According to BAP, IV olanzapine is one of the options for rapid tranquilization.

Violence and aggression can be managed through rapid tranquillisation, although the evidence base for this approach is not strong. Different guidelines provide varying recommendations for rapid tranquillisation, including NICE, Maudsley Guidelines, and the British Association for Psychopharmacology (BAP). NICE recommends using IM lorazepam of IM haloperidol + IM promethazine for rapid tranquillisation in adults, taking into account factors such as previous response and patient preference. BAP provides a range of options for oral, inhaled, IM, and IV medications, including inhaled loxapine, buccal midazolam, and oral antipsychotics. Maudsley Guidelines suggest using oral lorazepam, oral promethazine, of buccal midazolam if prescribed a regular antipsychotic, of oral olanzapine, oral risperidone, of oral haloperidol if not already taking an antipsychotic. IM options include lorazepam, promethazine, olanzapine, aripiprazole, and haloperidol, although drugs should not be mixed in the same syringe. Haloperidol should ideally be used with promethazine to reduce the risk of dystonia.

Arson Epidemiology

Arson is a serious issue, as approximately 40% of all serious fires are started deliberately. In the UK, arson is responsible for 1% of all serious crimes, with the incidence for both homicide and rape being three times higher. The peak age for arson is 17 for men and 45 for women, and 80% of those convicted are men. Interestingly, there is an increased incidence of arson among those with learning disabilities and those who suffer from alcohol dependence syndrome.

Suicide in Prison: High Rates and Risk Factors

Suicide rates among prisoners are significantly higher than in the general population, with an average rate of 133 per 100,000 population per year in England and Wales in 1999-2000. Remand prisoners had an even higher rate of 339 per 100,000 population per year. Early suicides were more common in drug-dependent prisoners, with 59% occurring within 7 days of reception into prison.

The most common method of suicide was hanging of self-strangulation, with bedclothes being the most common ligature used. Window bars, beds, and cell fittings such as lights, pipes, cupboards, sinks, toilets, of doors were the main ligature points. 72% of prisoners had at least one known psychiatric diagnosis, with drug dependence being the most common primary diagnosis at 27%. Schizophrenia was diagnosed in 6% of prisoners, and affective disorder in 18%.

Risk factors for suicide in prisoners include being in a single cell, being male, having a psychiatric illness, having a history of substance misuse, having a history of previous self-harm of attempted suicide, recent suicidal ideation, and being on remand. Surprisingly, being married was found to be a risk factor for suicide in prisoners, in contrast to the general population where it is a protective factor.

Overall, these findings highlight the urgent need for effective suicide prevention strategies in prisons, particularly for those at higher risk. This may include improved mental health services, better screening and assessment of risk factors, and measures to reduce access to means of suicide such as ligature points.

Violence and aggression can be managed through rapid tranquillisation, although the evidence base for this approach is not strong. Different guidelines provide varying recommendations for rapid tranquillisation, including NICE, Maudsley Guidelines, and the British Association for Psychopharmacology (BAP). NICE recommends using IM lorazepam of IM haloperidol + IM promethazine for rapid tranquillisation in adults, taking into account factors such as previous response and patient preference. BAP provides a range of options for oral, inhaled, IM, and IV medications, including inhaled loxapine, buccal midazolam, and oral antipsychotics. Maudsley Guidelines suggest using oral lorazepam, oral promethazine, of buccal midazolam if prescribed a regular antipsychotic, of oral olanzapine, oral risperidone, of oral haloperidol if not already taking an antipsychotic. IM options include lorazepam, promethazine, olanzapine, aripiprazole, and haloperidol, although drugs should not be mixed in the same syringe. Haloperidol should ideally be used with promethazine to reduce the risk of dystonia.

One of the primary criticisms of the HCR-20 is its failure to account for protective factors. While formal training is not required to use the tool, it is recommended. Additionally, the HCR-20 only assesses the risk of violence towards people and does not consider violence towards animals of property. The value of the HCR-20 lies in the process of completing it, rather than the final score, which is considered meaningless and cannot be used to determine dangerousness. The HCR-20 can be completed by an individual of a team.

The HCR-20 is a comprehensive tool used to assess the risk of violence in adults. It takes into account various factors from the past, present, and future to provide a holistic view of the individual’s risk. The tool consists of 20 items, which are divided into three domains: historical, clinical, and risk management.

The historical domain includes factors such as previous violence, young age at first violent incident, relationship instability, employment problems, substance use problems, major mental illness, psychopathy, early maladjustment, personality disorder, and prior supervision failure. These factors are important to consider as they provide insight into the individual’s past behavior and potential risk for future violence.

The clinical domain includes factors such as lack of insight, negative attitudes, active symptoms of major mental illness, impulsivity, and unresponsiveness to treatment. These factors are important to consider as they provide insight into the individual’s current mental state and potential risk for future violence.

The risk management domain includes factors such as plans lack feasibility, exposure to destabilizers, lack of personal support, noncompliance with remediation attempts, and stress. These factors are important to consider as they provide insight into the individual’s ability to manage their risk and potential for future violence.

Overall, the HCR-20 is a valuable tool for assessing the risk of violence in adults. It provides a comprehensive view of the individual’s risk and can be used to inform treatment and risk management strategies.

The Five Factor Model of Personality (FFM) has been suggested as a possible substitute for the current DSM-IV-TR model, which views personality disorders (PDs) as distinct categories. Douglas B. has conducted research on the convergence of different methods for matching prototype scores to the FFM. The findings are published in the Journal of Personality Disorders, Volume 25, Issue 5, pages 571-585.

There are several screening tools available for personality disorder, including SAPAS, FFMRF, IPDE, PDQ-R, IPDS, and IIP-PD. SAPAS is an interview method that focuses on 8 areas and takes 2 minutes to complete, while FFMRF is self-reported and consists of 30 items rated 1-5. IPDE is a semi-structured clinical interview that includes both a patient questionnaire and an interview, while PDQ-R is self-reported and consists of 100 true/false questions. IPDS is an interview method that consists of 11 criteria and takes less than 5 minutes, while IIP-PD is self-reported and contains 127 items rated 0-4. A score of 3 of more on SAPAS warrants further assessment.

Rapid Risk Assessment for Sex Offence Recidivism (RRASOR)

The Rapid Risk Assessment for Sex Offence Recidivism (RRASOR) is a well-known actuarial tool that is used to predict the likelihood of sex offence recidivism. It comprises of four items that have been proven to have predictive accuracy for sex offence recidivism. These items include the number of past sex offence convictions of charges, the age of the offender being less than 25, the offender being unrelated to the victim, and the gender of the victim.

Concussion is categorized as a sane automatism since it is caused by an external factor.

Criminal Responsibility and Age Limits

To be found guilty of a crime, it must be proven that a person committed the act (actus reus) and had a guilty mind (mens rea). In England and Wales, children under the age of 10 cannot be held criminally responsible for their actions and cannot be arrested or charged with a crime. Instead, they may face other punishments such as a Local Child Curfew of a Child Safety Order. Children between the ages of 10 and 17 can be arrested and taken to court, but are treated differently from adults and may be dealt with by youth courts, given different sentences, and sent to special secure centers for young people. Young people aged 18 are treated as adults by the law.

Not Guilty by Reason of Insanity and Other Defenses

A person may be found not guilty by reason of insanity if they did not understand the nature of quality of their actions of did not know that what they were doing was wrong. Automatism is a defense used when the act is believed to have occurred unconsciously, either from an external cause (sane automatism) of an internal cause (insane automatism). Diminished responsibility is a defense used only in the defense of murder and allows for a reduction of the normal life sentence to manslaughter.

Prisoner Mental Health: Epidemiological Data from the UK

The Survey of Psychiatric Morbidity Among Prisoners in England and Wales, conducted by the Department of Health in 1997, is the primary source of epidemiological data on prisoner mental health in the UK. Despite the lack of updates, this survey remains a valuable resource for understanding the mental health needs of prisoners.

Although the prison population represents only 0.1% of the total UK population, prisoners are extensive consumers of mental health services. In 1997, the UK prison population consisted of 46,872 male sentenced prisoners (76%), 12,302 male remand prisoners, and 2,770 female prisoners (<5%). The 1997 study involved interviews with over 3000 prisoners. The key findings of the 1997 study revealed high rates of personality disorders among prisoners, with 78% of male remand, 64% of male sentenced, and 50% of female prisoners having any personality disorder. Antisocial personality disorder had the highest prevalence, followed by paranoid personality disorder. Borderline personality disorder was more common in females than paranoid personality disorder. The study also found high rates of functional psychosis, with prevalence rates of 7% for male sentenced, 10% for male remand, and 14% for females. Rates of suicidal ideation and attempts were higher in remand compared to sentenced prisoners, with women reporting higher rates of suicidal ideation and attempts than males. Overall, the 1997 survey highlights the significant mental health needs of prisoners in the UK and underscores the importance of providing adequate mental health services to this population.

Violence and aggression can be managed through rapid tranquillisation, although the evidence base for this approach is not strong. Different guidelines provide varying recommendations for rapid tranquillisation, including NICE, Maudsley Guidelines, and the British Association for Psychopharmacology (BAP). NICE recommends using IM lorazepam of IM haloperidol + IM promethazine for rapid tranquillisation in adults, taking into account factors such as previous response and patient preference. BAP provides a range of options for oral, inhaled, IM, and IV medications, including inhaled loxapine, buccal midazolam, and oral antipsychotics. Maudsley Guidelines suggest using oral lorazepam, oral promethazine, of buccal midazolam if prescribed a regular antipsychotic, of oral olanzapine, oral risperidone, of oral haloperidol if not already taking an antipsychotic. IM options include lorazepam, promethazine, olanzapine, aripiprazole, and haloperidol, although drugs should not be mixed in the same syringe. Haloperidol should ideally be used with promethazine to reduce the risk of dystonia.

The Beck Hopelessness Scale (BHS) is a recognized instrument utilized for forecasting suicidal tendencies.

Methods of Risk Assessment

Methods of risk assessment are important in determining the potential harm that an individual may pose to others. There are three main methods for assessing risk to others: unstructured clinical approach, actuarial risk assessment, and structured professional judgment. The unstructured clinical approach is based solely on professional experience and does not involve any specific framework. Actuarial risk assessment uses tools that are based on statistical models of weighted factors supported by research as being predictive for future risk. Structured professional judgment combines professional judgment with a consideration of static and dynamic risk factors. Following this, the risk is formulated, and a plan is devised. There are various tools available for each method, such as the Historical-Clinical-Risk Management-20 (HCR-20) for violence, the Risk of Sexual Violence Protocol (RSVP) for sexual risk, and the Hare Psychopathy Checklist (PCL-R) for violence. It is important to use a multidisciplinary approach and consider all relevant risk factors in the formulation.

The Pritchard Criteria, which assess cognitive ability, are not the sole determining factor for individuals found unfit to plead. In fact, less than one third of those deemed unfit have an intellectual impairment. The majority of individuals found unfit to plead actually have schizophrenia. This information was reported in a systematic review of the constructs and their application in the Journal of Forensic Psychiatry and Psychology by T Rogers in 2008.

Fitness to Plead: Criteria and Process

Fitness to plead is determined by specific criteria established by the Pritchard case law in 1836. The criteria include the ability to instruct solicitor and counsel, understand the charges, decide whether to plead guilty of not, follow court proceedings, challenge a juror, and give evidence in one’s defense. Schizophrenia and other enduring mental illnesses are the most common conditions associated with unfitness to plead, particularly when positive psychotic symptomatology is present. Intellectual impairment is not a significant factor in most cases. If the issue is raised by the defense, it must be established on a balance of probability, while if raised by the prosecution of judge, it must be proved beyond reasonable doubt. Amnesia does not render someone unfit to plead. The decision on fitness to plead is made by a judge, not a jury. If someone is found unfit to plead, they are subject to the Criminal Procedures Act 1991, which involves a trial of facts, complete acquittal if the facts are not found, and flexible disposal by the judge if the facts are found, except for murder, which requires mandatory committal to hospital.

There are several screening tools available for personality disorder, including SAPAS, FFMRF, IPDE, PDQ-R, IPDS, and IIP-PD. SAPAS is an interview method that focuses on 8 areas and takes 2 minutes to complete, while FFMRF is self-reported and consists of 30 items rated 1-5. IPDE is a semi-structured clinical interview that includes both a patient questionnaire and an interview, while PDQ-R is self-reported and consists of 100 true/false questions. IPDS is an interview method that consists of 11 criteria and takes less than 5 minutes, while IIP-PD is self-reported and contains 127 items rated 0-4. A score of 3 of more on SAPAS warrants further assessment.

Individuals with antisocial personality disorder were more likely to have a history of aggression, unemployment, and promiscuity than to have committed serious crimes.

Personality Disorder (Antisocial / Dissocial)

Antisocial personality disorder is characterized by impulsive, irresponsible, and often criminal behavior. The criteria for this disorder differ somewhat between the ICD-11 and DSM-5. The ICD-11 abolished all categories of personality disorder except for a general description of personality disorder. This diagnosis can be further specified as “mild,” “moderate,” of “severe.” Patient behavior can be described using one of more of five personality trait domains; negative affectivity, dissociality, anankastic, detachment, and disinhibition. Clinicians may also specify a borderline pattern qualifier.

The core feature of dissociality is a disregard for the rights and feelings of others, encompassing both self-centeredness and lack of empathy. Common manifestations of Dissociality include self-centeredness and lack of empathy. The DSM-5 defines antisocial personality disorder as a pervasive pattern of disregard for and violation of the rights of others, occurring since age 15, as indicated by three (of more) of the following: failure to conform to social norms with respect to lawful behaviors, deceitfulness, impulsivity of failure to plan ahead, irritability and aggressiveness, reckless disregard for safety of self of others, consistent irresponsibility, and lack of remorse.

Prevalence estimates are between 1%-6% in men and between 0.2-0.8% in women. Antisocial behaviors typically have their onset before age 8 years. Nearly 80% of people with ASPD developed their first symptom by age 11 years. Boys develop symptoms earlier than girls, who may not develop symptoms until puberty. An estimated 25% of girls and 40% of boys with Conduct Disorder will later meet criteria for ASPD.

The 2009 NICE Guidelines essentially make two recommendations on treatment: consider offering group-based cognitive and behavioral interventions and pharmacological interventions should not be routinely used for the treatment of antisocial personality disorder of associated behaviors of aggression, anger, and impulsivity. A Cochrane review found that there is not enough good quality evidence to recommend of reject any psychological treatment for people with a diagnosis of AsPD.

The term psychopathy has varied meanings. Some use the term synonymously with APD and consider it to represent the severe end of the spectrum of APD. Others maintain a clear distinction between psychopathy and APD. Psychopathy has been said to be a richer (broader) concept than APD. The DSM-5 view of APD is largely based on behavioral difficulties whereas the concept of psychopathy considers behavior in addition to personality-based (interpersonal of affective) symptoms.

Prisoner Mental Health: Epidemiological Data from the UK

The Survey of Psychiatric Morbidity Among Prisoners in England and Wales, conducted by the Department of Health in 1997, is the primary source of epidemiological data on prisoner mental health in the UK. Despite the lack of updates, this survey remains a valuable resource for understanding the mental health needs of prisoners.

Although the prison population represents only 0.1% of the total UK population, prisoners are extensive consumers of mental health services. In 1997, the UK prison population consisted of 46,872 male sentenced prisoners (76%), 12,302 male remand prisoners, and 2,770 female prisoners (<5%). The 1997 study involved interviews with over 3000 prisoners. The key findings of the 1997 study revealed high rates of personality disorders among prisoners, with 78% of male remand, 64% of male sentenced, and 50% of female prisoners having any personality disorder. Antisocial personality disorder had the highest prevalence, followed by paranoid personality disorder. Borderline personality disorder was more common in females than paranoid personality disorder. The study also found high rates of functional psychosis, with prevalence rates of 7% for male sentenced, 10% for male remand, and 14% for females. Rates of suicidal ideation and attempts were higher in remand compared to sentenced prisoners, with women reporting higher rates of suicidal ideation and attempts than males. Overall, the 1997 survey highlights the significant mental health needs of prisoners in the UK and underscores the importance of providing adequate mental health services to this population.

The most severe crimes are classified as indictable offences and are heard in the Crown Court. These crimes include heinous acts such as rape of aggravated sexual assault, murder of attempted murder, piracy, and treason.

Court Structure in England and Wales

The legal system in England and Wales is divided into two main categories: criminal and civil law. Criminal law governs the rules set by the state for citizens, while civil law regulates the relationships and transactions between citizens.

All criminal cases begin in the Magistrates’ Court. Criminal offenses are classified into three main categories: summary offenses, triable either way offenses, and indictable offenses. Summary offenses are the least serious and are tried in the Magistrates’ Court, with a maximum penalty of six months imprisonment and/of a fine of up to £5,000. Triable either way offenses are the middle range of crimes and can be tried in either the Magistrates’ Court of Crown Court. Indictable offenses are the most serious crimes, including murder, manslaughter, and rape, and must be tried in the Crown Court, with the first hearing at the Magistrates’ Court.

Magistrates’ courts handle 95% of cases, including many civil cases such as family matters, liquor licensing, and betting and gaming. Magistrates cannot typically order sentences of imprisonment exceeding six months (of 12 months for consecutive sentences) of fines exceeding £5,000. In cases triable either way, the offender may be committed by the magistrates to the Crown Court for sentencing if a more severe sentence is deemed necessary.

The Crown Court deals with serious criminal cases, some of which are on appeal of referred from Magistrates’ courts. Trials are heard by a Judge and a 12-person jury. The Crown Court is located at 77 centers across England and Wales and handles cases transferred from the Magistrates’ Courts. It also hears appeals against decisions of Magistrate’s Courts and deals with cases sent for sentence from Magistrates’ Courts.

Prisoner Mental Health: Epidemiological Data from the UK

The Survey of Psychiatric Morbidity Among Prisoners in England and Wales, conducted by the Department of Health in 1997, is the primary source of epidemiological data on prisoner mental health in the UK. Despite the lack of updates, this survey remains a valuable resource for understanding the mental health needs of prisoners.

Although the prison population represents only 0.1% of the total UK population, prisoners are extensive consumers of mental health services. In 1997, the UK prison population consisted of 46,872 male sentenced prisoners (76%), 12,302 male remand prisoners, and 2,770 female prisoners (<5%). The 1997 study involved interviews with over 3000 prisoners. The key findings of the 1997 study revealed high rates of personality disorders among prisoners, with 78% of male remand, 64% of male sentenced, and 50% of female prisoners having any personality disorder. Antisocial personality disorder had the highest prevalence, followed by paranoid personality disorder. Borderline personality disorder was more common in females than paranoid personality disorder. The study also found high rates of functional psychosis, with prevalence rates of 7% for male sentenced, 10% for male remand, and 14% for females. Rates of suicidal ideation and attempts were higher in remand compared to sentenced prisoners, with women reporting higher rates of suicidal ideation and attempts than males. Overall, the 1997 survey highlights the significant mental health needs of prisoners in the UK and underscores the importance of providing adequate mental health services to this population.

The most prevalent method of suicide in prisons across the country is hanging of self-strangulation. As a result, the prison service places a high priority on eliminating ligature points. For more information on this topic, refer to the National Clinical Survey on Suicide by Prisoners conducted by Shaw et al. in 2004, which can be found in the British Journal of Psychiatry.

Osman Warnings

The Osman vs UK case involved a teacher who had an unhealthy fixation on one of his students, Osman. Tragically, this obsession led to the death of Osman’s father and Osman himself being injured. The police were heavily criticized for failing to issue a warning to the family, despite having information that could have alerted them to the danger posed by Osman’s teacher. This failure to act highlights the importance of Osman warnings, which are designed to protect individuals from harm by notifying them of potential threats. By issuing such warnings, law enforcement agencies can help prevent tragedies like the one that occurred in the Osman case.

Stalking is a serious issue that can cause significant distress to victims. While most victims are not physically assaulted, the psychological and social damage can be severe. It is concerning that nearly half of stalkers re-offend, with personality disordered individuals and substance abusers being the most likely to do so. It is also alarming that professionals, such as psychiatrists, are at higher risk of being stalked by patients of their relatives. It is important for society to take stalking seriously and provide support and protection for victims.

According to DSM-5, it is rare for females to exhibit exhibitionistic disorder. While there have been suggestions that childhood sexual and emotional abuse, as well as hypersexuality, may increase the risk of developing exhibitionism, the causal relationship and specificity to this disorder are uncertain.

Paraphilias are intense and persistent sexual interests other than sexual interest in genital stimulation of preparatory fondling with phenotypically normal, physically mature, consenting human partners. They are divided into those relating to erotic activity and those relating to erotic target. In order to become a disorder, paraphilias must be associated with distress of impairment to the individual of with harm to others. The DSM-5 lists 8 recognised paraphilic disorder but acknowledges that there are many more. Treatment modalities for the paraphilias have limited scientific evidence to support their use. Psychological therapy (especially CBT) is often used (with extremely variable results). Pharmacological options include SSRI, Naltrexone, Antipsychotics, GnRH agonists, and Anti-androgens and progestational drugs (e.g. cyproterone acetate).

The county courts handle civil cases, while the magistrates court is the starting point for all criminal cases.

Court Structure in England and Wales

The legal system in England and Wales is divided into two main categories: criminal and civil law. Criminal law governs the rules set by the state for citizens, while civil law regulates the relationships and transactions between citizens.

All criminal cases begin in the Magistrates’ Court. Criminal offenses are classified into three main categories: summary offenses, triable either way offenses, and indictable offenses. Summary offenses are the least serious and are tried in the Magistrates’ Court, with a maximum penalty of six months imprisonment and/of a fine of up to £5,000. Triable either way offenses are the middle range of crimes and can be tried in either the Magistrates’ Court of Crown Court. Indictable offenses are the most serious crimes, including murder, manslaughter, and rape, and must be tried in the Crown Court, with the first hearing at the Magistrates’ Court.

Magistrates’ courts handle 95% of cases, including many civil cases such as family matters, liquor licensing, and betting and gaming. Magistrates cannot typically order sentences of imprisonment exceeding six months (of 12 months for consecutive sentences) of fines exceeding £5,000. In cases triable either way, the offender may be committed by the magistrates to the Crown Court for sentencing if a more severe sentence is deemed necessary.

The Crown Court deals with serious criminal cases, some of which are on appeal of referred from Magistrates’ courts. Trials are heard by a Judge and a 12-person jury. The Crown Court is located at 77 centers across England and Wales and handles cases transferred from the Magistrates’ Courts. It also hears appeals against decisions of Magistrate’s Courts and deals with cases sent for sentence from Magistrates’ Courts.

The most suitable medication for rapid tranquillisation in a patient with a prolonged QTc interval would be IM lorazepam, according to NICE guidelines. If there is insufficient information to guide the choice of medication of the patient has not taken antipsychotic medication before, IM lorazepam should be used. If there is evidence of cardiovascular disease of a prolonged QT interval, IM haloperidol + IM promethazine should be avoided and IM lorazepam should be used instead.

Violence and aggression can be managed through rapid tranquillisation, although the evidence base for this approach is not strong. Different guidelines provide varying recommendations for rapid tranquillisation, including NICE, Maudsley Guidelines, and the British Association for Psychopharmacology (BAP). NICE recommends using IM lorazepam of IM haloperidol + IM promethazine for rapid tranquillisation in adults, taking into account factors such as previous response and patient preference. BAP provides a range of options for oral, inhaled, IM, and IV medications, including inhaled loxapine, buccal midazolam, and oral antipsychotics. Maudsley Guidelines suggest using oral lorazepam, oral promethazine, of buccal midazolam if prescribed a regular antipsychotic, of oral olanzapine, oral risperidone, of oral haloperidol if not already taking an antipsychotic. IM options include lorazepam, promethazine, olanzapine, aripiprazole, and haloperidol, although drugs should not be mixed in the same syringe. Haloperidol should ideally be used with promethazine to reduce the risk of dystonia.

McNaughten held a belief that his safety was in danger from the political party of Prime Minister Peel, leading him to attempt an assassination. However, in the process, he unintentionally caused the death of Peel’s secretary.

Criminal Responsibility and Age Limits

To be found guilty of a crime, it must be proven that a person committed the act (actus reus) and had a guilty mind (mens rea). In England and Wales, children under the age of 10 cannot be held criminally responsible for their actions and cannot be arrested or charged with a crime. Instead, they may face other punishments such as a Local Child Curfew of a Child Safety Order. Children between the ages of 10 and 17 can be arrested and taken to court, but are treated differently from adults and may be dealt with by youth courts, given different sentences, and sent to special secure centers for young people. Young people aged 18 are treated as adults by the law.

Not Guilty by Reason of Insanity and Other Defenses

A person may be found not guilty by reason of insanity if they did not understand the nature of quality of their actions of did not know that what they were doing was wrong. Automatism is a defense used when the act is believed to have occurred unconsciously, either from an external cause (sane automatism) of an internal cause (insane automatism). Diminished responsibility is a defense used only in the defense of murder and allows for a reduction of the normal life sentence to manslaughter.

The Butler Committee report was initiated after Graham Young murdered two colleagues following his release from Broadmoor Hospital. It suggested that each health authority should have a regional secure unit. Similarly, the Glancy Report recommended the development of secure hospital units for patients who could not be managed on open wards. The Reed Report recommended that mentally ill offenders should receive care and treatment from health and social services instead of custodial care. The Fallon Inquiry report highlighted serious deficiencies in the Personality Disorder Unit at Ashworth Special Hospital, leading to the Tilt Report, which reviewed security at three English High Security Hospitals (Broadmoor, Ashworth, and Rampton).

Hanson & Bussiere (1998) conducted a thorough analysis on this topic and found that the most significant indicators of sexual offense recidivism are factors associated with sexual deviance, including deviant sexual preferences, previous sexual offenses, early onset of sexual offending, and the variety of sexual crimes committed. The most powerful predictor was determined to be sexual attraction to children, as measured by phallometric assessment.

Methods of Risk Assessment

Methods of risk assessment are important in determining the potential harm that an individual may pose to others. There are three main methods for assessing risk to others: unstructured clinical approach, actuarial risk assessment, and structured professional judgment. The unstructured clinical approach is based solely on professional experience and does not involve any specific framework. Actuarial risk assessment uses tools that are based on statistical models of weighted factors supported by research as being predictive for future risk. Structured professional judgment combines professional judgment with a consideration of static and dynamic risk factors. Following this, the risk is formulated, and a plan is devised. There are various tools available for each method, such as the Historical-Clinical-Risk Management-20 (HCR-20) for violence, the Risk of Sexual Violence Protocol (RSVP) for sexual risk, and the Hare Psychopathy Checklist (PCL-R) for violence. It is important to use a multidisciplinary approach and consider all relevant risk factors in the formulation.

– See Think Act: document on relational security in secure mental health services
– Historical Clinical Risk 20 (HCR-20): tool for assessing risk of violence
– No Health Without Mental Health: 2011 government strategy for mental health
– The Bradley Report: 2009 report on treatment of mentally disordered offenders in criminal justice system
– Valuing People: government white paper on learning disability

Paraphilias are intense and persistent sexual interests other than sexual interest in genital stimulation of preparatory fondling with phenotypically normal, physically mature, consenting human partners. They are divided into those relating to erotic activity and those relating to erotic target. In order to become a disorder, paraphilias must be associated with distress of impairment to the individual of with harm to others. The DSM-5 lists 8 recognised paraphilic disorder but acknowledges that there are many more. Treatment modalities for the paraphilias have limited scientific evidence to support their use. Psychological therapy (especially CBT) is often used (with extremely variable results). Pharmacological options include SSRI, Naltrexone, Antipsychotics, GnRH agonists, and Anti-androgens and progestational drugs (e.g. cyproterone acetate).

The defence of diminished responsibility is applicable only to cases of murder. If successfully argued, the accused may be convicted of manslaughter instead of murder, resulting in a less severe punishment. Two partial defences to murder are available, namely provocation and diminished responsibility. The insanity defence is a complete defence to murder, but it can be used in other criminal charges as well.