[Stalking of psychiatrists and psychotherapists : Results of an online survey]. / Stalking von Psychiatern und Psychotherapeuten : Ergebnisse einer Onlinestudie.

BACKGROUND: Currently, there are clear indications that due to their exposed occupational position psychiatrists and psychotherapists are at a higher risk than the general public to become the victim of stalking by patients. OBJECTIVES: This study investigated the frequency of stalking and its psychosocial impact among psychiatrists and psychotherapists in the Federal Republic of Germany. METHODS: Analysis of an online survey among members of the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) from 23 September 2015 until 22 October 2015. RESULTS: Of the respondents 26.5% reported having been the victim of stalking. In more than a third of the reported cases the stalking was described as severely or very severely debilitating. The majority of the perpetrators suffered from psychotic or personality disorders. Male victims were significantly more frequently stalked by a female perpetrator. Approximately 1 in 10 stalking victims continued the treatment of the perpetrator. The majority of the stalking victims did not obtain substantial support from their employer. CONSLUSION: The phenomenon of stalking within therapeutic relationships needs to be incorporated into the medical and psychotherapeutic professional training, e. g. by implementing specialized training courses and the systematic integration of this topic into clinical supervision. The institutional dealing with stalking by patients needs to optimized, e. g. by promptly transferring treatment of patients who stalk to other professionals and, where required, providing assistance in reporting stalking incidents to the police.

[DSM-5: What is new and what is relevant to forensic psychiatric assessment?]. / DSM 5: Was ist neu und was ist für die Begutachtung relevant?

DSM-5 lists a number of new diagnostic categories and also major changes in diagnoses that have previously been in use. The diagnostic sections of the DSM-5 and certain fundamental changes are presented. Some of the implications with respect to expert opinions are discussed. Certain aspects of the DSM-5 section on somatic symptom disorder will be discussed in more detail, since complaints of physical symptoms without an adequate medical explanation are very frequently encountered in the general population.

[Assessment of Trauma-Related Disorders]. / Begutachtung bei posttraumatischen Belastungsstörungen.

The assessment of trauma-related disorders is increasingly important in forensic psychiatric expert opinion. The most important diagnosis in this context is posttraumatic stress disorder. Diagnostic criteria of this disorder are outlined. Differential diagnostic considerations with regard to less specific symptom complexes, such as the complex posttraumatic stress disorder are discussed. Furthermore the significance of symptom validity tests is critically discussed. Test results have to be considered carefully in the medicolegal context and require thorough clinical assessment.

[Forensic Implications of Sleep-Associated Behavior Disorders]. / Strafrechtliche Implikationen schlafassoziierter Verhaltensstörungen.

Parasomnias represent a category of disorders that involve complex behaviors or emotional experiences, arising from or occurring during sleep, which might be also associated with (incomplete) awakening. These phenomena are classified as REM- or Non-REM-parasomnias. In particular the latter, including confusional arousal, sleepwalking and sleep terrors but also REM-sleep behavior disorder might result in criminal consequences. Using polysomnography, the pathophysiological mechanisms of these disorders have been investigated thoroughly. Nevertheless, in German literature, forensic implications of complex behaviors arising from sleep disorders have only been described insufficiently. Here we describe the most relevant parasomnias and also how to proceed in the context of forensic assessments.

[Difficulties in the assessment of trauma-related disorders]. / Begutachtung von Traumafolgestörungen.

Assessment of trauma disorders is becoming increasingly important. A major problem here is that trauma disorders are extremely heterogeneous. Moreover, they are often associated with comorbid disorders, such as borderline personality disorder. The valid diagnostic systems ICD-10 and DSM-5 poorly represent trauma disorders. The so-called complex post-traumatic stress disorder or DESNOS (disorders of extreme stress not otherwise specified) are listed .in either of the ICD-10 or DSM-5. The distinctiveness is not generally scientifically accepted. In addition, the assessment of trauma disorders is complicated because there are often multiple traumas of varying degrees of severity.

[Forensic psychiatric assessment of posttraumatic stress disorder]. / Forensisch-psychiatrische Beurteilung posttraumatischer Belastungsstörungen.

The assessment of trauma-related disorders is becoming increasingly more important in forensic psychiatric expert opinions. The most important diagnosis in this context is posttraumatic stress disorder. The essential diagnostic criteria of this disorder are outlined. Differential diagnostic considerations are often necessary with respect to less specific symptom complexes, such as the complex posttraumatic stress disorder or diagnoses which as a rule cannot etiologically be causally associated with trauma alone, such as depression or anxiety disorders. Furthermore, the significance of symptom validity tests is critically discussed. Test results have to be considered carefully in the medicolegal context and require a thorough clinical assessment.

[Assessment of legal capacity and testamentary capacity]. / Begutachtung der Geschäfts- und Testierfähigkeit.

The assessment of legal capacity and testamentary capacity require thorough knowledge of the legal framework and the relevant case law. This paper explains the concept of the legal capacity to contract and the concept of testamentary capacity with respect to German civil law. The relevance of major mental disorders for the assessment of legal capacity and testamentary capacity is discussed.

[Stalking: diagnostics, risk assessment, principles of treatment and forensic psychiatric assessment]. / Stalking: Diagnostik, Risikoeinschätzung, Behandlungsgrundsätze und Begutachtung.

Stalking is a widespread phenomenon describing a pattern of intrusive and threatening behavior that leads to the victim's perception of being harassed, threatened and frightened. Physical assault and even homicide may sometimes occur in the context of stalking. For psychiatry the following tasks result: (1) diagnosis and classification of stalking cases, (2) risk assessment of stalking cases, (3) counselling and treatment of victims of stalking and, (4) treatment and assessment of stalkers. Empirical findings and instructions are presented for these four areas.

Long-term efficacy and tolerability of clozapine combined with ziprasidone or risperidone.

INTRODUCTION: Treatment resistance in schizophrenia often leads to add-on of atypical antipsychotics to clozapine. METHODS: In a randomized trial, we recently obtained evidence for comparable efficacy and differential side effects of clozapine in combination with ziprasidone (CZ, N=12) versus risperidone (CR, N=12). Here, we present the open-label, long-term evaluations of these patients after 26 and 52 weeks. RESULTS: Sustained improvements of psychopathology as assessed by PANSS (positive and negative syndrome scale), SANS (scale for the assessment of negative symptoms), and HAMD (Hamilton depression scale) were documented in both subsamples being treated according to protocol, while dropouts reduced the study sample after 26 (CZ: reduced by -4; CR: -2) and 52 weeks (CZ: -0; CR: -5). We observed a slight increase of akathisia in the CZ group whereas general clozapine-associated side effects improved. DISCUSSION: The combinations of clozapine with ziprasidone or risperidone exhibit long-term efficacy, but the level of evidence is limited. Further head-to-head comparisons of atypical antipsychotics as add-on to clozapine are necessary.

[The "reasonable effort of will" in the expert opinion in social medicine]. / Die "zumutbare Willensanspannung" in der sozialmedizinischen Begutachtung.

The assessment of "effort of will" and "reasonableness" in the social medical expert opinion needs the empirical recording of concrete psychopathological and/or physical symptoms and its connection to fitness for work. The discussion of abstract, philosophical problems is not necessary. From the psychiatric point of view, a proposal for handling these complex terms is presented. The expert assessment should be carried out in several steps.

[Risk assessment of threatened amok. New responsibilities for psychiatry?]. / Risikoeinschätzung bei Amokdrohungen. Neue Aufgaben für die Psychiatrie?

Although instances of amok are very rare, they have captured media and political attention following several occurrences in German schools. Mental health professionals are increasingly faced with threat assessment in order to help prevent such tragedies. Since the base rate of amok is low and current risk assessment lacks empirical foundations, the likelihood of false-positive results is high. The role of mental health professionals in this domain should be reframed. The focus should not be risk assessment but risk management since most of the mass murderers are in need of some type of psychiatric intervention prior to the massacre. In contrast, compulsory admission and involuntary treatment are only justified if the threats occur in the context of a diagnosed mental disorder. Prospective research approaches that integrate psychopathological and neurobiological methods are urgently needed.

[Expert opinion on post-traumatic stress disorder]. / Begutachtung der posttraumatischen Belastungsstörung.

There is a high prevalence of post-traumatic stress disorder in community-based samples.Therefore, psychiatric assessment and expert opinion are often required. Professional standards for psychiatric expert opinion in the assessment of post-traumatic stress disorder are outlined. The significance of symptom validity tests is critically discussed. Test results have to be considered carefully in the medicolegal context and require thorough clinical assessment.

[Symptom validity tests in psychiatric assessment: a critical review]. / Kritische Bestandsaufname zum Einsatz von Beschwerdenvalidierungstests in der psychiatrischen Begutachtung.

Neuropsychological symptom validity testing is increasingly used even in psychiatric expert assessment. Low scores on symptom validity tests can only demonstrate exaggerated symptoms. However, symptom validity tests do not address the question of whether the result is intentionally produced or motivated by internal incentives. Therefore, symptom validity tests cannot differentiate between malingering and somatoform disorder. Test results have to be considered carefully in the medicolegal context and require thorough clinical assessment.

Efficacy and tolerability of ziprasidone versus risperidone as augmentation in patients partially responsive to clozapine: a randomised controlled clinical trial.

Patients suffering from schizophrenic psychoses sometimes insufficiently respond to antipsychotic monotherapy and then combination approaches are preferred. We aimed in validating the add-on of ziprasidone and risperidone to clozapine, and we performed a randomised head-to-head trial. Patients with partial response to clozapine were randomly attributed to augmentation with ziprasidone (n = 12) or risperidone (n = 12). Efficacy assessments included the Positive and Negative Syndrome Scale (PANSS), the Scale for the Assessment of Negative Symptoms (SANS), the Hamilton Depression Scale (HAMD), the Clinical Global Impression (CGI) and the Global Assessment of Functioning (GAF). Furthermore, several safety and tolerability measures were obtained. After six weeks, both groups showed significant reductions of positive and negative symptoms. In addition, affective state, psychosocial functioning and clozapine side effects improved without significant differences between the groups. Both approaches were well tolerated. However, the ziprasidone group experienced a small elongation of the QTc interval and a reduction of extrapyramidal symptoms. Patients under clozapine-risperidone therapy developed a rise of serum prolactin levels. The clozapine augmentation with ziprasidone or risperidone resulted in significant psychopathological improvements. The side effects differed between the treatment groups. Further head-to-head comparisons of atypical antipsychotics as add-on to clozapine are necessary.

[Cyberstalking]. / Cyberstalking.

The term cyberstalking appears in the media with increasing frequency. So far epidemiological studies are sparse. Since researchers have used different definitions and study samples for cyberstalking, widely varying prevalence rates have been published. We report here a case of cyberstalking and discuss available empirical data. Cyberstalking may cause psychological distress similar to that of real world stalking. The need for a scientific definition of cyberstalking and for future studies is presented. Since it is likely that psychiatrists will encounter victims of cyberstalking they should have knowledge of this phenomenon.

[Is the "psychopathy concept" applicable to expert opinions in civil suits?]. / Die Bedeutung des "Psychopathy-Konzeptes" in der Begutachtung von psychischen Unfallschäden.

The assessment of the psychological consequences of an accident is a complex and sophisticated challenge for physicians. Pre-traumatic personality traits and the post-traumatic course must be assessed with care. The evaluation of pre-traumatic personality traits is often an issue of particular debate. In this paper, the concept of "psychopathy" according to Hare is outlined, and the potential application of this concept in the assessment procedure is discussed. Typical personality traits such as glibness, superficial charm, egocentricity, pathological lying and deception, lack of remorse and lack of empathy may provide valuable hints for the expert opinion.

[Malingering of post-traumatic stress disorder]. / Simulation bei posttraumatischer Belastungsstörung.

Post-traumatic stress disorder is a frequently diagnosed disorder. Expert assessments of claimants with PTSD symptoms have become a common challenge for physicians in civil lawsuits. Since diagnosis of PTSD relies primarily on the patient's subjective report, this syndrome is particularly vulnerable to malingering. For this reason, it is important for physicians to try to identify individuals with true PTSD and differentiate them from those who malinger the disorder. This paper outlines the general problems and assessment strategies involved in the detection of malingering. A special focus is placed on the typical presentation of malingered PTSD symptoms.