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Psychiatry

Malingering – Presentations of Malingered Psychiatric Symptoms

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Malingering is a forensic topic that is also relevant to most nonforensic clinicians. Almost every experienced psychiatrist, psychologist, or therapist has wrestled with, or wondered about, patients who appear to be faking symptoms in order to gain something of obvious value (or avoid something obviously painful). In this column, I will focus on malingered psychiatric or neuropsychiatric symptoms, but the definitions given below apply to malingered general medical symptoms as well. It’s Not Munchausen’s or “Psychosomatic” Take out a copy of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)1 and look at the small, but very important, differences among malingering, factitious syndromes, and somatoform syndromes (Table 1). Although these concepts are often confused, it’s easy to separate them once you understand that malingering refers to feigning or significantly exaggerating symptoms for a conscious gain or purpose, * factitious refers to feigning symptoms for a largely or wholly unconscious

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Sexual Boundary Issues and Violations

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SEXUAL BOUNDARY VIOLATIONS

All major professional organizations decry sexual activity with patients. Many also include past patients. Several states have laws making such behaviors specific causes of action for lawsuits, or even crimes. The prohibitions often seem clear, but may not define “sexual activity” very well. In addition, statutes and ethical guidelines may not differentiate 1) brief behaviors from lasting, calculated, and/or predatory ones; 2) recent behavior from that which occurred decades ago; or 3) intense therapeutic relationships from one-time consultations. Nevertheless, rigid requirements and interpretations are facts of life. Clinicians should be highly aware of the rules in their profession and locale, and how their behavior may appear to a sometimes accusing or suspicious public. An older clinician with an excellent reputation had a brief affair with a patient early in his career. He quickly felt remorse and took all the professional steps believed appropriate by his profession at the time of the transgression (e.g., took responsibility for his behavior,

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Psychology of Compulsory Detention

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The compulsory detention and treatment of patients against their will is unique to psychia try. It is arguably the most stressful event in psychiatric practice, both for the doctor and for the patient, and yet, although much has been written about the details of mental health legislation (Clare, 1980; Fennell, 1995), very little has been said about the psychological impact that this procedure has on either the doctor or the patient (exceptions are Mills, 1962; Rogers et al 1993). This paper will examine the emotional factors involved when a patient is deprived of his or her liberty, and will take as its point of reference the Scottish Mental Health Act. Among psychiatrists there is a spectrum of attitudes towards compulsory detention. At one end there is the position, exemplified by Thomas Szasz, which views psychiatric intervention as an infringement of personal liberty. If,for example, a person wishes to kill himself, that is his right and no one should interfere.

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Interrogation under Drug Influence

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It has long been known that certain drugs which have a depressing effect upon central nervous system function, also produce a remarkable candor or freedom from inhibition in the subject, which causes him to give truthful answers to questions. The oldest of these drugs is alcohol. For centuries investigators have realized that one method of loosening the tongue and eliminating repressive influences in an uncommunicative subject is to ply him with liquor. This well-known effect of alcohol has given rise to the time-honored aphorism "in vino veritas"- in wine there is truth.1 With the advent of anesthesia about a century ago, it was observed that during the induction period and particularly during the recovery, interval, patients were prone to make extremely naive remarks about personal matters, which, in their normal state, would never have been revealed. Probably the earliest direct attempt to utilize this phenomenon in criminal interrogation stemmed from observations of...

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Lies And Coercion: Why Psychiatrists Should Not Participate in Police and Intelligence Interrogations

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Police interrogators routinely use deceptive techniques to obtain confessions from criminal suspects. The United States Executive Branch has attempted to justify coercive interrogation techniques in which physical or mental pain and suffering may be used during intelligence interrogations of persons labeled unlawful combatants. It may be appropriate for law enforcement, military, or intelligence personnel who are not physicians to use such techniques. However, forensic psychiatry ethical practice requires honesty, striving for objectivity, and respect for persons. Deceptive and coercive interrogation techniques violate these moral values. When a psychiatrist directly uses, works with others who use, or trains others to use deceptive or coercive techniques to obtain information in police, military, or intelligence interrogations, the psychiatrist breaches basic principles of ethics.

Direct or indirect participation of a psychiatrist with police, military, or intelligence personnel when interrogators use deception or psychological or physical coercion violates basic principles of ethical forensic psychiatric practice. Such involvement leads our profession down the slippery slope of designing, endorsing, and participating in

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Why Lying Pays: Truth Bias in the Communication with Conflicting Interests

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Abstract

We conduct experiments of a cheap-talk game with incomplete information in which one sender type has an incentive to misrepresent her type. Although that Sender type mostly lies in the experiments, the Receiver tends to believe the Sender’s messages. This confirms “truth bias” reported in communication theory in a one-shot, anonymous environment without nonverbal cues. These results cannot be explained by existing refinement theories, while a bounded rationality model explains them under certain conditions. We claim that the theory for the evolution of language should address why truthful communication survives in the environment in which lying succeeds.

1 Introduction

Verbal communication can occur even between senders and receivers with conflicting interests, and is often accompanied by lying and suspicion. Some communication-theoretic literature reports that, even in such situations, although senders usually lie, most receivers believe senders’ messages; this is called “truth bias,” the receiver’s intrinsic presumption that the senders are telling the truth (McCornack and Parks, 1986). The purpose of this paper is to...

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The Buck Stops Where? Defining Controlling Person Liability

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I. INTRODUCTION

From 1929 to 1933, the securities markets lost half of their value, a startling 20% of the workforce was unemployed, and productivity was 50% less than it had been in previous years. As the United States grappled with the Great Depression, it asked why such catastrophes had happened. It became apparent that the structural flaws of Wall Street—that is, its anemic self-regulation deserved a large part of the blame. Congress sought to implement legislation in the form of the Securities Act of 1933 and Exchange Act of 1934, which would prevent such a catastrophe from ever occurring again. These statutes established liability for those who commit securities fraud, and were designed to restore investor confidence in a badly shaken market. These Acts went even further, however, by creating liability for those who “control” the company behind the scenes. Section 15 of the 1933 Act and Section 20(a) of the 1934 Act established that the...

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State Standards Charts for Assisted Treatment Civil Commitment Criteria and Initiation Procedures by State

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Introduction

This document contains critical state-by-state information about civil commitment laws and criteria for inpatient and outpatient treatment, emergency hospitalization for psychiatric evaluation, and initiating proceedings for court-ordered intervention in a mental health emergency. Each chart may also be found as an individual document under LEGAL RESOURCES on the Treatment Advocacy Center site. While we hope you find this document helpful, please note that the charts summarize only the most crucial provisions of the pertinent statutes for each state. This information does not constitute legal advice and should not be relied upon as a substitute for seeking legal counsel.

Assisted Psychiatric Treatment
Inpatient and Outpatient Standards by State
The following chart captures the most essential information about the laws for inpatient and outpatient assisted treatment in each state court ordered treatment for symptoms of severe mental illness. Please note that while this chart contains much of each standard’s actual language, it summarizes only the most crucial provisions

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The Disease of Ritual: Obsessive Compulsive Disorder as an Outgrowth of Normal Behavior

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Introduction

In an influential paper, Fiske and Halsam (1997) begin with a description of a man in an unfamiliar country. We observe him to be dressed all in red in a red doorway, washing his hands six times in six different basins that have been arranged meticulously. His eyebrows are plucked bare, and as he washes, he repeats the same phrase, occasionally tapping his earlobe with his right index finger. Their question to the hypothetical observer is: Is this man a priest performing a sanctified ritual? Or is he afflicted with obsessive compulsive disorder? Is he normal, or mad? The question resides in a space between clinical psychiatry and anthropology and is much more far-reaching than the surface implication that normality is culturally constructed. The striking similarities between the form and content of normal ritual and the ritualistic behavior of obsessive compulsive disorder (OCD) invite a deeper analysis. This paper is concerned with the implications of a common ground between normal ritual...

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Bias in Psychiatric Diagnosis

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The word “name-calling” provokes negative associations, but the term “diagnostic labeling” has an aura of scientific precision, objectivity, and professionalism that lends it tremendous power. Language confers power (Miller and Swift 1977), and that power is “not distributed equitably across the social hierarchy” (Hare-Mustin and Marecek 1997, 106), a fact that has had tremendous impact on those who have sought mental health services. Diagnosis of physical problems has often been extremely useful, and in principle, psychiatric diagnosis can be helpful, too (e.g., Emily J. Caplan, chapter 5 in this volume). Unfortunately, psychiatric labeling has been conceived of and applied in extremely biased ways and is surprisingly unwarranted by scientific research, and thus it can result in serious harm (P. Caplan 1995). As Hare-Mustin and Marecek note: “a diagnostic label . . . has a profound influence on what we think of people so labeled and how they think about themselves” (1997, 105). In addition, diagnostic labels often create problems with employers and the...

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The Psychiatry of Opera

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A Personal View

That art is an expression of man's attempts to understand himself and his environment is as important as the purely aesthetic qualities of the piece, whatever it may be. Opera, together with the other performing arts, literature and painting, cannot simply be seen as pure entertainment. It is also a reflection of the society in wHich the composer and librettist lived, and the issues and values contemporary to those people. Opera with its fusion of words, music and theatre is able to delineate those issues involved and present them with an emotional intensity possibly unequalled elsewhere in art. Musical imagery is used to portray and develop the characters in opera by inflecting the librettist's words and embedding them in a sound world. This is how we can gain access to those characters' thoughts and emotions. As psychodramas the works of the late 19th and the 20th centuries reach the greatest level of complexity

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Sexual Attraction to Corpses: A Psychiatric Review of Necrophilia

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Necrophilia, a sexual attraction to corpses, is a rare disorder that has been known since ancient times. According to Herodotus,' the ancient Egyptians took precautions against necrophilia by prohibiting the corpses of the wives of men of rank from being delivered immediately to the embalmers, for fear that the embalmers would violate them. According to a legend, King Herod had sex with his wife Marianne for seven years after he killed her.3.4 Similar legends exist about King Waldemar and Charle-mag~e.'.~ Necrophilia was considered by the Catholic Church to be neither whoring ("fornicatio") nor bestiality, but "pollution with a tendency to ~horing."~ In more recent times, necrophilia has been associated with cannibalism and myths of vampirism. The vampire, who has been romanticized by the Dracula tales, obtains a feeling of power from his victims, "like I had taken something powerful from them."' Cannibalistic tribal rituals are based on the notion that consumption of human flesh imparts a special power or

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Sexual Motives,Gender and Sexual Behavior

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Abstract

The roles of gender and the sexual motives of Love, Pleasure, Conformity, Recognition, Dominance, and Submission in numerous usual and unusual sexual behaviors were investigated. In a survey of 191 college undergraduates it was found that Love, Pleasure, Conformity, and Recognition motives, often in interaction with gender, were all important predictors of sexual behavior. Gender was the best predictor of initiating usual sexual behavior, whereas the Love motive was the best predictor of actually engaging in usual sexual behavior. Pleasure and Recognition in interaction with gender were the best predictors of engaging in unusual sexual behavior. None of the sexual motives predicted initiating unusual sexual behavior. Findings suggest that a variety of sexual motives may underlie sexual behavior.

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Psychological Aspects of Terrorism

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It used to be fairly common, but now hardly a day goes by without someone asking “You’re a psychiatrist—so tell me, what makes people become terrorists?” or “What’s wrong with those people?” My answer in this month’s column is the same as it has always been. First, there are many different kinds of terrorism and terror-violence (a term coined, or at least popularized, by Professor M. Cherif Bassiouni of Loyola School of Law, Chicago). The “answer,” to the extent that anyone knows it, varies from type to type and event to event. Second, although everyone has a personality, and personality is important in behavior, the idea that there are archetypal terrorist personalities, or mental illnesses that predispose one to what most people call terrorism, is simply a myth. For these reasons, this month’s column may not sound very psychiatric at times. I will talk more about what terrorism is not (vis-à-vis psychiatry and psychology) than what it is, in an effort to help readers...

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Begging And Bragging: The Self And The Commodification Of Intellectual Activity

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There are always risks involved in giving a lecture like this. There is a risk that, in assembling such a broad range of people from so many different parts of one’s life one ends up, in the attempt to interest and please everyone, boring or annoying the entire audience. There are the twin risks of under or over preparing: the first leading to drying up; the latter to the woodenness of delivery that comes from remembering (or, worse, reading) words having almost forgotten the meaning they were originally intended to convey. And of course there is the general occupational risk that every writer, teacher, preacher and politician takes, of simply making a prat of oneself. Being more of a fool than an angel, I have managed to add several further risks to these. I have chosen a title that, even allowing for...

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Brief Screening For Family Psychiatric History

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Abstract

Background Brief screens to collect lifetime family psychiatric history are useful in clinical practice and for identifying potential families for genetic studies.

Methods The Family History Screen (FHS) collects information on 15 psychiatric disorders and suicidal behavior in informants and their first-degree relatives. Since each question is posed only once about all family members as a group, the administrative time is 5 to 20 minutes, depending on family size and illness. Data on the validity against best-estimate (BE) diagnosis based on independent and blind direct interviews on 289 probands and 305 relatives and test-retest reliability across 15 months in 417 subjects are presented.

Results Agreement between FHS and BE diagnosis for proband and relative self-report had median sensitivity (SEN) of 67.6 and 71.1 respectively; median specificity (SPC) was 87.6 and 89.4, respectively. Marked decrease in SEN occurred when a single informant...

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