A prospective comparison of four insanity defense standards

Article Abstract:

The legal defense of insanity has been debated in the United States for the last century. Controversy has intensified in recent years with attempts to modify or eliminate the defense altogether. It has been important in these debates to try and define exactly what is meant by 'insanity.' A study was undertaken to determine if different standards for judging insanity produced different judgments, and to look at those cases where the standards appeared to make a difference. Four forensic psychiatrists were asked to indicate whether they thought 164 defendants met any or all of four standard insanity tests. The four tests were the American Law Institute (ALI) cognitive criterion, the ALI volitional criterion, the American Psychiatric Association (APA) test, and the M'Naughten rule. The APA rule recommends that the defense be used where there is evidence of cognitive (mental) impairment at the time of a crime rather than mental incapacity or volitional incapacity (acting against one's will). The M'Naughten rule is similarly based on mental impairment. The four psychiatrists determined that 97.5 percent of the defendants met the ALI volitional criterion, 73.9 percent met the APA criterion, 70.3 percent met the M'Naughten rule criteria, and 69.5 percent met the ALI cognitive criterion. Nearly two thirds of the defendants met all four insanity tests, and 24.4 percent met only the ALI volitional test. Few defendants met cognitive test criteria without also meeting those of the ALI volitional test. Elimination of the volitional test reduced the rate of psychiatric recommendations of acquittal by 24.4 percent. This findings suggest that there are differences between volitional and cognitive standards which are important. The differences between types of cognitive standards are not as important to consider. The variation among individual raters must also be viewed as an important determinant of how any insanity standard is applied. (Consumer Summary produced by Reliance Medical Information, Inc.)

Standards, Methods, Evaluation, Forensic psychiatry, Insanity defense

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Decision making in psychiatric civil commitment: an experimental analysis

Article Abstract:

Legislation in the United States and Canada that was designed to reduce the use of involuntary mental hospitalization has interestingly resulted in an increase in the number of commitments. A number of explanations have been proposed, including increases in involuntary readmissions, changes in the characteristics of the patient population served (e.g. needier patients are being seen more frequently), agencies having difficulty adjusting to the substantial changes in the laws, the laws being too flexible to begin with, and the perceived moral obligation of some psychiatrists not to neglect patients that do not otherwise meet the criteria for civil commitment. One important factor that has been overlooked as a possible explanation for the increase is the importance of the different variables used in the decision-making process. It is possible that such factors as availability of beds and psychiatrists' concern about liability play a strong part in final decisions. All psychiatrists in Ontario, Canada were sent a questionnaire asking them to make commitment decisions based on hypothetical cases. Four factors were varied in the different cases: the patients' legal commitability (i.e., dangerousness to self or others, inability to care for self), potential ease of treatment, availability of alternate resources other than hospitalization, and psychotic symptoms (i.e., hearing voices or seeing visions). There were 495 completed questionnaires returned, each with three cases assessed. All four variables were significant in expected ways. Legal commitability and the presence of psychotic symptoms accounted for the majority of the final decisions to commit. The results suggest that psychiatrists in Ontario rely primarily on legal factors in making decisions to commit. It is important, however, to note that a considerable amount of individual variation may exist as well. (Consumer Summary produced by Reliance Medical Information, Inc.)

Laws, regulations and rules, Insane, Civil commitment, Mentally ill persons, Mentally ill, Psychiatry, Civil rights

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Diagnostic legitimacy of factitious disorder with psychological symptoms

Article Abstract:

The validity of factitious disorder with psychological symptoms has been questioned and some of the unresolved issues surrounding the diagnosis are illustrated by the case histories of two patients diagnosed with the disorder. The Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III), a reference work of diagnostic criteria for psychiatric disorders, describes the disorder as consisting of the deliberate creation or emulation of psychiatric symptoms without apparent motivation in the absence of another disorder with similar symptoms. Implicit is the psychological need of the patient to assume the sick role. This is distinct from malingering, where there is an underlying motive to intentionally manufacture symptoms. The first case study discusses an individual who may, in fact, have had an underlying reason to adopt the role of a patient. The desire for institutionalization or the inability to cope successfully with community life were possible explanations for his behavior and, therefore, the diagnosis of malingering could not be ruled out. The second case illustrates the difficulty of obtaining a clear assessment of a patient with multiple and, apparently, contradictory behaviors. The accurate determination of a motivation for her behavior is unlikely in such a case. Both cases underscore the weaknesses in the existing methods of diagnosis of this disorder; namely, the lack of clear criteria for the qualification of the disorder and the ambiguity which exists when trying to rule out underlying motivations for exhibited behavior. These unresolved issues expose the weakness of the current criteria used in the DSM-III, and the authors question the diagnostic legitimacy of the disorder. It is recommended that before factitious disorder with psychological symptoms be included in the upcoming new edition of the DSM, further study be conducted to more clearly establish the validity of this condition.

Analysis, Diagnosis, Criticism and interpretation, Psychology, Pathological, Psychopathology, Diagnostic and Statistical Manual of Mental Disorders (Book), Factitious disorder, Factitious disorders

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