Dilemmas faced by expert physicians in the face of puerperl psychosis related to infanicide

Introduction: Puerperal psychosis is defined as a type of brief psychotic disorder occurring within three weeks after delivery, but predominantly within the first 48-72 hours, although rare (0.1 to 0.2%), it is a medical emergency and should be be treated as soon as possible. The presence of prodromal symptoms (irritability, sudden change in behavior, among others) that rapidly progress to a psychotic condition (delusions and hallucinations). In this context, infanticide is the apex for forensic interpretation. In 2021, The Lancet publishes an article questioning whether puerperal psychosis is a new disease. Neither the ICD nor the DSM bring this diagnosis as a distinct disease . Objective: To expose the main conflicts faced by medical experts in the face of the alleged crime of infanticide from the perspective of the Penal Code Conceptual framework: Establishing the nexus between puerperal psychosis and infanticide is a very difficult task and often depends on documents from the attending physician. Material and methods: Study carried out at the Department of Legal Medicine, Bioethics, Occupational Medicine and Physical and Rehabilitation Medicine of the Faculty of Medicine of the University of São Paulo. A narrative review of the literature was carried out, focusing on signs and symptoms suggestive or conclusive of puerperal psychosis in the face of the crime of infanticide. Articles in the Lilacs and PubMed databases were accessed, applying the descriptors “psychotic disorder”, “postpartum psychosis”, “expertise”; Textbooks were also included. No time limit was established for the search, but articles obtained in full were included. Results: Article 123 of the Penal Code, from 1940, determines that the crime of infanticide is “killing, under the influence of the puerperal state, one’s own child, during childbirth or shortly after: Penalty – detention, from two to six years. ”, at this point it is visible the difficulty to assertively define what it is right after, as well as to establish the mental criteria that made this crime an action in which the woman was not aware of the fact performed. Science still struggles to establish nosology and the temporal relationship between the onset of mental changes and childbirth and which biological changes are involved, these are the words of one of the greatest researchers on the subject, Patrick McGorry. The search for a genetic relationship between bipolar disorder and puerperal psychosis has been suggested. But, another issue to be discussed, not all puerperal psychoses are linked to infanticide. Another dilemma faced is the lack of habit in applying the terms infanticide and neonaticide with their individual designations. The first would be the death of a child in the first year of life by its mother and the second would be the death within the first 24 hours of life. The central question for the medical expert is to establish whether the neonaticide stems from a social issue in which the child is unwanted or whether it stems from a dissociative, depersonalization or hallucinatory disorder in which the mother does not have the capacity for understanding and self-determination. The medical literature rarely attributes neonaticide to mental illness. It is up to the medical expert to establish with technical rigor that at the time of the criminal act the woman was under a condition of illness that completely abolished her capacity. In this way, the medical expert must carry out the examination by complying with the technical rite and request medical documentation on the clinical and mental conditions of the expert at the time of the puerperium. The search for risk factors can help the doctor, but it is necessary to know that the profile of women varies according to the typology of the fact, that is, neonaticide and infanticide. Differential diagnoses between delusional misidentification syndrome which may be accompanied by hostility towards delusional erratic identification, Capgras syndrome in which the woman may believe that her child has been switched and that the child in front of her is an imposter. Due to the transience of psychotic symptoms, the psychiatric expertise that determines the imputability of the infanticidal mother is often performed in the absence of any clinical manifestation of psychosis. Conclusion: The psychiatric expertise of the woman who claims puerperal psychosis is challenging due to the elusiveness of the symptomatic picture and the late realization. It is based on an analysis of medical documentation – from the moment of childbirth and the puerperium – symptoms described by close family members, the epidemiology of the condition and its association with mood disorders.