Forensic Psychiatry_ Clinical, Legal and Ethical Issues Book 1

Treatment of personality disorder

what was said, it would never be sufficient. He saw that such as social skills training, psychoeducation and sup-
other patients were also being provided with feedback at portive therapies (Brazier et al., 2006; Duggan et al., 2007).
the same time, but he was envious of them, believing that The NICE guidelines on treatment of antisocial personality
they were seen as performing better than he. He began to disorder (NICE, 2009a) and borderline personality disorder
move forward when he agreed that this was beginning to (NICE, 2009b) while the Brazier (2006) review incorporates
interfere with his capacity to work in therapy. evidence on cost as well as effectiveness. Leichsenring and
Leibing (2003) came to an optimistic conclusion, that there
Collating the evidence for psychological was evidence for the effectiveness of both dynamic and
treatments for personality disorder cognitive therapies, but a larger overall effect size for the
A number of useful systematic reviews have been published dynamic therapies. Other reviewers are more cautiously
of studies evaluating the main psychological treatments for positive. Gerber et  al. (2011) note the superiority of psy-
personality disorder. These range from the more specific, chodynamic therapy to non-specific work or waiting list
for example randomised controlled trials of psychody- conditions, but equivalence with other therapies. Table 16.5
namic psychotherapy (Gerber et  al., 2011), through com- builds on and updates material from the Duggan et  al.
paring psychodynamic therapy with cognitive behavioural (2007) review of randomized controlled trials. Therapeutic
approaches but incorporating a range of trial designs communities will be dealt with separately, below.
(Leichsenring and Liebing, 2003), to those confining them-
selves to RCTs but covering a wider range of treatments. The most striking thing about the randomised con-
The latter include the psychodynamic therapies and their trolled trials summarised in table 16.5 is that there have
developments such as mentalization therapies, the cogni- been few evaluations of treatment for any personality dis-
tive behavioural therapies (CBT), and their developments, order other than borderline personality disorder, and there
such as dialectical behaviour therapies (DBT), and schema- is also a heavy bias towards women as patients. Most of
focused therapies (SFT), and practical, holding therapies the trials were of treatment in an outpatient setting. The
table gives little flavour of the very wide range of outcome
measures used, but it must be noted that, in many cases,

Table 16.5   Summary of completed randomised controlled trials of psychological treatments for
people with personality disorder

Study Sample Therapy Usable Duration of Authors’ conclusions
outcomes1 trial
* Bateman and 44 women with Psychoanalytically 18 months + 18 Psychoanalytically oriented
Fonagy, 1999; BPD oriented partial Leaving early2; months follow-up treatment better on range
2001 hospitalisation v. quality of life; psych. of measures from 6 months,
Bateman and 27 men general psych. care service use Up to 18 months maintained through follow-up
Fonagy, 2009 107 women with Mentalization based Improvement in both groups,
BPD; many with treatment v. structured Suicide/self- 20 weeks + 12 more in the mentalisation group
Blum et al., 2008 axis I comorbidity clinical management harm attempts, months follow-up
and add. PDs hospitalisations, Discontinuation rate high in both
* Brooner 21 men Systems Training for length of hosp. 13 weeks groups; advantage for STEPPS
et al., 1998 103 women with Emotional Predictability group on BPD and other
BPD and Problem Solving Zanarini BPD scale; 12 months measures except for self-harm
Clarkin et al., (STEPPS) +TAU4 v. depression, self- or hospitalisations
2007 35 men TAU harm, impulsivity, 20 weeks; add. Both groups did well, n.s.
8 women with Contingency crisis service use; follow-up 6, 12, difference between them
* Colom opioid dependence management global function 18, 24 months
et al., 2004 and ASPD intervention v. Leaving early; return Improvements in all groups,
7 men methadone substitution to routine care most in transference based
83 women with Transference focused
BPD psychotherapy v. DBT Mental state, 100% control group relapsed:
v. supportive therapy suicidality, 67% psychoeducation; latter
9 men impulsivity, longer to relapse
28 women with Psychoeducation aggression and
bipolar disorder and v. unstructured violence (Continued)
any PD intervention, both + Global state
medication

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Personality disorders

Table 16.5   (Continued)

Study Sample Therapy Usable Duration of Authors’ conclusions
outcomes1 trial
* Davidson 17 men CBT + TAU4 v. TAU Self-harm, mental 12 months, add. CBT group less likely to be
et al., 2006 89 women with state, quality of life, follow-up 18 and hospitalised or use A&E;
BPD Transference-focused service use, leaving 24 months reduced no. of suicidal acts
Doering psychotherapy early 12 months
et al., 2010 104 women with v. treatment Leaving early, Transference-focused therapy
BPD by community self-harm; 6 months; follow- superior on most measures
* Emmelkamp psychotherapists general mental up at (including specific PD)
et al., 2006 30 men state; personality 12 months
* Evans et al., 32 women with PD CBT v. organisation, global 6 months At end of treatment and follow-
1999 brief dynamic therapy function up: CBT best; brief dynamic
34 men v. waiting list Behaviour avoidance 3 years therapy equivalent to waiting list
* Giesen-Bloo and women MACT (manual- scale; mental state; MACT superior in reducing
et al. 2006 (proportions not assisted cognitive- quality of life 14 weeks suicidal acts and depression
* Gratz and stated) cluster B PD behaviour therapy) v. Leaving early; global
Gunderson, 6 men TAU mental state; quality 6 months Both therapies significantly
2006 80 women with Schema-focused v. of life reduced BPD specific and
* Kool et al., BPD transference focused 6 months general psychopathology
2003 22 women with therapies Leaving early, mental Emotional regulation groups
BPD Emotional regulation state, behaviour 12 months + 12 advantage for self-harm,
* Koons groups v. TAU months follow-up BPD specific and general
et al., 2001 49 men Leaving early, mental 12 months + 4 psychopathology
79 women with Short psychodynamic state, behaviour months follow-up Combined therapy was more
* Linehan depression, supportive therapy effective for depressed PD
et al., 1991 128 with PD + antidepressants v. Mental state, global 12 months + 4 patients but not for depressed
* Linehan 28 women with antidepressants state months follow-up patients without PD
et al. 1999 BPD DBT v. TAU 12 months + 12 Decrease in parasuicide,
Service admissions; months follow-up experienced anger and
* Linehan 63 women with DBT v. TAU parasuicide, mental 12 months dissociation
et al. 2002 BPD state, leaving early,
* Linehan DBT v. TAU no BPD criteria 16 weeks + Less parasuicide, more
et al. 2006 28 women with Parasuicide; early up to 40 weeks treatment engagement and
McMain et al., BPD DBT v. comprehensive leaving follow-up fewer inpatient days with DBT
2009 validation therapy + DBT group greater reductions
23 women with 12 step Leaving early; death; in drug abuse in treatment year
* Messina et al., BPD DBT v. ‘community substance use and at follow-up; in treatment
2003 treatment by experts’ longer; better global and social
101 women Leaving early; time adjustment at follow-up than
with axis I and II DBT v. general spent in prison TAU group
disorders psychiatric Both treatments effective; small
15 men management Quality of life; differences between them
165 women with behaviour; mental
BPD and 2 + self- CBT v. contingency state DBT uniquely effective in
injuries in past 5 management (CM) Frequency and reducing suicidal behaviours; not
years v. CBT + CM, all severity of self-harm a general effect of psychotherapy
34 men with methadone Both groups improved
14 women maintenance (MM) v. Substance use significantly on self-injury and
with ASPD and MM alone other clinical measures
substance misuse
CM most effective

410 © 2014 by Taylor & Francis Group, LLC

Treatment of personality disorder

Table 16.5   (Continued)

Study Sample Therapy Usable Duration of Authors’ conclusions
outcomes1 trial
* Oosterbaan 48 men CBT v. moclobemide Leaving early; side- CBT superior (but for social
et al., 2001 34 women with v. placebo effects 15 weeks + up phobia rather than PD)
social phobia, 50% to 15 months
* Springer avoidant PD DBT-based creative Mental state; follow-up Both groups improved, n.s.
et al., 1996 10 men coping group v. behaviour differences between them
21 women with PD wellness and lifestyles Not stated
* Stravynski et al. several types group Both groups showed benefits
1994 Social skills training in Leaving early 8 weeks; 6 but the ‘in vivo’ training did not
* Svartberg 18 men the clinic v. training ‘in months follow-up enhance the social skills training
et al., 2004 13 women with vivo’ Both groups improved; n.s.
avoidant PD CBT v. short-term Mental state; quality 40 weeks; differences between them
* Turner, 2000 25 men psychodynamic therapy of life follow-up
25 women with @ 12 and 24 DBT more improvement than the
* Tyrer et al., cluster C PDs DBT v. client centred Mental state, no. months CCT group on most measures.
2004 therapy (CCT) of new admissions; Quality of therapeutic alliance
5 men leaving early 12 months accounted for significant variance
* van den Bosch 19 women with MACT v. TAU for both treatments
et al. 2005 BPD Number with PD Up to 7 No difference in self-harm rates;
DBT v. TAU having at least one treatments; MACT more expensive than
* van den Bosch 154 men self-harm incident follow-up @ 6 TAU for patients with BPD, but
et al., 2002 326 women with DBT v. TAU and 12 months less so with other PDs
* Verheul deliberate self- Parasuicidal and self- Advantage for DBT in self-harm
et al., 2003 harm, 202 with PD DBT v. TAU mutilation; substance 52 weeks; follow- and impulsive behaviours and
58 women with use; behaviour scale up @ 78 weeks alcohol use, sustained @ 6
* Vinnars et al., BPD Manualised scores months; no difference for illicit
2005 supportive expressive drug use
64 women with psychotherapy (SEP) Leaving early; 12 months BPD as Verheul
* Weinberg BPD v. psychodynamic behaviour; et al. 2003; this article confirmed
et al., 2006 psychotherapy (PsDP) substance use 12 months no effect on substance misuse
58 women with MACT + TAU v. TAU DBT better retention rates and
* Winston BPD Suicidal and SEP 40 weeks; 21 more reduction in self-harm
et al., 1994 Brief adaptive self-mutilating sessions PsDP than TAU
49 men psychotherapy v. short- behaviours; service
107 women with term psychodynamic v. engagement Improvement in global function,
PD waiting list reduced prevalence of PD both
Global state; mental groups; SEP group fewer follow-
30 women BPD state up visits to community mental
health teams
33 men Suicidal acts and 6-8 weeks, Reduced frequency and severity
48 women with PD behavioural scale follow-up @ 8 of deliberate self-harm with
months MACT; no reduction in suicidal
Leaving early; ideation
mental state; social 6 months; up to Both treatment groups had
function 4.5 years follow- significant advantage over waiting
up (mean 1.5 list group
years)

1Usable outcomes refers to all those outcomes measured systematically and reported sufficiently transparently to allow for meta-analysis.
2Leaving early refers to leaving the therapy and/or the study before complete.
Abbreviations: as table 16.4 and add., additional; A&E, accident and emergency; psych, psychiatric; hosp., hospitalisation; n.s., not significant; TAU,
treatment as usual.

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any advantage found for a therapy was in reduction in self- generally followed the conceptual TC route (e.g. Wexler,
harm rate or some specific symptom change rather than 1997), in the UK, even in prisons, the democratic TC has
fundamental personality change. This is perhaps unsurpris- been the leading model (e.g. Gunn et  al., 1978; Morris,
ing as in under half the cases was treatment given for 12 2004; Genders and Player, 2010).
months or more, but examination of briefer interventions
does offer some help with our starting point – that brief Lees et al. (1999, 2004) conducted a systematic review
therapies may be most desirable for reasons of access and of studies of the effectiveness of therapeutic communi-
economics. Comparison of one active treatment against ties for people with personality disorder, covering the
another brought less clarity, which takes us back to our literature from the inception of TCs up to 1997. The
non-specificity discussion. It is reassuring, at least, that search located over 8,000 studies, but just 10 randomised
all trials of active treatment against placebo favoured the controlled trials to that date, 10 cross-institutional, cross-
active treatment in some respect. treatment or comparative studies and 32 other studies
using some sort of control; 41 of the total of 52 studies
Therapeutic communities related to democratic TCs and 11 to concept-based TCs;
The term ‘therapeutic community’ (TC) is generally 29 studies were amenable to meta-analysis. This indicated
attributed to Main (1946), however in initial concept a positive effect, with an effect size of 2.5, which it has been
it was rather similar to the Quaker reforms to mental suggested is what is required to indicate a clinically signifi-
health institutions introduced in the late eighteenth cen- cant, but small outcome (Haddock et  al., 1998). Another
tury, for example at the Retreat, York, in England. Much way of looking at their findings is to observe that four of
later, this interpretation of the idea was taken up by the the eight RCTs and 15 of the 21 other controlled studies
anti-psychiatry movement to create ‘alternative asylums’, favoured TCs. Restricting consideration to the RCTs, the
with flattened hierarchies within and between staff and US study of a secure democratic TC suggested that its
residents and, often, commitment to a particular philo- graduates did about twice as well as those from a conven-
sophical style. Two more specific approaches are relevant tional setting (Auerbach, 1977; odds ratio (OR): 0.524, 95%
to treatment of personality disorder. The ‘true therapeutic confidence interval (CI) 0.28–0.98), but the British coun-
community’ was originally a principally British develop- terpart was equivocal (Cornish and Clarke, 1975); open,
ment led by Maxwell Jones ( Jones, 1968, 1982). It is a democratic TCs fared little better. Results were better for
small, cohesive, ‘democratic community’ in which there is the concept based therapeutic communities. We cannot
a clear distinction between staff and residents, although find a more up-to-date review of therapeutic communi-
little hierarchical difference, and they work together at all ties. Most of the controlled studies of TCs are, therefore,
times in a spirit of co-operation, jointly setting the rules quite old, and we are not aware of current trials in this
and procedures for the community  – and the sanctions field with people who explicitly have personality disorder.
if broken – and commonly sharing decisions about who A later systematic review and meta-analysis of concept
should become residents. While therapeutic expertise TCs (Smith et al., 2006), albeit here strictly for substance
may lie with the staff, the whole community is expected misuse rather than personality disorder, found results of
to take a part in the therapeutic process, and in support- RCTs to be equivocal overall, but observed that the two
ing community members through crises. The Henderson prison studies were positive in finding lower recidivism
hospital model is probably the best known example of a rates for the TC men for up to 12 months after release
democratic therapeutic community in the UK (Whitely, (Sacks et al., 2004; Wexler et al., 1999). This, however, leads
1980; Dolan, 1997). The ‘concept based community’ was to another word of caution. Long-term follow-up was for
originally founded in the USA, when a recovering alco- up to 10 years in a US prison-based TC study. Therapeutic
holic, Charles Dederich, set up Synanon in response to community graduates had an early advantage compared
the perceived needs of addicts. In his hands, this form of with youths in an ordinary prison environment, but, after
community relied on membership for which people quali- 10 years there was a cross-over, with the TC graduates
fied through their abuse of drugs, and were sustained in faring worse (McCord and Sanchez, 1982). Speculation
conformity by aggressive confrontation; in the absence was that this could be explained by the development of
of professionals, and reliant on the charisma of its leader, new skills and ways of thinking in the TC having been
this pioneer of the model lost its way, amid law suits about outside the participants’ own cultural context. There is
cruelty and coercion (Galanter, 1999). The principle of the a great deal more to learn about the place of therapeutic
concept based community, however, survived through communities, but results of their evaluation to date are
more openness to external review, with the Phoenix sufficiently promising that this should be attempted.
House model (De Leon, 1973) perhaps best known for its
incarnations in the UK. While the US route to introducing Managed Clinical Networks
TC models for offenders through the correctional system
Life events literature confirms that people commonly
find major transitions in relationships or accommodation

412 © 2014 by Taylor & Francis Group, LLC

Dangerous and severe personality disorder (DSPD): The rise and fall of a concept

extremely difficult, with a higher chance of becoming psy- 1. one person to be appointed with overall responsibility
chologically distressed or ill at these times (Holmes and for each patient’s network: a clinician, manager or other
Rahe, 1967). It is arguable that most people who have attach- professional;
ment difficulties as a fundamental part of their personality
disorders are going to find change exceptionally difficult, 2. the purpose is to improve equality and convenience of
particularly if they have just made a healthy attachment in access to care and its co-ordination; expected service
therapy, or to the therapeutic community. It is important, improvements (and cost savings) are made explicit
therefore, that treatment is not happening with one person from the outset, and effectiveness of the MCN measured
in isolation, but a system, or network is in place to support against these;
the individual in all his or her areas of difficulty, and that it is
particularly robust at times of transition. Furthermore, the 3. adherence to evidence-based treatments, and support
importance of the network in supporting the therapist and for research wherever these are lacking; support for
other key workers is not to be underestimated. professional development;

Baker and Lorimer (2000) define a managed clinical 4. audit is an integral part of the network;
network (MCN) as: 5. each network makes an annual overview of its activities

a linked group of health professionals and organiza- available to the public;
tions from primary, secondary, and tertiary care, work- 6. all members of the network, including the patients/
ing in a coordinated way that is not constrained by
existing organizational or professional boundaries to service users, are involved in shaping it.
ensure equitable provision of high quality, clinically
effective care….The emphasis … shifts from build- Dangerous and severe
ings and organizations towards services and patients. personality disorder (DSPD):
The MCN has the following functions: The rise and fall of a concept
●● monitoring and updating core standards of care;
●● developing and updating skills and knowledge; The term ‘dangerous and severe personality disorder’ (DSPD)
●● audit and research; is uniquely English, having been created by politicians and
●● leadership and authority; civil servants in 1999 to define a group of offenders who
●● coordinating and managing change. often fell uncomfortably between the criminal justice sys-
MCNs are important for offenders with personality dis- tem on the one hand and forensic mental health services
order for several reasons. First, personality disorder is an on the other. As perceived by the government, the problem
enduring condition, so it is important that provision is was that mental health services wanted to deal only with
made seamlessly across the life span. Secondly, and this psychotic or seriously mentally ill offenders – whilst grow-
especially applies to offenders with personality disorder, ing public concern about sexual and violent recidivism had
many agencies are likely to be involved, fielding personnel no regard for diagnostic niceties. This perception was thrust
with different philosophies and priorities. Thirdly, psycho- into the spotlight by the case of Michael Stone, who was
logical therapies, the mainstay of treatment if available, are convicted of killing a mother and daughter in an unpro-
delivered by ‘…a range of sometimes rivalrous professionals voked attack in rural Kent, the second daughter making a
– psychologists, psychiatrists, nurses – who are currently miraculous recovery from potentially fatal injuries.
managed in different ways’ (Holmes and Langmaack,
2002). Fourthly, there are few practitioners who have Does the Home Secretary believe that further measures
particular skills in this field, so it is difficult to build up will be needed to deal with offenders who are deemed
a critical mass of them. Finally, assessment, management to be extremely violent because of mental illness or
and treatment of personality disorder are still developing, personality disorder, but whom psychiatrists diagnose
so, not only is time needed to keep abreast of scientific as not likely to respond to treatment? Alan Beith, MP.
advances and adapt service provision accordingly, but also Yes, I entirely agree with the Right Honourable gentle-
it is an advantage to bring together people with different man that there must be changes in law and practice
knowledge bases and skills. in that area. We are urgently considering the matter
with my Right Honourable friends in the Department
A formal MCN builds on informal arrangements and of Health … the psychiatric profession … 20 years ago
professional relationships. It is fundamental that there adopted what I would call a common sense approach
should be defined areas of accountability between the indi- … but these days go for a much narrower interpretation
viduals within the network and that boundaries are clearly of the law. Jack Straw, MP (Hansard 26 October 2000).
defined. The idea has been promoted particularly strongly These politicians had not seen, at that stage, the report of
in Scotland, where the Scottish Office (1998c) has provided the independent inquiry into the killings:
the following guidance on framework: The Panel is of the firm view that the policy debate
concerning the adequacy of the law, policy and guid-
ance should take place in the context of the actual

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Personality disorders

facts of the case of Michael Stone, as opposed to the identification of a population with so-called DSPD. It took
incomplete and in some cases inaccurate accounts that hard lobbying by clinicians to force an acceptance that
have appeared to date. (Francis, Higgins & Cassam, standard measures, particularly on risk, have been vali-
2006; South East Coast Strategic HA, Kent County dated for groups, and translation from this to the individual
Council, Kent Probation Area commissioned independ- is not straightforward. It is not possible to avoid a measure
ent report, 30 November 2000, published October 2006.) of clinical judgment as the final arbiter for admission to any
The issues are, in fact, better illustrated by a series of kill- treatment service, and, given a scarce and costly resource,
ings by predatory paedophiles (Oliver and Smith, 1993). hospital staff must also consider clinical treatment needs
When some of them came to medical attention towards as well as diagnosis and risk.
the end of prison sentences, there was general agreement
on the presence of mental disorder and continuing risk, yet DSPD services were implemented in 2003. Evaluation
psychiatrists refused to detain them in hospital because was built in to the pilot projects. Preliminary evaluation
they considered that the problems of these offenders were reports fuelled further debate, in 2007 a whole issue of the
‘untreatable’ in terms of the Mental Health Act 1983. British Journal of Psychiatry (190:49) being allocated to this.
It has become possible to identify strengths and weak-
A fierce debate ensued. The government charged the nesses of the programme.
profession with evading its responsibilities for dangerous
and difficult patients, whilst the profession took the sup- A Critique of DSPD
posed moral high ground, arguing that doctors should not
become jailers. There was and is a moral and philosophi- The term DSPD may be unique, but the problems it
cal argument, but there are also practical and economic attempts to encompass are not, nor are methods of assess-
dimensions. Mental health services operate at full capacity ing and treating personality disorder. The origins of the
and, except for a handful of tertiary services such as the programme can be traced to four major influences:
high security hospitals, generally have little or no expertise 1. decreasing tolerance of the risks associated with crime
in treating personality disorder. So, the government took
the initiative, not only by creating this new category of and violence;
disorder, and proposing radical new services, but also pro- 2. growth of standardised risk assessment and the PCL-R;
viding funds for developments. The concept of DSPD was 3. the Dutch TBS (Terbeschikkingstelling) system (van
born, and 300 new beds were created, half in high security
hospitals and half in prisons; later developments extended Marle, 2002; McInerny, 2000);
to medium secure hospitals and the community. 4. the development of cognitive behavioural programmes

for sexual and violent offenders.

DSPD: An Operational Definition 1. Decreasing tolerance of risk of crime
Over the last two or three decades, most developed coun-
The DSPD service was defined as being for offenders who tries have become less tolerant of the risks associated with
met the following criteria: sexual and violent offending, as reflected in changes to crim-
1. severe personality disorder, severe meaning a score of inal justice legislation and sentencing. The reasons for these
changes are complex. It is a mistake to see them as the whims
30+ on the PCL-R for men or 25 for women, or a score of authoritarian governments; they owe far more to populist
of 25+ and one or more personality disorders other democracy, the growth of feminism, and increasing respect
than antisocial personality disorder, according to for the rights of children and of victims of crime. DSPD was
international classification of mental disorder, or two or also consistent with a strategy to combat social exclusion.
more such personality disorders; Furthermore, knowledge has changed substantially since the
2. high risk of committing a further serious sexual or 1980s, with greater and more widespread understanding of
violent offence, this risk to be informed by standardised predatory paedophiles (D’Arcy and Gosling, 1998; Oliver and
instruments at a cut-off indicating a greater than 50% Smith, 1993) and of the lasting psychological harm done to
risk over the time frame of the instrument. Serious, many survivors of physical and sexual assault.
here, to be defined as likely to cause physical or
psychological harm from which the victim was unlikely These social changes had their greatest impact on the
ever to recover fully; criminal justice system, but mental health services could
3. a functional link between the personality disorder and not expect to remain isolated from these evolving values
the risk; and expectations. Indeed, over the same period there has
4. absence of major mental illness. been growing demand that professionals become more
The problems with this definition arise from its non- responsive to the needs and concerns of their clients or
clinical origins. It was intended that standardised meas- patients. In this context, psychiatrists’ attempts to wash
ures of personality disorder and risk would allow precise their hands of responsibility for offenders with personality

414 © 2014 by Taylor & Francis Group, LLC

Dangerous and severe personality disorder (DSPD): The rise and fall of a concept

disorder were anachronistic and doomed to failure. DSPD know how well these proxy measures of change will corre-
developments may have been the starting point of a new late with behaviour in the community when patients move
approach to people with personality disorder, but it has on. Any attempt to measure such correlations is fraught
become just one small part of a process that includes policy with methodological problems – not least, the fact that only
and attitude change, as in the NIHME (2003) document patients who appear to do well on the proxy measure are
Personality Disorder: No Longer a Diagnosis of Exclusion, the likely to be exposed to the outside world.
development of Multi-Agency Public Protection Panels/
Panel Arrangements (MAPPPS/MAPPAs), development One of the original concerns about the emphasis on
and demise of a National Patient Safety Agency and an the PCL-R and risk assessment tools in defining DSPD was
overarching determination to develop safer services. that this would result in the locking away of ‘people who
have not done anything’, but just happened to get a high
2. Standardised risk assessment and score on an instrument about an abstract concept. This
the Psychopathy Checklist worry has proved unfounded. The main reason is that, for
We introduced this chapter with concerns about reliable all the claims to statistical sophistication, violence risk
and valid diagnosis of personality disorder; in particular, assessment relies on the old adage that the past is the best
categorical diagnosis of antisocial personality disorder guide to the future. The risk threshold set for entry to DSPD
has been so confounded with criminality that it hardly services ensures that people must have done something
discriminates between prisoners. In the USA, for example, in order to get over the bar. In this context, strengths of
one study found 90% of prisoners had the diagnosis (Guze, the risk assessment tools recommended are that they rely
1976), while in England and Wales the rate was so high largely on historical and verifiable fact and are transparent.
that the Office of National Statistics researchers took the
decision to exclude it from most calculations (Singleton 3. The Dutch TBS system
et al., 1998a). This unsatisfactory situation changed to some The Dutch TBS system has been managing violent and
extent with the concept of the psychopathy, and develop- sexual offenders in institutions and in the community since
ment of the Psychopathy Checklist – Revised (­PCL-R; Hare, 1928. Under TBS legislation, offenders convicted of a seri-
2003). It is not perfect, and there is plenty of room for ous sexual or violent offence and judged to present a high
argument about the nature of psychopathy, but the PCL-R risk of re-offending are sentenced by the criminal court to a
satisfied the first precondition for research by allowing TBS order. They serve a prison sentence appropriate to the
measurement and discrimination between groups. Similar offence and are transferred to a TBS facility for treatment
considerations apply to the management of risk; some of at the end of that sentence. They remain within the TBS
the claims for actuarial risk measures are overblown, and system indefinitely (subject to regular review by a tribunal),
they are of limited use in individual risk prediction, but first in a secure institution and, when safe, as conditionally
standardised measures have allowed systematic descrip- discharged, supervised patients in the community. Dutch
tion and communication of risk, and lend themselves to courts rarely give a sentence of life imprisonment and the
population studies (see also chapter 22). It is fair to say that, TBS order is in many ways a substitute.
without the improvements resulting from the use of stand-
ardised measures of personality disorder and risk, there Treatment within the TBS system is eclectic, but CBT
could never have been a DSPD service. An early vision of is prominent, and there is also an emphasis on therapeutic
DSPD services was that all prisoners would be measured on community principles and on work; patients are expected
a battery of scales and those with the ‘correct scores’ would to spend about half the week in paid employment. Anti-
go to the new service. This approach oversimplifies the libidinal medication is widely used with sex offenders, and
hazy boundaries between different types of deviance, and it accounts for much of the medical input as most other treat-
risks repetition of old mistakes in medicalising criminality ments are delivered by psychologists or specially trained
(Sim, 1990; Maden, 1993). (non-medical) therapists.

We have also explored another historical problem in The practical outcome of a TBS order – prison then
the treatment of personality disorder – how to measure indefinite detention in hospital – is the same as for many
change. Clinicians accustomed to monitoring progress by English prisoners transferred to hospital near the end of
the fading of symptoms such as hallucinations or delu- their sentence, but the Dutch system is more transpar-
sions struggle with patients who often do not present with ent. The future is spelled out at the time of sentencing;
sustained descriptions of subjective complaints in this kind planning can begin early. The experience of staff in DSPD
of way, and it is easy to lose sight of treatment goals. DSPD hospital units has been that they spend much time and
services were ahead of most UK forensic mental health ser- energy mollifying patients who are understandably angry
vices in exploring the use of structured dynamic measures at being transferred to hospital just as they were expecting
to define goals and progress towards them. We do not yet release to the community. The nature of DSPD means that
the information to support detention on grounds of risk
was available at the time of sentencing, so it is reasonable

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Personality disorders

to ask why, if an indeterminate order is appropriate, it was Nevertheless, there is a problem with offending behav-
not considered so by the sentencing judge. iour programmes which must be acknowledged. They are
designed to reach the maximum number of offenders at
The problem was often compounded by the Mental minimum cost so are, by nature, ‘one size fits all’, with little
Health Act (MHA) 1983, worded so as to encourage attempt to tailor the intervention to individual pathology.
patients in a belief that refusal to co-operate would One would not, therefore, expect outliers on any dimension
lead to their being deemed untreatable and, therefore, to do well. Drop-outs are not of major concern so long as
not detainable. In fact mental health review tribunals most people complete the course – indeed, drop-outs cre-
rarely discharge patients on such grounds, and perhaps ate a place for someone else when places on such courses
the removal of the language of ‘treatability’ by the MHA are in high demand. High PCL-R scorers were, thus, often
2007 will help. By contrast, people in the TBS system excluded from standard programmes, so some more spe-
are always given the simple message that movement cialist versions have been developed through the DSPD
through the system depends on progress in treatment, initiative, for example the Chromis programme (Wallace
so, where possible, everything works much more quickly. and Newman, 2004).
Nevertheless, the TBS units also suffer from difficulties
in discharging patients; after a minimum of 6 years of At present, only evidence relating to the generally
treatment, about 20% of patients are judged unlikely available programmes, applied to less selected groups of
ever to be discharged and plans are made for indefinite offenders, is available, although there are no RCTs. Most
detention, subject to rights of appeal and regular review, of the published trials have relied on matching. Hanson
with priority given to quality of life. Hitherto, even high et al. (2002) reviewed 43 studies that included at least a
security hospitals in England have rarely had to contem- matched, untreated group, yielding a total of 9,454 sexual
plate indefinite stay for any patient, least of all those with offenders (5,078 treated and 4,376 untreated). Meta-
personality disorder ( Jamieson and Taylor, 2002). A threat analysis showed treated v. untreated recidivism rates of
was that the DSPD initiative might have made English 12.3% v. 16.8% for sexual offending and 27.9% v. 39.2%
hospital units more like the Dutch TBS units in this less for all offending. For both groups of offenders, these
appealing way. Sentencing within the ‘indefinite public differences are statistically significant; when analysis
protection’ (IPP) framework, however, went some way is restricted to interventions explicitly meeting current
down this road, attracting a great deal of approprium as standards for OBPs, the differences are more substantial:
result (See chapter 2). 9.9% v. 17.4% for sexual recidivism, and 32% v. 51% for
all recidivism. So, there is cautious optimism about such
4. Cognitive behavioural programmes programmes, although Marshall and McGuire (2003)
for sexual and violent offenders note we do not know ‘with which types of offenders’
DSPD may also be seen as a part of the backlash against the treatment is most likely to be effective (p.654). It is likely,
therapeutic nihilism that infected prisons in the 1970s and however, that impact will be least on predatory offend-
1980s. The ‘what works?’ movement of the 1990s (McGuire, ers or those with ‘stranger’ victims and perhaps those
1995) sought to counter this pessimism and led to a rapid with high psychopathy scores – in other words, those
growth in CBT based programmes for sexual and violent for whom DSPD services were designed (Maden, 2007).
offenders. Canada can claim to be the birthplace of such Brooks-Gordon and Bilby (2006) echo the note of caution,
offending behaviour programmes (OBPs), but they have albeit principally for sex offenders, and draw attention
now been developed in prisons in many countries, and to the ‘enormous political and institutional pressure to
some specialist mental health services are beginning to prove that treatment works’.
consider that versions of them might usefully be developed
for patients too. Inevitably, some offenders benefit more Despite this uncertainty, cognitively based programmes
than others from OBPs, and there have been research remain at the heart of OBPs for DSPD, not least because
reports claiming that people with high scores on the PCL-R of the advantage that staff in a prison can be maximally
are likely to do worse than others in most respects: more involved in delivering such programmes; training, and
likely to drop-out, to disrupt treatment or to re-offend support in delivering the programme, is far less costly
after treatment. There have even been claims in this last than a full clinical training, for whatever clinical discipline.
respect that such programmes make high PCL-R scorers Then, too, explanations of behaviour couched in cognitive
worse, although a systematic review of the literature found terms make sense to staff and offenders alike, and they
that of the 24 studies of this identified, only three were of help both to structure expectations and plan care path-
appropriate design for the research question, and none ways. Explicit procedures and aims facilitate evaluation.
met the reviewers’ methodological standards (D’Silva et al., Even if more evidence is needed on effectiveness, they
2004). There may, in fact, be little case for the gloom about also provide for methods to achieve that. The Violence
potential responsiveness. Reduction Programme (Wong et  al., 2007) at Saskatoon’s
Regional Psychiatric Centre (RPC), a specialised unit of
the Canadian correctional system, is an example of one of

416 © 2014 by Taylor & Francis Group, LLC

Personality disorder: Some conclusions

these programmes. Maden et  al. (2004) contrasts it with Personality disorder:
the DSPD programme, for which it served as a model. Some conclusions
There are two major differences: first, the Saskatoon unit is
part of the prison system. All programme participants are Personality disorder is a common problem – in one form
serving prisoners who have volunteered and can be sent or another far more common in the general population
back to ordinary prisons if they are violent within the unit, than schizophrenia – and yet its assessment and treat-
or if treatment is not progressing; second, the Canadian ment has been peripheral in most general psychiatric
correctional system includes a ‘Supermax’ prison (see also services. Forensic mental health services are beginning
chapter 25) that, effectively, provides backup in dealing to respond, and some have specialist personality dis-
with the most disruptive or violent behaviour. By contrast, order services, with naturalistic outcome data that are
the English DSPD system is committed to providing two promising. Personality disorders are the cause of much
parallel and different services – the hospital stream and the misery for the primary sufferers and for their family and
prison stream. The challenge for the high secure hospitals friends. They have serious consequences in the associ-
is daunting; if there is too much emphasis on control and ated mortality rates from suicide and accident, which
security the CBT will not work, yet too much reliance on are much higher than in the general population; some
self-control may lead to indiscipline and the disruption of personality disorders have a strong association with
therapy. repeated offending, sometimes serious offending. The
nature of disorders of personality is becoming clearer, but
The Future: Beyond DSPD there is still much to learn to meet the substantial per-
sonal and population needs created by them. With such
The DSPD service was expensive, with a bed in a high improvements in knowledge about genetic loading and
secure hospital costing about £240,000 per annum. This environmental hazards that may contribute in various
is a huge sum when it is anticipated that standard cases mixes to causing them, personality disorders may, with
will require between 3 and 5 years of treatment and many benefit, be conceptualised as developmental disorders.
patients will be there for much longer, although compared Improvements in assessments can and are being brought
to some innovative treatments in physical medicine, the to bear on improving treatment, and there is growing, if
figure may pale into insignificance. Whatever the ethical far from good enough evidence that treatment, especially
and scientific controversies about the service have been, to psychological treatments delivered within an appropri-
a large extent, economics have determined its future. Study ately multi-professional framework, can make a positive
of the economics of treating personality disorder more gen- difference to health and social function. Borderline and
erally is becoming ever more sophisticated (e.g. Soeteman antisocial personality disorders are not the most com-
et  al., 2010), and the full NICE guidelines on treatment of mon in the general population, but they tend to be the
antisocial personality disorder and borderline personal- ones most frequently seen in specialist forensic services,
ity disorder (NICE, 2009a,b) include financial information whether based in health or criminal justice services.
along these lines. The true cost of untreated personality Forensic mental health practitioners currently lead much
disorder in serious offenders, including recidivist child sex of the good practice in working with people with such dis-
offenders is, however, incalculable. Decommissioning of orders. It is important that the skills and the willingness
some of the DSPD pilot units will allow for funding of a to treat people with personality disorder are disseminated
‘personality disorder pathway’, with access to psychologi- more widely throughout mental health services if such
cally informed planned environments (PIPES) in prisons people are to be held on a recovery trajectory and, where
and the community and extension of currently accredited the disorders are linked with serious offending, they, their
programmes (Joseph and Benefield, 2012). families and the wider community are to be made safer.

© 2014 by Taylor & Francis Group, LLC 417

17
Deception, dissociation and malingering

Edited, written and revised by Written by
John Gunn
John Gunn
  1st edition edited by Paul Mullen David Mawson
Paul Mullen
Peter Noble

I have done that – says my memory. I could not have a tragic attempt to restore an unbearable loss through
done that – says my pride; [the] end remains inexorable. pursuit of the substituted goal.
Eventually memory gives in. (Nietzche, 1886)
Daydreaming
Deceptive mental mechanisms
Daydreaming is the way in which we turn away from
Deception occupies a central and privileged place in foren- the daunting task of wresting the desired from reality, or
sic psychiatry. The founding fathers of the speciality, such from the conflicts inherent in current obligations, into a
as Haslam (1817a,b), Ray (1838) and East (1927), were all world of fantasy and make-believe. In children, the world
much concerned with the need to recognize fraudulent of private make-believe and public reality can merge
claims in the accused, the claimant and the conscripted and mix. In some adults, the dividing line between the
serviceman, to potentially mitigating, compensable or internal world of fantasy and the shared external world
exempting disorders. The touchstone of the expert’s skill of consensual reality remains wavering and uncertain.
used to be in distinguishing between the genuine and the The French concept of mythomania, often treated as
simulated. Although this particular question has lost much synonymous with pathological lying, captures this quality
of its urgency, what remains central are issues surrounding of being caught up in one’s own fantasies and imaginery
those, all too human, tendencies to deny, to lie to others, adventures.
and to lose oneself in self-deception.
Lying
The tendency to modify our experiences of current
reality by how we think rather than by what we do, and Lying, or to use the minimally less pejorative and far broader
to interpret and edit memories of the past in pursuit of term ‘deception’, is universal. Advertisers ‘put a gloss’ on
present needs is universal. We try to escape the contingen- their products, companies fail to disclose the whole story,
cies of reality by a variety of mechanisms, many wholly politicians distort, sportsmen break rules when they think
unconscious. they will not be detected, and we all deceive on occasions
to obtain advantage or avoid embarrassment. Lying may
Substituting even be part of normal development and individuation
(Ford et al., 1988). Hartshorne and May (1928) conducted a
Available alternatives are sometimes substituted for those series of elegant experiments demonstrating the frequency
objects of our desire which appear beyond reach. Pets of deceptive behaviour amongst youngsters. Most authors
may be substituted for people, especially children. The agree that lying involves the consciousness of falsity, the
displacement of desire, or aggression, on to a more avail- intent to deceive, and a preconceived goal or purpose.
able, or vulnerable object, is common. In some claim- Normal prevarication is instrumental and, at least initially,
ants and litigants this mechanism can be at work. The the liar is aware of the deception. In practice, the inten-
bereaved, deprived of their loved one, may displace their tional lie merges into self-deception and we move, all too
energy from the pursuit of the lost love on to the pursuit easily, from knowingly fabricating into believing our own
of compensation. At first glance, their actions may appear stories.
venal and self-serving, but behind this appearance can lie

418 © 2014 by Taylor & Francis Group, LLC

Deceptive mental mechanisms

In pathological lying (pseudologia fantastica; see below), Self-deception is in part about how information is
there is created a tissue of fantastic lies in which the decep- interpreted and what aspects are acknowledged but, more
tion is not merely about matters of fact, but aims to create important, it is about self-presentation; it is about what we
a whole new identity. The lies, though they may begin as avow as our motivations and what we accept has been our
instrumental, in the sense of bringing pecuniary advan- behaviour. The simplest model of self-deception is of hold-
tage or prestige, rapidly develop to a stage where they are ing two incompatible beliefs, one of which is not noticed
disproportionate to any discernible end or personal gain. or acknowledged. Self-deception is not just persisting in
Commonplace lies deceive about matters of fact, the fabri- beliefs in the face of contrary evidence, nor merely holding
cations of the pathological liar deceive about who and what incompatible beliefs, for it implies an active engagement
s/he is; they are about creating a new identity and recreat- which strives to maintain ignorance. The characteristics
ing the world. Pseudologia fantastica is about lying, but it is of self-deception as viewed from the vantage point of an
also about fantasy run riot which involves self-deception as observer include:
much as deceiving others. 1. activities which appear incompatible with the individu-

Denial al’s previous claims or behaviour;
2. the refusal of the self-deceiver to give adequate (or at
Denial of current reality is one way of coping with the
disturbing and the threatening. Denial differs from lying least acceptable) justifications for his or her activities;
in that it is not an attempt to convince others, or oneself, 3. a refusal to accept responsibility for activities and their
of a different reality, but involves turning away from the
unacceptable. Clearly, denial involves deception and self- consequences which appears to stem not from disre-
deception, but lacks the intention to affirm a new and false gard of those responsibilities, but from an inability to
reality. In practice, denial often slips into fabrication. Denial recognize the transgressions;
involves the claim that something did not occur or, if it did, 4. an adherence to the deception which persists even
the subject has no memory for the events. when it becomes personally disadvantageous.
The latter two characteristics which speak of loss of self-
Amnesia control tend to soften, or even remove, the moral con-
demnation of the self-deceiver. What of the experience of
Amnesia is an inability to remember or a denial of memory. self-deception for the self-deceiver? This is difficult to pin
Selective memory which leaves convenient blanks is a com- down. Totally successful self-deception would presum-
mon enough indulgence, and is to be expected in those ably be experienced as having a conviction or desire no
where forgetting may bring considerable advantage. The different from any other. We assume that some discom-
distinctions and overlaps between so-called psychogenic fort and disequilibrium accompanies most self-deceptive
amnesia and organic memory disturbances are considered engagements, which may be experienced as unease or
later in this chapter and in chapter 12. a puzzlement at one’s own apparently disproportionate
vehemence.
Self-deception Self-deception covers a wide range of human activity.
It covers the exuberant, if shallow individuals, who com-
Self-deception is a concept presenting profound theo- mit themselves to a course of action in the enthusiasm of
retical ambiguities, but is none the less potentially of wide the moment, only to later disavow that commitment. It
applicability in psychiatry. Many aspects of what we term includes the envious, who undermine and damage those
unconscious, dissociative, hysterical, or even abnormal ill- around them under the guise of friendship, apparently
ness behaviour can, from a different perspective, be spoken in ignorance of their own motives. It includes those who
of as types of self-deception. convince themselves of their own illness and disability. It
includes most of us as we try and impose coherence and
The central paradox of self-deception was described by create a flattering tale out of our past and present activities.
Fingarette (1969): Occasionally, it is possible to see self-deception emerg-
ing. A young man who had strangled his girlfriend was
For as deceiver one is insincere, guilty: whereas if genu- examined a matter of a few hours after the event. He gave,
inely deceived, one is the innocent victim. at that time, an account of the killing marked by great dis-
Is then the self-deceiver both perpetrator and sufferer? The tress and genuine perplexity about how he came to commit
psychiatrist’s view of self-deception is often influenced by such an act. A few days later he claimed to have only the
the Freudian vocabulary which articulates the phenom- vaguest memories of the event leading up to the killing
enon as one of helplessness in the grip of unconscious and none for the act itself. A week or so later, a story began
conflict, for the self-deceiver is spoken of as the victim of gradually to emerge as he ‘remembered’ what had really
the compulsive force of the unconscious. happened and the provocations which had occasioned
the act. The following month, he gave a clear account of

© 2014 by Taylor & Francis Group, LLC 419

Deception, dissociation and malingering

intolerable provocation which culminated in his loss of continuum between the experiences and activities of us all
control and which ‘must have led to the killing’, although he and the disorders to be described. Deception is, however, a
said he could not recall committing the deed. Somewhere term redolent of judgment and rejection. Here the empha-
in that progression, self-deception must have played a part sis is on the recognition of distress and disorder, so that it
but, by the time this man went to trial, he seemed to hon- can be treated, rather than identifying deceptions in order
estly believe his own account of the events, and certainly he to confound or condemn them.
was filled with a genuine sense of grievance and injustice
when his defence foundered. Lying

Self-deception involves the editing and reorganization Lying, as has been noted, is a frequent, universal, human
of memory to serve the needs of current imperatives. In activity. It needs to be distinguished from confabulation
fact, such restructuring of memory is to some degree a which does not include any intent to deceive. Lying is so
normal process which is going on constantly. The view ubiquitous that it must have many different functions, for
of human memory as analogous to a massive filing sys- example in social parlance we distinguish between ‘white’
tem or the hard disk of a computer, which assuming you lies and other types such as ‘barefaced’. White lies may be
employ the correct access codes calls up exactly what was to assist someone else for example giving them reassur-
filed away, is increasingly coming under critical scrutiny. ance or unwarranted praise. The lie that is most frowned
Memory is, at least in part, a functional and selective sys- upon is of course the lie to gain dishonest advantage or to
tem which is constantly evolving and adapting to current escape from the consequences of one’s actions. There is
needs (Rosenfield, 1988). In a mundane way, we all re-write a large industry in the criminal justice world of trying to
our own histories so as to ease the disjunctions between tell whether a witness or a potential perpetrator is telling
our present attitudes and positions and our past actions the truth or not. This arises from the somewhat mistaken
and views. Self-deception is essential to righteousness, or notion that the best witness to an event is the central
any other form of pomposity. Equally, it plays a prominent participant who will be able to explain what they saw or
role in creating and maintaining some of our patients’ did to other people. Many police officers see their central
difficulties. role in detective work as getting a guilty person to ‘cough’
or ‘confess’. More sophisticated police  officers and others
Pathological falsification involved in crime detection know that uncorroborated con-
fessions are poor evidence. Yet the belief that somehow, in
Confabulation some way ‘science’ will enable the liar to be unmasked, dies
very hard indeed. It is possible to find at least 10 ways of
Confabulation is the falsification of memory occurring attempting to detect lies with various forms of technology.
in clear consciousness in association with an organically These include the polygraph, the fMRI scanner, the voice
derived amnesia (Berlyne, 1972). On occasion, it is the stress test, and others. Most of the techniques are trying
fabricating of false statements by someone with impaired to detect a rise in arousal and anxiety when the subject
memory in order to cover his or her embarrassment at is being questioned or interviewed. This is based on the
forgetting. It is typically encountered in amnesic disorders premise that all lying is accompanied by anxiety. Most of us
when the patients lack insight into their impairment and, can subjectively refute this notion and indeed the research
therefore, would be incapable of constructing falsifica- results from the various instruments are disappointing if
tions to cover a deficit which they were unaware existed. they are to be the centrepiece of, for example, a criminal
Bonhoeffer (1904) distinguished between ‘momentary’ investigation. None of the results from this type of technol-
confabulation, where the patient, when asked specifically ogy are allowed in British courts.
about recent events, responds by recounting more distant
unrelated memories and ‘fantastic’ confabulations which An exception to the arousal theory is the attempt to
involved spontaneous creations, often grandiose or absurd. detect lying by using the fMRI scanner. Initial research sug-
The fantastic, or spontaneous, confabulations tend to be gested that the act of lying produces more prefrontal cortex
associated with amnesias in which there is associated fron- activity than telling the truth does. However some sophis-
tal lobe dysfunction, whereas the provoked, or momentary ticated transAtlantic collaborative research has found that
confabulations, are the result of an attempt to respond to subjects can beat the scanning test by simple distracting
specific enquiries in those with a defective memory. It is countermeasures, presumably to deflect their concentra-
found in amnesic patients and, to a lesser extent, in nor- tion, when they are lying (Ganis et al., 2011). The authors
mal subjects whose memory fails them for some reason conclude that this renders the otherwise attractive lie
(Kopelman, 1987a). It is not a form of intentional deception. detector as vulnerable in ‘real world situations’. In fact the
accuracy dropped from 100% to 33% if the subject applied
This chapter is concerned with a variety of condi- countermeasures; a fairly stark warning to the overenthusi-
tions, disparate in many ways, but in which deception, astic technological interrogator.
both of others and the self, plays a part. The introduction
was intended to emphasize the extent to which there is a

420 © 2014 by Taylor & Francis Group, LLC

Pathological falsification

The basis of this work lies in experiments conducted ‘The sweets killed Udit.’ Throughout the test, she did not
by Spence and others (e.g. Spence et al., 2004; Spence 2005; say a word. She didn’t have to. As each statement was
Spence et al., 2008). These showed that deception is an read, the EEG machine measured the frequencies of the
executive task; it elicits greater activation of the prefron- electrical signals from the surface of her scalp and fed
tal regions and also incurs a processing cost, manifest in them through a set of rainbow-coloured wires into the
longer response times. room next door. Here a computer, almost five feet tall, per-
formed a set of calculations and spat out its conclusion
A scholarly account of what lies are about and how to in red letters on to its screen: ‘Experiential knowledge’.
detect them is given by Vrij (2008) who goes on to discuss This meant knowledge of planning the murder, of getting
ways in which training can assist in the difficult task of the sweets, of buying the arsenic and of calling Bharati
detecting lies. At the end of his book he lists 24 studies and arranging the fatal meeting. Guilty. Evidence from
giving an indication of how far training can help. By and the scan took up almost ten pages of the judge’s ruling
large the studies show that observers are only about 50% when a year later, on 12 June 2008, he jailed Sharma for
accurate in detecting lies (i.e. not much better than guess- life – making her the first person in the world reported to
ing) but this can be improved by training sessions, in one be convicted of murder based on evidence that included
remarkable example raising the detection rate from 54% to a brain scan. ‘I am innocent and have not committed any
69%. However he concludes: crime,’ she implored Phansalkar-Joshi… But science had
spoken: and in the six months that followed, the same lab
In this book I reported that several researchers have would provide evidence that convicted two more people
claimed to have developed techniques that discriminates of murder. Neuro-imaging as truth teller had come of age.
between truths and lies with very high accuracy. My It is important that we do not get bemused by new tech-
advice to them is to keep their feet firmly on the ground. nologies. No doubt they will find a niche, but let us hope
In my view no tool is infallible. that they do not become used extensively until they can be
Our view remains that would-be lie detectors, for example shown to produce valid evidence. That day is a long way off
police officers, will be better employed in trying to get and in the meantime we should heed careful studies such
evidence by other means, even though no criminal inves- as the one quoted above by Ganis et al.
tigation would be complete without talking to the alleged
offender. Pseudologia fantastica (pathological lying)
A group of disorders have been reported which involve
The dangers of using neuroscience results as evidence fantastic lies that are developed into complex systems of
of crime are perhaps best shown in India. Angela Saini deception. The terms employed for this condition include
(2009), a web journalist wrote of the case of a woman tried pseudologia fantastica, mythomania and pathological liars
for murder in June 2008. She headed the article ‘The Brain (Delbrueck, 1891; Dupré, 1905, 1925; Healy and Healy, 1915;
Police: Judging Murder With an MRI.’ However the article King and Ford, 1988; Myslobodsky, 1997). The following are
says that the accused had an ‘EEG’ brain scan. the clinical characteristics:
1. Extensive and gross fabrications.
To Judge Shalini Phansalkar-Joshi, sentencing her last 2. The content and extent of the lies are disproportionate
June to life in prison, Sharma’s electro-encephalogram
left no doubt: the brain scan revealed ‘experiential knowl- to any discernible end or personal advantage.
edge’ which proved that she had to be the killer. Her ex- 3. The lies deceive not just about matters of fact, but at-
fiancé Udit Bharati, a 24-year-old fellow student at Pune’s
Indian Institute of Modern Management, had been found tempt to create a new and false identity for the liar.
dead after eating sweets laced with arsenic… As the 4. The subject appears to become caught up in his or her
judge saw it, the proof was in the science. Sharma had
manifested an undeniable ‘neuro experiential knowledge’ own fabrications which take on a life of their own in
of the crime – which the brain could acquire only through which the subject seems eventually to believe.
direct experience – when she had undergone a brain scan 5. The lying is a central and persistent feature of the pa-
in Mumbai a year earlier… A tape played a voice reading tient’s life and the mythologism of a lifetime comes to
a series of statements in Hindi, each detailing an aspect supplant valid memories.
of the murder as the investigators understood it. Sharma When pathological liars are enmeshed in their fabric of
said nothing as the EEG machine measured her brain lies, the degree of self-deception may make it difficult to
activity. For a while, the statements elicited no detectable distinguish them from patients in the grip of a delusional
EEG response. Then she heard: ‘I had an affair with Udit.’ system. Kraepelin (1896) included some patients with
A section of her brain previously dormant registered a systematized delusions under pseudologia fantastica and
brightly coloured response on the EEG. More statements Krafft Ebing (1886) used the term ‘inventive paranoia’ for
followed and the voice on the tape each time elicited both pathological liars and deluded subjects. Most writers,
similar EEG responses: ‘I got arsenic from the shop.’ ‘I
called Udit.’ ‘I gave him the sweets mixed with arsenic.’

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Deception, dissociation and malingering

however, excluded deluded or otherwise psychotic subjects investigated without any basis having been found. He
(e.g. Healy and Healy, 1915). Closely related conditions are gave a history of having been seduced in his early teens by
Munchausen’s syndrome (Asher, 1951) and feigned bereave- the mother of a school friend, and described a number of
ment (Snowdon et al., 1978). romantic adventures prior to his arrest on arson charges.
Other aspects of his history included a graphic account
Two clinical examples may help illustrate this disorder: of child abuse, remarkable academic and artistic success,
A patient was brought to the outpatient department by his cut short by circumstance, and a period of army service.
landlady who was concerned with his increasing depres- This young man attempted to create by his stories an
sion which she feared might lead him to harm himself. identity characterized by remarkable talents and charm,
She explained that he was now living in much reduced but a personal history replete with disadvantage and
circumstances, having suffered major financial losses tragedy. Misunderstood, abused, cheated and victim-
and the desertion of his erstwhile friends. It became clear ized, nevertheless, he struggled to realize his potential.
that he had been living rent free for some considerable Different stories were given to different members of staff
time, and the landlady was providing all his meals and a and even more dramatic discrepancies emerged between
regular supply of pipe tobacco, to say nothing of comfort his self-presentation to other patients and that to the staff.
and support. The patient was a well-dressed man in his During his time on the unit, his use of mimesis became
early 60s, who wore tinted spectacles and assumed an air obvious. He latched on to a patient and later a staff mem-
of profound sadness. He was induced to give his history ber whom he found admirable and began not only to talk
despite several claims that he did not want to go over the like his new-found models, but tried to present himself
past. The personal history provided was of humble origins in an identical manner. He even borrowed aspects of the
from which he escaped via a university scholarship. He personal histories of these two admired individuals, and
claimed to have left university prematurely to join the presented them as his own.
government forces fighting in Spain. At the end of the Schneider (1959) regarded this group of patients as
Spanish civil war, he reported a brief period in Rhodesia attention-seeking individuals who love to boast about
before joining the British army during the Second World themselves, and invent or act out fairy tales of self-aggran-
War. A distinguished army career was followed by a dizement. He noted that the true pathological liar begins
period working in the United Nations. The tale continued as a story teller, but becomes so caught up in his/her
with a series of great successes followed by undeserved fabrications that ‘they forsake actuality and finish up on
disasters until he reached his present homeless, lonely the stage of their own mind.’ Kraupl-Taylor (1979) took a
plight. The stories had plausibility and a wealth of detail. similar view describing the stories as hysterical confabula-
Suspicions as to their authenticity were raised by the tions. He believed that recent reminiscences are temporar-
remarkable similarity of some aspects of his account ily replaced by hallucinated reminiscences, which are true
to the memoirs of such figures as Orwell and Wingate. memories to the patient, at least for a time. Kraupl-Taylor
Over subsequent months, it emerged that the patient had emphasized the negative or disadvantageous aspects of
lived most of his life in London, he had never been in the this behaviour. Whilst the pathological liar has the grati-
army, far from being unmarried he had been married fication of an occasional audience that is impressed, this
on a number of occasions and his reported childlessness pleasure is short-lived, only to be followed by the humilia-
ignored a number of offspring. Following the exposure of tion of being treated as a liar. Such patients are soon gener-
his identity, the patient disappeared, but was encoun- ally disbelieved, and they may be teased mercilessly. Such
tered some years later having created for himself a new behaviour does merge into more externally goal-oriented
persona and an equally dedicated supporter in the form deception.
of another middle-aged lady sponsoring the ageing and
misunderstood artist. At a second encounter, he greeted Pathological lying is usually encountered in foren-
his doctor with apparent pleasure and without a blush, sic practice in those accused of fraud, swindling, mak-
or any visible unease, told of his new circumstances. He ing false accusations or false confessions (Powell et al.,
did not seem to be concerned about, or even aware of, the 1983; Sharrock and Cresswell, 1989). Once the counterfeit
possibility that his new identity might be threatened. He is exposed, the pathological liar will often give up his
believed in himself, or at least he evinced no insecurity. deceptions and readily confess, sometimes to offences in
The second case was admitted from prison where he was which he was not involved, thus beginning a new cycle of
said to have become depressed and suicidal. attention-seeking mythologies in the very act of acknowl-
He was a small young man who, though in his early 20s, edging the previous deceptions. The frauds and swindles
could have passed for 12 or 13 years of age. He gave an perpetrated by the pathological liar usually form part
account of having been raped in prison with the conniv- of an attempt to create a false identify. Such frauds are
ance of a number of prison officers. He had made these often flamboyant and have little in common with the fur-
allegations previously, and they had been extensively tive and carefully planned dishonesty of the more typical

422 © 2014 by Taylor & Francis Group, LLC

Pathological falsification

fraud. Pathological liars are closer to confidence tricksters, Abnormal Illness Behaviour
though unlike them, they do not take the money and run,
but persist in the pretence long after exposure is inevita- Parsons (1951) regarded illness and health as socially insti-
ble. Their lies are rarely aimed at excusing or exculpating tutionalized roles. A sick person’s role is legitimated and
their offences, but more frequently, at attracting notice and allowed by its undesirability and the need to co-operate
inflating their importance. with others to get well. While in the sick role, normal obli-
gations are suspended and responsibilities are reduced, but
After reviewing 72 published cases King and Ford the role might not be granted unless adequate evidence of
(1988) suggested that the sex distribution of cases is disease were available. Mechanic (1962) described ‘illness
approximately equal and the age of onset is usually ado- behaviour’ which referred to
lescence. Forty per cent of the cases they reviewed had a
history of some central nervous system abnormality, such the ways in which symptoms may be differentially per-
as an abnormal EEG, a history of head trauma, or CNS ceived, evaluated and acted (or not acted) upon by differ-
infection. Twenty-five per cent of the men had epilepsy. ent kinds of persons.
Other notable problems were criminality, psychiatric hos- Later, Mechanic (1986) emphasized that in his view illness
pitalization, suicide attempts and a family history of psy- and illness experience are shaped by socio-cultural and
chiatric illness. King and Ford suggest that when disease socio-psychological factors, irrespective of their genetic,
simulation (Munchhausen syndrome, about a quarter of physiological and other biological bases. Away from the
the cases) or impersonation of another person occurs it is research laboratory illness is often used to achieve a variety
the pseudologia fantastica which is the primary disorder. of social and personal objectives, having little to do with
King and Ford concluded their review by saying ‘ Further biological systems or the pathogenesis of disease.
research in this clinical area, particularly of the neuro-
physiologic correlates, is sorely needed.’ That remains the He went on to ask himself: Why do 50% of patients
position; no further research on this topic has been con- entering medical care have symptoms and complaints that
ducted. An interesting further case has been published do not fit the International Classification of Diseases? Why
(Birch et al., 2006). The woman in this case showed an are rates of depression and the use of medication relatively
interesting extra feature in that she was able to get other high among women, whereas alcoholism, hard drug use
people, intimates, to corroborate her fictional stories. This and violence are particularly common among men? Why
characteristic is rare but has been reported before (Healy among the Chinese are affective expressions of depression
and Healy, 1915; Weston, 1996). It has also, apparently, uncommon, but somatic symptoms relatively frequent?
been labelled by Helene Deutsch in a German paper as Why are rates of suicide among young black people in the
‘pseudologie à deux’ or ‘shared daydreams’ (quoted in Birch USA relatively low, but rates of homicide high? Rather than
et al., 2006). attempting answers to such questions, he urged us to look
beyond individuals to their social environment. He pointed
Enoch and Ball (2001) sub-classified pathological lying out that the nineteenth-century phenomenon of female
into four types: hysteria has all but disappeared in the west, perhaps
1. The professional impersonator who pretends to be a due to a change in social response to the characteristic
symptoms. Illness behaviour is more than a psychological
doctor, a priest, a lawyer. response among persons faced with a situation calling for
2. The swindler who pretends to be wealthy and/or an im- assessment. It arises in response to troubling social situ-
ations, and may serve as an effective means of achieving
portant business man. release from social expectations, as an excuse for failure,
3. An outraged woman who alleges a fictitious sexual or as a way of obtaining variety of privileges, including
monetary compensation. A complaint of illness is one way
assault. in our society of obtaining reassurance and support.
4. A false confessor who claims to have committed a seri-
Pilowski (1969) proposed ‘abnormal illness behaviour’
ous crime. as a subcategory of illness behaviour for those patients
To this list we would add the common fantasist, common who have physical symptoms for which no organic expla-
because the condition occurs more frequently than the oth- nation can be found. This is a useful extension of the
ers and s/he tells a whole series of apparently pointless tall concept of illness behaviour, even though it is not clear
stories set in a context of ordinariness. why it should be confined to physical symptoms and
organic disease. The forensic psychiatrist may be called
The common fantasist is not particularly dangerous, to see a number of conditions which in some ways can be
but the other types can produce serious consequences regarded as variants of malingering, but which can also
including bodily harm. Management is extremely difficult. be regarded as gross abnormalities of illness behaviour,
Even when prosecuted the fantastic tales may not subside. abnormalities of such a degree that instead of eliciting
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.

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Deception, dissociation and malingering

support and sympathy, they produce rejection and anger uterus and it was originally thought to be a disorder which
on the part of doctors, which are sometimes coupled with affected women exclusively and was caused by a wandering
frankly punitive responses. uterus. The term is still used colloquially to mean emo-
tional excesses and loss of self-control probably related to
Dissociative disorders panic. Charcot used to give his public demonstrations at
the famous Paris hospital, Salpêtrière. He described the
Dissociation course of the illness in these terms:

Dissociation is a commonly described mental mechanism. A little girl about seven years old begins to cough and goes
It implies separation and splitting. It often means that one on coughing for two months without any known cause.
part of the mind is paying no attention to another or is An experienced physician recognizes at once that he
unaware of it. It can be induced by hypnosis. For example has not to deal with a case of bronchitis but one of hys-
Charcot, the nineteenth-century ‘king of hysteria’, hyp- teria. Then the little girl is all at once affected with a stiff
notized one of his female patients (all his patients were neck… Hysterical torticollis is made out. …. The child’s leg
female) and suggested to her that she was two people. becomes stiff and painful. This is hysteric contracture…
Each side of her was to have a different boyfriend. She was Things go along pretty smoothly till menstruation. Then
introduced to these two men as she lay on a couch and she the child begins to get peculiar – to have curious ideas.
would allow each to caress his specified side of her body, She is alternately sad or cheerful to excess. Then, one day
but if his hand ventured to the other side she would angrily she utters a cry, falls to the ground, and presents all the
turn it away. symptoms of an attack of hystero-epilepsy. She begins to
assume various postures, to speak of fantastic animals, to
The idea of splitting and separation so that parts of an mention words which are neither suitable to her age nor
individual’s body are dysfunctional and out of touch with to her position in society.1
other parts, and parts of the individual’s mind, includ- Charcot unhooked hysteria from the uterus and from
ing their memory, are separated from other parts, lies the demonic possession theories that also abounded.
underneath many of the topics discussed in this chapter. He described it as an inherited neurological disorder,
Psychogenic non-epileptic seizures can be, at least in part, neither madness nor malingering (Hustvedt, 2011). The
understood in this way and are sometimes called dissocia- patients may suffer from anaesthesia, hypersensitivity,
tive seizures. A remarkable philosophical treatise has been anorexia, bulimia, constipation, diarrhoea, excessive urina-
written on the subject, not by psychiatrists but by a phi- tion, retention of urine, depressed intellectual functions,
losopher, Ian Hacking (1995) in a book entitled Rewriting heightened intellectual functions, insomnia, attacks of
the Soul. He draws together many different threads and sleep, and violent seizures, said Bournville, a disciple of
implants the topic in its history. Dissociative phenomena Charcot’s; in other words contrasting bodily symptoms
have been observed from ancient times but the manifesta- which vary and fluctuate. Charcot himself described ‘grand
tion of these phenomena changes and so does the naming. hysteria’ characterized by episodic convulsions in four
For example Hacking suggests that the hysteria of Charcot phases. First, the epileptoid phase of tonic and clonic
which captivated the whole of France in the nineteenth seizures, preceded by an aura, just as in epilepsy. Second,
century, turning his kind of neurology into a public specta- grand movements or clownism simulated the contortions
cle didn’t just disappear at the beginning of the twentieth and acrobatics of circus performers. The third phase of
century, as many people believe, but it changed into other ‘passionate poses’ was when the patient acted out emo-
forms. Hacking suggests that in the United States it became tional states such as terror, ecstasy, and amorous supplica-
multiple personality disorder. tion, all ending in the final and fourth stage of delirium.
This material comes from a remarkable book on Charcot,
A full discussion about dissociative disorders does not his life and work and the story of three of his patients by
belong in a textbook of forensic psychiatry and they will Asti Hustvedt (2011).
therefore be dealt with briefly. They are mentioned at all
because of their relevance to simulation and malingering This history gives many clues to the disorders which
which may come to the attention of the forensic psychia- at the beginning of the twenty-first century we call dis-
trist who undertakes medico-legal compensation work. sociative disorders. The twentieth century saw the disease
They also have some relevance to the broader subject of of hysteria transmuted into other conditions such as
dishonesty and require a textbook in their own right. shellshock which reinforced the notion that the symptoms

To set the subject in context it is worth briefly con- 1This quote is taken from Hustvedt (2011) who is quoting Charcot’s
sidering the history of hysteria, for hundreds of years an paper ‘De l’influénce des lesions traumatiques sur le développement des
important disorder, particularly in women, which is now phénomènes d’hystérie locale,’ in Progrès Médical, May 4, 1878, cited in
disappeared from the psychiatric lexicon, although it is Goetz, Bonduelle, and Gelfand, Charcot, p.173.
almost certainly just transmuted into other disorders. The
term hysteria obviously implies something to do with the

424 © 2014 by Taylor & Francis Group, LLC

Dissociative disorders

arise from stress and trauma. By 2000 the nomenclature of conscious intervention to produce the fit. Even then mis-
these disorders was crystallized into perhaps six types of takes are made. One of us has a vivid memory of a patient
dissociation: who used to fold his glasses away carefully, take out his
hearing aid and lie on the floor before having his seizure.
depersonalization disorder in which an individual feels Many thought he was a fraud, but investigation showed
detached from his or her surroundings and may feel that he was not having a non-epileptic seizure, but an
outside of the body; psychogenic non-epilepetic seizures epileptic one, and he was preparing himself for the seizure
(see below); dissociative amnesia (see below); fugue (see during a fairly long aura.
below); dissociative identity disorder, sometimes known
as multiple personality disorder (see below); and posses- The diagnosis of epilepsy as opposed to a non-epileptic
sion states. seizure is based on careful observation, especially of the
This list is not exhaustive of dissociative phenomena, electroencephalogram, which ought, if there is any doubt,
symptoms change with time and place and often overlap, to be a continuous recording over several hours and whilst
Stengel (1941) included, in his series of fugue cases, a case ambulant.
which could also be considered a case of multiple personal-
ity disorder. One of Burt’s (1923) cases of pathological lying The features of non-epileptic seizure include
has subsequently appeared in the literature as illustrative of 1. attempted restraint of the convulsive movements leads
typical multiple personality (McKellar, 1979). It is the core
of dissociation which is important to understand if treat- to struggling, even combativeness;
ment is to be provided. 2. absence of cyanosis;
3. normal pupil responses and corneal reflexes present;
Psychogenic Non-epileptic Seizures 4. pressure on the supraorbital arch causes head

In our first edition we had a section on ‘pseudo-epileptic withdrawal;
seizures’. Like other dissociative disorders the name has 5. the level of consciousness fluctuates during the seizure;
changed. At one time many neurologists and psychiatrists 6. marked emotionality after the episode.
assumed that non-epileptic seizures were simulated or Such seizures can be preceded by auras involving somatic
malingered. It is interesting that Charcot thought they or visual symptoms and headache. Unlike true epilepsy, in
were always genuine. Modern thinking has moved nearer which the onset is usually abrupt, the non-epileptic seizure
to Charcot than was the case in the mid-twentieth cen- may be gradual in onset. Such seizures rarely result in inju-
tury. Undoubtedly some non-epileptic seizures will be ries either from falls or biting of the tongue. It should be
consciously simulated in order to gain something, perhaps remembered that epilepsy is more often misconstrued as a
attention, perhaps some compensation, perhaps a reason psychogenic seizure than the other way round. Fully delib-
to be excused duties. However, the topic of non-epileptic erately simulated seizures are rare. All psychogenic sei-
seizures illustrates as clearly as any how difficult it is to zures, even if they are considered to be factitious should be
discern underlying motive and distinguish it from distress treated by attention to any underlying mood disturbance
and organic pathology which justifies medical interven- or other psychological problem, and fairly prolonged psy-
tion. Indeed it is possible to argue that even if the seizures chotherapy in order to unravel the driving force behind the
are consciously contrived with an object in view, they are seizures, whether that force is conscious or unconscious,
still an important flag-waving phenomenon which requires so it may be faced and attended to psychotherapeutically
skilled intervention. or practically. Nevertheless it is well to remember that
well-established, long-standing, non-epileptic seizures are
A good review of this topic is given by Benbadis (2005) difficult to treat and have a poor prognosis.
in Wyllie’s textbook on the treatment of epilepsy. Benbadis
divides non-epilepetic seizures into three groups: soma- Dissociative or Psychogenic Amnesia
toform disorders, factitious disorders and malingering.
Somatoform disorders are physical symptoms caused by As we have seen in chapter 12, amnesia is a complex symp-
unconscious psychological factors. In turn somatoform tom. Distinguishing between genuine and feigned amnesia
disorders can be subdivided into conversion disorders may be difficult. Those charged with homicide offences are
and somatization disorders, but the nomenclature is now particularly likely to claim amnesia (Taylor and Kopelman,
becoming esoteric and unhelpful. Similarly the distinction 1984). However, Pyszora et al. (in preparation) in a 3-year
between factitious disorders and malingering is arcane follow-up study, suspected that 10% of a sample of men on
and boils down to whether the patient is to be treated remand in custody claimed amnesia for the alleged offence,
as such or rejected as a fraud. These distinctions are a finding only elicited in those charged with offences of vio-
extremely difficult if not impossible to make clearly, and lence. Within the amnesic group, nearly half were charged
the only time that malingering can be considered a cer- with murder. Only five of 59 amnesic offenders were sus-
tainty is when clear evidence is available of some sort of pected of feigning; the others were thought to have this
dissociative amnesia (see also chapter 12).

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Deception, dissociation and malingering

Lishman (1998) has suggested that the traditionally Strange Case of Dr Jekyll and Mr Hyde is a celebrated liter-
rigid distinction between psychogenic and organic memory ary example. Prince’s (1906) account of the case of Christine
disturbance may be an artificial one. Pathophysiology of Beauchamp and her three personalities and James’s (1890)
some kind accompanies psychogenic amnesia, just as a account of Ansel Bourne, led to considerable interest in the
psychological basis underlies the influence of emotion topic, particularly in America.
and motive in normal forgetting. Clinically, psychogenic
amnesia is either global and dense or more circumscribed. In the 1950s, multiple personalities re-emerged from the
Global amnesia may occur for long periods of life. The pages of old textbooks. A surge of reports, both in the popu-
amnesia may cover emotionally important events or issues, lar and scientific literature, followed publication of Thigpen
such as a violent outburst. Normal ability to learn new facts, and Cleckley’s (1957) case of Eve and her three faces. This is
but severe problems or recall of past events hints at psycho- a fictionalized account of a real case and the woman con-
genic amnesia. A total inability to retain new information, cerned has written two books giving her own account of
even briefly, also favours the psychogenic form. her illness (Sizemore, 1977 and 1989). The film was popular,
and may have had a role in the large number of cases that
The classic case of alleged malingered amnesia (Podola), subsequently appeared in the USA (Boor, 1982). The books
is dealt with in chapter 2. We will never know whether written by the patient may give a clearer insight into what
it was malingered or not as he was executed. The case it feels like to be in this situation.
demonstrates that it is not critical to a murder trial that
the defendant remembers what happened. Whether malin- The central clinical feature is the existence within
gered or dissociative, forgetting is almost certainly a means the individual of two or more distinct personalities. The
of coping with appalling guilt and shame. The amnesia recognition of this extraordinary state of affairs may be
becomes a problem when somebody has been convicted of complicated by the primary personality being unable to
a killing and still cannot remember what happened and so provide any account of the alter egos which are hidden
is able to participate in psychotherapy in a limited way. The behind a barrier of amnesia. A number of diagnostic signs
first aim of psychotherapy, and it may take a long time, is to have been described to assist the clinician (Greaves, 1980).
get the person concerned to retrieve some memory of the The patient may report time distortions or unexplained
events in question. This is a long supportive process requir- memory lapses for the period when the other personality
ing much patience and continuity of psychotherapist. One is in residence. Accounts may be provided by independent
of the interesting issues which may occur in that process, observers of discrepant behaviour patterns and patients
if it is successful, is that the patient may say, after s/he has calling themselves by different names. Writings, drawings,
recovered their memory, that they were simply lying and or other artefacts by patients may be discovered which
were in fact able to remember all along. Another dissocia- they have no memory of producing. Other features include
tive mechanism in action perhaps? Certainly it illustrates headaches, deep sleeps, employing ‘we’ rather than ‘I’, and
the vague borderland between unconscious repression of pseudo-hallucinations. The condition is said to begin in
thoughts and dissimulation. childhood or adolescence, often in the context of abuse,
neglect, or trauma (Congdon and Abels, 1983). Histrionic
Multiple Personality Disorder personality disorder, other dissociative states, superior
intellect and high hypnotizability, are all claimed to be asso-
Multiple personality has been described as: ciated with multiple personality disorder.
The presence in one patient of two or more personalities
each of which is so well defined as to have a relatively The origins of multiple personality have been hypoth-
coordinated, rich, unified, and stable mental life of its esized to lie in repeated dissociations. These patients are
own. (Taylor and Martin, 1944). peculiarly prone to dissociative states in response to stress.
They defend against fear, anxiety and depression by either
These differing personality systems tend to lose commu- denying that it is happening to them or escaping into the
nication with each other and amnesic barriers commonly new personality (Ludwig et al., 1972; Spiegel, 1984). These
divide and prevent integration between them (Hilgard, repeated dissociations are said to produce a separate store
1977). of memories which ultimately lead to different chains of
integrated memories with groups of specific behaviours
Before the eighteenth century, cases which may attract that can be separated by impermeable barriers (Braun,
the label multiple personality disorder now would probably 1984). William James put this more elegantly:
have been regarded as possession states. Cases of dual or
multiple personality were reported in the scientific litera- Alternating personality in its simplest phases seems
ture from the late eighteenth century onward and, by the based on lapse of memory… any man becomes, as we say,
end of the nineteenth, they had become a popular theme inconsistent with himself if he forgets his engagements,
for philosophers, psychiatrists and novelists (Ellenberger, pledges, knowledge and habits, and it is merely a question
1970; McKellar, 1979). Robert Louis Stevenson’s (1886) of degree at which point we shall say that his personality
is changed (James, 1890).

426 © 2014 by Taylor & Francis Group, LLC

Dissociative disorders

The authenticity of multiple personality as a clinical entity A story, probably apocryphal, is told of an Old Bailey
has been repeatedly questioned, although its advocates, judge called upon to sentence a man whose defence
such as Greaves (1980), considered its existence to be dem- claimed he suffered from multiple personality. The judge
onstrated beyond reasonable doubt. He claimed that its admitted to the sadness he felt that the model citizen and
infrequency in some services reflects not rarity, but clinical blameless character who stood before him should have
oversight on the part of those who cannot, or will not rec- to share his body with the villainous perpetrator of the
ognize the condition. This presumably means everywhere offences and, moreover, would have to be confined together
outside of North America, with the possible exception of with this criminal in a prison cell for the period of the sen-
the Netherlands. British scepticism was outlined by Fahy tence which he was about to impose.
(1988) in a review which plotted the rise of interest in the
disorder in the twentieth century. He was critical of the The lack of responsibility argument is akin to the argu-
vagueness of the diagnostic criteria which use the word ments that were once put (but not now allowed) about
‘personality’. All disorders which use the word ‘personal- the function of amnesia. If splitting or dissociation is a
ity’ in their criteria are necessarily vague, as the concept response to unpleasant realities, and a way of coping with
of personality is complex, subjective, and very difficult to stress, then it is perhaps an exaggeration of normal mental
measure. He described the disorder as an hysterical symp- mechanisms. If it is believed to involve a separation of dif-
tom; this term was still fairly widespread in the 1980s and ferent elements in the subject’s character and behaviour,
fitted with the Hacking view given above. Fahy was taken these elements arise from the individual’s responses to the
to task by a correspondent (Fleming 1989) who said that real world. The different personalities may, perhaps, be
he believed the condition exists! A beautiful example of regarded as different aspects of self, albeit compartmental-
reification. ized, rather than different selves. The appeal of the Jekyll
and Hyde story is surely, in part, that we all recognize the
What is difficult when dealing with dissociations in splits and incompatibilities in our desires, fantasies and
any form is to understand what the symptoms/syndrome even actions, and that most of us have done things which
represent to the patient. It is probably a culture bound retrospectively, or even at the time, seemed foreign to our
syndrome wrought out of the dissociative potential and personalities and we can say, afterwards, ‘that really wasn’t
suggestibility of distressed and confused people looking for me’. If the multiple personality is to be given the benefit of
a way out of their predicament. It is widely acknowledged repudiating legal responsibility for forbidden actions, why
that, in practice, the new personalities allow the patient not all criminals who can argue they acted out of character
to avoid the constraints, limitations and stresses of their and were thus not themselves at the time?
normal life (Prince, 1906; Taylor and Martin, 1944; Ludwig
et al., 1972; McKellar, 1979). Fugue States

In the United States, where the syndrome is diagnosed Fugue literally means to take flight or escape, but its use
more commonly, the potential significance of multiple in psychiatry is best confined to transitory abnormal
personality for questions of responsibility and culpability behaviour characterized by aimless wandering with altera-
was quickly recognized. It has been argued that multiple tion of consciousness, often associated with subsequent
personality is equivalent to sleepwalking and sufferers amnesia (Stengel, 1941). Fugues are encountered as one of
should benefit from a similar defence. Presumably, three the signs of a wide variety of psychiatric disorders, though
lines of defence could theoretically be argued; one would their manifestation probably depends on a predisposition
be that multiple personality disorder is a form of insanity, to disturbances of consciousness and dissociation. A trau-
the other would be that the usual personality cannot take matic event may act as the precipitant of the actual fugue
responsibility for the other personalities, i.e. the fictional Dr state. During the fugue the individual may be completely
Jekyll could not be held responsible for the actions of the amnesic for their usual life and they may assume a new
fictional Mr Hyde (Stevenson, 1886), and the third would be personality. The relationship between fugues, multiple per-
that like the sleepwalker the individual could be regarded sonality disorder, and dissociative amnesia is fairly clear.
as unconscious when in an altered state of personality. Such states are a gift for novel writers, but perhaps one of
the most famous fugues was the 11-day absence of Agatha
Without a proper study being available it is difficult to Christie who never explained where she had been or why;
know how often such defences are used in the United States she may have had amnesia. A fugue state is usually short-
and whether they are successful, although Abrams (1983) lived (hours to days), but can last months or longer. After
quotes a case from Ohio where a man accused of multiple recovery from a fugue, previous memories usually return
rapes was found not guilty by reason of insanity because intact, but there is complete amnesia for the fugue epi-
of his multiple personality disorder. The unconsciousness sode. Fugues are usually precipitated by a stressful episode,
argument has been advanced by French and Schechmeister and upon recovery there may be amnesia for the original
(1983). To reiterate, these observations made by others do stressor.
not help very much with understanding what the patient
experiences, and why.

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Deception, dissociation and malingering

Fugues may be encountered in forensic psychiatric 3. sudden termination of the attacks, sometimes in ex-
practice in subjects who, following committing a criminal tended stuporous sleep, but always with subsequent
act, or in the context of imminent detection, suddenly amnesia for the events.
wander off apparently in a state of disturbed conscious-
ness. For example, a young man may disappear suddenly This description is probably, at least in part, overlain by
from work, only to turn up 5 days later in a state of total mythology (see below).
exhaustion and inanition wandering in the outskirts of a
foreign city. When questioned, he claims no knowledge of A number of precipitants have been described, the
the events of the previous days, or how he had managed to most common involving some overwhelming blow to the
get there. Subsequently, it may emerge that an audit at his individual’s self-esteem and social prestige. Others include
place of work revealed that he had been misappropriating acute intoxication (Westermeyer, 1973); organic brain syn-
funds. Another example might be a man of previous good dromes (Van Loon, 1927); social stress as in migration; and
character stabbing an acquaintance in an argument, wan- relationship difficulties such as jealousy (Carr and Tan,
dering off into the freezing cold of a winter’s night without 1976). The Malay culture is said to place a strong emphasis
a jacket or overcoat, to be found some hours later walking for males on retaining social prestige and avoiding loss of
apparently aimlessly and in a perplexed and disoriented face. A powerful interdiction exists towards suicide. The
state and claiming total amnesia for the night’s events. act of running amok (becoming a pengamok) in traditional
Occasionally, acts committed during a fugue state may lead Malay culture allowed a discredited or shamed male to
to criminal charges. bring about his own destruction, as the amok was often
terminated by the killing of the pengamok or, if he survived,
As with all dissociative states, treatment, if considered restoring his prestige. Amok was a recognized, if not sanc-
necessary after a spontaneous recovery, should be support- tioned, social performance.
ive psychotherapy which aims to uncover, in a safe relation-
ship, the stresses that have driven the behaviour. Windigo is a related syndrome described in the Ojibwa
Indians of sub-Arctic North America. The males of this
Possession States tribe spend the long winter months hunting alone in the
frozen wastes. Their prestige depends on success, and
Possession states, which are a rare form of dissociative failure brings shame (Friedman, 1982). The windigo is
disorder in western societies, are characterized by claims believed to be a giant phantom compounded of all those
to have been taken over by a spirit or some external power. who have starved to death in the past (Meth, 1974). This
They have to be distinguished from the passivity experi- phantom is believed to be capable of possessing a man
ences and delusions of control found in the schizophrenias. and metamorphosing him into a murderous cannibalistic
monster. The development of windigo is associated with
In cases where fugue or possession states are claimed to failure in the hunt and especially famine. A prodrome of
have been present at the time of a serious act of violence, sleeplessness, depression and brooding is described, fol-
the defence, in Britain, may raise the issue of non-insane lowed by an outburst of murderous activity in which the
automatism, but they are unlikely to succeed now that family as well as fellow members of the tribe are attacked
violent automatic behaviour has been designated as insane and attempts made to consume their flesh (Landes, 1938).
automatism. The state is terminated by the killing of the windigo or by
his suicide. As with amok, this picture is at least in part
Amok and windigo mythological.
Amok (or amuck) is a term that has been applied to any sud-
den outbursts of violence, but in psychiatry it has tended to Analogies have been drawn between amok and the sud-
be confined to a so-called culture bound reactive syndrome den outbursts of murderous violence directed at a number
involving the peoples of the Malay archipelago (Linton, of victims which occur periodically in western societies
1956; Yap, 1969; Carr and Tan, 1976). Amok in Malay has (Teoh, 1972; Westermeyer, 1982). Superficial similarities
the meaning of rushing in a state of frenzy to the commis- certainly exist in that they both involve a public display of
sion of indiscriminate murder (Oxford English Dictionary). apparently motiveless violence, often terminated by the
There were reports from Java by early Dutch and British killing or suicide of the perpetrator. Both seem to have
colonists of Malays running amok (Spores, 1988). elements of contagion in that amok violence has been
described as spreading epidemics through some Asian
Amok was claimed originally to have three phases communities (Westermeyer, 1973) and spectacular mass
(Gimlette, 1901; Burton-Bradley, 1968; Westermeyer, 1982): killings can spawn copy-cat killings. The analogy, how-
1. a prodrome characterized by social withdrawal and ever, obscures more than it illuminates. Mass killers in
western societies are a heterogeneous mixture including
anxious brooding; disgruntled teenagers, gun-obsessed inadequates, deluded
2. a sudden furious outburst in which a number of people psychotics and misguided fanatics. Those who live to tell of
their outbursts are not reported to claim amnesia for the
are attacked at random; and events. To describe a sudden outburst of violence as amok,

428 © 2014 by Taylor & Francis Group, LLC

Deception

in the technical rather than lay sense, evokes a spurious almost always prompt and complete, except where litiga-
confidence that we have somehow understood the events. tion is involved. Thus, if a man falls off his own ladder and
This could inhibit the proper exploration of the actual con- bangs his head he recovers quickly, but if he falls off his
text and state of mind of the perpetrator. employer’s ladder and becomes involved in compensation,
persistent disability may follow.
From a treatment perspective it is essential to distin-
guish these dissociative states from systematized paranoia Lishman (1968) noted:
which frequently involves long-standing delusions, sexual Central to most descriptions are headaches and dizzi-
thoughts, planning, and mass destruction, often including ness, but to these may be added abnormal fatiguability,
suicide. The case of Ernst Wagner (chapter 9) is the first and insomnia, sensitivity to noise, irritability, and emotional
one of the best descriptions of this dangerous condition. instability. Anxiety and depression are often prominent.
Difficulties with concentration and memory may feature
Deception strongly among the complaints, and some degree of overt
intellectual impairment may on occasion be detected.
This section deals with topics where the possibility of With this mixture of quasi-organic and subjective symp-
deception is frequently raised. Many of the patients dis- toms, variously reported, it is scarcely surprising that the
cussed here are, however, not deceiving anyone. concept lacks clarity and that its aetiology has remained
in doubt. Nevertheless, its ubiquity following even minor
Compensation Neurosis blows to the head, and the regularity with which it fea-
tures among claims for compensation, have ensured that
It is probably wrong to include compensation neurosis it persists as an important subject for medical interest
under the general heading of deception as most of the peo- and debate.
ple claiming compensation after an accident are deceiving In his textbook Lishman (1998) pointed out:
neither themselves or anyone else, yet unfortunately com- In some, probably rare, cases there will be entirely con-
pensation neurosis has become a pejorative term which scious simulation for gain, but in the great majority the
has many pseudonyms, e.g. ‘accident neurosis’, ‘greenback compensation issue colours the picture in more subtle
neurosis’, ‘profit neurosis’, ‘railway spine’, and ‘unconscious ways. Once the possibility of compensation is raised the
malingering’. Kennedy (1946) gave expression to such patient finds himself in complex legal dealings; there
prejudice in the following aphorism: are frustrations due to delays, anxieties due to conflict-
ing advice and often capital outlay. In effect the injured
A compensation neurosis is a state of mind, borne out person is invited to complain and, having done so, finds
of fear, kept alive by avarice, stimulated by lawyers, and he has to complain repeatedly, over years to a number
cured by a verdict. of specialists. Repeated questioning from lawyers and
The difficulty is that the emotional effects of an injury doctors not only focuses the patient’s attention on early
manifest themselves within a personal and social con- symptoms which perhaps were due to recede, but in
text. Least psychological damage occurs when injury can addition reinforces the prospect of their continuance and
be accepted as part of a natural order. Feelings of anger worse to come.
and resentment exacerbate physical and psychiatric Thus in the early days or weeks after injury the post-
symptoms. Litigation is almost always protracted and concussional syndrome is probably directly related to the
involves repeated medical examination. The patient’s cerebral trauma but, subsequently, it becomes overlain
attention is focused on his or her grievance and symp- by psychological factors and in some cases deliberate
toms. Finally, in court, disability is financially rewarded exaggeration.
and any recovery may reduce the level of compensation.
This process exacerbates psychological symptoms and The literature on the recovery of psychological symp-
hampers recovery. The experience in New Zealand of a toms after settlement is confused. Miller (1961, 1966)
government-run accident compensation scheme has, followed-up an unrepresentative sample of 50 neurotic
however, amply demonstrated that merely removing the patients from a total of 200 head injury cases and found
courts and the litigation process in no way reduces either that 90% returned to the same or similar employment
the psychological problems or the temptation to exag- after their cases were settled. Kelly (1981) documented
gerate or fabricate compensatable injuries. In fact, it may 100 ‘post-traumatic syndrome’ patients, but traced only 43
increase these problems, as all injuries become poten- after a follow-up period averaging 2.8 years. No patient was
tially compensable irrespective of whose responsibility personally interviewed. Many patients had improved and
they may have been. returned to work by the time the case was settled, but of
the 26 not working by settlement, 22 were still not working
The problem is neatly illustrated by considering the at follow-up, which led him to conclude that the ‘cured by a
effects of minor concussional head injury. Virtually every verdict’ jibe is not correct.
individual who leads an active life has sustained an injury
causing a brief interruption of consciousness. Recovery is

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Deception, dissociation and malingering

Perhaps the most comprehensive review is by Mendelson basis, but is exaggerated, and what is gross malingering.
(1984). He looked at 18 follow-up studies of personal injury Often one develops chronologically from the other. It may
litigants. Of these only three studies, including the one by be that the immediate response to injury, be it physical or
Miller, favoured the view that claimants improved within psychological, is almost always genuine and would have
a fairly short time of the finalization of their claims. Six occurred in the absence of any compensation claimed. To
studies were discounted because of the small number of reiterate the point made by Lishman above, the lengthy
patients examined. Nine studies indicated that of patients process of pursuing compensation hampers recovery and
who stopped work following a head injury, between 50 and encourages exaggeration; sometimes naturally occurring
85% failed to return to work after a settlement. For patients recovery is not frankly admitted. As the litigation pro-
with a low back injury, 35% were unemployed after a mini- gresses over years, some suggestible individuals elaborate
mum of 3 years following settlement. Patients with neck their symptoms; these cases tend to carry a poor prognosis.
injuries had persistent disability of a severe degree, namely, The plaintiff ’s account of the past is often distorted and
12–60% of cases 5 years after the injury. Tarsh and Royston pre-accident physical and psychological disabilities may
(1985) carried out a follow-up of 35 claimants who had an be concealed. Careful examination of the full family prac-
‘accident neurosis’. Patients were followed-up from 1  to 7 titioner case notes and correspondence is often revealing.
years after compensation was received. Few recovered and Malingering can occur, but is difficult to detect on the basis
such recovery as did take place was unrelated to the time of a single psychiatric examination. Sometimes enquiry
of compensation. Most cases still had continuing and often agents’ reports and videos indicate that allegedly disabled
severe symptoms at follow-up, and about one-third of the subjects are, in fact, working clandestinely and leading
group seemed certain to be always going to lead lives of comparatively normal lives.
invalidism, totally dependent on other family members.
Management therefore requires a good deal of sensitive
Mendelson (2003) summarizes the situation well. He enquiry, a working relationship with the whole family (if
traces the beginnings of so-called compensation neurosis there is one) and above all the application of pressure to the
to the development of the railways in about 1830 which lawyers involved in the case to resolve the matter as quickly
gave rise to a lot of higher speed transport accidents and to as possible. This is difficult because lawyers believe that
symptoms that had not been noticed very often before, and their client has a right to the best possible financial settle-
thence to the new diagnoses of ‘railway spine’ and ‘nervous ment even if this means delay, and therefore delay in return
shock’. This latter term is still used within the legal world to health. Once the settlement has been agreed rehabilita-
(see p.53). Mendelson also indicates that the introduction tion may become difficult because an important purpose-
of workers’ compensation legislation at the end of the ful activity will have been removed from the patient’s life
nineteenth century led many to postulate that it was the and new activities which can fill that vacuum need to be
financial gain which led to the prolongation of disability. negotiated. The Miller view that patients get better as soon
This implied that compensation neurosis was a subtype as the compensation is paid is not our clinical experience
of malingering. Mendelson described such explanations as and many of the symptoms persist for many years as does
‘inaccurate and simplistic’. He said: the disability.

There are many factors that influence outcome following Malingering
compensable injury… and a new paradigm is needed that
takes into consideration these variables and provides a Malingering is a highly pejorative term, linked not only with
comprehensive explanatory model that, ultimately, may words such as lying and deceit, but also with scrounger,
lead to effective interventions. workshy, coward. It implies the wrongful acquisition of
Beck (1829) wrote in a nineteenth-century law textbook the privileged status of the ill, and it is further linked with
that where illness might be feigned we have a dishonest acquisition of money. In times of war it has the
double duty… to guard the interests of the public… and special odium of seeking personal safety and comfort when
also those of the individual so that he be not unjustly others are making sacrifices to achieve highly desired group
condemned. objectives. Such people may be branded as shirkers, funks
That advice may be nearly 200 years old, but it is a useful and degenerates. Above all, pretending to be ill is regarded
benchmark for the twenty-first century. as ‘shameful’. It is no wonder it is a vexed topic for medical
professionals as they are expected to accurately point the
In considering an individual case it is useful to remem- finger at those who shall be deprived of the illness status,
ber that ‘recovery’ and ‘return to employment’ are very dif- and their claims and who will thus fall to the very bottom of
ferent. Many complainants are manual workers in mid-life the social hierarchy. In times of war some alleged malinger-
who have little motivation to return to the sort of poorly ers may be regarded as so heinous that they are executed.
paid employment which would leave them little better
off than when in receipt of state benefit. The boundary The history of this problem has been briefly but well
is blurred between what is genuine, what has a genuine documented by Wessely (2003). He pointed out that the

430 © 2014 by Taylor & Francis Group, LLC

Deception

simulation of illness is as old as humankind. He suggested lunatic who was not an idiot would act cunningly and
that it was the introduction of progressive social legisla- answer intelligently.
tion in Germany between 1880 and 1890 and in Britain Chesterman has written two articles on psychiatric
in 1908 with The Workmen’s Compensation Act and the malingerer catching. Broughton and Chesterman (2001)
1911 National Insurance Act, that made this simulation a described a man who assaulted a teenage boy and then
medical problem. These acts were regarded by the medical feigned mental illness. He later confessed to malingering
profession as inducements to malinger and quite a number but doesn’t seem to have done very well. The authors do
of doctors set themselves up as gatekeepers for the state stress however that the discovery that an individual has
against such temptations. Initially malingering was thought fabricated symptoms should not exclude him or her from
to be mainly a matter for physicians and surgeons, but the further assessment and treatment, as such fabrication
First World War added a very significant psychological should be viewed as a form of abnormal illness behaviour
dimension even though the psychiatric casualties of that in an often resourceless, inadequate and vulnerable indi-
war were considered to be suffering from ‘nervous shock’ vidual. Chesterman et al. (2008) take twenty-first century
which was also thought to be a physical disorder (damage British psychiatrists, especially authors of this textbook, to
to the nervous system by terrible noise and blast from the task for not giving enough attention to malingering. They
heavy guns). Wessely suggested that at the beginning of the believe that this is due to a false assumption that psychotic
twentieth century there was a perceived decline in the pre- symptoms are faked in order to ward off real psychosis
war moral codes that had governed society. Malingering (Jung 1903). The paper is a useful review of the research in
was considered to be a form of lying and medical man was this field and suggests some tests which have all the draw-
best placed to detect it! backs and low validity one might expect, in order to detect
malingered psychosis. They go on to say:
As we have seen, if it really is lying, then it is going to be It appears that the incidence of malingered psychosis
mighty difficult to detect. Perhaps courts who claim to be may well have increased over recent years as a conse-
able to detect liars are better placed to do this work than quence of the closures of long-stay psychiatric institutions
doctors. Sprince (2003) suggested that medical evidence and the move towards care in the community. Many
about malingering is not particularly significant in a court chronically mentally ill patients, who may have preferred
of law. Where claims have been resisted in whole or in part the stable environment of the asylum, are now living in
by reference to malingering, courts have rarely reached a marginal circumstances in the community… Such indi-
positive finding that an individual is or is not malinger- viduals may therefore consciously exaggerate their symp-
ing and in appeal cases malingering rarely arises. Further toms in an effort to obtain shelter in the new generation
where the claim has been lost, presumably because the of psychiatric hospitals… It has also been proposed that
claim is not considered to be genuine in all respects, it is there has been a change in coping strategies among soci-
rarely followed by a criminal prosecution for fraud. ety’s disenfranchized individuals, who now present with
psychological rather than physical symptoms.
For a comprehensive text on malingering and illness They also emphasize the importance of detecting malin-
deception see Halligan et al. (2003). gering but don’t say what this importance is, other than a
possible miscarriage of justice in a homicide case in which
Feigned mental illness a manslaughter verdict of diminished responsibility on
In the nineteenth century, there was considerable interest grounds of mental disorder is preferred to a murder verdict.
in identifying malingerers who simulated mental disorder. There is no research on the prevalence of such problems.
Beck (1829), in spite of his views quoted above, devoted
considerable space in his text on medical jurisprudence The question of what is malingering is claimed by some
to the recognition of feigned diseases and, in particular, to be straightforward. An early authority, whose text on the
offered no fewer than 12 strategies for unmasking those subject was dedicated ‘to my friend the British workman,
pretending madness. Tuke (1892) noted that simulators to whom I owe so much’ (Collie, 1917) cited Lord Justice
of insanity made errors in such matters as adding 3 and Buckley. The judge defined a malingerer as ‘one who is not
4, or the number of shillings in a sovereign, or in identify- ill and pretends that he is.’ Collie also cited Bramwell who
ing commonplace objects. He stated that the unskilled distinguished between ‘malingering’ (conscious, deliberate
malingerer answers nothing right, constantly falling into simulation of disease, or exaggeration of symptoms) and
absurdities quite foreign to true insanity. Maudsley (1867) ‘valetudinarianism’, where the process is unconscious or
also noted: subconscious. In a more recent study of feigning after brain
or spinal injury, Miller and Cartlidge (1972) defined malin-
Imposters generally overact, thinking the lunatic widely gering as: ‘all forms of fraud relating to matters of health.’
different from a sane person… [he] pretends he cannot This includes the stimulation of diseases or disability which
remember things such as what day follows another, or are not present; the much commoner gross exaggeration
how many days there are in a week, that he cannot add
the simplest figures… [he] answers stupidly where a real

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Deception, dissociation and malingering

of minor disability; and the conscious and deliberate Whether or not this practice resolved the question of
attribution of a disability to an injury, or accident that did malingering, today it should surely be a matter for a profes-
not in fact cause it, for personal advantage. In a lecture, a sional licensing body.
psychiatrist with a medico-legal compensation practice in
Australia (Parker, 1988), claimed: To try to understand just how easy or difficult it is to
simulate mental disorder, Anderson et al. (1959) carried
A week will not go by without seeing at least two malin- out a study in Australia. Eighteen psychology students
gerers, and about the same number with gross conversion were asked to simulate mental disorder. Six were asked to
hysteria. imagine that they had committed murder and they were
Nevertheless, he went on to warn, using the words of Asher to feign insanity to escape the consequences. Twelve were
(1958): asked to feign insanity for their own reasons. The subjects
The pride of a doctor who has caught a malingerer is were then subjected to a standard psychiatric examination.
akin to that of a fisherman who has landed an enormous None of the pictures presented resembled well-defined
fish; and his stories (like those of fishermen) may become psychiatric disorders. Even the better performances lacked
somewhat exaggerated in the telling. consistency and persistence. The commonest simulation
It could be that there is a special form of malingering, the was of depression, in two people accompanied by amnesia;
feigning of psychotic illness. The following kind of argu- three also simulated paranoid features. On cognitive test-
ment may not be uncommon. ing, errors were produced, especially approximate answers.
The trouble is that as soon as the language of ‘patient- One tried to make out he was an epileptic, another tried to
treatment-disease’ is used, it is hard to diagnose insanity simulate feeble-mindedness. Unfortunately, the psychiatric
in anyone who commits a really horrible act; for to be examinations were not carried out blindly, so although the
cured of mental disease is to be sane, and a sane man experimenters were not very impressed by their students’
does not do such things; there is a merging of the lan- acting, it is difficult to know whether they could have actu-
guage of medicine and the language of morality; if bad is ally been fooled.
sick, then sick is bad, and sane must be good. The more
we treat someone as a patient, the more likely we are to Perhaps the most famous test of simulated psychosis is
give his sincerity the benefit of the doubt. We tend to ask ‘on being sane in insane places’ (Rosenhan, 1973). Five male
‘What makes him behave like that’ instead of ‘is he telling and three female volunteers, a psychology student, three
the truth?’ and ‘could he behave differently if it was to his psychologists, a paediatrician, a psychiatrist, a painter, and
advantage?’ (Mount, 1984). a housewife became pseudo-patients and gained ‘secret
It is certainly a robust statement of the antipsychiatry posi- admission’ to 12 different hospitals. The pseudo-patients
tion. Yet medical practitioners can also have considerable complained that they were hearing voices, they changed
scepticism about mental disorder in those charged with their names and occupations, but otherwise told the truth.
serious crimes. An anecdote from Ray (1838) illustrates The ‘voices’ were stopped immediately on admission.
just how far preconceptions about deception, malingering Each was diagnosed as having schizophrenia, but soon
and moral responsibility will take even the experienced discharged as in remission (length of stay varied from 7–52
observer. days). Other patients sometimes recognized the pseudo-
Jean Gerard, a bold villain, murdered a woman at Lyons patients as frauds. Rosenhan concluded, ‘it is clear we
in 1829. Immediately after being arrested, he ceased to cannot distinguish the sane from the insane in psychiatric
speak altogether and appeared to be in a state of fatuity. hospitals.’ A torrent of replies disagreed. The strongest criti-
He laid nearly motionless in his bed, and when food was cism was perhaps by Spitzer (1975), who pointed out that
brought his attendants raised him up and it was given it is not very surprising that psychiatrists do not diagnose
to him in that position. His hearing also seemed to be pseudo-patients when they are not looking for them. He
affected. The physicians who were directed to examine concluded himself, however, that the data actually sup-
him concluded that if this was actually what it appeared ported the view that psychiatrists are good at distinguish-
to be, paralysis of the nerves of the tongue and ear, actual ing the sane from the insane.
cautery applied to the soles of the feet would be a proper
remedy. It being used, however, for several days without None of this is much help if a psychiatrist is faced with
any success, it was agreed to apply it to the neck. For a patient in a situation in which having a psychosis would
two days no effect was produced, but on the third, while be a distinct advantage. There is no simple answer and the
preparations were making for its applications, Gerard principles of assessment and management will be the same
evinced some signs of repugnance to it, and after some as if simulation of physical disorder is suspected. As much
urging, he spoke, declaring his innocence of the crime of information as possible should be collected from as many
which he was charged. His simulation was thus exposed. 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).

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Deception

Malingered psychiatric disorders are encountered both proving, to the patient’s complete satisfaction, the delu-
in situations where compensation is at issue and in those sional claims. Malingered delusions are often said to have
facing criminal charges. Malingered psychiatric disorders emerged at a particular point, usually relatively recently,
may occasionally be encountered in those seeking admis- and to have, from the outset, their fully fledged content.
sion or transfer to a psychiatric hospital from prison. The In genuine delusions, it is usually possible to discern their
malingerer sometimes believes s/he has to appear mad gradual development from the initial intuition through an
or idiotic in every sphere of function and thus presents extended process as the patient uncovers the full extent
such an exaggerated picture that suspicions are raised, of ‘the truth’.
even in the most trusting. This type of malingerer, who
counterfeits a disorder too mad to be mad, often claims Language disorders are rarely, if ever, malingered. Manic
gross disorientation under the misapprehension that the states are difficult to imitate, but depressive syndromes rel-
mentally disordered suffer a global confusion. More subtle atively easy. Most of us have sufficient experience of despair
malingerers draw on their experience with mentally dis- and despondency to mimic depression. Where suicidal
ordered individuals. They may claim to be hallucinated, intent is claimed in the context of an account of depres-
in which case the hallucinations tend to be described sion which appears so atypical as to raise suspicions about
as omnipresent, distressing and without the usual asso- malingering, it is probably wiser to give the benefit of the
ciation with mood changes or delusional developments. doubt to the individual until s/he can be observed carefully.
Flamboyant claims about the content and extensive nature In disorganized and disturbed personalities, so common in
of hallucinations often contrast with the meagre and vague forensic psychiatry, instability of mood and markedly atypi-
account provided of the form of the experience in terms cal depressive syndromes occur not infrequently, and they
of being experienced in objective space, having directional are all too often coupled with self-destructive behaviour.
qualities. Malingered hallucinations may also take atypi-
cal forms as when a vision of a person is described which Malingered mental disorders are often presented flam-
talks to the patient and may even enter into conversation. boyantly and insistently. Any questioning of the reported
Occasionally, command hallucinations are offered as an experiences is likely to be greeted by assurances that it is
explanation of offending. These should be treated with ‘the truth’, or with the accusation that you don’t believe the
some scepticism when presented in the absence of other patient. In genuine disorders, the abnormalities of mental
features of psychotic illness. state usually emerge gradually as the interview progresses.
Some malingerers are suggestible and can be induced to
Command hallucinations have a particular appeal to add contradictory and absurd symptoms to their account,
the malingerer as they offer both evidence of mental disor- but more calculating malingerers will stick doggedly to
der and at the same time incorporate a direct exculpatory their basic story.
element. Claims are made by offenders that they commit-
ted criminal acts because the voices told them to do so, and To summarize, the detection of malingering is a diffi-
they were unable to resist the instruction. In fact violent cult, but not entirely mysterious art. The longer the patient
acts secondary to command hallucinations are rare, even is studied, the more carefully the information is gathered
among people suffering from psychosis (see chapter 14). and checked, the easier it becomes to detect malingering.
Occasionally, distressed and disturbed individuals will The patient should be encouraged to talk freely rather than
report command hallucinations to dramatize their suicidal to answer formulaic questions. Malingering patients tend
or homicidal impulses. to have an air of exaggeration, a disproportionate bias in
their symptoms, and their complaints do not fit with objec-
Fabricated delusions are less common. Malingerers tive observations from others. They tend to tell lies and so
usually present a straightforward account of persecution their accounts differ from time to time. However, it also
or control which accounts conveniently for their acts has to be remembered that differences between objective
or makes necessary their transfer. The accounts differ and subjective accounts may be due to many factors other
from actual delusional experiences both in providing an than malingering. Inconsistencies between interviews may
unusually clear storyline and paradoxically containing be entirely compatible with the memory failures of normal
elements of the totally fantastic. One young man gave an recall, and with clinical change as the disorder progresses.
account of being followed and persecuted by shadowy Exaggerated, overoptimistic, or even pessimistic accounts
figures whom he claimed had arranged for him to be may be due to mood changes. Self-deception may replace
locked in a cell on board a ship which was about to be conscious lying and dissimulation. There are no absolutes
sunk. When questioned, he went to the prison window in the detection of malingering, but standard techniques
and pointed out at the surrounding sea, then abruptly fled of cross-checking, observation, repeated interviewing,
under the table claiming the boat (prison) was sinking. together with the skill of an experienced interviewer who is
Fabricated accounts, unlike true systematized delusions, alive to the possibility of malingering are the best that can
rarely contain the typical mixture of self-referential mate- be done. It is worth remembering that hostile questioning
rial and laboured constructions placed on minor points of distressed patients will probably increase rather than
reduce error.

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The growing neuroscience of perceptual and cognitive repeated self-injury. There is usually no attempt at mim-
distortions explored by Myslobodsky (1997) and Halligan icking of genuine medical disorders, although occasionally
et al. (2003) is likely to enhance our understanding of bizarre skin lesions are induced which raise questions as
just how blurred the boundaries between normality and to their origin. In one case, the patient injected air under
abnormality may be. the skin and persuaded one hospital to treat her for gas
gangrene.
Munchausen’s syndrome
Munchausen’s syndrome was described and named by Ganser states
Asher in 1951. Like the famous Baron whose tales were A strange mental state described by Ganser in 1898 was
bowdlerized and published by Raspe (1786), the affected regarded in its day as a ‘prison psychosis’. If it occurs at
persons had travelled widely, and they related tales which all nowadays it is extremely rare and is included here for
were both dramatic and untruthful. Typically, such patients completeness and historical interest and show how dis-
will be admitted to hospital with an acute, harrowing, but sociative/malingered symptoms vary with time and place.
not entirely convincing history; their manner is evasive The clinical features are
and truculent; and, on enquiry, it may be revealed that they 1. approximate answers;
have attended and deceived other hospitals, often discharg- 2. clouding of consciousness with disorientation in time,
ing themselves against advice.
place, and occasionally person;
Most cases resemble organic emergencies and favour 3. vivid hallucinosis, both visual and auditory;
three main variants: 4. areas of analgesia and hyperalgesia with, on occasion,
1. The acute abdomen type which is usually accompanied
motor disturbances which were considered ‘hysterical
by a multiplicity of abdominal scars. stigma’;
2. The haemorrhagic type, usually reporting haemoptosis, 5. complete and often sudden clearing of the disorder,
leaving the patient with a total amnesia for the period
haematemesis, or haematuria. of the disorder.
3. The neurological type, with headache, odd fits, or loss of The description of the peculiar way of answering questions
was the feature which intrigued subsequent investigators
consciousness. and guaranteed the survival of the putative syndrome
Asher’s title for this group of patients now seems well-estab- (Auerbach, 1982). The phenomenon of approximate
lished. The patients tend to be emotionally labile, lonely, answers (Vorbeireden or Vorbeigehen) was described by
attention-seeking and establish little rapport. Multiple Anderson and Mallinson in 1941 as
aliases and repeated admissions are central features and A false response of a patient to the examiner’s question,
some cases also fulfil the criteria for pseudologica fantas- where the answer, although wrong, is never far wrong and
tica. Some are seeking narcotic drugs. bears a definite and obvious relation to the question, indi-
cating clearly that the question has been grasped.
A sinister variant of the condition has been described Anderson and Mallinson went on to make clear that this
as ‘Munchausen syndrome by proxy’ (Meadow, 1977, 1982, is not merely giving random responses. Among Ganser’s
1989; Black, 1981). This involves children whose mothers examples was a prisoner who, when asked how many
or caregivers invent stories of illness about their child and fingers he had, replied 11 and said a horse had three legs,
in some cases fabricate false physical signs. Older children but an elephant five. Counting, simple arithmetic, identify-
may even be coached by the parent on how to deceive the ing letters of the alphabet and reading, are all reported to
doctor. Meadow (1989) describes the consequences for produce obvious errors and omissions. One of our cases,
children who are falsely labelled as ill: when shown a chessman and asked what it was, replied
1. They receive needless investigations and treatment. after several minutes of puzzled examination that it was a
2. Real injury may be caused by the mother’s action, for little statue whose function quite escaped him. This same
man correctly identified a watch and could tell the time,
example by giving drugs to induce unconsciousness. but called a key a knife, and added a little pantomime of
3. They are at risk from becoming chronic invalids or hos- horrified withdrawal. One of Ganser’s own cases identified
a key as a revolver.
pital addicts in their own right. The possibility that the Ganser state is a manifestation
The parents’ motivations have been considered to include of the conscious simulation of mental disorder is consid-
a desire for the status and attention provided by being ered frequently in the literature, usually to be dismissed in
the mother of a sick child, the enjoyment of help from the favour of unconscious mechanisms, or the impact of major
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

434 © 2014 by Taylor & Francis Group, LLC

Deception

stress on somebody who already has a mental disorder. It is at its worst in large teaching hospitals, he said, and
What Ganser added to previous descriptions of feigned can easily be diagnosed by the general practitioner who
mental disorder in prisoners was his personal assurance telephones to seek admission for a patient. The condi-
that ‘it could not be doubted’ that the prisoners being tion then manifests itself in the form of a newly qualified
examined were not malingering, but ‘truly sick’. intern treating the general practitioner as though he
were a medical student presenting himself for a viva. The
The Ganser state has almost disappeared, but before least subtle sign is when the body language and voice
it goes entirely it might help to consider whether we inflection asking the patient about symptoms gives the
think of it as malingering, pathological lying, or a dis- distinct impression that the assessing doctor believes
sociative disorder. Some of the patients we have seen the patient is a liar. The main complication of malingero-
labelled as ‘Ganser’ turned out later to be psychotic; all of phobia is that the patient is rejected and the patient’s
them needed help. problems are undiagnosed. Doctors dealing with such
patients become bored and impatient. The worst com-
Malingerophobia plication is the enquiry, sometimes by a coroner, when
We cannot leave the topics of malingering and feigned something goes wrong. The cure for this disorder is
mental illness without reference to Pilowsky’s (1985) paper simple, says Pilowski, it is an increased readiness to take
on malingerophobia. It describes an important syndrome patients on, especially for treatment, coupled with a
which every physician, and especially every psychiatrist, tolerance of occasional malingering. This will prevent
should know about. Pilowsky likened the medical altruis- the development of a fortress mentality and improve
tic impulse to body temperature which can under stress working conditions as well as treatment. Perhaps we
become too warm or too cold. He maintained that it is a can add to Pilowsky’s remedies that much more atten-
contagious condition and is defined as tion should be paid to understanding and assessing the
rich diversity of mental states that patients present, an
an irrational and maladaptive fear of being tricked into approach which may well save a lot of time in the long
providing healthcare to individuals who masquerade as run and certainly gets closer to the core task of being a
sick, but either have no illness at all, or have a much less medical practitioner.
severe one than they claim.

© 2014 by Taylor & Francis Group, LLC 435

18
Addictions and dependencies: their
association with offending

Edited by Written by
Pamela J Taylor Mary McMurran and
Adrian Feeney: Alcohol
Ilana Crome and
Roger Bloor: Other drug
abuse and offending
John Gunn and
Pamela J Taylor:
gambling

1st edition authors: John Gunn, John Hamilton, Andrew Johns, Michael D Kopelman,
Anthony Maden, John Strang and Pamela J Taylor

Society remains ambivalent about use and abuse of mind DSM-IV substance abuse amounts to repeated social
altering substances and towards the people who use and ­failures in the context of using the drug (including alcohol,
abuse them. Even the professions seem to struggle with but not nicotine or caffeine) but with patterns falling short
attitudes to the behavioural disorders associated with such of dependency.
substances in ways that perhaps reflect tensions between
construing them as primary disorders of mental health or as In the UK, the Academy of Medical Sciences (2008) has
moral lapses. It is not uncommon even for people with une- taken a lead in bringing a more scientific perspective. It has
quivocal psychotic illnesses to be rejected from psychiatric brought back the terminology of addiction, and made clear
services on grounds that their disorder is substance-induced its multi-factorial origins. It acknowledges risk factors and
rather than illness. Terminology is also elusive. The two main protective factors, and that these lie in a range of personal,
diagnostic and statistical manuals (ICD-10, WHO, 1992a; physical and experiential domains as well as in availability
DSM-IV, American Psychiatric Association, 2004) no longer of the objects of addiction and attitudes in wider society
use the terminology of addiction. The former deals with a and the media. The Academy further notes the similarities
variety of ‘mental and behavioural disorders due to psycho- in presentation between addictions to chemical substances
active substance use’ in a simple descriptive way, while the and to other repeated behaviours, particularly problem
latter takes the simpler label of ‘substance-related disorders’, gambling (euphoria on winning, tolerance on repetition,
but suggests a fundamental distinction between ‘substance- compulsion, withdrawal and craving). It makes parallels
induced disorders’, subliminally justified by including toxic between them in terms of similar areas of brain activation
substances which are not abused as well as those that may when winning and after administration of drugs of abuse
be, and ‘substance use disorders’. In the case of substance- (e.g. Reuter et al., 2005). We too extend this chapter to con-
induced disorders, the implicit blame falls on the substances. sideration of behavioural addictions, here exemplified by
DSM criteria for substance abuse and dependency disorders gambling, although in some cases, shoplifting, arson, and
make repeated use of the word ‘failure’. For dependency, even interpersonal violence may fall within this spectrum.
Such a broad construction means that addictions, depend-
The key issue … is not the existence of the problem, but encies or substance abuse in an individual are central issues
rather the individual’s failure to abstain from using the for the health service, even though many may first present
substance despite having evidence of the difficulty it is to criminal justice services. It also means that public health
causing (DSM-IV, p.179). policies and legislative controls have a fundamental part to
play in protecting both the individual and wider society. This

436 © 2014 by Taylor & Francis Group, LLC

Alcohol

chapter is mostly about clinical detection, legal issues, rela- How Alcohol Exerts its Effects
tionships between substance misuse and offending, man-
agement and treatment of the addictions. Consideration of Intoxication
genetic and other aetiological factors is mainly in chapter 8. The immediately observable effects of alcohol intoxication
are impairments such as slurred speech, slowed mental
Alcohol and physical reaction times, and difficulty walking. They
may be apparent even at small doses, are dose-dependent
The World Health Organization (WHO, 2002a) placed alco- and are due to the depressant effects of alcohol caused by
hol consumption among the top 10 global risk factors in reduced excitatory actions of the neurotransmitter gluta-
terms of the burden of disease caused. In the year 2000, 1.8 mate and increased inhibitory actions of gamma-aminobu-
million deaths worldwide were attributable to alcohol con- tyric acid (GABA) (National Institute on Alcohol Abuse and
sumption as well as 4% of the total global burden of disease, Alcoholism, 2000). In most cases, the impairments caused
including an estimated 20–30% of each of the following: by intoxication are temporary, but intoxication can lead to
liver disease, oesophageal cancer, epilepsy, road traffic acci- death from respiratory failure, accidents associated with
dents and intentional injuries. Problem drinking presents loss of consciousness (e.g. hypothermia; choking on vomit)
a risk for mental ill health too, although mental disorders or accidents associated with cognitive or motor impair-
also increase the risk of alcohol-related problems (WHO, ment (e.g. road or machinery accidents).
2004a). Globally, alcohol is a major contributor to violence,
including homicide, domestic violence and child abuse, and Pathological intoxication (mania à potu) has generally
sexual violence (WHO, 2002b). been defined as sudden onset aggressive behaviour, atypi-
cal for the individual when sober and seen after a small
Perhaps in recognition of its part in this global crisis, the quantity of alcohol, and which, in normal people, would
prime minister’s strategy unit developed an ‘Alcohol harm not be associated with such behaviour. It may be associ-
reduction strategy for England’ (Cabinet Office, 2004). Similar ated with alcohol-induced amnesia for the events involved.
strategies already existed for Scotland (Scottish Executive, Coid (1979), however, cast doubt over its authenticity, after
2002/7), Wales (Welsh Assembly Government, 2008b), and reviewing the literature. Close scrutiny of any case com-
Northern Ireland (DHSSPS, 2000). All focus on combating monly shows that the person has had more than a small
alcohol-related crime and disorder through prevention, early drink of alcohol and has a history of violence.
intervention, and treatment, but specifically, too, endorse
the development of offender treatments. In parallel with the In an uncontrolled study, Maletzky (1976) gave alcohol
Cabinet Office work, other bodies, as diverse as the Academy infusions to 22 people with histories suggestive of the condi-
of Medical Sciences (2004), and the Prison Reform Trust tion. At high blood alcohol levels (mean: 195 mg/100 ml) 15
(2004; http://www.prisonreformtrust.org.uk) and The Royal col- of them had unusual reactions. Nine became violent, four
lege of Physicians (2001) have also provided strategic reviews. showed delusions and hallucinations, and a further two pre-
sented with mix of these problems. Maletzky concluded that
These documents were consistent in pointing out that reactions to alcohol were on a continuum and that there
over 8 million adults in the UK exceeded the safe weekly was no discrete entity of pathological intoxication. It is of
drinking limits, then 14 units for women and 21 units for note that high blood alcohol levels were required to precipi-
men (a unit is 8 g/10 ml of alcohol). About half of all violent tate the phenomena Maletzky observed. Nevertheless, path-
crimes each year are alcohol-related, amounting to 1.2 mil- ological intoxication remains of interest to defence counsels
lion in England and Wales alone, perhaps not surprising as simple intoxication provides no legal excuse for actions.
given the age range of the heaviest drinkers. The UK General
Household Survey 2002 (Rickards et al., 2004) showed that Blackouts
these were among 16- to 24-year-old men, averaging 21.5 Blackouts occur during drinking bouts. They are character-
units per week. The trend, however, is for a slight decrease ized by discrete amnesic periods of up to several hours,
in consumption by young men but increasing consumption during which the individual is apparently able to carry out
among 16- to 24-year-old women who, in 2002, had been normal activities. In an influential study, 100 hospitalized
averaging 14 units. A revision of national health service alcohol-dependent patients were interviewed. Sixty-four
(NHS) policy now recommends a maximum intake of 2–3 reported blackouts which were of two very distinct types:
units per day for women and 3–4 units for men, with at least (1) classic en bloc, with total memory loss; (2) fragmentary
two alcohol-free days per week, and its alcohol learning cen- blackouts after which the sufferer may be able to recall,
tre regularly produces guidance sheets for clinical staff and with prompting, some of the events which occurred dur-
for patients, variously showing what a unit looks like and ing the blackout which were not initially remembered
offering advice (http://www.a­ lcohollearningcentre.org.uk). (Goodwin et al., 1969; see also chapter 12). Goodwin et al.
(1970) also studied blackouts by giving 16–18 ounces of 86%
Overall, in England and Wales alone, alcohol misuse proof alcohol to 10 alcohol-dependent men in controlled
costs around £20 bn per year in healthcare, crime-related
costs, and loss of productivity in the workplace.

© 2014 by Taylor & Francis Group, LLC 437

Addictions and dependencies: their association with offending

conditions. They were then presented with novel informa- The alcohol dependence syndrome represents a change
tion and tested 2 minutes, 30 minutes and 24 hours later. in the relationship between the individual and alcohol.
All were able to recall the information at 2 minutes but five Instead of using alcohol in the context of social cues, drink-
were unable to do so at 30 minutes and 24 hours. This sug- ing becomes an end in itself and is self-perpetuating.
gests that blackouts are a result of an inability to transfer
information from immediate recall to short-term memory Withdrawal, fits and delirium tremens
rather than inattention or a process of forgetting. Sweeney If an alcohol-dependent person stops or reduces alcohol
(1990) argued that the high blood alcohol levels required for consumption s/he may trigger a withdrawal syndrome,
an alcoholic blackout may severely disrupt other brain func- generally 3–12 hours after the change. Alcoholic with-
tions, such as reasoning and planning, but Lishman (1998) drawal is not infrequent among people detained after
observed that they are probably associated with a sharp arrest, is possibly becoming more likely and may affect fit-
rise and fall in blood alcohol rather than high levels per se, ness to be interviewed. In a sample from the 1980s, at least
and they do not appear to be predictive of cortical atrophy 4% of pretrial male prisoners showed signs of withdrawal
(Ron, 1983). They may be relevant in court if ability to form on reception into prison (Taylor and Gunn, 1984). In a
intent is compromised. Fenwick (1990) asserted that they 2007–2008 sample of newly remanded men at least 17%
are examples of ‘sane automatism’ (see also chapter 2). had alcohol withdrawal symptoms on reception, although
over 40% had an Alcohol Use Disorders Identification Test
A Dutch study of drivers stopped by traffic police or (AUDIT; Saunders et al., 1993) score indicating dependency
involved in car accidents supports a sceptical view of a (Taylor et  al., 2009), which was a higher proportion than
direct link between alcohol level and alleged blackout (van the Office of National Statistics figure of 30% from the 1987
Oorsouw et al., 2004). Of the 100 people stopped, 14 told the England and Wales prison survey (Singleton et  al., 1999).
traffic police that they had had an alcoholic blackout, but Withdrawal in prison may also be precipitated by abrupt
their blood alcohol levels were not significantly different cessation of drinking ‘hooch’, brewed there from such
(180 mg/100 mL) from those of the people who made no diverse sources as rotten fruit or boot polish.
such claim (190 mg/100 mL). The main difference between
the two groups was in whether or not they had had an Withdrawal is characterized by autonomic hyperac-
accident. Twelve of the 14 (86%) claiming a blackout had tivity, including tremor, insomnia, sweating, tachycar-
caused an accident compared with 30 (35%) of the rest. dia, hypertension and anxiety (Raistrick, 2001). It may be
Interpretation of this is difficult; could the high reporting accompanied by acute hallucinosis in clear consciousness;
rate of blackouts among those who had crashed reflect at h­ allucinations may occur in any modality, but visual and
some level avoidance of prosecution, or the lower reporting tactile modes are especially common. Violent or criminal
rates a reluctance to put their driving licence in jeopardy? acts may be committed while blood alcohol levels are falling.
Could alleged blackouts be related more to the trauma of
the accident than the alcohol? Withdrawal fits may occur 12–48 hours after cessa-
tion of drinking; 5–10% of alcohol-dependent individuals
Dependence experience them. The fits are generalized, tonic–clonic
The alcohol dependence syndrome, as described by bursts of activity and are therefore characterized by loss of
Edwards and Gross (1976), remains a useful guide for rec- consciousness followed by involuntary movements of the
ognition of need for intervention: limbs and accompanied by an abnormal electroencepha-
1. a narrowed drinking repertoire, characterized by a set logram (EEG). The EEG is, however, generally normal
between such fits, indicating that they are a manifestation
routine of consumption in an effort to maintain blood al- of the withdrawal rather than an independent epileptiform
cohol levels and therefore avoid withdrawal symptoms; phenomenon. Having a withdrawal seizure is a risk factor
2. increased salience of drinking, such stereotyped drink- for further seizures during subsequent withdrawal states,
ing is pursued to the exclusion of all other activities; therefore a history of withdrawal seizures is an indication
3. increased tolerance to alcohol, a manifestation of both for detoxification to be undertaken as an inpatient.
increased metabolic capacity based upon hepatic en-
zyme induction and increased brain receptor tolerance; Delirium tremens (DT) presents 3–4 days after absti-
4. withdrawal symptoms; nence (Victor and Adams, 1953). It has a mortality of up
5. relief or avoidance of withdrawal symptoms by further to 5 per cent; cause of death is typically cardiovascular
drinking; collapse, hypothermia or intercurrent infection. It presents
6. subjective awareness of the compulsion to drink; with vivid hallucinations, delusions, profound confusion,
7. reinstatement after abstinence, the phenomenon of tremor, agitation, insomnia, and autonomic over-activity.
rapidly returning to the previous stereotyped drinking Visual hallucinations may be Lilliputian (very small). The
pattern after a period of abstinence, for instance a pe- onset may be sudden, although often there is a prodromal
riod of imprisonment. phase, which went unnoticed. The patient may be gripped
with terror, although this is not invariable. DT usually

438 © 2014 by Taylor & Francis Group, LLC

Alcohol

lasts up to 3 days, ending with a prolonged sleep. The show no change (Victor et al., 1971). Schacter (1986) was
patient wakes feeling better, if tired, although occasionally unable to find any recorded case of an amnesic syndrome
an amnesic syndrome is evident. Delirium tremens may being cited as a defence. One of us, however, has experi-
­provide for an insanity defence (see also chapter 2). ence of unfitness to plead being found in the presence of
Korsakoff ’s syndrome, since the defendant could neither
Best practice in managing withdrawal states is preven- remember the alleged assault nor could he follow a trial.
tive – to identify people at high risk and provide them
with planned detoxification (see below). Use of the AUDIT In view of the high risks attached to Wernicke’s encepha-
to supplement interview questions as part of screening lopathy, prophylactic vitamin B1 (thiamine) should be given
on reception into custody may enhance identification of to dependent drinkers, particularly during withdrawal.
those at risk. British Association of Psychopharmacology guidelines
(Lingford-Hughes et al., 2004) recommend a 1-month course
Wernicke/Korsakoff’s syndrome of 100–200 mg thiamine per day for healthy, low risk alcohol-
dependent patients undergoing ­detoxification and those
Wernicke’s encephalopathy (WE) is an acute brain dis- who are thought to be at high risk of developing Wernicke’s
order caused by viatlacmohinolBd1 e(ptheinadmeinncee) deficiency, com- encephalopathy. (Cook [2000] suggests that anyone meeting
monly linked to in combination criteria for inpatient detoxification, for whatever reason), or
with poor appetite, malnutrition, poor absorption, and already showing signs of Wernicke’s encephalopathy, should
impaired thiamine storage by the liver. This deficiency be treated with parenteral B-vitamin complex for up to 5
causes abnormalities in and around the third ventricle days. Such parenteral administration, which includes vita-
and the aqueduct of the brain. Such changes have been min C, has a small associated risk of anaphylaxis and must
found at post-mortem in 12% of people who had been only be given where there is adequate medical support.
alcohol-dependent (Torvik et  al., 1982) although they
have also been found in 1.5% of people who had neither Alcoholic hallucinosis
abused alcohol nor had neurological abnormalities in life Alcoholic hallucinosis is rare, characterized by auditory
(Thomson and Pratt, 1992). WE may be of sudden onset, hallucinations, commonly derogatory comments, in clear/
and there may be memory problems even in the acute very slightly clouded consciousness which follows heavy
phase. Only 10% of patients present with the classic triad drinking. It may generally be distinguished from schizo-
of opthalmoplegia/nystagmus, ataxia, and delirium, and phrenia, even though secondary delusions may follow.
there is a risk that the condition may be mistaken for Glass (1989) provides a full account of its controversial
drunkenness. A presumptive diagnosis should be made in history as a concept and a review of outcome. Treatment
anyone undergoing detoxification who develops any one is absolute abstinence, although low dose antipsychotic
of these signs, or hypotension or impaired consciousness medication may be helpful.
(Cook, 2000). Failure to treat immediately with parenteral
B-complex vitamins puts the person at risk of permanent Alcohol and behaviour
brain damage or death. Victor et  al. (1971), studying Alcohol affects behaviour idiosyncratically: people respond
patients with Wernicke’s encephalopathy, found that over differently from each other and, indeed, one person may
84% went on to develop Korsakoff ’s syndrome. react differently on separate drinking occasions. The fac-
Korsakoff ’s syndrome is a similar, but more chronic tors explaining these individual differences will be explored
state characterized by abnormalities of both anterograde with particular reference to aggression and violence.
and retrograde memory in the presence of apathy but
otherwise relatively well-preserved intellectual function. It has been noted that ‘alcoholic intoxication dissolves
At post-mortem, the cerebral pathology is virtually identi- the super ego before it dissolves the power to act’ and
cal to that in Wernicke’s encephalopathy (Malamud and that drunken people do things which they would not do
Skillicorn, 1956). As Lishman (1998) observed, the patho- when sober (Merikangas, 2004). In laboratory studies, alco-
logical process following thiamine deficiency is the same, hol fuels aggression mainly in men who have personality
merely differing in speed of development. traits of irritability or aggression (Chermack and Giancola,
Classically, the patient is able to register new informa- 1997; Godlaski and Giancola, 2009). The effect of alcohol
tion (e.g. to perform the digit span test) but is unable to on aggression is observed after provocation and is most
retain new information for 5 minutes or more. Temporal evident at higher doses. Acute intoxication is more com-
sequencing of events is particularly impaired, and sufferers monly associated with violence than is chronic, heavy
may make up stories to try to hide such deficits (confabu- drinking (Pillman et  al., 2000). Throughout the UK, there
lation); these are not invariably far-fetched. Confabulation is particular current concern over ‘binge drinking’ and dis-
is not unique to Korsakoff ’s syndrome. Prognosis is poor, orderly conduct among young people, although there is no
but not invariably hopeless; 25% of people recover, one half generally accepted definition of binge drinking. Commonly,
show some improvement with time and the other quarter

© 2014 by Taylor & Francis Group, LLC 439

Addictions and dependencies: their association with offending

it is taken to mean consumption of more than twice the violent’ and ‘if I drink I can take sexual risks’ (McMurran
recommended upper daily limit of alcohol in one sitting and Bellfield, 1993). Recent research has, however,
(over 8 units for men or 6 units for women). According to indicated that alcohol–aggression expectancy effects
this measure, about one-third of people in their twenties disappear after controlling of for an aggressive disposi-
binge on alcohol (Williamson et  al., 2003a). Binge drink- tion; it is the conjunction of the psychopharmacological
ing is a strong predictor of violence, at least in young effects of alcohol with an aggressive disposition which
males (Richardson and Budd, 2003). Accepting that alcohol really leads to aggression (Giancola, 2006).
changes behaviour, it is instructive to identify the mecha- ●● Type of beverage. Different drinks affect behaviour dif-
nisms that explain this. ferently, for example violence is more likely with spir-
●● Anxiety reduction. At high doses and in settings which its than beer or wine (Gustafson, 1999). This may be
accounted for by chemical differences between bever-
are highly provocative of anxiety, the anxiolytic effect of ages (different congeners), by differing speed of alcohol
alcohol reduces the inhibitory effect of fear (Ito et  al., ingestion and metabolism (drinks of different strengths
1996), without which aggression and social rule break- lead to intoxication at different rates), the effects of
ing are more likely. social custom (e.g. ‘aggression-producing drinks’ are pre-
●● Pain reduction. Alcohol is an analgesic, and one com- ferred by aggressive people), or expectation (e.g. a per-
mon euphemism for drunkenness – ‘feeling no pain’ son’s perception of drink type-specific behaviour links).
– has literal truth to it. Knowledge from experience of ●● Context. Alcohol and aggression co-occur in certain set-
this may reduce fear of starting fights; the analgesic tings, typically city centre entertainment venues where
effect removes a reason for ceasing any fight (Cutter young men gather and drink heavily, especially at week-
et al., 1979). ends (Lang et al., 1995). It is also important that people
●● Increasing psychomotor activity. At lower doses, alcohol tend to gather there to seek sexual partners, even to
increases psychomotor activity, which may increase compete over them, thus increasing the volatility of the
the risk of instigating trouble or provoking others (Pihl situation (Charles and Egan, 2005).
et al., 2003; Pihl and Hoaken, 1997). ●● Excuses or facilitators. Some people drink deliberately to
●● Disruption to executive cognitive functioning (ECF). The ‘loosen up’ or give them courage to behave in ways they
concept of executive cognitive functioning has been otherwise would not, thus making alcohol an excuse for
defined by Giancola (2000, p.582) as ‘… a higher order antisocial behaviour, or blaming it after the act (Zhang
cognitive construct involved in the planning, initiation, et al., 2002).
and regulation of goal-directed behaviour’. He presents Each of these aspects may play some role in any alcohol-
a strong case for its disruption affecting alcohol-related related offence. Furthermore, the aggregation of factors
aggression and violence. Alcohol disrupts regulation of should be understood within a cultural context, with differ-
goal-directed behaviour by reducing ability to attend to ences in cultural (or subcultural) norms providing a behav-
all the features of a situation, interfering with appraisal ioural baseline, regardless of intoxication. Factors that
of information, reducing ability to see the situation from need to be taken into account in explaining alcohol-related
the perspective of others, diminishing the ability to crime are summarized in figure 18.1.
consider the consequences of one’s actions, and reduc-
ing availability of alternative responses in a situation. Beverage Drinking style Trigger
Disruption to any of these processes results in failures Crime
of behaviour control. The effects of alcohol will depend Person Environment
on sober-state function, that is how good one’s executive Culture
cognitive functioning is to begin with. Its disruption may
explain much impulsive or imprudent behaviour associ- Figure 18.1     Factors implicated in explaining
ated with alcohol intoxication, including risky sexual alcohol-related crime.
behaviour, disorderly conduct, and driving while drunk.
●● Outcome expectancies. Alcohol may influence behaviour Alcohol and the Law
through outcome expectancies, which are cognitive
representations of an ‘if–then’ relationship; here, they General
represent what has been learned about the effects of In the UK, alcohol is legally available but subject to con-
alcohol through instruction, observation, and experi- trols. In his social history of drinking, Barr (1998) noted that
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

440 © 2014 by Taylor & Francis Group, LLC

Alcohol

Britons have always been heavy drinkers, with documented conducting an orderly house. It is an offence for the licensee
references to exceptional levels of drunkenness as far back or any employee to allow disorderly conduct on licensed
as the eighth century, and the heaviest drinking period premises, to sell alcohol to a person who is drunk, or to
in British history occurring in the eighteenth century. It sell alcohol to underage drinkers. If such breaches occur,
was then that legislation to control alcohol began, and then the police have authority to take action to suspend or
that Thomas Trotter completed his MD thesis describing withdraw a license.
habitual drunkenness as a ‘disease of the mind’ (Trotter,
1804/1985). According to Barr (1998), when William of In addition, other laws exist to control disorderly or
Orange took the English throne in 1688, war was declared dangerous conduct relating to alcohol. Its consumption
on France and trade sanctions reduced the availability of may be prohibited in certain public places, for example city
French brandy. This was accompanied by promotion of centre streets, parks, special transport to sporting events,
domestic manufacture of spirits to maximize state revenue. and at sporting events (Criminal Justice and Police Act
British-grown corn was distilled into gin, consumption 2001; Sporting Events (Control of Alcohol etc.) Act 1985).
of which increased from half a million gallons in 1688 to Driving a motor vehicle with more than 80 milligrams of
19  million by 1742. Consequent social and medical prob- alcohol per 100 millilitres of blood is an offence under the
lems eventually led to the Gin Acts. The first, in 1736, levied Road Traffic Act 1988.
a heavy duty on gin so that most people could no longer
afford it. In 2009, raising the price of alcohol was again Intoxication and the law
suggested as a route to containing the public health threat. While intoxication may lead to criminal charges, such as
In 1736, however, increased duty perversely led to greater ‘drunk and disorderly’, might it also constitute evidence for a
problems. Production was driven underground. Over the defence against more serious crimes? Self-induced intoxica-
next 15 years, the Act was revised, lowering the duty but tion is generally no defence to a criminal charge, and, explic-
restricting availability. Consumption eventually fell. The itly, may not be raised in respect of crimes of basic intent
principle of imposing a duty on the sale of alcohol and (Majewski). In England and Wales, however, it may, rarely, be
requiring producers and retailers to be licensed, at a cost, raised as a defence or mitigation if it can be shown that the
has been retained ever since, with a consequent tension defendant was so intoxicated as to have been unable to form
between the health of the population and the health of the the specific intent necessary for the crime (Beard). Beard was
economy. extremely drunk and suffocated a young girl while raping
her. It was ruled that he lacked the mens rea for murder and
The most recent legislation for England and Wales was convicted instead of manslaughter. A North American
is the Licensing Act 2003. It covers a range of ‘licensable mock court room study showed that volunteer jurors there
activities’, including the sale and supply of alcohol, the pro- readily rejected the intoxication defence, and emphasized
vision of regulated entertainment, and the provision of late the personal responsibility of the defendant for his or her
night refreshments. It brought relaxation of previous licens- actions even when intoxicated (Golding and Bradshaw,
ing laws, permitting citizens and visitors the ‘opportunity to 2005). This is formally recognized in Dutch law, where there
enjoy themselves with a drink or a meal at any time’ (Home is a concept of culpa in causa: an individual is responsible for
Office, 2000, p.5). As before, sale of alcohol was restricted to his/her actions under the influence of alcohol because he is
licensed premises, but with without nationally prescribed expected to know the effects of alcohol before s/he drinks.
opening hours. Alcohol may be sold 24 hours a day, 7 days Scottish law similarly is less concerned with the ability to
per week. form intent than the actual harm caused.

The legal age for purchasing and drinking alcohol in Alcohol and defences when charged
licensed premises is 18 years, although 16 and 17 year olds with a crime
are permitted to drink it if less than spirit strength with Other alcohol-related defences can only be sustained where
meals served at table. Children under 16 may enter licensed it can be shown that there is either cerebral damage
premises only if accompanied by an adult; younger children secondary to the use of alcohol or if the drinking has
may be excluded. Children of 5 years and over are allowed become involuntary, e.g. Tandy. When an alcoholic mother
alcohol, but not on licensed premises. Children under 5 appealed a conviction for the murder of her 11-year-old
years old may be given alcohol only on medical order. daughter, the court ruled that alcoholism could only qualify
as a disease of the mind if the drinking were involuntary.
In conjunction with longer drinking hours, govern- This state would only be recognized if the first drink of the
ment goals for the Licensing Act 2003 included reduction day were involuntary. It is, though, apparent that the ‘first
in crime and disorder and improved domestic and public drink of the day’ test is an arbitrary criterion with which to
safety, the rationale being that the risk of intensive bouts of identify alcohol dependence.
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

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Addictions and dependencies: their association with offending

Mental health legislation and alcohol held for violent offences. McMurran (2005) used the AUDIT
The earliest legislation enacted to control public drunken- with a much smaller sample of male prisoners, and found
ness was the Habitual Drunkards Act 1879, which allowed that those convicted of alcohol-related violence were the
for voluntary inpatient treatment at designated ‘retreats’ most extreme drinkers.
for up to 2 years. The Inebriates Act 1898 followed, allowing
for the compulsory detention in a ‘reformatory’ for up to 3 Findings from these cross-sectional studies are aug-
years of any offender found to have been intoxicated with mented by longitudinal studies. In a large New Zealand
alcohol at the time of his/her offence. All such institutions birth cohort (n = 1,265), for example, Fergusson et al. (1996)
had been closed by 1921. found that 15- to 21-year-old heavy drinkers, after control-
ling for shared risk factors such as socioeconomic status,
As scientific acceptance grows that substance dependen- education, and family background, were three times as
cies and misuse disorders, like mental illnesses, have their likely to be violent as light drinkers. Similarly, Farrington
origins as much in genetics and/or physical brain damage (1995) found that heavy drinking at age 18 was predictive
as environmental factors, so mental health legislation has of violent crime in adulthood.
moved away from embracing these conditions as disorders
which might lead to a requirement for detention in hospi- Alcohol and domestic violence
tal or forms of coerced treatment. The Mental Health Act Alcohol is strongly associated with domestic vio-
(MHA) 1959 did not specifically exclude alcohol depend- lence (Leonard, 2001). Gilchrist and colleagues (2003)
ence from its definition of mental disorder, although these found  that nearly half of 336 offenders on probation
grounds were seldom used; the MHA 1983 did if dependency for domestic violence offences had a history of alco-
on alcohol or drugs was the sole presenting condition. Under hol abuse; 73% had consumed alcohol just before the
Section 1(3) this explicit exclusion has been retained in the offence. Fals-Stewart’s (2003) study of drinking and
MHA 2007 revision, notwithstanding the widening of the domestic violence showed that violence to partners was
definition of mental disorder to include almost everything eight times more likely on drinking days than abstinent
else (see also chapter 3). days, with the risk of severe violence 11 times higher on
drinking days. Nevertheless, the role of drinking and
Alcohol and Offending intoxication in domestic violence remains controver-
sial. Little is known about whether partner violence
Alcohol and violence risk decreases after alcohol treatment (O’Farrell et  al.,
In 2007–2008, almost 5 million crimes were recorded by the 2003), and such treatment is unpopular. Many domes-
police in England and Wales; 961,175 (19%) of them were tic violence treatments have emerged from a feminist
crimes of non-sexual violence (Home Office, 2009). It is perspective, where the root cause is seen as the man’s
estimated that around half of violent incidents involve alco- desire to control his female partner (Corvo and Johnson,
hol, with increased alcohol consumption associated with 2003). McMurran and Gilchrist (2008) argued that,
increased violence rates most marked in countries where while power and control may be fundamental to some
binge drinking is a typical pattern (Room and Rossow, domestic violence, interventions to reduce drinking are
2001). Homicide rates are associated with total alcohol important for reducing risk of injury.
sales, most strongly so in northern rather than southern
European countries (Rossow, 2001). Alcohol and sexual offending
Several researchers have reported that between 30 and
Alcohol appears as a problem in all custodial set- 50% of rapists had been drinking at the time of the offence
tings. In a study of 622 men and women in police custody, (Maldonado et  al., 1988; Martin, 2001; West and Wright,
Bennett (1998) identified 25% testing positive for alcohol, 1981), while others have shown that alcohol consumption
a likely underestimate since those who were unfit to be by convicted rapists and child molesters is significantly
interviewed through drink or drugs or posing a threat of higher than that of non-sexually violent offenders (Abracen
violence were not tested. Singleton et al. (1999) examined et al., 2000). Sex offending theories place alcohol variously
pre-imprisonment alcohol use with the AUDIT in a survey in the roles of overcoming internal inhibitions to offend
of prisoners in England and Wales. This 10-item screening (Finkelhor, 1984), interfering with self-regulation (Ward and
tool includes items on quantity, frequency, dependency, Hudson, 1998), and impairing cognitive function (Seto and
and associated problems; scores range from 0–40, with 8 Barbaree, 1995). Emotional loneliness may be a common
the accepted cut-off for hazardous drinking. The Singleton factor that explains both drinking and sexual offending
group found that 63% of sentenced men were hazardous (Abracen et al., 2000). Research testing these putative roles
drinkers, as were 58% of male remand prisoners, 36% of is scarce. Findings from laboratory research are equivocal,
female remand prisoners and 39% of female sentenced but there is evidence that alcohol may disinhibit sexual
prisoners. The hazardous drinkers were typically young
(16–24), single and white, with men, but not women, being

442 © 2014 by Taylor & Francis Group, LLC

Alcohol

arousal (Seto and Barbaree, 1995), and some to suggest that only 7% who had schizophrenia uncomplicated by alcohol
rapists expect drinking to lead them to doing something abuse (Rice and Harris, 1995a). Among 1423 people con-
sexually risky (McMurran and Bellfield, 1993). victed of homicide in a 12-year period in Finland, Eronen
et  al. (1996c) identified 93 with schizophrenia; those with
Alcohol and acquisitive offending uncomplicated schizophrenia had a homicide rate about
Alcohol-related acquisitive crime has received far less seven times that of the general population, but men with
attention than its drug-related counterpart. The ‘economic schizophrenia and comorbid alcoholism were 17 times
necessity’ argument, that ‘addicts’ are driven to purchase more likely to have killed.
expensive drugs, is applied less to heavy drinkers, but drink-
ing and associated activities (e.g. entrance to clubs, taxis) Räsänen and colleagues (1998) did a prospective study
are expensive. Acquisitive offences may also be committed of an unselected Finnish birth cohort (n = 11,017) over 26
under the influence of alcohol, through impaired judgment, years. Using national databases, they calculated the likeli-
but this aspect too has rarely been investigated. hood of offending and recidivism for people with schizo-
phrenia with and without alcohol dependence. There were
Bennett and Wright (1984) studied 121 offenders serv- 51 men with schizophrenia in the sample, 11 of whom were
ing sentences for burglary, and found that over a third dependent on or abusing alcohol. Seven of the 51 had com-
admitted committing their offence under the influence of mitted a violent offence, four with alcohol problems and
alcohol. Bennett (1998) found that 26% of those arrested three without. The men with both schizophrenia and alco-
for burglary tested positive for alcohol, but only 2% of those hol problems were 25 times more likely to have offended
who drank reported offending to get money to buy alcohol. violently compared with increased odds among those with
Arrestees who tested positive for alcohol did, however, uncomplicated schizophrenia of only 3–4. None of the men
accrue over £4,000 per annum by illegal means. McMurran with schizophrenia uncomplicated by alcohol problems
and Cusens (2005) found that, among 126 male prisoners had offended more than twice, while those with both prob-
in England and Wales, 11% of those convicted of violent lems had a 10-fold increase in such recidivism compared
acquisitive offences (e.g. robbery) said that their offending with the general population. The odds seem impressive,
had been to support their alcohol habit, compared with but they rest on just seven men who had been violent as
18% of those convicted of strictly property based offences well as having schizophrenia. Further, the extra elevation in
(e.g. burglary). The former had significantly higher scores rate of violence among people who abuse alcohol as well as
on the AUDIT than those with other motives. having schizophrenia was not borne out by a US study with
much larger numbers in the groups of interest (Tardiff and
Drunk driving Sweillam, 1980); however, as a sample of patients admitted
In the UK, about 15% of road deaths occur when the driver to a pair of US psychiatric hospitals during 1 year in the
is over the legal alcohol limit (Department of Transport, mid-1970s, the sample was highly selected – for treatment.
2012). There is evidence that the relative risk of ­involvement There is no perfect study; population-based samples are
in a fatal vehicle crash increases steadily with increasing doomed to tiny groups of core interest, but larger samples
blood alcohol concentration, for both sexes and all ages, selected for the disorder, the violence or both may be sub-
although the risk is disproportionately increased for young ject to selection biases.
male drivers (Zadok et al., 2000).
Another explanation for discrepancies may be real
Alcohol, Mental Disorder and Offending change over time. McMahon et  al. (2003) analysed all
admissions to England’s high security hospitals between
While associations between schizophrenia, substance mis- 1975 and 1999. During that time, there was a linear increase
use in general, and offending have been extensively inves- in the proportion of people admitted who had been drink-
tigated, this is less true of the more specific relationship ing more than 21 units of alcohol per week in the year prior
between alcohol dependence, schizophrenia and offending. to their index offence. By diagnosis, the highest increase
In their England and Wales prison survey, Singleton et al. was in the psychosis with personality disorder group.
(1999) reported that severe alcohol problems were associ-
ated with mental ill health. Having an AUDIT score of 16 or Alcohol, personality disorder and offending
more increased the odds of having a diagnosed personality Comorbidity between substance misuse disorders and per-
disorder by 2.27, psychosis by 1.75, and neurosis by 1.53, sonality disorders is common, with stronger associations
as measured by the Schedules for Clinical Assessment in between illicit drug use (rather than alcohol) and any per-
Neuropsychiatry (SCAN; WHO, 1992b). sonality disorder and between substance misuse generally
and the cluster B types (e.g. antisocial personality disorder
In a study of 618 offenders in Canada, 26% of those (ASPD), borderline personality disorder (BPD)) (Verheul
with schizophrenia who abused alcohol were violent, but et al., 1995). Among substance misusers, co-occurrence of
ASPD is twice as common in men as women, and most

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Addictions and dependencies: their association with offending

likely in those who use both alcohol and illicit drugs (Flynn alone was found to be 14%, although rather higher in the
et  al., 1996), while severity of substance misuse is associ- psychosis–personality disorder comorbid group (Taylor
ated with multiple abnormal traits (Cecero et  al., 1999). et al., 1998); Corbett et al. (1998) gave a rather similar figure
Mood disorders often further complicate the picture, being (18%) in another, with 4.5% being illicit drug dependent
about three times more common among substance misus- and 6.4% alcohol dependent. Coid et  al. (1999), studying
ers with a personality disorder than those without (Kokkevi other secure settings, offered much higher figures; 53% of
et al., 1998); they are also related to severity of the depend- patients with personality disorder were judged as having
ence (Cecero et  al., 1999); alcohol misuse, alone or with a lifetime alcohol misuse diagnosis, and 47% were consid-
illicit drugs, has also been associated with anxiety disorders ered to have a lifetime drug misuse diagnosis. There are a
(Flynn et al., 1996). number of possible reasons for such apparent discrepan-
cies. Some studies, as the Taylor group, stick strictly to
Rates of substance misuse and personality pathology diagnostic concepts, whereas others depend more heavily
comorbidity are so high that some are concerned that on amounts of substance used. A more likely explanation
this conceptualization is tautologous (Rounsaville et  al., for the substantial differences described here, however,
1998); however, even when substance-related symptoms lies in changing habits over time. Many of the high security
are excluded from the criteria for personality disorder hospital residents were last in the community when avail-
diagnoses, such comorbidity is only somewhat lowered ability of substances was much lower, indeed observation
(Rounsaville et  al., 1998; Verheul et  al., 1995). This sug- of admission cohorts over time, confirms that rates of
gests that personality disorder diagnoses are not simply substance misuse in the year prior to admission were very
surrogates for substance abuse, or vice versa. One way significantly higher in the 1990s than the 1970s (McMahon
of unpicking the association with ASPD particularly is to et al., 2003).
separate its likely components, for example as in the anti-
social behaviour and the affective coldness dimensions on Treatment gains are generally less in people who misuse
the Psychopathy Checklist – Revised (PCL-R; Hare, 2003). substances and also have personality disorder than those
In one study, those with a diagnosis of ASPD had a higher without personality disorder, yet in both groups treatment
rate of alcohol problems, drug problems, and criminal does lead to reduced substance misuse and symptoms
activity than those with a high PCL-R score (Windle, 1999). over time (Brooner et al., 1998; Cecero et al., 1999; Kokkevi
Smith and Newman (1990), studying low security prisoners, et al., 1998; Linehan et al., 1999). Treatment for substance
showed that substance misuse was related to the PCL-R misuse may also have different effects according to per-
antisocial lifestyle dimension (Factor 2) rather than the sonality type; it has been shown to reduce crime in those
affective dimension (Factor 1). with ASPD, although not those with BPD (Hernandez-Avila
et  al., 2000). People with comorbid personality disorder,
A comparison of alcohol-dependent, violent offenders particularly ASPD, are more likely to drop out of treatment
with and without ASPD yielded two subgroups (Tikkanen for substance abuse, but there is evidence that this may
et  al., 2007). The smaller (20% of the sample) were high actually be related to comorbid depression rather than
scorers on the PCL-R and demonstrated low harm avoid- personality disorder (Kokkevi et al., 1998). Since treatment
ance but were responsible for fewer acts of impulsive vio- completion is important to a good outcome, it is crucial
lence; only half fulfilled diagnostic criteria for ASPD. The to assess for and treat depression in substance misusers,
majority (80%) showed high harm avoidance but higher with or without personality disorders; withdrawal from
levels of impulsive behaviour, and were more likely to have substances may be a cause of low mood, but does not
ASPD or BPD. A study of offenders followed for an average preclude depressive illness. People with ASPD often com-
of 8 years after discharge from a maximum security institu- plete substance abuse treatment when that treatment is
tion, either psychiatric hospital or prison, yielded similar compulsory, in which case they too show good outcomes
findings. Overall, alcohol abuse was associated with violent (Hernandez-Avila et al., 2000).
recidivism, but high PCL-R scorers were the most likely to
be violent recidivists and, in their case, alcohol abuse did Alcohol, intellectual disability and offending
not add to the accuracy of violence prediction (Rice and Reviews of alcohol use among people with intellectual
Harris, 1995a). If violent people who get high scores on the disability suggest that their problematic drinking rates are
PCL-R are likely to be violent with or without taking alco- low, but when they do use alcohol their risk of misuse is
hol, then treatment of alcohol misuse is unlikely to reduce high (McGillicuddy et al., 1998). In many respects, alcohol
their violence. After treatments to reduce violence, how- misusers  with intellectual disability are similar to their
ever, control of substance misuse remains important, not peers without it; most are men, living alone, more likely
only on health grounds, but also so that unchecked abuse to smoke tobacco, use soft drugs, experience consequent
does not interfere with other treatment gains. work problems and get into trouble for offences such as
public intoxication, disturbing the peace, assault, indecent
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

444 © 2014 by Taylor & Francis Group, LLC

Alcohol

exposure, breaking and entering, and driving whilst intoxi- patient does not drink alcohol during the detoxification
cated (Krishef and DiNitto, 1981; McGillicuddy and Blane, regime, but s/he sometimes does.
1999).
Outpatient detoxification is possible for people who
Treatment of Alcohol Problems are moderately dependent (Bennie, 1998). Daily collection
of medication gives an opportunity to check for signs of
Voluntary versus compulsory treatment withdrawal or alcohol consumption and to give encourage-
Compulsory treatments for alcohol problems may be effec- ment and advice. Inpatient detoxification is indicated for
tive (Sullivan et  al., 2008), although positive outcomes for those with a history of withdrawal fits, delirium tremens,
compulsory treatment of offenders may only be evident early signs of encephalopathy, who lack social support and/
in community settings (Parhar et  al., 2008). Gregoire and or who are unlikely to remain abstinent during the detoxi-
Burke (2004) used a measure of ‘readiness to change’ to fication. The same criteria may be used to identify those
study motivation in a mixed group of substance misusers, in prison who can be safely detoxified on normal location
41% of whom were abusing alcohol. Their study suggested and those who need to be admitted to the healthcare/detox
that treatment under a compulsory order was associated unit.
with increased motivation to change during treatment.
Adequate management of withdrawal should reduce
Detoxification the likelihood of withdrawal fits and delirium tremens
Once alcohol dependence has become established, the (DT). If fits do occur, then diazepam should be given either
brain physically adapts to the presence of the depressant by slow intravenous injection or per rectum. If DT becomes
effects of alcohol. In consequence there are compensatory established then the patient should be nursed in a low
changes in brain chemistry, which lead to over-activity stimulus environment and fluid balance closely monitored
when alcohol is withdrawn. For those who are only mildly and supported as necessary. Oral rather than parenteral use
dependent, cessation of alcohol may be possible by gradual of a shorter acting benzodiazepine, possibly with a neuro-
reduction of alcohol consumption. However, those drinking leptic, may be helpful. Attempts should be made to identify
more than 15 units per day are likely to need some form of any contributory medical conditions such as head injury,
pharmacological support to control withdrawal symptoms. hypoglycaemia, hepatic failure, gastro-intestinal bleeding,
Detoxification is the process of substituting alcohol with liver failure or infection, through full physical examination
a reducing course of medication to alleviate withdrawal and regular checks of body temperature, blood glucose and
symptoms and prevent the associated seizures. electrolytes. If the patient becomes agitated then paren-
teral sedation (IV diazepam and/or IM haloperidol) may
Benzodiazepines have become the treatment of choice be indicated.
in detoxification, since they relieve withdrawal symptoms
and have good anti-convulsant properties. A reducing Pharmacological agents promoting abstinence
course over 5 to 7 days is generally adequate. The two ●● Disulfiram (Antabuse) is the most established agent
drugs most often used are chlordiazepoxide and diaz- designed to promote sobriety. The two newer agents
epam, although the latter has a greater street value. These (acamprosate and naltrexone) have only been studied as
two drugs have long half-lives and, therefore, theoretically adjuncts to psychosocial interventions. Comparison of out-
have less mood altering effects and less addictive poten- come data between these drugs is difficult as the trials used
tial than short-acting agents such as lorazepam. A typical different end points and outcome measures.
starting dose of chlordiazepoxide is 20 mg three to four
times a day, and of diazepam 15 mg four times per day. Disulfiram blocks the liver enzyme aldehyde dehy-
Doses may be doubled (with longer reducing courses) in drogenase. After consumption of alcohol, blockade of
adult men who are severely dependent (consuming over this enzyme results in the accumulation of acetaldehyde.
40 units per day); such doses are not recommended for Resultant signs include: flushing, nausea, vomiting, head-
women or the elderly. Higher doses are also required for ache, tachycardia and palpitations. After a large alcohol
those with a history of dependence on both alcohol and load the reaction can be severe, resulting in hypertension,
benzodiazepines. Small does of lorazepam, with a shorter circulatory collapse and death. The enzyme is effectively
half-life, are preferable for people with established liver blocked after several days of disulfiram at a daily dose of
impairment, who should be inpatients due to their risk 100–200 mg. The reaction is so aversive that disulfiram acts
of fatal accumulation of benzodiazepines if their metabo- as a deterrent from further drinking, although it may also
lism is compromised. Chlormethiazole had previously deter the individual from taking further disulfiram if s/he is
been a popular drug here, but it may cause fatal respira- determined to continue drinking. The drinker needs only
tory depression if taken with alcohol, and has a greater one tablet in the morning to know that s/he is effectively
addiction potential if abused. It is important that the 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

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Addictions and dependencies: their association with offending

data to show that it is associated with reduction in the 12-step programme in reducing drinking (Project MATCH
number of drinking days and the amount of alcohol con- Research Group, 1997). A review of motivational interview-
sumed but not an increase in abstinence (Garbutt et  al., ing interventions with offenders indicated that it can lead
1999; Hughes and Cook, 1997). Supervised consumption to improved retention in treatment, enhanced motiva-
enhances its efficacy. In a naturalistic follow-up study com- tion to change, and behaviour changes (McMurran, 2009).
paring patients attending a disulfram clinic, those patients ●● Behavioural self-control. Like motivation to change, self-
compelled to attend under a court order were significantly control is not a trait, but rather the likelihood of drinking
more likely to attend than those under voluntary arrange- in response to a range of physical, emotional, and psycho-
ments (61%:18.2%) (Martin et al., 2004). logical triggers that are associated with drinking. The task
●● Acamprosate. A number of meta-analyses have found in therapy is to teach the user to identify the triggers for
acamprosate to be superior to placebo on a variety of absti- drinking, control urges to drink, and develop coping strate-
nence-related outcomes (Lingford-Hughes et  al., 2004), gies. Behavioural self-control training has proved effective
although its mode of action is still not clear. Verheul and as a component of intervention for alcohol problems (see
colleagues (1999) hypothesize that it works by reducing Miller, 1992), and is now core practice in many cognitive
craving for alcohol. It should be started as soon as possible behavioural interventions.
after stopping alcohol for people who are aiming for absti- ●● Cognitive coping skills. Cognitive coping includes
nence, ideally in combination with psychosocial interven- micro-skills, such as positive self-talk and self-instruction
tions. It has some gastro-intestinal side effects (diarrhoea (Meichenbaum, 1977). Positive self-statements are taught
and nausea). to assist people to cope with cravings (e.g. ‘This feeling
●● Naltrexone is an opioid antagonist, which is not licensed won’t last’; ‘I don’t have to use’) and avoid the goal violation
for marketing for the treatment of alcohol dependency, but effect (‘A lapse does not have to become a relapse’). Self-
it may be prescribed. Some drinkers report that it reduces instruction involves the construction and use of scripts to
the high they associate with alcohol, and this is why it may use as an internal commentary to support implementation
be prescribed (Ulm et al., 1995). Several meta-analyses have of new coping skills. Alcohol outcome expectancies require
suggested that it is better than placebo on a number of both attention to moderate positive outcome expectancies,
outcomes but there are studies which have not found this. such as improving social confidence, and to diminish the
The British Association for Psychopharmacology guidance strength of associated criminogenic beliefs, for example
on the management of substance misuse gives a good sum- that sexually risky behaviour or violence will happen after
mary of the evidence (Lingford-Hughes et al., 2004). There drinking (McMurran and Bellfield, 1993; Quigley et  al.,
is some evidence that it reduces the risk of relapse to heavy 2002). Training in problem-solving skills is usually integrat-
drinking (Garbutt et al., 1999).  ed into CBT to teach strategies for increasing independent
functioning.
Psychosocial interventions for alcohol misuse ●● Interpersonal skills. Peer pressure to drink may be
Cognitive behavioural treatments are particularly well tackled by teaching assertion and refusal skills, but must
suited to helping people gain control over drinking behav- be augmented by helping people resist the desire to fit in
iours. The key components are motivation enhancement, with their drinking peers. The ability to make and sustain
behavioural self-control, cognitive coping skills, interper- satisfying relationships is important for maintenance of
sonal skills, relapse prevention, and lifestyle change. treatment gains; interpersonal conflict is a potent risk
●● Motivation enhancement. Motivating substance users relapse factor (Marlatt, 1996). Interpersonal skills which
to engage in treatment has long been acknowledged as will generally benefit from attention include negotiation
the key to treatment effectiveness. Miller (1985) argued and conflict resolution.
that motivation to change should be viewed as a dynamic ●● Relapse prevention. Marlatt and Gordon (1985) rede-
state, and the task of therapy should be to alter both fined relapse as a process, rather than an event. Marlatt
internal and external factors to increase the probability (1996) identified several risk factors for relapse into
of the person actively engaging in the treatment process. drinking which require specific attention to increase the
Motivational interviewing (MI) is a strategic counselling chances of maintenance of change. Relapse prevention
technique which has been developed from this position (RP) teaches participants to identify and cope with high-
(Miller and Rollnick, 2002). Its aims are to help the user to risk situations, for example by avoiding or escaping from
move from ambivalence to change towards taking action, cues that trigger cravings or urges, and learning to cope
based upon a spirit of collaboration between therapist and with them if they happen. RP helps people limit the goal
user, and drawing on his/her own capacity and resources violation effect, which occurs when a minor lapse (e.g.
for change. In Project MATCH, a four-session motivational one drink) turns into a full-blown relapse (e.g. the whole
enhancement therapy worked as well for most people as bottle). Relapse rehearsal enhances self-effectiveness
12 sessions of either cognitive behaviour therapy (CBT) or a

446 © 2014 by Taylor & Francis Group, LLC

Alcohol

through developing the ability to imagine coping in a Alcoholics Anonymous (AA)
high risk situation. RP may also tackle broader issues, AA is a worldwide self-help network based on a simple set
such as social support for change, stress management, of principles offering life-long support to the recovering
lifestyle balance, and positive substitutes for the addic- alcohol-dependent drinker. Alcoholism is described as a
tive behaviour. In a review of clinical trials, Carroll (1996) disease ‘like an allergy to alcohol’. Members are encour-
found RP to be more effective than no treatment for sub- aged to avoid the first drink, as their condition can never
stance misuse, but not convincingly superior to other be cured, only arrested by absolute sobriety.
active interventions. There was evidence of a delayed
effect, where RP reduced the severity of lapses when they The AA meeting is central. Meetings have a set format,
did occur, and that RP was more effective with severely which includes one or two testimonies from recovering
impaired substance users. alcoholics highlighting the problems associated with their
●● Lifestyle change. Sustaining a non-substance using, former drinking life, the moment when they decided to
non-criminal life may also require general changes in seek sobriety and the positive contribution AA has had in
accommodation, work, leisure activities, social networks, supporting that sobriety. This leads to contributions from
and close relationships; promoting abandonment of the the floor, as those present identify with each speaker’s
‘addict’ or ‘criminal’ identity can promote commitment to experiences and encourage further sobriety. Meetings may
a new lifestyle. be held in prisons and hospitals, secure or not, or the wider
community. Meetings are open to those who are only
General versus specific programmes recently abstinent and those who have not drunk for many
for alcohol misusers years, and this mix is an important feature of AA, providing
Generic programmes that help people to reduce or role models for newcomers and allowing those who have
stop drinking may be effective also in reducing crime. been abstinent for many years to revisit the AA principles
Programmes aimed at specific alcohol related offences (the 12 steps) in their role as mentors.
may, however, be useful in some cases. Intoxicated aggres-
sion requires the integration of treatments for anger and The first of the 12 steps is to ‘admit that we are powerless
aggression with those for alcohol abuse (Graham et  al., over alcohol – that our lives had become unmanageable.’
1998). Treatments for domestic violence also show a con- The second step is to recognize that there is a higher power
vergence of CBT with interventions focusing on drinking that can restore sanity. This religious/spiritual component
(Corvo and Johnson, 2003). A similar combined approach may be off-putting to an atheist, but many AA members do
for drink-drivers has proven effective. A meta-analysis of not interpret this in a religious way, while some see it as the
215 treatment programmes indicated an 8–9% reduction power of the group itself. Vaillant (1995) concluded, after a
in recidivism for treated over untreated participants, long-term outcome study of alcohol dependency, that last-
with the most effective interventions combining edu- ing improvement in an individual’s life was associated with
cation, psychological therapy, and supervision (Wells- a commitment to change and at least one of the following:
Parker et al., 1995). (1) a substitute for the dependency; (2) powerful resources
of self-esteem and hope; or (3) a new stable relationship. AA
Therapeutic communities for alcohol misusers may offer all these.
The aim of therapeutic communities (TCs) is to foster a
functional lifestyle through democratic process, in which A 12-step approach has been shown to be as effec-
residents confront and correct each other’s maladaptive tive as the cognitive behavioural or motivation based
behaviour, offer each other support through the difficult approaches just described. Outcomes at 3-year follow-
change process, and sometimes reward improvement by up  were slightly better with the 12-step approach than
offering those achieving change promotion within the the other two modes for those drinkers who lacked a
community. A ‘concept TC’ is one specifically designed non-drinking support network (Project MATCH, 1998).
for people with substance use problems (Wexler, 1995). In a meta-analysis comparing  AA attendance with other
The abstinence-oriented, 12-step approach of Narcotics treatments and no treatment, however, AA was found to
Anonymous (NA) and Alcoholics Anonymous (AA) has be associated with worse outcomes. It has been suggested
been widely adapted by professionals into concept TCs. TCs that this is because some of those attending AA groups
have also been adapted for correctional settings, where they were obliged to do so and so biased the outcome data
have a good track record, (e.g. in the USA: Wexler and De (Kownacki and Shadish, 1999).
Leon 1997; in the UK: Gunn et al., 1978, Malinowski, 2003,
and Martin and Player, 2000; see also chapters 16 and 25). Treatment in the context of comorbidity
The term ‘dual diagnosis’ is widespread, generally indicat-
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

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Addictions and dependencies: their association with offending

the importance of integrating a number of approaches in mental state and compliance with medication (possibly
order to bring about useful change. It is acknowledged that including disulfiram) but also alcohol-related work.
a balance must be struck between empathy, unconditional
regard and nurturance to develop motivation on the one Other substance misuse
hand, and discipline and structure to foster self-control on
the other (Mueser et al., 2003). A national outcome survey Misuse of psychoactive drugs other than alcohol is
of all 959 patients discharged from UK medium secure units also a cause for concern worldwide. The World Health
in the 12 months after 1 April 1997 demonstrated both the Organization (WHO), for example, has had an Expert
extent of co-occurrence of alcohol problems and illness Committee on Drug Dependence since 1949, which pro-
in an offender-patient population and the association duces regular reports and has a mandatory task, under
between such problems and poorer outcomes (Scott et al., international treaties, to carry out medical and scien-
2004). Patients were classified as having alcohol problems if tific evaluations of the abuse liability of dependence-
there were records of excessive drinking. They were evident producing drugs falling within the terms of the 1961 Single
in 381 people (40%), with similar rates in men and women. Convention on Narcotic Drugs and the 1971 Convention
During the 2-year follow-up period, there was a significant on Psychotropic Substances. It then makes recommenda-
difference in re-conviction rates between those with alco- tions to the United Nations (UN) Commission on Narcotic
hol problems and those without (49%:39% reconvicted). Drugs on the control measures, if any, that it considers
appropriate.
For those with substance misuse diagnoses com-
plicating mental illness, the latter often resolves with Since the late 1990s there has been increasing interest
antipsychotic medication within a secure, drug-free envi- in and awareness of drug problems in the UK, reflected in a
ronment. Ongoing risk is then closely linked to the likeli- raft of policy initiatives, including
hood of further substance abuse, but, since alcohol and ●● Purchasing effective treatment and care for drug misusers
illicit drugs are forbidden in secure settings, and rare
commodities even if the cordon is occasionally breached, (Department of Health (DoH) 1997b);
treatment of the substance problems may not be ade- ●● Clinical guidelines on the management of drug misuse
quately prioritized. O’Grady (2001) argued for better
integration of forensic, general psychiatry and substance and dependence (DoH, 1999c; DoH et al., 2007);
misuse services to tackle this problem, although there is ●● Substance misuse detainees in police custody (3rd edn)
little evidence for the benefits of integrated treatment
(Cleary et al., 2010). (Association of Forensic Physicians and Royal College
of Psychiatrists, 2006);
The Royal College of Psychiatrists’ Research Unit sur- ●● Safer services (NCISH, 1999);
vey of the 28 medium secure units (MSUs) in England ●● Safety first (NCISH, 2001);
(excluding learning disability, personality and adolescent ●● Avoidable deaths (NCISH, 2006);
units) highlighted their inadequacies in tackling substance ●● Tackling drugs to build a better Britain (HM Government,
misuse: 1998);
●● despite security measures, alcohol and drugs had been ●● national drugs strategic statements (HM Government,
2012; Home Office, 2012);
used in every English MSU during the 1-year survey ●● recommendations from the British Association of
period; Psychopharmacology (Lingford-Hughes et al., 2004);
●● of the drugs abused, cannabis and alcohol were thought ●● Drug misuse: Opioid detoxification (National Institute
to cause the greatest problems; for Health and Clinical Excellence (NICE), 2008a);
●● few MSUs had comprehensive treatment services for ●● Psychosocial interventions in drug misuse (NICE, 2007a).
substance misuse;
●● few MSUs employed staff with specialist training in Why is Knowledge About Drug
substance misuse; Misuse so Important to the
●● disagreement regarding the model of care: some units Practising Forensic Clinician?
pursued and abstinence approach, others favoured
controlled drinking (Durand et al., 2005). Drug misusers present in some form to all the major
In the period before a patient’s discharge, controlled drink- specialties in medical practice, perhaps especially acci-
ing or abstinence may be tested out during leave periods. dent and emergency units, general medical and surgical
Ideally, patients should begin to engage with community specialities (Fingerhood, 2000), but forensic, liaison, ado-
support at this stage, such as their future community lescent and old age psychiatry in hospital, community
psychiatric nurse (CPN), alcohol treatment services, or and criminal justice settings are increasingly contributing
AA group, building towards seamless transfer of support to their treatment. Even if the patient presents with a
on discharge. The receiving CPN should not only monitor 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

448 © 2014 by Taylor & Francis Group, LLC

Other substance misuse

present with abstinence syndromes, convulsions, acute outlined in tables 18.1 and 18.2 (ICD-10: WHO, 1992a;
disturbance (psychosis, panic, confusion, perceptual dys- DSM-IV, 1994; APA, 1994). For the purposes of treatment
function), trauma, cancer, or cardiovascular conditions. and management it is helpful to distinguish non-depend-
ent substance misuse from dependent use. In the UK,
What is a Drug? drugs are classified, according to perceived seriousness of
consequences of taking them, under the Misuse of Drugs
In this chapter, the term ‘drug’ will be used to cover illicit Act 1971; the government may change a drug’s classifica-
substances, central nervous system depressants such as tion from time to time as new evidence about its proper-
opiates and opioids (e.g. heroin, methadone), stimulants ties emerges. The current classification according to this
(e.g. cocaine, crack, amphetamine, ecstasy), and LSD, khat act is set out in table 18.3.
and magic mushrooms. It will also be used to describe
street use and non-compliant use of prescription drugs The inter-relationships between physical health,
such as benzodiazepines and non-compliance in use of mental health, and drug misuse are well-documented.
over-the-counter preparations such as codeine-based Apart from the direct effects of drugs on general health
products (e.g. cough medicines, decongestants). (see later), there are indirect effects such as dietary
neglect, impoverishment, trauma, bereavement and
Clinical experience and a growing literature base indi- loss. Malnutrition, for instance, may emanate from
cate that people may use a combination of licit and illicit drug-induced anorexia, malabsorption and/or economic
substances, as well as prescribed and over-the-counter deprivation. Liver dysfunction, for example with HIV,
medications used both compliantly and non-compliantly. hepatitis B or C, produces psychological as well as physi-
Patients may borrow and/or share drugs, may not report cal problems.
all medications, may use out-of-date drugs, may take foods
and drugs that interact, and may store drugs inappro- Psychiatric conditions such as anxiety, depression,
priately. This complexity, and so-called polypharmacy or post-traumatic stress disorder, drug-induced psychosis,
polydrug misuse is a particular issue in older people who schizophrenia, delirium, and dementia may lead to, be a
have physical or psychological comorbidity. ‘Misuse’ may consequence of, or coincide with drug misuse. Withdrawal
be the result of lack of judgment, misconceptions about from barbiturates and benzodiazepines leads to delirium,
the drug(s), inability to purchase medications, inability whereas head injuries and serious infections are associ-
to manage the combination of medications (perhaps due ated with dementia. The differing mechanisms and types
to memory problems) or patients may be intentionally of relationship require careful history-taking and judi-
using medications for purposes other than those intended. cious interpretation. Depression, dementia, delirium and a
Unravelling all this is what makes this work challenging heightened risk of suicide are probably the problems most
and stimulating! commonly faced by clinicians. Some of these conditions are
associated with chronic pain and sleep disorders, which
Concepts of Harmful Use may be the problems which made the patient seek relief
and Dependence from prescription and non-prescription medications in a
non-compliant way. Since there are effective interventions
Criteria for the diagnosis of substance problems from for many psychiatric conditions, correct diagnosis and
both main current disease classification systems are treatment have real benefits.

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 A pattern of psychoactive substance use that is causing damage to health.
impairment or distress, as manifested by one (or more) of the following The damage may be physical or mental
occurring within a 12-month period
(1) Recurrent substance use resulting in a failure to fulfil major role Actual damage should have been caused to the physical or mental health
obligations at work, school, or home 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 Acute intoxication not in itself evidence. Should not be diagnosed if…
or interpersonal problems caused or exacerbated by the effects of the another specific form of drug- or alcohol-related disorder is present
substance
(B) Symptoms have never met the criteria for Substance Dependence for
this class of substance

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Addictions and dependencies: their association with offending

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 A cluster of physiological, behavioural and cognitive phenomena. [...] A
impairment or distress, as manifested by three (or more) of the following, definite diagnosis should usually be made only if three or more of the
any time in the same 12-month period following have been experienced or exhibited at some time during the
previous year
(1) tolerance, as defined by either (1) a strong desire or sense of compulsion to take the substance
need for markedly increased amounts of substance to achieve intoxication
or desired effect, or (2) difficulties in controlling substance-taking behaviour in terms of its
markedly diminished effect, with continued use of the same amount of onset, termination, or levels of use
the substance
(2) withdrawal, as evidenced by either of the following: (3) a physiological withdrawal state when substance use has ceased or
the characteristic withdrawal syndrome for the substance, or been reduced, as evidenced by:
the same (or closely related) substance is taken to relieve or avoid the characteristic withdrawal syndrome for the substance
withdrawal symptoms or
(3) the substance is often taken in larger amounts over a longer period use of the same (or closely related) substance with the intention of
than was intended relieving or avoiding withdrawal symptoms
(4) evidence of tolerance, such that increased doses of the psychoactive
(4) persistent desire or repeated unsuccessful efforts to cut down or substance are required in order to achieve effects originally produced by
control substance use lower doses
(5) progressive neglect of alternative pleasures or interests because of
(5) a great deal of time is spent in activities necessary to obtain the psychoactive substance use, increased amount of time necessary to obtain
substance, use the substance, or recover from its effects or take the substance or to recover from its effects
(6) persisting with substance use despite clear evidence of overly harmful
(6) important social, occupational, or recreational activities given up or consequences (physical or mental)
reduced because of substance use
(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 Example drugs1 Maximum penalty Supply
Class A Possession 6 months and £5,000 fine
Cocaine and crack cocaine ecstasy, heroin, LSD, Magistrates’ court Life, an unlimited fine or both
Class B methadone, methamphetamine, magic mushrooms, any 6 months and £5,000 fine 6 months and £5,000 fine
Class B drug which is injected Crown Court 14 years, a fine or both
Class C 7 years, an unlimited fine or both 3 months and £2,000 fine
Amphetamine, barbiturates, codeine Magistrates’ court 14 years, a fine or both
3 months and £2,500 fine
Cannabis2, ketamine, anabolic steroids, minor Crown Court
tranquillizers 5 years, a fine or both
Magistrates’ court
3 months and £500 fine
Crown Court
2 years, a fine or both

1These are examples and reference should be made to amendments to the legislation, which are accessible online: http://www.legislation.gov.uk/all?title=drugs/
2Cannabis 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.

Epidemiology of Illicit Drug Use England and Wales, about one-third of the population
have admitted to illegal drug misuse in the year prior to
The UK has among the highest levels of substance mis- rating. The British Crime Survey, a household interview
use in Europe and illicit substance misuse is a substan- study, found in 2006/7 that 35.5% of 16–59 year olds (11¼
tial problem. In post-millennium surveys carried out in

450 © 2014 by Taylor & Francis Group, LLC

Other substance misuse

million) had used one or more illicit drugs in their lifetime, an average of at least one crime a day, compared with
10% had used one or more illicit drugs in the year (¾ mil- 3% of other arrestees;
lion) and 5.9% (2 million) in the month prior to interview ●● between one-third and one-half of all new receptions to
(Murphy and Roe, 2007). Four and a half million (13.8%) prison are estimated to be problem drug users (about
reported use of Class A drugs at least once in their lifetime, 45,000–65,000 prisoners in England and Wales);
1 million (3.4%) in the previous year, and 500,000 (1.7%) ●● drug-related crime costs an estimated £13.5 billion in
in the previous month (Murphy and Roe, 2007). Cannabis England and Wales alone (UKDPC, 2008).
was the most likely drug to have been taken, having been In addition, illicit drugs as well as alcohol play a role in
used by 8.2% of these 16–59 year olds, followed by cocaine about 45% of homicides. One in six homicides is commit-
(powder or crack), which was used by 2.6%. Class A drugs ted by a person with severe mental illness who was abusing
had been used by proportionately more people during substances (Shaw et al., 2006).
the year prior to interview in 2006/7 than in 1998, but the
proportion using any illicit drug in the previous year was Mortality
lower in 2006/7 than in 1998.
Premature mortality is high among substance misusers
Young people generally report higher levels of drug use (Ghodse et  al., 1998; Lind et  al., 1999); illicit drug misuse
than older people, but Class A drug use among young peo- is responsible for approximately 3,000 deaths each year,
ple has remained stable since 1998 and the reported use of although in numerical terms deaths from legally available
any drug in the previous decade actually fell in the 16- to substances are even higher (in England and Wales 120,000
24-year-old age group. Over the course of their lifetime, deaths annually from smoking-related disorders and 40,000
2¾ million (44.7%) young people aged 16–24 had used an from alcohol-related disorders). The mortality associated
illicit drug, 1½ million (24%) had used an illicit drug in the with alcohol and drugs is between nine and 16 times higher
previous year, and 1 million (14.3%) in the previous month. than in the general population and substance misuse is a
One million (16.3%) had used a Class A drug during their very strong predictor of completed suicide (Marsden et al.,
lifetime, 500,000 (8.1%) in the previous year and 250,000 2000; NCISH, 2006, 2001, 1999; Weaver et  al., 2003; Wilcox
(4.3%) in the previous month. Young women are one and a et al., 2004). In England and Wales, 33% of inpatient suicides
half to three times more likely to use substances than older have a history of alcohol misuse and 30% a history of drug
women. International studies demonstrate that about misuse, while 41% of suicides in the community have a his-
20–25% of women in younger age groups have used illicit tory of alcohol misuse and 28% a history of drug misuse
drugs in the past year. (NCISH, 2001). The Confidential Enquiry into Maternal
Deaths in the UK from 2002–2004 found that, when all
One of the problems in planning services for drug deaths up to 1 year from delivery were taken into account,
users is the considerable country and regional variation in 8% were caused by substance misuse (Lewis, 2004).
drug use overall and in choice of specific drugs, so some
local knowledge is essential. When comparing English Morbidity
Government Office Regions and Wales with each other, for
example, according to the 2006/07 British Crime Survey, Alcohol, drugs and nicotine affect all organs of the body
the South West (11.1%) and the North West (11.0%) had and the interactions of substance misuse with health
the highest levels of any drug use while the West Midlands are multiple and complex. Effects may be very rapid or
(9.2%) and the Eastern region (9.1%) had the lowest levels. insidious, and by a direct pharmacological or physiologi-
Class A drugs were nearly twice as likely to be used in the cal action or indirectly due to associated behaviours. As
highest regions (North East: 4.1%; North West: 4.0%) as in with alcohol, the acute effects of intoxication with illicit
Wales (2.5%) (Murphy and Roe, 2007). drugs, the impact of chronic use and the development of
withdrawal and dependence may lead to an array of physi-
Problem drug users are much more likely to be found cal and psychological problems and social consequences.
within the criminal justice system than in the general Dependence on some substances develops very rapidly,
population. A review commissioned by the UK Drugs Policy within weeks or months. These conditions may be related
Commission (UKDPC) reported that: to high-risk behaviours such as injecting, needle shar-
●● at least 1/8 arrestees (equivalent to about 125,000 peo- ing, unsafe sex and the use of substances to the point of
intoxication. Psychological symptoms or signs, including
ple in England and Wales) are estimated to be problem hallucinations, mood change, impulsivity, aggression and
heroin and/or crack users, compared with about 1/100 disinhibition or psychiatric syndromes, such as anxiety,
among the general population; depression, psychotic illness, post-traumatic stress disor-
●● of arrestees who used heroin and/or crack at least der, personality disorder or eating disorders are all among
once a week, 81% said that they had committed an the risks of use. Self-harm may result, with eventual suicide.
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

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Addictions and dependencies: their association with offending

These difficulties may lead to homelessness, unemploy- In the UK, Weaver et al. (2003) examined mental illness
ment, poverty and criminality, as well as disengagement and substance misuse presenting to community mental
from families, communities and services. Patients with health teams and substance misuse services. Forty-four
comorbid conditions have poorer prognosis and place a per cent of patients in community mental health teams
heavy burden on services because of higher rates of relapse reported substance misuse in the previous year, while 75%
and re-hospitalization, serious infections such as hepatitis of drug service patients and 85% of alcohol service patients
and HIV, and/or prostitution, violence, arrest and even had suffered from a psychiatric disorder in the previous
imprisonment. All substance misuse, but perhaps espe- year. In England and Wales, one-third of suicides in the
cially multiple use, must be seen in the context of its social community have a history of alcohol and/or drug misuse
as well as its medical difficulties (Little et  al., 2005; Okah (NCISH, 2001). A recent Canadian psychological autopsy
et al., 2005; Velez et al., 2006). study (Séguin et al., 2006) demonstrated that 90% of people
who complete suicide suffer from comorbid mental disor-
Comorbidity is a term used to describe the co-occur- ders, mainly mood disorders and substance misuse.
rence of psychiatric disorder and substance misuse
(Banerjee et al., 2002; Crome and Day, 2002; Day and Crome, In 1997 the Office for National Statistics (ONS) under-
2002; Waller and Rumball, 2004). Chronic use or intoxica- took a survey of psychiatric morbidity among 3,000 remand
tion with depressant drugs, or withdrawal from stimulants and sentenced prisoners aged 16–64 in England and Wales
produce symptoms similar to depression, while acute (Singleton et  al., 1998; see chapter 25 for more detail). A
intoxication from stimulants and cannabis may mimic a high proportion, particularly of the men, had substance
schizophrenic illness. Withdrawal from depressant drugs misuse disorders. Prisoners with antisocial personality
may result in symptoms of anxiety, panic, and even con- disorder were over six times more likely than the others
fusional states. The difficulty for the clinician is, therefore, to report drug dependence in the year before coming to
the extent to which the presentation is a simple drug effect prison, though without a detailed chronology there may
and the extent to which there is an additional independent be a risk of over-diagnosing such comorbidity (Kaye et al.,
mental disorder. An association between drug use and psy- 1998).
chiatric conditions has been consistently documented in
substance misusing clinical populations, psychiatric popu- In Greece, male drug users from community treatment
lations, the general population, prisons, and among the services were compared with male prisoners registered as
homeless. Indeed, in the US Epidemiological Catchment drug dependent in the previous 12 months (Kokkevi and
Area (ECA) study, drug addiction was associated with a Stefanis, 1995). Lifetime affective disorders (32%:20%, p = 0.10)
53.1% lifetime rate of an additional mental disorder (Regier and anxiety disorders (53%:14%) were more prevalent among
et al., 1990). drug users recruited from treatment services than among
drug users in prison, while ASPD was more prevalent among
In any patient the following hypotheses for association prisoners (76%:61%), suggesting considered service selection
between apparent mental illness and substance use should biases.
be considered:
●● a primary psychiatric and/or physical illness may pre- Current UK legislation on Drugs

cipitate or lead to a substance problem; Most countries have legislation to limit the production,
●● substance misuse may worsen or alter the course of a administration, use, supply, import and export of certain
drugs. They differ considerably, but here discussion will be
psychiatric and/or physical illness; confined to UK law.
●● intoxication and/or substance dependence may lead to
Misuse of Drugs Act 1971 and its amendments
psychological and physical symptoms; This act, which evolved from a series of UK legislative inter-
●● substance misuse and/or withdrawal may lead to psy- ventions, is designed to control the use of certain drugs
that are viewed as having medical applications. It has been
chiatric or physical symptoms or illnesses; the subject of many amendments since the original version
●● it is no longer possible to tell which came first but each in 1971, which can be found online: (http://www.ukcia.org/
pollaw/lawlibrary/misuseofdrugsact1971.php).
contributes to a cycle of deterioration.
Practitioners working with substance misusers need to be It first classified drugs into three categories (A, B and C;
aware that substance misusers may have vascular, infec- see table 18.3) and defined the penalties for their production,
tious, carcinogenic or traumatic conditions directly related supply and possession. A 2001 amendment to the Act created
to their misuse. life-saving measures could be required. For the offence of ‘knowingly allowing premises’ owned or man-
these reasons, it is vital to establish whether recent sub- aged by a person to be used for the unlicensed production,
stance use, including the types, quantities, route and the use or supply of any controlled drug. In England and Wales,
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.

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Other substance misuse

cannabis and cannabis resin were reclassified from Class Mental health legislation
B to Class C from 2004, after the Criminal Justice Act 2003 Throughout the UK, mental health legislation explicitly
amended the Misuse of Drugs Act 1971. This amendment excludes compulsory detention in hospital on grounds solely
also increased the maximum penalty for trafficking in Class C of substance misuse or dependence. The expectation gen-
drugs, from 5 to 14 years. Cannabis is being considered by the erally is that people must engage voluntarily in treatment.
UK government for reclassification back to Class B, despite Community-based coercion into treatment or rehabilitation,
advice to the contrary given by the Advisory Council on the incorporating regular drug testing, is confined to convicted
Misuse of Drugs ((ACMD), 2008; Home Office, 2012). offenders. In England and Wales they may receive a Drug
Testing and Treatment Order (DTTO) under the Crime and
The Misuse of Drugs Regulations 2001 Disorder Act 1998, or more likely now, a Drug Rehabilitation
These regulations cover the overlap between the Misuse of Requirement Order (DRRO) in conjunction with a community
Drugs Act 1971 and instances where there are legitimate sentence or suspended prison sentence under the Criminal
medical applications of controlled drugs. These regulations Justice Act 2003.
further classify drugs into schedules to reflect the degree of
control over possession, use, prescribing and supply, sum- Drugs and Crime
marized in table 18.4.
The association between drug use and criminal behaviour
Medicines Act 1968 varies in terms both of strength of association and of sever-
The manufacture, supply and prescription of medicinal ity of the behaviour. A simple classification of crime catego-
drugs are also controlled by the Medicines Act, which has ries and the strength of association with drug use has been
undergone many amendments since 1968. Such drugs are constructed (Parker and Bottomley, 1966); it recognizes five
classified into prescription only drugs, pharmacy sales patterns:
drugs and general sales drugs. There is a complex overlap ●● Type A: Drug users who rarely commit crimes and
with the regulations of the Misuse of Drugs Act, particularly
with regard to the possession of some minor tranquillizers. offenders who rarely use drugs.
●● Type B: Acquisitive criminal behaviour to fund drug
Some drugs, such as heroin and LSD, can only be pre-
scribed by doctors who possess a specific licence. Other use.
drugs, such as schedule 3 and schedule 4, part 1 benzodiaz- ●● Type C: Drug supply for financial gain.
epine tranquillizers may be prescribed by any doctor, but it ●● Type D: Criminal acts committed as a result of the psy-
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 chotropic effect of drugs.
to another person. ●● Type E: Those with a previous criminal career who

move to heavy drug use, which increases their criminal
behaviour. Those drug users whose criminal  behav-
iour moves to a level beyond funding their own use.

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
2 resin) Import, export, production, possession and supply only permitted
under Home Office licence for medical or scientific research.
3 Heroin, cocaine, methadone, morphine, amphetamine, Cannot be prescribed by doctors or dispensed by pharmacists.
dexamphetamine, pethidine and quinalbarbitone
4 Part 1 May be prescribed and lawfully possessed when on prescription.
4 Part 2 Barbiturates, temazepam, flunitrazepam, buprenorphine, Otherwise, supply, possession, import, export and production are
5 pentazocine and diethylpropion offences except under Home Office licence. Particular controls on
their prescription, storage and record keeping apply.
Benzodiazepines (except flunitrazepam and temazepam)
and pemoline May be prescribed and lawfully possessed when on prescription.
Anabolic steroids Otherwise, supply, possession, import, export and production are
offences except under Home Office licence. Particular controls
Compound preparations such as cough mixtures which on their prescription and storage apply. Temazepam prescription
contain small amounts of controlled drugs such as requirements are less stringent than those for the other drugs in
morphine. Some may be sold over-the-counter 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.

Authority needed for their production or supply but can be freely
imported, exported or possessed (without a prescription).

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Addictions and dependencies: their association with offending

An analysis of the association between crime patterns and non-adherence to medication prescribed for the illness
and drug use patterns using this model suggested that is particularly risky. In the USA, Swartz et  al. (1998) found
most people involved in crime are not drug users, or only that violence is twice as likely among such patients as among
use substances recreationally, and most of those involved those with either problem alone. Erkiran et al. (2006) showed
in drug use are not involved in crime (Royal College of that seriousness of violence as well as its frequency was
Psychiatrists, 2000). higher among people comorbid for psychosis and substance
misuse disorders than those with psychosis alone.
An alternative empirical classification of the asso-
ciation, particularly taking causative mechanisms into Drug misuse and acquisitive crimes
account, has been proposed by Boles and Miotto (2003). In Property theft, car theft, shoplifting, fraud and defrauding
this system violence is seen as following from: social benefit schemes are among the commonest crimes
a. pharmacological consequences, such as intoxication or associated with drug use in the UK. These crimes are most
commonly committed to fund the purchase of drugs or to
withdrawal, or maintain basic living needs in the absence of any legal, paid
b. systemic issues, such as drug trade disputes, drug gang employment.

violence, violence to informants and violence related to Drug misuse and sexual crime
collection of drug-related debts, or Sex-related crime in a drug use setting is most commonly
c. economic factors related to the need to fund drug use involved with prostitution. Studies of pathways into pros-
through crime. titution have often given conflicting results. One study of
A more recent meta-analysis of 30 studies confirmed that 1142 female prisoners, for example, found that drug abuse
there is an association between drug use and crime and did not explain their entry into prostitution (McClanahan
provided a quantitative measure of the strength of the et  al., 1999), but Gossop et  al. (1994) reached a different
relationship and variation with type of drug used (Bennett conclusion. They studied 51 women who were working as
et  al., 2008): the odds of offending were greater for drug prostitutes and found that half of them had started this in
users than for non-drug users, but the odds were not the order to pay for drugs. A more recent study supported the
same for all drug types. Crack users carried the highest risk Gossop findings, and also showed that crime other than
of offending, followed by heroin users, then other cocaine prostitution is little reported in this population. This may
users. Recreational drug use was shown to carry a lower reflect the displacement of other criminal activity or that
risk of offending, but within this group, cannabis users had the sums of money obtained from prostitution (£112–132
the highest risk, followed by amphetamine users. per day, on average 2004/5) are adequate for the individual’s
drug use needs (Bloor et al., 2006).
Interaction between drugs of abuse,
mental illness and crime The use of drugs to facilitate sexual assault (drug-
At least since Swanson and colleagues (1990) examined facilitated sexual assault: DFSA) has no adequate defini-
mental illness and violence relationships in the US ECA data tion, according to Hall and Moore (2008) in their review
(see also chapter 14), it has been recognized that use of drugs of the field. They propose a distinction between proactive
and alcohol by people with a mental illness substantially (planned) DFSA and opportunistic DFSA. The more popu-
increases their risk of violence. In the UK, Wheatley (1998) lar terminology of ‘date rape drugs’ refers in the main to the
compared patients detained in specialist forensic psychiat- use of rohypnol, together with other drugs such as gamma-
ric services with those in generic services and found that it hydroxybutyric acid (GHB), which can easily be concealed
was the higher prevalence of substance use by the former in alcoholic drinks. Reviews of cases of ‘date rape’ using
which distinguished them. This was confirmed by Penk et al. drugs such as rohypnol have indicated that, in many cases,
(2000), who showed that people diagnosed with schizophre- the level of alcohol ingested was also considerable and that
nia and substance abuse disorders were more behaviourally the involvement of rohypnol itself may not be as central
dysfunctional (though more socially competent) than their as previously believed (Advisory Council on the Misuse of
non-substance misusing schizophrenic peers. Those with Drugs, 2007a).
both diagnoses had a high prevalence of childhood trauma.
Scott et  al. (1998) investigated the relationship in more Drugs and driving
detail, but with a small sample, by interviewing 27 comorbid Fitzpatrick et al. (2006), in Ireland, reviewed the prevalence of
and 65 ‘pure’ psychotic patients from medium security hos- positive drug tests in drivers suspected of being intoxicated
pitals, and reviewing their records. They also interviewed through alcohol or drug use; over 30% of drivers whose alco-
staff working closely with them. Individuals with illness and hol level was below the legal limit when tested were positive
substance misuse comorbidity were more likely to report any for one or more illicit drugs. Of those drivers whose alcohol
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

454 © 2014 by Taylor & Francis Group, LLC

Other substance misuse

level was above the legal limit, 14% were positive for one or difficulty in thinking. These effects on cognitive functions
more illicit drugs. Zero blood concentration limits for con- may persist for over 24 hours after use of cannabis.
trolled substances whilst driving have been introduced in
Sweden, but have not resulted in a reduction in the number Health complications
of cases of driving under the influence of drugs (Jones, 2005). Cannabis has effects on physical health, with even higher
rates of lung and heart disease, and cancers of the head
 Types of Drugs and their Effects and neck, among cannabis smokers than among nicotine
cigarette smokers. Cannabis use may lead to depression,
The health risks posed by drug use include the toxicity anxiety and paranoia. Panic attacks are a feature and there
of the drug itself, the route of use, blood-borne patho- is controversy as to whether cannabis ‘causes’ an enduring
gens, contaminants, unknown purity, and quantity. Adverse schizophrenia-like psychosis or simply exacerbates it (Sewell
effects for each of the most commonly used drugs are sum- et al., 2009; Tucker, 2009). Memory and learning are impaired.
marized below (Banerjee et al., 2002).
Offending
Heroin Review of the evidence linking cannabis use with aggres-
Effects of intoxication sion has indicated that cannabis intoxication reduces the
Diverted pharmaceutical opiates and opioids may be for- risk of violence, whereas withdrawal from cannabis may
mulated for injection or oral use, or as suppositories. increase it (Hoaken and Stewart, 2003). Cannabis depend-
Tablets may be crushed and injected. Dependence can ency was one of only three disorders of mental health inde-
develop within weeks. Since tolerance also develops rapidly, pendently linked to violence in the Dunedin birth cohort
but diminishes quickly after abstinence, relapse can lead to (Arsenault et al., 2000).
overdose and death. This is also the case for methadone.
Heroin may be smoked, inhaled or heated on foil and the Psychostimulants – amphetamines and cocaine
fumes inhaled. The short-term effects include a rapid onset Effects of intoxication
of euphoria with a sensation of heavy extremities. The user Most psychostimulants may be used orally, ‘snorted’ as a
will then experience alternating wakeful and drowsy states. powder through the nose, or injected or smoked, producing
Heroin is a central nervous system depressant and has an intense euphoric state, possibly accompanied by restless
effects on reaction times and ability to concentrate. and agitation, rapid speech and increased wakefulness.
Health complications Health complications
Repeated use of heroin induces a state of dependency with Psychostimulants may precipitate anxiety states, confu-
a need for increased doses and increased frequency of use. sion, convulsions and cardiovascular problems, and acute
The occurrence of withdrawal symptoms triggers further psychotic episodes are not uncommon. The sharing of
use to relieve these symptoms. Repeated injections result in injection equipment carries the same risks as for heroin
collapsed veins, infection of the heart lining and valves and use, but its risk is often underestimated in the stimu-
skin and muscle infections. Sharing of injection equipment lant using population. Use of stimulants may lead to
also carries a high risk of blood-borne infections such as exhaustion, depression, and weight loss. A paranoid and/
HIV and hepatitis C. Opiates and opioids depress coughing, or confusional state may also occur. Hypertension, car-
breathing and heart rate, dilate blood vessels, reduce bowel diac arrhythmias, stroke, hepatic and renal damage and
activity and produce constipation. Overdose usually occurs abscesses are the result of heavy use, especially if injecting.
when in combination with other drugs. Violent and aggressive behaviour may ensue. Snorting of
Offending cocaine leads to nasal septal perforation and damage to
Hoaken and Stewart (2003), in a review of aggressive the nasal passages.
behaviour in heroin users, concluded that their high rates Offending
of aggression may be independent of their heroin use and Methamphetamine use is often cited as having a direct link
more closely related to personality factors linked with with violent crime, but the relation between its use and vio-
that dependence. lence is indirect and unclear (Tyner and Fremouw, 2008).

Cannabis Benzodiazepines

Effects of intoxication Effects of intoxication
Cannabis is either smoked or eaten. Use is accompanied In the short term, users may experience tiredness, depressed
by distorted time perception, impaired coordination and respiration, dizziness, and unsteadiness.

© 2014 by Taylor & Francis Group, LLC 455

Addictions and dependencies: their association with offending

Health complications than others. Hair analysis, for example, enables detection of
If combined with other depressants such as alcohol or opi- regular use of many drugs over periods of several months. A
ates, overdose can be fatal. Dependence can develop on low secure ‘chain of custody’ from initial collection is essential
doses and convulsions occur with withdrawal. Rebound to ensure accurate sample attribution to a specified indi-
symptoms such as insomnia, anxiety, and tension may vidual. There is variability between substances in duration
occur. of time for detection, from a few hours to 10 days or more
(see table 18.5). It is important to ensure that appropriate,
Offending rigorously applied laboratory testing procedures are used,
The evidence regarding the effect of benzodiazepines use with appropriate cut-offs for interpreting results (Wolff
on offending behaviour is conflicting. A case-crossover et al., 1999a,b).
study of the role of alcohol and drugs in triggering criminal
violence (Haggard-Grann et  al., 2006) showed that whilst Examination of drug users
alcohol is a strong trigger for criminal violence, the use of It is recommended that, as drug use is of such a high preva-
benzodiazepines in combination with the alcohol does not lence, all healthcare professionals should be able to identify
increase the risk. Other studies have suggested that in some and carry out a basic assessment of people who use drugs
individuals the use of benzodiazepines may trigger a para- (NICE, 2008a), and that this should include examination of
doxical aggressive reaction, but that this is more related to the user both as an aid to confirming drug use and identi-
individual personality factors rather than a pharmacologi- fying the physical complications of drug use, such as infec-
cal, dose-related effect (Bramness et al., 2006). tions and abscesses.

Polysubstance use Drug use assessment tools
People commonly use more than one substance, but an
Australian study reported that only the use of alcohol and Current guidance for England and Wales suggests that all
inhalants appeared to have significant relationships with drug users should have an assessment that includes the
recidivism in young offenders (Putnin¸š, 2003). following (NICE, 2007b):
●● medical, psychological, social and occupational needs;
Screening, Assessment and ●● history of drug use;
Diagnosis of Drug Misuse ●● experience of previous treatment, if any;
●● goals in relation to his or her drug use;
A number of screening methods for illicit drug use are ●● treatment preferences. 
available (see box 18.1). These depend on the purpose, A review of assessment data for the evaluation of drug
setting, nature of the target group and the technology and misuse has been published (Effective Interventions Unit,
resources available for the screening programme. Screening 2002), which provides information on three commonly
and assessment are not the same thing. Screening is an used assessment tools.
initial, simple enquiry about indicators of health and ●● The Maudsley Addiction Profile (MAP): A short assess-
social problems. Assessment is an ongoing, sometimes
protracted, process (Crome et al., 2006). ment tool, which takes around 12 minutes to admin-
ister and covers four areas: substance use, health risk
Drug screening behaviour, physical and psychological health, and per-
Some biological indicators, such as blood, urine and saliva sonal/social functioning (Marsden et al., 1998).
drug or drug metabolite levels, are more commonly used ●● The Christo Inventory for Substance-misuse Services
(CISS): A 10-item questionnaire with a single score of

Box 18.1 Screening methods Table 18.5   Period of time over which more
commonly used substances are likely to remain
Self-report questionnaire detectable in the blood (Adapted from Banerjee
Psychiatric history taking assessment et al., 2002)
Semi-structured interview
Structured interview Drug Maximum range
Physical markers
Cocaine 12–72 hours
Urinalysis Amphetamines 2–4 days
Blood tests Heroin 2–4 days
Hair tests Codeine 2–4 days
Fingernail clippings Cannabis 30 days
Diazepam 30 days

456 © 2014 by Taylor & Francis Group, LLC

Other substance misuse

0–20, covering areas such as physical and psychologi- Box 18.3 The CRAFFT questionnaire (Knight
cal health, drug use, HIV risk and criminal behaviour et al., 2002)
(Christo, 2000). 1. Have you ever ridden in a car driven by someone
●● The Rickter scale: A non-paper based self-assessment,
allowing the user to identify treatment goals and can (including yourself) who was ‘high’ or had been using
be used to develop treatment action plans (Hutchinson alcohol or drugs?
and Stead, see Northumbria University, 2012). 2. Do you ever use alcohol or drugs to relax, feel better
The National Treatment Agency (NTA) care planning about yourself, or fit in?
practice guide (NTA, 2006a) provides a summary of the 3. Do you ever use alcohol or drugs when you are by
characteristics of a selection of tools that may be used for yourself, alone?
assessment and outcome measurement in a drug treat- 4. Do you ever forget things you did while using alcohol
ment setting ( for a list, see box 18.2). or drugs?
Based on the AUDIT (Saunders et al., 1993), a cannabis 5. Do your family or friends ever tell you that you should
screening instrument has been developed (the Cannabis cut down on your drinking or drug use?
Use Disorders Identification Test (CUDIT) Adamson and 6. Have you ever gotten into trouble while you were
Sellman, 2003). More recently, the Drug Use Disorders using alcohol or drugs?
Identification Test (DUDIT) has been developed and piloted For each positive response, score 1. A CRAFFT score of ≥2
in criminal justice settings (Berman et al., 2005). There are identifies a substance problem, disorder, or dependence.
also instruments for screening and assessing substance use
in young people (Effective Interventions Unit, 2004). A brief A&E departments or GP surgeries may be used as regular
six-item questionnaire by Knight et al. (2002) is also useful supplementary sources of supply. There is also a risk that
(see box 18.3). casual non-dependent users will thus get pharmaceuti-
People who are drug dependent may seek urgent profes- cally pure preparations of dependence-producing drugs,
sional help, asking for immediate treatment of withdrawal on which they may accidentally overdose. A careful history
symptoms, often claiming to be unable to get to their usual to establish that there is dependence is, therefore, always
treatment unit or that their prescribed supplies have been essential, as is a thorough physical examination to establish
lost or stolen. In this situation, and regardless of manipula- the nature and severity of any abstinence syndrome.
tive threats that, if they are not given a prescription, they
will have to resort to illegal activity, the governing principle Treatment for Drug Misuse
is that nothing should be prescribed unless there are clear
physical signs of the relevant abstinence syndrome. Rigid Pharmacological treatment options
application of this rule is essential, otherwise hospital A detailed account of specific treatment régimes and the
supporting evidence is beyond the scope of this chapter.
Box 18.2 Drug use outcome measurement tools A range of guidance is available, such as that produced by
(NTA, 2006a) the British Association of Psychopharmacology (Lingford-
Hughes et al., 2004), Department of Health (2007) and the
Maudsley Addiction Profile (MAP) National Institute of Clinical Excellence (NICE 2007a,b,c,
Addiction Severity Index (ASI, European adaptation) 2008a). Much of this does not, however, deal with complex
Opiate Treatment Index (OTI) comorbid conditions such as those found in the criminal
OTI modified for amphetamine users justice system.
Global Appraisal of Need (GAIN)
Leeds Dependence Questionnaire (LDQ) A growing variety of pharmacological treatments are
Severity of Dependence Scale (SDS) available (Lingford-Hughes et  al., 2004), for stabilization,
The Craving Questionnaires detoxification, reduction, maintenance and relapse preven-
Readiness to Change Questionnaire (RTQ) (Treatment tion, in addition to treatment for psychiatric disorder or
Version) physical problems (Chandler and McCaul, 2003; Rayburn
Injecting Risk Questionnaire and Bogenschutz, 2004). Most of these treatments can be
Drug Taking Confidence Questionnaire (DTCQ) administered in the community, with close supervision, but
Inventory of Drug-Taking Situations patients may need to be admitted to hospital or to a reha-
Quality of Life Inventory (QOLI) bilitation unit. These decisions are clinically complex and
Beck Depression Inventory (BDI) depend on a range of factors, including degree of depend-
Beck Anxiety Inventory (BAI) ence, number of substances used, social stability and
Hospital Anxiety and Depression Scale (HADS) support network. The treatment must be individualized.
General Health Questionnaire (GHQ-28)

© 2014 by Taylor & Francis Group, LLC 457

Addictions and dependencies: their association with offending

The benefits must, where possible, be weighed against the essential to improvement (Crome and Ghodse, 2007).
potential risks, which the patient must understand. It can- Information-based approaches are useful in less complex
not be over-emphasized that pharmacological treatments situations. These might include education about harm
must always be prescribed in full knowledge of the person’s minimization, immunization and vaccination.
psychosocial situation, and with psychological support,
which may include individual, group or family interven- In the addiction literature the term ‘counselling’ is used
tions. In summary, the most usual situations in which to incorporate brief or intensive interventions, in the form
medication may be helpful are of supportive, directive or motivational approaches, deliv-
●● emergencies,e.g.overdose,fits,dehydration,hypothermia; ered for the individual, family or group, and also social net-
●● detoxification and withdrawal syndromes, e.g. lofex- work behavioural therapy. Cognitive behavioural or person
centred techniques are most commonly employed, but psy-
idine, methadone, buprenorphine; chodynamic techniques also used. The aim of counselling
●● substitution, e.g. methadone, buprenorphine; may be to reduce the use of alcohol and drugs, their nega-
●● relapse prevention, e.g. naltrexone; tive consequences, or related problems. Assessment should
●● comorbid substance problems; move seamlessly into engagement, support and therapy.
●● comorbid psychiatric disorders; The non-judgmental and empathic method of engaging
●● comorbid physical disorders, e.g. HIV, hepatitis C, the patients in challenging decisions and assumptions
him/herself in motivational interviewing is important.
diabetes. Objectives may include
●● problem solving: developing competence in dealing
Summary of recommendations from the British
Association of Psychopharmacology (BAP) with a specified problem;
guidelines ●● acquisition of social skills: mastery of social and inter-
In the BAP guidelines, Lingford-Hughes et  al. (2004) cite
considerable evidence for the use of methadone, buprenor- personal skills by assertiveness or anger control;
phine, and α2 agonists (clonidine, lofexidine) in manag- ●● cognitive change: modification of irrational beliefs and
ing withdrawal. Differences in choice of medication may
depend on priorities such as duration of treatment, adverse maladaptive patterns of thought;
effects (brachycardia and hypotension due to α2 adrener- ●● behaviour change: modification of maladaptive behav-
gic agonists) and withdrawal severity. The patient’s clinical
condition, degree of dependence, preference and practi- iour;
tioner experience will determine choice of drug. ●● systemic change: introducing change into family sys-

Similarly, there is an established evidence base for tems.
methadone maintenance treatment and for buprenor- The main treatment options, the choice of which depends
phine. There is inadequate evidence for treatment with nal- on the nature and extent of the problem, will now be dealt
troxone or injectable opioids, or for using coercive methods. with in a bit more depth.

For stimulant drugs, such as cocaine and amphetamine, 1. Non-directive counselling comprises the following com-
the guidelines do not recommend the use of dopamine ago- ponents: patient determination of content and direc-
nists, anti-depressants, or carbamazepine. Furthermore, tion of the counselling; exploration of inner conflict
there is no clear evidence to support substitute prescribing and emotions at the time; empathic reflection from the
of dexamphetamines. In fact, ‘psychosocial’ interventions counsellor, while the counsellor desists from offering
are considered the ‘mainstay’ of treatment, although the advice and feedback.
evidence is limited.
2. A cognitive behavioural approach assumes that the pa-
The guidelines also make recommendations for benzo- tient would like to change. Identification, then analysis
diazepine dependence, whether the benzodiazepines have of situations that cause drug use are central, so that
been prescribed or are illicit. In early or mild dependence, these can be altered. Problem-solving techniques, self-
‘minimal’ interventions, such as relaxation or general prac- monitoring, anger management, relapse prevention,
titioner advice, are suggested. For more severe dependence, assertiveness training and the acquisition of social
graded discontinuation is advised. For ‘illicit’ misusers, skills and modification of irrational beliefs or patterns
there is no evidence that continued prescribing is benefi- of thought or behaviour are used. Individual, group and
cial, except possibly in reducing illicit use. family therapies used in the treatment of addiction are
often based along cognitive behavioural lines.
Psychological interventions for drug misusers
Most treatments in this field are based on learning the- 3. Social network behaviour therapy considers the social
ory models, but there is also recognition that a holis- environment as being important in the development,
tic approach, including practical social interventions, is maintenance and resolution of substance problems. It
maximizes positive social support, which is central to
the process. The therapist offers advice and feedback
and thereby facilitates change in the patient’s social
world. Behaviour is not interpreted and engagement

458 © 2014 by Taylor & Francis Group, LLC