Skip to main content Accessibility help
  • Print publication year: 2008
  • Online publication date: August 2009

24 - Forensic psychiatry

from Section 4 - Psychiatry in Specific Settings


This chapter describes the classical subtypes, differential diagnosis, epidemiology and genetics of schizophrenia and related disorders. Relatives are examined for some of the biological abnormalities which are found in their schizophrenic kin. The relatives of patients with schizophrenia have also been reported to be more likely than control subjects to have poor performance on cognitive tests measuring memory functions. The discovery of risk factors acting in early life has been central to the neurodevelopmental hypothesis of schizophrenia. Magnetic resonance imaging (MRI) studies have consistently demonstrated that people with schizophrenia have increased lateral ventricular volume and also show a slight decrease in cortical volume with greater decrements in the hippocampus, amygdala and thalamus. Children destined to develop schizophrenia often have subtle developmental delays and deficits in motor and cognitive function, tend to be solitary and show an excess of social anxiety. The chapter reviews the essential principles of management for psychosis.


American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders, 4th edn. (DSM-IV). Washington, DC: American Psychiatric Association.
Appelbaum, P. S., Robbins, P. C., & Monahan, J. (2000). Violence and delusions: data from the MacArthur Violence Risk Assessment Study. Am J Psychiatry 157:566–72.
Arseneault, L., Cannon, M., Murray, R., et al. (2003). Childhood origins of violent behaviour in adults with schizophreniform disorder dagger. Br J Psychiatry 183:520–5.
Arseneault, L., Moffitt, T. E., Caspi, A., et al. (2000). Mental disorders and violence in a total birth cohort: results from the Dunedin Study. Arch Gen Psychiatry 57:979–86.
Arseneault, L., Tremblay, R. E., Boulerice, B., et al. (2000). Minor physical anomalies and family adversity as risk factors for violent delinquency in adolescence. Am J Psychiatry 157:917–23.
Barlow, K., Grenyer, B., & Ilkiw-Lavalle, O. (2000). Prevalence and precipitants of aggression in psychiatric inpatient units. Aust N Z J Psychiatry 34:967–74.
Bassarath, L. (2001). Conduct disorder: a biopsychosocial review. Can J Psychiatry 46:609–16.
Birmingham, L., Mason, D., & Grubin, D. (1996). Prevalence of mental disorder in remand prisoners: consecutive case study. BMJ 313:1521–4.
Black, D. W., Baumgard, C. H., & Bell, S. E. (1995). The long-term outcome of antisocial personality disorder compared with depression, schizophrenia, and surgical conditions. Bull Am Acad Psychiatry Law 23:43–52.
Blair, R. J. (2003). Neurobiological basis of psychopathy. Br J Psychiatry 182:5–7.
Bonta, J., Law, M., & Hanson, K. (1998). The prediction of criminal and violent recidivism among mentally disordered offenders: a meta-analysis. Psychol Bull 123:123–42.
Brennan, P. A., Grekin, E. R., & Mednick, S. A. (1999). Maternal smoking during pregnancy and adult male criminal outcomes. Arch Gen Psychiatry 56:215–19.
Brennan, P. A., Mednick, S. A., & Hodgins, S. (2000). Major mental disorders and criminal violence in a Danish birth cohort. Arch Gen Psychiatry 57:494–500.
Brower, M. C., & Price, B. H. (2001). Advances in neuropsychiatry: neuropsychiatry of frontal lobe dysfunction in violent and criminal behaviour: a critical review. J Neurol Neurosurg Psychiatry 71:720–6.
Buchanan, A. (1999). Risk and dangerousness. Psychol Med 29:465–73.
Buchanan, A., & Leese, M. (2001). Detention of people with dangerous severe personality disorders: a systematic review. Lancet 358:1955–9.
Butler Report (1975). Report of the Committee on Mentally Disordered Offenders. London: Her Majesty's Stationery Service.
Callicott, J. H., Mattay, V. S., Verchinski, B. A., et al. (2003). Complexity of prefrontal cortical dysfunction in schizophrenia: more than up or down. Am J Psychiatry 160:2209–15.
Cannon, M., Huttunen, M. O., Tanskanen, A. J., et al. (2002). Perinatal and childhood risk factors for later criminality and violence in schizophrenia. Longitudinal, population-based study. Br J Psychiatry 180: 496–501.
Caspi, A., McClay, J., Moffitt, T. E., et al. (2002). Role of genotype in the cycle of violence in maltreated children. Science 297:851–4.
Cleckley, H. (1976). The Mask of Sanity, 6th edn. St Louis, MO: Mosby.
Copas, J., & Marshall, P. (1998). The offender group reconviction scale: a statistical reconviction score score for use by probation officers. Appl Stat 47:159–71.
Cornell, D. G., Warren, J., Hawk, G., et al. (1996). Psychopathy in instrumental and reactive violent offenders. J Consult Clin Psychol 64:783–90.
Cote, G., & Hodgins, S. (1992). The prevalence of major mental disorders among homicide offenders. Int J Law Psychiatry 15:89–99.
Craissati, J. (2004). Managing High Risk Sex Offenders in the Community. Hove and New York: Brunner-Routledge.
Cuffel, B. J., Shumway, M., Chouljian, T. L., et al. (1994). A longitudinal study of substance use and community violence in schizophrenia. J Nerv Ment Dis 182:704–8.
d'Orban, P. T. (1979). Women who kill their children. Br J Psychiatry 134:560–571.
Dean, K., Walsh, E., Morgan, C., et al. (2007). Aggressive behaviour at first contact with services: findings from the AESOP First Episode Psychosis Study. Psychol Med 37:547–57.
Denkowski, G., & Denkowski, G. (1985). The mentally retarded offender in the state prison system: identification, prevalence, adjustment and rehabilitation. Crim Justice Behav 12:55–70.
Dolan, M., & Park, I. (2002). The neuropsychology of antisocial personality disorder. Psychol Med 32:417–27.
Dolan, M. C., Deakin, J. F., Roberts, N., et al. (2002). Quantitative frontal and temporal structural MRI studies in personality-disordered offenders and control subjects. Psychiatry Res 116:133–49.
Dolan, M., & Doyle, M. (2000). Violence risk prediction. Clinical and actuarial measures and the role of the Psychopathy Checklist. Br J Psychiatry 177: 303–11.
Edwards, J., Pattison, P. E., Jackson, H. J., et al. (2001). Facial affect and affective prosody recognition in first-episode schizophrenia. Schizophr Res 48:235–53.
Erb, M., Hodgins, S., Freese, R., et al. (2001). Homicide and schizophrenia: maybe treatment does have a preventive effect. Crim Behav Ment Health 11:6–26.
Eronen, M., Hakola, P., & Tiihonen, J. (1996). Mental disorders and homicidal behavior in Finland. Arch Gen Psychiatry 53:497–501.
Fazel, S., & Danesh, J. (2002). Serious mental disorder in 23000 prisoners: a systematic review of 62 surveys. Lancet 359:545–50.
Fazel, S., & Grann, M. (2006). The population impact of severe mental illness on violent crime. Am J Psychiatry 163:1397–1403.
Frick, P. J., Cornell, A. H., Bodin, S. D., et al. (2003). Callous-unemotional traits and developmental pathways to severe conduct problems. Dev Psychol, 39:246–60.
Frick, P. J., & Ellis, M. (1999). Callous-unemotional traits and subtypes of conduct disorder. Clin Child Fam Psychol Rev 2:149–68.
Frith, C. D. (2004). Schizophrenia and theory of mind. Psychol Med 34:385–9.
Gottlieb, P., Gabrielsen, G., & Kramp, P. (1987). Psychotic homicides in Copenhagen from 1959 to 1983. Acta Psychiatr Scand 76:285–92.
Gray, N. S., Snowden, R. J., MacCulloch, S., et al. (2004). Relative efficacy of criminological, clinical, and personality measures of future risk of offending in mentally disordered offenders: a comparative study of HCR-20, PCL-SV, and OGRS. J Consult Clin Psychol 72:523–30.
Gretton, H. M., Hare, R. D., & Catchpole, R. E. (2004). Psychopathy and offending from adolescence to adulthood: a 10-year follow-up. J Consult Clin Psychol 72:636–45.
Grubin, D. H. (1991). Unfit to plead in England and Wales, 1976–88. A survey. Br J Psychiatry 158:540–8.
Gudjonsson, G. H., & Petursson, H. (1986). Changing characteristics of homicide in Iceland. Med Sci Law 26:299–303.
Hall, I. (2000). Young offenders with learning disability. Adv Psychiatr Treat 6:278–86.
Haque, Q., & Cumming, I. (2003). Intoxicaction and legal defences. Adv Psychiatr Treat 9:144–51.
Hare, R. (1991). The Hare Psychopathy Checklist – Revised. Toronto: Multi-Health Systems.
Hare, R. D. (1999). Psychopathy as a risk factor for violence. Psychiatr Q 70:181–97.
Harris, G. T., Rice, M. E., & Quinsey, V. L. (1993). Violent recidivism of mentally disordered offenders: the development of a statistical prediction instrument. Crim Justice Behav 20:315–35.
Hart, S. D., Cox, D. N., & Hare, R. D. (1995). The Hare Psychopathy Checklist – Screening Version (PCL:SV). Toronto, Ontario, Canada: Multi-Health Systems.
Hart, S. D., & Hare, R. D. (1996). Psychopathy and antisocial personality disorder. Curr Opin Psychiatry 9:129–32.
Hemphill, J. F., Hare, R. D., & Wong, S. (1998). Psychopathy and recidivism: a review. Legal Criminol Psychol 3:139–70.
Hinshaw, S. P. (1992). Externalizing behavior problems and academic underachievement in childhood and adolescence: causal relationships and underlying mechanisms. Psychol Bull 111:127–55.
Hodgins, S. (1992). Mental disorder, intellectual deficiency, and crime. Evidence from a birth cohort. Arch Gen Psychiatry 49:476–83.
Hodgins, S., Hiscoke, U. L., & Freese, R. (2003). The antecedents of aggressive behavior among men with schizophrenia: a prospective investigation of patients in community treatment. Behav Sci Law 21:523–46.
Hodgins, S., Mednick, S. A., Brennan, P. A., et al. (1996). Mental disorder and crime. Evidence from a Danish birth cohort. Arch Gen Psychiatry 53:489–96.
Intrator, J., Hare, R., Stritzke, P., et al. (1997). A brain imaging (single photon emission computerized tomography) study of semantic and affective processing in psychopaths. Biol Psychiatry 42:96–103.
Johns, A. (1998). Substance misuse and offending. Curr Opin Psychiatry 11:669–73.
Kiehl, K. A., Smith, A. M., Mendrek, A., et al. (2004). Temporal lobe abnormalities in semantic processing by criminal psychopaths as revealed by functional magnetic resonance imaging. Psychiatry Res 130:297–312.
Kroner, D. G. (2005). Issues in violent risk assessment: lessons learned and future directions. J Interpers Violence 20:231–5.
Leal, J., Ziedonis, D., & Kosten, T. (1994). Antisocial personality disorder as a prognostic factor for pharmacotherapy of cocaine dependence. Drug Alcohol Depend 35:31–5.
Lelliott, P., & Audini, B. (2003). Trends in the use of Part II of the Mental Health Act 1983 in seven English local authority areas. Br J Psychiatry 182:68–70.
Leong, G. B., & Silva, J. A. (1995). A psychiatric-legal analysis of psychotic criminal defendants charged with murder. J Forensic Sci 40:445–8.
Lewis, P. (1991). The report of the working party on the assessment and treatment of sex offenders at Broadmoor Hospital [Internal Document].
Lindberg, N., Tani, P., Stenberg, J. H., et al. (2004). Neurological soft signs in homicidal men with antisocial personality disorder. Eur Psychiatry 19:433–7.
Lindqvist, P., & Allebeck, P. (1990). Schizophrenia and crime. A longitudinal follow-up of 644 schizophrenics in Stockholm. Br J Psychiatry 157:345–50.
Linehan, M. (1993). The Skills Training Manual for Treating Borderline Personality Disorder. New York: Guilford Press.
Link, B. G., Stueve, A., & Phelan, J. (1998). Psychotic symptoms and violent behaviors: probing the components of “threat/control-override” symptoms. Soc Psychiatry Psychiatr Epidemiol 33(Suppl 1):S55–60.
Lorber, M. F. (2004). Psychophysiology of aggression, psychopathy, and conduct problems: a meta-analysis. Psychol Bull 130:531–52.
Lyall, I., Holland, A. J., & Collins, S. (1995). Offending by adults with learning disabilities and the attitudes of staff to offending behaviour: implications for service development. J Intellect Disabil Res 39(Pt 6):501–8.
McNulty, C., Kissi-Deborah, R., & Newsome-Davies, I. (1995). Police involvement with clients having intellectual disabilities: a pilot study in South London. Ment Handicap Res 8:129–36.
Mills, J. F. (2005). Advances in the assessment and prediction of interpersonal violence. J Interpers Violence 20:236–41.
Modestin, J., & Ammann, R. (1996). Mental disorder and criminality: male schizophrenia. Schizophr Bull 22:69–82.
Monahan, J. (1997). Clinical and Actuarial predictions of violence. In D. Faigman, D. Kaye, M. Saks, et al., eds. Modern Scientific Evidence: The Law and Science of Expert Testimony. St Paul, Minnesota: West, pp. 300–18.
Monahan, J., Steadman, H. J., Appelbaum, P. S., et al. (2000). Developing a clinically useful actuarial tool for assessing violence risk. Br J Psychiatry 176:312–19.
Moran, P. (1999). Should Psychiatrists Treat Personality Disorders?, 7th edn. Maudsley Discussion Paper No. 7. Psychiatr Bull 24:358.
Moran, P., Walsh, E., Tyrer, P., et al. (2003). Impact of comorbid personality disorder on violence in psychosis: report from the UK700 trial. Br J Psychiatry 182:129–34.
Morrell, J., & Murray, L. (2003). Parenting and the development of conduct disorder and hyperactive symptoms in childhood: a prospective longitudinal study from 2 months to 8 years. J Child Psychol Psychiatry 44:489–508.
Mullen, P. (2006). Schizophrenia and violence: from correlations to preventive strategies. Adv Psychiatr Treat 12:239–48.
Mullen, P. E., Burgess, P., Wallace, C., et al. (2000). Community care and criminal offending in schizophrenia. Lancet 355:614–17.
Murray, G., Briggs, D., & Davies, C. (1992). Psychopathic disordered/mentally ill, and mentally handicapped sex offenders: a comparative study. Med Sci Law 32:331–6.
Naudts, K., & Hodgins, S. (2006). Neurobiological correlates of violent behavior among persons with schizophrenia. Schizophr Bull 32:562–72.
Patrick, C. J. (1994). Emotion and psychopathy: startling new insights. Psychophysiology 31:319–30.
Puri, B. K., Brown, R. A., McKee, H. J., et al. (2005). History of mental health legislation. In Mental Health Law: A Practical Guide. London: Hodder Arnold, pp. 1–10.
Raine, A., Brennan, P., & Mednick, S. A. (1994). Birth complications combined with early maternal rejection at age 1 year predispose to violent crime at age 18 years. Arch Gen Psychiatry 51:984–8.
Raine, A., Lencz, T., Bihrle, S., et al. (2000). Reduced prefrontal gray matter volume and reduced autonomic activity in antisocial personality disorder. Arch Gen Psychiatry 57:119–127; discussion 128–9.
Raine, A., Moffitt, T. E., Caspi, A., et al. (2005). Neurocognitive impairments in boys on the life-course persistent antisocial path. J Abnorm Psychol 114:38–49.
Rasanen, P., Tiihonen, J., Isohanni, M., et al. (1998). Schizophrenia, alcohol abuse, and violent behavior: a 26-year follow-up study of an unselected birth cohort. Schizophr Bull 24:437–41.
Regier, D. A., Farmer, M. E., Rae, D. S., et al. (1990). Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. JAMA 264:2511–18.
Ritchie, J. H., Dick, D., & Lingham, R. (1994). The Report of the Inquiry into the Treatment of Christopher Clunis. London: Her Majesty's Stationery Office.
Robins, L. N., Tipp, J., & Przybeck, T. (1991). Antisocial personality. In L. N. Robins & D. Regier, eds. Psychiatric Disorders in America: The Epidemiologic Catchment Area Study. New York: Macmillan/Free Press, pp. 258–90.
Sahota, K., & Chesterman, P. (1998). Sexual offending in the context of severe mental illness. J Foren Psychiatry 9:267–80.
Schanda, H., Knecht, G., Schreinzer, D., et al. (2004). Homicide and major mental disorders: a 25-year study. Acta Psychiatr Scand 110:98–107.
Serin, R. C., & Amos, N. L. (1995). The role of psychopathy in the assessment of dangerousness. Int J Law Psychiatry 18:231–8.
Shaw, J., Appleby, L., Amos, T., et al. (1999). Mental disorder and clinical care in people convicted of homicide: national clinical survey. BMJ 318:1240–4.
Shaw, J., Hunt, I. M., Flynn, S., et al. (2006). Rates of mental disorder in people convicted of homicide. National clinical survey. Br J Psychiatry 188:143–7.
Simons, K. (2000). Life on the Edge. The Experiences of People with a Learning Disability Who Do Not Use Specialist Services. Brighton: Pavilion Publishing/Joseph Rowntree Foundation.
Simpson, A. I., McKenna, B., Moskowitz, A., et al. (2004). Homicide and mental illness in New Zealand, 1970–2000. Br J Psychiatry 185:394–8.
Singleton, N., Meltzer, H., & Gatward, R. (1998). Psychiatric Morbidity Among Prisoners in England and Wales. London: Her Majesty's Stationery Office.
Snowden, P. (2001). Substance misuse and violence: the scope and limitations forensic psychiatry's role. Adv Psychiatr Treat 2001:189–97.
Swanson, J., Estroff, S., Swartz, M., et al. (1997). Violence and severe mental disorder in clinical and community populations: the effects of psychotic symptoms, comorbidity, and lack of treatment. Psychiatry 60:1–22.
Swanson, J. W., Holzer, C. E., 3rd, Ganju, V. K., et al. (1990). Violence and psychiatric disorder in the community: evidence from the Epidemiologic Catchment Area surveys. Hosp Commun Psychiatry 41:761–70.
Swanson, J. W., Swartz, M. S., Elbogen, E. B., et al. (2004). Reducing violence risk in persons with schizophrenia: olanzapine versus risperidone. J Clin Psychiatry 65:1666–73.
Swanson, J. W., Van Dorn, R. A., Monahan, J., et al. (2006). Violence and leveraged community treatment for persons with mental disorders. Am J Psychiatry 163:1404–11.
Swartz, M. S., Swanson, J. W., Hiday, V. A., et al. (1998). Violence and severe mental illness: the effects of substance abuse and nonadherence to medication. Am J Psychiatry 155:226–31.
Taylor, P. J., & Gunn, J. (1984). Violence and psychosis. I. Risk of violence among psychotic men. Br Med J (Clin Res Ed) 288:1945–9.
Taylor, P. J., & Gunn, J. (1999). Homicides by people with mental illness: myth and reality. Br J Psychiatry 174:9–14.
Tiihonen, J., Isohanni, M., Rasanen, P., et al. (1997). Specific major mental disorders and criminality: a 26-year prospective study of the 1966 northern Finland birth cohort. Am J Psychiatry 154:840–5.
Volavka, J., Laska, E., Baker, S., et al. (1997). History of violent behaviour and schizophrenia in different cultures. Analyses based on the WHO study on Determinants of Outcome of Severe Mental Disorders. Br J Psychiatry 171:9–14.
Wallace, C., Mullen, P. E., & Burgess, P. (2004). Criminal offending in schizophrenia over a 25-year period marked by deinstitutionalization and increasing prevalence of comorbid substance use disorders. Am J Psychiatry 161:716–27.
Wallace, C., Mullen, P., Burgess, P., et al. (1998). Serious criminal offending and mental disorder. Case linkage study. Br J Psychiatry 172:477–84.
Webster, C., Douglas, K., Eaves, D., et al. (1997). HCR-20. Assessing Risk for Violence. Version2. Burnaby, Canada: Mental Health Law and Policy Institute.
Wessely, S. C., Castle, D., Douglas, A. J., et al. (1994). The criminal careers of incident cases of schizophrenia. Psychol Med 24:483–502.
West, D., & Farringdon, D. (1973). Who Becomes Delinquent. London: Heinemann.
Williamson, S., Harpur, T. J., & Hare, R. D. (1991). Abnormal processing of affective words by psychopaths. Psychophysiology 28:260–73.
Winter, N., Holland, A. J., & Collins, S. (1997). Factors predisposing to suspected offending by adults with self-reported learning disabilities. Psychol Med 27:595–607.
Wong, M., & Singer, K. (1973). Abnormal homicide in Hong Kong. Br J Psychiatry 123:295–8.
Wootton, J. M., Frick, P. J., Shelton, K. K., et al. (1997). Ineffective parenting and childhood conduct problems: the moderating role of callous-unemotional traits. J Consult Clin Psychol 65:301–8.
World Health Organisation. (1992). The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organisation.
World Health Organisation. (2003). Mental Health Legislation and Human Rights (Mental Health Policy and Service Guidance Package). Geneva: World Health Organisation.
Young, J. (1999). Cognitive Therapy for Personality Disorders: A Schema Focused Approach. Sarasota, Florida: Professional Resource Press.