[The situation in the German forensic commitment-Results of a survey by the DGPPN]. / Die Situation des deutschen Maßregelvollzugs ­ Ergebnisse einer Umfrage der DGPPN.

BACKGROUND AND OBJECTIVE: In German forensic psychiatry detention under Sections 63 and 64 of the German Penal Code have been repeatedly reformed over the past years; however, despite the most recent amendments to the law on detention, clinics and state authorities warn of insufficient capacities and worrying conditions. Media reports paint a defiant picture. At the same time, there is a lack of valid data that would allow an objective description of the situation in forensic psychiatry. Against this background the management of institutions in Germany has been surveyed. MATERIAL AND METHODS: The survey was conducted as an online survey and sent to all 78 forensic hospitals in Germany. The survey covered topics such as structural data of the facilities, the occupancy and staffing situation, incidents, support from supervisory authorities and funding agencies, and patient characteristics. The results are presented descriptively. RESULTS: Of the 78 facilities contacted, 45 (approximately 60%) participated at least partially in the survey. Many of the clinics (68.5%) complained of significant overcrowding. A clear lack of staff and rooms was reported, at the same time it was stated that patients do not receive adequate treatment. Approximately 1 in 5 patients have a length of stay for more than 10 years and one third of the clinics reported an increasing number of physical assaults by patients. CONCLUSION: This overview shows that the forensic psychiatric hospitals are in very different but generally strained situations. A significant number of clinics are under great pressure. Financial, structural, spatial and personnel resources were described as insufficient to properly and professionally fulfill the legal mandate. The treatment standards presented by the DGPPN in 2017 are not met in many clinics.

Widespread and interrelated gray matter reductions in child sexual offenders with and without pedophilia: Evidence from a multivariate structural MRI study.

AIM: To further investigate the neuroanatomical correlates of child sexual offending and disentangle them from the neural correlates of pedophilia, using a multivariate analytical approach in order to minimize loss of statistical power. METHODS: This study presents structural MRI data on gray matter in an incarcerated, male population of 22 pedophilic and 21 non-pedophilic child sexual offenders, and 20 violent non-sexual offender controls, based on a multivariate whole-brain approach using source-based morphometry. RESULTS: We identify a network of several neuroanatomical regions exhibiting interrelated reduced gray matter in both child sexual offender groups relative to controls, comprising extensive clusters in the bilateral cerebellum and frontal lobe, as well as smaller clusters in the bilateral parietal, temporal, and occipital lobes, the bilateral basal ganglia, the medial cingulate and the hippocampus. CONCLUSION: Our results speak to the interpretation that there are inter- and possibly connectivity-related brain structural abnormalities in child sexual offenders that are not (only) pertaining to pedophilia per se. Interpretations and limitations of the present data are discussed and recommendations for future works are given.

[Revision of §64 of the German Penal Code from a psychiatric perspective-Position paper of a task force of the German Association for Psychiatry, Psychotherapy and Psychosomatics]. / Neuregelung des § 64 StGB aus psychiatrischer Sicht ­ Positionspapier einer Task-Force der DGPPN.

In Germany every second offence occasioning bodily harm and every fourth sexual offence occur under the influence of alcohol or drugs. Untreated substance use disorders are a risk factor for further offences. The §64 of the German Penal Code (StGB) regulates the commitment of offenders to a Forensic addiction treatment unit as a result of an addiction to excessive consummation of intoxicating substances. The previous regulation has come under criticism because too many patients are committed, the sentence is often given to the wrong persons, the treatment is often terminated without success and the sentence consumes to many resources. From a psychiatric perspective the reform of commitment to a Forensic addiction treatment unit (§64 StGB) must fulfil the principles of medical ethics, in particular the respect for the autonomy of the patient, the principle of distributional justice and the code of medical professional ethics. The commitment according to §64 must be restricted to the treatment of people with a clinically relevant substance use disorder. From a psychiatric perspective, decisive for the prospect of success are the willingness to be treated and self-determination for admission to the clinic. In order to release the treatment from the extrinsic influences of the enforcement law, on admission to treatment a sufficient amount of the sentence should have already been served that the commitment only serves the purpose of the treatment and resocialization, so that the risk of further substance-related offences is reduced. The legal term "Entziehungsanstalt" should be replaced by "Forensic Clinic for Dependancy Diseases".

[The expert in criminal and enforcement proceedings: Mission, qualification, delimitation of competence]. / Der Sachverständige im Straf- und Vollstreckungsverfahren. Auftrag, Qualifikation, Kompetenzabgrenzung.

Die Rolle von Sachverständigen im Erkenntnis- und Vollstreckungsverfahren wurde mit der Novellierung des Rechts der Unterbringung in einem psychiatrischen Krankenhaus erneut gestärkt. Sachverständige verfügen über ein spezifisches Fachwissen und haben insoweit eine Garantenstellung gegenüber dem Gericht. Dieses interdisziplinäre Zusammenwirken birgt Gefahren, die zu kritischem und die Fach- und Kompetenzgrenzen wahrendem Zusammenwirken führen müssen. Kompetenzüberschreitungen und Grenzverletzungen können zu Eingriffen in die Grundrechte von Betroffenen führen, die auch haftungsrechtlich relevant werden können. Im Folgenden werden die Rahmenbedingungen der interdisziplinären Zusammenarbeit und insbesondere die Bedeutung der Kompetenzentrennung in foro verdeutlicht.

Violent aggression predicted by multiple pre-adult environmental hits.

Early exposure to negative environmental impact shapes individual behavior and potentially contributes to any mental disease. We reported previously that accumulated environmental risk markedly decreases age at schizophrenia onset. Follow-up of matched extreme group individuals (≤1 vs. ≥3 risks) unexpectedly revealed that high-risk subjects had >5 times greater probability of forensic hospitalization. In line with longstanding sociological theories, we hypothesized that risk accumulation before adulthood induces violent aggression and criminal conduct, independent of mental illness. We determined in 6 independent cohorts (4 schizophrenia and 2 general population samples) pre-adult risk exposure, comprising urbanicity, migration, physical and sexual abuse as primary, and cannabis or alcohol as secondary hits. All single hits by themselves were marginally associated with higher violent aggression. Most strikingly, however, their accumulation strongly predicted violent aggression (odds ratio 10.5). An epigenome-wide association scan to detect differential methylation of blood-derived DNA of selected extreme group individuals yielded overall negative results. Conversely, determination in peripheral blood mononuclear cells of histone-deacetylase1 mRNA as 'umbrella mediator' of epigenetic processes revealed an increase in the high-risk group, suggesting lasting epigenetic alterations. Together, we provide sound evidence of a disease-independent unfortunate relationship between well-defined pre-adult environmental hits and violent aggression, calling for more efficient prevention.

Virtual reality applications for diagnosis, risk assessment and therapy of child abusers.

Despite the successful application of virtual reality (VR) in a wide variety of mental disorders and the obvious potentials that VR provides, the use of VR in the context of criminology and forensic psychology is sparse. For forensic mental health professionals, VR provides some advantages that outrun general advantages of VR, e.g., ecological validity and controllability of social situations. Most important seems to be the unique possibility to expose offenders and to train coping skills in virtual situations, which are able to elicit disorder-relevant behavior-without endangering others. VR has already been used for the assessment of deviant sexual interests, for testing the ability to transfer learned coping skills communicated during treatment to behavior, and for risk assessment of child abusers. This article reviews and discusses these innovative research projects with regard to their impact on current clinical practice regarding risk assessment and treatment as well as other implementations of VR applications in forensic mental health. Finally, ethical guidelines for VR research in forensic mental health are provided.

Neural correlates of subliminally presented visual sexual stimuli.

In the context of forensic psychiatry, it is crucial that diagnoses of deviant sexual interests are resistant to manipulation. In a first attempt to promote the development of such tools, the current fMRI study focusses on the examination of hemodynamic responses to preferred, in contrast to non-preferred, sexual stimuli with and without explicit sexual features in 24 healthy heterosexual subjects. The subliminal stimulus presentation of sexual stimuli could be a new approach to reduce vulnerability to manipulation. Meaningful images and scrambled images were applied as masks. Recognition performance was low, but interestingly, sexual preference and explicitness modulated stimulus visibility, suggesting interactions between networks of sexual arousal and consciousness. With scrambled masks, higher activations for sexually preferred images and for explicit images were found in areas associated with sexual arousal (Stoleru, Fonteille, Cornelis, Joyal, & Moulier, 2012). We conclude that masked sexual stimuli can evoke activations in areas associated with supraliminal induced sexual arousal.

[Failure of a study in forensic psychiatric hospitals : Clinical trial to investigate the additive effect of triptorelin on the efficacy of psychotherapy]. / Vom Scheitern einer Studie in Maßregelvollzugskrankenhäusern : Klinische Prüfung zum additiven Effekt von Triptorelin auf die Wirksamkeit von Psychotherapie.

BACKGROUND: A testosterone-lowering medication is relatively commonly used as a form of treatment for sexual offenders with severe paraphilic disorders in German forensic psychiatric hospitals; however, a double-blind, controlled and randomized study, which investigates the efficacy of this medication, is still lacking. AIM: This article describes the process from the planning to the rejection of a clinical trial over the period from 2009 to 2015. METHODS AND RESULTS: Despite the careful planning with an interdisciplinary team and giving special consideration to the complex legal situation, the Federal Institute for Drugs and Medical Devices (BfArM) rejected the proposed trial in a brief formal letter with reference to the German Drug Law (§ 40 para. 1 p. 3 nr. 4 AMG). The ethics committee of the Hamburg Medical Association considered that clinical research is basically not possible with patients detained in a forensic psychiatric hospital. DISCUSSION: In the opinion of the authors, the described facts illustrate how legal regulations that should protect vulnerable groups in medical research, in a specific case can lead to the fact that a therapy form relevant to the corresponding patient group cannot be scientifically investigated.

[Treatment structures for men with pedosexual problems]. / Versorgungsstrukturen für Männer mit pädosexueller Problematik.

Pedophilia is defined as a persistent or dominating sexual preference for prepubescent children characterized by persistent thoughts, fantasies, urges, sexual arousal and behavior. Less than 50% of all child abusers fulfill the diagnostic criteria and an even smaller part exclusively has a preference for children. Following psychiatric classification systems, pedophilia must be distinguished from child sexual abuse. Outpatient treatment and treatment in forensic psychiatry clinics, sociotherapeutic facilities and in correction facilities are different aspects of prevention. So-called grey area projects (Dunkelfeldprojekte) are special facilities of primary and secondary prevention. The aim is to prevent sexual abuse by reducing and controlling of risk factors.

Changed processing of visual sexual stimuli under GnRH-therapy--a single case study in pedophilia using eye tracking and fMRI.

BACKGROUND: Antiandrogen therapy (ADT) has been used for 30 years to treat pedophilic patients. The aim of the treatment is a reduction in sexual drive and, in consequence, a reduced risk of recidivism. Yet the therapeutic success of antiandrogens is uncertain especially regarding recidivism. Meta-analyses and reviews report only moderate and often mutually inconsistent effects. CASE PRESENTATION: Based on the case of a 47 year old exclusively pedophilic forensic inpatient, we examined the effectiveness of a new eye tracking method and a new functional magnetic resonance imaging (fMRI)-design in regard to the evaluation of ADT in pedophiles. We analyzed the potential of these methods in exploring the impact of ADT on automatic and controlled attentional processes in pedophiles. Eye tracking and fMRI measures were conducted before the initial ADT as well as four months after the onset of ADT. The patient simultaneously viewed an image of a child and an image of an adult while eye movements were measured. During the fMRI-measure the same stimuli were presented subliminally. Eye movements demonstrated that controlled attentional processes change under ADT, whereas automatic processes remained mostly unchanged. We assume that these results reflect either the increased ability of the patient to control his eye movements while viewing prepubertal stimuli or his better ability to manipulate his answer in a socially desirable manner. Unchanged automatic attentional processes could reflect the stable pedophilic preference of the patient. Using fMRI, the subliminal presentation of sexually relevant stimuli led to changed activation patterns under the influence of ADT in occipital and parietal brain regions, the hippocampus, and also in the orbitofrontal cortex. We suggest that even at an unconscious level ADT can lead to changed processing of sexually relevant stimuli, reflecting changes of cognitive and perceptive automatic processes. CONCLUSION: We are convinced that our experimental designs using eye tracking and fMRI could prospectively add additional and valuable information in the evaluation of ADT in paraphilic patients and sex offenders. But with respect to the limited significance of this single case study, these first results are preliminary and further studies have to be conducted with healthy subjects and patients.

Acceptance of a Web-Based Intervention in Individuals Who Committed Sexual Offenses Against Children: Cross-Sectional Study.

BACKGROUND: Individuals who have committed sexual offenses against children often have difficulties finding treatment, despite its potential effectiveness. Although the development of web-based interventions could enhance therapeutic supply, up to now the acceptance thereof among this target group is unknown. OBJECTIVE: For the first time, this study assesses the acceptance of a web-based intervention among individuals who committed sexual offenses against children and analyzes variables that predict acceptance. Following the Unified Theory of Acceptance and Use of Technology (UTAUT), it is assumed that acceptance of web-based interventions in individuals who have committed sexual offenses against children follows the same mechanisms as for individuals in general psychiatry. METHODS: This cross-sectional study is based on the data from an ongoing clinical trial (@myTabu) evaluating the effectiveness of a web-based intervention in individuals who committed sexual offenses against children (N=113). Acceptance level was measured using a questionnaire based on the UTAUT and modified for the target group. Furthermore, predictors of acceptance from the UTAUT (performance expectancy, effort expectancy, and social influence [SI]), attitudes toward web-based interventions, and internet anxiety were assessed at baseline. RESULTS: Most participants (61.1%, 69/113), reported high acceptance, while 36.3% (41/113) of them indicated moderate acceptance, and 2.7% (3/113) of them expressed low acceptance. In a linear regression model, the predictors explained 41.2% of the variance (F11,101=9.055; P=.01). Attitudes toward web-based interventions (B=0.398, 95% CI 0.16-0.64; P=.001) and SI (B=0.183, 95% CI 0.03-0.38; P=.04) significantly predicted acceptance. Post hoc explorative analysis showed that the participants' belief that people close to them would recommend the use of a web-based intervention is a predictor of acceptance. In contrast, the belief that their community supervisor would recommend the use thereof was not predictive in this respect. CONCLUSIONS: For the participants of this study, we identified high acceptance of web-based interventions for the majority of participants. SI and the participants' attitudes toward web-based interventions were important in predicting acceptance. TRIAL REGISTRATION: German Clinical Trial Registration (DRKS, Deutsches Register Klinischer Studien) DRKS 00021256; https://drks.de/search/de/trial/DRKS00021256.

How to prepare for conversations with children about suspicions of sexual abuse? Evaluation of an interactive virtual reality training for student teachers.

BACKGROUND: Training for child interviewing in case of suspected (sexual) abuse must include ongoing practice, expert feedback and performance evaluation. Computer-based interview simulations including these components have shown efficacy in promoting open-ended questioning skills. OBJECTIVE: We evaluated ViContact, a training program for childcare professionals on conversations with children in case of suspected abuse. PARTICIPANTS AND SETTING: 110 student teachers were divided into four groups and took part either in a two-hour virtual reality training through verbal interaction with virtual children, followed by automated, personalized feedback (VR), two days of online seminar training on conversation skills, related knowledge and action strategies (ST), a combination of both (ST + VR), or no training (control group, CG). METHODS: We conducted a pre-registered, randomized-controlled evaluation study. Pre-post changes on three behavioral outcomes in the VR conversations and two questionnaire scores (self-efficacy and - undesirable - naïve confidence in one's own judgment of an abuse suspicion) were analyzed via mixed ANOVA interaction effects. RESULTS: Combined training vs. CG led to improvements in the proportion of recommended questions (ηp2 = 0.75), supportive utterances (ηp2 = 0.36), and self-efficacy (ηp2 = 0.77; all ps < .001). Both interventions alone improved the proportion of recommended questions (VR: ηp2 = 0.67, ST: ηp2 = 0.68, ps < .001) and self-efficacy (VR: ηp2 = 0.24, ST: ηp2 = 0.65, ps < .001), but not supportive utterances (VR: ηp2 = 0.10, ST: ηp2 = 0.13, both n. s.). CONCLUSIONS: The combination of VR and ST proved most beneficial. Thus, VR exercises should not replace, but rather complement classical training approaches.

Recidivism and characteristics of highly dangerous offenders being released from retrospectively imposed preventive detention: an empirical study.

This study examines the recidivism of offenders who are considered to be highly dangerous but who, as a result of a decision of the German Federal High Court, have not been in preventive detention because it was imposed retrospectively (Group II preventive detention cases; § 66b StGB). Taking into consideration the restrictions imposed by the study, the data were evaluated regarding their usefulness for predicting the likelihood of reoffending. The results of this study suggest that it could be useful to describe criteria for the not very severe reoffending group.

[The Influence of Occupational Group and Experience with Regard to the Criteria-Based Assessment of Culpability for Paraphilic Disorders - A Randomized Control Trial]. / Der Einfluss von Profession und Erfahrung hinsichtlich der kriteriengeleiteten Beurteilung der Schuldfähigkeit bei paraphilen Störungen ­ eine randomisierte kontrollierte Studie.

OBJECTIVE: This study examines whether occupation and level of experience have an impact on criteria-based assessment of criminal responsibility in paraphilic disorders. METHODS: Two different sets of criteria were tested for predictive validity by three different professional groups (psychologists, psychiatrists and lawyers), each with different levels of prior experience. For this purpose, 349 raters evaluated the criteria of one of two criteria catalogs on the basis of one of two exemplary case vignettes. Group assignment was randomized. RESULTS: The variables degree of experience and professional affiliation did not show a connection with the prediction performance regarding the estimation of the severity of the disorder and the diminished capacity, respectively, with respect to either of the two sets of criteria. CONCLUSION: Using a criteria based approach, the methodology used in the present study (presentation of short case vignettes) did not reveal any significant influence of professional group and experience on the assessment in questions of criminal responsibility related to paraphilic disorders. The use of criteria catalogs may be able to contribute substantially to predictive performance relatively independent of relevant prior experience in the area of the assessment of criminal responsibility, but should not be considered the sole source of assessment.

Are sadomasochism and hypersexuality in autism linked to amygdalohippocampal lesion?

INTRODUCTION: Pathologies of the amygdala and the hippocampus have been argued to be critically involved in autism as well as in sadomasochism. In line with Kluver and Bucy syndrome, clinical observations, animal models and a few case reports emphasize that temporal brain changes are important for the etiopathogenesis of sexual deviant behaviour. In particular, the amygdalohippocampal region has been linked to hypersexuality, transvestitism and fetishism. While cases and studies are rare, the impact of amygdalohippocampal changes in criminal behaviour remains unclear so far. AIM: To demonstrate the impact of subcortical neurobiological changes in the etiopathogenesis of autism and sadomasochism. METHODS: We report on a forensic psychiatric inpatient due to murderer with autism and sadomasochism who had amgdalohippocampal abnormalities bilaterally. Studies on the neurobiological underpinnings of autism and of sadomasochism are reviewed in particular regarding amygdalohippocampal region. RESULTS: In this patient, MRI scan showed hypointensities in amygdala-hippocampal complex bilaterally medial to both cornua inferiores corresponding to an amygdalo-hippocampal atrophy. CONCLUSIONS: In line with the literature, this case report links autism and sadomasochism to amygdalohippocampal pathology emphasising its impact in the etiopathogenesis of both disorders. Further research is needed to elucidate the interaction of amygdalohippocampal changes, disturbed emotion precessing and sex offenses.

Psychopathy--an approach to neuroscientific research in forensic psychiatry.

"Psychopathy" is a construct that has come into vogue again in science and practice. In line with the growing impact, different diagnostic approaches have been used to investigate forensically relevant social behavior as well as involved brain functions and structures. Research on psychopathy has become of major importance for empirical research in forensic psychiatry. An overview on the development of the concept of psychopathy is given; the heterogeneity of the diagnostic tools is addressed, focusing critically on the characteristics of the included samples. Neurobiological findings on psychopathy are presented, focusing in particular on structural and functional imaging data. Limitations and further requirements of neuroimaging research in psychopathy are discussed. In order to emphasize the limitations of lesion studies, in particular in a forensic context, a case report on pseudoneurasthenia following orbitofrontal brain damage without any change in behavior is presented.

Prevention of Sexual Child Abuse: Preliminary Results From an Outpatient Therapy Program.

In Germany, access to outpatient treatment services devoted to the prevention of (further) sexual offenses against minors and child sexual exploitation material (CSEM) offenses is often limited. The therapy project "Prevention of Sexual Abuse" tries to fill this gap by providing treatment to patients with a self-reported sexual interest in children and adolescents, irrespective of whether or not they are pedophilic or prosecuted by the legal justice system. Within the project, a treatment manual was developed which specifically addresses dynamic risk-factors in child sexual abusers and CSEM offenders. The treatment manual was conceived to reduce recidivism risk and to contribute to the enhancement of the patients' personal well-being. In this paper, results of the accompanying scientific research are presented: offense-supportive attitudes (N = 23), self-reported CSEM use (N = 10), emotional distress (N = 24), and participants' subjective risk perception of committing (further) sexual offenses (N = 25) reduced during the course of treatment. A reduction of offense-supportive attitudes was further observed from pre-intervention to 1-year follow-up (N = 8). Changes with regard to self-efficacy, quality of life, participants' self-perceived ability to control sexual impulses toward children and adolescents permanently, and several measures assessing different kinds of sexual recidivism did not, however, reach any level of significance. During an average observation period of 2.4 years, six patients confessed to have conducted new sexual exploitation material offenses, while no further sexual abuse cases were reported (N = 19). Due to the used research design and small sample sizes, treatment effects cannot be inferred and external validity is limited. This notwithstanding, results provide first evidence for a relationship between treatment participation and self-reported recidivism and psychological well-being.

@myTabu-A Placebo Controlled Randomized Trial of a Guided Web-Based Intervention for Individuals Who Sexually Abused Children and Individuals Who Consumed Child Sexual Exploitation Material: A Clinical Study Protocol.

Background: There is a high demand for evidence-based and cost-effective treatment concepts for convicted individuals who sexually abused children (ISAC) and individuals who consumed child sexual exploitation material (ICCSEM) under community supervision (CS). The @myTabu-consortium developed a guided web-based intervention for convicted ISAC and ICCSEM under CS consisting of six online modules targeting psychological meaningful risk factors. The study aims to evaluate the effectiveness of this guided web-based intervention in reducing dynamic risk factors and the risk to re-offend compared to a placebo condition. Furthermore, these dynamic risk factors are measured before and after every module to evaluate their individual effectiveness to reduce the respective risk factor as well as risk to re-offend. This clinical trial protocol describes the planned methods as well as the intervention concept. Methods: The methodological design is a placebo controlled randomized add-on trial (N = 582) with follow-ups at 8 points in time. The placebo condition controls for attention and expectation effects and comprises the same amount of modules with a comparable temporal effort as the experimental intervention. The trial is conducted as an add-on to community supervision as usually done. Primary outcomes are dynamic risk factors assessed by self-report risk assessment tools and officially recorded re-offenses. Discussion: To the best of our knowledge, the study is the first to compare the (cost-) effectiveness of a guided web-based intervention for convicted ISAC and ICCSEM under community supervision against a placebo condition. Methodological limitations (e.g., potential ceiling- or volunteers-effects) are discussed. Clinical Trial Registration: German Clinical Trial Register (DRKS 00021256). Prospectively registered: 24.04.2020.