[Response distortion or symptom severity? Symptom description by psychiatric patients and sociomedical assessment subjects]. / Antwortverzerrung oder Symptombelastung? Beschwerdeschilderung von psychiatrischen Patienten und sozialmedizinischen Begutachtungsprobanden.

BACKGROUND: Psychiatric disorders are the most frequent cause for premature retirement; however, trying to verify claims of performance deficits due to psychiatric disorders without the actual existence of the latter in sociomedical assessments is problematic. For this reason, differentiation between actual psychiatric disorders with real presence of symptoms and simulated or aggravated symptoms is of importance in sociomedical assessments. In recent years, symptom validity tests (SVT) have been increasingly utilized in psychiatric/psychological assessments; however, knowledge of the validity of these tests and the relation to symptom severity is still lacking. OBJECTIVE: This study aimed to compare the validity of different SVTs depending on symptom severity (Structured Inventory of Malingered Symptomatology (SIMS), Word Memory Test (WMT), Symptom Checklist-90-R (SCL-90­R), Minnesota Multiphasic Personality Inventory­2 (MMPI-2)). MATERIAL AND METHODS: Clinically treated inpatient psychiatric patients (n = 30) were compared with subjects of sociomedical assessments (n = 29) regarding their tendency to simulate or aggravate symptoms. RESULTS: It could be shown that the WMT and the SIMS both failed in the differentiation between psychiatric patients and subjects of sociomedical assessments, regarding description of symptoms or (un)restricted performance motivation. Furthermore, 20% of psychiatric patients were classified as false positive in WMT. The results of the SIMS were significantly related to the severity of psychiatric symptoms in SCL-90­R, therefore the severity of symptoms was assessed rather than the response distortion. CONCLUSION: The results underline the importance of further research on SVTs in sociomedical assessments, especially regarding symptom severity and response distortion.

Forensic psychiatry in Europe: The perspective of the Ghent Group.

OBJECTIVE: The Ghent Group was established in 2004 as a forum for forensic psychiatrists from different countries in Europe in order to bridge the gaps in knowledge, experience, practice and care which exist between them due to their different legal traditions and constitutions in dealing with people having mental disorders who come into conflict with the law. METHODS: The Ghent Group considers itself as a loosely organised think tank to which all interested and invited professionals can contribute without statutory restraints. Its aim is to facilitate communication with mentally disordered offenders appearing in court, to understand the procedures of our neighbouring countries and to find common ground between clinicians. RESULTS: The major focus of the Ghent Group is on teaching and training both at a national level, where one can learn about the methods of training from each other, and at a European level. The group of trainees from different countries experiment in seminars in solving medico-legal cases considering European Human Rights issues and their respective national procedures and institutions. CONCLUSIONS: This helps not only to understand the differences between the national medico-legal procedures but also to deepen the understanding of the principles and practice in one's own country.

Guilty by suspicion? Criminal behavior in frontotemporal lobar degeneration.

OBJECTIVE: Our aim was to compare the frequency of criminal conduct in patients with behavioral variant frontotemporal dementia (bvFTD), semantic dementia (SD), and Alzheimer disease. BACKGROUND: A few small-scale studies of antisocial and criminal behavior in patients with frontotemporal lobar degeneration have focused on the clinical subtype bvFTD. It is not yet known whether antisocial behavior affects patients with other clinical subtypes of frontotemporal lobar degeneration, like SD, and patients with other dementing disorders, like Alzheimer disease. METHODS: We used a standardized caregiver interview to assess criminal behavior in 83 outpatients: 32 with bvFTD, 18 with SD, and 33 with Alzheimer disease. RESULTS: We found criminal behavior (theft, willful damage to property, housebreaking, assault, or indecent behavior) in 54% of the patients with bvFTD and 56% of those with SD, but only 12% of those with Alzheimer disease. CONCLUSIONS: Just over half of our patients with bvFTD or SD had committed crimes. When middle-aged or older patients commit minor crimes, frontotemporal lobar degeneration should be considered as a possible cause. If an affected person faces criminal charges, the court might take incapability or diminished responsibility into account in reaching a verdict.

Teaching forensic psychiatry in Europe.

BACKGROUND: Forensic psychiatry was long regarded as sufficiently defined by the laws of a country to be restricted by national boundaries in all but a few areas. European Union (EU) employment rights and travel facilities have changed that within the EU. AIMS: The goal of this research is to explore the role and development of a network of teachers and trainees in forensic psychiatry. INFORMATION AND DISCUSSION: European Union countries differ widely in the extent to which they recognise forensic psychiatry as a specialty and thus also in the amount of training clinicians receive before they present themselves as expert witnesses in court, or develop or run services, or manage and treat individual offender patients. Nevertheless, a summer seminar for practicing clinicians, who also present evidence to court and for bodies considering discharge of potentially dangerous patients, has proved a useful forum for joint 'European learning'. Participants have left with a sense of improved understanding of their own law and practices as well as new perspectives on what works for offenders with mental disorder.

Recidivism in female offenders: PCL-R lifestyle factor and VRAG show predictive validity in a German sample.

A clear and structured approach to evidence-based and gender-specific risk assessment of violence in female offenders is high on political and mental health agendas. However, most data on the factors involved in risk-assessment instruments are based on data of male offenders. The aim of the present study was to validate the use of the Psychopathy Checklist Revised (PCL-R), the HCR-20 and the Violence Risk Appraisal Guide (VRAG) for the prediction of recidivism in German female offenders. This study is part of the Munich Prognosis Project (MPP). It focuses on a subsample of female delinquents (n = 80) who had been referred for forensic-psychiatric evaluation prior to sentencing. The mean time at risk was 8 years (SD = 5 years; range: 1-18 years). During this time, 31% (n = 25) of the female offenders were reconvicted, 5% (n = 4) for violent and 26% (n = 21) for non-violent re-offenses. The predictive validity of the PCL-R for general recidivism was calculated. Analysis with receiver-operating characteristics revealed that the PCL-R total score, the PCL-R antisocial lifestyle factor, the PCL-R lifestyle factor and the PCL-R impulsive and irresponsible behavioral style factor had a moderate predictive validity for general recidivism (area under the curve, AUC = 0.66, p = 0.02). The VRAG has also demonstrated predictive validity (AUC = 0.72, p = 0.02), whereas the HCR-20 showed no predictive validity. These results appear to provide the first evidence that the PCL-R total score and the antisocial lifestyle factor are predictive for general female recidivism, as has been shown consistently for male recidivists. The implications of these findings for crime prevention, prognosis in women, and future research are discussed.

Assessing measurement invariance of PCL-R assessments from file reviews of North American and German offenders.

Cross-cultural research on psychopathy necessitates assessment methods that are generalizable across linguistic and cultural differences. Multiple-group confirmatory factor analysis was used to compare the factorial structure of Psychopathy Checklist-Revised (PCL-R) assessments obtained from file reviews of North-American (N=2622) and German (N=443) male offenders. The analyses indicated that the 18 item, 4-factor model of the PCL-R obtained with the standard PCL-R protocol (interview and file review) also holds for file review data. On a factor-by-factor level, the data are commensurate with strong factorial invariance of factor loadings and item thresholds for the Interpersonal and Lifestyle factors, and with likely metric invariance for the Affective factor. The Antisocial factor showed structural differences between the two samples. The results imply that cultural or environmental factors more strongly influence the judgment and/or expression of antisociality. Based on the results, cross-cultural comparisons between North-American and German offenders in terms of PCL-R psychopathy should be limited to the Interpersonal and Lifestyle factors. Further research using data obtained through the standard protocol (i.e., interview plus file information) is encouraged.

[Ambulatory aftercare of forensic patients after release]. / Ambulante Sicherungsnachsorge.

OBJECTIVE: The efficacy of specific forensic outpatient treatment should be investigated. METHODS: In 2000 the Ministry of Social Affairs of the State of Bavaria, Germany, implemented a model for forensic outpatient treatment. Three forensic hospitals established forensic outpatient clinics. The Department of Forensic Psychiatry of the Psychiatric Hospital of the Ludwig Maximilian University of Munich evaluated the treatment and management programs with financial support from the Ministry. RESULTS: 111 mentally ill offenders were included after release from forensic hospitals. 65 % suffered from schizophrenia. In 4.5 years time of observation a recidivism rate of 0.9 % of severe offences could be found (3.6 % including cases of suspicion). 17 % of the patients needed a rehospitalisation and 12 % a legal intervention. At the end of the observation period 42 patients still needed treatment, but 44 patients continued therapy in the forensic outpatient setting out of own interests. CONCLUSIONS: In accordance to literature very low rates of criminal recidivism under specific forensic outpatient aftercare could be found, and in addition a relatively high compliance with the treatment.

The role of forensic psychiatry in mental health systems in Europe.

BACKGROUND: Forensic psychiatry at first glance seems to differ from one country to another due to different historical developments, different legal systems and different mental health systems. In spite of that, forensic psychiatry has several goals shared across countries, principally: assurance of treatment for severely mentally ill people who become delinquent; giving evidence to courts in cases when the offender's mental responsibility is in question; working effectively at the interface of the law and psychiatry, and, in so doing, working well with other clinical and non-clinical professionals in the field; preventing relapse of offenders with mental disorder. In order to achieve these goals, special knowledge and skills must be developed, especially in assessment and management of violence and sexual deviance and of the risk of these behaviours, incorporating techniques developed in neighbouring disciplines. One of the greatest challenges in the development of forensic psychiatry lies in its relationship with general psychiatry. It is arguable that the specialization of psychiatry into sub-specialties has lead to loss of some skills in general psychiatry and to a 'forensification' of people who would previously have been treated as general psychiatry patients. AIMS: In partnership, however, general and forensic psychiatrists could potentially achieve more than either group on its own: they could better prevent people with mental illness from becoming offenders; prevent people with mental illness from becoming victims of crime; intervene in the vicious circle from victim to perpetrator; assess young people at risk for antisocial behaviour and protect them from becoming criminals. Clinical research on these topics is just beginning and this article argues for a close integration of forensic psychiatry into the wider mental health system and for a more intensive exchange of knowledge and skills from forensic psychiatry to general psychiatry and vice versa.

[Assessment of sexual deviance by forensic psychiatrists]. / Begutachtung bei Sexualstörungen in der Forensischen Psychiatrie.

The article reviews the legal changes in dealing with sexual offenders in Germany during the last ten years. The developments described are in many respects comparable to other countries of Northern and Western Europe and to Austria. The laws, which regulate the penal aspects for sexual deviance, have been drastically tightened up. Publicist, political and public pressure against perpetrators and their advocates has massively grown; the number of committals in special institutions has dramatically increased. On the other hand the handling of these individuals by forensic psychiatrists has become much more professional. Standards for the assessment of culpability have been established, the treatment facilities have been largely extended, instruments for risk assessment and the prediction of recidivism have been developed and validated for German speaking countries. With respect to the political consideration to coercive treatment and for tightened and prolonged security measures for all sexual perpetrators professionals have to emphasize that sexual deviant individuals have to be differentiated, not only regarding their crimes and their personality but also regarding their potential to profit from treatment and their probability for recidivism

The validity of the Violence Risk Appraisal Guide (VRAG) in predicting criminal recidivism.

INTRODUCTION: The VRAG is an actuarial risk assessment instrument, developed in Canada as an aid to estimating the probability of reoffending by mentally ill offenders. AIM: To test the predictive validity of the VRAG with a German sample. METHOD: The predictive validity of the VRAG was tested on a sample of 136 people charged with a criminal offence and under evaluation for criminal responsibility in the forensic psychiatry department at the University of Munich in 1994-95. The predicted outcome was tested by means of ROC analysis for correlation with the observed rate of recidivism between discharge after the 1994-95 assessment and the census date of 31 March 2003. Recidivism rate was calculated from the official records of the National Conviction Registry. RESULTS: Just over 38% of the sample had reoffended by 2003. Their mean time-at-risk was 58 months (SD 3.391; range 0-115 months). The VRAG yielded a high predictive accuracy in the ROC analysis with an AUC of 0.703. For a constant time-at-risk < = 7 years, the predicted probability and observed rates of recidivism correlated significantly with Pearson's r = 0.941. CONCLUSIONS: The validity of the VRAG was replicated with a German sample. The VRAG yielded good predictive accuracy, despite differences in sample and outcome variables compared with its original sample.

Inpatient risk management with mentally ill offenders: results of a survey on clinical decision-making about easing restrictions.

BACKGROUND: Procedures for easing restrictions in forensic hospitals are an important part of treatment and serve to prepare inpatients for community conditions. In spite of this, there are still very few empirical data on the assessment of the risks involved. Clinical experience, expert knowledge and theoretical considerations indicate that the risk factors for recidivism after discharge from hospital are not identical with those that predict incidents during hospitalization or during the easing of restrictions. AIMS: To determine both possible risk factors for incidents during hospitalization and criteria allowing easing of regulations and confinement. METHODS: A survey was conducted of clinicians in forensic hospitals concerning their perception of risk and protective factors. RESULTS: The survey revealed that stable dynamic factors were more relevant for clinicians than static risk factors. Furthermore, clinicians rated protective factors as being as important as risk factors. Depending on the rehabilitation process, aspects of the social network outside the institutions were also rated as being important. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: These findings offer some clarification of the concept of clinical judgment as applied to assessment of readiness for discharge of offender patients from specialist forensic psychiatric hospitals. Research into risk assessment and management might be improved by taking account of explicit clinical concerns.

[Psychiatrists as victims of stalking]. / Psychiater als Opfer von Stalking.

Stalking is defined as notorious following, menacing, harassing, and contacting of a victim against his or her declared will. Such behavior can occur in a variety of psychiatric disorders. Attending physicians can also become victims of stalking. Especially psychiatrists appear to have a high risk of being stalked. Up to now, only a few studies investigated stalking behavior of patients aimed at medical professionals. In most cases, it was investigated together with aggressive behavior and sexual harassment. Cases of psychiatrists being stalked by patients or clients have not been described in detail. This case report describes a patient with erotomania who developed stalking behavior and victimized his attending psychiatrist. The relevance of stalking for clinical practice, the context of stalking behavior, and underlying psychiatric disorders and legal issues are discussed.