A Nurse Is Reviewing the Chart of a Client Who Has Dissociative Amnesia

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Amnesia and Criminal offense

Journal of the American Academy of Psychiatry and the Law Online December 2007, 35 (4) 469-480;

Abstruse

Amnesia for serious offenses has important legal implications, particularly regarding its relevance in the contexts of competency to stand trial and criminal responsibility. Forensic psychiatrists and other mental health professionals are ofttimes required to provide skilful testimony regarding amnesia in defendants. Notwithstanding, the diagnosis of amnesia presents a challenge, as claims of memory impairment may stem from organic disease, dissociative amnesia, amnesia due to a psychotic episode, or malingered amnesia. We review the theoretical, clinical, and legal perspectives on amnesia in relation to crime and present relevant cases that demonstrate several types of offense-related amnesia and their legal repercussions. Consideration of the presenting clinical features of crime-related amnesia may enable a fuller understanding of the different types of amnesia and assist clinicians in the medico-legal assessment and diagnosis of the claimed memory impairment. The development of a profile of aspects characteristic of crime-related amnesia would build toward establishing guidelines for the assessment of amnesia in legal contexts.

The forensic literature is replete with reports of offenders who have claimed total or fractional amnesia for trigger-happy crimes, including murder or attempted murder.^1–fourteen Claims of amnesia have been reported in an estimated range of 10 to 70 pct of homicides. Memory impairment during the commission of crimes has also been reported past perpetrators of domestic violence^15–19 and past sex activity offenders.^1–three,vi

Dissociation and Dissociative Amnesia

While memory disturbances are frequently associated with organic encephalon illness, crime-related amnesia raises the question of dissociation, a term that refers to the disruption of normally integrated functions of consciousness, memory, identity, or perception of the environment. A dissociative state is an altered state of consciousness concurrent with a traumatic experience. Dissociative amnesia, formerly termed psychogenic or functional amnesia, is a disorder characterized by the inability to remember important personal experiences and events later on a traumatic experience of psychological origin.²⁰

Electric current psychiatric diagnostic systems differ in their definition of the term dissociation and in the classification of dissociative disorders. These inconsistencies accept, in part, resulted in defoliation surrounding how dissociation is conceptualized. Spitzer and colleagues²¹ reviewed contempo efforts to clarify the conceptualization of dissociation by distinguishing between types (pathologic versus nonpathologic dissociation) and related phenomena (detachment versus compartmentalization). Pathologic dissociation has been viewed as a chiselled phenomenon characteristic of individuals with dissociative disorder,²² while nonpathologic dissociation has been conceptualized equally a dimensional construct that may range from common daydreaming to severe dissociative disorders.^23–26 Although there is some empirical evidence of a distinction between pathologic and nonpathologic dissociation,^22,27 there is ongoing controversy over its application to clinical diagnosis and classification.²¹

Detachment is thought to arise from intense fear or trauma and has been divers as an altered state of consciousness involving a disconnection from one's sense of self (depersonalization) or the external world (derealization).²⁸ Dissociative amnesia may result when detachment interferes with the encoding and storage of traumatic information.^21,28,29 Compartmentalization is characterized by the failure to command cognitive functions or actions commonly amenable to intentional command (including the inability to bring normally accessible information into conscious awareness).²⁸ The affected functions and related information are preserved and proceed to influence emotion, cognition, and behavior. In this view, dissociative amnesia may represent the compartmentalization form of dissociation and reflect a retrieval deficit that prevents the volitional recall of stored information.

Theoretical Perspectives on Amnesia

Dissociative Amnesia

Diverse frameworks take been put along to account for how and why dissociative amnesia might occur. Many psychological explanations include the proposal that dissociative amnesia serves a protective part of minimizing the agin emotional consequences of trauma, either by impairing encoding of the traumatic experience,³⁰ or by repressing the experience from witting awareness.^10,11 Although repressed retention may exist a plausible caption for dissociative amnesia, the lack of scientific testify of repression has been noted.³¹

Another explanation holds that dissociative amnesia is best understood from a biological and neurological perspective.³² In this view, biological reactions to psychological trauma, such as neuroendocrine dysregulation resulting from farthermost stress, have acute effects on attention and memory encoding and consolidation.^30,32 Repeated exposure to stress may result in widespread alterations in neurotransmission^33,34 and straight effects on encephalon role.^32,35

Studies of glucocorticoid treatment in humans have shown that elevated glucocorticoid levels reduce traumatic memory retrieval^36–40 by inhibiting activity in the medial temporal lobe.³⁷ Acute psychosocial stress may impair delayed memory retrieval in humans.⁴¹ Kuhlmann and colleagues⁴¹ propose that retrieval of emotionally arousing material is specially sensitive to the issue of psychosocial stress.

Information technology has been noted that the distinction between organic amnesia and dissociative amnesia may be arbitrary, as both may be a issue of brain changes that lead to disruptions of memory processes. Markowitsch and colleagues^42–46 described several patients with dissociative amnesia who, compared with nonamnesic patients, showed metabolic brain alterations in retentivity-processing regions. In one patient, positron emission tomography (PET) imaging did not evidence increased correct-hemispheric glucose metabolism during a task requiring autobiographical memory,⁴² whereas another patient displayed substantially reduced glucose metabolism in the right frontotemporal area.⁴⁵ Based on this research, Markowitsch⁴⁷ suggested that the retrieval of autobiographical events is blocked or disrupted every bit a consequence of an imbalance in brain activity in patients with dissociative amnesia. In contrast, Yasuno et al.⁴⁸ plant increased activation in the right anterior medial temporal lobe (including the amygdala) in a patient with dissociative amnesia during a chore requiring explicit retrograde retentivity. In control subjects, bilateral hippocampal region activation was increased during the chore. During recovery from the amnestic state one year later, the subject showed decreased activation in the medial temporal region and increased activation in the right hippocampal region.

Psychiatric accounts of crime-related dissociative amnesia suggest that a dissociative state due to stiff emotional stress is present during the committee of the offense. In this view, dissociation occurs and afterward memory retrieval is impaired past farthermost levels of arousal accompanying offense-related behavior. A heightened state of arousal may inhibit the encoding of an autobiographical memory for the effect,⁴⁹ or the person's own deportment may be the source of the stress, impairing encoding and producing the amnesia.^31,50 Still, the premise that dissociative amnesia stems from concurrent loftier emotional stress has been questioned, based mainly on the argument that amnesia does not always develop for events that are accompanied past strong emotional reactions.⁵¹

Amnesia Due to a Psychotic Episode

Crime-related amnesia may occur due to the presence of a psychotic episode. Psychosis is associated with an increased prevalence of tearing crime, including homicidal behavior.^52–59 Taylor and Kopelman¹⁴ reported that 7 of nineteen offenders who claimed amnesia for their violent crimes had a principal diagnosis of schizophrenia. A contempo study of the psychiatric aspects of 118 cases of criminal homicide establish that psychotic disorder, mainly paranoid schizophrenia, and alcohol intoxication accounted for the offenses of 24 pct of offenders who claimed amnesia for their crimes.⁶⁰ It has been suggested that the presence of psychosis impairs attention, impeding the encoding of events.^2,9

Amnesia Due to Sleep Disorders

Amnesia for crime may also exist associated with sleep disorders. There are several case reports of amnesia for violence, including homicide, committed in a land of sleepwalking (somnambulism)^61–68 or sleep terror.^69,lxx Shapiro and colleagues⁷¹ describe a parasomnic behavior (termed sexsomnia) based on a example series of xi individuals who initiated sexual behavior while asleep. All of the individuals claimed to be unaware of their beliefs. Three cases faced legal charges pertaining to the sexual behavior. Polysomnographic features of parasomnia were revealed in sleep studies of all (9) tested individuals. The authors note distinguishing features of sexsomnia and propose that sexsomnia exist viewed as a distinct variant of sleepwalking.⁷¹

Clinical Perspectives on Criminal offense-Related Amnesia

In clinical practice, at that place is a need to distinguish betwixt different types of claimed memory damage, including amnesia caused past organic affliction, dissociative amnesia, amnesia due to a psychotic episode, and feigned or malingered amnesia. Several clinical and criminal offence-related features have been observed in offenders who claim amnesia for crimes.

Amnesia for an law-breaking is commonly associated with excessive consumption of alcohol, with or without concurrent use of other licit or illicit drugs and may be classified as a dissociative or an organic form of amnesia. When viewed as an organic class, amnesia resulting from intoxication generally involves extreme peak levels⁷² and a longstanding history of alcohol corruption.^2,6,73 Memory impairments produced by alcohol have been linked to a disruption of hippocampal function by ethanol, which directly alters hippocampal neural activeness and interacts with neurons in afferent encephalon structures (for a review, see Ref. 74). Memory loss due to alcohol intoxication may occur because of an encoding deficit that results in a "coma" of the offense.

The state-dependent memory theory⁷⁵ is invoked to account for the combination of dissociative amnesia and alcohol or drug employ. In this theory, memories encoded during intoxication cannot exist retrieved unless the intoxication is reinstated. Every bit some researchers take found a correlation of learning and memory with mood state,⁷⁶ the state-dependent memory theory may warrant further investigation and research. Conversely, Wolf⁷⁷ showed that when a significant amount of alcohol was given to homicide offenders claiming amnesia for crimes committed under the influence of alcohol, the offenders continued to study retentiveness loss for details of their crimes.

Organic Amnesia

Organic amnesia is caused by a structural defect such as traumatic encephalon injury, neurologic disease, or acute alcohol or drug intoxication. Organic retrograde amnesia occurs virtually often with bilateral damage to medial or anterior temporal or prefrontal brain regions.⁴⁷ The right temporofrontal region is thought to exist important in the retrieval of by personal emotional events.⁷⁸ However, every bit organic pathology is normally indicated by failures of retention of data,^two problems with memory storage rather than retrieval may underlie the retention dysfunction in organic amnesia.⁷⁹

Individuals with organic amnesia often show an emotional flattening and reduced insight into their condition.⁴⁵ Crime-related organic amnesia is oft for events of lengthy duration and may be for events not directly related to the offense.² The memory impairment is permanent and may be complete or partial.^ii,73,80

Dissociative Amnesia

Studies of dissociative amnesia in relation to criminal behavior report an association betwixt a claim of amnesia and several variables relating to the offense or to the offender. Although there are reports of full or complete dissociative amnesia, it is commonly described as a hazy or patchy memory for events straight related to the criminal offence and localized to the actual time of the act itself.² The amnestic menstruation has a sudden onset^two and has been described as blurred at the start and cease.⁷³ While few studies accept examined follow-up data regarding recovery of retentivity, in that location are reports of transient retentivity loss for crimes.^73,lxxx

Dissociative amnesia is associated with crimes that are committed in a state of extreme emotional arousal and in which the victim is known intimately by the offender.^{2,12,14–19,73,79,81} Frequently, the crime is unplanned and no motive is discernible.^14,73,79 The incidence of amnesia claims increases with the severity of the violence.^{ane–3,12,xiv,49,82} Crime-related dissociative amnesia is associated with alcohol abuse,^{1,xi,xiv,xviii,73,79,80,83,84} and alcoholic offenders may be over-represented.⁴

In a recent Canadian case, a nurse experienced a dissociative episode when an elderly bedridden patient yelled at her for accidentally spilling a bedpan. With her emotional triggers setting off her dissociative behavior, she did not call back using a metal table leg to strike repeatedly and impale the patient, who died of a astringent encephalon injury. She had had previous amnestic episodes and received a diagnosis of dissociative disorder. Her dissociative behavior is thought to be based in part on a deprived childhood and sexual abuse. She was found not to exist criminally responsible for the criminal offense.⁸⁵

Some studies of dissociative amnesia for crimes report that offenders who merits memory loss are more likely than nonamnesic offenders to accept a history of alcoholic or dissociative blackouts non due to organic causes, or a previous psychiatric disorder.^14,73,80 Depressive symptoms take been reported in offenders claiming amnesia for their crimes.^11,14

An investigation of the role of personality factors in crime-related amnesia found that offenders who claimed partial amnesia for their crimes scored college than nonamnesic offenders on measures of introversion and lower on measures of impulsivity and hostility.^{half dozen} In a study of 105 defendant homicide offenders, Parwatikar and coworkers¹¹ reported that those who claimed amnesia for their crimes scored higher on the neurotic triad scales of the MMPI. Other psychological characteristics, such equally relatively low intelligence and manipulative beliefs, including the tendency to feign symptoms, have been noted in offenders who claim amnesia for their crimes.^{3,9,eleven,84} Notwithstanding, other research establish no evidence to advise that offenders who claimed amnesia for their crimes had lower intelligence levels.^four

Offenders who merits amnesia for crimes are, on average, older^{four,14,eighty} and may have more prior convictions than those who do not claim amnesia.⁴ It has been noted that offenders who claim crime-related dissociative amnesia frequently alert the police to their crimes⁷⁹ and are less likely to deny the law-breaking than are those who exercise non merits amnesia.^31,lxxx

Dissociative Identity Disorder

Dissociative identity disorder (DID; formerly termed multiple-personality disorder) is considered to be a astringent dissociative disorder. The DSM-IV²⁰ characterizes DID past the presence of at to the lowest degree two distinct identities that, in turn, take command of the individual's behavior. Retentivity dysfunction is a key diagnostic criterion of DID.²⁰ The post-traumatic model of DID proposes that the disorder stems from a natural defensive reaction to farthermost childhood trauma that results in dissociative states (viewed as separate identities) in which memories of traumatic events are stored.^86–89 In this model, dissociated memories of experiences may exist partially or totally inaccessible for voluntary retrieval by some dissociative identities (interidentity amnesia).^xc–92 Interidentity amnesia may be one-style (asymmetric) or 2-way (symmetric) and can coexist in an private with DID.⁹⁰

Controversy surrounds the diagnostic validity of DID. While results of studies on interidentity amnesia in dissociative disorders indicate that explicit memory appears to be diminished in DID (for a review, see Ref. 93), skepticism has been raised, in part by reports of cases of DID with apparent malingering^94–97 and assertions that symptoms of DID cannot be reliably distinguished from malingering.^98–100

The potential for malingering presents a significant claiming in forensic assessments of offenders diagnosed with DID and challenge amnesia for violent crimes. Perr¹⁰¹ reviewed a case in which a 49-year-sometime human (Mr. A) was given a diagnosis of multiple personality disorder (MPD) in 1975, ten years before he was charged with the murder of his girlfriend. He denied any noesis of the homicide, just stated that i of his other personalities, Billy Ray, may have committed the murder. While Mr. A claimed to have no personal awareness of his alternate personalities, others reported several experiences with Billy Ray, described as a sociopathic personality that displayed baroque, threatening, and violent behavior.

Extensive corroborative reports of Mr. A'southward history of vehement beliefs and psychiatric records were available for a 9-twelvemonth period before the homicide. Mr. A had received several diagnoses in add-on to MPD, including paranoid schizophrenia, bipolar disorder with psychotic features, major depression, psychotic depressive reaction, and alcohol abuse. Longstanding periods of amnesia and fugue states were indicated. Despite Mr. A'due south psychiatric history, a mental status review xi months subsequently the homicide revealed no signs or symptoms of mental illness, raising the concern of possible malingering. Nonetheless, extensive records and observations supported the existence of a severe and chronic condition, and Mr. A was establish non guilty by reason of insanity.¹⁰¹

Amnesia Due to a Psychotic Episode

Amnesia for crime may result from impairments of attention due to the delusional thinking characteristic of near types of schizophrenia. Nevertheless, some psychotic individuals have no obvious delusions or hallucinations but display outbursts of violent behavior, including homicidal behavior, for which there is no discernible motive.¹⁰² Clinical features include denial of the illness and amnesia for schizophrenic outbursts. This occurs mostly in individuals with disorganized schizophrenia, which is characterized by severe disorganization of thinking and behavior.

Nolan and colleagues¹⁰³ assessed the extent to which psychosis, matted impulse control, and psychopathy contribute to assaultive behavior of psychiatric inpatients, most of whom had a diagnosis of schizophrenia or schizoaffective disorder. Factor analysis of assailant interview ratings revealed that positive psychotic symptoms (i.e., delusions and hallucinations with threatening content) accounted for most xx per centum of assaults. However, the analysis also showed a high loading for "amnesia," indicating frequent endorsement of items indicating assailants' inability to provide a reason for the assault or lack of retrieve of the event itself. Nolan et al. suggest that psychotic confusion and disorganization may contribute to aggression by causing assailants to misunderstand the actions of their victims.

Amnesia due to a psychotic episode is illustrated in a case examined by one of the authors (DB), of a human in his early 20s who was involved in repeated incidents of physical assault on adolescent victims. The homo's beliefs and thinking were severely disorganized, and he was unable to provide a coherent account of the incidents. His psychotic state and disorganized, unpredictable behavior had developed in a progressive fashion. Collateral information from his relatives revealed that his overall level of functioning had significantly declined over the previous two years. While the homo was reclusive and withdrawn, his parents had observed numerous instances of abnormal and bizarre beliefs. His diagnosis was schizophrenia, disorganized type.

Psychotic features (i.east., delusions and auditory and/or visual hallucinations) occur relatively ofttimes in major depressive episodes.¹⁰⁴ While information technology has been reported that psychotic depression is more than severe than nonpsychotic depression,¹⁰⁵ Ohayon and Schatzberg¹⁰⁴ determined in a full general population written report that low with psychotic features was non associated with severity. These authors found that feelings of worthlessness or guilt were frequently associated with psychotic features.

Malmquist¹⁰⁶ proposed that most depressed individuals who commit homicide are of the psychotic blazon. Depressive disorders have been reported frequently in parents who have murdered their children.^107–111 In a recent study of fathers who had committed filicide we adamant that psychotic elements were present at the fourth dimension of the criminal offense in 12 (39%) of the 31 cases in which the diagnosis was depression.¹⁰⁹

Amnesia Due to Sleep Disorders

Current DSM-4 criteria for sleepwalking disorder include behavioral arousals in slow-wave sleep, unresponsiveness during the episode, confusion or disorientation afterwards awakening, and amnesia for the episode after full awakening.^xx Disturbed psychological performance can continue for as long every bit one hour after an episode of violent behavior.⁷⁰ Slumber terror disorder differs from sleepwalking disorder by the presence of autonomic and emotional arousal. The two parasomnia disorders may occur in the same episode and may overlap.⁷⁰ In both disorders the trigger-happy behavior typically follows an episode of partial arousal from early non-REM sleep, usually within 2 hours subsequently sleep onset.¹¹² This episode of partial arousal from deep slumber is characterized by the appearance of waking brain functioning in some simply not all brain areas.^lxx Highly complex activities tin be engaged in for extended periods during both sleepwalking and sleep terrors.^70,113

A recent comprehensive review of not-REM parasomnias in adults¹¹⁴ concludes that sleepwalking may result from the interaction of physical and environmental factors in a genetically susceptible individual. Factors that may contribute to the onset of sleepwalking episodes by increasing ho-hum-moving ridge sleep or making arousal from sleep more than difficult include prior ingestion of alcohol, drugs, and (or) medication, prior slumber deprivation, and situational stress.

A review of 50 reports of sleepwalking violence noted that the fierce behavior was often described as unpremeditated.¹¹² Well-nigh of the offenders were men between the ages of 27 and 48, with a marked personal and/or family history of parasomnia disorders.

Several features may distinguish sexual behavior in sleep from other parasomnias such as sleepwalking.⁷¹ In most cases, sexsomnia originates from non-REM sleep and occurs at whatever time during sleep. There is widespread autonomic activation, and sexual arousal is often (but not ever) nowadays. Violence or injurious behavior occurs infrequently.

In their written report of nine men and ii women who initiated sexual behavior while comatose, Shapiro and colleagues⁷¹ reported that about had a personal and/or family unit history of parasomnia (sleepwalking, sleep talking, and slumber terror). Other related diagnoses included sleep apnea and paraphilia, post-traumatic stress disorder, major depression, schizophrenia, and developmental filibuster.¹ Five of the individuals had a history of substance corruption or used booze in excess earlier the effect. Ages ranged from 16 to 43 years.

Sexsomnia is illustrated in the instance of a 49-year-erstwhile man who was charged with sexual assault on a 14-twelvemonth-old girl after he had entered the girl'due south bed and fondled her. The man presented a defense of being in a state of somnambulism when the event occurred, and his girlfriend testified that he often initiated sex with her while sleeping. Even so, the court found him guilty. As the man was not considered to be a take chances to society, he was given absolute discharge and two years' probation.¹¹⁵

Malingered Amnesia

Some other interpretation of crime-related amnesia acknowledges the likelihood that some offenders intentionally fabricate memory loss to avoid punishment for a offense or for other personal proceeds. While an early report reported that 20 per centum of the offenders challenge amnesia were fabricating the memory loss,⁷³ it has been suggested that the rate of malingering is higher.¹¹⁶ The likelihood of malingered amnesia may be greater in offenders with antisocial personality disorder.^31,84 Using polygraphy, Lynch and Bradford⁸⁴ showed that offenders with antisocial personality disorder accept a higher propensity to feign amnesia for crimes, compared with those with no personality disorder or other psychopathologic disorders. Information technology has been suggested that offenders with antisocial personality disorder may be prone to malingering amnesia for crimes in role because of the tendencies of manipulation, habitual cant, and a general poverty in major affective reactions that characterize this disorder.^31,84 Other authors have noted the possible contribution of low intelligence and frontal executive dysfunction to the feigning of amnesia for crimes.^iii,117 All the same, as it is possible that highly intelligent malingerers are more adept at feigning amnesia for crimes and may thus evade detection and less oft receive a diagnosis of malingering, further research may assist to clarify a link between low intelligence/frontal executive dysfunction and feigned amnesia.

Legal Perspectives on Amnesia

Amnesia for serious offenses has important legal implications in the contexts of competency to stand trial and criminal responsibleness. As per the competency standard set by Dusky v. U.Due south.,¹¹⁸ amnesia could return a defendant incompetent to stand trial because memory loss for the events would prevent him or her from having a reasonable degree of rational agreement and restrict his or her ability to assistance counsel in the preparation of his or her defence. Moreover, Tysse¹¹⁹ points out that considering of the defendant's disability to help in his or her own defense, he or she could non accept a fair trial, as he or she might not be able to employ some circumstance meaning to his or her own defence. The issue of competency to stand trial was addressed in the famous case of Wilson v. U.S.¹²⁰ Robert Wilson sustained a serious head injury in a motor vehicle accident while allegedly attempting to escape from the scene of a robbery. When he regained consciousness iii weeks later, Mr. Wilson reported that he had no recollection of events surrounding the offense. While an initial hearing concluded that Mr. Wilson was suffering organic amnesia and was incompetent, a second hearing found him competent to stand trial despite his continued reported inability to remember the relevant events of the crime. Mr. Wilson was subsequently tried and convicted. In that decision, the U.S. Court of Appeals, DC Circuit, ruled that a lack of retentiveness for an alleged offense does not automatically establish incompetence. The U.S. Court of Appeals concluded that six factors should exist addressed in evaluating the impact of amnesia on a defendant's ability to stand trial. These factors involved the accused's ability to consult with and assist his chaser, the extent to which the retention loss affected the defendant's ability to prove and to reconstruct evidence extrinsically; the extent to which the government assisted in that reconstruction; the force of the prosecution's case; and whatsoever other general factors relevant to the case.

Regarding cases involving psychosis, a disordered thought procedure or delusions may render a defendant incapable of a rational understanding of charges, or limit his total appreciation of a faced judgement. However, the presence of psychosis is not sufficient in itself for a finding of incompetency to stand trial if the accused is considered able to consult with his or her lawyer and participate in the legal process (for a review, run into Ref. 121).

Amnesia for serious offenses has particular relevance in the context of criminal responsibility, every bit it may signal automatism, which refers to criminal behavior that is not voluntarily controlled and is executed without intent. In Canada, the automatism defense is either insane (mental disorder) or non-insane (nonmental disorder) automatism. Insane automatism applies to a crime arising from organic brain dysfunction, signifying an involuntary action resulting from a disease of the mind (and therefore a defense of mental disorder and a verdict of non criminally responsible past reason of mental disorder). Non-insane automatism refers to a offense attributed to involuntary activeness due to a transitory impairment of mental functioning which does not stem from a disease of the mind (entitling the accused to an acquittal, if successful).

The Automatism Defence

In Canada in 1971, the automatism defense force was extended to include automatism induced by psychological trauma, a state of dissociation also referred to as psychological blow automatism. The first Supreme Court case dealing with psychological accident automatism was R. v. Rabey,¹²² in which a 20-year-former Academy of Toronto student, infatuated with a female student, had learned that she thought of him as a "nothing." The next mean solar day, he met the woman by chance, hitting her on the head with a rock he had obtained from the geology lab, and tried to strangle her. He had amnesia for the event, and afterward was extremely confused, dazed, and emotionally distraught. The trial guess put the issue of non-insane automatism to the jury, which acquitted. On entreatment, information technology was determined that the trial judge erred in his finding of non-insane automatism, and a new trial was ordered. The Court made the distinction betwixt internal and external causes of automatism, based on theories that suggest that a status stemming from the psychological or emotional make-up of the accused, rather than some external gene, should lead to a finding of insanity. On the basis of that distinction, the majority decided that an internal, psychological accident such equally the accused suffered was bereft to cause non-insane automatism.

In 1992 the Supreme Courtroom of Canada considered the example of R. v. Parks,¹²³ in which the accused, while sleepwalking, collection to the home of his in-laws, murdered his mother-in-law, and severely injured his father-in-constabulary. He and then confessed his actions to the police. The trial judge put the plea of non-insane automatism to the jury. At that place was no event over the voluntariness of the accused's actions; the jury accustomed the expert bear witness that the defendant was sleepwalking. The defendant was acquitted of both charges. In addressing whether somnambulism is a disease of the heed, the court focused on the continuing danger theory, which holds that any condition likely to nowadays a recurring danger to the public should be treated as insanity. The courtroom assessed the likelihood of recurrence of the violent beliefs and upheld the acquittals.

In the landmark Supreme Court of Canada case of R. v. Rock,¹²⁴ a 42-year-old man accused of murdering his wife while plainly in a dissociative country raised the defenses of provocation and non-insane automatism based on a psychological accident. The deceased had been making insulting comments directed toward his virility and most the fidelity of his former married woman, comments described past the defense skilful equally "uncommonly cruel, psychologically sadistic, and profoundly rejecting." The accused went into an automated state and stabbed his married woman 47 times. He disposed of the body and left the jurisdiction, but returned a few weeks later and surrendered to police. The jury ruled that the defendant was not suffering from a disease of the mind. The defense force of automatism was rejected, and the accused was bedevilled of manslaughter, based on the provocation defence. Appeals from conviction and against the Crown's sentence were dismissed.

The law of automatism was rewritten in the Rock case. Earlier the case, unconsciousness was viewed every bit the predominant element in a state of automatism. Yeo¹²⁵ noted that the Stone case clarified that unconsciousness need not be in a land of automatism; rather, the important element in automatism is whether criminal behavior is involuntary or not. Automatism was redefined as a state of impaired consciousness in which an private, though capable of action, has no voluntary control over that activeness, and two types of automatism were delineated (insane and not-insane). It was also determined that a single arroyo to all cases involving claims of automatism would exist taken, as automatism may ascend in unlike contexts (i.due east., psychological blow automatism, somnambulism, and extreme intoxication akin to a country of automatism).

The principles contained within the Stone instance form the footing under which any defense of automatism must proceed. The get-go stage of the automatism assay sets out what an accused must do to satisfy the evidentiary burden of automatism, to establish a proper foundation for such a defense. The second stage determines whether the automatistic state is due to a affliction of the mind.

To satisfy the evidentiary brunt of automatism, the defendant must claim that he or she acted involuntarily at the relevant time, and the defence must present expert psychiatric evidence confirming its claim. More weight is given to medical testify if the defendant has a history of automatistic-similar dissociative states. The automatism assay must likewise consider the nature of the alleged automatism trigger. Finally, the assay must consider whether there is evidence of a motive for the criminal offence. A motiveless deed would more often than not lend plausibility to a claim of involuntariness.

If the accused has laid proper foundation for the defense force of automatism, it must and then exist determined whether the alleged automatistic state was caused by a disease of the mind. Two distinct approaches may be taken: the internal-crusade test and the continuing-danger test. Nether the internal cause theory, developed in the context of psychological-blow automatism, the defendant's automatistic reaction to the psychological blow, the alleged trigger, is assessed from the perspective of an ordinary normal private experiencing the same stressful circumstances. If it is adamant that a normal individual would accept reacted in a like manner by experiencing an automatistic land, a defense of not-insane automatism would be supported, equally the cause of the automatism would be considered to be an external result and not due to the psychological or emotional grapheme of the accused.

Under the continuing-danger theory, the likelihood of a recurrence of violence that would present a danger to the public suggests a illness of the listen. Particularly relevant in the examination of this factor are the psychiatric history of the accused and the likelihood that the alleged trigger would recur. A documented history of automatistic-like dissociative states suggests a recurring nature. The greater the anticipated frequency of the trigger in the accused's life, the greater the chance posed to the public, and therefore the more probable that a disease of the mind is present.

In determining whether the declared condition is a illness of the mind, other factors must as well be considered, including the possibility that the automatism is feigned. This gene is particularly relevant in cases in which consideration of the internal cause and continuing danger factors solitary does not allow a conclusive answer to the question of disease of the listen.

If the guess determines that there is a disease of the mind, then the defence force of insane automatism is left to the jury, who decides whether the accused has proven on a balance of probabilities that he or she suffered from a mental disorder that rendered him or her incapable of appreciating the nature and quality of the human activity in question. A positive decision results in a disposition of not criminally responsible past reason of mental disease. If the approximate determines that at that place is no affliction of the heed, then the defense of non-insane automatism goes to the jury, which decides whether the defence force has proven that the accused acted involuntarily on a residue of probabilities. A positive decision results in absolute acquittal.

The conclusion in Stone has been applied to subsequent cases, including R. v. Campbell,¹²⁶ in which the accused was charged with attempted murder subsequently he attacked his sleeping girlfriend with a pocketknife while he was sleepwalking. There was no trigger and no motive for the attack. The judge accustomed that the accused was in fact sleepwalking at the fourth dimension of the attack, and therefore the attack was non voluntary. Nevertheless, the judge also constitute that sleepwalking represents a continuing danger to the public with an internal cause, and therefore somnambulism is a disease of the mind. The accused was institute non criminally responsible by reason of mental disorder.

Discussion

Memory damage for crimes is a controversial issue with clinical and legal implications. Claims of amnesia are quite mutual in clinical practise, and because dissociative states fall nether a defence of mental disorder in Canada, forensic psychiatrists and other mental health professionals are ofttimes required to provide expert testimony in cases involving amnesia in relation to offense.

Dissociative amnesia ofttimes has legal repercussions, in part due to its relevance to the legal constructs of competency to stand trial and criminal responsibleness. Amnesia can affect an individual'due south competency to stand trial if he or she cannot plead or advise the lawyer. Experiencing a dissociative state can decrease an individual's chapters to control his or her deportment and therefore diminish criminal responsibility. Moreover, defendants who claim amnesia are usually regarded equally having express credibility or are fifty-fifty disregarded considering of the inherent possibility of malingering. When a defendant claims not to call back the event in question, the court can have considerable difficulty formulating a decision. Wrongful decisions regarding the authenticity of an individual's amnesia can exist very plush, with the consequence that lighter or harsher sentences are given than is just.

The controversy surrounding crime-related amnesia is in part due to the potential for fabrication of memory loss. Undoubtedly, some practise feign amnesia for their crimes. Nonetheless, genuine amnesia for crimes is often seen in clinical practice, whether due to a dissociative state, a psychotic episode, or organic causes. In accepting evidence supporting the validity of amnesia claims, it seems clear that the of import issue should be determining how to distinguish between genuine amnesia, whatever the cause, and malingered amnesia in cases raising an index of suspicion. Despite several attempts to solve this dilemma,^{ii,xi–13,84} in that location is still no clear reply. While case studies advise the efficacy of the Symptom Validity Exam (SVT) in identifying malingered amnesia,^127,128 others take argued that the SVT lacks sensitivity.¹²⁹ Moreover, limitations to its use in the clinical or forensic setting have been noted (east.g., Ref. 116). As the potential volition ever exist for offenders to feign memory loss for their crimes, it seems important that time to come studies focus on developing and testing valid and reliable screening and diagnostic tools to assess the likelihood of malingered amnesia.

In a medico-legal context, forensic psychiatrists examining individuals who have committed a homicide are required to offer an opinion on the mental state of the person at the time of the criminal offence. In clinical practise, information technology may exist hard to differentiate between organic, dissociative, and malingered amnesia solely on the ground of interviews with the accused. While repeated interviews allowing the creation of a bond betwixt an individual and a mental health professional may encourage recollect of the event, a proper diagnosis requires a thorough investigation using a multidisciplinary and multitechnique arroyo. An evaluation of the individual's verbal and nonverbal behaviors that could indicate possible malingering should be undertaken during interviews relating to the event in question. Self-report questionnaires such as the Structured Inventory of Malingered Symptomatology¹³⁰ tin can exist used to evaluate the tendency to exaggerate retentivity complaints (indicative of malingering). The Dissociative Experiences Scale¹³¹ can exist employed as a screening instrument for dissociative symptoms, and structured interviews such as the Dissociative Disorders Interview Schedule¹³² can be used to assess whether the individual has a dissociative disorder. While DSM-IV criteria are a useful tool, all relevant information, including clinical history and assessment, collateral information, and past and present behavior should exist considered in a primary diagnosis. Whatsoever history of alcohol and other substance misuse should be established. The blueprint and characteristics of the claimed amnesia should be investigated, and a history of previous dissociative or amnestic incidents determined. Further enquiry should be made into the presence or absence of any condition or trigger probable to accept produced dissociation, reasonableness of business relationship in lite of the specified circumstances, and collateral observations, all of which would provide invaluable clinical data in assessing claims of amnesia in a legal context.

Regarding claimed amnesia due to sleep disorders, Horn¹³³ contends that difficulty in evaluating claims of sleepwalking is acquired by the beingness of three unlike sleepwalking defenses amid U.S. courts (i.due east., classifying sleepwalking equally an unconscious defence force, People 5. Sedeno ¹³⁴; an automatism defence force, McClain 5. Indiana ¹³⁵; or an insanity defence, Bradley v. Country ¹³⁶). Horn¹³³ notes that the legal nomenclature of sleepwalking based on involuntary mental incapacity (unconsciousness), physical incapacity (automatism), or insanity is not supported by medical show on sleepwalking, and proposes that the credibility of a sleepwalking defense should be assessed using a test of objective criteria based on empirical medical research that suggests that sleepwalking is a physiological condition (and not a psychological disorder). A decision every bit to whether a accused was sleepwalking during an alleged crime may exist enabled past consideration of the private'south predisposition to sleepwalking, the existence of precipitating factors associated with sleepwalking, and the elapsing between sleep onset and the fourth dimension the criminal human activity took place.

While it is beyond the scope of this article to provide an in-depth review of neuropsychological and neuroanatomical studies of retentivity, advances in neuroimaging techniques and the evolution of new paradigms and theories on the human memory system serve to remind us that much remains to be learned in the expanse of normal and dysfunctional or abnormal retentiveness.¹³⁷ From a physician-legal perspective, a meliorate agreement and determination of cognitive capacities in an individual presenting with a memory disorder is likely to bear on assessments of fitness and criminal responsibleness. The fact that a brain injury or brain damage contributing to the amnesia tin can be demonstrated objectively would exist of invaluable assistance in the context of a forensic psychiatric assessment.

A review of the literature reveals several clinical features observed in cases of crime-related amnesia. Consideration of the characteristics of the study of the event and of the individual challenge memory loss may facilitate an evaluation of the amnesia. As it now stands, the forensic assessment of individuals who claim amnesia represents a most interesting challenge. Further inquiry aimed at delineating such features would be useful, every bit developing a profile of aspects characteristic of crime-related amnesia would enable a fuller clinical understanding of the different types of amnesia and build toward establishing important guidelines for the issue of dissociative amnesia in legal contexts.

• American Academy of Psychiatry and the Law

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