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Rom J Leg Med [18] 289 294 [2010] DOI: 10.4323/rjlm.2010.289
2010 Romanian Society of Legal Medicine
________________________ *!) Corresponding author, MD, PhD,
Psychiatry and for Safety Measures Hospital Sapoca, Buzau, E-mail:
[email protected], Phone: 0238 528146, fax: 0238528474; 2)
Professor, MD, PhD, University of Medicine and Pharmacy Gr. T. Popa
Iasi; Clinical Hospital of Psychiatry Socola, Iasi; 3) MD, PhD,
Chairperson, Medical - Legal Services, Buzau County; 4) Professor,
MD, PhD, University of Medicine and Pharmacy Gr. T. Popa Iasi,
Clinical Hospital of Psychiatry Socola, Iasi
289
Assessement and management of violence risk in Forensic
Psychiatry Monica Moescu*1, Roxana Chiri2, Magdalena Dragu3, Vasile
Chiri4
____________________________________________________________________________
Abstract: In an atempt to evaluate the accuracy of
risk-assessment and risk-management of violence especially for
mentally ill persons, we performed a statistical analisys
(crosstabulations, factor analysis) based on a retrospective study
of 176 clinical files of adult patients hospitalized during three
years at SPMS Sapoca for forensic psychiatric evaluation. Our study
revealed that psychotic disorder didn't significantly associate
with the violence of the offence even when it is dually diagnosed
with personality disorder but it was strongly associated with the
lack of judgement. A positive and significant correlation was
demonstrated between judgement and the proposed safety measure.
Key words: forensic psychiatry, risk-assessment,
risk-management
he psychiatric medico-legal examination, common land of legal
medicine and psychiatry, is the work of interdisciplinary and
scientific research where the responsibility and ethical
consciousness of experts is committed to the highest degree [1].
V. Gheorghiu (2008) emphasizes: the psychiatric medical legal
expertise is primarily a scientific work, being developed by
complying with rigorous scientific standards, in accordance with
national and international regulations of classification of the
diseases and of the methods of analyse and expert
evaluation[2].
Forensic psychiatric assessment is considered to be a crucial
element in the judicial process, influencing all subsequent
decisions on sentence, detention, placement or treatment of the
person concerned [3].
There are a huge interest in the last years regarding
relationship between mental disorders (especially psychotic
disorders) and violence. Not every mentally ill person is
dangerous. And even if he/she is part of a pathological class with
high risk of aggression, how a psychiatrist can foresee an
aggressive act that would happen? [4]. There are a large consensus
to accept good results of assesment and management of violence risk
so every medical-legal psychiatric examination should respect
principles of risk-assessment and risk-management. Violence, even
that of the mentally ill person, is not purely a psychiatric
problem but also social and legal issue making the problem of
danger a socio-criminological and psychiatric complex problem
[5].
This is a reason for what risk assessment considers clinical and
historical data obtained from patient, family or other official
records. Risk assessment focused especially on prediction of
violence of mentally ill and this represents a form of primary
prevention of violence. But risk assessment with his clinical
applications leads also to risk management which, pointedly,
identifies risk factors and protective factors for violence and
build individual treatment strategies. This paper analyse a small
sample of forensic psychiatric examination looking for risk factors
of violence focusing especially on relationship between violence
and psychotic disorders.
T
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Mosescu M et al Assessement and management of violence risk in
Forensic Psychiatry
290
Material and Methods The study is retrospective, passive,
uncontrolled by documents (case report forms) of adults
hospitalized in order to be forensic psychiatric evaluated
between 01.01.2006-31.12.2008 in SPMS Sapoca. We followed 16
variables: age, sex, marital status, location, occupation,
education, diagnosis (I and II axis), co morbidity, psychiatric,
criminal and forensic records, complementary investigation,
offence, judgement, proposed safety measure. The diagnoses were
established according to ICD-10 criteria (International
Classification of Diseases ) and personality disorder was evaluated
based on SCID-II (Structured Clinical Interview for DSM axis II).
After the recodifications there were obtained 15 variables, each
containing between two and five items (table no 1).We used
Statistical Package for the Social Sciences (SPSS) version 17.0
(for Windows Vista).
The final number of participants was N=176 (exclusion criteria:
civil cases and cases with incomplete information). It has been
respected the ethical rules of the scientific research based on
documents, the work being approved by the Board of Ethics of SPMS
Sapoca.
Working hypothesis: the demonstration of the importance of the
psychiatric medical legal examination in the assessment and risk
management of violence. We mention that Buzau county is
characterized by the absence of significant variations from the
national average regarding the facts committed with great violence
[6].
We calculated the frequencies, percentiles and a correlative
bivariate analysis was performed. Following the results of
bivariate correlation it was performed cross tabulation on
relations assessed as significant. Depending on the main results
obtained it was made a classification of the factors that may
interfere in assessment and risk management through hierarchical
cluster and a dimensional factorial reduction using the Variant
method in 3 rotations.
Results and Discussions Sample Characteristics We noticed the
dominance of men (86,4%) and the age group 26-45 years (51,1%) and
of the rural
residence (67,3%). There were encountered extreme ages of 18 and
respective 79 years and the average age was 37.9 years. Data
regarding the sex and age group corresponds with literature of
speciality [5, 7, 8, 9, 10]. The repartition on origin depends on
the characteristics of the country and of the county (Table 1).
Personality disorders (41,2%) was more diagnosed then psychotic
disorders (15,3%). Psychotic disorders had the same representation
(13,5%) in both age groups 26-45 years and 46-64 years and there
were absent in the age group over 65 years. In our study there are
different data obtained compared to those at INML (National
Institute of Legal Medicine) Bucuresti [7] and IML (Institute of
Legal Medicine) Iasi [5] regarding the psychotic disorders and
schizophrenia in particular. The differences are mainly caused by
the method of selection of local judicial system on request of
forensic assessment and of Buzau county profile with a lower
prevalence of psychotic disorder compared to the rest of the
country. Observation demonstrates the need for relevant
multi-centre study of such data.
The offence provided by the Penal Code, as the reason for
psychiatric medical legal examination was theft in 23,6% of cases
while offences with aggressive component represented 56,6% of all.
Comparative to study from IML Iasi [5] there are no big differences
regarding the theft dominance but in the study from INML Bucuresti
[7] the murder dominated with 16,2% from all, because
methodological through which at Bucuresti there are psychiatric
medical-legal evaluated the prisoners who committed murder from all
country. In Sweden the most common offences for which they were
evaluated there were: violent crimes, sexual offences and arson
[10]. The differences are caused by the legal stipulations of each
country on the offences for which it is requested the psychiatric
medical-legal examination.
In our sample patients diagnosed with psychotic disorders
engaged in all types of crimes: from murder to exhibitionism while
30% of patients with personality disorder and 43,7%.with organic
disorders committed theft. In cases of murder and attempted murder
55,5% of the cases were diagnosed with personality disorder and
33,3% with psychotic disorders. The data from Iasi show a low
representation among those who have committed murders both for
personality disorder (12,7%) and schizophrenia (6,4%) [5].
Differences over some international studies [8, 9, 10, 11] is due
to the same legal stipulations for psychiatric medical-legal
examination.
In our sample 67% had psychiatric history, 20% criminal and
16,5% forensic records comparative to study from Bucuresti where
43,5% had a psychiatric history and 18,6% criminal
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Romanian Journal of Legal Medicine Vol. XVIII, No 4 (2010)
291
records [7] In a report presented in Canada: 86% had a
psychiatric history, 33% even psychiatric hospitalization and 75%
had a criminal record. [12] Therefore the difficulties related with
primary prevention are similar in many countries. Table 1
Presentation Sample Population no. Variables Items Frequencies
Percentiles
1 Sex 1 = male 2 = female
152 24
86,4 13,6
2 Location 1= urban 2 = rural
61 115
34,7 65,3
3 Age group 1 = 18-24 years 2 = 25-44 years 3 = 45-64 years 4 =
over 65 years
30 90 48 8
17 51,1 27,3 4,5
4 Psychiatric history
1= with 2 = without
120 56
68,2 31,8
5 Criminal records
1= with 2 = without
35 151
19,9 80,1
6 Forensic history
1= with prior forensic evaluation 2= prior forensic evaluation
security measures
146 29
83,5 16,5
7 Alcohol use 1= with 2 = without
76 100
43,2 56,8
8 Epilepsy 1= with 2 = without
10 166
5,7 94,3
9 Head trauma 1= with 2 = without
17 159
9,7 90,3
10 Psychotics disorders
1= absent 2= with psychotics disorders (including schizophrenia,
schizoaffective disorders, delusional disorders)
147 29
83,5 16,5
11 Personality disorders
1 = absent 2 = present
100 76
56,8 43,2
12 Offense's violence
1= without violence 2= with violence
76 100
43,2 56,8
13 Violence's level
1=high violence: murder, infanticide, attempt murder, serious
sexual crimes 2= low/medium violence: strike, aggression,
destruction, robbery, threat, arson, offences against public order,
breaking and entering, bodily harm 3= absence of violence
23
75
78
13,1
42,6
44,3 14 Judgement 1 = preserved
2 = low 3 = absent
129 23 24
73,3 13,1 13,6
15 Safety measures
1= without 2= compulsory outpatient treatment (art. 113CP) 3=
compulsory psychiatric hospitalization (art. 114CP)
128 28
29
72,7 15,9
11,4
A low or absent judgement was evaluated in the majority of those
with psychotic disorders
(96,6%) and of those with organic disorders (75%). Safety
measures have been proposed to 27,3% like that: outpatient
compulsory treatment at 15,9% (art.113 Penal Code) and compulsory
hospitalization (art.114 from Penal Code) at 11,4% from all cases.
Psychotic disorders represented 80% of those who were proposed for
compulsory hospitalization treatment and 30,4% of those who were
proposed the compulsory outpatient treatment. Organic disorders
represented 43,4% from those with proposal of compulsory outpatient
treatment.
In conclusion our sample comply largely with characteristics
shown by other scientific papers from the field: predominance of
men, rural residence, low education, single status, the average age
around 35 years, personality disorder were more frequently than
psychotic disorders and the most frequently act committed was
theft. The most patients with psychotic disorders had low or absent
judgement in contrast to most of those diagnosed with personality
disorder, alcohol-related disorders or mental retardation which had
present judgement. Safety measure of hospital treatment was
recommended more to people with psychotic disorders while
compulsory outpatient treatment was recommended, especially those
with organic disorders
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Mosescu M et al Assessement and management of violence risk in
Forensic Psychiatry
292
Bivariate Correlative Analysis Kendall's tau_b Table 2 shows the
results from the analysis of Kendall coefficient through bivariate
correlation
method. We noticed that the most correlations certify the high
level of reliability for psychiatric medical-legal activity at
Buzau Medical-Legal Unit (logic correlation in terms of
psychopathology).
Table 2 - Bivariate Correlative Analyze Kendall's tau_b No.
Variables correlated Coef.
Kendall Coef. sigma
N p Correlation
1 Psychotics disorders and: psychiatric history criminal records
judgement safety measures
0,204 0,183 0,722 0,700
0.008 0,016 0 0
172 176 176 176
0,01 0,01 0,05 0,01
Negative Positive Negative Negative
2 Personality disorder and: criminal records judgement safety
measures
0,342 0,388 0,405
0 0 0
176 176 176
0,01 0.01 0,01
Negative Positive Positive
3 Offense's violence - marital status
0,231 0,02 164 0,05 Negative
4 Violence's level and: psychiatric history age group
0,165 0,171
0,0310,016
172 176
0,05
Negative Positive
5 Psychiatric history forensic history
0,196 0,010 99 0,05 Positive
6 Judgement and: psychiatric history criminal records
0,266 0,261
0 0
99 176
0,01 0,01
Positive Negative
7 Safety measures and: criminal records psychiatric history
forensic history judgement
0,265 0,277 0,162 0, 975
0 0 0,027 0
176 172 176 176
0,01 0.01 0,05 0,01
Negative Positive Positive Positive
Also in table 2 it can be noticed that the male is not
significantly correlated with violence, even
in association with psychotic disorders or personality disorder
so it's rise the opportunity for discussion about on the one hand,
the trend to increase the anti-social behaviour of young age and
female persons and, on the other hand, multiple and classifiable
conditioning of such behaviour.
Cross tabulation Analysis For variables that were significantly
correlated at bivariate correlative analyse we applied
crosstabulation analysis with chi-square test of association
(table 3)
Table 3 - Crosstabulation Analysis No Variables correlated N
valid p 2 df Cramer 1 Psychotics disorder Offense's violence 176
0,762
(>0,05) 0,543 2 NA
2 Psychotics disorder + Personality disorder Offense's
violence
176 0,056 (>0,05)
3,659 1 NA
3 Psychotics disorder absence judgement 176
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293
psychotic illness like hallucinations and delusional,
psychopatic traits or substance abuse [15]. We believe that
different observations are due to both, the varies designs of
studies and varied cross-cultural and legal conditions. In this
respect our results do not differ from other studies, but it is a
further proof for the destigmatization of mental illness and, of
course, of people with mental disorders that would significantly
improve the quality of psychiatric care within the family and
community.
Significant results regarding relationship: psychotic disorders
- absence of judgement - medical safety measures proposed
demonstrates the reliability of psychiatric medical legal
examination, and through high effect size, it argues the need for
institutions that demand forensic assessment to keep in mind these
considerations.
The offenses committed without violence are significantly
correlated with psychiatric history which support the above results
on relationship violence - psychotic disorders - psychiatric
history and reveals the importance of establishing of clear
principles of risk management in scope to an efficent
psycho-prophylaxis of violence. There is a significant correlation
(with a low Phi Cramer coefficient) between psychotic disorder and
the absence of criminal history that bring into discussion the
theory of psychopathology of the medical legal debuts and the
significance of psycho-prophylaxis in vioence prevention.
The absence or low judgement correlated with low levels of
violence raises psycho-prophylaxis problem to avoid relapses and
incite theoretical discussions about a possible gradual increase of
aggressivity to psychotic patients during evolution of disease.
Hierarchical cluster analysis A first classification took into
account ten variables that were grouped into three clusters as
follows:
Cluster 1: psychotic disorders, personality disorder, sex,
offence's violence, psychiatric history, criminal record, forensic
history
Cluster 2: judgement and safety measures Cluster 3: age
group.
A second cluster analysis consider only five variables grouped
also into three clusters as follows: Cluster 1: psychotic disorders
and psychiatric history Cluster 2: offence's violence and
personality disorders Cluster 3: judgement
This classification shows additional issues of the correlative
analysis: association on personality disorder - psychopathology -
sex the fact that the age group represents a single cluster which
we have outlined previously above support
the movement of anti-social behaviour to young age Analysis of
factors reduction By analysing of reducing factors through Varimax
method, the psychotic disorder was the factor that
reduced correlated variables through Kendall method. Reported to
psychotic disorders there are only two components instead of three
which proves that in relation to psychotic disorder in the analysis
at level of psychiatric medical-legal examination involve both
psychiatric and medical-legal criteria (according to current
methodology for conducting forensic psychiatric expertise) and
mixed criteria. The two components are: 1) psychotic disorders,
epilepsy, criminal records and 2) personality disorder, offence's
violence, alcohol use, psychiatric history, forensic history,
judgement, safety measures, sex, age group.
By reducing factors we analysed the variables that were
correlated by chi-square method and we found also two components.
Psychiatric history and judgement is one component which is logical
because the judgement is established for a time before examination
and psychiatric analysis is a longitudinal type. The second
component includes three variables of which two are equal:
offence's violence and personality disorder and the third:
psychotic disorders. This reduction factor is similar with the
second cluster presented above. The results obtained show the
reliability of the methodology of psychiatric medical legal
expertise in our country.
Methodological Limitations At SPMS Sapoca there are hospitalised
mentally ill persons from eight counties and capital,
Bucuresti, who committed an offence according to Romanian Penal
Code. These counties belongs to South-East Romania. There are no
significant numerical differences between urban and rural
population. The medical-legal work is directly supervised by
National Medical-Legal Institute (INML) Bucuresti (methodological
centre for all country) while psychiatric activity is supervised by
Clinical Hospital of
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Mosescu M et al Assessement and management of violence risk in
Forensic Psychiatry
294
Psychiatry Socola Iasi which have a long history of forensic
psychiatry care. All these factors could differentiate violent
behaviour and principles of risk-management in other parts of the
country.
Conclusions Results obtained by analysing this sample
demonstrate that that through the methodology of forensic
psychiatric examination it can be identified risk factors for
violence: male gender, ages 26-45, personality disorder,
psychiatric and forensic history, criminal records, alcohol use,
being un-employed. These risk factors split into two categories:
risk factors can be modified by applying safety measures
(especially clinical) and risk factors that can not be influenced
by medical safety measures (especially historical). Assistance with
safety measures should address especially to those people with
mental disorders for which risk factors for violence can be
influenced. A good risk assessment procedure should be predictive:
must identify, assess and prioritize legal psychiatric services,
social services and interventions according to the patients'
violence risk. There is a general consensus to recognize that risk
assessment should lead to risk management so forensic psychiatric
examination should include suggestions for reducing the probability
of violence through treatment. Some authors go even further
claiming that risk assessment is pointless if it incorporates
directions for treatment and not focuses on the causes of violence
[19].
Commission of forensic psychiatric examination, based on
assessment of mental disorders and historical variables, should
guide the mentally ill person with medical safety measures (or
forensic patient) to medical institutions that provide forensic
psychiatric services (hospitals, hospital units, extra-muros
structures) stratified according to risk assessed in forensic
psychiatric examination: minimal, medium and maximum risk.
Allocating financial and human resources in forensic psychiatry is
made according to practical needs arising from risk assessment
which helps to identify individuals with higher risk and need more
intensive services. Applications of principles of assessment and
management of violence risk for every medical-legal psychiatry
examination can be achieved a planning and optimal efficiency of
the resources and for a long term a reduction in funds allocated to
assist patients with medical safety measures.
In legal medicine, through excellence, truth is the conformity
of ideas with the objective reality, naked reality of subjectivity,
which is why any medical-legal work must represent a real
scientific research based on scientific criteria, on the
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