involved in inpatient aggression than their male counterparts. Several recommendations for gender-responsive treatment and directions for future research are provided.     

First report from the Swedish National Forensic Psychiatric Register (SNFPR)

To the best of our knowledge, the present register is the only nationwide forensic psychiatric patient register in the world. The aim of this article is to describe the content of the Swedish National Forensic Psychiatric Register (SNFPR) for Swedish forensic patients for the year 2010. The subjects are individuals who, in connection with prosecution due to criminal acts, have been sentenced to compulsory forensic psychiatric treatment in Sweden. The results show that in 2010, 1476 Swedish forensic patients were assessed in the SNFPR; 1251 (85%) were males and 225 (15%) were females. Almost 60% of the patients had a diagnosis of schizophrenia, with a significantly higher frequency among males than females. As many as 70% of the patients had a previous history of outpatient psychiatric treatment before becoming a forensic psychiatric patient, with a mean age at first contact with psychiatric care of about 20 years old for both sexes. More than 63% of the patients had a history of addiction, with a higher proportion of males than females. Furthermore, as many as 38% of all patients committed crimes while under the influence of alcohol and/or illicit drugs. This was more often the case for men than for women. Both male and female patients were primarily sentenced for crimes related to life and death (e.g., murder, assault). However, there were more females than males in treatment for general dangerous crimes (e.g., arson), whereas men were more often prosecuted for crimes related to sex. In 2010, as many as 70% of all forensic patients in Sweden had a prior sentence for a criminal act, and males were prosecuted significantly more often than females. The most commonly prescribed pharmaceuticals for both genders were antipsychotics, although more women than men were prescribed other pharmaceuticals, such as antidepressants, antiepileptics, and anxiolytics. The result from the present study might give clinicians an opportunity to reflect upon and challenge their traditional treatment methods.     

Liberty and tardive dyskinesia: informed consent to antipsychotic medication in the forensic psychiatric hospital

This paper addresses informed consent to antipsychotic medication of those incarcerated in a forensic psychiatric hospital. The ways in which the unique setting of the forensic psychiatric hospital impinge upon the three components of informed consent--information, voluntariness, and competency--are explored. Special attention is given to the risk-benefit ratio of receiving antipsychotic medication in terms of the liberty interests at stake--freedom of movement, that is, the effects of tardive dyskinesia, and freedom of space, that is, release from the forensic psychiatric facility.     

Psychiatric evaluations of sexual offenders

Ninety-five defendants charged with sexual offenses were evaluated in a forensic psychiatry clinic. Their psychiatric diagnoses, as well as social, demographic, and criminal characteristics, were studied. Almost half were found to have personality disorders, while one-fifth were given a diagnosis of schizophrenia, affective disorder, or an atypical psychosis. Surprisingly few were diagnosed as having a paraphilia.     

Ethical issues in child and adolescent forensic psychiatry: a review

Ethical challenges in child and adolescent forensic psychiatry arise, on the one hand, from the dilemmas commonly faced in forensic psychiatry with adult patients, such as the dual role of the forensic psychiatrist, questions of criminal responsibility, autonomy and competence and involuntary treatment, and, on the other, from the immaturity and dependent position of the minor. Child and adolescent forensic psychiatry deals with minors involved in crime, not only as offenders, but also as victims. In this review, we attempt to describe ethical challenges in child and adolescent psychiatry using as a frame of reference the principles of biomedical ethics according to Beauchamp and Childress.     

司法精神病学鉴定为无精神病刑事案例的智力分析

目的研究司法精神病学鉴定中被鉴定为无精神病刑事案件者的智力水平。方法对88例被鉴定为无精神病的刑事案例及89例被鉴定为精神分裂症的刑事案例的智力测验结果进行对比分析。结果无精神病组与精神分裂症组的性别、年龄、文化、职业、婚姻及案件类型的构成差异无统计学意义;无精神病组的智力测验成绩显著优于精神分裂症组但低于正常水平(常模);自称有精神病或否认有精神病案例间智商的差异无统计学意义。结论无精神病案例的智力测验结果反映这类被鉴定人的智力有轻微受损。     

Forensic psychiatry: a subspecialty. The presidential address at the nineteenth annual meeting of the American Academy of Psychiatry and the Law

The implications of the definition of forensic psychiatry are explored, with particular reference to the field as a subspecialty of general psychiatry. The allegation of undue moral uncertainty in forensic psychiatry is denied and the moral issues are revealed to be related to the status of the underlying philosophical disputes. An outline for the organization of the forensic psychiatric assessment is presented. The charge that forensic psychiatry is not as "hard" a science as the other forensic sciences is denied. The administrative and political organizational problems facing the subspecialty are explored. The practitioners in the field are encouraged to recognize that forensic psychiatry is a subspecialty and to work for official subspecialty status. Cautious predictions about the future of the field are provided.     

A study of the use of sedative PRN medication in patients at a secure hospital

We have investigated the use of ‘as required’ (PRN), sedative psychotropic medication in 242 forensic rehabilitation patients at a UK secure psychiatric hospital. In total, 176 (73%) patients were prescribed PRN medication and 90 (37%) received a total of 542 doses in the preceding two weeks. The principle indication for use was agitation. Oral benzodiazepines, particularly Lorazepam, were most commonly prescribed and administered followed by Haloperidol. Although high-dose antipsychotics and polypharmacy due to PRN prescribing were common (11 and 20%, respectively), on only 6% of the days studied did patients actually receive PRN antipsychotic medication. Using univariate analyses, PRN administration was associated with younger age, female gender, emotionally unstable personality disorder, shorter length of stay and detention in medium security. Case note documentation of PRN administration was often absent (44%) or vague. Further research, both quantitative and qualitative, is needed into the precise circumstances under which PRN is administered.     

Fatal Diabetic Ketoacidosis and Antipsychotic Medication

Hyperglycemia and new onset diabetes have been described with certain antipsychotic medications and some of the initial presentations are fatal diabetic ketoacidosis (DKA). We report 17 deaths due to DKA in psychiatric patients treated with second generation antipsychotic medications. Death certificates and toxicology data were searched for DKA and hyperglycemia. We reviewed the medical examiner records which included the autopsy, toxicology, police, and medical examiner investigators' reports. The decedents ranged in age from 32 to 57 years (average 48 years). There were 15 men and two women. The immediate cause of death was DKA in all. The psychiatric disorders included: 10 schizophrenia, three bipolar/schizophrenia, two bipolar, and two major depression. The most frequent atypical antipsychotic medications found were quetiapine and olanzapine followed by risperidone. In 16 deaths, we considered the medication as primary or contributory to the cause of death.     

精神分裂症与司法精神病鉴定

精神分裂症在司法精神病鉴定中占首位,精神分裂症患者的作案动机、作案方式及作案后果均具有特殊性,因此精神分裂症在司法精神病鉴定中占有很重要的地位。笔者结合国内外有关文献,对精神分裂症患者所致司法案件的作案特征以及患者的责任能力、受审能力、服刑能力的研究进行综述。     

Stigma and discrimination in mentally disordered offender patients – a comparison with a non-forensic population

High levels of stigma and discrimination are reported by individuals with mental health problems. Aim: To assess self-reported levels of stigma and discrimination in forensic psychiatric patients, with psychotic illness, compared with general adult psychiatric patients with psychosis. Hypothesis: Individuals with a history of violent offending, as well as severe mental illness, report more stigma and discrimination, than non offender patients, as a result of them being perceived as dangerous and unpredictable. Method: Experiences of stigma and discrimination were compared in 32 forensic and 32 non-forensic general psychiatric patients, with schizophrenia or schizoaffective disorder, using the Stigma and Discrimination Scale (DISC). Results: Stigma and discrimination were widely reported by all patients, particularly affecting relationships with family, intimate relationships and friendships. No significant difference emerged between the forensic and non-forensic patients, in experienced or anticipated stigma. Conclusions: We suggest that the lower level of psycho pathology, longer inpatient stays and intensive rehabilitation for forensic patients may reduce the extent to which these patients experience stigma and discrimination.     

Assessing reliability, validity, and clinical utility of the BEST-Index in measuring living skills among forensic inpatients

The assessment of behavioral change as a result of inpatient treatment in forensic psychiatry is an important precondition for violence risk prediction in forensic psychiatry. In relation to a multitude of diagnostically based risk assessment instruments, there is a shortage of appropriate instruments with which to carry out valid and reliable therapeutic assessments that are behaviorally based and therefore appropriate for use within varied psychiatric contexts. There is also a need for instruments which will offer assessors the opportunity to examine possible relationships between criteria of social risk and criteria of more general aspects of social functioning. Tapping the issues pointed out above, the authors present an overview of a normatively based social profiling instrument (the BEST-Index), and discuss evidence for its validity, reliability, and aspects of clinical utility.     

Who's afraid of forensic psychiatry?

Forensic psychiatry has come under mounting criticism from the press and other medical professionals, largely for its participation in the insanity defense. The author argues that the expertise available from the specialty is of increasing importance to psychiatry as a whole, as more and more legal issues become relevant to the practice of general psychiatry, and should be actively encouraged and legitimized rather than ostracized. All psychiatrists should be exposed to forensic principles and practices during their training, and the ability of forensic psychiatrists to serve as transducers between the clinical and the legal/judicial should be increasingly used to present the clinical viewpoint effectively in courts and legislatures.     

"Theory of Mind" and Executive Functioning in Forensic Patients with Schizophrenia

Abstract:  Previous studies in forensic patients with schizophrenia have shown that delinquent patients may outperform nondelinquent patients with regards to "theory of mind" (ToM). Findings were, however, confounded by a lack of control for executive functioning. We examined 33 forensic patients with schizophrenia regarding ToM, intelligence, executive functioning, and psychopathology. Results were compared with a nonforensic schizophrenia sample and a group of healthy controls. Both patient groups performed more poorly on most measures compared with controls. Forensic and nonforensic patients did not differ in task performance. In the forensic group ToM correlated inversely with "excitement" and cognitive symptoms. When "excitement" was covaried out, forensic patients outperformed nonforensic patients with regards to ToM. This study supports the hypothesis that schizophrenic patients with a criminal record are equally impaired in their ability to infer mental states compared with nonforensic patients, but for different reasons associated with a divergent psychopathological profile.