Characteristics and offences of women with borderline personality disorder in forensic psychiatry: a multicentre study

Although female forensic patients diagnosed with borderline personality disorder (BPD) are generally considered taxing in clinical practice, little is known about their specific characteristics or offences. In this study, 156 female forensic psychiatric patients diagnosed with BPD were compared to 113 diagnosed otherwise. Information on demographic and psychiatric characteristics, victimization, index offences, and incidents during treatment was gathered from patient files. Risk factors for recidivism were assessed using the PCL-R and historical items of the HCR-20, including items from the new Female Additional Manual (FAM). Compared to non-BPD women, BPD women were more likely to have been abused as children and to have a history of outpatient treatment. While less likely to be convicted for (attempted) homicide, a higher percentage of BPD women was convicted for arson. Comorbid substance abuse was more frequent in the BPD group and incidents towards others and themselves were more violent in nature. The PCL-R and the H-scale of the HCR-20/FAM indicated several risk factors especially important for BPD women, such as poor behavioural control, impulsivity, and irresponsibility. The results support the clinical impression that women diagnosed with BPD are a subgroup within the female forensic psychiatric population, with specific focus points for treatment and management.     

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.     

Mentally challenged patients in a forensic hospital: a feasibility study concerning the executive functions of forensic patients with organic brain disorder, learning disability, or mental retardation

The past years have seen an increasing number of patients of lower intelligence or with organic brain disorder being committed into our forensic psychiatry. Our clinic has an ongoing scientific project to investigate the possibilities of reducing costs while at the same time guaranteeing adequate treatment and enforcement practice in forensic hospitals. This current project did not take these kinds of patients into consideration initially. This feasibility study is intended to examine if and to what extent these patients can be part of the scientific project. All patients of forensic psychiatry in Rostock (Mecklenburg-Western-Pomerania) with an IQ<80 (learning disorder) or a primary or secondary organic brain dysfunction that have been committed to the clinic since 2009 are included. These patients went through an extensive battery of neuropsychological tests. Furthermore, the treating psychotherapists had to rate the prognoses for criminal re-offending at discharge. Patients affected by lower intelligence or an organic brain dysfunction achieve lower results in neuropsychological testing than other patients participating in the main project. Nevertheless, participation in neuropsychological testing does not appear to overtax them. Future examination of the patients will be conducted to investigate to what extent certain therapeutic methods have been of noticeable benefit to this problematic group.     

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)     

No-show at a forensic psychiatric outpatient clinic: risk factors and reasons

Nonattendance for and late cancellations of scheduled appointments, that is no-show, is a well-known phenomenon in psychiatric outpatient clinics. Research on the topic of no-show for initial and consecutive appointments in the field of forensic psychiatry is scarce. This study therefore aims to determine the prevalence and causes of no-show and to explore reasons for nonattendance. The study was carried out in an outpatient clinic in northern Netherlands. Telephone interviews were administered to 27 no-show clients, 84 follow-up no-show clients, and 41 attendees of 18 years and older. A no-show rate of 24.9% and a follow-up no-show rate of 9.8% was found. The majority of appointments missed were in the beginning phase of clinic contact. No-show clients were younger than their attending counterparts and more often dropped out from clinic contact. Also, less family social support was experienced by nonattendees. Reasons for nonattendance were having forgotten about appointment and work commitments.     

Domestically and generally violent forensic psychiatric outpatients: personality traits and behavior

A group of 63 domestically violent patients and a group of 103 generally violent patients at a Dutch forensic psychiatric outpatient clinic are examined with regard to personality traits and problem behaviors to develop treatment programs for domestically violent patients. The domestically violent patients are more unstable from a psychological viewpoint but not more inclined to anger than the average Dutch male. They report less anxiety in situations in which criticism can be given but more anxiety in situations in which someone can be given a compliment. When comparing domestically violent patients with generally violent patients, domestically violent patients score lower on anger as disposition and on aggressive behavior than the generally violent patients do. However, both groups do not differ from each other in their score on the dimension of psychopathy.     

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.     

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.     

法医精神病鉴定内容架构及评定要点解析

法医精神病鉴定在刑事、民事和行政三大诉讼领域中,以鉴定意见的证据形式发挥着重要作用。然而,与其重要性不相匹配的是,法医精神病鉴定学科发展尚不完善、专业发育尚不成熟,尚不能满足社会和民众的期盼和要求,甚至引发负面评价。为进一步促进法医精神病鉴定规范化、标准化建设。以法医精神病鉴定人的视角,结合法医精神病鉴定的内容架构,重点阐述法医精神病鉴定主要项目及其作用、评定要点,尤其聚焦刑事责任能力评定,阐明当前存在分歧和困难;简要介绍法医精神病鉴定人执业要求、法医精神病鉴定质量控制;以及简述法医精神病鉴定与临床精神医学实践的区别与联系。     

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.     

Self-reported versus diagnosed paraphilias in outpatient sexual offenders

Literature has repeatedly reaffirmed sexual deviance as a risk factor for sexual recidivism, making it an important subject to examine. Yet, not all studies confirm the relevance of sexual deviance and there is a lack of consensus regarding the assessment of it. In the current study, 499 Dutch adult male subjects, admitted for sexual misconduct (possession of child abuse material, child molestation and other types of inappropriate sexual behaviour) to an outpatient forensic treatment facility, were compared regarding sexual paraphilias using self-reports from clients and official DSM-IV-TR diagnoses assessed by professionals. Analyses revealed a relatively low similarity between self-reports and diagnoses, self-reports generating considerably more information. Furthermore, correlating the paraphilias revealed paedophilia associated minimally with the other paraphilias. Lastly, the different types of offenders varied significantly in number of self-reported and diagnosed paraphilias, with the miscellaneous group presenting the most. Considering these outcomes may help assessment and target treatment goals in forensic psychiatry.     

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.     

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.     

The prognostic value of the PCL-R in relation to the SUD treatment ending

Scientific research about patients with substance use disorders (SUD) treated within the context of forensic compulsory addiction treatment is seldom available. Scientifically supported surveys regarding the treatability of SUD patients are rare. Some authors claim that the Psychopathy-Checklist-Revised (PCL-R) has value for predicting therapeutic success. PCL-R scores rely on extensive interview data and a detailed review of criminal records and social history. The scores reflect 1) the affective and interpersonal psychological traits; and 2) socially deviant conduct. This study was conducted by the forensic professional clinic at the hospital for Psychiatry and Neurology Hildburghausen. We assessed 102 male patients using the PCL-R. This investigation evaluated the Total score of the PCL-R and the score of Factor 1 and Factor 2 in relation to the end of treatment by court order. The results showed significant differences between patients who completed treatment and those who did not. Patients that dropped out of treatment had a higher score in PCL-R. With the use of the PCL-R it is possible to make a quantitative statement about which patients will complete treatment.     

Evidence-based practice in group work with incarcerated youth

As a result of the Youth Criminal Justice Act's increased focus on restorative justice, treatment, rehabilitation, and reintegration of youth, many more juvenile offenders require mental health services while resident in youth detention facilities [Youth Criminal Justice Act (2002, c.1). Ottawa: Department of Justice Canada. Retrieved September 19, 2008 from http://laws.justice.gc.ca/en/Y-1.5]. Several common characteristics such as violence, aggression, and other antisocial behaviors, associated with criminal behavior, have been identified among male and female offenders. Dialectical behavior therapy, originally developed by Linehan [Linehan, M. M., 1993a. Cognitive–behavioural treatment of borderline personality disorder. New York: Guildford Press] for chronically parasuicidal women diagnosed with borderline personality disorder, has been successfully modified for use with other populations, including violent and impulse-oriented male and female adolescents residing in correctional facilities. The intent of this article is to encourage the wider use of dialectical behavior therapy (DBT) with young offenders. It includes an extensive review of the evidence-base to date and describes some of the creative modifications that have been made to standard DBT program format to meet the particular needs of various groups in both Canada and the United States. In keeping with the movement toward more evidence-based practice, the authors argue that DBT is a promising approach in group work with incarcerated adolescents and should be more widely used.     

Doing justice to justice

Adshead's recognition that only when taken together can the many different conceptions of justice accommodate what is called for in the particularly demanding setting of forensic mental health care, is to be applauded. Each must be honoured and built into the systems of assessment and treatment that are the tasks of the forensic psychiatrist, she demonstrates. Adshead's far‐reaching revisions could resolve much that is troubling about the present practice of forensic psychiatry. Yet how much these revisions can overcome the moral dilemmas associated with dual roles in forensic psychiatry, is not so clear.     

略论“鉴定留置”——由邓玉姣案说起

邓玉娇故意伤害案中的司法精神医学鉴定的过程,非常典型地暴露出了我国司法精神医学鉴定中有关＂鉴定留置＂制度缺位的严重问题。精神病鉴定虽然是一个医学问题,但它更是一个法律问题,我国对司法精神病鉴定制度的规定存在严重的缺失,对精神病鉴定等一系列问题的立法必须提升到我国立法的议事日程上来。对此,我们应当借鉴国外成熟经验,首先,应认识到对犯罪嫌疑人精神病鉴定是需要干涉公民人身自由的强制处分行为,并明确限定鉴定留置的范围。其次,对于鉴定留置的适用条件,在决定适用此措施之前必须听取鉴定人、辩护人意见,同时,鉴定留置措施只能适用于具有重大犯罪嫌疑的被指控人。再次,应明确规定对犯罪嫌疑人精神病鉴定的期间,在对犯罪嫌疑人精神病鉴定的期间不计羁押期限的基础上,明确犯罪嫌疑人精神病鉴定的时间,应当能够折抵刑期。     

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.     

刑事诉讼中法医精神病鉴定争议的反思与理论诠释

法医精神病鉴定在一些重大刑事案件中持续成为舆论关注的焦点。不论法医精神病鉴定启动与否均会陷入被质疑的困境。这既存在制度安排的问题,也存在鉴定本身的问题,还存在凭直觉判断的问题,更存在理论误导的问题。这些问题叠加在一起衍生了较为复杂的中国性问题。这一复杂问题的解决,需要合理配置启动法医精神病鉴定程序的权力(利),科学对待法医精神病鉴定本质,尊重法医精神病鉴定的医学认定,正确使用法医精神病鉴定意见中的刑事责任能力判断,在正当程序中维护法医精神病鉴定的科学性。对于非制度问题需要正确的理论诠释,避免因实践难题与理论缺陷交织触发一些不具有实质意义的纷争和枉顾科学的呼吁。