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.
Trang 1Edited, written and revised by
John Gunn
Written by John Gunn David Mawson Paul Mullen Peter Noble Deception, dissociation and malingering
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
foren-sic 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
contingen-cies 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
avail-able, or vulnerable object, is common In some
claim-ants and litigclaim-ants 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
1st edition edited by Paul Mullen
a tragic attempt to restore an unbearable loss through pursuit of the substituted goal
DaydreamingDaydreaming 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
LyingLying, 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 inten-tional lie merges into self-deception and we move, all too easily, from knowingly fabricating into believing our own stories
Trang 2In pathological lying (pseudologia fantastica; see below),
there is created a tissue of fantastic lies in which the
decep-tion 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
advan-tage or prestige, rapidly develop to a sadvan-tage where they are
disproportionate to any discernible end or personal gain
Commonplace lies deceive about matters of fact, the
fabri-cations of the pathological liar deceive about who and what
s/he is; they are about creating a new identity and
recreat-ing the world Pseudologia fantastica is about lyrecreat-ing, 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
self-deception, 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
com-mon 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
theo-retical ambiguities, but is none the less potentially of wide
applicability in psychiatry Many aspects of what we term
unconscious, dissociative, hysterical, or even abnormal
ill-ness behaviour can, from a different perspective, be spoken
genu-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
phenom-enon 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 hold-ing 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:
1 activities which appear incompatible with the al’s previous claims or behaviour;
individu-2 the refusal of the self-deceiver to give adequate (or at least acceptable) justifications for his or her activities;
3 a refusal to accept responsibility for activities and their consequences which appears to stem not from disre-gard of those responsibilities, but from an inability to recognize the transgressions;
4 an adherence to the deception which persists even when it becomes personally disadvantageous
The latter two characteristics which speak of loss of control tend to soften, or even remove, the moral con-demnation 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 presum-ably be experienced as having a conviction or desire no different from any other We assume that some discom-fort and disequilibrium accompanies most self-deceptive engagements, which may be experienced as unease or
self-a puzzlement self-at one’s own self-appself-arently disproportionself-ate vehemence
Self-deception covers a wide range of human activity
It covers the exuberant, if shallow individuals, who mit 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
com-in ignorance of their own motives It com-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 ing A young man who had strangled his girlfriend was examined a matter of a few hours after the event He gave,
emerg-at themerg-at time, an account of the killing marked by greemerg-at tress 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
Trang 3dis-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
hon-estly 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
sys-tem 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
sys-tem 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
falsifica-tions 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
fron-tal 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
nor-mal 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
condi-tions, 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 empha-sis 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
LyingLying, 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 ance 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
reassur-a lreassur-arge industry in the criminreassur-al 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 con-fessions 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 technol-ogy are allowed in British courts
An exception to the arousal theory is the attempt to detect lying by using the fMRI scanner Initial research sug-gested that the act of lying produces more prefrontal cortex activity than telling the truth does However some sophis-ticated transAtlantic collaborative research has found that subjects can beat the scanning test by simple distracting countermeasures, presumably to deflect their concentra-tion, 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 overenthusi-astic technological interrogator
Trang 4The 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
prefron-tal 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
guess-ing) 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
inves-tigation 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 knowl- edge’ which proved that she had to be the killer Her ex- fiancé 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, per- formed 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 do not get bemused by new nologies No doubt they will find a niche, but let us hope that they do 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
tech-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:
1 Extensive and gross fabrications
2 The content and extent of the lies are disproportionate
to any discernible end or personal advantage
3 The lies deceive not just about matters of fact, but tempt to create a new and false identity for the liar
at-4 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
5 The lying is a central and persistent feature of the tient’s life and the mythologism of a lifetime comes to supplant valid memories
pa-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,
Trang 5however, excluded deluded or otherwise psychotic subjects
(e.g Healy and Healy, 1915) Closely related conditions are
Munchausen’s syndrome (Asher, 1951) and feigned
bereave-ment (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
depres-sion 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
encoun-tered 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
conniv-ance 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 victim- ized, 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 mem- ber 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-aggran-dizement 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 confabula-tions He believed that recent reminiscences are temporar-ily 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 grati-fication of an occasional audience that is impressed, this pleasure is short-lived, only to be followed by the humilia-tion of being treated as a liar Such patients are soon gener-ally disbelieved, and they may be teased mercilessly Such behaviour does merge into more externally goal-oriented deception
Pathological lying is usually encountered in sic practice in those accused of fraud, swindling, mak-ing false accusations or false confessions (Powell et al., 1983; Sharrock and Cresswell, 1989) Once the counterfeit
foren-is exposed, the pathological liar will often give up hforen-is 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 acknowl-edging 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 fur-tive and carefully planned dishonesty of the more typical
Trang 6fraud Pathological liars are closer to confidence tricksters,
though unlike them, they do not take the money and run,
but persist in the pretence long after exposure is
inevita-ble 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
ado-lescence 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
hos-pitalization, suicide attempts and a family history of
psy-chiatric 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
neuro-physiologic correlates, is sorely needed.’ That remains the
position; no further research on this topic has been
con-ducted 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 à deux’ or ‘shared daydreams’ (quoted in Birch
et al., 2006)
Enoch and Ball (2001) sub-classified pathological lying into four types:
1 The professional impersonator who pretends to be a
doctor, a priest, a lawyer
2 The swindler who pretends to be wealthy and/or an
im-portant business man
3 An outraged woman who alleges a fictitious sexual
assault
4 A false confessor who claims to have committed a
seri-ous crime
To this list we would add the common fantasist, common
because the condition occurs more frequently than the
oth-ers 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
discus-sion in an attempt to provide some insight and help induce
some self-control, but these efforts often fail
Abnormal Illness BehaviourParsons (1951) regarded illness and health as socially insti-tutionalized 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 obli-gations 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 ceived, evaluated and acted (or not acted) upon by differ- ent kinds of persons.
per-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 do with biological systems or the pathogenesis of disease
He went on to ask himself: Why do 50% of patients entering medical care have symptoms and complaints that
do 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 situ-ations, 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 expla-nation 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
Trang 7support 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’,
hyp-notized 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,
includ-ing 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
dissocia-tive seizures A remarkable philosophical treatise has been
written on the subject, not by psychiatrists but by a
phi-losopher, 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
manifesta-tion 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
specta-cle 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
psychia-trist 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
con-sidering 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 do 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 emo-tional 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 hys- teria 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.1Charcot 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 urina-tion, 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 tional states such as terror, ecstasy, and amorous supplica-tion, all ending in the final and fourth stage of delirium
emo-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 sociative disorders The twentieth century saw the disease
dis-of hysteria transmuted into other conditions such as shellshock which reinforced the notion that the symptoms
1 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.
Trang 8arise 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 sion states.
posses-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
personal-ity 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
treat-ment 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
cen-tury 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
interven-tion 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:
soma-toform 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
cer-tainty is when clear evidence is available of some sort of
conscious intervention to produce the fit Even then takes 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
mis-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
1 attempted restraint of the convulsive movements leads
to struggling, even combativeness;
2 absence of cyanosis;
3 normal pupil responses and corneal reflexes present;
4 pressure on the supraorbital arch causes head withdrawal;
5 the level of consciousness fluctuates during the seizure;
6 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 inju-ries 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 delib-erately simulated seizures are rare All psychogenic sei-zures, 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 chotherapy in order to unravel the driving force behind the seizures, whether that force is conscious or unconscious,
psy-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 tom 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,
symp-a finding only elicited in those chsymp-arged with offences of lence Within the amnesic group, nearly half were charged with murder Only five of 59 amnesic offenders were sus-pected of feigning; the others were thought to have this dissociative amnesia (see also chapter 12)
Trang 9vio-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
psycho-genic 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 2 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
malin-gered 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
requir-ing 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
dissocia-tive 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
commu-nication 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
litera-ture 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
liter-ary 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 popu-lar 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 cerned 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
con-it feels like to be in this scon-ituation
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 asso-ciated with multiple personality disorder
The origins of multiple personality have been esized to lie in repeated dissociations These patients are peculiarly prone to dissociative states in response to stress
hypoth-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).
Trang 10The authenticity of multiple personality as a clinical entity
has been repeatedly questioned, although its advocates,
such as Greaves (1980), considered its existence to be
dem-onstrated 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
rec-ognize 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
‘personal-ity’ 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
symp-tom; 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 do
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 sen-tence which he was about to impose
The lack of responsibility argument is akin to the ments 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 dif-ferent 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 compartmental-ized, 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?
argu-Fugue StatesFugue literally means to take flight or escape, but its use
in psychiatry is best confined to transitory abnormal behaviour characterized by aimless wandering with altera-tion 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 matic 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 per-sonality disorder, and dissociative amnesia is fairly clear
trau-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 lived (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 epi-sode Fugues are usually precipitated by a stressful episode, and upon recovery there may be amnesia for the original stressor
Trang 11short-Fugues may be encountered in forensic psychiatric
practice in subjects who, following committing a criminal
act, or in the context of imminent detection, suddenly
wander off apparently in a state of disturbed
conscious-ness For example, a young man may disappear suddenly
from work, only to turn up 5 days later in a state of total
exhaustion and inanition wandering in the outskirts of a
foreign city When questioned, he claims no knowledge of
the events of the previous days, or how he had managed to
get there Subsequently, it may emerge that an audit at his
place of work revealed that he had been misappropriating
funds Another example might be a man of previous good
character stabbing an acquaintance in an argument,
wan-dering off into the freezing cold of a winter’s night without
a jacket or overcoat, to be found some hours later walking
apparently aimlessly and in a perplexed and disoriented
state and claiming total amnesia for the night’s events
Occasionally, acts committed during a fugue state may lead
to criminal charges
As with all dissociative states, treatment, if considered
necessary after a spontaneous recovery, should be
support-ive psychotherapy which aims to uncover, in a safe
relation-ship, the stresses that have driven the behaviour
Possession States
Possession states, which are a rare form of dissociative
disorder in western societies, are characterized by claims
to have been taken over by a spirit or some external power
They have to be distinguished from the passivity
experi-ences and delusions of control found in the schizophrenias
In cases where fugue or possession states are claimed to
have been present at the time of a serious act of violence,
the defence, in Britain, may raise the issue of non-insane
automatism, but they are unlikely to succeed now that
violent automatic behaviour has been designated as insane
automatism
Amok and windigo
Amok (or amuck) is a term that has been applied to any
sud-den outbursts of violence, but in psychiatry it has tended to
be confined to a so-called culture bound reactive syndrome
involving the peoples of the Malay archipelago (Linton,
1956; Yap, 1969; Carr and Tan, 1976) Amok in Malay has
the meaning of rushing in a state of frenzy to the
commis-sion of indiscriminate murder (Oxford English Dictionary)
There were reports from Java by early Dutch and British
colonists of Malays running amok (Spores, 1988)
Amok was claimed originally to have three phases
(Gimlette, 1901; Burton-Bradley, 1968; Westermeyer, 1982):
1 a prodrome characterized by social withdrawal and
anxious brooding;
2 a sudden furious outburst in which a number of people
are attacked at random; and
3 sudden termination of the attacks, sometimes in tended stuporous sleep, but always with subsequent amnesia for the events
ex-This description is probably, at least in part, overlain by mythology (see below)
A number of precipitants have been described, the most common involving some overwhelming blow to the individual’s self-esteem and social prestige Others include acute intoxication (Westermeyer, 1973); organic brain syn-dromes (Van Loon, 1927); social stress as in migration; and relationship difficulties such as jealousy (Carr and Tan, 1976) The Malay culture is said to place a strong emphasis for males on retaining social prestige and avoiding loss of face A powerful interdiction exists towards suicide The act of running amok (becoming a pengamok) in traditional Malay culture allowed a discredited or shamed male to bring about his own destruction, as the amok was often terminated by the killing of the pengamok or, if he survived, restoring his prestige Amok was a recognized, if not sanc-tioned, social performance
Windigo is a related syndrome described in the Ojibwa Indians of sub-Arctic North America The males of this tribe spend the long winter months hunting alone in the frozen wastes Their prestige depends on success, and failure brings shame (Friedman, 1982) The windigo is believed to be a giant phantom compounded of all those who have starved to death in the past (Meth, 1974) This phantom is believed to be capable of possessing a man and metamorphosing him into a murderous cannibalistic monster The development of windigo is associated with failure in the hunt and especially famine A prodrome of sleeplessness, depression and brooding is described, fol-lowed by an outburst of murderous activity in which the family as well as fellow members of the tribe are attacked and attempts made to consume their flesh (Landes, 1938)
The state is terminated by the killing of the windigo or by his suicide As with amok, this picture is at least in part mythological
Analogies have been drawn between amok and the den outbursts of murderous violence directed at a number
sud-of victims which occur periodically in western societies (Teoh, 1972; Westermeyer, 1982) Superficial similarities certainly exist in that they both involve a public display of apparently motiveless violence, often terminated by the killing or suicide of the perpetrator Both seem to have elements of contagion in that amok violence has been described as spreading epidemics through some Asian communities (Westermeyer, 1973) and spectacular mass killings can spawn copy-cat killings The analogy, how-ever, obscures more than it illuminates Mass killers in western societies are a heterogeneous mixture including disgruntled teenagers, gun-obsessed inadequates, deluded psychotics and misguided fanatics Those who live to tell of their outbursts are not reported to claim amnesia for the events To describe a sudden outburst of violence as amok,
Trang 12in the technical rather than lay sense, evokes a spurious
confidence that we have somehow understood the events
This could inhibit the proper exploration of the actual
con-text and state of mind of the perpetrator
From a treatment perspective it is essential to guish these dissociative states from systematized paranoia
distin-which frequently involves long-standing delusions, sexual
thoughts, planning, and mass destruction, often including
suicide The case of Ernst Wagner (chapter 9) is the first and
one of the best descriptions of this dangerous condition
Deception
This section deals with topics where the possibility of
deception is frequently raised Many of the patients
dis-cussed here are, however, not deceiving anyone
Compensation Neurosis
It is probably wrong to include compensation neurosis
under the general heading of deception as most of the
peo-ple claiming compensation after an accident are deceiving
neither themselves or anyone else, yet unfortunately
com-pensation neurosis has become a pejorative term which
has many pseudonyms, e.g ‘accident neurosis’, ‘greenback
neurosis’, ‘profit neurosis’, ‘railway spine’, and ‘unconscious
malingering’ Kennedy (1946) gave expression to such
prejudice in the following aphorism:
A compensation neurosis is a state of mind, borne out
of fear, kept alive by avarice, stimulated by lawyers, and cured by a verdict.
The difficulty is that the emotional effects of an injury
manifest themselves within a personal and social
con-text Least psychological damage occurs when injury can
be accepted as part of a natural order Feelings of anger
and resentment exacerbate physical and psychiatric
symptoms Litigation is almost always protracted and
involves repeated medical examination The patient’s
attention is focused on his or her grievance and
symp-toms Finally, in court, disability is financially rewarded
and any recovery may reduce the level of compensation
This process exacerbates psychological symptoms and
hampers recovery The experience in New Zealand of a
government-run accident compensation scheme has,
however, amply demonstrated that merely removing the
courts and the litigation process in no way reduces either
the psychological problems or the temptation to
exag-gerate or fabricate compensatable injuries In fact, it may
increase these problems, as all injuries become
poten-tially compensable irrespective of whose responsibility
they may have been
The problem is neatly illustrated by considering the effects of minor concussional head injury Virtually every
individual who leads an active life has sustained an injury
causing a brief interruption of consciousness Recovery is
almost always prompt and complete, except where tion is involved Thus, if a man falls off his own ladder and bangs his head he recovers quickly, but if he falls off his employer’s ladder and becomes involved in compensation, persistent disability may follow
litiga-Lishman (1968) noted:
Central to most descriptions are headaches and ness, but to these may be added abnormal fatiguability, insomnia, sensitivity to noise, irritability, and emotional instability Anxiety and depression are often prominent
dizzi-Difficulties with concentration and memory may feature strongly among the complaints, and some degree of overt intellectual impairment may on occasion be detected
With this mixture of quasi-organic and subjective toms, variously reported, it is scarcely surprising that the concept lacks clarity and that its aetiology has remained
symp-in doubt Nevertheless, its ubiquity followsymp-ing even msymp-inor blows to the head, and the regularity with which it fea- tures among claims for compensation, have ensured that
it persists as an important subject for medical interest and debate.
In his textbook Lishman (1998) pointed out:
In some, probably rare, cases there will be entirely scious simulation for gain, but in the great majority the compensation issue colours the picture in more subtle ways Once the possibility of compensation is raised the patient finds himself in complex legal dealings; there are frustrations due to delays, anxieties due to conflict- ing advice and often capital outlay In effect the injured person is invited to complain and, having done so, finds
con-he has to complain repeatedly, over years to a number
of specialists Repeated questioning from lawyers and doctors not only focuses the patient’s attention on early symptoms which perhaps were due to recede, but in addition reinforces the prospect of their continuance and worse to come.
Thus in the early days or weeks after injury the concussional syndrome is probably directly related to the cerebral trauma but, subsequently, it becomes overlain
post-by psychological factors and in some cases deliberate exaggeration
The literature on the recovery of psychological toms after settlement is confused Miller (1961, 1966) followed-up an unrepresentative sample of 50 neurotic patients from a total of 200 head injury cases and found that 90% returned to the same or similar employment after their cases were settled Kelly (1981) documented
symp-100 ‘post-traumatic syndrome’ patients, but traced only 43 after a follow-up period averaging 2.8 years No patient was personally interviewed Many patients had improved and returned to work by the time the case was settled, but of the 26 not working by settlement, 22 were still not working
at follow-up, which led him to conclude that the ‘cured by a verdict’ jibe is not correct
Trang 13Perhaps the most comprehensive review is by Mendelson
(1984) He looked at 18 follow-up studies of personal injury
litigants Of these only three studies, including the one by
Miller, favoured the view that claimants improved within
a fairly short time of the finalization of their claims Six
studies were discounted because of the small number of
patients examined Nine studies indicated that of patients
who stopped work following a head injury, between 50 and
85% failed to return to work after a settlement For patients
with a low back injury, 35% were unemployed after a
mini-mum of 3 years following settlement Patients with neck
injuries had persistent disability of a severe degree, namely,
12–60% of cases 5 years after the injury Tarsh and Royston
(1985) carried out a follow-up of 35 claimants who had an
‘accident neurosis’ Patients were followed-up from 1 to 7
years after compensation was received Few recovered and
such recovery as did take place was unrelated to the time
of compensation Most cases still had continuing and often
severe symptoms at follow-up, and about one-third of the
group seemed certain to be always going to lead lives of
invalidism, totally dependent on other family members
Mendelson (2003) summarizes the situation well He
traces the beginnings of so-called compensation neurosis
to the development of the railways in about 1830 which
gave rise to a lot of higher speed transport accidents and to
symptoms that had not been noticed very often before, and
thence to the new diagnoses of ‘railway spine’ and ‘nervous
shock’ This latter term is still used within the legal world
(see p.53) Mendelson also indicates that the introduction
of workers’ compensation legislation at the end of the
nineteenth century led many to postulate that it was the
financial gain which led to the prolongation of disability
This implied that compensation neurosis was a subtype
of malingering Mendelson described such explanations as
‘inaccurate and simplistic’ He said:
There are many factors that influence outcome following
compensable injury… and a new paradigm is needed that
takes into consideration these variables and provides a
comprehensive explanatory model that, ultimately, may
lead to effective interventions.
Beck (1829) wrote in a nineteenth-century law textbook
that where illness might be feigned we have a
double duty… to guard the interests of the public… and
also those of the individual so that he be not unjustly
condemned.
That advice may be nearly 200 years old, but it is a useful
benchmark for the twenty-first century
In considering an individual case it is useful to
remem-ber that ‘recovery’ and ‘return to employment’ are very
dif-ferent Many complainants are manual workers in mid-life
who have little motivation to return to the sort of poorly
paid employment which would leave them little better
off than when in receipt of state benefit The boundary
is blurred between what is genuine, what has a genuine
basis, but is exaggerated, and what is gross malingering
Often one develops chronologically from the other It may
be that the immediate response to injury, be it physical or psychological, is almost always genuine and would have occurred in the absence of any compensation claimed To reiterate the point made by Lishman above, the lengthy process of pursuing compensation hampers recovery and encourages exaggeration; sometimes naturally occurring recovery is not frankly admitted As the litigation pro-gresses over years, some suggestible individuals elaborate their symptoms; these cases tend to carry a poor prognosis
The plaintiff ’s account of the past is often distorted and pre-accident physical and psychological disabilities may
be concealed Careful examination of the full family titioner case notes and correspondence is often revealing
prac-Malingering can occur, but is difficult to detect on the basis
of a single psychiatric examination Sometimes enquiry agents’ reports and videos indicate that allegedly disabled subjects are, in fact, working clandestinely and leading comparatively normal lives
Management therefore requires a good deal of sensitive enquiry, a working relationship with the whole family (if there is one) and above all the application of pressure to the lawyers involved in the case to resolve the matter as quickly
as possible This is difficult because lawyers believe that their client has a right to the best possible financial settle-ment even if this means delay, and therefore delay in return
to health Once the settlement has been agreed tion may become difficult because an important purpose-ful activity will have been removed from the patient’s life and new activities which can fill that vacuum need to be negotiated The Miller view that patients get better as soon
rehabilita-as the compensation is paid is not our clinical experience and many of the symptoms persist for many years as does the disability
MalingeringMalingering is a highly pejorative term, linked not only with words such as lying and deceit, but also with scrounger, workshy, coward It implies the wrongful acquisition of the privileged status of the ill, and it is further linked with dishonest acquisition of money In times of war it has the special odium of seeking personal safety and comfort when others are making sacrifices to achieve highly desired group objectives Such people may be branded as shirkers, funks and degenerates Above all, pretending to be ill is regarded
as ‘shameful’ It is no wonder it is a vexed topic for medical professionals as they are expected to accurately point the finger at those who shall be deprived of the illness status, and their claims and who will thus fall to the very bottom of the social hierarchy In times of war some alleged malinger-ers may be regarded as so heinous that they are executed
The history of this problem has been briefly but well documented by Wessely (2003) He pointed out that the
Trang 14simulation of illness is as old as humankind He suggested
that it was the introduction of progressive social
legisla-tion in Germany between 1880 and 1890 and in Britain
in 1908 with The Workmen’s Compensation Act and the
1911 National Insurance Act, that made this simulation a
medical problem These acts were regarded by the medical
profession as inducements to malinger and quite a number
of doctors set themselves up as gatekeepers for the state
against such temptations Initially malingering was thought
to be mainly a matter for physicians and surgeons, but the
First World War added a very significant psychological
dimension even though the psychiatric casualties of that
war were considered to be suffering from ‘nervous shock’
which was also thought to be a physical disorder (damage
to the nervous system by terrible noise and blast from the
heavy guns) Wessely suggested that at the beginning of the
twentieth century there was a perceived decline in the
pre-war moral codes that had governed society Malingering
was considered to be a form of lying and medical man was
best placed to detect it!
As we have seen, if it really is lying, then it is going to be mighty difficult to detect Perhaps courts who claim to be
able to detect liars are better placed to do this work than
doctors Sprince (2003) suggested that medical evidence
about malingering is not particularly significant in a court
of law Where claims have been resisted in whole or in part
by reference to malingering, courts have rarely reached a
positive finding that an individual is or is not
malinger-ing and in appeal cases malmalinger-ingermalinger-ing rarely arises Further
where the claim has been lost, presumably because the
claim is not considered to be genuine in all respects, it is
rarely followed by a criminal prosecution for fraud
For a comprehensive text on malingering and illness deception see Halligan et al (2003)
Feigned mental illness
In the nineteenth century, there was considerable interest
in identifying malingerers who simulated mental disorder
Beck (1829), in spite of his views quoted above, devoted
considerable space in his text on medical jurisprudence
to the recognition of feigned diseases and, in particular,
offered no fewer than 12 strategies for unmasking those
pretending madness Tuke (1892) noted that simulators
of insanity made errors in such matters as adding 3 and
4, or the number of shillings in a sovereign, or in
identify-ing commonplace objects He stated that the unskilled
malingerer answers nothing right, constantly falling into
absurdities quite foreign to true insanity Maudsley (1867)
also noted:
Imposters generally overact, thinking the lunatic widely different from a sane person… [he] pretends he cannot remember things such as what day follows another, or how many days there are in a week, that he cannot add the simplest figures… [he] answers stupidly where a real
lunatic who was not an idiot would act cunningly and answer intelligently.
Chesterman has written two articles on psychiatric malingerer catching Broughton and Chesterman (2001) described a man who assaulted a teenage boy and then feigned mental illness He later confessed to malingering but doesn’t seem to have done very well The authors do stress however that the discovery that an individual has fabricated symptoms should not exclude him or her from further assessment and treatment, as such fabrication should be viewed as a form of abnormal illness behaviour
in an often resourceless, inadequate and vulnerable vidual Chesterman et al (2008) take twenty-first century British psychiatrists, especially authors of this textbook, to task for not giving enough attention to malingering They believe that this is due to a false assumption that psychotic symptoms are faked in order to ward off real psychosis (Jung 1903) The paper is a useful review of the research in this field and suggests some tests which have all the draw-backs and low validity one might expect, in order to detect malingered psychosis They go on to say:
indi-It appears that the incidence of malingered psychosis may well have increased over recent years as a conse- quence of the closures of long-stay psychiatric institutions and the move towards care in the community Many chronically mentally ill patients, who may have preferred the stable environment of the asylum, are now living in marginal circumstances in the community… Such indi- viduals may therefore consciously exaggerate their symp- toms in an effort to obtain shelter in the new generation
of psychiatric hospitals… It has also been proposed that there has been a change in coping strategies among soci- ety’s disenfranchized individuals, who now present with psychological rather than physical symptoms.
They also emphasize the importance of detecting gering but don’t say what this importance is, other than a possible miscarriage of justice in a homicide case in which
malin-a mmalin-anslmalin-aughter verdict of diminished responsibility on grounds of mental disorder is preferred to a murder verdict
There is no research on the prevalence of such problems
The question of what is malingering is claimed by some
to be straightforward An early authority, whose text on the subject was dedicated ‘to my friend the British workman,
to whom I owe so much’ (Collie, 1917) cited Lord Justice Buckley The judge defined a malingerer as ‘one who is not ill and pretends that he is.’ Collie also cited Bramwell who distinguished between ‘malingering’ (conscious, deliberate simulation of disease, or exaggeration of symptoms) and
‘valetudinarianism’, where the process is unconscious or subconscious In a more recent study of feigning after brain
or spinal injury, Miller and Cartlidge (1972) defined gering as: ‘all forms of fraud relating to matters of health.’
malin-This includes the stimulation of diseases or disability which are not present; the much commoner gross exaggeration
Trang 15of minor disability; and the conscious and deliberate
attribution of a disability to an injury, or accident that did
not in fact cause it, for personal advantage In a lecture, a
psychiatrist with a medico-legal compensation practice in
Australia (Parker, 1988), claimed:
A week will not go by without seeing at least two
malin-gerers, and about the same number with gross conversion
hysteria.
Nevertheless, he went on to warn, using the words of Asher
(1958):
The pride of a doctor who has caught a malingerer is
akin to that of a fisherman who has landed an enormous
fish; and his stories (like those of fishermen) may become
somewhat exaggerated in the telling.
It could be that there is a special form of malingering, the
feigning of psychotic illness The following kind of
argu-ment may not be uncommon
The trouble is that as soon as the language of
‘patient-treatment-disease’ is used, it is hard to diagnose insanity
in anyone who commits a really horrible act; for to be
cured of mental disease is to be sane, and a sane man
does not do such things; there is a merging of the
lan-guage of medicine and the lanlan-guage of morality; if bad is
sick, then sick is bad, and sane must be good The more
we treat someone as a patient, the more likely we are to
give his sincerity the benefit of the doubt We tend to ask
‘What makes him behave like that’ instead of ‘is he telling
the truth?’ and ‘could he behave differently if it was to his
advantage?’ (Mount, 1984).
It is certainly a robust statement of the antipsychiatry
posi-tion Yet medical practitioners can also have considerable
scepticism about mental disorder in those charged with
serious crimes An anecdote from Ray (1838) illustrates
just how far preconceptions about deception, malingering
and moral responsibility will take even the experienced
observer
Jean Gerard, a bold villain, murdered a woman at Lyons
in 1829 Immediately after being arrested, he ceased to
speak altogether and appeared to be in a state of fatuity
He laid nearly motionless in his bed, and when food was
brought his attendants raised him up and it was given
to him in that position His hearing also seemed to be
affected The physicians who were directed to examine
him concluded that if this was actually what it appeared
to be, paralysis of the nerves of the tongue and ear, actual
cautery applied to the soles of the feet would be a proper
remedy It being used, however, for several days without
any success, it was agreed to apply it to the neck For
two days no effect was produced, but on the third, while
preparations were making for its applications, Gerard
evinced some signs of repugnance to it, and after some
urging, he spoke, declaring his innocence of the crime of
which he was charged His simulation was thus exposed.
Whether or not this practice resolved the question of malingering, today it should surely be a matter for a profes-sional licensing body
To try to understand just how easy or difficult it is to simulate mental disorder, Anderson et al (1959) carried out a study in Australia Eighteen psychology students were asked to simulate mental disorder Six were asked to imagine that they had committed murder and they were
to feign insanity to escape the consequences Twelve were asked to feign insanity for their own reasons The subjects were then subjected to a standard psychiatric examination
None of the pictures presented resembled well-defined psychiatric disorders Even the better performances lacked consistency and persistence The commonest simulation was of depression, in two people accompanied by amnesia;
three also simulated paranoid features On cognitive ing, errors were produced, especially approximate answers
test-One tried to make out he was an epileptic, another tried to simulate feeble-mindedness Unfortunately, the psychiatric examinations were not carried out blindly, so although the experimenters were not very impressed by their students’
acting, it is difficult to know whether they could have ally been fooled
actu-Perhaps the most famous test of simulated psychosis is
‘on being sane in insane places’ (Rosenhan, 1973) Five male and three female volunteers, a psychology student, three psychologists, a paediatrician, a psychiatrist, a painter, and
a housewife became pseudo-patients and gained ‘secret admission’ to 12 different hospitals The pseudo-patients complained that they were hearing voices, they changed their names and occupations, but otherwise told the truth
The ‘voices’ were stopped immediately on admission
Each was diagnosed as having schizophrenia, but soon discharged as in remission (length of stay varied from 7–52 days) Other patients sometimes recognized the pseudo-patients as frauds Rosenhan concluded, ‘it is clear we cannot distinguish the sane from the insane in psychiatric hospitals.’ A torrent of replies disagreed The strongest criti-cism was perhaps by Spitzer (1975), who pointed out that
it is not very surprising that psychiatrists do not diagnose pseudo-patients when they are not looking for them He concluded himself, however, that the data actually sup-ported the view that psychiatrists are good at distinguish-ing the sane from the insane
None of this is much help if a psychiatrist is faced with
a patient in a situation in which having a psychosis would
be a distinct advantage There is no simple answer and the principles of assessment and management will be the same
as if simulation of physical disorder is suspected As much information as possible should be collected from as many sources as possible, and a professional relationship should
be built with the patient In this way, the nature of the patient’s problem will emerge ( for the one thing that will
be true, unless s/he is one of Rosenhan’s research workers,
is that s/he will have a problem)
Trang 16Malingered psychiatric disorders are encountered both
in situations where compensation is at issue and in those
facing criminal charges Malingered psychiatric disorders
may occasionally be encountered in those seeking
admis-sion or transfer to a psychiatric hospital from prison The
malingerer sometimes believes s/he has to appear mad
or idiotic in every sphere of function and thus presents
such an exaggerated picture that suspicions are raised,
even in the most trusting This type of malingerer, who
counterfeits a disorder too mad to be mad, often claims
gross disorientation under the misapprehension that the
mentally disordered suffer a global confusion More subtle
malingerers draw on their experience with mentally
dis-ordered individuals They may claim to be hallucinated,
in which case the hallucinations tend to be described
as omnipresent, distressing and without the usual
asso-ciation with mood changes or delusional developments
Flamboyant claims about the content and extensive nature
of hallucinations often contrast with the meagre and vague
account provided of the form of the experience in terms
of being experienced in objective space, having directional
qualities Malingered hallucinations may also take
atypi-cal forms as when a vision of a person is described which
talks to the patient and may even enter into conversation
Occasionally, command hallucinations are offered as an
explanation of offending These should be treated with
some scepticism when presented in the absence of other
features of psychotic illness
Command hallucinations have a particular appeal to the malingerer as they offer both evidence of mental disor-
der and at the same time incorporate a direct exculpatory
element Claims are made by offenders that they
commit-ted criminal acts because the voices told them to do so, and
they were unable to resist the instruction In fact violent
acts secondary to command hallucinations are rare, even
among people suffering from psychosis (see chapter 14)
Occasionally, distressed and disturbed individuals will
report command hallucinations to dramatize their suicidal
or homicidal impulses
Fabricated delusions are less common Malingerers usually present a straightforward account of persecution
or control which accounts conveniently for their acts
or makes necessary their transfer The accounts differ
from actual delusional experiences both in providing an
unusually clear storyline and paradoxically containing
elements of the totally fantastic One young man gave an
account of being followed and persecuted by shadowy
figures whom he claimed had arranged for him to be
locked in a cell on board a ship which was about to be
sunk When questioned, he went to the prison window
and pointed out at the surrounding sea, then abruptly fled
under the table claiming the boat (prison) was sinking
Fabricated accounts, unlike true systematized delusions,
rarely contain the typical mixture of self-referential
mate-rial and laboured constructions placed on minor points
proving, to the patient’s complete satisfaction, the sional claims Malingered delusions are often said to have emerged at a particular point, usually relatively recently, and to have, from the outset, their fully fledged content
delu-In genuine delusions, it is usually possible to discern their gradual development from the initial intuition through an extended process as the patient uncovers the full extent
of ‘the truth’
Language disorders are rarely, if ever, malingered Manic states are difficult to imitate, but depressive syndromes rel-atively easy Most of us have sufficient experience of despair and despondency to mimic depression Where suicidal intent is claimed in the context of an account of depres-sion which appears so atypical as to raise suspicions about malingering, it is probably wiser to give the benefit of the doubt to the individual until s/he can be observed carefully
In disorganized and disturbed personalities, so common in forensic psychiatry, instability of mood and markedly atypi-cal depressive syndromes occur not infrequently, and they are all too often coupled with self-destructive behaviour
Malingered mental disorders are often presented boyantly and insistently Any questioning of the reported experiences is likely to be greeted by assurances that it is
flam-‘the truth’, or with the accusation that you don’t believe the patient In genuine disorders, the abnormalities of mental state usually emerge gradually as the interview progresses
Some malingerers are suggestible and can be induced to add contradictory and absurd symptoms to their account, but more calculating malingerers will stick doggedly to their basic story
To summarize, the detection of malingering is a cult, but not entirely mysterious art The longer the patient
diffi-is studied, the more carefully the information diffi-is gathered and checked, the easier it becomes to detect malingering
The patient should be encouraged to talk freely rather than
to answer formulaic questions Malingering patients tend
to have an air of exaggeration, a disproportionate bias in their symptoms, and their complaints do not fit with objec-tive observations from others They tend to tell lies and so their accounts differ from time to time However, it also has to be remembered that differences between objective and subjective accounts may be due to many factors other than malingering Inconsistencies between interviews may
be entirely compatible with the memory failures of normal recall, and with clinical change as the disorder progresses
Exaggerated, overoptimistic, or even pessimistic accounts may be due to mood changes Self-deception may replace conscious lying and dissimulation There are no absolutes
in the detection of malingering, but standard techniques
of cross-checking, observation, repeated interviewing, together with the skill of an experienced interviewer who is alive to the possibility of malingering are the best that can
be done It is worth remembering that hostile questioning
of distressed patients will probably increase rather than reduce error
Trang 17The growing neuroscience of perceptual and cognitive
distortions explored by Myslobodsky (1997) and Halligan
et al (2003) is likely to enhance our understanding of
just how blurred the boundaries between normality and
abnormality may be
Munchausen’s syndrome
Munchausen’s syndrome was described and named by
Asher in 1951 Like the famous Baron whose tales were
bowdlerized and published by Raspe (1786), the affected
persons had travelled widely, and they related tales which
were both dramatic and untruthful Typically, such patients
will be admitted to hospital with an acute, harrowing, but
not entirely convincing history; their manner is evasive
and truculent; and, on enquiry, it may be revealed that they
have attended and deceived other hospitals, often
discharg-ing themselves against advice
Most cases resemble organic emergencies and favour
three main variants:
1 The acute abdomen type which is usually accompanied
by a multiplicity of abdominal scars
2 The haemorrhagic type, usually reporting haemoptosis,
haematemesis, or haematuria
3 The neurological type, with headache, odd fits, or loss of
consciousness
Asher’s title for this group of patients now seems
well-estab-lished The patients tend to be emotionally labile, lonely,
attention-seeking and establish little rapport Multiple
aliases and repeated admissions are central features and
some cases also fulfil the criteria for pseudologica
fantas-tica Some are seeking narcotic drugs
A sinister variant of the condition has been described
as ‘Munchausen syndrome by proxy’ (Meadow, 1977, 1982,
1989; Black, 1981) This involves children whose mothers
or caregivers invent stories of illness about their child and
in some cases fabricate false physical signs Older children
may even be coached by the parent on how to deceive the
doctor Meadow (1989) describes the consequences for
children who are falsely labelled as ill:
1 They receive needless investigations and treatment
2 Real injury may be caused by the mother’s action, for
example by giving drugs to induce unconsciousness
3 They are at risk from becoming chronic invalids or
hos-pital addicts in their own right
The parents’ motivations have been considered to include
a desire for the status and attention provided by being
the mother of a sick child, the enjoyment of help from the
various medical professionals, and as a way of resolving or
avoiding marital conflicts
Self-mutilators
A related, and to some extent overlapping group of patients
are those who obtain medical attention, if not care, by
repeated self-injury There is usually no attempt at icking of genuine medical disorders, although occasionally bizarre skin lesions are induced which raise questions as
mim-to their origin In one case, the patient injected air under the skin and persuaded one hospital to treat her for gas gangrene
Ganser states
A strange mental state described by Ganser in 1898 was regarded in its day as a ‘prison psychosis’ If it occurs at all nowadays it is extremely rare and is included here for completeness and historical interest and show how dis-sociative/malingered symptoms vary with time and place
The clinical features are
1 approximate answers;
2 clouding of consciousness with disorientation in time, place, and occasionally person;
3 vivid hallucinosis, both visual and auditory;
4 areas of analgesia and hyperalgesia with, on occasion, motor disturbances which were considered ‘hysterical stigma’;
5 complete and often sudden clearing of the disorder, leaving the patient with a total amnesia for the period
of the disorder
The description of the peculiar way of answering questions was the feature which intrigued subsequent investigators and guaranteed the survival of the putative syndrome (Auerbach, 1982) The phenomenon of approximate
answers (Vorbeireden or Vorbeigehen) was described by
Anderson and Mallinson in 1941 as
A false response of a patient to the examiner’s question, where the answer, although wrong, is never far wrong and bears a definite and obvious relation to the question, indi- cating clearly that the question has been grasped.
Anderson and Mallinson went on to make clear that this
is not merely giving random responses Among Ganser’s examples was a prisoner who, when asked how many fingers he had, replied 11 and said a horse had three legs, but an elephant five Counting, simple arithmetic, identify-ing letters of the alphabet and reading, are all reported to produce obvious errors and omissions One of our cases, when shown a chessman and asked what it was, replied after several minutes of puzzled examination that it was a little statue whose function quite escaped him This same man correctly identified a watch and could tell the time, but called a key a knife, and added a little pantomime of horrified withdrawal One of Ganser’s own cases identified
a key as a revolver
The possibility that the Ganser state is a manifestation
of the conscious simulation of mental disorder is ered frequently in the literature, usually to be dismissed in favour of unconscious mechanisms, or the impact of major
Trang 18consid-stress on somebody who already has a mental disorder
What Ganser added to previous descriptions of feigned
mental disorder in prisoners was his personal assurance
that ‘it could not be doubted’ that the prisoners being
examined were not malingering, but ‘truly sick’
The Ganser state has almost disappeared, but before
it goes entirely it might help to consider whether we
think of it as malingering, pathological lying, or a
dis-sociative disorder Some of the patients we have seen
labelled as ‘Ganser’ turned out later to be psychotic; all of
them needed help
Malingerophobia
We cannot leave the topics of malingering and feigned
mental illness without reference to Pilowsky’s (1985) paper
on malingerophobia It describes an important syndrome
which every physician, and especially every psychiatrist,
should know about Pilowsky likened the medical
altruis-tic impulse to body temperature which can under stress
become too warm or too cold He maintained that it is a
contagious condition and is defined as
an irrational and maladaptive fear of being tricked into providing healthcare to individuals who masquerade as sick, but either have no illness at all, or have a much less severe one than they claim.
It is at its worst in large teaching hospitals, he said, and can easily be diagnosed by the general practitioner who telephones to seek admission for a patient The condi-tion then manifests itself in the form of a newly qualified intern treating the general practitioner as though he
were a medical student presenting himself for a viva The
least subtle sign is when the body language and voice inflection asking the patient about symptoms gives the distinct impression that the assessing doctor believes the patient is a liar The main complication of malingero-phobia is that the patient is rejected and the patient’s problems are undiagnosed Doctors dealing with such patients become bored and impatient The worst com-plication is the enquiry, sometimes by a coroner, when something goes wrong The cure for this disorder is simple, says Pilowski, it is an increased readiness to take patients on, especially for treatment, coupled with a tolerance of occasional malingering This will prevent the development of a fortress mentality and improve working conditions as well as treatment Perhaps we can add to Pilowsky’s remedies that much more atten-tion should be paid to understanding and assessing the rich diversity of mental states that patients present, an approach which may well save a lot of time in the long run and certainly gets closer to the core task of being a medical practitioner
Trang 19Society remains ambivalent about use and abuse of mind
altering substances and towards the people who use and
abuse them Even the professions seem to struggle with
attitudes to the behavioural disorders associated with such
substances in ways that perhaps reflect tensions between
construing them as primary disorders of mental health or as
moral lapses It is not uncommon even for people with
une-quivocal psychotic illnesses to be rejected from psychiatric
services on grounds that their disorder is substance-induced
rather than illness Terminology is also elusive The two main
diagnostic and statistical manuals (ICD-10, WHO, 1992a;
DSM-IV, American Psychiatric Association, 2004) no longer
use the terminology of addiction The former deals with a
variety of ‘mental and behavioural disorders due to
psycho-active substance use’ in a simple descriptive way, while the
latter takes the simpler label of ‘substance-related disorders’,
but suggests a fundamental distinction between
‘substance-induced disorders’, subliminally justified by including toxic
substances which are not abused as well as those that may
be, and ‘substance use disorders’ In the case of
substance-induced disorders, the implicit blame falls on the substances
DSM criteria for substance abuse and dependency disorders
make repeated use of the word ‘failure’ For dependency,
The key issue … is not the existence of the problem, but
rather the individual’s failure to abstain from using the
substance despite having evidence of the difficulty it is
causing (DSM-IV, p.179)
DSM-IV substance abuse amounts to repeated social
failures in the context of using the drug (including alcohol, but not nicotine or caffeine) but with patterns falling short
of dependency
In the UK, the Academy of Medical Sciences (2008) has taken a lead in bringing a more scientific perspective It has brought back the terminology of addiction, and made clear its multi-factorial origins It acknowledges risk factors and protective factors, and that these lie in a range of personal, physical and experiential domains as well as in availability
of the objects of addiction and attitudes in wider society and the media The Academy further notes the similarities
in presentation between addictions to chemical substances and to other repeated behaviours, particularly problem gambling (euphoria on winning, tolerance on repetition, compulsion, withdrawal and craving) It makes parallels between them in terms of similar areas of brain activation when winning and after administration of drugs of abuse (e.g Reuter et al., 2005) We too extend this chapter to con-sideration of behavioural addictions, here exemplified by gambling, although in some cases, shoplifting, arson, and even interpersonal violence may fall within this spectrum
Such a broad construction means that addictions, encies or substance abuse in an individual are central issues for the health service, even though many may first present
depend-to criminal justice services It also means that public health policies and legislative controls have a fundamental part to play in protecting both the individual and wider society This
Edited by
Pamela J Taylor
Written by Mary McMurran and Adrian Feeney: Alcohol Ilana Crome and
Roger Bloor: Other drug abuse and offending John Gunn and Pamela J Taylor:
Gambling
Addictions and dependencies: their
association with offending
1st edition authors: John Gunn, John Hamilton, Andrew Johns, Michael D Kopelman,
Anthony Maden, John Strang and Pamela J Taylor
Trang 20chapter is mostly about clinical detection, legal issues,
rela-tionships between substance misuse and offending,
man-agement and treatment of the addictions Consideration of
genetic and other aetiological factors is mainly in chapter 8
Alcohol
The World Health Organization (WHO, 2002a) placed
alco-hol consumption among the top 10 global risk factors in
terms of the burden of disease caused In the year 2000, 1.8
million deaths worldwide were attributable to alcohol
con-sumption as well as 4% of the total global burden of disease,
including an estimated 20–30% of each of the following:
liver disease, oesophageal cancer, epilepsy, road traffic
acci-dents and intentional injuries Problem drinking presents
a risk for mental ill health too, although mental disorders
also increase the risk of alcohol-related problems (WHO,
2004a) Globally, alcohol is a major contributor to violence,
including homicide, domestic violence and child abuse, and
sexual violence (WHO, 2002b)
Perhaps in recognition of its part in this global crisis, the prime minister’s strategy unit developed an ‘Alcohol harm
reduction strategy for England’ (Cabinet Office, 2004) Similar
strategies already existed for Scotland (Scottish Executive,
2002/7), Wales (Welsh Assembly Government, 2008b), and
Northern Ireland (DHSSPS, 2000) All focus on combating
alcohol-related crime and disorder through prevention, early
intervention, and treatment, but specifically, too, endorse
the development of offender treatments In parallel with the
Cabinet Office work, other bodies, as diverse as the Academy
of Medical Sciences (2004), and the Prison Reform Trust
(2004; http://www.prisonreformtrust.org.uk) and The Royal
col-lege of Physicians (2001) have also provided strategic reviews
These documents were consistent in pointing out that over 8 million adults in the UK exceeded the safe weekly
drinking limits, then 14 units for women and 21 units for
men (a unit is 8 g/10 ml of alcohol) About half of all violent
crimes each year are alcohol-related, amounting to 1.2
mil-lion in England and Wales alone, perhaps not surprising
given the age range of the heaviest drinkers The UK General
Household Survey 2002 (Rickards et al., 2004) showed that
these were among 16- to 24-year-old men, averaging 21.5
units per week The trend, however, is for a slight decrease
in consumption by young men but increasing consumption
among 16- to 24-year-old women who, in 2002, 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 units for men, with at least
two alcohol-free days per week, and its alcohol learning
cen-tre regularly produces guidance sheets for clinical staff and
for patients, variously showing what a unit looks like and
offering advice (http://www alcohollearningcentre.org.uk)
Overall, in England and Wales alone, alcohol misuse costs around £20 bn per year in healthcare, crime-related
costs, and loss of productivity in the workplace
How Alcohol Exerts its Effects
Intoxication
The immediately observable effects of alcohol intoxication are impairments such as slurred speech, slowed mental and physical reaction times, and difficulty walking They may be apparent even at small doses, are dose-dependent and are due to the depressant effects of alcohol caused by reduced excitatory actions of the neurotransmitter gluta-mate and increased inhibitory actions of gamma-aminobu-tyric acid (GABA) (National Institute on Alcohol Abuse and Alcoholism, 2000) In most cases, the impairments caused
by intoxication are temporary, but intoxication can lead to death from respiratory failure, accidents associated with loss of consciousness (e.g hypothermia; choking on vomit)
or accidents associated with cognitive or motor ment (e.g road or machinery accidents)
impair-Pathological intoxication (mania à potu) has generally
been defined as sudden onset aggressive behaviour, cal for the individual when sober and seen after a small quantity of alcohol, and which, in normal people, would not be associated with such behaviour It may be associ-ated with alcohol-induced amnesia for the events involved
atypi-Coid (1979), however, cast doubt over its authenticity, after reviewing the literature Close scrutiny of any case com-monly shows that the person has had more than a small drink of alcohol and has a history of violence
In an uncontrolled study, Maletzky (1976) gave alcohol infusions to 22 people with histories suggestive of the condi-tion At high blood alcohol levels (mean: 195 mg/100 ml) 15
of them had unusual reactions Nine became violent, four showed delusions and hallucinations, and a further two pre-sented with mix of these problems Maletzky concluded that reactions to alcohol were on a continuum and that there was no discrete entity of pathological intoxication It is of note that high blood alcohol levels were required to precipi-tate the phenomena Maletzky observed Nevertheless, path-ological intoxication remains of interest to defence counsels
as simple intoxication provides no legal excuse for actions
Blackouts
Blackouts occur during drinking bouts They are ized by discrete amnesic periods of up to several hours, during which the individual is apparently able to carry out normal activities In an influential study, 100 hospitalized alcohol-dependent patients were interviewed Sixty-four reported blackouts which were of two very distinct types:
character-(1) classic en bloc, with total memory loss; (2) fragmentary
blackouts after which the sufferer may be able to recall, with prompting, some of the events which occurred dur-ing the blackout which were not initially remembered (Goodwin et al., 1969; see also chapter 12) Goodwin et al
(1970) also studied blackouts by giving 16–18 ounces of 86%
proof alcohol to 10 alcohol-dependent men in controlled
Trang 21conditions They were then presented with novel
informa-tion and tested 2 minutes, 30 minutes and 24 hours later
All were able to recall the information at 2 minutes but five
were unable to do so at 30 minutes and 24 hours This
sug-gests that blackouts are a result of an inability to transfer
information from immediate recall to short-term memory
rather than inattention or a process of forgetting Sweeney
(1990) argued that the high blood alcohol levels required for
an alcoholic blackout may severely disrupt other brain
func-tions, such as reasoning and planning, but Lishman (1998)
observed that they are probably associated with a sharp
rise and fall in blood alcohol rather than high levels per se,
and they do not appear to be predictive of cortical atrophy
(Ron, 1983) They may be relevant in court if ability to form
intent is compromised Fenwick (1990) asserted that they
are examples of ‘sane automatism’ (see also chapter 2)
A Dutch study of drivers stopped by traffic police or
involved in car accidents supports a sceptical view of a
direct link between alcohol level and alleged blackout (van
Oorsouw et al., 2004) Of the 100 people stopped, 14 told the
traffic police that they had had an alcoholic blackout, but
their blood alcohol levels were not significantly different
(180 mg/100 mL) from those of the people who made no
such claim (190 mg/100 mL) The main difference between
the two groups was in whether or not they had had an
accident Twelve of the 14 (86%) claiming a blackout had
caused an accident compared with 30 (35%) of the rest
Interpretation of this is difficult; could the high reporting
rate of blackouts among those who had crashed reflect at
some level avoidance of prosecution, or the lower reporting
rates a reluctance to put their driving licence in jeopardy?
Could alleged blackouts be related more to the trauma of
the accident than the alcohol?
Dependence
The alcohol dependence syndrome, as described by
Edwards and Gross (1976), remains a useful guide for
rec-ognition of need for intervention:
1 a narrowed drinking repertoire, characterized by a set
routine of consumption in an effort to maintain blood
al-cohol levels and therefore avoid withdrawal symptoms;
2 increased salience of drinking, such stereotyped
drink-ing is pursued to the exclusion of all other activities;
3 increased tolerance to alcohol, a manifestation of both
increased metabolic capacity based upon hepatic
en-zyme induction and increased brain receptor tolerance;
4 withdrawal symptoms;
5 relief or avoidance of withdrawal symptoms by further
drinking;
6 subjective awareness of the compulsion to drink;
7 reinstatement after abstinence, the phenomenon of
rapidly returning to the previous stereotyped drinking
pattern after a period of abstinence, for instance a
pe-riod of imprisonment
The alcohol dependence syndrome represents a change
in the relationship between the individual and alcohol
Instead of using alcohol in the context of social cues, ing becomes an end in itself and is self-perpetuating
drink-Withdrawal, fits and delirium tremens
If an alcohol-dependent person stops or reduces alcohol consumption s/he may trigger a withdrawal syndrome, generally 3–12 hours after the change Alcoholic with-drawal is not infrequent among people detained after arrest, is possibly becoming more likely and may affect fit-ness to be interviewed In a sample from the 1980s, at least 4% of pretrial male prisoners showed signs of withdrawal
on reception into prison (Taylor and Gunn, 1984) In a 2007–2008 sample of newly remanded men at least 17%
had alcohol withdrawal symptoms on reception, although over 40% had an Alcohol Use Disorders Identification Test (AUDIT; Saunders et al., 1993) score indicating dependency (Taylor et al., 2009), which was a higher proportion than the Office of National Statistics figure of 30% from the 1987 England and Wales prison survey (Singleton et al., 1999)
Withdrawal in prison may also be precipitated by abrupt cessation of drinking ‘hooch’, brewed there from such diverse sources as rotten fruit or boot polish
Withdrawal is characterized by autonomic tivity, including tremor, insomnia, sweating, tachycar-dia, hypertension and anxiety (Raistrick, 2001) It may be accompanied by acute hallucinosis in clear consciousness;
hallucinations may occur in any modality, but visual and tactile modes are especially common Violent or criminal acts may be committed while blood alcohol levels are falling
Withdrawal fits may occur 12–48 hours after tion of drinking; 5–10% of alcohol-dependent individuals experience them The fits are generalized, tonic–clonic bursts of activity and are therefore characterized by loss of consciousness followed by involuntary movements of the limbs and accompanied by an abnormal electroencepha-logram (EEG) The EEG is, however, generally normal between such fits, indicating that they are a manifestation
cessa-of the withdrawal rather than an independent epileptiform phenomenon Having a withdrawal seizure is a risk factor for further seizures during subsequent withdrawal states, therefore a history of withdrawal seizures is an indication for detoxification to be undertaken as an inpatient
Delirium tremens (DT) presents 3–4 days after nence (Victor and Adams, 1953) It has a mortality of up
absti-to 5 per cent; cause of death is typically cardiovascular collapse, hypothermia or intercurrent infection It presents with vivid hallucinations, delusions, profound confusion, tremor, agitation, insomnia, and autonomic over-activity
Visual hallucinations may be Lilliputian (very small) The onset may be sudden, although often there is a prodromal phase, which went unnoticed The patient may be gripped with terror, although this is not invariable DT usually
Trang 22lasts up to 3 days, ending with a prolonged sleep The
patient wakes feeling better, if tired, although occasionally
an amnesic syndrome is evident Delirium tremens may
provide for an insanity defence (see also chapter 2)
Best practice in managing withdrawal states is tive – to identify people at high risk and provide them
preven-with planned detoxification (see below) Use of the AUDIT
to supplement interview questions as part of screening
on reception into custody may enhance identification of
those at risk
Wernicke/Korsakoff’s syndrome
Wernicke’s encephalopathy (WE) is an acute brain
dis-order caused by vitamin B1 (thiamine) deficiency,
com-monly linked to alcohol dependence in combination
with poor appetite, malnutrition, poor absorption, and
impaired thiamine storage by the liver This deficiency
causes abnormalities in and around the third ventricle
and the aqueduct of the brain Such changes have been
found at post-mortem in 12% of people who had been
alcohol-dependent (Torvik et al., 1982) although they
have also been found in 1.5% of people who had neither
abused alcohol nor had neurological abnormalities in life
(Thomson and Pratt, 1992) WE may be of sudden onset,
and there may be memory problems even in the acute
phase Only 10% of patients present with the classic triad
of opthalmoplegia/nystagmus, ataxia, and delirium, and
there is a risk that the condition may be mistaken for
drunkenness A presumptive diagnosis should be made in
anyone undergoing detoxification who develops any one
of these signs, or hypotension or impaired consciousness
(Cook, 2000) Failure to treat immediately with parenteral
B-complex vitamins puts the person at risk of permanent
brain damage or death Victor et al (1971), studying
patients with Wernicke’s encephalopathy, found that over
84% went on to develop Korsakoff ’s syndrome
Korsakoff ’s syndrome is a similar, but more chronic state characterized by abnormalities of both anterograde
and retrograde memory in the presence of apathy but
otherwise relatively well-preserved intellectual function
At post-mortem, the cerebral pathology is virtually
identi-cal to that in Wernicke’s encephalopathy (Malamud and
Skillicorn, 1956) As Lishman (1998) observed, the
patho-logical process following thiamine deficiency is the same,
merely differing in speed of development
Classically, the patient is able to register new tion (e.g to perform the digit span test) but is unable to
informa-retain new information for 5 minutes or more Temporal
sequencing of events is particularly impaired, and sufferers
may make up stories to try to hide such deficits
(confabu-lation); these are not invariably far-fetched Confabulation
is not unique to Korsakoff ’s syndrome Prognosis is poor,
but not invariably hopeless; 25% of people recover, one half
show some improvement with time and the other quarter
show no change (Victor et al., 1971) Schacter (1986) was unable to find any recorded case of an amnesic syndrome being cited as a defence One of us, however, has experi-ence of unfitness to plead being found in the presence of Korsakoff ’s syndrome, since the defendant could neither remember the alleged assault nor could he follow a trial
In view of the high risks attached to Wernicke’s lopathy, prophylactic vitamin B1 (thiamine) should be given
encepha-to dependent drinkers, particularly during withdrawal British Association of Psychopharmacology guidelines (Lingford-Hughes et al., 2004) recommend a 1-month course
of 100–200 mg thiamine per day for healthy, low risk dependent patients undergoing detoxification and those who are thought to be at high risk of developing Wernicke’s encephalopathy (Cook [2000] suggests that anyone meeting criteria for inpatient detoxification, for whatever reason), or already showing signs of Wernicke’s encephalopathy, should
alcohol-be treated with parenteral B-vitamin complex for up to 5 days Such parenteral administration, which includes vita-min C, has a small associated risk of anaphylaxis and must only be given where there is adequate medical support
Glass (1989) provides a full account of its controversial history as a concept and a review of outcome Treatment
is absolute abstinence, although low dose antipsychotic medication may be helpful
Alcohol and behaviour
Alcohol affects behaviour idiosyncratically: people respond differently from each other and, indeed, one person may react differently on separate drinking occasions The fac-tors explaining these individual differences will be explored with particular reference to aggression and violence
It has been noted that ‘alcoholic intoxication dissolves the super ego before it dissolves the power to act’ and that drunken people do things which they would not do when sober (Merikangas, 2004) In laboratory studies, alco-hol fuels aggression mainly in men who have personality traits of irritability or aggression (Chermack and Giancola, 1997; Godlaski and Giancola, 2009) The effect of alcohol
on aggression is observed after provocation and is most evident at higher doses Acute intoxication is more com-monly associated with violence than is chronic, heavy drinking (Pillman et al., 2000) Throughout the UK, there
is particular current concern over ‘binge drinking’ and orderly conduct among young people, although there is no generally accepted definition of binge drinking Commonly,
Trang 23dis-it is taken to mean consumption of more than twice the
recommended upper daily limit of alcohol in one sitting
(over 8 units for men or 6 units for women) According to
this measure, about one-third of people in their twenties
binge on alcohol (Williamson et al., 2003a) Binge
drink-ing is a strong predictor of violence, at least in young
males (Richardson and Budd, 2003) Accepting that alcohol
changes behaviour, it is instructive to identify the
mecha-nisms that explain this
●
● Anxiety reduction At high doses and in settings which
are highly provocative of anxiety, the anxiolytic effect of
alcohol reduces the inhibitory effect of fear (Ito et al.,
1996), without which aggression and social rule
break-ing are more likely
●
● Pain reduction Alcohol is an analgesic, and one
com-mon euphemism for drunkenness – ‘feeling no pain’
– has literal truth to it Knowledge from experience of
this may reduce fear of starting fights; the analgesic
effect removes a reason for ceasing any fight (Cutter
et al., 1979)
●
● Increasing psychomotor activity At lower doses, alcohol
increases psychomotor activity, which may increase
the risk of instigating trouble or provoking others (Pihl
et al., 2003; Pihl and Hoaken, 1997)
●
● Disruption to executive cognitive functioning (ECF) The
concept of executive cognitive functioning has been
defined by Giancola (2000, p.582) as ‘… a higher order
cognitive construct involved in the planning, initiation,
and regulation of goal-directed behaviour’ He presents
a strong case for its disruption affecting alcohol-related
aggression and violence Alcohol disrupts regulation of
goal-directed behaviour by reducing ability to attend to
all the features of a situation, interfering with appraisal
of information, reducing ability to see the situation from
the perspective of others, diminishing the ability to
consider the consequences of one’s actions, and
reduc-ing availability of alternative responses in a situation
Disruption to any of these processes results in failures
of behaviour control The effects of alcohol will depend
on sober-state function, that is how good one’s executive
cognitive functioning is to begin with Its disruption may
explain much impulsive or imprudent behaviour
associ-ated with alcohol intoxication, including risky sexual
behaviour, disorderly conduct, and driving while drunk
●
● Outcome expectancies Alcohol may influence behaviour
through outcome expectancies, which are cognitive
representations of an ‘if–then’ relationship; here, they
represent what has been learned about the effects of
alcohol through instruction, observation, and
experi-ence They are important in that they may predict
future actions (Goldman et al., 1999) Male offenders
expect alcohol to give them confidence in social
situa-tions (McMurran, 2007a) Some outcome expectancies
are criminogenic: for instance ‘if I drink, then I will be
violent’ and ‘if I drink I can take sexual risks’ (McMurran and Bellfield, 1993) Recent research has, however, indicated that alcohol–aggression expectancy effects disappear after controlling of for an aggressive disposi-tion; it is the conjunction of the psychopharmacological effects of alcohol with an aggressive disposition which really leads to aggression (Giancola, 2006)
●
● Type of beverage Different drinks affect behaviour
dif-ferently, for example violence is more likely with its than beer or wine (Gustafson, 1999) This may be accounted for by chemical differences between bever-ages (different congeners), by differing speed of alcohol ingestion and metabolism (drinks of different strengths lead to intoxication at different rates), the effects of social custom (e.g ‘aggression-producing drinks’ are pre-ferred by aggressive people), or expectation (e.g a per-son’s perception of drink type-specific behaviour links)
spir-●
● Context Alcohol and aggression co-occur in certain
set-tings, typically city centre entertainment venues where young men gather and drink heavily, especially at week-ends (Lang et al., 1995) It is also important that people tend to gather there to seek sexual partners, even to compete over them, thus increasing the volatility of the situation (Charles and Egan, 2005)
●
● Excuses or facilitators Some people drink deliberately to
‘loosen up’ or give them courage to behave in ways they otherwise would not, thus making alcohol an excuse for antisocial behaviour, or blaming it after the act (Zhang
et al., 2002)
Each of these aspects may play some role in any related offence Furthermore, the aggregation of factors should be understood within a cultural context, with differ-ences in cultural (or subcultural) norms providing a behav-ioural baseline, regardless of intoxication Factors that need to be taken into account in explaining alcohol-related crime are summarized in figure 18.1
alcohol-Alcohol and the Law
Drinking style
Trigger
Figure 18.1 Factors implicated in explaining
alcohol-related crime.
Trang 24Britons have always been heavy drinkers, with documented
references to exceptional levels of drunkenness as far back
as the eighth century, and the heaviest drinking period
in British history occurring in the eighteenth century It
was then that legislation to control alcohol began, and
that Thomas Trotter completed his MD thesis describing
habitual drunkenness as a ‘disease of the mind’ (Trotter,
1804/1985) According to Barr (1998), when William of
Orange took the English throne in 1688, war was declared
on France and trade sanctions reduced the availability of
French brandy This was accompanied by promotion of
domestic manufacture of spirits to maximize state revenue
British-grown corn was distilled into gin, consumption
of which increased from half a million gallons in 1688 to
19 million by 1742 Consequent social and medical
prob-lems eventually led to the Gin Acts The first, in 1736, levied
a heavy duty on gin so that most people could no longer
afford it In 2009, raising the price of alcohol was again
suggested as a route to containing the public health threat
In 1736, however, increased duty perversely led to greater
problems Production was driven underground Over the
next 15 years, the Act was revised, lowering the duty but
restricting availability Consumption eventually fell The
principle of imposing a duty on the sale of alcohol and
requiring producers and retailers to be licensed, at a cost,
has been retained ever since, with a consequent tension
between the health of the population and the health of the
economy
The most recent legislation for England and Wales
is the Licensing Act 2003 It covers a range of ‘licensable
activities’, including the sale and supply of alcohol, the
pro-vision of regulated entertainment, and the propro-vision of late
night refreshments It brought relaxation of previous
licens-ing laws, permittlicens-ing citizens and visitors the ‘opportunity to
enjoy themselves with a drink or a meal at any time’ (Home
Office, 2000, p.5) As before, sale of alcohol was restricted to
licensed premises, but with without nationally prescribed
opening hours Alcohol may be sold 24 hours a day, 7 days
per week
The legal age for purchasing and drinking alcohol in licensed premises is 18 years, although 16 and 17 year olds
are permitted to drink it if less than spirit strength with
meals served at table Children under 16 may enter licensed
premises only if accompanied by an adult; younger children
may be excluded Children of 5 years and over are allowed
alcohol, but not on licensed premises Children under 5
years old may be given alcohol only on medical order
In conjunction with longer drinking hours, ment goals for the Licensing Act 2003 included reduction
govern-in crime and disorder and improved domestic and public
safety, the rationale being that the risk of intensive bouts of
drinking in anticipation of closing time would be less likely
Anyone seeking a licence to sell alcohol must demonstrate
a plan for minimizing the likelihood of crime, disorder,
nuisance, or harm The Act also provides for conditions for
conducting an orderly house It is an offence for the licensee
or any employee to allow disorderly conduct on licensed premises, to sell alcohol to a person who is drunk, or to sell alcohol to underage drinkers If such breaches occur, then the police have authority to take action to suspend or withdraw a license
In addition, other laws exist to control disorderly or dangerous conduct relating to alcohol Its consumption may be prohibited in certain public places, for example city centre streets, parks, special transport to sporting events, and at sporting events (Criminal Justice and Police Act 2001; Sporting Events (Control of Alcohol etc.) Act 1985)
Driving a motor vehicle with more than 80 milligrams of alcohol per 100 millilitres of blood is an offence under the Road Traffic Act 1988
Intoxication and the law
While intoxication may lead to criminal charges, such as
‘drunk and disorderly’, might it also constitute evidence for a defence against more serious crimes? Self-induced intoxica-tion is generally no defence to a criminal charge, and, explic-itly, may not be raised in respect of crimes of basic intent
(Majewski) In England and Wales, however, it may, rarely, be
raised as a defence or mitigation if it can be shown that the defendant was so intoxicated as to have been unable to form
the specific intent necessary for the crime (Beard) Beard was
extremely drunk and suffocated a young girl while raping
her It was ruled that he lacked the mens rea for murder and
was convicted instead of manslaughter A North American mock court room study showed that volunteer jurors there readily rejected the intoxication defence, and emphasized the personal responsibility of the defendant for his or her actions even when intoxicated (Golding and Bradshaw, 2005) This is formally recognized in Dutch law, where there
is a concept of culpa in causa: an individual is responsible for
his/her actions under the influence of alcohol because he is expected to know the effects of alcohol before s/he drinks
Scottish law similarly is less concerned with the ability to form intent than the actual harm caused
Alcohol and defences when charged with a crime
Other alcohol-related defences can only be sustained where
it can be shown that there is either cerebral damage secondary to the use of alcohol or if the drinking has
become involuntary, e.g Tandy When an alcoholic mother
appealed a conviction for the murder of her 11-year-old daughter, the court ruled that alcoholism could only qualify
as a disease of the mind if the drinking were involuntary
This state would only be recognized if the first drink of the day were involuntary It is, though, apparent that the ‘first drink of the day’ test is an arbitrary criterion with which to identify alcohol dependence
Trang 25Mental health legislation and alcohol
The earliest legislation enacted to control public
drunken-ness was the Habitual Drunkards Act 1879, which allowed
for voluntary inpatient treatment at designated ‘retreats’
for up to 2 years The Inebriates Act 1898 followed, allowing
for the compulsory detention in a ‘reformatory’ for up to 3
years of any offender found to have been intoxicated with
alcohol at the time of his/her offence All such institutions
had been closed by 1921
As scientific acceptance grows that substance
dependen-cies and misuse disorders, like mental illnesses, have their
origins as much in genetics and/or physical brain damage
as environmental factors, so mental health legislation has
moved away from embracing these conditions as disorders
which might lead to a requirement for detention in
hospi-tal or forms of coerced treatment The Menhospi-tal Health Act
(MHA) 1959 did not specifically exclude alcohol
depend-ence from its definition of mental disorder, although these
grounds were seldom used; the MHA 1983 did if dependency
on alcohol or drugs was the sole presenting condition Under
Section 1(3) this explicit exclusion has been retained in the
MHA 2007 revision, notwithstanding the widening of the
definition of mental disorder to include almost everything
else (see also chapter 3)
Alcohol and Offending
Alcohol and violence
In 2007–2008, almost 5 million crimes were recorded by the
police in England and Wales; 961,175 (19%) of them were
crimes of non-sexual violence (Home Office, 2009) It is
estimated that around half of violent incidents involve
alco-hol, with increased alcohol consumption associated with
increased violence rates most marked in countries where
binge drinking is a typical pattern (Room and Rossow,
2001) Homicide rates are associated with total alcohol
sales, most strongly so in northern rather than southern
European countries (Rossow, 2001)
Alcohol appears as a problem in all custodial
set-tings In a study of 622 men and women in police custody,
Bennett (1998) identified 25% testing positive for alcohol,
a likely underestimate since those who were unfit to be
interviewed through drink or drugs or posing a threat of
violence were not tested Singleton et al (1999) examined
pre-imprisonment alcohol use with the AUDIT in a survey
of prisoners in England and Wales This 10-item screening
tool includes items on quantity, frequency, dependency,
and associated problems; scores range from 0–40, with 8
the accepted cut-off for hazardous drinking The Singleton
group found that 63% of sentenced men were hazardous
drinkers, as were 58% of male remand prisoners, 36% of
female remand prisoners and 39% of female sentenced
prisoners The hazardous drinkers were typically young
(16–24), single and white, with men, but not women, being
held for violent offences McMurran (2005) used the AUDIT with a much smaller sample of male prisoners, and found that those convicted of alcohol-related violence were the most extreme drinkers
Findings from these cross-sectional studies are mented by longitudinal studies In a large New Zealand
aug-birth cohort (n = 1,265), for example, Fergusson et al (1996)
found that 15- to 21-year-old heavy drinkers, after ling for shared risk factors such as socioeconomic status, education, and family background, were three times as likely to be violent as light drinkers Similarly, Farrington (1995) found that heavy drinking at age 18 was predictive
control-of violent crime in adulthood
Alcohol and domestic violence
Alcohol is strongly associated with domestic lence (Leonard, 2001) Gilchrist and colleagues (2003) found that nearly half of 336 offenders on probation for domestic violence offences had a history of alco-hol abuse; 73% had consumed alcohol just before the offence Fals-Stewart’s (2003) study of drinking and domestic violence showed that violence to partners was eight times more likely on drinking days than abstinent
vio-days, with the risk of severe violence 11 times higher on
drinking days Nevertheless, the role of drinking and intoxication in domestic violence remains controver-sial Little is known about whether partner violence risk decreases after alcohol treatment (O’Farrell et al., 2003), and such treatment is unpopular Many domes-tic violence treatments have emerged from a feminist perspective, where the root cause is seen as the man’s desire to control his female partner (Corvo and Johnson, 2003) McMurran and Gilchrist (2008) argued that, while power and control may be fundamental to some domestic violence, interventions to reduce drinking are important for reducing risk of injury
Alcohol and sexual offending
Several researchers have reported that between 30 and 50% of rapists had been drinking at the time of the offence (Maldonado et al., 1988; Martin, 2001; West and Wright, 1981), while others have shown that alcohol consumption
by convicted rapists and child molesters is significantly higher than that of non-sexually violent offenders (Abracen
et al., 2000) Sex offending theories place alcohol variously
in the roles of overcoming internal inhibitions to offend (Finkelhor, 1984), interfering with self-regulation (Ward and Hudson, 1998), and impairing cognitive function (Seto and Barbaree, 1995) Emotional loneliness may be a common factor that explains both drinking and sexual offending (Abracen et al., 2000) Research testing these putative roles
is scarce Findings from laboratory research are equivocal, but there is evidence that alcohol may disinhibit sexual
Trang 26arousal (Seto and Barbaree, 1995), and some to suggest that
rapists expect drinking to lead them to doing something
sexually risky (McMurran and Bellfield, 1993)
Alcohol and acquisitive offending
Alcohol-related acquisitive crime has received far less
attention than its drug-related counterpart The ‘economic
necessity’ argument, that ‘addicts’ are driven to purchase
expensive drugs, is applied less to heavy drinkers, but
drink-ing and associated activities (e.g entrance to clubs, taxis)
are expensive Acquisitive offences may also be committed
under the influence of alcohol, through impaired judgment,
but this aspect too has rarely been investigated
Bennett and Wright (1984) studied 121 offenders ing sentences for burglary, and found that over a third
serv-admitted committing their offence under the influence of
alcohol Bennett (1998) found that 26% of those arrested
for burglary tested positive for alcohol, but only 2% of those
who drank reported offending to get money to buy alcohol
Arrestees who tested positive for alcohol did, however,
accrue over £4,000 per annum by illegal means McMurran
and Cusens (2005) found that, among 126 male prisoners
in England and Wales, 11% of those convicted of violent
acquisitive offences (e.g robbery) said that their offending
had been to support their alcohol habit, compared with
18% of those convicted of strictly property based offences
(e.g burglary) The former had significantly higher scores
on the AUDIT than those with other motives
Drunk driving
In the UK, about 15% of road deaths occur when the driver
is over the legal alcohol limit (Department of Transport,
2012) There is evidence that the relative risk of involvement
in a fatal vehicle crash increases steadily with increasing
blood alcohol concentration, for both sexes and all ages,
although the risk is disproportionately increased for young
male drivers (Zadok et al., 2000)
Alcohol, Mental Disorder and Offending
While associations between schizophrenia, substance
mis-use in general, and offending have been extensively
inves-tigated, this is less true of the more specific relationship
between alcohol dependence, schizophrenia and offending
In their England and Wales prison survey, Singleton et al
(1999) reported that severe alcohol problems were
associ-ated with mental ill health Having an AUDIT score of 16 or
more increased the odds of having a diagnosed personality
disorder by 2.27, psychosis by 1.75, and neurosis by 1.53,
as measured by the Schedules for Clinical Assessment in
Neuropsychiatry (SCAN; WHO, 1992b)
In a study of 618 offenders in Canada, 26% of those with schizophrenia who abused alcohol were violent, but
only 7% who had schizophrenia uncomplicated by alcohol abuse (Rice and Harris, 1995a) Among 1423 people con-victed of homicide in a 12-year period in Finland, Eronen
et al (1996c) identified 93 with schizophrenia; those with uncomplicated schizophrenia had a homicide rate about seven times that of the general population, but men with schizophrenia and comorbid alcoholism were 17 times more likely to have killed
Räsänen and colleagues (1998) did a prospective study
of an unselected Finnish birth cohort (n = 11,017) over 26
years Using national databases, they calculated the hood of offending and recidivism for people with schizo-phrenia with and without alcohol dependence There were
likeli-51 men with schizophrenia in the sample, 11 of whom were dependent on or abusing alcohol Seven of the 51 had com-mitted a violent offence, four with alcohol problems and three without The men with both schizophrenia and alco-hol problems were 25 times more likely to have offended violently compared with increased odds among those with uncomplicated schizophrenia of only 3–4 None of the men with schizophrenia uncomplicated by alcohol problems had offended more than twice, while those with both prob-lems had a 10-fold increase in such recidivism compared with the general population The odds seem impressive, but they rest on just seven men who had been violent as well as having schizophrenia Further, the extra elevation in rate of violence among people who abuse alcohol as well as having schizophrenia was not borne out by a US study with much larger numbers in the groups of interest (Tardiff and Sweillam, 1980); however, as a sample of patients admitted
to a pair of US psychiatric hospitals during 1 year in the mid-1970s, the sample was highly selected – for treatment
There is no perfect study; population-based samples are doomed to tiny groups of core interest, but larger samples selected for the disorder, the violence or both may be sub-ject to selection biases
Another explanation for discrepancies may be real change over time McMahon et al (2003) analysed all admissions to England’s high security hospitals between
1975 and 1999 During that time, there was a linear increase
in the proportion of people admitted who had been ing more than 21 units of alcohol per week in the year prior
drink-to their index offence By diagnosis, the highest increase was in the psychosis with personality disorder group
Alcohol, personality disorder and offending
Comorbidity between substance misuse disorders and sonality disorders is common, with stronger associations between illicit drug use (rather than alcohol) and any per-sonality disorder and between substance misuse generally and the cluster B types (e.g antisocial personality disorder (ASPD), borderline personality disorder (BPD)) (Verheul
per-et al., 1995) Among substance misusers, co-occurrence of ASPD is twice as common in men as women, and most
Trang 27likely in those who use both alcohol and illicit drugs (Flynn
et al., 1996), while severity of substance misuse is
associ-ated with multiple abnormal traits (Cecero et al., 1999)
Mood disorders often further complicate the picture, being
about three times more common among substance
misus-ers with a pmisus-ersonality disorder than those without (Kokkevi
et al., 1998); they are also related to severity of the
depend-ence (Cecero et al., 1999); alcohol misuse, alone or with
illicit drugs, has also been associated with anxiety disorders
(Flynn et al., 1996)
Rates of substance misuse and personality pathology
comorbidity are so high that some are concerned that
this conceptualization is tautologous (Rounsaville et al.,
1998); however, even when substance-related symptoms
are excluded from the criteria for personality disorder
diagnoses, such comorbidity is only somewhat lowered
(Rounsaville et al., 1998; Verheul et al., 1995) This
sug-gests that personality disorder diagnoses are not simply
surrogates for substance abuse, or vice versa One way
of unpicking the association with ASPD particularly is to
separate its likely components, for example as in the
anti-social behaviour and the affective coldness dimensions on
the Psychopathy Checklist – Revised (PCL-R; Hare, 2003)
In one study, those with a diagnosis of ASPD had a higher
rate of alcohol problems, drug problems, and criminal
activity than those with a high PCL-R score (Windle, 1999)
Smith and Newman (1990), studying low security prisoners,
showed that substance misuse was related to the PCL-R
antisocial lifestyle dimension (Factor 2) rather than the
affective dimension (Factor 1)
A comparison of alcohol-dependent, violent offenders
with and without ASPD yielded two subgroups (Tikkanen
et al., 2007) The smaller (20% of the sample) were high
scorers on the PCL-R and demonstrated low harm
avoid-ance but were responsible for fewer acts of impulsive
vio-lence; only half fulfilled diagnostic criteria for ASPD The
majority (80%) showed high harm avoidance but higher
levels of impulsive behaviour, and were more likely to have
ASPD or BPD A study of offenders followed for an average
of 8 years after discharge from a maximum security
institu-tion, either psychiatric hospital or prison, yielded similar
findings Overall, alcohol abuse was associated with violent
recidivism, but high PCL-R scorers were the most likely to
be violent recidivists and, in their case, alcohol abuse did
not add to the accuracy of violence prediction (Rice and
Harris, 1995a) If violent people who get high scores on the
PCL-R are likely to be violent with or without taking
alco-hol, then treatment of alcohol misuse is unlikely to reduce
their violence After treatments to reduce violence,
how-ever, control of substance misuse remains important, not
only on health grounds, but also so that unchecked abuse
does not interfere with other treatment gains
In a complete resident cohort of England’s high security
hospital patients, the prevalence of substance misuse
dis-orders among those diagnosed with a personality disorder
alone was found to be 14%, although rather higher in the psychosis–personality disorder comorbid group (Taylor
et al., 1998); Corbett et al (1998) gave a rather similar figure (18%) in another, with 4.5% being illicit drug dependent and 6.4% alcohol dependent Coid et al (1999), studying other secure settings, offered much higher figures; 53% of patients with personality disorder were judged as having
a lifetime alcohol misuse diagnosis, and 47% were ered to have a lifetime drug misuse diagnosis There are a number of possible reasons for such apparent discrepan-cies Some studies, as the Taylor group, stick strictly to diagnostic concepts, whereas others depend more heavily
consid-on amounts of substance used A more likely explanaticonsid-on for the substantial differences described here, however, lies in changing habits over time Many of the high security hospital residents were last in the community when avail-ability of substances was much lower, indeed observation
of admission cohorts over time, confirms that rates of substance misuse in the year prior to admission were very significantly higher in the 1990s than the 1970s (McMahon
et al., 2003)
Treatment gains are generally less in people who misuse substances and also have personality disorder than those without personality disorder, yet in both groups treatment does lead to reduced substance misuse and symptoms over time (Brooner et al., 1998; Cecero et al., 1999; Kokkevi
et al., 1998; Linehan et al., 1999) Treatment for substance misuse may also have different effects according to per-sonality type; it has been shown to reduce crime in those with ASPD, although not those with BPD (Hernandez-Avila
et al., 2000) People with comorbid personality disorder, particularly ASPD, are more likely to drop out of treatment for substance abuse, but there is evidence that this may actually be related to comorbid depression rather than personality disorder (Kokkevi et al., 1998) Since treatment completion is important to a good outcome, it is crucial
to assess for and treat depression in substance misusers, with or without personality disorders; withdrawal from substances may be a cause of low mood, but does not preclude depressive illness People with ASPD often com-plete substance abuse treatment when that treatment is compulsory, in which case they too show good outcomes (Hernandez-Avila et al., 2000)
Alcohol, intellectual disability and offending
Reviews of alcohol use among people with intellectual disability suggest that their problematic drinking rates are low, but when they do use alcohol their risk of misuse is high (McGillicuddy et al., 1998) In many respects, alcohol misusers with intellectual disability are similar to their peers without it; most are men, living alone, more likely
to smoke tobacco, use soft drugs, experience consequent work problems and get into trouble for offences such as public intoxication, disturbing the peace, assault, indecent
Trang 28exposure, breaking and entering, and driving whilst
intoxi-cated (Krishef and DiNitto, 1981; McGillicuddy and Blane,
1999)
Treatment of Alcohol Problems
Voluntary versus compulsory treatment
Compulsory treatments for alcohol problems may be
effec-tive (Sullivan et al., 2008), although posieffec-tive outcomes for
compulsory treatment of offenders may only be evident
in community settings (Parhar et al., 2008) Gregoire and
Burke (2004) used a measure of ‘readiness to change’ to
study motivation in a mixed group of substance misusers,
41% of whom were abusing alcohol Their study suggested
that treatment under a compulsory order was associated
with increased motivation to change during treatment
Detoxification
Once alcohol dependence has become established, the
brain physically adapts to the presence of the depressant
effects of alcohol In consequence there are compensatory
changes in brain chemistry, which lead to over-activity
when alcohol is withdrawn For those who are only mildly
dependent, cessation of alcohol may be possible by gradual
reduction of alcohol consumption However, those drinking
more than 15 units per day are likely to need some form of
pharmacological support to control withdrawal symptoms
Detoxification is the process of substituting alcohol with
a reducing course of medication to alleviate withdrawal
symptoms and prevent the associated seizures
Benzodiazepines have become the treatment of choice
in detoxification, since they relieve withdrawal symptoms
and have good anti-convulsant properties A reducing
course over 5 to 7 days is generally adequate The two
drugs most often used are chlordiazepoxide and
diaz-epam, although the latter has a greater street value These
two drugs have long half-lives and, therefore, theoretically
have less mood altering effects and less addictive
poten-tial than short-acting agents such as lorazepam A typical
starting dose of chlordiazepoxide is 20 mg three to four
times a day, and of diazepam 15 mg four times per day
Doses may be doubled (with longer reducing courses) in
adult men who are severely dependent (consuming over
40 units per day); such doses are not recommended for
women or the elderly Higher doses are also required for
those with a history of dependence on both alcohol and
benzodiazepines Small does of lorazepam, with a shorter
half-life, are preferable for people with established liver
impairment, who should be inpatients due to their risk
of fatal accumulation of benzodiazepines if their
metabo-lism is compromised Chlormethiazole had previously
been a popular drug here, but it may cause fatal
respira-tory depression if taken with alcohol, and has a greater
addiction potential if abused It is important that the
patient does not drink alcohol during the detoxification regime, but s/he sometimes does
Outpatient detoxification is possible for people who are moderately dependent (Bennie, 1998) Daily collection
of medication gives an opportunity to check for signs of withdrawal or alcohol consumption and to give encourage-ment and advice Inpatient detoxification is indicated for those with a history of withdrawal fits, delirium tremens, early signs of encephalopathy, who lack social support and/
or who are unlikely to remain abstinent during the fication The same criteria may be used to identify those
detoxi-in prison who can be safely detoxified on normal location and those who need to be admitted to the healthcare/detox unit
Adequate management of withdrawal should reduce the likelihood of withdrawal fits and delirium tremens (DT) If fits do occur, then diazepam should be given either
by slow intravenous injection or per rectum If DT becomes
established then the patient should be nursed in a low stimulus environment and fluid balance closely monitored and supported as necessary Oral rather than parenteral use
of a shorter acting benzodiazepine, possibly with a leptic, may be helpful Attempts should be made to identify any contributory medical conditions such as head injury, hypoglycaemia, hepatic failure, gastro-intestinal bleeding, liver failure or infection, through full physical examination and regular checks of body temperature, blood glucose and electrolytes If the patient becomes agitated then paren-teral sedation (IV diazepam and/or IM haloperidol) may
neuro-be indicated
Pharmacological agents promoting abstinence
●
● Disulfiram (Antabuse) is the most established agent
designed to promote sobriety The two newer agents (acamprosate and naltrexone) have only been studied as adjuncts to psychosocial interventions Comparison of out-come data between these drugs is difficult as the trials used different end points and outcome measures
Disulfiram blocks the liver enzyme aldehyde drogenase After consumption of alcohol, blockade of this enzyme results in the accumulation of acetaldehyde
dehy-Resultant signs include: flushing, nausea, vomiting, ache, tachycardia and palpitations After a large alcohol load the reaction can be severe, resulting in hypertension, circulatory collapse and death The enzyme is effectively blocked after several days of disulfiram at a daily dose of 100–200 mg The reaction is so aversive that disulfiram acts
head-as a deterrent from further drinking, although it may also deter the individual from taking further disulfiram if s/he is determined to continue drinking The drinker needs only one tablet in the morning to know that s/he is effectively protected for a day or so against lapses
Disulfiram has been available for a considerable time, yet there are few controlled trials of its efficacy There are
Trang 29data to show that it is associated with reduction in the
number of drinking days and the amount of alcohol
con-sumed but not an increase in abstinence (Garbutt et al.,
1999; Hughes and Cook, 1997) Supervised consumption
enhances its efficacy In a naturalistic follow-up study
com-paring patients attending a disulfram clinic, those patients
compelled to attend under a court order were significantly
more likely to attend than those under voluntary
arrange-ments (61%:18.2%) (Martin et al., 2004)
●
● Acamprosate A number of meta-analyses have found
acamprosate to be superior to placebo on a variety of
absti-nence-related outcomes (Lingford-Hughes et al., 2004),
although its mode of action is still not clear Verheul and
colleagues (1999) hypothesize that it works by reducing
craving for alcohol It should be started as soon as possible
after stopping alcohol for people who are aiming for
absti-nence, ideally in combination with psychosocial
interven-tions It has some gastro-intestinal side effects (diarrhoea
and nausea)
●
● Naltrexone is an opioid antagonist, which is not licensed
for marketing for the treatment of alcohol dependency, but
it may be prescribed Some drinkers report that it reduces
the high they associate with alcohol, and this is why it may
be prescribed (Ulm et al., 1995) Several meta-analyses have
suggested that it is better than placebo on a number of
outcomes but there are studies which have not found this
The British Association for Psychopharmacology guidance
on the management of substance misuse gives a good
sum-mary of the evidence (Lingford-Hughes et al., 2004) There
is some evidence that it reduces the risk of relapse to heavy
drinking (Garbutt et al., 1999)
Psychosocial interventions for alcohol misuse
Cognitive behavioural treatments are particularly well
suited to helping people gain control over drinking
behav-iours The key components are motivation enhancement,
behavioural self-control, cognitive coping skills,
interper-sonal skills, relapse prevention, and lifestyle change
●
● Motivation enhancement Motivating substance users
to engage in treatment has long been acknowledged as
the key to treatment effectiveness Miller (1985) argued
that motivation to change should be viewed as a dynamic
state, and the task of therapy should be to alter both
internal and external factors to increase the probability
of the person actively engaging in the treatment process
Motivational interviewing (MI) is a strategic counselling
technique which has been developed from this position
(Miller and Rollnick, 2002) Its aims are to help the user to
move from ambivalence to change towards taking action,
based upon a spirit of collaboration between therapist and
user, and drawing on his/her own capacity and resources
for change In Project MATCH, a four-session motivational
enhancement therapy worked as well for most people as
12 sessions of either cognitive behaviour therapy (CBT) or a
12-step programme in reducing drinking (Project MATCH Research Group, 1997) A review of motivational interview-ing interventions with offenders indicated that it can lead
to improved retention in treatment, enhanced tion to change, and behaviour changes (McMurran, 2009)
motiva-●
● Behavioural control Like motivation to change,
self-control is not a trait, but rather the likelihood of drinking
in response to a range of physical, emotional, and logical triggers that are associated with drinking The task
psycho-in therapy is to teach the user to identify the triggers for drinking, control urges to drink, and develop coping strate-gies Behavioural self-control training has proved effective
as a component of intervention for alcohol problems (see Miller, 1992), and is now core practice in many cognitive behavioural interventions
●
● Cognitive coping skills Cognitive coping includes
micro-skills, such as positive self-talk and self-instruction (Meichenbaum, 1977) Positive self-statements are taught
to assist people to cope with cravings (e.g ‘This feeling won’t last’; ‘I don’t have to use’) and avoid the goal violation effect (‘A lapse does not have to become a relapse’) Self-instruction involves the construction and use of scripts to use as an internal commentary to support implementation
of new coping skills Alcohol outcome expectancies require both attention to moderate positive outcome expectancies, such as improving social confidence, and to diminish the strength of associated criminogenic beliefs, for example that sexually risky behaviour or violence will happen after drinking (McMurran and Bellfield, 1993; Quigley et al., 2002) Training in problem-solving skills is usually integrat-
ed into CBT to teach strategies for increasing independent functioning
●
● Interpersonal skills Peer pressure to drink may be
tackled by teaching assertion and refusal skills, but must
be augmented by helping people resist the desire to fit in with their drinking peers The ability to make and sustain satisfying relationships is important for maintenance of treatment gains; interpersonal conflict is a potent risk relapse factor (Marlatt, 1996) Interpersonal skills which will generally benefit from attention include negotiation and conflict resolution
●
● Relapse prevention Marlatt and Gordon (1985)
rede-fined relapse as a process, rather than an event Marlatt (1996) identified several risk factors for relapse into drinking which require specific attention to increase the chances of maintenance of change Relapse prevention (RP) teaches participants to identify and cope with high-risk situations, for example by avoiding or escaping from cues that trigger cravings or urges, and learning to cope with them if they happen RP helps people limit the goal violation effect, which occurs when a minor lapse (e.g
one drink) turns into a full-blown relapse (e.g the whole bottle) Relapse rehearsal enhances self-effectiveness
Trang 30through developing the ability to imagine coping in a
high risk situation RP may also tackle broader issues,
such as social support for change, stress management,
lifestyle balance, and positive substitutes for the
addic-tive behaviour In a review of clinical trials, Carroll (1996)
found RP to be more effective than no treatment for
sub-stance misuse, but not convincingly superior to other
active interventions There was evidence of a delayed
effect, where RP reduced the severity of lapses when they
did occur, and that RP was more effective with severely
impaired substance users
●
● Lifestyle change Sustaining a non-substance using,
non-criminal life may also require general changes in
accommodation, work, leisure activities, social networks,
and close relationships; promoting abandonment of the
‘addict’ or ‘criminal’ identity can promote commitment to
a new lifestyle
General versus specific programmes
for alcohol misusers
Generic programmes that help people to reduce or
stop drinking may be effective also in reducing crime
Programmes aimed at specific alcohol related offences
may, however, be useful in some cases Intoxicated
aggres-sion requires the integration of treatments for anger and
aggression with those for alcohol abuse (Graham et al.,
1998) Treatments for domestic violence also show a
con-vergence of CBT with interventions focusing on drinking
(Corvo and Johnson, 2003) A similar combined approach
for drink-drivers has proven effective A meta-analysis of
215 treatment programmes indicated an 8–9% reduction
in recidivism for treated over untreated participants,
with the most effective interventions combining
edu-cation, psychological therapy, and supervision
(Wells-Parker et al., 1995)
Therapeutic communities for alcohol misusers
The aim of therapeutic communities (TCs) is to foster a
functional lifestyle through democratic process, in which
residents confront and correct each other’s maladaptive
behaviour, offer each other support through the difficult
change process, and sometimes reward improvement by
offering those achieving change promotion within the
community A ‘concept TC’ is one specifically designed
for people with substance use problems (Wexler, 1995)
The abstinence-oriented, 12-step approach of Narcotics
Anonymous (NA) and Alcoholics Anonymous (AA) has
been widely adapted by professionals into concept TCs TCs
have also been adapted for correctional settings, where they
have a good track record, (e.g in the USA: Wexler and De
Leon 1997; in the UK: Gunn et al., 1978, Malinowski, 2003,
and Martin and Player, 2000; see also chapters 16 and 25)
Alcoholics Anonymous (AA)
AA is a worldwide self-help network based on a simple set
of principles offering life-long support to the recovering alcohol-dependent drinker Alcoholism is described as a disease ‘like an allergy to alcohol’ Members are encour-aged to avoid the first drink, as their condition can never
be cured, only arrested by absolute sobriety
The AA meeting is central Meetings have a set format, which includes one or two testimonies from recovering alcoholics highlighting the problems associated with their former drinking life, the moment when they decided to seek sobriety and the positive contribution AA has had in supporting that sobriety This leads to contributions from the floor, as those present identify with each speaker’s experiences and encourage further sobriety Meetings may
be held in prisons and hospitals, secure or not, or the wider community Meetings are open to those who are only recently abstinent and those who have not drunk for many years, and this mix is an important feature of AA, providing role models for newcomers and allowing those who have been abstinent for many years to revisit the AA principles (the 12 steps) in their role as mentors
The first of the 12 steps is to ‘admit that we are powerless over alcohol – that our lives had become unmanageable.’
The second step is to recognize that there is a higher power that can restore sanity This religious/spiritual component may be off-putting to an atheist, but many AA members do not interpret this in a religious way, while some see it as the power of the group itself Vaillant (1995) concluded, after a long-term outcome study of alcohol dependency, that last-ing improvement in an individual’s life was associated with
a commitment to change and at least one of the following:
(1) a substitute for the dependency; (2) powerful resources
of self-esteem and hope; or (3) a new stable relationship AA may offer all these
A 12-step approach has been shown to be as tive as the cognitive behavioural or motivation based approaches just described Outcomes at 3-year follow-
effec-up were slightly better with the 12-step approach than the other two modes for those drinkers who lacked a non-drinking support network (Project MATCH, 1998)
In a meta-analysis comparing AA attendance with other treatments and no treatment, however, AA was found to
be associated with worse outcomes It has been suggested that this is because some of those attending AA groups were obliged to do so and so biased the outcome data (Kownacki and Shadish, 1999)
Treatment in the context of comorbidity
The term ‘dual diagnosis’ is widespread, generally ing co-occurrence of a psychotic illness and a substance use disorder, but it is rarely an accurate indicator of the multi-plicity of disorders of health and behaviour that need atten-tion Nevertheless, the ‘dual diagnosis’ literature recognizes
Trang 31indicat-the importance of integrating a number of approaches in
order to bring about useful change It is acknowledged that
a balance must be struck between empathy, unconditional
regard and nurturance to develop motivation on the one
hand, and discipline and structure to foster self-control on
the other (Mueser et al., 2003) A national outcome survey
of all 959 patients discharged from UK medium secure units
in the 12 months after 1 April 1997 demonstrated both the
extent of co-occurrence of alcohol problems and illness
in an offender-patient population and the association
between such problems and poorer outcomes (Scott et al.,
2004) Patients were classified as having alcohol problems if
there were records of excessive drinking They were evident
in 381 people (40%), with similar rates in men and women
During the 2-year follow-up period, there was a significant
difference in re-conviction rates between those with
alco-hol problems and those without (49%:39% reconvicted)
For those with substance misuse diagnoses
com-plicating mental illness, the latter often resolves with
antipsychotic medication within a secure, drug-free
envi-ronment Ongoing risk is then closely linked to the
likeli-hood of further substance abuse, but, since alcohol and
illicit drugs are forbidden in secure settings, and rare
commodities even if the cordon is occasionally breached,
treatment of the substance problems may not be
ade-quately prioritized O’Grady (2001) argued for better
integration of forensic, general psychiatry and substance
misuse services to tackle this problem, although there is
little evidence for the benefits of integrated treatment
(Cleary et al., 2010)
The Royal College of Psychiatrists’ Research Unit
sur-vey of the 28 medium secure units (MSUs) in England
(excluding learning disability, personality and adolescent
units) highlighted their inadequacies in tackling substance
misuse:
●
● despite security measures, alcohol and drugs had been
used in every English MSU during the 1-year survey
period;
●
● of the drugs abused, cannabis and alcohol were thought
to cause the greatest problems;
● disagreement regarding the model of care: some units
pursued and abstinence approach, others favoured
controlled drinking (Durand et al., 2005)
In the period before a patient’s discharge, controlled
drink-ing or abstinence may be tested out durdrink-ing leave periods
Ideally, patients should begin to engage with community
support at this stage, such as their future community
psychiatric nurse (CPN), alcohol treatment services, or
AA group, building towards seamless transfer of support
on discharge The receiving CPN should not only monitor
mental state and compliance with medication (possibly including disulfiram) but also alcohol-related work
other substAnce misuseMisuse of psychoactive drugs other than alcohol is also a cause for concern worldwide The World Health Organization (WHO), for example, has had an Expert Committee on Drug Dependence since 1949, which pro-duces regular reports and has a mandatory task, under international treaties, to carry out medical and scien-tific evaluations of the abuse liability of dependence-producing drugs falling within the terms of the 1961 Single Convention on Narcotic Drugs and the 1971 Convention
on Psychotropic Substances It then makes tions to the United Nations (UN) Commission on Narcotic Drugs on the control measures, if any, that it considers appropriate
recommenda-Since the late 1990s there has been increasing interest
in and awareness of drug problems in the UK, reflected in a raft of policy initiatives, including
●
● Purchasing effective treatment and care for drug misusers
(Department of Health (DoH) 1997b);
●
● Clinical guidelines on the management of drug misuse and dependence (DoH, 1999c; DoH et al., 2007);
●
● Substance misuse detainees in police custody (3rd edn)
(Association of Forensic Physicians and Royal College
● Recommendations from the British Association of
Psychopharmacology (Lingford-Hughes et al., 2004);
●
● Drug misuse: Opioid detoxification (National Institute
for Health and Clinical Excellence (NICE), 2008a);
●
● Psychosocial interventions in drug misuse (NICE, 2007a).
Why is Knowledge About Drug Misuse so important to the Practising Forensic Clinician?
Drug misusers present in some form to all the major specialties in medical practice, perhaps especially acci-dent and emergency units, general medical and surgical specialities (Fingerhood, 2000), but forensic, liaison, ado-lescent and old age psychiatry in hospital, community and criminal justice settings are increasingly contributing
to their treatment Even if the patient presents with a drug problem, this may not be his or her major problem;
conversely, the presenting problem may not immediately
be recognized as relating to drug misuse People may
Trang 32present with abstinence syndromes, convulsions, acute
disturbance (psychosis, panic, confusion, perceptual
dys-function), trauma, cancer, or cardiovascular conditions
What is a Drug?
In this chapter, the term ‘drug’ will be used to cover illicit
substances, central nervous system depressants such as
opiates and opioids (e.g heroin, methadone), stimulants
(e.g cocaine, crack, amphetamine, ecstasy), and LSD, khat
and magic mushrooms It will also be used to describe
street use and non-compliant use of prescription drugs
such as benzodiazepines and non-compliance in use of
over-the-counter preparations such as codeine-based
products (e.g cough medicines, decongestants)
Clinical experience and a growing literature base cate that people may use a combination of licit and illicit
indi-substances, as well as prescribed and over-the-counter
medications used both compliantly and non-compliantly
Patients may borrow and/or share drugs, may not report
all medications, may use out-of-date drugs, may take foods
and drugs that interact, and may store drugs
inappro-priately This complexity, and so-called polypharmacy or
polydrug misuse is a particular issue in older people who
have physical or psychological comorbidity ‘Misuse’ may
be the result of lack of judgment, misconceptions about
the drug(s), inability to purchase medications, inability
to manage the combination of medications (perhaps due
to memory problems) or patients may be intentionally
using medications for purposes other than those intended
Unravelling all this is what makes this work challenging
and stimulating!
Concepts of Harmful Use
and Dependence
Criteria for the diagnosis of substance problems from
both main current disease classification systems are
outlined in tables 18.1 and 18.2 (ICD-10: WHO, 1992a;
DSM-IV, 1994; APA, 1994) For the purposes of treatment
and management it is helpful to distinguish ent substance misuse from dependent use In the UK, drugs are classified, according to perceived seriousness of consequences of taking them, under the Misuse of Drugs Act 1971; the government may change a drug’s classifica-tion from time to time as new evidence about its proper-ties emerges The current classification according to this act is set out in table 18.3
non-depend-The inter-relationships between physical health, mental health, and drug misuse are well-documented
Apart from the direct effects of drugs on general health (see later), there are indirect effects such as dietary neglect, impoverishment, trauma, bereavement and loss Malnutrition, for instance, may emanate from drug-induced anorexia, malabsorption and/or economic deprivation Liver dysfunction, for example with HIV, hepatitis B or C, produces psychological as well as physi-cal problems
Psychiatric conditions such as anxiety, depression, post-traumatic stress disorder, drug-induced psychosis, schizophrenia, delirium, and dementia may lead to, be a consequence of, or coincide with drug misuse Withdrawal from barbiturates and benzodiazepines leads to delirium, whereas head injuries and serious infections are associ-ated with dementia The differing mechanisms and types
of relationship require careful history-taking and cious interpretation Depression, dementia, delirium and a heightened risk of suicide are probably the problems most commonly faced by clinicians Some of these conditions are associated with chronic pain and sleep disorders, which may be the problems which made the patient seek relief from prescription and non-prescription medications in a non-compliant way Since there are effective interventions for many psychiatric conditions, correct diagnosis and treatment have real benefits
judi-Table 18.1 Criteria for substance abuse (DSM-IV) and harmful use (ICD-10)
DSM-IV (American Psychiatric Association, 1994) ICD-10 (World Health Organisation 1992a)
(A) A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following occurring within a 12-month period
A pattern of psychoactive substance use that is causing damage to health
The damage may be physical or mental (1) Recurrent substance use resulting in a failure to fulfil major role
obligations at work, school, or home
Actual damage should have been caused to the physical or mental health
of the user (2) Recurrent substance use in situations in which it is physically hazardous Harmful patterns of use are often criticized by others and frequently
associated with adverse social consequences (3) Recurrent substance-related legal problems
(4) Continued substance use despite having persistent or recurrent social
or interpersonal problems caused or exacerbated by the effects of the substance
(B) Symptoms have never met the criteria for Substance Dependence for this class of substance
Acute intoxication not in itself evidence Should not be diagnosed if…
another specific form of drug- or alcohol-related disorder is present
Trang 33Epidemiology of illicit Drug Use
The UK has among the highest levels of substance
mis-use in Europe and illicit substance mismis-use is a
substan-tial problem In post-millennium surveys carried out in
England and Wales, about one-third of the population have admitted to illegal drug misuse in the year prior to rating The British Crime Survey, a household interview study, found in 2006/7 that 35.5% of 16–59 year olds (11¼
Table 18.2 Criteria for substance dependence (DSM-IV) and dependence syndrome ( ICD-10)
DSM-IV (American Psychiatric Association, 1994) ICD-10 (World Health Organisation 1992a)
A maladaptive pattern of substance use, leading to clinically significant
impairment or distress, as manifested by three (or more) of the following,
any time in the same 12-month period
A cluster of physiological, behavioural and cognitive phenomena [ ] A definite diagnosis should usually be made only if three or more of the following have been experienced or exhibited at some time during the previous year
(1) tolerance, as defined by either
need for markedly increased amounts of substance to achieve intoxication
or desired effect, or
markedly diminished effect, with continued use of the same amount of
the substance
(1) a strong desire or sense of compulsion to take the substance
(2) withdrawal, as evidenced by either of the following:
the characteristic withdrawal syndrome for the substance, or
the same (or closely related) substance is taken to relieve or avoid
withdrawal symptoms
(2) difficulties in controlling substance-taking behaviour in terms of its onset, termination, or levels of use
(3) the substance is often taken in larger amounts over a longer period
than was intended
(3) a physiological withdrawal state when substance use has ceased or been reduced, as evidenced by:
the characteristic withdrawal syndrome for the substance
or
use of the same (or closely related) substance with the intention of relieving or avoiding withdrawal symptoms
(4) persistent desire or repeated unsuccessful efforts to cut down or
control substance use
(4) evidence of tolerance, such that increased doses of the psychoactive substance are required in order to achieve effects originally produced by lower doses
(5) a great deal of time is spent in activities necessary to obtain the
substance, use the substance, or recover from its effects
(5) progressive neglect of alternative pleasures or interests because of psychoactive substance use, increased amount of time necessary to obtain
or take the substance or to recover from its effects (6) important social, occupational, or recreational activities given up or
reduced because of substance use
(6) persisting with substance use despite clear evidence of overly harmful consequences (physical or mental)
(7) the substance use is continued despite knowledge of having had a
persistent or recurrent physical or psychological problem that is likely to
have been caused or exacerbated by the substance
Table 18.3 UK drug classification framework in 2011
Class A Cocaine and crack cocaine ecstasy, heroin, LSD,
methadone, methamphetamine, magic mushrooms, any Class B drug which is injected
2 years, a fine or both 14 years, a fine or both
1 These are examples and reference should be made to amendments to the legislation, which are accessible online: http://www.legislation.gov.uk/all?title=drugs/
2 Cannabis was in Class B under the Misuse of Drugs Act 1971; cultivation of the cannabis plant carries a maximum penalty of 6 months or fine of
£5,000 in a magistrates’ court; 14 years in prison or an unlimited fine or both in a Crown Court.
Trang 34million) had used one or more illicit drugs in their lifetime,
10% had used one or more illicit drugs in the year (¾
mil-lion) and 5.9% (2 milmil-lion) in the month prior to interview
(Murphy and Roe, 2007) Four and a half million (13.8%)
reported use of Class A drugs at least once in their lifetime,
1 million (3.4%) in the previous year, and 500,000 (1.7%)
in the previous month (Murphy and Roe, 2007) Cannabis
was the most likely drug to have been taken, having been
used by 8.2% of these 16–59 year olds, followed by cocaine
(powder or crack), which was used by 2.6% Class A drugs
had been used by proportionately more people during
the year prior to interview in 2006/7 than in 1998, but the
proportion using any illicit drug in the previous year was
lower in 2006/7 than in 1998
Young people generally report higher levels of drug use than older people, but Class A drug use among young peo-
ple has remained stable since 1998 and the reported use of
any drug in the previous decade actually fell in the 16- to
24-year-old age group Over the course of their lifetime,
2¾ million (44.7%) young people aged 16–24 had used an
illicit drug, 1½ million (24%) had used an illicit drug in the
previous year, and 1 million (14.3%) in the previous month
One million (16.3%) had used a Class A drug during their
lifetime, 500,000 (8.1%) in the previous year and 250,000
(4.3%) in the previous month Young women are one and a
half to three times more likely to use substances than older
women International studies demonstrate that about
20–25% of women in younger age groups have used illicit
drugs in the past year
One of the problems in planning services for drug users is the considerable country and regional variation in
drug use overall and in choice of specific drugs, so some
local knowledge is essential When comparing English
Government Office Regions and Wales with each other, for
example, according to the 2006/07 British Crime Survey,
the South West (11.1%) and the North West (11.0%) had
the highest levels of any drug use while the West Midlands
(9.2%) and the Eastern region (9.1%) had the lowest levels
Class A drugs were nearly twice as likely to be used in the
highest regions (North East: 4.1%; North West: 4.0%) as in
Wales (2.5%) (Murphy and Roe, 2007)
Problem drug users are much more likely to be found within the criminal justice system than in the general
population A review commissioned by the UK Drugs Policy
Commission (UKDPC) reported that:
●
● at least 1/8 arrestees (equivalent to about 125,000
peo-ple in England and Wales) are estimated to be problem heroin and/or crack users, compared with about 1/100 among the general population;
●
● of arrestees who used heroin and/or crack at least
once a week, 81% said that they had committed an acquisitive crime in the previous 12 months, compared with 30% of other arrestees; of arrestees who had used heroin and/or crack at least once a week, 31% reported
an average of at least one crime a day, compared with 3% of other arrestees;
●
● between one-third and one-half of all new receptions to prison are estimated to be problem drug users (about 45,000–65,000 prisoners in England and Wales);
MortalityPremature mortality is high among substance misusers (Ghodse et al., 1998; Lind et al., 1999); illicit drug misuse
is responsible for approximately 3,000 deaths each year, although in numerical terms deaths from legally available substances are even higher (in England and Wales 120,000 deaths annually from smoking-related disorders and 40,000 from alcohol-related disorders) The mortality associated with alcohol and drugs is between nine and 16 times higher than in the general population and substance misuse is a very strong predictor of completed suicide (Marsden et al., 2000; NCISH, 2006, 2001, 1999; Weaver et al., 2003; Wilcox
et al., 2004) In England and Wales, 33% of inpatient suicides have a history of alcohol misuse and 30% a history of drug misuse, while 41% of suicides in the community have a his-tory of alcohol misuse and 28% a history of drug misuse (NCISH, 2001) The Confidential Enquiry into Maternal Deaths in the UK from 2002–2004 found that, when all deaths up to 1 year from delivery were taken into account, 8% were caused by substance misuse (Lewis, 2004)
MorbidityAlcohol, drugs and nicotine affect all organs of the body and the interactions of substance misuse with health are multiple and complex Effects may be very rapid or insidious, and by a direct pharmacological or physiologi-cal action or indirectly due to associated behaviours As with alcohol, the acute effects of intoxication with illicit drugs, the impact of chronic use and the development of withdrawal and dependence may lead to an array of physi-cal and psychological problems and social consequences
Dependence on some substances develops very rapidly, within weeks or months These conditions may be related
to high-risk behaviours such as injecting, needle ing, unsafe sex and the use of substances to the point of intoxication Psychological symptoms or signs, including hallucinations, mood change, impulsivity, aggression and disinhibition or psychiatric syndromes, such as anxiety, depression, psychotic illness, post-traumatic stress disor-der, personality disorder or eating disorders are all among the risks of use Self-harm may result, with eventual suicide
Trang 35shar-These difficulties may lead to homelessness,
unemploy-ment, poverty and criminality, as well as disengagement
from families, communities and services Patients with
comorbid conditions have poorer prognosis and place a
heavy burden on services because of higher rates of relapse
and re-hospitalization, serious infections such as hepatitis
and HIV, and/or prostitution, violence, arrest and even
imprisonment All substance misuse, but perhaps
espe-cially multiple use, must be seen in the context of its social
as well as its medical difficulties (Little et al., 2005; Okah
et al., 2005; Velez et al., 2006)
Comorbidity is a term used to describe the
co-occur-rence of psychiatric disorder and substance misuse
(Banerjee et al., 2002; Crome and Day, 2002; Day and Crome,
2002; Waller and Rumball, 2004) Chronic use or
intoxica-tion with depressant drugs, or withdrawal from stimulants
produce symptoms similar to depression, while acute
intoxication from stimulants and cannabis may mimic a
schizophrenic illness Withdrawal from depressant drugs
may result in symptoms of anxiety, panic, and even
con-fusional states The difficulty for the clinician is, therefore,
the extent to which the presentation is a simple drug effect
and the extent to which there is an additional independent
mental disorder An association between drug use and
psy-chiatric conditions has been consistently documented in
substance misusing clinical populations, psychiatric
popu-lations, the general population, prisons, and among the
homeless Indeed, in the US Epidemiological Catchment
Area (ECA) study, drug addiction was associated with a
53.1% lifetime rate of an additional mental disorder (Regier
et al., 1990)
In any patient the following hypotheses for association
between apparent mental illness and substance use should
be considered:
●
● a primary psychiatric and/or physical illness may
pre-cipitate or lead to a substance problem;
●
● substance misuse may worsen or alter the course of a
psychiatric and/or physical illness;
●
● intoxication and/or substance dependence may lead to
psychological and physical symptoms;
●
● substance misuse and/or withdrawal may lead to
psy-chiatric or physical symptoms or illnesses;
●
● it is no longer possible to tell which came first but each
contributes to a cycle of deterioration
Practitioners working with substance misusers need to be
aware that substance misusers may have vascular,
infec-tious, carcinogenic or traumatic conditions directly related
to their misuse Life-saving measures could be required For
these reasons, it is vital to establish whether recent
sub-stance use, including the types, quantities, route and the
time course of use, may have a bearing on overt and covert
physical and psychological symptoms Even where the
inci-dence of serious adverse effects is low, the unpredictability
of these events makes the health consequences important
In the UK, Weaver et al (2003) examined mental illness and substance misuse presenting to community mental health teams and substance misuse services Forty-four per cent of patients in community mental health teams reported substance misuse in the previous year, while 75%
of drug service patients and 85% of alcohol service patients had suffered from a psychiatric disorder in the previous year In England and Wales, one-third of suicides in the community have a history of alcohol and/or drug misuse (NCISH, 2001) A recent Canadian psychological autopsy study (Séguin et al., 2006) demonstrated that 90% of people who complete suicide suffer from comorbid mental disor-ders, mainly mood disorders and substance misuse
In 1997 the Office for National Statistics (ONS) took a survey of psychiatric morbidity among 3,000 remand and sentenced prisoners aged 16–64 in England and Wales (Singleton et al., 1998; see chapter 25 for more detail) A high proportion, particularly of the men, had substance misuse disorders Prisoners with antisocial personality disorder were over six times more likely than the others
under-to report drug dependence in the year before coming under-to prison, though without a detailed chronology there may
be a risk of over-diagnosing such comorbidity (Kaye et al., 1998)
In Greece, male drug users from community treatment services were compared with male prisoners registered as drug dependent in the previous 12 months (Kokkevi and
Stefanis, 1995) Lifetime affective disorders (32%:20%, p = 0.10)
and anxiety disorders (53%:14%) were more prevalent among drug users recruited from treatment services than among drug users in prison, while ASPD was more prevalent among prisoners (76%:61%), suggesting considered service selection biases
Current UK legislation on DrugsMost countries have legislation to limit the production, administration, use, supply, import and export of certain drugs They differ considerably, but here discussion will be confined to UK law
Misuse of Drugs Act 1971 and its amendments
This act, which evolved from a series of UK legislative ventions, is designed to control the use of certain drugs that are viewed as having medical applications It has been the subject of many amendments since the original version
inter-in 1971, which can be found onlinter-ine: (http://www.ukcia.org/
pollaw/lawlibrary/misuseofdrugsact1971.php)
It first classified drugs into three categories (A, B and C;
see table 18.3) and defined the penalties for their production, supply and possession A 2001 amendment to the Act created the offence of ‘knowingly allowing premises’ owned or man-aged by a person to be used for the unlicensed production, use or supply of any controlled drug In England and Wales,
Trang 36cannabis and cannabis resin were reclassified from Class
B to Class C from 2004, after the Criminal Justice Act 2003
amended the Misuse of Drugs Act 1971 This amendment
also increased the maximum penalty for trafficking in Class C
drugs, from 5 to 14 years Cannabis is being considered by the
UK government for reclassification back to Class B, despite
advice to the contrary given by the Advisory Council on the
Misuse of Drugs ((ACMD), 2008; Home Office, 2012)
The Misuse of Drugs Regulations 2001
These regulations cover the overlap between the Misuse of
Drugs Act 1971 and instances where there are legitimate
medical applications of controlled drugs These regulations
further classify drugs into schedules to reflect the degree of
control over possession, use, prescribing and supply,
sum-marized in table 18.4
Medicines Act 1968
The manufacture, supply and prescription of medicinal
drugs are also controlled by the Medicines Act, which has
undergone many amendments since 1968 Such drugs are
classified into prescription only drugs, pharmacy sales
drugs and general sales drugs There is a complex overlap
with the regulations of the Misuse of Drugs Act, particularly
with regard to the possession of some minor tranquillizers
Some drugs, such as heroin and LSD, can only be scribed by doctors who possess a specific licence Other
pre-drugs, such as schedule 3 and schedule 4, part 1
benzodiaz-epine tranquillizers may be prescribed by any doctor, but it
is now illegal to be in possession of these drugs if they are
not prescribed It is illegal to sell or supply any Class C drug
to another person
Mental health legislation
Throughout the UK, mental health legislation explicitly excludes compulsory detention in hospital on grounds solely
of substance misuse or dependence The expectation erally is that people must engage voluntarily in treatment
gen-Community-based coercion into treatment or rehabilitation, incorporating regular drug testing, is confined to convicted offenders In England and Wales they may receive a Drug Testing and Treatment Order (DTTO) under the Crime and Disorder Act 1998, or more likely now, a Drug Rehabilitation Requirement Order (DRRO) in conjunction with a community sentence or suspended prison sentence under the Criminal Justice Act 2003
Drugs and CrimeThe association between drug use and criminal behaviour varies in terms both of strength of association and of sever-ity of the behaviour A simple classification of crime catego-ries and the strength of association with drug use has been constructed (Parker and Bottomley, 1966); it recognizes five patterns:
Table 18.4 Summary of Schedules of the Misuse of Drugs Regulations 2001
Schedule Main drugs included Restrictions
1 LSD, ecstasy, raw opium, psilocin, cannabis (herbal and
resin)
Import, export, production, possession and supply only permitted under Home Office licence for medical or scientific research
Cannot be prescribed by doctors or dispensed by pharmacists.
2 Heroin, cocaine, methadone, morphine, amphetamine,
dexamphetamine, pethidine and quinalbarbitone
May be prescribed and lawfully possessed when on prescription
Otherwise, supply, possession, import, export and production are offences except under Home Office licence Particular controls on their prescription, storage and record keeping apply.
3 Barbiturates, temazepam, flunitrazepam, buprenorphine,
pentazocine and diethylpropion
May be prescribed and lawfully possessed when on prescription
Otherwise, supply, possession, import, export and production are offences except under Home Office licence Particular controls
on their prescription and storage apply Temazepam prescription requirements are less stringent than those for the other drugs in this Schedule.
May be prescribed and lawfully possessed when on prescription
Otherwise, supply, possession, import, export and production are offences except under Home Office licence.
May be lawfully possessed by anyone even without a prescription, provided they are in the form of a medical product.
5 Compound preparations such as cough mixtures which
contain small amounts of controlled drugs such as morphine Some may be sold over-the-counter
Authority needed for their production or supply but can be freely imported, exported or possessed (without a prescription).
Trang 37An analysis of the association between crime patterns
and drug use patterns using this model suggested that
most people involved in crime are not drug users, or only
use substances recreationally, and most of those involved
in drug use are not involved in crime (Royal College of
Psychiatrists, 2000)
An alternative empirical classification of the
asso-ciation, particularly taking causative mechanisms into
account, has been proposed by Boles and Miotto (2003) In
this system violence is seen as following from:
a pharmacological consequences, such as intoxication or
withdrawal, or
b systemic issues, such as drug trade disputes, drug gang
violence, violence to informants and violence related to
collection of drug-related debts, or
c economic factors related to the need to fund drug use
through crime
A more recent meta-analysis of 30 studies confirmed that
there is an association between drug use and crime and
provided a quantitative measure of the strength of the
relationship and variation with type of drug used (Bennett
et al., 2008): the odds of offending were greater for drug
users than for non-drug users, but the odds were not the
same for all drug types Crack users carried the highest risk
of offending, followed by heroin users, then other cocaine
users Recreational drug use was shown to carry a lower
risk of offending, but within this group, cannabis users had
the highest risk, followed by amphetamine users
Interaction between drugs of abuse,
mental illness and crime
At least since Swanson and colleagues (1990) examined
mental illness and violence relationships in the US ECA data
(see also chapter 14), it has been recognized that use of drugs
and alcohol by people with a mental illness substantially
increases their risk of violence In the UK, Wheatley (1998)
compared patients detained in specialist forensic
psychiat-ric services with those in genepsychiat-ric services and found that it
was the higher prevalence of substance use by the former
which distinguished them This was confirmed by Penk et al
(2000), who showed that people diagnosed with
schizophre-nia and substance abuse disorders were more behaviourally
dysfunctional (though more socially competent) than their
non-substance misusing schizophrenic peers Those with
both diagnoses had a high prevalence of childhood trauma
Scott et al (1998) investigated the relationship in more
detail, but with a small sample, by interviewing 27 comorbid
and 65 ‘pure’ psychotic patients from medium security
hos-pitals, and reviewing their records They also interviewed
staff working closely with them Individuals with illness and
substance misuse comorbidity were more likely to report any
history of committing an offence or recent hostile behaviour
and key workers were more likely to report recent aggression
by those patients A combination of illicit substance misuse
and non-adherence to medication prescribed for the illness
is particularly risky In the USA, Swartz et al (1998) found that violence is twice as likely among such patients as among those with either problem alone Erkiran et al (2006) showed that seriousness of violence as well as its frequency was higher among people comorbid for psychosis and substance misuse disorders than those with psychosis alone
Drug misuse and acquisitive crimes
Property theft, car theft, shoplifting, fraud and defrauding social benefit schemes are among the commonest crimes associated with drug use in the UK These crimes are most commonly committed to fund the purchase of drugs or to maintain basic living needs in the absence of any legal, paid employment
Drug misuse and sexual crime
Sex-related crime in a drug use setting is most commonly involved with prostitution Studies of pathways into pros-titution have often given conflicting results One study of
1142 female prisoners, for example, found that drug abuse did not explain their entry into prostitution (McClanahan
et al., 1999), but Gossop et al (1994) reached a different conclusion They studied 51 women who were working as prostitutes and found that half of them had started this in order to pay for drugs A more recent study supported the Gossop findings, and also showed that crime other than prostitution is little reported in this population This may reflect the displacement of other criminal activity or that the sums of money obtained from prostitution (£112–132 per day, on average 2004/5) are adequate for the individual’s drug use needs (Bloor et al., 2006)
The use of drugs to facilitate sexual assault facilitated sexual assault: DFSA) has no adequate defini-tion, according to Hall and Moore (2008) in their review
(drug-of the field They propose a distinction between proactive (planned) DFSA and opportunistic DFSA The more popu-lar terminology of ‘date rape drugs’ refers in the main to the use of rohypnol, together with other drugs such as gamma-hydroxybutyric acid (GHB), which can easily be concealed
in alcoholic drinks Reviews of cases of ‘date rape’ using drugs such as rohypnol have indicated that, in many cases, the level of alcohol ingested was also considerable and that the involvement of rohypnol itself may not be as central
as previously believed (Advisory Council on the Misuse of Drugs, 2007a)
Drugs and driving
Fitzpatrick et al (2006), in Ireland, reviewed the prevalence of positive drug tests in drivers suspected of being intoxicated through alcohol or drug use; over 30% of drivers whose alco-hol level was below the legal limit when tested were positive for one or more illicit drugs Of those drivers whose alcohol
Trang 38level was above the legal limit, 14% were positive for one or
more illicit drugs Zero blood concentration limits for
con-trolled substances whilst driving have been introduced in
Sweden, but have not resulted in a reduction in the number
of cases of driving under the influence of drugs (Jones, 2005)
Types of Drugs and Their Effects
The health risks posed by drug use include the toxicity
of the drug itself, the route of use, blood-borne
patho-gens, contaminants, unknown purity, and quantity Adverse
effects for each of the most commonly used drugs are
sum-marized below (Banerjee et al., 2002)
Heroin
Effects of intoxication
Diverted pharmaceutical opiates and opioids may be
for-mulated for injection or oral use, or as suppositories
Tablets may be crushed and injected Dependence can
develop within weeks Since tolerance also develops rapidly,
but diminishes quickly after abstinence, relapse can lead to
overdose and death This is also the case for methadone
Heroin may be smoked, inhaled or heated on foil and the
fumes inhaled The short-term effects include a rapid onset
of euphoria with a sensation of heavy extremities The user
will then experience alternating wakeful and drowsy states
Heroin is a central nervous system depressant and has
effects on reaction times and ability to concentrate
Health complications
Repeated use of heroin induces a state of dependency with
a need for increased doses and increased frequency of use
The occurrence of withdrawal symptoms triggers further
use to relieve these symptoms Repeated injections result in
collapsed veins, infection of the heart lining and valves and
skin and muscle infections Sharing of injection equipment
also carries a high risk of blood-borne infections such as
HIV and hepatitis C Opiates and opioids depress coughing,
breathing and heart rate, dilate blood vessels, reduce bowel
activity and produce constipation Overdose usually occurs
when in combination with other drugs
Offending
Hoaken and Stewart (2003), in a review of aggressive
behaviour in heroin users, concluded that their high rates
of aggression may be independent of their heroin use and
more closely related to personality factors linked with
that dependence
Cannabis
Effects of intoxication
Cannabis is either smoked or eaten Use is accompanied
by distorted time perception, impaired coordination and
difficulty in thinking These effects on cognitive functions may persist for over 24 hours after use of cannabis
Health complicationsCannabis has effects on physical health, with even higher rates of lung and heart disease, and cancers of the head and neck, among cannabis smokers than among nicotine cigarette smokers Cannabis use may lead to depression, anxiety and paranoia Panic attacks are a feature and there
is controversy as to whether cannabis ‘causes’ an enduring schizophrenia-like psychosis or simply exacerbates it (Sewell
et al., 2009; Tucker, 2009) Memory and learning are impaired
OffendingReview of the evidence linking cannabis use with aggres-sion has indicated that cannabis intoxication reduces the risk of violence, whereas withdrawal from cannabis may increase it (Hoaken and Stewart, 2003) Cannabis depend-ency was one of only three disorders of mental health inde-pendently linked to violence in the Dunedin birth cohort (Arsenault et al., 2000)
Psychostimulants – amphetamines and cocaine
Effects of intoxicationMost psychostimulants may be used orally, ‘snorted’ as a powder through the nose, or injected or smoked, producing
an intense euphoric state, possibly accompanied by restless and agitation, rapid speech and increased wakefulness
Health complicationsPsychostimulants may precipitate anxiety states, confu-sion, convulsions and cardiovascular problems, and acute psychotic episodes are not uncommon The sharing of injection equipment carries the same risks as for heroin use, but its risk is often underestimated in the stimu-lant using population Use of stimulants may lead to exhaustion, depression, and weight loss A paranoid and/
or confusional state may also occur Hypertension, diac arrhythmias, stroke, hepatic and renal damage and abscesses are the result of heavy use, especially if injecting
car-Violent and aggressive behaviour may ensue Snorting of cocaine leads to nasal septal perforation and damage to the nasal passages
OffendingMethamphetamine use is often cited as having a direct link with violent crime, but the relation between its use and vio-lence is indirect and unclear (Tyner and Fremouw, 2008)
Benzodiazepines
Effects of intoxication
In the short term, users may experience tiredness, depressed respiration, dizziness, and unsteadiness
Trang 39Health complications
If combined with other depressants such as alcohol or
opi-ates, overdose can be fatal Dependence can develop on low
doses and convulsions occur with withdrawal Rebound
symptoms such as insomnia, anxiety, and tension may
occur
Offending
The evidence regarding the effect of benzodiazepines use
on offending behaviour is conflicting A case-crossover
study of the role of alcohol and drugs in triggering criminal
violence (Haggard-Grann et al., 2006) showed that whilst
alcohol is a strong trigger for criminal violence, the use of
benzodiazepines in combination with the alcohol does not
increase the risk Other studies have suggested that in some
individuals the use of benzodiazepines may trigger a
para-doxical aggressive reaction, but that this is more related to
individual personality factors rather than a
pharmacologi-cal, dose-related effect (Bramness et al., 2006)
Polysubstance use
People commonly use more than one substance, but an
Australian study reported that only the use of alcohol and
inhalants appeared to have significant relationships with
recidivism in young offenders (Putnin¸š, 2003)
screening, Assessment and
Diagnosis of Drug Misuse
A number of screening methods for illicit drug use are
available (see box 18.1) These depend on the purpose,
setting, nature of the target group and the technology and
resources available for the screening programme Screening
and assessment are not the same thing Screening is an
initial, simple enquiry about indicators of health and
social problems Assessment is an ongoing, sometimes
protracted, process (Crome et al., 2006)
Drug screening
Some biological indicators, such as blood, urine and saliva
drug or drug metabolite levels, are more commonly used
than others Hair analysis, for example, enables detection of regular use of many drugs over periods of several months A secure ‘chain of custody’ from initial collection is essential
to ensure accurate sample attribution to a specified vidual There is variability between substances in duration
indi-of time for detection, from a few hours to 10 days or more (see table 18.5) It is important to ensure that appropriate, rigorously applied laboratory testing procedures are used, with appropriate cut-offs for interpreting results (Wolff
et al., 1999a,b)
Examination of drug users
It is recommended that, as drug use is of such a high lence, all healthcare professionals should be able to identify and carry out a basic assessment of people who use drugs (NICE, 2008a), and that this should include examination of the user both as an aid to confirming drug use and identi-fying the physical complications of drug use, such as infec-tions and abscesses
preva-Drug use assessment tools
Current guidance for England and Wales suggests that all drug users should have an assessment that includes the following (NICE, 2007b):
●
● The Maudsley Addiction Profile (MAP): A short ment tool, which takes around 12 minutes to admin-ister and covers four areas: substance use, health risk behaviour, physical and psychological health, and per-sonal/social functioning (Marsden et al., 1998)
Table 18.5 Period of time over which more
commonly used substances are likely to remain detectable in the blood (Adapted from Banerjee
Trang 400–20, covering areas such as physical and cal health, drug use, HIV risk and criminal behaviour (Christo, 2000).
psychologi-●
● The Rickter scale: A non-paper based self-assessment,
allowing the user to identify treatment goals and can
be used to develop treatment action plans (Hutchinson and Stead, see Northumbria University, 2012)
The National Treatment Agency (NTA) care planning
practice guide (NTA, 2006a) provides a summary of the
characteristics of a selection of tools that may be used for
assessment and outcome measurement in a drug
treat-ment setting ( for a list, see box 18.2)
Based on the AUDIT (Saunders et al., 1993), a cannabis screening instrument has been developed (the Cannabis
Use Disorders Identification Test (CUDIT) Adamson and
Sellman, 2003) More recently, the Drug Use Disorders
Identification Test (DUDIT) has been developed and piloted
in criminal justice settings (Berman et al., 2005) There are
also instruments for screening and assessing substance use
in young people (Effective Interventions Unit, 2004) A brief
six-item questionnaire by Knight et al (2002) is also useful
(see box 18.3)
People who are drug dependent may seek urgent
profes-sional help, asking for immediate treatment of withdrawal
symptoms, often claiming to be unable to get to their usual
treatment unit or that their prescribed supplies have been
lost or stolen In this situation, and regardless of
manipula-tive threats that, if they are not given a prescription, they
will have to resort to illegal activity, the governing principle
is that nothing should be prescribed unless there are clear
physical signs of the relevant abstinence syndrome Rigid
application of this rule is essential, otherwise hospital
A&E departments or GP surgeries may be used as regular supplementary sources of supply There is also a risk that casual non-dependent users will thus get pharmaceuti-cally pure preparations of dependence-producing drugs,
on which they may accidentally overdose A careful history
to establish that there is dependence is, therefore, always essential, as is a thorough physical examination to establish the nature and severity of any abstinence syndrome
Treatment for Drug Misuse
Pharmacological treatment options
A detailed account of specific treatment régimes and the supporting evidence is beyond the scope of this chapter
A range of guidance is available, such as that produced by the British Association of Psychopharmacology (Lingford-Hughes et al., 2004), Department of Health (2007) and the National Institute of Clinical Excellence (NICE 2007a,b,c, 2008a) Much of this does not, however, deal with complex comorbid conditions such as those found in the criminal justice system
A growing variety of pharmacological treatments are available (Lingford-Hughes et al., 2004), for stabilization, detoxification, reduction, maintenance and relapse preven-tion, in addition to treatment for psychiatric disorder or physical problems (Chandler and McCaul, 2003; Rayburn and Bogenschutz, 2004) Most of these treatments can be administered in the community, with close supervision, but patients may need to be admitted to hospital or to a reha-bilitation unit These decisions are clinically complex and depend on a range of factors, including degree of depend-ence, number of substances used, social stability and support network The treatment must be individualized
Box 18.2 Drug use outcome measurement tools
(NTA, 2006a)
Maudsley Addiction Profile (MAP) Addiction Severity Index (ASI, European adaptation) Opiate Treatment Index (OTI)
OTI modified for amphetamine users Global Appraisal of Need (GAIN) Leeds Dependence Questionnaire (LDQ) Severity of Dependence Scale (SDS) The Craving Questionnaires Readiness to Change Questionnaire (RTQ) (Treatment Version)
Injecting Risk Questionnaire Drug Taking Confidence Questionnaire (DTCQ) Inventory of Drug-Taking Situations
Quality of Life Inventory (QOLI) Beck Depression Inventory (BDI) Beck Anxiety Inventory (BAI) Hospital Anxiety and Depression Scale (HADS) General Health Questionnaire (GHQ-28)
Box 18.3 The CRAFFT questionnaire (Knight
et al., 2002)
1 Have you ever ridden in a car driven by someone
(including yourself) who was ‘high’ or had been using alcohol or drugs?
2 Do you ever use alcohol or drugs to relax, feel better
about yourself, or fit in?
3 Do you ever use alcohol or drugs when you are by yourself, alone?
4 Do you ever forget things you did while using alcohol
or drugs?
5 Do your family or friends ever tell you that you should
cut down on your drinking or drug use?
6 Have you ever gotten into trouble while you were
using alcohol or drugs?
For each positive response, score 1 A CRAFFT score of ≥ 2 identifies a substance problem, disorder, or dependence.