The following case series describes three women who were gene carriers for HD. Although each patient had genetic testing for HD confirming a CAG triplet repeat expansion, the precise repeat length was unavailable. Due to the severity of their criminal behaviours and forensic risk, they were admitted to a neuropsychiatry unit in a psychiatric in-patient hospital setting. These cases highlight the need for awareness of increased risk of criminal behaviours in women who are gene positive for HD and how this neurodegenerative condition may contribute or predispose to criminal behaviour.
Case A
A was a 50 year old, admitted to psychiatric hospital under Section 38 of the UK Mental Health Act (which allows a court of law to send a patient to hospital for assessment and treatment before being sentenced) after she pleaded guilty to a charge of arson. She was brought to court by her landlord for deliberately setting fire to her home. At time of transfer to neuropsychiatry, she had neurological features typical of early stage HD including chorea and dystonia.
A was the main carer for her mother who had HD. Aged 27 yrs. she developed depression and anxiety becoming morbidly obese as she would comfort eat when anxious. A positive genetic test for HD at 43 yrs. triggered the first of many suicide attempts, suicide threats and episodes of self-harm. Several years later, events culminated with neighbours calling emergency services to put out a fire in her living room and she was arrested on suspicion of arson.
On admission A stated she would rather die than live with HD and was placed on close supervision as fire setting remained a risk. Increased physiotherapy input resulted in improved gait and posture through exercise and she enjoyed escorted community leave. A behavioural program using a token economy to address her aggression was implemented and home visits subsequently facilitated. Two years after admission there was an increase in levels of anger and frustration which the patient herself attributed to worsening mobility and falls. Cognitive decline with marked impulsivity was evident and she frequently required seclusion. Three years later she was discharged to a nursing home as she was no longer independently mobile and risk to self and others was therefore much reduced.
Case B
B was a 45 yr. old woman with premanifest HD admitted to psychiatric hospital under Section 38 (an hospital order). This was her first contact with psychiatric services. Prior to admission to neuropsychiatry B was charged with Actual Bodily Harm after she assaulted her partner and their young child. She was released on bail but subsequently placed on remand (detained in prison while awaiting trial after being arrested and charged for a criminal offence) after breaking bail conditions by breaking into and entering the family home despite a police restriction order. She had no movement disorder symptoms at this time and no psychiatric history. Although there was known HD in the paternal family line, her father died from complications of Crohn’s disease before developing any signs of HD.
B had been living with her partner and they had three children together. She graduated and worked in nursing before taking a postgraduate degree. She then renovated properties with her partner and also continued nursing part-time. Problems began several years earlier when she flew into a fit of rage overturning the dinner table after her partner undercooked the meat for Christmas dinner. There followed multiple episodes of domestic violence; she repeatedly hit her partner on the head with a mirror and radio in anger, she broke windows at home and had allowed an unpaid parking fine to escalate. On one occasion she slapped her frail and elderly grandmother. Police were called to the family home numerous times but charges were never pressed by her partner.
Throughout admission, B remained well presented, articulate with unremarkable mental state examination. Although full scale IQ (FSIQ) 89 was within normal range, estimated premorbid IQ 105 indicated cognitive decline, with a marked discrepancy between verbal and performance IQ (VIQ = 97, PIQ = 79). She demonstrated chaotic planning in the zoo map task assessing frontal executive abilities stating she had, “No choice but to break the rules”. Kitchen assessment with the occupational therapist found that she was unable to estimate time required for tasks and she could not budget for ingredients. Although there were no pathognomonic motor signs of HD, she was markedly slow at the 9 Hole Peg Test (right = 21.5 s, left = 32 s).
B was given leave to her sister’s home but problems occurred when she lost her youngest daughter in a crowded shopping area. She returned alone to her sister’s house instead of searching for her child, this caused a family argument and she stormed out of the house, needing to be recalled to hospital by police. Six weeks later, the recommendation for a section 37 of the MHA (allowing the court to send someone to hospital instead of prison) was overturned and B self-discharged prematurely before any community support could be put in place for her.
Case C
C was a 42 yr. old woman admitted to hospital after police found her walking in traffic with suicidal intent. At the time, neurological features were typical of early stage HD with mild chorea and a broad based gait.
C described a strict Catholic up-bringing and an unhappy childhood in an impoverished Italian immigrant family. There was no known history of Huntington’s disease in the family but both parents had passed away prematurely from cancer. As a child C was raped by her brother and described subsequently “never feeling good enough” despite achieving a university education. Psychiatric history was of alcohol dependency leading to downward social drift and eventual homelessness, this was exacerbated by difficulties coming to terms with a positive HD gene test. Her criminal record included: alcohol related driving offences, shoplifting, breech of conditional discharge, failure to comply with community order requirements, skipping bail, drunk on highway in a public place, drunk and disorderly and assaulting police. Although rehoused in a local authority flat, this was occupied by strangers who abused and exploited her in the community and she had attended hospital for alcohol detoxification and treatment of domestic violence injuries.
On admission C appeared dishevelled, irritable and suspicious with choreiform movements. She reported low self-esteem, guilt feelings and a death-wish. Neuropsychological assessment confirmed FSIQ = 70 (borderline), with a discrepancy between verbal and performance IQ (VIQ = 78, PIQ = 66), with extremely poor visuo-spatial abilities, language, attention, delayed memory, and impaired frontal function with difficulty planning and problem solving. Poor balance was noted (Berg scale 34/56) and she had several falls on the ward. Due to chorea, she would often accidentally drop cigarettes while smoking and was therefore at risk of burns and a fire hazard. Kitchen assessment highlighted safety concerns due to inability sequencing preparation of components for a meal and poor time monitoring. Personal hygiene required prompting and she was easily distractible when crossing roads.
She engaged well with a neurobehavioural levels system which rewards desirable and appropriate behaviours and she responded well to a highly structured ward environment resulting in successful discharge to a community placement 2 years later.