Forensic Psychiatry

We at Psychiatric Times wish to note, with great sadness, the passing of our colleague and editorial board member, Dr Gene Usdin, at the age of 87.

Child murder by parents is an upsetting topic for both the public and clinicians. It is even more distressing when a mother kills her child than when a father does because we expect mothers to love and protect their children at all costs.

Clinicians who treat patients with strong antisocial traits commonly struggle with the tension between conceptualizing them as either man or beast.2 On one hand, there is the well-intended goal of helping the offender develop into a more functional “human being.” On the other, there are the common emotional reactions of anger, disgust, and even fear of predation.3

Because numerous diseases- infectious, endocrinological, metabolic, and neurological, as well as connective-tissue disease-can induce psychiatric and/or behavioral symptoms, clinicians need to distinguish these neuropsychiatric masquerades from primary psychiatric disorders, warned José Maldonado, MD, the director of Stanford University’s Psychosomatic Medicine Service.

When sexual abuse is alleged, children may face investigative interviews, family disruptions, a change in their school environment, mental health counseling, and even trial court testimony.

The insanity defense represents a prominent symbol of the relationship between law and psychiatry. Despite the fact that it is infrequently raised and seldom successful, the insanity defense is the subject of intense legal and public scrutiny.

Since 1990, many states have instituted sexually violent predator (SVP) or sexually dangerous person (SDP) civil commitment stat­utes that seek to identify the small group of extremely dangerous incarcerated sexual offenders who would present a threat to public safety if released from custody.

The jaw-dropping indignity was easy to miss at a time when the O.J. Simpson murder trial was unfolding. A man named Colin Ferguson had been charged with killing 6 people and wounding another 19 after an apparently indiscriminant shooting spree aboard a Long Island railroad train.

Chronic posttraumatic stress disorder (PTSD) may occur secondary to combat, terrorism, civilian assaults including physical and sexual abuse, or other traumatic experiences.

DSM-IV-TR, our current diagnostic classification system of psychiatric disorders, follows the diagnostic paradigm first established by DSM-III in 1980.

We need to have a framework to make certain that our interventions are balanced, safe, and a function of the existing evidence.

Prognostication is a major part of what physicians do in many fields of medicine, and it is particularly relevant when a treatment or procedure is controversial or anxiety-provoking. Being able to accurately tell a prospective ECT patient how likely he or she is to respond would be helpful.

When historians try to understand why psychiatric diagnosis abandoned validity for the sake of reliability in the years surrounding the millennium, they will rely on The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder.

The Supreme Court's 2006 decision in Clark v Arizona1 was one of the most unexpected defeats the American Psychiatric Association (APA) has had since it began regularly submitting amicus briefs to the Court 35 years ago.

From Our Readers

Dr Jeffrey Metzner's brief article, "Evolving Issues in Correctional Psychiatry" (Psychiatric Times, September 2007) related many of the difficulties and complexities of the corrections world; however, it did not mention the greatest problem of all--"deinstitutionalization," which, over the past half century, has resulted in the wholesale diversion of patients with chronic mental illnesses--many of whom cannot be managed as outpatients--from hospitals to jails and prisons.

Paraphilias and paraphilia-related disorders (nonparaphilic sexual compulsivity or sexual addiction) are sexual disorders that predominantly afflict men.

The role of the forensic psychiatrist frequently requires straddling a fence. On the one side lie the standard function and commensurate ethics of a physician; on the other are the needs of the legal system calling for objectivity, truth, and justice.

Virtual games, such as World of Warcraft, The Sims, and Second Life, are played by thousands every day, allowing people, worldwide, to connect and share information. In fact, the virtual "worlds" that can be created in these games are now being used to make money (through buying and selling virtual objects), to form partnerships and friendships, and even to conduct business; it is easy to see how many become engrossed in this alternative life.

Many psychiatrists feel intimidated by or frightened about courtroom testimony. However, with the proper preparation, the psychiatrist need not have a difficult experience. It is the role of an expert witness to educate the court on matters that are beyond a layperson's understanding.

The clinical management of patients with psychopathy and other psychopathic disorders presents a vexing challenge for mental health professionals. The issues of hospital treatment and civil commitment can be especially confusing.

How time flies! It has been more than a year since my last column, when I staked my claim in psychiatry. I planned to eschew the medical rat race and find my own little piece of medicine as it used to be, when doctors were doctors, nurses were nurses, and insurance salespeople were . . . salespeople. Should one read anything into the long delay between that column and this one? Absolutely! But I'll get to that.

There is no disputing that the rapidly escalating rate of incarceration during the past decade in the United States has been associated with an increasing number of imprisoned individuals with a mental illness. Research indicates that as many as 20% of inmates in jail or prison are in need of psychiatric care, frequently because of a serious mental disorder.

Figures from the US Department of Justice indicate that more than half of prison and jail inmates have a mental health problem. Mental health courts (MHCs) were designed to divert mentally ill persons convicted of nonviolent crimes to supervised treatment instead of incarceration, but while the number of MHCs has grown substantially over the past decade, limited information has been available about outcomes and costs.

Psychiatrists who work in inpatient units are faced with daily decisions about predicting which patients will be violent, both in the hospital and after discharge. These decisions are often made using unstructured clinical judgment based on the clinician's experience and knowledge of the literature. How long such judgment stays the standard of care remains to be seen, because psychiatric researchers have produced a number of assessment and management tools to improve the accuracy and use of violence risk assessment. This article briefly outlines 3 tools: the Brøset Violence Checklist (BVC), the Classification of Violence Risk (COVR), and the Historical Clinical Risk-20 (HCR-20).

Patients with severe mental illness (SMI), such as schizophrenia, bipolar disorder, and major depression, are more likely to have experienced trauma in childhood, adolescence, and throughout their adult lives than the general population. This high exposure to traumatic events such as physical and sexual abuse and assault takes a heavy toll.

In "Intermittent Explosive Disorder: Common but Underappreciated"(Psychiatric Times,January 2007, page 1), Arline Kaplan wrote that intermittent explosive disorder (IED) "is not just another name for bad behavior." She quoted Dr Coccaro from the University of Chicago as asserting that patients with IED who react with rage to minor irritants have been shown to have reduced down-regulation of certain cortical nuclei that should be reined in by inhibitory stimuli from the frontal cortex.

The role of every emergency clinician is to determine whether the patient has a condition that threatens life or limb. Determining this in patients who malinger can be quite a challenge, because the malingering patient presents with false or exaggerated symptoms for secondary gain.

Few phenomena in medicine aremore confounding than the diagnosesinvolving deception:malingering, Munchausen syndrome,Munchausen by proxy (MBP), and factitiousdisorder.

Recent discoveries in neuroscience have ramifications for all aspects of clinical and forensic practice, including diagnosis, treatment, and testimony in civil and criminal justice cases.