Crime & Mental Disorder

Steve Ramplin Consultant Forensic Psychiatrist [email protected] “The Main Problem in discussing the relationship between criminal behaviour and mental disorder is that the two concepts are largely unrelated.” Prof. Gunn BJP 1977 Highlights from Crime in E&W 2018 • Is crime increasing or decreasing? Focus of Remainder of Session – , Schizotypal and Delusional Disorders – Disorders of Adult Personality and Behaviour – Affective and Neurotic Disorders (briefly)

• Covered in other sessions ... – Psychoactive Substance Use – Organic Mental Disorders – Paraphilias – – Puerperal (within other psychiatric defences) Discussion

• How are crime and psychotic mental illness related? Schizophrenia, Schizotypal and Delusional Disorders (1) • Epidemiology • Clinical Presentation and relevance to Crime • Delusional Disorders • Case Examples Schizophrenia, Schizotypal and Delusional Disorders (2) Epidemiology

From Walsh et al, BJP 2002, Violence and Schizophrenia: examining evidence

20% - Estimated prevalence of first admission patient with schizophrenia behaving in life threatening manner prior to admission (Humphreys et al 1992)

MacArthur Data: Violence in patients within 20 weeks post discharge Of 17% of discharged patients diagnosed with schizophrenia 9% were violent within 20 weeks post discharge Schizophrenia, Schizotypal and Delusional Disorders (3) Epidemiology

20 week Violence Prevalence by Diagnosis

30%

25%

20%

15%

10%

5%

0% Schizophrenia Depression Bipolar Other Substance Personality Psychosis Misuse Disorder Schizophrenia, Schizotypal and Delusional Disorders (4) Epidemiology

From Walsh et al, BJP 2002, Violence and Schizophrenia: examining evidence

Prevalence of Schizophrenia in individuals who have committed violent acts in prison remand population (Taylor and Gunn,1984) 11% of those later convicted of fatal violence 9% of those later convicted of non-fatal violence

General population base rate Schizophrenia, Schizotypal and Delusional Disorders (5) Epidemiology

From Walsh et al, BJP 2002, Violence and Schizophrenia: examining evidence

ECA Community Cohort 30% co-morbidity with substance misuse violent

8% with Schizophrenia Violent 2% with no mental illness violent Schizophrenia, Schizotypal and Delusional Disorders (6) Epidemiology Schizophrenia, Schizotypal and Delusional Disorders (7) Epidemiology

From Fazel et al, 2009, PLoS Medicine, Schizophrenia and Violence: Systematic Review and Meta-Analysis

Schizophrenia ♀ Pooled Odds Ratio (OR) 8.2

Schizophrenia ♂OR 4.7 (OR 3.8 adjusted for SEC) Schizophrenia, Schizotypal and Delusional Disorders (8) Epidemiology Schizophrenia, Schizotypal and Delusional Disorders (9) Epidemiology Schizophrenia, Schizotypal and Delusional Disorders (10) Clinical Presentation and Relevance to Crime

• Schizophrenia: – of Thought Interference (Thought withdrawal, insertion, broadcasting) – Delusions of Control (Passivity); Delusional Perception – Auditory Hallucinations (Running Commentary, Voices Arguing, thought echo) – Persistent Delusions – Persistent hallucinations in any modality – Formal – Catatonia – Negative Symptoms – Functional deterioration Schizophrenia, Schizotypal and Delusional Disorders (10) Clinical Presentation and Relevance to Crime

• Schizophrenia: – Delusions of Thought Interference (Thought withdrawal, insertion, broadcasting) – Delusions of Control (Passivity); Delusional Perception – Auditory Hallucinations (Running Commentary, Voices Arguing, thought echo) – Persistent Delusions: Persecutory – Persistent hallucinations in any modality, including command hallucinations – Formal thought disorder – Catatonia – Negative Symptoms – Functional deterioration Schizophrenia, Schizotypal and Delusional Disorders (10) Clinical Presentation and Relevance to Crime

• Schizophrenia: – Delusions of Thought Interference (Thought withdrawal, insertion, broadcasting) – Delusions of Control (Passivity); Delusional Perception – Auditory Hallucinations (Running Commentary, Voices Arguing, thought echo) – Persistent Delusions: Persecutory – Persistent hallucinations in any modality, including command hallucinations – Formal thought disorder – Catatonia – Negative Symptoms – Functional deterioration Schizophrenia, Schizotypal and Delusional Disorders (11) Homicide

National Confidential Inquiry into Suicide/Homicide by people with Mental Illness – Homicide data 2006-2016 - • 11% of homicide convictions in mental health patients, • average 71/year; • 6% = Schizophrenia, av 37/yr, including both patients and non-pts • Victim most likely to be an acquaintance compared to homicides by non-patients • Most patients had a history of alcohol/substance misuse • Absence of co-morbid substance misuse unusual • Around half of patients were not receiving care as intended Schizophrenia, Schizotypal and Delusional Disorders (12) Specific Disorders • Delusional Jealousy – Subject unreasonably believes he is the victim of his partner’s unfaithfulness, based on delusional evidence – Resistant to treatment & associated with Violent Crime • Partner > rival, men against women • Delusional Love (Erotomania / de Clérambault) – F > M; Mullen’s criteria: • conviction is loved, maintained by re-interpretation of words / actions & Preoccupation with supposed lover – Stalking Behaviour • Paranoid Litigants Schizophrenia, Schizotypal and Delusional Disorders (13) Case Examples

• Christopher Clunis • MH – two ABH (plea bargained from wounding) • MP – wounding (hammer assault) Knowledge Test - MCQs

1. Which of the following diagnoses is associated with the greatest prevalence of violence within 20 weeks of discharge from psychiatric hospital? a) Schizophrenia b) Personality Disorder c) Substance Misuse d) e) Depression 2. Which one of the following psychotic symptoms is not a threat / control override symptom? a) Thought insertion b) Thought withdrawal c) Somatic Passivity d) Delusional Perception e) Persecutory 3. Men with schizophrenia are how many times more likely to commit a violent act than men in the general population? a) They are no more likely to commit a violent act b) Twice as likely c) 5 times more likely d) 10 times more likely e) 15 times more likely Knowledge Test - MCQs

4. In terms of homicides by mental health patients, which of the following statements is untrue? a) Mental health patients with schizophrenia represent 11% of patient homicides b) Dual diagnosis is very common in mental health patient homicides c) Around half of patients convicted of homicide were not receiving care as intended d) Stranger homicides by mental health patients are uncommon e) Patients are also at higher risk of being victims of homicide

5. Which of the following statements about delusional jealousy is untrue? a) The deluded person is often emotionally dependent on the individual about whom they are jealous. b) While delusional jealousy is traditionally thought to be resistant to treatment, recovery can occur in more than half of cases. c) There is an association with alcohol misuse d) Rivals are more likely to be victims of violence than partners e) It can occur in civil partnerships. 5 minute break, then Discussion

• How are crime and personality disorder related? Disorders of Adult Personality & Behaviour (1) Crime and Personality Disorders • Antisocial Personality Disorder – Pervasive disregard for, or violation of rights of, others – ≥ 18 yrs but onset in childhood / early adolescent – ≥ 3 criteria from: • Nonconformity to socially lawful behaviour • Deceitfulness • Impulsivity • Aggression / irritability • Reckless disregard safety self / others • Consistent Irresponsibility • Remorseless

Disorders of Adult Personality & Behaviour (2) Crime and Personality Disorders • Psychopathy

Factor 1 COLD LIAR Factor 2 DISRUPTER Interpersonal / Affective Impulsive / Antisocial lifestyle Other SEX Callous Delinquency (Juvenile) Sexually Promiscuous Outward (Superficial Charm) Impulsivity Extra marital affairs Lying (pathological) Stimulation seeking Criminal versatility Deceitful (conning & manipulative) Responsibilities breached (irresponsibility) Lack remorse Unrealistic long term goals Importance (grandiose self worth) Parasitic lifestyle Affect Shallow Temper (poor behavioural control) . Responsibility denied Early behavioural problems Revocation conditional release Disorders of Adult Personality & Behaviour (3) Crime and Personality Disorders • ASPD & Psychopathy Incidence Rate ASPD / psychopathy via PCL-R & estimation Male Community ASPD 3% ASPD Female Community ASPD 1% Callous Male Forensic 47% (worldwide); 50-80% Obligations ignored (USA) Remorseless Psychopathy Female Forensic 23% (worldwide) Reckless Forensic Psychopathy Male 15-30% (approx ¼ of ASPD Underhand forensic incidence rate) Poor interpersonal relationships Forensic Psychopathy F 15% Touchy Community Psychopathy M 0.75% (estimation from ¼ male community ASPD) Community Psychopathy F 0.25% (as above) Disorders of Adult Personality & Behaviour (4) Factitious Disorder • Munchausen’s Syndrome • Intentional falsification of history, symptoms or signs of physical or mental disorder • Primary aim to obtain medical attention and treatment • Three types: wandering (M>F), non wandering, by proxy • Unknown aetiology, may have suffered CSA • Commoner in males and those with nursing / paramedical background. Associated with personality disorder • Involvement in crime by: – Committing crimes to gain notoriety – Falsifying crimes (e.g. claims of abuse) – Impersonation & Voluntary False Confessions – Inflicting harm on others (Munchausen’s by Proxy) Malingering

• DSM-IV: “Intentional production of fake or grossly exaggerated physical or psychological symptoms, motivated by external incentives” • Malingered psychosis not uncommon in forensic settings – estimated 15% forensic examinees, 7% non-forensic • Psychometric assessment of feigned psychosis: – Validity scales (e.g. on MMPI, Minnesota multiphasic personality inventory) – Projective testing (Rorschach) (dramatic and bizarre responses associated with feigning) – Structured interview of reported symptoms (SIRS); Miller Forensic Assessment of Symptoms Test (M-FAST) – Examination of feigned cognitive deficits: Test of Memory Malingering (TOMM) Mood & Affective Disorders • Relation of Offending to Mood disorders – Depression and homicide • Uncommon (NCI 11 of 6018 homicides 2002-2012, 0.18%) • Perpetrators: 91% male, median age 44, 3 previous convictions for violence, 73% - victim relationship spouse/partner • Victims: female sexual partners – Depression and • Theft • Arson • Alcohol Dependence and Offending • Personality Disorder • – Simple Assaults / threats or minor property damage – More serious offences less common e.g. Rape Neurotic Disorders

• Phobic Anxiety Disorders, Other Anxiety Disorders (GAD), OCD, Acute Stress Reaction, PTSD, Adjustment Disorder, Dissociative Disorders, Somatoform Disorder • Incidence of Crime in Neurosis: unknown, high in prisoners • PTSD – Victim issues – Link to offending e.g. Violent reaction during a flashback • Ganser Syndrome – Rare Dissociative disorder • Approximate Answers • Clouding of consciousness • Hysterical conversion symptoms • Auditory and visual hallucinations Knowledge Test - MCQs

6. Which of the following is not a component of the Psychopathy checklist (Revised)? a) Violent ideation b) Irresponsibility c) Juvenile Delinquency d) Promiscuity e) Lack of empathy 7. Which of the following has the lowest incidence rate? a) Men with ASPD in the community b) Women with ASPD in the community c) Women with psychopathy in a forensic cohort d) Men with psychopathy in a forensic cohort e) Men with ASPD in a forensic cohort Knowledge Test - MCQs

8. Which one of the following statements about factitious disorder is true? a) The wandering type is more common in women b) It is more common in those with a nursing / medical background c) It cannot present with psychiatric symptoms d) It is not associated with criminal impersonation e) Associated Personality disorder is rare 9. Which of the following is not typically associated with Ganser Syndrome a) Approximate answers b) Conversion symptoms c) Auditory hallucinations d) Hyper-vigilance e) Visual hallucinations 10. Which of the following statements about malingered psychosis is untrue? a) It is not uncommon in forensic settings b) It can be identified by feigned cognitive impairment c) It is motivated by an external incentive d) The SIRS is a very sensitive test for its detection e) There is evidence that it can be suggested by responses to the Rorschach test Concluding Remark

Forensic Psychiatrists encounter both the Minority of Criminal Acts & the Minority of individuals with Mental Disorder

Questions? References

Cited Articles / Texts: • Gunn, J. 1977. Criminal Behaviour and Mental Disorder, British Journal of Psychiatry http://bjp.rcpsych.org/content/130/4/317.full.pdf+html (requires RCPsych BJP log-in) • Crime in England and Wales https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/bulletins/crimeinenglandandwales/june2017 • Maden, T. Treating Violence: a guide to risk management in mental health (2007) OUP • Walsh et al. 2002. Violence and Schizophrenia: examining the evidence, British journal of Psychiatry http://bjp.rcpsych.org/content/180/6/490.full.pdf+html (requires RCPsych BJP log-in) • MacArthur Risk Assessment Study: http://www.macarthur.virginia.edu/risk.html • Swanson et al. 1990, Violence and Psychiatric Disorder in the Community: Evidence from the ECA Surveys, Hospital and Community Psychiatry • Fazel et al. 2009. Schizophrenia and Violence: Systematic Review and Meta-Analysis, PLoS Medicine http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000120 • National confidential inquiry into Suicide and Homicide by people with Mental Illness 2017 http://research.bmh.manchester.ac.uk/cmhs/research/centreforsuicideprevention/nci/ • Sims, A. 2003. Symptoms in the Mind. Saunders. • Mullen, P.E. and Lester, G. 2006. Vexatious Litigants, Unusually persistent complainants and petitioners: from querulous to querulous behaviour, Behavioural Science and the Law. http://netk.net.au/Psychology/VexatiousLitigants.pdf • Cleckley, 1941.The Mask of Sanity. http://www.cassiopaea.org/cass/sanity_1.PdF • Stone et al. 2000. Faulk’s Basic Forensic Psychiatry. 3rd Ed. Blackwell Publishing • Chesterman, L. Paul, Terbeck, S. and Vaughan, F.(2008) Malingered psychosis, Journal of Forensic Psychiatry & Psychology,19:3,275 — 300