Patients discharged from medium secure forensic psychiatry services: reconvictions and risk factors.
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BACKGROUND: Treatment within medium secure forensic psychiatry services is expected to reduce risk to the public. AIMS: To measure the period prevalence and incidence of offending following discharge and identify associated risk factors. METHOD: Follow-up of patients from 7 of 14 regional services in England and Wales who spent time at risk (n=1344) for a mean of 6.2 years. Outcome was obtained from offenders index, hospital case-files and the central register of deaths. RESULTS: One in 8 men and 1 in 16 women were convicted of grave offences. Incidence rates indicated low density and most patients were not subsequently convicted. Offence predictors included gender, younger age, early-onset offending, previous convictions and a comorbid or primary diagnosis of personality disorder. Longer in-patient stay and restriction on discharge were protective. CONCLUSIONS: Risks of reoffending remain for a subgroup of discharged patients. Future research should aim to improve their identification and risk management following discharge. (+info)
Posttraumatic stress disorder in a Swiss offender population.
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QUESTIONS UNDER STUDY: Various studies have repeatedly shown an increased prevalence for Posttraumatic Stress Disorder (PTSD) in delinquents when compared with the general population. Lifetime prevalence varies between 33% and 36%, and point prevalence between 17% and 21%. The aim of this study was to examine whether these findings are applicable to offenders detained in Switzerland. METHODS: The sample consisted of 86 offenders. In order to control for over-reporting of traumatic life events three sub-samples (remand, sentenced/inpatient and sentenced/outpatient) administered by the Office of Corrections of the Canton of Zurich were examined. PTSD was diagnosed using the Posttraumatic Diagnostic Scale (PDS), a self-rating instrument for diagnosing PTSD according to the Diagnostic and Statistical Manual of Mental Disorders, Version IV (DSM-IV). RESULTS: Point prevalence of PTSD was conservatively estimated at 27%. The three sub-samples did not differ in the prevalence of PTSD when adjusted for potential demographic differences. Seventy-five percent of the subjects had experienced at least one traumatic event that matched the criteria for a traumatic event according to the DSMIV. The Median number of traumatising life events according to the PDS was four in the examined sample. CONCLUSIONS: In this sample of male prisoners in Switzerland the prevalence of current PTSD was comparable to other international studies. The limitations and implications of these findings were discussed. (+info)
The super-ordinate nature of the psychopathy checklist-revised.
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Psychopathy, while perhaps the earliest and most recognized personality disorder, is the subject of intense debate about its nature and measurement. The most recent proposal on its structural nature suggests that it is a multifaceted construct, made up of at least four dimensions reflecting Interpersonal, Affective, Lifestyle, and Antisocial anomalies (Hare & Neumann, 2005, 2006). These dimensions are significantly interrelated, suggesting that they are indicators for a super-ordinate factor. The nature of this higher-order factor may reflect the unifying feature which comprehensively defines the disorder. To examine this super-factor, the current study used several very large data sets of male (N = 4865) and female (N = 1099) offenders, and forensic psychiatric patients (N = 965), who were assessed with the Psychopathy Checklist-Revised (PCL-R; Hare, 2003). Structural equation modeling results indicated that the four first-order factor dimensions could be explained by a single second-order cohesive super-factor. (+info)
A bifactor approach to modeling the structure of the psychopathy checklist-revised.
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To date, models of the structure of psychopathy as assessed by the Psychopathy Checklist-Revised (PCL-R) have taken a higher-order approach in which the factors of the PCL-R are modeled as correlated elements of a higher-order psychopathy construct. Here, we propose an alternative structural model of the PCL-R, the bifactor model, which accounts for the covariance among PCL-R items in terms of a general factor reflecting the overlap across all items, and independent subfactors reflecting the unique coherency among particular groups of items. We present examples of how this alternative structural model can account for diverging associations between different subsets of PCL-R items and external criteria in the domains of personality and psychopathology, and we discuss implications of the bifactor model for future research on the conceptualization and assessment of psychopathy. (+info)
Screening for personality disorders.
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A brief but valid self-report measure to screen for personality disorders (PDs) would be a valuable tool in making decisions about further assessment and in planning optimal treatments. In psychiatric and nonpsychiatric samples, we compared the validity of three screening measures: the PD scales from the Inventory of Interpersonal Problems, a self-report version of the Iowa Personality Disorder Screen, and the selfdirectedness scale of the Temperament and Character Inventory. Despite their different theoretical origins, the screeners were highly correlated in a range from .71 to .77. As a result, the use of multiple screeners was not a significant improvement over any individual screener, and no single screener stood out as clearly superior to the others. Each performed modestly in predicting the presence of any PD diagnosis in both the psychiatric and nonpsychiatric groups. Performance was best when predicting a more severe PD diagnosis in the psychiatric sample. The results also highlight the potential value of multiple assessments when relying on self-reports. (+info)
Ethical dilemmas in forensic psychiatry: two illustrative cases.
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One approach to the analysis of ethical dilemmas in medical practice uses the "four principles plus scope" approach. These principles are: respect for autonomy, beneficence, non-maleficence and justice, along with concern for their scope of application. However, conflicts between the different principles are commonplace in psychiatric practice, especially in forensic psychiatry, where duties to patients often conflict with duties to third parties such as the public. This article seeks to highlight some of the specific ethical dilemmas encountered in forensic psychiatry: the excessive use of segregation for the protection of others, the ethics of using mechanical restraint when clinically beneficial and the use of physical treatment without consent. We argue that justice, as a principle, should be paramount in forensic psychiatry, and that there is a need for a more specific code of ethics to cover specialised areas of medicine like forensic psychiatry. This code should specify that in cases of conflict between different principles, justice should gain precedence over the other principles. (+info)
Alcohol-induced sleepwalking or confusional arousal as a defense to criminal behavior: a review of scientific evidence, methods and forensic considerations.
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An increasing number of criminal cases have claimed the defendant to be in a state of sleepwalking or related disorders induced by high quantities of alcohol. Sleepwalkers who commit violent acts, sexual assaults and other criminal acts are thought to be in a state of automatism, lacking conscious awareness and criminal intent. They may be acquitted in criminal trials. On the other hand, criminal acts performed as the result of voluntary alcohol intoxication alone cannot be used as a complete defense. The alcohol-induced sleepwalking criminal defense is most often based on past clinical or legal reports that ingestion of alcohol directly 'triggers' sleepwalking or increased the risk of sleepwalking by increasing the quantity of slow wave sleep (SWS). A review of the sleep medicine literature found no sleep laboratory studies of the effects of alcohol on the sleep of clinically diagnosed sleepwalkers. However, 19 sleep laboratory studies of the effects of alcohol on the sleep of healthy non-drinkers or social drinkers were identified with none reporting a change in SWS as a percentage of total sleep time. However, in six of 19 studies, a modest but statistically significant increase in SWS was found in the first 2-4 h. Among studies of sleep in alcohol abusers and abstinent abusers, the quantity and percentage of SWS was most often reduced and sometimes absent. Claims that direct alcohol provocation tests can assist in the forensic assessment of these cases found no support of any kind in the medical literature with not a single report of testing in normative or patient groups and no reports of validation testing of any sort. There is no direct experimental evidence that alcohol predisposes or triggers sleepwalking or related disorders. A legal defense of sleepwalking resulting from voluntarily ingested alcohol should be consistent with the current state of art sleep science and meet generally accepted requirements for the diagnosis of sleepwalking and other parasomnias. (+info)
Challenges in residential treatment for prisoners with mental illness: a follow-up report.
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The October 2002 issue of Archives of Psychiatric Nursing reported on the design of a prison-based mental health program implemented during the mid-1990s. The aim of this program was to reduce debilitating symptoms and promote coping skills, thereby enhancing both the functional status and the clinical management of mentally ill prisoners. This article presents a qualitative study of the same program conducted in 2001-2003 and describes critical issues facing mental health providers, correctional officers, and prisoners involved in this program today. Of key interest is how subsequent developments have eroded the original focus of the program. (+info)