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PubMed2006

Factors related to hospitalization in elderly manic patients with early and late-onset bipolar disorder.

OBJECTIVE: To identify factors contributing to relapse and hospitalization in elderly patients with bipolar disorder. METHOD: Retrospective chart review surveyed consecutive patients over age 65 admitted to the Johns Hopkins Hospital for a manic episode over a five year period (n=73). Factors precipitating index admission were compared in patients with early-onset bipolar disorder ( age 45, n=35). RESULTS: The distribution of ages of onset of bipolar disorder was most consistent with a bimodal pattern with a cut-point at age 45. Early-onset patients were more likely to have been aggressive and threatening prior to admission (p=0.014) compared to late-onset patients and were more likely to have been brought to the emergency room on emergency petition for evaluation (p=0.028). Early-onset patients were also more likely to have been non-adherent with prescribed psychiatric medication (p=0.032). CONCLUSIONS: Relapse and rehospitalization were common among elderly manic patients with early-onset and late-onset bipolar disorder. Strategies which improve medication adherence are needed to help prevent recurring hospitalization.

Age Factors↗

PubMed1996

The effectiveness of outpatient civil commitment.

The effects of outpatient civil commitment on community tenure and functioning were studied in a group of 20 patients with a history of recurrent hospitalizations, noncompliance with outpatient treatment, and good response to treatment. During the first 12 months of outpatient commitment, patients experienced significant reductions in visits to the psychiatric emergency service, hospital admissions, and lengths of stay compared with the 12 months before commitment. They significantly increased the number of appointments kept with their psychiatrist. It appears that when used judiciously, outpatient civil commitment is a helpful tool in maintaining hospital recidivists in the community.

Adult↗

PubMed2004

Adult psychopathic personality with childhood-onset hyperactivity and conduct disorder: a central problem constellation in forensic psychiatry.

To describe lifetime mental disorders among perpetrators of severe inter-personal crimes and to identify the problem domains most closely associated with aggression and a history of repeated violent criminality, we used structured interviews, clinical assessments, analyses of intellectual functioning, medical and social files, and collateral interviews in 100 consecutive subjects of pretrial forensic psychiatric investigations. Childhood-onset neuropsychiatric disorders [attention-deficit/hyperactivity disorder (AD/HD), learning disability, tics and autism spectrum disorders] affected 55% of the subjects and formed complex comorbidity patterns with adult personality disorders [including psychopathic traits according to the Psychopathy Checklist (PCL-R)], mood disorders and substance abuse. The closest psychiatric covariates to high Lifetime History of Aggression (LHA) scores and violent recidivism were the PCL-R scores and childhood conduct disorder (CD). Behavioral and affective PCL-R factors were closely associated with childhood AD/HD, CD, and autistic traits. The results support the notion that childhood-onset social and behavioral problems form the most relevant psychiatric symptom cluster in relation to pervasive adult violent behavior, while late-onset mental disorders are more often associated with single acts of violent or sexual aggression.

Adolescent↗

PubMed1992

Are pretrial commitments for forensic evaluation used to control nuisance behavior?

The shift to dangerousness-oriented civil commitment criteria has led to speculation that mentally ill persons who do not meet those criteria are being hospitalized under criminal commitment statutes. Using data on patients' psychiatric symptoms at admission to a state hospital in Massachusetts, the authors retrospectively assessed whether patients charged with minor criminal offenses who were committed for evaluation of competence to stand trial would have met civil commitment criteria. The data suggest that most mentally ill patients who were criminally committed could have been civilly committed. However, a relatively greater proportion of persons with substance abuse, mental retardation, or other conditions who did not meet civil commitment criteria for mental illness were committed for pretrial evaluation.

Adult↗

PubMed1993

The PSDA and treatment refusal by a depressed older patient committed to the state mental hospital.

Since 1991, the Patient Self-Determination Act (PSDA) has required all health care institutions that receive Federal funds to inform patients upon admission of their rights to make decisions about medical care and to execute advance directives. Implementation of the PSDA presents a special challenge for state mental hospitals. The relevance and possible negative therapeutic impact of discussing end of life decisions at the time of an acute psychiatric admission has recently been raised in the literature. Other ethical dilemmas arising from the interplay between mental illness and informed consent for medical treatment, particularly for older patients committed to state mental hospitals, have been highlighted by the PSDA. In this article we discuss some of the issues raised by implementation of the PSDA in this setting.

Advance Directives↗

PubMed1991

Competent and incompetent criminal defendants: a quantitative review of comparative research.

Thirty studies comparing competent and incompetent criminal defendants (N = 8,170) were quantitatively reviewed to identify variables associated with judgments about defendants' competency to stand trial. Effect sizes reflecting the magnitude of the relationship between competency status and defendant characteristics were derived and averaged across studies. The characteristics most strongly related to incompetency were (a) poor performance on psychological tests or interviews specifically designed to assess defendants' legally relevant functional abilities, (b) a psychotic diagnosis, and (c) psychiatric symptoms reflective of severe psychopathology. To a lesser degree, traditional psychological tests, previous psychiatric hospitalization, previous legal involvement, marital resources, and demographic characteristics were also related to competency status. Although these results are generally consistent with the legal standard for competency to stand trial, some of the correlates of competency may reflect potential biases in the decision-making process. Limitations of existing research and directions for future inquiry are discussed.

Antisocial Personality Disorder↗

PubMed1991

The case of Valentine Shortis--yesterday and today.

Valentine Shortis, a young Irish immigrant, was convicted of murder in Quebec in 1895. His insanity defence was unsuccessful in spite of psychiatric evidence given by the leading psychiatrists in Canada. Shortis spent the next 42 years in custody. The case provides a good vehicle for exploring a number of aspects of the history of psychiatry, the insanity defence, and the treatment of the criminally insane in Canada. Comparisons are made with the insanity defence and the treatment of the criminally insane today.

Antisocial Personality Disorder↗

PubMed1990

Family members' opinions about civil commitment.

As part of a survey of 260 Oregon family members with mentally ill relatives, respondents were asked about their experiences with civil commitment and their opinions about proposed modifications in the commitment statutes. Family members typically described their mentally ill relative as a schizophrenic man in his thirties who had had six psychiatric hospitalizations and was currently being treated with medications at a community mental health center. Three-fourths of the relatives had been committed. A majority (57 percent) of the respondents were in favor of mandatory outpatient treatment and medication after involuntary hospitalization but were not enthusiastic about outpatient commitment without hospitalization. Family members also wanted more education about mental illness, more information about the commitment process, and assignment of a professional to help in the commitment process.

Bipolar Disorder↗

PubMed1998

Psychiatric impairment, social contact, and violent behavior: evidence from a study of outpatient-committed persons with severe mental disorder.

The need to better understand and manage risk of violent behavior among people with severe mental illness in community care settings is increasingly being recognized, as public-sector mental health systems face mandates to provide more cost-effective services in less restrictive environments. The potential for serious violence in a small proportion of severely mentally ill (SMI) individuals has emerged as a key factor that increases cost and limits continuity and normalization of community-based services for populations with psychiatric disabilities. A major challenge to developing better strategies for risk assessment and management in community care settings involves specifying complex interactions between psychiatric impairment and the conditions of social life--including the quality and frequency of contact with others at close quarters. This is a study of the determinants of violent behavior in a sample of 331 adults with severe mental disorders in community-based treatment. An interaction between severity of functional impairment and frequency of social contact was found to be significantly associated with risk of violence. Among respondents with Global Assessment of Functioning (GAF) scores in the lowest 20%, more frequent contact with family and friends was linked to a higher probability of violent events. However, among better functioning respondents, frequent social contact was associated with lower risk of violence and greater satisfaction with relationships. These findings suggest that, where violence risk is concerned, the most salient feature of psychiatric impairment is the impairment of social relationships--the ways in which disorders of thought and mood not only distort one's subjective appraisal of experience and threat, but impair the ability to relate meaningfully to others, to resolve conflict and derive necessary support from family and friends. Thus, social contact may be a mixed blessing for SMI individuals. For some, it signals a positive quality of life, but for others--particularly those with extreme psychiatric impairment--frequent contact may add to conflict, stress, and increased potential and opportunity for physical violence. The impact of psychiatric impairment on violent behavior cannot be known in isolation, but must be considered in a social context. Effective community-based strategies to anticipate and prevent violence in the lives of persons with severe mental illness must take into account such interactions between social and clinical variables.

Adolescent↗

PubMed1990

Offense type and two-point MMPI code profiles: discriminating between violent and nonviolent offenders.

Offense data and MMPI profiles were examined for 67 men who had been remanded by the courts to a psychiatric hospital forensic unit for pretrial assessment. They were classified as violent or nonviolent offenders based upon the nature of their offenses. Violent offenders were those charged with assault, robbery, sexual assault, and all degrees of homicide. Nonviolent offenders were those charged with break, enter and commit, uttering threats, and fraud. The controversial issue of two-point MMPI code types (4-3, 4-8/8-4) was addressed. Neither of these commonly employed two-point types successfully discriminated between violent and nonviolent offenders.

Antisocial Personality Disorder↗

PubMed1991

The role of the psychiatrist in dangerous offender hearings.

The current Canadian legislation regarding dangerous offenders is reviewed, with specific emphasis on the role of the required psychiatric testimony. It is suggested that, although this legislation as it is currently formulated could be viewed as an attempt to broaden the insanity defence, and permit the diversion of mentally ill offenders from a punitive to a therapeutic milieu, it enables the preventive detention of recidivist offenders. Some fundamental ethical issues which follow from this are identified, together with the issues which have dominated expert testimony in hearings held in British Columbia during the past 13 years.

Antisocial Personality Disorder↗

PubMed1988

Predictors of violence in civilly committed acute psychiatric patients.

The authors investigated the relationship between community violence and violence in the hospital for patients hospitalized through emergency civil commitment. The medical charts of 238 patients involuntarily admitted to a university-based acute inpatient unit were reviewed for evidence of violence during the 2 weeks before commitment and the first 72 hours of hospitalization. Patients who were violent in the community were more likely to be violent in the hospital. A discriminant function analysis was used to identify the combination of information concerning community violence and patient background characteristics that most efficiently predicted which patients were violent during emergency commitment.

Adolescent↗

PubMed2006

Theory of mind in Asperger's syndrome, schizophrenia and personality disordered forensic patients.

INTRODUCTION: The ability to conceptualise other individuals' mental states is dependent on having a 'theory of mind' (ToM). Individuals with Asperger's syndrome typically display ToM impairments, as do some individuals with schizophrenia, notably those with paranoid delusions. The presenting features of these and other individuals, such as those with some personality disorders, particularly in forensic patients, are often unclear. ToM performance was examined to see whether it could distinguish forensic patients with Asperger's syndrome from other patient groups. METHODS: The performance of three male patient groups (N = 39) detained in high security psychiatric care, including those with Asperger's syndrome, schizophrenia (with paranoid delusions and/or auditory hallucinations as their predominant symptoms), or a dissocial and/or borderline personality disorder were compared using the revised eyes task and the modified advanced ToM test. RESULTS: The Asperger's syndrome and schizophrenia groups performed significantly worse than the personality disorder group on both ToM measures. However, the Asperger's syndrome and the personality disorder groups had significantly higher levels of general intellectual functioning than the schizophrenia group. CONCLUSIONS: Whilst ToM performance may help to discriminate patients with Asperger's syndrome or schizophrenia from personality disorder ed patients, a wide range in performance made it difficult to specify a patient to a particular group. Theoretical and methodological issues are discussed along with the usefulness of ToM assessments with forensic patients.

Adult↗

PubMed1996

[Dangerousness prognosis in the clinical context of fulfillment of psychiatric criminal commitment].

The compilation and the reliability-based evaluation of the questionnaire including potentially prognosis-relevant clinical criteria for the release of male patients from rehabilitation and security measure (section 63 German Criminal Code) are presented. The restriction to clinical (rather than social statistical) criteria results in a concentration of the criminal aspects of treatment and/or therapy. The open and, more importantly, the "unconscious" focuses of forensic clinical action become transparent. However, the prognostic constructs of clinicians prove to be somewhat lacking in criteria and rather inconsistent. Until it is validated as a prognostic instrument and integrated in a multidimensional inventory of prognoses, this questionnaire can contribute towards conceptual transparency and help create a better link between treatment and release criteria.

Adult↗

PubMed1989

Psychiatric evidence: a study of psychological issues.

This article discusses the nature of psychiatric evidence in Icelandic criminal proceedings and presents findings from an investigation of the role of amnesia, malingering and overcontrolled hostility among different types of offenders. Amnesia was most common in homicide cases, and was almost invariably associated with alcohol intoxication. An unexpectedly high rate of overcontrolled hostility was found among sex offenders, which may have important theoretical and clinical implications. The results indicate that deliberate faking of an intellectual deficit on psychometric tests occurs rarely in a forensic context.

Adolescent↗

PubMed1993

[Multidimensional personality assessment in penal measures. An evaluation questionnaire as the deciding factor of dangerousness prognosis].

Predicting dangerousness is both the explicit and implicit basis for the decision on derestrictions of penal measures (treatment of mentally ill offenders in psychiatric hospitals). However, recent publications either criticize the validity of the applied criteria or question whether a valid prognosis is in any way possible. Since 1985, the Westfälische Zentrum für Forensische Psychiatrie at Lippstadt has been applying a standardized rating questionnaire to defined derestrictions: The therapeutic team is approaching the prognostic evaluation with multidimensional patient data and ratings. In a population of 263 mentally ill offenders receiving inpatient psychiatric treatment according to section 63 of the German Penal Code (StGB), an interdisciplinary research program used 202 rating questionnaires to investigate the decision-making and prediction criteria of derestriction practice. Empirical data and multivariate statistical analyses revealed that the decisions based on the rating questionnaire were thoroughly explored and responsibly substantiated: The risk in performing derestrictions of penal measures is taken in an calculated and justifiable manner. It is pointed out that the prediction of dangerousness must be considered not only when approving the derestrictions but also during the derestriction itself.

Antisocial Personality Disorder↗

PubMed1990

The attitudes toward committal of patients hospitalized in a psychiatric facility for the first time.

This study examines the attitudes toward committal of patients admitted to a psychiatric facility for the first time. Sixteen patients, from a group of 28 patients consecutively admitted to hospital on an Ontario Form 1 certificate were able to complete a satisfactory interview. In general, patients viewed the committal procedure favourably. They endorsed medical professionals as being best qualified to institute the committal procedure. A discrepancy between behaviour documented on the committal form and the patients' own perception of their mental state at the time of committal was noted. These findings are discussed with reference to previous research on civil commitment.

Adjustment Disorders↗

PubMed1991

Patients who reoffend while on warrants of the Lieutenant-Governor.

Occasionally, psychiatric patients detained in institutions against their will or residing in the community under legal restraints elope and commit serious offenses. The authors looked at the frequency with which this occurred with patients on warrants of the Lieutenant-Governor in Ontario. Using the files of the Ontario Lieutenant-Governor's Board of Review, they examined the records and isolated such recorded incidents over a 16 year period. In spite of the limitations identified by the authors, their findings indicate a lower than expected occurrence. As well, they point to the risk management implications of certain diagnostic groups being treated in a less than secure setting.

Adult↗