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CodEs and prinCiplEs Ethics is a branch of philosophy. It is the study of how moral ideas develop, how they interact, how they relate to other aspects of human learning and how they may be applied in practice. Medical ethics should be a systematic study of how moral principles can be applied to the practice of medicine. This chapter reflects the bias of this book and focuses on medical ethics, but many of the issues considered have relevance for other professions as well. Medicine is a highly value laden subject. The very definitions of disease and the attending on sick people are based on moral assumptions. These moral assumptions have changed with time, and will change further in the future, keeping within the broader ethical framework of the society in which they are placed, and they have to be tested within the peer group of other doctors. Morality so pervades psychiatry that every chapter in a psychiatric textbook will embrace moral issues either implicitly or explicitly. Questions about the suitability of retaining and treating people with mental disorder in prison are, for example, in large part moral ones. Scientific information about the efficacy of treatment in prison will influence the argument, but such scientific knowledge is unlikely ever to override completely the moral debate. This chapter on ethics is a chapter more for raising questions than for providing answers. Discourse on ethics frequently starts with the Greeks and the Hippocratic Oath (see appendix 4), or with Hammurabi and the Babylonians. Musto (1991) takes the reader from Greece and Rome to the religions of the middle ages, up to the French Revolution, and into nineteenthcentury Britain. This is appropriate as the modern medical profession did not really begin until the nineteenth century in spite of its apparently long history. In 1803, Thomas Percival published his famous Medical Ethics. It is even now of interest and resonant with some modern values, but it also illustrates our point that ethics are related to time and culture and some elements are subject to change. Percival says, for example

In contrast to Angloamerican and Scandinavian countries inpatient violence was not regarded as a problem in German-speaking countries for a long time. Only recently it has become a topic of increasing interest for clinical practice and research, whereby the present data exhibit significant parallels to the international development. After the discussion of methodological problems (e. g. varying definitions, sources of information, ways of registration) the paper presents the current state of knowledge about inpatient violence:Underestimation in general, mainly with respect to female patients; only a few patients are responsible for the majority of assaults; victims are rather staff members than fellow patients; discrepancy between the mostly minor physical, though major emotional consequences for victims; considerably negative effects on patient-staff interactions and ward climate. Aside from patient-related actuarial and dynamic risk factors (social origin, previous history of aggressive behaviour, dissocial personality traits and - partly - diagnoses, acute intoxication, substance abuse, lack of insight and compliance, psychotic symptoms) external/contextual factors as patient-staff ratio, ward size, structure and climate, staff-attitudes, recognition of early warning signs and handling of risk situations are of major importance for the frequency and severity of incidents. Intervention and prevention strategies are focussing - aside from medication - on the aforementioned staff-related factors and patient-staff interactions. They are the principal basis for sufficient inpatient treatment beyond the problem of violence.

There is a high prevalence of personality disorder in most prison populations. Many pass through the system undiagnosed. A screening instrument would improve identification. This study examined the screening properties of the Personality Diagnostic Questionnaire-4+ (PDQ-4+) in prisoners convicted of violent and sexual offenses. A sample of British prisoners completed the self-report PDQ-4+ and were interviewed using the Structured Clinical Interview for DSM-IV Axis II disorders. When used to generate a total score, the PDQ-4+ had an acceptable overall accuracy as measured by the area under the Receiver Operating Characteristics (ROC) curve. The PDQ-4+ appears to have the properties suitable for use as a screening instrument, particularly when screening for the presence or absence of personality disorder rather than for individual personality disorder categories. A graph is presented from which choices of cut-off score for different combinations of sensitivity and specificity can be made. A cut off total score of 25 or above yielded near optimal sensitivity and specificity. The suggested cut off score for this population is lower than that previously suggested.

INTRODUCTION: For England and Wales, Section 17 of the Mental Health Act 1983 allows for compulsorily detained patients to have trial leave (TL) between hospitals or from hospital to community to allow a period of testing readiness for a change in residency and/or legal status. The aim of this study was to document the use of TL for the largest sub-group of such patients within two discharge cohorts from one high security hospital and to test for correlates. METHOD: Data were collected from the special hospitals' case register for two Broadmoor Hospital discharge cohorts, 1984 and 1990-94, of offender patients with hospital orders under Home Office restrictions on discharge (Section 37/41). RESULTS: In 1984, only two of the 29 people leaving special hospital did so under trial leave arrangements, but by 1990 to 1994, 71% of restricted hospital order departures were under trial leave (92/130), a significant change in practice. Focusing on only the later cohort, women were disproportionately more likely to leave in this way. Trial leave was used more for patients with an index offence of homicide, similarly for violent offences but less so for sex offences. Nature of disorder did not have any bearing on the use of trial leave. Use of trial leave did not significantly shorten length of stay within the special hospital. CONCLUSION: Trial leave has become the most usual route out of special hospital, and is the departure route used almost exclusively for women patients, yet there appears to be no obvious advantage for the patient in shortening length of stay in high security. However, there is no way of knowing how long patients would have stayed had the option of trial leave not been available to them. Furthermore, no advantage for the public was found in the preferential use of TL for discharges to the community.

Background: There have been recent proposals in England and Wales to develop services aimed at reducing the risk to the public posed by offenders with so-called “severe personality disorder”. The emphasis of the proposals is on risk. However, prisoners with personality disorder may have psychiatric treatment needs other than those purely relating to public protection. The aim of the study was to examine the association between severity of self reported personality disorder pathology and psychological distress in serious offenders. Method: All male prisoners in two prisons, convicted of violent or sexual offences, were sent the Personality Diagnostic Questionnaire 4+(PDQ−4+) and the Symptom Checklist 90-R (SCL-90-R). Results: High levels of self reported personality pathology were associated with high levels of psychological distress. Conclusions: Offenders with the most severe self reported personality disorder pathology experience distress that may be clinically significant. Services for offenders with personality disorder will need to address their associated psychiatric symptoms.

This review focuses on various aspects of victimization: epidemiology, causes, effects and treatment approaches. Post-traumatic stress disorder is one possible outcome of victimization. However, the impact of trauma is variable and multifactorial. The following review emphasizes that additional factors, such as childhood experiences, past personality, past victimization, psychosocial factors, including social support, also affect the course of recovery.

Background Few follow-up studies of mentally disordered offenders have taken into account time spent in the community at risk of reoffending when calculating reconviction rates. Method This small exploratory study examined the effect of discharge destination (community or hospital) on reconviction over a nine-year period in an annual discharge cohort (1984) of special hospital patients with personality disorder, controlling for time spent ‘at risk’ in the community. Results Those discharged directly to the community spent significantly more time at risk in the community during follow-up but they were no more likely to be reconvicted than those discharged via a less secure hospital. Discussion One possible explanation is that less secure hospital units are not specifically equipped to treat people with a personality disorder. Alternatively, clinicians may be correctly identifying patients who are at greater risk of reoffending and thus recommending a more staged rehabilitation back to the community. It was apparent that there are very few official data available about placements following absolute discharge. The implications for this and other studies of this type are discussed.

BackgroundSpecial hospitals in England provide psychiatric care and treatment in high security. Their future is often questioned.AimsTo test for variation in demand for high-security psychiatric services over one 10-year period.MethodThis study was from the special hospitals' case registers and hospital records. The main measures were numbers and annual rates for referrals and beds offered; the Mental Health Act 1983 (MHA) classification of mental disorder; adjusted population rates by health region; admission episodes; legal category of detention; admission source and type of offence.ResultsReferrals to special hospitals showed no decrease during the 10 years; an apparent increase may reflect under-recording before 1992. Admissions fell by about 16% over the 10 years, but with regional variation. Women, civil cases, admissions under the MHA classifications of psychopathic disorder or mental impairment and directly from a court on a hospital order were most affected. There was an increase in admissions of pre-trial and sentenced male prisoners, and of transferred hospital order patients from other hospitals.ConclusionsThere is continuing demand from all parts of the country for high-security hospital beds. The smaller numbers admitted appear to include more demanding cases.

BackgroundA considerable proportion of patients with personality disorder are discharged directly to the community from special (high-security) hospitals.AimsTo examine whether patients with personality disorder discharged directly to the community are more likely to be re-convicted than those transferred to psychiatric hospitals of lesser security.MethodRe-conviction data for a f ive-to nine-year follow-up were collected for a four-year (1988–1991) special hospital discharge cohort of patients with personality disorder.ResultsIndividuals discharged directly to the community were not significantly more likely to be re-convicted than those transferred to less secure psychiatric hospitals. However, patients discharged to the community without formal conditions of supervision were more likely to be re-convicted than those discharged to the community with conditions or those transferred to other psychiatric hospitals.ConclusionsFormal supervision after discharge may be more important than actual destination in influencing the likelihood of re-conviction.

Background Little is known about the social and sexual functioning of men with schizophrenia who commit serious sex offences. Aims To examine social and sexual functioning, before and after illness onset, in a national sample of schizophrenic men who have been convicted of a contact sex offence against a woman, two hypotheses are tested. First, that there are no significant differences in social and sexual functioning between white and Afro-Caribbean men with schizophrenia who have sexually assaulted women. Second, that men who have a history of contact sex offending antedating the onset of schizophrenia are more likely to have poor pre-onset social and sexual functioning compared with men who begin sex offending after illness onset. Method A search of Home Office records was completed for all 84 male restricted hospital order inpatients with schizophrenia, resident in any hospital in England and Wales, during May 1997, with an index conviction for a contact sex offence against a woman. Results The group underwent a significant deterioration in social and sexual functioning after the onset of schizophrenia. Afro-Caribbean men had better pre-onset social and sexual adjustment compared with white men, but underwent a deterioration to a similar extent after developing schizophrenia. Men who began sex offending before the onset of schizophrenia were more likely to have impairment of pre-onset social and sexual functioning compared with men who did not offend sexually until after illness onset. However, controlling for other variables, only pre-onset social isolation remained significantly associated with sex offending before illness onset. Conclusions Whilst the findings do not support the first hypothesis they do provide evidence for the second hypothesis. Formulation of treatment programmes for schizophrenic sex offenders requires careful consideration of pre-onset as well as current social and sexual functioning.

Three studies are briefly reviewed as contributions to the epidemiology of violence and mental disorder. The samples were severally drawn from a then substantial regional pre-trial prison, a national high security hospital service and a general psychiatric hospital with a mainly local clientele. Delusions emerged consistently as having an important role in the precipitation of a violent act by a person with a psychotic illness; the more serious the act, the more delusions appear to have had a direct role. Nevertheless, given that delusions are very common symptoms of psychosis, but serious violence by someone with psychosis is unusual, other mediating factors must be operating. There is some support each for an interactional effect with other symptoms of the psychotic process, an influential effect on further symptom,-particularly affective symptom-development and at least two social relationship mechanisms. This augurs well for a shift from hitherto primarily observational work to hypothesis-generated research.

All personnel within one UK emergency service who had been identified during a six-month period as having been on sick leave for eight consecutive weeks or more were identified. Those consenting were interviewed once using both a semi-structured questionnaire and standardised instruments. There were three main objectives: to discover the nature of the presenting problem in terms of illness or injury, the extent to which psychological problems presented and the relative importance of general and/or traumatic stressors. The resulting sample of 17 people accounted for 2–3% of the workforce. Fifteen agreed to take part and 13 to full interview. of the 14 who completed the Hilton Drinking Behaviour Questionnaire 10 exceeded the threshold consistent with problem drinking. The reason for sick leave in all these cases was recorded as physical injury only.

BackgroundFrom a first clinical description of a complete resident sample of special (high security) hospital patients, we examined the association between mental disorder and violence.MethodA record survey of all 1740 patients resident at any time between 1 January and 30 June 1993. inclusive, and, for most, the official criminal record.Results1015 patients (58%) had functional psychosis, one-quarter of whom also had an independent personality disorder: 461 (26%)had personality disorders uncomplicated by psychosis, and 264 (16%) had learning disabilities. Pre-admission substance misuse, which was probably under-recorded, had been most common among those with psychosis and an independent personality disorder. Less than 10% had never been convicted of a criminal offence, although 25% had been admitted directly from other hospitals. Direct personal violence was more common among men, and fire-setting among women. Schizophrenia was most strongly associated with personal violence. More than 75% of those with a psychosis were recorded as being driven to offend by their delusions. In the absence of delusions, hallucinations had no such effect.ConclusionsFor people with personality disorder better clinical descriptions seem essential. For people with a pure psychosis, as symptoms were usually a factor driving the index offence, treatment appears as important for public safety as for personal health.

Certain childhood experiences, including deprivation and/or abuse, have been shown to contribute to the development of delinquency and later criminality. Although specific illness factors influence violent or offending behaviour by people with schizophrenia, such childhood experiences may also be relevant. This study examined such factors in a sample of 102 patients with schizophrenia in a special hospital. Information was obtained from the hospital case notes. Experiences of a disordered family were found to be common, particularly for the women. Four main subgroups of patients were identified in terms of childhood experiences. Three groups, accounting for two-thirds of the patients, had experiences of a range of problems in childhood before the manifest onset of schizophrenia. The first included patients with evidence of disorder of conduct but without remarkable environmental disadvantage (primary delinquency), the second those with multiple early environmental problems associated with a variety of personal conduct problems (secondary delinquency) and the third those with predominantly childhood neurotic problems in the absence of obvious family or environmental disturbance. Some 40% of the patients had ‘pure’ schizophrenia, its onset coming after an unremarkable childhood. Membership of one of the delinquency groups was associated with a significantly greater tendency to frequent, repeated violence. Group membership had no bearing on seriousness of violence, but there was a trend for people with ‘pure’ schizophrenia to have committed their index offence (usually the most serious) because of or mainly because of their psychotic symptoms. For patients with evidence of environmental disadvantage, conduct disorder or social difficulties as well as schizophrenia, there are likely to be complex interactions between such factors and symptoms of illness. For those with such experiences treatment is unlikely to be complete without attention to the impact and/or continuity of such problems

Objective: Antisocial personality disorder (ASPD) and schizophrenia, as well as childhood abuse, are associated with violent behaviour and show marked volumetric reduction in the anterior cingulate (AC), a brain region implicated in regulation of violence through its involvement in decision making, empathy, impulse control, and emotion regulation. The present study examined, for the first time to the authors’ knowledge, the grey matter volume of the AC in relation to seriously violent behaviour and childhood psychosocial deprivation (including physical and sexual abuse) in the context of a mental disorder (schizophrenia or ASPD). Methods: Fifty-seven men [14 with ASPD and a history of serious violence; 13 with schizophrenia and a history of serious violence (VSZ); 15 with schizophrenia without a violence history (SZ); 15 nonviolent healthy participants] underwent whole-brain magnetic resonance imaging and were rated on the presence of physical abuse, sexual abuse, neglect, extreme poverty, foster home placement, criminal parent, severe family conflict, and broken home (collectively ‘psychosocial deprivation’). Stereological volumetric ratings of the AC were examined for group differences and their association with childhood psychosocial deprivation. Results: A higher proportion of ASPD and VSZ patients had suffered psychosocial deprivation as children, in particular severe physical abuse, relative to SZ patients and healthy participants. ASPD and VSZ, but not SZ, patients had significantly lower AC volume relative to healthy participants. AC volumes correlated negatively with (total) psychosocial deprivation as well as physical and sexual abuse ratings. Group differences in AC volume became nonsignificant when psychosocial deprivation ratings were covaried for. Conclusions: Violent mentally disordered individuals with ASPD or schizophrenia suffer from a significant AC volume loss and this deficit, at least in part, is explained by their histories of stressful childhood experiences. Current and future therapies aiming to reduce violence in such populations would benefit by attending to biological (and other) correlates of childhood abuse.

Background: Some say 'prison works', others say that it only harms. Overall, longitudinal studies of prisoners suggest some positive impact on mental state, but post-release recidivism is high. How do men at high risk for repeated imprisonment experience it? Aim: To explore prison (gaol) experience among men awaiting trial in custody. Methods: In a prospective longitudinal study, 170 men were interviewed just after reception about their social context and mental state and again three weeks later, when each was asked to describe his current prison experience; 75% had been in prison before. Data were analysed qualitatively and quantitatively. Results: Each man had views on his imprisonment. Data were saturated after 20 interviews. The core concern was its overall emotional impact, in full negative to positive range, with recognition that this could and did change in either direction, both passively and through active processes. Underpinning themes were along the dimensions of missing people to asylum from the outside world; in-prison bullying to positive staff and/or inmate relationships; boredom to relief in routine; and 'doing my head in' to salvation from drug-induced decline. Testing the model in the whole sample confirmed no association between prison impact and pre-prison factors. Negative experience was associated with severe depression within but not before this imprisonment. More positive experience related to good in-prison relationships. Conclusions: During pre-trial custodial detention, there is a greater range of experience than generally previously reported. The simple expedients of prison staff developing good relationships with prisoners, and facilitating these between prisoners, could be life-saving. Highly positive experiences may be more an indictment on community services than an endorsement of imprisonment.

Background: Though slowly growing, knowledge about prisoners detained for having violated an Alien Act is still marginal and most studies involve detained asylum seekers in the USA and Australia. Little is known about prevalence rates of mental health disorders in such a population. The Brief Jail Mental Health Screening BJMHS has been demonstrated in other prison populations as a valid screening for serious mental illness. Aim: The aims of this study were to describe prevalence rates for mental disorders according to ICD-10 and to validate the BJMHS for this population. Methods: 80 inmates at a detention center for prisoners having violated the Swiss Aliens Act were surveyed using the BJMHS at their admission. The results were cross validated with the WHO Composite International Diagnostic Interview (CIDI). Results: When omitting disorders caused by smoking tobacco, 76% of the prisoners suffered from at least one mental disorder according to CIDI. Whereas the rates for disorders due to psychoactive substance use as well as schizophrenic and affective disorders were comparable with other prison populations, we found a specific increased reporting of phobic (14%) and post-traumatic stress disorders (23%).The BJMHS detected serious mental illness defined as schizophrenic or affective disorders with a sensitivity of 81.0% and a specificity of 74.6%. Discussion: As in other prison populations prevalence rates for mental disorders were markedly above the general population. The specific pattern with high rates of phobic as well as post-traumatic stress disorders may reflect the very often traumatic backgrounds of this population. Whereas the results for the validation of the BJMHS were even better than in other similar studies and the instrument proved to be practicable and helpful to detect serious mental illness, sensitivity for a screening tool of around 80% is still too low. Additionally the fact that other serious mental disorders are not covered emphasizes the importance of other elements in the screening process, including the need to have well-trained staff, and to have a low threshold for psychiatric examination

The majority of psychiatric patients, even those who also offend against the law, are likely to be served best by good community services but a few of them will need treatment in a secure hospital. Treatment in high security for patients from England and Wales is provided by three special hospitals. In the 1980s provision of medium-secure hospital units began, but there is still a considerable shortfall of such beds. Data from a variety of settings suggest that the continuing gap in medium-secure provision may be qualitative as well as quantitative. This paper considers the case for long-term medium security, and the likely size and nature of demand. It would be misleading to assume that those with long-term medium-security needs constitute a homogeneous group. Some new facilities, probably built on to existing medium secure hospital units, are likely to be needed; if estimates of real need for high-security places are correct, then some places already exist and are being used by default in the special hospitals. For some patients, notwithstanding the old image of special hospitals, these may be ideal placements if redesignated, even redesigned. A variety of provision and effective cooperation between purchasers and providers will be essential to satisfy real need and ensure that the number of patients needing secure accommodation remains more or less within present estimates. Copyright © 1996 Whurr Publishers Ltd.

Two experiments examined the influence of positive affect on probability estimation and choice. Participants in whom positive affect had been induced, as well as no-manipulation controls, were asked to make both numerical evaluations of verbal probabilities in three-outcome gambles and actual betting decisions about similar gambles. Results from Experiment 1 showed the phenomenon labeledcautious optimism:Positive affect participants significantly overestimated the probabilities associated with phrases for winning relative to their estimates of probability of losing for the same phrases (optimism), while participants in a control condition did not; yet, in actual gambling situations, affect condition participants were much less likely to gamble than were controls when a real loss was possible (caution). Results of the betting task from Experiment 2 further indicated that affect participants used a betting-decision rule that was different from that of controls: They bet less than controls in gambles where potential losses were large, even though probability of loss was small, and they bet more than controls in gambles where the amount of the potential loss was small, even though the probability of loss was moderate or large. These findings suggest that positive affect can promote an overt shift from a decision rule focusing primarily on probabilities to one focusing on utilities or outcome values, especially for losses. Taken together, the results are compatible with an interpretation of the influence of positive affect in terms of an elaboration of positive cognitive material, and purposive behavior in decisions, rather than in terms of mere response bias.

Recent government U turn leaves police healthcare adrift from the NHS In December 2015, the UK government announced that planned changes to the commissioning of healthcare for people held in police custody in England and Wales would not proceed. These changes had been well considered (having been in planning since a key report by Lord Bradley in 20091), set out formally, and described as one route to securing excellence.2 The government announcement, however, means that the commissioning of these specialist health services will remain with police and crime commissioners instead of being transferred to the National Health Service. This sets police healthcare apart from all other healthcare services, including those that are provided in other parts of the criminal justice pathway. The decision represents a missed opportunity. It will prevent much needed service development and could set back current healthcare delivery. It represents a policy reversal that …

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.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.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.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.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.

A small but significant relationship between schizophrenia and violence is well established, but not yet fully explained. Research has highlighted anger as an important factor in precipitating actual violence in general and psychiatric populations. However, anger has not been extensively studied as a risk factor for violence in people with schizophrenia and related psychoses. We evaluated published evidence on the relationship between anger and violence in patients with schizophrenia and related psychoses by means of a systematic review of the literature. A search of main online databases from inception till January 2012 was performed and supplemented with correspondence with authors and data available online. 11 studies which measured angry affect in patients with schizophrenia who had been violent were included in the review. 5 studies with a total of 510 individuals had anger data that were suitable to be pooled in a meta-analysis in form of standardised mean difference values comparing the anger scores of the non-violent groups with violent groups. All the studies included showed significantly higher scores for anger in the violent group compared with the non-violent group with the pooled result expressed as standardised mean difference of 0.74 95% CI (0.53, 0.94) and the Z value for overall effect = 7.01. The studies not included in the meta-analysis which looked at 610 individuals, were analysed descriptively and all of them reported higher scores for anger for individuals with schizophrenia who acted violently. There is a consistency of significant association between angry affect and violent behaviour in the context of psychotic illness across various study designs, settings and populations. Theoretical support already exists for this relationship and this review lends further support to explore this relationship further.

Alcohol is a preventable cause of illness, offending and other adversities worldwide. Prisoners are especially vulnerable. The aim of this study was to test the hypotheses that younger adult male prisoners are more likely to be hazardous drinkers than their older peers, but less likely to recognize this. The study cohort comprised 100 male prisoners aged 18-20 years and 157 aged 21 and over, who were interviewed and completed standard alcohol and drug questionnaires just after reception into prison. It was found that younger men were significantly more likely to be hazardous drinkers than their older peers but less likely to recognise this, even at scores on the Alcohol Use Disorders Identification Test (AUDIT) indicating dependency. They were also less likely to experience withdrawal symptoms, the main factor associated with problem drinking recognition at any age. Younger prisoners were less likely to be depressed, more likely to rate their social support as good and less likely to be dependent drug users. We conclude that reliance on younger prisoners to recognise their hazardous drinking would identify about one-fifth of them. With a lower likelihood of withdrawal symptoms than older men, they are probably still metabolizing alcohol more effectively. Given their similarities to older prisoners in terms of any previous imprisonment and likely personality disorder, formal screening for hazardous drinking might prevent decline into problem drug use, depression, reoffending, re-imprisonment, and social disconnection.

Background A small but significant association between schizophrenia and violence is open to a number of explanations. Impaired empathy has been associated with schizophrenia, and with violence in the general population. Our aim was to conduct a systematic review of any research into relationships between schizophrenia, empathy and violence. Methods The electronic databases Medline, Psychinfo, Embase, Cochrane and DARE were searched using combinations of terms for schizophrenia, empathy and violence, as were selected journals and reference lists of relevant articles. Selection of studies and data extraction was done by each of us, blind to the other. Results Six studies were identified, but sample selection, research procedures and empathy, illness and violence measures differed sufficiently between them that only descriptive analysis was possible. Apart from one single case study, sample sizes were between 24 (12 violent) and 116 (35 violent). A component of emotional empathy (emotion recognition) was measured in three of the studies, all of which showed some specific dysfunctional recognition related to violence. Cognitive empathy was measured in three studies, two linking impairments to violence and one not. Emotional responsiveness was measured in one study and no association with violence was found. Conclusion Although evidence is inconclusive on empathy impairment as a mediator of violence by people with chronic psychosis, it's likely relevance is most apparent in the better controlled studies. Larger scale studies are indicated with rigorous control for comorbidities.

Specialist forensic mental health (fmh) services are for people with serious mental disorders and grave offending behaviour who tend to be rejected from mainstream services. Although often triggered by single high profile cases, these specialist services are among the best planned and commissioned services in psychiatry, founded in evidence of need, risk and efficacy of interventions. They are grounded in a multidisciplinary clinical perspective and often have integrated academic units. They interface both with other clinical services and with the criminal justice service. Good relationships with the local community are vital for establishment and growth. Secure psychiatric hospitals have two overarching aims: improving health and delivering safety for patients and others. In secure hospitals, patients’ autonomy is limited in a number of important ways: they may not be allowed to leave the hospital at all, may be confined to a particular area within the hospital, and/or treatment may be enforced. Although these restrictions are undoubtedly at least partly in the interests of the patients themselves, they are commonly also in the interests of others. This chapter looks at service structure, including planning principles, principles of assessment, admission criteria, the pathway to treatment, and finally assessing outcomes.

BACKGROUND: Prison staff are repeatedly exposed to prisoners' suicidal behaviours; this may impair their capacity to care. Expressed emotion (EE), as a descriptor of the 'emotional climate' between people, has been associated with challenging behaviour in closed environments, but not previously applied to working alliances in a prison. AIMS: To investigate the feasibility of rating EE between staff and suicidal women in prison; to test the hypothesis that most such staff-inmate alliances would be rated high EE. METHODS: All regular staff on two small UK prison units with high suicidal behaviour rates were invited to participate. An audiotaped five-minute speech sample (FMSS) about work with one nominated suicidal prisoner was embedded in a longer research interview, then rated by two trained raters, independent of the interview process and the prison. RESULTS: Seven prison officers and 8 clinically qualified staff completed interviews; 3 refused, but 17 others were not interviewed, reasons including not having worked long enough with any one such prisoner. Participants and non-participants had similar relevant backgrounds. Contrary to our hypothesis, EE ratings were generally 'low'. As predicted, critical comments were directed at high frequency oppositional behaviour. CONCLUSIONS: EE assessments with prison staff are feasible, but our sample was small and turnover of prisoners high, so the study needs replication. Attributions about problem behaviour to illness, and/or traumatic life experience, tend to confirm generally supportive working relationships in this sample.

The aim of the study was to identify the phenomenological characteristics of those delusions which are associated with action. The sample consisted of 79 patients admitted to a general psychiatric ward, each of whom described at least one delusional belief. The variables studied included the phenomenology of the delusions, and behaviour. Two behavioural ratings were used, one derived from the subjects' own description of their behaviour and the other from information provided by informants. There was no association between delusional phenomenology and acting on a delusion when the subjects' behaviour was described by informants. When action was described by the subjects themselves, acting was associated with: being aware of evidence which supported the belief and with having actively sought out such evidence; a tendency to reduce the conviction with which a belief was held when that belief was challenged; and with feeling sad, frightened or anxious as a consequence of the delusion.

BACKGROUND: Pre-trial prisoners have high rates of mental disorder, but to date, little is known about mental state change or stability among them. AIM: The aim of this study was to describe mental state change over the first 4 weeks of imprisonment. METHODS: Two hundred and fifty-seven new pre-trial male prisoners consented to participate in a prospective interview study. Recruited men tended to be younger than non-recruited men, but otherwise similar. Mental state was assessed 1 and 4 weeks after reception, using the Comprehensive Psychopathological Rating Scale and two self-rating instruments [the 90-item symptom checklist (SCL-90); the Beck Depression Inventory]. RESULTS: After 4 weeks, 170 of the men were still in prison. In their demographics, previous offending, imprisonment, mental health histories or mental health ratings at initial interview, they did not differ from the 87 who were bailed, transferred, sentenced or had their case discontinued. The most sensitive of the rating schedules - the SCL-90 - identified only one new case among the 170 men, but the more illness-specific ratings suggested up to a 10% emergence of new cases by then. By contrast, while two-thirds of the men remained cases according to the SCL-90, about half of the men who had initial interview illness ratings were no longer 'cases'. DISCUSSION AND IMPLICATIONS FOR PRACTICE: Measured in terms of 'caseness', distress is likely to be apparent on reception into prison and relatively resistant to change compared with symptoms of mental disorder per se. One-off screening at reception could be misleading. A limitation of our study is that we could measure mental state only twice. A third measure would have clarified whether, in such circumstances, the trend towards improvement is sustained, but brevity of residence in any one prison at this stage tends to preclude this.

People with mental disorder and people who are violent are separately recognised as being at high risk of suicide. People detained in high security hospitals are recognised for their violence to others, but perhaps less so for their suicide potential. We aimed to investigate suicide rates among such patients during and after their high security hospital residency, and to establish risk factors for suicide.We extracted data from the Special Hospitals' Case Register on each person resident at any time between 1 January 1972 and 31 December 2000. Suicide rates were calculated for the whole period. We compared rates to the general population using standardised mortality ratios (SMRs). We used poisson regression to estimate the effects of gender, legal category of detention, offending history and length of admission on the suicide rate.Of the 5,955 individuals, 218 completed suicide. The suicide rate was nearly 7 times higher among resident men (SMR 662, 95% CI 478-845) and over 40 times higher in resident women (SMR 4,012, 95% CI 2,526-5,498) than in the general population; it was 23 times higher (SMR 2,325, 95% CI 1,901-2,751) and 45 times higher (SMR 4,486, 95% CI 2,727-6,245) among post-discharge men and women, respectively. The suicide rate was significantly higher among women than men inside high security but not after discharge.The suicide rate among high security hospital patients was significantly higher than in the general population. Women were especially at risk while resident, whereas for men, the risk was higher after discharge.

Of 253 patients in their first schizophrenic episode, 52 behaved in a way threatening to the lives of others before their admission to hospital. These 52 patients were studied from data collected at the time of their initial presentation. Despite a history of illness in excess of 1 year in 24 cases, and evidence that violence was motivated by psychotic symptoms in 23 cases, fewer than half of the patients were admitted to hospital as a direct result of their dangerous behaviour. Life-threatening behaviour was more common where the patient had been ill for longer, and where there were delusions of being poisoned.

People with schizophrenia who offend do not constitute a homogenous population. Pre-illness characteristics may distinguish groups.To test for differences in prevalence of childhood risk factors for offending between serious offenders with schizophrenia who had started offending before their first ever psychiatric admission (pre-admission offenders) and those who had started after it (post-admission offenders). Our hypothesis was that such adverse childhood factors would be more prevalent in the pre-admission offenders.Retrospective interview and records case-control study of all first high security hospital admissions diagnosed with schizophrenia in England 1972-2000. Risk factors were identified by multivariate logistic regression.853 patients were pre- and 741 post-admission offenders. Our hypothesis was confirmed in that factors associated with pre-admission offending were paternal criminal convictions, larger family size, and younger age at first use of illicit drugs, on first smoking cigarettes, and at maternal separation. There were differences too in pre-high security hospital treatment: pre-admission offenders had been younger at first court appearance and had more criminal justice system disposals, post-admission offenders were younger at first ever psychiatric hospital admission and more often hospitalized.While early offending among people with schizophrenia may delay treatment, making the distinction between pre-admission and post-admission offending may be useful in understanding the aetiology of the offending, and establishment of such a history may help in targeting interventions supplementary to treatment specific for the psychosis.

This study examined factors associated with lifetime experience of homelessness among young adults.Data were analyzed for 14,888 young adults (mean+/-SD age 21.97+/-1.77; 7,037 men and 7,851 women) who participated in the National Longitudinal Study of Adolescent Health (Add Health), a U.S. nationally representative, population-based sample. Data were collected from young adults through computer-assisted interviews six years after they had enrolled in the study as adolescents. Variables that have been associated with lifetime homelessness in at least one service sample were mapped to Add Health survey items. Data were analyzed by logistic regression.A total of 682 respondents (4.6%) were classified as ever being homeless. Several factors related to childhood experiences of poor family functioning, socioeconomic disadvantage, and separation from parents or caregivers were independently associated with ever being homeless. Other significant independent factors included current socioeconomic difficulty, mental health problems, and addiction problems. Indicators of involvement in crime and addiction problems with gambling and alcohol were not independently associated with homelessness.The findings underscore the relationship between specific indicators of adversity in childhood and risk of homelessness and point to the importance of early intervention efforts. Consistent with the extant research literature, mental health problems also appear to be associated with homelessness, highlighting the potentially complex service needs of this population.