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

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

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

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

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

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

Psychopathy in Italian female murderers.

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

Closing Italian Forensic Psychiatry Hospitals in Favor of Treating Insanity Acquittees in the Community.

Originally a hedge against the death penalty, the insanity defense came to offer hospitalization as an alternative to imprisonment. In the late 19th century Italy opened inpatient services first for mentally ill prisoners and then for offenders found not guilty by reason of insanity. Within the past decade, a series of decrees has resulted in transferring the responsibility for treating NGRI acquittees and "dangerous" mentally ill prisoners from the Department of Justice to the Department of Health, and their treatment from Italy's high security forensic psychiatric hospitals (OPGs) to community regional facilities (REMSs, Residences for the Execution of Security Measures), community mental health facilities, one of which is located in each region of Italy. Today community REMSs provide the treatment and management of socially dangerous offenders. The dynamic evolution of Italy's progressive mental health system for insanity acquittees, to our knowledge the most libertarian, community oriented approach of any country, is retraced. Discussion includes cautionary concerns as well as potential opportunities for improvements in mental health services. Copyright © 2016 John Wiley & Sons, Ltd.

Evaluation of safety at work in a psychiatric setting: the "Workplace Safety Assessment".

OBJECTIVES: Workplace violence is a common risk for mental health professionals, and psychiatrists often encounter it in a variety of settings. The aim of this study was to estimate the prevalence and features of violent episodes toward psychiatrists in various mental healthcare system settings. METHODS: All psychiatrists from the Region of Puglia (Apulia) were contacted (N=285) via email and were administered an on-line standardized questionnaire. RESULTS: The response rate by psychiatrists was 57%. The main types of violence revealed were "threats" and "verbal aggression" and, of particular importance, "stalking". Female psychiatrists seemed to be at a higher risk of becoming victims of workplace violence, especially as regards verbal abuse (OR: 2.7, 95% CI: 1.2-6.5, c2 6.7, p=0.0095) and reported more serious psychological consequences with need for rest after the episode of aggression. CONCLUSIONS: Our data confirm that mental health workers, particularly psychiatrists, are healthcare professionals at high risk for workplace violence. Future implementation of preventive strategies with the aim of reducing aggressive episodes towards psychiatrists should be a high priority for managers and policy-makers operating in the Italian healthcare sector.

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

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

Cannabis use and violent behaviour: a psychiatric patients cohort study in Southern Italy.

UNLABELLED: An ample volume of research evidence supports the conclusion that drug use/abuse is correlated with violent behavior. Some studies have shown that co-morbidity also appears to be predictive of violent behavior. The research evidence indicates gender differences, while socio-economic and familial factors play a role, too. METHOD: We conducted a retrospective study of the clinical files of four public psychiatric outpatient facilities during five years. The objectives of the research were to identify and analyze relationships between: a) cannabis use/abuse and violent behavior and b) cannabis use/abuse, psychopathology, and violent behavior. The study sample consisted of 1,582 subjects. The data, gathered in a dedicated database, were processed by applying univariate and multivariate analysis models. RESULTS: Subjects who used/abused cannabis showed a high prevalence of violent behavior, Regardless of the type of psychiatric disorder, the use of cannabis appears to be an evident risk factor. Significant correlations also emerged between cannabis use/abuse and the type of violent behavior, especially self-inflicted injury. Evidence also emerged that other factors are implicated. This is consistent with the current literature proposing multi-casual explanations of violent behavior.

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

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

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

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

[Mental Health Centers, in regard to professional confidentiality and privacy]. / I Centri di Salute Mentale tra segreto professionale e privacy.

Maintaining privacy in the complex operative reality of public psychiatric services is not easy. Many operational doubts arise and psychiatrists encounter difficulties in application of the privacy norms, partly due to the clinical and treatment peculiarities of the psychiatric domain and partly to organizational and structural limits. The risk addressed in this work is that the apparent complexity of the privacy norms may be perceived by psychiatrists in the public sector simply as a further bureaucratization of the doctor-patient relationship rather than as an opportunity to institute greater safeguards of patients' rights. Hence, the Authors aim to clarify the key points of the law, integrating them with the classic issues of confidentiality, in order to outline the goals, provide suggestions as to how best to adapt practice to conform to these norms, and highlight ways to simplify procedures. The Authors conclude by expressing the hope that the principles embodied in the privacy norms may become an integral part of the cultural heritage of territorial psychiatric services.

[ASO-TSO, emergency interventions: has anything changed? Old and new psychiatrist's professional responsibilities]. / ASO, TSO, interventi d'urgenza: è cambiato qualcosa? Vecchie e nuove responsabilità professionali dello psichiatra.

The Law 833 of 1978 on the subject of psychiatric emergency treatments in absence of consensus has contributed to grant mental patients equal guaranties and equal constitutional rights which, until that moment, they had been denied. This standpoint includes TSO in favor of mental patients. Ordered by the constitutional laws which guarantee a person's inviolable rights, TSO finds itself positioned between individual freedom and the freedom of treatment on the one hand, and the right to safeguard health on the other hand. The procedure of TSO is noticeable in its various phases so as to provide for the various levels of safeguarding a person who is temporarily deprived of the capacity to express valid consensus. On the other side it also has a certain amount of flexibility in its application, which guarantees adaptability of the norm in various contexts and various incidental situations. Nevertheless, the complexity of the law on TSO, as well as the interpretation margins of the procedure have contributed to the creation of an application frame which is not free of criticism. In this context, the recommendations of the Conference of Regions and Autonomous Provinces have particular importance. These recommendations deserve careful analysis, both for the presence of elements of novelty (in the very particular cases of TSO for children under 18 and TSO for decisionally impaired subjects) and for the reminder of the full application of "non-hospitalized TSO". The latter was provided for in Law 833/78 but has never been adequately and completely adopted because it has never been explained in its concrete applicability. Therefore, bearing in mind the already known responsibility of a psychiatrist in an emergency case, and with renewed interest in new medical performance a psychiatrist of public service has to guarantee, we are preparing to give our contribution on the subject of professional obligations at a historical moment in which known trials seem to assign the responsibility for the "dangerousness" of a mental patient to the psychiatrist.

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

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

[Suicide and malpractice]. / Suicidio e responsabilità professionale.

Some recent statements on the subject of psychiatrists' responsibility for suicide committed by patients have provoked lively discussions about the welfare duties of public psychiatric services, causing a widespread climate of alarm among medical institutions. The discussion is primarily about the extent of the psychiatrist's "posizione della garanzia", in particular the duty of protection and surveillance in relation to the risk of self-destructive behavior, referring to convictions not only in TSO cases but also in cases of voluntary hospitalization and valid consensus on treatment. The subject of suicide inevitably reminds us of the predictability of self-destructive behavior and, above all, of its prevention. The authors compare data from scientific literature on this subject - the organizational model of territorial psychiatry - with the principles ordered by the convictions, in particular the request for "ulterior and more rigorous protective rules", thus highlighting their complicated synthesis. In the authors' opinion, a possible literal interpretation of the legal indications would risk a profound change in the quality of the relationship between psychiatrist and patient. The authors, striving to adopt the psychiatrists' point of view, want to finally provide some operational advice with the objective to delimit good practice according to a medico-legal view.

[Parental bonds in adolescent perpetrators of sexual violence]. / Il legame genitoriale in adolescenti autori di violenza sessuale.

A deep understanding of the characteristics of sex offenders may serve to improve clinical prevention and treatment programs. Mostly, however, this knowledge can aid in the creation of better re-education and rehabilitation programs as well as criminological treatment. In prison systems outside of Italy, the use of treatment programs specifically designed for sex offenders is commonplace, whereas in Italy, there is only sporadic experimentation in this field which is aimed at evaluating adults. If this is true for adults, it is even more so for the minors who commit this type of crime that gives rise to worry and a great sense of alarm. The aim of this work is to show the preliminary results of an empirical study that explores the mental representations of the parents of minors who commit acts of sexual violence towards other. This study is an ongoing in collaboration with the Juvenile Justice Center (Centro Giustizia Minorile) of the Region of Apulia, whose first data on 10 juvenile perpetrators of such specific crimes are presented here.

An unusual case of serial poisoning of family members.

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

The psychopathic dimension in women of mafia.

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

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

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

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

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

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

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