Psychiatric Expertise Research Articles

Psychiatric assessment of adults in care proceedings

SUMMARYPsychiatric assessments of adults involved in care proceedings can play a critical role in assisting the family court to resolve proceedings justly. To properly carry out this role, the psychiatric expert should have an up-to-date understanding of the wider context within which they are working. This article outlines the legal framework of care proceedings in England and Wales and summarises the key aspects of the process. The duties of the expert and how the expert is engaged are explained. Finally, guidance is presented on how the expert should approach questions that are commonly raised in these proceedings.LEARNING OBJECTIVESAfter reading this article you will be able to: •appreciate the legal framework relevant to care proceedings in England and Wales•recognise the circumstances in which expert psychiatric evidence relating to adults in care proceedings is commissioned•understand the common questions posed to expert psychiatrists undertaking assessments of adults in care proceedings and develop an assessment framework.

The Insanity Defence: How Do We Handle Doubt?

This paper discusses how the legal definition of criminal insanity has been altered several times in the Norwegian criminal law, most recently in June 2019. There are difficulties in communicating between psychiatric experts, legal experts, and lay judges, since the description and understanding of psychotic cognition as well as the definition of legal terms are not equally understood.
 Not all insanity cases are clear-cut. The Norwegian forensic experts must not conclude that the charged person is considered ‘psychotic’ in the legal sense if they are not clinically sure of this. The courts, on the other hand, must not conclude that a person is ‘sane’ if there is doubt about this. This paper discusses how there is little practical knowledge of how experts and courts handle such doubts, and highlights the lack of discussion of these questions in the legal sources.

What does impartiality mean in medico-legal psychiatry? An international survey

Medico-legal psychiatry is the field of forensic psychiatry that consists of reporting to criminal, civil and administrative authorities and testifying in courts of law. As a forensic science, medico-legal psychiatry is based on the principle of impartiality. However, the notion of impartiality is not clearly defined and can be understood in many different ways. The purpose of this study was to explore the meaning that expert psychiatrists attribute to this notion. Members of the forensic sections of the World Psychiatric Association, the European Psychiatric Association and the American Academy of Psychiatry and the Law were surveyed by e-mail using a vignette and a questionnaire. One hundred and thirty-one responses were received. When commenting on the case presented in the vignette, a large majority of respondents considered that the personal moral convictions of the doctor were the main factor likely to cast doubt on the impartiality of the expert, followed by past personal experience and the fact that the expert was the treating doctor of the examinee. In the answers to the questionnaire, 54% of participants considered that the question of impartiality was similar in both the inquisitorial and adversarial systems. Impartiality was considered by most participants as both an ethical and a legal concept. The main factors considered as likely to affect the impartiality of an expert were past personal experience, personal beliefs and perceptions, and the fact that the expert was the treating doctor of the examinee. Training in forensic psychiatry and past professional experience were considered to be the most important factors that could enhance the impartiality of an expert. When asked about their own definition, 70% of respondents defined impartiality as a choice specific to the expert, and 27% of participants defined impartiality as a result of external factors. The term ‘objectivity’ was used in 30% of responses. Results revealed a rather unified view of the issue of impartiality by medico-legal psychiatrists, irrespective of their country and practice conditions. The notions of honesty and striving for objectivity, which are emphasized in several guidelines of forensic psychiatry associations, were cited by many participants. Impartiality appears to be considered as a coherent concept in both normative and consequentialist ethics and represents a useful reference in the practice of medico-legal psychiatry.

Clinical guidelines for the management of treatment-resistant depression: French recommendations from experts, the French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental

BackgroundClear guidance for successive antidepressant pharmacological treatments for non-responders in major depression is not well established.MethodBased on the RAND/UCLA Appropriateness Method, the French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental developed expert consensus guidelines for the management of treatment-resistant depression. The expert guidelines combine scientific evidence and expert clinicians’ opinions to produce recommendations for treatment-resistant depression. A written survey comprising 118 questions related to highly-detailed clinical presentations was completed on a risk-benefit scale ranging from 0 to 9 by 36 psychiatrist experts in the field of major depression and its treatments. Key-recommendations are provided by the scientific committee after data analysis and interpretation of the results of the survey.ResultsThe scope of these guidelines encompasses the assessment of pharmacological resistance and situations at risk of resistance, as well as the pharmacological and psychological strategies in major depression.ConclusionThe expert consensus guidelines will contribute to facilitate treatment decisions for clinicians involved in the daily assessment and management of treatment-resistant depression across a number of common and complex clinical situations.

Prises en charge de situations psycho-légales complexes aux urgences psychiatriques

During a significant and clinically-varied influx of patients arriving at emergency psychiatry units, for some of these people the problem with regard to forensic psychology arises of rapid resolutions to complex situations. These situations are alluded to in this presentation: treatments in danger of non-completion when close relations refuse to sign a third-party agreement; psychiatric expertise in emergency departments; the evaluation of patients in administrative or police border control retention centers; refusal of somatic care; unclassifiable situations.

Plastic Adaptation to Pathology in Psychiatry: Are Patients with Psychiatric Disorders Pathological Experts?

Psychiatric disorders share the same pattern of longitudinal evolution and have courses that tend to be chronic and recurrent. These aspects of chronicity and longitudinal evolution are currently studied under the deficit-oriented neuroprogression framework. Interestingly, considering the plasticity of the brain, it is also necessary to emphasize the bidirectional nature of neuroprogression. We review evidence highlighting alterations of the brain associated with the longitudinal evolution of psychiatric disorders from the framework of neuroplastic adaptation to pathology. This new framework highlights that substantial plasticity and remodeling may occur beyond the classic deficit-oriented neuroprogressive framework, which has been associated with progressive loss of gray matter thickness, decreased brain connectivity, and chronic inflammation. We also integrate the brain economy concept in the neuroplastic adaptation to pathology framework, emphasizing that to preserve its economy, i.e. function, the brain learns how to cope with the disease by adapting its architecture. Neuroplastic adaptation to pathology is a proposition for a paradigm shift to overcome the shortcomings of traditional psychiatric diagnostic boundaries; this approach can disentangle both the specific pathophysiology of psychiatric symptoms and the adaptation to pathology, thus offering a new framework for both diagnosis and treatment.

Brains and psyches: Child psychological and psychiatric expertise in a Swedish newspaper, 1980–2008

Most children and families have not had direct contact with child psychological and psychiatric experts. Instead they encounter developmental theories, etiological explanations and depictions of childhood disorders through indirect channels such as newspapers. Drawing on actor–network theory, this article explores two child psychological and psychiatric modes of ordering children’s mental health discernible in Sweden’s largest morning newspaper, Dagens Nyheter, during the years 1980 to 2008: a psychodynamic mode and a neuro-centered mode. In the article I show how these two relatively contemporaneous modes greatly differed in how they enacted children’s mental health. The psychodynamic mode stressed the parents’ role in structuring and affecting the child’s unconscious and saw them as the primary cause of any mental illness. In contrast, the neuro-centered mode highlighted that mental issues were related to the child’s brain and proposed different solutions depending on whether the child’s brain functioned in a ‘normal’ or ‘atypical’ manner. Each mode moreover suggested differing contexts to their discussions, with the psychodynamic mode solely discussing the parental milieu while the neuro-centered mode mainly focused on how society affected children with ‘atypical’ brains. The two modes thus had significantly diverging implications for the reader on how to understand and manage children and their psychological well-being. I further argue in the article for the relevance of actor–network theory in historical studies of psychology and psychiatry.

The ‘Nothing But’

This paper shares findings from a qualitative study on university student mental health and illness that included digitally recorded interviews with university student services and programs professionals and staff at a Canadian university. Transcripts were thematically coded and analyzed using a disability studies informed interpretive sociological approach. Four key themes emerged: dwelling with disclosure, being open to the ‘nothing but’, understanding oneself as ‘not a counselor’, and coming to terms with the reality that under neoliberalism ‘we all fall’ Two key insights also emerged from the analysis: 1) Access to university-based programs and services is shaped by assumptions about productivity and reputation; 2) Psychiatric knowledge and expertise influences and informs how university student services staff understand and enact their roles within the university system. This paper considers how university-wide productivity-oriented psy-knowledge and practices organize and authorize what one participant described as a ‘hidden curriculum’ of academic success. This hidden curriculum manifests in the form of a referral-based resiliency (govern)mentality in university student service provision. It closes with a reflection on the transformative potential of adopting a “critically maladaptive” (McLaren, 2010, p. 504) approach that is attentive to alterity in university-based student services professional perspectives which appears in the form of a thoughtful “but…”.

New opportunities for using the test “Prognoz”

Background. For the detection of violations of mental responses in military offices, use the “Prognoz” test. At the total score of this test, experts make a decision on limiting the service in the troops. However, not all questions of the test are equally important for the diagnosis of mental disorders of the psychotic level.
 By the amount of points should be not recognize the beginning of a psychotic disorder. Therefore, the “Prognoz” questionnaire has an additional reserve for the detection of psychotic disorders, if the psychologist and /or psychiatrist pay special attention to the specific questions of this test.
 Material and methods. According to the expert estimation method, the “Prognoz” test was worked out to determine the risk of psychotic disorder in the military. The basis of the evaluation was a comparison of diagnostic criteria for ICD-10 with test questions.
 Results. Qualified psychiatric experts have selected the most informative questions for identifying psychotic disorders, namely 16 out of 84 questions for the “Prognoz” test. If there are positive answers to 6 or more questions from selected 16, special attention should be paid to this and send respondents an additional psychiatric examination. Approval of this screening test on 18 patients with psychotic level disorders confirmed its diagnostic capabilities.
 Conclusions. According to the expert estimation method, an express method for the screening of psychotic disorders in soldiers has been approved. The testing confirmed its diagnostic capabilities.

ISSUES OF CONTEMPORARY STATE OF FORENSIC PSYCHIATRIC AND PSYCHOLOGICAL EXAMINATIONS

The problem of determining the limits of competence of a forensic psychiatrist expert and a psychologist expert, the principles of interaction of law, forensic psychiatry and psychology in modern domestic expert practice remain relevant to the present day. The current legislation of Ukraine regulates expert compliance with the limits of competence. In jurisprudence and psychiatry, the issue of the definition of the concept of “insanity” is currently debatable, since the so-called “formula of insanity” contains medical (biological) and psychological (legal) criteria.
 This article purpose The purpose of this paper: presenting of the author's systemic model of ascertaining insanity, which delimits the competences of lawyers and an expert psychiatrist; A written description of the psychiatric criteria (diagnostic, criticality and anamnestic) of determining the mental state of a person in a legally relevant period of time is given; The definition of the concept of “insanity” is formulated.
 No less urgent is the problem of further improvement and bringing into compliance of certain paragraphs the Procedure for conducting a forensic psychiatric examination of the current legislation of Ukraine and departmental regulatory acts governing the organization of forensic expert activity in state specialized expert institutions. Separate provisions of the Procedure for conducting a forensic psychiatric examination, which can create significant difficulties in the work of a forensic psychiatrist, are analyzed, and appropriate proposals are made to change the content of problematic provisions in the specified regulatory document.

The Age of “Amok”

The proliferation of mass-shootings in the United States since the 1960s has produced a character profile of largely unremarkable, middleclass male culprits who transform particular places of civil peace – schools, universities, shopping malls – into landscapes of war. On the one hand, the lack of clear motives has led mystified psychiatric experts to draw correlations between such events and “running amok” – the phenomenon of sudden outbursts of homicidal violence observed since early modernity in Southeast Asia. On the other hand, the details of how such acts are carried out as well as the notes of some perpetrators suggest that mass-shootings could also be understood as “interpretations” of American postwar society: from the “lonely crowd” of suburbia via “Reaganomics” to the present politics of fear and resentment to a society of preemptive control.

Integrating Non-Psychiatric Models of Delusion-Like Beliefs into Forensic Psychiatric Assessment.

In both clinical and forensic psychiatry, it can often be difficult to distinguish delusions from normal beliefs. The categorical approach of the Diagnostic and Statistical Manual of Mental Disorders (DSM) leaves few options to describe intermediate delusion-like beliefs (DLBs). Neurocognitive models offer an alternative view of DLBs as existing on a continuum that can be quantified based on dimensions of severity as well as underlying cognitive biases. The Internet provides broadened access to putative evidence for diverse beliefs, with filter bubbles and echo chambers that can amplify confirmation bias and strengthen conviction. It is therefore much easier now for fringe beliefs to be shared and much less clear when they should be considered delusional. To place DLBs into a forensically relevant framework, psychiatric expert witnesses should adopt a broad biopsychosocial understanding of belief formation and maintenance that integrates clinical expertise with knowledge about dimensional aspects of delusions, cognitive biases, and the processing of online misinformation. The unavoidable conclusion that normal thinking is replete with cognitive biases and misbeliefs challenges the legal concept of mens rea that forms the foundation of a retributivist American justice system.

Évaluation des pratiques de l’injonction de soins : étude sur 119 sujets

IntroductionThe injunction to care (IC) is a new compulsory treatment created by the Act of June 17, 1998. Initially, this judicial tool concerned mainly sex offenders, but then the number of overall crimes requiring an IC began to dramatically rise. The judge can order this measure only if a psychiatric expertise has concluded to its potential opportunity. Then the convict must undergo a psychiatric follow-up after having served the sentence. The creation of a court-ordered treatment is based on the premise that many offenders are affected by psychiatric disorders. For the lawmaker, the aim is to lower the risk of recidivism. PurposesThe main purpose of this study is to assess the convicts concerned by the IC describing their sociodemographic characteristics, psychiatric diagnostics and criminal characteristics. The second purpose is to assess the efficiency of this measure regarding re-offending and specifically legal recidivism. MethodsThis is a retrospective and descriptive study concerning 119 subjects followed-up by two “coordinating doctors” in the department of Sarthe who could assess their psychiatric diagnostics and sociodemographic characteristics. They could also compare medical data with the judicial data for 78 of the subjects. ResultsThe population was composed of 117 men (98.3%) aged 45 years old on average. They had a job in 37% of cases (n=44) and were single in 56.3% of cases (n=67). According to the DSM-IV-TR, only 29 subjects (24.4%) had an axis I disorder and 37.8% of the population had a pathological personality trait (non DSM-IV-TR categorized disorder). Furthermore, 51.3% (n=61) of the subjects were addicted (mainly alcohol). The medical follow-up was carried out by a psychiatrist in 83.2% of cases (n=99). The average duration of follow-up was five years. Among the 78 subjects for whom there was access to juridical data, 13 (16.7%) had committed a new offense during follow-up. Among them, seven had recidivated six of whom were initially sentenced for sexual offense. ConclusionsMost of the subjects in injunction to care had no axis I disorder but addictions and/or pathological personality traits. Nevertheless, the expert concluded the need of an IC. Personality and behavior disorders do not always require psychiatric care, and the management must be multidisciplinary. In France, the psychiatrist remains at the center of injunction to care measure. The addictology care is not developed whereas it is a population at risk and there is a lack of interactions between professionals (medical, social and judicial professionals). The IC is a measure that needs to be improved by means of better communication among the different professionals and a better global assessment of the subjects. Medical care must be a possible option but not a systematic treatment.

Trends in Psychiatric Emergency Department Visits Among Youth and Young Adults in the US.

Visits to the emergency department (ED) for psychiatric purposes are an indicator of chronic and acute unmet mental health needs. In the current study, we examined if psychiatric ED visits among individuals 6 to 24 years of age are increasing nationwide. ED data came from the 2011-2015 National Hospital Ambulatory Medical Care Survey, a national survey of ED visits across the United States. Psychiatric ED visits were identified by using the International Classification of Diseases, Ninth Revision and reason-for-visit codes. Survey-weighted logistic regression analyses were employed to examine trends in as well as correlates of psychiatric ED visits. Data from the US Census Bureau were used to examine population rates. Between 2011 and 2015, there was a 28% overall increase (from 31.3 to 40.2) in psychiatric ED visits per 1000 youth in the United States. The largest increases in psychiatric ED visits per 1000 US youth were observed among adolescents (54%) and African American (53%) and Hispanic patients (91%). A large increase in suicide-related visits (by 2.5-fold) was observed among adolescents (4.6-11.7 visits per 1000 US youth). Although psychiatric ED visits were long (51% were ≥3 hours in length), few (16%) patients were seen by a mental health professional during their visit. Visits to the ED for psychiatric purposes among youth are rising across the United States. Psychiatric expertise and effective mental health treatment options, particular those used to address the rising suicide epidemic among adolescents, are needed in the ED.

Mass murders in Germany – classification of surviving offenders based on the examination of court files

ABSTRACTPersonality, psychopathology, and motives of 44 surviving offenders committing mass murder in Germany over 25 years (1984–2009) were analyzed using court files and psychiatric expertises. Initially, 123 mass murders in Germany were detected in the time period 1980–2010 (inclusive deceased offenders). Using a data entry form based on ViCLAS (Violent Crime Linkage Analysis System), we categorized the 44 surviving mass murderers into three prototypes using the ‘TwoStep Cluster’-method (separation of the offenders in different groups depending on their similarity of specific items): 1. Narcissistic or aggressive men suffering from addiction or affective disorder, committing mass murder out of rage/hate when being intoxicated by alcohol, 2. Psychotic offenders with schizophrenia and comorbid substance abuse. 3. Aggressive, narcissistic or anxious adolescents, half of them suffering from affective disorder or ADHD, committing mass murder out of rage/hate. Not included are such events where the offenders died and therefore no court files or psychiatric expertises were available. Classification and subtyping of the offenders’ personalities and psychopathological conditions might help to improve the chances for an early detection of persons at risk.

De l’expertise psychiatrique des criminels et des victimes à l’expertise pour la commission internationale des miracles

In this interview, Louis Roure, a psychiatrist emeritus in psychiatric hospitals, an expert emeritus, accredited by the French Court of Cassation, and criminologist, talks of his experience in clinical practice and criminology, garnered throughout his rich professional career. He explains his vision for how his subject matter of expertise might evolve and considers the causes of the fall in the number of psychiatric experts in France in recent years, plus the probable reasons their lack of enrolment on the Court of Appeal's lists. In addition to this long and significant activity as a judicial expert, he tells of his experience of sharing his expertise with the international miracle commission of Lourdes (“la commission internationale des miracles”). He also evokes the Nice terrorist attack of 2016: the very grave consequences of this mass murder and the perception that we may have of the event.

Vaginismus and pregnancy: epidemiological profile and management difficulties.

BackgroundVaginismus affects up to 1% of the female population and often represents a physical manifestation of an underlying psychological problem. Our objective was to investigate the psychosomatic impact of vaginismus in pregnant women and evaluate the quality of their therapeutic care in Tunisia.MethodsWe included pregnant patients with vaginismus who presented at our obstetric emergency department between October 2016 and March 2017. All patients were interviewed by one expert psychiatrist and gynecologist using a standardized questionnaire. The State-Trait Anxiety Inventory (STAI) was used to determine anxiety and depression levels. Patients were prospectively followed until their postpartum period and were interviewed by the same experts after delivery. Sixteen weeks after hospital discharge, we contacted all patients via phone. All the information was simultaneously recorded in written form.ResultsTwenty pregnant patients with vaginismus were included (85% primary, 15% secondary). Most women described a conservative family background (70%) in which they received little or no sexual education (60%). All women described a feeling of anxiety and anger immediately before sexual intercourse and 40% have never sought medical consultation regarding their vaginismus before. Only 50% reported regular follow-up visits during their pregnancy (without vaginal examination), whereas 25% reported irregular follow-up visits with subjectively bad experiences during attempts of vaginal examinations.ConclusionPregnant women with vaginismus are at risk of non-follow-up during their pregnancy due to underlying feelings of shame and experienced lack of understanding by medical staff. Obstetricians should carefully and attentively approach pregnant women with vaginismus in order to ensure adequate medical care during pregnancy.

Texas County Pilots Telehealth Crisis Response Program

The use of an iPad can extend the expertise of psychiatrists and other mental health professionals when Harris County deputies encounter situations that involve people with mental illness.

Clinical guidelines for the management of depression with specific comorbid psychiatric conditions French recommendations from experts (the French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental)

BackgroundRecommendations for pharmacological treatments of major depression with specific comorbid psychiatric conditions are lacking.MethodThe French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental developed expert consensus guidelines for the management of depression based on the RAND/UCLA Appropriatneness Method. Recommendations for lines of treatment are provided by the scientific committee after data analysis and interpretation of the results of a survey of 36 psychiatrist experts in the field of major depression and its treatments.ResultsThe expert guidelines combine scientific evidence and expert clinician’s opinion to produce recommendations for major depression with comorbid anxiety disorders, personality disorders or substance use disorders and in geriatric depression.ConclusionThese guidelines provide direction addressing common clinical dilemmas that arise in the pharmacologic treatment of major depression with comorbid psychiatric conditions.

Introduction: The Revival of Francophone Research on Justice and Mental Health

In France, the relations between the justice system and psychiatry first attracted attention among scholars of the social sciences in the 1970s. At that time, these relations were studied mainly from one particular angle: that of the encounter between judges and psychiatric experts, often in a criminal court, as so often depicted in the media, in books and on film. With Bernard Tavernier’s film The Judge and the Assassin as a cinematographic reference, the French media displayed a frequent an...