RESUMO
The decision-making process of experts in forensic psychiatric investigations (FPI) is complex and reasoning regarding psychiatric diagnosis and severe mental disorder (SMD, the judicial concept central to legal exemption in Swedish law) has severe ramifications. Nevertheless, the qualitative aspects of FPI experts' decision-making process have seldom been studied systematically. METHOD: The participants (N = 41) were FPI experts: forensic psychiatrists (n = 15), forensic psychologists (n = 15) and forensic social workers (n = 11). Using three case vignettes and qualitative content analysis, it was explored how case-specific characteristics could affect which hypotheses FPI experts generated regarding a) psychiatric diagnosis and b) severe mental disorder and c) which information sources they required. Each case vignette described a diagnostically ambiguous case but indicated emphasis on: psychotic symptoms (case 1); personality disorder symptoms (case 2) and neurodevelopmental disorder symptoms (case 3). RESULTS: Experts reasoned in a similar manner regarding generating hypotheses and required information, but also in a case-adapted manner. Experts considered various diagnostic alternatives, and some (e.g. psychosis) were mentioned for all three cases. Other diagnoses were only suggested as hypotheses in certain cases (e.g. case 3: intellectual disability). DISCUSSION: In Sweden, a core basis for SMD is psychotic-like functioning, and psychosis was suggested as a hypothesis for all three cases. Experts reasoned in similar ways regarding SMD in all cases, considering various perspectives for and against SMD. Some case-specific arguments for and against SMD adapted to the psychopathological circumstances were found. These could be related to aspects of the SMD concept that become important to ascertain when the type of psychopathology indicated in the case vignette was present; for example, ascertaining reality monitoring for a person with potential delusions of being followed by a criminal gang requires investigation of criminal history and related conflicts. Taken together, FPI-experts considered a broad range of psychiatric diagnoses in various cases. Their reasoning regarding SMD was both based on general and case-specific (or psychopathology-specific) factors.
RESUMO
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.
Assuntos
Criminosos , Transtornos Mentais , Humanos , Psiquiatria Legal/métodos , Suécia , Reprodutibilidade dos Testes , Transtornos Mentais/diagnóstico , Transtornos Mentais/psicologia , Criminosos/psicologia , Prova PericialRESUMO
Background: Which type of information experts use to make decisions regarding legal insanity within forensic psychiatric investigations (FPI) is relatively unknown, both in general and when considering variations due to case context. It is important to explore this area to be able to counteract the effects of various kinds of cognitive bias. Method: The aim was to explore whether FPI expert groups differed regarding case-specific as well as general use of information types required to make decisions on severe mental disorder (SMD). Three FPI case vignettes were presented to three professional groups involved in FPIs in Sweden (n = 41): forensic psychiatrists (n = 15), psychologists (n = 15), and social workers (n = 11). The participants reported which types of information they required to reach conclusions regarding SMD in each case. They also reported which types of information they had used within general FPI praxis during the previous year and the information types' perceived usefulness. Results: The expert groups differed somewhat regarding what type of information they required for the cases (e.g., results from cognitive testing), but some information was required in all cases (e.g., client's self-report). Regarding the preliminary assessment of SMD in the three cases, minor differences were found. Within the general FPI praxis, experts reported using several information types, while the general perceived usefulness of these sources varied. Discussion: The professional groups relied partly on a "core" of information sources, but some case-specific adaptations were found. The professional groups' inclination to suspect SMD also varied somewhat. This indicates a need to explore the potential consequences of these similarities and differences.
RESUMO
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.
Assuntos
Criminosos , Transtornos Mentais , Viés , Criminosos/psicologia , Psiquiatria Legal/métodos , Humanos , Transtornos Mentais/diagnóstico , Transtornos Mentais/psicologia , SuéciaRESUMO
Non-neurological surgery has both acute and long-term effects on the brain. Markers for Alzheimer pathology may be used to study surgically induced neurological changes relevant for postoperative confusion, asthenia or cognitive decline. Inflammatory biomarkers, total tau (T-tau) and phosphorylated tau (P-tau) were recently shown to increase progressively in the cerebrospinal fluid (CSF) during surgery for nasal CSF leak, suggesting a neuroinflammatory response with signs of neuronal damage. We used a study group of 35 patients, undergoing knee arthroplasty with a spinal blockade and propofol sedation, to replicate this finding. Five CSF biomarkers were analyzed before, 3 h after and on the morning after the interventions: T-tau and P-tau for cortical axonal integrity and tangle pathology, respectively, the 42 amino acids form of amyloid ß (Aß42) for plaque formation, neurofilament light (NFL) for the integrity of large-caliber myelinated axons and glial fibrillary acidic protein (GFAp) for astroglial cell integrity. CSF T-tau concentrations increased significantly during and after surgery (p = 0.028) and were significantly correlated with the administered doses of bupivacaine. P-tau, Aß42 and NFL remained unchanged, while the mean GFAp concentration increased with a large standard deviation. CSF T-tau and P-tau correlated significantly with the CSF/serum albumin ratios as an indicator of blood-brain barrier permeability. Findings from earlier studies showing a significant increase in biomarkers for Alzheimer's pathology during surgery were partly replicated, as neurochemical signs of impaired cortical axonal integrity during non-neurological surgery were detected. Bupivacaine may be involved in these reactions.
Assuntos
Peptídeos beta-Amiloides/líquido cefalorraquidiano , Artroplastia do Joelho/métodos , Biomarcadores/líquido cefalorraquidiano , Proteína Glial Fibrilar Ácida/metabolismo , Proteínas de Neurofilamentos/líquido cefalorraquidiano , Fragmentos de Peptídeos/líquido cefalorraquidiano , Proteínas tau/líquido cefalorraquidiano , Idoso , Idoso de 80 Anos ou mais , Doença de Alzheimer/líquido cefalorraquidiano , Doença de Alzheimer/cirurgia , Análise de Variância , Feminino , Humanos , Hipnóticos e Sedativos/uso terapêutico , Traumatismos do Joelho/líquido cefalorraquidiano , Traumatismos do Joelho/cirurgia , Masculino , Pessoa de Meia-Idade , Propofol/uso terapêuticoRESUMO
BACKGROUND: Surgery launches an inflammatory reaction in the body, as seen through increased peripheral levels of cytokines and cortisol. However, less is known about perioperative inflammatory changes in the central nervous system (CNS).Our aim was to compare inflammatory markers in serum and cerebrospinal fluid (CSF) before and after surgery and evaluate their association with measures of blood-brain barrier (BBB) integrity. METHODS: Thirty-five patients undergoing knee arthroplastic surgery with spinal anesthesia had CSF and serum samples drawn before, after and on the morning following surgery. Cytokines and albumin in serum and CSF and cortisol in CSF were assessed at all three points. RESULTS: Cytokines and cortisol were significantly increased in serum and CSF after surgery (Ps <0.01) and CSF increases were greater than in serum. Ten individuals had an increased cytokine response and significantly higher CSF/serum albumin ratios (Ps <0.01), five of whom had albumin ratios in the pathological range (>11.8). Serum and CSF levels of cytokines were unrelated, but there were strong correlations between CSF IL-2, IL-10 and IL-13, and albumin ratios (Ps <0.05) following surgery. CONCLUSION: Cytokine increases in the CNS were substantially greater than in serum, indicating that the CNS inflammatory system is activated during peripheral surgery and may be regulated separately from that in the peripheral body. CSF cytokine increase may indicate sensitivity to trauma and is linked to BBB macromolecular permeability.
Assuntos
Artroplastia/efeitos adversos , Citocinas/sangue , Citocinas/líquido cefalorraquidiano , Inflamação/sangue , Inflamação/líquido cefalorraquidiano , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Hidrocortisona/líquido cefalorraquidiano , Inflamação/etiologia , Joelho/cirurgia , Masculino , Pessoa de Meia-Idade , ObservaçãoRESUMO
Insulin plays an important metabolic and transmitter role in the central nervous system, but few studies have investigated the relationship between central and peripheral insulin concentrations. 35 patients undergoing knee surgery had cerebrospinal fluid (CSF) samples drawn before, 3 h after, and in the morning following surgery. Serum insulin concentrations increased after surgery and CSF insulin concentrations changed in the same direction with far smaller amplitude. These results indicate that the blood-brain barrier protects the brain from stress-induced peripheral hormonal fluctuations.
Assuntos
Insulina/líquido cefalorraquidiano , Articulação do Joelho/cirurgia , Procedimentos Ortopédicos/efeitos adversos , Complicações Pós-Operatórias/líquido cefalorraquidiano , Idoso , Idoso de 80 Anos ou mais , Barreira Hematoencefálica/fisiologia , Feminino , Humanos , Insulina/sangue , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/etiologia , Estresse Fisiológico/fisiologiaRESUMO
Neurobiological markers in cerebrospinal fluid (CSF) and in serum, previously found to co-vary with destructive personality traits in violent offenders, were explored in a general population sample of 21 patients undergoing knee surgery. Results on the Karolinska Scales of Personality (KSP) and the Temperament and Character Inventory (TCI) were compared with CSF/serum albumin ratios and serum concentrations of beta-trace protein (betaTP) (as markers for blood-brain barrier (BBB) permeability), to CSF/serum albumin ratios between the dopamine and serotonin metabolites homovanillic acid (HVA)/5-hydroxyindoleacetic acid (HIAA) and to CSF and serum ratios between activated thyroid hormone (T3) and its precursor T4. Serum betaTP concentrations correlated with CSF/serum albumin ratios (P=0.018), but not with preoperative serum creatinine concentrations. Serum betaTP correlated significantly with Monotony Avoidance and Impulsiveness; CSF HVA/5-HIAA ratios with Irritability and low Cooperativeness. The betaTP is a potential serum marker for the integrity of the BBB that does not necessitate lumbar puncture. Thyroid hormones did not correlate with personality traits. As reported in forensic psychiatric patients, aggressive, unempathic personality traits were thus associated with increased dopaminergic activity in relation to the serotonergic activity and impulsivity to increased BBB permeability also in a general population group.
Assuntos
Psiquiatria Legal , Neuroquímica , Personalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Planejamento em Saúde Comunitária , Creatinina/sangue , Creatinina/líquido cefalorraquidiano , Feminino , Ácido Homovanílico/sangue , Ácido Homovanílico/líquido cefalorraquidiano , Humanos , Ácido Hidroxi-Indolacético/sangue , Ácido Hidroxi-Indolacético/líquido cefalorraquidiano , Oxirredutases Intramoleculares/sangue , Oxirredutases Intramoleculares/líquido cefalorraquidiano , Joelho/cirurgia , Lipocalinas/sangue , Lipocalinas/líquido cefalorraquidiano , Masculino , Pessoa de Meia-Idade , Inventário de Personalidade , Albumina Sérica/metabolismo , Hormônios Tireóideos/líquido cefalorraquidianoRESUMO
All 74 patients treated with vena cava filter insertion during 1991-2000 at Malmö University Hospital were reviewed. Thirty-nine patients (53%) died during follow-up. Indications for permanent filter insertion (n = 63, age 25-89 years, 35 men) were contraindication for or side effects of anticoagulant treatment, or pulmonary embolism during anticoagulant treatment. Temporary vena cava filters (n = 11, age 19-85 years, three men) were inserted during surgery or thrombolysis. No complications occurred during temporary filter insertion. During 33 (1-120) months of follow-up of patients with permanent vena cava filters 37 patients (59%) died, thrombosis of the inferior vena cava occurred in 14 patients (22%), and recurrent pulmonary embolism in five patients (8%). Vena cava filter insertion should be considered as an alternative treatment in a selected group of patients with contraindications to or insufficient effect of anticoagulant treatment.