Sexually Violent Predator Law in the United States.

Sexually violent predator (SVP) laws in the United States are controversial. They tend to be opposed by academics, libertarians, and professional organisations but are supported by states and the Supreme Court. This study reviews the history of SVP legislation, compares features of SVP laws among states, and summarise requirements by the Supreme Court that shaped these laws. Features of SVP laws include identification of sexual offenders with mental abnormality that predisposes them to sexually offending behaviours in the future, and standards of proof for conditional or unconditional release. A comprehensive understanding of all statutes can inform policymakers about SVP laws, whether supportive or restrictive of such legislation.

The fin de millénaire duty to warn or protect.

At the turn of the millennium, the authors summarize the evolution of a clinician's duty to protect third persons from a patient's violent acts over the past half century, with special emphasis on jurisprudential developments in the last decade. Four evolutionary periods are identified: Pre-Tarasoff, Inception, Diversification, and Retreat. The period of Retreat from Tarasoff in the nineties is characterized by the following approaches to Tarasoff: adoption, statutory containment, rejection of a duty to warn, rejection of a duty to control voluntary patients, and proactive circumscription of any protective duties. A more rational jurisprudential approach would permit some measure of flexibility for the proper exercise of clinical discretion.

To warn and to control: two distinct legal obligations or variations of a single duty to protect?

Prior to the Tarasoff decisions, jurisprudence pertaining to the duty to warn, or inform, to prevent violence to third persons, was separate from that pertaining to the duty to control to prevent such violence. The Tarasoff Principle consolidated preventive obligations in the face of foreseeable violence under a single "duty to protect." Even as courts adopted divergent rules for establishing foreseeability, many held to a single duty to protect with warnings as one possibility for fulfilling this option. Particularly over the past decade, courts have again disengaged the duty to warn and the duty to control, each requiring different legal predicates to occur. In recent years, courts have upheld or rejected a duty to warn, upheld or rejected a duty to control; and several courts have, within a single opinion, articulated fundamental distinctions between these two separate protective duties.

Factors in prison suicide: one year study in Texas.

UNLABELLED: The goal of the study was to examine psychopathology and stressors suffered by suicide victims, and to describe the characteristics of the suicides in the Texas Department of Criminal Justice between June of 1996 to June of 1997. Data on 25 completed suicides were collected from the records department. RESULTS: The authors identified 60% of the suicide victims with a history of psychiatric disorders. Seventy-six percent had been diagnosed with psychiatric disorders while incarcerated. The most frequent psychiatric disorders were mood disorders (64%), psychotic disorders (44%), personality disorders (56%), and comorbidity with a history of presentencing alcohol and drug abuse was common. Most of the victims experienced chronic and/or acute stressors of acute trauma, disrupted relationship, sentence hearing, and/or medical condition. We concluded that important factors associated with increased risk of prison suicide include psychiatric disorders, comorbid substance abuse, a history of suicide attempt, and chronic and/or acute stressors.

Combined homicide-suicide in Galveston County.

Combined homicide-suicides have been classified based on the psychopathology of the perpetrator and the nature of the relationship between perpetrator and victim(s). To further understand the nature of this tragic phenomenon and to test the validity and practicality of a previously suggested classification system, investigators systematically collected data on all combined homicide-suicide events that occurred in Galveston County, Texas over a continuous 18-year period (n = 20). The most common psychopathological finding for perpetrators was high serum alcohol levels that suggested intoxication. Most combined homicide-suicides fell into one of the relational categories and most of these, as predicted, were of the consortial type, possessive subtype. As expected, due to the small sample size, the less common types of combined homicide-suicide were not represented in this sample.

Introduction to this issue: international perspectives on psychopathic disorders.

The importance of characterological disturbances, that contribute towards individual patterns of law breaking behavior, to legal systems in all countries should be self-evident. Contributors to this international perspective issue represent Canada, Germany, Great Britain, and the United States, and data from several additional European countries were included in Hare's article. This issue addresses emotional deficiency, molecular genetics, construct and predictive validity of the PCL-R, psychosocial predictors and treatment. Critical analyses of current models for civil commitment and criminal responsibility vis-à-vis psychopathic disorders contribute towards informed dialectic on these compelling public policy issues. We hope that readers will find that these articles collectively advance our understanding of the nature of these disorders, currently available therapeutic interventions, and today's critical social issues.

The state of electroconvulsive therapy in Texas. Part I: reported data on 41,660 ECT treatments in 5971 patients.

The Texas Legislature in 1993 mandated a quarterly reporting requirement for hospitals and physicians performing electroconvulsive therapy (ECT) in the state (United States Government hospitals were excluded). The Texas Department of Mental Health and Mental Retardation (TDMHMR) was designated as the agency responsible for collecting and maintaining the data. This paper reviews the ECT data from 16 quarterly reports (09/01/93 through 08/31/97). The reports contained data on 41,660 ECT treatments in approximately 5971 patients. The results of this study support the proposition that ECT is an extremely safe and effective treatment for those individuals suffering from a serious mental illness. In Texas, ethnic groups other than non-Hispanic Anglo-Americans appear to be underserved in regards to ECT. Those patients without appropriate insurance or adequate personal finds are also underserved as a result of the few county and state hospitals performing ECT and the relatively small number of patients treated with ECT at those hospitals. Recommendations are suggested to improve the quality of the database and in informing the public as to the safety and efficacy of this valuable treatment modality. What, at first, was seen as an unwarranted legislative foray into the practice of medicine, has, in the end, become a source of valuable data supporting the use of ECT as an important treatment modality.

The state of electroconvulsive therapy in Texas. Part 2: contact with physicians, hospitals, medical liability insurance companies, and manufacturers of stimulus generating equipment.

Since mid-1993, all ECT treatments performed in the state of Texas (except for United States government hospitals) must be reported every quarter to the Texas Department of Mental Health and Mental Retardation (TXMHMR) on a data collection form provided by the Department. Part 1 of this paper reviewed that data. This paper reviews the responses to questionnaires and contacts made with physicians, hospitals, medical liability insurance companies, and manufacturers of stimulus generating devices regarding their experience with ECT in Texas. Questionnaires were sent to physicians and hospitals that had not performed ECT during the final two quarters of the review period. Medical liability insurance companies and the manufacturers of the stimulus generating equipment used in ECT were contacted regarding their experience with liability claims. The results indicate that medical liability in regards to the performance of ECT is extremely low. Physicians and hospitals that stopped performing ECT did so for reasons other than medical liability.

The clinician's duty to protect third parties.

The jurisprudence on a clinician's duty to protect third parties is complex and continues to evolve. Clinicians should familiarize themselves with civil commitment laws, privilege and confidentiality statutes, protective disclosure statutes, reporting requirements, and the Tarasoff Principle, as they would case law in the state in which they practice. Ethical codes and ethical position statements provide useful guidance. In their practices, clinicians should endeavor to conduct careful assessments for diagnoses, the patient's current situation, and dangerousness. Traditional clinical, therapeutic, and instructional measures should always be considered first, and reasonable efforts should be made to enlist the patient's cooperation. Occasionally, however, hospitalization or protective disclosures must be made. The proposed algorithm should be of help to the clinician in making critical decisions regarding hospitalization and disclosures to protect others. In following this decision tree, four questions are of key importance: (1) Is the patient dangerous to others?; (2) Is the danger due to serious mental illness?; (3) Is the danger imminent?; and (4) Is the danger targeted at identifiable victims? This algorithm is intended to assist in the application of, and should not replace, clinical judgment.

Assaultive eye injury and enucleation.

An especially dangerous behavior observed in some forensic and security hospital populations is assaultive eye gouging. Although a number of case reports in the literature concern auto-enucleation, gouging out the eyes of another is virtually unmentioned. We present a case series of eye gougers (n = 10) gathered through clinical contributions from several forensic populations in the United States and Russia. Four subjects were psychotic during the eye-gouging episode, one was only mentally retarded, and five, who were neither psychotic nor retarded, deliberately injured victims' eyes during acts of extreme sexual violence.

Tarasoff in Texas.

Texas physicians do not have a statutory duty to warn potential victims of their patients' violent conduct but may warn medical or law enforcement authorities if the patient is a danger to himself, to the treating physician, or to others. Moreover, the Medical Practice Act of Texas does not authorize even permissive exceptions to confidentiality, thereby preventing physicians from legally warning victims. Nonetheless, 5 Texas appellate courts already have addressed a clinician's duty to issue protective warnings to reasonably identifiable victims. The approaches of these 5 courts have been similar, but important differences warrant attention. In 1998, the Supreme Court of Texas, in a fact-specific decision, did not adopt a duty for physicians to protect third persons from their patients' violent acts. All Texas physicians should become familiar with the emerging jurisprudence of professional protective responsibilities and liabilities to third persons who can be harmed physically by their patients' violent conduct.

The effects of phenytoin on impulsive and premeditated aggression: a controlled study.

Studies of the effects of phenytoin on aggression have produced equivocal results primarily because of a lack of (1) common objective criterion measures of aggressive acts across studies; (2) rigorous inclusion and exclusion criteria for selecting subjects; and (3) a nosologic basis for classifying different types of aggression. The current study was designed to remedy these deficiencies. Aggression was defined using a nosology that defines three types of aggression: (1) medically related; (2) premeditated; and (3) impulsive. The purpose of this study was to test the hypothesis that phenytoin will decrease impulsive aggressive acts but not have a significant influence on premeditated aggressive acts. Sixty inmates were divided into two groups on the basis of committing primarily impulsive aggressive acts or premeditated aggressive acts while in prison. Medical aggression was ruled-out by subject selection. The study used a double-blind, placebo-controlled, crossover design. As hypothesized, phenytoin (200 mg a.m. and 100 mg p.m.) significantly reduced impulsive aggressive acts but not premeditated aggressive acts. Event-related potentials (ERPs) measured information processing in the cortex during drug/placebo conditions. The amplitudes of P300 ERP waveforms among impulsive aggressive subjects were increased significantly during the phenytoin condition but not during the placebo condition. There were no significant changes in P300 ERP waveforms between drug/placebo conditions among nonimpulsive aggressive subjects.

Neuropsychological and cognitive psychophysiological substrates of impulsive aggression.

The purpose of this study was to test whether subjects who commit impulsive vs non-impulsive aggression differ on measurements of personality, neuropsychology, and cognitive psychophysiology, and whether these differences can yield information regarding the etiology of impulsive aggression. Subjects were two groups of prison inmates, distinguished by their committal of impulsive or nonimpulsive aggression, and matched noninmate controls. All inmates met DSM III-R criteria for an antisocial personality disorder but for no other disorder. Impulsiveness, anger, and peak P300 latencies did not differ between the inmate groups, but verbal symbol decoding and peak P300 amplitudes did. Impulsiveness and verbal skills were inversely correlated. Impulsiveness was inversely correlated with, and verbal skills positively correlated with P300 amplitudes. The results indicate that aggression is not homogenous, even among antisocial persons, and that impulsive aggression is related to neuropsychological and cognitive psychophysiological measures of information processing beyond those factors related to criminality alone.

Does "isolation" cause jail suicides?

In their efforts to prevent suicides, psychiatrists who consult to jails face a terrible dilemma. Placing a suicidal inmate in a single cell to restrict access to harmful materials and instruments is a common practice. Yet, mental health authorities argue that isolating a suicidal inmate only fuels the flames of his self-destructive impulses. It behooves mental health professionals to advocate relentlessly for better staffing patterns in jails and more humane approaches to suicidal inmates. Meanwhile, in some jail settings, the combination of single cell placement, complete disarmament, and close observation may be the most effective available option.