Epilepsy

Epilepsy is a rare contributory factor to offending. More than 20 years ago Gunn (!.26) reported an increased prevalence of epilepsy in prisoners compared with the general population, but not with a population showing the same socio-economic disadvantage from which the prison population is typically drawn. Gunn's sample of epileptic prisoners showed no excess rates for crimes of violence. The study has not been repeated. Any excess of prisoners with epilepsy, if present today, probably arises from the fact that that the socio-economic and psychosocial correlates of epilepsy are similar to those for crime in general.

Serious violence as an ictal phenomenon is exceedingly rare (see discussion of automatic...behayloM[ below). Violence when it occurs in people with temporal lobe epilepsy is not simply the result of an electrical discharge in the brain; other factors have a contributory role. (12Z)

Factitious illness by proxy

This term (also known as Munchausen syndrome by proxy) correctly describes behaviour followed by a situation rather than a psychiatric disorder. ^l8.,,!29) The behaviour is the fabrication of symptoms in, or the injury of, a child by its carer (usually the mother) who then presents the child to a doctor or other agency for treatment (the situation). Bools(!29) describes a wide range of injurious behaviours from fabricating symptoms and tampering with specimens and charts to poisoning, smothering, and withholding of nutrients.

The behaviour may be a factor in systematic (and sometimes serial) child abuse and has been implicated in acts of serial killings by health-care workers. (130) There are commonly underlying psychiatric conditions such as personality disorders (particularly antisocial and borderline types), somatization, affective, eating, and substance misuse disorders. The behaviour has not surprisingly attracted wide interest and no shortage of speculation as to what might drive a person to act in this way. Meadow,(!28) the leading British paediatric authority on the behaviour, referred to the selfishness of unhappy mothers and found only a minority with feelings of envy, violence, and hatred towards their child. Psychodynamic literature offers various perspectives including disturbance in the perpetrator's own maternal object world/!31 dehumanization of the child as a fetishist object,(!32) and a perversion of motherhood. Perhaps the most unsettling aspect of the behaviour is that medical agencies, particularly paediatricians, are unwitting participants in the deceit until the diagnosis is suspected or confirmed.

Pathological jealousy and other disorders of passion

Delusional syndromes characterized by pathological feelings of jealousy, love, or entitlement are commonly associated with criminal behaviour (see Chapter.4.4). Pathological (or morbid) jealousy is the most common. The syndrome is seen in a variety of disorders including organic and paranoid disorders, alcohol psychosis, schizophrenia, and, rarely, affective disorders. (133)

There is no clear boundary between normal and pathological jealousy, both of which may generate criminal behaviour. Mullen (134135) emphasizes that pathological reactive jealousy may occur in response to real or imagined infidelity; the latter is not the issue. A pathological reaction is manifested by exaggerated responses which come to dominate personal functioning and relationships. It is commonly related to problems in personality development. The non-pathological 'jealous reactions experienced by most of us at some time in our lives''135) can and do drive criminal behaviour.

In forensic practice careful assessment is crucial and requires appraisals of premorbid personality, the relationship with the partner, and the nature of the provoking incident or behaviour. Often there is disparity between the partners in terms of social skills, educational attainment, or occupational status. The syndrome of pathological jealousy has a high association with violence and homicide. Both partners need to be made aware of the risks, and often separation is required; this clearly does not eliminate the risk of further violence.

The delusional conviction of being loved by someone who is identified but unattainable, usually by reason of their social class or importance, is the basis of erotomania or de Clérambault's syndrome (see Chapteild). The condition, which is seen in forensic populations as a result of criminal acts secondary to the delusion/136,13Z) suggests that multiple delusional objects and a history of other antisocial behaviour are predictive of future violence. The syndrome has various aetiologies (schizophrenic and affective), although it can present as a single delusional disorder. (138)

de Clerambault's syndrome is only one of a number of behaviours that may be associated with stalking, (139) a behaviour that has recently been recognized as an offence in England under the Protection from Harassment Act 1997. In 1990 California was the first State to introduce anti-stalking legislation. A study of 22 men and four women charged under the legislation was reported by Kienlen et al.:(!40) eight subjects had an Axis I diagnosis of a psychotic, disorder but only one had erotomanic delusions. Non-psychotic stalkers had Axis I diagnoses of major depression, adjustment disorder, or substance dependence. All the psychotic stalkers visited the home of their victim, but the non-psychotic group were more violent and included the two homicides in the study. The study confirms other work that psychotic phenomena are not, in themselves, a significant indicator of violence.

The conviction of having been wronged by others (e.g. a doctor or lawyer, employer, or government agency) and of consequent entitlement to redress is the basis of morbid querulousness. The convictions dominate, usually in fluctuating outbursts, the lives of sufferers who may hound victims with letters, distribute leaflets, initiate campaigns, daub walls, and write to newspapers and members of parliament. Often they are declared 'vexatious litigants' and become banned from using the courts. There is a high likelihood of assaults on the perceived 'wrong-doer', damage to his or her property, and, rarely, murder- suicide. As with other disorders of passion there are various aetiologies. (111,)

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