CASE PRESENTATION

Laura Davis

ST3 to Dr Ozdural

Forensic Psychiatry

BACKGROUND Mr P Age 41 Section 37/41 MHA Been on Kedleston LSU since June 2010

PERSONAL HISTORY Born in Northern Ireland 1970

Normal birth One of 12 children

Second youngest Father was a Sergeant Major in the Army Moved around regularly Mother died in a car accident in 1976 and the

family moved to Nottinghamshire Raised by Father

Contact with CAMHS ?ADHD

No history of abuse or disadvantaged upbringing

PERSONAL HISTORY History of truancy at school Also in trouble for smoking and fighting Suspended at the age of 13 Left school at 16

1 GCSE in English grade 5 Painting and decorating course 1 year Various jobs

Sacked for turning up late and missing daysLast job worked at an abattoir in Northern

Ireland 1995 for 8 months Never married, no dependents

FAMILY HISTORY One of 12 siblings Mother died 1976 in car accident Father died 1999 MI 1 brother died in 1989 from a

motorcycle accident 2 brothers committed suicide

No family history of mental health problems

DRUG AND ALCOHOL Alcohol – binge drinker

Magic mushrooms as a teenager Cocaine Crack cocaine Cannabis Heroin

FORENSIC HISTORY 1988 – convicted for assault 1989 – probation order for TWOC 1990 – fine for criminal damage 1990 – 18 months in YOI for burglary

and assaulting a police officer 1991 – 5 years imprisonment for

indecent assault on a female with ABH 1996 – 7 years imprisonment for 3

counts of rape, ABH and 3 threats to kill 2006 – S37/41 hospital disposal for

arson

FORENSIC HISTORY – INDECENT ASSAULT

Drinking all day. Heavily intoxicated and in a ‘rage’ thinking about

girlfriend who had recently left him for his friend. Felt life was being ‘unfair’ and everything was

going against him. A woman was walking in front of him. She was

about 40 and he thought she was good looking. He overtook her and gave her a ‘peck’ on the

lips. She looked shocked. He was then full of rage and head-butted her. He started hitting and punching her. Fractured nose, suspected fractured cheek bone and multiple lacerations

He dragged her to a grass verge, pulled her knickers down and put his finger into her vagina.

FORENSIC HISTORY - RAPE

Reports say that over a period of time he raped his niece, assaulted her and made threats to kill.

He reports that he had been drinking with his sister. Dropped off at her house Her daughter L (aged 16) had been asleep in lounge. He followed her upstairs but said he had not been

planning anything then. He went to L’s room to ‘talk to her’. Became aroused,

started kissing her and she had told him to get off and fallen on the fall. L had said that he had hit her

He put her back on the bed and had sex with her. She did not consent.

Made her commit a further sexual act whilst he was in possession of a knife

Did not think of L as his Niece.

FORENSIC HISTORY - RAPE

Regretted what he had done, went downstairs to get knife. Asked L to kill him with the knife ‘in the kidneys’

Told L he would kill her if her Mum came in the room after she had returned home.

He then went to bed.Said he was ‘pissed up’ and the

‘opportunity was there and I took it’.Denied having mental health problems

when arrested and sentenced.Arrested 12 hours later Released 1999

FORENSIC HISTORY - ARSON Day prior

Cut his throat with an intent to die Distressing auditory hallucinations Been using crack cocaine Attended A&E and discharged

Voices intensified Female voice telling him to kill himself/set a fire. Worse at night time. Caused him to feel low and distressed.

Lit a fire in response to command hallucinations Set fire to TV cabinet using clothing

Informed warden who contacted Fire Brigade Seen day after arson in prison

Auditory hallucinations every night several years, no increase in intensity/frequency, stable mental state, slightly low mood but no evidence of relapse

PSYCHIATRIC HISTORY Age 14 hearing noises and voices.

Remitted spontaneously 3 previous admissions including prison

transfers and informal admission. First psychotic illness 1993 whilst

imprisoned for indecent assault. Paranoid, thinking people were talking about

him. Hearing the voice of his dead brother externally Felt there was a conspiracy against him and

that somebody was trying to kill his family. Self neglect (stopped eating, drinking, washing) Tried to hang himself by his laces.

PSYCHIATRIC HISTORY Episodes of relapse tend to present

similarlyVisual hallucinations of people in his cellFeels people read his mind and will know

about his offences Observed responding to unseen stimuliHolds conversations with himselfLaughing inappropriatelyGrandiose delusions “Son of God”, “devil

has put part of my brain under control”Believed his brother entered his body and

forced him to commit rape

MEDICATION Previous

FlupenthixolThioridazineStelazineLithiumRisperdal constaModecate

CurrentHaloperidol decanoate 125mg 2 weekly

SELF HARM 1993 – attempted hanging 1996 – twice lacerated his neck in prison 2000 – overdose

82 paracetamol, 50:50 whether he would live

2006 – lacerated his neck 2006 – arson in a suicide attempt

BEHAVIOUR AND INCIDENTS October 2000 – sex in lift with mentally unwell patient

“it’s always them coming onto me” August 2008 – romantic interest in an OT.

Sent her a letter. Minimised incident ‘just a card’ October 2008 –

Making sexual gestures behind backs of female staff Put patient in a headlock and pulled him to the floor Assaulted staff

Refused to answer questions, no remorse, inappropriately smiling Has persistently minimised since, ‘not in control of actions’

February 2010 – Demanding to drink alcohol on ECL

Blamed staff for lack of clarity re S17 leave Protested by climbing on roof of smoking shed

Threw a bowl at staff AWOL – intoxicated

No remorse, thought he should be rewarded as he returned by himself

BEHAVIOUR AND INCIDENTS June 2010 – overfamiliar with female staff April 2011 – AWOL, intoxicated December 2011

Allegation of indecent assault against HCA Protesting his innocence by going on hunger strike No present charges

Prior to above incident was having large amounts of unescorted leave

Currently All leave suspended Remains isolative Refusing to speak to RC Wants to be transferred to a different hospital From review of notes he has done no SOTP work to date

PSYCHOLOGY REPORT Wathwood hospital 2007

Still affected by events from the past Sense of failure and inadequacy

General attitudes History of antisocial behaviour Tendency to see the world as unfair and hostile to him Uses self harm to demonstrate he is genuine in his remorse Failure to consider consequences for and needs of victims

First offence Emotional state of rejection, hurt and anger Attempted to kiss her and she was shocked. This made him

angry at her rejection and he physically attacked her Feelings potentiated by heavy alcohol consumption Impulsive and opportunistic Psychologist felt that the effect of the offence on his own life

may be overly represented in his sense of remorse

PSYCHOLOGY REPORT Second offence

No indication that he was experiencing any acute emotional problems at time

Had been drinking but knew what he was doing Opportunistic although the psychologist felt there may

have been some premeditation Felt it would have been worse if she had been a

stranger. Indifferent to her being blood relative The effect of the offence on his own life is

disproportionately represented in his remorseful feelings in relation to the effect on the victim

Shouldn’t have gone to prison – should have kept it in the family

He believes it is unfair to be on the sex offenders register as it will impact on his future relationships

DISCUSSION1. Diagnosis2. Risk3. Management

DISSOCIAL PERSONALITY DISORDER Callous unconcern for the feelings of others Gross and persistent attitude of

irresponsibility and disregard for social norms, rules and obligations

Incapacity to maintain enduring relationships, though with no difficulty in establishing them

Low tolerance to frustration and a low threshold for discharge of aggression including violence

Incapacity to experience guilt or to profit from adverse experience particularly punishment

Marked proneness to blame others, or to offer plausible rationalisations for the behaviour that has brought the individual into conflict with society

EMOTIONALLY UNSTABLE PD IMPULSIVE TYPE Marked tendency to act unexpectedly

and without consideration of consequences

Marked tendency to quarrelsome behaviour and to conflicts with others, especially when impulsive acts are thwarted or criticised

Liability to outbursts of anger or violence, with inability to control the resulting behavioural explosions

Difficulty in maintaining any course of action that offers no immediate reward

Unstable and capricious mood

SCHIZOPHRENIA 1 month duration At least 1 of

Thought echo, insertions, withdrawal or broadcasting Delusions of control, influence or passivity, clearly referred to

body or limb movements or specific thought, actions or sensations; delusional perception

Hallucinatory voices – running commentary or discussing patient or other voices coming from some other part of the body

Persistent culturally inappropriate delusions Or 2 of

Persistent hallucinations in any modality when accompanied by delusions or overvalued ideas

Neologisms, breaks or interpolations in train of thought – incoherence or irrelevant speech

Catatonic behaviour Negative symptoms