criminal behaviour and mental illness in the arab world

J Forensic Sci. 2021;00:1–12. wileyonlinelibrary.com/journal/jfo
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1© 2021 American Academy of Forensic Sciences.
Received: 29 April 2021
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Revised: 15 August 2021
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Accepted: 25 August 2021
DOI: 10.1111/1556-4029.14882
CRITICAL REVIEW
Criminal behavior and mental illness in the Arab world
Hassan S. Albarbari MBBS | Hashim M. Al- Awami MBBS | Ali A. Bazroon MBBS |
Hassan H. Aldibil MBBS | Salman M. Alkhalifah MBBS | Ritesh G. Menezes MD, DNB
College of Medicine, King Fahd Hospital
of the University, Imam Abdulrahman Bin
Faisal University, Dammam, Saudi Arabia
Correspondence
Ritesh G. Menezes, Forensic Medicine
Division, Department of Pathology,
College of Medicine, King Fahd Hospital
of the University, Imam Abdulrahman Bin
Faisal University, Dammam, Saudi Arabia.
Emails: mangalore97[email protected].in;
[e-mail]
Abstract
Numerous studies have highlighted significant correlations between major psychiat-
ric disorders and criminal behavior. However, the plethora of literature on criminality
among patients with major psychiatric disorders originated in the West. The objective
of the present paper is to review criminal behavior among individuals with mental illness
in Arab countries. Attributes of individuals assessed by forensic psychiatric committees
and identifying various aspects that may reinforce criminality among individuals with
mental illness were considered. Following the PRISMA guidelines, a systematic review
of literature from three databases (Scopus, PubMed, and Web of Science) was carried out.
A total of 20 articles were included. The publications span between 1975 and 2020 and
originated in seven different Arab countries including Egypt, Kuwait, Iraq, Saudi Arabia,
Tunisia, Jordan, and Algeria. Individuals evaluated by forensic psychiatric committees
were predominantly males. Excluding substance use disorder, psychotic disorders were
the most commonly diagnosed disorders among individuals evaluated by forensic psy-
chiatry committees. Concerning schizophrenia, concomitant substance use and nonad-
herence to therapy were significantly associated with increased criminality. The review
demonstrates that substance use is certainly linked to violence. There is a significant
association between mental illness and criminal behavior. Therefore, awareness of dif-
ferent characteristics and risk factors behind criminal behavior among mentally ill of-
fenders could allow us to design and implement effective preventative measures. The
Arab's contribution in this field of forensic psychiatry is relatively small. Indeed, further
investigation and contributions from the Arab world are required.
KEYWORDS
Arab world, criminal behavior, forensic psychiatry, mental illness, psychiatry and behavioral
science
Highlights
• We have outlined the various characteristics of offenders with mental illness in the Arab
world.
• Studying criminality among individuals with mental illness should consider the heterogeneity
among different populations.
• Personality disorders were the predominantly diagnosed mental illnesses among prisoners.
• Lack of mental health assessment and management are major problems faced in prisons.

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1 | INTRODUCTION
Forensic psychiatry represents an intersection between psychiatry
and the legal framework. It is defined as the application of psychiatry
within the legal context [1]. Criminal and civil forensic psychiatry are
the two main branches of forensic psychiatry. The criminal division
is mainly involved in determining criminal responsibility, fitness to
stand trials, and violence risk assessment [2]. Although the distinc-
tion between criminality, and legality seems straightforward, the
boundary between them is rather vague and hazy. One suggested
definition of criminality is deliberately engaging in an act that is pro-
hibited and punishable by laws and regulations without any defense
or justification [3].
In many cases, the judicial decision may be irreparable such as in
the case of execution. Therefore, forensic psychiatric committees
must make complex decisions. This is especially true when deciding
full responsibility, which abolishes any right for excuse or mitiga-
tion. Offensive behaviors conducted by individuals with mental ill-
ness invoke full criminal responsibility, insanity defense, or excuse
of provocation [4]. Insanity defense means that at the time of the
violation, the offender lacked the capacity to appreciate the nature
or wrongfulness of the committed crime due to severe mental ill-
ness; consequently, they are deemed not guilty [5]. In divergence,
the excuse of provocation is considered when the accused per-
son is deemed partially responsible due to the temporary mental
status of the offender [6]. Crime- centered classification could be
applied to appreciate the distinction between different forms of
crime. Hence, a criminal act could be categorized, based on the
inflicted harm, into two categories; the first one is crime against
person, which results in physical, psychological, or emotional harm
(e.g., homicide, sexual assault, and child abuse); the second cate-
gory is crime against property, which results in the interference
with others right without inflicting a direct harm on people (e.g.,
theft, arson, and shoplifting) [4]. The tragic nature of crimes com-
mitted by individuals with severe mental illness attracts people's
attention [7, 8]. Although individuals with mental illness are more
likely to be victimized, there is a significant correlation between
mental illness and violent behavior [9]. There is a large intersection
between mental illness and criminal behavior, especially violence
(the use of physical force that result in or has a high probability of
resulting in harm). Hence, violent behaviors acted by individuals
with mental illness are a common scenario encountered by psychi-
atrists during their practice. Although the precise degree of rep-
resentation is uncertain, an overrepresentation of offenders with
mental illness in the judicial system is evident [10]. A significant
correlation between major psychiatric disorders and violence has
been highlighted in various studies [11– 13]. This correlational rela-
tionship, however, should be interpreted with caution as comorbid
substance use disorder seems to play a major role. According to a
meta- analysis, the risk of homicide is nearly ten times higher among
individuals with schizophrenia than the general population; never-
theless, substance use disorder comorbidity appears to mediate
that excess risk [12]. Furthermore, it has been reported that almost
half of Swedish homicide offenders who had been evaluated for a
secondary psychiatric diagnosis had a comorbid substance use dis-
order [11]. Conversely, Joyal et al. [13] concluded that even without
substance use disorder, major psychiatric disorders, particularly
schizophrenia, are related to interpersonal violence. Although indi-
viduals with schizophrenia have a higher rate of committing a crime
than the general population, it has been suggested that the risk
of offensive behavior among individuals with schizophrenia is less
than those with antisocial personality and substance use disorders
[14, 15]. It has been shown that individuals with cluster B personal-
ity disorders were ten times more likely to be involved in a criminal
conviction [16]. Within the cluster B personality disorders, it has
been denoted that individuals with borderline personality disorder
carry a high risk for behaving violently, with up to 73% of those en-
gaging in violent behavior [17]. Additionally, a study conducted by
Ogloff et al. [18] suggested that 50%– 80% of the prison population
may display antisocial personality disorder.
While not all patients with mental illness commit crimes, spe-
cific psychiatric symptoms have been regarded as strong predictors
for criminal behavior, including persecutory delusions, command
hallucinations, impaired appreciation of committed acts, poor im-
pulse control, as well as noncompliance to medications [19– 21].
Furthermore, there are several sociodemographic factors presumed
to predict violence and crime in patients with mental illness, such
as male sex, violence prior the admission, prolonged hospitalization,
and cognitive impairment [22]. It is of paramount importance that
the legislative structure and forensic committees satisfy the need
for psychiatric evaluation and treatment in addition to public safety.
However, different countries have different guidelines and protocols
for forensic psychiatric assessment depending upon local legislation
and socio- cultural construct [23].
During the scientific flourishing in the Islamic golden age, medie-
val Islamic physicians were among the first in the world to diagnose
and treat schizophrenia. Furthermore, mental health hospitals in
Baghdad (750 AD) and Cairo (800 AD) were among the first founded
mental health facilities in the world [24]. Notwithstanding, the cur-
rent forensic psychiatric training and services are not widely estab-
lished and poorly organized in many of the Arab countries [25– 27].
Moreover, the substantial body of literature on criminal behavior
among people with mental illness mainly comes from the Western
world, while Arab data and research are scarce and not contributing
to the field, except putting a small dent in the ocean of knowledge
[26]. The population of the world is quite heterogeneous. In other
words, the sociodemographic characteristics and socio- cultural
construct, and other individual entities may differ significantly from
one region to another; consequently, these significant differences
should be considered when conducting any study. Similarly, studying
criminality among patients with mental illness should consider the
heterogeneity among different populations.
The present paper aims to analyze research published on criminal
behaviors among individuals with mental illness in Arab countries.

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This review focuses on two dimensions. The first one is to evaluate
sociodemographic, clinical, and other characteristics of individuals
evaluated by forensic psychiatric committees. The second dimension
is to identify various aspects that may reinforce criminality among
patients with mental illness. Herein, we map the literature to under-
stand the various characteristics of offenders with mental illness in
the Arab world.
2 | METHODS
In this paper, we designed a search strategy to identify relevant lit-
erature. Documents found in Scopus, Web of Science, and PubMed
were searched for articles concerning criminality among individuals
with mental illness in the Arab world. The following search term was
applied (Table S1): ALL ("schizophren*" OR "psychosis" OR "brief psy-
chotic episode" OR "schizoaffective" OR "schizophreniform" OR "manic
episode with psychotic features" OR "bipolar" OR "mania" OR "with
psychotic features" OR "anxiety with psychotic features" OR "mental ill-
ness" OR "psychotic features" OR "personality disorder with psychotic
features") AND ALL ("crim*" OR "homicide" OR "forensic" OR "Offense"
OR "criminal recidivism" OR "offending behavior" OR "filicide" OR "mur-
derer") AND AFFILCOUNTRY ("Arab*" OR "Egypt" OR "Algeria" OR "Iraq"
OR "Comoros" OR "Jordan" OR "Kuwait" OR "Lebanon" OR "Oman" OR
"Palestine" OR "Qatar" OR "Saudi Arabia" OR "Syria" OR "Djibouti" OR
"United Arab Emirates" OR "Libya" OR "Tunisia" OR "Mauritania" OR
"Morocco" OR "Somalia" OR "Sudan" OR "Yemen"). All available re-
sults were searched, spanning from database inception until the 4
October 2020.
Based on the PRISMA statement, the selection criteria were
developed [28]. The specific focus of the search was the existing
body of literature on mental illness and criminal behavior in the field
of medicine and social sciences. The spectrum of the search then
narrowed to involve psychiatry, psychology, and forensic medicine
fields. No time restriction was applied in the process of inclusion.
The Arab countries were exclusively considered. Therefore, all ar-
ticles from any other region were excluded. Titles/abstracts of the
articles were evaluated to verify the relevance. After checking the
duplicates, 101 articles were removed. At this stage, a total of 923
articles were excluded, while 60 records were extracted.
The review focused exclusively on original articles of research;
thus, literature reviews, case reports, thesis, and conference paper
abstracts were excluded. Original articles regarding the character-
istics of mentally ill offenders were the main focus. The articles’
full texts were assessed and analyzed to maintain the quality of the
included academic literature. This review is limited to the studies
published in the English language; therefore, a total of 21 articles
published in the French language were excluded from the study.
Based on the inclusion and exclusion criteria, each article was as-
sessed, and a total of 20 articles were selected.
At the stage of data extraction, 20 articles were included. The
characteristics of the extracted papers were as following:
• Original research
• Published in English
• Addressed characteristics of offenders with mental illness
• Conducted in any Arab country
3 | RESULTS AND DISCUSSION
The search generated a total of 1081 hits. Results were recognized
with Scopus (n = 838), PubMed (n = 182), and Web of Science (n = 61).
Additional three records were identified by mapping the references
of the included studies. After removing 101 duplicates, the remain-
ing 983 articles were checked for relevance; of those, 923 articles
were excluded. Afterward, the full- length of the remaining 60 ar-
ticles were evaluated for eligibility, and 40 articles were excluded.
Eventually, a total of 20 publications met the inclusion criteria and
were included in the current review (Figure 1) [29– 48].
The 20 analyzed articles span between 1975 and 2020. The in-
cluded papers were originated from seven different Arab countries.
Half of the investigated articles originated in Kuwait (n = 4) and
Egypt (n = 6); the remaining studies originated in Iraq (n = 3), Saudi
Arabia (n = 2), Tunisia (n = 2), Jordan (n = 2), and Algeria (n = 1).
3.1 | Characteristics of individuals evaluated by
forensic psychiatry committees
In this section, we discuss nine articles (n = 9) out of 20 included
articles that are concerning the characteristics of offenders referred
for psychiatric assessment (Table S2). The experiences of six differ-
ent countries were discussed. The reports were originated in Kuwait
(n = 2), Saudi Arabia (n = 1), Iraq (n = 3), Jordan (n = 1), Algeria (n = 1),
and Egypt (n = 1).
3.1.1 | Gender distribution
Across all studies, male subjects were overrepresented by a sub-
stantial margin. The percentages of male subjects ranged between
86% and 100% [29– 37]. This finding is in harmony with the find-
ings reported by several articles that originated in the West [49, 50].
Worth mentioning, in Arab culture, men, in general, tend to be more
outgoing and have more social interaction; thus, any behavioral dis-
turbance would be more easily detected in males than females.
3.1.2 | Other sociodemographic characteristics
In Kuwait, slightly above two- thirds (69%) were aged between 20
and 39 [29]. Unemployed individuals comprised 23% of the total
[29]. Individuals received intermediate education or below rep-
resented 74% of the sample [29]. Single individuals represent half

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of the sample (50%), while 17% were divorced [29]. In 1992, Fido
et al. [30] reported that the majority of subjects (73.9%) aged 20–
40 years. The majority of subjects had more than 4 years of educa-
tion, whereas 26% had less than 4 years [30]. More than two- thirds
(69.6%) of subjects were employed [30]. Single and divorced subjects
constituted two- thirds (66.6%) of subjects [30]. Previous psychiatric
record was reported in 66% of subjects and 34.8% of these had a
past criminal record [30].
In Saudi Arabia, the mean age of the study population was
31.33 years [31]. Murder and financial crime groups were having a
significantly higher mean age [31]. Low educational level, defined as
8 years or less of formal education, was found in 51% of the cases.
On the other hand, a higher education (>11 years) was found in
11% of the sample [31]. About two- thirds of the cases were singles
(64%) [31]. Individuals who committed a violent or simple offense
(e.g., disobedience of parents, traffic violations) showed a signifi-
cantly higher rate of singleness [31]. A total of 34% of cases were
unemployed, which is predominantly noted in the robbery cases
[31]. Previous contact with mental health services was observed in
58% of the sample with a mean of 18.7 ± 5.2 months; murder and
robbery groups were having significantly lower means (9.5 ± 2.3 and
10.5 ± 5.2, respectively) [31].
In Iraq, those aged 20– 40 constituted the largest proportion of
the offenders (55.7%) [32]. A large proportion of the sample (81%)
had a low education level (primary school education or less) and no
job (24.3%) [32]. Just below two- thirds (64.3%) of the sample were
married, while single individuals represented 30% of the sample [32].
In 2009, Ibrahim et al. [33] only reported the sociodemographic of
the group with schizophrenia. Age range 20– 40 constituted 57% of
the group [33]. Primary school education or less was found in 45% of
the group [33]. Single subjects represented 27% of the group [33]. A
long history of mental illness is stated by over two- thirds of patients
[33]; this may be attributed to the shortage of medical services and
cultural tradition that the individuals with psychiatric symptoms
first seen by native healers, which may extend the duration before
families seek mental health care. Therefore, this might reflect that
homicidal behavior in individuals with mental illness are a late ac-
companiment. The study demonstrates a higher rate of murderers
among offenders of urban residence [33]; this could be attributed
to the fact that in rural areas, psychiatric services might not be ac-
cessible and available leading to under detection and consequently
underreporting and representation. In 2007, Muslim et al. [34] re-
ported that over half of the offenders (58.46%) were aged 20– 39.
Primary educational level or less were found in 63% of the sample
and most of the offenders were unemployed [34]. Single (43%) and
married (43%) individuals were equally represented [34]. Previous
contact with mental health services was observed in 87.6% of the
sample [34].
In Jordan, younger age group [18– 27] represented the majority
of murderers and attempted murderers [35]. Regarding offenders
FIGURE 1 Study selection for review
– PRISMA flowchart

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ALBARBARI et AL.
with mental illness, married (51.3%) and unmarried (49.7%) subjects
were almost equally represented [35]. Previous contact with mental
health services was observed in 48.6% of offenders with mental ill-
ness [35].
In Algeria, the mean age was 30.6 years [36]. Regarding the ed-
ucational level, 68.9% of subjects attended school and a total of
82.8% were employed [36]. Single individuals represented 58% of
the sample [36]. Previous psychiatric record and previous criminal
record were reported in 17% and 19.3% of the sample, respectively
[36].
We notice that low educational level and unemployment were
frequently reported in the included studies. This might suggest that
low educational level and unemployment have a role in fostering
criminal behaviors. Similar associations have been highlighted in the
literature [49– 51]. Additionally, many factors that raise the crimi-
nality among individuals with mental illness are equivalently shared
with the general population.
3.1.3 | Presence of mental illness
Psychiatric disorders were diagnosed in the majority of individu-
als evaluated by forensic psychiatry committees with frequencies
ranging between 37% and 100% [29– 32, 35– 37]. The percentage
of individuals who were evaluated by forensic psychiatry commit-
tees and found not to suffer from any mental illness ranged between
0% and 62.2% [29– 32, 35– 37]. In two out of the nine discussed
studies, substance use disorder was the most commonly diag-
nosed disorder among individuals evaluated by forensic psychiatry
committees, followed by psychotic disorders [29, 31]. Conversely,
psychotic disorders were predominant diagnosis in the rest of the
studies [30, 32– 37]. Due to the heterogeneity of the involved sam-
ples, the aforementioned results should be interpreted with caution.
Notwithstanding the high prevalence of substance use reported by
many of the included studies in this review, three out of nine arti-
cles discussed in this section did not report the presence or absence
of substance use [32, 34, 35]. Noteworthy, underreporting of sub-
stance use may exaggerate the strength of the relationship between
mental illness and criminal behavior.
In Kuwait, psychiatric disorder was found in 83% of subjects [29].
Substance use disorder (41%) was the most commonly diagnosed
disorder (as comorbid in 36%), followed by psychosis (35%), person-
ality disorder (35%), and mood disorders (20%) [29]. The absence of
psychiatric disorder was noted in 15% of the offenders [29]. In 1992,
89.7% of referred prisoners were diagnosed with mental illness [30].
The predominant diagnosis was personality disorder (27.5%), fol-
lowed by schizophrenia (26.1%), substance use disorders (18.8%),
mania (5.8%), intellectual disability (5.8%), depression (4.3%), and
fictitious disorders (1.4%) [30]. The absence of psychiatric disorder
was noted in 10.3% of the offenders [30].
In Saudi Arabia, 90% of referred subjects were found to have
a mental illness [31]. Consistent with Alhumoud et al., the pre-
dominant diagnosed disorder was substance use disorder (56%),
followed by schizophrenia (13%) and antisocial personality dis-
order (10%) [31]. Additionally, substance use disorder was the
most common comorbid diagnosis, particularly amphetamine use
disorder [31]. Mental illness was not diagnosed in 10% of the
sample [31].
In Iraq, Hummadi et al. [32] found that 60% of evaluated indi-
viduals who were convicted of murder have a mental illness. The
most diagnosed disorder was psychotic disorder (32.9%), followed
by personality disorder (17.1%), and neurotic disorder (8.6%) [32].
On the other hand, slightly above one- third (38.6%) of the offend-
ers were free of any mental illness [32]. Substance use was not
reported in the study [32]. The study conducted by Ibrahim et al.
[33] included offenders (committed homicide) who were already
found to have a mental illness after forensic psychiatric evalua-
tion. Individuals with schizophrenia comprised 44% of the offend-
ers, followed by personality disorder (31.35%), delusional disorder
(6.77%), bipolar (2.54%), intellectual disability (5.08%), psychotic
depression (8.47%), and epilepsy (1.69%) [33]. Furthermore, about
33% of the total subjects and 31% of individuals with schizophre-
nia had a history of substance use [33]. More than 2 years history
of schizophrenia was seen in (60%) offenders with schizophrenia
[33]. As Ibrahim et al, Muslim et al. [34] included offenders who
were already found to have a mental illness after forensic psychiat-
ric evaluation. Schizophrenia represented 78.4% of the diagnosed
disorders, followed by delusional disorder (12.3%), bipolar disorder
(3.07%), psychotic depression (3.07%), epilepsy (1.53%), and intel-
lectual disability (1.53%) [34]. Substance use was not reported in
the study [34].
In Jordan, psychiatric disorder was found in 84% of the sample
[35]. The most commonly diagnosed disorder was schizophrenia
(34%), followed by anxiety disorder (13.6%), personality disorder
(11.4%), paranoid disorder (9%), epilepsy (6.8%), affective disorder
(4.5%), and mental subabnormality (4.5%) [35]. Psychiatric disorder
was not diagnosed in 15.9% of the offenders [35]. Substance use
was not reported in the study [35].
In Algeria, Touari et al. [36] reported the lowest prevalence of
mental illness (37%) across all the included studies, which could be
attributed to the substantially larger sample size. The study primarily
aimed to measure the frequency of psychosis [36]. Psychosis was
diagnosed in 13% of the total subjects. Other disorders, such as
personality disorder, depression, and dementia, were found in 24%
of the total subjects [36]. Three variables were determined to be
significantly associated with psychotic offenders, and were as fol-
lows: older subjects, previous psychiatric history, and not raised by
the two parents [36]. Surprisingly, less the 1% of the subjects re-
ported substance use [36]. The absence of mental illness was found
in 66.6% of the subjects [36].
In Egypt, all the evaluated subjects were found to have a men-
tal illness (100%) [37]. Schizophrenia was diagnosed in 90% of
the subjects, while organic psychosis (5%), and intellectual dis-
ability (5%) accounted for the rest [37]. Regarding concomitant
substance use, repeated alcohol use was reported in only a single
subject [37].