What I Learned Part 3

Oh my...I still have one more day to go at the conference and my brain is already full.

The award for Weird Presentation of the Week (and that's saying a lot at a forensic conference!) goes to the poster on zoophilic interests in cases of Asperger's syndrome. I'll say no more about that. Just make sure you know who's petting your dog.

Another poster was an interesting case presentation about sleep apnea and anger and hostility. Apparently treatment with continuous positive airway pressure therapy has lead to significant improvement in irritability for sleep apnea sufferers. You might want to read a little bit about previous research on this here.

I enjoyed a panel discussion about ethical issues in forensic evaluations, particularly as it related to interviews of collateral informants. Although non-confidentiality warnings are routinely given, there is still the possibility that an informant may volunteer self-incriminating information or information that falls under a mandatory reporting duty.

Unfortunately, our luncheon speaker was held up in Tennessee and couldn't make his talk. I was looking forward to listening to Jon Ronson, author of The Psychopath Test. Instead we heard a talk by Dr. Phil Resnick about the relationship between paranoid delusions and violence. In addition to hearing a number of good anecdotes, we learned that delusions are more highly correlated with violence than command hallucinations.

The best session of the day was a panel presentation about false confessions. This has always been an interest of mine, but I've rarely had the opportunity to hear the people who have done the original research. I learned a lot about the Reid technique, including which techniques are commonly used and how the techniques are varied depending upon the presence of mental illness. I learned that of people exonerated by DNA, 16% had given detailed confessions. Overall, 80% of defendants waive their Miranda rights. In Canada, interrogations don't have to end when a defendant asks for a lawyer or when he claims his right to avoid self-incrimination. One panelist presented the results of a survey of 332 Baltimore County police officers regarding their understanding of juvenile development and their use of interrogation techniques. The survey showed that even though they understood the developmental differences between juveniles and adults, their actual interrogation practices were no different.

I listened to a presentation about the new diagnostic criteria for antisocial personality disorder coming out in DSM-5. In a word: ugh. Don't ask me how people are going to interpret the "self-identity" and "self-direction" criteria. The requirement for childhood conduct disorder will be dropped. I'm predicting even greater diagnostic discrepancies than what we have now.

Finally, a group from West Virginia presented some background information about an ongoing survey project regarding the use of social media in forensic evaluations. There wasn't a lot of data available yet because many of the forensic fellows had not received the survey (it was sent to all program directors and their students). Social media use by forensic psychiatrists was not directly correlated to age. Both early and late career forensic psychiatrists used it. There was a good overview of how social media content could be used in both civil and criminal cases. During the question session I added a comment about social media use in medical education as well.

Tomorrow is the last day, then I make my way back through the storm (or hopefully, ahead of the storm). Wish me luck.

Mental Health, Military Style-- Guest Blogger Dr. Jesse Hellman

Today, we're talking about mental health and the military.  But first, I just learned, via Facebook, that today is International Polar Bear Day.  If you have one, hug him tight.  Make sure he's been fed first.


Over on his own blog, Pete Earley, has a post up about a veteran who was about to kill himself with a homemade gun.  He called a Suicide Hotline, the police were sent and the patient was charged with possessing a homemade gun.  It's a good post, worth the read, and Earley brings up issues about mental health emergencies and the legal system that aren't limited to veterans. 


Yesterday, the New York Times had an article about military discharges for a diagnosis of "personality disorder."  The diagnosis is presumed to be a pre-existing one, so once a soldier is diagnosed with a personality disorder, he can be discharged without the usual military benefits.  I know that our guest blogger Dr. Jesse Hellman  has an interest in the topic.  He spent two years as a military psychiatrist, and has attended hearings on the topic, so I asked him to do a quick guest post for us:


Jesse writes:
  The article tells of a 50 year old woman psychologist who enlisted, was sent to Afghanistan, and was involved in a number of incidents, eventually being accused of sexual harassment for remarks she had made. She was sent for psychiatric evaluation and was given the diagnosis of personality order on discharge. There are severe consequences of this diagnosis, which can include loss of future benefits, medical expenses, and more. Was the diagnosis properly considered? Did her commanding officer ask that she be given that diagnosis in order to reduce the huge medical expenses produced by the military?

This is not the first time I had heard of this problem. In the fall, I attended in Washington a meeting of the House Committee for Veteran Affairs. Joshua Kors, a writer who had several pieces in The Nation which addressed this very problem, was testifying along with a soldier who had been discharged as having a personality disorder. The Department of Defense sent several people to testify that there was no abuse of the diagnosis.

One of Mr. Kors's strongest points was the sheer number of personality disorder diagnoses that were being made. It looked like these were occurring at two bases in the United States that processed discharged soldiers: Could it possibly be that this number of applicants slipped through the initial screening process?

My own impressions were mixed. It seemed inconceivable to me that any military commander would directly order physicians to misdiagnose in order to reduce costs to another entity. Vastly too great a risk to him, and to what advantage? On the other hand, the diagnosis as described in the DSM is more severe than the problem warrants: it is possible that many soldiers enlisted thinking the military was for them but then, through various routes, found that life in Afghanistan, under fire, with all the dangers and rigors, was too much. Their attitudes disintegrated. They wanted out. They were poor soldiers who disrupted morale.

To those who understand how to use bureaucracy to effect one's ends, direct orders are not needed. If it takes one hour to examine a soldier and find a given diagnosis, but alternate diagnoses require much more paperwork, repeat examinations, record reviews, etc, and the caseload of the examiner is sufficiently great, is it not predictable that the particular diagnosis that minimizes work will increase in comparison to the alternatives?

So what do you think? There are many issues here worthy of discussion.

Last Chance for Your Input On Personality Disorders

DSM-5 Revisions for Personality Disorders Reflect Major Change

Public Comment Period for Proposed Diagnostic Criteria Extended Through July 15

 

ARLINGTON, Va. (July 7, 2011) – The American Psychiatric Association’s diagnostic criteria for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) propose a significant reformulation in how personality disorders are identified and assessed. The change integrates disorder types with pathological personality traits and, most importantly, levels of impairment in what is known as “personality functioning.” 

 

With its multidimensional framework, this hybrid model is very different from the way personality disorders are presented as rigid behavioral categories in the current manual. The goal of the new criteria is to maximize their utility to clinicians and benefit to patients.

 

DSM is the standard classification used by mental health and other health professionals for diagnostic and research purposes. The manual’s next edition, representing the latest scientific understanding of the etiology, characteristics and relationships of mental disorders, will be published in 2013. Release of DSM-5 will culminate more than a decade of rigorous work involving hundreds of experts from the United States and abroad.

 

The new draft criteria for personality disorders are currently being evaluated through field trials in real-world clinical settings across the country. Public comment also is invited on the proposed revisions to these and other diagnostic criteria. Submissions will now be accepted through July 15. All criteria are available for review on www.dsm5.org.

 

As recommended by the DSM-5 Personality and Personality Disorders Work Group, 10 categories will be reduced to six specific personality disorder types (antisocial, avoidant, borderline, narcissistic, obsessive/compulsive and schizotypal). But for a diagnosis within these descriptive classifications, several conditions must be met.

 

Critically, a person must have significant impairment in the two areas of personality functioning – self and interpersonal. Self is defined as how patients view themselves as well as how they identify and pursue goals in life. Interpersonal is defined as whether an individual is able to understand other people’s perspectives and form close relationships. The scale by which these will be judged ranges from mild to extreme.

 

In addition, the work group determined that pathological personality traits must be present in at least one of five broad areas – such as whether a person is antagonistic versus able to get along with others, or impulsive versus able to think through possible consequences of action.

“The importance of personality functioning and personality traits is the major innovation here,” said Andrew Skodol, M.D., the work group’s chair and a research professor of psychiatry at the University of Arizona College of Medicine. “In the past, we viewed personality disorders as binary. You either had one or you didn’t. But we now understand that personality pathology is a matter of degree.”

 

Noted Robert Krueger, Ph.D., a member of the work group and a professor of psychology at the University of Minnesota, “Our proposed criteria get away from the idea that personality pathology is just a group of disorders. We’re instead defining it as a much broader characteristic.”

 

Underlying the work group’s recommendations are longitudinal studies and other clinical research since the early 1990s that have revealed the shortcomings of the current behavior-based criteria. Because behavior can be intermittent and changeable over time, the criteria can hinder an accurate diagnosis and even impede treatment.

 

By contrast, impairments in personality functioning and pathological personality traits tend to be more stable over time and consistent regardless of the situation. Both stability and consistency would be required under the revisions to the diagnostic criteria.

 

Over the next year, the DSM-5 Task Force and its work groups will continue refining the categories and specifics of all disorders to be included in the next edition. The current public comment period will play into their deliberations. As with the first public review last year, when the APA received more than 8,000 written responses from clinicians, researchers and family and patient advocates, every comment will be considered. As of mid-June, nearly 1,800 additional responses had been submitted.

 

In the meantime, the first round of field trials continues at nearly a dozen larger academic and clinical centers; almost 3,900 mental health professionals in individual practice and smaller settings also will participate before the trials conclude. Another public comment period on the criteria will then follow.

 

The DSM-5 diagnostic criteria will be determined by 2012 and submitted to the APA’s Board of Trustees for review and approval.

 

The American Psychiatric Association is a national medical specialty society whose more than 36,000 physician members specialize in the diagnosis, treatment, prevention and research of mental illnesses, including substance use disorders. Visit the APA at www.psych.org and www.healthyminds.org

101 Dalmations (And Chihuahuas…And Cats….And…)

In the New York Times this week we have a story entitled Animal Abuse as Clue to Additional Cruelties. In this article Ian Urbina discusses the problem of people who hoard animals and the connection between animal abuse and violence toward people.

The link between animal cruelty and antisocial behavior is well known and was first studied in the 1960's by a researcher at Washington University by the name of Lee Robins. Dr. Robins followed the outcomes of children referred to a local mental health center for conduct problems, and learned that about one third of them developed antisocial behavior as adults. This is where we get the current conduct disorder criteria for antisocial personality disorder found in DSM-IV: firesetting, theft, running away, truancy and animal cruelty.

States are passing laws to better identify and track people who hoard or abuse animals, with the idea that people who do this are also likely to be abusing or neglect humans in their households. The laws allow for sharing of information between people who investigate domestic violence or child abuse and people who investigate animal neglect cases. Some states are even passing laws to create registries of animal abusers.

Two parts of this story caught my attention: the registry issue and the idea that neglecting an animal becomes a predicate offense for other investigations. Here in Maryland we're big on registries. We have a sex offender registry and child abuse and neglect registry. We have a law requiring child welfare agencies to compare recent birth certificate information to the child abuse registry, to see if any known child abusers are having more kids. Now maybe we should also check to see if they're adopting pets.

The whole idea of registering and tracking people is a bit uncomfortable for me. Registries don't prevent crime but they can prevent people from getting jobs, buying homes and reintegrating into society after they've served their time. Being on a registry (or not being on one) is not truly reflective of the risk that person poses to society. A demented little old lady found with 200 cats in her basement could end up on the Internet, with the implication that she since she has neglected animals she also abuses children. Registries also don't seem to do much for preventing people from getting access to what makes people truly violent: guns and alcohol. Perhaps we should require liquor stores to check registries before any beer transaction. While we're at it, violence is associated with mental illness, untreated mood disorders and personality disorders. Maybe a registry of psychiatric patients?

Please. Enough. I doubt Dr. Robins ever expected this kind of outcome to her work. The purpose of studies like hers was to identify people at risk, for intervention and treatment, not for prosecution and public censure. I think we need to get back to that original idea.

Who Is A Criminal?

I'll admit this seems like an odd question with an obvious answer. Most people would say that a criminal is anyone convicted of a crime. However, there is a difference between someone who has merely been convicted of a single crime and someone with a pattern of criminal behavior. Repetitive criminals may be psychopaths or sociopaths. Fictional characters like Hannibal Lechter or Tony Soprano are good examples of sociopathic or psychopathic personalities.

It might be a bit disconcerting to know that people like this actually exist and that they've been around for a long time. In 1837 an English psychiatrist named James Pritchard wrote a book entitled Treatise on Insanity in which he described people who lacked the ability to form attachments to others and who were unable to experience normal human affection or emotions. These individuals had little regard for the feelings or rights of others, however they didn't have the hallucinations or impaired cognitive functioning that was seen in other psychiatric disorders. Dr. Pritchard coined the term 'moral insanity' to describe this disorder, which he felt was a defect in area of the brain responsible for moral reasoning. Around this time the American Journal of Insanity (which later became the American Journal of Psychiatry) published several individual case studies of homicide offenders, all of which were entitled "A Case of Homicidal Insanity". They were all essentially just case descriptions of murderers. The letters to the editor of the journal following these case studies debated the validity of 'moral insanity' as a mental illness. The difficulty was that the term 'insanity' implied that from a legal standpoint the criminal should not be held responsible or punished for his behavior. Eventually the term 'moral insanity' was dropped in favor of the term 'psychopath', a term proposed by a Nineteenth Century German psychiatrist.

More recently, the term 'sociopath' has been used instead of 'psychopath'. This latest change happened because people were getting confused by the 'psycho' part of the psychopathy label---psychopathy doesn't mean that the criminal is psychotic. Actually, neither sociopathy nor psychopathy are actual 'official' psychiatric diagnoses in that they can't be found in the Diagnostic and Statistical Manual (DSM). The DSM uses the term antisocial personality disorder (ASPD). Patients with antisocial personality disorder have difficulty with lying, impulsivity, repeated criminal acts, and impulsivity or irresponsibility. The majority of people with ASPD are not psychopaths. Psychopaths represent a minority of severely disordered people who lack emotional attachments or responsiveness. They are narcissistic and are unable to learn from experience. They lack empathy or remorse and are cold, cruel, callous people. This callousness is what distinguishes psychopathy from antisocial personality disorder.

There are a lot of people with antisocial personality disorder---about 3% of the United States population or nine million people. The exact prevalence of psychopathy may never be known because psychopaths usually only come to the attention of clinicians when they are caught committing crimes or when those around them coerce them into treatment. The most skillful psychopaths may not come to the attention of the law and may function successfully as politicians, religious leaders or heads of large corporations.

A screening tool for psychopathy was developed in the 1980's and has been widely used in research and forensic practice. Scores on the Hare Psychopathy Check List-Revised (PCLR-R) have been found to be useful for predicting violence and criminal recidivism. Psychopaths identified by the PCLR-R are being studied through functional neuroimaging in order to identify the physical basis for the disorder. These studies have shown that in psychopaths the part of the brain responsible for processing emotions works differently than in normal people. They also have different physiologic responses to emotion.

There is a genetic component to both ASPD and psychopathy as shown by adoption and twin studies. One large twin study has shown that for severe psychopaths as much as two-thirds of psychopathy can be attributed to genetics rather than environmental influences. For ASPD, the condition originates in childhood. A study done in the 1960's followed children from a mental health center who were referred for evaluation of their behavior problems. The study found that over fifteen years, one-third of the children with conduct disorder grew up to have antisocial personality disorder.

Can psychopaths be treated?

This is a tough question to answer. Psychopaths don't generally seek treatment voluntarily because they aren't bothered by their condition. They must be coerced into treatment or persuaded to participate by engaging their self-interest. For example, by emphasizing that treatment is a condition of parole and is necessary to stay out of jail or prison. Since psychopaths have difficulty learning from consequences, several treatment attempts may be necessary. The treatment must be designed to have open lines of communication between others involved in the psychopath's life in order to ensure truthfulness. There must be clear, consistent and firm boundaries between the patient and the therapist. Psychopaths with a high risk of violent behavior should only be treated in a secure and structured setting like a correctional facility. Psychopaths and people with ASPD are at increased risk of developing other psychiatric conditions such as mood disorders and substance abuse. Medication may be indicated for treatment of these co-existing conditions.

There is no evidence that psychopathy or ASPD can be cured. The goal of treatment is to minimize the impact of the conditions on others and on the patient. For example, one goal of treatment might be to minimize the risk of accidental injury by teaching the patient to recognize situations that trigger dangerous risk-taking behavior. Violence is another focus of treatment with psychopaths; violent behavior can be managed with administrative disciplinary procedures within the correctional facility or through the use of medication.

Specific treatment goals should be set up collaboratively with the patient so that expectations and treatment parameters are clear. The patient's self-identified treatment goal may also reveal his level of insight. When I asked one of my prisoners what he was working on in therapy, his answer was telling. "The truth," he said. "Telling the truth, it's something I've been working on for a while."

It's a beginning.