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