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.     

Gender differences in violent offending: results from a multicentre comparison study in Dutch forensic psychiatry

ABSTRACT

The past two decades, a disproportionate growth of females entering the criminal justice system and forensic mental health services has been observed worldwide. However, there is a lack of knowledge on the background of women who are convicted for violent offenses. What is their criminal history, what are their motives for offending and in which way do they differ from men convicted for violent offenses? In this study, criminal histories and the offenses for which they were admitted to forensic care were analyzed of 218 women and 218 men who have been treated between 1984 and 2014 with a mandatory treatment order in one of four Dutch forensic psychiatric settings admitting both men and women. It is concluded that there are important differences in violent offending between male and female patients. Most importantly, female violence was more often directed towards their close environment, like their children, and driven by relational frustration. Furthermore, female patients received lower punishments compared to male patients and were more often considered to be diminished accountable for their offenses due to a mental illness.     

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.     

Forensic psychiatric inpatients and aggression: An exploration of incidence,prevalence, severity,and interventions by gender

BackgroundPrevious investigations suggest that women judged to be not criminally responsible on account of mental disorder (NCR-MD) differ markedly from their male counterparts in important ways, underscoring the necessity of subsequent study.ObjectiveThe goal of the present study was to inform our understanding of the presenting profile of female forensic psychiatric patients and contrast their risk of inpatient aggression with their male counterparts.MethodThe population of patients assessed and/or treated at a secure Canadian forensic psychiatric hospital were available for study. In total, 527 patients had complete data and were part of intensive retrospective file reviews; inpatient aggression was evaluated using the Overt Aggression Scale.ResultsWomen were no less likely than men to have a violent index offence and to perpetrate inpatient aggression. Examining the range of aggressive behaviours and severity levels did little to increase the relevance of gender to inpatient risk.DiscussionFemale forensic patients represent a highly selected subgroup of women with exceptional clinical and behavioural challenges and associated treatment needs.     

Does the Criminal Justice System Treat Domestic Violence and Sexual Assault Offenders Leniently?

We examine whether men who physically assault their female partners or who commit sexual assault receive more lenient treatment than offenders who commit other types of assaults. Analyses of the National Violence Against Women Survey do not support these hypotheses. Rather, they suggest that women who assault their male partners are particularly likely to avoid arrest. In addition, both men and women who assault partners are more likely to avoid conviction than other offenders. Evidence suggests that there has been an increase over time in rates of arrest and conviction for partner violence.     

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.     

Seasonal variation of seclusion incidents from violent and suicidal acts in forensic psychiatric patients

BackgroundA seasonal variation in violence and suicidal behaviour has been reported in several studies with partially congruent results. Most of forensic psychiatric patients have a history of severe violent behaviour that often continues in spite of regular treatment. In the forensic psychiatric hospital environment aggressive and suicidal acts are often sudden and unpredictable. For reasons of safety, rapid and intensive coercive measures, such as seclusion and restraint, are necessary in the treatment of such patients.ObjectiveTo examine whether these involuntary seclusions have a seasonal pattern, possibly similar than the reported seasonal variation in violence and suicidal behaviour. By investigating the possibility of a seasonal variation of seclusion incidents from violent and suicidal acts, it may become possible to improve the management of forensic psychiatric patients.MethodsThe hospital files of all secluded patients at Niuvanniemi Hospital from 1 January 1996 to 31 December 2002 were examined. In total, 385 patients (324 male and 61 female) were identified as being secluded at least once in 1930 different incidents (1476 from male and 454 from female patients). Seasonal decomposition and linear regression with dummy month variables were used to examine the possibility of annual variations for seclusions.ResultsThe seasonal variation of involuntary seclusion incidents was statistically significant. According to the linear regression model, most of the seclusion incidents, affecting many different patients, began in July and August, and were concentrated throughout the fall until November. The sum of all seclusion days was lowest in January and highest between July and November (difference + 31% to + 37%).ConclusionsThese findings are mainly in agreement with results from other studies on seasonal variation and violent behaviour. The allocation of staff for late summer and fall might enhance the management of forensic psychiatric patients, thus leading to possible decreases in seclusion incidents. The factors affecting violent, aggressive and suicidal behaviours are complex and more investigation is needed to understand, identify, intervene and effectively reduce such behaviours.     

Risk of homicidal behavior among discharged forensic psychiatric patients

We studied the risk of homicidal behavior among 281 released male forensic psychiatric patients during the 14-year period 1978–1991. Released patients were about 300 times more likely to commit a homicide than the general male population during the first year outside hospital, and the corresponding risk was 53-fold during a mean follow-up period of 7.8 years. The odds ratio for committing a homicide among all Finnish schizophrenics during the 12-year period 1980–1991 was 9.7, which indicates that previous criminality associated with schizophrenia also increases the risk of homicidal behavior remarkably when compared with schizophrenia per se. We believe that this kind of epidemiological approach is a useful method of identifying and classifying factors associated with very high risk of homicidal behavior and preventing homicidal behavior among high-risk populations.     

Comparing the developmental and behavioural characteristics of female and male juveniles who present with sexually abusive behaviour

Abstract

Relatively few studies have compared female and male juveniles who sexually abuse. These studies have reported that while female juveniles with sexually abusive behaviour are more likely to have experienced childhood sexual abuse, they display similar patterns of abusive behaviour. However, to date these findings have not been replicated in a UK sample. The current study compared 22 female and 254 male juveniles, referred to a UK specialist community forensic service, in relation to family environment, maltreatment experience, psychiatric diagnoses and perpetrated abusive behaviour. Consistent with previous studies perpetrated behaviour was similar across genders, but females were significantly more likely to have been sexually victimized as children, at a younger age and by a greater number of abusers. In addition, they were more likely to have been exposed to inadequate sexual boundaries at home. These findings suggest that females and males may follow different pathways to sexually abusive behaviour.     

Gender-specific risk factors for intimate partner homicide--a nationwide register-based study

The present study examined gender differences in intimate partner homicide (IPH) and offender characteristics with the focus on putative gender-specific risk factors in a nationwide consecutive sample of homicide offenders. Data on all offenders (N = 642; 91 females, 551 males) convicted of homicide and subjected to a forensic psychiatric examination in Finland were obtained for the years 1995 and 2004. IPH offenders, 39 female and 106 male, were compared for risk factors with female and male offenders whose victims were not spouses. The forensic psychiatric examination reports were retrospectively analyzed, and the Hare Psychopathy Checklist-Revised (PCL-R) was rated. Significant gender differences were found in four risk factors: employment, intoxication of victim, self-defense, and quarrel, mostly related to alcohol as a factor of the offense. The findings support the notion that female IPH is linked to defensive reactions resulting from prior abuse, and that IPH offenders resemble the general population more than offenders of other types of homicide.     

Finding a voice – the feasibility and impact of setting up a community choir in a forensic secure setting

This study reports on the feasibility and impact of running a choir for forensic psychiatric inpatients, staff and members of the local community, within the confines of a medium secure psychiatric unit. The choir ran between October and December 2013. Eight weekly workshops and a final concert performance were evaluated through participant observation and focus groups held with the participants. Between 12 and 16 male and female patients attended each workshop and the final concert. All participating patients had received a diagnosis of schizophrenia, schizo-affective disorder or personality disorder, all had committed serious violent or sexual offences and all were legally detained and receiving treatment in a forensic medium or low secure ward, under the Mental Health Act (England and Wales). Considerable benefits were reported by patients, as well as by the participating community choir members and staff. Primary benefits reported by patients included the following: improved happiness and well-being; increased confidence and self-esteem; greater emotional connectedness and reduced sense of stigma. Participating staff also reported increased feelings of well-being and happiness, greater tolerance and more positive perceptions of the functioning and capabilities of forensic psychiatric patients. The longer term benefits of music participation on the mental health and social functioning of forensic psychiatric patients require further investigation.     

Characteristics and personality profiles of first 100 patients admitted to a secure forensic adolescent hospital

Bluebird House is a mixed-gender adolescent medium-secure forensic unit. There is a paucity of data available about this unique patient group. We aimed to explore the demographic, clinical and personality characteristics of the first 100 patients admitted to a mixed-gender adolescent medium-secure forensic unit. We used a retrospective cross-sectional study of the first 100 consecutive patients admitted to Bluebird House. Demographic and clinical data were collected from the medical notes including the Millon Adolescent Clinical Inventory. The first 100 young people admitted to an adolescent medium-secure unit have had very high incident rates, particularly amongst the females. Incident rate was correlated with a history of sexual assault in female patients. The males were more likely to have been referred from custody and more likely to have a diagnosis of psychosis or autism. We describe similarities and differences to the first 100 admissions admitted to the first secure psychiatric unit for adolescents in Manchester over 20 years ago.     

Mental Disorder, Violence, and Gender

Recent studies have reported comparable rates of violence among men and women with mental disorder, raising important issues for clinical risk assessment. This study examines the relationship between gender and violence using data from the MacArthur Violence Risk Assessment Study. Patients in acute psychiatric wards were interviewed 5 times over the year following their discharge to the community. Results showed some differences between men and women in the violence committed immediately following discharge, with rates for men being higher. But the prevalence of violence over the 1 year was similar for female and male discharged patients. However, there were substantial gender differences in the situational context of the violence committed. Men were more likely to have been drinking or using street drugs, and less likely to have been adhering to prescribed psychotropic medication, prior to committing violence. The violence committed by men was more likely to result in serious injury than the violence committed by women, and men were more likely than women to be arrested after committing a violent act. Women were more likely to target family members and to be violent in the home.     

Neuropsychological and Criminological Features of Female Homicide Offenders

Few studies have examined life history and cognitive characteristics unique to female homicide offenders. Understanding these characteristics could aid in risk assessment for extreme violence in this group of offenders. The current study utilized t‐tests or chi‐square tests to compare 27 female and 81 male homicide offenders on psychiatric, neurologic, criminal, and cognitive characteristics. Additionally, we explored the role of abuse history in female offenders through Kruskal–Wallis or Fisher's exact tests. Results indicate that in comparison with male counterparts, females are more likely to have history of mood disorder, borderline personality disorder, and abuse. Cognitively, female homicide offenders exhibit circumscribed cognitive impairment in verbal abilities and perform similarly to male homicide offenders across most cognitive tasks. Within the female offender group, history of sexual abuse is associated with higher rates of impulsive homicide and poorer verbal abilities. These findings provide preliminary evidence for distinct factors associated with homicide in women.     

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.     

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.     

The impact of forced forensic psychiatric confinement on composition and structure in the personal networks of personality-disordered forensic psychiatric patients

This study explored to what extent the composition and structure of personal networks of personality-disordered forensic psychiatric patients changed before and after forced confinement in a forensic psychiatric centre. Semi-structured in-depth interviews with 36 patients and selected members of their networks were examined. During forensic psychiatric treatment, patients reported a decrease in network size, in the number of high-risk network members, and in the number of social ties between these high-risk network members. Personal relationships were of shorter duration, with lower levels of contact frequency and reciprocity. No changes were observed in the patients’ companionship, practical and emotional support networks. During forensic psychiatric treatment, patients reported some new relationships, especially with persons outside the forensic psychiatric centre. Information on compositional and structural personal network factors over time helps forensic mental health professionals to properly assess and manage the important dynamic social network conditions associated with recidivism.     

Substance use disorders in forensic psychiatric patients

There is a lack of detailed information on the role of substance use disorders (SUD) as a substantial factor in offences and treatment in forensic psychiatric patients. The aim of this study was to get a better understanding of these specifics. Clinical records of 193 male patients admitted to a Dutch forensic psychiatric hospital were scrutinized on anamnestic, diagnostic and risk assessment data. One of the central findings was that the prevalence of SUDs was high. Patients with an SUD had a more extensive criminal history, unstable and deviant lifestyle and higher risk of violent behavior than patients without a substance use disorder. No differences were found in duration of treatment, aggressive incidents and leave. Another important finding was that a distinction could be made between patients with substance use as a primary criminogenic risk factor and patients with substance use as a secondary risk factor. Although substance use is identified as a general risk factor, this study supports the idea of sub categorization of patients with an SUD and emphasizes the need for a different treatment approach. Further study is needed to identify specific treatment approaches, based on more differentiated profiles of these patients.     

Prison misconduct among female inmates with mental disorders,substance abuse/dependence,and co-occurring disorders in Taiwan

This survey study attempted to address two research questions: (1) whether female inmates with either singular mental illness or singular substance abuse/dependence disorders were more likely to break institutional rules in prison than their disorder-free counterparts; and (2) whether female inmates with both mental illness and substance abuse/dependence disorders (CODs) were more likely to engage in misbehaviour than either disorder-free or singularly disordered women during the course of their confinement. The current study employed a sample of 643 female inmates and the data for analyses contained information on inmates’ CODs, mental and substance abuse/dependence disorders, and pre-prison and prison experiences. The results showed that female inmates with CODs committed the most misconduct in prisons, but no significant effect was found on prison misconduct among inmates with singular disorders and disorder-free female inmates. Possible explanations for these results were suggested, and public policy implications were discussed in the concluding section.