Violence in the workplace: new perspectives in forensic mental health services in the USA.

BACKGROUND: This paper reviews current research on workplace violence in the USA and offers suggestions concerning the roles that mental health professionals with forensic expertise can play in this expanding field. AIMS: To clarify the role of the mental health professional in evaluating issues related to workplace violence. METHOD: Manual and computer literature searches were performed. RESULTS: The incidence of reported workplace violence is on the rise and can be devastating beyond the immediate injury. Forensically oriented mental health professionals can assist companies by providing pre-employment screenings, fitness-for-duty evaluations and threat assessment by using the results of current research on potentially violent individuals. CONCLUSIONS: With the growing interest in workplace violence come many opportunities for mental health professionals to assist companies in assessment, intervention and prevention.

Cycle of abuse and psychopathology in cleric and noncleric molesters of children and adolescents.

Sexual abuse in childhood is frequently reported among sex offenders and has been hypothesized to be one of a number of psychological factors etiologically related to perpetration of child molestation in adulthood. In the current study we examine a sample of cleric and noncleric admitted child molesters and normal control subjects in their exposure to sexual abuse in childhood and current psychopathology. Odds ratios for the association between exposure to sexual abuse and child molestation were obtained while adjusting for group differences in demographic and psychological characteristics. Results indicated exposure to sexual abuse in childhood was associated with becoming a child molester for both cleric and noncleric offenders (p < .0002). Nonclerics indicated more severe psychopathology than clerics. Sexual abuse in childhood is one of many risk factors for becoming a perpetrator of child molestation in adulthood for both cleric and noncleric child molesters. Noncleric offenders demonstrated more sociopathy and mental disorder in general while cleric offenders indicated more sexual conflictedness, suggesting different psychoetiologies of offending among cleric and noncleric child molesters.

Crime, psychiatry and the insanity defence: a report on some recent reforms in the United States.

There have been substantial developments in mental health law in the United States over the last 10-15 years. Once focal point has been the insanity defence, discussed here. The operational consequences of the legal changes remain to be assessed empirically, but informed speculation is possible. Both a description of the reforms and the assessment of their potential effect are relevant to members of the psychiatric profession in Australia, whether they be forensic specialists or traditional practitioners or researchers. Selective consideration of the American experience, as opposed to contemplating Wholesale transposition, is the appropriate posture for Australian policymakers.

Medroxyprogesterone and paraphiles: do testosterone levels matter?

We examine the associations between pretreatment testosterone (TTS) levels and sociodemographic, clinical, and sexual behavioral characteristics. Two groups, low and normal pretreatment TTS, were treated with medroxyprogesterone acetate (MPA) and compared on clinical response (deviant and nondeviant sexual behaviors; recidivism) and length of time to return to pretreatment TTS after discontinuing MPA. Thirteen paraphilic men who were treated with MPA and had TTS levels monitored at approximately three-month intervals during and after MPA were followed naturalistically. The principal outcome measures pertained to TTS levels and data from a self-report psychosexual inventory, which quantified deviant and nondeviant sexual activities. Time to return to baseline TTS levels were analyzed with Kaplan-Meier survival analysis. Nonparametric methods were used to compare the two groups on other variables. Multiple regression was used to examine the contribution of combinations of variables to TTS outcome. Subjects with low pretreatment TTS received MPA for longer periods of time, and older subjects took longer to return to pretreatment TTS levels despite being treated for shorter periods of time. Although subjects with lower pretreatment TTS levels may be more sensitive to MPA's TTS-suppressive effects, the multiple regression analysis showed that age may be an important determinant of the time it take for TTS levels to return to pretreatment baseline. Sociodemographic, clinical, and self-reported measures of sexual behavior did not distinguish between low and normal TTS level groups. Only one relapse was detected. Further studies with larger samples are required to better understand the role of TTS monitoring of sex offenders treated with MPA, in order to justify its continued use as a measurement of treatment adequacy and to study its potential role as a predictor of treatment outcome.

State psychiatric hospital patients with past arrests for violent crimes.

OBJECTIVE: This study examined associations between four types of major psychopathology--schizophrenia, schizoaffective disorder, and bipolar and unipolar affective disorders--and history of violent crime. The effects of demographic variables, substance abuse, psychosis, and paranoia on history of violent crime were also determined. METHODS: Diagnostic assessments using the Schedule for Affective Disorders and Schizophrenia and Research Diagnostic Criteria identified 172 state hospital inpatients with the four diagnoses of interest, as well as those with co-existing substance use disorders. Based on arrest records, patients were categorized according to the most violent crime for which they had been arrested. RESULTS: Patients with schizoaffective disorder were significantly more likely than those in the other diagnostic groups to have been arrested for a violent crime. Similar results were found for psychotic patients compared with nonpsychotic patients, patients who had paranoid schizophrenia compared with patients who had schizophrenia without paranoid features, and patients who had co-existing substance abuse compared with those with no history of substance abuse. Patients from racial minority groups and male patients were also more likely than white patients and female patients to have been arrested for a violent crime. CONCLUSIONS: Demographic features, a diagnosis of schizoaffective disorder, psychosis, paranoid symptoms, and substance abuse may all be associated with violent behavior.

Predicting the "revolving door" phenomenon among patients with schizophrenic, schizoaffective, and affective disorders.

OBJECTIVE: A subpopulation of chronically mentally ill patients, sometimes referred to as "revolving door" patients, are frequently readmitted to psychiatric units. This study examined the relationships among demographic features, diagnostic characteristics, and frequency of hospitalization of patients from four state hospitals. METHOD: Two semistructured, standardized instruments, the Schedule for Affective Disorders and Schizophrenia and a life events history, were administered to 135 inpatients who met the Research Diagnostic Criteria for schizophrenia (N = 56), schizoaffective disorder (N = 33), unipolar major depressive disorder (N = 23), and bipolar disorder (N = 23). Criminal history was assessed by arrest records. The main outcome measure was the number of hospitalizations. RESULTS: Chi-square and trend test analyses indicated that substance abuse and noncompliance with medication regimens were significantly associated with higher frequencies of hospitalization. A multiple regression model, which included alcohol/drug problems, medication noncompliance, and six sociodemographic and diagnostic variables (age, gender, race, marital status, years of education, and diagnosis) accounted for a significant proportion of the ability to predict frequency of hospitalization. Half of this predictability was due to the relationship of substance abuse and medication noncompliance with number of hospitalizations. CONCLUSIONS: Alcohol/drug problems and noncompliance with medication were the most important factors related to frequency of hospitalization. Preventing these behaviors through patient education may reduce rehospitalization rates.

Medroxyprogesterone treatment for paraphiliacs.

This study addresses the following questions: (1) what are the essential components of a medroxyprogesterone acetate (MPA) pretreatment evaluation?; (2) do paraphilic men treated with MPA (Depo-Provera) report a lowering of both deviant and nondeviant sexual drive and activities?; (3) is behavioral improvement associated with testosterone level reductions?; and (4) what significant side effects are associated with MPA treatment? A total of 29 paraphilic men who underwent a comprehensive psychiatric, medical, and legal evaluation and were eligible for treatment with MPA were followed naturalistically while receiving concurrent MPA and group therapy. The principal outcome measures were data obtained from a weekly self-reported psychosexual inventory that quantified five dimensions of deviant and nondeviant sexual activities and testosterone levels that were drawn pretreatment and after three and six months of MPA. Self-reported data were analyzed by nonparametric methods. Because MPA's effectiveness is evident early in treatment, we report on data from the first six months. Subjects reported a differential rate of suppression of sexual activities, a median of up to two weeks for deviant and 2 to 10 weeks for nondeviant behaviors (p < or = .01 for each of the five dimensions). Testosterone levels suppressed to less than 0.5 ng per milliliter for all but two subjects at three months and for all at six months. Recidivism was reported for one subject. Except for one subject who developed pulmonary emboli, no major medical problems were encountered. MPA safely and effectively reduced sex drive, controlled deviant sexual impulses and behavior, and lowered the testosterone levels of these paraphilic men during the first six months of treatment. However, the relative rapidity and completeness of the response raises questions regarding possible distortions in self-reported sexual activities. This should alert the practicing clinician to consider the use of collateral sources of information in interpreting treatment outcome for patients with paraphilic behaviors. Also, longer follow-up periods are required for monitoring treatment efficacy.

The psychometric assessment of alcoholism in forensic groups: the MacAndrew scale and response bias.

Although the MacAndrew Alcoholism scale is the most widely used Minnesota Multiphasic Personality Inventory (MMPI) measure of vulnerability to alcohol abuse, its accuracy has not been studied in patients intrinsically motivated to exaggerate or minimize psychopathology. We examined the usefulness of the MAC in predicting alcohol abuse in a forensic clinical sample. Results indicate the MAC (a) was not more effective than direct inquiry in this group, (b) scores were correlated negatively with minimization and positively with exaggeration for subjects with histories of alcohol abuse, (c) offered advantages over direct inquiry both in screening for alcohol history (sensitivity) and in confirming it (specificity), and (d) scores were only moderately more accurate in valid than in minimized or exaggerated MMPI protocols. The results suggest that clinicians should use the MAC cautiously, particularly when they suspect motivation to minimize psychopathology.

Psychopathology and denial in alleged sex offenders.

To investigate whether patients accused of having committed acts of sex offense manifest symptoms of psychopathology and whether they minimize or deny such symptoms during clinical evaluations, we administered the MMPI to 53 alleged sex offenders. We compared patients along two dimensions: a) whether they admitted or denied deviant sexual behavior, and b) whether they faced legal charges for sex offenses. Results indicated the following: a) Patients who denied deviant sexual behavior were significantly more likely to minimize psychopathology than were those who admitted to deviant sexual behavior (p less than .05). b) Patients facing no active legal charges showed significantly more psychopathology than did those facing legal charges (p less than .05). c) The most frequent forms of psychopathology shown by these patients were antisocial attitudes, depression, somatization, and cognitive disorganization. These findings suggest that many alleged sex offenders may experience, and deny, severe psychopathology in addition to their sexual disorders. Clinicians should be alert to subtle signs of psychopathology when evaluating alleged sex offenders who deny deviant sexual behavior, because these patients may be especially likely to minimize symptoms.

Do sex offenders minimize psychiatric symptoms?

With increasing frequency, forensic psychiatrists are called upon to evaluate sex offenders for the courts and criminal justice system. While many clinicians have observed that denial of paraphilia is common in sex offenders, few studies have examined whether this population has severe psychopathology other than paraphilia. Similarly, little is known about whether sex offenders minimize or deny symptoms of psychopathology when undergoing psychiatric evaluations. To study these questions, the authors administered the Minnesota Multiphasic Personality Inventory (MMPI) to 36 sex offenders, comparing the degree to which they minimized or denied psychopathology, dividing subjects among two dimensions: (a) whether they admitted to, or denied, paraphilia, and (b) whether or not they faced legal charges for sex offense. Results indicated that, first, patients who denied paraphilia were significantly more likely to minimize psychopathology than were those who admitted to paraphilia (P less than 0.05); second, patients who faced no legal charges showed significantly more psychopathology than did those who faced charges (P less than 0.05); and third, the most frequent forms of psychopathology were antisocial attitudes, depressive features, somatization, and thought disorder. These findings suggest that many sex offenders may experience, and deny, widespread and severe psychiatric symptoms in addition to their sexual disorders.

Simulation of brain damage: assessment and decision rules.

The possibility of fabricated or exaggerated organic deficits is a frequent concern in both civil and criminal forensic cases. Additionally, organic deficits may exist, but be incorrectly attributed to a claimed cause. Exaggeration or fabrication can apply to primary cognitive or emotional effects of brain damage or to secondary emotional effects. These categories of deficits, and their relationship to physical brain damage, must be clearly understood in order to comprehensively evaluate the possibility of malingering. This includes evaluation of different forms of consistency between (1) behaviors during evaluation, (2) claimed deficits and known organic syndromes, (3) behavior or claims during evaluation and actual life-functioning, and (4) test performance and known principles of cognitive functioning. Psychometric procedures and clinical strategies are described which can substantially aid in assessing consistency and distinguishing between honest and exaggerated self-reports. Limitations of available assessment techniques are described and a general decision model for evaluation of dissimulation of organic deficits is presented.

The detection of malingering in criminal forensic groups: MMPI validity scales.

Despite the value of the MMPI to the forensic assessment of malingering (exaggeration) of psychopathology, few studies have assessed the accuracy of the MMPI validity scales in criminal forensic populations. We administered the MMPI to 35 insanity defendants undergoing evaluation for fitness to stand trial and/or sanity at the time of the crime, who stood to benefit from being assessed as psychologically disturbed, and 39 subjects previously found not guilty by reason of insanity (NGRI), who did not stand to gain from such an assessment, Insanity defendants showed significantly more malingering than NGRI subjects, p less than .05. Racial differences did not affect the data. These findings support the efficacy of MMPI validity scales in assessing malingering within criminal forensic groups, and support the generalizability of the scales across race.

Validation of police officer recruit candidates' self-reported drug use.

Three hundred and fifty-nine Chicago Police Department recruit candidates submitted urine specimens as part of a drug-screening program. Candidates were tested in two groups about a week apart. About 20% of the recruit candidates in each group evidenced drug, primarily marijuana use. As part of a psychological screening test battery all the candidates also took the Inwald Personality Inventory (IPI). The IPI contains a self-report Drug Use Scale. Drug-Positive and Drug-Negative candidates' Drug Use Scale scores were matched by age, sex, and racial/ethnic group and compared to evaluate the accuracy of self-reported drug use when screening police recruit candidates. Results showed that Drug-Positive candidates' self-reported drug use was consistently higher than that of Drug-Negative candidates. Item-level analyses showed which drug use items best discriminate between Drug-Positive and Drug-Negative candidates. Implications are drawn for use of self-report as part of a police candidate screening process.

Physical examination of psychiatric outpatients: medical and legal issues.

The nation's courts are increasingly defining standards for the practice of psychiatry, but they have not given substantial attention to whether a psychiatrist can be found liable for failure to perform or obtain a physical examination of an outpatient. The few court decisions on this issue involve obvious infractions against good medical care and do not provide useful clinical guidelines. The authors' review of the literature indicates that although psychiatric patients are less healthy than the general population, and the majority of psychiatrists feel physical examination of outpatients is important, psychiatrists rarely conduct such examinations and only a small percentage initiate them. The authors offer recommendations concerning physical examinations that they believe are consonant with good psychiatric outpatient care.

Use of the SADS diagnostic interview in evaluating legal insanity.

Examined clinical usefulness of the SADS diagnostic interview in evaluations of criminal responsibility. Findings, based on 78 SADS evaluations from a specialized forensic clinic, indicated that SADS successfully differentiated between sane and insane evaluatees. These differences were found primilarily in the severity of psychotic symptoms and overall level of psychological impairment. In addition, preliminary data on institutionalized and outpatient Ss suggested the potential applicability of the SADS for assessing the general psychological functioning of insane patients in treatment.