Crime and mental disorder II. Forensic aspects of psychiatric disorder

Crime and mental disorder II. Forensic aspects of psychiatric disorder

James Higgins

Schizophrenia Aff ective disorder Antisocial personality disorder Neurotic disorders Learning disability Organic states Substance misuse Special syndromes  Minority groups


The relationship between psychiatric disorder and criminal behaviour is  far from straightforward. Few psychiatric patients are offenders, and few offenders have a psychiatric disorder (Gunn, 1977a). The relationship may be examined in two ways. Firstly, we can look at offences and offenders, and ask what psychiatric pathology can be observed in association with particular types of offences and with particular offender groups. Secondly, we can ask what features of an individual suffering from a psychiatric disorder might bring that individual i nto contact with the criminal justice system, and how likely this is to occur. The first question has been discussed in Chapter 2, where the limitations of the approach have rightly been emphasised.

The second perspective is the subject of this chapter. The issues are complex. What do we mean by  “an individual with  a psychiatric  disorder”? Is it a person who considers he has a psychiatric problem and desires  or insists u pon treatment, or a person treated by a general  practitioner  for minor psychological symptoms,  or  someone  treated  by  a  psychiatrist  as an out-patient or in-patient? When do below-average intellectual abilities, minor adverse personality characteristics, minor neurotic conflicts,  or harmful drinking or drug-taking patterns reach the level of a psychiatric disorder? I n a psychiatric clinic out-patient sample, Guze et al (1974) found that only 4% of attenders had a record of a relatively serious offence,  and  that personality disorder and alcoholism were by far the most common diagnostic categories. Serious f u nctional  psychoses  were  completely absent. Perhaps this is explained by early diversion  from  the  criminal  justice system of offenders who are seriously mentally ill. Such individuals are not recorded in criminal statistics, and a significant relationship may thereby   be  concealed.

The purpose of stressing the difficulties in examining the relationshi p between mental abnormality  and  offending  is to emphasise the complexity of the issues. It is important to avoid superficial and over-simplistic premises: for example, that  all offenders must  have  psychological  problems  or even a  psychiatric   disorder;  that  people  who  commit  rare,  serious  or   bizarre offences must be psychiatrically disordered; that those with psychiatric disorder are prone to committing offences; or that those with particular psychiatric syndromes are likely to act in a particular antisocial way. It is preferable to see each mentally disordered offender as a rare individual from a u nique social and cultu ral network, with particular advantages or disadvantages, who has acted in a particular way against people or property, at a particular time, in particular circumstances. He has been detected by the police, subsequently charged, and referred for a psychiatric assessment during which it has been discovered that there is sufficient psychopathology to constitute a diagnostic entity. The examining psychiatrist might then be able to attempt an explanation of what has taken place. But  the  ‘softer’ and the more minor the form of psychiatric disorder, the less likely is the emphasis  to  be  on  psychopathology  than  on social  and  psychological f actors which contribute to the generality of of fending. Even severe psychopathology, for which treatment in hospital may be advised, will rarely provide  a complete explanation  for the off ending  behaviour.

With these cautionary observations the  reader  should  consider  the  followi ng account of offending behaviour i n different psychiatric disorders. Whether or not the psychiatric disorder leads the police  or court  to  deal  with the offender in a special way is an entirely separate issue which is discussed  in  Chapters  4  and 5.

 

 

Schizophrenia

Research provides limited answers to some important questions. Does having schizophrenia lead to a greater risk of offending? What sort of offending might this be, and at what stage of the illness might it occur? What clinical features are important, and what steps can be taken to prevent, or at least diminish, the risk of similar behaviour i n the future? Most research studies deal pri ncipally with cohorts of people with schizophrenia selected in specific ways. They of ten omit details which enable comparisons to be made over time and in different countries. They concentrate on the most serious offences and the most easily studied populations, namely those on remand or serving a sentence in prison, or those detained in a secure psychiatric hospital. The relationship found between schizophrenia and offending depends on the nature of the sample under study.

Relationship  to offending behaviour

People with schizophrenia show a similar rate of  offending  in  general  as the rest of the population (Lindqvist & Allebeck, 1990). Although they are more  likely to commit  a crime  of  violence,  this will  usually  be  minor  in degree. They are more likely than other offenders to be detected and arrested (Robertson, 1988). When samples of discharged patients with schizophrenia are examined, we find rates of violent offending that are significantly higher than in the general population (e.g. Zitrin et al, 1976). This may be beca use more people wi th schizophrenia  are  i n  the commu nity, and therefore “available” for offending, than previously. For first admissions with schizophrenia, violence preceding admission is common (Humphreys et al, 1992). Similarly, among psychiatric in-patients, the highest frequency of violent incidents is found in those patients with schizophrenia  (Noble & Rodger, 1989).

In prison remand populations, a person with schizophrenia is six times more likely than other prisoners  to be facing  a charge for violence  (Taylor & Gunn, 1984). Among convicted prisoners serving sentences, Gunn et al (1991)  reported  that  1.5% suffered  from   schizophrenia.

The risk of violence by people with schizophrenia must be acknow­  ledged, but put i nto proper perspective. Schizophrenia (27 cases) was the largest single category of psychiatric disorder in 100 homicides by mentally disordered people identified in a recent report (Confidential Inquiry into Homicides & Suicides by Mentally Ill People, 1994), compared with a total  of approximately 1000 homicides in England and Wales during the same period. In a commu nity survey i n the US, Swanson et al (1990) found that any psychiatric diagnosis was  associated  with  assaultive  behaviour,  but that rates were higher in those with alcohol  and  drug  problems  than  in those   with  schizophrenia.

 

Patterns  of  clinical presentations

Patients with schizophrenia who offend fall into two broad categories, with some overlap. The first category consists of acutely ill patients with positive symptoms who act in response to delusional ideas, to redress a perceived wrong or to deal with a perceived threat. The link between the abnormal mental experiences and the offence is usually quite obvious. Patients with paranoid schizophrenia, in particular, may commit occasional but  of ten well planned  and serious violence.

In the second category of patients, some positive features of the illness are present but they tend to be less prominent. The significant features in this group are negative symptoms – the ravages of a more chronic and disabling illness. The offence is committed inadvertently or neglectf ully, when confronted or thwarted, when no other alternative seems available, or even qu ite deliberately to achieve ends such as survival in the community, admission to hospital or prison, or prevention of discharge from hospital. In contrast, and much less frequently, a chronically illpatient may show a sudden and u nexpected eruption of violence due to reactivation of an old delusional idea, the sudden emergence of a new highly  arousing  one,  or some other  new  mental phenomenon.

Clinical  features of  forensic importance

Although there have been attempts to identify what specif ic features of schizophrenia might motivate offending behaviour, it is not possible to make any definitive statements. Certain constellations of symptoms are more worrying than others, but no particular abnormal mental experience is of special value in predicting future offending behaviour. Indeed, it is remarkable how rarely patients act aggressively in the face of beliefs and experiences which give concern to others. Equally, any delusional idea, hallucinatory experience or other abnormal mental phenomenon may provide the focus for behaviour which could result in an offence. Each patient must be assessed individually. The assessment is not just of mental state, but also the availability and features of a specific victim, and whether there are social and environmental factors which might increase or reduce the risk. These are now considered  i n  tum.

 

The  illness

  • Level of arousal or Abnormal mental experiences affect patients in different ways. A patient who is manifestly distressed by them, who is anxious, u ncertain, perplexed, threatened or frightened, is more likely to act in an u npredictable way, either spontaneously or when confronted. Conversely, an emotionally blu nted individual with deterioration of personality may be able to cope, with apparent equanimity, with ideas and experiences which would seem to warrant offensive or defensive action. There has been interest in determining at what stage of a schizo­ phrenic illness violent behaviour occurs. Early in the illness, when starting to experience u ncertainties about himself and others around him, about his place and purpose  in the world, and while still retaining  a relatively   u ndamaged capacity for normal affective responses, he may become irritable and u ncertain and act aggressively towards others. Usually the persistence of normal aspects of personality acts as a brake on aggressive behaviour, especially in those not habitually prone to using violence to resolve interpersonal difficulties.

Progression of the ill ness, with elaboration and  crystallisation  of abnormal ideas, together with increasi ng damage to other aspects of the personality, might provide more fertile ground for  acting  on  delusional ideas (Taylor, 1985). As the illness develops further, encapsulation and emotional blu nting supervene and may again reduce the risk. Haf ner & Boker (1982) provided some support for such a progression.  In their sample of schizophrenic homicides in West  Germany  between  1953 and  1964,  only 3% of offenders killed within one month of the start of  their  illness, 84% had been ill for more than one year, and 55% for over five years. The patients  were  usually  well  known  to  the  psychiatric  services.

As a general principle it is prudent to pay particular attention to the patient’s  degree of  arousal, to estimate how close he seems to be to   loss of control, and how close he thinks he is to loss of control. It is essential to consult those who know him well for any new attitudes or behaviours which  might indicate impending  loss of control.

  • Delusional ideas. Delusional ideas often motivate an act. Half of the cohort reported by Wessely et al (1993) had acted on their delusions, although violent acts were uncommon. Haf ner & Boker (1982) found that delusions were present in 89% of their sample of violent schizophrenic offenders, compared with 76% of the schizophrenic controls; delusions of infidelity and infatuation were particularly common. Delusions of being directly threatened are  obviously  important,  particularly  when  the threat is specifically ascribed to an individual. Delusions of poisoning have also been described in relation to violence (Mawson, 1985). In a study of first schizophrenic episodes (Humphreys et al, 1992), half of the cohort acted violently i n response to delusions (usually of poisoning) or Violence seems particularly likely when the patient’s response to these delusions (of ten bizarre) is ignored by the recipient. Delusional ideas with marked religious components, or those  concerned  with  the  occult or with an omnipotent or cataclysmic quality, have an ominous ring. Strong emotional investment in such ideas, of ten after a period of considerable deliberation, sometimes permits the overriding of taboos against violence towards close relatives or neighbours. The violence may be  carried  out i n the victim’s supposed best  interest, or in the expectation  that it will  produce no real harm and might resolve  issues of cosmic   significance.

 

The particular risk of violence f rom jealous men, in this context those with delusions of jealousy in the setting of a schizophrenic illness, have been described by Mowat (1966). Other delusional ideas arising in schizophrenia, de Cleram bault’s syndrome (erotomania, see later), and Capgras’ syndrome (delusion of doubles) are occasionally reported as resulting in violent behaviour.

 

  • Other phenomena. Command hallucinations or other overwhelming hallucinatory or passivity experiences are worryi ng developments. Patients reporting these, especially if concerned about their ability to resist them, must be treated very seriously. Sadly, such phenomena are likely to be revealed only after the event and may even be denied bef orehand. Their existence may be suspected by sudden changes in attitude and behaviou r associated with obvious autonomic  features  of    Self-destruction may be seen by the patient as the only solution; attempted suicide by fire resulting  in  a  charge  of arson.

 

Features  of  the victim

There has already been reference to the importance of a readily available victim. Assaultive crimes by people with schizophrenia are similar to most assaults. For the most part these assaults are against victims they already know: wives, children, relatives, friends or neighbours. Perhaps in the killing of parents they may be exceptional (Gillies, 1976). The assault  of strangers by people with schizophrenia is, in fact, a rare event. The most commonly assaulted stranger is the arresting police officer af ter a pu blic order offence. In assessing the likely risk to a victim, it is essential to explore the delusional ideas very caref ully (an assessment analogous to that of risk of suicide). The better a specific victim  can  be  identif ied,  the more specific the threats that have been made, and  the  clearer  that  future  action  has been contemplated or planned, then the more serious the risk to the victim. The  real  or  perceived  response  of  the  victim  to  early  approaches is also i mportant. The response may be considered by the patient  to  be provocative,  either because  it is aggressive  in self-defence  or through  fear, or because  it was evasive  and  ambivalent.

 

Situational factors

The concept of high expressed emotion explains the effects that certain attitudes and behaviours of relatives can have on the  patient’s  mental state. Increasing tension, anger and frustration may result in emotional outbursts and violence. In hospital or other residential settings, institutional factors are equally important (Powell et al, 1994). An overcrowded, over­ restrictive ward, impoverished in occupational and recreational resources, may prove too u nsettli ng and stimulating for an actively psychotic patient. Certain times of day and certain ward activities are well recognised as the most unsettli ng; getting up, washi ng, meals and medication times are the most widely reported occasions when aggressive behaviours occur. Those looking after highly aroused and acutely ill patients should be aware of these features, and not see intensive social  interactions  as a necessary goal in the early stages of treatment. It is u nfortu nate that disturbed behaviour is so readily ascribed to features in a patient, rather than the quite u nsuitable  setting i n which  he may be treated.

Substance misuse is a recognised feature of much offending behaviour, and many mentally ill people are intoxicated when they commit offences. The interaction between substance misuse and scliizophrenia is complex and the magnitude of the problem underestimated (Smith & Hucker, 1994). Alcohol or drug misuse may be a precipitating factor, related to the onset or relapse of the illness. In a sample of acutely psychotic patients admitted to hospital, more florid symptoms were found in those with cannabis­ positive uri ne analyses than in others (Mathers & Ghodse, 1992). Substances may have been taken i n increasi ng quantity as the most readily available and effective tranquilliser for disturbing abnormal mental experiences. They may be used to give “Dutch courage” to act upon delusional ideas.   A caref ul assessment is required to evaluate the part played by alcohol or drugs for diagnostic,  management  and  predictive purposes.

It is essential to review the  availability  or possession  of  lethal weapons by the patient and to consider why a particular  weapon  was chosen;  this may have been on impulse or as a considered decision.  Sometimes  the patient may have carried the weapon as a result of his  illness  or  as  a  feature  of  his  cultural  or subcultu ral mores.

 

Personality  and  treatment  considerations

Consideration of personality features is important i n u nderstanding the interplay of factors produci ng offendi ng behaviour. This is necessary i n planning effective treatment and af tercare. The interplay of personality features and schizophrenia is complex, and the following  issues  are  relevant.

 

Premorbid  delinquency

An individual who subsequently develops schizophrenia may have the premorbid characteristics and social and cultural background of a ‘normal’ delinquent. When the illness supervenes, there is usually a change in the observable behaviour and this may result in a different type of offending. Treatment of the schizophrenia, and restitution of a,s near normal f u nc­ tioning as possible, is u nlikely to affect the pre-existing pattern of offendi ng, especially if this is ingrained and receives cultural reinforcement. Care is therefore required in assessing the effects of the illness, what treatment is required, and where this  should  take  place.  In  general,  a  schizophrenic  off ender’s need f or assessment and treatment in hospital should be determined solely by his mental state at the time of the examination. Occasionally, contin uing treatment of a  well-stabilised,  optimally-treated and compliant schizophrenic offender is practicable in prison. Psychiatric treatment, however,  is  much  more  than  the  use  of  medication.  Prison  is a stressf ul environment for a psychologically robust individual, let  alone  one who  is  mentally  ill.  Regimens  in  prisons  do  not  tolerate behavioural quirks and usually the only measure is one of containment. The organisation of  prisons  can  lead  to a mentally  ill prisoner  becoming  ‘lost’ to care.

On the other hand, suff ering from schizophrenia which is well under control should not provide an automatic escape from the results of wilf ul  and deliberate offending i n  a patient  who shows good  social adjustment. To summarise, any person with schizophrenia in custody should be transferred to hospital for assessment and treatment, unless there is a cogent case  for  a  contrary  approach.

 

Premorbid  schizoid  features

In some youths or you ng adults, offending  may be unexpected  in the  light of the person’s social and subcultural background. It  may  appear to  arise from a gradual development of schizoid personality characteristics, usually starting in early adolescence, with  the suggestion  of  u nderlying  psychosis. A caref ul assessment of such individuals is necessary, preferably in hospital, and probably involvi ng a trial of treatment with  neuroleptic  medication. This is easier to implement if the individual is willing to accept such  a course. If the of fence is m i nor there may be  d if f icu lty  in  justifying compu lsory detention and treatment in hospital. It is, however,  very important to make the  best  assessment  and  to institute treatment  quickly  to prevent further deterioration. When  such  diagnostic  difficulties  persist  in more serious offenders, and admission to hospital is not considered appropriate, the sentence of the court is of ten a disproportionately lengthy period of imprisonment, if only because of the psychiatric u ncertainty and possible risk. Such individuals of ten emerge later in prison with a florid psychotic il l ness. The subseq uent management of such potentially dangerous and damaged individuals, i n prison, i n hospital and i n the community,  requires  much  caref ul   planning.

 

Schizophrenia  and personality  deterioration

Undue emphasis is sometimes given to adverse personality characteristics, when all the  evidence  indicates  that  these  have  arisen  solely  as  a  result of a chronic schizophrenic illness. Deleterious effects  on  personality  are well recognised features of schizophrenia and it  seems  u nnecessary  to apply an additional diagnosis of  personality  disorder.  Perhaps  the  reason for this preoccupation with features of personality lies in frustration at the inability to manage, with the facilities available, that group of petty  recidivist, chronically psychotic, socially disadvantaged and friendless individuals, almost invariably of no fixed abode, who have been succinctly described by Rollin  (1969) as “incorrigible  i n  penal  terms and  untreatable in medical terms”.  Changes in the philosophy  of  psychiatric  care have Jed to  the  closure  of  facilities  which  can  provide  long-term  care  for  such individuals.  Unfortunately,  the  necessary  alternative  community facilities are rare, or patients decline to use them. Surely it cannot be intended that prisons should once again become the princi pal providers of care for people with chronic schizophrenia, arrested by the police because of their manifestly dilapidated and deteriorating state, or because of minor offences committed  to survive in the  community.

 

Schizophrenia   in  sentenced prisoners

Finally, imprisonment does not predispose or protect an individual from developing a first episode of schizophrenia. The majority of such  illnesses are u nremarkable in nature. Substance  misuse  is, however,  now  endemic in prisons, and psychosis may be attributed to drug-taki ng. Sometimes the drug-taking history  is u nconvinci ng,  or it follows the onset of  psychosis,  or the psychosis persists af ter a drug-free period, or reappears when  there has been no f urther drug misuse. The management of such a sentenced prisoner with an acute psychosis should be a relatively straightforward  matter. He should be transferred  under  Section  47 of  the  Mental  Health Act 1983 to a hospital offering the degree of security required by his mental state and behaviou r and by the perceived risk to the commu nity (see  Chapter 7).  If the  sentence  is a  long  one,  imposed  for  a serious  offence, a secure unit is appropriate, but when the sentence is short and the offence petty, there is of ten an u nfortu nate reluctance by local psychiatric hospitals to  agree  to  a transfer.

The management of prisoners with schizophrenia who are serving long sentences, particularly life imprisonment, poses  particular  difficu lties. Ideally such a prisoner should be transferred  to  hospital  for treatment  of  his mental illness. If treatment is successf ul, he must be remitted to prison; indeed, the patient may bitterly object to  continued  detention  in  a psychiatric hospital and may act out accordingly. If the prisoner then stops taking medication on retu rn to prison, the cycle of transfer to hospital will  be repeated. For some mentally ill life-sentenced prisoners, release is often much delayed, not because of risk to the public, or for reasons of retribution and deterrence, but because of the emergence of a psychiatric  disorder  which did not exist at the time of the index offence. Such prisoners are subjected to a form of double jeopardy, and it requires flexibility by the Home  Office  and  psychiatric  hospitals  to  circumvent  it.

 

Affective  disorder

The clinical features of the two main syndromes of affective disorder, depression and hypomania, determine what types of offending  behaviour may be likely. However, research in this area is limited and its interpretation is bedevilled by u ncertainties in the criteria  used  to  classify  depression over time and in different countries, and because the samples of hypomanic patients  who  have  committed  antisocial  acts  are  very  small.

 

Depression

Assessment of the nature, severity and relevance of depressive symptoms in forensic settings presents particular difficulties. Depression af ter arrest might incorrectly be seen as reactive to circumstances. A criminal act and its af termath may have a cathartic effect or be seen by the perpetrator as justified pu nishment, both resulting in deceptive presentations of calmness and detachment. Increased alcohol consumption is occasionally a major feature of a depressive disorder, and this may be seen as a prominent component in the explanation of the offender’s behaviour. A careful history is therefore required, not only to detect depression but to delineate its exact nature, to ensure that the most appropriate treatment approach is taken, and that the anticipated outcome is realistic. Overreliance on the effects of antidepressant medication without proper regard for personality features and the effects of social circumstances can result in therapeutic over-optimism,  only to be followed  by frustration  and disappointment.

 

Relationship  to offending behaviour

  • One i n six people with manic-depressive disorder kill themselves. Violence to others is much rarer; only six in  100 000  people with the disorder were seriously violent to others (Haf ner & Boker, 1982). However, there has been very little published research on the subject of violence and mania. Violence by people with depressive disorders is usually directed towards close family members: husbands towards wives and children; mothers towards children. The classical picture is that of psychotic depression with delusional ideas of unworthiness, self-criticism, failure, poverty and physical illness. The resultant suicidal ideation is then extended  to include the killing of close f amily members in an extended suicide, the patient believing that if the family members  were  dead  they  would  not  have to endure the additional distress,  humiliation  and stigma  of  a suicide in the family. Only a proportion of such depressive killers come to court because   many  succeed   in  committing  suicide  (West,  1965).

Some authors have questioned this simple picture of altruistic suicide, emphasising the frequency of insoluble conflicts in a chronically u nhappy relationship, particularly with men who kill their partners. These may result in mou nting tension, anger, frustration and even jealousy, which then explodes into lethal violence, often precipitated by a final but unremarkable event (Parker, 1979). In such cases, although depression is a prominent feature and may even be severe, the clinical picture is of a non-psychotic depressive episode in a personality with features vulnerable to, and perhaps contributing  to, chronic  marital disharmony.

Predicting which depressed women will kill their children, and husbands their wives, cannot be based on any particular feature of mental state but is analogous to the assessment of a potentially suicidal patient. Every seriously  depressed  individual,  psychotic  or otherwise, should  be asked about homicidal intent, particularly if there are vulnerable potential victims. Sadly, many cases will present with the killing and subsequent failed suicide, but it has been observed that the most likely time for such an outburst of violence, in depressed patients already known to psychiatric services, is some months af ter discharge from hospital, when drive has returned but the illness remains incompletely resolved (Haf ner & Boker, 1982).

 

  • Shoplif ting has been regularly reported in association with depression. Gibbens et al (1971), for a large sample of female shoplif ters assessed on bail, described 5% who required psychiatric treatment, 24% suffering from depressive disorder and 2% with a manic-depressive illness. In another sample of women remanded in custody, 4% were subsequently admitted to hospital, a third of  those  with  a  manic-depressive  illness. These proportions are very small, and while the diagnostic status of the manic-depressive cases is clear, Gibbens et al (1971)  is less specific about the nature of the depressive disorders. A presentation with mixed clinical features is commonly found in the  psychologically  disturbed  female  shoplif ter  (Gudjonsson,   1990).  Typically  she  harbours  suppressed   and u nexpressed emotions about the changes in her life in her middle age, frustration at her lack of opportu nity, and the u nrewarding natu re of changing family relationshi ps. She may have experienced a series of disturbing life events, or physical illness. Hostility and anger are often as prominent as depression, and biological featu res  may  not  always  be present.  Simple treatment with  antidepressants  is thus rarely successf ul. A  f ull  account of  other aspects of  shoplif ting  is discussed  in Chapter   2.

 

  • Other forensic presentations. Depression may result in attempted suicide by f ire, and a charge of arson may follow. A minor sexual offence by a depressed man may be best u nderstood as the result  of sexual regression, but occasionally it is difficu lt to avoid the view that it has a symbolic self­ destructive  quality  (see  Chapter  2).

 

Hypomania  and mania

Hypomania presents in forensic practice more frequently than depression. Elated, overactive, grandiose, irritable, paranoid and sexually disinhibited individuals, perhaps misusing alcohol, act in ways which are embarrassing, disruptive, intolerable or threatening. If the behaviour is not seen as an obvious mani f estation of mental ill ness, it may resu lt i n crimi nal prosecution.

Some hypomanic patients, especially those with a low-grade grumbling illness associated with chronic alcohol misuse, present particular problems in diagnosis. The affective illness is sometimes missed on remand, mistaken emphasis being given to the drinking problem. The illness may also  pass  unreported during a short period of imprisonment, provided the level of importu nate behaviour is not sufficiently irritating to raise the suspicion of anything other than the ‘personality disorder’ which the individual is thought to possess. The best way of  avoiding such errors is not so much  a caref ul mental state examination, which may be inconclusive, but a careful review of previous medical records that usually exist in abundance. Clear-cut episodes of affective illness may then be seen (depressive as well as hypomanic). The correct diagnosis, however, of ten does not make management any  easier.  It is  difficult  to  break  the  cycle  of  brief  and u nrewarding hospital admissions followed by default from af tercare, and a return  to alcohol  misuse  and subsequent  offending.

 

Relationship  to offending  behaviour

  • Petty offending. Traditionally the pattern of  offending  in  hypomania has been described as  quite  minor:  drunkenness,  minor  violence  and threats of violence, deception and misrepresentation, inappropriate and importunate sexual behaviour. Many manic patients, although acting  i n  ways which could attract a charge, are so obviously behaving  out  of character and are so obviously mentally ill that they are diverted from the criminal justice system and taken directly to hospital. On the other hand,  those who are more chronically disabled by the illness, of ten with a history  of petty recidivism and alcoholism, and who have not responded to or cooperated with psychiatric treatment i n the past, tend to  appear  before courts because there does not seem any better way of dealing with their persistently disruptive behaviour. Hospitals are reluctant to admit them because of the difficulty of  containment  and  compliance  experienced  in  the past. The lengthy remand period in prison, perhaps amounting to the length of sentence which can be i m posed, is of ten taken u p with negotiations  over  finding  a  place  i n

 

  • Serious offending. The work of Wulach (1983) provides a contrast. He described 100 manic offenders in custody, 13% of whom had committed serious offences, death by dangerous driving, arson and rape. This sample is clearly a much more selected one, but it serves-to indicate that manic people do commit more serious offences, as experience of worki ng in a regional secure u nit will readily

 

  • Female offenders. Women with bipolar illnesses consisting of short and rapid cycling episodes pose particular   Within  a  brief  period they can present  to psychiatrists  with  depression  and self-injury,  resulting in a short and u nsatisfactory admission to hospital, or they present to the police as irritable public nuisances, often intoxicated. Their volatility  of mood is frequently ascribed to an hysterical personality disorder, with or without  substance  misuse;  each  episode  is seen as a response  to  the socialor interpersonal problems with which they are of ten bu rdened. Again, a longitudinal perspective is often valuable. Periods of u nexpected stability may be seen on mental state examination, together with features hinting  at a primary affective disorder. Treatment is of ten rewarding if the illness is not too chronic or if adverse behavioural patterns are not too entrenched.

 

Schizoaffective illness

Reference to this diagnosis rarely appears in the forensic literature. D’Orban (1979), in his study of women who killed their children, does mention a few patients with such an illness, presumably schizodepressive in type. Occasionally a typical manic illness supervenes in an individual with a chronic paranoid illness or a markedly paranoid personality, the new affective features producing an additional dimension to previous aggressive behaviou r. The aff ective symptoms are likely to respond readily to treatment, but with little benefit to the u nderlying paranoid   personality.

 

Treatment  considerations

The treatment of forensic patients with affective disorders differs little from that in general psychiatric practice. However, two specifically forensic points are worthy of discussion. Firstly, no matter how typical the illness and the speed of its response to physical treatment, a depressed patient who has committed a seriously violent act or a homicide will require much psychotherapeutic assistance. This is needed  to allow the  patient  to come to terms with what is of ten a personal and family tragedy, particularly as there is retention of an intact personality structure. Secondly, as has been described, the depressive illnesses are of ten not typical, with personality features playing a prominent  part. Both considerations  make the appropriate placement of a depressed serious offender a dif ficult problem. Rapid response to treatment, which in a non-offending patient would indicate a prompt discharge  from  hospital,  might  not  meet  the needs of the patient and the family or the expectations of the public. A surprising proportion of offenders found to be of diminished responsibility, said to be due to depression, are  sent  to  prison  rather  than  to  hospital (Dell  & Smith, 1983).

Treatment of recurrent or chronic hypomania in an u nstable individual is difficult, whether the i nstability is independent or a result of the illness. Lithium is often u nsuitable as a prophylactic because of anticipated poor compliance. A depot neuroleptic might be preferable and is occasionally eff ective, but the characteristic long-term side-ef fects may be more prominent  in  hypomania  than  in schizophrenia.

 

 

Antisocial  personality  disorder

People with abnormalities and disorders of personality form a  large proportion of patients seen in forensic psychiatry. This section is concerned with t he relationshi p between personality disorder and of f ending behaviour, with particular emphasis on antisocial personality disorder. Conceptual understanding of personality  and  its  disorders  is  u nresolved and controversial. It is not possible to discuss  here  those  conceptual problems; there have  been  recent  reviews  by  Freeman  (1993)  and  Tyrer & Stein (1993) to which the reader is referred. There are two  particular pitfalls in forensic psychiatry in respect of personality disorder. First is the missing or making of such a diagnosis in the absence of a properly obtained history and appraisal of other information. Second is the tendency to be misled by stereotypes or caricatures, so that a diagnosis of personality disorder is made on the basis of little more than one criminal act simply because  the  latter  is particularly  grave  or horrif  ic.

 

Clinical  and legal concepts

Before discussing the relationship between personality disorder and offending, it is important to try to make sense of a conf using terminology. ‘Psychopathic disorder’ is a term that has come to be used in at least two quite separate ways. As a clinical term it is the rather outdated equivalent for what we would today call ‘antisocial personality disorder’. However, the term has also acquired a pejorative connotation, particularly when a patient is identified as “a psychopath” or as “psychopathic”. The impli­ cations are that the patient is u ntreatable, has no proper place in a hospital and is disliked by clinical staff. It is of ten employed in order to reject patients for treatment and for this purpose may be deliberately applied to patients with  other psychiatric  disorders such  as schizophrenia  or hypo-mania (Coid, 1988). For all these reasons it is best to avoid ‘psychopathic disorder’  as a  clinical term.

The term will not, however, disappear, because it is part of English law. Psychopathic disorder is one of the  four categories  of  mental  disorder  in the Mental Health Act 1983 for which compulsory admission may be appropriate (see Chapter 10). Forensic psychiatrists are  divided  in  their views as to whether or not psychopathic disorder should remain in mental health legislation (Cope, 1993). I n Scotland, although the words ‘psycho­ pathic disorder’ do not  appear  in  its legislation,  a phrase  almost  identical to  the  English  definition  does.  Legally,  psychopathic  disorder  is:

“a persistent disorder or disability of mind (whether or not including significant impairment of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned.” (Section  1(2), Mental Health Act  1983)

 

The Butler report (Home Office & Department of Health and Social Security, 1975) provides a usef ul historical account of the concept of ‘psychopathic disorder’. The ‘psychopath’  and  his  ancestor  in  legislation, the ‘moral imbecile’, represent one aspect of the way the law has tried to exercise control over unacceptable behaviour. In  its legal use  the term  has no specific clinical meaning.  It does not  mean  a  unitary  condition,  but  is  a generic term which might apply to any disorder (provided it is persistent) which results i n antisocial conduct. When using the legal term ‘psycho­ pathic disorder’, the psychiatrist should specify the nature of the clinical disorder   present.

In practice, it is preferable to avoid using the term except in its legal context. However, even that dictum would not end the conf usion because of  the equally inadequate  diagnostic  basis  of  the alternative, ‘antisocial personality disorder’. Dolan & Coid (1993) have reviewed the varied diagnostic approaches to antisocial personality disorder and their particular shortcomings in forensic practice. Offenders with personality  disorders rarely seem to f it neatly i nto a single type of personality disorder, be it antisocial, schizoid, paranoid or any other. Coid (1992) found  a  mean  of over three categories of personality disorder per patient in a sample  of  special hospital patients detained i n the legal category ‘psychopathic disorder’. Rather than stretching an ill-f itting category of  personality disorder, it is preferable to describe the particular manifestations of disordered   personality  seen  in  the  patient.

 

Personality  disorder  and offending

In the account that follows we will review the most prominent and broadest constellations of abnormal personality traits, and consider the types of offending behaviou r that commonly follow. These are identified for descrip­ tive purposes as  “immaturity”,  “inadequacy”,  “hostility  and  aggression” and “abnormal sexuality”. These are not used as scientific terms, bu t simply to  describe  the  behavioural   traits  most  commonly   encountered.

 

Immaturity

By the term ‘immature’ we refer to the persistence of attitudes and behaviour associated with you nger age, particularly egocentricity, emotional !ability, lack of foresight, impulsivity and the need for instant reward or gratif ication; all are features more characteristic of a child than an adult. Such charact­ eristics can bring individuals into conflict with various social agencies because of their self-serving, predatory or exploitative consequences. Resulting offences are usually minor bu t may be more serious: robbery; rape without particular sexual or aggressive psychopathology; arson for revenge or to disguise offending; and violence as an impulsive or ill­ considered solution to conflict. Alcohol is often a disinhibiting f actor. Adolescent or you ng adult males frequently show excitement-seeking and self-interested behaviour, but with age it usually declines. However, it may be found to persist, often well into middle-age, i n those who follow a habitually criminal lifestyle. A common sequence is for overt offending to cease in the early 20s, the consequences of immature traits then transferring from the macrosocial sphere of the community to the microsocial sphere of the family, with all the long-term consequences for partners and children.

 

Inadequacy

Some petty recidivist men and women show a striking i nability to organise their lives in an effective way. Their relationships are shallow and evan­ escent, exploitative or exploited. Their offending, mostly petty property offences,  repeatedly takes place  i n an attempt to survive, or at least  this is the explanation usually prof fered. Non-payment of f i nes or non­ compliance  with   probation   eventually  results  in   imprisonment.

Chronic substance misuse is common, principally alcohol and minor tranquillisers, the latter often prescribed for persistent feelings of depression and anxiety. Sexual and physical abuse of children may be found in the disorganised and disjointed family units such individuals form. In such vulnerable  women,  prostitution   is  another  way  of  coping.

 

Hostility  and aggression

Well integrated personalities. Some individuals with otherwise relatively well integrated personalities may use aggression  as  a  tool,  the  extent  of any violence dispensed being caref ully titrated to achieve desired ends. Professional criminals or “single issue fanatics”, such as terrorists or other ideologically motivated individuals, may demonstrate a wealth  of evidence  of adequate f u nctioning in almost all other aspects of their lives. Their inability  to empathise with  the targeted  individual  or innocent  stranger is   a  striking  flaw  in  an  otherwise  unremarkable  personality.

 

Habitually violent offenders. Habitually violent offenders are quite different, often with sensitive, paranoid and rather primitive personalities. They are anxious, ill-at-ease and quick to perceive a slight; they feel themselves constantly u nder threat, of ten to the extent of carrying a weapon for “self defence”.  Their  violence  is inappropriate,  disproportionate  and  ineffective i n achieving their aims, regularly generating  the  sequence  of  responses from  others which  they  claim  to  have  been  present  i n  the  first instance.

 

Paranoid personalities.  The severity and persistence  of paranoid  ideation i n some individuals can lead to the suspicion that there is a  psychotic element but, in the absence of other  features  of  psychosis,  the  paranoid ideas are better described as overvalued. The usual basis for this over­ sensitivity lies in low self-esteem, of ten despite marked protestations to the contrary. Low self-esteem is of ten understandable in the context of their damaging childhood and  early  adolescent  experiences.  Such  individuals  are habitually highly aroused, of ten misusi ng what tranquillisers are readily available, particularly alcohol. Their mood is very dependent on their perception of  their  immediate  social  circumstances,  which  they  attempt  to control by dominating those around them. In such a constellation of characteristics, possessive jealousy in their relationships is not u nexpected. Regular violence towards partners is common and occasionally fatal; mounting suspicion,  coupled with the disinhibiting  effects of  large amounts of  alcohol  or  drugs,  provides  a  lethal  combination.

 

Over-controlled personalities. For some violent offenders, it is said af ter the serious  assault  or  homicide  that  it  was  totally  out  of  character,  because they are the meekest and most non-violent of men. On investigation the history is of an inability to handle assertiveness and aggression i n an effective way. In a close or over-involved  relationship  that  they  cannot  give up for fear of f urther loss of self-esteem, they seek to accommodate  their partner at every turn, repressing the feelings of anger at  perceived slights, rejections, and manipulations. These over-controlled personalities struggle to contain hostile feelings, revealing them only obliquely as depression, anxiety or hypochondriacal preoccupations. One incident then breaches the dam. It may be very minor, no different from many that have gone  bef ore.  Alcohol,   drug  misuse,   tired ness,   physical   illness   or  an u nexpected life event outside the relationship may serve to act as the precipitant. The violence is often extreme, the memory of inflicting it of ten hazy or non-existent. The af termath is prof ound remorse, bland post­ cathartic serenity, or even denial of complicity. The problem having been resolved, the pre-existing style of personality f unctioning is likely to reassert itself , and therapy is thereby rendered difficult. A f urther outburst of such violence  is  u nlikely,  u nless  a similar  relationship  is formed.

 

Abnormal  sexuality

This topic is considered in more detail in Chapter 2. Some general points are given here. It is incorrect to assume that all sexual offences are primarily the result of sexual psychopathology. Aggression and desires to shock, frighten, exploit, degrade, hu rt and even kill are often intimately involved with sexual feelings. Aggression may play the major part i n offences which superficially appear to be sexual. For example, some male exhibitionists manifest a pattern of f rustration, disappointment and compulsion, exposing only at times of stress and often with  covert or overt aggressive    intent.

Many instances of the most serious sexual offences (i.e. rape and rape/ homicide) are principally offences of violence. The motivation, consciously or subconsciously, is of ten despoilation, revenge, destruction, or release of tension rather than sexual gratification. The psychopathology is usually that of unresolved aggressive feelings about significant female figures, of ten the mother, for whom the victim becomes a surrogate, or even a represent­ ation of all women. There is of ten a history of factors such as a cold and affectionless upbringing by u nloving parents, a violent father and an over­ involved mother, institutional rearing, sexual abuse, persistent uncertainties about sexual orientation, all in a setting of marked psychological distu rb­ ance and  low self-esteem.

 

Homosexuality

Only a small subgroup of homosexual men, like a similar subgroup of heterosexual men, have such difficulties  i n their relationships or in control  of  their sexual behaviou r that  they  act  i n  an  antisocial  way.  It is thus not homosexual activity which is illegal, but how, where and with whom it is performed. Accord ingly, as with heterosexual off ences, it is sexual behaviour which is coercive, pu blic, or with minors which is illegal; the psychopathology  associated  with  those features is important.

Treatment  considerations

The above description demonstrates the difficulties i n classifying person­ ality disorder into subtypes and in separating personality disorder from neurosis. Such nosological endeavours have their place but, when dealing with offenders who present with neurotic difficulties and show evidence  of personality abnormality, it is unusual for a distinct subtype of personality disorder to be identified. It is more common to find a series of characteristics or behaviou rs of varying severity which demonstrate the individuality of the offender rather than a manifestation of a particular type of personality. These individual characteristics and their origins and development  have to be assessed when considering treatment and prognosis. A diagnosis of personality disorder does not grant immu nity f rom developi ng other psychiatric illnesses; just the reverse seems to apply (Vize & Tyrer, 1994). Affective, paranoid, neurotic and somatic symptoms are common in this grou p  and  may  be severe enough  to warrant  a separate diagnosis.

A simple diagnostic category, particularly psychopathic or antisocial personality disorder, says little about the individual, and leads to therapeutic nihilism. This is not to minimise the diagnostic difficulties, nor to overstate the effectiveness of treatment for those with marked personality difficulties. However, u nless the presenti ng problems are analysed caref u lly, no treatment strategy can be formulated.  Such a strategy may  be as simple as bailing the patient out at times of stress and distress, dispensi ng medication for a short period, or offering a brief admission to hospital. Long-term psychotherapeutic support may be indicated  and welcomed  by a capable individual. More specific deficits may be tackled by various models of group or individual psychotherapy in settings determined  by the degree of structure and security required, the motivation of the patient and his capacities. Expectations of outcome need to be realistic and, usually, modest; an approach based  on limited  expectations of success, as with  other chronic psychiatric  illnesses,  is more appropriate.

 

Borderline personality Disorder

This term, with its shared origin in psychoanalysis and hospital psychiatry, has proved usef ul in describing a group of individuals with marked impairment of sense of self-worth and role who form damaged and volatile relationships with others. Jackson & Tarnopolsky (1990) provide an excellent review. People with borderline personality disorder are impulsive, destructive and self-destructive, experience bouts of despair, anomy, neurotic decompensation and even brief psychotic episodes characterised by partial loss of contact with reality, concreteness of thinking and paranoid ideation. The forensic importance of such people is in their capacity for bizarre and violent acting-out u nder stress, resulting in serious offences including sexual offences  and  arson.  When  such  people  are  in  hospital  or  prison,  acts  of  serious  self-harm  and  arson  are common.

Early damage to personality development, perhaps associated with sexual abuse, are common aetiological findings. Treatment is notoriously u nrewarding; many such patients are repeatedly imprisoned but a pro­ portion, particularly women, may spend lengthy periods in secure hospitals. In a study of self-mutilating women in Holloway remand prison, Wilkins & Coid (1991) found high rates of diagnoses of personality disorders, particularly of a borderline type. Neuroleptic medication Cor sometimes lithiu m) may induce a period of stability, but sometimes long-term contain­ ment may be the only realistic treatment option. Treatment approaches have been comprehensively  reviewed  by Tantam & Whittaker  (1992).

 

Neurotic  disorders

It is not common to find offending behaviour i n association with a condition that f ully satisfies the diagnostic criteria in ICD- 10 for neu rotic, stress­ related and somatoform disorders. That is not to say that neurotic symptoms are not common i n offenders; they are, but causal connection with  an offence is more likeiy to be f ound in an alternative psychiatric  diagnosis (e.g. personality disorder,  affective  disorder  or  substance misuse). There is, of course, a close link between personality disorder and neu rotic symptoms. The preferred diagnosis may depend  on whether a longitudinal (in the  former)  or  transverse  approach  (in  the  latter)  is adopted. Equally it may appear to depend on whether treatment is, or is not, recommended. Neu rotic conflicts (as distinct from disorders) may  play a speculative part in just about every type of off ence – as they may i n any example of abnormal behaviour. Such conflicts have been implicated i n shoplifting, fire-raising and sex offending, all of which are f u rther discussed  in  Chapter

  1. West (1988) provides a perceptive review of individual psychopathology and its relationship to crime. The factors that determine whether an offender with neurotic conflicts will receive treatment are complex and of ten depend on non-clinical issues. For the psychiatrist, decisions about treatment should, as ever, be made on clinical grounds according to the nature of the disorder and whether, even i n the absence of an offence, it reasonably warrants treatment.

 

Learning disability

The range of learning disabilities is wide, and is conventionally divided into  four groups:  profou nd, severe,  moderate  and  mild. The first three almost invariably have organic pathology or genetic abnormality, and are evenly distributed throughout the population. On the other hand, mild learning disability, with IQ ranging from 50-70, is unequally distributed and usually lacks gross organic pathology, although there may be features of more subtle and limited brai n damage. Mild learning disability predominates in the poorer socio-economic groups and  is accompanied by all attendant disadvantages: substandard housing, poor child-rearing practices  and  health  care, and  educational  u nder-achievement.

People with learning disabilities show a wide range of social skills and competence, their abilities very much dependent upon their background. Offending by those with severe disabilities is very rare. In contrast, offending by the mildly learning  disabled  merges  imperceptibly  with  that  by  those of normal intellectual ability and shares most of its features. While mild learning disability obviously confers particular disadvantages, it is frequently difficult to separate features specific to limited  intellectual  ability  from those  which   are  the  consequence  of   adverse  social  conditions.

 

Learning disability and offending  behaviour

It must be emphasised that the majority of people with a mild learning disability lead unremarkable lives, either independently or with the support of a caring family or relatives. However, when such protective social factors are absent, or when they are withdrawn, or when some u nexpected adverse life event supervenes,  the  individual  may decompensate.

Commonly occurring psychological features associated with learning disability indicate why an individual might  be  vulnerable  and  how he  or she might offend. Inadequate  or faulty socialisation,  impaired  self-control  or capacity to resist temptation, nai’vety and gullibility, and lack of compre­ hension of social norms or of how others might view behaviou r are all common features. These may be aggravated by a limited ability to verbalise affection, dissent, anger or frustration. Other impairments such as immatu re or disinhibited sexuality, poor capacity to manage f inancial aff airs, low self-esteem and poor self-image may cumulatively contribute to offending behaviour.

The significance of organic features is difficult to assess. Gross generalised brain damage, with consequent effects on intellectual performance, emo­ tional stability and judgement, is more likely to be associated with severe learning disability. More subtle organicity, minimal brain damage or attention def icit disorder are presu mably due to intrau terine ef fects, prematurity or other peri natal insults and may be associated  with sof t neu rological signs, intellectual impairment, childhood hyperactivity and behaviour disorder, and later with aggression. Physical abnormalities such as u n usual appearance or deficits of hearing and speech can lead to ridicule, further reducing self-esteem and exacerbating other disadvantages. Epilepsy may be f ound i n all degrees of learn i ng disability, bu t its significance will  be considered  separately later.

Offences

The general similarities in offending patterns of the mildly learning disabled and those of normal ability must  be stressed;  property  offences constitute the vast majority. There are, however, some differences. Offenders with a learning disability are more likely to commit  a  wider  range  of  offences than those of normal abilities and there is some evidence that they  have higher rates of recidivism (Robertson, 1981). Serious violence is less common, but arson and sexual offences were both overrepresented i n hospital-based  cohorts  (Walker  & McCabe,  1973; Day,  1988).

Property offences are of ten committed  with  a lack  of  forethought  and are opportunistic. Offenders with learning  disability who steal of ten  do so  in the company of others of normal  intelligence.  They are frequently  used  as look-outs or are given a role which carries the greatest risk of  being  caught. If he is associating with those chronologically, but  not intellectually or emotionally, you nger than himself , the older offender with a learning disability will frequently  be  regarded  as the  ringleader,  particularly  when he may be  the only member  of  the  group  old  enough  to be charged  with an offence. Offending may be associated with  periods of stress, petty thef t  or damage to property being a displacement activity or a symbolic act signifying an inability to commu nicate feelings to those with whom he is living  or  is  emotionally involved.

 

Sexual  offending

Both male and female learning disabled commit a disproportionate  number  of sex offences (Day, 1990). In women the offence is usually that of prostitution in the setting of social deprivation and personal disorganisation, where  it may perhaps  be  the only available source of  f u nds. Such  women are also exploited in casual sexual relationships, sometimes within their family unit. The overrepresentation of sex offending in men with a learning disability is real and not simply a reflection of differential rates of arrest and conviction (Day, 1994). The learning disabled male suffers a number of disadvantages in his relationships with females. He may not understand his own sexuality or comprehend the rules of sexual conduct. He is unlikely to attract a matu re adult sexual partner and will tend to associate with females of  his emotional,  rather than  chronological, age.

Fortu nately, most u nwanted approaches will simply be seen as clumsy exploratory behaviou r. If not threatening or repeated, they will result  in  a rebuff by the victim, a warning by parents or a caution by the police. More serious offending is seen in the seriously personality disordered person with a learning disability. lmpulsivity, poor self-control and an inability to appreciate f ully the gravity of what has been done contribute to a poor prognosis. For minor offenders, sex education and counselling is indicated. For repeated activity of a moderately serious degree, these approaches together with antilibidinal chemotherapy may be successf ul. For the rare, very serious case, protracted detention in hospital is often required for the protection  of women  or of you ng child ren of either sex.

 

Fire-raising

Fire-raising by those with learning  disability  is predominantly  the activity of the late adolescent or young adult male. Such acts by the learning  disabled, as by others, of ten appear to be motiveless (Lewis  & Yarnell, 1951), although it may be a means of commu nicating distress, anger or revenge (Jackson et al, 1987)(see Chapter 2). Making false fire calls, loitering around fire stations and ambitions to become a fireman may be associated with  a pathological  interest  in  f ires.

Fire-setting by women is generally less common. Tennent et al (1971) showed that fires tend to be set by severely  distu rbed  young women  with an intellectual level at the borderline of disability and the lower range of normal ability. They have a long history of  emotional  difficulties at home,  ru nning away, self-mutilation, criminal damage and promiscuity. Sexual abuse  at  home  is  sometimes  described   or  suspected.

Psychiatric treatment poses particular difficulties. A first fire which is small and non-threatening, and in which action can be taken to remedy the precipitants, may not require the patient to be admitted to a hospital. Repeated episodes by a learning disabled person, and for which no motive is offered, usually require detention in a secure setting. Whether this is a prison or a special hospital will depend on the degree of disability and optimism about response to treatment; criteria for detention on the grounds of mental impairment must be satisfied (see Chapter 10). Improvement of general social and personal performance and a lack of interest in fire­ setting  in  a structu red  environment,  however,  rarely  gives convincing indication of the likelihood or otherwise of further fire-raising on release; indeed, the stress of a move after a long period of secure in-patient care may be sufficient to provoke another fire-raising   attempt.

 

Recidivism  and treatment

Walker & McCabe (1973) found that, of almost 1200 patients detained under a hospital order, only 4.5% of the learning disabled were convicted of serious violence, compared with 20% of the mentally ill. However, on subsequent follow-up only 4% of the mentally ill had been severely violent again, compared with 9% of those with a learning disability. The mildly learning disabled who commit serious offences often have the constellation of adverse personality and social characteristics associated with serious offending in those of normal ability (Lund, 1990). The Mental Health Act 1983 reflects this, and there is a marked similarity in the criteria for detention under psychopathic disorder and mental impairment (see Chapter 10). Compulsory admission rates for people with a learning disability have declined drastically over the last two decades (Lund, 1990; Langton et al , 1993). When assessing a personality disordered offender of significantly limited intelligence, it may be quite arbitrary under which legal category (psychopathic disorder or mental impairment) admission to hospital takes place. But as has been suggested above, in serious offenders who have antisocial characteristics, the presence of learning disability worsens the prognosis and increases the subsequent risk. Hospital-based u nits for offenders with a learning disability have been described by Day (1988), Smith (1988) and Mayor et al (1990).

 

 

Organic states

Three issues are worthy of brief discussion: criminal behaviour resulti ng from personality changes in a dementing illness or other forms of brain damage; the relationship between epilepsy and crime; and the significance of  electroencephalographic  abnormalities  in  delinquent  behaviour.

 

Personality  change

Personality change is a frequent early  feature  of  dementia,  and  where  there are no obvious neurological features the underlying condition may remain u ndiagnosed for a considerable  time.  Offending  by  people  with this condition is rare. Sex offences against children are traditionally cited,  but the vast majority of the elderly who come before the courts are graduate offenders committing the commonest type of offence, namely theft. Non­ progressive damage as a result of head i nju ry or other cerebral i nsult may result  i n  personality  changes with  disinhibition  and consequent offending.

 

 

Although very much less common than dementia of Alzheimer’s type, the personality changes in Hu ntington’s chorea have generated much forensic interest. Antisocial behaviour of ten appears before any sign of neurological or psychiatric disturbance in Huntington’s chorea. Oliver (1970), in a series of 100 cases of Hu ntington’s chorea, f ound 38 patients who had exhibited antisocial behaviour, violence, inappropriate sexual behaviour, cruel and callous behaviour, of ten against the backgrou nd of membership of a chronically disorganised and disturbed family. It is therefore not surprising that  antisocial  behaviour  is also seen in non-affected relatives.

 

Epilepsy  and  criminal behaviour

Much has been written about the relationship between epilepsy and crime. Gunn (1977b) found the prevalence of epilepsy among prisoners to be twice that of the general population, but not greatly different from the rate found i n the most disadvantaged socio-economic groups. Contrary to popular misconceptions, there was no excess of violent crimes in epileptic prisoners. The rate and type of offending i n epileptics is similar to those of offenders in general. Therefore, the most likely explanation for the raised prevalence of epilepsy in prisoners is that epilepsy and offending are not causally related but that they share the same social and biological disadvantages which predispose to imprisonment (Whitman et al, 1984). Violence resulti ng directly from epileptic activity is rare (Hindler, 1989). It is usually conf used, non-goal directed activity in the post-ictal phase when the subject is being restrained. !eta! violence is even less common, although studies in clinical settings may u nderestimate its frequency. Offending as a result of epileptic automatism is also rare but is of medico­ legal interest, for u nder current legislation such automatism amounts to insanity (see Chapter 5). The clinical and medico-legal aspects of all forms of automatism  have been extensively reviewed  by Fenwick  (1990).

 

Electroencephalographic  abnormalities  and  crime

Correlations of abnormalities of the electroencephalogram (EEG) with personality disorder and associated delinquency and violence have been described for many years. Persistence of an excess of slow wave activity is seen as a maturational defect mirrori ng delayed psychological matur­ ation. However, such EEG findings are also widely distributed in the normal population  and no reliance can be placed  on them as an isolated  feature.

 

Substance misuse

There are complex relationships between substance abuse and criminality. These   relationshi ps,   although   marked ,   are   not   directly   causal ,  since premorbid personality characteristics, social and family background, provocative situational factors and even individual susceptibilities all play a part. Alcohol and drugs produce toxic effects and dependence syn­ dromes, both of which make offending behaviour more likely to take place and to be detected. However, features of maladjustment and delinquency and offences of a non-d rug and non-alcohol related nature regularly precede drug and alcohol-related offences.  Moreover,  abstinence  does not abolish offending, although it may reduce its frequency and alter its nature. A substantial proportion of substance-misusing offenders are not using  alcohol or drugs at the time of  committing  their  offences.

 

Alcohol

Alcohol misuse plays a significant part in various types of offences: in both perpetrators (55%) and victims (53%) of violence; i n rapists (34-72%); in sexual offences against children (49%); and in all  types  of  intrafamilial abuse and neglect (Wolfgang & Strohm, 1956; Rada, 1976; Coid, 1986). A substantial   proportion   of   property   offences  are  committed   to  generate f u nds for an  expensive  alcohol  habit,  but  as heavy  drinking  is  common in young men, the group which commits the most off ences, the exact significance  of  this  feature  is  u ncertain.

Care must be taken in drawing conclusions about causation from studies of selected samples of offenders. This applies particularly to prison popula­ tions of either serious offenders or repeated petty offenders. Both these groups will inevitably be found to have high rates of alcohol use, perhaps because it might have been stressed at trial as an explanation or a mitigating factor for violence, or because the serious social effects of  dependence are those which can lead to imprisonment. Persilia et al (1978) have shown that 70% of  habitual criminals in the commu nity misuse   alcohol.

What can be said about any specific relationship between alcohol and any particular type of off ence? Two special groups requ ire mention: habitual drunken offenders, and those suspected of having a pathological susceptibility to alcohol, even in small amounts. There are repeated drunken offenders, usually arrested for public order or property offences, who pose considerable problems in management. They are rarely con­ sidered suitable for alcohol treatment programmes and there is a reluctance to send such men yet again to prison (although this is sometimes contem­ plated as a lifesaving or therapeutic measure). The immediate need is frequently for detoxification, but this can rarely be provided. Of ten these off enders are simply dismissed f rom court to the care of volu ntary organisations or the probation service. The sterility of this cycle is evident, but with current attitudes to alcoholic offenders both inside and outside prison,  there  is no  apparent remedy.

Pathological   intoxication   (‘mania  a potu’)   is  a  much   debated  entity.

Anecdotal accounts of convincing cases have been  described   (Maletsky, 1976) but there has been criticism that it has not been possible to replicate in a clinical setting the reported spectacular effects caused by small amounts of alcohol. It has been suggested that in such a setting the necessary  triggering situational  factors are absent.

 

Drugs

Habitual criminality is an integral part of established drug dependence (Gordon, 1990). As with alcohol-misusing offenders, delinquent personality characteristics and non-drug related offending antedate drug misuse and drug-related offending. Drug misusers do not solely commit the specific offences of possession and supply of drugs, but a whole range of other offences to f u nd their habit. They may indulge in more organised serious criminal activities, including violence. In their pattern of offending, female addicts have much more in common with their male counterparts than non-addicted male and female offenders. They have  even  more  disrupted and delinquent pre-addiction backgrounds,  but  do not  commonly  commit the more serious violent and organised drug-related offences. Successf ul treatment of the drug misuse  does not  necessarily  abolish offending,  and the beneficial maturational effects of ageing may  take  longer  to  appear  than  in  non-addicted   offenders.

Descriptions of clinical syndromes resulting from acute intoxication by, idiosyncratic reactions to, or chronic abuse of, drugs such as amphetamine, heroin, lysergic acid diethylamide (LSD) and solvents are not appropriate here. Cannabis, because of its wide use in psychiatric and offender populations, warrants some discussion. In an extensive review, Thornicrof t (1990) concluded that there does not appear to be a separate  clinical entity of cannabis psychosis. However, cannabis may produce an acute organic reaction and, in heavy users, may precipitate a schizophreniform psychosis. Prolonged heavy use is associated with an increased risk of developing schizophrenia in the subsequent 15 years. Drug-misusing defendants who appear psychotic require very caref ul evaluation to ensure that the correct diagnosis is made, especially when they are facing serious charges. The interplay of personality, illness and drug dependence needs proper consideration so that the correct disposal, to hospital or prison, is recommended. Such an assessment should usually be carried out in hospital.

 

Morbid jealousy

Special syndromes

 

Sexual jealousy is a powerful human emotion. The view taken of it has  varied   over  culture  and  time,  with   a  shif t  f rom  a  socially  sanctioned response to i nf idelity, to a personal pathology which is the outward expression of u nnatural possessiveness and insecurity (Mullen, 1993). The boundary between normal jealousy and morbid jealousy is indistinct. The strength of feeling and the results which flow from it are insufficient to make the distinction, as is the presence or absence of actual u nfaithf ulness by the sexual partner. Jealousy or a tendency to be jealous can be: a normal and relatively transient response in an otherwise well-adjusted individual to frank infidelity; a neurotic preoccu pation of  a vulnerable and insecure individual; one feature in an individual with a paranoid personality disorder; an overvalued idea with no additional features of psychosis; or a frankly delusional idea arising suddenly and unexpectedly either as a single delusional idea or one of a number of related delusional ideas in a typical psychosis. Over the years various  authors have sought  to classify morbid jealousy by particular psychopathological features, so far without complete success (Mullen, 1990). Box 3.5 summarises features of morbid jealousy.

The forensic importance of morbid jealousy is its association with violence, of ten repeated violence, usually towards the sexual partner. Morbid jealousy contributes significantly to wife battering and homicides of spouses, and in the latter, psychiatrists are regularly requested to offer an opinion on whether the jealousy is normal or morbid, and whether it amounts to an abnormality of mind sufficient for a finding of diminished responsibility. This is of ten difficult. The severity of distress of the jealous individual, and the presence or absence of the common features of depression, anxiety and anger, of ten in association with alcohol consump­ tion, do not easily distinguish between normal and morbid forms. Frankly bizarre features such as elaborate surveillance, delusional misperceptions, or typical features of an organic, schizophrenic or affective illness make the  diagnosis very  much easier.

When morbid jealousy is only one feature of well-recognised psychiatric illness, the treatment is that of the underlying condition. This is of ten surprisingly effective.  Jealousy  which  is  part  of  a  neurotic  picture,  and  of ten  a neurotic  relationship  with  sexual  difficulties  and  possible provocative behaviour by both parties,  is much  more difficult to treat. Patterns of action and reaction are of ten well established and are difficult to break by psychotherapeutic means. Treatment of a paranoid personality disorder and overvalued ideas is even more difficult. It may be that the most effective approach is a merely symptomatic one, treating depressive features with an antidepressant, and tension and anger with a neuroleptic. Once the circle of events is loosened some progress may be possi ble. However, the risk of continuing jealousy, and more importantly the risk of continuing violence, must be assessed. If this seems grave, because a repeat of previous violence would be serious, or there are features which indicate that the  risk of violence is increasing, or that the violence is increasing in severity, or there are new and important situational factors, then  this risk should  be imparted to both parties, particularly the victim. It may be that the only effective advice is that the partners must separate, although this is of ten difficult  to achieve  and sustain.

 

Erotomania

De Clerambault’s syndrome, or erotomania, is described by Enoch & Trethowan (1979). The patient, typically a woman, presents with the delusional belief  that  a man,  usually  of  higher social status, or sometimes  a pu blic figure, is in love with her. The condition may exist as a mono­ delusion but is usually associated with a paranoid psychosis or schizo­  phrenic illness (Rudden et al , 1990). Such  patients  may  cause  distress to the victim and his family, for example, by sending numerous letters, making repeated telephone  calls  or  following  the  victim.  It  is  when  the  love  is  u nrequited that it may be replaced by anger, resentment  and  hatred. Repeated rebuttals may  lead  to  dangerous  behaviour,  such  as  assaults  and even attempts on the life of the victim or members of his family (Mullen & Pathe, 1994). I n some cases the treati ng psychiatrist can become the object  of  the  patient’s  delusions.

 

Miinchausen syndrome

Mu nchausen syndrome is characterised by the triad of dramatic present­ ations of acute medical or surgical symptoms, pathological lying or pseudologia fantastica, and wanderi ng the country repeatedly presenting to accident and emergency departments (Bursten, 1965). Munchausen syndrome is best u nderstood as a special presentation of a hysterical personality disorder. Such disabled personalities rarely cooperate with treatment; indeed, they usually quit hospital when the opin ion of a psychiatrist is mooted. To f u nd their peregrinations they may commit thef ts and create disturbances. A more recently described variant of particular importance is Mu nchausen syndrome by proxy, described  in Chapter  2.

 

Crime and  mental disorder II        81

 

Pathological  gambling

Gambling is a common social activity, but the frequency of excessive or pathological gambling in the general population is not known. “Maladaptive gambling behaviour” as defined in DSM-IV (American Psychiatric Associa­ tion, 1994) suggests that the disorder has much in common with addictive behaviour or a dependency disorder. Moran (1990) has described five subgrou ps of pathological gamblers: symptomatic (associated with illness,

e.g. depression); neurotic (in response to stress); impulsive (with loss of control); subcultural (socially acceptable); and psychopathic. This last group includes those whose gambling is part of a general pattern of antisocial and criminal behaviour. There is evidence that gambling is more common in offenders than in the general population (Cornish, 1978). Gambling and excessive gambling is highest in young offenders. Maden  et al (1992) found gamblers had greater records of criminality, custodial sentences, local authority care and psychiatric contact than non-gambling young offenders. In some cases, excessive gambling may lead to criminal behaviour in order to finance the habit, but in many cases pathological gambling is more generally associated with recidivism and other delinquent activity.

 

 

Minority groups

Ethnic  minorities

Afro-Caribbeans, but not Asians or other ethnic groups, are overrepresented in both the psychiatric and criminal justice systems, compared with their proportion in the general population of the UK. A disproportionate  number  of Af ro-Caribbeans, particularly British-born young men, are admitted to psychiatric hospitals with a diagnosis of schizophrenia.  They  are  more likely to be admitted f ollowing contact with the police and social services and to be detained under a section of the Mental Health Act 1983. The  highest admission rates are found for forensic sections under Part III of the Act. McGovern & Cope (1987) found that male Af ro-Caribbeans aged between 16 and 29 years were 25 times more likely than ‘whites’ to be detained as offender patients under Part Ill. Lipsedge (1994) has cautioned that the perception that Af ro-Caribbeans are prone to  manifest  a violent form  of  schizophrenia  is  an  example  of  dangerous   stereotyping.

Afro-Caribbeans are also overrepresented in special hospitals, medium secure units and in locked wards in psychiatric hospitals. In a  national  survey of secure units, 20% of admitted patients were of Afro-Caribbean origin (Jones & Berry, 1986). An  even higher proportion  (38%) was found  in the West Midlands  in a survey of  ethnic differences  upon  admission  to  a regional secure unit (Cope & Ndegwa, 1990). In this study, Afro-Caribbeans were significantly more likely to be admitted from prisons, especially while on remand. The majority of patients were considered to have a psychotic illness, almost invariably schizophrenia. Reasons for these findings are complex, but suggested factors include a more disturbed presentation of the illness, differential decision-making by psychiatrists, the police and courts, and a perception of the psychiatric services by patients as racist, coercive  and inappropriate  to the needs of  Afro-Cari bbean patients.

Af ro-Caribbeans are also overrepresented among arrest rates and in the prison population. There are approximately 5% of Afro-Caribbeans in the general population, compared with 11% of men and 25% of women in the sentenced prison population (Home Office, 1993). The latter figure includes large nu m bers of women, normally resident in West Africa, serving sentences for drug smuggling. There is debate about whether these findings reflect disproportionate criminality in Af ro-Cari bbeans, whether it is a feature of social disadvantage, or whether it is an artefact caused by a discriminatory criminal justice system. Studies have repeatedly discounted systematic discrimination, but there is a  widespread  perception  of  racial bias.  The  literature  on  the  subject  is summarised  by  Fitzgerald (1993).

In the assessment of offenders and others from ethnic minorities who either do not speak English or easily communicate in English, specialist interpreters should be obtained. It is not good practice to use relatives or friends, who may u nwittingly substitute their own interpretations in response to questions. Specialist interpreters are also available to the police and courts.

 

The deaf

Approximately 10% of referrals to specialist psychiatric units for the deaf come from the police, courts or solicitors. The majority have committed minor property or acquisitive offences, but a surprisingly high proportion have been charged with sexual offences. Deaf people do not commit disproportionately more sexual crimes than hearing people; their increased referral rate f or court reports is more likely to be a reflection of a lower threshold for referral by magistrates.

Deaf offender patients, particularly  those who have significant  problems in communication, may be found unfit to plead  (see Chapter  5). Gru bin (1991) found that seven out of a series of 295 cases found unfit  to  plead were deaf. Psychiatric assessment of deaf off enders presents special problems, particularly if there is profound hearing loss, or coexisting mental illness or learning disability. I n all cases, it is essential to obtain the services of a registered  interpreter  for the  deaf.  It is inappropriate  to use  a relative or social worker as interpreter, although it is of ten helpf ul to involve a specialist social worker for the deaf  to  aid  assessment  and  evaluation.  In all but the most straightforward cases, it is good practice to seek an expert opinion  from  a  psychiatrist  from  one  of  the  three  specialist  psychiatric  u nits  for  the  deaf ,  based  in  Birmingham,  London  and Manchester.

 

Elderly offenders

The offending rate of those over 60 years  of  age is very low,  but  physical and psychiatric illness is far more common  than  in  you nger  offenders. Their profile of crime appears broadly similar to that of you nger groups, although crimes of “disinhibition”  (e.g. sexual exhibitionism)  and violence as consequences of organic brain disease may  be  relatively  more common. In a sample of over 1000 male remand prisoners, half  of  those  over  55  years of age were recognised to be suffering from active  psychiatric symptoms on admission. Alcoholism was common, and affective psychoses made up a substantial minority (Taylor & Parrott, 1988). Of those in  this series who were convicted,  a third  were sentenced  to prison,  which  is only a little lower than the figures for you nger age groups. Most elderly offenders are socially isolated with broken marital and family ties, and they are frequently of no f ixed abode (Goetting, 1983). It has been pointed out that prisons provide an even less suitable environment for the detention of the elderly  than  they  do  for  the  rehabilitation  of  younger  offenders.

 

 

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