Introduction

In Turkey, the need for cooperation between forensic medicine and psychiatry is increasing. All kinds of firearm and blast injuries, stab wounds, traffic accidents, falls, assault injuries, industrial injuries, intoxications (drug, insecticide, chocking agents), burns (flame, hot liquids, heated solid objects, or hot gases) electric shock and lightning strike injuries, suicide attempts, torture victims, suspicious deaths and sexual assault victims should be considered as forensic cases (1). Owing to the legal requirements in Turkey, all physicians are required to have the necessary knowledge to prepare forensic reports and it is evident that such reports should be prepared properly (2).

Forensic report means a report prepared by individuals with specialized knowledge or training that is used in the course of an investigation into an alleged offence, and this report sets out the results of a forensic examination in the form of facts or opinions or a combination of both (3). Forensic reports have an important role in the protection of personal rights and in the decisions of the judiciary. If there is an element of crime according to the medical and physical examination of the patient, the report should include more detailed information about wounds and diagnosis. Psychiatric assessment for legal purposes should be multidimensional. Data obtained via mental state examination and history taking can be utilized to make a decision about important issues, such as the means of assault, criminal responsibility, capacity of emotional self-preservation, or penalty suspension (4). To understand the relationship between the act of law and physical and psychiatric disorders, physical and psychiatric evaluations must be performed thoroughly (5).

Following a traumatic injury, the instrument of crime can cause simple lesions or life threatening injuries. Besides this, psychiatric symptoms like anxiety, unhappiness, crying spells, sleep disturbances, deterioration of interpersonal relationships, compliance problems and decrease in problem solving skills may accompany physical findings (6). Relatively recently, a notion for psychological state and/or response has been incorporated into article 86 /1 of the Turkish Penal Code (TPC), more specifically, concerning the following clause: ‘injury excruciating one’s body/result in deterioration of physical health or perception ability’ (6).

Most of the time, symptomatology is enough to make a psychiatric diagnosis, but sometimes, subthreshold symptoms may be present, thus making the assessment and diagnosis difficult. Patients with psychiatric diagnosis should undergo medical treatment and follow up to understand and decide if the condition is temporary, persistent. The severity of the condition and the functionality of the person determine the follow-up period (7).

In addition to having a role in preventing legal penalties, forensic psychiatry also has a duty to protect individual rights in persons with psychiatric problems. Under current laws, one should be mentally healthy to have criminal liability and to exercise civil rights (5). In this context, sometimes courts may require psychiatric expert testimony. Rehabilitation, treatment, protection of civil rights and re-integration of people with mental illness is under the responsibility of psychiatrists.

With this study, our aim was to investigate the clinical features of victims (persons injured) and offenders (those committing the offences) evaluated by the forensic medicine department who had been referred for psychiatry consultation.

Materials and Methods

Judicial cases directed from legal authorities and administrative institutions to the forensic medicine department are evaluated by forensic specialists and, if necessary, referred to the psychiatry department for consultation.

The records of 177 cases evaluated by forensic specialists and were consulted to the psychiatry department between June 1, 2016 and December 31, 2017 are investigated retrospectively. Age, gender, marital status, education, occupation, city of residence, location of crime or scene, psychiatric diagnosis, presence of previous criminal records, time between application and reporting of the offence, presence of previous sexual, physical abuse and emotional neglect of victims and offenders recorded. The research protocol gained approval from the Ethics Committee of Aydın Adnan Menderes University Faculty of Medicine (protocol no: 20171273, date: 07.12.2017).

Statistical Analysis

Data is analyzed with the SPSS version 20 statistical software. Normal distribution of the sample is tested by Kolmogorov-Smirnov analysis, and because the sample is normally distributed the Student’s t-test was used for the comparison of numeric variables and chi-square tests were used for the comparison of categorical variables between groups.

Results

The study group was divided into two subgroups, victims (n=72) and offenders (n=105). Mean age of offenders was significantly lower than the mean age of victims (p=0.008). The frequency of male gender (p<0.001), the number of unemployed individuals (p=0.026), and the number of unmarried or divorced cases (p=0.013) were significantly higher in offender group (Table 1). Axis I comorbidities consisted of mental retardation (n=14), psychotic disorder (n=4), organic psychotic disorder (n=3), bipolar disorder (n=2), anxiety disorder (n=2) and depression (n=4) in victims; whereas, in the offender group, 30 subjects did not have any psychiatric disorder, 13 had mental retardation, 26 had psychotic disorder, 10 had bipolar disorder, 20 had addiction disorder, 3 had anxiety disorder, 2 had depression and 5 individuals had organic mental disorder. Psychotic disorder, bipolar disorder and addiction frequencies were significantly higher in the offender group (p<0.001). Among victims, 4 had previous criminal record; whereas, in the offender group, 36 had previous criminal records (p=0.001) (Table 2).

Decision timeline between the date of application and the settlement was 71 days in victims and 39 days in offenders. History of sexual abuse was reported by 23 cases, physical abuse by 14, physical neglect by 9; however, history of sexual abuse was reported by 5 cases, physical abuse is reported by 3, physical neglect is reported by 1 case. Having a history of physical neglect and abuse or sexual abuse were significantly more common in the victim group (p<0.001) (Table 3). When we investigated the reasons for application to our department, sexual crimes ranked first, assault crimes ranked second, and traffic accidents ranked third in the victim group. Among offenders, the leading causes for admission were: assault, theft, traffic accidents, and threat-insult crimes.

We found that judicial events mostly occurred during winter (51 events), while 34 events occurred in the spring and 30 occurred during summer. Interestingly, only 4 events occurred in the autumn season. Life threatening events in the victim group were gunshot wounds, assault and traffic accidents, respectively.

Within the contexts of the TPC articles, 31/2 and 32/1-2, 72 cases were examined to ascertain their ability to perceive the legal meaning and consequences of their acts and to determine whether they had developed cognitive capabilities to direct these behaviors. In 31 cases, it was decided that the individuals in question perceived the legal meaning of their actions and had control over their behavior. Eleven cases were deemed to have partial reduction in perceiving the legal meaning and consequences of their actions and the ability control their behavior (TPC 31/2). Eighteen cases were found to be incapable of perceiving the legal meaning and consequences of their actions and were deemed to be unable to control their related behaviors (TPC 31/1).

Discussion

The mean age of victims was 39.90 and offenders was 33.56 years in this study. In the literature, the mean age of judicial cases who are consulted to psychiatry are often reported to be between the ages of 21 and 30 years. People between this age range are actively taking part in daily life, and therefore, have higher probability to be involved in a judicial events (1-3). For the victims, mean duration of education was 7.8 years, while it was 6.6 years for offenders. Previous studies indicated that the education level of the people who are involved in crime is usually low, and lower education level seems to be related with recurrent criminal behavior (8,9). Male predominance among offenders is a frequently reported in previous studies (10-13). In the present study, male gender ratio is 83.8% among offenders which similar to results reported by some studies. Risk of development of conduct disorder, criminal behavior, antisocial personality and similar behavior patterns is increased with trauma in offenders, and this may explain the reason for the crime tendency in male gender (13,14-16).

According to the current results, the percentage of unemployed individuals was higher in offenders. Unemployment may be a contributor factor for tendency to commit crime. The number of unmarried cases was higher in offenders. This may be related with age. Additionally, divorce rates are also higher in offenders.

Mental retardation rates were similar in the two groups. Mental retardation enables and facilitates propensity to be mistreated, as well as to be an accessory.

Higher addiction rates in offenders may explain that it can be a risk factor for tendency to crime. Besides this, if the cases have a psychiatric disorder, the state of mind of the subject and the effect of the disorder on the subject’s behavior at the time of crime should be investigated thoroughly for decision.

In the current study, there were 17 cases with substance addiction and 3 cases with alcohol addiction disorder diagnosis. Only 2 cases were found guilty of possession of drugs and drug trafficking. All of the cases with drug and alcohol addiction were in the offender group. Courts need to determine the presence of addiction. Four of the victims have a history of being involved in a crime previously, while 36 cases in the offender group had a history of being involved in a crime. Previous history of crime in offenders may indicate that criminal behavior is a recurrent problem.

It is well known that posttraumatic stress disorder (PTSD) is the most common psychiatric diagnosis after sexual abuse (17). Deterioration of mental health in people who are exposed to any kind of psychic trauma will lead to harsher penalty. In the current study, all patients consulted to psychiatry for the assessment of mental health were victims (n=32); 15 of them had the diagnosis of PTSD, 2 had major depression and 4 had adjustment disorder. Five cases did not have any psychiatric disorder and 6 of them needed follow-up for definitive diagnosis. In 3 cases, a decision for hospitalization was made with respect to the diagnosis. According to the results of a retrospective research, 70% of the cases who were consulted to psychiatry clinic from forensic medicine had comorbid psychiatric disorder which indicates the importance of psychiatric examination (4).

A considerable amount of sexual offences occur in Turkey, treatment and rehabilitation of victims may decrease the problems. 61.9% of patients that suffered from sexual assault are reported to have some form of psychiatric disorder (15). Another study reported that 51 of 85 cases (60%) had sexual assault history and indicated importance of psychiatric examination besides physical examination (16).

Previous studies reported traffic accidents in the first rank, while battery (assault) was second (16,18,19). In the present study, when the cases are analyzed in two groups as victims and offenders, the most frequent application reason was sexual assault (29.2%), second reason was battery (assault) and the third most common reason was traffic accidents in the victim group. The most frequent reason of application in offenders was battery (assault) (29.9%), second was theft (16.4%) and the third reason was threat offences (14.9%). In the literature, traffic accidents are reported as the most frequent reason of application to forensic psychiatry; however, in the current study, this reason ranked third in victims and fourth in offenders. 

When we examine the assaults according to season, other studies reported that most of the assaults occurred in spring and summer in contrast to our findings (14,20). In the present study, we found that the life-threatening criminal cases involved shotgun wounds, battery assaults and traffic accidents; however, the previous studies in Turkey reported electric shock, shotgun wounds and stabbing wounds, respectively, as the most common life-threatening offences (12,21). In this study, judicial cases which result in decrease or loss of sense or organ function were traffic accidents (n=8), battery assault (n=7), suicide (n=1), sexual assault (n=1) and threat of gun violence (n=1). People who commit crime may request their evaluation for criminal liability (TPC 32/1, TPC 32/2). Thirty-one (43%) of the 72 cases included in the present study were found to have criminal liability, 11 cases (15.2%) had partial criminal liability (TPC 32/2), and 18 (25%) cases had a total absence of criminal liability. Twelve cases (16.6%) were referred for hospitalization to a psychiatry inpatient clinic for follow-up and consequent decisions. These ratios are compatible with the literature (22,23).

The important limitation of this study is its retrospective nature. Because the present study is retrospective, other factors like temperament, personality disorders and childhood traumas cannot be evaluated.

Conclusion

Psychiatric illness and criminal acts is a wellknown topic. However, patients with psychiatric illness are accepted as violent and aggressive. On the other side of the medallion, there is another fact that people with psychiatric illness are more likely to be a victim of a violent crime. Keeping archive records of forensic medicine regularly enables us to understand the sociodemographic and psychiatric properties of offenders and victims.

Ethics

Ethics Committee Approval: The research protocol gained approval from the Ethics Committee of Aydın Adnan Menderes University Faculty of Medicine (protocol no: 20171273, date: 07.12.2017).

Informed Consent: Retrospective study.

Peer-review: Externally peer-reviewed.

Authorship Contributions

Surgical and Medical Practices: Y.B.Ş., M.D., Concept: B.D., M.D., Design: B.D., M.D., Data Collection or Processing: B.D., M.D., Analysis or Interpretation: Y.B.Ş., Literature Search: Y.B.Ş., B.D., Writing: Y.B.Ş., B.D.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.