[The patient rules; the power of transference in the doctor-patient relationship]. / De patiënt aan het stuur.

The challenge of the doctor-patient relationship for the participants is maintaining their equivalence while respecting the needs of both sides. As the doctor has the expert power ('authority'), the patient reacts in different ways when he or she cannot release the control over the diagnostic situation. Regressive power can be exercised in three forms of transference relationships: the power of dependency, the power of dominance and the power of desorganisation. Doctors should recognize these forms of relationship but not engage in them. This implies that doctors should be educated in meta-communication with the patient and trained to keep up their warm interested neutrality and their ability to communicate from a scientific background.

[Structural changes in DSM-5: the beginning of a transformation?]. / Structurele wijzigingen in de DSM-5: begin van een hervorming?

BACKGROUND: The dsm-5 received both praise and criticism following its publication in May 2013. Some blamed the dsm classification system for the unsatisfactory diagnostic system within psychiatry. Over the last 30 years or so there have been no major breakthroughs in our field and there has been no reduction in the number of mental health problems in Western society. It is time for a change; the question is whether DSM-5 will succeed in bringing about this change. AIM: To update and analyse the structural, diagnosis-independent changes that have been incorporated in DSM-5. METHOD: We discuss the changes. RESULTS: The most important structural, diagnosis-independent changes include: 1. the separate classification of disorders that begin in childhood from those that begin in adolescence has been abolished; 2. the multi-axial system has disappeared; 3. the approach has become more dimensional, which allows for the assessment of the severity of a disorder. CONCLUSION: In the DSM-5 there are clear signs that a transformation of our psychiatric assessment system has begun; this can only be seen as a positive development, but is probably just the tip of the iceberg. Further changes are likely to occur, some in the near future, others in the long term.

[Impulse-control disorders and behavioural and personality disorders in DSM-5: no more age-limits or rigid category boundaries]. / Impulscontrole-, gedrags- en persoonlijkheidsstoornissen in de DSM-5: geen leeftijds- en categorische afgrenzing meer.

BACKGROUND: In the last edition of the DSM the externalising disorders have been fundamentally changed and have been separated from the neurodevelopmental disorders. AIM: To make a detailed study of the principal changes. METHOD: The old and new criteria for the behavioral disorders are compared and tested on the basis of their clinical utility, which is the underlying principle of the new DSM-5. RESULTS: More justice had been done to the gradual transition from symptoms of personality disorders to the illness itself. This has been done by placing the transition under the heading 'boundary-crossing behaviour' and by removing the rule that no-one under the age of 18 can be diagnosed as having a personality disorder. For personality disorders, the old category has been retained but a new one is proposed. CONCLUSION: In the 5th edition of the dsm the classification of behavioral disorders is much better and clearer than in the 4th edition. Careful attention has been given to the need to ensure that the severity of a patient's illness play a major role in the diagnosis. The classification of the personality disorders still needs further discussion.

Unraveling sexual associations in contact and noncontact child sex offenders using the single category - implicit association test.

Previous studies found associations between children and sex in child sex offenders (CSOs) using the Implicit Association Test (IAT). We used a modification of this task, the Single Category-Implicit Association Test (SC-IAT) to unravel child-sex associations in CSOs. Using the SC-IAT, we were able to test whether CSOs indeed hold stronger child-sex associations relative to adult-sex associations, compared to adult sex offenders and nonoffenders. Furthermore, we examined whether contact CSOs differed from noncontact CSOs in their child-sex associations. The hypothesis that CSOs would have stronger child-sex associations, relative to their adult-sex associations, than adult sex offenders and nonoffenders was confirmed. No difference between contact CSOs and noncontact CSOs was found. Although the Sex SC-IAT was able to distinguish CSOs from nonoffenders, the sensitivity and specificity of the test was poor (AUC of .65) and needs refinement. The results of this study support the existence of a child-sex association as a distinctive characteristic of CSOs. These findings are discussed in the context of theories on deviant cognitions in CSOs and risk for sexual offending.

[Staging and profiling of psychiatric disorders]. / Stagering en profilering van psychiatrische stoornissen.

BACKGROUND: Diagnostic issues are at the heart of medicine. Although the existing systems to classify mental disorders have been of tremendous value to Psychiatry, there is growing pressure to reform psychiatric diagnosis. In other areas in medicine staging and profiling has been a fruitful strategy to model the diagnosis of complex disorders. AIM: To examine whether staging and profiling may be a fruitful model for the diagnosis of psychiatric disorders. RESULTS: Clinical staging and profiling may help to reform our current static, descriptive and largely categorical classification of mental disorders and arrive at a diagnostic system that is developmental, that can accommodate better the continuous nature of most mental health problems and that is sensitive to etiologic and prognostic risk factors. CONCLUSION: Looking beyond the forthcoming revisions of DSM and ICD, clinical staging and profiling provide the necessary framework for a more fundamental reform of psychiatric diagnosis.

[Staging with profiles in offence analysis: diagnostic steps in forensic psychiatry]. / De stagering met profielen in de forensisch psychiatrische delictanalyse.

BACKGROUND: Forensic psychiatry is concerned particularly with accurate risk-assessment of offenders' future behaviour. AIM: To describe a staging and profiling system that is applicable to mentally-ill patients who have committed an offence. METHOD: The various steps in forensic psychiatric diagnosis are analysed and discussed. RESULTS: Three diagnostic steps within a treatment trajectory are described: stage 1. psychiatric diagnosis; stage 2. the course of the trajectory; stage 3. supervision (i.e. protection from danger). Each step is divided into profiles. CONCLUSION: By means of staging and profiling, the treatment plan is integrated into a dynamic model in which each stage contains a set of activities that gradually lead to unique profiles and interventions which incorporate evidence for subsequent diagnostics.

[Routine outcome monitoring in forensic psychiatry: a long story cut short]. / Routine outcome monitoring in de forensische psychiatrie: een lang verhaal in het kort.

BACKGROUND: It is difficult to do research relating to forensic psychiatric patients because there are a number of methodological problems inherent in systematic measurements in forensic psychiatry. AIM: To give readers an overview of the rom literature and some information about worthwhile developments in the field. METHOD: We studied the Dutch and international literature and took a closer look at some recent developments. RESULTS: For several reasons it is almost impossible to set up randomised controlled trials in forensic psychiatry. The main problems are as follows: the selection criteria for forensic psychiatric treatment are not psychiatric or they lack a behavioural focus, there is no standardised forensic psychiatric treatment for patients with a variety of psychiatric disorders and no theory concerning the relationship between disorder and offence. rom, therefore, may help to measure the clinical effectiveness of the treatments investigated. The forensic psychiatric literature gives very little advice on the choice of appropriate instruments. Clearly, however, the instruments have to embrace three distinct domains: psychopathology, the quality of life and the risk of recidivism. CONCLUSION: At least, however, we can recommend that all forensic psychiatric institutions should work together to develop a ROM system.

[The neurobiology of antisocial behaviour]. / Neurobiologische aspecten van antisociaal gedrag.

BACKGROUND: Neuro-imaging is being used increasingly to provide explanations for antisocial behaviour. AIM: To make a neurobiological contribution to the diagnosis of many types of antisocial behaviour. METHOD: The literature was searched using PubMed and combinations of the keywords 'psychopathy', 'antisocial', 'neurobiology' and 'neuro-anatomy' for the period 1990-2009. RESULTS: Impairments in the prefrontal cortex, amygdala, hippocampus, superior temporal gyrus, corpus callosum and anterior cingulate cortex provide a possible explanation for a large number of the symptoms associated with antisocial behaviour. The concept of psychopathy is connected mainly with impairments in a prefrontal-temporal-limbic system. CONCLUSION Combinations of deficiencies in the associated brain areas and malfunctioning of the communication between the various brain structures seem to play a more important role than deficiencies in the separate brain structures.

[The treatment of hypersexuality in a male with obsessive compulsive disorder as psychiatric co-morbidity]. / De behandeling van hyperseksualiteit bij een man met een obsessieve-compulsieve stoornis als psychiatrische comorbiditeit.

Patients with paraphilias often also have psychiatric co-morbidity. In this study of a case from an outpatient clinic we discuss the treatment of paraphilia not otherwise specified, characterised by hypersexuality, in a patient with paraphilia and psychiatric co-morbidity. After explaning the diagnosis and treatment plan we describe how the treatment proceeded. We begin by focusing on interventions to tackle the symptoms of obsessive-compulsive disorder and then concentrate more on the patient's hypersexuality and treatment by means of pharmacology. Thereafter we make a more detailed study of the role played by libido-reducing drug in the treatment of the patient's hypersexuality.

[Coercion and active interference in psychiatry]. / Dwang en bemoeizorg in de psychiatrie.

It is becoming increasingly clear that the autonomy and legal position of psychiatric patients are impediments to their adequate care. There is a strong emphasis on the voluntary cooperation of the patient involved. The patient as a person appears to be more important than his or her health status. There will always be tension between the right to self-determination and the dangers to the patient's health. There is a need for a law addressing the necessity to treat. In addition, a chain of care should be developed encompassing the whole spectrum of care institutions and centred around the individual's needs for food, shelter, care, financial support and medical attention.