Dominique Bourget

Homicide of Strangers by People with a Psychotic Illness

BACKGROUNDnThe homicide of strangers by people with psychosis, referred to here as stranger homicides, are rare and tragic events that generate adverse publicity for mental health services and have resulted in significant changes in mental health policy and law.nnnAIMnTo estimate the incidence of stranger homicides, using data from previously published studies, and to compare the characteristics of psychotic offenders who killed strangers with the characteristics of those who killed a close relative.nnnMETHODnMeta-analysis of the population-based studies of homicide by persons suffering from a psychosis in which the number of subjects who killed strangers was also reported. Characteristics of stranger homicide and family homicide offenders were examined in a multicenter case-control study of homicide during psychotic illness in four high-income countries.nnnRESULTSnA pooled estimate of 1 stranger homicide per 14.3 million people per year (95% confidence interval, 1 in 18.9 million to 1 in 11.5 million people per year) was calculated by meta-analysis of 7 studies. The characteristics of the 42 stranger homicide offenders from New South Wales [NSW], Quebec and Eastern Ontario, Finland, and the Netherlands were identified. Twenty seven (64%) of these had never previously received treatment with antipsychotic medication. The stranger homicide offenders were more likely to be homeless, have exhibited antisocial conduct, and had fewer negative symptoms than those who killed family members. The victims of stranger homicide were mostly adult males and the homicides rarely occurred in the victims home or workplace.nnnCONCLUSIONSnStranger homicide in psychosis is extremely rare and is even rarer for a patient who has received treatment with antipsychotic medication. A lack of distinguishing characteristics of stranger homicide offenders and an extremely low base rate of stranger-homicide suggests that risk assessment of patients known to have a psychotic illness will be of little assistance in the prevention of stranger homicides.

Familial Paraphilia: A Pilot Study with the Construction of Genograms

Biological factors are likely predisposing and modulating elements in sexually deviant behavior. The observation that paraphilic behavior tends to cluster in some families is intriguing and potentially raises questions as to whether shared genetic factors may play a role in the transmission of paraphilia. This pilot study introduces five families in which we found presence of paraphilia over generations. We constructed genograms on the basis of a standardized family history. Results document the aggregation of sexual deviations within the sample of families and support a clinical/phenomenological heterogeneity of sexual deviation. The concept of paraphilia in relation to phenotypic expressions and the likelihood of a spectrum of related disorders must be clarified before conclusions can be reached as to family aggregation of paraphilia based on biological factors.

Switching outpatients with schizophrenia and related disorders on long-acting injectable antipsychotics to olanzapine: an open-label naturalistic pilot study.

Little is known about the feasibility of switching patients with schizophrenia from long-acting injectable antipsychotics to oral olanzapine. We completed an open-label 14-week study to assess such a transition. This study included 25 stable outpatients (DSM-IV diagnosis of schizophrenia, schizophreniform disorder, or schizoaffective disorder) who were receiving long-acting injectable antipsychotics. Following a screening visit, patients began treatment with olanzapine 10 mg/day, which was initiated the day of their scheduled injection. Clinical assessments included the Clinical Global Impression—Improvement Scale (CGI-I) and the Positive and Negative Syndrome Scale (PANSS). Patient self-reports of adverse events were monitored and the Extrapyramidal Symptoms Rating Scale completed at each visit. In those completing the trial (N = 18), results revealed that a switch from injectable antipsychotics to olanzapine was associated with significant improvements on the CGI-I, negative symptoms, PANSS total scores, and parkinsonism. In considering the whole sample (last observation carried forward, N = 25), significant improvements on the CGI-I, parkinsonism, and dyskinesia were observed. Finally, those who failed to complete the trial (N = 7) did not change significantly from visit 1 to endpoint on any of the efficacy or safety measures. These results should be considered preliminary and require replication using appropriate control groups.

Child pornography offenders detected by surveillance of the Internet and by other methods

BACKGROUNDnAvailability of child pornography on the Internet has created new opportunities for offending. It has been noted that many people charged with offences relating to this had not previously been identified as sexual offenders against children.nnnAIMnOur aim was to compare the characteristics of people charged with child pornography offences as a result of police monitoring of the Internet with those detected by other means. We hypothesised that those apprehended via the Internet would be more likely to be older and less likely to have severe psychiatric disorder or to have been previously charged with a sexual offence involving contact with a child than those identified by other means.nnnMETHODSnData were extracted from the findings of clinical examinations by the authors either in the course of preparing reports for court, or in the course of providing treatment.nnnRESULTSnThere were 52 men detected by police Internet surveillance and 53 men detected by other means, the latter including 16 men who had not been charged with an offence at the time of referral. Those detected via the Internet were more likely to be in possession of very large quantities of child pornography. Those detected by other means were more likely to have major psychiatric and substance abuse disorders and to report childhood sexual abuse. A subgroup analysis of the 89 people who were facing charges at the time of the assessment found that the only significant differences were in the amount of material and the history of sexual abuse.nnnCONCLUSIONSnThe men recruited to this study, conducted over a period of nearly 10 years, reflect the changing nature of the technology used to commit this type of offence in that time. The characteristics of the subjects did not confirm the stereotype of an Internet child pornography offender who was high functioning and otherwise well adjusted and carried a low risk of other types of offences.

Managing pathologic aggression in people with psychotic disorders

A 55-year-old man had longstanding paranoid beliefs that the police were responsible for his personal bankruptcy. He believed they wanted to kill him through actual or simulated suicide, and he often carried a revolver. After attempting suicide by firearm, delusional disorder and major depression were diagnosed and he started risperidone and citalopram. A few years later, he shot 5 people, killing 1. He believed he saw police officers at his former company and believed they were conspiring to kill him.