11.1 Special syndromes with forensic relevance

Pathological intoxication and Ganser syndrome

• Pathological intoxication is diagnosed from onset within minutes, a quantity of alcohol too small to intoxicate most people, aggression out of character with sober behaviour, and absence of the usual signs of drunkenness.

• Markers of chronic heavy drinking, such as cirrhosis, contribute nothing to the diagnosis.

• Ganser syndrome is approximate (near-miss) answers with clouded consciousness, pseudo-hallucinations, conversion symptoms and amnesia for the episode.

• Ganser syndrome was first described in prisoners awaiting trial, and it is distinguished from malingering, factitious disorder and delirium.

Malingering and factitious disorder

• Munchausen syndrome was coined by Richard Asher in 1951; ICD-11 separates factitious disorder imposed on self from that imposed on another.

• Harm comes from induced illness and from unnecessary investigations or treatment, and wound interference or specimen contamination can kill.

• Genuine illness can coexist with any of these, and motives may be mixed.

• Management coordinates care, keeps procedures to a minimum and raises concerns without punishment; evidence for specific treatments is weak.

Fabricated or induced illness in another

• Fabricated or induced illness is harm arising when a caregiver presents a dependant, usually a child, as ill or more impaired than they are.

• It is a safeguarding description, not proof of a caregiver diagnosis, so clinicians follow child protection procedures without waiting for diagnostic certainty.

• Dependent adults are protected under adult safeguarding law, such as the Care Act 2014 in England.

• Clinicians never confront a suspected perpetrator alone or undertake covert surveillance.

Morbid jealousy

Morbid jealousy (Othello syndrome) is excessive preoccupation with a partner's suspected infidelity.

• Alcohol and separation both increase risk.

• The partner's and any named third party's safety are assessed separately.

Erotomania

Erotomania (de Clérambault's syndrome) is a fixed belief that another person, often of higher status, is in love with the patient.

• Rejection is read as secret confirmation, unlike ordinary unrequited love.

• Erotomania explains a minority of stalking, and legal restrictions alone may not alter the belief.

Homicide-suicide

• Most homicide-suicides are a man killing his current or former female intimate partner and then himself.

• Depression, particularly in men, is the disorder most consistently found in perpetrators, including in intimate-partner homicide-suicide.

• Psychosis, substance misuse and antisocial traits are more typical of homicide without suicide.

Killing of children

• Neonaticide's 24 hours is narrower than the 28-day neonatal period and the 12-month limit of infanticide.

• Neonaticidal mothers are younger than mothers who kill later in infancy.

• Violence in the perpetrator's current relationships is the most reliable risk factor for homicide of infants aged one day to one year in the UK.

• Maternal age under 20 years is an established risk factor for infant homicide.

• No factor reliably predicts which mother will commit filicide, because the outcome is rare and every associated factor is common among mothers who never harm a child.

• When women with a psychotic illness kill, the victim is usually a family member, most often their own young child.

• Child abduction by women most often falls into the family category, whereas stranger and acquaintance abduction are strongly male.

Terms for homicide within the family

Mariticide and uxoricide are the pair most easily confused: maritus is husband, uxor is wife.