Forensic psychiatry: profiles of two types of sex offenders.

The authors examined records of 239 individuals charged with sexual offenses and referred by the courts to a forensic service. Defendants charged with rape were typically under 30 with histories of antisocial behavior that included other types of violence. Major mental illness was rare in this group. Child molesters in the sample were of no particular age, usually had no history of violent behavior, and had a low incidence of psychosis. The most common secondary diagnosis in both groups was alcohol or drug abuse.     

Course and outcome of drug abuse and medical and social conditions in selected young drug abusers

The course and outcome of drug abuse and medical and social conditions were investigated by following--in some aspects for up to 10 years--selected groups of young drug abusers who had had contact with health care and social welfare authorities in Gothenburg at the end of the 1960's. The follow-up was carried out by studying different registers and through interviews. The abusers were compared with a control group matched in terms of sex, age and daily sickness allowance. Abuse of cannabis predominated (2:1) over heavier drugs (primarily central stimulants i.v.) in the out-patient materials, while the reverse was the case in the in-patient material. About 40% of the drug users were interviewed and judged to be representative of their groups. After 4-6 years, 36-49% of the males and 23-48% of the females in the different materials were found registered as drug abusers; 22-38% of the men and 11-19% of the women were found after 8-10 years. According to the interviews, drug abuse persisted in 56-71% of the men and 26-60% of the women after 4-6 years and in 44-69% of the men and 13-36% of the women after 7-9 years. Abuse of cannabis persisted more often than abuse of heavier drugs, and had a lower mortality. Between 40 and 55% of drug abuse in the out-patient material, as well as among males in the social welfare material, was hidden during the follow-up period. The hidden abuse involved primarily cannabis; abuse of heavier drugs was generally known to the health care or social welfare authorities. Repeated or lengthy sick leave was more common than in the control group. In-patient adult psychiatric treatment was common among those in the health care material, although 40% of those in the social welfare material had also received such treatment. A diagnosis of drug abuse clearly predominated. Treatment of hepatitis was noted for 30-40%. More than 90% of drug abusers were registered with the social welfare authorities compared with less than half of the controls. Possession of driving licence was less common and the males had less often completed basic military training. The majority of those not registered for drug abuse after 4-6 years were employed or studying, and had considerably less need for social welfare and sick leave than those who were registered.(ABSTRACT TRUNCATED AT 400 WORDS)     

Inhalant use, abuse, and dependence among adolescent patients: commonly comorbid problems

OBJECTIVE: Little is known about adolescents with DSM-IV-defined inhalant abuse and dependence. The aim of this study was to compare comorbidity among (1) adolescents with inhalant use disorders, (2) adolescents who reported using inhalants without inhalant use disorder, and (3) other adolescent patients drawn from an adolescent drug and alcohol treatment program. METHOD: The authors examined 847 admissions of patients who had completed structured diagnostic assessments. The three groups were compared for noninhalant substance use disorders, posttraumatic stress disorder, conduct disorder, major depression, previous suicide attempts, and physical/sexual abuse and neglect. RESULTS: Adolescents with inhalant abuse or dependence (group 1; n = 28) were significantly more likely to meet lifetime criteria for abuse or dependence on alcohol, hallucinogens, nicotine, cocaine, and amphetamines, to have had major depression, and to have attempted suicide compared with other adolescent patients who reported never using inhalants (group 3); adolescents with inhalant use disorders also reported significantly more abuse and neglect. Adolescents with inhalant abuse or dependence (group 1) did not differ significantly on any measure compared with adolescents who reported using inhalants without an inhalant use disorder (group 2). CONCLUSIONS: Adolescent patients with a history of inhalant use, abuse, or dependence entering treatment should be carefully screened for noninhalant substance use disorders, major depression, suicidality, and abuse and neglect.     

Childhood emotional abuse, dissociation, and suicidality among patients with drug dependency in Turkey

Aim: The aim of the present study was to determine the prevalence and correlates of dissociative disorders among patients with drug dependency. Methods: The Dissociative Experiences Scale (DES) was used to screen 104 consecutive patients at an addiction treatment center. Thirty‐seven patients who had scores ≥30 were compared with 21 patients who scored <10 on the DES. Both groups were then evaluated using the Dissociative Disorders Interview Schedule and the Structured Clinical Interview for Dissociative Disorders (SCID‐D). The interviewers were blind to the DES scores. Results: Twenty‐seven patients (26.0%) had a dissociative disorder according to the SCID‐D. Dissociative patients were younger than the non‐dissociative group. History of suicide attempt and/or childhood emotional abuse was significant predictors of a dissociative disorder. The majority (59.3%) of dissociative drug users reported that dissociative experiences had existed prior to substance use. More patients in the dissociative disorder than in the non‐dissociative group stopped their treatment prematurely. Conclusion: A considerable proportion of drug users have a dissociative disorder, which may also interfere with treatment process. The relatively young age of this subgroup of patients and frequent reports of childhood emotional abuse underline potential preventive benefits of early intervention among adolescents with developmental trauma history and dissociative psychopathology.     

Longitudinal studies of drug abuse in a fifteen-year-old population. 1. Drug career

A representative, stratified sample from a year cohort of ninth-graders, mostly 15 years of age, examined in 1968 with a questionnaire, was followed over a decade in official registers. After 5 and 8 years, subsamples were also interviewed. During the period in question there was a polydrug abuse pattern in the area of Gothenburg, the second city in Sweden with approx. 450,000 inhabitants. The sample comprised 1,047 individuals and the whole year cohort 5,367. The estimated proportions of registered drug abusers in the cohort were 9% men and 8% women. 3% men and 5% women had drug careers for 2 years or less, 1% men and 0.2% women for 10 years or more. Those who became registered had with few exceptions stated drug use in the school questionnaire or had attended special classes or dropped out of school prematurely. After 5 years 60-80% of the registered abuse remained among the men in these groups and 30-40% among the women. According to interviews abuse remained in 70-90% of men who had admitted drug use in the school survey and in 50-60% of the women from the same groups. According to both registers and interviews intravenous abuse of central stimulants had increased among men but decreased among women. After 11 years, 20-60% of the registered abuse remained in men and 5-60% in the women.     

Health service use among persons with comorbid bipolar and substance use disorders

OBJECTIVE: This study tested the hypothesis that patients with comorbid bipolar and substance use disorders use health services to a greater extent than patients with either bipolar or substance use disorder alone. METHODS: A retrospective chart review was conducted among patients who used health services at the Ralph H. Johnson Department of Veterans Affairs medical center in Charleston, South Carolina, and had bipolar disorder alone, substance use disorder alone, and comorbid bipolar and substance use disorders. Patients with a psychiatric admission between 1999 and 2003 were included in the study. Information was collected on the use of health services one year before and including the index admission. RESULTS: The records of 106 eligible patients were examined for this study: 18 had bipolar disorder alone, 39 had substance use disorder alone, and 49 had both bipolar and substance use disorders. Compared with the other two groups, the group with comorbid bipolar and substance use disorders was significantly more likely to be suicidal. Compared with the group with bipolar disorder alone, the group with comorbid disorders had significantly fewer outpatient psychiatric visits and tended to have shorter psychiatric hospitalizations. Among patients with an alcohol use disorder, those who also had bipolar disorder were significantly less likely than those with an alcohol use disorder alone to have had an alcohol-related seizure. Patients with comorbid bipolar and substance use disorders were significantly less likely than those with substance use disorder alone to be referred for intensive substance abuse treatment, even though both groups were equally likely to enter and complete treatment when they were referred. CONCLUSIONS: Despite significant functional impairment among patients with comorbid bipolar and substance use disorders, they had significantly fewer psychiatric outpatient visits than those with bipolar disorder alone and were referred for intensive substance abuse treatment significantly less often than those with substance use disorder alone.     

Intravenous drug use in alcoholics

The importance of a history of self-administration of drugs intravenously was evaluated in 507 consecutive inpatient male primary alcoholics and primary drug abusers with secondary alcoholism. The subjects were divided into three groups: Group 1 comprised 47 alcoholic men who had primary drug abuse, Group 2 comprised 42 primary alcoholics who used drugs intravenously but did not meet other diagnostic criteria for drug abuse, and Group 3 comprised 418 primary alcoholics who neither met diagnostic criteria for drug abuse nor had taken drugs intravenously. Interviews at the time of entry into the treatment program included the patient and two resource persons; follow-up was complete in 96% of the original sample. Subjects who did not meet research criteria for drug abuse but had taken drugs intravenously more closely resembled the primary drug abusers than they did the primary alcoholics in regard to the course of problems before entering treatment and the 1-year outcome.     

The long-term level of functioning in patients admitted for psychotic disorders with and without substance abuse

The main objective of this study was to compare life skills between psychotic patients with substance abuse problems and psychotic patients without substance abuse problems. This is a cross-sectional study of 48 patients (26 inpatients and 22 outpatients) in a clinic for early intervention in psychosis. Patients were grouped into two categories based on if they had a substance abuse problem or not. Twenty-one (43.8%) had a substance abuse problem and 27 (56.2%) had not. We used several scales to measure substance abuse and the Life Skills Profile to measure aspects of functioning. A parametric test (t-test) was used to compare continuous variables. A non-parametric chi-square test was used to compare frequencies. The self-care subscore and the non-turbulence subscore were higher in the group with psychosis alone. These results were not significant controlling for age. The social contact subscore, the communication subscore, the responsibility subscore and the Life Skills Profile total score did not differ significantly between the groups. The abusers did not differ from the non-abusers in functioning in any area measured.     

Differences in frontal lobe function between violent and nonviolent conduct disorder in male adolescents

Aims:  The objective of the present study was to investigate the differences in frontal lobe function between violent and nonviolent male adolescents with conduct disorder.
Methods:  A total of 309 male adolescents who had been admitted to the Nagoya Juvenile Classification Home participated. The participants were divided into two groups, a violent group composed of individuals who had committed violence against others, and a nonviolent group. The subjects were given the Wisconsin card sorting test (Keio version: KWCST) and the Iowa Gambling task. The presence of violent cases was analyzed in terms of age, family history (crime, drug abuse/dependence, alcohol-related disorder, and psychiatric treatment), experience of being abused by their parents or by the persons who were responsible for raising them, as well as categories achieved (CA) of KWCST (≤4, >4) and total selection of disadvantage cards of Iowa Gambling task (≥50, <50).
Results:  Multivariate logistic regression analyses indicated that a family history of drug abuse/dependence (odds ratio = 0.3, 95% confidence interval = 0.1–0.9) and a CA of the KWCST (odds ratio = 1.8, 95% confidence interval = 1.0–3.1) were significantly associated with violence.
Conclusions:  An impaired rate of CA of the KWCST was related to violence, whereas a family history of drug abuse/dependence was related to nonviolence in male adolescents with conduct disorder.     

Diagnosis of substance abuse in an adolescent psychiatric population

A retrospective study of forty-one consecutively admitted adolescent psychiatric patients who were not referred for substance abuse problems revealed a 71 percent rate of diagnosable abuse. Clinical interview, drug screening, and family history were assessed for their relative contribution to diagnoses. A conduct disorder diagnosis was found to be highly correlated with substance abuse. Both clinical interview and drug screening were found to be useful in diagnosing covert substance abuse. Covert drug abuse is a problem which can be uncovered by a clinical evaluation approach, including systematic clinical interviews and urine drug screening.     

Treating sexual abuse trauma with dually diagnosed women

Women who are diagnosed with a major mental illness, who have a history of drug or alcohol abuse, and who have been episodically homeless are also likely to have been the victims of sexual or physical abuse. Treatment for these women needs to incorporate an active program of trauma recovery. A program of trauma-based treatment that includes supportive group therapy, cognitive reframing, and social skills training is discussed along with clinical examples.     

Longitudinal studies of drug abuse in a fifteen-year-old population. 3. Hidden drug abuse

The hidden drug abuse in a stratified sample of a year cohort born in 1953 was studied by measuring the difference between drug abuse stated in interviews and registered in public health and social welfare files in 1968, 1973 and 1976. Among men who had stated high-frequency drug use in a school questionnaire in 1968 hidden drug abuse comprised two thirds of the total abuse, among women from the same group one half. In groups with lower degrees of abuse hidden drug abuse was 70-90% of the total abuse. Intravenous abuse was mostly known to public health and social welfare authorities. When trying to estimate the total number of drug abusers in an area there is reason to at least double the figures presented in case-finding studies.     

Risk factor characteristics in carers who physically abuse or neglect their elderly dependants

This study investigates the prevalence of, and differences in, risk factor characteristics in a sample of two select populations of carers, one of which physically abused their elderly dependants and one of which neglected them. Nineteen carers (nine who had physically abused and 10 who had neglected their elderly relatives), who were referred to clinical psychology by either their general practitioner or their psychiatrist, were invited to take part in this study. A detailed history of risk factors was obtained, including history of alcohol dependency, type and history of mental ill health, history of maltreatment earlier in life, who they were caring for, how long they had been a carer and whether they felt isolated as a carer. Subjects were then given five assessments to determine whether there were any differences between the two groups. These were the Conflict Tactic Scale, Strain Scale, Beck Depression Inventory, Beck Anxiety Inventory and Cost of Care Index. An examination of the risk factors suggests that heavy alcohol consumption and past childhood abuse by fathers were likely to lead to physical abuse. Significantly higher conflict and depression scores were also present in the physical abuse group, while the neglect group had significantly higher anxiety scores. It is suggested that these findings should be incorporated into an assessment of future risk of abuse or neglect by the carer.     

Suicide attempts of schizophrenia patients: a case-controlled study in tertiary care

BACKGROUND: Schizophrenia is one of the disorders in which suicide attempts and death by suicide are pronounced. However, there is paucity of data regarding suicide attempts by schizophrenia patients. The aim of the present study was to characterize a large sample of schizophrenia patients in tertiary care who had attempted suicide. METHOD: Over a 15-year period all computerized records of admissions of adult schizophrenia patients were examined. Patients who had attempted suicide were defined as the index group and the comparison group was comprised of the next admission of a patient suffering from schizophrenia who did not attempt suicide prior to hospitalization. RESULTS: There were 10,006 admissions of patients suffering from schizophrenia during the study period. Of these, 1094 (10.9%) records comprise the index group (patients who had attempted suicide), 380 women and 714 men, mean age for the group 39.6+/-12.9 years. The comparison group of patients matched for diagnosis (N=1094), consisted of 302 women and 792 men, mean age for this group was 42.9+/-13.7 years. Four variables significantly differentiated between groups. Patients who had attempted suicide were younger (39.6 vs. 42.9 years; p=0.00), higher percentage of females (34.7% vs. 27.6%; p=0.00), with increased rates of co-morbid physical illness (27.5% vs. 20.4%; p=0.00) notably cardiovascular and diabetes and with a higher rate of alcohol and drug abuse (32.1% vs. 12.4%; p=0.00). CONCLUSIONS: The present study emphasizes several significant factors associated with attempted suicide amongst schizophrenia patients notably physical co-morbidity and abuse of alcohol and drugs. These need be integrated into existing risk assessment schemes thus aiding in decreasing adverse outcomes in this vulnerable group of patients.     

Does stimulant treatment place children at risk for adult substance abuse? A controlled, prospective follow-up study

The sensitization hypothesis posits a neuroadaptation model in which exposure to stimulants results in dopamine system alterations that, in turn, increase sensitivity to the reinforcing effects of the previously experienced drug. This study examines whether stimulant treatment in childhood confers increased risk for substance use and abuse in later life, as the model predicts. Children, ages 7-12 years, with developmental reading disorders but no other psychiatric diagnoses were randomly assigned to methylphenidate treatment (n = 43) or matching placebo (n = 66) for 12-18 weeks. At 16-year follow-up (mean age 26 years), 94% of probands and 129 normal comparisons were evaluated by trained clinicians who were blind to group and treatment status. There were no significant differences between groups on the prevalence of substance use disorder (abuse or dependence) for any of the seven drug categories studied. There were no significant group differences among substance abusers regarding age at onset, duration, or number of episodes of substance abuse and dependence. Significantly more normals (60%) than treated (46%) and untreated probands (41%) ever used stimulants in adolescence or adulthood. Findings from this randomized trial contradict the notion that stimulant treatment in childhood leads to substance use or abuse in later life. The sensitization hypothesis is not supported.     

A comparative study of alcoholics and drug addicts in an Arabian Gulf country

Summary On the basis of 110 male patients admitted to the alcohol and drug abuse unit of the psychiatric hospital in Kuwait, a study was made of the inter-relationships between those who abused alcohol, those who abused drugs, and those who abused both. These three groups were compared for age, education, employment record, psychiatric disorders, history of marital problems or parental dysfunction, and organic illness. Findings indicate a correlation between those who abuse both substances and the more severe psychopathological illnesses. Those who primarily abused drugs were found to be younger, probably with a higher level of education, and to exhibit more antisocial behaviour. The alcoholics were older, had a higher divorce rate and demonstrated organic illness with their psychiatric disorder.     

Feasibility of a skills training approach to reduce substance dependence among individuals with schizophrenia

A novel treatment for persons who have both schizophrenia and substance abuse was evaluated by incorporating cognitive-behavioral drug relapse prevention strategies into a skills training method originally developed to teach social and independent living skills to patients with schizophrenia. Thirty-four of 56 patients completed treatment and a three-month follow-up assessment. Participants learned substance abuse management skills and reported that they found the treatment relevant, useful, and satisfying, and their drug use decreased. Improvements were noted in medication adherence, psychiatric symptoms, and quality of life. This manual-driven therapy may play an important role in the treatment of substance abuse among patients with schizophrenia.     

Physical abuse, sexual victimization and illicit drug use: a structural analysis among high risk adolescents

The relationships between child physical and sexual abuse and illicit drug use are relatively unexplored and obscure. Data gathered from a sample of youths in a juvenile detention center permitted an examination of this important issue. A structural model, specifying the influence of child physical and sexual abuse variables on the youths' illicit drug use, directly and as mediated by self-derogation, was estimated among male and female detainees. Results suggest that for both gender groups, sexual victimization had a primarily direct effect on drug use, whereas physical abuse had both a direct and an indirect effect on drug use. The indirect effect of physical abuse on drug use was mediated by self-derogation. Further analysis indicated race did not affect the results. The implications of these results for theory and research on the etiology of drug use and the identification of youths in high risk groups who are likely to become seriously involved in drug use are discussed.     

Follow-up of 97 young non-psychotic male opiate abusers: relationship between achieving abstinence, age, and duration of abuse.

Ninety-seven young non-psychotic men with intravenous opiate abuse, who had been admitted to a psychiatric hospital, were seen at follow-up 3 years after admission. All were traced. At follow-up, 19% were abstinent, 9% had died, whereas the remainder were still addicted. Those who had become abstinent had done so around the age of 20 and/or before they had been addicted to opiate for 3-4 years, almost regardless of the time at which their total drug abuse had started.