Forensic Psychiatry 1 Flashcards
1
Q
Prevalence of violence in the mentally ill
A
4-6x higher than general population
2
Q
In how many crimes is mental illness an attributable risk factor?
A
<10%
3
Q
Which factors have greater risk of violence than MI?
A
PD
Alcohol and drug misuse
Male
15-30 years of age
Low socioeconomic status
Past hx of violence
4
Q
How many patients with schizophrenia were violent in first 20 weeks of dc?
A
9%
5
Q
How many patients with depression were violent in first 20 weeks of dc?
A
19%
6
Q
How many patients with bipolar were violent in first 20 weeks of dc?
A
15%
7
Q
How many patients with substance misuse were violent in first 20 weeks of dc?
A
29%
8
Q
How many patients with PD were violent in first 20 weeks of dc?
A
25%
9
Q
How many patients with schizophrenia in the community have committed a violent act in a 12 month period?
A
10%
10
Q
How likely are men with schizophrenia to be convicted of serious violence?
A
5 times greater than general population
11
Q
Annual probability that a patient with schizophrenia will commit homicide
A
1:3000 for men
1:33000 for women
12
Q
Who did a systematic review of prison studies?
A
Fazel and Danesh 2002
13
Q
What did Fazel and Danesh’s systematic review involve?
A
62 surveys of prison studies covering 12 countries and 22,790 prisoners
14
Q
Findings of Fazel and Danesh’s systematic review?
A
In men 3.7% had psychosis, 10% had depression, 65% had a PD.
15
Q
How many prisoners suffer from an organic MI?
A
1%
16
Q
How many homicides are due to mental disorder?
A
34%
17
Q
How many homicides are linked to schizophrenia?
A
5%
18
Q
How many homicide offenders have active sx of schizophrenia at time of offence
A
10%
19
Q
Who suggested that psychosis is 10x more common in prison than the general population
A
Brugha et al 2005
20
Q
Reasons for mental disorder being more common in the criminal justice system
A
Epidemiological association
Prison psychosis
Institutional bias
Penrose Law
21
Q
What is prison psychosis
A
Incarceration is a causal agent attributed to mental disorders such as psychosis
22
Q
Who suggested institutional bias?
A
Seddon 2007
23
Q
What is the institutional bias hypothesis re MI in prisons?
A
Prison is a method of confining undesirable elements of society such as MH patients
24
Q
What is Penrose Law?
A
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.
25
Rate of homicide in the UK
1.2/100,000
26
How many patients convicted of homicide have some form of abnormal mental state at time of offence?
10%
27
How many patients with abnormal mental state at time of offence (homicide) have psychoses?
66%
28
How many homicide offenders have schizophrenia?
9%
29
How many homicide offenders have a secondary PD diagnosis?
54%
30
How many homicide mentally disordered offenders (MDO) had contact with MH services in past year?
10%
31
Annual risk of person with schizophrenia committing homicide in the UK
1 in 10,000
32
Annual risk of person with schizophrenia acquiring a conviction for violence
1 in 150
33
Victims of homicide by MDOs?
Acquaintances - family member usually
34
Who divided filicide into 6 groups?
D'obran 1979
35
What are the 6 groups of filicide
Battering mothers
Mentally ill mothers
Neonaticides
Retaliating women
Unwanted children
Mercy killing
36
What is another way of dividing filicide?
Altruistic
Psychotic
Accidental
Unwanted
Spousal revenge related
37
What is filicide?
Act of killing ones own child by the mother
38
Describe battering mothers
Impulsive killing
39
Most common MI in filicide mothers
Depression
Psychotic illness
PD
Dissociative responses
40
Most common PD in filicide mothers
BPD
Dependent PD
41
Prevalence of psychosis in filicide mothers
40%
42
Prevalence of depression in filicide mothers
25%
43
Define neonaticides
Killing a child during first 24 hours of life
44
Describe retaliating women
Aggression towards spouse displaced on to child
45
Describe unwanted children
Passive neglect or active aggression associated with unplanned pregnancies and socioeconomic hardships
46
Which Act uses the term infanticide
Infanticide Act 1938
47
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.
48
Incidence of infant homicide in the UK
30-45 per year
49
Risk factors for infanticide
Substance abuse
MI
50
Define murder-suicide
Murder followed by suicide of perpetrator within one week of homicide
51
Incidence of murder-suicide
0.2-0.3/100,000 per year
52
What MI is common in murder-suicides?
Depression 20-60%
53
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
54
What is Parricide?
Act of killing ones parents
55
How many homicides and parricide?
2%
56
Who is the perpetrator in most parricides?
Son
Aged 12-50
57
Motivations behind most parricides
Revenge for sexual abuse
Financial interest
58
Triggers of most parricides
Spontaneous act during domestic argument
Resentment, explosive anger, jealousy
59
Clinical risk factors of parricide
Sudden mood changes in background of intrafamilial conflict and repeated homicidal or suicidal threats
60
Prevalence of non fatal results in England and Wales
One million cases a year
61
Classifications of non-fatal assaults
Common assault
Aggravated assault
Battery
62
What is common assault?
Intentionally/recklessly causes another person to apprehend the application of immediate unlawful force
63
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
64
What is battery?
Intentionally/recklessly applying unlawful force to the body of another person
65
How many individuals convicted of non fatal violence were found to have schizophrenia?
9%
66
How many cases of shoplifting involve MI patients?
3.2%
67
Which MI is shoplifting linked to?
Affective disorders
Alcoholism
Drug addiction
68
When is depression linked to shoplifting?
Middle aged woman
69
When does shoplifting peak?
Adolescence
70
What is kleptomania?
Impulse control disorder
71
Where is Kleptomania found in ICD 10?
F63 - habit and impulse disorders
72
How many shoplifters have a hx of kleptomania?
1-2%
73
Gender differences in kleptomania
Most are women
74
How many people with kleptomania also have a PD?
50%
75
Most common PD in kleptomania?
Paranoid
Histrionic
76
How many fire setters intentionally started the fire?
25%
77
How many psychiatric patients have a hx of fire setting behaviour
26%
78
Which psych disorders have an association with fire setting?
PD
Schizophrenia - 8%
Bipolar - 11%
LD
Intoxication
79
Characteristics of fire settings
Young adult males
Relationship difficulties
Unmarried
Poorly educated
Isolated
Unemployed/unskilled labourers
80
M:F ratio of arson
2.1:1
81
Primary gain of arson
Relief or excitement
Delusional motive
Revenge/jealousy
Self-destruction/suicide
Recognition
Attention seeking
82
Secondary gain of arson
Financial
Extortion
Conceal crime
Vandalism
Political protest
83
Who divided arson into 2 groups?
Faulk
84
What is Group I arson?
Cases where the fire served as a means to an end e.g. revenge
85
What is Group II arson?
Cases where the fire itself was the phenomenon of interest e.g. pyromania
86
Describe pathological fire setters
Occurs on 2+ occassions
Preoccupation with fire
No excitement
87
Define pyromania
Occurs on 2+ occasions
Results in relief of tensions
88
What is a pyromaniac?
Fire-rasier who derives pathological excitement from setting fire
89
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
90
Exclusion criteria for pyromania
Behaviour not accounted for by CD or antisocial PD
91
Motive of fire setting in those <10 years
Curiosity
92
Gender differences in juvenile fire setters
More common in females
93
Females who are juvenile fire setters
Emotional meaning regarding property and others associated with revenge and hatred - displaced aggression
94
Recidivism rate of arson
4-20%
95
Poor prognostic feature of arson?
Presence of mental disorder
96
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
97
Treatment for arson
Behavioural or focused on intervening in family or intrapersonal stresses that may precipitate episodes.
98
What behavioural therapies help arsonists?
Aversive therapy
Positive reinforcement and stimulus satiation
99
What is stalking?
Repeated intrusion involving unwanted contact and communication
100
Behaviours associated with stalking
Threats
Assaults
Ordering or cancelling goods/services on victims behalf
Sending unsolicited gifts
Initialising spurious legal action
Making complaints
101
How many stalkers are men?
80-90%
102
Victim profile of stalking
Women in reproductive years who have had a sexual relationship with the stalker
103
Perpetrator profile of stalker
Unemployed
Better educated than other criminals
104
Who created typologies of stalking?
Mullen 1999
105
Name the typologies of stalking
Rejected
Intimacy seekers
Incompetent suitors
Resentful
Predatory
106
Which type of stalking forms part of sexual offending?
Predatory
107
Primary diagnosis in stalkers
Cluster B PD
Substance abuse
108
In which type of stalking is delusional disorder common?
Stranger and star stalkers
109
PTSD rates in victims of stalking
37-60%
110
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
111
What was the RCPsych stalking survey?
2007 survey of stalking of its members
112
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
113
Profile of stalkers who target MH professionals
Male with hx of stalking
Established Axis 1 or 2 disorder
Under care of stalked clinician
114
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
115
What can stalking be prosecuted under?
Protection from Harassment Act 1997
116
Which mental disorders are related to disinhibition?
LD
PD
Schizophrenia
Alcohol use
Hypomania
117
How many sex offenders have a MI?
<10%
118
How many offences are sexual offences?
1%
119
How many CSA offenders have victims known to them?
68%
120
How many CSA offenders have victims who are a relative?
13%
121
How many CSA offenders are adolescents?
33%
122
What is characteristics of high deviancy group of CSA offenders based on?
STEP project commissioned by Home Office
123
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
124
How many paedophiles can be diagnosed with another paraphilia?
50-70%
125
What is needed for the term incest to be used?
Penetration
126
Rates of incest?
Declining
127
Which type of relationship is not deemed incest in England but is in Scotland?
Sexual relations with step-relatives
128
How many cases of incest are against children?
30%
129
Recidivism of indecent exposure
Offender usually stops reoffending after conviction
20-30% reoffend
130
What is indecent exposure often a result of?
Impulsive act associated with decreased satisfaction in life.
131
When do most offenders commit indecent exposure?
Times of stress
More likely to be married
132
What is internet based sex-offending associated with?
Emotional dysregulation and intimacy deficits and depressive mood states
No prior convictions
133
Typologies of internet-based sex offending
Seeking emotional satisfaction
Intimacy deficit
Hypersexuality
134
Who conducted research into dynamic risk factors in sex offenders
Thornton, 2002
135
What are the dynamic risk factors in sex offenders
Sexual interests
Distorted attitudes and beliefs
Socio-affective management
Self-management
136
Give examples of socio-affective management
Emotional regulation
Intimacy difficulties
137
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
138
Who was influential in the development of CBT for sex offenders?
Finkelhor
139
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
140
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
141
Medicines used in sexual offending
Cyproterone acetate
Medroxyprogestone acetate
Buspirone
142
How does Cyproterone acetate work?
Blocks testosterone receptors
143
What are the main uses of Cyproterone acetate?
Reduction of sexual drive
Treatment of prostate ca in higher doses
144
SEs of Cyproterone acetate?
Deranged LFTs
Osteoporosis
Deterioration of depressive tendency
Gynaecomastia
145
When must Cyproterone acetate not be used?
Hx of severe depression
146
What is the main anti libidinal drug used in the USA?
Medroxyprogesterone acetate
147
How does Medroxyprogesterone acetate work?
Induces hepatic enzyme testosterone alpha-reductase, thus enhancing metabolic clearance of testosterone and reducing circulating testosterone levels
148
What as Buspirone been found to be useful in the treatment of?
Transvestic fetishism
149
Who did a study into male sex offenders in the USA
Abel et al
150
Recidivism of sex offending
Less than 1 in 5
151
Characteristics of sex offenders in Abels study
30% married
Most employed
40% had at least one year of college education
152
Targets of sex offenders in ABels study
67% targeted females
12% targeted males
21% targeted both
153
In how many subjects in Abels study did paraphilic tendencies start before 18 years of age?
>50%
154
How many sexual offenders have no previous conviction for a sexual offence?
75-80%
155
How many child sex offenders repeated their offence against a child?
71%
156
How many convicted sexual offenders reconvicted in 6 years?
10%
157
Which type of offence leads to lowest reconviction for sex offenders?
Offence against child in own family
<10% recidivism
158
Which type of sexual offence leads to highest reconviction?
Offence against child outside ones family.
159
In which group of offenders is risk of sexual recidivism higher?
Homosexual and extra-familial sex offenders
160
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
161
What phallometric evidence is linked to increased risk of reoffending?
Increased response to paedophile stimuli or nonsexual violence
162
How many female survivors do not tell anyone of DV?
31%
163
Who are the most likely to be told of DV?
Friends
Neighbours
Relatives
164
How likely are police to hear of DV?
20%
165
How likely are medical staff to hear of DV?
10%
166
How many cases of DV do the police come to know about?
17-23%
167
How many cases of sexual assault do the police come to know about?
Less than 1 in 7
168
How many women suffering DV believed telling the police would make things worse?
1 in 8
169
How many women are affected by DV at some point in their lives?
25%
170
Which women are at greater risk of DV?
<40 years of age
171
Attributable risk fraction of schizophrenia in causing violence?
2.3%
172
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
173
What type of violence is attributed to schizophrenics?
Type 2
174
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
175
Who proposed the Threat/control override theory?
Link and Steuve
176
What does the threat/control override theory explain?
Link between violence and psychosis
177
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.
178
What explains against the threat/control override theory?
Delusions are not associated with increased risk of violence
179
How many prisoners abuse substances?
>50%
180
How many non-fatal assaults are associated with acute intoxication?
50%
181
How many homicides are associated with acute intoxication?
66%
182
How likely are schizophrenics who misuse substances to offend?
25times more than the general population
183
Who are victims of most offenders with PD
Those known to them
184
Who are women with PD more likely to offend against compared to women without PD
Children
185
How many men in remand have antisocial PD
63%
186
How many sentenced men have antisocial PD
49%
187
How many female prisoners have antisocial PD
31%
188
How many forensic patients have antisocial PD?
67%
189
Risk of violence in antisocial PD
Tenfold increase
190
How many men in remand have BPD
23%
191
How many sentenced men have BPD
14%
192
How many female prisoners have BPD
20%
193
How many forensic patients have BPD
25-60%
194
How many remanded men have paranoid PD
29%
195
How many sentenced men have paranoid PD
20%
196
How many female prisoners have paranoid PD
16%
197
How many forensic patients have paranoid PD
18%
198
Psychopathy rates in the forensic population
15-30%
199
Psychopathy rates in the general population
4%
200
What score indicates psychopathy in the Hare Checklist
25 or more
201
What are the two clusters of psychopathy
Factor 1 - callous-unemotional
Factor 2 - antisocial
202
Describe factor 1 psychopathy
Arrogant interpersonal style
Grandiose, glib, deceitful, lack empathy
Deficient affective experience
203
What are most traits of Factor 1 psychopathy a result of?
Biological make-up
Heritability
204
Describe Factor 2 Psychopathy
Impulsive
Sensation-seeking
Lack of planning
Irresponsible
205
How many people with IQ <90 become delinquent?
20%
206
What did Lyall find re LD and offending?
2% of 358 adults with LD had contact with police in a year
207
Prevalence of aggressive behaviour amongst people with LD
17.6%
208
Patients with intellectual disability in forensic settings
These patients have longest duration of stay
Most difficult to discharge because of lack of available resources
209
Which offences are more common in people with LD?
Sex or fire-raising offences
Property offences
210
What do sex offenders with LD have a greater tendency towards?
Victims as young male children
211
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
212
Management of sex offenders with LD
SOTP
SSRI and anti-libidinals
213
Reoffending rates of sex offenders with LD who are untreated
40-70%
214
Reoffending rates of sex offenders with LD who are treated
20-55%
215
When is risk of recidivism high in sex offenders who have LD?
Year following d/c
216
When is depression seen as a risk factor for violence?
In the context of other risk factors such as substance misuse and psychosis
217
What type of violence is depression a risk factor for?
Domestic killings
218
How can depression lead to violence?
Can act as a disinhibitor after provocations
219
How many prisoners have a form of anxiety disorder
10-25%
220
When is dissociation seen in offenders?
At time of violence/arousal or in response to extreme fear which may precede violence
221
What is dissociative/psychogenic amnesia associated with?
Violence to a known victim and with the perpetrator aroused or intoxicated with alcohol.
222
Prevalence of epilepsy in prison
1-2%
223
When is ictal violence more likely?
Partial and tonic clonic seizures
224
Which two conditions related to epilepsy may be linked with violence?
Episodic dyscontrol syndrome
Explosive personality/intermittent explosive disorder
225
What happens in episodic dyscontrol syndrome?
Lack of memory for explosive violence
226
Which classification recognises intermittent explosive disorder?
DSM
227
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
228
ASD and link with violence?
Those with ASD commit more violent offences and criminal damage than general population
229
When violence occurs in sleep disturbance, which gender is it more common in?
Males
230
Factors associated with violence during sleep disorders
Hx of parasomnias
Sleep deprivation
Cannabis/alcohol use
231
What has been suggested for assessment of those who malinger
Prolonged admission for assessment
Use of SIRS/SIMS/TOMM
Polygraphs - USA only
232
What is SIMS
Structured inventory of reported/malingering symptoms
233
What is TOMM?
Test of malingering memory
234
What is Munchausens?
Factitious illness where sx are created intentionally, motivated to assume sick role with absence of external incentives
235
Factors associated with Mucnhausens
PD
Attention seeking behaviour
Masochistic tendernes
Medication seeking behaviours
236
Management of Munchausens
Safeguarding process if by proxy
Treat any depressive disorder
Efforts to limit behaviour
237
Common conditions related to Othello syndrome
Paranoid PD
238
Risks associated with Othello
Risk of partners and children
Self-harm
Substance Misuse
DV
Homicide
239
What is De Clerambaults syndrome?
Erotomania
240
Gender differences in Erotomania?
More common in women
241
What disorder is Erotomania associated with?
Psychotic disorders
242
Another name for Gansers syndrome?
Hysterical Dissociative disorder
243
What happens in Gansers syndrome?
Approximate answers
Clouding of consciousness with disorientation
Psychogenic physical sx
Amnesic for abnormal behaviour
244
Who is Gansers Syndrome common in?
Prisoners (esp military)
Individuals absenting themselves from navy/army
245
How many men are convicted by the age of 46?
33%
246
How many women are convicted by the age of 46?
9%
247
How many men are responsible for 2/3 of crimes?
8%
248
How many offenders are women?
1 in 5
249
Peak offending age of women vs men
2-3 years earlier than men
250
Peak age of offending in females
14
251
Peak age of ofgending in males
17-18
252
Sex ratio of convicted men to women
5:1
253
How many homicide victims were young men
55%
254
In how many homicides was both the perpetrator and victim female?
3%
255
What is index offence for women more likely to be?
Romantic or domestic disputes
256
How many women are in prison for non-violent offences?
68%
257
Who are victims of womens violent acts more likely to be?
Family members
258
How many women in prison are there due to drug offences?
25%
259
Difference in men and women who repeat violence
Women have less chance of receiving a custodial sentence
260
Psychiatric pleas made by women vs men who commit violence
Women make more pleas and receive more psychiatric disposals
261
How many women in prison are estimated to be mothers?
50%
262
Reoffending rate of men and women
46.6 - men
45 - women
263
How much more likely are women in custody to have MI compared to the general population?
5x
264
How many women in prison have a diagnosable MI?
80%
265
How many women on remand suffered from psychosis?
1 in 5
266
How many women attempted suicide during the year before custody
19%
3x higher than men
267
How many male and female offenders have alcohol misuse
42% - men
31% - women
268
Age of criminal responsibility in England and Wales
10
269
Age of criminal responsibility in Scotland
8
270
What is classed as a juvenile offender?
Aged 10-17
271
What is classed as a young offender?
18-21
272
What law is used when young people on conviction or remand are unmanageable at home or in foster care
Civil Child Care Law
273
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
274
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
275
Which type of crime is strongly associated with social withdrawal of the victim?
Sexual assault
276
How many prisoners have PTSD
20%
277
What is complex PTSD associated with?
Prolonged abuse as a child
278
What does psychosis combined with PTSD often result in?
More positive sx, thus possible increase in paranoid/violent thoughts and problem behaviours
279
When can the index offence be a trigger for PTSD?
If offence was unplanned
Offender was disinhibited
No past forensic hx
280
How many patients with SMI were victims of crime in past year?
40%
14% - general population
281
How likely are women with SMI to be victims of DV
4x more likely than general population
282
How likely are women with SMI to be victims of sexual violence
4x more than general population
283
How likely are women with SMI to be victims of any violence in the community
10x more likely than general population
