Autism as legal insanity - Neurocognitive and contextual arguments in Swedish forensic psychiatric evaluations

The specific circumstances under which autism spectrum disorder could meet the legal standards severe mental disorder (SMD; the core Swedish legal concept underpinning sentencing to forensic psychiatric care) in criminal court cases are unclear.

To explore which neurocognitive and contextual factors that have been emphasized in the assessment of SMD in cases of autism spectrum disorder.

A randomized sample (N = 20) was derived from a data set of forensic psychiatric evaluations (FPEs) conducted between 2016 and 2018 on violent offenders with autism. Qualitative content analysis was used separately for offenders who did (n = 10) and did not (n = 10) meet the standard for SMD.

A dimensional approach to autism-associated features was commonly used within SMD decision-making, including overall statements that autism was considered severe enough, or not, for SMD. Certain types of autism-associated features were more prominent in the SMD group, contributing to autism being considered more severe. Examples were very low psychosocial functioning, fixation on violence, few or rigid coping strategies, impaired central coherence/metacognition. Pronounced degree of idiosyncratic/atypical worldview, feelings of anxiety, insecurity, fear, or desperation were also emphasized in the SMD group. Degree of compulsive behavior could also be highlighted in the SMD group, particularly if it was considered associated with severe anxiety when routines were broken or certain stimulus was perceived. Emphasized characteristics in the no SMD group included antisocial traits, complex and/or vague psychopathology, substance abuse, intact reality monitoring, and the ability to integrate multiple perspectives.

Degree of autism-symptomatology and global/psychosocial functional impairment were considered both in the SMD and no SMD groups' FPEs. The no SMD group was often described as not exhibiting sufficiently marked autism-functioning, a lower degree of psychiatric symptomatology in general, and a motivation for the crime which is not considered clearly related to a non-normative perception of reality due to autism. The vagueness in when autism severity was considered "sufficient" for SMD, emphasizes the importance of further in-depth studies to inform the development and implementation of standards or guidelines to support experts in their decision-making.