FORENSIC PSYCHIATRY SPECIAL REPORT: PART I

We are pleased to offer a broad sampling of fascinating subjects by experts in forensic psychiatry. This 2-part Special Report focuses on pyromania, court testimony, avoiding malpractice, and psychopathy. Psychopathy is a particularly interesting subject in that it has been heavily researched, yet it remains something of a puzzle, and most certainly a huge burden on society.

 In forensic psychiatry, psychopathy is generally thought of as a more aggressive, narcissistic, predatory form of antisocial personality. French physician Philippe Pinel introduced the concept of the psychopathic personality at the turn of the 19th century.

 He described characteristics such as impulsive violence in the absence of appreciable deficits in intellect or cognition. In 1941, the classic text by Hervey Cleckley, MD, T

y, provided more detailed clinical descriptions. Building upon the work of Cleckley, Robert D. Hare, PhD, has approached the clinical construct by developing a research tool—the Psychopathy Checklist (PCL-R).

Nevertheless, there remain multiple conceptualizations of psychopathy, as well as problems with reliability.

 While a large body of research has been generated on the subject, the heterogeneous nature of psychopathy renders many conclusions speculative.

 In fact, the epidemiology of what I would like to call “antisocial spectrum” disorders is complicated by their heterogeneity. While it appears that antisocial behavior is heritable, its expression varies by age, definition, and adverse life circumstances—among other factors.

 Psychopathy research, conducted primarily on caught or “unsuccessful” psychopaths, continues to seek clarity via grouping characteristics into various facets or models.

For example, the triarchic model of psychopathy is a more recently developed model identifying 3 primary domains: they include boldness, meanness, and disinhibition (

 relates to fearlessness, toleration of danger, and high self-confidence. 

 encompasses lack of empathy, disregard for close attachments, and exploitative tendencies. 

 refers to poor impulse control, inability to delay gratification, and possibly frontal executive dysfunction.

Throughout the centuries, we have continued to puzzle over our capacity for antisocial behavior. All the while, it may be helpful to keep in mind the aphorism, “Bad men do what good men dream.”

 Or as the great psychoanalyst, Mick Jagger, aptly noted, “Just as every cop is a criminal, and all the sinners saints . . .”

is director of forensic psychiatry and professor of psychiatry at SUNY Upstate Medical University in Syracuse, NY. He is editor in chief emeritus of Psychiatric Times® (2010 to 2014).

1. DeLisi M, Reidy DE, Heirigs MH, et al. Psychopathic costs: a monetization study of the fiscal toll of psychopathy features among institutionalized delinquents. 

Traite, Medico – Philosophique Sur L’Alienation Mental.

3. Hare R. Psychopathy: A clinical and forensic overview. 

4. DeMatteo D, Hart SD, Heilbrun K, et al. Statement of concerned experts on the use of the Hare Psychopathy Checklist—Revised in capital sentencing to assess risk for institutional violence. 

5. Woody RH. Incidence of Psychopathy. In: 

Risks of Harm from Psychopathic Individuals.

 Cham, Switzerland: Springer; 2019: 29-31.

6. Goldstein RB, Chou SP, Saha TD, et al. The Epidemiology of Antisocial Behavioral Syndromes in Adulthood: Results From the National Epidemiologic Survey on Alcohol and Related Conditions-III. 

7. Gard A, et al. Genetic influences on antisocial behavior: Recent advances and future directions. 

8. Hyatt CS, Crowe ML, Lynam DR, Miller JD. Components of the Triarchic Model of Psychopathy and the Five-Factor Model domains share largely overlapping nomological networks. 

9. Skeem JL, Polaschek DL, Patrick CJ, Lilienfeld SO. Psychopathic personality: Bridging the gap between scientific evidence and public policy. 

Bad Men Do What Good Men Dream: A Forensic Psychiatrist Illuminates the Darker Side of Human Behavior.

 Arlington, VA: American Psychiatric Publishing; 2009.

Articles

Throughout the centuries, we have continued to puzzle over our capacity for antisocial behavior

Bad Men Do What Good Men Dream

Many psychiatrists are sued for malpractice every year. Some deserve it; some do not. We offer some practical tips for helping patients (most important), decreasing the chance of being sued, and increasing the odds of winning if you are. These are not legal tricks, but practice errors that plaintiffs’ lawyers look for, and ways to correct them.

To be successful in a malpractice action, the plaintiff must prove 4 things (

). If any of those 4 elements is not proved, then no malpractice has occurred. The level of proof required is fairly low, compared with criminal matters: preponderance of the evidence (merely more likely than not).

The authors have been involved in the clinical, legal, and administrative aspects of psychiatric malpractice cases, particularly those related to suicide, for more than 3 decades and in more than 30 states. We see the importance, to patients and courts alike, of practicing well. Neither medicine nor the law asks for perfection, but both demand competence and mindfulness of the concepts we will illustrate. Our comments are not meant to preach about clinical practice—many readers should already know most or all of what we describe—but to alert clinicians to the things that influence lawyers and juries as they consider alleged malpractice.

Most lists of the reasons people sue for psychiatric malpractice are misleading. The great majority of such lawsuits are related to one thing: 

. Many apparently non-suicide topics on those lists—such as inadequate assessment, treatment or follow-up—refer to cases in which suicide occurred. Others, such as violating confidentiality, lack of informed consent, failure to monitor lab results, adverse medication reactions, and danger to others are far less common than readers might think. Another, sex with patients, is almost always adjudicated as a nonmalpractice damage issue or a criminal and/or licensure offense, rarely as “malpractice” (and rarely covered by malpractice insurance).

Finally, some of the examples below allude to a combination of clinician and hospital responsibility. It is important to note that the standard of care (SOC) in malpractice cases requires physicians to recognize, within reason, unsafe treatment environments and procedures to which their patients are exposed, to protect patients from them, to bring them to others’ attention, and to advocate for their elimination.

Treat patients as you want your family members to be treated, and give time.

 Be sure to give the time needed in assessments, personal contact, family feedback, and follow-up. Take time explaining things, and time documenting in sentences rather than acronyms or quick words that do not reveal your thinking process and judgment. (More about medical record notes later.)

Understand the assessment, recognition, and management of suicide risk.

 Competently assess patients who are potentially suicidal, do so completely and regularly, not just on admission and discharge.

The point is risk assessment, not prediction. 

Suicide is unpredictable. So what? Don’t get hung up on predictability. Your job is to deal with risk. In malpractice cases, the legal test is foreseeability, defined as anticipation of risk, not predictability.

In most of the case examples, both a psychiatrist and a hospital were sued. Make no mistake, psychiatrists are important to facility policies and procedures, and to the individual actions of staff with whom they work. You are a care leader. You should know whether or not your hospital or clinic and its staff are treating patients properly. Even when hospital staff or procedures are faulty, juries often view the doctor as someone who failed to protect the patient from inadequate care (and they may be right). You have an ethical and legal duty to do or order what your patient needs in order to be safe during, and because of, treatment, regardless of schedule crunches, staffing limitations, or administrative pressures.

 Write more, not less. Short notes are very often inadequate, and abbreviated terms such as “No SI/HI” say little to malpractice juries (and clinical readers). How did you assess suicide risk and arrive at your decisions? What was your thinking?

Malpractice liability rarely comes from honest errors in judgment; it comes from lack of adequate examination and failure to use intelligent reasoning (eg, 

). If there isn’t clear evidence of reasonable professional judgment in the medical record, lawyers and jurors often assume there wasn’t any. Efforts to convince them by testifying months or years later sound hollow. If there is reasonable evidence supporting your actions in the record, lawyers usually do not file suit.

So-called “positive” or “protective” risk factors are worthless for assessing individual patient risk. 

Loving families, good jobs, status, certain age groups, and other conditions may be statistically associated with lower group risk, but patients are individuals. Suicide occurs in all social strata, ethnic groups, religions, and age groups; in close families and broken ones; and in people with jobs and without them.

“Dr Martin,” a successful scientist at a large government laboratory, was being treated for depression and severe anxiety by his family doctor. He declined referral to a psychiatrist, fearing his security clearance and position would be affected. One evening after dinner with his wife and children, he went into his study and shot himself in the head. The suit filed against the family doctor alleged that she had not adequately assessed the patient and inappropriately allowed his status to interfere with her pursuing necessary psychiatric referral.

“Dr Boris,” a prominent physician, was hospitalized after a large overdose that he said was “accidental.” The psychiatrist who assessed him strongly recommended inpatient psychiatric evaluation. The patient refused, saying he had “learned his lesson.” His wife was adamantly against inpatient treatment as well, referring to their close family and promising “We’ll take good care of him.”

The psychiatrist asked for a second opinion. The second psychiatrist concurred with the first. An involuntary hold was accomplished and the patient was allowed to go to a distant facility for further care.

At the end of the initial protective detention (5 days), the patient convinced his inpatient psychiatrist, who was aware of the overdose but never contacted the earlier consultants, that he no longer needed hospitalization. He was discharged and died by suicide within 24 hours. Malpractice suits against the distant facility and psychiatrist were settled for an undisclosed amount.

 Getting competent consultation before denying hospital admission, decreasing level of observation, or ordering discharge when a patient is at risk of suicide not only decreases the odds of a bad decision, it also reduces the chances of being sued if a tragedy occurs.

Don’t rely solely on the patient for information about suicidal thoughts and behaviors.

 If there is no other information source, be very cautious. Many patients lie or hide the truth. Even those who answer truthfully often do not understand their own symptoms, and cannot predict their future behavior.

“Mr Young” was brought to a general hospital emergency department by police officers, who had found him intoxicated and sitting precariously on an overpass railing above a busy highway. He said he was planning to jump in front of “the next 18-wheeler that comes along down there.” He was admitted for intoxication with suicide risk. Mr Young’s wife arrived as he was being transported to the psychiatric unit, but she was not allowed to accompany him. Staff added her contact information to the chart.

An inpatient psychiatrist saw him the next morning and reviewed the admission. Mr Young was anxious to go home, assuring the doctor that he had been drunk and had “acted stupid” the night before. “I was clearing my head, thinking about getting a divorce, not about jumping off the wall.” When the doctor asked about the police report, he said “I don’t remember that…they were trying to help, but I’m sober now and I don’t belong here.”

The psychiatrist went through the same suicide risk checklist that the emergency department social worker had used, relying on the patient’s own responses. Mr Young denied prior psychiatric history, suicidal thoughts, and past attempts; the checklist score was well below “high risk.” The psychiatrist ordered discharge for that morning with a note that said, “Pt. wants disch. No SI/HI apparent. No intent to die. Mar. probs./ intox… Own transp(ortation). Call PRN.”

Mr Young left the hospital via a hired car service and went to a bar. Several hours later he was struck and killed by a truck on the same highway where he had been found the prior night.

His widow sued the psychiatrist and the hospital. Past records and her deposition testimony indicated recent treatment for both substance abuse and depression, and a serious suicide attempt while intoxicated a few weeks before this incident. His wife testified that she had tried to talk with the admitting physician but was told to contact the psychiatric unit in the morning. She “thought he was safe in the hospital…[and] that they’d help him and call me and I’d tell them what he’d been doing…but they didn’t call, and when I finally called them, they’d already discharged him and nobody knew where he was.”

The attending psychiatrist settled out of court. The hospital, which employed the emergency department physician, lost at trial.

Never rely on “contracts for safety” (CFS, no harm contracts).

 Many hospitals and some psychiatrists still use these forms, despite the many studies that show their uselessness (and sometimes the damage they can do) for patients who are suicidal. Never rely on these forms when making decisions about admission, monitoring, or discharge.

“Mr Downton,” a widower and retired elementary school principal, shot himself after being released on pretrial bond for allegedly exposing himself to children. He was admitted; the wound was found to be non–life-threatening, and he was transferred to the psychiatry department on continuous observation.

Mr Downton slept poorly, did not participate in unit activities, declined contact with his only son, and was often seen staring tearfully out a window. He complained bitterly that being continuously observed made him feel worse, and said he had trouble using the restroom with an attendant talking to him through the door.

The nursing staff asked if his monitoring could be changed to checks every 15 minutes (Q15), citing a staffing shortage and 3 days of “No SI/HI” in the nursing notes. His psychiatrist talked briefly with Mr Downton, who denied suicidal thoughts, seemed optimistic as he spoke, and promised to tell staff if “those feelings” returned. Nursing policy required a CFS before the close monitoring could be stopped. He readily agreed and one-to-one monitoring was discontinued.

That evening, on the second Q15 round of the night shift, Mr Downton was found hanging by a sheet from his bathroom door.

The psychiatrist and the hospital were both sued. The plaintiff’s case hinged largely on expert testimony that the psychiatrist should have recognized substantial risk in Mr Downton’s history and symptoms; the suicide risk assessments were inadequate; Q15 is inadequate protection and below the standard for such patients; and it is below the SOC to rely on a CFS. The defendant psychiatrist testified that the CFS was a significant factor in eliminating continuous observation, and one that he and the staff often relied upon to decrease monitoring and “use nursing staff more wisely.” The plaintiff prevailed in both cases.

This vignette illustrates several critical errors. The patient had showed no objective signs of decreased suicide risk before 1:1 was discontinued; he had merely spent a few days without talking about suicide. Neither the psychiatrist nor the nursing staff had documented evidence of adequate suicide risk assessments after his admission. The record contained little description of the physician’s judgment in allowing release from 1:1 and deciding that Q15 was adequate for a greatly shamed man who had tried to shoot himself just a few days before. There were physical inadequacies with the patient’s room and bedding that made it easy for him to hang himself. In addition, posttrial juror questioning revealed that several faulted the physician for “going along with” a hospital CFS policy he should have known was wrong.

When considering discharge or decrease in monitoring level, be able to document what has changed for the patient.

 Make sure your documentation is more than a description of the time spent on the unit without an attempt. If there are no substantial, reliable changes, be very careful.

Beware of 2 substantial and common risk factors that are not on most checklists: instability and unpredictability. 

Because suicide is unpredictable, it is important to be cautious. Patients who are unstable, whether from psychosis, severe depression, 

 severe anxiety, substance abuse, borderline syndromes, recent loss, or something else, are inherently at higher risk.

“Ms Reynolds,” a young woman with a history of intensive but mercurial relationships, volatile moods, and episodes of overdose and cutting her wrists, stopped her medications and was hospitalized after stabbing herself during an argument with her boyfriend. She had accused him of causing her to miscarry and then cut herself across the abdomen.

Ms Reynolds seemed to respond to medication and support over 4 days of close observation. She denied suicidal thoughts and participated in groups. She talked with her boyfriend by phone, sometimes calmly but sometimes angry that he had not visited her. When he finally came to visit, she was inappropriately affectionate.

She requested discharge on her fifth hospital day. Nursing notes said her insight, judgment, and impulse control were “normal,” based primarily on her agreeing to take medication and denying suicidal thoughts. Her psychiatrist, relying on the nursing notes and brief daily interviews, discharged her within hours of removing her from continuous observation, and without a systematic risk assessment She was given a supply of medication and a clinic appointment in 3 weeks.

Ms Reynolds was found dead from an intentional overdose a week before her outpatient appointment. In the malpractice action, the defense argued that “You can’t protect patients from themselves; you have to discharge them sooner or later,” and said her prior overdoses and cutting were not “real” suicide attempts. The case was settled before trial.

This vignette illustrates the need to keep patients safe until treatment response is well established, then carefully reassess their risk. In addition, transition to aftercare is important, easing the change from 24-hour observation and support to virtually none. Discharge planning should include contact with the outpatient caregiver before discharge and a first outpatient appointment within days, not weeks.

The vignette also illustrates the folly of calling self-destructive behavior “minor” or “gestures.” There is no such thing as a suicide “gesture.”

Fifteen-minute checks (Q15) are below the SOC for patients with even moderate suicide risk.

 It is easy to kill oneself in 15 minutes, or 5 minutes for that matter, even if the checks are carried out as ordered (sometimes they are not). 

, describing very successful Johns Hopkins risk management procedures, are among the many who have established continuous observation as the SOC. Chassin and Loeb

 agree, citing Joint Commission on the Accreditation of Healthcare Organizations experience and a large professional literature.

“Mr Kane” was placed on Q15 for suicide risk. He was found dead during shift change early the next morning. His time of death was determined to be around 3:00 

, hours before he was found, but the Q15 record sheet indicated that an aide had observed him sleeping every 15 minutes through the night shift. At deposition, the aide admitted falsifying the Q15 shift record, with the excuse that “We do that all the time. I check the patient every 15 minutes, then fill everything in at the end.” He couldn’t explain why he had not noticed the patient hanging in the room for hours.

In the subsequent lawsuit, lack of continuous observation was found to be the main cause of Mr Kane’s death. The psychiatrist was found liable for not ordering continuous observation. The hospital settled out of court.

Falsified Q15 records are not rare. Nevertheless, the primary lesson is that if Mr Kane had been on continuous observation, his death would almost certainly have been prevented.

Communicate with corroborating sources, including family members. We have long taught 1 way of gathering of important clinical and safety information does not require a release of information (so long as the informant knows that the patient is in your care). Here is how it works: The doctor tells the relative or other person, “I cannot share what (the patient) has told me, but I would very much like for you to answer a few questions and tell me what you can.” Relatives and friends have no duty of confidentiality to the patient.

Do not let false confidentiality concerns threaten a patient’s life or limb when they are at risk for suicide or other substantial harm.

Regular contact with co-treaters is important to meeting the SOC. Unless you have terminated care entirely, you are still the patient’s doctor. Be sure that counselors and programs give you regular follow-up, document it, and do the same for them. There is no issue of clinical confidentiality between co-treaters.

Know your referral resources and co-treaters.

 You are responsible for knowing the general qualifications of clinicians and facilities to whom you refer. If you reasonably should have known that they were incompetent or otherwise inappropriate for the referral, you may be partially responsible for a negative outcome.

Never assume that a patient’s family can or will monitor the patient as well as hospital staff.

 Asking family to carry out hospital responsibilities is below the SOC. (Like several of the previous examples, this caveat applies to both hospital discharge and failure to admit an outpatient who is at substantial risk.)

After several days of psychiatric hospitalization following a hanging attempt, “Mr Frank” demanded release. His psychiatrist and the hospital discharge planner spoke with Mr Frank’s family, who promised to watch him “24/7.” Mr Frank was found hanging in their garage early on the second day after discharge to their care.

In the subsequent lawsuit, the family testified that they indeed had said they would monitor Mr Frank, and part of the psychiatrist’s defense was that he had essentially discharged Mr Frank to another “care environment”—his family home—as agreed. A jury found, however, that the psychiatrist was not entitled to rely on the family. They found that the family had no duty and no reasonable expectation of an ability to treat the patient as he would have been treated in a hospital, and releasing Mr Frank to the family was below the SOC and caused Mr Frank’s death.

Understand risk. Practice well. Document scrupulously. Be the doctor.

 is a clinical and forensic psychiatrist who has worked with attorneys in scores of malpractice actions. He is professor of psychiatry at the University of Texas Dell Medical School and clinical professor at Texas Tech University Health Sciences Center. 

 is a malpractice attorney for psychiatric and mental health organization matters, with cases throughout the United States. He is on the Board of Directors of the American Association of Suicidology.

1. Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). Suicide Reduction Measures. In: JCAHO. 

The Physician’s Promise: Protecting Patients from Harm

. 2nd Edition. Joint Commission Resources (JCR); 2006.

47 NYS 3d 782, 2017 NY Slip Op 01429, 1, 2017 WL 702943 (NY 2017).

The utility and effectiveness of 15-minute checks in inpatient settings

Chassin MR, Loeb JM. High-reliability health care: getting there from here. 

Practical tips for helping patients and simultaneously avoiding legal battles.

The Right Way to Avoid Malpractice Lawsuits

In law school, students are taught how to act, dress, and talk in court. They are told where to stand, what color suit to wear, what to say, and how to say it. They practice in lifelike simulations, held in courtrooms.

Psychiatrists—often called to testify in court—receive little if any of this training.

 They can feel unprepared when they first step on a 

stand. This article will help psychiatrists feel more comfortable with the testifying process by providing some necessary vocabulary, an outline of the judicial process, and practical tips on courtroom behavior.

There are many types of courtroom proceedings.

 There are hearings, in which judges make preliminary decisions on specific judicial issues, such as a civil commitment hearing. There are depositions, in which attorneys “discover” what the other side’s witnesses plan to say at trial. Finally, there are trials, in which cases that did not settle or otherwise resolve are ultimately decided.

Each of these judicial proceedings has its own set of rules and procedures, which vary from state to state. Psychiatrists can be asked or subpoenaed

 into any of these venues to testify under oath. This article focuses on trial 

, but the concepts are useful in any context.

When a psychiatrist testifies, it is either as a party or non-party. In criminal court, there are defendants and prosecutors. In civil court, there are plaintiffs, who file suit, and defendants, who are being sued. If a psychiatrist is sued by their patient, the patient becomes the plaintiff; the psychiatrist becomes the defendant. If that psychiatrist testifies at trial, they testify as a party.

More commonly, psychiatrists testify as a non-party—either as a fact witness or as an expert witness.

 A fact witness testifies about what they personally experienced. An expert witness testifies about their opinion. For example, after a car accident, a pedestrian who saw the collision would be a fact witness. A psychiatrist hired by the plaintiff to assess psychological damages would be an expert witness.

Another example would be a bank teller injured in a bank heist who sues their employer for emotional distress. If the bank teller (as the plaintiff) subpoenas their treating psychiatrist to testify about the bank teller’s pre-existing psychiatric condition, that psychiatrist would be a fact witness. If the bank teller’s attorney hires a psychiatrist to conduct an independent medical examination (after the robbery), that psychiatrist would be an expert witness.

Fact witnesses are usually unpaid. Expert witnesses are paid by the retaining attorney or the court. 

 can serve in a consulting role (reviewing a case and giving advice about trial strategy or chances of success) or a testifying role (reviewing a case and forming an opinion, and then testifying about a specific issue)—or both.

 In the bank teller example, a testifying expert witness could be asked to form an opinion on whether the bank teller had posttraumatic stress disorder and, if so, whether it was due to the bank robbery. In many states, physicians are required to offer their opinions with reasonable medical certainty. This is a legal standard that most often means more likely than not. For a summary of some of the roles, and responsibilities, of psychiatrists in court, see the 

As a witness, you should take advantage of your attorney’s expertise. Attorneys are trained in courtroom procedure. If you are a defendant, your attorney is on your side and should be a particularly helpful resource (make sure you meet with them before any proceeding). If you are a non-party witness, you should still avail yourself of the attorney who hired or subpoenaed you to ask logistical questions.

When you are asked to appear at a court proceeding, make sure you know where you need to be and at what time. Judges do not tolerate lateness. Plan to arrive at the courthouse at least 30 minutes early. Bring a government issued identification card. Know which courtroom in which you will be testifying and where you should wait (inside or outside of the courtroom). As a witness, you will not know exactly when you will be called to testify; you might be given a window of several hours. Bring relevant materials to review or a book to read.

When your name is called, go straight to the witness stand. At some point, either on the way there or once you sit down, you will be sworn in. The courtroom is the judge’s domain. Unlike a hospital, you are a guest. Act accordingly.

During a trial, questions are asked in a very stylized format. Your attorney will begin with direct examination. You should have discussed your testimony with your attorney before the trial and educated them on pertinent psychiatric concepts. Their ability to ask the right questions will depend on how well you have helped them understand your analysis and psychiatric opinions.

During direct examination, your attorney will guide you through a series of open-ended questions. Your fundamental responsibility is to present your opinions cogently and convincingly. On cross-examination, the opposing attorney will ask specific questions based on what was covered during direct examination.

The American court system is adversarial. One of the main purposes of cross-examination is to discredit you and/or your opinion. The key role of an opposing attorney is to knock you off balance. After cross-examination, attorneys have a chance for redirect, to help rehabilitate you (in the event any damage was done) and to give you an opportunity to clarify your answers. Then there is re-cross—the opposing attorney’s second chance to discredit you.

Your value as a witness is not just in what you say, but how you say it and how you come across (how credible you are). No matter how smart you are, if the judge or jury do not believe you, you will be an ineffective witness.

You always need to tell the truth, even when it goes against the side for which you are testifying. You need to be professional and likeable. Particularly with jury trials, it helps to act like the jury expects you (as a doctor) to act and look like they expect you to look.

Juries decide whether to believe a witness, including an expert witness, based on what they deem credible

 Credibility is judged on a variety of factors. This includes your professional credentials (where you went to school, how long you have practiced, what you have published, and so on), whether you appear biased, and your conduct.

Just like we evaluate our patients’ demeanor and appearance, judges and juries evaluate a witness’s demeanor. An important aspect of demeanor is attitude. It is okay to be nervous. It is not okay to be grandiose, entitled, or overly professorial. The worst sin is to appear arrogant. Do your best to be likeable.

Likeability is hard to teach. Even people who are likeable in real life can become hostile on cross-examination. It is helpful to view cross-examination as a tennis match; a series of volleys between 2 sides. Wait for the entire question to be asked, then pause and think. Only answer the question that is asked. Do not feel as if you need to keep talking. Embrace the silence, or pregnant pause, which opposing attorneys may use strategically to get a witness to keep talking.

Do not let the opposing attorney provoke you8, which they often try to do. For instance, if you are a defendant in a medical malpractice claim, the plaintiff’s attorney might lead you through a series of yes or no questions (eg, whether you ordered a series of tests you believed unnecessary)— knowing that you will answer “no” on each question. This can feel uncomfortable. Maintain your poise and calm demeanor. Take the high road. Be your professional self and avoid getting into arguments with the cross-examining attorney.

Your professional identity should come across in your appearance 

). Your look serves as jury’s first impression.

 Do not wear anything distracting, such as bright clothing or “loud” jewelry. Dress as if you are going to a job interview. Wear a nicely tailored, crisply pressed, dark-colored suit. Men should wear a light-colored dress shirt with a simple tie. Women should wear a high-cut blouse and closed-toe shoes, preferably with a low heel. Both men and women should pay particular attention to their grooming, making sure their hair is neatly styled.

It takes years of practice to become a stellar witness. But, even their first time, a psychiatrist can do a good job testifying.

 Just prepare adequately, remain calm, tell the truth (in easy-to-understand language), and remember that you are there as a doctor.

The courtroom is designed to be adversarial. To be an effective witness, credibility is key. Witness credibility hinges not just on what the witness says, but how they say it and their overall demeanor.

is a forensic psychiatry fellow, University Hospitals Cleveland Medical Center.

is professor of psychiatry, Case Western Reserve University School of Medicine. He serves on 

1. Williams J, Elbogen E, Kuroski-Mazzei A. Training directors’ self-assessment of forensic education within residency training. 

 17th ed. Chicago, IL: Thomson West; 2008.

3. Mossman D. ‘You’ve been served’: What to do if you receive a subpoena. 

4. Piel J, Resnick P. Psychiatrists as Expert Witnesses. 

5. Gutheil TG. The psychiatric expert witness. 

https://www.psychiatrictimes.com/view/psychiatric-expert-witness

6. Brodsky SL, Griffin MP, Cramer RJ. The witness credibility scale: An outcome measure for expert witness research. 

7. Discovery and depositions. In: Gutheil TG. 

 Washington, DC: American Psychiatric Press, Inc. 1998:59-75.

The Expert Expert Witness: More Maxims and Guidelines for Testifying in Court.

 Washington, DC: American Psychological Association. 1999:108-111.

9. Pitera M. Courtroom attire: ensuring witness attire makes the right statement. 

Strategies to remain calm under pressure; to be clear and concise; and to know what is expected in courtroom battles.

Tips for Testifying in Court

The association between Cannabis sativa (cannabis) and psychosis goes back at least as far as the Pen-ts’ao Ching, the world’s oldest pharmacopeia, which is attributed to the Chinese emperor Shen-Nung (circa 2700 BC). It says, “ma-fen [the fruit of cannabis] if taken in excess will produce visions of devils . . . over the long term, it makes one communicate with spirits.”

 In the West, cannabis was used as an experimental psychotomimetic in the 19th century by pioneering French psychiatrist Jacques-Joseph Moreau, and it 

 Cannabis’ acute psychotomimetic effect is transitory; however, consistent evidence indicates that the chronic and intense use of the plant, especially if started in adolescence, contributes to the occurrence of schizophrenia.

We know that cannabis contains about 100 cannabinoid compounds and that the psychotomimetic effects of the plant are induced by tetrahydrocannabinol (THC).

 However, we have also known since the early 1970s that the effects of cannabis cannot be attributed solely to THC.

 Other cannabinoids, including cannabidiol (CBD), have intrinsic actions as well.

In 1982, a study of the interactions between THC and CBD in healthy volunteers provided the first evidence that CBD might have antipsychotic properties. Our group administered oral CBD concomitantly with a high dose of THC to investigate whether CBD could attenuate THC-induced anxiety. Surprisingly, in addition to alleviating anxiety, CBD 

the psychotic symptoms commonly induced by THC.

More recently, this observation was confirmed in a study with THC administrated intravenously after oral pretreatment with CBD or placebo.

 In addition to blocking the psychotic symptoms induced by THC, CBD and THC presented opposite effects relative to placebo in terms of activation of the striatum during verbal recall, as assessed by functional MRI.

The early observation that CBD reduced THC-induced psychotic symptoms led us to carry out a pioneering study to test the effects of CBD in a model commonly used to identify drugs with an antipsychotic profile in laboratory animals.

 The stereotypy induced in rats by a dopaminergic agonist was clearly reduced by CBD, without producing the catalepsy that is associated with the extrapyramidal adverse effects (AEs) of classical antipsychotic drugs. This finding suggests that CBD has an atypical antipsychotic pattern. A series of other tests with different animal models confirmed and expanded the antipsychotic profile of CBD.

The next step was to evaluate the effects of CBD in a patient with schizophrenia. The patient was a woman with chronic psychosis who experienced many AEs with traditional antipsychotics, which provided the ethical justification for this first clinical test. After 4 weeks of treatment, the patient had a marked reduction in her psychotic symptoms as assessed by standardized rating scales. This published case report stimulated the undertaking of randomized controlled clinical trials (RCTs).

To date, 3 RCTs have evaluated the therapeutic effects of CBD in patients with schizophrenia. The first one, using a double-blind procedure, included 39 patients treated with either CBD (800 mg/day; n = 20) or the atypical antipsychotic amisulpride (800 mg/day; n = 19) for 4 weeks. The 2 drugs led to similar significant reductions in both positive and negative psychotic symptoms, but fewer AEs were seen in the CBD group.

In the other 2 RCTs, CBD was administered as an adjunctive treatment for 6 weeks with placebo control; however, the results were contradictory. CBD treatment (1000 mg/day; n = 42) was associated with a significant reduction in positive symptoms from baseline to the end point compared with placebo (n = 44) in one study (

 Results from the other RCT, which used a very similar methodology but a lower CBD dose (600 mg/day; n = 20), found no significant symptomatic differences between treatments with CBD and placebo (n = 19).

 A possible explanation for the contradictory results may be the 400-mg difference in daily CBD doses.

The CBD dose-response relationship appears to have a particular feature. The anxiolytic effects of CBD, described in the early 1980s and confirmed by later animal and human studies, clearly follow this dose-response pattern.

 In 1990, CBD was tested in a range of doses in rats with the elevated plus-maze model and was found to act according to a bell-shaped dose-response curve. CBD induced an anxiolytic-like effect only at intermediate doses.

This dose-response curve was also observed in healthy volunteers subjected to anxiety via a public speaking test and by public speaking in real-world settings.

 In both situations, treatment with CBD 300 mg was associated with significant decreases in anxiety symptoms, but this effect was not observed with lower or higher doses.

The same response pattern was observed in preclinical tests using other models of induced anxiety, cognitive impairment, and schizophrenia-like behavior.

 The findings suggest that this inverted U-shaped curve response pattern may be extended to other therapeutic effects of CBD, with different effective doses and therapeutic windows for each condition.

Accordingly, data from the 3 previously mentioned CBD RCTs suggest that the dose range to reduce psychotic symptoms (probably between 800 and 1000 mg/day), but not cognitive symptoms, should be higher than that used to induce anxiolytic effects (between 200 and 400 mg/day). However, precise dose ranges for each condition or symptom are yet to be determined in future RCTs with larger samples, different clinical populations, and multiple doses.

It seems that the antipsychotic effect of CBD is not limited to patients with schizophrenia. Antipsychotic effects of CBD (150 mg to 400 mg/day) were seen in patients with Parkinson disease who, for at least 3 months, had psychotic symptoms that could not be controlled by reducing antiparkinsonian drug regimens.

 We observed a reduction in psychotic symptoms (

) in addition to a significant improvement in global functioning (as assessed with the Unified Parkinson’s Disease Rating Scale and the Clinical Global Impression Scale).

This important study paved the way for a new, double-blind, placebo-controlled RCT with parallel groups of patients with Parkinson treated with 2 doses of CBD (75 mg and 300 mg/day) for 6 weeks. Patients with dementia or psychotic symptoms were excluded from the study to avoid the influence of psychotic symptoms. The results showed that CBD induced a significant improvement in nonmotor symptoms, including daily life activities and rapid eye movement sleep behavior disorder.

CBD presents multiple actions in the central nervous system that may have a crucial role in the pharmacotherapy of the motor and nonmotor effects of Parkinson disease. This cannabinoid was shown to have neuroprotective properties by enhancing the recycling of old/damaged cell components via the facilitation of autophagic action.

 Moreover, CBD exerts antioxidant activities, stimulates neurogenesis, regulates mood and sleep, improves cognition and motor activity, and restores dendritic arbor and brain-derived neurotropic factor levels in the hippocampus.

The specific pharmacological mechanisms underlying the antipsychotic action of CBD are not fully understood, as this compound seems to interfere with neurotransmitter systems in diverse ways.

 For instance, CBD inhibits the reuptake and metabolism of anandamide, which may be implicated in the antipsychotic effect of CBD, as the concentrations of this endocannabinoid in the cerebrospinal fluid of patients with schizophrenia are higher than in those of controls and are inversely correlated with psychotic symptoms. It suggests a feedback mechanism in which the anandamide increase outweighs the occurrence of psychotic symptoms. Moreover, patients with prodromal psychosis present higher anandamide levels in cerebrospinal fluid (CSF) than do controls.

 The clinical improvement produced by CBD in the patients with schizophrenia has been linked with increased CSF anandamide levels. The effects of CBD on anandamide regulation in different brain regions associated with the pathophysiology of schizophrenia could explain its antipsychotic action.8

Further mechanisms that could clarify the antipsychotic action of CBD include its ability to increase hippocampal neurogenesis and neuroprotection; its interaction with 5HT1A, GPR55, and TRPV1 receptors; and its antioxidant and anti-inflammatory effects. For instance, some second-generation antipsychotics, such as ziprasidone and aripiprazole, also activate 5-HT1A receptors, which may, at least in part (in addition to the noninvolvement of dopamine antagonism), explain the absence of extrapyramidal AEs of CBD.

Research has been conducted on CBD and its potential use for neuropsychiatric conditions such as schizophrenia, anxiety, Parkinson disease, depression, and dystonia, as well as for diseases and conditions that involve other organs and systems, such as inflammation, immune response, ischemia, diabetes, cancer, and many others. Most of this are preclinical studies in laboratory animals.

The only CBD formulation approved by the FDA is Epidiolex (GW Pharmaceuticals) to treat rare forms of epilepsy in children and adolescents; it is not currently available for use in schizophrenia. Although there are controlled good laboratory and manufacturing practices, and purified synthetic analogues for CBD exist, further safety and efficacy studies are needed.

CBD can be easily purchased throughout most of the United States, which raises concerns about the use of handcrafted, uncontrolled, cannabis-enriched CBD. However, there are well-known harmful long-term effects of THC on the developing brain, cognitive impairments associated with cannabis, and worsening of psychotic symptoms and antipsychotic response, particularly in younger patients. Therefore, well-designed RCTs with larger patient samples, using high-quality and reliable CBD, are needed to ascertain the effectiveness and safety of CBD as an antipsychotic medication and to ultimately receive FDA approval for use in schizophrenia.

is a full professor, Department of Neuroscience and Behavior, Ribeirão Preto Medical School, University of São Paulo, Brazil. 

 is a full professor, Department of Neuroscience and Behavior, School of Medicine of Ribeirão Preto, University of São Paulo, Brazil, and a member of the National Institute of Science and Technology for Translational Medicine, Brazilian National Council for Scientific and Technological Development, Brasília, Brazil. In addition, Dr Crippa is a member of the International Advisory Board of the Australian Centre for Cannabinoid Clinical and Research Excellence.

The acute psychotomimetic effect of cannabis is transitory, but evidence indicates that the chronic use, especially if started in adolescence, contributes to the occurrence of schizophrenia.

Psychiatric Times Vol 37, Issue 9

Bad Men Do What Good Men Dream

The Right Way to Avoid Malpractice Lawsuits

Tips for Testifying in Court

Exploring the Relationship Between Cannabidiol and Psychosis

Take 5 Before You Give 5: The Dos and Don’ts of Political Contributions

Psychiatry’s Intellectual Crisis: Giovanni Fava, MD

Anti-NMDA Receptor Encephalitis With Visual Hallucinations and Cognitive Impairment

Sheltered in Place

Surviving Coronavirus: A Psychiatrist’s Personal Journey

A Dose of Much-Needed Medicine

Delirium, Encephalopathy, and COVID-19: An Update From the Field

For Whom the School Bell Tolls: Helping Youth During the COVID-19 Crisis

What I Learned During My Summer Vacation

Pandemics Are Not Partisan