Forensic psychiatry

Forensic psychiatry

Prof Elham Aljammas
8th of April2014

Forensic comes from the latin forensisâ

(the forum or court).
The scope of forensic psychiatry can be broadly defined as those areas where psychiatry interacts with the law

The criminal justice process

The following outlines the chain of events that may happen following the commission of an offence:
Offence reported to police
police record offence
police investigate offence
police find suspect
police charge suspect
report to prosecutor
decision of prosecutor to prosecute
initial court appearance (remanded on bail or in custody)
trial
conviction
sentence (community, prison, fine, discharge, mental health disposal).


Most offenders will not go through all these stages (e.g. by pleading guilty )
an offender may go from initial court appearance directly to sentencing).
At various stages there may be specific provisions for mentally disordered offenders

Crime

A crime is an act that is capable of being followed by criminal proceedings. It is a man-made concept defined by the rules of the state and modified by legislation,
There are differences between countries and across time in the same country. Age of criminal responsibility

Classification of crime

Crimes against the person Offences of interpersonal violence: minor assault, homicide; sexual offences: indecent exposure, rape; robbery
Crimes of dishonesty Burglary; theft and handling stolen goods; fraud and forgery
Criminal damage Property damage; arson
Car crime
Drug crime Use, possession, supplying
Other

Who commits crimes?

Young males aged 10-20 yrs account for 50% of crime. Females -20% of offenders.
Peak age: males 14-17 yrs; females 12-15 yrs.
What are the causes of crime?
The following factors are associated with offending. They interact, and causality cannot be assumed.
Genetic factors MZ more concordant than DZ twins for officially recorded and self-reported offending. In adoption studies children are more similar to biological than adoptive parents.
Intelligence Low intelligence associated with offending.
Personality Impulsivity and lack of empathy.


causes
Family Childhood factors linked to later offending: poor parental supervision, erratic/harsh discipline, marital disharmony and parental separation, parental rejection, low parental involvement, antisocial parents, and large family size. Offenders who marry non-offending spouses reduce their rate of offending.
Peers Most delinquent acts are committed with others. Offending with others versus alone decreases with age. Close relationship between delinquent activities of friends. Offenders are unpopular in non-offending groups but popular in offending groups.

casues

Schools No clear evidence that school factors influence offending. The following are not related to delinquency rates: age and state of buildings, number of children, amount of space, pupil/teacher ratio, academic emphasis, teacher turnover, number of outings. High punishment and low praise associated with delinquency—but is this cause or effect? Alternative placements and approaches to disruptive and delinquent pupils may reduce delinquency compared with mainstream education.
Socio-economic deprivation Poverty and poor housing associated with later offending. Employment protective.
Ethnicity Higher rates of offending in Afro-caribbean than in white males. Lower rates in Asian males. Is association due to socio-economic deprivation, discrimination, different rates of arrest?
Alcohol and substance misuse

Homicide

Definition:-
Homicide is the killing of a person by another

Legal classification:

Lawful Justifiable (e.g. on behalf of State); excusable (e.g. accident
Unlawful Murder :mandatory life sentence; manslaughter/mental health disposal, discharge);
infanticide sentencing as for manslaughter;
death by dangerous driving.


violence

Violent acts involve a perpetrator, a victim, and contextual factors. There will usually be an interplay between factors related to these three. Many of the background factors associated with offending generally are associated with violence,
violent offenders are usually young adults rather than teenagers.
The specific factors of importance in determining the occurrence of aggressive acts are the same as those needing to be considered in assessing the risk of violence

violent offences

The seriousness of an assault may be determined by chance factors such as the availability of medical care and the physical health of the victim. Other ways of categorising violent offences are in terms of the victims and circumstances: domestic/spousal abuse, child abuse elder abuse.

Domestic violence

1 in 4 women experience domestic violence during their lifetimes. Women are victims of 70% of domestic violence. In over 10% of cases serious injuries occur (e.g. broken bones, loss of consciousness). May be a contributory factor in 25% of suicide attempts and in 75% of cases children witness the violence. Accounts for 25% of violent crime in Britain (which will be an underestimate).
Elder abuse
Prevalence (from US figures) 5% of the elderly subject to violence, neglect, or emotional abuse, particularly females. Perpetrators are usually son or daughter, perhaps under stress, with alcohol or drug problems and unable to cope with looking after Mental disorder

What is the relationship between mental disorder and offending?

Mental disorder is common and offending is common, so it would not be surprising to find an individual with both. But is the relationship more than coincidental? When looking at studies of this relationship one needs to consider:
The nature of the sample studied (community v institutional; clinical v epidemiological; pre-treatment v post-treatment; offenders v non-offenders)
The criteria used to define mental disorder (legal v clinical v operationalised) and the method used to determine its existence (case notes v interviews; clinically trained v lay interviewers)
The criteria used to define offending (types of officially recorded offences included; inclusion of unreported or unprosecuted offences and the method used to detect offences (official records v self-report v third-party

conclusions to be drawn from current evidence

. People with mental disorder as a broad group are no more or less likely to offend than the general population.
Some specific mental disorders do increase the risk of a person acting violently, particularly alcohol and drug-related disorders and personality disorders (especially those with predominant cluster B characteristics).
Schizophrenia has a modest association with violence, but the overwhelming majority of people with schizophrenia are never violent, being more likely to be victims than perpetrators of violence.


In people with mental disorders the factors most strongly associated with offending are the same as for non-mentally disordered offenders: male gender, young age, substance misuse, disturbed childhood, socioeconomic deprivation.
When considering an offence perpetrated by a person with mental disorder, one should bear in mind that, as with any offence, there is interplay between the perpetrator, the victim, and the situational circumstances. Although mental disorder may play a part it is rarely the only factor that leads to an offence.

Mental disorder and offending

Schizophrenia
The life-time risk of violence in people with schizophrenia is about 5 times that in the general population. People with schizophrenia account for less than 10% of all violent crime in Britain.
Delusional disorders
Delusional disorders are probably over-represented among patients detained in secure psychiatric hospitals
Affective disorders
Affective disorders have a far less strong relationship with offending and violence than schizophrenia. Mania commonly leads to minor offending due to grandiosity and disinhibition, but rarely leads to serious violence or sexual assaults. Depression is very rarely associated with violence or offending. Extended suicide (also known as altruistic homicide), in which a depressed parent (usually the father) kills members of their family before attempting and perhaps succeeding in killing themselves, is extremely rare and impossible to predict. In some cases it occurs in depressive psychosis associated with nihilistic delusions, but more commonly there is a history of marital breakdown in people who are depressed and suicidal but not psychotic

Alcohol and substance-related disorders

Alcohol and drug-related problems are more strongly linked to offending and violence than any other mental disorders.
Personality disorders
Personality disorder is more strongly related to offending and violence than mental illness. Personality disordered offenders are heterogeneous: only a small number are psychopathic Various aspects of personality disorder may be related to offending: impulsivity, lack of empathy, poor affect regulation, paranoid thinking, poor relationships with others, problems with anger and assertiveness.


Offending occurs more often in people with milder forms of learning disability than in those with severe learning disability. Offences are broadly similar to those in non-learning disabled offenders and are associated with family and social disadvantage. Evidence for increased rates of sex offending and fire-raising is based on highly selected patient samples in secure hospitals and is therefore questionable. In some learning disabled offenders poor social development, poor educational achievement, gullibility, and impaired ability to communicate may be important factors. Profound and severe learning disability may be associated with disturbed behaviour, including aggression, but would rarely come to the attention of the criminal justice system.
Organic disorders
Aggression is well recognised in dementia, but rarely leads to serious violence. Delirium and brain injury may lead to aggression. In head injury cases it may be difficult to differentiate the effects of the head injury from pre-morbid personality. Epilepsy is twice as common in offenders as in the general population, but this is probably due to shared environmental and biological disadvantages that predispose individuals to both. Violence resulting from epileptic activity is extremely rare.


consent

With the exception of lif threatening conditions ,physician must obtain consent from informed adult patient before proceeding in any medical or surgical treatment
Expressed consent may be in verbal, nonverbal or written form and is clearly and unmistakably stated.

Patient Confidentiality:

Physicians have always had a duty to keep their patients' confidences. In essence, the physician's duty to maintain confidentiality means that a physician may not disclose any medical information revealed by a patient or discovered by a physician in connection with the treatment of a patient.

Thank you& good Luck