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     Criminality & mental illness
               Personality disorder
Most likely
               Alcohol/drug dependence
MI in          Intellectual disability
ECA            Schizophrenia 10%
Swan et al.    Substance use 20%
Viol past 12   Schizophrenia + substance use 30%
months         Active psychotic sx  risk
       Violence & mental illness
               Drunkenness charges
Alcohol &
               Disinhibition  violence
crime links    Neuropsych complications of alcohol dependence
               Most common is sex off. Esp. exposure by males
               Victim usually known
disability     More likely to be caught
               Less likely to understand consequences of action
               If psychotic depression:
Mood                Homicide often followed by suicide
                    Family member with altruistic delusional motivation
               BPAD > Depression (total offending)
                    –Spending, stealing cars, fraud, false pretences
                    –Irritability can lead to aggression but resulting violence rarely
 Intermittent explosive disorder*
        Intermittent, unprovoked aggression
        Far in excess of appropriate reaction
        Not GMC, other psych or substance
        Family history
Aet &
        Non-specific EEG abnormalities esp. temporal lobe
clin    Soft neurological signs
        Not impulsive between episodes
        ?  5-HT
        Typical perpetrator:
             Large dependent male
             Feels impotent
             Abused as a child
             History of brain injury
ment    SSRIs
Risk of violence in schizophrenia
• 1 in 2000 will commit homicide (sl. )
• 5-10/100 patients per year will have violent
       Violence & schizophrenia
Because        Loss of control with non-systemtized delusions
               Persecutory systematized delusions
               Irresistable urges
               Command auditory hallucinations
               Unaccountable frenzy
Highest        Substance using
risk if +      Acutely psychotic
usual          Command hallucinations to violence
violence       Delusions
risk factors       Passivity
Types     Intimacy seeker
& Pathe
          Rejected lover
          Inadequate suitor
A/w       Personality disorder
          Persecutory delusions
Gender      ?F>M
Repeat      Previous history
risk        MI (in 10-30% of arsonists):
            Sexual gratification from offence (?evidence)
            Fascination with fire (note ICD-10 pyromania)

Female fire-setters ≈ other prisoners in psychopathology:
disturbed childhoods, unstable personalities
Definition   Stealing for its own sake:
             stolen item is not needed
             Impulse control disorder

Epid         Rare: 5% of shoplifters
             Onset 20, dx 10-20 years later
Theories   Instinct hypothesis: Lorenz
           Frustration-aggression: Dollard
           Frustration-aggression induced criminality: Berkowitz
           Learned response behaviour: Bandura
           CNS deficiency: Eisenberg & Earls

Homicide   75 % male (75% victim in UK, 25% victim in US!)
           20-24 highest risk
           80% known to victim
           At home >> outside (domestic crime with little
           relationship to long-term criminality!)
           Abnormal murder (Petursson & Gudjonsson)
               Mentally ill
               Diminished responsibility
           Primary v Secondary (in process of another crime)
               More likely acquainted
               Age similar
           Violence: Statistics
          Constant at 1.5/100,000

          Doubled from 10 to 20/100,000 in 80s

Serious   Quadrupled 20 to 80/100,000 in 80s
Assault   5 in 10,000 in schizophrenia
  Violence: factors that influence
           70% of homicide perpetrators & 50% of victims drunk
           Amphetamines: aggression/psychosis
& drugs    PCP: psychosis (watch for nystagmus)
           BDZ: paradoxical esp. in dementia or ID
           Others associated indirectly
           More in lower sociecomonic
           More if parents use aggressive discipline
           More if identification with violent hero
Firearms   Australia has (bar US) highest rates of gun suicide
            with risk
 AssociatedMultiple prior offences of reoffence
                  Esp. severe crime
history           Known victim
                  Bizarre offence
                  Abused or witness to abuse as a child, alcoholic father
characteristics   Young
                  Refuses to cooperate with treatment
                  Lack of remorse
                  Sadistic fantasy life
Mental state
                  Persecutory delusions
                  Morbid jealousy
                  Alcohol or drugs involved
                  Homelessness, low socio-eco
                  Peer group are violent
General riskviolence
 Previous history of
                     of violence
 < 25
 Substance abuse esp. alcohol
 Impulsivity history
 Acute psychotic state
    Risk of sexual re-offending
•A. Marital status: single
•B. Antisocial PD or traits/criminal history (history
of past criminal offences)
•C. History of prior sexual offences as such
•D. That the prior sexual offences were diverse
(different sorts of offence)
•E. Male victim
•F. Male perpetrator
•G. Prior failure to complete treatment programmes
•H. Positive penile phallometry
•I. Deviant sexual fantasies
•J. History of sexual offences against exclusively
male, child victims
•to be interviewed
•Understand the charges
•Be oriented to T/P/P & recognise role of interviewers
•Understand consequences of responses to questions

•to plead
•Understand the charges
•Distinguish between plea of guilty & not guilty
•Instruct counsel
•Follow proceedings in court
•Examine a witness/challenge juror
               Psychiatric pleas
Insanity          McNaughton ruling 1847

Diminished        Murder to manslaughter (culpable homicide:
                  where no specific intent to kill was present)
Intoxication      Involuntary e.g. spiking, iatrogenic
                  Voluntary: no defence unless because of mental

Automatism        Sane: not due to MI, leads to acquittal
                  Insane: a disease of the mind incl. Epilepsy,
        Criminal responsibility

Mens rea
“guilty mind”   Negligence
                Blameless inadvertence
                <10 no responsibility
                >14 responsibility
                10-14 no mens rea unless proven otherwise
                    (viz dolci incapax† phenomenon)
 Scales for assessing potential violence

HCR-20 History, clinical, risk
       20 questions
VRAG Violence and risk appraisal guide
  College on repressed abuse memories

• Media & legal system treatment of issues harms
• Psychiatrist to provide non-judgmental “haven”
  for patient to discuss issues
• Psychiatrist’s role is not to advocate “as victim”
  but to be neutral & empower patients to deal with
  issue whichever way they see fit
• It is impossible to know what happened between 2
  people without corroborating evidence
              Suicide theories
• Durkheim’s sociological
  – Altruistic: too much social integration with suicide the
    outgrowth e.g. for the country
  – Egoistic: lack of integration with social group e.g.
    singles > marrieds
  – Anomic: lack of social norms resulting disintegration
    e.g.  at times of societal upheaval
• Freud:
  – Aggression turned inwards towards an introjected
    ambivalently cathected love-object
• Menninger
  – Retroflexed murder/inverted suicide: it is anger against
    another that is turned on oneself
               Suicide: statistics
Epid           5-30/100,000
               80% saw GP in last year
               20% saw GP day before
Mental         80% MDD/BPAD               10x in  inpatients
illness: 95%   10% SCZ
                                           5x in  outpatients
               5% PD
Age            > 45
Gender         M 4x F (completed)
               F 3x M (attempted)
Genetics       First degree relatives x8
 risk         3/12 post attempt
               1/12 post discharge
               1st week of admission (normal by 3-5 weeks)
  Suicide aetiology: biological

Construed as impulsivity

5-HT          CSF (5HIAA) in autopsy
deficiency    5HT transporter sites
              5HT neuron size
HPA abnormality CRF in CSF
        Suicide and disorders
Depression      6% diagnosed, 10-15% if ever hospitalised commit
                25-50% attempt
                    Comorbid substance use
                    Isolation/ Lack of social support
                    No or inadequate treatment
                     Initially upon dx and at first treatment

ASPD            5%
                other MI
                life events
                poor coping skills
Substance use   Alcohol 15%, other 20x popn
        Suicide and disorders
Schizophrenia   10%
                  when first diagnosed
                  < 30
                  Post discharge
  Suicide and Bipolar Disorder
Stats    10-19%
         80% during MDE

Risks:   Suicide    Intent
                    Previous attempts
                    Family hx of suicide
         Illness    MDE
                    Hx mixed affective
                    Delusions & hallucination
                    Poor response to treatment
                    Recent diagnosis
         Personal   Personal or fam hx violence
                    No social supports
                    Interpersonal stress: divorce, self-esteem
                       Suicide risk
•   Male
•   Age >45
•   Single
•   Unemployed
•   Lack of social supports
•   Hx previous attempt
•   Within 3/12 of previous attempt
•   Within 1/12 of discharge
•   Hx previous admissions
•   Substance use
•   MDE
•   Psychosis with depressive sx
•   Access to lethal means
•   Plans
•   Recent life event: bereavement, divorce
•   Comorbid (esp. recently diagnosed) physical illness
               Deliberate self-harm
               1-5% of medical admissions
                    2.5% of men
                    4.5% of women

       All Axis I 2-4 x higher than community
       SCZ, BD, SA, ED 6-8x higher*
       ≈ 25-50% have Axis II
       OR: DSH in alcohol misuse (adjusted for MI) in Swedish conscripts: 8.8%
       Alcohol often precedes/accompanies it
       Childhood sexual abuse a/w
               Maladaptive response to stress
               Inability to cope with life problems
               Communication of distress
               Non-fatal suicide attempt
    Deliberate self harm: initial mgt
ED Triage ≥3
         Medical ax + physician/surgeon if needed
         Psychiatric ax with follow up
         Plan for treatment of mental disorder
     Collateral history
         GP, family/friends, previous medical notes
General         Manage medical complications
Hospital        Contain risk
                Ensure psychiatric assessment/follow up
                More time for corroborative hx/documents
           DSH: psych assessment
 Aims    Engagement & therapeutic alliance
         Psychiatric history (incomplete until fully conscious) incl.
             Risk ax
             Psychosocial assessment & collateral hx
         Identify & initiate treatment for any MI
         Co-ordinate follow up & support with family/GP/CMHC
         Document risk at transitions of care/discharge
         Provide/encourage resilience & adaptive coping mechanisms
   Community follow up:
   ENGAGEMENT is the priority
   40-70% don’t come for 1st appointment
   Outreach/domiciliary care improve outcomes

   Hospital: 10-20% referred/admitted to psychiatric hospitals after DSH
         DSH: Risk assessment
Act           Severity/lethality of method incl. perception thereof
              Attempts to hinder discovery/rescue
Ongoing       Thoughts/Intent/Plans
              Access to means
Background    MI
              Substance us
              Past hx DSH
              Family/peer hx DSH
              Psychosocial stressors e.g. divorce/retrenchment
              Social supports
              Coping styles/alternative ways to cope
              Ability to engage in therapeutic relationship
              Cognitive capacity
Reducing repetition of DSH: non-pharmacological strategies
  General Poor studies
            GPs can provide good PE & problems solving
            with access to psychiatrists

  Possible Dialectical Behaviour Therapy
  benefit     no benefit at long-term follow up
             Psychodynamically informed inpatient
             Brief psychodynamic-interpersonal therapy
 Possible Same therapist*
 harm        Recovered memories
             “Guarantee of safety” contracts
Other benefits:
    Improved problems solving
    Less depressive symptoms
    Attendance for ongoing psychiatric care
Reducing repetition of DSH: pharmacological strategies

General      •Use low toxicity agent if DSH risk
             •Inform re risk of agitation & suicidal
             ideation esp. if SSRI
                      SSRI > TCA from observational studies
                      FDA believes there’s no difference
Evidence Li: 5 (BD) - 7 (all mood D) x in DSH
                      Cochrane disputes methodology
             Flupenthixol: RCT evidence but SE preclude
             Paroxetine, Mianserin vs placebo: no diff.

Suicide as outcome:
   Hard to study as rare => huge sample sizes needed
   One RCT showed  rate if patients were sent letters over 5 years
             DSH: legal/ethical
Principles   Duty of care
                     e.g. in emergency tx is provided without consent
                     Can tx DSH despite patient’s request not to until
                     their competency to refuse tx can be determined
             Mental health & other legislation
                     Crimes Act allows anyone the use of force to
                     prevent another’s suicide

Procedures   Offer all medical/psychiatric care
             Deal with each case on its merits
             Inform patient fully of tx options and consequences
             Involve senior doctors early
             Involve family/supports
             Keep local policies & legislation in mind
             Document reasons for actions clearly