Chapter 28: Forensic Psychiatry

28.1: Introduction

• Forensic psychiatry — a subject dealing with the application of knowledge of psychiatry in the administration of justice.
• The recognition of the existence of mental disorders can be traced to ancient times. Certain reliable facts that may be considered here are:
  • Hippocrates (466-375 BC) taught that the brain is the seat of the mind.
  • The early Roman law, the Justinian Code, treated insanity as a special entity.
• The terminology of noncomposmentis or unsoundness of mind covers all disorders of the mind.

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28.2: Mental Health Act

• The Mental Health Act (MHA), is an Act to consolidate and amend the law relating to the treatment and care of mentally ill persons, to make better provisions with respect to their property and affairs, and for matters connected therewith or incidental thereto.
• To regulate admission to psychiatric hospitals or psychiatric nursing homes of mentally ill persons who do not have sufficient understanding to seek treatment on a voluntary basis, and to protect the rights of such persons while being detained;
• To protect society from the presence of mentally ill persons who have become or might become a danger or nuisance to others;
• To protect citizens from being detained in psychiatric hospitals or psychiatric nursing homes without sufficient cause;
• To regulate responsibility for maintenance charges of mentally ill persons who are admitted to psychiatric hospitals or psychiatric nursing homes;
• To provide facilities for establishing guardianship or custody of mentally ill persons who are incapable of managing their own affairs;
• To provide for the establishment of Central Authority and State Authorities for Mental Health Services;
• To regulate the powers of the Government for establishing, licensing, and controlling psychiatric hospitals and psychiatric nursing homes for mentally ill persons;
• To provide legal aid to mentally ill persons at State expense in certain cases.
• Chapter I of MHA: Deals with various terminologies and defines them.
  • Medical officer: Refers to a Gazette Medical Officer in government service appointed by the State Government to be a Medical Officer for purpose of this Act.
  • Medical officer in charge: A Medical Officer who for the time being is in charge of a psychiatric hospital or nursing home.
  • Medical practitioner: Refers to a person with recognized medical qualification under the provisions of the Act.
  • Mentally ill person: A person suffering from mental disorders other than mental retardation, needing treatment.
  • Mentally ill prisoner: A mentally ill person, ordered for detention in a psychiatric hospital, jail, or other safe custody.
  • Psychiatric hospital or nursing home: A hospital for mentally ill persons, maintained by the Government or private party with facilities for outpatient treatment and registered with appropriate Licensing authority.
  • Psychiatrist: Refers to a medical practitioner possessing a postgraduate degree or diploma in psychiatry recognized by IMC declared by the State Government for the purpose of this Act.
  • Reception order: Refers to an order for admission and detention of a mentally ill person in a psychiatric hospital or nursing home.
  • Relative: includes any person related to a mentally ill person by blood, marriage, or adoption.
• Chapter II of MHA — Provides the procedures for the establishment of mental Health Authorities at the Centre and State.
• Chapter III of MHA  — Lays down the guidelines for the establishment and maintenance of psychiatric hospitals and nursing homes.
• Chapter IV of MHA  — Provides the procedures for the admission and detention of a mentally ill patient in a psychiatric hospital or nursing home.
• Chapter V of MHA  — Provides formalities for inspection, discharge, leave of absence, and removal of mentally ill persons.
• Chapter VI of MHA  — Provides methods of judicial inquisition regarding alleged mentally ill persons possessing property, and how such property be managed.
• Chapter VII of MHA  — Provides procedures for the protection of the human rights of mentally ill persons.
• Chapter IX of MHA  — Provides the penalties for infringement of guidelines.
• Chapter X of MHA  — Deals with miscellaneous matters under the Mental Health Act.

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28.3: Current Concept of Forensic Psychiatry

• A mentally ill person should be treated like any other sick person without any stigma attached to such illness
• The law assumes that a person who is mentally ill is not responsible for his or her actions and therefore if such a person commits a crime, he or she is not to be punished for it.
• The law presumes that every person is mentally sound unless he or she is proven mentally disordered.

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28.4: Symptoms of Mental Illness

• Affect — the %%outward manifestation of a person’s feelings, emotions, tone or mood%%.
• Abreaction — a %%process of bringing to conscious awareness%%, previously suppressed unconscious conflicts and emotions.
• Aphasia — the %%loss of ability to express meaning%% by the use of speech or writing or to understand spoken or written languages.
• Cognition — refers to %%higher mental functions%%, e.g. memory, intelligence, concentration, orientation, etc.
• Confabulation — %%purely imaginary events or fabrications that fill the gap of pathological loss of memory%%. In other words, it comprises of false memory that the patient believes to be true.
• Delirium — is defined as an %%acute confusional state%%.
• Delusion — defined as %%a false, but firm belief in something that is not a fact%%.
  • Hypochondriacal delusion: A person feels that %%something is wrong in his or her body, though he or she is healthy%%.
  • Delusion of poverty: A person thinks he or she is %%poor/pauper, though he or she is rich.%%
  • Nihilistic delusion: A person declares that he or she %%does not exist and the world also has no existence%%, etc.
  • Delusion of grandeur: The person imagines that %%he is rich/and famous, wherein he is actually poor/and inconsequential%%.
  • Delusion of persecution (paranoid delusion): A person thinks that his or her %%nearest and dearest relatives are trying to poison or kill him or her%%.
  • Delusion of reference: A person believes that people, things, or events happening around him or %%she is referred to him or her in a special or indirect way%%.
  • Delusion of influence (control): A person feels that he or she is %%controlled by an outside power%%, agency, radio, hypnotized telepathy, etc.
  • Delusion of infidelity: A person i%%magines that his/her spouse is unfaithful%%.
  • Delusion of self-accusation: A person keeps on %%blaming himself/ herself for trivial incidents that happened in the past%%.
  • Erotomania (Clerambault-Kandinsky Complex): Common among females, in which she is convinced that a particular individual, especially her %%superior officer or her employer, is in love with her%%.
  • Pseudologia phantastica: A variation of this is Munchausen’s syndrome, in which the person is %%convinced that he/she is seriously ill%%, and visits doctor-to-doctor, hospital-to-hospital in a vain attempt to diagnose the non-existing illness.
  • Bizarre delusion: is an %%outrageous delusion, which can take various forms%%.

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28.5: Déjà Vu

• Dèjá vu — a %%sense of familiarity with unfamiliar surroundings%%.
• Disorientation — an %%impairment of the understanding%% of temporal, spatial or personal relationships, e.g. data given by such patients about time, place, people, etc., will be totally wrong.
• Fugue — defined as a %%state of disturbed consciousness%% with which a patient performs some acts. Though he or she looks apparently normal while doing the act, on recovery he has no recollection of events.
• Hallucination — defined as a %%false perception without sensory stimulus%%.
  • Visual hallucinations: (more common) Person imagines that a lion or a tiger, etc attack him or her when %%none of them exists in front of him or her%%.
  • Auditory hallucinations: A person %%hears voices or imagines that another person is speaking to him%% or her when no one is present.
  • Olfactory hallucinations: A person %%smells pleasant or unpleasant odors%% when nothing exists in reality.
  • Gustatory hallucinations: A person feels %%a good or bad taste in the mouth%%, though no food is actually served.
  • Tactile hallucinations: A person imagines that %%insects are crawling under his or her skin%% or bed when actually there are none.
  • Trichotillomania: A person has an %%irresistible urge to pluck his/her own hair%%.
• Illusion — defined as a %%false interpretation of an external object or stimulus%%, which has a real existence of its own, e.g. mistaking a stick for a snake.
• Insight — %%awareness of one's own mental condition%%, characterized by significant basic changes in future behavior and personality.
• Intelligence quotient — the %%intellectual capacity of an individual in relation to his or her chronological age%%. It is expressed as a percentage.
• Lucid interval — defined as a %%period in the course of mental illness during which there is a complete cessation of symptoms of insanity%% and the person is considered perfectly normal mentally.
• Mood — the %%pervasive emotion or feeling, which is sustained%%.
• Neurosis — an emotional disorder in which the patient %%does not lose touch with reality%%.
• Obsession: A person will have a symptom of a single idea, thought, or emotion entertained constantly and continuously, which %%persists in spite of recognizing it as irrational and all efforts being made to drive it from the mind%%.
• Panic — an acute, intense, %%overwhelming episode of anxiety%% associated with feelings of impending doom.
• Phobia — an excessive or %%irrational fear of an object, situation, or activity%%.
• Psychopath — a personality disorder, wherein the person is neither mentally ill nor defective but %%does not conform to be normal due to failure to adopt normal ethical standards%% of behavior in society.
• Psychosis — a mental disorder, which is %%severe and characterized by withdrawal from reality and living as if in another world%%, a world of fantasy with delusions and hallucinations.
  • The Psychotic Killer: Such a person is incapable of knowing the nature of his act or his judgment is faulty due to delusion and hallucinations.
  • The Psychopathic Killer: The killing may be unintentional due to loss of control.
• Stupor — a %%state of akinesis and mutism%%, with complete suppression of speech, movement, and action with no disturbance of consciousness.
• Trance — a state of %%altered consciousness%% often with the absence of voluntary movement or automation as in hypnotism/epilepsy.
• Twilight state — a state of %%diminished awareness of acts of relatively short duration%%; the actions performed during the state leaves little or no subsequent memory.
• Undue influence — defined as %%physical or mental pressure of such degree that a person is deprived of his or her privilege to exercise his free will%%, e.g. a son refusing to give his father a painkiller to relieve the pain of surgical amputation unless he signs the will be bequeathing all his property to his name.

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28.6: Dementia

• Dementia — a type of organic psychosis, wherein the mind, after reaching a certain stage of development, begins to deteriorate.
• Organic Dementia — due to localized or diffuse brain lesions.
• Senile Dementia — due to old age and cerebral arteriosclerosis.
• Other Types of Dementia
  • Crenty field Jacob’s disease,
  • Pick’s disease,
  • Dementia due to head injury,
  • Anemia,
  • Hyperthyroidism, and
  • Infective (Syphilitic and HIV).
• Drugs that can produce psychoses are:
  • Alcohol
  • Heroin
  • Morphine
  • Cannabis indicia
  • Cocaine
  • D-lysergic acid diethyl amide (LSD)
• Mental disorders produced by alcohol are included under this and they are:
  • Delirium tremens and acute confusion
  • Korsakoff’s psychoses (confabulation)
  • Alcohol dementia
  • Sexual jealousy and crime
• Both can produce progressive mental deterioration leading to:
  • Loss of interest in the environment.
  • Lowered intellectual efficiency.
  • No self-respect and trust.
  • May commit any crime to get the drug.
• In cannabis psychosis, insanity can develop called hashish psychosis characterized by:
  • Addiction.
  • The hallucination of sensuous type.
  • Delusion of grandeur/persecution.
  • Sexual jealousy and crime.
  • Run-amok: The person will kill first his enemy and then everyone else on his way and finally commands suicide.
• Cocaine Psychosis can be characterized by:
  • Delusion of persecution.
  • Hallucinations of tactile type (cocaine bugs) and visual type.
  • On prolonged use, it can lead to both mentals as well as physical deterioration.
• In LSD psychoses, a condition called bad trip can develop which is characterized by:
  • Acute anxiety
  • Depersonalization
  • Psychotic episode persists for months
  • On prolonged use, it can lead to permanent damage of brain cells.
• Confusional State Psychoses: The patient presents with a state of confusion and various causes leading to this disorder are excess of physical/mental fatigue, acute infectious diseases, epilepsy, childbirth and other stresses of life, and trauma (head injury).

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Psychosis Following Epilepsy

• Pre-epileptic confusional state
  • It may commence a few days before onset of the fit development of convulsions.
  • Mood irritability
  • Clouding of consciousness
  • Delusions and hallucinations under which, he/she may perform a crime.
• Masked or psychomotor epilepsy
  • Here the patient does not show any convulsions.
  • He or she undergoes a mental disturbance, which replaces the convulsion completely, and these mental disturbances may bring about certain outrageous acts such as the murder of a person who is usually a stranger.
• Post-epileptic automatism
  • It commences after convulsions, for instance in petitmal epilepsy, the patient will have a lapse of consciousness, and performs acts without volition, which cannot be recollected after gaining consciousness.

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28.7: Schizophrenia

• Schizophrenia — a type of functional psychosis, is said to be a disorder of thought and disintegration of emotional stability.

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Two Phases of Schizoprenia

• Early phase: Usually presents with one of the following predominating at a given stage.
  • Disorder of thought: Misinterpretations of reality due to hallucinations, illusions, delusions, etc., making him dwell in his own world.
  • The disintegration of emotional stability: change in behavior, e.g. withdrawn, depressive/violent, etc.
• Late phase: As the disease progresses, it makes the person withdrawn from the environment with:
  • Lack of drive and ambitions
  • Gives up all hobbies
  • Loss of interest in friends
  • Stands indifferent to his or her surroundings, etc.

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Four Subtypes of Schizoprenia

1. Schizophrenia simplex: The patient will show all clinical findings described above, but the symptoms that help in diagnosing the type are by observing his/her reactions to happenings of great importance as if they are not concerned with him/her.

2. Hebephrenic schizophrenia: The patient is very much disorganized by hallucinations, illusions, and delusions, etc., that he or she may become impulsive and commit crimes.

3. Paranoid schizophrenia: In this type, the patient will retain much of the original personality but will suffer from distortion of thought with persecutory or grandiose delusions and hallucinations to such an extent that he/she will pose a distorted view of the world around.

   1. Othello Syndrome — a dangerous state of morbid jealousy.

4. Catatonic schizophrenia: In this type, patients will have mood disorders characterized by rigidity stupor, agitation, bizarre posturing, and repetitive imitation of movements or speech of other people. They are at risk of malnutrition, exhaustion, and self-injury.

5. Undifferentiated schizophrenia: In this type, the patient will have characteristic positive and negative symptoms of schizoma but do not meet the specific criteria of other subtypes.

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Paranoid Status

• Paranoid state — a type of functional psychosis.
• The patient presents purely with a variety of delusions with or without hallucinations, but there is no disturbance of mood and thinking, and their personality is preserved well.

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Two Types of Paranoid Status

• Paranoia: Age of onset – 25 to 40 years. This type is common in males. This is a rare illness of the mind, wherein the patient develops gradual delusions of persecution of systematized nature, having a grave criminal association.
• Paraphrenia: Age of onset – 45 years or so. This is a rare type of mental illness, wherein the patient develops systematized delusions, ideas of reference, and vivid hallucinations of auditory type, commonly.

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28.8: Diagnosis of Mental Illness and Certification

• Preliminary Particulars

  • Record the name, age, sex, marital status, education, occupation, income, address, religion, socioeconomic background, etc of the patient.
  • Record all particulars of the accompanying person especially name, age, sex, and address, whether staying with the patient or not, etc.
  • Also note down the statement of the accompanying person in addition to patient’s statement.
  • Note two identification marks such as moles, birthmarks, etc.

• Presenting Complaints: Record the presenting complaints with particular reference to onset of present illness, duration, course, precipitating, aggravating, maintaining or relieving factors, etc.

• History of Present Illness

  • Note down details on when was the last time patient appeared normal, evolution of symptoms in a chronological order.
  • Record about details on any suicidal intentions/attempts, insomnia or disturbances of sleep, appetite, sexual functions, etc.

• Past History

  • Note down any similar or other major/ minor illness and treatment received in the past.
  • Elicit about alcoholism or other drug abuse in the past.

• Family History: History of chorea, epilepsy or frank mental illness, etc, may be found among the parents or siblings of the patients, as most of the mental illnesses are hereditary in origin, seen in members of the same family.

• Personal History

  • Elicit proper childhood history, play history, friends, puberty, menstrual and obstetrics history if female, history of any head injury, drug addiction, certain problems, which are unbearable such as domestic difficulties, emotional shock, frustration in life, love, sex, etc., may be elicited as precipitating factors in the onset of mental illness.
  • Record also about the premorbid personality details such as the interpersonal relationships, attitude towards self and others, attitude towards work, religious beliefs and moral attitudes, mood particulars, habits, fantasy life, leisure activities, etc.

• Physical Examination: Patient can present with deformities in the head or body, careless dressing style, abnormal walking manners, furred tongue, dry skin, moist palms and soles, rapid pulse, abnormally high body temperature, etc.

• Examination of Mental Status/Conditions

  • Memory test — ask him/her for the day, date, time, name and names of his relatives, etc. He or she will not be in a position to answer properly.
  • Power of reasoning and sound judgment — simple mathematical sums may be asked, which he or she will not be able to solve.
  • Handwriting will not be clean and clear but shabby.
  • Speech look for rate, quantity, volume, tone, flow and rhythm.
  • Conduct before, during and after the incidents — the patient may not be able to show any response to any incidents taking place around or may be reacting in his or her own way unconnected to the incident or happening.
  • Assessment of general appearance and behavior — general appearance can be assessed by the type of physique, build, height, weight, dress, hygiene, gait, posture, etc.
  • Cognition assessment — is done by looking for consciousness, orientation, attention, concentration, abstract thinking, etc.
  • Insight assessment — assess the degree of awareness and understanding of the patient regarding his illness.
  • Assessment on the ability to judge — done by assessing the ability to understand the situations correctly and act appropriately.

• Investigations

  • Following tests are useful
  • Complete medical toxicological screening tests
  • Drug levels
  • Electro-physiological tests
  • Brain imaging tests
  • Neuroendocrine tests
  • Genetic tests
  • Sexual disorder investigations, etc.

• Diagnostic Formulation

  • After complete psychiatric assessment, diagnosis and differential diagnostic assessment is done along with a proper treatment plan.

• Certification

  • A certification of a mentally ill by a doctor on single examination is not correct. Recommendations in issuing certificate for mental illnesses are as follows:

  • Conduct three consecutive examinations on three occasions.

  • Describe the actual clinical picture in the certificate.

  • Give clear-cut reasons of diagnosis made.

  • Rule out the possibilities of feigned insanity.

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Feigned Insanity

• Feigned insanity — defined as a condition wherein a person is pretending to be insane.
• Purpose:
  • To escape capital punishment by a criminal (criminal death sentences)
  • To avoid business transactions or deeds.
  • To quit service in military jobs.
• Several features suggestive of feigned insanity:
  • Onset sudden (with some motive)
  • Acts as insane only when observed
  • Symptoms are not of one type of insanity
  • Pretending insanity can lead to exhaustion
  • A malingerer as a rule is not dirty or filthy in habits. Usually keeps clean, eats well, etc.
  • A malingerer resents frequent examinations
  • It is impossible to feign insomnia for a long time
  • Feigned deafness and mutism.

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28.9: Restraint Mentally Ill

• Restraint of the mentally ill or insane — defined as keeping a dangerous insane person under lawful restraint in a mental hospital.
• In immediate restraint the patient needs to be restrained immediately. The following can be the indications to this:
  • When a person develops profound mental incapacity turning gravely dangerous to himself or others
  • Delirium due to disease
  • Delirium tremens
• Methods: Safely locking in a room, with the consent of the guardians or others. Consent is not necessary if there is no time to obtain it. However, he or she should release the person whenever he or she becomes no more dangerous.

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28.10: Admission to Psychiatric Hospital

• Voluntary or Direct Restraint: Here the mentally unsound person submits a written application directly to the officer in-charge of the hospital for admission and treatment.

• Reception Order on Petition: Here the insane is admitted to the mental hospital only if the following formalities are fulfilled:

  • Petition: It is an application to the magistrate in a prescribed form by a relative or a friend, who is taking care of the patient at least for a period of 14 days prior to date of petition writing.
  • A medical certificate from registered Medical practitioner stating that patient needs mental hospitalization for treatment.
  • A certificate from a gazetted medical officer who has examined the patient within 7 days prior to issuing the certificate specifying the need for hospitalization.
  • A doctor’s certificate mentioning physical fitness of the patient to travel.
  • Magistrate’s order of reception: Magistrate shall issue the order of reception and if there is a need he or she may personally come and examine the patient. This order holds good for 30 days.

• Reception Order other than on Petition

  • Wandering and dangerous lunatic
  • Police officer is authorized to arrest such patient and then produce before a magistrate.
  • Magistrate can issue reception order directly or in case of doubt he or she may send the patient for medical examination and then, issue reception order only if the patient is certified medically as mentally ill and dangerous.
  • Lunatic not cared for properly:
  • Police officer can produce a mentally ill person who is not properly cared for or cruelly treated by the relatives to the magistrate and a reception order can be sanctioned.

• Reception after Judicial Inquisition: If a person possessing huge property turns mentally ill, the high court or district court may pass an order of inquisition and arrange for:

  • Reception of the patient to a mental hospital
  • Proper care of his or her property
  • Arrangement for recovering necessary fees from the profits or income from property of the patient under court care.

• Reception of Mentally Ill Criminal: It is one who is mentally ill and has committed a crime or become mentally ill after being imprisoned. For such a patient’s reception presiding officer of the court issues order.

• Reception of the Escaped Mentally Ill: Such a patient can be readmitted to mental hospital by a police officer or any officer or servant of the hospital.

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28.11: Responsibilities of an Insane

• Civil Responsibilities

  • Management of Property.
  • Contracts.
  • Marriage and divorce.
  • Competency as a witness.
  • Validity of consent.
  • Testamentary capacity.

• Criminal Responsibilities

  • In law Criminal responsibility is defined as criminal liabilities due for punishment.
  • Law presumes that every person is sane and accountable for his or her actions until the contrary is proved.
  • Law also assumes that every person who is proved to being insane is not responsible for his actions.
  • According to Section 84 of IPC, nothing is an offense which is done by a person, who at the time of doing it, by any reason, is suffering from unsoundness of mind and is incapable of knowing:
  • The nature of the act done or,
  • What is done is either wrong or contrary to law.
  • Legal test — Defined as the test for insanity, which precludes responsibility for the commission of a crime. The test should provide evidence of:
  • Presence of mental illness or defect.
  • Presence of the same at the time of committing the crime.
  • Disease making the person unable to assess his or her acts as wrong or contrary to law.
  • Insanity and murder
  • Psychotic murderer (schizophrenic committing a murder)
  • Sexual killer
  • Psychopathic killer (hit man-killer)
  • Jealous killer (Othello syndrome)
  • Alcoholic killer (infidelity)
  • Insanity and other pleas
  • Please on somnambulism: It is a dissociated consciousness and crime committed during this is usually not willful or pre-planned.
  • Hypnosis and crime: A hypnotized person cannot be tricked to do immoral or dishonest acts.
  • Delirium (Hallucination and delusion): A delirious person committing a crime is not punishable.
  • Drunkenness and criminal responsibility: A person is not held responsible for any acts amounting to crime, under the influence of alcohol or such other intoxicative drugs, provided he was made to consume it without his knowledge.
  • Impulse: Irresistible forces compelling to do certain conscious acts without motive or forethought are not punishable if the impulsive disorder is due to some organic mental illnesses.

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