FORENSIC PSHYCHIATRY

Dr.Abhishek KarnAsst. Professor, Dept of Forensic

Medicine & Toxicology

• Psychiatry is the medical specialty devoted to the study and treatment of mental disorders—which include various affective, behavioural, cognitive and perceptual disorders.

• Forensic psychiatry: it deals with application of psychiatry in the administration of justice.

• Due to the lack of proper mental illness screenings & checkups for criminals, many mentally-ill people are punished the same way any other criminal would be and are deprived of much needed health care and facilities

• Affective disorder : psychiatric disorder in which the chief feature is a relatively prolonged affective change of an abnormal degree. E.g. depression and mania.

INSANITY• Is a spectrum of behaviors characterized by

certain abnormal mental or behavioral patterns.

• Condition of an individual who is suffering from some defect or d/s of mind which affects his personality, mental status, analytical faculties, emotional process & his relation & interaction with immediate/ total social environment.

Amnesia• loss of memory • May be seen in alcohol

intoxication & severe depression.

• Medico legal importance: It can be used as an offence (inadequate recall of what had happened)

• It should be distinguished from malingering in an attempt to avoid the consequences of the offence.

Automatism

• It is conduct that is performed by a person whose consciousness is impaired to such an extent that he is not fully aware of his actions.

• It is seen in epilepsy ,concussion or cerebral disease, hypoglycemia & somnambulism.

Delirium:• It is disturbance of consciousness where there is

impaired orientation, blunted critical faculties and irrelevant or incoherent thought content.

• The patient suffer from insomnia ,hallucination and disorientation.

• It is seen in mental unsoundness, drug intoxication, Dhatura poisoning and continuous high temperature.

Delusion

• It is fixed and false belief or erroneous judgment which can’t be changed by logical argument or evidence to the contrary.

• There are different types of delusions.1. Persecutory (paranoid):- believes people

around are planning to do some harm and even remark is looked upon suspiciously. E.g. In schizophrenia

2. Infidelity :- person believes his/her spouse to be unfaithful though he/she is not so infact and may even assault spouse/partner.

3. Reference :- the person believes that people, things, events etc., refer to him in a special way. He believes that even strangers in the street are looking at him and talking about him.

3. Nihilistic :- the person declares that he does not exist and world has come to an end.

4. Grandeur :- the person believes himself to be very rich but in fact he is not.

Medico legal importance

• Delusions are themselves not sign of insanity and indicate only cerebral disorganization.

• They effect the thoughts and actions which may lead to his committing criminal acts so they can’t be regarded as fully responsible for his action.

Dementia• It means degeneration of

mental faculties after full development.

• It may occur due to old age, Alzheimer’s disease involving brain, etc.

• loss of higher cognitive functions & social inhibition---sexual offences against children, shoplifting

Depersonalization

• The person does not believe in his own existence or identity.

• It occurs in schizophrenia and depressive psychosis.

Erotomania

• It is a delusion in which the person believes that someone is deeply in love with him/her.

Factitious disorder

• It is intentional production or feigning of physical or psychological symptoms which can be attributed to a need to assume the sick role.

Malingering• It is fraudulent stimulation or exaggeration of

symptoms.

• It differs from factitious disorder in that the production of symptoms is motivated by external incentives whereas in factitious disorder there are no external incentives but psychological need for the sick role.

Fugue state

• A state of altered awareness during which an individual forgets part or whole of his life, leaves home and wanders.

• It is seen in hysteria, schizophrenia & epilepsy.

Hallucination• It is a false sensory perception without any actual

stimulus. • It can be visual, auditory, olfactory, gustatory, tactile

and psychomotor.• A person suffering from hallucination maybe incited to

commit suicide or homicide.• Visual hallucinations are commonest in organic mental

disorders such as delirium tremens, schizophrenia, etc.• Auditory hallucinations are commonest in functional

disorders such as schizophrenia, delirium and psychotic mood disorders.

Illusion• These are false interpretation of sensory stimuli

often visual or auditory which has real existence.

• They maybe seen in normal persons, in dark or during emotional stress and in organic brain disease and maybe associated with hallucination.

• E.g. A dog maybe interpreted as a tiger.A rope maybe mistaken for a snake.

Impulse• Sudden uncontrollable desire to

do something without any motive or forethought.

• An insane person is incapable of weighing the consequences of the act and does it as soon as the idea occurs to him.

• He has no power to control it.

• It is seen in dementia, acute manias & epilepsy

Types of Impulses :

1. Kleptomania: irresistible desire to steal articles of little value.

2. Pyromania: irresistible desire to set fire to things

3. Mutilomania: irresistible desire to mutilate animal.

4. Dipsomania: irresistible desire for alcoholic drinks at periodic intervals.

5. Suicidal or homicidal impulses

6. Sexual impulses

Lucid interval

• It is the interval occurring in the course of mental disease when there is complete temporary cessation of symptoms.

• The person is legally liable for his actions.

• In mania and melancholia lucid intervals are common.

Mutism• There is complete loss of speech.

Obsession• It is anxiety reaction characterized by

preoccupation with certain thoughts and ideas.• The patient recognizes them as useless and tries to

get rid of them by persistent thoughts & acts but the thoughts return to his mind in spite of all his efforts to dispel them.

• Victim lives in constant fear of having done or having omitted to do something.

• E.g. The patient spends whole night in frequently seeing whether the door is bolted or not.

• Twilight states: It is state of diminished awareness of acts of relatively short duration of which he has no recollection.

• Oneirophrenia: It is a dream like state which may last for days or weeks. The patient suffers from mental confusion ,amnesia , illusions, hallucinations, disorientation and anxiety.

PSYCHOSES: • Types of mental illness arising out of mental

causes and not due to environmental or external factors.

• They are characterized by a withdrawal from reality & living in a world of fantasy.

• mainly two types: (a) organic psychosis (b) functional psychosis

A. Organic psychosis (a) Senile dementia(b) Presenile dementia(c) Cerebral tumour.(d) Cerebral trauma(e) Drug induced psychosis(f) Toxic psychosisg) Metabolic derangementh) Epileptic psychosis: pre-epileptic psychosis post-epileptic psychosis psychomotor epilepsy

B. Functional psychosis(a) Schizophrenia- a personality split disorderThought disorder-atustic thinking, loosening of

association, thought blockade, neologism .(b) Delusion(c) Affect disorder.(d) Disorder of behavior- withdrawal from reality,

self preoccupation, depersonalization, passivity of feeling

(e) Hallucination

Disorder of motor behavior: Simple schizophrenia Hebephrenia Catatonia Paranoid Schizo-affective psychosis Pseudo-neurotic Affective psychosis• Manic depressive psychosisManiac phaseDepressive phase

NEUROSIS

• Personality disturbances resulting from reaction to life situation

• Types: i. anxiety neurosisii. hysterical neurosisiii. phobic neurosisiv. obsessive-compulsive neurosisv. depressive neurosis

Persistent delusion disorder• Presence of delusion of the different type for more

than 3month. • Absence of significant hallucination• Absence of organic mental disorder or

schizophrenia,or mood disorder.

Acute and transient psychotic disorder • Acute onset within 48hr and gradual onset within 2

week, complete recovery with in 2-3 month

Suicide pacts:• It is a condition in which two people agree that at

the same time each will take his or her own life.• It should have to be distinguished from cases where

murder is followed by suicide.

Somnambulism: It means walking during sleep. It is state of

automatism.

Somnolentia: It is midway between sleep and waking.

• Catatonia:

It is characterized by alternating stages of depression ,excitement and stupor.

• Delirium tremens: It is psychotic condition in alcoholics which occurs due to sudden increase of dose and sudden withdrawal. There are tremor, Insomnia, mental confusion, loss of memory, disorientation and hallucination of horror.

• Korsakoff’s psychosis: It is a psychological and neurogenic deranged condition occurring in some chronic alcoholics where there is peripheral neuritis with polyneuritis, muscular degeneration with weakness, disorientation , some hallucination and retrograde amnesia.

• Drunkenness: It is the state of a person under the influence of alcohol such that he lost control to such an extent that he is unable to perform his duty in which he was engaged at the material time.

HUNTINGTON’S DISEASE• an inherited d/s---causes degeneration of

nerve cells in the brain. • broad impact on a person's functional abilities• results in movement, thinking (cognitive) &

psychiatric disorders.• can exhibit inappropriate sexual activities,

antisocial, cruel & violent behaviour

MEDICOLEGAL ASPECTS OF INSANITY

Civil Responsibility1. Management of property and affairs

If a mentally ill person is found incapable of managing his property and affairs, but is not dangerous to himself or to others, the court appoints a manager to look after his property, granting his necessary power.

The manager is paid for his service from the property or the income of the mentally ill person

2. Business Contract

• If one of the parties at the time of making a contract was incapable of understanding what he was doing due to insanity the contract is invalid.

• Contract entered into with a mentally ill person may be valid, if the other party can show that he didn’t know that the other party was mentally ill and that the contract is a fair contract.

3. Marriage Contract

• A marriage is considered invalid, if at the time of marriage either party- is incapable of giving valid consent due to insanity.- though capable of giving valid consent, has been suffering from such a kind or degree of mental disorder as to be unfit for marriage and procreation- has been suffering from recurrent attacks of insanity

4. Competency as a witness- An insane person is not competent to give

evidence if he cannot understand the necessity of telling the truth due to insanity.

- An insane person is competent to give evidence if he is able to tell what he has seen and understands the obligation of an oath

5. Consent The consent is invalid if it is given by an insane

person who is unable to understand the nature and consequences of the act.

6. Testamentary Capacityis the mental ability of a person to make a valid will.

• A person affected by an insane delusion can make a valid will if he delusion is not related in any way to disposal of the propertyPersons can make valid wills during lucid interval

• A will is considered valid even though the testator committed suicide shortly after making a will if there is no other evidence of mental disorder.

• A person of extreme age with defective memory can make a valid will unless their mind has become so impaired that they are unable to understand its nature and consequence.

• A will executed by a dying person during delirium would be invalid.

Criminal Responsibility

• A person may plead insanity to avoid :

→CONVICTION, if the accused was insane when the alleged crime was committed

→ TRIAL, when the accused is insane and cannot plead

→ CAPITAL PUNISHMENT, when a condemned prisoner is insane

The tests for determining criminal responsibility

1. Mc. Naughten Rule ( the legal test) - “an accused person is not legally responsible, if it is clearly proved, that at the time of committing the crime, he was suffering from such a defect of reason from abnormality of mind, that he did not know the nature and quality of the act he was doing or that what he was doing was wrong.”

• This is the guideline followed in British courts for consideration of the liability of a mentally ill person who commits a crime

2. Durham Rule (1954)“an accused person is not criminally responsible, if his unlawful act is the product of mental disease or mental defect.”

3.Curren’s Rule (1961)“an accused person is not criminally responsible, if at the time of committing the act, he did not have the capacity to regulate his conduct to the requirements of the law, as a result of the mental disease or defect.”

4. The Irresistible Impulse Test (New Hampshire Doctrine)

“an accused person is not criminally responsible, even if he knows the nature and quality of his act and knows that he is wrong, if he is incapable of restraining himself from committing the act, because of free agency of his will has been destroyed by mental disease.”

5. The American Law Institute Test (1972) “a person is not responsible for criminal conduct if at the time of such conduct, as a result of mental disease or defect he lacks adequate capacity either to appreciate the criminality of his conduct, or to adjust his conduct to the requirement of the law.”

Insanity and Murder

• If the mental disorder impairs the cognitive faculties of the accused, he is not held responsible for his acts.

• If insanity affects only emotions and the will, but not the cognitive faculties, the person is held responsible for his acts.

Doctrine of Diminished Responsibility

• If an unlawful act is committed by a person who is suffering from some degree of mental illness, should not be treated like a sane person who committed an unlawful act.

• According to this theory, such mentally ill persons have diminished responsibility.

contd….• Punishment for them for commission of and unlawful

act should be less.• This theory could not gain much popularity as it is

not much impressive, because the criminal responsibility of insane person should be considered in such a way as, it either recognizes the responsibility of the person committing the unlawful act or does not recognize his responsibility anyway

Responsibility of Intoxicated Persons

In Civil cases If any intoxicated person involves in any civil responsibility,

then the case will be considered according to the nature of the work and merit of the consequences.

In Criminal cases

• An intoxicated person may not be held responsible for his act, if at the time of commission, due to the effect of intoxication, he did not understand the nature and quality of the act and its consequences and legal position

• If the person has taken the intoxicating agent on his own and with a mind to perform the criminal act easily, he will be held responsible for its commission.

• Feigned Insanity: simulation of mental illness in order to avoid or lessen the consequences of a confrontation or conviction for an alleged crime.

Difference between True & Feigned Insanity

Examination and Certification of Insanity

Psychiatric History• A consistent scheme should be used

• The patient should be seen first

• Patient should be put at ease and a warm empathic relationship should be established

• Record patient’s responses verbatim

• Ask open-ended and non- directive questions

• Listen and show interest in patient

• Confidentiality should be maintained

Psychiatric assessmentIdentification data

• Name• Age• Sex • Marital status• Education• Occupation• Income• Residential and office address• Religion and socioeconomic background

In medico-legal cases, in addition, two identification marks should also be recorded.

InformantsInformants should be assessed on the following

parameters-

• Relationship with patient• Intellectual and observational ability• Familiarity with the patient and length of stay with

patient.• Degree of concern regarding the patient.

Presenting chief complaints

Both patient’s and informant’s version should be recorded.

Patients own word should be used. Following points should be noted-

• Onset of present illness.• Duration of present illness.• Course• Precipitating factors• Aggravating, maintaining and / or relieving factor

History of Present Illness

• When the patient was well last time• Time of onset• Symptoms of illness should be narrated

chronologically• The presenting complains should be expanded• Any disturbance in physiological functions like sleep,

appetite and sexual functioning should be inquired• Enquire about presence of suicidal ideation• Important negative history( h/o head injury)

Past Psychiatric and medical history

• H/o similar illness, or in the past• H/o psychotropic medication, alcohol and drug abuse

or dependence and psychiatric hospitalization.• H/o serious medical, surgical or neurological illness.

Treatment history along with response to treatment

Family History

• Family structure

• Family history of similar or other psychiatric or other serious medical illness

• Current social situation

Personal History

• Perinatal history• Childhood history• Educational history• Puberty• Menstrual and Obstetric history• Occupational history• Sexual and marital history

Premorbid Personality

• Interpersonal relationship• Use of leisure time• Predominant mood• Attitude to self and others • Attitude to work and responsibility• Religious belief and moral attitudes• Fantasy life• Habits

Physical Examination

• Detailed General physical and Systemic examination is must

• Physical disease etiologically important( for causing psychiatric symptomatology), accidentally co-existent, or secondarily caused by psychiatric condition is often present

Mental Status examination (MSE)I. Appearance and Behaviour II. SpeechIII. MoodIV. Depersonalization and DerealizationV. Obsessional phenomenaVI. DelusionsVII. Illusions and hallucinationsVIII. OrientationIX. Attention and ConcentrationX. MemoryXI. Insight

Reference : Oxford Textbook of Psychiatry

Mental Status ExaminationI. Appearance and behavior

General appearance – 1. Self neglect – alcoholism, drug addiction, depression,

dementia, schizophrenia 2.Bright colored clothes – manic pts. 3. Wt. loss – physical illness, anorexia nervosa,

depressive disorders

Facial appearance

1. In depressed patients -

2. In anxious patients -

3. In patients with Parkinsonian side-effects - elation, irritability and anger with unchanging

‘wooden’ expression of patients

Posture and Movement

• In depressed patient – sits leaning forward, head inclined downwards and gaze directed to floor

• In anxious patient – sits upright with head erect, often on the edge of the chair with hands gripping its sides

Social Behavior

• Maniac – often break social convention and are unduly familiar to people they don’t know well

• Demented patients – respond inappropriately to convention of medical interview or continue with their private preoccupation as if interview were not taking place

• Schizophrenic patients – behave oddly, some are overactive and socially disinhibited, some are withdrawn and others are aggressive

II. Speech• Maniac – fast rate, amount of speech is

increased• Depressed/Demented – long pause, short

answer with little spontaneous speech• Schizophrenic – lack of logical thread• Thought blocking – sudden interruptions• Flight of ideas- rapid shift of one subject to

others

III. Mood

• Mania – general warmth, euphoria, elation, exaltation and/or ecstasy

• Anxiety – anxious and restless• Depression – sad, irritable, angry and/or

despaired• Schizophrenia – shallow, blunted, indifferent,

restricted, inappropriate and/or labile

IV. Depersonalization and derealization

V. Obsessional phenomena Obsessional thoughts Compulsive rituals VI. Delusion

VII. Illusions and hallucination

VIII. Orientation

IX. Attention and concentration

• Digit forward and digit backward test• 100 – 7 test• 40 – 3 test• Count backward form 20 • Enumerate names of months in reverse orders

X. Memory

• Immediate retention and recall Digit span test - digit forward test - digit backward test

• Recent memory

• Remote memory

XI. Insight

• Interviewer should have a provisional estimate of how far the patient is aware of morbid nature of his experiences

Mini - Mental State Examination

Headings Score

Orientation 10

Registration 3

Attention and calculation 5

Recall 3

Language 9

Biological Investigations

• Medical screening – Hb, TLC/ DLC, Blood glucose, Mean Corpuscular Volume(MCV), Urinalysis, RFT, LFT, Thyroid function test, ECG, HIV testing

• Toxicology screen for – alcohol, cocaine, opiates, cannabis, BZD

• EEG – seizures, dementia, pseudoseizures vs. seizures• Brain imaging - CT scan – dementia, delerium,

seizures - MRI scan – dementia

Contd….• Biochemical tests –i. 5- Hydroxyindole acetic acid (5 - HIAA) –

decreased in depression, suicidal and/or aggressive behavior

ii. Platelet MAO – decreased in depression iii. Catecholamine levels – increased in organic

anxiety disorders• Sexual disorders investigations – papavarine test, serum

testosterone, penile doppler

Contd…

• Miscellaneous

i. Lactate provocation test – panic disorders

ii. Drug assisted interview (Amytal interview)- Unexplained mutism, dissociative stupor