The rediscovery of the importance of mental illness in the risk assessment and management of those who threaten, approach, and harm public figures has led to a new way of dealing with those that threaten public figures. This approach emphasises the role of “fixation” which may be defined as an intense preoccupation pursued to an abnormally intense degree. It integrates a threat assessment paradigm with the literature on stalking. The need for such an approach was highlighted in research on the prevalence of harassment of public figures. Psychiatry has a key role in this approach which sees mental health clinicians and Police work together in Fixated Threat Assessment Centres (FTACs). An FTAC functions by assessing the level of concern and sharing information to facilitate interventions that are often mental health based. The purpose is not the hopeless task of identifying those who will go on to perpetrate serious violence, rather to intervene in the group they emerge from, to prevent harm. As well as decreasing risk to the persons fixated upon, this approach improves care to the mentally disordered people who harass and threaten them and, in doing so, decreases the likelihood of their criminalization while enhancing their quality of life. As expertise in the area has grown, policing and security agencies in several countries have expanded the FTAC model to cover individuals thought at risk of lone-actor grievance-fueled violence, a term that captures both different forms of mass killing and lone actor terrorism.

Little is known whether differences exist in motivation and reactive/instrumental offense behaviors between murder offenders with and without psychotic disorder. To contribute to better prevention strategies, the aim of this study was to investigate offense characteristics in murder offenders with a psychotic, nonpsychotic or no psychiatric diagnosis, and whether these factors differ according to sex. This data study examined the population of murder offenders between 1997 and 2005 ( N = 435) in Victoria, Australia. Apparent motive for murder was allocated to one of six classifications. Assignations of reactive versus instrumental offense categories, co-offending, victim-offender relationship were determined by review of case material. Mental health service usage and prevalence of mental illnesses were identified through data with the statewide register of contacts with the public mental health system. Of the 435 offenders, 43 (9.9%) had been diagnosed with a psychotic illness. Gender differences between and within offenders with and without a psychotic disorder were analyzed. Murder offenders with a psychotic disorder were 3.19 (95% confidence interval [CI] = [1.27, 8.03]) times more likely to be motivated by revenge than nonpsychotic offenders and those with no diagnosis (odds ratio [OR] = 2.46, 95% CI = [1.10, 5.53]). The diagnostic groups did not differ on premeditation of their offenses or prior convictions. Perpetrators with psychotic illness were significantly more likely to kill family members and others known to them. It appears that for the psychotic disorder group, the perception of having been wronged in some way is a potential risk marker for planning and committing a serious offense. Care should be taken to improve adherence and access to care to avoid possible future serious violence especially in female patients with a high burden of mental illness like schizophrenia or severe mood disorders.

A threat is an utterance whose content implies an intention to do harm. The motivational typology presented in the chapter distinguishes between the intention to threaten and the commitment to act. The commonest threats in everyday life are the expletive screams. These threats may also reflect a preexisting angry or fearful state of mind and presage further aggression, though not necessarily against the person threatened. Threateners whose intention is to shield themselves are, if anything, committed to avoiding violence. Those who intend to shock are using the threat as a weapon to cause distress. Those who threaten to signal their commitment to enact are sending a clear warning that produces apprehension in even the most stoic. Those who scheme, coerce action through menacing behavior. Given that any threatener can escalate to violence, all threats need to be taken seriously and assessed carefully. Management reduces the commitment to violence and challenges the choice to threaten.

Stalking and querulousness describe problem behaviours characterized by persistently pursuing a person or a cause in such a manner, or to such an extent, that the behaviour creates fear, distress, or disruption to those involved or targeted. An obvious obsessive or fixated quality is associated with both behaviours, and personality traits of rigidity and rumination are frequently observed, though the state of mind rarely conforms to that found in obsessional disorders. Stalkers and querulants rarely regard their behaviour as unjustified, let alone irrational, and few see their persistence as senseless. They may resist the impulse or urge to pursue their victims or cause on occasion but, for the most part, devote themselves wholeheartedly to their objectives. This chapter explores the epidemiology ad phenomenology of stalking and querulousness and the role of (forensic) psychiatry in responding not only to the perpetrators of these behaviours, but also to the unfortunate victim’s of their disordered attention.

The rediscovery of the importance of mental illness in the risk assessment and management of those who threaten, approach, and harm public figures has led to a new way of dealing with those that threaten public figures. This approach emphasises the role of "fixation" which may be defined as an intense preoccupation pursued to an abnormally intense degree. It integrates a threat assessment paradigm with the literature on stalking. The need for such an approach was highlighted in research on the prevalence of harassment of public figures. Psychiatry has a key role in this approach which sees mental health clinicians and Police work together in Fixated Threat Assessment Centres (FTACs). An FTAC functions by assessing the level of concern and sharing information to facilitate interventions that are often mental health based. The purpose is not the hopeless task of identifying those who will go on to perpetrate serious violence, rather to intervene in the group they emerge from, to prevent harm. As well as decreasing risk to the persons fixated upon, this approach improves care to the mentally disordered people who harass and threaten them and, in doing so, decreases the likelihood of their criminalization while enhancing their quality of life. As expertise in the area has grown, policing and security agencies in several countries have expanded the FTAC model to cover individuals thought at risk of lone-actor grievance-fueled violence, a term that captures both different forms of mass killing and lone actor terrorism.

This study sought to enhance knowledge of the link between child sexual abuse (CSA) and long-term criminality by investigating gender-specific effects and the role of index sexual abuse characteristics, revictimization, and serious mental health problems. An Australian sample of 2,759 documented cases of sexual abuse and 2,677 community controls were linked to statewide police records and public mental health service databases, with a follow-up period of 13-44 years. Four key findings emerged from the analysis: (1) CSA victims were more likely than controls to engage in all types of criminal behaviors including violent, sexual, and other offending; (2) gender moderated the relationship between CSA and criminal offending, with stronger associations found among females for general and violent offending, and among males for sexual offending; (3) certain features of the index sexual abuse (i.e., developmental period, number of perpetrators, relation to perpetrator), further victimization experiences, and the development of serious mental health problems were all associated with an increased likelihood of criminal behavior among CSA victims; (4) CSA victims who engaged in criminal offending were more likely to present with cumulative risks than victims not engaging in criminal offending. Implications for future research and clinical practice are discussed.

Lone actor attacks like those at Port Arthur and Parklands High School Florida remain rare events though more frequent year by year. Psychiatrist are unlikely to see such killers either before or after an attack. What they do encountered on occasion are patients threatening to commit such a massacre. These threats need to be taken seriously primarily because they usually indicate significant distress but also because there is a remote chance they may try and act on the threat. Threats state an intention with the chances of enactment depending on the degree of commitment. Commitment is reflected in the level of preoccupation, plausibility, planning and preparation. Most threats have no commitment to act being an end in themselves motivated by such things as the desire to express an emotion, the wish to frighten, the attempt to manipulate others, though just occasionally they are a warning with some level of commitment to act. The assessment of threats to commit a massacre is considered in terms of the motivation and apparent commitment. Those who threaten mass killings also differ significantly from Lone Actor Attackers in their clinical pictures which further assists assessment of risk. There are some where doubts remain about the level of threat they present. The management of this group is discussed.

Australian & New Zealand Journal of Psychiatry, 51(11) vitamin D: factors that are common in the general population and even more common in a population with serious mental illness (SMI). More recently, some clinicians have expressed concern regarding the potential relationship between chronically elevated prolactin levels and breast cancer; however, there remains no conclusive evidence that antipsychotics and increased prolactin contribute to the pathogenesis of breast cancer (Ajmal et al., 2014; De Hert et al., 2016). Furthermore, the results are merely correlative, from which causation cannot be extrapolated (De Hert et al., 2016). Rather lifestyle factors similar to those implicated in osteoporosis with the addition of nulliparity for females: factors which are overly represented in an SMI population are more detrimental (De Hert et al., 2016). In the context of schizophrenia and antipsychotic use, this unnecessary testing of prolactin levels when not indicated by symptomatology is a waste of both time and resources. Both of which would be better utilized by a thorough history taken with regard to hyperprolactinemia symptoms as well as trying to motivate clients to consider and implement healthier lifestyle practices that contribute to a myriad of chronic illnesses that are overly represented in an SMI population. Furthermore, this unnecessary testing may lead to the unwarranted switching of antipsychotics to prolactin-sparing agents or the addition dopamine agonists, both of which can have a detrimental impact to the patient’s mental health and stability. Therefore, it is asserted that even if prolactin levels increase from baseline up to 2000 μg/L, if the patient is not exhibiting symptoms of hyperprolactinemia, nothing should be done. Beyond this level, further investigation is indicated.

The association between child sexual abuse (CSA) and risk for re-victimization is well-documented; however, less is known about the temporal progression of re-victimization experiences over the early life-course among CSA survivors, and whether this differs from that of those without known sexual abuse histories. This study investigated whether there are distinct temporal pathways of interpersonal re-victimization between the ages of 10–25 years among medically confirmed CSA cases, and considered whether abuse variables, re-victimization variables, and the presence of other adverse outcomes, were associated with heterogeneity in re-victimization pathways. The data were collected as part of a large-scale data-linkage study in which the medical records of 2759 cases of contact-CSA between 1964 and 1995 were linked, between 13 and 44 years following abuse, to police and public psychiatric databases; cases were compared to a matched community sample (n = 2677). Using a subsample of 510 (401 victims; 109 comparisons) individuals with an interpersonal (re)victimization history, we examined the aggregate ‘age-(re)victimization’ curves for CSA victims and comparisons, respectively. Further, we applied longitudinal latent class analysis to explore heterogeneity in re-victimization trajectories among abuse survivors across their early life-course. Four latent pathways were identified, labeled: Normative; Childhood-Limited; Emerging-Adulthood; and Chronic re-victimization trajectories. Older age at abuse, a criminal history, and mental health problems were uniquely predictive of membership to the more problematic and persistent re-victimization trajectories. Findings indicate that individuals exposed to CSA during adolescence may be particularly vulnerable to poorer re-victimization trajectories, characterized by multiple risk indices, and thus may warrant increased service provision.

Objectives: There is a growing body of research investigating the relationship between child sexual abuse and a range of adverse outcomes. However, very little is known about the long-term co-occurrence of psychiatric disorders and behavioral problems among this vulnerable population, or the interaction between characteristics of the abuse, such as the nature and timing of the child sexual abuse, and the extent of subsequent adversities. This study aimed to determine the rate and co-occurrence of mental health morbidity, criminal justice system contact, and fatal self-harm among medically confirmed victims of child sexual abuse, and to identify abuse variables associated with a greater likelihood of cumulative adverse experiences.Methods: The forensic medical records of 2759 cases of child sexual abuse assessed between 1964 and 1995 were linked with public psychiatric, criminal justice and coronial administrative databases between 13 and 44 years following abuse. Cases were compared to 2677 matched comparisons from the general population.Results: Abuse victims were more likely (odds ratio = 7.2, 95% confidence interval = [4.9, 10.4], p < 0.001) to experience cumulative adverse psychiatric and behavioral problems relative to comparisons. Almost half (47.6%) of victims who died of suicide or drug overdose had a history of offending, further victimization and mental illness. Relative to comparisons, female victims demonstrated the largest increase in odds for cumulative outcomes (odds ratio = 9.8, 95% confidence interval = [5.8, 16.8], p < 0.001), whereas in absolute terms, male victims were at an elevated risk for all types and combinations of adverse outcomes, except fatal self-harm. Boys who were older at abuse, had multiple abuse episodes or who were abused by an extra-familial perpetrator were most likely to experience poorer clinical trajectories. Only being older at abuse was associated with cumulative adverse experiences for females.Conclusions: Sexual abuse, particularly during adolescence (ages 12-16 years), appears to be a risk factor for co-occurring adverse experiences. This study identifies particular groups of child sexual abuse victims as at-risk and requiring targeted intervention.

Very little research has been conducted to show the way in which criminal behavior unfolds over the life-course in children who have been sexually abused, and whether it differs from the 'age-crime' patterns consistently documented in the criminology literature. This study investigated the temporal pathways of criminal offending between the ages of 10-25 years among medically confirmed cases of child sexual abuse (CSA), and considered whether abuse variables, offense variables, and the presence of other adverse outcomes, were associated with heterogeneity in offending pathways among CSA survivors. This study utilized data gathered as part of a large-scale study involving the linkage of forensic examinations on 2759 cases of medically ascertained CSA between 1964 and 1995, to criminal justice and public psychiatric databases 13-44 years following abuse, together with a matched comparison sample of 2677 individuals. We used the subsample of 283 offending individuals (191 victims; 92 comparisons) for whom complete offending data were available. We compared the aggregate age-crime curves for CSA victims and comparisons, and applied longitudinal latent class analysis to identify distinct subgroups of offending pathways between ages 10-25 years within the abuse sample. Four latent pathways emerged among sexually abused offenders, labeled: Early-Onset/High-Risk/Adolescence-Limited; Intermediate-Onset/Low-Risk/Adolescence-Limited; Late-Onset/Low-Risk/Slow-Declining; and Early-Onset/High-Risk/Persistent offenders. Age at abuse, the nature and frequency of offending, and mental health problems, were associated with the offending pathway followed by CSA victims. Consistent with criminological literature, findings indicate considerable heterogeneity in the longitudinal offending patterns of offenders exposed to CSA. Implications for clinical practice and directions for research are highlighted.

This study assessed the reliability and validity of the Stalking Risk Profile (SRP), a structured measure for assessing stalking risks. The SRP was administered at the point of assessment or retrospectively from file review for 241 adult stalkers (91% male) referred to a community-based forensic mental health service. Interrater reliability was high for stalker type, and moderate-to-substantial for risk judgments and domain scores. Evidence for predictive validity and discrimination between stalking recidivists and nonrecidivists for risk judgments depended on follow-up duration. Discrimination was moderate (area under the curve = 0.66-0.68) and positive and negative predictive values good over the full follow-up period (Mdn = 170.43 weeks). At 6 months, discrimination was better than chance only for judgments related to stalking of new victims (area under the curve = 0.75); however, high-risk stalkers still reoffended against their original victim(s) 2 to 4 times as often as low-risk stalkers. Implications for the clinical utility and refinement of the SRP are discussed.

There is increasing recognition that family violence may be perpetrated by juveniles against their parents and siblings, however empirical research regarding the nature and causes of such violence is relatively limited. This study examines juvenile family violence in the context of an Intervention Order (IO) being sought against a relative aged 18years or less. All cases over a 3-year period involving an IO application in a major metropolitan Children's Court in Australia were analysed (n=438). The majority of applicants/victims were parents (78%) and to a lesser extent siblings (11%) and other relatives (9%). Most parents who sought applications were mothers (63%) and one-parent households were over-represented (66%). The majority of defendants/perpetrators were male (69%), though juvenile females constituted a significant minority (31%). Intervention orders were sought to prohibit property damage (61%), physical assaults (59%) and/or threats (53%). According to the victim reports, these behaviours emerged in the context of prolonged behavioural problems (49%), a desire to intimidate the victim (12%) or retaliation (8%). While 44% of IO applications were granted, the majority were not (56%) due to the victim discontinuing the application prior to a formal hearing. Of the orders that were granted, a third (32%) were subsequently reported as having been breached. Juvenile family violence is a serious social problem that requires more systematic research to identify the correlates of this behaviour and effective interventions to prevent or reduce its occurrence.

This chapter focuses on two large-scale legal changes that have occurred in England and Wales since the publication of the first edition of this text, the Mental Capacity Act 2005, and the Mental Health Act 2007. Mental health law is concerned with the management of people who are afflicted with poor mental health. Mental health legislation, like all European legislation, is subject to the European Convention on Human Rights. Mental capacity was hardly mentioned in psychiatric books in the twentieth century; it is everywhere and causing some confusion. An approved clinician may be a doctor or other mental health professional who has had specialized training. The pre-2007 Mental Health Act 1983 contained various ‘exclusions whereby a person might not be treated as suffering from a mental disorder by reason only of promiscuity or other immoral conduct, sexual deviancy or dependence on alcohol or drugs.’.