"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.     

The character of danger in psychiatric practice: are the mentally ill dangerous?

This paper explores the question of dangerousness and the mentally ill. Research for this paper was stimulated by the death by homicide of two psychiatrists in Oregon in 1985. The paper reviews three distinct areas in the psychiatric literature: the arrests of mental patients, assaults against psychiatrists and other mental health professionals, and assaultive behaviors exhibited by patients in hospitals and other psychiatric settings. The author concludes that the risks are real but are dependent, for the most part, on setting and the acuteness of illness. Realism in regard to risk is critical for the mentally ill, their families, professional caregivers, and society in general.     

Applying a forensic actuarial assessment (the Violence Risk Appraisal Guide) to nonforensic patients

The actuarial Violence Risk Appraisal Guide (VRAG) was developed for male offenders where it has shown excellent replicability in many new forensic samples using officially recorded outcomes. Clinicians also make decisions, however, about the risk of interpersonal violence posed by nonforensic psychiatric patients of both sexes. Could an actuarial risk assessment developed for male forensic populations be used for a broader clientele? We modified the VRAG to permit evaluation using data from the MacArthur Violence Risk Assessment Study that included nonforensic male and female patients and primarily self-reported violence. The modified VRAG yielded a large effect size in the prediction of dichotomous postdischarge severe violence over 20 and 50 weeks. Accuracy of VRAG predictions was unrelated to sex. The results provide evidence about the robustness of comprehensive actuarial risk assessments and the generality of the personal factors that underlie violent behavior.     

Elderly sexual offenders admitted to a maximum-security forensic hospital

The purpose of the study was to determine the clinical and demographic characteristics of elderly sexual offenders at a maximum-security forensic hospital. Charts of male elderly patients charged with sexual offenses were reviewed to obtain clinical and demographic data. The majority of sexual offenders had mood or psychotic disorders. Almost one third had a history of violent or assaultive behavior. 57% had significant medical history. A history of violence and sexual assaultive behavior may be risk factors for future sexual offenses.     

The Darkest Figure of Crime: Perceptions of Reasons for Male Inmates to Not Report Sexual Assault

Although sexual assault behind bars is recognized as problematic, very few of the sexual assaults that occur behind bars are officially reported. Many researchers have examined the individual and institutional variables which can help predict an inmate’s probability of being victimized by his fellow inmates. With a sample obtained from a sample of eight Texas prisons, the current survey will disentangle the individual, institutional, and individual–institutional level variables which contribute to the rationales behind inmates choosing to report or not report sexually assaultive behavior. The findings somewhat mirror the findings of sexual assaults in the free community, with inmates indicating that the primary reasons to not report include embarrassment, fear of harassment, and retaliation from the perpetrator.     

A Comparison of Forensic and Nonforensic Malingerers: A Prototypical Analysis of Explanatory Models

Explanatory models of malingering strive to understand the primary motivation underlying attempts to feign. Rogers, Sewell, and Goldstein (1994) provided empirical support for the conceptualization of pathogenic, criminological, and adaptational models. In the current study, a prototypical analysis of 221 forensic experts results in a slightly refined formulation: the adaptational model was decomposed into its two broad dimensions (cost–benefit analysis and adversarial setting). An important finding is that the factor structure for the explanatory models remained stable when applied to both forensic and nonforensic cases. As a first investigation, significant differences were observed in prototypical cases of malingering by the category of referral (forensic or nonforensic) and by type of feigning (mental disorders, cognitive impairment, and medical syndromes). Surprisingly, the feigning of medical syndromes appeared to play a relatively prominent role in both forensic and nonforensic cases and to be influenced by the apparent adversarial context of the assessment. Finally, important gender differences were observed, especially with nonforensic prototypical cases of malingering.     

Assaults on prison officers: Interactional themes

Little is known of the circumstances surrounding prison inmates' assaults on correctional officers. To provide a foundation for understanding the meaning of these events, this exploratory study analyzes a sample of 694 official reports of assaultive incidents in a large state prison system over a one-year period. Results of a content analysis suggest that assaultive events occur in relation to a number of interactional themes—unexplained, officer's command, protest, search, inmates' fighting, movement, contraband, restraint, discipline, emotional instability, sexual, intoxication, and medical. The study's findings affirm that prisoners and officers must cooperate in order to negotiate each day with a minimum of disruption. When either party violates salient norms, mutually beneficial interaction patterns may break down and violent interactions may result. Officially reported assaults on staff members may be understood most clearly by considering the authority of officers, the autonomy of prisoners, and processes of social control enacted by prisoners and officers alike.     

Medical school forensic psychiatry units in health care delivery facilities rather than criminal justice institutions: an alternative model

We have presented a model for developing forensic psychiatric treatment and teaching services of a medical school Department of Psychiatry, but where these services are the basic comprehensive health care delivery system for the entire community. These offer consultative and treatment services for adult and family court clinic, psychiatric forensic services, of forensic psychiatry open bed and medium security-type bed, as well as day hospital and outpatient services. All of these are sited in the normal health care delivery system of the university teaching hospitals and its patient treatment, teaching, and research facilities. Consultative services are offered on request to the criminal justice system, but the basic health care delivery system is controlled administratively by the ordinary university teaching hospital authorities and exists as a one of a kind unit at the Royal Ottawa Hospital. The Royal Ottawa Hospital is a private nonprofit hospital, with its own Board of Trustees, and is affiliated with the medical school, as part of a major university network. We believe it important to present this model for an overall forensic psychiatric service, in contradistinction to the more commonly established forensic psychiatric facilities in state mental hospitals, in a special facility for the criminally insane, or in a criminal justice system institution such as a penitentiary. We believe that our model for forensic psychiatric facilities has great advantages for the patient. Here the patient is treated in a specialized facility (as all psychiatric patients with specialized problems should be); but one which is a specialized forensic facility, within the range of specialized psychiatric facilities that are needed by an urban community.(ABSTRACT TRUNCATED AT 250 WORDS)     

Creating a State‐Academic Partnership to Advance a Forensic Teaching Service: Benefits and Barriers

In Washington State, like many states, there is a shortage of forensically trained mental health clinicians to work with criminal justice‐involved individuals. At the direction of the state legislature, a collaborative project was undertaken by the University of Washington, the state Department of Social and Health Services, and a state psychiatric hospital to develop a proposal for a jointly sponsored forensic teaching service. The authors reviewed the literature, surveyed and interviewed forensic psychiatry and psychology training directors, and conducted site visits of selected training programs that offer multidisciplinary training or have affiliations with state hospitals. The authors conducted focus groups of additional stakeholders, including clinicians and patients in forensic settings, to better understand the needs in Washington. The authors report on several common benefits and barriers to establishing forensic teaching services. Other states and forensic programs may find this article useful in identifying common considerations for forensic mental health teaching services.     

Interpersonal violent crime in Ghana: The case of assault in Accra

This study examined the trends, patterns, and socio-spatial conditions and factors that foster assaultive incidents and behaviors in Accra, Ghana. Specifically, the study examined how much assaults occurred over time, background characteristics of the victims and offenders, victim-offender relationships, and the housing units that recorded the most assaults. Among the triggers of assaults were females in familial settings and neighborhood propinquity, that is, disputants related through kinship, residential proximity, and contractual obligations. Arguments, drunkenness name-calling, jokes, funerals, inheritance, property, festivals, chieftaincy, communal living and sharing, such spatial factors as transient populations and routine activities were among the remote and immediate causes of the assaultive incidents. Among the housing units, the compound houses recorded the highest assaults. The majority of the victims and suspects were young males, between eighteen and thirty-four years, unemployed or in low paying blue-collar jobs. The majority of the assaults occurred in Accra Central, the precinct with the most compound homes and lower-class neighborhoods, followed by Nima, Kaneshie, and Kpeshie. Most assault incidents occurred in the morning, between 6:00 a.m. to 9:00 a.m. and in the afternoon, between 5:00 p.m. to 7:00 p.m.     

The Criminogenic,Clinical, and Social Problems of Forensic and Civil Psychiatric Patients

Forensic psychiatric patients consume an increasing proportion of mental health resources in Canada and the United States. To inform mental health policy and practice, we compared the criminogenic, clinical, and social problems of forensic patients to those of civilly committed psychiatric patients in two Canadian studies. We predicted that forensic patients would score higher on criminogenic problems and lower on clinical and social problems than civil patients in two studies: one comparing 83 forensic and 189 civil inpatients on a clinician-completed form, the Resident Assessment Instrument--Mental Health, at an urban mental health center, and the second comparing 423 forensic and 178 civil patients assessed at different times using the Patient Problem Survey. The two studies were quite similar in their findings, despite differences in their samples, measures, and data collection methods. In both studies, forensic patients were similar to or lower than civil psychiatric patients in all criminogenic, clinical, and social problems. We conclude that forensic mental health services would benefit greatly by drawing from knowledge accumulated in the general psychiatric literature. This finding also supports the idea that many forensic patients can be appropriately diverted to nonforensic mental health services.     

Characteristics of assaultive patients with schizophrenia versus personality disorder: six year analysis of the Assaulted Staff Action Program (ASAP)

Literature reviews of individual assaultive patients, repetitively violent patients, and restrained assaultive patients document that persons diagnosed with schizophrenia or personality disorder are at the highest risk to become assaultive. While there has been some initial research of possible predictor variables across diagnostic groups, this six-year retrospective study is the first to compare only persons with schizophrenia or personality disorder on basic demographic and the selected clinical variables of history of violence, personal victimization, and substance use disorder. In this study, the variance suggested that persons with schizophrenia and personality disorder were both likely to be assaultive. Assaults by persons with schizophrenia were somewhat proportional to their presence in the population studied. However, personality disordered patients represented a disproportional increase from the population studied. Younger females with a diagnosis of personality disorder and with histories of violence toward others and personal victimization appeared at increased risk to be assaultive and to require restraints. The findings and their implications for safety and clinical care are discussed.     

Criminal Recidivism After Forensic Psychiatric Treatment. A Multicenter Study on the Role of Pretreatment,Treatment-Related,and Follow-Up Variables

This study examined associations between criminal recidivism after discharge from forensic treatment and variables related to either the time before the current forensic treatment, or the current forensic treatment, or the follow-up after discharge. Participants were treated in 12 forensic clinics according to section 63 of the German penal code. A patient was classified as a criminal recidivist when the patient or the aftercare reported that the patient was delinquent at follow-up. Patients without criminal recidivism were patients for which both perspectives (patient and aftercare) reported no delinquency at follow-up. Mann–Whitney U-tests and Fisher's exact tests were performed. Data to classify patients were available for N = 249 patients. Fifteen patients (6%) were classified as criminal recidivists. The follow-up was M = 12.58 (SD = 1.84) months, and the criminal acts occurred M = 6.00 (SD = 5.55) months after discharge. Differences between patients with and without criminal recidivism were found in pretreatment (young age at first crime, early onset of mental disorder, previous forensic treatments), treatment-related (disorder due to psychoactive substance use, gradual release abuses, outbreaks, assaults against staff, criminal act during treatment, type of discharge, outcome ratings), as well as follow-up variables (no specified housing situation, not being abstinent from psychoactive substances, inpatient readmission, course of outpatient treatment, course of mental disorder) (all p < 0.05). To conclude, it is important to consider variables related to the time before the current treatment, treatment-related variables, and variables related to the follow-up to identify the patients at risk of criminal recidivism after discharge from forensic treatment.     

ESCALATION AND DESISTANCE OF WIFE ASSAULT IN MARRIAGE*

This article examines two widely held beliefs concerning the nature of “careers” of wife assault. Most researchers and members of the public believe that assaultive behavior in marriage, once begun, tends to continue for the life of the marriage. It is also commonly believed that minor violence (e.g., slapping, shoving, throwing things at a spouse) is unrelated to severe assaults (e.g., punching, kicking, using a weapon). These beliefs are based on the most severe cases of wife battering, as described by the media and by women in shelters. Despite these beliefs, we suggest that wife assault is similar to other forms of deviance and crime, in that desistance is common and engaging in minor forms of deviance is a risk factor for engaging in major forms of deviance and crime. The article reports a study using data on a sample of 380 married respondents who reported some violence in their marriage in 1985 and were reinterviewed in 1986. The findings indicate that most marital violence is transient, but even minor violence by a wife poses a risk of escalation to more dangerous assaults by a husband. Theoretical and practical implications of the findings are discussed.     

Predicting discharge in forensic psychiatry: the legal and psychosocial factors associated with long and short stays in forensic psychiatric hospitals

In Germany, both the number of patients treated in forensic psychiatric hospitals and the average inpatient treatment period have been increasing for over thirty years. Biographical and clinical factors, e.g., the number of prior offences, type of offence, and psychiatric diagnosis, count among the factors that influence the treatment duration and the likelihood of discharge. The aims of the current study were threefold: (1) to provide an estimate of the German forensic psychiatric patient population with a low likelihood of discharge, (2) to replicate a set of personal variables that predict a relatively high, as opposed to a low, likelihood of discharge from forensic psychiatric hospitals, and (3) to describe a group of other factors that are likely to add to the existing body of knowledge. Based on a sample of 899 patients, we applied a battery of primarily biographical and other personal variables to two subgroups of patients. The first subgroup of patients had been treated in a forensic psychiatric hospital according to section 63 of the German legal code for at least ten years (long-stay patients, n=137), whereas the second subgroup had been released after a maximum treatment period of four years (short-stay patients, n=67). The resulting logistic regression model had a high goodness of fit, with more than 85% of the patients correctly classified into the groups. In accordance with earlier studies, we found a series of personal variables, including age at first admission and type of offence, to be predictive of a short or long-stay. Other findings, such as the high number of immigrants among the short-stay patients and the significance of a patient's work time before admission to a forensic psychiatric hospital, are more clearly represented than has been observed in previous research.     

Approaches to the improvement of forensic medical expertise in the cases of sexual crimes and doubtful gender status

The authors analyzed the results of the forensic medical expertise of the cases of sexual assaults and covert sexual abuse. Special attention is given to the peculiarities of forensic-medical expertise in the cases of veneral diseases and HIV-infection, injuries to sexual organs in women and men. The specific approaches to the examination of corpses in the cases of atypical sexual behavior or a murder supposedly committed for sexual motives are considered.     

Particularities Regarding the Etiology of Sepsis in Forensic Services

If in clinical practice definitive diagnostic criteria had been established, after death sepsis is often difficult to diagnose, especially if a site of origin is not found or if no clinical data are available. This article will analyze the etiology of sepsis in a medical‐legal service with emphasis on the differences in diagnosing it in clinical and forensic environments. A total of 78 cases of sepsis cases diagnosed or confirmed at the autopsy were selected. The etiological agent was determined either during the hospitalization or by postmortem bacteriology. A high prevalence of Gram‐negative sepsis was found, especially multidrug‐resistant micro‐organisms. Most frequent etiological agents were Acinetobacter baumannii, Escherichia coli, Enterobacter, Enterococcus, Pseudomonas, and Klebsiella. Polymicrobial sepsis is much more frequent than in nonforensic cases. In legal medicine, the prevalence of Gram‐negative sepsis is much higher than in nonforensic autopsies, and the point of origin is shifted toward the skin and the gastrointestinal system.     

The impact of a change in commitment procedures on the character of involuntary psychiatric patients

The statutory requirements for involuntary civil psychiatric confinement have become increasingly restrictive. In the jurisdiction under investigation, patients were originally admitted under an Order to Apprehend (OTA) procedure simply on the petition of two affiants who indicated the patient was in need of care. A newly elected judge instituted changes requiring affiants to claim the subject was "dangerous" to self or others and asking for a clinical assessment and recommendation before signing the petitioned request for involuntary confinement. It might be expected that the more restrictive procedures would have produced a population of more assaultive patients. A study of petitions signed under in the earlier (N = 133) and later, more restrictive (N = 218) procedures indicated that the proportion of assaultive or dangerous patients was virtually identical. Further investigation, using hospital data an OTA patients from this area in both time periods, suggested that while patients were not more assaultive, they appeared to be more seriously ill or psychiatrically impaired. Apparently, movement to a dangerousness standard that allows clinical discretion in interpreting its presence may result in involuntary commitments for more seriously ill, although not necessarily more assaultive, patients.     

Family violence reported in a psychiatric emergency room

The prevalence of family violence reported in psychiatric emergency rooms is relatively undocumented, despite the clinical and legal concern for dangerousness. This study assesses the prevalence of aggression incidents reported to clinicians and physicians during evaluation interviews (n =389).Two-thirds of the total number of subjects reported being involved in an aggression incident sometime in their past. Only 8% reported being the victim of such incidents. About one-half of the cases involved physical assaults; nearly one-half of these assaults had family members as victims. One third of the total cases had been assaultive within 3 months; one sixth had been assaultive within 2 weeks of visiting the hospital. Clinicians and researchers are urged to consider more systematically family violence in psychiatric settings.     

Capital Offenders in Texas Prisons: Rates, Correlates, and an Actuarial Analysis of Violent Misconduct

This study analyzed the records of 136 recently incarcerated capital murder offenders in the initial phase (M = 2.37 years, range = 6-40 months) of their life sentences in the Texas Department of Criminal Justice. Prevalence rates of institutional violence were inversely related to severity: potentially violent misconduct (36.8%), assaultive violations (14%), serious assaults (5.1%), and homicides (0%). Consistent with prior studies, factors correlated with assaultive misconduct included age (inversely), prior prison confinement, and concurrent robbery or burglary in the capital offense. A simplified Burgess scale entitled the Risk Assessment Scale for Prison-Capital (RASP-Cap) was moderately successful in identifying varying levels of improbability of committing violence-related misconduct however defined (AUC = .715-.766).