Psychische Erkrankungen in der Lebensspanne ... - DGPPN

Topic 17 G Forensische Psychiatrie // Forensic psychiatry
Topic: 17 Forensische Psychiatrie
Donnerstag, 26. 11. 2009, 10.30 – 12.00 Uhr, Saal 7
HS-003 Hauptsymposium / Main Symposium
International perspectives on psychopathic disorders
Vorsitz: H. Saß (Aachen), A. Felthous (Saint Louis, MO, USA)
001
Conceptual Issues on Psychopathic Disorders from the German
Perspective
Henning Saß (Universitätsklinikum Aachen, Vorstand)
Every society must contend with psychopathically disturbed individuals,
even if the usual „approach“ is avoidance. Not only avoidance
of the psychopathic disturbances themselves, but also avoidance of
or at least remarkably little regard for how such disorders are conceptualized
in other countries and for how the law addresses issues
that involve psychopathically disturbed individuals. Concepts of
psychopathic disorders have common heritage and yet are quite
different in Europe and North America. By comparing commonalities
and differences in concepts and classifications, fresh questions
arise about how such disorders are to be understood and addressed.
The main conceptual principles for diagnosing psychopathic or dissocial
personality disorders, for assessing legal responsibility and
for the choice of treatment or commitment in forensic settings in
Germany are discussed. Without providing definitive solutions to
the various and vexing problems generated by individuals with psychopathic
disorders, it is hoped that by focusing international attention
on this spectrum of psychopathology more thoughtful attention
will be directed to psychopathic disorders which in turn
will yield more effective responses than public policies characterized
predominantly by avoidance.
002
Psychopathic Disorders and Criminal Responsibility in the USA
Alan Felthous (Saint Louis University, Neurology & Psychiatry, Saint
Louis, MO, USA)
Evolving views of policy makers in the USA about the role of psychopathic
disorders and criminal responsibility parallel views of
the insanity defense. In 1938 Isaac Ray criticized earlier tests of insanity
based on rationality as too limited. He argued for a broad
approach that would include as qualifying consitions „general moral
mania“ and „partial moral mania“, i. e., conditions with poor
impulse control, some of which would apply to psychopathic disorders.
Ray‘s approach was used in the successful defense of
Daniel M‘Naghten in England in 1943. Nonetheless, the enduring
M‘Naghten Rule was a test of rationality. The M‘Naghten test was
widely adopted throughout the USA, sometimes with the controversial
„irre sistible impulse“ test added. After a broad „product“
test was adopted by the federal appellate court for the District of
Columbia in 1954, psychopathic disorders were proposed as qualifying
conditions. The court‘s resulting consternation caused it to
turn to the ALI test, as would most US juristictions eventually. This
test contained both cognitive and volitional prongs, and also a second
paragraph that excluded conditions manifested only by repeated
criminal conduct. This provision was intended to exclude psychopathic
disorders. Some state legislatures pointedly excluded
personality or psychopathic disorders. By the early 1980s, popular
opinion was becoming increasingly skeptical of the insanity defense.
Insanity laws reverted to the purely cognitive, M‘Naghten approach,
and several states abolished their insanity tests altogether.
Today five states no longer have a special insanity defense. Regard-
less the arguments for and against insanity acquittal or diminished
responsibility for defendants with psychopathic disorders, the current
political battle line in the USA lies on the insanity defense itself.
At stake is the survival of the possibility for acquittal of defendants
whose criminal acts were due to a psychotic disorder.
003
Treating psychopaths in a forensic psychiatric setting
Rüdiger Müller-Isberner (Ärztlicher Direktor, Vitos Klinik für forensische
Psychiatrie Haina)
Introduction: The assessment of psychopathy is becoming increasing
ly routine in both forensic mental health and criminal justice
settings. Since the early 1990s there is a notion that treatment
might make psychopaths worse. Using data from a Canadian forensic
psychiatric institution Rice et al. (1992) showed that while a therapeutic
community type program was effective in reducing violent
recidivism among non-psychopaths, it had a reverse effect in psychopaths.
In a more recent overview, however, D‘Silva et al. (2004)
reviewed the literature finding that ‚we simply do not know‘ whether
treatment makes psychopaths worse.
Method: In an ambitioned attempt to address the treatment needs
of forensic patients scoring high on the PCL a ‚Psychopathy Ward‘
was established at the Haina Forensic Psychiatric Hospital in 1997.
Discussion / Results: Even though the ward program was well prepared
using all resources available in the mid-1990s the experiment
failed. However, the causes of this failure might inform future attempts
to reduce the risk of reoffending among offenders scoring
high on the PCL-R. The outcome of our experiment indicates that
forensic mental health settings may not be the best place to provide
services to this type of offenders.
004
Treatment and Rehabilitation Programs for Psychopathic Disorders
in the Netherlands
Uta Kröger (Utrecht, Niederlande)
D. van Beek
005
Treatment and Rehabilitation Programs for Psychopathic Disorders
in the Netherlands
Daan van Beek (Utrecht, Niederlande)
U. Kröger
Introduction: This presentation will firstly get into the question of
how psychopathy is viewed at among Dutch forensic professionals.
Secondly we will elaborate on the implications of this perspective
on management and treatment of this disorder. Only a small proportion
of the Dutch psychopaths undergo mandatory treatment
that is exclusively offered in forensic psychiatric institutes under the
so-called ‘tbs-order’. In these institutes treatment is scarcely specifically
modulated to the treatment needs of psychopathic patients.
Most of the time they are offered a more general treatment package,
thought to be effective for all forensic patients. Some research shows
that outcome of these treatment programs is rather poor with these
patients. Only recently experiments are carried out to improve effectiveness
of treatment for psychopathic patients. Promising ingredients
in a treatment package suitable for psychopaths include
the what works principles with emphasis on enhancement of motivation
for change, the self regulation model, the goodlivesmodel
and biomedical interventions. In de Van der Hoevenkliniek we developed
a treatment program including these elements. In particular
we will also get into some pitfalls that will threaten effective
treatment of these patients. Some clinical impressions of the effectiveness
of our approach will also be presented. Finally we will
highlight the issue of societal pressure not to take any risk with
high-risk patients on one hand and not holding patients in the in-
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