Harald Dressing

Compulsory admission of mentally ill patients in European Union Member States

Abstract.Background and aims:A standardised and systematic analysis of commitment laws in the European Union Member States is still missing. This study aimed at gathering, describing and analysing information on the differences or similarities of legal frameworks for involuntary placement and treatment of mentally ill patients across the European Union Member States.Method:Information was gathered by means of a detailed questionnaire filled in by experts from all EU Member States. Legal criteria for compulsory admission and details of the assessment and decision process of compulsory admission are outlined.Results:Although common patterns among Member States can be identified upon comparison of crucial legislative or procedural details, these patterns are far from being consistent across all analysed items or approaches. With regard to compulsory admission quotas no significant influence of legal commitment criteria and the involvement of judicial authorities could be found, but Member States with an obligatory inclusion of a legal representative during the commitment procedure showed significantly lower compulsory admission quotas.Conclusions:Results of this study show the strong necessity for further research in this field. Common international health reporting standards as annually updated involuntary placement rates detailed for regular and emergency cases seem to be essential.

Abnormal amygdala activation profile in pedophilia

Despite considerable public interest research in neurobiological correlates of pedophilia is scarce. Since amygdala activation is central for emotional valuation, arousal, and salience, we investigated the activation profile of this structure in 10 male subjects with pedophilia (exclusively attracted to boys), all convicted sex-offenders and sentenced to forensic psychiatric treatment along with ten male heterosexual matched controls. We used a sexually non-explicit functional Magnetic Resonance Imaging (fMRI) paradigm with images of men, women, boys or girls randomly embedded in neutral target/non-target geometrical symbols. We applied statistical parametric mapping (SPM2) and SPSS 14 for image processing and analysis. While controls activated significantly less to pictures of children compared to adults, the activation profile was reversed in subjects with pedophilia, who exhibited significantly more activation to children than adults. The highest activation was observed for boys in the patient group, and for women in control participants. Our data show enhanced activation to children’s pictures even in an incidental context and suggest the provocative hypothesis that a normally present mechanism for reduced emotional arousal for children relative to adults is reversed in pedophilia, suggesting a neural substrate associated with deviant sexual preference in this condition. More extensive research in this field would be of benefit for both the victims and the offenders.Despite considerable public interest research in neurobiological correlates of pedophilia is scarce. Since amygdala activation is central for emotional valuation, arousal, and salience, we investigated the activation profile of this structure in 10 male subjects with pedophilia (exclusively attracted to boys), all convicted sex-offenders and sentenced to forensic psychiatric treatment along with ten male heterosexual matched controls. We used a sexually non-explicit functional Magnetic Resonance Imaging (fMRI) paradigm with images of men, women, boys or girls randomly embedded in neutral target/non-target geometrical symbols. We applied statistical parametric mapping (SPM2) and SPSS 14 for image processing and analysis. While controls activated significantly less to pictures of children compared to adults, the activation profile was reversed in subjects with pedophilia, who exhibited significantly more activation to children than adults. The highest activation was observed for boys in the patient group, and for women in control participants. Our data show enhanced activation to children’s pictures even in an incidental context and suggest the provocative hypothesis that a normally present mechanism for reduced emotional arousal for children relative to adults is reversed in pedophilia, suggesting a neural substrate associated with deviant sexual preference in this condition. More extensive research in this field would be of benefit for both the victims and the offenders.

Coercion, involuntary treatment and quality of mental health care: is there any link?

Purpose of review This paper summarizes major results and debates in the field of coercive or involuntary treatment of the mentally ill and how these relate to the quality of care, as published in literature during 2002 and 2003. Recent findings Studies focus on four major issues: involuntary hospital placement and treatment of mentally ill patients, compulsory outpatient treatment, attitudes towards or perceived coercion, and ethics of coercive measures in mental health care. Studies suggest a complex correlation between the involuntary placement of mentally ill patients, coercive measures, and outcomes. Outcome indicators for the quality of mental health care are not standardized, but vary with the point of view of the individual or collective assessor. None of the results question the necessity or the legality of involuntary treatments or conclude to refrain from employing coercive measures in mental health care if these cannot be avoided. Many results of research on attitudes towards involuntary treatments or perceived coercion suggest an acceptance of the application of coercive measures, even by the persons concerned, if the legal conditions are clearly defined. Research standards or study designs may benefit from some improvement. Study samples usually are small and only in rare cases has their selection been representative. Summary Research activities are remarkably few in number, especially considering the frequency of involuntary measures and the controversial perception or discussion of these measures among the persons concerned, professionals, or a wider public. Many basic research questions still remain to be adequately addressed, such as the long-term effects of involuntary treatment.

The epidemiology and characteristics of stalking.

Purpose of review This article summarizes major results in the field of epidemiology and characteristics of stalking, as published in literature between 2003 and October 2005. Recent findings Although stalking had been only recently conceptualized, it soon became evident that it represents a significant social and medical problem. Community-based studies on the prevalence of stalking are scarce and predominantly from English-speaking countries. All epidemiological studies, however, revealed that stalking is a widespread phenomenon with lifetime prevalence rates of stalking victimization ranging 12–16% among women and 4–7% among men. With regard to the impact of stalking, studies suggest that stalking can cause serious economic, social, medical and psychiatric consequences. Growing evidence suggests that serious violence and even homicide may occur in the context of stalking, and research on risk assessment has yielded an improved understanding of risk factors. Research on therapy of stalkers and stalking victims is still at its beginning; however, there are some preliminary reports with encouraging results. Summary Although there are research activities in the main fields, many basic questions still remain to be adequately addressed. Increased social and political awareness and expanded research funding are obligatory prerequisites to realize sound and well designed studies.

From the hospital into the community and back again - A trend towards re-institutionalisation in mental health care?

Background: Despite numerous and indispensable advantages, the shift from hospital-based to community mental healthcare has engendered problems. To analyse whether or not the process of de-institutionalization has gone too far, studies are needed that cover general psychiatry, forensic psychiatry, and penitentiaries as interlocked systems, but these are still scarce. Method: We combined epidemiological and service utilization data from three recent European studies that explored the legal frameworks for and the practices with regard to involuntary treatment in general mental healthcare, to the care of mentally disordered offenders in forensic care and to the care of mentally ill inmates in the European prison systems, and used more specific data from one country to illustrate how changes to the legal frameworks in one sector may potentially affect the others. Results: Time series from European Union (EU) member states suggest that civil detention rates remained more or less stable during the 1990s, though on rather different levels internationally. Admissions to forensic psychiatric facilities increased during the same period. Data on the mental state (or changes in rates of psychiatric morbidity) in European prison populations are not available–aside from the prison suicide rate. Data from selected countries are likely to suggest that changes to the legal framework in one sector may considerably affect admission rates in others. Conclusions: National or regional studies are needed to analyse the linkage between sectors and to identify inappropriate patient shifting. National and international data bases need to be implemented or improved.

Stalking Behavior – An Overview of the Problem and a Case Report of Male-to-Male Stalking during Delusional Disorder

Stalking is a widespread phenomenon describing a pattern of intrusive and threatening behavior leading to the victim’s perception of being harassed and rendered fearful. This paper outlines relevant aspects of the stalking concept and reviews the historical development of this categorization, different typologies of stalking behavior, associated psychiatric diagnoses, frequency and demographic data, psychomedical impact on the victims and therapeutic approaches. Special gender aspects are discussed by presenting a case history of male-to-male stalking.

Reduced embodied simulation in psychopathy

Abstract Objectives. Psychopathy is characterized by severe deficits in emotion processing and empathy. These emotional deficits might not only affect the feeling of own emotions, but also the understanding of others’ emotional and mental states. The present study aims on identifying the neurobiological correlates of social-cognitive related alterations in psychopathy. Methods. We applied a social-cognitive paradigm for the investigation of face processing, emotion recognition, and affective Theory of Mind (ToM) to 11 imprisoned psychopaths and 18 healthy controls. Functional magnetic resonance imaging was used to measure task-related brain activation. Results. While showing no overall behavioural deficit, psychopathy was associated with altered brain activation. Psychopaths had reduced fusiform activation related to face processing. Related to affective ToM, psychopaths had hypoactivation in amygdala, inferior prefrontal gyrus and superior temporal sulcus, areas associated with embodied simulation of emotions and intentions. Furthermore, psychopaths lacked connectivity between superior temporal sulcus and amygdala during affective ToM. Conclusions. These results replicate findings of alterations in basal face processing in psychopathy. In addition, they provide evidence for reduced embodied simulation in psychopathy in concert with a lack of communication between motor areas and amygdala which might provide the neural substrate of reduced feeling with others during social cognition.

Prisoners with mental disorders in Europe.

The prevalence of psychiatric disorders in prisoners is substantially higher than in the general population.[1][1] Additionally, there is scientific evidence that the number of prison inmates with mental disorders is rising. As a consequence, the World Psychiatric Association has repeatedly voiced

Admission of mentally disordered offenders to specialized forensic care in fifteen European Union member states.

ObjectiveDespite a high ranking on the public and political agenda, across Europe and all over the world there is a surprising shortage of basic information and evidence on the quantity and quality of services available for mentally disordered or ill offenders, the frequency of cases in specialized forensic facilities or the effectiveness of provided care in the various countries. Against poor evidence the rapid European integration and the strive for models of good practice require valid and reliable international overviews, sound studies and profound analyses of this most controversial issue.AimsTo harmonize and give an overview of prevalence and incidence data of persons in forensic psychiatric care available from official sources across fifteen European Union-Member States.MethodData was gathered and provided by forensic experts from each included country.ResultsTotal numbers as well as prevalence and incidence on persons placed or treated under legal forensic regimes vary remarkably across the EU, although a tendency of constantly, but slowly rising rates from 1990 onwards may be concluded from available time series. However, variation supports the hypothesis of a variety of unknown influencing factors, which need to be analysed for each country separately.ConclusionsCommon EU-wide patterns of psychiatric forensic prevalence or incidence rates can hardly be detected from available administrative data. Results show the necessity for international harmonisation of definitions or indicators as a basic requirement for strongly needed further research in this crucial field.

Preventing compulsory admission to psychiatric inpatient care through psycho-education and crisis focused monitoring.

BackgroundThe high number of involuntary placements of people with mental disorders in Switzerland and other European countries constitutes a major public health issue. In view of the ethical and personal relevance of compulsory admission for the patients concerned and given the far-reaching effects in terms of health care costs, innovative interventions to improve the current situation are much needed. A number of promising approaches to prevent involuntary placements have been proposed that target continuity of care by increasing self-management skills of patients. However, the effectiveness of such interventions in terms of more robust criteria (e.g., admission rates) has not been sufficiently analysed in larger study samples. The current study aims to evaluate an intervention programme for patients at high risk of compulsory admission to psychiatric hospitals. Effectiveness will be assessed in terms of a reduced number of psychiatric hospitalisations and days of inpatient care in connection with involuntary psychiatric admissions as well as in terms of cost-containment in inpatient mental health care. The intervention furthermore intends to reduce the degree of patients’ perceived coercion and to increase patient satisfaction, their quality of life and empowerment.Methods/DesignThis paper describes the design of a randomised controlled intervention study conducted currently at four psychiatric hospitals in the Canton of Zurich. The intervention programme consists of individualised psycho-education focusing on behaviours prior to and during illness-related crisis, the distribution of a crisis card and, after inpatient admission, a 24-month preventive monitoring of individual risk factors for compulsory re-admission to hospital. All measures are provided by a mental health care worker who maintains permanent contact to the patient over the course of the study. In order to prove its effectiveness the intervention programme will be compared with standard care procedures (control group). 200 patients each will be assigned to the intervention group or to the control group. Detailed follow-up assessments of service use, psychopathology and patient perceptions are scheduled 12 and 24 months after discharge.DiscussionInnovative interventions have to be established to prevent patients with mental disorders from undergoing the experience of compulsory admission and, with regard to society as a whole, to reduce the costs of health care (and detention). The current study will allow for a prospective analysis of the effectiveness of an intervention programme, providing insight into processes and factors that determine involuntary placement.Trial registrationCurrent Controlled Trials ISRCTN63162737.