The link between crime and
mental disorder: Part 2
Local Education Programme
Forensic Session 3
Outline of the day
1–2
2–3
3 – 3.15
3.15 – 3.30
3.30 – 4.30
4.30 – 5
Case Presentation
Journal Club Presentation
Break
555
‘The link between crime and
mental disorder – part 2’
MCQs & reflection
Curriculum Links
12.1
Relationship between crime and mental disorder
12.1.2
The relationship between specific mental disorders and crime:
substance misuse; epilepsy; schizophrenia; bipolar affective
disorder; neuro-developmental disorders; personality disorders.
12.1.3
Special syndromes: morbid jealousy, erotomania, Munchausen and
Munchausen by proxy.
12.1.5
Effect of victimisation and vulnerability: anxiety states including
post-traumatic stress disorder; suggestibility; anger and aggressive
behaviour. Effect of compensation on presentation
Learning Objectives
To develop an understanding of…
• The role of mental disorder in offending
• The frequency of and types of offences
committed by those with serious mental
illness (SMI)
• The role of special syndromes in offences
• Vulnerability and suggestibility in mentallydisordered offenders
The link between crime and
mental disorder part 2
Mental disorder and offending
Offending in patients with SMI
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•
•
•
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Psychosis – brief overview
Affective Disorders
Personality disorder
Substance Misuse
Epilepsy & neuro-developmental disorders
PSYCHOSIS AND OFFENDING
Are schizophrenic patients more
violent?
• ECA survey re-examined (Swanson et al 1990)
– Increased violent offences in SZ
• Elbogen & Johnson (2009)
– SMI alone does not predict violence
– Other factors for violence reported more frequently in
SMI
• Fazel et al (2009)
– Substance use is biggest contributory factor
Homicide and psychosis
• Nielssen et al (2010)
– Annual rate homicide by SZ patients 1 in 3000
– Increased risk of homicide in FEP
– Annual rate homicide before treatment is 15 times
higher than after treatment
Homicide and psychosis
• Shaw et al (2006)
– 34% homicides – lifetime mental disorder
• 5 – 7% schizophrenia
• 9 – 11% personality disorder
• 5 – 6% psychotic at time of offence
Psychotic symptoms and violence
• Delusions
– 50% psychotic violent offenders attributed it to delusions
– MacArthur study found no such association
• Hallucinations
– Rudrick (1999)- no association between command
hallucinations and violence
– But may add to risk with congruent delusions
• Threat / control over-ride symptoms
– MacArthur study found no association (Appelbaum 2000)
– Various studies show this is a critical factor
Delusional content and violence
• Delusional jealousy
• Erotomania
• Delusional misidentification
• Delusions of passivity
• Querulous delusions
OFFENDING IN AFFECTIVE
DISORDERS
Mood disorders & violence
• MacArthur Study (Monahan et al 2001)
– Rate of violence 1 year post-discharge
• Depression 28.5%
• BPD 22%
• SZ 14.8%
• Manic patients more likely to show violence on
admission
– AESOP study (Dean et al 2007)
– 3 x more likely to be aggressive than SZ
Mood disorder & homicide
• National Confidential Inquiry (Hunt et al (2010) Shaw et al (2006))
– 7% homicide offenders have lifetime mood disorder
• Less likely to have had contact with MH services
• Homicide-Suicide
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–
–
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Rare – 30 / year
Offenders usually male
Men kill partners, women kill children
Mood disorder and PD
Flynn et al (2009)
Mood disorders & sex offending
• No clear evidence / studies
• Mania
– Sexual disinhibition
– Increased libido
• Depression
– Weaken internal controls
OFFENDING IN PERSONALITY
DISORDERS
Personality Disorder
• No gold standard test for diagnosing PD
– NICE (QS88) – structured clinical assessment
• Prevalence of any PD ranges from 4 – 6%
– 54% have one PD only
• All PDs (except schizotypal) more common in
men
Antisocial PD & Offending
• 40 – 70% conduct disorders convert into ASPD
• Substance Use
– Most common comorbidity
– Men 3-5 times more likely to have substance use
– Increases risk of violence
ASPD & Offending
• Come into contact with CJS commonly
• 50 – 60% male prisoners have ASPD
– More criminal versatility
– 10 – 20 times more likely to commit homicide
– Violent offences more likely
(Roberts & Coid 2010)
• Brain changes - ? Genetic component
ASPD & Offending
• Very little evidence-based effective treatment
• NICE
– Cognitive / behavioural interventions
– Medication not used routinely
– Treat alcohol and substance use
Psychopathy
• PCL-R – 20 items (Hare 1991)
• ≥ 30 (USA) or ≥ 25 (UK)  psychopathy
Glibness & superficial charm
Promiscuous sexual behaviour
Grandiose sense of self-worth
Early behavioural problems
Need for stimulation / prone to boredom
Lack of realistic long-term goals
Pathological lying
Impulsivity
Conning and manipulative
Irresponsibility
Lack of remorse or guilt
Failure to accept responsibility for actions
Shallow affect
Many short-term relationships
Callous / lack of empathy
Juvenile delinquency
Parasitic lifestyle
Revocation of conditional release
Poor behavioural controls
Criminal versatility
Psychopathy & offending
• Loss of inhibition to antisocial behaviour
• May be a desire to control, demean and
humiliate
• Impulsive and risky behaviour
• Argued that many may function well in
corporate life
Other PDs and offending
• Borderline PD
– Female violent prisoners 4 x more likely to have
borderline PD (Logan & Blackburn 2009)
– MacArthur study data (Newhill et al 2009)
• Borderline PD more likely to commit violent acts
• Paranoid PD
– Linked to morbid jealousy
– Increased risk of violence (Carroll 2009)
OFFENDING IN SUBSTANCE MISUSE
Association with violence
1. Intoxication directly increases risk of violence
2. Exacerbation of mental illness
3. Other characteristics
4. Socio-economic
Offending & Substance misuse
• Remember Fazel et al (2009) looking at
psychosis and violence
– Substance use is biggest contributory factor
• Steadman et al (1998) looked at MacArthur
study for violence and SMI
– Substance use increased rate of violence in all
groups
OFFENDING IN EPILEPSY &
NEURODEVELOPMENTAL DISORDERS
Learning-disabled offenders
• 0.8% all adult LD have contact with CJS
• Characteristics include:
– Young men
– Borderline / mild LD (as opposed to severe) [62%]
– Psychosocial deprivation
– Co-morbid psychiatric disorders [44%]
– Family h/o offending
Learning-disabled offenders
• Range of behaviours
– Physical aggression (52%)
– Verbal aggression (40%)
– Damage to property (24%)
– Inappropriate sexual behaviour (18%)
– Cruelty and neglect to children (11%)
– Fire-setting (1%)
Challenging behaviour
Behaviour can be described as challenging when it is of such an intensity,
frequency or duration as to threaten the quality of life and / or the physical
safety of the individual or others and is likely to lead to responses that are
restrictive, aversive or result in exclusion.
• Challenging behaviour in LD populations
– 10 – 60%
– 9.8% point prevalence for aggression
– 4.9% point prevalence for self-injurious behaviour
Tsiouris (2010)
Management of challenging behaviour
• CBT / behavioural modification
• Environmental modification
• Specialist placements
• Medication
– Antipsychotics ONLY for underlying mental disorder
– ? Risperidone for autism
– SSRIs
Offending & LD
• Borderline LD over-represented in LD
populations
– Lack of abstract thinking
– Reduced capacity to delay gratification
– Reduced capacity to modify behaviour
– Socio-economic stressors
– ? More likely to get caught
– Skills deficits
– Social naivety / vulnerability
ASD & Offending
• Offences that may suggest ASD
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–
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Stalking / obsessive harassment
Inexplicable violence
Computer crime
Offences due to misjudged social relationships
• Management
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Setting
Psychological
Pharmacological
Environmental
Epilepsy & offending
• Rarely associated with violence but may be raised in
defences (Part 4)
• Prevalence: gen pop < prisoners < forensic pts
• Co-morbid psychiatric conditions 20 – 30%
• 5 possible causes of violence in epilepsy
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–
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Violent automatism
Prodromal irritability
Post-ictal confusion
Lower socioeconomic status
Brain damage
Epileptic offending / post-ictal
• Criteria to suspect criminal act due to epilepsy
– Evidence of epilepsy
– Crime sudden with no obvious motive / no
planning
– Crime senseless & no attempt at concealment /
escape
– Short duration
– Witness descriptions
– Amnesia
Lishman (1998)
Parasomnias & violence
• Rarely associated with violence
• Disorders of arousal from sleep:
1.
2.
3.
4.
Sleep drunkenness
Violence associated with sleepwalking
Violence associated with night terrors
REM sleep behaviour disorder
Parasomnias & violence
• History is vital – patient & bed partner
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Onset
Action
Victim
Level of consciousness
After the action
(Bournemann et al 2006)
• Physiological measures of sleep and muscular
activity – Sleep lab
Acquired Brain Injury
• Link between ABI and offending
• Increased prevalence ABI in prisoners / forensic
patients
• ABI predisposition to violence
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PFC lesions  disinhibition
Temporal lobe lesions  aggression
Substance use
Self-directed violence
ABI & offending
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•
•
•
•
•
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Cognitive impairment
Impulse control deficit
Personality change / irritability / aggression
Poor social judgement
Vulnerability
Comorbidity
Disinhibition
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