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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