Mental disorder and violence. A special (high security) hospital study

Socio-demographic, clinical and offense-related characteristics of forensic psychiatric inpatients in Hunan, China: a cross-sectional survey

BACKGROUND

There is still a lack of comprehensive research on the profile of patients in forensic mental health hospitals in China. This study aims to investigate the socio-demographic, clinical, and offense-related characteristics of mentally ill offenders in the Hunan Provincial Forensic Psychiatric Hospital in China.

METHODS

This study was conducted from November 1, 2018, to January 30, 2019. The data of socio-demographic, clinical, and offense-related characteristics of the patients were collected. The Brief Psychiatric Rating Scale (BPRS), the Modified Overt Aggression Scale (MOAS), and the Clinical Global Impression-Severity (CGI-S) scale were used to measure their psychiatric conditions.

RESULTS

A total of 461 participants were enrolled in this study. Among them, 86.3% were males and 56.8% were unmarried; the average age of them was 44.7 ± 10.1 years, and the mean years of education were 7.51 ± 3.3 years. Before their current offense, a total of 345 patients (74.8%) had sought medical help for their mental illnesses. While 303 (87.8%) of these patients were prescribed antipsychotics, 254 (73.6%) failed to take them regularly. Of all the inpatients, 90.5% were diagnosed with schizophrenia; 385 (83.5%) engaged in homicidal offenses, with 54.0% of the victims being their family members. In homicide cases, the relatives were more likely to be victims of female patients. The mean length of stay in the forensic hospital was 8.02 ± 4.74 years, and over 80.0% of the patients had been hospitalized for over 5 years.

CONCLUSIONS

To our knowledge, this is the first study investigating the profile of forensic patients receiving compulsory treatments in a forensic psychiatric hospital in China. These results add to the world literature on the characteristics of forensic patients and can help identify common treatment and risk-related needs of this population.

Influencing factors for assessment of criminal responsibility in patients with mental disorders: A forensic case analysis between 2010 and 2020

BACKGROUND

In China, police departments usually initiate assessment of criminal responsibility after patients with mental disorders commit crimes. However, the specific conditions demanding assessment are not clearly stipulated by law. Few studies have been conducted on the epidemiological characteristics and assessment of criminal responsibility in patients with mental disorders. This study aimed to analyze the features and identify influencing factors for assessment of criminal responsibility for patients with mental disorders in a single-center cohort.

METHODS

Cases undergoing criminal responsibility assessment at the Center of Forensic Science, East China University of Political Science and Law in Shanghai (CFS, ECUPL) between 2010 and 2020 were retrospectively reviewed. Criminal responsibility was categorized as criminal irresponsibility, diminished criminal responsibility, and full criminal responsibility. Differences among the groups were then statistically analyzed.

RESULTS

In the study period, 437 patients including 361 males (82.61%) were referred for criminal responsibility assessment. Their ages ranged from 15 years to 91 years. After assessment, the number of cases with criminal irresponsibility, diminished criminal responsibility, and full criminal responsibility were 196 (44.85%), 181 (41.42%), and 60 (13.73%), respectively. The Chi-square test and nominal regression analysis showed that influencing factors for assessment of criminal responsibility comprised crime in public places (OR = 14.734; 95% CI: 1.463-148.424), crime in victim's residence (OR = 10.852; 95% CI: 1.068-110.214), crime in suspect's residence (OR = 9.542; 95% CI: 1.046-87.092), forensic psychiatric diagnosis of F1X (OR = 0.014,0.011; 95%CI:0.001-0.261,0-0.5), F2X (OR = 5.75; 95%CI:1.315-23.145), F4X (OR = 0.077; 95%CI:0.016-0.38,) and F6X (OR = 0.112,0.075; 95% CI: 0.022-0.558,0.006-0.959), criminal object of property (OR = 9.989; 95% CI: 1.305-76.455), cases of theft (OR = 0.09, 0.087; 95% CI: 0.013-0.648,0.012-0.654), and cases of endangering public security (OR = 0.152, 0.205; 95% CI: 0.034-0.678, 0.045-0.931).

CONCLUSION

Crime in public places, suspect's residence and victim's residence, forensic psychiatric diagnosis of F1X, F2X, F4X and F6X, criminal object of property, case types of theft and endangering public security were influencing factors in assessment of criminal responsibility. Therefore, special attention should be paid to patients with mental disorders under such circumstances in order to avoid bias on assessment of criminal responsibility.

Prevalence and correlates of aggressive behavior in psychiatric inpatient populations

Aggressive behavior in patients with psychiatric disorders is attracting increasing research interest. One reason for this is that psychiatric patients are generally considered more likely to be aggressive, which raises a related question of whether diagnoses of psychiatric disorders predict the prevalence of aggressive behavior. Predicting aggression in psychiatric wards is crucial, because aggressive behavior not only endangers the safety of both patients and staff, but it also extends the hospitalization times. Predictions of aggressive behavior also need careful attention to ensure effective treatment planning. This literature review explores the relationship between aggressive behavior and psychiatric disorders and syndromes (dementia, psychoactive substance use, acute psychotic disorder, schizophrenia, bipolar affective disorder, major depressive disorder, obsessive-compulsive disorder, personality disorders and intellectual disability). The prevalence of aggressive behavior and its underlying risk factors, such as sex, age, comorbid psychiatric disorders, socioeconomic status, and history of aggressive behavior are discussed as these are the components that mostly contribute to the increased risk of aggressive behavior. Measurement tools commonly used to predict and detect aggressive behavior and to differentiate between different forms of aggressive behavior in both research and clinical practice are also reviewed. Successful aggression prevention programs can be developed based on the current findings of the correlates of aggressive behavior in psychiatric patients.

Motivational Influences and Trajectories to Violence in the Context of Major Mental Illness

Developmental trajectories regarding the age onset of violence and offending have not routinely considered the role of major mental illness (MMI). In parallel, despite several studies investigating the relationship between MMI, violence and offending, fewer have identified motivational processes that may link illness to these outcomes in a more direct and proximal manner. This study investigates whether subtypes of forensic psychiatric patients deemed Not Criminally Responsible on account of Mental Disorder (N = 91) can be identified based on the age onset of mental illness and offending behavior, and whether information on motivational influences for offending-elicited both from the patient directly and detailed collateral information-contributes to the clinical utility of this typology. Results indicated that most patients reported engaging in violence (51%) or antisocial behaviors (72%) prior to the onset of MMI, but that the index offense(s) resulting in forensic admission were predominantly psychotically motivated. In contrast to patients for whom the onset of MMI occurred prior to offending, patients exhibiting premorbid violence had higher levels of risk and criminogenic need; they were more likely to be diagnosed with personality and substance use disorders, and to have conventional (i.e., non-illness-related) motivations ascribed to their index offense. Findings are consistent with the existing literature regarding subgroups of mentally disordered offenders, but provide new information regarding proximal risk factors for violence through better identification of motivational processes.

Clinical and neurodevelopmental correlates of aggression in early psychosis

BACKGROUND

Although mental illness accounts for only 4% of aggressive behavior in the general population, there remains a modest association between aggressive behavior and psychotic disorders, particularly in the early stages of the illness. However, little is known about the specific factors associated to this increased risk.

AIMS

The present study aims to assess the rates, characteristics and risk factors of aggressive behavior in first episode psychosis patients (FEP).

METHOD

We conducted a retrospective chart review of 449 FEP patients recruited from an outpatient early psychosis clinic. Aggressive behavior and clinical information were rated based upon information gathered from the chart review of data collected at baseline and after 6 months of follow-up.

RESULTS

Rates of aggressive behavior were 54.3% in FEP patients. Aggressive behavior was significantly associated with higher rates of history of birth complications, neurodevelopmental delays, learning difficulties, alcohol use disorders, and the clinical domain of poverty symptoms. In addition to aggressive behavior, 16.7% of FEP patients exhibited suicidal ideation or behaviors and 11.4% exhibited non-suicidal self-injurious behavior (NSSIB). In contrast to baseline, aggressive behaviors at 6 months follow up were almost entirely absent.

CONCLUSIONS

Patients at early stages of psychosis have high rates of aggressive and suicidal behavior prior to contact with clinical services. Neurodevelopmental adversities, alcohol use disorders and poverty symptoms are associated to higher risk of aggression in early psychosis. Participation in early psychosis specialty care resulted in a dramatic reduction in aggressive behavior.

Prevalence and phenomenology of violent ideation and behavior among 200 young people at clinical high-risk for psychosis: an emerging model of violence and psychotic illness

In a previously reported longitudinal study of violent ideation (VI) and violent behavior (VB) among 200 youths at clinical high-risk (CHR) for psychosis, we found that VI, hitherto underinvestigated, strongly predicted transition to first-episode psychosis (FEP) and VB, in close temporal proximity. Here, we present participants' baseline characteristics, examining clinical and demographic correlates of VI and VB. These participants, aged 13-30, were examined at Columbia University Medical Center's Center of Prevention and Evaluation, using clinical interviews and the structured interview for psychosis-risk syndromes (SIPS). At the onset of our longitudinal study, we gathered demographics, signs and symptoms, and descriptions of VI and VB. One-third of participants reported VI (n = 65, 32.5%) at baseline, experienced as intrusive and ego-dystonic, and associated with higher suspiciousness and overall positive symptoms. Less than one-tenth reported VB within 6 months of baseline (n = 17, 8.5%), which was unrelated to SIPS-positive symptoms, any DSM diagnosis or other clinical characteristic. The period from conversion through post-FEP stabilization may be characterized by heightened risk of behavioral disinhibition and violence. We provide a preliminary model of how violence risk may peak at various points in the course of psychotic illness.

Age onset of offending and serious mental illness among forensic psychiatric patients: A latent profile analysis

BACKGROUND

Developmental typologies regarding age of onset of violence and offending have not routinely taken account of the role of serious mental illness (SMI), and whether age of onset of offending in relation to onset of illness impacts on the manifestation of offending over the life course.

AIMS

To test whether forensic psychiatric patients can be classified according to age of onset of SMI and offending, and, if so, whether subtypes differ by sex.

METHODS

Details of all 511 patients enrolled into a large forensic mental health service in Ontario, Canada, in 2011 or 2012 were collected from records.

RESULTS

A latent profile analysis supported a 2-class solution in both men and women. External validation of the classes demonstrated that those with a younger age onset of serious mental illness and offending were characterised by higher levels of static risk factors and criminogenic need than those whose involvement in both mental health and criminal justice systems was delayed to later life.

CONCLUSIONS

Our findings present a new perspective on life course trajectories of offenders with SMI. While analyses identified just two distinct age-of-onset groups, in both the illness preceded the offending. The fact that our sample was entirely drawn from those hospitalised may have introduced a selection bias for those whose illness precedes offending, but findings underscore the complexity and level of need among those with a younger age of onset. Copyright © 2018 John Wiley & Sons, Ltd.

Schizophrenia and Criminal Responsibility: A Systematic Review

The significant progress of psychiatry in the 20th century provided a sophisticated theoretical framework to analyze the complex relationships between crime and mental illness. Schizophrenia has been traditionally associated with severe cognitive and affective deficits that heavily influence empathy, judgment capacities, but also control of impulsiveness. Although there is an association between psychotic disorders and absence or decrease of legal responsibility, their relationship is also determined by sociodemographic, developmental, and clinical factors. These disorders are associated not only with abolished criminal responsibility but also with diminished responsibility. We conduct a systematic literature review to examine the relation between schizophrenia and criminal responsibility. We have found that this clinical entity is often associated with diminished or abolished criminal liability. We discuss these findings, focusing on the specific deficits found in patients with schizophrenia and examining how this problem affects their behavior and eventually their accountability for their crimes.

Management of schizophrenia in conditions of high security

There are four high-security hospitals in the UK: Broadmoor Hospital in Berkshire (founded in 1863), Rampton Hospital in Nottinghamshire (1914), Ashworth Hospital in Merseyside (1990), which opened following the amalgamation of Park Lane (1974) and Mosside Hospitals (1913), and the State Hospital at Carstairs in Lanarkshire (1948). The first three are known as the special hospitals and serve England and Wales. The latter offers a special security service, combining high and medium secure care, for the whole of Scotland and Northern Ireland – there is no form of medium secure psychiatric provision in these countries. All four hospitals provide care for patients with mental disorders and dangerous, violent or criminal propensities. There are approximately 1550 beds in these facilities and all patients are formally detained under mental health or criminal legislation. The special hospitals are currently administered by the high-security psychiatric services commissioning team, managed locally as individual authorities, although in the future it is intended to integrate them more fully into the National Health Service (NHS) and to organise both high and medium secure services at a regional level. Carstairs is administered by the State Hospital Board for Scotland which has the status of a special health board.

A postal survey of the assessment procedure for personality disorder in forensic settings

Aims and Method

A survey of 50 in-patient forensic health care and prison services in England, Wales and Scotland was employed to evaluate: (a) how severe personality disorder is assessed; and (b) how assessments compare with recommendations concerning standardised assessment by the Working Group on Psychopathic Disorder (Reed, 1994).

Results

Seventy per cent of services responded, of whom 40% formally assessed personality disorder. Fifty-four instruments were routinely employed. Assessments of personality structure and cognitive/emotional styles were more common than structured diagnostic instruments or ratings of interpersonal functioning. Of the assessment tools, 25.7% of services provided at least one suggested by Reed (1994).

Clinical Implications

A nationally agreed, focused repertoire of instruments should be encouraged within secure forensic settings offering assessments to individuals with severe personality disorder.

Pharmacological interventions for sex offenders: A poor evidence base to guide practice

Although a significant proportion of prisoners and patients in secure hospitals are sex offenders and victim surveys reveal a high level of hidden sexual victimisation, the authors of this Cochrane review found only very limited support for pharmacological intervention with sex offenders. Given the nature and extent of the problem of sexual offending and the promise shown by new drugs, there is a need for clinical scientists, lawyers and ethicists to rise to the challenge of ascertaining the effectiveness and safety of drugs which are being used to treat sex offenders, some involuntarily, without the evidence base to justify confidence as to their effectiveness and safety.

Antipsychotic prescribing of consultant forensic psychiatrists working in different levels of secure care with patients with schizophrenia

Aims and method To detect any differences in the antipsychotic prescribing practices of consultant forensic psychiatrists working in different levels of secure care with patients diagnosed with schizophrenia, and to identify potential reasons for any differences. Prescribing data were collected from four secure hospitals within one National Health Service trust. A questionnaire was sent to consultant forensic psychiatrists working at those hospitals as well as those working in the trust's community forensic services. Results Consultants working in high security prescribed more oral antipsychotics than consultants working in medium and low security, who prescribed more depot antipsychotics, as established via the prescribing data. The questionnaire provided insight regarding the reasons for these preferences. Clinical implications There were differences in the antipsychotic prescribing practices of consultant forensic psychiatrists working in different levels of secure care, and, overall, the rate of depot antipsychotic prescribing was lower than might be expected. Although it was positive that the rate of polypharmacy was low when compared with earlier studies, the lower-than-expected rate of depot antipsychotic prescribing has clinical implications.

Psychotropic prescribing in seriously violent men with schizophrenia or personality disorder in a UK high security hospital

OBJECTIVES

To analyze antipsychotic prescribing patterns in a UK high security hospital (HSH) that treats seriously violent men with either schizophrenia or personality disorder and examine how different groups consented to treatment and prescribing for metabolic conditions. We hypothesized that there would be high prevalence of antipsychotic polypharmacy, and high-dose antipsychotic and clozapine prescribing.

BACKGROUND

HSHs treat seriously violent, mentally disordered offenders, and the extant literature on prescribing patterns in forensic settings is sparse.

METHODS

Prescribing and clinical data on all 189 patients in a UK HSH were collected from the hospital's databases. Data were analyzed using SPSS.

RESULTS

The population was split into the following groups: schizophrenia spectrum disorder (SSD-only), personality disorder (PD-only), and comorbid schizophrenia spectrum disorder and PD. The majority (93.7%) of all patients were prescribed at least one antipsychotic, and (27.5%) were on clozapine. Polypharmacy was prevalent in 22.2% and high-dose antipsychotic in 27.5%. Patients on clozapine were more likely to be prescribed antidiabetic, statins, or antihypertensive medication. Patients in the PD-only group were more likely to be deemed to have the capacity to consent to treatment and be prescribed clozapine in contrast to the SSD-only group.

CONCLUSIONS

Rates of clozapine and high-dose antipsychotic prescribing were higher than in other psychiatric settings, while polypharmacy prescribing rates were lower. Higher clozapine prescribing rates may be a function of a treatment-resistant and aggressive population. A higher proportion of PD-only patients consented to treatment and received clozapine compared with in-house SSD-only as well as other psychiatric settings. Implications of the findings are discussed.

Anti-social personality characteristics and psychotic symptoms: Two pathways associated with offending in schizophrenia

BACKGROUND

Several research groups have shown that people with schizophrenia who offend do not form a homogenous group. A three-group model claimed by Hodgins proposes distinguishing between people who start offending before the onset of psychosis (early starters), after psychosis onset but at age 34 years or under (late starters) and after psychosis onset but at age 35 years or older (late first offenders).

AIMS

This study aimed to test the hypotheses (1) that the personality of early starters and non-psychotic offenders would be similar, but different from either late-starter group; (2) that the late-starter groups would be more likely to have positive psychotic symptoms than non-criminal patients with schizophrenia; and (3) that symptom types would differentiate the psychotic groups.

METHODS

A retrospective file study was conducted on cases of 97 early starters, 100 late starters and 26 late first offenders all drawn from the Netherlands Institute of Forensic Psychiatry and Psychology (NIFP) archives 1993-2008, 115 non-psychotic offenders from 2005-2008 NIFP archives and 129 patients with schizophrenia and no criminal history from one general service in Rotterdam.

RESULTS

Early starters closely resembled the non-psychotic offenders in their premorbid anti-social personality characteristics. The two late-onset offending psychosis groups were more likely to have persecutory and/or grandiose delusions than non-offenders with psychosis, but so were the early starters.

IMPLICATIONS

In a first study to compare subgroups of offenders with psychosis directly with non-psychotic offenders and non-offenders with psychosis, we found such additional support for a distinction between early and late starters with psychosis that different treatment strategies would seem indicated, focusing on personality and substance misuse for the former but psychotic symptoms for all. It remains to be seen whether the higher rate of alcohol misuse amongst late first offenders is a fundamental distinction or a function of age difference.

Pharmacological interventions for those who have sexually offended or are at risk of offending

BACKGROUND

Sexual offending is a serious social problem, a public health issue, and a major challenge for social policy. Victim surveys indicate high incidence and prevalence levels and it is accepted that there is a high proportion of hidden sexual victimisation. Surveys report high levels of psychiatric morbidity in survivors of sexual offences.Biological treatments of sex offenders include antilibidinal medication, comprising hormonal drugs that have a testosterone-suppressing effect, and non-hormonal drugs that affect libido through other mechanisms. The three main classes of testosterone-suppressing drugs in current use are progestogens, antiandrogens, and gonadotropin-releasing hormone (GnRH) analogues. Medications that affect libido through other means include antipsychotics and serotonergic antidepressants (SSRIs).

OBJECTIVES

To evaluate the effects of pharmacological interventions on target sexual behaviour for people who have been convicted or are at risk of sexual offending.

SEARCH METHODS

We searched CENTRAL (2014, Issue 7), Ovid MEDLINE, EMBASE, and 15 other databases in July 2014. We also searched two trials registers and requested details of unidentified, unpublished, or ongoing studies from investigators and other experts.

SELECTION CRITERIA

Prospective controlled trials of antilibidinal medications taken by individuals for the purpose of preventing sexual offences, where the comparator group received a placebo, no treatment, or 'standard care', including psychological treatment.

DATA COLLECTION AND ANALYSIS

Pairs of authors, working independently, selected studies, extracted data, and assessed the risk of bias of included studies. We contacted study authors for additional information, including details of methods and outcome data.

MAIN RESULTS

We included seven studies with a total of 138 participants, with data available for 123. Sample sizes ranged from 9 to 37. Judgements for categories of risk of bias varied: concerns were greatest regarding allocation concealment, blinding of outcome assessors, and incomplete outcome data (dropout rates in the five community-based studies ranged from 3% to 54% and results were usually analysed on a per protocol basis).Participant characteristics in the seven studies were heterogeneous, but the vast majority had convictions for sexual offences, ranging from exhibitionism to rape and child molestation.Six studies examined the effectiveness of three testosterone-suppressing drugs: cyproterone acetate (CPA), ethinyl oestradiol (EO), and medroxyprogesterone acetate (MPA); a seventh evaluated two antipsychotics (benperidol and chlorpromazine). Five studies were placebo-controlled; in two, MPA was administered as an adjunctive treatment to a psychological therapy (assertiveness training or imaginal desensitisation). Meta-analysis was not possible due to heterogeneity of interventions, comparators, study designs, and other issues. The quality of the evidence overall was poor. In addition to methodological issues, much evidence was indirect.

PRIMARY OUTCOME

recividism. Two studies reported recidivism rates formally. One trial of intramuscular MPA plus imaginal desensitisation (ID) found no reports of recividism at two-year follow-up for the intervention group (n = 10 versus one relapse within the group treated by ID alone). A three-armed trial of oral MPA, alone or in combination with psychological treatment, reported a 20% rate of recidivism amongst those in the combined treatment arm (n = 15) and 50% of those in the psychological treatment only group (n = 12). Notably, all those in the 'oral MPA only' arm of this study (n = 5) dropped out immediately, despite treatment being court mandated.Two studies did not report recidivism rates as they both took place in one secure psychiatric facility from which no participant was discharged during the study, whilst another three studies did not appear directly to measure recividism but rather abnormal sexual activity alone.

SECONDARY OUTCOMES

The included studies report a variety of secondary outcomes. Results suggest that the frequency of self reported deviant sexual fantasies may be reduced by testosterone-suppressing drugs, but not the deviancy itself (three studies). Where measured, hormonal levels, particularly levels of testosterone, tended to correlate with measures of sexual activity and with anxiety (two studies). One study measured anxiety formally; one study measured anger or aggression. Adverse events: Six studies provided information on adverse events. No study tested the effects of testosterone-suppressing drugs beyond six to eight months and the cross-over design of some studies may obscure matters (given the 'rebound effect' of some hormonal treatments). Considerable weight gain was reported in two trials of oral MPA and CPA. Side effects of intramuscular MPA led to discontinuation in some participants after three to five injections (the nature of these side effects was not described). Notable increases in depression and excess salivation were reported in one trial of oral MPA. The most severe side effects (extra-pyramidal movement disorders and drowsiness) were reported in a trial of antipsychotic medication for the 12 participants in the study. No deaths or suicide attempts were reported in any study. The latter is important given the association between antilibidinal hormonal medication and mood changes.

AUTHORS' CONCLUSIONS

We found only seven small trials (all published more than 20 years ago) that examined the effects of a limited number of drugs. Investigators reported issues around acceptance and adherence to treatment. We found no studies of the newer drugs currently in use, particularly SSRIs or GnRH analogues. Although there were some encouraging findings in this review, their limitations do not allow firm conclusions to be drawn regarding pharmacological intervention as an effective intervention for reducing sexual offending.The tolerability, even of the testosterone-suppressing drugs, was uncertain given that all studies were small (and therefore underpowered to assess adverse effects) and of limited duration, which is not consistent with current routine clinical practice. Further research is required before it is demonstrated that their administration reduces sexual recidivism and that tolerability is maintained.It is a concern that, despite treatment being mandated in many jurisdictions, evidence for the effectiveness of pharmacological interventions is so sparse and that no RCTs appear to have been published in two decades. New studies are therefore needed and should include trials with larger sample sizes, of longer duration, evaluating newer medications, and with results stratified according to category of sexual offenders. It is important that data are collected on the characteristics of those who refuse and those who drop out, as well as those who complete treatment.

Alcohol abuse as the strongest risk factor for violent offending in patients with paranoid schizophrenia

Aim

To determine predictive risk factors for violent offending in patients with paranoid schizophrenia in Croatia.

Method

The cross-sectional study including male in-patients with paranoid schizophrenia with (N = 104) and without (N = 102) history of physical violence and violent offending was conducted simultaneously in several hospitals in Croatia during one-year period (2010-2011). Data on their sociodemographic characteristics, duration of untreated illness phase (DUP), alcohol abuse, suicidal behavior, personality features, and insight into illness were collected and compared between the groups. Binary logistic regression model was used to determine the predictors of violent offending.

Results

Predictors of violent offending were older age, DUP before first contact with psychiatric services, and alcohol abuse. Regression model showed that the strongest positive predictive factor was harmful alcohol use, as determined by AUDIT test (odds ratio 37.01; 95% confidence interval 5.20-263.24). Psychopathy, emotional stability, and conscientiousness were significant positive predictive factors, while extroversion, pleasantness, and intellect were significant negative predictive factors for violent offending.

Conclusion

This study found an association between alcohol abuse and the risk for violent offending in paranoid schizophrenia. We hope that this finding will help improve public and mental health prevention strategies in this vulnerable patient group.

Rape and sexual assault of the elderly – an exploratory study of 10 cases referred to the Irish Forensic Psychiatry Service

Objectives: This small exploratory study aims to investigate the characteristics of those convicted of rape or serious sexual assault against an elderly person (aged 65 years or over) who were referred to the Irish Forensic Psychiatry Service for assessment.

Method: A retrospective examination of the case histories of such individuals both at the Central Mental Hospital, Dundrum, Dublin and at Arbour Hill Prison, Dublin between 1989 and 1995.

Results: Ten such cases were found. The most frequent diagnoses were those of schizophrenia and alcohol dependence syndrome. A dual diagnosis of both schizophrenia and alcohol dependence was common. A high percentage of the schizophrenia cases had been previously charged with sexual offences and most were non-compliant with prescribed psychotropic medication at the time of the offence.

Conclusions: A very small number of people with mental illness may be at increased risk of committing a sexual offence against an elderly person. Further study of such offenders is merited.

A non-randomised controlled trial of the R&R2MHP cognitive skills program in high risk male offenders with severe mental illness

BACKGROUND

The growing popularity of offending behavior programs has led to the interest of whether such programs are effective with mentally disordered offenders. This study aimed to evaluate the effectiveness of the Reasoning and Rehabilitation program adapted for offenders with severe mental illness (R&R2 MHP).

METHODS

A sample of 59 adult high risk males detained in a high secure hospital completed questionnaires at baseline and post treatment to assess violent attitudes, anger, coping processes and social problem-solving. An informant measure of social and psychological functioning, including disruptive behavior, was completed by staff at the same time. The data of 30 patients who participated in the group condition were compared using intention to treat analysis with 29 controls who received treatment as usual.

RESULTS

80% of group participants completed the program. In contrast to controls, significant medium-large treatment effects were found at outcome on self-reported measures of violent attitudes, social problem-solving and coping processes. Improvements were endorsed by informant ratings of disruptive behavior, social and psychological functioning.

CONCLUSIONS

The R&R2MHP had a comparatively low dropout rate and was effective in a sample of high risk mentally disordered offenders requiring detention in high security. Future research should use a randomized controlled design.

TRIAL REGISTRATION

Current Controlled Trials ACTRN12613000216718.

Motivational influences in persons found not criminally responsible on account of mental disorder: a review of legislation and research

This paper provides a review of the legislative reforms and case law that have impacted the defense of Not Criminally Responsible on Account of Mental Disorder (NCRMD) in Canada over the past three decades. As in other jurisdictions internationally, we observe that legislative reforms of procedural, as opposed to substantive, aspects of the NCRMD defense have impacted the manner in which NCRMD criteria are applied in common practice. More people are being declared NCRMD in recent years, and there is greater heterogeneity in the offending and psychiatric profiles of these individuals, suggesting that NCRMD criteria are being applied more liberally over time. In light of the substantial growth of the forensic mental health system over the past two decades, witnessed both in Canada and abroad, we propose that the study of motivational influences underlying the offending behaviors of persons with serious mental illness (SMI) is necessary to begin disentangling symptom-based offending from violent and antisocial behaviors that may have other motives. This, in turn, can help to determine legal issues, better define the nature of each person's offending and treatment needs, and provide a more fine-grained analysis of the drivers behind the growth experienced by the forensic system.

Oral fluid testing as an alternative to urine testing for drugs of abuse in inpatient forensic settings: giving patients choice

Background and aims

The abuse of illicit substances is very common amongst forensic psychiatry populations and is known to be one of the most potent risk factors for interpersonal violence. Forensic psychiatry units hence strive to keep themselves as free as possible from illicit substances and in Scotland drugs of abuse have traditionally been screened for by means of urine testing. The aim of this study is to examine patients’ preferences for drug testing methods and to compare the acceptability of urine testing versus oral fluid testing (OFT) within a secure hospital setting.

Methods

Patients in three continuing care wards at the State Hospital, Carstairs were offered the choice of either urine or oral fluid testing. We developed protocols and recording forms and trained staff in the administration of the OFT. We recorded the sampling time for OFT and urine, and the views of patients and staff on the testing procedures over a six month period.

Results

Sixty-two samples were taken, with 53 (85%) opting for OFT and nine (15%) opting for urine sampling. The average time taken for OFT was 13 minutes, while the average time taken for urine sampling was 33 minutes. The majority of patients and staff rated oral fluid and urine testing as comfortable and easy. Patients recorded comments on 46 (87%) of OFT samples, only two of which were negative. In general they preferred the OFT because it was quicker and easier and they commented on it being more dignified and private. Patients recorded comments on five (55%) of urine samples, with one of the primary reasons for opting for urine sampling appearing to be a reluctance to try new things, though a few said they did not want to have anything in their mouths. Staff returned comments on 24 (45%) of OFT samples and one (11%) of urine samples. Comments on the OFT were overwhelmingly positive and pointed out the relative speed and ease of this sampling method.

Conclusions

We concluded that the pilot study was successful. OFT was found to be generally preferred by patients and staff. Although there was an additional financial cost, this was considered to be outweighed by the significant benefits arising from offering patients choice, the preservation of patient dignity and staff time savings. The option of OFT has now been extended to all patients within the State Hospital. Practitioners will wish to consider the value of OFT in forensic psychiatry inpatient settings given the benefits identified within this study.

Angry affect and violence in the context of a psychotic illness: a systematic review and meta-analysis of the literature

A small but significant relationship between schizophrenia and violence is well established, but not yet fully explained. Research has highlighted anger as an important factor in precipitating actual violence in general and psychiatric populations. However, anger has not been extensively studied as a risk factor for violence in people with schizophrenia and related psychoses. We evaluated published evidence on the relationship between anger and violence in patients with schizophrenia and related psychoses by means of a systematic review of the literature. A search of main online databases from inception till January 2012 was performed and supplemented with correspondence with authors and data available online. 11 studies which measured angry affect in patients with schizophrenia who had been violent were included in the review. 5 studies with a total of 510 individuals had anger data that were suitable to be pooled in a meta-analysis in form of standardised mean difference values comparing the anger scores of the non-violent groups with violent groups. All the studies included showed significantly higher scores for anger in the violent group compared with the non-violent group with the pooled result expressed as standardised mean difference of 0.74 95% CI (0.53, 0.94) and the Z value for overall effect=7.01. The studies not included in the meta-analysis which looked at 610 individuals, were analysed descriptively and all of them reported higher scores for anger for individuals with schizophrenia who acted violently. There is a consistency of significant association between angry affect and violent behaviour in the context of psychotic illness across various study designs, settings and populations. Theoretical support already exists for this relationship and this review lends further support to explore this relationship further.

Subtypes of aggression in patients with schizophrenia: the role of personality disorders

BACKGROUND

Research has repeatedly demonstrated that schizophrenia has a small but significant association with violence. It is further recognised that a subgroup of people with such links also have personality disorders, but the extent to which type of violence or aggression varies according to subgroup is less clear.

AIM

This study aimed to investigate, among co-morbid cases, if the number or type of personality disorders predicts type of aggression.

METHODS

In a cross-sectional study, 108 patients with schizophrenia were assessed for personality disorder, Axis-I diagnosis, verbal IQ, social functioning and type of aggression.

RESULTS

Logistic regression revealed that the more personality disorders identified (Cluster B personality disorders compared with Clusters A and C) and anti-social personality disorder compared with other Cluster B disorders significantly predicted premeditated aggression.

CONCLUSIONS

These findings suggest that detailed personality assessment should be a routine part of comprehensive assessment of patients with schizophrenia. Improved knowledge of the presence and type of personality disorders may help detect and manage the risk of some types of aggression.

Empathy, schizophrenia and violence: a systematic review

BACKGROUND

A small but significant association between schizophrenia and violence is open to a number of explanations. Impaired empathy has been associated with schizophrenia, and with violence in the general population. Our aim was to conduct a systematic review of any research into relationships between schizophrenia, empathy and violence.

METHODS

The electronic databases Medline, Psychinfo, Embase, Cochrane and DARE were searched using combinations of terms for schizophrenia, empathy and violence, as were selected journals and reference lists of relevant articles. Selection of studies and data extraction was done by each of us, blind to the other.

RESULTS

Six studies were identified, but sample selection, research procedures and empathy, illness and violence measures differed sufficiently between them that only descriptive analysis was possible. Apart from one single case study, sample sizes were between 24 (12 violent) and 116 (35 violent). A component of emotional empathy (emotion recognition) was measured in three of the studies, all of which showed some specific dysfunctional recognition related to violence. Cognitive empathy was measured in three studies, two linking impairments to violence and one not. Emotional responsiveness was measured in one study and no association with violence was found.

CONCLUSION

Although evidence is inconclusive on empathy impairment as a mediator of violence by people with chronic psychosis, it's likely relevance is most apparent in the better controlled studies. Larger scale studies are indicated with rigorous control for comorbidities.

Theory of mind and paranoia in schizophrenia: a game theoretical investigation framework

INTRODUCTION. Ample evidence already shows that theory of mind (ToM) is impaired in people with schizophrenia. Our aim was to critically review this literature. METHOD. We completed a selected review of the research literature on ToM in schizophrenia. RESULTS. Gaps in ToM research were identified. A specific relationship between impaired ToM and paranoid delusions, although intuitively reasonable from a theoretical basis, has only been demonstrated in a few studies. Psychometric properties of ToM tasks employed in these studies may be a confounding factor in drawing conclusions about the relationship. Because most ToM measures have focused on the third-person perspective, participants are not actively interacting. The tasks fail to capture the cognitive demands faced by individuals in real-life situations, and, in effect, are not a direct measure of ToM. CONCLUSIONS. Potential research areas are discussed. Since game theoretical paradigms require the direct involvement of the first person and situate the participant's interpersonal reasoning within an interactive context, they provide more ecologically valid experimental platforms than conventional questionnaire measures to assess ToM in schizophrenia research.

Relapsing versus non relapsing course of schizophrenia: a cohort study in a community based mental health service

Aim - We examined the effect of several clinical variables on the tendency to relapse and to require hospitalization in a cohort of patients, living in the community and followed up naturalistically for seven years. Method - Forty-six patients affected by schizophrenia and schizoaffective disorder, according to both DSM-IV and ICD-10 criteria, were assessed by Positive and Negative Syndrome Scale and Life Skills Profile (LSP). All patients consecutively enrolled, were assessed in a stable clinical phase of illness and treated as usual by their reference psychiatrist. Social and clinical outcome was assessed yearly for seven years after the study entry and analyzed with survival analysis. Results - Patients who did not relapse, were characterized by higher functioning, lower positive symptoms, higher ability in self-care and non-turbulence and higher IQ at their baseline clinical evaluation. These variables were entered in a Cox regression model to corroborate the predictive power on the relapsing course of illness. Only IQ and non-turbulence scores of LSP were entered in the equation (Wald method: p=0.007 and p=0.002 respectively). Conclusions - Several factors interact with the course of illness and influence the tendency to require hospitalization. In the present study we report that non-turbulence is a significant predictor of a non-relapsing course of illness. Further studies are needed to clarify the role of other mediating variables.

Declaration of Interest: none.

Psychotic-like experiences are associated with violent behavior in adolescents

OBJECTIVE

The diagnosis of psychotic disorder is associated with a risk of violence. Psychotic-like experiences (PLEs) in the general population may share an etiological background with psychotic disorders. The present study has evaluated the association between PLEs and violent behavior in adolescents.

METHODS

PLEs and violent behavior were assessed using a self-report questionnaire administered to 18,104 Japanese adolescents. Potential confounding factors were also evaluated.

RESULTS

After controlling for the effects of age, gender, GHQ-12 total score, victimization, and substance use, the existence of PLEs was significantly associated with both interpersonal violence (odds ratio (OR)=1.36, 95% confidence interval (CI): 1.23 to 1.51) and violence towards objects (OR=1.46, 95%CI: 1.33 to 1.61). The greater the number of such psychotic experiences, the higher the risk of violence. Particular types of PLEs ('spied-upon' and 'voice hearing') are significantly associated with interpersonal violence, while all of the types of PLEs assessed in this study were significantly associated with violence towards objects.

CONCLUSION

PLEs may be a risk factor for violent behavior in adolescents. Violent acts by individuals with schizophrenia may not be a direct consequence of the disease itself, but may instead share an etiological background with such behavior in the general population.

Protecting the prominent? A research journey with Paul Mullen

Recent research from the United Kingdom has called into question entrenched assumptions from the USA about public figure threat assessment, in particular the low importance given to mental illness and to the making of threats. This article reviews some of the evidence, concluding that the high prevalence of psychotic illness in threateners and harassers of public figures and the frequency of warning behaviours determines that these factors should be accorded a central role in the assessment and management of such cases. It is noted that data in US studies do not differ greatly from those in UK studies, but rather their interpretation. The practical benefits of attending to the factors in question are illustrated by reference to the activities of the United Kingdom's Fixated Threat Assessment Centre. The overlap is noted between the fields of public figure threat assessment and stalking, which have hitherto developed separately. The issue of public figure threat assessment is used to illustrate some of the attitudes and personal qualities which have typified the career and achievements of Paul Mullen in forensic psychiatry research.

Characteristics of offenders deemed not guilty by reason of insanity in Portugal

In Portugal, offenders found not guilty by reason of insanity (NGRI), may be given a restricted order to a special hospital as an alternative to prison. In European countries there is a recognized need for data concerning this special population. The aim of the present study was to examine the characteristics of all the NGRI subjects (n = 274) detained in the country in a descriptive and retrospective survey conducted in January 2009. Offence committed, demographic factors, diagnosis at admission, background of substance abuse and diagnostic stability were recorded. Schizophrenia was the commonest diagnosis (51.5%). Mean population age was 42.6 years, with only 6.2% women. Homicide was the most common offense (41.2%). A background of substance abuse was found in 42.3% of subjects. There were significant differences in the schizophrenia and mental retardation patient groups when compared individually with the other diagnoses concerning homicide and arson as the offence. Mean duration of inpatient stay did not differ significantly between diagnoses. The findings also point to poor follow-up of the NGRI patients after admission.

Schizophrenia with impulsive and aggressive behaviors

Impulsive and aggressive behaviors are important clinical challenges in the treatment of patients with schizophrenia. They occur both in the acute phase as well as in the chronic phase of the disorder and call for differentiated treatment interventions. It is important to always first consider behavioral and nonpharmacological interventions. High levels of structure and organization together with a nonconfrontational approach may be very successful interventions. In terms of acute pharmacological interventions, clinicians now have a broad spectrum of intramuscular antipsychotic compounds available with rapid onset of action and relatively little sedation. There is a need for new compounds with a more acceptable tolerability profile for the long-term treatment of these important syndromes.

Dysfunctional, but not functional, impulsivity is associated with a history of seriously violent behaviour and reduced orbitofrontal and hippocampal volumes in schizophrenia

Aggression and violent acts have been linked with impulsive responding. We investigated whether impulsive personality trait, especially suggestive of dysfunctional impulsivity (i.e. fast and inaccurate responding where this is non-optimal), is associated with a history of seriously violent behaviour and specific brain deficits in schizophrenia. Twenty-four male participants with schizophrenia, of whom 10 had a history of serious physical violence, and 14 healthy male participants were assessed on impulsiveness (dysfunctional impulsivity), venturesomeness (functional impulsivity), and empathy. All participants underwent magnetic resonance imaging. The results revealed that participants with schizophrenia and a history of violence showed elevated impulsiveness but had comparable scores on venturesomeness and empathy dimensions. Impulsiveness scores correlated negatively with reduced orbitofrontal grey matter volume in both the patient and healthy control groups, and with hippocampal volume in the patient group. Our findings suggest that dysfunctional, but not functional, impulsivity is elevated in patients with schizophrenia with a propensity for repetitive violence, and this in turn appears to be associated with reduce volumes of both the orbitofrontal cortex grey matter and the hippocampus. Violence risk prediction and management strategies in schizophrenia may benefit from including specific measures of dysfunctional impulsive traits.

[Forensic importance of homicide]

INTRODUCTION

This study encompassed the total number of homicides in Bosnia and Herzegovina (B&H) in the period from 1st January 1997 to 31st December 2006 and then analysed homicidal behaviour. The aim is to assess the differences between the people who committed violent and those who committed accidental homicide in Bosnia and Herzegovina.

MATERIAL AND METHODS

In a multicentric, retrospective study of comparing the groups with equal number of respondents we analysed the individuals who had committed violent (n=135) and accidental homicides (n=135). The homicides were tested by using sociodemographic and psychosocial items. Measurement instruments were: General data list, Eysenck Personality Questionnaire (EPQ), Hamilton Depression Rating Scale (HDRS), Emotions Profile Index (EPI). The descriptive and multivariable logistic analysis was done statistically.

RESULTS

In the descriptive analysis the socio-demographically violent murderers were: male gender (chi 2=3.340, P=0.009), more workers than officials (chi 2=7.340, P=0.011), fathers were more often workers/farmers (chi 2=1.430, P=0.046), gambling (chi 2=13.100, P=0.001) and possible recidivism (chi 2=6.770, a P=0.001). The accidental murderers were family people (chi 2=4.100, P=0.041), with more frequent drug abuse (chi 2=3.190, P=0.012) and they would not repeat the delict. In the multivariate analysis the violent murderers were highly discriminated (P=0.001) from accidental ones by: war involvement r=0.1148, OR=2.971 (95%), CI=1.040-7.890; age, father's education, psychoticism (EPQ) r =-0.1085, OR=0.291 (95%), CI=0.110-0870, HDRS-total r=-0.1797, OR=0.830 (95%), CI=0.710-0.930, destructiveness r=0.1270, OR=1.560 (95%), (CI=1.197-2.032, and deprivation in the P. I. E. tests.

CONCLUSION

By the violence of their acts murderers confirm micro-social model of transferring the violence, and transition and heredity confirm the ecological-developmental trans-generation model of violence. Accidental murderers commit homicide in anomy, with intoxications and prolonged psycho-traumatism.

Variations in rates of comorbid substance use in psychosis between mental health settings and geographical areas in the UK. A systematic review

BACKGROUND

Comorbid substance misuse in psychosis is associated with significant clinical, social and legal problems. An epidemiologically informed approach to planning service delivery requires an understanding of which clinical populations are at particularly high risk for such 'dual diagnosis'. Evidence has now been accumulating in the UK since the early 1990s, and allows a relatively comprehensive comparison of rates between service settings, geographical areas and social contexts in terms of ethnic background.

METHODS

A literature search was carried out with the aim of investigating: (a) comorbid alcohol and drug misuse rates in people with established psychosis in different mental health and addiction settings in the UK, (b) variations in such rates between different population groups.

RESULTS

There are wide variations in reported drug and alcohol misuse rates in psychosis. Most recent UK studies report rates between 20 and 37% in mental health settings, while figures in addiction settings are less clear (6-15%). Rates are generally not as high as in US studies, but appear to be especially high in inpatient and crisis team settings (38-50%) and forensic settings. In terms of geography, rates appear highest in inner city areas. Some ethnic groups are over-represented among clinical populations of people with dual diagnosis.

CONCLUSIONS

Rates of substance misuse in psychosis are likely to be influenced by service setting, population composition and geography. Acute and forensic settings are especially appropriate for the development of targeted interventions.

A comparison of the family and childhood backgrounds of hospitalised offenders with schizophrenia or personality disorder

BACKGROUND

Previous studies have demonstrated high levels of childhood adversity and familial criminality in offender patients with schizophrenia and/or personality disorder, but few have directly compared these groups.

AIMS

To compare the parenting histories of offender patients with schizophrenia with those with personality disorder. We hypothesised that rates of family criminality and experiences of disrupted parenting would be higher in the personality disorder group than the schizophrenia group.

METHOD

A retrospective case-control methodology compared the family background and childhood experiences of patients with either schizophrenia or personality disorder (n = 3088) admitted to any of the English high-security hospitals.

RESULTS

Compared with those with schizophrenia, patients with personality disorder had experienced higher rates of family criminality, parental separation, and multiple changes of caregiver and institutional care. There was no significant difference in the prevalence of family psychiatric history between the groups.

DISCUSSION

Although our hypotheses were sustained, we were impressed that rates of disruption to parenting were high in the schizophrenia group as well as in the personality disorder group. Less than a third of the personality disorder group had survived childhood without a change in parenting, but this was true for about half of the schizophrenia group, too. Family work tailored for people with schizophrenia is needed, even though within personality disorder services, a greater demand for disorder-sensitive family work is likely to be encountered.

Mental disorders and request for psychiatric intervention in an Italian local jail

The issue of the prevalence of psychiatric illnesses in Italian prison samples has not received the same attention paid at an international level. The aims of the present study were to evaluate the prevalence of psychiatric disorders diagnosed according to DSM-III-R criteria among an Italian prisoner population, and to examine prisoners' requests for psychiatric intervention in relationship to the presence or absence of different psychiatric disorders. One hundred forty-two Italian male subjects from the Casa Circondariale of Messina, Italy, were evaluated using the Structured Clinical Interview for DSM-III-R Non-Patient Version - SCID I and SCID II. A very high rate of disorders was found among inmates: 85.2% (n=121) of the sample were affected by a psychiatric disorder. Of the total sample, 51.4% (n=73) had requested psychiatric treatment during detention. The detection, diagnosis and treatment of the mentally ill prisoners is a primary goal for a better organization of services and prison settings; screening procedures for evaluating the presence of psychiatric disorders, with the aim to promote differential strategies for the care and rehabilitation of inmates, are needed.

Psychosis and violence: stories, fears, and reality

Individuals with psychosis are often feared. In fact, they are themselves likely to be victims of violence; however, the main aim of this review is to provide an overview of the evidence on relations between psychosis and violence to others. The terms psychosis and violence were used in a literature search limited to the Cochrane Library and PubMed, a manual search of 8 journals, and a follow-up of additional references in the articles found. The overview draws on new empirical data and major reviews. Almost all sound epidemiologic data on psychosis and violence dates from 1990. There is consistency on a small but significant relation between schizophrenia and violent acts. Since then there has also been movement toward understanding the nature of associations and progress on strategies for managing individuals who have psychosis and are violent. Public fears about individuals with psychotic illnesses are largely unfounded, although there would be benefit in greater attention to the safety of those in their close social circle. The task for the next 10 years must be the development and application of knowledge to improve specific treatments-that is, interventions that go beyond holding and caring to bring about substantial change.

Executive function and in-patient violence in forensic patients with schizophrenia

BACKGROUND

The literature on the association between neuropsychological deficits and in-patient violence in schizophrenia is limited and the findings inconsistent.

AIMS

To examine the role of executive function deficits in inpatient violence using measures of dorsolateral (DLPFC) and ventrolateral prefrontal cortical (VLPFC) function.

METHODS

Thirty-three violent and forty-nine non-violent male forensic in-patients with schizophrenia were assessed using neuropsychological tasks probing DLPFC and VLPFC function and on measures of symptoms and psychopathy.

RESULTS

There were no significant group differences in neuropsychological task performance. Higher rates of violence were significantly associated with lower current IQ scores and higher excitement symptom scores. The 'violent' group had significantly higher interpersonal and antisocial domain psychopathy scores. In a logistic regression analysis, IQ and the interpersonal domain of psychopathy were significant discriminators of violent v. non-violent status.

CONCLUSIONS

Personality factors rather than symptoms and neuropsychological function may be important in understanding in-patient violence in forensic patients with schizophrenia.

Acting on harmful command hallucinations in psychotic disorders: an integrative approach

Although harmful command hallucinations have been linked to violent behavior, few studies have examined factors mediating this relationship. The principal aim of this study was to examine a range of factors potentially associated with acting on harmful command hallucinations using a multivariate approach. The sample comprised 75 participants drawn from community and forensic services. Measures assessing characteristics of the command hallucination and the hallucinator, including forensic risk factors, were administered. Using ordinal logistic regression, we found compliance to be associated with increasing age, viewing the command hallucination as positive, congruent delusions, and reporting low maternal control in childhood. Antipsychotic medication was protective while, contrary to expectations, traditional predictors of violence reduced the odds of compliance with command hallucinations viewed as threatening. The findings suggest that compliance with harmful commands is driven by a complex interaction between beliefs related to the command hallucination and personal characteristics, with risk of compliance increasing with age.

Presentations of psychosis with violence: variations in different jurisdictions. A comparison of patients with psychosis in the high security hospitals of Scotland and England

BACKGROUND

International literature is consistent on there being a significant relationship between psychosis and violence, less so on its extent and nature, but two main presentational types are increasingly recognized. In one, people are unremarkable before onset of illness and psychotic symptoms commonly drive violence; in the other, psychosis is preceded by childhood conduct problems, associated with personality disorder, and psychotic symptoms seem less relevant.

AIMS

To explore the extent to which variations in aspects of social and service context in different jurisdictions affect presentational type among people admitted to high security hospitals.

HYPOTHESES

There will be differences between jurisdictions in proportions of patients with pure psychosis or with psychosis and antecedent personality disorder, but symptom drive to violence will be more common in the pure psychosis group regardless of social, legal and service context.

METHOD

Independently conducted record studies were used to compare high security hospital patients with psychosis in Scotland and England, all resident between 25 August 1992 and 13 August 1993.

RESULTS

The cohorts were similar in offence histories, predominance of schizophrenia, age at first hospitalization for psychosis and first high security hospitalization. More Scottish patients had co-morbid substance misuse diagnoses and/or personality disorder than patients in England. Psychotic symptom drive to the index offence was, however, four times more likely in the pure psychosis groups, regardless of sex, ethnic group or country. Scottish patients spent less time in high security after the index act.

CONCLUSIONS

Our hypotheses were sustained. Knowledge about lifestyle before onset of psychosis is important for interpreting literature on how psychotic symptoms relate to violence. This may also influence longer term outcome, although the shorter length of secure hospital stay in Scotland was perhaps affected more by greater availability of open 'step-down' beds.

Violence and aggression: a literature review

This paper reports the results of a literature review that was undertaken to provide background for a small pilot study that introduced violence measurement instruments that was to assist the development of nursing practice on an acute psychiatric unit. Multiple databases were searched, focusing on publications since 1994: CINAHL, Ovid Healthstar, Ovid MEDLINE (R), EMBASE, and PsycINFO. The search used the following four groups of key word alternatives (used in truncated form to allow for ending permutations) in combination with each other: violence, aggression, dangerous; prediction, assessment, factor, risk, issue, cause, reason; mental, psychiatric; inpatient, short-term, acute, admission. Searching was supplemented with footnote chasing of those papers retrieved and existing resources of the first author. Consequently, the synthesis of the results discussed cannot be considered a systematic review of the literature and is a reflection of some of the key issues found in the literature.

[Forensic evaluation of persons with destructive behavior in the postwar Bosnia and Hertzegovina]

BACKGROUND/AIM

Different persons show forensic differences related to aggressive behavior in criminal and violation acts. The aim of this study was to forensicly analyze the influence of socio-dynamic conditions and stress in testing the forensic hypothesis of hetero-destruction, and analysis of persons with destructive behavior in Bosnia and Hertzegovina (B&H) in the period from 1996-2005.

METHODS

The experimental group consisted of 125 persons who had committed a crime according to the Criminal Law of B&H and, thus were under security measures or treatment The control group consisted of 125 persons who had committed a violation. The following psychometric tests/questionnaires were used in the study: Eysenek Personality Questionnaire (EPQ), Beck Anxiety Inventory (BAI) and Profile Index of Emotions (PIE).

RESULTS

There were a significant difference between the respondents' groups related to gender (p < 0.01), while broken family, migration, and family comorbidity showed insignificant differences. EPQ test showed statistically significant differences between the groups for all four variables, and Beck test found significant differences only for some ones. PIE test proved the relations of the basic emotions confirmed by discriminative function.

CONCLUSION

High level of hetero-destruction in crime was proven in the study. Criminal acts and violations were committed by the persons without psychopathology, as well as by the persons with mental diseases, which rendered a forensic responsibility and analysis of such an influence on behavior.