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Diagnosis and Formulation


an IQ score of 70 is the conventional cut-off for intellectual disability, this cannot be said to be absolutely precise. Tere is an advantage in criteria being precise with respect to reliability, but there is a danger that the precise IQ is overemphasised. For example, a defendant with an IQ of 71 but with significant impairment in adaptive functioning might still fulfill the criteria for intellectual disability. In any event an IQ score is subject, statistically, to potential inaccuracy by way of 4 points in either direction.


Adaptive functioning is complex and for most prisoners the expectations of their functioning are limited. Function is considered in different domains: communication; self-care; home living; social/interpersonal skills; use of community resources; self-direction; functional academic skills; work; leisure; health and safety. Te assessment can be difficult to establish in prison and it may be particularly important to gain collateral information about function in the community.


Formulation


Diagnosis is almost inevitably followed by formulation, both in clinical practice and medico-legal practice. Diagnosis provides a reliable and succinct way to communicate the category within which that person falls in terms of the nature of their disorder, but it is limited as regards inferring an understanding of the individual. Formulation is more hypothetical and incorporates the underlying causes, precipitants and maintaining factors associated with a person’s mental disorder and behaviour; essentially it amounts to offering an ‘understanding’ of the individual’s mental functioning and of its relationship with his offending (see Chapter 7).


As in many other types of criminal case, in a capital case it is likely that the formulation will represent a ‘causal bridge’ between the diagnosis of the disorder and the offending behaviour. Te focus might be on developing a formulation in relation to episodes of mental ill health, risky or dangerous behaviour, or another specific aspect of a person’s life. Such formulation of a case can be applied, not only to elucidate how past offences came to be committed, but to also, offer a foundation for risk assessment and risk management for the future. Hence in capital cases it can be relevant, both at trial to the partial defence of ‘diminished responsibility’ and, if that fails and the defendant is convicted of murder, to the assessment of risk of future serious offending in terms applicable to the legal test for imposition of the discretionary death penalty of being ‘beyond reformation’.


In summary, in forensic psychiatric practice, diagnosis rarely provides a complete explanation for behaviour, and formulation introduces necessary complexity and understanding into the process. However, the methods by which the two are achieved are entirely distinct, as are their validity bases.


The detail of formulation Te important factors in considering formulation relating to offending will include:


• Developmental factors, including early abuse or neglect • Genetic vulnerability to mental disorder • Loss of caregivers in early life • Childhood antisocial behaviour


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