Extreme Overvalued Beliefs

An extreme overvalued belief is shared by others in a person's cultural, religious, or subcultural group. The belief is often relished, amplified, and defended by the possessor of the belief and should be differentiated from a delusion or obsession. Over time, the belief grows more dominant, more refined, and more resistant to challenge. The individual has an intense emotional commitment to the belief and may carry out violent behavior in its service. Study participants (n = 109 forensic psychiatrists) were asked to select among three definitions (i.e., obsession, delusion, and extreme overvalued belief) as the motive for the criminal behavior seen in 12 randomized fictional vignettes. Strong interrater agreement (kappa = 0.91 [95% CI 0.83-0.98]) was seen for vignettes representing extreme overvalued belief. Vignettes representing delusion and obsession also had strong reliability (kappa = 0.99 for delusion and 0.98 for obsession). This preliminary report suggests that forensic psychiatrists, given proper definitions, possess a substantial ability to identify delusion, obsession, and extreme overvalued belief. The rich historical foundation of extreme overvalued belief and this small survey study highlight the benefit of inclusion of "extreme overvalued belief" in future glossaries of the Diagnostic and Statistical Manual.

Unsolicited E-mails to Forensic Psychiatrists

E-mail communication is pervasive. Since many forensic psychiatrists have their e-mail addresses available online (either on personal websites, university websites, or articles they have authored), they are likely to receive unsolicited e-mails. Although there is an emerging body of literature about exchanging e-mail with patients, there is little guidance about how to respond to e-mails from nonpatients. Therefore, we used a Delphi technique to develop a consensus about salient points for the forensic psychiatrist to consider regarding responding to e-mails from nonpatients and the risks entailed. Four scenarios are described, including e-mails from nonpatients and unknown others requesting advice or help. The potential ethics-related, legal, moral, and practical concerns for forensic psychiatrists are discussed. Finally, potential pitfalls for forensic psychiatrists are described.

Filicide in the United States

In the United States the Accreditation Council of Graduate Medical Education determines the curriculum required for fellows in forensic psychiatry to become board certified as a subspecialist. Areas that must be covered during the one year fellowship include criminal issues, such as insanity; civil issues, such as tort law and Workers' Compensation; legal regulation of psychiatry, such as confidentiality and involuntary hospitalization; and correctional psychiatry issues, such as dual agency and prisoner's rights. Fellows are also expected to have knowledge about juvenile courts, the structure of the legal system, and child custody issues. In addition, fellows are required to analyze complex cases and write forensic reports which are well reasoned. Teaching methods include lectures, storytelling, use of video vignettes, and mock trials. Additional teaching methodologies include group supervision of fellows in their report writing and direct observation of giving testimony. During the year we see fellows evolve and shift their orientation from being an advocate for patients to perceiving their role as serving justice.

Anders Breivik: Extreme Beliefs Mistaken for Psychosis

The case of Anders Breivik, who committed mass murder in Norway in 2011, stirred controversy among forensic mental health experts. His bizarrely composed compendium and references to himself as the "Knights Templar" raised concerns that he had a psychotic mental illness. Beliefs such as Mr. Breivik's that precede odd, unusual, or extremely violent behavior present a unique challenge to the forensic evaluator, who sometimes struggles to understand those beliefs. Psychotic disorder frequently is invoked to characterize odd, unusual, or extreme beliefs, with a classification that has evolved over time. However, the important concept of overvalued idea, largely ignored in American psychiatry, may better characterize these beliefs in some cases. We discuss the definitions of delusion and overvalued ideas in the context of Anders Breivik's rigidly held extreme beliefs. We also review the British definition of overvalued idea and discuss McHugh's construct, to introduce the term "extreme overvalued belief" as an aid in sharpening the forensic evaluator's conceptualization of these and similar beliefs.

Listening to voices: the use of phenomenology to differentiate malingered from genuine auditory verbal hallucinations

The experience of hearing a voice in the absence of an appropriate external stimulus, formally termed an auditory verbal hallucination (AVH), may be malingered for reasons such as personal financial gain, or, in criminal cases, to attempt a plea of not guilty by reason of insanity. An accurate knowledge of the phenomenology of AVHs is central to assessing the veracity of claims to such experiences. We begin by demonstrating that some contemporary criminal cases still employ inaccurate conceptions of the phenomenology of AVHs to assess defendants' claims. The phenomenology of genuine, malingered, and atypical AVHs is then examined. We argue that, due to the heterogeneity of AVHs, the use of typical properties of AVHs as a yardstick against which to evaluate the veracity of a defendant's claims is likely to be less effective than the accumulation of instances of defendants endorsing statements of atypical features of AVHs. We identify steps towards the development of a formal tool for this purpose, and examine other conceptual issues pertinent to criminal cases arising from the phenomenology of AVHs.

Child murder by parents and evolutionary psychology

This article explores the contribution of evolutionary theory to the understanding of causation and motive in filicide cases and also reviews special issues in the forensic evaluation of alleged perpetrators of filicide. Evolutionary social psychology seeks to understand the context in which our brains evolved, to understand human behaviors. The authors propose evolutionary theory as a framework theory to meaningfully appreciate research about filicide. Using evolutionary psychology as a theoretical lens, this article reviews the research on filicide over the past 40 years, and describes epidemiologic and typologic studies of filicide, and theoretical analyses from a range of disciplines.

Mothers who kill: evolutionary underpinnings and infanticide law

Women who kill their children present a profound challenge to accepted notions of motherhood and the protection offered by mothers to their children. Historically, societies have varied in the sanctions applied to perpetrators of such acts, across both time and place. Where penalties were once severe and punitive for mothers, in modern times some two dozen nations now have infanticide acts that reduce the penalties for mothers who kill their infants. Embedded within these acts are key criteria that relate (a) only to women who are (b) suffering the hormonal or mood effects of pregnancy/lactation at the time of the offence which is (c) usually restricted to within the first year after delivery. Criticisms of infanticide legislation have largely centered on inherent gender bias, misconceptions about the hormonal basis of postpartum psychiatric disorders, and the nexus and contribution of these disorders to the offending in relation to issues of culpability and sentencing. Important differences between female perpetrators relative to the age of the child victim have also highlighted problems in the implementation of infanticide legislation. For example, women who commit neonaticide (murder during the first day of life) differ substantially from mentally ill mothers who kill older children. However, despite these shortcomings, many nations have in recent years chosen to retain their infanticide acts. This article reviews the central controversies of infanticide legislation in relation to current research and fundamental fairness. Using evolutionary psychology as a theoretical framework to organize this discussion, it is argued that infanticide legislation is at best unnecessary and at worst misapplied, in that it exculpates criminal intent and fails to serve those for whom an infanticide defense might otherwise have been intended.

Planning, writing, and editing forensic psychiatric reports

Forensic psychiatric reports are often the final product of a psychiatrist's work in a particular case because most cases do not go to trial but instead are settled through negotiation or plea bargaining. This article addresses the planning, writing, and editing of forensic reports. Planning a report requires thorough data gathering, and thoughtful organization of the report into specific subheadings. Throughout the report there should be a clear separation of factual data from professional opinions. Ten pitfalls of report writing are identified. The most important part of the forensic report is the opinion section. The evidence for the opinion should begin with the strongest points and the reasons supporting the opinion should be completely explained. Finally, ethical issues are addressed.

Feigning in adjudicative competence evaluations

Competence to stand trial (adjudicative competence) is the most requested forensic psychiatric evaluation, with an estimated 60,000 referrals annually. The challenge of detecting feigned incompetence has not been systematically studied until the past decade. Estimates of feigned adjudicative incompetence vary from 8 to 21%. This article reviews techniques for detecting malingered psychosis and malingered cognitive impairment during competence evaluations. Specific techniques for assessing feigned adjudicative incompetence and estimating the malingerer's genuine abilities are discussed. A stepwise approach to suspected feigned adjudicative incompetence is proffered.

Postpartum Depression: An Update

Postpartum depression occurs in at least one in seven new mothers, usually within the first 6 months after delivery. By the time of onset of postpartum depression, the mother has usually long since been discharged from the maternity hospital. Early identification and treatment of these mothers reduces both maternal and infant suffering. Careful risk–benefit decision-making regarding various treatment options in the postpartum should be discussed with the mother. Risks of untreated depression include poor bonding with the infant, lack of self care, infant neglect and infanticide.

Neonaticide: Phenomenology and considerations for prevention

This article explores the phenomenon of neonaticide, the murder of an infant during the first day of life. Characteristics of maternal neonaticide offenders in industrialized countries were identified based on a systematic literature review. Neonaticides were most often committed by poor, relatively young, single women who lacked prenatal care. Efforts to better prevent these tragedies should include improved sex education and contraceptive access. Two legal responses to the problem of neonaticide, Safe Haven laws utilized in the United States, and anonymous birth options in Europe are discussed.

My favorite tips for detecting malingering and violence risk

This article presents specific tips for detecting malingering and the risk of violence. Specific topics include detailed inquiry into symptoms, endorsement of bogus symptoms, and confrontation of a patient with a paranoid persecutor. It ends with strategic tips and an illustrative dialogue showing how these tips can be implemented in practice.

The detection of malingered post-traumatic stress disorder

The detection of malingered PTSD is made particularly challenging by the subjective nature of PTSD criteria and requires a thorough, systematic approach. The psychiatrist must gather and analyze evidence from the evaluation, clinical records, psychologic testing, third parties, and other sources. Although some individuals may malinger PTSD to avoid criminal sanctions, the most common motivation for malingering PTSD is financial gain. Clinical nuances may help distinguish genuine from malingered PTSD. The psychiatrist should be aware of the differences observed between civilian and combat-related PTSD. Although special effort is required, the psychiatrist bears considerable responsibility to assist society in differentiating true PTSD from malingering.Undetected malingering is not limited simply to fraudulent monetary awards, but can involve misuse of limited mental health resources, leading to negative consequences for the mental health system. As Burkett aptly notes, malingered combat PTSD cases "take time, energy, and financial resources away from treating true combat veterans with PTSD. And real combat vets who truly need help end up in group therapy with phonies, get disgusted, and quit treatment".

Child murder committed by severely mentally III mothers: an examination of mothers found not guilty by reason of insanity. 2005 Honorable Mention/Richard Rosner Award for the best paper by a fellow in forensic psychiatry or forensic psychology

Forensic hospital records of 39 severely mentally ill mothers adjudicated Not Guilty by Reason of Insanity for filicide (child murder by parents) were analyzed to describe characteristics preceding this tragedy and to suggest prevention strategies. Almost three-quarters of the mothers (72%) had previous mental health treatment. Over two thirds (69%) of the mothers were experiencing auditory hallucinations, most frequently command hallucinations, and half (49%) were depressed at the time of the offense. Over one third (38%) of the filicides occurred during pregnancy or the postpartum period, and many had a history of postpartum psychosis. Almost three-quarters (72%) of the mothers had experienced considerable developmental stressors, such as death of their own mother or incest. Maternal motives for filicide were predominantly "altruistic" (meaning murder out of love) or "acutely psychotic" (occurring in the throes of psychosis, without rational motive). Psychiatrists should perform careful risk assessments for filicide in mothers with mental illnesses.

Child murder by mothers: a critical analysis of the current state of knowledge and a research agenda

OBJECTIVE

Maternal filicide, or child murder by mothers, occurs more frequently in the United States than in other developed nations. However, little is known about factors that confer risk to children. The authors review the literature to identify predictors of maternal filicide and identify gaps in knowledge about maternal filicide.

METHOD

Databases were systematically searched for studies of maternal filicide and neonaticide (murder in the first day of life) that were conducted in industrialized countries and were published in peer-reviewed, English-language publications after 1980.

RESULTS

Women who committed filicide varied greatly by the type of sample studied. Neonaticide was often committed by young, poor, unmarried women with little or no prenatal care.

CONCLUSIONS

The results of the review suggest that little is known about the predictors of maternal filicide and that a systematic, focused program of research on reliable markers for maternal filicide is needed to better prevent these events.

Filicide-suicide: common factors in parents who kill their children and themselves

The purpose of this phenomenological study was to identify commonly occurring factors in filicide-suicide offenders, to describe this phenomenon better, and ultimately to enhance prevention of child murder. Thirty families' files from a county coroner's office were reviewed for commonly occurring factors in cases of filicide-suicide. Parental motives for filicide-suicide included altruistic and acutely psychotic motives. Twice as many fathers as mothers committed filicide-suicide during the study period, and older children were more often victims than infants. Records indicated that parents frequently showed evidence of depression or psychosis and had prior mental health care. The data support the hypothesis that traditional risk factors for violence appear different from commonly occurring factors in filicide-suicide. This descriptive study represents a step toward understanding filicide-suicide risk.

Gender differences in criminality: bipolar disorder with co-occurring substance abuse

Outpatient interviews to collect criminal history data were conducted with 55 women and 77 men who had the dual diagnosis of rapid-cycling bipolar disorder with co-morbid substance abuse disorders (DD-RCBD), to ascertain gender-related similarities and differences. Fifty-three percent of women and 79 percent of men reported that they had been charged with a crime, and nearly half of those charged had been incarcerated. Men with DD-RCBD were more likely to have committed a felony and had a trend of committing more misdemeanors. Although women with DD-RCBD were less likely to have a criminal history than their male counterparts, they were far more likely to have a criminal history than were women in the general population. Implications from this pilot study include the need for earlier identification of bipolar disorder and for the increased availability of psychiatric and substance abuse services within correctional facilities.

The psychiatric expert witness

The novice psychiatric expert witness undergoes intense scrutiny and enters an unfamiliar legal system. Caution must be taken to maintain professional integrity and avoid bias. Educating the court about matters pertaining to mental health is a critical function of the expert. Forming well-reasoned opinions that are communicated with clear language enhances this task. An expert who is both knowledgeable and well prepared will better serve the court, and is less likely to be intimidated by the adversarial process.

The detection of malingered psychosis

The detection of malingered psychosis is sometimes quite difficult. The decision that an individual is malingering is made by assembling all of the clues from a thorough evaluation of a person's past and current functioning with corroboration from clinical records and other people. Identifying malingered psychosis will prevent unnecessary hospital admissions and is critical in forensic assessments. Indeed, clinicians bear considerable responsibility to assist society in differentiating true psychosis from malingered madness.

Legal issues in treating perpetrators and victims of violence

Psychiatrists are faced increasingly with the difficult responsibility of evaluating perpetrators and victims of violence. The following guidelines will help the clinician avoid legal difficulty: 1. Become knowledgeable about your state statutes regarding civil commitment and duty to third parties. 2. Document thoroughly your risk assessment and the factors you considered in reaching your judgment. 3. Consider obtaining a second opinion in difficult cases. 4. Follow hospital policies regarding seclusion, restraints, and emergency medication of the patient. 5. Adhere to mandatory reporting requirements for victims of abuse.

Child stealing by cesarean section: a psychiatric case report and review of the child stealing literature

A highly unusual case of child stealing by cesarean section resulting in the death of the mother is presented. The judicial proceedings are summarized. The literature on the psychiatric status of perpetrators committing child stealing is presented. Two methods of psychiatrically categorizing these perpetrators are reviewed. The relevance of the literature to this and possible future cases is discussed.

Posttraumatic stress disorder in murderers

Three case histories of men who suffered posttraumatic stress disorders after committing homicides are presented. These men were relatively young and had chaotic childhoods and minimal criminal histories. Each had killed a woman with whom he had a significant but intensely turbulent emotional relationship. The killings all occurred during altered mental states that were unrelated to the use of drugs or alcohol. The clinical significance and some of the medicolegal implications of this phenomenon are discussed.