E.L. is an 18-year-old Caucasian male, who is accused of having severely wounded another student in a scuffle after school two years earlier. Due to the physical conflict, E.L.'s schoolmate reported an injury of his left eyeball, and E.L. was charged with causing serious personal injuries.
E.L. has a complex clinical history. Born at term of natural childbirth, he was artificially fed, and his development followed regular phases until the age of 2. In the course of subsequent months, first symptoms of a delay in language development emerged, and, at the age of 4, E.L. was diagnosed with an Autism Spectrum Disorder (ASD). While attending the first years of primary school, he showed good interactions with peers, though experiencing significant learning difficulties. According to his parents' accounts and consistent with school reports, sometimes E.L. appeared restless and hyperactive. Clinical assessment identified mild cognitive disability associated with language disorder, subsequently revised as learning disability associated with affective immaturity and scarce tolerance to frustrations. At the age of 8, E.L. was hospitalized for re-assessment of his diagnosis, which was indeed revised as a developmental mixed disorder with a major impairment of linguistic capacity. In the same period, E.L. experienced epileptiform seizures. At the age of 9, following a MRI, he was diagnosed with Grey Matter Heterotopia, while first problems of socialization appeared alongside: E.L. became a target of his peer social pressure and bullying to the extent that he decided to move school the year after.
E.L. has a mild and submissive temperament, particularly wishful to establish meaningful friendship relationships, a trait of his personality that has paradoxically backfired with him becoming the object of bad jokes and mistreatments by his classmates and acquaintances. He has a very supportive family, with parents thoughtfully caring for his health and social concerns. Over the years, E.L. has undergone further diagnostic refinements, which progressively evidenced depressive tendencies and social withdrawal along with linguistic and cognitive disabilities and developmental emotional disorder. In medical records, the condition of E.L. is described as characterized by attention and memory lability especially in the school context, motor instability, affective immaturity, and difficulty in emotion regulation and inhibition (F80.8, F81.9, F93 ICD10). Within the overall picture, however, the clinical implications of GMH are left almost completely unconsidered except for their role in the emergence of epileptic seizures.
The troubles in adaptation and socialization led E.L. to experience severe episodes of social rejection and bullying, which made him feel profoundly sad and worthless. As an aggravation of this psychological condition, at the age of 16, seven months before the dispute with his schoolmate, he engaged in a suicidal attempt by ingesting an overdose of sleeping pills. He was hospitalized with the diagnosis of depression in a passive-dependent personality and thought disorders, started on antipsychotic treatment (aripiprazole, 10 ml per day). The therapeutic program increased his behavioral control, but negatively affected personal interests, energy, and socialization, so that the antipsychotic dosage was progressively reduced until complete discontinuation, which was reached a couple of months before the criminal conduct he was later charged with. On the day of the alleged offence, E.L. had a verbal dispute with one of his classmates for a trivial reason, and received verbal abuse in return. On leaving the school, E.L. found that girl along with her boyfriend and other schoolmates, waiting for him beyond the school gate threateningly staring at him. Frightened by the scene, E.L. tried to escape running as fast as he could, but he was intercepted and stopped by the boyfriend of his classmate who roughly blamed him for the dispute he had had with the girl few hours before. A scuffle ensued, and the two boys fell to the ground, with E.L. punching blindly a break through and free himself from people around him. Following the fight, E.L. reported small facial and knee injuries while his antagonist was diagnosed with an outbreak of his left eyeball. Shocked by the unpredictable evolution of the events, E.L. became progressively more aware of the severity of the injuries he had inflicted. Very soon, he started to feel guilty and became regretful. He repeatedly declared he had never intended to harm his mate so severely and explained his exclusive aim had been to escape the frightened situation he had found himself in. Rather interestingly, he also displayed an almost complete amnesia for the event and his running off.
E.L. is submitted to expert examination following a Court order to establish his criminal liability at the time of the facts and the actual risk of recidivism. The psycho-forensic assessment included clinical interviews and test administration, the results of which are displayed in Table 1. Furthermore, E.L. underwent a structural Magnetic Resonance Imaging (sMRI) scan to ascertain the presence of a previously reported area of heterotopic grey matter in E.L.'s brain. MRI was performed on a GE Signa 3T scanner (GE Healthcare).
As Table 2 shows, E.L. appears to have a normal level of intelligence with mild impairment in processing speed and receptive linguistic capacities. He appears suspicious, with persistent persecutory thought contents, phobic ideas, and obsessive worries regarding the future. E.L. preferably adopts a defensive modality of coping with anger expression, with a dominance of repressive and avoidant tendencies. His affective state is dysphoric and characterized by high levels of anxiety. The neuropsychological assessment reveals a poor executive capacity of inhibiting dominant responses, set shifting, planning, and strategic control. However, E.L. appears able to choose and manage effective problem solving strategies, which do not imply space or time constraints. Finally, a low risk propensity is observed. The psychometric conclusions are consistent with evidence obtained through the clinical interviews.
The outcome of sMRI scanning confirms previous evidence of a sub-ependymal GMH in E.L.'s brain, excluding the presence of other morphological and/or structural abnormalities (Figure 1).