Case report:
A 35-year-old woman was hospitalized for observation as part of a forensic psychiatric assessment, according to the 25 bis Article of the 2004/40 Tunisian mental health and hospital conditions’ law. This hospitalization aimed to evaluate her criminal responsibility with reference to the murder of her daughter.
The patient is the youngest of two siblings. She grew up in a family of rural origin with a high socioeconomic level. Her mother died at the age of 64 years, six months before the current episode. She graduated in Industrial Economics at the age of 28, and she has remained unemployed since. She is married and she is a mother of three aged 9 years, 4 years, and 18 months.
About her pre-morbid functioning, the patient was dynamic, curious, independent, sociable, and well suited. A quiet and balanced atmosphere reigned within her family. She described a conflictual relationship with the mother, without the latter being repulsive. She spoke coldly of her mother, who had just died, describing her as ambivalent; she was both protective and unfair since she always preferred the patient’s brother. Her father was described as rigorous, meticulous, and anxious. She reported good marital harmony and a warm relationship with her children.
The interview with the family revealed a change in behavior since the ”Tunisian revolution” in 2011, characterized by social withdrawal, emotional coldness, exaggerated interest in politics, and extremism in religious practice. All of it was tolerated and even trivialized by her husband. Five years later, the mother took the patient to consult a psychiatrist who prescribed risperidone at a dose of 4 mg per day. The treatment was refused by the patient. Then, she was hospitalized at the request of her family in a psychiatric hospital, for a fruitful delusional episode characterized by themes of persecution and influence, with
hallucinatory and interpretative mechanisms. This delusional episode was triggered by a psycho-emotional stress: arguing with the teacher of her eldest daughter, forcible confinement for nearly an hour in the school with her two children, followed by an aggressive arrest at the police station. The diagnosis of schizoaffective disorder was held requiring antipsychotics and mood stabilizers. After being discharged, the follow-up and monitoring were discontinued, and she did not consult again until the murder. The entourage reported a change in the patient’s behavior after the death of her mother. She became fulfilled and jovial.
On the day of the crime, the patient was at her father’s with her two daughters. In the late afternoon, she suddenly got agitated, and she banged her youngest girl violently against the wall several times. Then, she stabbed her with two different knives.
The examination and autopsy of the infant revealed:
- Multiple bruises on the inside of the scalp, associated with subarachnoid hemorrhage and subdural hematoma, whose appearance is consistent with injuries caused by a blunt object that had hit the head;
- Multiple transfixing wounds of both eyeballs (the reflex zones) caused by a pungent and sharp object (emergence of several wounds with persistence inter-membranous flanges at both eyelids)
- A left pneumothorax compression in connection with penetrating wounds in the left chest;
- Multiple wounds somewhat ecchymotic and deep in the epigastric region of the abdomen, back, and lumbar region, whose appearance is consistent with damage caused by a pungent and sharp object;
- Post-mortem wounds in the abdominal organs (liver, right kidney, stomach, and intestine). A wound on one liver may match that of a bite.
The infant death is related to head trauma associated with eye and chest wounds.
On admission, the patient was stammering, asthenic, and would only remember the strong smell of blood. She also asked if the deceased girl was indeed her own daughter. Throughout the interviews, anxiety was dominant when she talked about her act. She accused the police of having substituted her daughter to be able to monitor her. She saw her as a double of her daughter; physically identical but she was a dangerous object that threatened her family. A destructive fury then fell on this danger.
She confessed that when she was pregnant she considered her daughter as ”sacred” and wanted to give birth at home for fear of being substituted by another child, something that was not allowed by her family. Since the birth of her child, she had doubts about her identity. At the same time, she said ”this girl is my spitting image”.
The patient’s physical examination, biological tests, electroencephalogram, and cerebral magnetic resonance imaging were free of abnormalities.
Therefore, the presence of a mental disorder causing a lack of judgment led to the conclusion of criminal irresponsibility objectified by the expert in psychiatric forensic.
Discussion:
The pathological nature of filicide, in this observation, appears through the psychiatric history of the patient and the murderous act committed. Children murdered by their parents are usually grouped under the term ”infanticide”. Several classifications have been proposed, including that of JP Resnick who distinguishes neonaticide (murder of a 24 hour-) from filicide (the murder of a child older than 24 hours by a parent) [10].
J. Delay et al [11] established a clinical classification of pathological infanticide: Melancholy infanticide, infanticide during the period of puerperium, accidental infanticide, and infanticide during delusional experiences such as the case of our patient. Delusions of this patient were chronic, insidious, and had a mystical aspect. Thus, they were credible for her husband. Furthermore, the weird and impulsive nature of this homicide reveals major anxiety. The data and findings of the autopsy of the victim works as an argument toward the psychotic nature of the patient’s disease. The amnesia of the facts recorded in the register of a confusing episode might be misdiagnosed with a seizure. This remains improbable because of the normal neurological explorations.
The category named ”pathological filicide” is well described in the literature, where violence aims to control the perceived threat [12], such as our patient, whose deeds place her in a space between the monster and the sick. This is a dive into the clinic of horror. This murder seems absurd, illogical, outrageous, out of proportion with avowed causes, or even without apparent motive. It is far from the usual criminal motivations. It would refer to a pathological dimension of the act, such as unmotivated brutal, hermetic, and cold murders. This woman with chronic psychosis, facing the challenge of controlling the unthinkable, worries, and illusions related to the imminent catastrophic danger, was unable to control her impulses. She committed her crime without premeditation, under the effect of a morbid impulse supported by a delirious illusion of look-alikes that corresponds to a Capgras syndrome. Indeed, she captured the likeness of the body to her daughter but she disregarded her identity. She was convinced that her daughter has been replaced by a look-alike that returned a sense of significant persecution and fear of annihilation by bad objects. Thus, to preserve and protect herself, she resorted to physical violence because of profound failures of mentalizing.
Marinopouls S [13], supports that the child dies from not existing in the maternal psyche; our patient also doubted the authenticity of her descendant from birth, accusing the police and the ”system” of substituting her child. On the other hand, the patient said ’this child is my spitting image ”; in this sense, Wieder reports a situation where ”the violent act had not targeted her child, but the bad parts of self” [14]. In other cases, filicide could be considered a suicidal equivalent, especially among mothers who projected their psychotic symptoms on their children. The child, then considered a duplicate of herself, is included in a suicidal urge, finally becoming the only victim [15]. Through this observation, it is important to note the central role of delusions in the genesis of crime; first in imaginative reconstructions about her mother, accentuated by prejudiced thoughts, and later about her daughter, who was thought to be substituted. The filicide crime is related to a defect in the filiation link between the mother and her child as if there was some kind of confusion of generations, between a desire of matricide and a desire of infanticide. The issue of confusion of generations, mother and daughter, arises in the case of our patient. In fact, the same year her mother died, she killed her youngest daughter. This confusion might sign a psychotic break.
C. Ley et al [16] reported that homicidal acts break definitively the chain of descent already weakened in the psyche of the murderer. Simonnot AL [17] confirmed that the occurrence of infanticide can be understood only by involving psychodynamic lighting in the context of serious disorders affecting the functioning of an entire family. According to some authors [18,19], women’s violence reflects the presence of a destructive mother, and these committing filicides have a defective relationship with their mothers. Thus, through the internalization of the destructive maternal picture, acting out filicide would form a dynamic of intergenerational repetition.
The peculiarity of our case is the fact that the act of filicide was supported by a DMS precisely Capgras syndrome. Although Capgras syndrome was described as a specific risk factor for homicidal behavior against of the misidentified person [8, 20], to our knowledge, no similar case has been reported in the literature, and there is few data exploring the association between DMS and infanticide.
Capgras syndrome, or illusion look-alikes, corresponds to the belief that one or more people close to the patient in the matter have been replaced by doubles [7]. These doubles are physically identical to the originals but are psychologically different. These impostors are often hostile, malicious, and persecutor [7]. Intra-family homicides were often described in cases of Capgras syndrome [21]. The authors are often male And it is mostly a well-planned act contrary to our case, where the abusive fierceness to the victim could be explained by the strange nature of the delusional ideation, the derealization at the crime time, and a bizarre urge to silence his victim. It is precisely the combination of Capgras delirium and the persecution delirium against the cops, which was at the origin of this imminent danger. The prognosis did not depend only on her disease, but a whole environment and a whole bundle of situational factors, namely: the important diagnostic and therapeutic delay due to the uneasily detected signs of her disease, and the trivialization from her family side though they were of a good social level; in addition to non-adherence to treatments.
In this sense, some authors [22, 23, 24, 25] highlight the importance of assessment of violence associated with DMS, and the interest of developing more in-depth studies in order to better understand the mechanisms underlying these disorders and the plausible association between these syndromes and overkill homicide, especially since the data in the literature on the subject are still limited, to finally allow adapted therapeutic perspectives.