The Predictive Properties of Psychiatric Diagnoses, Dynamic Risk and Dynamic Risk Change Assessed by the VRS-SO in Forensically Admitted and Released Sexual Offenders

Individuals under voluntary treatment with sexual interest in minors: what risk do they pose?

Child Sexual Abuse (CSA) and the production, use, and distribution of Child Sexual Abuse Material (CSAM) are key threats to children's mental health. From the perspective of indicated prevention, it can be assumed that some persons with a sexual interest in children commit such unreported crimes. Accordingly, the German Network kein Täter werden (meaning do not offend) has implemented a confidential treatment service for persons with a sexual interest in minors who voluntarily seek therapy, might or might not have offended but have not yet been detected or have fulfilled all legal requirements (here referred to as non-forensic individuals). However, this offer has been questioned for investing resources in a group which critics consider as low risk. The following study addresses the question of recidivism risks for CSA or viewing CSAM among non-forensic individuals. We found significantly higher rates of CSA/CSAM in our participants' history compared to a German study on a representative sample of males. Regarding CSAM, the recidivism rate of 39% was found to be 11 times higher than the expected recidivism rate based on previous publications. Regarding CSA, the recidivism rate of 14% was not significantly different from the expected rate reported for subjects with a conviction for a sexual contact offense. Among various risk instruments, only the CPORT with CASIC rating was able to predict CSA (AUC = 0.69, 95% CI = 0.55, 0.82) and CSAM (AUC = 0.63, 95% CI = 0.53, 0.73) among individuals with a history of CSAM, but with poor discrimination. We conclude that a large proportion of our sample poses a substantial risk and therefore treatment resources are well invested. However, further studies are needed to improve risk assessment among non-forensic clients.

Violence risk assessment instruments in forensic psychiatric populations: a systematic review and meta-analysis

BACKGROUND

Although structured tools have been widely used to predict violence risk in specialist mental health settings, there is uncertainty about the extent and quality of evidence of their predictive performance. We aimed to systematically review the predictive performance of tools used to assess violence risk in forensic mental health, where they are routinely administered.

METHODS

In our systematic review and meta-analysis, we followed PRISMA guidelines and searched four databases (PsycINFO, Embase, Medline, and Global Health) from database inception to Nov 1, 2022, to identify studies examining the predictive performance of risk assessment tools in people discharged from forensic (secure) mental health hospitals. Systematic and narrative reviews were excluded from the review. Performance measures and descriptive statistics were extracted from published reports. A quality assessment was performed for each study using the Prediction Model Risk of Bias Assessment Tool. Meta-analysis was conducted on the performance of instruments that were independently externally validated with a sample size greater than 100. The study was registered with PROSPERO, CRD42022304716.

FINDINGS

We conducted a systematic review of 50 eligible publications, assessing the predictive performance of 36 tools, providing data for 10 460 participants (88% men, 12% women; median age [from 47 studies] was 35 years, IQR 33-38) from 12 different countries. Post-discharge interpersonal violence and crime was most often measured by new criminal offences or recidivism (47 [94%] of 50 studies); only three studies used informant or self-report data on physical aggression or violent behaviour. Overall, the predictive performance of risk assessment tools was mixed. Most studies reported one discrimination metric, the area under the receiver operating characteristic curve (AUC); other key performance measures such as calibration, sensitivity, and specificity were not presented. Most studies had a high risk of bias (49 [98%] of 50), partly due to poor analytical approaches. A meta-analysis was conducted for violent recidivism on 29 independent external validations from 19 studies with at least 100 patients. Pooled AUCs for predicting violent outcomes ranged from 0·72 (0·65-0·79; I2=0%) for H10, to 0·69 for the Historical Clinical Risk Management-20 version 2 (95% CI 0·65-0·72; I2=0%) and Violence Risk Appraisal Guide (0·63-0·75; I2=0%), to 0·64 for the Static-99 (0·53-0·73; I2=45%).

INTERPRETATION

Current violence risk assessment tools in forensic mental health have mixed evidence of predictive performance. Forensic mental health services should review their use of current risk assessment tools and consider implementing those with higher-quality evidence in support.

FUNDING

Wellcome Trust.

Outcome Evaluation of a Treatment Program for Men with Paraphilic Disorders Convicted of Sexual Offenses: 10-Year Community Follow-up

Evidence concerning specific paraphilia treatment effectiveness is limited. We present observation data of 127 men convicted of paraphilic sexual offenses who attended inpatient and outpatient follow-up treatment in Czechia. We collected participants' sociodemographic and treatment-related information, including STATIC-99R scores, and used proportional hazards models to analyze variables' effect on recidivism risk. Within the observation period, the general recidivism and sexual recidivism rates were 33.1% and 16.5%, respectively, and the sexual contact recidivism rate was 4.7%. The total STATIC-99 score for those who re-offended was 5.65 (SD = 2.11) and for those who did not was 3.98 (SD = 2.02). Recidivism risk was 7.52 times higher for those diagnosed with exhibitionism than with pedophilia, sadomasochism, or antisocial personality disorder. General recidivism is comparable to others' findings. We attribute the lower sexual contact recidivism rate to the combined effects of psychological and pharmacological treatment, and higher numbers of non-contact offenses to limited antidepressant use.

A psychodynamic contribution to the understanding of anger - The importance of diagnosis before treatment

This paper starts from the claim that a shared understanding of anger, in both its normal and psychopathological dimensions, is missing and that there are various therapeutic paths that seem to be less effective than those related to other pathologies. A major limitation of anger research and of its treatments lies in the lack of precise clinical diagnoses to inform therapy. For this reason, the first aim of our work is to survey critical literature in order to find useful elements to differentiate anger, starting from the evidence of negative and positive outcomes of treatments. Such evidence will then be enhanced in our proposal of interpretation and intervention, within a dynamic framework and with particular reference to Orefice’s thought. The core focus is to explore the different functions that anger has for the patient and to investigate the elementary functioning of the self. Our reading of the phenomena related to anger will provide useful tools both for understanding the dynamics underlying anger and as a guide for clinical intervention.

A cluster analytic examination and validation of adult victim sexual offending subtypes in two Canadian samples

The development and validation of sexual offense perpetrator typologies remains a useful endeavor with implications for theory and correctional/clinical practice. Most such typologies—which rely on factors such as the individual’s motivation for offending—have not been validated empirically. The current study utilized a validated sexual violence risk-needs instrument, the Violence Risk Scale—Sexual Offense version (VRS-SO; Wong, Olver, Nicholaichuk, & Gordon [2003, 2017], Regional Psychiatric Centre and University of Saskatchewan, Saskatoon, Canada), to develop and validate an empirically-derived adult victim sexual offense (AVSO) typology through model-based cluster analysis of dynamic risk-need domains. The study featured two treated samples of men (n = 283 and 169) convicted for contact sexual offenses against adult victims. A three-cluster solution was identified and replicated across the two samples: high antisociality high deviance (HA-HD), high antisociality low deviance (HA-LD), and low antisociality low deviance (LA-LD). External validation analyses demonstrated that HA-HD men had more dense sexual offense histories, were more likely to be diagnosed with a paraphilia, and had the highest rates of sexual recidivism (Sample 2 only). By contrast, the HA-LD men had greater concerns on indexes of nonsexual criminality, particularly high base rates of antisocial personality and substance use disorders, and high rates of general violent recidivism (particularly Sample 1). The findings suggest that the VRS-SO factors may have utility in discriminating between AVSO types to inform sexual offending theory, case formulation, and risk management.

„Die Relevanz eines kohärenten forensischen Beurteilungs- und Behandlungsprozesses“: großer Wurf oder alter Wein in undichtem Schlauch?

Borchard und Gerth legen in ihrem Beitrag „Die Relevanz eines kohärenten forensischen Beurteilungs- und Behandlungsprozesses: Grenzen der allgemeinpsychiatrischen Diagnosesysteme ICD und DSM für die forensische Fallkonzeption“ (Borchard und Gerth 2020) ein Plädoyer für ein eigenes forensisch-psychiatrisches Diagnosesystem vor. Der folgende Beitrag setzt sich mit diesem Anliegen kritisch auseinander und zeigt, warum der Forderung nach einem forensisch-psychiatrischen Diagnosesystem jenseits von DSM‑5 und ICD-10/ICD-11 nicht gefolgt werden kann. Ein eigener forensisch psychiatrischer Diagnose- und Krankheitsbegriff ist weder erforderlich, noch kann er in der juristisch-medizinischen Schnittstelle sinnvoll angewandt werden. Stattdessen drohen terminologische Schwierigkeiten und die Gefahr einer Pathologisierung delinquenten Verhaltens, was am Beispiel des von Borchard und Gerth empfohlenen FOTRES und Urteilen des Schweizerischen Bundesgerichts dargestellt und diskutiert wird.

A 24-Year Follow-up Study on Recidivism in Male Mentally Disordered Sexual Offenders With and Without Psychotic Disorders

There is a lack of knowledge on mentally disordered sex offenders (MDSOs) targeting adult victims, especially regarding recidivism patterns and the specific subgroup with psychiatric disorders. This paper presents index offense data, clinical data, and recidivism patterns over up to 24 years in a cohort of 146 MDSOs, with and without psychotic disorders, sentenced in Sweden between 1993 and 1997. At the time of the offense, all offenders were affected by clinical, developmental, and criminal history factors. MDSOs with psychotic disorders only marginally differed from those without, the former being less likely to have been institutionalized during childhood, intoxicated during the index offense, or diagnosed with a personality disorder, substance use disorder, or paraphilic disorder. In the cohort, 3.4% of the MDSOs were reconvicted for a new sex offense over 2 years, 9.6% over 5 years, 13.0% over 10 years, and 17.1% over the entire follow-up period of 24 years. In MDSOs with psychotic disorders, no subjects were reconvicted during the first 2 years, while 2.6% were reconvicted over 5 years, 5.3% over 10 years, and 7.9% over 24 years. Recidivism rates for violent and general reoffenses were 39.0% and 37.7%, respectively, for the cohort of MDSOs, and subjects with psychotic disorders reoffended significantly later in general offenses. In conclusion, MDSOs with psychotic disorders showed the same recidivism pattern as MDSOs without psychotic disorders. Furthermore, recidivism research may preferably focus on follow-up periods of 5-10 years since most offenders appear to recidivate within this timeframe.