Forensic Psychiatry 1 Flashcards
Prevalence of violence in the mentally ill
4-6x higher than general population
In how many crimes is mental illness an attributable risk factor?
<10%
Which factors have greater risk of violence than MI?
PD Alcohol and drug misuse Male 15-30 years of age Low socioeconomic status Past hx of violence
How many patients with schizophrenia were violent in first 20 weeks of dc?
9%
How many patients with depression were violent in first 20 weeks of dc?
19%
How many patients with bipolar were violent in first 20 weeks of dc?
15%
How many patients with substance misuse were violent in first 20 weeks of dc?
29%
How many patients with PD were violent in first 20 weeks of dc?
25%
How many patients with schizophrenia in the community have committed a violent act in a 12 month period?
10%
How likely are men with schizophrenia to be convicted of serious violence?
5 times greater than general population
Annual probability that a patient with schizophrenia will commit homicide
1: 3000 for men
1: 33000 for women
Who did a systematic review of prison studies?
Fazel and Danesh 2002
What did Fazel and Danesh’s systematic review involve?
62 surveys of prison studies covering 12 countries and 22,790 prisoners
Findings of Fazel and Danesh’s systematic review?
In men 3.7% had psychosis, 10% had depression, 65% had a PD.
How many prisoners suffer from an organic MI?
1%
How many homicides are due to mental disorder?
34%
How many homicides are linked to schizophrenia?
5%
How many homicide offenders have active sx of schizophrenia at time of offence
10%
Who suggested that psychosis is 10x more common in prison than the general population
Brugha et al 2005
Reasons for mental disorder being more common in the criminal justice system
Epidemiological association
Prison psychosis
Institutional bias
Penrose Law
What is prison psychosis
Incarceration is a causal agent attributed to mental disorders such as psychosis
Who suggested institutional bias?
Seddon 2007
What is the institutional bias hypothesis re MI in prisons?
Prison is a method of confining undesirable elements of society such as MH patients
What is Penrose Law?
Lionel Penrose examined association between no of people in mental institutions and crime rates in Europe.
Occupancy rates in mental institutions increased with reduction in number of murders and numbers of individuals in prison and number of live births per 1000.
Rate of homicide in the UK
1.2/100,000
How many patients convicted of homicide have some form of abnormal mental state at time of offence?
10%
How many patients with abnormal mental state at time of offence (homicide) have psychoses?
66%
How many homicide offenders have schizophrenia?
9%
How many homicide offenders have a secondary PD diagnosis?
54%
How many homicide mentally disordered offenders (MDO) had contact with MH services in past year?
10%
Annual risk of person with schizophrenia committing homicide in the UK
1 in 10,000
Annual risk of person with schizophrenia acquiring a conviction for violence
1 in 150
Victims of homicide by MDOs?
Acquaintances - family member usually
Who divided filicide into 6 groups?
D’obran 1979
What are the 6 groups of filicide
Battering mothers Mentally ill mothers Neonaticides Retaliating women Unwanted children Mercy killing
What is another way of dividing filicide?
Altruistic Psychotic Accidental Unwanted Spousal revenge related
What is filicide?
Act of killing ones own child by the mother
Describe battering mothers
Impulsive killing
Most common MI in filicide mothers
Depression
Psychotic illness
PD
Dissociative responses
Most common PD in filicide mothers
BPD
Dependent PD
Prevalence of psychosis in filicide mothers
40%
Prevalence of depression in filicide mothers
25%
Define neonaticides
Killing a child during first 24 hours of life
Describe retaliating women
Aggression towards spouse displaced on to child
Describe unwanted children
Passive neglect or active aggression associated with unplanned pregnancies and socioeconomic hardships
Which Act uses the term infanticide
Infanticide Act 1938
Definition of infanticide under the Infanticide Act
When a mother causes death of her child under the age of 12 months by wilful act or omission, but at the time of the act or omission the balance of her mind was disturbed by reason of her not having fully recovered from the effect of her having given birth to the child or by reasons of effect of lactation consequent to the birth of the child.
Incidence of infant homicide in the UK
30-45 per year
Risk factors for infanticide
Substance abuse
MI
Define murder-suicide
Murder followed by suicide of perpetrator within one week of homicide
Incidence of murder-suicide
0.2-0.3/100,000 per year
What MI is common in murder-suicides?
Depression 20-60%
Typical clinical presentations of murder-suicides
Middle-aged man recently separated of facing separation from partner, depressed and access to firearms
Older male who is caregiver of spouse who is ill where there is recent onset of new illness in the male, depression and access to firearms
What is Parricide?
Act of killing ones parents
How many homicides and parricide?
2%
Who is the perpetrator in most parricides?
Son
Aged 12-50
Motivations behind most parricides
Revenge for sexual abuse
Financial interest
Triggers of most parricides
Spontaneous act during domestic argument
Resentment, explosive anger, jealousy
Clinical risk factors of parricide
Sudden mood changes in background of intrafamilial conflict and repeated homicidal or suicidal threats
Prevalence of non fatal results in England and Wales
One million cases a year
Classifications of non-fatal assaults
Common assault
Aggravated assault
Battery
What is common assault?
Intentionally/recklessly causes another person to apprehend the application of immediate unlawful force
What is aggravated assault?
When an individual attempts to cause serious bodily injury to another or does so purposely, knowingly or recklessly under extreme indifference to value of human life
Or attempts to cause knowingly bodily injury to another with a deadly weapon
What is battery?
Intentionally/recklessly applying unlawful force to the body of another person
How many individuals convicted of non fatal violence were found to have schizophrenia?
9%
How many cases of shoplifting involve MI patients?
3.2%
Which MI is shoplifting linked to?
Affective disorders
Alcoholism
Drug addiction
When is depression linked to shoplifting?
Middle aged woman
When does shoplifting peak?
Adolescence
What is kleptomania?
Impulse control disorder
Where is Kleptomania found in ICD 10?
F63 - habit and impulse disorders
How many shoplifters have a hx of kleptomania?
1-2%
Gender differences in kleptomania
Most are women
How many people with kleptomania also have a PD?
50%
Most common PD in kleptomania?
Paranoid
Histrionic
How many fire setters intentionally started the fire?
25%
How many psychiatric patients have a hx of fire setting behaviour
26%
Which psych disorders have an association with fire setting?
PD Schizophrenia - 8% Bipolar - 11% LD Intoxication
Characteristics of fire settings
Young adult males Relationship difficulties Unmarried Poorly educated Isolated Unemployed/unskilled labourers
M:F ratio of arson
2.1:1
Primary gain of arson
Relief or excitement Delusional motive Revenge/jealousy Self-destruction/suicide Recognition Attention seeking
Secondary gain of arson
Financial Extortion Conceal crime Vandalism Political protest
Who divided arson into 2 groups?
Faulk
What is Group I arson?
Cases where the fire served as a means to an end e.g. revenge
What is Group II arson?
Cases where the fire itself was the phenomenon of interest e.g. pyromania
Describe pathological fire setters
Occurs on 2+ occassions
Preoccupation with fire
No excitement
Define pyromania
Occurs on 2+ occasions
Results in relief of tensions
What is a pyromaniac?
Fire-rasier who derives pathological excitement from setting fire
DSM IV criteria of pyromania
Deliberate and purposeful fire setting on more than one occasion
Affective arousal and tension prior to act
Fascination with fire and its situational context
Pleasure, gratification or relief when setting fires or witnessing aftermath
Exclusion criteria for pyromania
Behaviour not accounted for by CD or antisocial PD
Motive of fire setting in those <10 years
Curiosity
Gender differences in juvenile fire setters
More common in females
Females who are juvenile fire setters
Emotional meaning regarding property and others associated with revenge and hatred - displaced aggression
Recidivism rate of arson
4-20%
Poor prognostic feature of arson?
Presence of mental disorder
Main factors of recidivism in MDOs who are arsonists
Childhood firesetting Younger age at first arson Total number of firesetting offences No concurrent charges other than arson Verbalised threats to commit arson Setting fires alone Unmarried Low IQ
Treatment for arson
Behavioural or focused on intervening in family or intrapersonal stresses that may precipitate episodes.
What behavioural therapies help arsonists?
Aversive therapy
Positive reinforcement and stimulus satiation
What is stalking?
Repeated intrusion involving unwanted contact and communication
Behaviours associated with stalking
Threats Assaults Ordering or cancelling goods/services on victims behalf Sending unsolicited gifts Initialising spurious legal action Making complaints
How many stalkers are men?
80-90%
Victim profile of stalking
Women in reproductive years who have had a sexual relationship with the stalker
Perpetrator profile of stalker
Unemployed
Better educated than other criminals
Who created typologies of stalking?
Mullen 1999
Name the typologies of stalking
Rejected Intimacy seekers Incompetent suitors Resentful Predatory
Which type of stalking forms part of sexual offending?
Predatory
Primary diagnosis in stalkers
Cluster B PD
Substance abuse
In which type of stalking is delusional disorder common?
Stranger and star stalkers
PTSD rates in victims of stalking
37-60%
Factors likely to increase risk of assault in stalking
Substance misuse History of offending behaviour Male Making threats o violence or suicide or fantasising about assaults Presence of narcissistic or antisocial PD Unemployed and socially isolated Access to victims Sense of desperation Hx of non-compliance to treatment
What was the RCPsych stalking survey?
2007 survey of stalking of its members
Results of RCPsych stalking survey
22% of psychiatrists had been stalked
1 in 3 had experience of stalking behaviours which met legal definition of harassment
One college member becomes victim of new stalking every week
Profile of stalkers who target MH professionals
Male with hx of stalking
Established Axis 1 or 2 disorder
Under care of stalked clinician
What is clinical management of stalking based on
Nature of contributory mental disorder and understanding of what is sustaining the behaviour
Confronting self-deception
Instilling empathy for victim
Addressing inadequate social and interpersonal skills
Combating substance misuse
What can stalking be prosecuted under?
Protection from Harassment Act 1997
Which mental disorders are related to disinhibition?
LD PD Schizophrenia Alcohol use Hypomania
How many sex offenders have a MI?
<10%
How many offences are sexual offences?
1%
How many CSA offenders have victims known to them?
68%
How many CSA offenders have victims who are a relative?
13%
How many CSA offenders are adolescents?
33%
What is characteristics of high deviancy group of CSA offenders based on?
STEP project commissioned by Home Office
Characteristics of high deviancy CSA offenders?
Committing offences inside and outside the family
Offending against both boys and girls
Previous sexual offences
Abuse as a child
How many paedophiles can be diagnosed with another paraphilia?
50-70%
What is needed for the term incest to be used?
Penetration
Rates of incest?
Declining
Which type of relationship is not deemed incest in England but is in Scotland?
Sexual relations with step-relatives
How many cases of incest are against children?
30%
Recidivism of indecent exposure
Offender usually stops reoffending after conviction
20-30% reoffend
What is indecent exposure often a result of?
Impulsive act associated with decreased satisfaction in life.
When do most offenders commit indecent exposure?
Times of stress
More likely to be married
What is internet based sex-offending associated with?
Emotional dysregulation and intimacy deficits and depressive mood states
No prior convictions
Typologies of internet-based sex offending
Seeking emotional satisfaction
Intimacy deficit
Hypersexuality
Who conducted research into dynamic risk factors in sex offenders
Thornton, 2002
What are the dynamic risk factors in sex offenders
Sexual interests
Distorted attitudes and beliefs
Socio-affective management
Self-management
Give examples of socio-affective management
Emotional regulation
Intimacy difficulties
What is penile plethysmography
Allows to determine level of sexual arousal by measuring changes in penile tumescence when visual or auditory cues of deviant sexual material are presented
Who was influential in the development of CBT for sex offenders?
Finkelhor
What are the four stages of Finkelhors model for sexual offending?
Motivation to abuse sexually
Overcoming internal inhibitions
Overcoming external inhibitions
Overcoming resistance of victim
Treatment strategies of sex offending
Understanding offence cycle Challenging distorted thinking Understanding harm to victims Fantasy modification Social skills and anger control Relapse prevention work
Medicines used in sexual offending
Cyproterone acetate
Medroxyprogestone acetate
Buspirone
How does Cyproterone acetate work?
Blocks testosterone receptors
What are the main uses of Cyproterone acetate?
Reduction of sexual drive
Treatment of prostate ca in higher doses
SEs of Cyproterone acetate?
Deranged LFTs
Osteoporosis
Deterioration of depressive tendency
Gynaecomastia
When must Cyproterone acetate not be used?
Hx of severe depression
What is the main anti libidinal drug used in the USA?
Medroxyprogesterone acetate
How does Medroxyprogesterone acetate work?
Induces hepatic enzyme testosterone alpha-reductase, thus enhancing metabolic clearance of testosterone and reducing circulating testosterone levels
What as Buspirone been found to be useful in the treatment of?
Transvestic fetishism
Who did a study into male sex offenders in the USA
Abel et al
Recidivism of sex offending
Less than 1 in 5
Characteristics of sex offenders in Abels study
30% married
Most employed
40% had at least one year of college education
Targets of sex offenders in ABels study
67% targeted females
12% targeted males
21% targeted both
In how many subjects in Abels study did paraphilic tendencies start before 18 years of age?
> 50%
How many sexual offenders have no previous conviction for a sexual offence?
75-80%
How many child sex offenders repeated their offence against a child?
71%
How many convicted sexual offenders reconvicted in 6 years?
10%
Which type of offence leads to lowest reconviction for sex offenders?
Offence against child in own family
<10% recidivism
Which type of sexual offence leads to highest reconviction?
Offence against child outside ones family.
In which group of offenders is risk of sexual recidivism higher?
Homosexual and extra-familial sex offenders
Predictors of sexual offence
Sexual deviancy Diversity in offending Offences against male children Phallometric evidence Elevated Hare Psychopathy Scale score Reduced self-esteem and impaired victim empathy or increased anger Victim of childhood sexual abuse Violent sexual fantasies Social isolation Choice of occupational location for offending Use of sadomasochisti/paedophilic pornography Non-compliance with treatment Psychological maladjustment
What phallometric evidence is linked to increased risk of reoffending?
Increased response to paedophile stimuli or nonsexual violence
How many female survivors do not tell anyone of DV?
31%
Who are the most likely to be told of DV?
Friends
Neighbours
Relatives
How likely are police to hear of DV?
20%
How likely are medical staff to hear of DV?
10%
How many cases of DV do the police come to know about?
17-23%
How many cases of sexual assault do the police come to know about?
Less than 1 in 7
How many women suffering DV believed telling the police would make things worse?
1 in 8
How many women are affected by DV at some point in their lives?
25%
Which women are at greater risk of DV?
<40 years of age
Attributable risk fraction of schizophrenia in causing violence?
2.3%
What is Type 1 violence in schizophrenia?
Organised delusional systems relating to violence
No hx of conduct problems
Commit violence after entering treatment, almost always attacking carer or acquaintance
What type of violence is attributed to schizophrenics?
Type 2
What is Type 2 violence in schizophrenia?
Disorganised clinical syndromes
Hx of conduct disorder
Early onset substance misuse
Diverse set of offending prior to diagnosis
Who proposed the Threat/control override theory?
Link and Steuve
What does the threat/control override theory explain?
Link between violence and psychosis
Explain the threat/control override theory
Sx represent experiences of patients feeling that people are trying to harm them and experience their mind being dominated by forces outside themselves.
What explains against the threat/control override theory?
Delusions are not associated with increased risk of violence
How many prisoners abuse substances?
> 50%
How many non-fatal assaults are associated with acute intoxication?
50%
How many homicides are associated with acute intoxication?
66%
How likely are schizophrenics who misuse substances to offend?
25times more than the general population
Who are victims of most offenders with PD
Those known to them
Who are women with PD more likely to offend against compared to women without PD
Children
How many men in remand have antisocial PD
63%
How many sentenced men have antisocial PD
49%
How many female prisoners have antisocial PD
31%
How many forensic patients have antisocial PD?
67%
Risk of violence in antisocial PD
Tenfold increase
How many men in remand have BPD
23%
How many sentenced men have BPD
14%
How many female prisoners have BPD
20%
How many forensic patients have BPD
25-60%
How many remanded men have paranoid PD
29%
How many sentenced men have paranoid PD
20%
How many female prisoners have paranoid PD
16%
How many forensic patients have paranoid PD
18%
Psychopathy rates in the forensic population
15-30%
Psychopathy rates in the general population
4%
What score indicates psychopathy in the Hare Checklist
25 or more
What are the two clusters of psychopathy
Factor 1 - callous-unemotional
Factor 2 - antisocial
Describe factor 1 psychopathy
Arrogant interpersonal style
Grandiose, glib, deceitful, lack empathy
Deficient affective experience
What are most traits of Factor 1 psychopathy a result of?
Biological make-up
Heritability
Describe Factor 2 Psychopathy
Impulsive
Sensation-seeking
Lack of planning
Irresponsible
How many people with IQ <90 become delinquent?
20%
What did Lyall find re LD and offending?
2% of 358 adults with LD had contact with police in a year
Prevalence of aggressive behaviour amongst people with LD
17.6%
Patients with intellectual disability in forensic settings
These patients have longest duration of stay
Most difficult to discharge because of lack of available resources
Which offences are more common in people with LD?
Sex or fire-raising offences
Property offences
What do sex offenders with LD have a greater tendency towards?
Victims as young male children
What factors in sex offenders who have LD make their offences more likely compared to non-LD population?
Higher incidence of family psychopathology
Psychiatric illness
Social naivety
Poor ability to form normal sexual relationships
Poor impulse control
Low self-esteem
Management of sex offenders with LD
SOTP
SSRI and anti-libidinals
Reoffending rates of sex offenders with LD who are untreated
40-70%
Reoffending rates of sex offenders with LD who are treated
20-55%
When is risk of recidivism high in sex offenders who have LD?
Year following d/c
When is depression seen as a risk factor for violence?
In the context of other risk factors such as substance misuse and psychosis
What type of violence is depression a risk factor for?
Domestic killings
How can depression lead to violence?
Can act as a disinhibitor after provocations
How many prisoners have a form of anxiety disorder
10-25%
When is dissociation seen in offenders?
At time of violence/arousal or in response to extreme fear which may precede violence
What is dissociative/psychogenic amnesia associated with?
Violence to a known victim and with the perpetrator aroused or intoxicated with alcohol.
Prevalence of epilepsy in prison
1-2%
When is ictal violence more likely?
Partial and tonic clonic seizures
Which two conditions related to epilepsy may be linked with violence?
Episodic dyscontrol syndrome
Explosive personality/intermittent explosive disorder
What happens in episodic dyscontrol syndrome?
Lack of memory for explosive violence
Which classification recognises intermittent explosive disorder?
DSM
How can Aspergers lead to violence?
ToM deficit
Presence of egocentricity
Deficits in social reciprocity
All can lead to lack of awareness of impact on victims and what is wrong
ASD and link with violence?
Those with ASD commit more violent offences and criminal damage than general population
When violence occurs in sleep disturbance, which gender is it more common in?
Males
Factors associated with violence during sleep disorders
Hx of parasomnias
Sleep deprivation
Cannabis/alcohol use
What has been suggested for assessment of those who malinger
Prolonged admission for assessment
Use of SIRS/SIMS/TOMM
Polygraphs - USA only
What is SIMS
Structured inventory of reported/malingering symptoms
What is TOMM?
Test of malingering memory
What is Munchausens?
Factitious illness where sx are created intentionally, motivated to assume sick role with absence of external incentives
Factors associated with Mucnhausens
PD
Attention seeking behaviour
Masochistic tendernes
Medication seeking behaviours
Management of Munchausens
Safeguarding process if by proxy
Treat any depressive disorder
Efforts to limit behaviour
Common conditions related to Othello syndrome
Paranoid PD
Risks associated with Othello
Risk of partners and children Self-harm Substance Misuse DV Homicide
What is De Clerambaults syndrome?
Erotomania
Gender differences in Erotomania?
More common in women
What disorder is Erotomania associated with?
Psychotic disorders
Another name for Gansers syndrome?
Hysterical Dissociative disorder
What happens in Gansers syndrome?
Approximate answers
Clouding of consciousness with disorientation
Psychogenic physical sx
Amnesic for abnormal behaviour
Who is Gansers Syndrome common in?
Prisoners (esp military)
Individuals absenting themselves from navy/army
How many men are convicted by the age of 46?
33%
How many women are convicted by the age of 46?
9%
How many men are responsible for 2/3 of crimes?
8%
How many offenders are women?
1 in 5
Peak offending age of women vs men
2-3 years earlier than men
Peak age of offending in females
14
Peak age of ofgending in males
17-18
Sex ratio of convicted men to women
5:1
How many homicide victims were young men
55%
In how many homicides was both the perpetrator and victim female?
3%
What is index offence for women more likely to be?
Romantic or domestic disputes
How many women are in prison for non-violent offences?
68%
Who are victims of womens violent acts more likely to be?
Family members
How many women in prison are there due to drug offences?
25%
Difference in men and women who repeat violence
Women have less chance of receiving a custodial sentence
Psychiatric pleas made by women vs men who commit violence
Women make more pleas and receive more psychiatric disposals
How many women in prison are estimated to be mothers?
50%
Reoffending rate of men and women
46.6 - men
45 - women
How much more likely are women in custody to have MI compared to the general population?
5x
How many women in prison have a diagnosable MI?
80%
How many women on remand suffered from psychosis?
1 in 5
How many women attempted suicide during the year before custody
19%
3x higher than men
How many male and female offenders have alcohol misuse
42% - men
31% - women
Age of criminal responsibility in England and Wales
10
Age of criminal responsibility in Scotland
8
What is classed as a juvenile offender?
Aged 10-17
What is classed as a young offender?
18-21
What law is used when young people on conviction or remand are unmanageable at home or in foster care
Civil Child Care Law
Options for convicted young offenders and those on remand
Young offender institutes Secure training centres Detention schools Secure childrens homes for young offenders 12-16 years Adolescent secure hospitals
BME and MH care
More likely to be diagnosed with schizophrenia
More likely to be admitted involuntarily
More likely to be secluded and restrained
More likely to be given custodial sentence
Over-representation in criminal justice system
Which type of crime is strongly associated with social withdrawal of the victim?
Sexual assault
How many prisoners have PTSD
20%
What is complex PTSD associated with?
Prolonged abuse as a child
What does psychosis combined with PTSD often result in?
More positive sx, thus possible increase in paranoid/violent thoughts and problem behaviours
When can the index offence be a trigger for PTSD?
If offence was unplanned
Offender was disinhibited
No past forensic hx
How many patients with SMI were victims of crime in past year?
40%
14% - general population
How likely are women with SMI to be victims of DV
4x more likely than general population
How likely are women with SMI to be victims of sexual violence
4x more than general population
How likely are women with SMI to be victims of any violence in the community
10x more likely than general population
