Forensic Psychiatry in The UK

An Introduction to Forensic Psychiatry

Forensic comes from Latin forensis which means forum or court. The scope of Forensic Psychiatry is defined as those areas where Psychiatry meets with law. In practice the remit of Forensic Psychiatry is the assessment and management of mentally disordered offenders and other psychiatric patients who are actually or potentially violent.

Crime

Crime is defined as “an act that is capable of being followed by criminal proceedings”. The age of criminal responsibility is 10 years in England and Wales and 8 years in Scotland.

Classification of crime

• Crimes against the person: i.e. violence, Sexual offences.
• Crimes of dishonesty: i.e. Burglary, fraud.
• Criminal damage: i.e. property damage, arson.
• Car crime
• Drug crimes: including the use, possession and supply of illicit drugs.
  Other crimes.
  

Causes of crime

• Genetic factors: mono zygotic twins are more concordant than Di zygotic for offending.
• Intelligence: low Intelligence has been associated with offending.
• Personality traits: including impulsivity lack of empathy.
• Family: childhood factors such as poor parenting, harsh discipline have been linked to later offending.
• Peers. Most delinquent acts are committed with others.
• Socio-economic derivation
• Alcohol and illicit drugs misuse.

Homicide

Homicide is defined as the killing of a person by another. It often involves the use alcohol and illicit drugs. A proportion of Perpetrators suffer from mental disorders including in a decreased prevalence alcohol dependence, personality disorder, schizophrenia and depression. Figures from 2006 showed that 5% of homocide perpetrators had a life time diagnosis of schizophrenia and 10% had symptoms of mental disorder at the time of the offence. The homocide perpetrator will face the charge of murder if he/she is of a sound mind and had intent to cause death or grievous bodily harm. The charge may be reduced to manslaughter when criteria for murder are not met or when there are mitigating factors (killing in self defence)

Arson

Arson is a very serious offence because of its potential to cause serious damage. Reasons for arson (fire setting) include: Insurance fraud, covering the evidence of crime, political motives, gang activity for excitement, revenge, self protection, anger, cry for help, irresistible impulse (Pyromania), sexual excitement and finally Psychosis.

The Criminal Justice System

The following chain of events may happen after committing an offence:

Police will investigate and report to Crown prosecution service CPS. A
decision has then to be made by CPS to charge and prosecute the suspect. When charged, the defendant is put on trial before magistrates’ court. Serious cases will normally be referred to crown court. The defendant is either remanded on bail or in custody. Following conviction the court will decide on sentencing which could be a fine, prison sentence or discharge…etc


Schizophrenia and violence

Schizophrenia has been associated with violence. A small minority of people with schizophrenia commit violent crimes. Delusions may lead the patient to take pre-emptive violent actions. A combination of command auditory hallucinations, passivity phenomena and lack of insight may increase the risk of violence.


Substance misuse and offending

Substance misuse is more strongly linked to violence than mental disorders.
Offending may be related to direct consequences of intoxication, dependence or long term use. The motive for offending could be funding the habit.


Personality disorder and offending

Personality disorder particularly anti-social is strongly associated with offending. Certain aspects of PD may be related to offending, i.e. impulsivity, lack of empathy, paranoia and anger management problems. Substance misuse is usually an associated finding.

Psychopathy and offending

Psychopathy is a clinical concept not to be confused with the term psychopathic disorder which is a legal term used in MHA 1983. Psychopathy is characterized by cognitive, affective and behavioural symptoms.
Interpersonally psychopathic individuals are callous, superficial and manipulative. Affectively they are short tempered, and lack guilt and fears.
Behaviourally they are impulsive and prone to criminality. The disorder is strongly linked with violence. Psychopathy checklist PCL-R is used to measure psychopathy.


Sexual offending

Most sex offenders do not suffer from a mental illness. Between 25 and 50% suffer from personality disorder. Sexual offending may be associated with organic brain damage learning disability, hypomania or psychosis. Assessment should include a full psychiatric history, psycho-sexual history, mental state examination and risk assessment. Treatment modalities for sexual offending include CBT, Cyproterone acetate, SSRI.


Risk assessment

Hazard is defined as a potential to cause harm, whereas risk refers to likelihood of such harm occurring. It is important to know that risk can be assessed and managed, but not accurately predicted or eliminated.
Risk areas in psychiatry include DSH and suicide, harm to others, substance misuse, neglect, vulnerability to exploitation and poor concordance with treatment.


Assessing the risk of violence should incorporates the following factors

- Historical factors such as previous history of violent offending, substance misuse, mental illness, PD.
- Clinical factors such as delusions, hallucinations, thoughts, plans or threats to harm others, violent fantasies, impulsivity and lack of insight.
- External factors such as access to victim and weapons, support network.
- Other factors may include, gender, unemployment, ongoing substance misuse problems.


Violence Risk assessment tools

- Actuarial methods are based on selected data that have been empirically associated with violence, similar to the way insurers determine insurance premiums based on factors such as age, sex and past claim.
- Clinical methods: involves clinicians reaching judgment based on their personal impression of an individual.
- Structured professional judgment is the best method incorporating clinical and actuarial factors.

Psychiatry and criminal proceedings


Fitness to plead

This is concerned with defendant’s mental state at the time of trial. To fulfil criteria for fitness to plead the defendant must have capacity to; understand the charge, instruct a lawyer, challenge a juror, plead to the charge and understand the evidence in court. The defendant must fulfil all criteria before entering a plea. Mental illness may affect individual’s fitness to plead.

Insanity

The defence of insanity is based on absence of intend at the time of an offence. For a successful defence the court should be satisfied that “at time of committing the act the accused was labouring under such a defect of reason from a disease of mind, to not know the nature and quality of the act, or that if he did know it that he did not know that what he was doing was wrong”.
A successful defence of insanity will lead to acquittal.

Diminished responsibility

This defence applies only to murder cases and if successful it reduces the crime to manslaughter. It does not lead to acquittal. For a successful defence on this ground the court should be satisfied that “the person was suffering from such abnormality of mind as substantially impaired his mental responsibility for his acts”

Automatism

This is a legal concept not to be confused with clinical automatism in epilepsy.
It is based on absence of intend when mind does not have the potential to control physical acts. Causes of automatism include delirium, hypoglycaemia, epileptic fits, night terror, sleep walking.


Law

Common Law is case law i.e. judgments reached by judges in individual cases, usually referred to as complainant versus defendant. Common law is based on Roman principles of good and evil. In contrast Statuary law is a one which is passed on by parliament (House of Commons). Government has a duty to implement it and produce a code of practice. MHA 1983 is a statuary Law.


Legal provisions for mentally disordered offenders

Mentally ill offenders can be diverted to mental health services for assessment and or treatment at various stages of criminal proceeding (Pre-sentence, post-sentence and at point of sentencing). Most provisions are made under MHA 1983.