What leads to high antipsychotic dosing in forensic patients with schizophrenia?

Earlier findings suggest that forensic schizophrenia patients are treated with higher doses of antipsychotics. This practice-based specificity is insufficiently studied, and clinicians' motives regarding this practice remain poorly understood. In this editorial, the authors provide their data on treatment of forensic schizophrenia patients and identify characteristics of psychopathology and previous types of behaviors, including suicidal attempts, as potential reasons for the practice. They also emphasize that "these previous acts" often took place years ago, and suggest that current or recent aggression is unlikely the main reason for dosing, but rather the clinicians' intention to maintain "must remain unaggressive" condition. Therefore, the authors suggest new ideas that may contribute to a better understanding of the specific prescribing patterns in the forensic population and hope that these ideas would be implemented in further well-designed prospective studies.

Alcohol abuse as the strongest risk factor for violent offending in patients with paranoid schizophrenia.

AIM: To determine predictive risk factors for violent offending in patients with paranoid schizophrenia in Croatia. METHOD: The cross-sectional study including male in-patients with paranoid schizophrenia with (N=104) and without (N=102) history of physical violence and violent offending was conducted simultaneously in several hospitals in Croatia during one-year period (2010-2011). Data on their sociodemographic characteristics, duration of untreated illness phase (DUP), alcohol abuse, suicidal behavior, personality features, and insight into illness were collected and compared between groups. Binary logistic regression model was used to determine the predictors of violent offending. RESULTS: Predictors of violent offending were older age, DUP before first contact with psychiatric services, and alcohol abuse. Regression model showed that the strongest positive predictive factor was harmful alcohol use, as determined by AUDIT test (odds ratio 37.01; 95% confidence interval 5.20-263.24). Psychopathy, emotional stability, and conscientiousness were significant positive predictive factors, while extroversion, pleasantness, and intellect were significant negative predictive factors for violent offending. CONCLUSION: This study found an association between alcohol abuse and the risk for violent offending in paranoid schizophrenia. We hope that this finding will help improve public and mental health prevention strategies in this vulnerable patient group.

Offender patients' opinions on placement in a forensic hospital.

BACKGROUND: People who become patients in secure hospitals may not understand their situation and have different opinions about the nature of institutionalisation from each other and from staff and the authorities. More knowledge of patient perspectives could improve treatment outcomes. AIMS: Our aim was to evaluate patients' beliefs about whether placement in an institution should be mainly punitive, therapeutic or a mixture of both and whether offence type should have any influence on the nature of the institutionalisation. METHODS: Inpatients with schizophrenia or schizoaffective disorder, from the Department of Forensic Psychiatry in Popovaca, Croatia, were asked to report their personal opinions about appropriateness of placements according to three case vignettes related to psychotically motivated offences of (1) homicide; (2) property damage; and (3) arson. RESULTS: A total of 52 patients were eligible for participation and consenting. Their average age was 44 (± 9.56) years and the mean duration of treatment in the specialist hospital was 7.7 (± 5.59) years; just over a third of them (20 patients) had committed or attempted homicide. They were more likely than not to favour at least 5 years of detention in a secure hospital for a person with psychosis who had killed another, regardless of mental state, but that for minor property damage, improvement in mental state should be the key determinant of discharge. They were more equivocal about arsonists. CONCLUSIONS: Perceptions of male offenders with psychosis on determinants of length of stay in a secure hospital appear to have much in common with what one would expect in the wider community. The fact that in spite of generally having poor insight into their own situation, these men could make judgments about fictitious but similar patients that appeared so unremarkable raised the possibility of building on this vignette study towards an educationally therapeutic module in preparation for rehabilitation.

Forensic aspects in domestic homicide.

The aim of the study was investigation of specific forensic aspects in offenders involved in domestic homicide cases in regard to sociodemographic and psychosocial variables and modalities of the offense. The research was conducted at the Department of Forensic Psychiatry in Neuropsychiatric Hospital "Dr. Ivan Barbot" in Popovaca, Croatia. The sample in this study consisted of domestic homicide group (N = 162). The results showed certain characteristics within the group of domestic homicide offenders. Generally speaking the offenders in domestic homicide cases were often married and were living in their families. Moreover, they were brought up in families with both parents and they had history of regular military service. Furthermore, offenders in domestic homicide cases were less involved in intervention from social services with rare history of home runaway and substance abuse during adolescence. Finally, the same group of offenders was less often had mothers or close friends with antisocial personality disorder but had frequent language and speech problems during adolescent period. In regard to the victims of domestic homicide they were often aged females. The offenders usually commit crime in their living space, either in the house or in the apartment. Based on these findings we conclude there are certain specific characteristics in the domestic homicide cases compared to homicide in general.

What associates Charles Bonnet syndrome with age-related macular degeneration?

Charles Bonnet syndrome (CBS) is a condition related to patients with visual loss due to age related macular degeneration or glaucoma that are having complex visual hallucinations. The CBS was first described by Swiss physician Charles Bonnet in 1760. Affected patients, who are otherwise mentally healthy people with significant visual loss, have vivid, complex recurrent visual hallucinations (VHs). One characteristic of these hallucinations is that they usually are "Lilliputian hallucinations" as patients experience micropsia (hallucinations in which the characters or objects are distorted and much smaller than normal). The prevalence of Charles Bonnet Syndrome has been reported to be between 10% and 40%; a recent Australian study has found the prevalence to be 17.5%. The high incidence of non-reported CBS is thought to be as a result of patient's fear to report the symptoms as they could be labeled as mentally insane since those type of visual hallucinations could be found in variety of psychiatric and neurological disorders such as drug or alcohol abuse (delirium tremens), Alice in Wonderland syndrome (AIWS), psychosis, schizophrenia, dementia, narcolepsy, epilepsy, Parkinson disease, brain tumors, migraine, as well as, in long term sleep deprivation. VHs can also be presented as the initial sign of the Epstein-Barr virus infection in infectious mononucleosis. Patients who suffer from CBS usually possess insight into the unreality of their visual experiences, which are commonly pleasant but may sometimes cause distress. The hallucinations consist of well-defined, organized, and clear images over which the subject has little control. It is believed that they represent release phenomena due to deafferentiation of the visual association areas of the cerebral cortex, leading to a form of phantom vision. Cognitive defects, social isolation, and sensory deprivation have also been implicated in the etiology of this condition. This study was conducted on 350 patients diagnosed with Age-Related Macular Degeneration (AMD) and shows incidence of CBS in 13% of patients with AMD. Furthermore, we have found higher incidence of CBS in patients with massive loss of vision in peripheral visual field which is not age related.

Neuroimaging techniques in modern forensic psychiatry.

Applied neuroscientific knowledge such as brain neuroimaging has widespread application in the medical diagnostic and treatment areas. Neuroscientific progress such as cognitive neuroscience has strong implications in specific medical fields such as forensic psychiatry. Significant progress in forensic psychiatry has affected the practice of law, in which an understanding of the complex relationship among mind, brain, and behavior is becoming necessary. Forensic psychiatry is concerned with the relationship between psychiatric abnormalities and legal violations and crimes. Due to the lack of available biological criteria, assessment, evaluation and therapy in forensic psychiatry have so far been restricted to psychosocial and mental criteria of offender personality. Recent advances in nuclear radiology such as brain imaging techniques (fMRI, DT-MRI, PET SPECT) allow a closer approach to the neural correlates of personality, moral judgments and decision-making. Introduction of neurobiological criteria (based on advanced neuroimaging techniques) in the field of forensic psychiatry and establishing the rules to what extent such biological criteria will be more reliable choice in evaluating mentally ill offenders would be of fundamental value in the modern forensic psychiatry. Psychosocial and subjective criteria in forensic evaluation will be more accomplished by biopsychosocial and objective criteria. Advances in the neuroimaging techniques bring specificity to the problems underlying the application of neuroscience to criminal law.

Predictors of aggressiveness in schizophrenic patients treated in inpatient forensic institutions.

Aggressiveness is a frequent and problematic aspect of the treatment of forensic patients. This study examines the correlation of aggressiveness and its subtypes with quality of life enjoyment and satisfaction, personality dimensions and family functioning. The research is conducted on 99 psychiatric patients diagnosed with schizophrenia or psychotic disorder similar to schizophrenia (F20-F29) in two forensic psychiatry institutions. The patients committed criminal offence in state of insanity. These offences had signs of aggressive acts and the patients were therefore admitted to inpatient psychiatric forensic institutions. The research was conducted by using the Aggressiveness Questionnaire (AG-87), the Eysenck Personality Questionnaire, the Quality of Life Enjoyment and Satisfaction Questionnaire and the Family Functioning Scale. The results show that aggressiveness has a negative correlation with the quality of life enjoyment and satisfaction. Regression analyses indicate that bad family relations and psychoticism are significant predictors of aggressiveness and its subtypes. We can conclude that forensic patients who committed aggressive offence in psychotic state, who at the same time score higher values on psychoticism scale and report negative family relations, are more likely to express aggressiveness also during their stay in forensic psychiatric hospital.

Domestic homicide cases related to schizophrenic offenders.

The goal of this study was identification of highly specific patterns of schizophrenia related domestic homicides by comparing schizophrenic homicide offenders with related domestic homicide group of offenders diagnosed with other psychiatric disorders. This study was based on the comparison of schizophrenic homicide group and other homicide group of offenders on the basis of differences in psychosocial and sociodemographic patterns and the modality of crime. The survey was conducted on mentally insane domestic homicide offenders diagnosed with schizophrenia (n=44) and second group of mentally insane offenders diagnosed with other psychiatric diagnosis (n=43). All offenders were admitted to Department of Forensic Psychiatry (Neuropsychiatric Hospital "Dr. Ivan Barbot", Popovaca, Croatia) for psychiatric evaluation. They have undergone psychological testing and psychiatric evaluation in order to make forensic expert analyses of each case particularly. This study showed some specific characteristics in the cases of schizophrenic offenders; they are more often commit parricides and siblicides, the victims are often males with their own physical strength. Furthermore, schizophrenic offenders were indifferent upon killing their victim; they were less often provoked by a victim itself and were sober tempore criminis. Moreover, in the same homicide group we found young, single offenders with high school education, average intelligence and with positive psychiatric heredity. Finally, in the same group of offenders we have found no history of military serving, less social developmental disruptions, less history of drug and alcohol abuse during adolescence and adult age.

Chromotherapy in the regulation of neurohormonal balance in human brain--complementary application in modern psychiatric treatment.

Chromotherapy is based on the effect of colored light with different frequencies on human neurohormonal pathways, precisely on melatonin and serotonin pathways in brain. There is evidence that visible electromagnetic spectrum of light we see as colors can have impact on human health, Cicardian rhythm or biological clock is complex fundamental physiological and biological cycle in human organism. The biological clock in humans is located in the specialized group of brain cells called suprachiasmatic nucleus (SCN) within the anterior hypothalamus. The complex process of neurohormonal regulation of cicardian rhythm in humans is essential for synchronized interaction and coordination of internal body function with the environment. Given these facts it is clear that any shift in cicardian rhythm results in neurohormonal imbalance which consequently could lead to various psychiatric disorders affecting humans. Studies on sleep disorders, depression, seasonal affective disorder (SAD) and post-traumatic stress disorder (PTSD) suggested that symptoms, signs, and biologic markers associated to these psychiatric disorders are due to marked alterations in melatonin and serotonin levels. The main hypothesis of chromotherapy is that specific colors of the visible spectrum are activators or inhibitors of complex physiological, biological and biochemical processes in human brain such as synthesis of various neurohormons. According to all previous findings, our goal is future investigation of the effect and possible application of chromotherapy in the complementary psychiatric treatment in patients with diagnostic criteria which are clearly related to melatonin and serotonin disturbances.

Successful treatment of polydipsia, water intoxication, and delusional jealousy in an alcohol dependent patient with clozapine.

The beneficial effect of clozapine on polydipsia and water intoxication in patients with schizophrenia has been demonstrated many times. The authors report a successful clozapine treatment of polydipsia, intermittent water intoxication, and delusional jealousy of an alcoholic. This is a rare case of clozapine treatment of a non-schizophrenic patient affected by polydipsia.