Forensic Psychiatry

Branch of Psychiatry Dealing with Issues Arising in the Interface Between Psychiatry and the Law

• Legal issues impinging on the practice of psychiatry.
• All actions of psychiatrists in helping the law carry out some of its responsibilities.
• A forensic psychiatrist is a psychiatrist who has additional training and/or experience related to the various interfaces of mental health/illness with the law.

• When legal matters involve issues outside lay (general public) expertise, lawyers and judges regularly seek consultation from professionals in a wide variety of fields, including medical specialties.
• Such professionals are often called "experts" or "expert witnesses."
• Forensic experts usually are truly knowledgeable, the criteria for "expert" designation in such cases are legal ones, and not necessarily scientific.
• Sometimes the expertise is sought in an effort to provide the best possible information to judges or juries, but there are many other situations in which a prudent attorney, judge, or other party may request consultation.

Most forensic psychiatrists don't specialize in criminal matters. The word "forensic" refers to anything that has to do with the law. Forensic psychiatrists thus may be involved with:

• criminal matters
• civil litigation (such as malpractice lawsuits)
• competence to do things (like make a will, consent to medical care, or take care of children)
• child custody
• treating and working with mentally ill people who get in trouble with the law
• helping victims of crimes
• helping lawyers and judges understand the psychological aspects of their cases.

• Intentional act/omission in violation of criminal law, committed without defense or justification and sanctioned by the state as felony or misdemeanor.
• Defined by each society.
• Offending may peak in teenage years and early adulthood.
• For most crimes, actus reus (guilty act) and mens rea (guilty intention) are needed.
• Stigmata related to the “born Criminal”
• Deviation in head size
• Asymmetry of the face
• Large jaw and cheekbones
• Nose flattened, upturned in thieves or beak-like in murderers
• Features similar to apes and early man
• Supranumerary toes and fingers
• Abundance and precocity of wrinkles, etc.
• About 18 features in all!

Aetiology of Crime

• Lombroso (1876) - Physical stigmata: shape of skull, large ears of criminals/unscientific curiosity.
• Higher concordance rate in MZ (monozygotic) vs. DZ (dizygotic) twins.
• Adoption studies (Scandinavia) – genes only significant in severe criminality. Approximately 50% of persistent antisocial behavior is due to genetic factors, with heritability greater in males than females.
• XYY chromosome – tall, aggressive, violent. May also be due to bodily abnormality.
• Association between low IQ and delinquency - Rutter & Gilles - not due to likelihood of duller offenders being caught.

Psychosocial Correlates

• Unemployment, poverty, drugs, low social class, deprivations, sex, personality, etc.
• Women are less violent than males, but often extensive users of the criminal justice system - rates of mental problems are higher in them than in males.
• Family influences – poor parental supervision, harsh discipline, marital disharmony, large family, broken homes.

Mental Illness and Offending

• Most offending by mentally ill is minor in degree.
• When serious violence occurs, it is likely to be domesticated (by a carer or family member).
• Major mental illness increases the likelihood of criminal conviction for violent crime.
• Antisocial personality disorder and substance disorders have a greater association with offending than other major mental disorders.

• Schizophrenia – delusions/hallucinations, command type paranoid & residual, irresistible urges/loss of control. Symptoms result in violence if feelings of personal threat emerge.
• Effect of alcohol/drugs.
• Personality difficulties / all-around social incompetence.
• Social stresses (unemployment, poverty, homelessness, lack of support).
• Poor drug compliance.
• Caring role burdensome.

Affective Disorder

• Manic – Grandiose, fraud, public disorder, impersonation, disinhibition.
• Irritability, aggression, violence.
• Depression – Altruistic homicide - kills family members, neonaticide, then attempts suicide.
• Confessions, attempted suicide, shoplifting – about 1% prevalence of depression or B.A.D. in shoplifters.
• In general, association of major affective disorder with crime is less strong compared with schizophrenia.

Neuroses

• Neurotic symptoms are common in offenders - the offense may be senseless, e.g., kleptomaniac – these individuals have:
• Fragile personalities, socially isolated.
• Unable to resist the impulse to steal.
• Relief at the time of committing theft.
• Poor treatability.
• No specific neurotic disorder found to be causally related to any particular offense.

Learning Disorders

• Unable to understand implications of behavior.
• Susceptible to exploitation - lack IQ to plan crimes properly.
• More likely to apprehension.
• Association with sexual offenses because they are rejected/denied legitimate expression of sexuality, also with theft and arson.
• Violent crime is less common.

Alcohol/Drugs

• May reduce inhibitions.
• Alcoholic hallucinosis, D.T. Amnesias.
• Morbid jealousy.
• May contribute to homicide in victim/offender.
• Drug dependence may offend to procure drug.
• Implicated in family violence, child abuse, rape, sex offenses, homicide.
• In Nigeria, alcohol & cannabis use are high among criminals.

Organic Disorders

• Impaired judgment/disinhibition characterize organic brain disease, may lead to crimes of dishonesty/sexual offenses.
• Geriatric men may abuse children – Dementia.
• Acute organic disorders may also lead to offending.

Delusion of Love

• Erotomania/Declarambault’s syndrome – delusion of love by a distinguished person, unattainable by reason of social class.
• Physical pursuit of “lover”, invasion of privacy, leading to criminal acts secondary to delusion.

Premenstrual Syndrome & Crime

• Consists of depression, irritability, and behavioral disturbances.
• Association between behavioral disturbance & the paramenstrum.
• Association may apply only to vulnerable group of women, prone to impulsive behavior.

Female Offenders

• Fewer studies on female offenders.
• Women who enter the justice system are less violent than males but become extensive users of the system.
• Incarcerated women have a significantly higher incidence of mental disorders than non-incarcerated women.

Fitness to Plead

• Relates to mental state at time of trial.
• Understand charge.
• Know the difference between pleading guilty and not guilty.
• Challenge juror.
• Follow proceedings in court.
• Instruct counsel.
• Not suffer from a mental illness.

• Mental state/Level of intent - mens rea, e.g., intent to inflict grievous harm by pouring acid.
• Act itself - guilty act/actus reus.
• A concurrence in time between both.
• Prove above beyond reasonable doubt before conviction recorded for most offenses.
• Age, Mental Disorder, Drugs, Automatism may impair mens rea.
• Age of the accused in most jurisdictions usually affects their capacity to form the intent to commit a crime.
• For example, in English law, children under 10 years are excluded because they are deemed incapable of forming criminal intent (doli incapax).
• Children between the ages of 10 and 14 years may be convicted if there is evidence of mens rea and that the child knew that the offense was legally or morally wrong.

Mental Disorder: M'Naghten Rule

• Defendant suffers from a disease of the mind at the time of the offense.
• Caused a defect of reason which:
• Robbed them of capacity to know action or know it was wrong – M'Naghten rules.
• Every person is presumed sane until the contrary is proved.
• To establish the defense of insanity, prove that the accused was laboring under a defect of reason, from disease of mind, so as not to know the nature/quality of the act they were doing, or if they knew it, did not know they were doing wrong (at the time of the offense).

Insanity

• Suffers from a disease of the mind/natural mental infirmity which:
• Deprived them of the capacity to understand action or control action or
• Know they ought not to do/make omission - natural mental infirmity and uncontrollable impulse differentiate from M'Naghten.

Diminished Responsibility

• Shades of mental impairment can affect mens rea, not necessarily completely nullifying it.
• Lesser degree of intent.
• Applicable only to murder.
• Responsibility diminished.
• Not guilty of murder but manslaughter.

Alcohol/Drugs Effect

• Intoxication not in itself a defense. If involuntary or non-consensual, or caused by malicious act or negligence of another - yes.
• Voluntary intoxication – exculpates if drugs caused disease of mind (McNaughton).
• If drugs lead to mind abnormality to impair responsibility (Diminished Responsibility).
• If a requirement of specific intent for a crime, e.g., murder, evidence of intoxication may be used to show inability to form that intent.

• Psychiatrists are called to evaluate capacity, e.g., write a will, enter a contract, psychological autopsy.
• Determination of incapacity results in social control of the individual.
• Need to be ethical and make sure your decision is based on the best available clinical evidence.
• Assumed in law that a person is competent to make decisions unless proven otherwise.

Capacity Recommendations

• Major mental disorder does not automatically produce incapacity in general - capacity may fluctuate/competency is not an all or none concept but tied to a specific decision/function to be accomplished.
• Finding of incapacity should be time-limited - review from time to time. For example, a stroke patient may be incompetent to drive but may be competent to make contracts or manage finances. With treatment/rehabilitation, they may regain capacity.

Testamentary Capacity

• Ability to write a valid will.
• Also refers to capacity to understand the nature and effects of writing a will.
• Testator must understand the nature of the will and its implications.
• Must know the nature and extent of property.
• Must know people who may expect to be beneficiaries even though they choose to exclude them.
• Must not suffer from a disorder of the mind.

Power of Attorney

• Impairment of ability to manage affairs may cause problems for relatives and associates.
• Relatives may apply and obtain a power of attorney to manage the property and affairs of such an ill member.
• Durable power of attorney - Permits persons to make provision for anticipated loss of decision-making capacity and advance selection of a decision-maker to act in proxy when illness/dementia sets in.

Entering into Contracts

• Validity of a contract entered into by a mentally ill individual depends on the test of their capacity to understand the nature of the contract and its implications.
• Does not depend on diagnosis or status, e.g., detained.
• Incapable patients require protection, as do those who transact business with them.
• A mentally incapable patient is bound by their contract, unless they can show the other party knew of their incapacity when they made the contract.

Competence to be Executed

• New area of competence that emerged.
• Requirement anchored on:
• Punishment is meaningless unless the offender is aware of what is going on - must be mentally able to make whatever peace is appropriate with religion, e.g., confession.
• Possibility of recalling forgotten details of events or crimes that may prove exonerating.
• Ethical issues - physician’s duty to preserve life transcends competing requirements.

• Rising wave of legalism, mental health not immune.
• Why?
• Patients have greater expectations of doctors.
• Competitive nature of legal practice.
• Innovations in medicine requiring greater skills/knowledge. By definition, it means,
• Intervention given which falls below acceptable standards of practice allowed - judicial principle.

Proof of Malpractice

• A doctor-patient relationship, creating a duty of care.
• Deviation from the standard of care.
• Damage to the patient.
• Direct causation between deviation and damage.
• 4D’s - each must be present. Preponderance of evidence required.

Example of Malpractice

Liabilities include failure to properly evaluate, negligent prescription practices (exceeding dose, using wrong meds, failure to disclose side effects), ECT with undiagnosed fracture, failure to obtain informed consent resulting in irreversible damage (T.D.), suicides, boundary violations, mechanical restraint causing disability, breach of confidentiality, prolonged and unnecessary incarceration that is ultra vires, absconding patient kills self (Dickson Igbokwe vs. U.C.H.).

Violence and Malpractice

• May be sued for failure to control aggressive outpatients and for discharge of violent inpatients.
• Tarasoff v University of California regents - Supreme Court ruled that endangered third parties must be notified.
• Required to predict future behavior of violent patients - poor performance here.

Tarasoff 1

Poddar (student/outpatient) told therapist of intention to kill Tatiana Tarasoff.

Therapist decided to commit but supervisor vetoed.

Poddar absconded from clinic and killed her.

Psychiatrist believing patient may injure/kill must notify potential victim/relative/authority.

Tarasoff 2

1982 - California Supreme Court ruled on duty to protect, broadening earlier ruling.

Relates to release of violent patients.

Never discharge without adequate follow-up.

Critique of Tarasoff Decisions

• Informing at the beginning of the session of a possible breach of confidentiality may deter individuals from entering therapy, thus putting the public at greater peril from potentially violent individuals who go untreated.
• Such patients may not talk about the violence, thus diminishing the value of psychotherapy.
• Therapists could overreact and practice defensively by warning too often.

Vicarious Liability

Legal Doctrine.

Respondeat Superior

Servant’s act considered to be that of master - Let the master answer for the deeds of the servant.

Take on indemnity. Dickson Igbokwe v UCH Board of Management.