Forensic Psychiatry Flashcards
Definition and role of forensic psychiatry
-The assessment and treatment of mentally disordered offenders as well as the assessment of the dangerousness of individuals who may not yet have committed an offence: those who pose a high risk to the safety of others
=Typical offences that can lead to assessment = murder, attempted murder, severe sexual assault or arson
-Some patients can be managed in the community, others may require treatment and rehab in a secure environment
=Range of security levels – general prison population à locked ward in psychiatric hospital à high-security hospital (e.g. Broadmoor)
Epidemiology of forensic psychiatry
-The majority of patients with a mental illness never commit an offence
-Most offences are not committed as a result of mental illness
-Patients with mental illness are 4x more likely to be a victim of violence than the general population
-However, there is a significantly higher prevalence of mental illness among the prison population than the general population
=1 in 6 prisoners have a major depressive or psychotic illness, F>M
-Substance misuse is extremely common in prisons (around one quarter misuse alcohol and one third misuse other substances)
-The suicide rate in custody is 9x greater than the general population:
=Especially: male remand prisoners, those in their first week, with a history of substance misuse, charged with violent or sexual offence and in single cell accommodation
Mental illnesses associated with crime
-Personality disorder 10-65%
=Violent crime, especially antisocial PD Antisocial and EUPD are frequently diagnosed in the forensic setting, often with comorbid substance abuse
-Alcohol substance misuse 10-60% substance, 10-30% alcohol misuse
=Significant increase in risk of violence. Alcohol freq causes driving offences, breach of the peace. Offences may be committed to fund habits
-Psychotic disorders 5%
=4x increased risk of violent acts in schizophrenia, though most offences minor, more likely to be a victim
-Mood disorders 10% depression, 2-7% bipolar affective disorder
=Mood-congruent delusions can
result murder-suicide rarely
=Post-natal depression risk for maternal filicide rarely
=Crime when manic is often not serious (financial errors)
Aetiology of forensics
-A mental disorder alone is rarely sufficient to lead to offending behaviour
-In reality, risk factors which predispose to a mental illness commonly also predispose to offending (e.g. chronic stress, childhood abuse, substance misuse)
Assessing the risk of violence
-Number of approaches to estimating risk exist (e.g. actuarial methods [“bigdata” prediction]; structured clinical interviews e.g. Historical Clinical Risk Management 20-item scale [HCR-20]), no definitive methods (pros & cons with all)
-Balance of risk to community vs respecting human rights of the individual
-Forensic MDTs have moved to predicting the risk of future violence= formulation of scenarios in which future violence more likely to occur= management plans to decrease future risk proactively (e.g. trigger avoidance)
-History of violent behaviour is the best predictor for future violence
-Clinicians have a duty to breach confidentiality if a significant specific risk to others is identified (e.g. a clear target for violence)
Factors associated with risk of violence (HCR-20)
H= Historical
H1. Violence (best predictor for future violence)
H2. Other antisocial behaviour
H3. Relationships
H4. Employment
H5. Substance use
H6. Major mental disorder
H7. Personality disorder
H8. Traumatic experience
H9. Violent attitudes
H10. Treatment or supervision repsonse
Clinical (recent problems)
C1. Insight
C2. Violent ideation or intent
C3. Symptoms of major mental disorder
C4. Instability
C5. Treatment or supervision response
Risk management (future problems)
R1. Professional services and plans
R2. Living situation
R3. Personal support
R4. Treatment or supervision response
R5. Stress or coping
Internal vs external factors
-Internal
=Symptoms (delusions, hallucinations)
=Threats (towards particular victim or group)
=Fantasies (violent, sexual)
=Attitudes (pro-criminal, minimization, denial)
=Impulsivity/ instability (affective, behavioural, cognitive)
=Insight (Into illness, personality, previous violence precursors)
=Response to treatment or supervision (pharmacological and psychosocial)
=Plans (realistic)
-External
=Weapons
=Access to victims
=Support (formal and informal)
=Destabilisers (alcohol, drugs, homelessness, victimisation)
=Stress (relationship problems, debt, life events)
Factors in history
-Previous violence, whether investigated, convicted or unknown
to the criminal justice system.
-Relationship of violence to mental state.
-Lack of supportive relationships.
-Poor concordance with treatment, discontinuation or
disengagement.
-Impulsivity.
-Alcohol or substance use, and the effects of these.
-Early exposure to violence or being part of a violent subculture.
-Triggers or changes in behaviour or mental state that have
occurred prior to previous violence or relapse.
-Are risk factors stable or have any changed recently?
-Is anything likely to occur that will change the risk?
-Evidence of recent stressors, losses or threat of loss.
-Factors that have stopped the person acting violently in the past.
-Are the family/carers at risk? History of domestic violence.
-Lack of empathy.
-Relationship of violence to personality factors.
Factors in mental state
-Evidence of symptoms related to threat or control, delusions
of persecution by others, or of mind or body being controlled
or interfered with by external forces, or passivity experiences.
-Voicing emotions related to violence or exhibiting emotional
arousal (e.g. irritability, anger, hostility, suspiciousness, excitement, enjoyment, notable lack of emotion, cruelty or incongruity).
-Specific threats or ideas of retaliation.
-Grievance thinking.
-Thoughts linking violence and suicide (homicide–suicide).
-Thoughts of sexual violence.
-Evolving symptoms and unpredictability.
-Signs of psychopathy.
-Restricted insight and capacity.
-Patient’s own narrative and view of their risks to others.
-What does the person think they are capable of? Do they think
they could kill?
-Beware ‘invisible’ risk factors
Risk formulation
-How serious is the risk?
-How immediate is the risk?
-Is the risk specific or general?
-How volatile is the risk?
-What are the signs of increasing risk?
-Which specific treatment, and which management plan, can
best reduce the risk?
Management of offenders with mental illnesses
Government initiatives aimed at treating and rehabilitating these offenders in specialist units until they can be reintroduced into society has resulted inpatients with personality disorders being detained longer than those without who have committed similar crimes
Considerations in court proceedings against individual with diagnosed or suspected mental illness
-Fitness to plead
=Able to understand the difference between guilty and not guilty, understand the charges, instruct legal counsel, follow evidence in court, challenge a juror)
-Criminal responsibility
=Whether, at the time of the offence, the accused realised the nature of, and intended to commit, an unlawful act.
=May be decreased due to: age (children <10yrs are deemed incapable of criminal acts), reason of insanity, diminished responsibility (murder / manslaughter only),automatism (act committed without presence of mind e.g. during a seizure or asleep)
-Note – self-induced intoxication cannot be used as a defence on the grounds of insanity or diminished responsibility
Orders the courts can impose under the Criminal Procedure Act Scotland to admit offenders with mental disorder to psychiatric hospital
-Assessment Orders and Treatment Orders: allows for assessment in hospital prior to conviction or acquittal. Only the Treatment Order allows psychotropic medication to be given.
-Compulsion Orders: allows for treatment in hospital (or the community) as an alternative to prison. This is very similar to a Compulsory Treatment Order.
-Compulsion Order and Restriction Order: a Restriction Order is added to a Compulsion Order when the court thinks that a person is a serious risk to the public. The person may have their freedoms restricted through things like drug testing and having exclusion zones from places due to victim issues. The Scottish Government need to be involved in decision around passes and risk assessment.
-Transfer for Treatment Direction: this allows for sentenced prisoners to be admitted to hospital if they develop a mental illness within prison
