Forensic Psychiatric Evaluation Research Articles

Estimating Present and Future Damages Following Child Maltreatment

The child psychiatric forensic evaluation of children and adolescents who are plaintiffs in civil lawsuits regarding their present and future damages from child maltreatment requires knowledge of current research findings on the short-term and long-term consequences of child maltreatment, evidence-based treatments for psychological trauma, and relevant professional guidelines, along with knowledge of the ethics and laws governing mental health expert practice and testimony in personal injury litigation. This article reviews current research and recommends an approach to these evaluations and expert testimony that is informed by current research findings, recently developed professional guidelines, and many years of professional experience.

P02-201 - Lack of quality assurance in forensic psychiatry: false positive prevalence of antisocial personality disorder among norwegian inmates on preventive detention

IntroductionA Norwegian government publication (1) claims a prevalence of around 50% of Antisocial Personality Disorder (APD) in a small group of male detainees on preventive detention. The present study population is recruited from more or less the same population as those among whom a 50% prevalence of APD has been claimed (1). Norwegian forensic investigators rarely (17%) apply psychometric tools to confirm their clinical diagnosis (2).AimsTo confirm the diagnosis of APD applying SCID axis II. Methods: Fifty six inmates were available at the prison. Twenty eight were willing to participate (50%). Two were excluded. Thus, 26 (46%) inmates participated. DSM IV, SCID axis II was applied.ResultsNone of the 26/56 matched the APD criteria, mainly failing to fulfil the diagnosis of Conduct Disorder (CD) before the age of 15 years. All the inmates had a history of antisocial behaviour.ConclusionsTo explain the claim of around 50% APD in view of the present results, close to 100% APD should be found among the remaning thirty non-participating inmates. We consider this unlikely.A diagnosis of APD based on the history of antisocial behaviour alone represents a pitfall. Lack of quality assurance could lead to false positive diagnosis. The need for a standardized approach and quality assurance in Norwegian forensic psychiatric evaluations seems nevessary to avoid false positive diagnosis.

P02-188 - Forensic aspects of schizotypal patients

Schizotypal disorder comprises a wide spectrum of schizophrenic disorders from personality to sub-psychotic disorders. As a result, psychiatric evaluation of this psychopathology is ambiguous and a challenge to forensic psychiatry. The other important side of the problem is the prevention of social aggression of these patients.For the aim of investigation of these aspects a cohort of 82 patients was studied. All of them committed crimes and had been diagnosed “schizotypal personality disorder”(12), or “schizotypal disorder” (pseudopsychopatic (38), pseudoneurotic schizophrenia (13), schizophrenia with bare symptoms (16), schizophrenic reaction (3).We found that the main criteria for the forensic psychiatric evaluation of schizotypal disorders include personal, social and clinical aspects. The patients with schizoptypal personality disorder can demonstrate mostly integrity of cognitive sphere and singularity of emotions, also rather high level of social adjustment. The patients with mild forms of schizophrenia show pathology in sphere of thinking and emotions, social problems, so the psychiatric forensic conclusion can be different from irresponsibility.The main factors of criminal aggressive behavior of patients were pseudopsychopatic syndrome with disability of critical functions and brutish behavior pathology.

Forensic psychiatric evaluation of sexual offence victims

The role of the forensic medical expert in the field of forensic psychiatry in criminal cases is usually related to offenders’ examination in terms of evaluation of their discernment. Within this article we approach the tasks of forensic psychiatry in victims of sexual offence examination in order to bring elements of differentiation between rape and statutory rape in case of minors under the age of fifteen. In Romania the legal age of consent to sexual activities is 15 years. The inability or impossibility of the victim to defend or to express his/her will must be evaluated carefully since the presence of this criterion concludes the allegation of rape instead of sexual act with a minor. Although minor persons consent is considered is considered invalid by Law if aged fewer than 15, it is important to establish the possibility or ability to express their consent. The state of impossibility to express the will may be either temporary (e.g. alcohol and/or drug intoxication) or permanent (mental retardation). The question of extreme youth is an issue of debate, with imprecise criteria of determination. The ethical concern of autonomy respect versus obligation of the society to protect its vulnerable members against undesired sexual acts is also discussed.

Feigning in adjudicative competence evaluations

Competence to stand trial (adjudicative competence) is the most requested forensic psychiatric evaluation, with an estimated 60,000 referrals annually. The challenge of detecting feigned incompetence has not been systematically studied until the past decade. Estimates of feigned adjudicative incompetence vary from 8 to 21%. This article reviews techniques for detecting malingered psychosis and malingered cognitive impairment during competence evaluations. Specific techniques for assessing feigned adjudicative incompetence and estimating the malingerer's genuine abilities are discussed. A stepwise approach to suspected feigned adjudicative incompetence is proffered.

Association between Intimate Partner Violence and Posttraumatic Stress Disorder: A Case-Control Study

BackgroundIntimate partner violence (IPV) against women is a common form of interpersonal violence in both developed and developing countries, and represents a forensic and public health problem. IPV is related to Post-traumatic Stress Disorder (PTSD). This relationship however, has not been investigated in Colombian population. ObjectiveTo determine the strength of the association between IPV and PTSD in women referred for forensic psychiatric evaluation in Bucaramanga, Colombia. MethodA case-control study was designed. A total of 132 cases involving women referred for forensic psychiatric evaluation met criteria for PSTD according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). A group of 262 women without PTSD were taken as controls. First, odds ratio (OR) was computed. Logistic regression was used to control confounding variables. ResultsA total of 76 (56.6%) in the case group reported IPV during the past year compared to 85 (32.6%) in the control group. IPV and PTSD were associated (OR=3.09, 95%CI: 1.58-6.03) after controlling for age, employment, medico-legal loss or injury, and current aggressor (partner). ConclusionsIPV increased the risk for PTSD three-fold among women attending forensic assessment in Bucaramanga, Colombia.

The Utility of Rorschach in Forensic Psychiatric Evaluations – A Case Study

The use of the Rorschach Comprehensive System (RCS) in forensic psychiatric evaluations has evoked criticism. This study examined the use of the RCS in forensic psychiatric evaluations by studying to what extent a valid interpretation and an assessment can be made on information based solely on the RCS. Psychological assessments (N 34) based solely on RCS information were compared with the responses made by a forensic psychiatrist who had evaluated one offender. Agreement was found in 14 of 19 statements, which were related to the capacities and personality characteristics underlying criminal responsibility and mental state at the time of offense. The findings support the use of the RCS in forensic psychiatric evaluations, although no explicit conclusion can be drawn from one case. Further studies with more cases are needed.

PW01-116 - Clinical-psychopathological prerequisites of criminal violence in veterans of local wars

The aim of the investigation was to determine clinical-dynamic characteristics of combat-related PTSD, as well as individual and personality features and prerequisites of criminal aggression and mental disturbances observed at the moment of offence.Subjects and methods174 male combatants aged 22-43 y.o.; clinico-psychopathological and statistical methods; quality of life self-evaluating scales.ResultsCombatants were divided into 5 groups: 3 psychotic and 2 nonpsychotic. The probability of heteroaggressive behavior seems to increase in accordance with duration of exposure and severity of stress factors. Criminal behavior dominated in first three years after the impact of the combat stress factors. Besides various PTSD symptoms mentioned in ICD-10, DSM-IV, new personality features in emotional, cognitive and motivational value spheres were observed. The more pronounced were these changes, the more prominent were interpersonal difficulties and violence. A frequent or chronical emotional prerequisite of aggression was proneness to emotional excitement in an interpersonal conflict. «Flashbacks» about war situations seemed to release under the influence of strong emotion. Their value system was polar: black and white: either friend or enemy. Therefore, their opinions were rigid, not realistic. They committed offences against person in emotional conditions triggered by stress, when situation was associated with life threat at war or an emotionally overwhelming opposition.ConclusionDetailed analysis of personality characteristics of the offender, duration of exposure to combat stress and its severity, as well as subsequent social stress factors and their psychological impact, and circumstances of offence itself is essential for correct judgement during forensic psychiatric evaluation.

P01-171 - Medical and social consequences of child abuse

Child abuse and neglect are a cause of psychological problems which may have further negative influence on the future life of children. Alongside with symptoms of deprivation, disorders of mental development and affective sphere and vegetal dysfunction such children can display disinhibition of instincts with sadistic propensities and form a personality without positive social attitudes, aspiration for delinquent behavior.Aim of the researchTo study the role of child abuse in genesis of criminal and aggressive behavior in adolescents.Material and methods650 adolescents that underwent forensic psychiatric evaluation in the Serbsky Centre were examined by complex clinical psychopathological, pathopsychological and instrumentally diagnostic methods. The average age of patients was 16.7 years old.Results and discussionsThe research has revealed that 60.5% adolescents have committed aggressive and violent crimes (murder, sexual assault), 86% adolescents of the sample were brought to trial for murder and grave bodily injuries that resulted in death of the victims, 12% have committed sexual crimes. Examination of the micro social factors showed that 80% of the adolescents were brought up in disadvantaged families under conditions of emotional deprivation, 55% of them were physically abused and 30% of them were victims of sexual abuse.ConclusionOur research proves that a factors of “learning of violence” at home play a great role in aggressive behavior formation in children and adolescents. Continuous chain of violence and abuse that a child suffers at home leads to abnormal personal development, distortion of socialization and formation of delinquent behavior.

How neuroscience and behavioral genetics improve psychiatric assessment: report on a violent murder case.

Despite the advances in the understanding of neural and genetic foundations of violence, the investigation of the biological bases of a mental disorder is rarely included in psychiatric evaluation of mental insanity. Here we report on a case in which cognitive neuroscience and behavioral genetics methods were applied to a psychiatric forensic evaluation conducted on a young woman, J.F., tried for a violent and impulsive murder. The defendant had a history of multidrug and alcohol abuse and non-forensic clinical evaluation concluded for a diagnosis of borderline personality disorder. We analyzed the defendant's brain structure in order to underlie possible brain structural abnormalities associated with pathological impulsivity. Voxel-based morphometry indexed a reduced gray matter volume in the left prefrontal cortex, in a region specifically associated with response inhibition. Furthermore, J.F.'s DNA was genotyped in order to identify genetic polymorphisms associated with various forms of violence and impulsive behavior. Five polymorphisms that are known to be associated with impulsivity, violence, and other severe psychiatric illnesses were identified in J.F.'s DNA. Taken together, these data provided evidence for the biological correlates of a mental disorder characterized by high impulsivity and aggressive tendencies. Our claim is that the use of neuroscience and behavioral genetics do not change the rationale underlying the determination of criminal liability, which must be based on a causal link between the mental disorder and the crime. Rather, their use is crucial in providing objective data on the biological bases of a defendant's mental disorder.

Forensic psychiatric perspective on criminality associated with intellectual disability: a nationwide register‐based study

Contrasting views exist over the association of intellectual disability (ID) and criminal offending. This nationwide study attempts to shed further light to expand understanding to substantiate the relation between socio-demographic characteristics, psychiatric co-morbidity and criminal behaviour among the Finnish forensic population with ID. We reviewed all forensic psychiatric examination reports of individuals with ID who underwent a pre-trial forensic psychiatric evaluation in Finland during an 11-year period (1996-2006). One-third of the offenders had been regularly and sufficiently treated as outpatients. Half of the offenders had previous criminality, and the single most common crime was arson. Almost half of the offenders were diagnosed with alcohol abuse/dependence and two-thirds with any substance abuse/dependence. Furthermore, almost half were intoxicated during the index crime. Antisocial personality disorder was diagnosed in 25% of the offenders. Almost half of the offenders were placed in involuntary special care for the ID, which lasted ca 2 years. Among the last-mentioned, two-thirds of the nursing care plans lacked recommended structure. The offenders with so-called triple diagnosis - substance abuse, mental illness and ID - form a small subgroup of criminal offenders with complex needs. The results of the present study underline the importance of close, long-term cooperation among specialists in the field of ID, addiction service, mental health services and forensic psychiatry.

Matricídio e transtorno bipolar

BACKGROUND: Matricide is the killing of one's own mother, and a type of homicide rarely seen on psychiatric practice. Matricide cases studies have shown the presence of mental disorders, such as schizophrenia, bipolar disorder, personality disorders and alcoholism, and have also found cases where there is no evidence of mental disorders. OBJECTIVE: We aim to report a case of a woman with bipolar disorder that murdered her own mother and had a psychiatric forensic evaluation to ascertain her penal imputability. METHODS: Psychiatric interview was carried out and the psychiatric diagnosis was established based on the interview and analysis of forensic and hospitalar records, using the DSM-IV-TR criteria. RESULTS: The examinee was considered not guilty by reason of insanity, due to the presence of a mental disorder that affected her entire understanding and determination of the practiced delict. She has been under inpatient forensic psychiatric care for two years. DISCUSSION: It is important that psychiatrists and other mental health professionals be alert to the risk of violent behavior in patients that present a long history of mental disorder and present episodes of violence during the acute phase, or threats against relatives and friends, or the lack of regular psychiatric treatment.

S27-01 Gender specific and structured approach to violence risk assessment - the Munich Prognosis project (MPP)

A clear structured approach to violence risk assessment that is both, evidence-based and gender specific- is high on the political and mental health agendas. The individual risk of perpetrators depends on several parameters that are incorporated into assessment instruments. Most data about risk factors included in risk assessment instruments were derived only on male offenders.This study is part of Germany's biggest risk assessment study, -the Munich Prognosis project (MPP) - and focuses on factors included in risk assessment instruments associated with criminal and violent recidivism in a sample of male and female delinquents referred for forensic-psychiatric evaluation prior sentencing. The predictive validity of four instruments (HCR 20, ILRV, VRAG and PCL-R) for violent and general repeat offenses was analyzed.When comparing the predictive validity of the four instruments for male offenders, the results were in favor of the PCL-R, i.e. PCL-R Factor 2 when focusing on violent recidivism.For female offenders ROC analysis found superior results of the HCR 20-R items (AUC .793 p< .05), the ILRV D variables (AUC .814), p< .05) and the VRAG (AUC .864, p< .05) for violent recidivism. They were in favor of the PCL-R Factor 1 (AUC .666, p< .05) when focusing on general recidivism.The importance of gender specific violence risk assessment will be discussed.

Claims of Amnesia for Criminal Offenses: Psychopathology, Substance Abuse, and Malingering

The forensic psychiatric examiner often encounters defendants who deny memory for their offense. Past research proposes a variety of factors to account for offense amnesia. To date there have been few systematic studies of offense amnesia in relation to psychiatric diagnosis, either alone or in combination with other known factors such as substance use and malingering. We studied 53 pretrial felony defendants who had been referred for psychiatric examination; 40% claimed amnesia for their offense. Examinees with psychotic disorders in general, and schizophrenia in particular, were relatively less likely to claim amnesia than were examinees with other diagnoses. Substance use at the time of the offense and associated substance use disorder diagnoses were positively associated with offense amnesia. Malingering diagnosed by general clinical criteria was a poor predictor of amnesia claims. These data suggests that two prominent reasons for referral for forensic psychiatric evaluation include the presence of psychotic symptoms and claims of amnesia for the offense.

Psychiatric morbidity in arsonists referred for forensic psychiatric assessment in Sweden

Little is known about the pattern of psychiatric morbidity in arsonists referred for psychiatric evaluation, and how this compares with other violent offenders. Furthermore, there is uncertainty around whether there are differences in the psychiatric morbidity of female and male arsonists. We investigated all arsonists referred for an inpatient forensic psychiatric examination in Sweden over a five-year period (1997–2001). Diagnostic information was collected on 214 arsonists, of whom 155 were men and 59 women. Principal and comorbid DSM-IV psychiatric diagnoses in these arsonists were compared with those of 2395 other violent offenders who received forensic psychiatric examinations over the same period. We found the most common Axis I diagnoses for individuals convicted of arson and referred for forensic psychiatric evaluation were psychotic illnesses and substance use disorders. Compared with other violent offenders referred for forensic psychiatric examinations, arsonists were more likely to be diagnosed with a learning disability and, in the men, Asperger's syndrome. The pattern of psychiatric morbidity in these arsonists did not appear to differ between women and men. We conclude that the treatment needs of arsonists with psychiatric morbidity primarily relate to psychotic illnesses and substance use disorders. In addition, forensic psychiatric services could consider the involvement of learning disability expertise in meeting treatment needs.

The homicide phenomenon: The role of mental ilness

Background and Aims:The homicide phenomenon is a complex phenomenon that enhances Man complexity. This study aims to contribute to a better understanding of this phenomenon and its protagonists.Methods:Data were collected from clinical records of a Forensic Psychiatry Unit (Magalhaes Lemos Hospital) using a specific clinical protocol, being selected those with “homicide or homicide attempt” as the motive for evaluation.Results and Discussion:The sample was mainly formed by men (94.4%M vs. 5.6%F), with an average age of 37.78 years-old (sd +- 13.63), mostly single (n=25; 53.2%) and unemployed (n=24; 44.4%). The majority of the individuals were detained in a prisional facility (n=35; 64.8%). Thirteen of the victims were first degree relatives to the murderers. Homicide was consumed in 29 cases and in 25 of them it was a failed attempt. Twelve individuals (22.2%) were under suspicion of drug abuse (mainly alcohol) at the moment of the crime. The murderers percentage with psychiatric surveillance was 40.7% (n=22); 90.7% (n=49) had a psychiatric diagnosis and 27.8% (n=15) had a Psychotic Disorder. There were found a significant number of individuals with mental retardation and personality disorder. The conclusion of psychiatric forensic evaluation was “criminal responsibility” in thirty individuals (55.6%). Twenty individuals were considered “not criminally responsible” and psychiatric treatment and security measures were proposed.Conclusions:The homicide act of the individuals proposed for Forensic Psychiatric evaluation seems to be an isolated phenomenon that appears mostly in individuals with mental illness, often those having alcohol abuse or dependence.

Insanity Defense Evaluations: Toward a Model for Evidence-Based Practice

The insanity defense has been described as a symbol of the relationship between law and psychiatry (Stone, 1984b). As such, it has always been the subject of intense legal and public scrutiny, despite the fact that it is infrequently raised and seldom successful. Forensic psychiatrists are often depended upon by the criminal justice system to provide these evaluations, which require a high degree of training and expertise. In 2002, the American Academy of Psychiatry and the Law published it’s Practice Guideline for Forensic Psychiatric Evaluation of Defendants Raising the Insanity Defense (AAPL, 2002). While noting that any attempt to promulgate guidelines will be limited by evolving legal doctrine and psychiatric science, the intent of the guidelines was to describe ‘‘acceptable forensic psychiatric practices.’’

Gender Differences in Diagnoses of Mentally Disordered Offenders

We investigated differences in psychiatric diagnoses and medicolegal insanity decisions between female and male forensic psychiatric patients. Data on all offenders (N = 4396) subjected to a court-ordered forensic psychiatric inpatient evaluation were obtained for the years 1992–2000. A significantly higher proportion of female mentally disordered offenders were given a diagnosis of personality disorder while mentally disordered male offenders more often had a diagnosis of alcohol and/or drug dependence or sexual disorders. There was an increased likelihood that violent women would be declared legally insane even after controlling for a number of potential confounders. This may reflect an underlying difference in the severity of psychiatric morbidity not accounted for diagnostically or that a gender bias exists in the forensic psychiatric evaluation process.

Evidence of gender bias in legal insanity evaluations: A case vignette study of clinicians, judges and students

Forensic psychiatric decision-making plays a key role in the legal process of homicide cases. Research show that women defendants have a higher likelihood of being declared legally insane and being diverted to hospital. This study attempted to explore if this gender difference is explained by biases in the forensic psychiatric assessments. Participants were 45 practicing forensic psychiatric clinicians, 46 chief judges and 80 psychology students. Participants received a written vignette describing a homicide case, with either a female or a male perpetrator. The results suggested strong gender effects on legal insanity judgements. Forensic psychiatric clinicians and psychology students assessed the case information as more indicative of legal insanity if the perpetrator was a woman than a man. Judges assessed offenders of their own gender, as they were more likely to be declared legally insane than a perpetrator of the opposite gender. Implications of and possible ways to minimize such gender biases in forensic psychiatric evaluations need to be thoroughly considered by the legal system.

Aspectos psicopatológicos e forenses de mulheres homicidas com diagnóstico de transtornos psicóticos primários: estudo de série de casos

OBJETIVO: Avaliar amostra de todas as mulheres com diagnóstico de transtorno psicótico primário que receberam medida de segurança e estavam em hospital de custódia e tratamento psiquiátrico em regime de internação (n = 8), em virtude de homicídio ou tentativa de homicídio (artigo 121 do Código Penal Brasileiro). MÉTODOS: Trata-se de um estudo de série de casos. Foi realizado o levantamento retrospectivo de dados por meio de registros periciais e pareceres de equipes de assistência. O diagnóstico psiquiátrico final foi realizado com base na entrevista psiquiátrica e observação dos registros, utilizando-se os critérios diagnósticos do DSM-IV-TR. Houve aplicação de questionário padronizado e escala das síndromes positiva e negativa (PANSS). RESULTADOS: Sete pacientes receberam diagnóstico de esquizofrenia e uma de transtorno esquizoafetivo. A maioria das vítimas (n = 6, 60%) era membro familiar das pacientes. Foi encontrado que 37,5% (n = 3) das pacientes tinham história prévia de comportamento violento. De acordo com a avaliação da perícia psiquiátrica inicial, cinco (62,5%) pacientes da amostra total apresentavam sintomatologia psicótica no momento desta avaliação. As alucinações auditivas foram os sintomas psicóticos mais comuns. CONCLUSÃO: O estudo de fatores motivadores do comportamento homicida pode fornecer conhecimentos para o estabelecimento de intervenções terapêuticas em mulheres com transtornos mentais que apresentem risco para este ou outros comportamentos violentos.