司法精神医学鉴定中的性别差异

目的：了解司法精神医学鉴定中的性别差异。方法：通过回顾性研究,对227例司法精神医学鉴定资料,对其中184例进行统计、比较。结果：女性平均年龄比男性小、女性精神发育迟滞诊断率明显高于男性、男性凶杀、盗窃、伤害案占的比重大,女性性伤害案占的比重大;男性责任能力评定比例明显多于女性,女性行为能力和精神伤害评定比例多于男性;女性完全责任能力评定率高于男性。结论：男性以攻击性案件为主,须加强监管;女性以性伤害案件为主,须加强监护。     

Cause-specific mortality in Finnish forensic psychiatric patients

Purpose: To analyze the causes of mortality among patients committed to compulsory forensic psychiatric hospital treatment in Finland during 1980–2009 by categorizing the causes of mortality into somatic diseases, suicides and other unnatural deaths.

Materials and methods: The causes of mortality were analyzed among 351 patients who died during the follow-up. Standardized mortality ratio (SMR) was calculated as the ratio of observed and expected number of deaths by using the subject-years methods with 95% confidence intervals, assuming a Poisson distribution. The expected number of deaths was calculated on the basis of sex-, age- and calendar-period-specific mortality rates for the Finnish population.

Results: The vast majority (249/351) of deaths were due to a somatic disease with SMR of 2.6 (mean age at death 61 years). Fifty nine patients committed suicide with a SMR of 7.1 (mean age at death 40 years). Four patients were homicide victims (mean age at death 40 years) and 32 deaths were accidental (mean age at death 52 years). The combined homicides and accidental deaths resulted in a SMR of 1.7.

Conclusions: The results of this study point out that the high risk for suicide should receive attention when the hospital treatment and the outpatient care is being organized for forensic psychiatric patients. In addition, the risk of accidents should be evaluated and it should be assured that the patients receive proper somatic healthcare during the forensic psychiatric treatment and that it continues also in the outpatient setting.     

Violence in a Finnish forensic psychiatric hospital

Background: Patients with schizophrenia have a high risk of cardiovascular disease (CVD). High aerobic intensity training (HIT) improve peak oxygen uptake (VO_2peak), net mechanical efficiency of walking and risk factors for CVD but has not been investigated in patients with schizophrenia. Aims: To investigate effects from HIT on VO_2peak, net mechanical efficiency of walking and risk factors for CVD in patients with schizophrenia. Methods: 25 inpatients (F20–29, ICD-10) were allocated to either HIT or playing computer games (CG), 3 days per week for 8 weeks. HIT consisted of 4 × 4-min intervals with 3-min break periods, at 85–95% and 70% of peak heart rate, respectively. Results: 12 and seven patients completed HIT and CG, respectively. The baseline VO_2peak in both groups combined (n = 19) was 36.8 ± 8.2 ml/kg/min and 3.12 ± 0.55 l/min. The HIT group improved VO_2peak by 12% from 3.17 ± 0.59 to 3.56 ± 0.68 l/min (P < 0.001), more than the CG group (P = 0.014). Net mechanical efficiency of walking improved by 12% in the HIT group from 19.8 ± 3.0% to 22.2 ± 4.5% (P = 0.005), more than the CG group (P = 0.031). The psychiatric symptoms, expressed as the Positive and Negative Syndrome Scale (PANSS) and the Calgary Depression Scale for Schizophrenia (CDSS), did not improve in either group. Conclusions: VO_2peak and net mechanical efficiency of walking improved significantly by 8 weeks of HIT. HIT should be included in rehabilitation in order to improve physical capacity and contribute risk reduction of CVD.     

Fratricide: a forensic psychiatric perspective

Analyses of fratricide rates based on national homicide data have provided some general information pertaining to offenders and victims of sibling homicide but are limited by data constraints to examining a few major variables. Exploring fratricide from a forensic psychiatric perspective could uncover other related factors and provide insight into why some individuals murder their siblings. In a retrospective study of data from coroners' files on domestic homicide pertaining to individuals killed by their siblings over a 10-year period in Quebec, Canada, we identified several specific offender and victim characteristics and circumstances surrounding offenses. The impact of mental illness and substance abuse on fratricidal behavior is indicated, underscoring the importance of identifying existing psychopathology. From a forensic psychiatric perspective, we identify characteristic patterns and discuss potential dynamics operating in fratricide. We raise some issues relevant to treatment and prevention, including the fact that most cases are alcohol-related, impulsive, and unpredictable until the moment they occur.     

South Africa: Challenges and successes of the COVID-19 lockdown

At the beginning of March 2020, South Africa (59 million inhabitants) was hit by the pandemic of COVID-19 and soon became the most affected country in Africa by the SARS-CoV-2 virus. From one single case on March 5th, the number of cases increased rapidly, forcing the South-African Government to swiftly react and place the country under strict lockdown for six weeks. The strategy of the South African Government bore fruits with a contained spread of the virus. If the number of positive cases at the end of the lockdown reached 5647, the number of fatal casualties was limited to 103 deaths. The lockdown was overall well respected, even if serious problems of food supply soon occurred in informal settlements, leading to riots and confrontation with security forces. Indeed, populations were obedient, but not being able to practice sport or outdoors activities appeared heavy. The constant fear of the poorest not to have enough money to pay rent and buy food (even if the Government organised food parcels’ distributions), and to find less and less work was echoed by the fear of losing jobs among those more privileged. Despite the risk of an economic crisis, the South African Government has continued on the reasonable path of containing the pandemic with ending the lockdown at a slow pace, in five phases.     

Seclusion practice in a Canadian forensic psychiatric hospital

In this study, seclusion practice was examined in a multilevel, secure psychiatric hospital, serving federally sentenced individuals in the Prairie Region, as defined by the Correctional Service of Canada. Between August 1996 and February 1999, 183 patients (27.7% of total admissions) were secluded on 306 occasions. The mean duration of seclusion was 90.3 hours (minimum I hour; maximum 908 hours). A higher proportion of female patients (60%) was secluded than of male patients (25%). Sixty-five percent of the patients were secluded once, 29.5 percent two to four times, and 5.5 percent more than four times. Suicidal threats and self-harm gestures were the reasons for initiating seclusion in 27.4 percent of cases. Patients with diagnosed substance-related disorders accounted for 40.8 percent of all seclusion episodes, whereas those with schizophrenia and related psychoses accounted for 28.1 percent. These findings suggest that seclusion remains a relatively common intervention in some disturbed patients in a forensic setting.     

法医精神病学鉴定中的精神发育迟滞受害人

目的 探讨法医精神病学鉴定中精神发育迟滞受害人的特征.方法 采用四川大学法医精神病学教研室性自卫能力鉴定案例登记表、大体功能评定量表(GAF)、社会功能缺陷筛选量表(SDSS)、成人智残评定量表(AMDRS),对152例相关案例进行登记评分和统计处理.结果 被害人的文化程度为文盲占53.9%,小学占42.8%.被鉴定的性受害人与被告人相识者占86.8%,发生在被害人家中(38.8%)、被告人家中(27.6%)或野外(21.1%),采取暴力、胁迫(56.6%)或诱骗(40.8%)的方式.受害时完全顺从者52.0%,受害后无所谓者78.3%.精神发育迟滞受害人的平均智商(IQ)为(40.29±11.40),SDSS的平均分数(12.84±2.65).缺乏和无性自卫能力两组比较总智商(t=6.855,P＜0.01)、言语智商(t=6.583,P＜0.01),操作智商(t=4.878,P＜0.01),SDSS评分(t=-6.292,P＜0.01)、GAF评分(t=6.643,P＜0.01)、AMDRS评分(t=-7.397,P＜0.01)间的差异均有统计学意义.结论 MR性受害人受教育程度低,易被熟人胁迫或诱骗,受害时多不知反抗,受害后多表现无所谓,智商低于正常,社会功能受损明显.智商和社会功能与性自卫能力有关,应该作为评定性自卫能力的重要依据.     

The clinical and forensic psychiatric issues of retifism

The literature on the etiological theories, clinical manifestations and treatment of retifism (foot fetishism) and fetishisms in general are briefly reviewed. The case of a 27 year old married male foot-fetishist is presented with emphasis on the psychosexual development leading to the specific sexual deviation. The specific behavioural treatment consisted of covert aversive conditioning using self-reports of sexual urges and psychophysiological monitoring as objective measures of therapeutic change. The theoretical basis for the therapeutic response is discussed.     

1002例服刑人员精神障碍鉴定资料分析

目的 了解服刑罪犯中精神障碍的鉴定情况.方法 整理2003年～2007年的精神医学鉴定资料1002例.结果 发现此类患者受教育程度低,男性罪犯多见,暴力型罪犯为主,青壮年比例最高,慢性起病多见.鉴定构成比依次为精神分裂症及精神病性障碍385例,占38.4%;情感性精神障碍137例,占13.7%;癔症90例,占9.0%;人格障碍84例,占8.3%;应激相关障碍61例,占6.1%;精神发育迟滞60例,占6.0%;颅脑损伤所致精神障碍48例,占4.8%.无精神病63例,占6.3%.其它74例,占7.4%.送鉴原因依次为:言行异常(53.4%),包括自语、傻笑、呆滞、冲动行为;不服从管教、违反监规(50.3%),包括违反劳动、学习纪律、不听从管理和教育;人际交往差(40.2%),平时很少与人交往,不参加群体活动.结论 与一般司法鉴定相比,精神分裂症、精神发育迟滞比例较低,情感性精神障碍、应激相关障碍、人格障碍的比例较多,同时无精神病的结论比例明显较低.此类特殊人群的患者除了普通精神病人的表现外,还具有对象的特殊性和复杂性,要求鉴定人员具有较强的执法意识、严谨的工作作风和扎实的专业技能.     

Community forensic psychiatry: restoring some sanity to forensic psychiatric rehabilitation

OBJECTIVE: To review clinical and legal paradigms of community forensic mental health care, with specific focus on New Zealand, and to develop a clinically based set of guiding principles for service development in this area. METHOD: The general principles of rehabilitating mentally disordered offenders, and assertive community care programmes were reviewed and applied to the law and policy in a New Zealand forensic mental health setting. RESULTS: There is a need to develop comprehensive community treatment programmes for mentally disordered offenders. The limited available research supports assertive community treatment models, with specialist forensic input. Ten clinically based principles of care provision important to forensic mental health assertive community treatment were developed. CONCLUSION: Deinstitutionalization in forensic psychiatry lags behind the rest of psychiatry, but can only occur with well-supported systems in place to assess and manage risk in the community setting. The development of community-based forensic rehabilitation services in conjunction with general mental health is indicated.     

Post-traumatic stress disorder in the forensic psychiatric setting

The objective was to assess the prevalence of post-traumatic stress disorder (PTSD) in offenders who undergo forensic psychiatric evaluation (FPE), compare differences with regard to the prevalence of PTSD between immigrants and Swedes, compare psychiatric comorbidity and offenses between PTSD and non-PTSD patients, and compare various instruments and questionnaires when assessing the level of PTSD symptoms. Twenty-five immigrants and 25 Swedes were studied consecutively. The Clinician-Administered PTSD Scale (CAPS), Impact of Event Scale-22 (IES), Post-traumatic Symptom Scale (PTSS-10), and Structured Clinical Interview for DSM-IV (SCID)-PTSD were administered. In the immigrant group, 60 percent had PTSD, compared with 12 percent of the Swedes. Subjects with PTSD scored higher on IES-22 and PTSS-10 than those without PTSD. Considering the number of sexual and violent offenses together, the proportion of these types of offenses was higher in the PTSD group than in the non-PTSD group.     

Sleep disturbances in a clinical forensic psychiatric population

Objective

Poor sleep is known to cause detrimental effects on the course of diverse psychiatric disorders and is a putative risk factor for hostility and aggression. Thus, sleep may be crucial in forensic psychiatric practice. However, little is known about the prevalence of sleep disturbances in these complex psychiatric patients.

Methods

In this study we investigated the presence of sleep disorders and subjective sleep quality using the Sleep Diagnosis List (SDL), the Pittsburgh Sleep Quality Index (PSQI), interviews addressing the causes of sleep complaints, and file information on sleep medications in 110 patients admitted to a forensic psychiatric hospital.

Results

Almost 30% of the participants suffered from one or more sleep disorders, especially insomnia. An even larger proportion of the participants (49.1%) experienced poor sleep quality. Interestingly, patients with an antisocial personality disorder or traits were particularly dissatisfied with their sleep. The most common causes of sleep problems were suboptimal sleep hygiene, stress or ruminating, negative sleep conditioning, and side effects of psychotropic medication. Of the poor sleepers, 40.7% received a hypnotic drug.

Conclusion

Despite intensive clinical treatment, sleep problems are experienced by a large number of forensic psychiatric patients. It would be worthwhile to examine the effects of pharmacological and non-pharmacological sleep interventions on both psychiatric symptoms and reactive aggressive behavior in forensic patients.     

The presentation of forensic psychiatric evidence in court

After defining the role of expert witness, the article reviews the basics of courtroom testimony under the rubrics of (a) truth (presenting under oath only that testimony that one can "swear to," to a reasonable degree of medical certainty); (b) testing (including both psychological testing and tests to assess admissibility standards); and (c) theater (including elements of drama, solemnity, and ritual as well as persuasiveness to the "audience"). Pathways to effectiveness are discussed, including use of visual materials, adjustment of language level for the jury's comprehension and attention to the narrative dimension of the case. Areas of excluded testimony are identified, such as the "ultimate issue" in the case, comments on credibility of other witnesses and comments on the legal process itself. Pitfalls that lie on the path to effectiveness are described, including narcissistic arrogance, anger, and using testimony in a personal crusade; means of avoiding these pitfalls are noted. The author concludes that effective courtroom testimony fulfills expert witness functions necessary to the legal system.