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Correlates and types of criminal behavior in a sample of hospitalized Egyptian mentally ill patients

Abo Zaid, Mohamed Youssef; Sabry, Walaa; Moneim Mahmoud, Dalia Abdel; Bastawy, Mostafa; Refaat, Ghada; Adel, Diana

Middle East Current Psychiatry: July 2016 - Volume 23 - Issue 3 - p 134–141
doi: 10.1097/01.XME.0000481456.17276.60
Original articles

Background Criminal behavior is strikingly increasing in a sample of mentally ill patients in forensic setting. This necessitates proper assessment of the different factors that reinforce criminality rates. Very few studies investigated the rate of criminal behavior and its correlates among Egyptian mentally ill patients.

Aims The current study aimed to investigate the rate of criminal behavior in a sample of Egyptian patients with psychiatric disorders and to identify the various sociodemographic and clinical correlates associated with criminal behavior and its type among these patients.

Patients and methods One hundred patients with Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) diagnosis of different psychiatric disorders were enrolled in the study. They were recruited from the Acute Psychiatric Inpatient Unit of Institute of Psychiatry, Ain Shams University Hospitals, and were assessed using the following tools: Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II), Symptom Check List-90-Revised, and questionnaire designed for assessment of sociodemographic data and the patients’ past forensic history.

Results Twenty-three percent of the study patients had a past history of committing a criminal behavior. Male sex and substance abuse/dependence are the only factors that correlated to high criminal behavior, whereas none of the patients’ personality traits correlated to criminal behavior. High hostility symptoms on Symptom Check List-90-Revised was the only symptom that highly correlated (P≤0.001) to criminal behavior. Personal crimes were more prevalent compared with property crimes in the study sample. None of the clinical variables was found to be significantly correlated with a specific crime type, but patients with polysubstance abuse and those with cluster B personality traits had a greater tendency to commit personal crimes.

Conclusion There is a substantial rate of criminal behavior among Egyptian mentally ill patients. Personal crimes are more common in mentally ill patients compared with property crimes. Patients with substance use and hostility had a greater tendency to exhibit criminal behavior.

Department of Psychiatry, Institute of Psychiatry, Ain Shams University Hospitals, Ain Shams University, Cairo, Egypt

Correspondence to Walaa Sabry, MD, Department of Psychiatry, Institute of Psychiatry, Ain Shams University Hospitals, Ain Shams University, Abbassia Square, Cairo 11657, EgyptTel: +20 127 847 7746; fax: +2 02 26836379; +2 02 22678032; e-mail:

Received October 30, 2015

Accepted February 16, 2016

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Mental illness and crime are usually intertwined. Mentally ill patients have more often been accused of and arrested for criminal behaviors compared with individuals in the general population. Although the precise degree of the over-representation of people living with mental illness in the justice system is uncertain, there is no doubt that a clear relation does exist and is significant 1.

Numerous studies showed a moderate but statistically significant association between major mental disorders, criminal behavior, and violent crimes 2–6.

Various research studies examining the relationship between schizophrenia and violence have found that patients with schizophrenia are at a higher risk for criminal behavior compared with the control group, but at a lower risk when compared with patients with antisocial personality disorders and substance abuse 5,7.

Studies on the relationship between affective disorder and criminal behavior revealed conflicting results. Some studies have noted that depressed patients are significantly less likely to commit criminal act compared with individuals with other types of disorders 8–12. In contrast, some other studies have found a relationship between affective disorders and criminal behavior, especially in children and adolescents 13. Personality disorders received a great research interest in relation to criminal behavior. Antisocial personality disorder is considered the most frequent diagnosis among offenders, which Ogloff 14 has estimated could constitute as high as 60–80% of the prison population.

However, not all patients with mental illness commit criminal acts, but they often do so out of having certain symptoms of the illness – for example, command hallucinations, paranoid delusions, or incapability to understand the nature and implications of the act they are committing and doing so as an impulse 15–17.

In addition, a number of sociodemographic factors have been postulated to predict crime and violence in the mentally ill patients. For example, violence before admission to a hospital is associated with violence after discharge, male sex, age, increased length of stay, and cognitive impairment 18.

Previous studies on relationships between mental disorder and crime have tended to group the mental disorders, the crimes, or both, leaving uncertainty about a more specific mental disorder: crime relationships; very few researchers examined this relationship 19.

The plethora of research on criminality among psychiatric patients is mainly coming from western society. Studies on this issue in the Arab world are very scarce. Motivated by these facts, the research team aimed to investigate the risk for criminal behavior and its correlates among a sample of hospitalized Egyptian patients with mental illness.

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The current study aimed to investigate the rate of criminal behavior in a hospitalized sample of Egyptian mentally ill patients and to identify the various clinical patients’ characteristics associated with different types of criminal behavior among mentally ill patients.

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Patients and methods

Site of the study

The study was a cross-sectional descriptive study that was conducted at the Acute Psychiatric Inpatient Unit of the Institute of Psychiatry, Ain Shams University.

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Ethical consideration (approvals and consent)

All procedures were reviewed and approved by the Ethical Committee of Ain Shams University and Institute of Psychiatry. The patients were informed about the nature of the study and the confidentiality of the obtained information. It was stated that the participation in the study was voluntary and that the participants had the freedom to withdraw at any time; a printed consent form was signed by each participant.

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Selection of participants

The sample was recruited from mentally ill Egyptian patients who were admitted to the Inpatient Unit of the Institute of psychiatry, Ain Shams University, over a 6-month period from the beginning of January to the end of June 2015. Inclusion criteria were as follows: having Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) diagnosis of schizophrenia, mood disorders, dual diagnosis, and substance use disorders; having a past history of reported criminal behaviors; age range between 18 and 60 years; and both sexes. It is noteworthy that the patients who committed recent crimes around the time of admission were not admitted to the Institute of Psychiatry, but referred to the criminality section in Al Abbasia Hospital. Hence, those patients could not be enrolled in this current study due to the strict admission policy of the institute. Exclusion criteria included concomitant nonpsychiatric illness that can cause violence or enduring personality changes. Patients with psychiatric diagnosis other than those mentioned above (e.g. anxiety disorder, personality disorders, etc.) were excluded as they were rarely to be admitted. Complete information was collected from the patients themselves, relatives, and their psychiatric files.

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Procedure and tools

After application of the inclusion and exclusion criteria, the final sample included 25 patients diagnosed with mood disorders, 25 patients with schizophrenia, 25 with dual diagnosis, and 25 patients diagnosed with polysubstance abuse.

Patients were assessed using the following tools:

  • Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I): It is a semistructured diagnostic interview based on an efficient but thorough clinical evaluation 20. The study used the Arabic version of the SCID-I 21. It was used to elicit and confirm the patients’ clinical diagnoses.
  • TheStructured Clinical Interview for DSM-IV Axis II Disorders (SCID-II)22(Arabic version23): It is a semistructured interview that was developed to categorically and/or dimensionally assess the DSM-IV personality disorders. It could be used in both clinical as well as research settings. Items are organized by personality disorder. The Arabic version used in this research was translated and used in a previous Egyptian study 23.
  • Designed questionnaire: This was used to elicit sociodemographic data and inquire about the detailed forensic history in patients with past history of criminal behaviors and information on substance intake around the crime time.
  • Operational definitions:
  • Although lay people often feel they can easily identify crime and criminals, and deviants and deviance, there are in fact unclear boundaries between legality and illegality and between normality and deviance.
  • Criminal behavior was defined as behaviors or actions that are prohibited by the state and punishable under the law 24. There are different classifications for criminal behaviors. However, for the purposes of this study, we used crime-centered classification according to Farr and Gibbon’s classification 25. Thus, criminal behavior was divided into two types according to the type of inflicted harm: personal crimes, which involve personal harm that results in physical, emotional, or psychological harm to the victim, such as assault, homicide, sexual abuse, child abuse, and kidnaping; and property crimes in the form of crimes against property, which do not necessarily involve harm to another person. Instead, they involve an interference with another person’s right to use or enjoy their property (e.g. theft, motor vehicle theft, arson, shoplifting, escaping from military service, and vandalism). Eligible patients for our study were the ones who declared to have a past history of criminal behavior if any of these two crime types was attempted during the period of mental illness. This was verified from the patients, their families, and their previous psychiatric records.
  • Symptom Check List-90-Revised (SCL-90-R)26: It was used to assess different categories of symptomatology. The primary symptom dimensions are somatization, obsessive compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. A large number of studies have been carried out showing the reliability, validity, and utility of the questionnaire 26. The Arabic validated version of SCL-90-R questionnaire was used 27.

Each participant was interviewed by the investigators at least once, and some patients needed more sessions to finalize their assessment.

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Statistical analysis

Data were recorded and analyzed using the statistical package of social sciences (SPSS, 20th version, 2011; SPSS Inc., Chicago, Illinois, USA). The results were tabulated, grouped, and statistically analyzed using the following tests: mean

, SD (for quantitative data), and frequency with percentage (for qualitative data). The χ2-test was used for the comparison of categorical variables. Continuous normally distributed variables were compared using the independent sample t-test. Comparisons between different groups of participants were performed using analysis of variance. A statistical level of significance was set at 0.05.

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Sociodemographic and clinical characteristics of the study sample

The study sample consisted of 100 psychiatric patients from the inpatient unit; 80% of cases were men and only 20% were women. The mean age for the cases was 31.33±4.25 years. A total of 36% of cases were university graduates, 23% of patients studied in technical school, 10% studied in an institute, 25% were school dropouts, and 6% of patients were illiterate. A total of 59% of the participants were single, 32% were married, 8% were divorced, and 1% was widowed. Unemployment was found in 42% of cases, whereas 58% of cases were employed (Table 1).

Table 1

Table 1

On assessment of different symptomatology type with SCL-90-R, phobic symptomatology was highly common in the study sample (95%), followed by obsessive symptoms (92%) and anxiety symptoms (87%); the least common symptoms were psychoticism (Table 1).

In terms of clinical diagnosis using SCID-I, the participant diagnoses were classified as follows: 25% of patients were diagnosed with mood disorders, 25% with schizophrenia, 25% with dual diagnosis, and 25% of patients were diagnosed with polysubstance abuse. Apart from patients with the diagnoses of polysubstance abuse and dual diagnosis, all other patients denied the history of substance use at the time of their criminal behavior.

Personality assessment according to SCID-II is illustrated in Fig. 1. The results revealed that the majority of the study sample was having mixed personality traits (32%). None of the patients ever had the diagnosis of personality disorder. On grouping, the incidence of personality traits were as follows: cluster B, 64% of the sample; cluster A, 18% of the sample; no specific traits, 10% of the study sample; cluster C, 7% of the study sample; and multiple clusters, 1% of the study sample (Fig. 1).

Figure 1

Figure 1

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Rate of criminal behavior in the study sample

Twenty-three percent of the study patients had a past history of at least one criminal behavior during their psychiatric illness. There were two types of crimes: personal crimes (16%) and property crimes (7%). Personal crimes included assault (3%), sexual assault (2%), homicide (1%), drug trafficking (4%), and drug abuse (6%). Property crimes consisted of escape from military service (5%), theft (1%), and expense issue (1%) (Fig. 2).

Figure 2

Figure 2

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Sociodemographic and clinical correlates of criminal behavior

The results revealed that male sex was significantly correlated to higher criminal behavior compared with female sex (P=0.04); the rest of the studied sociodemographic variables were not found to be correlated with criminality in the study sample.

In terms of clinical variables, data displayed that having a substance use diagnosis and dual diagnosis were significantly correlated with high criminality (P=0.04). None of the patients’ personality traits was correlated to criminal behavior. On SCL-90-R assessment of the patients’ symptomatology, the results showed that hostility was the only symptom that was highly correlated (P≤0.001) to criminal behavior in the study sample (Table 2).

Table 2

Table 2

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Correlation between clinical variables and type of crime

As shown in Table 3, personal crimes were significantly associated with cluster B personality traits. They also tended to be more common in patients with the diagnosis of substance use disorders and dual diagnosis, although this finding was not statistically significant.

Table 3

Table 3

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Criminal behavior among individuals with severe mental illness has become an important focus in community-based care, often as the result of tragic, albeit uncommon events 28,29.

The current results revealed that 23% of the study cases had a history of at least one criminal behavior. This rate is higher than that reported in other studies such as that by Asnis et al.30, who found that 4% of their study outpatients reported a history of homicide attempts. However, Ghoreishi et al. 31 showed a higher rate than that reported in the current results, as 59.2% of their study sample comprised offenders with criminal status.

Difference in results could be explained by methodological differences, such as sample sizes and the type of the sample, either community-based sample or hospitalized psychiatric patients. Community-based epidemiological studies may underestimate the true prevalence of criminality among individuals with mental disorder, as individuals who are incarcerated or hospitalized would not be included in the sampling frame. Conversely, studies of hospitalized patients or incarcerated offenders may overestimate the true association between mental disorder and criminality, as individuals who are aggressive may be expected to be selected into a patient group by being hospitalized or an offender group by being incarcerated 32.

Current study results showed that mentally ill male patients had a higher rate of criminality history compared with their female counterparts, with a statistically significant difference (P≤0.05). In the general population, the proportion of men engaging in violent and criminal behavior is expected to be higher than that of women 33,34. However, studies on sex differences in criminality among psychiatric populations showed inconsistent results. For example, in a community-based epidemiological studies of self-reported violence and in studies of criminality among individuals with mental disorder, male sex is a significant predictor of criminal behavior 33,35–37. Similarly, a study showed that mentally ill male patients were more likely to be arrested during their lifetime for violent and nonviolent offenses compared with women 38. However, other studies showed that male patients were no more likely to be violent compared with female patients 39,40. Busfield 41 suggested that the violence committed by men is more likely to lead to serious injury. This may explain the elevated arrest rates among male patients with mental disorders.

Different studies on the correlation of other sociodemographic with criminality among mentally ill patients revealed discrepant results. Current findings showed no specific relation between age and rate of criminal behavior. In contrast, some studies showed that younger age was highly associated with the risk for criminal behavior 33,42–44. Difference in results could be attributed to the fact that age effect may be moderated by the presence of psychiatric symptoms. In a 30-year retrospective birth cohort study, Hodgins 45 found that a significant number of male patients with major mental illness began their criminal careers across all age groups.

However, the current study did not find an association between any of the sociodemographic factors and the criminality rate in the study sample. In contrast to our findings, other studies 33,46,47 found that marriage, employment, and education are protective against crimes even in the mentally disordered patients, as a large percentage of the their offenders were single, less educated, and unemployed. This study finding is in agreement with those of other studies, as that by Linhorst et al. 48, who found that sociodemographic variables such as age, race, and current marital status were not correlated with history of committing assault crimes. Differences in results between studies could be due to different methodologies and sample size.

According to the DSM-VI Axis I diagnosis, patients are equally distributed (25%) into four major psychiatric diagnoses: mood disorders, schizophrenia, dual diagnosis, and polysubstance abuse. Unsurprisingly, our results showed that patients diagnosed with polysubstance abuse reported the highest rate of committing a crime followed by those having dual diagnosis, whereas patients diagnosed with mood disorders and schizophrenia were the least to commit crimes; the difference was statistically significant (P=0.04).

The relationship between substance abuse and crime has been widely studied. The results revealed increased crime rate among substance abusers and dependants 45,49–52 and in cases with dual diagnosis 53,54. This is genuinely expected and explained by the fact that substance abuse is associated with the loss of inhibition on aggressive and sexual impulses, with increased irritability, poor judgement, paranoid ideation, and distorted perception.

Similarly, a recent comprehensive review of papers published between 1966 and the end of 2012 reported that the risk for violent behavior was actually higher for bipolar disorder than for schizophrenia 55. Other studies by Hodgins et al. 56 and Corrigan and Watson 57 found that those with major affective disorders were more likely to be convicted of any offense than those with schizophrenia.

Asnis et al.58 did not find any difference among patients engaging in attempted homicide on the basis of diagnosis. Conversely, Eronen et al.59 found that men with schizophrenia were at elevated risk for homicide, but individuals with bipolar disorder or major depression were not. The reasons for these disparities may be multimediated. First, the differences in findings across studies may be methodologically based. Some of the divergence in the findings may be related to how psychiatric disorder is operationally defined and measured across studies. Moreover, the manner in which violence and criminality is measured may also account for the inconsistency of the findings.

According to the DSM-IV Axis II diagnosis of personality traits section, the study displayed that mixed personality traits were the most common personality (32%) in the study sample. On grouping the personality traits, cluster B constituted 64% of the sample. Interestingly, it was observed that individuals with cluster B personality traits showed a higher tendency for committing crimes compared with other clusters. In concordance with the current findings, other studies 44,60–63 showed that patients with cluster B personality disorders were more likely to commit a range of violent acts during adolescence and early adulthood. In this study, all of the patients had only traits that were not fulfilling the criteria for the diagnosis of different personality disorders; this might be the reason for the nonsignificant relation between different personality clusters and criminal behavior. However, previous studies recommended that it is essential and may be more fruitful to study active symptoms of psychiatric disorders as well as dimensional psychological traits rather than categorical disorders such as schizophrenia or antisocial personality disorder. The transient and episodic nature of symptoms of personality traits or psychiatric disorder may be central to understanding any relationship existing between mental illness and crime and may account for the different results found across studies 64,65. For example, specific personality traits such as uncontrolled anger may be more relevant in the study of aberrant behavior compared with actual personality disorders.

For the above reasons, the study team preferred to use the SCL-90-R to examine various patients’ symptomatology instead of studying only the psychiatric disorders. The results showed that among all symptomatology items, hostility was solely positively correlated with history of committing a crime (P≤0.001). This is in agreement with the study by Buckley et al. 66 and Fava et al. 67, who found that mentally ill patients with high anger and irritability were more prone to become violent.

A specific mental disorder, crime relationships, is still a debatable issue, as the majority of the previous studies on the relationships between mental disorder and crime have tended to group the mental disorders, the crimes, or both. In the current study, we tried to examine the relationship between the specific types of criminal behavior and certain psychiatric disorder.

The current study revealed that personal crimes are more common in the study participants (16%) compared with property crimes (7%). This is in accordance with the results of the study by Vinkers et al.19, who found that homicidal attempts or threats (types of personal crimes) had the strongest relationship with psychiatric illness. However, property crimes had the weakest relationship with these disorders.

On examining the relationship between types of psychiatric or personality disorders and types of crime, the results showed no statistically significant relation between types of crimes and either Axis I or Axis II psychiatric diagnoses of patients (P=0.3 and 0.4, respectively). However, personal crimes are mainly committed by patients diagnosed with polysubstance abuse (n=7) followed by those with dual diagnosis (n=4). They were common in patients with cluster B personality traits than the other two clusters.

In contrast to the current study findings, the results of the study by Vinkers et al.19 showed that personal crimes had the strongest relationship with mainly psychotic, organic, and some developmental disorders. However, property crimes had the weakest relationship with these disorders. In contrast, other Axis I disorders, personality traits, or an IQ score of less than 85 points were only moderately related. Difference in results could be explained by different sample size and type as in Vinkers et al. 19. They included larger sample size (21 424 pre trail defendants) and their data were extracted from pretrial forensic psychiatric records. This denotes that their criminal cases were more common to be alleged with homicidal/assault offenses than drug offenses. However, our sample was a clinically based sample that included all psychiatric diagnoses as a possibility.

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Rate of criminal behavior among psychiatric patients appears to be eminently high. Results suggest that substance use disorders, dual diagnosis, and hostility are highly associated with criminal behavior among psychiatric patients and that personal crimes are more common in mentally ill patients compared with property crimes. Measuring rates of criminal behavior and understanding the factors associated with it are an important part of devising proper management strategies to protect the patients themselves and the community.

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Strength and limitations

The study is one of the few Egyptian studies that investigated the rate of criminal behavior in a sample of mentally ill patients. The use of valid reliable tools in assessment strengthened the results. The current study examined the patients’ symptomatology, which was more beneficial and unique to this study. Thus, we were able to study the active symptoms of psychiatric disorders as well as dimensional psychological traits rather than only the categorical disorders. In addition, this study is one of the fewest that settled to examine the more specific mental disorder: crime type relationships.

However, the study was limited by a small sample size and type of psychiatric diagnoses enrolled, which may limit the generalization of the study results. Future studies on large numbers of patients are needed. Furthermore, it was a cross-sectional study and hence caution is still warranted in explaining the findings compared with longitudinal studies that would be more confirmative. Another limitation is the lack of collateral information on the criminal behavior from police or court reports. However, it could serve as a preliminary research to be followed by more specific research into each psychiatric disorder.

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Conflicts of interest

There are no conflicts of interest.

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correlates; criminal behavior; sociodemographic; violence

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