The Forensic Psychiatrist

Forensic Psychiatrist

In this country, Forensic Psychiatry is one of the least developed branch or field of both Forensic Medicine and Psychiatry. Neither a Forensic specialist is encouraged or is interested in this superspeciality, nor a psychiatrist is ever seriously interested to be well conversant with relevant legal aspects. However, in matters of legal disputes, needing a specialists opinion about the mental condition of a person, the service of a psychiatrist is more often summoned by the legal people than of a Forensic specialist. Of course, many 3 times the man of Forensic Medicine is a member of a board along with the psychiatrist, in the examination of an alleged mentally unsound person, either by order of the Ld. Court or otherwise. Instead of dissatisfaction over this issue of non-involvement or only partial involvement in these cases, the Forensic specialists in this country should feel satisfied, so long they are not well conversed with the discipline of psychiatry and its development. For bridging the gap, either a Forensic specialist should do an additional diploma in psychiatry or a specialist in psychiatry should in addition have atleast a diploma in Forensic Medcine.

Role of a Forensic Psychiatrist in litigations involving mental soundness of a person

The functions of Forensic Psychiatrist in such cases are multiple and variant in nature. He has to certify mental capacity and soundness of a person in the following circumstances.

(a) In relation to criminal cases

Forensic Psychiatrist1. When a defence is attempted on the ground that an act which is otherwise considered as a crime, has been committed by a person in a state of mental unsoundness.
2. When an accused on the ground of insanity, expresses his inability to plead his defence during trial.
3. When after being convicted in a court of law, petition is filed before the court, to defer the execution of the punishment till the convict is mentally sound or, to send him to a mental asylum for treatment, instead of sending him to the prison to serve the term of imprisonment.
4. When it is claimed that a person has committed suicide due to the effect of mental unsoundness.
5. In connection with criminal breach of trust or fraud committed against an insane relating business or property matter.
6. In connection with abetment of suicide of an insane person.
7. When an insane woman is raped.

(b) In relation to civil cases

1. Testamentary capacity or capacity to make a valid will.
2. Continuance or dissolution of a business contact on the ground of mental abnormality of either partner.
3. In connection with nullity of marriage or divorce cases.
4. Regarding capacity or validity to act (or competence) as a witness.
5. Regarding validity of consent given by an insane person.
6. In certain contingencies, like appointment of a curator or caretaker of a mentally unsound person who is unable to look after his property.

To decide the above cases, it is necessary to have a clear idea as to whether a person is mentally sound or not, i.e., whether a person is insane or not. There is no legal definition of insanity. In the truest sense, law does not require also a clear definition of insanity. The purpose of law is to know whether at the material time, the person concerned is or was mentally sound or unsound and  if he was mentally unsound then, whether the mental unsoundness or abnormality the person is/was suffering from, is linked with his act in question. Thus, as a sane person is responsible for his act, a mentally unsound person also may be responsible for committing an offence, if it is not the result of unsoundness of his mind (inspite of his being mentally unsound).

The special legal entity of an insane person was first recognised and approved in Roman law (in Justinian law).

Definition of insanity – It is difficult to define insanity in such a way as would serve legal requirements. The condition can be perceived as one in which the patient suffers from some defect or disease of the mind which affects his personality, mental status, critical faculties, emotional process, and his relation and interaction with his immediate as well as total social environment.

Causes of insanity or mental unsoundness – As it is possible in physical illness, it is not so, to fix up one or more single cause for any type of mental illness. For insanity, complete interaction of forces within the individual and his environment is probably mostly responsible. Accordingly, the causative factors may be classified as –

A. Intrinsic factors

(a) Genetic –

1. Specific gene or genes
2. Chromosomal anomalies
3. Biochemical anomalies.

(b) Constitutional –

1. Physical or physique of the subject
2. Personality
3. Temperament
4. Autonomic reactivity.

B. Extrinsic factors

(a) Physical –

1. Intoxication
2. Injury (head)
3. Infection
4. Malnutrition
5. Others.

(b) Psycho-social –

1. Early upbringing
3. Mental conflicts
4. Personal or familial loss
5. Psychosocial stress
6. Cultural background of the society.

Classification of mental illness

1. Organic disorders –

(a) Acute – Delirium and subdelirious states, toxic confusional states, Korsakow’s syndrome.
(b) Chronic – Disorders due to degenerative, epileptic, traumatic, drug and other intoxications, metabolic, infective, demyelinating, neoplastic, cardiovascular causes.

2. Affective disorders (involving the .mood primarily) – Manic-depressive psychosis (mania and melancholia), anxiety state, phobic state.

3. Psychosomatic illness – In these conditions, emotional and physical factors precipitate or aggravate some somatic disorders. These may affect, respiratory, gastrointestinal, skin, menstrual and reproductive, endocrine, cardiovascular systems and muscles and joints.

4. Compulsive conditions – Obsession, impulse, psychopathic disorders.

5. Others (not grouped in any specific type)

(a) Schizophrenia
(b) Mental subnormality
(c) Personality disorder
(d) Psychosexual anomalies
(e) Hysteria.

Some terms which are commonly used in psychiatric disorders –

ILLUSION – Illusion is erroneous interpretation of some external object or stimulus. Thus a person, out of illusion may think a rope, a snake. An insane person out of illusion, may think a dog a tiger.

Illusion may occur both in a sane or an insane person. A sane person, after close scrutiny or examination will realize his mistake, whereas an insane person will persist with the wrong interpretation, even after repeated demonstration of his error.

Medicolegal importances — A criminal act committed by a sane person, due to illusion will make him responsible for his act and he will be liable to be punished. But if the act is committed by an insane person, out of illusion, then he may not be held responsible or may be held partially responsible for commission of the act.

HALLUCINATION – In hallucination, there is false sense perception without any external object or stimulus.

Apart from insanity, hallucination may also occur in conditions like, high fever, drug intoxications and as withdrawal symptom of some drugs of addiction. It may affect one or more than one of the special nerves or nervous system. Accordingly, hallucinations are of the following types –

1. Visual hallucination In this condition the sufferer experiences (visualizes) non-existent sights. He observes something without anything being present in his front.
2. Auditory hallucination The sufferer in this condition hears voice or sound without any source or any such thing.
3. Olfactory hallucination Here, there as a false sense of smelling without any source.
4. Gustatory hallucination Without any food or drink the sufferer experiences different tastes.
5. Tactile hallucination The sufferer experiences crawling of insects over his body without any such thing.
6. Psychomotor hallucination There is a feeling of movement of a part of the body, say a limb, though in reality there is no such movement.

DELUSION – Delusion is a false belief in something without any basis and the belief cannot be removed from the mind of the sufferer. It is rather persistent, even after the falsity of the belief is clearly demonstrated or explained with all possible arguments. Some false beliefs and understandings are not unusual in normal healthy persons. For a sane person there must be some reasonable basis for that and after reasonable arguments, explanations and demonstration he can be convinced about the falsity of his belief. But in case of an insane person the false belief is persistent and cannot be removed in any way. Delusion indicates some sort of mental abnormality.

Types of delusion – According to the nature of belief, delusions may be of various types –

1. Delusion of grandeur – It is also termed as delusion of exaltation. This is a delusion of pleasant belief or feeling. The sufferer remains exalted with feelings of greatness, power and wealth. He may be expansive in his thoughts. The sufferer may be extravagant in his thinking and action and may commit some crime in such a state of mind or may squander his money or property.

2. Delusion of persecution – This is an unpleasant delusion. The sufferer believes that something bad is going to happen to him. He fears that he may be killed by somebody or his property may be robbed. He is suspicious and apprehensive and leads a life of distress and pain. Such a person may feel himself so helpless that he may even commit suicide or may kill his own family members to “save” them from some imaginary danger. He may even kill some innocent person thinking him to be his enemy who is “out to destroy him, his family and his property”.

3. Delusion of influence – The sufferer strongly believes that his thought process, activities and behaviour all are controlled by some external power – often a superpower. Such a person, on the basis of some imaginary “command” from some supernatural power, may commit any unlawful act.

4. Delusion of reference – Here the sufferer believes that, he is being referred to by all agencies, media and persons around him in all matters concerning him or others. This may put him to unnecessary conflicts with strangers and he may get involved in some undesirable acts.

5. Hypochondriacal delusion – Here the person believes that there is some pathology or abnormality with some part or system or organ of his body, though in reality he is physically healthy. This sort of belief ultimately may lead to delusion of persecution. In extreme cases some of these persons may commit suicide.

6. Nihilistic delusion – The sufferer does not believe in the existence of earthly matters or happenings. He even may not believe in his own existence. Such persons suffer from an extreme negative attitude about everything. These subjects may be the victims of accidents and they may even commit suicide.

7. Delusion of infidelity – Males are the usual sufferers. Without basis, the sufferer strongly thinks that his wife is not faithful to him and is not trustworthy so far her private life is concerned. She does not love him and has intimate relationship with some other person. Such a mental sufferer may torture his wife, may kill her or may himself commit suicide.

8. Delusion of self-reproach or self criticism – The sufferer unnecessarily censures himself for some imaginary offence or misdeed “committed” by him. In serious cases, the person may punish himself by terminating his own life.

Medicolegal importances – Delusions, without any doubt, reflects mental abnormality. Hence, it has many legal bearings. When a person does some act due to the direct effect of delusion he suffers from, then he will not be held responsible for that act. Example – when an insane person kills an innocent person thinking that he (the innocent person) is about to kill him and to protect himself, he hits that person fatally, as a result of which the innocent person dies, then he will not be held responsible for his act. But, by virtue of delusion he suffers from, if he thinks that another person is out to cheat him and on such a false belief if he kills that person then he will be responsible for the killing. This is as per the provision of the law and natural justice, because law provides that a man reserves the right to protect his own life, if necessary at the cost of the life of the person who attempts to kill him. But law does not approve the killing of a cheat. The doctrine of diminished responsibility is applicable to an insane person who does certain unlawful act due to delusion, e.g., when the delusion reduces his power of reasoning and understanding capacity which leads him to commit some act which is not directly related with the effect of the delusion but has indirect bearing. When a person suffering from delusion of grandeur, believes that he will be killed by another person for the huge property he owns and if as remedial step he kills that person then he will be taken to have diminished responsibility for the commission of the act because though in this case there are elements of fear and apprehension about his own life and to safeguard his life he has killed the person, yet he is not fully absolved from the act he has committed because in this particular case he could have tried lawful protective steps for his life i. e., he could have sought for the help of the police.

In an insane person, delusion of grandeur may change to delusion of persecution. A man who wrongly believes that he possesses enormous property, may at a time start to think wrongly that, another person is out to kill him to succeed his property. Alternatively, a person suffering from delusion of persecution may after some period suffer from delusion of grandeur just in a reverse way. After some day’s wrongful belief that some person is after his life, the sufferer may start reasoning for such “intention” of that person that, as he possesses huge property the other person is thinking to kill him to grab his property.

IMPULSE – Impulse is sudden and irresistible desire or force in a person, compelling him to the conscious performance of some act for which there was neither a motive nor any forethought and preparation.

There may be several types of impulsive acts –

1. Kleptomania – This means an irresistible desire to steal articles which may be of small value and even, may be of no use to the person stealing the article.
2. Dipsomania – This is found in alcoholics who feel irresistible desire to take alcoholic drinks.
3. Pyromania – Here, there is an irresistible desire to set fire on things, which may be important and valuable. The person is not conscious or careful, at least temporarily, to the possible dangers of his act.
4. Mutilomania – This is an irresistible desire to injure and mutilate animals, commonly the domestic pets.
5. Sexual impulse – The person may feel compulsive urge to perform sexual intercourse, which may often be in a perverted way. There may be some psychic problem in the sexual behaviour or the person may be a victim of mental subnormality.
6. Suicidal impulse – There is definite mental problem. Often intoxication like, that with L.S.D. may lead to suicidal impulse.
7. Homicidal impulse – Here also mental abnormality is mostly responsible. In certain chronic intoxications, as in case of chronic use of cannabis, a man may develop sudden killing spree.

A sane person having self-control and judgement capacity, may not finally give shape to his impulsive or compulsive desire. But an insane person who lacks in self-control and judgement capacity, cannot resist the impulse and may commit any offence. Thus, in connection with commission of an unlawful act, impulse is a good defence for an insane person which is not so for a sane person.

DELIRIUM – In delirium, the consciousness of the subject is disturbed with impaired orientation, blunted critical faculties and irrelevant or incoherent thought content. A person may go into the state of delirium in many conditions, namely :

1. Due to mental unsoundness
2. In acute conditions, like high fever
3. In acute poisoning cases, as in datura poisoning
4. As a complication of chronic drug intoxication, as in case of chronic alcoholics.

In delirium, the patient is restless, agitated and may even be violent. He suffers from insomnia, hallucination and disorientation. He may fail to recognise known things and known persons. During such a mental state the person may commit some unlawful, destructive act for which he is not legally responsible, because delirium is considered as a state of definite mental abnormality.

OBSESSION In obsession, the sufferer constantly entertains an idea, unnecessarily, inspite of all his efforts to drive the idea out of his mind. This is a sort of compulsive phenomenon. The classical example of this condition person while going to bed at night, bolts the door of the room from inside, but after going to the bed he feels the necessity to verify and does so to see if he has bolted the door or not. He repeats this act again and again, inspite of his consciousness and inspite of his desire and efforts to stop the act. Obsession is considered a borderline state between sanity and insanity. In the above case, a sane person will stop after repeating the act of verification for a few times. But an insane person may continue the act all throughout the night without sleeping.

SOMNAMBULISM – This is a condition in a subject when he walks during sleep. In the state of somnambulism, the person while sleeping, may get up from the bed, open the door, walk out a distance and return to his bed to sleep again, to remember nothing in the next day. During the whole episode the subject is in a state of dissociated consciousness, and may perform automatic acts, over which he has no control and which he does not remember afterwards. He is in a state of hallucination and his acts are not in consonance with his immediate environment. His mind is apparently undisturbed and is uninfluenced by too many factors, as is usual during the busy hours of the day. For this reason he can concentrate much in such act of automatism, he performs in the state of somnambulism.

This is why it is occasionally observed that, a person can solve a difficult problem during the state of somnambulism which he could not do otherwise. The same act of automatism may be repeated in different attacks of somnambulism or often, a coordinated work may be performed part by part during the phases of different attacks. The act of automatism remains limited within the sleeping hours and does not influence the rest of the period of the day, and he has no mental abnormality when he is awake. If in a fit of somnambulistic automatism, a person commits a criminal act, he will not be held responsible for the same.

Somnolentia or Semisomnolence – It is that state of mind when a person is in a condition in between sleep and wake. The state of mind is comparable with the same of a person, who is suddenly aroused from deep sleep. In such a state, a person may behave very abnormally for a short period, say for a few minutes. During the period his mind is untouched with the reality and the circumstance. The condition is often termed as sleep-drunkenness. When suddenly awaken from a deep sleep, such person may perform some violent act without awareness and understanding. He is not responsible for any criminal act performed by him during such a state of mind.

CLAUSTROPHOBIA – This means suffering from fear and apprehension, inside a closed place.

DEPERSONALISATION – The person does not believe in his own existence, or identity. This occurs in schizophrenia or depressive psychosis.

DEREALIZATION – It means feeling of unreality or unreal things, as it happens usually in a dream during sleep. It commonly occurs in schizophrenia and depressive psychosis.

ABREACTION – It means an emotional reaction seen in circumstances of narcoanalysis, due to memorisation of past painful experiences.

DISORIENTATION – It means lack of clear awareness regarding one’s environment, particularly regarding the time, space and person.

AMBIVALENCE – It means contradictory emotional reactions-towards a person, at the same time.

EUPHORIA – An exaggerated sense of wellbeing.

APATHY – Abnormal lack of activity and interest.

PERSEVERATION – Inability to change the idea about something, though the circumstance or the matter is changed. In some cases when a patient of schizophrenia or dementia is engaged with some idea, it becomes difficult for him to change his mind to something else. Thus, if the person is once shown the picture of a cow, he may recognize it, but after that any picture shown to him, he will repeat the word ‘cow’.

MANNERISM – Constant repetition of a trick or gesture or speech.

STEREOTYPY – Repetition of same act or same phrase tirelessly.

NEGATIVISM – Doing just the opposite of what he is asked to do.

NARCOANALYSIS – Analysis of mental content of a person, done after application of a light general anaesthetic agent.

NARCOLEPSY – An irresistible and unusual desire to sleep.

ECHOPRAXIA – Repeating the act of another.

ECHOLALIA – Repeating the words uttered by another person.

VERVIGERATION – Use of clusters of needless words.

NEOLOGISM – Coining or using new meaningless words.

CIRCUMSTANTIALITY – Going into unnecessary details of things or incidents.

DISTRACTION – Diversion or lack of concentration of mind.

NEUROSIS – Functional disorder related to mental disorder, of which the patient is unaware. Hysteria, anxiety state, obsession and reactive depression are the common varieties.

NEURASTHENIA – A condition arising out of physical or mental exhaustion.

PSYCHOSIS – Types of mental illness arising out of mental causes and not due to environmental or extraneous factors. In psychosis, there is loss of touch with reality.

LUCID INTERVAL – It is a period during which the mentally unsound person behaves very much like abnormal person. During this period all the signs and symptoms of insanity are absent. The person is responsible for all his acts, performed during the period of lucid interval. But if he commits a hard crime then, he may take the plea that, his abnormal behaviour has started again, which will be convincing because, he is a known lunatic. In fact, after a period of normal behaviour, the mental abnormality of an insane person, may in reality also, start again with some violent act.