Forensic Psychiatry

Notwithstanding the personal implications and its centrality to mental health professionals, in my 30 years of teaching and writing about the intersection of psychiatry and law, I had managed to avoid that rite of passage. I was not comfortable and found it difficult to say something original on a topic that has been so extensively explored.

Patients who exaggerate, feign, or induce physical illness are a great challenge to their physicians. Trained to trust their patients’ self-reports, even competent and conscientious physicians can fall victim to these deceptions.

While violence is often portrayed in the media as related to persons with mental illnesses, there are limited research data to support this idea. This article reviews laws and obligations for mental health professionals.

There is no magic moment when it becomes clear that the world needs a new edition of the DSM. With just one exception, the publication dates of all previous DSM’s were determined by the appearance of new revisions of the International Classification of Diseases (ICD). Thus, DSM-I appeared in conjunction with ICD-6 in 1952; DSM-II with ICD-8 in 1968; DSM-III with ICD-9 in 1980; and DSM-IV with ICD-10 in 1994. The lone exception was DSM-IIII-R, which appeared in 1987-out of cycle only because it was originally meant to be no more than a minor revision. The official publication date for DSM-V is May 2012. That date was picked to be consistent with an earlier, no longer correct, expectation that ICD-11 would be published in that same year.

The process of adapting to prison life, or “prisonization,” exerts a dehumanizing effect that may result in feelings of hopelessness and alienation.

Two randomized controlled trials have shown the Systems Training for Emotional Predictability and Problem Solving (STEPPS) program to be effective in reducing the intensity of core aspects of borderline personality disorder (BPD), Dr Donald Black and social worker Nancee Blum announced at the annual meeting of the American Psychiatric Association held recently in San Francisco. Black summarized, “Data from several studies show that STEPPS reduced global severity as rated by clinicians and patients, borderline personality disorder symptoms, and depressive symptoms.”

The epidemiology and management of psychiatric disability have gained increased attention for a variety of reasons in the past 3 decades. There are issues of empowerment, advocacy, and reduction of stigma. There are also concerns about cost containment as well as reliability, validity, and efficacy of the determination process.

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.