CRIME & MENTAL DISORDER

1. CRIME & MENTAL DISORDER

2. 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.

3. 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.

4. Link between crime and mental disorder not new… • 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.

5. Mental Disorder 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

6. DSM-V 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

7. Defining Mental Disorder 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

8. Diagnosing Mental Disorder 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

9. DSM-V diagnoses • 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.

10. Categories of Mental Disorder 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)

11. Dissociative Disorders and Crime 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

12. Dissociative Disorders and Crime 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.

13. Dissociative Disorders and Crime Dissociative Identity Disorder • “UFO of psychiatry” • Within the person, two or more distinct personalities or personality states. • Recurrently take control of behaviour.

14. Dissociative Disorders and Crime Criminal Responsibility Automatism Form of unconscious behaviour or actions done in an altered state of consciousness Somnambulism Sleepwalking R. v. Parks

15. Psychotic Disorders and Crime 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.

16. Major Affective Disorders and Crime 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

17. Psychosis and 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.

18. Psychosis and 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

19. Psychosis and 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.

20. Psychosis and 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.

21. Common Classifications Include: • 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

22. Mentally Disordered Defendants and Offenders • 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

23. ‘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

24. Insanity Defence in Canada • 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

25. Forensic Psychiatric Services Commision • 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.)

26. Violence & Mental Illness • 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

27. Mental Disorder Violence Patterns • 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

28. Mental Disorders & 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

29. Psychotic Disorders and Crime • 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

30. Psychotic Disorders and Crime Schizophrenia Severe breakdowns in • Thought patterns • Emotions • Perceptions. Disorganization and failure to correspond to reality.

31. Schizophrenia 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

32. Psychotic Disorders and Crime • 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).

33. Schizophrenia symptoms • “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.

34. Five subtypes of Schizophrenia (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.

35. Schizophrenia and Crime • 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

36. Psychosis and 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.

37. Psychosis and 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

38. Threat/Control Override Symptoms • 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.

39. Threat/control override symptoms 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?

40. 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!”

41. Psychotic Disorders and Crime • 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.

42. Major Affective Disorders 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

43. Depressive Disorders and Crime • 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”

44. MacArthur Research Network (Monahan et al, 2001) • 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

45. Hodgins & Côté (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

46. Hodgins & Côté (1990)

47. Swedish Metropolitan Project Hodgins (1993) Methodology: • 15,000 people born in Stockholm, Sweden in 1953 • Collected data on: • criminal records • Mental health records

48. Swedish Metropolitan Project 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

49. Swanson et al. (1990) 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

50. % Violent in past year by Diagnosis