Autism spectrum disorder (ASD) and sexual offending: A systematic review.

The relationship between autism spectrum disorder (ASD) and sexual offending (SO) is an overlooked issue, both in clinical practice and in research. Based on a pre-specified protocol (PROSPERO: CRD42024501598), we systematically searched Pubmed and Scopus, between January 1st, 1994 and January 12th, 2024, for articles related to SO in ASD. Study quality was assessed with study design-specific tools (Study Quality Assessment Tools, NHLBI, NIH). We found 19 relevant publications (five cross-sectional studies, two case-control studies, and 12 case reports). Seven of the studies were deemed of "good" quality, the rest as "fair". Included studies addressed three key aspects: 1) psychopathological characteristics of individuals with ASD that increase the risk of committing SO; 2) intervention strategies for individuals with ASD and SO; 3) involvement of individuals with ASD and SO in the justice system. Overall, while there is an increasing interest in this topic, more rigorous study designs, including randomised controlled trials, are needed to inform clinical practice and healthcare and social policies.

Excellence in forensic psychiatry services: international survey of qualities and correlates.

BACKGROUND: Excellence is that quality that drives continuously improving outcomes for patients. Excellence must be measurable. We set out to measure excellence in forensic mental health services according to four levels of organisation and complexity (basic, standard, progressive and excellent) across seven domains: values and rights; clinical organisation; consistency; timescale; specialisation; routine outcome measures; research and development. AIMS: To validate the psychometric properties of a measurement scale to test which objective features of forensic services might relate to excellence: for example, university linkages, service size and integrated patient pathways across levels of therapeutic security. METHOD: A survey instrument was devised by a modified Delphi process. Forensic leads, either clinical or academic, in 48 forensic services across 5 jurisdictions completed the questionnaire. RESULTS: Regression analysis found that the number of security levels, linked patient pathways, number of in-patient teams and joint university appointments predicted total excellence score. CONCLUSIONS: Larger services organised according to stratified therapeutic security and with strong university and research links scored higher on this measure of excellence. A weakness is that these were self-ratings. Reliability could be improved with peer review and with objective measures such as quality and quantity of research output. For the future, studies are needed of the determinants of other objective measures of better outcomes for patients, including shorter lengths of stay, reduced recidivism and readmission, and improved physical and mental health and quality of life.

Between psychopathy and deviant socialization: A close look at the mafia men.

The Italian mafia organizations represent a subculture with values, beliefs and goals that are antithetical to and undermining of the predominant society. The conduct of individual members includes such extreme violence for material gain, it may at least superficially suggest a severe personality disorder. Since the first edition of the DSM and into the 21st century, various terms have been used, sometimes interchangeably, but over time inconsistently, to designate the mentality and practices of mafia members. Only recently has the psychology of mafia members become a focus of serious scientific study. Following broader national multicenter research, the present study aimed at investigating the possible differences in psychopathy between those mafia associates who had been convicted only of mafia association (Group A, bosses), and those who were also convicted of violent crimes (Group B, soldiers). The Psychopathy Checklist-Revised (PCL-R) was administered to n = 48 male inmates convicted of mafia association (Mage 45.0 years, SD 10.9, range 20-80 years); Group A consisted of n = 26 (54%) subjects, Group B n = 22 (46%). Most of the sample (73%) did not manifest psychopathy (PCL-R ≥ 25) nor Mann-Whitney U test disclosed significant differences in the total PCL-R scores between the study groups. We found significantly higher scores of PCR-R factor 1 (interpersonal / affective) in the members of the mafia association also convicted of violent crimes (PCL-R F1, group A: 5.8 ± 3.7; group B: 7.9 ± 3.5; p < 0.05), this difference appeared explainable on the basis of a higher component of affective psychopathy. These initial results add to the limited literature on mafia and psychopathy and seem to suggest the existence of a specific component of psychopathy in the subgroup of mafiosi with overtly violent conduct.

Reporting Incidents in the Psychiatric Intensive Care Unit: A Retrospective Study in an Italian University Hospital.

ABSTRACT: To evaluate the characteristics of the reported workplace violence in a psychiatric intensive care unit (PICU) by analyzing an electronic hospital incident reporting system (IRS). One hundred thirty reports were retrieved from January 2017 to June 2020, referring to assaults committed by patients (71% males) with an average age of 29.8 years (SD, 14.9). The most frequent psychiatric diagnosis was a neurodevelopmental disorder (33%). Physical aggression (84%) was more frequent than the other types of aggression. Nurses and unlicensed assistive personnel were the most frequent victims (65%). Aggressions were more frequent on Friday (18%) and between 4 p.m. and 8 p.m. (35%). A total of 64.9% of the incidents happened in the first 5 days of hospitalization. A significant association between physical aggression and diagnosis of neurodevelopmental disorder emerged. IRS could be helpful to identify high-risk patient groups and develop clinical strategies to reduce adverse events in clinical practice.

Antipsychotic Polypharmacy and High-Dose Antipsychotic Regimens in the Residential Italian Forensic Psychiatric Population (REMS).

Few data exist regarding treatment with antipsychotics in forensic psychiatric patient populations with high social dangerousness. We performed a secondary analysis of 681 patients treated with at least one antipsychotic, extracted from a 1-year observational retrospective study, conducted on 730 patients treated in the Italian Residencies for Execution of Security Measures (REMS) (96.4% of the REMS population). We aimed at investigating antipsychotic polypharmacy (prescription of two or more concomitant antipsychotics) and high dose/very high-dose antipsychotics, as well as the possible factors associated with such therapeutic regimens. High dose/very high-dose antipsychotics were defined as a prescribed daily dose to WHO-defined daily dose ratio greater than 1.5 or 3.0, respectively. Binary logistic regression analysis was used in three models to test possible predictors of antipsychotic polypharmacy, high-dose antipsychotics, and very high-dose antipsychotic prescription. Antipsychotic polypharmacy resulted in n = 308 (45.2%) of the patients, n = 346 (50.8%) received high-dose antipsychotics, and n = 96 (14.1%) very high-dose antipsychotics. The multivariate analysis disclosed an association between antipsychotic polypharmacy and male gender (odds ratio (OR): 2.75 and 95% CI: 1.34-5.65), long-acting injectable (LAI) antipsychotic prescription (OR: 2.62 and 95% CI: 1.84-3.74), and aggressive behavior in REMS (OR: 1.63 and 95% CI: 1.13-2.36). High-dose antipsychotics were also associated with male gender (OR: 2.01 and 95% CI: 1.02-3.95), LAI antipsychotic prescription (OR: 2.78 and 95% CI: 1.95-3.97), and aggressive behavior in REMS (OR: 1.63 and 95% CI: 1.12-2.36). The use of antipsychotic polypharmacy and high-dose antipsychotics is frequent in the REMS population. These results might depend on regulatory and organizational aspects of the REMS system, including variability in structures, lack of a common model of care, and lack of stratified therapeutic security.

Differences Between Readmitted and Non-readmitted Women in an Italian Forensic Unit: A Retrospective Study.

The main objective of this study was to compare readmitted (RW) and non-readmitted (NRW) female psychiatric patients after being conditionally or unconditionally released from Italian inpatient forensic psychiatry services, in order to identify variables that were significantly linked with readmission. This study included all patients who were discharged from the female Residences for the Execution of the Security Measure (REMS) of Castiglione delle Stiviere from January 2008 to June 2015 who were not readmitted until December 31, 2018 (48). In addition, data were collected on female patients who were discharged from the same REMS before 2008 and readmitted from January 2008 to December 2018 (42). A key finding of our study was that the readmission into a female REMS was positively associated with the presence of substance use disorders (SUD) and a primary diagnosis on Axis II. To a lesser extent, younger age, being unconditionally discharged when first released, having had a shorter length of inpatient stay and having committed a crime against property for the first REMS admission was also variables that were apparently linked with readmission. The present research continues the previous research on gender-specific mentally ill offenders. Hence, the decision to proceed separately with a sample of men only and one of women only. For all these reasons, young female patients with personality disorder and SUD perhaps should remain longer in REMS and be released with conditions. In most European countries, the length of stay depends on the clinical condition and risk assessment, with some exceptions where the courts set a maximum length of stay at the outset, as in Italy. All the factors listed above influence the risk assessment. Finally, from integrating these findings into the increasing international literature on conditional release and considering the recent changes in the Italian forensic treatment model, we recommend continuing research on individual risk and protective factors as well as risk assessment instruments on conditionally and unconditionally released inpatients with genders studied separately.

Non-intimate Relationships and Psychopathic Interpersonal and Affective Deficits as Risk Factors for Criminal Career: A Comparison Between Sex Offenders and Other Offenders.

Sex-offenders are at risk of criminal recidivism. For the treatment to be truly effective, it must be individualized. For this purpose, an accurate assessment should focus on criminological, psychological, and psychopathological features. The present study compared sex offenders with other offenders on historical experiences (i.e., problems with violence, anti-social behaviors, problems with personal relationships, problems with substance use, traumatic experiences, and parenting style). In addition, given the association between life events and psychopathy, we explored whether the relation between life events and crime type (sexual crime vs. other types of crime) might be moderated by psychopathy traits (interpersonal and affective deficits and antisocial behavior). Eighty-eight sex offenders (76% of whom child molesters) and 102 other offenders were included. The Historical, Clinical and Risk Management - 20 item Version 3 (HCR-20V3) and Psychopathy Checklist-Revised (PCL-R) were administered. The scores of the HCR-20V3 Historical scale items were computed to assess life events. The scores of the PCL-R factors, F1 Interpersonal affective deficits and F2 Antisocial behavior, were recorded. The presence of a history of problems with non-intimate relationships was the only significant risk factor for sexual crime compared with other crimes. Interpersonal and affective deficits provided an increased likelihood of being sex offenders as compared with other offenders when problems with non-intimate relationships were possibly/partially or certainly present.

DSM-5 personality trait facets amongst child molesters: an exploratory comparison with other types of offenders.

BACKGROUND: DSM-5 provided a dimensional model of personality disorders which may be more clinically informative for the assessment and management of prisoners than a categorical one, as diagnoses of personality disorders alone cannot explain the type of violence. The role of DSM-5 personality facets is however understudied in child molesters, and no study compared these clinical features between individuals who have committed sex crime against children and those who have committed other types of crime. The present study compared DSM-5 personality trait facets between prisoners who had committed sex crime against children, prisoners who had committed property crime (i.e., robbery, fraud) and those who had committed crime against the person (i.e., homicide, assault or violence not implying a sexual element). A further aim was to explore which facets were associated with sex crime against children as compared with the other types of crime, controlling for socio-demographics (age, gender), psychiatric comorbidity (presence of any psychiatric diagnoses) and general psychopathy traits. METHODS: One hundred sixty-seven prisoners participated (91 had committed sex crime against children, 25 property crime, and 51 committed a crime against the person) and completed the Personality Inventory for the DSM-5 and the Psychopathy Checklist-Revised. RESULTS: Prisoners who had committed sex crime against children reported higher Restricted Affectivity traits than those who had committed property crime and crime against the person and higher Irresponsibility traits than those who had committed property crime. The results of a multinomial logistic regression analysis showed that on the one hand being a man, having a higher age, and the presence of a psychiatric comorbidity were more likely to be related to sex crime than property crime, on the other hand higher Irresponsibility personality traits, being a man, and the presence of a psychiatric comorbidity were more likely to be related to sex crime against children than crime against the person. CONCLUSIONS: The Irresponsibility facet might be specific to child molesters and can differentiate this group from offenders who have committed other crime types. This facet might be considered a key target of a tailored assessment and treatment planning during clinical practice with child molesters.

Women and men of mafia between traditional cultural contexts and new social roles.

The Italian mafia organizations represent a subculture with values, beliefs, and goals that are antithetical to and undermining of the predominant society. The conduct of individual members includes such extreme violence for material gain, it may at least superficially suggest a severe personality disorder. Since the first edition of the DSM and into the 21st century, various terms have been used, sometimes interchangeably, but over time inconsistently, to designate the mentality and practices of mafia members. Only recently has the psychology of mafia members become a focus of serious scientific study. For the first time, investigators for the present study applied instruments, including the PCL-R, to examine for character psychopathology and specifically degrees of psychopathy in male and female mafia members, 20 female and 21 male members. Results showed some gender difference with the women having a higher score on Factor 1, in contrast to men who showed a lower score. Psychopathy and personality disorder were not found to be associated with membership in the mafia for either gender. Some psychopathic traits and gender differences warrant further research. Meanwhile these findings are consistent with a mentality characterized by beliefs and practices determined by a deviant culture rather than psychopathology.

An unusual case of serial poisoning of family members.

The authors present an unusual criminal case of delusionally motivated, serial intrafamilial killings by a psychotic offender. Because the offender retained instrumental rationality and killed his victims by stealth, viz. surreptitious poisoning, the killing of his first victims went undetected. Persecutory delusions of being poisoned not uncommonly result in defensive violence, whereas in this case, religious delusions resulted in the mentally ill person killing others by poisoning them. Here, the psychotic offender killed his victims by means of poisoning based upon motivation driven by religious delusions. This case illustrates the importance of index of suspicion and appropriate investigation of mysterious deaths, and careful forensic psychiatric assessment to distinguish delusional versus extreme overvalued belief-motivated killings in addressing the insanity defense.

Forensic psychiatric evaluation of 187 homicidal assailants with and without a schizophrenia spectrum disorder: Clinical, criminological and behavioral characteristics.

Intentional homicide, a declining phenomenon in Italy, represents one of the most extreme forms of violence. A specific subgroup of homicidal assailants is represented by those affected by mental disorders, where the relationship between psychopathology and characteristics of the homicidal attack is not yet fully understood. We analyzed the case files of 187 homicides or attempted homicides, in which the defendant had undergone a forensic psychiatric evaluation within the previous 10 years from a single forensic psychiatric center. We described and analyzed the perpetrator, victim and criminological characteristics of the study cases. A diagnosis of a schizophrenia spectrum disorder, a victim who was the perpetrator's biological child and absence of a personality disorder diagnosis were associated with an increased probability of having been adjudicated as lacking or having substantially diminished criminal responsibility due to a mental disorder. Homicidal assailants with a schizophrenia spectrum disorder showed some differences in criminological characteristics compared with murderers without a schizophrenic spectrum disorder, including a higher incidence of parricide, interruption of pharmacotherapy before the crime and disorganized post-crime behavior.

The psychopathic dimension in women of mafia.

The authors focus their interest on the socially deviant mafia world, especially on the question of a psychopathic dimension of individuals in mafia. From the scientific point of view this continues to be an unknow world. In all these cases, individuals in mafia, their "feats", their profiles seem to correspond to popular conceptions of the psychopath. Even less known is the women's role in criminal organizations. Their historical role in recent decades has gradually shifted and become more important than it was in the past. The investigators' interest was focused on identifying the prevalence of the psychopathic dimension in mafia women. So the authors examined a sample of 20 convicted mafia women coming from Campania and Calabria, the regions of Camorra and 'Ndrangheta respectively, historical Italian criminal organizations. These women inherited their roles from previous bosses and successfully carried on the criminal business. The authors compared this sample of mafia women with a sample of female offenders with full criminal responsibility who were in common female prisons. Like men of mafia, the women of mafia have a low prevalence of the psychopathic dimension. Further research is necessary to identify the psychopathic dimension in larger samples of women, and then compare them with similar male samples.

Women and Men who Committed Murder: Male/Female Psychopathic Homicides.

The present study was designed to compare gender differences in psychiatric diagnosis with the dimension of psychopathy in women and men who had attempted or committed homicide. The study samples consisted of 39 homicidal females and 48 homicidal males who were confined in one of Italy's REMS or prison facilities in two southern provinces of Italy (Puglia and Basilicata). Assessment instruments included the SCID-5, the PID-5 IRF, and the PCL-R. Each gender group was stratified according to the level of criminal responsibility for the homicidal offense (full, partial, absent), and after assessments, according to the degree of the psychopathic dimension. There were clear gender differences in homicidal individuals. Female offenders were less likely to have had a record of criminal charges/convictions or imprisonment, and their homicides were more often intrafamilial, victimizing especially of their children, whereas males targeted intimate partners and extrafamilial victims. In the entire group, there was an inverse relationship between the level of psychopathy and the personality disorder on one side, and the psychotic disturbance on the other. Factor 2 (lifestyle/antisocial dimension) of the PCL-R was higher among the homicidal males, whereas females tended to score higher on Factor 1 (the interpersonal/affective dimension). Finally, if the psychopathic dimension is a qualifier for antisocial personality disorder, as indicated in DSM-5, this appears to be less true for females who tend to have other personality disorders.

Female psychopathy: A descriptive national study of socially dangerous female NGRI offenders.

Understudied is psychopathy in females, particularly socially dangerous NGRI females, where the construct could be of forensic, clinical and criminologic significance. Italy's recent transformation of its mental health system created the context for studying such a population on a national level. Throughout the twentieth century until their closure in 2015, offenders found to be not guilty by reason of insanity (NGRI) and socially dangerous were placed in one of the the six high security hospitals in Italy (OPGs). Only one hospital, the Castiglione delle Stiviere maximum security hospital (OPG) in North Italy, treated female offenders, who came from all parts of Italy. The authors studied 66 of all 86 women in Castiglione delle Stiviere OPG. The aims of this study were to identify the prevalence of psychopathy in NGRI female offenders and eventually to identify any phenotypic gender-specific features of psychopathy. The SCID I and II interviews and other tests (MMPI-2, MCMI-III, R-Bans) were administered to all the women. Clinical historical information was obtained. Finally for all women who consented to participate in the study, the researchers administered the PCL-R version validated for the Italian population. The final sample consisted of 66 women, who were deemed NGRI and socially dangerous. Here the authors present the final results as well as limitations of the research.

Translating clinical findings to the legal norm: the Defendant's Insanity Assessment Support Scale (DIASS).

Insanity definition and the threshold for satisfying its legal criteria tend to vary depending on the jurisdictions. Yet, in Western countries, the legal standards for insanity often rely on the presence of cognitive and/or volitional impairment of the defendant at crime time. Despite some efforts having been made to guide and structure criminal responsibility evaluations, a valid instrument that could be useful to guide forensic psychiatrists' criminal responsibility assessments in different jurisdictions is lacking. This is a gap that needs to be addressed, considering the significant forensic and procedural implications of psychiatric evaluations. In addition, differences in methodology used in insanity assessments may also have consequences for the principle of equal rights for all citizens before the law, which should be guaranteed in the European Union. We developed an instrument, the Defendant's Insanity Assessment Support Scale (DIASS), which can be useful to support, structure, and guide the insanity assessment across different jurisdictions, in order to improve reliability and consistency of such evaluations.

Psychopathy in Italian female murderers.

Over the years, the number of homicides in Italy has progressively decreased, ultimately becoming one of the lowest rates in Europe (357 = 0.7 per 100,000 inhabitants in 2017, according to ISTAT). The number of homicides committed by women was about 9% of the total number of homicides during our study period. The percentage has increased in recent years because the total number of homicides has decreased without a proportionate decrease in the number of female homicides. Indeed, murder is an unusual type of crime for a woman and is often associated with a mental disorder, so when a woman committed a homicide, a psychiatric assessment was often performed. A forensic psychiatry expert was assigned to investigate the offender's psychopathology and mental state at the time of the offense. The root causes of the crime remained unexplained, however, due to the lack of a psychiatric precedent to justify this kind of assessment. The role of psychopathy in homicide has seldom been studied in female offenders, even though psychopathy has an important role in violent crimes. The investigators examined, clinically and historically, a sample of women who committed murder with different levels of criminal responsibility (female homicide offenders found not guilty by reason of insanity, having partial criminal responsibility, and convicted as criminally responsible and sentenced to prison) to identify the prevalence of the psychopathic dimension and its possible role in this sample. Prevalence and degree of psychopathic traits were examined in these female offenders using the Psychopathy Checklist-Revised. This study showed that females who had committed homicide were likely to suffer from mental illness; most of the homicidal acts were committed impulsively; and most female homicides occurred within the family, especially among women who were psychotic, but less so if they were psychopathic. Psychopathy tended to co-occur more with personality disorders than with psychotic psychopathology. Psychopathy was more evident among female homicide offenders who had been abused or traumatized. Psychopathic women who killed had high factor F1 scores and low antisocial component of factor F2.

The factors associated with forensic psychiatrists' decisions in criminal responsibility and social dangerousness evaluations.

Despite the central role in criminal trials, there is little research on the decision-making processes of experts in forensic psychiatry. We aimed to investigate the role of sociodemographic, psychopathological, and criminological characteristics in forensic psychiatric decisions on criminal responsibility and social dangerousness in criminal trials. We analyzed 302 forensic psychiatric reports provided by 16 forensic psychiatrists from the North, Central and Southern Italy. Defendants' psychiatric symptom severity was evaluated through the 24-item Brief Psychiatric Rating Scale (BPRS), the Clinical Global Impression (CGI) scale and the Global Assessment of Functioning (GAF). Defendants judged not criminally responsible (Not-CRDs) presented with more severe psychiatric symptoms (positive symptoms, negative symptoms, manic excitement / disorganization), were more likely to be female, to be affected by a schizophrenia spectrum disorder, or bipolar spectrum disorder and to have had a higher number of previous psychiatric treatments and previous involuntary hospitalizations compared to their criminally responsible counterparts. Not-CRDs affected by a schizophrenia spectrum disorder, personality disorder, with severe psychiatric symptoms and with histories of criminal convictions and more victims were more likely to have received a judgment of social dangerousness. The forensic psychiatric evaluations were carried out on average of 770 days after the time of the crime, which in light of the other results, suggests an effect of the perceptions of the expert on the judgment of responsibility, raising the possibility of time bias on forensic judgments concerning defendants' mental responsibility.

A multidisciplinary approach in overkill: Analysis of 13 cases and review of the literature.

The term overkill usually indicates the infliction of massive injuries by far exceeding the extent necessary to kill the victim. Only few articles or textbooks report this term that is mostly associated with sex-motivated homicides where injuries, generally stabbing, are directed to significant sexual parts of the body. The aim of this study is to shed light on the phenomenon of overkill by reviewing some cases personally analyzed by the authors from both a forensic pathology rather than forensic psychiatry views. The reported results coupled with the literature revision confirmed the importance of a complete analysis of all criminological elements for better defining overkill cases.

Psychopathy and Female Gender: Phenotypic Expression and Comorbidity; A Study Comparing a Sample of Women Hospitalized in Italy's Maximum Security Facility with Women Who were Criminally Sentenced and Imprisoned.

Various studies have shown that women with psychopathy tend to commit crimes that are less violent than those of psychopathic men. The present study was designed to address the influence of psychopathy on the crimes committed by female offenders. A national sample of female offenders found NGRI or of diminished responsibility and at risk for criminal recidivism (OPG patients) was compared with a sample of female offenders who were convicted and imprisoned. Results of this comparison between the two groups of female offenders indicate that psychopathy is a transversal psychopathological dimension which may or may not be associated with other mental disorders. In both samples, the most commonly reported offenses among women with high PCL-R scores were minor offenses, not particularly violent, but they appear to be related to typical psychopathic features such as superficial charm, pathological lying, and manipulation.