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Menschen, die infolge einer schwerwiegenden psychischen Storung straffallig geworden sind und infolge dieser Storung weiterhin gefahrlich sind, konnen zur Besserung und Sicherung in den Masregelvollzug nach §§ 63 und 64 des Strafgesetzbuches (StGB) untergebracht werden. In Deutschland werden gegenwartig etwa 9000 Patienten in Kliniken fur forensische Psychiatrie und Psychotherapie auf Grundlage des § 63 StGB und in Entziehungsanstalten auf Grundlage des § 64 StGB stationar behandelt. Die Behandlung der Patienten im Masregelvollzug ist landerrechtlich geregelt, sodass sich die Rahmenbedingungen der Behandlung in den einzelnen Bundeslandern unterscheiden. Wahrend fur die Erstellung von Gutachten zur Schuldfahigkeit und zur Legalprognose bereits Mindestanforderungen publiziert worden sind, liegen konsentierte Standards fur die Behandlung im psychiatrischen Masregelvollzug bislang nicht vor. Vor diesem Hintergrund beauftragte die DGPPN 2014 eine interdisziplinare Arbeitsgruppe damit, fachliche Standards fur die Behandlung in der forensischen Psychiatrie zu erarbeiten. Dabei sollten die rechtlichen, ethischen, strukturellen, therapeutischen und prognostischen Standards nach dem aktuellen Stand der Wissenschaft beschrieben werden. Nach dreijahriger Bearbeitungsphase wurden die Ergebnisse der interdisziplinaren Arbeitsgruppe im Fruhjahr 2017 vorgelegt und vom Vorstand der DGPPN konsentiert. Die Standards fur die Behandlung im psychiatrischen Masregelvollzug wollen eine Diskussion anstosen mit dem Ziel, die Behandlungsbedingungen zu vereinheitlichen und fachlich begrundete Empfehlungen zu verankern.

Early exposure to negative environmental impact shapes individual behavior and potentially contributes to any mental disease. We reported previously that accumulated environmental risk markedly decreases age at schizophrenia onset. Follow-up of matched extreme group individuals (≤1 vs. ≥3 risks) unexpectedly revealed that high-risk subjects had >5 times greater probability of forensic hospitalization. In line with longstanding sociological theories, we hypothesized that risk accumulation before adulthood induces violent aggression and criminal conduct, independent of mental illness. We determined in 6 independent cohorts (4 schizophrenia and 2 general population samples) pre-adult risk exposure, comprising urbanicity, migration, physical and sexual abuse as primary, and cannabis or alcohol as secondary hits. All single hits by themselves were marginally associated with higher violent aggression. Most strikingly, however, their accumulation strongly predicted violent aggression (odds ratio 10.5). An epigenome-wide association scan to detect differential methylation of blood-derived DNA of selected extreme group individuals yielded overall negative results. Conversely, determination in peripheral blood mononuclear cells of histone-deacetylase1 mRNA as 'umbrella mediator' of epigenetic processes revealed an increase in the high-risk group, suggesting lasting epigenetic alterations. Together, we provide sound evidence of a disease-independent unfortunate relationship between well-defined pre-adult environmental hits and violent aggression, calling for more efficient prevention. This work was supported by the Max Planck Society, the Max Planck Förderstiftung, the DFG (CNMPB), EXTRABRAIN EU-FP7, the Niedersachsen-Research Network on Neuroinfectiology (N-RENNT), and EU-AIMS. The research of EUAIMS receives support from the Innovative Medicines Initiative Joint Undertaking under grant agreement n°115300, resources of which are composed of financial contribution from the European Union’s Seventh Framework Programme (FP7/2007–2013), from the EFPIA companies, and from Autism Speaks. Moreover, support from Centro de Investigación en Red de Salud Mental (CIBERSAM); Instituto de Salud Carlos III (PI16/00998), Comissionat per a Universitats i Recerca del DIUE (2014SGR1636) and Spanish Ministry of Economy and Competitiveness (ES-EUEpiBrain, SAF2015-71526-REDT) is gratefully acknowledged. We thank all subjects for participating in the study, and all the many colleagues who have contributed over the past decade to the GRAS data collection.

This chapter proposes that using knowledge about the implementation of change in organizations can facilitate the implementation of evidence-based practices in forensic mental health services. It explains a case study, during a 20-year period, to implement the use of different versions of HCR-20 in Vitos Haina Forensic Psychiatric Hospital, Haina, Germany. Forensic mental health services aim to reduce symptoms of mental disorders and antisocial, aggressive, and violent behaviors, and increase psychosocial functioning. In mental health services generally, and in forensic mental health, there is a wide gap between available evidence on effective assessment, treatment, and management strategies and clinical services. Performance implementation produces actual benefits to consumers, organizations, and systems, and requires careful and thoughtful efforts. Evidence-based practice refers to assessment tools that have been proven to be valid and treatment and management strategies that have proven efficacy and effectiveness. Efficacy is achieved when a study shows that a new treatment leads to a better outcome than treatment as usual.

This article describes the contributions of the German workgroup to the second revision of the HCR-20 (HCR-20V3). In 2009, a beta-testing of draft 1 of the HCR-20V3 was conducted. The results were considered in the revision process of draft 1. In 2013, an interrater reliability study of the German translation of draft 2 of the HCR-20V3 was conducted. After a two-day workshop five raters (psychologists) without experience in structured professional judgment each rated the same 30 cases. The selected cases covered a range of diagnoses and risk levels. Intraclass Correlation Coefficients (ICCs) and the percentage of agreement were calculated for each item, each sub item, and the Summary Risk Ratings (SRRs). The interrater reliability of the SRRs (ICC = .86) was excellent. For the item-level ratings of the risk factors, the mean ICC for the H scale items and sub-items was .65, which would be “good.” The average item-level ICC of the C scale items (.66) and R scale items (.73) would be categorized similarly. T...

Es gibt mittlerweile eine robuste Evidenz dafur, dass Schizophrenie das Risiko fur Gewalttaten erhoht. Schizophrene Rechtsbrecher sind die Hauptursache fur die europaweit zu beobachtende Zunahme forensischer Behandlungsplatze. Die Arbeit untersucht das empirisch gesicherte Wissen uber den Zusammenhang von Schizophrenie und Gewalt. Es wurde eine systematische Literaturauswertung durchgefuhrt. Menschen, die an einer Schizophrenie erkrankt sind, haben im Vergleich zur restlichen Bevolkerung ein erhohtes Risiko, wegen Gewalttaten verurteilt zu werden oder sich anderweitig aggressiv zu verhalten. Psychotische Symptome erklaren nur das in akuten Phasen haufige aggressive Verhalten, nicht aber vergleichbares Verhalten vor Ausbruch der Erkrankung oder auserhalb akuter Krankheitsphasen. Drei distinkte Phanotypen schizophrener Gewalttater konnten identifiziert werden: Individuen mit einer im Kindesalter beginnenden Storung des Sozialverhaltens, die sowohl vor als auch nach Ausbruch der Schizophrenie antisoziales und aggressives Verhalten zeigen; Individuen ohne Vorgeschichte von Verhaltensproblemen, die mit Ausbruch der Erkrankung aggressives Verhalten zeigen; und Individuen, die nach vieljahrigem Krankheitsverlauf schwere Gewalthandlungen begehen. Uber die Atiologie dieser drei Typen von Rechtsbrechern ist ebenso wenig bekannt wie uber die neuronalen Mechanismen, die dieses Verhalten initiieren und aufrechterhalten. Psychiatrische Versorgungssysteme mussen dem von schizophren erkrankten Menschen ausgehenden Gewaltrisiko durch angemessene Risikoeinschatzungen und Interventionen, die antisoziales und aggressives Verhalten fokussieren, Rechnung tragen.

The HCR-20 is widely used to assess risk of violence among patients with schizophrenia. Further understanding of the accuracy and changes over time in C and R scores is needed. Using prospectively collected data on 248 men with schizophrenia, the present study found that the HCR-20 significantly predicted aggressive behavior over 24 months. The H, C, R, HCR-20 total, and final risk judgment scores were unable to predict aggressive behavior better than chance among the general psychiatric patients in the first six months after discharge. Changes in three C items, the total R score, and in three R items significantly predicted changes in aggressive behavior.

Fragestellung: Entwicklung einer Strategie zur Umsetzung des am 1. Oktober 2007 in Kraft getretenen Hessischen Nichtraucherschutzgesetzes in der Vitos Klinik für forensische Psychiatrie Haina. Methoden: Nach einer umfassenden Literaturrecherche zur Bedeutung des Tabakkonsums im Zusammenhang mit psychischen Erkrankungen wurde ein komplettes Rauchverbot für die gesamte Klinik und sämtlichen dazugehörigen Außenflächen implementiert. Ergebnisse: Das Rauchverbot führte nicht zu der befürchteten Zunahme des aggressiven Verhaltens der Patienten und Verstöße gegen das Verbot nahmen in den folgenden 18 Monaten kontinuierlich ab. Das Rauchverbot stieß jedoch auf ein negatives Medienecho und gerichtliche Eingaben der Patienten zwangen die Klinik dazu, das Rauchen im Außenbereich wieder zu gestatten. Fazit: Grundsätzlich ist die Umsetzung eines kompletten Rauchverbots in einer forensisch psychiatrischen Klinik möglich, ohne dass eine Zunahme aggressiven Verhaltens der Patienten zu erwarten ist. Eine Verbesserung der Akzeptanz eines solchen Rauchverbots wäre durch entsprechende Qualifikation von Mitarbeitern, mehr finanziellen Ressourcen und größerem zeitlichem Spielraum mit mehr Vorbereitungszeit zu erzielen.

Although it is generally presumed that there will be an association between the levels of security at which clients are held in a forensic hospital and the formal ratings of violence risk ascribed to them, such a relationship is seldom demonstrated. One measure in this study was the security level of 218 inpatients held in a German forensic hospital. The other measure was the C- and R-score of the HCR-20 (CR-10). The results were clear in showing an orderly correspondence between the two measures (C-scale: r = .37; Rscale: r = .52). The CR-10 part of the HCR-20 seems to be a useful measure to gauge progress in forensic psychiatric inpatient treatment.

Schizophrenia is associated with an elevated risk for violence. The response has been to incarcerate people with schizophrenia and to increase the number of forensic beds. Most of these beds are filled by men with schizophrenic disorders with long histories of offending and of treatment in general psychiatry. Outcome from forensic, as compared to general psychiatric services, is unknown. The present study compared outcome defined as levels of positive and negative symptoms, readmission, and aggressive behavior for 248 men with schizophrenic disorders (150 discharged from forensic hospitals and 98 from general adult wards) during a two-year period after discharge from forensic and general psychiatric services. Patients were intensively assessed at discharge and four times during the subsequent two years. Illicit drug use was assessed both objectively and by self-report. More of the forensic than the general patients had failed to complete high school, had displayed a stable pattern of antisocial behavior s...

Die aus Richtern am Bundesgerichtshof, Bundesanwalten, forensischen Psychiatern und Psychologen, Sexualmedizinern und weiteren Juristen bestehende interdisziplinare Arbeitsgruppe, die sich bereits mit Mindestanforderungen fur Schuldfahigkeitsgutachten befasst hat 2 , hat nun auch die nachfolgenden Empfehlungen fur die vielfaltig zu erstattenden forensischen Prognosegutachten erarbeitet. Wegen der Haufigkeit und der Bedeutung dieser Gutachten in der Strafvollstreckung ist die Arbeitsgruppe um drei erfahrene Vollstreckungsrichter erweitert worden. Die Mitglieder waren: VRinBGH Dr. Rissing-van Saan, VRiBGH Nack, RiBGH Basdorf, RiBGH Dr. Bode, RiBGH Dr. Boetticher, RiBGH Maatz, RiBGH Pfister, VRiBGH a.D. Dr. Schafer, die Bundesanwalte Hannich und Altvater, die Vollstreckungsrichter RiOLG Bohm, Karlsruhe, RiOLG Dr. Muller-Metz, Frankfurt a.M., VRiLG Dr. Wolf, Marburg, der Kriminologe Prof. Dr. Schoch, Munchen, der Rechtsanwalt Dr. Deckers, Dusseldorf, die forensischen Psychiater Prof. Dr. Berner, Hamburg, Prof. Dr. Dittmann, Basel, Prof. Dr. Krober, Berlin, Prof. Dr. Leygraf, Essen, Dr. Muller-Isberner, Giesen, Prof. Dr. Nedopil, Munchen, Prof. Dr. Sas, Aachen, Dr. Habermeyer, Rostock, die Sexualmediziner Prof. Dr. Dr. Beier, Berlin, Prof. Dr. Bosinski, Kiel, und der Rechtspsychologe Prof. Dr. Kohnken, Kiel.

Mittels umfangreicher, fur Praxiszwecke erhobener Daten lassen sich Entwicklungen in der psychiatrischen Kriminaltherapie Hessens aufzeigen. Daten zu Aufnahmen von Behandlungsfallen (1990–2004), Stichtagen (1970 bis 2006), Entlassungen von Behandlungsfallen, Wiederaufnahmen, Entweichungen und schweren Zwischenfallen (1990–2005) wurden ausgewertet. Gesamtbelegung und die Aufnahmezahlen stiegen, verursacht durch schizophrene Gewalttater und Patienten fremdkultureller Herkunft, deutlich an, die Zahl der Entlassungen nahm geringfugig zu. Die Stichtagsverweildauer stieg seit 1993 an, die mittlere Gesamtbehandlungsdauer und die durch Ruckfalldelinquenz verursachte Wiederaufnahmerate nahmen ab. Jeder 2. Patient hat Ausgang ohne Personalbegleitung, die Entweichungsrate nahm stark ab. Auch unter schwierigen Rahmenbedingungen ist es moglich, wesentliche Leistungskennwerte in der Kriminaltherapie konstant zu halten bzw. zu verbessern.

This article presents reasons for undertaking “The Comparative Study of the Prevention of Crime and Violence by Mentally Ill Persons” and reasons for decisions regarding the study design and choice of measures. A brief portrait of the forensic patients that have been recruited is also presented. Community treatment programs could offer long-term cost-effective care for offenders with major mental disorders (MMDs). The study aims to identify the necessary ingredients of an effective program. Sites are selected in four countries where identification of most, if not all, persons with MMD who commit crimes within the catchment area was possible. Within each site, two samples of patients with MMD are recruited, one from a forensic hospital and one from a general psychiatric hospital. Assessments are completed prior to discharge. Participants are followed during a 5-year period. Comparisons of the forensic patients recruited in the four sites indicate many more similarities than differences.

The study aimed to shed light on the recent dramatic increase in the number of forensic beds in Europe. A total of 184 patients being discharged from forensic hospitals and 122 from general psychiatry wards in sites in Canada, Finland, Germany, and Sweden were assessed and followed for two years. Information was collected from multiple sources. Forensic patients were distinguished from general psychiatric patients primarily by their histories of physical violence towards others and the trait of callousness. At discharge, the level of risk for future violence was similar among the general and forensic patients, but associated factors differed. The increase in forensic beds appears to be a response to violent behavior on the part of male patients with schizophrenia.

Ziel dieser Studie war der Vergleich von forensischen Patienten und Patienten der Allgemeinpsychiatrie in Deutschland im Hinblick auf Variablen zur Vorhersage von zukunftiger Gewalttatigkeit. Zum Zeitpunkt der Entlassung aus der stationaren Behandlung wurden fur 50 forensische und 29 allgemeinpsychiatrische Patienten empirisch fundierte, potenzielle Risikovariablen anhand des HCR-20 erfasst. Insgesamt zeigte sich nur ein geringer Unterschied zwischen den forensischen Patienten und denen der Allgemeinpsychiatrie im Bezug auf die Einschatzung spaterer Gewalthandlungen. Forensische Patienten zeigten aufgrund von Variablen aus der Vorgeschichte ein hoheres Risiko, wahrend das Risiko der allgemeinpsychiatrischen Patienten auf ihr akuteres klinisches Zustandsbild zuruckzufuhren ist. Einige Delikte konnten verhindert werden, wenn in der Allgemeinpsychiatrie mehr Augenmerk darauf gerichtet werden wurde, Patienten mit hohem Gewaltrisiko rechtzeitig zu erkennen und psychotische Symptome vor der Entlassung hinreichend zu reduzieren.

Before risk assessment instruments can be used to guide treatment, it is necessary to demonstrate accurate identification of patients at high risk for violence and of the factors associated with these behaviors for each individual. Predictors of violence vary by diagnosis, setting, and behavior being predicted. The present study examined violent and antisocial behavior of 216 patients in a forensic hospital during a one year period. The HCR-20 was completed by trained raters independent of those who collected information on antisocial and violent behavior. The HCR-20 predicted antisocial but not violent behavior. Different predictors were associated with different types of behaviors for different diagnostic groups. The HCR-20 score was highly positively correlated with patients' level of security.

BackgroundKnowledge of when and how to implement treatments to prevent criminal offending among people with schizophrenia is urgently needed.AimsTo identify opportunities for interventions to prevent offending among men with schizophrenic disorders by tracking their histories of offending and admissions to hospital.MethodWe examined 232 men with schizophrenic disorders discharged from forensic and general psychiatric hospitals. Data were collected from participants, family members and official records.ResultsMore than three-quarters (77.8%) of the forensic patients had previously been admitted to general psychiatric services; 24.3% of the general psychiatric patients had a criminal record. Offences had been committed by 39.8% of the forensic patients and 10.8% of the general psychiatric patients before their first admission to general psychiatry, and after their first admission these 59 patients committed 195 non-violent and 59 violent offences. Subsequently, 49 of them committed serious violent offences that led to forensic hospital admission. The offenders were distinguished by a pervasive and stable pattern of antisocial behaviour evident from at least mid-adolescence.ConclusionsGeneral psychiatry requires resources in order to prevent criminal offending among a subgroup of patients with schizophrenic disorders.

The HCR-20 has gained considerable acceptance by mental health, forensic, and criminal justice professionals since its initial publication only seven and a half years ago. Scientific evidence has gradually accrued to show that the guide can be used reliably and validly. Yet the scheme is sometimes misapplied. It is important that HCR-20 item definitions be kept anchored to the text to prevent “drift” that the guide be seen as a vehicle to promote discussion among colleagues rather than being viewed as capable of offering violence risk estimates that necessarily approach full accuracy; that would-be users should receive practice in coding case examples; and that, as urged in the basic manual, clinicians and researchers make all possible effort to avoid omitting items. The paper offers suggestions about conceptual and research work that needs to be completed in the future and offers one concrete example of a project in progress.

The correlation of formal thought disorder (FTD) symptoms and subsyndromes with neuropsychological dimensions is as yet unclear. Evidence for a dysexecutive syndrome and semantic access impairments has been discussed in positive FTD, albeit focusing mostly on patients with schizophrenia. We investigated the correlation of the full range of positive and negative as well as subjective and objective FTD with neuropsychological domains in different patient groups. Patients with ICD-10 schizophrenia (n = 51), depression (n = 51), and bipolar mania (n = 18), as well as healthy subjects (n = 60), were interviewed with the Rating Scale for the Assessment of Objective and Subjective Formal Thought and Language Disorder (TALD) and assessed using a multidimensional neuropsychological test battery (executive function, semantic and lexical verbal fluency, attention, working memory, and abstract thinking). Partial correlation analysis, controlling for age and word knowledge, revealed significant results for the objective positive FTD dimension and executive dysfunctions. Objective negative FTD was associated with deficits in lexico-semantic retrieval, as well as attention and working memory dysfunctions. The results suggest that different neuropsychological substrates correlate with the multidimensional and phenomenologically different FTD syndromes. FTD is a complex, multidimensional syndrome with a variety of neuropsychological impairments, which should be accounted for in future studies investigating the pathogenesis of FTD.

Formal thought disorder (FTD) is a core syndrome of schizophrenia. However, patients with other diagnoses, such as mania and depression amongst others, also present with FTD. We introduce a novel, comprehensive clinical rating scale, capturing the full variety of FTD phenomenology including subjective experiences. The 30-item Thought and Language Disorder (TALD) scale is based on a detailed review of the literature, encompassing all formal thought disorder symptoms reported from the early 20th century onwards. Objectively observable symptoms as well as subjective phenomena were included. Two hundred and ten participants (146 patients ICD-10 diagnoses: depression n. = 63, schizophrenia n. = 63, mania n. = 20; 64 healthy control subjects) were interviewed and symptoms rated with the TALD, TLC, HAMD, YMRS and SAPS/SANS. A principal component analyses was performed for the TALD to differentiate sub-syndromes. The principal component analysis revealed four FTD factors; objective and subjective as well as positive and negative factor dimensions. The correlation analyses with the TLC and the SAPS/SANS FTD sub-scores demonstrated the factor validity for the objective factors. The different diagnoses showed a distinct pattern of symptom severity in each of the factors, with mania patients exhibiting the highest value in the positive, objective dimension. The scale showed good psychometric results, which makes it a practicable, nosologically-open instrument for the detailed assessment of all FTD dimensions. The results strengthen the importance of subjective symptom assessment reported by the patient. DFG (project no. Ki 588/6-1) Scopus

The Scale for the Assessment of Thought, Language and Communication (TLC) represents an instrument for the assessment of formal thought disorder (FTD). The factorial dimensionality of the TLC has yielded ambiguous results for a distinction between positive (e.g. circumstantiality) and negative (e.g. poverty of speech) FTD. The purpose of the current study was to first translate and validate the TLC scale in German. Second, the internal structure was explored in order to identify different FTD dimensions. Two hundred and ten participants (146 patients with ICD-10 diagnoses: depression n = 63, schizophrenia n = 63, mania n = 20; 64 healthy subjects) were interviewed and FTD was rated with the TLC. The principal component analysis of the German TLC version revealed a 3-factor solution, reflecting a disorganized factor, an emptiness factor and a linguistic control factor. The current investigation yielded similar results to those originally reported for the TLC. Thus, a distinction between a positive disorganized, a negative and a semantic word level factor can be supported for the German translation.

Offenders with mental illness challenge forensic systems throughout the world. Those with personality disorders present additional challenges. In this article, the authors describe relevant German legislation and the consequent forensic treatment of personality-disordered offenders in the German psychiatric and correctional systems, with a focus on the German state of Hessen. The development of laws and regulations are addressed, as are the parallels and distinctions between forensic hospitals and correctional settings. Current treatment approaches and programs are described. Research initiatives and future directions for the system, and comparisons with the system in the United States conclude the article.

Background Persons with schizophrenia have been found to be at increased risk for homicide as compared with the general population. The increased risk may be associated with the implementation of the policy of deinstitutionalization. Method Persons with schizophrenia who had committed or attempted homicide in the German state of Hessen from 1992 to 1996 and in the Federal Republic of Germany from 1955 to 1964 were compared. Results Schizophrenia increased the risk of homicide 16.6 times (95% CI 11.2–24.5) in the recent cohort and 12.7 times (95% CI 11.2–14.3) in the older cohort. These odds ratios are not statistically different. The lack of appropriate services for chronic high-risk patients and the non-use of mental health services by first episode, acutely psychotic patients were associated with homicide. Conclusion There has been no increase in the risk of homicide among persons with schizophrenia since the implementation of the policy of deinstitutionalization. The examination of the recent period suggests that the provision of specialized long-term care to persons with schizophrenia who are at high risk for violent behaviour and the use of mental health services by acutely psychotic persons may reduce the risk of homicide. Copyright © 2001 Whurr Publishers Ltd.

Since last January, when Kendra Webdale was pushed in front of a Manhattan subway train by a man with a history of mental problems, politicians in Albany have been debating whether to make it easier to force people with mental illness to take their medication. Andrew Goldstein, the man accused of shoving Ms. Webdale to her death, had been repeatedly hospitalized for schizophrenia, but seemed to have a pattern of dropping out of his treatment programs and neglecting to take his medicine.

Bei ca. 40 % der Patienten des psychiatrischen Masregelvollzuges liegt eine Personlichkeitsstorung vor (Jockei und Muller-Isberner 1994), zum grosen Teil kompliziert durch weitere Auffalligkeiten (z. B. dissoziale Charaktermerkmale, Substanzmisbrauch, Intelligenzmangel).