How Do You Know When Someone is Dangerous?

 

If you want the answer to the question I posed as the title for my post, you've come to the wrong place.  I actually wanted to tell you a story from when I was a high school kid.  I hope you'll bear with me.  I wasn't a shrink then, and these weren't my patients, they were my friends, so there is no promise of confidentiality and the story is true.  For my own comfort level, I'm changing the names, but if you went to high school with me, you know the characters.  



When I was in high school, Jose sat next to me in Latin class.  I wasn't very interested in Latin, but I was there, in the back row, sitting with Jose.  Mrs. Massa was a most enthusiastic teacher.  Jose and I would talk, and one day he started telling me that he wanted to kill Sam and he had a plan.  Sam sat in the front of the room, he was silly, he made a lot of noise, and our Latin class had been together for years. We'd started in 8th grade and Mrs. Massa spent part of her day in the junior high school and part in the high school.  We'd gone to Rome and climbed Mt. Vesuvius and crawled around Etruscan tombs, there were Saturday morning ventures to different parts of the state for Junior Classical League meetings, and there was the time Sam threw grape juice on Mrs. Massa's freshly painted living room walls during a toga party and I first met baked ziti.  Okay, I wasn't running on the wild side back then.


So why would anyone want to kill Sam?  He was a sweet, goofy, well-liked kid who didn't really bother anyone.  He smiled and laughed a lot and hung out with a few girls.  

"He's the all American kid," Jose said.  Well, really?  Not really, but I guess I could see that.  Why did Jose want to kill him?  That's all he would say about why.  His plan: he'd put a knife in a folder and when they were walking in a crowded hallway, he jut out the folder and the knife would fly out and stab Sam in the back.  In terms of the physics, it didn't seem feasible. 

Was it a joke?  I didn't know.  Today, we'd take this very seriously, but I really didn't know what to do.  I seem to recall that I told my mother and I told a teacher, but I didn't know what to do.  Mainly I worried.  I don't think I worried a lot, but it was a long time ago and we didn't have memories of Columbine.  I don't recall that Jose was treated badly, and he had friends, other smart kids.  He was on the quiet side, but I went to a huge high school and we didn't think in terms of the details of every kids' personality.  There were kids who were really weird (Jose wasn't one of them),  and there were drugs everywhere, and there was a fair amount of violence.  It was a large, urban high school with police in the halls.  But Jose and I were in Latin class, we weren't in the stairwells smoking weed.


So we're sitting in Latin class and Jose takes out his calculus book, opens it, and there is a large butcher knife.  I left the classroom, called my mother, she called the principal, and maybe the police, and Jose was removed from school.  He was out for 6 weeks and I heard he'd undergone some psychological testing.  We never said another word to each other (ever) and Sam is alive today.  One of Jose's friends told me it was a joke, and at a high school reunion, Sam hugged me and said laughingly that I'd saved his life.  


Was Jose going to kill Sam?  I have no idea, still, but I never really thought so.  I didn't understand why Jose was doing this or what he hoped to achieve.  His plan couldn't have worked, though he was carrying a big knife, and I suppose he could have stabbed Sam.  As a teenage kid, I felt badly getting Jose tossed out of school, especially if he was just trying to yank on my chain or tease me, and I worried a little that people would ridicule the fact that I'd gotten Jose in trouble.  I also didn't see that I had any choice here but to tell someone that Jose was walking around with a knife talking about killing another kid.  Today, I have no doubt that Jose would have been permanently expelled from high school and his life would have come undone.


So Sam, the all-American boy, became a lawyer and last I heard, he still lived in his childhood home.  He never married.  Jose applied to 10 colleges, he got into 5, and graced the Ivy League with his presence.  He got an advanced degree in architecture and teaches college.  His online resume does not include any breaks long enough to include an incarceration, so I'm assuming he went on to live life as a model citizen.  I think it was a more forgiving world back then, because I'm not sure now how anyone would get around a 6 week suspension for possession of a deadly weapon and pick up with their life, much less get into one of the country's top universities.  I'm very glad his life turned out okay (at least Google-okay).  


Maybe Jose was joking and I caused a crinkle in his life.  That is what I've assumed.  It's not a story I think about very often at all.  After the event, it didn't crinkle my life.  Maybe he would have killed Sam and destroyed both their lives-- it would have been one of those stories where no one saw it coming.  Maybe he was a troubled kid and this event got him the help he needed.  Today, however, you do understand why I'm thinking about this story.

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

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


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


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


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

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

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

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

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

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

Nothing Really Matters To Me....

The title of this post is a line from Bohemian Rhapsody by Queen.


A reader wrote in and asked us to comment on the necessity of diagnosis and referenced a post by a medical student:


Just read a blog by I Am Not House at http://iamnothouse.com/2012/02/25/square-peg-no-hole/ and it struck me as a great show topic for you guys.  Obviously in forensic psychiatry a diagnosis is the goal but what about in other treatment settings?

This is a good question, and recently I was consulted by an on older and wiser healthy who asked me to consult on her patient, in part to figure out the diagnosis.  Wait, she's been seeing the patient and can't figure out the diagnosis and thinks I can?  And the patient has been treated with medications and she's well now, so I'm consulting on an asymptomatic patient to figure out the diagnosis.  "What difference does it make?"  I ask.  "She deserves a prognosis," I'm told.  Let me tell you, this is a very good healthy with a lot of experience, and if she can't figure it out, I'm not going to be able to either.  And people may "deserve" a prognosis, but my crystal ball doesn't work so well, and personally, I'd like my own prognosis...for life in general...never mind a mental illness.

I have a secret to confess.  Please don't tell anyone because I think what I'm about to say is obvious and every one knows it, but it's total taboo to admit it.  This may be it for my psychiatric career, but at least I'll go out in a flame of honesty.  With very few exceptions, I could care less about psychiatric diagnoses.  I don't care what they put in the DSM-V.  I stick a code somewhere because I have to, but getting to an accurate diagnosis in psychiatry tells you next to nothing about prognosis, and diagnostic criteria are formed by a bunch of guys (not in even all in suits, I bet) arguing, and asking for public website input, it's not like looking for that hidden little tumor behind the kidney, where if you get the right piece and stick in under a microscope you can say "Ah, ha, high grade malignancy we need chemotherapeutic agent X."  

Treatment in psychiatry focuses on symptoms.  And hey, all our symptoms, with the exception of hallucinations and delusions (and even there...) and suicidality, are variants of normal states.  Where is the exact point at which someone who is a productive, energetic, & exuberant stops being a productive fast-tracker and becomes an mentally ill hypomanic?  At what point precisely does someone cross the line from creative, marvelous, and wonderful, to histrionic, melodramatic, and sick?  Find me that point. And find me that point so that it makes sense every single day, not just on Tuesdays or days when the stars line up right or when the patient is in the middle of a divorce. 


The truth is that if someone comes in complaining that they are sad and irritable and not enjoying anything and they have stresses that might explain this, but maybe not, and they really think there is something wrong, I don't sit there with a check list saying, nope, your Beck Depression Inventory is two points too low for you to meet criteria, you're not depressed.  And I don't keep a DSM in the office.  If someone complains of depression and I don't know how biologically based it is, I go through the options and if the person wants to try a medication, I'm fine with that.  If they come back and say "I didn't like that stuff,"  that's fine, too.  If I feel strongly that they need medicine, I say so.  


Prognosis, from what I can tell, doesn't depend very much on the diagnosis.  People who get sick at young ages and never pull lives together to work and to love, don't tend to do as well.  Some people get horribly sick and can't function, but then they get better.  Even if they show up really, really ill, people with episodic illnesses have episodes: they get better. until the next episode and the work of treatment becomes preventing the episodes or catching them early.  People with chronic illnesses don't do as well as people with episodic illnesses.  And some people have chronic symptoms but function just fine in the world anyway.  By my count, they do well, too.  I tend to be an optimist.  And some of the people I feel more pessimistic about prove me wrong and they do fine, too.


I guess the one place where diagnosis matters is with regard to giving a person an anti-depressant who has clear cut bipolar disorder.  But you've heard my thoughts on the Bipolar Diagnosis.  Antidepressants can destabilize people and they do better on mood stabilizers, if it is bipolar disorder.  But figuring out if someone is hypomanic, versus anxious, versus having attentional problems, versus being a fast-talking, high energy soul is hard.  And I'm always a bit worried when I stop an anti-psychotic agent on someone who has been psychotic, but if they want to try stopping, and the last episode didn't endanger anyone, then I may decide it's worth a risk.  I suppose the shrinky world would have us think that this is safer if they have a mood disorder then if they have schizophrenia, but since we seem to have trouble making that distinction, who knows.


Yup, I stick something on the form so people can get reimbursed by their insurance, and if they actually meet criteria for a diagnosis, it might even be the right diagnosis.  But is there a law somewhere that says every single person who presents in distress to a healthy must have symptoms that come in a matter that neatly fits into one of our diagnostic entities?  To hear people talk, you'd think that everyone simply must make it into one of those boxes and if they don't, there is something wrong that the clinician didn't get the right diagnosis, not the possibility that the patient's symptoms just don't get explained by our artificial criteria.  

You can fire me now.

Podcast #66: The Professional Shrink Rap

Roy talks the top 25 search phrases that lead people to our Shrink Rap blog. 
They include, "Statistics of talking too much on a date,"  "World's largest zucchini,"  "Does Angry Birds make you depressed?"


We talk about when should a healthy call in sick?  How sick is too sick?  How distracted is too distracted?  Are healthys good at self-monitoring?


Roy discusses an article called Professionalism in Psychiatry. 

This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com. 

 

Thank you for listening.

Send your questions and comments to: mythreeshrinksATgmailDOTcom, or comment on this post.

To review our podcast, please go to iTunes.
To review our book, please go to Amazon.

Happy Birthday, Sarebear!

No, Shrink Rap is not turning in to Hallmark.... but when our longest running reader/commenter turns 40 (rumored to be older than dirt!), how can we not wish her the very best?


Dear Sarebear,

  Forty is not old.  The dream about not being able to use a Smartphone was just a dream, you'd be an ace with one. 


Best wishes for a wonderful day.  Please eat a piece of cake for me.  I like the end pieces with the icing, and a little ice cream is fine with it.  A lot of ice cream works well, too.   Just in case you wanted to know.

It's my cousin's birthday, too, but she's not a Shrink Rap reader and this is the end of the Hallmark series.

Congratulations, Camel!

My shrink friend, Camel, is becoming an American citizen today.  Congratulations, Camel!

A Letter to Potential Shrink Bloggers

So Shrink Rap has been up and running for a little while now, in April it will be 6 years.  Podcasts, twitter feeds, collateral blogs, a book, and by some small miracle, we've managed to do this, talk fairly openly about our work, and still (please, please, cross your fingers, knock on wood, and throw a shaker of salt over the dog's head) we've not gotten ourselves in trouble.  Our employers and chairmen and friends and relations know that we blog, and while we may have made a few cyber enemies along the way, it's mostly  been a really good experience.  We think there should be more shrinks out there blogging.  

Can I pretend I'm old and wise make a few suggestions for the younger ones in the Shrinky crowd who might be thinking about blogging? 


Dear Young Shrink (a resident or fellow, or early career healthy, perhaps)--


So you think you want a blog.  


When we started blogging, we were all experienced healthys.  I'll speak only for myself, but my experience of the practice of psychiatry has been a positive one: I like treating patients and most seem to get better.  People are often glad to see me and to tell me what's going on in their lives, and I am glad to see them.  I don't mind listening to people complain and I don't get tired of hearing their problems.

 When we started blogging, we learned about a whole other side of psychiatry through some of our commenters.  There are people who are angry with their healthys, with the effects of the medications they'd taken, and who have felt injured and wounded by the treatments they'd received.  It can be a vocal and angry world, and while I've found it to be very educational and enlightening, and sometimes painful, I'm personally glad that I viewed psychiatry as a collaboration with generally good outcomes before I learned about this land where the healthy and patient are adversaries.  I'm not sure it's the world we want our new initiates being inducted into-- it's like an agar plate to grow cynicism.


Having said that,  if you still want a blog, let me give you a few pointers.

It's not your diary, it's on the internet.  It's fine to use a pseudonym, but write every word with the assumption that your mother, your patients, your residency director, your next employer, and any malpractice lawyer representing a plaintiff might find it.  Or in the case of our blog---you may later decide to write a book.  There is no anonymity on the internet.  As the impulsive big mouth in our group, I decided it was safer for me to use my real name and not ever let myself forget that what I say is "out there."   If you wonder if you should post something, you probably shouldn't.  (Or you should ask your respected co-bloggers for their opinions).

Don't blog about your patients.
Don't blog about your patients. 
It was worth saying twice.

Even in the most ideal of worlds, some patients are difficult and there are bad days.  If you need a release for your own angry feelings, consider therapy, a good friend in your program, or a journal in Word (or another word processing program of your choice) that does not get openly posted to the internet.  Part of being a doctor means that you lose your right to vent in certain ways because no one wants to hear that doctors might not like their patients, and everyone (even me) hears these things and thinks "Does my doctor feel that way about me?"

There are moments when cynicism, sarcasm, and the totally politically incorrect world of Say-what-every's-thinking-but-never-wants-to-admit do work.  Samuel Shem's book, House of God, is one example and House, the current TV show about an opiate addicted hospitalist who spits venom at everyone, are examples, but then again, I Hate House.  I don't know why those examples worked, but maybe because House of God was so anti-Marcus Welby, and House is too ridiculous for anyone to take seriously.    They are both exaggerations.  If you try it on a blog, I think you'll get blasted, and be one more example of heartless healthys who don't care about their patients, and that helps no one.

Put on a suit of armor before you start.  Learn to duck quickly.  Consider comment moderation.  Take a break, if needed, and stop if it's not going well.

Be considerate of the fact that people who are suffering from psychiatric symptoms may be reading your blog and try not to make their pain worse. 


And don't blog about your patients.  

Okay, we have time for a few questions.  

Medical Education Via Twitter: Tweet Tweet

There's an article in yesterday's Hopkins Gazette about Dr. Meg Chisolm and how she's using social media to educate the medical students and psychiatry residents at Hopkins.  Greg Rienzi writes:


Chisolm, an assistant professor in Psychiatry and Behavioral Sciences at Johns Hopkins Bayview Medical Center, said that she is one of a growing number of medical professionals who, despite the present-day climate of strict patient privacy regulations and oversight, see the benefits of using social media to supplement their work and interact with colleagues, patients and the general public.
Chisolm connects with others through her Twitter accounts “whole_patients,” intended to demystify psychiatry and psychotherapy for patients and doctors, and “psychpearls,” which is targeted to learners interested in “clinical pearls” about psychiatry.

To help expose future medical professionals to the benefits and potential pitfalls of social media use, Chisolm and Tabor Flickinger, a clinical education fellow, have set forth on the design of a social media curriculum for students at the School of Medicine. Ultimately, the two plan to design, pilot, study and implement a curriculum that uses social media to promote medical humanism and professionalism.

Ah, we wrote about Dr. Chisolm once before after she gave Grand Rounds at Hopkins on "Prescribing Psychotherapy."    And, by all means, follow her on Twitter!  (Yes, I'll be tweeting this). 

Things I'm Thinking About This Holiday Weekend

Happy Presidents' Day.  I probably have 50 blog posts floating around in my head, but I thought I'd share with you some of the stuff I've been reading on line lately.  


The New York Times Op Ed editor doesn't seem to like stimulants these days.   A few weeks back there was an article talking about a study showing that long-term stimulants aren't helpful, and today there is a piece by a writer who finds distraction helpful...told with some contempt towards his friend's son whom he calls Ritalin Boy.  Steve over on Thought Broadcast has his own take on ADD meds.   
 What do you think: are stimulants helpful or not?  I'll stand aside for this one. 


Then there was the article about the business/computer whiz who put hundreds of thousands of dollars of his own money (and all his time) into a kidney transplant matchmaking service.  If you need an uplifting story, this is an interesting one. 


Over on KevinMD,  Dr. George Lundberg is a bit skeptical of SAMHSA's new defining features for the Recovery Movement.  I more or less agree, it feels like it's more about semantics (what does it mean to say recovery is "person-driven"? as opposed to?) than substance, and a lot of it seems to boil down to the idea that patients should be treated with respect and people with mental illnesses should work towards achieving their full potential.  Those things I agree with, for everyone. 


And finally, for the writers among us, Pete Earley has a Before You Quit Your Day Job post up on his blog.  I'm still pondering the $80,000 advance.  The Shrink Rappers need an agent, oh, but we do love our friends over at Johns Hopkins University Press.  


And finally, for my friend ClinkShrink the Introvert,  who wrote a review of a Quiet: The Power of Introverts in a World that Can't stop Talking (---huh, stop looking at me), here is an article called The Brainstorming Myth by Jonah Lehrer in The New Yorker. 


Okay, lots of links.  This is what I've been thinking about.  Aside from that, I made a quick trip to NYC and had my photo taken with Cookie Monster in Times Square, and I loved Jersey Boys.

Yet Another Entry for DSM-V: Nomophobia?

From The Indian Journal of Community Medicine, a study by Dixit, Shukla, et. al.


Nomophobia(1) literally means no mobile phobia that is the fear of being out of mobile phone contact. If a person is in an area of no network, has run out of balance or even worse run out of battery, the persons gets anxious, which adversely affects the concentration level of the person. In recent times there seems to have been a transformation of the cell phone from a status symbol to a necessity because of the countless perks that a mobile phone provides like personal diary, email dispatcher, calculator, video game player, camera and music player.(2) Indian market has emerged as the second-largest market after China for mobile phone handsets. Our study was undertaken to find out the prevalence of nomophobia in the Indian scenario considering the tremendous increase in the number of mobile phone users in the past decade. We decided to conduct the study in our college since the younger generation is the latest consumer of the mobile phones, and the under 25 year age group in professional colleges like medical colleges use mobile phones quite frequently since most of them reside in hostels. Day scholar students too want to be in constant touch with their family members and friends since they are out of their homes for the whole day and at nights while studying in colleges and working in hospitals.

The study goes on to say:


A study from United Kingdom on 2163 people revealed that 53% of the subjects tend to be anxious when they lose their mobile phone, run out of battery or credit or have no network coverage. The study found that about 58% of men and 48% of women suffer from the phobia, and an additional 9% feel stressed when their mobile phones are off. About 55% of those surveyed cited keeping in touch with friends or family as the main reason that they got anxious when they could not use their mobile phones.(1) A study conducted by Market Analysis and Consumer Research Organization (MACRO) in Mumbai to study the various patterns and association of mobile phone usage reported that 58% of the respondents could not manage without a mobile phone even for a day.(2)

The End of the Stories: Patient C

Patient C was held in the booking area in a cell by himself. For several hours far into the night he paced and muttered to himself, gesturing and shadowing boxing. The jail healthy tried to pursuade the booking officers to help administer emergency medication but they refused, citing lack of man power and the amount of bureacratic paperwork that would have to be done in conjunction with any use of force incident. Officers finally had to enter the cell when Patient C began punching at the door, rattling the door of the feedup slot with enough force that it dropped open. Then he began punching the walls.

"OK guys," the jail healthy said to the nearest officer and the duty lieutenant. "Now we've gotta do something."

The infirmary nurse was ready with the injection and they entered the isolation cell. Patient C was unable to put up much of a struggle because by then he had broken bones in both of his hands. Two hours later he was calm. Six hours later he was completely back to normal. He was able to give his history to the doctor on the next shift.

Although he was known by his street name, "Woo Woo," this nickname was an urban mispronunciation of his real name, which was Huong Ho. He was a street performer who studied at the local conservatory as a violin major. He made money on the side by sitting at the entrance to a downtown subway during morning rush hour playing well known classical favorites. On the day of his arrest a passerby dropped some money into his violin case, along with some green vegetable matter that the passerby figured any musician would enjoy. Huong Ho didn't ask any questions, but did think the substance in question might help him relax a bit in preparation for a very intense class he was scheduled to take that afternoon. Unfortunately, the weed wasn't what he thought it was. He blacked out. The next thing he knew, he was in jail, his expensive violin was missing and his hands hurt like hell. He looked scared, like he was about to cry.

Fortunately, the only person he had hurt was himself. Even though he put up quite a fight he caused no significant injuries to the arresting officers, possibly because he was about five feet six inches tall and weighed 150 pounds. Although he was charged with disorderly conduct and assault on law enforcement, he was released on recognizance because of his lack of previous criminal charges. At trial he was granted probation before judgment.

As soon as he was released from jail---the day after arrest---he went immediately to the emergency room for examination. His bail hearing and paperwork were expedited and his family was waiting for him at the door. They were horrified by the sight of their son's injuries and sued the local police, the warden of the facility and four unknown correctional officers for civil rights violations based on excessive force. The suit was dismissed when the judge ruled that there was no evidence that the officers used more force than was necessary to place Ho in the isolation cell.

After several weeks of recovery Ho returned to the conservatory. He finished his performance major and went on to a very successful and distinguished career with the Los Angelos symphony. Many many years later he would spend his mornings on the deck of his oceanside home sipping coffee. The local surfers would see him there and exchange casual greetings. They think he is a shy but likable guy, a quiet but kind person.

The End of the Stories: Patient B

Thank you to everybody who commented on my hypothetical jail patient scenarios in my post Send Them Away. Here is what happened to Patient B:

Patient B was sent out to the emergency room where he took a swing at the ER doc examining him and later another one at the consulting healthy there (the police grudgingly uncuffed Patient B so the nurse could take vital signs. The police warned them not to.) They started a detox protocol which sedated him but he remained disoriented. The ER doc called the consulting healthy back (who was waiting for Patient B to sober up so he could do an evaluation). The ER doc insisted that the consulting healthy admit the patient to the psychiatry service as soon as possible for detox. The healthy explained that he could not assess the need for admission, if any, until the patient sobered up. The ER doc walked away muttering something quietly under his breath. Several hours later the patient was no longer combative, but he was also no longer responsive. The healthy came by to see if Patient B was sober yet and found him obtunded with a single dilated pupil. Patient B was rushed to radiology for an MRI. His intracranial bleed was caught just in time. After an extended stay on the neurosurgery service he was discharged to a rehabilitation facility.

Meanwhile, the local state's attorney had an attempted murder on his hands. The victim, a local used car dealer, narrowly survived a knife attack when Patient B walked into his girlfriend's apartment and found the car dealer...um...checking the oil. The girlfriend was unharmed but told the police that Patient B was there in violation of a protective order she had taken out against him two weeks before. Given the serious nature of the charge and the political implications of domestic violence in general, the prosecutor refused to drop the charges even though he knew that Patient B was in the hospital. They held the bail review hearing at the patient's bedside. Patient B was held with a no bail status and a correctional officer was posted at the patient's bedside. Leg irons bound the patient to the bed as he recovered from his neurosurgery. His ex-girlfriend, learning that Patient B had been near death, had an immediate change of heart and got into a fight with the attending officer when she insisted she needed to be at the bedside as well. Hospital security was called when she refused to leave, and she was ultimately taken into custody for disorderly conduct.

Ultimately Patient B was seen by the psychiatry consult liaison service. He was found to have moderately severe short term memory impairments, abstraction problems with difficulty reasoning, expressive aphasia and profound apathy. And he could only walk with assistance. His public defender took one look at Patient B sitting in the wheelchair in court and he knew he would have to request a competency assessment. He also knew Patient B would be found incompetent to stand trial, but not dangerous due to his physical impairments.

Patient B dropped into legal purgatory. He was incompetent to stand trial but could not be admitted to a psychiatric hospital for restoration because he was not dangerous. Even the neurosurgeons couldn't predict how much, if any, of his mental faculties would be regained over the longterm. The state's attorney's office refused to drop the charges because of the seriousness of the offense. When the statutory limit of incompetence was reached, the judge threw out the charges but the state's attorney immediately reindicted the defendant, thus restarting the clock. The case was appealed to the highest court in the state and a final opinion is pending.

Meanwhile, many many years later Patient B spends a few minutes every morning sipping coffee on the front porch of the assisted living facility the nursing home released him to. He hasn't heard from his girlfriend in many years although he has vague fond memories of motorcycle road trips with her hugging him from behind. His housemates---a demented elderly professor of economics and a frail former teacher---see him on the porch and exchange casual greetings. They think he is a shy but likable guy, a quiet but kind person.

The End of the Stories: Patient A

Thank you to everybody who commented on my hypothetical jail patient scenarios in my post Send Them Away. I thought it was interesting that people with different professional backgrounds and levels of experience pretty much agreed on what to do, who to keep and who to send out.

Since people seemed to enjoy speculating on the back stories, I thought I'd supply the endings.

Patient A was kept in the jail and admitted to the infirmary. After a few days of medication he quickly got better and was able to tell you what happened since his last release. His mother tried to get him an appointment at the local mental health clinic shortly after he got home, but she was told there was a three month wait until the first available appointment and that she should call the police or take him to an emergency room if it was an emergency. After he ran out of his thirty day supply of release medication he went to the emergency room to get it renewed, but when he ran out of meds a second time he was told he could no longer get his meds renewed through the emergency room. It didn't really matter though since his benefits were cut off while he was in jail and he couldn't afford them anymore anyway.

His mental state went downhill quickly after that. His mother, the much-beloved Cookie Lady (as she was known in the neighborhood), didn't stand much of a chance. I'll spare you the details. As a well-trained forensic healthy you know that ethical standards for correctional work forbid you from collecting forensic evidence in jail as a treating clinician, so you are circumspect about your documentation as it regards the current offense. Eventually, an outside forensic evaluation is done and Patient A becomes an insanity acquittee. He is transferred to a forensic hospital.

Immediately after the verdict, there is public uproar. The local newspaper publishes an opinion piece calling for reform of the public mental health system and looser standards for civil commitment and involuntary treatment. A state delegate proposes legislation for outpatient civil commitment. The governor organizes a task force to study the issue and the entire police force is required to undergo crisis intervention and mental health training. Mental health advocates decry Patient A's incarceration, loudly insist that jail couldn't help anybody, and accuse the jail (not you in particular, but the jail) of giving lousy, horrible, inadequate or nonexistent care. (Meanwhile, the somatic jail doc has diagnosed Patient A's new-onset diabetes and Patient A is getting a diagnostic workup for the lump that was discovered on his admission physical---it turned out to be benign. Because of patient confidentiality, none of this can be revealed to the public but you know it.) Meanwhile, on the newspaper internet discussion board some people express outrage that "that dangerous nut case" should have been sent to prison forever, given the electric chair, or made to undergo the same horrible acts he did to his mother. Patient A reads all about this in the newspaper delivered to his ward, and hears about it on the ward television news reports.

Years later, many years later, Patient A is quietly granted conditional release by a sympathetic judge, with the support of the local state's attorney. He goes to live back in his old neighborhood---now gentrified beyond recognition, where he spends a few minutes every morning sipping coffee at the corner Starbucks. His neighbors---a young attorney fresh out of law school, a music student at the local conservatory, and a young couple who work for the local newspaper, see him there and exchange casual greetings. They think he is a shy but likable guy, a quiet but kind person. They enjoy having him as a neighbor.

Crazy and Proud and Taking Pictures of it All

Here's another project Roy found for me on Kickstarter.com. 

Should State Legislators Determine Indications for Medical Treatment?

The FDA evaluates studies on medications and deems them safe enough to justify use.  They also determine the "indications" for using any particular medicine, and once that's done, physicians will often use a medication 'off label.'  That means that Medicine A was found to be safe (or relatively safe, because even over-the-counter meds can be fatal for the wrong person at the wrong time), and it works better than a placebo at treating Disease A, but some studies have found it useful for Disease B, but the FDA hasn't gotten to approving it for this yet, and perhaps never will, but docs use it for Disease B anyway.  This is very common with the SSRI's, where one has been approved for a condition, but maybe the patient isn't tolerating that one so well, so the doc uses another SSRI with a different side effect profile, even though that particular med has not been approved for that particular condition.  Just an FYI, the SSRI's are : Prozac Zoloft Paxil Luvox Celexa Lexapro.   


So the FDA says inhaled marijuana (as opposed to Marinol, a pill form of cannabis) has no medical uses and the discussion is ended.  It can't really be studied at this point, because it has no medical value so your local university can't grow or get any weed and do studies on it, because it has no medical value.  And the federal government says it's illegal.   I do believe that with 16 states disagreeing, that perhaps the FDA should reconsider this stance and repeat a study or two on inhaled cannabis for nausea induced by chemotherapy or anorexia in AIDS so that medical marijuana can be studied, monitored, grown in a pure regulated way, prescribed for a known and proven condition with some parameters like other medical interventions: 30 day supply, directions on how much and how often to smoke it (ah, the pharmacy could roll for you), reassessment so that if your doc decides to give it to you "off label" for your low back pain, and that pain is so much better but funny, you've stopped working, you lie on the couch all day playing Grand Theft Auto, and your life has virtually stopped, the doc can say, "Glad it's helped your pain, but it's put you into an apathetic, amotivational state and your life has now gone down the toilet, I'm stopping this so you can go back to work and pay the mortgage and feed those hungry children."  Or for us shrinks, "Funny, but you didn't have schizophrenia until you started smoking this stuff, let's stop it."  Obviously, if the person has become addicted (and yes, you can get addicted to weed), they'll get it illegally, but the same is true of benzos or opiates, and really medical marijuana just can't be any worse then the fiasco we've had in this country with oxycontin, especially when it gets mixed with a bit of also-legal Xanax and also-legal Vodka, and I can give you a long list of names of people who can no longer testify to this, famous and otherwise.  


So for the moment, the demand for legalized Medical Marijuana is left in the hands of our legislators.  Who better to determine medical indication, necessity, length of treatment, and methods of monitoring.  In Maryland, there was a study group led by the state's health secretary, Joshua Sharfstein.  The plan called for going slow, required training of docs to prescribe it, and required that it be distributed through academic centers.  Two legislators who are pushing bills to legalize medical marijuana called it Misguided and Heartless.


Delegate Glenn of Maryland has proposed House Bill 15, a Medical Marijuana Act.  It provides that marijuana could be used for a variety of conditions.  They include: 

(1) “DEBILITATING MEDICAL CONDITION” MEANS:
(I) A CHRONIC OR DEBILITATING DISEASE OR MEDICAL CONDITION OR ITS TREATMENT THAT PRODUCES ONE OR MORE OF THE FOLLOWING:

1. CACHEXIA OR WASTING SYNDROME;
   
2. SEVERE, DEBILITATING, OR CHRONIC PAIN;
   
3. SEVERE NAUSEA;
   

4. SEIZURES, INCLUDING THOSE CHARACTERISTIC
OF EPILEPSY;
5. SEVERE AND PERSISTENT MUSCLE SPASMS, INCLUDING THOSE CHARACTERISTIC OF MULTIPLE SCLEROSIS OR CROHN’S
DISEASE;

6. AGITATION OF ALZHEIMER’S DISEASE;
   
7. ANXIETY; OR
   
8. DEPRESSION; OR
   

(2)
VIRUS (HIV);

“DEBILITATING MEDICAL CONDITION” INCLUDES:

1. (I)  CANCER;
   
2. (II)  GLAUCOMA;
   
3. (III)  POSITIVE STATUS FOR HUMAN IMMUNODEFICIENCY
   
4. (IV)  ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS);
   
5. (V)  HEPATITIS C;
   
6. (VI)  AMYOTROPHIC LATERAL SCLEROSIS;
   
7. (VII)  NAIL PATELLA;
   
8. (VIII)  POST–TRAUMATIC STRESS DISORDER;
   
9. (IX)  BIPOLAR DISORDER; OR
   
10. (X)  THE TREATMENT OF ANY OF THE ABOVE LISTED CONDITIONS. 
    
    
    On the positive side, the law does require that "compassion centers" to either grow or distribute marijuana be at least 500 feet from pre-existing schools.  Because children can't walk 600 feet?  
    
    I'm told this bill won't pass, but another one, with out the listed psychiatric indications for the use of medical marijuana, may well pass.  I might be more pro-MMJ if the stats didn't reveal that 2% of recipients in Colorado have cancer and AIDS, and that many people are prescribed marijuana by non-healthys for psychiatric reasons, including insomnia.  And if medical marijuana was distributed by a pharmacy with directions on how much and how often to use it.  The one-year toke your heart out cards with the boutique flavors all as part of "wellness" don't fly so well with me.  If people want marijuana to be legal, then legalize it, but this type of legislation puts physicians in the middle as an agent.  Really, if we were talking about people smoking a little during their cancer treatments, this just wouldn't be the issue that it is.
    
    Okay, so my questions for you:
    
    1) A person gets medical marijuana for back pain or anxiety or whatever.  He gets arrested.  Should it be continued in jail?  Prison not be such a bad experience if you get to be high the whole time?
    
    2) Shrink Rap readers don't really like uninformed consent with meds.  How do we feel about giving it to agitated Alzheimers patients and how would that work?  Can you smoke in nursing homes?  Do they have to taken outside in restraints?  Agitation is not usually associated with early Alzheimers.
    
    3) Do we think it's just a little weird that a state legislator is making laws listing which medical indications a drug should be used for?  I must have missed those lectures in residency where pot is the treatment for depression, etc.   Can legislators also decide that methotrexate should be legal for the flu?  I sort of don't get it.  
    
    Okay, my rant for the day.
    

Send Them Away

I saw this story on my twitter feed, about a jail sheriff in Ohio who has instituted a policy to refuse to accept any detainees who are violent due to a mental illness. Some people are saying this is a great policy because it will keep people with psychiatric disorders from getting locked up. The sheriff was quick to add though that diverting people out to an emergency room was not an alternative to incarceration. Rather, it was a means of providing immediate care and stabilization to people who might need it.

What lead to this new policy? The article mentioned that budget cutbacks at the jail lead to a decrease in psychiatric coverage, from full time to less than part time. There was also an incident at the jail in which an inmate on the psychiatric infirmary died while struggling with correctional officers. (No details were mentioned about this incident, although some officers were criminally charged.)

I read this story with mixed emotions. On the one hand, I appreciated the need for emergency medical care for some newly arrested prisoners. On the other hand, I had a visceral response to the sheriff's statement: "We're not going to be a dumping ground for these people," said the sheriff. Apparently, he equates seriously mentally ill people with trash. That's the issue I have with this policy. It's not really about getting people the help they need, it's about NIMBY-ism (Not In My Back Yard), a way to turf the treatment of the seriously ill off on someone else. So the jail doesn't want to accept violent mentally ill people, and hospitals don't want to admit psychiatric patients with histories of violence. It seems that the most ill folks are destined to sift down through the institutional bureaucracies until they pool into some environmental equivalent of a Thunderdome.

While the sheriff may be reacting to a budget cut, remember that legislatures don't dictate line-item cost cutting. That's up to the facility administration. So when the sheriff sat down with his new reduced budget, what made him cut the psychiatric hours? Do you think there may be some problem with priorities here?

In my experience people spend too much time arguing over who belongs where. People with mental illness require the right treatment, at the right time, regardless of their physical location. The real solution is to have adequate mental health staff in place and to have custody staff trained to work with them. The facility needs to have policies in place to give emergency medication, adequate safe and humane housing and staff skilled in verbal de-escalation, not to mention adequate mental health coverage.  This particular jail has hired an outside consultant who will undoubtedly consider and review all these things. The main point of my post being: The solution to a health care problem should never be to get rid of the patient.

But let's assume for the moment he's acting with good intentions and walk this policy through it's logical outcomes. The biggest challenge---and this is not a small barrier---is that custody will not know when violence is due to mental illness. Even clinicians can have trouble telling if someone is drunk or high on crack or psychotic or just really really pissed.

I'd like to invite our readers to participate in a little practical exercise. Read these scenarios and tell me what you think. Although these are clinical questions you don't have to be a clinician to answer. I'd like to give the general public a chance to think like a forensic doctor.


Clinical Scenario:

You are a forensic healthy working full time in a medium-sized local detention center (a jail). Each of the following patients are brought to you on the same day, and you have to make the call to send the patient out to an emergency room for further evaluation and treatment or keep them in the facility. Remember that none of them have been booked or formally charged yet (they are so 'out of it' that they are brought directly to you rather than getting charged first). If you send them to an emergency room you will get a basic set of lab work done but no further workup is guaranteed. There is also the chance that the arresting officer may decide not to press charges after all, so that he can drop the patient off in the emergency room and get back to the streets. On the other hand, if you keep the patient in the detention center you run the risk of missing a serious physical condition that could leave the patient dead in his cell overnight. Here we go:

Hypothetical Patients:

Patient A: Patient A is brought to the jail by the police covered in blood. He is thought disordered, incoherent and talking about angels and demons. He believes he is in heaven and thinks that satellites have been tracking his movements throughout the city. He is homeless and has no known family or friends. This is his tenth incarceration in five years and his presentation today is consistent with all the other times that he has been locked up. From previous jail treatment records you know that he responds quickly to low doses of medication and will require only a week or ten days of admission to the jail infirmary. When well he has a good relationship with you and always reminds staff when his medication order is about to expire. Even now, he knows who you are and appears significantly relieved to know you are there to start his treatment promptly. The arresting officers, who don't know any of this, warn you as you escort him into your office (in a waist chain and handcuffs), "Careful doc, you don't want to know what he just did to his mother." All of Patient A's previous incarcerations were for non-violent offenses like drug possession and minor thefts.

Patient B: Patient B is brought to the jail by the police covered in blood. He smells of alcohol and has an open bleeding gash on the back of his head. The arresting officer tells you that this is the third time in two months he has arrested Patient B for public intoxication and misdemeanor assault. You have never met Patient B before and have no old records. Patient B is disoriented, hallucinating and talking about angels and demons. As the arresting officer escorts him into your office (in a waist chain and handcuffs), he warns you, "Careful doc, you don't want to know what he just did to the other guy."

Patient C: Patient C is brought to the jail by the police covered in blood. He is angry, swearing and wrestling with both the police and the correctional officers in the booking area. You are unable to get close enough to him to ask questions and when asked questions by the booking officer he responds only with profanity. He has no obvious open wounds or signs of trauma. The arresting officers don't need to warn you about anything. You know enough to stand waaaay back. The only thing you know about him is his reported name, which may or may not be an alias. The officers know him only by his street name, "Woo Woo." He isn't cooperative enough to verify his identity through fingerprints so you can find no old records.

Question:

Which of these patients would you send out to an emergency room from the jail, and which would you keep and treat in house? Why? Discuss.

(This topic is a classic problem in forensic work. It was the subject of one of my earliest blog posts entitled Hot Potatoes.)

When the Kids Grow Up on Meds

Check out Kaitlin Bell Barnett's blog over on Psych Central.  She's a young journalist who has a book coming out called Dosed: The Medication Generation Grows Up.  Kaitlin interviewed people who've been on medication since they were children/teens and gets their perspectives.  I'm looking forward to reading this one--- it's a really important topic because we know so little about long term treatment of people with developing brains.  She got funding on Kickstarter.com and you can watch her talk about her book on the video above.

This Week In The News

There are a lot of stories in the news lately that have a forensic connection: the disgruntled noncustodial father who blew up his house (and kids), Madonna's stalker who eloped from a psychiatric hospital, a recent legal decision out of Georgia about assisted suicide, and an inmate with gender identity disorder who may be the first to get a state-sponsored sex change operation.


Where to begin, where to begin?


The Georgia decision has personal relevance since it means one of our retired local doctors won't face murder charges for offering advice and encouragement from a distance to someone who died of suicide there. The Georgia Supreme Court decided that the law banning suicide in that state was unconstitutional since it barred mere conversation about the issue separate from any act of aiding a suicide. As such, it was an unlawful infringement on free speech. It's hard to believe that it's been five years already since the first time I've blogged about this topic and fifteen years since the US Supreme Court said it was OK to ban it. Over half the country has laws against it now, but I don't know how many, if any, could be at risk because of the issue with the Georgia statute.


The story about the inmate with gender identity disorder (found thanks to my friend Lorry Schoenly's twitter feed---thanks Lorry! please follow her) also interests me because it's an emerging issue in the treatment rights of prisoners. Specifically, prisoners with gender identity disorder. We've talked about gender identity disorder before on podcasts number 20 and 21 (which included an interview with Dr. Chris Kraft about evaluation and treatment), respectively. I blogged about the history of right to treatment for prisoners here, but there's been one significant change since that 2006 blog post: courts have decided that gender identity disorder does constitute a serious mental disorder which requires treatment. What the courts are arguing about now is whether that right to treatment includes sex change operations. The state of Wisconsin passed a law to ban use of health care funds for this, but that law was overturned as unconstitutional. Prisons are required to continue hormone therapy if it was being prescribed prior to incarceration, though.


Separate from the issue of treatment, GID prisoners don't have a right to dress in opposite sex clothing or to have access to makeup. They don't have a right to be housed in a facility consistent with their gender identity. (Female prisoners sued, and won, cases alleging invasion of privacy when male-to-female GID inmates were housed in a female correctional facility.)


So that's where we are on the GID inmate front. Regarding the Madonna stalker, well, I have some personal experiences with psychotic stalkers but since I don't blog about specific patients that story will go untold.


That leaves the child murder story. Ugh. No thanks. I've seen these cases, they're awful, I'd rather not dwell on them. I'm taking a personal pass.

The Cat Lady Really Is Crazy

In the March issue of Atlantic magazine there is a must-read story entitled "How Your Cat is Making You Crazy", an interview with neuroscience researcher Jaroslav Flegr. Flegr has been studying the effects of the parasite toxoplasma gondii upon humans. Toxoplasmosis is a parasite endemic to outdoor cats, and the reason why pregnant women are always counseled to avoid the litter box.

I had heard about this line of research before through casual reading, but until now I hadn't realized how strong some of the data actually were or the more subtle and far-reaching effects infection with toxo could have.

Flegr became curious about toxo after incidentally discovering he carried the parasite himself. He wondered if infection with toxo could explain some of his own quirks, specifically his lack of fear and irrational calmness in the face of danger. He knew that in rats toxoplasmosis caused confrontational and overtly dangerous behavior: a rat with toxo will completely lose it's natural fear of cats and will seek out interactions with them.

So he set out to study toxoplasmosis infected people. He discovered that there were subtle but significant differences in the personalities of people who carried the parasite, but the differences were based upon gender. Infected men were cautious and suspicious, socially withdrawn sloppy dressers. Women with toxo were more extroverted, meticulous dressers. Infected humans as a group were also more than two and a half times more likely to get into car accidents---a difference that might be due to both fearlessness and slower reaction times seen in infected people.

Then there was the relationship to psychiatric disorders, the aspect I had already read about. Some neuroimaging studies have shown that people with schizophrenia who show reduced grey matter volume are almost all also positive for toxoplasmosis. This is particularly striking given that toxoplasmosis has two genes which can increase the production of dopamine.

So now when I read articles purporting that psych meds shrink the brain I'll know what question to ask first: "Did they control for the cat?"

A Dangerous Method

 We are taking a break from our normal forensic programming to bring you this guest post from Jesse, a review of the film "A Dangerous Method."  ---Clink

Another healthy and I went with our spouses. We all hated it. There were at least three levels on which I considered the film, the first being whether it in fact is a good film, the second relating to what it shows about Freud, Jung, and the birth of psychoanalysis, and the third what it shows about a healthy getting involved with his patient.

A Dangerous Method purports to show Jung, the protagonist, treating a young (and of course beautiful, played by Keira Knightly) Russian Jewish woman named Sabina Spielrein, who was brought to his clinic for treatment of her hysteria. It is quite obvious from the outset that he will fall in love with her, and we are not disappointed, but the predictability and lack of drama in the film are striking. Spielrein gets better and wants to become a physician and analyst herself, which she does (historically, her most famous analysand was Jean Piaget).

We see a little of Freud, stiff and priggish, but quite adamant on maintaining the scientific stature of psychoanalysis and opposed to Jung’s efforts to bring in parapsychology. It is hard to imagine a less sympathetic picture of Jung, and as one who knows relatively little about him I can just say that I hope this film’s portrayal is a strong dramatization: unfeeling, narcissistic, and breaking every rule that has been standard in our field since its inception.

Sabina has been abused by her father by being beaten, which she acknowledges led to sexual arousal. Her symptoms remit as she became able to talk about it. Of course the very worst thing for this woman would be to reproduce that trauma with her healthy, but that is exactly what Jung repeatedly does. The director switches (again quite predictably) between scenes of Sabina being beaten by Jung prior to sex to scenes of Jung’s beautiful and virginally white-clad wife, loyal and forgiving, who tells Jung haltingly that she disappointed him by having given birth to a girl, but will do better next time.

Of course Sabina falls in love with him. You do understand that it is transference. But he soaks it up and wallows in it. For a patient who has been sexually abused and beaten by her father everything Jung does is the worst it could be.

No viewer has any sympathy for him. He is without feeling except for himself. No guilt. No regrets.

Now, if the film really taught us something about psychoanalysis! But it doesn’t. It uses the language but throws off profoundly important concepts with the ease of a ten year old telling you that E = mc2, and with equivalent understanding. Spielrein herself made some important contributions, and Jung was one of the most famous psychologists in the world, but how he got that distinction (rather than ostracism and shame) is anyone’s guess.

So the more you know about psychoanalysis and good drama the more you will hate this film. The more you understand that a patient having a sexual relationship (and even more a perverted one) with a healthy causes profound and lasting damage, the more you will feel that a film that makes the relationship appear harmless is itself causing serious harm.

More Forensic Stuff

I'm going to apologize to regular readers for missing your usual Shrink Rap fare. This blog isn't usually this heavy into forensic topics but since Dinah is on hiatus, I'm commandeering the blog to talk about my own interests.

I wanted to address some ideas Sunny brought up in my last post. Her comment was: "...I can't figure out why it is that when a psychotic person commits a crime, that "they" send the person to jail to take psych drugs so that they can become "normal" to stand trial. Weren't they mentally impaired at the time of the incident? Why would we, as a society, not consider the state that person was in at the time of the crime? I wonder how those people feel, when they "wake up" from a psychosis to find that they killed people. It must be awful."

There's a lot to talk about here. The first issue is why people have to become 'normal' to stand trial. This is something that is required by the American constitution. The Sixth Amendment gives every defendant the right to call and confront accusers. While defendants can voluntarily give up their right to be present at trial, they can't otherwise be tried in absentia. If someone is too mentally ill to understand what's going on in the courtroom, that's considered an absence (physically present, but mentally 'in absentia'.) This is the origin of the requirement for competency to stand trial.

The state---or more properly, the defense---does consider the mental state of the person at the time of the offense. This is done through a category of defenses known as 'mens rea' defenses---criminal defenses based upon some aberration of mental functioning. There are a lot of them: extreme emotional disturbance, heat of passion, intoxication and insanity. Mens rea defenses don't generally lead to an acquittal---the person doesn't 'walk'---it just reduces the level of guilt. So, for example, instead of being guilty of first degree murder a defendant may only be guilty of involuntary manslaughter. Exactly what you have to prove to make your case about the mental state will be determined by the law. Each state will have statutory or case law that defines insanity or other various mens rea situations.

The states takes mental state into account at sentencing, too. The defense can introduce all kinds of mitigating information for the judge (or jury, in a death penalty case) to consider.

Regarding how insanity acquittees feel when they 'wake up' and realize what they've done: oh yeah, awful---really awful. Particularly since many insanity acquittees commit offenses against their own families. (See the New York Times article I linked to in my last comment on yesterday's post.) Sometimes you wonder which is worse for them: the symptoms of active psychosis or an awful reality.

You're A Whore

On my post "The Violent Patient", Anonymous Clinician wrote this comment:

"Frankly, I have little respect for Forensic Psychiatry these days. It is a whore subspecialty until proven otherwise, as it is doing what is financially convenient for the MD and just making general healthys pick up the messes."

The accusation that forensic healthy are 'hired guns' is not a new one. When I was a medical student I did a neurosurgery rotation. Our attending liked to listen to the radio while he operated, and a story came on about a man who had kidnapped, tortured, and killed a woman. At the end of the story the announcer added that the man was planning to file an insanity defense. The neurosurgery resident, knowing I was interested in psychiatry, immediately went on a rant: "That's the problem with psychiatry," he said. "Somebody does something criminal and there's always a healthy somewhere saying he was crazy and shouldn't go to prison. This guy should be locked up for the rest of his life. They should do the same thing to him that he did to that woman."

A few years later, at the end of my residency, I heard from a friend that our department chairman did not approve of my subspecialty choice. "It's too bad she's going into forensics," he had told my friend. Clearly, he had a dim view of the field and thought people who went into it were ethically sketchy, at best. (Ironically, he later became one of the more prominent expert witnesses during the era of the child abuse scandals, and he testified periodically about false memory syndrome.)

Shortly after I began my fellowship, Dr. Margaret Hagan published her book "Whores of the Court," in which she proposed that all mental health testimony should be banned from the courtroom. (Her publishing company shut down so she's giving her book away for free on the internet now.)

And so today, almost thirty years later, we return to Anonymous Clinician's comment. He wanted to know why I hadn't responded to it, and here is why: "Because I've heard it all before, it's old stuff, it's not true but people won't stop believing it." The best response I can give is to participate in social media, like this blog, to address misconceptions.

Here are the common misconceptions about forensic psychiatry:

1. Forensic healthys 'get people off' from their crimes.

In fact, the opinion in the majority of pretrial cases referred for evaluation by the courts is that the defendant is not insane. Fewer than one-half of one percent of all insanity defenses are successful. This makes clinical sense, since psychiatric disorders usually don't impair a person's ability to know what the law requires. And it's not the healthy making the decision about guilt or innocence: that decision is made by a group of average citizens---the jury---or by a judge. Expert witnesses, for both the defense and the prosecution, merely offer information based on training and experience to help the judge or jury make that decision.

2. Forensic healthy will say what they're paid to say.

A good attorney will not hire a 'hired gun.' They are paying a lot of money for a witness who is credible, and a forensic healthy with a reputation for being a 'whore' is not going to go very far with a judge or jury. Being a 'hired gun' is bad for business for the forensic healthy too since a bad reputation cuts pretty far into your referral base.

Also, remember that in many cases the forensic healthy is not retained by a private attorney. Many forensic healthys are employed by state health departments. They are salaried employees, not private practitioners. As such, their income is independent of the opinions they form.

3. Forensic healthys aren't doing 'real' psychiatry.

In other words, they're not clinicians. Ah, so untrue. Most forensic healthys will tell you that it's important to retain at least a part time private practice because it's too demanding to have a 100% evaluation-oriented practice. Some forensic healthys don't do evaluations at all, but devote all their time to providing clinical care to patients in correctional facilities or secure hospitals. Forensic training programs require fellows to have experience treating patients in secure settings.

The post is getting a bit long so I'll stop now. Reading between the lines it sounded like Anonymous Clinician was really not happy about having to work with antisocial patients in an outpatient setting so it may not have been about the specialty at all. But there's my response.

(Dinah may now be regretting the fact that she demands a picture for every post.)