Are symptoms assessed differently for schizophrenia and other psychoses in legal insanity evaluations of violent crimes?

BACKGROUND: Forensic evaluations of legal insanity include the experts' assessment of symptoms present at the mental state examination (MSE) and the mental state at the time of offense (MSO). Delusions and hallucinations are most important. We explored how often symptoms were recorded in written forensic reports. DESIGN: This exploratory, cross-sectional study included 500 reports of legal insanity written in 2009-2018 from cases of violent crimes in Norway. The first author read all reports and coded symptoms recorded from the experts' assessments of the offenders. Two co-authors repeated this procedure for 50 randomly selected reports. Interrater reliability was calculated with Gwet's AC1. Generalized Linear Mixed Models with Wald tests for fixed effects and Risk Ratios as effect sizes were used for the statistical analyses. RESULTS: Legal insanity was the main conclusion in 23.6% of the reports; 71.2% of these were diagnosed with schizophrenia while 22.9% had other psychotic disorders. Experts recorded few symptoms from MSO, but more from MSE, although MSO is important for insanity. We found a significant association between delusions and hallucinations recorded present in the MSO and legal insanity for defendants with other psychotic disorders, but no association for defendants with schizophrenia. The differences in symptom recordings between diagnoses were significant. CONCLUSION: Few symptoms were recorded from the MSO. We found no association between presence of delusions or hallucinations and legal insanity for defendants with schizophrenia. This may indicate that a schizophrenia diagnosis is more important to the forensic conclusion than the symptoms recorded in the MSO.

Use of assessment instruments in forensic evaluations of criminal responsibility in Norway.

OBJECTIVES: Assessment instruments are often used to enhance quality and objectivity in therapeutic and legal settings. We aimed to explore the use of instruments in Norwegian reports of forensic evaluations of criminal responsibility; specifically, whether this use was associated with diagnostic and forensic conclusions. METHODS: Our study has an exploratory cross-sectional design. We examined 500 reports filed with the Norwegian Board of Forensic Medicine in 2009-2018 regarding defendants indicted for the most serious violent crimes. The first author coded data from all reports according to a registration form developed for this study. Two co-authors then coded a random sample of 50 reports, and inter-rater reliability measures were calculated. The first author coded 41 reports for calculation of intra-rater reliability. Descriptive statistics are presented for the use of assessment instruments, and a generalized linear mixed model (GLMM) was used to estimate associations between the use of instruments and diagnostic and forensic conclusions. RESULTS: Instruments were used in 50.0% of reports. The Wechler's Adult Intelligence Scale (WAIS), Historical Clinical Risk-20 (HCR-20), and the Structured Clinical Interview for DSM disorders (SCID I), were used in 15.8, 13.8, and 9.0% of reports, respectively. The use of instruments increased from 36% in 2009 to 58% in 2015; then decreased to 49% in 2018. Teams of two experts wrote 98.0% of reports, and 43.4% of these teams comprised two psychiatrists. In 20.0% of reports, the diagnostic conclusion was schizophrenia, and in 8.8% it was other psychotic disorders. A conclusion of criminal irresponsibility was given in 25.8% of reports. Instruments were more often used in reports written by teams that comprised both a psychiatrist and a psychologist, compared to reports by two psychiatrists. The use of instruments was strongly associated with both diagnostic and forensic conclusions. CONCLUSION: Instruments were used in 50% of reports on forensic evaluations of criminal responsibility in Norway, and their use increased during the study period. Use of instruments was associated with diagnostic and forensic conclusions.

Stalking experiences and associated factors--a controlled population-based study from Norway.

BACKGROUND: Stalking is a considerable health problem. In order to develop interventions for victims, more knowledge is needed concerning prevalence, stress and coping related to stalking as well as associated symptomatology in the victims. This is the first population-based study of stalking in Norway. AIMS: To examine the prevalence of stalking in relation to gender and time, and the association with indicators of socio-demographic status and mental health. METHODS: A cross-sectional case-control questionnaire design. The sample, 5000 Norwegians aged 20-59 years, was nationally representative according to gender, 10-year age groups and county of living. A total of 248 (5%) of the mailed envelops were returned due to wrong address, leaving 4752 individuals as possible respondents. Among them 1520 (32%) returned the questionnaire, but 98 of them had to be discarded due to lack of completion, giving a sample of 1422 valid questionnaires (30%). RESULTS: The total weighted lifetime prevalence of stalking was 8.1% (95% CI 6.6-9.4%), for females 11.8% (95% CI 10.2-13.5%) and for males 4.3% (95% CI 3.2-5.3%) [corrected]. The point prevalence of current stalking was 2.8% (95% CI 2.0-3.7%). The stalked individuals had a significantly poorer social situation and mental health than the controls. Few significant group differences were observed between males and females exposed to stalking. CONCLUSIONS: The prevalence of stalking was within the range observed by questionnaire studies in other cultures.

Therapists' handling of patients with cluster B personality disorders in individual psychotherapy.

Individual psychotherapy is a recommended treatment of patients with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition , cluster B personality disorders. Due to their pathology, these patients represent a challenge in psychotherapy, and guidelines for practical handling exist. This study examined the attitudes of psychotherapists toward these challenges. Three hundred twenty-four experienced Norwegian therapists filled in a questionnaire on issues relevant to individual psychotherapy of patients with personality disorders. The attitudes toward cluster B patients were examined and compared with those of clusters A and C patients on contract issues, acting out, use of drugs, information to relatives, and contraindications. A considerable gap was found between therapists' attitudes toward cluster B patients and published guidelines. The therapists mostly handled cluster B in the same way as clusters A and C. Empirical investigations of therapists' handling provide an important feedback from everyday clinical practice on divergences in relation to guidelines derived from experts' consensus and research.

Quality of life in patients with personality disorders seen at an ordinary psychiatric outpatient clinic.

BACKGROUND: Epidemiological studies have found reduced health-related quality of life (QoL) in patients with personality disorders (PDs), but few clinical studies have examined QoL in PDs, and none of them are from an ordinary psychiatric outpatient clinic (POC). We wanted to examine QoL in patients with PDs seen at a POC, to explore the associations of QoL with established psychiatric measures, and to evaluate QoL as an outcome measure in PD patients. METHODS: 72 patients with PDs at a POC filled in the MOS Short Form 36 (SF-36), and two established psychiatric self-rating measures. A national norm sample was compared on the SF-36. An independent psychiatrist diagnosed PDs and Axis-I disorders by structured interviews and rated the Global Assessment of Functioning (GAF). All measurements were repeated in the 39 PD patients that attended the 2 years follow-up examination. RESULTS: PD patients showed high co-morbidity with other PDs and Axis I mental disorders, and they scored significantly lower on all the SF-36 dimensions than age- and gender-adjusted norms. Adjustment for co-morbid Axis I disorders had some influence, however. The SF-36 mental health, vitality, and social functioning were significantly associated with the GAF and the self-rated psychiatric measures. Significant changes at follow-up were found in the psychiatric measures, but only on the mental health and role-physical of the SF-36. CONCLUSION: Patients with PDs seen for treatment at a POC have globally poor QoL. Both physical and mental dimensions of the SF-36 are correlated with established psychiatric measures in such patients, but significant changes in these measures are only partly associated with changes in the SF-36 dimensions.

A comparison of gains after treatment at a psychiatric outpatient clinic in patients with cluster A + B, or cluster C personality disorders, and non-psychotic axis I disorders.

Few studies exist on the outcome of patients with personality disorders (PDs) treated at ordinary outpatient clinics. This study examines the gains of such patients 2 years after treatment start at an outpatient clinic. Three patient groups were sampled: cluster A + B PDs, cluster C PDs and axis I disorders. Fifty-eight patients (53%) were amenable to follow-up, and they did not show less psychopathology than the non-compliers. All patients had structured interviews and filled in questionnaires. Patients in the PDs cluster A + B group showed considerable gains, while that was not found for the PDs cluster C and Axis I disorder groups. Since almost all patients received long-term psychotherapy sometimes combined with antidepressant drugs, the finding that such a treatment mainly shows gains in more severely disturbed PDs patients should be replicated in larger samples at ordinary psychiatric outpatient clinics.

Experienced therapists' opinions on central issues in psychodynamic psychotherapy of patients with personality disorders.

Individual psychodynamic psychotherapy is a recommended, but controversial, treatment for patients with personality disorders (PDs). The aim of this study was to examine the relationship between demographic and professional characteristics of experienced psychotherapists and their attitudes and opinions towards aspects of this kind of psychotherapy. A questionnaire covering these issues of psychodynamic psychotherapy with patients belonging to all three DSM-IV clusters of PD was developed. A sample of 324 Norwegian psychiatrists and clinical psychologist with considerable experience in individual dynamic psychotherapy of patients with PDs filled in valid questionnaires. The therapists' age, gender, profession, postgraduate courses and degree of experience were examined as to their opinions on the following issues: alliances, aims, contraindications, needs to terminate, suicides, use of drugs, length of treatment, need for supervision and complaints to colleagues about patients' behaviour in such therapy with PD patients. Independent sample t-tests of the mean z-transformed group scores were the main statistical method applied. Therapist experience made the most significant differences as to treatment issues, while some differences also were found for age, gender and profession. The influence of postgraduate courses was negligible. Our study might have a selection bias towards therapist with strong psychodynamic orientation and particular interest in the psychotherapy of patients with PDs.