Pathways for VA and community stakeholder management of military veterans with sexual offenses: Sexual and nonsexual recidivism rates and risk factors in military veterans released from California sexually violent predator (SVP) commitment.

Military veterans with sexual offenses committed after discharge are often eligible for Veterans Affairs (VA) services including health care. There are few, if any, studies of sexual recidivism among military veterans with sexual offense histories to guide clinical management. This study examined diagnostic and postrelease sexual and nonsexual recidivism among military sexual offenders released from California sexually violent predator (SVP) commitment. The sample consisted of 363 males; 131 were identified as military veterans and 232 as civilians. The rates of recidivism were assessed for two follow-up periods: a fixed 5-year and a total 21-year follow-up. Recidivism was operationalized as any new sexual, violent, or general criminal arrest or conviction occurring after discharge to the community in California. We found a low risk for sexual reoffense for both groups. Specific to veterans, the rates for sexual and nonsexual violent recidivism were under 7% for both follow-up periods. Diagnostically, veterans had a significantly higher rate of pedophilic disorder and lower rate of antisocial personality disorder than civilians; neither were predictive of sexual recidivism or any other recidivism. On average, veterans were 61 years old at discharge; and older age at discharge was associated with a significantly lower likelihood of recidivism of any type. A relatively high proportion of veterans had a history of childhood sexual abuse and head trauma. Trauma-informed care may be a particularly valuable treatment approach for veterans with sexual offenses. These data may aid the VA and other providers in forming evidence-based decisions regarding the management of veterans with sexual offenses. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

California Sexually Violent Predator (SVP) Evaluations in the Field: Static-99R and Diagnostic Field Reliability.

Tests and diagnoses used in sexually violent predator (SVP) evaluations must be reliable, as reliability is foundational to validity. The current study contained a stratified sample of evaluations of 395 individuals referred as potential SVPs between 2012 and 2017. Each individual was initially evaluated by at least two experts. The sample included three groups: individuals not meeting SVP criteria (N = 200, or 400 evaluations), individuals meeting SVP criteria (N = 95, with 190 evaluations), and individuals where evaluators disagreed (N = 100, with 200 evaluations). The sample also included 200 subsequent independent evaluations on these "disagree" cases. Static-99R score intraclass coefficient (ICC) interrater reliability was good to excellent within each group and overall. Evaluators scored the Static-99R within one point of each other 87% of the time. Cohen's kappa diagnostic agreement for Pedophilic Disorder was substantial. ASPD and substance abuse kappa were in the "fair" range, while OSPD diagnoses in the positive group were at the "moderate" level of agreement. Ethnic differences in diagnoses were consistent with other studies, with equivalent Static-99R ICC values across ethnic groups. There were no significant differences between state civil servants versus contracted experts in Static-99R ratings or final determinations. The results suggest that Static-99R scores have acceptable reliability in these evaluations, and Pedophilic Disorder (the most common paraphilic disorder in our study) and OSPD can be reliably diagnosed. We discuss limitations of the study, as well as the need for care in high-stakes evaluations given the imperfect reliability of psychological measurements.

Needed: consensus and classification for terms used in cognitive, forensic and clinical bias discussions.

All evolving disciplines have long grappled with nomenclature inconsistencies. Precise terminology facilitates communication among individuals, clinicians, academics and researchers. To arrive at definitions, the concepts underlying basic scientific vocabularies must be universally acceptable to all users. This is not always easy. Tarachow cautioned in 1965 about how contractions and abbreviations, "…eliminated practically all the associations connected with the original title and did not at all have the evocative impact of the complete word or title"[1] (Tarachow, 1965). Clinical medicine has designed and used with some success disease-diagnosis based classification systems. Forensic science, as does clinical medicine, relies on cognitive processes for its mission to achieve expert accuracy. Both fields are vulnerable to biases and errors in cognition, more so when no terminology standards exist. It is time to develop a nomenclature system in the field of cognitive bias and cognitive errors. This system should build transdisciplinary understanding, at least during expertise-based undertakings in forensic and clinical sciences.

Blinding or information control in diagnosis: could it reduce errors in clinical decision-making?

Background Clinical medicine has long recognized the potential for cognitive bias in the development of new treatments, and in response developed a tradition of blinding both clinicians and patients to address this specific concern. Although cognitive biases have been shown to exist which impact the accuracy of clinical diagnosis, blinding the diagnostician to potentially misleading information has received little attention as a possible solution. Recently, within the forensic sciences, the control of contextual information (i.e. information apart from the objective test results) has been studied as a technique to reduce errors. We consider the applicability of this technique to clinical medicine. Content This article briefly describes the empirical research examining cognitive biases arising from context which impact clinical diagnosis. We then review the recent awakening of forensic sciences to the serious effects of misleading information. Comparing the approaches, we discuss whether blinding to contextual information might (and in what circumstances) reduce clinical errors. Summary and outlook Substantial research indicates contextual information plays a significant role in diagnostic error and conclusions across several medical specialties. The forensic sciences may provide a useful model for the control of potentially misleading information in diagnosis. A conceptual analog of the forensic blinding process (the "agnostic" first reading) may be applicable to diagnostic investigations such as imaging, microscopic tissue examinations and waveform recognition. An "agnostic" approach, where the first reading occurs with minimal clinical referral information, but is followed by incorporation of the clinical history and reinterpretation, has the potential to reduce errors.

Diagnosing Crime and Diagnosing Disease-II: Visual Pattern Perception and Diagnostic Accuracy.

Previously, we reviewed how general cognitive processes might be susceptible to bias across both forensic and clinical fields, and how interdisciplinary comparisons could reduce error. We discuss several examples of clinical tasks which are heavily dependent on visual processing, comparing them to eyewitness identification (EI). We review the "constructive" nature of visual processing, and how contextual factors influence both medical experts and witnesses in decision making and recall. Overall, studies suggest common cognitive factors uniting these visual tasks, in both their strengths and shortcomings. Recently forensic sciences have advocated reducing errors by identifying and controlling nonrelevant information. Such efforts could effectively assist medical diagnosis. We suggest potential remedies for cognitive bias in these tasks. These can generalize across the clinical and forensic domains, including controlling the sequencing of contextual factors. One solution is an agnostic primary reading before incorporation of a complete history and interpretation.

Diagnosing Crime and Diagnosing Disease: Bias Reduction Strategies in the Forensic and Clinical Sciences.

Cognitive effort is an essential part of both forensic and clinical decision-making. Errors occur in both fields because the cognitive process is complex and prone to bias. We performed a selective review of full-text English language literature on cognitive bias leading to diagnostic and forensic errors. Earlier work (1970-2000) concentrated on classifying and raising bias awareness. Recently (2000-2016), the emphasis has shifted toward strategies for "debiasing." While the forensic sciences have focused on the control of misleading contextual cues, clinical debiasing efforts have relied on checklists and hypothetical scenarios. No single generally applicable and effective bias reduction strategy has emerged so far. Generalized attempts at bias elimination have not been particularly successful. It is time to shift focus to the study of errors within specific domains, and how to best communicate uncertainty in order to improve decision making on the part of both the expert and the trier-of-fact.

Symptom exaggeration and symptom validity testing in persons with medically unexplained neurologic presentations.

Neurologists often evaluate patients whose symptoms cannot be readily explained even after thorough clinical and diagnostic testing. Such medically unexplained symptoms are common, occurring at a rate of 10%-30% among several specialties. These patients are frequently diagnosed as having somatoform, functional, factitious, or conversion disorders. Features of these disorders may include symptom exaggeration and inadequate effort. Symptom validity tests (SVTs) used by psychologists when assessing the validity of symptoms and impairments are structured, validated, and objectively scored. They could detect poor effort, underperformance, and exaggeration. In settings with appropriate prior probabilities, detection rates for symptom exaggeration have diagnostic utility. SVTs may help in moderating expensive diagnostic testing and redirecting treatment plans. This article familiarizes practicing neurologists with their merits, shortcomings, utility, and applicability in practice.

Recognizing and reducing cognitive bias in clinical and forensic neurology.

In medicine, cognitive errors form the basis of bias in clinical practice. Several types of bias are common and pervasive, and may lead to inaccurate diagnosis or treatment. Forensic and clinical neurology, even when aided by current technologies, are still dependent on cognitive interpretations, and therefore prone to bias. This article discusses 4 common biases that can lead the clinician astray. They are confirmation bias (selective gathering of and neglect of contradictory evidence); base rate bias (ignoring or misusing prevailing base rate data); hindsight bias (oversimplification of past causation); and good old days bias (the tendency for patients to misremember and exaggerate their preinjury functioning). We briefly describe strategies adopted from the field of psychology that could minimize bias. While debiasing is not easy, reducing such errors requires awareness and acknowledgment of our susceptibility to these cognitive distortions.

First-in-man demonstration of a fully implanted myoelectric sensors system to control an advanced electromechanical prosthetic hand.

BACKGROUND: Advanced motorized prosthetic devices are currently controlled by EMG signals generated by residual muscles and recorded by surface electrodes on the skin. These surface recordings are often inconsistent and unreliable, leading to high prosthetic abandonment rates for individuals with upper limb amputation. Surface electrodes are limited because of poor skin contact, socket rotation, residual limb sweating, and their ability to only record signals from superficial muscles, whose function frequently does not relate to the intended prosthetic function. More sophisticated prosthetic devices require a stable and reliable interface between the user and robotic hand to improve upper limb prosthetic function. NEW METHOD: Implantable Myoelectric Sensors (IMES(®)) are small electrodes intended to detect and wirelessly transmit EMG signals to an electromechanical prosthetic hand via an electro-magnetic coil built into the prosthetic socket. This system is designed to simultaneously capture EMG signals from multiple residual limb muscles, allowing the natural control of multiple degrees of freedom simultaneously. RESULTS: We report the status of the first FDA-approved clinical trial of the IMES(®) System. This study is currently in progress, limiting reporting to only preliminary results. COMPARISON WITH EXISTING METHODS: Our first subject has reported the ability to accomplish a greater variety and complexity of tasks in his everyday life compared to what could be achieved with his previous myoelectric prosthesis. CONCLUSION: The interim results of this study indicate the feasibility of utilizing IMES(®) technology to reliably sense and wirelessly transmit EMG signals from residual muscles to intuitively control a three degree-of-freedom prosthetic arm.

Development of an implantable myoelectric sensor for advanced prosthesis control.

Modern hand and wrist prostheses afford a high level of mechanical sophistication, but the ability to control them in an intuitive and repeatable manner lags. Commercially available systems using surface electromyographic (EMG) or myoelectric control can supply at best two degrees of freedom (DOF), most often sequentially controlled. This limitation is partially due to the nature of surface-recorded EMG, for which the signal contains components from multiple muscle sources. We report here on the development of an implantable myoelectric sensor using EMG sensors that can be chronically implanted into an amputee's residual muscles. Because sensing occurs at the source of muscle contraction, a single principal component of EMG is detected by each sensor, corresponding to intent to move a particular effector. This system can potentially provide independent signal sources for control of individual effectors within a limb prosthesis. The use of implanted devices supports inter-day signal repeatability. We report on efforts in preparation for human clinical trials, including animal testing, and a first-in-human proof of principle demonstration where the subject was able to intuitively and simultaneously control two DOF in a hand and wrist prosthesis.