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.)

Ketamine, Special K, and Depression

I just wrote a post over on Clinical Psychiatry News about the experimental use of ketamine (aka, rave drug "Special K") for instant relief of depression and suicidal ideation.

Please go over there to read it (link above), and feel free to comment there (sorry, registration is required but it's free) or here. I'd like to hear about providers who have used ketamine for their patients and from people who themselves have used it for depression.

Edit: find a list of clinical trials using ketamine for depression on clinicaltrials.gov.

The Violent Patient

On the New York Time's Well blog recently, nurse Theresa Brown wrote a piece entitled "Feeling Strain When Violent Patients Need Care," in which she talked about caring for a very threatening, potentially dangerous patient suffering from cancer. This patient, a large 300 pound man, had a reputation for causing havoc in the hospital. He had been banned from one ward for tearing a light fixture off the wall and fighting with hospital security. He had "slugged" a family member at the nursing station and threatened to kill a nurse. In spite of all this, he apparently was not in custody at the time that Ms. Brown was caring for him, which meant that he was not a prisoner in shackles and there was no dedicated law enforcement professional watching over the situation. Understandably, Ms. Brown was afraid.

What some people might not appreciate or been aware of, was that she was also embarrassed about being afraid. Working in the health care field, and in nursing in particular, meant that one could be exposed to volatile situations at any time. Being a professional meant being able to stay calm and poised enough to manage these situations, and this is where the author of this piece felt lacking. She felt she should have been tougher, more unflappable, or somehow invincible to this very concerning patient's intimidating demeanor. Ultimately she was replaced on the case by a male nurse. We never find out what happened to the patient, whether he actually did commit acts of violence during that admission, or whether he calmed down with the male nurse and cooperated with the care he needed. We also don't come to any resolution about what a health care professional should do in a situation like this. This is not a question the narrative was meant to answer, apparently.

As always in story like this, the most interesting part to me were the comments that followed. Over the next two days nearly one hundred people wrote in, mostly nurses and doctors and other health care professionals, to talk about the multiple incidents in which they were bitten, scratched, spat upon, cursed, hit and kicked in the emergency room, on the psychiatric unit, and in the intensive care unit. Half way through the comments I found myself wondering what the incidence of post-traumatic stress disorder must be among health care professionals after a few years of routine work. (I don't know the answer to that question.)

I was also impressed by the range of thoughtfulness that some commenters brought to the situation. Some quickly speculated that the patient might have been a veteran or someone equally traumatized, who would naturally have responded with aggression when startled awake in the middle of the night by a stranger. Others speculated that he might have been having an unexpected reaction to a medication, or been in the midst of a delirium. Some suggested that a CT scan should have been done to make sure his impulsivity and temper weren't due to a malignant brain metastasis. Clearly, these health care professional readers were setting aside their own personal experiences to consider the cause of the patient's emotional reaction and behavior. This was heartening to me.

Other comments were less sympathetic, implying that hospitals should be more liberal in their use of physical and chemical restraints and that assaultive and threatening patients should be prosecuted consistently.

I felt rather fortunate after reading this piece. I've worked with patients known for this kind of violence, but I've been comfortable doing so knowing that safety and security were a necessary and essential condition to providing treatment. I've always felt safer in most correctional facilities I've worked in than in some more traditional clinical settings. Even so, I rarely have had to deal with patients who were so angry or potentially dangerous that I wasn't sure I could treat them even in the correctional setting. That's not good because in most cases there is no one else to turn the patient's care over to when you're the only shrink in the building. This is how I've managed to handle it:

If the patient starts the appointment calmly but escalates during the interview, the first thing I do is slow down. I want time to listen, to think, to make sure the patient knows that I'm hearing him and am concerned about what he's saying. This also helps me listen better. I set my pen down and stop taking notes. I look at the patient. I make sure he knows he has my full attention. If he allows me, I will ask questions to get more information or to clarify something he has said. I repeat what he's told me, and ask him if I am understanding him. If and when he says 'yes', things chill out immediately and we negotiate a treatment plan.

If this doesn't help, or if I start to feel I can't listen safely, I tell the patient I feel uncomfortable or worried. It's not waving a red flag in front of a bull to admit that you're scared. You'd be surprised how many temperamental men (I only treat male prisoners) have no awareness whatsoever that they are talking way too loud or gesturing too broadly or behaving in a way that attracts attention. The nearest correctional officer usually notices first. If I see an officer glancing in to check on me that gives me a nice opportunity to point out to the patient that his behavior is arousing the concern of custody. That always works.

I'm surprised how often an angry inmate will suddenly pull himself together and calm down once you tell him you're scared. Some of them are quick to apologize, or emphasize that---in spite of what they might have done in the past---they have never laid hands on a woman.

Lastly, I know when to recognize when I need to take a break. If I find myself wanting to cut the patient off or getting annoyed---too annoyed to listen---I know it's time to call it a day and try again another time. These are the times when mistakes get made. I can ask the patient if we can take a break and come back to the discussion later in the clinic session, or on another day. I explain that things have gotten heated and I really want to make sure I'm taking the time to think about his care.

If none of this works, I still keep trying. I will make sure I have any necessary security in place, and explain to the patient why it's needed. If someone is available, I may ask another health care professional to sit in the room with me. And make sure an officer is outside the door. In extreme cases, it might be necessary to put the person in handcuffs and a waist chain for the appointment.

Hospitals aren't used to doing any of this, or can't. But when 15% of all US nonfatal on the job injuries take place in health care settings, through patient assaults on staff, it's time to take de-escalation training seriously.