Granting Leave to Patients in Bavarian Forensic-Psychiatric Hospitals: A Survey to Describe the Current Process and Develop Guidelines.

Forensic-psychiatric patients reoffending or absconding during the leave granted to them (hereafter referred to as "granted leave") have gained increased attention by researchers and the general public. The patients' right to freedom on the one hand and the need for protection of the general public from serious harm on the other hand represent broadly discussed ethical issues. Thus, demands on quality regarding decisions on patients' granted leaves might be high. Despite such requirements, research on decision-making processes regarding granting leave in forensic psychiatry is very limited and focuses primarily on particular aspects. The present study aims at providing a first overview of the decision-making processes regarding granted leave in forensic psychiatry as a whole. Furthermore, the link between the particular steps of the process and absconding should be explored. In this way, the study results should contribute to provide a theoretical framework for the development of guidelines concerning granted leave in forensic psychiatry. A combination of qualitative and quantitative approaches will be used to collect data: information about risk assessment, decisions on granted leave, and documentation systems in forensic psychiatry will be collected via semi-structured interviews and quantified for further analyses using a checklist developed for this study; data on the implementation of risk assessment tools and documented patient information will be obtained via two self-constructed questionnaires; information about the absolute number of abscondences per hospital will be obtained from the Bavarian Authority for Forensic Commitment. The sample will include staff from all 13 forensic-psychiatric hospitals in Bavaria (Germany) comprising six professional groups: hospital directors, security officers, complementary therapists, psychiatrists, psychologists, social workers, and nursing staff. In each hospital, at least one member of each professional group should participate in the study. In total, 151 interviews will be held. As the study goals are descriptive, there are no pre-formulated hypotheses. Developing guidelines would be the first step towards further standardization of the granted leave decisional process in forensic psychiatry and to make it more transparent for patients, staff members, hospital directors, and the government.

[The forensic preventive outpatient clinic in Ansbach : Evaluation of the model project for treatment of psychiatric risk patients]. / Die forensische Präventionsambulanz Ansbach : Evaluation des Modellprojekts zur Behandlung psychiatrischer Risikopatienten.

BACKGROUND: Patients suffering from severe mental disorders and who have an increased risk of violent behavior, tend to be insufficiently cared for until committing a violent offense leads to compulsory placement in a forensic psychiatric clinic. OBJECTIVE: The concept of the preventive outpatient clinic has been recently published in this journal. The aim of the study was to evaluate whether treatment in the outpatient clinic is preventive with respect to violence and whether there is a positive therapeutic outcome. METHOD: The study design was quasi-experimental and longitudinal. The control group consisted of comparable patients from an adjacent healthcare catchment area. Measurements were taken on admission (t0) and after 6 and 12 months of treatment (t1 and t2, respectively). Dynamic risk factors, i.e. subscales C and R of the history clinical risk-20 version 2 (HCR-20 V2) scale and global assessment of functioning (GAF) scale were used as indicators of treatment success, involving both clinician ratings and self-reports. Multiple imputed data for 70 subjects in the experimental group and 51 in the control group were analyzed by mixed effects models with group as a fixed effect. RESULTS: The interaction effect between time and group was statistically significant for the R (risk management) subscale and the GFA values but not for the C (clinical risk) value (after Bonferroni correction), whereby controls were made for multiple testing. CONCLUSION: The hypothesis with respect to the efficacy of the treatment could be maintained regarding risk markers and global assessment of functioning. With respect to clinical parameters there was a positive tendency in the expected direction. The data therefore indicate a positive effect of the preventive outpatient clinic for the patients treated.

Coercive Sexual Sadism: a Systematic Qualitative Review.

PURPOSE OF REVIEW: Coercive sexual sadism can be distinguished from consensual BDSM (bondage discipline/dominance submission/sadism masochism) role-play and from everyday sadism, a personality trait. The purpose of this paper is to provide a systematic qualitative review of the pertinent literature on coercive sexual sadism from the last three years. RECENT FINDINGS: Clinical assessment of sexual sadism can be made more objective through behavioral checklists based on crime scene actions. The latent structure of sexual sadism is likely dimensional, placing the disorder at the upper end of a continuum of sexually aggressive behavior. Sexual sadism does not seem to increase the risk of violent offense recidivism (including sexual contact offenses) above and beyond the risk implied by established risk factors of delinquency. Coercive sexual sadism denotes a disposition for sexually aggressive behavior. Whether this disposition is put into practice is likely due to other trait and state variables. Treatment studies are completely lacking in the recent literature.

Sadism among sexual homicide offenders: Validation of the Sexual Sadism Scale.

Sexual sadism is assumed to be a crucial factor in sexual homicide. Prevalence estimates vary greatly due to differences in the definition of sexual sadism. A nationwide sample of 350 male perpetrators who had committed a sexual homicide offense against a female 14 years of age or above in England or Wales was assessed based on archival records. Sexual sadism was assessed using the Sexual Sadism Scale (SeSaS). Item response theory (IRT) analyses were conducted focusing on the 2-parameter logistic model. The single-factor structure of the SeSaS Part 1 was tested using confirmatory factor analysis. Estimates of both internal consistency and interrater agreement were satisfactory to substantial. IRT analysis showed that the Part 1 items captured moderate to severe levels of the latent construct (i.e., theta levels >0). Based on the Posterior Probability of Diagnosis index, the prevalence of the disorder was estimated at 37% in the sample. The substantial correlation between the SeSaS Part 1 total score and original clinical diagnoses of sadism confirms the criterion validity of the scale. Exertion of control and infliction of torture were among the more informative items. In sum, the results support the usefulness of the SeSaS instrument for assessing forensically relevant forms of sadism. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Psychopathic men: Deficits in general mental ability, not emotion perception.

Psychopathy is characteristically associated with deficits in emotion perception; however, findings surrounding this deficit are actually quite mixed. This is most likely due to limitations of study methodology, including the use of tasks with unknown or poor psychometric properties, underpowered samples, and a lack of control for third variables. We present a study that addressed these limitations. A sample of men (n = 339) ranging across the psychopathy continuum, recruited in and out of the German prison system, completed three psychometrically validated tasks that assessed the ability to perceive facially expressed emotions. Using latent variable modeling, we show that deficits in emotion perception ability associated with psychopathy are fully attributable to deficits in general mental ability. Modeling relations at the manifest level, separately for inmates and noninmates, support these conclusions. We conclude that emotion general and emotion-specific deficits associated with psychopathy have been exaggerated and instead indicate deficits in general mental ability. (PsycINFO Database Record

Sadism and Violent Reoffending in Sexual Offenders.

A diagnosis of sadism in sexual offenders is commonly regarded as indicative of high risk for violent reoffending. The purpose of the current two studies was to evaluate whether sadism is indeed associated with higher rates of violent (including sexual) reoffending. In Study 1 (meta-analysis), the rate of violent and sexual recidivism was assessed across seven samples of male sex offenders (total N = 2,169) as a function of diagnoses of sexual sadism. In Study 2 (N = 768) the outcome (violent recidivism yes/no) was regressed on sadism, along with behavioral indicators of sexually sadistic offending, and scores from violence risk assessment instruments. In Study 1 (meta-analysis), the overall risk of sadists compared with nonsadists with respect to violent (including sexual contact) reoffending was slightly elevated (by a factor of 1.18), yet not significantly increased. Similarly, the risk of sexual reoffending among sadists was slightly, but not significantly, higher than among nonsadists (factor 1.38). According to Study 2, only a measure of sadistic behavior, not the clinical diagnosis, was associated with violent reoffending. This association, however, was not present once age and customary risk assessment instruments for violence risk were included in the regression. A clinical diagnosis of sexual sadism and behavioral measures of sadism are related to the risk of violent reoffending in sexual offenders. These associations, however, are weak and do not hold once variables relevant for the prediction of violence are controlled for. At the individual level, the risk for future violence in sadists can therefore be adequately described by customary risk assessment instruments.

Variants of psychopathy in adult male offenders: A latent profile analysis.

As measured with the Psychopathy Checklist-Revised (PCL-R), psychopathy is a dimensional construct underpinned by 4 correlated factors: Interpersonal, Affective, Lifestyle, and Antisocial. Theorists and clinicians (e.g., Karpman and Arieti) have posited 2 variants of "primary" or "true" psychopathy, both distinct from so-called "secondary" or "pseudopsychopathy." We used latent profile analysis to determine if homogeneous classes exist within a sample of 1,451 male offenders with high PCL-R scores (≥ 27). The 4 PCL-R factors were the dependent variables for clustering. A solution with 3 latent classes showed a better fit to the data than did a unitary model without latent classes. Tentative labels for the latent classes are Manipulative (Latent Class 1 [LC1]), Aggressive (Latent Class 2 [LC2]), and Sociopathic (Latent Class 3 [LC3]). The latter class represented an antisocial group that lacked the emotional detachment observed in the other 2 groups. We propose that LC1 and LC2 reflect phenotypic variations on a theme of the traditional construct of psychopathy, and that LC3 is consistent with conceptions of antisocial personality disorder and sociopathy. Replication and external classification with an independent data set of 497 adult male offenders again yielded clearly separable clusters, as well as meaningful differences or trends among latent classes on education, intelligence, symptoms of antisocial personality disorder, and self-reported psychopathic traits and negative affect. The conceptualization of psychopathy in terms of manipulative and aggressive variants is consistent with clinical theory and is empirically grounded.

Sadism in sexual offenders: evidence for dimensionality.

Recurrent and intense sexual fantasies and urges that circle around the infliction of pain or humiliation on another human being may predispose individuals toward acts of sexual aggression against nonconsenting victims. Consequently, sexual sadism is a paraphilia with particular relevance for forensic psychology and psychiatry. Using behavioral indicators derived from crime scene actions as well as clinical data, we sought in the present study to identify the latent structure of the disorder. We analyzed data from a national sample of male sexual offenders from Austria (N = 1,020). In addition to latent profile analysis, 3 conceptually different taxometric methods were applied. The results of the analyses were more in accordance with a dimensional interpretation than with a categorical distinction. That is, sadistic conduct in sexual offenses is likely an extreme form of coercion, but not a qualitatively different entity. The implications with respect to the current debate on the diagnostic criteria for sadism are discussed.

Association between brain structure and phenotypic characteristics in pedophilia.

Studies applying structural neuroimaging to pedophiles are scarce and have shown conflicting results. Although first findings suggested reduced volume of the amygdala, pronounced gray matter decreases in frontal regions were observed in another group of pedophilic offenders. When compared to non-sexual offenders instead of community controls, pedophiles revealed deficiencies in white matter only. The present study sought to test the hypotheses of structurally compromised prefrontal and limbic networks and whether structural brain abnormalities are related to phenotypic characteristics in pedophiles. We compared gray matter volume of male pedophilic offenders and non-sexual offenders from high-security forensic hospitals using voxel-based morphometry in cross-sectional and correlational whole-brain analyses. The significance threshold was set to p < .05, corrected for multiple comparisons. Compared to controls, pedophiles exhibited a volume reduction of the right amygdala (small volume corrected). Within the pedophilic group, pedosexual interest and sexual recidivism were correlated with gray matter decrease in the left dorsolateral prefrontal cortex (r = -.64) and insular cortex (r = -.45). Lower age of victims was strongly associated with gray matter reductions in the orbitofrontal cortex (r = .98) and angular gyri bilaterally (r = .70 and r = .93). Our findings of specifically impaired neural networks being related to certain phenotypic characteristics might account for the heterogeneous results in previous neuroimaging studies of pedophilia. The neuroanatomical abnormalities in pedophilia seem to be of a dimensional rather than a categorical nature, supporting the notion of a multifaceted disorder.

Sexual sadism: current diagnostic vagueness and the benefit of behavioral definitions.

The phenomenon of sexual sadism was first scientifically described by Richard von Krafft-Ebing in 1999 as a sexual preference disorder that focuses on the infliction of suffering, pain, or humiliation to achieve sexual gratification. The present article reviews the historical development of the term sexual sadism, including the current descriptive nosology of psychiatric classification. Despite clear definitions that specify the sexual objects, duration, and distress necessary for a disorder, evidence for the diagnostic reliability for sexual sadism in the forensic domain is mixed. We argue that the reliance on the patient's willingness to divulge corresponding violent sexual fantasies is the Achilles' heel of the diagnosis. In an attempt to improve agreement across diagnosticians, we argue for the use of behavioral indicators. We summarize the extant research on the Severe Sexual Sadism Scale (SESAS), which is a file-based observer rating of pertinent crime-scene actions. We conclude that the analysis of crime-scene behavior, as achieved with the SESAS, can provide a useful complement for the clinical diagnosis in forensic psychiatry and psychology.

Computerized assessment of pedophilic sexual interest through self-report and viewing time: reliability, validity, and classification accuracy of the affinity program.

Affinity is a computerized assessment tool that combines viewing time and self-report measures of sexual interest. The present study was designed to assess the diagnostic properties of Affinity with respect to sexual interest in prepubescent children. Reliability of both self-report and viewing time components was estimated to be high. The group profile of a sample of pedophilic adult male child molesters (n = 42, all of whom admitted their offenses) differed from the group profiles of male community controls (n = 95) and male nonsexual offenders (n = 27), respectively. More specifically, both ratings and viewing times for images showing small children or prejuvenile children were significantly higher within the child molester sample than in either of the other two groups, attesting to the validity of the measures. Overall classification accuracy, however, was mediocre: A multivariate classification routine yielded 50% sensitivity for child molester status at the cost of 13% false positives. The implications for forensic use of Affinity are discussed.

Empathy in sexually sadistic offenders: an experimental comparison with non-sadistic sexual offenders.

Previous studies suggest that severe sexual sadism and psychopathy are phenotypically different, although both are characterized by deficits in emotional processing. We assessed empathic capacity in a sample of 12 sexual sadists in comparison with 23 non-sadistic offenders using the Multifaceted Empathy Test (MET). All participants were forensic patients under mandatory treatment orders who had committed sexual offenses. The MET is a computerized rating task that differentiates and measures cognitive and emotional components of empathy, or perspective-taking versus compassionate components. To identify the effects of possible empathy deficits caused by psychopathic traits, we controlled both samples for psychopathy as a covariate, measured by the Psychopathy Checklist-Revised (PCL-R). According to our results, sexual sadists did not differ from non-sadistic sexual offenders with regard to emotional empathy for either positive or negative stimuli. The results suggest that severe sexual sadism is a distinct, pathological sexual arousal response, not a deficit in emotional processing.

The Severe Sexual Sadism Scale: cross-validation and scale properties.

The Severe Sexual Sadism Scale (SSSS) is a screening device for the file-based assessment of forensically relevant sexual sadism. The SSSS consists of 11 dichotomous (yes/no) items that code behavioral indicators of severe sexual sadism within sexual offenses. Based on an Austrian sample of 105 sexual offenders, the present study replicated the 1-dimensional scale structure of the SSSS, as evidenced by confirmatory factor analysis. More specifically, the scale was commensurate with the 1-parameter logistic test model (Rasch model). Reliability was estimated to be good. Criterion validity for the clinical diagnosis of sexual sadism was good. With a cutoff value of 7 points, sensitivity and specificity were estimated at 56% and 90%, respectively.

Functional cortical and subcortical abnormalities in pedophilia: a combined study using a choice reaction time task and fMRI.

INTRODUCTION: Pedophiles show sexual interest in prepubescent children but not in adults. Research into the neurofunctional mechanisms of paraphilias has gathered momentum over the last years. AIM: To elucidate the underlying neural processing of sexual interest among pedophiles and to highlight the differences in comparison with nonparaphilic sexual interest in adults. METHODS: Nine pedophilic patients and 11 nonpedophilic control subjects underwent functional magnetic resonance imaging (fMRI) while viewing pictures of nude (prepubescents, pubescents, and adults) and neutral content, as well as performing a concomitant choice reaction time task (CRTT). MAIN OUTCOME MEASURES: Brain blood oxygen level-dependent (BOLD) signals and response latencies in the CRTT during exposure to each picture category. RESULTS: Analysis of behavioral data showed group differences in reaction times regarding prepubescent and adult but not pubescent stimuli. During stimulation with pictures displaying nude prepubescents, pedophiles showed increased BOLD response in brain areas known to be involved in processing of visual sexual stimuli. Comparison of pedophilic patients with the control group discovered differences in BOLD responses with respect to prepubescent and adult but not to pubescent stimuli. Differential effects in particular occurred in the cingulate gyrus and insular region. CONCLUSIONS: The brain response of pedophiles to visual sexual stimulation by images of nude prepubescents is comparable with previously described neural patterns of sexual processing in nonpedophilic human males evoked by visual stimuli depicting nude adults. Nevertheless, group differences found in the cingulate gyrus and the insular region suggest an important role of these brain areas in pedophilic sexual interest. Furthermore, combining attention-based methods like CRTT with fMRI may be a viable option for future diagnostic procedures regarding pedophilia.

[Schizophrenic diseases, psychosis and homicide: the importance of community psychiatry for the prevention of offences]. / Schizophreniforme Erkrankungen, Psychose und Tötungsdelikte: Die Bedeutung sozialtherapeutischer Maßnahmen zur Prävention von Delikten.

OBJECTIVE: Even though homicides of psychotic patients are relatively rare, they have a great impact on the public opinion about the mentally ill. Current literature indicates that psychotic patients are at an increased risk to commit violent offences. The risk of this group to commit a homicide is even more increased. The question of our study was to find out whether past homicides of schizophrenic patients could have been avoided if treatment had been administered properly. METHODS: Review of 39 homicide cases, committed by patients who had been psychotic during the offence. RESULTS: 10.2 % of the homicides could have been prevented in the absence of mistakes of therapists or legal authorities. Another 15.4 % of the homicides could have probably been avoided in case of communication between the treating therapists and family of the patient previously to the offence. CONCLUSIONS: The whole family of the patient should be involved in the therapy. Possibilities are home visits on the basis of community care. Furthermore, threats of psychotic patients should be taken seriously.

Psychopathy and sexual sadism.

Psychopathic personality disorder and sexual sadism share several common characteristics, such as emotional detachment from the suffering of others or the preparedness to inflict pain or injuries. Based on a sample of 100 male forensic patients (all of them sex offenders, half of them sadistic), the concept of psychopathy and sexual sadism as a unified construct was tested empirically. Pooling indicator variables for psychopathic and sexually sadistic disorders showed that a two-factorial solution yielded a better fit than a single-factor model. The two factors identified psychopathy and sexual sadism as separate latent variables. More specifically, the data were compatible with a path model in which affective deficits and behavioral disinhibition of the psychopathy domain are precursors to sexually sadistic conduct.

A cumulative scale of severe sexual sadism.

The article assesses the scale properties of the criterion set for severe sexual sadism in a sample of male forensic patients (N = 100). Half of the sample consists of sexual sadists; the remainder is sampled at random from the general group of nonsadistic sex offenders. Eleven of 17 criteria (plus the additional item of inserting objects into the victim's bodily orifices) of Marshall, Kennedy, Yates, and Serran's list form a cumulative scale. More specifically, this scale comprises all the 5 core criteria that Marshall and his colleagues considered particularly relevant. The resulting 11-item scale of severe sexual sadism is highly reliable (r(tt) = .93) and represents a strong scale (H = .83) of the Guttman type (coefficient of reproducibility = .97). The 11-item scale distinguishes perfectly between sexual sadists and nonsadistic sex offenders in the sample.

Severe sexual sadism--an underdiagnosed disorder? Evidence from a sample of forensic inpatients.

Severe sexual sadism is a disorder of sexual preference that focuses on humiliation and subjugation of the victim, sometimes causing grievous injury or death. Sexual sadists pose a particular risk. However, the diagnosis as such is unreliable and prevalence estimates vary. In a sample of male high-security forensic inpatients who had committed sexual offenses, we found two-thirds of sexual sadists had not been identified as such prior to commitment. Possible reasons for missing the diagnosis are many fold. Present data support the notion that unrecognized sexual sadists more closely resembled non-sadistic sex offenders than accurately diagnosed sadists. In particular, initially unrecognized sexual sadists had less severe previous convictions, less vocational training, and experienced a less supportive upbringing than their correctly identified sadistic counterparts. The latter, in contrast, more often reached media coverage through their offense(s). We conclude that severe sexual sadism is likely an underdiagnosed, yet forensically highly relevant disorder.