Experts' decision-making processes in Swedish forensic psychiatric investigations: A case vignette study.

It has previously been demonstrated that decisions made by forensic experts can suffer from issues with both bias and poor reliability. The outcome of Swedish forensic psychiatric investigations can have a major impact on the courts' choice of sanction for a mentally disordered offender. These investigations are performed by multi-professional teams of experts, where each expert is obliged to state their opinion on whether the client has a severe mental disorder (SMD) or not. In the present study, a case vignette design was used to simulate the decision-making process of forensic psychiatric investigations. Of the 73 Swedish experts working with forensic psychiatric investigations, a total of 27 (37%) participated in the study. The results showed that the Swedish experts formulated multiple diagnostic hypotheses about cases throughout the process and revised these hypotheses when presented with new information. There was substantial variation between the experts in which hypotheses were seen as most relevant. While the experts grew more certain of their opinions on SMD during the simulated investigation, there was considerable variation in their opinions both throughout and at the end of the process. Although low statistical power and the sample not being randomized limit generalizations, the results indicate no idiosyncratic patterns in the decision-making processes of Swedish experts or signs of confirmation bias. If used properly, the variation in both process and outcome could be used to safeguard and possibly increase the reliability and validity of the final decision of Swedish forensic psychiatric investigations.

Prevalence and heritability of alcohol use disorders in 18-year old Swedish twins.

Background: Heritability of alcohol use disorders (AUDs) varies widely, with reported estimates of 30-78% in twin studies. This variation might be due to methodological differences (e.g., using different thresholds for AUDs, age differences between samples). Aim: To investigate the heritability of AUDs in a nation-wide sample of male and female twins in late adolescence (18 years). Participants: The study is based on data from 8,330 18-year-old Swedish monozygotic (MZ) and dizygotic (DZ) twins from the Child and Adolescent Twin Study (Sweden). Method: Univariate sex-limitation twin analyses were performed using (a) total AUDIT score, (b) different AUDIT cut-offs (AUDIT-10: potentially harmful alcohol use and most likely alcohol dependent ; AUDIT-C: potential hazardous alcohol consumption/active alcohol use disorders), and (c) a risk-group classification for alcohol dependence based on AUDIT total score. Results: Prevalence of potential hazardous alcohol consumption/active alcohol use was 57.1%, and for potentially harmful alcohol use prevalence was 26.5%. Prevalence was higher among females (59.0% and 31.1% respectively) than males (54.4% and 20.0% respectively). Overall, the results of the univariate model fitting indicated that there were qualitative sex differences in the genetic and environmental influences on AUDs, with generally moderate heritability estimates ranging between 0.37 and 0.50. Discussion: At odds with previous research, a harmful/hazardous drinking pattern was more common in this age group among females than a low-risk drinking pattern (where males were overrepresented). Heritability estimates were moderate throughout all measures and cut-offs, with equally high contributions from shared and non-shared environment. Sex-limitation models revealed qualitative sex differences for AUDs, suggesting that different genetic and/or environmental factors influence variation in AUDs in males and females.

Autism Spectrum Disorders in forensic psychiatric investigations-patterns of comorbidity and criminality.

Background: There are contradictory research findings regarding whether individuals with Autism Spectrum Disorders (ASDs) are more or less likely to commit crimes. The aims of the current study were to: (1) Describe psychiatric and crime-related characteristics of a large group of offenders with ASD who had undergone a Forensic Psychiatric Investigation (FPI). (2) Identify clinical subgroups among this group of offenders. (3) Investigate associations between the identified clinical subgroups and (a) psychiatric comorbidity (b) types of crimes and (c) criminal responsibility. Methods: The study cohort consists of all subjects (n = 831) who received an ASD-diagnosis at an FPI between 2002 and 2018 in Sweden. Descriptive and clinical, as well as crime related variables were obtained from the FPIs. Non-parametric (Pearson χ2, Fisher's exact and Mann-Whitney U-test) inferential statistics were used for analyses of between-group differences and effect sizes were reported. A Latent Class Analysis was used to identify homogeneous subgroups (or classes) from categorical characteristics. Results: The cohort consisted of 708 men and 123 women, aged 18 to 74 yrs. Two-thirds (66.7%) of the cohort had at least one other psychiatric diagnosis, the most prevalent was substance use disorder (SUD). A severe mental disorder, equivalent to lack of criminal responsibility, was most often reported among offenders with a comorbid diagnosis of schizophrenia spectrum disorder. The most common type of crime was violent crime. Three person-oriented clinical subgroups were identified; (1) ASD with few other diagnoses; (2) ASD and very high levels of SUDs, plus moderate levels of other externalizing disorders and psychotic psychopathology and (3) ASD and moderate to high levels of personality disorders (other than ASPD) and SUDs. Conclusion: Our results highlight the importance of all parts of the CJS to be prepared to handle offenders with ASD, often with high levels of additional psychiatric problems. Traditional approaches in treatment or other psychosocial interventions for ASD may need to be adapted to at least three general clinical profiles- one with mainly neurodevelopmental problems, one with a spectrum of externalizing problems and one with complex personality related difficulties.

Lethal and severe violence: Characterizing Swedish female offenders with and without a severe mental disorder.

Aim: In studies on lethal and severe violence, male offenders have historically been in focus while female offenders, in comparison, have often been excluded. In this study, we aimed to characterize female violent offenders and compared those with and without a severe mental disorder (SMD). Method: All females charged with lethal or attempted lethal violence, who had undergone forensic psychiatric investigations (FPI) in Sweden between 2000 and 2014, constituting the two groups SMD (n = 84) and no SMD (n = 91), were included. Information from their FPI reports and court verdicts was collected regarding background and demographics, mental health, substance use, and crime characteristics. Results: Overall, both groups were often unemployed, previously victimized within close relations, had psychiatric health issues, and more than half of them had previously attempted suicide. Specifically, the SMD group more often had psychotic disorders, had attempted homicide-suicide (at the time of the crime), and had children or friends/acquaintances as victims. The no-SMD group more often manifested patterns of anxiety, personality disorders, and substance use disorders compared to the SMD group. The no-SMD group also differed from the SMD group by more often having a previous criminal record, being charged with lethal index violence, having male adult intimate partners/ex-intimate partners as victims who had abused the offender, and both offender and victim had more often been under the influence of a substance. Conclusion: Female offenders of lethal and severe violence had a high prevalence of previous violent victimization which should be considered in forensic assessment and treatment regardless of the offender's SMD status. However, more focus on substance use disorders and intimate partner relations appears relevant for females without an SMD. Contrary to that, early interventions regarding psychotic processes are probably a helpful preventive measure for females with an SMD. In sum, the heterogeneity of female offenders of lethal and severe violence emphasizes the necessity of developing nuanced interventions to meet their rehabilitative needs as well as the requirements of community protection.

What does current science tell us about the accuracy, reliability, and completeness of intoxicated witnesses? A case example of the murder of a prime minister.

Generally, the testimony of intoxicated witnesses has been considered relatively unreliable, but recent research has nuanced the knowledge base regarding these vulnerable witnesses. Purpose: To demonstrate the application of recent research findings regarding intoxicated witnesses to the statements made by a key witness to the murder of Olof Palme, Sweden's prime minister, in 1986. An additional purpose was to illustrate the use of a nuanced calculation of blood alcohol concentration (BAC) for researchers. Methods: The Palme murder has been debated since the crime was committed and no one has yet been sentenced. One of the witnesses was intoxicated and to estimate a range for his BAC at the time, a comprehensive BAC calculation was conducted in this study to illustrate important factors to consider in these types of cases. Results: Through the demonstration of the use of a nuanced BAC formula and by applying recent research results from studies on intoxicated witnesses, it was estimated that the possible BAC of the witness in the Palme-case at the time of the witnessed crime ranged between BAC = 0 to BAC = 0.13, depending on the type of alcoholic beverage consumed and whether the witness was a social or heavy drinker. This puts the witness either well within the span of maintained completeness as well as maintained accuracy rate (if considering: lowest dose and heavy drinker), or slightly exceeding this span into the BAC-range of reduced completeness but maintained accuracy rate (if considering: highest dose and social drinker). He was questioned immediately, and thereafter repeatedly, and he reported similar information throughout the interviews, which is in line with previous results on information maintenance over repeated interviews among intoxicated witnesses. Conclusion: The current case example shows how recent research on intoxicated witnesses can be applied in praxis, illustrating important factors for legal practitioners to consider when interpreting information from intoxicated witnesses. It also provides legal practitioners and researchers with an example of a structured approach to more nuanced BAC-calculations.

The decision-making process in Swedish forensic psychiatric investigations.

Forensic psychiatric investigations in Sweden can have a major impact on the choice of sentence in criminal cases. Previous research shows that the decisions in several forensic fields, including forensic psychiatry, can be affected in a negative way by factors not relevant to the case. In the present study, the decision-making process of forensic psychiatric investigations was explored by using semi-structured interviews with experts (n = 38) and analyzing these interviews thematically. The results showed that the decision-making process is both complex and iterative, where the experts use and shape a substantial amount of information to reach their decisions. The experts work in teams, which add both benefits and risks to the process, and feel that particularly time constraints may reduce the quality of their decisions. In summary, the decision-making process of Swedish forensic psychiatric investigations creates a potential for high validity, but also contains risks for bias effects that could warrant further mitigation.

Autistic Personality Traits and Treatment Outcome for Alcohol Use Disorders.

ABSTRACT: The importance of personality traits for the outcome of psychiatric treatment, including treatment for alcohol use disorder (AUD), has been widely acknowledged. Also, research on autism spectrum disorders has evolved in recent years, emphasizing that the behavioral traits within these neuropsychiatric disorders exist on a dimension both within and outside the boundaries of psychopathology. In the present study, the relationship between personality traits associated with autistic functioning and level of alcohol use among patients before and after concluded AUD treatment was investigated. The participants (n = 165, diagnosed with AUD) were part of a longitudinal project on AUD treatment. Data from personality questionnaires (Structured Clinical Interview of Personality Disorders II and Temperament and Character Inventory) were used to assess autistic personality traits (APTs) based on behavior within Wing's triad, which were related to background and treatment outcome. The chosen APT items illustrated a personality functioning with an emphasis on social interaction and rigidity. Only certain included questions were indicative of still having a problematic drinking pattern 2.5 years after treatment entry, which adhered to phobic, obsessive-compulsive, and schizoid personality traits, as well as rigidity/stubbornness. Albeit with modest influence, the degree of APTs was associated with heavier drinking at treatment entry, and symptoms relating to social interaction and rigidity were associated with still having a problematic drinking pattern 2.5 years after treatment entry. A higher degree of such traits may result in having problems taking advice from others and establishing treatment alliance, important parts of treatment efficacy, making assessment of such traits relevant to clinicians.

Time and Alcohol Do Not Change Everything: How Intoxicated Witnesses Perceive Aggression in Intimate Partner Violence.

Although alcohol-intoxicated witnesses to violent crimes are common, research on how alcohol affects witnesses' perception of aggression is sparse. In the present study, it was investigated whether different levels of intoxication altered how severe witnesses perceived aggression displayed by involved parties in an intimate partner violence (IPV) scenario to be. An experimental mixed-groups design 3 (sober vs. moderate vs. high breath alcohol concentration [BAC]) x 2 (immediate vs. one week delayed interview) was used. Socially drinking men and women (n = 137; 67 and 70, respectively) were randomized to an alcohol condition (0.8 g/kg adjusted to 0.75 g/kg for women, divided into two intoxication groups: moderate ≤0.08 and high ≥0.08) or a control condition (juice). They were also randomized into a direct interview condition or a delayed interview condition. In a laboratory setting, they consumed drinks and viewed an IPV scenario on film. During their interview, the participants rated how severe they perceived the involved parties' aggression to be. Inter alia, participants in the high BAC group perceived both parties' physically aggressive behavior as comparatively less severe than the sober and moderately intoxicated witnesses did. The high BAC group also perceived the IPV scenario as less unpleasant than the other two groups, and they maintained this perception over time and repeated interviews. A BAC level of ≥0.08 was required to significantly lower witnesses' perceived severity of physical aggression, possibly caused by alcohol's anxiety-dampening effect as well as its impairing effect on cognitive processing capacity over this level of intoxication. That alcohol intoxication at (or over) such a BAC level makes witnesses perceive physical aggression as less severe and less unpleasant, and also that such an altered perception holds over time and repeated interviews, is important for legal practitioners to be aware of when handling intoxicated witnesses to violence. Therefore, this issue warrants further investigation.

A Bad Start: The Combined Effects of Early Onset Substance Use and ADHD and CD on Criminality Patterns, Substance Abuse and Psychiatric Comorbidity among Young Violent Offenders.

Substance abuse, conduct disorder (CD) and attention deficit/hyperactivity disorder (ADHD) are all known risk factors for developing aggressive behaviors, criminality, other psychiatric comorbidity and substance use disorders (SUD). Since early age of onset is important for aggravating the impact of several of these risk factors, the aim of the present study was to investigate whether young adult violent offenders with different patterns of early onset externalizing problems (here: substance use < age 15, ADHD, CD) had resulted in different criminality profiles, substance use problem profiles and psychiatric comorbidity in young adult age. A mixed-method approach was used, combining a variable-oriented approach (with Kruskal Wallis tests) and a person-oriented approach (with Configural frequency analysis). Overall, this combined approach indicated that persons with combined ADHD+CD and persons with CD + early onset of substance use had a more varied history of violent crimes, a more comprehensive history of aggressive behaviors in general, and more psychiatric comorbidity, as well as more varied SUD and destructive substance abuse in adult age, than persons without ADHD, CD or early SU. Results are in line with previous variable-oriented research, but also indicate that individuals in this group with heavy problem aggregation early in life have a wider spectrum of problems in young adult age. Importantly, among these young violent offenders, problem aggregation was the overwhelming norm, and not the exception, as in studies of the general population. This emphasizes the need for early coordinated interventions, but also that treatment within correctional facilities in adult age needs to be comprehensive and take individual patterns of comorbidity into account.

Interviewing intoxicated witnesses: Memory performance in theory and practice.

Memory encoding and recall involving complex, effortful cognitive processes are impaired by alcohol primarily due to impairment of a select few, but crucial, cortical areas. This review shows how alcohol affects some, but not all, aspects of eyewitnesses' oral free recall performance. The principal results, so far, are that: a) free recall reports by intoxicated witnesses (at the investigated BAC-levels) may contain less, but as accurate, information as reports by sober witnesses; b) immediate reports given by intoxicated witnesses may yield more information compared to reports by sober witnesses given after a one week delay; c) an immediate interview may enhance both intoxicated and sober witnesses' ability to report information in a later interview; and d) reminiscence seems to occur over repeated interviews and the new information seems to be as accurate as the previously reported information. Based on this, recommendations are given for future research to enhance understanding of the multifaceted impact of alcohol on witnesses' oral free recall of violent crimes.

To wait or not to wait? Improving results when interviewing intoxicated witnesses to violence.

Witnesses to violent crimes are often alcohol intoxicated, but few studies have investigated the impact of alcohol on witness reports. This study investigated how alcohol intoxication and time of interview affected reports of intimate partner violence (IPV). One hundred thirty six healthy men (N = 66) and women (N = 70) were randomized to an alcohol group (0.8g/kg for men, 0.75g/kg for women) (N = 70) or control group (N = 66), given juice. Participants consumed drinks in a laboratory setting before they witnessed an IPV scenario. Fifty percent of the intoxicated and sober participants were interviewed ten minutes after viewing the film and all participants were interviewed one week later. For the analyses, participants in the alcohol group were divided into two groups (moderately/highly intoxicated) based on their BAC-level. Ten minutes after viewing the event, highly (BAC = 0.08-0.15) intoxicated witnesses gave shorter, but as accurate, reports as moderately intoxicated/sober witnesses. All witnesses gave shorter and less accurate reports one week later compared to immediately after. However, an immediate interview increased completeness one week later. In general, time and high intoxication made witnesses give less detailed accounts of actions and verbal information, but not of objects. Highly intoxicated witnesses reported less actions and verbal information in all interviews, while information regarding objects was reported to a similar extent. At the present BAC-level, it is beneficial to conduct an immediate free recall interview with intoxicated witnesses to obtain a maximum amount of correct information and minimize the negative effect of time.

Alcohol Intoxicated Witnesses: Perception of Aggression and Guilt in Intimate Partner Violence.

Many witnesses to violent crimes are alcohol intoxicated, but research is lacking regarding how alcohol affects their perception of aggression and guilt. This study investigated to what extent alcohol intoxicated eyewitnesses differed from sober witnesses regarding how aggressive and guilty they perceived the involved parts in an intimate partner violence (IPV) situation. Eighty-seven healthy men ( n = 44) and women ( n = 43) were randomized to an alcohol group (0.7 g/kg) or a non-alcohol group. In a laboratory setting, alcoholic/non-alcoholic drinks were consumed before viewing a film depicting IPV between a man and a woman. Ten min after viewing, in an interview, the participants rated how aggressive and guilty they perceived the involved parts to be. Alcohol intoxicated participants perceived both parts' physically aggressive behavior as comparatively less severe, but their neutral behavior as more hostile. Sober witnesses perceived the man to be the most guilty part, whereas intoxicated witnesses distributed guilt more evenly. Alcohol had a strong but complex impact on the perception of aggression in IPV (i.e., heightened during the neutral interaction and lowered during physical aggression). These results may be explained by the cognitive consequences of alcohol's anxiety-dampening effects. Regarding the asymmetric difference in perceived guilt, stereotypical expectations of gender-appropriate behavior in an IPV situation may need to be considered.