Dangerous or merely difficult? The new population of forensic mental hospitals.

BACKGROUND: During recent decades, there has been a substantial increase in admissions to forensic mental hospitals in several European countries. It is not known if reforms implemented in mental health policies and practices are responsible for this development. OBJECTIVE: Our study examined the development of mental health care in Austria and the incidence and prevalence of mentally disordered offenders judged not guilty by reason of insanity (NGRI). METHODS: We analysed data on service provision and data from criminal statistics between 1970 and 2008 from several national sources. RESULTS: During the first decade when reforms to mental health practice were implemented, the incidence and prevalence of offenders judged NGRI remained unchanged, despite a reduction of mental hospital beds by nearly 50% and little outpatient care. Surprisingly, the enormous increase in admissions to forensic inpatient treatment began in Austria only after community mental health services were rolled out across the country in the 1990s. This increase was primarily due to admissions of patients who had committed less severe offences, while rates of those who had committed homicide remained unchanged. CONCLUSION: Our results cannot be explained by details of the reforms such as the downsizing of mental hospitals or a lack of outpatient facilities, nor by changes to criminal sentencing. Rather, the results provide evidence of an increasingly inadequate provision of comprehensive care for "difficult" but not extremely dangerous psychotic patients living in the community. This may result from the attitudes of mental health professionals who have become less inclined to integrate aggressive behaviour into their understanding of psychosis. As a consequence, increasing numbers of "difficult" patients end up in forensic psychiatric institutions. This development, which can be observed in nearly all European countries, raises concerns with regard to efforts to destigmatize both patients and psychiatry.

[Investigating the association between psychosis and criminality/violence]. / Untersuchungen zur Frage des Zusammenhangs zwischen Psychosen und Kriminalität/Gewalttätigkeit -- Studiendesigns, methodische Probleme, Ergebnisse.

This review systematically describes the methodological difficulties arising at the interpretation of studies on the association between psychoses (major mental disorders) and criminality/violence: diagnostic issues, different definitions of illegal behaviour and of the connection between mental illness and crime, different sources of information, differences in the recruitment of cases and control groups and in the time under study, impact of interfering variables and statistical issues, problems of the transferability of results. On this basis the data of 23 papers published between 1981 and 2004 are discussed in detail. Even under consideration of sociodemographic variables and comorbid substance abuse, most studies show a moderate albeit statistically significant association between major mental disorders and crime. This association is especially proven in subjects suffering from schizophrenia. Their risk of committing a crime increases with the severity of the offence and is -- compared with the general population -- substantially higher for homicide. However, in general much more danger for the public arises from subjects with substance abuse and personality disorders. The severest expressions of violence can be interpreted -- at least partly -- as a direct consequence of the illness. The association between psychosis and criminality in general seems to be rather an indirect one, mediated through an illness-related increased vulnerability for general criminogenic factors as poverty, social deprivation and substance abuse, intensified by deficits of modern mental health care.

Homicide and major mental disorders: a 25-year study.

OBJECTIVE: This study was designed to investigate the association between major mental disorders (MMDs) and homicide. METHOD: The rates of exculpations because of MMDs among 1087 Austrian homicide offenders during 1975 and 1999 were compared with the rates of the respective disorders in the general population. RESULTS: MMDs were associated with an increased likelihood of homicide (two-fold in men and six-fold in women). This was exclusively because of schizophrenia (age-adjusted ORs in men 5.85, CI 4.29-8.01; in women 18.38, CI 11.24-31.55) and delusional disorder in men (OR 5.98, CI 1.91-16.51). Comorbid alcohol abuse/dependence (additionally) increased the odds in schizophrenia, major depression and bipolar disorder. CONCLUSION: The increased likelihood of homicide in subjects with MMDs cannot be fully explained by comorbid alcoholism. The results point to the special importance of sufficient treatment for a subgroup of mentally ill individuals being at higher risk of violence.

Old wine in new bottles? Stability and plasticity of the contents of schizophrenic delusions.

A number of recent case reports published during the last 20 years described a quick inclusion of new technologies and cultural innovations into schizophrenic delusions which led many of the authors to the conclusion that the 'Zeitgeist' is creating new delusional contents. On the other hand, long-term comparisons and comparative transcultural studies on delusions showed, despite a certain degree of variability, a stability of delusional themes over longer periods of time. Combining anthropological and historical theories of the development of societies with a differentiated psychopathological approach (Klosterkötter's three-stage model of the formation of schizophrenic delusions), we were able to resolve the problem of the ostensibly divergent results: there are only a few themes of extraordinary anthropological importance for the organization of human relationships which can be found in every epoch and in different cultures (persecution, grandiosity, guilt, religion, hypochondria, jealousy, and love). With the exception of persecution and grandiosity, these themes showed a certain variability over time and between cultures. The 'new' themes, referring to the development of modern technology and the rapid changes of 'cultural patterns' turned out to be only the shaping of the basic delusional themes on the 3rd stage of Klosterkötter's phase model (concretization).

Are we witnessing the disappearance of catatonic schizophrenia?

The decrease in the frequency of diagnosed catatonic subtypes among schizophrenic disorders as a whole during the last 50 years has long been regarded as an established fact. Until now the factors responsible for this development have been under discussion. As it is not clear if there is a true decrease or an ostensible one due to other factors such as changed diagnostic habits or neuroleptic treatment, we examined 174 consecutively admitted schizophrenic patients from three different psychiatric institutions diagnosed according to DSM-IV and Leonhard's criteria. It turned out that-depending on the diagnostic system-the rates of diagnosed catatonias were 10.3% (DSM-IV) and 25.3% (Leonhard's criteria). Comparison of the two original Leonhard cohorts (1938 to 1968, 1969 to 1986) with our own (1994 to 1999) shows a decrease in the frequency of catatonias from 35% to 25%, which-albeit statistically significant-is much less pronounced than in studies that used a narrower definition of catatonia. Here, besides sociocultural developments, the use of neuroleptics seems to effect the decrease in the frequency of catatonias in two ways: on one hand, they cause a decrease of hyperkinesia, excitement, or impulsivity; while on the other hand, they themselves produce motor abnormalities like rigidity, effects that favor the attribution of motoric symptoms to neuroleptics.

[Inpatient violence: frequency, risk factors, preventive strategies]. / Aggressives Verhalten psychisch Kranker im stationären Bereich: Häufigkeit, Risikofaktoren, Prävention.

In contrast to Angloamerican and Scandinavian countries inpatient violence was not regarded as a problem in German-speaking countries for a long time. Only recently it has become a topic of increasing interest for clinical practice and research, whereby the present data exhibit significant parallels to the international development. After the discussion of methodological problems (e. g. varying definitions, sources of information, ways of registration) the paper presents the current state of knowledge about inpatient violence:Underestimation in general, mainly with respect to female patients; only a few patients are responsible for the majority of assaults; victims are rather staff members than fellow patients; discrepancy between the mostly minor physical, though major emotional consequences for victims; considerably negative effects on patient-staff interactions and ward climate. Aside from patient-related actuarial and dynamic risk factors (social origin, previous history of aggressive behaviour, dissocial personality traits and - partly - diagnoses, acute intoxication, substance abuse, lack of insight and compliance, psychotic symptoms) external/contextual factors as patient-staff ratio, ward size, structure and climate, staff-attitudes, recognition of early warning signs and handling of risk situations are of major importance for the frequency and severity of incidents. Intervention and prevention strategies are focussing - aside from medication - on the aforementioned staff-related factors and patient-staff interactions. They are the principal basis for sufficient inpatient treatment beyond the problem of violence.

[Mental health care at the turn of the millennium--on the way toward two-class psychiatry]. / Die Versorgung psychisch Kranker zur Jahrtausendwende--ein Weg in die 2-Klassen-Psychiatrie?

Up to now the special position of psychiatry is determined by prejudices in connection with violence and dangerousness of the mentally ill. The reforms of mental health care since the fifties were directed not only at the improvement of the treatment and the situation of psychiatric patients, but also at the reduction of prejudices and stigmata--i.e. a normalisation of the aforementioned special position. However, in connection with the stepwise progress of the reforms one could notice an increasing neglect of a subgroup of severely mentally ill who are not able to accept the offers of modern mental health care, or whose care-requirements are not met by the current developments. This together with the withdrawal of psychiatry from all those aspects of treatment, dealing with aggressive behaviour of or coercion against mentally ill led to a stepwise removal of certain patients--recruited mainly from the aforementioned subgroup--from the general mental health care system. Initially this development could be observed only in the USA, but in the meantime several European countries are appearing to catch up. This reinforces the prejudices against mental patients in general which are present up to now, is counterproductive with regard to the intended aims of mental health reforms and increases the danger of undifferentiated and restrictive political reactions.

Guilt and depression: a cross-cultural comparative study.

Although nearly a century has passed since Kraepelin's investigations in Java [Cbl Nervenheilk Psychiatr 1904; 27:468-469], one crucial question regarding guilt in the course of depression has still not been decided: Is there a more or less stable connection independent of culture, or is guilt confined to certain civilisations? This study investigated this issue in 100 Pakistani and 100 Austrian out-patients diagnosed with 'major depression' according to DSM-IV by means of standardised instruments (Schedule for Affective Disorders and Schizophrenia-Life Time Version, Hamilton Rating Scale for Depression, 21-item version). The experiences of guilt were subdivided into ethical feelings (ethical anxiety and feelings of guilt) and delusions of guilt. It turned out that ethical feelings could be found in both cultures regardless of age and sex. They seem to be primarily related to the extent of depressive retardation. However, the distribution of the two subsets of ethical feelings was culture dependent. Delusions of guilt were confined to patients of the Austrian sample. So, our data qualify the exclusivity of the aforementioned two points of view and support the need for a psychopathologically differentiated approach.

[Aggressive behavior of mentally incompetent psychiatrically ill criminals during inpatient treatment]. / Aggressives Verhalten zurechnungsunfähiger psychisch kranker Straftäter während stationärer Behandlung.

UNLABELLED: OBJECTIVE, METHODS: To assess the amount of violent behaviour among mentally ill offenders NGRI during forensic long-term inpatient-treatment we retrospectively investigated the official incident-reports concerning verbal and physical aggression and damage to foreign property during an 8-year period in Austria's central high-security institution. RESULTS: 29.2% of our patients exhibited violent behaviour with only 7.8% being responsible for 41.1% of all incidents. Mentally impaired patients were significantly overrepresented in the violent group. Physical violence was reported in 25.8% (= 16.48 assaults/100 patients/year). 68% of the total amount of physical violence was directed against fellow patients. Violent behaviour was less driven by psychotic symptoms but rather by current everyday conflicts and stress situations. CONCLUSIONS: The majority of incidents had only minor consequences. Yet, an inquiry concerning the offenders' intentions and the danger experienced by staff members indicated a reasonable violent potential also in minor assaults which appears to be important with respect to ward climate and distress of staff.

[Problems in the treatment of mentally ill offenders--a problem of general psychiatry?]. / Probleme bei der Versorgung psychisch kranker Rechtsbrecher--ein Problem der Allgemeinpsychiatrie?

The special position of psychiatry among the various medical disciplines is determined not least by the phenomenon of violent behaviour of some of its patients and the possibility of coercive measures against patients. The worldwide process of deinstitutionalization since the last decades is characterized by a substantial reduction of inpatient treatment and the expansion and improvement of increasingly specialized community care offers. Yet, at the same time paradoxically we are confronted with an increasing neglect of the special care requirements of a certain group of difficult-to-place patients (mostly severely chronically ill with high rates of comorbidity). Despite different social and legal conditions this has uniformly led to an increasing shift of these patients into the forensic system which is illustrated by a comparison of international and Austrian data. Forensic psychiatry is hardly able to cope with this development because of structural and personal deficits existing and is in danger of being misused primarily as an instrument of social control. From the position of forensic psychiatry the limits of deinstitutionalization are set by the feeling of responsibility of general psychiatry for a subgroup of troublesome and difficult to treat patients.

Paranoia and dysphoria: historical developments, current concepts.

Regarding diagnostic criteria for paranoia (delusional disorder) today psychiatry usually refers to Kraepelin, suggesting that this diagnostic category has existed more or less unchanged since the end of the 19th century. But, reviewing German literature on this topic, one can find a lively discussion with regard to definition, development and course. In this context, the position of affective symptomatology - especially dysphoria with its various meanings - is of major interest. This paper aims at clarifying some definitory questions and at recalling the 'old' paranoia dispute which is worth rediscovering as a stimulation for modern classification and clinical practice.

Outpatient treatment of mentally disordered offenders in Austria.

The mental health system is faced with a growing number of MDOs with treatment orders. For more than 90% of our sample of 157 discharged irresponsible MDOs a mandatory outpatient treatment was ordered. Considering the fact that half of these patients are transferred after discharge to institutions like psychiatric hospitals or nursing homes (Leygraf, 1988), institutional as well as outpatient treatment options are needed (Silver & Tellefsen, 1991). Within the Austrian mental health system here is an enormous lack of post-discharge treatment facilities for forensic patients (Meise, Rossler, & Hinterhuber, 1994). Furthermore, the existing structures obviously do not meet the special needs of forensic patients. Although this point of view is shared by the psychiatric hospitals and their contentment with the settings for forensic outpatient treatment was low, only one hospital intended conceptional change and modifications. Facing the reality that the same psychiatric hospital authorities complained that they could not release MDOs from an inpatient status because of inappropriate outpatient facilities, the responsibility for forensic patients seems to be projected from the medical to the legal system. This can be seen as a symptom of the tendency to a step wise and long-standing exile of forensic patients from the mental health system. Actually, forensic patients were for various reasons refused by mental health professionals and could not get psychotherapy, medication or adequate psychosocial care. A possible answer to these problems is to establish institutionalized outpatient facilities in the "hybrid" gap between the legal and mental health system (Lamb, Weinberger, & Gross, 1988). The new outpatient clinic in Vienna deals with rejected treatment-order patients, most of them with additional treatment problems such as impulsivity, substance abuse, and mental impairment (Cote & Hodgins, 1990). The special structure of the institution (i.e., a multiprofessional team that offers a wide and easily accessible spectrum of interventions, the realization of individual treatment programs with psychotherapeutic and psychosocial as well as biological aspects, and the long-term personal continuity of care by staff members with forensic psychiatric skills) promoted the experience that after some time half of the patients came on a voluntary basis (Fenell, 1992; Winick, 1994). Some pressure by the court was an efficient way to guarantee regular treatment for patients with personality disorders and perversions. The model of a special, structured, multiprofessional outpatient clinic is successful, but the role of such complementary pilot institutions is ambiguous. Simultaneously, the deficit of adequate outpatient care for MDOs has to be opposed by stopping the unacceptable withdrawal of general psychiatry from the forensic sector.

[Discharge of incompetent mentally abnormal criminals: experience from the Austrian central treatment institution]. / Die Entlassung von zurechnungsunfähigen geistig abnormen Rechtsbrechern: Erfahrungen aus Osterreichs zentraler Behandlungsinstitution.

Based on the data of 66 male patients not guilty for reason of insanity, who were treated in Justizanstalt Göllersdorf, Austria's central institution for mentally ill offenders, we examined the influence of age, duration of detention, diagnosis, and offence on discharge. Law provides a yearly, compulsory examination of the necessity of further inpatient-treatment. We also tried to describe a concept of further dangerousness (considered to be the essential basis for the decision of possible discharge) in a four-factor-model including the criteria psychopathology, insight, conflict behaviour, and social competence. Concerning the various levels of decision finding (institution, expert, court) different interpretations of these criteria could be demonstrated. Independent of diagnostic and prognostic considerations the court stressed mainly kind of offence as the most important factor for the possibility of discharge.

Premorbid adjustment of schizophrenic criminal offenders.

The premorbid psychosocial adjustment of 28 schizophrenic criminal offenders, 23 non-criminal-offender schizophrenics (ICD-9) and 14 nonpsychotic criminals was compared by means of the Premorbid Adjustment Scale (PAS). The schizophrenic groups did not differ regarding age, marital status, diagnostic subgroup or length of illness. PAS scores showed highly significant differences between the schizophrenic groups and the controls on every subscale and on average scores. Yet, aside from 2 items (sociability/withdrawal in adulthood and education), no differences could be found between offender and non-offender schizophrenics. Furthermore, the PAS scores showed a markedly better premorbid psychosocial adjustment in schizophrenics with offending behaviour (and convictions) before the onset of the psychosis than in schizophrenics without previous convictions, who committed one rather severe crime that was closely connected to psychosis itself.

Predicting course and outcome in delusional psychoses.

Eighty-four of 90 patients with delusional syndromes of different nosological attribution underwent a 7-year follow-up. From 179 items covering the whole spectrum of psychiatric description of index examination, 20 were found to be statistically significant in predicting different aspects of course and outcome by stepwise discriminant analysis. Course and outcome were defined by 6 criteria (course of illness, course of delusion, development of deficiency, length of inpatient care, adequate activity and social adjustment) encompassing separate (but only partly independent) aspects of a disorder. In contrast to the literature, clinical and psychopathological variables have major prognostic weight for different psychopathological as well as psychosocial aspects of outcome. Ten of the 20 significant items cover psychopathology, 4 pre-index course, 3 precipating events, 2 data from childhood, and 1 premorbid personality. Our results stress the importance of sensitive data collection and a clear separation of different outcome variables.

Why do the results of follow-up studies in delusional disorders differ?

In this paper 4 studies on the course of delusional disorders of midlife, partly diagnosed as 'late schizophrenias' in the sense of M. Bleuler, published up to the 70s and 3 studies on the same topic which were published in the 80s, all European, are analysed with regard to differences in their results in order to find out factors operating on these differences and to propose standards to be followed in such studies. Four such factors are stressed: different follow-up times leading to different rates of loss of probands by death, unreliable use of diagnostic terms and, probably more influential, unreliable use of terms describing the course, and different preconditions of the recruiting process by differences in the care systems the probands are collected in. Four conclusions are derived from this finding: the need for comprehensive and valid information, for reliable use of terms describing the course, for information about the care system the patients come from as an important precondition of the process of recruiting probands, and probably for the further development of a 'language' for the description of course.

[Depression and anxiety--a study for validating subtypes of depression]. / Depression und Angst--Eine Untersuchung zur Validierung von Subtypen der Depression.

Psychopathological analysis of the patterns of symptoms in 176 depressive in-patients disclosed in 73.3% of all patients the presence of anxiety symptoms: of these, 38.6% merely had diffuse anxiety, whereas 34.7% showed either additionally or alone specific anxiety symptoms such as phobias and panic attacks. Similar to the results obtained by dividing the patients into an "endogenous" and "neurotic" group, namely, that there was no difference between the subtypes in respect of triggering the depressive episodes by life events, or in respect of the suicide rate 30 months after discharge and in respect of a chronic course developing during the 2 years following the discharge, there was likewise no difference with regard to these criteria if the patients were subdivided into depressive patients without anxiety and those with anxiety symptoms. However, a subdivision of the depressive patients with anxiety symptoms into a group having only free-floating anxiety and a group with specific anxiety symptoms, resulted in a clear association with these criteria: If a phobia or panic attacks were present, triggering by life events was far more frequent than if there was only free-floating was more often chronic in the first group, but there was no difference in suicidality. The results indicate that it will be necessary to provide for a more differentiated classification of anxiety symptoms before deciding in clinical routine what steps to take wherever depression and anxiety symptoms are present side by side. The same applies to treatment studies.

Are there differences in the course of delusional disorders in different periods of time?

The results of two follow-up studies on delusional disorders of midlife of probands who fell ill in different periods of time with different access to treatment (modern pharmacotherapy not developed - developed) are compared with each other. The frequencies of uniform versus polymorphous and episodic versus chronic course did not differ in the two studies. These data suggest that the form of course belongs to the natural history of the disorder. The authors stress the importance of developing differentiated prognostic instruments, mainly in order to ameliorate prognostic hypotheses as a basis for rational therapeutic interventions.

[Treatment of mentally abnormal offenders in the Göllersdorf legal institution]. / Die Behandlung geistig abnormer Rechtsbrecher in der Justizanstalt Göllersdorf.

The Austrian penal reform of 1975 offered the legal basis for the opening of the Justizanstalt Göllersdorf, an institution for the inpatient-treatment of mentally ill offenders in 1985. After a short survey about comparable institutions in other countries the paper explains the structural and hierarchical principles and the problems of distributions of competences, the latter caused by the doubtful position between psychiatric hospital and prison. The therapeutical strategies and the diagnoses, delicts, and diagnosis/delict constellations of 178 patients treated between January 1985 and July 1st 1987 are presented. Despite difficult structural and external conditions the Justizanstalt Göllersdorf is able to refer to a number of successes. New legal conditions coming into force since March 1st 1988 could support the development of the Justizanstalt Göllersdorf as a primarily therapeutic institution.