Special Focus in Forensic Psychiatry
Topics of relevance as identified by the
American Board of Psychiatry & Neurology Board Certification Examination Content Outline.
Learn Forensic Psychiatry is not affiliated with nor endorsed by ABPN.
Battered Woman Syndrome
Battered Woman Syndrome
A psychological condition resulting from prolonged and severe intimate partner violence (IPV) (physical, psychological, or sexual abuse)
No formal definition or DSM diagnostic criteria; symptoms are similar to those seen in PTSD.
Serves as the basis for the “battered woman defense”
Most courts admit expert testimony on the psychological effects of IPV regardless of victims’ gender.
Ibn-Tamas experienced intimate partner violence for many years. She shot and killed her husband, the perpetrator of the violence, during an argument, claiming self-defense and fear of imminent danger. Her husband had threatened her with a firearm as recently as that morning.
Defense tried to offer expert testimony on Battered Woman Syndrome to explain Ibn-Tamas’ mental state at the time, which was found inadmissible due to potential prejudicial impact. Ibn-Tamas was convicted of murder.
Court of Appeals reversed and remanded, finding that the expert testimony was admissible because the probative value outweighed potential prejudicial impact.
Self-Defense Defenses
Perfect Self-Defense: belief that one is in imminent danger of serious injury or death, resulting in reasonable use of force proportionate to the threat; can result in acquittal.
Imperfect Self-Defense: belief that one is in imminent danger of serious injury or death resulting in use of force, however, belief is objectively unreasonable, force was excessive, or defendant was initial aggressor; can mitigate severity of charges.
Ethics Guidelines
AAPL Ethics Guidelines for the Practice of Forensic Psychiatry
Applies to psychiatrists working in forensic roles
Serves as a supplement to the APA & AMA Guidelines
Emphasizes principles of “respect for persons, honesty, justice, and social responsibility”
AMA Council on Ethical and Judicial Affairs
Maintains the AMA Code of Medical Ethics
Promotes adherence to professional ethical standards
APA Ethics Guidelines (Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry)
Provides professional ethical guidance for psychiatrists
APA maintains jurisdiction for ethics complaints regarding APA members
Expert Witness
Types of Witnesses
Fact Witness
Provides testimony about direct observations.
Generally not asked to provide opinions.
Example: treating psychiatrist asked to testify about their clinical patient’s psychiatric treatment.
Expert Witness
Provides testimony about “specialized knowledge”
Generally asked to provide opinions on medicolegal issues or questions.
Not an advocate for a specific party.
Must strive to maintain an objective, neutral, impartial stance, with a focus on truth & honesty.
Example: independent forensic psychiatrist retained to evaluate a defendant with respect to competency to stand trial
Federal Rule of Civil Procedure 26 (Rule 26)
Provides rules for use of expert witnesses in federal cases.
Each party must provide a list of experts they plan to call at trial at least 90 days prior.
Rule 26 Expert Reports: Experts must prepare a report containing their opinions and their basis, data reviewed, expert qualifications, compensation, and a list of prior testimony over the past 4 years.
Federal Rule of Evidence 702 (FRE 702)
Governs admissibility of expert testimony in federal cases.
Expert must be qualified by knowledge, skill, experience, training, or education, with specialized knowledge beyond what the ordinary person would know.
Expert may testify if:
Expert’s specialized knowledge will help the trier of fact to understand the evidence or determine a fact at issue.
Testimony is based in sufficient facts & data.
Testimony is the product of reliable principles and methods.
Expert has reliably applied the principles and methods to the facts of the case.
Hypnosis
Information obtained via hypnosis may be inaccurate, and must be thoroughly corroborated.
Hypnosis may result in false memories. Hypnotically-refreshed recall may ultimately be more inaccurate than non-refreshed recall.
The American Psychiatric Association provides a position statement on hypnosis.
Sell was attacked by an unknown assailant. She subsequently underwent hypnosis to enhance recall. The hypnosis session was conducted by Dr. Spiegel, with a detective present.
During hypnosis, she was asked if the attacker was her ex-husband (Hurd), which she affirmed. After the session ended, she expressed doubt. The identification was suppressed in court due to concern that it had been induced.
Dr. Orne, a hypnosis expert, testified for the defense and provided a list of safeguards for hypnosis.
Court found hypnotically-refreshed memory is admissible on a case-by-case basis, using Orne Criteria as safeguards for admissibility.
Orne Criteria (Safeguards for Admissibility of Hypnotically-Refreshed Memory)
Hypnosis should be conducted by a psychiatrist or psychologist trained in hypnosis.
Professional must be independent of any party to the case.
Any information given to the professional by law enforcement must be in writing.
Professional should obtain a detailed description of facts from subject prior to hypnosis.
All contacts between professional and subject should be recorded; videotaping is preferred.
Only the professional and the subject should be present during session.
Malingering & Factitious Disorder
Malingering
Intentional production of false or grossly exaggerated symptoms motivated by external incentives (secondary gain)
Types
Pure Malingering: producing symptoms that are entirely false.
Partial Malingering: exaggerating severity of real symptoms.
False imputation: attributing real symptoms to an unrelated cause.
Psychometric Tests for Evaluation of Malingering
Structured Interview of Reported Symptoms (SIRS)
Personality Assessment Inventory (PAI)
Minnesota Multiphasic Personality Inventory (MMPI-2)
Miller Forensic Assessment of Symptoms Test (M-FAST)
Test of Memory Malingering (TOMM)
May be considered criminal behavior in some jurisdictions.
Feigning
Intentional production of false or grossly exaggerated symptoms without assumptions about motivation.
Factitious Disorder
Intentional falsification of physical or psychological symptoms or infliction of injury or disease without clear external gain.
Factitious Disorder Imposed on Another
Intentional falsification of physical or psychological symptoms or infliction of injury or disease on another without clear external gain.
Neuroimaging
May be introduced subject to standards of admissibility of scientific evidence (Frye, Daubert)
Structural imaging (CT, MRI) is used to examine anatomic structures, while functional imaging (fMRI, PET, SPECT) is used to assess brain function.
Has been used to demonstrate specific brain structural or functional deficits or abnormalities suggestive of specific diagnoses (ex: TBI, dementia, Antisocial Personality Disorder, Schizophrenia) or traits (poor impulse control, violence) which may support an argument of diminished culpability.
Polygraphy
Polygraph Machine (“Lie Detector Test”)
Measures physical indicators, such as heart rate, blood pressure, respiratory rate, and skin conductivity, which may change under stress.
Subject is asked questions while these measures are recorded. The information is analyzed to determine whether there are physiological changes suggestive of stress, which may indicate deception.
Does not directly measure whether someone is lying, but rather, measures physiological changes. These changes could be caused by factors other than lying, such as fear or anxiety.
Frye was on trial for murder charges, and presented an expert witness to testify about the results of a “deception test” (an early lie-detector), which aimed to detect lies via rises in systolic blood pressure. This testimony was found to be inadmissible by the judge.
On appeal, the court found that the “deception test” lacked sufficient general acceptance in the scientific community, upholding the judge’s decision to exclude.
Practice of Forensic Psychiatry
Audio/Video Recording of Evaluations
Many forensic psychiatrists record their evaluations. If planning to record an evaluation, the retaining party should be informed in advance.
Pros
Promotes transparency, providing an accurate, unaltered record of the evaluation.
Facilitates review at a later date, such as trial.
May serve as a safeguard against potential misconduct violations.
Cons
Potential for privacy concerns.
Physical presence of camera may impact behavior of both the evaluator & evaluee.
The American Academy of Psychiatry and the Law (AAPL) provides Guidelines for Video Recording of Forensic Psychiatric Evaluations. AAPL recommendations include:
The option of video recording is an ethically acceptable medical practice, but a blanket rule requiring video recording of all forensic evaluations is not supported.
In certain circumstances, video recording may be recommended or required by legal or professional sources. (ex. hypnosis, evaluations for child sexual abuse)
Videotaped interviews can be useful teaching tools.
Confidentiality
Forensic psychiatric evaluations differ from clinical evaluations with respect to confidentiality.
Unlike clinical evaluations, forensic evaluations may not be confidential.
Often requested by a third party, to whom a report is to be provided.
Information obtained may be used in legal proceedings.
AAPL Ethics Guidelines require that evaluees are advised of confidentiality limitations prior to forensic evaluations. This notice should be documented in the report.
The purpose of the evaluation should be explained to the evaluee, as well as identification of who request the evaluation, and to whom the report will be provided.
Dual Agency
Dual agency issues may arise when responsibilities are owed both to a patient and to a third party.
AAPL Ethics Guidelines discourage treating psychiatrists from performing medicolegal evaluations or serving as an expert witness for their clinical patients. Serving in such a role may be damaging to the therapeutic relationship.
Dual agency may be unavoidable in certain situations (such as civil commitment hearings, worker’s compensation, disability evaluations)
Psychological Autopsies
Psychological Autopsy: A systematic, retrospective investigation process aimed at understanding the mental state of a now-deceased individual in the time leading up to their death.
May be requested when cause of death is in question (sudden unexplained death, suicide), especially when this may impact insurance claims or criminal investigations.
Given that the subject is deceased, information must be obtained from other sources, such as diaries, suicide notes, police reports, autopsy reports, toxicology screens, medical records, correspondence (texts, emails), employment or school records, legal records, and interviews of survivors (family, friends, & acquaintances) & witnesses.
No standardized protocol.
Unable to provide a definitive, conclusory determination.
Psychopathy & Antisocial Personality Disorder
Antisocial Personality Disorder
DSM diagnosis involving pervasive disregard for and violation of the rights of others.
Must be at least 18, with evidence of conduct disorder prior to age 15.
Symptoms:
Failure to conform behaviors to the law & social norms
Deceitfulness
Impulsivity
Irritability & aggression; tendency towards fights
Reckless disregard for safety
Irresponsibility
Lack of remorse
Higher incidence in incarcerated populations
Psychopathy
Not an official DSM diagnosis.
Often assessed using the Hare Psychopathy Checklist Revised (PCL-R), an instrument which measures personality traits and behaviors. The PCL-R is often used to predict recidivism risk.
Characteristics may include:
Lack of empathy & remorse
Shallowness
Superficial charm
Grandiosity
Promiscuity
Manipulativeness & Deceitfulness
Impulsivity
Irresponsible behavior
Antisocial behavior & criminal activity
Less common than ASPD; shares a higher incidence in incarcerated populations.
Risk Assessments
Types of Risk Assessments
Unstructured Clinical Judgment
Assesses risk using clinical judgment.
No formal structure; clinician uses their training and experience to weigh relevant risk and protective factors.
Entirely subjective; greater potential for bias, but also more room to tailor assessment to the individual case.
Structured Professional Judgment (SPJ)
Assesses risk using both structured criteria & professional judgment.
Involves a comprehensive checklist of relevant empirical risk & protective factors, which serves as a structured framework to guide clinical decision-making. Leaves room for professional judgment.
More structure & reliability than unstructured clinical judgment.
Example: Historical Clinical Risk Management (HCR-20)
Actuarial Tools
Predict risk or behavior using statistical data.
Statistical models that utilize mathematical formulas and empirical data to estimate risk.
Replace clinical decision-making; no room for professional judgment.
Example: Violence Risk Appraisal Guide (VRAG), Static-99
Common Forensic Risk Assessment Tools
Violence Risk Assessment
Violence Risk Appraisal Guide (VRAG)
Actuarial tool; uses statistical data to predict violence recidivism risk.
Historical Clinical Risk Management (HCR-20)
Structured Professional Judgment tool used to assess violence risk.
Examines factors across three domains:
Historical (ex. history of violence, age at index offense)
Clinical (ex. active mental illness, impulsivity)
Risk management (ex. lack of supports, treatment nonadherence)
Sexual Offender Risk Assessment
Static-99
Actuarial tool; uses statistical data to predict sexual offense recidivism risk in adult male offenders.