[Female intimate partner homicide: clinical and criminological issues]. / Singularités cliniques et criminologiques de l'uxoricide: éléments de compréhension du meurtre conjugal.

BACKGROUND: Female intimate partner homicide (FIPH) is a fatal complication of domestic violence. The aim of this study was to describe the socio-demographic, clinical and criminological characteristics of male perpetrators of FIPH and to compare them to the perpetrators of extrafamilial homicide and the perpetrators of intrafamilial homicide other than FIPH. METHODS: Between 1975 and 2005, 32 FIPH were perpetrated in the region of Angers (France), and these were compared to 26 intrafamilial homicides other than FIPH and to 97 extrafamilial homicides perpetrated in the same period, in the same region. The socio-demographic, clinical and criminological data were collected from psychiatric expert reports and medical files. RESULTS: The mean age of the FIPH perpetrators was 37.8years. They were professionally active, in majority as manual workers. They had a psychiatric record (69%), a previous criminal record (31%), and a history of violence against others (47%). Half of these perpetrators also had experienced a traumatic event before the age of 18. Compared to extrafamilial homicide perpetrators, FIPH perpetrators occupied more frequently a manual job and had prior criminal records less frequently. In the majority of cases of FIPH and intrafamilial homicide, the murder occurred in the evening, at the victim's home, and while the perpetrator was intoxicated. FIPH was mostly premeditated and was accompanied four times less frequently by another criminal behaviour compared to extrafamilial homicide. The FIPH perpetrators had more depressive symptoms and suicidal ideations when committing the crime and remained on the crime scene more often than extrafamilial homicide perpetrators who mostly attempted to flee the crime scene. FIPH perpetrators and extra- and intrafamilial homicide perpetrators were found criminally responsible in half of the cases. The socio-demographic, clinical and criminological characteristics of FIPH perpetrators were not statistically different from those of perpetrators of another intrafamilial homicide except that conflict preceded FIPH more frequently. CONCLUSION: Identification of specific features of FIPH could contribute to the early identification of domestic violence at risk of becoming lethal and to the elaboration of preventive strategies.

[Homicide and acute cortico-induced psychosis: A case report]. / Homicide et épisode psychotique aigu cortico-induit : à propos d'un cas.

BACKGROUND: Since their commercialization in 1950, the first psychiatric side effects of steroids have been reported. Today, steroids have become an important therapeutic tool in many diseases, but pharmacological mechanisms responsible for their side effects are still little known. The neuropsychiatric side effects concern 15% of patients while severe reactions occur in 5% of cases, mostly as acute psychotic episodes such as delusion. Serious forensic risks in this context are poorly documented and underestimated. CASE REPORT: We report the case of a 77 year-old man, treated by methylprednisolone for chronic lymphoid leukemia. After two months of treatment, although stabilized for the neoplastic disease, he stabbed his wife to death with a knife. In the emergency unit, an acute delirious state, a disorganization syndrome, and confusion items such as amnesia, disorientation and symptomatology fluctuation were observed. Mr. M also presented with hyponatremia and infectious pneumonia. Steroids were stopped and his condition rapidly declined, he died one month later during the hospitalization. DISCUSSION: This clinical case underlines the importance of the early detection of steroid psychosis and its management. Treatment should not be stopped brutally and a dose reducing strategy should be applied in combination with a mood stabilizer or antipsychotic treatment. Disease management strategies are insufficiently documented to be recommended. The extremely acute onset of the symptoms, a partial insight into delusions, a history of iatrogenic neuropsychiatry, the existence of somatic precipitating disorders and confusion factors should always alert the practitioner. The patient, and eventually his family circle, must be aware of the risks of adverse psychiatric effects of steroids for both ethical and forensic reasons, and must report them as early as possible to the clinician if they occur.

[Homicide and major mental disorder: what are the social, clinical, and forensic differences between murderers with a major mental disorder and murderers without any mental disorder?]. / Homicide et maladie mentale grave: quelles sont les différences sociodémographiques, cliniques et criminologiques entre des meurtriers malades mentaux graves et ceux indemnes de troubles psychiatriques?

OBJECTIVES: To establish the social, clinical, and forensic differences between murderers suffering from a major mental disorder and murderers without any psychiatric disorder and, in particular, to compare their respective records of psychiatric symptoms and their respective relationship with their victims. METHOD: We studied 210 forensic examinations of murderers, the offences related to the murders, and the social and clinical information collected from psychiatric court reports on persons convicted of homicide. Firstly, we identified the socio-demographic, clinical and criminological profiles of 210 murderers from which were distinguished murderers with major mental disorder. Then, we compared the profiles of murderers suffering from a major mental disorder with those of murderers without any mental disease. In other words, we compared 37 persons affected with major mental disorder (schizophrenia, paranoiac delusional disorder, and affective disorder) with 73 persons without any mental disorder. We deliberately excluded subjects with personality disorder or abuse of/dependency on drugs, mental retardation or dementia. RESULTS: With the exception of certain variables, murderers with major mental disorder have the same characteristics as others murderers: young man, living alone, with psychiatric and offence records and substance abuse. Murderers with major mental disorder are older (37.8 versus 31.7 years old) than perpretators without any mental disorder, and the former have a psychiatric record more often than the latter (81 versus 32.9%). In addition, contrary to the latter, the former show clinical symptoms of a psychopathological process. Depression, delusional and suicidal ideas are frequent among murderers with a major mental disorder, whereas the persons without mental disorder quarrel or have a row with their victim just before their crime. The victim was known to the perpetrator significantly more often in the major mental disorder group than in the no mental disorder group (94,6 versus 76,7%, p=0,008). The most major mental disorders' homicide was more likely to be against intimates than strangers. The application of the former article 64 or the present article 122-1 of the French Criminal Code are envisaged more often in the major mental disorder group than in the no mental disorder group. CONCLUSION: The main difference between murderers with a major mental disorder and murderers without any mental disorder is the psychopathology of the morbid process which underlies the homicide. Impairment of judgment at the time of the crime should be taken into account. As a clinician, we should focus our attention on general risk factors of violence and homicide (male, young, underprivileged class, abuse of alcohol) and on more specific factors (mental disorder co-morbidities...). To these factors should be added the dynamic characteristics of the meeting of the protagonists.

[Homicide and psychosis: criminological particularities of schizophrenics, paranoiacs and melancholic. A review of 27 expertises]. / Homicide et psychose: particularités criminologiques des schizophrènes, des paranoïaques et des mélancoliques. A propos de 27 expertises.

INTRODUCTION: During the night of the 11 to 12 of December 2002, Mathieu X. 21 years old, convinced he was defending himself from evil human beings decapitated a nurse and an auxiliary nurse of the psychiatrist hospital. This crime, which received saturated media coverage, obviously raises questions about the dangerous and violent nature of the mentally ill, which can sometimes culminate in homicide. Firmly rooted in the collective consciousness is the popular idea that someone who kills an unknown person in the street is mentally ill. Conversely, the epidemiological data are reassuring; only 15% of such crimes are committed by the seriously mentally ill (schizophrenia, paranoia, melancholia). AIM: Typing and comparison of homicides committed by schizophrenic, paranoiac and melancholic persons. METHOD: Several murders committed by psychotic persons are presented in this article. This retrospective study shows several types of pathological murder (schizophrenia, paranoiac delirious disorder, affective disorder: melancholia and hypomania). Twenty-seven cases have been selected and analysed from 268 cases prepared over 30 years by two psychiatrists, whose diagnoses were schizophrenia, paranoia, melancholia or hypomania. RESULTS: From these 268 cases of homicide examined, 27 murderers were psychotic. Ten of these were young, single, jobless, male schizophrenics: they drank little alcohol. Most of them had a criminal history. They were paranoid schizophrenics whose hallucinatory mechanisms fed mostly persecuted, sexual and metaphysical themes. Forty percent of them were disorganised, and half of them showed negative features. They knew their victim (family, friends). Nine others were paranoiac, for the most part male, older, married, family men, without psychiatric or criminal record. Intuitions with delirious fed persecuted (77%), jealous (40%) or prejudicial themes. They murdered their wife or husband or neighbour. Alcohol consumption was often involved. Schizophrenic and paranoiac murderers often have an emotional temper. Conversely, melancholic murderers are mostly female aged around 30, married, family women, drinking little alcohol. Two-thirds of them have psychiatric records of depression, bipolar disorders and attempted suicide. Altruism is the most frequent delirious theme. Their murders are more often premeditated. They know the victim: child or partner. Suicide often follows the murder.

Psychiatric side effects of interferon-beta in multiple sclerosis.

Psychiatric disorders, especially depression, are frequent in patients with multiple sclerosis (MS). They are attributed both to the psychosocial impact of a chronic, usually progressive, disabling illness and to cerebral demyelination. Besides, drugs such as corticosteroids and possibly interferon (IFN) may also have depressogenic effects. Major depressive disorders and/or suicidal ideation are a major concern and efforts to identify and minimize these reactions are of much importance. Psychiatric side effects, particularly depression, are widely reported with IFN-alpha and have been suspected with IFN-beta but are not yet fully established. Our review of the literature revealed that most studies discard an association between IFN-beta and depression or suicide. However, few patients, especially those with a history of depression, might be at higher risk for depression when treated with IFN-beta. Overall, considering the uncertainty of a link between IFN-beta and depression and/or suicide, as well as the complete remission of psychiatric complications after IFN discontinuation and/or antidepressant treatment, physicians should closely monitor the psychiatric status of patients, but should not refrain from including them in IFN-beta treatment programs, even when they have past or present depression.

[Evaluation of a university hospital unit specialising in treating adults at risk of suicide]. / Evaluation de l'unité spécialisée d'accueil des suicidants adultes au CHU d'Angers.

In France, suicide prevention has been a public health priority since 1992. Half of all suicide attempts are repeated attempts made by people who have already tried to commit suicide, and the risk of death increases by 1% after the first attempt. Today, hospitalisation has become an unavoidable consequence for those who have attempted suicide, and recommendations for best practice were recently issued in France (1998). The objective of this study was two-fold: 1) to assess the quality of management and care provided for patients hospitalised in a university hospital in Angers after having attempted suicide, an evaluation that was based in part on the criteria of the National Agency on Health Accreditation and Evaluation (ANAES); and 2) the demonstrate the value and high utility of such a unit specialising in caring for patients recovering from attempted suicide. The unit has now been in existence for over 5 years, and has treated 42% of such patients who require hospitalisation. One investigator was responsible for asking 251 patients (on the day of their release) who had been hospitalised anytime during the given 6 month period (November 2002 - May 2003) to complete a questionnaire containing approximately 100 items. In order to be eligible for the study, patients had to be older than 16 years and hospitalised for at least 48 hours. 155 questionnaires were completed (62%), and there were 96 patients were notable to participate on the day of their release. Nine of the 14 criteria recommended by the ANAES were met in over 65% of the cases, and three in less than 40%. Following the analysis of the data through logic regression, it remained clear that unit specialising in the care of people who have attempted suicide was better able and equipped to meet the standards of the ANAES' recommendations than a standard hospital medical unit. Visits with a psychiatrist or psychiatric nurse occurred more frequently in the specialised unit (p < 0.04), interviews with the patients' family members were more frequent (p < 0.01), the confidentiality of the discussions from the interviews was more often respected and maintained (p < 0001), and the information provided by the caregivers and staff was more effective in the specialised unit (p < 0.03). One of the main benefits and results of these aforementioned differences is that the patients in the suicide unit more often perceived a distinct improvement in their depression (p < 0.007). All of these arguments indicate that hospitalisation in a special unit provides real benefits to patients, and the results of this study advocate strongly in favour of increasing the capacity of the unit, which is currently limited to only 6 beds.

Acute delirium, delusion, and depression during IFN-beta-1a therapy for multiple sclerosis: a case report.

Adverse effects of interferon (IFN) treatment are common, and efforts to minimize these reactions are of considerable importance. IFN-beta-1a is an established therapy for patients with relapsing-remitting multiple sclerosis (MS). Its psychiatric side effects are debated and not yet fully established. The authors report here the case of a patient on IFN-beta-1a therapy for MS who developed acute delirium, delusion, and depression that ceased with treatment discontinuation. Although he had a history of recurrent major depressive disorder, his prior psychiatric illness had followed a course that was clinically independent of other signs of MS. This observation points out psychiatric vulnerability of patients taking IFN-beta-1a therapy for MS and suggests that IFN-beta-1a may induce or exacerbate preexisting psychotic symptoms.

[Psychiatric complication of an implanted automatic defibrillator]. / Conséquence psychiatrique après l'implantation d'un défibrillateur automatique. A propos d'un cas.

The implantable automatic defibrillator has completely changed the prognosis of potentially fatal ventricular arrhythmias by the delivery of an electric shock in the event of ventricular tachycardia or fibrillation. This vital device is sometimes poorly accepted from the psychological point of view by patients having been traumatised by experiences of sudden death from which they have been rescuscitated. Anxiety and depression are common and they have an important effect on the quality of life. The unpredictable occurrence of painful, multiple and uncontrollable electrical shocks may induce a state of acute stress with stunning, the resemblance of which to the model of learned helplessness described experimentally in the animal by Seligman, is discussed. The authors report the case of a 20 year old man whose automatic defibrillator was activated twenty times in one night. His state of stress and impotence was such that he lay prostate in his bed. Suicide seemed to be the only possible way of escaping from the electrical shocks of the device which was perceived as being dangerous. The management of this condition is not standardised but it requires the collaboration of the cardiac rhythmological and psychiatric teams. Medication with antidepressant drugs alone is not sufficient. The regulation of the sensitivity of the defibrillator gives the patient a feeling of mastering the situation: submission is not total! Research along this line should improve the patients' acceptation of the device and their quality of life.

[Suicidal impulses in patients with chronic viral hepatitis C during or after therapy with interferon alpha]. / Pulsions suicidaires chez des malades atteints d'hépatite chronique C au cours ou au décours du traitement par l'interféron alpha.

UNLABELLED: We report 5 cases of psychiatric side effects in patients treated with alpha interferon for chronic viral C hepatitis. The first case includes depression with suicidal impulses without a suicide attempt; there was a positive rechallenge of interferon. In the second and third cases, depression occurred during interferon therapy, but has not disappeared after interferon withdrawal. In the 4th and 5th cases, depression occurred after interferon withdrawal. Overall, suicide was attempted in 4 cases after interferon withdrawal and was responsible for 2 deaths. The prevalence of suicide attempts during the 6 to 12 months of interferon therapy was 0% compared to 1.3% during the 6 months after interferon therapy (P < 0.05) in 306 patients with chronic hepatitis C treated by interferon in our local area network during the same period. IN CONCLUSION: a) depression does not always disappear after interferon is discontinued; b) regular psychiatric follow-up is justified during treatment with interferon; c) psychiatric supervision should be continued, even more frequently after interferon withdrawal; d) the increased risk of psychiatric side-effect due to interferon as well as their severity suggest interferon should be administered with caution; e) the role of interferon can only be evaluated in controlled studies including the incidence and predictive value of emotional disorders.

[Is an authorization for care necessary for the incapacitated adult?]. / Faut-il une autorisation de soins pour l'incapable majeur?

We report the case of a 30-year-old mentally disabled patient who presented for diagnostic colonoscopy. This patient raised the problem of authorization for such a procedure and the related anaesthetic. The French law of 1968 on the protection of severely incapacitated persons does not clearly solve the problem of the consent for procedures with a therapeutic finality. The distinction relies usually on the extent of the planned act, for asking for an agreement of the guardian, judge of guardianship or the family board. In such cases the problem of the practice of an anaesthetic remains unsolved. For scheduled procedures it is recommended to obtain the written consent of the guardian before any medical act.

[General practitioners' practices and attitudes in regard to suicidal behavior]. / Pratiques et attentes des médecins généralistes à l'égard des conduites suicidaires.

As demonstrated at the recent Consensus Conference on the "suicidal crisis" held by the French Psychiatry Union and the National Agency for the Accreditation and the Evaluation of Care, suicide is recognised as a current public health problem. The general practitioner's role is situated on two levels: in a preliminary stage, the early identification of risk, and in a secondary stage, the provision of care at the time of a suicide attempt and then the provision of on-going follow-up care in partnership with other special services. The study aimed at evaluating general practitioners' practices when encountered with suicidal patients and assessing their management of suicidal behaviour, as well as difficulties met and their expectations. Responses to a questionnaire were received from 290 general practitioners in one regional department in France. The results revealed that two-thirds of the respondents considered the identification of suicidal tendencies as being difficult, in particular with regard to the detection of young people at risk. General hospitals are the most common structures where patients are referred to in the event of a suicide attempt, as a facility that is permanently open and capable of delivering ambulatory care. A majority of the general practitioners expressed the need for training which was focused on methods for the early identification of risk as well as the development of listening skills.

Homicide and associated steroid acute psychosis: a case report.

We report the case of an old man treated with methylprednisolone for chronic lymphoid leukemia. After two months of treatment, he declared an acute steroid psychosis and beat his wife to death. Steroids were stopped and the psychotic symptoms subsided, but his condition declined very quickly. The clinical course was complicated by a major depressive disorder with suicidal ideas, due to the steroid stoppage, the leukemia progressed, and by a sudden onset of a fatal pulmonary embolism. This clinical case highlights the importance of early detection of steroid psychosis and proposes, should treatment not be stopped, a strategy of dose reduction combined with a mood stabilizer or antipsychotic treatment. In addition have been revised the risks of the adverse psychiatric effects of steroids.

Metabolic complications of bypass surgery for morbid obesity.

Postoperative complications resulting from bariatric surgery can lead to severe vitamin-deficiency states. A patient who underwent bariatric bypass surgery and later developed Wernicke's encephalopathy prompted us to present her interesting case history for discussion. Although bariatric surgery is known to be a risk factor for Wernicke's encephalopathy, this diagnosis is only rarely evoked in the postoperative course. We recommend that the occurrence of digestive, psychiatric or neurological symptoms after bariatric surgery should suggest a thiamine deficiency that must be promptly assessed. Without waiting for the results, thiamine supplementation should be initiated.

Study of haemostasis in depressive patients treated with fluoxetine.

The object of this study was to investigate a possible pharmacological effect of fluoxetine on haemostatic function, with special attention on primary haemostasis, in order to explain haemorrhagic complications reported in some treated, depressed patients. The haemostatic function of depressive patients, who required fluoxetine therapy, was studied before and after 1 month of treatment with fluoxetine 20 or 40 mg daily. Exclusion criteria were: pregnancy, initial abnormal haemostatic function, history of coagulation abnormalities, treatment with drugs that interfere with haemostasis, and recent fluoxetine therapy. The following tests were performed: prothrombin time, partial thromboplastin time, thrombin time, plasma fibrinogen, platelet counts, bleeding time, platelet aggregation induced by ADP, epinephrine, ristocetin, collagen, arachidonic acid, and plasma determination of fluoxetine and norfluoxetine levels. Statistical analysis was performed by Wilcoxon paired sample, one-tailed test (alpha=0.05). Among 18 patients included, only eight completed the trial. The single statistically significant difference was a decreased velocity in platelet aggregation induced by epinephrine without increased bleeding time. The results failed to demonstrate any compromised haemostatic function after 20 mg daily fluoxetine therapy in patients with initial haemostatic function. However, the results suggest possible effects of fluoxetine on platelet adrenoreceptors.