Childhood trauma, psychiatric disorders, and criminality in women: Associations with serum levels of brain-derived neurotrophic factor.

Psychiatric disorders and childhood trauma are highly prevalent in female inmates. Brain-derived neurotrophic factor (BDNF) plays a number of roles in neuronal survival, structure, and function. Data in the literature suggest that it is a neurobiological substrate that moderates the impact of childhood adversities on the late expression of psychiatric disorders. The aim of this study was to determine whether five childhood trauma subtypes-physical abuse, sexual abuse, emotional abuse, physical neglect, and emotional neglect-are associated with adult psychiatric disorders, BDNF levels, and criminality among incarcerated women. This was a cross-sectional study involving a consecutive sample of 110 women, divided into three groups of women (forensic - mentally ill who committed crimes, clinical psychiatric inpatients and healthy controls). The Childhood Trauma Questionnaire and the Mini-International Neuropsychiatric Interview-Plus were applied in the whole sample, and BDNF levels were measured in a sub-sample of 54 women. The rates of mental illness and childhood trauma were high in the forensic group. Emotional abuse was higher in the clinical and forensic groups than in the healthy control group. Lower BDNF levels were associated with emotional abuse in the forensic group as well as with sexual abuse in the healthy control group. After multinomial logistic regression, lower levels of BDNF, higher levels of emotional abuse and the presence of familial offense were considered factors related to clinical psychiatric group. The results of this study underscore the idea that BDNF may be an important factor related to the development of diseases and criminality in women who are victims of childhood trauma, becoming a possible biological marker.

Attempted Serial Neonaticides: Case Report and a Brief Review of the Literature.

Neonaticide is an infant murder occurring on the day of birth. The case reports found in the literature are often focused on the mother as the agent in the context of pregnancy denial, dissociative symptoms, or psychosis. However, this report describes a rare case of attempted serial neonaticides, in which the acts were committed by a nurse at the nursery of a referral hospital in Brazil. The authors describe a forensic psychiatric evaluation for criminal responsibility and correlate the information from this particular case with relevant forensic themes, namely neonaticide, Munchausen by proxy syndrome, and serial healthcare killers.

Serum concentrations of brain-derived neurotrophic factor and mental disorders in imprisoned women

Objective: Mental disorders and early trauma are highly prevalent in female inmates. Brain-derived neurotrophic factor (BDNF) plays an important role in learning, memory processes, and mood regulation. The aim of this study was to evaluate the relationship between serum BDNF levels and mental disorders among imprisoned women as compared with age- and education-matched controls. Methods: A consecutively recruited sample of 18 female prisoners with mental disorders was assessed for sociodemographic, criminal, and clinical variables using standardized instruments, the Mini International Neuropsychiatric Interview Plus (MINI Plus), and serum BDNF levels. Results: High rates of childhood sexual abuse and posttraumatic stress disorder (PTSD) were found in the group of forensic patients. Serum BDNF levels in the forensic group did not differ from those of healthy controls, and were significantly higher when compared with those of women with mental disorders hospitalized in a general hospital. Conclusion: Elevated serum BDNF levels were found in imprisoned women. The results of this study may suggest neurobiological mechanisms similar to those seen in previous clinical and preclinical studies showing the involvement of BDNF in the pathophysiology of PTSD. .

Phenomenological aspects of the cognitive rumination construct.

OBJECTIVE: To evaluate the importance of phenomenological aspects of the cognitive rumination (CR) construct in current empirical psychiatric research. METHOD: We searched SciELO, Scopus, ScienceDirect, MEDLINE, OneFile (GALE), SpringerLink, Cambridge Journals and Web of Science between February and March of 2014 for studies whose title and topic included the following keywords: cognitive rumination; rumination response scale; and self-reflection. The inclusion criteria were: empirical clinical study; CR as the main object of investigation; and study that included a conceptual definition of CR. The studies selected were published in English in biomedical journals in the last 10 years. Our phenomenological analysis was based on Karl Jaspers' General Psychopathology. RESULTS: Most current empirical studies adopt phenomenological cognitive elements in conceptual definitions. However, these elements do not seem to be carefully examined and are indistinctly understood as objective empirical factors that may be measured, which may contribute to misunderstandings about CR, erroneous interpretations of results and problematic theoretical models. CONCLUSION: Empirical studies fail when evaluating phenomenological aspects of the cognitive elements of the CR construct. Psychopathology and phenomenology may help define the characteristics of CR elements and may contribute to their understanding and hierarchical organization as a construct. A review of the psychopathology principles established by Jasper may clarify some of these issues.

Public health system and psychiatry in the treatment of 'dangerous' young offenders in Brazil.

We describe the Experimental Health Unit, a special forensic mental health facility in Brazil, created by court order and administered by the São Paulo Department of Health. It was designed for young offenders receiving compulsory inpatient treatment for severe personality disorders. All nine patients admitted to date came from Foundation CASA (a socio-educational centre of assistance for adolescents, the juvenile correctional centres managed by the São Paulo state Department of Justice). The court decision is questionable, relying on a new interpretation of the Child and Adolescent Statute and the law that regulates psychiatric treatment in Brazil. The public health system and psychiatry have been supporting the isolation of some individuals from society, based on the seriousness of their crimes and possession of particular personality characteristics. The decision to commit and send a small group of personality disordered individuals to this unit as inpatients is an unfair decision, since jails and correctional centres hold a high number of psychopathic who have also committed barbaric crimes. The central mental health issue is the role that the public health system should play in the custody of dangerous people; the cost-effectiveness of this model, the accuracy of risk assessment and tractability of people with severe personality disorders are also debatable. From a legal perspective, the operation of this facility raises questions about age of legal majority, the maximum period of incarceration of young offenders and use of whole-life sentences for certain types of crimes and criminals in Brazil.

Phenomenological aspects of the cognitive rumination construct / Aspectos fenomenológicos relacionados ao construto de ruminação cognitiva

Objective: To evaluate the importance of phenomenological aspects of the cognitive rumination (CR) construct in current empirical psychiatric research. Method: We searched SciELO, Scopus, ScienceDirect, MEDLINE, OneFile (GALE), SpringerLink, Cambridge Journals and Web of Science between February and March of 2014 for studies whose title and topic included the following keywords: cognitive rumination; rumination response scale; and self-reflection. The inclusion criteria were: empirical clinical study; CR as the main object of investigation; and study that included a conceptual definition of CR. The studies selected were published in English in biomedical journals in the last 10 years. Our phenomenological analysis was based on Karl Jaspers' General Psychopathology. Results: Most current empirical studies adopt phenomenological cognitive elements in conceptual definitions. However, these elements do not seem to be carefully examined and are indistinctly understood as objective empirical factors that may be measured, which may contribute to misunderstandings about CR, erroneous interpretations of results and problematic theoretical models. Conclusion: Empirical studies fail when evaluating phenomenological aspects of the cognitive elements of the CR construct. Psychopathology and phenomenology may help define the characteristics of CR elements and may contribute to their understanding and hierarchical organization as a construct. A review of the psychopathology principles established by Jasper may clarify some of these issues. .

Objetivo: Verificar a importância de aspectos fenomenológicos relacionados ao construto de ruminação cognitiva (RC) nas pesquisas empíricas psiquiátricas atuais. Método: Foram pesquisadas as bases de dados SciELO, Scopus, ScienceDirect, MEDLINE, OneFile (GALE), SpringerLink, Cambridge Journals e Web of Science, entre fevereiro e março de 2014, buscando artigos cujo tópico ou título contivessem os seguintes termos-chave: ruminação cognitiva; escala de resposta ruminativa; e autorreflexão. Os critérios de inclusão foram: estudos clínicos empíricos; RC como principal objeto de pesquisa; e estudos que incluíssem uma definição conceitual de RC. Foram considerados apenas artigos em inglês publicados em periódicos biomédicos nos últimos 10 anos. Nossa análise fenomenológica se fundamentou na Psicopatologia Geral de Jaspers. Resultados: Os conceitos de RC atualmente encontrados nas pesquisas empíricas utilizam majoritariamente elementos fenomenológicos em suas definições. Entretanto, esses elementos cognitivos são indistintamente entendidos como elementos objetivos (empíricos), passíveis de mensuração, e não parecem ser cuidadosamente examinados. Este fato pode contribuir para uma compreensão enganosa sobre RC, além de favorecer a interpretação errônea de resultados e a elaboração de paradoxos teóricos problemáticos. Conclusão: As pesquisas empíricas atuais sobre RC falham ao avaliar os aspectos fenomenológicos inerentes ao construto de RC. A psicopatologia e o método fenomenológico podem ajudar a definir características relacionadas aos elementos da RC, bem como contribuir para a sua compreensão e organização hierárquica enquanto construto. Um retorno aos princípios da psicopatologia, nos moldes de Jaspers, poderia trazer esclarecimentos ao tema. .

Serum concentrations of brain-derived neurotrophic factor and mental disorders in imprisoned women.

OBJECTIVE: Mental disorders and early trauma are highly prevalent in female inmates. Brain-derived neurotrophic factor (BDNF) plays an important role in learning, memory processes, and mood regulation. The aim of this study was to evaluate the relationship between serum BDNF levels and mental disorders among imprisoned women as compared with age- and education-matched controls. METHODS: A consecutively recruited sample of 18 female prisoners with mental disorders was assessed for sociodemographic, criminal, and clinical variables using standardized instruments, the Mini International Neuropsychiatric Interview Plus (MINI Plus), and serum BDNF levels. RESULTS: High rates of childhood sexual abuse and posttraumatic stress disorder (PTSD) were found in the group of forensic patients. Serum BDNF levels in the forensic group did not differ from those of healthy controls, and were significantly higher when compared with those of women with mental disorders hospitalized in a general hospital. CONCLUSION: Elevated serum BDNF levels were found in imprisoned women. The results of this study may suggest neurobiological mechanisms similar to those seen in previous clinical and preclinical studies showing the involvement of BDNF in the pathophysiology of PTSD.

Drug-related disorders and the criminal and clinical background of the prison population of São Paulo State, Brazil.

OBJECTIVE: To analyze the association between drug (DAD) and alcohol (AAD) abuse and dependency and criminal and clinical background by gender of prisoners in São Paulo, Brazil. METHOD: Cross-sectional study, random sample stratified by administrative district, from which prisons and prisoners were selected via random, multistage sampling. Psychiatric diagnoses were made with the CIDI 2.1. Lifetime prevalence and 95% CI were calculated and adjusted via analysis of complex samples. Multinomial logistic regression analysis was carried out with four categories of dependent variables: presence AAD; presence DAD; presence of another mental disorder; no mental disorders. For female alcohol and drug abuse and dependency (ADAD) were combined into a single category. RESULTS: The sample was composed by 1809 interviewed prisoners (1192 men and 617 women). Prevalence of DAD and AAD was 25.2% and 15.6%, respectively, among female prisoners, and 26.5% and 18.5% among males. Male prisoners with DAD were more likely to have a criminal record as an adolescent (OR 2.17), to be a repeat offender (OR 2.85), and to have committed a property crime (OR 2.18). Prisoners with AAD were repeat offenders (OR 2.18). Among female prisoners, ADAD was associated with repeat offenses (OR 3.39), a criminal record as an adolescent (OR 9.24), a clinical or infectious condition (OR 5.09), another health problem (OR 3.04), and violent crime (OR 2.5). CONCLUSION: The study confirmed an association between drug-use disorders and the criminal and clinical background in the study population. Prisoners with such disorders were more likely to be repeat offenders and to have a criminal record as adolescents. Among female prisoners disorders were also associated with violent crime and health problems, while among males they were associated with property crime. These patterns in clinical and criminal backgrounds illustrate the need for social rehabilitation programs and specific medical treatment for prison populations.

Prevalence of mental disorders among prisoners in the state of Sao Paulo, Brazil.

OBJECTIVE: To determine the prevalence of psychiatric disorders in the prison population in the State of São Paulo, Brazil. METHODS: Through stratified random sampling, 1.192 men and 617 women prisoners were evaluated for the presence of psychiatric disorders by the Composite International Diagnostic Interview, 2.1 version, according to definitions and criteria of International Classification of Diseases (ICD-10). The prevalence estimates of mental disorders and their respective 95% confidence intervals were calculated and adjusted for sample design through complex sample analysis. RESULTS: Lifetime and 12-month prevalence rates differed between genders. Lifetime and 12-month prevalence of any mental disorder was, respectively, 68.9% and 39.2% among women, and 56.1% and 22.1% among men. Lifetime and 12-month prevalence of anxious-phobic disorders was, respectively, 50% and 27.7% among women and 35.3% and 13.6% among men, of affective disorders was 40% and 21% among women and 20.8% and 9.9% among men, and of drug-related disorders was 25.2% and 1.6% among women and 26.5% and 1.3% among men. For severe mental disorders (psychotic, bipolar disorders, and severe depression), the lifetime and 12-month prevalence rates were, respectively, 25.8% and 14.7% among women, and 12.3% and 6.3% among men. CONCLUSIONS: This is the first large-scale epidemiological study performed with the prison population in Brazil, revealed high rates of psychiatric disorders among men and women. Many similarities, as well as some differences, were found between our results and those of studies conducted in other countries. The differences observed are more likely due to the peculiarities of the prison systems in each country than to the diagnostic criteria adopted in the studies. This fact reinforces the importance of conducting such studies as part of planning and development of appropriate policies for the particular mental health needs of specific prison populations.

Mental health law in Brazil.

Brazil is a Federal Union which comprises 27 member states, one Federal District, and about 5000 municipalities. According to the Federal Constitution (Constituição da República Federativa do Brasil; Diário Oficial da União, 05/out/1988), the competence to rule over health issues is shared by all of them. So, in each part of the country three levels of legislation apply: federal, state and local law. However, as an inferior level of law must not conflict with a superior one, there is a relative uniformity throughout the country, at least in theory. Regarding actual mental healthcare delivery, there are many differences across the Brazilian regions, mostly due to socioeconomic variation.

Cerebral calcifications and schizophreniform disorder / Calcificações cerebrais e transtorno esquizofreniforme

OBJECTIVES: Discuss pathophysiological aspects of cerebral calcifications (CC) and highlight its importance related to the occurrence of neuropsychiatric syndromes. METHOD: Single case report. RESULT: Man 52 years old, 20 years after going through a total thyroidectomy, starts showing behavioral disturbance (psychotic syndrome). He was diagnosed as schizophrenic (paranoid subtype) and submitted to outpatient psychiatric treatment. During a psychiatric admission to evaluate his progressive cognitive and motor deterioration, we identified a dementia syndrome and extensive cerebral calcifications, derived from iatrogenic hypoparathyroidism. CONCLUSION: The calcium and phosphorus disturbances, including hypoparathyroidism, are common causes of CC. Its symptoms can imitate psychiatric disorders and produce serious and permanent cognitive sequelae. The exclusion of organicity is mandatory in any psychiatric investigative diagnosis in order to avoid unfavorable outcomes, such as in the present case report.

OBJETIVOS: Discutir aspectos fisiopatológicos das calcificações cerebrais (CC) e ressaltar sua importância na ocorrência de síndromes neuropsiquiátricas. MÉTODO: Relato de caso individual. RESULTADO: Homem 52 anos de idade, 20 anos após tireoidectomia total, iniciou com alteração comportamental (síndrome psicótica), foi diagnosticado como portador de esquizofrenia paranoide e encaminhado para ambulatório de psiquiatria. Durante internação psiquiátrica, para avaliação de importante deterioração cognitivo e motora, foi verificada a vigência de síndrome demencial e extensas CC, secundários a hipoparatiroidismo iatrogênico. CONCLUSÃO: Os distúrbios do metabolismo do cálcio e do fósforo, incluindo o hipoparatiroidismo, são causas frequentes de CC. Seus sintomas podem mimetizar transtornos psiquiátricos e provocar sequelas cognitivas permanentes. A exclusão de organicidade é mandatória durante toda investigação diagnóstica na psiquiatria, a fim de evitar desfechos desfavoráveis, como no presente relato de caso.

Accuracy of the Historical, Clinical and Risk Management Scales (HCR-20) in predicting violence and other offenses in forensic psychiatric patients in Brazil.

BACKGROUND: Assessing the risk of violence is a complex task. In Latin America it is often based on clinical criteria that are not very objective or structured. HCR-20 has been used to increase the accuracy of this exam. AIMS: The aim of this study was to examine the predictive validity of the Historical, Clinical and Risk Management Scales (HCR-20) violence risk assessment scale on a sample of Brazilian male forensic psychiatric inpatients. METHOD: A concurrent prospective cohort design was used. The cohort was selected among the population of inpatients in Unit D (N=68) at Instituto Psiquiátrico Forense Mauricio Cardoso (IPF), Brazil. For the baseline assessment the following instruments: HCR-20-Assessing Risk for Violence, Version 2, and Hare Psychopathy Checklist, Revised (PCL-R) were used. During the one-year follow up, episodes of violent and/or anti-social behavior were assessed, and recorded on the Yudofsky's Overt Aggression Scale (OAS) and Tengström et al.'s Follow-Up Questionnaire. The accuracy of HCR-20 and PCL-R to predict violent and/or anti-social behavior was assessed. RESULTS AND CONCLUSIONS: For the whole cohort, the mean total score of PCL-R was 13.54 and of HCR-20 it was 23.32. The rate of recidivism in the twelve month follow up was 73.5%. Outstanding among the risk factors explored for their predictive efficacy are scale HCR-20 and subscale H for any event, and scale HCR-20 for a violent event. The predictive efficacy of scales HCR-20 and PCL-R was greater for any antisocial event than for a violent event. By taking into account the possibility of recidivism and the probability of recidivism accumulated over time, instruments HCR-20 and PCL-R behaved as expected. In all these explorations, the instruments significantly differentiated the group of the sample that recidivated earlier.

Sexual disorders and crime.

PURPOSE OF REVIEW: Highlighting the relationship between sexual disorders and crime, reviewing and summarizing the articles published throughout 2011 which add to the current knowledge on this subject. RECENT FINDINGS: Studies on specific populations confirm the association between sexual disorders and crime, particularly between paraphilias and sexual crimes regarding male offenders. Female offenders are less likely to be diagnosed with a sexual disorder. Some case reports focus on unusual paraphilias and lead us to question the vast possibilities of paraphilic contents and sexual arousal patterns. The variations of paraphilic-associated sexual arousal patterns, unconventional sex behaviors or paraphilic disorders are constantly changing. In this sense, the American Psychiatric Association's DSM-5 current proposals for a sexual dysfunction diagnostic category are under intense discussion because of their important clinical and forensic consequences. SUMMARY: Sexual violence is a theme not well understood yet. Because of its nature, researching it can raise many ethical problems. There is no possibility of clinical trials and of case-control studies. Even cohort studies may be problematic in themselves. So, most of the research involves biased samples or case reports, or is merely theoretical. Further research is needed to improve our understanding of the subject, so that preventive and rehabilitative measures can be taken.

Incidência de conduta violenta e antissocial em população psiquiátrica forense / Incidence of violent and antisocial behavior in a forensic psychiatric population

INTRODUÇÃO: As consequências de comportamentos violentos e antissociais de internos em hospitais psiquiátricos são graves e podem determinar prejuízo ao tratamento do agressor. A falta de conhecimento sobre a incidência desse fenômeno e suas características favorece sua perpetuação. OBJETIVOS: Apresentar uma revisão bibliográfica atualizada do tema, informar a incidência de conduta violenta e antissocial em uma população manicomial e descrever a implementação de um método de registro sistematizado desse fenômeno. MÉTODO: A coorte foi selecionada dentro da população de pacientes do Instituto Psiquiátrico Forense Maurício Cardoso (IPFMC). Foi utilizada a Escala de Agressividade Declarada de Yudofsky (Overt Aggression Scale, OAS) e o Questionário de Seguimento de Tengström et al. Durante o período de seguimento de 1 ano, foram avaliados diariamente episódios de conduta violenta e antissocial, registrando-se os mesmos na escala e no questionário. A amostra em estudo foi composta de 68 pacientes homens selecionados de forma aleatória entre a população em cumprimento de medida de segurança no IPFMC. RESULTADOS: A incidência de comportamento violento/antissocial no período estudado foi de 200 episódios, envolvendo 50 pacientes. Houve predomínio de agressões e conduta antissocial durante o dia. As intervenções mais utilizadas foram manejo verbal, isolamento do paciente e aplicação de medicação intramuscular. CONCLUSÃO: Foi possível, pela primeira vez, medir a ocorrência de conduta violenta e antissocial em uma população psiquiátrica forense.

INTRODUCTION: The consequences of violent and antisocial behaviors among psychiatric hospital inpatients are serious and may affect the treatment of the aggressor. Lack of knowledge concerning the incidence of this phenomenon and its characteristics helps perpetuate the current scenario. OBJECTIVES: To present an updated literature review on the topic, to estimate the incidence of violent and antisocial behaviors in a mental hospital population, and to describe the implementation of a systematic method to record this phenomenon. METHOD: A cohort was selected among the psychiatric inpatients at Maurício Cardoso Forensic Psychiatry Institute (Instituto Psiquiátrico Forense Maurício Cardoso, IPFMC). Yudofsky's Overt Aggression Scale (OAS) and Tengström et al.'s Follow-Up Questionnaire were used. During a 1-year follow-up period, episodes of violent and antisocial behavior were evaluated daily and recorded on both the scale and the questionnaire. The population sample included 68 male patients randomly selected among the committed inpatients at IPFMC. RESULTS: The incidence of violent/antisocial behavior along the period assessed was 200 episodes involving 50 patients. Aggressions and antisocial behavior occurred mainly in daytime. The interventions most commonly used were verbal management, patient isolation, and intramuscular medication. CONCLUSION: For the first time, the occurrence of violent and antisocial behavior was measured in a forensic psychiatric population.

Mental disorders in prisons.

PURPOSE OF REVIEW: The existence of people with mental disorders in prisons is a reality found worldwide. The purpose of this article is not only to review the publications on this subject in 2009 but also to stimulate discussions that could contribute to its further scientific study. RECENT FINDINGS: Most studies published in 2009 related to drug use among inmates and its consequences made it clear that this kind of disorder has a closer relationship with the crime than with mental illness. SUMMARY: The existence of the mentally ill in prisons is a complex issue and the studies attempt to analyze aspects such as the type of disorder, sex of criminals, the opposition between incarceration and treatment, policy, harm reduction and stigma. A further study on the variables raised in this work is required, as well as examining others, to the extent that they are relevant to the various socio-economic and cultural realities.

Reliability of the Brazilian version of HCR-20 Assessing Risk for Violence.

OBJECTIVE: Assessing risk for violence is a complex task often based on not objective or structured clinical evaluations. HCR-20 Assessing Risk for Violence has been used in several countries to increase the accuracy of this exam. The purpose of this study was to inform on central aspects of this instrument, as well as the results of the reliability assessment of the HCR-20 Assessing Risk for Violence in a Brazilian inpatient criminal population. METHOD: Two examiners independently assessed a random sample of 30 patients that were under criminal commitment at the Mauricio Cardoso Forensic Psychiatric Institute RESULTS: Mean consensus values means were as follows: Historical = 13.1; Clinical = 4.8 and Risk management = 5.8. The value of the Intraclass Correlation Coefficient for the score of subscale Historical was 0.97, for subscale Clinical it was 0.94, and for subscale Risk management, 0.96. As to the individual items of the HCR-20 Assessing Risk for Violence, the result of the Intraclass Correlation Coefficient was good to excellent (mean = 0.97; interval, from 0.60 to 0.99). CONCLUSION: The interrater reliability of the Brazilian version of the HCR-20 Assessing Risk for Violence scale was similar to the results of studies in other countries.

Reliability of the Brazilian version of HCR-20 Assessing Risk for Violence / Confiabilidade da versão brasileira do HCR-20 Assessing Risk for Violence

OBJECTIVE: Assessing risk for violence is a complex task often based on not objective or structured clinical evaluations. HCR-20 Assessing Risk for Violence has been used in several countries to increase the accuracy of this exam. The purpose of this study was to inform on central aspects of this instrument, as well as the results of the reliability assessment of the HCR-20 Assessing Risk for Violence in a Brazilian inpatient criminal population. METHOD: Two examiners independently assessed a random sample of 30 patients that were under criminal commitment at the Mauricio Cardoso Forensic Psychiatric Institute RESULTS: Mean consensus values means were as follows: Historical = 13.1; Clinical = 4.8 and Risk management = 5.8. The value of the Intraclass Correlation Coefficient for the score of subscale Historical was 0.97, for subscale Clinical it was 0.94, and for subscale Risk management, 0.96. As to the individual items of the HCR-20 Assessing Risk for Violence, the result of the Intraclass Correlation Coefficient was good to excellent (mean = 0.97; interval, from 0.60 to 0.99). CONCLUSION: The interrater reliability of the Brazilian version of the HCR-20 Assessing Risk for Violence scale was similar to the results of studies in other countries.

OBJETIVO: A avaliação de risco de violência é uma tarefa complexa baseada muitas vezes em critérios clínicos pouco objetivos e estruturados. O HCR-20 Assessing Risk for Violence tem sido usado em diversos países para aumentar a precisão deste exame. O presente estudo tem como objetivo informar aspectos nucleares deste instrumento, bem como os resultados da avaliação da confiabilidade do HCR-20 Assessing Risk for Violence em uma amostra da população manicomial brasileira. MÉTODO: Dois examinadores avaliaram independentemente uma amostra de 30 pacientes selecionada aleatoriamente da população em cumprimento de Medida de Segurança no Instituto Psiquiátrico Forense Maurício Cardoso. RESULTADOS: Os valores das médias de consenso entre os entrevistadores foram os seguintes: Histórica = 13,1; Clínica = 4,8 e Manejo de risco = 5,8. O valor do Coeficiente de Correlação Interno para a pontuação da subescala Histórica foi 0,97; para a pontuação da subescala Clínica foi 0,94; e para a subescala Manejo de risco foi 0,96. Quanto aos itens individuais do HCR-20 Assessing Risk for Violence, o resultado do Coeficiente de Correlação Interno foi de bom a excelente (média = 0,97; intervalo de 0,60 a 0,99). CONCLUSÃO: A confiabilidade entre os avaliadores da versão brasileira da escala HCR-20 Assessing Risk for Violence foi similar aos resultados de estudos em outros países.

Legal controls of the medical profession.

PURPOSE OF REVIEW: The authors, after a brief historical review of the theme, review the articles published in the last year. The purpose is to verify how the field has moved on during this period, as a constant increase of legal and social controls on the medical profession is perceived. RECENT FINDINGS: Surprisingly, very few articles treating directly the theme reviewed were found. The better part of the articles examined legal aspects of the medical profession in a nonsystematic way. Among the ones selected those that dealt with internal controls (produced by the professional categories such as the Clinical Practice Guidelines) and those that dealt with external controls (produced by other social groups) could be identified. SUMMARY: The authors conclude that the existence of limits and internal and external controls is fundamental for a professional medical practice of quality. However, the excess of controls, which causes a defensive attitude, may negatively interfere in the quality of the care offered to patients.