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Forensic Psychiatry

Dr. S. K. Roy Chaudhary

Explain the term Forensic+ Psychiatry (Study & treatment of mental illness, emotional disturbance, and abnormal behaviour: soul, mind + healing) Explain Importance of Insanity in Forensic Medicine. Non-compos mentis, unsoundness of mind, lunacy, madness & mental derangement are synonyms The term "philosophical intoxication", for instance, was widely applied to the mental disorders diagnosed when people disagreed with the country's Communist leaders and, by referring to the writings of the Founding Fathers of Marxism–Leninism—Karl Marx, Friedrich Engels, and Vladimir Lenin—made them the target of criticism. Article 58-10 of the Stalin-era Criminal Code, "Anti-Soviet agitation", was to a considerable degree preserved in the new 1958 RSFSR Criminal Code as Article 70 "Anti-Soviet agitation and propaganda". In 1967 a weaker law, Article 190-1 "Dissemination of fabrications known to be false, which defame the Soviet political and social system", was added to the RSFSR Criminal Code. These laws were frequently applied in conjunction with the system of diagnosis for mental illness, developed by Academician Andrei Snezhnevsky. Together they established a framework within which non-standard beliefs could easily be defined as a criminal offence and the basis, subsequently, for a psychiatric diagnosis. The "anti-Soviet" political behavior of some individuals — being outspoken in their opposition to the authorities, demonstrating for reform, and writing critical books — were defined simultaneously as criminal acts (e.g., a violation of Articles 70 or 190-1), symptoms of mental illness (e.g., "delusion of reformism"), and susceptible to a ready-made diagnosis (e.g., "sluggish schizophrenia").^[8] Within the boundaries of the diagnostic category, the symptoms of pessimism, poor social adaptation and conflict with authorities were themselves sufficient for a formal diagnosis of "sluggish schizophrenia."^[9]

The psychiatric incarceration of certain individuals was prompted by their attempts to emigrate, to distribute or possess prohibited documents or books, to participate in civil rights protests and demonstrations, and become involved in forbidden religious activities.^[10] The religious beliefs of prisoners, including those of well-educated former atheists who had become adherents of a religious faith, was considered to be a form of mental illness that required treatment. The KGB routinely sent dissenters to psychiatrists for diagnosing to avoid embarrassing publiс trials and to discredit dissidence as the product of ill minds. The Russian Federation acknowledged that before 1991 psychiatry had been used for political purposes and took responsibility for the victims of "political psychiatry."^[

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Differences Between

Psychiatric Disorders

&

Insanity

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Introduction

Insanity is certified only by a court
An Insane person is not legally responsible for his acts.
Privileges of a common man are not allowed to him.
Special care in diagnosis, & treatment of insanity.
Duty to warn to include duty to protect- Tarasoff case

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Insanity, (Lunacy, Madness, Unsoundness of mind, Non-compos mentis)

Definition

When the illness interferes with a patient’s perception, thinking, and feeling so profoundly that what he says to his fellow men no longer makes any sense to them, he is regarded as insane or in medical language psychotic
It connotes a degree of mental disturbance so menacing and so disabling that the patient may be considered from legal point of view to be immune from certain responsibilities and may disallow him certain privileges that may require a degree of competence such as power to marry, make business contracts, ability to manage property, and may be enough criteria for compulsory hospitalisation (Modi)

Lunatic or Insane means:- Psychiatric disorder of such severity that a court holds that there is no criminal liability

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Mental Illness

Means a substantial disorder of thinking, mood, perception, orientation or memory that grossly impairs judgment, behaviour, capacity to recognize reality or ability to meet the ordinary demands of life, mental conditions associated with the abuse of alcohol and drugs, but does not include mental retardation which is a condition of arrested or incomplete development of mind of a person, specially characterised by subnormality of intelligence

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Terms Used in Psychiatry

Psychosis-

Qualitative deviation from normalcy

Neurosis-

Quantitative deviation from normalcy

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FUNCTIONAL

“ functional implies physiological, which manifests itself only in the form of a happening and in bodily performance without morphological change”

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Terms used in psychiatry

Lucid Interval

It is a period of normalcy between two attacks of any psychotic, epileptic, or organic brain disorder

Dementia

Organic and global deterioration of intellectual functioning without clouding of consciousness

Deja vu

Illusion of visual recognition in which a new situation is incorrectly regarded as a repetition of previous memory

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Psychiatric terms (Cont.)

Affect means emotion or mood

A person’s immediate emotional state,

Disorientation

Means loss of bearing with regard to place, time, and other people.

Stupor

Complete suppression of speech, movement, and action not accounted for by profound disturbance of consciousness
Seen in schizophrenia

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Terms used in Psychiatry

Delusion-

It is a disturbance in content of thought in which there is false or erroneous belief in something which is not a fact. It is not consistent with patients intelligence, education and socio-cultural beliefs and cannot be corrected by any amount of logic, reasoning, or argument.
A delusion is a belief that is firmly held despite evidence to the contrary and is not a conventional belief that the person might be expected to hold given his educational & cultural background

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Delusion

An incorrect belief which is out of keeping with the person's cultural context, intelligence and social background and which is held with unshakeable conviction.

Delusional mood

Also known as wahnstimmung, a feeling that something unusual is about to happen of special significance for that person.

Delusional perception

A normal perception which has become highly invested with significance and which has become incorporated into a delusional system, e.g. 'when I saw the traffic lights turn red I knew that the dog I was walking was a Nazi and a lesbian Nazi at that'.

the psychiatrist and philosopher Karl Jaspers was the first to define the three main criteria for a belief to be considered delusional in his 1917 book General Psychopathology. These criteria are:

certainty (held with absolute conviction)

incorrigibility (not changeable by compelling counterargument or proof to the contrary)

impossibility or falsity of content (implausible, bizarre or patently untrue)

These criteria still continue in modern psychiatric diagnosis. The most recent Diagnostic and Statistical Manual of Mental Disorders defines a delusion as:

A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everybody else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by other members of the person's culture or subculture

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Definition (Cont.)

A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everybody else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary (Diagnostic and Statistical Manual of Mental Disorders )

An incorrect belief which is out of keeping with the person's cultural context, intelligence and social background and which is held with unshakeable conviction.
The belief is NOT one, ordinarily accepted by other members of person’s caste or community

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Karl Jasper’s Criteria

A belief to be considered delusional

Certainty (held with absolute conviction)
Incorrigibility (not changeable by compelling counterargument or proof to the contrary)
Impossibility or falsity of content (implausible, bizarre or patently untrue)

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Delusion-Cont.

Types of delusion

Of persecution-

These are the most common type of delusions and involve the theme of being followed, harassed, cheated, poisoned or drugged, conspired against, spied on, attacked, or obstructed in the pursuit of goals.

Of Grandeur-

A person's exaggerated conception of his or her importance , power or identity

Of Reference-

False belief that others are talking about him / her ( ex- people on radio or TV are talking to or about the person)

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Types of Delusion

Of Infidelity

( Delusional Jealousy) - false belief about a person's lover being unfaithful.

Nihilistic delusion-

Belief that self, others or the world is nonexistent or coming to an end).

Of poverty-

A rich man believing that he is poor or will be deprived of his possession.

Delusion of self-accusation-

False feeling of remorse or guilt
Somatic delusions-

False belief involving functioning of body ( belief that the brain is rotting or melting).

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Types of Delusion

Bizarre delusion-

An absurd, totally implausible strange false belief ( ex- invaders from space have implanted electrodes in a person's brain)
Systematized delusion-

False belief / believes united by single event or theme ( a person is being prosecuted by the CBI, IB, RAW, or the Mafia)

Mood congruent delusion-

Delusion with mood appropriate content ( a depressed person believing that he is responsible for destruction of the world)

Mood incongruent delusion-

Delusion with content that has no association to mood or is mood neutral ( for ex- a depressed patient has delusion of thought control or broadcasting)

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Types of Delusion

Delusion may be

Primary (autochthonous)- of mood or perception
Or secondary- a depressed person with abdominal complaints may have delusion of cancer in abdomen

M. L. Importance of delusion

Observed in Schizophrenia and MDP (Bipolar disorder)
These are searched in diagnosis of a person as insane/ lunatic (immune from criminal liability)
Some times normal beliefs were classified as delusional “ Martha Mitchell Effect”
Some of religious beliefs may be so strong as to be confused as delusional

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Diagnosis

A belief is delusional if it is either patently bizarre, causes significant distress, or excessively pre-occupies the patient, especially if the person is subsequently unswayed in belief by counter-evidence or reasonable arguments.

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Hallucination

Hallucinations are defined as perceptions in a conscious and awake state in the absence of external stimuli which have qualities of real perception, in that they are vivid, substantial, and located in external objective space
It is a disturbance of perception in which there is false sensory perception not associated with real external stimuli. There may or may not be a delusional interpretation of the hallucinatory experience.
It is perception without stimulus
Hallucinations can be associated with drug (particularly deliriants) or alcohol use, sleep deprivation, psychosis, neurological disorders, and delirium tremens.

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An abnormal sensory experience that arises in the absence of a direct external stimulus, and which has the qualities of a normal percept and is experienced as real and usually in external space

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Hallucinations can occur in any sensory modalities —

Visual,
Auditory,
Olfactory,
Gustatory,
Tactile,
Proprioceptive

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Hallucination

Schizophrenia-

hallucinations are voices- threatening, obscene, accusatory or insulting, two or more voices may converse among themselves or a voice may comment on the patient's life or behaviour
Their visual counterpart can also be behind the patient's back. It can be a feeling of being looked-stared at, usually with malicious intent. Not infrequently, auditory hallucinations and their visual counterpart are experienced by the patient together.

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Hallucination

Hypnagogic hallucination-

False sensory perception occurring while falling asleep - non-pathological

Hypnopompic hallucination-

hallucination while awakening from sleep- non-pathologic.

Gustatory h- Caused in uncinate seizure
Tactile ( haptic) h- false perception of touch or surface sensation as from an amputated limb ( phantom limb) crawling sensation on or under the skin ( formication)

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Hallucination

Somatic h- (cen·es·thet·ic H)- occurring in or to the body most often visceral in origin burning sensation in brain , cutting sensation in bone marrow.
Olfactory hallucination- Fragrance/ foul smell
Lillipution h ( micropsia) object are seen as reduced in size.
Mood congruent h - depressed person hears voices calling him bad person. Manic patient hears being called in exaggerated terms about his worth, power , or knowledge.
Mood incongruent h-

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Hallucination

Hallucinosis-

Hallucinations. Most often auditory, that are associated with chronic alcohol abuse and that occur within a clear sensorium , as opposed to delirium tremens (DTS) in which hallucinations occur during clouded sensorium.

Command hallucination-

False perception of orders that a person may feel obliged to obey or unable to resist.

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Terms in Psychiatry(Cont.)

Illusion ( False perception)

It is a disturbance of perception in which there is misinterpretation of real external sensory stimuli. This may be corrected by reasoning. It may be seen in schizophrenic patients during active phase but may occur during prodromal phase or during remission. Strong emotion or fear may also provoke illusion Ex. Shadow seen as ghost in burial ground.
They also occur in cases of substance abuse and in elderly persons where it may be transitory

Complex

Is a block in free flow of libidous energy. A group of repressed connected ideas so charged with emotion that it impels a person to think, feel, and act after a habitual pattern

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Obsession

It is a disturbance of the content of thought in which there is pathological persistence of an irresistible, recurrent and intrusive thought, feeling, idea, or sensation that the sufferer recognises as irrational or disproportionate but can not eliminate from consciousness by logical effort. It is associated with anxiety which is reduced by a specific compulsive behaviour.

Washing of hand or cloth, checking of locks or doors.

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Obsession -An unpleasant or nonsensical thought which intrudes into a person's mind, despite a degree of resistance by the person who recognises the thought as pointless or senseless, but nevertheless a product of their own mind. Obsessions may be accompanied by compulsive behaviours which serve to reduce the associated anxiety.

it is a disturbance of the content of thought in which there is pathological persistence of an irresistible thought or feeling that cannot be eliminated from consciousness by logical effort. It is associated with anxiety. An obsession is a recurrent and intrusive thought , feeling idea or sensation which the suffers recognises as irrational or disproportionate. Obsession increases anxiety. And is associated with a compulsive behaviour which is also conscious of standardized and has recurring pattern. The compulsive behaviour reduces the anxiety caused by obsession but if compulsive behaviour is resisted then anxiety is increased. Generally obsession are often time consuming and interfere significantly with people's normal routine, occupational functioning usual social activities or relationships with friends and family members.

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Terms in Psychiatry

Compulsion

These Are Repetitive behaviours or Mental Acts(e.g.. Praying, ,counting, repeating Words Silently) That the Person Feels Driven to Perform in response to an Obsession for preventing or reducing distress. But these are not connected realistically or are clearly excessive.

Repression-

Suppression unconsciously done by the defence mechanism of mind

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Delirium

A state of clouding of consciousness in which the person is bewildered, restless, disoriented, and may be associated with fear and hallucination
It is an acute organic brain syndrome secondary to physical causes in which consciousness is affected and disorientation results often associated with illusions, visual hallucinations and persecutory ideation.
There is total amnesia for the period of attack on recovery
Seen in hyper pyrexia, Infection, poisoning, chr.granulomas, GPI, Dementia, & antitoxin

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Delirium

An acute organic brain syndrome secondary to physical causes in which consciousness is affected and disorientation results often associated with illusions, visual hallucinations and persecutory ideation.

Delirium- bewildered, restless, confused, disoriented reaction associated worth fear and hallucinations. A state of clouding of consciousness in which awareness is markedly restricted or recovery there is total amnesia for the period of delirious episode. Anti-toxin , poison , infection subacuti-chrgranudoma, GPI. Chronic -Dementia

Amnesia

A partial of complete loss of memory. Anterograde amnesia is a loss of memory subsequent to any cause e.g. brain trauma. Retrograde amnesia is a loss of memory for a period of time prior to any cause.

Agnosia

An inability to organise sensory information so as to recognise objects (e.g. visual agnosia) or sometimes even parts of the body, (e.g. hemisomatoagnosia).

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Amnesia

A partial or complete loss of memory.
Anterograde amnesia is a loss of memory subsequent to any cause e.g. brain trauma.
Retrograde amnesia is a loss of memory for a period of time prior to any cause.

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Agnosia

An inability to organise sensory information so as to recognise objects (e.g. visual agnosia) or sometimes even parts of the body, (e.g. hemisomatoagnosia)

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Terms in Psychiatry

Impulse (Compulsive behaviour) /Control Disorder

This is a sudden and irresistible force compelling a person to the conscious performance of some action without motive or forethought

Kleptomania,
Dipsomania-condition of periodic, compulsive bouts of alcohol intake
Pyromania,
Mutilomania(Multilomania),
Sexual impulses, Compulsive sexual behaviour/ sexual addiction / hypersexuality/excessive sexual desire disorder
Suicidal and homicidal impulses

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Klepto mania- Irresistible desire to steal things of little value. Multilomania-To maim animals

Historically the name dipsomania was coined by German physician Dr. C. W. Hufeland in 1819 before it was superseded by alcoholism. The term "alcoholism" was first used in 1849 by the Swedish physician Magnus Huss to describe the systematic adverse effects of alcohol. Dipsomania is a historical term describing a medical condition involving an uncontrollable craving for alcohol. It was used in the 19th century to describe a variety of alcohol-related problems, most of which are most commonly conceptualized today as alcoholism, but it is occasionally still used to describe a particular condition of periodic, compulsive bouts of alcohol intake. The idea of dipsomania is important for its historical role in promoting a disease theory of chronic drunkenness. The word comes from Greek δίψα thirst and μανία mania. It is still mentioned in the WHO ICD10 as an alternative description for alcohol dependence syndrome, episodic use F10.26

Am I distressed by my sexual behaviors? Is my sexual behavior hurting my relationships, affecting my work or resulting in negative consequences, such as getting arrested? Do I try to hide my sexual behavior? Keep in mind what you say to a doctor or mental health counselor is kept confidential, except in cases where you report that you're going to hurt yourself or someone else, you report sexual abuse of a child, or you report abuse or neglect of someone in a vulnerable population.. This term has been used synonymously with others, such as compulsive sexual behaviors, hypersexuality, and excessive sexual desire disorder.¹ It can take many forms, and although it may seem obvious to diagnose, standardized criteria have yet to be developed. Furthermore, debate is ongoing about where this behavioral pattern fits into the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-IV), and how it should be classified and conceptualized.² Is it an addictive disorder, an impulse-control disorder, or a variant of obsessive compulsive disorders? Does it merit enough empirical evidence to stand alone as a separate disorder? Finally, what are the boundaries and limits that distinguish disease patterns, at-risk behaviors, and socially appropriate expression? hypersexuality, sexual addiction, or compulsive sexual behaviors are terms that are not found within the DSM-IV. Others will demonstrate elements of an impulse control disorder, namely reporting irresistible urges and impulses, both physically and mentally, to act out sexually without regard to the consequences. Finally, there are patients who demonstrate sexual obsessions and compulsions to act out sexually in a way that resembles obsessive compulsive disorders. They do so to quell anxiety and to minimize fears of harm. For these patients, the thoughts and urges to act out sexually are ego-dystonic, whereas other types of patients describe ego-syntonic feelings about their sexual behaviors.

Compulsive sexual behavior can be divided into paraphilic and non-paraphilic subtypes. Paraphilic behaviors refer to behaviors that are considered to be outside of the conventional range of sexual behaviors. These include the eight paraphilias recognized in the DSM-IV: Exhibitionism, voyeurism, pedophilia, sexual masochism, sexual sadism, transvestic fetishism, fetishism, and frotterurism.³ There are many other forms of paraphilias that are not listed in DSM-IV (e.g., gerontophilia, necrophilia, zoophilia) that exist but have not been yet recognized as clinical disorders. A key clinical feature in diagnosing a paraphilic sexual behavior is that it must be distressing and cause significant impairment in one's life, with the exception of pedophilia and fetishism. In other words, with the noted exceptions, engagement in these behaviors leads to sexual gratification but does not cause distress or impairment and do not represent clinical disorders.⁷ Thus, frequency, amount of time spent, and amount of money spent are not necessarily reliable indicators of the presence of a compulsive sexual disorder. Paraphilias begin in late adolescence and peak in the mid-20s.⁸Commonly, paraphilias do not occur in isolation; as the expected course is characterized by multiple paraphilic and non-paraphilic behaviors.⁶

Non-paraphilic behaviors represent engagement in commonly available sexual practices, such as attending strip clubs, compulsive masturbation, paying for sex through prostitution, excessive use of pornography, and repeated engagement in extramarital affairs. The onset, clinical course, and male predominance are fairly similar to paraphilic disorders.⁹ Various epidemiological studies estimate that close to six percent of the general population meet criteria but there are no national or large datasets to confirm this.⁸ Because of the variety of activities possible, non-paraphilic compulsive sexual behavior can present in a number of ways. This has the potential to confuse and cloud clinicians. In addition, a clinician that screens only for some but not all of the potentially problematic sexual behaviors is likely to miss important clinical information. Thus, asking about both paraphilic and non-paraphilic behaviors is critical in screening. In addition, it is important to assess the consequences as well as the nature of the behavior. A person who spends $1000 per week on strip clubs may at first glance appear to meet criteria, but if there are no notable adverse consequences in his or her life, then the disorder may not be present

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Somnambulism

Also called (Sleep walking)

Motor activity during sleep for which there is no memory in morning when the person gets up.
Somnolentia or semi somnolence is known as sleep drunkenness

These are considered Insanity

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Circumstantiality

A simple thing described in very round about manner
Indirect speech that is delayed in reaching the point but eventually gets from original point to desired goal.
It is characterised by an over inclusion of details and parenthetical remarks

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Phobia

A phobia is a fear of particular situations or things that are not dangerous and which most people do not find troublesome.
It is persistent, irrational, exaggerated, and invariably pathological dread of a specific stimulus or situation.
It causes a compelling desire to avoid the feared stimulus.
Agoraphobia- Literally- fear of the marketplace taken now to be a fear of public places (Open place)
Claustrophobia – fear of Closed space- becomes panicky if asked to enter a cave or a tunnel.

Acro-phobia- Dread of high places

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Agoraphobia

Fear of the marketplace literally; taken now to be a fear of public of public places associated with panic disorder. Phobia - Persistent, irrational, exaggerated , and invariably pathological dread of specific stimulus or situation results in a compelling desire to avoid the feared stimulus.

Specific phobia- Dread of a specific object or situation ( dread of spider or snakes)

Social phobia- dread of pubic humiliation as in fear of public speaking , performing, eating in public.

Aero-phobia- Dread of high places

Agora phobia- Dread of pain

Ailuro phobia- Dread of cats

Erythrophobia- Dread of red ( refers to a fear of blushing)

Pan phobia- dread of every thing

Claustro phobia- Dread of closed spaces

Xeno phobia- Dread of strangers

Lachanophobia- Phobia of vegetables "vegetable" (or really anything cultivated in a garden, as opposed to collected from the wild. Eating or merely sight of vegetables leads to panic reactions sweating palpitations etc.

Zoo phobia-Dread of animals

Needle phobia- The persistent, intense, pathological fear of receiving an injection

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Phobia

Aero phobia- An abnormal fear of draughts of air
Ailuro phobia- Dread of cats
Erythrophobia- Dread of red ( refers to a fear of blushing)
Xeno phobia-Intense fear or dislike of foreign things, people, their customs, and culture Dread of strangers
Lachanophobia- Phobia of vegetables "vegetable" (or really anything cultivated in a garden, as opposed to collected from the wild. Eating or merely sight of vegetables leads to panic reactions sweating palpitations etc.

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Phobia

Photophobia- Irrational fear of light or lighted space
Pyrophobia- Irrational fear of fire
Xylophobia- Fear of wooden objects or forest
Pan phobia- Dread of every thing
Specific phobia- Dread of a specific object or situation Ex. ( dread of spider or snakes)
Social phobia- Dread of public humiliation as in fear of public speaking , performing, eating in public.

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Terms in Psychiatry

EGO-

It is an attribute of the personality which keeps on moderating the Id in relation to its reality testing function which is also controlled by the superego

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Ego

Id

Super

Ego

Level of consciousness

Subconscious

Conscious

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Egosyntonic- Behaviours, values, and feelings that are in harmony with or acceptable to the needs and goals of the ego or consistent with one’s ideal self image

Egodystonic- It is the opposite, referring to thoughts, and behaviours that are in conflict or dissonant with the needs and goals of the ego or further in conflict with a person’s ideal self-image.

In psychoanalysis egosyntonic refers to the behaviors, values, and feelings that are in harmony with or acceptable to the needs and goals of the ego, or consistent with one's ideal self-image Ex. Anorexia Nervosa in which the patient considers her wt. loss as positively good for her self image hence difficult to treat.. Egodystonic (or ego alien^[1]) is the opposite, referring to thoughts and behaviors (dreams, impulses, compulsions,desires, etc.) that are in conflict, or dissonant, with the needs and goals of the ego, or, further, in conflict with a person's ideal self-image Ex. Egodystonic sexual orientation.

An illustration of the differences between an egodystonic and egosyntonic mental disorder is in comparing obsessive-compulsive disorder and obsessive-compulsive personality disorder. OCD, is considered to be egodystonic as the thoughts and compulsions experienced or expressed are not consistent with the individual's self-perception, meaning the patient realizes the obsessions are unreasonable and are often distressed by their obsessions. In contrast, obsessive-compulsive personality disorder is egosyntonic, as the patient generally perceives their obsession with orderliness, perfectionism, and control, as reasonable and even desirable

syntonic

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Fugue

It is a state of dissociated consciousness in which, during the attack, the person unconsciously changes his identity and vocation.
With taking of new identity there is amnesia for old identity.
Habits and skills are unaffected
It is a suicide equivalent

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10/08/2022