Attempted suicide by hanging in a pregnant adolescent with psychiatric illness: A case report.

Cases of mental illnesses and suicide attempts while pregnant are of grave concern because they negatively affect both the mother and her fetus. Here we report a case of an 18-year-old woman, who was found at 35 weeks into her pregnancy. She was unconscious when her sister-in-law rescued her. Upon arrival, she was agitated and had respiratory distress. She went into spontaneous labor the next day and delivered a premature infant who succumbed within 24 h. She had a history of mental illness in the past and previous suicide attempts. The reason for her suicide stemmed from conflicts within her family and disagreement with her husband. Various psychosocial elements play a role in suicide risk, such as young age, having a history of mental health issues, experiencing trauma facing domestic violence, and dealing with financial stress. This underlines the need for mental health screening in the course of antenatal visits for a complete risk assessment.

Application of Facial Expression Analysis Technology in Violence Risk Assessment of Individuals with Mental Disorders in Supervised Settings.

OBJECTIVES: To explore the association between violent behaviors and emotions in individuals with mental disorders, to evaluate the application value of facial expression analysis technology in violence risk assessment of individuals with mental disorders in supervised settings, and to provide a reference for violence risk assessment. METHODS: Thirty-nine male individuals with mental disorders in supervised settings were selected, the participant risk of violence, cognitive function, psychiatric symptoms and severity were assessed using the Modified Overt Aggression Scale (MOAS), the Historical, Clinical, Risk Management-Chinese version(HCR-CV), the Positive and Negative Syndrome Scale (PANSS) and the Brief Psychiatric Rating Scale (BPRS). An emotional arousal was performed on the participants and the intensity of their emotions and facial expression action units was recorded before, during and after the arousal. One-way analysis of variance (ANOVA) was used to compare the differences in the intensity of emotions and facial expression action units before, during and after the arousal. Pearson correlation analysis was used to calculate the correlations between the intensity of the seven basic emotional facial expressions and the scores of the assessment scales. RESULTS: The intensity difference of sadness, surprise and fear in different time periods was statistically significant (P<0.05). The intensity of the left medial eyebrow lift action unit was found significantly different before and after the emotional arousal (P<0.05). The intensity of anger was positively correlated with the Modified Overt Aggression Scale score throughout the experiment (P<0.05). CONCLUSIONS: Eye action units such as eyebrow lifting, eyelid tightening and upper eyelid lifting can be used as effective action units to identify sadness, anger and other negative emotions associated with violent behaviors. Facial expression analysis technology can be used as an auxiliary tool to assess the potential risk of violence in individuals with mental disorders in supervised settings.

Putting the usability of wearable technology in forensic psychiatry to the test: a randomized crossover trial.

Introduction: Forensic psychiatric patients receive treatment to address their violent and aggressive behavior with the aim of facilitating their safe reintegration into society. On average, these treatments are effective, but the magnitude of effect sizes tends to be small, even when considering more recent advancements in digital mental health innovations. Recent research indicates that wearable technology has positive effects on the physical and mental health of the general population, and may thus also be of use in forensic psychiatry, both for patients and staff members. Several applications and use cases of wearable technology hold promise, particularly for patients with mild intellectual disability or borderline intellectual functioning, as these devices are thought to be user-friendly and provide continuous daily feedback. Method: In the current randomized crossover trial, we addressed several limitations from previous research and compared the (continuous) usability and acceptance of four selected wearable devices. Each device was worn for one week by staff members and patients, amounting to a total of four weeks. Two of the devices were general purpose fitness trackers, while the other two devices used custom made applications designed for bio-cueing and for providing insights into physiological reactivity to daily stressors and events. Results: Our findings indicated significant differences in usability, acceptance and continuous use between devices. The highest usability scores were obtained for the two fitness trackers (Fitbit and Garmin) compared to the two devices employing custom made applications (Sense-IT and E4 dashboard). The results showed similar outcomes for patients and staff members. Discussion: None of the devices obtained usability scores that would justify recommendation for future use considering international standards; a finding that raises concerns about the adaptation and uptake of wearable technology in the context of forensic psychiatry. We suggest that improvements in gamification and motivational aspects of wearable technology might be helpful to tackle several challenges related to wearable technology.

Case report: Assessing criminal responsibility and recidivism risk in the behavioral variant of frontotemporal dementia.

Frontotemporal dementia (FTD) affects the frontal and temporal lobes of the brain, leading to personality changes, language impairments, and behavioral disturbances, including impulsivity and disinhibition. Assessing responsibility and recidivism risk in forensic evaluations is challenging due to the evolving nature of FTD. Despite limited literature, we present a case of a 45-year-old man with no prior legal or medical history, who committed criminal acts due to behavioral changes linked to the behavioral variant of frontotemporal dementia (bvFTD). Initial assessment found him irresponsible, with a non-evaluable risk of recidivism. Subsequent evaluation showed a low recidivism risk based on clinical evolution. We discuss these findings considering existing literature and Swiss jurisprudence.

A narrative of recovery in forensic hospitals.

AIM: Concerns about the applicability of recovery orientation to forensic care have surfaced due to the traditionally restrictive practices associated with forensic institutions. We interviewed 19 experts-by-experience and 18 professionals working with them across five Finnish forensic hospitals and one out-patient clinic to describe how they define recovery in forensic. METHODS: We utilized semi-structured, one-on-one interviews and then analyzed the collected data using structural narrative analysis. Our points of interest were the plots of the recovery stories and the ways in which various factors affected recovery. We also investigated whether staff and experts-by-experience had different perceptions of recovery in forensic psychiatry, and whether recovery-oriented practices were present in these accounts. RESULTS: A wider mutual narrative with a chronological plot was identified, and recovery-oriented practices and goals were found with a special emphasis on offending. Insight into mental illness, motivation for self-care, trust in therapeutic relationships, and gaining possibilities to proceed in care were found to promote recovery, whereas insufficient understanding of the illness, a closed environment, lack of trust, and substance abuse hindered the recovery process. Both the professionals and experts felt that the most prominent goal of recovery is integration into society. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The views of the interviewed experts-by-experience and professionals regarding recovery were rather univocal. Forensic psychiatric services in Finland were found to demonstrate recovery-oriented features, which can be promoted further by involving experts-by-experience in different assignments. The results also highlight that the families of patients should become more active partners in care. IMPACT AND IMPLICATIONS STATEMENT: Recovery in forensic psychiatric hospitals can be perceived as a process towards a new role in society. To reach this goal the forensic patients need support from staff, peers, and family. We found numerous factors which enable and hinder the recovery process, and which should be considered during forensic care.

Forensic psychiatric assessment in autism spectrum disorder: Experience of a forensic psychiatry inpatient clinic from Türkiye.

Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by marked differences in communication patterns, reciprocal social interactions, and restricted, stereotyped, and repetitive interests and activities. Various behavioral problems in ASD, more so when accompanied by coexisting psychopathology, can sometimes lead to legal problems. In this study, the cases in which an opinion was requested in terms of criminal responsibility with the diagnosis of ASD in the 5-year period between 2018 and 2022 in the expertise department of psychiatric observation, where psychiatric cases were hospitalized and observed in the Council of Forensic Medicine (CFM), which is the official expert institution in Türkiye, were retrospectively evaluated. The mean age of the group whose criminal responsibility was reduced or removed was 22.9 years (±7.52) and the mean IQ score was 76.63 ± 18.94. The most common crime in this group was intentional injury (5/11), and it is noteworthy that the victims of these crimes were usually relatives of people with ASD (5/6). The criminal acts of people with ASD are usually single-movement, spontaneous, unplanned, impulsive acts. In addition, although there is no problem in cognitive perception in people with high functioning ASD (HF-ASD), various forensic situations may arise due to defects in emotional awareness. When we look at the practices of the CFM in Türkiye, it is seen that in cases where the diagnosis of ASD is clear and can be associated with the crime, criminal responsibility is usually completely eliminated. In HF-ASD types, although it is important to be associated with the crime, it is seen that criminal responsibility is generally reduced.

The predictive validity and temporal characteristics of the HCR-20v3 for inpatient violence in forensic inpatient settings. An international study.

Aggression and violence are common day to day problems in psychiatric settings. However, the optimal means of assessing that risk remains unclear. In the context of that uncertainty many tools have evolved, among which the HCR-20 is one of the most globally accepted, though many questions remain about its performance, how and when it should be deployed and how it can be most effectively used. In this 12 month follow up study of 210 forensic psychiatric inpatients with a diagnosis of a schizophrenia spectrum disorder we explored these issues. We found that the performance of the HCR-20v3, especially its Total score, performed well up to 6 months after it was rated but its performance deteriorated after that. Repeating the HCR-20v3 at 6 months stabilised the risk assessment and led to improved performance in the second months over and above the first rating. The HCR-20v3 was good at identifying those subjects at low risk of violence over 6 months of follow up in a forensic inpatient setting. The real-world implications of this study are that the HCR-20v3 is an effective means of identifying patient at low risk of violence, but it should be reassessed every 6 months.

Attitudes of Forensic Fellowship Psychiatry Directors towards an Applicant Match.

Forensic psychiatry fellowship programs recruit applicants through a nonstandardized process that differs by program. Although there are deadlines, informal guidance, and more recent communication guidelines, perceived differences in recruitment practices persist between geographic regions, small and large programs, and newer and more well-established programs. In the wake of a survey of fellowship applicants that found mixed opinions surrounding the application process, U.S. forensic fellowship directors undertook a mixed method quantitative-qualitative survey of their colleagues to assess interest in a match as a potential improvement and factors influencing that interest (e.g., program size, age, and unfilled positions). With responses from all 46 active U.S. programs, results indicated broad support for principles of fairness, transparency, and minimizing pressure on applicants, with an almost perfectly divided interest in a match. Respondents supported the use of a centralized database to standardize the application process and favored certain exceptions for internal applicants. Hypotheses about the reasons underlying program directors' attitudes toward a match did not yield significant results, with only the size of a program approaching significance. This novel comprehensive survey of forensic fellowship directors offers a model for assessing and monitoring the evolution of application processes for medical subspecialties interested in expanding and improving their recruitment.

Forensic Neurology and the Role of Neurologists in Forensic Evaluations.

There is a clear need for experts with the requisite knowledge and experience to offer medicolegal opinions pertaining to various neuropsychiatric conditions. There is also an important distinction between clinical and medicolegal roles, and the need for training and expertise applicable to forensic assessment. But there remain few available experts with credentials spanning neuropsychiatry and forensic assessment. This creates a dilemma whereby parties involved in litigation featuring neuropsychiatric illness or injury are frequently forced to choose between experts with either knowledge and skills applicable to neuropsychiatric conditions or experts with skills and experience applicable to forensic assessment. Either choice introduces risk. Whether flawed medicolegal opinions are a consequence of deficient medical knowledge or an inadequate forensic evaluation process, the result remains the same, with triers of fact potentially being exposed to problematic testimony. There is, however, a more fundamental problem that implicates patient care more broadly: spurious dichotomies created by the historical segregation of psychiatry and neurology. Optimizing clinical care for patients with neuropsychiatric conditions, improving medical education in support of such care, and enabling forensic neuropsychiatric assessment must then start with more proactive efforts to reintegrate psychiatry and neurology.

Transgressive incidents targeted on staff in forensic psychiatric healthcare: a latent class analysis.

Transgressive incidents directed at staff by forensic patients occur frequently, leading to detrimental psychological and physical harm, underscoring urgency of preventive measures. These incidents, emerging within therapeutic relationships, involve complex interactions between patient and staff behavior. This study aims to identify clusters of transgressive incidents based on incident characteristics such as impact, severity, (presumed) cause, type of aggression, and consequences, using latent class analysis (LCA). Additionally, variations in incident clusters based on staff, patient, and context characteristics were investigated. A total of 1,184 transgressive incidents, reported by staff and targeted at staff by patients between 2018-2022, were extracted from a digital incident reporting system at Fivoor, a Dutch forensic psychiatric healthcare organisation. Latent Class Analysis revealed six incident classes: 1) verbal aggression with low impact; 2) verbal aggression with medium impact; 3) physical aggression with medium impact; 4) verbal menacing/aggression with medium impact; 5) physical aggression with high impact; and 6) verbal and physical menacing/aggression with high impact. Significant differences in age and gender of both staff and patients, staff function, and patient diagnoses were observed among these classes. Incidents with higher impact were more prevalent in high security clinics, while lower-impact incidents were more common in clinics for patients with intellectual disabilities. Despite limitations like missing information, tailored prevention approaches are needed due to varying types of transgressive incidents across patients, staff, and units.

A Primer for Increasing Competency in Forensic Psychiatry Research.

Empirical research is foundational to the discipline of forensic psychiatry. Candilis and Parker provide a cogent systematic review of the empirical literature on restoration of competence to stand trial using National Institutes of Health quality metrics. Components of the study methodology are highlighted, as they represent current best practices for conducting a systematic review. A discussion of strategies to increase empirical research uptake in forensic psychiatry is pursued alongside concrete examples of how the American Academy of Psychiatry and the Law Research Committee can help facilitate this goal.

Prison and forensic mental health staff after suicides in their care. A narrative review of international and German national evidence.

There is a growing body of international research investigating the impact of patient suicide on mental health professionals. The experience of losing a patient to suicide can have a significant and, in some cases, long-lasting (negative) impact on mental health professionals. However, the nature and extent of the impact on prison staff or forensic mental health professionals in particular is less clear. This narrative review summarises both quantitative and qualitative studies and key findings in this area, focusing on the above professions. A literature search was conducted using PsychInfo and Google Scholar, covering the period from 2000 onwards. The vast majority of findings relate to mental health professionals in general. We were unable to identify any published reports on the responses of forensic psychiatric staff. The majority of identified studies in the prison context are qualitative. Studies from German-speaking countries are particularly scarce in both the prison and mental health contexts. We conclude that there is a profound lack of knowledge about the impact of client/patient suicide on the subgroups of (German) prison and forensic psychiatric staff. Clearly, more research is needed on both the nature and extent of the impact, as well as on the specific organisational and supportive factors that help to mitigate the negative effects of suicide.

Post-Dobbs Psychiatric Exceptions in Abortion-Restricting States.

Mental disorders and suicide are important causes of increased morbidity and mortality rates during pregnancy. Since the U.S. Supreme Court's 2022 Dobbs decision, many state legislatures have passed stringent abortion bans and restrictions. These laws define exceptions under which abortion may be legally obtained. Suicidality and other psychiatric symptoms have been excluded from such definitions. In this column, the authors examine how legislatures, courts, and professional regulatory bodies in several abortion-restricting states have defined their medical emergency exceptions. The authors argue that psychiatrists should be concerned about the management of psychiatric emergencies during pregnancy as well as emerging legal intrusions into physician-patient decision making.

Advancing Youth Justice: The Child and Adolescent Psychiatrist's Role.

Child and adolescent psychiatrists (CAPs) play a crucial role beyond the provision of clinical care. CAPs are uniquely placed to understand and help patients navigate the fine line among psychiatric care, health and well-being, and the laws and policies supporting or impairing these processes. Focusing on vulnerable populations, such as legal system impacted youth and families, CAPs can contribute to the ongoing development of a more just and equitable world for the children of today and of tomorrow.

Dissociation and the insanity defense: A review of U.S. Federal appellate case law.

Pathological dissociation is relatively common in the United States and may be associated with violent or criminal behavior. Dissociative Disorders, especially Dissociative Identity Disorder, are considered controversial diagnoses by some in the psychiatric and legal professions. Individuals who offend during dissociative states may not be criminally responsible if they meet the legal standard for insanity, however, insanity pleas based on dissociative symptoms are rare. This review examined Federal appellate case law for potential legal barriers to the insanity defense for dissociative conditions and any restrictions imposed on related expert evidence. Few rulings directly addressed these questions but there do not appear to be any unique barriers for dissociation-related insanity pleas. Some cases provided valuable insights regarding the admission of expert evidence, effective expert testimony, and the role of defense counsel.