Forensic Issues in Child and Adolescent Psychiatry Flashcards

Question

Factors associated with dangerousness

Answer 1

Male gender History One or more previous episodes of violence Repeated impulsive behaviour Evidence of difficulty in coping with stress Previous unwillingness to delay gratification Antisocial traits and lack of social support History of conduct disorder ``` The offence Bizarre violence Lack of provocation Lack of regret Continuing major denial ``` ``` Mental state Morbid jealousy Paranoid beliefs plus a wish to harm others Deceptiveness Lack of self-control Threats to repeat violence Attitude to treatment, poor compliance ``` Circumstances Provocation or precipitant likely to recur Alcohol or drug misuse Social difficulties and lack of support

Answer 2

E. Various types of studies have been hitherto employed to study the association between recorded crime and psychosis. One must remember that offi cially recorded crime may only be the tip of the proverbial iceberg in such studies. Various regional policies, jurisdictions, and practices affect the rate of recorded crime; in any case, these rates are not a true refl ection of violence in the society. Many such studies have consistently found that a narrow diagnosis of schizophrenia or much broader psychosis have an increased risk of both non-violent and violent offending; this risk is greatest and most consistent for violent offences

Answer 3

E. The risk factors associated with violence in mental illness is a favourite topic in MRCPsych exams. It has been cogently shown that the magnitude of risk associated with a combination of factors such as male sex, young age, and lower socioeconomic status in a mentally ‘well’ person with no psychiatric history is higher than the risk of violence presented by mental disorders per se. Despite varied research, the causal pathway from mental illness to violence is still poorly sketched. The most consistently established risk factors that further increase the risk of violence among schizophrenia patients are (a) comorbid substance abuse, (b) comorbid personality disorder, (c) non-compliance with medication, and (d) active psychotic symptoms. Depression does not seem to be a major mediator of violence in schizophrenia patients

Answer 4

E. Most schizophrenia patients do not offend in direct response to delusions or hallucinations, although homicide offenders may be over-represented in those who are actively psychotic at the time of the offence. In general, schizophrenia patients who offend tend to have long histories of substance misuse, conduct problems, and delinquency, with extensive nonviolent and violent offending prior to the onset of illness. Thus, the tendency to reoffend does not fall after a diagnosis of schizophrenia. The basic tenet one needs to remember regarding the epidemiology of violence in schizophrenia is that those risk factors for violence which operate in subjects without mental illness also operate in patients with schizophrenia.

Answer 5

B. Most research in forensic psychiatry has examined the relative risk of violence among the mentally ill compared with the general population. The population-attributable risk fraction (PAR%) refers to the percentage of violence in the population that can be ascribed to schizophrenia and thus could be eliminated if schizophrenia were eliminated from the population. Fazel and Grann (2006) reported that the population-attributable risk varied by gender and age in a given population. Overall, the PAR% of violence for psychiatric patients was 5.2%, suggesting that patients with severe mental illness commit 1 in 20 violent crimes. These data were obtained from analysing Swedish health registers between 1988 and 2000. This value may vary between countries and across various generations of birth cohorts.

Answer 6

D. The population-attributable risk of violence in those with schizophrenia is a more important public health measure than relative risk as it indicates how much violence/crime could be eliminated if mental illness is ‘eliminated’. It provides an easier and more accurate refl ection than relative risk for the general public. When the crime rates in a society increase, the population-attributable risk due to any mental illness reduces. The population-attributable risk fraction of violence for mental illness rate is estimated as 5% using Swedish registers; this suggests that most crimes in Europe are not related to mental illness.

Answer 7

D. The killing of a child by its mother is very rare and is called fi licide. It is linked to depressive disorders more than any other mental illness. Patricide refers to the act of killing one’s father. Sororicide is the act of killing one’s sister. Matricide is the killing of one’s mother and mariticide is killing of one’s spouse. Fraternicide refers to killing one’s brother

Answer 8

B. The fi ve criteria currently used in court in England and Wales to determine fi tness to plead have remained unchanged for over 150 years. These are collectively termed Pritchard’s criteria: (1) ability to plead; (2) ability to understand evidence; (3) ability to understand the court proceedings; (4) ability to instruct a lawyer; (5) knowing that a juror can be challenged. As the degree of mental illness can vary with time, its effect on fi tness to stand trial can differ. Hence it is important to establish fi tness/unfi tness in the defendant as applicable at the time of the trial proceedings

Answer 9

E. In the UK, the Bolam test has been the benchmark for assessing professional negligence since1957. According to the Bolam test, ‘A doctor is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art’. In other words, a doctor is not negligent if he is acting in accordance with such a practice, merely because there is a body of opinion that takes a contrary view. McNaughton’s test refers to the assessment of diminished responsibility in the wake of mental illness in court. The MacArthur competency assessment tool and Pritchard’s criteria are used for assessing fi tness to plead. Hare’s checklist is used for the assessment of psychopathy.

Answer 10

B. If a defendant is found unfit to plead the likelihood of becoming fi t is initially considered. If this is likely, e.g. following treatment, then the trial can be adjourned until such improvement occurs. If such improvement is unlikely, a jury trial of the facts takes place in the defendant’s absence to determine whether the individual committed the alleged crime. If the individual is unfit to plead but at the end of the trial of facts it is established that he/she has committed the act, then one or other form of court disposal (e.g. a hospital order, supervision order or absolute discharge) is given.

Answer 11

D. HCR-20 (historical, clinical, risk management – 20) incorporates static historical risk factors, such as previous violence and early maladjustment, together with dynamic factors that may be particularly important in individual cases, such as level of insight and lack of personal support. It is a commonly used structured clinical risk assessment scale. VRAG is an actuarial tool that incorporates important predictors of reconviction studied in a sample of Canadian male offenders with mental disorder followed up for 7 years. PCL-R stands for the revised version of psychopathy checklist. It is used with HCR-20; it is not a stand-alone risk assessment instrument. MMPI is used as a psychometric tool for personality variables. The Iterative Classifi cation Tree is an actuarial decision-making tool produced by Monahan et al. (2001) using data from the MacArthur risk assessment study. This tool uses many different combinations of bivariate risk factors to classify a person as high or low risk.

Answer 12

C. VRAG is an actuarial risk tool that incorporates 12 items which are scored on the basis of a weighting procedure developed from the original study of Canadian prisoners. The variable with the heaviest weighting is the PCL-R psychopathy score, which is incorporated as a subscale. It does not use HCR-20 as a subscale. The factors positively associated with increased risk of recidivism are psychopathy score, history of elementary school diffi culties, diagnosis of a personality disorder, young age, separation from parents prior to age 16, failure on prior conditional release, history of non-violent offences, never been married, and history of alcohol abuse. A diagnosis of schizophrenia is considered to reduce the overall risk of recidivism

Answer 13

E. Signifi cantly below average intellectual ability is an independent predictor of future offending, irrespective of a diagnosis of learning disability (LD). Individuals with mild LD show a higher rate of offending than age- and sex-matched individuals without LD. No correlation has been found between the severity of intellectual disadvantage and the seriousness of the offence committed. In fact, individuals with more severe or profound learning disability rarely commit serious offences. Studies in the UK have shown a rate of 2–5% for recorded offences among the learning-disabled population. The degree of disability does not correlate with rate of offending. The most common offences by the learning-disabled group are property offences. Many risk factors that operate in the general population for risk of violence operate in the learningdisabled population, e.g. being young and male, a history of family offending, being unemployed, drug use, psychosocial disadvantage, etc

Answer 14

E. Almost 80% of male remand prisoners in England and Wales were found to have at least one personality disorder, with antisocial personality disorder being most prevalent. From the Offi ce of National Statistics data (1997) the prevalence of any personality disorder was 78% for male remand prisoners, 64% for male sentenced prisoners and 50% for female prisoners (both sentenced and remand). Antisocial personality disorder had the highest prevalence of any category of personality disorder (63% of male remand prisoners, 49% of male sentenced prisoners, and 31% of female prisoners) followed by paranoid personality disorder in men (29% of male remand prisoners, 20% of male sentenced, and 16% of female prisoners) and borderline personality disorder in women (20% of female prisoners). Compare these rates with a weighted prevalence for any personality disorder of 4.4% among people aged 16–74 years in households in England, Scotland and Wales

Answer 15

D. The McNaughton rules refer to a set of guidelines for the insanity defence that was used in England until the 1960s. According to these rules one can plead the defence of insanity only if ‘at the time of committing the act, the accused was labouring under such a defect of reason from disease of the mind, as not to know the nature and quality of the act he was doing, or if he did know it then he did not know he was doing what was wrong’. Those who merely lack the capacity to control a criminal action could still be deemed punishable. Hence, a defect of moral judgement or failure to exercise existing capability to make the right decision cannot be brought up as an insanity defence under the McNaughton rules.

Answer 16

E. The constructs of psychopathy and antisocial or dissocial personality are often referred to interchangeably, but in reality these are quite different concepts. Approximately 3–5% of people in the general population would meet the criteria for antisocial personality. But less than 1% will meet the criteria for psychopathy (i.e. a high score (30/40) on the PCL-R). Similarly, although only 15% of male prisoners have scores that fall in the psychopathy range on the PCL-R, nearly 80% of them will satisfy the criteria for antisocial personality disorder. In other words, although most patients (81%) diagnosed as psychopaths by the PCL-R criteria met the criteria for a diagnosis of antisocial personality disorder, only a minority (nearly 35–40%) of those with antisocial personality receive a diagnosis of PCL-R psychopathy. The correlation between antisocial personality disorder and PCL-R scores was much higher for behavioural (social deviance: r = 0.65) factor of psychopathy than affective (interpersonal: r = 0.39) factor. Psychopaths are less impulsively aggressive than those with antisocial personality disorder, but are more likely to engage in antisocial behaviour of an instrumental nature. Those with psychopathy commit higher rates of serious violence and have strikingly high rates of recidivism than those with antisocial personality disorder but who are not psychopathic.

Answer 17

A. Various neurobiological fi ndings have been demonstrated in those with psychopathy. These include impairments in appreciation of the emotional signifi cance of external experience, strikingly low levels of baseline and reactive autonomic arousal and reduced fear-based learning. Although impaired verbal abilities have been demonstrated as a consistent risk factor for serious antisocial and delinquent behaviour, those with psychopathic traits often show serious antisocial behaviour, despite showing no impairment in their verbal abilities. In fact, Individuals who were high on callous–unemotional traits (a feature of psychopathy) with higher scores on the measure of verbal abilities reported the greatest violent delinquency in a sample of adolescent delinquents. For non-psychopathic individuals, a signifi cant difference in P300 amplitude was noted between target and non-target stimuli. But in psychopathic individuals reliable P300 amplitude differences between the target and non-target visual conditions were not seen.

Answer 18

E. Even in those who are violent but do not have a demonstrable mental illness, the likelihood of having had a neurodevelopmental insult is high. This is shown by the presence of higher rates of minor physical anomalies in violently delinquent adolescents. Similarly, higher rates of neurological soft signs, maternal smoking during pregnancy, and obstetric complications have also been demonstrated. Defects in executive functioning and impulse control have also been shown to correlate with violence in the non-mentally ill samples.

Answer 19

B. Children differ in their response to maltreatment in terms of future risk of criminal behaviour. Although maltreatment increases the risk of later criminality by about 50%, most maltreated children do not become delinquents or adult criminals. It is possible that certain genetic susceptibility factors could infl uence the causal pathway. Caspi et al. demonstrated that the effect of childhood maltreatment on antisocial behaviour was signifi cantly weaker among males with high MAO-A activity than among males with low MAO-A activity. It was also shown that girls with a low MAO-A activity genotype but not those with high MAO-A activity were more likely to develop conduct disorder if they were maltreated. Hence, high MAO-A activity has a protective infl uence against maltreatment for both sexes.

Answer 20

A. Depending on the defi nitions used, the rates of ‘mental disorder’ vary greatly among homicide offenders. The national confi dential inquiry into suicide and homicide by people with mental illness in the UK established the frequency of mental illness in a complete national sample of homicides as 44% (lifetime history of mental disorder). At the time of the homicide, 14% had symptoms of mental illness. The most frequent diagnosis was personality disorder (11%), closely followed by alcohol dependence (10%) and drug dependence. Among major mental illnesses, affective disorders (10%) were more common than schizophrenia (7%).

Answer 21

B. From the national confi dential inquiry on homicide (1996–9) data, only 8–11% of the total sample of all homicide offenders (n=1594) were in contact with mental health services at some time in the preceding year. The main diagnoses in those with any previous contact with mental health services were schizophrenia (24%), personality disorder (18%), and depressive disorder (16%). Psychiatric reports were not available for nearly one-quarter of all homicide cases.

Answer 22

E. The national confi dential inquiry on homicide (1996–9) data found that 22% of all reported homicides were stranger homicides. In stranger homicides the perpetrator was more likely to be a young male and less likely to have a history of mental disorder or a history of contact with mental health services. They were also less likely to have psychiatric symptoms at the time of the offence than perpetrators of non-stranger homicides. They were more likely to have a history of drug or alcohol misuse

Answer 23

C. Traditional expert views on the association between sexual offending and psychiatric disorders were challenged by a case–control study using 13 years’ data from Swedish crime registers conducted by Fazel et al (2007). The authors compared sexual offenders with a random sample of men from the general population and reported that sexual offenders were more likely to have been hospitalized for a psychiatric condition than men in the general population (odds ratio (OR) 6.3). They also showed that sexual offenders were more likely to have a severe mental illness, including schizophrenia (OR 4.8), bipolar disorder (OR 3.4), other psychoses (OR 5.2), or an organic psychiatric condition (OR 2.4).

Answer 24

B. As stated in the question, research is scarce in the area of criminality in elderly people. A case–control study comparing elderly sex offenders with elderly non-sex offenders showed that the rates of psychotic illness, depressive disorders, personality disorders, and dementia did not differ signifi cantly between the two groups. Signifi cant differences were observed at the level of personality traits wherein sex offenders were observed to have more schizoid, obsessive– compulsive, and avoidant traits but fewer antisocial traits than non-sex offenders. Similar to any other age group of sex offenders, the elderly group consisted exclusively of males. The authors concluded that sex offending in elderly people is associated more with personality factors than with mental illness or organic brain disease.

Answer 25

C. The data from Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) project were analysed for the effect of antipsychotics on violent behaviour in those with schizophrenia. Violence declined from 16% to 9% in those who completed the antipsychotic treatment throughout the trial period of 6 months. But no demonstrable difference was found among the different medication groups; medication adherence was associated with a reduced risk of violence only in patients with no history of childhood antisocial conduct. Hence the effect of antipsychotics on violence in schizophrenia seems to depend on the effect of the drugs on acute psychopathology. This study did not show an advantage for second-generation antipsychotics in violence risk reduction when compared with fi rst-generation antipsychotic perphenazine.

Answer 26

B. Automatism is a psychiatric defence used in cases of homicide. Under automatism, the defence counsel argues that the accused person’s behaviour at the time of the offence was ‘automatic’. In other words, mens rea was absent and the act was merely done without the conscious force of the mind – no intention was present. Some causes of automatism include hypoglycaemia, sleep walking, epilepsy, etc. In general, the defendant is acquitted if he/she is found to have a case of sane automatism, i.e. automatisms that occur due to external causes; these are unlikely to recur, hence the acquittal. Insane automatisms are due to ‘internal diseases’ or disorders of the mind, which have a propensity to recur. This classifi cation is purely legal and not based on the impulsive nature of the crime or treatability of the condition. Note that both types of automatisms, by defi nition, mean that there is a lack of intent (mens rea). Often discrete medical disorders can be classifi ed in either type of automatism.

Answer 27

E. Morbid jealousy (also known as Othello syndrome) may be a presenting feature of schizophrenia, delusional disorder, organic brain syndromes, or affective psychosis. It is not coded separately in ICD-10 or DSM-IV but as a subtype of delusional disorder; the delusion of infi delity is described by both systems of classifi cation. Alcohol, amphetamine, or cocaine use can give rise to delusions of jealousy that may develop into full-blown delusional disorder in vulnerable individuals

Answer 28

A. Using a broad defi nition of stalking the British Crime Survey (2000) estimated that 2.9% of adults aged 16–59 had been stalked in the preceding year. Women (4.0%) were more likely to be victims of stalking/harassment than men (1.7%). Risks were particularly high for young women aged between 16 and 19 (16.8%). About a third of incidents were perpetrated by someone who was in an intimate relationship with the victim at the start of the episode or in the past. A community-based epidemiological study on stalking from a medium-sized German city reported that most of the stalking victims (32%) were pursued by former intimate partners.

Answer 29

B. Delusional disorder or erotomanic type has a well-known link with stalking behaviour. An often-cited descriptive study of stalking was carried out by Mullen et al. (1999) in a group of 145 stalkers referred to a psychiatric centre. Mullen grouped stalkers into rejected, intimacyseeking, incompetent, resentful, and predatory types. These are arbitrary and not entirely exclusive groupings, although such typology helps in predicting the likely nature and duration of stalking and the risk of assault to a certain extent. Among these, the rejected stalkers make up the largest group, formed predominantly of ex-partners. The predatory stalkers form a small group with a high potential for sexual violence. Mullen described incompetent stalkers as ‘intellectually limited and socially incompetent individuals with rudimentary courting rituals’ whose victims do not reciprocate their affection. Resentful stalkers tend to frighten and distress the victim because of a sense of grievance. The intimacy-seeking stalkers form a spectrum, from those with erotomania to those with rigid infatuations. The erotomanic delusions could be both secondary to pre-existing psychotic disorders such as schizophrenia and as part of a delusional disorder.

Answer 30

D. It is well established that having a convicted mother, father, brother, or sister signifi cantly predicts juvenile delinquency in boys. Thus intergenerational continuity in offending has been noted. There is no evidence that criminal parents directly encourage their children to commit crime; in fact, most convicted men disagreed with the statement that ‘I would not mind if my son/daughter committed a criminal offence’. Epidemiological studies have shown that it was extremely rare for a parent and a child to be convicted for an offence committed together. Thus, the major mediator between parental criminality and juvenile delinquency seems to be poor parental supervision, with some role for genetic transmission of antisocial behaviour.

Answer 31

A. Violent acts during epilepsy are extremely uncommon. But epileptic automatisms have been invoked as a defence in courts time and again. Most cases involved spontaneous, nondirected, stereotyped aggressive movements, with violence against property being more common than infl icting serious bodily injuries. Severe violence, if seen at all, is largely restricted to postictal states. When aggression presents as a feature of an epileptic seizure, it usually begins suddenly without provocation, lasts only for brief periods, and ends abruptly with evidence of impaired consciousness during the act. The act usually does not involve detailed or interactive behaviour but appears stereotyped. Episodes of postictal or ictal violence are usually associated with amnesia for the event

Answer 32

B. Pyromania is an extremely rare disorder that presents with repeated fi re-setting. It is recognized as a category in both ICD-10 and DSM-IV, under impulse control disorders. The diagnostic criteria include tension or affective arousal before the act of setting the fi re, fascination with, interest in, curiosity about, or attraction to fi re and its situational contexts, as well as pleasure, gratifi cation, or relief when setting fi res or when witnessing or participating in the aftermath of a fi re.

Answer 33

C. Masochism refers to a paraphilia characterized by persistent interest in sexual activities that demean, humiliate, or cause suffering to self. Masochism requires a partner who complies by dominating and infl icting suffering. In contrast, sadism refers to a paraphilia wherein sexual arousal and gratifi cation are obtained by infl icting pain and suffering upon the partner. Hence a sadist and a masochist can be mutual partners. Voyeurism is characterized by achieving gratifi cation by watching people undressing or having sexual intercourse. It is the most common paraphilia reported. Fetishism refers to compulsive sexual interest in inanimate objects that are often worn by or associated with sexual partners. Hypoxyphilia (autoerotic asphyxiation) is not separately coded as a paraphilia in ICD/DSM; it refers to a specifi c form of masochism in which sexual arousal is attained by self-suffocation, e.g. via hanging while masturbating.

Answer 34

E. Kleptomania is considered by some as part of the obsessive–compulsive spectrum. Extending the effectiveness of selective serotonin reuptake inhibitors (SSRI) in obsessive compulsive spectrum disorders, several case series of successful SSRI use in kleptomania have appeared. A response rate of nearly 80% at week 7 was reported for kleptomania in an open-label trial of escitalopram; this was not maintained to the same degree in a subsequent double-blind placebo-controlled discontinuation trial. Naltrexone and mood stabilizers have also been studied in open-label trials for kleptomania, with variable benefi ts. To date, no strong evidence from randomized controlled trials exists to support pharmacological interventions in kleptomania.

Answer 35

A. Traditionally it was thought that 40% of those with conduct disorder experience lifetime persistence of traits that are termed as antisocial personality disorder. But this has been now challenged to be an underestimate; data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) in the USA suggests that nearly 75% of adults who were retrospectively identifi ed to have had conduct disorder as children satisfi ed current criteria for antisocial personality disorder. Although this is a retrospective design, the estimates are from a more representative sample than older retrospective studies

Answer 36

C. The prevalence of schizophrenic disorders in the general population is below 1%, but patients with schizophrenia constitute between 5% and 20% of all homicide offenders. An increased risk of homicide has been associated with the fi rst episode of psychosis. A metaanalysis of studies reporting homicide offences in psychotic patients showed that 38.5% of homicides occurred during the first episode of psychosis, prior to initial treatment. The rate ratio of homicide in the first episode of psychosis was 15.5 times the annual rate of homicide after treatment for psychosis. Nearly 40% of patients with schizophrenia who commit homicides do not have any history of psychiatric care

Answer 37

B. Shoplifting is different from kleptomania: the former is a broadly defi ned behaviour whereas the latter is a specifi c psychiatric diagnostic category. Data from a national study carried out in the USA (National Epidemiologic Survey on Alcohol and Related Conditions) have demonstrated that most individuals (nearly 90%) who admitted to at least one episode of lifetime shoplifting had a lifetime history of at least one psychiatric diagnosis, compared with nearly 50% in non-shoplifters. In both groups, the most prevalent disorders were nicotine dependence and alcohol use disorders, with nearly three or four times increased risk respectively; among shoplifters, the strongest associations were found for antisocial personality disorder and substance use disorders. Kleptomania is a rare condition and occurs in less than 5% of identifi ed shoplifters and less than 0.6% of the general population

Answer 38

C. In Tarasoff v The Regents of the University of California et al., a case was brought by the parents of Tatiana Tarasoff, who had been murdered by Prosenjit Poddar. Poddar had previously disclosed his violent feelings against Tarasoff to Dr Moore, the campus psychologist. Although Dr Moore notifi ed the police of his concerns about Poddar, the police released him after questioning. Ms Tarasoff and her family were not warned of the danger she faced. The court ruled that the clinician had a duty to protect and warn a third party from risk of harm from his/her patient, even though that third party was not under the clinician’s clinical care. In the UK, a Tarasoff ruling does not apply directly; breach of confi dentiality for the sake of public interest has been recognized. According to Tarasoff principles, the police and third parties must be warned of the risk as well as the wife.

Answer 39

D. Data from Psychiatric Morbidity among Prisoners in England and Wales 1998 showed that a large proportion of all prisoners had several mental disorders. Only 1 in 10 or fewer showed no evidence of any of the fi ve disorders considered in the survey (personality disorder, psychosis, neurosis, alcohol misuse, and drug dependence). Thus the rate of psychiatric diagnosis was nearly 90% in prisons. Most prisoners who had a psychiatric diagnosis had more than one diagnosable condition; this was especially true if the primary diagnosis was psychotic illness. Rates for multiple disorders were higher among remand than sentenced prisoners. Despite this, most prisoners receive poor, if any, psychiatric services in prison.

Answer 40

D. Homicide–suicides are mostly family affairs, especially when the perpetrator is female. Barraclough and Harris (2002) studied all murder–suicides over a 4-year period in the UK and found that 3% of male, 11% of female, and 19% of child homicides were of this type. Similarly, of all suicides, 0.8% male and 0.4% female deaths occurred as homicide–suicides. The typical cases involved families of low socioeconomic status. Death or fatal injury occurred on the same day in nearly 90% of incidents; in atypical cases the maximum interval between suicide and homicide was 10 months. In elderly people such homicide–suicide combinations are often suicide pacts complicated by depression or dementia in a couple or one of the partners. They can be considered altruistic, as often elderly people believe that the world will be better off without them.

Answer 41

A. A 2-year national survey of prison suicides described the clinical and social circumstances of self-infl icted deaths among prisoners in England and Wales. Nearly one-third occurred within 7 days of arrival in prison. The commonest method (nearly 92%) was hanging or selfstrangulation; nearly three-quarters had a history of mental disorder. The commonest primary diagnosis was drug dependence

Answer 42

D. Anatomical dolls are used in forensic investigation of children who are alleged victims of sexual abuse. Various procedures such as drawings, puppets, observation for sexualized behaviour, etc., have been used to obtain a child’s report of sexual abuse. But research has not confi rmed that responses supposedly indicative of abuse (e.g. drawing genitalia in human fi gure drawings, demonstrating intercourse, or oral sex between anatomical dolls, etc.) consistently occur with high frequency among abused children. Hence the use of such methods is controversial.

Answer 43

B. The Remission in Schizophrenia Working Group defi ned remission ‘as a state in which patients have experienced improvements in core signs and symptoms to the extent that any remaining symptoms are of such low intensity that they no longer interfere signifi cantly with behaviour and are below the threshold typically utilized in justifying an initial diagnosis of schizophrenia’. Thus ‘remission’ is not the same as ‘recovery’, which is the ability to function in the community, socially and vocationally, as well as being relatively free of psychopathology. Accordingly, remission is a necessary but not suffi cient step towards recovery. Note that such a scientifi c defi nition of recovery views recovery as a state of outcome; this is very different from the concept of recovery promulgated by consumer groups

Answer 44

D. In clinical practice, medication adherence is either assumed de facto or assessed from patients’ self-reports. Both these measures of adherence have limited validity. Medication levels in body fl uids are susceptible to manipulation. The use of electronic monitoring and a third party such as a pharmacist/clinical assistant to assess adherence may be more useful. Using the measurement of adherence as a dichotomous variable, a study comparing adherence estimates by patients, clinicians, and research assistants using electronic monitors was carried out. Compared with electronic monitoring, prescribers dramatically overestimated adherence levels. Electronic monitoring detected greater non-adherence rates (57%) than either prescribers (7%) or patients (5%), although independent third-party ratings were closer to electronic ratings (54%).

Answer 45

C. Homelessness has a recognized association with severe mental illness. ‘Roofl essness’ refers to those living on the streets; it is diffi cult to include them in research surveys. Hence most researchers use a looser defi nition of having no fi xed address and include people living in hostels and emergency accommodation. A broader term of ‘housing instability’ refers to the tenuousness of housing tenure. In the USA, community studies show that about a fi fth of those with schizophrenia had no fi xed address – a rate that was 2.4 times higher than for major depression. The European Schizophrenia Cohort (Bebbington et al., 2005) found that 32.8% of the British sample had experienced homelessness in their lifetime compared with 8.4% in Germany and 12.9% in France. The rate in London was even higher (43%).

Answer 46

A. Assertive community treatment (ACT) was initially developed from the ‘training in community living’ programme at the Mendota Mental Health Institute in Madison, Wisconsin, by Marx, Stein, and Test. According to them community rehabilitation existent in the 1970s served only to maintain patients in ‘a tenuous community adjustment on the brink of rehospitalization’, instead of helping patients to meet all their needs. The key principle was to provide treatment in community settings, because skills learnt in the community can be better applied in the community. In the UK it has been shown that community mental health teams are able to support people with serious mental illnesses as effectively as ACT teams, but ACT may be better at engaging clients and may lead to greater satisfaction with services (UK-700 and REACT studies; see Burns et al. for more information). A systematic review of the evidence on the ACT model has suggested that the degree of reliance on hospitalization may be the key factor in heterogeneity of outcomes seen in ACT services: the higher the reliance on hospitalization in a community, the more effective the ACT-based services are for that community. Other options in the question are false. The cost of skills training is not a major factor behind the advocacy of the ACT model.

Answer 47

B. QOL is measurable using questionnaires; these measures can be subjective or objective and many standardized instruments for both are available. Most but not all QOL instruments contain ‘emotional’ items, mostly relating to depression and anxiety. Such scales when applied to psychiatric conditions become tautological as the content of both measures largely overlap, e.g. the Quality of Life in Depression Scale (QLDS), which is made up mainly of depressive symptoms. Subjective measures of QOL in psychiatry are particularly problematic because of ‘affective, cognitive or reality distortion fallacies’. A depressed patient may underestimate his true QOL; similarly, psychopathological states may lead to distorted appraisal of one’s QOL. Hence external (e.g. relatives/carers) appraisal may be necessary to complement subjective QOLs in psychiatry. Another specifi c type of bias noted in QOL studies in psychiatry is what is termed as ‘standard drift fallacy’. Quality of life can be thought of as the gap between a person’s expectations and achievements. This gap can be kept minimal (i.e. good QOL) either by living up to one’s expectations or lowering these expectations. Many patients with long-term mental disorders report being ‘satisfi ed with life’ in conditions that would be regarded as inadequate or unbearable by other factions of the society. This is due to the tendency of chronic mentally ill people to lower their standards over time and thus keep the gap between expectations and achievements narrow (falsely infl ated subjective QOL)

Answer 48

B. Different models of therapeutic communities have been tried as alternatives to hospitalization for people diagnosed with schizophrenia. Some of these models emphasized the need for individuals to experience psychosis with minimal interference and high levels of support instead of early intervention with antipsychotic medication. In the UK, initiatives such as Kingsley Hall, associated with Laing, and Villa 21, associated with David Cooper, are examples. In the USA, the ‘Soteria paradigm,’ was developed by Mosher and colleagues; the critical elements of Soteria are provision of a small, community-based therapeutic milieu; signifi cant lay person staffi ng; preservation of personal power and social networks; sustained communal responsibilities; a ‘phenomenological’ relational style (giving meaning to the subjective experience of psychosis by ‘being with’ and ‘doing with’ the client); and no or low-dose antipsychotic medication administered from a position of choice and without coercion. Henderson hospital is a therapeutic community for personality disorders, not schizophrenia. The PACE (Personal Assessment and Crisis Evaluation) Clinic is a centre for people with suspected incipient psychosis in Australia where trialled interventions aimed at preventing or delaying the onset of psychotic disorders are used; these interventions include psychological and social interventions, either alone or in combination with pharmacotherapy. Partial hospitalisation refers to mentalization-based therapy for borderline personality disorder

Answer 49

E. According to the health belief model four main belief categories have an impact on patients’ compliance with prescribed treatment. These are (1) perceived benefi ts, (2) perceived costs, (3) perceived susceptibility to illness and cure, (4) secondary benefi ts of medication and adherence. This model emphasizes the patient’s decision-making process, which is composed of a subjective cost–benefi t analysis in the context of the patient’s personal goals and priorities. Thus any changes in levels of adherence are possible only via alteration of the patient’s perceptions. The more severe the illness, the higher the likelihood of perceived benefi ts. Social criticism does not constitute a major factor in adherence according to the health benefi ts model, unless avoiding it is perceived directly as a benefi t by the patient.

Answer 50

B. Competitive employment rates are low in schizophrenia. People with mental health disorders represent the largest group (40%) who claim incapacity benefi t. Various vocational programmes have been tried and tested in schizophrenia rehabilitation. Work acts as both a process and the outcome for rehabilitation in chronic schizophrenia. Sheltered employment refers to the traditional ‘train and place model’ where gradual stepwise skills training is initially carried out; when an individual makes suffi cient progress, later placement is offered, often in sheltered workshops but not in competitive job markets. This approach remains the most widespread in Europe. Models that emphasize relatively quick placement in competitive jobs with continued support from employment specialists (supported employment models) are shown to have considerable impact compared with schemes that concentrate on social skills training or voluntary non-competitive work. This is the individual placement and support model in contrast to traditional stepwise support-till-placement (train and place approach) models. A multicentred RCT of Individual placement and training model (IPS) was carried out across six centres in Europe, including London. The results indicated that IPS was more effective than usual rehabilitation and vocational services for every work-related outcome, with 55% of patients assigned to IPS working for at least 1 day compared with 28% patients assigned to vocational services; the drop-out and readmission rates were comparatively lower in the IPS group. Local unemployment rates across the six centres accounted for a substantial amount of the heterogeneity in IPS effectiveness. Clubhouses offer an opportunity for a person with schizophrenia to resume an independent lifestyle with decent housing, facilities for education, job training, and placement via membership at a common daycentre. Token economy cannot be considered as a vocational model; it is a behavioural technique using secondary reinforcers (tokens) in rehabilitation units to enable desirable behaviour.

Answer 51

A. Annual (now quarterly) labour force surveys in the UK yield the rates of employment for the mentally ill population. Patients with a signifi cant mental illness are among the most excluded in society. It is estimated that, at best, 15% of working age people with long-term mental health problems are working, far lower than any other group of disabled people. Even when working they work fewer hours and earn only two-thirds of the national average hourly rate. The employment rates for those with less serious mental health problems are relatively better at 20–25% but still people with mental disorders constitute 39% of all claimants of Disability Allowance and 34% of Incapacity Benefi t, according to Department of Works and Pensions, UK. Joblessness and lack of social networks are often exacerbated by discrimination and profound loss of social status suffered by the mentally ill. Recovery from mental illness is signifi cantly impeded by the above.

Answer 52

The answer is D Sexual involvement with patients accounts for 6 percent of malpractice claims against psychiatrists and is the least common cause of malpractice litigation. This fact does not, however, minimize its importance as a problem. (It should be noted that the short statute of limitations for this particular offense may well discourage patients from pursuing litigation because they have not had sufficient time to reach a point of emotional readiness.) Sexual intimacy with a patient is both illegal and unethical. There are also serious legal and ethical questions about a psychotherapist’s dating or marrying a patient even after discharging the patient from therapy. Most psychiatrists believe in the adage “Once a patient, always a patient.” For other malpractice claims, the following figures are given: failure to manage suicide attempts, 21 percent; failure to treat psychosis, 14 percent; and improper use of restraints, 7 percent. Substance dependence accounts for about 10 percent of claims and refers to the patient’s having developed a substance-related disorder as a result of a psychiatrist’s not carefully monitoring the prescribing of potentially addicting drugs.

Answer 53

The answer is C No precise, generally accepted definition of legal insanity exists. Tests of insanity have always been controversial and have undergone much modification and refinement over the years. The insanity defense standard has four basic elements: 1. Presence of a mental disorder 2. Presence of a defect of reason 3. A lack of knowledge of the nature or wrongfulness of the act 4. An incapacity to refrain from the act The insanity defense is one of the most controversial issues in American jurisprudence. The presence of a mental disorder has remained the consistent core of the insanity defense; the other elements have varied in importance over time. The finding of incompetence to stand trial is unrelated to this defense. Defendants with mental impairments who are found competent to stand trial may still seek acquittal on the claim of insanity, alleging that they were not criminally responsible for their actions at the time the offense was committed. The term insanity is a legal construct, not a psychiatric diagnosis.

Answer 54

The answer is D The law and ethical analysis of informed consent and refusal inside corrections are complicated. The legal rule is that inmates have the right to consent to care but do not necessarily have equally extensive rights to refuse care. Complicating this issue is the reality that distinguishing between a refusal of care and a possible denial of care is often difficult. An additional complication is the fact that other correctional staff may not want to offer appropriate psychiatric treatment for a variety of reasons (e.g., security risks, cost, deservedness). Simultaneously, inmates can be insistent and manipulative and sometimes seek care for inappropriate reasons. Despite these pressures from opposite poles, correctional psychiatric personnel must ensure that patients get appropriate care. Medical autonomy means that nonmedical personnel cannot overrule the professional judgment of correctional psychiatrists regarding their patients’ needs. Medical autonomy means that only legitimate clinical decisions direct patient care, not patient wishes. Correctional psychiatrists should be neutral in nonmedical matters. Aligning with security staff costs them their rapport with their patients. Alternatively, being inmate advocates for non–health-related issues would cost them their rapport with their correctional coworkers.

Answer 55

The answer is A Youth suicide in juvenile detention and correctional facilities have been shown to occur four times more often than youth suicide in the general population. Yet 75 percent of the nation’s confined juveniles are in facilities that fail to conform to even the most basic suicide prevention guidelines. Several studies note that 25 percent (not 80 percent) of incarcerated boys and 50 percent of incarcerated girls meet criteria for posttraumatic stress disorder (PTSD). Juvenile detention centers are short-term facilities that confine juveniles who are awaiting trial; juvenile confinement facilities are long-term facilities (e.g., residential treatment centers and training schools) for the confinement of juveniles convicted of crimes. Mental illness in detention centers has not been extensively researched.

Answer 56

The answer is D The most appropriate placement for this patient is in a psychiatric facility within a correctional facility. Because she was arrested for cocaine use before her hospital referral, she still has charges pending against her and cannot be released to her home or the care of her family. Although a substance abuse detoxification center may be helpful in the future, she first must have her legal situation dealt with. Discharge to a local jail is inappropriate in this case as well because the local jail will not be able to adequately address her mental illness (major depression).

Answer 57

The answer is E Because self-mutilation is hard to control, it is a serious challenge for correctional officials and psychiatric staff. When selfmutilation is not the product of a mental disorder, mental health professionals often deny admission to the mental health unit. This confuses correctional authorities who view such behavior as a sign of mental instability. It is essential to have clear protocols for self-mutilation when it is (1) a psychiatric symptom, (2) a manipulative gesture to escape a dangerous situation, and (3) an effort to manipulate the system for personal gain. This woman’s documented history of major depressive disorder should alert correctional staff to the likelihood that cutting her wrists is a true suicide attempt. She should have a complete evaluation by a psychiatrist to determine the extent of her current symptoms. If this woman is indeed having an exacerbation of her symptoms of major depression, continuing to withhold medications and simply putting her on a one-on-one suicidal watch may not be enough and is neglectful. However, a thorough evaluation should precede any treatment.

Answer 58

The answer is D The failure to adequately document events in the written clinical record is a major reason for lack of credibility to legal testimony. The psychiatrist in this case testified that he completed a formal assessment of suicide risk, but there is no way to prove this is true with no documentation. Although the patient was at a greater risk of suicide after administration of an antidepressant drug, the psychiatrist cannot be held liable for starting treatment with an antidepressant, which is the standard of care. It is also arguable that the psychiatrist had not placed total reliance on the suicide prevention contract but had used it appropriately to assess the working alliance with the patient, that is, the patient’s willingness to work toward getting better. There is an adage in legal circles that if it is not documented, it was not done.

Answer 59

The answer is A To be found not guilty by reason of insanity, the defendant, as a result of a severe mental disease or defect, must be unable to appreciate the nature and quality or the wrongfulness of his acts. In making an insanity determination, the threshold issue is not the existence of a mental disease or defect per se but the lack of substantial capacity caused by it. In this case, the fact that the man tried to dispose of the bodies shows he was aware of the criminal act, negating any insanity plea. For conviction of any crime, a criminal state of mind (mens rea) must be accompanied by the commission of a prohibited act (actus reus). Both must be present for a guilty verdict, and neither has to do with mental illness. The physical act must be conscious and volitional for a person to be found guilty. The law also recognizes shades of mental impairment that can affect mens rea, but not necessarily to the extent of completely nullifying it. The concept of diminished capacity allows the defendant to introduce medical and psychological evidence that relates directly to the mens rea for the crime charged without having to assert a defense of insanity. For example, in the crime of assault with the intent to kill, psychiatric testimony may be permitted to address whether the offender acted with the purpose of committing homicide at the time of the assault. Mental illness per se is not a defense, and nothing in the case indicates this man did not intend to kill his wife and her lover.

Answer 60

The answer is D What happens to a defendant after a judge or jury returns a finding of insanity depends on the crime committed and on the state in which the trial takes place. Usually, those found “not guilty by reason of insanity” are confined for treatment in a special hospital for severely mentally ill persons who have committed crimes. After a period of time, the person may request a hearing to determine if he or she is no longer a danger to him- or herself or others or is no longer mentally ill and is therefore eligible to be released. Studies showthat persons found not guilty by reason of insanity, on average, are held at least as long as—and often longer than—persons found guilty and sent to prison for similar crimes. In this case, the person was sent to jail because his insanity defense did not prevail. Jails are correctional facilities that confine individuals involved in the criminal justice system who are awaiting trial or serving short sentences for misdemeanors. Alocal lockup may be a police precinct cell, a sheriff’s office, or any other place, including a correctional facility used to detain an arrested individual pending arraignment

Answer 61

The answer is C A writ of habeas corpus (literally, “you must have the body”) is a legal procedure that asks a court to decide whether a patient has been hospitalized or imprisoned without due process of law. The writ tests only whether a prisoner has been accorded due process, not whether he or she is guilty. The automatism (or unconscious) defense recognizes that some criminal acts may be committed involuntarily. Testimonial privilege is the right of the patient to maintain secrecy or confidentiality in the face of a subpoena. Parens patriae is the doctrine that allows the state to intervene and act as a surrogate for those who are unable to care for themselves or may harm themselves. Respondeat superior is Latin for “let the master answer for the deed of the servant.” This states a person high in the chain of command is responsible for the actions of those under his or her supervision.

Answer 62

The answer is C The duty to protect patients and endangered third parties should be considered primarily a professional and moral obligation and only secondarily a legal duty. Most psychiatrists acted to protect their patients and threatened others from violence long before Tarasoff. Psychiatrists should consider the Tarasoff duty to be a national standard of care even if they practice in states that do not have a duty to warn and protect. Indeed, not all states have duty to warn statutes, so there is no legal obligation necessarily in all states that permits or requires psychiatrists to prevent the harm from occurring. If a patient gives the psychiatrist sufficient reason to believe that a warning should be issued to an endangered third party, the confidentiality of the communication that gave rise to the warning may be lost.

Answer 63

The answer is E Incompetence is a broad concept that encompasses many different legal issues and contexts. It refers to a court adjudication Incapacity indicates a functional inability determined by a clinician. It is a legal term that is applied to people who are considered by law not to be mentally capable of performing a particular act or assuming a particular role. Its adjudication is issue specific; someone judged to be incompetent to do one thing is not automatically incompetent to do other things. A lack of competency cannot be presumed from a person’s treatment for mental illness or from institutionalization. Mental disability does not necessarily render a person incompetent or incompetent in all areas of functioning.

Answer 64

The answer is A A tort is any wrongdoing for which an action for damages may be brought. A writ is a written court order directing a person to perform or refrain from performing a specific act. A subpoena is a writ commanding a designated person upon whom it has been served to appear (as in court or before a congressional committee) under a penalty (as a charge of contempt) for failure to comply. A judgment is a formal decision or determination on a matter or case by a court. A good deed is obviously not a tort

Answer 65

The answer is C In a tort, wrongdoers are motivated by the intent to harm another person or should have realized that such harm is likely to result from their actions. For example, telling a patient that sex with the therapist is therapeutic perpetrates a fraud. Although hugging a patient and dating a patient’s family member are both unethical, they are examples of boundary violations, not a tort. Various criminal law statutes have been used against psychiatrists who violate this ethical principle. Privilege is the right to maintain confidentiality in the face of a subpoena. Privileged communications are statements made by certain persons within a relationship—such as husband–wife, priest–penitent, or doctor–patient—that the law protects from forced disclosure on the witness stand. Listing the adverse effects of drugs when prescribing drugs is an example of good medical practice and is not a tort.

Answer 66

The answer is E (all) Psychiatrists, similar to other people, can be sued for anything. This includes battery, defined as the unlawful and unwanted touching or striking of one person by another with the intention of bringing about a harmful or offensive contact. Invasion of privacy, defined as the intrusion into the personal life of another without just cause, can give the person whose privacy has been invaded a right to bring a lawsuit for damages against the person or entity that intruded. Misrepresentation, defined as a statement made by a party to a contract, that a thing relating to it is in fact in a particular way when he or she knows it is not so. False imprisonment, defined as restraining another person without having the legal right to do so, is a misdemeanor and a tort

Answer 67

The answer is A Suicide and suicide attempts are the most frequent causes for lawsuits against psychiatrists; 50 percent of suicides lead to malpractice actions by relatives. The greatest degree of supervision (inpatient setting) is associated with the most culpability. The use of restraints, drug reactions, and patients committing violence are all potential causes of malpractice that can be forestalled with proper documentation of clinical decision making and informed consent. Sexual involvement with a patient is both illegal and unethical.

Answer 68

The answer is E (all) A potential pitfall of involuntary discharge or termination is the charge of abandonment. Malpractice litigation is often associated with situations in which there are bad feelings and a bad outcome. Consultation and careful documentation are important safeguards. Charges of abandonment can be avoided by referring the patient to another hospital or therapist. Some authorities recommend giving a patient three names of therapists, clinics, or hospitals. A patient’s treatment cannot be terminated while in a state of emergency. The emergency must be resolved (e.g., by hospitalization in cases of dangerousness) before treatment can be terminated and the patient transferred.

Answer 69

The answer is E (all) The requirement for competence to be executed rests on a few general principles. A person’s awareness of what is happening is supposed to heighten the retributive element of the punishment. Punishment is meaningless unless the person is aware of it and knows the punishment’s purpose. A competent person who is about to be executed is believed to be in the best position to make whatever peace is appropriate with religious beliefs, including confession and absolution. A competent person who is about to be executed preserves, until the end, the possibility (admittedly slight) of recalling a forgotten detail of the events or the crime that may prove exonerating

Answer 70

The answer is C The Supreme Court, in Dusky v United States (1960), approved a test of competence that seeks to ascertain whether a criminal defendant “has sufficient present ability to consult with his lawyer with a reasonable degree of rational understanding and whether he has a rational as well as factual understanding of the proceedings against him.” In the 1976 case of O’Connor v Donaldson, the Supreme Court ruled that harmless mental patients cannot be confined against their wills without treatment if they can survive outside. In 1966, the District of Columbia Court of Appeals ruled in Rouse v Cameron that an involuntary inpatient who is not receiving treatment has a constitutional right to be discharged. According to this decision, the purpose of involuntary hospitalization is treatment. In Wyatt v Stickney (1971), it was decided that civilly committed patients have a constitutional right to receive adequate treatment. In Tarasoff I (the case of Tarasoff v Regents of the University of California in 1974), it was ruled that a psychotherapist or physician who has reason to believe that a patient may injure or kill someone must notify the potential victim, the patient’s relatives or friends, or the authorities.

Answer 71

The answer is A The action of a court in a child custody dispute is now predicated on the child’s best interests. The maxim reflects the idea that a natural parent does not have an inherent right to be named a custodial parent, but the presumption, although a bit eroded, remains in favor of the mother in the case of young children. As a rule, courts presume that the welfare of a child of tender years generally is best served by maternal custody when the mother is a good and fit parent. The best interest of the mother may be served by naming her as the custodial parent because a mother may never resolve the effects of the loss of a child, but her best interest is not to be equated ipso facto with the best interest of the child. More fathers are asserting custodial claims. In about 5 percent of all cases, fathers are named custodians. The movement supportingwomen’s rights is also enhancing the chances of paternal custody.With more women going to work outside the home, the traditional rationale for maternal custody has less force today than it did in the past.

Answer 72

The answer is A Confidentiality pertains to the premise that all information imparted to a physician by a patient should be held secret. However, sharing information with other staff members treating the patient, clinical supervisors, and a medical or psychiatric consultant does not require the patient’s permission. Sharing patient information with the patient’s family, the patient’s attorney, the patient’s previous therapist, or an insurer of the patient does require the patient’s permission. Courts may compel disclosure of confidential material (subpoena duces tecum). In emergencies, limited information may be released, but after the emergency, the clinician should inform the patient.

Answer 73

The answer is E (all) Negligent prescription practices usually include exceeding recommended dosages and then failing to adjust the medication level to therapeutic levels, unreasonable mixing of drugs, prescribing medication that is not indicated, prescribing too many drugs at one time, and then failing to disclose medication effects. Although exceeding the recommended dosage may be considered negligent, if it must be done, it should be documented in the patient’s chart. Multiple psychotropic medications must be prescribed with special care because of their possible harmful interactions and adverse effects. Psychiatrists must explain the diagnosis, risks, and benefits of the drug. Informed consent should be obtained each time a medication is changed and a new drug is introduced. If patients are injured because they were not properly informed of the risks and consequences of taking a medication, sufficient grounds may exist for a malpractice action. Finally, poor handwriting and the misreading of the prescription by nurses or pharmacists is a major source of error.

Answer 74

The answer is A The Gault decision applies to minors, those under the care of a parent or guardian and usually younger than 18 years of age. In the case of minors, the parent or guardian is the person legally empowered to give consent to medical treatment. However, most states by statute list specific diseases or conditions that a minor may consent to have treated, such as sexually transmitted infections, pregnancy, substance-related disorders, and contagious diseases. In an emergency, a physician may treat a minor without parental consent. The trend is to adopt the mature minor rule, allowing minors to consent to treatment under ordinary circumstances. As a result of the Gault decision, the juvenile must now be represented by counsel, be able to confront witnesses, and be given proper notice of any charges. Emancipated minors have the rights of adults when it can be demonstrated that they are living as adults with control over their own lives.

Answer 75

The answer is E (all) In some situations—such as suspected child abuse—the physician must report to the authorities, as specifically required by law. According to the American Psychiatric Association, confidentiality may be broken when the patient will probably commit murder and the act can only be stopped by notification of police, when the patient will probably commit suicide and the act can only be stopped by notification of police, or when a patient who has potentially life-threatening responsibilities (e.g., an airline pilot) shows marked impairment of judgment.

Answer 76

D In 1954 in the case of Durham v United States, a decision resulted in the product rule of criminal responsibility, or the Durham rule, which states that an accused is not criminally responsible if his or her unlawful act was the product of mental disease or mental defect. Judge Bazelon stated that the purpose of the rulewas to get good and complete psychiatric testimony

Answer 77

C In the 1976 case of O’Connor v Donaldson, the U.S. Supreme Court ruled that harmless mental patients cannot be confined against their will without treatment if they can survive outside. According to the Court, a finding of mental illness alone cannot justify a state’s confining persons in a hospital against their will; such patients must be considered dangerous to themselves or others before they are confined.

Answer 78

B In 1971, in Wyatt v Stickney in Alabama Federal District Court, it was decided that persons civilly committed to a mental institution have a constitutional right to receive adequate care, and standards were established for staffing, nutrition, physical facilities, and treatment.

Answer 79

A In 1966, the District of Columbia Court of Appeals in Rouse v Cameron ruled that the purpose of involuntary hospitalization is treatment and that a patient who is not receiving treatment has a constitutional right to be discharged from the hospital.

Answer 80

D In The Myth of Mental Illness, Thomas Szasz argued that the various psychiatric diagnoses are totally devoid of significance and that therefore all forced confinements because of mental illness are unjust. Szasz contended that psychiatrists have no place in the courts of law.

Answer 81

1136 d/c from AAMHIU in 3 NA cities Interviewed every 10 weeks for 1 year Those who did not use alcohol or drugs, were no more violent than controls Subjects were more likely to use alcohol or drugs

Answer 82

Forensic hx: Hx of previous violence Dev hx: adverse childhood experiences behavioural problems Social hx: social instability, poor employment, disturbed relationships substance use personal hx: self harm, impulsive behaiour poor compliance/engagement with treatment ``` psych sx: persecutory command hallucinations passivity irritability anger hostility suspiciousness lack of insight specific threats identified precipitants/stressors ```

Answer 83

``` VRAG VRAM HCR-20 Static 99- sexual recividism Sexual offender risk apraisal guide ```

Answer 84

``` 1. Historical previous violence young age at first offence relationship instability employment problems substance abuse major mental illness psychopathy early maladjustment personality disorder prior supervision failure ``` ``` 2. Clinical lack of insight negative attitudes active symptoms of mental illness impulsivity unresponsive to treatment ``` ``` 3. Risk management Plans lack feasability Exposure to de-stabilisers Lack of personal support Non-compliant with remediation attempts Stress ```

Answer 85

1. dual agency dilemma 2. obtain informed consent 3. confidentiality 4. Duty to warn 5. Respect autonomy 6. Fitness to plead

Answer 86

A defendant must understand: 1. the charges 2. distinguish between a plea of guilty and not guilty 3. instruct counsel 4. follow proceedings in court 5. challenge a juror

Answer 87

1. Cognitive distortion 2. Self esteem and assertiveness 3. Sexuality/social skills training 4. Role of fantasy 5. Victim empathy 6. Relapse prevention strategies

Forensic Issues in Child and Adolescent Psychiatry Flashcards

(116 cards)