Forensic Psychiatry

Psychiatrists often believe they are protected from liability when conducting third-party evaluations in civil litigation. However, the nature of the physician-patient relationship and the issue of associated liability is not that straightforward.

The concept of Primum non nocere ("First, do no harm") is a cornerstone of medical education. This Latin phrase reminds physicians that medical treatments can potentially have both good and bad effects. Sometimes, the ultimate net benefit of an intervention is clear to both the physician and the patient, and treatment proceeds unimpeded by doubt. When the net benefit of a treatment is less certain, in most branches of medicine patient choice and self-determination play a major role in determining which "gray zone" treatments are appropriate. For the most part, this is also true in psychiatry.

Somatoform disorders (disorders that are not fully explained by a medical condition or mental disorder) may require psychiatrists to consult with physicians.

All physicians need to be aware of the medicolegal aspects of practicing medicine, but because emergency psychiatrists must sometimes treat patients against their will or act as consultants to determine capacity, they must be especially vigilant when dealing with the overlap between law and medicine.

Assessment and management of dual diagnosis--that is, the comorbidity of substance use disorder in persons with mental illness--is a major challenge for clinicians, especially in the emergency department (ED). It is widely accepted, but perhaps less well appreciated in the clinical realm, that substance abuse comorbidity is more the rule than the exception in persons with serious mental illness.

Following reports that psychologists and psychiatrists have been involved in interrogations in Guantanamo Bay, Cuba, and other locations, Dr. Stone calls on the professional organizations for both specialties to make it clear that torture is not condoned by the medical or psychological profession.

Although forensic psychiatry is a formal subspecialty, general clinicians are often called upon to perform the bulk of forensic assessment. As such, the need for some basic training in and knowledge of forensic psychiatry is clearer than ever.

Forensic examinations involving children and adolescents are particularly difficult, due to the vulnerability of this patient population. What ethical guidelines should be followed and what sorts of pitfalls should clinicians attempt to avoid?

Forensic psychiatry is increasingly emerging into treatment psychiatry as a respected subspecialty. However, there are important clinical and business distinctions between the practice of treatment psychiatry and the practice of forensic psychiatry. The essential components of setting up a forensic psychiatry practice are outlined.

The infamous trial of People v Schmidt, presided over by Justice Benjamin Cardozo, provides a cautionary tale for forensic psychiatrists. In his commentary on a biography of the celebrated judge, Stone assesses the quest to clarify the meaning and scope of the insanity defense.

Impulsive behaviors play an important role in both bipolar and substance abuse disorders. However, results of studies investigating this link are often ambiguous, in part, due to the multidimensional nature of the impulsivity construct and the fact that many studies use a single measurement technique. We describe a model of impulsivity characterized by three components: response initiation, response inhibition and consequence sensitivity. How these components differ from one another in terms of their use, behavioral theory and biological function is discussed, along with measurement techniques.

Proposed changes in the conceptualization of compulsivity and impulsivity in the DSM-V will have important implications in the way clinicians recognize and treat these disabling conditions.

The case of dentist Charles Sell, who suffers from delusional disorder, still awaits resolution. In the meantime, Sell remains incarcerated while his competency to stand trial is debated. Does this serve justice?

Of concern is the safety of our roadways as the effects of aging take their toll upon drivers nationwide. Are there accurate ways to test the cognition and response ability of elderly drivers?

During a trip to Beijing on behalf of the World Psychiatric Association, Dr. Stone witnessed up close how the psychiatry is practiced in today's China. What he found may surprise you--it certainly surprised him.

Psychiatric evaluation of juveniles who commit murder is perhaps one of the most difficult tasks in forensic psychiatry. A study has shown that these inmates are more likely to have been abused, be addicted to drugs or alcohol, or have a serious psychiatric disorder. Additionally, they are more likely to engage in risky behavior without thinking about the consequences.

Osteoporosis is a disorder characterized by low bone mass and microarchitectural deterioration with resulting compromised bone strength and increased risk of fracture.1 The World Health Organization defines osteoporosis based on T-scores, which reflect bone mineral density (BMD) relative to mean BMD for healthy 25-year-old same-sex populations. A T-score between 0 and 21 is considered normal density, a score between 21 and 22.5 indicates osteopenia, and a score of less than 22.5 signifies osteoporosis.2 Severe osteoporosis is defined as a T-score of less than 22.5 combined with a fragility fracture.2

Comorbid substance use disorders may complicate treatment for both the hepatologist and psychiatrist. Comprehensive assessment of psychiatric illness and psychopharmacological management may be critical.

Telepsychiatry has been hailed as the future of psychiatry. Proponents have claimed that it can reduce costs and allow access to difficult-to-reach patients. What are the promises and pitfalls of this new technology?

When disputes arise concerning custody and visitation, mental health care professionals can inform and assist judges by performing competent custody evaluations.

Allegations of complicity by Chinese psychiatrists in abuse and persecution of members of the Falun Gong continues to trouble the World Psychiatric Association. Are the steps being taken to learn the truth enough? Dr. Stone provides a look at the events that have unfolded to date.

Psychiatrists and other mental health activists have been working in various countries around the globe to bring an end to unjust psychiatric incarceration for political beliefs and to improve living conditions for those patients in psychiatric hospitals. The former Soviet Union, China and India are all current targets of focus for this human rights movement. What are human rights organizations doing and how can psychiatrists help?

Both the mental health and justice communities have been troubled by the increased number of mentally ill individuals in the prison populations. Legislation awaiting passage in the U.S. Congress would fund collaborative programs between these two fields that would try to alleviate this growing problem.

Cognitive-behavioral therapy can be tailored for use with children who have experienced sexual abuse in order to relieve symptoms of PTSD.

This introduction article elucidates how the various contributions to this special report help make psychiatry such a rich and varied field.