[Risk assessment of sex offenders in a German-speaking sample. Applicability of PCL-SV, HCR-20+3, and SVR-20]. / Gutachterliche Risikoeinschätzung bei Sexualstraftätern. Anwendbarkeit von PCL-SV, HCR-20+3 und SVR-20.

Regarding the relatively high relapse rates of sex offenders, an increasing need for forensic prognosis reports, doubts about their validity, and a continued lack of qualified forensic experts makes the supposedly simple application of instruments such as the Psychopathy Check List Screening Version (PCL-SV), HCR-20+3, or the Sexual Violence Risk 20 (SVR-20) very tempting. Those tools supply numeric values for quantifying assumed risk and have begun appearing more frequently in forensic reports. Their use for specific collectives without prior examination of accuracy, admissibility, and accountability may lead to serious mistakes and risks. This study by the Forensic Department of the Psychiatric University Hospital in Basel, Switzerland, is part of a larger cohort study on forensic risk assessment. It investigates among others the differential indication for PCL-SV, HCR-20+3, and SVR-20. In the present study, 64 sex offenders were retrospectively rated with these three instruments based on their respective reports for prior risk assessment, including criminal reports. Those ratings were then compared with prior results from the Structured Risk Assessment of Basel, as performed by the experts. Results of this study confirm the utility of PCL-SV, HCR-20+3 and SVR-20 in a German-speaking sample of sex offenders primarily as a scientific instrument. Beyond that, these instruments may also be used literally as a checklist. Their use for risk quantification should be limited primarily to the subgroup of antisocial and physically aggressive sex offenders.

Use of army weapons and private firearms for suicide and homicide in the region of Basel, Switzerland.

OBJECTIVES: Switzerland has one of the highest rates of firearm suicides in the world. International studies show a positive correlation between the rate of households with guns and femicides with guns. Because its defense system requires a militia to keep personal firearms at home, Switzerland has a high rate of households with a gun. METHODS: Records of suicides in the region of Basel between 1992 and 1996 were reviewed. Suicides with either army weapons or private firearms and suicides by other means were compared. Methods and types of homicides that occurred in the region at the same time were also analyzed. FINDINGS: Firearm suicides were clearly the most frequent means of suicide. They were also used in 30.0% of domestic homicides, although other means were used at similar rates. Firearms for suicide were mainly used by men, especially army weapons. These men were younger, professionally better qualified, and fewer had ever been treated in one of the local state psychiatric services. DISCUSSION: The use of firearms for suicide, rather than homicide, and particularly of army weapons by young, well-educated men, requires more attention in debates and informed policy regarding access to firearms and suicide prevention in Switzerland.

[Examination of victims of sexual violence--the problem of false reports]. / Untersuchungen von Opfern sexueller Gewalt- das Problem der Falschanzeige.

Some people claim to be victims of sexual violence and abuse the judicial system by filing a false police report. Generally, motivation for such behaviour is assumed to be that the self-proclaimed victims try to avoid taking responsibility for a sexual act in which they have been an active, willing participant. Concise motivations include attempts to mask a sexual affair from a partner, or to mask a first sexual intercourse by pretending to be the victim of an act of violence. By the nature of many judicial systems that are abused for such purposes, clinical forensic specialists are confronted with such cases far more often than clinical doctors not serving judicial authorities. In adults, history, injuries and other findings often show patterns that can be recognized as evidence of deception or as signs for self-inflicted injury for the trained specialist. This is far less often the case in infants and children.

Assisted suicide as conducted by a "Right-to-Die"-society in Switzerland: a descriptive analysis of 43 consecutive cases.

BACKGROUND AND METHODS: The Swiss "Right-to-Die"-society EXIT enables assisted suicide by providing terminally ill members with a lethal dosage of barbiturates on request. This practice is tolerated by Swiss legislation. EXIT insists on its assumption that people with serious illness and suffering have the competency to take such a decision. The case of two patients who committed suicide a short time after their release from a psychiatric clinic raised some doubts about the practice of EXIT. The files of all 43 cases of suicide assisted by EXIT between 1992 and 1997 in the region of Basle kept in the Institute of Forensic Medicine were examined for accuracy of the medical data. This sample was compared for age, gender-ratio and prior psychiatric treatment with 425 ordinary suicides in the same region. An attempt was made to assess whether only terminally ill and people with intolerable suffering had been assisted with suicide and what efforts EXIT had made to rule out psychiatric illnesses or poor social conditions as the reason for the wish to die. RESULTS: A medical report of the treating doctor(s) was in the files in only five cases. The "EXIT" cases where older than the "ordinary"-sample. Among those over 65 years old there were almost twice as many women as men. 16 of the 24 women older than 65 years were widowed. There were 20 cases of cancer; but in eleven cases medical files revealed no apparent medical condition to explain a death-wish. Five of the patients declared a social loss or fear of such loss as the reason for their wish to die. Six persons had formerly been in psychiatric care, though this was not mentioned in the files. CONCLUSIONS: Due to the scarcity of information in the files as regards previous palliative care, the high proportion of old women and the high percentage of people not suffering from a terminal illness compared to the literature we conclude that psychiatric or social factors are not an obstacle for EXIT to assist with suicide.

Contingent negative variation and attention in schizophrenic and depressed patients.

Contingent negative variation (CNV) is supposed to be a psychophysiological indicator of attention and arousal. Both have been reported to be deteriorated in schizophrenic and depressed patients. Thirty-four patients with major depression, 43 patients with schizophrenia and 49 healthy subjects were investigated during acute illness with a complex three-stimulus go/no-go task which requires different states of attention: trials consisted of three complex figures that were tachistoscopically presented. Three identical figures had to be confirmed by pressing a button (target condition). CNV was measured: (1) after the first figure waiting for the second (baseline condition), (2) after two identical figures waiting for the third (response-relevant condition), (3) after two different figures waiting for the third (response-irrelevant condition). The response-relevant condition compared to baseline significantly intensified CNV in healthy controls and to a minor extent in depressed patients but not in schizophrenics. In the response-relevant conditions in healthy controls, CNV was significantly reduced compared to the response-relevant condition. This clear discrimination between response-relevant and response-irrelevant conditions was not observed in either group of patients. Thus, the applied CNV paradigm was able to discriminate schizophrenic and depressed patients from healthy controls. Furthermore, subtle differences between schizophrenic and depressed patients were detected, reflected by the different CNV development across experimental conditions.

[Diagnosis and therapy of personality disorders]. / Diagnostik und Therapie von Persönlichkeitsstörungen.

Approximately 10% of the unselected population are affected with personality disorders, among the patients of psychiatrists and family doctors the quota goes up to 40%. Personality disorders comprise deeply ingrained and enduring behaviour patterns, manifesting themselves as inflexible responses to a broad range of personal and social situations. They are stable and lead frequently to subjective distress and/or to impaired social functioning. The division in subgroups is made on the reason of typical patterns of experience and behaviour, but overlapping between different subtypes is frequent. People with personality disorders often come into conflicts with their environment because of their maladaptive behaviour which lead to crises and need of intervention. Psychopharmaca can be given in such situations, but substances with an addictive potential like benzodiazepines should not be prescribed for a longer period. The long-term psychotherapy of personality disordered persons requires an individual planing after a careful analysis of the behaviour pattern and should focus on concretely defined and reachable aims. Personality disordered persons belong to the most difficult patients, their long-term treatment demands appropriate therapeutic skills. In the primary care family doctors therapy and support is important but several basic rules should be followed.

[Integrative concepts in modern forensic psychiatry]. / Integrative Konzepte in der modernen forensischen Psychiatrie.

Forensic psychiatric diagnosis and treatment should be guided by juridical goals and never be an end in itself. As a whole it is a public service concerning the interests of the perpetrators and the security of the entire population as well. Recent progress in forensic psychiatry is based on integral and comprehensive concepts. In the evaluation of criminal responsibility the new approaches of psychiatric diagnosis like operationalism, application of quantificating instruments and multiaxial diagnostic systems are of considerable importance. The ICD-10 classification of WHO can now be regarded as our reference system. To be acceptable for juridical purposes the evaluation of criminal responsibility has to be based on a systematical analysis of all important factors like actual situation of crime, environment, influence of psychotropic substances, psychosocial stressors, influences of biography and mental disorders. Assessment of prognosis is obligatory by law in many cases. These are juridical decisions, which have to be prepared by the psychiatric experts in the form of risk evaluations considering factors like development of delinquency, analysis of crime, kind of mental disturbance, insight of the perpetrator in his disorder, social competence, selfexamination of the perpetrator of his crime, possible therapies and social circumstances after discharge. Only an integral multiprofessional approach can be regarded as successful in the therapy of forensic high risk patients with paraphilas and aggressive impulse-control disorders. In Switzerland there is still a considerable lack of appropriate institutions for these patients. The vast amount of data accumulated during forensic psychiatric routine should be analysed in multicenter studies with scientific documentation systems to achieve progress in forensic risk calculation and efficiency of therapies.

Mental and behavioural disorders due to use of psychoactive substances (F1). Results from the ICD-10 field trial of the Diagnostic Criteria for Research in German-speaking countries.

The results of the ICD-10 Diagnostic Criteria for Research (DCR) field trial in German-speaking countries concerning section F1 (mental and behavioural disorders due to use of psychoactive substances) show a comparatively sufficient level of acceptance. The subjective assessment of the diagnostic process and the chance-corrected interrater reliability (kappa = 0.70) are below average but quite acceptable, which is possibly due to the study design as well as the high comorbidity of disorders in this field. However, interrater reliability based on the strictly defined operationalized criteria of the DCR improved markedly compared to earlier ICD-10 field trials in German-speaking countries.

Disorders of adult personality and behaviour (F6). Results from the ICD-10 field trial of the Diagnostic Criteria for Research in German-speaking countries.

Results of the ICD-10 Diagnostic Criteria for Research (DCR) field trial in German-speaking countries revealed a high level of interrater reliability (kappa = 0.79) for disorders of adult personality and behaviour (section F6) with marked differences between specific diagnoses: borderline personality = 0.76, transsexualism = 0.98, factitious disorder = 0.33. Compared with the results of the field trial concerning the Clinical Guidelines for section F6 of ICD-10, the application of the more precise and restrictive DRC led to an improvement of general kappa values of 0.15.

Seasonal affective disorder: are the DSM-III-R criteria valid?

Retrospective analysis of the stringency of diagnosis and therapeutic response was carried out in 80 patients with major recurrent winter depression (SAD) who had participated in controlled light therapy trials in Switzerland from 1984 to 1990. Two groups were formed with respect to anamnestic information: patients whose previous episodes of seasonal depression had been reconstructed graphically, and those who could only globally recollect prior depressive phases. These data were taken to test conformity to DSM-III-R criteria for seasonal pattern, as well as its prognostic usefulness for response to light therapy. The more liberal 'Rosenthal criteria' for SAD of at least two consecutive, seasonally recurring major depressive episodes were sufficient to predict improvement with light: none of the other DSM-III-R criteria differentiated further, and few patients could remember previous depressive episodes in precise detail. Our data support suggestions to revise the restrictive SAD diagnostic criteria for DSM-IV.

[ICD-10 in psychiatric diagnosis. The concept and initial practical experiences]. / Die ICD-10 in der psychiatrischen Diagnostik. Konzept und erste praktische Erfahrungen.

With introduction of ICD-10 from 1992 in WHO-memberstates there will be considerable change in psychiatric diagnoses. It is the first time that an operational diagnostic approach is introduced in psychiatric routine with a WHO-classification system. Following a historical overview basic concepts of ICD-10 and the most important innovations are demonstrated in view of the results of field trials. The new classification was widely accepted during the first tests, reliability of diagnosis could be improved. It should not be overlooked that in spite of methodological perfection many problems regarding content still have to be solved.

Modern psychiatric classification in research and clinical practice.

After general "antipsychiatric" criticism and with empirical results, which demonstrated partly very low interrater reliabilities of conventional psychiatric diagnosis a new appreciation of nosological difficulties in psychiatry arose. Based on philosophical concepts of logical empiricism which had been established in philosophy at the beginning of our century the operational psychiatric diagnosis was developed. The first system, the Research Diagnostic Criteria (RDC), was used for scientifical purpose in the early seventies. Based upon this system the American Psychiatric Association (APA) introduced DSM-III in 1980, which had a very strong influence on psychiatric diagnosis and classification during the last ten years. Operational psychiatric diagnosis is demanding precise criteria for inclusion and exclusion and definite diagnostic rules. The tenth revision of the International Classification of Diseases (ICD-10) of the WHO is in preparation and will also contain an operational approach. This new instrument will be introduced from 1992 in WHO member states. As a result of a number of empirical studies an improvement of interrater reliability in psychiatric diagnosis using DSM-III, DSM-III-R and the drafts of ICD-10 as well was demonstrated. An other important innovation of modern classification systems is the multiaxial diagnosis. These approaches have a number of advantages for clinicians, for communication in health service systems as well as for epidemiological and biological psychiatric research.

Chapter V (F) of ICD-10: mental, behavioural and developmental disorders--introduction and overview.

The need for precise psychiatric diagnoses is indisputable, both for cooperation within the health service systems and for scientific purposes. Over the last few years there has been a revival of interest in psychiatric nosology. Despite new strategies and the results of numerous individual research efforts, no uniform and general satisfactory theory, and thus no classification of mental disorders, has been developed. After the Second World War, the WHO succeeded in introducing an internationally accepted diagnostic system, the ICD-classification. In 1980 the American Psychiatric Association (APA) introduced its DSM-III classification with explicit diagnostic criteria and rules. The ICD-10 has been in preparation since 1982, and will differ considerably from ICD-9: An alpha-numerical system of coding expands the possibilities for diagnoses. For the first time in the history of ICD operational diagnostic criteria and rules are being introduced. The new structure will permit adjustments without the need to completely change the entire classification. The WHO division of mental health is preparing a range of documents and instruments for various purposes; clinical descriptions and diagnostic guidelines for daily clinical use, a short version and the more detailed research criteria; a multiaxial coding is planned as well. The classification of the mental disorders is based on etiological considerations, as far as these are known, in particular in the case of organic disorders, disorders due to the use of psychoactive substances, and stress-related disorders. In other areas, a more non-theoretical and descriptive approach was chosen. As a major change the large "blocks" psychoses and neuroses have been abandoned.(ABSTRACT TRUNCATED AT 250 WORDS)