[Recurrent, severe epistaxis in COVID-19 patients]. / Rezidivierende, schwere Epistaxis bei COVID-19-Patienten.

A 12-year-old female patient presented in the emergency room due to spontaneous, recurrent, fulminant epistaxis. As an additional finding a COVID-19-infection was noticed. Persisting hemorrhage led to increasing symptoms of shock. The current literature indicates a clear correlation of a SARS-CoV­2-infection to spontaneous fulminant epistaxis, most likely due to a mucosal inflammation; however, other typical causes must be ruled out.

[Standards for treatment in forensic committment according to § 63 and § 64 of the German criminal code : Interdisciplinary task force of the DGPPN]. / Standards für die Behandlung im Maßregelvollzug nach §§ 63 und 64 StGB : Interdisziplinäre Task-Force der DGPPN.

People who have been convicted of a crime due to a severe mental disorder and continue to be dangerous as a result of this disorder may be placed in a forensic psychiatric facility for improvement and safeguarding according to § 63 and § 64 of the German Criminal Code (StGB). In Germany, approximately 9000 patients are treated in clinics for forensic psychiatry and psychotherapy on the basis of § 63 of the StGB and in withdrawal centers on the basis of § 64 StGB. The laws for treatment of patients in forensic commitment are passed by the individual States, with the result that even the basic conditions differ in the individual States. While minimum requirements have already been published for the preparation of expert opinions on liability and legal prognosis, consensus standards for the treatment in forensic psychiatry have not yet been published. Against this background, in 2014 the German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology (DGPPN) commissioned an interdisciplinary task force to develop professional standards for treatment in forensic psychiatry. Legal, ethical, structural, therapeutic and prognostic standards for forensic psychiatric treatment should be described according to the current state of science. After 3 years of work the results of the interdisciplinary working group were presented in early 2017 and approved by the board of the DGPPN. The standards for the treatment in the forensic psychiatric commitment aim to initiate a discussion in order to standardize the treatment conditions and to establish evidence-based recommendations.

[Schizophrenia and violence]. / Schizophrenie und Gewalt.

BACKGROUND: There is now robust evidence that schizophrenia is associated with an increased risk of violence. Across Europe, the numbers of forensic hospital beds have dramatically increased largely due to admissions of men with schizophrenia. OBJECTIVE: This article critically reviews the extant literature on schizophrenia and violence. MATERIAL AND METHODS: A systematic review of the literature was carried out. RESULTS: People with schizophrenia are at increased risk, as compared to the general population, to be convicted for violent crimes because they are more likely to engage in aggressive behaviour towards others. While psychotic symptoms explain aggressive behaviour during acute episodes, they do not explain such behaviour at other stages of the illness or prior to onset of illness. Three distinct phenotypes of offenders with schizophrenia have been identified: individuals with a childhood onset of conduct disorder who display antisocial and aggressive behaviour both before and after schizophrenia onset, individuals with no history of conduct problems who begin engaging in aggressive behaviour at the onset of illness, and individuals who engage in a severe physical assault after many years of illness. Little is known about the aetiology of the three types of offenders and about the neural mechanisms that initiate and maintain these forms of behaviour. CONCLUSION: Mental health services need to assess the risk of violence among patients with schizophrenia and provide treatments that directly target antisocial and aggressive behaviour.

[Patients in forensic and general psychiatry. Do risk assessment measures detect differing risks of future violence?]. / Forensische Patienten und Patienten der Allgemeinpsychiatrie. Bilden Prognoseinstrumente unterschiedliche Gewalttäterrisiken ab?

BACKGROUND: The aim of this study was to assess the potential for future violent behaviour comparing patients recruited from forensic and general psychiatric wards in Germany. PATIENTS AND METHODS: Fifty patients were recruited from a forensic hospital and 29 from a general psychiatric hospital. In the weeks preceding discharge, structured assessments of the future risk of violent behaviour were completed using the HCR-20. RESULTS: There was little difference in the risk presented by the two groups. Forensic patients presented an elevated risk of violence because of historical factors, while the risk among patients from general psychiatry was due to clinical symptoms. CONCLUSION: Some criminal offences could be prevented if more time and effort were spent in general psychiatric practice in identifying patients at high risk for violence and in reducing symptoms of psychoses before discharge.

Preventing crime by people with schizophrenic disorders: the role of psychiatric services.

BACKGROUND: Knowledge of when and how to implement treatments to prevent criminal offending among people with schizophrenia is urgently needed. AIMS: To identify opportunities for interventions to prevent offending among men with schizophrenic disorders by tracking their histories of offending and admissions to hospital. METHOD: We examined 232 men with schizophrenic disorders discharged from forensic and general psychiatric hospitals. Data were collected from participants, family members and official records. RESULTS: More than three-quarters (77.8%) of the forensic patients had previously been admitted to general psychiatric services; 24.3% of the general psychiatric patients had a criminal record. Offences had been committed by 39.8% of the forensic patients and 10.8% of the general psychiatric patients before their first admission to general psychiatry, and after their first admission these 59 patients committed 195 non-violent and 59 violent offences. Subsequently, 49 of them committed serious violent offences that led to forensic hospital admission. The offenders were distinguished by a pervasive and stable pattern of antisocial behaviour evident from at least mid-adolescence. CONCLUSIONS: General psychiatry requires resources in order to prevent criminal offending among a subgroup of patients with schizophrenic disorders.

Affect regulation in borderline personality disorder: experimental findings from psychophysiology and functional neuroimaging.

BACKGROUND: Intense and rapidly changing mood states are a major feature of borderline personality disorder (BPD), which is thought to arise from affective vulnerability. OBJECTIVE: There have been only a few studies investigating affective processing in BPD, and particularly neither psychophysiological nor neurofunctional correlates of abnormal emotional processing have been identified so far. METHODS: Studies are reported using psychophysiological or functional neuroimaging methodology. RESULTS: The psychophysiological study did not indicate a general emotional hyperresponsiveness in BPD. Low autonomic arousal seemed to reflect dissociative states in borderline subjects experiencing intense emotions. In the functional magnetic resonance imaging study enhanced amygdala activation was found in BPD, and it is suggested to reflect the intense and slowly subsiding emotions commonly observed in response to even low-level stressors. CONCLUSIONS: Implications for psychotherapy are discussed.

Emotion in criminal offenders with psychopathy and borderline personality disorder.

BACKGROUND: Criminal offenders with a diagnosis of psychopathy or borderline personality disorder (BPD) share an impulsive nature but tend to differ in their style of emotional response. This study aims to use multiple psychophysiologic measures to compare emotional responses to unpleasant and pleasant stimuli. METHODS: Twenty-five psychopaths as defined by the Hare Psychopathy Checklist and 18 subjects with BPD from 2 high-security forensic treatment facilities were included in the study along with 24 control subjects. Electrodermal response was used as an indicator of emotional arousal, modulation of the startle reflex as a measure of valence, and electromyographic activity of the corrugator muscle as an index of emotional expression. RESULTS: Compared with controls, psychopaths were characterized by decreased electrodermal responsiveness, less facial expression, and the absence of affective startle modulation. A higher percentage of psychopaths showed no startle reflex. Subjects with BPD showed a response pattern very similar to that of controls, ie, they showed comparable autonomic arousal, and their startle responses were strongest to unpleasant slides and weakest to pleasant slides. However, corrugator electromyographic activity in subjects with BPD demonstrated little facial modulation when they viewed either pleasant or unpleasant slides. CONCLUSIONS: The results support the theory that psychopaths are characterized by a pronounced lack of fear in response to aversive events. Furthermore, the results suggest a general deficit in processing affective information, regardless of whether stimuli are negative or positive. Emotional hyporesponsiveness was specific to psychopaths, since results for offenders with BPD indicate a widely adequate processing of emotional stimuli.

[Impulse control and affect regulation in personality disorders]. / Impulskontrolle und Affektregulation bei Persönlichkeitsstörungen.

In borderline and antisocial personality disorder there is a close interaction between affect dysregulation and impulse control disorder. Different approaches are presented that focus on affective responses to experimental stimuli in these personality disorders. Results suggest that in borderline personality disorder intense emotional responses occur in the context of specific stressors, in particular fear of being abandoned. Evidence for a general emotional hyperreactivity was not found; on the contrary, female borderline subjects rather showed reduced emotional arousal. Regarding the psychopathic subtype of antisocial personality disorder, results provided strong support for the theory of emotional detachment, which may predispose to violence through a lack of feeling of fear or also of compassion which could counteract violent impulses. Consequences for psychotherapy in BPD are considered.

[Criminal acts leading to commitment according to psychiatric jurisprudence]. / Einweisungsdelikte im psychiatrischen Massregelvollzug.

The analysis of the delinquency bringing disordered offenders into a hospital order institution reveals a lot of very conscious and well organized behavior during the criminal activity. This must be taken into account in therapy and prognosis.

[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.

[Serious crimes during treatment in legal psychiatric commitment (section 63 StGB)]. / Gravierende Delikte während der Behandlung im psychiatrischen Massregelvollzug (Section 63 StGB).

The analysis of 11 cases of violent offenses committed during hospital order treatment in the Haina Forensic Psychiatric Hospital between 1985 and 1991 showed that biographical and forensic variables are more powerful predictors of dangerousness than treatment and psychopathological data. In more than half of these cases it was at least questionable whether the individuals had been placed correctly inside the hospital order system. In comparison to data found in inmate populations and a new study from North America the question arises as to whether the treatment might not have contributed to increase dangerousness in at least some of our cases.