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PubMed1990

Automatism, medicine and the law.

The law on automatism is undergoing change. For some time there has been a conflict between the medical and the legal views. The medical profession believes that the present division between sane and insane automatism makes little medical sense. Insane automatism is due to an internal factor, that is, a disease of the brain, while sane automatism is due to an external factor, such as a blow on the head or an injection of a drug. This leads to the situation where, for example, the hypoglycaemia resulting from injected insulin would be sane automatism, while hypoglycaemia while results from an islet tumour would be insane automatism. This would not matter if the consequences were the same. However, sane automatism leads to an acquittal, whereas insane automatism leads to committal to a secure mental hospital. This article traces the development of the concept of automatism in the 1950s to the present time, and looks at the anomalies in the law as it now stands. It considers the medical conditions of, and the law relating to, epilepsy, alcohol and drug automatism, hypoglycaemic automatisms, transient global amnesia, and hysterical automatisms. Sleep automatisms, and offences committed during a somnambulistic automatism, are also discussed in detail. The article also examines the need of the Courts to be provided with expert evidence and the role that the qualified medical practitioner should take. It clarifies the various points which medical practitioners should consider when assessing whether a defence of automatism is justified on medical grounds, and in seeking to establish such a defence. The present law is unsatisfactory, as it does not allow any discretion in sentencing on the part of the judge once a verdict of not guilty by virtue of insane automatism has been passed. The judge must sentence the defendant to detention in a secure mental hospital. This would certainly be satisfactory where violent crimes have been committed. However, it is inappropriate in many cases where non-violent confusional crimes, such as petty larceny, have been committed. Suggestions are made for desirable changes in the law.

Automatism↗
PubMed1991

The case of Valentine Shortis--yesterday and today.

Valentine Shortis, a young Irish immigrant, was convicted of murder in Quebec in 1895. His insanity defence was unsuccessful in spite of psychiatric evidence given by the leading psychiatrists in Canada. Shortis spent the next 42 years in custody. The case provides a good vehicle for exploring a number of aspects of the history of psychiatry, the insanity defence, and the treatment of the criminally insane in Canada. Comparisons are made with the insanity defence and the treatment of the criminally insane today.

Antisocial Personality Disorder↗
PubMed2002

Automatism: comparison of common law and civil law approaches--a search for the optimal.

This article reviews common and civil law approaches to automatism with discussion of legal definitions and the conditions in which automatism occurs. The common law approach to sane (exogenous) and insane (endogenous) automatism is examined. Despite a change in the law, which obviates mandatory incarceration for all persons found not guilty on the basis of insane automatism, the stigma of insanity remains. A number of Continental jurisdictions, though, have adopted an approach divorced from judgmental labels, whereby acts, which result from automatism, are classified under the rubric of unconsciousness. The article draws upon this approach, analyses alternatives to insane automatism and proposes instead an analysis by reference to "cognitive dysfunction", thereby removing all reference to the concept of insanity.

Automatism↗
PubMed1989

The psychiatrist's guide to right and wrong: Part III: Postpartum depression and the "appreciation" of wrongfulness.

Whether or not the psychiatrist testifies on the ultimate issue in insanity defense cases, it is critically important that he familiarize himself with the applicable legal standards and interpretations in order properly to relate his clinical findings to the relevant criteria for insanity and thereby enhance the probative value of his testimony. This is the third in a series of articles which attempts to explicate judicial and statutory standards of insanity and correlate them with the psychiatrist's findings of psychopathology. This article analyzes the Model Penal Code formulation of insanity, with special emphasis on the all important distinction between "know" and "appreciate." This formulation permits the defendant possessed of mere surface knowledge or cognition to be exculpated, requiring that he have a deeper affective appreciation of the legal and moral import of the conduct involved if he is to be held criminally responsible. The Model Penal Code approach more readily lends itself to application as a standard of responsibility in cases involving affective disorders. An important disorder within this group, postpartum depression, is discussed in the context of raising the insanity defense in a case of infanticide.

Adult↗
PubMed1994

Beyond competence and sanity: the influence of pretrial evaluation on case disposition.

A preliminary investigation of the impact of pretrial evaluations of trial competence and legal insanity, and the variables that mediate case outcomes is reported. Twenty-four percent of defendants evaluated as incompetent to stand trial were found competent by the court or were tried without the question of competence being adjudicated. Charges were dropped in more than half of the cases in which an evaluator considered a defendant incompetent, most frequently in cases involving misdemeanor charges and/or the clinician considered it unlikely that the defendant could be restored to competence. One third of defendants considered to meet criteria for legal insanity subsequently were acquitted NGRI; more than half did not present an insanity defense and were ultimately convicted or plea bargained a guilty verdict. The defendants considered to meet the criteria for legal insanity were more likely than their mentally ill but not insane counterparts to have treatment ordered in lieu of incarceration. The defendant's age and race and the evaluator's professional discipline were unrelated to case outcome.

Antisocial Personality Disorder↗
PubMed2005

Some origins of cross-cultural psychiatry.

The interface between insanity, race and culture was a challenging subject for some of the most influential nineteenth-century alienists. Our paper reviews some of the theoretical and clinical investigations of comparative psychiatry of this period. The idea that insanity was supposedly rare among 'primitive' people, e.g., Africans, American Natives and some Eastern populations, was repeatedly defended by prominent alienists. Associated with this notion, many authors believed that insanity tends to become more prevalent as civilization evolves. According to them, civilization had an unfavourable effect on insanity rates because it demanded a much higher degree of organization and mental production. Moreover, a greater degree of mental excitation would explain why insanity occurs more frequently in Europe than in the East, Africa or South America. Eventually, at the end of the nineteenth century, the coalition of cross-cultural and neuropsychiatry produced a notion that the brain of the 'native' is more simple and crude than that of the civilized, and more vulnerable to the evil effects of civilized life. In conclusion, some ethnocentric bias and racial stereotypes still pervasive in contemporary psychiatry are identified and traced back to their historical origins.

Cross-Cultural Comparison↗
PubMed2003

[Epidemiologic parameters of mentally ill patients subjected to mandatory treatment].

INTRODUCTION: Criminally insanes form a special group of mentally ill patients. This paper investigated some psychiatric, criminological and social aspects of the above mentioned group of patients. PATIENTS AND METHODS: The author summarized the data of 114 patients whom he treated in the Forensic Mental Institute at least for two months between 1st February 1997 and 31th January 2002. And these data of mandatory treated patients were compared with that of offenders being sentenced because of a violent crime. RESULTS: The reason of why the majority of criminally insanes ran counter to the law was that they committed or attempted homicide, while violent offenders rather committed rowdyism, bodily injury and robbery. Concerning the victims of crimes the subgroups of male and female mandatory treated insanes showed similarity to the groups of male and female offenders committed violent crime, respectively. Namely males committed crime against their non-family members, while in the majority of cases females attacked their family members. The pecularities of mandatory treated insanes are the following. The majority of those were single and had been treated in a psychiatric department before mandatory treatment started, but only the minority of those attempted suicide. It was not a negligible subgroup of criminal insanes whose illness was diagnosed after they had committed the crime. The question emerges whether in these cases a latent development of disease or an initial delict should be taken into consideration. CONCLUSION: The initiation of a national, comparative survey is necessary, which on the one hand would help in psychiatric prevention, on the other hand the scientific investigation of criminalization of mentally ill patients would promote the elimination of prejudice saying that mentally ill patients commit violent crimes more frequently than their normal counterparts.

Adult↗
PubMed1977

[The emergence of the Québec asylum in the 19th century.].

This team of five philosophers analyses the 18th and 19th century Quebec discourse on the subject of insanity. The 18th century saw the insane excluded from social contact with the state recognizing only their indigence. They were relegated either to the "Loges", designed to expiate their sins since insanity was linked to an abuse of mind and body, or to prison for appropriate punishment, since madness was considered to lead to crime. But economic pressures produced by the growing number in indigents, including the mentally ill, led to the creation of the Beauport asylum in 1845. The authors then describe how the urban insane, marginal to both the French Canadian and English Canadian communities* were placed in private institutions and subjected to a system of profit maximization controlled by bourgeois physicians. This situation increased the distance between proprietors and occupants, and accounts for the lack of original discourse on the subject of insanity. In addition, the reasoning of the alienist physicians was without scientific foundation, taking root rather in the dominant industrial capitalist ideology. As for the content of the discourse, the Beauport physicians borrowed from moral treatment and restraint system notions, giving them a certain Quebec character.

English Abstract↗
PubMed1992

Epilepsy and criminal law.

Automatic episodes of aggressive or violent behaviour may occur during or after an epileptic fit. Epileptic automatisms are regarded by the law as 'insane automatisms'. A person who commits a crime during the course of a seizure is therefore legally insane and must be committed to a psychiatric hospital. The law of insanity is inappropriate when applied to epileptic automatisms. A change in the law is therefore necessary to remove epileptic offenders from the legal ambit of insanity, and to save them the threat of detention in a mental hospital as a consequence of their crime.

Aggression↗
PubMed1994

Personality disorders and 'restoration to sanity'.

Historically, the use of the insanity defense has been limited although not exclusively to those with a psychotic mental disorder at the time of the crime. Occasionally, an insanity acquittee may primarily suffer from a personality disorder at the time of commitment to the psychiatric hospital. Such examples can include someone with a personality disorder who malingers psychosis and legal insanity or who at the time of the crime may have been suffering from a drug-induced or brief reactive psychosis. One such case will be presented as well as dilemmas created for the clinician and forensic evaluator. In addition, pertinent medical and psychological literature and legal case precedents will be discussed. Finally, a proposed guideline for the treatment and evaluation of the personality-disordered insanity acquittee will be offered, focusing specifically on the aspects of the personality disorder that contribute to the individual's dangerousness.

Adult↗
PubMed1997

Urban birth and residence as risk factors for psychoses: an analysis of 1880 data.

It is known that social drift to cities increases the urban prevalence for severe mental illnesses. Recent studies in England and Sweden have reported that being born in, or raised in, an urban area is also a risk factor for later developing schizophrenia. The present study utilized 1880 census data, the most complete enumeration of severely mentally ill individuals ever done in the United States, to examine the association of urban residence and severe mental illnesses. Individuals identified as having one of seven forms of 'insanity' (n = 91959) were allocated to their county of origin (n = 2661) in the census. Rates of 'insane' persons per 1000 population were calculated for each county. The counties were then divided by degree of urbanization based on the largest cities and the percentage of population living in towns of 4000 or more. The point prevalence of 'insanity' in the United States as a whole in 1880 was 1.8 per 1000. There was a significant association between 'insanity' by county and degree of urbanization, with odds ratios of 1.66 for urban, 1.46 for semi-urban, and 1.44 for semi-rural, and 1.37 for rural, using completely rural counties as a baseline. Most completely rural counties with high rates included mining camps, lumbering camps, or fishing villages, and not farming areas. In addition to urban drift, urban birth and residence appear to be risk factors for developing severe mental illnesses. Psychological and biological explanations have both been proposed. However, recent studies reporting winter birth and urban birth or residence as synergistic risk factors favor the latter.

Cluster Analysis↗
PubMed1981

The social structure of the medical model of madness and the physician's role.

In this paper the origins of the medical model of madness are traced in the sociohistorical context of institutional and professional development. The paper establishes the emergence of the three primary conditions necessary for the medical model to exist: (a) the view that madness is a separate ontological reality which can be differentiated from the insane person; (b) the concept that insane people do not have a completely free will and therefore cannot be held responsible for their actions; and (c) the creation of specific criteria to classify the disease into empirically derived nosologies. These conditions and their acceptance as an explanatory paradigm of insanity result from the political economy of the late Middle Ages and are reflected in the institutional arrangement for insane persons of the 17th and 18th centuries. Finally, the role of the physician-psychiatrist is explained in terms of an ability to (a) serve as a technician for the new political forces, and (b) dislodge the moral entrepreneurs and become the only profession able to offer a proper scientific and secular treatment of madness. The psychiatrist is presented as a by-product of the dominance of the medical model rather than as the agent who created it.

History, 15th Century↗
PubMed1994

Law and psychiatry in America over the past 150 years.

American forensic psychiatry was founded in 1838 with the publication of Isaac Ray's Treatise on the Medical Jurisprudence of Insanity. Ray's ideas were influential in the early history of forensic psychiatry but were overlooked in the formulation of the M'Naghten Rules in England, an early parliamentary effort to define criteria for the insanity defense. In the mid-1800s, asylum-based psychiatrists formulated model laws addressing involuntary commitment and debated the definition of mental illness for legal purposes. In the late 1800s, courts became interested in findings of brain pathology in insanity defense cases, and neurologists joined psychiatrists as expert witnesses. Beginning around 1950, increased judicial activism led to a new standards for insanity in criminal cases, advances in the civil rights of mentally ill persons, and refinements in the role of expert witnesses. In 1969 forensic psychiatrists established a professional organization, and board certification in the subspecialty began in 1979.

Expert Testimony↗
PubMed1999

The medico-legal status of young sex offenders: forensic psychiatric evaluations in Sweden 1988-1995.

Young sex offenders (YSOs) attract significant public and professional concern. YSOs might be perceived as more psychologically deviant or dangerous than other offenders. This study focused on how often YSOs subjected to forensic psychiatric investigation (FPI) were declared medico-legally insane as compared to young non-sex offenders and adult sex offenders. Logistic regression models were applied to data from all major FPIs performed in Sweden between 1988 and 1995 (N=4354) to explore factors affecting the likelihood of receiving a medico-legal insanity declaration. When we adjusted for the statistical effects of age, sex offender status, and psychopathology, YSOs (n=47) were three to four times more likely to be declared insane in the medico-legal sense. The results indicate that YSOs in Sweden constitute a medico-legally distinct subgroup of forensic psychiatric examinees.

Adolescent↗
PubMed2004

Opinion formation in evaluating sanity at the time of the offense: an examination of 5175 pre-trial evaluations.

Sanity evaluations are high-stake undertakings that explicitly examine the defendant's culpability for a crime and implicitly explore clinical information that might inform a plea agreement. Despite the gravity of such evaluations, relatively little research has investigated the process by which evaluators form their psycholegal opinions. In the current study, we explore this process by examining 5175 sanity evaluations conducted by a cohort of forensic evaluators in Virginia over a ten-year period. Our analyses focus on (i) the clinical, criminal, and demographic attributes of the defendant correlated with opinions indicative of insanity; (ii) the clinical content of the evaluations and the legal criteria referenced as the basis for the psycholegal opinion; (iii) the process and outcome differences in the sanity evaluations conducted by psychologists versus psychiatrists; and (iv) the consistency in these opinions over a ten year period. Analyses predicting an opinion of insanity indicate a positive relationship with psychotic, organic, and affective diagnoses and previous psychiatric treatment. Analyses also indicate a negative relationship with prior criminal history, drug charges, personality disorder diagnosis, and intoxication at the time of the offense. Modest racial disparities were observed with evaluators offering opinions that the defendant was insane more often for white than for minority defendants despite comparable psychiatric and criminal characteristics.

Adolescent↗
PubMed2001

Mental illness: psychiatry's phlogiston.

In physics, we use the same laws to explain why airplanes fly, and why they crash. In psychiatry, we use one set of laws to explain sane behaviour, which we attribute to reasons (choices), and another set of laws to explain insane behaviour, which we attribute to causes (diseases). God, man's idea of moral perfection, judges human deeds without distinguishing between sane persons responsible for their behaviour and insane persons deserving to be excused for their evil deeds. It is hubris to pretend that the insanity defence is compassionate, just, or scientific. Mental illness is to psychiatry as phlogiston was to chemistry. Establishing chemistry as a science of the nature of matter required the recognition of the non-existence of phlogiston. Establishing psychiatry as a science of the nature of human behaviour requires the recognition of the non-existence of mental illness.

Forensic Psychiatry↗
PubMed1988

The detection of malingering in criminal forensic groups: MMPI validity scales.

Despite the value of the MMPI to the forensic assessment of malingering (exaggeration) of psychopathology, few studies have assessed the accuracy of the MMPI validity scales in criminal forensic populations. We administered the MMPI to 35 insanity defendants undergoing evaluation for fitness to stand trial and/or sanity at the time of the crime, who stood to benefit from being assessed as psychologically disturbed, and 39 subjects previously found not guilty by reason of insanity (NGRI), who did not stand to gain from such an assessment, Insanity defendants showed significantly more malingering than NGRI subjects, p less than .05. Racial differences did not affect the data. These findings support the efficacy of MMPI validity scales in assessing malingering within criminal forensic groups, and support the generalizability of the scales across race.

Adolescent↗
PubMed1976

Psychiatric aspects of murder and attempted murder.

The clinical data and forensic aspects of 28 individuals charged with murder and 10 charged with attempted murder examined over the last 35 years are recorded. The majority of those aged 40 years or over were criminally insane. A positive family history of psychiatric illness was present in the majority of the criminally insane group. Murder and attempted murder in the setting of a stable marriage was almost invariably the result of serious psychiatric illness. After the clearcut cases of schizophrenia and depressive illness were separated there were left a mixed paranoid group and a large group of individuals with severe personality disorders. Of the forensic aspects a case is made for the wider use of "unfitness to plead" in the severely psychotic. The follow-up of cases strongly suggested that those found not guilty on psychiatric grounds were likely to be held for longer periods than those treated as criminals. The author suggests that the public would be better protected if the Crown sought an insanity verdict in some cases rather than oppose it.

Adolescent↗