What I Learned Part 4

This is a belated post about the AAPL conference, since yesterday was devoted to finding my way home around Sandy. It's rainy heavily here and the wind is starting to pick up a bit. Dinah's at home waiting for a tree to fall on her house but there's no word from Roy. I'm hoping all our readers are home safe and prepared.

The last day of the conference was worth waiting for. I regularly attend the presentations given by the Computers in Psychiatry committee, and this year was no exception. Two presenters had to leave early due to the storm, but the remaining members talked about how to do Google power searches (using conjunctive and disjunctive search terms and site-specific searches) and other non-Google search engines (there's something other than Bing?). There was also a presentation about a wide variety of health care related smart phone apps. As yet, the FDA does not regulate these as medical devices and there is no standard method for assessing accuracy, efficacy or reliability. For those docs "prescribing" or recommending apps, there was discussion about whether or not the use of apps is becoming a standard of care for medicine and at what point there may be liability for their use---not following up on an app "flag" for instance. I was pleasantly surprised to see that one of the first psychiatry apps mentioned was "What's My M3?", a project that Roy has been affiliated with. (Maybe Roy might want to right a post about the standard of care and liability issues I mentioned? I'm sure this has been discussed and I'm curious.)

The last session of the day was about assessment of stalkers. I learned that three-fourths of more than 400 Canadian politicians had experienced an overt threat. When assessing risk, the assessment considers both the stalker and the situation. The three main considerations are level of persistence, risk of injury to the target and the potential for recurrence if the stalking has stopped or interrupted. The most persistent stalkers are those with psychotic illnesses, specifically delusions. Grandiose or erotomanic stalkers are less likely to present a risk of danger since they are seeking intimate contact rather than violent contact. People with paranoid delusions who are also angry are more likely to present a risk of violence. There's a lot more to these assessments, but those were the highlights that I took away.

That was the last session of the conference. I confirmed my flight as I left the hotel, but by the time I got to the airport checkin desk it was cancelled. Such is the risk of the AAPL conference. Last year at this time in Boston we were facing an impending snowstorm.

If you're in need of more conference fixes, I'd recommend the Child Sexual Abuse Conference (hashtag #CSAC12 on Twitter) which is live-streaming some talks.

What I Learned Part 3

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

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

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

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

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

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

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

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

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

What I Learned Part 2

Oh my, it's hard to keep my mind on professional things when I see a hurricane headed toward my home. The airline says they're not expecting it to affect my flight back, but I'll believe that when I see it.

But on to the conference...

The poster session was notable for a nice outcome study done in Georgia about the efficacy and cost impact of a jail-based competency restoration program. Another poster about assisted outpatient treatment in New York showed that there was considerable variation in willingness to seek outpatient commitment, possibly related to available outpatient services. There was a presentation about the use of restraints in pregnant psychiatric patients which was interesting. There was a national survey of mental health program directors which showed that up to 80% of responding systems had no established policy about this.

There was a panel presentation about the AAPL guidelines for sanity evaluations, which are being updated. Members were given the opportunity to comment upon the current guidelines and any issues that needed to be revised.

I was pleased to see ethics featured prominently at this conference, including a very informative panel presentation about the process by which AAPL and APA manage ethical complaints and the difficulties writing and enforcing professional guidelines. I learned that about 10 to 15% of ethical complaints to APA district branches are related to forensic issues.

The luncheon speaker was David Kaczynski, brother to the infamous Unabomber Theodore Kaczynski. He gave a very moving talk about his early life with his older brother, Kaczynski's gradual withdrawal from his family and society in general, and the slowly growing realization that his older brother was indeed a killer. He talked about his struggle to come to terms with his suspicions, the impact on his elderly mother and what it felt like to be caught between preventing future murders and potentially sending his brother to a death sentence. He talked about his work after the trial, reconciling with some of the victim's families. My most memorable quote: "Teddy's bombs destroyed lives, but healing is possible."

The early afternoon session was a smorgasboard of random topics. There was a survey of judges regarding their willingness to allow defendants to represent themselves at court (pro se defenses). Judge weight heavily the defendant's ability to understand the risk of a pro se defense and the defendant's willingness to accept standby counselor. Psychiatric input is considered, but mainly as it related to a description of symptoms and impairment rather than the ultimate opinion of competence. There was a description of a telepsychiatry program used in the New York prison system, where fourteen facilities used teleconferencing to provide over 12,000 patient contacts in one year.

Finally, the secondary them of this conference appears to be the use of psychological tests by healthys. The last session of the day was entitled "Psychology vs Psychiatry in Risk Assessment". The panel presented individual cases and general principles related to the use of violence prediction instruments and how they are currently used in forensic work. The limitations of these instruments were also discussed, which was interesting because this is not something that often gets discussed by those who use them (at least in my experience). One example of this was the use of a violence risk instrument for conditional release. Since the risk of dangerousness must be due to a mental illness, and since the instrument did not rely upon illness-based dangerousness, the instrument was not relevant to the legal question at issue.

So that was the day. You can follow my live tweets from the conference at: www.twitter.com/clinkshrink

What I Learned Part 1

Those of you who have been reading the blog for a while know that every year I blog and live-tweet from the American Academy of Psychiatry and Law conference. This year we are hosted in Montreal, the land of fine dining and the most beautiful language in the world. Thus, the foodie picture. When I fly back I will be carrying extra baggage and I don't mean my luggage.

The poster session this morning was quite crowded and I wasn't able to get near most of them, but I did see a lot about legal and clinical implications of synthetic marijuana. Forty-one states have laws criminalizing sale and use of these new chemicals which go by a variety of street names. Effects on mental state can be extreme, including disorganized and violent behavior and hallucinations. So far there are no known longterm clinical effects associated with its use, however. Intoxication has been used in criminal defenses to mitigate culpability (although not generally successful as the basis for an insanity defense) and in states where the substances are still legal courts are struggling to figure out how it should play into a mental state defense.

Dr. Charles Scott gave an outstanding presidential address entitled "Believing Doesn't Make It So: Forensic Education and the Search for Truth." He discussed the evolving---and higher---expectations for forensic evidence, including psychiatric testimony, and how this should inform forensic training and practice.

The next session was a very nice (if I do say so myself) panel presentation about civil commitment of mentally ill offenders following release from prison. California has a mandatory civil commitment law which requires transfer of certain violent offenders with serious mental disorders to a psychiatric hospital at the end of incarceration. Legal challenges to this law were discussed and compared to the New Jersey system, which uses a non-mandatory administrative procedure instead. Finally, these procedures were compared to the state of Maryland where there is no established transfer policy but a wide degree of consultation and collaboration between the correctional and mental health systems, which in many cases obviates a need for hospital transfer.

[At this point in the day I stepped out for lunch and came back four courses later. Oh my, the food was amazing.]

The afternoon session was a very practical panel presentation about who should get access to forensic reports and the implications of HIPAA on evaluee access to protected health information in the report. Historically forensic reports were considered legal work products rather than medical documents, and as such an evaluee did not necessarily have a right to get a copy of or read the report. Under HIPAA some types of reports---such as a disability evaluation or fitness for duty evaluation---might be considered to be protected health information which an evaluee has a right to access. This is an evolving area, however. And under HIPAA, evaluees do not have a right to reports generated for civil, criminal or administrative hearings. This isn't a settled issue and there was good audience discussion.

The evening session was a mock trial which presented the new DSM 5 proposed criteria for hebephilia. The limitations and implications of the new criteria were discussed, which appeared to rely heavily upon an assessment of the victim's Tanner stage. The issue was presented in the context of a fictional sex offender civil commitment hearing, with three mock experts: one for the state, one for the defense, and one independent court-appointed expert. A strong case was made against inclusion when the defense expert testified that the new criteria could result in an 80 percent increase in false positive diagnoses.

So that was the first day. More to come so stay tuned. Live-tweets can be followed at: www.twitter.com/clinkshrink. [For those concerned about speakers' informed consent for social media coverage, all presenters are advised at abstract submission that sessions are recorded and they know that sessions may be covered by the media.]

What I Learned Part III

• More on social media and medicine today. One survey of a surgery department showed half of residents and faculty had public Facebook accounts and a third posted professional information.
• People are using "mindfulness" therapy to treat sex offenders. No studies on efficacy.
• Offenders with bipolar and psychotic disorders are twice as likely to have more than two additional arrests than non- SMI offenders.
• Some criminal defendants try to claim that the government is a corporation, and that they should be tried under contract law rather than criminal law. This is sometimes called a "straw man defense" and may prompt judges to request a competency assessment.
• Defendants who graduate from mental health courts demonstrate improved life circumstnaces with regard to housing, quality of life, symptoms and compliance. Some studies have shown mental health courts to result in improvement for as many as 78% of defendants.
• Court ordered custody evaluators are more likely to recommend paternal custody if the mother is poor or has a history of psychiatric admissions. They are more likely to recommend maternal custody if the father has a history of arrests.
• No suicide prediction tool has a predictive validity greater than 3%.
• Forty percent of patients given opioids for non-cancer pain misuse their meds, 5% become addicted.
• In the UK people with ASPD may be subject to multiagency public protection agreements, sharing information between government agencies.

Coming up tomorrow:
      Correctional risk management and the forensic sciences sampler. Good luck to everyone without power in the snow!

What I Learned Part II

Psychiatry residents on the APA listserv were surveyed about their experiences with social media. 9.7% of residents had gotten friend requests from patients. The remaining residents were asked what they would do if they got such requests. 85% of residents said they would automatically ignore them. 15% said they would discuss the request with the patient, then decline it. Less than 3% of residents received any training about proper social media use in residency. Half admitted googling their patients.

One poster presented the results of a one year study of four major media outlets: the New York Times, the LA Times, USA Today and Fox News. The outlets were culled for articles related to mental illness and violence. The stories were scored according to how many contained one of the follow true facts about mental illness and violence:
1. The majority of mentally ill are never violent.
2. People with mental illnesses are more likely to be victims of violence than perpetrators
3. People with mental illnesses are more likely to be violent against themselves than against others
4. When violent, they are more likely to victimize family than strangers.
Fewer than five percent of the articles contained any of these facts.

The state of New York has successfully used electronic monitoring and regular clinician feedback to reduce the use of polypharmacy in the state prison system.

All state prison systems were surveyed regarding their policies regarding pornography. Of 43 responding states, all banned material that represented a risk to institutional safety and security. There was high variability regarding allowed visual or verbal depictions of sexual acts. There is no published data to support any policy link between prison safety and the presence of pornography.

Crisis intervention training for police is thought to be helpful to reduce incidents of violent outcomes when responding to acutely mentally ill people, but the content of the training varies between program and lacks consistency. There also needs to be more outcome studies to learn if these programs do actually divert mentally ill people out of the criminal justice system.

The PCL-R is coming under pressure as a risk prediction tool. There was a great pro-con debate about this presented by a panel of Broadmoor Hospital healthys. Although interrater reliability is 0.8, there is still significant variance in scores and this could be enough to cause inconsistency when using cutoff scores to determine readiness for release from their severe personality disorder program. It stood out as a risk prediction tool in the 1990's because it was the only one of its kind, but newer tools are being developed with better ROC-AUC scores.

Lastly, multiple personality disorder is coming back. In spite of recent books such as Sybil Exposed, Creating Hysteria and I'm Eve, which document the role the therapist played in the creation or course of the disorder, one presentation today still featured a criminal defendant thought to suffer from multiple personality disorder. This presentation would have been much more effective had there been another expert presenting the potential pitfalls of examining criminal defendants for this disorder. The healthy in this presentation fell into many of those pits: he presented a videotape of the interview in which he asked probing and leading questions (admitting at one point he had to "dig" for symptoms for 20 minutes before the defendant reported any!), and occasionally referring to the defendant as a "patient" rather than as a defendant---clear evidence of bias. The redeeming feature of the presentation was an overview of case law regarding competency and insanity and MPD.

In 2006 there were 4000 civilly committed sex offenders in the US. In this panel they took maps of several large cities in New York, overlaid a map of schools and school bus stations, then overlaid a map of available housing. Finally, the last overlay was a map of legal exclusion zones---boundaries of areas that were legally "off-limits" to convicted sex offenders. This illustrated, at least in Buffalo, New York, that there was literally no place for a sex offender to legally live within city limits. Then they overlaid a map of reported home addresses of sex offenders: 90% were living in restricted areas. There is increasing evidence to suggest that sex offender registration and living restrictions may increase recidivism.

So that's the second conference day. I also enjoyed the computer committee's presentation, which was a two hour geek-fest off all things tech and forensic. It's something you just have to witness to appreciate, sorry. Lots of cloud-based software for document management and report-writing. Not relevant to most Shrink Rap readers but fun for me.

What I Learned Part I

Regular readers know that every year I tweet and blog from the conference of the American Academy of Psychiatry and Law. This group of forensic healthys consists of about 1800 of the country's practitioners. Topics are quite diverse and sometimes rather unusual. It's a lot of fun. Here's just a small smattering of factoids I picked up yesterday:

• The "sovereign citizen" defense can prompt a competency eval, but is not a delusion. The sovereign citizen movement is a recognized subculture of people who believe the government has no jurisdiction over them.
• Of 200 defendants cleared by DNA, one-fourth had confessed to the crime.
• According to FBI uniform crime reports, between 2001 to 2009 2.2% of police murders took place while responding to calls involving a mentally ill person.
• The collection and selling of serial killer memorabilia is also a venue for potential fraud.
• President Peter Ash gave an interesting and useful Presidential address about juvenile violent offenders. Persistent juvenile offenders tend to become more impulsive with age, not less. They commit an average of 30 to 70 previous offenses before they are caught for the index violent offense. They differ from adult violent offenders in that they tend to act in groups rather than alone, they commit impulsive rather than planned violence, and their criminal activities tend to be more diverse than adults. There is a .3 correlation between juvenile psychopathy scores and later adult psychopathy, but this only accounts for ten percent of the variance. Translation: most violent juvenile offenders do not become violent adults. Nobody knows for sure why.
• There was frequent discussion of the hazards and pitfalls of involvement in social media, including discussion about using it to impeach or undermine witness credibility. So far though, when questioned nobody had actually seen this happen to an expert witness. Concern seems to be out of proportion to reality.

HIGHLIGHT OF THE DAY:

My favorite part of this first conference day was the luncheon speech by Pete Earley. Mr. Earley is a former Washington Post report and New York Times bestselling author who's son has a serious mental illness. His book Crazy is required reading in my training program. The book is a description of life inside of one state's broken forensic mental health system. He is passionate and compassionate, and a vigorous and outspoken advocate. The audience was clearly captivated by what he had to say, and at sometimes it was frankly hard not to stand up and shout 'amen'! when he made his points. (Take home quotes for me: "Never give up hope! People get better!" and "A single person can change the system.") I was thrilled to finally meet this very warm man whom I admire. And I'm not just saying this because he wrote a blurb for our book!

SUB-HIGHLIGHT:

I attended a presentation about healthys in the media. The panel presented an interesting categorization of activities: healthy as scientist (presenting and interpreting studies), educator, storyteller, celebrity commentator and curbside therapist. I was surprised and flattered to see the home page of Shrink Rap, and the cover of the book, as an example of "healthy as educator" in the media. I'm glad to see we seem to be accomplishing something helpful.


So that's the first day. You can follow me on Twitter (see the sidebar). If you're here at the conference and want to #OccupyAAPL, drop me a note!

What I Learned: Part 3

Continued coverage of the American Academy of Psychiatry and Law (AAPL) conference. For Part 2, click here.

The first talk of the day was a discussion of SB1070, the Arizona law which required police officers to verify the citizenship status of anyone suspected of being an illegal alien. I learned that there were several parts to the law and that some parts were under injunction and were working their way through legal challenges. An immigration attorney talked about the ambiguity of the law and how it could be misapplied. For example, one provision barred anyone from picking up day laborers. In theory, it could be used against emergency medical personnel who transported illegal aliens. He also talked about the problems faced by mentally ill illegals who were deported to Mexico where they had no family support or access to mental health services.

I was planning to go the session about fMRI's in court, but I ended up getting invited on a trip to Tupac, AZ. Very cool little place with nice shops. Incidentally, Tupac is just past the Titan Missile Museum. I didn't go tour the museum because it creeped me out a bit but you can see a short video of the place on their web site.

I got back for the afternoon sessions. Dr. Ezra Griffith gave the Isaac Ray lecture entitled "Identity, Representation, and Oral Performance in Forensic Psychiary." I could never give it justice in a short summary. Fortunately you can read the full text of his talk here, because AAPL continues to be one of the few organizations that still keeps it's articles open to the public for free. Griffith talked about the role of perfomance in expert testimony. While most people would think of this solely in terms of communication skills, he put testimony in the context of the performing arts or literary narrative. The telling of the crime "story" is like drama, with behavioral elements and a physical context (the court room). The expert's purpose is to develop the facts as one would a character, so that the listener can hear the facts in a coherent way and is able to infer a line of understanding about the case. The jury then chooses between two competing narratives, the defense and the prosecution. Read the paper, Ezra explains it much better than I can.

The last session was about privacy in forensic psychiatry. I tweeted the highlights until my data coverage gave out. There was a lot of discussion about the "evils" of social media and the Internet, and how it could be used against you. There was no mention of any potential utility of Facebook, Twitter, blogs, etc. which I found highly ironic. Here I am using these same tools to (hopefully) provide a little public education while the speaker was cautioning the audience against them. The second speaker gave a great presentation about patient privacy rights in the emergency department. He presented literature that psychiatric patients get disrobed and searched in the emergency department twice as often as medical patients, although both patients are equally likely to bring weapons into the department (about 14% of all ED patients are found with weapons). Finally, there was an interesting talk about DNA privacy, legal cases challenging mandated DNA sampling (eg. sex offenders and violent offenders) and potential future misuse of current DNA samples. There have been two recent lawsuits challenging how hospitals store and use newborn blood samples drawn for routine disease screening. Read the details here.

So that's the end of day three. There is one more morning session tomorrow, but I may or may not have time to blog afterward. Hope you enjoyed this.

PS The support duck did not go to Tupac.

What I Learned: Part 2

Continued coverage of the American Academy of Psychiatry and Law (AAPL) conference. For Part 1, click here.

Day Two began with a section on PTSD as a criminal defense in military criminal cases. There was a presentation of a murder case committed by several military personnel in Iraq, followed by a discussion of the uniform code of military justice (UCMJ) rules of criminal procedure. The limitations of PTSD as a diagnosis was discussed, specifically the fact that many symptoms of PTSD overlap with other psychiatric diagnoses and that some people meet symptom criteria for PTSD without ever being exposed to a traumatic event. In 2008, 2.9 million veterans were receiving compensation for PTSD.

In criminal cases, defendants can claim self-defense if they have a reasonable belief that they are in imminent danger of serious bodily injury or death, if the force used in self-defense was reasonable, if the defendant was not the aggressor and if the defendant had no opportunity to retreat. Problems happen when the defendant reasonably believes he is in danger, but there is no objective evidence of imminence. (Eg. battered spouse syndrome and "burning bed" cases: a woman believes she is in danger and pre-meditates violence in self defense.) Soldiers with exposure to traumatic events may base a PTSD defense on a reasonable belief of danger, in the absence of imminence. Although the term "battered soldier syndrome" is not actually used in these military cases, they are clearly drawing an analogy.

As an aside, the UCMJ is interesting in that in courts martial, the military panel (analagous to a jury) decides guilt and also passes sentence. Judges have no role in sentencing. Also, there is no option for bail at the pretrial stage. Defendants have a right to a trial within 120 days, which is not much time to prepare a case for a felony offense.

In a presentation about zolpidem (Ambien) I learned that there were 22 criminal cases at the appellate level in which this medication was used as a defense. Ten were driving cases, seven were violent offenses. Zolpidem has been associated with sleep disordered behavior when combined with an SSRI. There have been 16 cases reports of zolpidem causing improvement in a chronic vegetative state.

There was a fascinating talk about tasers given by a guy from Utah. Apparently tasers have a USB data port that is used to gather stored information about when the taser was used and how many tasing cycles were triggered on a defendant. The presenter collected data from many police departments around the country regarding taser use and the nature of the defendant. He found out that in two-thirds of the cases the taser is never actually fired---merely pointing the taser at a defendant is enough to cause the defendant to surrender. When a taser is used, 82.2% of people required a single cycle. The majority of the cases in which a taser was used was on a defendant who was mentally ill and/or intoxicated. According to 1999 Justice Department data, only 2.1% of arrests actually require the use of a police weapon.

I went to the forensic sciences lecture, which is usually my favorite presentation. The American Academy of Forensic Sciences is a companion organization to AAPL and some of our members are shared between the two organizations. Anyway, this year's presentation was about computer crime. Sadly, it was bad. While the investigator was a good speaker, he didn't say much of anything about the techniques of how computer crime is actually investigated. There was no case presentation. The only crime discussed was online child pornography. The mental health professional talked about child porn users, but made at least three pretty outrageous anti-feminist statements. (Eg. women who made late accusations of child sexual abuse had been 'brainwashed by the feminist movement.') A female forensic healthy audibly blurted out "that's bullshit!" and I could hear the silent dropping of jaws. The most enjoyable part of this talk was when the computer investigator had trouble getting the audience survey system to work.

Lastly, I went to a talk about a survey given to 492 members of the South Carolina bar. 83% of the lawyers said they felt their law school training about mental health law was inadequate. Two-thirds had personal or close experience with mental illness. Judges were the least knowledgable about mental health law compared to public defenders, private attorneys and prosecutors.

Tidbits from the poster session:

• 27 states have statutes with lifetime restrictions on gun ownership for people with mental illness. Other states have time limited restrictions on ownership, and some allow restoration of full rights contingent on a physician's documentation of recovery.
• One poster studied inpatient threats in a state hospital over one year. Only one-quarter of the threats were deemed credible by the treatment team, and only one-half of these threats were thought to meet criteria to carry out a Tarasoff warning.
• There was an interesting review of the Maurice Clemmons case in which public information was used to assess his risk of violence. I blogged about the case here, and provided links to the published clemency materials. Using two violence risk assessment instruments, the poster found Clemmons to be a high risk offender. Easy to say based on his history, but of course the limitation of static risk assessment instruments is that your base risk never lowers. You can get worse, but never better.
• A national household survey of substance abuse, done annually with tens of thousands of people, showed that 3.8% off all women had used methamphetamine at least twice in the past year. Female meth users were more likely than users of other substances to be involved with the law, but not necessarily for violent offenses.
• Two states automatically drop misdemeanor charges against incompetent defendants, as required by their statutes.
• One study found no correlation between a history of childhood sexual abuse and being a perpetrator or victim of inpatient violence.
• Prisoners over the age of 65 are twice as likely to have at least one chronic medical condition compared to an age-matched sample in free society.
• Medical students from UCSD who rotate in a jail for their psychiatry experience consistently rate this rotation as their favorite. One quote from the medical student survey stated: "I love jail!"

Finally, my favorite poster: THE FORENSIC ASPECTS OF SERVICE ANIMALS!

YES!!! EMOTIONAL SUPPORT DUCKS HAVE COME TO AAPL!

This is the poster that won my heart. We've discussed this on the blog and we mention it in the book. Now, the "official" word. A poster entitled "Noah's Ark: A Forensic Review of Service Animals in Psychiatric Settings" provided an overview of ADA requirements for service animals in hospitals and clinics. In addition to guide dogs for the blind, other service animal cases involved monkeys, chimpanzees, miniature horses and parrots. Animals may be excluded from operating rooms but not any other general treatment setting. Potential for infection cannot be used to exclude animals, nor can mere concern about safety separate from an actual safety-related incident. Animals have to be able to meet minimal expectations for cleanliness, orderliness, nonaggression and "unnecessary vocalization". The sole determinant of whether an animal is a service animal versus a pet is the patient's declaration: a health care facility cannot demand documentation that an animal is certified or trained as a service animal. Finally, there have been cases of fraudulent service animals: people who put homemade "vests" on their animals and falsely identified them as a service animal. In California this is a crime punishable by six months of incarceration and a thousand dollar fine. I'm not sure how you'd get a vest on a fake service parrot.

So there you have it. I'm bringing my duck to the next session.

What I Learned: Part 1

For new readers, it's my tradition to put up posts summarizing tidbits I picked up at the annual American Academy of Psychiatry and Law (AAPL) conference. It's random, it's not explained in detail, but it's stuff I thought was interesting.

The conference started out with a keynote speech by AAPL President Stephen Billick. The title of his talk was "Be True To Psychiatry". His point was that forensic healthys are clinicians first, and that even a forensic evaluation can have therapeutic effects. He cited many examples in his practice in which a criminal or civil evaluation had potential beneficial "side effects" regardless of the forensic opinion. His main point: the forensic healthy's obligation to be neutral and objective does not preclude kindness. A point well taken, and appreciated.

A session on suicide risk assessment gave a very nice illustration of the basic problem inherent in these assessments: even assuming an "ideal" case situation with a "perfect" healthy, a thorough suicide risk assessment would take four hours. Risk assessment is time consuming and inherently will be incomplete. We make the best decisions we can based on the limited data we have at the time. A malpractice defense attorney talked about inpatient suicides: he was shocked when he realized in the course of his practice that many doctors didn't know that most inpatient deaths occured by hanging. They do. About 1500 deaths per year, in fact. Seventy percent of suicide deaths take place in the patient's bedroom, bathroom or closet. One-third happen while the patient is on fifteen minute checks.

There were a few themes to today's conference: conflicts of interest, maintenance of certification, and neuroimaging. The luncheon speaker was the best one I've ever heard at an AAPL conference. Dr. Helen Mayberg has been doing neuroimaging studies for 25 years and was one of the creators of deep brain stimulation. She has testified in several death penalty cases regarding the limitations of inference in imaging, particularly in regard to forensic issues. She was balanced, impartial and scientifically impeccable. Notable quote: "Brain scans have no place in the court room." An afternoon session on "diffusion tensor imaging" and mild traumatic brain injury basically came to the same conclusion, albeit after an astoundingly incomprehensible explanation of "diffusion tensor imaging" technology.

There was a great overview of Munchausen's syndrome by proxy, including a summary of 38 family case studies in which a mother was convicted of MSBP. In this case series a third of the mother's had some health care training and 60% had previously had factitious disorder themselves. Ninety percent of the perpetrators did not admit their abuse even after conviction. Several factors were associated with a worse outcome for the child: reunification with the untreated mother, an absent father, and a history of MSBP abuse lasting over two years. If the child was abused by suffocation or poisoning, about a tenth of them eventually died two years after reunification. Siblings in these cases were also at significant risk of being victims of MSBP.

Another session I attended was a 15 year review of state and Federal case law regarding automatism defenses. An automatism defense is one in which the defendant alleges that a crime was due to some unconscious behavior, like sleepwalking or seizure. Without going into legalisms, I'll just say that states are divided on whether or not automatism is allowed as the basis of an insanity defense. It's clinically and legally complicated so I leave the details for a future blog post if I have the inclination to go into it. If you can't wait, there's a nice concise description here.

Finally, some interesting tidbits from the poster session:

• There were two posters on forced meds for prisoners. One poster found a significant decrease in infractions and disciplinary problems for prisoners who were ordered to take meds against their will. Another poster found split results: some had fewer infractions, some had more. Infractions may be related to mental illness, but others are due to personality problems and involuntary meds may not touch this.
• States are developing jail diversion programs for veterans, modeled after diversion programs for the mentally ill.
• A study of suicides in New York's prison and jail system showed that 2/3rd's of completed suicides had no previous history of suicide attempts.
• Dr. Paul Federoff and his colleagues had an interesting poster in which they found that increased LH and FSH levels correlated with violent and sexual recidivism. He had another poster session which described a nonprofit program that helped sex offenders transition back into the community. I'm always impressed by the quality of Canadian forensic research.
• There are 5000 honors killings per year worldwide, and most are committed by fathers or brothers.
• Mental health providers are not required to report threats against the President except for threats covered by state Tarasoff statutes.
• Parasomnias sometimes result in violence, but this is rare. Most violence is from random thrashing movements, although there have been rare incidents of parasomnia-associated choking.

So that's it for today. Tomorrow's topics: murder in Iraq, AAPL interfacing with the American Medical Association and the American Psychiatric Association, the forensic sciences sampler (my favorite!! This year the topic is computer crime), and the "Zolpidem defense".

I'll be tweeting throughout the conference. The preliminary program is available here, and I'll consider requests about which sessions to attend.