Examining violence among Not Guilty by Reason of Insanity state hospital inpatients across multiple time points: the roles of criminogenic risk factors and psychiatric symptoms.

OBJECTIVE: Institutional violence in state hospitals is a public health problem that has been severely understudied. Given the personal (ie, staff and patients) and fiscal harms associated with institutional violence, more research into contributing factors for violence is needed. The overarching aim of this study then was to examine associations among psychiatric symptoms, criminal risk factors, and institutional violence. METHODS: Participants were 200 male, female, and transgender forensic mental health inpatients adjudicated Not Guilty by Reason of Insanity and committed to the California Department of State Hospitals. Participants completed a psychiatric symptom measure, and measures of and associated with criminal risk. Institutional violence was recorded from file review and includes physical violence toward staff or patients for 6-months prior to and post patient participation in this study. RESULTS: After adjusting for previous institutional violence, results indicated that psychiatric symptoms were not associated with follow-up institutional violence; however, criminal risk was associated with follow-up institutional violence. Unexpectedly, 2 aspects of criminal risk, antisocial cognitions and associates, were not associated with follow-up institutional violence after adjusting for previous institutional violence. Results also provided a tentative cutoff score on the Self-Appraisal Questionnaire for predicting follow-up institutional violence. CONCLUSIONS: These results have important implications for treating and managing patients at risk for institutional violence, including the need to assess criminogenic risk and leverage treatments that target these risk factors as a best practice approach.

Trauma and Suicide Attempts among Insanity Acquittees.

Although many studies have assessed trauma as a suicide risk factor, to the authors' knowledge this is the first study of that risk factor among forensic psychiatric populations. Using a cross-sectional self-report survey methodology, this study investigated trauma histories, adverse childhood experiences (ACEs), posttraumatic stress disorder symptoms, and lifetime suicide attempts among forensic hospital patients adjudicated not guilty by reason of insanity ( n = 107). About 45 percent reported a previous suicide attempt and 22 percent reported multiple attempts, higher than the general population. The average number of attempts was 1.05 (2.39 among those with at least one attempt). The only PTSD symptoms significantly associated with attempting suicide were negative emotions and anhedonia, both in the cognitive/mood cluster, which was the only one of the four clusters to be significantly associated with attempting suicide. Childhood physical abuse was the only trauma significantly associated with attempting suicide. Higher number of attempts was significantly associated with ACEs (emotional neglect and abuse, sexual abuse, physical neglect, and household members with substance-related problems), number of traumas, substance-related problems (especially from alcohol), arousal symptoms (excessive startle, inattention) and negative emotions. We found several statistically significant suicide risk factors, particularly ACEs. Possible explanations and implications of the results are discussed.

Dissociative Identity Disorder and the Law: Guilty or Not Guilty?

Dissociative identity disorder (DID) is a dissociative disorder that gained a significant rise in the past few decades. There has been less than 50 DID cases recorded between 1922 and 1972, while 20,000 cases are recorded by 1990. Therefore, it becomes of great significant to assess the various concepts related to DID to further understand the disorder. The current review has a goal of understanding whether an individual suffering from DID is legally responsible for the committed crime, and whether or not he or she can be considered competent to stand trial. These two questions are to be raised in understanding DID, by first shedding a light on the nature of the disorder and second by examining the past legal case examples. Despite the very nature of the disorder is characterized by dissociative amnesia and the fact that the host personality may have limited or no contact with the alters, there is no consensus within the legal system whether the DID patients should be responsible for their actions. Further to that, courts generally deny the insanity claims for DID suffering patients. In conclusion, more studies in the field are suggested to incorporate primary data into research, as the extensive reliance on secondary data forces us to believe the conclusions that were previously made, and no opportunity to verify those conclusions is present.

Neurodevelopmental Conditions and the NGRI Defense.

Guina et al. summarize the literature on neurodevelopmental conditions and crime, focusing on the use of the insanity plea for this population. There have been a small number of cases in several jurisdictions, using both cognitive and volitional prongs, generating questions about the use of the defense for people with neurodevelopmental conditions. There are theoretical scenarios in which the defense seems appropriate, such as the argument that higher order moral reasoning is contingent on a series of developmental steps, including the development of theory of mind. Other lines of argument could be based on differences in conceptual thinking, reasoning, language, memory, attention, executive functioning, emotional regulation, and impulsivity. There are multiple barriers, however, to the use of the defense, including its antiquated language, which does not reflect our current conceptualizations of mental conditions and disorders. Another barrier is associated with the implicit stigmatization of defining a different way of being as a disorder, a position at the core of the important and burgeoning neurodiversity movement. It is not clear whether neurodevelopmental conditions will become the basis for an increasing number of insanity pleas, but more information in the form of primary data and good analysis is a critical next step.

Prevalence of Traumas and PTSD Among Individuals Adjudicated Not Guilty by Reason of Insanity.

Trauma and posttraumatic stress disorder (PTSD) are common among psychiatric and criminal populations, yet there have been few studies among forensic psychiatric populations and no known studies have specifically examined insanity acquittees. This study aimed to identify the prevalence of trauma and to assess recognition of PTSD in forensic settings. Using a cross-sectional self-report survey methodology, we examined traumas, adverse childhood experiences (ACEs), and PTSD in insanity acquittees (n = 107). Most insanity acquittees experienced trauma (86%, averaging 11 events) and ACEs (76%, averaging 3 types). The most commonly experienced traumas were sudden death of a loved one, witnessed death or serious injury, adult physical assault, and motor vehicle accident. Women were significantly more likely to experience any ACE (especially witnessing domestic violence, household members with mental illness, emotional abuse, and emotional neglect) and adult sexual assault. PTSD prevalence was 25 percent, with 97 percent of cases being previously undiagnosed. Sexual traumas and younger age were significantly associated with PTSD. These results suggest that insanity acquittees have high levels of trauma, ACEs, and PTSD. While PTSD was about seven times more common than in previous findings in the general population, it frequently goes undiagnosed in forensic settings. Potential explanations and implications of our findings are discussed.

Anxiety Mediates the Link Between Psychopathy and Aggression in NGRI Acquittees.

Psychopathy has been long associated with anxiety, and anxiety has been argued to play an important role in psychopathy-related behaviors, such as aggression. However, these associations have not yet been explored in Not Guilty by Reason of Insanity (NGRI) Acquittees. The goals of the present study were to test the correlations between the 4-facet psychopathy construct and anxiety, and to assess whether anxiety mediates the association between psychopathy and aggression. In a sample of 81 NGRI acquittees, anxiety was positively related to the lifestyle facet. When testing the mediating role of anxiety on the psychopathy-aggression link, the results showed that low anxiety mediated the link between the interpersonal facet and aggression. By contrast, high anxiety mediated the link between the lifestyle facet and aggression. These results highlight the disparate associations between specific psychopathy features and anxiety in predicting aggressive behavior. The present findings demonstrate that violence reduction strategies may need to become more tailored to individual needs when it comes to reducing risk among people with varying levels of psychopathic traits and serious mental illness.

A New Commitment Pathway for Offenders With Serious Mental Illness: Expedited Diversion to Court-Ordered Treatment.

The authors propose a new form of civil commitment that would benefit individuals with serious mental illness involved with the criminal justice system. This population has complex needs rooted in comorbid conditions, alienation from treatment and support systems, and poor access to care. Although many dollars are spent on costly assessments and hospitalization of jail detainees with serious mental illness to ensure that they are competent to stand trial, these detainees typically do not receive adequate services during incarceration or after release and recidivate at high rates. The proposed commitment pathway would expeditiously divert offenders with serious mental illness into treatment, providing services under court supervision while avoiding unnecessary and often fruitless interactions with the criminal justice system.

The influence of defendant race and mental disorder type on mock juror decision-making in insanity trials.

This study examined the joint influence of defendant race (Black/White) and mental disorder type (schizophrenia/depression) on mock juror decisions in a Not Guilty by Reason of Insanity (NGRI) case. We reasoned that unwillingness to vote for insanity would be more pronounced for a Black defendant with schizophrenia, given overlapping dangerousness and criminality stereotypes associated with those groups. Online community participants (N = 216) read a fictional second-degree murder case in which we varied mental disorder type and defendant race, then provided a verdict (guilty/NGRI) and answered questions regarding the trial. In line with hypotheses, participants were significantly more likely to vote guilty for a Black defendant with schizophrenia as compared to depression, but there were no significant differences for the White defendant. Results of this study suggest that bias in insanity trials can be exacerbated for a racialized defendant.

Female psychopathy: A descriptive national study of socially dangerous female NGRI offenders.

Understudied is psychopathy in females, particularly socially dangerous NGRI females, where the construct could be of forensic, clinical and criminologic significance. Italy's recent transformation of its mental health system created the context for studying such a population on a national level. Throughout the twentieth century until their closure in 2015, offenders found to be not guilty by reason of insanity (NGRI) and socially dangerous were placed in one of the the six high security hospitals in Italy (OPGs). Only one hospital, the Castiglione delle Stiviere maximum security hospital (OPG) in North Italy, treated female offenders, who came from all parts of Italy. The authors studied 66 of all 86 women in Castiglione delle Stiviere OPG. The aims of this study were to identify the prevalence of psychopathy in NGRI female offenders and eventually to identify any phenotypic gender-specific features of psychopathy. The SCID I and II interviews and other tests (MMPI-2, MCMI-III, R-Bans) were administered to all the women. Clinical historical information was obtained. Finally for all women who consented to participate in the study, the researchers administered the PCL-R version validated for the Italian population. The final sample consisted of 66 women, who were deemed NGRI and socially dangerous. Here the authors present the final results as well as limitations of the research.

Psychopathy and Female Gender: Phenotypic Expression and Comorbidity; A Study Comparing a Sample of Women Hospitalized in Italy's Maximum Security Facility with Women Who were Criminally Sentenced and Imprisoned.

Various studies have shown that women with psychopathy tend to commit crimes that are less violent than those of psychopathic men. The present study was designed to address the influence of psychopathy on the crimes committed by female offenders. A national sample of female offenders found NGRI or of diminished responsibility and at risk for criminal recidivism (OPG patients) was compared with a sample of female offenders who were convicted and imprisoned. Results of this comparison between the two groups of female offenders indicate that psychopathy is a transversal psychopathological dimension which may or may not be associated with other mental disorders. In both samples, the most commonly reported offenses among women with high PCL-R scores were minor offenses, not particularly violent, but they appear to be related to typical psychopathic features such as superficial charm, pathological lying, and manipulation.

Psychiatric monitoring of not guilty by reason of insanity outpatients.

Individuals deemed Not Guilty by Reason of Insanity (NGRI) by the courts, under Article 20 of the Portuguese Criminal Code, have often committed very serious crimes. It is unreasonable to consider that these patients were usually kept without adequate supervision after the security measure had been declared extinct. They often decompensated after leaving the institution where they complied with the security measure, and/or relapsed to alcohol and drug abuse. Very often, severe repeated crime erupted again. Considering this, there was an urgent need to keep a follow-up assessment of these patients in order to prevent them from relapsing in crime. This work presents the results of a psychiatric follow-up project with NGRI outpatients. The main goals of the project were: ensuring follow-up and appropriate therapeutic responses for these patients, maintaining all individuals in a care network, and preventing them from decompensating. The team consisted of a psychiatrist, a nurse, and a psychologist. Seventy-two patients were monitored during two years. Results demonstrated the unequivocal need to follow up decompensated patients after the court order is extinguished. Suggestions are presented for a better framing and psychiatric follow-up of these patients.

Drug driven psychoses and legal responsibility or insanity in six Western Pacific nations.

Prompted by four questions, forensic mental health clinicians from Russia, China, Japan, Hong Kong, Australia and New Zealand provided information on both the legislative basis and current practice concerning the relationship between legal insanity, intoxication and drug induced psychosis in their six Pacific Rim Countries which account for nearly 20% of the world's population. Details of the survey for each contributing nation are provided. While there are significant variations in practice that have been shaped by regional legal, clinical and cultural influences there is considerable similarity in the legislation underpinning how these issues are considered. Consequently there remain similar challenges for each nation. In none of the legislative bases was the issue of drug induced psychosis specifically addressed. The authors conclude that evolving pharmaco-neuropsychiatric knowledge, societal values and patterns of substance misuse require nations to consider developments in scientific and clinical knowledge to support their interpretations of the relationship between altered mental states as a result of substance use and the legal construct of insanity.