Dissociation: Defining the Concept in Criminal Forensic Psychiatry.

Claims of amnesia and dissociative experiences in association with a violent crime are not uncommon. Research has shown that dissociation is a risk factor for violence and is seen most often in crimes of extreme violence. The subject matter is most relevant to forensic psychiatry. Peritraumatic dissociation for instance, with or without a history of dissociative disorder, is quite frequently reported by offenders presenting for a forensic psychiatric examination. Dissociation or dissociative amnesia for serious offenses can have legal repercussions stemming from their relevance to the legal constructs of fitness to stand trial, criminal responsibility, and diminished capacity. The complexity in forensic psychiatric assessments often lies in the difficulty of connecting clinical symptomatology reported by violent offenders to a specific condition included in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This article provides a review of diagnostic considerations with regard to dissociation across the DSM nomenclature, with a focus on the main clinical constructs related to dissociation. Forensic implications are discussed, along with some guides for the forensic evaluator of offenders presenting with dissociation.

Reliability and validity of the DSM-IV-TR and proposed DSM-5 criteria for pedophilia: Implications for the ICD-11 and the next DSM.

We tested the inter-rater reliability and criterion-related validity of the DSM-IV-TR pedophilia diagnosis and proposed DSM-5 pedohebephilia diagnosis in a sample of 79 men who had committed child pornography offenses, contact sexual offenses against children, or who were referred because of concerns about whether they had a sexual interest in children. Participants were evaluated by two independent psychiatrists with an interview and questionnaire regarding demographic characteristics, sexual history, and self-reported sexual interests; they also completed phallometric and visual reaction time testing. Kappa was .59 for ever meeting DSM-IV-TR criteria for pedophilia and .52 for ever meeting the proposed DSM-5 criteria for pedohebephilia. Ever meeting DSM-IV-TR diagnosis was significantly related to self-reported index of sexual interest in children (highest AUC=.81, 95% CI=.70-.91, p<.001) and to indices of sexual interest in children from phallometric testing (AUC=.70; 95% CI=.52-.89; p<.05) or a computerized assessment based on visual reaction time and self-report (AUC=.75; 95% CI=.62-.88; p<.005). Ever meeting the proposed DSM-5 "diagnosis" was similarly related to self-report (AUC=.84, 95% CI=.74-.94, p<.001) and to the two objective indices, with AUCs of .69 (95% CI=.53-.85; p<.05) and .77 (95% CI=.64-.89; p<.001), respectively. Because the pDSM-5 criteria did not produce significantly better reliability or validity results and users are more familiar with the current DSM-5 criteria, we believe these results suggest the revision of DSM-5 and development of ICD-11 could benefit from drawing on the current DSM-5 criteria, which are essentially the same as DSM-IV-TR except for a distinction between having a paraphilia (the interest) and a paraphilic disorder (the paraphilia plus clinically significant distress or impairment).

Assessment of the paraphilias.

Paraphilias are recurrent, persistent, and intense sexual interests in atypical objects or activities. The most commonly encountered paraphilias in sexological or forensic settings are pedophilia, sexual sadism, exhibitionism, and voyeurism. Paraphilias are often comorbid with other sexual, mood, and personality disorders. Assessment and diagnosis require an integration of multiple sources of clinical information, given the limits and biases of self-report (through clinical interview or questionnaires). Clinicians ideally have access to more objective assessment methods, such as phallometric testing of sexual arousal. The accurate assessment and diagnosis of paraphilias is essential to effective treatment and management.

Sexual sadism in sexual offenders and sexually motivated homicide.

This article gives a clinically oriented overview of forensically relevant forms of sexual sadism disorder and its specific relationship to sexual homicide. In sexual homicide perpetrators, peculiar patterns of sexual sadism may be a motivational pathway to kill. Sexual sadism increases the risk for reoffending in sexual offenders. Through psychotherapy and pharmacological interventions, treatment of sadistic sex offenders has to consider special characteristics that may be different from those of nonsadistic sex offenders. Many of these offenders share a combination of sexual sadistic motives and an intact self-regulation, sometimes combined with a high level of sexual preoccupation.

Women who kill their mates.

Spousal homicide perpetrators are much more likely to be men than women. Accordingly, little research has focused on delineating characteristics of women who have committed spousal homicide. A retrospective clinical review of coroners' files containing all cases of spousal homicide occurring in Quebec over a 20-year period was carried out. A total of 276 spousal homicides occurred between 1991 and 2010, with 42 homicides by female spouses and 234 homicides by male spouses. Differences between homicides committed by female offenders and male offenders are discussed, and findings on spousal homicide committed by women are compared with those of previous studies. Findings regarding offenses perpetrated by females in the context of mental illness, domestic violence, and homicide-suicide are explored. The finding that only 28% of the female offenders in the Quebec sample had previously been subjected to violence by their victim is in contrast to the popular belief and reports that indicate that most female-perpetrated spousal homicide occurs in self-defense or in reaction to long-term abuse. In fact, women rarely gave a warning before killing their mates. Most did not suffer from a mental illness, although one-fifth were acutely intoxicated at the time of the killing. In the vast majority of cases of women who killed their mates, there were very few indicators that might have signaled the risk and helped predict the violent lethal behavior.

Familial paraphilia: a pilot study with the construction of genograms.

Biological factors are likely predisposing and modulating elements in sexually deviant behavior. The observation that paraphilic behavior tends to cluster in some families is intriguing and potentially raises questions as to whether shared genetic factors may play a role in the transmission of paraphilia. This pilot study introduces five families in which we found presence of paraphilia over generations. We constructed genograms on the basis of a standardized family history. Results document the aggregation of sexual deviations within the sample of families and support a clinical/phenomenological heterogeneity of sexual deviation. The concept of paraphilia in relation to phenotypic expressions and the likelihood of a spectrum of related disorders must be clarified before conclusions can be reached as to family aggregation of paraphilia based on biological factors.

Psychopathology and Suicide among Quebec Physicians: A Nested Case Control Study.

Objective. To describe a psychiatric profile and characteristics of physicians who killed themselves in Quebec between 1992 and 2009. Method. The cases of 36 physicians (7 females and 29 males) and 36 nonphysicians who committed suicide were matched for age and gender and examined in a nested case control design. All subjects were judged as definite suicide by the Quebec Coroner Head Office. Consensus regarding DSM-IV diagnoses was established by two forensic psychiatrists. Results. Rates of all Axis I diagnoses were 83% for physicians and 91% for nonphysicians at the time of suicide. Major depressive disorders were the most frequently observed pathology in both groups (61% and 56%, resp.). Conclusions. Physicians and nonphysicians who committed suicide in Quebec suffered from the same type of psychiatric disorder at the time of killing themselves. The findings advocate strongly for more efficient suicide prevention measures including early detection and treatment of mood disorders for the physicians.

Child pornography offenders detected by surveillance of the Internet and by other methods.

BACKGROUND: Availability of child pornography on the Internet has created new opportunities for offending. It has been noted that many people charged with offences relating to this had not previously been identified as sexual offenders against children. AIM: Our aim was to compare the characteristics of people charged with child pornography offences as a result of police monitoring of the Internet with those detected by other means. We hypothesised that those apprehended via the Internet would be more likely to be older and less likely to have severe psychiatric disorder or to have been previously charged with a sexual offence involving contact with a child than those identified by other means. METHODS: Data were extracted from the findings of clinical examinations by the authors either in the course of preparing reports for court, or in the course of providing treatment. RESULTS: There were 52 men detected by police Internet surveillance and 53 men detected by other means, the latter including 16 men who had not been charged with an offence at the time of referral. Those detected via the Internet were more likely to be in possession of very large quantities of child pornography. Those detected by other means were more likely to have major psychiatric and substance abuse disorders and to report childhood sexual abuse. A subgroup analysis of the 89 people who were facing charges at the time of the assessment found that the only significant differences were in the amount of material and the history of sexual abuse. CONCLUSIONS: The men recruited to this study, conducted over a period of nearly 10 years, reflect the changing nature of the technology used to commit this type of offence in that time. The characteristics of the subjects did not confirm the stereotype of an Internet child pornography offender who was high functioning and otherwise well adjusted and carried a low risk of other types of offences.

Homicide of strangers by people with a psychotic illness.

BACKGROUND: The homicide of strangers by people with psychosis, referred to here as "stranger homicides," are rare and tragic events that generate adverse publicity for mental health services and have resulted in significant changes in mental health policy and law. AIM: To estimate the incidence of stranger homicides, using data from previously published studies, and to compare the characteristics of psychotic offenders who killed strangers with the characteristics of those who killed a close relative. METHOD: Meta-analysis of the population-based studies of homicide by persons suffering from a psychosis in which the number of subjects who killed strangers was also reported. Characteristics of stranger homicide and family homicide offenders were examined in a multicenter case-control study of homicide during psychotic illness in four high-income countries. RESULTS: A pooled estimate of 1 stranger homicide per 14.3 million people per year (95% confidence interval, 1 in 18.9 million to 1 in 11.5 million people per year) was calculated by meta-analysis of 7 studies. The characteristics of the 42 stranger homicide offenders from New South Wales [NSW], Quebec and Eastern Ontario, Finland, and the Netherlands were identified. Twenty seven (64%) of these had never previously received treatment with antipsychotic medication. The stranger homicide offenders were more likely to be homeless, have exhibited antisocial conduct, and had fewer negative symptoms than those who killed family members. The victims of stranger homicide were mostly adult males and the homicides rarely occurred in the victim's home or workplace. CONCLUSIONS: Stranger homicide in psychosis is extremely rare and is even rarer for a patient who has received treatment with antipsychotic medication. A lack of distinguishing characteristics of stranger homicide offenders and an extremely low base rate of stranger-homicide suggests that risk assessment of patients known to have a psychotic illness will be of little assistance in the prevention of stranger homicides.

Domestic homicide and homicide-suicide: the older offender.

The importance of clarifying the features characteristic of older homicide offenders is highlighted by recent research that indicates an increase in rates of homicides followed by suicides of older perpetrators. In a retrospective study of data from coroners' files on domestic homicides involving individuals killed by an older spouse or family member (65+ years of age) over a 15-year period in Quebec, Canada, we identified several specific offender and victim characteristics and circumstances surrounding the offenses. The homicide was frequently followed by the suicide of the perpetrator. Several victims had pre-existing medical illnesses, indicating that the offenses may have been committed by individuals who were caregivers to chronically ill spouses. At the time of the offense, most of the perpetrators had a mental illness, usually depressive disorder, but few had received psychiatric help. The impact of mental illness on domestic homicide-suicide is indicated, underscoring the importance of identifying existing psychopathology.

Commentary: A response to Wortzel and Arciniegas about amnesia and crime.

The review by Wortzel and Arciniegas of the phenomenology and neuroanatomy of memory is a welcome complement to our psychiatric clinical perspective on the concept of amnesia in relation to crime. The authors raise their concerns in noting that certain concepts referred to in the literature are inconsistent with the phenomenology and neurobiology of memory. In response, we clarify the DSM-IV-TR nomenclature and provide information on current research exploring various mechanisms outlining memory impairment and other neurocognitive deficits in schizophrenia and other psychoses. In relation to amnesia and crime, the practice of forensic psychiatry requires the expert to be able to consider the validity of amnesia claims in criminal proceedings, translate scientific knowledge into a language accessible to the court, and provide an opinion. As such, a psychiatric clinical approach to the concept of amnesia in relation to crime provides a useful framework.

Amnesia and crime.

Amnesia for serious offenses has important legal implications, particularly regarding its relevance in the contexts of competency to stand trial and criminal responsibility. Forensic psychiatrists and other mental health professionals are often required to provide expert testimony regarding amnesia in defendants. However, the diagnosis of amnesia presents a challenge, as claims of memory impairment may stem from organic disease, dissociative amnesia, amnesia due to a psychotic episode, or malingered amnesia. We review the theoretical, clinical, and legal perspectives on amnesia in relation to crime and present relevant cases that demonstrate several types of crime-related amnesia and their legal repercussions. Consideration of the presenting clinical features of crime-related amnesia may enable a fuller understanding of the different types of amnesia and assist clinicians in the medico-legal assessment and diagnosis of the claimed memory impairment. The development of a profile of aspects characteristic of crime-related amnesia would build toward establishing guidelines for the assessment of amnesia in legal contexts.

Parricide: a comparative study of matricide versus patricide.

Between 1990 and 2005, 64 parents were killed by their children in the province of Quebec, Canada. The authors reviewed all consecutive coroners' files on these cases and found that 27 mothers and 37 fathers were the victims of parricide. The sample included 56 perpetrators: 52 sons and 4 daughters; 9 cases of double parricide were found. Approximately 15 percent of the perpetrators (8/56) attempted suicide following the parricide. A psychiatric motive (stemming from depression or psychotic illness) was determined for 65.5 percent (36/56) of the perpetrators, and 67 percent of them had a psychotic disorder. Similarities and differences were found between cases of matricide and patricide.

Dissociating medication effects from learning and practice effects in a neurocognitive study of schizophrenia: Olanzapine versus haloperidol.

OBJECTIVE: To contrast the effect of a typical antipsychotic (haloperidol) and an atypical antipsychotic (olanzapine) on neurocognitive functioning in schizophrenia when learning and practice (LP) effects are controlled. METHODS: Two groups of participants were recruited, 27 schizophrenia patients in their first 5 years of illness and 13 normal controls. Prior to double-blind randomisation, all subjects were assessed on four occasions within 5 days (prerandomisation period) on the same neurocognitive battery. Repeated assessment prior to randomisation was chosen as a method to control for LP effects. Patients were then randomised to 56 days of treatment with haloperidol or olanzapine (postrandomisation). All subjects were assessed on neurocognitive measures at Days 28 and 56. RESULTS: LP effects were present during the prerandomisation period on motor tasks, verbal and visual short-term memory, attention, and on a measure of verbal working memory. There were no changes in performance for patients randomised to treatment with olanzapine or haloperidol or the normal control group during the postrandomisation period. CONCLUSIONS: Once LP effects are controlled, olanzapine and haloperidol do not affect performance on measures of motor functioning, verbal short-term memory, attention, verbal working memory, reaction time, visuospatial short-term memory, and visual working memory beyond that observed from LP effects.

A review of maternal and paternal filicide.

Filicide, the murder of a child by a parent, is a multifaceted phenomenon with various causes and characteristics. This review of the existing literature delineates the present state of knowledge regarding filicide and illustrates similarities and differences between offenses perpetrated by mothers and by fathers. The importance of numerous reports of an association between filicide and parental pre-existing psychiatric disorders is compounded by indications that a significant number of homicidal parents come to the attention of psychiatrists or other health professionals before the offense occurs. As prevention implies the recognition of causes involved in particular situations, a better understanding of potentially fatal parental/familial dynamics leading to filicide could facilitate the identification of risk and enable effective intervention strategies.

Fratricide: a forensic psychiatric perspective.

Analyses of fratricide rates based on national homicide data have provided some general information pertaining to offenders and victims of sibling homicide but are limited by data constraints to examining a few major variables. Exploring fratricide from a forensic psychiatric perspective could uncover other related factors and provide insight into why some individuals murder their siblings. In a retrospective study of data from coroners' files on domestic homicide pertaining to individuals killed by their siblings over a 10-year period in Quebec, Canada, we identified several specific offender and victim characteristics and circumstances surrounding offenses. The impact of mental illness and substance abuse on fratricidal behavior is indicated, underscoring the importance of identifying existing psychopathology. From a forensic psychiatric perspective, we identify characteristic patterns and discuss potential dynamics operating in fratricide. We raise some issues relevant to treatment and prevention, including the fact that most cases are alcohol-related, impulsive, and unpredictable until the moment they occur.