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Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective
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Mike Musker, Forensic Mental Health Service, James Nash House: The Trauma of Homicide: A Perpetrators Perspective

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Mike Musker, Advanced Clinical Services Coordinator, Forensic Mental Health Service, James Nash House delivered this presentation at the 2013 National Forensic Nursing conference. The annual event …

Mike Musker, Advanced Clinical Services Coordinator, Forensic Mental Health Service, James Nash House delivered this presentation at the 2013 National Forensic Nursing conference. The annual event promotes research and leadership for Australia’s forensic nursing community. For more information about the conference and to register, please visit the website: http://www.healthcareconferences.com.au/forensicnursing

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  • 1. PTSD and Related Disorders in Forensic Mental Health Mike Musker Advanced Clinical Services Coordinator FMHS RMN, DPSN, BA(Hon), MSc, PGDE
  • 2. Murder capital of the world
  • 3. Aims of the Presentation         An Introduction to PTSD Why study this area / this population / homicide Aims of the research project - hypothesis Tools and methodology used in the research Perpetrator Induced Stress in context Data and analysis and Data Experience of interviews Comorbidity (MH / drug abuse) and PTSD
  • 4. Audience members with PTSD  Warning  There will be discussion about Trauma, offences like homicide, child abuse, infanticide, that may be distressing to some.  You are welcome to leave if you feel it may distress you, or if you feel discomfort at anytime.
  • 5. Perpetrator Induced Trauma (PITS) MacNair, R 2002, Perpetration-Induced Traumatic Stress: The psychological consequences of killing, Psychological dimensions to war and peace, Praeger, London.
  • 6. Post Traumatic Stress Disorder  309.81 PTSD DSM IV-TR (APA 2000)  Criterion A: “The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others”  Intense fear, helplessness, or horror
  • 7. Pollock (1999) When the killer suffers: Post-traumatic stress reactions following homicide  “With reference to criterion A, the offender does experience, witness and confront an event which involves actual death of another by fact. The offender’s response to this event may represent a more critical point. He or she may experience horror in response to his or her own behaviour, particularly if the violence displayed constitutes a rare, sudden, surprising, single episode attack of limited duration”
  • 8. Types of Trauma Experienced (CAPS) 3 Transportation accident 29 74% 6 Physical Assault 29 74% 16 Serious injury, harm, or death you caused to someone else 28 72% 15 Sudden unexpected death of someone close to you 27 69% 7 Assault with a weapon 21 54% 17 Any other stressful event 20 51% 14 Sudden violent death ie homicide suicide 14 36% 13 33% 13 33% 2 Fire or Explosion 12 31% 4 Serious accident 11 28% 9 Other unwanted or uncomfortable sexual experience 10 26% 8 21% 11 Captivity 8 21% 13 Severe human suffering 8 21% 6 15% 2 5% 8 Sexual Assault 12 Life threatening illness 5 Exposure to toxic substances 1 Natural Disaster 10 Combat or exposure to war
  • 9. Prioritising your stressors CAPS EVENTS Serious injury, harm, or death you caused to someone else Sudden unexpected death of someone close to you Sexual Assault Sudden violent death ie homicide suicide Any other stressful event Transportation accident Physical Assault Assault with a weapon Other unwanted or uncomfortable sexual experience Life threatening illness Severe human suffering Natural Disaster Fire or Explosion Serious accident Exposure to toxic substances Combat or exposure to war Captivity 16 7 4 4 2 1 1 1 1 1 1 0 0 0 0 0 0 41% 18% 10% 10% 5% 3% 3% 3% 3% 3% 3% 0% 0% 0% 0% 0% 0%
  • 10. Major Symptoms of PTSD (17)  B: Re-experiencing (1 symptom of 5) – Flashbacks, Intrusive recollections, Dreams  C: Avoidance (3 symptom of 7) – Difficulty remembering, avoiding places, thoughts, or talking about it  D: Hyperarousal (2 symptom of 7) – Unable to sleep, Jumpy, anxious, anger, hypervigilance  E: How long have the symptoms persisted
  • 11. CAPS (Clinically Administered PTSD Scale)  Initially validated using Veterans - has since been used in: – Victims of crime; Catastrophes; Terrorism; Accidents  Diagnostic Criteria (every area must be endorsed): – – – – – – A: Exposure to a traumatic stressor – 3 areas B: Re-experiencing 1-5 C: Avoidance and numbing 6-12 D: Hyperarousal 13-17 E: Duration – 3 month? Lifetime? Acute <3m> chronic / delayed F: Impairment of functioning / distress  (item) I SEV 4 Rule – Frequency (Experience) + Intensity  (total) TSEV 45 - 65 (typically 10 or more symptoms endorsed)  Minimum score for diagnosis is 24 (ie 6 areas x isev4)
  • 12. CAPS Prioritised Symptoms Significant avoidance symptoms 8 11 10 1 4 13 15 2 6 9 16 3 5 7 12 14 17 Avoid Avoid Avoid Re-experience Re-experience Hyperarousal Hyperarousal Re-experience Avoid Avoid Hyperarousal Re-experience Re-experience Avoid Avoid Hyperarousal Hyperarousal Trouble remembering Feeling emotionally numb Feeling Distant or cut off Repeated Disturbing Memories Feeling very upset Trouble falling asleep Having difficulty concentrating Repeated Disturbing Dreams Avoiding Thinking about Loss of interest Being Super alert or watchful Suddenly acting or feeling Having physical reactions Avoiding activities of situations Feeling as if future cut short Feeling irritable Feeling Jumpy 20 19 18 17 16 15 15 13 13 13 10 9 9 9 9 7 7 51% 49% 46% 44% 41% 38% 38% 33% 33% 33% 26% 23% 23% 23% 23% 18% 18%
  • 13. WHY STUDY THIS AREA?  28 years of working in forensic MH  Interested in learning more about patients or a deeper level – their perspectives on crime?  Offence work with offenders is limited  Alleviate trauma effects to promote successful rehabilitation (as opposed to basket weaving)  Benchmarking and exploration of the forensic population of South Australia
  • 14. My Hypothesis  People in forensic mental health services will have a higher incidence of PTSD than the general population  People who commit homicide, attempted homicide and serious acts of aggression towards others will be traumatised by the event. NB: Most patients in forensic facilities are found “not guilty” by reason of insanity
  • 15. National Comorbidity (America/Australia) Kessler, R et al (1995) 'Ptsd in the National Comorbidity Survey', Arch Gen Psychiatry, vol. 52, no. December, pp. 1048-1060.  National Studies incidence of PTSD in general population is around – 5% for men – 10.4% for women – usual ratio of 1-2 – Australian studies suggest lower rates for 12 month (lifetime) diagnosis of PTSD of 1.3% using DSMIV criterion (Creamer et al 2001 Australian National Mental Health Survey)  Up to 88% of sufferers had at least one other psychiatric diagnosis  8.8% will have a substance use disorder  6% will have alcohol use disorder
  • 16. The Research (20 questionnaires)  Study a sample population – Forensic SA  New admissions – plus current population  Use of trauma questionnaires / interviews  CAPS (Clinician Administered PTSD scale)  CIDI (Composite International Diagnostic Interview)  ICSAH (Impact Childhood Stress on Adult Health)  Others PFAV / AQ & PCL-C  Convenient data (Risk Assessment / GAF / BPRS / DASA)
  • 17. Other Questionnaires and information  PCL-C: Post Traumatic Stress Disorder Checklist – (Weathers et al 1993):  Patients Feelings and Acts of Violence (PFAV) Scale – (Plutchik & Van Praag 1990)  Aggression Questionnaire (Buss & Perry 1992)  BPRS (Brief Psychiatric Rating Scale)  DASA Average DASA – (Dynamic Appraisal of Situational Aggression)  Risk to Self: S / Risk to Others: O from – CR62 hospital based risk assessment / HCR 20  GAF Global Assessment of Functioning  DG coder – mental health database / JIS system  Clinical Notes
  • 18. Research Participation  Interviewers Started on 1st January 2007 to 5th August 2010 (3.5 yrs.) – processing data and thesis further 2yrs  48 forensic patients or prisoners (39 Valid sets of data) – 48=29 Homicide or attempted / other (15 & 14 / 19) – 39=26 Homicide or attempted / other (13 & 13 / 13)  7 refusals, with some partial participants 2  Ave 4 hrs. 37 min of interviewing per patient  348 interviews over 278 hrs. (split 10min-1.5hrs)  Average of 9 interviews each over an average 28 days
  • 19. Aliya Zilic 'slit throat of Imran Zilic at Coober Pedy' JORDANNA SCHRIEVER, COURT REPORTER From: The Advertiser November 11, 2009 12:48PM Source: The Advertiser The mineshaft near Coober Pedy where the body was found. A FATHER slit his toddler son's throat with a steak knife and threw him down a disused mineshaft because the boy was "the devil's helper", a court has heard. The father, 33, has been charged with the murder of the boy, 3, at Coober Pedy between April 20-24 last year. During a trial by judge alone, prosecutor Jim Pearce today told the Supreme Court the father was a drug addict and schizophrenic who believed his ex-wife, was "working for the devil" and "possessed by demons". The court heard the father told police he believed his son to be in the hands of God. “He said Allah's name and dropped him in a shaft," Mr Pearce said.
  • 20. Stabbing victims ask court not to release schizophrenic attacker SEAN FEWSTER, COURT REPORTER From: The Advertiser March 04, 2008 11:30PM Steven Jobson and Adam Rayner display their injuries outside court in 2006 after they were attacked by paranoid schizophrenic at their home in Thebarton. Source: The Advertiser TWO men viciously stabbed by a neighbour who believed them to be "evil clones" have urged a court not to let their attacker back into the community.
  • 21. PTSD as a Defence? . Confounding Issues: • Now used as a legal defence? • What came first PTSD or Offence? ABC NEWS Feb 10, 2010
  • 22. The BIG question answered – CAPS Results:  33% (n=13) of sample had a cut-off score >=45 – i.e. positive score  10 % (n=4) subthreshold scores of 39 but <45 Similar to MH population McFarlane et al 2006 – 28% current ptsd  28% (n=9 out of 32 of males) had positive score (>=45)  57% (n=4 out of 7 of females) had positive score (>=45) Severe Symptoms  16% (n=5 out of 32) of males had severe symptoms with scores >=65  43% (n=3 out of 7) of females had severe symptoms with scores >=65
  • 23. Trauma expressed in Literature  British Veteran – Anglo Boer War 1899 – “I killed a man at Greenspan – I killed him fair in fight – And the Empires’ poets and the Empires Priests – Swear blind I acted right….…. – But they can’t stop the eyes of the man I killed – From starin’ into mine.” Others include Dostoesvsky, Poe, Shakespeare
  • 24. „Out, damned spot! Out I say‟ Lady Macbeth Reliving the incident: „Yet who would have thought the old man to have had so much blood in him‟ „What, will these hands ne'er be clean?‟ „Here's the smell of the blood still: all the perfumes of Arabia will not sweeten this little hand‟ (Macbeth Act V Scene I).
  • 25. An example of a Coroner‟s report – multiple stabbings – Homicide SA The examiner observed a total of 42 individual stab wounds to the victim, mainly to the chest and abdominal region. The examiner summarised his opinion concerning the cause of death as follows: „Death was due to multiple stab wounds. Many penetrated the chest cavity and/or upper abdomen with additional stab wounds to the left and right upper arms (injuries 5 and 27 respectively) and to the neck (injury 2). Three injuries to the hands consistent with defence injuries were noted. One stab wound entered the spinal canal but did not injure the spinal cord (injury 37). Internally, the wounds to the chest resulted in seven full thickness punctures of heart chambers (6 to left ventricle, one to right atrium), any of which in isolation could have proved rapidly fatal. In addition, there were multiple punctures of the lungs (13 in total), two stab wounds to the liver and one to the spleen.
  • 26. Case Studies – nightmares “I felt like I had blood all over me, after I woke up I couldn‟t get back to sleep…. because when I woke up, I was either stabbing him at the end or stabbing myself I can‟t remember exactly, but I woke up thinking I had blood all over me and I had to get out of bed and go and have a drink of water …..I touched myself to see if I had blood all over me” (Audio interview DW A0021 28:00)
  • 27. Dreaming a difference “I had a dream when I woke up screaming …. I‟m back in the street with the knife in my hand and I‟m walking down the street and I feel right, I‟m going to have to kill him or I‟m going to die or something like that and I‟m trying to stab myself. I‟m trying to kill myself but it won‟t go in … I have to kill him before he gets me – that‟s not what actually transpired, that‟s what I‟m dreaming.” (Audio interview DW A0021 27:00)  When asked why he was stabbing himself in the dream? “because I wanted to die instead of killing him.”
  • 28. Re - experiencieng “Well I think that‟s reliving it, not dreaming about it; reliving it”. (Audio interview DW A00353 7:00) “well in my dream sometimes I take a different sort of measure, I don‟t do what I did to her …. She‟s still alive … like in the dreams I make it go different” (Audio interview DW A00353 7:00)
  • 29. Filicide – death of a child  “I just can‟t believe that I did it. I remember … the moment he died …. I think about it every day, it causes me a lot of distress – it makes my hair fall out. I will remember it for the rest of my life. I dream about it all the time, but when I dream about it, he‟s alive and happy, I think about how beautiful he was and how easy he was to look after.” DW A0337 0:30
  • 30. Kill or be killed “Just at that point in time with my paranoia I thought he had been hired to take me out, as a result of that I ended up shooting him, I shot him, because I thought it was a contract out on me basically…. I thought he was going to shoot me” (DW A001 39:50).
  • 31. I heard the girls screaming It wasn‟t like reality….. It was like I was asking somebody the whole time what should I do, it was like I was being directed what to do the whole time…. I remember I stabbed her, but I don‟t really remember, I don‟t think my mind wants me to” DW A0352 7:00 “
  • 32. Data and Analysis  Statistical analyses were performed using SAS Version 9.2 (SAS Institute Inc., Cary, NC, USA).Continuous outcomes were compared between the three offense groups using one way ANOVA models. Results are shown in the table below.  Example interpretation - PCL scores: The mean PCL score was highest in offense type 2 criminals (mean = 43.38, SD = 17.90) and lowest for offense type 3 criminals (mean = 35.62, SD = 13.19). A one-way ANOVA model did not find a significant difference in means between the three groups however (F (2,36) = 1.13, p = 0.33).  As all the p-values were > 0.05, there was no statistical evidence to suggest that there were differences between the three groups in the measures considered. Offense type 1 (n=13) Mean SD Offense type 2 (n=13) Mean SD Offense type 3 (n=13) Mean SD Variable PCL Num DF 2 22.97 47.85 30.96 39.70 2.73 10.92 7.65 9.54 17.58 81.00 22.19 76.77 7.84 37.00 12.93 33.23 19.97 30.54 25.55 22.46 16.89 1.99 0.1508 36 0.60 0.5531 36 0.51 0.6028 9.19 28.46 36 17.09 33.15 0.4197 7.81 66.46 0.89 26.34 7.54 36 13.19 34.15 0.4393 2 35.62 0.84 2 17.90 33 2 43.38 P value 0.3336 2 13.37 F value 1.13 2 35.85 Den DF 36 CAPS Personal feelings Aggression BPRS Impact events
  • 33. Demographics (N=39)  30 patients (77%) had left school before the age of 16 and 9 (23%) of those had left before the age of 14.  29 patients (74%) did not complete year 12.  23 patients (59%) had no qualifications whilst 5 (13%) had higher qualifications such as diplomas, or degrees.  14 patients (36%) had part time or full time employment prior to admission, whilst 16 were on a disability pension. Others were unemployed or doing home duties.  25 patients (64%) had household incomes of less than $50,000 (19 or 49% of those with less than $30,000). 10 patients (26%) had household incomes above $80,000.  30 patients (77%) identified that they were on a government pension or allowance, whilst 8 (21%) were earning a wage.  22 (56%) patients had no children, 17 had children, although 1 patient said he had 10 children whilst the clinical team believed he had none.  5 (13%) Patients considered themselves aboriginal and 34 (87%) did not.
  • 34. Study sample (n=48) Males Females 32 (average age 35) 7 (average age 40) Refusals or dropout 4 dropped out after first interview 3 refused 2 discharged prior to interviews Homicide Attempted Homicide Serious Assault (GBH) Armed Robbery Stalking Arson Other 5 aboriginal 0 aboriginal Total 9 4 (all men – 3 aboriginal) 3 (1 woman and 2 men) paranoia – other motives 2 (2 men) – agreed but left soon after 15 14 8 3 2 1 5
  • 35. Offence Types Beating 15 (4 homicides) 7 Strangulation / suffocation 6 (all homicides) Shooting 4 (2 homicides) Other weapon (eg hammer, Plank) 3 (2 homicides) Stabbing or using knife Arson 3 (1 homicides) 3 1 Other 7 Motor vehicles Stalking or sexual
  • 36. Previous Contact with MH Services Previous Contact General Practitioner Psychiatrist Psychologist Social Worker or welfare worker Drug and alcohol counsellor Other counsellor Nurse Mental Health Team % N= 29 25 10 18 74% 64% 26% 46% 8 21% 1 20 22 3% 51% 56%
  • 37. Serious drug problems Yes Have you ever used illicit drugs?(This includes marijuana) 35 90% About how many times have you used illicit drugs? (*more that 25-100) 31 79% Were your parents ever separated or divorced? 25 64% 23 59% 21 54% Have you ever injected illicit drugs? 20 51% Have you ever considered yourself to be addicted to illicit drugs? 19 49% During the first 18 years of life….. Did you live with anyone who was a problem drinker or alcoholic? 18 46% Have you ever had a problem with your use of illicit drugs? Did you ever run away from home more than one day?
  • 38. CIDI DATA DSMIV Code 296 /300 300.22/23/ 29 300.1/11/2 1/81 and 307.51 295/298 309.81 296.3/41/4 2/43 300.3 305.90i DSM IV Diagnosis All Male % Female % 51% 14 36% 6 15% 18 46% 17 44% 1 3% 15 38% 11 28% 4 10% 14 36% 12 31% 2 5% 12 10 31% 26% 8 9 21% 23% 4 2 10% 5% 18% 5 13% 2 5% 5% 1 3% 1 3% Depressive / Dysthymic 20 Disorders Phobic Disorders % Anxiety Disorders Psychotic Disorders (schizo - type) PTSD Bipolar Disorders Obsessive Compulsive 7 Disorder Pain Disorder 2
  • 39. Drug Abuse Met & Partially met DSMIV Code 305.2 DSM IV Diagnosis All % Male % Female % Cannabis 24 Abuse Alcohol Abuse 17 62% 21 54% 3 8% 44% 15 38% 2 5% 305.4 Sedative Abuse 8 21% 7 18% 1 3% 305.7 Amphetamine 7 Abuse 18% 7 18% 0 0% 305.3 Hallucinogen Abuse Opioid Abuse 5 13% 4 10% 1 3% 4 10% 4 10% 0 0% 305 305.5 305.90i Inhalant Abuse 2 5% 2 5% 0 0% 305.6 Cocaine Abuse 1 3% 1 3% 0 0%
  • 40. Homicide and Attempted cases (N=29) Homicide and Attempted Homicide (n=29 ) 14 14 12 10 24 victims = Male 10 8 Series1 6 3 4 2 2 0 stranger family friend other Homicide only (n=15) 7 7 6 5 13 victims = Male 5 4 3 Series1 3 2 1 0 0 stranger family friend other
  • 41. Relationship with victims (n=48) • • • • • 27 strangers 9 family member 2 friends 4 police 5 Others (1 Care worker / 1 property / 1 Drugs / 2 neighbours) 30 27 25 20 Series1 15 9 10 4 5 5 3 0 stranger family friend police other
  • 42. Frequency of being hit? Being Hit as a Child Positive Often and Very often combined 24 How often were you hit? 36 92% 11 25 How severely were you hit? 69% 11 27 male 26 How old were you the last time you remember being hit? female 13 13 28 % 41 %
  • 43. Violence toward mother? Patients were asked about witnessing violence toward their mother with the options of Never, once or twice, sometimes, often, very often. 20 21 22 23 Push, grab, slap or throw something at her? Kick, bite, hit her with a fist, or hit her with something hard? Repeatedly hit her over at least a few minutes? Threaten her with a knife or gun or use a knife or gun to hurt her? Often and Very often combined Positive 31 79% 23 59% 22 56% 18 46% 18 46% 15 38% 3 8% 3 8%
  • 44. Relationship with Mum? order of question 1 3 6 7 11 4 5 2 9 12 13 14 8 10 15 Mothers Relationship not true positive answer My mother was overprotective of me. My mother was over-controlling of me. My mother was critical of me. My mother was unpredictable towards me. My mother left me on my own a lot. My mother sought to make me feel guilty My mother ignored me My mother was verbally abusive of me My mother was physically violent or abusive of me. My mother would forget about me. My mother was uninterested in me. My mother made me feel in danger. My mother was uncaring of me. My mother was rejecting of me. My mother made me feel unsafe. 10 18 21 24 24 27 27 28 29 21 18 15 15 12 12 11 74% 54% 46% 38% 38% 31% 31% 28% 28 11 28% 30 31 31 32 32 32 9 8 8 7 7 7 23% 21% 21% 18% 18% 18%
  • 45. Relationahip with Dad? order of question 11 13 5 6 2 3 10 12 1 9 7 14 4 8 15 Relationship with Father not true positive answer My father left me on my own a lot. My father was uninterested in me. My father ignored me My father was critical of me. My father was verbally abusive of me My father was over-controlling of me. My father was rejecting of me. My father would forget about me. My father was overprotective of me. My father was physically violent or abusive of me My father was unpredictable towards me. My father made me feel in danger. My father sought to make me feel guilty My father was uncaring of me. My father made me feel unsafe. 20 20 21 21 22 23 23 23 24 19 19 18 18 17 16 16 16 15 49% 49% 46% 46% 44% 41% 41% 41% 38% 24 15 38% 25 25 26 26 28 14 14 13 13 11 36% 36% 33% 33% 28%
  • 46. Sample from Aggression Questionnaire Question – the frequently selected Somewhat or characteristic aspects have been Extremely listed here. Characteristic I am an even tempered person. % women % of women men (n=7) % of men (n=32) When people are especially nice, I wonder what they want. 32 22 18 17 16 16 16 16 15 15 15 82% 56% 46% 44% 41% 41% 41% 41% 38% 38% 38% 7 100% 2 29% 1 14% 2 29% 0 0% 2 29% 0 0% 2 29% 2 29% 5 71% 3 43% 25 20 17 15 16 14 16 14 13 10 12 78% 63% 53% 47% 50% 44% 50% 44% 41% 31% 38% I have become so mad that I have broken things. 13 33% 1 12 38% I tell my friends openly when I disagree with them. If I have to resort to violence to protect my rights, I will. If somebody hits me, I hit back. I flare up quickly but get over it quickly When frustrated, I let my irritation show. There are people who pushed me so far that we came to blows. I am suspicious of overly friendly strangers. When people annoy me, I may tell them what I think of them. I can think of no good reason for ever hitting a person. 14%
  • 47. Personal Feelings And Violence Questionnaire Question All Positive % women % of women men (n=7) % of men (n=32) How often do you feel very angry at people? Have you ever used a weapon to try to harm someone? 29 29 74% 74% 5 5 71% 71% 24 24 75% 75% Have you ever been arrested for a violent crime such as armed robbery or assault? 29 74% 5 71% 24 75% Have you ever hit or attacked someone who is not a member of your family? 28 72% 2 29% 26 81% Have you ever caused injury in a fight (for example, bruises, bleeding or broken bones)? 26 67% 5 71% 21 66% How ofen have you been arrested for a nonviolent crime such as shoplifting? 24 62% 1 14% 23 72% Do you find that you get angry very easily? 22 20 56% 51% 4 5 57% 71% 18 15 56% 47% 20 12 51% 31% 2 2 29% 29% 18 10 56% 31% 12 10 31% 26% 1 1 14% 14% 11 9 34% 28% Have you ever hit or attacked a member of your family? Are weapons easily accessible to you? Do you find that you get angry for no reason at all? When angry, do you get a weapon Do you keep weapons in your home that you know how to use?
  • 48. Suicidality Suicidality 1 In the past month did you think you would be better off dead or wish you were dead? 2 In the past month did you want to harm yourself? 3 In the past month did you think about suicide? 4 In the past month did you have a suicide plan? 5 In the past month did you attempt suicide? 6 In your lifetime did you ever make a suicide attempt? Yes 11 28% 3 8 1 0 22 8% 21% 3% 0% 56% 16 Did anyone in your household attempt to commit suicide? 6 15% 19 Have you ever attempted to commit suicide? 22 56% a If Yes, how old were you the time you attempted suicide? 18 under 25 b If Yes, how old were you the last time you attempted suicide? 10 over 25 c How many times have you attempted suicide? 17 more than once d Did any suicide attempt ever result in an injury, poisoning or overdose that had to be treated by a doctor or nurse? 16 73%
  • 49. Brief Psychiatric Rating Scale Question Number Question All 2 Anxiety Guilt Feelings Emotional Withdrawal Conceptual Disorganisation Grandiosity Unusual Thought Disorder Tension Suspiciousness Blunted Affect Excitement Somatic Concerns Depressive Mood Hostility Hallucinatory Behaviour Uncooperativeness Motor Retardation Mannerisms and Posturing Disorientation 22 16 14 13 12 12 11 10 10 10 9 9 7 7 6 5 4 1 5 3 4 8 15 6 11 16 17 1 9 10 12 14 13 7 18 women 56% 41% 36% 33% 31% 31% 28% 26% 26% 26% 23% 23% 18% 18% 15% 13% 10% 3% % of women (n=7) 5 5 3 3 0 4 0 1 3 1 4 4 1 2 1 1 0 0 71% 71% 43% 43% 0% 57% 0% 14% 43% 14% 57% 57% 14% 29% 14% 14% 0% 0% men % of men (n=32) 17 11 11 10 12 8 11 9 7 9 5 5 6 5 5 4 4 1 53% 34% 34% 31% 38% 25% 34% 28% 22% 28% 16% 16% 19% 16% 16% 13% 13% 3%
  • 50. Dissociation Symptoms (only part of questionnaire 38 items) Sometimes, mostly, often and always combined result Question Number Dissociation 38 I have difficulty concentrating. 31 79% 10 I have problems remembering important details of stressful events. 26 67% 30 25 24 64% 62% 24 62% 24 I say things without meaning to. I feel unable to think straight. I underestimate or overestimate the amount of time that has passed. I do many things that I regret afterwards. My moods can really change. 23 23 59% 59% 20 Things seem to go by faster or slower than they really do. 22 56% 29 37 My memory for upsetting events is patchy. I feel distant and cut off from others around. 22 22 56% 56% 2 I cannot get angry about the things that should annoy me. 21 54% 33 I feel like I don't belong. I have conflicting desires. I feel emotionally numb (eg. Feel sad but can't cry, unable to have loving feelings). I have no memory for some important events in my life (for example, a wedding or graduation). 21 20 54% 51% 19 49% 19 49% 13 31 3 11 14 26 (NB: only part of questionnaire 38 items)
  • 51. Janoff Bulman: World Assumptions Scale order of question Patients who agreed with these statements disagree 1 2 3 agree 4 5 6 23 I take the actions necessary to protect myself against misfortune. 6 33 85% 17 I almost always make an effort to prevent bad things from happening to me. 7 32 82% 14 People will experience good fortune if they themselves are good. 8 31 79% 25 The world is a good place. 9 30 77% 27 I usually behave so as to bring about the greatest good for me. 9 30 77% 4 Human nature is basically good. 10 29 74% 20 Through our actions we can prevent bad things from happening to us. 10 29 74% 26 People are basically kind and helpful. 10 29 74% 22 If people took preventive actions, most misfortune could be avoided. 11 28 72% 11 28 72% 12 27 69% 16 If you look closely enough, you will see that the world is full of goodness. When I think about it, I consider myself very lucky. 11 People's misfortunes result from mistakes they have made. 13 26 67% 10 I am basically a lucky person. 14 25 64% 19 By and large, good people get what they deserve in this world. 14 25 64% 32 I am luckier than most people. There is more good than evil in the world. 14 15 25 24 64% 62% 30 9
  • 52. National Homicide Monitoring Programme NHMP (77 variables) – collected since 1989  2003-4: Murder profile in SA N=37 – Intimate 16% – Family 19% – Friends 22% – Strangers 32% – Others 11% *killed by 2 offenders – 30 % (compared to N=74 in NSW) (compared to 19% NSW) (compared to 9% NSW)  Over 15 years: – 4696 homicide incidents – 5050 victims – 5124 offenders  More likely to be killed on a Friday / Saturday night  Main motives for murder are domestic arguments, revenge, money and drugs Mouzos, J (2005) Homicide in Australia. Australian Institute of Criminology. Canberra. WWW.AIC.GOV.AU
  • 53. Homicide – the killing of one human being by another FBI Stats 2007 (Green, D. & Roberts, A {2008} Helping Victims of Violent Crime. Springer. New York) % of pop per 100000 per 100000 Age Victims Offenders population Victims Offenders Under 14 4.8% 0.5% 20.5% 1.8% 20.0% 14-17 5.0% 10.4% 6.1% 6.4% 14.9% 18-24 23.9% 36.6% 10.8% 17.0% 29.3% 25-34 28.8% 28.4% 15.7% 14.2% 15.8% 35-49 22.8% 17.3% 20.5% 8.6% 7.3% 50-64 9.3% 5.1% 14.2% 5.1% 3.1% 65+ 5.3% 1.7% 12.3% 3.4% 1.2%
  • 54. Family Homicide  In Australia 2 in 5 homicides occur between family members (Siblicide) (38% of family murders over 13 years)  Each Year: An average of 129 family homicides occur (60% intimate partners (uxoricide) – usually males killing females 75% of these cases / 25% of these cases are estranged couples).  Indigenous partners represent around 25% of intimate partner homicides – rarely involved in any stranger murders.  Each Year: An average of 25 children are killed - filicide (children age <1 most likely victims – infanticide) Mouzos, J and Rushforth, C (2003) Family Homicide in Australia. Australian Institute of Criminology. Canberra. WWW.AIC.GOV.AU
  • 55. Family Homicide Ot he r Sibl ic i de (5 Parr ic ide Fil ici Mouzos, J and Rushforth, C (2003) Family Homicide in Australia. Australian Institute of Criminology. Canberra. WWW.AIC.GOV.AU F am il y (9 %) %) Intimates Filicide Parricide Siblicide Other Family (9%) de (1 7%) Inti m at es (60% )
  • 56. Less common:  Children killing their parents (parricide) – 12 per year (usually male perpetrators)  Between family members (Siblicide) – 6 per year  Sorocide (sister) / Fratricide (brother) / feticide (foetus) / Matricide / Patricide  Useless Facts: There is a bird called the Nazca Booby – kills its siblings without fail.  Ottoman Empire Mehmed III – new sultan killed his 19 brothers by strangulation to prevent war.
  • 57. Questionnaire Average Times  Clinically Administered PTSD Scale took on average 1 hour and 25 minutes  Impact of Childhood Stress on Adult Health took on average 1 hour and 11 minutes  CIDI; AQ and PFAV scale took on average 2 hours and 1 minute.  Total Average Interview Time took 4 hours and 37 minutes  There were many issues in arranging interviews; reasons: Not feeling well enough; Didn‟t feel like it; Had a visit from a family or friend; Being interviewed by another professional; Participating in Occupational Activities or groups; Participating in a game, or sports; Mealtimes such as a barbecue; Sleeping
  • 58. Alcohol and Drugs Never How often during the year before admission have you found that you were unable to stop drinking once you had started (or prior to prison)? 28 72% 1 How many standard drinks did you have on a typical day when you were drinking? 2 Less than Monthly monthly weekly daily 5 1 1 4 13% 3% 3% 10% 3-4 5-6 7 or more Amount of drinks on a typical day 6 3 11 9 10 15% 8% 28% 23% 26%
  • 59. Smoking  35 (90%) of the patients identified that they had smoked at least 100 cigarettes in their lives. Whilst 31 (79%) continued to smoke. 27 (69%) patients identified that they had smoked prior to the age of 16 with a range of starting to smoke between the ages of 8 and 30 years. The median amount of cigarettes smoked per day was 20 cigarettes, with a range of 5 to 50 cigarettes per day.
  • 60. PTSD Checklist (PCL)  The three most prominent symptoms identified by the PCL were avoiding thinking about it at 56%; repeated disturbing memories at 51% and having difficulty concentrating at 49%. 6 Avoid 1 Re-experience (4) 15 Hyperarousal 4 Re-experience 9 Avoid 10 Avoid (3) 13 Hyperarousal 8 Re-experience (1) 16 Hyperarousal 7 Avoid 3 Re-experience 5 Re-experience 2 Re-experience 11 Avoid (2) 12 Avoid 17 Hyperarousal 14 Hyperarousal Avoiding Thinking about Repeated Disturbing Memories Having difficulty concentrating Feeling very upset Loss of interest Feeling Distant or cut off Trouble falling asleep Trouble remembering Being Super alert or watchful Avoiding activities of situations Suddenly acting or feeling Having physical reactions Repeated Disturbing Dreams Feeling emotionally numb Feeling as if future cut short Feeling Jumpy Feeling irritable 22 20 19 17 16 16 16 15 13 12 11 11 9 9 9 8 5 56% 51% 49% 44% 41% 41% 41% 38% 33% 31% 28% 28% 23% 23% 23% 21% 13%
  • 61. Specific Aims of Project 1. 2. 3. 4. 5. 6. 7. To explore the diagnosis of current PTSD symptoms and its relationship with mental illness. To examine the prevalence of substance abuse disorders in the research population. To measure the expression of aggression and correlation to PTSD and mental illness. To explore causal links between criminal offences against the person, post traumatic stress and mental illness. To identify specific cases and frequency of „perpetrator induced traumatic stress‟ (PITS). To identify trends in symptomatology such as suicidality, anxiety and depression. Work through individual case studies
  • 62. Research Approval  Both health clients & prisoners  Vulnerable population (incarcerated / ill)  Reading ability / lingual ability  Identifying the risks / re-traumatize  Amount of questionnaires – time  Validity and reliability of all questionnaires  Ongoing monitoring (do no harm)
  • 63. Anticipated & Realised Problems  Patient‟s too psychotic (aggression?)  Refusals – small population – follow up  Early return to prison prior to completion  Time Management – Stamina (holidays etc)  Information management & backup  Too ambitious / clinical support  Current Ethics approval from „Families & Communities‟ for future expansion of research
  • 64. Questions from RAH research committee  It should be assured that all participants have an adequate reading age.  The Information Sheet should have a separate RISKS section, which lists the risks. These should include possible deteriorations in mental state, etc.  There are many questionnaires / tests. The information sheet should state how long participation in this study will require.  Given this large number of questionnaires / tests, please provide comment on whether all are needed and whether each has adequate validity and reliability.  Will there be a debriefing interview at the conclusion of someone’s participation? Please comment on this.
  • 65. Trauma of illness  Comorbidity (chicken or the egg) – hallucinations / delusions – Multiple traumas – Living Nightmares / real nightmares – Drug Induced Psychosis – Hospitalisation / restraint / enforced treatment – Arrest / questioning / legal process / prison environs – Types & Frequency of illness in relation to symptoms
  • 66. Dr Craig Raeside – Forensic Psychiatrist (1994) PTSD in a female prisoner population          53 women prisoners (80/20 caucasion / aboriginal) 100% positive psychiatric diagnosis 88% significant trauma 81% Severe PTSD 89% depression 97% Substance abuse 25% committed first offence by age 12 64% by age 15 (theft 50%: Violence=20% Drugs=17% ) Types of Trauma – (Violence =78%: Rape-Sexual Assault=71%: Child-SA 55%) – (physical assault=31%:Accidents=31%:Child physical abuse 21%)
  • 67. Other Studies (cited in Spitzer et al 2006) study N=32 Complex posttraumatic stress disorder and child maltreatment in forensic inpatients Stralsund forensic hospital, a maximum security facility in Pomerania (north-eastern region of Germany). –  One investigation found that almost all adolescents in      juvenile probation hall (97%) endorsed a trauma history (Carrion & Steiner, 2000) 70% of female juvenile offenders had been sexually abused (Dixon,Howie, & Starling, 2005). Childhood sexual abuse was found in 40% of male inmates (Fondacaro, Holt, & Powell, 1999) Objective evidence of severe child abuse was obtained in 11 out of 12 murderers with dissociative identity disorder (Lewis, Yeager, Swica, Pincus, & Lewis, 1997). Previous trauma (of all kinds) had been experienced by half of the adult homicide offenders studied by Hakkanen (2005). 28% complex (chronic) ptsd and 44% lifetime
  • 68. Damage: Trauma and Violence in a Sample of Women Referred to a Forensic Service Gwen Adshead Behavioral Sciences and the Law, Vol. 12,235-249 (1994)  The number of men in prison in the U.K. is 30 times that of women  Abuse in childhood, 81% (13) of the group had a history of sexual abuse and 50% (8) had a history of physical abuse  victimization experience as an adult, 56% (9) of the women had suffered either physical or sexual abuse, while 38% (6) said that they had been raped or sexually assaulted. None had reported their experience to the police,  44% (7) described mental phenomena involving harm to self, usually in the form of “wishes” but also in the form of “pictures” or “voices.” However, 81% described experiencing some form of mental phenomena that involved harming others.
  • 69. Post-traumatic Stress Disorder in the forensic Psychiatric Setting Marianne Kristiansson, MD, PhD, Kerstin Sumelius, MSW, and Hans-Peter Søndergaard, MD, PhD J Am Acad Psychiatry Law 32:399–407, 2004  Compared immigrants and Swedes in a forensic unit – N = 50. Events that involve the element of interpersonal assault carry higher risks of PTSD than do events that lack this element.  (cites NZ study of prisoners) In one national study from New Zealand, prevalence of psychiatric disorders was investigated. The prevalence of PTSD in sentenced men was 8.5 percent and in remanded men 9.5 percent.  immigrant group, subjects were assigned a diagnosis of PTSD in 60% of cases. Greater proportion of sexual/violent crimes in the PTSD group. In fact, all offences in the PTSD group were classified as either violent or sexual.  43% declined participation Among the 87 subjects who were asked to participate in the study, 20 immigrants and 17 Swedes refused.
  • 70. Wider Application / Prevention / Rehabilitation / War / Disaster  Early intervention in trauma and trauma related societal behaviour ie. Prevention (Illness/Crime)  Providing therapeutic intervention for trauma prior to release ie. rehabilitation  Experience of veterans / police / ambulance officers following war trauma / incident trauma  An awareness of how populations may be affected in disaster – involving violence / survival / cumulative traumas  Population studies / interstate / international -AIC
  • 71. Experience of Interviews  Long time gaining research approval  Interviews have to be chunked (brief sessions)  Up to 5 hrs per patient  Difficulty in fitting in times with pts day  Systematic interviews  Yet to interview newly admitted patients  Enlightening information / getting to know  Patient‟s view – my view
  • 72. Comparative Populations / Research  International Studies on Forensic Populations  Australain Institue of Criminology / UK Home Office  Bushfire Studies – PTSD general population sample  QEH –McFarlane et al–violence and trauma Psych patients  Related literature – – – – – – Mental Health and trauma Veteran Research - Perpetrator perspectives Criminology literature Psychiatric / Psychology literature Psychobiology & genetics Police / Ambulance officers / executioners
  • 73. Trauma Contexts / Relationships  The human puzzle – premorbid trauma – – – – – – – Childhood / Life Trauma (sexual abuse / violence etc) Social contexts (neighbourhoods / abusive partners) Background (education level / criminal history) Exposure to violence / abuse (prison culture / torture) Family – history of mental illness / genetic / crime Exposure to natural disasters or automotive accidents Terrorism / immigration
  • 74. Thanks for listening

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