Among a German Sample of Forensic Patients,Previous Animal Abuse Mediates Between Psychopathy and Sadistic Actions

In an attempt to explain the relationship between psychopathy and severe violent behavior, this study associates previous animal abuse, psychopathy, and sadistic acting in forensic patients. Two topics are addressed: (i) whether previous animal abuse can be identified by a patient's Psychopathy Checklist profile and (ii) whether animal abuse statistically mediates between psychopathy and sadistic acting. In a German forensic hospital, 60 patients were investigated. Animal abuse was assessed using face‐to‐face interviews and the Psychopathy Checklist: Screening Version (PCL:SV), and sadistic acting was identified by file records.Discriminant analysis separated previous animal abuse (10/60) by high adolescent antisocial behavior, superficiality, lack of remorse, lack of empathy, and grandiosity. The mediation from psychopathy to sadistic acting (6/60) through animal abuse was found to be complete.The results, although sample size is limited and base rate of animal abuse and sadistic acting are low, fit with a model suggestive of animal abuse as a causal step toward sadistic crimes. Animal abuse correlates with callous, unemotional traits, and a development of sadistic crimes.     

The Eyeball Killer: Serial Killings with Postmortem Globe Enucleation

Although serial killings are relatively rare, they can be the cause of a great deal of anxiety while the killer remains at‐large. Despite the fact that the motivations for serial killings are typically quite complex, the psychological analysis of a serial killer can provide valuable insight into how and why certain individuals become serial killers. Such knowledge may be instrumental in preventing future serial killings or in solving ongoing cases. In certain serial killings, the various incidents have a variety of similar features. Identification of similarities between separate homicidal incidents is necessary to recognize that a serial killer may be actively killing. In this report, the authors present a group of serial killings involving three prostitutes who were shot to death over a 3‐month period. Scene and autopsy findings, including the unusual finding of postmortem enucleation of the eyes, led investigators to recognize the serial nature of the homicides.     

Self‐Embedding Behavior in Adults: A Report of Two Cases and a Systematic Review

Self‐embedding behavior (SEB) is the repeated insertion of sharp objects, such as needles or pins, into the soft tissues of abdomen, limbs, and other body parts. In this study, two cases of SEB were reported and the scientific worldwide literature reviewed. Thirty‐two cases of SEB were identified through systematic searches in the main bibliographic databases. Mean age was 35 years (SD = 8.97). Just over two‐thirds of the patients were female. Although the number of embedded objects could be as high as 200, major clinical and surgical complications were uncommon and mortality was null. Patients with SEB presented three major diagnoses: psychotic (25%), personality (21.9%), and factitious (28.1%) disorders. The practice of SEB largely went undetected as the patients themselves did not bring it to the attention of family members or physicians and usually denied they have engaged in SEB. A high level of suspicion is required to avoid a missed diagnosis.     

A case of factitious pedophilia

Factitious disorder involves feigning, exaggerating, or self-inducing physical and/or psychological ailments with the goal of assuming the "sick" or "patient" role. In turn, the sick role entitles the factitious disorder patient to care, nurturance, and protection; it also exempts one from usual responsibilities. In this paper, we present the first reported case of factitious pedophilia. Although it seems counterintuitive, this middle-aged man has falsely claimed or exaggerated sexual desire for minors ostensibly to remain in a state hospital; indeed, he has remained in the same inpatient facility for more than 20 years as a result of his deceptions. At times, his reports have included disconfirmed claims of bizarre accidents and other physical travails. This case enlarges the literature on factitious psychological disorders and shows that some individuals may falsify paraphilic behaviors, although clearly minimization of these behaviors remains more common.     

Failings of Trauma‐Specific and Related Psychological Tests in Detecting Post‐Traumatic Stress Disorder in Forensic Settings

Judges and juries tend to be particularly impressed by test data, especially quantitative test data. Psychometric tests specific for assessing the presence of post‐traumatic stress disorder (PTSD) are commonly employed by forensic mental health evaluators. Most of these instruments, however, have been designed to detect PTSD in treatment or research, and not forensic, settings. Those who rely on these measures without adequate awareness of their often significant limits in correctly identifying malingering may induce finders of fact to inordinately confidently accept the presence of PTSD. This article reviews problematic structural and content components of trauma‐specific and related instruments used to evaluate PTSD and discusses the utility of specific techniques liable to be used in forensic settings to “fool” these measures.     

Physical Restraint and Near Death of a Psychiatric Patient

Physical restraint is used as a last resort emergency measure to calm and safeguard agitated and/or aggressive psychiatric patients. This can sometimes cause injuries, and rare fatalities have occurred. One mechanism of injury and death while in physical restraint is that of severe asphyxiation. We present the case of a hospitalized man in his mid‐30s, suffering from schizophrenia. The patient was obese. He became aggressive and had to be manually restrained with a “takedown.” After having been put in the prone position on the floor with a significant weight load on his body, he lost respiration and consciousness. Subsequently, he was given CPR. He regained consciousness and respiration, while the cyanosis receded in 1–2 min. Psychiatrists and pathologists should be aware that physically restraining a patient in the prone position with a significant weight load on the torso can, in rare cases, lead to asphyxiation.     

Severe Sexual Sadism—An Underdiagnosed Disorder? Evidence from a Sample of Forensic Inpatients

Abstract:  Severe sexual sadism is a disorder of sexual preference that focuses on humiliation and subjugation of the victim, sometimes causing grievous injury or death. Sexual sadists pose a particular risk. However, the diagnosis as such is unreliable and prevalence estimates vary. In a sample of male high-security forensic inpatients who had committed sexual offenses, we found two-thirds of sexual sadists had not been identified as such prior to commitment. Possible reasons for missing the diagnosis are many fold. Present data support the notion that unrecognized sexual sadists more closely resembled non-sadistic sex offenders than accurately diagnosed sadists. In particular, initially unrecognized sexual sadists had less severe previous convictions, less vocational training, and experienced a less supportive upbringing than their correctly identified sadistic counterparts. The latter, in contrast, more often reached media coverage through their offense(s). We conclude that severe sexual sadism is likely an underdiagnosed, yet forensically highly relevant disorder.     

The Role of Fantasy in a Serial Sexual Offender: A Brief Review of the Literature and a Case Report

Abstract: Extensive research has attempted to elucidate the role of fantasy in sexual offending. In this paper, the authors summarize the main results of the literature, especially the contents, themes, dynamics, etiopathogenesis, and potential functions of fantasy in sexual offending. Further, the authors analyze the case of a serial sexual offender who assaulted 39 women. The forensic‐psychiatric assessment revealed that his fantasies of forced sex, sexual coercion, and dominance, which were linked to narcissistic personality organization and functioning, were the primary drive mechanism in his crimes, because he imagined himself in the role of the aggressor, identified with the power associated with the role of perpetrator, and was sexually aroused by such images of omnipotent control of the victim. In conclusions, the authors suggest that fantasies of sexual aggression, coercion, and dominance of women may stimulate grandiosity and omnipotence and, in a minority of cases, may lead to sexual offending.     

The Relationship Between Mental Disorders and Types of Crime in Inmates in a Brazilian Prison

This cross‐sectional study conducted in prisons in the city of Salvador, Bahia, Brazil, investigated the association between the presence of psychiatric disorders in 462 prisoners and the types of crimes committed by them. Psychiatric diagnosis was obtained by means of the Brazilian Portuguese version of the Mini‐International Neuropsychiatric Interview. A statistically significant association was found between some psychiatric disorders and specific groups of crime: lifelong substance addiction with sex crimes and homicide; antisocial personality disorder with robbery and with kidnapping and extortion; borderline personality disorder with sex crimes; and lifelong alcohol addiction with fraud and conspiracy and with armed robbery and murder. It was concluded that the mental disorders considered more severe (psychosis and bipolar disorder) were not associated with violent crimes, suggesting that the severity of the psychotic disorder may be the factor that has caused psychosis to be associated with violent crimes in previous studies.     

Mental health weapons prohibition: demographic and psychiatric factors in petitions for relief

Federal law and most states prohibit possession of firearms by individuals with a history of certain psychiatric diagnoses and/or treatment. In California, an involuntary 72-h hold can trigger a 5-year ban on firearm possession. Individuals so prohibited may petition for early termination of the ban. We report on the demographic and psychiatric characteristics of a sample of individuals petitioning for early relief in Los Angeles County, and on the results of their petitions. The majority of petitioners were Caucasian men over age 40. Sixteen percent of petitioners were employed in law enforcement or armed security, and all of their petitions were granted. Individuals for whom there was greater evidence of mental disorder were significantly less likely to petition successfully. The results are discussed in terms of the benefits of involving a forensic expert in the petition process, which is not presently required under California law.     

简易精神症状自陈量表对主观夸大精神症状的测试分析

目的 应用简易精神症状自陈量表检测法医精神鉴定中主观夸大精神症状的情况,并分析其测试结果。方法 对206名不同类型的法医精神鉴定的被鉴定人用该量表进行检测．并由两名鉴定专业人员对被鉴定人是否有主观夸大精神症状分别进行评定。结果 （1）以该量表判断主观故意或夸大精神症状的划界分（13分）对测试的被鉴定人进行检测,206例被鉴定人中有71例被判定为主观夸大精神症状（34．5％）。与专家评定的结果相比,量表评定的假阴性为19．8％,假阳性率为1．7％;总准确率为90．8％。（2）工伤和交通事故精神伤残理赔鉴定案例主观夸大精神症状的比例较高（51％）。结论 简易精神症状自陈量表是检测主观夸大精神症状的有效评定工具。     

Either or? Reconciling Findings on Mental Health and Extremism using a Dimensional Rather than Categorical Paradigm

The background for this paper is the debate over what role mental illness plays in radicalization to violent extremism. While one camp points to cases of abnormal functioning of perpetrators, another argues that normal psychological mechanisms are central. Through a review of these perspectives, it becomes clear that mental illness cannot be ruled out as an epi‐phenomenon, but is not a necessary condition either. The paper draws on work in psychiatric nosology on dimensional and categorical conceptions of illness and argues that the perspectives in this literature reflect a categorical approach to normal and abnormal functioning. Under a dimensional perspective, findings converge. The paper concludes by showing how this new dimensional approach to the role of mental illness in radicalization has implications for the design of risk assessment tools and leads to the recommendation for stronger inter‐agency cooperation between mental health professionals, social services, and police and intelligence services.     

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.     

Patient characteristics related to length of stay in Dutch forensic psychiatric care

Create an overview of characteristics of patients in long-term forensic psychiatric care (LFPC) with a higher length of stay (LOS) care compared to patients in regular forensic psychiatric care (RFPC) with a shorter LOS. Data were collected from 139 patient records. This study examined whether patients in LFPC differ from patients in RFPC on sociodemographic data, legal data and clinical data and whether those characteristics are able to predict LOS. Patients in LFPC were more often born in a Dutch Caribbean country, less often had a substance abuse disorder, were more often emotionally neglected during childhood, had a higher HCR-20 risk item score, a higher security needs score, a higher (less successful) recovery score, were more often recidivist and had absconded more often than RFPC patients. Certain characteristics were able to distinguish the longer LOS group which might be useful to establish sequel services and enhance treatment efficiency.     

Association for Methodology and Documentation in Psychiatry Profiles Predict Later Risk for Criminal Behavior and Violent Crimes in Former Inpatients with Affective Disorder*

Abstract: Few studies have investigated criminal and violent behavior in patients with affective disorders. We reviewed the national crime register for records of criminal offenses committed by 1561 patients with affective disorders and studied the predictive value of certain psychopathological symptoms assessed with the Association for Methodology and Documentation in Psychiatry (AMDP) system concerning future criminal behavior. Sixty‐five (4.2%) patients had been convicted in the 7–12 years after discharge (307 cases). Patients with the AMDP syndrome mania had a significantly higher risk for later criminal behavior. The combination with the hostility syndrome further increased the risk. These findings are in line with previous data indicating a higher risk for later criminal behavior in patients with a manic/bipolar disorder compared to depressive disorder. As previously demonstrated in another sample of schizophrenic patients, the AMDP syndromes mania (and hostility) is associated with a higher risk of later criminal behavior.     

A Clinical Study of Competency to Consent to Hospitalization and Treatment in Geriatric Inpatients*

Abstract: This study used a Competency Questionnaire modified for medical surgical patients (CQ‐Med). Twenty‐nine patients (ages 65–94 years) admitted to a geriatric medicine unit were studied. Along with the CQ‐Med, patients were administered several WAIS‐R subtests, the Blessed Dementia Scale (BDS), and Mini Mental State Exam (MMSE). Additionally, a blind forensic evaluation for competency to consent to hospitalization and treatment was performed for the purpose of validation of the CQ‐Med. Results of the study found that, as expected, increased age was correlated with decreasing performance on the CQ‐Med and decreased findings of competence by clinical exam. However, there was great variability within each age group, demonstrating individual differences in the progress of declining competency. CQ‐Med scores also correlated well with the WAIS‐R subtest raw and scaled scores. Scores on the MMSE and BDS were less well correlated. The CQ‐Med may be a useful adjunct in assessing declining competency in geriatric patients.     

The prevalence of mental disorders in prisoners in the city of Salvador, Bahia, Brazil

The number of individuals affected by serious psychiatric disorders in Brazilian prisons is unknown. This cross-sectional study was conducted in prison complexes within the city of Salvador, Bahia, Brazil. The sample consisted of 497 prisoners, and the outcome measure was the Brazilian Portuguese version of the Mini International Neuropsychiatric Interview. The prevalence rates found in the closed and semi-open prison systems, respectively, were as follows: depression 17.6% and 18.8%; bipolar mood disorder 5.2% and 10.1%; anxiety disorders 6.9% and 14.4%; borderline personality disorder 19.7% and 34.8%; antisocial personality disorder 26.9% and 24.2%; alcohol addiction 26.6% and 35.3%; drug addiction 27.9% and 32.4%; psychosis 1.4% and 12.6%; attention deficit/hyperactivity disorder (ADHD) in childhood 10.3% and 22.2%; and ADHD in adulthood 4.1% and 5.3%. This study revealed higher rates of substance-related disorders and lower rates of psychotic and mood disorders compared to other prevalence studies carried out in prison populations.     

The paraphilia-related disorders: an investigation of the relevance of the concept in sexual murderers

Paraphilic disorders (PAs) and sexual preoccupation are known risk factors for recidivism in sexual offenders. Nonparaphilic sexual excessive behaviors-so-called paraphilia-related disorders (PRDs), like paraphilias, are also characterized by sexual preoccupation and volitional impairment and can be diagnosed in paraphilic men. The prevalence and clinical significance of PRDs in sexual homicide perpetrators, however, is unknown. We investigated the relationship between PAs and PRDs retrospectively in a sample of 161 sexual murderers. Four groups were compared: men without a PA or a PRD diagnosis, men with at least one PRD but no PA, men with at least one PA but no PRD, and finally, those with a combination of both (PA+PRD). The PA+PRD group had the most lifetime cumulative sexual impulsivity disorders, more developmental problems, the highest persistent frequency of sexual activity, the highest number of previous sexual offences, more sexual sadism, and compulsive masturbation. Men of the PRD subsample had suffered more from childhood sexual abuse, showed more promiscuity, psychopathy, and alcohol problems. The use of the PRD concept in this special offender group should be further investigated with prospectively designed studies.     

Sleep apnea as a possible factor contributing to aggression in sex offenders

Sleep disorders, such as obstructive sleep apnea (OSA), are often unrecognized and undertreated. A disruption in normal sleep may be associated with increased irritability and aggression. To elucidate further the impact of OSA on hostility of forensic patients, we performed a retrospective chart review of 10 consecutive outpatient sex offenders who were diagnosed with OSA and treated with continuous positive airway pressure (CPAP). The Buss-Perry Aggression Questionnaire was compared pre- and posttreatment. Following treatment, the total Buss-Perry score was significantly lower, with lower scores on the anger, physical aggression, hostility, and verbal aggression subscales. These results suggest that in sex offenders suffering from OSA, aggression and hostility may be significantly reduced through CPAP treatment. Further investigation is required to investigate if reducing aggression and hostility in this manner impacts recidivism and overall functioning.     

Attention‐Deficit/Hyperactivity Disorder in Young French Male Prisoners

While forensic studies have reported higher than community rates of mental disorders in imprisoned populations, few studies have focused on attention‐deficit/hyperactivity disorder (ADHD) in these subjects. The aim of this study was to investigate ADHD prevalence among young French male prisoners. A specific diagnostic interview (Conners' Adult ADHD Diagnostic Interview for DSM‐IV, CAADID) was used. Correlations between ADHD, subsyndromal ADHD, and criminal features were investigated. 11% of young male prisoners among 93 male subjects aged 18–35 years met the criteria for actual ADHD, and 17% met those for childhood ADHD. Considering ADHD and subsyndromal ADHD, prevalence was about 43% in adulthood. ADHD and subsyndromal ADHD in adulthood were significantly associated with a higher number of imprisonments and a younger age at first arrest. It could be advisable to better identify subjects with ADHD symptoms among prison populations.