The forensic assessment of dissociation: Distinguishing real from the unreal.

Because a wide range of disorders incorporate dissociative symptoms, evaluators should be familiar with evidence-based approaches to evaluating dissociation claims in the clinical and forensic context. This article provides specific guidelines for practitioners when conducting a forensic assessment of individuals who report dissociative symptoms. We review the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition disorders that include dissociation as a symptom, highlight how to distinguish genuine versus atypical symptoms of dissociative identity disorder, and summarize strengths and weaknesses of structured assessments in the evaluation of dissociative claims.

Role of Mandated Community Treatment for Justice-Involved Individuals With Serious Mental Illness.

OBJECTIVE: Research has suggested that increased length of mandated community treatment for individuals with a serious mental disorder leads to better outcomes, but few studies have described whether these outcomes are maintained after treatment ends. The goal of this study was to evaluate the impact of court-mandated treatment on outcomes for individuals found not guilty by reason of insanity (NGRI) and released to the community. METHODS: Ninety-three patients who were found to be NGRI participated in this study. Rearrest rates were compared for three groups: patients released to the community with court-mandated treatment (conditional release), patients who were conditionally released but later "restored to sanity" with no further court supervision, and patients released from the hospital to the community by the court with no court-imposed conditions. Patients were followed for an average of 4.83 years after discharge. RESULTS: Nearly half (43.8%) of the patients released to the community without court-mandated supervision were arrested for another offense in the study period, compared with 8.2% of patients released under the supervision of the conditional release program. In contrast, those who were restored to sanity and ultimately released unconditionally had higher arrest rates (25%). CONCLUSIONS: This study suggests that court oversight on an ongoing basis may be necessary to help justice-involved individuals with a serious mental disorder avoid the criminal justice system and remain engaged in community treatment. More research is needed to determine whether these findings can be extrapolated to civil commitment procedures.

Jail diversion: a practical primer.

The United States has the highest incarceration rate in the world. With a substantial number of inmates diagnosed with mental illness, substance use, or both, various diversion strategies have been developed to help decrease and avoid criminalization of individuals with mental illness. This article focuses primarily on the first three Sequential Intercept Model intercept points as related to jail diversion and reviews types of diversion programs, research outcomes for diversion programs, and important components that contribute to successful diversion.

Violence and Suicide Risk Assessment in Youth with Psychotic Disorders: Practical Considerations for Community Clinicians.

Psychosis is a unique and significant risk factor associated with violent and suicidal behavior and warrants special consideration. This article presents a careful review of the literature on violence risk and psychosis and suicide risk and psychosis as it pertains to youth or those who have been newly diagnosed with or are at high risk for psychotic disorders. Each topic is covered in reference to general considerations and specific psychotic symptoms (eg, hallucinations, delusions, paranoia). The reader can refer to practical boxes to assist in identifying relevant risk factors and examples of questions to ask the patient and family.

Psychiatric education in the correctional setting: challenges and opportunities.

As the need for mental healthcare services within correctional settings in the US increases, so does the need for a mental health workforce that is motivated to work within such systems. One potentially effective method by which to increase the number of psychiatrists working in jails, prisons, and parole clinics is to provide exposure to these environments during their training. Correctional settings can serve as unique training sites for medical students and psychiatric residents and fellows. Such training experiences can provide a host of benefits to both trainees and staff within the correctional mental health system. Alongside many potential benefits exist substantial potential barriers to coordinating correctional training experiences, including both programme directors' and residents' concerns regarding safety and enjoyment and negative perceptions of inmate and prisoner patients. The establishment of academic affiliations with correctional institutions and didactic instruction on commonly encountered clinical issues with inmate populations may be methods of diffusing these concerns. Improving residents' and fellows' training experiences offers a hope for increasing the attractiveness of a career in correctional psychiatry.

Clinical assessment of psychotic and mood disorder symptoms for risk of future violence.

This article reviews important components to consider when evaluating the relationship of psychotic and mood disorder symptoms to violence. Particular attention is given to assessing persecutory delusions and command auditory hallucinations. Clinical implications of research findings to evaluating violence risk in psychiatric patients are reviewed.

Characteristics of female homicide offenders found not guilty by reason of insanity.

Until recently, there has been little information regarding female offenders who commit homicides that are motivated by psychosis. We investigated gender differences in the characteristics of psychosis and crime variables in psychotically motivated homicide. In the study, conducted at a large U.S. forensic facility, we reviewed the records of women (n = 47) found not guilty by reason of insanity (NGRI) who were hospitalized between January 1991 and August 2005 for a homicide offense. A random sample of 47 men who were committed during the same period for the same offenses was selected for comparison. Religious delusions were found more often in women who killed infants (0-1 year of age) and children between the ages of 2 and 18. Women were more likely to have a diagnosis of an affective problem and borderline personality disorder. The results indicate gender-specific areas to focus on during clinical and forensic assessments of the risk of violence in women with psychosis.

Malingering in the correctional system: does incentive affect prevalence?

Incentives to malinger vary greatly dependent on the context, as does the prevalence. Malingering in the medico-legal context of the criminal courts is generally for one of two purposes: to present as incompetent to stand trial or to successfully plead not guilty by reason of insanity. Estimates of the prevalence of malingering in these contexts vary between 8 and 21%. The prevalence of malingering increases dramatically in a general offender sample, where the external incentive is likely to be substantially different. Malingering in this context can be as high as 56% and generally occurs to obtain a more desirable housing situation or desired medications. Our study examined data from two distinct samples to evaluate incentives to malinger: patients found incompetent to stand trial (IST) and sent to a state hospital for restoration and jail inmates seeking psychiatric services (JPS). Our results indicate that the rate of malingering in the IST sample was consistent with rates published in comparable samples (17.5%) and the rate for the JPS sample was substantially higher (64.5%). Only in the IST sample was rate of malingering associated with offense severity: patients found IST for murder and robbery evidenced malingering rates more than double the sample as a whole. Offense severity bore no relationship to malingering in the JPS sample.

Believing doesn't make it so: forensic education and the search for truth.

The American Academy of Psychiatry and the Law (AAPL) was organized in 1969, in large part through the efforts of Dr. Jonas Rappeport. The founders of AAPL emphasized that an important purpose of the organization was to advance knowledge in the area of psychiatry and the law. The science of forensic psychiatry has since been vigorously debated. In 2005, Congress enacted a statute authorizing the National Academy of Sciences (NAS) to conduct a study on the state of the forensic sciences in the United States. As a result of this legislation, a forensic science committee was formed, and the report, "Strengthening Forensic Science in the United States: A Path Forward," was produced, emphasizing the need for research in the forensic disciplines, particularly those that rely on more subjective assessments. The committee also identified two important factors relevant to standards of evidence admissibility: the scientific methodology used and the impact of bias on the interpretation of data. In this article, I apply the NAS committee's findings to the field of forensic psychiatry, with specific recommendations to assist educators in achieving more objective assessment methodologies, critical in forensic education and the search for truth.

Brown v. Plata: prison overcrowding in California.

California's prisons are currently designed to house approximately 85,000 inmates. At the time of the U.S. Supreme Court's 2011 decision in Brown v. Plata, the California prison system housed nearly twice that many (approximately 156,000 inmates). The Supreme Court held that California's prison system violated inmates' Eighth Amendment rights. The Court upheld a three-judge panel's order to decrease the population of California's prisons by an estimated 46,000 inmates. They determined that overcrowding was the primary cause of the inmates' inadequate medical and mental health care. As a result, the California Department of Corrections and Rehabilitation (CDCR) has been working to redistribute inmates and parolees safely and decrease the overall population to the mandated levels. These large-scale adjustments to California's penal system create potential opportunities to study the long-term effects on affected inmates.

Evaluating amnesia for criminal behavior: a guide to remember.

This article provides a guide that is important to remember in evaluating a criminal defendant's amnesia claim. Important concepts to understand regarding memory formation, memory systems, proposed causes of amnesia, reasons why amnesia claims may be true or false, and important strategies to implement as part of the evaluation process are reviewed. Structured assessment approaches are critical components of amnesia evaluations and generally require detailed questioning, review of collateral records, medical and neurologic workups, psychological testing, neuropsychological testing, and specific malingering assessments.

Decertification outcomes for bipolar disorder in an inpatient community mental health treatment center: impact on subsequent service use over two years.

This study investigated differences in usage of inpatient and outpatient mental health services over a 2-year period following the index hospitalization between 50 decertified and 48 certified subjects with bipolar manic or mixed episode from an inpatient mental health treatment center. The decertified group had higher number of rehospitalization over the 2-year period compared to certified group (mean = 2.26, SE = 0.41 vs. mean = 1.19, SE = 0.24; Wald χ (2) = 5.50, p = 0.02). Median time to first rehospitalization was 40 weeks in the certified and 17 weeks in the decertified group, but the difference in time to rehospitalization failed to achieve statistical significance (p = 0.18). History of prior hospitalization was associated with higher numbers of rehospitalizations and crisis room visits (both p < 0.01) and with shorter time before first rehospitalization (p < 0.001).

The predictive ability of the Classification of Violence Risk (COVR) in a forensic psychiatric hospital.

OBJECTIVE: Aggression is a common problem in psychiatric and correctional facilities. An actuarial instrument, the Classification of Violence Risk (COVR), has demonstrated utility in predicting community aggression among civilly committed psychiatric patients and, more recently, an ability to predict institutional aggression in a forensic facility. This prospective study aimed to extend validation of the use of the COVR in a forensic facility. METHODS: The study, conducted at a large U.S. forensic facility, used nursing records to document incidents of physical aggression by 146 patients for 20 weeks after COVR administration. Correlational and chi square analyses were conducted to evaluate the efficacy of the COVR in predicting aggression. RESULTS: The COVR showed modest predictive ability for institutional aggression, with a correlation of .331 and an area under the curve of .725. CONCLUSIONS: Results support use of the COVR in a forensic facility; its ability to predict institutional aggression is similar to that found for community aggression.

Child sex tourism: extending the borders of sexual offender legislation.

Child sex tourism, the act of traveling to engage in sexual acts with minors, plagues developing nations worldwide. Several laws have been passed internationally in recent years designed to curtail this practice. Government entities and human rights organizations have driven these efforts. United States citizens represent a significant proportion of participants in child sex tourism. The PROTECT Act of 2003 prohibits United States citizens from participating in sexual acts with minors while traveling, and establishes extraterritorial jurisdiction. The case of Michael Lewis Clark, the first United States citizen convicted under this legislation, is highlighted. Child sex tourism poses unique issues to courts that will require ongoing clarification as challenges arise. This article discusses potential future challenges, describes strategies to address this problem, and relates this issue to psychiatry. Mental health providers may have the role of evaluating both the victims and perpetrators of child sex tourism. The authors propose a classification system for offenses and an initial list of topics to discuss with victims. The authors also describe the proper mechanism for reporting United States citizens suspected of participating in child sex tourism.

Juveniles in court.

Nineteenth-century American reformers were concerned about the influence of immaturity and development in juvenile offenses. They responded to their delinquent youths through the creation of juvenile courts. This early American juvenile justice system sought to treat children as different from adults and to rehabilitate wayward youths through the state's assumption of a parental role. Although these rehabilitative goals were never fully realized, the field of American child psychiatry was spawned from these efforts on behalf of delinquent youths. Early child psychiatrists began by caring for juvenile offenders. The function of a child psychiatrist with juvenile delinquents expanded beyond strictly rehabilitation, however, as juvenile courts evolved to resemble criminal adult courts-due to landmark Supreme Court decisions and also juvenile legislation between 1966 and 1975. In response to dramatically increased juvenile violence and delinquency rates in the 1980s, juvenile justice became more retributional, and society was forced to confront issues such as capital punishment for juveniles, their transfer to adult courts, and their competency to stand trial. In the modern juvenile court, child psychiatrists are often asked to participate in the consideration of such issues because of their expertise in development. In that context we review the role of psychiatrists in assisting juvenile courts.