In a peer-to-peer discussion, a slew of psychiatrists huddled together in the Exhibit Hall at this year's Psychiatric Congress meeting in Orlando to ask questions of Phillip Resnick, MD, a board member of Psychiatric Times and professor of psychiatry at Case Western Reserve University. Dr Resnick has been a consultant in many high profile cases—including those of Jeffrey Dahmer, Susan Smith, Timothy McVeigh, Andrea Yates, Scott Peterson, William Kennedy Smith, and Theodore Kaczynski (the Unabomber). Here are a handful of questions he adeptly answered. The cases and scenarios he addresses are all hypothetical.
Question (Q): Would an act of rage fall under the irresistible impulse rule?
Dr Resnick (PR): Let’s say an intoxicated husband comes home to find his wife in bed with another man. He kills them both. If it can be proven that the act of murder flowed from disease (eg, the defendant has schizophrenia) and not from rage, intoxication, or jealousy, he may be found not guilty by reason of insanity. Rage, jealousy, and intoxication alone would not be enough to prove irresistible impulse because they do not flow from a mental disease.
Q: Can you talk about chemical castration in the case of pedophiles?
PR: Chemical castration with Depo Provera can be effective but it does not change the object preference of the offender. It just turns down the thermostat of sexual drive.
Q: What about cases in which a patient sues a doctor for boundary violations?
PR: The burden of proof is on the plaintiff. Boundary violations usually precede frank sexual misconduct. A doctor sees this theoretical patient last in the day, does not bill, and shares his own concerns. The typical doctor offender is in his 50s, has a bad marriage, and the patient is 20 years younger. To prove a case would require corroboration of the plaintiff ‘s version (eg, telephone recordings, cards, gifts, and/or witnesses).
Q: How does the broadening of Tarasoff in some states affect the prospect of liability risk?
PR: In short, human life trumps confidentiality in the event of imminent risk.
Q: Does an intoxicated patient in the emergency department who threatens suicide and later renounces it remain a suicide risk?
PR: All cases are different, but in general, a physician should first wait until the patient sobers up. If the patient tried to overdose, he should probably be held against his will. Verbal threats are less clear and require the exercise of good clinical judgement.
Q: What about chronic suicidality?
PR: Some say a psychiatrist should keep no more than 2 chronically suicidal patients at a time because of the toll it takes on a clinician. It is important to involve the family because a surprised family is more likely to sue. The patient then becomes a “shared risk,” and the likelihood of being sued diminishes.
Q: Someone with extreme religious beliefs kills an abortion doctor. Can he qualify for an insanity defense?
PR: If the killer believes that abortion is a crime punishable by death for nonpsychotic reasons, he cannot succeed with an insanity defense. But if it can be proven that the defendant has delusional beliefs that are based on psychosis, he could possibly win. Juries are always skeptical about malingering. For the defense to prevail in an insanity case, it is always an uphill battle. To detect malingering, you must know about the phenomenology of genuine symptoms. See my chapter on Detecting Malingered Psychosis in Richard Rogers’ Clinical Assessment of Malingering and Deception (3rd ed: New York: Guilford Press; 2007).