Dangerous or merely difficult? The new population of forensic mental hospitals.

BACKGROUND: During recent decades, there has been a substantial increase in admissions to forensic mental hospitals in several European countries. It is not known if reforms implemented in mental health policies and practices are responsible for this development. OBJECTIVE: Our study examined the development of mental health care in Austria and the incidence and prevalence of mentally disordered offenders judged not guilty by reason of insanity (NGRI). METHODS: We analysed data on service provision and data from criminal statistics between 1970 and 2008 from several national sources. RESULTS: During the first decade when reforms to mental health practice were implemented, the incidence and prevalence of offenders judged NGRI remained unchanged, despite a reduction of mental hospital beds by nearly 50% and little outpatient care. Surprisingly, the enormous increase in admissions to forensic inpatient treatment began in Austria only after community mental health services were rolled out across the country in the 1990s. This increase was primarily due to admissions of patients who had committed less severe offences, while rates of those who had committed homicide remained unchanged. CONCLUSION: Our results cannot be explained by details of the reforms such as the downsizing of mental hospitals or a lack of outpatient facilities, nor by changes to criminal sentencing. Rather, the results provide evidence of an increasingly inadequate provision of comprehensive care for "difficult" but not extremely dangerous psychotic patients living in the community. This may result from the attitudes of mental health professionals who have become less inclined to integrate aggressive behaviour into their understanding of psychosis. As a consequence, increasing numbers of "difficult" patients end up in forensic psychiatric institutions. This development, which can be observed in nearly all European countries, raises concerns with regard to efforts to destigmatize both patients and psychiatry.

The age of onset of schizophrenia and the theory of anticipation.

The clinical phenomenon called anticipation is usually defined as a decrease in age at onset and/or an increase in disease severity in successive generations of afflicted families. The purpose of this study was to examine variables that might influence anticipation in schizophrenia. A total of 380 Austrian patients, born between 1935 and 1964, met criteria for schizophrenia with ICD-8 or ICD-9, SADS-L and DSM-III-R criteria. The inclusion criteria also required medical records of patients to contain information about the year of birth, season of birth, age at onset, accidents or meningoencephalitic diseases during childhood, first- and second-degree relatives afflicted with schizophrenia, sibship size, sib order, education of patient, age of parents, occupation of parents, loss of parents, and place of residence. A Cox multiple-regression analysis showed three factors as having a significant influence on the age of disease onset, including year of birth (which had the largest influence), family history (sporadic cases showed an onset 2 years later than familial cases) and residence (urban dwellers showed psychotic symptoms approximately 1 year sooner than rural ones). A Kaplan-Meier Survival Analysis showed that younger cohorts had onset approximately 10 years earlier in sporadic and familial cases. This cohort effect might be a major source of bias in studies of anticipation.

Being a webcam.

Searching through studies of schizophrenic delusions with a view to the new media, we came across the case of a young woman who integrated the Internet in her delusional system. Analysing the story she told, we recognised a psychotic symptom, which we preliminarily called 'perception broadcast'. Perception broadcast shows a more complex structure than the related first rank symptom 'thought broadcast' described by Kurt Schneider. In our view the existence of a structure like perception broadcast depends on the existence of new technologies, such as the World Wide Web and 'virtual reality', creating new cultural patterns which themselves are associated with collective perceptions of derealisation.

Old wine in new bottles? Stability and plasticity of the contents of schizophrenic delusions.

A number of recent case reports published during the last 20 years described a quick inclusion of new technologies and cultural innovations into schizophrenic delusions which led many of the authors to the conclusion that the 'Zeitgeist' is creating new delusional contents. On the other hand, long-term comparisons and comparative transcultural studies on delusions showed, despite a certain degree of variability, a stability of delusional themes over longer periods of time. Combining anthropological and historical theories of the development of societies with a differentiated psychopathological approach (Klosterkötter's three-stage model of the formation of schizophrenic delusions), we were able to resolve the problem of the ostensibly divergent results: there are only a few themes of extraordinary anthropological importance for the organization of human relationships which can be found in every epoch and in different cultures (persecution, grandiosity, guilt, religion, hypochondria, jealousy, and love). With the exception of persecution and grandiosity, these themes showed a certain variability over time and between cultures. The 'new' themes, referring to the development of modern technology and the rapid changes of 'cultural patterns' turned out to be only the shaping of the basic delusional themes on the 3rd stage of Klosterkötter's phase model (concretization).

Guilt and depression: a cross-cultural comparative study.

Although nearly a century has passed since Kraepelin's investigations in Java [Cbl Nervenheilk Psychiatr 1904; 27:468-469], one crucial question regarding guilt in the course of depression has still not been decided: Is there a more or less stable connection independent of culture, or is guilt confined to certain civilisations? This study investigated this issue in 100 Pakistani and 100 Austrian out-patients diagnosed with 'major depression' according to DSM-IV by means of standardised instruments (Schedule for Affective Disorders and Schizophrenia-Life Time Version, Hamilton Rating Scale for Depression, 21-item version). The experiences of guilt were subdivided into ethical feelings (ethical anxiety and feelings of guilt) and delusions of guilt. It turned out that ethical feelings could be found in both cultures regardless of age and sex. They seem to be primarily related to the extent of depressive retardation. However, the distribution of the two subsets of ethical feelings was culture dependent. Delusions of guilt were confined to patients of the Austrian sample. So, our data qualify the exclusivity of the aforementioned two points of view and support the need for a psychopathologically differentiated approach.

Are we witnessing the disappearance of catatonic schizophrenia?

The decrease in the frequency of diagnosed catatonic subtypes among schizophrenic disorders as a whole during the last 50 years has long been regarded as an established fact. Until now the factors responsible for this development have been under discussion. As it is not clear if there is a true decrease or an ostensible one due to other factors such as changed diagnostic habits or neuroleptic treatment, we examined 174 consecutively admitted schizophrenic patients from three different psychiatric institutions diagnosed according to DSM-IV and Leonhard's criteria. It turned out that-depending on the diagnostic system-the rates of diagnosed catatonias were 10.3% (DSM-IV) and 25.3% (Leonhard's criteria). Comparison of the two original Leonhard cohorts (1938 to 1968, 1969 to 1986) with our own (1994 to 1999) shows a decrease in the frequency of catatonias from 35% to 25%, which-albeit statistically significant-is much less pronounced than in studies that used a narrower definition of catatonia. Here, besides sociocultural developments, the use of neuroleptics seems to effect the decrease in the frequency of catatonias in two ways: on one hand, they cause a decrease of hyperkinesia, excitement, or impulsivity; while on the other hand, they themselves produce motor abnormalities like rigidity, effects that favor the attribution of motoric symptoms to neuroleptics.

Homicide and major mental disorders: a 25-year study.

OBJECTIVE: This study was designed to investigate the association between major mental disorders (MMDs) and homicide. METHOD: The rates of exculpations because of MMDs among 1087 Austrian homicide offenders during 1975 and 1999 were compared with the rates of the respective disorders in the general population. RESULTS: MMDs were associated with an increased likelihood of homicide (two-fold in men and six-fold in women). This was exclusively because of schizophrenia (age-adjusted ORs in men 5.85, CI 4.29-8.01; in women 18.38, CI 11.24-31.55) and delusional disorder in men (OR 5.98, CI 1.91-16.51). Comorbid alcohol abuse/dependence (additionally) increased the odds in schizophrenia, major depression and bipolar disorder. CONCLUSION: The increased likelihood of homicide in subjects with MMDs cannot be fully explained by comorbid alcoholism. The results point to the special importance of sufficient treatment for a subgroup of mentally ill individuals being at higher risk of violence.

Sibling orders of schizophrenic patients in Austria and Pakistan.

The influence of siblings on the socialization of the individual has been recognized as a fact by both psychology and sociology. The significance of sibling order for the outbreak of psychiatric diseases on the other hand is still discussed controversially. In our study, we compared the expected values and the positions actually found in the sibling order of 379 (233 males, 146 females) Austrian and 144 (101 males, 43 females) Pakistani patients diagnosed with schizophrenia according to DSM-IV (295). The position in the sibling order had no influence on the outbreak of schizophrenia in Austria; with Austrian schizophrenics, the results found were very near to the expected values. In Pakistan on the other hand, the eldest brothers from families with 2-4 siblings had a significantly higher risk of falling ill. The investigation of the composition of the sibships of schizophrenic patients also showed a high overrepresentation of men in the firstborn position in Pakistan. These facts seem to exercise influences that may either protect against the outbreak or encourage it. The differences found agree well with the fact that in Pakistan, both the gender of a child and the position in the sibling order entail different ways of treatment and different scopes of responsibility. Socialization in Austria on the other hand, at least in the recent decades, has become very uniform for both sexes, regardless of the sibling position.