[Risk of recidivism for forensic psychiatric patients with an autism spectrum disorder]

BACKGROUND

There is limited knowledge of the predictive validity of risk factors and protective factors for recidivism in forensic psychiatric patients with an autism spectrum disorder (ASD).

AIM

To examine risk factors, protective factors and the predictive value of these factors in relation to recidivism for forensic psychiatric patients with ASD compared to patients without ASD.

METHOD

For 69 patients, including 32 patients with ASD, the risk factors and protective factors were measured at the start and end of treatment. Of these 69 patients recidivism was examined for 23 patients, including 10 patients with ASD. Furthermore, the predictive validity of these measurements in relation to recidivism was explored.

RESULTS

The positive changes on risk and protective factors at the end of treatment did not differ significantly between both groups, except for the external protective factor, on which patients with ASD scored less favourable. We used a follow-up period of 2.5 to 4 years. Only 1 out of 10 ASS-patient showed recidivism compared to 7 out of 13 in the non-ASD-group. The scores on the risk assessment instruments at the start of treatment showed a significant predictive validity for recidivism, the scores at the of the end treatment did not. Structured clinical judgment of recidivism showed no significant predictive validity at the start as well as the end of treatment.

CONCLUSION

Despite the small sample, the results give rise to further research about risk factors and protective factors for recidivism, and the usability of risk-assessment for forensic patients with ASD.

On the Link Between Emotionally Driven Impulsivity and Aggression: Evidence From a Validation Study on the Dutch UPPS-P

The UPPS-P seems to be a promising instrument for measuring different domains of impulsivity in forensic psychiatric patients. Validation studies of the instrument however, have been conducted only in student groups. In this validation study, three groups completed the Dutch UPPS-P: healthy student ( N = 94) and community ( N = 134) samples and a forensic psychiatric sample ( N = 73). The five-factor structure reported previously could only be substantiated in a confirmatory factor analysis over the combined groups but not in the subsamples. Subgroup sample sizes might be too small to allow such complex analyses. Internal consistency, as assessed by Cronbach's alpha, was high on most subscale and sample combinations. In explaining aggression, especially the initial subscale negative urgency (NU) was related to elevated scores on self-reported aggression in the healthy samples (student and community). The current study is the second study that found a relationship between self-reported NU and aggression highlighting the importance of addressing this behavioural domain in aggression management therapy.

[Neurofeedback and attention deficit hyperactivity disorder: what is it and is it working?]

BACKGROUND Neurofeedback (nf) is a method of treatment that is being used increasingly in the Netherlands, particularly in psychological practices. Many psychiatric and somatic symptoms are currently being treated with the help of nf. In particular, nf is being used more and more to treat attention deficit hyperactivity disorder (adhd). Despite its growing popularity, nf is still a relatively unknown treatment method in psychiatric practices.

AIM

To investigate the scientific evidence for treating adhd with nf.

METHOD

We searched the literature for reports on controlled trials that investigated the effectiveness of nf on adhd. results Six controlled trials were located. The studies reported that nf had a positive effect on adhd, but all the studies were marred by methodological shortcomings.

CONCLUSION

On the basis of currently available research results, no firm conclusion can be drawn about the effectiveness of treating adhd by means of nf. In view of the fact that nf is being used more and more as a method of treatment, there is an urgent need for scientific research in this field to be well planned and carefully executed.

[Lithium levels need to be monitored: discrepancies between guidelines and practice]

BACKGROUND

Since lithium can affect the thyroid gland and the kidneys, it is important to perform regular checks on levels of lithium, creatinine and thyroid-stimulating hormone (TSH).

AIM

To investigate whether psychiatrists and general practitioners (GPs) perform the required checks twice a year on the levels of lithium, creatinine and tsh in accordance with the Dutch guidelines on bipolar disorder as laid down in 2001.

METHOD

The study was based on data that the clinical-chemical laboratory had regarding the lithium checks performed in 2004 in GPs' practices or by the mental health authority in Apeldoorn and the surrounding area. About 250,000 people live in this region.

RESULTS

Some of the psychiatrists (11%) and GPs (about 25%) did not check lithium levels as frequently as recommended in the guidelines of 2001. The GPs checked significantly less frequently that the psychiatrists. Both the GPs and the psychiatrists monitored creatinine and TSH less frequently than recommended in the guidelines, creatinine was monitored in 65.8 and 61.2% and TSH in 68.3 and 58% respectively. CONCLUSION We recommend that a warning system be installed in the laboratory which will alert the doctor when a patient has missed a check. Another suggestion is that lithium should be prescribed only by psychiatrists, and not by GPs.

[Psychodynamic clinical assessment of psychotic symptomatology: valid or obsolete?]

BACKGROUND

This article considers whether failure to include a patient's subjective experiences in a psychiatric assessment can result in an inadequate diagnosis of psychotic symptoms. A psychodynamic approach gives specific attention to a patient's subjective experiences.

AIM

To investigate whether a psychodynamic assessment of psychotic symptoms based on the structural interview devised by Kernberg can be useful in clinical practice.

METHOD

First of all, the psychodynamic assessment of reality testing is described. This is followed by an investigation of the extent to which this method is compatible with the findings of the cognitive model for psychoses. Then some interrater-reliability studies are discussed.

RESULTS

Within the psychodynamic interview the focus on inducing anxiety and on withholding contextual information from the patient is compatible with the cognitive model for psychoses. Reliability studies should be confined to delusions and hallucinations.

CONCLUSION

Psychodynamic assessment can be a useful addition to the standard psychiatric assessment of psychotic symptoms. However, further studies of the reliability of the psychodynamic assessment are required.

Individual–context interaction as a guide in the treatment of personality disorders

The diagnosis and treatment of personality disorders is strongly influenced by personality theories based on trait models, and the influence of the context is relatively neglected. Developments within psychology and neurobiology have led to the awareness that the manner in which personality characteristics are expressed is strongly determined by interaction with the context. The clinical implications of these developments are set out and Acceptance and Commitment Therapy (Hayes, Strosahl, & Wilson, 1999) is highlighted as a development within psychotherapy that is linked to a contextual diagnosis. Employment reintegration of patients with personality disorders is presented as an example of a context-oriented approach. Neurobiological insights support the idea that active focusing on the outer world reduces negative affects.

[Differential diagnosis of psychopathy and autism spectrum disorders in adults. Empathic deficit as a core symptom]

BACKGROUND

There is an overlap between the symptoms of psychopathy and autism spectrum disorders.

AIM

To contribute to an adequate differential diagnosis of these disorders.

METHOD

We reviewed the literature with the help of PubMed, using as key words: 'empathy', 'psychopathy', 'autism', 'aggression' and 'antisocial' for the period 1980-2004. We also consulted papers listed in the bibliographic references for these articles.

RESULTS

Empathic deficit is a core symptom of both disorders. In psychopathy there are signs of an emotional empathic deficit, an inability to feel along with another person (insensitivity). Research into autism spectrum disorders points to a cognitive empathic deficit, an inability to take the perspective of another person (innocence). The antisocial behaviour that can accompany both disorders might be due to the type of empathic deficit. In psychopathy the antisocial behavior often involves insensitive manipulation and exploitation ofanother person. In autism spectrum disorders there is sometimes antisocial behaviour which could be caused partly by incorrect evaluation of social situations. In both psychopathy and autism spectrum disorders dysfunctioning of the orbitoftontal cortex and the amygdala is often mentioned as a possible cause of empathic deficit.

CONCLUSION

An accurate diagnosis of the type of empathic deficit involved could help to differentiate psychopathy from autism spectrum disorders. Good diagnostic tools are not yet available.