Ebook Forensic psychiatry - Clinical, legal and ethical issues (2/E): Part 2

17
Deception, dissociation and malingering
Edited, written and revised by
John Gunn

Written by
John Gunn
David Mawson
Paul Mullen
Peter Noble

  1st edition edited by Paul Mullen

I have done that – says my memory. I could not have
done that – says my pride; [the] end remains inexorable.
Eventually memory gives in. (Nietzche, 1886)

Deceptive mental mechanisms
Deception occupies a central and privileged place in forensic psychiatry. The founding fathers of the speciality, such
as Haslam (1817a,b), Ray (1838) and East (1927), were all
much concerned with the need to recognize fraudulent
claims in the accused, the claimant and the conscripted
serviceman, to potentially mitigating, compensable or
exempting disorders. The touchstone of the expert’s skill
used to be in distinguishing between the genuine and the
simulated. Although this particular question has lost much
of its urgency, what remains central are issues surrounding
those, all too human, tendencies to deny, to lie to others,
and to lose oneself in self-deception.
The tendency to modify our experiences of current
reality by how we think rather than by what we do, and

to interpret and edit memories of the past in pursuit of
present needs is universal. We try to escape the contingencies of reality by a variety of mechanisms, many wholly
unconscious.

Substituting
Available alternatives are sometimes substituted for those
objects of our desire which appear beyond reach. Pets
may be substituted for people, especially children. The
displacement of desire, or aggression, on to a more available, or vulnerable object, is common. In some claimants and litigants this mechanism can be at work. The
bereaved, deprived of their loved one, may displace their
energy from the pursuit of the lost love on to the pursuit
of compensation. At first glance, their actions may appear
venal and self-serving, but behind this appearance can lie

a tragic attempt to restore an unbearable loss through
pursuit of the substituted goal.

Daydreaming
Daydreaming is the way in which we turn away from
the daunting task of wresting the desired from reality, or
from the conflicts inherent in current obligations, into a
world of fantasy and make-believe. In children, the world
of private make-believe and public reality can merge
and mix. In some adults, the dividing line between the
internal world of fantasy and the shared external world
of consensual reality remains wavering and uncertain.
The French concept of mythomania, often treated as
synonymous with pathological lying, captures this quality
of being caught up in one’s own fantasies and imaginery
adventures.

Lying
Lying, or to use the minimally less pejorative and far broader
term ‘deception’, is universal. Advertisers ‘put a gloss’ on
their products, companies fail to disclose the whole story,
politicians distort, sportsmen break rules when they think
they will not be detected, and we all deceive on occasions
to obtain advantage or avoid embarrassment. Lying may
even be part of normal development and individuation
(Ford et al., 1988). Hartshorne and May (1928) conducted a
series of elegant experiments demonstrating the frequency
of deceptive behaviour amongst youngsters. Most authors
agree that lying involves the consciousness of falsity, the
intent to deceive, and a preconceived goal or purpose.
Normal prevarication is instrumental and, at least initially,
the liar is aware of the deception. In practice, the intentional lie merges into self-deception and we move, all too
easily, from knowingly fabricating into believing our own
stories.

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In pathological lying (pseudologia fantastica; see below),
there is created a tissue of fantastic lies in which the deception is not merely about matters of fact, but aims to create
a whole new identity. The lies, though they may begin as

instrumental, in the sense of bringing pecuniary advantage or prestige, rapidly develop to a stage where they are
disproportionate to any discernible end or personal gain.
Commonplace lies deceive about matters of fact, the fabrications of the pathological liar deceive about who and what
s/he is; they are about creating a new identity and recreating the world. Pseudologia fantastica is about lying, but it is
also about fantasy run riot which involves self-deception as
much as deceiving others.

Denial
Denial of current reality is one way of coping with the
disturbing and the threatening. Denial differs from lying
in that it is not an attempt to convince others, or oneself,
of a different reality, but involves turning away from the
unacceptable. Clearly, denial involves deception and selfdeception, but lacks the intention to affirm a new and false
reality. In practice, denial often slips into fabrication. Denial
involves the claim that something did not occur or, if it did,
the subject has no memory for the events.

Amnesia
Amnesia is an inability to remember or a denial of memory.
Selective memory which leaves convenient blanks is a common enough indulgence, and is to be expected in those
where forgetting may bring considerable advantage. The
distinctions and overlaps between so-called psychogenic
amnesia and organic memory disturbances are considered
later in this chapter and in chapter 12.

Self-deception
Self-deception is a concept presenting profound theoretical ambiguities, but is none the less potentially of wide
applicability in psychiatry. Many aspects of what we term
unconscious, dissociative, hysterical, or even abnormal illness behaviour can, from a different perspective, be spoken
of as types of self-deception.

The central paradox of self-deception was described by
Fingarette (1969):
For as deceiver one is insincere, guilty: whereas if genuinely deceived, one is the innocent victim.
Is then the self-deceiver both perpetrator and sufferer? The
psychiatrist’s view of self-deception is often influenced by
the Freudian vocabulary which articulates the phenomenon as one of helplessness in the grip of unconscious
conflict, for the self-deceiver is spoken of as the victim of
the compulsive force of the unconscious.

Self-deception is in part about how information is
interpreted and what aspects are acknowledged but, more
important, it is about self-presentation; it is about what we
avow as our motivations and what we accept has been our
behaviour. The simplest model of self-deception is of holding two incompatible beliefs, one of which is not noticed
or acknowledged. Self-deception is not just persisting in
beliefs in the face of contrary evidence, nor merely holding
incompatible beliefs, for it implies an active engagement
which strives to maintain ignorance. The characteristics
of self-deception as viewed from the vantage point of an
observer include:
1. activities which appear incompatible with the individual’s previous claims or behaviour;
2. the refusal of the self-deceiver to give adequate (or at
least acceptable) justifications for his or her activities;
3. a refusal to accept responsibility for activities and their
consequences which appears to stem not from disregard of those responsibilities, but from an inability to
recognize the transgressions;
4. an adherence to the deception which persists even
when it becomes personally disadvantageous.
The latter two characteristics which speak of loss of selfcontrol tend to soften, or even remove, the moral condemnation of the self-deceiver. What of the experience of
self-deception for the self-deceiver? This is difficult to pin

down. Totally successful self-deception would presumably be experienced as having a conviction or desire no
different from any other. We assume that some discomfort and disequilibrium accompanies most self-deceptive
engagements, which may be experienced as unease or
a puzzlement at one’s own apparently disproportionate
vehemence.
Self-deception covers a wide range of human activity.
It covers the exuberant, if shallow individuals, who commit themselves to a course of action in the enthusiasm of
the moment, only to later disavow that commitment. It
includes the envious, who undermine and damage those
around them under the guise of friendship, apparently
in ignorance of their own motives. It includes those who
convince themselves of their own illness and disability. It
includes most of us as we try and impose coherence and
create a flattering tale out of our past and present activities.
Occasionally, it is possible to see self-deception emerging. A young man who had strangled his girlfriend was
examined a matter of a few hours after the event. He gave,
at that time, an account of the killing marked by great distress and genuine perplexity about how he came to commit
such an act. A few days later he claimed to have only the
vaguest memories of the event leading up to the killing
and none for the act itself. A week or so later, a story began
gradually to emerge as he ‘remembered’ what had really
happened and the provocations which had occasioned
the act. The following month, he gave a clear account of

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intolerable provocation which culminated in his loss of
control and which ‘must have led to the killing’, although he
said he could not recall committing the deed. Somewhere
in that progression, self-deception must have played a part
but, by the time this man went to trial, he seemed to honestly believe his own account of the events, and certainly he
was filled with a genuine sense of grievance and injustice
when his defence foundered.
Self-deception involves the editing and reorganization
of memory to serve the needs of current imperatives. In
fact, such restructuring of memory is to some degree a
normal process which is going on constantly. The view
of human memory as analogous to a massive filing system or the hard disk of a computer, which assuming you
employ the correct access codes calls up exactly what was
filed away, is increasingly coming under critical scrutiny.
Memory is, at least in part, a functional and selective system which is constantly evolving and adapting to current
needs (Rosenfield, 1988). In a mundane way, we all re-write
our own histories so as to ease the disjunctions between
our present attitudes and positions and our past actions
and views. Self-deception is essential to righteousness, or
any other form of pomposity. Equally, it plays a prominent
role in creating and maintaining some of our patients’
difficulties.

Pathological falsification
Confabulation
Confabulation is the falsification of memory occurring
in clear consciousness in association with an organically
derived amnesia (Berlyne, 1972). On occasion, it is the
fabricating of false statements by someone with impaired

memory in order to cover his or her embarrassment at
forgetting. It is typically encountered in amnesic disorders
when the patients lack insight into their impairment and,
therefore, would be incapable of constructing falsifications to cover a deficit which they were unaware existed.
Bonhoeffer (1904) distinguished between ‘momentary’
confabulation, where the patient, when asked specifically
about recent events, responds by recounting more distant
unrelated memories and ‘fantastic’ confabulations which
involved spontaneous creations, often grandiose or absurd.
The fantastic, or spontaneous, confabulations tend to be
associated with amnesias in which there is associated frontal lobe dysfunction, whereas the provoked, or momentary
confabulations, are the result of an attempt to respond to
specific enquiries in those with a defective memory. It is
found in amnesic patients and, to a lesser extent, in normal subjects whose memory fails them for some reason
(Kopelman, 1987a). It is not a form of intentional deception.
This chapter is concerned with a variety of conditions, disparate in many ways, but in which deception,
both of others and the self, plays a part. The introduction
was intended to emphasize the extent to which there is a

continuum between the experiences and activities of us all
and the disorders to be described. Deception is, however, a
term redolent of judgment and rejection. Here the emphasis is on the recognition of distress and disorder, so that it
can be treated, rather than identifying deceptions in order
to confound or condemn them.

Lying
Lying, as has been noted, is a frequent, universal, human
activity. It needs to be distinguished from confabulation
which does not include any intent to deceive. Lying is so
ubiquitous that it must have many different functions, for

example in social parlance we distinguish between ‘white’
lies and other types such as ‘barefaced’. White lies may be
to assist someone else for example giving them reassurance or unwarranted praise. The lie that is most frowned
upon is of course the lie to gain dishonest advantage or to
escape from the consequences of one’s actions. There is
a large industry in the criminal justice world of trying to
tell whether a witness or a potential perpetrator is telling
the truth or not. This arises from the somewhat mistaken
notion that the best witness to an event is the central
participant who will be able to explain what they saw or
did to other people. Many police officers see their central
role in detective work as getting a guilty person to ‘cough’
or ‘confess’. More sophisticated police  officers and others
involved in crime detection know that uncorroborated confessions are poor evidence. Yet the belief that somehow, in
some way ‘science’ will enable the liar to be unmasked, dies
very hard indeed. It is possible to find at least 10 ways of
attempting to detect lies with various forms of technology.
These include the polygraph, the fMRI scanner, the voice
stress test, and others. Most of the techniques are trying
to detect a rise in arousal and anxiety when the subject
is being questioned or interviewed. This is based on the
premise that all lying is accompanied by anxiety. Most of us
can subjectively refute this notion and indeed the research
results from the various instruments are disappointing if
they are to be the centrepiece of, for example, a criminal
investigation. None of the results from this type of technology are allowed in British courts.
An exception to the arousal theory is the attempt to
detect lying by using the fMRI scanner. Initial research suggested that the act of lying produces more prefrontal cortex
activity than telling the truth does. However some sophisticated transAtlantic collaborative research has found that
subjects can beat the scanning test by simple distracting

countermeasures, presumably to deflect their concentration, when they are lying (Ganis et al., 2011). The authors
conclude that this renders the otherwise attractive lie
detector as vulnerable in ‘real world situations’. In fact the
accuracy dropped from 100% to 33% if the subject applied
countermeasures; a fairly stark warning to the overenthusiastic technological interrogator.

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The basis of this work lies in experiments conducted
by Spence and others (e.g. Spence et al., 2004; Spence 2005;
Spence et al., 2008). These showed that deception is an
executive task; it elicits greater activation of the prefrontal regions and also incurs a processing cost, manifest in
longer response times.
A scholarly account of what lies are about and how to
detect them is given by Vrij (2008) who goes on to discuss
ways in which training can assist in the difficult task of
detecting lies. At the end of his book he lists 24 studies
giving an indication of how far training can help. By and
large the studies show that observers are only about 50%
accurate in detecting lies (i.e. not much better than guessing) but this can be improved by training sessions, in one
remarkable example raising the detection rate from 54% to
69%. However he concludes:
In this book I reported that several researchers have
claimed to have developed techniques that discriminates

between truths and lies with very high accuracy. My
advice to them is to keep their feet firmly on the ground.
In my view no tool is infallible.
Our view remains that would-be lie detectors, for example
police officers, will be better employed in trying to get
evidence by other means, even though no criminal investigation would be complete without talking to the alleged
offender.
The dangers of using neuroscience results as evidence
of crime are perhaps best shown in India. Angela Saini
(2009), a web journalist wrote of the case of a woman tried
for murder in June 2008. She headed the article ‘The Brain
Police: Judging Murder With an MRI.’ However the article
says that the accused had an ‘EEG’ brain scan.
To Judge Shalini Phansalkar-Joshi, sentencing her last
June to life in prison, Sharma’s electro-encephalogram
left no doubt: the brain scan revealed ‘experiential knowledge’ which proved that she had to be the killer. Her exfiancé Udit Bharati, a 24-year-old fellow student at Pune’s
Indian Institute of Modern Management, had been found
dead after eating sweets laced with arsenic… As the
judge saw it, the proof was in the science. Sharma had
manifested an undeniable ‘neuro experiential knowledge’
of the crime – which the brain could acquire only through
direct experience – when she had undergone a brain scan
in Mumbai a year earlier… A tape played a voice reading
a series of statements in Hindi, each detailing an aspect
of the murder as the investigators understood it. Sharma
said nothing as the EEG machine measured her brain
activity. For a while, the statements elicited no detectable
EEG response. Then she heard: ‘I had an affair with Udit.’
A section of her brain previously dormant registered a
brightly coloured response on the EEG. More statements

followed and the voice on the tape each time elicited
similar EEG responses: ‘I got arsenic from the shop.’ ‘I
called Udit.’ ‘I gave him the sweets mixed with arsenic.’

‘The sweets killed Udit.’ Throughout the test, she did not
say a word. She didn’t have to. As each statement was
read, the EEG machine measured the frequencies of the
electrical signals from the surface of her scalp and fed
them through a set of rainbow-coloured wires into the
room next door. Here a computer, almost five feet tall, performed a set of calculations and spat out its conclusion
in red letters on to its screen: ‘Experiential knowledge’.
This meant knowledge of planning the murder, of getting
the sweets, of buying the arsenic and of calling Bharati
and arranging the fatal meeting. Guilty. Evidence from
the scan took up almost ten pages of the judge’s ruling
when a year later, on 12 June 2008, he jailed Sharma for
life – making her the first person in the world reported to
be convicted of murder based on evidence that included
a brain scan. ‘I am innocent and have not committed any
crime,’ she implored Phansalkar-Joshi… But science had
spoken: and in the six months that followed, the same lab
would provide evidence that convicted two more people
of murder. Neuro-imaging as truth teller had come of age.
It is important that we do not get bemused by new technologies. No doubt they will find a niche, but let us hope
that they do not become used extensively until they can be
shown to produce valid evidence. That day is a long way off
and in the meantime we should heed careful studies such
as the one quoted above by Ganis et al.
Pseudologia fantastica (pathological lying)
A group of disorders have been reported which involve

fantastic lies that are developed into complex systems of
deception. The terms employed for this condition include
pseudologia fantastica, mythomania and pathological liars
(Delbrueck, 1891; Dupré, 1905, 1925; Healy and Healy, 1915;
King and Ford, 1988; Myslobodsky, 1997). The following are
the clinical characteristics:
1. Extensive and gross fabrications.
2. The content and extent of the lies are disproportionate
to any discernible end or personal advantage.
3. The lies deceive not just about matters of fact, but attempt to create a new and false identity for the liar.
4. The subject appears to become caught up in his or her
own fabrications which take on a life of their own in
which the subject seems eventually to believe.
5. The lying is a central and persistent feature of the patient’s life and the mythologism of a lifetime comes to
supplant valid memories.
When pathological liars are enmeshed in their fabric of
lies, the degree of self-deception may make it difficult to
distinguish them from patients in the grip of a delusional
system. Kraepelin (1896) included some patients with
systematized delusions under pseudologia fantastica and
Krafft Ebing (1886) used the term ‘inventive paranoia’ for
both pathological liars and deluded subjects. Most writers,

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however, excluded deluded or otherwise psychotic subjects
(e.g. Healy and Healy, 1915). Closely related conditions are
Munchausen’s syndrome (Asher, 1951) and feigned bereavement (Snowdon et al., 1978).
Two clinical examples may help illustrate this disorder:
A patient was brought to the outpatient department by his
landlady who was concerned with his increasing depression which she feared might lead him to harm himself.
She explained that he was now living in much reduced
circumstances, having suffered major financial losses
and the desertion of his erstwhile friends. It became clear
that he had been living rent free for some considerable
time, and the landlady was providing all his meals and a
regular supply of pipe tobacco, to say nothing of comfort
and support. The patient was a well-dressed man in his
early 60s, who wore tinted spectacles and assumed an air
of profound sadness. He was induced to give his history
despite several claims that he did not want to go over the
past. The personal history provided was of humble origins
from which he escaped via a university scholarship. He
claimed to have left university prematurely to join the
government forces fighting in Spain. At the end of the
Spanish civil war, he reported a brief period in Rhodesia
before joining the British army during the Second World
War. A distinguished army career was followed by a
period working in the United Nations. The tale continued
with a series of great successes followed by undeserved
disasters until he reached his present homeless, lonely
plight. The stories had plausibility and a wealth of detail.
Suspicions as to their authenticity were raised by the
remarkable similarity of some aspects of his account
to the memoirs of such figures as Orwell and Wingate.

Over subsequent months, it emerged that the patient had
lived most of his life in London, he had never been in the
army, far from being unmarried he had been married
on a number of occasions and his reported childlessness
ignored a number of offspring. Following the exposure of
his identity, the patient disappeared, but was encountered some years later having created for himself a new
persona and an equally dedicated supporter in the form
of another middle-aged lady sponsoring the ageing and
misunderstood artist. At a second encounter, he greeted
his doctor with apparent pleasure and without a blush,
or any visible unease, told of his new circumstances. He
did not seem to be concerned about, or even aware of, the
possibility that his new identity might be threatened. He
believed in himself, or at least he evinced no insecurity.
The second case was admitted from prison where he was
said to have become depressed and suicidal.
He was a small young man who, though in his early 20s,
could have passed for 12 or 13 years of age. He gave an
account of having been raped in prison with the connivance of a number of prison officers. He had made these
allegations previously, and they had been extensively

investigated without any basis having been found. He
gave a history of having been seduced in his early teens by
the mother of a school friend, and described a number of
romantic adventures prior to his arrest on arson charges.
Other aspects of his history included a graphic account
of child abuse, remarkable academic and artistic success,
cut short by circumstance, and a period of army service.
This young man attempted to create by his stories an
identity characterized by remarkable talents and charm,

but a personal history replete with disadvantage and
tragedy. Misunderstood, abused, cheated and victimized, nevertheless, he struggled to realize his potential.
Different stories were given to different members of staff
and even more dramatic discrepancies emerged between
his self-presentation to other patients and that to the staff.
During his time on the unit, his use of mimesis became
obvious. He latched on to a patient and later a staff member whom he found admirable and began not only to talk
like his new-found models, but tried to present himself
in an identical manner. He even borrowed aspects of the
personal histories of these two admired individuals, and
presented them as his own.
Schneider (1959) regarded this group of patients as
attention-seeking individuals who love to boast about
themselves, and invent or act out fairy tales of self-aggrandizement. He noted that the true pathological liar begins
as a story teller, but becomes so caught up in his/her
fabrications that ‘they forsake actuality and finish up on
the stage of their own mind.’ Kraupl-Taylor (1979) took a
similar view describing the stories as hysterical confabulations. He believed that recent reminiscences are temporarily replaced by hallucinated reminiscences, which are true
memories to the patient, at least for a time. Kraupl-Taylor
emphasized the negative or disadvantageous aspects of
this behaviour. Whilst the pathological liar has the gratification of an occasional audience that is impressed, this
pleasure is short-lived, only to be followed by the humiliation of being treated as a liar. Such patients are soon generally disbelieved, and they may be teased mercilessly. Such
behaviour does merge into more externally goal-oriented
deception.
Pathological lying is usually encountered in forensic practice in those accused of fraud, swindling, making false accusations or false confessions (Powell et al.,
1983; Sharrock and Cresswell, 1989). Once the counterfeit
is exposed, the pathological liar will often give up his
deceptions and readily confess, sometimes to offences in
which he was not involved, thus beginning a new cycle of
attention-seeking mythologies in the very act of acknowledging the previous deceptions. The frauds and swindles

perpetrated by the pathological liar usually form part
of an attempt to create a false identify. Such frauds are
often flamboyant and have little in common with the furtive and carefully planned dishonesty of the more typical

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fraud. Pathological liars are closer to confidence tricksters,
though unlike them, they do not take the money and run,
but persist in the pretence long after exposure is inevitable. Their lies are rarely aimed at excusing or exculpating
their offences, but more frequently, at attracting notice and
inflating their importance.
After reviewing 72 published cases King and Ford
(1988) suggested that the sex distribution of cases is
approximately equal and the age of onset is usually adolescence. Forty per cent of the cases they reviewed had a
history of some central nervous system abnormality, such
as an abnormal EEG, a history of head trauma, or CNS
infection. Twenty-five per cent of the men had epilepsy.
Other notable problems were criminality, psychiatric hospitalization, suicide attempts and a family history of psychiatric illness. King and Ford suggest that when disease
simulation (Munchhausen syndrome, about a quarter of
the cases) or impersonation of another person occurs it is
the pseudologia fantastica which is the primary disorder.
King and Ford concluded their review by saying ‘ Further
research in this clinical area, particularly of the neurophysiologic correlates, is sorely needed.’ That remains the
position; no further research on this topic has been conducted. An interesting further case has been published

(Birch et al., 2006). The woman in this case showed an
interesting extra feature in that she was able to get other
people, intimates, to corroborate her fictional stories. This
characteristic is rare but has been reported before (Healy
and Healy, 1915; Weston, 1996). It has also, apparently,
been labelled by Helene Deutsch in a German paper as
‘pseudologie à deux’ or ‘shared daydreams’ (quoted in Birch
et al., 2006).
Enoch and Ball (2001) sub-classified pathological lying
into four types:
1. The professional impersonator who pretends to be a
doctor, a priest, a lawyer.
2. The swindler who pretends to be wealthy and/or an important business man.
3. An outraged woman who alleges a fictitious sexual
assault.
4. A false confessor who claims to have committed a serious crime.
To this list we would add the common fantasist, common
because the condition occurs more frequently than the others and s/he tells a whole series of apparently pointless tall
stories set in a context of ordinariness.
The common fantasist is not particularly dangerous,
but the other types can produce serious consequences
including bodily harm. Management is extremely difficult.
Even when prosecuted the fantastic tales may not subside.
The best that can be offered is support and detailed discussion in an attempt to provide some insight and help induce
some self-control, but these efforts often fail.

Abnormal Illness Behaviour
Parsons (1951) regarded illness and health as socially institutionalized roles. A sick person’s role is legitimated and
allowed by its undesirability and the need to co-operate
with others to get well. While in the sick role, normal obligations are suspended and responsibilities are reduced, but

the role might not be granted unless adequate evidence of
disease were available. Mechanic (1962) described ‘illness
behaviour’ which referred to
the ways in which symptoms may be differentially perceived, evaluated and acted (or not acted) upon by different kinds of persons.
Later, Mechanic (1986) emphasized that in his view illness
and illness experience are shaped by socio-cultural and
socio-psychological factors, irrespective of their genetic,
physiological and other biological bases. Away from the
research laboratory illness is often used to achieve a variety
of social and personal objectives, having little to do with
biological systems or the pathogenesis of disease.
He went on to ask himself: Why do 50% of patients
entering medical care have symptoms and complaints that
do not fit the International Classification of Diseases? Why
are rates of depression and the use of medication relatively
high among women, whereas alcoholism, hard drug use
and violence are particularly common among men? Why
among the Chinese are affective expressions of depression
uncommon, but somatic symptoms relatively frequent?
Why are rates of suicide among young black people in the
USA relatively low, but rates of homicide high? Rather than
attempting answers to such questions, he urged us to look
beyond individuals to their social environment. He pointed
out that the nineteenth-century phenomenon of female
hysteria has all but disappeared in the west, perhaps
due to a change in social response to the characteristic
symptoms. Illness behaviour is more than a psychological
response among persons faced with a situation calling for
assessment. It arises in response to troubling social situations, and may serve as an effective means of achieving
release from social expectations, as an excuse for failure,

or as a way of obtaining variety of privileges, including
monetary compensation. A complaint of illness is one way
in our society of obtaining reassurance and support.
Pilowski (1969) proposed ‘abnormal illness behaviour’
as a subcategory of illness behaviour for those patients
who have physical symptoms for which no organic explanation can be found. This is a useful extension of the
concept of illness behaviour, even though it is not clear
why it should be confined to physical symptoms and
organic disease. The forensic psychiatrist may be called
to see a number of conditions which in some ways can be
regarded as variants of malingering, but which can also
be regarded as gross abnormalities of illness behaviour,
abnormalities of such a degree that instead of eliciting

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support and sympathy, they produce rejection and anger
on the part of doctors, which are sometimes coupled with
frankly punitive responses.

Dissociative disorders
Dissociation
Dissociation is a commonly described mental mechanism.
It implies separation and splitting. It often means that one
part of the mind is paying no attention to another or is

unaware of it. It can be induced by hypnosis. For example
Charcot, the nineteenth-century ‘king of hysteria’, hypnotized one of his female patients (all his patients were
female) and suggested to her that she was two people.
Each side of her was to have a different boyfriend. She was
introduced to these two men as she lay on a couch and she
would allow each to caress his specified side of her body,
but if his hand ventured to the other side she would angrily
turn it away.
The idea of splitting and separation so that parts of an
individual’s body are dysfunctional and out of touch with
other parts, and parts of the individual’s mind, including their memory, are separated from other parts, lies
underneath many of the topics discussed in this chapter.
Psychogenic non-epileptic seizures can be, at least in part,
understood in this way and are sometimes called dissociative seizures. A remarkable philosophical treatise has been
written on the subject, not by psychiatrists but by a philosopher, Ian Hacking (1995) in a book entitled Rewriting
the Soul. He draws together many different threads and
implants the topic in its history. Dissociative phenomena
have been observed from ancient times but the manifestation of these phenomena changes and so does the naming.
For example Hacking suggests that the hysteria of Charcot
which captivated the whole of France in the nineteenth
century, turning his kind of neurology into a public spectacle didn’t just disappear at the beginning of the twentieth
century, as many people believe, but it changed into other
forms. Hacking suggests that in the United States it became
multiple personality disorder.
A full discussion about dissociative disorders does not
belong in a textbook of forensic psychiatry and they will
therefore be dealt with briefly. They are mentioned at all
because of their relevance to simulation and malingering
which may come to the attention of the forensic psychiatrist who undertakes medico-legal compensation work.
They also have some relevance to the broader subject of

dishonesty and require a textbook in their own right.
To set the subject in context it is worth briefly considering the history of hysteria, for hundreds of years an
important disorder, particularly in women, which is now
disappeared from the psychiatric lexicon, although it is
almost certainly just transmuted into other disorders. The
term hysteria obviously implies something to do with the

uterus and it was originally thought to be a disorder which
affected women exclusively and was caused by a wandering
uterus. The term is still used colloquially to mean emotional excesses and loss of self-control probably related to
panic. Charcot used to give his public demonstrations at
the famous Paris hospital, Salpêtrière. He described the
course of the illness in these terms:
A little girl about seven years old begins to cough and goes
on coughing for two months without any known cause.
An experienced physician recognizes at once that he
has not to deal with a case of bronchitis but one of hysteria. Then the little girl is all at once affected with a stiff
neck… Hysterical torticollis is made out. …. The child’s leg
becomes stiff and painful. This is hysteric contracture…
Things go along pretty smoothly till menstruation. Then
the child begins to get peculiar – to have curious ideas.
She is alternately sad or cheerful to excess. Then, one day
she utters a cry, falls to the ground, and presents all the
symptoms of an attack of hystero-epilepsy. She begins to
assume various postures, to speak of fantastic animals, to
mention words which are neither suitable to her age nor
to her position in society.1
Charcot unhooked hysteria from the uterus and from
the demonic possession theories that also abounded.
He described it as an inherited neurological disorder,

neither madness nor malingering (Hustvedt, 2011). The
patients may suffer from anaesthesia, hypersensitivity,
anorexia, bulimia, constipation, diarrhoea, excessive urination, retention of urine, depressed intellectual functions,
heightened intellectual functions, insomnia, attacks of
sleep, and violent seizures, said Bournville, a disciple of
Charcot’s; in other words contrasting bodily symptoms
which vary and fluctuate. Charcot himself described ‘grand
hysteria’ characterized by episodic convulsions in four
phases. First, the epileptoid phase of tonic and clonic
seizures, preceded by an aura, just as in epilepsy. Second,
grand movements or clownism simulated the contortions
and acrobatics of circus performers. The third phase of
‘passionate poses’ was when the patient acted out emotional states such as terror, ecstasy, and amorous supplication, all ending in the final and fourth stage of delirium.
This material comes from a remarkable book on Charcot,
his life and work and the story of three of his patients by
Asti Hustvedt (2011).
This history gives many clues to the disorders which
at the beginning of the twenty-first century we call dissociative disorders. The twentieth century saw the disease
of hysteria transmuted into other conditions such as
shellshock which reinforced the notion that the symptoms
1
This quote is taken from Hustvedt (2011) who is quoting Charcot’s
paper ‘De l’influénce des lesions traumatiques sur le développement des
phénomènes d’hystérie locale,’ in Progrès Médical, May 4, 1878, cited in
Goetz, Bonduelle, and Gelfand, Charcot, p.173.

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arise from stress and trauma. By 2000 the nomenclature of
these disorders was crystallized into perhaps six types of
dissociation:
depersonalization disorder in which an individual feels
detached from his or her surroundings and may feel
outside of the body; psychogenic non-epilepetic seizures
(see below); dissociative amnesia (see below); fugue (see
below); dissociative identity disorder, sometimes known
as multiple personality disorder (see below); and possession states.
This list is not exhaustive of dissociative phenomena,
symptoms change with time and place and often overlap,
Stengel (1941) included, in his series of fugue cases, a case
which could also be considered a case of multiple personality disorder. One of Burt’s (1923) cases of pathological lying
has subsequently appeared in the literature as illustrative of
typical multiple personality (McKellar, 1979). It is the core
of dissociation which is important to understand if treatment is to be provided.

Psychogenic Non-epileptic Seizures
In our first edition we had a section on ‘pseudo-epileptic
seizures’. Like other dissociative disorders the name has
changed. At one time many neurologists and psychiatrists
assumed that non-epileptic seizures were simulated or
malingered. It is interesting that Charcot thought they
were always genuine. Modern thinking has moved nearer
to Charcot than was the case in the mid-twentieth century. Undoubtedly some non-epileptic seizures will be
consciously simulated in order to gain something, perhaps

attention, perhaps some compensation, perhaps a reason
to be excused duties. However, the topic of non-epileptic
seizures illustrates as clearly as any how difficult it is to
discern underlying motive and distinguish it from distress
and organic pathology which justifies medical intervention. Indeed it is possible to argue that even if the seizures
are consciously contrived with an object in view, they are
still an important flag-waving phenomenon which requires
skilled intervention.
A good review of this topic is given by Benbadis (2005)
in Wyllie’s textbook on the treatment of epilepsy. Benbadis
divides non-epilepetic seizures into three groups: somatoform disorders, factitious disorders and malingering.
Somatoform disorders are physical symptoms caused by
unconscious psychological factors. In turn somatoform
disorders can be subdivided into conversion disorders
and somatization disorders, but the nomenclature is now
becoming esoteric and unhelpful. Similarly the distinction
between factitious disorders and malingering is arcane
and boils down to whether the patient is to be treated
as such or rejected as a fraud. These distinctions are
extremely difficult if not impossible to make clearly, and
the only time that malingering can be considered a certainty is when clear evidence is available of some sort of

conscious intervention to produce the fit. Even then mistakes are made. One of us has a vivid memory of a patient
who used to fold his glasses away carefully, take out his
hearing aid and lie on the floor before having his seizure.
Many thought he was a fraud, but investigation showed
that he was not having a non-epileptic seizure, but an
epileptic one, and he was preparing himself for the seizure
during a fairly long aura.
The diagnosis of epilepsy as opposed to a non-epileptic

seizure is based on careful observation, especially of the
electroencephalogram, which ought, if there is any doubt,
to be a continuous recording over several hours and whilst
ambulant.
The features of non-epileptic seizure include
1. attempted restraint of the convulsive movements leads
to struggling, even combativeness;
2. absence of cyanosis;
3. normal pupil responses and corneal reflexes present;
4. pressure on the supraorbital arch causes head
withdrawal;
5. the level of consciousness fluctuates during the seizure;
6. marked emotionality after the episode.
Such seizures can be preceded by auras involving somatic
or visual symptoms and headache. Unlike true epilepsy, in
which the onset is usually abrupt, the non-epileptic seizure
may be gradual in onset. Such seizures rarely result in injuries either from falls or biting of the tongue. It should be
remembered that epilepsy is more often misconstrued as a
psychogenic seizure than the other way round. Fully deliberately simulated seizures are rare. All psychogenic seizures, even if they are considered to be factitious should be
treated by attention to any underlying mood disturbance
or other psychological problem, and fairly prolonged psychotherapy in order to unravel the driving force behind the
seizures, whether that force is conscious or unconscious,
so it may be faced and attended to psychotherapeutically
or practically. Nevertheless it is well to remember that
well-established, long-standing, non-epileptic seizures are
difficult to treat and have a poor prognosis.

Dissociative or Psychogenic Amnesia
As we have seen in chapter 12, amnesia is a complex symptom. Distinguishing between genuine and feigned amnesia
may be difficult. Those charged with homicide offences are

particularly likely to claim amnesia (Taylor and Kopelman,
1984). However, Pyszora et al. (in preparation) in a 3-year
follow-up study, suspected that 10% of a sample of men on
remand in custody claimed amnesia for the alleged offence,
a finding only elicited in those charged with offences of violence. Within the amnesic group, nearly half were charged
with murder. Only five of 59 amnesic offenders were suspected of feigning; the others were thought to have this
dissociative amnesia (see also chapter 12).

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Lishman (1998) has suggested that the traditionally
rigid distinction between psychogenic and organic memory
disturbance may be an artificial one. Pathophysiology of
some kind accompanies psychogenic amnesia, just as a
psychological basis underlies the influence of emotion
and motive in normal forgetting. Clinically, psychogenic
amnesia is either global and dense or more circumscribed.
Global amnesia may occur for long periods of life. The
amnesia may cover emotionally important events or issues,
such as a violent outburst. Normal ability to learn new facts,
but severe problems or recall of past events hints at psychogenic amnesia. A total inability to retain new information,
even briefly, also favours the psychogenic form.
The classic case of alleged malingered amnesia (Podola),
is dealt with in chapter 2. We will never know whether
it was malingered or not as he was executed. The case

demonstrates that it is not critical to a murder trial that
the defendant remembers what happened. Whether malingered or dissociative, forgetting is almost certainly a means
of coping with appalling guilt and shame. The amnesia
becomes a problem when somebody has been convicted of
a killing and still cannot remember what happened and so
is able to participate in psychotherapy in a limited way. The
first aim of psychotherapy, and it may take a long time, is to
get the person concerned to retrieve some memory of the
events in question. This is a long supportive process requiring much patience and continuity of psychotherapist. One
of the interesting issues which may occur in that process,
if it is successful, is that the patient may say, after s/he has
recovered their memory, that they were simply lying and
were in fact able to remember all along. Another dissociative mechanism in action perhaps? Certainly it illustrates
the vague borderland between unconscious repression of
thoughts and dissimulation.

Multiple Personality Disorder
Multiple personality has been described as:
The presence in one patient of two or more personalities
each of which is so well defined as to have a relatively
coordinated, rich, unified, and stable mental life of its
own. (Taylor and Martin, 1944).
These differing personality systems tend to lose communication with each other and amnesic barriers commonly
divide and prevent integration between them (Hilgard,
1977).
Before the eighteenth century, cases which may attract
the label multiple personality disorder now would probably
have been regarded as possession states. Cases of dual or
multiple personality were reported in the scientific literature from the late eighteenth century onward and, by the
end of the nineteenth, they had become a popular theme

for philosophers, psychiatrists and novelists (Ellenberger,
1970; McKellar, 1979). Robert Louis Stevenson’s (1886)

Strange Case of Dr Jekyll and Mr Hyde is a celebrated literary example. Prince’s (1906) account of the case of Christine
Beauchamp and her three personalities and James’s (1890)
account of Ansel Bourne, led to considerable interest in the
topic, particularly in America.
In the 1950s, multiple personalities re-emerged from the
pages of old textbooks. A surge of reports, both in the popular and scientific literature, followed publication of Thigpen
and Cleckley’s (1957) case of Eve and her three faces. This is
a fictionalized account of a real case and the woman concerned has written two books giving her own account of
her illness (Sizemore, 1977 and 1989). The film was popular,
and may have had a role in the large number of cases that
subsequently appeared in the USA (Boor, 1982). The books
written by the patient may give a clearer insight into what
it feels like to be in this situation.
The central clinical feature is the existence within
the individual of two or more distinct personalities. The
recognition of this extraordinary state of affairs may be
complicated by the primary personality being unable to
provide any account of the alter egos which are hidden
behind a barrier of amnesia. A number of diagnostic signs
have been described to assist the clinician (Greaves, 1980).
The patient may report time distortions or unexplained
memory lapses for the period when the other personality
is in residence. Accounts may be provided by independent
observers of discrepant behaviour patterns and patients
calling themselves by different names. Writings, drawings,
or other artefacts by patients may be discovered which
they have no memory of producing. Other features include

headaches, deep sleeps, employing ‘we’ rather than ‘I’, and
pseudo-hallucinations. The condition is said to begin in
childhood or adolescence, often in the context of abuse,
neglect, or trauma (Congdon and Abels, 1983). Histrionic
personality disorder, other dissociative states, superior
intellect and high hypnotizability, are all claimed to be associated with multiple personality disorder.
The origins of multiple personality have been hypothesized to lie in repeated dissociations. These patients are
peculiarly prone to dissociative states in response to stress.
They defend against fear, anxiety and depression by either
denying that it is happening to them or escaping into the
new personality (Ludwig et al., 1972; Spiegel, 1984). These
repeated dissociations are said to produce a separate store
of memories which ultimately lead to different chains of
integrated memories with groups of specific behaviours
that can be separated by impermeable barriers (Braun,
1984). William James put this more elegantly:
Alternating personality in its simplest phases seems
based on lapse of memory… any man becomes, as we say,
inconsistent with himself if he forgets his engagements,
pledges, knowledge and habits, and it is merely a question
of degree at which point we shall say that his personality
is changed (James, 1890).

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The authenticity of multiple personality as a clinical entity
has been repeatedly questioned, although its advocates,
such as Greaves (1980), considered its existence to be demonstrated beyond reasonable doubt. He claimed that its
infrequency in some services reflects not rarity, but clinical
oversight on the part of those who cannot, or will not recognize the condition. This presumably means everywhere
outside of North America, with the possible exception of
the Netherlands. British scepticism was outlined by Fahy
(1988) in a review which plotted the rise of interest in the
disorder in the twentieth century. He was critical of the
vagueness of the diagnostic criteria which use the word
‘personality’. All disorders which use the word ‘personality’ in their criteria are necessarily vague, as the concept
of personality is complex, subjective, and very difficult to
measure. He described the disorder as an hysterical symptom; this term was still fairly widespread in the 1980s and
fitted with the Hacking view given above. Fahy was taken
to task by a correspondent (Fleming 1989) who said that
he believed the condition exists! A beautiful example of
reification.
What is difficult when dealing with dissociations in
any form is to understand what the symptoms/syndrome
represent to the patient. It is probably a culture bound
syndrome wrought out of the dissociative potential and
suggestibility of distressed and confused people looking for
a way out of their predicament. It is widely acknowledged
that, in practice, the new personalities allow the patient
to avoid the constraints, limitations and stresses of their
normal life (Prince, 1906; Taylor and Martin, 1944; Ludwig
et al., 1972; McKellar, 1979).
In the United States, where the syndrome is diagnosed
more commonly, the potential significance of multiple

personality for questions of responsibility and culpability
was quickly recognized. It has been argued that multiple
personality is equivalent to sleepwalking and sufferers
should benefit from a similar defence. Presumably, three
lines of defence could theoretically be argued; one would
be that multiple personality disorder is a form of insanity,
the other would be that the usual personality cannot take
responsibility for the other personalities, i.e. the fictional Dr
Jekyll could not be held responsible for the actions of the
fictional Mr Hyde (Stevenson, 1886), and the third would be
that like the sleepwalker the individual could be regarded
as unconscious when in an altered state of personality.
Without a proper study being available it is difficult to
know how often such defences are used in the United States
and whether they are successful, although Abrams (1983)
quotes a case from Ohio where a man accused of multiple
rapes was found not guilty by reason of insanity because
of his multiple personality disorder. The unconsciousness
argument has been advanced by French and Schechmeister
(1983). To reiterate, these observations made by others do
not help very much with understanding what the patient
experiences, and why.

A story, probably apocryphal, is told of an Old Bailey
judge called upon to sentence a man whose defence
claimed he suffered from multiple personality. The judge
admitted to the sadness he felt that the model citizen and
blameless character who stood before him should have
to share his body with the villainous perpetrator of the
offences and, moreover, would have to be confined together

with this criminal in a prison cell for the period of the sentence which he was about to impose.
The lack of responsibility argument is akin to the arguments that were once put (but not now allowed) about
the function of amnesia. If splitting or dissociation is a
response to unpleasant realities, and a way of coping with
stress, then it is perhaps an exaggeration of normal mental
mechanisms. If it is believed to involve a separation of different elements in the subject’s character and behaviour,
these elements arise from the individual’s responses to the
real world. The different personalities may, perhaps, be
regarded as different aspects of self, albeit compartmentalized, rather than different selves. The appeal of the Jekyll
and Hyde story is surely, in part, that we all recognize the
splits and incompatibilities in our desires, fantasies and
even actions, and that most of us have done things which
retrospectively, or even at the time, seemed foreign to our
personalities and we can say, afterwards, ‘that really wasn’t
me’. If the multiple personality is to be given the benefit of
repudiating legal responsibility for forbidden actions, why
not all criminals who can argue they acted out of character
and were thus not themselves at the time?

Fugue States
Fugue literally means to take flight or escape, but its use
in psychiatry is best confined to transitory abnormal
behaviour characterized by aimless wandering with alteration of consciousness, often associated with subsequent
amnesia (Stengel, 1941). Fugues are encountered as one of
the signs of a wide variety of psychiatric disorders, though
their manifestation probably depends on a predisposition
to disturbances of consciousness and dissociation. A traumatic event may act as the precipitant of the actual fugue
state. During the fugue the individual may be completely
amnesic for their usual life and they may assume a new
personality. The relationship between fugues, multiple personality disorder, and dissociative amnesia is fairly clear.

Such states are a gift for novel writers, but perhaps one of
the most famous fugues was the 11-day absence of Agatha
Christie who never explained where she had been or why;
she may have had amnesia. A fugue state is usually shortlived (hours to days), but can last months or longer. After
recovery from a fugue, previous memories usually return
intact, but there is complete amnesia for the fugue episode. Fugues are usually precipitated by a stressful episode,
and upon recovery there may be amnesia for the original
stressor.

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Fugues may be encountered in forensic psychiatric
practice in subjects who, following committing a criminal
act, or in the context of imminent detection, suddenly
wander off apparently in a state of disturbed consciousness. For example, a young man may disappear suddenly
from work, only to turn up 5 days later in a state of total
exhaustion and inanition wandering in the outskirts of a
foreign city. When questioned, he claims no knowledge of
the events of the previous days, or how he had managed to
get there. Subsequently, it may emerge that an audit at his
place of work revealed that he had been misappropriating
funds. Another example might be a man of previous good
character stabbing an acquaintance in an argument, wandering off into the freezing cold of a winter’s night without
a jacket or overcoat, to be found some hours later walking
apparently aimlessly and in a perplexed and disoriented

state and claiming total amnesia for the night’s events.
Occasionally, acts committed during a fugue state may lead
to criminal charges.
As with all dissociative states, treatment, if considered
necessary after a spontaneous recovery, should be supportive psychotherapy which aims to uncover, in a safe relationship, the stresses that have driven the behaviour.

Possession States
Possession states, which are a rare form of dissociative
disorder in western societies, are characterized by claims
to have been taken over by a spirit or some external power.
They have to be distinguished from the passivity experiences and delusions of control found in the schizophrenias.
In cases where fugue or possession states are claimed to
have been present at the time of a serious act of violence,
the defence, in Britain, may raise the issue of non-insane
automatism, but they are unlikely to succeed now that
violent automatic behaviour has been designated as insane
automatism.
Amok and windigo
Amok (or amuck) is a term that has been applied to any sudden outbursts of violence, but in psychiatry it has tended to
be confined to a so-called culture bound reactive syndrome
involving the peoples of the Malay archipelago (Linton,
1956; Yap, 1969; Carr and Tan, 1976). Amok in Malay has
the meaning of rushing in a state of frenzy to the commission of indiscriminate murder (Oxford English Dictionary).
There were reports from Java by early Dutch and British
colonists of Malays running amok (Spores, 1988).
Amok was claimed originally to have three phases
(Gimlette, 1901; Burton-Bradley, 1968; Westermeyer, 1982):
1. a prodrome characterized by social withdrawal and
anxious brooding;
2. a sudden furious outburst in which a number of people

are attacked at random; and

3. sudden termination of the attacks, sometimes in extended stuporous sleep, but always with subsequent
amnesia for the events.
This description is probably, at least in part, overlain by
mythology (see below).
A number of precipitants have been described, the
most common involving some overwhelming blow to the
individual’s self-esteem and social prestige. Others include
acute intoxication (Westermeyer, 1973); organic brain syndromes (Van Loon, 1927); social stress as in migration; and
relationship difficulties such as jealousy (Carr and Tan,
1976). The Malay culture is said to place a strong emphasis
for males on retaining social prestige and avoiding loss of
face. A powerful interdiction exists towards suicide. The
act of running amok (becoming a pengamok) in traditional
Malay culture allowed a discredited or shamed male to
bring about his own destruction, as the amok was often
terminated by the killing of the pengamok or, if he survived,
restoring his prestige. Amok was a recognized, if not sanctioned, social performance.
Windigo is a related syndrome described in the Ojibwa
Indians of sub-Arctic North America. The males of this
tribe spend the long winter months hunting alone in the
frozen wastes. Their prestige depends on success, and
failure brings shame (Friedman, 1982). The windigo is
believed to be a giant phantom compounded of all those
who have starved to death in the past (Meth, 1974). This
phantom is believed to be capable of possessing a man
and metamorphosing him into a murderous cannibalistic
monster. The development of windigo is associated with
failure in the hunt and especially famine. A prodrome of

sleeplessness, depression and brooding is described, followed by an outburst of murderous activity in which the
family as well as fellow members of the tribe are attacked
and attempts made to consume their flesh (Landes, 1938).
The state is terminated by the killing of the windigo or by
his suicide. As with amok, this picture is at least in part
mythological.
Analogies have been drawn between amok and the sudden outbursts of murderous violence directed at a number
of victims which occur periodically in western societies
(Teoh, 1972; Westermeyer, 1982). Superficial similarities
certainly exist in that they both involve a public display of
apparently motiveless violence, often terminated by the
killing or suicide of the perpetrator. Both seem to have
elements of contagion in that amok violence has been
described as spreading epidemics through some Asian
communities (Westermeyer, 1973) and spectacular mass
killings can spawn copy-cat killings. The analogy, however, obscures more than it illuminates. Mass killers in
western societies are a heterogeneous mixture including
disgruntled teenagers, gun-obsessed inadequates, deluded
psychotics and misguided fanatics. Those who live to tell of
their outbursts are not reported to claim amnesia for the
events. To describe a sudden outburst of violence as amok,

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Deception

in the technical rather than lay sense, evokes a spurious
confidence that we have somehow understood the events.
This could inhibit the proper exploration of the actual context and state of mind of the perpetrator.
From a treatment perspective it is essential to distinguish these dissociative states from systematized paranoia
which frequently involves long-standing delusions, sexual
thoughts, planning, and mass destruction, often including
suicide. The case of Ernst Wagner (chapter 9) is the first and
one of the best descriptions of this dangerous condition.

Deception
This section deals with topics where the possibility of
deception is frequently raised. Many of the patients discussed here are, however, not deceiving anyone.

Compensation Neurosis
It is probably wrong to include compensation neurosis
under the general heading of deception as most of the people claiming compensation after an accident are deceiving
neither themselves or anyone else, yet unfortunately compensation neurosis has become a pejorative term which
has many pseudonyms, e.g. ‘accident neurosis’, ‘greenback
neurosis’, ‘profit neurosis’, ‘railway spine’, and ‘unconscious
malingering’. Kennedy (1946) gave expression to such
prejudice in the following aphorism:
A compensation neurosis is a state of mind, borne out
of fear, kept alive by avarice, stimulated by lawyers, and
cured by a verdict.
The difficulty is that the emotional effects of an injury
manifest themselves within a personal and social context. Least psychological damage occurs when injury can
be accepted as part of a natural order. Feelings of anger
and resentment exacerbate physical and psychiatric
symptoms. Litigation is almost always protracted and
involves repeated medical examination. The patient’s

attention is focused on his or her grievance and symptoms. Finally, in court, disability is financially rewarded
and any recovery may reduce the level of compensation.
This process exacerbates psychological symptoms and
hampers recovery. The experience in New Zealand of a
government-run accident compensation scheme has,
however, amply demonstrated that merely removing the
courts and the litigation process in no way reduces either
the psychological problems or the temptation to exaggerate or fabricate compensatable injuries. In fact, it may
increase these problems, as all injuries become potentially compensable irrespective of whose responsibility
they may have been.
The problem is neatly illustrated by considering the
effects of minor concussional head injury. Virtually every
individual who leads an active life has sustained an injury
causing a brief interruption of consciousness. Recovery is

almost always prompt and complete, except where litigation is involved. Thus, if a man falls off his own ladder and
bangs his head he recovers quickly, but if he falls off his
employer’s ladder and becomes involved in compensation,
persistent disability may follow.
Lishman (1968) noted:
Central to most descriptions are headaches and dizziness, but to these may be added abnormal fatiguability,
insomnia, sensitivity to noise, irritability, and emotional
instability. Anxiety and depression are often prominent.
Difficulties with concentration and memory may feature
strongly among the complaints, and some degree of overt
intellectual impairment may on occasion be detected.
With this mixture of quasi-organic and subjective symptoms, variously reported, it is scarcely surprising that the
concept lacks clarity and that its aetiology has remained
in doubt. Nevertheless, its ubiquity following even minor
blows to the head, and the regularity with which it features among claims for compensation, have ensured that

it persists as an important subject for medical interest
and debate.
In his textbook Lishman (1998) pointed out:
In some, probably rare, cases there will be entirely conscious simulation for gain, but in the great majority the
compensation issue colours the picture in more subtle
ways. Once the possibility of compensation is raised the
patient finds himself in complex legal dealings; there
are frustrations due to delays, anxieties due to conflicting advice and often capital outlay. In effect the injured
person is invited to complain and, having done so, finds
he has to complain repeatedly, over years to a number
of specialists. Repeated questioning from lawyers and
doctors not only focuses the patient’s attention on early
symptoms which perhaps were due to recede, but in
addition reinforces the prospect of their continuance and
worse to come.
Thus in the early days or weeks after injury the postconcussional syndrome is probably directly related to the
cerebral trauma but, subsequently, it becomes overlain
by psychological factors and in some cases deliberate
exaggeration.
The literature on the recovery of psychological symptoms after settlement is confused. Miller (1961, 1966)
followed-up an unrepresentative sample of 50 neurotic
patients from a total of 200 head injury cases and found
that 90% returned to the same or similar employment
after their cases were settled. Kelly (1981) documented
100 ‘post-traumatic syndrome’ patients, but traced only 43
after a follow-up period averaging 2.8 years. No patient was
personally interviewed. Many patients had improved and
returned to work by the time the case was settled, but of
the 26 not working by settlement, 22 were still not working
at follow-up, which led him to conclude that the ‘cured by a

verdict’ jibe is not correct.

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Deception, dissociation and malingering
Perhaps the most comprehensive review is by Mendelson
(1984). He looked at 18 follow-up studies of personal injury
litigants. Of these only three studies, including the one by
Miller, favoured the view that claimants improved within
a fairly short time of the finalization of their claims. Six
studies were discounted because of the small number of
patients examined. Nine studies indicated that of patients
who stopped work following a head injury, between 50 and
85% failed to return to work after a settlement. For patients
with a low back injury, 35% were unemployed after a minimum of 3 years following settlement. Patients with neck
injuries had persistent disability of a severe degree, namely,
12–60% of cases 5 years after the injury. Tarsh and Royston
(1985) carried out a follow-up of 35 claimants who had an
‘accident neurosis’. Patients were followed-up from 1  to 7
years after compensation was received. Few recovered and
such recovery as did take place was unrelated to the time
of compensation. Most cases still had continuing and often
severe symptoms at follow-up, and about one-third of the
group seemed certain to be always going to lead lives of
invalidism, totally dependent on other family members.
Mendelson (2003) summarizes the situation well. He

traces the beginnings of so-called compensation neurosis
to the development of the railways in about 1830 which
gave rise to a lot of higher speed transport accidents and to
symptoms that had not been noticed very often before, and
thence to the new diagnoses of ‘railway spine’ and ‘nervous
shock’. This latter term is still used within the legal world
(see p.53). Mendelson also indicates that the introduction
of workers’ compensation legislation at the end of the
nineteenth century led many to postulate that it was the
financial gain which led to the prolongation of disability.
This implied that compensation neurosis was a subtype
of malingering. Mendelson described such explanations as
‘inaccurate and simplistic’. He said:
There are many factors that influence outcome following
compensable injury… and a new paradigm is needed that
takes into consideration these variables and provides a
comprehensive explanatory model that, ultimately, may
lead to effective interventions.
Beck (1829) wrote in a nineteenth-century law textbook
that where illness might be feigned we have a
double duty… to guard the interests of the public… and
also those of the individual so that he be not unjustly
condemned.
That advice may be nearly 200 years old, but it is a useful
benchmark for the twenty-first century.
In considering an individual case it is useful to remember that ‘recovery’ and ‘return to employment’ are very different. Many complainants are manual workers in mid-life
who have little motivation to return to the sort of poorly
paid employment which would leave them little better
off than when in receipt of state benefit. The boundary
is blurred between what is genuine, what has a genuine

basis, but is exaggerated, and what is gross malingering.
Often one develops chronologically from the other. It may
be that the immediate response to injury, be it physical or
psychological, is almost always genuine and would have
occurred in the absence of any compensation claimed. To
reiterate the point made by Lishman above, the lengthy
process of pursuing compensation hampers recovery and
encourages exaggeration; sometimes naturally occurring
recovery is not frankly admitted. As the litigation progresses over years, some suggestible individuals elaborate
their symptoms; these cases tend to carry a poor prognosis.
The plaintiff ’s account of the past is often distorted and
pre-accident physical and psychological disabilities may
be concealed. Careful examination of the full family practitioner case notes and correspondence is often revealing.
Malingering can occur, but is difficult to detect on the basis
of a single psychiatric examination. Sometimes enquiry
agents’ reports and videos indicate that allegedly disabled
subjects are, in fact, working clandestinely and leading
comparatively normal lives.
Management therefore requires a good deal of sensitive
enquiry, a working relationship with the whole family (if
there is one) and above all the application of pressure to the
lawyers involved in the case to resolve the matter as quickly
as possible. This is difficult because lawyers believe that
their client has a right to the best possible financial settlement even if this means delay, and therefore delay in return
to health. Once the settlement has been agreed rehabilitation may become difficult because an important purposeful activity will have been removed from the patient’s life
and new activities which can fill that vacuum need to be
negotiated. The Miller view that patients get better as soon
as the compensation is paid is not our clinical experience
and many of the symptoms persist for many years as does

the disability.

Malingering
Malingering is a highly pejorative term, linked not only with
words such as lying and deceit, but also with scrounger,
workshy, coward. It implies the wrongful acquisition of
the privileged status of the ill, and it is further linked with
dishonest acquisition of money. In times of war it has the
special odium of seeking personal safety and comfort when
others are making sacrifices to achieve highly desired group
objectives. Such people may be branded as shirkers, funks
and degenerates. Above all, pretending to be ill is regarded
as ‘shameful’. It is no wonder it is a vexed topic for medical
professionals as they are expected to accurately point the
finger at those who shall be deprived of the illness status,
and their claims and who will thus fall to the very bottom of
the social hierarchy. In times of war some alleged malingerers may be regarded as so heinous that they are executed.
The history of this problem has been briefly but well
documented by Wessely (2003). He pointed out that the

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simulation of illness is as old as humankind. He suggested
that it was the introduction of progressive social legislation in Germany between 1880 and 1890 and in Britain

in 1908 with The Workmen’s Compensation Act and the
1911 National Insurance Act, that made this simulation a
medical problem. These acts were regarded by the medical
profession as inducements to malinger and quite a number
of doctors set themselves up as gatekeepers for the state
against such temptations. Initially malingering was thought
to be mainly a matter for physicians and surgeons, but the
First World War added a very significant psychological
dimension even though the psychiatric casualties of that
war were considered to be suffering from ‘nervous shock’
which was also thought to be a physical disorder (damage
to the nervous system by terrible noise and blast from the
heavy guns). Wessely suggested that at the beginning of the
twentieth century there was a perceived decline in the prewar moral codes that had governed society. Malingering
was considered to be a form of lying and medical man was
best placed to detect it!
As we have seen, if it really is lying, then it is going to be
mighty difficult to detect. Perhaps courts who claim to be
able to detect liars are better placed to do this work than
doctors. Sprince (2003) suggested that medical evidence
about malingering is not particularly significant in a court
of law. Where claims have been resisted in whole or in part
by reference to malingering, courts have rarely reached a
positive finding that an individual is or is not malingering and in appeal cases malingering rarely arises. Further
where the claim has been lost, presumably because the
claim is not considered to be genuine in all respects, it is
rarely followed by a criminal prosecution for fraud.
For a comprehensive text on malingering and illness
deception see Halligan et al. (2003).
Feigned mental illness

In the nineteenth century, there was considerable interest
in identifying malingerers who simulated mental disorder.
Beck (1829), in spite of his views quoted above, devoted
considerable space in his text on medical jurisprudence
to the recognition of feigned diseases and, in particular,
offered no fewer than 12 strategies for unmasking those
pretending madness. Tuke (1892) noted that simulators
of insanity made errors in such matters as adding 3 and
4, or the number of shillings in a sovereign, or in identifying commonplace objects. He stated that the unskilled
malingerer answers nothing right, constantly falling into
absurdities quite foreign to true insanity. Maudsley (1867)
also noted:
Imposters generally overact, thinking the lunatic widely
different from a sane person… [he] pretends he cannot
remember things such as what day follows another, or
how many days there are in a week, that he cannot add
the simplest figures… [he] answers stupidly where a real

lunatic who was not an idiot would act cunningly and
answer intelligently.
Chesterman has written two articles on psychiatric
malingerer catching. Broughton and Chesterman (2001)
described a man who assaulted a teenage boy and then
feigned mental illness. He later confessed to malingering
but doesn’t seem to have done very well. The authors do
stress however that the discovery that an individual has
fabricated symptoms should not exclude him or her from
further assessment and treatment, as such fabrication
should be viewed as a form of abnormal illness behaviour
in an often resourceless, inadequate and vulnerable individual. Chesterman et al. (2008) take twenty-first century

British psychiatrists, especially authors of this textbook, to
task for not giving enough attention to malingering. They
believe that this is due to a false assumption that psychotic
symptoms are faked in order to ward off real psychosis
(Jung 1903). The paper is a useful review of the research in
this field and suggests some tests which have all the drawbacks and low validity one might expect, in order to detect
malingered psychosis. They go on to say:
It appears that the incidence of malingered psychosis
may well have increased over recent years as a consequence of the closures of long-stay psychiatric institutions
and the move towards care in the community. Many
chronically mentally ill patients, who may have preferred
the stable environment of the asylum, are now living in
marginal circumstances in the community… Such individuals may therefore consciously exaggerate their symptoms in an effort to obtain shelter in the new generation
of psychiatric hospitals… It has also been proposed that
there has been a change in coping strategies among society’s disenfranchized individuals, who now present with
psychological rather than physical symptoms.
They also emphasize the importance of detecting malingering but don’t say what this importance is, other than a
possible miscarriage of justice in a homicide case in which
a manslaughter verdict of diminished responsibility on
grounds of mental disorder is preferred to a murder verdict.
There is no research on the prevalence of such problems.
The question of what is malingering is claimed by some
to be straightforward. An early authority, whose text on the
subject was dedicated ‘to my friend the British workman,
to whom I owe so much’ (Collie, 1917) cited Lord Justice
Buckley. The judge defined a malingerer as ‘one who is not
ill and pretends that he is.’ Collie also cited Bramwell who
distinguished between ‘malingering’ (conscious, deliberate
simulation of disease, or exaggeration of symptoms) and
‘valetudinarianism’, where the process is unconscious or

subconscious. In a more recent study of feigning after brain
or spinal injury, Miller and Cartlidge (1972) defined malingering as: ‘all forms of fraud relating to matters of health.’
This includes the stimulation of diseases or disability which
are not present; the much commoner gross exaggeration

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of minor disability; and the conscious and deliberate
attribution of a disability to an injury, or accident that did
not in fact cause it, for personal advantage. In a lecture, a
psychiatrist with a medico-legal compensation practice in
Australia (Parker, 1988), claimed:
A week will not go by without seeing at least two malingerers, and about the same number with gross conversion
hysteria.
Nevertheless, he went on to warn, using the words of Asher
(1958):
The pride of a doctor who has caught a malingerer is
akin to that of a fisherman who has landed an enormous
fish; and his stories (like those of fishermen) may become
somewhat exaggerated in the telling.
It could be that there is a special form of malingering, the
feigning of psychotic illness. The following kind of argument may not be uncommon.
The trouble is that as soon as the language of ‘patienttreatment-disease’ is used, it is hard to diagnose insanity
in anyone who commits a really horrible act; for to be
cured of mental disease is to be sane, and a sane man

does not do such things; there is a merging of the language of medicine and the language of morality; if bad is
sick, then sick is bad, and sane must be good. The more
we treat someone as a patient, the more likely we are to
give his sincerity the benefit of the doubt. We tend to ask
‘What makes him behave like that’ instead of ‘is he telling
the truth?’ and ‘could he behave differently if it was to his
advantage?’ (Mount, 1984).
It is certainly a robust statement of the antipsychiatry position. Yet medical practitioners can also have considerable
scepticism about mental disorder in those charged with
serious crimes. An anecdote from Ray (1838) illustrates
just how far preconceptions about deception, malingering
and moral responsibility will take even the experienced
observer.
Jean Gerard, a bold villain, murdered a woman at Lyons
in 1829. Immediately after being arrested, he ceased to
speak altogether and appeared to be in a state of fatuity.
He laid nearly motionless in his bed, and when food was
brought his attendants raised him up and it was given
to him in that position. His hearing also seemed to be
affected. The physicians who were directed to examine
him concluded that if this was actually what it appeared
to be, paralysis of the nerves of the tongue and ear, actual
cautery applied to the soles of the feet would be a proper
remedy. It being used, however, for several days without
any success, it was agreed to apply it to the neck. For
two days no effect was produced, but on the third, while
preparations were making for its applications, Gerard
evinced some signs of repugnance to it, and after some
urging, he spoke, declaring his innocence of the crime of
which he was charged. His simulation was thus exposed.

Whether or not this practice resolved the question of
malingering, today it should surely be a matter for a professional licensing body.
To try to understand just how easy or difficult it is to
simulate mental disorder, Anderson et al. (1959) carried
out a study in Australia. Eighteen psychology students
were asked to simulate mental disorder. Six were asked to
imagine that they had committed murder and they were
to feign insanity to escape the consequences. Twelve were
asked to feign insanity for their own reasons. The subjects
were then subjected to a standard psychiatric examination.
None of the pictures presented resembled well-defined
psychiatric disorders. Even the better performances lacked
consistency and persistence. The commonest simulation
was of depression, in two people accompanied by amnesia;
three also simulated paranoid features. On cognitive testing, errors were produced, especially approximate answers.
One tried to make out he was an epileptic, another tried to
simulate feeble-mindedness. Unfortunately, the psychiatric
examinations were not carried out blindly, so although the
experimenters were not very impressed by their students’
acting, it is difficult to know whether they could have actually been fooled.
Perhaps the most famous test of simulated psychosis is
‘on being sane in insane places’ (Rosenhan, 1973). Five male
and three female volunteers, a psychology student, three
psychologists, a paediatrician, a psychiatrist, a painter, and
a housewife became pseudo-patients and gained ‘secret
admission’ to 12 different hospitals. The pseudo-patients
complained that they were hearing voices, they changed
their names and occupations, but otherwise told the truth.
The ‘voices’ were stopped immediately on admission.

Each was diagnosed as having schizophrenia, but soon
discharged as in remission (length of stay varied from 7–52
days). Other patients sometimes recognized the pseudopatients as frauds. Rosenhan concluded, ‘it is clear we
cannot distinguish the sane from the insane in psychiatric
hospitals.’ A torrent of replies disagreed. The strongest criticism was perhaps by Spitzer (1975), who pointed out that
it is not very surprising that psychiatrists do not diagnose
pseudo-patients when they are not looking for them. He
concluded himself, however, that the data actually supported the view that psychiatrists are good at distinguishing the sane from the insane.
None of this is much help if a psychiatrist is faced with
a patient in a situation in which having a psychosis would
be a distinct advantage. There is no simple answer and the
principles of assessment and management will be the same
as if simulation of physical disorder is suspected. As much
information as possible should be collected from as many
sources as possible, and a professional relationship should
be built with the patient. In this way, the nature of the
patient’s problem will emerge ( for the one thing that will
be true, unless s/he is one of Rosenhan’s research workers,
is that s/he will have a problem).

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Malingered psychiatric disorders are encountered both
in situations where compensation is at issue and in those

facing criminal charges. Malingered psychiatric disorders
may occasionally be encountered in those seeking admission or transfer to a psychiatric hospital from prison. The
malingerer sometimes believes s/he has to appear mad
or idiotic in every sphere of function and thus presents
such an exaggerated picture that suspicions are raised,
even in the most trusting. This type of malingerer, who
counterfeits a disorder too mad to be mad, often claims
gross disorientation under the misapprehension that the
mentally disordered suffer a global confusion. More subtle
malingerers draw on their experience with mentally disordered individuals. They may claim to be hallucinated,
in which case the hallucinations tend to be described
as omnipresent, distressing and without the usual association with mood changes or delusional developments.
Flamboyant claims about the content and extensive nature
of hallucinations often contrast with the meagre and vague
account provided of the form of the experience in terms
of being experienced in objective space, having directional
qualities. Malingered hallucinations may also take atypical forms as when a vision of a person is described which
talks to the patient and may even enter into conversation.
Occasionally, command hallucinations are offered as an
explanation of offending. These should be treated with
some scepticism when presented in the absence of other
features of psychotic illness.
Command hallucinations have a particular appeal to
the malingerer as they offer both evidence of mental disorder and at the same time incorporate a direct exculpatory
element. Claims are made by offenders that they committed criminal acts because the voices told them to do so, and
they were unable to resist the instruction. In fact violent
acts secondary to command hallucinations are rare, even
among people suffering from psychosis (see chapter 14).
Occasionally, distressed and disturbed individuals will
report command hallucinations to dramatize their suicidal

or homicidal impulses.
Fabricated delusions are less common. Malingerers
usually present a straightforward account of persecution
or control which accounts conveniently for their acts
or makes necessary their transfer. The accounts differ
from actual delusional experiences both in providing an
unusually clear storyline and paradoxically containing
elements of the totally fantastic. One young man gave an
account of being followed and persecuted by shadowy
figures whom he claimed had arranged for him to be
locked in a cell on board a ship which was about to be
sunk. When questioned, he went to the prison window
and pointed out at the surrounding sea, then abruptly fled
under the table claiming the boat (prison) was sinking.
Fabricated accounts, unlike true systematized delusions,
rarely contain the typical mixture of self-referential material and laboured constructions placed on minor points

proving, to the patient’s complete satisfaction, the delusional claims. Malingered delusions are often said to have
emerged at a particular point, usually relatively recently,
and to have, from the outset, their fully fledged content.
In genuine delusions, it is usually possible to discern their
gradual development from the initial intuition through an
extended process as the patient uncovers the full extent
of ‘the truth’.
Language disorders are rarely, if ever, malingered. Manic
states are difficult to imitate, but depressive syndromes relatively easy. Most of us have sufficient experience of despair
and despondency to mimic depression. Where suicidal
intent is claimed in the context of an account of depression which appears so atypical as to raise suspicions about
malingering, it is probably wiser to give the benefit of the
doubt to the individual until s/he can be observed carefully.

In disorganized and disturbed personalities, so common in
forensic psychiatry, instability of mood and markedly atypical depressive syndromes occur not infrequently, and they
are all too often coupled with self-destructive behaviour.
Malingered mental disorders are often presented flamboyantly and insistently. Any questioning of the reported
experiences is likely to be greeted by assurances that it is
‘the truth’, or with the accusation that you don’t believe the
patient. In genuine disorders, the abnormalities of mental
state usually emerge gradually as the interview progresses.
Some malingerers are suggestible and can be induced to
add contradictory and absurd symptoms to their account,
but more calculating malingerers will stick doggedly to
their basic story.
To summarize, the detection of malingering is a difficult, but not entirely mysterious art. The longer the patient
is studied, the more carefully the information is gathered
and checked, the easier it becomes to detect malingering.
The patient should be encouraged to talk freely rather than
to answer formulaic questions. Malingering patients tend
to have an air of exaggeration, a disproportionate bias in
their symptoms, and their complaints do not fit with objective observations from others. They tend to tell lies and so
their accounts differ from time to time. However, it also
has to be remembered that differences between objective
and subjective accounts may be due to many factors other
than malingering. Inconsistencies between interviews may
be entirely compatible with the memory failures of normal
recall, and with clinical change as the disorder progresses.
Exaggerated, overoptimistic, or even pessimistic accounts
may be due to mood changes. Self-deception may replace
conscious lying and dissimulation. There are no absolutes
in the detection of malingering, but standard techniques
of cross-checking, observation, repeated interviewing,

together with the skill of an experienced interviewer who is
alive to the possibility of malingering are the best that can
be done. It is worth remembering that hostile questioning
of distressed patients will probably increase rather than
reduce error.

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The growing neuroscience of perceptual and cognitive
distortions explored by Myslobodsky (1997) and Halligan
et al. (2003) is likely to enhance our understanding of
just how blurred the boundaries between normality and
abnormality may be.
Munchausen’s syndrome
Munchausen’s syndrome was described and named by
Asher in 1951. Like the famous Baron whose tales were
bowdlerized and published by Raspe (1786), the affected
persons had travelled widely, and they related tales which
were both dramatic and untruthful. Typically, such patients
will be admitted to hospital with an acute, harrowing, but
not entirely convincing history; their manner is evasive
and truculent; and, on enquiry, it may be revealed that they
have attended and deceived other hospitals, often discharging themselves against advice.
Most cases resemble organic emergencies and favour
three main variants:

1. The acute abdomen type which is usually accompanied
by a multiplicity of abdominal scars.
2. The haemorrhagic type, usually reporting haemoptosis,
haematemesis, or haematuria.
3. The neurological type, with headache, odd fits, or loss of
consciousness.
Asher’s title for this group of patients now seems well-established. The patients tend to be emotionally labile, lonely,
attention-seeking and establish little rapport. Multiple
aliases and repeated admissions are central features and
some cases also fulfil the criteria for pseudologica fantastica. Some are seeking narcotic drugs.
A sinister variant of the condition has been described
as ‘Munchausen syndrome by proxy’ (Meadow, 1977, 1982,
1989; Black, 1981). This involves children whose mothers
or caregivers invent stories of illness about their child and
in some cases fabricate false physical signs. Older children
may even be coached by the parent on how to deceive the
doctor. Meadow (1989) describes the consequences for
children who are falsely labelled as ill:
1. They receive needless investigations and treatment.
2. Real injury may be caused by the mother’s action, for
example by giving drugs to induce unconsciousness.
3. They are at risk from becoming chronic invalids or hospital addicts in their own right.
The parents’ motivations have been considered to include
a desire for the status and attention provided by being
the mother of a sick child, the enjoyment of help from the
various medical professionals, and as a way of resolving or
avoiding marital conflicts.
Self-mutilators
A related, and to some extent overlapping group of patients
are those who obtain medical attention, if not care, by

repeated self-injury. There is usually no attempt at mimicking of genuine medical disorders, although occasionally
bizarre skin lesions are induced which raise questions as
to their origin. In one case, the patient injected air under
the skin and persuaded one hospital to treat her for gas
gangrene.
Ganser states
A strange mental state described by Ganser in 1898 was
regarded in its day as a ‘prison psychosis’. If it occurs at
all nowadays it is extremely rare and is included here for
completeness and historical interest and show how dissociative/malingered symptoms vary with time and place.
The clinical features are
1. approximate answers;
2. clouding of consciousness with disorientation in time,
place, and occasionally person;
3. vivid hallucinosis, both visual and auditory;
4. areas of analgesia and hyperalgesia with, on occasion,
motor disturbances which were considered ‘hysterical
stigma’;
5. complete and often sudden clearing of the disorder,
leaving the patient with a total amnesia for the period
of the disorder.
The description of the peculiar way of answering questions
was the feature which intrigued subsequent investigators
and guaranteed the survival of the putative syndrome
(Auerbach, 1982). The phenomenon of approximate
answers (Vorbeireden or Vorbeigehen) was described by
Anderson and Mallinson in 1941 as
A false response of a patient to the examiner’s question,
where the answer, although wrong, is never far wrong and

bears a definite and obvious relation to the question, indicating clearly that the question has been grasped.
Anderson and Mallinson went on to make clear that this
is not merely giving random responses. Among Ganser’s
examples was a prisoner who, when asked how many
fingers he had, replied 11 and said a horse had three legs,
but an elephant five. Counting, simple arithmetic, identifying letters of the alphabet and reading, are all reported to
produce obvious errors and omissions. One of our cases,
when shown a chessman and asked what it was, replied
after several minutes of puzzled examination that it was a
little statue whose function quite escaped him. This same
man correctly identified a watch and could tell the time,
but called a key a knife, and added a little pantomime of
horrified withdrawal. One of Ganser’s own cases identified
a key as a revolver.
The possibility that the Ganser state is a manifestation
of the conscious simulation of mental disorder is considered frequently in the literature, usually to be dismissed in
favour of unconscious mechanisms, or the impact of major

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stress on somebody who already has a mental disorder.
What Ganser added to previous descriptions of feigned
mental disorder in prisoners was his personal assurance
that ‘it could not be doubted’ that the prisoners being

examined were not malingering, but ‘truly sick’.
The Ganser state has almost disappeared, but before
it goes entirely it might help to consider whether we
think of it as malingering, pathological lying, or a dissociative disorder. Some of the patients we have seen
labelled as ‘Ganser’ turned out later to be psychotic; all of
them needed help.
Malingerophobia
We cannot leave the topics of malingering and feigned
mental illness without reference to Pilowsky’s (1985) paper
on malingerophobia. It describes an important syndrome
which every physician, and especially every psychiatrist,
should know about. Pilowsky likened the medical altruistic impulse to body temperature which can under stress
become too warm or too cold. He maintained that it is a
contagious condition and is defined as
an irrational and maladaptive fear of being tricked into
providing healthcare to individuals who masquerade as
sick, but either have no illness at all, or have a much less
severe one than they claim.

It is at its worst in large teaching hospitals, he said, and
can easily be diagnosed by the general practitioner who
telephones to seek admission for a patient. The condition then manifests itself in the form of a newly qualified
intern treating the general practitioner as though he
were a medical student presenting himself for a viva. The
least subtle sign is when the body language and voice
inflection asking the patient about symptoms gives the
distinct impression that the assessing doctor believes
the patient is a liar. The main complication of malingerophobia is that the patient is rejected and the patient’s
problems are undiagnosed. Doctors dealing with such
patients become bored and impatient. The worst complication is the enquiry, sometimes by a coroner, when

something goes wrong. The cure for this disorder is
simple, says Pilowski, it is an increased readiness to take
patients on, especially for treatment, coupled with a
tolerance of occasional malingering. This will prevent
the development of a fortress mentality and improve
working conditions as well as treatment. Perhaps we
can add to Pilowsky’s remedies that much more attention should be paid to understanding and assessing the
rich diversity of mental states that patients present, an
approach which may well save a lot of time in the long
run and certainly gets closer to the core task of being a
medical practitioner.

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18
Addictions and dependencies: their
association with offending
Edited by
Pamela J Taylor

Written by
Mary McMurran and
Adrian Feeney: Alcohol
Ilana Crome and
Roger Bloor: Other drug
abuse and offending

John Gunn and
Pamela J Taylor:
gambling

1st edition authors: John Gunn, John Hamilton, Andrew Johns, Michael D Kopelman,
Anthony Maden, John Strang and Pamela J Taylor

Society remains ambivalent about use and abuse of mind
altering substances and towards the people who use and
abuse them. Even the professions seem to struggle with
attitudes to the behavioural disorders associated with such
substances in ways that perhaps reflect tensions between
construing them as primary disorders of mental health or as
moral lapses. It is not uncommon even for people with unequivocal psychotic illnesses to be rejected from psychiatric
services on grounds that their disorder is substance-induced
rather than illness. Terminology is also elusive. The two main
diagnostic and statistical manuals (ICD-10, WHO, 1992a;
DSM-IV, American Psychiatric Association, 2004) no longer
use the terminology of addiction. The former deals with a
variety of ‘mental and behavioural disorders due to psychoactive substance use’ in a simple descriptive way, while the
latter takes the simpler label of ‘substance-related disorders’,
but suggests a fundamental distinction between ‘substanceinduced disorders’, subliminally justified by including toxic
substances which are not abused as well as those that may
be, and ‘substance use disorders’. In the case of substanceinduced disorders, the implicit blame falls on the substances.
DSM criteria for substance abuse and dependency disorders
make repeated use of the word ‘failure’. For dependency,
The key issue … is not the existence of the problem, but
rather the individual’s failure to abstain from using the
substance despite having evidence of the difficulty it is
causing (DSM-IV, p.179).

DSM-IV substance abuse amounts to repeated social
­failures in the context of using the drug (including alcohol,
but not nicotine or caffeine) but with patterns falling short
of dependency.
In the UK, the Academy of Medical Sciences (2008) has
taken a lead in bringing a more scientific perspective. It has
brought back the terminology of addiction, and made clear
its multi-factorial origins. It acknowledges risk factors and
protective factors, and that these lie in a range of personal,
physical and experiential domains as well as in availability
of the objects of addiction and attitudes in wider society
and the media. The Academy further notes the similarities
in presentation between addictions to chemical substances
and to other repeated behaviours, particularly problem
gambling (euphoria on winning, tolerance on repetition,
compulsion, withdrawal and craving). It makes parallels
between them in terms of similar areas of brain activation
when winning and after administration of drugs of abuse
(e.g. Reuter et al., 2005). We too extend this chapter to consideration of behavioural addictions, here exemplified by
gambling, although in some cases, shoplifting, arson, and
even interpersonal violence may fall within this spectrum.
Such a broad construction means that addictions, dependencies or substance abuse in an individual are central issues
for the health service, even though many may first present
to criminal justice services. It also means that public health
policies and legislative controls have a fundamental part to
play in protecting both the individual and wider society. This

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chapter is mostly about clinical detection, legal issues, relationships between substance misuse and offending, management and treatment of the addictions. Consideration of
genetic and other aetiological factors is mainly in chapter 8.

Alcohol
The World Health Organization (WHO, 2002a) placed alcohol consumption among the top 10 global risk factors in
terms of the burden of disease caused. In the year 2000, 1.8
million deaths worldwide were attributable to alcohol consumption as well as 4% of the total global burden of disease,
including an estimated 20–30% of each of the following:
liver disease, oesophageal cancer, epilepsy, road traffic accidents and intentional injuries. Problem drinking presents
a risk for mental ill health too, although mental disorders
also increase the risk of alcohol-related problems (WHO,
2004a). Globally, alcohol is a major contributor to violence,
including homicide, domestic violence and child abuse, and
sexual violence (WHO, 2002b).
Perhaps in recognition of its part in this global crisis, the
prime minister’s strategy unit developed an ‘Alcohol harm
reduction strategy for England’ (Cabinet Office, 2004). Similar
strategies already existed for Scotland (Scottish Executive,
2002/7), Wales (Welsh Assembly Government, 2008b), and
Northern Ireland (DHSSPS, 2000). All focus on combating
alcohol-related crime and disorder through prevention, early
intervention, and treatment, but specifically, too, endorse
the development of offender treatments. In parallel with the
Cabinet Office work, other bodies, as diverse as the Academy

of Medical Sciences (2004), and the Prison Reform Trust
(2004; ) and The Royal college of Physicians (2001) have also provided strategic reviews.
These documents were consistent in pointing out that
over 8 million adults in the UK exceeded the safe weekly
drinking limits, then 14 units for women and 21 units for
men (a unit is 8 g/10 ml of alcohol). About half of all violent
crimes each year are alcohol-related, amounting to 1.2 million in England and Wales alone, perhaps not surprising
given the age range of the heaviest drinkers. The UK General
Household Survey 2002 (Rickards et al., 2004) showed that
these were among 16- to 24-year-old men, averaging 21.5
units per week. The trend, however, is for a slight decrease
in consumption by young men but increasing consumption
among 16- to 24-year-old women who, in 2002, had been
averaging 14 units. A revision of national health service
(NHS) policy now recommends a maximum intake of 2–3
units per day for women and 3–4 units for men, with at least
two alcohol-free days per week, and its alcohol learning centre regularly produces guidance sheets for clinical staff and
for patients, variously showing what a unit looks like and
offering advice (http://www.­alcohollearningcentre.org.uk).
Overall, in England and Wales alone, alcohol misuse
costs around £20 bn per year in healthcare, crime-related
costs, and loss of productivity in the workplace.

How Alcohol Exerts its Effects
Intoxication
The immediately observable effects of alcohol intoxication
are impairments such as slurred speech, slowed mental
and physical reaction times, and difficulty walking. They
may be apparent even at small doses, are dose-dependent
and are due to the depressant effects of alcohol caused by

reduced excitatory actions of the neurotransmitter glutamate and increased inhibitory actions of gamma-aminobutyric acid (GABA) (National Institute on Alcohol Abuse and
Alcoholism, 2000). In most cases, the impairments caused
by intoxication are temporary, but intoxication can lead to
death from respiratory failure, accidents associated with
loss of consciousness (e.g. hypothermia; choking on vomit)
or accidents associated with cognitive or motor impairment (e.g. road or machinery accidents).
Pathological intoxication (mania à potu) has generally
been defined as sudden onset aggressive behaviour, atypical for the individual when sober and seen after a small
quantity of alcohol, and which, in normal people, would
not be associated with such behaviour. It may be associated with alcohol-induced amnesia for the events involved.
Coid (1979), however, cast doubt over its authenticity, after
reviewing the literature. Close scrutiny of any case commonly shows that the person has had more than a small
drink of alcohol and has a history of violence.
In an uncontrolled study, Maletzky (1976) gave alcohol
infusions to 22 people with histories suggestive of the condition. At high blood alcohol levels (mean: 195 mg/100 ml) 15
of them had unusual reactions. Nine became violent, four
showed delusions and hallucinations, and a further two presented with mix of these problems. Maletzky concluded that
reactions to alcohol were on a continuum and that there
was no discrete entity of pathological intoxication. It is of
note that high blood alcohol levels were required to precipitate the phenomena Maletzky observed. Nevertheless, pathological intoxication remains of interest to defence counsels
as simple intoxication provides no legal excuse for actions.
Blackouts
Blackouts occur during drinking bouts. They are characterized by discrete amnesic periods of up to several hours,
during which the individual is apparently able to carry out
normal activities. In an influential study, 100 hospitalized
alcohol-dependent patients were interviewed. Sixty-four
reported blackouts which were of two very distinct types:
(1) classic en bloc, with total memory loss; (2) fragmentary
blackouts after which the sufferer may be able to recall,
with prompting, some of the events which occurred during the blackout which were not initially remembered

(Goodwin et al., 1969; see also chapter 12). Goodwin et al.
(1970) also studied blackouts by giving 16–18 ounces of 86%
proof alcohol to 10 alcohol-dependent men in controlled

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conditions. They were then presented with novel information and tested 2 minutes, 30 minutes and 24 hours later.
All were able to recall the information at 2 minutes but five
were unable to do so at 30 minutes and 24 hours. This suggests that blackouts are a result of an inability to transfer
information from immediate recall to short-term memory
rather than inattention or a process of forgetting. Sweeney
(1990) argued that the high blood alcohol levels required for
an alcoholic blackout may severely disrupt other brain functions, such as reasoning and planning, but Lishman (1998)
observed that they are probably associated with a sharp
rise and fall in blood alcohol rather than high levels per se,
and they do not appear to be predictive of cortical atrophy
(Ron, 1983). They may be relevant in court if ability to form
intent is compromised. Fenwick (1990) asserted that they
are examples of ‘sane automatism’ (see also chapter 2).
A Dutch study of drivers stopped by traffic police or
involved in car accidents supports a sceptical view of a
direct link between alcohol level and alleged blackout (van
Oorsouw et al., 2004). Of the 100 people stopped, 14 told the
traffic police that they had had an alcoholic blackout, but
their blood alcohol levels were not significantly different

(180 mg/100 mL) from those of the people who made no
such claim (190 mg/100 mL). The main difference between
the two groups was in whether or not they had had an
accident. Twelve of the 14 (86%) claiming a blackout had
caused an accident compared with 30 (35%) of the rest.
Interpretation of this is difficult; could the high reporting
rate of blackouts among those who had crashed reflect at
some level avoidance of prosecution, or the lower reporting
rates a reluctance to put their driving licence in jeopardy?
Could alleged blackouts be related more to the trauma of
the accident than the alcohol?
Dependence
The alcohol dependence syndrome, as described by
Edwards and Gross (1976), remains a useful guide for recognition of need for intervention:
1. a narrowed drinking repertoire, characterized by a set
routine of consumption in an effort to maintain blood alcohol levels and therefore avoid withdrawal symptoms;
2. increased salience of drinking, such stereotyped drinking is pursued to the exclusion of all other activities;
3. increased tolerance to alcohol, a manifestation of both
increased metabolic capacity based upon hepatic enzyme induction and increased brain receptor tolerance;
4. withdrawal symptoms;
5. relief or avoidance of withdrawal symptoms by further
drinking;
6. subjective awareness of the compulsion to drink;
7. reinstatement after abstinence, the phenomenon of
rapidly returning to the previous stereotyped drinking
pattern after a period of abstinence, for instance a period of imprisonment.

The alcohol dependence syndrome represents a change
in the relationship between the individual and alcohol.
Instead of using alcohol in the context of social cues, drinking becomes an end in itself and is self-perpetuating.

Withdrawal, fits and delirium tremens
If an alcohol-dependent person stops or reduces alcohol
consumption s/he may trigger a withdrawal syndrome,
generally 3–12 hours after the change. Alcoholic withdrawal is not infrequent among people detained after
arrest, is possibly becoming more likely and may affect fitness to be interviewed. In a sample from the 1980s, at least
4% of pretrial male prisoners showed signs of withdrawal
on reception into prison (Taylor and Gunn, 1984). In a
2007–2008 sample of newly remanded men at least 17%
had alcohol withdrawal symptoms on reception, although
over 40% had an Alcohol Use Disorders Identification Test
(AUDIT; Saunders et al., 1993) score indicating dependency
(Taylor et  al., 2009), which was a higher proportion than
the Office of National Statistics figure of 30% from the 1987
England and Wales prison survey (Singleton et  al., 1999).
Withdrawal in prison may also be precipitated by abrupt
cessation of drinking ‘hooch’, brewed there from such
diverse sources as rotten fruit or boot polish.
Withdrawal is characterized by autonomic hyperactivity, including tremor, insomnia, sweating, tachycardia, hypertension and anxiety (Raistrick, 2001). It may be
accompanied by acute hallucinosis in clear consciousness;
­hallucinations may occur in any modality, but visual and
tactile modes are especially common. Violent or criminal
acts may be committed while blood alcohol levels are falling.
Withdrawal fits may occur 12–48 hours after cessation of drinking; 5–10% of alcohol-dependent individuals
experience them. The fits are generalized, tonic–clonic
bursts of activity and are therefore characterized by loss of
consciousness followed by involuntary movements of the
limbs and accompanied by an abnormal electroencephalogram (EEG). The EEG is, however, generally normal
between such fits, indicating that they are a manifestation
of the withdrawal rather than an independent epileptiform
phenomenon. Having a withdrawal seizure is a risk factor

for further seizures during subsequent withdrawal states,
therefore a history of withdrawal seizures is an indication
for detoxification to be undertaken as an inpatient.
Delirium tremens (DT) presents 3–4 days after abstinence (Victor and Adams, 1953). It has a mortality of up
to 5 per cent; cause of death is typically cardiovascular
collapse, hypothermia or intercurrent infection. It presents
with vivid hallucinations, delusions, profound confusion,
tremor, agitation, insomnia, and autonomic over-activity.
Visual hallucinations may be Lilliputian (very small). The
onset may be sudden, although often there is a prodromal
phase, which went unnoticed. The patient may be gripped
with terror, although this is not invariable. DT usually

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lasts up to 3 days, ending with a prolonged sleep. The
patient wakes feeling better, if tired, although occasionally
an amnesic syndrome is evident. Delirium tremens may
­provide for an insanity defence (see also chapter 2).
Best practice in managing withdrawal states is preventive – to identify people at high risk and provide them
with planned detoxification (see below). Use of the AUDIT
to supplement interview questions as part of screening
on reception into custody may enhance identification of
those at risk.

Wernicke/Korsakoff’s syndrome
Wernicke’s encephalopathy (WE) is an acute brain disorder caused by vitamin B1 (thiamine) deficiency, commonly linked to alcohol dependence in combination
with poor appetite, malnutrition, poor absorption, and
impaired thiamine storage by the liver. This deficiency
causes abnormalities in and around the third ventricle
and the aqueduct of the brain. Such changes have been
found at post-mortem in 12% of people who had been
alcohol-dependent (Torvik et  al., 1982) although they
have also been found in 1.5% of people who had neither
abused alcohol nor had neurological abnormalities in life
(Thomson and Pratt, 1992). WE may be of sudden onset,
and there may be memory problems even in the acute
phase. Only 10% of patients present with the classic triad
of opthalmoplegia/nystagmus, ataxia, and delirium, and
there is a risk that the condition may be mistaken for
drunkenness. A presumptive diagnosis should be made in
anyone undergoing detoxification who develops any one
of these signs, or hypotension or impaired consciousness
(Cook, 2000). Failure to treat immediately with parenteral
B-complex vitamins puts the person at risk of permanent
brain damage or death. Victor et  al. (1971), studying
patients with Wernicke’s encephalopathy, found that over
84% went on to develop Korsakoff ’s syndrome.
Korsakoff ’s syndrome is a similar, but more chronic
state characterized by abnormalities of both anterograde
and retrograde memory in the presence of apathy but
otherwise relatively well-preserved intellectual function.
At post-mortem, the cerebral pathology is virtually identical to that in Wernicke’s encephalopathy (Malamud and
Skillicorn, 1956). As Lishman (1998) observed, the pathological process following thiamine deficiency is the same,
merely differing in speed of development.

Classically, the patient is able to register new information (e.g. to perform the digit span test) but is unable to
retain new information for 5 minutes or more. Temporal
sequencing of events is particularly impaired, and sufferers
may make up stories to try to hide such deficits (confabulation); these are not invariably far-fetched. Confabulation
is not unique to Korsakoff ’s syndrome. Prognosis is poor,
but not invariably hopeless; 25% of people recover, one half
show some improvement with time and the other quarter

show no change (Victor et al., 1971). Schacter (1986) was
unable to find any recorded case of an amnesic syndrome
being cited as a defence. One of us, however, has experience of unfitness to plead being found in the presence of
Korsakoff ’s syndrome, since the defendant could neither
remember the alleged assault nor could he follow a trial.
In view of the high risks attached to Wernicke’s encephalopathy, prophylactic vitamin B1 (thiamine) should be given
to dependent drinkers, particularly during withdrawal.
British Association of Psychopharmacology guidelines
(Lingford-Hughes et al., 2004) recommend a 1-month course
of 100–200 mg thiamine per day for healthy, low risk alcoholdependent patients undergoing ­detoxification and those
who are thought to be at high risk of developing Wernicke’s
encephalopathy. (Cook [2000] suggests that anyone meeting
criteria for inpatient detoxification, for whatever reason), or
already showing signs of Wernicke’s encephalopathy, should
be treated with parenteral B-vitamin complex for up to 5
days. Such parenteral administration, which includes vitamin C, has a small associated risk of anaphylaxis and must
only be given where there is adequate medical support.
Alcoholic hallucinosis
Alcoholic hallucinosis is rare, characterized by auditory
hallucinations, commonly derogatory comments, in clear/
very slightly clouded consciousness which follows heavy
drinking. It may generally be distinguished from schizophrenia, even though secondary delusions may follow.

Glass (1989) provides a full account of its controversial
history as a concept and a review of outcome. Treatment
is absolute abstinence, although low dose antipsychotic
medication may be helpful.
Alcohol and behaviour
Alcohol affects behaviour idiosyncratically: people respond
differently from each other and, indeed, one person may
react differently on separate drinking occasions. The factors explaining these individual differences will be explored
with particular reference to aggression and violence.
It has been noted that ‘alcoholic intoxication dissolves
the super ego before it dissolves the power to act’ and
that drunken people do things which they would not do
when sober (Merikangas, 2004). In laboratory studies, alcohol fuels aggression mainly in men who have personality
traits of irritability or aggression (Chermack and Giancola,
1997; Godlaski and Giancola, 2009). The effect of alcohol
on aggression is observed after provocation and is most
evident at higher doses. Acute intoxication is more commonly associated with violence than is chronic, heavy
drinking (Pillman et  al., 2000). Throughout the UK, there
is particular current concern over ‘binge drinking’ and disorderly conduct among young people, although there is no
generally accepted definition of binge drinking. Commonly,

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it is taken to mean consumption of more than twice the
recommended upper daily limit of alcohol in one sitting

(over 8 units for men or 6 units for women). According to
this measure, about one-third of people in their twenties
binge on alcohol (Williamson et  al., 2003a). Binge drinking is a strong predictor of violence, at least in young
males (Richardson and Budd, 2003). Accepting that alcohol
changes behaviour, it is instructive to identify the mechanisms that explain this.
●●

●●

●●

●●

●●

Anxiety reduction. At high doses and in settings which
are highly provocative of anxiety, the anxiolytic effect of
alcohol reduces the inhibitory effect of fear (Ito et  al.,
1996), without which aggression and social rule breaking are more likely.
Pain reduction. Alcohol is an analgesic, and one common euphemism for drunkenness – ‘feeling no pain’
– has literal truth to it. Knowledge from experience of
this may reduce fear of starting fights; the analgesic
effect removes a reason for ceasing any fight (Cutter
et al., 1979).
Increasing psychomotor activity. At lower doses, alcohol
increases psychomotor activity, which may increase
the risk of instigating trouble or provoking others (Pihl
et al., 2003; Pihl and Hoaken, 1997).
Disruption to executive cognitive functioning (ECF). The
concept of executive cognitive functioning has been

defined by Giancola (2000, p.582) as ‘… a higher order
cognitive construct involved in the planning, initiation,
and regulation of goal-directed behaviour’. He presents
a strong case for its disruption affecting alcohol-related
aggression and violence. Alcohol disrupts regulation of
goal-directed behaviour by reducing ability to attend to
all the features of a situation, interfering with appraisal
of information, reducing ability to see the situation from
the perspective of others, diminishing the ability to
consider the consequences of one’s actions, and reducing availability of alternative responses in a situation.
Disruption to any of these processes results in failures
of behaviour control. The effects of alcohol will depend
on sober-state function, that is how good one’s executive
cognitive functioning is to begin with. Its disruption may
explain much impulsive or imprudent behaviour associated with alcohol intoxication, including risky sexual
behaviour, disorderly conduct, and driving while drunk.
Outcome expectancies. Alcohol may influence behaviour
through outcome expectancies, which are cognitive
representations of an ‘if–then’ relationship; here, they
represent what has been learned about the effects of
alcohol through instruction, observation, and experience. They are important in that they may predict
future actions (Goldman et  al., 1999). Male offenders
expect alcohol to give them confidence in social situations (McMurran, 2007a). Some outcome expectancies
are criminogenic: for instance ‘if I drink, then I will be

violent’ and ‘if I drink I can take sexual risks’ (McMurran
and Bellfield, 1993). Recent research has, however,
indicated that alcohol–aggression expectancy effects
disappear after controlling of for an aggressive disposition; it is the conjunction of the psychopharmacological
effects of alcohol with an aggressive disposition which

really leads to aggression (Giancola, 2006).
●● Type of beverage. Different drinks affect behaviour differently, for example violence is more likely with spirits than beer or wine (Gustafson, 1999). This may be
accounted for by chemical differences between beverages (different congeners), by differing speed of alcohol
ingestion and metabolism (drinks of different strengths
lead to intoxication at different rates), the effects of
social custom (e.g. ‘aggression-producing drinks’ are preferred by aggressive people), or expectation (e.g. a person’s perception of drink type-specific behaviour links).
●● Context. Alcohol and aggression co-occur in certain settings, typically city centre entertainment venues where
young men gather and drink heavily, especially at weekends (Lang et al., 1995). It is also important that people
tend to gather there to seek sexual partners, even to
compete over them, thus increasing the volatility of the
situation (Charles and Egan, 2005).
●● Excuses or facilitators. Some people drink deliberately to
‘loosen up’ or give them courage to behave in ways they
otherwise would not, thus making alcohol an excuse for
antisocial behaviour, or blaming it after the act (Zhang
et al., 2002).
Each of these aspects may play some role in any alcoholrelated offence. Furthermore, the aggregation of factors
should be understood within a cultural context, with differences in cultural (or subcultural) norms providing a behavioural baseline, regardless of intoxication. Factors that
need to be taken into account in explaining alcohol-related
crime are summarized in figure 18.1.
Trigger

Beverage

Drinking style
Crime

Person

Environment

Culture

Figure 18.1     Factors implicated in explaining
alcohol-related crime.

Alcohol and the Law
General
In the UK, alcohol is legally available but subject to controls. In his social history of drinking, Barr (1998) noted that

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Britons have always been heavy drinkers, with documented
references to exceptional levels of drunkenness as far back
as the eighth century, and the heaviest drinking period
in British history occurring in the eighteenth century. It
was then that legislation to control alcohol began, and
that Thomas Trotter completed his MD thesis describing
habitual drunkenness as a ‘disease of the mind’ (Trotter,
1804/1985). According to Barr (1998), when William of
Orange took the English throne in 1688, war was declared
on France and trade sanctions reduced the availability of
French brandy. This was accompanied by promotion of
domestic manufacture of spirits to maximize state revenue.
British-grown corn was distilled into gin, consumption

of which increased from half a million gallons in 1688 to
19  million by 1742. Consequent social and medical problems eventually led to the Gin Acts. The first, in 1736, levied
a heavy duty on gin so that most people could no longer
afford it. In 2009, raising the price of alcohol was again
suggested as a route to containing the public health threat.
In 1736, however, increased duty perversely led to greater
problems. Production was driven underground. Over the
next 15 years, the Act was revised, lowering the duty but
restricting availability. Consumption eventually fell. The
principle of imposing a duty on the sale of alcohol and
requiring producers and retailers to be licensed, at a cost,
has been retained ever since, with a consequent tension
between the health of the population and the health of the
economy.
The most recent legislation for England and Wales
is the Licensing Act 2003. It covers a range of ‘licensable
activities’, including the sale and supply of alcohol, the provision of regulated entertainment, and the provision of late
night refreshments. It brought relaxation of previous licensing laws, permitting citizens and visitors the ‘opportunity to
enjoy themselves with a drink or a meal at any time’ (Home
Office, 2000, p.5). As before, sale of alcohol was restricted to
licensed premises, but with without nationally prescribed
opening hours. Alcohol may be sold 24 hours a day, 7 days
per week.
The legal age for purchasing and drinking alcohol in
licensed premises is 18 years, although 16 and 17 year olds
are permitted to drink it if less than spirit strength with
meals served at table. Children under 16 may enter licensed
premises only if accompanied by an adult; younger children
may be excluded. Children of 5 years and over are allowed
alcohol, but not on licensed premises. Children under 5

years old may be given alcohol only on medical order.
In conjunction with longer drinking hours, government goals for the Licensing Act 2003 included reduction
in crime and disorder and improved domestic and public
safety, the rationale being that the risk of intensive bouts of
drinking in anticipation of closing time would be less likely.
Anyone seeking a licence to sell alcohol must demonstrate
a plan for minimizing the likelihood of crime, disorder,
nuisance, or harm. The Act also provides for conditions for

conducting an orderly house. It is an offence for the licensee
or any employee to allow disorderly conduct on licensed
premises, to sell alcohol to a person who is drunk, or to
sell alcohol to underage drinkers. If such breaches occur,
then the police have authority to take action to suspend or
withdraw a license.
In addition, other laws exist to control disorderly or
dangerous conduct relating to alcohol. Its consumption
may be prohibited in certain public places, for example city
centre streets, parks, special transport to sporting events,
and at sporting events (Criminal Justice and Police Act
2001; Sporting Events (Control of Alcohol etc.) Act 1985).
Driving a motor vehicle with more than 80 milligrams of
alcohol per 100 millilitres of blood is an offence under the
Road Traffic Act 1988.
Intoxication and the law
While intoxication may lead to criminal charges, such as
‘drunk and disorderly’, might it also constitute evidence for a
defence against more serious crimes? Self-induced intoxication is generally no defence to a criminal charge, and, explicitly, may not be raised in respect of crimes of basic intent
(Majewski). In England and Wales, however, it may, rarely, be
raised as a defence or mitigation if it can be shown that the

defendant was so intoxicated as to have been unable to form
the specific intent necessary for the crime (Beard). Beard was
extremely drunk and suffocated a young girl while raping
her. It was ruled that he lacked the mens rea for murder and
was convicted instead of manslaughter. A North American
mock court room study showed that volunteer jurors there
readily rejected the intoxication defence, and emphasized
the personal responsibility of the defendant for his or her
actions even when intoxicated (Golding and Bradshaw,
2005). This is formally recognized in Dutch law, where there
is a concept of culpa in causa: an individual is responsible for
his/her actions under the influence of alcohol because he is
expected to know the effects of alcohol before s/he drinks.
Scottish law similarly is less concerned with the ability to
form intent than the actual harm caused.
Alcohol and defences when charged
with a crime
Other alcohol-related defences can only be sustained where
it can be shown that there is either cerebral damage
secondary to the use of alcohol or if the drinking has
become involuntary, e.g. Tandy. When an alcoholic mother
appealed a conviction for the murder of her 11-year-old
daughter, the court ruled that alcoholism could only qualify
as a disease of the mind if the drinking were involuntary.
This state would only be recognized if the first drink of the
day were involuntary. It is, though, apparent that the ‘first
drink of the day’ test is an arbitrary criterion with which to
identify alcohol dependence.

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Mental health legislation and alcohol
The earliest legislation enacted to control public drunkenness was the Habitual Drunkards Act 1879, which allowed
for voluntary inpatient treatment at designated ‘retreats’
for up to 2 years. The Inebriates Act 1898 followed, allowing
for the compulsory detention in a ‘reformatory’ for up to 3
years of any offender found to have been intoxicated with
alcohol at the time of his/her offence. All such institutions
had been closed by 1921.
As scientific acceptance grows that substance dependencies and misuse disorders, like mental illnesses, have their
origins as much in genetics and/or physical brain damage
as environmental factors, so mental health legislation has
moved away from embracing these conditions as disorders
which might lead to a requirement for detention in hospital or forms of coerced treatment. The Mental Health Act
(MHA) 1959 did not specifically exclude alcohol dependence from its definition of mental disorder, although these
grounds were seldom used; the MHA 1983 did if dependency
on alcohol or drugs was the sole presenting condition. Under
Section 1(3) this explicit exclusion has been retained in the
MHA 2007 revision, notwithstanding the widening of the
definition of mental disorder to include almost everything
else (see also chapter 3).

Alcohol and Offending
Alcohol and violence
In 2007–2008, almost 5 million crimes were recorded by the

police in England and Wales; 961,175 (19%) of them were
crimes of non-sexual violence (Home Office, 2009). It is
estimated that around half of violent incidents involve alcohol, with increased alcohol consumption associated with
increased violence rates most marked in countries where
binge drinking is a typical pattern (Room and Rossow,
2001). Homicide rates are associated with total alcohol
sales, most strongly so in northern rather than southern
European countries (Rossow, 2001).
Alcohol appears as a problem in all custodial settings. In a study of 622 men and women in police custody,
Bennett (1998) identified 25% testing positive for alcohol,
a likely underestimate since those who were unfit to be
interviewed through drink or drugs or posing a threat of
violence were not tested. Singleton et al. (1999) examined
pre-imprisonment alcohol use with the AUDIT in a survey
of prisoners in England and Wales. This 10-item screening
tool includes items on quantity, frequency, dependency,
and associated problems; scores range from 0–40, with 8
the accepted cut-off for hazardous drinking. The Singleton
group found that 63% of sentenced men were hazardous
drinkers, as were 58% of male remand prisoners, 36% of
female remand prisoners and 39% of female sentenced
prisoners. The hazardous drinkers were typically young
(16–24), single and white, with men, but not women, being

held for violent offences. McMurran (2005) used the AUDIT
with a much smaller sample of male prisoners, and found
that those convicted of alcohol-related violence were the
most extreme drinkers.
Findings from these cross-sectional studies are augmented by longitudinal studies. In a large New Zealand
birth cohort (n = 1,265), for example, Fergusson et al. (1996)

found that 15- to 21-year-old heavy drinkers, after controlling for shared risk factors such as socioeconomic status,
education, and family background, were three times as
likely to be violent as light drinkers. Similarly, Farrington
(1995) found that heavy drinking at age 18 was predictive
of violent crime in adulthood.
Alcohol and domestic violence
Alcohol is strongly associated with domestic violence (Leonard, 2001). Gilchrist and colleagues (2003)
found  that nearly half of 336 offenders on probation
for domestic violence offences had a history of alcohol abuse; 73% had consumed alcohol just before the
offence. Fals-Stewart’s (2003) study of drinking and
domestic violence showed that violence to partners was
eight times more likely on drinking days than abstinent
days, with the risk of severe violence 11 times higher on
drinking days. Nevertheless, the role of drinking and
intoxication in domestic violence remains controversial. Little is known about whether partner violence
risk decreases after alcohol treatment (O’Farrell et  al.,
2003), and such treatment is unpopular. Many domestic violence treatments have emerged from a feminist
perspective, where the root cause is seen as the man’s
desire to control his female partner (Corvo and Johnson,
2003). McMurran and Gilchrist (2008) argued that,
while power and control may be fundamental to some
domestic violence, interventions to reduce drinking are
important for reducing risk of injury.
Alcohol and sexual offending
Several researchers have reported that between 30 and
50% of rapists had been drinking at the time of the offence
(Maldonado et  al., 1988; Martin, 2001; West and Wright,
1981), while others have shown that alcohol consumption
by convicted rapists and child molesters is significantly
higher than that of non-sexually violent offenders (Abracen

et al., 2000). Sex offending theories place alcohol variously
in the roles of overcoming internal inhibitions to offend
(Finkelhor, 1984), interfering with self-regulation (Ward and
Hudson, 1998), and impairing cognitive function (Seto and
Barbaree, 1995). Emotional loneliness may be a common
factor that explains both drinking and sexual offending
(Abracen et al., 2000). Research testing these putative roles
is scarce. Findings from laboratory research are equivocal,
but there is evidence that alcohol may disinhibit sexual

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