Driving skills in unmedicated first- and recurrent-episode schizophrenic patients.

The present study was designed to examine driving skills according to regulations of the German guidelines for road and traffic safety in unmedicated schizophrenic inpatients. A total of 13 first-episode (FES) and 13 recurrent-episode (RES) schizophrenic inpatients were included in the analysis and compared with a group of 20 healthy controls (HC). Data were collected with the computerised Wiener Testsystem measuring visual perception, reactivity and stress tolerance, concentration and vigilance. Analysis of data indicates that a great proportion (58 %) of schizophrenic patients were impaired in psychomotor functions related to driving skills. FES and RES significantly differed with respect to driving ability with a greater proportion in the FES (38 %) showing severe impairments when compared with RES (25 %). Differences with respect to HC performance were most pronounced in concentration and for the FES additionally in visual perception. Analysis of our data indicates that a great proportion of schizophrenic patients are impaired in psychomotor functions related to driving skills that cannot be attributed to adverse side effects of psychopharmacological treatment. Besides, we cannot confirm a chronical decline of psychomotor functions related to driving skills at least in the early course of schizophrenic illness.

[Infanticide. Social and forensic aspects]. / Kindstötungen. Soziale und gutachterliche Aspekte.

Infanticides are not specifically classified in German criminal records. Thus, the number of infanticides varies depending on different sources of information. Reports from expert witnesses (n=48, 1980-2007) from the German regions around Munich and Rostock were analyzed retrospectively in order to identify sociodemographic, clinical and forensic characteristics of child murders. In 87.5% of the cases the victims were the natural children of which 25 were younger than 1 year old. Female offenders outnumbered male offenders by 3:1 and on average females were 8 years younger than males (26.5 years for females and 34.2 years for males). The motives included unwanted pregnancy/child, altruistic deeds, acute psychoses, child abuse (sexual abuse, neglect or negligence), drug or alcohol abuse, sadistic punishment of the child and revenge on partners. In 27 cases a restricted or exemption from criminal responsibility was acknowledged. About one third of the offenders consulted a physician before the crime. For an improvement in primary prevention, support networks should be integrated and sensitized to the problem.

[Psychiatric assessment in civil law questions]. / Psychiatrische Begutachtung bei zivilrechtlichen Fragestellungen.

Psychiatric reports in German civil law cases are required if questions are raised of legal capacity, capacity to express a testamentary will, ability to sue or be sued, capacity to marry, ability of mentally disordered patients to consent to treatment, and when custody or hospital orders of these patients is considered or compensation is due for mental disorders resulting from accidents. Many reports must decide whether the ability to decide using sound reason or motives is or was impaired by a mental disorder. This capability is attributed to every adult person; only if incapability is claimed must it be proven by psychiatric assessment. As in most psychiatric court reports, such assessments must be structured in several steps. First a clinical diagnosis has to be established which must then be translated into legal terminology. After this has been accomplished, the psychiatrist must describe the functional impairments caused by the disorder and define the probability with which these impairments might affect the legal act in question. Most reports are prepared in the context of custody law, which centers on helping those patients who, due to a mental disorder, cannot manage their own legal matters.

[Structured psychiatric assessment of risk for violent recidivism in juvenile offenders]. / Psychiatrische Beurteilung des Gewaltrisikos im Jugendalter.

The psychiatric assessment of violence in youth represents a critical and essential part of forensic expertise and clinical practice. New methodical approaches are offered by structured risk rating scales and checklists which encompass psychopathy. The recently translated German version of Structured Assessment of Violence Risk in Youth (SAVRY), which is based on the Historical, Clinical, Risk Management Scheme (HCR 20), was evaluated in a sample of forensically assessed youth (n=83) regarding the predictive validity for criminal recidivism. Receiver operating characteristic (ROC) analyses attested medium (general delinquency), moderate (violent reoffending) and high (serious violent reoffending) effect strength, depending of the type of offence. Survival analyses showed that juveniles rated as high risk for violence were significantly faster and in a higher proportion recidivistic than those with a moderate or low risk. The results indicate the applicability of risk assessment instruments for German juveniles. Approaches for preventive, therapeutic and reintegrating measures are demonstrated, taking relapse patterns and dynamic risk aspects into consideration.

[Sadistic fetishism--deadly passion. Forensic psychiatric assessment of sex offenders]. / Tödliche Lust--sadistischer Fetischismus. Forensisch-psychiatrische Begutachtung von Sexualstraftätern.

This article reviews current developments in psychiatric assessment of sex offenders for criminal courts. These developments are characterized by constantly changing laws and increasing neurobiological findings about paraphilias. Psychiatrists must prepare their reports taking into account the tension between psychopathological, neurobiological, and normative aspects of their judgement. The complexity of such assessments can best be demonstrated by narratives. This narrative concerns a 47-year-old patient who killed eight women after strangling them and masturbating or having intercourse with the unconscious victims. He explained in detail six of these crimes and gave ample information about his history, sexual development, fantasies, and a number of other sexual crimes he had committed. From this information a plausible explanation of his development to sexual fetishism and from there to sadism could be derived. Brain MRI displayed gliotic scars in the frontal lobe and right hippocampus. Consequences of the various findings on psychiatric assessment of legal culpability are discussed in this paper, concluding that a differentiated approach to the assessment is possible only from a psychopathological point of view in which behaviour, clinical features, and motivations are analysed.

[Misdemeanor in frontotemporal dementia]. / Frontotemporale Demenz und delinquentes Verhalten.

The nature and prevalence of misdemeanor in patients with dementia due to frontotemporal lobar degeneration has been described in a few case reports and in two small U.S. studies. Our clinical impression suggests that antisocial and aggressive behaviour are relatively frequent in this patient population. The objective of the present study was to verify this observation. For this purpose we developed a standardized questionnaire on misdemeanor in Frontotemporal Dementia. Using this instrument caregivers of 30 patients with Frontotemporal Dementia (FTD), 11 patients with Semantic dementia (SD) and 33 patients with Alzheimer-type dementia (AD) were interviewed. The interview included questions about theft, burglary, damaging other peoples' belongings, verbal or physical offence, bodily harm, drug abuse and use of weapons. Questions about the frequency of criminal behaviour, the amount of damages and consequences if applicable completed the questionnaire. Misdemeanor was found in half of the patients with FTD (15 out of 30) and in 7 out of 11 patients with SD, but only in one out of 33 patients with AD. The most frequent type of inappropriate behaviour was theft (13 patients), particularly shoplifting. 8 patients with FTD, 1 patient with SD and 1 patient with AD entered someone else's house without permission. 10 patients with FTD and 3 patients with SD but none of the patients with AD had physically threatened spouses, relatives or strangers. In one case another person was hurt.

[Evaluation of risk assessment instruments for sex offenders]. / Rückfallprognosen bei Sexualstraftätern--Vergleich der prädiktiven Validität von Prognoseinstrumenten.

In order to evaluate risk assessment instruments for sex offenders in Germany, we compared the predictive validity of the Static-99, HCR-20, SVR-20, and PCL-R scales for 134 sex offenders. The mean follow-up time was 9 years (range 1-340 months), using the first entry into the National Register of Criminal Convictions as endpoint variable. For the estimate of predictive power, the area under the curve (AUC) of receiver operating characteristic (ROC) analysis was calculated. The AUC plots accurately identified violent or sexual recidivists and "false positives" at all scale levels. Comparing the predictive validity of these four instruments, the results favored Static-99. As for the limited sample size, differences between the assessment instruments were, however, not statistically significant. The ROC analysis for Static-99 showed that including treatment dropouts does not improve predictive accuracy (including dropouts: AUC 0.710; excluding dropouts: AUC 0.721). Kaplan-Meier survival analyses yielded highly a significant correlation to recidivism time point for two Static-99 and SVR-20 risk categories. Higher-risk categories were related to earlier recidivism. However, relying on the Static-99 and SVR-20 alone showed false positive results: for up to two out of three sex offenders, they predicted recidivism which did not occur.

[Psychiatric disorders and the prognosis for criminal recidivism]. / Psychiatrische Erkrankungen und die Prognose krimineller Rückfälligkeit.

The risk for criminal recidivism of mentally ill offenders is, unlike the general risk of delinquency, not well established. The relationship between psychiatric diagnosis and criminal recidivism was examined in the context of the Munich project on risk assessment. A total of 185 offenders had been examined on the question of culpability between 1992 and 1993. Re-offenses committed before the end of 2001 were recorded according to the Federal Registry of court sentences (Bundeszentralregister); 38.8% of the total group recidivated. High rates of recidivism were observed for individuals with substance abuse (45.5%) and with personality disorders (46.6%). The combination of the two illnesses increased the rate for recidivism to 50%. For individuals with organic, affective and neurotic disorders the rates for recidivism were below the average. Rates of recidivism for schizophrenic offenders were slightly higher, if re-offenses in the state of inculpability were included. The HCR-20 predicted recidivism equally well for offenders with and without a psychiatric diagnosis. In both groups, individuals with HCR-20 scores above the mean recidivated more often and after shorter periods of time.

[Alcohol and drugs and their relation to criminal recidivism]. / Alkohol und Drogen als Risikofaktoren für kriminelle Rückfälle.

This report assesses the influence of alcohol- and drug- induced disorders on criminal recidivism. A sample of 185 delinquents was examined for their criminal responsibility in the department of forensic psychiatry in the years 1992 and 1993. Official criminal records were obtained in December 2001. 27.3 % of the delinquents with alcohol abuse, 47.3 % with drug abuse and 47.2 % with a family history of alcohol abuse recidivated with a crime. 50 % of the individuals with an own alcohol- and drug abuse together with a family history of alcohol abuse recidivated. 62.5 % of offenders with both, own drug abuse and an alcohol abuse in their family history re-offended. The co-occurrence of both, own drug abuse and a family history of alcohol abuse is highly correlated with criminal recidivism and should be considered in treatment and aftercare programs.

[Criteral for assessing quantitative disability in expert determination of functional physical disorders. Review of the literature]. / Kriterien zur Beurteilung der quantitativen Leistungseinschränkung bei der Begutachtung funktioneller körperlicher Störungen. Eine Literaturübersicht.

The assessment of individuals with somatoform disorders seeking payments or compensation is a major challenge for psychiatrists, insurers and the social welfare system. It is difficult to examine these disorders objectively and to quantify the impairment people experience in their work or private life. In order to develop more rational criteria for the assessment of these patients, we first reviewed the relevant literature and extracted the criteria mentioned by the respective authors. We then grouped these criteria in clinically plausible dimensions in order to develop a list of parameters that could help psychiatric experts to analyse the impairment more objectively and to help institutions in evaluating the assessments.

[Quantitative detection of dyssocial and psychopathic personalities in criminal expert assessment. Retrospective study of the value of the German version of the Hare Psychopathy Checklist]. / Quantitative Erfassung dissozialer und psychopathischer Persönlichkeiten bei der strafrechtlichen Begutachtung. Retrospektive Untersuchung zur Anwendbarkeit der deutschen Version der Hare-Psychopathie-Checkliste.

In 1980, the Hare Psychopathy Checklist (PCL), an operationalised rating scale for the quantitative assessment of "psychopathy" as seen in the Anglo-American literature, was developed by R.D. Hare in Canada. It proved to be the most valid prognostic instrument for assessing relapse of criminals in English-speaking countries. This study was aimed at verifying the applicability of a German version of the revised PCL (PCL-R) on carefully selected subjects from the Forensic Psychiatric Department of the Psychiatric University Hospital in Munich. Two groups with an equal number of different forensic-psychiatric reports were evaluated retrospectively using the PCL-R. The results confirm the applicability of the PCL-R for the assessment of psychopathy in our sample population. One can expect that the positive experiences with the PCL-R abroad can be transferred to German conditions. The results are encouraging as to the practicability of the PCL-R as a prognostic instrument in routine forensic assessment.

[Ethics of physician-patient relationship]. / Ethik der Arzt-Patienten-Beziehung.

Ethical questions pertaining to the examination and treatment of patients have gained considerable importance during the last decades, also in psychiatry and psychotherapy. Interest in these questions, however, is moderate among students and beginning therapists. Ethical and legal problems often arise during practical work and are frequently solved without much consideration of the current ethical opinions and legal issues involved. This article tries to elaborate on the current ethical positions from an historical perspective and to come to a hierarchy of values, which could guide the therapeutic decisions. Nonmaleficence and autonomy are considered to be on top of that hierarchy, paternalism which was a guideline until the early sixties has lost its importance. The article discusses the consequences of this change of values in different practical fields, e.g. consent to long-term treatment with uncertain outcome, confidentiality in the face of dangers to third parties, suicidal patients.

Competence to give informed consent to clinical studies. Statement by the taskforce on "ethical and legal questions" of the Association for Neuropsychopharmacology and Pharmacopsychiatry ("Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie [AGNP]").

Over the last 50 years, patient autonomy has become an increasingly important part of the principles of medical ethics, or rather of the ethics of the doctor-patient relationship. While the principle of charity and the associated paternalism became less important, the patient's active consent became more and more relevant (Sass, 1989; Bayer, 1998; Nedopil, 1998). This development was inevitably also accompanied by a demand for more detailed information prior to medical interventions (Appelbaum and Grisso, 1988; Weisstub, 1990; Kreussler, 1997; Ulsenheimer, 1995; Laufs, 1997; Sommer, 1997) and for complete information on medical procedures subsequent to interventions (e. g. Bender, 1997). Determination of a person's competence to give informed consent is a central problem in the assessment of his expression of consent to a medical intervention. The capacity to adequately express consent can be impaired at certain stages of life and during some illnesses. Patients in borderline situations, children, mentally ill patients and old people with dementia may either be limited in their capacity to give informed consent, or be completely unable to do so. This results in special ethical problems when such groups are included in research projects.

[Compliance with psychiatric legal ordinance section 63 STGB. Legal principles--current status--treatment concepts--perspectives]. / Psychiatrischer Massregelvollzug gemäss section 63 STGB. Rechtsgrundlagen - Derzeitige Situation - Behandlungskonzepte - Perspektiven.

According to German law, delinquents who are considered either not fully responsible or not responsible at all for their actions because of a mental disorder receive no punishment or a lesser degree of punishment in criminal trials. They may, however, be sentenced to psychiatric treatment either in a psychiatric hospital or in an addiction centre, if the risk of them committing such offenses in the future is considered to be high. This article reviews the current situation of mentally ill offenders in hospitals and explores possible developments in forensic psychiatry. It outlines the legal framework, and the current and developing treatment strategies, and finally raises the question of whether these developments will lead to further specialization of forensic psychiatry or to a reintegration of forensic knowledge into general psychiatry.