Psychiatric Diagnoses and Criminal Responsibility: An Argument for the Relevance of Intellectual Disability

A conceptual framework for the revision of the ICD‐10 classification of mental and behavioural disorders

Diagnostic Manual–Intellectual Disability: A Textbook of Diagnosis of Mental Disorders in Persons With Intellectual Disability, by R. Fletcher, E. Loschen, C. Stavrakaki, and M. First

The principle of nullum crimen sine culpa in Polish criminal law from a constitutional perspective

The interface between criminal law and the field of psychiatry has manifested predominantly with reference to the defence of pathological criminal incapacity, more commonly referred to as the insanity defence. The threshold requirement for establishing the defence of pathological criminal incapacity entails that the accused at the time of the commission of the offence should have suffered from a ‘mental illness’ or ‘mental defect’. Once it is established that the accused suffered from a mental illness or mental defect at the time of the commission of the offence, an assessment is conducted to determine whether the illness or defect rendered the accused either incapable of appreciating the wrongfulness of the act or of acting in accordance with such appreciation. The problem that inevitably arises during the assessment of the defence relates to the fact that the terms ‘mental illness’ and ‘mental defect’ are not defined. Mental health practitioners mainly rely on the DSM for answers, yet the DSM cautions that the disorders contained may not be wholly relevant for legal purposes. Postpartum disorders are generally classified as postpartum depression and the more serious manifestation, postpartum psychosis. Postpartum disorders were not provided for in the DSM-IV (1994) or the DSM-IV-TR (2000) as distinct mental disorders. The DSM-5 came into operation in 2013, and yet again these disorders fall outside the scope of the DSM-5. Research indicates that the mental health professional plays a vital and pivotal role in explaining these disorders and the various complexities associated with them. The focus of this article is to illustrate the phenomena of postpartum depression and postpartum psychosis against the backdrop of the defence of pathological criminal incapacity within the context of South African criminal law. The vital and essential role of the mental health expert within this context is explored.

Crimes committed by the mentally ill may give rise to critical conflicts on whether the criminals should receive punishment or treatment. Therefore, our criminal code has a legal provision for mental handicap and criminal responsibility, which can reduce or exempt the criminal penalty. This process requires a psychiatric evaluation of the defendants as well as normative decisions by judges. The psychiatric evaluation and diagnosis precede the court judgement, and are used by the court to judge the mental handicap of the defendant at the time of the crime. However, judgments on the criminal responsibility of a defendant with mental disorder are very complex and challenging because of time gaps and difficulties faced in the evaluation of human mental ability. We analyzed court rulings in 19 cases where the defendants claimed to be mentally handicapped. The analysis results showed that the mental handicap was recognized in nine cases, rejected in four cases, and not mentioned by the court in six cases. Further, psychiatric evaluation was not performed in three cases. Apart from the result of the evaluation, the judges seem to consider other factors for sentencing, like recidivism risk, premeditation of crimes, and their brutality. These results suggest that the rationale and procedure of court rulings involving mentally handicapped persons may be debatable. We argue that psychiatric evaluations should be made indispensable in judicial procedures for cases involving mentally handicapped persons, and judges should clearly indicate their decision on mental handicap or criminal responsibility in the sentencing.

Proposals for ICD-11: a report for WPA membership.

Accessible summaryPeople with intellectual disability have multiple health problems.People with intellectual disability have more physical and mental health conditions than people without intellectual disabilities.People with intellectual disability may need more health checks due to increased prevalence of physical and mental illnesses.More studies are needed to understand what interventions are effective to reduce health problems in people with intellectual disability.AbstractBackgroundStudies have reported increased prevalence of physical and mental health conditions in people with intellectual disabilities (ID) compared to people without intellectual disabilities. However, there are no studies looking into specific health conditions at a national level and comparing with areas that are socio‐economically disadvantaged (e.g. low income and low education attainment). This study examines and compares the prevalence of physical and mental health morbidity in people with and without intellectual disabilities at a local and national level in the UK.MethodThis study was an anecdotal analysis of physical and mental health data and annual health check‐up for England (national), London (regional) and Haringey (inner‐city borough of London) in 2016/17 using data from the NHS Digital database.ResultsPatterns of mental and physical conditions for people with and without intellectual disabilities were similar across Haringey, London and England data. Severe mental illness was more prevalent among people with intellectual disabilities compared to non‐intellectual disability peers. This further increased in the inner‐city London borough for the intellectual disability group. Certain physical health conditions were also more prevalent in people with intellectual disabilities. Certain activities such as monitoring blood pressure, recording body mass index and checking HbA1C were better in people with intellectual disabilities. Uptake of annual health checks for people with intellectual disabilities remained around 50%.DiscussionThis study further highlights the increased prevalence of mental and physical disorders in people with intellectual disabilities compared to people without intellectual disabilities. Further increased risk of mental disorders in an inner London borough compared to national data aligns with existing literature that highlights the negative impact of socio‐economic deprivation on mental and physical health. Further studies are needed to assess the health and social care measures that can reduce the physical and mental health morbidity in people with intellectual disabilities.

The scientific article is dedicated to an in-depth examination of one of the most complex and, at the same time, pressing issues in contemporary criminal justice – the classification and legal understanding of mental disorders in the context of criminal liability. The author explores this issue at the intersection of law, psychiatry, and forensic psychology, which ensures an interdisciplinary depth to the research. In the modern context of the humanization of criminal law and legal practice, the importance of adequate assessment of an individual’s mental state is growing. Consequently, the determination of criminal responsibility, the ability to participate in legal proceedings, and the selection of appropriate legal measures depend on the accuracy of such assessments. The article investigates the concept and classification of mental disorders within the framework of criminal justice, taking into account their impact on the determination of guilt and the imposition of punishment. The complexity of the issue arises from the necessity to ensure fairness in cases where the mental state of a suspect or defendant may affect their ability to understand and control their actions. The research methodology includes an analysis of contemporary scientific works, diagnostic criteria, as well as legal norms and precedents regulating the assessment of mental state in criminal proceedings. The article systematizes and classifies mental disorders such as schizophrenia, bipolar disorder, depression, and others, which may affect criminal responsibility – the capacity of a person to fully understand and control their actions. Moreover, the article analyzes various approaches to determining insanity and diminished responsibility across different jurisdictions and their implications for legal consequences. The article clearly formulates the problem: the diversity of terminology regarding mental states in Ukrainian criminal and criminal procedural legislation leads to challenges in legal practice. The author convincingly substantiates the need for unification and harmonization of terms with reference to international classifications. In conclusion, the article emphasizes the importance of a comprehensive approach to assessing mental disorders to ensure equality before the law and the protection of the rights of all participants in the criminal process. It also highlights the necessity for further research to improve legal mechanisms and practices that consider mental disorders in criminal justice.

Entirely revised and updated, this edition of a very well-received and successful book provides the essentials for all those involved in the fields of intellectual, developmental and learning disabilities and mental retardation, drawing both on clinical experience and the latest research findings. An international, multidisciplinary team of experts cover the available literature in full and bring together the most relevant and useful information on mental health and behavioural problems of people with intellectual, developmental and learning disabilities and mental retardation. In addition, this book highlights the principles behind clinical practice for assessment, management and services. It offers hands-on, practical advice for psychiatrists, psychologists, nurses, therapists, social workers, managers and service providers

A new cycle is starting in the development of international classification and diagnostic systems. The World Health Organization (WHO) Department of Mental Health organized in January 2007 the first meeting of an Advisory Committee for the preparation of the Mental Disorders Chapter of the Eleventh Revision of the International Classification of Diseases (ICD-11), to be consistent with the overall ICD-11 plan coordinated by the WHO Classification Office. Of relevance, there has been an active process of collaboration between the World Psychiatric Association (WPA) and WHO since 2001 to explore new classification and diagnostic paths. Also presently, the American Psychiatric Association (APA) is preparing the bases for its Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V). Furthermore, other active national and regional psychiatric bodies such as the Chinese Society of Psychiatrists and the Latin American Psychiatric Association are researching and refining, respectively, their Chinese Classification of Mental Disorders, 3rd Edition (CCMD-3) and Latin American Guide for Psychiatric Diagnosis (GLADP), which represent ICD adaptations to local realities and needs. As health professionals and institutions consider and undertake these important activities on central topics for clinical care and public health, it may be wise to reflect carefully on their fundamental purposes so that their conceptualization can be optimized. A full international revision of classification and diagnostic systems takes place only every 10–20 years, and therefore this represents an opportunity as well as a responsibility not to be missed to advance our field. The term diagnosis has a widely accepted central position in the process of medical care. Feinstein (1) has noted that diagnostic categories provide the locations where clinicians store the observations of clinical experience and the diagnostic taxonomy establishes the patterns according to which clinicians observe, think, remember and act. But, what is diagnosis? The eminent historian and philosopher of medicine, Laín–Entralgo (2), has pointed out that ‘diagnosis is more than identifying a disorder (nosological diagnosis) or distinguishing one disorder from another (differential diagnosis); diagnosis is really understanding what is going on in the mind and body of the person who presents for care’. In an attempt to delineate the nature and scope of that ‘understanding’ required to achieve a proper diagnosis, we may find the following reflections helpful. As health professionals, our natural area of concern is health. In Sanskrit, the mother of all Indo-European languages, the term for health is hal, meaning ‘wholeness’. Ancient Greek philosophers pointed out that if the whole is not well, it is impossible for the part to be well (3). Furthermore, WHO (4) has enshrined in its Constitution that ‘health is a state of complete physical, emotional, and social well being and not merely the absence of disease’. As we know, medicine at large and psychiatry in particular are professions committed to helping people restore and promote their health. In fact, health promotion, in addition to health restoration (disease cure, alleviation or management), is increasingly recognized as a proper and important task of clinical care (5, 6). From the above reflections, it should be possible to accept that diagnosis would fulfill better its fundamental role as informational basis for clinical care if it were to have a scope broad enough to describe the overall health status of the person presenting for care. And this means covering both ill health (or disease) and positive health, the latter involving domains such as functioning, personal and social values and resources, and quality of life (7). This also means bringing up to the front the humanistic purpose of clinical care (8). Its target and focus is the health of people who are not simply carriers of disease, but human beings with history and aspirations, whose dignity is to be respected and promoted. In connection to this, it should be recognized that diagnosis is not only a formulation, but an interactive process as concluded by trialog forums of patients, families and health professionals (9). It is encouraging to note an array of recent national and international developments and policies in mental health that are quite consistent with the above perspectives. A US Presidential Commission on Mental Health (10) has recommended to place consumers and families as well as integration of services at the center of an urgently needed transformation of the health systems. Also relevant here are recent policy statement on value-based practice from the National Institute of Mental Health of England, and the French Etats Generaux de la Psychiatrie in June 2003 demanding attention to ‘complex clinical situations’ through contextualized diagnosis and care. The WHO European Ministerial Conference on Mental Health (11) has spoken on the cruciality of mental health and the need to empower people and to obtain patient- and carer-centered integration of services. In connection to the historical aspirations noted earlier and the above policy developments in the international health field, the WPA prepared and published in 2003 a set of International Guidelines for Diagnostic Assessment (IGDA) that pointed out that a patient is more than a carrier of disease and proposed a comprehensive diagnostic model with standardized and idiographic components that reflect person-centered integrative perspectives. More recently, WPA approved at its 2005 General Assembly an Institutional Program on Psychiatry for the Person: from Clinical Care to Public Health (IPPP). It represents an initiative affirming the whole person of the patient in context as the center and goal of clinical care and health promotion, at both individual and community levels. It involves an articulation of science and humanism to optimize attention to the ill and positive health aspects of the person. It includes four operational components: Conceptual Bases, Clinical Diagnosis, Clinical Care, and Public Health. The IPPP initiative finds stimulating consistency on many points with such significant conceptual developments in the field as the European Medicine de laPersone (12), the Value-based Practice Approach promoted by the National Institute of Mental Health of England (8), and the Recovery Movement originating in the United States and now extending internationally (13, 14). In April 2006, WPA updated its formal position concerning the development of ICD-11 and related diagnostic systems. This statement recognized that WPA over the past several years, particularly through its Classification Section and in collaboration with WHO and national and regional psychiatric associations, has contributed significantly to setting the foundations of future international classification and diagnostic systems. Key activities have included a large International Survey on the Use of ICD-10, DSM-IV and Related Diagnostic Systems, a number of WPA-WHO Symposia on International Classification and Diagnosis at WPA Congresses and Conferences, which have led to three published monographs and crucial advances in the field, and work commissioned by WHO on the bases for the development of the ICD-11 mental health component presented at WHO meetings from 2003 to 2005. It also noted that the process of ICD revision has recently entered a new phase with the WHO Classification Office directing the overall developmental process and the WHO Mental Health Department directing the development of the Mental Disorders Chapter. The position statement declared that WPA will offer its full collaboration to the World Health Organization for the preparation of ICD-11 and related diagnostic systems, and that it will cooperate with its Member Societies, including the American Psychiatric Association and other national and regional associations, concerning their own classification projects with the expectation that they be as consistent as possible with WHO's ICD-11 and Family of International Classifications. To ensure this, effective interactive mechanisms for coordination and harmonization should be implemented. The position statement further indicated that WPA will continue exploring through its various components, particularly its Section on Classification and Diagnostic Assessment and pertinent Institutional Programs, and in collaboration with WHO and national and regional associations, the most promising approaches to fulfill etiopathogenic and clinical diagnostic validities and the accomplishment of the following principal developmental tasks: striving for the best possible core international classification of mental disorders, attending to the elucidation of optimal definitions and thresholds for the ascertainment of mental disorders, utilizing complementary dimensional approaches, and taking into consideration the most appropriate cultural framework for classification and diagnosis, and working for the development of the most useful comprehensive and integrative diagnostic models to enhance clinical care and health promotion. This is widely regarded as an important task. Obtaining an improved nosology of mental disorders would respond to the well-established expectations of clinicians, researchers, educators and public health planners for a tool long considered as crucial for their work. The assignment rules related to the definitions of the classified disorders would allow health professionals to identify them in the clinic and the community in a reasonably reliable manner for their pertinent professional purposes. In the Laín-Entralgo (2) terminology outlined earlier, this disorder identification process corresponds to nosological diagnosis. Of relevance to this critical task, WHO following its constitutional responsibilities is launching the development of the 11th Revision of the International Classification of Diseases. This work is coordinated at the whole system level by the WHO Classification Office and at the mental disorders chapter level by the WHO Mental Health Department. At this more specific level, the work is expected to include discussions on how this chapter will fit within the whole system, the particular uses of the classification in the mental health field, the definition of mental disorders, the conceptualization of broad and narrow categories, the use of dimensionality, the presentation of the classification for research and for clinical care in specialized and primary care settings, the organization of workgroups for major disorder categories and cross-cutting themes, the harmonization of the ICD classification with those developed by national and regional associations, and the engagement of world-wide scientific and stake holder contributions. It is hoped that the development of the mental disorders chapter, through alpha and beta versions, be completed around 2012, with a possible approval of the whole ICD-11 in 2014. WPA, which has a substantial record of collaboration with WHO on the matter (15, 16), will participate actively throughout this developmental process, at the various levels of work and through the engagement of national psychiatric societies and classification groups. The American Psychiatric Association, which has contributed richly to the field through the preparation and publication of path-opening editions of its Diagnostic and Statistical Manual of Mental Disorders, particularly DSM-III and DSM-IV, is working intensively towards the preparation of a DSM-V (17). It is presently holding a series of research conferences on psychopathological and methodological aspects of the classification. It has included WHO and WPA representatives in their advisory committees for DSM-V. There are also other national and regional psychiatric associations which have developed substantial adaptations of the International Classification of Mental Disorders to their particular circumstances and purposes. Specially notable are the Chinese Classification of Mental Disorders, 3rd Edition (CCMD-3) published by the Chinese Society of Psychiatry (18), the French Classification of Child and Adolescent Mental Disorders prepared by the French Federation of Psychiatry (19), the Third Cuban Glossary of Psychiatry (GC-3) (20), and the Latin American Guide of Psychiatric Diagnosis produced by the Latin American Psychiatric Association (21). All these associations, among others, are expected to contribute to the development of ICD-11 in coordination with the World Psychiatric Association. Along with all this activity, a consensus is emerging towards ICD-11 as a single international reference for the classification of mental disorders, with national and regional versions representing adaptations, annotations or extensions of the ICD core classification. The plan for the development of a Person-centered Integrative Diagnosis (PID) as a theoretical model as well as a practical guide is an initiative of the World Psychiatric Association through its Institutional Program on Psychiatry for the Person (IPPP). Collaboration for this development is being arranged with WPA's scientific sections and member societies and their national diagnosis and classification groups as well as with WHO. The growth of the World Psychiatric Association in recent years, in terms of the enlargement and strengthening of the WPA family of national psychiatric societies, its wide array of scientific sections, and active publications program is bolstering the position of WPA to undertake major global initiatives such as PID. A key starting point for the development of PID would be the schema combining standardized multiaxial and personalized idiographic formulations at the core of the WPA International Guidelines for Diagnostic Assessment (IGDA) (22). Also informative to this process would be the recent Evaluation of the DSM Multiaxial System, which has documented the value of such a system and offered recommendations for its further development and implementation (23). At the heart of Person-centered Integrative Diagnosis (PID) is a concept of diagnosis different from the more conventional notion of just identifying and differentiating disorders. In PID, diagnosis is tentatively defined as the description of the positive and negative aspects of health, interactively, within the person's life context. PID would include the best possible classification of mental and general health disorders (expectedly the ICD-11 classification of diseases and its national and regional adaptations) as well as the description of other health-related problems, and positive aspects of health (adaptive functioning, protective factors, quality of life, etc.), attending to the totality of the person (including his/her dignity, values, and aspirations). The approach would employ categorical, dimensional, and narrative descriptive approaches as needed, to be formulated and applied interactively by clinicians, patients, and families. It appears that PID comes close to Laín-Entralgo's (2) concept of real diagnosis. The proposed phases for the development of Person-centered Integrative Diagnosis, including its theoretical model and its practical guide or manual, in terms of main activities and outcomes, follow. Design of the Person-centered Integrative Diagnostic (PID) Model. This would encompass a review of the pertinent background (including the monographs listed above) aimed at evaluating critically the status of the diagnostic field, its fundamental limitations to provide an adequate basis for clinical care and public health actions, and the most suitable and promising domains and structures for the diagnosis of a person's health. Possible domains include illnesses, disabilities/functioning, risk and protective factors (resilience, resources, supports) and quality of life. Possible structures may include multilevel schemas encompassing standardized (categories and dimensions) and idiographic/narrative information. This work would include literature research conducted and discussed by members of the IPPP Clinical Diagnosis Component through the internet and face to face meetings, with input from WPA components and pertinent health stakeholders. The timeline for this phase would be calendar year 2007. Development of the Person-centered Integrative Diagnostic (PID) Guide. The sub-phases of the PID Guide development would include the following: Preparation of the PID Guide draft. This would include the schemas, instruments and procedures to evaluate real persons according to each of the domains of the PID. This work would include literature research and intense interactive discussions conducted by members of the IPPP Clinical Diagnosis Component through the internet and face to face meetings, with input from WPA components and pertinent health stakeholders. This draft is hoped to be ready by the end of 2008. Evaluation of the PID Guide draft. This evaluation would be conducted by the IPPP Clinical Diagnosis Workgroup in collaboration with the WPA Global Consortium of Classification and Diagnosis Sections through clinical and epidemiological studies using reliability, validity, and feasibility criteria. This work is hoped to be completed by the end of 2009. Preparation and publication of the final version of the PID Guide. This work will be based on the results of the evaluative phase outlined above, expert discussions and health stakeholders input. This is hoped to be accomplished by the end of 2010. Person-centered Integrative Diagnosis Guide translations, implementation, and training. This work would include, first, the translation of the PID Guide to prominent world languages; second, the promotion and facilitation of the implementation of the PID Guide across the world; and third, the development of training curricula and programs at graduate, post-graduate and continuing professional education levels both for specialty and primary care arenas. The work would be conducted by the IPPP Clinical Diagnosis Workgroup in collaboration with partner organizations in the year 2011 and thereafter. The upcoming work on the development of the best possible classification of mental disorders (through WHO's ICD-11 and related versions from the APA and other national and regional psychiatric associations) as well as that of a Person-centered Integrative Diagnosis brings a sense of excitement and historical responsibility to the many institutions and individuals involved. It will be certainly a world-wide effort. In contemplating this scenario from the pages of Acta Psychiatrica Scandinavica it is necessary to reflect on the enormous contributions from Nordic European colleagues to the foundations of these developments. We are celebrating this year the 300th birthday of Carolus Linnaeus, who as professor of biology and medicine at Uppsala University set key principles for systematization in the life sciences. We must also recognize the contributions of Stengel (24) to the international classification of mental disorders and of Essen-Moeller and Wohlfahrt (25) to the original conceptualization of multiaxial diagnosis. Last, but not least, we would like to thank Otto Steenfeldt-Foss (26), who has argued cogently that psychiatry and medicine being based on science and humanism must be personalized in diagnosis and care.

Notes of a traveller

Background: Intellectual developmental disorder (IDD) may pre-dispose for mental health disorders. It is sometimes debated whether the needs of this group are adequately met in general psychiatry. However, little is known about patients with IDD in the psychiatric clinical setting—occurrence, clinical diagnoses, or service use.Aims: This study aimed to assess the number of adult patients diagnosed with IDD in a psychiatric clinic, their psychiatric diagnoses, and their use of psychiatric services.Methods: Individuals with registered IDD diagnoses were identified in a university hospital adult psychiatric clinic register comprising 67 384 patients.Results: IDD had been diagnosed in 0.6% of the patients. Psychotic disorders were the most common co-existing psychiatric diagnoses (25.5%). In 21.8% no psychiatric diagnosis other than IDD was registered. More than 50% had been inpatients; 21% had been compulsorily admitted. Patients with IDD had required a mean of five hospital beds per day.Conclusions: The percentage, 0.6%, of IDD diagnoses was lower than estimates of the prevalence of IDD in the general population. This may reflect a lower need for psychiatric care, barriers to access services, or diagnostic over-shadowing. One fifth of the patients in this study had no psychiatric diagnosis beside IDD, which may be due to diagnostic difficulties, or other problems (e.g. somatic or behavioural disorders) leading to psychiatric contact. Since patients with IDD use the equivalent of five inpatient beds every year, it is suggested that it may be worthwhile to consider specialized psychiatry with expertise in IDD, even though this group is small.

Specific copy number variants (CNVs) have been robustly associated with intellectual disability, autism, and schizophrenia. Most of the literature focus has been on documenting the existence of these phenomena. There are few data to guide therapeutic choices for these “orphan” diseases. We call for systematic and longitudinal case reports which, if carefully conducted, may provide crucial initial knowledge to guide therapeutics. We provide a step-by-step overview, a tailored set of consensus criteria for high-quality case reports, and a specific set of learning resources.

To investigate the association between a maternal history of spontaneous abortion and intellectual disability in children. This cohort study included 1778786 children (913 340 males, 865 085 females, 361 missing data; mean age 15y 2mo, SD 8y 11mo, range birth to 40y) born in Denmark between 1977 and 2016. Cox proportional hazard regression was used to estimate the hazard ratios (HRs) of intellectual disability. The overall HR of intellectual disability for children with a maternal history of spontaneous abortion was 1.17 (95% confidence interval [CI] 1.12-1.22) and the risk for multiple spontaneous abortions (HR=1.30, 95% CI 1.20-1.40) was higher than for a single spontaneous abortion (HR=1.13, 95% CI 1.07-1.18). When only cases of inpatient intellectual disability were included, the estimates increased slightly: the overall HR was 1.22 (95% CI 1.12-1.32), the HR for multiple spontaneous abortions was 1.37 (95% CI 1.20-1.58), and the HR for a single spontaneous abortion was 1.17 (95% CI 1.07-1.28). The risks were similar regardless of whether spontaneous abortion occurred before or after the index delivery. Estimates were nearly unchanged after adjusting for preterm birth, low birthweight, or Apgar score. Children born to mothers with spontaneous abortion, especially multiple spontaneous abortions, may be at a higher risk of intellectual disability in later life, regardless of whether spontaneous abortion occurred before or after the index delivery. The findings have clinical implications for targeted early intervention of children with intellectual disability. What this paper adds A maternal history of spontaneous abortion was associated with a risk of intellectual disability in offspring. The risk was higher in children whose mothers previously had multiple spontaneous abortions. Similar risks were observed regardless of whether spontaneous abortion occurred before or after childbirth.

Editorial: Introduction to Special Section on Evidence-Based Practices for Persons With Intellectual and Developmental Disabilities