Introduction
to
Forensic Psychiatry
World Psychiatric Association
Scientific Section Forensic Psychiatry
Secretary: Prof. Birgit A. Völlm
Overview
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Definition “forensic psychiatry”
What do forensic psychiatrists do?
Brief history of forensic psychiatry – UK perspective
The nature and classification of crime
The criminal justice system
Risk factors for criminal behaviour
Mental disorders and offending
The forensic psychiatrist as expert witness
Writing of court reports
Risk assessment
Prison psychiatry
Services for mentally disordered offenders (MDOs)
Treatment of MDOs
Ethical issues in forensic psychiatry
2
Definition
“Forensic psychiatry is a subspecialty of
psychiatry in which scientific and clinical expertise
is applied to legal issues in legal contexts
embracing civil, criminal, correctional or legislative
matters; it should be practiced in accordance with
guidelines and ethical principles enunciated by the
profession of psychiatry.”
(American Academy of Psychiatry and the Law Ethical Guidelines)
3
Definition
“Interpreters of medical and psychological findings
into language which judges, attorneys and
administrators and, in common law jurisdictions
the ‘common man’, can understand and to which
they can apply their rules.”
(Nedopil 2009)
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What do forensic psychiatrists do?
• Assessment of mentally disorders offenders
• Expert witness
- Civil
- Criminal
• Advice to general psychiatrists and other professionals
• Treatment of mentally disordered offenders
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Brief history of forensic psychiatry – UK
• 1800 Criminal Lunatics Act
- James Hadfield attempted to assassinate King
George III (delusional belief – must die at hand of
others)
- First mention of “not guilty being under the influence
of insanity”
- Introduction of Criminal Lunatics Act: Indefinite
detention of mentally ill offenders
• 1843 Mac Naughton rules
- Daniel Mac Naughton attempted to assassinate
Prime Minister (killed his secretary instead) delusional
- Rules for insanity defence
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Brief history of forensic psychiatry - UK
• 1863 State Criminal Lunatic Asylum (Broadmoor High
Secure Hospital opens)
• 1948 NHS
• Homicide Act 1957: “diminished responsibility”
• 1969 Death penalty abolished
• 1970ies onwards: Introduction of medium secure units,
allowing care closer to home in less restrictive settings
(up to then only 3 high secure hospitals in country)
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Crime
• A crime is an act capable of being followed by criminal
proceedings
• Crime is a man made concept defined by legislation
• Actus rea (bad act) + mens rea (guilty state of mind)
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Classification of crime
• Crimes against person: violence, sexual offences,
robbery
• Crimes of dishonesty: burglary, theft, fraud and forgery
• Criminal damage: property damage and arson
• Car crimes: driving without licence, driving whilst
disqualified
• Drug crimes: use, possession, supply
• Other crimes
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Criminal Justice System
Aims of the Criminal Justice System
• Detection and prevention of crime
• Rehabilitation and punishment of offenders
• Victim support
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Criminal Justice System
Crime
Police investigates
Prosecution
Acquittal
•Fitness to be interviewed
Court
•Fitness to stand trial
•Fitness to plead
•Criminal responsibility
Trial
Conviction + sentencing
Appeal
•Discharge
•Fine
•Community order
•Prison sentence
•Hospital admission
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Risk factors for criminal behaviour
• Being male + young
• Genetic factors
MZ twins are more concordant than DZ for recorded and
self reported crimes
• Intelligence
Low IQ has been linked to offending
• Socio-economic deprivation
Poverty, poor housing and unemployment
• Ethnicity
Higher rates of offending in African-Caribbean and lower
in Asians compared to Whites
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Risk factors for criminal behaviour
• Family factors
Poor parental supervision, harsh discipline, marital
disharmony, parental separation, antisocial parents and
large family size
• Peers
Most delinquent acts are committed with others
• Personality factors
Psychopathy, impulsivity, anger and lack of empathy
• Substance Misuse
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Criminogenic needs
• Empirically-identified, dynamic risk factors
• Eight central risk-need factors identified
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Antisocial behaviour,
Antisocial personality,
‘The Big Four’
Antisocial cognitions,
Antisocial associates
Family or relationship problems
School or work
Leisure
Substance abuse
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How about mental disorders?
• Up to end 1970ies/beginning of 1980ies: no
relationship between mental disorder and
crime/violence when taking into account
confounders
• Since then: relationship established between
(offending)/violence and mental disorder
• Mental disorder one of many risk factors
• General risk factors still apply to MDOs
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Study designs
• Prevalence of mental disorders in criminals (e.g. prison
studies)
• Prevalence of offending in patient cohorts
• Epidemiological studies in the general population
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Mental disorders in criminals
Prison Population (UK; Singleton et al, 1998)
General population
Gender
Remand prisoners
Male
Female
Male
Female
Psychosis
0.5
0.6
10
14
Neurosis
12
18
59
76
PD
5.4
3.4
78
50
Drug abuse
13
8
51
54
Suicide
10 / 100 000
128 / 100 000
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Offending in psychiatric populations
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10 – 40% physically assaultative prior to
hospitalisation
High rates of violent incidents in in-patients
Schizophrenia and dementia particular risk
Small percentage (5%) of patients responsible for over
half of incidents
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Offending in psychiatric populations
Camberwell Case Register Study (UK; Wessely et al, 1994)
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Every first episode of schizophrenia 1964 – 1984
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Matched control group
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Time at risk
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Control for gender and age
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Based on criminal records
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Overall conviction rates did not differ
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Convictions for violence x 3 in patients
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But independent and more powerful contribution of other
risk factors (age, gender, ethnicity, etc.)
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General population studies
Epidemiological Catchment Area study (US; Swanson et al, 1990)
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Sample 10 000
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Self-report
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Risk factors for violence: young age, male sex, low
socioeconomic status and psychiatric disorder
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Prevalence of violence
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Base rate 2%
In those with mental illness (Axis I) 12%
Mental illness + substance abuse 35%
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Antisocial PD, substance misuse, mania, psychosis all linked to
crime
Dunedin study (New Zealand birth cohort; Arsenault et al, 2000)
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Risk for conviction was 2.7 for mentally disordered individuals
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Individuals with ASPD and marijuana dependence most likely to
have convictions whereas those with anxiety disorders least likely
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General population studies
Cross-sectional study (UK; Coid et al, 2006)
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Five year self-reported prevalence of violence with
victim harm
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2% in those with no mental disorder
7% neurotic disorder
18% in those with alcohol dependence
25% in those with drug dependence
25% in those with antisocial PD
7% in those with any PD
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Mental disorder and offending: Take
home messages
• Methodological issues: follow up, time at risk, self report,
etc.
• Modest association between mental illness & violence
• Patients with schizophrenia particularly at risk
• Life time risk of violence in people with schizophrenia is
3 - 5 X that of general population
• But: risk is markedly higher among people with
substance misuse disorders and antisocial personality
disorder
• Factors associated with violence are the same in people
with mental illness than in those without
• Majority of people with mental illness are never violent
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Why does this link exist?
• Factors pre-dating onset of active symptoms
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Childhood factors: upbringing, neglect, abuse
Antisocial traits
Poor social skills
Poor education
• Factors arising as a direct result of symptoms
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Particular symptoms
• Factors arising as a long-term consequence of illness
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Stigma
Social exclusion
Unemployment
Deterioration of social skills
Substance misuse
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Schizophrenia & Violence
Schizophrenia in prison samples
• 6% of remand prisoners had schizophrenia (Taylor &
Gunn, 1985)
• 1.5% of sentenced prisoners had schizophrenia (Taylor
& Gunn, 1991)
Swedish case register of hospital admissions &
crime (Fazel, 2009)
• Compared violence rates in schizophrenia patients with
general population
- Schizophrenia 13% vs 5% in general population
- Schizophrenia + substance misuse 28%
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Schizophrenia & Violence
Systematic review of violence and
schizophrenia (Fazel et al, 2009)
• 20 studies, 18,000 subjects
• Men: pooled x 3.8; Women: pooled x 8.2
• Violence risk: substance misuse + psychosis >
psychosis only
• 1 in 300 people with Schizophrenia kill
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Schizophrenia & Violence
Clinical considerations
• Chronicity
• Symptoms
• Victims
• Environmental factors
• Other factors
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Schizophrenia & Violence
Chronicity
Two types of offenders with schizophrenia
• Acutely psychotic: delusions and command
hallucinations
• Chronic defect state: personality deterioration,
homelessness, poverty
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Schizophrenia & Violence
Symptoms
• Threat/control/override symptoms
– Believing that others are controlling movements and
thoughts
– Believing that others are plotting against them, trying
to hurt or poison
– Beliefs of being followed
– Thought withdrawal / insertion
– Command auditory hallucinations
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Schizophrenia & Violence
Victims
• Violence tends to be against family and friends
• Violence against strangers rare
Environmental factors
• High expressed emotion in families
• Hospital setting: overcrowded, restrictive, little
occupational activities
Other factors
• Pre-morbid risk factors
• Consequences of illness
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Depression & Offending
Violent offending
• Rare
• Close family members at particular risk
• Offender with poor coping skills, low self
esteem and feelings of inadequacy in setting
of chronic marital disharmony
Non-violent offending
• Shoplifting: Gibbens (1971): 24% of women
had depression
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Depression & Offending
Psychotic depression
• Delusional ideas of unworthiness, self
criticism, failure, poverty and physical illness
• Often kill themselves
• Suicidal ideation extended to include other
family
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Bipolar Disorder & Offending
Swedish case register (Fazel, 2010)
• Individuals with bipolar disorder (n = 3743),
general population controls (n = 37 429)
• Violence: bipolar 8.4% vs general population
3.5%
• The risk was largely confined to substance
abuse co-morbidity (OR, 6.4)
• Minimal risk without substance abuse comorbidity (OR 1.3)
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Bipolar Disorder & Offending
• Offending is typically associated with
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Drunkenness
Threats
Deception
Inappropriate sexual behaviour
• Manic offenders in custody (Wallach, 1993)
– Out of 100 manic offenders 13% had committed a
serious offence (dangerous driving, rape, arson)
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Personality Disorder & Offending
(Singleton et al, 1998)
Type of PD
Male remand
%
Male sentenced
%
Female
%
Schizotypal
2
2
4
Schizoid
8
6
4
Paranoid
29
20
16
Antisocial
28
30
11
Histrionic
1
2
4
Narcissistic
8
7
6
Borderline
23
14
20
Avoidant
14
7
11
Dependent
4
1
5
O-C
7
10
10
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Personality Disorder & Offending
Clinical factors
• Hostility and anger
• Difficulties in delaying gratification
• Impulsive behaviour
• Lack of insight and remorse
• Lack of victim empathy
• Callousness and lying
• Deficits in recognising emotions like fear, disgust, anger
Associated factors
• Upbringing, etc.
• Substance misuse
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Substance Misuse & Offending
Author, year
Prison sample
Male
%
Male youth
%
Female
%
Maden et al 1995
Remand
39.0
36.4
41.6
Gunn et al 1991
Sentenced
22.7
18.6
30.8
Singleton et al 1997
Remand
Sentenced
Alcohol
58
63
Alcohol
36
39
Singleton et al 1997
Remand
Sentenced
Drugs
51
43
Drugs
54
41
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Substance Misuse & Offending
• Substance misuse disorders are strongly
associated with violent behaviour
• Greater association than other mental disorders
• Individuals with schizophrenia who abuse
substances more likely to be violent than those
that do not
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Substance Misuse & Offending
Explaining the link
• Linkage between substance misuse and crime
subcultures
• Possession is an offence
• Motivation for criminal activity
• Leads to psychiatric disorders / increase in symptoms
which lead to offending
• Brain damage
• Effects of the drug
– Disinhibition
– Acute intoxication
• Effects of drug withdrawal
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Organic Disorders & Offending
Prevalence studies
• Hafner and Boker 1973
533 mentally abnormal homicide offenders:
6% dementia, 5% epilepsy, 6% brain damage
• Gunn and Taylor 1991
1% of sentenced prisoners in England and Wale had an
organic brain disorder
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Organic Disorders & Offending
Epilepsy
• Evidence of higher rates of epilepsy in prisoners
compared to general population
– Whitman et al (1984), 24/1000
– Gunn (1991), 4-5 /1000
• Type and rate of offending in epileptics is similar to those
of offenders in general
• Violence resulting directly from epileptic activity is rare
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Organic Disorders & Offending
Epilepsy
Reasons for increased prevalence of epilepsy in prisoners
• Brain dysfunction may lead to epilepsy and offending
behaviour
• Epilepsy associated with mental disorder which may
lead to offending behaviour
• Poor environments may lead to both epilepsy and
offending behaviour
• Offending behaviour may lead to head injuries which
lead to epilepsy
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Organic Disorders & Offending
Epilepsy - automatism
Automatism (Bratty 1963)
‘The state of a person who, though capable of
action is not conscious of what he is doing…. It
means unconscious involuntary action and it is a
defence because the mind does not go with what
is being done’ (Bratty, 1963)
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Organic Disorders & Offending
Epilepsy – automatism (Fenwick, 1990)
• Patient should be known to be epileptic
• The act should be out of character and inappropriate
for the circumstances
• There should be no evidence of premeditation or any
attempts to conceal the offence
• Any witnesses to the offence should describe disturbed
consciousness including a description of the subject
becoming suddenly aware of their surroundings and
confusion as the automatism ends
• Amnesia for whole period of the automatism
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Organic Disorders & Offending
Dementia /delirium
• Increase irritability, aggressiveness, suspiciousness
• Disinhibition
• Forgetfulness (shoplifting)
Organic personality disorder
• Huntington’s chorea (antisocial behaviour appears
before neurological and psychiatric signs)
• Disinhibition
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Learning Disability & Offending
Prevalence of LD in offenders
• Police stations (UK)
– Gudjohnsson et al (1993)
– Lyall et al (1995)
8.6%</=70,
42% 70 -79
4.4% Mild LD
0.4% severe LD
• Courts (Australia)
– Hayes 1993
– Hayes 1996
14.2% </=70
8.8% 70 -79
36.0% </=70
20.9% 70-79
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Learning Disability & Offending
Author
Country
Prison type
Results
Coid1988
England
remand
5.1% < 75
Murphy 1995
England
remand
0% </= 70
5.7% </= 75
Brown and
Courtless 1971
USA
convicted
9.5%
MacEachron
1979
US
convicted
1.5 -5.6%
Denowski
&Denowski
US
convicted
0.2-5.3%
Gunn et al 1991
UK
convicted
0.4%
Brooke et al 1996
UK
convicted
0.8%
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Learning Disability & Offending
Longitudinal studies (Hodgins 1992)
• Cohort of 15,000 Swedish children born 1953
• Men with LD
– 3 times more likely to have a conviction by age 30
– 4 times more likely to have committed a violent
offence
• Women with LD
– 4 times more likely to have a conviction by age 30
– 25 times more likely to have committed a violent
offence
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Learning Disability & Offending
Characteristic of LD offenders
• Young
• Male
• Severe psychosocial disadvantage
• Offending by other family members
• Behavioural problems dating back to early childhood
• High rates of unemployment
• Mental health needs
• Offending more likely in mild to moderate LD range
• Likely to commit a wide range of offences
• May have higher rates of recidivism (Robertson 1981)
• May have higher rates of arson and sexual offences (Walker and
McCabe 1973, Day 1988)
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Specific Crimes & Mental Disorder
Homicide
• National survey (UK; Shaw et al, 2006)
• 1594 individuals convicted of homocide
• 34% had a mental disorder: most not attended
psychiatric services
• 5% had schizophrenia
• 10% had symptoms of mental illness at the time of
offence
• 9% received diminished responsibility verdict
• 7% received a hospital order
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Specific Crimes & Mental Disorder
Arson
• PD: antisocial traits, impulsivity, high level of
carelessness and hostility
• Low IQ
• Alcohol abuse
• A minority have mental illness like schizophrenia
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Specific Crimes & Mental Disorder
Motives and reasons for arson
• Insurance fraud
• Political
• Desire to be seen as a hero
• Psychosis
• Pyromania
• Antisocial attitudes
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Specific Crimes & Mental Disorder
Sexual offending
• Mania, hypomania
• PD: impulsivity, antisocial traits, anger, low self esteem,
psychopathy and deviant sexual fantasies
• Substance misuse linked to recidivism among sex
offenders
• Sadistic sex offenders tend to have PD (narcissistic &
antisocial)
• Specific disorders of sexual preference
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Specific Crimes & Mental Disorder
Morbid jealousy (Othello syndrome)
• Jealousy ‘ feeling or showing resentment
towards a person one thinks of as a rival’
• Healthy people: jealous only in response to
evidence, prepared to modify their beliefs and
reactions as new information becomes available,
jealousy directly towards one person
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Specific Crimes & Mental Disorder
Morbid jealousy
• A range of irrational thoughts and emotions, together
with associated unacceptable or extreme behaviour, in
which the dominant theme is a preoccupation with a
partner’s sexual unfaithfulness based on unfounded
evidence
• Interpretation of irrelevant occurrences as evidence of
infidelity, refuses to change beliefs even in the face of
conflicting information, and tend to accuse the partner of
infidelity with many others
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Specific Crimes & Mental Disorder
Morbid jealousy: Psychopathology
• Content
- Preoccupation with a partner’s sexual fidelity
• Form
- Delusions (delusional disorder, schizophrenia,
psychotic depression, in context of organic brain
disorders)
- Obsessions
- Overvalued ideas (paranoid, borderline PD)
- Associated with alcohol misuse
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Specific Crimes & Mental Disorder
Morbid jealousy: Violence
• Homicide
- Dell (1984): 17% of homicides
- Mooney (1965): 14% of morbidly jealous sample had
committed homicide
- Most victims close family members
• Domestic violence
- Mullen & Mack (1985): > 50% of morbidly jealous had
assaulted partner, none come to notice of CJS
- Silva et al (1998): of 20 morbidly jealous, 13
threatened to kill, 9 had attacked. Presence of
paranoid delusions, command hallucinations and
alcohol consumption associated with higher risk of
assault
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Specific Crimes & Mental Disorder
Stalking
• Schizophrenia: delusional stalkers likely to cause high
level of harm
• PD: narcissism, paranoia and antisocial
• Substance misuse
• IQ higher amongst stalkers than other offenders
• Other factors: male gender, young age, unemployment,
recent loss, and childhood experiences (attachment
disturbance)
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The forensic psychiatrist as expert
witness
Civil matters
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Guardianship
Child custody/parental fitness
Child abuse/neglect
Psychiatric disability (benefits, insurance)
Testamentary capacity
Psychiatric malpractice/negligence
Psychological damage
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Legal issues
• Pre-trial issues
– Fitness to be interviewed
– Diversion
• Fitness to plead
• Fitness to stand trial
• Trial issues
– Mens rea
– ‘Psychiatric defenses’
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Insanity
Diminished responsibility
Automatism
Infanticide
• Sentencing issues
– ‘Dangerousness’
– Mitigation
– Medical disposals
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Fitness to plead
• Concerns accused mental state at time of trial
• Current mental state would not allow person to conduct proper
defence
• Defendant must be able to
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Understand the charge
Enter a plea
Follow course of trial
Instruct legal advisors
Challenge jurors
• Decided by judge
• Trial of the facts
– If not found to have done the act - acquitted
• Different disposals for those found unfit to plead, often Hospital
Order
– Could return to trial when fit
60
Mens rea
• Actus reus non facit reum nisi mens sit rea = “The act is
not culpable unless the mind is guilty"
• I.e. a ‘guilty mind’ (mens rea) is a prerequisite of
responsibility for a crime and so to be punished
• Individuals with mental disorders may not have mens rea
due to mental state at the time of the offence
• Different levels of mens rea:
– Intent: wants consequence to happen
– Recklessness: foresees consequence, taking risk
– Negligence: does not foresee or desires consequence but
should have done
– But: accident: would not have been possible to predict the
outcome; no guilt
61
Insanity
• Every person is presumed to be sane, unless the
contrary is proved
• Punishment requires ‘guilty mind’, i.e. ability to form
intent to commit crime
• Someone with severe mental disorder may be ‘insane’,
i.e. not guilty due to their disorder
• McNaughten rules for insanity – used in common law
countries - At the time of the act the defendant was:
– “labouring under defect of reason, from disease of the mind, as
to not know the nature or quality of the act he was doing, or, if he
did know it, that he did not know that what he was doing was
wrong”
• Usually associated with severe mental illness Schizophrenia, Bipolar Disorder
• Can result in diversion to hospital or absolute discharge62
Diminished responsibility
• In UK only for homicide
• Section 2 Homicide Act 1957
– Reduces murder to manslaughter
– “abnormality of the mind (whether arising from arrested or
retarded development of the mind, disease or injury or other
inherent cause) such as to substantially impair mental
responsibility”
– ‘Abnormality of mind’: “any condition so different from that of the
ordinary human being that the reasonable man would call it
abnormal”
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Writing of court reports I
Preliminary matters
• Is it appropriate to take this case?
- Expertise
• Ensure instructions are clear and adequate
- Timescales
- Questions
• What issues are at stake?
• Request more information if necessary
• Gather all relevant information before interviewing
accused
64
Writing of court reports II
Interviewing the accused
• Appropriate setting and timing
• Interview
- Introduction
- Who instructed – questions asked
- Special relationship
- Limits of confidentiality
- Possible outcome of assessment
- Capacity to consent + consents
- Access to further information (notes and
informants)?
65
Writing of court reports III
Further information / investigations
• Review of notes
- Medical notes
- Police interviews
- Witness statements
• Interview staff
• Diagnostics:
- Brain scan
- Structured interviews
- Neuropsychological testing
66
Writing of court reports IV
Writing style
• Clarity
• Minimal use of technical language – non-experts
• Structure / use headings
• Length
• Only what is relevant
• Avoid value laden statements
• Stick to your expertise – no comment on legal issues
• Awareness that you might have to defend your
opinion / wording
67
Writing of court reports V
Structure and content
• Introduction
- Very brief summary of case
- Who instructed
- Questions asked
• State your expertise
• Sources of information
- Interview with accused
- Review of notes
- Interview of other informants
- Further investigations
- Any difficulties with assessment
68
Writing of court reports VI
Background history
• Family history
• Personal history
• Medical history
Psychiatric history
• including substance misuse
Offending history
• Previous offending
• Index offence
69
Writing of court reports VII
Progress in prison
Interview and mental state
Other investigations
70
Writing of court reports VIII
Conclusion and recommendations
• Summary of case
• Formulation
- Relevant factors in offending
- Role of mental disorder in offending
• Diagnosis
• Risk
• Treatment issues
• Answer questions
• Give reasons for your conclusions / recommendations
• State limitations of your conclusions
• Comments on other expert’s reports
71
Issues in the role as expert witness
• ‘Dual role dilemma’ (e.g. psychiatrist has responsibility
towards offender patient and society, i.e. court,
protection of public)
• Not usual doctor – patient relationship
• Limitations of confidentiality
• Only advice not decision making
• Translation of concepts
• Expertise potentially leading to adverse outcome to the
offender patient, i.e. admission to secure hospital
72
Risk assessment
• Part of all forensic-psychiatric assessments
• Risk domains, e.g. risk
- To others
- To self
- Risk of violence
- Sexual risk
• Time frame of risk
• Short term – easier to predict
• Longer term – much more difficult to predict
• Static – dynamic risk factors
• Static – won’t change, e.g. male gender
• Dynamic – can change, e.g. symptoms of disorder
• Aim to develop risk management plan, not just to make
predictions
• Accuracy limited – false positives and false negatives
73
• Risk cannot be eliminated
Prison psychiatry
• Prevalence of mental disorders high
• More MDOs in prison than in psychiatric institutions
• Assessment of prisoners
- Advice to transfer to treatment institutions
• Issues with transfer to psychiatric institutions
- Identification of cases
- Delays
- Highly dependent on systems available in country
• MDOs in prison system
- Is it ever appropriate?
- Ill people need to be in hospital? Depends on
criminal responsibility?
- Equivalence of care
• High risk of reoffending
- Higher than after forensic-psychiatric treatment
74
Treatment facilities for MDOs
How to get into treatment facility
• Mental disorder
• UK: detainable under Mental Health Act
regardless of responsibility
- Issue is need for treatment
• Other countries: has to have some level of
reduced responsibility
• Some countries exclude specific conditions, e.g.
substance abuse or personality disorders
• From court
• From prison
75
• Referral from other treatment facilities
Treatment facilities for MDOs
How to get out of treatment facility
• Depends on laws of country
• Usually for those who are not fully criminally
responsible and remain high risk
• Forensic-psychiatric detention not time limited
• Prison transfer – Acutely unwell may be
transferred to hospital for short term treatment,
then return to prison
76
Principles of treatment - basics
• Respect for dignity, integrity, privacy and
autonomy
• Recovery focus
• Least restrictive principle
• Individualised care
• Collaborative approach
77
Multidisciplinary team
• Psychiatry
- Consultant forensic psychiatrist
- Trainee doctors
- Ward doctors
• Other medics
• Pharmacy
• Psychology
- Forensic
- Clinical
• Social work
• Nursing
- Staff nurses
- Nursing assistants
• Occupational therapists
• Education
• Other therapists
78
Principles of treatment
• Security
- Structural
- Procedural
- Relational
•
•
•
•
•
•
Importance of a structure and boundaries
Consistency
Multidisciplinary working
Named nurse
Selection of staff
Staff training and supervision
79
Principles of treatment, ctd.
•
•
•
•
•
Pharmacological and psychological interventions
All activity to support process of change
Role modeling
Risk – need – responsivity
Group and 1:1
80
Stages of treatment
• Assessment
• Stabilisation
• Preparation for Change
- Motivational work
- Psychoeducation
• Addressing personality and
interpersonal issues
- Specific personality work
- Interpersonal skills
- Problem solving, thinking skills
In parallel:
Ward interaction
Family work
Activities
Work
Self esteem
Quality of life
• Addressing offending / criminogenic factors
• Relapse prevention
• Rehabilitation
81
Ethical issues
• ‘Dual role’ of forensic psychiatrist
–Obligation towards patient and society
• Pressure from society in high profile cases
• Principle of patient autonomy
–Consent
–Needs capacity + information + understands
information + freely consents
• Forced treatment
• Best interest of patient
• Least restrictive care
82
Ethical issues, ctd.
• Effect of decisions on doctor-patient relationship
• Treatment in hospital might be longer than in
prison
• Interpretation of risk assessments
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