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CRIME & MENTAL DISORDER. Aileen Wuornos. Personal Quote: "I'd just like to say I'm sailing with the rock and I'll be back like Independance day with Jesus, June 6, like the movie, big mothership and all. I'll be back." Last words before being executed.

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Aileen wuornos
Aileen Wuornos

Personal Quote:

  • "I'd just like to say I'm sailing with the rock and I'll be back like Independance day with Jesus, June 6, like the movie, big mothership and all. I'll be back."

    • Last words before being executed.


Is there a fundamental link between mental disorder and violence
Is there a fundamental link between mental disorder and violence?

  • The public seems to think so

  • Popular misconception that brutal, violent, and senseless crimes are committed by people who are “mentally ill” or “sick”.

  • Media influence on connections between mental disorder and crime, particularly serious violent crime.

    • Along with greed and revenge, mental illness is a basic motivation for criminality in the vast majority of crimes on TV and media.


Link between crime and mental disorder not new
Link between crime and mental disorder not new… violence?

  • What are some assumptions about mentally disordered people?

    • do not play be the rules of society

    • unpredictable

    • cannot control their own actions.

    • since they are apt to do anything at any given time, these “crazy people” are potentially dangerous.

  • What are some people’s assumptions about atrocious incomprehensible, senseless violence?

    • That the offenders must be “crazy” or “sick”

  • Thus, some assume that the mentally ill are dangerous; other believe people who commit bizarre crimes are mentally ill.


Mental disorder
Mental Disorder violence?

Issue of normality – criteria fluctuate

  • DSM-V release

  • bible of mental illness expands with each revision

  • ‘illness’ versus ‘disorder’

  • ‘disorder’ -- no conceptual limitations

  • disorder of mind-- interferes substantially w/ life on daily basis, a group of symptoms

  • manifested in behavior deviating notably from normal conduct


  • Dsm v
    DSM-V violence?

    The current version lists many mental disorders.

    • About half of all people in North America will qualify for a DSM diagnosis at some point in their lifetimes.

    • Diagnoses based on the DSM are also provided to courts in a wide range of forensic settings

      • evaluations of competence to stand trial

      • mental state at the time of the offence

      • sentencing

      • assessments of harm suffered by victims


    Defining mental disorder
    Defining Mental Disorder violence?

    What is a mental disorder?

    • Behavioural or psychological syndrome

    • Clinically significant

    • Presents distress or disability

      Two basic guiding principles:

      Negative consequences

      A dysfunction of internal process


    Diagnosing mental disorder
    Diagnosing Mental Disorder violence?

    The DSM-IV

    Axis I – Clinical Syndromes

    Axis II – Personality Disorders and Mental Retardation

    Axis III – General Medical Disorders

    Axis IV – Psychosocial/Environmental Problems

    Axis V – Global Assessment of Functioning (GAF)

    This classification system is gone with the DSM-V


    Dsm v diagnoses
    DSM-V diagnoses violence?

    • Two important points about mental disorders and crime:

      • persons with these disorders are not “crime prone”

      • even if individuals are diagnosed with these disorders, they still can be held responsible for their behavior.


    Categories of mental disorder
    Categories of Mental Disorder violence?

    Anxiety Disorders (e.g., Agoraphobia, Obsessive Compulsive Disorder, Panic Disorder)

    Depressive Disorders (e.g. Major Depressive Disorder)

    Dissociative Disorders (Depersonalization Disorder -outside looking in- , Dissociative Amnesia, Dissociative Fugue, Dissociative Identity Disorder)

    Psychotic Disorders (Delusional Disorder, Schizoaffective Disorder, Schizophrenia, Substance-Induced Psychotic Disorder)


    Dissociative disorders and crime
    Dissociative Disorders and Crime violence?

    Dissociative Disorders involve the:

    Dissociation, or splitting apart, of components of the personality that are normally integrated.

    Dissociation (adaptive process)

    involuntary response to psychological stress


    Dissociative disorders and crime1
    Dissociative Disorders and Crime violence?

    Dissociative Amnesia

    Partial or total forgetting of past experiences,

    Not an organic cause; response to psychological stress.

    Dissociative Fugue

    “Travelling amnesia”.

    Taking a sudden, unexpected trip away from home.


    Dissociative disorders and crime2
    Dissociative Disorders and Crime violence?

    Dissociative Identity Disorder

    • “UFO of psychiatry”

    • Within the person, two or more distinct personalities or personality states.

    • Recurrently take control of behaviour.


    Dissociative disorders and crime3
    Dissociative Disorders and Crime violence?

    Criminal Responsibility

    Automatism

    Form of unconscious behaviour or actions done in an altered state of consciousness

    Somnambulism

    Sleepwalking

    R. v. Parks


    Psychotic disorders and crime
    Psychotic Disorders and Crime violence?

    Delusional Disorders

    A mental disorder characterized by a system of false beliefs.

    In delusional disorder

    • Delusions are reasonably believable.

    • i.e., neighbour is spying on you and attempting to poison your dog.

      In schizophrenia

    • Delusions are bizarre

    • i.e., neighbour has disguised himself as a mosquito and is hovering outside one’s window.


    Major affective disorders and crime
    Major Affective Disorders and Crime violence?

    Major Affective Disorders

    Extremely depressed for at least a 2 week period (inability to anticipate happiness or pleasure)

    Accompanied by a generalized slowing down of mental and physical activity.

    Depression and Criminality

    Depression may be strongly linked with delinquency (in females)

    Indifference to personal safety/consequences


    Psychosis and violence
    Psychosis and Violence violence?

    A hallucination is

    A sensory perception experienced in the absence of an external stimulus.

    Different from an illusion, which is a misperception of an external stimulus.

    Command Hallucinations

    Auditory hallucinations that instruct a person to act in a specific way.


    Psychosis and violence1
    Psychosis and Violence violence?

    Delusions are

    Fixed or persistent false beliefs that have no basis in reality and may accompany a variety of psychological conditions.

    Most widely experienced positive symptom of schizophrenia

    Types of delusions may include

    • Delusions of grandeur

    • Delusions of reference


    Psychosis and violence2
    Psychosis and Violence violence?

    Delusions relevant to violence or aggression

    • Delusions of Persecution

      • The belief that one is being plotted against, spied upon, threatened, or otherwise mistreated, particularly by a conspiracy.

    • Threat-Control-Override Symptoms

      • Thoughts that people are trying to harm you or that others are controlling one’s thoughts, feelings, and actions.


    Psychosis and violence3
    Psychosis and Violence violence?

    Persecutory delusions and violence:

    Experience of delusional distress

    Co-occurrence of “distress factors” (low self-esteem, high anxiety, anger) and persecutory delusions increase risk for violence.

    Violence may appear as a forced choice in patients who experience persecutory delusions associated with a strong idiosyncratic conviction of being threatened and forced to defend oneself.


    Common classifications include
    Common Classifications Include: violence?

    • Adjudicated by the courts

      1) Unfit to Stand Trial (FIT)

      2) Not Criminally Responsible on Account of Mental Disorder

      3) Mentally disordered sex offenders (MDSO)

      4) Administratively transferred from a prison to a mental hospital (transfers)

      Most mentally disordered committed involuntarily during trial, especially if found NCRMD


    Mentally disordered defendants and offenders
    Mentally Disordered Defendants and Offenders violence?

    • Unfit to stand trial

    • Distinct from insanity

      -state of mind at time during trial proceedings vs. at time of offense

    • Unfit population: marginal, poorly educated, clinical diagnoses


    Insanity defense
    violence?Insanity’ Defense

    • Judicial determination of NCRMD

    • Not Criminally Responsible refers to a person’s state of mind at time an offense was committed

    • Law assumes mental disorder can eliminate free will or ability to make appropriate choices

    • = Lack of responsibility

    • # of insanity defenses is small to total # of criminal cases


    Insanity defence in canada
    Insanity Defence in Canada violence?

    • C.C.C. (1992), Section 16, Bill C-30, April 1992: NCRMD

      • No person is criminally responsible for an act committed or an omission made while suffering from a mental disorder that rendered that person incapable of appreciating the nature and quality of an act or omission or of knowing that it was wrong


    Forensic psychiatric services commision
    Forensic Psychiatric Services Commision violence?

    • Specialized assessment, treatment & case management

    • 190-bed forensic psychiatric hospital

    • Services include:

    • Court ordered assessments

    • Services to persons found NCRMD or Unfit to Stand Trial

    • Mental status assessments for pre-sentence reports

    • Treatment of mentally disordered offenders in provincial correctional centres

    • Court ordered assessment & treatment of offenders on bail, probation, conditional sentences & dangerous offender and/or sex offender classifications

    • Sex offender treatment (400 patients annually in B.C.)


    Violence mental illness
    Violence & Mental Illness violence?

    • Public fears violence that is random, senseless & unpredictable, associating it with mental illness

      • Such assumptions lead to discrimination & stigma

    • Recent studies show modest assoc b/w mental illness & violence, even when main risk factors for violence such as gender, age, socio-economic status, are controlled for

      • Nature of assoc remains unclear b/c of sig methodological challenges

      • Substance abuse major factor, especially as it it related to medication non-compliance

      • Bipolar & major depression show high rates of violence


    Mental disorder violence patterns
    Mental Disorder Violence Patterns violence?

    • Mentally disordered who commit violence

    • In the family when relationships are characterized by mutual threat, hostility and financial dependence

    • Schizophrenia concurrent w/ substance abuse

    • (MacArthur Risk Assessment Study)

      • Sparked by conditions of their social life

      • Typically in the home

      • Family members or friends (87%)

    • In Canadian study, of 1151 newly detained people, 3% of violent crimes accruing to this sample were attributable to people w/ major mental disorders such as schizo or depression


    Mental disorders violence
    Mental Disorders & Violence violence?

    • Limited connection exists b/w major mental disorder & violence

    • 3 ‘types’ of violence & mental disorder studies exist (11 studies over 15 years used):

      • Patients being violent before hospitalization

      • Patients being violent during hospitalization

      • Patients being violent after hospitalization

      • 10-40% of patient samples committed physical assault against another shortly before hospitalization

    • Paranoid schizophrenics experience higher violent rates than non-mentally disordered

      • Persecutory delusional disorder (psychotic symptoms)

    • Prelim data on depression indicate strong assoc w/ violence

    • APD – hx of continuous in which rights of others violated

    • ‘catch all category’

    • Frequently offered as diagnosis in criminal courts & corrections


    Psychotic disorders and crime1
    Psychotic Disorders and Crime violence?

    • Psychotic Disorders

      • Psychosis – a severe impairment of thinking or emotion such that an individual is seriously out of contact with reality

      • Schizophrenic Disorders

      • Paranoid Disorders-Delusional Disorders

      • Psychotic disorders not elsewhere classified


    Psychotic disorders and crime2
    Psychotic Disorders and Crime violence?

    Schizophrenia

    Severe breakdowns in

    • Thought patterns

    • Emotions

    • Perceptions.

      Disorganization and failure to correspond to reality.


    Schizophrenia
    Schizophrenia violence?

    Schizophrenia– is a psychotic disorder marked by a severe breakdown in thoughts, emotions & perceptions

    Core Symptoms:

    • Positive Symptoms

      • Hallucinations

      • Delusions

    • Negative Symptoms

      • Avolition – lack of energy and an absence of interest in or ability to persist in usual routines

      • Alogia –speech impoverished in terms of volume or content

      • Flat affect – stimuli elicit little or no outward emotional expressionAsociality – severe impairments in terms of social relationships and social functioning

    • Disorganized Symptoms


    Psychotic disorders and crime3
    Psychotic Disorders and Crime violence?

    • Schizophrenia

      • Symptoms

        • Delusions (false beliefs about the world)

        • hallucinations (sensory perceptions which other people would not sense and that do not exist outside one’s own perception…perceiving things that others do not)

        • disorganized speech (e.g., frequent derailment or incoherence; speaking in abstracts; neologisms).

        • grossly disorganized behavior (e.g. dressing inappropriately, crying frequently) or catatonic behavior

        • negative symptoms, i.e., affective flattening (lack or decline in emotional response – monotone voice, expressionless face), alogia (lack or decline in speech), or avolition (lack or decline in motivation).


    Schizophrenia symptoms
    Schizophrenia symptoms violence?

    • “The problem is insects. My brother used to collect insets. He’s now a man 5 foot 10 inches. You know, 10 is my favorite number”

    • “For about 7 years – except during sleep – I have never had a single moment in which I did not hear voices. They accompany me to every place and at all times; they continue to sound even when I am in conversation with other people, they persist undeterred even when I concentrate on other things, for instance reading a book…they are drowned by the stronger sound of the spoken word…But the well-known phrases recommence at once

    • “I felt that the government agencies had planted transmitters and receivers in my apartment so that I could hear what they were saying and they could hear what I was saying. I also felt as if the government had bugged my clothing, so that whenever I went outside my apartment I felt like I was being pursued. I felt like I was being followed and watched 24 hours a day.”

    • “The inmates here hate me extremely because I am sane…They talk to me telepathically continuously…By the power of their imagination…they create extreme pain in my head, brain, eyes, heart, stomach and in very part of my body…by telepathy and imagination, they force me to say orally whatever they desire, whenever they desire, and as long as they desire. I never said a word of my own. I never created a thought of my own.


    Five subtypes of schizophrenia dsm iv not in dsm v
    Five subtypes of Schizophrenia violence?(DSM-IV, not in DSM-V)

    • Disorganized

      • inappropriate affect; marked incoherence and disorganization in thought patterns

    • Catatonic

      • severe disturbance in muscular and voluntary movement. Mutism and parrot-like word repetition.

    • Paranoid type:

      • delusions and hallucinations (often command)

    • Undifferentiated type

      • psychotic symptoms that cannot be classified into other categories

    • Residual type

      • individual has had at least one episode, and evidence that some of the symptoms are continuing.


    Schizophrenia and crime
    Schizophrenia and Crime violence?

    • Core Symptoms

      • Positive Symptoms

        • Hallucinations

          • A sensory perception experienced in the absence of an external stimulus.

          • Different from an illusion, which is a misperception of an external stimulus.

          • Command Hallucinations

            • Auditory hallucinations that instruct a person to act in a specific way.

        • Delusions

          • Threat-Control-Override (TCO) Delusions

          • Persecutory Delusions


    Psychosis and violence4
    Psychosis and Violence violence?

    Command hallucinations and violence

    McNeil, Eisner, and Binder (2000)

    Study of 103 psychiatric inpatients

    33% reported having a command hallucination

    22% reported they complied with such commands

    • Patients who experienced command hallucinations to harm others were more than twice as likely to be violent, even when controlling for other variables.


    Psychosis and violence5
    Psychosis and Violence violence?

    Command Hallucinations and Compliance:

    Who obeys and when? (R. Erkwoha, 2000)

    Three psychopathological characteristics

    • A voice known to the patient;

    • Emotional involvement during the hallucinations; and

    • Seeing the voice as real.

      Who obeys and when? (R. Borum, 1998)

  • Recognition of hallucinated voice

  • Hallucination related to a delusion


  • Threat control override symptoms
    Threat/Control Override Symptoms violence?

    • Delusional Symptoms that are more associated with violence.

    • Feeling “gravely” threatened by someone who intends to cause harm

    • Persecutory delusions

    • An override of self-control through external forces; mind/body dominated by external forces.


    Threat control override symptoms1
    Threat/control override symptoms violence?

    How often have you…

    • Felt your mind was dominated by forces beyond your control?

    • Felt that thoughts were put into your head that were not your own?

    • Felt that there were people who wished you harm?


    Delusional disorders paranoid disorders not schizophrenia
    Delusional Disorders (paranoid disorders—not schizophrenia)

    • Delusional Disorders:

      • Presence of one or more nonbizarre delusions for 1 month or more.

      • Delusional disorders often accompany other disorders (such as paranoid personality disorder, depression, anxiety)

      • Common delusions beliefs

        • persecutory beliefs about being spied on, cheated, conspired against, followed, drugged, harassed, etc.

      • Anger, resentment, suspiciousness, and sometimes violence accompany these false persecutory beliefs.

      • 7 types – the persecutory type is most closely associated with criminal conduct, particularly violence – also seen Erotomanic “they love me!”


    Psychotic disorders and crime4
    Psychotic Disorders and Crime schizophrenia)

    • Delusional Disorders (Paranoid)

      • A mental disorder characterized by a system of false beliefs.

        • In delusional disorder

          • Delusions are reasonably believable.

          • E.g.: Neighbour is spying on you .

        • In schizophrenia

          • Delusions are bizarre

          • E.g.: Neighbour is spying on you because he knows that you have pieced together important clues about an upcoming terrorist attack.


    Major affective disorders
    Major Affective Disorders schizophrenia)

    Affective disorders– disorders of mood or emotion

    Depression– a period of great sadness associated with decreased levels of mental and physical activity

    Mania– a period of intense elation indicated by symptoms of talkativeness, distractibility, flight of ideas, grandiose plans & purposeless activity

    Bipolar– episodes of mania & depression; or mania alone


    Depressive disorders and crime
    Depressive Disorders and Crime schizophrenia)

    • Affective disorders, mood disorders, bipolar disorder, major depressive disorder

      • Extremely depressed state, accompanied by a generalized slowing down of mental and physical activity, gloom, despair, feelings of worthlessness, and perhaps suicidal ideations.

      • Deeper and longer lasting than “normal” ups and downs.

    • Role of depression and criminal behavior is just beginning to be explored

      • Depression associated with delinquency in adolescence (particularly girls) – indifferent to their own personal safety and the consequences of their actions. “don’t care”

      • Depression also plays role in mass murders, work place violence, and “suicide by cop”


    Macarthur research network monahan et al 2001
    MacArthur Research Network (Monahan et al, 2001) schizophrenia)

    • Followed over 100 psychiatric patients discharged from psychiatric hospitals to see who became violent over 1 year

    • Past mental disorder alone is not a good predictor

    • Mental disorder most closely related to violence is schizophrenia

      • In particular schizophrenic males who also score high on the PCL-R (psychopathy scale) or show antisocial behaviour at an early age, often have persistent violent offending


    Hodgins c t 1990
    Hodgins & C schizophrenia)ôté (1990)

    Methodology:

    • random sample of 495 male prisoners in Quebec assessed for mental disorder

      Results:

    • Higher rates of MD in the prisoners compared to men in the general population

    • fundamental methodological weakness


    Hodgins c t 19901
    Hodgins & C schizophrenia)ôté (1990)


    Swedish metropolitan project hodgins 1993
    Swedish Metropolitan Project schizophrenia)Hodgins (1993)

    Methodology:

    • 15,000 people born in Stockholm, Sweden in 1953

    • Collected data on:

      • criminal records

      • Mental health records


    Swedish metropolitan project hodgins 19931
    Swedish Metropolitan Project schizophrenia)Hodgins (1993)

    Compared to non-mentally disordered persons:

    • men with major mental disorders were more likely to have a criminal record (48% vs. 29%)

    • men with major mental disorders were more criminally involved (13.2 mean convictions vs. 7.3 mean convictions)

    • similar pattern for women


    Swanson et al 1990
    Swanson et al. (1990) schizophrenia)

    Methodology:

    • 10,000 people from 3 urban centres in the U.S. were interviewed & evaluated for mental disorder

    • Participants self-reported the occurrence of certain types of violent behaviour



    Swanson et al 19901
    Swanson et al. (1990) schizophrenia)

    • Violence is 5 times more prevalent among major mental disorders (vs. no disorder)

    • Schizophrenia, major depression and mania/bi-polar exhibit similar levels of violence

    • violence is at least 12 times more prevalent among alcohol/substance abusers


    Epidemiological Studies Conclusions schizophrenia)

    • Mental disorders cause a slight increase risk for violence

      • The increase rises sharply when mental disorders are combined with substance abuse

    • Having active psychotic symptoms also increases the risk for violence


    Epidemiological studies
    Epidemiological Studies schizophrenia)

    Jeffrey Swanson – ECA Project


    Rationality within irrationality
    Rationality-within-irrationality schizophrenia)

    Principle of rationality-within-irrationality – violence may be a ‘rational’ behavioural response to ‘irrational’ psychotic symptoms

    Violence is more likely where psychosis involves symptoms of threat/control-override

    (Link & Stueve, 1994)


    Link and colleagues
    Link and colleagues schizophrenia)

    Link and Stueve Study


    Swanson et al 1996
    Swanson et al. (1996) schizophrenia)

    Participants with TCO symptoms were…

    • 2 times more likely to report violence vs. other psychotic symptoms

    • 6 times more likely to report violence vs. no mental disorder

    • 8-10 times more likely to report violence when combined with alcohol/substance use disorders vs. no mental disorder


    Who obeys and when reminder
    Who obeys and when? Reminder… schizophrenia)

    Factors increasing compliance(Bjorkly, 2002)

    • A voice known to the patient;

    • A voice the persons trusts;

    • Additional beliefs about the consequences of dis/obedience

    • Hallucinations are consistent with delusions


    Summary
    Summary schizophrenia)

    • It appears mental disorder is a risk factor for violence

    • The magnitude of the relationship to violence does not appear to be large

    • the combination of major mental disorder and substance abuse probably raises the risk of violence significantly

      Mulvey (1994)


    Summary1
    Summary schizophrenia)

    • The relationship of mental disorder and violence probably exists even after accounting for demographic variables

    • Active symptoms are probably more important risk factors than the mere the presence of a mental disorder

      • Delusions - TCO

      • hallucinations (command)

      • disorganized thought

      • mania

        Mulvey (1994)


    Summary2
    Summary schizophrenia)

    • The pathways producing the association between mental disorder & violence remain unclear

    (Douglas & Hart, 1996)


    Summary3
    Summary schizophrenia)

    Most people who have mental disorders are not violent

    Likewise, most people who commit violence do not have a mental disorder

    However, some mental disorders are associated with a greater likelihood of committing violent acts


    Diagnoses associated with violence
    Diagnoses Associated with Violence schizophrenia)

    In general, the more serious disorders carry a greater risk for violence

    People who have delusions may be at specific risk

    In the manic phase of bipolar disorder, people can be impatient and easily angered


    Likely interrelationships
    Likely Interrelationships schizophrenia)

    Main effects

    Psychosis and substance use both have independent effects

    Interactions

    Psychosis and substance use have exponential effects, when the co-occur

    Transactions

    Psychosis, substance use, and violence influence each other over time


    Mental disorder is indirectly related to violence through substance abuse

    Substance Abuse

    Violence

    Mental Disorder

    Time


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