Forensic Psychiatric Assessment Research Articles

Examining the Mr Tsafendas enquiry trial: Current insights on forensic psychiatric assessment and ethics

On 6 September 1966, the prime minister of South Africa, Dr HF Verwoerd was killed by Mr Tsafendas, a Portuguese national of Greek descent, in parliament by stabbing him in the chest. Mr Tsafendas was a messenger in parliament. At the enquiry trial of Mr Tsafendas, he was found unfit to stand trial on the ground that he suffered from schizophrenia. The psychiatric evidence during the enquiry trial was reviewed and discussed under the following headings: Diagnosis of schizophrenia; Consideration of cultural factors in forensic psychiatric settings; Delusional infestation v. extreme overvalued beliefs; Simulation of psychosis; Ethical considerations in criminal capacity and trial competency assessments. Lessons from the Mr Tsafendas enquiry trial for forensic psychiatrists where a defendant previously diagnosed with schizophrenia commits a prominent political murder, are summarised. It is emphasised that the personhood of an accused referred for forensic observation should be respected and protected, instead of focusing exclusively on a specific diagnosis.

«Проблемные ситуации»: апробация в качестве судебно-психиатрического метода исследования при изменении гражданско-правового статуса

<p style="text-align: justify;">As part of solving the task of developing methods to improve the quality and evidence of forensic psychiatric decisions, in a comparative non-randomized study the “Problem Situations” methodology was tested as a method of forensic psychiatric assessment in civil cases on applications for change civil legal status. The sample consisted of 67 subjects who underwent inpatient forensic psychiatric examination in connection with the decision on the issue of changing their civil status in 2021—2022. A conclusion corresponding to legal capacity was given in relation to 12 people; diminished legal capacity - 24 people; incapacity — 31 people. Pairwise group comparisons using Pearson’s goodness-of-fit test (Chi-square) and biclustering procedures confirmed the predictive validity of the method.</p>

The gendered context of women charged with violent offences in the forensic psychiatric setting.

Women charged with violent offences may be referred by courts for forensic psychiatric assessment to determine whether mental disorder or intellectual disability impacts their fitness to stand trial and/or criminal responsibility. The profile of these women is a poorly researched area in South Africa. This study examined the socio-demographic, offence-related, and clinical profile of South African women charged with violent offences referred for forensic assessment. Fort England Hospital (FEH), a forensic psychiatric institution in the Eastern Cape. The clinical records of 173 women referred by courts for forensic psychiatric evaluation over a 24-year period (1993-2017) to FEH were systematically reviewed. Most women were single, black mothers with dependent children, who were unemployed and socio-economically impoverished. Many had backgrounds of pre-offence mental illness, alcohol use and alleged abuse. The majority were first-time offenders whose victims were known to them. Most child victims were biological children killed by their mothers. Likely primary motives for violence were related to psychopathology in half of cases, and interpersonal conflict in a third. Forensic assessment most frequently confirmed psychotic disorders and dual diagnoses. Half the cases were fit to stand trial and under half were criminally responsible. Violent female offending occurs within a gendered context, with high rates of prior trauma, alcohol use and psychosocial distress in perpetrators. An emphasis on gender-sensitive psychosocial interventions is required. This study highlights the nature and context of violent offending by women referred for forensic psychiatric assessment in South Africa.

Criminological and Psychiatric Profiles of Immigrant and Refugee Offenders: A Retrospective Analysis of Cases in a Forensic Setting.

This study aimed to scrutinize the characteristics of immigrant and refugee offenders within our institution, focusing on factors such as immigrant status, country of birth, duration of residence in Turkey, as well as psychiatric, socio-demographic, and criminal profiles. The data were obtained through a retrospective examination of case records referred to the Observation Department of the Council of Forensic Medicine for the assessment of criminal responsibility between 2017 and 2022. The study categorized the cases into two groups: refugees and immigrants, comprising 35 and 22 offenders, respectively. Significant differences in educational levels were identified between immigrants and refugees within our study group (p < .001). Notably, drug use disorders were more prevalent among refugees, whereas alcohol use disorders were more common among immigrants, with statistical significance (p < .005). During forensic psychiatric assessments, 57.1% of refugees and 54.5% of immigrants required interpretation services. The most prevalent offense in the refugee group was homicide (37.1%), followed by child sexual abuse (28.6%). In contrast, homicide (31.8%) and theft and extortion (22.7%) were the most common offenses for the immigrant group. Six cases (10.5%) were judged to have reduced or no criminal liability. Among the cases, 52.6% had a history of prior outpatient psychiatric referrals, with the most frequent diagnosis being atypical psychosis at 10.5%. The findings underscore the necessity for additional research and targeted interventions to address the mental health and criminological complexities confronted by this vulnerable population.

An Update Review to Cast Light on the Possible Role of Altered Oropharyngeal Microbiota in Differentiating True Psychosis from Malingered Psychosis in a Forensic Psychiatric Setting

Over the past few years, malingered psychosis has had a progressive occurrence since a great deal of attention has been directed to the closures of long-stay psychiatric institutions and care in the community. Therefore, malingered psychosis needs to be identified to conduct precise forensic assessments and prevent miscarriages of justice and misuse of restricted healthcare resources. Although, over the past decades, researchers have introduced a number of workable psychometric strategies and tools for diagnosing true psychosis, it is still sometimes challenging to differentiate between true and malingered psychosis. Hence, identifying reliable and innovative diagnostic alternatives seems crucial. Accordingly, a summary of gathered evidence is provided by the present review for enhancing future evaluation of oropharyngeal microbiome composition as a practical indicator for diagnosing true psychosis in a forensic psychiatric setting. As per the systematic search terms (namely, “diagnostic marker,” “oropharyngeal microbiome,” “forensic psychiatric setting,” “psychosis,” and “oropharyngeal microbiota”), relevant English publications were searched from January 1, 1980, to September 15, 2023, in Scopus, the Web of Science, Embase, Cochrane Library, PubMed, and Google Scholar databases. Finally, eight articles were included in the present review. Also, we adopted the narrative technique so that the material synthesis leads to a cohesive and compelling story. The results revealed that the periodontal disease and saliva microbiome were possibly associated with true psychosis. Thus, since oropharyngeal microbial compositions are highly different among healthy controls and patients with true psychosis, future research can take advantage of saliva to differentiate between fake and true fake psychosis throughout the initial stages of forensic psychiatric assessment. As a substrate of interest, saliva could also be used for characterizing the various stages of psychosis under a forensic psychiatric setting.

Forensic mental health in Kuwait: filling the gaps

The case of M’Naghten (1843) laid out the insanity defence test for the British legal system. Later, many countries basing their criminal legislation on the British common law system, including the Criminal Act of Kuwait, adopted the test. The Act forms the basis for forensic psychiatric assessments. Several countries amended their criminal laws to provide a better balance between public safety and human rights protection. However, the Criminal Act of Kuwait remains unchanged for offenders with mental illness since its enactment in the early 1960s, with several gaps concerning the detention mechanisms and the discharge of such offenders. However the Kuwait Mental Health Law (2019) eventually filled these gaps. This paper describes the function of forensic mental health services in Kuwait, discusses and compares the Criminal Act of Kuwait with other nations’ criminal laws and describes the forensic section of the Kuwait Mental Health Law (2019).

Forensic psychiatry evaluation of criminal law cases at a university hospital in Eastern Turkey

ABSTRACT This study aimed to determine the epidemiological distribution of the cases referred to the forensic psychiatric assessments according to the reasons for their referral. The medical files of 214 cases referred to the Forensic-Psychiatry Outpatient-Clinic and forensic reports within the scope of criminal law were reviewed retrospectively. 76% of cases were ‘suspected perpetrators’ who were sent for the purpose of determining criminal responsibility, 9.3% were ‘’mentally disordered victims’, 14% were sent to determine ‘victim developing a mental disorder(MD)’. In our study, it was determined that the majority of the suspected perpetrators were male and in the 20–39 age group. Marriage rates were high in both suspected perpetrator groups with(42.2%) or without(39.9%) of MD. The most common diagnosis of suspected perpetrators was schizophrenia/psychosis. Regarding the group sent as perpetrators, it was found that the rate of intellectual disability(ID) has a high rate of 20.2% among all cases, and the diagnoses of substance use disorder(SUD) and personality disorder(PD)were low. Full criminal responsibility was significantly correlated with age, PD, SUD, and pre-criminal substance use. Logistic regression analysis was determined gender and education can predict the perpetration or victimization of individuals with MD. Our findings show that protective-preventive practices specific to risk groups should be developed for the sociodemographic and clinical differences we detected in the Turkish forensic psychiatry sample. In the process of evaluating whether there is a medical problem in the marriage of patients with schizophrenia, possible harm to the spouse and children of the patient should be considered. We are of the opinion that all MD should be evaluated from the perspective of the implementation of preventive security measures, the focus of which is the state of dangerousness.

Nationwide study on antipsychotic polypharmacy among forensic psychiatric patients

ABSTRACT This nationwide retrospective cross-sectional study examines the prevalence of antipsychotic polypharmacy (APP) and demographic, forensic, and clinical factors associated with its practice among Greenlandic forensic psychiatric patients. We collected data from electronic patient files, court documents, and forensic psychiatric assessments. We defined APP as two or more concurrent prescriptions of antipsychotic medication. The study population of 74 patients had a mean age of 41.4 years, and 61 were men. All included patients had either schizophrenia or another ICD-10 F2-diagnosis. We used unpaired t-tests and Chi2 or Fisher’s exact test. The prevalence of APP was 35% (n = 26), and there was a significant association between APP and a prescription of clozapine (Chi2, p = 0.010), olanzapine (Fisher’s test, p = 0.003), and aripiprazole (Fisher’s test, p = 0.013). Furthermore, we found a significant association between APP and prescription of a first-generation antipsychotic (FGA) (Chi2, p = 0.011). Despite recommendations in guidelines, the use of APP is common practice. The majority of forensic psychiatric patients suffer from severe psychiatric disorders, often with other comorbidities, including substance use disorder. The severity and complexity in mental health render forensic psychiatric patients at high risk of APP treatment. Further knowledge on APP use is crucial to secure and further improve the psychopharmacological treatment for this group of patients.

Expert opinions on criminal law cases in Switzerland – an empirical pilot study

Criminal courts of law rely on forensic psychiatric/psychological reports when clarifying legal questions of culpability, dangerousness, and the need for therapeutic measures for offenders. Incorrect decisions owing to a lack of expert report quality and comprehensibility can have serious consequences for potential victims, offenders themselves, or societal use of resources. In this pilot study, we started from the hypothesis that forensic psychiatric/psychological reports meet the minimum requirements for legally admissible expert opinions. Within the framework of assessment by the Concordat Expert Commission of Northwestern and Central Switzerland, 58 adult criminal law reports were randomly selected. Two researchers extracted and analyzed standardized data descriptively. For quality assurance, they followed the extended codebook of the Research and Development Department of the Zürich Office of Corrections and Reintegration. Psychopathological findings accounted for only 1% of the reports, which seemed problematic considering that these findings reflect the personality traits of offenders. Furthermore, only 7% of offenders underwent physical examinations, and the reasons for not performing physical examinations were noted in fewer than half of these offenders. Of 26 sexual offenders, only one was physically assessed. Additional imaging or neurophysiological examinations (e.g. electroencephalogram) were conducted in only one offender. Furthermore, published baseline recidivism rates were used in only 37.9% of the reports. The results of this study suggest that current forensic psychiatric assessment is deficient. The infrequent use of published recidivism rates for risk communication denies prosecutors and judges solid reference values for the actual recidivism probability. Moving away from somatic medicine contradicts the federal court judgment, which disqualifies psychologists from providing a forensic report owing to their lack of expertise in physical examination. The authors recommend the multidisciplinary involvement of forensic psychiatrists and psychologists and, in certain cases, of specialists in somatic medicine to produce accurate and well-founded reports.

Plasma neurofilament light chain protein is not increased in forensic psychiatric populations: a pilot study.

Neurofilament light chain protein (NfL) is a fluid biomarker of neural injury measurable in cerebrospinal fluid and blood. Patients with different neurodegenerative disorders and mild traumatic brain injury display elevated levels of NfL. However, so far, elevated levels of NfL have not been demonstrated in persons with psychiatric disorders. To our knowledge, the occurrence of NfL in the blood has not previously been studied in persons undergoing forensic psychiatric assessment or persons treated in forensic mental health services. Supposedly, these persons suffer from experiences and conditions with a higher risk of neural injury than other psychiatric patients. In this pilot study, we investigated plasma levels of NfL in 20 persons undergoing forensic psychiatric assessment and 20 patients at a forensic psychiatric hospital. NfL values were compared with control groups of healthy individuals matched for age and sex. The prevalence of increased NfL in both forensic groups was low and did not differ compared with the controls. However, some persons undergoing forensic psychiatric assessment showed slightly elevated values. The slightly elevated values were observed in the group investigated closer in time to the index crime, when elevated NfL levels could be expected to be more prevalent due to acute conditions from the time of the offense. This gives reason to look further into this group.

Bias analysis in forensic and non-forensic psychiatric assessments

In this research, we provide two important contributions to the psychiatric community. First, we offer the first valid and reliable cognitive test that measures forensic clinicians' ability to detect and avoid diagnostic biases in psychiatric assessments. Second, we also estimate the prevalence of clinical decision bias detection and prevention ability among psychiatrists and psychologists. A total of 1069 clinicians from different specialties (317 psychiatrists and 752 clinical psychologists, of which 286 were forensic clinicians) participated in this research. The Checklist of Biases for Clinicians (BIAS-31) was developed, and its psychometric properties were analyzed. The prevalence of bias detection and prevention was estimated using BIAS-31 scores. The BIAS-31 is valid and reliable for measuring clinicians' ability to avoid and detect clinical biases. Between 41.2% and 55.8% of clinicians try to avoid biased clinical judgments. Likewise, between 48.5% and 57.5% of clinicians were able to correctly detect the biases involved in the diagnostic assessment process. We did not expect to obtain these prevalences. Therefore, we discuss to what extent specific training in the prevention of diagnostic biases is necessary and propose several clinical strategies to prevent a priori the occurrence of biases in the psychiatric assessment.

Criminological characteristics of sexual assault perpetrators: a Tunisian study

IntroductionIn Tunisia, Sexual assaults constitute a pervasive problem that concerns the health care system and the country’s judicial authorities alike.ObjectivesThe aims of our study were to estimate the incidence of sexual assault encountered in the context of forensic psychiatric assessment and to assess the criminological profile of sexual assault perpetrators.MethodsWe conducted a retrospective study of a series of sexual assault perpetrators examined in a forensic psychiatric assessment in the psychiatry C department at Hedi Chaker university Hospital in Sfax, from January 2010 to December 2021.ResultsOver the period of 11 years (2010 to 2021), we collected 374 forensic psychiatric assessment files. Among them, 49 were those of sexual assaults (13.10%). It was a rape assault in 54.4% of cases. Aggravating circumstances have been noted in 87% of cases. These were mainly assaults on minors (54.3%) and assaults associated with physical violence (38.4%).The victim gender was female in 63% of cases, with an average age of 21 years 9 months. and was among the relatives of the sexual assault perpetrator in 28.3% of cases.ConclusionsRape seems to represent a non-negligible proportion of the offenses motivating a forensic psychiatric assessment in Tunisia. Sexual assaults against minors are frequent, despite undeniable under-reporting.Disclosure of InterestNone Declared

Sexual aggressors with mental disorders: characterization of a Tunisian sample

IntroductionSexual violence is a worldwide public health concern. Nevertheless, the psychopathology of perpetrators of sexual assault still nowadays poorly documented.ObjectivesThe aim of this study was to assess the characteristics of sexual aggressors with mental disorders.MethodsIt was a retrospective study that included a series of sexual aggressors examined in forensic psychiatric assessment in the psychiatry C department at Hedi Chaker university Hospital in Sfax, from January 2010 to December 2021. Data were collected from psychiatric expert reports.ResultsThe sample was exclusively composed of men with an average age of 37 years and 07 months (± 12.75 years). 54.4% of sexual aggressors suffered from mental disorder. Personality disorder was the most prevalent psychiatric disorder and the antisocial type was noted in 23.9% of cases.Sexual aggressors suffering from mental disorder were more likely to commit rape followed by murder (p=0.05). They used physical violence far more than the others did (p=0.007) and they were more apt to threaten their victims with weapon during the assault (p=0.038). They were also more likely to abuse the power given by their professional roles (15,2 % versus 5,6 %; p=0.07). They more frequently attacked unknown victims (p=0.019).ConclusionsMore than half of sexual aggressors suffered from psychiatric disorder. Therefore, the detection and treatment of psychiatric morbidity among sexual aggressors may minimize the risk of recidivism.Disclosure of InterestNone Declared

Механизмы совершения виртуальных сексуальных правонарушений и их судебно-психиатрическая оценка

The issues of an integrated approach to the forensic psychiatric assessment of persons who have committed sexual crimes by information and telecommunication technologies are considered. The main stages of decision-making are identified and analyzed. The features of the formation of ideas about the problem being solved, decision-making strategies, and the choice of alternatives are considered. Approaches to assessing the subject's ability to comprehend and regulate legally significant behavior are defined. An algorithm for forensic psychiatric assessment is formulated, according to which the most significant are the severity and nature of the leading psychopathological symptoms and the degree of its influence on the cognitive and volitional components of behavior regulation.

Introduction to the Civil Forensic Psychiatric Assessment (III)

Offence type and neurodiversity: A comparison of 12‐17‐year‐old boys charged with a criminal offence by diagnosis of autism spectrum disorder, attention deficit hyperactivity disorder or both

Autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) have been evidenced as common among adolescents with delinquent behaviour. Less is known, however, about the relationship between these disorders and type of alleged offence, when the adolescent is involved with the criminal justice system. Our aim was to investigate whether the type of alleged index offences among 12-17-year-olds differ between those diagnosed with ASD, ADHD or ASD+ADHD. The sample was selected for ASD and/or ADHD diagnoses from a database of all pre-trial forensic psychiatric and psychological assessments of male adolescents of 12-17years old in the Netherlands for the years 2013 and 2014. For each record, independent researchers scored a 76-item checklist encompassing health and offending characteristics. Sixty-nine of the 1799 pre-trial assessments of these male adolescents had a diagnosis of ASD, 90 of ADHD and 29 had been diagnosed with both; these 188 cases formed our sample. The rate of sex offences was significantly higher among those with ASD (N=20, 29%) than those with ADHD (N=10, 11%) or both (N=4, 14%; Fisher's exact test=8.54; p=0.014). By contrast, the rate of property offences without violence was significantly higher among those with ADHD (N=22, 24%) than those with ASD (N=4, 6%) or both (N=5, 17%; Fisher's exact test=10.50, p=0.004), whereas violent offending rates did not differ between the three groups. Specific offence types were not equally distributed among male adolescents with different psychiatric diagnoses. In our sample of male adolescents suspected of an offence nearly one-third of those diagnosed with ASD were convicted of a sex offence, suggesting highly specialised needs for further assessment and intervention. Among those diagnosed with ADHD, significantly more adolescents were charged with non-violent property offences. Such unequal distribution of alleged offence types among adolescents with different psychiatric diagnoses justifies tailor-made attention for offending adolescents with different psychiatric diagnoses.

Introduction to the Civil Forensic Psychiatric Assessment (II)

Introduction to the Civil Forensic Psychiatric Assessment (I)

Criminal recidivism in offenders with and without intellectual disability sentenced to forensic psychiatric care in Sweden-A 17-year follow-up study.

BackgroundOffenders with intellectual disability (ID) constitute a distinct subgroup of offenders with mental disorders. Regarding criminal recidivism, it is unclear whether or not offenders with ID in forensic psychiatric settings differ from offenders without ID. Factors associated with criminal recidivism among offenders with ID have been scarcely investigated.AimTo investigate the association between ID and criminal recidivism among offenders sentenced to forensic psychiatric care and to explore the impact of clinical, sociodemographic and offense variables.Materials and methodsWe conducted a retrospective cohort study based on Swedish nationwide registers. A total of 3,365 individuals being sentenced to forensic psychiatric care in Sweden in 1997–2013 were followed from the forensic psychiatric assessment until first reconviction, death, emigration, or 31 December 2013, whichever occurred first. Cox regression models compared rates of recidivism in individuals with and without ID. Impact of clinical, sociodemographic, and offense variables on risk of criminal recidivism was presented as hazard ratios (HRs) with 95% confidence intervals (CIs).ResultsOut of 3,365 offenders sentenced to forensic psychiatric care, 259 (7.7%) were diagnosed with ID. During follow-up (0–17 years, median 6 years), one third (n = 1,099) of the study population relapsed into criminality, giving a recidivism rate of 50.5 per 1,000 person-years. We observed an association between ID and a decreased risk of recidivism (HR 0.8, 95% CI 0.6–1.0, p = 0.063), although this reached statistical significance only for the subgroup of male offenders (HR 0.8, 95% CI 0.6–1.0, p = 0.040) and not females (HR 1.0, 95% CI 0.6–1.8). ID offenders with concurrent ADHD tended to have a higher rate of recidivism (73.9 per 1,000 person-years, HR 1.2, 95% CI 0.6–2.4) than ID offenders without ADHD (42.5 per 1,000 person-years, HR 0.8, 95% CI 0.6–1.1). Amongst ID offenders, concurrent autism spectrum disorder, young age or male sex were not associated with recidivism, while previous criminal convictions were strongly associated with recidivism.ConclusionA diagnosis of ID was associated with a lower risk of criminal recidivism among male offenders sentenced to forensic psychiatric care. The association between ADHD and recidivism among ID offenders highlights eligible focus areas in the management of offenders with ID.

Gender differences vs gender bias in forensic psychiatric assessment of non-psychotic mentally disturbed violent defendants in Denmark

ABSTRACT This retrospective study aimed to explore possible gender bias in a population of non-psychotic but otherwise mentally disturbed violent defendants (The Danish Penal Code section 69) evaluated at the Clinic of Forensic Psychiatry in Copenhagen from 2007 to 2016 (N = 678). The results showed that female defendants in the total sample were 2.5 times more likely to be recommended for treatment than comparable male defendants, even when controlling for several confounders. However, when separating serious offences from less serious offences, the significant difference persisted only for the group of defendants charged with less serious violence. A logistic regression model including the gender of the defendant, the gender of the psychiatrist, and the interaction between these terms showed no significant interaction. Possible explanations concerning leniency, victimisation, and gender-specific criminogenic factors as well as diagnosis are discussed. However, interpreting real-life data is always complex and blinded case studies with psychiatrists evaluating the same case, but being randomized to different information concerning the gender of the defendant, are recommended to assess gender bias and explore the factors influencing such bias.