Preexisting vulnerabilities

There exists extensive research on the relevance in offender populations of the associations between such variables as age, gender, prior offending, and personality profiles, to the outcome of reoffending/4 4344 and 45> Some recent studies have put in question the extent to which established risk factors within mentally competent populations may be uncritically applied to mentally disordered populations, particularly those with no prior histories of offending. (1, SID Nevertheless we have to rely heavily on extrapolations from offender, or general populations, to the mentally disordered for many of the relevant pre-existing vulnerabilities.


Serious crimes of violence among the mentally competent are almost exclusively a male preserve. In the mentally ill the disparity between men and women with regard to violent behaviour is less marked.(48,4 and 50) The transfer of our assumptions about low levels of violent behaviour among women, derived from experience with non-disordered populations, to the mentally disordered is a potent source of error in clinical predictions which tends consistently to underrate the risks of violence in female patients.(46) Nevertheless males with mental disorders are significantly more likely to be violent than females who are similarly afflicted.

Criminality in general, and violent offending in particular, is usually associated with youth but this relationship, though present, is less marked in the mentally abnormal offender whose first offence tends to occur at a later age and whose likelihood of acting violently does not decrease so dramatically with advancing years.(! ,50ยป


There is among some clinicians an assumption of a close link between personality deviations and criminal behaviour. (5 52) This assumption is built into the definition of some personality disorders. In DSM-IV this is most obvious in the antisocial category but also is present in the criteria for those of the borderline, histrionic, narcissistic, and passive-aggressive types. Some claim despite this that the best general predictor among those with personality disorders is not the label, or their score on a check list, but their past behaviour. (53,54) Others in contrast place considerable reliance on measures which quantify psychopathic traits. (2,55> It is in the evaluation of aspects of antisocial and paranoid traits that existing actuarial instruments have the best established role. Clinically it is impulsivity, suspiciousness, and irritability which are characteristics enhancing the probability of aggression. Arguably, instruments like the Psychopathy Check List-Revised tap into these same vulnerabilities in a more systematic manner.

When a severely mentally disordered individual becomes threatening and combative, there can be an assumption that this reflects primarily a problem in their personality rather than the influence of their illness. Furthermore, if the antisocial behaviour persists when active symptoms are not obvious, the mentally ill patient may find himself, on this basis, redefined as personality disordered and denied appropriate treatment and support. It is also worth noting that such clinical errors are reinforced by failing to remember that integral to the schizophrenic process is the possibility of an erosion of the personality which can lead to the emergence of feckless and apparently callous behaviours.

Intellectual function

The role of low IQ and frank intellectual disability in the genesis of antisocial and violent behaviour remains controversial. (5 5Z> A high proportion of those arrested for a range of offences have low IQs and those ascertained intellectually disabled are more likely to acquire convictions, (48) but employing IQ measures as independent predictors of future dangerousness is fraught with problems.(58) Clinicians would be advised to look at the effects of limited coping skills and the potential for misinterpreting situations on the likelihood of both future conflict, and on the control of impulses, rather than to rely on the levels of intellectual function itself.

Educational failure, irrespective of inherent ability, is associated with later criminality (59> though it is possible that it is the emergence of conduct disorder and disruptive behaviour which determines the educational failure. One comfort in the field of predicting future probabilities is that causality is irrelevant; only association counts. Thus educational failure is associated with, and therefore predicts, criminality.

Neurobiological factors

The hopes of finding some form of biochemical or psychophysiological marker for predicting violence have so far produced little of clinical relevance, ^d4,6 ,) although there are claims that the inclusion of 5-hydroxytryptamine variables improves predictive equations. (61> There is a long-established feeling that neurological deficits, or damage, may predispose to violent behaviour; an unstable brain leading to unstable behaviour. This concept emerges periodically in dubious concepts such as the episodic dyscontrol syndrome. Brain damage, particularly involving the frontal lobes, can leave the patient disinhibited and occasionally more prone to irritability. Dementing processes also on occasion increase aggression and decrease self-control. It is, however, still difficult to go beyond these obvious clinical realities to any clinically relevant neurobiological marker for violence.

The enthusiastic study of the genetic and chromosomal contributions to crime has a long history with many false dawns but no lack of continuing advocates. (6 6 and 64 It still has no place in prediction.

History of abuse in childhood

There is a strongly held view among clinicians that childhood deprivation and abuse, both physical and sexual, predisposes to impulsive, aggressive, and potentially criminal behaviours in adult life, particularly among abused males. Empirical evidence for such an association exists (6,66> but some of the best research in the area provides evidence for only modest correlations.(6 68) In contrast clinicians who work with offenders, particularly recidivist violent offenders, are confronted daily with meaningful connections between abuse during childhood and adult impulsivity and aggression. As a result many come to believe this represents a strong causal nexus.

In the mentally disordered the evidence remains sparse though at least one study identified early parental separation as a risk factor for recidivism. (69> Experienced clinicians would be alerted by a history of child abuse and neglect to look even more carefully for impulsivity, substance abuse, and conflictual relationships with intimates, through which a connection between abuse and violence might be mediated.

Idiosyncratic sensitivities

Individuals, whether mentally disordered or not, acquire from experience areas of particular sensitivity. Those who have experienced persistent bullying, during childhood, adolescence, or adult life, may become sensitive and grossly overreact to intrusive and even mildly intimidatory approaches. Members of racial or ethnic minorities, immigrants, particularly when separated from their new peers by language barriers, the deaf, and any other stigmatized and isolated minority may all harbour resentments or suspicions, contributing to both a general volatility and a tendency to overreact to particular provocations.

Histories of conduct disorder, delinquency, and adult offending

Strictly, a history of antisocial behaviour is not a vulnerability but an indicator of such vulnerability. The truism that past behaviour predicts future behaviour applies to the mentally disordered as to the mentally competent, but needs to be applied taking the effects of illness into account. Mental disorders, by their very nature, are a break with the regularities of the past. In the mentally disordered individual violent behaviour can emerge as a direct result of specific morbid experiences with no, or far less, connection with the habitual ways of acting which characterized the patient prior to the onset of illness. This illness-related risk will disappear when the illness remits, but may reappear with relapse. This implies that for illness-related violence it is the behaviour during active disorder which is of particular predictive value. A history of the ready resort to violence when symptom free does increase the risks of violence when ill (illness adds disabilities but sadly rarely removes pre-existing difficulties and disadvantages) but the absence of a history of such violence does not carry as much comfort of future good conduct as it would in the general population. A history of serious violence in the past remains, however, a strong predictor of violence, in the initial period after admission and following discharge. (70Z1 and 72> The extent and frequency of offending may often be a more reliable guide to future conduct than any specific form of offending (though there are obvious exceptions as with child molestation). Thus a long history of offences including those against property, drug laws, and the person can be more predictive than an isolated act of more serious violence. Generally, offenders including the mentally disordered are not specialists but offend across a wide spectrum of criminality.

Facility with violence

Individuals vary widely in their past experience of fighting and using weapons. (The immediate availability of weapons is best regarded as a situational trigger whereas the knowledge and familiarity with their use is a pre-existing vulnerability.) Experience with various forms of combat, often now euphemistically called self-defence, does not necessarily increase the probability of behaving violently. In some the confidence which comes from combat skills may decrease fear and inhibit impulsive and overhasty responses, thus reducing the risk of acting violently. In others a fascination with asserting power and control through force may reduce the barriers against acting violently. One thing is certain that, rightly or wrongly, those with training in martial arts and the use of weapons, should they become seriously mentally disordered, induce considerable anxiety.

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