Factors Contributing to the Development of Pathological Gambling
Some individuals, however, use humor as an unhealthy way to avoid conflict. Representative Patrick Kennedy and his Congressional staff. And then, when the tears dry, nothing is ever said again about the words of her outburst. He eventually appealed the death sentence on grounds of current and chronic mental illness which rendered him unable ". Feel the pain for the sake of your sanity. In ancient times, the term victim referred to an animal offered in sacrifice.
Build a bibliography or works cited page the easy way
Annette Reynolds and Douglas Mossman provides helpful guidance. Psychiatrists, psychologists, and other professionals should already know to be cautious with patient-related email and texting, but patients themselves often initiate risky email communication, sending doctors and therapists detailed, confidential, or time-sensitive information in the unwarranted belief that their email will only be seen by the clinician, and will be read at once.
When one receives such messages, it's a good idea to respond generically that such topics will not be discussed or considered by email or text, highlight the confidentiality risks and others; see below , and require a telephone or face-to-face interaction in order to proceed. First, the security issues. Neither the clinician nor the patient knows who may have access to unencrypted email. One may be not be communicating with the patient at all, but with a family member or friend using his computer.
Server operators can — but usually don't — intercept and read messages. At the clinician's end, unless precautions are taken, emails may be opened and read by office staff and others. And we all know about illegally "spoofed" email addresses. At the least, clinicians should have a dedicated professional email account that is not combined with other uses.
Get patients' explicit written is best consent before using email communication. That consent should, among other things, notify the patient of the security risks, discuss expected reading and response times, outline what is and is not appropriate for both subject lines and the body of messages, and disclose who has known access to your email account.
Let patients know that they must not rely on email for things like urgent matters and sensitive or confidential topics. Anything that requires multiple email exchanges should probably be addressed in person or by phone.
Reading and response time is a big deal. Both doctors and patients must understand that there is no assurance that an email will be promptly read and dealt with. Finally, remember that email or text communication creates the same clinician duties and responsibilities as does any other form of communication. Answering clinically-related emails from a non-patient may inadvertently create a new doctor-patient relationship, with all its attendant duties. Information given, responses considered, and decisions made on the basis of email communication must comply with clinical standards of care.
Read the article for yourself; it's shorter than the page numbers imply. Reynolds A, Mossman D . Before you hit "SEND": Will an email to your patient put you at legal risk? I continue to be very disappointed that acutely depressed and suicidal patients rarely have opportunity for electroconvulsive therapy ECT. In my malpractice cases that involve suicide — the majority of such cases and the number one malpractice cause of action against psychiatrists and psychiatric hospitals — ECT, one of the fastest, best and safest treatments, has rarely been adequately considered.
The psychiatric literature is currently touting ketamine treatment for major depressive episodes. In spite of lack of proof of lasting benefit, and being fraught with potential for adverse effects, some authors want to place a ketamine trial before ECT in treatment algorythms.
Other authorities — cooler heads, in my view — don't recommend that see, e. A word to the wise about ketamine. Am J Psychiatry Kellner and others, experts in ECT, succinctly outline the fact that ECT is a proven, standard treatment; ketamine is not Kellner et al.
Am J Psychiatry : Failure to adequately consider ECT in acute, potentially suicidal depression is routinely below the standard of care. This treatment saves lives, and an ECT consultation goes a long way toward showing that the treating clinician has exercised good judgment in patient care and risk mitigation. Assessing Risk of Violence: I recently read an article that brought up an old, but continuing, problem inherent in acronym-based checklists for assessing violence risk or risk of suicide for that matter.
Such acronyms rarely differentiate highly important or critical risk factors from those that are much less useful. Without meaning to castigate Drs. Newman and Xiong, who were no doubt trying to encourage clinicians to think about a broad range of risk factors when evaluating patients or clients for violence risk, their acronym — DISTURBED — unfortunately mixes important risk factors with relatively unimportant ones, and doesn't prioritize the items.
Some of their factors are virtually useless when assessing individual risk as contrasted with statistical risk among large groups. Correlation, after all, is a large-group statistic. Further, correlations of violence with the demographics mentioned are generally low although positive anyway.
That's a lot of false positives. It's also an opportunity to downplay real risk in people who don't fit the demographic model. My point is that if one is trying to assess individual risk of violence, or trying to develop a screening instrument to help in that effort, it is crucial to pay far more attention to factors that are very highly correlated with violence and often should simply block out less important factors than to those with little predictive value in one person.
In addition, anyone asked to evaluate risk of violence should first ask what kind of violence is being contemplated, and in what context. Suicide is far and away the most common cause of action in malpractice lawsuits against psychiatrists and other mental health clinicians and entities. The civil portion of my forensic practice is filled with clinicians accused of being negligent in assessing or managing suicide risk, whose alleged negligence allowed — or was said to have caused — a preventable suicide.
The most vulnerable defendants are those who fail to provide adequate assessment and protection for patients at acute risk, but I am continually amazed at the number of both acutely and chronically suicidal patients who don't receive the psychotherapy that could really help them, could lower their risk, and could decrease their psychiatrists' risk of malpractice suits and the heartache that comes from having a patient kill himself or herself.
The fact is, competent counselors and psychotherapists should know the kinds of therapy that often work with suicidal patients. The research is there, and has been well-known for many years. Good training programs teach it. Continuing education programs regularly feature the counseling techniques that can save lives and save quality of life.
It's just not rocket science! Cognitive-behavioral therapy CBT is one of the best, most reliable, and most studied treatment formats for many suicidal patients, and for many of the disorders — such as severe depression and anxiety — associated with suicide. A quick search of the professional literature try the National Library of Medicine at http: Yet few of the hospitals or clinicians whose suicide-related cases I review have used CBT, or used it competently.
Here's what I'm not talking about: I'm not talking about the kind of counseling or so-called "therapy" that most hospitals and many practitioners rely on for patients with thoughts of killing themselves. Virtually every psychiatric hospital and partial hospital program I know of from clinical experience or from tragic forensic cases gives all patients the same, cookie-cutter group "therapy" that's rarely therapy at all.
I'm tired of seeing completely generic groups that focus on "daily living," "activities," and supportive counseling being sold to patients, families, and insurance companies as if they were "individualized treatment" for patients who need specific, truly individualized care in order to address their mental disorders and reduce their suicide risk.
Psychiatric hospitals should not merely be protective places to wait for the medication to take effect. If you're a clinician, advocate for much broader and better care for your patients. If you're a patient or a member of a patient's family, ask questions about the kind of counseling that's being used, and the qualifications of the counselors who provide it. The Effect of Suicide on Treating Psychiatrists. There's a great article in January, , issue of The Atlantic on suicide and, in part, its effect on treating psychiatrists.
It's not really "forensic," but it's a very good, non-technical, read. A recent thoughtful presentation by Dr. Paul Applebaum to the American Association of Psychiatric Administrators was so full of important facts about mental illness and violence that I wanted to bring some of them to the website. What follows in the next few vignettes are some of Dr. Applebaum's points, blended with other information and a few of my own observations.
Mental Illness and Violence. In the aggregate which excepts multiple murders — which in turn are very rare compared with other killings , violence by mental patients looks the same as violence by people in the general population.
The rates, kinds of victims, demographics, rationales for the acts, etc. One important consideration is substance abuse primarily intoxication and drug-seeking behaviors.
As it turns out, intoxication and drug seeking affect violence statistics for the general population and persons with mental disorders in the same way: There are two primary kinds of multiple murders: School shootings may involve mental illness in many — not all — cases, but it is important to remember that, in spite of their enormous publicity, they are extremely rare and a tiny portion of U.
New York's very large, very comprehensive, and very unwieldy SAFE Act requires that all firearms sales and transfers, public or private, go through a federally licensed firearms dealer. That dealer must do the federally-required background check of the purchasrr or recipient. New York also requires all health or mental heal professionals who evaluate or treat a suicidal or homocidal person to report that person, by name, to the NY Office of Mental Health website.
Reporting is mandatory, though there are provisions that indemnify clinicians for good faith reporting or decisions that a patient is not eligible for reporting.
The names reported to OMH are checked against the names of persons who own licensed handguns or "assault weapons" however those are defined , after which any matched names are forwarded to a law enforcement agency in the person's community. What law enforcement does with the information is up to each agancy but, as Dr.
Applebaum points out, such a procedure is rife with opportunity for discrimination and heavy-handed government control. In addition, it interferes substantially with access to menatl health care, and with clinicians' efforts to help people with psychiatric disorders. Physicians licensed in Illinois know that a new statute regarding concealed carry of handguns contains a draconian in my opinion requirement that physicians and others must report patients who they determine present a "clear and present danger" to themselves or others, or are simply "developmentally disabled" or "intellectually disabled.
Florida's recent so-called "gag order" statute, that forbade clinicians from asking patients and their families whether or not there were guns in their homes, has reportedly been overturned on First Amendment grounds, and in any event is apparently not being enforced. The law, originally supported by misguided gun rights and privacy advocates, applied to, among other professionals, psychiatrists, psychologists, pediatricians concerned about child and family safety. Indiana has a new statute that allows police to confiscate any form of firearms from people they deem a threat to themselves or others.
The intent is apparently to allow law enforcement personnel who encounter high risk of domestic violence or suicide to temporarily remove the guns and decrease the risk of serious injury or death. In spite of the apparent opportunity to advocate for better mental health services, it is counterproductive to "use" such tragedies as the shootings at Newtown, CT; Columbine, CO; Ft.
To do so enhances the media's marked misconstruing of both the role of mental illness in U. Short-term gains in funding, if they come, from riding a groundswell of misguided impressions could well be at the unacceptable cost of increased, unfair stigmatization of an enormous group of people whom we have worked hard to better understand, help, and de-stigmatize for over a century.
The authors note that although women are traditionally considered less aggressive than men, those with severe mental illness have similar violence potential but appear to resort to violence less often. Women who commit violent crime "are violating social and psychological norms to a much higher extent that their male counterparts.
The most striking difference between the male and female groups was in the ages of their victims. All of the men's victims in this sample were adults. Three-quarters of the males' victims were outside the perpetrators' families, compared to ouly about a third of the females' victims a result confounded by the large number of child victims.
Women were much more likely to have borderline personality disorder; however, that diagnosis is rarely applied to men in any event. There were no real differences in race or education. About two-thirds of the men had never been married, compared with one-third of the women again, a finding confounded by the nature of the victims.
The authors' discussion of their findings is important to understanding their data. For example, many of the characteristics summarized are either unevenly distributed between non-offending males and females or confounded by victim or offense characteristics, and males who plead insanity may fare differently at trial than females.
For details, consult the original paper in the Journal of the American Academy of Psychiatry and the Law. Characteristics of female homicide offenders found not guilty by reason of insanity. J Am Acad Psychiatry Law 41: Abolish the Insanity Defense?
Morse and Richard J. Bonnie have published a thoughtful paper in the Journal of the American Academy of Psychiatry and the Law rebutting the frequent calls from several quarters to abolish the insanity defense. Some of their arguments are already summarized elsewhere on this website, but one — that considering mens rea in lieu of an affirmative insanity defense is fundamentally unfair and unconstitutional — has not been discussed here.
During the s and s, a few states experimented with abolishing the affirmative defense of insanity. Idaho substituted statutory wording allowing criminal defendants to allege that they lacked the mental intent mens rea required to be convicted of a crime. Idaho's statute has been affirmed by virtue of the U.
Supreme Court's denying certiori on appeal Dwelling v. Idaho , S. That substitution appears on its surface to give adequate attention to the due process clause of the Fifth Amendment, but the authors argue that it is "fundamentally unfair" for the State to convict and impose punishment on persons not responsible for their otherwise criminal behavior by depriving defendants of an affirmative insanity defense. Negation of mens rea , the authors write, is legally consitiutionally different from a successful insanity defense rare in any iteration — and thus not a substantial State interest from a public safety viewpoint — but very important to justice and preservation of civil rights.
In particular, the concept of mens rea as contemplated in this sense cf. Public opposition to the insanity defense is almost always based on lack of knowledge about its Constitutional underpinnings, inherent fairness, rarity of use, rarity of success, and substantial safeguards for public safety.
The authors note that every U. Abolition of the insanity defense violates due process. Recent changes in "official" psychiatric diagnostic nomenclature from DSM-IV-TR to DSM-5 are important to those cases in which we are asked whether or not a person meets specific criteria for some compensable disorder. One of the most common, and thorniest, in legal settings is post-traumatic stress disorder PTSD.
PTSD is a real condition, a pathologic, sometimes disabling, chronic reaction to extraordinary physical or emotional trauma. There are traumas — both sudden and ongoing — that are so severe that normal coping mechanisms are overwhelmed, leaving the victim chronically incapacitated. There are also victims whose coping skills and strengths are insufficient to deal with trauma that normal people are able to weather without lasting pathological effects.
That having been said, PTSD is among the most abused concepts in mental health law. Lawyers, the media, family and friends, sometimes expect trauma victims to take on an undeserved and psychologically harmful "sick" role, occasionally even defining them erroneously as disabled.
Plaintiffs' attorneys and family members may encourage victims — sometimes subtly — to remain symptomatic in order to collect compensation. All of these frequently delay the victim's emotional recovery, and sometimes prevent recovery altogether. Lawyers, and some plaintiffs, also know that PTSD is easy to fake. Malingering doesn't always occur, of course, but when it does, it's hard to detect. There are no reliable "tests" for PTSD. Psychological testing instruments that purport to reveal the presence or absence of the diagnosis are predicated on the patient's honesty, and on the premise that the person is seeking treatment, not compensation.
Most are simply self-report checklists that easily guide any unscrupulous test-taker to create the result he or she wishes to convey. Sometimes symptom exaggeration isn't exactly "malingering. People who have been involved in lawsuits for months or years often find it difficult to tell the lawyer — or their families — "I feel a lot better now; maybe we shouldn't make such a big deal of this," especially when their lawyer has spent thousands of dollars on it.
Cases are sometimes pursued beyond their logical end because "I didn't want to disappoint my lawyer" and sometimes "my family". Sometime during the s, after the U. Veterans Administration declared PTSD a compensable disability, a veterans group in the Pacific Northwest published a notice describing its symptoms and recommending that affected veterans go to the local VA medical center to be evaluated for monetary benefits.
One of the symptoms mentioned was "survivor's guilt," which a typographical error unhfortunately called "survivor's quilt. You guessed it, several of the scores of veterans who showed up for evaluation brought quilts as proof of their PTSD. Suicide Risk Assessment Model. Wortzel, Matarazzo, and Homaifar began a short series on suicide risk assessment in the July, , issue of the Journal of Psychiatric Practice Vol. They speak of a balance between the general respect for patient autonomy that is a part of almost all clinical care and protecting at-risk patients from actions fueled by mental-illness-associated poor insight, judgement, and impulse control.
The not that there is sometimes a tension between attention to acute risk and considering longer-term therapeutic objectives and chronic risk. The authors note that competent risk assessment is at the center of the care of the suicidal patient — if you don't adequately assess the patient, you can't expect to recognize risk and risk level — and that "hospitalization is a necessary and appropriate part of managing the patient at high acute risk of suicide.
They also reiterate the uselessness of "contracting for safety" when patient lives are on the line, and draw a distinction between "contracting for safety" and well-thought-out safety plans for patients who are at some increased risk but may not require hospitalization.
Unfortunately, this first article doesn't provide detailed recommendations for safety plans though it does refer the reader to a Veterans Administration document at http: I'll summarize the follow-up article when it appears.
That's not an indictment of either correctional institutions or our judicial system; it's simply a statistical finding that occurs for a number of demographic reasons. Most prisons, and many jails, have relatively sophisticated psychiatric services for their inmates. There are myriad scholarly treatises on recognition, treatment, and inmate protection in correctional settings.
Recognized jail and prison standards are clear about the level of care that should be met, but problems occur. Jails are particularly vulnerable to falling below the required standards, in part because of their transient and varied populations, as well as their wide variety of sizes and levels of sophistication, but they are by no means alone. Dean Aufderheide focuses on managing litigation risk, in the process outlining several principles that help to keep correctional institutions within the standard of care.
He frames them as elements of a "legally defensible program"; I like to think they're things an institution and its staff should do regardless of the chance of a malpractice lawsuit. One item I didn't see in this article is Documentation.
Detailed, contemporaneous notes about what mentally ill inmates say and do, what staff observes, what is done to address problems, and why things are done are critical to staff communication, continuing care, later understanding of problem situations, and defense of one's actions should complaints or litigation arise. Nevertheless, once the institution takes custody of an individual it becomes responsible for meeting revelant standards for his or her care a "duty of care".
Correctional systems should reasonably expect that they will encounter a variety of mentally ill persons, many of whom require special recognition, diagnosis, protection, and care.
Nevertheless, as the APA nomenclature has become standard in U. Perhaps more important for forensic purposes, the original intent of the DSM is often forgotten, or at least set aside. The civil and criminal law must often consider scientific or clinical concepts. One way that it does so is by using experts in a particular field to translate our professional jargon and issues in such a way that attorneys, judges, and juries can examine their relevance to a case at hand.
Experts don't make the legal or judicial decisions, but we're relied upon to present professional information clearly and accurately so the courts can do their work. Lawyers and litigants want to win their cases. They may — intentionally or simply erroneously — misconstrue professional information, such as DSM-5 diagnostic criteria, to fit their interests. It's our — mental health experts' — job to temper that misguidedness with knowledge and honesty. Psychiatrists, psychologists, and other mental health experts are often tempted to skew their diagnostic views as well.
Lawyers can be very persuasive, and litigants can appear deserving even when the facts don't support their cases. Clinical professionals with limited forensic training or experience are particularly vulnerable to misusing the DSM in forensic settings. The text speaks for itself:. T he use of DSM-5 should be informed by an awareness of the risks and limitations of its use in forensic settings. In most situations, the clinical diagnosis.
Use of DSM-5 to assess for the presence of a mental disorder by. Nonclinical decision makers should be cautioned that a diagnosis does not carry any necessary implications regarding the etiology or causes of the individual's mental disorder or the individual's degree of control over behaviors. Note that the above is excerpted from the complete Cautionary Statement. I recommend that you read it for yourself. Irritating Patients with Real Medical Needs.
Nonpsychiatric physicians often refer to psychiatrists when a patient's symptoms can't be explained by a general medical problem. That's usually a good thing, and fosters recognition and respect for the interface between psychiatry and the rest of medicine.
But now and then psychiatrists overdiagnose "psychosomatic" conditions, or a psychiatric-sounding clinical presentation interferes with a complete medical workup. Sometimes part of the problem is that the patient is irritating. Jail and prison inmates exaggerate or just fake symptoms all the time. Patients who "should" get better but don't are frustrating, and remind us of our fallibility.
When things get frustrating, it's all too common to look for flaws in the patient — he's trying to get out of work; she's just looking for more pain meds; he won't follow my orders. A case report in Correct Care isn't particularly psychiatric and primarily involves nursing care rather than a physician , but it reminded me of the issue. A young, athletic jail inmate complained over and over, for more than a month, of a seemingly minor wound that wouldn't heal with standard antibiotic treatment.
His pain complaints got worse; he collapsed in the shower; he complained of lower extremity numbness and inability to walk; he had a rectal prolapse that a, nurse, according to the article, simply re-inserted.
The nurse who was treating him apparently assumed he was lying about his symptoms. When a physician finally ordered hospitalization and an MRI, a perispinal abscess had already caused permanent lower extremity paralysis. Profit and prisoner's paralysis: It happens to psychiatrists and psychologists, too, of course. We all dread missing things like brain tumors and treatable pseudodementias. Sometimes a general medical referral is sufficient, but we shouldn't always assume that a screening consultation rules out "organic" illness.
We should be especially careful if a patient's "psychosomatic" condition doesn't improve, or gets worse. One of my early forensic cases illustrates the point:.
A woman complained of difficulty walking just after having a baby. She had no other symptoms, and no indication of infection. A neurological exam was said to be negative, and the obstetrician believed the problem was psychosomatic.
He referred her to a psychiatrist, who admitted her to the hospital's psychiatric unit. Over several days, her leg weakness seemed to get worse, and she said she couldn't walk at all, but no additional neurological or other medical consultations were ordered at the time. The psychiatrist took a "behavioral" approach to the problem, ordering the nursing staff not to help her or allow her to use a wheelchair.
She was forced to crawl to meals and the bathroom, on the theory that she would soon tire of the inconvenience and begin to improve. After several more days without improvement, the psychiatrist ordered another neurological consultation. Testing revealed a large perispinal abscess. Unfortunately, her paralysis had become permanent; diagnosed earlier, she would probably have recovered fully. If the problem persists, consider doing it again.
As my friend Dr. Tom Gutheil often says about seeking help, "Never worry alone. DSM-5 and Forensic Psychiatry. Hal Wortzel of the University of Colorado Medical Center has taken over my spot as forensic contributing editor of the Journal of Psychiatric Practice. Wortzel notes that the substantial change in diagnostic structure, including the elimination of the "axis" multiaxial system, could give rise to increased cynicism in courts and "renewed skepticism" about mental diagnoses "and the forensic psychiatrists who testify about them.
Allen Frances, who chaired the APA DSM-IV task force years ago, has cautioned that even modest changes in the evolving clinical nomenclature can have unintended consequences. He refers particularly to what he described as "three false positive 'epidemics'" to which DSM-IV contributed — ADHD, autistic disorder, and childhood bipolar disorders — and for which apparent over-diagnosis has caused clinical, financial, and forensic consternation British Medical Journal Wortzel notes that forensic settings are even more prone to unintended consequences and misuse of the DSM than clinical ones, since forensic users and audiences such as lawyers, judges, and juries lack the clinical training, purposes, and attitudes contemplated by the APA task force.
Experts and other forensic practitioners, should remember that most of the forensic issues in which we become involved hinge on psychiatric symptoms and mental function , not diagnosis.
Criminal responsibility, competence to stand trial or do other things, capacities such as testamentary capacity , suicide risk, and emotional damage, for example, rest far more on individual function and behavior than on the labels attached to them. Wortzel's article is in the Journal of Psychiatric Practice 19 3: My local news recently reported the death of a woman who was brandishing a handgun in a downtown area at two in the morning.
She refused to put down the pistol. The police attempted nonlethal intervention pepper spray, taser. She kept pointing the handgun at them and, according to reports, they had to shoot. She apparently never fired the weapon. Local media reported it as a possible "suicide by cop.
In another case, a man drove into a police station parking lot and began firing at an empty police car. He was severely wounded in a literal hail of bullets. After the incident, it became clear that none of the dozens of shots he fired with three weapons was really in the direction of officers.
He had a history of great respect for law enforcement, and planned for the officer who he believed would kill him to be rewarded as a "hero. The bumper-sticker phrase "suicide by cop" isn't very artful. It describes situations that law enforcement officers encounter with some regularity, never knowing whether or not they are in imminent danger.
They need to protect themselves and others, but must make critical decisions with very little information. Collins described people whose wish to die is often more ambivalent than that of other people who make lethal or near-lethal suicide attempts. They create highly volatile situations that attract the attention of law enforcement officers, create a strong impression of danger to others including officers , and usually brandish a weapon which may be a fake one.
Sometimes severe violence has already occurred, such as the killing of a spouse. Sometimes the person is intoxicated. Serious mental illness is common, but can't always be an immediate concern when the danger is acute or must be assumed so. Negotiation procedures discussed briefly elsewhere on this website, much more specifically in the law enforcement literature, and far more a matter for crisis-trained law enforcement personnel than for mental health professionals are sometimes successful, but often not.
More than half of the cases studied ended in death of the subject, some involving the subject killing himself in front of officers.
Men were more likely than women to be involved, but women were said to have been more likely to act quickly and less ambivalent about that action. Let's not forget that the police suffer, too. They risk their lives handling the event and are often placed in near-impossible situations. Anytime there is a "shooting," their lives change immediately for the worse, and for a long time. When a subject is killed, those consequences administrative and, even more, personal are enormous.
Regardless of the circumstance and administrative outcome, they know, better than anyone, that there's really no "good" shooting. Psychotic Patients' Risk of Violence. Forensic psychiatrists Charles Scott and Phillip Resnick offer a brief update on some classic principles for assessing risk of violence in psychotic patients. It's brief, but discusses two common factors that should be evaluated: Journal of Nervous and Mental Disease , Dimensional approach to delusions.
American Journal of Psychiatry : Scott and Resnick also note that some evidence indicates that persons with both persecutory delusions and negative affect that is, having delusions that make the person feel angry, frightened, or otherwise "negative" is associated with increased risk of violence.
Evaluating psychotic patients' risk of violence. At a time when laypersons and the media are clamoring to blame a lot of violence on mental disorders or inadequate recognition and treatment of them , it is important to note that psychiatric patients' risk of being victims themselves is probably a much greater problem.
It seems intuitive that "mental patients are dangerous," yet just the opposite is true for most diagnostic groups. There are exceptions, of course such as for combinations of some diagnoses and substance abuse , but many studies — that don't seem to make it into the mainstream media — indicate either neutral or decreased violence among most kinds of patients. People with serious mental illness are much more likely to be victims of violence than to be perpetrators.
They often live in dangerous settings, sometimes with no real home at all, exposed to whomever might harm them. They are often unable, or poorly able, to defend themselves, and sometimes don't have the judgment or means to avoid danger. The people around whom they live are often those that you or I would avoid, and certainly not associate with or share sleeping arrangements. Their behaviors, on the street or in a domicile, may be intrusive or irritating to others, which can precipitate a physical attack.
Misunderstanding of their behavior or intentions can cause others to become frightened or angry, sometimes striking out at them. A recent paper in the British Medical Journal by Crump et al. March 4, , Substance abuse was a factor, but did not explain all of the variance. Clinicians who do work for attorneys and courts sometimes have problems defining their roles, getting access to records or litigants, dealing with unexpected changes or additions to their tasks, or being compensated for their work.
Understanding the context of the forensic consultation and the processes commonly employed by lawyers and the judiciary can prevent many problems. Be cautious about "informal' requests from attorneys, particularly if they involve your own patients. Maintain solid business practices and make sure your role, relationship, and financial agreement with the person or entity retaining you are clear, ethical, and well documented before you begin work on a case.
Journal of Psychiatric Practice ; The recent Florida malpractice verdict in Perez v. As I teach clinical assessment and risk management, and work with plaintiff and defense matters involving suicide, these are topics that come up over and over again.
Their importance to patient safety is obvious; their recognition by courts and triers juries and judges is getting better. Perez had a history of, among other things, severe depression and psychosis, suicidal thoughts, and past elaborate and detailed suicide plans. He received all of his care from Veterans Administration VA caregivers; and his psychiatrists and other staff had access to his past psychiatric records.
He committed suicide while in outpatient treatment. His family sued and the matter came before a judge in a bench trial one in which a judge decides both the matters of law and the matters of fact; there is no jury.
After reviewing thousands of pages of records and depositions and hearing from experts for both sides, the judge found for the plaintiff, citing several breaches of the applicable standard of care and ratifying many of the assessment and treatment principles mentioned on this website:. The outpatient psychiatrist should have been more aware of Mr. Perez's well-documented, substantial risk of suicide ; his care would probably have been different if he had been.
Manov, and a more careful evaluation of his status by VA staff when he presented himself to the Clinic in April Addressing foreseeable risk , a very important issue in assessing liability, the court referred to Florida's concept of a "zone of risk" created by the defendant VA's negligence.
For example, a restaurant's failure to refrigerate its mayonnaise unacceptably increases the risk that some patron will become sick as a result. An injured plaintiff would not be required to show that the restaurant could have predicted who or when; the issue is risk. The outpatient psychiatrist should have assessed Mr. Perez regularly during treatment, and should have performed regular suicide risk assessments.
Perez's known condition, leaving him " alone and without the benefit of a therapeutic relationship with anyone regarding his psychiatric care—all while his psychological status foreseeably deteriorated. The outpatient psychiatrist should not have relied solely or so much on Mr. Perez's own statements that he was not suicidal.
It is not sufficient or clinically appropriate for treaters to rely family members to diagnose, monitor, or treat suicide risk in ways that would be expected of health care professionals. Perez's suicide was found not to have been an intentional act as often alleged by the defense in suicide cases. His substandard care allowed "mental deterioration. In assessing causation, the court considered what it believed were clinical shortcomings occurring months and years before Mr.
Perez's suicide, exploring the role of a lengthy chain of events that led to his suicide. It did not limit itself to considering those that occurred a few days or weeks before it. Sometimes it is reasonable to cite consequences of a patient's being placed on an erroneous pathway of care months or years before, and sometimes it is not, but the Florida court did not dismiss past errors out of hand.
Thanks to attorney Skip Simpson for the reference. I use the term "patient"; some therapists prefer "client. The case was one in which a general practitioner treated a woman and her husband for various things over many years, including the wife's psychiatric symptoms. He eventually had a year-long affair with the woman which she ended. The couple then sued the physician and other providers. The doctor argued that although his behavior might be considered unethical for purposes of professional licensing or medical organization membership, and although some of the patient's care had addressed psychiatric symptoms, the fact that he was not a mental health professional meant that no "therapist-patient" relationship was formed, and thus he was not liable under then-applicable Pennsylvania law.
A trial court agreed; an appeals court eventually overturned the trial court, and the Pennsylvania Supreme Court, reframing the questions a bit, found with at least one strong dissent sufficient difference between general practitioners and mental health professionals to preclude extending mental health clinician tort liability to GPs that is, they found in favor of the physician.
Setting aside for a moment the obvious ethics issues, which are vigorously pursued by professional organizations and licensing boards, and also setting aside the fact that several states view various levels of doctor-patient sex as criminal offenses even if consent is alleged, two issues remain. First, as a practical matter, few such "consensual-sex" cases are actually filed anymore.
That doesn't mean that patient allegations and injuries are not addressed through other means, such as licensing board censure, expulsion from professional organizations, or criminal prosecution, but almost all U. Their view seems to be that such intimacy is not part of professional practice, and thus is not covered as "malpractice. Zonana points out in his article, a great deal of psychiatric and psychological assessment, diagnosis and treatment is carried out by primary care physicians.
If the concept seems confusing, consider nonpsychiatric examples such as cardiological or obstetrical care. A GP is generally responsible for knowing when specialty referral is indicated, and if he or she decides that referral is unnecessary then the patient is entitled to assume that the care received will be adequate. The reverse applies to psychiatrists: If we decide to treat a patient's hypertension or diabetes, then we must meet the general medical standard of care, not some special, lower "psychiatrist" standard.
Ryan and Richard C. Hall recently published a stellar summary and re-examination of the concept of "compensation neurosis. It involves various aspects of "secondary gain," including symptoms and defenses related to protracted or simply pending lawsuits, other litigation, or administrative disability investigations. Compensation neurosis is separate from intentional feigning such as that seen in malingering and factitious symptoms. It has many presentations and is known by several other names.
One, only partially on the point of this article, invokes a "green poultice" of compensation money which is applied to the hurt part of the body to make it better.
Compensation neurosis has waxed and waned in popularity over the decades. Hall and Hall provide a scholarly but very practical review and discussion of conditions that should be considered by anyone evaluating personal injury damages for a lawsuit including malpractice litigation, workers compensation, and vocational disability. It's not often that an article this complete and useful comes along.
Download the entire text without charge at http: A Too Quickly Forgotten Concept? J Am Acad Psychiatry Law 40: Suicide Risk Management and Standard of Care. Mace Beckson and Joseph Penn wrote an interesting piece on suicide risk, standard of care, and potential liability in the April, , issue of American Academy of Psychiatry and the Law Newsletter p.
Some good points were made, but the comments were incomplete and aimed more at expert witnesses than preventing suicide itself. To be fair, one focus of both the Academy and the Newsletter is professional and ethical behavior of psychiatric expert witnesses.
The crux of the article was that experts must not confuse the required standard of care generally one of clinical adequacy rather than excellence with an optional, higher standard.
The point was made that "guidelines," such as the American Psychiatric Association's guidelines for the management of suicidal patients, do not always become "standards," and sometimes but not always refer to better-than-adequate care. In discussing suicide risk assessment, the authors noted that every case and patient is different, that clinicians cannot reasonably predict suicide itself but are expected to follow an adequate risk assessment process given individual patient circumstances , that clinical judgement is important, that there is no official "standard" risk assessment format or algorhythm, and that rote forms and checklists alone are often inadequate for the task.
At least one item in the article was misleading in its incompleteness, and needs correcting for those who may search it out and rely upon it.
The authors' statement that "The standard of care for a suicidal patient is to do a suicide risk assessment" leaves out at least four very important points some or all of which I'm sure the authors realize, but weren't clear in the article:. Alabama considered with Jackson v. Hobbs that mandatory life imprisonment is an unconstitutional sentencing procedure for juvenile offenders, regardless of their crimes.
It violates the cruel and unusual punishment clause of the 8th Amendment. Alabama slip opinion at http: The American Psychiatric Association has participated in an amicus brief that explained the immature and developing nature of juveniles' brains, as well as their greater-than-adult likelihood of rehabilitation.
Capital punishment and life-without-parole for non-homicide crimes have previously been found unconstitutional by the USSC. Duty to Third Parties: Malpractice Liability for Damage to Family Members. The finding applies to a case brought on behalf of the young children of a confessed murderer for whom two steroids, a central nervous system stimulant, two antidepressant medications, and an anxiolytic had been prescribed.
The case alleges that negligent prescribing of those medications was a cause of David Ragsdale's January, , murder of his wife. Health care providers perform a societal function of undoubted social utility, but they are not entitled to an elevated status in tort law that would categorically immunize them from liability when their negligent prescriptions cause physical injury to nonpatients. The case is B. Several medical associations testified or filed amicus briefs to the effect that physicians and other providers should not be held responsible for damage to third parties in circumstances such as this case.
Physicians have often been found liable to third parties in other kinds of cases, when their negligence involved foreseeable events. One important issue is the foreseeability of damage, which the Utah Supreme Court appears to have ruled is a matter for a trial court fact finder usually a jury to decide. A so-called "duty to protect" third parties from reasonably foreseeable patient violence or a somewhat different "duty to warn" third parties was a common litigation topic some years ago, particularly following California's Tarasoff decision Tarasoff v.
Regents of the University of California, 17 Cal. Most states have statutes or case law to guide courts in hearing — or declining to hear — similar cases. The Utah decision may or may not involve a different slant, but the implications for public policy are interesting. School Crime and School Safety Reports. The current issue March 1, of the NCJRS Justice Information newsletter mentions a new government publication that presents current school crime and safety findings for Three items highlighted on the information page cited below:.
For more information, or to download the entire report, go to http: Department of Justice, is a great and free source of information about criminal justice and corrections, including statistics, grants and other funding opportunities, victim services, adult and juvenile correctional services, and much more. For more information, or to subscribe to their free online and email newsletter JustInfo , go to https: Many jurisdictions limit expert testimony in malpractice cases to physicians or other clinicians who have training and expertise in the defendant's field of practice particularly those testifying for a plaintiff.
For example, allegations of nursing negligence must usually be supported by testimony from a nurse-expert; a psychiatrist is unlikely to be allowed to testify about the standard of care for surgeons. This principle often applies to the defendant's occupation or specialty, and not so much to the patient's symptoms or needs.
Thus a judge could but does not always require an expert in emergency medicine to testify about alleged negligence by an ER physician treating a depressed person, or a primary care doctor rather than a psychiatrist for criticism of how a schizophrenic patient was managed in a family medicine clinic.
In many cases, though, and in many jurisdictions, courts recognize that the standard of care should be applied to the patient's characteristics, not just the doctor's. That is, if a family practitioner chooses to diagnose and treat a person with severe depression, rather than referring him or her to a psychiatrist, that patient is entitled to treatment that meets the psychiatric standard, and a psychiatrist is the proper expert to offer opinions about the mental aspects of the case.
The sword cuts both ways: If a psychiatrist chooses to treat a patient's diabetes or thyroid problem, the psychiatrist is expected to meet the general medical standard for that care, not some special, lesser, one for psychiatrists. Skip Simpson, a Dallas-area plaintiffs' attorney, recently sent the following summary of a ruling that allowed a psychiatrist to testify in the matter of a man with no mental diagnosis who committed suicide while in great physical pain. Expert testimony of a psychiatrist, that the patient's suicide was the result of extreme pain he had suffered following back surgery and that the patient had not chosen suicide rationally, was admissible, in a medical malpractice wrongful death action, to show that the nonpsychiatrist physician's alleged negligence was the proximate cause of patient's suicide, since the psychiatrist was board-certified, and had experience and training in diagnosing and treating similar patients.
The fact that patient had not been diagnosed with a mental disorder was not a basis on which to exclude the psychiatrist's testimony V. Tens of thousands of jail and prison inmates in the U.
For some inmates, their mental disorders led to arrest and incarceration; in others, they were coincidental to it. Most clinical issues are similar for inmates and those in the "free world" although the distribution of diagnoses and types of symptoms vary ; the real differences are in the setting, rigid rules, and day-to-day practice. The inmate "culture" that both patients and clinicians must deal with is a big part of those differences, but the culture of the corrections officers and staff is strikingly important as well.
Jails are different from prisons. Jails are places of temporary housing, where inmates live for days, weeks, or months. Many are awaiting trial or bond, and thus have an uncertain future. Jails are noisy places, often seeming chaotic and frightening to new arrestees. They are overseen by counties, with local control withn broad accreditation standards. Most jails don't have in-house medical or mental health services beyond a nurse, and educational and vocational programs are rare. Prisons, on the other hand, are long-term residences, communities in many ways.
The inmates are convicted felons rather than a mix of arrestees and misdemeanants. One conceivable component of risk aversion in the framework of PT is that the degree of risk aversion apparent will vary depending on where along the curve our decision lies. PT captures this pattern of differentially weighting objective probabilities subjectively with an S-shaped weighting function.
A framing effect occurs when transparently and objectively identical situations generate dramatically different decisions depending on whether the situations are presented or perceived as either potential losses or gains. Risky prospects are characterized by their possible outcomes and by the probabilities of these outcomes. The following pair of problems attests to the power of framing effects in manipulating either risk-averse or risk-seeking behavior.
The total number of respondents in each problem is denoted by N, and the percentage who chose each option is indicated in parentheses. Imagine that the U. Two alternative programs to combat the disease have been proposed. Assume that the exact scientific estimates of the consequences of the programs are as follows:.
If Program B is adopted, there is a one-third probability that people will be saved and a two-thirds probability that no people will be saved. Which of the two programs would you favor? The formulation of Problem 1 implicitly adopts as a reference point a state of affairs in which the disease is allowed to take its toll of lives.
The outcomes of the programs include the reference state and two possible gains, measured by the number of lives saved. As expected, preferences are risk averse: Now consider another problem in which the same cover story is followed by a different description of the prospects associated with the two programs:. If Program D is adopted, there is a one-third probability that nobody will die and a two-thirds probability that people will die. It is easy to verify that options C and D in Problem 2 are indistinguishable in real terms from options A and B in Problem 1, respectively.
The second version, however, assumes a reference state in which no one dies of the disease. The best outcome is the maintenance of this state and the alternatives are losses measured by the number of people that will die of the disease. People who evaluate options in these terms are expected to show a risk-seeking preference for the gamble option D over the sure loss of lives.
If preferences reverse based on inconsequential aspects of how the problem is framed, people cannot possibly be maximizing expected utility. This may be based on a rephrasing of the outcomes that conveys no differential information about the treatments and that changes nothing about the outcomes themselves. While risk aversion is commonly explained through EUT and PT, observed risk-aversion behavior remains solely an artifact of these two theories, and extends beyond the bounds of what each theory can explain.
EUT and PT predict that people should not purchase insurance for small-stakes risks, yet such forms of insurance e. By paying a premium often higher than the cost of replacement for the possibility that insurance may come in handy, people display direct risk aversion by valuing a risky prospect below the value of its worst possible outcome replacement at face-value.
Suppose you are undecided whether or not to purchase earthquake insurance because the premium is quite high. As you hesitate, your friendly insurance agent comes forth with an alternative offer: This is a good deal because for half the price you are covered for more than half the days.
Why do most people find such probabilistic insurance distinctly unattractive? Reducing the risk by half, then, is not worth half the premium. The aversion to probabilistic insurance is significant for three reasons.
First, it undermines the classical explanation of insurance in terms of a concave utility function. Both EUT and PT are probability-outcome independent theories, as they posit separate functions for the evaluation of outcomes and probabilities.
In , two researchers from the University of Chicago, Rottenstreich and Hsee, conducted a series of three experiments to illustrate probability-outcome dependence, using an affective approach. Participants then had to indicate how much money they would have to be offered for them to be indifferent between receiving that dollar amount for sure and having the specified chance of winning the prize.
Affect-rich outcomes yield more pronounced overweighting of small probabilities, but more pronounced underweighting of large probabilities.
The outcomes studies in Experiments 1 and 2 were gains above the status quo. When a positive outcome is available, any departure from impossibility may engender hope affect-rich and positive , and any deviation from certainty may produce fear affect-rich but negative.
The following study demonstrates that the opposite pattern is also true: They were then asked to indicate how much money they would have to pay for them to be indifferent between paying that amount for sure and participating in the hypothetical experiment. Both Experiments 1 and 2 investigated outcomes that were gains over the status quo.
Experiment 3 studied negative outcomes and also found evidence of a weighting function that is more S-shaped for affect-rich that affect-poor prizes. Therefore, probability-outcome dependence based on the affect-rich psychology of risk applies in the domains of both gains and losses. Do you remember the worst thing that has happened to you? What about the best? At what frequency are you able to recall memories that are negative in comparison to those that are positive?
Does it seem like negative information is remembered with more ease and clarity than positive information? Why is it easier to know the percentage of fatal car accidents each year, as opposed to the percentage of accidents without fatalities? The human brain demonstrates a partiality for the processing of negative information. In comparison with their positive counterparts, negative stimuli receive a larger allocation of attention and a swifter response once recognized by the brain.
Researchers localized this particular ERP to the ventrolateral occipital cortex. Given that a greater amount of attention is allotted to the processing of negative stimuli, the negativity bias may also be indicative of an attentional bias. The negativity bias is noticeable in a plethora of situations related to the formation of risk-averse behaviour.
Notably, any stimuli that evokes the expression of fear encourages risk -aversion. The human brain has adapted to easily parse out these stimuli from a sea of benign stimuli. Decision making and emotion, intertwined, cannot be separated from each other, as emotion can either benefit or hinder the attainment of maximized utility.
Three different emotional states influence decision making: Your current emotional state i. How do you feel while you are making a decision? Your past emotional state i. How did you feel anticipating your decision? Your future emotional state i. How will your decision affect how you feel in the future; What effect will the decision have on your emotional well-being? Researching decision-making and affect, Antoine Bechara, Antonio Damasio and colleagues ; discovered that damage to a brain area associated with emotional processing impairs effective decision-making.
In creating this task, Damasio wondered whether decision-making was afflicted because emotion was a necessary component to making effective decisions. In the task, participants continuously draw from one out of four possible decks — participants may switch decks at any point during the study.
Participants are unaware that 2 of the decks correspond to net winnings — low payoffs and even lower losses. The other 2 decks correspond to net losses — high payoffs and even higher losses.
Researchers instruct participants to maximize their utility — gain the most money by the end of the task. In order to complete this task successfully, participants must discern that the decks associated with net winning, yet low payoffs, maximize their utility. Damasio noticed that participants with damage to their orbitofrontal cortex were unable to realize that the deck associated with low payoffs yielded higher reward. Other researchers suggest that the difficulty encountered by patients with orbitofrontal cortex damage on Iowa Gambling Task is because the task requires participants to change their initial perception of potential gains and losses.
Thus, orbitofrontal cortex damage inhibits the adaptation to changing patterns of rewards and punishment. This conclusion has been replicated in primates, where orbitofrontal damage prevented the extinction of a learned association. Damasio posited that emotional information in the form of physiological arousal, is needed to inform decision making.
When confronted with a decision, we may react emotionally to the situation, a reaction that manifests as changes in physiological arousal in the body, or somatic markers. Given data collected from the Iowa Gambling Task, Damasio postulated that the orbitofrontal cortex assists individuals in forming an association between somatic markers and the situations that trigger them.