You are in: eMedicine Specialties > Psychiatry > Adult Psychiatric Illness Associated With CriminalityArticle Last Updated: Sep 14, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 8
  Author: Michael Menaster, MD, MA, Specialist in General and Forensic Psychiatry, Private Practice Michael Menaster is a member of the following medical societies: Sigma Xi Coauthor(s): William H Wilson, MD, Professor of Psychiatry, Director of Inpatient Psychiatry, Department of Psychiatry, Oregon Health and Science University; Kathleen A Trott, MD, Staff Psychiatrist, Gundersen Lutheran Behavioral Health - La Crosse Editors: Denis F Darko, MD, Director, Central Nervous System Clinical Research, Clinical Science, Green Hospital; 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: 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 INTRODUCTIONSection 2 of 8
  Like the word insanity, criminality is a legal term and is specifically not a medical or psychiatric diagnosis, illness, or syndrome. As defined in Webster's Dictionary, criminality has 2 meanings: "the quality or state of being a criminal; criminal activity." Webster's Dictionary 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 that violates the law. Criminality usually involves intent to commit a wrong or serious negligence; individuals who lack criminal intent or negligence, such as infants, are usually not convicted of crimes (although they can be held liable in civil courts of law). While this exoneration appears unfair at first blush, 2 common purposes of law are to deter and punish criminal behavior, neither of which is accomplished by punishing those without criminal intent. Mental illness further complicates matters because mental illness is frequently associated with criminality, yet it can also be a defense against criminality (eg, the insanity defense); again, it would not benefit society to deter and punish individuals who cannot be held responsible for their behavior. Different societies frequently have different customs, philosophies, and standards of behaviors, all of which form the basis for laws and law enforcement. 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 so treated. 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 based upon a given society, no surgical or medical interventions can treat it per se. However, mental illness can result in symptoms associated with and sometimes even leading to criminal activity. Because these symptoms can be treated, criminality in a sense can be indirectly treated. Almost any psychiatric symptom can be associated with criminality because symptoms can cause impaired judgment and directly or indirectly violate societal norms. For example, a depressed patient with insomnia may fall asleep while driving and kill a pedestrian, which could result 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 patients with mental illness are not violent. In fact, a recent study of patients with psychotic disorders found that they were responsible for only 5% of all violent crimes (Fazel, 2006). The eMedicine journal has further information on these disorders. Please click on the hyperlinks for further information. Psychiatric diagnoses associated with criminality Dementias Impulse Control Disorders Mood Disorders Personality Disorders, especially antisocial personality disorder Pervasive Developmental Disorder (autism) Psychotic Disorder, Not Otherwise Specified Substance Abuse Substance Dependence 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). People with such illnesses are not criminal 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 8
Antisocial personality disorder Estimated prevalence of this disorder in the general population is 3% of males and less than 1% of females. It is more common in impoverished, urban areas. By definition, individuals with antisocial personality disorder must be at least 18 years of age. In a review of 62 surveys, Fazel et al found that 47% of prison inmates were diagnosed with antisocial personality disorder (Fazel, 2002). 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. Women are more likely than men to be diagnosed with kleptomania. Often, a lag time of up to several decades passes between the onset of the behavior and an individual's presentation for treatment, usually in the context of contact with the criminal justice system. Women with this disorder enter treatment in the fourth decade of life, men in their sixth decade. Pyromania: This disorder is rare and more frequent 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 United States, according to strict diagnostic criteria, this disorder is rare. Males constitute 80% of the people with this disorder. 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 8
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. History of conduct disorder is present with onset when younger than 15 years. Unlike most personality disorders, individuals must be at least aged 18 years. They demonstrate a pervasive pattern of disregard for and violation of the rights of others, as indicated by at least 3 of the following:
Impulse control disorders
Paraphilias
Schizophrenia Media hype to the contrary, most patients with schizophrenia do not pose a risk of violence. However, one subgroup of people with schizophrenia does have 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. The current approach to schizophrenia treatment is multimodal, combining medications with psychological and social approaches. CAUSESSection 5 of 8
Most psychiatric disorders are syndromes, such that a specific cause is unknown. In accord with the biopsychosocial model of mental illness, a complex interaction between environment, heredity, personality, and biochemistry are thought to be involved with mental illness. Antisocial personality disorder Heredity and environment appear strongly associated with this 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 the one most relevant theory to criminology, because it includes the acquisition of criminal behavior patterns. Social learning theorists, especially Albert Bandura, argue that people are not born with the ability to act criminally but that they learn to be aggressive and commit crime through life experiences. Social learning theory believes that criminality is learned through modeling. Crime and aggression usually are modeled on 3 principal sources: family members, environmental experiences, and the mass 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. The literature suggests an association with reactive hypoglycemia or a decreased concentration of 3-methoxy-4-hydroxyphenylglycol and 5-hydroxyindoleacetic acid (5-HIAA) in the cerebrospinal fluid. In general, low levels of 5-HIAA is also associated with impulsivity (Cremniter, 1999). 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. An association with CNS dysfunction is apparent but does not imply causality. People with this disorder show abnormalities in neurological examination results, neuropsychological test results, and electroencephalogram results. Associations also have been made with attention deficit hyperactivity disorder or learning disability. Research also has implicated abnormalities in levels of neurotransmitters and hormones. Paraphilias: Few scientifically rigorous studies have been conducted 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 dysthymia, and phobias. A finding suggestive of a psychological basis is that individuals with paraphilias have difficulty forming more socialized sexual relationships. It also has been hypothesized that some types of paraphilia involve a conditioned response in which nonsexual objects become sexually arousing when paired with a pleasurable activity (eg, masturbating). TREATMENTSection 6 of 8
Antisocial personality disorder Little evidence exists that this disorder can be treated successfully with usual psychiatric interventions. Antisocial personality disorder is among the disorders most resistant to treatment because these individuals have ego-syntonic symptoms, deception as a hallmark symptom, and little incentive to change. Insight-oriented psychotherapy is contraindicated due to the risk of inducing acting-out behavior in these patients. Benzodiazepines are generally contraindicated due to the high frequency of substance abuse and drug diversion. Fortunately, 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 may help in some cases. Pharmacotherapy may be used to alleviate impulsivity and aggression. Treatment of comorbid conditions tends to be more successful, though less so as compared to 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. Atypical antipsychotics, selective serotonin reuptake inhibitors (SSRIs), and serotonin/norepinephrine reuptake inhibitors (SNRIs) are also efficacious as 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 atypical antipsychotics are efficacious. Psychotic disorders Atypical antipsychotics (eg, aripiprazole, olanzapine, quetiapine, risperidone) are the treatment of choice for psychotic disorders. Careful attention to side effects of elevated blood sugar, prolactin, and lipid levels and possibly tardive dyskinesia are important considerations. For noncompliant patients, a depot form of risperidone is available. First-generation antipsychotics are useful, particularly given the depot forms of haloperidol and fluphenazine. Haloperidol is the most frequently used antipsychotic in emergency departments and is relatively safe in the short term. Beta-blockers, valproic acid, and benzodiazepines are also reportedly effective in treating aggression in patients with schizophrenia. Substance abuse and dependence Acamprosate, naltrexone, atypical antipsychotics, valproate, topiramate, gamma-hydroxybutyric acid (GHB), and SSRIs (eg, citalopram, sertraline, fluoxetine) 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. 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 success is limited. Studies show greater efficacy with behavioral and cognitive-behavioral psychotherapies, particularly when practitioners integrate social skills training, problem solving, cognitive restructuring, and relapse prevention as a part of a comprehensive treatment plan. Alternatively, pharmacotherapy with SSRIs, such as escitalopram and fluvoxamine, is of benefit. 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. 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, has success. Antiandrogen 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 8
Confidentiality issues are important. Courts sometimes mandate psychiatric treatment for individuals as a condition of parole or probation; successful parole or probation requires regular contact with parole or probation officers. Because criminality is associated with harm toward others and recidivism, clinicians must continuously evaluate patients for dangerousness to self and others. Most jurisdictions require clinicians to protect or warn identifiable victims against patients, based upon California's Tarasoff decision. Other common laws require reports to the authorities of reasonable suspicion of child, elder, and dependent adult abuse. Some jurisdictions, such as San Francisco, mandate reports to the police of domestic violence. In short, it is important to become familiar with the laws of your community. Accordingly, documenting findings in the medical record for medicolegal reasons is important. Nonphysicians may try to pressure clinicians into making diagnoses where none exist. For example, clinicians should not diagnose mental illness just because a patient holds different cultural, religious, or political beliefs. Similarly, they should not automatically diagnose mental illness in people only because they have committed a criminal act. At the same time, physicians must be in a position to recognize and treat comorbid conditions, particularly substance abuse. REFERENCESSection 8 of 8
Psychiatric Illness Associated With Criminality excerpt Article Last Updated: Sep 14, 2006 |
