Maindiff Court Hospital

What is needed to carry out a thorough risk assessment of an ex-offender? This article describes four major components: (a) a functional analysis of the offense process in order to determine how the offenders’ problems contributed to their offending and to identify the modus operandi used in their offense(s); (b) the application of a suitable actuarial risk predictor to assess the offender’s global level of risk; (c) identification of stable dynamic risk factors that make potential treatment targets; and (d) monitoring of acute dynamic factors that indicate offending is imminent. Professionals working with sexual offenders are often called on to assess the risk that the offenders present. These assessments are normally concerned either with the risk of further sexual offenses or with the risk of future violence of any kind. To carry out this task, the professional can use an actuarial risk predictor or clinical judgment. Actuarial instruments are empirically derived but are essentially atheoretical in character, in that they provide no guidance on which psychological risk factors underlie risk and hence no indication of how risk can be reduced or when such a reduction in risk has taken place (e.g., through successful treatment). Clinical judgment may allow a decision to be made at an ideographic level but has until recently been both idiosyncratic and unfounded in the research. In the last few years very real attempts have been made to draw these approaches together, both in general risk assessment (i.e., Andrews & Bonta, 1995) and its application to sexual offenders (Beech, Erikson, Friendship, & Hanson, 2002; Thornton, 2002).

Interviews with 28 sexual murderers were subjected to grounded theory analysis. Five implicit theories (ITs) were identified: dangerous world, male sex drive is uncontrollable, entitlement, women as sexual objects, and women as unknowable. These ITs were found to be identical to those identified in the literature as being present in rapists. The presence of dangerous world and male sex drive is uncontrollable were present, or absent, such that three groups could be identified: (a) dangerous world plus male sex drive is uncontrollable; (b) dangerous world, in the absence of male sex drive is uncontrollable; (c) male sex drive is uncontrollable in the absence of dangerous world. These three groups were found to differ in motivation: (a) were motivated by urges to rape and murder; (b) were motivated by grievance, resentment and/or anger toward women; (c) were motivated to sexually offend but were prepared to kill to avoid detection, or secure compliance.

BACKGROUND: Individuals with repetitive or impulsive aggression in the absence of other disorders may be diagnosed with intermittent explosive disorder according to DSM-IV, but no such diagnostic category exists in ICD-10. Mood stabilisers are often used off-license for the treatment of aggression associated with a variety of psychiatric conditions, but their efficacy in these and in idiopathic aggression is not known. AIMS: To summarise and evaluate the evidence for the efficacy of mood stabilisers (anticonvulsants/lithium) in the treatment of impulsive or repetitive aggression in adults. METHOD: A meta-analysis of randomised controlled trials that compared a mood stabiliser with placebo in adults without intellectual disability, organic brain disorder or psychotic illness, identified as exhibiting repetitive or impulsive aggression. RESULTS: Ten eligible trials (489 participants) were identified A pooled analysis showed an overall significant reduction in the frequency/severity of aggressive behaviour (standardised mean difference (SMD) = -1.02, 95% CI -1.54 to -0.50), although heterogeneity was high (I(2) = 84.7%). When analysed by drug type, significant effects were found in the pooled analysis of three phenytoin trials (SMD = -1.34, 95% CI -2.16 to -0.52), one lithium trial (SMD = -0.81, 95% CI -1.35 to -0.28), and two oxcarbazepine/carbamazepine trials (SMD = -1.20, 95% CI -1.83 to -0.56). However, when the results of only those studies that had a low risk of bias were pooled (347 participants), there was no significant reduction in aggression (SMD = -0.28, 95% CI -0.73 to 0.17, I(2) = 71.4%). CONCLUSIONS: There is evidence that mood stabilisers as a group are significantly better than placebo in reducing aggressive behaviour, but not all mood stabilisers appear to share this effect. There is evidence of efficacy for carbamazepine/oxcarbazepine, phenytoin and lithium. Many studies, however, were at risk of bias and so further randomised controlled trials are recommended.

This study compared 58 sexual murderers and 112 rapists who were about to undergo treatment in prison for their sexual offending behavior. The two groups were compared on background, personality, offense, and victim characteristics. The sexual murderer group were less likely to have been involved in a relationship at the time of their index offense, generally attacked older victims, and had higher self-esteem. The rapist sample were found to have more violent previous convictions and scored higher on measures of historical deviance (nonsexual), paranoid suspicion, and resentment. No differences were found on the personality or clinical syndrome scales of the Millon Clinical Multiaxial Inventory-III. However, the rapist sample had significantly higher mean scores on the Paranoid Suspicion, Resentment, and Self-Esteem subscales of the Antisocial Personality Questionnaire. Future research should compare the two groups on dynamic or changeable factors to determine differential treatment needs.

Following the meta-analysis by Bonta, Law, and Hanson, (1998) this study examined the ability of personal demographic, criminal history, and clinical variables to predict reoffending in offenders in the United Kingdom who had mental disorders. The efficacy of each variable in predicting rate of general reoffending and violent reoffending was investigated. Age on admission, number of days hospitalized, and number of previous offenses were the most effective variables in predicting re-offending, with number of previous offenses being the strongest predictor. Clinical diagnosis was not predictive of reoffending when the variance attributable to these other predictors was controlled for. None of the variables were able to discriminate between general offenders and violent offenders indicating that the same variables predict both types of reoffending. The results showed that reconviction in offenders with mental disorders can be predicted using the same criminogenic variables that are predictive in offenders without mental disorders.

The response of patients with major depressive illness to citalopram of amitriptyline was compared in a double-blind multi-centre trial. No differences in efficacy were observed, but citalopram had less hypnotic effect, and a remarkably lower profile of side-effects.

OBJECTIVE: Our aim was to review all the evidence of lamotrigine's effectiveness in treatment resistant depression after at least one failed antidepressant trial. METHOD: We used a systematic search strategy to identify studies that included adults aged 18-65 years with a diagnosis of unipolar depression who had not responded to at least a 4-week course of a recommended dose of an antidepressant. RESULTS: We found only one randomized, double blind study that has been published, showing its effectiveness for treatment-resistant depression. In this study, lamotrigine was found statistically superior to placebo on the CGI scale for severity and improvement; however, it was not on the HAM-D (primary end point) and MADRS scales. There were a number of smaller non RCT's which are included. CONCLUSIONS: There is little evidence to guide the use of lamotrigine for depression that has not responded to a course of antidepressants. Treatment-refractory depression continues to be significant mental health problem and large RCT trials are needed to inform clinical practice.

BACKROUND: XEN45 Gel stents are in their infancy, and clinical expertise with microsurgical glaucoma devices are increasing. The soft flexible nature of the XEN stent together with its malleability under the conjunctival tissue should negate any risk of exposure of the XEN45 stent (XEN). However, we report a case in which sight-threatening endophthalmitis was the presenting feature of this complication. CASE REPORT: We present a case of uncomplicated XEN implantation that developed endophthalmitis 4 months after surgery. She gave an 8-day history of diarrhea before presentation. She was noted to have exposure of the XEN stent at the point of entry of the XEN into the subconjunctival space. The stent was removed, pars plana vitrectomy was carried out, and intravitreal antibiotics were administered. Achieving low intraocular pressures, bearing in mind her preservative allergy, became a challenge, as we struggled to manage her advanced glaucoma medically. A CyPass Micro-Stent was subsequently inserted to control the intraocular pressure. CONCLUSIONS: Episodes of XEN stent exposure may not be so isolated. We postulate that poor handwashing transmitted the causative organism to the exposed stent, which then resulted in endopthalmitis. We would like to highlight a few learning points from this case.

BACKGROUND: Postnatal depression is more common in women positive for thyroid autoantibodies, independent of thyroid hormone dysfunction, but the basis of this association is unclear. AIMS: The objective of the work reported here has been to investigate from data obtained from previously published research, a possible association between life events, postnatal depression and the development of thyroid dysfunction in women who are positive for thyroid autoantibodies. METHOD: A cohort of pregnant women whose thyroid antibody status was positive (N = 115), was identified at antenatal booking (approximately 16 weeks). These, and a group of women negative for thyroid antibodies (N = 123), were assessed for depression at six to eight weeks postpartum and then at 12, 20 and 28 weeks postpartum according to Research Diagnostic Criteria (RDC). The number and type of life events over the preceding year were also assessed at eight weeks postpartum using Paykel's Life Event Schedule. At four weekly intervals post-partum until six months, thyroid antibody levels and thyroid function (plasma T3 T4 and TSH) were measured. RESULTS: As anticipated, the thyroid antibody status remained the same throughout the study, and there was no difference in the number or type of life events reported in the preceding year, between antibody positive and antibody negative women. Postnatal depression was associated with an excess of both total and negative life events, independent of thyroid antibody status or actual thyroid hormonal status. Women who developed thyroid dysfunction did not report an excess of life events (total, negative or neutral) in the preceding year. CONCLUSION: There was an excess of reported total and negative life events in women with postnatal depression, but this was independent of thyroid antibody status or function.

Although there is a substantial literature looking at the relationship between deviant sexual fantasies and child sexual abuse, there is scant previous work that focuses upon the actual content of such fantasies. The present study looks at child sexual abusers' deviant fantasies both pre- and postintervention. Using both qualitative and quantitative methodologies, a description of the frequency and content of, and triggers for, child sexual abusers' deviant fantasies is reported both pre- and postintervention. The implications of this information for subsequent intervention programs is explored.

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

The prelims comprise: Introduction Rationale For Drug and Alcohol Programmes Evidence Base For Programme Targets Outcome Evidence For Drug and Alcohol Programmes Programme Content and Application Issues Future Directions For Drug and Alcohol Programmes Conclusions References

There is little research in the UK that focuses on medium secure psychiatric nursing staff attitudes, beliefs and knowledge about alcohol and illicit substances, substance use and mental illness. The current study presents data from 98 staff, working within a medium secure psychiatric hospital, and compares differences between staff groups in relation to general drug knowledge and attitudes towards both alcohol and illicit substances and the mentally ill patients who use them. Data suggest that, even for qualified staff, training in alcohol and illicit substances was inadequate in both length and depth. Qualified nursing staff had better knowledge of licit and illicit drug use than unqualified nursing staff and non-clinical staff, and also had different beliefs about why people with severe mental illnesses use licit and illicit drugs. However, no significant differences were found between groups for either level of punitive attitude towards people with severe mental illness who use drugs or the impact that certain factors have on severe mental health problems. These results identify the need for training in drug knowledge and drug use in mental illness, for those staff working in the field. The need for ongoing post-registration training in substance use and mental health is emphasized.

The factors involved in rehabilitating an offender back into a family are discussed from the perspective of the assessment and treatment goals required for the offender. The sources of information available to use for assessment are described and the limitations and difficulties of each source are discussed. As a way of ensuring that all relevant factors are addressed, a model is presented which indicates which areas need to be assessed for each individual. This covers denial, social inadequacy, pro-offending attitudes and relapse prevention. Copyright © 1998 John Wiley & Sons, Ltd.

BACKGROUND: XEN® gel stent (Allergan, Dublin/Republic of Ireland) is a relatively new microinvasive glaucoma device providing an ab-interno approach to the subconjunctival space for aqueous drainage and reduction of intraocular pressure. It is thought to be less invasive, reduce surgical time and post-operative infection rates compared with traditional glaucoma procedures. Little information however, has been published regarding complications and subsequent management. CASE PRESENTATION: The authors highlight five complicated cases of XEN® stent insertion, how they were managed and key learning points. Cases include: entire stent found at the bottom of the anterior chamber several months after uncomplicated insertion, stent broke into multiple pieces during manipulation within subconjunctiva, XEN45 stent migrated into the anterior chamber 7 months post-operatively and a case of limbal-based conjunctival dissection during open revision which lead to additional scarring around the stent and subsequent raised intraocular pressure. CONCLUSIONS: We present some new and interesting complications of XEN implant as well as potential management options. This can assist clinical decision-making and enable better pre-operative discussions with patients regarding risks of surgery.

In recent years cognitive‐behavioural techniques have begun to be applied to psychotic symptoms with positive results. There is little in the literature to suggest that such techniques have been used to help people with learning disabilities who experience psychosis. The case report provided here details the teaching of cognitive‐behavioural strategies for managing auditory hallucinations and their effective use by a woman with mild learning disabilities. A number of benefits of the intervention are noted including decreases in subjective distress and use of PRN medication, as well as improved mood and reported increases in the use of positive coping strategies and self‐esteem.

Dissociative seizures are common in routine neurological practice and cause considerable morbidity. However, explaining such episodes to patients is rarely straightforward. Taking a neuropsychological perspective, we present a strategy for communicating this diagnosis to both patients and families.

This chapter contains sections titled: Defining Core Schemas/Implicit Theories in Sexual Offenders Empirical Studies Assessing Implicit Theories in Adult Abusers Deriving Motivations for Sexual Murder and Rape by the Relative Presence/ Absence of Key Implicit Theories Convergent Utility of the Identified Groups of Sexual Murderers and Rapists Treatment Needs of Three Identified Rape and Sexual Murder Groups Conclusions References

This article provides an overview of the current situation regarding the management and treatment of sexual offenders in Britain. It also describes the work of the National Association for the Development of Work with Sex Offenders (NOTA), a professional association for those involved in working with sexual offenders, and it gives a brief overview of the first of a series of treatment evaluation studies commissioned by the British government.

Aspects of personality or attributional style may account for the previously reported (Farmer et al., 1996) discrepancy between self-reported and objectively rated psychiatric morbidity in subjects with operationally defined Chronic Fatigue Syndrome (CFS). The Eysenck Personality Questionnaire (EPQ) (Eysenck & Eysenck, 1975) and the Attributional Style Questionnaire (ASQ) (Peterson et al., 1982) have been administered to CFS patients, depressed subjects and two healthy control groups for comparison. Sixty-two CFS subjects and 48 psychologically healthy controls completed the EPQ. Fifty CFS subjects, 100 healthy controls and 37 depressed individuals completed the ASQ. CFS subjects with concurrent depression scored significantly higher than CFS subjects without depression or healthy controls on the neuroticism subscale of the EPQ. For the social desirability subscale, CFS patients scored no different from the controls. The attributional style of CFS patients for good events resembled the healthy group. However, CFS patients tend to view bad events as due to external factors beyond personal control yet which are immutable (stable) and which affect all aspects of life (global). Composite ASQ scores for bad events for CFS patients with concurrent depression resembled the depressed group while the non-depressed CFS patient's responses resembled healthy subjects. Scores on the EPQ and ASQ in CFS subjects are no different from healthy controls except for those CFS subjects who are also concurrently depressed where the scores resemble patients with depression. Thus these measures have not explained the discrepant self-report and clinical interview rating of psychiatric morbidity in CFS patients. However, the external, global and stable attributions for bad events may explain the immutable views some CFS patients have regarding the physical nature of their illness.