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To best care for your patients, take care of yourself
Every psychiatrist has experienced professional highs and lows. Whether helping a schizophrenia patient return to college, collaborating effectively with nursing staff, or achieving board certification, doctors—like everyone else—thrive on success. These accomplishments motivate us to help others and advance our careers.
However, psychiatrists also are vulnerable to ego insults associated with unavoidable negative and sometimes disastrous outcomes of their work. Doctors fail to "cure" every patient, may be “fired” by a patient, or may lose a patient to suicide.
Physicians spend so much time caring for their patients that they often neglect their own health. Self-care is not a core competency for trainees and many residency programs ignore this important issue. Negative outcomes can have profound effects on physicians, including shock; crying/grief/sadness; changed relationships with colleagues; disassociation from the event; crises of faith in education, training, and competency; shame and embarrassment; fear of reprisal; grandiosity; or a belief that the physician should have been all-knowing. Even when a patient commits suicide, the impact of this difficult and painful event on the clinician often is ignored.1 Physician suicide rates have been reported to be higher than those of the general population.2 Barriers to self-preserving treatment include:
Time constraints. Many doctors work up to 80 hours per week. Self-preservation does not become a priority for professionals until a lack of self-care interferes with their personal or professional life.
Limited resources. Physicians, like the general public, find it difficult to get appointments with primary care physicians and psychiatrists. Some doctors feel guilty about taking a slot from another patient or failing to see one of their own patients during that time. Simply finding a provider who is comfortable treating another doctor may be a challenge.
Stigma. It can be embarrassing for doctors to admit they are human, are vulnerable, and have health care needs. Fear of scrutiny for having an illness such as depression is so severe that surveyed psychiatrists said they would rather treat themselves than seek professional help.3
Psychiatrists who face sensitive emotional material on an hourly basis are susceptible to internalizing their work. For those who work with the vulnerable and victimized, meeting our own needs is fundamental to our ability to thrive. Regular practices that promote reflection are crucial to a psychiatrist’s compassion and self-preservation. Suggestions for appropriate self-care are described in the Table.
Table
Psychiatrists’ health: Guidelines for self-preservation
| Practice | Examples |
|---|---|
| Define your professional role and know your level of competency | Work within the confines of your skill set Refer patients to more specialized physicians when you feel their illnesses are outside your scope of expertise Consult colleagues for help with difficult cases |
| Respect your own boundaries | Delineate professional and personal boundaries Reflect on "shades of gray" or ambiguity Seek reinforcement from a supervisor |
| Ask for help | Clearly articulate your needs to supervisors, colleagues, family, and friends Create a positive environment among colleagues |
| Be demanding of yourself and others | Expect yourself and others to live with honesty, integrity, and compassion Identify the source of any inability to maintain these standards Correct your behavior when your work is substandard |
| Treat depression | Find time to visit a mental health professional Seek out a physician skilled at and comfortable with treating physicians |
| Keep balance in life | Foster hobbies Exercise on a routine basis |
Discuss this article at www.facebook.com/CurrentPsychiatry
1. Hausman K. Psychiatrists often overwhelmed by a patient’s suicide. Psychiatric News. July 4 2003.
2. Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. 2004;161(12):2295-2302.
3. Balon R. Psychiatrist attitudes toward self-treatment of their own depression. Psychother Psychosom. 2007;76(5):306-310.
Every psychiatrist has experienced professional highs and lows. Whether helping a schizophrenia patient return to college, collaborating effectively with nursing staff, or achieving board certification, doctors—like everyone else—thrive on success. These accomplishments motivate us to help others and advance our careers.
However, psychiatrists also are vulnerable to ego insults associated with unavoidable negative and sometimes disastrous outcomes of their work. Doctors fail to "cure" every patient, may be “fired” by a patient, or may lose a patient to suicide.
Physicians spend so much time caring for their patients that they often neglect their own health. Self-care is not a core competency for trainees and many residency programs ignore this important issue. Negative outcomes can have profound effects on physicians, including shock; crying/grief/sadness; changed relationships with colleagues; disassociation from the event; crises of faith in education, training, and competency; shame and embarrassment; fear of reprisal; grandiosity; or a belief that the physician should have been all-knowing. Even when a patient commits suicide, the impact of this difficult and painful event on the clinician often is ignored.1 Physician suicide rates have been reported to be higher than those of the general population.2 Barriers to self-preserving treatment include:
Time constraints. Many doctors work up to 80 hours per week. Self-preservation does not become a priority for professionals until a lack of self-care interferes with their personal or professional life.
Limited resources. Physicians, like the general public, find it difficult to get appointments with primary care physicians and psychiatrists. Some doctors feel guilty about taking a slot from another patient or failing to see one of their own patients during that time. Simply finding a provider who is comfortable treating another doctor may be a challenge.
Stigma. It can be embarrassing for doctors to admit they are human, are vulnerable, and have health care needs. Fear of scrutiny for having an illness such as depression is so severe that surveyed psychiatrists said they would rather treat themselves than seek professional help.3
Psychiatrists who face sensitive emotional material on an hourly basis are susceptible to internalizing their work. For those who work with the vulnerable and victimized, meeting our own needs is fundamental to our ability to thrive. Regular practices that promote reflection are crucial to a psychiatrist’s compassion and self-preservation. Suggestions for appropriate self-care are described in the Table.
Table
Psychiatrists’ health: Guidelines for self-preservation
| Practice | Examples |
|---|---|
| Define your professional role and know your level of competency | Work within the confines of your skill set Refer patients to more specialized physicians when you feel their illnesses are outside your scope of expertise Consult colleagues for help with difficult cases |
| Respect your own boundaries | Delineate professional and personal boundaries Reflect on "shades of gray" or ambiguity Seek reinforcement from a supervisor |
| Ask for help | Clearly articulate your needs to supervisors, colleagues, family, and friends Create a positive environment among colleagues |
| Be demanding of yourself and others | Expect yourself and others to live with honesty, integrity, and compassion Identify the source of any inability to maintain these standards Correct your behavior when your work is substandard |
| Treat depression | Find time to visit a mental health professional Seek out a physician skilled at and comfortable with treating physicians |
| Keep balance in life | Foster hobbies Exercise on a routine basis |
Discuss this article at www.facebook.com/CurrentPsychiatry
Every psychiatrist has experienced professional highs and lows. Whether helping a schizophrenia patient return to college, collaborating effectively with nursing staff, or achieving board certification, doctors—like everyone else—thrive on success. These accomplishments motivate us to help others and advance our careers.
However, psychiatrists also are vulnerable to ego insults associated with unavoidable negative and sometimes disastrous outcomes of their work. Doctors fail to "cure" every patient, may be “fired” by a patient, or may lose a patient to suicide.
Physicians spend so much time caring for their patients that they often neglect their own health. Self-care is not a core competency for trainees and many residency programs ignore this important issue. Negative outcomes can have profound effects on physicians, including shock; crying/grief/sadness; changed relationships with colleagues; disassociation from the event; crises of faith in education, training, and competency; shame and embarrassment; fear of reprisal; grandiosity; or a belief that the physician should have been all-knowing. Even when a patient commits suicide, the impact of this difficult and painful event on the clinician often is ignored.1 Physician suicide rates have been reported to be higher than those of the general population.2 Barriers to self-preserving treatment include:
Time constraints. Many doctors work up to 80 hours per week. Self-preservation does not become a priority for professionals until a lack of self-care interferes with their personal or professional life.
Limited resources. Physicians, like the general public, find it difficult to get appointments with primary care physicians and psychiatrists. Some doctors feel guilty about taking a slot from another patient or failing to see one of their own patients during that time. Simply finding a provider who is comfortable treating another doctor may be a challenge.
Stigma. It can be embarrassing for doctors to admit they are human, are vulnerable, and have health care needs. Fear of scrutiny for having an illness such as depression is so severe that surveyed psychiatrists said they would rather treat themselves than seek professional help.3
Psychiatrists who face sensitive emotional material on an hourly basis are susceptible to internalizing their work. For those who work with the vulnerable and victimized, meeting our own needs is fundamental to our ability to thrive. Regular practices that promote reflection are crucial to a psychiatrist’s compassion and self-preservation. Suggestions for appropriate self-care are described in the Table.
Table
Psychiatrists’ health: Guidelines for self-preservation
| Practice | Examples |
|---|---|
| Define your professional role and know your level of competency | Work within the confines of your skill set Refer patients to more specialized physicians when you feel their illnesses are outside your scope of expertise Consult colleagues for help with difficult cases |
| Respect your own boundaries | Delineate professional and personal boundaries Reflect on "shades of gray" or ambiguity Seek reinforcement from a supervisor |
| Ask for help | Clearly articulate your needs to supervisors, colleagues, family, and friends Create a positive environment among colleagues |
| Be demanding of yourself and others | Expect yourself and others to live with honesty, integrity, and compassion Identify the source of any inability to maintain these standards Correct your behavior when your work is substandard |
| Treat depression | Find time to visit a mental health professional Seek out a physician skilled at and comfortable with treating physicians |
| Keep balance in life | Foster hobbies Exercise on a routine basis |
Discuss this article at www.facebook.com/CurrentPsychiatry
1. Hausman K. Psychiatrists often overwhelmed by a patient’s suicide. Psychiatric News. July 4 2003.
2. Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. 2004;161(12):2295-2302.
3. Balon R. Psychiatrist attitudes toward self-treatment of their own depression. Psychother Psychosom. 2007;76(5):306-310.
1. Hausman K. Psychiatrists often overwhelmed by a patient’s suicide. Psychiatric News. July 4 2003.
2. Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. 2004;161(12):2295-2302.
3. Balon R. Psychiatrist attitudes toward self-treatment of their own depression. Psychother Psychosom. 2007;76(5):306-310.
Practicing psychiatry via Skype: Medicolegal considerations
Dear Dr. Mossman:
I practice in a region with few psychiatrists and very little public transportation. For many patients, coming to my office is inconvenient, expensive, or time-consuming. Sometimes, their emotional problems make it hard for them to travel, and sometimes, bad weather makes travel difficult. I am considering providing remote treatment via Skype. Is this a reasonable idea? What are the risks of using this technology in my practice? — Submitted by “Dr. A”
Diagnosing and treating patients without a face-to-face encounter is not new. Doctors have provided “remote treatment” since shortly after telephones were invented.1 Until recently, however, forensic psychiatrists advised colleagues not to diagnose patients or start treatment based on phone contact alone.2
The Internet has revolutionized our attitudes about many things. Communication technologies that seemed miraculous a generation ago have become commonplace and have transformed standards for ordinary and “acceptable” human contact. A quick Internet search of “telephone psychotherapy” turns up hundreds of mental health professionals who offer remote treatment services to patients via computers and Web cams.
Physicians in many specialties practice telemedicine, often with the support and encouragement of state governments and third-party payers. To decide whether to include telepsychiatry in your psychiatric practice, you should know:
- what “telemedicine” means and includes
- the possible advantages of offering remote health care
- potential risks and ambiguity about legal matters.
Defining telemedicine
Studies of remote, closed-circuit “telediagnosis” extend back more than 4 decades, closely following mid-20th century advancements in audio and video relay technologies that made space broadcasts possible.3 Then as now, “telemedicine” simply means conveying health-related information from 1 site to another for diagnostic or treatment purposes.4 It’s an adaptation of available technology to deliver care more easily, with the goal of improving patients’ access to care and health status.
Telemedicine usage accelerated as the Internet and related technologies developed. Telemedicine programs in the United States increased by 1,500% from 1993 to 1998.4 Telemedicine use has grown 10% annually in recent years and has become a $4 billion per year industry in the United States.5 Recently enacted federal legislation is likely to extend health care coverage to 36 million Americans and require coverage of pre-existing conditions. To make these changes affordable, health care delivery will need to exploit new, efficiency-enhancing technologies.6
Advantages of telemedicine
State governments and some third-party payers have recognized that telemedicine can overcome geographic and cost barriers to health services and patient education.5,7-9 Although closed-circuit video transmission has served this purpose for some time, Skype—free software that allows individuals to make video phone calls over the Internet using their computers—is an option that doctors are using to treat patients.10-12
Research suggests that telepsychiatry may provide huge benefits to medically underserved areas while reducing health care costs.4 Telepsychiatry can reduce travel time and expenses for professionals and patients, and it also may lower wait times and “no-show” rates (Table 1).4 Telepsychiatry lets patients see caregivers when winter weather makes roads unsafe. It may allow geriatric patients who can no longer drive to access psychiatric care and it lowers health care’s “carbon footprint,” making it “eco-friendly.”13
Social media strategies are playing an expanding role in medical education,14,15 and this probably will help practitioners feel more at ease about incorporating the underlying technologies into work with patients. Increased use of laptops and mobile phones lends itself well to telepsychiatry applications,13 and studies have examined the feasibility of psychotherapies delivered via remote communication devices.16 Smartphone apps are being designed to assist mental health professionals17 and consumers.18
Table 1
Potential benefits of telemedicine
| Category | Benefit(s) |
|---|---|
| Access | Patients can see specialists more readily Addresses regional doctor shortages Reduces health care disparities between urban and rural areas |
| Urgent care | Facilitates information transfer for rapid interventions |
| Productivity | Provides a conduit for clinicians to share skills and expertise Facilitates remote monitoring and home care |
| Cost | No travel costs Alternative revenue stream for health care organizations that offer more broadly delivered medical services |
| Patient-centric care | Care is taken to the patient Translator services are more readily available |
| Source: Reference 4 | |
Potential pitfalls and drawbacks
Although convenience, access, cost, and fossil fuel savings may favor video-chat doctor visits, telemedicine has downsides, some of which apply specifically to psychiatry. First, no current technology provides psychiatrists with “the rich multidimensional aspects of a person-to-person encounter,”19 and remote communication may change what patients tell us, how they feel when they tell us things, and how they feel when we respond. Often, an inherent awkwardness affects many forms of Internet communication.20
Also uncertain is whether Skype is compliant with the Health Insurance Portability and Accountability Act and protects doctor-patient privacy well enough to satisfy ethical standards—although it probably is far better than e-mail in this regard. Third-party payers often will not reimburse for telephone calls and may balk at paying for Skype-based therapy, even in states that require insurers to reimburse for telemedicine.
Psychiatrists typically have limited physical contact with patients, but we often check weight and vital signs when we prescribe certain psychotropic medications. Results from home- and drugstore-based blood pressure monitors may not be accurate enough for treatment purposes. Remote communication also reduces the quality of visual information,20 which can be crucial—for example, when good lighting and visual resolution is needed to decide whether a skin rash might be drug-induced.
Telemedicine raises concerns about licensure and meeting adequate standards of care. Medical care usually is deemed to have occurred in the state where the patient is located. For example, only physicians licensed to practice medicine in California are legally permitted to treat patients in California. As is the case with any treatment, care delivered via telemedicine must include appropriate patient examination and diagnosis.21
Help and guidance
Despite these potential drawbacks, many state agencies recognize the promise of telemedicine, and have developed networks to promote it (Table 2).7-9,22,23 These networks have various goals but share a common pattern of establishing infrastructure, policies, and organized results. In the future, states may adopt laws or regulations that address conflicts in malpractice standards and liability coverage, licensing, accreditation, reimbursement, privacy, and data protection policies that now may impede or inhibit use of telepsychiatric services across jurisdictional boundaries. Last year, Ohio produced regulations to guide psychiatrists in prescribing medication remotely without an in-person examination. The University of Hawaii suggested steps that its state legislature might take to help providers predict the potential legal ramifications of telemedicine.6
Further help for telepsychiatry practitioners may be found in practice standards and guidelines developed by the American Telemedicine Association.24,25 These documents gave guidance and support for the practice of telemedicine and for providing appropriate telepsychiatry health services.
Table 2
Telemedicine services available in different states
| State/Network | Description |
|---|---|
| Arizona www.narbha.org7 | The Northern Arizona Regional Behavioral Health Authority manages a comprehensive telemental health network (NARBHAnet) that uses 2-way videoconferencing to connect mental health experts and patients. It has provided >50,000 clinical psychiatric sessions |
| Kansas www.kumc.edu8 | The University of Kansas Medical Center provides specialty services (including telepsychiatry) through 14 clinical sites in rural Kansas. Cost-sharing helps the telepsychiatric application be successful |
| Montana www.emtn.org9 | Eastern Montana Telemedicine Network is a consortium of not-for-profit facilities that link health care providers and their patients in Montana and Wyoming. This telemental health network includes shared sites for all physicians practicing in the network and has yielded large out-of-pocket savings for patients |
| Oregon www.ortelehealth.org22 | The Telehealth Alliance of Oregon, which began in 2001 as a committee of the Oregon Telecommunications Coordinating Council, was created by the legislature and has served as advisors to the governor and the legislature regarding telecommunications in Oregon |
| Texas www.jsahealthmd.com23 | The Burke Center provides services to people in 12 counties in East Texas. It uses telepsychiatry services to conduct emergency evaluations, therefore keeping people in mental health crises out of emergency rooms |
What should Dr. A do?
In answer to Dr. A’s question, many factors favor including telepsychiatry in her practice. Yet we know little about the accuracy and reliability of psychiatric assessments made solely via Skype or other remote video technology in ordinary practice. Legislation and legal rules about acceptable practices are ambiguous, although in the absence of clear guidance, psychiatrists should assume that all usual professional standards and expectations about adequate care apply to treatment via Skype or other remote communication methods.
Related Resources
- Skype. www.skype.com.
- American Telemedicine Association. www.americantelemed.org.
1. Lipman M. The doctor will Skype you now. Consum Rep. 2011;76(8):12.-
2. Simon RI. Clinical psychiatry and the law. 2nd ed. Washington DC: American Psychiatric Press; 1992.
3. Murphy RL, Jr, Bird KT. Telediagnosis: a new community health resource. Observations on the feasibility of telediagnosis based on 1000 patient transactions. Am J Public Health. 1974;64(2):113-119.
4. Hilty DM, Yellowlees PM, Cobb HC, et al. Models of telepsychiatric consultation—liaison service to rural primary care. Psychosomatics. 2006;47(2):152-157.
5. Freudenheim M. The doctor will see you now. Please log on. New York Times. May 29 2010:BU1.
6. University of Hawai’i. Report to the 2009 legislature: preliminary report by the John A. Burns School of Medicine on the current practices of Hawai’i telemedicine system for 2009. http://www.hawaii.edu/offices/eaur/govrel/reports/2009. Published November 2008. Accessed September 27 2011.
7. Northern Arizona Regional Behavioral Health Authority. http://www.narbha.org. Accessed September 27 2011.
8. University of Kansas Medical Center. http://www.kumc.edu. Accessed September 27 2011.
9. Eastern Montana Telemedicine Network. http://www.emtn.org. Accessed September 27 2011.
10. Ciccia AH, Whitford B, Krumm M, et al. Improving the access of young urban children to speech, language and hearing screening via telehealth. J Telemed Telecare. 2011;17(5):240-244.
11. Hori M, Kubota M, Ando K, et al. The effect of videophone communication (with skype and webcam) for elderly patients with dementia and their caregivers [in Japanese]. Gan To Kagaku Ryoho. 2009;36(suppl 1):36-38.
12. Klock C, Gomes Rde P. Web conferencing systems: Skype and MSN in telepathology. Diagn Pathol. 2008;3(suppl 1):S13.-
13. Luo J. VoIP: The right call for your practice? Current Psychiatry. 2005;4(10):24-27.
14. George DR, Dellasega C. Use of social media in graduate-level medical humanities education: two pilot studies from Penn State College of Medicine. Med Teach. 2011;33(8):e429-434.
15. Lillis S, Gibbons V, Lawrenson R. The experience of final year medical students undertaking a general practice run with a distance education component. Rural Remote Health. 2010;10(1):1268.-
16. Bee PE, Bower P, Lovell K, et al. Psychotherapy mediated by remote communication technologies: a meta-analytic review. BMC Psychiatry. 2008;8:60.-
17. Maheu MM. iPhone app reviews for psychologists and mental health professionals. http://telehealth.net/blog/554. Accessed September 27 2011.
18. Maheu MM. iPhone apps reviews for mental health psychology and personal growth consumers. http://telehealth.net/blog/557. Accessed September 27, 2011.
19. Eckardt MH. The use of the telephone to extend our therapeutic availability. J Am Acad Psychoanal Dyn Psychiatry. 2011;39(1):151-153.
20. Hoffman J. When your therapist is only a click away. New York Times. September 23 2011:ST1.
21. Medical Board of California. Practicing medicine through telemedicine technology. http://www.mbc.ca.gov/licensee/telemedicine.html. Accessed September 27 2011.
22. Telehealth Alliance of Oregon. http://www.ortelehealth.org. Accessed October 31 2011.
23. JSA Health Telepsychiatry. http://jsahealthmd.com. Accessed September 27 2011.
24. American Telemedicine Association. Telemental standards and guidelines. http://www.americantelemed.org/i4a/pages/index.cfm?pageID=3311. Accessed September 27 2011.
25. American Telemedicine Association. Evidence-based practice for telemental health. http://www.americantelemed.org/i4a/forms/form.cfm?id=25&pageid=3718&showTitle=1. Accessed September 27 2011.
Helen M. Farrell, MD
Dr. Farrell is an instructor at Harvard Medical School and a staff psychiatrist at Beth Israel Deaconess Medical Center, Boston, MA
Douglas Mossman, MD
Dr. Mossman is administrative director, Glenn M. Weaver Institute of Law and Psychiatry, University of Cincinnati College of Law, and Adjunct Professor of Clinical Psychiatry and Training Director for the University of Cincinnati Forensic Psychiatry Fellowship, Cincinnati, OH
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Helen M. Farrell, MD
Dr. Farrell is an instructor at Harvard Medical School and a staff psychiatrist at Beth Israel Deaconess Medical Center, Boston, MA
Douglas Mossman, MD
Dr. Mossman is administrative director, Glenn M. Weaver Institute of Law and Psychiatry, University of Cincinnati College of Law, and Adjunct Professor of Clinical Psychiatry and Training Director for the University of Cincinnati Forensic Psychiatry Fellowship, Cincinnati, OH
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Helen M. Farrell, MD
Dr. Farrell is an instructor at Harvard Medical School and a staff psychiatrist at Beth Israel Deaconess Medical Center, Boston, MA
Douglas Mossman, MD
Dr. Mossman is administrative director, Glenn M. Weaver Institute of Law and Psychiatry, University of Cincinnati College of Law, and Adjunct Professor of Clinical Psychiatry and Training Director for the University of Cincinnati Forensic Psychiatry Fellowship, Cincinnati, OH
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Dear Dr. Mossman:
I practice in a region with few psychiatrists and very little public transportation. For many patients, coming to my office is inconvenient, expensive, or time-consuming. Sometimes, their emotional problems make it hard for them to travel, and sometimes, bad weather makes travel difficult. I am considering providing remote treatment via Skype. Is this a reasonable idea? What are the risks of using this technology in my practice? — Submitted by “Dr. A”
Diagnosing and treating patients without a face-to-face encounter is not new. Doctors have provided “remote treatment” since shortly after telephones were invented.1 Until recently, however, forensic psychiatrists advised colleagues not to diagnose patients or start treatment based on phone contact alone.2
The Internet has revolutionized our attitudes about many things. Communication technologies that seemed miraculous a generation ago have become commonplace and have transformed standards for ordinary and “acceptable” human contact. A quick Internet search of “telephone psychotherapy” turns up hundreds of mental health professionals who offer remote treatment services to patients via computers and Web cams.
Physicians in many specialties practice telemedicine, often with the support and encouragement of state governments and third-party payers. To decide whether to include telepsychiatry in your psychiatric practice, you should know:
- what “telemedicine” means and includes
- the possible advantages of offering remote health care
- potential risks and ambiguity about legal matters.
Defining telemedicine
Studies of remote, closed-circuit “telediagnosis” extend back more than 4 decades, closely following mid-20th century advancements in audio and video relay technologies that made space broadcasts possible.3 Then as now, “telemedicine” simply means conveying health-related information from 1 site to another for diagnostic or treatment purposes.4 It’s an adaptation of available technology to deliver care more easily, with the goal of improving patients’ access to care and health status.
Telemedicine usage accelerated as the Internet and related technologies developed. Telemedicine programs in the United States increased by 1,500% from 1993 to 1998.4 Telemedicine use has grown 10% annually in recent years and has become a $4 billion per year industry in the United States.5 Recently enacted federal legislation is likely to extend health care coverage to 36 million Americans and require coverage of pre-existing conditions. To make these changes affordable, health care delivery will need to exploit new, efficiency-enhancing technologies.6
Advantages of telemedicine
State governments and some third-party payers have recognized that telemedicine can overcome geographic and cost barriers to health services and patient education.5,7-9 Although closed-circuit video transmission has served this purpose for some time, Skype—free software that allows individuals to make video phone calls over the Internet using their computers—is an option that doctors are using to treat patients.10-12
Research suggests that telepsychiatry may provide huge benefits to medically underserved areas while reducing health care costs.4 Telepsychiatry can reduce travel time and expenses for professionals and patients, and it also may lower wait times and “no-show” rates (Table 1).4 Telepsychiatry lets patients see caregivers when winter weather makes roads unsafe. It may allow geriatric patients who can no longer drive to access psychiatric care and it lowers health care’s “carbon footprint,” making it “eco-friendly.”13
Social media strategies are playing an expanding role in medical education,14,15 and this probably will help practitioners feel more at ease about incorporating the underlying technologies into work with patients. Increased use of laptops and mobile phones lends itself well to telepsychiatry applications,13 and studies have examined the feasibility of psychotherapies delivered via remote communication devices.16 Smartphone apps are being designed to assist mental health professionals17 and consumers.18
Table 1
Potential benefits of telemedicine
| Category | Benefit(s) |
|---|---|
| Access | Patients can see specialists more readily Addresses regional doctor shortages Reduces health care disparities between urban and rural areas |
| Urgent care | Facilitates information transfer for rapid interventions |
| Productivity | Provides a conduit for clinicians to share skills and expertise Facilitates remote monitoring and home care |
| Cost | No travel costs Alternative revenue stream for health care organizations that offer more broadly delivered medical services |
| Patient-centric care | Care is taken to the patient Translator services are more readily available |
| Source: Reference 4 | |
Potential pitfalls and drawbacks
Although convenience, access, cost, and fossil fuel savings may favor video-chat doctor visits, telemedicine has downsides, some of which apply specifically to psychiatry. First, no current technology provides psychiatrists with “the rich multidimensional aspects of a person-to-person encounter,”19 and remote communication may change what patients tell us, how they feel when they tell us things, and how they feel when we respond. Often, an inherent awkwardness affects many forms of Internet communication.20
Also uncertain is whether Skype is compliant with the Health Insurance Portability and Accountability Act and protects doctor-patient privacy well enough to satisfy ethical standards—although it probably is far better than e-mail in this regard. Third-party payers often will not reimburse for telephone calls and may balk at paying for Skype-based therapy, even in states that require insurers to reimburse for telemedicine.
Psychiatrists typically have limited physical contact with patients, but we often check weight and vital signs when we prescribe certain psychotropic medications. Results from home- and drugstore-based blood pressure monitors may not be accurate enough for treatment purposes. Remote communication also reduces the quality of visual information,20 which can be crucial—for example, when good lighting and visual resolution is needed to decide whether a skin rash might be drug-induced.
Telemedicine raises concerns about licensure and meeting adequate standards of care. Medical care usually is deemed to have occurred in the state where the patient is located. For example, only physicians licensed to practice medicine in California are legally permitted to treat patients in California. As is the case with any treatment, care delivered via telemedicine must include appropriate patient examination and diagnosis.21
Help and guidance
Despite these potential drawbacks, many state agencies recognize the promise of telemedicine, and have developed networks to promote it (Table 2).7-9,22,23 These networks have various goals but share a common pattern of establishing infrastructure, policies, and organized results. In the future, states may adopt laws or regulations that address conflicts in malpractice standards and liability coverage, licensing, accreditation, reimbursement, privacy, and data protection policies that now may impede or inhibit use of telepsychiatric services across jurisdictional boundaries. Last year, Ohio produced regulations to guide psychiatrists in prescribing medication remotely without an in-person examination. The University of Hawaii suggested steps that its state legislature might take to help providers predict the potential legal ramifications of telemedicine.6
Further help for telepsychiatry practitioners may be found in practice standards and guidelines developed by the American Telemedicine Association.24,25 These documents gave guidance and support for the practice of telemedicine and for providing appropriate telepsychiatry health services.
Table 2
Telemedicine services available in different states
| State/Network | Description |
|---|---|
| Arizona www.narbha.org7 | The Northern Arizona Regional Behavioral Health Authority manages a comprehensive telemental health network (NARBHAnet) that uses 2-way videoconferencing to connect mental health experts and patients. It has provided >50,000 clinical psychiatric sessions |
| Kansas www.kumc.edu8 | The University of Kansas Medical Center provides specialty services (including telepsychiatry) through 14 clinical sites in rural Kansas. Cost-sharing helps the telepsychiatric application be successful |
| Montana www.emtn.org9 | Eastern Montana Telemedicine Network is a consortium of not-for-profit facilities that link health care providers and their patients in Montana and Wyoming. This telemental health network includes shared sites for all physicians practicing in the network and has yielded large out-of-pocket savings for patients |
| Oregon www.ortelehealth.org22 | The Telehealth Alliance of Oregon, which began in 2001 as a committee of the Oregon Telecommunications Coordinating Council, was created by the legislature and has served as advisors to the governor and the legislature regarding telecommunications in Oregon |
| Texas www.jsahealthmd.com23 | The Burke Center provides services to people in 12 counties in East Texas. It uses telepsychiatry services to conduct emergency evaluations, therefore keeping people in mental health crises out of emergency rooms |
What should Dr. A do?
In answer to Dr. A’s question, many factors favor including telepsychiatry in her practice. Yet we know little about the accuracy and reliability of psychiatric assessments made solely via Skype or other remote video technology in ordinary practice. Legislation and legal rules about acceptable practices are ambiguous, although in the absence of clear guidance, psychiatrists should assume that all usual professional standards and expectations about adequate care apply to treatment via Skype or other remote communication methods.
Related Resources
- Skype. www.skype.com.
- American Telemedicine Association. www.americantelemed.org.
Dear Dr. Mossman:
I practice in a region with few psychiatrists and very little public transportation. For many patients, coming to my office is inconvenient, expensive, or time-consuming. Sometimes, their emotional problems make it hard for them to travel, and sometimes, bad weather makes travel difficult. I am considering providing remote treatment via Skype. Is this a reasonable idea? What are the risks of using this technology in my practice? — Submitted by “Dr. A”
Diagnosing and treating patients without a face-to-face encounter is not new. Doctors have provided “remote treatment” since shortly after telephones were invented.1 Until recently, however, forensic psychiatrists advised colleagues not to diagnose patients or start treatment based on phone contact alone.2
The Internet has revolutionized our attitudes about many things. Communication technologies that seemed miraculous a generation ago have become commonplace and have transformed standards for ordinary and “acceptable” human contact. A quick Internet search of “telephone psychotherapy” turns up hundreds of mental health professionals who offer remote treatment services to patients via computers and Web cams.
Physicians in many specialties practice telemedicine, often with the support and encouragement of state governments and third-party payers. To decide whether to include telepsychiatry in your psychiatric practice, you should know:
- what “telemedicine” means and includes
- the possible advantages of offering remote health care
- potential risks and ambiguity about legal matters.
Defining telemedicine
Studies of remote, closed-circuit “telediagnosis” extend back more than 4 decades, closely following mid-20th century advancements in audio and video relay technologies that made space broadcasts possible.3 Then as now, “telemedicine” simply means conveying health-related information from 1 site to another for diagnostic or treatment purposes.4 It’s an adaptation of available technology to deliver care more easily, with the goal of improving patients’ access to care and health status.
Telemedicine usage accelerated as the Internet and related technologies developed. Telemedicine programs in the United States increased by 1,500% from 1993 to 1998.4 Telemedicine use has grown 10% annually in recent years and has become a $4 billion per year industry in the United States.5 Recently enacted federal legislation is likely to extend health care coverage to 36 million Americans and require coverage of pre-existing conditions. To make these changes affordable, health care delivery will need to exploit new, efficiency-enhancing technologies.6
Advantages of telemedicine
State governments and some third-party payers have recognized that telemedicine can overcome geographic and cost barriers to health services and patient education.5,7-9 Although closed-circuit video transmission has served this purpose for some time, Skype—free software that allows individuals to make video phone calls over the Internet using their computers—is an option that doctors are using to treat patients.10-12
Research suggests that telepsychiatry may provide huge benefits to medically underserved areas while reducing health care costs.4 Telepsychiatry can reduce travel time and expenses for professionals and patients, and it also may lower wait times and “no-show” rates (Table 1).4 Telepsychiatry lets patients see caregivers when winter weather makes roads unsafe. It may allow geriatric patients who can no longer drive to access psychiatric care and it lowers health care’s “carbon footprint,” making it “eco-friendly.”13
Social media strategies are playing an expanding role in medical education,14,15 and this probably will help practitioners feel more at ease about incorporating the underlying technologies into work with patients. Increased use of laptops and mobile phones lends itself well to telepsychiatry applications,13 and studies have examined the feasibility of psychotherapies delivered via remote communication devices.16 Smartphone apps are being designed to assist mental health professionals17 and consumers.18
Table 1
Potential benefits of telemedicine
| Category | Benefit(s) |
|---|---|
| Access | Patients can see specialists more readily Addresses regional doctor shortages Reduces health care disparities between urban and rural areas |
| Urgent care | Facilitates information transfer for rapid interventions |
| Productivity | Provides a conduit for clinicians to share skills and expertise Facilitates remote monitoring and home care |
| Cost | No travel costs Alternative revenue stream for health care organizations that offer more broadly delivered medical services |
| Patient-centric care | Care is taken to the patient Translator services are more readily available |
| Source: Reference 4 | |
Potential pitfalls and drawbacks
Although convenience, access, cost, and fossil fuel savings may favor video-chat doctor visits, telemedicine has downsides, some of which apply specifically to psychiatry. First, no current technology provides psychiatrists with “the rich multidimensional aspects of a person-to-person encounter,”19 and remote communication may change what patients tell us, how they feel when they tell us things, and how they feel when we respond. Often, an inherent awkwardness affects many forms of Internet communication.20
Also uncertain is whether Skype is compliant with the Health Insurance Portability and Accountability Act and protects doctor-patient privacy well enough to satisfy ethical standards—although it probably is far better than e-mail in this regard. Third-party payers often will not reimburse for telephone calls and may balk at paying for Skype-based therapy, even in states that require insurers to reimburse for telemedicine.
Psychiatrists typically have limited physical contact with patients, but we often check weight and vital signs when we prescribe certain psychotropic medications. Results from home- and drugstore-based blood pressure monitors may not be accurate enough for treatment purposes. Remote communication also reduces the quality of visual information,20 which can be crucial—for example, when good lighting and visual resolution is needed to decide whether a skin rash might be drug-induced.
Telemedicine raises concerns about licensure and meeting adequate standards of care. Medical care usually is deemed to have occurred in the state where the patient is located. For example, only physicians licensed to practice medicine in California are legally permitted to treat patients in California. As is the case with any treatment, care delivered via telemedicine must include appropriate patient examination and diagnosis.21
Help and guidance
Despite these potential drawbacks, many state agencies recognize the promise of telemedicine, and have developed networks to promote it (Table 2).7-9,22,23 These networks have various goals but share a common pattern of establishing infrastructure, policies, and organized results. In the future, states may adopt laws or regulations that address conflicts in malpractice standards and liability coverage, licensing, accreditation, reimbursement, privacy, and data protection policies that now may impede or inhibit use of telepsychiatric services across jurisdictional boundaries. Last year, Ohio produced regulations to guide psychiatrists in prescribing medication remotely without an in-person examination. The University of Hawaii suggested steps that its state legislature might take to help providers predict the potential legal ramifications of telemedicine.6
Further help for telepsychiatry practitioners may be found in practice standards and guidelines developed by the American Telemedicine Association.24,25 These documents gave guidance and support for the practice of telemedicine and for providing appropriate telepsychiatry health services.
Table 2
Telemedicine services available in different states
| State/Network | Description |
|---|---|
| Arizona www.narbha.org7 | The Northern Arizona Regional Behavioral Health Authority manages a comprehensive telemental health network (NARBHAnet) that uses 2-way videoconferencing to connect mental health experts and patients. It has provided >50,000 clinical psychiatric sessions |
| Kansas www.kumc.edu8 | The University of Kansas Medical Center provides specialty services (including telepsychiatry) through 14 clinical sites in rural Kansas. Cost-sharing helps the telepsychiatric application be successful |
| Montana www.emtn.org9 | Eastern Montana Telemedicine Network is a consortium of not-for-profit facilities that link health care providers and their patients in Montana and Wyoming. This telemental health network includes shared sites for all physicians practicing in the network and has yielded large out-of-pocket savings for patients |
| Oregon www.ortelehealth.org22 | The Telehealth Alliance of Oregon, which began in 2001 as a committee of the Oregon Telecommunications Coordinating Council, was created by the legislature and has served as advisors to the governor and the legislature regarding telecommunications in Oregon |
| Texas www.jsahealthmd.com23 | The Burke Center provides services to people in 12 counties in East Texas. It uses telepsychiatry services to conduct emergency evaluations, therefore keeping people in mental health crises out of emergency rooms |
What should Dr. A do?
In answer to Dr. A’s question, many factors favor including telepsychiatry in her practice. Yet we know little about the accuracy and reliability of psychiatric assessments made solely via Skype or other remote video technology in ordinary practice. Legislation and legal rules about acceptable practices are ambiguous, although in the absence of clear guidance, psychiatrists should assume that all usual professional standards and expectations about adequate care apply to treatment via Skype or other remote communication methods.
Related Resources
- Skype. www.skype.com.
- American Telemedicine Association. www.americantelemed.org.
1. Lipman M. The doctor will Skype you now. Consum Rep. 2011;76(8):12.-
2. Simon RI. Clinical psychiatry and the law. 2nd ed. Washington DC: American Psychiatric Press; 1992.
3. Murphy RL, Jr, Bird KT. Telediagnosis: a new community health resource. Observations on the feasibility of telediagnosis based on 1000 patient transactions. Am J Public Health. 1974;64(2):113-119.
4. Hilty DM, Yellowlees PM, Cobb HC, et al. Models of telepsychiatric consultation—liaison service to rural primary care. Psychosomatics. 2006;47(2):152-157.
5. Freudenheim M. The doctor will see you now. Please log on. New York Times. May 29 2010:BU1.
6. University of Hawai’i. Report to the 2009 legislature: preliminary report by the John A. Burns School of Medicine on the current practices of Hawai’i telemedicine system for 2009. http://www.hawaii.edu/offices/eaur/govrel/reports/2009. Published November 2008. Accessed September 27 2011.
7. Northern Arizona Regional Behavioral Health Authority. http://www.narbha.org. Accessed September 27 2011.
8. University of Kansas Medical Center. http://www.kumc.edu. Accessed September 27 2011.
9. Eastern Montana Telemedicine Network. http://www.emtn.org. Accessed September 27 2011.
10. Ciccia AH, Whitford B, Krumm M, et al. Improving the access of young urban children to speech, language and hearing screening via telehealth. J Telemed Telecare. 2011;17(5):240-244.
11. Hori M, Kubota M, Ando K, et al. The effect of videophone communication (with skype and webcam) for elderly patients with dementia and their caregivers [in Japanese]. Gan To Kagaku Ryoho. 2009;36(suppl 1):36-38.
12. Klock C, Gomes Rde P. Web conferencing systems: Skype and MSN in telepathology. Diagn Pathol. 2008;3(suppl 1):S13.-
13. Luo J. VoIP: The right call for your practice? Current Psychiatry. 2005;4(10):24-27.
14. George DR, Dellasega C. Use of social media in graduate-level medical humanities education: two pilot studies from Penn State College of Medicine. Med Teach. 2011;33(8):e429-434.
15. Lillis S, Gibbons V, Lawrenson R. The experience of final year medical students undertaking a general practice run with a distance education component. Rural Remote Health. 2010;10(1):1268.-
16. Bee PE, Bower P, Lovell K, et al. Psychotherapy mediated by remote communication technologies: a meta-analytic review. BMC Psychiatry. 2008;8:60.-
17. Maheu MM. iPhone app reviews for psychologists and mental health professionals. http://telehealth.net/blog/554. Accessed September 27 2011.
18. Maheu MM. iPhone apps reviews for mental health psychology and personal growth consumers. http://telehealth.net/blog/557. Accessed September 27, 2011.
19. Eckardt MH. The use of the telephone to extend our therapeutic availability. J Am Acad Psychoanal Dyn Psychiatry. 2011;39(1):151-153.
20. Hoffman J. When your therapist is only a click away. New York Times. September 23 2011:ST1.
21. Medical Board of California. Practicing medicine through telemedicine technology. http://www.mbc.ca.gov/licensee/telemedicine.html. Accessed September 27 2011.
22. Telehealth Alliance of Oregon. http://www.ortelehealth.org. Accessed October 31 2011.
23. JSA Health Telepsychiatry. http://jsahealthmd.com. Accessed September 27 2011.
24. American Telemedicine Association. Telemental standards and guidelines. http://www.americantelemed.org/i4a/pages/index.cfm?pageID=3311. Accessed September 27 2011.
25. American Telemedicine Association. Evidence-based practice for telemental health. http://www.americantelemed.org/i4a/forms/form.cfm?id=25&pageid=3718&showTitle=1. Accessed September 27 2011.
1. Lipman M. The doctor will Skype you now. Consum Rep. 2011;76(8):12.-
2. Simon RI. Clinical psychiatry and the law. 2nd ed. Washington DC: American Psychiatric Press; 1992.
3. Murphy RL, Jr, Bird KT. Telediagnosis: a new community health resource. Observations on the feasibility of telediagnosis based on 1000 patient transactions. Am J Public Health. 1974;64(2):113-119.
4. Hilty DM, Yellowlees PM, Cobb HC, et al. Models of telepsychiatric consultation—liaison service to rural primary care. Psychosomatics. 2006;47(2):152-157.
5. Freudenheim M. The doctor will see you now. Please log on. New York Times. May 29 2010:BU1.
6. University of Hawai’i. Report to the 2009 legislature: preliminary report by the John A. Burns School of Medicine on the current practices of Hawai’i telemedicine system for 2009. http://www.hawaii.edu/offices/eaur/govrel/reports/2009. Published November 2008. Accessed September 27 2011.
7. Northern Arizona Regional Behavioral Health Authority. http://www.narbha.org. Accessed September 27 2011.
8. University of Kansas Medical Center. http://www.kumc.edu. Accessed September 27 2011.
9. Eastern Montana Telemedicine Network. http://www.emtn.org. Accessed September 27 2011.
10. Ciccia AH, Whitford B, Krumm M, et al. Improving the access of young urban children to speech, language and hearing screening via telehealth. J Telemed Telecare. 2011;17(5):240-244.
11. Hori M, Kubota M, Ando K, et al. The effect of videophone communication (with skype and webcam) for elderly patients with dementia and their caregivers [in Japanese]. Gan To Kagaku Ryoho. 2009;36(suppl 1):36-38.
12. Klock C, Gomes Rde P. Web conferencing systems: Skype and MSN in telepathology. Diagn Pathol. 2008;3(suppl 1):S13.-
13. Luo J. VoIP: The right call for your practice? Current Psychiatry. 2005;4(10):24-27.
14. George DR, Dellasega C. Use of social media in graduate-level medical humanities education: two pilot studies from Penn State College of Medicine. Med Teach. 2011;33(8):e429-434.
15. Lillis S, Gibbons V, Lawrenson R. The experience of final year medical students undertaking a general practice run with a distance education component. Rural Remote Health. 2010;10(1):1268.-
16. Bee PE, Bower P, Lovell K, et al. Psychotherapy mediated by remote communication technologies: a meta-analytic review. BMC Psychiatry. 2008;8:60.-
17. Maheu MM. iPhone app reviews for psychologists and mental health professionals. http://telehealth.net/blog/554. Accessed September 27 2011.
18. Maheu MM. iPhone apps reviews for mental health psychology and personal growth consumers. http://telehealth.net/blog/557. Accessed September 27, 2011.
19. Eckardt MH. The use of the telephone to extend our therapeutic availability. J Am Acad Psychoanal Dyn Psychiatry. 2011;39(1):151-153.
20. Hoffman J. When your therapist is only a click away. New York Times. September 23 2011:ST1.
21. Medical Board of California. Practicing medicine through telemedicine technology. http://www.mbc.ca.gov/licensee/telemedicine.html. Accessed September 27 2011.
22. Telehealth Alliance of Oregon. http://www.ortelehealth.org. Accessed October 31 2011.
23. JSA Health Telepsychiatry. http://jsahealthmd.com. Accessed September 27 2011.
24. American Telemedicine Association. Telemental standards and guidelines. http://www.americantelemed.org/i4a/pages/index.cfm?pageID=3311. Accessed September 27 2011.
25. American Telemedicine Association. Evidence-based practice for telemental health. http://www.americantelemed.org/i4a/forms/form.cfm?id=25&pageid=3718&showTitle=1. Accessed September 27 2011.
Dissociative identity disorder: No excuse for criminal activity
Formerly called multiple personality disorder, dissociative identity disorder (DID) is a controversial diagnosis that challenges forensic psychiatrists, other mental health clinicians, legal professionals, the media, and the public. DID cases often present in the criminal justice system rather than in the mental health system, and the illness perplexes experts in both professions.
Individuals may commit criminal acts while in a dissociated state. A study that tracked 21 reported DID cases found that 47% of men and 35% of women reported engaging in criminal activity, including 19% of men and 7% of women who committed homicide.1 Defendants occasionally use DID as a basis for pleading not guilty by reason of insanity (NGRI). Controversy over the DID diagnosis has contributed to debates about the disorder’s role in criminal responsibility.
The DID diagnosis
An American Psychiatric Association Work Group has proposed new diagnostic criteria for DID for DSM-5, which is scheduled to be published in May 2013.2 Presently, DID is listed in DSM-IV-TR as an axis I disorder.3 Criteria for DID include the presence of ≥2 distinctive identities or personality states that recurrently take control of an individual’s behavior (Table 1).3 This is accompanied by an inability to recall important personal information to an extent that cannot be explained by ordinary forgetfulness. Patients with DID typically have a primary identity that is passive, dependent, guilty, and depressed, and alternate identities with characteristics that differ from the primary identity, commonly in reported age and gender, vocabulary, general knowledge, or predominant affect.3
Dissociative pathology may result from trauma, comorbid mental illness, or other medical issues, including complex partial seizures. Developmental theorists have proposed that severe sexual, physical, or psychological trauma in childhood predisposes an individual to develop DID.4 Theoretically, harm by a trusted caregiver forces a child to split off awareness and memory of the trauma to survive in the relationship. Later these memories and feelings are experienced as a separate personality. Because this process happens repeatedly, the patient develops multiple personalities; each has different memories and performs different functions, which may be helpful or destructive. Later, dissociation becomes a coping mechanism when individuals face stressful situations.5
Personality traits that may predispose patients to develop a dissociative disorder include mental absorption, suggestibility, ability to be easily hypnotized, and tendency to fantasize.6 Patients with dissociation also may meet criteria for posttraumatic stress disorder, borderline personality disorder, somatoform disorder, eating disorder, or substance use disorders.7
Table 1
DSM-IV-TR criteria for dissociative identity disorder
| The presence of ≥2 distinct identities or personality states, each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self |
| At least 2 of these identities or personality states must recurrently take control of the person’s behavior |
| An inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness |
| The disturbance is not due to the direct physiological effects of substance or a general medical condition. In children, the symptoms are not attributable to imaginary playmates or other fantasy play |
| Source: Reference 3 |
DID and NGRI
An insanity defense is raised in <1% of felony cases, and is successful in only a fraction of those.8 A criminal defendant who claims NGRI asserts that he committed the offense and asks the court to find him not culpable because of his mental state when the offense occurred.
The legal approach used by the defense in cases of NGRI due to DID will be determined by the jurisdiction in which the case is tried. The “Alter-in-control” approach considers the key issue as which “alter” (personality) was in control at the time of the offense and whether he or she met the insanity standard, the “Each-alter” approach considers whether each personality met the insanity standard, and the “Host-alter” approach considers whether the dominant or primary personality met the insanity standard.9
Legal and mental health professionals are divided on whether DID warrants an acquittal for insanity. The first time DID was recognized as a mental disorder that could excuse criminal responsibility occurred in State v Milligan (1978).10 The court declared serial rapist Billy Milligan insane due to lack of one integrated personality and therefore not culpable of the crimes he committed. Public outrage was extraordinary. Since this case, most DID defenses have not been successful (Table 2).10-16
In a 1980 court case,11 a defendant charged with murder pleaded NGRI due to having multiple personalities. The court found that having alter personalities was not necessarily a mental disease that would preclude responsibility for the murder.
In State v Grimsley (1982),12 the defense used NGRI due to multiple personalities in a drunk driving case. The court ruled that it is immaterial what state of consciousness or personality the defendant was in as long as the personality controlling the behavior was conscious and aware of his or her actions.
In Kirkland v State (1983),13 attorneys for a woman who committed a bank robbery asserted an insanity defense based on a psychogenic fugue, which is sudden, unexpected travel away from home accompanied by inability to recall one’s past and confusion about identity or assumption of a new identity.3 The court found that the law adjudges criminal liability according to the person’s state of mind at the time of the act and will not inquire whether an individual possesses other personalities, fugues, or even moods in which he would not have performed the crime.
In State v Jones (1988),14 the court found the defendant guilty of murdering a woman he met at a bar despite expert testimony that his multiple personalities “paralyzed” him from knowing right from wrong.
More recently, courts have rejected the admissibility of DID evidence, including expert testimony, because the scientific evidence failed to meet reliability standards, and therefore is not ultimately useful to the judge or jury. In State v Greene (1998),15 the defendant claimed that 1 of his 24 alters was responsible for killing his therapist. The Supreme Court of Washington affirmed that evidence of Mr. Greene’s DID, including expert testimony, was not reliable and not admissible.
Similarly, in State v Lockhart (2000),16 Mr. Lockhart contested his conviction of first degree sexual assault on the basis that he was not permitted to present evidence of DID to support his insanity defense. The West Virginia Court held that the diagnosis of DID was speculative and therefore did not meet reliability standards for evidence.
Table 2
Using dissociative identity disorder* as a basis for not guilty by reason of insanity
| Case | Year | Charge | Defense | Court ruling |
|---|---|---|---|---|
| State v Milligan10 | 1978 | Rape | NGRI-MPD | Lack of an integrated personality meant the defendant was not culpable |
| State v Darnall11 | 1980 | Murder | NGRI-MPD | Multiple personalities do not preclude criminal responsibility |
| State v Grimsley12 | 1982 | Drunk driving | NGRI-MPD; primary personality had no control over the ‘alter’ | State of consciousness or personality of defendant is immaterial |
| Kirkland v State13 | 1983 | Bank robbery | NGRI-psychogenic fugue | Law does not inquire about other personalities, fugue states, or moods in cases of criminal liability |
| State v Jones14 | 1988 | Murder | NGRI-MPD | Alter personalities will not be an excuse for inability to distinguish right from wrong |
| State v Greene15 | 1998 | Murder | NGRI-DID; primary personality was ‘unconscious’ | Evidence of DID, including expert testimony, was not admissible because it did not meet reliability standards |
| State v Lockhart16 | 2000 | Sexual assault | NGRI-DID | DID was not allowed into evidence by the West Virginia Court due to lack of scientific evidence |
| *Dissociative identity disorder formerly was referred to as multiple personality disorder DID: dissociative identity disorder; MPD: multiple personality disorder; NGRI: not guilty by reason of insanity. | ||||
Evaluating DID
Because the courts may ask psychiatrists to provide expert opinion on DID to assist with legal rulings, clinicians must remain vigilant to the possibility of DID as well as to defendants who may malinger multiple personalities to evade punishment. In such situations, factors to consider include the mental status examination, data and history collection, collateral information, criminal background, mental health history, history of abuse, and objective assessment tools.
Extensive field testing has shown that the Structured Clinical Interview for Dissociative Disorders (SCID-D) has good reliability and excellent validity.17 The SCID-D allows a trained interviewer to assess the severity of 5 dissociative symptoms: amnesia, depersonalization, derealization, identity confusion, and identity alteration.17 Other tools that may help assess a patient with suspected DID are listed in Table 3.
Patients who commit criminal acts while in a dissociated state may assert a defense of NGRI due to DID, but rarely has this defense been successful. Although a patient may have distinct personalities that control his or her behavior, this condition does not preclude criminal responsibility.
The role of hypnosis in evaluating DID is controversial. The introduction of pseudo-memories and potential for iatrogenic DID may complicate the clinical presentation and subsequent diagnosis.18
Table 3
Tools for diagnosing dissociative identity disorder
| Structured Clinical Interview for Dissociative Disorders |
| Dissociative Disorder Interview Schedule |
| Dissociative Experiences Scale |
| Childhood Trauma Questionnaire |
Related Resource
- West S, Noffsinger S. Is this patient not guilty by reason of insanity? Current Psychiatry. 2006;5(8):54-62.
Disclosure
Dr. Farrell reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Putnam. Diagnosis and treatment of multiple personality disorder. New York, NY: The Guilford Press; 1989.
2. American Psychiatric Association. DSM-5 Development. 300. 14. Dissociative identity disorder. Proposed revision. Available at: http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=57. Accessed April 22 2011.
3. Diagnostic and statistical manual of mental disorders. 4th ed, text rev. Washington DC: American Psychiatric Association; 2000.
4. Sadock BJ, Sadock VA. eds. Dissociative disorders. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock’s comprehensive textbook of psychiatry. 7th ed. New York, NY: Lippincott Williams & Wilkins; 2000:1544–1576.
5. Lyons-Ruth K, Dutra L, Schuder MR, et al. From infant attachment disorganization to adult dissociation: relational adaptations or traumatic experiences? Psychiatr Clin North Am. 2006;29(1):63-86, viii.
6. Brahams D. Automatism and post-traumatic stress disorder. Lancet. 1990;335(8701):1333.-
7. Simeon D, Guralnik O, Knutelska M, et al. Personality factors associated with dissociation: temperament, defenses, and cognitive schemata. Am J Psychiatry. 2002;159(3):489-491.
8. Perlin M. The jurisprudence of the insanity defense. Durham NC: Carolina Academic Press; 1994.
9. Steinberg M, Bancroft J, Buchanan J. Multiple personality disorder in criminal law. Bull Am Acad Psychiatry Law. 1993;21(3):345-356.
10. State v Milligan, No 77-CR-11-2908 (Franklin County, Ohio, December 4 1978).
11. State v Darnall, 47 Or App 161, 614 P2d 120 (1980).
12. State v Grimsley, 3 Ohio App 3d 165 444 NE2d 1071 (1982).
13. Kirkland v State, 166 Ga App 478, 304 SE2d 561 (1983).
14. State v Jones, 743 P2d 176 (Wash Ct App 1987) aff’d, 759 P2d 1183, 1185 (Wash 1998).
15. State v Greene, 92 Wn App 80, 960 P2d 980 (1998).
16. State v Lockhart, 208 W Va 622 (2000).
17. Steinberg M, Rounsaville B, Cicchetti D. Detection of dissociative disorders in psychiatric patients by a screening instrument and a structured diagnostic interview. Am J Psychiatry. 1991;148(8):1050-1054.
18. Putnam FW. Dissociative phenomena. In: Tasman A ed. Annual review of psychiatry. Washington, DC: American Psychiatric Press; 1991:145–160.
Formerly called multiple personality disorder, dissociative identity disorder (DID) is a controversial diagnosis that challenges forensic psychiatrists, other mental health clinicians, legal professionals, the media, and the public. DID cases often present in the criminal justice system rather than in the mental health system, and the illness perplexes experts in both professions.
Individuals may commit criminal acts while in a dissociated state. A study that tracked 21 reported DID cases found that 47% of men and 35% of women reported engaging in criminal activity, including 19% of men and 7% of women who committed homicide.1 Defendants occasionally use DID as a basis for pleading not guilty by reason of insanity (NGRI). Controversy over the DID diagnosis has contributed to debates about the disorder’s role in criminal responsibility.
The DID diagnosis
An American Psychiatric Association Work Group has proposed new diagnostic criteria for DID for DSM-5, which is scheduled to be published in May 2013.2 Presently, DID is listed in DSM-IV-TR as an axis I disorder.3 Criteria for DID include the presence of ≥2 distinctive identities or personality states that recurrently take control of an individual’s behavior (Table 1).3 This is accompanied by an inability to recall important personal information to an extent that cannot be explained by ordinary forgetfulness. Patients with DID typically have a primary identity that is passive, dependent, guilty, and depressed, and alternate identities with characteristics that differ from the primary identity, commonly in reported age and gender, vocabulary, general knowledge, or predominant affect.3
Dissociative pathology may result from trauma, comorbid mental illness, or other medical issues, including complex partial seizures. Developmental theorists have proposed that severe sexual, physical, or psychological trauma in childhood predisposes an individual to develop DID.4 Theoretically, harm by a trusted caregiver forces a child to split off awareness and memory of the trauma to survive in the relationship. Later these memories and feelings are experienced as a separate personality. Because this process happens repeatedly, the patient develops multiple personalities; each has different memories and performs different functions, which may be helpful or destructive. Later, dissociation becomes a coping mechanism when individuals face stressful situations.5
Personality traits that may predispose patients to develop a dissociative disorder include mental absorption, suggestibility, ability to be easily hypnotized, and tendency to fantasize.6 Patients with dissociation also may meet criteria for posttraumatic stress disorder, borderline personality disorder, somatoform disorder, eating disorder, or substance use disorders.7
Table 1
DSM-IV-TR criteria for dissociative identity disorder
| The presence of ≥2 distinct identities or personality states, each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self |
| At least 2 of these identities or personality states must recurrently take control of the person’s behavior |
| An inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness |
| The disturbance is not due to the direct physiological effects of substance or a general medical condition. In children, the symptoms are not attributable to imaginary playmates or other fantasy play |
| Source: Reference 3 |
DID and NGRI
An insanity defense is raised in <1% of felony cases, and is successful in only a fraction of those.8 A criminal defendant who claims NGRI asserts that he committed the offense and asks the court to find him not culpable because of his mental state when the offense occurred.
The legal approach used by the defense in cases of NGRI due to DID will be determined by the jurisdiction in which the case is tried. The “Alter-in-control” approach considers the key issue as which “alter” (personality) was in control at the time of the offense and whether he or she met the insanity standard, the “Each-alter” approach considers whether each personality met the insanity standard, and the “Host-alter” approach considers whether the dominant or primary personality met the insanity standard.9
Legal and mental health professionals are divided on whether DID warrants an acquittal for insanity. The first time DID was recognized as a mental disorder that could excuse criminal responsibility occurred in State v Milligan (1978).10 The court declared serial rapist Billy Milligan insane due to lack of one integrated personality and therefore not culpable of the crimes he committed. Public outrage was extraordinary. Since this case, most DID defenses have not been successful (Table 2).10-16
In a 1980 court case,11 a defendant charged with murder pleaded NGRI due to having multiple personalities. The court found that having alter personalities was not necessarily a mental disease that would preclude responsibility for the murder.
In State v Grimsley (1982),12 the defense used NGRI due to multiple personalities in a drunk driving case. The court ruled that it is immaterial what state of consciousness or personality the defendant was in as long as the personality controlling the behavior was conscious and aware of his or her actions.
In Kirkland v State (1983),13 attorneys for a woman who committed a bank robbery asserted an insanity defense based on a psychogenic fugue, which is sudden, unexpected travel away from home accompanied by inability to recall one’s past and confusion about identity or assumption of a new identity.3 The court found that the law adjudges criminal liability according to the person’s state of mind at the time of the act and will not inquire whether an individual possesses other personalities, fugues, or even moods in which he would not have performed the crime.
In State v Jones (1988),14 the court found the defendant guilty of murdering a woman he met at a bar despite expert testimony that his multiple personalities “paralyzed” him from knowing right from wrong.
More recently, courts have rejected the admissibility of DID evidence, including expert testimony, because the scientific evidence failed to meet reliability standards, and therefore is not ultimately useful to the judge or jury. In State v Greene (1998),15 the defendant claimed that 1 of his 24 alters was responsible for killing his therapist. The Supreme Court of Washington affirmed that evidence of Mr. Greene’s DID, including expert testimony, was not reliable and not admissible.
Similarly, in State v Lockhart (2000),16 Mr. Lockhart contested his conviction of first degree sexual assault on the basis that he was not permitted to present evidence of DID to support his insanity defense. The West Virginia Court held that the diagnosis of DID was speculative and therefore did not meet reliability standards for evidence.
Table 2
Using dissociative identity disorder* as a basis for not guilty by reason of insanity
| Case | Year | Charge | Defense | Court ruling |
|---|---|---|---|---|
| State v Milligan10 | 1978 | Rape | NGRI-MPD | Lack of an integrated personality meant the defendant was not culpable |
| State v Darnall11 | 1980 | Murder | NGRI-MPD | Multiple personalities do not preclude criminal responsibility |
| State v Grimsley12 | 1982 | Drunk driving | NGRI-MPD; primary personality had no control over the ‘alter’ | State of consciousness or personality of defendant is immaterial |
| Kirkland v State13 | 1983 | Bank robbery | NGRI-psychogenic fugue | Law does not inquire about other personalities, fugue states, or moods in cases of criminal liability |
| State v Jones14 | 1988 | Murder | NGRI-MPD | Alter personalities will not be an excuse for inability to distinguish right from wrong |
| State v Greene15 | 1998 | Murder | NGRI-DID; primary personality was ‘unconscious’ | Evidence of DID, including expert testimony, was not admissible because it did not meet reliability standards |
| State v Lockhart16 | 2000 | Sexual assault | NGRI-DID | DID was not allowed into evidence by the West Virginia Court due to lack of scientific evidence |
| *Dissociative identity disorder formerly was referred to as multiple personality disorder DID: dissociative identity disorder; MPD: multiple personality disorder; NGRI: not guilty by reason of insanity. | ||||
Evaluating DID
Because the courts may ask psychiatrists to provide expert opinion on DID to assist with legal rulings, clinicians must remain vigilant to the possibility of DID as well as to defendants who may malinger multiple personalities to evade punishment. In such situations, factors to consider include the mental status examination, data and history collection, collateral information, criminal background, mental health history, history of abuse, and objective assessment tools.
Extensive field testing has shown that the Structured Clinical Interview for Dissociative Disorders (SCID-D) has good reliability and excellent validity.17 The SCID-D allows a trained interviewer to assess the severity of 5 dissociative symptoms: amnesia, depersonalization, derealization, identity confusion, and identity alteration.17 Other tools that may help assess a patient with suspected DID are listed in Table 3.
Patients who commit criminal acts while in a dissociated state may assert a defense of NGRI due to DID, but rarely has this defense been successful. Although a patient may have distinct personalities that control his or her behavior, this condition does not preclude criminal responsibility.
The role of hypnosis in evaluating DID is controversial. The introduction of pseudo-memories and potential for iatrogenic DID may complicate the clinical presentation and subsequent diagnosis.18
Table 3
Tools for diagnosing dissociative identity disorder
| Structured Clinical Interview for Dissociative Disorders |
| Dissociative Disorder Interview Schedule |
| Dissociative Experiences Scale |
| Childhood Trauma Questionnaire |
Related Resource
- West S, Noffsinger S. Is this patient not guilty by reason of insanity? Current Psychiatry. 2006;5(8):54-62.
Disclosure
Dr. Farrell reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Formerly called multiple personality disorder, dissociative identity disorder (DID) is a controversial diagnosis that challenges forensic psychiatrists, other mental health clinicians, legal professionals, the media, and the public. DID cases often present in the criminal justice system rather than in the mental health system, and the illness perplexes experts in both professions.
Individuals may commit criminal acts while in a dissociated state. A study that tracked 21 reported DID cases found that 47% of men and 35% of women reported engaging in criminal activity, including 19% of men and 7% of women who committed homicide.1 Defendants occasionally use DID as a basis for pleading not guilty by reason of insanity (NGRI). Controversy over the DID diagnosis has contributed to debates about the disorder’s role in criminal responsibility.
The DID diagnosis
An American Psychiatric Association Work Group has proposed new diagnostic criteria for DID for DSM-5, which is scheduled to be published in May 2013.2 Presently, DID is listed in DSM-IV-TR as an axis I disorder.3 Criteria for DID include the presence of ≥2 distinctive identities or personality states that recurrently take control of an individual’s behavior (Table 1).3 This is accompanied by an inability to recall important personal information to an extent that cannot be explained by ordinary forgetfulness. Patients with DID typically have a primary identity that is passive, dependent, guilty, and depressed, and alternate identities with characteristics that differ from the primary identity, commonly in reported age and gender, vocabulary, general knowledge, or predominant affect.3
Dissociative pathology may result from trauma, comorbid mental illness, or other medical issues, including complex partial seizures. Developmental theorists have proposed that severe sexual, physical, or psychological trauma in childhood predisposes an individual to develop DID.4 Theoretically, harm by a trusted caregiver forces a child to split off awareness and memory of the trauma to survive in the relationship. Later these memories and feelings are experienced as a separate personality. Because this process happens repeatedly, the patient develops multiple personalities; each has different memories and performs different functions, which may be helpful or destructive. Later, dissociation becomes a coping mechanism when individuals face stressful situations.5
Personality traits that may predispose patients to develop a dissociative disorder include mental absorption, suggestibility, ability to be easily hypnotized, and tendency to fantasize.6 Patients with dissociation also may meet criteria for posttraumatic stress disorder, borderline personality disorder, somatoform disorder, eating disorder, or substance use disorders.7
Table 1
DSM-IV-TR criteria for dissociative identity disorder
| The presence of ≥2 distinct identities or personality states, each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self |
| At least 2 of these identities or personality states must recurrently take control of the person’s behavior |
| An inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness |
| The disturbance is not due to the direct physiological effects of substance or a general medical condition. In children, the symptoms are not attributable to imaginary playmates or other fantasy play |
| Source: Reference 3 |
DID and NGRI
An insanity defense is raised in <1% of felony cases, and is successful in only a fraction of those.8 A criminal defendant who claims NGRI asserts that he committed the offense and asks the court to find him not culpable because of his mental state when the offense occurred.
The legal approach used by the defense in cases of NGRI due to DID will be determined by the jurisdiction in which the case is tried. The “Alter-in-control” approach considers the key issue as which “alter” (personality) was in control at the time of the offense and whether he or she met the insanity standard, the “Each-alter” approach considers whether each personality met the insanity standard, and the “Host-alter” approach considers whether the dominant or primary personality met the insanity standard.9
Legal and mental health professionals are divided on whether DID warrants an acquittal for insanity. The first time DID was recognized as a mental disorder that could excuse criminal responsibility occurred in State v Milligan (1978).10 The court declared serial rapist Billy Milligan insane due to lack of one integrated personality and therefore not culpable of the crimes he committed. Public outrage was extraordinary. Since this case, most DID defenses have not been successful (Table 2).10-16
In a 1980 court case,11 a defendant charged with murder pleaded NGRI due to having multiple personalities. The court found that having alter personalities was not necessarily a mental disease that would preclude responsibility for the murder.
In State v Grimsley (1982),12 the defense used NGRI due to multiple personalities in a drunk driving case. The court ruled that it is immaterial what state of consciousness or personality the defendant was in as long as the personality controlling the behavior was conscious and aware of his or her actions.
In Kirkland v State (1983),13 attorneys for a woman who committed a bank robbery asserted an insanity defense based on a psychogenic fugue, which is sudden, unexpected travel away from home accompanied by inability to recall one’s past and confusion about identity or assumption of a new identity.3 The court found that the law adjudges criminal liability according to the person’s state of mind at the time of the act and will not inquire whether an individual possesses other personalities, fugues, or even moods in which he would not have performed the crime.
In State v Jones (1988),14 the court found the defendant guilty of murdering a woman he met at a bar despite expert testimony that his multiple personalities “paralyzed” him from knowing right from wrong.
More recently, courts have rejected the admissibility of DID evidence, including expert testimony, because the scientific evidence failed to meet reliability standards, and therefore is not ultimately useful to the judge or jury. In State v Greene (1998),15 the defendant claimed that 1 of his 24 alters was responsible for killing his therapist. The Supreme Court of Washington affirmed that evidence of Mr. Greene’s DID, including expert testimony, was not reliable and not admissible.
Similarly, in State v Lockhart (2000),16 Mr. Lockhart contested his conviction of first degree sexual assault on the basis that he was not permitted to present evidence of DID to support his insanity defense. The West Virginia Court held that the diagnosis of DID was speculative and therefore did not meet reliability standards for evidence.
Table 2
Using dissociative identity disorder* as a basis for not guilty by reason of insanity
| Case | Year | Charge | Defense | Court ruling |
|---|---|---|---|---|
| State v Milligan10 | 1978 | Rape | NGRI-MPD | Lack of an integrated personality meant the defendant was not culpable |
| State v Darnall11 | 1980 | Murder | NGRI-MPD | Multiple personalities do not preclude criminal responsibility |
| State v Grimsley12 | 1982 | Drunk driving | NGRI-MPD; primary personality had no control over the ‘alter’ | State of consciousness or personality of defendant is immaterial |
| Kirkland v State13 | 1983 | Bank robbery | NGRI-psychogenic fugue | Law does not inquire about other personalities, fugue states, or moods in cases of criminal liability |
| State v Jones14 | 1988 | Murder | NGRI-MPD | Alter personalities will not be an excuse for inability to distinguish right from wrong |
| State v Greene15 | 1998 | Murder | NGRI-DID; primary personality was ‘unconscious’ | Evidence of DID, including expert testimony, was not admissible because it did not meet reliability standards |
| State v Lockhart16 | 2000 | Sexual assault | NGRI-DID | DID was not allowed into evidence by the West Virginia Court due to lack of scientific evidence |
| *Dissociative identity disorder formerly was referred to as multiple personality disorder DID: dissociative identity disorder; MPD: multiple personality disorder; NGRI: not guilty by reason of insanity. | ||||
Evaluating DID
Because the courts may ask psychiatrists to provide expert opinion on DID to assist with legal rulings, clinicians must remain vigilant to the possibility of DID as well as to defendants who may malinger multiple personalities to evade punishment. In such situations, factors to consider include the mental status examination, data and history collection, collateral information, criminal background, mental health history, history of abuse, and objective assessment tools.
Extensive field testing has shown that the Structured Clinical Interview for Dissociative Disorders (SCID-D) has good reliability and excellent validity.17 The SCID-D allows a trained interviewer to assess the severity of 5 dissociative symptoms: amnesia, depersonalization, derealization, identity confusion, and identity alteration.17 Other tools that may help assess a patient with suspected DID are listed in Table 3.
Patients who commit criminal acts while in a dissociated state may assert a defense of NGRI due to DID, but rarely has this defense been successful. Although a patient may have distinct personalities that control his or her behavior, this condition does not preclude criminal responsibility.
The role of hypnosis in evaluating DID is controversial. The introduction of pseudo-memories and potential for iatrogenic DID may complicate the clinical presentation and subsequent diagnosis.18
Table 3
Tools for diagnosing dissociative identity disorder
| Structured Clinical Interview for Dissociative Disorders |
| Dissociative Disorder Interview Schedule |
| Dissociative Experiences Scale |
| Childhood Trauma Questionnaire |
Related Resource
- West S, Noffsinger S. Is this patient not guilty by reason of insanity? Current Psychiatry. 2006;5(8):54-62.
Disclosure
Dr. Farrell reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Putnam. Diagnosis and treatment of multiple personality disorder. New York, NY: The Guilford Press; 1989.
2. American Psychiatric Association. DSM-5 Development. 300. 14. Dissociative identity disorder. Proposed revision. Available at: http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=57. Accessed April 22 2011.
3. Diagnostic and statistical manual of mental disorders. 4th ed, text rev. Washington DC: American Psychiatric Association; 2000.
4. Sadock BJ, Sadock VA. eds. Dissociative disorders. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock’s comprehensive textbook of psychiatry. 7th ed. New York, NY: Lippincott Williams & Wilkins; 2000:1544–1576.
5. Lyons-Ruth K, Dutra L, Schuder MR, et al. From infant attachment disorganization to adult dissociation: relational adaptations or traumatic experiences? Psychiatr Clin North Am. 2006;29(1):63-86, viii.
6. Brahams D. Automatism and post-traumatic stress disorder. Lancet. 1990;335(8701):1333.-
7. Simeon D, Guralnik O, Knutelska M, et al. Personality factors associated with dissociation: temperament, defenses, and cognitive schemata. Am J Psychiatry. 2002;159(3):489-491.
8. Perlin M. The jurisprudence of the insanity defense. Durham NC: Carolina Academic Press; 1994.
9. Steinberg M, Bancroft J, Buchanan J. Multiple personality disorder in criminal law. Bull Am Acad Psychiatry Law. 1993;21(3):345-356.
10. State v Milligan, No 77-CR-11-2908 (Franklin County, Ohio, December 4 1978).
11. State v Darnall, 47 Or App 161, 614 P2d 120 (1980).
12. State v Grimsley, 3 Ohio App 3d 165 444 NE2d 1071 (1982).
13. Kirkland v State, 166 Ga App 478, 304 SE2d 561 (1983).
14. State v Jones, 743 P2d 176 (Wash Ct App 1987) aff’d, 759 P2d 1183, 1185 (Wash 1998).
15. State v Greene, 92 Wn App 80, 960 P2d 980 (1998).
16. State v Lockhart, 208 W Va 622 (2000).
17. Steinberg M, Rounsaville B, Cicchetti D. Detection of dissociative disorders in psychiatric patients by a screening instrument and a structured diagnostic interview. Am J Psychiatry. 1991;148(8):1050-1054.
18. Putnam FW. Dissociative phenomena. In: Tasman A ed. Annual review of psychiatry. Washington, DC: American Psychiatric Press; 1991:145–160.
1. Putnam. Diagnosis and treatment of multiple personality disorder. New York, NY: The Guilford Press; 1989.
2. American Psychiatric Association. DSM-5 Development. 300. 14. Dissociative identity disorder. Proposed revision. Available at: http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=57. Accessed April 22 2011.
3. Diagnostic and statistical manual of mental disorders. 4th ed, text rev. Washington DC: American Psychiatric Association; 2000.
4. Sadock BJ, Sadock VA. eds. Dissociative disorders. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock’s comprehensive textbook of psychiatry. 7th ed. New York, NY: Lippincott Williams & Wilkins; 2000:1544–1576.
5. Lyons-Ruth K, Dutra L, Schuder MR, et al. From infant attachment disorganization to adult dissociation: relational adaptations or traumatic experiences? Psychiatr Clin North Am. 2006;29(1):63-86, viii.
6. Brahams D. Automatism and post-traumatic stress disorder. Lancet. 1990;335(8701):1333.-
7. Simeon D, Guralnik O, Knutelska M, et al. Personality factors associated with dissociation: temperament, defenses, and cognitive schemata. Am J Psychiatry. 2002;159(3):489-491.
8. Perlin M. The jurisprudence of the insanity defense. Durham NC: Carolina Academic Press; 1994.
9. Steinberg M, Bancroft J, Buchanan J. Multiple personality disorder in criminal law. Bull Am Acad Psychiatry Law. 1993;21(3):345-356.
10. State v Milligan, No 77-CR-11-2908 (Franklin County, Ohio, December 4 1978).
11. State v Darnall, 47 Or App 161, 614 P2d 120 (1980).
12. State v Grimsley, 3 Ohio App 3d 165 444 NE2d 1071 (1982).
13. Kirkland v State, 166 Ga App 478, 304 SE2d 561 (1983).
14. State v Jones, 743 P2d 176 (Wash Ct App 1987) aff’d, 759 P2d 1183, 1185 (Wash 1998).
15. State v Greene, 92 Wn App 80, 960 P2d 980 (1998).
16. State v Lockhart, 208 W Va 622 (2000).
17. Steinberg M, Rounsaville B, Cicchetti D. Detection of dissociative disorders in psychiatric patients by a screening instrument and a structured diagnostic interview. Am J Psychiatry. 1991;148(8):1050-1054.
18. Putnam FW. Dissociative phenomena. In: Tasman A ed. Annual review of psychiatry. Washington, DC: American Psychiatric Press; 1991:145–160.
Did brain trauma lead to crime?
CASE: Self-reported TBI
When charged with raping a 19-year-old woman, Mr. P, age 32, pleads not guilty by reason of insanity (NGRI). He has a self-reported history of traumatic brain injury (TBI) and claims that since suffering a blow to the head 8 years before the rape, he has experienced episodes of personality changes, psychosis, and violent behavior. Mr. P is adamant that any wrongdoing on his part was beyond his control, and he argues that consequences of the brain injury, such as hallucinations and aggressive behavior, had recently emerged. The court asks that a forensic psychiatrist evaluate Mr. P.
An only child, Mr. P was raised by his mother in an inner city area. His father was dependent on alcohol and cocaine and abandoned the family shortly after Mr. P’s birth. Mr. P abuses alcohol, as evidenced by previous driving under the influence charges, but denies illicit drug use. He graduated from high school with average grades and denies a history of disciplinary action at school or home. Although Mr. P was charged with misdemeanors in his late teens, the sexual assault is his first felony charge. Mr. P describes himself as a “charmer.”
After high school, Mr. P worked full-time in construction, where he claims he suffered a traumatic blow to the head. Despite this injury, he continued to work and socialize and never sought treatment at a mental health clinic.
The authors’ observations
Although defendants may legitimately suffer from TBI and resultant complications, many individuals capitalize on a history of minor head injury to support their NGRI defense.1 Forensic psychiatrists must retain a healthy degree of clinical suspicion for malingering in defendants who claim NGRI as a result of complications from brain injury, especially when the injury and complications are not documented and simply patient-reported.
TBI is a CNS injury that occurs when an outside force traumatically injures the brain and can cause a variety of physical, cognitive, emotional, and behavioral effects ( Table 1 ).2 Cognitive deficits include:
- impaired attention
- disrupted insight
- poor judgment
- thought disorders.
Reduced processing speed, distractibility, and deficits in executive functions such as abstract reasoning, planning, problem solving, and multitasking have been documented. Memory loss—the most common cognitive impairment among head-injured people—occurs in 20% to 79% of people with closed head trauma, depending on injury severity.3 People who have suffered TBI may have difficulty understanding or producing spoken or written language, or with more subtle aspects of communication, such as body language.
TBI may cause emotional or behavioral problems and personality changes. Mood and affect changes are common. TBI predisposes patients to obsessive-compulsive disorder, substance abuse, dysthymia, clinical depression, bipolar disorder, phobias, panic disorder, and schizophrenia.4 Frontal lobe injuries have been correlated with disinhibition and inappropriate or childish behavior, and temporal lobe injuries with irritability and aggression.5
Table 1
TBI symptoms correspond to area of injury
| Area of injury | Motor/sensory | Psychiatric/behavioral | Cognitive |
|---|---|---|---|
| Brain stem | Decreased vital capacity in breathing, dysphagia | Sleep difficulties | Inability to categorize objects, difficulty with organization |
| Frontal lobe | Aphasia, praxis | Disinhibition, personality changes | Impaired executive function |
| Cerebellum | Nystagmus, tremor | Labile emotions | Inability to process information |
| Parietal lobe | Apraxia | Personality changes | Neglect |
| Occipital lobe | Visual field cuts; diminished proprioception | Visual hallucinations | Color agnosia; inability to recognize words; difficulty reading, writing, and recognizing drawn objects |
| Temporal lobe | Seizure | Libido changes, humorless verbosity, aggression, olfactory perceptual changes | Prosopagnosia, aphasia, agnosia, memory loss, inattention |
| TBI: traumatic brain injury | |||
| Source: Reference 2 | |||
TBI and the insanity defense
The M’Naghten Rule of 1843 requires that for an insanity defense, the defendant must have a mental disease or defect that causes him not to know the nature and quality or the wrongfulness of his act.6 TBI is an abnormal condition of the mind leading to a mental disease that can substantially affect control of emotions and behaviors.
Nevertheless, TBI-induced criminality remains controversial.7 Theories on the etiology of impulse dyscontrol resulting from TBI have suggested structural damage to the brain and altered neurotransmitters. In TBI, the amygdala—which is located within the anterior temporal lobe and adjoins emotions to thoughts—often is injured. Damage to this structure leads to poor impulse control and violent behavior. Damage to specific neurotransmitter systems that causes elevated norepinephrine and dopamine levels and reduced serotonin levels have also been implicated as a cause of impulse dyscontrol in TBI patients.8
In theory, TBI patients potentially could have enough cognitive impairment to have a substantial lack of appreciation of the criminality or wrongfulness of an act. TBI-related impulsivity and cognitive impairment can lead to recklessness and negligence.9 The U.S. Supreme Court has acknowledged that CNS dysfunction affects judgment, reality testing, and self-control.10
EVALUATION: Vague answers
To determine whether Mr. P’s defense is plausible, the forensic psychiatrist must pay attention to the details of the patient’s presentation and history. During the interview, Mr. P quickly shifts from cooperative to obstinate and restricted. He ruminates on the head injury causing him to suffer auditory hallucinations, which he claims he always obeys. Mr. P refuses to provide details of the hallucinations, however, and answers most questions about the head injury or his defense with vague answers, including “I don’t know.”
Because of Mr. P’s reluctance to share information, his lack of psychiatric symptoms other than those he self-reports, and the presence of potential secondary gain from an NGRI defense, the psychiatrist begins to suspect malingering.
The authors’ observations
Malingering is a condition—not a diagnosis—characterized by intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives.11 The presence of external incentives distinguishes malingering from psychiatric illnesses such as factitious and somatoform disorders, in which there is no apparent external incentive. Malingering of psychiatric symptoms occurs in up to 20% of forensic patients, 5% of military recruits, and 1% of mental health patients.5 Stimuli for malingering range from seeking food and shelter to avoiding criminal responsibility ( Table 2 ). Malingering is more common in individuals being evaluated for criminal responsibility than for competence to stand trial. The 3 categories of malingering are:
Table 2
Common external incentives for malingering
| Evading criminal responsibility |
| Disability claims/financial gain |
| Avoiding military duty |
| Evading work |
| Obtaining drugs |
| Seeking food/shelter |
- pure malingering—feigning a nonexistent disorder
- partial malingering—consciously exaggerating real symptoms
- false imputation—ascribing real symptoms to a cause the individual knows is unrelated to the symptoms.12
Determining if a defendant with a history of TBI is malingering requires a multi-step approach that encompasses the clinical interview, a thorough review of collateral data, and focused psychological testing. In interviews, psychiatrists detect approximately 50% of lies, which is no better than would be discovered by chance.13 If you suspect a patient is malingering, combine a structured clinical interview with collateral sources such as old hospital records, treatment history, insurance records, police reports, and interviews with close family and friends.
TBI patients’ poor cognition, memory deficits, and inattention will prove challenging. Malingering patients who attempt to capitalize on a pre-existing TBI to evade responsibility for a current criminal charge may grossly exaggerate or even fake intellectual deficits. Be patient with such defendants and remain aware that such people will give vague or hedging answers to straightforward questions, often accompanied by “I don’t know.” Prolonging the interview may be helpful because it may fatigue a defendant who is faking.12
Some patients who malinger after sustaining a TBI will attempt to feign psychotic symptoms. Table 3 14 illustrates criteria for assessing a patient suspected of malingering psychosis and Table 4 14 highlights atypical psychotic symptoms that suggest feigning illness. Malingering of psychosis can be both assessed in the interview and through testing.
Table 3
Criteria for malingered psychosis
| A. Understandable motive to malinger |
| B. Marked variability of presentation as evidenced by ≥1 of the following: 1. Marked discrepancies in interview and non-interview behaviors 2. Gross inconsistencies in reported psychotic symptoms 3. Blatant contradictions between reported prior episodes and documented psychiatric history |
| C. Improbable psychiatric symptoms as evidenced by ≥1 of the following: 1. Reporting elaborate psychotic symptoms that lack common paranoid, grandiose, or religious themes 2. Sudden emergence of purported symptoms to explain antisocial behavior 3. Atypical hallucinations and delusions |
| D. Confirmation of malingering by either: 1. Admission of malingering following confrontation, or 2. Presence of strong corroborative information, such as psychometric data or history of malingering |
| Source: Reference 14 |
Table 4
Atypical psychotic symptoms that suggest malingering
| Hallucinations |
| Continuous rather than intermittent |
| Vague or inaudible auditory hallucinations |
| Stilted language reported in hallucinations |
| Inability to state strategies to diminish voices |
| Self-report that all command hallucinations were obeyed |
| Visual hallucinations in black and white |
| Delusions |
| Abrupt onset or termination |
| Eagerness to call attention to delusions |
| Conduct markedly inconsistent with delusions |
| Bizarre content without disordered thinking |
| Source: Reference 14 |
Psychological testing
Several standardized diagnostic instruments can be used to help determine whether a patient is feigning or exaggerating psychotic symptoms or cognitive impairments ( Table 5 ). Testing for a patient such as Mr. P—who attributes any criminal wrongdoing to psychosis and also cites limited cognition as a reason for trouble in the interview—would include personality tests, tests to assess exaggerations of psychosis, and cognitive tests.
In the forensic setting, the preferred personality test is the MMPI-2.15 It consists of 567 items, with 10 clinical scales and several validity scales. The F scale, “faking good” or “faking bad,” detects people who are answering questions with the goal of appearing better or worse than they actually are. The Personal Assessment Inventory (PAI)16 is a 344-item test with a 4-point response format. The 22 scales cover a range of important axis I and II psychopathology.
SIRS17 is the gold standard in detecting malingered psychiatric illness; it includes questions about rare symptoms and uncommon symptom pairing. M-FAST18 was developed to provide a brief, reliable screen for malingered mental illness. It has shown good validity and high correlation with the SIRS and MMPI-2.
Tests of exaggerated cognitive impairment are extremely important in evaluating patients who claim to suffer from complications following TBI. TOMM19 —a 50-item recognition test designed to discriminate between true memory-impaired patients and malingerers—is the most studied and valid of such tests. Defendants’ scores that meet the recommended criteria for detecting malingering—≥5 errors on the retention trial—were found to also report a history of head injury.1
Although not as well validated, the Portland Digit Recognition Test (PDRT)20 is an alternative to the TOMM. This test is a forced-choice measure of recognition designed for assessing the possibility of malingering in individuals claiming mental illness because of head injury. The Victoria Symptoms Validity Test (VSVT)21 is used in outpatient and inpatient settings and also uses a forced-choice model to assess possible exaggeration or feigning of cognitive impairments. Finally, the Word Memory Test (WMT)22 is a neuropsychological assessment that evaluates the effort participants put forth.
Table 5
Standardized diagnostic instruments for detecting malingering
| Test | Clinical use |
|---|---|
| Personality | |
| MMPI-2 | F scale detects lying. Several validity scales |
| PAI | Covers a range of axis I and II psychopathology |
| Psychotic symptoms | |
| SIRS | Gold standard in detecting exaggerated psychotic symptoms |
| M-FAST | Screening tool to assess exaggerated psychosis; brief and reliable |
| Cognitive impairment | |
| TOMM | Highest validity of all tools to test memory malingering |
| PDRT | Assesses the possibility of malingering. Not widely studied and validity/reliability are suspect |
| VSVT | Useful for inpatient and outpatient settings |
| WMT | Evaluates effort put forth by the participant |
| M-FAST: Miller Forensic Assessment of Symptoms Test; MMPI-2: Minnesota Multiphasic Personality Inventory; PAI: Personal Assessment Inventory; PDRT: Portland Digit Recognition Test; SIRS: Structured Interview of Reported Symptoms; TOMM: Test of Memory Malingering; VSVT: Victoria Symptoms Validity Test; WMT: Word Memory Test | |
OUTCOME: Unsupported claims
Mr. P’s hospital records reveal a very minor head trauma that resulted in no structural brain abnormalities on imaging tests. Collateral interviews with Mr. P’s family and close friends fail to support the defendant’s claim that after the accident he began to experience behavioral changes and periods of psychosis. Mr. P’s SIRS and TOMM scores indicate malingering, and the psychiatrist did not support his NGRI defense.
Related resource
- Williamson DJ. Neurocognitive impairment: feigned, exaggerated, or real? Current Psychiatry. 2007;6(8):19-37.
Disclosure
Dr. Nasrallah receives research grant/research support from Forest Pharmaceuticals, GlaxoSmithKline, Janssen, Otsuka America Pharmaceuticals, Pfizer Inc., Roche, sanofi-aventis, and Shire, is on the advisory board of Abbott Laboratories, AstraZeneca, Janssen, Novartis, Pfizer Inc., and Merck, and is on the speakers’ bureau for Abbott Laboratories, AstraZeneca, Janssen, Novartis, Pfizer Inc., and Merck.
Dr. Farrell reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Delain SL, Stafford KP, Yosef SB. Use of the TOMM in a criminal court forensic assessment setting. Assessment. 2003;10(4):370-381.
2. Rao V, Lyketsos C. Neuropsychiatric sequelae of traumatic brain injury Psychosomatics. 2000;41:95-103.
3. Hall RC, Hall RC, Chapman MJ. Definition, diagnosis, and forensic implications of postconcussional syndrome. Psychosomatics. 2005;46(3):195-202.
4. Arlinghaus KA, Shoaib AM, Price TRP. Neuropsychiatric assessment. In: Silver JM, McAllister TW, Yudofsky SC. Textbook of traumatic brain injury. Arlington, VA: American Psychiatric Publishing, Inc.; 2005:63-65.
5. West S, Noffsinger S. Is this patient not guilty by reason of insanity? Current Psychiatry. 2005;5(8):54-62.
6. Barzman D, Kennedy J, Fozdar M. Does traumatic brain injury cause violence? Current Psychiatry. 2002;1(4):49-55.
7. Silver JM, Yudofsky SC, Hales RE. Neuropsychiatry of traumatic brain injury. Washington, DC: American Psychiatric Press, Inc.; 1994.
8. Melton GB, Petrila J, Poythress NG, et al. Psychological evaluations for the courts. New York, NY: The Guilford Press; 1997.
9. Lewis DO, Pincus JH, Feldman M, et al. Psychiatric, neurological, and psychoeducational characteristics of 15 death row inmates in the United States. Am J Psychiatry. 1986;143:838-845.
10. Diagnostic and statistical manual of mental disorders, 4th ed, text revision. Washington, DC: American Psychiatric Association; 2000.
11. Sadock VA. Kaplan and Sadock’s synopsis of psychiatry. Philadelphia, PA: Lippincott, Williams, and Wilkins; 2007:887.
12. Resnick PJ. Faking it: how to determine malingered psychosis. Current Psychiatry. 2005;4(11):12-25.
13. Samuel RZ, Mittenberg W. Determination of malingering in disability claims. Primary Psychiatry. 2005;12(12):60-68.
14. Resnick PJ. Malingered psychosis. In: Rogers R, ed. Clinical assessment of malingering. 2nd ed. New York, NY: The Guilford Press; 1997:47-67.
15. Hathaway SR, McKinley JC. The Minnesota Multiphasic Personality Inventory-2. Minneapolis, MN: University of Minnesota Press; 1989.
16. Rogers R, Sewell KW, Morey LC, et al. Detection of feigned mental disorder on the personality assessment inventory: a discriminate analysis. J Pers Assess. 1996;67:629-640.
17. Rogers R, Bagby RM, Dickens SE. Structured Interview of Reported Symptoms (SIRS). Lutz, FL: Psychological Assessment Resources; 1992.
18. Miller H. Miller Forensic Assessment of Symptoms Test (M-FAST). Professional Manual. Lutz, FL: Psychological Assessment Resources; 2001.
19. Tombaugh TN. The Test of Memory Malingering. Toronto, ON, Canada: Multi-Health Systems; 1996.
20. Binder LM. Malingering following minor head trauma. Clin Neuropsychol. 1990;4:25-36.
21. Slick D, Hopp G, Strauss E, et al. Victoria Symptom Validity Test professional manual. Lutz, FL: Psychological Assessment Resources; 1997.
22. Green P. Word Memory Test. Edmonton, Alberta, Canada: Green’s Publishing; 2003.
CASE: Self-reported TBI
When charged with raping a 19-year-old woman, Mr. P, age 32, pleads not guilty by reason of insanity (NGRI). He has a self-reported history of traumatic brain injury (TBI) and claims that since suffering a blow to the head 8 years before the rape, he has experienced episodes of personality changes, psychosis, and violent behavior. Mr. P is adamant that any wrongdoing on his part was beyond his control, and he argues that consequences of the brain injury, such as hallucinations and aggressive behavior, had recently emerged. The court asks that a forensic psychiatrist evaluate Mr. P.
An only child, Mr. P was raised by his mother in an inner city area. His father was dependent on alcohol and cocaine and abandoned the family shortly after Mr. P’s birth. Mr. P abuses alcohol, as evidenced by previous driving under the influence charges, but denies illicit drug use. He graduated from high school with average grades and denies a history of disciplinary action at school or home. Although Mr. P was charged with misdemeanors in his late teens, the sexual assault is his first felony charge. Mr. P describes himself as a “charmer.”
After high school, Mr. P worked full-time in construction, where he claims he suffered a traumatic blow to the head. Despite this injury, he continued to work and socialize and never sought treatment at a mental health clinic.
The authors’ observations
Although defendants may legitimately suffer from TBI and resultant complications, many individuals capitalize on a history of minor head injury to support their NGRI defense.1 Forensic psychiatrists must retain a healthy degree of clinical suspicion for malingering in defendants who claim NGRI as a result of complications from brain injury, especially when the injury and complications are not documented and simply patient-reported.
TBI is a CNS injury that occurs when an outside force traumatically injures the brain and can cause a variety of physical, cognitive, emotional, and behavioral effects ( Table 1 ).2 Cognitive deficits include:
- impaired attention
- disrupted insight
- poor judgment
- thought disorders.
Reduced processing speed, distractibility, and deficits in executive functions such as abstract reasoning, planning, problem solving, and multitasking have been documented. Memory loss—the most common cognitive impairment among head-injured people—occurs in 20% to 79% of people with closed head trauma, depending on injury severity.3 People who have suffered TBI may have difficulty understanding or producing spoken or written language, or with more subtle aspects of communication, such as body language.
TBI may cause emotional or behavioral problems and personality changes. Mood and affect changes are common. TBI predisposes patients to obsessive-compulsive disorder, substance abuse, dysthymia, clinical depression, bipolar disorder, phobias, panic disorder, and schizophrenia.4 Frontal lobe injuries have been correlated with disinhibition and inappropriate or childish behavior, and temporal lobe injuries with irritability and aggression.5
Table 1
TBI symptoms correspond to area of injury
| Area of injury | Motor/sensory | Psychiatric/behavioral | Cognitive |
|---|---|---|---|
| Brain stem | Decreased vital capacity in breathing, dysphagia | Sleep difficulties | Inability to categorize objects, difficulty with organization |
| Frontal lobe | Aphasia, praxis | Disinhibition, personality changes | Impaired executive function |
| Cerebellum | Nystagmus, tremor | Labile emotions | Inability to process information |
| Parietal lobe | Apraxia | Personality changes | Neglect |
| Occipital lobe | Visual field cuts; diminished proprioception | Visual hallucinations | Color agnosia; inability to recognize words; difficulty reading, writing, and recognizing drawn objects |
| Temporal lobe | Seizure | Libido changes, humorless verbosity, aggression, olfactory perceptual changes | Prosopagnosia, aphasia, agnosia, memory loss, inattention |
| TBI: traumatic brain injury | |||
| Source: Reference 2 | |||
TBI and the insanity defense
The M’Naghten Rule of 1843 requires that for an insanity defense, the defendant must have a mental disease or defect that causes him not to know the nature and quality or the wrongfulness of his act.6 TBI is an abnormal condition of the mind leading to a mental disease that can substantially affect control of emotions and behaviors.
Nevertheless, TBI-induced criminality remains controversial.7 Theories on the etiology of impulse dyscontrol resulting from TBI have suggested structural damage to the brain and altered neurotransmitters. In TBI, the amygdala—which is located within the anterior temporal lobe and adjoins emotions to thoughts—often is injured. Damage to this structure leads to poor impulse control and violent behavior. Damage to specific neurotransmitter systems that causes elevated norepinephrine and dopamine levels and reduced serotonin levels have also been implicated as a cause of impulse dyscontrol in TBI patients.8
In theory, TBI patients potentially could have enough cognitive impairment to have a substantial lack of appreciation of the criminality or wrongfulness of an act. TBI-related impulsivity and cognitive impairment can lead to recklessness and negligence.9 The U.S. Supreme Court has acknowledged that CNS dysfunction affects judgment, reality testing, and self-control.10
EVALUATION: Vague answers
To determine whether Mr. P’s defense is plausible, the forensic psychiatrist must pay attention to the details of the patient’s presentation and history. During the interview, Mr. P quickly shifts from cooperative to obstinate and restricted. He ruminates on the head injury causing him to suffer auditory hallucinations, which he claims he always obeys. Mr. P refuses to provide details of the hallucinations, however, and answers most questions about the head injury or his defense with vague answers, including “I don’t know.”
Because of Mr. P’s reluctance to share information, his lack of psychiatric symptoms other than those he self-reports, and the presence of potential secondary gain from an NGRI defense, the psychiatrist begins to suspect malingering.
The authors’ observations
Malingering is a condition—not a diagnosis—characterized by intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives.11 The presence of external incentives distinguishes malingering from psychiatric illnesses such as factitious and somatoform disorders, in which there is no apparent external incentive. Malingering of psychiatric symptoms occurs in up to 20% of forensic patients, 5% of military recruits, and 1% of mental health patients.5 Stimuli for malingering range from seeking food and shelter to avoiding criminal responsibility ( Table 2 ). Malingering is more common in individuals being evaluated for criminal responsibility than for competence to stand trial. The 3 categories of malingering are:
Table 2
Common external incentives for malingering
| Evading criminal responsibility |
| Disability claims/financial gain |
| Avoiding military duty |
| Evading work |
| Obtaining drugs |
| Seeking food/shelter |
- pure malingering—feigning a nonexistent disorder
- partial malingering—consciously exaggerating real symptoms
- false imputation—ascribing real symptoms to a cause the individual knows is unrelated to the symptoms.12
Determining if a defendant with a history of TBI is malingering requires a multi-step approach that encompasses the clinical interview, a thorough review of collateral data, and focused psychological testing. In interviews, psychiatrists detect approximately 50% of lies, which is no better than would be discovered by chance.13 If you suspect a patient is malingering, combine a structured clinical interview with collateral sources such as old hospital records, treatment history, insurance records, police reports, and interviews with close family and friends.
TBI patients’ poor cognition, memory deficits, and inattention will prove challenging. Malingering patients who attempt to capitalize on a pre-existing TBI to evade responsibility for a current criminal charge may grossly exaggerate or even fake intellectual deficits. Be patient with such defendants and remain aware that such people will give vague or hedging answers to straightforward questions, often accompanied by “I don’t know.” Prolonging the interview may be helpful because it may fatigue a defendant who is faking.12
Some patients who malinger after sustaining a TBI will attempt to feign psychotic symptoms. Table 3 14 illustrates criteria for assessing a patient suspected of malingering psychosis and Table 4 14 highlights atypical psychotic symptoms that suggest feigning illness. Malingering of psychosis can be both assessed in the interview and through testing.
Table 3
Criteria for malingered psychosis
| A. Understandable motive to malinger |
| B. Marked variability of presentation as evidenced by ≥1 of the following: 1. Marked discrepancies in interview and non-interview behaviors 2. Gross inconsistencies in reported psychotic symptoms 3. Blatant contradictions between reported prior episodes and documented psychiatric history |
| C. Improbable psychiatric symptoms as evidenced by ≥1 of the following: 1. Reporting elaborate psychotic symptoms that lack common paranoid, grandiose, or religious themes 2. Sudden emergence of purported symptoms to explain antisocial behavior 3. Atypical hallucinations and delusions |
| D. Confirmation of malingering by either: 1. Admission of malingering following confrontation, or 2. Presence of strong corroborative information, such as psychometric data or history of malingering |
| Source: Reference 14 |
Table 4
Atypical psychotic symptoms that suggest malingering
| Hallucinations |
| Continuous rather than intermittent |
| Vague or inaudible auditory hallucinations |
| Stilted language reported in hallucinations |
| Inability to state strategies to diminish voices |
| Self-report that all command hallucinations were obeyed |
| Visual hallucinations in black and white |
| Delusions |
| Abrupt onset or termination |
| Eagerness to call attention to delusions |
| Conduct markedly inconsistent with delusions |
| Bizarre content without disordered thinking |
| Source: Reference 14 |
Psychological testing
Several standardized diagnostic instruments can be used to help determine whether a patient is feigning or exaggerating psychotic symptoms or cognitive impairments ( Table 5 ). Testing for a patient such as Mr. P—who attributes any criminal wrongdoing to psychosis and also cites limited cognition as a reason for trouble in the interview—would include personality tests, tests to assess exaggerations of psychosis, and cognitive tests.
In the forensic setting, the preferred personality test is the MMPI-2.15 It consists of 567 items, with 10 clinical scales and several validity scales. The F scale, “faking good” or “faking bad,” detects people who are answering questions with the goal of appearing better or worse than they actually are. The Personal Assessment Inventory (PAI)16 is a 344-item test with a 4-point response format. The 22 scales cover a range of important axis I and II psychopathology.
SIRS17 is the gold standard in detecting malingered psychiatric illness; it includes questions about rare symptoms and uncommon symptom pairing. M-FAST18 was developed to provide a brief, reliable screen for malingered mental illness. It has shown good validity and high correlation with the SIRS and MMPI-2.
Tests of exaggerated cognitive impairment are extremely important in evaluating patients who claim to suffer from complications following TBI. TOMM19 —a 50-item recognition test designed to discriminate between true memory-impaired patients and malingerers—is the most studied and valid of such tests. Defendants’ scores that meet the recommended criteria for detecting malingering—≥5 errors on the retention trial—were found to also report a history of head injury.1
Although not as well validated, the Portland Digit Recognition Test (PDRT)20 is an alternative to the TOMM. This test is a forced-choice measure of recognition designed for assessing the possibility of malingering in individuals claiming mental illness because of head injury. The Victoria Symptoms Validity Test (VSVT)21 is used in outpatient and inpatient settings and also uses a forced-choice model to assess possible exaggeration or feigning of cognitive impairments. Finally, the Word Memory Test (WMT)22 is a neuropsychological assessment that evaluates the effort participants put forth.
Table 5
Standardized diagnostic instruments for detecting malingering
| Test | Clinical use |
|---|---|
| Personality | |
| MMPI-2 | F scale detects lying. Several validity scales |
| PAI | Covers a range of axis I and II psychopathology |
| Psychotic symptoms | |
| SIRS | Gold standard in detecting exaggerated psychotic symptoms |
| M-FAST | Screening tool to assess exaggerated psychosis; brief and reliable |
| Cognitive impairment | |
| TOMM | Highest validity of all tools to test memory malingering |
| PDRT | Assesses the possibility of malingering. Not widely studied and validity/reliability are suspect |
| VSVT | Useful for inpatient and outpatient settings |
| WMT | Evaluates effort put forth by the participant |
| M-FAST: Miller Forensic Assessment of Symptoms Test; MMPI-2: Minnesota Multiphasic Personality Inventory; PAI: Personal Assessment Inventory; PDRT: Portland Digit Recognition Test; SIRS: Structured Interview of Reported Symptoms; TOMM: Test of Memory Malingering; VSVT: Victoria Symptoms Validity Test; WMT: Word Memory Test | |
OUTCOME: Unsupported claims
Mr. P’s hospital records reveal a very minor head trauma that resulted in no structural brain abnormalities on imaging tests. Collateral interviews with Mr. P’s family and close friends fail to support the defendant’s claim that after the accident he began to experience behavioral changes and periods of psychosis. Mr. P’s SIRS and TOMM scores indicate malingering, and the psychiatrist did not support his NGRI defense.
Related resource
- Williamson DJ. Neurocognitive impairment: feigned, exaggerated, or real? Current Psychiatry. 2007;6(8):19-37.
Disclosure
Dr. Nasrallah receives research grant/research support from Forest Pharmaceuticals, GlaxoSmithKline, Janssen, Otsuka America Pharmaceuticals, Pfizer Inc., Roche, sanofi-aventis, and Shire, is on the advisory board of Abbott Laboratories, AstraZeneca, Janssen, Novartis, Pfizer Inc., and Merck, and is on the speakers’ bureau for Abbott Laboratories, AstraZeneca, Janssen, Novartis, Pfizer Inc., and Merck.
Dr. Farrell reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
CASE: Self-reported TBI
When charged with raping a 19-year-old woman, Mr. P, age 32, pleads not guilty by reason of insanity (NGRI). He has a self-reported history of traumatic brain injury (TBI) and claims that since suffering a blow to the head 8 years before the rape, he has experienced episodes of personality changes, psychosis, and violent behavior. Mr. P is adamant that any wrongdoing on his part was beyond his control, and he argues that consequences of the brain injury, such as hallucinations and aggressive behavior, had recently emerged. The court asks that a forensic psychiatrist evaluate Mr. P.
An only child, Mr. P was raised by his mother in an inner city area. His father was dependent on alcohol and cocaine and abandoned the family shortly after Mr. P’s birth. Mr. P abuses alcohol, as evidenced by previous driving under the influence charges, but denies illicit drug use. He graduated from high school with average grades and denies a history of disciplinary action at school or home. Although Mr. P was charged with misdemeanors in his late teens, the sexual assault is his first felony charge. Mr. P describes himself as a “charmer.”
After high school, Mr. P worked full-time in construction, where he claims he suffered a traumatic blow to the head. Despite this injury, he continued to work and socialize and never sought treatment at a mental health clinic.
The authors’ observations
Although defendants may legitimately suffer from TBI and resultant complications, many individuals capitalize on a history of minor head injury to support their NGRI defense.1 Forensic psychiatrists must retain a healthy degree of clinical suspicion for malingering in defendants who claim NGRI as a result of complications from brain injury, especially when the injury and complications are not documented and simply patient-reported.
TBI is a CNS injury that occurs when an outside force traumatically injures the brain and can cause a variety of physical, cognitive, emotional, and behavioral effects ( Table 1 ).2 Cognitive deficits include:
- impaired attention
- disrupted insight
- poor judgment
- thought disorders.
Reduced processing speed, distractibility, and deficits in executive functions such as abstract reasoning, planning, problem solving, and multitasking have been documented. Memory loss—the most common cognitive impairment among head-injured people—occurs in 20% to 79% of people with closed head trauma, depending on injury severity.3 People who have suffered TBI may have difficulty understanding or producing spoken or written language, or with more subtle aspects of communication, such as body language.
TBI may cause emotional or behavioral problems and personality changes. Mood and affect changes are common. TBI predisposes patients to obsessive-compulsive disorder, substance abuse, dysthymia, clinical depression, bipolar disorder, phobias, panic disorder, and schizophrenia.4 Frontal lobe injuries have been correlated with disinhibition and inappropriate or childish behavior, and temporal lobe injuries with irritability and aggression.5
Table 1
TBI symptoms correspond to area of injury
| Area of injury | Motor/sensory | Psychiatric/behavioral | Cognitive |
|---|---|---|---|
| Brain stem | Decreased vital capacity in breathing, dysphagia | Sleep difficulties | Inability to categorize objects, difficulty with organization |
| Frontal lobe | Aphasia, praxis | Disinhibition, personality changes | Impaired executive function |
| Cerebellum | Nystagmus, tremor | Labile emotions | Inability to process information |
| Parietal lobe | Apraxia | Personality changes | Neglect |
| Occipital lobe | Visual field cuts; diminished proprioception | Visual hallucinations | Color agnosia; inability to recognize words; difficulty reading, writing, and recognizing drawn objects |
| Temporal lobe | Seizure | Libido changes, humorless verbosity, aggression, olfactory perceptual changes | Prosopagnosia, aphasia, agnosia, memory loss, inattention |
| TBI: traumatic brain injury | |||
| Source: Reference 2 | |||
TBI and the insanity defense
The M’Naghten Rule of 1843 requires that for an insanity defense, the defendant must have a mental disease or defect that causes him not to know the nature and quality or the wrongfulness of his act.6 TBI is an abnormal condition of the mind leading to a mental disease that can substantially affect control of emotions and behaviors.
Nevertheless, TBI-induced criminality remains controversial.7 Theories on the etiology of impulse dyscontrol resulting from TBI have suggested structural damage to the brain and altered neurotransmitters. In TBI, the amygdala—which is located within the anterior temporal lobe and adjoins emotions to thoughts—often is injured. Damage to this structure leads to poor impulse control and violent behavior. Damage to specific neurotransmitter systems that causes elevated norepinephrine and dopamine levels and reduced serotonin levels have also been implicated as a cause of impulse dyscontrol in TBI patients.8
In theory, TBI patients potentially could have enough cognitive impairment to have a substantial lack of appreciation of the criminality or wrongfulness of an act. TBI-related impulsivity and cognitive impairment can lead to recklessness and negligence.9 The U.S. Supreme Court has acknowledged that CNS dysfunction affects judgment, reality testing, and self-control.10
EVALUATION: Vague answers
To determine whether Mr. P’s defense is plausible, the forensic psychiatrist must pay attention to the details of the patient’s presentation and history. During the interview, Mr. P quickly shifts from cooperative to obstinate and restricted. He ruminates on the head injury causing him to suffer auditory hallucinations, which he claims he always obeys. Mr. P refuses to provide details of the hallucinations, however, and answers most questions about the head injury or his defense with vague answers, including “I don’t know.”
Because of Mr. P’s reluctance to share information, his lack of psychiatric symptoms other than those he self-reports, and the presence of potential secondary gain from an NGRI defense, the psychiatrist begins to suspect malingering.
The authors’ observations
Malingering is a condition—not a diagnosis—characterized by intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives.11 The presence of external incentives distinguishes malingering from psychiatric illnesses such as factitious and somatoform disorders, in which there is no apparent external incentive. Malingering of psychiatric symptoms occurs in up to 20% of forensic patients, 5% of military recruits, and 1% of mental health patients.5 Stimuli for malingering range from seeking food and shelter to avoiding criminal responsibility ( Table 2 ). Malingering is more common in individuals being evaluated for criminal responsibility than for competence to stand trial. The 3 categories of malingering are:
Table 2
Common external incentives for malingering
| Evading criminal responsibility |
| Disability claims/financial gain |
| Avoiding military duty |
| Evading work |
| Obtaining drugs |
| Seeking food/shelter |
- pure malingering—feigning a nonexistent disorder
- partial malingering—consciously exaggerating real symptoms
- false imputation—ascribing real symptoms to a cause the individual knows is unrelated to the symptoms.12
Determining if a defendant with a history of TBI is malingering requires a multi-step approach that encompasses the clinical interview, a thorough review of collateral data, and focused psychological testing. In interviews, psychiatrists detect approximately 50% of lies, which is no better than would be discovered by chance.13 If you suspect a patient is malingering, combine a structured clinical interview with collateral sources such as old hospital records, treatment history, insurance records, police reports, and interviews with close family and friends.
TBI patients’ poor cognition, memory deficits, and inattention will prove challenging. Malingering patients who attempt to capitalize on a pre-existing TBI to evade responsibility for a current criminal charge may grossly exaggerate or even fake intellectual deficits. Be patient with such defendants and remain aware that such people will give vague or hedging answers to straightforward questions, often accompanied by “I don’t know.” Prolonging the interview may be helpful because it may fatigue a defendant who is faking.12
Some patients who malinger after sustaining a TBI will attempt to feign psychotic symptoms. Table 3 14 illustrates criteria for assessing a patient suspected of malingering psychosis and Table 4 14 highlights atypical psychotic symptoms that suggest feigning illness. Malingering of psychosis can be both assessed in the interview and through testing.
Table 3
Criteria for malingered psychosis
| A. Understandable motive to malinger |
| B. Marked variability of presentation as evidenced by ≥1 of the following: 1. Marked discrepancies in interview and non-interview behaviors 2. Gross inconsistencies in reported psychotic symptoms 3. Blatant contradictions between reported prior episodes and documented psychiatric history |
| C. Improbable psychiatric symptoms as evidenced by ≥1 of the following: 1. Reporting elaborate psychotic symptoms that lack common paranoid, grandiose, or religious themes 2. Sudden emergence of purported symptoms to explain antisocial behavior 3. Atypical hallucinations and delusions |
| D. Confirmation of malingering by either: 1. Admission of malingering following confrontation, or 2. Presence of strong corroborative information, such as psychometric data or history of malingering |
| Source: Reference 14 |
Table 4
Atypical psychotic symptoms that suggest malingering
| Hallucinations |
| Continuous rather than intermittent |
| Vague or inaudible auditory hallucinations |
| Stilted language reported in hallucinations |
| Inability to state strategies to diminish voices |
| Self-report that all command hallucinations were obeyed |
| Visual hallucinations in black and white |
| Delusions |
| Abrupt onset or termination |
| Eagerness to call attention to delusions |
| Conduct markedly inconsistent with delusions |
| Bizarre content without disordered thinking |
| Source: Reference 14 |
Psychological testing
Several standardized diagnostic instruments can be used to help determine whether a patient is feigning or exaggerating psychotic symptoms or cognitive impairments ( Table 5 ). Testing for a patient such as Mr. P—who attributes any criminal wrongdoing to psychosis and also cites limited cognition as a reason for trouble in the interview—would include personality tests, tests to assess exaggerations of psychosis, and cognitive tests.
In the forensic setting, the preferred personality test is the MMPI-2.15 It consists of 567 items, with 10 clinical scales and several validity scales. The F scale, “faking good” or “faking bad,” detects people who are answering questions with the goal of appearing better or worse than they actually are. The Personal Assessment Inventory (PAI)16 is a 344-item test with a 4-point response format. The 22 scales cover a range of important axis I and II psychopathology.
SIRS17 is the gold standard in detecting malingered psychiatric illness; it includes questions about rare symptoms and uncommon symptom pairing. M-FAST18 was developed to provide a brief, reliable screen for malingered mental illness. It has shown good validity and high correlation with the SIRS and MMPI-2.
Tests of exaggerated cognitive impairment are extremely important in evaluating patients who claim to suffer from complications following TBI. TOMM19 —a 50-item recognition test designed to discriminate between true memory-impaired patients and malingerers—is the most studied and valid of such tests. Defendants’ scores that meet the recommended criteria for detecting malingering—≥5 errors on the retention trial—were found to also report a history of head injury.1
Although not as well validated, the Portland Digit Recognition Test (PDRT)20 is an alternative to the TOMM. This test is a forced-choice measure of recognition designed for assessing the possibility of malingering in individuals claiming mental illness because of head injury. The Victoria Symptoms Validity Test (VSVT)21 is used in outpatient and inpatient settings and also uses a forced-choice model to assess possible exaggeration or feigning of cognitive impairments. Finally, the Word Memory Test (WMT)22 is a neuropsychological assessment that evaluates the effort participants put forth.
Table 5
Standardized diagnostic instruments for detecting malingering
| Test | Clinical use |
|---|---|
| Personality | |
| MMPI-2 | F scale detects lying. Several validity scales |
| PAI | Covers a range of axis I and II psychopathology |
| Psychotic symptoms | |
| SIRS | Gold standard in detecting exaggerated psychotic symptoms |
| M-FAST | Screening tool to assess exaggerated psychosis; brief and reliable |
| Cognitive impairment | |
| TOMM | Highest validity of all tools to test memory malingering |
| PDRT | Assesses the possibility of malingering. Not widely studied and validity/reliability are suspect |
| VSVT | Useful for inpatient and outpatient settings |
| WMT | Evaluates effort put forth by the participant |
| M-FAST: Miller Forensic Assessment of Symptoms Test; MMPI-2: Minnesota Multiphasic Personality Inventory; PAI: Personal Assessment Inventory; PDRT: Portland Digit Recognition Test; SIRS: Structured Interview of Reported Symptoms; TOMM: Test of Memory Malingering; VSVT: Victoria Symptoms Validity Test; WMT: Word Memory Test | |
OUTCOME: Unsupported claims
Mr. P’s hospital records reveal a very minor head trauma that resulted in no structural brain abnormalities on imaging tests. Collateral interviews with Mr. P’s family and close friends fail to support the defendant’s claim that after the accident he began to experience behavioral changes and periods of psychosis. Mr. P’s SIRS and TOMM scores indicate malingering, and the psychiatrist did not support his NGRI defense.
Related resource
- Williamson DJ. Neurocognitive impairment: feigned, exaggerated, or real? Current Psychiatry. 2007;6(8):19-37.
Disclosure
Dr. Nasrallah receives research grant/research support from Forest Pharmaceuticals, GlaxoSmithKline, Janssen, Otsuka America Pharmaceuticals, Pfizer Inc., Roche, sanofi-aventis, and Shire, is on the advisory board of Abbott Laboratories, AstraZeneca, Janssen, Novartis, Pfizer Inc., and Merck, and is on the speakers’ bureau for Abbott Laboratories, AstraZeneca, Janssen, Novartis, Pfizer Inc., and Merck.
Dr. Farrell reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Delain SL, Stafford KP, Yosef SB. Use of the TOMM in a criminal court forensic assessment setting. Assessment. 2003;10(4):370-381.
2. Rao V, Lyketsos C. Neuropsychiatric sequelae of traumatic brain injury Psychosomatics. 2000;41:95-103.
3. Hall RC, Hall RC, Chapman MJ. Definition, diagnosis, and forensic implications of postconcussional syndrome. Psychosomatics. 2005;46(3):195-202.
4. Arlinghaus KA, Shoaib AM, Price TRP. Neuropsychiatric assessment. In: Silver JM, McAllister TW, Yudofsky SC. Textbook of traumatic brain injury. Arlington, VA: American Psychiatric Publishing, Inc.; 2005:63-65.
5. West S, Noffsinger S. Is this patient not guilty by reason of insanity? Current Psychiatry. 2005;5(8):54-62.
6. Barzman D, Kennedy J, Fozdar M. Does traumatic brain injury cause violence? Current Psychiatry. 2002;1(4):49-55.
7. Silver JM, Yudofsky SC, Hales RE. Neuropsychiatry of traumatic brain injury. Washington, DC: American Psychiatric Press, Inc.; 1994.
8. Melton GB, Petrila J, Poythress NG, et al. Psychological evaluations for the courts. New York, NY: The Guilford Press; 1997.
9. Lewis DO, Pincus JH, Feldman M, et al. Psychiatric, neurological, and psychoeducational characteristics of 15 death row inmates in the United States. Am J Psychiatry. 1986;143:838-845.
10. Diagnostic and statistical manual of mental disorders, 4th ed, text revision. Washington, DC: American Psychiatric Association; 2000.
11. Sadock VA. Kaplan and Sadock’s synopsis of psychiatry. Philadelphia, PA: Lippincott, Williams, and Wilkins; 2007:887.
12. Resnick PJ. Faking it: how to determine malingered psychosis. Current Psychiatry. 2005;4(11):12-25.
13. Samuel RZ, Mittenberg W. Determination of malingering in disability claims. Primary Psychiatry. 2005;12(12):60-68.
14. Resnick PJ. Malingered psychosis. In: Rogers R, ed. Clinical assessment of malingering. 2nd ed. New York, NY: The Guilford Press; 1997:47-67.
15. Hathaway SR, McKinley JC. The Minnesota Multiphasic Personality Inventory-2. Minneapolis, MN: University of Minnesota Press; 1989.
16. Rogers R, Sewell KW, Morey LC, et al. Detection of feigned mental disorder on the personality assessment inventory: a discriminate analysis. J Pers Assess. 1996;67:629-640.
17. Rogers R, Bagby RM, Dickens SE. Structured Interview of Reported Symptoms (SIRS). Lutz, FL: Psychological Assessment Resources; 1992.
18. Miller H. Miller Forensic Assessment of Symptoms Test (M-FAST). Professional Manual. Lutz, FL: Psychological Assessment Resources; 2001.
19. Tombaugh TN. The Test of Memory Malingering. Toronto, ON, Canada: Multi-Health Systems; 1996.
20. Binder LM. Malingering following minor head trauma. Clin Neuropsychol. 1990;4:25-36.
21. Slick D, Hopp G, Strauss E, et al. Victoria Symptom Validity Test professional manual. Lutz, FL: Psychological Assessment Resources; 1997.
22. Green P. Word Memory Test. Edmonton, Alberta, Canada: Green’s Publishing; 2003.
1. Delain SL, Stafford KP, Yosef SB. Use of the TOMM in a criminal court forensic assessment setting. Assessment. 2003;10(4):370-381.
2. Rao V, Lyketsos C. Neuropsychiatric sequelae of traumatic brain injury Psychosomatics. 2000;41:95-103.
3. Hall RC, Hall RC, Chapman MJ. Definition, diagnosis, and forensic implications of postconcussional syndrome. Psychosomatics. 2005;46(3):195-202.
4. Arlinghaus KA, Shoaib AM, Price TRP. Neuropsychiatric assessment. In: Silver JM, McAllister TW, Yudofsky SC. Textbook of traumatic brain injury. Arlington, VA: American Psychiatric Publishing, Inc.; 2005:63-65.
5. West S, Noffsinger S. Is this patient not guilty by reason of insanity? Current Psychiatry. 2005;5(8):54-62.
6. Barzman D, Kennedy J, Fozdar M. Does traumatic brain injury cause violence? Current Psychiatry. 2002;1(4):49-55.
7. Silver JM, Yudofsky SC, Hales RE. Neuropsychiatry of traumatic brain injury. Washington, DC: American Psychiatric Press, Inc.; 1994.
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