Forensic Issues in Child and Adolescent Psychiatry Flashcards
Psychosocial risk factors for criminality
Individual and family factors Prenatal and perinatal influences—birth complications, maternal rejection, fetal neurological maldevelopment, maternal nicotine and alcohol consumption Hyperactivity and impulsivity Low intelligence Punitive parenting style—poor supervision, harsh discipline, rejection Teenage mothers Parental conflict—separations Criminal parents Large family size
Social factors Socioeconomic deprivation Peer influences School influences Community influences
Relationship between schizohrenia and offending (particularly homicide)
The association between mental disorder and violence
has been repeatedly demonstrated. Fazel et al. (2009a)
conducted a systematic review of violence and schizophrenia and other psychoses. This meta-analysis of
20 studies, including 18,423 individuals, found that
schizophrenia and other psychoses were associated
with violence (especially homicide). However, this risk
was mediated by comorbid substance abuse, and was
the same for individuals with substance abuse without psychosis. The increased risk of violent offending
in both men and women with a diagnosis of affective
psychosis could be accounted for by alcohol and substance misuse. Alcohol and substance misuse by themselves are associated with a substantially increased risk
of violent offending, as is personality
Association of mental illness and crime
Only a small minority of all people who commit violent acts have serious mental illness such as psychosis.
Swedish national registers linking hospital admissions
and criminal convictions over 13 years demonstrated a
population-attributable risk fraction of 5.2% (i.e. only
5% of convictions were accounted for by individuals with severe mental illness)
Attributable risk fraction was higher in women across all age bands. In
women aged 25–39 years, it was 14.0%, and in those
aged 40 years or over, it was 19.0% (Fazel and Grann,
2006). In a more recent Swedish register study, Fazel
et al. (2014a) showed that, within 5 years of their first
diagnosis of schizophrenia, 10.7% of men and 2.7% of
women were convicted of a violent offence. The vast
majority of patients with psychotic illnesses are no
more dangerous than members of the general population. There is no evidence that homicidal behaviour
is becoming more common in people with mental illness—indeed, it appears to have been declining since
the early 1970s (Large et al., 2008).
ASPD and substance use have greater association with offending than does any MMI
Where serious violence occurs, it is likely to be directed at a family member or carer
Most offending in minor in nature
Link between alcohol and crime
Alcohol and crime are related in three important ways:
1. Alcohol intoxication may lead to charges related to
public drunkenness or to driving offences.
2. Intoxication reduces inhibitions and is strongly associated with crimes of violence, including murder.
3. The neuropsychiatric complications of alcoholism
may also be linked with crime.
Delusions associated with increased risk of violence
Persecution
Being spied on
Conspiracy
PTSD association with violence
Post-traumatic stress disorder (PTSD) may be related to
offending in three ways:
● PTSD patients may abuse drugs and alcohol.
● PTSD is associated with increased irritability and
decreased affect regulation.
● PTSD patients may rarely experience dissociative episodes involving violence, especially in circumstances
resembling their original trauma. This is often hard to
determine retrospectively
Cognitive distortions associated with pathalogical gambling
magnification of gambling skill, superstitions, temporal telescoping, predictive skill, and obviously
selective memory
Factors associated with reoffending in individuals sexual offending
● Previous criminal history
● Higher number of sexual offences and more than
one type of sexual offence
● Being a childhood victim of sexual abuse
● Violent sexual fantasies
● Negative attitudes to women
● Belief that victims consent to or enjoy the act
● Choice of location and occupation to facilitate
access to victims
● Use of sadomasochistic or paedophilic pornography
● Substance misuse
● Treatment non-compliance
Paedophilie definition
Paedophiles
are defined as having a primary sexual interest in prepubertal children. They are almost always male, either
homosexual or heterosexual, and usually abuse children
not previously well known to them. Paedophiles are
rarely mentally ill. Victims are often prepared (‘groomed’)
over a long period of time, increasingly via the internet.
Some paedophiles may seek work in occupations where
they will have access to children who will be left in their
care
Recidivism rate in child sexual offenders
The prognosis is difficult to determine. Among those
who receive a prison sentence, the recidivism rate is
about one in three. An important minority progress to
violent sexual offences, so psychiatrists may be asked to
give an opinion on their dangerousness
Sexual assault stats
● About 1% of women said that they had been subject to some form of sexual victimization in the
past year.
● In total, 0.4% of women (leading to an estimate of
61,000 victims in the UK) said that they had been
raped in the previous year.
● Current partners (at the time of the attack) were
responsible for 45% of rapes. Strangers were
responsible for a minority (8%) of attacks.
● Around 18% of sexual assaults were reported to the
police.
1/3 sexual assaults go to police, 1/3 of those to court, 1/3 of those rapists convicted. Most serve half time.
Reconviction rates of rapists
30%
Mental illness most commonly associated with sho lifting
depression
Groups that set fires
Certain groups can be recognized:
● Fire-setters who are free from psychiatric disorder and who
start fires for financial or political reasons, or for revenge;
they are sometimes referred to as motivated arsonists.
● So-called pathological fire-setters, who suffer from
learning difficulties, mental illness, or alcoholism;
this group accounts for about 10–15% of arsons.
● A group that meet the DSM-5 criteria for pyromania
(see page 520). These individuals (who sometimes join
conspicuously in firefighting) obtain intense satisfaction and relief of tension from fire-setting.
● Those with psychotic illness
The factors associated with an increased risk of repetition include:
● antisocial personality disorder
● learning difficulties
● persistent social isolation
● fire-setting for sexual gratification or relief of tension(Anwar et al., 2009)
Is critical incident debriefing helpful for victims of crime
No
Critical incident debriefing as a routine treatment is not
helpful (Raphael and Wilson, 2000). Clinical judgement
is needed in assessing the severity and persistence of
psychological problems to determine whether victims
require specific psychological help.
Intention to commit crime- essential principles
The underlying principle is that no one
should be regarded as culpable unless they were able to
control their own behaviour and to choose whether to
commit an unlawful act or not. In determining guilt, it
is necessary to consider the mental state at the time of
the act, and especially intention (mens rea). This means
the person perceives and intends that their act will produce unlawful consequences. Three other forms of intent
need consideration.
1. Recklessness. The deliberate taking of an unjustifiable
risk when the consequences can be foreseen but are
not avoided.
2. Negligence. Bringing about a consequence which a
‘reasonable and prudent’ person would have foreseen
and avoided.
3. Accident (or ‘blameless inadvertence’).
The key issue is whether the accused had the mental
capacity to form the intention, or whether mental disorder might have affected that capacity. Sometimes
it will be beyond psychiatric expertise or evidence to
answer this question. Asked to give an opinion on these
matters, the psychiatrist should liaise closely with the
lawyer
Inability of children under 10 to form intent- Latin term
children under 10 years of age are excluded
because they are deemed incapable of forming criminal intent. The Latin term for this is doli incapax.
Competence to stand trial
It is necessary to determine how far the defendant can:
● understand the nature of the charge
● understand the difference between pleading guilty
and not guilty
● instruct counsel
● challenge jurors
● follow the evidence presented in court
McNaughton rules, including case precedent
In English law, insanity is defined in law by the
McNaughton Rules, after the famous case of Daniel
McNaughton, who in 1843 shot and killed Edward
Drummond, the Private Secretary to the then Prime
Minister, Sir Robert Peel. In the trial at the Old Bailey, a
defence of insanity was presented on the grounds that
McNaughton had suffered from delusions that he was
being persecuted by spies. His delusional system gradually
focused on the Tory Party, and he decided to kill their
leader, Sir Robert Peel. McNaughton was found not guilty
on the grounds of insanity, and was admitted to Bethlem
Hospital. Because this was such a contentious decision,
rules were provided for guidance. It must be clearly proved
that, at the time of committing the act, the accused was:
labouring under such a defect of reason, from disease of the
mind, as not to know the nature and quality of the act he was
doing, or, if he did know it, that he did not know what he was
doing was wrong.
Diminished responsibility
In English law, it is only available in relation
to the charge of murder, and is defined as follows:
where a person kills or is party to a killing of another, he shall
not be convicted of murder if he was suffering from such abnormality of mind (whether arising from a condition of arrested
or retarded development of mind or any inherent causes or induced by disease or injury) as substantially impaired his
mental responsibility for his acts and omissions in doing or
being party to the killing
Types of false confessions
Gudjonsson (1992) suggested that there are three main types of false confession:
- Voluntary.
- Coerced–compliant.
- Coerced–internalized.
Reason to transfer psychiatrically unwell prisoners
● Psychosis
● Failure to improve with medical treatment in prison
● Refusal to have treatment for serious psychiatric
illness
● Life-threatening self-harm
● Risk of abuse
Following a violent incident in hospital, considerations
After an incident has occurred, the clinical team
should meet to consider the following issues.
● The future care of the patient. For mentally disordered
patients, there should be a review of the drugs prescribed and their dosage. When violence occurs in a
person with a personality disorder, medication may
be required in an emergency, but it is usually best
to avoid maintenance medication. Other measures
include trying to reduce factors that provoke violence,
or providing the patient with more constructive ways
of managing tension, such as taking physical exercise
or asking a member of staff for help.
● Supportive psychological interventions. These may be
required for patients or staff who have been the victims of a violent assault (see the earlier section on victims of crime).
● Whether the police should be informed. It should not be
forgotten that such assaults may be criminal. Opinion
has moved to a preference for involving the police more
often, although they are often reluctant to press charges.
● The possible effect on the whole patient group. Other
patients may need support whether or not they were
present at the incident.
● The need for changes in the general policy of the ward.
A violent incident may enable lessons to be learned
that are applicable in a general way to ward policies
and procedures.
2 approaches to risk assessment
There have been two broad approaches to risk
assessment.
1. Clinical psychiatrists have tried to identify factors associated with dangerousness in an individual patient (see
Box 18.9). While general predictors of violence (e.g.
past violence, antisocial personality disorder, substance
misuse) are helpful, they lack specificity in identifying
particular individuals at risk (Fazel et al., 2012).
2. Actuarial methods have been used to predict future
criminal behaviour among offenders and psychiatric
patients. In general, the low correlations between predicted and observed behaviour have meant that
they have been unhelpful for making individual
predictions. Recent instruments have an improved
predictive accuracy, but may be more useful in predicting those not likely to be violent than those who
are (Fazel et al., 2012
Factors associated with dangerousness
Male gender
History
One or more previous episodes of violence
Repeated impulsive behaviour
Evidence of difficulty in coping with stress
Previous unwillingness to delay gratification
Antisocial traits and lack of social support
History of conduct disorder
The offence Bizarre violence Lack of provocation Lack of regret Continuing major denial
Mental state Morbid jealousy Paranoid beliefs plus a wish to harm others Deceptiveness Lack of self-control Threats to repeat violence Attitude to treatment, poor compliance
Circumstances
Provocation or precipitant likely to recur
Alcohol or drug misuse
Social difficulties and lack of support
Which of the following is true with regard to the association between
schizophrenia and recorded crime rates?
A. The risk is increased for non-violent crimes only
B. The risk is increased for violent but not non-violent crimes
C. The risk of crime is increased for narrow diagnosis of schizophrenia rather than broad
diagnosis of psychosis
D. The association is seen only for less serious violent acts
E. The risk is highest for violent crimes for both narrowly defi ned schizophrenia and
broadly defi ned psychosis
E. Various types of studies have been hitherto employed to study the association between
recorded crime and psychosis. One must remember that offi cially recorded crime may only
be the tip of the proverbial iceberg in such studies. Various regional policies, jurisdictions, and
practices affect the rate of recorded crime; in any case, these rates are not a true refl ection of
violence in the society. Many such studies have consistently found that a narrow diagnosis of
schizophrenia or much broader psychosis have an increased risk of both non-violent and violent
offending; this risk is greatest and most consistent for violent offences
All of the following factors are signifi cantly associated with increased risk of
violence among those with schizophrenia except
A. Comorbid substance use
B. Comorbid personality disorder
C. Acute psychotic symptoms
D. Non-compliance with treatment
E. Comorbid depression
E. The risk factors associated with violence in mental illness is a favourite topic in MRCPsych
exams. It has been cogently shown that the magnitude of risk associated with a combination of
factors such as male sex, young age, and lower socioeconomic status in a mentally ‘well’ person
with no psychiatric history is higher than the risk of violence presented by mental disorders
per se. Despite varied research, the causal pathway from mental illness to violence is still poorly
sketched. The most consistently established risk factors that further increase the risk of violence
among schizophrenia patients are (a) comorbid substance abuse, (b) comorbid personality
disorder, (c) non-compliance with medication, and (d) active psychotic symptoms. Depression
does not seem to be a major mediator of violence in schizophrenia patients
Which of the following is true about the epidemiology of violence in
schizophrenia?
A. Most offenders with schizophrenia offend for the fi rst time after the onset of illness
B. Most offenders with schizophrenia have delusions directly relevant to violence
C. Most offenders with schizophrenia do not have substance use problems
D. Most offenders with schizophrenia do not reoffend if the illness is diagnosed
E. The risk factors increasing violence is similar in both schizophrenia and
non-schizophrenia populations
E. Most schizophrenia patients do not offend in direct response to delusions or
hallucinations, although homicide offenders may be over-represented in those who are actively
psychotic at the time of the offence. In general, schizophrenia patients who offend tend to have
long histories of substance misuse, conduct problems, and delinquency, with extensive nonviolent
and violent offending prior to the onset of illness. Thus, the tendency to reoffend does
not fall after a diagnosis of schizophrenia. The basic tenet one needs to remember regarding the
epidemiology of violence in schizophrenia is that those risk factors for violence which operate in
subjects without mental illness also operate in patients with schizophrenia.
The amount of societal violence rate that can be ascribed to psychiatric illness is A. 1 in 10 B. 1 in 20 C. 1 in 5 D. 1 in 2 E. 1 in 100
B. Most research in forensic psychiatry has examined the relative risk of violence among
the mentally ill compared with the general population. The population-attributable risk
fraction (PAR%) refers to the percentage of violence in the population that can be ascribed to
schizophrenia and thus could be eliminated if schizophrenia were eliminated from the population.
Fazel and Grann (2006) reported that the population-attributable risk varied by gender and age
in a given population. Overall, the PAR% of violence for psychiatric patients was 5.2%, suggesting
that patients with severe mental illness commit 1 in 20 violent crimes. These data were obtained
from analysing Swedish health registers between 1988 and 2000. This value may vary between
countries and across various generations of birth cohorts.
With respect to population-attributable risk of violence in those with
schizophrenia, which of the following is true?
A. It is a more important public health measure than relative risk
B. It increases with increasing overall crime rates
C. Most crimes in Europe are committed by those with schizophrenia
D. It decreases with increasing overall crime rates
E. It represents the amount of crime that would remain if schizophrenia is completely
eliminated from a population
D. The population-attributable risk of violence in those with schizophrenia is a more
important public health measure than relative risk as it indicates how much violence/crime
could be eliminated if mental illness is ‘eliminated’. It provides an easier and more accurate
refl ection than relative risk for the general public. When the crime rates in a society increase,
the population-attributable risk due to any mental illness reduces. The population-attributable
risk fraction of violence for mental illness rate is estimated as 5% using Swedish registers; this
suggests that most crimes in Europe are not related to mental illness.
The term filicide refers to A. Killing of father by son B. Killing of a sister by another C. Killing of husband by wife D. Killing of a child by mother E. Killing of a parent by child
D. The killing of a child by its mother is very rare and is called fi licide. It is linked to
depressive disorders more than any other mental illness. Patricide refers to the act of killing
one’s father. Sororicide is the act of killing one’s sister. Matricide is the killing of one’s mother and
mariticide is killing of one’s spouse. Fraternicide refers to killing one’s brother
To be applied successfully the fi tness to plead criteria must be found relevant to a defendant at the time of A. The criminal offence B. The trial proceedings C. Being interviewed in custody D. Sentenced imprisonment E. The arrest
B. The fi ve criteria currently used in court in England and Wales to determine fi tness to
plead have remained unchanged for over 150 years. These are collectively termed Pritchard’s
criteria: (1) ability to plead; (2) ability to understand evidence; (3) ability to understand the court
proceedings; (4) ability to instruct a lawyer; (5) knowing that a juror can be challenged.
As the degree of mental illness can vary with time, its effect on fi tness to stand trial can differ.
Hence it is important to establish fi tness/unfi tness in the defendant as applicable at the time of
the trial proceedings
Which of the following refers to assessment of medical negligence?
A. McNaughton’s criteria
B. MacArthur’s competency assessment tool
C. Pritchard’s criteria
D. Hare’s checklist
E. Bolam criteria
E. In the UK, the Bolam test has been the benchmark for assessing professional negligence
since1957. According to the Bolam test, ‘A doctor is not guilty of negligence if he has acted in
accordance with a practice accepted as proper by a responsible body of medical men skilled
in that particular art’. In other words, a doctor is not negligent if he is acting in accordance
with such a practice, merely because there is a body of opinion that takes a contrary view.
McNaughton’s test refers to the assessment of diminished responsibility in the wake of mental
illness in court. The MacArthur competency assessment tool and Pritchard’s criteria are used for
assessing fi tness to plead. Hare’s checklist is used for the assessment of psychopathy.
A ‘trial of facts’ takes place in which of the following conditions?
A. Defendant is highly suggestible
B. Defendant is unfi t to plead
C. Defendant has learning disability
D. Defendant has amnesia for the event of crime
E. Defendant is found not guilty by reason of insanity
B. If a defendant is found unfit to plead the likelihood of becoming fi t is initially considered.
If this is likely, e.g. following treatment, then the trial can be adjourned until such improvement
occurs. If such improvement is unlikely, a jury trial of the facts takes place in the defendant’s
absence to determine whether the individual committed the alleged crime. If the individual is
unfit to plead but at the end of the trial of facts it is established that he/she has committed the
act, then one or other form of court disposal (e.g. a hospital order, supervision order or absolute
discharge) is given.
Which of the following is a structured clinical risk assessment tool used in a
forensic setting?
A. Psychopathy Check List – Revised
B. Violence Risk Appraisal Guide (VRAG)
C. Iterative classifi cation tree
D. HCR-20
E. Minnesota Multiphasic Personality Inventory (MMPI)
D. HCR-20 (historical, clinical, risk management – 20) incorporates static historical risk
factors, such as previous violence and early maladjustment, together with dynamic factors that
may be particularly important in individual cases, such as level of insight and lack of personal
support. It is a commonly used structured clinical risk assessment scale. VRAG is an actuarial tool
that incorporates important predictors of reconviction studied in a sample of Canadian male
offenders with mental disorder followed up for 7 years. PCL-R stands for the revised version of
psychopathy checklist. It is used with HCR-20; it is not a stand-alone risk assessment instrument.
MMPI is used as a psychometric tool for personality variables. The Iterative Classifi cation Tree
is an actuarial decision-making tool produced by Monahan et al. (2001) using data from the
MacArthur risk assessment study. This tool uses many different combinations of bivariate risk
factors to classify a person as high or low risk.
Which of the following is true with regard to VRAG?
A. It incorporates HCR-20 as a subscale
B. It contains 24 items
C. Presence of schizophrenia is a predictor of lower risk
D. Psychopathy is not included as a predictor
E. It is a structured clinical risk assessment tool
C. VRAG is an actuarial risk tool that incorporates 12 items which are scored on the
basis of a weighting procedure developed from the original study of Canadian prisoners. The
variable with the heaviest weighting is the PCL-R psychopathy score, which is incorporated as a
subscale. It does not use HCR-20 as a subscale. The factors positively associated with increased
risk of recidivism are psychopathy score, history of elementary school diffi culties, diagnosis
of a personality disorder, young age, separation from parents prior to age 16, failure on prior
conditional release, history of non-violent offences, never been married, and history of alcohol
abuse. A diagnosis of schizophrenia is considered to reduce the overall risk of recidivism
Which of the following is true with regard to the association between
learning disability and offending?
A. Above average IQ is an independent risk factor for offending
B. Severity of learning disability correlates with severity of the offence
C. Degree of learning disability correlates with rate of offending
D. Homicide is the most common offence committed by those with a learning disability
E. Substance abuse is associated with a risk of offending among the learning disabled
E. Signifi cantly below average intellectual ability is an independent predictor of future
offending, irrespective of a diagnosis of learning disability (LD). Individuals with mild LD show a
higher rate of offending than age- and sex-matched individuals without LD. No correlation has
been found between the severity of intellectual disadvantage and the seriousness of the offence
committed. In fact, individuals with more severe or profound learning disability rarely commit
serious offences. Studies in the UK have shown a rate of 2–5% for recorded offences among the
learning-disabled population. The degree of disability does not correlate with rate of offending.
The most common offences by the learning-disabled group are property offences. Many risk
factors that operate in the general population for risk of violence operate in the learningdisabled
population, e.g. being young and male, a history of family offending, being unemployed,
drug use, psychosocial disadvantage, etc
The proportion of male remand prisoners in England and Wales with at least one personality disorder is A. 20% B. 10% C. 50% D. 33% E. 80%
E. Almost 80% of male remand prisoners in England and Wales were found to have at least
one personality disorder, with antisocial personality disorder being most prevalent. From the
Offi ce of National Statistics data (1997) the prevalence of any personality disorder was 78% for
male remand prisoners, 64% for male sentenced prisoners and 50% for female prisoners (both
sentenced and remand).
Antisocial personality disorder had the highest prevalence of any category of personality disorder
(63% of male remand prisoners, 49% of male sentenced prisoners, and 31% of female prisoners)
followed by paranoid personality disorder in men (29% of male remand prisoners, 20% of male
sentenced, and 16% of female prisoners) and borderline personality disorder in women (20% of
female prisoners). Compare these rates with a weighted prevalence for any personality disorder
of 4.4% among people aged 16–74 years in households in England, Scotland and Wales
The McNaughton rules are often discussed when a defence of insanity
is used. Which of the following is NOT a factor that can be used for the
insanity defence under the McNaughton rules?
A. Disease of the mind
B. Defect of reason
C. Not knowing the nature and quality of the act
D. Defect of moral judgement
E. Absence of knowledge that the act is wrong
D. The McNaughton rules refer to a set of guidelines for the insanity defence that was used
in England until the 1960s. According to these rules one can plead the defence of insanity only
if ‘at the time of committing the act, the accused was labouring under such a defect of reason
from disease of the mind, as not to know the nature and quality of the act he was doing, or if he
did know it then he did not know he was doing what was wrong’. Those who merely lack the
capacity to control a criminal action could still be deemed punishable. Hence, a defect of moral
judgement or failure to exercise existing capability to make the right decision cannot be brought
up as an insanity defence under the McNaughton rules.
Which of the following statements is true with regard to the relationship
between antisocial personality disorder and psychopathy?
A. A minor subgroup of those with psychopathy have anti-social personality disorder
B. All those with antisocial personality are psychopathic
C. Only multiple homicide offenders can be classifi ed as psychopathic
D. Antisocial personality is a better predictor of violence risk than psychopathy
E. Impulsive aggression is more common in those with antisocial personality without
psychopathy
E. The constructs of psychopathy and antisocial or dissocial personality are often referred
to interchangeably, but in reality these are quite different concepts. Approximately 3–5% of
people in the general population would meet the criteria for antisocial personality. But less than
1% will meet the criteria for psychopathy (i.e. a high score (30/40) on the PCL-R). Similarly,
although only 15% of male prisoners have scores that fall in the psychopathy range on the
PCL-R, nearly 80% of them will satisfy the criteria for antisocial personality disorder. In other
words, although most patients (81%) diagnosed as psychopaths by the PCL-R criteria met the
criteria for a diagnosis of antisocial personality disorder, only a minority (nearly 35–40%) of
those with antisocial personality receive a diagnosis of PCL-R psychopathy. The correlation
between antisocial personality disorder and PCL-R scores was much higher for behavioural
(social deviance: r = 0.65) factor of psychopathy than affective (interpersonal: r = 0.39) factor.
Psychopaths are less impulsively aggressive than those with antisocial personality disorder, but are
more likely to engage in antisocial behaviour of an instrumental nature. Those with psychopathy
commit higher rates of serious violence and have strikingly high rates of recidivism than those
with antisocial personality disorder but who are not psychopathic.
Various neurobiological abnormalities have been documented in those with
psychopathy. Which of the following is one such feature?
A. Reduced fear-based learning
B. Increased baseline autonomic arousal
C. Reduced verbal IQ
D. Increased reactive autonomic arousal on stimulation
E. Increased P300 differentiation between target and non-target stimuli
A. Various neurobiological fi ndings have been demonstrated in those with psychopathy.
These include impairments in appreciation of the emotional signifi cance of external experience,
strikingly low levels of baseline and reactive autonomic arousal and reduced fear-based learning.
Although impaired verbal abilities have been demonstrated as a consistent risk factor for serious
antisocial and delinquent behaviour, those with psychopathic traits often show serious antisocial
behaviour, despite showing no impairment in their verbal abilities. In fact, Individuals who
were high on callous–unemotional traits (a feature of psychopathy) with higher scores on the
measure of verbal abilities reported the greatest violent delinquency in a sample of adolescent
delinquents. For non-psychopathic individuals, a signifi cant difference in P300 amplitude was
noted between target and non-target stimuli. But in psychopathic individuals reliable P300
amplitude differences between the target and non-target visual conditions were not seen.
Which of the following is associated with a risk of aggression or violent
behaviour in those without serious mental illness?
A. Neurological soft signs
B. Executive function defi cits
C. Minor physical anomalies
D. Obstetric complications in pregnancy
E. All of the above
E. Even in those who are violent but do not have a demonstrable mental illness, the
likelihood of having had a neurodevelopmental insult is high. This is shown by the presence of
higher rates of minor physical anomalies in violently delinquent adolescents. Similarly, higher rates
of neurological soft signs, maternal smoking during pregnancy, and obstetric complications have
also been demonstrated. Defects in executive functioning and impulse control have also been
shown to correlate with violence in the non-mentally ill samples.
In those who experience childhood maltreatment which of the following has
been associated with a later risk of antisocial behaviour?
A. Serotonin transporter polymorphism
B. MAO enzyme polymorphism
C. Dopamine receptor polymorphism
D. COMT polymorphism
E. Trinucleotide repeats in chromosome X
B. Children differ in their response to maltreatment in terms of future risk of criminal
behaviour. Although maltreatment increases the risk of later criminality by about 50%, most
maltreated children do not become delinquents or adult criminals. It is possible that certain
genetic susceptibility factors could infl uence the causal pathway. Caspi et al. demonstrated that
the effect of childhood maltreatment on antisocial behaviour was signifi cantly weaker among
males with high MAO-A activity than among males with low MAO-A activity. It was also shown that
girls with a low MAO-A activity genotype but not those with high MAO-A activity were more likely
to develop conduct disorder if they were maltreated. Hence, high MAO-A activity has a protective
infl uence against maltreatment for both sexes.
The most common group of mental disorders diagnosed among homicide offenders is A. Personality disorders B. Substance use disorders C. Schizophreniform disorders D. Affective disorders E. Learning disabilities
A. Depending on the defi nitions used, the rates of ‘mental disorder’ vary greatly among
homicide offenders. The national confi dential inquiry into suicide and homicide by people with
mental illness in the UK established the frequency of mental illness in a complete national sample
of homicides as 44% (lifetime history of mental disorder). At the time of the homicide, 14% had
symptoms of mental illness. The most frequent diagnosis was personality disorder (11%), closely
followed by alcohol dependence (10%) and drug dependence. Among major mental illnesses,
affective disorders (10%) were more common than schizophrenia (7%).
The proportion of those who commit homicide who are in contact with
mental health services within the previous year is
A. 1–4%
B. 8–11%
C. 40–43%
D. 60–63%
E. 80–86%
B. From the national confi dential inquiry on homicide (1996–9) data, only 8–11% of the
total sample of all homicide offenders (n=1594) were in contact with mental health services at
some time in the preceding year. The main diagnoses in those with any previous contact with
mental health services were schizophrenia (24%), personality disorder (18%), and depressive
disorder (16%). Psychiatric reports were not available for nearly one-quarter of all homicide
cases.
Compared with homicide perpetrators who kill those who are known to
them, perpetrators who kill strangers are more likely to
A. Have a history of mental disorder
B. Have a history of contact with mental health services
C. Be a young female
D. Have psychiatric symptoms at the time of offence
E. Have a history of drug misuse
E. The national confi dential inquiry on homicide (1996–9) data found that 22% of all
reported homicides were stranger homicides. In stranger homicides the perpetrator was more
likely to be a young male and less likely to have a history of mental disorder or a history of
contact with mental health services. They were also less likely to have psychiatric symptoms at
the time of the offence than perpetrators of non-stranger homicides. They were more likely to
have a history of drug or alcohol misuse
