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Seasonality of bipolar disorders in a forensic setting.

The authors studied 180 men who were found not guilty by reason of insanity (NGBRI) and committed to a forensic hospital for treatment. The 57 men diagnosed as bipolar disorder committed the crime for which they were found NGBRI (and which was, therefore, the result of mental illness) significantly more frequently during the 6 months August through January. The crimes committed by those in the bipolar group who were 31 years or older showed even seasonality. The crimes committed by the 123 men found NGBRI but not diagnosed as bipolar showed no seasonality. During the past 5 years on the forensic unit, the seclusion time, which was due primarily to manic behavior, was significantly higher during the 4 months December through March. These observations establish a seasonality of mania that appears age-related.

Adolescent↗

Applications for release by Australians in Victoria found not guilty of offences of violence by reason of mental impairment.

Much research in relation to mental illness and the law has concentrated upon when accused persons are entitled to avail themselves of the defence of not guilty by reason of insanity or mental impairment. However, the decision as to when persons found not guilty by such pleas should be released step by step back into the community involves difficult analyses of the risk of recidivism by persons who have committed serious acts of violence whilst mentally ill. This article analyses some 70 cases heard by the Supreme Court of Victoria in Australia since the jurisdiction to make such decisions has been transferred from the executive arm of government to the judiciary. The jurisprudence generated by the Victorian Supreme Court constitutes Australia's most developed law in relation to prediction of dangerousness. This article evaluates the different and subtle dynamics that have influenced the judges in an increasingly sophisticated way to grapple with the phenomenon of mental illness in deciding when persons who have already killed can safely be released from involuntary detention status within the confines of a forensic psychiatric institution back into the general community.

Australia↗

Violent offender research and implications for the criminal justice system.

Some offenders are at very high risk to reoffend. Research conducted at the author's institution and elsewhere shows that psychopathic offenders are especially likely to be violent, that future violence can be predicted with considerable accuracy among men who have committed at least 1 violent offense, and that treatment programs to reduce dangerousness do not always have the intended effects (i.e., they may actually increase the dangerousness of some individuals). Implications for the criminal justice system pertain to release following insanity acquittal, offender sentencing and parole, preventive detention, offender treatment, and program evaluation.

Antisocial Personality Disorder↗

Risk assessment and management: a community forensic mental health practice model.

In Victoria, the Crimes (Mental Impairment and Unfitness to be Tried) Act (1997) reformed legal practice in relation to the detention, management and release of persons found by a court to be not guilty on the grounds of insanity or unfit to be tried. This Act provides a legal structure for such 'forensic patients' to move from secure inpatient facilities into the community. This new legislative landscape has generated challenges for all stakeholders and has provided the impetus for the development of a risk assessment and management model. The key components of the model are the risk profile, assessment and management plan. The discussion comprises theory, legislation, practice implications and limitations of the model. Practice implications concern the provision of objective tools, which identify risk and document strategic interventions to support clinical management. Some of the practice limitations include the model's applicability to risk assessment and management and its dependence on a mercurial multi-service interface in after-hours crisis situations. In addition to this, the paper articulates human limitations implicit in the therapeutic relationship that necessarily underpins the model. The paper concludes with an exploration of the importance of evaluative processes as well as the need for formal support and education for clinicians.

Community Mental Health Services↗

[Does the evaluation of affect crimes deal with a psychopathologic problem?].

The reformulation of the sections 20, 21 StGB (concerning the defense of insanity in the German law) brought a renewed interest in the controversy about the disease concept and the assessment of responsibility in forensic psychiatry. Although the opinions of Kurt Schneider are still very influential, there are competing conceptions based on positions of normal psychology, social psychology or motivational psychology. The controversial issues are discussed and an integrating approach is proposed, though the psychopathological analysis is still regarded as the most important aspect. The question, whether one of the categories of the sections 20, 21 StGB is qualified and whether the intensity of the psychological disturbance indicates a reduced responsibility, must be answered regarding the empirical knowledge of mentally ill, abnormal and sane individuals. Instead of the former concept of disease, which was based on a known or postulated somatic pathology, a psychopathological system of reference for each category of the sections 20, 21 StGB has to be developed for the assessment of the disfunction during the offense. As an example, two catalogues of positive and negative criteria are proposed for the detection of a "profound disturbance of consciousness" in crimes of passion.

Dangerous Behavior↗

Criminal responsibility: an action language approach.

Traditionally, the propositions of psychiatry are said to be in conflict with those of the law since psychiatry assumes a "psychic determinism" and the law assumes freedom of the will (Stone, 1978). An argument always arises over the insanity defense since it bridges psychiatry and the law. But one may hold that there is nothing intrinsic to psychiatry which requires causally stated propositions. By formulating psychiatric propositions in a different form, specifically by adopting the action language of Roy Schafer (1976a), there need be no incompatibility between psychiatric and legal statements about criminal responsibility.

Criminal Psychology↗

Death of a president and his assassin--errors in their diagnosis and autopsies.

On July 2, 1881, Charles Julius Guiteau shot President James Abram Garfield in the right flank. The President died because of infection produced by the unsterile fingers and probes repeatedly inserted into the wound. The major complaint of the wounded President was intractable pain in his legs and feet. This symptom failed to alert the doctors to the possibility of vertebral and spinal cord injury. Garfield died with sepsis after 80 days of intense national concern, and for the patient there was psychological, physical, and nutritional deprivation. His autopsy revealed the bullet was not in the pelvis as his doctors had expected, but adjacent to the first lumbar vertebra it had shattered. The trial and execution of Guiteau split the medical community into those that considered him insane and those who felt execution was justified. Guiteau was delusional and his brain revealed chronic inflammation and histological features suggestive of syphilis. At the time, and since, the propriety of the execution has been questioned.

Autopsy↗

Spitzka and Spitzka on the brains of the assassins of presidents.

Although four American Presidents have been assassinated (Lincoln, Garfield, McKinley, Kennedy), only the assassins of Garfield (Charles Julius Guiteau) and McKinley (Leon Franz Czolgosz) were tried, convicted, and executed for their crime. In 1882 Edward Charles Spitzka, a young New York neurologist with a growing reputation as an alienist, testified at the trial of Guiteau. He was the only expert witness who was asked, based on his personal examination of the prisoner, a direct question concerning the mental state of Guiteau. Spitzka maintained the unpopular view that Guiteau was insane. In spite of aggressive and spirited testimony on Spitzka's part, Guiteau was convicted and hanged. However, even before the execution it was acknowledged, by some experts, that Spitzka was undoubtedly right. About 20 years later, in 1901, Edward Anthony Spitzka, the son of Edward Charles Spitzka, was invited to conduct the autopsy on Czologsz, the assassin of McKinley. At the time Spitzka the younger, who had just published a detailed series of papers on the human brain, was in the fourth year of his medical training. It was an unusual series of fortuitous events that presumably led to Edward A. Spitzka conducting the autopsy on the assassin of the President of the United States while still a medical student. This, in light of the fact that other experts were available. Each Spitzka went on to a career of note and each made a number of contributions in their respective fields. It is however, their participation in the 'neurology', as broadly defined, of the assassins of Presidents Garfield and McKinley that remains unique in neuroscience history. Not only were father and son participants in these important events, but these were the only times that assassins of US Presidents were tried and executed.

Autopsy↗

William A. Hammond, the dynamograph, and bogus neurologic testimony in old New York.

April 25, 1870, court of General Sessions, New York City, Doctor William A. Hammond, neurologist and former Surgeon General of the United States Army, testified at the trial of his patient Daniel McFarland. McFarland had fatally wounded famous journalist Albert Richardson in November of 1869. Dr. Hammond said McFarland suffered from temporary insanity due to cerebral congestion from over use of the brain. Hammond told the jury he had, "devoted the last five years of his professional life exclusively to the study of the mind", and opined that the evidence of cerebral congestion was profound: McFarland's head was hot, and his carotid throbbed. The proof came from the test with the dynamograph machine: McFarland could not keep a pencil still to trace a straight line in the center of a moving piece of paper. The dynamograph, Dr. Hammond assured the jury, measured the power of a man over his will and thus provided "full and decided evidence" there can be no doubt that McFarland "could not control his will". What were the motivations behind the testimony of this famous expert witness? Did bogus neurologic testimony exist in old New York over a century before our time?

Equipment and Supplies↗

Court diversion in perspective.

Court diversion schemes have been running for a decade in New Zealand and are increasing in number in Australia. This paper aims to give an international and historical context to these developments, by reference to psychiatric initiatives at courts in the US and in England and Wales. From a review of the specialist literature, an account is given of three forms of psychiatric intervention in courts over the last 90 years: court psychiatric clinics and mental health courts in the US, and court diversion schemes in England and Wales. High levels of psychiatric morbidity among prisoners, coupled with a continuing increase in prisoner numbers, demonstrate the need for systems for dealing with mentally ill people who come before the courts. Court diversion in England and Wales developed as part of a system where the mentally ill who are found guilty are sent to hospital in lieu of any other sentence. Its focus is on a form of psychiatric triage, and its ethos is the health of the patient. Court psychiatric clinics in the US grew up as an alternative to assessment in prison. Their focus has been on full psychiatric evaluation in an insanity and incompetence jurisdiction. The ethos has been that of serving the court. Mental health courts are heavily influenced by ideas of therapeutic jurisprudence, and their emphasis has been on a judge holding minor offenders in community care through the threat of judicial sanction. Experience in England and Wales has shown that court diversion can be a powerful and effective intervention. In order for it to function properly, those running court schemes need direct admission rights to psychiatric beds, both open and locked. Court diversion schemes are best as part of a spectrum of services to police stations, courts and prisons, which involved both general and forensic psychiatrists.

Ambulatory Care Facilities↗

Treatment of forensic patients: an expanding role for public psychiatric hospitals.

This article explores the increased role of state-operated public psychiatric hospitals in treating forensic patients. Patients with a forensic legal status have a mental illness and are involved with the criminal justice system. Using data from Missouri's forensic system, the article compares the characteristics of voluntary hospital patients with those of the largest hospitalized group of forensic patients--those found not guilty by reason of insanity (NGRI). Overall, NGRI patients tended to be higher functioning, less likely to have committed assaultive acts, and more likely to have substance abuse and personality disorder diagnoses. The article explores the treatment needs of forensic patients who reside in public psychiatric hospitals and discusses the effect of the strong presence of forensic patients in public psychiatric hospitals on social work practice, including clinical work with forensic patients, social work administration, and social work advocacy.

Criminal Law↗

Clinical predictors of self-mutilation in hospitalized forensic patients.

This study evaluated the clinical correlates and inpatient course of self-mutilation in a diagnostically diverse sample of hospitalized forensic patients. Fifty-three male forensic inpatients, treated in a maximum-security hospital, who engaged in at least one instance of self-mutilation during a 2-year period, were studied and compared with 50 male forensic patients at the same hospital who had not engaged in self-mutilation. Self-mutilating patients were younger, more likely to carry a diagnosis of personality disorder or mental retardation, engaged in more outwardly directed aggressive behavior as assessed by the Overt Aggression Scale, were treated with substantially higher doses of neuroleptics, and were more likely to be civil or correctional patients than insanity acquittees. The two groups did not differ on variables such as history of suicide, history of violence, neurological characteristics, and other demographic variables. After an incident of self-mutilation, the probability of recurrence was high. The substantially higher level of outwardly directed aggression of self-mutilating patients, along with their higher apparent need for neuroleptization and the high risk of recurrence of the self-mutilation, suggest that they are a subset of violent individuals who are relatively unresponsive to treatment and who are dangerous to self and others.

Adult↗

Culture, law and psychiatry in Hawaii.

Hawaii is a set of islands with a broad mix of cultures. The law is American, but it was predominantly derived from English Common Law. Thus, the law is derived from a very distant culture. Theoretically, this 'transplanted' law could cause difficulties for people from Pacific cultures. Indeed, it appears to create difficulties for individuals with mental illness. A substantial number of these people are arrested for disobedience of a law that is not sensible for their culture. This problem is an example of the need for cultural knowledge when a psychiatrist conducts an examination for the legal system. An individual may appear legally guilty or medically insane when acting within cultural norms.

Adult↗

Psychiatric court reports in Iceland 1970-1982.

This paper looks closely at psychiatric court reports in criminal cases in Iceland. Psychiatric court reports are in the great majority of cases requested by the State Criminal Investigation Police (SCIP) on behalf of the court in major criminal cases (e.g. homicide, sexual offences, arson, physical assault). Reports are very rarely requested by the defence. During the 13-year period 1970-1982 there were 97 requests for psychiatric reports by the police/court (i.e. an annual rate of about 7.5 reports). About two-thirds of the defendants were found to have some psychiatric abnormality, although only a minority (8%) were considered criminally insane at the time of the offence. Psychiatric reports were most often requested to assess criminal responsibility, and, to a much lesser extent, sentencing issues. Psychiatric experts almost never have to present their evidence in person in court, nor are they cross-examined on their evidence. This paper discusses some of the strengths and limitations of psychiatric evidence in Iceland, and the need for an organized forensic service.

Criminal Psychology↗

Actions, causes, and psychiatry: a reply to Szasz.

In a recent paper, it was argued forcefully by Thomas Szasz that it is crucial to the scientific credibility of psychiatry that it abandon talk of the behaviour of the mentally "ill" in terms of causes: such behaviour is not caused by their condition--it simply has reasons, which are discounted by the medical model. It is argued in this paper that Szasz's theory is incomplete for two reasons: first, in assuming that reasons are radically different from causes, it cannot account for the possibility that "sane" behaviour might be just as much caused as "insane"; and second, it tacitly assumes that the origin of behaviour always lies with the agent--a view that arguably is an accident of grammar. Hence while there is no mental illness, this is because there is nothing that could be ill--and this means that there is no such thing as mental "health" either.

Attitude to Health↗

Acquired sociopathy and frontotemporal dementia.

BACKGROUND: It is not understood why some patients with frontotemporal dementia (FTD) manifest sociopathic behavior. OBJECTIVE: To examine the prevalence and characteristics of sociopathic behavior in FTD patients as compared to those with Alzheimer's disease (AD). METHODS AND PARTICIPANTS: We surveyed a group of FTD patients and a group of AD patients for sociopathic behavior, evaluated the characteristics surrounding their acts, and compared the groups on neuropsychological tests and functional neuroimaging. Twenty-eight outpatients with FTD (15 men, 13 women; 61.9+/-7.1 years; Mini-Mental State Examination score 23.6+/-8.1) were compared with 28 patients with clinically probable AD (13 men, 15 women; 66.1+/-9.2 years; Mini-Mental State Examination score 21.3 +/- 5.3). Main outcome measures included: (a) the prevalence of sociopathic acts; (b) a structured interview; (c) neuropsychological tests including the Frontal Assessment Battery, and (d) clinically obtained positron emission tomography or single photon emission tomography scans. RESULTS: Sixteen (57%) of the FTD patients had sociopathic behavior compared to two (7%) of the AD patients (chi(2)=13.84, p<0.001). Sociopathic acts among FTD patients included unsolicited sexual acts, traffic violations, physical assaults, and other unacceptable behaviors. On interview, the FTD patients with sociopathic acts were aware of their behavior and knew that it was wrong but could not prevent themselves from acting impulsively. They claimed subsequent remorse, but they did not act on it or show concern for the consequences. Among FTD patients with sociopathy, neuropsychological assessment showed impaired motor inhibition, and functional neuroimaging showed right frontotemporal involvement. CONCLUSION: The results suggest that sociopathy in FTD results from a combination of diminished emotional concern for the consequences of their acts and disinhibition consequent to right frontotemporal dysfunction. In many jurisdictions, FTD patients with sociopathy would not pass legal criteria for 'not guilty by reason of insanity'.

Aged↗

Liability of the mentally ill and their insurers in negligence and other civil actions.

Although familiar with the insanity defense, psychiatrists know little about the liability of mentally ill persons in civil actions or the secondary liability of their insurers. Generally the mentally ill are responsible civilly for their actions regardless of mental state except where the law requires specific intent and the illness negates such intent. Psychiatrists and other mental health workers may thus have grounds for suit against patients who injure them. While insurance coverage may exclude intentional acts, insurers may be civilly liable, even for blatant criminal acts. The author reviews the relevant laws and presents illustrative case examples.

Criminal Law↗

Psychiatry and the criminal justice system: testing the myths.

Several states are changing legislation and treatment programs for mentally ill offenders without knowing how current laws and programs operate. To address this problem the authors linked data from police records, court reports, and clinical files for 2,735 psychiatric referrals from the criminal justice system of Alaska from 1977 through 1981. They found that only 0.2%-2.0% of all schizophrenic persons in the community were arrested for violent crimes each year, accounting for 1.1%-2.3% of all arrests for violent crimes; that psychiatrists agreed about competency and responsibility in 79% of the cases evaluated by more than one clinician; and that a successful insanity defense occurred in 0.1% or less of all criminal cases.

Adolescent↗