On Skepticism and Tolerance in Psychiatry and Forensic Psychiatry

Clinical and forensic psychiatrists today share a number of challenges related to the tools we use in diagnosis and management and to the rapid advances in our understanding of the brain. 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.

The ever-pervasive DSM strongly influences both clinical and forensic practice, but DSM can clearly be misused in the courtroom. At the same time, legitimate questions have been raised concerning conflicts of interest in those who have contributed to the development of DSM and the resulting potential for the dissemination of pseudoevidence-based medicine.

In introducing this special bonus issue of Psychiatric Times, we will briefly explore some of these key concerns and will then point you toward the outstanding collection of articles on clinical psychiatry and the law prepared for this issue by a number of distinguished contributors.

Frontiers in forensic psychiatry: back to the future
To many, the brain is the final frontier of medical science. As psychiatrists, we are uniquely positioned to take advantage of the continual breakthroughs in our understanding of the brain.

In the forensic realm, a greater understanding of the neuroscience of behavior has potentially transformative implications. Advances in imaging of organic brain deficits may change the nature of forensic analysis; moreover, inquiries into the causality of behavior from a neurobiological perspective may alter our ideas of free will and criminality.¹ Genomics research can contribute here also, but it is important to remember that although genes may predispose, they are not deterministic: heritability does not translate to inevitability. Finally, the power of the mind may come to be revealed as mind/body interaction perspectives deepen in such areas as state-of-the-mind influences on pain perception and pain-related impairment.²

Despite the (justifiable) excitement surrounding these new avenues of research, healthy doses of skepticism and tolerance are essential. We must look at all new research attempting to shed light on the mysteries of the mind and its relationship to the body with scholarly skepticism and a tolerance for complexity and diversity of opinion.

Equally important is consideration of the effects of new findings on confidentiality. In order to fully bear the fruits of the labors of scientific research, we must continually strive to protect patient confidentiality. The need to be mindful of confidentiality and privacy can be a consideration even in the forensic context when there is no doctor-patient relationship or when there is a limited waiver of confidentiality and privacy for the purpose of courtroom testimony.

Outside influence and conflicts of interest
An examination of the issues facing forensic psychiatry today would be incomplete without discussing the important "the DSM emperor wears no forensic clothes" problem. Contrary to pronouncements by ill-trained attorneys that DSM is the "bible of psychiatry" and some quick-fix, pseudoevidence-based guidelines that imply that psychiatry can be practiced from a cookbook, there is a growing recognition of the wisdom of the caveat that DSM-IV-TR cannot be used for forensic purposes. As the authoritative text on psychiatric taxonomy, DSM has been enormously influential in shaping clinicians' diagnostic reasoning. Thus, it is clear that its influence on forensic practice-despite the aforementioned caveat to the contrary-needs to be examined closely.

One source of negative influence is the categorical structure of DSM that sharply divides the neuropsychiatric spectrum of human suffering into easily digestible, "sound-bite" syndromes presented in bold-type criteria.^3-5 The categorical approach is especially vulnerable to oversimplification, particularly during time-pressured situations, whether in the clinic or in the course of courtroom testimony.

Under conditions of uncertainty and time pressure, clinicians simplify by using shortcuts, ie, simple rules or heuristics, in the course of diagnostic reasoning.⁶ With insufficient time to get to know individual patients, to listen carefully to a patient's life narrative unfolding over time, and to observe what is not spoken, there is a growing tendency to make premature cognitive commitments to diagnoses that fit the menu or bullet-point layout of DSM.³ Such premature closure of inquiry can overlook atypical presentations, the variability of disorder presentations across settings and cultures, and the individuality and complexity of suffering. As a result, diagnostic reliability is conflated with diagnostic validity.

The influence of DSM gains even more importance in light of recent reports on the failure to disclose that many of the contributors to DSM-IV had ties to pharmaceutical companies.⁷ In light of this and other reports exposing the unduly intimate relationships between doctors and the pharmaceutical industry,^8,9 it is clear that conflicts of interest exist within medicine. Psychiatry, including forensic psychiatry, can take the lead in addressing how these conflicts can be best resolved, beyond mere disclosure or draconian exclusion of interested yet informed experts.

The consequences of conflicts of interest within medicine are far-reaching and extend beyond the erosion of public trust. Within the current climate of evidence-based clinical practice and quality improvement,¹⁰ vested interests can have a pernicious influence on the evidence physicians use to make clinical decisions. The result can be pseudoevidence-based medicine: the practice of medicine based on spurious evidence disseminated as truth, then adopted by unwitting practitioners of evidence-based medicine.¹¹ The existence of pseudoevidence is supported by a variety of reports such as those indicating connections between drug company sponsorship and positive conclusions in psychopharmacology trials.^12-14

What the future holds
The problematic influence of DSM and substantial industry emphasis on pharmacotherapy devoid of psychotherapy have combined to drive too many of the students most adept at psychiatric diagnostic interviewing away from psychiatry. Moreover, those who enter the field are not being taught proper interviewing techniques. This does not bode well for the future of psychiatry, and we must turn a keen eye to the insidious influences that are quickly dominating our field.

In forensic psychiatry, where the art of the interview is essential for discovering fruitful alternative hypotheses, it must be stressed that structured interviews or checklists can never replace unstructured, time-consuming yet thoughtfully probing diagnostic interviews. Thus, it is essential for forensic psychiatry to join the rest of psychiatry in beginning to consider whether the confounding of reliability with validity within psychiatric practice as a whole has been unduly influenced by DSM structures, which in turn may be unduly influenced by insurance and pharmaceutical industry interests.

As clinicians, what are we to do? A first step is an ongoing awareness of pseudoevidence and widespread conflicts of interest generated by pharmaceutical companies directly and indirectly funding much of psychiatric research, continuing education, and some psychiatric practice. Moreover, a deeper awareness that our taxonomic system sometimes sacrifices validity for reliability is critical.

At the individual level, the specter of pseudoevidence can be met with heightened skepticism similar to that used by forensic psychiatrists to evaluate evidence, as well as ethical professionalism in relationships with patients and in scientific research.¹¹ For example, the results of the groundbreaking CATIE study should give us pause to reconsider our most basic assumptions about the risk/benefit balance of long-term involuntary use of medications.¹⁵

At the group level, psychiatry should foster mechanisms, long embedded in forensic psychiatry, such as the practice in an adversarial justice system of opposing counsels to each retain their own experts to be heard by independent finders of fact. For psychiatry this would suggest a mandate to ensure that clinically sophisticated critics of the pharmaceutical and insurance industries are actively involved, especially with respect to the construction of the new DSM-V and APA-endorsed treatment guidelines.¹⁶

Challenges in forensic psychiatry
The evolution of forensic psychiatry brings with it a host of challenges, old and new. The articles contained in this bonus issue address some areas of fundamental forensic interest including the evaluation of mental damages (Drukteinis) and the evolving nature of psychiatric malpractice (Dondershine and colleagues).

The next group of articles address some of the most salient questions facing the field today. Several articles explore the clinical and forensic approaches to long-standing, alien conditions such as factitious disorder (Dyer and Feldman), malingering (LeBourgeois), suicidality (Frierson), and paraphilia (Malin and Saleh). The importance of the therapeutic alliance in the treatment of addiction is addressed by Johnson and colleagues. Finally, Medina takes a skeptical look at the intriguing efforts to use functional MRI of the brain as a lie detector.

Conclusion
The challenges of the frontiers of forensics can only be met with active, critical engagement and tolerance. We must ask this rigor of ourselves, and in keeping with our historical expertise in listening and interviewing, we must practice the qualities of skepticism, consideration, and tolerance. Forensic psychiatry can thus continue to develop as a voice for the analysis of complexity at the ever-evolving boundary between psychiatry and law while, at the same time, serve as a reminder about why the practice of psychiatry is much more than simply prescribing based on bullet points.

References:

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3. Tufte ER. The Cognitive Style of PowerPoint. Cheshire, Conn: Graphics Press LLC; 2003.
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13. Heres S, Davis J, Maino K, et al. Why olanzapine beats risperidone, risperidone beats quetiapine, and quetiapine beats olanzapine: an exploratory analysis of head-to-head comparison studies of second-generation antipsychotics. Am J Psychiatry. 2006;163:185-194.
14. Djulbegovic B, Lacevic M, Cantor A, et al. The uncertainty principle and industry-sponsored research. Lancet. 2000;356:635-638.
15. Lieberman JA, Stroup TS, McEvoy JP, et al. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med. 2005;353:1209-1223.
16. Cosgrove L, Bursztajn H. Beyond pseudo-neutrality in conflict of interest policies in medicine: the case of psychiatry. In press.