A Guide for Post-Traumatic Stress Disorder
Predicting Outcomes of Insanity Acquittees Released to the Community
Forensic Mental
Evaluation of the Violent Sexual Offender
Follow-up after Release
of Insanity Acquittees, Mental Disordered Offenders, and Convicted Felons
The Hormonal
Treatment of Paraphiliacs with Depo-Provera

Marchia I. Cohen, M.C.P
Michael K. Spodak, M.D.
Stuart B. Silver, M.D.
​Katherine Williams, Ph.D.

Michael K. Spodak, M.D.
Stuart B. Silver, M.D.
Marchia I. Cohen, M.C.P

Michael K. Spodak, M.D.
Z. Ann Falck, R.N.
Jonas R. Rappeport, M.D.

Michael K. Spodak, M.D.
Stuart B. Silver, M.D.

By Michael K. Spodak, M.D.

With the enormous increase in psychiatric involvement with civil and criminal  cases, there have been  a great deal of misunderstanding about what constitutes an appropriate evaluation and how to arrive at an appropriate diagnosis. This has been both clarified and complicated by the attempts to use the DSM-III, Diagnostic and Statistical Manual Third Edition, American Psychiatric Association, 1980. There is no area that causes greater confusion than that of post-traumatic stress disorder
This research developed a model for forensic release decisions that incorporated actuarial and psychiatric predictors. The model was based on research that compared 127 insanity acquittees in the State of Maryland with a matched control group of 127 convicted felons and a comparison group of 135 mentally disordered prison transfers. The three cohorts were followed for an average of 10 years after release from hospital or prison. Findings on two outcome indicators are reported in this article: rearrests within 5 years after release and overall functioning in the community during 2½ years after release. Discriminant analysis was performed on the outcome variable of rearrest; it was found to accurately predict the outcome of 75% of the subjects with the following six variables: adjustment in hospital, clinical assessment of hospital staff, Global Assessment Scale score at release, functioning prior to instant offense, heroin addiction, and birth order. A second discriminant analysis identified seven variables that accurately predicted the overall functioning of 80.4% of the insanity acquittees.
Violent sex offenders may require mental evaluation at various times as they pass through the criminal justice system. Upon arrest, they may exhibit symptoms of acute illness needing prompt diagnosis and treatment. Later, specific legal questions may be posed. This chapter explores considerations relevant to evaluation for competency to stand trial and criminal responsibility, focusing on violent sexual offenses. A case example illustrates a defendant's movement though the pretrial forensic mental evaluation process. 
The authors compared 127 insanity acquittees in the state of Maryland with a matched prisoner control group of 127 convicted felons and a comparison group of 135 mentally disordered prisoners transferred for hospital treatment. Subjects were followed from five to 17 years after discharge from hospital or release from prison. Subsequent arrests, hospitalizations, employment, and functioning of these large cohorts were studied and compared. The study focused on outcome data at five years after release. The authors found that, at five years postrelease, 54.3 percent of the insanity acquittees, 65.4 percent of the prisoner control group, and 73.3 percent of the mentally disordered prison transfers were rearrested. At 17 years postrelease, rearrest rates increased to 65.8 percent of the insanity acquittees, 75.4 percent of the prisoner controls, and 78.4 percent of the prison transfers. Significantly more mentally disordered prison transfers than NGRls were rehospitalized during the follow-up period. Overall, the prison transfers had significantly poorer outcomes on nearly all variables studied compared with the other two groups. The authors conclude that although there were a substantial number of rearrests among insanity acquittees, that group had a statistically significantly lower rate of criminal activity compared with the other two groups of offenders.
Psychological therapies as described by Marshall are but one means of reducing the rapist's and child molester's sexual aggressive urges and behaviors. Various organic therapies have been recommended, including psychosurgery and surgical castration. Spodak, Falck, and Rappeport review a newer and more reversible form of castration, chemical castration by the use of the female hormone medroxyprogesterone acetate and the new antiandrogen, cyproterone acetate. These drugs are used to decrease the functioning level of the male hormone, testosterone. Reduction of testosterone appears to decrease overall sexual drive and rather rapidly allows the rapist or child molester to gain greater control (in some cases complete control) of his aggressive sexual urges.
Spodak, Falck, and Rappeport describe the use of these hormonal agents, their effects and side effects, and give therapists some guidelines to follow when using these chemical interventions. Although not seen as a panacea, these agents do appear rapidly to assist the deviant in gaining control of his urges, and when coupled with psychotherapy they serve a valuable adjunct to the therapist armamentarium.

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