Forensic Psychiatry

The assessment of malingering presents a significant challenge for mental health clinicians.

A forensic book with a superb format, clinical wisdom, and eminent readability.

Five words that are guaranteed to annoy your patientwith a diagnosis of psychogenic movementdisorder (PMD) are It's all in your head.It's the worst thing you can say, said Katie Kompoliti,MD, associate professor of neurological sciencesat Rush University Medical Center in Chicago.

Anxiety is a ubiquitous, natural affective state that is essential for evolutionary survival. Nearly as common, however, are experiences of anxiety that exceed social, psychological, or physiological needs, leading to functional impairment. Indeed, primary anxiety disorders, including panic disorder, social phobia, and generalized anxiety disorder (GAD), represent the most common category of mental illness in the United States. Secondary, or reactive, anxiety is also widespread and can arise not only from numerous medical causes but also from the psychological process of coping with illness.

Psychiatry is the go-to specialty for determining whether a patient in need of inpatient hospitalization or has an alternative motivation?

Dr Steven King provided an interesting summary of complex regional pain syndrome (CRPS) in Psychiatric Times (Complex Regional Pain Syndrome, June 2006, page 9). We felt it would be useful to provide some additional observations on the relationship between CRPS type I and psychological causes of pain.

It can be difficult to determine whether unusual, paroxysmal behavior represents a seizure or a nonepileptic event. Patients with convulsive, clonic movements may, in fact, be experiencing psychogenic events.

Spontaneous nontraumatic intracerebral hemorrhage is associated with greater mortality and more severe neurologic deficits than any other stroke subtype, with as many as half of all patients dying within 30 days and only 10% of survivors regaining functional independence.

While many parents fear that strangers might kill their children, a parent is actually more likely to be the perpetrator. This column focuses on preventing the tragedy of maternal filicide.

Stalking is defined as repeated and persistent unwanted communications and/or approaches that produce fear in the victim. Stalking intrudes on the victim's privacy and evokes a fear of violence. Such fears are justified, as threats, property damage and assault occur all too frequently in association with stalking.

Paraphilias as defined by DSM-IV, are sexual impulse disorders characterized by intensely arousing, recurrent sexual fantasies, urges and behaviors (of at least six months' duration) that are considered deviant with respect to cultural norms and that produce clinically significant distress or impairment in social, occupational or other important areas of psychosocial functioning. The common paraphilias described include exhibitionism (exposure of genitals to a stranger), pedophilia (sexual activity with a prepubescent child, generally 13 years of age or younger), voyeurism (observing others' sexual activities), fetishism (use of inert objects, such as female undergarments), transvestic fetishism (cross-dressing), sexual sadism (inflicting suffering or humiliation), sexual masochism (being humiliated, beaten, bound or made to suffer) and frotteurism (touching, rubbing against a nonconsenting person).

While dementia is marked by such cognitive deficits as disorientation, memory loss and changes in intellectual functioning, these are not the symptoms that cause the most distress to caregivers.

This article focuses on data concerning the efficacy of mood stabilizers in the treatment of BPD.

The evidence showing a relationship between mental disorders in childhood and adulthood has increased in the last several decades.

Dr Muller describes a case of a patient with a paranoid psychosis who clearly needs help, yet refuses treatment.

Neurotechnologic devices are proving themselves in clinical medicine. Many of these devices offer several distinct advantages over traditional pharmaceutical-based therapies: their effects are reversible, they are often cheaper than pharmaceuticals, and they solve therapy adherence issues. "If a problem occurs, you can turn off the device; or if the disease evolves over time, you can dynamically adjust the device," explained Ali R. Rezai, MD, chairman of the Center for Neurological Restoration at the Cleveland Clinic.

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.

Pediatric psychosomatic research shows that emotional, behavioral, and psychiatric symptoms are found more often in children and adolescents with chronic illnesses than in healthy children.

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.

Psychiatrists specialize in mental phenomena, but this special expertise does not confer license to ignore the additional information that can be gathered from physical signs.

About 25% of patients seen in epilepsy clinics and monitoring units who do not respond to antiepileptic drugs (AEDs) have received a misdiagnosis.1-3 The eventual diagnosis for most of these patients will be psychogenic nonepileptic seizure (PNES)1,4-a somatoform conversion disorder. It is treatable, but diagnosis, delivery of the diagnosis, and management present significant challenges. A major barrier to care has been the stigma associated with the label "psychogenic."

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.