Forensic Psychiatry: Fritz A.Henn,
Marijan
Anatomy
Herjanic.
and Robert
of a Service H. Vanderpearl
C
RIMINAL BEHAVIOR and its relationship to psychiatric illness poses a real dilemma to both the court and psychiatrist. Nowhere are the ethical problems in defining the rights of the individual versus the rights of society more clearly etched than in the questions of commitment and competency. The role of psychiatry in this area has been strongly challenged both from within the profession’ and by leading jurists.’ In order to respond, it is useful to review the record and document in detail the workings of a forensic service. Data such as these can serve to illuminate the scope of the problem, and ideally focus the debate on substantive issues. They can also provide a longitudinal view of how one service evolved in dealing with the complex area of criminal responsibility and competency. They cannot nor should they be thought to provide solutions to the philosophic issues. This must come in an ongoing dialogue between spokesmen for psychiatry, law, and society as a whole, but must be anchored to what we do know, in an area in which much remains undetermined. This study reviews the 22 year history of the Forensic Service at Malcolm Bliss Mental Health Center. The center was constructed in 1938 as the psychiatric unit of the St. Louis City Hospital. It provided evaluation and short-term treatment for city residents, becoming part of the State of Missouri’s mental health system in 1964 and a community mental health center in 1966. A separately organized forensic service was initiated at Malcolm Bliss Mental Health Center in 1952. It was responsible for all court referrals in the City of St. Louis and has been staffed by a psychiatrist, resident psychiatrist, psychologist, and a social worker. Between eight and twelve beds have been available to the service on general psychiatric wards and evaluation of defendants and their court reports were carried out by a team specially assigned to this task. MATERIALS
AND
METHODS
The Forensic Service records of ah patients admitted to the service since its inception in 1952 were reviewed by the authors. The patients on whom no report was rendered to the court were excluded from the study. A form containing demographic data, source of referral, purpose of the examination, crimes charged, psychiatric diagnosis, and the report to the court was made out for each patient. The data were coded and punched on computer cards and processed. For convenience, the data will be
From the Department of Psychiatry, The University of Iowa College of Medicine, Iowa City, Iowa, and Malcolm Bliss Mental Health Center and Washington University School of Medicine, St. Louis. Mo. Fritz A. Henn, Ph.D., M.D.: Assistant Professor of Psychiatry, University of Iowa College of Medicine, Iowa City, Iowa; Marijan Herjanic, M.D.: Associate Professor of Psychiatry. Washington University School of Medicine. and Assistant Superintendent, Bliss Center; and Robert H. Vanderpearl, M.D.: Clinical Assistant Professor of Psychiatry, Washington University School of Medicine, and Director of the Forensic Service, Malcolm Bliss Mental Health Center, St. Louis, MO. Reprint requests should be addressed to Dr. Fritz A. Henn. Department of Psychiatry, University of Iowa College of Medicine, 500 Newton Road, Iowa City, Iowa 52242. .~,I977 by Grune & Stratton, Inc.
Comprehensive
Psychiatry.
Vol. 18. No. 4 (July/August).
1977
337
HENN.
338
HERJANIC.
AND
VANDERPEARL
presented divided into four time periods: 1952-1958, 1959-1963, 1964-1968, 1969-1973. The first period includes 7 years while the other three are 5 year time periods. A total of 1195 patients were included in the study. They included all admissions to the Forensic Service since its inception, with the exception of about fifty cases from the period of 19541956 for which records were not available.
RESULTS
Referrals of nearly 90% of the cases represented defendants who were accused of crimes in the City of St. Louis; the remaining 10% came from surrounding suburban counties. A large and steadily increasing majority of the cases were referred for pretrial evaluations. Over 80% were seen for this purpose prior to 1958, while in the last 5 years this number has risen to 93%. The remainder usually involved presentence evaluation and 1% (twelve defendants) reevaluation regarding release. The majority of defendants (92%) were referred by courts to obtain a psychiatric opinion regarding competency to stand trial and/or sanity at the time the crime(s) was committed. Eight per cent (93 defendants) were admitted first for treatment because of abnormal behavior (75) or suicide attempt (18) in jail, while the request for psychiatric opinion followed later. The 1195 cases were analyzed for age distribution. Figure 1 illustrates the increasing preponderance of defendants between 20-24 years of age over the course of the study. The proportion of defendants seen in this age bracket accounts for nearly 30% of all patients in the years 1969-1973, while in the earliest
Fig.
1.
increasing
Age
distribution
proportion
of
of
admissions
defendants
below
for
4 time
intervals
25 with each succeeding
at the
Forensic
interval.
Service.
Note
the
FORENSIC
PSYCHIATRY
339
Table 1.
Raceand
1952-1958
Sex Distribution of Defendants
1959-1963
1964-1968
1969-1973
AllCases
Race Black
22%
41%
53%
59%
46%
White
78%
59%
47%
41%
54%
Male
84%
86%
92%
93%
89%
Female
16%
14%
8%
7%
11%
Sax
two periods this group accounted for under 20% of the total. The age distribution of defendants sent for psychiatric evaluation parallels that seen for all defendants in St. Louis. The two exceptions are at the two ends of the age range, juvenile and elderly. Juvenile arrests make up approximately one-fifth of all arrests in the city of St. Louis. The Forensic Service sees a very small proportion of them because they are referred to child psychiatry clinics for evaluation. On the other hand, the percentage of defendants over 35 admitted to the Forensic Service is nearly double that seen in the general criminal population. This is probably accounted for by the increasing accumulation of defendants suffering from dementias and organic brain syndromes. Table 1 shows the racial and sexual breakdown of defendants admitted to the Forensic Service. There is an increasing proportion of black male patients, which probably reflects the changing characteristics of the St. Louis population.* The proportion of males arrested remained constant at about 87% in St. Louis until the last decade. Recently, however, an increasing percentage of males is being referred to the Forensic Service. A comparison of the distribution of the offenses patients referred to the Forensic Service were charged with over four time periods (Table 2) demonstrates a substantial increase in those charged with homicide and assault and a decrease of “other” crimes. “Other” includes a wide range of public offenses, such as vaTable 2. TOM CnmmalCharges
1952-1958 n =183
by Criminal Charges*
1959-1963 n=303
%
%
4.4
1964-1968
1969-1973
n=354
n=355
%
%
5.7
134
18.5
10.3 6.4
6.5 9.7
10.8
16.7
132
11.7
Burglary
11.7
15.3
12.0
11.2
Larceny and Auto Theft ACKKI
10.8 1.5
5.4 17
47
7.2
33
3.0
9.3 0
4.6 0
Homicide Robbery Assault
Forgery and Fraud Narcotic Offenses
-
Distribution of Defendants
28
1.5
0
27
Sexual Offenses
196
24.4
21.2
18.0
Other
26.0
26.7
18.4
9.5
* Includes first charge only.
*Population
of the City of St.
Louis: 1950, 18%
black; 1970,40%
black.
340
HENN.
Table 3. Crimes Against:
AND VANDERPEARL
Distribution of Types of Offenses Charged to Defendants*
1952-1958
-
HERJANIC.
1959-1963
1964-1968
1969-1973
Total
Persons and 36%
44%
55%
62%
56%
Property
Sex Crimes
33%
27%
23%
24%
26%
Public
31%
29%
22%
14%
18%
* Includes first charge only.
grancy, disorderly conduct, etc. This category is decreasing principally due to increasing police awareness that it is not necessary to invoke the criminal justice system to deal with petty offenses in defendants who appear to suffer from a mental illness. The patients are more routinely brought directly to the hospital for treatment without formal criminal charges being filed. Sexual crimes constitute the predominant offense seen on the service and were analyzed in detail elsewhere.3 These consist of several categories of offenses with child molestation being the most prevalent charge, accounting for over 40% of these cases. The steady trend pointed to by the data on crimes becomes evident in Table 3, in which classes of crime against persons, property, and the public have been tabulated for the four time periods. Crimes against the public include all nondestructive offenses such as vagrancy, disturbing the peace, etc. This table reveals a continuing increase in the proportion of crimes against persons referred to the Forensic Service. Whereas at the inception of the service, the three categories of offense were seen roughly in equal proportions, currently over 62% of all defendants are charged with crimes against persons. This points to an ever increasing referral of the violent or potentially violent defendants, many of whom did not suffer from a psychiatric illness. Table 4 shows a tabulation of the proportion of defendants charged with a particular crime sent for forensic evaluation during the period from 1964-1973. This time interval was chosen because complete Forensic Service and police statistics were available. Persons charged with serious crimes were more likely to be referred for psychiatric evaluation; the service examined about 1 of 15 defendants charged with homicide, 1 of 28 arsonists, 1 of 36 sexual offenders, and less than 1 of 100 defendants for all other offenses. Table 4.
Proportion of Arrested Defendants
Crimes Charged
No. Arrested
Referred 1964-1973
NO Admitted
%of Defendants Referred
2083
129
6.50
12,188
113
0.93
Assault
14.796
105
0.70
Burglary
48.192
98
0.20
Larceny and Auto Theft
57,718
46
0.07
651
23
3.53
3909
19
0.48
Homicide Robbery
Arson’ Forgery and Fraud Narcotic Offenses Sexual Offenses ‘Police records available for decade 1964-l
19,260
11
0.05
5868
163
2.77
973 only
FORENSIC
341
PSYCHIATRY
Figure 2 shows the diagnosis given the defendants over four time periods. The diagnosis used was the diagnosis of the court report. Throughout the history of the Forensic Service at Malcolm Bliss, the Kraepelinian tradition has been followed. In particular schizophrenia was given a narrow definition, referring to a chronic, frequently progressive disorder characterized by formal thought disorder, prominent delusions or hallucinations, insidious onset, and poor prepsychotic adjustment. The diagnosis is that described by Langfeldt” and Stevens et al.” Several trends are apparent and deserve comment. First, the proportion of defendants receiving a diagnosis of antisocial personality is nearly double the next most prevalent diagnosis. In addition, the proportion of defendants given the diagnosis of antisocial personality appears to be increasing with successive time periods. It should be noted that these diagnoses were the primary diagnoses received by the defendant, not the secondary diagnoses. Secondly, there has been a marked decrease in the diagnosis of personality disorders other than antisocial personality and a concomitant increase in cases in which no illness was noted in the court report, which reflects the difficulty in forming diagnostic criteria for personality disorders”‘7 and the feeling that these conditions do not constitute a barrier to rendering an individual competent to aid in their own defense or to understand the proceedings against them. Nor was it felt that these conditions would result in a lack of appreciation of the nature, quality, or wrongfulness of one’s conduct or render one incapable of conforming one’s conduct to the requirements of the law. Since we find it difficult to produce well-defined criteria for these diagnoses and
IO) Other Diagnosis
9) Affective Disorder
8) Schizophrenia
71 Mental Retardation
6)
6.1
6.9
16.4
8
75%
62.5%
organic Brain Syndmme
5) Sexual Deviance 4) Alcoholism and Drug Addiction
3) Other Personality Dlsarder
12.5%
Fig. noses the over
2.
Distribution
showing
total _. 4
which
of
diag-
the percentage each
tmw Intervals..
constituted
of
342
HENN,
HERJANIC.
AND VANDERPEARL
Table 5. Distribution of Outcome of Forensic Evaluation Over 4 Time Intervals 1952-1958
1959-1963
1964-1968
1969-1973
Insane
30%
34%
27%
19%
Sane
70%
66%
73%
81%
Competent
83%
71%
78%
94%
Incompetent
17%
29%
22%
6%
since they would not alter the position of the defendant before the court, they are rarely used. It is probable that many of the defendants thought to have “no psychiatric illness” during the last period would have received a diagnosis of a personality disorder (other than antisocial) during previous periods. Most common among them was passive-aggressive personality. Missouri law specifically excludes antisocial personality, alcoholism without psychosis, drug abuse without psychosis, and sexual deviation as mental diseases or defects. These diagnoses, which do not indicate mental disease in the eyes of the court, plus personality disorders and defendants found to have no illness account for 5 1% of all cases seen on the Forensic Service. It is obvious that the court (and the attorneys who may petition in the court) erred on the cautious side requesting psychiatric evaluation for two defendants, only one of whom was found to suffer from a psychiatric illness which could affect his position before the court. Examining the patterns of referral (Tables 2 and 4), it appears that the insanity plea was considered more often when a serious crime was involved. Also, the large number of defendants without a serious psychiatric illness (schizophrenia, affective disorder, organic brain syndrome, and mental retardation) makes it highly probable that most, if not all, of those charged with a crime and suffering from a serious psychiatric illness were referred for evaluation. Of the remaining diagnoses accounting for all mental conditions commonly leading to psychosis, schizophrenia predominates. Combining schizophrenia, probable schizophrenia, and schizoaffective disorders indicates that these conditions account for over 16% of the defendants seen on the Forensic Service. This is approximately twice the rate of the next most prevalent disorders, organic brain syndromes and mental deficiency. Affective disorders are found at a relatively low rate, possibly due to the relatively young age of the defendants. The outcome of the forensic evaluation is shown in Table 5, where the results of sanity evaluations and competency determinations are shown. These data show a striking change in the degree of incompetency reported to the court in the last period, 1969-1973. This decrease reflects the increased efforts at treatment aimed to render defendants competent to stand trial. In parallel with this, a smaller number of defendants were found insane over the last five year period, which reflects both the increased referral of defendants involved in violent assaults, who tend to be antisocial and young, and the decrease of obviously ill petty offenders. COMMENT
In order to place the data describing this Forensic Service in perspective a comparison with reports describing similar services is necessary. This will be restricted to services operating in English-speaking countries for these all share a common legal heritage derived from the M’Naghten Rules.‘” Reports concerning
FORENSIC
343
PSYCHIATRY
forensic psychiatry are often stimulated by changes in the existing legal framework. This was the case in England following the Mental Health Act of 1959.“-” Rollinx commenting on the fourfold increase in male referrals to Horton Hospital subsequent to the Mental Health Act, felt that the Act encouraged the premature discharge of chronic schizophrenic patients to the community. His finding was that the Act was commonly invoked to return chronic schizophrenics to the hospital via prisons for what in large part were trivial legal offenses (vagrancy, petty larceny, etc.) as shown in Table 6. The overwhelming majority of his cases received a diagnosis of schizophrenia. Consistent with this picture is the age distribution of his cases showing an older population. Subsequently, Bearcroft and Donovan” and Bearcroft” published two papers in which they reviewed the structure of another London forensic service. Their conclusion was that the increase in forensic admissions might be due in part to chronic schizophrenics who under current conditions in England could be released to community care. But an even more important factor, they felt, might be the inclusion of psychopathy as a recognized mental disorder. The Act states that psychopathy is “. . a persistent disorder. .. of mind . . which results in abnormally aggressive or seriously irresponsible conduct . . and which requires or is susceptible to medical treatment.” The data in Table 6 suggest that their sample was more influenced by this type of individual than Rollin’s population. This is born out by the fact that 25% of defendants in Bearcroft’s study received a primary diagnosis of antisocial personality. This may reflect differences in the catchment areas of the two services studied: Bearcroft worked in a hospital serving the east end of London, while Rollin’s study took place in Horton Hospital serving metropolitan London. Bearcroft and coworkers felt that social factors played a crucial role in determining which mentally ill patients came into conflict with the law. The factors isolated were high mobility, low level skills, divorce, and a background of being raised in a broken home. Binns and coworkers”*‘” reviewed both in- and outpatient court referrals to a forensic service in Glasgow, Scotland. Their study took place in a hospital which handled a quarter of all involuntary commitments in Scotland under Section 54 of the Mental Health Act, and illustrates some of the points suggested by the present study. Those defendants remanded for inpatient evaluation in general were suffering from more serious mental illness, while those examined on an outpatient basis had less severe mental illness. As we also found, the tendency for serious crimes was greatest among those suffering from antisocial personality as opposed to a serious psychotic illness. This is seen in Table 5 where the outpatient population is charged with offenses against people or property in nearly 70% of the cases, while the inpatient population carried such charges only 37% of the time. Also in accord with our findings is the age distribution among the two groups. We suggest that defendants suffering from serious chronic mental illness appear to Table 6. Distribution of Criminal Offenses in Various Forensic Services Crimes Agamst
Binns Inpatient”
Bearcrof?
Persons and Sex Crimes
14%
25%
34%
20%
55%
56%
Property
52%
53%
36%
17%
34%
26%
Public
34%
22%
30%
63%
11%
1 8%
344
HENN.
HERJANIC.
AND VANDERPEARL
continue to have problems throughout life. whereas antisocial defendants appear as agroup to have much less trouble after 40. This is suggested by the fact that the proportion of defendants over 40 seen in the St. Louis Forensic Service having a diagnosis of antisocial personality is under 8% of antisocial defendants, while those over 40 in the schizophrenic group comprise over 27% of those having this diagnosis. Since the inpatient group reported by the Scottish workers reflects defendants suffering from chronic mental illness while the outpatient group is skewed toward antisocial offenders, it is gratifying that the outpatients prove to be a considerably younger group. Jablon et a1.13 reviewed a forensic service operating within a Philadelphia area prison. In this setting, defendants are admitted to the hospital for a 60 day observation period during which they are treated and evaluated. At the end of the period, the psychiatric report is forwarded to the court and the court determines the disposition for each defendant. The case load at this hospital primarily includes those individuals charged with major felonies. This population resembles that seen in Binns’ outpatient group and our study to some extent. For example, nearly 11% of the defendants were charged with murder, similar to the proportion found in our sample. In contrast to our results, 43% of the defendants in Jablon’s cohort received a diagnosis of schizophrenia. Unfortunately, little is said about the criteria for this diagnosis, so further comparison is impossible. They found 42% of their defendants suffering from personality disorders. Since the rate of admission into the Philadelphia service (240 cases over two years) is consistent with the rate of admission observed in St. Louis, it would be of interest to know the breakdown of crimes charged to individuals carrying a diagnosis of schizophrenia. From our results, one would expect that this preponderance of schizophrenics would be accounted for by relatively minor charges. This was certainly true of those patients study of defendants admitted to Boston who were called psychotic in McGarry’s” State Hospital. In this study, 29% of defendants were called psychotic, with 13.1% suffering from schizophrenia, 8.4% from organic brain syndromes, and 7.5% from affective disorders. These 27 patients accounted for only nine charges against either persons or property with the overwhelming majority of charges being for petty offenses. Our study revealed that in St. Louis there have been steady trends over time which have redefined the nature of referrals to the Forensic Service. First, there is an increase of young male defendants. Second, there is an increase in defendants being charged with violent crimes. Third, there is an increase in defendants with diagnoses which do not, under Missouri law, constitute grounds for a plea of insanity, such as antisocial personality, drug or alcohol abuse. And finally, during the most recent period, there is an increase in the proportion of defendants found competent to stand trial. Referral patterns to a forensic service are not purely a reflection of the psychiatric illness present among criminal defendants. The patterns are determined by the courts and depend in part on the philosophy as well as index of suspicion concerning psychiatric illness found among prosecutors and attorneys for the defense. The increase in referrals of young, antisocial, chemically-dependent (drugs and alcohol) males reflects the principal problem of the criminal justice system, and may be a plea for some guidance from psychiatry. It appears that psychiatry has had only limited success in dealing with these research is greatly problems,15 and this may suggest an area in which treatment
FORENSIC
345
PSYCHIATRY
needed. The proportion of antisocial or drug-abusing patients seen in Englishspeaking forensic services appears to vary both as a function of the catchment of the particular service and the laws applicable to the region in which the service is located. From the reports of the Scottish service, it appears that this category of individual is often dealt with via outpatient evaluation either in prison or while out on bail. The problems of antisocial personality, alcoholism, and drug abuse dominate psychiatric conditions found among convicted felons from the recent studies of Guze and co-workers.‘“P’X They did not find psychosis to be a factor in convicted felons and so it appears that, in Missouri, those cases do get referred to a psychiatric facility and they are separated out through the process of pretrial evaluation. SUMMARY
An examination of an urban forensic service over a 22 year period was undertaken by reviewing the records of 1195 defendants admitted. This revealed an increasing referral of violent and youthful defendants. Referral rates were highest for homicide. The prominent diagnosis seen was antisocial personality (27%), while schizophrenia (16%) was the next most common diagnosis. The reports to the court indicate an increasing tendency toward a finding of competency to stand trial as a result of increasing pretrial treatment. These data are compared to reports for other English-speaking forensic services and a correlation between admissions of schizophrenic defendants and a tendency toward relatively minor criminal offenses is seen. REFERENCES I, Szasz TS: Mental illness as metaphor. Nature 242:305 307, 1973 2. Bazelon DL: The perils of wizardry. Am J Psychiatr 131:1317~1322, 1974 3. Henn FA, Herjanic M, Vanderpearl RH: Forensic psychiatry: Profiles of sexual offenders. Am J Psychiatr 133:694- 696, 1976 4. Langfeldt LG: The prognosis rn schizophrenia. Acta Psychiatr Stand (Suppl) I IO, 1956 5. Stevens JH, Astrup C, Mangrum JC: Prognostic factors in recovered and deteriorated schizophrenics. Am J Psychiatr 122:1116~1120, 1966 6. Liss J, Weiner A, Robins E: Personality disorder. Part I: Record study. Br J Psychiatr 123:685 -692, 1973 7. Weiner A. Liss J, Robins E: Personality disorder: Part II. Follow-up. Br J Psychiatr 124:359-366, 1974 8. Rollin HR: Social and legal repercussions of the Mental Health Act, 1959. Br Med J 1:786-788, 1963 9. Bearcroft JS, Donovan MD: Psychiatric referrals from courts and prisons. Br Med J 2:1519-1523, 1965 IO. Bearcroft JS: A comparison of psychiatric admissions from prison and other sources. Br J Psychiatr 112:58 I-587, 1966 I I. Binns JK. Carlisle J, Nimmo D, et al: Re-
manded in hospital for psychiatric examination. Br J Psychiatr 115:112551132, 1969 12. Binns JK, Carlisle J, Nimmo D, et al: Remanded in custody for psychiatric examination. Br J Psychiatr Il5:1133~1139. 1969 13. Jablon N, Sadoff R, Heller M: A unique forensic diagnostic hospital. Am J Psychiatr 126:1663-1667, 1970 14. McGarry L: Competency process via the state hospital. 122:623 -630, 1965
for trial and due Am J Psychiatr
15. Levine W, Bornstein P: Is the sociopath treatable? The contribution of psychiatry to a legal dilemma. Washington University Law Quart 693 -7 1I, 1972 16. Guze Psychiatric reference to J Nerv Ment
SB, Tuason VB, Gatfield PD, et al: illness and crime with particular alcoholism: A study of 223 criminals. Dis 134:512-521, 1962
17. Guze SB, Goodwin DW, Crane B: Criminal recidivism and psychiatric illness. Am J Psychiatr 127:832-835, 1970 18. Cloninger R, Guze SB: Psychiatric illness and female criminality: The role of sociopathy and hysteria in the antisocial woman. Am J Psychiatr 127:303331 I, 1970 19. Daniel M’Naughten’s Fin. 200, 8 English Reports.
Case, 10 Clark 718, 1843
and
Marijan
Anatomy
Herjanic.
and Robert
of a Service H. Vanderpearl
C
RIMINAL BEHAVIOR and its relationship to psychiatric illness poses a real dilemma to both the court and psychiatrist. Nowhere are the ethical problems in defining the rights of the individual versus the rights of society more clearly etched than in the questions of commitment and competency. The role of psychiatry in this area has been strongly challenged both from within the profession’ and by leading jurists.’ In order to respond, it is useful to review the record and document in detail the workings of a forensic service. Data such as these can serve to illuminate the scope of the problem, and ideally focus the debate on substantive issues. They can also provide a longitudinal view of how one service evolved in dealing with the complex area of criminal responsibility and competency. They cannot nor should they be thought to provide solutions to the philosophic issues. This must come in an ongoing dialogue between spokesmen for psychiatry, law, and society as a whole, but must be anchored to what we do know, in an area in which much remains undetermined. This study reviews the 22 year history of the Forensic Service at Malcolm Bliss Mental Health Center. The center was constructed in 1938 as the psychiatric unit of the St. Louis City Hospital. It provided evaluation and short-term treatment for city residents, becoming part of the State of Missouri’s mental health system in 1964 and a community mental health center in 1966. A separately organized forensic service was initiated at Malcolm Bliss Mental Health Center in 1952. It was responsible for all court referrals in the City of St. Louis and has been staffed by a psychiatrist, resident psychiatrist, psychologist, and a social worker. Between eight and twelve beds have been available to the service on general psychiatric wards and evaluation of defendants and their court reports were carried out by a team specially assigned to this task. MATERIALS
AND
METHODS
The Forensic Service records of ah patients admitted to the service since its inception in 1952 were reviewed by the authors. The patients on whom no report was rendered to the court were excluded from the study. A form containing demographic data, source of referral, purpose of the examination, crimes charged, psychiatric diagnosis, and the report to the court was made out for each patient. The data were coded and punched on computer cards and processed. For convenience, the data will be
From the Department of Psychiatry, The University of Iowa College of Medicine, Iowa City, Iowa, and Malcolm Bliss Mental Health Center and Washington University School of Medicine, St. Louis. Mo. Fritz A. Henn, Ph.D., M.D.: Assistant Professor of Psychiatry, University of Iowa College of Medicine, Iowa City, Iowa; Marijan Herjanic, M.D.: Associate Professor of Psychiatry. Washington University School of Medicine. and Assistant Superintendent, Bliss Center; and Robert H. Vanderpearl, M.D.: Clinical Assistant Professor of Psychiatry, Washington University School of Medicine, and Director of the Forensic Service, Malcolm Bliss Mental Health Center, St. Louis, MO. Reprint requests should be addressed to Dr. Fritz A. Henn. Department of Psychiatry, University of Iowa College of Medicine, 500 Newton Road, Iowa City, Iowa 52242. .~,I977 by Grune & Stratton, Inc.
Comprehensive
Psychiatry.
Vol. 18. No. 4 (July/August).
1977
337
HENN.
338
HERJANIC.
AND
VANDERPEARL
presented divided into four time periods: 1952-1958, 1959-1963, 1964-1968, 1969-1973. The first period includes 7 years while the other three are 5 year time periods. A total of 1195 patients were included in the study. They included all admissions to the Forensic Service since its inception, with the exception of about fifty cases from the period of 19541956 for which records were not available.
RESULTS
Referrals of nearly 90% of the cases represented defendants who were accused of crimes in the City of St. Louis; the remaining 10% came from surrounding suburban counties. A large and steadily increasing majority of the cases were referred for pretrial evaluations. Over 80% were seen for this purpose prior to 1958, while in the last 5 years this number has risen to 93%. The remainder usually involved presentence evaluation and 1% (twelve defendants) reevaluation regarding release. The majority of defendants (92%) were referred by courts to obtain a psychiatric opinion regarding competency to stand trial and/or sanity at the time the crime(s) was committed. Eight per cent (93 defendants) were admitted first for treatment because of abnormal behavior (75) or suicide attempt (18) in jail, while the request for psychiatric opinion followed later. The 1195 cases were analyzed for age distribution. Figure 1 illustrates the increasing preponderance of defendants between 20-24 years of age over the course of the study. The proportion of defendants seen in this age bracket accounts for nearly 30% of all patients in the years 1969-1973, while in the earliest
Fig.
1.
increasing
Age
distribution
proportion
of
of
admissions
defendants
below
for
4 time
intervals
25 with each succeeding
at the
Forensic
interval.
Service.
Note
the
FORENSIC
PSYCHIATRY
339
Table 1.
Raceand
1952-1958
Sex Distribution of Defendants
1959-1963
1964-1968
1969-1973
AllCases
Race Black
22%
41%
53%
59%
46%
White
78%
59%
47%
41%
54%
Male
84%
86%
92%
93%
89%
Female
16%
14%
8%
7%
11%
Sax
two periods this group accounted for under 20% of the total. The age distribution of defendants sent for psychiatric evaluation parallels that seen for all defendants in St. Louis. The two exceptions are at the two ends of the age range, juvenile and elderly. Juvenile arrests make up approximately one-fifth of all arrests in the city of St. Louis. The Forensic Service sees a very small proportion of them because they are referred to child psychiatry clinics for evaluation. On the other hand, the percentage of defendants over 35 admitted to the Forensic Service is nearly double that seen in the general criminal population. This is probably accounted for by the increasing accumulation of defendants suffering from dementias and organic brain syndromes. Table 1 shows the racial and sexual breakdown of defendants admitted to the Forensic Service. There is an increasing proportion of black male patients, which probably reflects the changing characteristics of the St. Louis population.* The proportion of males arrested remained constant at about 87% in St. Louis until the last decade. Recently, however, an increasing percentage of males is being referred to the Forensic Service. A comparison of the distribution of the offenses patients referred to the Forensic Service were charged with over four time periods (Table 2) demonstrates a substantial increase in those charged with homicide and assault and a decrease of “other” crimes. “Other” includes a wide range of public offenses, such as vaTable 2. TOM CnmmalCharges
1952-1958 n =183
by Criminal Charges*
1959-1963 n=303
%
%
4.4
1964-1968
1969-1973
n=354
n=355
%
%
5.7
134
18.5
10.3 6.4
6.5 9.7
10.8
16.7
132
11.7
Burglary
11.7
15.3
12.0
11.2
Larceny and Auto Theft ACKKI
10.8 1.5
5.4 17
47
7.2
33
3.0
9.3 0
4.6 0
Homicide Robbery Assault
Forgery and Fraud Narcotic Offenses
-
Distribution of Defendants
28
1.5
0
27
Sexual Offenses
196
24.4
21.2
18.0
Other
26.0
26.7
18.4
9.5
* Includes first charge only.
*Population
of the City of St.
Louis: 1950, 18%
black; 1970,40%
black.
340
HENN.
Table 3. Crimes Against:
AND VANDERPEARL
Distribution of Types of Offenses Charged to Defendants*
1952-1958
-
HERJANIC.
1959-1963
1964-1968
1969-1973
Total
Persons and 36%
44%
55%
62%
56%
Property
Sex Crimes
33%
27%
23%
24%
26%
Public
31%
29%
22%
14%
18%
* Includes first charge only.
grancy, disorderly conduct, etc. This category is decreasing principally due to increasing police awareness that it is not necessary to invoke the criminal justice system to deal with petty offenses in defendants who appear to suffer from a mental illness. The patients are more routinely brought directly to the hospital for treatment without formal criminal charges being filed. Sexual crimes constitute the predominant offense seen on the service and were analyzed in detail elsewhere.3 These consist of several categories of offenses with child molestation being the most prevalent charge, accounting for over 40% of these cases. The steady trend pointed to by the data on crimes becomes evident in Table 3, in which classes of crime against persons, property, and the public have been tabulated for the four time periods. Crimes against the public include all nondestructive offenses such as vagrancy, disturbing the peace, etc. This table reveals a continuing increase in the proportion of crimes against persons referred to the Forensic Service. Whereas at the inception of the service, the three categories of offense were seen roughly in equal proportions, currently over 62% of all defendants are charged with crimes against persons. This points to an ever increasing referral of the violent or potentially violent defendants, many of whom did not suffer from a psychiatric illness. Table 4 shows a tabulation of the proportion of defendants charged with a particular crime sent for forensic evaluation during the period from 1964-1973. This time interval was chosen because complete Forensic Service and police statistics were available. Persons charged with serious crimes were more likely to be referred for psychiatric evaluation; the service examined about 1 of 15 defendants charged with homicide, 1 of 28 arsonists, 1 of 36 sexual offenders, and less than 1 of 100 defendants for all other offenses. Table 4.
Proportion of Arrested Defendants
Crimes Charged
No. Arrested
Referred 1964-1973
NO Admitted
%of Defendants Referred
2083
129
6.50
12,188
113
0.93
Assault
14.796
105
0.70
Burglary
48.192
98
0.20
Larceny and Auto Theft
57,718
46
0.07
651
23
3.53
3909
19
0.48
Homicide Robbery
Arson’ Forgery and Fraud Narcotic Offenses Sexual Offenses ‘Police records available for decade 1964-l
19,260
11
0.05
5868
163
2.77
973 only
FORENSIC
341
PSYCHIATRY
Figure 2 shows the diagnosis given the defendants over four time periods. The diagnosis used was the diagnosis of the court report. Throughout the history of the Forensic Service at Malcolm Bliss, the Kraepelinian tradition has been followed. In particular schizophrenia was given a narrow definition, referring to a chronic, frequently progressive disorder characterized by formal thought disorder, prominent delusions or hallucinations, insidious onset, and poor prepsychotic adjustment. The diagnosis is that described by Langfeldt” and Stevens et al.” Several trends are apparent and deserve comment. First, the proportion of defendants receiving a diagnosis of antisocial personality is nearly double the next most prevalent diagnosis. In addition, the proportion of defendants given the diagnosis of antisocial personality appears to be increasing with successive time periods. It should be noted that these diagnoses were the primary diagnoses received by the defendant, not the secondary diagnoses. Secondly, there has been a marked decrease in the diagnosis of personality disorders other than antisocial personality and a concomitant increase in cases in which no illness was noted in the court report, which reflects the difficulty in forming diagnostic criteria for personality disorders”‘7 and the feeling that these conditions do not constitute a barrier to rendering an individual competent to aid in their own defense or to understand the proceedings against them. Nor was it felt that these conditions would result in a lack of appreciation of the nature, quality, or wrongfulness of one’s conduct or render one incapable of conforming one’s conduct to the requirements of the law. Since we find it difficult to produce well-defined criteria for these diagnoses and
IO) Other Diagnosis
9) Affective Disorder
8) Schizophrenia
71 Mental Retardation
6)
6.1
6.9
16.4
8
75%
62.5%
organic Brain Syndmme
5) Sexual Deviance 4) Alcoholism and Drug Addiction
3) Other Personality Dlsarder
12.5%
Fig. noses the over
2.
Distribution
showing
total _. 4
which
of
diag-
the percentage each
tmw Intervals..
constituted
of
342
HENN,
HERJANIC.
AND VANDERPEARL
Table 5. Distribution of Outcome of Forensic Evaluation Over 4 Time Intervals 1952-1958
1959-1963
1964-1968
1969-1973
Insane
30%
34%
27%
19%
Sane
70%
66%
73%
81%
Competent
83%
71%
78%
94%
Incompetent
17%
29%
22%
6%
since they would not alter the position of the defendant before the court, they are rarely used. It is probable that many of the defendants thought to have “no psychiatric illness” during the last period would have received a diagnosis of a personality disorder (other than antisocial) during previous periods. Most common among them was passive-aggressive personality. Missouri law specifically excludes antisocial personality, alcoholism without psychosis, drug abuse without psychosis, and sexual deviation as mental diseases or defects. These diagnoses, which do not indicate mental disease in the eyes of the court, plus personality disorders and defendants found to have no illness account for 5 1% of all cases seen on the Forensic Service. It is obvious that the court (and the attorneys who may petition in the court) erred on the cautious side requesting psychiatric evaluation for two defendants, only one of whom was found to suffer from a psychiatric illness which could affect his position before the court. Examining the patterns of referral (Tables 2 and 4), it appears that the insanity plea was considered more often when a serious crime was involved. Also, the large number of defendants without a serious psychiatric illness (schizophrenia, affective disorder, organic brain syndrome, and mental retardation) makes it highly probable that most, if not all, of those charged with a crime and suffering from a serious psychiatric illness were referred for evaluation. Of the remaining diagnoses accounting for all mental conditions commonly leading to psychosis, schizophrenia predominates. Combining schizophrenia, probable schizophrenia, and schizoaffective disorders indicates that these conditions account for over 16% of the defendants seen on the Forensic Service. This is approximately twice the rate of the next most prevalent disorders, organic brain syndromes and mental deficiency. Affective disorders are found at a relatively low rate, possibly due to the relatively young age of the defendants. The outcome of the forensic evaluation is shown in Table 5, where the results of sanity evaluations and competency determinations are shown. These data show a striking change in the degree of incompetency reported to the court in the last period, 1969-1973. This decrease reflects the increased efforts at treatment aimed to render defendants competent to stand trial. In parallel with this, a smaller number of defendants were found insane over the last five year period, which reflects both the increased referral of defendants involved in violent assaults, who tend to be antisocial and young, and the decrease of obviously ill petty offenders. COMMENT
In order to place the data describing this Forensic Service in perspective a comparison with reports describing similar services is necessary. This will be restricted to services operating in English-speaking countries for these all share a common legal heritage derived from the M’Naghten Rules.‘” Reports concerning
FORENSIC
343
PSYCHIATRY
forensic psychiatry are often stimulated by changes in the existing legal framework. This was the case in England following the Mental Health Act of 1959.“-” Rollinx commenting on the fourfold increase in male referrals to Horton Hospital subsequent to the Mental Health Act, felt that the Act encouraged the premature discharge of chronic schizophrenic patients to the community. His finding was that the Act was commonly invoked to return chronic schizophrenics to the hospital via prisons for what in large part were trivial legal offenses (vagrancy, petty larceny, etc.) as shown in Table 6. The overwhelming majority of his cases received a diagnosis of schizophrenia. Consistent with this picture is the age distribution of his cases showing an older population. Subsequently, Bearcroft and Donovan” and Bearcroft” published two papers in which they reviewed the structure of another London forensic service. Their conclusion was that the increase in forensic admissions might be due in part to chronic schizophrenics who under current conditions in England could be released to community care. But an even more important factor, they felt, might be the inclusion of psychopathy as a recognized mental disorder. The Act states that psychopathy is “. . a persistent disorder. .. of mind . . which results in abnormally aggressive or seriously irresponsible conduct . . and which requires or is susceptible to medical treatment.” The data in Table 6 suggest that their sample was more influenced by this type of individual than Rollin’s population. This is born out by the fact that 25% of defendants in Bearcroft’s study received a primary diagnosis of antisocial personality. This may reflect differences in the catchment areas of the two services studied: Bearcroft worked in a hospital serving the east end of London, while Rollin’s study took place in Horton Hospital serving metropolitan London. Bearcroft and coworkers felt that social factors played a crucial role in determining which mentally ill patients came into conflict with the law. The factors isolated were high mobility, low level skills, divorce, and a background of being raised in a broken home. Binns and coworkers”*‘” reviewed both in- and outpatient court referrals to a forensic service in Glasgow, Scotland. Their study took place in a hospital which handled a quarter of all involuntary commitments in Scotland under Section 54 of the Mental Health Act, and illustrates some of the points suggested by the present study. Those defendants remanded for inpatient evaluation in general were suffering from more serious mental illness, while those examined on an outpatient basis had less severe mental illness. As we also found, the tendency for serious crimes was greatest among those suffering from antisocial personality as opposed to a serious psychotic illness. This is seen in Table 5 where the outpatient population is charged with offenses against people or property in nearly 70% of the cases, while the inpatient population carried such charges only 37% of the time. Also in accord with our findings is the age distribution among the two groups. We suggest that defendants suffering from serious chronic mental illness appear to Table 6. Distribution of Criminal Offenses in Various Forensic Services Crimes Agamst
Binns Inpatient”
Bearcrof?
Persons and Sex Crimes
14%
25%
34%
20%
55%
56%
Property
52%
53%
36%
17%
34%
26%
Public
34%
22%
30%
63%
11%
1 8%
344
HENN.
HERJANIC.
AND VANDERPEARL
continue to have problems throughout life. whereas antisocial defendants appear as agroup to have much less trouble after 40. This is suggested by the fact that the proportion of defendants over 40 seen in the St. Louis Forensic Service having a diagnosis of antisocial personality is under 8% of antisocial defendants, while those over 40 in the schizophrenic group comprise over 27% of those having this diagnosis. Since the inpatient group reported by the Scottish workers reflects defendants suffering from chronic mental illness while the outpatient group is skewed toward antisocial offenders, it is gratifying that the outpatients prove to be a considerably younger group. Jablon et a1.13 reviewed a forensic service operating within a Philadelphia area prison. In this setting, defendants are admitted to the hospital for a 60 day observation period during which they are treated and evaluated. At the end of the period, the psychiatric report is forwarded to the court and the court determines the disposition for each defendant. The case load at this hospital primarily includes those individuals charged with major felonies. This population resembles that seen in Binns’ outpatient group and our study to some extent. For example, nearly 11% of the defendants were charged with murder, similar to the proportion found in our sample. In contrast to our results, 43% of the defendants in Jablon’s cohort received a diagnosis of schizophrenia. Unfortunately, little is said about the criteria for this diagnosis, so further comparison is impossible. They found 42% of their defendants suffering from personality disorders. Since the rate of admission into the Philadelphia service (240 cases over two years) is consistent with the rate of admission observed in St. Louis, it would be of interest to know the breakdown of crimes charged to individuals carrying a diagnosis of schizophrenia. From our results, one would expect that this preponderance of schizophrenics would be accounted for by relatively minor charges. This was certainly true of those patients study of defendants admitted to Boston who were called psychotic in McGarry’s” State Hospital. In this study, 29% of defendants were called psychotic, with 13.1% suffering from schizophrenia, 8.4% from organic brain syndromes, and 7.5% from affective disorders. These 27 patients accounted for only nine charges against either persons or property with the overwhelming majority of charges being for petty offenses. Our study revealed that in St. Louis there have been steady trends over time which have redefined the nature of referrals to the Forensic Service. First, there is an increase of young male defendants. Second, there is an increase in defendants being charged with violent crimes. Third, there is an increase in defendants with diagnoses which do not, under Missouri law, constitute grounds for a plea of insanity, such as antisocial personality, drug or alcohol abuse. And finally, during the most recent period, there is an increase in the proportion of defendants found competent to stand trial. Referral patterns to a forensic service are not purely a reflection of the psychiatric illness present among criminal defendants. The patterns are determined by the courts and depend in part on the philosophy as well as index of suspicion concerning psychiatric illness found among prosecutors and attorneys for the defense. The increase in referrals of young, antisocial, chemically-dependent (drugs and alcohol) males reflects the principal problem of the criminal justice system, and may be a plea for some guidance from psychiatry. It appears that psychiatry has had only limited success in dealing with these research is greatly problems,15 and this may suggest an area in which treatment
FORENSIC
345
PSYCHIATRY
needed. The proportion of antisocial or drug-abusing patients seen in Englishspeaking forensic services appears to vary both as a function of the catchment of the particular service and the laws applicable to the region in which the service is located. From the reports of the Scottish service, it appears that this category of individual is often dealt with via outpatient evaluation either in prison or while out on bail. The problems of antisocial personality, alcoholism, and drug abuse dominate psychiatric conditions found among convicted felons from the recent studies of Guze and co-workers.‘“P’X They did not find psychosis to be a factor in convicted felons and so it appears that, in Missouri, those cases do get referred to a psychiatric facility and they are separated out through the process of pretrial evaluation. SUMMARY
An examination of an urban forensic service over a 22 year period was undertaken by reviewing the records of 1195 defendants admitted. This revealed an increasing referral of violent and youthful defendants. Referral rates were highest for homicide. The prominent diagnosis seen was antisocial personality (27%), while schizophrenia (16%) was the next most common diagnosis. The reports to the court indicate an increasing tendency toward a finding of competency to stand trial as a result of increasing pretrial treatment. These data are compared to reports for other English-speaking forensic services and a correlation between admissions of schizophrenic defendants and a tendency toward relatively minor criminal offenses is seen. REFERENCES I, Szasz TS: Mental illness as metaphor. Nature 242:305 307, 1973 2. Bazelon DL: The perils of wizardry. Am J Psychiatr 131:1317~1322, 1974 3. Henn FA, Herjanic M, Vanderpearl RH: Forensic psychiatry: Profiles of sexual offenders. Am J Psychiatr 133:694- 696, 1976 4. Langfeldt LG: The prognosis rn schizophrenia. Acta Psychiatr Stand (Suppl) I IO, 1956 5. Stevens JH, Astrup C, Mangrum JC: Prognostic factors in recovered and deteriorated schizophrenics. Am J Psychiatr 122:1116~1120, 1966 6. Liss J, Weiner A, Robins E: Personality disorder. Part I: Record study. Br J Psychiatr 123:685 -692, 1973 7. Weiner A. Liss J, Robins E: Personality disorder: Part II. Follow-up. Br J Psychiatr 124:359-366, 1974 8. Rollin HR: Social and legal repercussions of the Mental Health Act, 1959. Br Med J 1:786-788, 1963 9. Bearcroft JS, Donovan MD: Psychiatric referrals from courts and prisons. Br Med J 2:1519-1523, 1965 IO. Bearcroft JS: A comparison of psychiatric admissions from prison and other sources. Br J Psychiatr 112:58 I-587, 1966 I I. Binns JK. Carlisle J, Nimmo D, et al: Re-
manded in hospital for psychiatric examination. Br J Psychiatr 115:112551132, 1969 12. Binns JK, Carlisle J, Nimmo D, et al: Remanded in custody for psychiatric examination. Br J Psychiatr Il5:1133~1139. 1969 13. Jablon N, Sadoff R, Heller M: A unique forensic diagnostic hospital. Am J Psychiatr 126:1663-1667, 1970 14. McGarry L: Competency process via the state hospital. 122:623 -630, 1965
for trial and due Am J Psychiatr
15. Levine W, Bornstein P: Is the sociopath treatable? The contribution of psychiatry to a legal dilemma. Washington University Law Quart 693 -7 1I, 1972 16. Guze Psychiatric reference to J Nerv Ment
SB, Tuason VB, Gatfield PD, et al: illness and crime with particular alcoholism: A study of 223 criminals. Dis 134:512-521, 1962
17. Guze SB, Goodwin DW, Crane B: Criminal recidivism and psychiatric illness. Am J Psychiatr 127:832-835, 1970 18. Cloninger R, Guze SB: Psychiatric illness and female criminality: The role of sociopathy and hysteria in the antisocial woman. Am J Psychiatr 127:303331 I, 1970 19. Daniel M’Naughten’s Fin. 200, 8 English Reports.
Case, 10 Clark 718, 1843
and
