Part 2 book “Forensic psychiatry - Clinical, legal and ethical issues” has contents: Deception, dissociation and malingering, addictions and dependencies - their association with offending, juvenile offenders and adolescent psychiatry, principles of treatment for the mentally disordered offender,… and other contents.
17 Deception, dissociation and malingering Edited, written and revised by John Gunn Written by John Gunn David Mawson Paul Mullen Peter Noble 1st edition edited by Paul Mullen I have done that – says my memory I could not have done that – says my pride; [the] end remains inexorable Eventually memory gives in (Nietzche, 1886) Deceptive mental mechanisms Deception occupies a central and privileged place in forensic psychiatry The founding fathers of the speciality, such as Haslam (1817a,b), Ray (1838) and East (1927), were all much concerned with the need to recognize fraudulent claims in the accused, the claimant and the conscripted serviceman, to potentially mitigating, compensable or exempting disorders The touchstone of the expert’s skill used to be in distinguishing between the genuine and the simulated Although this particular question has lost much of its urgency, what remains central are issues surrounding those, all too human, tendencies to deny, to lie to others, and to lose oneself in self-deception The tendency to modify our experiences of current reality by how we think rather than by what we do, and to interpret and edit memories of the past in pursuit of present needs is universal We try to escape the contingencies of reality by a variety of mechanisms, many wholly unconscious Substituting Available alternatives are sometimes substituted for those objects of our desire which appear beyond reach Pets may be substituted for people, especially children The displacement of desire, or aggression, on to a more available, or vulnerable object, is common In some claimants and litigants this mechanism can be at work The bereaved, deprived of their loved one, may displace their energy from the pursuit of the lost love on to the pursuit of compensation At first glance, their actions may appear venal and self-serving, but behind this appearance can lie a tragic attempt to restore an unbearable loss through pursuit of the substituted goal Daydreaming Daydreaming is the way in which we turn away from the daunting task of wresting the desired from reality, or from the conflicts inherent in current obligations, into a world of fantasy and make-believe In children, the world of private make-believe and public reality can merge and mix In some adults, the dividing line between the internal world of fantasy and the shared external world of consensual reality remains wavering and uncertain The French concept of mythomania, often treated as synonymous with pathological lying, captures this quality of being caught up in one’s own fantasies and imaginery adventures Lying Lying, or to use the minimally less pejorative and far broader term ‘deception’, is universal Advertisers ‘put a gloss’ on their products, companies fail to disclose the whole story, politicians distort, sportsmen break rules when they think they will not be detected, and we all deceive on occasions to obtain advantage or avoid embarrassment Lying may even be part of normal development and individuation (Ford et al., 1988) Hartshorne and May (1928) conducted a series of elegant experiments demonstrating the frequency of deceptive behaviour amongst youngsters Most authors agree that lying involves the consciousness of falsity, the intent to deceive, and a preconceived goal or purpose Normal prevarication is instrumental and, at least initially, the liar is aware of the deception In practice, the intentional lie merges into self-deception and we move, all too easily, from knowingly fabricating into believing our own stories 418 K17373.indb 418 3/31/14 6:17 PM Deceptive mental mechanisms In pathological lying (pseudologia fantastica; see below), there is created a tissue of fantastic lies in which the deception is not merely about matters of fact, but aims to create a whole new identity The lies, though they may begin as instrumental, in the sense of bringing pecuniary advantage or prestige, rapidly develop to a stage where they are disproportionate to any discernible end or personal gain Commonplace lies deceive about matters of fact, the fabrications of the pathological liar deceive about who and what s/he is; they are about creating a new identity and recreating the world Pseudologia fantastica is about lying, but it is also about fantasy run riot which involves self-deception as much as deceiving others Denial Denial of current reality is one way of coping with the disturbing and the threatening Denial differs from lying in that it is not an attempt to convince others, or oneself, of a different reality, but involves turning away from the unacceptable Clearly, denial involves deception and selfdeception, but lacks the intention to affirm a new and false reality In practice, denial often slips into fabrication Denial involves the claim that something did not occur or, if it did, the subject has no memory for the events Amnesia Amnesia is an inability to remember or a denial of memory Selective memory which leaves convenient blanks is a common enough indulgence, and is to be expected in those where forgetting may bring considerable advantage The distinctions and overlaps between so-called psychogenic amnesia and organic memory disturbances are considered later in this chapter and in chapter 12 Self-deception Self-deception is a concept presenting profound theoretical ambiguities, but is none the less potentially of wide applicability in psychiatry Many aspects of what we term unconscious, dissociative, hysterical, or even abnormal illness behaviour can, from a different perspective, be spoken of as types of self-deception The central paradox of self-deception was described by Fingarette (1969): For as deceiver one is insincere, guilty: whereas if genuinely deceived, one is the innocent victim Is then the self-deceiver both perpetrator and sufferer? The psychiatrist’s view of self-deception is often influenced by the Freudian vocabulary which articulates the phenomenon as one of helplessness in the grip of unconscious conflict, for the self-deceiver is spoken of as the victim of the compulsive force of the unconscious Self-deception is in part about how information is interpreted and what aspects are acknowledged but, more important, it is about self-presentation; it is about what we avow as our motivations and what we accept has been our behaviour The simplest model of self-deception is of holding two incompatible beliefs, one of which is not noticed or acknowledged Self-deception is not just persisting in beliefs in the face of contrary evidence, nor merely holding incompatible beliefs, for it implies an active engagement which strives to maintain ignorance The characteristics of self-deception as viewed from the vantage point of an observer include: activities which appear incompatible with the individual’s previous claims or behaviour; the refusal of the self-deceiver to give adequate (or at least acceptable) justifications for his or her activities; a refusal to accept responsibility for activities and their consequences which appears to stem not from disregard of those responsibilities, but from an inability to recognize the transgressions; an adherence to the deception which persists even when it becomes personally disadvantageous The latter two characteristics which speak of loss of selfcontrol tend to soften, or even remove, the moral condemnation of the self-deceiver What of the experience of self-deception for the self-deceiver? This is difficult to pin down Totally successful self-deception would presumably be experienced as having a conviction or desire no different from any other We assume that some discomfort and disequilibrium accompanies most self-deceptive engagements, which may be experienced as unease or a puzzlement at one’s own apparently disproportionate vehemence Self-deception covers a wide range of human activity It covers the exuberant, if shallow individuals, who commit themselves to a course of action in the enthusiasm of the moment, only to later disavow that commitment It includes the envious, who undermine and damage those around them under the guise of friendship, apparently in ignorance of their own motives It includes those who convince themselves of their own illness and disability It includes most of us as we try and impose coherence and create a flattering tale out of our past and present activities Occasionally, it is possible to see self-deception emerging A young man who had strangled his girlfriend was examined a matter of a few hours after the event He gave, at that time, an account of the killing marked by great distress and genuine perplexity about how he came to commit such an act A few days later he claimed to have only the vaguest memories of the event leading up to the killing and none for the act itself A week or so later, a story began gradually to emerge as he ‘remembered’ what had really happened and the provocations which had occasioned the act The following month, he gave a clear account of 419 K17373.indb 419 3/31/14 6:17 PM Deception, dissociation and malingering intolerable provocation which culminated in his loss of control and which ‘must have led to the killing’, although he said he could not recall committing the deed Somewhere in that progression, self-deception must have played a part but, by the time this man went to trial, he seemed to honestly believe his own account of the events, and certainly he was filled with a genuine sense of grievance and injustice when his defence foundered Self-deception involves the editing and reorganization of memory to serve the needs of current imperatives In fact, such restructuring of memory is to some degree a normal process which is going on constantly The view of human memory as analogous to a massive filing system or the hard disk of a computer, which assuming you employ the correct access codes calls up exactly what was filed away, is increasingly coming under critical scrutiny Memory is, at least in part, a functional and selective system which is constantly evolving and adapting to current needs (Rosenfield, 1988) In a mundane way, we all re-write our own histories so as to ease the disjunctions between our present attitudes and positions and our past actions and views Self-deception is essential to righteousness, or any other form of pomposity Equally, it plays a prominent role in creating and maintaining some of our patients’ difficulties Pathological falsification Confabulation Confabulation is the falsification of memory occurring in clear consciousness in association with an organically derived amnesia (Berlyne, 1972) On occasion, it is the fabricating of false statements by someone with impaired memory in order to cover his or her embarrassment at forgetting It is typically encountered in amnesic disorders when the patients lack insight into their impairment and, therefore, would be incapable of constructing falsifications to cover a deficit which they were unaware existed Bonhoeffer (1904) distinguished between ‘momentary’ confabulation, where the patient, when asked specifically about recent events, responds by recounting more distant unrelated memories and ‘fantastic’ confabulations which involved spontaneous creations, often grandiose or absurd The fantastic, or spontaneous, confabulations tend to be associated with amnesias in which there is associated frontal lobe dysfunction, whereas the provoked, or momentary confabulations, are the result of an attempt to respond to specific enquiries in those with a defective memory It is found in amnesic patients and, to a lesser extent, in normal subjects whose memory fails them for some reason (Kopelman, 1987a) It is not a form of intentional deception This chapter is concerned with a variety of conditions, disparate in many ways, but in which deception, both of others and the self, plays a part The introduction was intended to emphasize the extent to which there is a continuum between the experiences and activities of us all and the disorders to be described Deception is, however, a term redolent of judgment and rejection Here the emphasis is on the recognition of distress and disorder, so that it can be treated, rather than identifying deceptions in order to confound or condemn them Lying Lying, as has been noted, is a frequent, universal, human activity It needs to be distinguished from confabulation which does not include any intent to deceive Lying is so ubiquitous that it must have many different functions, for example in social parlance we distinguish between ‘white’ lies and other types such as ‘barefaced’ White lies may be to assist someone else for example giving them reassurance or unwarranted praise The lie that is most frowned upon is of course the lie to gain dishonest advantage or to escape from the consequences of one’s actions There is a large industry in the criminal justice world of trying to tell whether a witness or a potential perpetrator is telling the truth or not This arises from the somewhat mistaken notion that the best witness to an event is the central participant who will be able to explain what they saw or did to other people Many police officers see their central role in detective work as getting a guilty person to ‘cough’ or ‘confess’ More sophisticated police officers and others involved in crime detection know that uncorroborated confessions are poor evidence Yet the belief that somehow, in some way ‘science’ will enable the liar to be unmasked, dies very hard indeed It is possible to find at least 10 ways of attempting to detect lies with various forms of technology These include the polygraph, the fMRI scanner, the voice stress test, and others Most of the techniques are trying to detect a rise in arousal and anxiety when the subject is being questioned or interviewed This is based on the premise that all lying is accompanied by anxiety Most of us can subjectively refute this notion and indeed the research results from the various instruments are disappointing if they are to be the centrepiece of, for example, a criminal investigation None of the results from this type of technology are allowed in British courts An exception to the arousal theory is the attempt to detect lying by using the fMRI scanner Initial research suggested that the act of lying produces more prefrontal cortex activity than telling the truth does However some sophisticated transAtlantic collaborative research has found that subjects can beat the scanning test by simple distracting countermeasures, presumably to deflect their concentration, when they are lying (Ganis et al., 2011) The authors conclude that this renders the otherwise attractive lie detector as vulnerable in ‘real world situations’ In fact the accuracy dropped from 100% to 33% if the subject applied countermeasures; a fairly stark warning to the overenthusiastic technological interrogator 420 K17373.indb 420 3/31/14 6:17 PM Pathological falsification The basis of this work lies in experiments conducted by Spence and others (e.g Spence et al., 2004; Spence 2005; Spence et al., 2008) These showed that deception is an executive task; it elicits greater activation of the prefrontal regions and also incurs a processing cost, manifest in longer response times A scholarly account of what lies are about and how to detect them is given by Vrij (2008) who goes on to discuss ways in which training can assist in the difficult task of detecting lies At the end of his book he lists 24 studies giving an indication of how far training can help By and large the studies show that observers are only about 50% accurate in detecting lies (i.e not much better than guessing) but this can be improved by training sessions, in one remarkable example raising the detection rate from 54% to 69% However he concludes: In this book I reported that several researchers have claimed to have developed techniques that discriminates between truths and lies with very high accuracy My advice to them is to keep their feet firmly on the ground In my view no tool is infallible Our view remains that would-be lie detectors, for example police officers, will be better employed in trying to get evidence by other means, even though no criminal investigation would be complete without talking to the alleged offender The dangers of using neuroscience results as evidence of crime are perhaps best shown in India Angela Saini (2009), a web journalist wrote of the case of a woman tried for murder in June 2008 She headed the article ‘The Brain Police: Judging Murder With an MRI.’ However the article says that the accused had an ‘EEG’ brain scan To Judge Shalini Phansalkar-Joshi, sentencing her last June to life in prison, Sharma’s electro-encephalogram left no doubt: the brain scan revealed ‘experiential knowledge’ which proved that she had to be the killer Her exfiancé Udit Bharati, a 24-year-old fellow student at Pune’s Indian Institute of Modern Management, had been found dead after eating sweets laced with arsenic… As the judge saw it, the proof was in the science Sharma had manifested an undeniable ‘neuro experiential knowledge’ of the crime – which the brain could acquire only through direct experience – when she had undergone a brain scan in Mumbai a year earlier… A tape played a voice reading a series of statements in Hindi, each detailing an aspect of the murder as the investigators understood it Sharma said nothing as the EEG machine measured her brain activity For a while, the statements elicited no detectable EEG response Then she heard: ‘I had an affair with Udit.’ A section of her brain previously dormant registered a brightly coloured response on the EEG More statements followed and the voice on the tape each time elicited similar EEG responses: ‘I got arsenic from the shop.’ ‘I called Udit.’ ‘I gave him the sweets mixed with arsenic.’ ‘The sweets killed Udit.’ Throughout the test, she did not say a word She didn’t have to As each statement was read, the EEG machine measured the frequencies of the electrical signals from the surface of her scalp and fed them through a set of rainbow-coloured wires into the room next door Here a computer, almost five feet tall, performed a set of calculations and spat out its conclusion in red letters on to its screen: ‘Experiential knowledge’ This meant knowledge of planning the murder, of getting the sweets, of buying the arsenic and of calling Bharati and arranging the fatal meeting Guilty Evidence from the scan took up almost ten pages of the judge’s ruling when a year later, on 12 June 2008, he jailed Sharma for life – making her the first person in the world reported to be convicted of murder based on evidence that included a brain scan ‘I am innocent and have not committed any crime,’ she implored Phansalkar-Joshi… But science had spoken: and in the six months that followed, the same lab would provide evidence that convicted two more people of murder Neuro-imaging as truth teller had come of age It is important that we not get bemused by new technologies No doubt they will find a niche, but let us hope that they not become used extensively until they can be shown to produce valid evidence That day is a long way off and in the meantime we should heed careful studies such as the one quoted above by Ganis et al Pseudologia fantastica (pathological lying) A group of disorders have been reported which involve fantastic lies that are developed into complex systems of deception The terms employed for this condition include pseudologia fantastica, mythomania and pathological liars (Delbrueck, 1891; Dupré, 1905, 1925; Healy and Healy, 1915; King and Ford, 1988; Myslobodsky, 1997) The following are the clinical characteristics: Extensive and gross fabrications The content and extent of the lies are disproportionate to any discernible end or personal advantage The lies deceive not just about matters of fact, but attempt to create a new and false identity for the liar The subject appears to become caught up in his or her own fabrications which take on a life of their own in which the subject seems eventually to believe The lying is a central and persistent feature of the patient’s life and the mythologism of a lifetime comes to supplant valid memories When pathological liars are enmeshed in their fabric of lies, the degree of self-deception may make it difficult to distinguish them from patients in the grip of a delusional system Kraepelin (1896) included some patients with systematized delusions under pseudologia fantastica and Krafft Ebing (1886) used the term ‘inventive paranoia’ for both pathological liars and deluded subjects Most writers, 421 K17373.indb 421 3/31/14 6:17 PM Deception, dissociation and malingering however, excluded deluded or otherwise psychotic subjects (e.g Healy and Healy, 1915) Closely related conditions are Munchausen’s syndrome (Asher, 1951) and feigned bereavement (Snowdon et al., 1978) Two clinical examples may help illustrate this disorder: A patient was brought to the outpatient department by his landlady who was concerned with his increasing depression which she feared might lead him to harm himself She explained that he was now living in much reduced circumstances, having suffered major financial losses and the desertion of his erstwhile friends It became clear that he had been living rent free for some considerable time, and the landlady was providing all his meals and a regular supply of pipe tobacco, to say nothing of comfort and support The patient was a well-dressed man in his early 60s, who wore tinted spectacles and assumed an air of profound sadness He was induced to give his history despite several claims that he did not want to go over the past The personal history provided was of humble origins from which he escaped via a university scholarship He claimed to have left university prematurely to join the government forces fighting in Spain At the end of the Spanish civil war, he reported a brief period in Rhodesia before joining the British army during the Second World War A distinguished army career was followed by a period working in the United Nations The tale continued with a series of great successes followed by undeserved disasters until he reached his present homeless, lonely plight The stories had plausibility and a wealth of detail Suspicions as to their authenticity were raised by the remarkable similarity of some aspects of his account to the memoirs of such figures as Orwell and Wingate Over subsequent months, it emerged that the patient had lived most of his life in London, he had never been in the army, far from being unmarried he had been married on a number of occasions and his reported childlessness ignored a number of offspring Following the exposure of his identity, the patient disappeared, but was encountered some years later having created for himself a new persona and an equally dedicated supporter in the form of another middle-aged lady sponsoring the ageing and misunderstood artist At a second encounter, he greeted his doctor with apparent pleasure and without a blush, or any visible unease, told of his new circumstances He did not seem to be concerned about, or even aware of, the possibility that his new identity might be threatened He believed in himself, or at least he evinced no insecurity The second case was admitted from prison where he was said to have become depressed and suicidal He was a small young man who, though in his early 20s, could have passed for 12 or 13 years of age He gave an account of having been raped in prison with the connivance of a number of prison officers He had made these allegations previously, and they had been extensively investigated without any basis having been found He gave a history of having been seduced in his early teens by the mother of a school friend, and described a number of romantic adventures prior to his arrest on arson charges Other aspects of his history included a graphic account of child abuse, remarkable academic and artistic success, cut short by circumstance, and a period of army service This young man attempted to create by his stories an identity characterized by remarkable talents and charm, but a personal history replete with disadvantage and tragedy Misunderstood, abused, cheated and victimized, nevertheless, he struggled to realize his potential Different stories were given to different members of staff and even more dramatic discrepancies emerged between his self-presentation to other patients and that to the staff During his time on the unit, his use of mimesis became obvious He latched on to a patient and later a staff member whom he found admirable and began not only to talk like his new-found models, but tried to present himself in an identical manner He even borrowed aspects of the personal histories of these two admired individuals, and presented them as his own Schneider (1959) regarded this group of patients as attention-seeking individuals who love to boast about themselves, and invent or act out fairy tales of self-aggrandizement He noted that the true pathological liar begins as a story teller, but becomes so caught up in his/her fabrications that ‘they forsake actuality and finish up on the stage of their own mind.’ Kraupl-Taylor (1979) took a similar view describing the stories as hysterical confabulations He believed that recent reminiscences are temporarily replaced by hallucinated reminiscences, which are true memories to the patient, at least for a time Kraupl-Taylor emphasized the negative or disadvantageous aspects of this behaviour Whilst the pathological liar has the gratification of an occasional audience that is impressed, this pleasure is short-lived, only to be followed by the humiliation of being treated as a liar Such patients are soon generally disbelieved, and they may be teased mercilessly Such behaviour does merge into more externally goal-oriented deception Pathological lying is usually encountered in forensic practice in those accused of fraud, swindling, making false accusations or false confessions (Powell et al., 1983; Sharrock and Cresswell, 1989) Once the counterfeit is exposed, the pathological liar will often give up his deceptions and readily confess, sometimes to offences in which he was not involved, thus beginning a new cycle of attention-seeking mythologies in the very act of acknowledging the previous deceptions The frauds and swindles perpetrated by the pathological liar usually form part of an attempt to create a false identify Such frauds are often flamboyant and have little in common with the furtive and carefully planned dishonesty of the more typical 422 K17373.indb 422 3/31/14 6:17 PM Pathological falsification fraud Pathological liars are closer to confidence tricksters, though unlike them, they not take the money and run, but persist in the pretence long after exposure is inevitable Their lies are rarely aimed at excusing or exculpating their offences, but more frequently, at attracting notice and inflating their importance After reviewing 72 published cases King and Ford (1988) suggested that the sex distribution of cases is approximately equal and the age of onset is usually adolescence Forty per cent of the cases they reviewed had a history of some central nervous system abnormality, such as an abnormal EEG, a history of head trauma, or CNS infection Twenty-five per cent of the men had epilepsy Other notable problems were criminality, psychiatric hospitalization, suicide attempts and a family history of psychiatric illness King and Ford suggest that when disease simulation (Munchhausen syndrome, about a quarter of the cases) or impersonation of another person occurs it is the pseudologia fantastica which is the primary disorder King and Ford concluded their review by saying ‘ Further research in this clinical area, particularly of the neurophysiologic correlates, is sorely needed.’ That remains the position; no further research on this topic has been conducted An interesting further case has been published (Birch et al., 2006) The woman in this case showed an interesting extra feature in that she was able to get other people, intimates, to corroborate her fictional stories This characteristic is rare but has been reported before (Healy and Healy, 1915; Weston, 1996) It has also, apparently, been labelled by Helene Deutsch in a German paper as ‘pseudologie deux’ or ‘shared daydreams’ (quoted in Birch et al., 2006) Enoch and Ball (2001) sub-classified pathological lying into four types: The professional impersonator who pretends to be a doctor, a priest, a lawyer The swindler who pretends to be wealthy and/or an important business man An outraged woman who alleges a fictitious sexual assault A false confessor who claims to have committed a serious crime To this list we would add the common fantasist, common because the condition occurs more frequently than the others and s/he tells a whole series of apparently pointless tall stories set in a context of ordinariness The common fantasist is not particularly dangerous, but the other types can produce serious consequences including bodily harm Management is extremely difficult Even when prosecuted the fantastic tales may not subside The best that can be offered is support and detailed discussion in an attempt to provide some insight and help induce some self-control, but these efforts often fail Abnormal Illness Behaviour Parsons (1951) regarded illness and health as socially institutionalized roles A sick person’s role is legitimated and allowed by its undesirability and the need to co-operate with others to get well While in the sick role, normal obligations are suspended and responsibilities are reduced, but the role might not be granted unless adequate evidence of disease were available Mechanic (1962) described ‘illness behaviour’ which referred to the ways in which symptoms may be differentially perceived, evaluated and acted (or not acted) upon by different kinds of persons Later, Mechanic (1986) emphasized that in his view illness and illness experience are shaped by socio-cultural and socio-psychological factors, irrespective of their genetic, physiological and other biological bases Away from the research laboratory illness is often used to achieve a variety of social and personal objectives, having little to with biological systems or the pathogenesis of disease He went on to ask himself: Why 50% of patients entering medical care have symptoms and complaints that not fit the International Classification of Diseases? Why are rates of depression and the use of medication relatively high among women, whereas alcoholism, hard drug use and violence are particularly common among men? Why among the Chinese are affective expressions of depression uncommon, but somatic symptoms relatively frequent? Why are rates of suicide among young black people in the USA relatively low, but rates of homicide high? Rather than attempting answers to such questions, he urged us to look beyond individuals to their social environment He pointed out that the nineteenth-century phenomenon of female hysteria has all but disappeared in the west, perhaps due to a change in social response to the characteristic symptoms Illness behaviour is more than a psychological response among persons faced with a situation calling for assessment It arises in response to troubling social situations, and may serve as an effective means of achieving release from social expectations, as an excuse for failure, or as a way of obtaining variety of privileges, including monetary compensation A complaint of illness is one way in our society of obtaining reassurance and support Pilowski (1969) proposed ‘abnormal illness behaviour’ as a subcategory of illness behaviour for those patients who have physical symptoms for which no organic explanation can be found This is a useful extension of the concept of illness behaviour, even though it is not clear why it should be confined to physical symptoms and organic disease The forensic psychiatrist may be called to see a number of conditions which in some ways can be regarded as variants of malingering, but which can also be regarded as gross abnormalities of illness behaviour, abnormalities of such a degree that instead of eliciting 423 K17373.indb 423 3/31/14 6:17 PM Deception, dissociation and malingering support and sympathy, they produce rejection and anger on the part of doctors, which are sometimes coupled with frankly punitive responses Dissociative disorders Dissociation Dissociation is a commonly described mental mechanism It implies separation and splitting It often means that one part of the mind is paying no attention to another or is unaware of it It can be induced by hypnosis For example Charcot, the nineteenth-century ‘king of hysteria’, hypnotized one of his female patients (all his patients were female) and suggested to her that she was two people Each side of her was to have a different boyfriend She was introduced to these two men as she lay on a couch and she would allow each to caress his specified side of her body, but if his hand ventured to the other side she would angrily turn it away The idea of splitting and separation so that parts of an individual’s body are dysfunctional and out of touch with other parts, and parts of the individual’s mind, including their memory, are separated from other parts, lies underneath many of the topics discussed in this chapter Psychogenic non-epileptic seizures can be, at least in part, understood in this way and are sometimes called dissociative seizures A remarkable philosophical treatise has been written on the subject, not by psychiatrists but by a philosopher, Ian Hacking (1995) in a book entitled Rewriting the Soul He draws together many different threads and implants the topic in its history Dissociative phenomena have been observed from ancient times but the manifestation of these phenomena changes and so does the naming For example Hacking suggests that the hysteria of Charcot which captivated the whole of France in the nineteenth century, turning his kind of neurology into a public spectacle didn’t just disappear at the beginning of the twentieth century, as many people believe, but it changed into other forms Hacking suggests that in the United States it became multiple personality disorder A full discussion about dissociative disorders does not belong in a textbook of forensic psychiatry and they will therefore be dealt with briefly They are mentioned at all because of their relevance to simulation and malingering which may come to the attention of the forensic psychiatrist who undertakes medico-legal compensation work They also have some relevance to the broader subject of dishonesty and require a textbook in their own right To set the subject in context it is worth briefly considering the history of hysteria, for hundreds of years an important disorder, particularly in women, which is now disappeared from the psychiatric lexicon, although it is almost certainly just transmuted into other disorders The term hysteria obviously implies something to with the uterus and it was originally thought to be a disorder which affected women exclusively and was caused by a wandering uterus The term is still used colloquially to mean emotional excesses and loss of self-control probably related to panic Charcot used to give his public demonstrations at the famous Paris hospital, Salpêtrière He described the course of the illness in these terms: A little girl about seven years old begins to cough and goes on coughing for two months without any known cause An experienced physician recognizes at once that he has not to deal with a case of bronchitis but one of hysteria Then the little girl is all at once affected with a stiff neck… Hysterical torticollis is made out … The child’s leg becomes stiff and painful This is hysteric contracture… Things go along pretty smoothly till menstruation Then the child begins to get peculiar – to have curious ideas She is alternately sad or cheerful to excess Then, one day she utters a cry, falls to the ground, and presents all the symptoms of an attack of hystero-epilepsy She begins to assume various postures, to speak of fantastic animals, to mention words which are neither suitable to her age nor to her position in society.1 Charcot unhooked hysteria from the uterus and from the demonic possession theories that also abounded He described it as an inherited neurological disorder, neither madness nor malingering (Hustvedt, 2011) The patients may suffer from anaesthesia, hypersensitivity, anorexia, bulimia, constipation, diarrhoea, excessive urination, retention of urine, depressed intellectual functions, heightened intellectual functions, insomnia, attacks of sleep, and violent seizures, said Bournville, a disciple of Charcot’s; in other words contrasting bodily symptoms which vary and fluctuate Charcot himself described ‘grand hysteria’ characterized by episodic convulsions in four phases First, the epileptoid phase of tonic and clonic seizures, preceded by an aura, just as in epilepsy Second, grand movements or clownism simulated the contortions and acrobatics of circus performers The third phase of ‘passionate poses’ was when the patient acted out emotional states such as terror, ecstasy, and amorous supplication, all ending in the final and fourth stage of delirium This material comes from a remarkable book on Charcot, his life and work and the story of three of his patients by Asti Hustvedt (2011) This history gives many clues to the disorders which at the beginning of the twenty-first century we call dissociative disorders The twentieth century saw the disease of hysteria transmuted into other conditions such as shellshock which reinforced the notion that the symptoms This quote is taken from Hustvedt (2011) who is quoting Charcot’s paper ‘De l’influénce des lesions traumatiques sur le développement des phénomènes d’hystérie locale,’ in Progrès Médical, May 4, 1878, cited in Goetz, Bonduelle, and Gelfand, Charcot, p.173 424 K17373.indb 424 3/31/14 6:17 PM Dissociative disorders arise from stress and trauma By 2000 the nomenclature of these disorders was crystallized into perhaps six types of dissociation: depersonalization disorder in which an individual feels detached from his or her surroundings and may feel outside of the body; psychogenic non-epilepetic seizures (see below); dissociative amnesia (see below); fugue (see below); dissociative identity disorder, sometimes known as multiple personality disorder (see below); and possession states This list is not exhaustive of dissociative phenomena, symptoms change with time and place and often overlap, Stengel (1941) included, in his series of fugue cases, a case which could also be considered a case of multiple personality disorder One of Burt’s (1923) cases of pathological lying has subsequently appeared in the literature as illustrative of typical multiple personality (McKellar, 1979) It is the core of dissociation which is important to understand if treatment is to be provided Psychogenic Non-epileptic Seizures In our first edition we had a section on ‘pseudo-epileptic seizures’ Like other dissociative disorders the name has changed At one time many neurologists and psychiatrists assumed that non-epileptic seizures were simulated or malingered It is interesting that Charcot thought they were always genuine Modern thinking has moved nearer to Charcot than was the case in the mid-twentieth century Undoubtedly some non-epileptic seizures will be consciously simulated in order to gain something, perhaps attention, perhaps some compensation, perhaps a reason to be excused duties However, the topic of non-epileptic seizures illustrates as clearly as any how difficult it is to discern underlying motive and distinguish it from distress and organic pathology which justifies medical intervention Indeed it is possible to argue that even if the seizures are consciously contrived with an object in view, they are still an important flag-waving phenomenon which requires skilled intervention A good review of this topic is given by Benbadis (2005) in Wyllie’s textbook on the treatment of epilepsy Benbadis divides non-epilepetic seizures into three groups: somatoform disorders, factitious disorders and malingering Somatoform disorders are physical symptoms caused by unconscious psychological factors In turn somatoform disorders can be subdivided into conversion disorders and somatization disorders, but the nomenclature is now becoming esoteric and unhelpful Similarly the distinction between factitious disorders and malingering is arcane and boils down to whether the patient is to be treated as such or rejected as a fraud These distinctions are extremely difficult if not impossible to make clearly, and the only time that malingering can be considered a certainty is when clear evidence is available of some sort of conscious intervention to produce the fit Even then mistakes are made One of us has a vivid memory of a patient who used to fold his glasses away carefully, take out his hearing aid and lie on the floor before having his seizure Many thought he was a fraud, but investigation showed that he was not having a non-epileptic seizure, but an epileptic one, and he was preparing himself for the seizure during a fairly long aura The diagnosis of epilepsy as opposed to a non-epileptic seizure is based on careful observation, especially of the electroencephalogram, which ought, if there is any doubt, to be a continuous recording over several hours and whilst ambulant The features of non-epileptic seizure include attempted restraint of the convulsive movements leads to struggling, even combativeness; absence of cyanosis; normal pupil responses and corneal reflexes present; pressure on the supraorbital arch causes head withdrawal; the level of consciousness fluctuates during the seizure; marked emotionality after the episode Such seizures can be preceded by auras involving somatic or visual symptoms and headache Unlike true epilepsy, in which the onset is usually abrupt, the non-epileptic seizure may be gradual in onset Such seizures rarely result in injuries either from falls or biting of the tongue It should be remembered that epilepsy is more often misconstrued as a psychogenic seizure than the other way round Fully deliberately simulated seizures are rare All psychogenic seizures, even if they are considered to be factitious should be treated by attention to any underlying mood disturbance or other psychological problem, and fairly prolonged psychotherapy in order to unravel the driving force behind the seizures, whether that force is conscious or unconscious, so it may be faced and attended to psychotherapeutically or practically Nevertheless it is well to remember that well-established, long-standing, non-epileptic seizures are difficult to treat and have a poor prognosis Dissociative or Psychogenic Amnesia As we have seen in chapter 12, amnesia is a complex symptom Distinguishing between genuine and feigned amnesia may be difficult Those charged with homicide offences are particularly likely to claim amnesia (Taylor and Kopelman, 1984) However, Pyszora et al (in preparation) in a 3-year follow-up study, suspected that 10% of a sample of men on remand in custody claimed amnesia for the alleged offence, a finding only elicited in those charged with offences of violence Within the amnesic group, nearly half were charged with murder Only five of 59 amnesic offenders were suspected of feigning; the others were thought to have this dissociative amnesia (see also chapter 12) 425 K17373.indb 425 3/31/14 6:17 PM Deception, dissociation and malingering Lishman (1998) has suggested that the traditionally rigid distinction between psychogenic and organic memory disturbance may be an artificial one Pathophysiology of some kind accompanies psychogenic amnesia, just as a psychological basis underlies the influence of emotion and motive in normal forgetting Clinically, psychogenic amnesia is either global and dense or more circumscribed Global amnesia may occur for long periods of life The amnesia may cover emotionally important events or issues, such as a violent outburst Normal ability to learn new facts, but severe problems or recall of past events hints at psychogenic amnesia A total inability to retain new information, even briefly, also favours the psychogenic form The classic case of alleged malingered amnesia (Podola), is dealt with in chapter We will never know whether it was malingered or not as he was executed The case demonstrates that it is not critical to a murder trial that the defendant remembers what happened Whether malingered or dissociative, forgetting is almost certainly a means of coping with appalling guilt and shame The amnesia becomes a problem when somebody has been convicted of a killing and still cannot remember what happened and so is able to participate in psychotherapy in a limited way The first aim of psychotherapy, and it may take a long time, is to get the person concerned to retrieve some memory of the events in question This is a long supportive process requiring much patience and continuity of psychotherapist One of the interesting issues which may occur in that process, if it is successful, is that the patient may say, after s/he has recovered their memory, that they were simply lying and were in fact able to remember all along Another dissociative mechanism in action perhaps? Certainly it illustrates the vague borderland between unconscious repression of thoughts and dissimulation Multiple Personality Disorder Multiple personality has been described as: The presence in one patient of two or more personalities each of which is so well defined as to have a relatively coordinated, rich, unified, and stable mental life of its own (Taylor and Martin, 1944) These differing personality systems tend to lose communication with each other and amnesic barriers commonly divide and prevent integration between them (Hilgard, 1977) Before the eighteenth century, cases which may attract the label multiple personality disorder now would probably have been regarded as possession states Cases of dual or multiple personality were reported in the scientific literature from the late eighteenth century onward and, by the end of the nineteenth, they had become a popular theme for philosophers, psychiatrists and novelists (Ellenberger, 1970; McKellar, 1979) Robert Louis Stevenson’s (1886) Strange Case of Dr Jekyll and Mr Hyde is a celebrated literary example Prince’s (1906) account of the case of Christine Beauchamp and her three personalities and James’s (1890) account of Ansel Bourne, led to considerable interest in the topic, particularly in America In the 1950s, multiple personalities re-emerged from the pages of old textbooks A surge of reports, both in the popular and scientific literature, followed publication of Thigpen and Cleckley’s (1957) case of Eve and her three faces This is a fictionalized account of a real case and the woman concerned has written two books giving her own account of her illness (Sizemore, 1977 and 1989) The film was popular, and may have had a role in the large number of cases that subsequently appeared in the USA (Boor, 1982) The books written by the patient may give a clearer insight into what it feels like to be in this situation The central clinical feature is the existence within the individual of two or more distinct personalities The recognition of this extraordinary state of affairs may be complicated by the primary personality being unable to provide any account of the alter egos which are hidden behind a barrier of amnesia A number of diagnostic signs have been described to assist the clinician (Greaves, 1980) The patient may report time distortions or unexplained memory lapses for the period when the other personality is in residence Accounts may be provided by independent observers of discrepant behaviour patterns and patients calling themselves by different names Writings, drawings, or other artefacts by patients may be discovered which they have no memory of producing Other features include headaches, deep sleeps, employing ‘we’ rather than ‘I’, and pseudo-hallucinations The condition is said to begin in childhood or adolescence, often in the context of abuse, neglect, or trauma (Congdon and Abels, 1983) Histrionic personality disorder, other dissociative states, superior intellect and high hypnotizability, are all claimed to be associated with multiple personality disorder The origins of multiple personality have been hypothesized to lie in repeated dissociations These patients are peculiarly prone to dissociative states in response to stress They defend against fear, anxiety and depression by either denying that it is happening to them or escaping into the new personality (Ludwig et al., 1972; Spiegel, 1984) These repeated dissociations are said to produce a separate store of memories which ultimately lead to different chains of integrated memories with groups of specific behaviours that can be separated by impermeable barriers (Braun, 1984) William James put this more elegantly: Alternating personality in its simplest phases seems based on lapse of memory… any man becomes, as we say, inconsistent with himself if he forgets his engagements, pledges, knowledge and habits, and it is merely a question of degree at which point we shall say that his personality is changed (James, 1890) 426 K17373.indb 426 3/31/14 6:17 PM Dissociative disorders The authenticity of multiple personality as a clinical entity has been repeatedly questioned, although its advocates, such as Greaves (1980), considered its existence to be demonstrated beyond reasonable doubt He claimed that its infrequency in some services reflects not rarity, but clinical oversight on the part of those who cannot, or will not recognize the condition This presumably means everywhere outside of North America, with the possible exception of the Netherlands British scepticism was outlined by Fahy (1988) in a review which plotted the rise of interest in the disorder in the twentieth century He was critical of the vagueness of the diagnostic criteria which use the word ‘personality’ All disorders which use the word ‘personality’ in their criteria are necessarily vague, as the concept of personality is complex, subjective, and very difficult to measure He described the disorder as an hysterical symptom; this term was still fairly widespread in the 1980s and fitted with the Hacking view given above Fahy was taken to task by a correspondent (Fleming 1989) who said that he believed the condition exists! A beautiful example of reification What is difficult when dealing with dissociations in any form is to understand what the symptoms/syndrome represent to the patient It is probably a culture bound syndrome wrought out of the dissociative potential and suggestibility of distressed and confused people looking for a way out of their predicament It is widely acknowledged that, in practice, the new personalities allow the patient to avoid the constraints, limitations and stresses of their normal life (Prince, 1906; Taylor and Martin, 1944; Ludwig et al., 1972; McKellar, 1979) In the United States, where the syndrome is diagnosed more commonly, the potential significance of multiple personality for questions of responsibility and culpability was quickly recognized It has been argued that multiple personality is equivalent to sleepwalking and sufferers should benefit from a similar defence Presumably, three lines of defence could theoretically be argued; one would be that multiple personality disorder is a form of insanity, the other would be that the usual personality cannot take responsibility for the other personalities, i.e the fictional Dr Jekyll could not be held responsible for the actions of the fictional Mr Hyde (Stevenson, 1886), and the third would be that like the sleepwalker the individual could be regarded as unconscious when in an altered state of personality Without a proper study being available it is difficult to know how often such defences are used in the United States and whether they are successful, although Abrams (1983) quotes a case from Ohio where a man accused of multiple rapes was found not guilty by reason of insanity because of his multiple personality disorder The unconsciousness argument has been advanced by French and Schechmeister (1983) To reiterate, these observations made by others not help very much with understanding what the patient experiences, and why A story, probably apocryphal, is told of an Old Bailey judge called upon to sentence a man whose defence claimed he suffered from multiple personality The judge admitted to the sadness he felt that the model citizen and blameless character who stood before him should have to share his body with the villainous perpetrator of the offences and, moreover, would have to be confined together with this criminal in a prison cell for the period of the sentence which he was about to impose The lack of responsibility argument is akin to the arguments that were once put (but not now allowed) about the function of amnesia If splitting or dissociation is a response to unpleasant realities, and a way of coping with stress, then it is perhaps an exaggeration of normal mental mechanisms If it is believed to involve a separation of different elements in the subject’s character and behaviour, these elements arise from the individual’s responses to the real world The different personalities may, perhaps, be regarded as different aspects of self, albeit compartmentalized, rather than different selves The appeal of the Jekyll and Hyde story is surely, in part, that we all recognize the splits and incompatibilities in our desires, fantasies and even actions, and that most of us have done things which retrospectively, or even at the time, seemed foreign to our personalities and we can say, afterwards, ‘that really wasn’t me’ If the multiple personality is to be given the benefit of repudiating legal responsibility for forbidden actions, why not all criminals who can argue they acted out of character and were thus not themselves at the time? Fugue States Fugue literally means to take flight or escape, but its use in psychiatry is best confined to transitory abnormal behaviour characterized by aimless wandering with alteration of consciousness, often associated with subsequent amnesia (Stengel, 1941) Fugues are encountered as one of the signs of a wide variety of psychiatric disorders, though their manifestation probably depends on a predisposition to disturbances of consciousness and dissociation A traumatic event may act as the precipitant of the actual fugue state During the fugue the individual may be completely amnesic for their usual life and they may assume a new personality The relationship between fugues, multiple personality disorder, and dissociative amnesia is fairly clear Such states are a gift for novel writers, but perhaps one of the most famous fugues was the 11-day absence of Agatha Christie who never explained where she had been or why; she may have had amnesia A fugue state is usually shortlived (hours to days), but can last months or longer After recovery from a fugue, previous memories usually return intact, but there is complete amnesia for the fugue episode Fugues are usually precipitated by a stressful episode, and upon recovery there may be amnesia for the original stressor 427 K17373.indb 427 3/31/14 6:17 PM Index clinical approach to assessment interviews, 391–392 cluster A, B, C, 385 cluster B types, 512 comorbidity, 397–398, 514 concepts and diagnoses, 383–386 conclusions, 417 dangerous and severe, 413–417 developmental factors, 393–394 diagnostic interview schedules, 387 diagnostic questionnaires, 387–388 domain-based conceptualisation, 386 drug treatments, 403–407 effective treatment preparation, 399–402 emergence from normality, 384 and empathy theory, 394–395 evidence for effectiveness of treatment, 402–412 evidence for psychological treatments, 409, 412 failure to meet needs, 112 famous cases, 58 and filicide, 508 focus on behaviour versus dysfunctions, 385 future research, 412 gender differences among prisoners, 517 genetic factors, 393–394 Harold Shipman case, 689 inferring from comorbid substance abuse, 339 legal and political context, 383 maladaptive learning and, 395–396 managed clinical networks, 412–413 medication effectiveness, 403–407 multiple, 426–427 neurochemistry roots, 394 neuropsychiatric roots, 394 and non-violent offences, 282 and offending with alcohol use, 443–444 overuse of term, 383 in persons with intellectual disabilities, 319 physical routes, 394 prevalence, 389–390 prevention, 399 primary traits, 386 promoting patient engagement, 400–401 and psychodynamic psychotherapies, 583 psychological routes to development, 394–396 psychosis and violence with, 346 reclassification as, 128 risk-taking irresponsible groups, 384 secondary domains, 386 self-assessment limitations, 389 and sex offending, 262 sharing diagnosis with patients, 401 staff needs in treatment, 399–400 stepped approach to treatment, 403 subdomain assessments, 388 subdomains, 385 terminology issues, time-limited psychological treatments for offenders, 407–409 trait-based interviews, 387 trait-based non-diagnostic questionnaires, 388 trauma as precursor, 396 treatability, 13 treatment, 398–413 treatment challenges, 398–399 treatment goal-setting, 401–402 two- and three-factor models, 385 in violent offenders, 242 withdrawn types, 385 in women offenders, 512–514 Personality disorder assessment tools, 386–387 beyond self-assessment, 389 diagnostic questionnaires, 387–388 domain-specific assessments, 388 interview schedules, 387 trait-based interviews, 387 trait-based non-diagnostic questionnaires, 388 Personality Disorder Questionnaire 4+, 388 Personality disorder treatment, 398 evidence for effectiveness, 402–412 medication, 403–407 therapeutic communities, 412 time-limited psychological treatments, 407–409 Persuasion, legal emphasis on, 150 ‘Peter Grimes’, xxiv–xxv Pharmaceutical companies, and DSM classifications, 10 Pharmacological challenge studies, serotonergic function, 308–309 Pharmacological treatment clozapine, 563–564 for drug misuse, 457–458 first and second line drug treatments for persistent violence, 563 first generation antipsychotics, 565–566 medication for violence, 560–566 medication non-compliance, 566–567 parenteral medication for acute agitation and threatened violence, 562 second generation antipsychotics, 562, 563–565 in secure settings, 558–567 and violence with mental disorder, 559–560 Philosophy context, 6–7 Physical health disorders among offenders, in secure facilities, 567–568 Physical restraint, 593–595 Physical security, 592–593 Physically deteriorated neighborhoods, 179 Physician-patients, 692–693 Physiology, and women offenders, 501–502 Physique, role in female offending, 501 Pillars of care, Ireland, 617 Place of safety, 48, 64 Pleiotropy, 187 Police, 48–49 collaboration led by, 620–622 contractual work with, 624–625 cooperation with, 619–620 ethics of working with, 667 in Ireland, 656 as patients, 625 psychiatrist-led collaboration, 622–624 recording of violence, 700–701 roles in Scotland, 652 in Scotland, 652 social worker–led collaboration, 624 training by psychiatrists, 625 Police interviews, as evidence, 621–622 Police sieges, 624–625 Political arson, 274 Polygraphy, 420 in sex offending, 246, 256 Polysubstance use, 456 979 K17373.indb 979 3/31/14 6:19 PM Index Population-based statistics, 190 Portman Clinic, Positivism, in law, 148 Positron emission tomography (PET) studies, 302–303 Possession states, 428–429 Post-concussion syndromes, 429 Post-conviction sex offender testing (PCSOT), 256 Post-doctoral fellowships, 137 Post-ictal confusion, 285, 287 Post-ictal phase, 284 Post-ictal sex offences, 287 Post-ictal violence, 286–287 Post-traumatic stress disorder (PTSD), 52, 712 adaptive information processing treatment, 730–731 aetiology and transgenerational transmission, 717 after head injury, 713 after miscarriage of justice, 716–717 among military personnel, 715 anxiety management and coping in, 727–728 appraisals and meanings, 723 associative learning in, 722 as attachment disorder, 721 attachment perspectives, 717–718 CBT models, 723–724 CBT treatment, 727–729 cognitive behavioural perspective, 721–724 cognitive restructuring, 728 complex, 712 coping and adaptation in, 721–722 disordered sensitization in, 720 dissociation in, 723 in domestic violence, 713–714 EMDR treatment, 729–731 emotional dysregulation in, 720–721 emotional reactions, 723 epidemiology, 712 establishing and measuring, 726 evidence-based treatments, 724–725 exposure to reminders, 728 in families of homicide victims, 713 implications as attachment disorder, 720–721 importance of social support, 721 incident-related forms, 713–717 integrated cognitive model, 724 internal working model formation and, 718 juvenile interventions, 487 memory and, 722 and nature of trauma, 711–712 preliminary assessment, 725–726 preventing, 705–706 psychobiological attunement and, 718 and psychobiological substrate of attachment behaviour, 717–718 psychoeducation in treatment of, 727 psychological processes in, 721–722 psychological understanding, 717 in rape victims, 714–715 reflective functioning and, 718 and responses to major accidents, disaster and terrorist attack, 716 risk factors for developing, 713 secure and insecure attachments and, 718–720 therapeutic relationship and, 727 in torture victims, 716 treating complex, 729 treatment assessment and formulation, 726–727 treatment process, 725–731 and type of childhood abuse, 344 work with traumatic memory, 728 Postpartum depression, 506 infanticide and, 510 psychotic breakdown during, 520 Poverty and offending, 178 stigma of, 510 Powerlessness, and violence, 214 Powers of attorney enduring, 83 lasting, 83 Scotland, 93 Powers of Criminal Courts Act 2000, 44 Prader–Willi syndrome, 210, 322 assessment of offending behaviour in, 322 Pragmatism, in law, 148 Pre-ictal phase, 284 Pre-school programmes, 183 Pre-sentence report, 641–642 Precedent, 19 in common law, 18 Predatory stalkers, 376 Predictability, valuation by law, 149 Prefrontal cortex, brain imaging studies, 306 Pregnancy concealed or denied, 510 drug abuse in, 464–465 drug detoxification during, 465–466 physical treatment for drug use during, 465–466 stimulants and cannabis use, 466 Prenatal infection, and schizophrenia, 210 Pretrial phase, 23–25 amnesia defence, 25 fitness to plead, 24–25 report uses, 158–159 Prevention anti-bullying programmes, 184 of delinquency and offending, 181 family-based, 181–182 home visiting programmes, 182 parent management training, 182–183 of personality disorder, 399 pre-school programmes, 183 school programmes, 183 Primary care, meeting prisoner health needs in, 631 Primary generalized epilepsy, 284 Primary psychopathy, 502 Principles of practice, 68 Prison-based support, 648–649 Prison healthcare policy, England and Wales, 628 Prison hospital case records, 154 Prison in-reach, 616 Prison nursing home care, 527 Prison population gender differences in USA, 516 with mental illness, 123 proportion of women internationally, 516 rise in older offenders, 524 sharp rise in, 40 Prison sentences, 39 additional controls for sex offenders, 41 fixed-term sentences, 39 indeterminate sentences, 39–41 parole board role, 41–43 Prison treatment Controlling Anger and Learning to Manage it (CALM) programme, 226 Enhanced Thinking Skills (ETS) programme, 225–226 mother and baby units (MBUs), 519 980 K17373.indb 980 3/31/14 6:19 PM Index for violent offenders, 225–226 for women offenders, 517–519 Prisoners mortality among, physical health disorders in, treatment denial based on PCL-R scores, 13 Prisoner’s dilemma game, 214 Prisons-Addressing Substance Related Offending (P-ASRO), 229 Pritchard criteria, 24, 166 Private prosecution, 50 Probability, in psychiatry versus law, 149 Probation of Offenders Act 1907 Probation Service, 37, 40 community orders, 642 court diversion schemes, 640–641 enforcement and compliance, 643–644 in England and Wales, 638 inter-agency information sharing, 642–643 inter-agency strategic bodies, 644 Ireland, 657 multi-agency public protection arrangements (MAPPA), 644–645 Northern Ireland, 656 organization and management, 638–640 pre-sentence report, 641–642 psychiatric report, 642 risk assessment, 644 victim’s perspective, 645 work of, 640 Procedural considerations, 53 Procedural security, 593–596 child visiting, 595–596 escape and absconding, 595 patients’ romantic and sexual relationships, 596 seclusion and physical restraint, 593–595 Prodromal irritability, 285 Professional misconduct, 675 Professional standards, 14, 119 Professional witnesses, 148 Profit neurosis, 429 Profitable arson, 274 Prognosis, arson, 274 Programme requirement, 37 Prolactin response, blunting in personality disorder, 308 Prominent people, threats to, 545 Property crime, 269 Prospective longitudinal studies, 170 offending, 171–172 Prostitution, as female crime, 503–504 Protein synthesis, 186 Proteins, genes and, 186–187 Provocation defence, 29–31, 128 abolishment, 31 Proximate cause, 51 Pseudo-epileptic seizures, 425 Pseudologia fantastica, 421–423 Psychiatric assessment, difficulty of obtaining, 43 Psychiatric care of IPP offenders, 40 managing in community, 30 Psychiatric damage, 53 Psychiatric defences, 162 Australia, 129–130 Canada, 132 dangerous offenders, 131 Denmark, 130 diminished responsibility, 163 infanticide, 163–164 insanity, 162–163 Japan, 131–132 New Zealand, 130 Nine Nations study, 128–129 non-pathological incapacity, 131 Northern Ireland, 102–103 Scotland, 94 South Africa, 130–131 Sweden, 129 in USA, 120–122 Psychiatric diagnoses, among older prisoners, 526 Psychiatric disposal Ireland, 657 in Scotland, 642–653 for women offenders, 500 Psychiatric history, 157, 167 prior to cause of action, 154 Psychiatric hospitals, admissions, 61 Psychiatric injury, 50–53 damages for, 167 Psychiatric morbidity, in sex offending, 253 Psychiatric negligence actions, 167–168 Psychiatric records, 154 Psychiatric reports appearance as a witness, 168 children’s issues, 162 civil capacity, 165–167 civil matters, 165–168 clinical interviews, 154 compliance issues, 161–162 consulting other psychiatric experts, 154–155 damages for psychiatric injury, 167 diminished responsibility defences, 163 ethical considerations, 151 evidence reliability, 160–161 examples of other documents, 168–169 false confessions, 160–161 further investigations, 154 infanticide defence, 162–164 insanity defence, 162–163 legal forum background issues, 148–153 legal forums in England and Wales, 152–153 for legal purposes, 148 medical disposal, 164–165 memory/recall issues, 161–162 for MHTR creation, 37 preliminary matters, 151 pretrial stage uses, 158–159 for Probation Service, 642 psychiatric defences, 162–164 psychiatric negligence actions, 167–168 psychology and psychiatry in highprofile cases, 159 remands for, 64 report construction, 153–158 report structure, 155–158 reviews of detention, 165 role in sentence mitigation, 164–165 sentencing phase, 164–165 subject interviews, 153–154 suggestibility issues, 161–162 trial stage uses, 159–164 use in criminal proceedings, 188–165 vulnerable witnesses/suspects, 159–160 Psychiatric thought, interpretive nature of, 148 Psychiatrists as agents of society, 666–667 criminal and civil law for, 18 government appointments, 137 refusal to admit based on untreatability, 59 Psychiatry avoiding amateur law practice in, 14 communication with laymen, 981 K17373.indb 981 3/31/14 6:19 PM Index contentious word examples, and justice, 116 medicolegal issues, 14–16 perceptions of failure, 56 Psycho-education, 573 in treatment of PTSD, 727 Psycho-motor activity, increases with alcohol, 440 Psycho-motor seizures, 284 Psychoanalytic psychotherapies, for sex offending, 258–259 Psychobiological attunement, 718 Psychodynamic perspectives, violence, 212–213 Psychodynamic psychotherapies challenges and recent developments, 583–584 effectiveness, 580 general principles, 580–582 with offender-patients, 580–584 in personality disorder, 583 and psychosis, 582–583 role of, 579–580 in secure settings, 579 Psychogenic non-epileptic seizures, 425 Psychological damage, in epilepsy, 285–286 Psychological interventions, for drug misusers, 459–460 Psychological treatments CBT in forensic hospitals, 569–570 cognitive behavioural therapy, 569 competencies in behaviour disorders, evidence for effectiveness in personality disorder, 409, 412 randomised controlled trials in personality disorder, 409–411 in secure facilities, 568–569 Psychologists, increased prominence in correctional services, 137 Psychometry, 154 Psychopathic disorders application to women offenders, 514–515 lack of definition, Northern Ireland, 102 medical terminology issues, 11 Scotland, 96 Psychopathy, medical terminology issues, 11 Psychopathy Checklist (PCL-R), 262, 415, 444 application to women offenders, 514 Psychosexual history, 157 Psychosis affective, in older offenders, 525 with amnesia, 295 anger and violence in, 354 and arson, 340 CBT for, 573–574 and childhood trauma, 345 childhood trauma and violence, 344–345 clinical characteristics with violence, 348–354 coercion into treatment, 365 cognitive behavioural therapy in schizophrenia, 361–362 comorbid mental disorders and, 345–348 and crime, 334 criminal justice management models, 365 delusions and threat/controloverride symptoms, 348–352 early/late onset of offending distinctions, 342–343 early-onset, 487 empathy deficits and violence, 354 environmental factors relevant to violence, 354–357 epidemiology, 339–340 and epidemiology of crime, 336–341 family environmental factors, 354–356 feigned, 432 first episode of offending, 343–344 homicide and, 337–338 illustrative cases, 335–336 impact of models for treatment and management, 366 implications for practice, 348 literature strengths and limitations, 335 longitudinal risk based studies, 338–339 management and treatment, 357–366 medication conclusions, 360–361 medication management, 358–360 and miscellaneous offending, 340–341 miscellaneous psychosocial treatments, 362–363 need to maintain physical health, 358 and offending, 340–341 pathways into violence, 341–345 and PCL-R, 346–347 and perpetration of violence, 334–335, 335–336 in physician-patients, 692 psychodynamic psychotherapies and, 582–583 psychological treatments, 361–363 psychosocial treatments, 363 psychotic symptoms and violence, 348–354 puerperal, 501 safety behaviours, 352 and sex offending, 340 and substance misuse, 347–348 treatment framework models, 364–366 and victimization, 334–335 and violence, 334 violence with and without, 336–337 and wider community role, 357 and women offenders, 514–515 Psychosocial interventions, for alcohol misuse, 446–447 Psychosocial milieu, of offenders, 170, 172 Psychosocial treatments, in psychosis, 362–363 Psychostimulants, 455 Psychosurgery, 67 Psychotic disorders, and non-violence offences, 280–281 Psychotic fire-setters, 275–276 Psychotic stealing, 270 Psychotic symptoms hallucinations and violence, 353 interpersonal communications about delusions/violence, 352–353 threat/control-override symptoms, 348–352 and violence, 339–340, 353–354, 358–354 Puberty, 473 Public figures stalking, 377–378 threat assessment, 547 threats to, 543–545 Public health knowledge/skills, Public health solutions, preventing victimisation, 703–704 Public hostility, to sex offenders, 264–265 Public opinion, shifts in, 114–116 Puerperal depressive illness, 164 982 K17373.indb 982 3/31/14 6:19 PM Index and women offenders, 501 Punishment impact studies, of patients, 682 Pyromania, 275 Q Quantitative genetic studies, 186 adoption studies, 188 antisocial behaviour, 195–197 family studies, 187–188 gene–environment interplay, 191–192 heritability issues, 190 integrating with molecular, 195 schizophrenia, 208 substance misuse, 200–201 twin studies, 188–190 twin study advances, 190–191 Quantitative model-fitting approaches, 190 Quetiapine, 565 R Railway spine, 429 Rape, 248–249 of males, 249 PTSD in victims, 714–715 widening of definition, 243 Rapid eye movement (REM) sleep behaviour disorder, 291 Re-convictions, risk assessment, 538 Re-offending, 254 Reasons letter, 43 Recall, 161 Recidivism among older offenders, 526, 527 among women offenders, 511, 513, 518 CBT and reductions in violent and non-violent, 575 in medicated sex offenders, 261 in personality disorders, 13 predicting with VRAG, 536 in sex offenders, 257 Reciprocity, Scotland, 89 Recklessness, 22, 32, 120 as mens rea for manslaughter, 33 Recombination, 187 Referral order, 44 Rehabilitation for Addicted Prisoners Trust (RAPT), 229 Rehabilitation potential, shift away from, Rehabilitation psychiatry, Reification, 8–9 of evil, in law, 150 Rejected stalkers, 375 Relapse prevention, in alcohol abuse, 446–447 Relational security, 596–597 Relevant circumstances, 79 Reliability of evidence, 160 of personality disorder diagnostic tools, 387 REM sleep behaviour disorder, 291 Remand to hospital, 81, 124 Remediation, 571 Remorse, as criterion for release, 12 Reparation order, 44 Report structure, 155 alleged offences, 157 appendices, 158 and assumed facts, 155–156 background history, 157 declarations, 158 enquiry description, 156 facts, 156–157 and hearsay, 155–156 introduction, 156 mental state examination, 157 opinion, 157–158 previous medical history, 157 previous psychiatric history, 157 psychosexual history, 157 recommendations, 158 signature, 158 statements of truth, 158 summary of conclusions, 158 Report writing versus advice to counsel, 151 appendices, 158 assumed facts, 155–156 for courts and lawyers, declarations, 158 description of enquiry, 156 facts supporting opinion, 156–157 hearsay problems, 155–156 introductory section, 156 for mitigation, 164–165 opinion section, 157–158 recommendations section, 158 signature, 158 statements of truth, 158 structure, 155 summary of conclusions, 158 Republic of Ireland, 86 admission orders, 109 approved centres, 108 assessment and treatment, 107 court diversion, 109–110 Criminal Law (Insanity) Act 2006, 107, 108 diminished responsibility, 108 fitness to plead, 107 insanity law, 106 legal process, 109 mental disorder definition, 108–109 Mental Health Act 2001, 106, 107, 108 mental health review boards, 108 mental illness definitions, 107 recent mental health law developments, 106–107 transfer to hospital, 109 Research comparative international studies, 143–144 Mental Capacity Act 2005, 85 mental health tribunals, 71 paucity in USA, 144 Scotland, 93–94 Resentful stalkers, 376 Resettlement provision schemes, 492 Residence requirement, 37 Resource issues, 30 hospital orders, 38 Responsibility, 22 comparative legal definitions, 129 criminal, 18 degrees of, 25 issues for adolescent offenders, 476 and morality, and multiple personality disorder, 427 new laws in Sweden, 115 Responsible clinician (RC), 62, 72 Responsible medical officer (RMO), 62 Restoration of competence, 119 ethical issues, 119–120 Restorative justice model, 478 Restraint, 557–558, 593–595 Restricted patients mental health tribunals and, 70–71 Scotland, 89 supervision of conditionally discharged, 73 Restriction orders, 38–39 lack of tribunal jurisdiction over, 71 for offender-patients, 65 Retracted confessions, 161 Revenge fire-setting, 274–275 983 K17373.indb 983 3/31/14 6:19 PM Index Reward pathway, 200 genes involved in, 205 Rhetoric, legal emphasis on, 150 Ribonucleic acid (RNA), 186 Ribosomes, 187 Right to treatment, 123, 667–668 Risk communication about, 547–548 defined, 531 and discharge decisions, 74 in secure institutional services, 601–603 to self and others, 60, 62, 65 in sex offending, 254–256 Risk analysis, 532 Risk assessment, 529, 644 actuarial, 532–533 clinical, 531–532 continuous cycle of, 532 dilemmas for psychiatrists, 149 homicide inquiry, 698 for juvenile offenders, 485 and management, 548–549 as part of management process, 253 in sex offending, 253–254, 255 and structured judgment tools, 533–534 for suicide, 233 use in forensic psychiatric practice, 539 for violent crimes, 241 Risk assessment tools, 5, 65 Northern Ireland, 102 Scotland, 99 Risk categories, 541 Risk factors, 531 PTSD development, 713 risk prediction tools, 535 violence, 534, 535 Risk-focused prevention, 181 Risk identification, 532 Risk level, 531 Risk management, 132, 529, 548–549 with CPA approach, 698 Risk Management Authority (RMA), Scotland, 88–89 Risk prediction tools, 531, 535 Risk reduction, 532 Risperidone, 564 Robbery offences, 47 Role expectations, 151 Roman law, 18, 112 Royal Air Force, 103 Royal College of Psychiatrists, 16 Royal Navy, 103 S Safeguards, 67, 85 Scotland, 91 Safety, place of, 64 Safety behaviours, 352 Sally Clark case, 671–673, 675 Scatologia, 247 Schizophrenia, 280, 443 versus alcoholic hallucinosis, 439 and CNVs, 209 cognitive behavioural therapy in, 353, 361–362 as developmental disorder, 341 and erotomania, 368 family burden with, 355 gene–environment interplay, 210 genetic influences, 186, 207–210 and homicide, 337 late onset of offending in, 343 molecular genetic studies, 208–210 versus personality disorder, 383 prenatal infection and, 210 as protective factor against violence, 538 quantitative genetic studies, 208 risk of victimisation, 334 specific genetic disorders and risk, 210 terminology issues, and violence, 337 in women offenders, 514 and youth substance abuse, 488 Schizotypal personality disorders, engagement barriers, 400 School bullying, 184 School failure, 174 School influences, and offending, 178 School programmes, to prevent offending, 183 Schoolchildren cohort studies, Scientific Group for the Discussion of Delinquency, Scotland, 115 absolute discharge, 99 accredited risk assessors, 100 age of criminal responsibility, 87 appeals, 91 assessment and treatment needs, 652 automatism, 95 children’s law, 87 community sentences, 87 compulsion order, 96 compulsory measures, 91 conditional discharge, 99 Court of Session, 88 court services, 652–653 criminal justice social work, 654 Criminal Procedure Act 1995, 97–98 criminal procedures for mentally disordered offenders, 94–96, 99–101 criminal responsibility in mental disorder, 95 criteria for compulsion, 90 dangerous offenders, 99–100 devolution, 87 diminished responsibility, 96 diversion and psychiatric disposals, 652–653 diversion to mental health services, 96 drug courts, 653 equality principle, 89 fitness to be interviewed, 652 fitness to remain in custody, 652 funds management, 93 further reading, 146 future of forensic psychiatry, 613 general civil matters, 88 general criminal matters, 87–88 health service–based forensic psychiatry service provision, 611 High Court of Criminal Appeal, 87 high security psychiatric hospitals, 612–613 hospital treatment in, 612–613 hybrid treatment orders, 99 incapacity definition, 93 incapacity legislation, 91, 93–94 independent sector facilities, 613 informal care principle, 89 intervention and guardianship orders, 94 juvenile offenders, 480–481 lack of probation service, 88 least restrictive alternative principle, 89 legal arrangements, 87 legal mental health principles, 90 Lord Advocate, 87 low security psychiatric services, 613 medical treatment, 93 medium security psychiatric services, 613 mental disorder definition, 90 Mental Health (Public Safety and Appeals) Act 1999, 99 984 K17373.indb 984 3/31/14 6:19 PM Index Mental Health (Care and Treatment) Act 2003, 97–98, 612 Mental Health Division at the Scottish Government, 88 mental health legislation, 89–91 Mental Health Tribunal for Scotland, 88 Mental Welfare Commission for Scotland, 88 multi-agency public protection arrangements, 100–101 need for appropriate adult, 652 Nine Nations study, 126 non-discrimination principle, 89 Office of the Public Guardian, 89 order for lifelong restriction (OLR), 99 Order for Life-long Restriction (OLR), 115 pathways to services, 651–652 place of safety, 652 police roles, 652 powers of attorney, 93 prison services, 653–654 prison studies of psychiatric morbidity, 653 psychiatric defences, 94 psychiatric services to police stations, 652 reciprocity principle, 89 research, 93 respect for carers, 89 respect for diversity principle, 89 risk assessment order, 99 Risk Management Authority (RMA), 88–89 safeguards, 91 Scottish Commission for the Regulation of Care, 89 service organization and policy framework, 611–612 service provision for mentally disordered prisoners, 651 sex offender legislation, 99 Sex Offenders Act 1997, 99 Sexual Offences Act 2003, 99 sheriffdoms, 88 shrievel panel, 99 Solicitor General, 87 specialist forensic community psychiatric services, 613 Statutory bodies, 88–89 summary cases, 87 supervising bodies, 93 treatment options, 91 unfitness for trial, 94–95 Scottish Risk Management Authority (RMA), 548 Screening Questionnaire Interview for Adolescents (SQUIFA), 490 Seclusion, 557–558, 593–595 Second-degree murder, 31, 121 Second generation antipsychotics (SGAs), 358, 562, 563 aripiprazole, 565 clozapine, 562–564 lack of psychotic symptom reduction with, 359 olanzapine, 564–565 quetiapine, 565 risperidone, 564 ziprasidone, 565 Second opinions, 67, 73–74 Secondary offences, 270 Secure accommodation government policy, 490–491 for young offenders, 44, 490–491 Secure attachments, and PTSD, 718 Secure facilities acute agitation oral medication, 561 acute agitation parenteral medication, 562 attachment and psychodynamic therapies in, 579–585 balancing care and control in, 552–553 CBT applications and effectiveness, 573–578 cognitive behavioural therapy in, 569–573 consolidation process in, 578–579 creative and arts therapies in, 558 dental health education, 568 first and second line drugs for persistence violence, 563 first generation antipsychotics, 565–566 inherent risks, 601–603 medication for violence in, 560– 566, 562–563 medication non-compliance, 566–567 nurse–patient dynamics, 554–556 nursing observations, 533–534 nursing roles in, 553–558 occupational therapy in, 558 persistent aggression medications, 562–563 pharmacological treatments, 558–567 physical healthcare issues, 567–568 proximity to patients, 553 psychological treatments in, 568–579 second generation antipsychotic medications, 562, 563–565 speech and language therapies in, 558 staff, services and psychodynamics, 584–585 stigma and discrimination issues, 579 therapeutic environments in, 552–558 threatened violence oral medication in, 561 threatened violence parenteral medication in, 562 treatment principles, 551 unintended transferences, 554–556 violence in mental disorder in, 559–560 Secure training centres (STCs), 490 Secure training centres (STCs), for young offenders, 44–45 Security Australia, 129–130 Canada, 132 Denmark, 130 Japan, 131–132 as means of treatment, New Zealand, 130 South Africa, 130–131 Sweden, 120 Security measures, Nine Nations study, 128–132 Segregation, genetic, 187 Seizures definition, 284 psychogenic non-epileptic, 425 Selection theories, 176 Selective placement, 188 Selective serotonin reuptake inhibitors (SSRIs), 260–261 in sex offender treatment, 260 Self-assessment, in personality disorders, 389 Self-deception, 419–420 Self-harm among prisoners, 632–634k DBT for, 574–575 Self-immolation, 276 Self-mutilation, 434 985 K17373.indb 985 3/31/14 6:19 PM Index Self-reports, of offending, 172 Sense of self, 719–720 Sensitivity, versus specificity, 536 Sentenced prisoners, transfer to hospital, 65 Sentencing, 35 for 18+-year-old offenders, 45–46 additional controls for sex offenders, 41 alcohol treatment requirement, 38 changes with Criminal Justice Act 2003, 36 community orders, 37 dangerous offenders, 45–48 discharges, 36–37 drug rehabilitation requirement, 38 fixed-term sentences, 39 guardianship orders, 39 hospital orders, 38 indeterminate sentences, 39–41 mental health treatment requirement, 37 parole board, 41–43 prison sentences, 39–43 programme requirement, 37 report writing for, 164–165 residence requirement, 37 restriction orders, 38–39 supervision, 37 types of, 36 for young offenders, 44 Sentencing Council for England and Wales, 36 Sentencing guidelines, 36 Sentencing theory, 35–36 Serial killers, 239–240 doctors as, 686, 688 rarity among women, 507 Serious harm, 46, 47 Serious offences, specified, 45 Seriously disturbed adolescents, 482 Serotonergic function acute tryptophan depletion (ATD) studies, 309 in aggressive and impulsive behaviour, 306–312 brain imaging and 5-HT, 310 conclusions, 312 CSF studies, 308 measuring in humans, 307 pharmacological challenge studies, 308–309 SSRI treatment studies, 311–312 studies of peripheral, 307–308 treatment implications, 310, 312 Serotonergic neurotransmission and antisocial behaviour, 198 and substance abuse, 205–206 Serotonin opposition to dopamine, 260 role in sex offending, 259–260 Serotonin receptor genes, 198, 205 Serotonin transporter gene (SERT), 198 Service structures, 597–599 admissions to hospital security units, 599–600 capacity planning, 600–601 Severe mental impairment, 314 Sex chromosomes, 187 Sex offender treatment, 256 adolescents, 263–264 anti-androgens, 260 checklist, 265 cognitive behavioural therapy (CBT), 258, 416–417 effectiveness, 257–258 family reunification, 259 group treatment, 262–263 history and current context, 256–257 with intellectual disabilities, 328–329 learning disability, 263 managing denial, 261–262 medication, 259–261 mentally ill offenders, 262–263 psychoanalytic psychotherapies, 258–259 selective serotonin reuptake inhibitors (SSRIs), 260–261 systemic approaches, 259 treatment models, 258 Sex Offender Treatment and Evaluation Project (SOTEP), 257 Sex offenders, 49 Australian legislation, 116 Danish treatment programme, 140 older males, 524 over age 60, 525, 526–527 Scottish legislation, 99 sentencing controls for, 41 US programmes, 125 Sex Offenders Act 1997, 41 Sex offending, 5, 243–244, 244–245 acute dynamic risk factors, 255 addictions and, 253 by adolescents, 252 affective disorder in, 253 alcohol and, 442–443 assessment in intellectual disability, 328 bestiality, 248 CBT for, 577–578 child sexual abuse, 249–250 child victims, 243 cognitive distortions, 258 contact offences, 251–252 defining risk in, 254–256 denial in, 258, 265 and drug misuse, 454 emotions generated by, 243 in epilepsy, 287 exhibitionism, 247 by females, 252 impulse control disorders, 253 incest, 249–250 indecent exposure, 247 Internet sex offending, 250–252 by known perpetrators, 243 and legitimate violence, 244 male sexual offenses, 246–252 medical models, 252–253 medication for, 265 necrophilia, 247–248 needs assessment, 258 obscene telephone calls, 247 obsessive compulsive disorder (OCD) spectrum, 253 by older offenders, 527 Paedophilia, 250 paraphilia, 245–246 polygraphy, 256 psychiatric morbidity, 253 psychiatric questions, 252–253 psychosis and, 340 public hostility, 264–265 rape, 248–249 rape of males, 249 reduction in England, 243 relapse prevention, 258 responsivity to treatment, 258 risk assessment, 253–254, 258 risk factors, 255 scatologia, 247 sexual arousal, 254 sexual violence towards women, 248–249 social variables, 244 stable dynamic risk factors, 255 static risk factors, 254 stigma attached to, 264 total cost of crime, 244 treatment, 256–264 986 K17373.indb 986 3/31/14 6:19 PM Index treatment in intellectual disability, 328–329 treatment versus control, 264–265 victim empathy training, 265 victim impact, 243 voyeurism, 247 zoophilia, 248 Sex trafficking, 503 Sex workers, 503 Sexual abuse Clifford Ayling case, 684–685 as crime versus disease, 250 Kerr and Haslam cases, 685–686 of patients, 681, 684–686, 691, 692 and psychosis with violence, 345 Sexual arousal, 254 medication targeting, 259 in paraphilia, 245 Sexual arousal disorder of childhood, 495 Sexual deviation, 245, 246 Sexual fantasy, 251 Sexual Offences Act 2003, 41, 243 Sexual offenders, civil commitment in USA, 123–124 Sexual preference disorders, 245 Sexually abusive behaviour adolescent treatment, 495 in juveniles, 494–495 Sexually violent predator laws, 125 in US, 124 Shaken baby case, 671–673 Shame, 215 Shared environmental influences, 188 and abstinence from alcohol, 201 Shooting sprees, 235–239 Shoplifting, 271–272 depression and, 294 eating disorders and, 281 Shoplifting Act 1699, 271 Short-term prison sentences, Shortage of services, 13 Japan, 132 Shrievel panel, 99 Significant risk, 45 Silcott, Ben, 58 Single nucleotide polymorphisms (SNPs), 194 Single photon emission tomography (SPECT) studies, 302–303 Situational influences, and offending, 179 Sleep disorders, 289–290 arousal disorders, 290–291 clinical/legal assessment, 291–292 management and treatment, 292 REM sleep behaviour disorder, 291 sleep drunkenness, 290–291 violence in sleep-walking, 291 violence with night terrors, 291 Sleep drunkenness, 290–291 Sleepwalking, 290 violence with, 291 Smoking cessation treatments, 567–568 Social ambivalance, 116 toward mental disorders, 128 Social class, and offending, 177 Social cognitive perspectives, violence, 213–214 Social controls, effects on female crime, 500 Social desirability bias, in intellectually disabled offenders, 332 Social drop-out criminality, 280 Social factors community influences, 178–179 and offending, 177 peer influences, 177–178 school influences, 178 socioeconomic deprivation, 177 Social learning theory, 174 Social purification, 679 Social support, for PTSD, 721 Social upheaval, and female crime, 500 Social workers interagency collaboration led by, 624 in Scotland, 654 Socioeconomic deprivation, and offending, 177 Socioeconomic status (SES) and psychosis with violence, 341 and women offenders, 502 Solitary confinement, 113, 114 Somatoform disorders, 227 South Africa capacity to stand trial, 127–128 cases cited, 795 civil commitment, 135 dangerous offenders, 131 fitness to plead, 127 FMH services, 140–141 further reading, 147 high violent crime rate, 131 Nine Nations study, 126 non-pathological incapacity defence, 131 primary, secondary, tertiary care systems, 135 psychiatric defences, 130–131 security measures, 130–131 Special courts, 152 Special verdict, 27–28 insanity defence, 33 Specialist forensic mental health services See Forensic mental health (FMH) services Specialist medico-legal assessment, 492–494 for women offenders, 519–521 Specialist recognition in Europe and Nine Nations study, 141–142 in USA, 142–143 Specific intent, 32, 33 Specificity, versus sensitivity, 536 Specifics, versus group research data, 14 Specified offences, 45 Speech and language therapies, in secure settings, 558 SSRI treatment studies, in impulsiveaggressive patients, 311–312 Stabilization, 571 Stable attachment, 190 Staff needs, 584–585 empathy training, 557 in personality disorder treatment, 399–400 Stalking, 373 affective health effects, 374 among juveniles, 376–377 assault risks, 380 behavioural disturbance impacts, 374 of celebrities and public figures, 377–378 classifications and typologies, 375–376 cognitive health impacts, 374 communicating about, 379 cyberstalking, 377 epidemiology, 374–375 as erotomania, 367 evaluation, 379–380 general disturbance due to, 374 health professionals, 378–379 history, 373–374 impact of, 374 incompetent suitor types, 375–376 intimacy seeking and, 375 987 K17373.indb 987 3/31/14 6:19 PM Index legal issues, 377 minimising against clinicians, 378–379 persistence or recurrence, 379 physical health impacts, 374 predatory stalker type, 376 progress and knowledge summary, 380 psychological and social damage to victims from, 379–380 record keeping, 379 rejected stalker type, 375 resentful stalker type, 376 resilience impacts, 374 resource impacts, 374 risk management, 379–380 security measures, 379 social health impacts, 374 threats and, 545–546 unwanted communications, 379 of women by men, 374 Stalking Risk Profile, 546, 547 Standard authorization, 81–82 Standard list offences, 172 Standard of proof, for civil versus criminal law, 50 State-based services, Australia, 139 State hospital populations, in USA, 118 State mental hospitals, 122 Statements of truth, 158 Statistical approach, to risk management, 540 Statistical illiteracy, 530 Status stealing, 270 Statutory principles, MCA 2005, 77–78 Stigma from detention, 58 of mental illness, 579 and secure mental health services provision, 589–590 Stigmatizing terms, 10 psychopathic disorder, 11 Stockholm Adoption Study, 202 Stone, Michael, 58 Stranger homicide, 529 Stress, and female offending, 501 Stress hormones MAOA and, 200 and substance abuse, 206 Structured Assessment of Risk and Need (SARN), 255 Structured Clinical Interview for DSM-IV Axis II Personality Disorder, 387 Structured clinical judgment aids, use in forensic practice, 539 Structured group treatment as preferred modality in sex offences, 263 of sex offenders, 262 Structured judgment tools HCR-20, 537 risk assessment and, 533–534 VRAG, 536–537 Study of Abuse and Neglect of Older People, 228 Subspecialties, Substance abuse among older offenders, 526 DSM-IV criteria, 449, 450 gender differences among prisoners, 516 government policy, 491–492 juvenile interventions, 488 role in female crime, 518 and women offenders, 514 Substance metabolism, genes involved in, 205 Substance misuse, 281, 448–468 See also Drug abuse candidate gene studies, 205 clinical symptoms, 200 comorbidity with antisocial behaviour, 203–204 dopaminergic neurotransmission and, 205 early trauma and, GABA neurotransmission and, 206 Gene–environment interplay and, 206–207 genes involved in metabolism, 205 genes involved in reward pathway, 205 genetic influences, 186, 200 in intellectual disabilities, 324 molecular genetic studies, 204–206 and non-violent offences, 282 opioidergic and cannabinoid neurotransmission and, 206 protective factors, 207 psychosis and, 347–348 quantitative genetic studies, 200–204 and reduced impulse control, 347 schizophrenia and, 339 serotonergic neurotransmission and, 205–206 specific gene involvement, 205–206 stress hormones and, 206 and violence, 228–229 Substance-related disorders, 436 Substituting, 418 Sudden infant death, as female crime, 506–507 Suggestibility, 161 Suicide among older offenders, 525 among prisoners, 632–634 early trauma and, by fire, 276 as leading cause of maternal death, 501 links to infanticide, 509 in motoring offences, 278 UK national confidential inquiry, 697 Supervision, 37 doctors’ reluctance to seek, 692 of psychiatrists to prevent misconduct, 691 Supervision order, 44 to prevent child abuse, 224 Supranational legal structures, 113–114 Supreme Court, 20 Survivors, 694–695, 731 help and treatment, 724–731 learning from, 695–706 Susceptibility loci, 192 SWANZDSAJCS study, 125 See also Nine Nations study Sweden capacity issues, 125 civil commitment, 133–134 FMH services, 138–139 further reading, 147 lack of responsibility law, 115 Nine Nations study, 126 psychiatric defenses, 129 security measures, 129 Symbolic stealing, 270 T Tariff, 47–48 Teaching and learning ethics, 660–661 Technology, limitations in detection of lying, 421 Teenage mothers, and offending, 175 Television, and violence, 216–217 Terrorism, 235 PTSD responses to, 716 Testamentary capacity, 165, 166 988 K17373.indb 988 3/31/14 6:19 PM Index Testosterone, synergism with dopamine, 260 Thames Valley Community Domestic Violence Programme (CDVP), 220 Theft, 266, 269–271 motor vehicles, 278 Theft Act 1968, 21, 170 Therapeutic communities, 583 for alcohol misusers, 447 for personality disorder, 412 Therapeutic environment balancing care and control in, 552–553 contributions of physical environment, 556 creating in secure settings, 552 nurse–patient dynamics, 554–556 nursing observations, 553–554 nursing roles in, 553–558 professional identity issues, 553 proximity to patients, 553 unintended transferences, 554–556 violence reductions strategies, 556–557 Therapeutic relationship and CBT treatment of PTSD, 727 creating with volunteer agencies, 649 medical power balance in, 680 Threat assessment and management, 542–543 for public figures, 547 threats to public features, 543–545 Threat/control-override symptoms, 340 three symptoms, 349 and violence, 348–352 Threat management, 542–543 Threatened violence, oral medication for, 561 Threats against British monarchs, 545 to celebrities, 543 direct versus indirect, 544 Exceptional Case Study (ECS), 544–545 lack of predictive value, 544 to prominent people, 545 to public figures, 543–545 and stalking, 545–546 to US Congress members, 543–544 to US judiciary, 544 to US presidents, 543 Torture victims, PTSD in, 716 Tradition, as ethical justification, 660 Training in Germany, 112, 142 in Nine Nations study countries, 141 of police by psychiatrists, 625 scientist–practitioner model, 137 Trait-based interviews, for personality disorder, 387 Trait-based questionnaires, for personality disorder, 388 Transcription factor 4, 209 Transferences, 683, 693 and medical ethics, 682 unintended, 554–556 Transiently abnormal mental states, 163 Trauma nature of, 711–712 reactions to, 711–717 Trauma theories, 175 and personality disorder development, 396 and precipitation of fugue states, 427 Traumatic attachment, 719 Traumatic brain injury, juvenile interventions, 487–488 Traumatic memory, 728 Treatability, 62, 63 Japanese law, 132 patient perspective, 13 as political concept, 13 removal of criterion, 57, 60 service perspective, 13 terminology issues, 13 Treatment alcohol problems, 445–448 consent to, 668 for drug misuse, 458–467 gender-specific approaches, 518 goal-setting, 401–402 inappropriate use of, 679 right to, 66–668 stepped approach in personality disorder, 403 Treatment availability, 63 personality disorder, 398–399 Treatment compliance, insight and, 12 Treatment consent, 67–68 advance decisions to refuse, 84 Treatment effectiveness, in sex offending, 257–258 Treatment frameworks, psychosis and violence, 364–365 Treatment models, sex offenders, 258–261 Treatment principles acute agitation oral medication, 561 acute agitation parenteral medication, 562 anger management and CBT, 575 ariprprazole, 575 attachment psychotherapies, 579 balancing care and control, 552–553 barriers to therapeutic relationships, 553–558 benzodiazepines, 566 breadth of nursing role, 553 CBT applications and effectiveness, 573–578 CBT-based intervention applications, 571 CBT-based risk reduction therapies, 576–578 CBT-based treatments versus adult psychiatric services, 579 CBT in forensic hospital settings, 569–570 CBT stages of engagement, 570– 571 challenges and recent developments, 583–584 clinical-forensic formulation objectives, 570 clozapine, 563–564 cognitive behavioural therapy, 569 cognitive remediation, 573 consolidation process, 578–579 creative and arts therapies, 558 DBT for self-harm, 574–575 dental health education, 568 emotion dysregulation therapy, 574–575 facilitators to therapeutic relationships, 553–558 fire-setting CBT-based therapies, 576–577 first and second line drug treatments, 563 first generation antipsychotics, 565–566 group work, 572–573 impulse control therapy, 574–575 individual sessions, 572–573 medication for violence, 560–566 medication non-compliance, 566–567 989 K17373.indb 989 3/31/14 6:19 PM Index mental health restoration, 571–572, 573–575 mentally disordered offenders, 551 mood stabilizers, 566 nurse–patient dynamics, 554–556 nursing observations, 553–554 nursing professional identity, 553 nursing roles, 553–558 occupational therapy, 558 offending behaviour, 571–572 olanzapine, 564–565 parenteral medication for acute agitation, 562 persistent aggression and violence, 562–563 personality disorder and CBT, 574 personality disorder and psychodynamic psychotherapy, 583 pharmacological treatments, 558–567 physical healthcare, 567–568 principles of psychodynamic psychotherapy, 580–584 proximity to patients, 553 psycho-education, 573 psychodynamic psychotherapy, 579–580 psychological treatments, 568–579 psychosis and CBT, 573–574 psychosis and psychodynamic psychotherapy, 582–583 quetiapine, 565 reducing concurrent behavioural problems, 575 risperidone, 564 seclusion and restraint, 557–558 second generation antipsychotic medication choices, 562, 563–565 sexual offending CBT-based therapies, 577–578 skills training, 576 speech and language therapy, 558 staff, services and psychodynamics, 584–585 stigma and discrimination issues, 579 substance misuse and CBT, 576 therapeutic environment creation, 552–558 threatened violence oral medication choices, 561 threatened violence parenteral medication choices, 562 treatment modality, 572–573 unintended transferences, 554–556 violence CBT-based therapies, 577 violence in mental disorder, 559–560 violence reduction strategies, 556–557 ziprasidone, 565 Treatment refusal, 7, 66, 82 advance decisions, 84 Canada, 136 Trial phase, 25–26 automatism defence, 26–27 children’s issues, 162 compliance issues, 161–162 evidence reliability, 160 false confessions, 160–161 insanity defence, 27 intent issues, 162 memory/recall issues, 161–162 psychiatric defences, 162–164 psychology and psychiatry in, 159 report uses, 159–164 special verdict, 27–28 suggestibility issues, 161–162 vulnerable witness handling, 159–160 Tribunals, 67, 152 See also Mental health tribunals Triggers, 131 Triple-P Parenting programme, 182, 183 Trupti Patel case, 674–675 Tryptophan hydroxylase (TPH), 198 in alcohol and heroin dependence, 206 Tuberous sclerosis, 322–323 assessment of offending behaviour in, 323 Twin studies, 188–190 alcohol abuse, 201 externalizing behaviours, 204 illicit drug abuse, 202 internalizing behaviours, 204 limitations, 189 Tyrer’s Personality Assessment Schedule, 387 U UK national confidential inquiry, 697 UN Convention on the Rights of the Child, 479 Unborn children, intentional destruction, 229 Unemployment, and offending, 177 Unfitness for trial Channel Islands, 105 Scotland, 94–95 United Kingdom, cases cited, 795–798 United States adversarial system, 118 affirmative defences, 120 assassinations in, 234 balance of power, 117 capacity legislation, 118–120 cases cited, 798 civil commitment, 122–123 constitutional issues, 117–118 decline in child sexual abuse, 244 diminished responsibility, 120 Due Process clause, 14th Amendment, 119 FMH services, 117–118 forensic psychiatry expert recognition and training, 142–143 further reading, 147 institutions and programmes, 124 mental health courts, 23 miscellaneous civil commitment, 124 psychiatric defenses, 120–122 sex offender programmes, 125 sexual offender commitment, 123–124 States’ rights, 117–118 Unlawful detention, 61 Unrestricted patients, mental health tribunals and, 70 Unstable attachment relationships, 506 Untreatability, 59, 60 See also Treatability personality disorders, Unwanted children, 5, 29 and filicide, 509 Unwise decisions, right to make, 77 Urgent authorizations, 82–83 US Congress members, threats to, 543–544 US judiciary, threats to, 544 US presidents, threats to, 543 US Supreme Court, 120 sexually violent predator rulings, 124 Utilitarianism, 660 V Val allele, 199, 206 Value differences, law versus psychiatry, 149 990 K17373.indb 990 3/31/14 6:19 PM Index Vernacular terms, versus medical terminology, Vexatious litigants, 381–382 Victim-centred approach, 12 Victim contact work discharge and community aftercare, 711 during discharge preparations, 710–711 effective practice issues, 711 first-tier tribunals, 711 initial contact, 710 with patient in hospital, 710 principles and purpose, 709–710 victim contact scheme, 710–711 Victim empathy, role in sex offender treatment, 265 Victimisation, 694–695 and adolescence, 473 alcohol and violence perspectives, 702 apparent differences in rates, 702 care pathway, 704 combining patient care with practical prevention, 704–705 in forensic psychiatry definition, hospital emergency department data, 701–702 household crime surveys, 701–702 independent and public inquiries, 695–699 individual case inquiries, 695–696 individual homicide inquiry reports, 695–696 law and statutory framework, 709 preventing PTSD, 705–706 prevention of future, public health solutions, 703–704 risk among schizophrenics, 334 secondary prevention, 705 in sufferers of mental disorders, tertiary prevention, 705 UK national confidential inquiry into suicide and homicide, 697 victim contact work, 709–710 workplace violence and bullying, 699–700 Zito Trust, 707–708 Victims, xxiii, 694 and forensic mental health services, 707 initial contact with, 710 learning from, 695–706 of mentally disordered offenders, 708–709 problems of, voluntary and non-statutory bodies inspired by, 706–709 voluntary sector, 707–708 Victims’ rights, 68, 711 Vietnam Era Twin Study, 203 Violence, 5, 170, 211 acute agitation and, 561 alcohol and, 228–229, 437, 442 in amnesia, 293–294 amnesia and, 293 anger and psychosis associations, 354 assessment, 241–242 attachment theory and, 215–216 biological perspectives, 212 brain imaging studies for understanding, 297–306 CBT for, 577 and childhood trauma, 344–345 to children, 221–224 clinical characteristics, psychosis with, 348–354 cognitive behavioural theories, 214–215 committed by older offenders, 524 community-based and psychosis, 338 and comorbid psychosis/ personality disorder, 346 in context of mental disorder, 559–56 crimes, 229–242 definitions, 211 developmental perspectives, 215–216 domestic, 218–221 dominance and helplessness in, 214 due to brain damage, 298 to elderly persons, 227–228 and empathy deficits in psychosis, 354 epidemiology of psychosis and, 339–340 epilepsy and, 284–285 estimating community levels, 700 factitious illness, 226–227 family and close social circle influences, 354–356 gender and risk factors, 504 hallucinations and, 353 as health issue, 217–229 ictal and post-ictal, 286–287 illustrative cases, 335–336 impact of people with psychosis on community, 338 induced illness, 226–227 inhibiting by guilt and empathy, 215 inhibiting by shame, 215 and interpersonal communications about delusions, 352–353 learning perspectives, 213 levels in England and Wales, 229 long-term solutions for children, 224–225 male perpetrator profiles, 220 and MAOA gene, measurements of brain abnormalities, 298–306 medication for, 560–561 miscellaneous, 240–241 miscellaneous psychotic symptoms and, 353–354 Munchausen syndrome by proxy, 26–227 with night terrors, 291 pathways through psychosis, 341–345 perpetration and psychosis, 334–335 PET and SPECT studies, 302 police recording, 700–702 predictive tools, 538, 548 prevention as public health task, 217 prison treatment, 225–226 Prisons-Addressing Substance Related Offending programme, 229 psychodynamic perspectives, 212–213 as psychologically meaningful, 551 psychosis and, 334, 335–336 psychosis and comorbid mental disorders, 345–348 psychotic symptoms and, 339–340, 348–354 Rehabilitation for Addicted Prisoners Trust (RAPT) programme, 229 risk factors, 534, 535 in same-sex relationships, 219 and schizophrenia, 207, 208 sexual, towards women, 248–249 social cognitive perspectives, 213–214 substance misuse and, 228–229 theoretical background, 211–212 991 K17373.indb 991 3/31/14 6:19 PM Index and threat/control-override symptoms, 348–352 and traumatic brain injuries, 488 as universal phenomenon, 211 victim’s perspective, 702 visual media and, 216–217 vulnerability to, 334–335 while sleepwalking, 291 with and without psychosis, 336–337 Violence management training, 557 Violence reduction strategies, 556–557 Violence Risk Assessment Guide (VRAG), 536 evidence summary, 537 follow-up period, 537 predictive ability, 531–532 Violent crimes, 229 amok, 235–236 assassinations, 234–234 autogenic massacres, 235–239 CASK/clinicide, 240 cognitive behavioural programmes, 416–417 fixations, 234–235 gender issues, 498 homicide, 230–242 medication as treatment, 242 multiple homicides, 235–240 murder by children, 233–234 non-lethal, 504 parricide, 231–232 serial killers, 239–240 shooting sprees, 235–239 terrorism, 235 total cost per crime, 241 victim cost per crime, 241 women and, 504–505 VISOR, 49 Visual media, and violence, 216–217 Voice stress test, 420 Void, evil as, Voluntary agencies advocacy, 651 arts and creative work, 649 assertive engagement, 650 background to, 646–647 choice to engage, 650 co-ordination services, 650 community-based schemes, 648 court support, 648 engagement without assessment, 650 future of, 709 helplines, 649 navigation services, 650 need for, 647–648 Northern Ireland, 656 peer support, 649 persistence by, 650 practical support across institutional boundaries, 650 principles of engagement, 649–651 prison-based support, 648–649 responses, 648–649 role modelling by, 650 therapeutic relationship creation, 649 for victims, 707–708 working with, 646, 651 Voluntary confessions, 161 Voluntary treatment, alcohol problems, 445 Voyeurism, 247 Vulnerability-increasing genotypes, 207 Vulnerable witnesses, 159–160 W Wagner, Ernst, 235–237, 429 Waiver of counsel, competence, 120 Wales juvenile offenders, 480 Nine Nations study, 126 Warfare, terrorism and, 235 Warrior and worrier alleles, 199 and drug addiction, 206 Wechsler Adult Intelligence Scale (WAIS-III), 314 Weight gain, from antipsychotic medications, 358, 360 Welfare agenda, 479 Welfare tribunals, in Scotland, 480 Wernicke’s encephalopathy (WE), 439 Whitman, Charles, 238 WHO Patient Safety Programme, 77 Williams syndrome, 323 assessment of offending behaviour, 323 Windigo states, 428–429 Withdrawal, alcoholic, 438 Within arm’s length observation, 554 Within-eyesight observation, 554 Witness to facts, 148 appearance as, 168 Witnesses, older people as, 523 WMA Declaration of Helsinki, 794 WMA International Code of Medical Ethics, 793 Women offenders, 498–499 acquisitive offenses among older, 524 administrative aspects of mental disorder, 500–501 age and desistance from crime, 511–512 arson and, 504 attention deficit hyperactivity disorder in, 512 barriers to crime, 500 child abduction and, 504 child abuse and, 505–506 child sexual abuse and, 505 childhood experiences, 502 cognitive behavioural therapy for, 521 conduct disorder in, 512 constitutional predisposition, 501 conviction rates, 503 crime and, 499–512 depression and, 515 developmental disorders in, 512 economic marginalization and, 500 factitious and induced illness among, 506–507 family disruption and, 500 filicide and, 508–509 gender crime-rate differences, 500–502 genetic factors, 501 homicide and, 517 infanticide and, 510 international prison comparisons, 516 inured types, 518 lenient legal treatment, 500 long-term outcome after homicide, 510–511 masking of female crime, 500 mental disorders and, 512–515 mother and baby units for, 519 Munchausen syndrome by proxy, 506–507 neonaticide and, 509–510 offence categories, 502–511 over age 60, 524 personality, 502 personality disorder in, 512–514 physiological factors, 501–502 physique factors, 501 policy matters, 519 predictive tools, 538 992 K17373.indb 992 3/31/14 6:19 PM Index in prison, 515–519 prison treatment programmes, 517–519 prostitution, 503–504 psychiatric diagnosis and, 502 psychopathic concepts and, 514–515 psychosis and, 514–515 recidivism, 511, 513, 518 separation from children, 517 services for, 515–521 social and demographic characteristics, 502 social controls and, 500 specialist forensic mental health services for, 519–521 specialist hospital services, 520 specific treatment issues, 520–521 spirited type, 517 stress factors, 501 and substance misuse, 514 sudden infant death and, 506–507 troubled types, 518 violent child abuse and neglect among, 505–506 violent offences, 504–505 volatile types, 518 Women’s Safety Workers, 221 Workmen’s Compensation Act, 431 Workplace violence, 699–700 Written care plan, 65 Wrongness, 28 Y Yorkshire Ripper trial, 6, Young Offender Assessment Profile (ASSET), 490 Young Offender Institutions (YOIs), 45, 488 Young offenders, 43–45 legal definition, 47 life sentencing for, 46 local authority secure children’s homes, 45 secure accommodation, 44 secure training centres (STCs), 44–45 sentences for, 44 Young Offender Institutions (YOIs), 45 Youth Justice Board for England and Wales (YJB), 43–44 Youth Offending Teams (YOTs), 44 Young people drug misuse among, 466–467 policy directions for drug use, 466–467 Youth courts, 476, 477 Youth Justice Board for England and Wales, 43–44, 479–480, 488 mental health needs of young people, 482–484 Youth Offending Teams (YOTS), 44 Z Ziprasidone, 565 Zito, Jonathan, 58, 335, 336 Zito Trust, 707–708 Zoophilia, 248 993 K17373.indb 993 3/31/14 6:19 PM ... Executive, 20 02/ 7), Wales (Welsh Assembly Government, 20 08b), and Northern Ireland (DHSSPS, 20 00) All focus on combating alcohol-related crime and disorder through prevention, early intervention, and. .. heaviest drinkers The UK General Household Survey 20 02 (Rickards et al., 20 04) showed that these were among 1 6- to 24 -year-old men, averaging 21 .5 units per week The trend, however, is for a slight... among 1 6- to 24 -year-old women who, in 20 02, had been averaging 14 units A revision of national health service (NHS) policy now recommends a maximum intake of 2 3 units per day for women and 3–4