Summary of all articles and lectures of course 4.3 Forensic diagnostics and treatment
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Course
Forensic Diagnostics And Treatment
Institution
Erasmus Universiteit Rotterdam (EUR)
this summary includes all articles and lectures notes on the course 4.3 Forensic diagnostics and treatment of the master program Forensic and legal psychology of Erasmus University Rotterdam
Summary block 4.3 Forensic Diagnostics and Treatment
General literature
Beach (2017) Teaching psychiatric trainees to think dirty
De Ruiter (2015) Forensic psychological assessment in practice, Chapter 1
Lilienfeld (2013) Symptom validity testing
Tomlin (2020) Forensic mental health in Europe
Van Buitenen (2020) The prevalence of mental disorders and patterns of comorbidity
Radovic (2015) Introducing a standard of legal insanity
Week 1 – PTSD
Lecture notes
DSM-5 Criteria
Rogers (2018) An introduction to response styles
Burges (2001) The ability of naïve participants to report symptoms of PTSD
Friedman (2016) Correcting misconceptions about the diagnostic criteria for PTSD
Friel (2008) PTSD and criminal responsibility
Hall (2006) Malingering of PTSD
Hickling (2002) Detection of malingered MVA related PTSD
Spitzer (2001) PTSD in forensic inpatients
Boskovic (2018) Fake PTSD costs real money
Otgaar (2019) The return of the repressed
McMahon (1999) Battered women and bad science
Rassin (2018) PTSD and diminished criminal responsibility as new evidence
Week 2 – personality disorders
Lecture notes
DSM-5 Criteria
Davison (2012) Personality disorder and criminal behavior
De Page (2020) Association between supernormality, narcissism and depression
Gilbert (2011) Illuminating the relationship between personality disorder and violence
Kröber (2000) Bad or mad?
Laajasalo (2013) Homicidal behavior among people with avoidant, dependent and obsessive-
compulsive personality disorder
Lobbestael (2015) Personality disorders and crime
Twenge (2003) Isn’t it fun to get the respect that we’re going to deserve?
Young (2018) Disorder in the court
Cima (2003) The other side of malingering: supernormality
Fakhrzadegan (2017) The relationship between personality disorders and the type of crime
Forouzan (2005) Figuring out la femme fatale
Sprague (2012) Borderline personality disorder as a female phenotypic expression of psychopathy
Chakhssi (2014) Treating the untreatable
Week 3 – intellectual disability
Lecture notes
DSM-5 Criteria
Cockram (2005) Justice or differential treatment?
Crocker (2006) Prevalence and types of aggressive behavior among adults with ID
Gudjonsson (2000) Assessing the capacity of people with intellectual disabilities to be witnesses
Hayes (2007) The prevalence of intellectual disability in a major UK prison
Keulen-De Vos (2016) Aggressive behavior in offenders with intellectual disabilities
Novaco (2004) Assessment of anger and aggression in male offenders with developmental disabilities
Salekin (2009) Malingering intellectual disability
Salekin (2010) Offenders with intellectual disability
Shandera (2010) Detection of malingered mental retardation
Cockram (2005) People with an intellectual disability in the prisons
McCarthy (2015) Improving the detection of detainees with suspected intellectual disability
Podesta (2016) Autism and violent offending
Schalock (2007) The renaming of mental retardation
Haskins (2006) Asperger’s disorder and criminal behavior
,Week 4 – psychotic disorders
Lecture notes
DSM-5 Criteria
Bo (2011) Risk factors for violence among patients with schizophrenia
Gregg (2007) Reasons for increased substance use in psychosis
Nijman (2003) Nature and antecedents of psychotic patients’ crimes
Peters (2016) Psychotic disorders and violence
Resnick (2018) Malingered psychosis
Tandon (2008) Schizophrenia just the facts: epidemiology and etiology
Tandon (2010) Schizophrenia just the facts: treatment and prevention
Van der Heide (2020) Psychosis as a confounder of symptom credibility testing
Volavka (2011) Pathways to aggression in schizophrenia affect results of treatment
Albalawi (2019) Court diversion for those with psychosis and its impact on re-offending rates
Fazel (2011) Psychotic disorders and repeat offending
Leucht (2009) Second-generation versus first-generation antipsychotic drugs
Singh (2011) Structured assessment of violence risk in schizophrenia
, General literature
Beach, Taylor, & Kontos (2017) Teaching psychiatric trainees to think dirty:
uncovering hidden motivations and deception
The recommendation to think dirty was one of 3 tenets of approaching patient formulation
recommended by George Murray. He encouraged his trainees to think first about patients neuro-
anatomically, by considering which brain regions and neural networks may account for certain
symptoms and behavior. He advised thinking existentially by recognizing a patient’s life struggles and
the larger philosophical questions defining their presentation. However, he also emphasized ‘thinking
dirty’.
The phrase thinking dirty means recognizing hidden motivations and being alert to unseemly,
distressing, or even pathologic reasons for patients to deceive or withhold information from their
providers. It says to take nothing at face value, to be alert to the presence of deception, and to also be
interested in the patient’s motives. It also means recognizing that many patients deceive clinicians for
reasons involving stigma, shame, and fear that are not necessarily pathologic. Importantly, thinking
dirty is not about catching patients or assuming the worst in people, but instead about seeking truth
without embarrassing or humiliating patients.
Thinking dirty involves recognizing stigmatized motivations for symptoms or behaviors, understanding
the significant potential for lies about sex, drugs, and money, and being aware of situations in which
patients act in a way that is counterproductive to their own best interest. It’s a vital part of pursuing
correct diagnoses and prognoses, selecting appropriate treatments, and accomplishing these tasks
with an eye to the individual patient’s needs. This article provides a comprehensive strategy for
teaching this concept to psychiatric trainees.
The didactic approach
First hour
At minimum, a series of 3 didactic hours dedicated to this concept is recommended. The structure is
more important than the specific content, which can be tailored to the training, experience and
literature review. The first talk introduces trainees to the differential diagnosis for deceptive patients
and focuses on building knowledge of pathologic and non-pathologic reasons for lying. One of the key
learning objectives in this first hour is understanding that many patients deceive their providers in
some way.
Another key learning objective here is the concept that most patients who deceive providers do so for
non-pathologic reasons. One very common reason is fear or anxiety about possible consequences of
disclosing the whole truth, which may stem from stigma regarding mental illness. The patient might
worry that being truthful may result in hospitalization, being restrained of having medications
administered. Finally, the seminar should introduce more codified forms of deception, including
malingering and factitious disorder. Risk factors and behavioral markers for these conditions are
discussed.
Second hour
The second seminar focuses on strategies for approaching the deceptive patient, including using
gentle confrontation techniques. Reinforcement of the concept that detecting lying with high accuracy
is impossible is of importance. Trainees should be provided with guidance around identifying
circumstances in which patients are prone to fake good or bad. Interviewing strategies for patients
should also be emphasized. Different techniques can be explained to deal with the different types of
deception.
Hidden motivations behind deception:
1. Manufacturing symptoms: fear that if treatment is not obtained, such thoughts will develop,
concern about having to wait weeks to months to see a psychiatrist, or desire to obtain shelter
and food. For example, endorsing suicidal thoughts when not present.
2. Omitting symptoms: shame or guilt about relapse, drug use violates terms of parole and
patient may face legal action, or concern that acknowledgement of substance use will prompt
referral to detox facility rather than locked inpatient unit. For example, denying recent
substance use in the setting of relapse.
, 3. Amplifying/minimizing actual symptoms:
- Amplification: patient has belief that he is truly sick, spousal relationship maintained by
patient being in a dependent state. For example, disabled by seemingly minor pain.
- Minimization: parents both died in this hospital during patient’s youth. For example, denies
objectively evident pain.
4. Omission of details from narrative: regret at having felt ready for discharge prematurely, worry
that readmission will be denied due to poor usage of treatment, or shame or guilt about
behavior at other facility. For example, does not report discharge from another psychiatric
facility this morning.
5. Creation of fictional details in narrative: fears immediate needs will not be met, previous
reports of suicidal ideation not taken seriously by emergency department providers, or
conflation of suicide attempts and non-suicidal self-injury. For example, reports multiple past
suicide attempts that did not occur.
Third hour
This seminar focuses on effective strategies for confronting willfully deceptive patients, including the
potential for discharge of patients with malingering behavior or factitious disorder. Risks and benefits
of confrontation as well as potential strategies for both direct and indirect confrontation are outlined.
Case examples are used, and trainees may be given opportunity to practice in role play. The focus
then shifts to potential discharging of patients if evidence strongly suggests pathologic deception.
Finally, instruction in how to document deceptive behavior in the medical record is provided.
Documentation should include details of current and prior deceptive behavior, as well as proposed
diagnostic etiology of such behavior. Emphasis should be placed on how to conceptualize an objective
risk assessment in the presence of deception.
Process rounds
The second key component of teaching trainees to think dirty relies on the presence of process
rounds, also known as autognosis or self-knowledge rounds. The purpose is to enhance recognition
among trainees of their countertransference and other reactions to patients and enhance their ability to
effectively manage those emotions. Ideally, process rounds are led by a senior psychiatrist who is not
involved in the evaluation of residents on that rotation. Process rounds help to normalize for residents
the experience of having patients lie to them, and force them to think through adaptive strategies for
dealing with these patients.
Clinical experience
The final essential component of this curriculum occurs in the clinical setting. In addition to modeling
by faculty during walk rounds, residents are strongly encouraged to apply interviewing techniques
discussed in the second didactic lecture. Attending staff should be encouraged to bring junior
residents along when they confront deceptive patients. Once they have witnessed a confrontation,
residents should be given the opportunity to lead such an encounter with supervision. This allows
trainees to develop their own techniques for confrontation and to practice these skills in a safer setting.
Discussion
Learning to think dirty has great value in psychiatric training. It imparts a basic understanding of
conditions such as malingering behavior and factitious disorder. Teaching trainees this approach helps
to normalize their experiences of being deceived or having information withheld from them. Trainees
must be taught to develop strategies for approaching patients with hidden motivations, as they will
otherwise respond instinctually, often with strongly negative countertransference reactions. Teaching
trainees to better recognize motivations and deception has the potential to increase empathy for
deceptive patients by allowing trainees to recognize the frequently non-pathologic reasons for lying.
By teaching trainees to think dirty, they are able to consider a wider range of motivation and resulting
behavior, allowing for a more complete perspective of their patients.
De Ruiter & Kaser-Boyd (2015) Forensic psychological assessment in practice
Forensic mental health assessment
Most psychologists practicing FMHA are originally trained as clinical psychologists, and it’s important
to realize the differences between clinical and forensic psychological assessment. The first notable
difference is the purpose of the assessment. In clinical assessment, this is often to diagnose an
individual’s symptoms and to make treatment recommendations. Forensic assessment is performed to
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