CRIME & MENTAL DISORDER

Aileen WuornosPersonal 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?

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… 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

Issue of normality – criteria fluctuate DSM-V release bible of mental illness expands with each revision

‘illness’ versus ‘disorder’‘disorder’ -- no conceptual limitationsdisorder of mind -- interferes substantially w/ life on daily basis, a group of symptomsmanifested in behavior deviating notably from normal conduct

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

Defining Mental DisorderWhat 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 DisorderThe 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

• 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 DisorderAnxiety 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 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 Crime

Dissociative AmnesiaPartial 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 Crime

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 CrimeCriminal Responsibility

AutomatismForm of unconscious behaviour or actions done in

an altered state of consciousness

SomnambulismSleepwalking

R. v. Parks

Psychotic Disorders and CrimeDelusional 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 DisordersExtremely 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 CriminalityDepression may be strongly linked with

delinquency (in females)Indifference to personal safety/consequences

Psychosis and ViolenceA 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 ViolenceDelusions 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 ViolenceDelusions 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 ViolencePersecutory delusions and violence:

Experience of delusional distressCo-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:

Adjudicated by the courts

1) Unfit to Stand Trial (FIT)2) Not Criminally Responsible on Account of Mental Disorder3) 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 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

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

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

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

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

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

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 Crime

Psychotic Disorders Psychosis – a severe impairment of thinking or

emotion such that an individual is seriously out of contact with reality

1. Schizophrenic Disorders

2. Paranoid Disorders-Delusional Disorders

3. Psychotic disorders not elsewhere classified

Psychotic Disorders and Crime

SchizophreniaSevere breakdowns in

Thought patterns Emotions Perceptions.

Disorganization and failure to correspond to reality.

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

Core Symptoms:1. Positive Symptoms

1. Hallucinations2. Delusions

2. Negative Symptoms1. Avolition – lack of energy and an absence of interest in or ability to persist in usual

routines2. Alogia –speech impoverished in terms of volume or content3. 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 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).

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.

Five subtypes of Schizophrenia (DSM-IV, not in DSM-V)

1) Disorganized• inappropriate affect; marked incoherence and disorganization in thought

patterns2) Catatonic

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

3) Paranoid type:• delusions and hallucinations (often command)

4) Undifferentiated type• psychotic symptoms that cannot be classified into other categories

5) Residual type• individual has had at least one episode, and evidence that some of the

symptoms are continuing.

Schizophrenia and Crime Core Symptoms

1. 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 ViolenceCommand 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 ViolenceCommand 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 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 symptomsHow often have you…1. Felt your mind was dominated by forces beyond

your control?

2. Felt that thoughts were put into your head that were not your own?

3. Felt that there were people who wished you harm?

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 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.

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

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”

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

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

Hodgins & Côté (1990)

Disorder

Quebec

Inmates (%)

General

Population (%)

Organic brain .40 0.9 - 3.1

Schizophrenia 7.5 0.5 - 1.2

Bipolar 4.8 0.7 - 1.1

Depression 16.9 2.1 - 5.9

Swedish Metropolitan Project Hodgins (1993)

Methodology: 15,000 people born in Stockholm, Sweden in 1953

Collected data on: criminal records Mental health records

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

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

% Violent in past year by DiagnosisDiagnosis % Violence

No disorder 2.1

Schizophrenia 12.7

Major depression 11.7

Mania or bi-polar 11.0

Alcohol abuse/dependence 24.6

Drug abuse/dependence 34.7

Swanson et al. (1990)1. Violence is 5 times more prevalent among

major mental disorders (vs. no disorder)

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

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

1-year probability of violence by diagnosisSwanson (1994)

0

5

10

15

20

25

None

Anxiety

Disorde

r

Mood Diso

rder

Schizo

phreni

a

Substa

nce Abus

e

females

males

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 Conclusions

Epidemiological Studies

7.3112.97

14.55 16.14

30.7233.12 34.91

42.59

55.2

43.57

57.86

63.89

0

10

20

30

40

50

60

70

Per

cen

t V

iole

nt

None Schizophrenia orMajor Affective

Disorder

Substance Use Major MD +Substance Use

Current-year Major Psychiatric Diagnosis

Two-item

Four-item

Five-item

Jeffrey Swanson – ECA Project

Rationality-within-irrationality

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

3.611.5

27.1

14.718.8

58.1

2.99.8

29

0

10

20

30

40

50

60

70

Low Medium High

Level of TCO Symptoms

Per

cent

Vio

lent

(5

Yea

rs)

HittingFightingWeapon

Link and Stueve Study

Swanson et al. (1996)

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…

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

Summary1. It appears mental disorder is a risk factor for

violence

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

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

Mulvey (1994)

Summary

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

5. 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)

Summary The pathways producing the association

between mental disorder & violence remain unclear

(Douglas & Hart, 1996)(Douglas & Hart, 1996)

Summary

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

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

Main effectsPsychosis and substance use both have

independent effects

InteractionsPsychosis and substance use have exponential

effects, when the co-occur

TransactionsPsychosis, substance use, and violence

influence each other over time

Mental disorder is indirectly related to violence through substance abuse

Substance Abuse

Mental Disorder Violence

Time