Psychiatrists are particularly exposed to the risk of being victims of stalking (repeated persecution, unwanted communicating & contact causing fear) by patients.

To summarize the latest research findings on this topic. We conducted a literature review on Medline sources. Key words: Stalking by patients, psychiatrists, mental health professionals.

Up to 20% of psychiatrists have been victims of stalking, at least once. Stalkers are usually male, single & unemployed, and under the care of the clinician; 3/4 of them suffer from a psychotic and/or personality disorder(s), mainly cluster B personality disorder(s). Duration of stalking varies between several weeks and could reach 16 years. Methods of harassment include intrusive approaches, loitering near the victim, telephone calls, following the victim, spreading gossip, violating property, and sending unwanted material (letters, sexual material etc). Victims most commonly express fear, anger, helplessness or even PTSD symptoms. Stalked psychiatrists are usually male consultants but also at risk are inexperienced trainees. Most victims search assistance and counselling from colleagues, family, friends, police or lawyers.

Countermeasures include modifying professional style, taking more precautions at work, changing telephone number, increasing home security; in serious cases residence change is needed. Any attempt of the victim to contact the stalker gets things worse.

Whether the stalker's behaviour is motivated by anger, envy, delusion, or because of misunderstandings about the nature of the psychotherapeutic relationship (false sense of intimacy), psychiatrists should maintain high levels of attention. the threat of stalking should not be underestimated.

Compulsory admission is practiced around the world with legislative variations. the legal status during compulsory hospitalization might be changed to consent or the patient might be discharged against medical advice (AMA), if he no longer poses a risk.

In the present study we investigated the outcome of compulsory admitted patients who left the hospital after commitment period despite request by the treating psychiatrist to remain in the hospital (AMA) vs. those who agreed to prolong their hospitalization.

Of 320 patients with schizophrenia admitted involuntarily, 157 (49%) were discharged without converting to consent and 163 (51%) agreed to stay in the hospital. There was no difference in baseline clinical and demographic characteristics and outcome measures (rate of readmission, legal status of next admission and length of stay in the next admission) between the two groups.

Prolongation of length of stay in compulsorily psychiatrist-ordered schizophrenia patients did not affect their rate of re-hospitalizations or the length of next admission compared to those who left the hospital immediately after the change in their legal status AMA.

Violence in psychiatric wards is common, and it is on the rise. This study examined the frequency and types of aggressive and violent behaviors in acute psychiatric inpatient settings and focuses on the possible complex interaction between ward staffing, patient mix, and violence.

Data were gathered prospectively in two acute psychiatric units in two general hospitals and two units in a psychiatric hospital in Isfahan, Iran. Staff recorded violent and aggressive incidents by using Morrison's hierarchy of aggressive and violent behavior. They also completed weekly reports of Ward Activity Index (patient mix), and Staff Level Index were developed by the researcher. Regression analysis was used to calculate relative rates.

A total of 429 violent incidents were recorded over a three-month period. Based on the scale, more than 50 percent of the incidents were serious. Seventy-eight percent were directed toward nursing staff. Complex relationships between staffing, patient mix, and violence were found. Relative risk increased with more nursing staff (of either sex), more non nursing staff on planned leave, more patients known to instigate violence, a greater number of disoriented patients, more patients detained compulsorily, and more use of seclusion. the relative risk decreased with more young staff (under 30 years old), more nursing staff with unplanned absenteeism, more admissions, and more patients with substance abuse or physical illness.

Violent incidents within psychiatric facilities were frequent and serious, with great significance for occupational health. Some clues were found in the prediction of violence.

Few papers reported that schizophrenia predisposes to homicidal behavior. the aim of this paper is to report our experience with homicidal behavior in Schizophrenic patients admitted at Ibin-AL-Haitham a high secure unit, in AL-Rashad Teaching Mental Hospital, Baghdad.

Homicide offenders are subjected to intensive forensic psychiatric investigations in Iraq. Therefore, it was possible to obtain and review data of 118 homicide offenders admitted in Ibin Al-Hiathim Secure Unit in AL-Rashad Teaching Hospital of Baghdad during period from July 2003 to July 2008.

The percentage of schizophrenia in this sample was 44% and 57% of schizophrenic offenders were in the age group (20–40years). There were more males; simply because males are more liable to break the law than females. Higher number of urban living offenders is probably attributed to the fact that psychiatric institutions and services are more accessible, and accurate recording in urban areas than in rural areas. Victims are mostly of first degree relatives of the offenders.

According to our experience there is a strong relationship between schizophrenia and homicidal behavior.

This work describes a sample about gender dysphoria in different male and female personalities.the diagnosis could be a difficult process.the treatment for transsexualism includes sex reasignment surgery that involves the removal of body parts. Surgical procedures include several surgical complications.

Expose difficulties and ethical dilemma about transsexuals.

Through the last 12 years we had examinate about 24 cases of gender dysphoria in transsexuals individuals, 10 female to male and 14 male to female, who requested the change to be made in their civilian condition and surgical adequacy by the request of the intervinient judges. in all cases the solicitors personality features existence or not of psychiatrist disturbance are analized during the expert examinations in order to determine their psychologicall capacity, freedom of discernment, regarding the desicion of going under a surgical practice which implies serious irreversible injuries in their bodies.

The solicitors typical profile described, both the female- male and male-female, fit inside criteria of the psychiatrist international classification, ninety per cent were classified primary transsexualism and the remainder ten per cent as secondaries. Cases which not fit in the profile or have psychiatric diagnosis, surgical interventions are not recommended for us. Two cases are shown as examples.

We are requested by the judge to make psychiatric diagnosis of normality of a person in order to change this norm, this can turn out to be paradoxical for any phisician,this topic is open to discussion.

Every death at a psychiatric hospital raises questions about its cause and the forensic responsibilities it engages.

• - To assess the rate of deaths posing forensic problems at a psychiatric hospital.

• - To determine the patients’ victimological profile.

• - To identify the causes and risk factors of these deaths.

We conducted a retrospective and descriptive study based on the forensic autopsies and the medical files of patients who died during their stay at AlRazi psychiatric hospital between January 2000 and December 2010.

During the study period, 115 deaths were recorded. We studied the deaths of 33 autopsied patients (28.69% of all deaths). Patients are predominantly male (60%), aged 43 on average, mostly smokers (66%), with a low socioeconomic level (61%) and a medical history (40%) primarily of hypertension and diabetes. 40% of our casualties are schizophrenic, mostly of the paranoid form (60%). Antipsychotics are the most prescribed drugs (87.5%). High doses are used (mean chlorpromazine equivalent dose: 1237 mg/day). Most deaths occurred at night, during weekends. 21% died within the first 24 hours of their hospital stay. A cause for death was identified in ¾ of cases. 75.75% are sudden deaths mainly due to respiratory (40%), or cardiovascular causes (20%). Accidental deaths (18.18% of all deaths) include choking (50%), thermal burns (33.4%) and iatrogenic causes (16.6%). Suicides account for 6% of all deaths.

Reducing the incidence of deaths posing forensic problems at psychiatric hospitals is an important goal to achieve through careful identification of risk factors.

The combination auto - And the heteroaggressive tendencies is actual problem for diagnostics of schizophrenia and choice of medical measures as preventive maintenance of crimes. the aim of research is definition ofclinical, social, and personal factors of heteroaggressive actions of schizophreniс patients with autoaggressive behavior as the base of perfection of diagnostics, forensic-psychiatric estimation and preventive maintenance of patients with both forms of disorders.

We studied the cohort of 97 men at the age from 19 till 63 years old, divided into 2 groups. the first (basic) groop is 54 patients of a schizophrenia committed auto - And heteroaggressive actions and second (control) 43 patients commited only heteroaggressive actions.

Autoaggressiveness in a cases of schizophrenia is important for:

• 1) Diagnostic process,

• 2) Forensic-psychiatric asessment,

• 3) Clinical and social prevention of autoaggression in future. This clinical disorders defines by two mechanism - psychotic or non-psychotic (mostly pdeudopsychopatic).

The correlation is revealed between following signs:the first severe autoaggressive episode and subsequent crime with heteroaggression. Dominating situational factors of autoaggression and direction of crime on relatives. A leading syndrome (the psychotic and not psychotic register) and situative provocation of autoaggression, and also exogenic factors like alcohol intoxication; Episodes of autoaggression and severe aggressive crimes which often reflect stability of mechanisms and motives of behavioral disorders.

Thus, the forensic estimation of schizophreniс patients who committed crimes has to consider all clinical, social, situational factors also datas about heteroaggression in the past.

According to the Portuguese Mental Health Law (PMHL), compulsory admission (CA) may be used whenever someone bears a “severe psychic anomaly” which is causing, or may cause, danger to his own juridical rights or to those of others, given that the subject refuses adequate treatment. A psychiatric evaluation, in emergency settings, might be ordered by a judge through a warrant and a report must be sent to the court about the clinical need of CA.

Assess the appropriate use of PMLH in what refers to its legal and clinical aspects in the emergency room. We explored social-demographic and clinical variables of the subjects submitted to CA and studied the relation between the patients subjected to psychiatric evaluation by court order and those were actually compulsory admitted.

We studied retrospectively, the clinical files of 4537 patients who attended the psychiatric emergency of the Coimbra University Hospital between January and June, 2010.

1,3% of all patients were compulsory admitted, two thirds of which were male, half were unemployed or retired. 1,7% were subjected to psychiatric evaluation by court order, about 50% weren’t admitted compulsory. the majority of warrants were issued because of aggressive behaviour or behavioural changes. the most frequent diagnosis in CA were schizophrenia and delusional disorders.

Understanding CA patterns helps to identify possible misuses of the law and may serve to recognize subgroups of patients in need of specific interventions to prevent the use of judicial processes concerning psychiatric patients.

Mental health workers play different roles in the Open District Mental Health Service, and they differs in professional education skills. Taking care of psychotic patients also include to administrate and observate the medication in practice, but there are different experiences in this area.

To gain knowledge about the practice in the Open District Mental Health Service according to medication trends.

To gain knowledge and information about the daily practice.

This pilotstudy was done in 2011. Focusgroup interwievs where the informants was leaders and professional workers in two different municipalities in Nortern Norway in 2011. Literature rewievs was also done. Next step is quantitative methods based on the results in the pilot study.

The results show that the Open District Mental Health Service practice differed in organization of the service. the one who has the resonsibility of medication for the patients in daily settings differed. the most educated persons in the mental health team took care of the treatment only in communication with the psychotic persons, while the lowest educated personal in the home care settings administrated to give patients medicine. Some of the workers in the home care settings had only a 10 hours medical course. They was afraid of the patients who could be aggressive and denied to take medication.

The organization of the medication responsibilty need to be focused more upon because of the need of good observation of the effects on the patients.

Parental alienation is a form of psychological and emotional child abuse which generally is initiated after the divorce, when one parent (the guardian) starts to disqualify and demoralize the other parent (the alienated), trying to keep the child away from the last one and destroying basic emotional links between them.

On the 26th of August 2010, the Brazilian Parliament ratified a law (Law nº 12.318) against parental alienation, which defines and punishes this act.

To demonstrate that parental alienation is a major cause of distress for the child, independent of the evaluation of sexual abuse. Parental alienation can bring psychosomatic and psychiatric problems as well.

To prevent “alienation” cases which can cause harmful effects in the child's life.

Evalluation of a case report studied by Psychiatrists and Psychologists in Rio de Janeiro. A girl who was taken away from her father by her mother after the divorce, when she was 6 months old. the mother tried to avoid the father's contact with the child, alleging that he sexually abused the kid. Nowadays, the girl hates her father.

It was not possible to conclude if the child was sexually abused or not. But it was clear that the girl was a victim of emotional and psychological abuse.

A child's life can be devastated by parental alienation because of the “loss” of one parent and the negative effects in the development of emotional life. Severe penalties for the parents should be taken to prevent it.

Delusional Disorder is an illness characterized by the presence of nonbizarre delusions, sometimes being the only clinical characteristic. A middle-aged woman made a formal accusation against her neighbour. She had Myasthenia Gravis (a neuromuscular disease) for a long time and persecutory symptoms and was being analyzed for Civil Capacity.

To discuss about Psychiatry Disorders with paranoia symptoms and the accusations and complaints of the patient because they can be true and bring consequences to the patient's life.

To have a closer view of the patient with persecutory symptoms because their complaints can really be well-founded.

Evaluation of a case report that was studied by a Psychiatrist in Rio de Janeiro, in which the prosecutor wanted to know whether the woman was capable of expressing her will and being responsible for her civil rights and obligations.

The woman was suffering from a Delusional Disorder and needed to have Psychiatry treatment and to be attended by a legal representative. But her accusation against her neighbour had to be investigated by the authorities.

We cannot disqualify patients with persecutory symptoms and their attempt to have justice, even when they do not have good insight into their pathological experiences. Our job is to help the patients by treating them, supporting them and maintaining their quality of life.

Mentally disordered prisoners (MDPs) have an increased vulnerability to victimization and suicide. in the last years, there is a trend to assign their treatment to the civil psychiatric services.

To compare forensic with civil psychiatric services users (FPSUs vs CPSUs) regarding clinical and care needs.

A cross-sectional study of FPSUs and CPSUs from 2 prisons, 1 prison-hospital and 1 general hospital, all located in the Lisbon region, was conducted. the forensic sample was constituted by all users during one year period (2009–2010), and the civil sample was matched for age and gender. the data was collected from users and staff interviews. the instruments included a specific questionnaire, MINI, BPRS and CANFOR.

The samples comprised 114 prisoners and 121 civil patients. FPSUs had better family inclusion and employment status but poorer academic achievement than CPSUs. the FPSUs presented significantly higher prevalence for major depression, suicide risk, anxiety disorders, drugs addiction and anti-social personality disorder than CPSUs. Comparatively, FPSUs had more prescriptions for hypnotics and CPSU had more prescriptions for antidepressants and anxiolytics. the FPSUs rated significantly more needs and unmet needs than CPSUs. However, the staff rated no differences between the two groups.

The FPSUs presented a higher prevalence of non-psychotic pathology than CPSUs. However, it seems that medication is insufficient regarding the clinical severity.

The unmet needs of FPSUs were significantly higher than CPSUs, and cover multiple domains.

The displacement of MDPs to civil psychiatric facilities should consider their specificities and needs.

Forensic Mental Health provision in secure healthcare is complex. the availability of a short and quantifiable, yet comprehensive instrument for summarising patient progress encompassing multi-professional clinical input would facilitate clinical decision-making.

To develop and validate a Progress Rating Scale (PRS) for use in secure healthcare to assess patient course in treatment.

PRS items will reflect multi-professional clinical input. Measurement will be valid and reliable.

Scale items

Development was undertaken at the Personality Disorder Service, Arnold Lodge Regional Secure Unit. Thematic analysis of 5 randomly selected archived treatment reviews resulted in a preliminary list of items. This scale was then piloted and refined via independent rating of further anonymised reports.

Validation and further development

To assess content validity, 3 independent raters applied the scale on archived treatment reviews of 12 randomly selected patients. Following examination of single-rating intra-class correlations (ICCs), items were revised to achieve greater content validity.

The domains of the scale were: Engagement, Behaviour, Mental State, Interactions with Peers and Staff, Insight, Supportive relationship, Employment, Leave, Violence/risk, Psychometric score and Final outcome (upon discharge). Initial inter-rater agreement ranged from fair to substantial (ICCs: 0.37–0.82). Following revisions, agreement improved ranging from moderate to substantial (ICCs: 0.63–0.92), the latter applying to most items.

A scale for evaluating patient progress was developed based on multi-professional clinical input. the scale was refined to improve content validity. Internal consistency and factorial structure are under scrutiny and results will be available at the conference.