Crime and psychiatry.

Psychiatry and crime are linked in certain ways. On one hand, we have criminal offenders with serious psychopathology; and on the other hand, we have psychiatric patients who may commit criminal offences during the influence of a psychiatric disorder. The psychiatrist in practice has to come in contact with the criminal justice system at some point of time in his career. Forensic psychiatry under whose realm these issues reside is a branch yet underdeveloped in India. The present paper reviews the inter-relationship between crime and psychiatry and the factors involved therein.

Introduction

Psychiatry and crime are at times intertwined. It has always been perceived that criminal offenders are crazy and mentally ill while on the other hand there is another view that psychiatric patients are dangerous and more likely to commit criminal offences (Watson et al., 2001[23]). Media often plays a role in highlighting the works of criminal offenders, as well as news of any wrong doing by psychiatrically ill patients. This relationship has been examined by various agencies since the past 200 years. This paper will discuss the inter-relationship between crime and psychiatry and the factors that play a role therein.

The Relationship Between Crime and Psychiatric Patients

The mentally ill have been often depicted in a criminalised manner. A large body of evidence suggests that the mentally ill are arrested, convicted and sent to prison in proportions that surpass their actual criminal behaviour (Skeem, Manchak and Peterson, 2011[18]). The mentally ill are often ‘referred’ to the criminal justice system due to poor or inappropriate resources in the mental health sector and this is due to the phenomenon of ‘deinstitutionalisation’ seen in many countries in the last few decades (Hamden et al., 2011[7]). The community mental health movement aimed at moving mental health away from psychiatric hospital to the community has never been properly implemented in India. As a result of deinstitutionalisation, the mentally ill increasingly come into contact with the police and courts, thus inflating the apparent relationship between crime and mental illness (Rai et al., 2014[14]).

Many psychiatric patients abandoned by relatives take to the streets and are often arrested by the police for petty crimes as a preventive law and order measure (Golightley, 2014[5]). Many of the symptoms of mental illness are behaviours considered to be antisocial or criminal, such as violence or wandering behaviour (Fisher and Lieberman, 2013[4]). Mental illness elevates the risk of arrest as detection and subsequent calls to the police are more likely in those with such problems (Smith and Alpert, 2007[17]). There is also a bias in convictions, as the mentally ill are more likely to be charged and spend a longer time in jail for similar crimes (McNeill, 2009[10]).

Criminals and Psychiatry

An important point is the psychiatric referral and psychiatric labelling of criminals. Conduct problems are often viewed as symptoms of psychological disorder and for many years, people felt that all criminals were psychiatrically ill. Psychiatry is often abused in the area of crime; for example, in China, psychiatry has been used to ‘imprison’ political dissidents with similar abuses noted earlier in the former Soviet Union as well (Bonnie, 2002[1]). High levels of mental illness in prisons is largely due to the psychiatric labelling of criminals and psychiatric concepts are commonly applied to convicted individuals due to ethical and social issues rather than medical considerations (Lamberti et al., 2001[9]). For disorders such as borderline personality disorder, sadism and intermittent explosive disorder, violent behaviour is one of the key diagnostic symptoms, and such psychiatric conceptualisations of violence as a key symptom leads to an over-diagnosis of these conditions (Paris, 1994[12]). The symptoms of specific mental illness may directly include crime or delinquency, for example in conduct disorder or oppositional defiant disorder. An important diagnosis is ‘Antisocial Personality Disorder’ (ASPD), which is the most common diagnosis in prisoners. ASPD is being criticised, with there being controversy over whether it constitutes a mental illness, and many suggest that it is no more than a moral judgement given a diagnostic label. Most reports and reviews says that it is an incurable disorder as are most personality disorders, yet the diagnosis is ever increasing with a need to label criminals as victims of psychiatric illness (Mulder, 1996[11]). The personality disorder diagnosis must be used where the characteristics traits of a personality disorder make its appearance in childhood with antecedents to the same being present and most characteristics being noted by the age of 14–15 years. It is wrong to diagnose someone with crimes seen after the age of 18 years as a case of personality disorder just to save him from the clutches of the law. It is also paramount that legal systems realise that personality disorders cannot be equated with major mental illnesses like schizophrenia and bipolar disorder which start and may be episodic while personality disorders are a lifelong enduring pattern of traits and behaviour.

The Common Link Between Criminality and Psychiatry

There are a number of common factors shared by both criminals and psychiatric patients. Demographic variables such as age, socio-economic status and race predict both crime (Farrington and Welsch, 2006[2]) and mental illness (Green et al., 2010[6]). Patients with personality disorders share a number of factors with criminals, both usually being young men, poorly educated, unemployed, and having a deprived upbringing and disorganised home environment (Samuels, 2011[15]). In essence, the mentally ill are prone to experience the same factors that predict criminality in the mentally healthy. What we mean here is that there may be a considerable overlap between the risk factors for major psychiatric disorders and criminality. Poverty, lack of social support, children from divorced families, exposure to severe trauma, child sexual abuse etc., are all risk factors for psychiatric illness in later life but these are the same factors that have been implicated in the genesis of crime and antisocial personality. It is worthwhile to note that risk factors in the genesis of psychiatric disorders and criminality may be similar, or at times even the same, but to imply thereby that crime and psychiatric disorders are causally linked is tenuous and incorrect. There are also a number of factors that predict crime and violence in the mentally ill. Violence prior to admission to a hospital is associated with violence after discharge, as is male gender, age, increased length of stay and cognitive impairment (Steinert et al., 2010[18]). Research suggests that the mentally ill may only be more prone to violence if they receive inadequate treatment (Volavka and Citrome, 2011[21]), have a long-standing paranoid attitude (Walsh et al., 2002[22]) and are actively experiencing delusions (Torrey, 2006[19]). Not all patients with mental illness may commit criminal acts but often when they so it is because they are under the sway of certain symptoms of the illness that prompt them to do so, e.g., command hallucinations; or they may be actively paranoid and deluded but left undiagnosed and untreated. They very often may not understand the nature and implications of the act they are committing and may do so on an impulse. Therefore, treatment directed toward full and complete remission of such symptoms should be the norm.

Substance Abuse

An important consideration is the impact of substance abuse in both crime and psychiatry. Long-term substance abuse is an independent risk factor for violence, and a diagnosis of a substance abuse disorder places individuals at risk of violence more than any other major mental illness (Fazel et al., 2009[3]). In those with a major mental disorder, co-morbid substance abuse increases the risk of violence four-fold. Substance abuse is frequently co-morbid with a variety of mental illnesses (Kelly et al., 2012[8]), and levels of co-morbidity appear to be elevated in mentally ill offenders (Pickard and Fazel, 2013[13]). Elevated substance abuse in psychopaths largely explains related violent crime (Trull et al., 2010[20]). Comorbid substance abuse may not only increase the risk of violent crime in the mentally ill, but may account for the relationship entirely, as studies have found that increased violent crime in the mentally ill is limited to those with a history of alcohol and/or drug abuse (Kelly et al., 2012[8]).

Flowchart of the paper

Conclusions [See also Fig 1: Flowchart of the Paper]

Crime and psychiatry are inter-related. There are criminals who have serious psychiatric illness and psychiatric patients who tend to commit serious crimes. The factors leading to crime and psychiatric disorders may be similar and at times intrinsically linked. It is very difficult to pinpoint one factor in the causation of both as multiple factors at various levels and trajectories play their part. The interdependence and intersection of crime and psychiatry need further research and elucidation though it is a difficult area of enquiry.

Take Home Message

The inter-relationship between crime and psychiatry is complex and needs further research and elucidation.

Questions that the Paper Raises

What is the relationship between crime and psychiatry?

What are the common factors that link both criminality and psychiatric illness?

What is the role of substance abuse comorbidity in crime and psychiatric illness?

Is criminality more in patients with psychiatric illness?

Is psychiatric illness more common in criminal offenders?

About the Author

Yusuf Matcheswalla MD is Honorary Professor of Psychiatry at the Grant Medical College and Sir JJ Group of Hospitals, Mumbai. He is also Head of the Department of Psychiatry at Masina Hospital, Mumbai. He is a regular speaker at various conferences all over India. He is interested in various social mental health and general health activities through his non-governmental organization ‘Humanity Health Organization’ and runs one of the largest support groups for relatives of patients with psychiatric illness called ‘Dilaasa’.

Avinash De Sousa MD is a consultant psychiatrist and psychotherapist with a private practice in Mumbai. He has over 280 publications in national and international journals. His main areas of interest are alcohol dependence, child and adolescent psychiatry, mental retardation, autism and developmental disabilities and electroconvulsive therapy. He teaches psychiatry, child psychology and psychotherapy at over 18 institutions as a visiting faculty. He is one of the few psychiatrists who, in addition to a psychiatry degree, has an MBA in Human Resource Development, a Masters in Psychotherapy and Counseling, an MPhil in Psychology and a doctorate in Clinical Psychology.