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Background Motivation to change is a central component of successful psychotherapeutic treatment. It is however unclear how external pressures in court-mandated treatments interfere with a patient's internal motivation. This study sought to investigate service providers' and users' experiences with court-mandated psychotherapeutic treatment and its effects on a patient's motivation. Methods We conducted a qualitative interview study with 41 older incarcerated persons receiving involuntary treatment and 63 mental health professionals (MHP) from Canada and Switzerland. Interviews were analyzed using thematic analysis. Results MHP participants referred to the difficulties of using internal motivation as selection criterion for treatment participation but emphasized the advantage of the legal referral as a chance to connect with a person who would otherwise not seek treatment. This coerced participation in psychotherapy allowed the MHPs to build internal motivation throughout the intervention. Further, we delineate certain external and internal factors that influence treatment motivation. For instance, a patient's strategic motivation to engage in treatment to regain freedom; the influence of authorities' decision-making processes on treatment motivation; conveying and understanding of psychotherapy to promote active participation. Conclusions Our study provides important empirical findings on the effects of the legal referral on a patient's motivation. Findings suggest that the legal referral in itself does not stand in contradiction to internal motivation. In fact, it facilitates the engagement with a person needing treatment. However, a patient's internal motivation is challenged if goals set by external decision-makers are unclear, unpredictable, and vague. To increase the effectiveness of court-mandated treatment, institutions should therefore establish clear goals that are communicated clearly and transparently to the patients. With this clarity, a patient's internal motivation can be enhanced, which ultimately affects outcomes of court-mandated treatment orders.

Recovery orientation (RO) is a modality of supporting patients to improve self-determination, leading a meaningful life and well-being in general. This approach is widely studied in general psychiatry, but evidence is lacking for forensic inpatient settings in Switzerland. While secure forensic clinics tend to be regarded as total institutions, which are an anathema to RO, a project to implement RO interventions in this setting was financed by the Swiss Federal Office of Justice. This explorative study investigates baseline expectations and views of patients in forensic wards in German-speaking Switzerland in the context of a recovery-oriented intervention. As such wards are non-existent in Latin-speaking Switzerland, the investigation could only be carried out in this language region. Six focus groups with 37 forensic inpatients were conducted. Thematic analysis revealed two major and several subthemes. The major theme “heteronomy” includes the subthemes “stigmatization and shame,” “coercion,” “lack of support,” “mistrust,” “waiting,” and “structural impediments.” The subthemes “learning to live with the disorder and working on oneself,” “participation,” “connectedness,” “confidence,” and “joie de vivre” belong to the major theme “regaining self-determination.” In this way, results of prior research are extended to forensic peculiarities. Furthermore, the personal views of patients are discussed in detail regarding their possible influence on therapeutic outcomes and personal recovery. These findings should be of help to therapeutic staff in the respective setting to be better informed about, and to counter the effects of, heteronomy and long-term hospitalization. Important in this regard is the concept of procedural justice and the subjective client's perception thereof.

The present study aimed to differentiate pedophilic child sex offenders (CSOs) from nonoffending controls (CTLs), as well as contact from noncontact CSOs. For this purpose, we investigated 21 contact CSOs, 20 noncontact CSOs (child pornography offenders), as well as 21 CTLs on neuropsychological test measures and indirect test measures of sexual interest. Multiple logistic regression models showed that three parameters of indirect tests and two neuropsychological test parameters allowed the differentiation of CSOs from CTLs with a maximum accuracy of 87%. The profile of contact and noncontact CSOs was remarkably similar and the optimal model for this group differentiation had a maximum accuracy of 66%, with slightly increased levels of risk-taking behavior and greater susceptibility for perceptual interference in contact CSOs than in noncontact CSOs. The findings suggest that standardized, objective methods can support the assessment of sexual offenders against children in forensic psychiatry and legal psychology.

Studies in child sex offenders (CSO) often report deviant personality characteristics. In our study, we investigated neuroticism in CSO and tested the hypothesis that CSO with high neuroticism show more serious abuse behavior and are more likely to exhibit sexual dysfunction and cognitive distortions, as compared to CSO with low neuroticism. A sample of 40 CSO (both child sexual abusers and child sexual material users) was split into two subsamples based on their neuroticism scores, obtained by the NEO-Personality Inventory-Revised (NEO-PI-R) questionnaire. Subsequently, we compared their scores in the Multiphasic Sex Inventory (MSI) questionnaire and Symptom Checklist-90-Revised (SCL-90-R). Our results show that CSO exhibited higher levels of neuroticism than controls, but were still in the normal range. In CSO, neuroticism was associated with sexual dysfunction and cognitive distortions, rather than with more severe abuse behavior. Moreover, neuroticism in this group was linked to a broad range of psychological problems and psychopathological symptoms, such as somatization or anxiety. Our findings suggest that neuroticism even below the level of personality disorder is associated with a broader range of psychological problems in CSO, which should be addressed in therapy.

Personality traits are considered as an important aspect in the assessment of child sex offenders (CSOs). The current study sought to elucidate the association between neuroticism, psychopathy, and abusive behavior in low risk CSOs. 43 pedophilic CSOs and 21 controls (CTLs) completed the NEO-Personality Inventory-Revised (NEO-PI-R), Psychopathy Checklist: Screening Version (PCL:SV), and Multiphasic Sex Inventory (MSI). Our results revealed small differences in PCL scores between CSOs and CTLs, with comparatively low levels of psychopathy in both groups. Higher levels of neuroticism were associated with higher PCL scores, in both CSOs and CTLs. However, higher PCL scores in CSOs did not correlate with higher MSI total scores on the subscale child molest. These findings suggest an ambiguous role of psychopathy in CSOs: higher levels of psychopathy co-occur with higher levels of neuroticism, but psychopathy does apparently not modulate abusive behavior, at least not in low risk offenders, as currently investigated.

Objectives Impairment in working memory (WM) is a core symptom in schizophrenia. However, little is known about how clinical features influence functional brain activity specific to WM processing during the development of first-episode psychosis (FEP) to schizophrenia (SZ). We compared functional WM-specific brain activity in FEP and SZ patients, including the effects of the duration of illness, psychopathological factors and antipsychotic medication. Methods Cross-sectional study of male FEP (n = 22) and SZ (n = 20) patients performing an n-back task when undergoing functional magnetic resonance imaging (fMRI). Clinical features were collected by semi-structured interviews and medical records. Results The SZ group performed significantly worse than the FEP group in the 2-back condition. The SZ group also showed significantly higher activation in the left superior frontal gyrus in the 2-back versus 0-back condition (2-back > 0-back). This frontal activation correlated positively with negative symptoms and with cumulative antipsychotic medication during the year before the fMRI examination. There were no significant correlations between activation and duration of illness. Conclusion There was greater frontal neural activation in SZ than in FEP. This indicated differences in WM processing, and was significantly related to cumulative antipsychotic exposure and negative symptoms, but not to the duration of illness.

Objective Impaired response inhibition might play a role in child sexual offences. Recording of event-related potentials (ERPs) can help to clarify whether child sexual offenders (CSOs) show an altered processing of stop signals and commission errors. Methods In the current ERP study, we investigated these processes in a Go/Nogo task on two groups of CSOs, pedophilic contact CSOs and non-contact CSOs (child pornography offenders), as well as on non-offenders as controls. Results Behaviorally, CSOs showed a slight, but non-significant increase of the false alarm rate to Nogo cues, as compared to controls. The amplitudes of the ERP components N2 and P3 to Nogo cues followed by correctly withhold responses did not vary between CSOs and controls. The analysis of the ERPs to committed errors showed that the Ne amplitudes (reflecting error detection) did not differ between the groups either, whereas the Pe amplitudes (reflecting error evaluation and error awareness) were strongly diminished in CSOs. This diminishment was primarily found in contact CSOs. Conclusions The findings suggest that response inhibition, processing of stop signals, and error detection are not necessarily impaired in CSOs. However, CSOs appear to dedicate less cognitive resources to the evaluation of committed errors. Significance This selective alteration could reflect a reduced sense of responsibility for misconduct in this offender group, which might contribute to their delinquent behavior.

Ziel der Studie: In der vorliegenden Studie wurden eine Ubersetzung und eine deutschsprachige Validierung des Stress Appraisal Measure (SAM) von Peacock und Wong an einer studentischen Stichprobe vorgenommen. Der SAM ist ein vergleichsweise kurzer Fragebogen (28 Items) zur Bewertung eines aktuellen, stressauslosenden Ereignisses. Den theoretischen Hintergrund lieferte das Stressmodel von Lazarus und Folkman. Methodik: Bei 85 Studenten (Durchschnittsalter: 23; 59 Frauen, 26 Manner; Rucklaufquote: 42 %) wurde anhand von kurzen Imaginationsgeschichten Stress induziert, und anschliesend sollte der SAM ausgefullt werden. Zunachst wurde die stressauslosende Wirkung der Imaginationsgeschichten gepruft. Als weiterer statistischer Analyseschritt wurden eine Faktorenanalyse sowie die Bestimmung der internen Konsistenzen der sieben SAM-Skalen durchgefuhrt. Auserdem wurde die konvergente Validitat des SAM zum State and Trait Anxiety Inventory (STAI), zum Coping Inventory for Stressful Situations (CISS) und zu spezifischen Emotionsskalen mittels Pearson-Produkt-Moment-Korrelation ermittelt. Ergebnisse: Eine stressinduziernde Wirkung der Imaginationsgeschichten konnte nachgewiesen werden. Die Faktorenstruktur, die internen Konsistenzen der einzelnen Skalen sowie die konvergente Validitat des SAM aus der ursprunglichen Studie konnten in der vorliegenden deutschen Version in grosen Teilen repliziert werden. Einzelne Items (besonders des funften Faktors) luden allerdings auf anderen Faktoren als bei der Studie von Peacock und Wong. Schlussfolgerung: Der SAM konnte nun auch in deutscher Sprache eingesetzt werden.

Findings on the relationship of experienced sexual abuse and abuse behavior in adulthood are ambiguous. However, associations between experienced abuse and neuroticism as well as between neuroticism and active child abuse have been reported repeatedly. In our study, we compared pedosexual child abusers with consumers of internet child pornography and control subjects with adult-sexual preference with regard to traumatic childhood experience (Childhood Trauma Questionnaire, CTQ), personality traits (NEO - Personality Inventory - Revised, NEO-PI-R), and sexual abnormalities (Multiphasic Sex Inventory, MSI). In an initial analysis, sexual abuse experienced in childhood was not directly linked to sexual abuse behavior in adulthood. However, this relationship was mediated by neuroticism. In a second step, the CTQ scales were conflated and, using a structural equation model, direct links between the overall level of abuse experienced in childhood (generally high CTQ levels) and sexual abuse behavior in adulthood revealed again the mediation by neurotic personality. We conclude that the overall level of abuse experienced in childhood in general, and less sexual abuse experience in particular, modulates the tendency for child sexual abuse behavior in adulthood. Data suggest that, depending on the resilience of an individual, abuse experience during childhood increases the likelihood of developing neurotic personality traits in later life, which are in turn considered to increase the risk of child sexual abuse in child sex offenders.

Convictions for taking, possessing and distributing pornographic photographs of children have increased with the growing use of the Internet. Previous studies of any progression to contact offences have been small scale and only a few of these have included an investigation of subsequent reconvictions for use of illegal and especially of child pornography. The aims of the present study are to compare reconviction rates among illegal pornography offenders with and without previous child contact offences. The former are referred to as “dual offenders”. This study is a national cohort study of all individuals in Switzerland convicted of an illegal pornography offence since 1973 and was followed-up until 1st November 2008. Reconvictions were ascertained using criminal records from the Federal Office of Justice of Switzerland, leading to a total of 4612 offenders, consisting of 4249 illegal pornography offenders and 363 dual offenders. Comparison of 3-year reconviction rates showed that only 0.2% of the illegal pornography offenders were convicted of contact child sex offences, whereas 2.6% of the dual offenders were reconvicted. The illegal pornography offenders were also significantly less likely to be convicted of further pornography offences, or indeed other sexual offences. The very low “progression rate” among illegal pornography offenders to contact child sexual offences, and their low rate of even repeat pornography offences suggests that community sentences remain appropriate. It is important, however, to bear in mind that conviction rates tend to underestimate the true offending rates, and that with greater access to the Internet, characteristics of pornography users may change over time.

Background Certified medical specialists, including forensic psychiatrists, from the 27 member states of the European Union (EU) may practise in each other's countries, but there are professional and legal differences between them. One may lie in whether a patient's treating doctor/clinician may give expert evidence about that person in court. Aims To examine similarities and differences between EU jurisdictions in law and practice in combining or separating such roles and to review the evidence in support of either position. Methods A psychiatrist with court experience was contacted in each EU country about law, practice and guidance on division of clinician–expert roles. Published literature was searched for an evidence base for practice in the field. Additional material is from discussion at a residential meeting of practising forensic psychiatrists from Austria, Belgium, Denmark, Germany, Hungary, the Netherlands, Switzerland and the UK. Results All acknowledge that a treating clinician can never be an independent expert in that case, but the 22 (of 27) EU countries responding vary in law and practice on whether the dual role may be assumed. There has been almost no research interest in factors relevant to separation of roles. International discussion revealed that ethical and practice issues are not straightforward. Conclusions On current evidence, either separation or combination of clinical and expert roles in a particular case may be acceptable. Insofar as there are national legal or professional guidelines on this issue, anyone practising in that country must follow them and may safely do so, regardless of practice in their native country. The most important ethical issue lies in clarity for all parties on the nature and extent of roles in the case. This paper has additional material online. Copyright © 2012 John Wiley & Sons, Ltd.

Background: Ghrelin is a 28-amino acid gut-brain peptide, mainly secreted by the gastric mucosa. Its effects are linked to energy homeostasis and particularly seem to increase hunger and food intake. In recent years, studies suggested that appetite-regulating peptides, such as ghrelin play a relevant role in alcoholism. Since data published to date on the potential role of ghrelin as state and/or trait marker in alcoholism and the association with craving are controversial, we aimed at further elucidating these aspects. Patients and Methods: One-hundred nine alcohol-dependent abstinent patients after withdrawal (27 f, 82 m), (ICD 10 F 10.25) and 45 healthy volunteers (12 f, 33 m) were included. Laboratory testing (Ghrelin RIA 90, Mediagnost Inc., Germany) was performed and several craving scales [Obsessive Compulsive Drinking Scale, Alcohol Urge Questionnaire and Visual Analogue Scale (VAS)] were applied at the beginning and at the end of the 3-week rehabilitation program. Results: (1) Ghrelin levels are significantly higher in female alcohol-dependent patients as compared to controls, not, however, in men alcoholics. (2) In several statistical subanalyses, an association of craving and ghrelin was found. The results, however, remain heterogeneous. Conclusion: The data suggest gender-dependent ghrelin levels in alcohol-dependent patients. We therefore conclude, that it might be useful to perform statistical analyses gender-specific. With regard to a potential correlation of ghrelin and craving the results seem to depend on gender, duration of the abstinence period and the instrument used.

Personality disorders (PD) and substance use disorders (SUD) lead to high violent criminality. The influence of co-morbidity on recidivism remains unclear. Recidivism of 379 offenders was assessed at 8 years of follow-up. Sixty-nine percent of PD+SUD, 45% of SUD- and 33% of PD- subjects showed any recidivism. However, violent recidivism was highest in the PD- group.

Background: The failure to inhibit pleasurable but inappropriate urges is associated with frontal lobe pathology and has been suggested as a possible cause of pedophilic behavior. However, imaging and neuropsychological findings about frontal pathology in pedophilia are heterogeneous. In our study we therefore address inhibition behaviorally and by means of functional imaging, aiming to assess how inhibition in pedophilia is related to a differential recruitment of frontal brain areas. Method: Eleven pedophilic subjects and 7 nonpedophilic controls underwent fMRI while performing a go/no-go task composed of neutral letters. Results: Pedophilic subjects showed a slower reaction time and less accurate visual target discrimination. fMRI voxel-level ANOVA revealed as a main effect of the go/no-go task an activation of prefrontal and parietal brain regions in the no-go condition, while the left anterior cingulate, precuneus and gyrus angularis became more activated in the go condition. In addition, a group × task interaction was found in the left precuneus and gyrus angularis. This interaction was based on an attenuated deactivation of these brain regions in the pedophilic group during performance of the no-go condition. The positive correlation between blood oxygen level-dependent imaging signal and reaction time in these brain areas indicates that attenuated deactivation is related to the behavioral findings. Conclusion: Slower reaction time and less accurate visual target discrimination in pedophilia was accompanied by attenuated deactivation of brain areas belonging to the default mode network. Our findings thus support the notion that behavioral differences might also derive from self-related processes and not necessarily from frontal lobe pathology.

Background Most neuroimaging studies investigating sexual arousal in paedophilia used erotic pictures together with a blocked fMRI design and long stimulus presentation time. While this approach allows the detection of sexual arousal, it does not enable the assessment of the immediate processing of erotically salient stimuli. Our study aimed to identify neuronal networks related to the immediate processing of erotic stimuli in heterosexual male paedophiles and healthy age-matched controls. Methods We presented erotic pictures of prepubescent children and adults in an event related fMRI-design to eight paedophilic subjects and age-matched controls. Results Erotic pictures of females elicited more activation in the right temporal lobe, the right parietal lobe and both occipital lobes and erotic pictures of children activated the right dorsomedial prefrontal cortex in both groups. An interaction of sex, age and group was present in the right anteriolateral oribitofrontal cortex. Conclusions Our event related study design confirmed that erotic pictures activate some of the brain regions already known to be involved in the processing of erotic pictures when these are presented in blocks. In addition, it revealed that erotic pictures of prepubescent children activate brain regions critical for choosing response strategies in both groups, and that erotically salient stimuli selectively activate a brain region in paedophilic subjects that had previously been attributed to reward and punishment, and that had been shown to be implicated in the suppression of erotic response and deception.

ObjectivesDeviant sexual preference is known as a risk factor for child abuse. Most often the examination of sexual preferences relies on interviews, self-ratings like the Multiphasic Sex Inventory or rather invasive methods like phallometry respectively the so called Abel-Screen, derived from the latest. The computer based Implicit Association Test (IAT) has proven its validity in several fields like sexism or racism by measuring the subjects attitude to certain association. Gray et al. from Cardiff published in 2005 significant associations between children and sex in pedophiles.MethodsAs part of a larger study about visual erotic stimulation of child abusers and internet sex offenders, we conducted the IAT in two different versions with visual stimuli on both child abusers and internet sex offenders as well as on male and female comparison samples. Psychological and Personality profiles were assessed by HAWIE, WCST - 64, SKID, MMPI, MSI, IPO and SCL-90 R.ResultsPreliminary data suggests discriminant validity of the IAT concerning sexual preference. In addition, tests for frontal inhibition show poor performance of child abusers in contrast to controls and internet sex offenders.ConclusionsOur preliminary data about the IAT suggests that both child abusers and internet sex offenders display other associations on visual erotic stimulations than the comparison sample. Further research about deviant sexual preferences should take the impact of cognitive processes into consideration.

ObjectivesRecent research about pedophilia suggested an association between pedophilia, neurocognitive disturbance and specific personality profiles. Especially neuropsychological functions associated with the prefrontal and motor processing loops showed to be impaired in pedophilia. But in most studies about pedophilia subjects were recruited from high security forensic hospitals. The results might therefore be influenced by selection bias. To overcome this bias we conducted a study that aimed to compare neurocognitive disturbance and specific personality profiles of pedophile sexual abusers, pedophile internet abusers and controls.MethodsWe included until now 5 male pedophile sexual abusers, 4 male pedophile internet abusers and 6 male control subjects. Subjects were matched for age and IQ. Personality profiles were assessed by SKID and MMPI. Response inhibition was tested in a classical Go/NoGo task.ResultsAssessments of personality profiles showed similar sub threshold profiles for the controls and the group of internet abusers while subjects from security forensic hospital setting fulfilled criteria of personality disorders. Accordingly showed the Go/NoGo task higher rates of failed response inhibition in the group of paedophilic subjects from high security forensic hospital setting and lower rates for pedophile internet abusers and/or controls.ConclusionsOur preliminary data suggests that results of recent studies about neurocognitive disturbance and neuroimaging correlates of paedophilia might be influenced by selection bias and might rather reflect impairment of personality and social interaction in a broader sense. Future research about paedophilia should consequently aim to disentangle personality impairment from sexual orientation.

Internet sex offending is a rather new class of criminal acts and therefore little is known about previous convictions, recidivsm and especially correlation with hands-on sexual offences. Previous studies on small samples reported an insignificant correlation between previous convictions for child pornography and later contact sex offences on the one hand and an important role of pornography as a risk factor for sexual recidivsm of convicted sexual offenders. As an increasing number of defendants accused of child pornography is assigned for forensic risk assessment, better evidence and understanding of the role and the amount of the influence of child pornography on later offending is most urgently needed.We therefore explore these correlations by means of the complete set of all offenders convicted of illegal pornography in the Swiss federal crime registry at the time of november 2008. The analysis of 4658 criminal records reveal that 7.9% of the internet sex offenders were at the same time convicted of child abuse. The child molesters with 20.7% recidivated more frequently in general, compared to 9.8% of the offenders who were not convicted of a contact offence. Furthermore, the contact offenders with 11.4% were significant more likely to reoffend in terms of illegal pornography and sexual acts involving children with 6.0%.We will present all recidivism rates and our conclusions at the conference.