Introduction to Forensic Psychiatry World Psychiatric Association Scientific Section Forensic...

Introduction to

Forensic Psychiatry

World Psychiatric Association Scientific Section Forensic Psychiatry

Secretary: Prof. Birgit A. Völlm

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Overview • 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

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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)

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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

Trial

Crime Police investigates

Prosecution

Court

•Fitness to be interviewed

•Fitness to stand trial•Fitness to plead•Criminal responsibility

Acquittal

•Discharge•Fine•Community order•Prison sentence•Hospital admission

Conviction + sentencing

Appeal

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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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• 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

Risk factors for criminal behaviour

Criminogenic needs

• Empirically-identified, dynamic risk factors• Eight central risk-need factors identified

- Antisocial behaviour, - Antisocial personality, - Antisocial cognitions, - Antisocial associates- Family or relationship problems- School or work- Leisure- Substance abuse

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‘The Big Four’

How about mental disorders?

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• 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

Study designs

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• 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 Remand prisoners

Gender 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

• 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) • Every first episode of schizophrenia 1964 – 1984• Matched control group• Time at risk• Control for gender and age• Based on criminal records• Overall conviction rates did not differ• Convictions for violence x 3 in patients• 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)• Sample 10 000 • Self-report• Risk factors for violence: young age, male sex, low socioeconomic

status and psychiatric disorder• Prevalence of violence

– Base rate 2%– In those with mental illness (Axis I) 12%– Mental illness + substance abuse 35%

• Antisocial PD, substance misuse, mania, psychosis all linked to crime

Dunedin study (New Zealand birth cohort; Arsenault et al, 2000)• Risk for conviction was 2.7 for mentally disordered individuals• 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) • Five year self-reported prevalence of violence with

victim harm• 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- Childhood factors: upbringing, neglect, abuse- Antisocial traits- Poor social skills- Poor education

• Factors arising as a direct result of symptoms- Particular symptoms

• Factors arising as a long-term consequence of illness- 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%


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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Clinical considerations• Chronicity • Symptoms• Victims• Environmental factors• Other factors

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Chronicity

Two types of offenders with schizophrenia• Acutely psychotic: delusions and command

hallucinations• Chronic defect state: personality deterioration,

homelessness, poverty

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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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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

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 co-

morbidity (OR 1.3)

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Bipolar Disorder & Offending

• Offending is typically associated with – 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

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Alcohol

36

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Singleton et al 1997

Remand

Sentenced

Drugs

51

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Drugs

54

41

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• 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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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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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

Organic Disorders & Offending

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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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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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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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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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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) 8.6%</=70,

42% 70 -79– Lyall et al (1995) 4.4% Mild LD

0.4% severe LD

• Courts (Australia)– Hayes 1993 14.2% </=70

8.8% 70 -79– Hayes 1996 36.0% </=70

20.9% 70-79

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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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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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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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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

Specific Crimes & Mental Disorder

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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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Motives and reasons for arson• Insurance fraud• Political• Desire to be seen as a hero• Psychosis• Pyromania• Antisocial attitudes


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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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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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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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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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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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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• 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’

• Insanity• Diminished responsibility• Automatism• Infanticide

• Sentencing issues– ‘Dangerousness’– Mitigation– Medical disposals

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

- 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

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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 guilt61

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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 discharge

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

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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)?

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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

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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

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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

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Writing of court reports VI

Background history • Family history• Personal history• Medical history

Psychiatric history• including substance misuse

Offending history• Previous offending• Index offence

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Writing of court reports VII

Progress in prison

Interview and mental state

Other investigations

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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

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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

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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• Risk cannot be eliminated

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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

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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• Referral from other treatment facilities

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

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Treatment facilities for MDOs

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Principles of treatment - basics

• Respect for dignity, integrity, privacy and autonomy

• Recovery focus• Least restrictive principle• Individualised care• Collaborative approach

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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

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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

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Principles of treatment, ctd.

• Pharmacological and psychological interventions• All activity to support process of change• Role modeling• Risk – need – responsivity• Group and 1:1

• Assessment • Stabilisation• Preparation for Change

- Motivational work- Psychoeducation

• Addressing personality and

interpersonal issues- Specific personality work- Interpersonal skills- Problem solving, thinking skills

• Addressing offending / criminogenic factors• Relapse prevention• Rehabilitation

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Stages of treatment

In parallel:Ward interactionFamily workActivitiesWork Self esteemQuality of life

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

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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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