You are in: eMedicine Specialties > Psychiatry > Adult Psychiatric Illness Associated With CriminalityArticle Last Updated: Jul 7, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Michael Menaster, MD, MA, General and Forensic Psychiatrist, Private Practice Editors: Denis F Darko, MD, Executive Director, Clinical Research and Development, Neuroscience Global Licensing Medical Director, Clinical Neuroscience Therapy Area and CNS and Pain Control Research Area, AstraZeneca LP; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; David Bienenfeld, MD, Vice-Chair, Program Director, Professor, Department of Psychiatry, Wright State University School of Medicine; Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin; Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA Author and Editor Disclosure Synonyms and related keywords: psychosis, psychopath, psychotic disorders, sociopath, criminality, criminal, defendant, litigant, criminal behavior, nonconformist behavior, impulse control, impaired judgment, suspiciousness, disinhibition, paranoia, impaired communication skills, impaired social interaction, psychiatric disorder, criminality, antisocial personality disorder, impulse control disorder, intermittent explosive disorder, kleptomania, pyromania, pyromaniac, kleptomaniac, gambling, paraphilias, exhibitionism, voyeurism, frotteurism, pedophilia, schizophrenia, tardive dyskinesia INTRODUCTIONSection 2 of 10
  Like the term insanity, criminality is a legal term and is specifically not a medical or psychiatric term, diagnosis, illness, or syndrome. Webster's dictionary defines criminality as "the quality or state of being a criminal; criminal activity." Webster's further defines a criminal as "relating to, involving, or being a crime; relating to crime or to the prosecution of suspects in a crime; guilty of crime; also: of or befitting a criminal; disgraceful." In other words, the term refers to a pattern of human behavior or a specific act violating a law. Different societies frequently have different customs, philosophies, and standards of behaviors, all of which impact their laws and criminal justice system. Accordingly, criminality is relative to society; individuals in one society may be treated as criminals, while the same individuals in another society would not be treated as such. Further complicating matters, police, courts, and governments have flexibility with enforcing laws, which determines who should be prosecuted as a criminal. For example, some societies are so intolerant of diversity that they treat political dissidents as criminals. Because criminality is a legal issue that is relative to a particular society, no surgical, medical, or psychiatric interventions can treat it per se. However, mental illness can result in symptoms associated with criminal activity and sometimes actual criminal activity. Because those symptoms may be treatable, in a sense, criminality could be treated. Nearly any psychiatric symptom can be associated with criminality, because symptoms can impair judgment and directly or indirectly violate societal norms. For example, an individual with major depression and insomnia may fall asleep while driving and kill a pedestrian, resulting in a manslaughter conviction. Frequent psychiatric conditions associated with criminality are listed below. Incarceration itself is distressing and can be associated with the onset or exacerbation of psychiatric disorders. However, most individuals with mental illness are not violent.1 In fact, a study of individuals with psychotic disorders found that those with a mental illness were responsible for only 5% of all violent crimes.2 An exception to this rule involves sexual offenders, who had high rates of substance use disorders, paraphilias, mood disorders, impulse control disorders, anxiety disorders, eating disorders, and antisocial personality disorders.3 Other exceptions include antisocial personality disorder and substance abuse.4 The eMedicine journal has further information on these disorders. Please click on the following hyperlinks for further information. Psychiatric diagnoses commonly associated with criminality Dementias Impulse control disorders Intoxication or withdrawal from medications or drugs Mood disorders Personality disorders, especially antisocial personality disorder Pervasive developmental disorder (autism) Psychotic disorder, not otherwise specified Substance dependence and abuse Traumatic brain injury These psychiatric disorders comprise the principal psychiatric illnesses found in individuals involved with the criminal justice system. Disorders defined by behaviors more directly linked to criminality include antisocial personality disorder, impulse control disorders (eg, intermittent explosive disorder, kleptomania, pyromania, pathological gambling), and paraphilias (eg, voyeurism, exhibitionism, frotteurism, pedophilia). However, individuals with these illnesses are not criminals by virtue of having the disorder. Rather, such disorders are considered more closely linked to criminality, because the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria for diagnosing these disorders include symptoms that tend to violate the rights of others. EPIDEMIOLOGYSection 3 of 10
Substance Abuse Substance abuse dramatically increases the risk of criminal behavior, particularly violence. Individuals who abuse alcohol or drugs have a higher lifetime prevalence of arrests than individuals with schizophrenia, personality disorders, or mood disorders.5 Women with antisocial personality disorder who are alcohol dependent have 40-50 times higher rates of homicide than the general population.6 Compared with individuals who are mentally ill without substance abuse, dual diagnosis individuals are 240% more likely to engage in violence. A history of alcohol abuse is the strongest predictor of domestic violence and elder abuse.7 Chronic alcohol dependence is more predictive of violence than acute alcohol use.8 In addition, intoxication or withdrawal is highly associated with violence.9 Antisocial personality disorder The estimated prevalence of antisocial personality disorder in the general population is 3% of males and less than 1% of females. It is more prevalent in impoverished, urban areas. By definition, individuals with antisocial personality disorder must be at least 18 years of age. Antisocial personality disorder is highly associated with violence.4 It is also strongly associated with incarceration. In a meta-analysis, 47% of prison inmates were diagnosed with antisocial personality disorder.10 Impulse control disorders Kleptomania: Few studies have been published on this relatively rare condition, the prevalence of which is 0.6%. Accordingly, fewer than 5% of shoplifters meet the criteria for this disorder. Typically, several decades pass between the onset of thefts and an individual's presentation for treatment, usually in the context of involvement with the criminal justice system. Women are more likely than men to be diagnosed with kleptomania. Women with this disorder enter treatment in the fourth decade of life, men in their sixth decade. Pyromania: This disorder is rare, occurring more frequently in males than in females. It is often associated with a history of fascination with fire, dating back to childhood or early adolescence. Ninety percent of arsonists have documented psychiatric histories; 36% of those individuals had schizophrenia or bipolar disorder, while 64% were using alcohol or drugs during their fire-setting activity. A few reports note an association between fire-setting and epilepsy. However, pyromania was diagnosed only in 3 of 283 cases. Motives vary from anger to delusions. Pathological gambling: Estimated incidence in the general population is 3%. Cultural and sociological factors play a role in the specific manifestation of behavior (eg, horseracing, cockfights, ma jong, pai gow, the stock market, lotteries, bingo). Curiously, although 30% of individuals with this condition are females, women constitute only 2-4% of Gamblers Anonymous membership. Intermittent explosive disorder: Although episodic violence is common in the Paraphilias: More than 90% of people with this disorder are male. In more than 50% of people with the disorder, onset of paraphilic arousal occurs when they are younger than 18 years. CLINICAL FEATURESSection 4 of 10
Antisocial personality disorder The course of antisocial personality disorder is variable. Generally, the course improves with age. Many become incarcerated, develop comorbid substance abuse or dependency, and incur injuries and violent deaths. According to the DSM-IV-TR, diagnostic criteria for antisocial personality disorder are as follows:
Impulse control disorders According to the DSM-IV-TR, the criteria for impulse control disorders are as follows:
Paraphilias According to the DSM-IV-TR, diagnostic criteria for paraphilias are as follows:
Schizophrenia Media hype to the contrary, most patients with schizophrenia generally do not pose an elevated risk of violence. However, one subgroup of patients with schizophrenia has an increased risk of violence and arrest. A significant degree of the criminality of schizophrenia is related to its symptoms, and criminality is reduced when the illness is treated. A study of 42 individuals found not guilty by reason of insanity (NGRI) found a high prevalence of schizophrenia and schizoaffective disorder with comorbid substance abuse.11 The current approach to schizophrenia treatment is multimodal, combining medications with psychological and social approaches. CAUSESSection 5 of 10
Most psychiatric disorders are syndromes in that a specific cause is unknown. Contemporary psychiatry views psychiatric disorders as being multifactorial in origin and based upon a combination of heredity/biochemistry, environment, personality, and biochemistry, collectively known as the biopsychosocial theory. Antisocial personality disorder Heredity and environment are associated with this antisocial personality disorder. This disorder occurs 5 times more commonly in first-degree relatives of males with the disorder. Twin studies also support a genetic contribution to this disorder. Environmental studies find an association of this disorder with absent, abusive, or inconsistent parenting. In addition, the social learning theory is quite applicable to this disorder. Social learning theorists, especially Albert Bandura, argue that people are not born with the ability to act criminally, but rather they learn to be aggressive and commit crime through life experiences. Criminality is learned by modeling, based upon 3 principal sources: family members, environmental experiences, and the media. Impulse control disorders Kleptomania: Because few scientifically rigorous studies have been carried out, the etiology is unknown. Associations, which do not imply causality, have been found with depression, bipolar disorder, substance abuse, anxiety, and eating disorders. First-degree relatives have been found to have major mood disorders, substance abuse, or anxiety disorders. Pyromania: Few scientifically rigorous studies have been performed; therefore, the etiology is unknown. Psychosocial hypotheses suggest this disorder may be understood as a communication from an individual with few social skills or a symbolic solution to conflict arising from ungratified sexuality. Low levels of serotonin are associated with violence and impulsivity.12 Pathological gambling: The etiology of pathological gambling is uncertain. Associations have been made with affective disorders, addiction, biological abnormalities, unconscious motivations, or behavioral anomalies. Intermittent explosive disorder: The etiology is unclear, although an association with CNS dysfunction is apparent. Individuals with this disorder show abnormalities in neurological examination results, neuropsychologic test results, and EEG results. Associations have also been made with attention deficit hyperactivity disorder or learning disability. Research also has implicated abnormalities in levels of neurotransmitters and hormones. Paraphilias: Little research exists on paraphilias, and the etiology of the disorder is unknown. A strong association has been established between this disorder and substance abuse, major depression or dysthymic disorder, and phobias. A finding suggestive of a psychological basis is that individuals with paraphilias have difficulty forming more socialized sexual relationships. One theory holds that paraphilias involve a conditioned response in which nonsexual objects become sexually arousing when paired with a pleasurable activity (eg, masturbating). TREATMENTSection 6 of 10
Antisocial personality disorder Little evidence exists that this disorder can be treated successfully with conventional psychiatric interventions. Antisocial personality disorder is among the disorders most resistant to treatment because these individuals have ego-syntonic symptoms and little incentive to change. Therapeutic rapport is tenuous at best, particularly since deception is a hallmark of this disorder. Insight-oriented psychotherapy is contraindicated due to the risk of inducing acting-out behavior in these individuals. Benzodiazepines are generally contraindicated due to the high frequency of substance abuse and diversion. However, antisocial behavior decreases with age. The most effective short-to-intermediate term treatment appears to be in residential or confined settings, where peer confrontation, behavior therapy, and empathy training and peer confrontation can occur. Psychopharmacotherapy may be used to alleviate impulsivity and aggression. Treatment of comorbid conditions tends to be more successful, though less so as compared with individuals without this personality disorder. Anxiety disorders When not contraindicated by substance abuse or antisocial personality disorder, benzodiazepines provide immediate, short-term relief of anxiety, though the risk of abuse and dependence is an important consideration. Atypical antipsychotics, selective serotonin reuptake inhibitors (SSRIs), and serotonin/norepinephrine reuptake inhibitors (SNRIs) are also efficacious as both short- and long-term treatments. See Anxiety Disorders. Mood disorders For unipolar depression, SSRIs (eg, citalopram, fluoxetine, paroxetine, sertraline) and SNRIs (eg, venlafaxine duloxetine) are the treatments of choice. For bipolar spectrum disorders, lithium, valproic acid, lamotrigine, topiramate, and the atypical antipsychotics are efficacious treatments of choice. Psychotic disorders Atypical antipsychotics (eg, aripiprazole, olanzapine, quetiapine, risperidone) are the current treatment of choice for psychotic disorders. These medications efficaciously treat psychosis regardless of its etiology. However, these medications are not without risks and require evaluation of blood sugar, prolactin, and lipid levels. Although relatively uncommon, tardive dyskinesia (TD) has been reported with the atypical antipsychotics,13, 14, 15 and reports of TD in the atypical antipsychotics are likely to increase in the future, given nature of delayed onset in TD. Substance abuse and dependence Acamprosate, naltrexone, atypical antipsychotics, valproate, topiramate, gamma-hydroxybutyric acid (GHB), and SSRIs (eg, citalopram, sertraline, fluoxetine) can reduce alcohol cravings. Disulfiram (Antabuse) does not treat alcohol craving, but it can reduce impulsive alcohol consumption. Gabapentin is efficacious in treating cocaine craving, anxiety, and withdrawal symptoms, particularly seizures that may occur in alcohol or benzodiazepine withdrawals.16 Topiramate is efficacious in treating opiate withdrawal.17 Despite advances in biological psychiatry, 12-step programs remain the mainstay of substance abuse treatment. Impulse control disorders Kleptomania: Treatment successes are difficult to identify due to the paucity of published case material. Nonpharmacologic measures include insight-oriented psychotherapy, systematic desensitization, assertiveness training, aversive conditioning, covert sensitization, and self-imposed banning by shoppers. Case reports note success with paroxetine, fluvoxamine, fluoxetine, lithium, valproate, amitriptyline, imipramine, nortriptyline, and trazodone. Pyromania: Cognitive-behavioral treatment and fire safety education are effective in reducing fire involvement, fire interest, and risk. These interventions were more efficacious than home visits from a firefighter. The literature is lacking in reports about efficacious pharmacologic interventions. Pathological gambling: Traditionally, psychoanalysis was the most commonly used treatment, but research on its efficacy is limited. Behavioral and cognitive-behavioral psychotherapies are proven efficacious, particularly when practitioners integrate social skills training, problem-solving, cognitive restructuring, and relapse prevention. In addition, pharmacotherapy with SSRIs, such as escitalopram and fluvoxamine, can be efficacious. Case reports noted the efficacy of lithium or clomipramine in treating pathological gambling. Use of 12-step programs, such as Gamblers Anonymous, may help in some cases, and, given its low risk of side effects, should be recommended routinely. Intermittent explosive disorder: Acute management of violent behavior may involve use of physical restraint and medications, particularly antipsychotics and benzodiazepines. Psychopharmacotherapy and cognitive-behavior psychotherapy is efficacious with some patients over the short term. Carbamazepine, lithium, propranolol, and serotonin-selective medications such as buspirone and SSRIs have been beneficial. Paraphilias: No evidence supports the efficacy of any specific modality. In particular, insight-oriented and supportive psychotherapy has been found to be relatively ineffective. Behavioral therapy, including aversive therapy, desensitization, social skills training, and orgasmic reconditioning, may be efficacious in some patients. Anti-androgen medications, including intramuscular medroxyprogesterone acetate and cyproterone acetate, which are competitive inhibitors of androgen receptors, decrease testosterone levels and have been successful in decreasing aberrant sexual tendencies. Chemical castration may be achieved with the use of intramuscular leuprolide and triptorelin, synthetic gonadotropin-releasing hormone analogs that dramatically decrease testosterone levels; this may completely abolish deviant sexual tendencies. Oral estrogen in the form of ethinyl estradiol has been used less successfully to decrease aberrant sexual tendencies. The intensity of aberrant sexual urges may be attenuated by clomipramine and SSRIs, which act to decrease the compulsivity/impulsivity of the act. Because these treatments affect significant others, including them in the informed consent process and educating them as to the impact of treatment interventions are important. ETHICAL AND LEGAL ISSUESSection 7 of 10
In clinical and forensic settings, confidentiality is an important consideration. Court-ordered evaluations limit but do not completely preclude confidentiality. Courts sometimes mandate psychiatric treatment for individuals as a condition of parole or probation. Again, confidentiality is limited, but nonetheless present. When working with court-ordered individuals, coordination of care with parole or probation officers is essential. Because criminality is associated with harm toward others and recidivism, clinicians must continuously evaluate patients for dangerousness to themselves and others. When feeling trapped or when taken into custody, these individuals can become depressed and/or suicidal. Most jurisdictions require clinicians to protect or warn identifiable victims against patients, based upon PATIENT AND FAMILY EDUCATIONSection 8 of 10
ACKNOWLEDGMENTSSection 9 of 10
The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors William H Wilson, MD and Kathleen A Trott, MD to the development and writing of this article. REFERENCESSection 10 of 10
Psychiatric Illness Associated With Criminality excerpt Article Last Updated: Jul 7, 2008 |
