Search Results (35)

Background/Objectives: Antisocial personality disorder (ASPD) is strongly associated with violence, substance use, criminal behavior, and elevated suicide risk. Although inflammatory and metabolic dysregulation have been implicated in severe psychiatric disorders, the biological correlates of impulsivity, aggression, and suicide risk in forensic ASPD populations remain unclear. This study aimed to investigate whether routine hematological, inflammatory, and metabolic parameters are associated with these clinical features. Methods: This cross-sectional study included 57 male individuals diagnosed with antisocial personality disorder (ASPD) who had committed crimes and were referred to the Forensic Psychiatry Department of Elazığ Fethi Sekin City Hospital in Turkey by the court, and 56 age-matched healthy controls. Participants completed standardized assessments of impulsivity (BIS-11), aggression (BPAQ), and suicide probability (SPS). Hematological indices, inflammatory markers, and routine biochemical parameters were analyzed. Group comparisons, correlation analyses, and multivariable logistic regression were performed. Results: Compared with age-matched controls, individuals with ASPD showed markedly higher impulsivity, aggression, and suicide probability, alongside substantially higher rates of substance use, imprisonment history, and suicide attempts (all p < 0.001). Hematological and inflammatory analyses revealed lower red blood cell (RBC) counts and elevated mean corpuscular volume (MCV), red cell distribution width (RDW), C-reactive protein (CRP), neutrophil-to-lymphocyte ratio (NLR), and CRP–albumin ratio (CAR) in the ASPD group (all p < 0.05). Biochemical profiling showed reduced glucose, total protein, albumin, HDL, ALT, and vitamin B12 levels, with increased uric acid levels in ASPD (p < 0.05). Multivariable analysis indicated that being married and having higher education were protective against ASPD, whereas higher uric acid and CAR levels were associated with increased risk. Conclusions: The findings indicate that criminal offenders with ASPD show increased inflammatory markers and altered hematological and biochemical profiles. Routine blood parameters, combined with psychometric assessments, may help identify individuals at higher behavioral risk and support early risk stratification in forensic psychiatric settings, although causal relationships cannot be inferred from this cross-sectional study. Full article

Foreign material is an uncommon finding in routine gastrointestinal histopathology, but may occasionally contribute to disease pathogenesis or create diagnostic pitfalls. We report two illustrative cases highlighting the diverse clinical and histologic implications of ingested plant material. The first case involves a 10-year-old boy who presented with clinical features consistent with acute appendicitis and underwent appendectomy. Although gross examination revealed a macroscopically unremarkable appendix, histological evaluation demonstrated mucosal ulceration associated with an impacted plant seed within the appendiceal lumen, supporting a diagnosis of obstructive acute appendicitis. The second case describes a 60-year-old woman undergoing a screening colonoscopy, during which a small sessile lesion in the transverse colon was resected. Histologic examination revealed no colonic mucosa; instead, the specimen consisted entirely of plant material, morphologically consistent with a tomato seed, representing an incidental finding mimicking a colonic polyp. These cases underscore that plant seeds, while rare, may act as obstructive agents in appendicitis or simulate true pathological lesions during endoscopic and histologic evaluation. Awareness of the characteristic microscopic features of plant material is essential to avoid misdiagnosis and to recognise their potential clinical and forensic relevance. Full article

Background/Objectives: Calcaneal spurs are pathological bone formations at entheseal attachment sites with clinical implications but limited forensic anthropological applications. While entheseal changes have been proposed as age estimation markers in forensic contexts, empirical validation remains insufficient, particularly for Southeast Asian populations. This study evaluated calcaneal spur utility for forensic age estimation in Thai skeletal remains while establishing population-specific osteological reference data for forensic individuation. Materials and Methods: The 3516 dry calcanei from 1758 Northeastern Thai skeletons (1031 males, 727 females; age 22–106 years) were examined. Spurs were classified by anatomical location as dorsal (D-type), plantar (P-type), or combined plantar–dorsal (P–D type). The morphometric measurements were performed bilaterally. Age-associated patterns were analyzed across four age cohorts (≤40, 41–50, 51–60, ≥61 years), and Random Forest machine learning classification tested forensic age estimation capacity using 10-fold cross-validation. Results: Overall prevalence reached 67.63% with distinctive P–D type predominance. While age-stratified prevalence increased from 24.56% (≤40 years) to 74.77% (≥61 years), Random Forest modeling explicitly demonstrated overall classification accuracy of 62.5%. Compared between sexes, the maximum length of calcaneal spurs was significantly longer in males. Dimensional analyses revealed weak age correlations and substantial inter-individual morphological variation precluded reliable age prediction. Interestingly, the unique P–D type distribution pattern (77.5% among spur-bearing individuals) may serve as an auxiliary marker for Thai population affinity assessment in forensic contexts. Conclusions: This study established the first comprehensive Thai-specific osteological reference for calcaneal spurs, revealing distinctive plantar–dorsal type predominance valuable for forensic population affinity assessment and provided population-specific baseline data for forensic individuation. Full article

Background/Objectives: Viper envenomation in Italy is uncommon but carries significant clinical and forensic implications: an average of 257 bites per year are estimated, with only one fatality. This epidemiological context necessitates careful consideration of the standard of care and professional liability The article aims to outline the clinical and medico-legal dimensions of viper bites within both national and international contexts. Methods: We report the case of a 40-year-old woman bitten by a viper in an urban environment. At the initial emergency department visit the presentation was classified as Grade 0 (“dry bite”) according to Boels and, after 21 h, was discharged in good condition. Three days later, she returned with worsening symptoms and CT imaging revealed intrafascial and subcutaneous edema. The subsequent onset of complications prompted a criminal malpractice investigation. Therefore, we performed a PubMed search which yielded 125 records; after applying eligibility criteria, 33 articles were included, supplemented by manual reference checking for a total of 60 sources reviewed. Results: Comparison with the Australian model suggests the need for more standardized care pathways in Italy, while accounting for local toxicological and epidemiological specificities. Conclusions: This case and the accompanying literature analysis highlight that, even in low-incidence settings, structured patient communication, multidisciplinary management, collaboration with Poison Control Centers, and adherence to good clinical practice are crucial for patient safety and for mitigating medico-legal risk. Full article

Introduction: Gender-based violence and femicide represent the most extreme manifestation of a deep-rooted cultural distortion embedded within patriarchal social structures. In this study, adopting a comparative and multidisciplinary approach, we analyzed the evolution of international legislation and the major historical milestones in the protection of women’s rights and the prevention of gender-based violence at both the global and Italian levels. Specific protocols such as the “Pink code” were examined, with particular attention to medico-legal implications and the clinical management of victims, highlighting how violence against women continues to be fuelled by stereotypes, discrimination, and unequal power relations. Materials and Methods: Gender-based violence and femicide were examined from both national and international perspectives. A total of 73 scientific articles in English and 28 legal sources were selected from an initial pool of 918 publications, through a narrative review with a structured search strategy of international and Italian legislation and scientific literature. Electronic databases (PubMed and Google Scholar) were searched for the period 2000–2025. Only original observational studies, medico-legal analyses, epidemiological reports, and forensic case series were included. Cases primarily related to pregnancy, migration, infanticide, suicide, or substance abuse were excluded to reduce heterogeneity and focus on violence rooted in gender-based power asymmetries. Results: The legislative analysis shows a progressive strengthening of protection mechanisms, particularly between 2012 and 2023, following the ratification of the Istanbul Convention, the increase in intimate partner violence, and the COVID-19 pandemic. In Italy, the repeal of discriminatory norms and the introduction of specific legislative measures have led to increased attention toward prevention, protection, and prosecution of gender-based violence. Protocols such as the ‘Pink Code’, an Italian hospital-based multidisciplinary pathway activated mainly in emergency departments for the early identification, clinical care, medico-legal documentation, and judicial protection of victims of gender-based violence, have improved multidisciplinary management of victims within healthcare and judicial settings, although significant challenges remain regarding the full enforcement of legislation and the effective protection of women. The analysis focuses on female victims, in accordance with the Italian legal definition of gender-based violence, while other forms of gender-related violence were considered beyond the scope of this review. Conclusions: Despite substantial legal advances, combating gender-based violence clearly requires an integrated approach that combines prevention, assistance, and prosecution. Strengthening collaboration among institutions, healthcare services, and the judicial system—consistent with international recommendations—is essential to ensure an effective and rights-based response to victims. Overcoming the cultural and social barriers that perpetuate violence remains a fundamental priority, alongside promoting genuine gender equality. Full article

The overdose mortality landscape has shifted from predominantly opioid exposures to a polysubstance epidemic increasingly driven by illicit fentanyl and fentanyl analogs combined with other centrally active agents. Among the co-intoxicants, veterinary α₂-adrenoceptor (α₂AR) agonists such as xylazine have emerged as clinically confounding adulterants. Recent reports from forensic toxicology, medical examiners, and border/interdiction agencies indicate that medetomidine, a veterinary sedative racemate with the highly selective α₂AR agonist enantiomer dexmedetomidine, is increasingly being detected together with fentanyl and its analogs in seized materials and postmortem assays. Prior reviews have covered these aspects. The current review synthesizes current evidence and clinical experience relevant to fentanyl + medetomidine co-exposure-induced respiratory depression—a primary cause of death. We focus on convergent µ-opioid receptor (MOR) and α₂AR signaling within key physiological substrates, including respiratory rhythm-generating networks, ascending arousal pathways, chemosensory reflex control of ventilation, and autonomic cardiovascular regulation, integrating mechanistic pharmacology, respiratory and cardiovascular toxicology, emergency-room treatment, and emerging public-health implications. Available evidence supports a model in which combined MOR and α₂AR activation produces additive-to-synergistic suppression of ventilation and consciousness, attenuation of hypoxic ventilatory drive and CO₂ responsiveness, with marked sympatholysis manifested as bradycardia and hypotension, all of which can persist beyond presumptive opioid reversal with a MOR antagonist. We discuss the implications for prehospital and emergency care. In sum, the increasing detection of medetomidine in the illicit fentanyl supply represents an emerging and potentially high-risk co-exposure pattern that may be only partially naloxone-responsive. Lastly, we highlight potential future pharmacologic countermeasures for polysubstance overdose, such as the BK-channel antagonist ENA-001, which may address naloxone-insensitive ventilatory suppression in opioid-dominant polysubstance overdose. Full article

Background/Objectives: The external occipital protuberance (EOP) is an anatomical landmark with radiological and anthropological implications. Although the morphology and prevalence of EOP have been studied in many populations, data remain lacking for Northeastern Thais. Population-specific characterization of EOP variation may improve diagnostic and forensic accuracy applications. Materials and Methods: This study has investigated the prevalence and morphometry of EOPs using two primary sources: CT brain scans from 750 adult patients (375 males, 375 females) and anatomical investigations of 1060 dry skulls. EOPs were classified as Type I (flat), Type II (crest), or Type III (spur). Measurements for Type II (crest-shaped) EOPs were performed using standardized linear and angular parameters. Data differences were analyzed by sex and age group; intra- and inter-observer reliability was calculated for imaging measurements. Results: The study showed that Type II EOP was most common in both CT (56.1%) and dry skull (64.6%) samples. Type I was significantly more frequent in females (CT: 37.0%; dry skull: 32.8%), while Type III prevalence was higher in males (CT: 28.5%; dry skull: 18.4%). After age 60, the incidence of Type III declined in both datasets. Type II EOPs were significantly larger in males (mean crest length in CT: males 7.1 ± 0.1 mm, females 5.6 ± 0.1 mm; p < 0.001), with notable sex- and age-associated variation in associated angular dimensions. Conclusions: These findings established the first region-specific morphometric reference database for EOP in Northeastern Thais. The demonstrated sexual dimorphism in Type II EOP measurements provided the foundational data that may support future applications in clinical assessment, radiological interpretation, and forensic sex estimation in this population. Full article

Background: The human skull has a very complex and diverse structure, and morphological characteristics vary by population. The purpose of this study is to comprehensively analyze the cranial morphology using postmortem computed tomography (PMCT), and to identify anatomical characteristics through a multifaceted approach in Koreans. Methods: 358 PMCT cross-sectional images (179 males, 179 females) provided by the National Forensic Service were analyzed, and the average age was 55.1 ± 18.9 years. The maximum cranial length was divided by the maximum cranial width and multiplied by 100 to calculate the cranial index (CI). Petrous ridge–midline angle (PMA) was measured as the angle between the petrous ridge and the midline. Results: In both the classification of skull shape using CI and PMA, the brachycranic type showed the highest frequency (p < 0.001). Classified by CI, there were no significant differences in frequency by sex (p = 0.533), or age (p = 0.110). However, classified by PMA, the frequency of the brachycranic type in men was significantly higher than in women (p = 0.022), and there was a significant difference in the frequency of cranial morphology by age (p < 0.001). Conclusions: The results of cranial morphology classification targeting Koreans are expected to provide useful basic data for clinical and forensic use. Full article

Background: This article presents an international comparative review of involuntary psychiatric care, Community Treatment Orders (CTOs), and forensic mental health services, with operational implications for Italy. Italy has a community-based model inspired by the “Basaglia Law” (Law No. 180/1978), emphasizing deinstitutionalization and continuity of care. Nevertheless, risk governance gaps persist for high-complexity patients, imposing a disproportionate legal and clinical burden on mental health professionals. This group includes individuals who refuse treatment despite meeting criteria for compulsory admission, patients at elevated risk with substantial management complexity, and offenders with a current or suspected psychiatric disorder. Methods: We conducted a comparative legal and policy review across seven jurisdictions (Italy, England and Wales (UK), France, Germany, Spain, the United States, and Canada) to map frameworks for involuntary treatment, forensic services, CTOs (or equivalents), and community-based risk management. We also extracted procedural safeguards, duration and renewal limits, and interfaces with forensic services. Results: CTOs are available in five of the seven jurisdictions (England and Wales, France, Spain, the United States, and Canada) but are absent in Italy and Germany. We propose a three-pillar framework: (1) enforceable outpatient measures, including CTOs; (2) Forensic Psychiatry Units within Local Health Authorities; and (3) oversight boards with judicial, clinical, and social representatives. These components aim to redistribute responsibility, ensure continuity of care, and provide proportional oversight within a least restrictive, graduated system. Conclusions: When narrowly targeted, time limited, and paired with robust safeguards and service-quality standards, CTOs can support adherence and continuity for patients who repeatedly disengage from care. For Italy, integrating this instrument within the three-pillar framework and under independent oversight could strengthen patient rights and public safety, reduce revolving-door admissions, and improve outcomes. Full article

Impulsivity and compulsivity are key transdiagnostic constructs implicated in addictive and criminal behaviors, often overlapping under the broader concept of behavioral dysregulation. While impulsivity has been widely assessed using experimental tasks and self-report measures, few tools specifically target compulsivity in forensic populations. This study aimed to adapt and validate the Spanish version of the Impulsive-Compulsive Behaviours Checklist (ICB) in a prison sample. The ICB was administered to 700 incarcerated men (mean age = 37.33 years) following a rigorous translation and back-translation procedure, along with pilot testing for clarity. Exploratory and confirmatory factor analyses revealed a stable two-factor structure consistent with theoretical expectations. Internal consistency was satisfactory (McDonald’s omega and Cronbach’s alpha = 0.79–0.80), and convergent validity was supported by significant correlations with the UPPS-P Impulsive Behavior Scale, the Obsessive Beliefs Questionnaire (OBQ-44), the European Addiction Severity Index (EuropASI), and the Symptom Checklist-90-Revised (SCL-90-R). These findings support the Spanish ICB as a valid and reliable tool for assessing impulsive and compulsive traits in forensic contexts. Its use may enhance the identification of differentiated clinical profiles and inform targeted interventions for mental health and reintegration in prison populations. Full article

Background: Adverse childhood experiences (ACEs) are linked to increased risk of deliberate self-harm (DSH), yet little is known about how women in forensic inpatient settings with histories of childhood abuse understand their self-harm. This study aimed to explore how such women make sense of their self-harm, including perceived contributing and protective factors. Methods: Semi-structured interviews were conducted with six female psychiatric inpatients (aged 22–38) detained in a low-secure forensic hospital in the north of England. All had a history of ACEs and DSH. Interpretative phenomenological analysis (IPA) was used to analyse the data. Results: Three overarching themes were identified: (1) Journey of self-harm, (2) reasons for self-harm, and (3) relationships and self-harm. Participants described self-harm as a method of emotional regulation, a way to regain control, or a means of feeling something. Protective factors included supportive relationships, self-awareness, and having meaningful goals. The findings reflect complex, evolving understandings of self-harm shaped by personal histories and relational dynamics. Conclusions: This study highlights the persistent and multifaceted nature of self-harm among women in forensic settings. The findings support the need for trauma-informed interventions that address emotion regulation, relational support, and personal empowerment. Implications for clinical practice and directions for future research are discussed. Full article

Munchausen Syndrome by Proxy (MSBP) is recognized as a form of child abuse in which a caregiver induces or fabricates illnesses in their child to gain medical and social attention. MSBP represents one of the most complex and insidious forms of child abuse, characterized by an ambiguous clinical presentation that poses significant challenges for physicians, psychiatrists, and social workers. However, this condition raises critical questions regarding its diagnosis, management, and forensic implications. Traditionally, MSBP has been framed as an individual pathological manifestation of the mother, overlooking the role of the healthcare and legal systems in its identification and management. In this article, we propose a critical reflection on MSBP, emphasizing how the issue is not merely a “parental failure” but rather a systemic failure of healthcare, social, and judicial institutions in recognizing, preventing, and effectively managing such cases. Full article

Few studies have examined how committing criminal acts of violence impacts the lives of perpetrators who were mentally ill at the time of offence and in which the act itself reflects behaviour that is uncharacteristic of the individual. Theoretical accounts and clinical reports describe a phenomenon termed moral injury, which profiles the deleterious emotional effects that can arise from actions that transgress moral beliefs and expectations. Shame, guilt, spiritual/existential conflict, and loss of trust are considered to be core symptoms of moral injury with growing empirical studies which examine moral injury in military and public safety worker samples. The extent to which these kinds of moral injury phenomena might be evident among mentally ill perpetrators was explored using a qualitative-methods approach in a sample of 19 adult participants hospitalized in a Canadian forensic programme inpatient service. The sample consisted of 13 male and 6 female patients, with a mean age of 36.2 years (SD = 10.8), and the majority diagnosed with schizophrenia or schizoaffective disorder. A qualitative interview was conducted where participants were asked to describe feelings about the index offence, the effect it has had on their well-being, and how they have coped with having committed the offence. Using a reflexive thematic analysis process, 5 themes and 23 subthemes were generated that relate to the various resultant impacts. The five themes which emerged were (1) Living with the Emotional Aftermath; (2) Trying to Make Sense and Coming to Terms; (3) My Eyes Have Opened; (4) Facing the Music; and (5) Moving On. The findings are discussed in terms of their implications for understanding forensic inpatients who may be attempting to come to terms with violence they committed while mentally ill and for informing moral injury intervention strategies which might be adapted for forensic mental health services and public health recidivism prevention programmes. Full article

Bone age (BA) reflects skeletal maturity and is crucial in clinical and forensic contexts, particularly for growth assessment, adult height prediction, and managing conditions like short stature and precocious puberty, often using X-ray, MRI, CT, or ultrasound imaging. Traditional BA assessment methods, including the Greulich-Pyle and Tanner–Whitehouse techniques, compare morphological changes to reference atlases. Despite their effectiveness, factors like genetics and environment complicate evaluations, emphasizing the need for new methods that account for comprehensive variations in skeletal maturity. The limitations of classical BA assessment methods increase the demand for automated solutions. The first automated tool, HANDX, was introduced in 1989. Researchers now focus on developing reliable artificial intelligence (AI)-driven tools, utilizing machine learning and deep learning techniques to improve accuracy and efficiency in BA evaluations, addressing traditional methods’ shortcomings. Recent reviews on BA assessment methods rarely compare AI-based approaches across imaging technologies. This article explores advancements in BA estimation, focusing on machine learning methods and their clinical implications while providing a historical context and highlighting each approach’s benefits and limitations. Full article

The belief that people suffering from psychiatric disorders are more violent, in particular psychotic patients that do not have insight into their illness, is very common in the general population. Therefore, this review aimed to present a more accurate depiction of the link between lack of insight and violent behavior, by evaluating the existing scientific literature on the topic. For this purpose, a literature search on PubMed, Embase, and Google Scholar was conducted, selecting the relevant papers published during a 20-year period (2004–2024). The paper defined insight as a multi-dimensional concept and discussed its classification, explanatory models, and clinical implications, followed by a presentation of several insight-measuring scales. The meaning of violent behavior, its prevalence, underlying mechanisms, and different measuring scales were discussed, followed by the confounding factors that influence the relationship between insight and violent behavior, treatment options for violence in forensic psychiatry settings, and methods to improve medication adherence. Contrasting results were observed regarding the impact of each factor on leading to violent acts, which suggested that the relationship between insight and violence is more complex than previously thought. In conclusion, increased attention must be paid to the investigated dimensions of both the concepts and the confounding factors, with further research required on this topic. Full article