[Ethics and law in the application of new technology in forensic psychiatry]. / Ethiek en recht bij toepassing van nieuwe technologie in de forensische psychiatrie.

Background Technological innovations often come hand in hand with ethical and legal challenges. This especially applies to forensic psychiatry due to its legal framework and the often accompanying obligatory nature of treatment. Aim To identify ethical and legal considerations related to new, non-linguistic technologies in which little to no written language is used, in a forensic psychiatric context. Method A concise ethical and legal analysis of several emerging technologies that can (potentially) be applied within forensic psychiatry, based on relevant scientific literature. Results Technologies such as virtual reality, biosensors, and neuro-interventions offer possibilities to improve forensic psychiatric treatment. However, little is known about their effectiveness and integration into treatment, but also regarding ethical and legal aspects. For each technology, we discuss three important considerations, amongst which persuasiveness, informed consent, privacy, data ownership, and mental integrity. These topics serve as starting points for future research. Conclusion To gain timely insight into ethical and legal considerations and incorporate them into development and implementation processes, it is important to integrate knowledge from ethicists, lawyers, healthcare providers, patients, researchers, technology developers, and policymakers.

[The (im?)possibility of a biological substrate for mental disorders]. / Een biologisch substraat voor psychische stoornissen: gouden toekomst of gouden bergen?

BACKGROUND: The constructivist position is often used for psychiatric diseases, in contrast with the general medical view. In the medical view a biological substrate is decisive for a classification as 'disease', which is not the case in the constructivist position.
AIM: We investigate how both positions relate to each other in psychiatric diseases.
METHOD: Analysis based on a conceptual analysis of Ian Hacking's book The Social Construction of What? (1999).
RESULTS: Different objects ought to be distinguished in a constructivist analysis of psychiatric diseases; the disease itself and the idea or concept of that disease. These different objects interact with each other. These interactions can be made explicit by distinguishing interactive kinds from indifferent kinds. Doing so makes it clear that even if a disease is not determined by a biological substrate, this does not imply that a biological substrate is something completely separate from that disease.
CONCLUSION: Hacking's philosophy makes it possible to move beyond the opposition between the medical and the constructivist account of psychiatric diseases by combining both accounts.

Legal insanity and risk: An international perspective on the justification of indeterminate preventive commitment.

Modern legal systems typically link the insanity or diminished responsibility of an offender for a crime committed in the past to his future dangerousness. This nexus serves across legal systems as a justification for the indeterminate commitment of the offender with diminished or no criminal responsibility. Conceptually, however, insanity and risk are not related legal issues. Moreover, empirical research suggests that there is only a weak link between insanity, diminished responsibility and mental illness on the one hand and risk of recidivism on the other. Other risk factors seem to be more important. The inference of risk from insanity or diminished responsibility that lies at the heart of the indeterminate commitment of mentally disordered offenders is therefore problematic. This should lead to a reconsideration of the preconditions for indeterminate commitment of mentally disordered defendants.

Differences in executive functioning between violent and non-violent offenders.

BACKGROUND: A growing body of neuropsychological and neurobiological research shows a relationship between functioning of the prefrontal cortex and criminal and violent behaviour. The prefrontal cortex is crucial for executive functions such as inhibition, attention, working memory, set-shifting and planning. A deficit in these functions - a prefrontal deficit - may result in antisocial, impulsive or even aggressive behaviour. While several meta-analyses show large effect sizes for the relationship between a prefrontal deficit, executive dysfunction and criminality, there are few studies investigating differences in executive functions between violent and non-violent offenders. Considering the relevance of identifying risk factors for violent offending, the current study explores whether a distinction between violent and non-violent offenders can be made using an extensive neuropsychological test battery. METHOD: Male remand prisoners (N = 130) in Penitentiary Institution Amsterdam Over-Amstel were administered an extensive neuropsychological test battery (Cambridge Automated Neuropsychological Test Battery; CANTAB) measuring response inhibition, planning, attention, set-shifting, working memory and impulsivity/reward sensitivity. RESULTS: Violent offenders performed significantly worse on the stop-signal task (partial correlation r = 0.205, p = 0.024), a task measuring response inhibition. No further differences were found between violent and non-violent offenders. Explorative analyses revealed a significant relationship between recidivism and planning (partial correlation r = -0.209, p = 0.016). CONCLUSION: Violent offenders show worse response inhibition compared to non-violent offenders, suggesting a more pronounced prefrontal deficit in violent offenders than in non-violent offenders.

[The importance of neuropsychological assessment for forensic psychiatric evaluations of defendants]. / De betekenis van neuropsychologisch onderzoek voor de rapportage pro Justitia.

BACKGROUND: In criminal law, increased interest is being shown in brain disorders, cognitive impairment and neuroimaging, particularly in connection with pre-trial reports. In a number of cases the contribution made by neuropsychology to the forensic diagnosis is considerable, and there is a need for further clarification.
AIM: To clarify the relevance of the neuropsychological assessment of suspects and to explore the implications for forensic psychiatry.
METHOD: We discuss recent literature and present a characteristic case selected from the Dutch jurisdiction.
RESULTS: On the basis of neuropsychological assessment it is possible to obtain insight into the relation between brain disorders and criminal behaviour. The case that we present shows that the court may consider the influence of cognitive impairment on behavior to be very important.
CONCLUSION: Neurocognitive disorders can make an important contribution to psychiatric assessments of defendants. In the forensic practice a combined diagnostic approach consisting of psychiatric evaluation, neurological assessment of behaviour, imaging techniques and neuropsychological assessment, is clearly preferable.

[Mandatory treatment of forensic psychiatric patients in the Netherlands: costs and benefits in perspective]. / De tbs-maatregel: kosten en baten in perspectief.

BACKGROUND: So far, it is not known what costs and benefits are connected with the tbs-measure, a measure that involves a mandatory treatment programme for forensic psychiatric patients.
AIM: To explore the costs and benefits that the tbs-measure has on society, on other important stakeholders such as victims and/or next-of-kin and the forensic psychiatric patients themselves.
METHOD: We studied the relevant literature.
RESULTS: The average costs of the tbs-treatment programme are 1.5 million euros. Additional costs result from recidivism among patients after tbs-treatment. Of these, 21.2% commit another serious offence after 9 years; this recidivism rate is much lower than rates for former offenders who have not received tbs-treatment (63.8%). Other costs arise through the impact that crimes have on stake-holders. Among the benefits of the tbs-programme are a reduction in psychopathological symptoms and in risk factors and lower recommitment rates (including judicial, non-judicial, voluntary and mandatory recommitment rates). Yet another benefit is the resultant increase of protective factors.
CONCLUSION: Forensic psychiatric patients form a unique group within the mental health system in the Netherlands; these patients have multiple complex psychiatric problems and display serious criminal behavior. This group cannot easily be treated elsewhere in the existing judicial or mental health care system because these systems differ in (judicial) frameworks and have different treatment goals, and the forensic psychiatric patients have different psychiatric disorders and display more serious criminal behaviour than patients in the alternative systems. The daily costs of treatment in the tbs-system are higher that in other systems - but they are not exorbitant, given the complexity of the group. The tbs-measure therefore contributes to the safety of society.

Moving Perspectives on Patient Competence: A Naturalistic Case Study in Psychiatry.

Patient competence, defined as the ability to reason, appreciate, understand, and express a choice is rarely discussed in patients with obsessive compulsive disorder (OCD), and coercive measures are seldom used. Nevertheless, a psychiatrist of psychologist may doubt whether OCD patients who refuse treatment understand their disease and the consequences of not being treated, which could result in tension between respecting the patient's autonomy and beneficence. The purpose of this article is to develop a notion of competence that is grounded in clinical practice and corresponds with the experiences of patients with obsessions and/or compulsions. We present a naturalistic case study giving both the patient's and the therapist's perspective based on in-depth interviews and a narrative analysis. The case study shows that competence is not merely an assessment by a therapist, but also a co-constructed reality shaped by the experiences and stories of patient and therapist. The patient, a medical student, initially told her story in a restitution narrative, focusing on cognitive rationality. Reconstructing the history of her disease, her story changed into a quest narrative where there was room for emotions, values and moral learning. This fitted well with the therapist's approach, who used motivational interventions with a view to appealing to the patient's responsibility to deal with her condition. We conclude that in practice both the patient and therapist used a quest narrative, approaching competence as the potential for practical reasoning to incorporate values and emotions.

[Psychiatric comorbidity: theoretical and clinical dilemmas]. / Psychiatrische comorbiditeit: theoretische en klinische dilemma's.

BACKGROUND: The high prevalence of psychiatric comorbidity is usually considered to be a problematic artefact of the DSM. Clinicians appear to be reluctant to register comorbid diagnoses. AIM: To provide insight into the concept of 'psychiatric comorbidity', so that the phenomenon can be dealt with more efficiently in clinical practice. METHOD: We studied the literature and performed a theoretical analysis. RESULTS: The high prevalence of psychiatric comorbidity is closely linked to the structure of the DSM and is leading increasingly to practical and theoretical problems. These problems have stimulated the development of several valuable alternative models of psychopathology. In the context of these developments, however, the use of terms such as 'artificial' has led to a needless and unfruitful polarisation of the debate. The debate needs to focus primarily on the usefulness of various models for patient care and research. CONCLUSION: Psychiatric comorbidity is an inevitable consequence of a categorical approach to psychopathology, which is basically legitimate. As long as the dsm in its current form constitutes an important part of our diagnostic 'arsenal', we advise clinicians to register comorbid classifications in as much detail as possible and at the same time to give close attention to the correct interpretation of the phenomenon.

[Neurolaw: its relevance for forensic psychiatry]. / Neurolaw: de relevantie voor de forensische psychiatrie.

BACKGROUND: Neurolaw is a new interdisciplinary area of research which investigates, from different perspectives, the significance of the neurosciences for law. AIM: To clarify the relevance of neurolaw for forensic psychiatry. METHOD: The importance of neurolaw developments for forensic psychiatry was analysed on the basis of recent literature. RESULTS: Some of the developments in the field of neurolaw research concern issues that are currently evaluated by forensic psychiatrists, such as risk of recidivism and legal insanity. CONCLUSION: Developments in neurolaw are relevant for forensic psychiatry in a number of ways. An important problem, not yet resolved, is to what extent psychiatry will be prepared to help in shaping these developments.

[Self-experience in the early phase of psychosis: a phenomenological approach]. / Zelfbeleving in de vroege fase van psychose: een fenomenologische benadering.

BACKGROUND: The early detection of psychotic disorders is seen to be increasingly important. Authors of recent articles are adopting a phenomenological approach, taking the view that changes in self-experience represent a major prodromal feature of psychotic disorders. AIM: To find out what a phenomenological approach can contribute to the study of the early phase of psychotic disorders. METHOD: We discuss the literature that explores to what extent changes in self-experience are a central phenomenon in the prodromal phase of psychotic disorders. We also present a phenomenological model that explains these changes. RESULTS: Characteristic changes in self-experience during the prodromal phase of psychotic disorders can provide the framework for an empirical, phenomenological explanatory model. CONCLUSION: In an empirical, phenomenological approach early changes in a patient’s self-experience are considered to play a central role. There are some indications that semi-structured interviews focusing on changes in a patient’s self-experience can contribute to the early detection of psychotic disorders.

A systematic review of the literature about competence and poor insight.

OBJECTIVE: Formally, incompetence implies that a patient cannot meet the legal requirements for informed consent. Our aim was to review the scientific literature on the relationship between competence and insight in patients with psychiatric disorders, how competence and insight are connected in these patients and whether there are differences in competence and insight among patients with different disorders. METHOD: A search in PubMed/Medline was performed. Articles were assessed on relevance criteria by two independent reviewers. Study design, population, variables, and outcomes were extracted. RESULTS: Seven articles were included on studies of psychiatric inpatients and outpatients and of psychotic and non-psychotic patients. All studies used the MacArthur Competence Assessment Tool (MacCAT). All studies but one found a strong correlation between poor insight and incompetence. Psychotic patients with poor insight are very likely to be incompetent, and psychotic patients with adequate insight are generally competent. One well-executed study showed that in non-psychotic disorders, however, another relationship emerges; competence and insight do not completely overlap in these patients. CONCLUSION: Most incompetent psychotic patients have poor insight, but non-psychotic patients with adequate insight were incompetent in a substantial number of cases. In sum: non-psychotic patients with adequate insight can be incompetent.

[Seven views on mental disorder]. / Zeven visies op een psychiatrische stoornis.

BACKGROUND: Anyone attempting to devise a system for classifying mental disorders, such as DSM-5, needs to know what is meant by a mental disorder. This matter is also highly relevant for doctors in their daily practice and for persons involved in scientific research. AIM: To present and discuss important views on the concept of mental disorder. METHOD: Recent relevant literature is discussed, the main emphasis being on philosophical studies of the concept of mental disorder. RESULTS: None of the views discussed provides a satisfactory answer to the question of how mental disorder should be defined and demarcated. Each view, however, does contain valuable points and elements that may help to offer a meaningful perspective on mental disorder. CONCLUSION: Mental disorder is a complex concept. The way in which it is defined and applied has far-reaching consequences. Psychiatry has a duty to define this concept as clearly and accurately as possible.