Transcript Psychiatric Diagnoses and Their Relationship to Affirmative Defenses

Psychiatric Diagnoses and Their
Relationship to Affirmative Defenses
Bruce Wright, MD
Mental Illness and
Mental Health Defenses:
Perceptions of the Criminal Bar
Frierson, et al
Journal of the American Academy of Psychiatry & the Law
43: 483-91, 2015
Which of the following is the correct
definition of PSYCHOSIS?
1. Loss of contact with reality
2. Rapidly shifting mood states
3. Repetitive behavior such as counting or handwashing
4. Loss of contact with reality; persistent and
extreme elevation in mood
Which of the following is the correct
definition of a DELUSION?
1. A false belief firmly held by the patient despite evidence to
the contrary.
2. A false sensory perception, such as seeing or hearing things
that are not present.
3. Impairment of thinking where a patient becomes
disoriented to time, place, or events
4. A rapid succession of fragmentary thoughts or speech in
which content changes abruptly
Which of the following is the most
severe and chronic mental illness?
1. Major depression
2. Bipolar disorder
3. Schizophrenia
4. Obsessive-compulsive disorder
What is the definition of?
1. Not Guilty by Reason of Insanity
2. Guilty But Mentally Ill
Psychiatric Diagnoses
•Guide Treatment
•Prognosis
•Research
•Forensic issues - ?????
• Diagnoses are assigned if
the symptoms are
consistent with the DSM
criteria
• Psychiatric Diagnoses do
not identify a specific
etiology
106
Diagnoses
130
pages
DSM II 1968
DSM III 1980
DSM IV 1994
↓
↓
DSM 5 2013
757
Disorders
947
pages
DSM I
1952
What is Different about DSM 5?
1.Digit not Roman numeral
2.Multi-axial diagnostic system
3.Some diagnoses have changed names
Dementia
Major
Neurocognitive
Disorder
Minor
Neurocognitive
Disorder
Mental
Retardation
Intellectual
Disability
Judge Scalia – US Supreme Court:
They changed their mind, counsel. This APA is
the same organization that once said that
homosexuality was a mental disability and
now says it’s perfectly normal. They change
their minds.
Hall v Florida, 2014
Criticism of the DSM - 5
1.Just a money maker for the APA
Criticism of the DSM - 5
1.Just a money maker for the APA
2.Blurs the line between normal and
pathological
Normal vs Pathological
Examples include:
1. Normal grief may be diagnosed as Major Depression
2. Behavioral addiction ( ex: internet gaming disorder)
3. Gluttony (binge eating 12x’s in 3 months) is
diagnosable
4. Mild neurocognitive disorder = benign forgetfulness
5. Childhood temper tantrums = disruptive mood
dysregulation disorder
6. Female vs. Male sexual disorder
Criticism of the DSM - 5
1.Just a money maker for the APA
2.Blurs the line between normal and
pathological
3.Significant problems with inter-rater
reliability
The Initial Field Trials of DSM-5:
New Blooms and Old Thorns
Freedman, et al
The American Journal of Psychiatry,
2013
The Initial Field Trials of DSM-5:
New Blooms and Old Thorns
Kappa Coefficient (K)
Causes of inter-rater reliability problems:
• Examiner’s questions
• Individual’s answers
• Available history and collateral information
• We don’t have diagnostic tests or imaging to
confirm diagnoses
Delusions
Hallucinations
Formal Thought Disorder
PSYCHOSIS
delusions
hallucinations
formal
thought
disorder
Psychosis seen with:
• Schizophrenia
• Schizoaffective disorder
• Delusional Disorder
• Mood Disorder with psychosis (Major Depression, Bipolar)
• Delirium
• Intoxication/Withdrawal
• others
Definition of Personality Disorder
• Enduring pattern of inner experience and
behavior that deviates from cultural expectations
• Inflexible and Pervasive
• Cognitive, Affective, Behavioral, or Interpersonal
manifestations
Cluster A: (ODD)
• Paranoid
• Schizoid
• Schizotypal
Cluster B: (DRAMATIC)
• Antisocial
• Borderline
• Histrionic
• Narcissistic
Cluster C: (ANXIOUS)
• Avoidant
• Dependent
• Obsessive
Compulsive
DSM-5 CAUTIONARY STATEMENT
When DSM-V categories, criteria, and textual descriptions are
employed for forensic purposes, there is a risk that diagnostic
information will be misused or misunderstood. These dangers arise
because of the imperfect fit between the questions of ultimate
concern to the law and the information contained in a clinical
diagnosis. In most situations, the clinical diagnosis of a DSM-V
mental disorder such as intellectual disability (intellectual
development disorder), schizophrenia, major neurocognitive
disorder, gambling disorder, or pedophilic disorder does not imply
that an individual with such a condition meets legal criteria for the
presence of a mental disorder or a specified legal standard (e.g. for
competence, criminal responsibility, or disability).
DSM-5: Challenging
Diagnostic Testimony
Hagan, et al
International Journal of Law and Psychiatry,
2015
Expert testimony re: the
diagnosis (although it might
be interesting) is irrelevant in
most legal cases
The expert opinion must address
how that psychiatric illness (or
disease of the mind) affects the
individual’s thoughts processes,
cognitive capacity, and behavior.
What is the one exception?
2002
US Supreme Court
Atkins v. Virginia
The execution of mentally retarded criminals violated the
Eight Amendment prohibition of cruel and unusual
punishment.
The definition of MR/ID has changed with
time
DSM I
NO IQ PARAMETERS
DSM II
IQ = 52-67
DSM III
IQ BETWEEN 50 - 70
DSM IV
HIGH OF APPROXIMATELY 70
DSM 5
IQ NOT INCLUDED IN DIAGNOSTIC
CRITERIA
•Insanity
•Diminished Capacity
•GBMI
Judge David Bazelon, 1954
United State Court of Appeals
“Our collective conscience does
not allow punishment where it
cannot impose blame.”
1. Did the defendant suffer from a mental disorder at
the time of the alleged crime?
2. Was there a relationship between the mental
disorder and the criminal behavior?
3. If so, were the criteria met for the jurisdiction’s
legal test for being found not criminally
responsible?
•Insanity
•Diminished Capacity
•GBMI
Pre-M’Naghten
1723 -- WILD BEAST TEST
A man must be…totally deprived of his
understanding and memory, and doth not know
what he is doing, no more than an infant,…a
brute, or a wild beast… before being found
insane.
Pre-M’Naghten
1840 - IRRESISTIBLE IMPULSE TEST
For a person to be acquitted, as a result of a
mental disorder, he could not resist the
impulse to commit the crime.
1843 - M’Naghten
Every man is presumed to be sane….To establish a
defense on the grounds of insanity, it must be
proved that, at the time of the committing of the act,
the party was laboring under such a defect of
reasoning from a disease of the mind as to not know
the nature or quality of the act he was doing, or, if he
did know, he did not know it was wrong
M’Naghten
DEFECT OF REASONING FROM
A DISEASE OF THE MIND
DID NOT KNOW THE
NATURE AND QUALITY
OF THE ACT
or
DID NOT KNOW THE
ACT WAS WRONG
Post M’Naghten
1870 – PRODUCT TEST aka DURHAM TEST:
No man shall be held accountable, criminally, for an act
which was the offspring and product of a mental
disease.
Post M’Naghten
1955 - MODEL PENAL CODE
A person is not responsible for criminal conduct if at the time
of such conduct as a result of mental disease or defect he
lacks substantial capacity either to appreciate the criminality
of his conduct or to conform his conduct to the requirements
of law.
Post Hinckley
1984 - Insanity Defense Reform Act
A defendant will be found not guilty by reason of
insanity if, as a result of severe mental disease or
defect, he was unable to appreciate the nature
and quality or the criminality or wrongfulness of
his acts.
•M’Naghten
•Durham – Product Test
•Model Penal Code
•Insanity Defense Reform Act
Not Available
M'Naghten
Model Penal Code
Durham Test
The Insanity Defense
Reform Act of 1984:
Much Ado About Nothing
Finkel
Behavioral Sciences and the Law,
1989
US v Freeman 1966
The determination whether a man is or is not held
responsible for his conduct is not a medical, but a social
or moral judgement. Ideally, the psychiatrist, much like
experts in other fields, should provide grist for the legal
mill , should furnish the raw data upon which the legal
judgement is based. It is the psychiatrist who informs
as to the mental state of the accused, his
characteristics, his potentialities, his capabilities.
PENNSYLVANIA -- M’Naghten
DEFECT OF REASONING FROM
A DISEASE OF THE MIND
DID NOT KNOW THE
NATURE AND QUALITY
OF THE ACT
or
DID NOT KNOW THE
ACT WAS WRONG
Which psychiatric diagnoses qualifiy
for the M’Naghten defense?
•Dementia
•Schizophrenia
•Major Depression
•Delirium
•Alcohol Intoxication
INSANITY is not in the DSM-5
INSANITY EVALUATION
Particular attention to:
• Mental state at the time of the offense
oCognitive
oPsychotic
• Behavior at the time of the offense
• Motive
• Planning and preparation
• Ability to complete other deliberate acts
• Ability to control behavior
• Knowledge of wrongfulness
Insanity evaluation
Ground for suspicion:
1. Efforts at flight
2. Efforts at concealment of the crime
3. Efforts at concealment of evidence
•Insanity
•Diminished Capacity
•GBMI
First Degree murder requires:
1. The victim is dead
2. The defendant killed him
3. The defendant did so with a SPECIFIC INTENT TO KILL
and with malice
Diminished Capacity
Diminished Capacity
Diminished capacity is not available where the
defendant denies committing the act
Diminished Capacity
Specific intent to kill – does not require
planning or previous thought or any
particular length of time; all that is required
is that the defendant formed the intent to kill
and is conscious of his intentions
Diminished Capacity
Commonwealth v Logan:
Specific intent to kill means that the killer plans and
carries out the act to advance his or her own
desire and that he or she knows that act will result
in the death of another
Diminished Capacity
Psychiatric testimony must speak to the MENTAL
DISORDER affecting cognitive functions necessary
to from a specific intent to kill
Diminished Capacity
Commonwealth v Zettlemoyer 1982
• Testimony is irrelevant unless it speaks to mental
disorders affecting the cognitive functions of
deliberation and premeditation necessary to
formulate a specific intent to kill
• Testimony that speaks to irresistible impulse or
inability to control self would be irrelevant
• Must ask about whether the defendant had the
capacity to kill rather than whether he had the intent
to kill
Diminished Capacity
Commonwealth v Vandivner, 2009
• An inability to control actions, or impulsive acts are
irrelevant to specific intent to kill and not admissible
to support diminished capacity
•Insanity
•Diminished Capacity
•GBMI
GBMI:
“The defendant LACKS SUBSTANTIAL
CAPACITY either to APPRECIATE the
wrongfulness of what he is doing or to
conform his conduct to the
requirements of the law”
Other considerations:
1. Voluntary intoxication
2. Involuntary intoxication
3. Heat of passion
4. Battered woman syndrome
Other considerations:
MALINGERING – the voluntary
production of symptoms for an
identifiable goal
Interview Techniques for
Suspected Malingerers:
1. Always suspect malingering -- Especially in forensic
settings
2. Do your homework
3. Look for unusual/rare/unique symptoms
4. Start with non-related subjects
SUMMARY:
• Psychiatric diagnoses
• Mental health issues pertaining to Insanity, Diminished
Capacity, GBMI