Download CRIME & MENTAL DISORDER

CRIME & MENTAL
DISORDER
Aileen Wuornos
Personal Quote:
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"I'd just like to say I'm sailing with the rock and I'll be
back like Independance day with Jesus, June 6, like
the movie, big mothership and all. I'll be back."
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Last words before being executed.
Is there a fundamental link between mental
disorder and violence?
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The public seems to think so
Popular misconception that brutal, violent, and
senseless crimes are committed by people who are
“mentally ill” or “sick”.
Media influence on connections between mental
disorder and crime, particularly serious violent crime.
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Along with greed and revenge, mental illness is a basic
motivation for criminality in the vast majority of crimes on
TV and media.
Link between crime and mental
disorder not new…
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What are some assumptions about mentally disordered
people?
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What are some people’s assumptions about atrocious
incomprehensible, senseless violence?
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do not play be the rules of society
unpredictable
cannot control their own actions.
since they are apt to do anything at any given time, these
“crazy people” are potentially dangerous.
That the offenders must be “crazy” or “sick”
Thus, some assume that the mentally ill are dangerous;
other believe people who commit bizarre crimes are
mentally ill.
Mental Disorder
Issue of normality – criteria fluctuate
 DSM-V release
 bible of mental illness expands with each revision
‘illness’
versus ‘disorder’
‘disorder’ -- no conceptual limitations
disorder of mind -- interferes substantially w/ life on daily
basis, a group of symptoms
manifested in behavior deviating notably from normal conduct
DSM-V
The current version lists many mental disorders.
 About half of all people in North America will qualify
for a DSM diagnosis at some point in their lifetimes.
 Diagnoses based on the DSM are also provided to
courts in a wide range of forensic settings
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evaluations of competence to stand trial
mental state at the time of the offence
sentencing
assessments of harm suffered by victims
Defining Mental Disorder
What is a mental disorder?
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Behavioural or psychological syndrome
Clinically significant
Presents distress or disability
Two basic guiding principles:
Negative consequences
A dysfunction of internal process
Diagnosing Mental Disorder
The DSM-IV
Axis I – Clinical Syndromes
Axis II – Personality Disorders and Mental
Retardation
Axis III – General Medical Disorders
Axis IV – Psychosocial/Environmental Problems
Axis V – Global Assessment of Functioning (GAF)
This classification system is gone with the DSM-V
DSM-V diagnoses
Two important points about mental
disorders and crime:
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persons with these disorders are not “crime prone”
even if individuals are diagnosed with these
disorders, they still can be held responsible for their
behavior.
Categories of Mental Disorder
Anxiety Disorders (e.g., Agoraphobia, Obsessive
Compulsive Disorder, Panic Disorder)
Depressive Disorders (e.g. Major Depressive Disorder)
Dissociative Disorders (Depersonalization Disorder outside looking in- , Dissociative Amnesia,
Dissociative Fugue, Dissociative Identity Disorder)
Psychotic Disorders (Delusional Disorder,
Schizoaffective Disorder, Schizophrenia, SubstanceInduced Psychotic Disorder)
Dissociative Disorders and Crime
Dissociative Disorders involve the:
Dissociation, or splitting apart, of
components of the personality that are
normally integrated.
Dissociation (adaptive process)
involuntary response to psychological stress
Dissociative Disorders and Crime
Dissociative Amnesia
Partial or total forgetting of past experiences,
Not an organic cause; response to
psychological stress.
Dissociative Fugue
“Travelling amnesia”.
Taking a sudden, unexpected trip away from
home.
Dissociative Disorders and Crime
Dissociative Identity Disorder
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“UFO of psychiatry”
Within the person, two or
more distinct personalities
or personality states.
Recurrently take control of
behaviour.
Dissociative Disorders and Crime
Criminal Responsibility
Automatism
Form of unconscious behaviour or actions done in
an altered state of consciousness
Somnambulism
Sleepwalking
R. v. Parks
Psychotic Disorders and Crime
Delusional Disorders
A mental disorder characterized by a system of
false beliefs.
In delusional disorder
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Delusions are reasonably believable.
i.e., neighbour is spying on you and attempting to
poison your dog.
In schizophrenia
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Delusions are bizarre
i.e., neighbour has disguised himself as a mosquito
and is hovering outside one’s window.
Major Affective Disorders and Crime
Major Affective Disorders
Extremely depressed for at least a 2 week
period (inability to anticipate happiness or
pleasure)
Accompanied by a generalized slowing down
of mental and physical activity.
Depression and Criminality
Depression may be strongly linked with
delinquency (in females)
Indifference to personal safety/consequences
Psychosis and Violence
A hallucination is
A sensory perception experienced in the
absence of an external stimulus.
Different from an illusion, which is a
misperception of an external stimulus.
Command Hallucinations
Auditory hallucinations that instruct a person
to act in a specific way.
Psychosis and Violence
Delusions are
Fixed or persistent false beliefs that have no
basis in reality and may accompany a variety
of psychological conditions.
Most widely experienced positive symptom of
schizophrenia
Types of delusions may include
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Delusions of grandeur
Delusions of reference
Psychosis and Violence
Delusions relevant to violence or aggression
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Delusions of Persecution
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The belief that one is being plotted against,
spied upon, threatened, or otherwise
mistreated, particularly by a conspiracy.
Threat-Control-Override Symptoms
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Thoughts that people are trying to harm you
or that others are controlling one’s thoughts,
feelings, and actions.
Psychosis and Violence
Persecutory delusions and violence:
Experience of delusional distress
Co-occurrence of “distress factors” (low selfesteem, high anxiety, anger) and persecutory
delusions increase risk for violence.
Violence may appear as a forced choice in
patients who experience persecutory
delusions associated with a strong
idiosyncratic conviction of being threatened
and forced to defend oneself.
Common Classifications Include:
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Adjudicated by the courts
1) Unfit to Stand Trial (FIT)
2) Not Criminally Responsible on Account of Mental Disorder
3) Mentally disordered sex offenders (MDSO)
4) Administratively transferred from a prison to a mental hospital
(transfers)
Most mentally disordered committed involuntarily during trial,
especially if found NCRMD
Mentally Disordered Defendants and
Offenders
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Unfit to stand trial
Distinct from insanity
-state of mind at time during trial proceedings vs.
at time of offense
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Unfit population: marginal, poorly educated,
clinical diagnoses
‘Insanity’ Defense
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Judicial determination of NCRMD
Not Criminally Responsible refers to a person’s state of mind at time
an offense was committed
Law assumes mental disorder can eliminate free will or ability to
make appropriate choices
= Lack of responsibility
# of insanity defenses is small to total # of criminal cases
Insanity Defence in Canada
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C.C.C. (1992), Section 16, Bill C-30, April 1992:
NCRMD
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No person is criminally responsible for an act
committed or an omission made while suffering from
a mental disorder that rendered that person incapable
of appreciating the nature and quality of an act or
omission or of knowing that it was wrong
Forensic Psychiatric Services Commision
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Specialized assessment, treatment & case management
190-bed forensic psychiatric hospital
Services include:
Court ordered assessments
Services to persons found NCRMD or Unfit to Stand Trial
Mental status assessments for pre-sentence reports
Treatment of mentally disordered offenders in provincial
correctional centres
Court ordered assessment & treatment of offenders on bail,
probation, conditional sentences & dangerous offender and/or sex
offender classifications
Sex offender treatment (400 patients annually in B.C.)
Violence & Mental Illness
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Public fears violence that is random, senseless &
unpredictable, associating it with mental illness
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Such assumptions lead to discrimination & stigma
Recent studies show modest assoc b/w mental illness
& violence, even when main risk factors for violence
such as gender, age, socio-economic status, are
controlled for
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Nature of assoc remains unclear b/c of sig methodological
challenges
Substance abuse major factor, especially as it it related to
medication non-compliance
Bipolar & major depression show high rates of violence
Mental Disorder Violence Patterns
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Mentally disordered who commit violence
In the family when relationships are characterized by
mutual threat, hostility and financial dependence
Schizophrenia concurrent w/ substance abuse
(MacArthur Risk Assessment Study)
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Sparked by conditions of their social life
Typically in the home
Family members or friends (87%)
In Canadian study, of 1151 newly detained people,
3% of violent crimes accruing to this sample were
attributable to people w/ major mental disorders such
as schizo or depression
Mental Disorders & Violence
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Limited connection exists b/w major mental disorder & violence
3 ‘types’ of violence & mental disorder studies exist (11 studies over 15
years used):
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Patients being violent before hospitalization
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Patients being violent during hospitalization
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Patients being violent after hospitalization
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10-40% of patient samples committed physical assault against another
shortly before hospitalization
Paranoid schizophrenics experience higher violent rates than non-mentally
disordered
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Persecutory delusional disorder (psychotic symptoms)
Prelim data on depression indicate strong assoc w/ violence
APD – hx of continuous in which rights of others violated
‘catch all category’
Frequently offered as diagnosis in criminal courts & corrections
Psychotic Disorders and Crime
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Psychotic Disorders
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Psychosis – a severe impairment of thinking or
1.
emotion such that an individual is seriously out of contact
with reality
Schizophrenic Disorders
2.
Paranoid Disorders-Delusional Disorders
3.
Psychotic disorders not elsewhere classified
Psychotic Disorders and Crime
Schizophrenia
Severe breakdowns in
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Thought patterns
Emotions
Perceptions.
Disorganization and failure to correspond to
reality.
Schizophrenia
Schizophrenia – is a psychotic disorder marked by a severe breakdown in thoughts,
emotions & perceptions
Core Symptoms:
1. Positive Symptoms
1. Hallucinations
2. Delusions
2. Negative Symptoms
1. Avolition – lack of energy and an absence of interest in or ability to persist in usual
routines
2. Alogia –speech impoverished in terms of volume or content
3. Flat affect – stimuli elicit little or no outward emotional expressionAsociality –
severe impairments in terms of social relationships and social functioning
3. Disorganized Symptoms
Psychotic Disorders and Crime
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Schizophrenia
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Symptoms
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Delusions (false beliefs about the world)
hallucinations (sensory perceptions which other people would not
sense and that do not exist outside one’s own perception…perceiving
things that others do not)
disorganized speech (e.g., frequent derailment or incoherence;
speaking in abstracts; neologisms).
grossly disorganized behavior (e.g. dressing inappropriately, crying
frequently) or catatonic behavior
negative symptoms, i.e., affective flattening (lack or decline in
emotional response – monotone voice, expressionless face), alogia
(lack or decline in speech), or avolition (lack or decline in
motivation).
Schizophrenia symptoms
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“The problem is insects. My brother used to collect insets. He’s now a man 5 foot 10
inches. You know, 10 is my favorite number”
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“For about 7 years – except during sleep – I have never had a single moment in which I
did not hear voices. They accompany me to every place and at all times; they continue
to sound even when I am in conversation with other people, they persist undeterred
even when I concentrate on other things, for instance reading a book…they are
drowned by the stronger sound of the spoken word…But the well-known phrases
recommence at once
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“I felt that the government agencies had planted transmitters and receivers in my
apartment so that I could hear what they were saying and they could hear what I was
saying. I also felt as if the government had bugged my clothing, so that whenever I
went outside my apartment I felt like I was being pursued. I felt like I was being
followed and watched 24 hours a day.”
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“The inmates here hate me extremely because I am sane…They talk to me
telepathically continuously…By the power of their imagination…they create extreme
pain in my head, brain, eyes, heart, stomach and in very part of my body…by telepathy
and imagination, they force me to say orally whatever they desire, whenever they
desire, and as long as they desire. I never said a word of my own. I never created a
thought of my own.
Five subtypes of Schizophrenia
(DSM-IV, not in DSM-V)
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2)
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4)
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5)
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Disorganized
inappropriate affect; marked incoherence and disorganization in thought
patterns
Catatonic
severe disturbance in muscular and voluntary movement. Mutism and
parrot-like word repetition.
Paranoid type:
delusions and hallucinations (often command)
Undifferentiated type
psychotic symptoms that cannot be classified into other categories
Residual type
individual has had at least one episode, and evidence that some of the
symptoms are continuing.
Schizophrenia and Crime
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Core Symptoms
1.
Positive Symptoms
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Hallucinations
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A sensory perception experienced in the absence of an external stimulus.
Different from an illusion, which is a misperception of an external stimulus.
Command Hallucinations
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Auditory hallucinations that instruct a person to act in a specific way.
Delusions
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Threat-Control-Override (TCO) Delusions
Persecutory Delusions
Psychosis and Violence
Command hallucinations and violence
McNeil, Eisner, and Binder (2000)
Study of 103 psychiatric inpatients
33% reported having a command hallucination
22% reported they complied with such commands
 Patients who experienced command
hallucinations to harm others were more
than twice as likely to be violent, even when
controlling for other variables.
Psychosis and Violence
Command Hallucinations and Compliance:
Who obeys and when? (R. Erkwoha, 2000)
Three psychopathological characteristics
 A voice known to the patient;
 Emotional involvement during the
hallucinations; and
 Seeing the voice as real.
Who obeys and when? (R. Borum, 1998)
 Recognition of hallucinated voice
 Hallucination related to a delusion
Threat/Control Override Symptoms
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Delusional Symptoms that are more
associated with violence.
Feeling “gravely” threatened by someone
who intends to cause harm
Persecutory delusions
An override of self-control through external
forces; mind/body dominated by external
forces.
Threat/control override symptoms
How often have you…
1.
2.
3.
Felt your mind was dominated by forces beyond
your control?
Felt that thoughts were put into your head that were
not your own?
Felt that there were people who wished you harm?
Delusional Disorders (paranoid disorders—
not schizophrenia)
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Delusional Disorders:
 Presence of one or more nonbizarre delusions for 1 month or
more.
 Delusional disorders often accompany other disorders (such as
paranoid personality disorder, depression, anxiety)
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Common delusions beliefs
 persecutory beliefs about being spied on, cheated, conspired against,
followed, drugged, harassed, etc.
Anger, resentment, suspiciousness, and sometimes violence accompany
these false persecutory beliefs.
7 types – the persecutory type is most closely associated with criminal
conduct, particularly violence – also seen Erotomanic “they love me!”
Psychotic Disorders and Crime
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Delusional Disorders (Paranoid)
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A mental disorder characterized by a system of false
beliefs.
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In delusional disorder
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Delusions are reasonably believable.
E.g.: Neighbour is spying on you .
In schizophrenia
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Delusions are bizarre
E.g.: Neighbour is spying on you because he knows that you have
pieced together important clues about an upcoming terrorist attack.
Major Affective Disorders
Affective disorders – disorders of mood or emotion
Depression – a period of great sadness associated with
decreased levels of mental and physical activity
Mania – a period of intense elation indicated by symptoms
of talkativeness, distractibility, flight of ideas, grandiose
plans & purposeless activity
Bipolar – episodes of mania & depression; or mania alone
Depressive Disorders and Crime
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Affective disorders, mood disorders, bipolar disorder,
major depressive disorder
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Extremely depressed state, accompanied by a generalized
slowing down of mental and physical activity, gloom, despair,
feelings of worthlessness, and perhaps suicidal ideations.
Deeper and longer lasting than “normal” ups and downs.
Role of depression and criminal behavior is just beginning
to be explored
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Depression associated with delinquency in adolescence
(particularly girls) – indifferent to their own personal safety and
the consequences of their actions. “don’t care”
Depression also plays role in mass murders, work place
violence, and “suicide by cop”
MacArthur Research Network
(Monahan et al, 2001)
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Followed over 100 psychiatric patients discharged
from psychiatric hospitals to see who became violent
over 1 year
Past mental disorder alone is not a good predictor
Mental disorder most closely related to violence is
schizophrenia
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In particular schizophrenic males who also score high on
the PCL-R (psychopathy scale) or show antisocial
behaviour at an early age, often have persistent violent
offending
Hodgins & Côté (1990)
Methodology:
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random sample of 495 male prisoners in Quebec
assessed for mental disorder
Results:
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Higher rates of MD in the prisoners compared to
men in the general population

fundamental methodological weakness
Hodgins & Côté (1990)
Quebec
Inmates (%)
General
Population (%)
Organic brain
.40
0.9 - 3.1
Schizophrenia
7.5
0.5 - 1.2
Bipolar
4.8
0.7 - 1.1
Depression
16.9
2.1 - 5.9
Disorder
Swedish Metropolitan Project Hodgins
(1993)
Methodology:
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15,000 people born in Stockholm, Sweden in 1953
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Collected data on:
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criminal records
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Mental health records
Swedish Metropolitan Project Hodgins
(1993)
Compared to non-mentally disordered persons:
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men with major mental disorders were more
likely to have a criminal record (48% vs. 29%)
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men with major mental disorders were more
criminally involved (13.2 mean convictions vs.
7.3 mean convictions)
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similar pattern for women
Swanson et al. (1990)
Methodology:
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10,000 people from 3 urban centres in the
U.S. were interviewed & evaluated for mental
disorder
Participants self-reported the occurrence of
certain types of violent behaviour
% Violent in past year by Diagnosis
Diagnosis
% Violence
No disorder
2.1
Schizophrenia
12.7
Major depression
11.7
Mania or bi-polar
11.0
Alcohol abuse/dependence
24.6
Drug abuse/dependence
34.7
Swanson et al. (1990)
1.
Violence is 5 times more prevalent among
major mental disorders (vs. no disorder)
2.
Schizophrenia, major depression and
mania/bi-polar exhibit similar levels of
violence
3.
violence is at least 12 times more prevalent
among alcohol/substance abusers
25
20
1-year probability of violence by diagnosis
Swanson (1994)
15
females
males
10
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Epidemiological Studies Conclusions
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Mental disorders cause a slight increase risk
for violence
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The increase rises sharply when mental disorders
are combined with substance abuse
Having active psychotic symptoms also
increases the risk for violence
Epidemiological Studies
70
63.89
55.2
Percent Violent
60
50
42.59
40
33.12
30.72
57.86
43.57
34.91
30
20
10
12.97
7.31
14.55
Two-item
Four-item
16.14
Five-item
0
None
Schizophrenia or
Major Affective
Disorder
Substance Use
Major MD +
Substance Use
Current-year Major Psychiatric Diagnosis
Jeffrey Swanson – ECA Project
Rationality-within-irrationality
Principle of rationality-within-irrationality
– violence may be a ‘rational’ behavioural
response to ‘irrational’ psychotic symptoms
Violence is more likely where psychosis
involves symptoms of threat/control-override
(Link & Stueve, 1994)
Link and colleagues
Percent Violent (5 Years)
70
58.1
60
50
40
27.1
30
20
10
18.8
14.7
3.6
11.5
9.8
2.9
0
Low
Medium
Level of TCO Symptoms
Link and Stueve Study
High
29
Hitting
Fighting
Weapon
Swanson et al. (1996)
Participants with TCO symptoms
were…
2 times more likely to report violence vs. other
psychotic symptoms
 6 times more likely to report violence vs. no
mental disorder
 8-10 times more likely to report violence when
combined with alcohol/substance use disorders
vs. no mental disorder

Who obeys and when? Reminder…
Factors increasing compliance (Bjorkly, 2002)
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A voice known to the patient;
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A voice the persons trusts;
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Additional beliefs about the consequences of
dis/obedience
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Hallucinations are consistent with delusions
Summary
1.
2.
3.
It appears mental disorder is a risk factor for
violence
The magnitude of the relationship to violence
does not appear to be large
the combination of major mental disorder
and substance abuse probably raises the risk
of violence significantly
Mulvey (1994)
Summary
4.
5.
The relationship of mental disorder and
violence probably exists even after
accounting for demographic variables
Active symptoms are probably more
important risk factors than the mere the
presence of a mental disorder
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Delusions - TCO
hallucinations (command)
disorganized thought
mania
Summary
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The pathways producing the association
between mental disorder & violence remain
unclear
(Douglas & Hart, 1996)
Summary
Most people who have mental disorders
are not violent
Likewise, most people who commit
violence do not have a mental disorder
However, some mental disorders are
associated with a greater likelihood of
committing violent acts
Diagnoses Associated with Violence
In general, the more serious disorders
carry a greater risk for violence
People who have delusions may be at
specific risk
In the manic phase of bipolar disorder,
people can be impatient and easily
angered
Likely Interrelationships
Main effects
Psychosis and substance use both have
independent effects
Interactions
Psychosis and substance use have exponential
effects, when the co-occur
Transactions
Psychosis, substance use, and violence
influence each other over time
Mental disorder is indirectly related to
violence through substance abuse
Substance Abuse
Mental Disorder
Time
Violence