Forensic Psychiatry Interdisciplinary Research Group


The aims of the Forensic Psychiatry Interdisciplinary Research Group (IRG) are:

Interdisciplinary Research Group Research Report for 1996


Forensic psychiatry continues to maintain its high political profile. Prison populations in Britain are rising, the pressure on secure beds in the NHS is intolerable, individual incidents (such as the Dunblane massacre) make headline news, and all teaching centres are now trying to develop forensic psychiatry departments. Paradoxically academic resources in forensic psychiatry are very low. Space, funds and trained staff are all in short supply. Nevertheless research activity in this important area continues to grow, slowly, at the Institute of Psychiatry.

Last year we completed our epidemiological survey of English prisons, and we produced a report on the growing suicide in prison problem, we furnished a report on the role of the police in London in the diversion of mentally disordered people from the criminal justice system to the health care system, and our programme of work in the maximum security hospital system has made a very promising start.

Prison Studies

The prison epidemiological studies have revealed a large number of important findings. The study of sentenced prisoners identified the unmet needs of that population and showed, for example, that well over 1000 extra beds are needed within the NHS (mainly in maximum security) for mentally disordered prisoners. The recent study of English prisons has indicated that a further 100-300 beds are required for people remanded in custody, this time mainly in medium security units and local hospitals.

Substance abuse is a particular problem among prisoners and more emphasis needs to be given to this in the NHS. The remand survey and the Scottish prison survey have both indicated the high suicide risk among young prisoners. Preliminary findings suggest that patients with personality disorder are as likely to die by suicide as psychotic prisoners and substance abuse is of considerable importance in provoking suicidal behaviour.

An adjunct to the prison epidemiological work was a review and policy paper identifying the national requirements for longterm medium security units. Whilst the need is clear it is difficult to quantify exactly, but perhaps some extra 1200 beds in England & Wales are required to fill an important gap in the provision of services for mentally disordered offenders.

Police and Court Studies

An elaborate observational study of the Metropolitan Police at work, both day and night, showed that over 1% of all police detainees suffer from serious (major) mental disorder and a further 1% probably have other serious psychiatric disabilities. These figures are minimal and based on observations rather than interviews. The study highlighted the urgent need for more and better medical, especially psychiatric, involvement with work at the police station. The "community" embraces the local police station, the local court, and the local prison, all centres dealing with considerably psychopathology. A special comment has been made on the use of the "appropriate adult" in the police station for mentally disordered people. A clear distinction should be made between juveniles and adults.

Diverting mentally disordered offenders from the criminal justice system to the health care system is both government policy and a central interest of the group. Schemes and studies were proposed from the Institute long before it became fashionable. In his time with us Philip Joseph set up and evaluated both court schemes and care for the homeless. Tim Exworthy has continued this work with other court schemes and a prison scheme.

Risk Assessment

"Risk assessment" has become a buzz phrase in recent years. One or two lectures have been given by members of the research group to indicate the importance of risk management rather than risk assessment on its own. A major review of this field has been published. Professor Thornicroft has received a small DOH grant to develop some instrumentation in this field. A number of follow-up studies have been undertaken to determine the actual outcome of patient care from those who have stayed in maximum security and medium security hospitals.

Trauma and Antisocial Behaviour

There is a growing understanding of the centrality of the experience of trauma in the development of repetitive antisocial behaviour. Most of the work has focused on bad experiences in childhood or in war, but the Joint Hospital now has extensive experience of the effects of adult and civilian trauma. Many forensic psychiatry patients are victims, all either create victims or have the potential to do so, the prevention and treatment of victimisation and its consequences are therefore key issues for forensic psychiatry. The victims' service is also planning a series of projects concerned with the development and treatment of traumatic psychological reactions, and Til Wykes continues to assess the effects of assaults on nursing staff within the Joint Hospital.

Personality Disorder

There has been a strong tradition within forensic psychiatry at the Institute for the study of patients with personality disorder. The Institute was a pioneer in studying the effectiveness of the most important therapeutic community for personality disordered prisoners in Britain, Grendon prison; and treatment studies of personality disorder are continuing at Broadmoor Hospital.


The new professorial unit at Broadmoor, which was opened by Princess Diana at the end of 1995, now forms a major part of the research group. It is headed by Professor Pamela Taylor. There are three senior lecturer and two lecturer posts. The unit forms a separate section within the Department of Forensic Psychiatry and its members are full members of the research group. At Broadmoor Hospital teaching links are being developed with Oxford and Southampton universities, and with St Bartholomew's Hospital. It is hoped that these links will also recruit active researchers.

The unit produces its own annual research bulletin which is distributed internally within Broadmoor Hospital. Anyone interested in this document can obtain a copy on application to Professor Taylor at Broadmoor Hospital.

Serious Violence and Schizophrenia

The Department of Forensic Psychiatry was demonstrating the association between serious violence and schizophrenia at a time when this was thought not to be an important issue. One study showed that some ten per cent of homicides in Britain are committed by patients with schizophrenia. Collaborative work with a multi-centre study in the USA has led to the development of a clinical rating scale to assist with more accurate prediction of high risk patients with schizophrenia. Other work here has shown that such high risk patients have usually been ill for more than five years; they have had short term psychiatric care, and have prominent delusional beliefs which are very important to them, for which they seek evidence, and which are often associated with an unpleasant affect. This work is being continued at Broadmoor Hospital and a recent record survey of all 1740 patients resident in special hospital during the first six months of 1993 yielded a subsample of 1461 people convicted of a serious offence. Except for affective symptoms, almost no symptoms were recorded among the non-psychotic, but delusions and affective symptoms had been common among those with psychosis, usually schizophrenia.

Special hospital patients not uncommonly have more than one diagnosis, so the patients were classified according to the principal disorder. Among those with psychosis uncomplicated by any of the other principal disorders, delusions were not only present, but driving the offence in nearly 80% of cases. This is a higher rate of delusional drive than previously recognised, but is compatible with this being a sample of people who had been very seriously violent.

Hallucinations on their own were not found to have had the same sort of impact, but they may increase risk of violence in conjunction with delusional drive.

Case Register

The special hospitals have a case register. This was used to study the mortality of special hospital (high security) patients resident between 1977 and 1993. This is a long stay population (average 8 years, about two-thirds of whom have a chronic psychotic illness, usually schizophrenia, 25% a personality disorder, and the remainder mental retardation). The sample consisted of 4704 people. The figure shows a small, more or less constant number of unnatural deaths (mostly suicide, but including Coroners' verdicts of accident or misadventure), more during subsequent residency in the community or other services than while still resident in special hospital. The number of natural deaths increased annually in the generally older discharged groups. Both within and beyond special hospital, the people with a chronic psychotic illness or a personality disorder show an equivalent and important vulnerability to unnatural death which is significantly greater than that for the people with a mental retardation.

Female Mentally Disordered Offenders

A matter of growing public concern is the management of female mentally disordered offenders. The group will take an increasing interest in this field. This year Tony Maden has written a book about women in prison.

Research Club

The group has a regular monthly meeting (the "119 Club") when work in progress is presented to other members. Visitors are welcome (secretary - Dr Tracey Heads).

Criminal Behaviour and Mental Health

Three senior member of the IRG (David Farrington, John Gunn and Pamela Taylor) edit an international journal in forensic psychiatry and psychology Criminal Behaviour and Mental Health.

International Work

International collaboration is difficult in a field with strong legal and administrative aspects, but we are in regular touch with the Department of Forensic Psychiatry in Melbourne, Australia, and with the United States MacArthur Research Network on Mental Health and the Law. We are trying to establish links with Japan and with Russia.

Our legal interests do not attract funds, but we continue to produce policy and review papers on issues of topical importance.


Aetiological Studies

Pamela Taylor has been awarded a small grant from the Stanley Foundation (USA) to undertake MRI scanning of the brains of men who have a predominantly delusional presentation of their psychosis, to determine whether they differ from men who have a mixed presentation and men who have no psychosis. Tonmoy Sharma has been recruited to the group as advisor, and he will be using some newer US techniques of scanning.

Alec Buchanan has recently completed a report for the Special Hospital Service Authority describing the circumstances in which patients from special hospitals go on to commit serious offences after discharge.

Andrew Johns has been commissioned by the Department of Health to review the psychological effects of cannabis misuse.

Gisli Gudjonsson is looking at the family backgrounds of people who begin to make allegations that they were sexually abused as children, after they have started psychotherapy. The number of such cases reported in the UK is growing and they could become a major medico-legal problem.

Treatment Studies

Tony Maden and Sue Rutter have begun an 18 month follow-up study to describe and evaluate the outcome of all patients who have been through our medium security unit (the Denis Hill Unit) since it opened. An attempt will be made to identify any relationship between ethnic origin and outcome. Gisli Gudjonsson and Sue Rutter are analysing the clinical psychology data which has been collected on the Unit since it began; they hope to test associations between behaviour (eg violence, compliance) and psychological test results. Gisli Gudjonsson is also looking in detail at all violent incidents since the secure unit opened in 1980, to describe the nature of change in pattern of those incidents. A trainee doctor (Chris Krasucki) is in the process of documenting substance abuse histories in previous inpatients; It is hoped that this will lead to the development of intervention programmes within the inpatient services.

A large clinical research programme being undertaken by Pamela Taylor in three special hospitals (Broadmoor, Rampton & Ashworth) is a study of patients in maximum security with schizophrenia who are resistant to treatment or resisting it. The project will include a diagnostic and symptomatic survey from case records, a detailed descriptive account of a sample of special hospital patients with treatment resistant schizophrenia, and a randomised trial and follow up of patients started on clozapine or risperidone. Tracey Heads has included an assessment of early childhood experiences as possible factors to distinguish between the violent and the less violent. Martin Butwell is also undertaking a descriptive account of the trends in referrals, admissions and bed occupancy over the eight years 1985-92. Preliminary analysis of the diagnostic and symptom survey of special hospital patients confirms the importance of delusions as risk factors.

Interface Between Law and Behavioural Sciences

Gisli Gudjonsson and his colleagues continue with their series of studies of remanded and convicted individuals who assert that during police questioning they made false confessions. It has already been shown that some psychiatric patients are particularly likely to make false confessions and this work is of considerable pioneering interest.

Pamela Taylor, in conjunction with Angus Cameron and Michael Kennedy, is studying the impact of legal changes on care provision. A paper on the impact of judicial review is ready for publication. Models of throughcare and the care planning approach are to be tested in a special hospital sample.

A study of changes in anger in special hospital patients brought about by a therapeutic theatre project has been conducted by Clive Meux and David Reiss.

Organisation of Services

Following earlier psychiatric needs assessments of the prison population of England and Wales, and of the English special hospitals, Tony Maden and his colleagues (Celia Taylor and Deborah Brooke) are currently conducting a national epidemiological survey of untried prisoners to determine their mental health and psychiatric needs. In this way a total picture of the psychiatric needs of the offender population in this country is gradually being put together. Earlier papers have already influenced Department of Health and Home Office policies. The clinical services here have pioneered the development of care in the community for mentally disordered offenders.


John Gunn, and David Farrington are seeking funds to re-examine 400 males born in Camberwell in 1951-4. These men form the Cambridge Delinquent Development cohort which has been so productive in determining important correlates of criminal behaviour. This time it is hoped to interview them to determine their psychiatric histories and pathology with a view to relating contemporaneously collected data with this new psychiatric outcome data.

The studies of brain structure and function being carried out by Pamela Taylor will, it is hoped, be amplified by a new series of studies. The availability of an improved portable MRI scanner has made volumetric analysis feasible in Broadmoor patients.

David Forshaw has established a specialised inpatient service for addictive behaviours at Broadmoor Hospital. He hopes to describe and evaluate this new service.

Pamela Taylor proposes a follow-up study of the prisoners she studied 12-15 years ago. This was the pioneer study mentioned above, which showed a relationship between psychosis and violence. It is hoped to determine whether the subjects have had further criminal careers, and whether they still survive.

It is proposed that a monograph will be written putting together the various studies which have been undertaken on the epidemiology of abnormal offenders with the view of drawing up a needs assessment of mentally disordered offenders in institutions. The group is also hoping to extend its work into risk assessment by designing user friendly instruments for general psychiatrists and paramedics, as well as conducting intensive follow-up studies of "dangerous patients."

Tim Exworthy is seeking funds for a follow up study of mentally disordered offenders diverted from custody. Sophie Davison, an SHSA research fellow who has just completed her criminology degree, will be working with Pamela Taylor on a comparative study on men with personality disorder referred for a special hospital bed, between those accepted, those rejected, and those in prison never referred. It is hoped to extend this work to include women with personality disorder. Andrew Johns and Pamela Taylor are planning a study of factors influencing the disposal of life sentenced prisoners who are cared for in special hospitals.

David Reiss is proposing to collaborate with Professor Checkley in studying cortisol levels in patients with post-traumatic stress disorder (PTSD). David Reiss and Tonmoy Sharma are also writing a protocol to examine brain function in traumatised patients, using the functional MRI scanner. Ronan McIvor is examining the growth hormone response to apomorphine in patients with PTSD. John Gunn and David Reiss have been negotiating a source of newly traumatised patients who can be studied as they recover and treated in experimental ways. The burns unit at Queen Victoria Hospital, East Grinstead, is interested in this work and a joint proposal for funding is being rafted. Pamela Taylor and Mark Turner are examining a large set of reports from one defence expert in the psychological trauma field, to understand better the areas of conflict in legal cases. Celia Taylor is trawling Broadmoor Hospital for pedigrees of patients who are both violent and suffer from schizophrenia, with a view to conducting molecular genetic studies on any identified. This work will be done in collaboration with Professor Mullan of the University of South Florida. A new development for 1996 has been closer collaboration with Professor Jeremy Coid of St Bartholomew's Hospital. Professor Coid holds six grants valued at more than half a million pounds, studying such matters as personality disorder in opiate users, needs assessments of mentally disordered offenders, and severe mental disorder in Afro-Caribbean people. Professor Coid is now a full member of the IRG and we hope to welcome other members of his team later and perhaps undertake collaborative work.