Insight et dangerosité psychiatrique : revue de la littérature

Introduction

Violence committed by individuals with severe mental illness has become an increasing focus of concern among clinicians, policy makers, and the general public, often as the result of tragic events. Research has shown in the past two decades an increased risk of violence among patients with mental disorder. Nevertheless, of those suffering from mental illness, perpetrators of other directed violence form a minority subgroup. The means by which there is this association between mental illness and violence has remained controversial. Factors such as positive psychotic symptoms, medication non-adherence, alcohol or psychoactive substance abuse and antisocial personality were found to be predictive of violence. Overall, literature provides support to the assertion that violent behavior of mentally ill patients is a heterogeneous phenomenon that is driven by multiple inter-related and independent factors. Furthermore, psychiatrists are often asked to predict an individual's future dangerousness, in a medical or a legal context. In the process of risk assessment of dangerousness, more focus has been placed on dynamic risk factor. In this context, lack of insight has established itself both as a part of violence risk models and as a clinical item in structured approaches to measure dangerousness. However, few studies have tested these associations. The main purpose of this paper is to review the literature concerning the relationship between insight and dangerousness and discuss the contributions of the insight in the assessment of dangerousness in patients with mental illness. We included twenty studies that evaluated the association between insight and variable such as physical or verbal violence, aggressiveness, hostility or sexual aggression.

Violent fantasy, dangerousness, and the duty to warn and protect

An evaluation of homicidal ideation is a routine component of a mental status examination and may be evaluated in more depth in forensic evaluations as a dangerousness risk assessment. The evaluation of dangerousness often includes asking about violent fantasies that may have physical or sexual content. The authors examine the circumstances in which the revelation of violent fantasies to a mental health professional may trigger a duty to warn or protect third parties. Legal cases in which violent fantasies were considered in the context of assessing potential dangerousness are reviewed. The research literature on homicidal and sexually violent fantasies in both non-incarcerated and offender populations is examined. No consistent predictive relationship between violent fantasies and criminally dangerous behavior is reported in the available scientific literature. The authors suggest factors that mental health professionals may consider when assessing whether a particular violent fantasy indicates that a patient's thoughts could give rise to a duty.     

Guidelines for developing multidisciplinary treatment plans

The formulation of a multidisciplinary treatment plan is important not only because it is required by federal and accreditation agencies but because it increases communication, consistency, and direction among members of the treatment team. Input from all disciplines is most effectively obtained through the multidisciplinary treatment planning conference. The author provides guidelines for formulating a plan in each of four major steps: assessment, problem identification, planning (including priorities, long- and short-term goals, and interventions), and evaluation.     

La législation actuelle face à l’évaluation des comportements criminels violents : l’urgence d’une réforme

The clinical examination of mental patients committed to specialized hospitals as well as the practice of criminal psychiatric expertise do not at present allow the serious assessment of the dangerousness and risk of violent recidivism. The use of diagnostic and predictive scientific methods has become indispensable. In criminal cases, the expert must also take into account the actual facts of the offense: degree of premeditation, organization of the crime scene, dynamics and typology of violence, relational and environmental context, victimology, judicial information. Traditional psychiatric expertise must now give way to a comprehensive, multidisciplinary criminological form of analysis combining all individual and collective factors of a subjective and objective nature.     

Assessing the reliability,predictive and construct validity of historical,clinical and risk management-20 (HCR-20) in Mexican psychiatric inpatients

Introduction: Assessing dangerousness to gauge the likelihood of future violent behaviour has become an integral part of clinical mental health practice in forensic and non-forensic psychiatric settings, one of the most effective instruments for this being the Historical, Clinical and Risk Management-20 (HCR-20). Objective: To examine the HCR-20 factor structure in Mexican psychiatric inpatients and to obtain its predictive validity and reliability for use in this population. Method: In total, 225 patients diagnosed with psychotic, affective or personality disorders were included. The HCR-20 was applied at hospital admission and violent behaviours were assessed during psychiatric hospitalization using the Overt Aggression Scale (OAS). Construct validity, predictive validity and internal consistency were determined. Results: Violent behaviour remains more severe in patients classified in the high-risk group during hospitalization. Fifteen items displayed adequate communalities in the original designated domains of the HCR-20 and internal consistency of the instruments was high. Conclusion: The HCR-20 is a suitable instrument for predicting violence risk in Mexican psychiatric inpatients.     

The Italian guidelines for early intervention in schizophrenia: development and conclusions

Aim: The effectiveness of early intervention in schizophrenia is still under discussion. The guidelines described in the present paper were aimed at contributing to the current debate by providing Italian practitioners, families, patients and health managers with evidence‐based information on early intervention. They also examined the diagnostic tools that are currently available for assessing different stages of psychotic disorders. Methods: A multidisciplinary panel of experts (the Guidelines Development Group) used a set of key‐questions to develop an explicit search strategy to conduct a systematic review of the literature published from January 2000 to June 2006. Trained personnel then selected papers from those yielded by the literature search. The Guidelines Development Group's final recommendations were scaled according to the Italian National Guidelines System grading system. Results: The evidence available up to the time of the literature search does not allow for recommendation of early intervention targeting prodromal or at‐risk patients to prevent progression from the prodromal phase to acute, full‐blown psychosis, nor to improve prognosis. Conversely, identification and timely treatment of first‐episode psychotic patients through specific early intervention programmes are highly recommended. Conclusions: The Italian Guidelines on early intervention in schizophrenia are based on a comprehensive assessment of an updated, large‐scale body of literature. They draw specific, evidence‐based conclusions to assist clinicians and stakeholders in the planning and implementation of appropriate intervention programmes. Further research is needed to ascertain the effectiveness of early intervention in delaying or preventing the conversion to psychosis and improving prognosis in prodromal or at‐risk patients. Further investigation is also required for first‐episode and critical period patients.     

An overview of juveniles and school violence.

Despite the relative rarity of school shootings, targeted violence, and school-associated violent deaths, any youth who presents with words, gestures, or actions of a threatening or violent nature in a school setting should be assessed and referred for further evaluation by a mental health professional and, if clinically indicated, a forensic evaluator.The request for a juvenile risk assessment for future dangerousness requires careful delineation of role and agency; confidentiality issues; a comprehensive diagnostic evaluation of the youth; and a detailed assessment of the youth's perceived threat or problematic behavior. Various protective and risk factors and consideration of other individual, family, school/peer, and situational factors should also be explored.There is still much information that is unknown when considering school violence or targeted school violence. There is clearly a need for additional research on the identification of at-risk youths, the contributions and significance of various protective and risk factors, the impact of peer relationships, and perceived rejection, socioeconomic status, subtypes of aggression, and developmental stages. Examples of future research direction might include difference by gender, presence of affective or psychotic disorders, substance abuse, emerging characterologic disturbances, and physiologic markers, such as cortisol or serotonin. Additional research regarding best practices and the development of clinical guidelines or practice parameters is also needed.     

Royal Park Multidiagnostic Instrument for Psychosis: Part II. Development, reliability, and validity

The Royal Park Multidiagnostic Instrument for Psychosis is a validity-oriented assessment procedure developed for the acute psychotic episode using serial interviews and multiple information sources. This article describes the development and structure of the RPMIP and reports the findings of an interrater reliability study (n = 50). In addition, results are presented from a study that examined aspects of the procedural validity of the instrument when contrasted with consensus diagnoses made by a team of clinicians applying operational criteria in a less formal way to a common sample of patients (n = 87). Finally, the role of assessment procedures of this type in research into psychiatric disorders is briefly discussed.     

The aggressive child

Acute assessment and management of the aggressive or violent child or adolescent are a challenge for clinicians. Early recognition of signs of impending violence and a clear understanding of the progression of violent behavior are essential to ensure safety of patients and staff. The management of violent and aggressive patients using behavioral interventions tailored to the stage of violence or aggression is critical to reducing the likelihood that the child or adolescent will attack staff or injure self or others. The indications and risks of chemical and physical restraints and hospital standards and guidelines that govern the use of behavioral and experience regarding the prevalence, presentation, and differential diagnosis of psychotic disorders in juveniles. The clinician must rapidly disentangle which elements of the clinical presentation indicate true psychotic thought processes versus elements that represent misunderstood developmentally appropriate phenomena, symptoms of nonpsychotic illnesses, or harbingers of an underlying primary medical illness. A thorough assessment is required before appropriate treatment can begin.     

Emergency psychiatric assessment of violence

OBJECTIVE: The purpose of the study was to 1) ascertain whether there are clinical and demographic characteristics that distinguish dangerous from nondangerous patients evaluated in a psychiatric emergency service and 2) identify variables that distinguish dangerous patients who are hospitalized form those who are not. METHOD: The authors conducted a case comparison study of 99 psychiatric emergency patients whom staff identified as dangerous to others, that is, violent or potentially violent. Clinical staff were interviewed and records reviewed. These data were contrasted with record review data for 95 nondangerous patients. RESULTS: Log linear analysis showed that 1) variables relating to violence in community samples--age, sex, and past history of violence--related minimally or not at all to violence in this sample and 2) disposition to hospital versus community was associated with psychotic mental status and restraint in the psychiatric emergency service. Patients requiring restraint were more likely to have recently committed assault or battery and to have been brought in by the police. CONCLUSIONS: Enduring personal characteristics of patients relate neither to psychiatric emergency service assessments of current dangerousness nor to the decision to hospitalize. These determinations appear to be related to assessments of current patient state and immediate past behavior.     

An inventory for the evaluation of dangerousness in mental patients]

The authors of the article propose an inventory for the systematic assessment of the dangerousness of psychiatric patients. This clinical tool is qualitative and is helpful in a case-by-case approach. The prediction of violent behaviour is discussed; quantitative and qualitative research perspectives are also mentioned.     

On social dangerousness of mental patients

The relationship of the definition of social dangerousness and its application to mental patients is explored from a criminology perspective wherein social dangerousness is described as a universal concept used to assess damage done to society; and a socially dangerous individual is defined as having the potential to commit an offense. The risk of social dangerousness of mental patients is high and typically occurs during the first 4 years of the illness. It is dependent upon complex interactions between psychopathologic phenomena, environmental stimuli, and personality characteristics of the patient; and detection requires a general definition of the dangerous psychotic state and an elaboration of the methods for diagnosis.     

The Early Recognition Inventory ERIraos detects at risk mental states of psychosis with high sensitivity

The identification of patients carrying an increased risk of psychosis is one of the most important demands in schizophrenia research. Currently used diagnostic instruments mainly focus on either attenuated psychotic symptoms and brief limited intermittent psychotic symptoms or solely cognitive basic symptoms. The “Early Recognition Inventory based on IRAOS” (ERIraos) has been developed as a comprehensive assessment of both symptom groups within one scale. We compared the results obtained by ERIraos with an international standard instrument, the “Comprehensive Assessment of At Risk Mental States” (CAARMS) and applied both scales in a sample of 121 outpatients positively tested on a screening checklist for at risk mental states (ARMS). Subsamples were classified as first episode of psychosis, late ARMS with prevalent attenuated psychotic symptoms and/or brief limited intermittent psychotic symptoms, earlier stages of ARMS presenting cognitive basic symptoms as well as a vulnerability group, also differing regarding mean age and psychosocial functioning. Our results point to a higher sensitivity of ERIraos compared to scales that mainly focus on attenuated psychotic symptoms and brief limited intermittent psychotic symptoms. A detailed assessment of cognitive basic symptoms seems to be important in early detection, might be an important focus for therapeutic interventions in ARMS patients and might sustain attempts to alleviate cognitive dysfunction in schizophrenia.     

Critical review of measures of quality of life in schizophrenia

In order to provide clinicians, researchers, program evaluators and administrators with current information on the assessment of humanistic outcomes of services for schizophrenic patients, a literature review is performed in which references to quality of life (QOL) assessment were made in the context of schizophrenia. Measures are summarized according to purpose, content, psychometric properties. Fifteen QOL instruments are summarized and reflect considerable variability on the relevant criteria: 11 are developed for persons with severe and persistent mental illnesses and used among populations including a major part of schizophrenic patients; 3 are specific QOL measures for schizophrenic patients; 1 is a generic QOL instrument used among psychotic patients. Given that none of these QOL measures has been widely used or accepted as a standard, the choice of a measure must rest on the investigator's particular purpose and needs. CONCLUSION: There is a clear need for a QOL instrument that is specific for schizophrenia, given its high prevalence and chronic nature. The lack of information related to responsiveness of these scales stresses the problems of their inclusion in clinical trials. Scales that have been used in studies of schizophrenia were nearly all developed in the United States and the relevance of their content must be questioned. Rather than relying on the literature or experts to determine those needs that are important to patients with schizophrenia, the content of the instrument should be derived from qualitative interviews with patients who are at different stages of their illness. Moreover, the questionnaire should be self-administered.     

A multidisciplinary treatment approach to postpartum psychoses.

Psychosis after childbirth occurs as a result of unique developmental and social demands. The authors have developed a treatment approach for the management of postpartum psychotic mothers admitted with their babies, based on their experience on an acute psychiatric inpatient unit with a special interest in the treatment of postpartum disorders. Five phases of the acute illness and recovery process are outlined. For each phase, a typical clinical situation, the specific tasks of the phase, and special problem areas are presented. The management guidelines are based on a multidisciplinary team and phase-oriented approach.     

Évaluation des besoins des patients et éducation thérapeutique

Therapeutic education aims at helping patients acquire of maintain competencies they need to cope with chronic illness. It goes further than simple information because its objective is to improve autonomy and quality of life, not just treatment observance. Therapeutic education is an important instrument for psychiatric rehabilitation, notably in foster home care. Because of the various possible themes of therapeutic education, our institution worked toward the identification of situation needing a structured program of therapeutic education. A pluridisciplinary group was set up, aiming at building structured therapeutic education programs and following their implementation. This group built a questionnaire for mental health team members, care givers and patients. Mental health team members expressed their views during a focus group. They identified several issues such as: food and overweight, digestive problems, medication side effects, smoking, diabetes. The questionnaire was sent by post to foster caregivers: 63% of them answered. Sixty-four percent of the answers identify one or several problems encountered by patients: lack of information concerning treatment (27%), stress due to vexation (26%), medication side effects (18%), lack of information concerning mental illness (9%). Twenty-four patients were interviewed, expressing their difficulties: over sedation, loneliness and boredom, anxiety, food, information concerning medication and mental illness. Patients expressed specific needs: Food and overweight, information on medication and illness, activities, smoking cessation. This questionnaire, requiring approximately 45 minutes interview, was living positively by patients. This preliminary inquiry led to identification of difficult themes for therapeutic education: medication and illness, smoking, nutritional balance. In order to both identify unmet needs, we decided to use an instrument developed in Lausanne, called ELADEB (Lausanne instrument to evaluate patients’ needs and difficulties)     

Early-onset psychosis in youth with intellectual disability

Background Accurate diagnosis of psychotic disorders may be very difficult in youth with intellectual disabilities. Method The authors reviewed the assessment, treatment and follow‐up of 21 youths with ID referred because of early onset of psychotic symptoms. Results Just over one half of the patients had a diagnosis of schizophrenia or schizoaffective disorder. One third of the sample carried the diagnosis of psychosis NOS (not otherwise specified). After careful review, five out of seven of these psychotic‐like cases were assessed as non‐psychotic. Patients with Psychosis NOS associated with moderate or severe ID had the worst outcome. Conclusion This clinical review provides important information about the identification, diagnosis and outcome of psychotic symptoms in youth with low verbal abilities.     

The INTERMED: a screening instrument to identify multiple sclerosis patients in need of multidisciplinary treatment

OBJECTIVE: To analyse the value of the INTERMED, a screening instrument to assess case complexity, compared with the Expanded Disability Status Scale (EDSS) and the Guy's Neurological Disability Scale (GNDS) to identify multiple sclerosis (MS) patients in need of multidisciplinary treatment. METHODS: One hundred MS patients underwent INTERMED, EDSS, and GNDS examinations. Patient care needs were assessed by a multidisciplinary team and a goal oriented treatment plan was defined. Correlations between INTERMED, individual INTERMED domains, EDSS, GNDS sum score, and total number of proposed disciplines involved in the treatment plan were studied. RESULTS: Mean (SD) age was 40.6 (10.1) years. Median scores were 14.0 for the INTERMED, 4.0 for the EDSS, and 13.5 for the GNDS sum score. Moderate correlations were found between the INTERMED sum score and EDSS (r=0.59) and GNDS sum score (r=0.60). The number of disciplines as proposed by the multidisciplinary team showed the highest statistically significant correlation with the INTERMED sum score (r=0.41) compared with EDSS (r=0.32) and GNDS sum score (r=0.34). No significant or only weak correlations were found between the psychological domain of the INTERMED and EDSS or GNDS. CONCLUSION: The findings in this study show that there is an additional value of the INTERMED compared with the EDSS and GNDS in identifying MS patients in need of multidisciplinary treatment. The INTERMED domains show the area of the patient's vulnerability and care needs: especially the INTERMED's psychological and social domains may guide the clinician to deal with specific problems that complicate healthcare delivery.     

Screening for personality disorder in incarcerated adolescent boys: preliminary validation of an adolescent version of the standardised assessment of personality - abbreviated scale (SAPAS-AV)

ABSTRACT: BACKGROUND: Personality disorder (PD) is associated with significant functional impairment and an elevated risk of violent and suicidal behaviour. The prevalence of PD in populations of young offenders is likely to be high. However, because the assessment of PD is time-consuming, it is not routinely assessed in this population. A brief screen for the identification of young people who might warrant further detailed assessment of PD could be particularly valuable for clinicians and researchers working in juvenile justice settings. METHOD: We adapted a rapid screen for the identification of PD in adults (Standardised Assessment of Personality - Abbreviated Scale; SAPAS) for use with adolescents and then carried out a study of the reliability and validity of the adapted instrument in a sample of 80 adolescent boys in secure institutions. Participants were administered the screen and shortly after an established diagnostic interview for DSM-IV PDs. Nine days later the screen was readministered. RESULTS: A score of 3 or more on the screening interview correctly identified the presence of DSM-IV PD in 86% of participants, yielding a sensitivity and specificity of 0.87 and 0.86 respectively. Internal consistency was modest but comparable to the original instrument. 9-days test-retest reliability for the total score was excellent. Convergent validity correlations with the total number of PD criteria were large. CONCLUSION: This study provides preliminary evidence of the validity, reliability, and usefulness of the screen in secure institutions for adolescent male offenders. It can be used in juvenile offender institutions with limited resources, as a brief, acceptable, staff-administered routine screen to identify individuals in need of further assessment of PD or by researchers conducting epidemiological surveys.