Forensic Psychiatry

Overview

As per the Royal College of Pychiatrists, Forensic Psychiatry is a specialty which helps mentally disordered people who are a risk to the public. Forensic psychiatrist work side by side with the police, courts and prisons. A Forensic Pyschiatrist is involved in the assessment and treatment of mentally disordered individuals who have already offended or are considered very high risk of committing an offence. They are regarded by the court as an Expert Witness, and their oral testimony or writtent report amay be crucial in determining the outcome of a case.

Definition of terms

Term	Definition
Forensic	Relating to the application of scientific methods and techniques to the investigation of crime or legal problems
Forensic Psychiatry	A medical subspeciality that includes research and clinical practice in the many areas in which psychiatry is applied to legal issues (psychiatry in low) and the application of legal knowledge to psychiatric issues (law in psychiatry). Forensic psychiatrist is primarily concerned with the assessment, treatment and rehabilitation of mentally disordered offenders

• Areas covered in Forensic Psychiatry (according to the Royal College of Psychiatrists)
  • The assessment and treatment of mentally disordered offenders
  • Investigation fo complex relationships between mental disorder and criminal behavior
  • Working with the criminal justicee agencies to support patients and protect the public

Violence and Mental Disorders

Mental illness directly accounts for a small proportion of violent crimes. The mentally ill are more likely to be victims of violence (including homicide) than the general population. Among psychotic individuals, threat/control-override (TCO) symptoms have been associated with a risk of violence. If a specific individual is being blamed by the patient as being responsible, there is an increased risk of violence against that person. Victims are usually known to the patient e.g. mother, partner or healthcare provider.

5 – 10% of all homicides are committed by psychotic individuals. Assuming a prevalence rate of psychosis of 1 – 2% in the general population , psychosis is associated with a bout a five-fold increase risk of violence. More than 1/3 of these homicides are committed during the first episode usually before contact with psychiatric services (risk reduces once treatment is started). Women who commit homicide are more likely to be mentally ill at the time of homicide compared to men, and are more likely to commit suicide after. Post-partum psychosis (especially with prominent depressive features) is associated with a higher risk of infanticide and maternal suicide.

For homicide-suicide, the perpetrateor is typically a man and the vicrim is his wife and children (a whole family can be killled). Pending divorce or recent separation initiated by the female partner is a well recognised trigger (prior to the H-S the male may threaten to kill the wife or stalk her). Another scenario is an elderly, controlling husband killing his wife then himself. H-S isassociated with depression and delusions of jealousy.

Definition of terms

Term	Definition
Threat/Control-override (TCO) symptoms	Delusions in which patients feel under imminent ’threat’ or that they are being ‘controlled’ and overriden’ from outside. Patient’s with TCO symptoms may act violently to ‘remove’ the threat and regain control

• Risk factors for violence
  • Past violence
  • Male gender
  • Adolescence and young adults age group
  • Low socio-economic status
  • Alcohol and substance misuse
  • Conduct disorder
  • Antisocial personality disorder
• Examples of TCO symptoms
  • Delusions that someone is plotting to harm or kill them
  • Passivity delusions (that one’s thoughts and actions are being remotely controlled)
  • Comman hallucinations (ordering patients to harm others)

Fitness to Plead or Competence to Stand Trial

Fitness to plead, in Commonwealth Countries, refers to the defendant’s ability to properly defend onself in court. It applies to the state of mind of the accused at the time of the trial (not the alleged crime). The defendant should posses the basic intellect to both understand the relevant issues and communicate their views. Any Defendant is considered ‘Fit to Plead’ unless it can be proven otherwise. If there is concern, a formal assessment by a Psychiatrist is performed before trial. Fitness to plead is a dynamic concept (it can be retained with an episodic mental illness e.g. psychosis, and may be unregained with stable disorders e.g. severe intellectual disability)

It is equivalent to ‘Competence to Stand Trial’ in the United States, which is concerned with the defendant’s capacity (not willingness to stand trial). Presence of mental illness is not equal to a lack of competence to stand trial.

Trial of the facts: if the defendant is unfit, the Court may still decide to proceed with the Trial in order to establish the facts; even if it concludes that the Defendant committed the crime, the Judge will not record a conviction.

• Requirments for fitness to plead (Pritchard Criteria 1836; with modifications)
  • Understand charge(s) and decide whether to plead guilty or not
  • Instruct one’s legal counsel
  • Comprehend the evidence
  • Follow the course of the trial proceedings
  • Challenge any juror whom one may object
• Requirments for Competence to Stand Trial (Dusky Criteria 1960)
  • Understant factually and rationally the proceedings of the trial
  • Assist their attorney in one’s defence
• Outcomes for ‘Unfit’ Defendants
  • Absolute Discharge: Release of accused without any punishment (’Absolute Discharge)
  • Supervision Order: Release of the accused into the community but with mandatory supervition e.g. follow-up by probation/psychiatric/social services
  • Treatment Order: placement in a non-prison but high security Forensic Psychiatric setting to prevent future offending. Duration may exceed prison sentence they might have received (if Fit to Plead and Guilty) if there is a high risk of re-offending.

Insanity Defence

Insanity defence is related to the mental state of the Defendant at the time of the alleged offence (the ‘Insanity’ evaluation is retrospective). To be found guilty, both mens rea (’guilty mind’ or criminal motive/intent) and actus rea (’guilty act’) needs to be established.

A Defendants (or his legal team) is able to use the Insanity Defence if a psychiatric assessment concludes that the Defendant was so severely mentally incapacitated at the time of the offence, that they were **incapable of having the mens rea to commit the crime ****even if the actus rea is established beyond reasonable doubt. If insanity defence is accepted by the court, the outcome is ‘Not guilty by reason of insanity’. Those found NGrI often spend the same amount of time or more as involuntary psychiatric patients than they would have spent in prison if they were found guilty. In the case of homicide, the concept of ‘Diminished Responsibility’, is applied and the person is convicted of ‘Manslaughter’. In some countries, specific infanticide laws have been placed to deal leniently with mentally unwell mothers e.g. postpartum psychosis, who kill their babies.

Historical perspective

Term	Description
McNaughton (M’Naghten Rules)	An accused person in not legally responsible, if it clearly proved, that at the time of committing the crime, he was suffering from such a defect of reason from abnormality of mind, that he did not know the nature and quality of the act he was doing or that what he was doing was wrong
Daniel McNaughton (1843)	M’Naghten rules were outlined by the british House of Lords in 1843 following the acquittal of Daniel McNaughten who killed the prime Minister’s Secretary (Edward Drummond) after mistaking Drummond for the Prime Minister (Robert Peel). He was found ‘Not Guilty by Reason of Insanity’ and was sent to a Psychiatric asylum. This caused stricted standards to be mande for the insanity defence. If M’Naghten rules were applied in his own trial he would have been found guilty and executed.

• Other standards that may be applied (appart from Mc’Naughton rules)
  • The Irresistible Impulse Test
  • The Durham Rule
  • The American Law Institute Rule
  • The guilty but Mentally Ill (GBMI) Standard
• Structure instrument used to assess ‘legal insanity’
  • Rogers Criminal Responsibility Assessment Scales (R-CRAS): Has 30 items (’Behavioral and Psychological Variables’) under 5-sub-group (’scales’) covering psychopathology (e.g. psychosis), organicity (e.g. brain damage), cognitive controle (e.g. planning), behavioral control (e.g. impulsivity) and patient reliability (e.g. malingering)
• Where might mens rea be absent in?
  • Ages < 10 years: 10-14 years must have proof of mens rea
  • Lack of criminal intent e.g. accident
  • Automatism (rarely invoked) e.g. epilepsy and sleepwalking: the act was a result of unconscious involuntary behavior over which the Defendant had no control. Divided into ‘Sane’/’External’ (e.g. Insulin-induced hypoglycaemia) and ‘Insane’/’Internal’ (e.g. Diabetic Hyperglcaemia) types.
  • Mental illness (rarely invoked to deny mens rea)
• Outcomes of an accepted Insanity Defence
  • Acquittal
  • Supervision Order
  • Hospital Order
  • Restriction Order

Pathological Jealousy

‘Normal’ jealousy is a universal emotion. The distinction between ‘normal jealousy’ and ‘pathological jealousy’ is not always clear. Only cases of severe, delusional pathological jealousy come to light, and they may manifest an underlying psychiatric disorder e.g. schizophrenia, delusional disorder, depression or mania. Mainly in delusional disorder is the jealousy referred to as Pathological Jealousy. Preoccupations may be obsessional in nature rather than delusional. If they are obsessional, the individual has insight and is ashamed, but still cannot avoid, to control and restrict their partners activity. Pathological jealousy is an important risk factor for serious aggression, including homicide. It is not uncommon for the patient to come to the attention of psychiatric services after the damage has been done.

Pathological jealousy is more common in men. Age of onset is later than Schizophrenia. Geriatric-onset pathological jealosy can occur (consider organic causes)

Definition of terms

Term	Description
Jealousy	Evoked by fear of losing something that one values e.g. wife, husband, partners etc. It is directed towards the person ov value that one already ‘possesses’.
Envy	Evoked by the desire of something that one values but is possessed by another person e.g. wealth, fame, beauty, intellect etc. It is directed at the other person who possesses what one values.
Pathological Jealousy	Pathological jealousy is AKA Morbid Jealousy or Othello Syndrome (Based on Shakespear’s character). It is generally characterised by preoccupation about the sexual infidelity of one’s partner.
Pathological Jealousy with overvalued ideas	Intermediate in conviction between obsessions and delusions. Characteristic of Paranoid Personality Disorder.
Duty to Warn	This applies to psychiatric patients with homicidal ideation. If the partner (or subject) is unaware of the threats made by the patient (e.g. disclosed only to the psychiatrist), the partner needs to be informed. It is appropriate to breach confidentiality in such cases.
Duty to protect	If any potential harm is imminent and/or serious, the Police and Social Services may need to be informed

• Factors that suggest pathological jealousy
  • Secretly following the partner
  • Checking the partner’s posts/e-mails/phone calls/text
  • Checking the partner’s body for evidence of sex with another person
  • Checking the partner’s underwear for evidence e.g. semen stains of another person
  • Prominent fears of being humiliated by losing one’s partner to another
• Factors that increase the risk of violence
  • History of violence
  • Co-morbid alcohol or substance use
• Effects of Pathological Jealousy
  • Serious aggression or homicide towards the partner
  • Risk of harm to third party (the alleged ‘secret lover’)
  • Risk of self-harm
  • Adverse psychological effects on the partner and children
• Treatment of pathological jealousy
  • Admission: if the patient totally lacks insight and there is a high risk fo violence
  • Antipsychotics: if there is an underlying psychotic disorder
  • Separation (if there is a significant risk of harm)
  • Adjunctive treatments (in adition to antipsychotics)
    • Antidepressants and mood stabilisers
    • Psychotherapy e.g. CBT, Couples Therapy

Stalking

Stalking is the behaviour in which an individual (stalker) repeatedly and intrusively makes or attempts to make unwanted contact with anotehr person (the victim) in a manner which creates fear, distress, or helplessness in the victim.

80% of stalkers are men, and up to 80% of victims are women. Anyone can be a victim of stalking. Very rarely, a ‘victim’ may falsely claim that they are being stalked.

5 main types of stalkers

Type of stalker	Description
The rejected stalker	The most common type of stalker in forensic psychiatry. 90% are men. The victim is typically female (ex-wife or ex-partner). Stalking is used as revenge or to force reconciliation. These usually have personality disorders but not psychosis
The intimacy-seeking stalker	The stalker is more likely to be a female. Usually a lonely person seeking a relationship. The victim may be a stranger, acquaintance celebrity or health professional. The stalker may have ‘erotomanic delusions’ (De Clerambault Syndrome). They tend to be very persistent but violence is unusual.
The predatory stalker	The stalker is almost always a man. Associated with sexually deviant behavior and sexual offending. The stalker chooses the victim, follows them, systematically gathers information and sexually assaults the victim. Seen in serial rapists and serial child molesters. They gain sadistic pleasure from the control they exercise over unsuspecting victims.
The resentful stalker	Has no desire for any kind of personal relationship with the victim. Typically a paranoid man who feels that he has been unjustly treated by the victim. They may resort to harassment through online platforms (’Cyberstalking’). Examples include animal rights activits stalking researchers doing animal experiments, and politicla activists stalking politicians with a different ideology
The incompetent suitor	Typically a male with poor social skills. The victim is usually a female stranger or casual acquintance. The motivation is to establish a brief relationship with the victim. Over time the stalker may lose interest, but soon move on to harass another. It is common in the community.

• 5 main types of stalkers
  • The rejected stalker
  • The intimacy-seeking stalker
  • The predatory stalker
  • The resentful stalker
  • The incompetent suitor
• Stalker behavior
  • Following the victim
  • Loitering around the home of the victim
  • Repeated (including threatening) phone calls, text messages, e-mails, letters, notes and even graffiti
  • Sending unsolicited gifts to the victimg
  • Ordering or cancelling items on behalf the victim
  • Making unsubstantiated complaints e.g. made by a patient stalking his doctor
  • Spreading unfounded rumours e.g. in the workplace or online
  • Causing damage to the victim’s property
  • Violence against the victim
• Consequences of stalking on the victim
  • General: loss of appetite, loss of sleep
  • Psychological: feeling helpless, blaming oneself; losing self-esteem
  • Psychiatric: anxiety, panic, PTSD, depression, substance use
  • Social: withdrawing from normal activities, fearful to go out of the home or answer the doorbell, telephone etc.
  • Relationship: impact on relationship with one’s partner, children, etc.
  • Practical: having to move home or change/leave job in order to feel safe

Arson and Pyromania

Arson is a major crime. It is easy to commit (needs no weapon, accomplice or physical victims). Since fire-setting is usually committed alone without any witnessess, only a minority of arsonists get arrested or convicted. Some may come to the attention of psychiatric services.

Definition of terms

Term	Description
Fire setting	An act. Not all fire setting is arson. Only deliberate fire-setting with criminal intent is Arson.
Arson	Legal term. It is derived from the Latin word ardere ‘to burn’.
Pyromania	A diagnosis (ICD & DSM). Not all arsonists satisfy the criteria for pyromania.

• Risk factors for arson
  • Male gender
  • Late adolescent and early adulthood
  • Living alone
  • Single marital status
  • Lower level of education
  • Unemployment
  • Nighttime
  • Weekends
  • Urban areas
• Conditions associated with arsonists
  • Alcohol and substance misuse
  • Intellectual Disability
  • Pervasive Developmental Disorders
  • Psychotic Disorders
  • Antisocial Personality Disorders
  • Mood and Anxiety Disorders
  • HIstory of Sexual Abuse (in female arsnist)
  • Other impulse control disorder e.g. Gambling

Testamentary Capacity (Sound and Disposing Mind and Memory)

Testamentary capacity refers to the ability of an individual (the ‘Testator’) to make a valid will. The Testator should be of ‘Sound Mind’ at the time of making the will, and should have the independence to decide the contents of the will. Even if there is mental illness, as long as the will is not directly influenced by symptoms (such as delusions), the will is still considered valid. All Testators are asssumed to have ‘Sound Mind’ (Capacity) unless proven otherwise. In complex cases e.g. early dementia or mental illness, the Testamentary Capacity should be certified by a Psychiatrist at the time of the Will in order to reduce the risk of future challenges.

Undue influence: Physical (including threats) or psychological (persuasion or deception) that coerce the Testator to change the contents of the Wil to benefit the influence. The Will can be declared invalid even if the Testator had Capacity if it was drawn under ‘Undue Influence’

Historical perspective

Event	Description
Banks vs. Goodfellow case	This is the basis of testamentary capacity. The Will made by John Banks in which he left his property to his niece was contested by his sound on the grounds that their father had mental illness. The Judge ruled that Banks had Testamentary Capacity despite being deludid, since the delusions did not directly influence the contents of the will

• Criteria for testamentary capacity (Banks vs. Goodfellow tests)
  • The testator must be capable of basic understanding of:
    • The nature and effect of the will
    • The extent of his or her property or estate (in broad terms)
    • The claims of those who expect to benefit from the will
  • The testator should not have mental illness that influences him/her to make bequeaths in the will that he/she would not have otherwise included
• Factors suggesting Undue Influence
  • The Infleuncer deliberately isolates the Testator from others
  • The Attorney involved is known only to the Influencer and not the Testator
  • The Influencer benefits disproportionately from the Will
  • The Testator is helplessly dependent on or susceptible to the influencer

Risk assessment

Generally, risk assessment is concerned to risk to self (risk of self-harm, suicide, neglect etc.). For forensic psychiatry, risk assessment is manly concerned with risk to others (e.g. violence, sexual reoffending etc.). Risk assessment is always never straightforwards. Risk is influenced by a number of factors that may be well beyond the control os psychiatris srvices. Only a small proportion of individuals identified as ‘Dangerous’ go on to commit a srerious offence.

• Features of an ideal risk assessment
  • A clear, validated definition of the risk being assessed
  • Access to all the date which would enable identification of all potentially relevant factors related to that Risk
  • Being able to come to a confident conclusion about the likelihood or probability of the specific risk event occurring within a specific time frame
• Scales used in Forensic Psychiatry for Risk Assessment
  • Psychopathy Checklist – Revised (PCL-R)
  • Historical, Clinical and Risk Management Scale (HCR-20)
  • Violence Risk Appraisal Guide (VRAG)