Psychiatrists as forensic authorities: evaluation of dangerous habitual offenders in West Germany during the 1960s - the Helmut Hoinka case.

Background: Preventive detention for highly dangerous habitual offenders has been in force in Germany for 90 years. The necessity of this measure is hotly debated from a legal perspective. However, the assignment of preventive detention is largely determined by the opinion of medical experts. This article discusses the role of medical experts and the issues they face in evaluating the dangerousness of habitual offenders using the case of the marriage swindler Helmut Hoinka, prosecuted several times in the Federal Republic of Germany in the 1960s. Methods: Helmut Hoinka's case was chosen for analysis because of the rare opportunity to access detailed materials that allowed us to follow in detail the reasoning of the medical experts who evaluated Hoinka: medical reports stored in the Gerd Huber Archive at the University of Ulm, and Hoinka's court case from the State Archive of North Rhine-Westphalia. To examine these sources, we implemented the historical-critical method. Results: The medical experts who evaluated Hoinka were aware of the defendant's criminal record prior to the evaluation, which was a source of bias. In addition, the criteria for classifying the offender as a dangerous habitual offender were open to a wide range of interpretations. Hoinka's high level of intelligence was negatively emphasized. Some test results were considered unreliable because it was assumed that Hoinka had manipulated his answers. Personal value judgments were allowed in assessing Hoinka's personality. Hoinka's criminal behavior was considered a medical symptom of psychopathy because it violated general moral and social norms. The medical reports of both experts showed that the psychiatrists believed in the genetic nature of psychopathy and criminal behavior. Their criminological prognosis was fully supported by the court in imposing the sentence. Conclusion: Challenges to Hoinka's criminological prognosis were the experts' personal biases, their belief in the theory of genetic predisposition to crime, the lack of clear criteria for antisocial personality disorder, and the absence of forensic recommendations for "psychopathic" criminals. The experts' opinion on Hoinka's criminal predisposition was crucial to the imposition of the sentence.

Self-induced extreme intoxication akin to automatism: A psycholegal tug of war.

Self-induced extreme intoxication akin to automatism (SIEA) is a complicated and controversial legal concept resistant to jurisdictional consensus. In the United States, SIEA has, at times, been considered under the concept of "settled insanity.". In the United Kingdom, the defense may be allowed for specific intent crimes, though the defendant's awareness of the foreseeability of risk is addressed at trial. In Canada, recent jurisprudence has led to legal and practice landscape changes related to self-induced extreme intoxication. Here, we provide an overview of automatism and an update on the Canadian perspective with a review of the facts and an analysis of the Supreme Court of Canada's landmark decision in R v. Brown, where the court permitted the SIEA defense to be utilized for general intent crimes and acquitted Matthew Winston Brown, a 26-year-old male with no history of mental illness, with respect to two counts of "break and enter" and one count of "aggravated assault." We review the social and legislative response to the changing case law as well as related implications for expert testimony, which may be provided by forensic mental health professionals. Given the judicial and legal implications of the recent changes for both perpetrators and victims of violent crime and given the dynamic international landscape on extreme intoxication in criminal law, the review is thought to be of interest to a broad category of stakeholders including policymakers and those working in forensic psychiatry and law.

Attempted suicide by hanging in a pregnant adolescent with psychiatric illness: A case report.

Cases of mental illnesses and suicide attempts while pregnant are of grave concern because they negatively affect both the mother and her fetus. Here we report a case of an 18-year-old woman, who was found at 35 weeks into her pregnancy. She was unconscious when her sister-in-law rescued her. Upon arrival, she was agitated and had respiratory distress. She went into spontaneous labor the next day and delivered a premature infant who succumbed within 24 h. She had a history of mental illness in the past and previous suicide attempts. The reason for her suicide stemmed from conflicts within her family and disagreement with her husband. Various psychosocial elements play a role in suicide risk, such as young age, having a history of mental health issues, experiencing trauma facing domestic violence, and dealing with financial stress. This underlines the need for mental health screening in the course of antenatal visits for a complete risk assessment.

Prison mental health in South-East Asia: A narrative review.

BACKGROUND: South-East Asia is a densely populated region with a considerable, however, under-prioritized mental health burden. Little is known about the mental health burden and services status in the prisons of the region. OBJECTIVES: We aimed to investigate the individual country-wise prison mental health status in South-East Asian region. METHODS: We performed a narrative review based on the evidence available in PubMed, Scopus, PsycINFO, Google, and Google Scholar considering the review objectives. We highlighted country perspectives on total population, prison numbers, prisoner numbers, the prevalence of psychiatric disorders and suicide among prisoners, prison mental health services, current challenges, and ways ahead. RESULTS: We discussed the prison mental health of five countries (Bangladesh, India, Indonesia, Nepal, and Sri Lanka). We found overcrowding (131.4%-215.6%) in the prisons, a high prevalence of psychiatric disorders in the prisons (40%-100%), negligible prison mental health services, and a lack of data on prison suicide with some variations among the five countries. Among the countries, Bangladesh has the highest prevalence (66.4%-100%) of psychiatric morbidity with an absence of a mental health system. CONCLUSIONS: Prison mental health in tSouth-East Asia is a neglected domain and warrants attention regarding ensuring adequate mental health services to the prisoners as there are high unmet mental health needs and an absence of poorly supported mental health needs.

Application of Facial Expression Analysis Technology in Violence Risk Assessment of Individuals with Mental Disorders in Supervised Settings.

OBJECTIVES: To explore the association between violent behaviors and emotions in individuals with mental disorders, to evaluate the application value of facial expression analysis technology in violence risk assessment of individuals with mental disorders in supervised settings, and to provide a reference for violence risk assessment. METHODS: Thirty-nine male individuals with mental disorders in supervised settings were selected, the participant risk of violence, cognitive function, psychiatric symptoms and severity were assessed using the Modified Overt Aggression Scale (MOAS), the Historical, Clinical, Risk Management-Chinese version(HCR-CV), the Positive and Negative Syndrome Scale (PANSS) and the Brief Psychiatric Rating Scale (BPRS). An emotional arousal was performed on the participants and the intensity of their emotions and facial expression action units was recorded before, during and after the arousal. One-way analysis of variance (ANOVA) was used to compare the differences in the intensity of emotions and facial expression action units before, during and after the arousal. Pearson correlation analysis was used to calculate the correlations between the intensity of the seven basic emotional facial expressions and the scores of the assessment scales. RESULTS: The intensity difference of sadness, surprise and fear in different time periods was statistically significant (P<0.05). The intensity of the left medial eyebrow lift action unit was found significantly different before and after the emotional arousal (P<0.05). The intensity of anger was positively correlated with the Modified Overt Aggression Scale score throughout the experiment (P<0.05). CONCLUSIONS: Eye action units such as eyebrow lifting, eyelid tightening and upper eyelid lifting can be used as effective action units to identify sadness, anger and other negative emotions associated with violent behaviors. Facial expression analysis technology can be used as an auxiliary tool to assess the potential risk of violence in individuals with mental disorders in supervised settings.

Which diagnoses and arguments regarding severe mental disorder do forensic psychiatric experts in Sweden consider in different cases? A qualitative vignette study.

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.

Case report: Assessing criminal responsibility and recidivism risk in the behavioral variant of frontotemporal dementia.

Frontotemporal dementia (FTD) affects the frontal and temporal lobes of the brain, leading to personality changes, language impairments, and behavioral disturbances, including impulsivity and disinhibition. Assessing responsibility and recidivism risk in forensic evaluations is challenging due to the evolving nature of FTD. Despite limited literature, we present a case of a 45-year-old man with no prior legal or medical history, who committed criminal acts due to behavioral changes linked to the behavioral variant of frontotemporal dementia (bvFTD). Initial assessment found him irresponsible, with a non-evaluable risk of recidivism. Subsequent evaluation showed a low recidivism risk based on clinical evolution. We discuss these findings considering existing literature and Swiss jurisprudence.

Forensic psychiatric assessment in autism spectrum disorder: Experience of a forensic psychiatry inpatient clinic from Türkiye.

Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by marked differences in communication patterns, reciprocal social interactions, and restricted, stereotyped, and repetitive interests and activities. Various behavioral problems in ASD, more so when accompanied by coexisting psychopathology, can sometimes lead to legal problems. In this study, the cases in which an opinion was requested in terms of criminal responsibility with the diagnosis of ASD in the 5-year period between 2018 and 2022 in the expertise department of psychiatric observation, where psychiatric cases were hospitalized and observed in the Council of Forensic Medicine (CFM), which is the official expert institution in Türkiye, were retrospectively evaluated. The mean age of the group whose criminal responsibility was reduced or removed was 22.9 years (±7.52) and the mean IQ score was 76.63 ± 18.94. The most common crime in this group was intentional injury (5/11), and it is noteworthy that the victims of these crimes were usually relatives of people with ASD (5/6). The criminal acts of people with ASD are usually single-movement, spontaneous, unplanned, impulsive acts. In addition, although there is no problem in cognitive perception in people with high functioning ASD (HF-ASD), various forensic situations may arise due to defects in emotional awareness. When we look at the practices of the CFM in Türkiye, it is seen that in cases where the diagnosis of ASD is clear and can be associated with the crime, criminal responsibility is usually completely eliminated. In HF-ASD types, although it is important to be associated with the crime, it is seen that criminal responsibility is generally reduced.

A narrative of recovery in forensic hospitals.

AIM: Concerns about the applicability of recovery orientation to forensic care have surfaced due to the traditionally restrictive practices associated with forensic institutions. We interviewed 19 experts-by-experience and 18 professionals working with them across five Finnish forensic hospitals and one out-patient clinic to describe how they define recovery in forensic. METHODS: We utilized semi-structured, one-on-one interviews and then analyzed the collected data using structural narrative analysis. Our points of interest were the plots of the recovery stories and the ways in which various factors affected recovery. We also investigated whether staff and experts-by-experience had different perceptions of recovery in forensic psychiatry, and whether recovery-oriented practices were present in these accounts. RESULTS: A wider mutual narrative with a chronological plot was identified, and recovery-oriented practices and goals were found with a special emphasis on offending. Insight into mental illness, motivation for self-care, trust in therapeutic relationships, and gaining possibilities to proceed in care were found to promote recovery, whereas insufficient understanding of the illness, a closed environment, lack of trust, and substance abuse hindered the recovery process. Both the professionals and experts felt that the most prominent goal of recovery is integration into society. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The views of the interviewed experts-by-experience and professionals regarding recovery were rather univocal. Forensic psychiatric services in Finland were found to demonstrate recovery-oriented features, which can be promoted further by involving experts-by-experience in different assignments. The results also highlight that the families of patients should become more active partners in care. IMPACT AND IMPLICATIONS STATEMENT: Recovery in forensic psychiatric hospitals can be perceived as a process towards a new role in society. To reach this goal the forensic patients need support from staff, peers, and family. We found numerous factors which enable and hinder the recovery process, and which should be considered during forensic care.

Putting the usability of wearable technology in forensic psychiatry to the test: a randomized crossover trial.

Introduction: Forensic psychiatric patients receive treatment to address their violent and aggressive behavior with the aim of facilitating their safe reintegration into society. On average, these treatments are effective, but the magnitude of effect sizes tends to be small, even when considering more recent advancements in digital mental health innovations. Recent research indicates that wearable technology has positive effects on the physical and mental health of the general population, and may thus also be of use in forensic psychiatry, both for patients and staff members. Several applications and use cases of wearable technology hold promise, particularly for patients with mild intellectual disability or borderline intellectual functioning, as these devices are thought to be user-friendly and provide continuous daily feedback. Method: In the current randomized crossover trial, we addressed several limitations from previous research and compared the (continuous) usability and acceptance of four selected wearable devices. Each device was worn for one week by staff members and patients, amounting to a total of four weeks. Two of the devices were general purpose fitness trackers, while the other two devices used custom made applications designed for bio-cueing and for providing insights into physiological reactivity to daily stressors and events. Results: Our findings indicated significant differences in usability, acceptance and continuous use between devices. The highest usability scores were obtained for the two fitness trackers (Fitbit and Garmin) compared to the two devices employing custom made applications (Sense-IT and E4 dashboard). The results showed similar outcomes for patients and staff members. Discussion: None of the devices obtained usability scores that would justify recommendation for future use considering international standards; a finding that raises concerns about the adaptation and uptake of wearable technology in the context of forensic psychiatry. We suggest that improvements in gamification and motivational aspects of wearable technology might be helpful to tackle several challenges related to wearable technology.

Attitudes of Forensic Fellowship Psychiatry Directors towards an Applicant Match.

Forensic psychiatry fellowship programs recruit applicants through a nonstandardized process that differs by program. Although there are deadlines, informal guidance, and more recent communication guidelines, perceived differences in recruitment practices persist between geographic regions, small and large programs, and newer and more well-established programs. In the wake of a survey of fellowship applicants that found mixed opinions surrounding the application process, U.S. forensic fellowship directors undertook a mixed method quantitative-qualitative survey of their colleagues to assess interest in a match as a potential improvement and factors influencing that interest (e.g., program size, age, and unfilled positions). With responses from all 46 active U.S. programs, results indicated broad support for principles of fairness, transparency, and minimizing pressure on applicants, with an almost perfectly divided interest in a match. Respondents supported the use of a centralized database to standardize the application process and favored certain exceptions for internal applicants. Hypotheses about the reasons underlying program directors' attitudes toward a match did not yield significant results, with only the size of a program approaching significance. This novel comprehensive survey of forensic fellowship directors offers a model for assessing and monitoring the evolution of application processes for medical subspecialties interested in expanding and improving their recruitment.

The predictive validity and temporal characteristics of the HCR-20v3 for inpatient violence in forensic inpatient settings. An international study.

Aggression and violence are common day to day problems in psychiatric settings. However, the optimal means of assessing that risk remains unclear. In the context of that uncertainty many tools have evolved, among which the HCR-20 is one of the most globally accepted, though many questions remain about its performance, how and when it should be deployed and how it can be most effectively used. In this 12 month follow up study of 210 forensic psychiatric inpatients with a diagnosis of a schizophrenia spectrum disorder we explored these issues. We found that the performance of the HCR-20v3, especially its Total score, performed well up to 6 months after it was rated but its performance deteriorated after that. Repeating the HCR-20v3 at 6 months stabilised the risk assessment and led to improved performance in the second months over and above the first rating. The HCR-20v3 was good at identifying those subjects at low risk of violence over 6 months of follow up in a forensic inpatient setting. The real-world implications of this study are that the HCR-20v3 is an effective means of identifying patient at low risk of violence, but it should be reassessed every 6 months.

Forensic Neurology and the Role of Neurologists in Forensic Evaluations.

There is a clear need for experts with the requisite knowledge and experience to offer medicolegal opinions pertaining to various neuropsychiatric conditions. There is also an important distinction between clinical and medicolegal roles, and the need for training and expertise applicable to forensic assessment. But there remain few available experts with credentials spanning neuropsychiatry and forensic assessment. This creates a dilemma whereby parties involved in litigation featuring neuropsychiatric illness or injury are frequently forced to choose between experts with either knowledge and skills applicable to neuropsychiatric conditions or experts with skills and experience applicable to forensic assessment. Either choice introduces risk. Whether flawed medicolegal opinions are a consequence of deficient medical knowledge or an inadequate forensic evaluation process, the result remains the same, with triers of fact potentially being exposed to problematic testimony. There is, however, a more fundamental problem that implicates patient care more broadly: spurious dichotomies created by the historical segregation of psychiatry and neurology. Optimizing clinical care for patients with neuropsychiatric conditions, improving medical education in support of such care, and enabling forensic neuropsychiatric assessment must then start with more proactive efforts to reintegrate psychiatry and neurology.

Prison and forensic mental health staff after suicides in their care. A narrative review of international and German national evidence.

There is a growing body of international research investigating the impact of patient suicide on mental health professionals. The experience of losing a patient to suicide can have a significant and, in some cases, long-lasting (negative) impact on mental health professionals. However, the nature and extent of the impact on prison staff or forensic mental health professionals in particular is less clear. This narrative review summarises both quantitative and qualitative studies and key findings in this area, focusing on the above professions. A literature search was conducted using PsychInfo and Google Scholar, covering the period from 2000 onwards. The vast majority of findings relate to mental health professionals in general. We were unable to identify any published reports on the responses of forensic psychiatric staff. The majority of identified studies in the prison context are qualitative. Studies from German-speaking countries are particularly scarce in both the prison and mental health contexts. We conclude that there is a profound lack of knowledge about the impact of client/patient suicide on the subgroups of (German) prison and forensic psychiatric staff. Clearly, more research is needed on both the nature and extent of the impact, as well as on the specific organisational and supportive factors that help to mitigate the negative effects of suicide.

A comparison of patient ratings and staff ratings of disability using the World Health Organisation Disability Assessment Schedule in individuals with psychotic spectrum disorders who are forensic psychiatric inpatients.

BACKGROUND: Psychosocial rehabilitation in forensic psychiatric services requires sound measurement of patient and staff perceptions of psychosocial function. The recommended World Health Organisation Disability Assessment Schedule 2.0 (WHODAS), designed for this, has not been examined with offender patients. AIMS: To examine patient and staff WHODAS ratings of secure hospital inpatients with psychosis, any differences between them and explore associations with other clinical factors. METHODS: Seventy-three patients self-rated on the WHODAS after 3 months as inpatients. An occupational therapist interviewed the patient's primary nurse and care team at about the same time (staff ratings). Scores were calculated according to the WHODAS manual. WHODAS scores and interview-rated symptom severity, cognitive measures, daily antipsychotic dose and duration of care were compared. RESULTS: Patient ratings indicated less disability than staff ratings for total score and for the domains of understanding and communicating, getting along and life activities. Self-care and participation ratings were similar. Patients were more likely to rate themselves as disabled in getting around (mobility). Only one-fifth of patient- and staff- ratings (16, 22%) were similar, while for nearly a third of the patients (23, 32%) self-ratings were higher than staff ratings. More severe positive symptoms were associated with higher self-rated WHODAS disability after accounting for treatment duration, negative symptoms, cognitive score and antipsychotic dose. No variable accounted for the staff/patient differences in ratings. CONCLUSION: Our mean WHODAS score findings echoed those in other patient samples-of patient underestimation of disability, linked to severity of symptoms. In this study using the WHODAS for the first time in a forensic mental health secure inpatient service, however, we found that, by comparing individuals, half of the patients reported equivalent or greater disability than did staff. Future research should focus on elucidating from patients what contributes to their self-ratings. Understanding their thought processes in rating may enhance rehabilitation planning.

Dissociation and the insanity defense: A review of U.S. Federal appellate case law.

Pathological dissociation is relatively common in the United States and may be associated with violent or criminal behavior. Dissociative Disorders, especially Dissociative Identity Disorder, are considered controversial diagnoses by some in the psychiatric and legal professions. Individuals who offend during dissociative states may not be criminally responsible if they meet the legal standard for insanity, however, insanity pleas based on dissociative symptoms are rare. This review examined Federal appellate case law for potential legal barriers to the insanity defense for dissociative conditions and any restrictions imposed on related expert evidence. Few rulings directly addressed these questions but there do not appear to be any unique barriers for dissociation-related insanity pleas. Some cases provided valuable insights regarding the admission of expert evidence, effective expert testimony, and the role of defense counsel.