Shorter Oxford Textbook of Psychiatry, 6th Ed.

CHAPTER 24. Forensic psychiatry

Introduction

General criminology

Causes of crime

The association between mental disorder and crime

Specific offender groups

Psychiatric aspects of specific crimes

Psychiatric aspects of being a victim of crime

The role of the psychiatrist in the criminal courts

The treatment of offenders with mental disorder

The management of violence in healthcare settings

Risk assessment

The psychiatric report

Introduction

Chapter 4 covered general legal and ethical issues in the practice of medicine and psychiatry. This chapter is concerned with other aspects of psychiatry and the law covered by the term forensic psychiatry, which is used in two ways.

1. Narrowly, it is applied to the branch of psychiatry that deals with the assessment and treatment of mentally abnormal offenders.

2. Broadly, the term is applied to all legal aspects of psychiatry, including the civil law and laws regulating psychiatric practice.

Forensic psychiatrists are concerned with both of these issues. In addition, they also assess risk and treat people with violent behaviour who have not committed an offence in law. They have a growing role in the assessment and treatment of victims.

Offenders with mental disorders constitute a minority of all offenders, but they present many difficult problems for psychiatry and the law. These include legal issues, such as the relationship between the mental disorder and the crime, which may affect the court’s determination of responsibility, and practical clinical questions, such as whether an offender needs psychiatric treatment, and finding the appropriate setting for that treatment.

Box 24.1 Ethical issues in forensic psychiatry

The principal ethical issues relate to ‘boundary problems.’ The psychiatrist and others involved need to be clear about accountability to legal authorities, etc., rather than to the individual who is being assessed and treated. This applies to a variety of activities:

1. Preparation of medicolegal reports. In the UK, the responsibility of the psychiatrist is to the Court rather than to the patient or their legal representative.

2. Assessment of risk. Assessment of the risk to others may be paramount.

3. Voluntary and compulsory treatment. The primary reason for treatment may involve decreasing the risk of harm to others.

The psychiatrist therefore needs knowledge not only of the law but also of the relationship between particular kinds of crime and particular kinds of psychiatric disorder. Mental health services form only a small part of the social and legal response to criminal deviance. The psychiatrist who is working with offenders needs to be able to liaise with others in the criminal justice system, such as lawyers, prison staff, and probation officers. Concepts of deviance, guilt, and legality are influenced by legal, political, and social factors, as well as by clinical issues.

In reading this chapter it is important to be aware of the very large differences between countries and jurisdictions, with substantial national variations in epidemiology, definitions of crime, legal practice, and the role of the psychiatrist. Readers need to be aware of legal issues and procedures in their jurisdiction. In the following account, the situations and procedures in the UK (and more especially England and Wales) are used as examples to illustrate general themes. Ethical issues are summarized in Box 24.1.

General criminology

There is a very large literature on criminology and many theories of the causes of crime; interested readers are referred to criminology textbooks (see Maguire and Morgan, 2002). Most theories have emphasized the sociological aspects of crime and deviance, including social and economic causes of crime in the family, peer group, and subculture. These include poverty, poor schooling, and unemployment. The proposed predisposing social and individual factors are often interrelated, so simple conclusions are not possible. However, these causes are widely considered more important than individual factors such as genetics and psychological traits. Despite this, psychological risk factors determine most correctional and forensic mental health programmes, which encourage, for example, the development of coping skills (Dowden et al., 2003).

Prevalence

Prevalence figures must be viewed cautiously because they depend on reporting, and much criminal behaviour is unrecorded by the police. This is especially true of violence within the home, such as rape, child abuse, or partner battering. Crime surveys probably provide more accurate figures. Data from the British Crime Survey are shown in Figure 24.1, and crimes recorded by the police in England and Wales during the period 2002–2003 are shown in Figure 24.2, classified by type of offence together with the same data for the British Crime Survey (Simmons and Dodd, 2003). Property offences are the most common type of crime, but forensic mental health services are most likely to be involved with crimes of interpersonal violence.

National differences

There are large national differences in the rates and patterns of crime. Within Europe, overall crime rates in the UK are lower than those in the Netherlands but higher than those in the Scandinavian countries. Crimes of assault are more common in the USA and Australia (US Dept of Justice, 2004). National statistics are affected by local legislation, the recording of crimes, and by the conduct of legal proceedings.

Gender

Crime is predominantly an activity of young men. In England and Wales, 50% of all indictable offences are committed by males aged under 21 years, and 25% by those under 17 years. Men represent at least 80% of offenders (Monahan, 1997), and, in most Western countries, male prisoners outnumber female prisoners by 30:1. This gender difference is reflected in forensic mental health services, where the majority of patients are male.

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Figure 24.1 Crimes reported to the British Crime Survey by the public during the period 1981–2003.

Ethnicity

Ethnic-minority groups are usually over-represented in prisoner populations. Minority groups are more likely to be poor, unemployed, and living in poor housing, all of which are risk factors for crime. Consequently, they are over-represented in forensic patient populations (Kaye and Lingiah, 2000).

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Figure 24.2 Crimes recorded by the police and those reported to the British Crime Survey by victims of crime during the period 2002–2003. Some of the categories differ and drug offences are not included in the crime survey figures.

The high rates of arrests and convictions in ethnic-minority groups may also reflect discrimination at all stages of the criminal justice system—from stop and search through to trial and sentencing.

Victims

Most property crime is committed against strangers, but most serious interpersonal violence (rape, homicide, or child abuse) is committed by offenders known to the victim. Women are exposed to sexual violence from men in both developed and developing countries. Women and children are particularly at risk in developing countries during armed conflicts, where about 70% of casualties are non-combatants (Kennedy Bergen et al., 2005).

Victims of crime tend to be disadvantaged groups living in poorer parts of urban communities, so the mentally disordered are more likely to be victims of crime, and the risk is further increased as a consequence of their illness (Dean et al., 2007).

Causes of crime

Criminal behaviour (crime) needs to be distinguished from rule-breaking behaviour. Not all rule-breaking or socially unacceptable behaviour is criminal, nor is all criminal behaviour violent. In fact the vast majority is not, so general theories of the causes of crime will not necessarily address the causes of violence. Aggressive behaviour is not always violent, as it can be constrained by social rules. Violence is aggressive behaviour that transgresses social norms, as in street fighting as opposed to, for example, boxing.

Many factors determine whether an individual is aggressive in a particular situation. These include personality, the immediate social group, the behaviour of the victim, disinhibiting factors such as alcohol or drugs, general environmental factors such as noise and social pressure, physiological factors such as fatigue, hunger, and lack of sleep, and the presence of mental abnormality.

Genetic and physiological factors

Early studies of twins suggested that concordance rates for criminality were substantially greater in monozygotic twins than in dizygotic twins (Lange, 1931). Subsequent adoption studies in Sweden and Denmark have confirmed the genetic influence, but have shown that it is more modest than Lange supposed, and that it is mainly significant for severe and persistent criminality. Genetic factors are well established for conduct disorder in children, and the continuity in aggressive antisocial behaviour between childhood and adolescence is largely mediated by genetic influences (Eley et al., 2003). How genetic factors might mediate this increased risk is unclear, but it could involve hyperactivity and low IQ, both of which are risk factors in children for subsequent adult offending (Rutter, 2005).

The gender difference in offending has raised the question of the influence of either the Y chromosome or testosterone levels on offending. However, there is little evidence that chromosomal or hormonal abnormalities are causally associated with criminal behaviour or aggression. As was noted in Chapter 7, low brain 5-HT function has been associated with impulsive aggression. There is growing evidence that individuals with sociopathic personalities have long-standing neuropsychological deficits, particularly in executive processes (Raine et al., 2005).

Psychosocial factors

Individual psychological development interacts with social factors and cultural values to make offending more likely (see Table 24.1). Rule-breaking and antisocial behaviour often starts in childhood or early adulthood:

• Follow-up studies of delinquent young people show that early patterns of antisocial behaviour are likely to persist into adulthood.

• Delinquency is associated with harsh parenting and poverty.

• Exposure to physical abuse or neglect in childhood significantly increases the risk of violent offending in later life, for both men and women (Rutter, 2005).

The association between childhood adversity and violence may have several mechanisms. Abused and neglected children may have a heightened perception of threat from others. They may have decreased capacities to form successful interpersonal relationships, due to either decreased empathy for others, or reduced capacity for self-awareness. Alternatively, they may have a decreased capacity to manage arousal or regulate anger or anxiety arising from excessive exposure to fear experiences. It is also possible that children and parents simply share genetic factors that impair affect regulation or the ability to empathize. However, it is always important to consider the impact of resilience or vulnerability factors, such as temperament (Rutter, 2005).

Table 24.1 Psychosocial risk factors for offending

Individual factors

Hyperactivity and impulsivity

Low intelligence

Child-rearing—poor supervision, harsh discipline, rejection, teenage mothers

Parental conflict—separations

Criminal parents

Large family size

Social factors

Socio-economic deprivation

Peer influences

School influences

Community influences

See Farrington (2000).

Psychiatric causes

A small but important group of offenders exhibit criminal behaviour which seems to be partly explicable by specific psychological or psychiatric abnormalities. This group particularly concerns the psychiatrist, and is discussed in the next section.

The association between mental disorder and crime

Frequency

The association between mental disorder and violence has been repeatedly demonstrated. Fazel et al. (2009) 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.

From a large Danish birth cohort, Brennan et al. (2000) reported the following findings:

1. The risk of being arrested for a violent offence was significantly greater in both men (odds ratio 4.6), and women (odds ratio 23.2) who had been hospitalized for schizophrenia.

2. The risk of being arrested for a violent offence was also greater in men who had been hospitalized for organic psychosis (odds ratio 8.8).

3. Unlike Fazel, Brennan did not find that the increased risk could be explained by demographic factors or comorbid substance misuse.

4. Both men and women with a diagnosis of affective psychosis showed an increased risk of violent offending, but this could be accounted for by alcohol and substance misuse.

5. Alcohol and substance misuse by themselves are associated with a substantially increased risk of violent offending, as is antisocial personality disorder (see Table 24.2) (Chiswick, 2000).

Research on the prevalence and association of mental disorder in prisoners has recognized limitations:

• Not all criminals are brought to trial and found guilty.

• Not all criminals go to prison (potential sampling bias).

• Mentally disordered offenders may be diverted away from courts and prisons, or they may not be prosecuted.

The proportion of prisoners with mental disorders is higher than the proportion of the general population with such disorders. In a meta-analysis of 62 psychiatric surveys of prisoners, Fazel and Danesh (2002) found that about one in seven had a treatable psychiatric illness (see Table 24.3). A larger number suffer from antisocial personality disorder.

The nature of the association

A causal relationship between mental disorder and crime is difficult to show empirically, especially if the type of crime is not defined. The finding that mentally disordered individuals are over-represented in prison does not necessarily mean that their mental disorder caused them to offend. Nor is criminal law-breaking an indicator in itself of mental disorder, no matter how heinous or bizarre the behaviour.

Table 24.2 The 1944–1947 Danish Birth Cohort Study: relative risk estimates of violent crime between 1978 and 1990

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Table 24.3 Meta-analysis of 62 psychiatric surveys of prisoners

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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). This 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). 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).

For a review of the association between psychiatric disorder and offending, see Chiswick (2000) (see also Box 24.2).

Specific psychiatric disorders

Substance dependence and crime

There are close relationships between substance abuse and crime which have substantially affected legislation, enforcement, and national policies (Grann and Fazel, 2004).

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.

Offences may be committed during alcoholic amnesias or ‘blackouts.’ Blackouts are periods of several hours or days which the heavy drinker cannot recall, although at the time they appeared normally conscious to other people and were able to carry out complicated actions. However, the association is complex, and social factors related to drinking may be as important as alcohol itself. For a review, see Johns (2000).

Box 24.2 Psychiatric disorder and offending

• People with psychotic disorders are more likely than members of the general public to acquire convictions for violent or other crimes (by factors of approximately 4 and 10, respectively).

• This increased likelihood is altered in strength by local factors such as crime rate and socio-demographic variables.

• Antisocial personality disorder and substance misuse disorders have stronger associations with offending than does psychotic illness.

• A combination of psychiatric disorders (particularly when one of them is substance misuse disorder) may be more relevant than any single category of psychiatric disorder.

• Most offending by those with psychiatric disorder is minor in nature; violence, when it occurs, is likely to be targeted at a family member.

Data from Chiswick (2000) and Mullen (2006).

Intoxication with drugs may lead to criminal behaviour, including violent offences. Drug misusers, especially those who are dependent on heroin and cocaine, commit repeated offences against both property and people in order to fund their drug habit. Some of the offences involve violence. Rates of drug abuse are increased among prisoners, and many succeed in obtaining drugs in prison. Involvement in criminal activity and with other criminals may lead to drug usage. For a review of the relationship between drug dependence and crime, see Johns (2000).

Learning disability

There is no evidence that most criminals are of markedly low intelligence. However, reduced intellectual ability is an independent predictor of offending (Holland et al., 2002).

People with learning disabilities may commit offences because they do not understand the implications of their behaviour, or because they are susceptible to exploitation by others. Property offences are the most common, but sexual offences are over-represented, particularly indecent exposure by males (Perry et al., 2002). The exposer is often known to the victim and therefore the rate of detection is high. There is also an association between learning disability and arson (Chiswick, 2000).

Mood disorder

Depressive disorder is sometimes associated with shoplifting. Severe depressive disorder may rarely lead to homicide. The depressed person may be deluded, for example, that the world is too dreadful to live in, and they consequently kill their family members in order to spare them. Suicide often follows. A mother suffering from postpartum disorder may sometimes kill her newborn child or her older children. Rarely, a person with severe depressive disorder may commit homicide because of a persecutory belief—for example, that the victim is conspiring against them. Occasionally, ideas of guilt and unworthiness lead depressed patients to confess to crimes that they did not commit.

Manic patients may spend excessive amounts of money on expensive objects, such as jewellery or cars, that they cannot pay for. They may be charged with fraud, theft, or false pretences. They are also prone to irritability and aggression, which may lead to offences of violence, although this is seldom severe.

Schizophrenia and related disorder

Psychotic illnesses may be associated with violence, especially when paranoid symptomatology is present, or the patient also has a substance abuse problem. Violence may occur because the offender is frightened, and self-control may be reduced by the presence of the psychotic state. Any state in which paranoid psychotic symptoms feature carries an increased risk of violent behaviour.

Epidemiology

Epidemiological studies have strongly suggested that schizophrenia is associated with an increased risk of both violent and non-violent offending (Brennan et al., 2000). This risk is substantially increased by substance misuse, but the proportion of violent crime attributable to schizophrenia is low (Fazel et al., 2009). A number of clinical risk factors for violence in schizophrenia have been proposed, including the following:

• fear and loss of self-control associated with non-systematized delusions

• systematized paranoid delusions, including the conviction that enemies must be defended against

• irresistible urges

• instructions from hallucinatory voices (command hallucinations)

• dual diagnosis, particularly substance misuse

• a strong negative affect (e.g. depression, anger, agitation).

Risk assessment is discussed on p. 729. Violent threats made by patients with psychosis should be taken very seriously (especially in those with a history of previous violence). Most serious violence occurs in those already known to psychiatrists, particularly if there is an identifiable victim.

Post-traumatic stress disorder

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.

PTSD has been the basis for psychiatric defences to homicide. Especially in cases of battered women with a history of prolonged trauma, occasional acts of retaliatory violence are not uncommon.

Morbid jealousy

The syndrome of morbid (pathological) jealousy (see p. 304) may be associated with several of the above diagnoses. It has been identified in 12% of ‘insane’ male and 3% of ‘insane’ women murderers. It is particularly dangerous because of the risk of the offence being repeated with another partner. It may sometimes be difficult to distinguish morbid jealousy from extreme possessiveness or control over women’s behaviour, which may be accompanied by violence, seen in some cultures.

Organic mental disorders

Delirium is occasionally associated with criminal behaviour, usually because of the associated confusion or disinhibition. Diagnostic problems may arise if the mental disturbance improves before the offender is examined by a doctor.

Dementia is sometimes associated with offences, although crime is otherwise uncommon among the elderly, and violent offences are rare. Violent and disinhibited behaviour may also occur after traumatic damage to the brain following head injury (Fazel et al., 2009). It may be difficult to distinguish the effects of post-traumatic neurological difficulties from post-traumatic psychological disorder.

Epilepsy

The association between epilepsy and crime is complex and poorly understood. While it has been widely believed that the risk of epilepsy is greater in prisoners than in the general population, a meta-analysis of seven studies indicated that this was not the case (Fazel et al., 2002), and a later meta-analysis of nine studies by Fazel et al. (2009) found some evidence of an inverse relationship between epilepsy and violence. Violent behaviour is sometimes associated with EEG abnormalities in the absence of clinical epilepsy, but it is doubtful whether this indicates a causal relationship (Fazel et al., 2009). Epileptic automatisms may, very rarely, be associated with violent behaviour and subsequent criminal proceedings. Violence is more common in the post-ictal state than ictally.

Impulse control disorders

DSM-IV contains a category ‘impulse control disorders not otherwise classified’ which brings together four speculative conditions relevant to forensic psychiatry—intermittent explosive disorder, pathological gambling, pyromania, and kleptomania. In ICD-10 these conditions are classified under abnormalities of adult personality and behaviour as ‘habit and impulse disorders.’ Whatever the clinical value of such classifications, none of these conditions has been established as a separate diagnostic entity.

Intermittent explosive disorder

This term is used to describe repeated episodes of seriously aggressive behaviour out of proportion to any provoking events and not accounted for by another psychiatric disorder (e.g. antisocial personality disorder, substance abuse, or schizophrenia). The aggression may be preceded by tension, followed by relief of this tension, which is in turn followed by remorse. The condition is rare, and many psychiatrists doubt whether it is a distinct psychiatric disorder.

Pathological gambling

Gambling is pathological when it is repeated frequently and dominates the person’s life, and persists when the person can no longer afford to pay their debts. The person lies, steals, defrauds, or avoids repayment in order to continue the habit. Family life may be damaged, other social relationships may be impaired, and employment put at risk.

Pathological gamblers have an intense urge to gamble, which is difficult to control. They are preoccupied with thoughts of gambling, much as a person dependent on alcohol is preoccupied with thoughts of drink. Increasing sums of money are gambled, either to increase the excitement or in an attempt to recover previous losses. If gambling is prevented, the person becomes irritable and even more preoccupied with the behaviour.

Similarities with the behaviour of people who are dependent on drugs have led to the suggestion that pathological gambling is itself a form of addictive behaviour. Brain imaging studies of pathological gamblers show abnormalities in mesolimbic reward pathways similar to those in drug dependence (Goudriaan et al., 2004).

The prevalence of pathological gambling is not known. It is probably more frequent among males. Most gamblers who are seen by psychiatrists are adults, but there is concern that young people are increasingly being involved, usually with gambling machines in amusement arcades. For a review of pathological gambling, see Dickerson and Baron (2000).

Pyromania

Pyromania refers to repeated episodes of deliberate fire-setting, which are not carried out for identifiable reasons such as monetary gain, to conceal a crime, as an act of vengeance, or as a consequence of hallucinations or delusions. Impaired judgement resulting from intoxication, dementia, or mental retardation also excludes pyromania, and the diagnosis is precluded by antisocial personality disorder, a manic episode, or (among children or adolescents) a conduct disorder. In the rare condition of pyromania, the act of fire-setting is preceded by tension or arousal, followed by relief. People with pyromania have a preoccupation with fires and firefighting, and enjoy watching fires. They may plan the fire-setting in advance, taking no account of the danger to other people caused by their actions. Some authors doubt the existence of pyromania as a diagnosis.

Kleptomania

Kleptomania refers to repeated failure to resist impulses to steal objects that are not needed, either for use or for their monetary value. The impulses are not associated with delusions or hallucinations, or with motives of anger or vengeance. Before stealing there is increased tension, which the stealing relieves. The diagnosis is excluded by associated antisocial personality disorder, a manic episode, or (among children or adolescents) a conduct disorder, or when the stealing results from sexual fetishism. The objects stolen may be of little value and could have been afforded; they may be hoarded, thrown away, or later returned to the owner. The patient knows that the stealing is unlawful, and may feel guilty and depressed after the immediate pleasurable sensations that follow the act.

Kleptomania occurs more often among women. Associations with anxiety and eating disorders have been described. It may be sporadic with long intervals of remission, or may persist for years despite repeated prosecutions. Some authorities doubt its existence as a separate syndrome, pointing out that diagnosis depends entirely on accused individuals’ descriptions of their own motives.

Specific offender groups

Female offenders

Women are more law-abiding than men. Shoplifting accounts for 50% of all their convictions, and violent and sexual offences are uncommon.

Men and women are treated differently by the criminal justice system. Women are sentenced more leniently for similar offences, and they are more likely to be viewed as ‘sick.’ Psychiatric disorder is frequent among women admitted to prison, with personality disorder and substance misuse being especially common (Fazel and Danesh, 2002), and self-harm before and during imprisonment is also common (Jenkins et al., 2005).

A ‘premenstrual syndrome’ was sometimes proposed by defence lawyers, but this rarely happens now. Premenstrual symptoms may complicate or exacerbate pre-existing social and psychological difficulties, but there is no evidence that they are a primary cause of offending.

Young people

National crime statistics indicate that increasing numbers of people under 18 years of age are involved in criminal behaviour. In Scotland, for example, in the year 2000, 34% of young people (aged 12–15 years) reported committing a criminal offence in the previous year, compared with 22% in 1992 (Scottish Executive Central Research Unit, 2002). Where a young person engages in serious interpersonal violence, the victim is often well known to them, and is commonly a family member. Serious violence by young people and children is rare, and the individuals involved have frequently been the recipients of violence themselves, both within and outside their families (Hamilton et al., 2002).

Ethnic minorities

Some ethnic groups are over-represented as offenders in the criminal justice system, and also in forensic psychiatric services. Non-white patients may be more likely to receive diagnoses of mental illness, with individual personality difficulties being overlooked. People from ethnic minorities may be discriminated against in the criminal justice system. People of African Caribbean origin have higher rates of imprisonment in the UK, but lower rates of psychiatric morbidity (Coid et al., 2002). This contrasts with the excess of African Caribbeans in secure hospitals, which suggests that those offending while mentally ill are more likely to be admitted to hospital.

Psychiatric aspects of specific crimes

The following sections are concerned with the types of offences that are most likely to be associated with psychological factors. These are crimes of violence, sexual offences, and some offences against property.

Crimes of violence

Violence among mentally abnormal offenders is more strongly associated with personality disorder than with major mental illness. It is particularly common in people with antisocial personality traits who misuse alcohol or drugs, or who have marked paranoid or sadistic traits. It is often part of a persistent pattern of impulsive and aggressive behaviour, but it may be a sporadic response to stressful events in ‘over-controlled’ personalities. The assessment of dangerousness and the management of violence are discussed on p. 729.

Homicide

Most jurisdictions recognize different categories of homicide, according to the degree of intention and responsibility shown by the perpetrator. In the USA, defendants may be charged with different ‘degrees’ of murder. In England and Wales, there are three ‘legal categories’ of homicide—murder, manslaughter, and infanticide—and murder and manslaughter are defined by historical precedent, not by statute.

Manslaughter covers unlawful homicides that are not murder. It is customary to distinguish between voluntary and involuntary manslaughter. In voluntary manslaughter, the defendant may have malice aforethought, but mitigating circumstances reduce their crime. In involuntary manslaughter, there is no malice aforethought; it includes, for example, causing death by gross negligence.

Normal and abnormal homicide

Mental disorders may count as mitigation for an individual charged with murder, reducing the charge to manslaughter. Homicide can be divided according to the legal outcome into normal (murder or common-law manslaughter) and abnormal (insane murder, suicide murder, diminished responsibility, or infanticide).

Normal homicide accounts for half to two-thirds of all homicides in the UK, as in other Western countries, even in the USA, where the overall homicide rate is much higher. It is most likely to be committed by socially disadvantaged young men. In the UK, the victims are mainly family members or close acquaintances. In countries with high homicide rates, a greater proportion of killings are associated with robbery or sexual offences. Sexual homicide may result from panic during a sexual offence. Alternatively, it may be a feature of a sadistic killing, sometimes committed by a shy man with bizarre sadistic and other violent fantasies.

Abnormal homicide accounts for one-third to half of all homicides in the UK. It is usually committed by older people. The victims of abnormal homicide are often family members. The most common psychiatric diagnoses are psychoses, substance use disorder, and personality disorder (Fazel and Grann, 2004). Depressive disorder can also be involved, especially in those who kill themselves afterwards. Homicide by women is much less frequent than that by men, but is nearly always ‘abnormal.’

A large proportion of all murderers are under the influence of alcohol at the time of the crime, and drug misuse is also an important factor.

Multiple homicide

Multiple murders are rare, although they attract great public attention. They include:

• individuals without mental illness who kill several people at once, sometimes a family killing which is often followed by suicide. Paranoid and grandiose character traits are common (Mullen, 2004)

• killings attributable to a psychotic illness in which the killer aims to save himself or his family from a perceived threat

• serial killings that take place over a period of time. These may be ‘normal’ (e.g. killings by terrorists) or ‘abnormal’ (e.g. psychotic, or motivated by sexual sadism or necrophilia).

Homicide followed by suicide

Homicide followed by suicide accounts for about 50 deaths in the UK annually, while in the USA the comparable figure is 1000–1500 (Chiswick, 2000). An epidemiological survey of 180 victims and 147 perpetrators in the UK reported the following findings (Barraclough and Harris, 2002):

• Around 80% of the incidents involved one victim and one perpetrator.

• Around 88% of the incidents exclusively involved members of the same family.

• Around 75% of the victims were female, while 85% of the perpetrators were male.

• The victims of the male perpetrators were nearly always current or previous female partners and their children, while the victims of female perpetrators were predominantly their children.

• A few men kill strangers and then themselves. Such individuals are usually young (under 35 years of age) and may be psychotic or more commonly have paranoid and narcissistic traits and take revenge for trivial or imagined slights or humiliations (Flynn et al., 2009).

Parents who kill their children

Around 25% of all victims of murder or manslaughter in the UK are under the age of 16 years, and babies under the age of 1 year are at the highest risk of all age groups (Breslin and Evans, 2004). Most children are killed by a parent who is mentally ill, usually the mother. The classification of child murder is difficult, but useful categories are mercy killing, psychotic murder, and killing as the end result of battering or neglect (D’Orban, 1979). This last category is most common.

Infanticide

A woman who kills her child may be charged with murder or manslaughter. English law recognizes a special category, infanticide, where the child is under 12 months of age. Infanticide is treated as manslaughter with less harsh penalties, and the same freedom of sentencing as for manslaughter. The English legal concept of infanticide is unusual, as it is only required that the woman’s mind was disturbed as a result of birth or lactation, not that the killing was a consequence of her mental disturbance.

Fewer than five cases a year are recorded in the UK. Infants are most at risk on the first day of life, and the relative risk decreases steadily to that of the general population by 1 year. Fathers are slightly more likely to be recorded as the prime suspect over time. Mothers have received less severe sentences than fathers. Puerperal psychotic illness is a relatively infrequent cause of homicide, and depression is a factor in some cases. Later infant homicides are usually due to fatal child abuse. Infanticide has been strongly associated with motherhood at a young age.

Family homicide

Another useful way to distinguish homicides is in terms of the relationship between perpetrator and victim. Most serious violence takes place within the family (25% of all homicide victims are aged under 16 years, and 80% are killed by their parents). Most homicide perpetrators know their victims well; around 50% of the female victims of homicide are wives or partners of the perpetrator, and the rest are often friends or relatives.

Domestic violence

Domestic violence accounts for about 25% of all violent incidents measured by the British Crime Survey. In England and Wales there are about one million incidents of domestic violence annually, about two-thirds of these against women. Most batterers do not have either a diagnosable mental disorder or a criminal history. However, heavy drinking is common.

Some people are violent only within their family, while others are also violent outside the family. Violence in the family can have long-term deleterious effects on the psychological and social development of the children and on the mental health of the partner (see Chapter 8).

Violence in the family may also be directed towards children (child abuse is reviewed on p. 674) and towards elderly relatives (elder abuse is referred to on p. 497). Any of these forms of violence may rarely result in homicide.

Alertness to possible domestic violence is required not only in Accident and Emergency departments, but also in primary care and in obstetric and paediatric clinics. Intervention is difficult and raises ethical issues (see Table 24.4).

Violence towards partners

Violence by men towards their female partners is much more frequent than violence by women towards their male partners, is physically more serious, and is more often reported. Most ‘wife batterers’ are men with aggressive personalities, while a minority are violent only when psychiatrically unwell, usually with a depressive disorder. Other common features among these men are morbid jealousy and heavy drinking. Such men may have suffered violence in childhood, and often come from backgrounds in which violence is frequent and tolerated. Behaviour by the victim may contribute to or provoke (but not justify) violence, but this is difficult to assess if only the perpetrator is interviewed. However, when battering is seen as a ‘joint’ problem, the batterer may have less incentive to stop. Repetitive battering, especially in the context of jealousy, is a real risk factor for homicide.

Table 24.4 Ethical and legal issues: domestic violence

Confidentiality is especially important because of the risk of retaliation by the abuser.

Careful records are essential, including documentation of the injuries. Written consent should be obtained for photographs.

Specialist advice should be sought about providing practical and other help to those who wish to end the relationship.

Where the risk of serious violence is believed to be very high, disclosure to the police and other authorities and other individuals in order to provide protection needs to be carefully planned with the maximum collaboration with the victims.

Sexual offences

Sexually violent offences

In the UK, sexual offences account for less than 1% of all indictable offences recorded by the police, but account for a significant proportion of offenders referred to psychiatrists. However, only a small proportion of people who are charged with sexual offences are assessed by psychiatrists. Most sexual offences are committed by men.

Sexual offenders are generally older than other offenders, and reconviction rates are generally lower. The minority of recidivist sexual offenders are extremely difficult to manage (see Box 24.3). In the UK, Part 1 of the Sex Offenders Act 1997 requires those convicted or cautioned for relevant sex offences to be kept by police on the Sex Offender Register.

The most common sexual offences are indecent assault against women, indecent exposure, and unlawful intercourse with girls aged under 16 years. Some sexual offences do not involve physical violence (e.g. indecent exposure, voyeurism, and most sexual offences involving children); others may involve considerable violence (e.g. rape). The nature and treatment of non-violent sexual offences are discussed in Chapter 14, but their forensic aspects are considered here. For a review, see Gordon and Grubin (2004).

Box 24.3 Some factors associated with increased risk of reoffending in sex offenders

• 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

Source: Gordon and Grubin (2004).

The psychological consequences for victims of sexual offences are discussed on p. 721, and sexual abuse of children is discussed below.

Sexual abuse of children

The age of consent varies in different countries. In England and Wales it is illegal to have any sexual activity with a person aged under 16 years. Sexual offences involving children account for over 50% of all reported sexual offences in the UK. It is probable that many more offences are not reported, particularly those that occur within families. The offences vary in severity from mild indecency to seriously aggressive behaviour, but the large majority do not involve violence.

Adults who commit sexual offences against children may or may not be paedophilic. Paedophiles are defined as having a primary sexual interest in prepubertal children. They are almost always male. They may be either homosexual or heterosexual, and usually abuse children not previously well known to them. They are rarely mentally ill. Victims are often prepared (‘groomed’) over a long period of time. Some paedophiles may seek work in occupations where they will have access to children who will be left in their care.

It is difficult to classify paedophiles, but the following groups have been recognized:

• the timid and sexually inexperienced

• the learning disabled

• those who have experienced normal sexual relationships but prefer sexual activity with children

• a predatory group who may use violence. In rare cases, paedophile sexual activities end in murder.

However, not all child sex offenders are paedophiles thus defined. A significant majority do not have a primary sexual interest in children. Many have ‘normal’ heterosexual histories and may be involved in such relationships at the time when they offend. Paedophilic child sex offenders typically are strangers to children, or else have gained opportunistic access through their chosen work or social activities. However, the majority of child sex offending is carried out by men (usually) who have some familial relationship to the child. Most commonly these are stepfathers or other male members of the extended family circle. These men are typically not primary paedophiles, although some primary paedophiles may marry women with children in order to access potential victims.

A proportion of men who appear to be primarily attracted to adult women also describe attraction to children. Some theorists have argued that what child sex offenders are excited by is the vulnerability of children and the discrepancy in power between adults and children, rather than the physical qualities of childhood. Sexual abuse of children by family members is considered on p. 677.

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.

Assessment

Usually, the perpetrator and the victim are assessed by different people. The interviewing of children after sexual abuse is considered on p. 678. This section considers interviews with the adult. When trying to decide whether an offence is likely to be repeated or to progress to more serious offences, the psychiatrist should first consider the depositions and the victim’s statement to gain available information about the following:

• the duration and frequency of the particular sexual activity in the past (remembering that paedophiles often deny their offending)

• the offender’s predominant sexual preferences; exclusively paedophile inclinations and behaviour indicate a greater risk of repetition. Older paedophiles are less likely to be aggressive.

The interviews should determine:

• the offender’s previous sexual history

• whether alcohol or drugs played any part in the offence, and if so whether the person is likely to continue to use them

• whether there are any feelings of regret or guilt

• any stressful circumstances associated with the offence (and the likelihood that these will continue)

• the degree of access to children

• evidence of any psychiatric disorder or relevant personality features. When drawing conclusions it is important to be aware of the limitations of psychiatric knowledge of this form of behaviour.

Treatment

Treatment is directed towards any associated psychiatric disorder. Direct treatment of the sexual behaviour is difficult. Group therapy run jointly by mental health and probation services may be helpful. A recent systematic review showed some effect of group cognitive–behaviour therapy to reduce reoffending at one year (NNT = 6) (Kenworthy et al., 2004). The use of anti-androgens such as cyproterone and medroxyprogesterone has also been advocated, but their use is associated with many adverse effects. Luteinizing hormone-releasing hormone agonists are better tolerated, but current studies have methodological weaknesses (Briken et al., 2003). In addition, treatment of this nature raises ethical issues.

Indecent exposure

This is the legal term for the offence of indecently exposing the genitals to other people. It is applied to all forms of exposure; exhibitionism is by far the most frequent form, but exposure may also occur as an invitation to intercourse, as a prelude to sexual assault, or as an insulting gesture. Exhibitionism (see also p. 373) is the medical name for the behaviour of those who gain sexual satisfaction from repeatedly exposing to the opposite sex. In England and Wales, indecent exposure is one of the most frequent sexual offences. It is most common in men aged between 25 and 35 years. Indecent exposers rarely have a history of psychiatric disorder or other criminal behaviour. However, they may have other types of compulsive disorder or substance misuse. Despite this, exhibitionism is listed as a psychiatric disorder in both DSM-IV and ICD-10. A proportion of offenders are repeat recidivists, and may proceed to more serious sexual violence.

Indecent assault

The term indecent assault refers to a wide range of behaviour, from attempting to touch a stranger’s buttocks to sexual assault without attempted penetration. The psychiatrist is most commonly asked to give a psychiatric opinion on adolescent boys and on men who have assaulted children. Although many adolescent boys behave in ways that could be construed as ‘indecent’, more serious indecent behaviour is associated with aggressive personality, ignorance, lack of social skills and, occasionally, learning difficulties. Treatment depends on the associated problems.

Stalking

The lay term ‘stalking’ is usually taken to mean the repeated, unwanted, and intrusive targeting of a particular victim with following and other harassment (Mullen et al., 2009). It implies an intensive preoccupation with the victim. The scope of behaviour is wide, and includes:

• following the victim

• communication by telephone, mail, and electronic communication

• ordering goods and services in the victim’s name

• aggression and threats, including violence, damage to property, and false accusations.

Most stalkers are men, and most victims are women. The victims invariably suffer severe distress. Management requires cooperation between forensic psychiatrists and the criminal justice system in assessing risks, treating any associated psychiatric disorder (e.g. erotomania), and protecting and treating the victim. For a review, see Mullen et al. (2009) (also see Chapter 12).

Rape

In English law, a man commits rape if:

• he has unlawful sexual intercourse (whether vaginal or anal) with a woman or man who at the time of the intercourse does not consent to it

• at the time he knows that the victim does not consent to the intercourse, or he is reckless as to whether they consent to it.

Most jurisdictions define rape in terms of the lack of consent of the victim. Not all jurisdictions recognize male rape or sexual assault. Some countries (such as the USA) additionally define lack of consent by age—so-called ‘statutory rape.’ English law is among the few that recognize rape within marriage.

Rape is a violent act. It varies in the degree of aggression used, and the extent to which this is instrumental in exerting control, or exciting for its own sake. Most rapists are married or in partnerships; over 50% fail to perform sexually during the assault. Rapists frequently have previous convictions for non-sexual violent offences.

Most rapists know their victims and, contrary to popular belief, stranger rape is rare. Stranger rapes are more likely to be physically violent and involve the use of weapons; this may reflect the fact that rapists who know their victims may not need to use physical threats to control them. Instead, family members may be threatened. Most rapes take place in the home, again in contrast with popular belief (see Box 24.4).

Epidemiology

Rape and other forms of sexual aggression towards women are probably much more frequent in the population than the number of such incidents reported to the police (see Box 24.4). Only one-third of reported rapes are proceeded with by the police, and only one-third of those proceeded with will be heard at a higher court. Even then, the alleged rapist has only a one in three chance of being convicted, and this is most likely where the rape fits the stereotype of stranger rape. Victims of acquaintance rape (often rightly) assume that they will not be believed.

The prevalence of male rape is unknown. It is likely that many male rapes go unreported, as male victims may be reluctant to come forward. As in rape of females, rape of males is often associated with a wish to degrade or dominate the other person. Rapists of males tend to be violent heterosexual men; it is possible that they have anxieties about their masculine identity. There has been some suggestion that rape of either men or women is associated with gender identity problems in the rapist.

Box 24.4 Sexual assault of women: findings from the British Crime Survey of 2000

• About 1% of women said that they had been subject to some form of sexual victimization in the last 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.

Source: Myhill and Allen (2002).

Causes

Most explanations of rape are sociocultural in terms of cultural attitudes to women, and social constructions of male and female gender roles. In psychological terms, men who are violent towards women often have a rigid and conservative view of the female role, coupled with denigration of any woman who transgresses that role. Rapists frequently blame their victims for the attack, by justifying the rape in terms of the woman’s behaviour (e.g. ‘She deserved it because she was flirting with X’). The fact that in many cases the victim is an acquaintance of the rapist, and in 20% of cases there appears to have been some initial participation by the victim in events leading up to the offence, should not be interpreted as voluntary participation in the rape itself. There is little evidence for the frequently expressed view that rape victims encourage the rape, or change their minds about having sex.

Rape has been found in population studies to be associated with severe mental illness, and the proportion of all sexual crimes that were committed by patients psychiatrically hospitalized at some point in their lifetimes is 20% (Fazel et al., 2007). In these cases it may be that sexual behaviour is associated with disinhibition as part of a manic illness or other psychotic illness, substance abuse comorbidity, or paranoid delusions in psychotic states. Evidence of current substance abuse is found in at least 50% of rapists. In many cases, both the rapist and the victim will have been using drugs or alcohol, as many rape scenarios begin in social situations. Some men who commit rape, homicide, or other violent offences have considerable sexual problems or suffer sexual jealousy, and these may have contributed to their dangerousness. A small group of men obtain sexual pleasure from sadistic assaults on unwilling partners (Novak et al., 2007).

Prognosis

In the UK, most rapists serve only half their sentence in prison, and are then released on licence to be supervised by the probation service. The reconviction rate is 30%. The prison service offers psychological treatment to rapists as part of the Sex Offender Treatment Programme (SOTP) in prisons, but data to date suggest that little improvement occurs in individuals on this programme (Marques et al., 2005).

Child abduction

Child abduction is rare. A child may be abducted by one of the parents, by a man with a sexual motive, or by an older child. Babies are usually abducted by women. Their motives are to achieve comfort, or to manipulate another person, or may occur on impulse in psychiatrically disturbed women. Fortunately, most stolen babies are well cared for and are found quickly.

Offences against property

Shoplifting

The vast majority of shoplifting, like other theft, is carried out by people without any mental disorder. Many adolescents admit to occasional shoplifting. Both observational studies and the reports of huge losses from shops suggest that shoplifting is common among adults (including shop staff).

A minority of shoplifters suffer from psychiatric disorders. Depressive disorders are most common, but various other psychiatric diagnoses can be associated with shoplifting (Lamontagne et al., 2000). Patients with any type of mental illness, especially those with substance abuse problems, may steal because of economic necessity. Patients with disinhibiting conditions may be more likely to steal impulsively, and patients with eating disorders may steal food. In other conditions, shoplifting may result from distractibility—for example, in organic mental disorders, when the person is confused or forgetful, and during panic attacks when the person may run out of the shop without paying.

The assessment of a person charged with shoplifting is similar to that for any other forensic problem. If the accused has a depressive disorder at the time of the examination, the psychiatrist should try to establish whether the disorder was present at the time of the offence or developed after the charge was brought. The legal question most often posed is whether the accused had the intention to steal, and if a mental condition could have affected that intention.

Arson

Arson is regarded extremely seriously, because it can result in great damage to property and threatens life. Most arsonists are males. Although the courts refer many arsonists for psychiatric assessment, the psychiatric literature on arson is small. 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-IV criteria for pyromania (see p. 714), although the validity of this diagnostic category is unsubstantiated; these individuals (who sometimes join conspicuously in firefighting) obtain intense satisfaction and relief of tension from fire-setting

• those with psychotic illness (Anwar et al., 2009).

Soothill et al. (2004) found at follow-up that while about 10% of offenders were re-convicted for arson, over 50% were charged with offences of other kinds. A person convicted of arson a second time is at much greater risk of committing further offences.

The factors that are associated with an increased risk of a further fire-setting offence include:

• antisocial personality disorder

• learning difficulties

• persistent social isolation

• evidence that fire-setting was done for sexual gratification or relief of tension.

The scope for psychiatric intervention is limited. Management of arsonists within hospital requires a secure setting and close observation.

Children also present with problems of fire-setting. Sometimes the behaviour represents extreme mischievousness in psychologically normal children, at times it is a group activity, and sometimes it arises from psychiatric disturbance, most commonly conduct disorder (Martin et al., 2004). Among children charged with fire-setting, the recurrence rate in the following 2 years is reported to be less than 10%.

Psychiatric aspects of being a victim of crime

It is only relatively recently that criminology and society have paid attention to the role and needs of victims (Mezey and Robbins, 2009). Surveys of general populations indicate that being a victim of crime is frequent, and is related to geographical area, gender, age, and social habits. Much violence, especially sexual and domestic assaults, is unreported. Young men are particularly at risk of personal violence, whereas women are more likely to suffer domestic and sexual violence. In the UK, around one-sixth of assaults on Asians and Afro-Caribbeans are believed to be racially motivated.

The response of the victim is important in determining whether an offence is reported to the police and whether charges are brought.

Psychological impact

Childhood abuse and experience of violence during childhood may have major consequences in adulthood.

Adult crime victims are at risk of a variety of early and late psychological problems. These include the immediate distress following the crime, and the subsequent distress associated with the investigation and court hearings. Posttraumatic stress disorder is frequently reported. These consequences are more common and severe immediately after the crime, but they may persist for many years.

Types of crime

Murder

Relatives of victims experience feelings of isolation and shame, and an inability to share their distress greater than in other kinds of bereavement. The bureaucracy of legal processes increases feelings of anger and of being apart from the rest of the world (Rock, 1998).

Rape

There is much evidence that rape victims may suffer long-term psychological effects (Mezey and Robbins, 2009). Recent research has shown very high levels of intrusive thoughts and other post-traumatic symptoms in the week following rape. Serious distress may also be experienced by the partners and families of rape victims.

In many countries, including the UK, crisis intervention centres staffed by multidisciplinary teams have been set up for rape victims. Police practice has significantly improved, and there is now more sensitive handling of rape cases.

Burglary and robbery

Although the consequences are less severe than those following violent crime, they include adjustment disorder and post-traumatic stress disorder. Victims may become excessively preoccupied with security.

Terrorist crimes

There have been many published reports of terrorist crimes, including shootings, bombings, and hostage taking. All have reported severe immediate distress. However, post-traumatic stress disorder and other psychiatric consequences become persistent only in a minority of cases.

Management

The severity and persistence of psychological problems determine the need for both routine and specialist help for victims. Critical incident debriefing as a routine treatment is not helpful (Raphael and Wilson, 2000).

Support for victims of crime may be available within the community. In the UK, the Home Office funds the national Victim Support schemes, which routinely contact victims of crime to offer support, and a service is also available to support crime victims appearing at the Crown Court. However, these services rely on volunteers who may not be able to offer long-term help and who cannot offer specialist psychiatric intervention. Voluntary groups, such as Rape Crisis, offer support to victims of sexual assault. Compensation is available to crime victims from the Criminal Injuries Compensation Board, and psychiatrists may be asked to provide reports in relation to claims for compensation for psychological distress.

Specialist services

There is a need for access to specialist psychiatric assessment and treatment services with particular experience of the problems suffered by victims. These may be provided within normal community services, within a specialized trauma clinic or, occasionally, in more narrowly defined units such as rape clinics.

Routine psychiatric care

It is important that assessment of routine referrals to psychiatric services includes enquiry about experiences of being a victim, as this may be important in both aetiology and planning treatment.

The role of the psychiatrist in the criminal courts

Mental state, intention, and responsibility

Most jurisdictions require evidence of guilty intention for an offender to be convicted. Psychiatrists are therefore most often asked to provide opinions about whether psychiatric illness in the accused affected the intent to commit the crime. Underlying the need for psychiatric opinion is the principle that a person should not 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).

In effect the person perceives and intends that their act will produce unlawful consequences. Three other forms of intent need consideration.

1. Recklessness. This is defined as the deliberate taking of an unjustifiable risk. A person is reckless when they can foresee the consequences but do not avoid them.

2. Negligence. Acting negligently is defined as bringing about a consequence which a ‘reasonable and prudent’ person would have foreseen and avoided.

3. Accident (or ‘blameless inadvertence’).

The key issue in responsibility 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. A psychiatrist who has been asked to give an opinion on these matters should liaise closely with the lawyers as to the relevant psychiatric contribution.

Children

In most jurisdictions, the age of the accused may be thought to affect their capacity to form the intent to commit crime. Most jurisdictions exclude children under a certain age from criminal prosecution; for example, in English law, children under 10 years of age are excluded because they are deemed incapable of forming criminal intent (the Latin term for this being doli incapax). Children between the ages of 10 and 14 years may be convicted if there is evidence of mens rea and that the child knew that the offence was legally or morally wrong. The English age for legal responsibility is lower than in most other European states, and is likely to be raised in the near future.

Competence to stand trial

This issue may arise in relation to any charge. Most jurisdictions require that a defendant must be in a fit condition to defend themselves. In English law, the issue is called ‘fitness to plead’ and may be raised by the defence, the prosecution, or the judge. It cannot be decided in a magistrates’ court, but only by a jury.

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.

A person may be suffering from severe mental disorder but still be fit to stand trial.

If an individual is found not fit to plead, the court will hold a ‘trial of the facts’ to determine whether the individual carried out the offence. If the offence is not serious, the court may make an order directing the offender to have treatment, often as an outpatient. In cases where the offence is serious, or carries a mandatory penalty (e.g. murder), the court will direct the offender to be detained in hospital indefinitely. If the person should become fit to plead, they may be returned to court for a trial. Detention after being found unfit to plead (or legally insane; see below) operates in the same way as detention accompanied by a restriction order.

Legal insanity (not guilty by reason of insanity)

This defence may also be raised to any charge. It is argued that the defendant lacked mens rea for the charge because they were ‘legally insane.’ This term has nothing to do with diagnostic terms or classifications such as ICD-10 or DSM-IV. Legal insanity is defined in different ways in different jurisdictions, and a finding of insanity usually results in the defendant being admitted for treatment in hospital, as opposed to being sent to prison. In some jurisdictions, a ‘not guilty by reason of insanity’ verdict may result in more lenient sentencing.

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 a contentious decision, the judges of the time drew up rules which were not enacted in the law but provided guidance. To establish a defence on the grounds of insanity, it must be clearly proved that, at the time of committing the act, the party 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.

Several other jurisdictions (including some states in the USA and Australia) have used the McNaughton Rules as a basis for their own definitions of legal insanity. Many critics have argued that the rules are much too narrow, and that few truly mentally ill offenders would fulfil these criteria. Indeed, it is doubtful whether McNaughton himself fulfilled them. In some countries, the insanity defence is widely used whenever an individual with a mental illness is charged with an offence, especially crimes of violence such as homicide. In English law, the insanity defence is rarely used, mainly because the alternative defence of diminished responsibility (see below) is available.

Diminished responsibility

Some jurisdictions include the concept of diminished responsibility, i.e. an individual’s blameworthiness may be reduced by his having a mental illness. 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.

There are difficulties with this definition. ‘Abnormality of mind’ bears no resemblance to any diagnostic category; it is basically anything which the ‘reasonable man’ would call abnormal. It has been widely interpreted. Successful pleas have been based on conditions such as ‘emotional immaturity’, ‘mental instability’, ‘psychopathic personality’, ‘reactive depressed state’, ‘mixed emotions of depression, disappointment, and exasperation’, and ‘premenstrual tension.’

The relationship between abnormality of mind and responsibility is not established empirically, and psychiatrists do not necessarily have expertise in this area. Most legal commentators argue that any finding of responsibility is for the jury to decide, and is not a matter of expert evidence. Nevertheless, psychiatrists may be asked to comment on this issue.

Assessment

Most defendants who are charged with murder undergo extensive psychiatric assessment, often by a specialist in forensic psychiatry but sometimes by a general psychiatrist. Defence lawyers often seek independent psychiatric advice. It is good practice for the doctors involved, whether engaged by prosecution or defence lawyers, to discuss the case together. Disagreement is unusual. Copies of the reports are distributed to the judge and to the prosecution and defence lawyers. Similar arrangements apply to other offences in which a psychiatric opinion is required.

If the psychiatric evidence is accepted by the court, supporting diminished responsibility, the defendant will be convicted of manslaughter rather than murder. In some jurisdictions, diminished responsibility may protect the convicted offender from the death penalty.

In the UK, offenders who are convicted of manslaughter in this way may be detained in hospital under the Mental Health Act. If the offence is particularly dangerous, and the offender presents a risk to the public, the court may impose a restriction order, requiring the Home Office to agree discharge.

Infanticide is a particular form of manslaughter charge, which can only be brought against women who have killed their newly born children (under 1 year old). If there is psychiatric evidence to show that the woman was mentally ill at the time of the killing, she will be found guilty of infanticide rather than murder. In this case the court may make a hospital order; restriction orders are rarely applied. This is a rare example of the English law formally recognizing the existence of psychiatric illness, namely postpartum psychosis, as relevant to the commission of an offence.

Absence of intention (automatism)

In some cases, it will be argued that the defendant lacked intention altogether for an offence (technically, the absence of mens rea)—this is referred to as automatism. The paradigm example is acts committed while sleepwalking. Automatism is difficult to determine retrospectively, and the defence is now rarely used, although it played a significant role in nineteenth-century psychiatry. This issue may arise in relation to patients who abuse alcohol or drugs, where it may be argued that they were ‘intoxicated’ and therefore had no intention to commit the crime. The law on intoxication is complicated, and specialist legal advice should be sought.

Fitness to be punished

In those jurisdictions that have corporal or capital punishment, psychiatrists may be asked to assess offenders to determine whether they are mentally well enough to be punished. In addition to assessment, psychiatrists may be asked to treat offender patients in order to make them fit to be punished or executed. Most authorities consider that it is unethical for psychiatrists to be involved in such procedures.

Other psychiatric issues that may be relevant to the criminal court

Amnesia

Over one-third of those charged with serious offences, especially homicide, report some degree of amnesia for the offence and inadequate recall of what happened. It has been argued, unsuccessfully, that loss of memory should be regarded as evidence of unfitness to plead. The factors most commonly associated with claims of amnesia are extreme emotional arousal, alcohol abuse and intoxication, and severe depression. Amnesia has to be distinguished from malingering in an attempt to avoid the consequences of the offence. However, there appear to be instances of true amnesia for offences, just as there is impaired recall by victims and witnesses of offences. Moreover, the factors associated with amnesia are similar in offenders and victims. In the absence of a relevant neuropsychiatric disorder, the presence of amnesia is unlikely to be accepted as having any legal implications (Johns, 2000).

False confessions

False confessions to criminal deeds are sometimes made, but their frequency is unknown. Gudjonsson (1992) suggested that there are three main types of false confession:

1. voluntary

2. coerced–compliant

3. coerced–internalized.

Voluntary confessions may arise from a morbid desire for notoriety, from difficulty in distinguishing fact from fantasy, from a wish to expiate guilt feelings, or from a desire to protect another person. Coerced–compliant confessions result from forceful interrogation, and are usually retracted subsequently. Coerced–internalized confessions are made when the technique of interrogation undermines the suspect’s own memories and recollections, so that they come to believe that they may have been responsible for the crime. Factors that make a person more likely to make a false confession include a history of substance abuse, head injury, a bereavement, current anxiety, or guilt.

The assessment of possible false confessions is difficult. It requires a thorough review of the circumstances of arrest, custody, and interrogation, as well as an assessment of the personality and the current mental and physical state of the suspect. Clinical psychologists can carry out a neuropsychological assessment and, in some cases, an assessment of suggestibility.

False accusations

Occasionally there are reports of individuals who claim to be the victims of a crime that has not occurred, and who make false accusations. Examples are accusations of rape and also of stalking (Pathé et al., 1999). Legal and clinical experience suggests such cases are uncommon, and that accusers frequently have severe personality and other problems.

The treatment of offenders with mental disorder

General issues

The assessment needs to include as much information as possible from a variety of sources, including, if possible, the general practice notes. In forensic cases the relatives may not be the most reliable informants, particularly if they are victims of interpersonal violence. Careful attention must be paid to both mental illness and personality disorders, as well as histories of substance misuse, which are extremely common.

Forensic psychiatric treatment usually involves treating general psychiatric conditions in specialized settings, such as secure treatment units or hospitals. It may also involve involuntary outpatient care (Swanson et al., 2000). Treatment planning involves not only the appropriate medications, but also organization of appropriate psychological interventions. This is particularly important for forensic patients with severe personality disorders. Management of such patients requires specialist training for staff, and support by forensic psychotherapists. It also depends upon introducing evidence-based psychiatric care into forensic practice. Many forensic patients have personality disorder; the general principles of management are described in Chapter 7 (see also Bateman and Tyrer, 2004a,b).

Settings of treatment

After conviction, an offender may be treated on either a compulsory or voluntary basis. In the UK, special treatment for mentally abnormal offenders is, in principle, provided by the Home Office (the prison medical service and the probation service) and by the Department of Health (high secure hospitals, specialist forensic services, and general psychiatry services). There has been a lack of research in forensic psychiatry, which means that the evidence base for effective treatment is slender. For a general review of the organization of forensic psychiatric services, see Bluglass (2000).

Much work with offenders is carried out by general psychiatrists, who assess patients and prepare court reports. General psychiatrists as well as forensic psychiatrists treat offenders who have been given non-custodial sentences. Forensic psychiatrists work in separate units and undertake specialized assessment and court work. In many places there are community forensic services to provide assessment and treatment. Forensic psychiatrists may work to provide care for patients who need security in ordinary psychiatric hospitals.

The mentally abnormal in prison

About one-third of sentenced prisoners have a psychiatric disorder and 4% have a psychosis (Fazel and Danesh, 2002). Most of these disorders can be treated in prison, but a few offenders need transfer to a hospital (see Box 24.5).

Prison medical services have to provide psychiatric care under extremely difficult conditions, and it has been argued that there should be a substantial increase in the contribution of psychiatrists to the provision of medical care within prisons. A few prisons offer psychological treatment, usually for personality disorders and sexual offences, as a main part of their work. Grendon Underwood in England is a long-established specialist prison for such treatments. Although there is an undoubted need for psychiatric care within prisons, there would be disadvantages in a system that encouraged the courts to send the mentally abnormal to prison rather than to hospital services.

Box 24.5 Reasons for hospital transfer of prisoners with psychiatric disorder

• Psychosis

• Failure to improve with medical treatment in prison

• Refusal to have treatment for serious psychiatric illness

• Life-threatening self-harm

• Risk of abuse

Offenders in hospital

Most jurisdictions allow for the detention of mentally abnormal offenders in secure psychiatric settings. In England and Wales, a convicted offender may be committed to hospital for compulsory psychiatric treatment under a Mental Health Act hospital order. There is also provision in law for a prisoner to be transferred from prison to a psychiatric hospital. Hospital orders may have no time limit, whereas most prison sentences are of fixed length. The length of stay in a psychiatric hospital may be shorter than a prison sentence, or it may be longer.

Special hospitals and secure units in the UK

In the UK, detention of mentally abnormal offenders may be in a local psychiatric hospital, a medium security unit, or a maximum secure hospital (‘special hospital’). In England, the first special provision for the criminally insane was made in 1800, when a criminal wing was established at the Bethlem Hospital. In 1863, Broadmoor, the oldest of the special hospitals, opened under the management of the then Home Office. There are now four high-security special hospitals in England and Wales for patients who require very high levels of security.

The detention of patients in special hospitals is usually for an indeterminate duration. For those with mental illness (mostly schizophrenia), the length of detention is determined by the severity or chronicity of the psychiatric disorder, rather than by the nature of the offence. By contrast, for patients suffering from psychopathic disorder, the main determinant of length of stay is the assessment of the future risk of offending.

The closure of the larger mental hospitals in the UK has had unforeseen consequences for the care of mentally abnormal offenders. There is less physical security in the new psychiatric wards and hospitals, and less willingness by hospital staff and other patients to tolerate severely disturbed behaviour. Allied with shorter admission practices, it has become increasingly difficult to arrange admission to hospital for offenders, particularly those who are severely disturbed. Two alternative provisions have been developed:

1. well-staffed secure areas in ordinary psychiatric hospitals in which the less dangerous of these patients can be treated

2. special secure units associated with psychiatric hospitals, to provide a level of security intermediate between that of an ordinary hospital and a special hospital (medium-secure units).

Dangerous Severe Personality Disorder (DSPD) units

The notion of Dangerous Severe Personality Disorder (DSPD) is an administrative category based on clinical diagnosis and risk assessment. It was introduced in England in 1999 as a response to two pressing problems of public safety. The first was offenders coming to the end of their sentences with a persisting serious risk of violence. The second was that psychiatrists would not detain severely personality-disordered individuals because they judged there to be no evidence of their ‘treatability.’ Treatability was, uniquely, required in the 1983 Mental Health Act for personality disorder but not for mental illness stemming from the original 1959 Act.

Four pilot units were established—two in prisons and two in high secure hospitals. They reflected the context of decreased public tolerance of risk of violent crime, improved standardized risk assessment, establishment of cognitive–behaviour therapy programmes for sexual and violent offenders (McGuire, 2008), and international experience from the Netherlands and Canada (Maden, 2007). The criteria for admission were very prescriptive (see Box 24.6).

In practice the units have proved difficult to staff and utilize fully, and the introduction of indefinite sentencing has removed much of their raison d’être. The hospital units are already being run down, and the prison units are under review.

Box 24.6 Criteria for admission to DSPD units

1. More likely than not to commit an offence that might be expected to lead to serious physical or psychological harm from which the victim would find it difficult or impossible to recover.

2. Having a severe personality disorder determined by:

• psychopathy measured by a PCL-R (Hare, 1991) score of ≥ 30, or

• a PCL-R score of ≥ 25 plus at least one personality disorder (excluding antisocial personality) according to ICD-10 or DSM-IV criteria, or

• two or more personality disorders (one of which can be antisocial) according to ICD-10 or DSM-IV criteria.

3. Having a link between their personality disorder and previous offence(s) and/or offence-like behaviour in prison.

Treatment in the community

Offender patients may not pose sufficient risk, or be sufficiently ill, to require treatment in hospital. Courts may also use non-custodial sentences in which the offender-patient may receive support from the probation service as well as psychiatric treatment. On occasion, psychiatric treatment may be made a condition of probation, with which the offender must agree to comply.

The psychiatric treatment provided for a mentally abnormal offender is similar to that for a patient with the same psychiatric disorder who has not broken the law. It is often difficult to provide psychiatric care for offenders with chronic psychiatric disorders who commit repeated petty offences. In the past they would have been long-stay patients in a psychiatric hospital, but now, treated in the community, they may be unwilling to cooperate with treatment and difficult to follow up because they change address or become homeless.

The management of violence in healthcare settings

Violent incidents are not confined to patients with forensic problems, but this is a convenient place to consider their management. Although not frequent, violent incidents in hospitals are increasing. The reasons for this increase appear to include the following:

• changes in mental health policies that have made dangerousness a relatively more common reason for admission (as non-violent patients are more likely to be treated in the community)

• overcrowding

• lack of sufficiently experienced staff

• increased use of illegal substances.

All psychiatrists should be familiar with how to manage incidents of violence in inpatient settings. Prior education and training are essential, and the National Institute for Health and Clinical Excellence (2005c) has provided guidelines (see Figure 24.3). It is important that staff have a clear policy for managing incidents of violence and are trained to implement it. Such a policy calls for attention to the design of wards, arrangements for summoning assistance, and suitable training of staff.

When violence is threatened or actually occurs, staff should be available in adequate numbers, and emergency medication such as intramuscular lorazepam and haloperidol should be unobtrusively available. The emphasis should be on the prevention of violence (see Box 24.7).

Potentially dangerous people can often be calmed by sympathetic discussion or reassurance, preferably given by someone whom they know and trust. It is important not to challenge the patient. It is inappropriate to reward violent or threatening behaviour by making concessions with regard to treatment or ward rules, but every effort should be made to allow the patient to withdraw from confrontation without loss of face. The use of medication should be followed by appropriate monitoring (for advice about the use of medications in emergencies, see p. 529).

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 are forms of interpersonal violence, which may be criminal. Opinion has changed in this area, with a preference for involving the police more often, although the police 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 which are applicable in a general way to ward policies and procedures.

Images

Figure 24.3 Algorithm for the short-term management of disturbed or violent behaviour in healthcare settings. Reproduced from National Institute for Health and Clinical Excellence (2005) Adapted from ‘CG 25 Violence: the short-term management of disturbed/ violent behaviour in psychiatric in-patient settings and emergency departments’. London: NICE. Available from www.nice.org.uk. Reproduced with permission.

Box 24.7 De-escalation techniques used to prevent violence

• One staff member should take overall charge of the situation.

• Move the patient to a suitable room or area to help to reduce arousal.

• Make sure that sufficient staff are available.

• Explain to the patient what the staff are doing and how they hope to resolve the situation.

• Attempt to establish rapport. Show concern and listen attentively. Ask open questions. Monitor your own verbal and non-verbal behaviour. Do not patronize the patient or minimize their concerns.

• If a weapon is involved, ask for it to be put in a neutral location rather than handed over.

Source: National Institute for Health and Clinical Excellence (2005c).

Risk assessment

The change to community care has made both minor criminality and rare violent offences more conspicuous, and has resulted in increased public disquiet. Psychiatric services need the resources to minimize difficulties and to identify and manage serious threats of violence. For a review of dangerousness and risk, see Buchanan (2008). The psychiatrist may need to assess risk in everyday psychiatric practice and also in forensic work.

In everyday practice, both outpatients and inpatients may appear to be dangerous, and careful risk assessment may be required so that the most appropriate steps can be taken in the interests of the patient and of other people. Risk of serious harm to others is an important criterion for compulsory detention in hospital.

In forensic work, the court may ask for the psychiatrist’s advice on the defendant’s dangerousness, so that a suitable sentence can be passed. The psychiatrist may also be asked to comment on offenders who are detained in institutions and who are being considered for release. In both situations there is an ethical dilemma due to the conflict between the need to protect the community from someone who might exhibit violent behaviour, and the obligation to respect the human rights of the offender.

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 Table 24.5). Although some general predictors of violence (e.g. antisocial personality disorder, substance misuse) are helpful, they lack specificity in identifying particular individuals at risk (Dolan and Doyle, 2000).

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. Although some recent instruments have an improved predictive accuracy, they are time-consuming to administer (Monahan et al., 2000).

There are no fixed clinical rules for assessing risk, but there are recognized basic principles. A thorough review should be conducted of the history of previous violence, the characteristics of the current offence and the circumstances in which it occurred, and the mental state of the individual (see Figure 24.4). When making the review, it is helpful to consider the following key factors:

• whether any consistent pattern of behaviour can be discerned

• whether any circumstances have provoked violence in the past and are likely to occur again in the future

• whether there is any good evidence that the defendant is willing to change their behaviour

• whether there is likely to be any response to treatment (see Figure 24.4).

Table 24.5 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

Of these predictors, the most useful is a history of past violence (Buchanan, 2008).

Particular difficulties may arise in the assessment of dangerousness in people with antisocial personality or learning disabilities, who may be poorly motivated. Another difficult problem is presented by the person who threatens to commit a violent act such as homicide. Here the assessment is much the same as for suicide threats (see p. 427) but with a lower threshold for intervention. The psychiatrist should ask the individual about their intent, their motivation, and the potential victim, and should make a full assessment of the person’s mental state. Some patients who make threats can be helped by outpatient support and treatment, but sometimes hospital admission is required if the risk is high. It may be necessary to warn potential victims or the police.

Images

Figure 24.4 Schematic representation of the issues that should be considered when assessing the probability of violent behaviour. After Mullen P and Oglof RP (2009). Dangerousness, risk and the prediction of probability. In: Gelder MG, Andreasen NC, López-Ibor JJ Jr and Geddes JR (eds) The New Oxford Textbook of Psychiatry, 2nd edn. Oxford University Press, Oxford. Reproduced with permission.

It is a valuable principle for the psychiatrist not to rely entirely on his or her own evaluation of dangerousness, but to discuss the problem with other colleagues, including other psychiatrists, general practitioners, social workers, and the individual’s relatives.

The psychiatric report

A psychiatric report prepared for a major criminal charge is an important document, and should be based on a full psychiatric and social examination. It is essential that the psychiatrist reads all of the depositions by witnesses, statements by the accused, and any previous medical notes and social reports. Family members should be interviewed. When evidence about previous offences is not admissible (as is the case in English law) the psychiatrist’s report should not include these facts. This may cause problems for the psychiatrist, whose opinion is often based in large part on the previous behaviour of the offender. The writing of the court report follows the format described in Box 24.8, and should include an assessment of the person’s mental state at the time of the alleged offence, and of their fitness to plead. The involvement of the psychiatrist at various stages of the legal process in England and Wales is shown in Table 24.6.

The role of the psychiatrist in relation to the court

The psychiatrist’s role is to draw on their special knowledge to help the court. They should not attempt to tell the court what to do. In the UK, the duty of the expert medical witness is to the court as a whole; they are not expected to be partisan. It is sometimes hard for psychiatrists to appreciate that they must remain neutral and not provide evidence to order that supports the party instructing them. This is particularly difficult because most psychiatrists use their clinical skills to establish rapport with individuals on whom they are preparing a report, and they experience a desire to advocate for them.

The psychiatrist should be aware that the court will see the report and that it may be read out in open court. Reports that are commissioned and paid for by lawyers are the property of the court.

Box 24.8 Some headings for a court report

• A statement of the psychiatrist’s full name, qualifications, and present appointment (and, in England and Wales, whether they are approved under Section 12 of the Mental Health Act).

• Where and when the interview was conducted and whether any third person was present.

• Sources of information, including documents that have been examined.

• Family and personal history of the defendant/plaintiff. Usually this does not need to be given in great detail, particularly if a social report is available to the court. The focus should be on information that is relevant to the diagnosis and disposal.

• Present mental state. Only the salient positive findings should be stated, and negative findings should be omitted. A general diagnosis should be given in the terms used in the old 1983 Mental Health Act (mental illness, mental impairment, or psychopathic disorder). A more specific diagnosis can then be given, but the court will be interested in a categorical statement rather than the finer nuances of diagnosis.

• Mental state at the time of the relevant events. This is often a highly important issue, especially in criminal cases, and yet it can be based only on retrospective speculation. The assessment can be helped by accounts given by eye witnesses who saw the offender at the time of the crime or soon afterwards. A current psychiatric diagnosis may suggest the likely mental state at the time of the crime. For example, if the accused suffers from chronic schizophrenia or a chronic organic mental syndrome, the mental state may well have been the same at the time of the crime as at the examination. However, if the accused suffers from a depressive disorder (now or recently) or from an episodic disorder such as epilepsy, it is more difficult to infer what the mental state is likely to have been at the material time. To add to the difficulty, even if it is judged that the defendant was suffering from a mental disorder, a further judgement is needed as to their mens rea at the time of the crime.

• Conclusions. A summary of the key findings.

Table 24.6 The involvement of psychiatrists in the stages of the UK legal process

Images

The assessment

When conducting a psychiatric assessment on a person who is accused of a crime or who has been convicted of an offence, some key points should be kept in mind.

1. Prepare as thoroughly as possible before the interview. Have a clear idea of the purpose of the examination, and particularly about any question of fitness to plead. Obtain details of the present charge and past convictions, together with copies of any statements made by the defendant and witnesses. Study any available reports of the defendant’s social history; during the subsequent interview go through this report with the defendant and check its accuracy.

2. Begin by explaining the source of the referral and why it was made. You should explain that their opinion may be given in court and that they are under no obligation to answer any of your questions if they choose not to.

3. Make detailed notes, recording any significant comments in the defendant’s own words. At some stage in the interview (not necessarily at the start), the alleged crime should be discussed. The defendant may or may not admit guilt, but the psychiatrist is not obliged to comment on this.

4. Take a detailed history of any physical illnesses, paying particular attention to neurological disorders, including head injury and epilepsy.

5. Obtain a careful history of previous psychiatric disorder and treatment. Make a full examination of the present mental state. Special investigations should be requested if appropriate. If the defendant’s intelligence level is under question, a clinical psychologist should make a separate assessment.

6. If possible, obtain further information from relatives and other informants. If the defendant is remanded in custody, the staff may have long periods of contact with the prisoner and may be able to provide particularly useful information.

Preparing the report

The preparation of a court report will be affected by the circumstances of the case, and the instructions given by solicitors. Court reports for civil and criminal cases may be very different. A possible outline is shown in Box 24.8. For further details, see Grounds (2000).

When preparing a court report, the psychiatrist should remember that it will be read by people with a non-medical background. Therefore the report should be written in simple English and should avoid the use of jargon. If technical terms are used, they should be defined as accurately as possible. The report should be concise.

Advice on medical treatment

One of the psychiatrist’s main functions is to give an opinion on whether psychiatric treatment is indicated. The psychiatrist should make sure that any recommendations on treatment are feasible, if necessary by consulting colleagues, social workers, or others. If hospital treatment is recommended, the court should be informed whether or not a suitable placement is available.

The assessment of risk is important here (see p. 729). The psychiatrist should not recommend any form of disposal other than treatment. However, the court often welcomes respectfully worded comments on the suitability of possible sentences, particularly in the case of young offenders.

The psychiatrist appearing in court

The psychiatrist appearing in court should be fully prepared and should have well-organized copies of all reports and necessary documents. It is helpful to speak to the lawyer involved beforehand, in order to clarify any points that may be raised in court. When replying to any questions in court, it is important to be brief and clear, to restrict the answers to the psychiatric evidence, and to avoid speculation. A number of expert witness training programmes are available, which may be useful for psychiatrists who often give expert evidence.

Further reading

Gelder MG, Andreasen NC, López-Ibor JJ Jr and Geddes JR (eds) (2009). Part 11: Forensic psychiatry. The New Oxford Textbook of Psychiatry, 2nd edn. Oxford University Press, Oxford.

Maguire M, Morgan M and Reiner R (2002). The Oxford Handbook of Criminology. Oxford University Press, Oxford. (An authoritative review of criminology, with numerous chapters that are relevant to forensic psychiatry.)

Gunn J and Taylor P (2006). Forensic Psychiatry. Hodder Arnold, London. (A detailed and useful textbook.)

The format and extent of an assessment will depend on the nature of the presenting problem. The following scheme is taken from the book by Graham (1999), which should be consulted for further information. Graham suggests that clinicians with little time available should concentrate on the items in bold type

1 Nature and severity of presenting problem(s). Frequency. Situations in which it occurs. Provoking and ameliorating factors. Stresses thought by parents to be important.

2 Presence of other current problems or complaints.

(a) Physical. Headaches, stomach ache. Hearing, vision. Seizures, faints, or other types of attacks.

(b) Eating, sleeping, or elimination problems.

(c) Relationship with parents and siblings. Affection, compliance.

(d) Relationships with other children. Special friends.

(e) Level of activity, attention span, concentration.

(f) Mood, energy level, sadness, misery,

(g) Response to frustration. Temper tantrums.

(h) Antisocial behaviour. Aggression, stealing, truancy.

(i) Educational attainments, attitude to school attendance.

(j) Sexual interest and behaviour.

(k) Any other symptoms, tics, etc.

3 Current level of development.

(a) Language: comprehension, complexity of speech.

(b) Spatial ability.

(c) Motor coordination, clumsiness.

4 Family structure.

(a) Parents. Ages, occupations. Current physical and emotional state. History of physical or psychiatric disorder. Whereabouts of grandparents.

(b) Siblings. Ages, presence of problems.

(c) Home circumstances: sleeping arrangements.

Family function.

(a) Quality of parental relationship. Mutual affection. Capacity to communicate about and resolve problems. Sharing of attitudes over child’s problems.

(b) Quality of parent-child relationship. Positive interaction: mutual enjoyment. Parental level of criticism, hostility, rejection.

(c) Sibling relationships.

(d) Overall pattern of family relationships. Alliance, communication. Exclusion, scapegoating. Intergenerational confusion.

6 Personal history.

(a) Pregnancy complications. Medication. Infectious fevers.

(b) Delivery and state at birth. Birth weight and gestation. Need for special care after birth.

(c) Early mother-child relationship. Post-partum maternal depression. Early feeding patterns.

(d) Early temperamental characteristics. Easy or difficult, irregular, restless baby and toddler.

(e) Milestones. Obtain exact details only if outside range of normal.

(f) Past illnesses and injuries. Hospitalizations.

(g) Separations lasting a week or more. Nature of substitute care.

(h) Schooling history. Ease of attendance. Educational progress.

7 Observation of a child’s behaviour and emotional state.

(a) Appearance. Signs of dysmorphism. Nutritional state. Evidence of neglect, bruising, etc.

(b) Activity level. Involuntary movements. Capacity to concentrate.

(c) Mood. Expression of signs of sadness, misery, anxiety, tension.

(d) Rapport, capacity to relate to clinician. Eye contact. Spontaneous talk. Inhibition and disinhibition.

(e) Relationship with parents. Affection shown. Resentment. Ease of separation

(f) Habits and mannerisms.

(g) Presence of delusions, hallucinations, thought disorder.

(h) Level of awareness. Evidence of minor epilepsy.

8 Observation of family relationships.

(a) Patterns of interaction – alliances, scapegoating.

(b) Clarity of boundaries between generations: enmeshment.

(c) Ease of communication between family members.

(d) Emotional atmosphere of family. Mutual warmth. Tension, criticism.

9 Physical examination of child.

10 Screening neurological examination.

(a) Note any facial asymmetry

(b) Eye movements. Ask the child to follow a moving finger and observe eye movement for jerkiness, incoordination.

(c) Finger-thumb apposition. Ask the child to press the tip of each finger against the thumb in rapid succession. Observe clumsiness, weakness.

(d) Copying patterns. Drawing a man.

(e) Observe grip and dexterity in drawing.

(f) Jumping up and down on the spot.

(g) Hopping.

(h) Hearing. Capacity of child to repeat numbers whispered two metres behind him.