Medical Issues and Criminogenic Risk

1. Medical Issues and Criminogenic Risk Edward Pontius MD Medical Director, Crisis & Counseling 11/12/09

2. Medical Issues and Criminogenic Risk Theories of Criminogenesis

3. Medical Issues and Criminogenic Risk Theories of Criminogenesis Principles of Biological Treatment

4. What Is Crime? Definitions: • CRIME: The breach of one or more rules or laws for which some governing authority, via mechanisms such as police power, may ultimately prescribe a conviction. • OFFENCE: a violation of the penal law. An offence can range from a simple misdemeanour (e.g. a traffic violation) to a felony (e.g. capital murder). In common law usage, 'offence' differs from 'crime' in that there is typically no victim, but the action remains prohibited by statute.

5. Who Is A Criminal? • Legal Institutions, Media and Society use different standards to determine who is a ‘criminal’. • Under the idea of “innocent until proved guilty,” successful prosecution is necessary to establish the title of criminal • White Collar Criminals are not usually called criminals until their offense gains national notoriety. • People who make a lifestyle of committing significant crimes are criminals. (see http://socyberty.com)

6. Criminal behavior…

7. Criminal behavior… Is not always viewed as part of a deviant lifestyle…

10. 2007 Crime Rate for Maine The crime rate in Maine is about 32% lower than the national average rate. Property crimes account for around 95.4% of the crime rate in Maine which is 26% lower than the national rate. The remaining 3.2% are violent crimes and are about 75% lower than other states. The following graph shows how Maine compared to the rest of the states. State Crime Rates (Per 100,000 People)

11. 2004 Corrections Population Maine has 12,852 adults under correctional supervision (prisons, jails, probation, and parole). The supervision rate (number of offenders per 100,000 people) is about 48% lower than the national rate. State Population Rates (Per 100,000 People)

12. 2007 Incarceration Information Maine has a rate 64% lower than the national average of incarcerated adults per 100,000. Incarceration Rate (Per 100,000) (Place your mouse over a bar for details, or click on a bar to view that state's profile.)

13. 2008 Corrections Percentage of Total State Government Expenditures Taxpayers paid 27% lower than than the national average in 2008. Most recent Maine data from http://www.nicic.org/features/statestats/?State=ME accessed 11/11/09. Original Data Sources:The PEW Center on the States Federal Bureau of Investigation, U.S. Dept. of Justice Bureau of Justice Statistics, U.S. Dept. of Justice American Jail Assoc. American Correctional Assoc. State Government Data and Websites.

14. How Does Psychiatric Illness Impact Criminal risk • Psychiatric illness is associated with risk of both criminal behavior and violent crime • Illnesses associated with criminality include substance use disorders, conduct disorder, antisocial personality disorder, borderline personality disorder, bipolar disorder, schizophrenia, organic brain syndromes. • Association is not proof of causality • Patients with psychiatric illness are more likely to be VICTIMS of crime than perpetrators • Patients with Psychotic Illness are more likely to be perpetrators if comorbid with SUD’s

15. General CriteriaDSM-IV TR Personality Disorders • General diagnostic criteria • According to DSM-IV-TR (see page 689)[7], the diagnosis of a personality disorder must satisfy the following general criteria, in addition to the specific criteria listed under the specific personality disorder under consideration. • A. An enduring pattern of inner experience and behavior deviating markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas: • cognition (perception and interpretation of self, others and events) • affect (the range, intensity, lability and appropriateness of emotional response) • interpersonal functioning • impulse control • B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. • C. The enduring pattern leads to clinically significant distress or impairment in social, occupational or other important areas of functioning. • D. The pattern is stable and of long duration and its onset can be traced back at least to adolescence or early adulthood. • E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder. • F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma).

16. General CriteriaDSM-IV TR Personality Disorders • Cluster A (odd or eccentric disorders) • Cluster B (dramatic, emotional or erratic disorders) • Cluster C (anxious or fearful disorders)

17. Cluster B (dramatic, emotional or erratic disorders) • Cluster B (dramatic, emotional or erratic disorders) • Antisocial personality disorder (DSM-IV code 301.7): a pervasive disregard for the law and the rights of others. • Borderline personality disorder (DSM-IV code 301.83): extreme "black and white" thinking, instability in relationships, self-image, identity and behavior. • Histrionic personality disorder (DSM-IV code 301.50): pervasive attention-seeking behavior including inappropriate sexual seductiveness and shallow or exaggerated emotions. • Narcissistic personality disorder (DSM-IV code 301.81): a pervasive pattern of grandiosity, need for admiration, and a lack of empathy.

18. DSM-IV TR CriteriaAntisocial Personality Disorder • A) There is a pervasive pattern of disregard for and the rights of others occurring since the age of 15, as indicated by three (or more) of the following:[1] • failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest; • deceitfulness, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure; • impulsivity or failure to plan ahead; • irritability and aggressiveness, as indicated by repeated physical fights or assaults; • reckless disregard for safety of self or others; • consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations; • lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another. • B) The individual is at least 18 years of age. • C) There is evidence of Conduct disorder with onset before age 15. • D) The occurrance of antisocial behavior is not exclusively during the course of schizophrenia or a manic episode. • Deceit and manipulation are considered essential features of the disorder. Therefore, it is essential in making the diagnosis to collect material from sources other than the individual being diagnosed.[8] • It is a requirement of DSM-IV that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

19. Medical Issues and Criminogenic Risk a. Criminal Classification and Medical Diagnostic Classification b. Is Criminality An Illness? How is Antisocial Personality Disorder related to Criminality?

20. Medical Issues and Criminogenic Risk a. Criminal Classification and Medical Diagnostic Classification b. Is Criminality An Illness? How is Antisocial Personality Disorder related to Criminality? c. The Dimensions of the Problem: How Many Criminals Do We Have In Maine?

21. Medical Issues and Criminogenic Risk a. Criminal Classification and Medical Diagnostic Classification b. Is Criminality An Illness? How is Antisocial Personality Disorder related to Criminality? c. The Dimensions of the Problem: How Many Criminals Are Their In Maine? d. What Does Criminality and Its Consequences Cost Maine?

22. Medical Issues and Criminogenic Risk a. Criminal Classification and Medical Diagnostic Classification b. Is Criminality An Illness? How is Antisocial Personality Disorder related to Criminality? c. The Dimensions of the Problem: How Many Criminals Are Their In Maine? d. What Does Criminality and Its Consequences Cost Maine? e. Criminality and Incarceration: A Growing Issue for Maine

23. 2. Theories of Criminogenesis

24. 2. Theories of Criminogenesis a. Racial Theories and the Eugenics Movement

25. Eugenics

26. Cephalometry

28. 2. Theories of Criminogenesis a. Racial Theories and the Eugenics Movement • Modern Understanding of Gene Action: Behavioral Genetics • Basic Foundation: • Genes- coded sequences in DNA- both instruct cells in how to create proteins and how to function, and serve as basis for inheritance of genetic inheritance • Genes are arranged on large paired structures of DNA and regulatory molecules called CHROMOSOMES. • Some human genes reside in mitochondria with their own heritage (maternal only)

29. Human Chromosomes

30. Klinefelter’s Syndrome (47 XXY)

31. 2. Theories of Criminogenesis a. Racial Theories and the Eugenics Movement b. Modern Understanding of Gene Action: Behavioral Genetics c. Non-Genetic Biological Influences d. Environmental & Interactive Theories

32. What Is COMT and Why Does It Matter?(Catechol-O-Methyl Transferase)

33. What Is COMT and Why Does It Matter?(Catechol-O-Methyl Transferase) Single Amino Acid Change From val=>met at position 108 decreases enzyme effectiveness by 75% Increasing Dopaming, Increasing risk for Schizophrenia, ADHD, Conduct Disorder

35. Epigenetics • epigenetics refers to changes in phenotype (appearance) or gene expression caused by mechanisms other than changes in the underlying DNA sequence • Stress Hormones- • Environmental Pollutants • Multigenerational Impact

36. Pollution now causes the majority of male fish in some species to become intersex- What’s that doing to us?

37. Does Race Matter?

38. Does Race Matter? Association of Substance Use Disorders With Childhood Trauma but not African Genetic Heritage in an African American Cohort Francesca Ducci, M.D., Ph.D., Alec Roy, M.D., Pei-Hong Shen, M.S., Qiaoping Yuan, Ph.D., Nicole P. Yuan, Ph.D., Colin A. Hodgkinson, Ph.D., Lynn R. Goldman, M.D., M.P.H., and David Goldman, M.D. Am J Psychiatry 2009; 166:1031-1040

39. Genetic Ancestry of 864 African American Patients With Substance Dependence and Comparison Subjects

40. Individual and Group Levels of Genetic Ancestry From Seven Populations for 407 African American Patients With Substance Dependence and 457 Comparison Subjects

41. Does Race Matter?

42. Does Race Matter? No.

43. What Does Matter? What Matters Is Childhood Abuse and Neglect emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect

44. Abuse and Neglect Is NOT Racially Determined Lack of Relationship Between African Ancestry and Scores for Childhood Abuse or Neglect in 310 African American Patients With Substance Dependence and 180 Comparison Subjects

45. What Matters for Risk of SUD is Nurturing Children and Keeping Them Safe… Association of Substance Use Disorders With Childhood Trauma but not African Genetic Heritage in an African American Cohort Francesca Ducci, M.D., Ph.D., Alec Roy, M.D., Pei-Hong Shen, M.S., Qiaoping Yuan, Ph.D., Nicole P. Yuan, Ph.D., Colin A. Hodgkinson, Ph.D., Lynn R. Goldman, M.D., M.P.H., and David Goldman, M.D. Am J Psychiatry 2009; 166:1031-1040 CONCLUSIONS: These results suggest that African genetic heritage does not increase the likelihood of genetic risk for addictions. They highlight the complex interrelation between genetic ancestry and social, economic, and environmental conditions and the strong relation of those factors to addiction.

46. Principles of Biological Treatment a. Where Serious Mental Illness is Present, Treat i. Psychotic Disorders ii. Mood Disorders b. Where Drug Problems Are Present, Treat c. Future Directions in Modulating Criminogenic Factors i. Can Screening for Criminogenic Risk Be Justified? ii. Heart Rate as Predictor for Aggressive Trait- Aggression vs. Criminality iii. Modulating Adrenergic Systems iv. Criminogenesis and The Future of Gene Therapy d. The Most Important Strategy for Today: Prevention & Secondary Prevention e. The Single Most Important Prevention Strategy: Ensuring the Safety of Children

47. Medical Issues and Criminogenic Risk Edward Pontius MD Medical Director, Crisis & Counseling 11/12/09