Major affective disorders and forensic psychiatry.

Major mental illnesses, such as major affective disorders and schizophrenias, form a relatively small diagnostic group among mentally disordered offenders. The major affective disorders are less common when compared with schizophrenics among such offenders. Yet, some of the most violent crimes, such as murder, attempted murder, and serious assaults, especially intrafamilial violence, are committed by major affective disorder patients. The offenses by this group of patients are committed while suffering from active symptoms of the illness. As such, a substantial majority is not considered fully criminally responsible for the offense. Many such offenders are found not guilty by reason of insanity and are sent to psychiatric hospitals.     

Reassessing the aftercare treatment of individuals found not guilty due to a mental disability in Hunan, China: supplemental study into the disposition of mentally ill offenders after forensic psychiatric assessment

OBJECTIVE: The purpose of the present paper was to examine the disposition of individuals in Hunan, China who are found not criminally responsible due to a mental disorder or defect. METHOD: Self-developed questionnaires were mailed to the family members of 240 patients who had received forensic psychiatric evaluations at the forensic psychiatric assessment center of Central South University, between 2001 and 2002. RESULTS: One hundred and seventy questionnaires were fully completed and returned by the patients' family members. According to the answers, 64.1% (109 patients) were found not criminally responsible due to a mental disorder or defect. In 87.6% of the cases, a judgement of guilty was in agreement with the psychiatrist's recommendation concerning criminal responsibility. A total of 61.8% of the patients found not guilty were discharged to their families and did not receive any further psychiatric treatment. CONCLUSION: In most cases, judicial decisions are consistent with a psychiatrist's opinion of criminal responsibility due to a mental disorder or defect. After such adjudication, further psychiatric treatment is often neglected due to the lack of resources and information. Hunan, China must make a continued investment into the availability and quality of outpatient mental health treatment for forensic patients after they have been discharged.     

NGRI and Megan's Law: no exit?

Megan's Law, an effort to enhance community safety by requiring sex offenders to register and to notify their communities, often for life, has been enacted in all jurisdictions of the United States. Although the ostensible intent of the law is nonpunitive, many registrants feel it infringes on their freedom. Nevertheless, the law has passed constitutional scrutiny. Megan's Law pertains principally to convicted sex offenders, including those adults and juveniles who have entered guilty pleas. This article reveals that many jurisdictions require individuals found not guilty by reason of insanity (NGRI) to register if the offense in question falls under Megan's Law. Thus, insanity acquittees run the risk of interminable supervision. We discuss a recent challenge to the Arkansas registration law and the decision's implications for planning forensic mental health testimony.     

Older criminals: a descriptive study of psychiatrically examined offenders in Sweden

OBJECTIVE: We retrospectively examined psychiatric diagnoses of older offenders referred by court for psychiatric assessment in Sweden, and compared them with younger offenders. METHOD: In Sweden, structured court-ordered forensic psychiatric evaluations are undertaken by a forensic psychiatric team. Data on age, sex, citizenship, psychiatric diagnoses, offences, and legal insanity declarations were obtained for the years 1988-2000 (n = 7297). RESULTS: There were 210 forensic psychiatric evaluations in those aged 60 and over. 7% had a diagnosis of dementia, 32% psychotic illness, 8% depressive or anxiety disorder, 15% substance abuse or dependence, and 20% personality disorder. Older offenders were significantly less likely to be diagnosed with schizophrenia or a personality disorder, and more likely to have dementia or an affective psychosis compared to younger ones. Logistic regression analyses suggested that of the studied factors, the ones most typical of older offenders were a diagnosis of dementia and being charged with a sexual offence. CONCLUSION: There appear to be important differences in psychiatric morbidity between older offenders and younger ones who come into contact with forensic psychiatric services. This research may assist in the planning of forensic and therapeutic services for the increasing number of older adults passing through the criminal justice system.     

精神疾病患者的暴力行为及其责任能力评定

精神疾病与暴力行为之间存在着较为密切的联系。精神疾病患者暴力作案的责任能力评定是司法鉴定中的常见和难点问题。本文从患者暴力行为特征、责任能力相关影响因素以及未来发展趋势等方面,结合国内外研究进展进行了综合评述,以期对精神疾病患者刑事责任能力评定的研究和实践提供理论参考。     

Childhood psychiatric disorders and young adult crime: a prospective, population-based study

OBJECTIVE: While psychopathology is common in criminal populations, knowing more about what kinds of psychiatric disorders precede criminal behavior could be helpful in delineating at-risk children. The authors determined rates of juvenile psychiatric disorders in a sample of young adult offenders and then tested which childhood disorders best predicted young adult criminal status. METHOD: A representative sample of 1,420 children ages 9, 11, and 13 at intake were followed annually through age 16 for psychiatric disorders. Criminal offense status in young adulthood (ages 16 to 21) was ascertained through court records. RESULTS: Thirty-one percent of the sample had one or more adult criminal charges. Overall, 51.4% of male young adult offenders and 43.6% of female offenders had a child psychiatric history. The population-attributable risk of criminality from childhood disorders was 20.6% for young adult female participants and 15.3% for male participants. Childhood psychiatric profiles predicted all levels of criminality. Severe/violent offenses were predicted by comorbid diagnostic groups that included both emotional and behavioral disorders. CONCLUSIONS: The authors found that children with specific patterns of psychopathology with and without conduct disorder were at risk of later criminality. Effective identification and treatment of children with such patterns may reduce later crime.     

Dangerous or merely ‘difficult’? The new population of forensic mental hospitals

BackgroundDuring recent decades, there has been a substantial increase in admissions to forensic mental hospitals in several European countries. It is not known if reforms implemented in mental health policies and practices are responsible for this development.ObjectiveOur study examined the development of mental health care in Austria and the incidence and prevalence of mentally disordered offenders judged not guilty by reason of insanity (NGRI).MethodsWe analysed data on service provision and data from criminal statistics between 1970 and 2008 from several national sources.ResultsDuring the first decade when reforms to mental health practice were implemented, the incidence and prevalence of offenders judged NGRI remained unchanged, despite a reduction of mental hospital beds by nearly 50% and little outpatient care. Surprisingly, the enormous increase in admissions to forensic inpatient treatment began in Austria only after community mental health services were rolled out across the country in the 1990s. This increase was primarily due to admissions of patients who had committed less severe offences, while rates of those who had committed homicide remained unchanged.ConclusionOur results cannot be explained by details of the reforms such as the downsizing of mental hospitals or a lack of outpatient facilities, nor by changes to criminal sentencing. Rather, the results provide evidence of an increasingly inadequate provision of comprehensive care for “difficult” but not extremely dangerous psychotic patients living in the community. This may result from the attitudes of mental health professionals who have become less inclined to integrate aggressive behaviour into their understanding of psychosis. As a consequence, increasing numbers of “difficult” patients end up in forensic psychiatric institutions. This development, which can be observed in nearly all European countries, raises concerns with regard to efforts to destigmatize both patients and psychiatry.     

Review of psychiatric services to mentally disordered offenders around the Pacific Rim

This article was commissioned to collate and review forensic psychiatric services provided in a number of key Pacific Rim locations in the hope that it will assist in future dialogue about service development. The Board of the Pacific Rim College of Psychiatrists identified experts in forensic psychiatry from Australia, Canada, China, Hong Kong, Japan, Russia, Singapore, Taiwan, and the US. Each contributor provided an account of issues in their jurisdiction, including mental health services to mentally disordered offenders in prison, competence or fitness to stand trial, legal insanity as a defense at trial, diminished responsibility, and special forensic services available, including forensic hospitals and community forensic mental health services. Responses have been collated and are presented topic by topic and country by country within the body of this review. The availability of mental health screening and psychiatric in‐reach or forensic liaison services within prisons differed considerably between countries, as did provisioning of community forensic mental health and rehabilitation services. Diversion of mentally disordered offenders to forensic, state, or hybrid hospitals was common. Legal constructs of criminal responsibility (insanity defense) and fitness to stand trial (“disability”) are almost universally recognized, although variably used. Disparities between unmet needs and resourcing available were common themes. The legislative differences between contributing countries with respect to the mental health law and criminal law relating to mentally disordered offenders are relatively subtle. The major differences lie in operationalizing and resourcing forensic services.     

Mental disorder, intellectual deficiency, and crime. Evidence from a birth cohort.

Studies of criminality among patients in psychiatric hospitals and of mental disorder among incarcerated offenders have suggested an association between the major mental disorders (schizophrenia and major affective disorders) and crime. However, these investigations are characterized by notable methodological weaknesses, and, consequently, this conclusion has remained tentative. Little is known about the criminality of intellectually handicapped people. The present study examined the relationship between crime and mental disorder and crime and intellectual deficiency in an unselected Swedish birth cohort followed up to age 30 years. It was found that men with major mental disorders were 2 1/2 times more likely than men with no disorder or handicap to be registered for a criminal offense and four times more likely to be registered for a violent offense. Women with major disorders were five times more likely than women with no disorder or handicap to be registered for an offense and 27 times more likely to be registered for a violent offense. These subjects committed many serious offenses throughout their lives. The criminal behavior in over half these cases appeared before the age of 18 years. Intellectually handicapped men were three times more likely to offend than men with no disorder or handicap and five times more likely to commit a violent offense. Intellectually handicapped women were almost four times more likely to offend than women with no disorder or handicap and 25 times more likely to commit a violent offense.(ABSTRACT TRUNCATED AT 250 WORDS)     

Criminal responsibility in sexual homicide perpetrators

OBJECTIVE: Evaluation of criteria for criminal responsibility, esp. in paraphilias and personality disorders. METHODS: We compared sexual murderers with diminished responsibility or not-guilty for reasons of insanity (n = 73) and those held fully responsible (n = 61) regarding psychiatric disorders, signs of severe paraphilias, level of personality structure (using Operationalized Psychodynamic Diagnostics) and offence related criteria. RESULTS: Sexual murderers found as diminished responsible or not-guilty, especially those detained in forensic psychiatric hospitals, showed more signs of a progressive sadistic development and lower levels of personality structure. Offence related criteria that are regarded as not supporting a diminished capacity plea (purposeful actions, long duration, complex, stepwise course of the offence) were found more frequent in those offenders that were detained in forensic hospitals. CONCLUSIONS: Signs for severity of paraphilias and personality disorders are useful in decisions about criminal responsibility. Criteria regarding purposeful course of action appear not to be adequate for the assessment of paraphilic sexual offenders.     

Mental disorders of male parricidal offenders

Background  

Information on parricidal offenders is mainly derived from selective samples of hospitalized patients. According to literature, a substantial proportion of parricidal offenders suffers from major mental disorders and is found to be not guilty by reason of insanity. The aim of this study was to examine and compare diagnoses and criminal responsibilities of matricidal and patricidal offenders in detail using a comprehensive national data set.     

Forensic psychiatric perspective on criminality associated with intellectual disability: a nationwide register-based study

Background   Contrasting views exist over the association of intellectual disability (ID) and criminal offending. This nationwide study attempts to shed further light to expand understanding to substantiate the relation between socio-demographic characteristics, psychiatric co-morbidity and criminal behaviour among the Finnish forensic population with ID.
Method   We reviewed all forensic psychiatric examination reports of individuals with ID who underwent a pre-trial forensic psychiatric evaluation in Finland during an 11-year period (1996–2006).
Results   One-third of the offenders had been regularly and sufficiently treated as outpatients. Half of the offenders had previous criminality, and the single most common crime was arson. Almost half of the offenders were diagnosed with alcohol abuse/dependence and two-thirds with any substance abuse/dependence. Furthermore, almost half were intoxicated during the index crime. Antisocial personality disorder was diagnosed in 25% of the offenders. Almost half of the offenders were placed in involuntary special care for the ID, which lasted ca 2 years. Among the last-mentioned, two-thirds of the nursing care plans lacked recommended structure.
Conclusions   The offenders with so-called triple diagnosis – substance abuse, mental illness and ID – form a small subgroup of criminal offenders with complex needs. The results of the present study underline the importance of close, long-term cooperation among specialists in the field of ID, addiction service, mental health services and forensic psychiatry.     

Court-mandated outpatient treatment for insanity acquittees: clinical philosophy and implementation

Court-mandated outpatient treatment for offenders found not guilty by reason of insanity is an alternative form of treatment in which insanity acquittees may be released into the community after serving part of their commitment in a forensic hospital. Working with this difficult population requires a close liaison with the criminal justice system and a clearly articulated treatment philosophy. Essential elements include an emphasis on structure and supervision, recognition of the importance of neuroleptic medication, a reality-based approach to therapy and a focus on the problems of everyday living, and incorporation of the principles of case management. Treatment staff must be comfortable with giving support, enforcing limits, and recommending revocation of the patient's community status when necessary. Case illustrations of successful and unsuccessful community treatment for insanity acquittees are included.     

Borderline Personality Disorder in the Courtroom

The insanity defense has been criticized with consequences for individuals with real mental illness. In the United States, several states have redefined the insanity defense by excluding antisocial personality disorder from consideration for the not guilty by reason of insanity plea. Four states have eliminated the insanity defense completely. The purpose of this article is to analyze the diagnosis of borderline personality disorder, its relevance in the courtroom setting, and how this speaks to the approach of the insanity defense in general. The history of the insanity defense, impulsive nature of borderline personality disorder, and the reasons that make personality disorders controversial are reviewed. The impulsive nature, and the association to childhood trauma, dissociation, and frontolimbic abnormalities support the continued protection of borderline personality disorder under the insanity defense. Knowledge of these facts will assist the forensic psychiatrist in effectively educating the courtroom about borderline personality disorder. Key words: borderline personality disorder, cortico-limbic model, dissociation, forensic psychiatry, insanity defense, splitting, suicide     

Sex offenders and insanity: an examination of 42 individuals found not guilty by reason of insanity

Although currently there is a large body of research on the characteristics and treatment of sex offenders, very little research has been conducted to investigate the characteristics of sex offenders who have been adjudicated insane. This study included 42 patients at Napa State Hospital who were adjudicated not guilty by reason of insanity (NGRI) for a sex offense. The sample was further divided into offenders whose victims were children and those whose victims were adults. Data were collected with a structured chart review instrument. A large percentage of the sex offenders received a primary diagnosis of schizophrenia or schizoaffective disorder, and many had a comorbid substance use disorder. The high percentage of sex offenders in the current study with diagnosed schizophrenia or schizoaffective disorder may represent a previously unstudied subgroup of sex offenders. An alternative explanation is that the experts did not evaluate substance use and intoxication adequately, assess for malingering, or apply the proper legal standard for insanity.     

The profile of a major affective disorder offender

The authors review the studies on the relationship between crime and mental disorder conducted in various settings and point out that the incidence of major mental illnesses in general and of major affective disorders in particular, among the criminal population is relatively small. They present the profile of a major affective disorder offender presenting at a forensic psychiatric department of a university-based psychiatric hospital in a major Canadian city. This profile is based on the demographic, psychiatric, psychological and legal data on a sample of 46 consecutive patients with a diagnosis of major affective disorder. Even though the majority of these offenders are charged with relatively minor crimes and property offenses, they are often referred by the courts for in-patient assessment as many show active symptoms at the time of initial appearance in court. The ways the criminal justice system deals with these offenders are discussed. The benefits and limitations of describing a profile of any group of offenders are also considered.     

The effect of length of hospitalization on re-arrest among insanity plea acquittees

State psychiatric hospitals are increasingly populated by forensic patients. In New York State, the growth in the forensic population is largely attributable to increased lengths of stay of patients deemed not guilty by reason of insanity (NGRI). This research was conducted to determine whether longer periods of hospitalization are associated with better outcomes in the community, as measured by re-arrest for any offense and re-arrest for violence. The sample included 386 NGRI patients released into the community in New York State. A Cox regression proportional hazards model was used to assess the unique effects of length of hospitalization on re-arrest. The results showed that the length of treatment had little effect on either measure of re-arrest. Re-arrest was largely explained by demographics and prior criminal histories.     

Psychopathology in adolescent and young adult criminal offenders (15–21 years) in Sweden

Background This study examined rates of psychopathology among adolescent and young adult serious offenders referred to pre-sentence forensic psychiatric services and compared patterns of psychiatric morbidity with adult forensic referrals and age-matched general psychiatric inpatients. Methods In Sweden, criminal offenders can be referred for an extensive court-ordered pre-sentence inpatient forensic psychiatric examination (FPE). Data on all 3,058 of these offenders (90% male, mean age = 35.3 years) during 1997–2001 were obtained from the National Board of Forensic Medicine. We compared DSM-IV psychiatric diagnoses across age bands 15–17 years (N = 60), 18–21 years (N = 300) and 22 years and older (N = 2,698). Comparative data by age bands were also obtained for inpatient diagnoses among individuals admitted to general psychiatric hospitals. Results Compared with the adult forensic psychiatric examinees, those aged 15–17 years and 18–21 years had higher rates of depression, and childhood and developmental disorders but lower rates of psychosis, bipolar disorder, and substance use disorders. Compared with general psychiatric inpatients, offenders aged 15–17 years had higher prevalences of depression and attention-deficit or disruptive disorders and lower ones of alcohol and drug misuse disorders. Conclusions There are significant differences in patterns of psychiatric morbidity in adolescent and young adult offenders that come into contact with psychiatric services compared with older offenders and adolescent psychiatric inpatients. This suggests that the development of health services addressing the psychiatric needs of younger offenders needs to draw on information on their specific mental health needs.     

Risk of repeat offending among violent female offenders with psychotic and personality disorders

OBJECTIVE: The aim of this study was to examine the rate of criminal recidivism among female homicide offenders evaluated by forensic psychiatrists, to compare this rate with that of other violent female offenders, and to analyze the explanatory variables of recidivism. METHOD: This was a retrospective study of all women (N=132) sent for forensic psychiatric examination after being convicted of homicide or attempted homicide in Finland during 1982-1992; subjects were followed up until mid-1999. Data were collected from the national crime register, the prisoner record, and Statistics Finland. The authors compared the rate of violent repeat offending in this group with that of other violent women and analyzed the explanatory variables of recidivism. RESULTS: During the follow-up period, 23% of the study group committed a repeat offense, 15% of which were violent and 3% of which were homicides. Almost half of all repeat offenses occurred within the first 2 years after the index offense. There was no statistically significant difference in violent recidivism between the study group and other violent female offenders. Of those who committed repeat offenses, 81% were diagnosed with a personality disorder, and 10% were diagnosed with psychosis. Criminality prior to the index event, alcohol or drug dependency, and young age significantly raised the risk and rapidity of further offenses. CONCLUSIONS: The risk of recidivism was high in this study group yet was similar to that of other violent female offenders. The risk was high very early after release. It seems that women and men who are violent and have personality disorders are comparable in their risk of recidivism.     

L’unité pour malades difficiles de Cadillac en Gironde : données d’activité, pathologies et approches thérapeutiques

This communication presents a high security facility in the hospital of Cadillac, near Bordeaux (France). This structure provides intensive psychiatric care for patients with mental disorders and often violent or criminal propensities, all of them compulsorily hospitalized, who need particular security measures. The objective of the study was to describe activity data, characteristics of patients, main diagnoses for year 2018. Among 125 patients, about half (48%) came from Nouvelle-Aquitaine, a large administrative area, and the other came from other regions of France. Most patients were addressed by general psychiatric services (73%). Some were declared not guilty for insanity after a crime (18%), or were detainees (9%). Schizophrenia was the most frequent diagnostic (60%), often associated with substance use disorder. We purpose a clinical approach of different profiles of patients, and a review of therapeutics.