Commentary: The forensic psychiatry of frontotemporal dementia.

The article by Dr. Mendez is a timely contribution to the literature on the study of antisocial behavior associated with frontotemporal dementia. My commentary is focused on the need to take into account the neuroscientific advances involving frontotemporal dementia and the way in which such information may be conceptually helpful in furthering our understanding of forensic psychiatric cases of individuals with frontotemporal dementia. I place particular emphasis on the need to present basic psychiatric-legal aspects of such cases before we attempt to integrate the relevant neuropsychiatric information. I use the cases presented by Dr. Mendez to highlight this important need in forensic neuropsychiatry. With this commentary, I support the view that both theoretical and practical aspects of neuropsychiatric and forensic psychiatric knowledge must be carefully integrated to achieve effective forensic neuropsychiatric assessments.

Competence to be executed: An ethical analysis post Panetti.

Competence to be executed evaluations in effect can prevent an execution or remove the last meaningful impediment to it. Forensic psychiatrists have primary duties to the legal system and truth and honesty, but like all other areas of medical consultation also should balance conflicting secondary traditional medical ethical duties. Participation in a legally authorized execution so violates medical roles, that it is ethically prohibited by the American Medical Association and American Psychiatric Association. This prohibition includes treatment intended to restore competence to be executed. However, despite the primary treatment intent otherwise being appropriate ethically, like relieving suffering or fostering prison safety, if competence to be executed almost predictably would be a treatment result, at least the risk of this result should be considered ethically as if it were intended. In contrast, competence to be executed assessments can be ethical. Diamond's approach of performing honest evaluations only for the defense is an ethical option for such assessments. However, it is challenging to persuade judges and juries of the objectivity of such honest legitimate assessments. Most practitioners therefore likely would consider assessing competence to be executed for either side. This ethically hazardous position necessitates sensitivity to potentially seriously conflicting duties and roles.

Forensic psychiatry, neuroscience, and the law.

The rise of modern neuroscience is transforming psychiatry and other behavioral sciences. Neuroscientific progress also has had major impact in forensic neuropsychiatric practice, resulting in the increased use of neuroscientific technologies in cases of a psychiatric-legal nature. This article is focused on the impact of neuroscientific progress in forensic psychiatry in relation to criminal law. Also addressed are some emerging questions involving the practice of forensic neuropsychiatry. These questions will be reframed by providing alternative perspectives consistent with the objectives of forensic neuropsychiatric practice. The last part of the article is a discussion of potential developments that may facilitate the integration of neuroscientific knowledge in forensic neuropsychiatric practice.

Back to the past in California: a temporary retreat to a Tarasoff duty to warn.

The original Tarasoff decision created a duty for California psychotherapists to warn potential victims of their patients. After rehearing the matter two years later, the California Supreme Court, in the landmark second Tarasoff decision, changed the duty to warn to a duty to protect potential victims, with warning as only one of the options for discharging that duty. Despite this change, the Tarasoff duty frequently was referred to erroneously as a duty to warn. This misunderstanding and an ambiguous California immunity statute culminated in "simplified" jury instructions and two appellate court decisions in 2004 in which it was assumed without question that there was a duty to warn, with liability for not doing so regardless of rationale. As a result of persistent lobbying by the California Psychiatric Association and other mental health groups, a recent bill corrected the problem created by the courts, returning the Tarasoff duty to a duty to protect.

Asperger's disorder and criminal behavior: forensic-psychiatric considerations.

Asperger's Disorder remains an under-diagnosed condition because of clinical unfamiliarity with its adult presentation. As forensic clinicians become familiar with the presentation of Asperger's disorder, it appears that affected individuals are over-represented in forensic criminal settings. Unique features of such persons may heighten their risks for engaging in criminal behavior. Both Theory of Mind deficits and a predilection for intense narrow interests, when coupled with deficient social awareness of salient interpersonal and social constraints on behavior, can result in criminal acts. We discuss comorbidities of forensic relevance. We present several cases that highlight these issues and review the relevant forensic literature. Furthermore, there may be valid questions as to degree of criminal responsibility in such persons. From a neuropsychiatric perspective, these disorders appear to have a biological underpinning for deficits in empathy, a finding that may have important repercussions when assessing remorse in criminal proceedings.

A neuropsychiatric developmental model of serial homicidal behavior.

Serial sexual homicide has been the object of intensive study from forensic psychiatric, criminological, developmental, and sociological perspectives. In contradistinction to these approaches, neuropsychiatric concepts and methods have received relatively little attention in this area. In this article we adopt a neuropsychiatric developmental perspective and undertake a review of the psychiatric literature on violence and autism spectrum disorders. Our analysis of this literature suggests the presence of an association between autism spectrum psychopathology and serial homicidal behavior. Recommendations for further research to help clarify the nature of this association are briefly discussed.

Misidentification of the self in a patient with a psychotic disorder and post-traumatic stress disorder.

The central characteristic of the delusional misidentification syndromes is a delusion of personal misidentification of the self or of others. Other symptoms of psychopathology in addition to delusional misidentification may be important contributors to the misidentification of people. In this article we report the case of a man who suffered from the syndrome of subjective doubles, reverse subjective doubles associated with a psychotic disorder and post-traumatic stress disorder. The contribution of his psychiatric disorders in the genesis of delusional misidentification is explored. Capgras Syndrome was also present.

Neuroleptic-induced akathisia and violence: a review.

Surprisingly, the association of neuroleptic-induced akathisia and aggressive behavior was not formally recognized until nearly two and one-half decades of antipsychotic prescribing had passed. Using a search of the anglophonic literature, this phenomenon is reviewed. Advances in psychopharmacology have reduced neuroleptic-induced akathisia and hold promise to eliminate it altogether. Nonetheless, important clinical and forensic aspects of neuroleptic-induced akathisia and aggression remain and are explored.

The case of Jeffrey Dahmer: sexual serial homicide from a neuropsychiatric developmental perspective.

Sexual serial homicidal behavior has received considerable attention during the last three decades. Substantial progress has been made in the development of methods aimed at identifying and apprehending individuals who exhibit these behaviors. In spite of these advances, the origins of sexual serial killing behavior remain for the most part unknown. In this article we propose a biopsychosocial psychiatric model for understanding the origins of sexual serial homicidal behavior from both neuropsychiatric and developmental perspectives, using the case of convicted serial killer Jeffrey Dahmer as the focal point. We propose that his homicidal behavior was intrinsically associated with autistic spectrum psychopathology, specifically Asperger's disorder. The relationship of Asperger's disorder to other psychopathology and to his homicidal behavior is explored. We discuss potential implications of the proposed model for the future study of the causes of sexual serial homicidal crime.

The functional neuroanatomy of the placebo effect.

OBJECTIVE: Administration of placebo can result in a clinical response indistinguishable from that seen with active antidepressant treatment. Functional brain correlates of this phenomenon have not been fully characterized. METHOD: Changes in brain glucose metabolism were measured by using positron emission tomography in hospitalized men with unipolar depression who were administered placebo as part of an inpatient imaging study of fluoxetine. Common and unique response effects to administration of placebo or fluoxetine were assessed after a 6-week, double-blind trial. RESULTS: Placebo response was associated with regional metabolic increases involving the prefrontal, anterior cingulate, premotor, parietal, posterior insula, and posterior cingulate and metabolic decreases involving the subgenual cingulate, parahippocampus, and thalamus. Regions of change overlapped those seen in responders administered active fluoxetine. Fluoxetine response, however, was associated with additional subcortical and limbic changes in the brainstem, striatum, anterior insula, and hippocampus, sources of efferent input to the response-specific regions identified with both agents. CONCLUSIONS: The common pattern of cortical glucose metabolism increases and limbic-paralimbic metabolism decreases in placebo and fluoxetine responders suggests that facilitation of these changes may be necessary for depression remission, regardless of treatment modality. Clinical improvement in the group receiving placebo as part of an inpatient study is consistent with the well-recognized effect that altering the therapeutic environment may significantly contribute to reducing clinical symptoms. The additional subcortical and limbic metabolism decreases seen uniquely in fluoxetine responders may convey additional advantage in maintaining long-term clinical response and in relapse prevention.