Delusional misidentification syndrome and criminal acting ou
A 35-year-old woman was hospitalized for observation as part of a forensic psychiatric assessment, according to the 25 bis Article of the 2004/40 Tunisian mental health and hospital conditions’ law. This hospitalization aimed to evaluate her criminal responsibility for the murder of her daughter.

The patient is the younger of two siblings. She grew up in a family with a high socioeconomic level living in a rural community. Her mother died at the age of 64 years, six months prior to the current episode. She graduated in Industrial Economics at the age of 28, and she has remained unemployed since. She is married and a mother of three, aged 9 years, 4 years, and 18 months.

Concerning her premorbid functioning, the patient was dynamic, curious, independent, sociable, and well-suited. A quiet and balanced atmosphere reigned within her family. She described a conflictual relationship with her mother, without the latter being repulsive. She spoke coldly of her mother, who had just died, describing her as ambivalent; she was both protective and unfair since she always preferred the patient's brother. Her father was described as rigorous, meticulous, and anxious. She reported good marital harmony and a warm relationship with her children.

The interview with the family revealed a behavioral change since the “Tunisian revolution” in 2011, characterized by social withdrawal, emotional coldness, exaggerated interest in politics, and extremism in religious practice. All of it was tolerated and even trivialized by her husband. Five years later, the patient was seen by a psychiatrist who prescribed risperidone at a dose of 4 mg per day. The treatment was refused by the patient. Then, she was admitted under the request of her family in a psychiatric hospital, for a fruitful delusional episode characterized by themes of persecution and influence, with hallucinatory and interpretative mechanisms.

This delusional episode was triggered by psycho-emotional stress: arguing with her eldest daughter's teacher, forcible confinement for nearly an hour in the school with her two children, followed by an aggressive arrest at the police station. The diagnosis of schizoaffective disorder was held requiring antipsychotics and mood stabilizers. After being discharged, the follow-up and monitoring were discontinued, and she did not consult again until the murder. The entourage reported a change in the patient's behavior after the death of her mother. She became fulfilled and jovial.

On the day of the murder, the patient was at her father's home with her two daughters. In the late afternoon, she suddenly got agitated, and she banged her youngest daughter violently against the wall several times. Then, she stabbed her with two different knives.

The examination and autopsy of the infant revealed:
-- Multiple bruises on the inside of the scalp, associated with subarachnoid hemorrhage and subdural hematoma, whose appearance is consistent with injuries caused by a blunt object that had hit the head.
-- Multiple transfixing wounds of both eyeballs (the reflex zones) caused by a pungent and sharp object (emergence of several wounds with persistence inter-membranous flanges at both eyelids).
-- A left pneumothorax compression in connection with penetrating wounds in the left chest.
-- Multiple deep ecchymoses in the epigastric region of the abdomen, back, and lumbar region, whose appearance is consistent with damage caused by a pungent and sharp object.
-- Postmortem wounds in the abdominal organs (liver, right kidney, stomach, and intestine). A bite-like wound was found on the liver.
The infant's death is related to head trauma and chest wounds.

On the first day of hospitalization, the patient was stammering, asthenic and would only remember the smell of blood. She also asked whether the deceased girl was indeed her own daughter. Throughout the interviews, her anxiety was intense when she talked about her act. She accused the police of having substituted her daughter to be able to monitor her. She saw the deceased daughter as a double of her daughter, physically identical, but it was a dangerous object that threatened her family. A destructive fury then fell on this danger.

She confessed that during her pregnancy, she considered her daughter as “blessed.” She wanted to give birth at home out of fear of substituting her child with another, something that was not allowed by her family. Since the birth of her child, she has had doubts about her identity. At the same time, she said “this girl is my spitting image.”

The patient's physical examination, biological tests, electroencephalogram, and cerebral magnetic resonance imaging were free of abnormalities.

The presence of a mental disorder causing a lack of judgment led to the conclusion of criminal irresponsibility objectified by the forensic psychiatry expert.

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