Interactive Brains

Neuroanatomy was my favorite class in medical school. I loved tracing out the brain pathways, figuring out which part did what, connecting up clinical syndromes to what I knew about brain structure and the nervous system. I learned all this back in the dark ages, back in the paleontologic age when whales had legs, before comets struck the earth and caused the last ice age. The World Wide Web didn't exist then either. I had to learn this stuff by examining the actual brains of dead people, by looking at stained microscope slides of brains and by pouring over books (the things with pages, covers and ink) rather than web sites.

So now the modern age is here and students get all kinds of cool high tech stuff to learn with. Just out of curiosity I scoured the web and put together a quick and dirty list of some web sites that provide interactive imaging of the human brain. Dang, I wish I had that when I was a med student.

Michigan State Brain Bank

Harvard's Whole Brain Atlas

University of Florida (takes a while to load, Flash-based, no labels)

University of Washington

Wayne State University

University of Utah (This one was my favorite atlas. It shows actual photographs of gross brain anatomy. You can click on the name of the structure and an arrow points to it. No neuroimaging to interpret, just identification of gross structures.)

University of Michigan

Columbia Brain Atlas

Neuroscience Funding Gets A Boost

Just a couple weeks ago the Justine and Catherine MacArthur Foundation awarded a $10 million dollar grant to twelve universities to study neuroimaging and the law. The purpose of the grant is to get a better understanding of the relationship between functional neuroimaging studies and forensic issues such as competence to make decisions, criminal responsibiity and disabiity. This grant has the potential to really change the nature of psychiatric expert testimony.

The grant has three components: brain abnormalities, substance abuse and decision-making. There will be some overlap between these areas, but the general idea is to start bridging the gap between what is seen on a functional MRI and the ultimate legal questions of criminal culpability and competence. This can be a life or death question---in Roper v Simmons neuroimaging was used as evidence that juveniles should not be given the death penalty. Hopefully the MacArthur grant will shed some light on whether the degree of brain myelination in juveniles is, in fact, relevant at all to criminal responsibility. Right now the legal opinions based on neuroimaging have tended to leap a bit beyond what science has shown in my opinion.

What I Learned Part 3

The final installment in my conference series. Tomorrow I come home to my fellow bloggers! I miss them.

• In France they are doing an interesting project to look at the effects of incarceration. They are asking prisoners to spontaneously describe their incarceration experience and how they think it has affected them, then they are using computerized lexicographical analysis to define common domains of concern.

• There was a poster looking at the neuroanatomical basis of empathy, sympathy and moral reasoning. Highly theoretical and completely lacking in data, unfortunately.

• In 1895 Bridget Cleary was burned to death by her husband, who believed that she had been kidnapped by fairies and a changeling left in her place. It is possible that Michael Cleary suffered from a form of Capgras delusion.

• Someone tried to do a study looking at treatment compliance and motivation for change in sex offenders, but there weren't enough sex offenders motivated to participate in the research.

• Very few states have laws requiring mandatory reporting of impaired drivers to the MVA.

• One Russian psychiatrist proposed that the term "dependent behavior disorder" be used as a diagnosis for a broad range of compulsive behaviors.

• The first documented use of telepsychiatry was in 1959. In the U.K. a criminal justice statute required the installation of teleconferencing equipment throughout the courts and correctional facilities in the country. This is now being used to perform clinical and court-ordered psychiatric assessments. Free society studies have shown patient satisfaction to be similar between telepsychiatry evaluations and face-to-face interviews. In the U.S. there are a number of undefined legal issues with regard to telepsychiatry and computer-assisted treatment. These including licensing issues for practice across state lines, informed consent for remote clients/patients and malpractice coverage across state lines.

• Directors of forensic fellowship training are working to create measurement tools and procedures to meet the core competency requirements of the American Council for Graduate Medical Education (ACGME). There was a very nice workshop that presented a "toolbox" of techniques for documenting residents' competency as well as a discussion regarding how to prepare for an accreditation visit. The workshop also discussed the challenges of funding a forensic fellowship program.

THE END

Thank you for reading

What I Learned Part 2

Here's the second installment in my conference ramblings:

• The Supreme Court decided in Sutton vs. United Airlines that for the purposes of the Americans with Disabilites Act the disability must be assessed only after attempts have been made to correct the impairment.
  

• Liability in medication-related tort claims is best reduced by well-documented informed consent (Duh. But that came up a lot this year so I mention it.)

• In states that allow for outpatient commitment, only 20% of pretrial detainees who are referred for commitment actually end up getting commitment orders. This is because most of them are either sent to prison prior to a commitment hearing or because they are committed to a hospital for restoration to competence prior to an outpatient commitment hearing.

• Death Penalty

In 2006 there were 53 people executed, 32 were white and 21 were black. In 2005 there were 1805 whites and 1372 blacks on death row. One out of 12 death row inmates had committed previous homicides. Death penalty aggravating and mitigating factors are set by state statute. Aggravating factors include victim characteristics (law enforcement or firefighting personnel, children, pregnant women), defendant characteristics (previous violent offenses), and offense characteristics (murder committed during the course of a felony, contract killings). By law all possible mitigating evidence is allowed to be heard during the sentencing phase of a death penalty proceeding. Although mental health issues are statutory mitigating factors, sentencing juries actually consider them as aggravators and they are more likely to result in a death sentence. The main purpose of expert mental health testimony in a death penalty hearing is to humanize the defendant and to change the focus of the hearing from the crime to the defendant. It also serves to give the defendant an opportunity to communicate to the jury through the expert. Surveyed death penalty defense attorneys usually prefer psychiatrist rather than psychologist expert testimony. They prefer forensically trained experts with an area of expertise that is relevant to the case, with good testifying skills.

• Risk Assessment in the U.K.

The U.K. has a relatively new law that allows for the indefinite detention and/or community supervision of violent offenders. This led to the creation of the Risk Management Authority, an administrative body that trains, supervises and regulates official risk management assessors. The assessments are quite exhaustive and includes a minimum 6 hour interview over three days. It is primarily a clinical assessment although it does require the use of at least one "official" approved actuarial tool. There were only 7 orders for assessments filed in 2006. Some offenders refuse to cooperate since they know it could result in a lifetime of supervision and mandatory treatment.

Another development was the creation of a Dangerous and Severe Personality Disorder Service, which essentially is a tool for civil commitment of psychopaths. This has led to 150 referrals a month and an increased number of non-mentally ill sociopaths in forensic hospitals. (One presenter's quote: "The system is swamped.") They are treated with cognitive-behavioral therapy at a cost of $500,000 per inmate per year. Remarkably, there have only been three minor inpatient assaults involving these patients over five years.

• Liability and risk management in forensic practice

Case law is still defining areas of liability for forensic clinicians. Most liability seems to arise as a result of independent medical evaluations (IME's). The 2006 case Harris v. Kreutzer determined that there was a limited physician-patient relationship created during the IME. The three duties created as a result of this are: 1) to cause no injury during the evaluation (read the Harris case), 2) disclose significant findings to the evaluee (eg. an orthopedic surgeon doing an IME who incidentally discovers a tumor), 3) maintain confidentiality (eg HIPAA compliance)

Most states have limited civil immunity for expert testimony but this is not absolute & varies with jurisdiction. Experts appointed by medical boards for peer review have been sued with varying degrees of success by their evaluees. A forensic expert could face discipline from the AMA, the state medical board, or a specialty organization. In general psychiatric practice most liability comes from suicide or from medication-related injuries.

• Ethics of Forensic Psychiatry

In 1982 Harvard professor Dr. Alan Stone gave an address in which he suggested that it was unethical for psychiatrists to be involved in expert testimony. The last panel today was an update by Dr. Stone on his position and a response from a number of illustrious colleagues. I can only give this topic pitiful recapitulation here. Stone argued that psychiatry has no absolute truths to offer and that professional consensus is dangerously misleading. Panelists Ezra Griffith, Stephen Morse and Paul Appelbaum responded that it is ethical for professionals to aid the court's search for truth and to promote justice. While acknowledging potential ethical pitfalls, there was a consensus that evolving standards of science provide something to offer.

(Incidentally, in Podcast #14 (No April Fool) I talked about the New York Times article, Brain On The Stand, which quotes Dr. Morse's views on the use of neuroimaging in forensics. Now that I've had a chance to listen to this guy speak it is clear that he is someone to keep an eye on. Interesting things are going to be coming out of U. Penn, particularly with his involvement in the recent $10 million MacArthur grant for neuroscience and the law. This is probably worth a blog post all on its own, when I get the chance. Right now I'm off to dinner.)

What I Learned Part 1

This is my second annual blog post that summarizes my experiences at the forensic conference I attend every year. Last year I put up a three part "What I Learned" series, which I occasionally go back to when questions come up and I know I heard something about it once but can't remember the details.

So here goes:

• The Atlantic ocean is surprisingly warm for October.
• There are approximately 5000 women murdered every year in honor killings. Syria and Jordan still have laws on the books for men to kill their wives without consequences if they are caught in the act of adultery.
• There is evidence that the Slater method may be effective for restoring developmentally disabled defendants to competence to stand trial.
• Only two states in the country (Connecticut and Indiana) have laws that allow police to seize legally owned weapons from dangerous individuals.
• Violence predictions instruments, even the PCL-R, has not been validated for use with women and it is not recommended to use them as a predictive tool for female defendants or prisoners.
• Vaginal plethysmography exists but has not been validated for use in evaluating female sex offenders.
• In recent years the number of women found Not Guilty By Reason of Insanity (NGBRI) has increased. This may be due to increased awareness of post-partum psychiatric illness.
• Culture-bound syndromes can be seen in immigrant populations and it is necessary to understand these phenomena in order to distinguish them from delusions. Ashanti witchcraft, "root workers" and others may lead to commonly held cultural beliefs.
• A woman named Marti Ripoli was an infamous serial killer in the nineteenth century. She was thought to be responsible for the deaths of 25 children, whose blood she used to make magical remedies that she sold on the streets. Belle Gunness had nothing on this lady.
• Alan Felthous gave an amazing Presidential Address in which he reviewed the religious and philosophical underpinnings of free will from Aristotle up to the neuroanatomy of decision-making as shown by functional MRI's. All in less than an hour. Wow.
• There was a great panel presentation about cults. They discussed the difference between a religion, a sect and a cult. They described characteristics of cult leaders and followers and cult dynamics including recruitment, retention and deprogramming. They presented case law regarding deprogramming practices and risk management issues for psychiatrists. Finally, they presented the satanic cult abuse issues of the 1980's and the lessons learned from this. (I enjoyed the tutorial about the Church of Satan and what to ask your Goth patients. Also the Church of Satan tattoos. Personally, if I saw a 'Satan Rules' tattoo I don't think I'd need to ask too many more questions.)
• In Germany forensic experts are always the agents of the court rather than agents of an adversarial attorney. The goal is a neutral and impartial evaluation. (We could learn something from that here in the States. I bet their malpractice costs are significantly lower.)
• The concealed information test is the most commonly used experimental deception paradigm. It has been used in functional MRI lie detection studies, the first one of which was published in 2001. The number of fMRI lie detection studies has increased quickly since then, but a number of the authors are partners in two companies that do commercial fMRI lie detection, Cephos and No Lie MRI. (We discussed this topic in Podcast 5: Sex, Lies and Neuroeconomics.) Functional MRI's cost about $1800.
  
• SPECT scans are very sensitive but completely nonspecific. They are abnormal in a broad variety of conditions but there is a lot of overlap between conditions. When using SPECT to evaluate mild traumatic brain injury, it is important to first rule out the confounding variable of clinical depression.
• Problematic Internet use covers a broad range of behaviors: cyberstalking, cyberbullying, excessive surfing, excessive online gaming and inappropriate work behavior.
• When evaluating a building for Sick Building Syndrome it is important to do a visual inspection first, then take samples if necessary. Sampling includes measurements of wall and room humidity, temperature, carbon monoxide and carbon dioxide levels and surface swabs. A normal carbon dioxide level is 1000 parts per million. Normal building temperature is from 68-72 degrees in the wintertime with less than 60% humidity. Some plaintiffs alleging sick building syndrome are actually suffering from somatization disorder so it may be necessary to involve forensic psychiatrists in these evaluations.

PHEW. And that's only the first day. Here's the other thing that I learned:

I love eating lobster while watching the ocean. Beats the heck out of working in prison.

My Three Shrinks 5: Sex, Lies, and Neuroeconomics

[4] . . . [5] . . . [6] . . . [All]

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Today's podcast is brought to you by the letter "M" and the number "5".

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January 9, 2007:
Topics include:

• New Yorker Magazine (Sep 18, 2006): Mind Games: What Neuroeconomics tells us about money and the brain, by John Cassidy. The neuroanatomy and functional connectivity that lies behind our economic decisions and risk aversion. As measured by functional MRI imaging (fMRI), the constant tug-of-war between the orbitofront al lobe, the amygdala, and the insular cortex mediates everyday economic decisions. Related links include the Neuroscience Marketing blog, New York University's Center for Brain Imaging, Google "neuroeconomics", and the Omnibrain blog (one of our favorites).
• Book "Paving Wall Street: Experimental Economics and the Quest for the Perfect Market", by Dinah's brother, Ross.
• Dinah refers back to a Shrink Rap post on compulsive blogging and to another one on a combination Wellbutrin (bupropion)/Revia (naltrexone) pill called Contrave for weight loss.
• The Interview Room, a novel by forensic psychiatrist Roderick Anscombe, provides insight into how the brain betrays people's lies. His website provides 14 tips on how to spot the liar (very interesting reading).
• Washington Post (Oct 30, 2006): Using fMRI machines to detect lies. See also website for No Lie MRI.
• Be nice to Dinah, who had a bad day.
• Clink's Favorite Podcasts: BusinessWeek, NPR, State Department Press Briefings, Slash Dot Review, Byzantine Emperors.
  
• Roy's Favorite Podcasts: Comic Strip Live, FLOSS Weekly, Futures in Biotech, Inside the Net (now http://www.twit.tv/ITN), NEJM, This Week in Tech (TWiT).
  
• Dinah's Favorite Podcasts: "Umm, why would I want to listen to podcasts, anyway?"

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Find show notes with links at:
iTunes. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com.

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