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Die Forensische Psychiatrie befindet sich im Spannungsfeld zwischen Patienten- und Sicherheitsinteressen. Mario Gmur hat ihr in einem fruheren SAZ-Beitrag Unwissenschaftlichkeit und unethisches Verhalten vorgeworfen. Die Autoren widerlegen diesen Vorwurf und verweisen auf den medizinischen und kriminologischen Wissensstand.

A diagnosis of sadism in sexual offenders is commonly regarded as indicative of high risk for violent reoffending. The purpose of the current two studies was to evaluate whether sadism is indeed associated with higher rates of violent (including sexual) reoffending. In Study 1 (meta-analysis), the rate of violent and sexual recidivism was assessed across seven samples of male sex offenders (total N = 2,169) as a function of diagnoses of sexual sadism. In Study 2 ( N = 768) the outcome (violent recidivism yes/no) was regressed on sadism, along with behavioral indicators of sexually sadistic offending, and scores from violence risk assessment instruments. In Study 1 (meta-analysis), the overall risk of sadists compared with nonsadists with respect to violent (including sexual contact) reoffending was slightly elevated (by a factor of 1.18), yet not significantly increased. Similarly, the risk of sexual reoffending among sadists was slightly, but not significantly, higher than among nonsadists (factor 1.38). According to Study 2, only a measure of sadistic behavior, not the clinical diagnosis, was associated with violent reoffending. This association, however, was not present once age and customary risk assessment instruments for violence risk were included in the regression. A clinical diagnosis of sexual sadism and behavioral measures of sadism are related to the risk of violent reoffending in sexual offenders. These associations, however, are weak and do not hold once variables relevant for the prediction of violence are controlled for. At the individual level, the risk for future violence in sadists can therefore be adequately described by customary risk assessment instruments.

Plant poisonings have been reported since ancient times. Despite this, little attention is paid to intoxications with herbal poisons by psychiatric literature and the danger from poisonous plants is commonly underestimated. This problem is discussed here, and advice for the prevention of plant poisonings and generally dealing with patients intoxicated by herbal poisons is given.

The concept "stalking" refers to willful, malicious, and repeated following or harassment of another person that threatens her or his security. Although there is nothing new about the occurrence of this conduct it has been discussed in psychiatry more intensely in recent years. As a result there are a few attempts at classification, without any claim of general validity. Patterns of stalking behaviour reflect a wide spectrum from aggressive actions in the course of conflicts in a relationship to schizophrenia. Thus, it is not adequate to classify this as a psychiatric disorder per se. Thorough diagnostic assessments are mandatory before introducing legal measures, whereas if these are omitted, the term "mental disorder" may be inappropriately used in a wider sense. This may entail unfavourable consequences to be discussed in this paper.

Die §§ 104, 105 des BGB unterscheiden zwischen uberdauernden und vorubergehenden Storungen der Geistestatigkeit, wobei nur die zuerst genannten zu Geschaftsunfahigkeit fuhren. Angesichts der weitreichenden Folgen einer Geschaftsunfahigkeit mussen beide Storungsgruppen sorgfaltig unterschieden werden. Klare gesetzliche Richtlinien fur diese Unterscheidung stehen jedoch, ebenso wie eindeutige psychiatrische Stellungnahmen, noch aus. Im Folgenden wird, ausgehend von den aktuellen diagnostischen Konventionen der ICD-10-Forschungskriterien, ein Losungsmodell entwickelt, das den gegenwartigen Kenntnisstand uber Therapie und Verlauf psychischer Storungen berucksichtigt und zur Qualitatssicherung psychiatrischer Gutachten beitragen kann.

Aspects of "stalking" behaviour have been discussed predominantly in the Anglo-American psychiatric literature. However following new legal regulations, "stalking" is expected to gain relevance for the German forensic psychiatry. "Stalkers" are a heterogeneous group presenting with a wide range of relational or even psychotic motives for their behaviour. Therefore careful diagnostics are required. Legal responsibility can be estimated by assessing the capacity of the offender to understand (cognitive functioning) and to control his behaviour (volitional functioning). The severity of possible restrictions can be assessed by comparing them to the known impairments in cases of erotomania.

After summarising the legal requirements of contractual capacity, an attempt is made to define the term will with psychiatric conceptualisations. Possible restrictions of a free declaration of will are outlined. Symptoms, which possibly influence cognitive preconditions of will and personal values, are taken into account. Our considerations are supposed to improve orientation in this complex field and to contribute to the communication between psychiatric expert and the court. However, the analysis of each individual case remains essential.

As compared to the general population schizophrenic patients are at increased risk of becoming delinquent. The majority of schizophrenic patients do not commit any crime, and the risk of the general population to be a target of a violent act by a person with schizophrenia is low. The causes of delinquency in schizophrenia are complex, but certain risk characteristics (e. g. an accompanying substance abuse) have been identified. The treatability and legal prognosis of schizophrenic offenders are good, which suggests that establishing a suitable helpers network could also be used for violence prevention in patients at risk.Schizophrene Menschen haben ein gegenüber der Allgemeinbevölkerung erhöhtes Risiko, straffällig zu werden. Der weitaus überwiegende Teil schizophrener Patienten begeht jedoch keine Straftaten und das Risiko, von einer Gewalttat eines Schizophrenen betroffen zu sein, ist für die Allgemeinbevölkerung gering. Die Ursachen von Delinquenz bei Schizophrenen sind komplex, jedoch können bestimmte Risikomerkmale (z.B. eine begleitende Substanzabhängigkeit) benannt werden. Die Behandelbarkeit und Legalprognose schizophrener Straftäter sind gut, was dafür spricht, dass bei Risikopatienten durch Etablierung eines geeigneten Helfernetzes auch präventiv gearbeitet werden kann.Les personnes schizophrènes ont en comparaison avec la population générale un risque elevé de tomber dans la délinquance. La majorité des patients schizophrènes n'ont commis aucun crime, et le risque de la population générale d'être affectée par un acte de violence par un schizophrène est faible. Les causes de la délinquance des schizophrènes sont complexes, mais certaines caractéristiques de risque (par exemple, un abus de substances d'accompagnement) ont pu être identifiées. La traitabilité et le prognostic ligal des délinquants schizophrènes sont bons, ce qui suggère qu'un réseau d'aide adapté pourrait être utilisé aussi préventivement chez les patients à risque.

The Psychopathy Checklist-Revised (PCL-R) and its screening version, the PCL:SV, are clinical assessment instruments for the observer rating of psychopathic personality in offenders. Given the link between PCL-R/SV total scores and violent offending, these instruments have been incorporated into various risk assessment protocols in forensic psychology. The purpose of the present study was to examine the predictive validity of the PCL-R/SV instruments in German-speaking countries. We collated data from 11 published studies (total-N = 2,412 offenders). Based on suitable diagnostic cutscores for prototypical psychopathy, the proportions of true-positive and false-positive cases with respect to violent reoffending were compared. Overall, sensitivity was estimated at 27% and specificity at 88% for the PCL-R (or at 28% and 90% for the PCL:SV, respectively). At critical score levels, the odds for violent offense recidivism were more than two times higher than at subcritical levels for both instruments. A decision-theory analysis suggested that the implicit utility of false-positive risk assessments was about halfway between the minimal utility of false-negative assessments and the maximal utility of correct assessments. Both the PCL-R and its screening version are viable instruments for the prediction of violent offense recidivism in German-speaking countries.

The aim of this study was to contribute to the characterization of the entactogen (ecstasy) substance group. The psychopathological, neuroendocrine and autonomic effects of common recreational doses of the entactogen 3,4-methylenedioxyethylamphetamine (MDE), the hallucinogen psilocybin, the stimulant d-methamphetamine and placebo were investigated in a double-blind study with healthy volunteers (n = 32). Psychological effects of the drugs were assessed by means of standardized rating scales, self assessment inventories and free descriptions. The most characteristic effects of MDE were pleasant emotional experiences of relaxation, peacefulness, content and closeness to others. However, significant stimulant and hallucinogen-like effects were also present, although the latter were weaker than the effects of psilocybin. MDE elicited the strongest endocrine and autonomic effects among the three drugs, including robust rises of serum cortisol and prolactin, elevations of blood pressure and heart rate, and a moderate, but significant rise of body temperature. The apparent contrast between psychological and autonomic effects (subjective relaxation versus physical activation) was a unique feature of the MDE state. Our findings are in line with both users' reports and results from previous experimental studies, and support the view that entactogens constitute a distinct psychoactive substance class taking an intermediate position between hallucinogens and stimulants.

Eighty years ago, preventive detention for dangerous offenders was implemented in the German Penal Code (Section 66). In 2011, about 500 individuals were incarcerated under a preventive detention order in Germany. Through semi-structured clinical interviews and/or collateral file review, the present investigators assessed the sociobiographic, criminological, and clinical characteristics of 58 men for whom preventive detention had been ordered in two German federal states. In addition, risk assessment instruments were administered. The majority of the inmates were sexual offenders. The main mental health problems were antisocial personality disorder (APD), substance abuse/disorder, and paraphilias. Most individuals had a history of poor socialization. Structured clinical judgment as well as actuarial risk assessment instruments identified all inmates as high-risk offenders. Future development of preventive detention in Germany must emphasize treatment interventions. Given the life histories and the mental health problems of the detainees assessed in the present study, the implementation of effective treatment will prove difficult.

Previous studies have reported numerous correlations between psychopathy and various personality traits, behavioural tendencies or clinical characteristics. The present study examined in greater depth the relationships between the components of psychopathy as measured by the Psychopathy Checklist-Revised (PCL-R) and intelligence as well as impulsivity. A total of ninety male violent offenders were recruited from a prison and a forensic-psychiatric hospital in Germany. All of the subjects were assessed using the PCL-R, the Barratt Impulsiveness Scale (BIS-11), and a short version of the German Wechsler Adult Intelligence Scale (WIP). As expected, a canonical correlation analysis showed a negative association between spatial intelligence and the Factor 2 subtotal on the PCL-R (reckless lifestyle/antisociality). In addition, our results agreed with the assumption of an association between impulsivity and the subtotal for PCL-R Factor 2. The positive relationship between verbal intelligence and the subtotal for Factor 1 of the PCL-R (insincere, manipulative conduct/affective deficits) vanished after controlling for educational level. The results indicate that there is a relationship between the spatial components of intelligence and the concept of psychopathy as described by Hare. This result supports the spatial impairment aetiological model of antisocial behaviour.

The diagnosis kleptomania is based on diagnostic criteria which describe a particular distinctive behaviour. Both the DSM-IV and the WHO-ICD10 neglect the different etiologic possibilities. The high co-morbidity of kleptomania with other mental disorders is another problem. The assessment of legal responsibility should not only focus on the analysis of the stealing act, but has to consider potential associated psychopathology. It appears insufficient to describe complex organic disorders (for example a dementia) with the term kleptomania. However, the forensic relevance of kleptomania, which seems to be very rare, is a result of symptom progression, decreasing satisfaction and feelings of shame or distress.

Vor mehr als 10 Jahren offerierte Prof. H. Sas dem Autor die Moglichkeit, Gutachten bei Sicherungsverwahrten zu erstellen. Damit begann eine Beschaftigung mit der Sicherungsverwahrung, die zunachst ein Ausenseiterthema darstellte, dann aber zunehmend in den Fokus der Offentlichkeit ruckte und den wissenschaftlichen Werdegang des Autors bis heute pragt (Habermeyer 2008; Habermeyer u. Sas 2004; Habermeyer et al. 2007, 2008, 2009). Die folgenden Zeilen fassen aktuelle Entwicklungen in diesem Bereich zusammen. Sie bieten daruber hinaus die Moglichkeit, Prof. Sas fur die Schulung im forensisch-psychiatrischen Bereich und seine Bereitschaft, dem Autor fruhzeitig interessante und anspruchsvolle Aufgaben zu ubertragen, zu danken.

The juridical guidelines for legal capacity demand the distinction between continuous and temporary mental disorders. A case report illustrates the problematic nature of this distinction. In addition the parallels to legal requirements for guardianship are discussed.

In Germany, preventive detention can be imposed if a repeat offender shows a proclivity to commit further significant criminal acts. The courts require expert opinion to provide information about personality traits relevant for this disposition. However, currently, consensus about this topic is lacking. On the basis of a standardized examination, the relevance of Hare's concept of "psychopathy" for expert opinion is discussed in the context of preventive detention.

Zusammenfassung: Eine Fülle von standardisierten Instrumenten ermöglicht mittlerweile an empirischen Daten ausgerichtete Aussagen zur Kriminalprognose. Der vorliegende Beitrag zeigt am Beispiel von weit verbreiteten und für die praktische Anwendung relevanten Verfahren (Violence Risk Appraisal Guide, Static-99, Historical Clinical Risk Management-20, Psychopathy Checklist-Revised) Limitationen der Anwendbarkeit solcher Instrumente auf. Vor diesem Hintergrund soll deutlich werden, dass der psychopathologische Arbeitsansatz durch den Einsatz standardisierter kriminalprognostischer Instrumente nicht überflüssig, sondern im Sinne eines integrativen Vorgehens sinnvoll ergänzt wird

Es wird uber 2 Patienten mit einer paranoiden Schizophrenie berichtet, bei denen das Internet in einen Beziehungs-, Beeinflussungs- oder Verfolgungswahn einbezogen war. Von einem dieser Patienten wurden im Computer gespeicherte Dateien in phanomenologisch ahnlicher Weise als durch andere Personen lesbar bzw. abrufbar erlebt, wie es bezuglich der eigenen Gedanken bei der Gedankenausbreitung der Fall ist. Die vorgelegten Kasuistiken demonstrieren die Zeitgebundenheit der Wahninhalte schizophrener Psychosen.

Die modernen Klassifikationssysteme DSM-IV (APA, 1994) und ICD-10 (WHO, 1994) sprechen von einer Personlichkeitsstorung, wenn zeitlich uberdauernde und unflexible Verhaltens-, Gefuhls- und Denkmuster vorhanden sind, die merklich von den Erwartungen der soziokulturellen Umgebung abweichen und sich in einem breiten Spektrum sozialer und personlicher Situationen bemerkbar machen. Diese Personlichkeitszuge sollen in klinisch bedeutsamer Weise zu Leiden oder Beeintrachtigung in sozialen, beruflichen oder anderen wichtigen Funktionsbereichen fuhren.

From a psychiatric viewpoint the internet as a communication medium bears some risks but also has some exceptional potential. The paper reports about an internet based discussion board that specifically addressed people with borderline personality disorder and that was continuously moderated by mental health professionals.Discussion board participants were monitored over the course of the study with regard to the perceived helpfulness of the board discussion and psychological symptoms assessed with brief versions of the Symptom Checklist (SCL-10) and the Borderline Symptom List (BSL-15).With more than 16 000 log-ins during the last month the web board found wide acceptance. The majority of the users stated, that the internet can easily reach people with mental health problems and reported that the continuous support by mental health professionals was helpful. Over the course of the project the web board users reported reductions with regard to the severity and frequency of borderline symptoms.The results suggest that the internet might be helpful in the treatment of borderline patients, especially with regard to the coordination of therapeutical interventions or as an amendment of traditional face-to-face therapies.

The free will debate widely exceeds the neuroscientific and philosophical fields due to profound implications for legislation, case law and psychiatric expert opinion. Data from Benjamin Libet's experiments on the readiness potential have been used as an argument against personal responsibility and for changes in the law. Due to the explicit use of the term "free will" in German civil law, the psychiatrist as an expert witness is confronted with this debate. In this article we outline the role of this crucial term in German civil law and we describe the neurophysiologic challenge in the form of Libet's experiments, which is led on three levels: the correctness of the data, the impact on the question of whether free will exists and possible consequences for the law. We conclude that the problem of free will cannot be debated on the basis of the data provided by Libet's experiments and that doubts about the existence of a free will must not lead to changes in the law or in psychiatric expert testimony. Therefore, advice for the psychiatrist as an expert witness is offered on the basis of a psychopathological approach that takes into account cognitive and motivational preconditions and the structure of values and personality.

The quality of the therapeutic relationship between psychiatric patients and their attending physicians plays a key role in treatment success. We hypothesize that mandatory treatment is negatively associated with the quality of the therapeutic relationship. In a cross-sectional study design, data on psychopathological symptom load (as captured with the Brief Psychiatric Rating Scale) and on the quality of the therapeutic relationship (as measured with the Scale to Assess the Therapeutic Relationship) were collected from 113 adult male psychiatric patients and 35 attending physicians. Patients belonged to one of three groups: self-referred or involuntarily admitted patients from general psychiatry wards or patients from medium secure forensic psychiatric units. On average, self-referred patients rated the quality of the therapeutic relationship significantly more positive than did involuntarily admitted patients in general psychiatry wards. Forensic psychiatric patients, on average, gave an intermediate rating of the quality of the therapeutic relationship. There was no association between patients’ ratings and physicians’ ratings of the quality of the therapeutic relationship. Patients’ ratings of the quality of the therapeutic relationship were inversely related to symptom severity in general and hostility in particular. Ratings of the quality of the therapeutic relationship are not associated with patients’ legal status but rather with patients’ symptoms of hostility.

Wichtige forensisch-psychiatrische Fragestellungen, die insbesondere Aspekte der Qualitatssicherung betreffen, sind bislang nicht zufrieden stellend geklart. Wenn es um Entwicklungen in der forensischen Psychiatrie gehen soll, stellt sich daher die Frage, inwiefern innerhalb dieses facettenreichen Teilgebietes der Psychiatrie Leitlinien fur ein sachgerechtes Vorgehen erarbeitet und etabliert werden konnen. Die vorliegende Arbeit wird grundlegende Problemstellungen skizzieren und Losungsansatze vorstellen, die dazu beitragen konnen, dass forensisch-psychiatrische Arbeit fachlich fundiert und auf qualitativ hohem Niveau geleistet werden kann.

Preventive detention can be ordered, if a person falls back into crime repeatedly and shows a "disposition to commit substantial offences". In the trial and at subsequent points of time expert opinions supporting this personal disposition have to be obtained. However up to now it is not clear on which basis such statements should be made. On the basis of a retrospective investigation of the author's own expert opinions the paper discusses the relevance of Hare's psychopathy concept for opinions on criminal disposition.

The diagnosis kleptomania is based on diagnostic criteria which describe a particular distinctive behaviour. Both the DSM-IV and the WHO-ICD10 neglect the different etiologic possibilities. The high co-morbidity of kleptomania with other mental disorders is another problem. The assessment of legal responsibility should not only focus on the analysis of the stealing act, but has to consider potential associated psychopathology. It appears insufficient to describe complex organic disorders (for example a dementia) with the term kleptomania. However, the forensic relevance of kleptomania, which seems to be very rare, is a result of symptom progression, decreasing satisfaction and feelings of shame or distress.

The paper comments the German legal and forensic-psychiatric positions regarding the complex and yet unsolved question of insight in the context of criminal responsibility. Possible restrictions of insight are discussed. Finally a solution is suggested, which connects the assessment of insight with the ability to declare a free will: Both terms deal with the predecisional cognitive and motivational foundation of acts. Insight is closely associated with the competence to constitute a free will. Symptoms and disorders which tend to disturb this ability can be assessed by psychopathological methods. Possible restrictions concern mental retardation, dementia, organic personality disorders, mental disorders with delusional ideation and residual states of schizophrenia.

A case of bipolar disorder and transsexualism is reported and discussed. The case report shows the problematic nature of the distinction between transsexualism and psychosis-induced transsexual desires. If there is a true comorbidity of these disorders, a subtly differentiated process to guide medical expert opinion and therapy is necessary.

SummaryClinical evidence suggests that hallucinogenic drug-induced altered states of consciousness (ASCs) and the incipient, acute stages of endogenous psychoses share many common phenomenological features. The aim of our study was to assess hallucinogen-like phenomena in endogenous psychotic patients using standardised methods. We examined 93 endogenous psychotic patients, 50 healthy controls and a small group of drug induced psychotic patients (n= 7) with two ASC self-assessment scales (questionnaire APZ =AbnormerPsychischerZustand = Altered State of Consciousness [Dittrich et al, 1985]; and questionnaire OAV = Abbreviation of the three subscales:Oceanic Boundlessness/Angst = Dread of Ego Dissolution/Visionary Restructuralisation [Bodmer 1989]). Patients were examined shortly after remission of their last acute psychotic episode and they answered the questionnaires referring to the early phase of this episode. Differences in the questionnaire scores were significant between psychotic patients and controls. Drug induced patients had numerically higher scores than endogenous psychotic patients, however these differences were only significant for the APZ total score and the undifferentiated items of the APZ, but not for the three APZ subscale and the OAV scores. More than 50% of the endogenous psychotic patients answered 26% of the APZ-and 43% of the OAV-items with “yes”. The OAV total score and the OSE (OzeanischeSelbstentgrenzung = oceanic boundlessness) scores of both questionnaires correlated significantly with BPRS Factor 3 (thought disturbance). Our results support the hypothesis that hallucinogen-like experiences represent common phenomena during the acute stages of endogenous psychoses. Remarkably, these phenomena include subjectively pleasant experiences of the OSE dimension. In the routine clinical assessment of endogenous psychotic patients experiences of this dimension may be more easily overlooked than the negative experiences of the AIA dimension (AIA:Angst vor derIch-Auflösung = dread of ego dissolution).