Forensic psychopathology – a summary of disorders, e.g. personal disorder, psychopathy
Numerous studies have indicated a higher prevalence’s of psychiatric disorders in prisoners than in the general population. (Hollin, 1989; Singleton et al, 1998; Singleton et al, 1999; Fazel & Danesh, 2002)
However, it is a common misconception that mental illness and offending behaviour are closely related. (Gunn, 1977). Higgins (1995) cautions that the relationship between mental ill health and offending behaviour is complex, and can be oversimplified. “Even severe psychopathology, for which treatment in hospital may be advised, will rarely provide a complete explanation for the offending behaviour.” (ibid: 53)
A study of 3,142 prisoners in England ands Wales by the ONS exploring the prevalence of 5 psychiatric disorders (psychosis, neurosis, personality disorder, hazardous drinking and drug dependence) found ‘probable psychosis’ in amongst 4% of sentenced male prisoners and 9% of male prisoners on remand. In females these rates increased to 10% and 21% respectively. The prevalence’s of ‘neurotic disorders’ (which includes phobias, panic and anxiety disorders, depression, OCD and PTSD) were higher, in females 76% of those on remand and 63% of those sentenced, and for males 59% and 40% respectively. (Singleton et al, 1998)
In a meta-analytic study of 109 samples including 33, 588 prisoners in 24 countries Fazel & Seewald (2012) found a prevalence of psychosis of 3.6% in male prisoners and 3.9% in female prisoners, which increased to 5.5% in low-middle income countries. The prevalence of major depression was 10.2% in male prisoners and 14.1% in female prisoners.
Although it is typical to think in terms of diagnoses, Yakeley (2010) proposes that “psychological theories of mind linking personality with mental illness” (ibid, pp.28) could have more explanatory power than diagnostic classifications based on epidemiological research and empirical observation, in seeking the root causes of offending behaviour. The forensic patient can have psychopathology ranging from dementia to overt psychosis, including psychopathic personality. (Welldon, 1997)
What follows is structured in diagnostic categories.
Common disorders in forensic populations
Schizophrenia
“Schizophrenia is characterized by delusions, hallucinations, disorganized speech and behaviour, and other symptoms that cause social or occupational dysfunction. For a diagnosis, symptoms must have been present for six months and include at least one month of active symptoms.”
American Psychiatric Association, DSM V (2013)
Singleton, et al (1998) found that of a sample of prisoners in England and Wales, diagnosed through clinical interviews, 2% of males on remand, 1% of males sentenced, and 3% of female prisoners indicated schizophrenia. Taylor & Gunn (1984) found 6.1% of male prisoners had a diagnosis of schizophrenia.
Individuals diagnosed with schizophrenia are no more likely than the rest of the population to commit an offence (Lindqvist & Allebeck, 1990). However, they are more likely to be detected and arrested (Robertson, 1988), and they are more likely to have committed a violent offence. (Zitrin et al, 1976; Humphreys et al, 1992; Noble & Rodger, 1989; Taylor & Gunn, 1984; Taylor et al , 1994; Link & Stueve, 1994; Hodgins, 1992; Eronen et al, 1996; Wallace et al, 1998) Swanson et al (1996) identified command hallucinations, delusions of thoughts-insertion, or of the individual’s mind being controlled by an external entity as linked to greater risk of aggression.
Individuals diagnosed with schizophrenia who offend fall into two broad categories. The first category includes acutely ill patients with positive symptoms, who are responding to a delusional idea, and the connection between the abnormal mental experience and the offending behaviour is usually clear. The second category of patients includes some less prominent positive features, alongside the negative symptoms which have emerged during the course of chronic illness. In these cases the offence is committed unintentionally, out of necessity to achieve survival, admission to hospital or prison, or prevent admission to hospital. (Higgins, 1995)
Depression
There is a broad range of depressive disorders.
“The common feature of all of these disorders is the presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function. What differs among them are issues of duration, timing, or presumed etiology.”
American Psychiatric Association, DSM V (2013)
Depression does not present often in violent forensic populations. One in six individuals diagnosed as manic-depressive commit suicide, and violence towards others is much rarer, around 6 in 100,000 (Hafner & Boker, 1982). Violence towards others is usually constrained to close family members, and emanates from psychotic depression with delusional ideas. (Higgins, 1995)
Shoplifting is associated with depression. In a large sample of female shoplifters, 5% needed psychiatric treatment, 24% suffered a depressive disorder and 2% had manic-depression. However, the picture is likely to be more complicated; Gudjonsson (1990) found that psychologically disturbed shoplifters often present comorbidities.
Learning Disability
Whilst it is unusual for individuals with profound, severe or moderate learning disability to be within the forensic population, there are characteristics of having a mild learning disability which, when coupled with diminished or lacking protective factors, or with unexpected adverse life events, can result in offending behaviour. According to the UK Department of Education learning difficulties could include any of the following specific learning disabilities or dyslexia, dyspraxia, speech, language and communication problems, sensory impairments, attention-deficit hyperactivity disorder (ADHD), and autism spectrum disorder (ASD). In the UK the rate of intellectual impairment amongst offenders is higher when both intellectual disability and learning difficulties are present (at between 20-30%) (Talbot, 2008) than in the general population – 2% with intellectual disability (Loucks, 2007) and IQ lower than 85 (17%). However, it also true that unless the offending behaviour is especially serious, those with moderate to severe intellectual disability are rarely dealt with through the criminal; justice system. (RCPsych, 2014)
Substance misuse (alcohol, drugs)
There are marked relationships between drug and alcohol abuse, although these are not causal as a number of other factors also contribute, for example, personality characteristics, social and family background, etc. Alcohol and drug use and dependency does produce effects that make offending more likely, especially violent behaviour (Steadman et al, 1998). However, it is often the case that individuals have offended prior to drug or alcohol abuse. (Higgins, 1995)
Alcohol misuse is present in a significant number of the perpetrators of rape (34-72%), in child sexual offences (49%) and in instances of abuse and neglect within families (Wolfgang & Strohm, 1956; Rada, 1976; Coid, 1986).
Drug-dependence and habitual criminality are often in close association. (Gordon, 1990) As in the case of alcohol misuse, a history of offending usually predates drug-related offending.
Sexual offending
In England and Wales, the numbers of offenders in custody for sexual offences has increased from 9% in 2005 to 14% in 2013. In 2011, 42% of prisoners sentenced for sexual offences had committed ‘other sexual offences’, which includes sexual activity with minors (excluding rape and sexual assaults), exposure, voyeurism etc.
In a study exploring the psychopathology of sex offenders in Colorado in comparison to general inmates, Ahlmeyer, et al (2003) found that sex offenders displayed characteristics in keeping with schizoid, avoidant, depressive, dependent, self-defeating, and schizotypal personality disorders, alongside anxiety, dysthymia, PTSD, and major depression.
Disorders of Personality
Individuals with disorders of personality make up a high proportion of patients seen in forensic settings. Singleton, et al (1998) found that of a sample of prisoners in England and Wales, diagnosed through clinical interviews, 78% of males on remand, 64% of males sentenced, and 50% of female prisoners manifested a personality disorder. In all three groups, antisocial personality disorder was most common (63%, 49% and 31% respectively). Such rates have not been found in other studies. Taylor & Gunn (1984) found 13.8% of male prisoners had a personality disorder.
Antisocial personality disorder
“APD (Antisocial Personality Disorder) is a diagnosis assigned to individuals who habitually violate the rights of others without remorse.”
American Psychiatric Association, DSM V (2013)
Personality traits such as “immaturity”, “inadequacy”, “hostility and aggression”, and “abnormal sexuality” are commonly associated with anti social personality disorder. (Higgins, 1995)
Higgins (1995) makes clear that, in a clinical sense, antisocial personality disorder is the modern form of now anachronistic terms ‘psychopathic’ or ‘psychopath’, which implies in its perjorative sense, that a patient is untreatable, is used to reject patients from hospital, and applied casually to those with other psychiatric disorders, such as schizophrenia, or hypomania. (Coid, 1988) However, the term is likely to remain in use as it is enshrined in the Mental Health Act (1983) applying to “a persistent disorder or disability of mind [�] which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned.” (ibid, Section 1(2)). In a similar way, there is much to be desired in the clarity of the concepts of personality disorder. (Dolan & Coid, 1993; Coid, 1992)
Borderline Personality disorder
“A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning in early adulthood and present in a variety of contexts.”
American Psychiatric Association, DSM V (2013)
This is a term that has evolved jointly through psychoanalysis and hospital psychiatry, and has been useful to describe a set of individuals with impaired sense of self-worth, who tend of develop damaged and volatile relationships. (Higgins, 1995) Such individuals tend to exhibit behaviours that are impulsive, destructive and self-destructive, and experience periods of despair, and anomie, and sometimes brief psychotic episodes. (Jackson & Tarnopolsky, 1990) Such people are capable of serious offences including sexual offences and arson, and when in prison or hospital of serious self-harm and arson. Treatment has a reputation for being challenging. The different approaches have been explored by Tantam & Whittaker (1992)