Cambridge MRCPsych Course Dr Samantha Dove MENTAL ILLNESS AND OFFENDING Schizophrenia There have been a large number of studies looking into the connection between schizophrenia and offending, in particular violence.
There has previously been a consensus that schizophrenia does not lead to an overall increased risk of criminal behaviour but that there is an increased risk of violent offending compared with other mental illnesses and that this is less evident when no co morbid substance misuse. The Northwick Park Study of first episode of schizophrenia reported that >1/3 of first episode patients had behaved violently in the month before admission. More recent studies over the past ten years have come to other conclusions. This body of evidence has been well summarised in Mullen‟s paper in APT: Schizophrenia and Violence; from correlations to preventative strategies 2006. Mullen cites a number of studies, which have demonstrated that correlation between schizophrenia and increased rates of antisocial behaviour in general, and violence in particular (Hodgins et al 1996). Taylor examined consecutive sample of remands to Brixton Prison. Nearly 9% had some form of psychosis and nearly all had active symptoms. Of those charged with homicide there was a diagnosis of Schizophrenia in 8%. Prisons throughout the western world show rates of 5-10% in those awaiting trial for murder will have a schizophrenic illness. National Confidential Inquiry found 5% of those convicted of homicide had symptoms of psychosis. Most likely victim is a family member. Taylor and Gunn‟s study in 1984 has the most robust methodology in studying those who are convicted of violence. They found that 11% of those convicted of homicide and 9% of those found guilty of non-fatal violence would meet the criteria for a diagnosis of schizophrenia. Much research into whether particular symptoms are associated with violence. Some support of threat/control override symptoms as being associated with violence. Evidence weak when control for substance misuse. Crime usually associated with either the active psychotic symptoms or the deterioration in personality associated with the illness. Minor offences more common than serious offences but people with schizophrenia overrepresented among violent offenders and a violent in patients Individual phenomenology, situational factors and features of the victim may all contribute to the violence Vulnerabilities that may predispose to violence in schizophrenia: 1
Cambridge MRCPsych Course Dr Samantha Dove (From Mullen APT 2006) Pre-dating onset of illness: Developmental difficulties Dissocial traits Educational failure Increased rates of conduct disorder Non socialised delinquency Early onset substance misuse Vulnerabilities acquired as a result of active illness: Active symptoms Personality deterioration Social dislocation Substance misuse Unemployment Vulnerabilities imposed: Drug side effects; notably akathesia Increased isolation Erosion of social skills Incarceration Delusional (Paranoid) Disorders Includes Erotomania and Pathological Jealousy Delusional syndromes Do not often seek psychiatric help and only come to the attention of services when offending leads to a court referral for assessment. Can arise primarily as a disorder or as a symptom within another disorder such as schizophrenia.
Morbid Jealousy: focus on being a victim of infidelity which dominates thinking and action to a pathological degree. Victims are usually partners or perceived rivals. May induce severe psychological distress as well as actual violence. Erotomania: characterised by a morbid belief in being loved. Mullen proposes three criteria: 1. The conviction of being loved despite the supposed lover having done nothing to encourage it. 2. A propensity to reinterpret the words and actions of their attention to maintain the belief. 3. Preoccupation with the supposed love, which comes to form a central part of the subject‟s existence. Can occur as part of another disorder, usually schizophrenia or an affective disorder.
Cambridge MRCPsych Course Dr Samantha Dove Victims usually drawn from own relationships but media attention when prominent public figure. Health professional also susceptible to being victims. Mullen identifies stalking as an inevitable accompaniment to erotomania. Involves determined attempts to make contact with the victim. Violence often arises in the face of rejection. Mood Disorders (Affective Psychoses) The relationship between mood disorders and crime is not so well studied. Less common than schizophrenic or delusional disorders in prison population. Relation to offending:
Depression: 1. Homicide: Severe depression can lead to hopelessness and view death is the only solution. Cases of „altruistic homicide‟ are rare but well recognised phenomenon. Depressed person, usually parent, kills one or more family members, usually a including a child and then commits or attempts murder. Given high rate of depression and rarity of such homicides it appears impossible to predict such cases. Rate of suicide after homicide has varied in different studies. A high proportion of such suicides were associated with a mental disorder. Depression was the most common. 2. Infanticide: Killing may arise directly from delusions or hallucinations or from irritability associated with affective disturbance. 3. Theft: a. Regressive comforting act b. Draw attention to plight c. Absent minded in distracted state 4. Arson: Attempt to destroy due to feelings of hopelessness and despair or to relieve tension and dysphoria 5. Alcoholism: disinhibition of alcohol and depression may lead to offending, including sexual offending. 6. PD: May be less able to cope with feeling depressed. Discomfort may lead to outbursts of violence or destructive behaviour. Relief of tension. 7. Adolescents: May mask depression. May be histrionic behaviour or conduct disorder. Usually normal behaviour and personality in past if associated with depression. Manic States: Offending may be associated with hallucinations and/or grandiose delusions. Grandiosity of mood and disinhibition in mania and hypomania may lead to public disorder and driving offences or fraud from failure to pay for restaurant or hotel bills. Combination of poor judgement and substance misuse in mania may also contribute to antisocial behaviour. Personality Disorder PD high in offender populations, offending is component in diagnosing antisocial PD. Rarely pure antisocial PD often overlap with other categories of PD together with other psychiatric symptoms and mental illness.
Cambridge MRCPsych Course Dr Samantha Dove Contrast between clinical diagnosis of PD and legal category of psychopathic disorder. This legal definition refers to a disorder that results in abnormally aggression or seriously irresponsible behaviour. Limited number of transfers to hospital under category of psychopathic disorder, in part due to the difficulties in measuring changes in PD patients.
Follow-up has shown that psychopathic patients discharged from secure hospitals reoffend at twice the rate of those with a diagnosis of mental illness. Dangerous and Severe Personality Disorder (DSPD) units now opened in medium security and high security. Previously only run within prison system. Strict admission criteria, which vary between units. Generally need to meet criteria for two PD and need to be willing to engage in treatment. Identified in prison as suitable then transfer for trial of treatment with potential to return to prison if fails. Neuroses Symptoms are common in offenders but rarely a causal relationship. In a study of shoplifters some 10% found to be neurotic. Common in male and female prison population. Far higher than community control. Co-morbidity with substance misuse and PD is common. Most common disorders seen in offenders are anxiety states and neurotic depressions. Difficult to tease out contribution to offending due to co-morbidity. Homicide: reactive neurotic state has been associated with homicidal outburst with no evidence of underlying PD. In combination with PD may serve to disinhibit and allow outburst. Theft: May be associated with neurotic depressive states, comfort or to draw attention. Arson: well recognised association in particular with states of tension. Setting fire may relieve tension, depressive feelings or symbolically destroy the source of pain. Co-morbidity with substance misuse and PD important. Alcohol: Disinhibiting PTSD: Trauma in childhood, physical and sexual abuse strongly linked to the abused person becoming a perpetrator or victimiser in adult life. If repetitive may impair normal personality development. Linked with repetitive maladaptive or violent behaviours which re-enact elements of the trauma. Imprisonment may produce or exacerbate neurotic symptoms in the offender. Learning Disability A reduction over the past forty years in hospital disposals of those categorised under learning disability.
Cambridge MRCPsych Course Dr Samantha Dove Offending in those with learning disability is subject to all the influences, which usually affect offending: disruptive childhoods, poor parenting, substance misuse, socioeconomic disadvantage and educational underachievement. Predominantly property offences. Some evidence of increased arrest rates. Serious violence less common. Sexual offences and arson are over represented in hospital-based cohorts. Ganser Syndrome Classified as a dissociative disorder in ICD-10 (F44.8) Ganser described three prisoners who became mentally disturbed with: 1. Inability to answer simple question. E.g. Q. “How many legs does a horse have?” A. “Three” 2. A clouding of consciousness 3. Hysterical conversion symptoms 4. Hallucinations 5. Temporary abrupt end to disturbance, loss of all symptoms, return of clarity. Followed by deep depression and recurrence of symptoms.
Believed to be hysterical disorder. Debated ever since. Most commonly accepted English view is a hysterical reaction resulting from state of depression. Substance Misuse Linked to crime in a variety of ways. Illegality of drugs and therefore possession and supply and acquisitive offending to fund drugs. Substantial body of evidence linking violence to substance misuse. May be through direct toxic effects, links with subculture of crime, associated psychiatric disorder, and brain damage resulting from substance misuse. Alcohol is the drug most clearly associated with violent crime. It is also an important situational factor in both perpetrators and victims of violent offences. For homicide it may be a more important factor in males than females. Risk of violence in the mentally ill is substantially increased when they have co morbid substance misuse.
Epilepsy Not regarded as a mental disorder. Can be intimately associated with a mental disorder. The mental disorder then forms the basis of the defence or mitigation and for any treatment under the MHA. No evidence of excessive criminality in outpatients with epilepsy.
Cambridge MRCPsych Course Dr Samantha Dove Gunn showed incidence of epilepsy in prisons to be higher than in the general population in a study in 1977. Not higher when compared with a group with similar socioeconomic advantage. No excess rate of violence in this group. Epilepsy may be a factor leading to anti-social behaviour in some cases but the association is not common and it is rare to offend at the time of a fit. Likely that any link is attributable to the socioeconomic and psychosocial correlates of epilepsy are similar to those for offending.
Association of Offending and Epilepsy by Gunn: 1. The offence may occur in a disturbed state induced directly by a fit (rare). 2. The offence and the fit may be coincidental. 3. The brain damage leading to the epilepsy may have led to personality problems resulting in antisocial behaviour. 4. The subject may have developed strong antisocial attitudes as a result of difficulties in his life due to illness. 5. Early deprivation may have engendered antisocial attitudes and epileptic features 6. Antisocial subjects may expose themselves to dangerous situations and sustain more head injuries than normal which may cause epilepsy. Amnesia Particularly related to intoxication with drugs or alcohol and the degree of violence involved. Victims of violent crime more likely to have memory loss for the even than victims of non violent crime. Perpetrators of homicide more likely to have amnesia for their offence. Frequency varied from 25-45%. Initial cause frequently organic, i.e. intoxication, amnesia maintained by psychogenic factors. Particularly when spouse or family member killed. Taylor described factors associated with amnesia for offending: 1. Violence of the crime, particularly homicide; 2. Extreme emotional arousal during the offence 3. alcohol abuse and intoxication 4. depressed mood in the perpetrator Does not in itself make a defendant unfit to plead or prove the absence of mens rea for an offence. OFFENCES AND MENTAL ILLNESS Arson Among the leading causes of fires around the world. A grave crime for which life imprisonment can be considered. The „clear up rate is 16%, on of the lowest for any crime. Therefore studies on captive populations will miss approximately 90% of offenders. 6
Cambridge MRCPsych Course Dr Samantha Dove
A number of attempts to classify arsonists mostly based on assessment, or speculation of their motivation. The problems with research in this area include a lack of adequate controls and the fact that motivations are often multifactorial. Psychiatric disorder and organic disorders: Fires may be set by patients with schizophrenia in response to psychotic symptoms, by LD patients for excitement, by those who are intoxicated or alcoholic hallucinosis or delirium tremens. Some gain pleasure from watching fire and emergency response. Often attend scene and behave heroically, could lead to a diagnosis of pyromania (ICD-10) Fire setting can be financially motivated, in revenge, to cover a crime scene or in political protests. No classification sufficient to provide guidance on treatment and prognosis. Only a small number receive a psychiatric disposal in court. Estimates are that in 1030% of cases there may be a mental illness, most likely schizophrenia or an associated paranoid psychosis. Among population of patients detained in secure hospitals with a learning disability arson is a common index offence. Re-offending rates of between 5 and 30%. Sexual Offending Almost exclusively men among whom mental illness is not prevalent. No absolute links between any particular type of sexual offence and any particular type of sexual disorder as classified in ICD – 10. Rape Low conviction rate; 1-2%. Combination of underreporting a difficulty obtaining conviction. Sexual crime is not a mental disorder therefore no clinical classification of rapists. Studies of convicted and generally imprisoned rapists find predominantly young men with poor social backgrounds and education. Usually an over-representation from black ethnic minorities. Most have criminal records, often for violence and up to a third for sexual offences. Not greatly different from other prisoners. Some report fantasies and „try-out‟ but significance is unclear. Sadistic fantasy common in men, it is combination with other factors that leads certain men to put these into practice. Sexual Offending Against Children Large number of cases of incest 200-500 per year, usually father-daughter. Gross underreporting. Family factors in incest have been identified, a dysfunctional family with generational blurring. Wives often absent or incapacitated or have a passive role in the family. 7
Cambridge MRCPsych Course Dr Samantha Dove Up to 30% incest perpetrators have a preference for children, nearly half have offended outside the family. Other factors; alcohol abuse, antisocial PD, victim of child sexual abuse.
Other offences against children: Adolescent boys who demonstrate such behaviour it tends to be associated with poor social skills, unattractiveness and peer group isolation. (See research from Eileen Vizzard – Young Offenders Project. Adult offenders are more likely to demonstrate features of paedophilia. Target vulnerable children, grooming behaviour, and gradually increasing intimacy. Emotional bribery is employed to maintain secrecy. Indecent exposure Only a minority of offences are reported and an even smaller number result in conviction. Traditionally divided into „exhibitionists‟ and those who expose in the context of drunkenness or disinhibiting psychiatric disorder such as schizophrenia, hypomania, organic brain disorder or a learning disability. Exhibitionists, typically men, expose their genitals to women in a public place but quiet location, e.g. public transport, car, home. Associated with sexual excitement and often masturbate afterwards, often to the image of exposure. Few attempt to speak to or touch their victims. Greater risk associated with arousal at time or approaching victims Small proportion progress to more serious crimes. Subsequent more serious offending associated with childhood conduct disorder, other criminal offences and pursuing or touching the victim. Assessment of sexual offenders: Information from various sources. Establish presence or absence of a mental disorder. Detailed psychosexual history. Consideration of situational factors such as substance misuse (assailant and victim). Psychotic illness in sexual offenders is unusual though occasionally disinhibition due to mania or schizophrenia may be a factor, rarely a response to delusions or hallucinations. Abnormalities and disorders of personality and associated alcohol misuse are common. Few sex offenders seen other than when face criminal charges or when considered for release from prison. Treatment considerations balanced with CJS. Those with underlying Mental Illness usually require treatment. Frequently difficult to engage and minimise offending. Re-offending and community treatment: Mandatory supervision for sex offenders.
Cambridge MRCPsych Course Dr Samantha Dove
Sex Offenders Act 1997 requires sex offenders discharged from prison or hospital to notify themselves to the police within 14 days. Must give name, date of birth and home address. Re-offending rates of fewer than 20% compared with over 80% for other offenders. High correlations for re-offending; childhood conduct disorder, parental instability, previous sexual offending, early first conviction, diagnosis of PD (Grubin and Wingate). Variables predicative only for groups not individuals. Factors to address in treatment are anger, self-esteem, social skills and victim empathy. Treatment in the community in sex offender treatment programmes run within probation. Expanding within secure services for both in and outpatients. Also run within the prison system. SOTP (Sex Offender Treatment Programme) is a structured CBT based programme. Addresses cognitive distortions, self-esteem, assertiveness, sexuality, the role of fantasy, victim empathy and relapse prevention techniques. Anti androgen treatment used in some cases, lowers libido. Does not tackle the other contributions to offending. Chemical castration has also been used in some centres, in particular in Canada. In this instance used in conjunction with other psychological interventions. Graded approach to treatment according to perceived risk and engagement. Homicide Homicide rate steadily increasing in the UK. Number attributed to those with mental illness not increasing. A psychiatrist examines all defendants charged with murder for the purposes of a report. Victims usually known to their killers. Arguments/ loss of temper account for 50% of killings. „Abnormal‟ murder comprises convictions for; manslaughter on the grounds of diminished responsibility, infanticide, in context of a failed suicide pact and insanity. This accounts for less than 1 in 5 killings. Association with homicide and some psychiatric disorders; schizophrenia, PD, alcohol. Stronger association in women who commit homicide. Homicide-suicide mostly men who have killed wife and/or children. Most commonly associated with relationships ending, depression, and jealousy. In nearly a third of cases alcohol abuse contributed. Within abnormal killings usually a family or domestic killing. Associations with interpersonal difficulties, jealousy, substance misuse, chronic ill health and mental illness. Even when mental illness contributes still usually a large contextual component and relationship between the victim and killer. Infants < 1 year who are victims of homicide, 60% killed by their mother. Often associated with chronic ill treatment and neglect.
Cambridge MRCPsych Course Dr Samantha Dove
Patricide more common than Matricide, although both rare. An association between matricide and schizophrenia. May relate to opportunity as well as psychopathology as many young men with schizophrenia live with or are dependant on their Mother/parents. Can be associated with strained relationships and lead to mothers; becoming the target of aggression. Stranger homicides are less often associated with mental illness in the accused. Rarely identify victim on the basis of psychotic symptoms. However stranger murders, sadistic and sexual murder always attracts media coverage/publicity. This can be further exacerbated if there is a perceived association with mental illness. (Anthony Joseph/ John Barrett – recent cases in the news).