Forensic Diagnostics and Treatment
General Literature
Teaching Psychiatric Trainees to Think Dirty: Uncovering Hidden Motivations and Deception: Beach,
Taylor and Kontos
Abstract: Trainees often encounter patients trying to manipulate and lie, but get little training in
uncovering/incorporating hidden motives in patients into their interviews and plans. This leads to
resident dissatisfactions, decreased empathy for patients, and negative countertransference
reactions. This article looks at a psychiatry training program for trainees to recognize hidden
motives and deception. It found that it improved trainee understanding of patient motivations and
trainee emotional responses to patients deceiving them. Thus, training can lead to better patient
outcomes and decreased resident burnout.
"Thinking dirty" was a recommendation of Dr Murray, who encouraged trainees to think about
patients neuroanatomically - what brain regions cause what behaviour. Thinking dirty means
recognizing hidden motivations and being aware of pathological reasons for patients to lie, to learn
to take nothing at face value. It's not about catching patients, but about seeking the truth without
humiliating them and recognizing stigmas as reasons to lie. It can enhance patient care.
The Didactic Approach says to take 3 didactic hours to lecture on why patients lie, how to approach a
deceptive patient, and confrontation of potential discharge of a deceptive patient. It teaches the
pathological and nonpathological reasons for lying or leaving out information, e.g. minimizing or
maximising symptoms.
The training not only helps in terms of assessing malingering and patient statements, but also helps
trainees to normalize the experience of being lied to. Without training, people respond with strongly
negative countertransference reactions, which is bad for patient care. Recognizing motivations
increases empathy from the trainee for the patient and can help them understand their psychological
distress. It also prevents trainee burnout, which is caused by feeling incompetent and emotionally
exhausted.
Forensic Mental Health in Europe: Some Key Figures: Tomlin et. al.
Abstract: across the EU, forensic patient demographics and stays and legal frameworks differ
substantially, making comparative research difficult. This study looked at 17 EU states' data on
forensic bed prevalence rates, gender distributions, and average lengths of stay in forensic facilities.
Findings showed that they average length of stay differed greatly, with NL having 10x longer stays
than Slovenia, and the UK having 4x more female patients than Slovenia. NL had 17x more bed rates
per 100,000 than Spain. Average length of stay was associated with GDP, healthcare expenditure and
democracy.
Care provided for mentally disordered offenders is very different across the EU, with the levels of
care being different but also the legal frameworks that ensure one is admitted to care. These
differences aren't just in forensic mental health, but also general mental health services, as some EU
states have many more psychologists than others despite having the same prevalence of mental
illness. Differences are due to economic, political and sociocultural variation, stemming from lack of
money and knowledge. There is more research needed on why there is so much variation between
,states. Countries should develop common definitions and practices to develop equity in forensic
mental health across Europe.
Symptom Validity Testing: Unresolved Questions Future Directions: Lilienfeld, Thames, & Watts
SVTs are used for detecting malingering, low effort, and problematic response sets often in
neuropsychology, but there are some issues regarding their construct validity and clinical utility. This
study found that SVTs are important for detecting aberrant response sets in neuropsychology, but
need more clarification. It addresses 6 questions:
1. Are SVTs clinically valid? This has not yet been fully demonstrated. They must enhance
convergent validity of measures, e.g. by identifying a subgroup of respondents for whom
scores on the measure are less valid.
2. Is malingering taxonic? Taxon means class, and often malingering is classed as fully
malingering or totally not malingering, however it's in reality more dimensional than that,
and some malingerers may be unaware of their intentions.
3. Is there an overarching dimension of malingering and low effort? Certain disorders increase
the risk of low effort on psychological tests, and this should not be confused with malingering.
4. How should we combine info from different SVTs? It is not always helpful to add info from
interviews to info from tests in terms of validity, as it can decrease clinician accuracy. It may
be better to just have the relevant info, so we need to research how to combine SVTs to
maximise validity and clinical predictions.
5. Can assessing psychopathy supplement info from SVTs? Psychopathy is characterized by
manipulativeness and may be helpful in malingering detection in conjunction with SVTs.
Detecting psychopathy may help in malingering assessments as they are more likely to
malinger.
6. How do ethnicity and culture affect the interpretation of SVTs? Cultural differences can lead
to poorer results on neuropsychological tests due to misunderstanding of instructions,
inappropriate item content, differential prior exposure to test material, and poor rapport
between examiner and examinee.
The Prevalence of Mental Disorders and Patterns of Comorbidity Within a Large Sample of Mentally
Ill Prisoners: A Network Analysis: van Buitenen et. al.
Abstract: comorbidity of mental disorders is important, but we don't know enough about it, so this
article aims to explore relationships between comorbid disorders. Comorbidity has negative effects
on disorder progression, symptom severity, treatment outcome, and antisocial behaviour. It leads to
more disability and higher need for service. This study looked at DSM diagnoses of patients in
Penitentiary Psychiatric Centres (PPCs) in NL. It found that schizophrenia (57%) and SUDs (43%) were
most prevalent, and over half of patients had a comorbid disorder. The main groups of disorders
found were: substance use, impulsivity, poor social skills, and disruptive behaviours. Psychotic was
considered separate and unconnected to other disorders. These findings showed that comorbid
mental disorders are like connected networks.
NL has one of the lowest incarceration rates in Europe, like Sweden and Finland. Still, there is high
mental illness prevalence in prison populations despite the high utilization of forensic clinics. This
study looks at the prevalence of mental disorders and comorbidity in mentally ill prisoners. It also
looks at underlying attributes and direct relations between mental disorders.
,Findings showed 57% of prisoners had at least 2 diagnoses. SUDs are extremely prevalent, and these
disorders are clearly linked to criminal behaviour. The impulsivity group included those with
externalizing disorders like ADHD, which are linked to SUDs due to antisocial factors. The poor social
skills group portray, for example, eccentric sexual behaviours and overlap for PDs. The disruptive
behaviour group includes those who are aggressive and destructive, often with intellectual
disabilities. The psychotic disorder group are not connected to these other groups, even though they
often have comorbid SUD.
De Ruiter & Kaser-Boyd, Forensic Psychological Assessment in Practice: Case Studies: pages 11-15
Most psychologists practicing FMHA (forensic mental health assessment) are originally trained in
clinical psychology, but clinical assessment is very different in some ways. The purpose of assessment
is very different, in clinical it is to diagnose and treat, in forensic you're more like an objective
scientist whose job is to assist legal fact finders in making decisions. There is more of an adversarial
as opposed to therapeutic relationship, so there is more demand on the test instruments and the
clinician.
Distorted responses are likely to occur due to this, but also because there are more Cluster B
personality disorders in criminals (borderline, antisocial, narcissistic). These are characterized by an
externalization of blame and distorted responding, they're likely to respond in a defensive or
desirable way. Self-report tools are vulnerable to this, so ones that include an examination of
response style should be used. Cross validating tests and using multiple data sources, like records and
observations, can help FMHA. Another difference between clinical and forensic assessment is the
type of referral questions and how these impact assessment methods. FAIs (forensic assessment
instruments) improve FMHA and are used to make assessment more accurate.
Week One
INTRO: PTSD is more frequent in the forensic population than the general public, and may be linked
to violence. It is relevant in court for many reasons, e.g. responsibility, insanity defence, claims etc.
Forensic Mental Health Assessment
Goal: examination and presentation of professional opinion with the highest possible psychological
certainty. When selecting tests for FMHA, the main domains covered are: cognitive functioning (so
intelligence, impulse control, critical thinking – relevant for understanding Miranda rights),
neuropsychological screening, personality (for both traits and pathology), trauma testing, and
projective techniques (but there’s no consensus on this last one).
Main legal questions:
competency to stand trial (doesn't exist in NL)
criminal responsibility This is the part
personal injury where we as forensic
child custody
psychologists have
Specific forensic tests: the most influence
- violence risk assessment
, - malingering (SIMS, MENT, TOMM)
- criminal responsibility (RCRAS)
Forensic Diagnostics
This is a part of FMHA, a result of it. This differs mostly from clinical assessment but not completely.
Purpose of diagnoses: we want this so we know what treatment is appropriate and what legal
decision is the best fit. If they don't get treatment, we shouldn't diagnose people in our lives just to
label them for no reason.
Differential diagnosis:
Prior to making a diagnostic decision, we have to exclude what it is not. After each diagnostic
decision, we see what the differential diagnosis should exclude in the DSM5 per each specific
disorder. The general steps for differential diagnosis are:
1. Rule out malingering or fake disorders. We need to know this is not fabrication of symptoms.
2. Rule out substance abuse as aetiology
3. Rule out disorder due to general medical conditions, e.g. tumour
4. Determine the specific primary disorder
5. Differentiate adjustment disorders from residual other unspecified disorders.
6. Establish the boundary with no mental disorder
PTSD
It has a high prevalence in the forensic population, higher than in the general population (17-50%).
There is an existing relationship between PTSD and violence.
It plays a role in determining criminal responsibility, self-defence, insanity, personal injury claim,
financial benefit e.g. compensation, admission to forensic hospital. These benefits are important to
keep in mind for malingering.
There is a screening tool for PTSD called the PCL-5, but it is very easy to meet the cut-point score of
32 without PTSD. 94% of naïve participants successfully fulfilled PTSD criteria.
PTSD is the only disorder in the entire DSM that says there HAS to be x, y and z that has happened in
order to be diagnosed. (Irena does not agree with the DSM5 criteria that says if you hear about a
trauma to a loved one then you can also have PTSD, but for now it is in there.) It was moved from
anxiety disorders to trauma or stress related disorders.
About 70% of people experience trauma, but only 10% of that experience PTSD. This depends on the
type of exposure, for example: PTSD in victims of sexual abuse is up to 80%, war veterans up to 58%
etc.
PTSD DSM5 Criteria:
1. Exposure – exposure to actual or threatened death, serious injury, or sexual violence in at
least 1 of the following ways: directly experiencing it, witnessing it in person as it occurs to
others, learning that it happened to a close person, experiencing repeated or extreme
exposure to aversive details of the traumatic event like what first responders and police see
2. Intrusion symptoms – at least one of the following associated with the trauma: recurrent
distressing dreams, dissociative reactions like flashbacks or feeling like the event is
happening, intense or prolonged psychological distress in response to cues that represent
the event, marked physiological reactions to cues that represent the event
