Prediction of violence: Part contagious disease, part unpredictable individual: Is a public health assessment approach an additional option and at what cost?

On a population level, violence shares many similarities with communicable disease states and other public health issues. Therefore, there has been a push to apply public health interventions to the problem of societal violence and for some to even identify violence as the product of a disease state (e.g., changed brain). This conceptualization could lead to the development of new risk violence assessment tools and approaches predicated more on the public health model rather than existing instruments that have often been based on inpatient mental health populations or incarcerated populations. In this article, we will discuss aspects of legal obligation for risk violence "prediction/stratification", the application of the public health communicable disease model to violence, as well as identify why it may not always translate to the individual with whom a clinician or forensic mental health evaluator interacts.

Forensic issues in medical evaluation: competency and end-of-life issues.

Decision-making capacity is a common reason for psychiatric consultation that is likely to become more common as the population ages. Capacity assessments are frequently compromised by misconceptions, such as the belief that incapacity is permanent or that patients with dementia categorically lack capacity. This chapter will review the conceptual framework of decision-making capacity and discuss its application to medical decision-making. We will review selected developments in capacity assessment and recommend an approach to assessing decision-making capacity. We will discuss the unique challenges posed by end-of-life care, including determining capacity, identifying surrogate decision-makers, and working with surrogate decision-makers. We will discuss clinical and legal approaches to incapacity, including advance directives, surrogate decision-makers, and guardians. We will discuss the legal standards based on which surrogates make medical decisions and outline options for resolving disagreements between clinical staff and surrogate decision-makers. We will offer recommendations for approaching decision-making capacity assessments.

Psychopathology in a Galaxy Far, Far Away: the Use of Star Wars' Dark Side in Teaching.

Star Wars is well known, timeless, universal, and incorporated into shared culture. Trainees have grown up with the movies, and based on their enduring popularity, attending psychiatrists are likely to have seen them too. This article highlights psychopathology from the Dark Side of Star Wars films which can be used in teaching. These include as follows: borderline and narcissistic personality traits, psychopathy, PTSD, partner violence risk, developmental stages, and of course Oedipal conflicts.

Teaching Psychopathology in a Galaxy Far, Far Away: The Light Side of the Force.

Star Wars films are among the top box office hits of all time. The films have been popular internationally for almost 40 years. As such, both trainees and attending psychiatrists are likely to be aware of them. This article highlights a vast array of psychopathology in Star Wars films which can be useful in teaching, even when the characters are considered the "good guys". Included are as follows: histrionic, obsessive-compulsive, and dependent personality traits, perinatal psychiatric disorders, prodromal schizophrenia, pseudo-dementia, frontal lobe lesions, pathological gambling, and even malingering. As such, Star Wars has tremendous potential to teach psychiatric trainees about mental health issues.

Prevalence and Assessment of Malingering in Homicide Defendants Using the Mini-Mental State Examination and the Rey 15-Item Memory Test.

This study surveyed malingering prevalence in pretrial homicide defendants and assessed the usefulness of the Mini-Mental State Examination (MMSE) and the Rey 15-Item Memory Test (FIT) in detecting malingering among them. Malingering prevalence was 17%. MMSE and FIT scores were positively correlated. The MMSE and FIT had modest positive predictive value (67% and 43%), but reasonably good negative predictive value (93% and 89%), for malingering. Overall, the MMSE outperformed the FIT, with no advantage to combined use of the MMSE and FIT over the MMSE. The widely used MMSE, traditionally a bedside test of cognition, may have a role in malingering assessment.

The Therapeutic Impact of Plant-Based and Nutritional Supplements on Anxiety, Depressive Symptoms and Sleep Quality among Adults and Elderly: A Systematic Review of the Literature.

BACKGROUND: The emerging research in the literature continues to forecast a drastic and alarming increase in negative mental health and sleep health outcomes among populations, especially after the COVID-19 pandemic, which significantly influenced people's way of life. With mental health pharmaceutical interventions continuing to be stigmatized and inaccessible among populations, natural supplements provide an opportunity for intervention. OBJECTIVE: This study sought to conduct a systematic review of the literature on the most recent comprehensive evidence for which nutritional supplements have the greatest therapeutic impact on symptoms of anxiety, depression, and insomnia. METHODS: A systematic search of the literature, utilizing several databases, including PubMed and Web of Science, was conducted on 29 April 2022. We used developed keywords and MeSH terms for the search. The study eligibility criteria included (1) a randomized control trial; (2) investigating a plant-based therapeutic or natural supplement as the intervention; (3) measuring at least one health outcome of the following: anxiety symptoms, depressive symptoms, or sleep health outcomes; (4) utilizing validated measurement tools to measure the outcome of interest; (5) written in the English language; (6) peer reviewed; and (7) focused on adults and elderly populations. MAIN RESULTS: Following the PRISMA guidelines, 76 studies were included in this review. We used the revised Risk of Bias tool (RoB2) to assess the quality of all included randomized control trials. A qualitative data synthesis was conducted. Overall, we found several valuable insights from the evidence in the literature, including evidence that demonstrates the benefits of probiotics and vitamin B complexes on anxiety symptoms, depressive symptoms, and sleep quality. Implication of Key Findings: This review provides the most updated findings in the literature on the topic, including an abundance of research that was published in the past 5 years. Given the expected rise in negative mental and sleep health outcomes following the pandemic, the supplements and therapeutics identified in this study should be the target of intervention measures to increase their accessibility and affordability and allow them to be incorporated into clinical guidelines of treatment. PROSPERO registration number: CRD42022361130.

Florida Law Enforcement Policies for and Experience With Tarasoff-Like Reporting.

Mandatory duty to warn law enforcement for mental health professionals in Florida took effect on July 1, 2019, as part of the recommendations from the Marjory Stoneman Douglas School (Parkland) Shooting Commission's report. Prior to this, Florida had been a permissive Tarasoff state. Although this change was intended to promote public safety, there is scant literature on the interactions between mental health providers and law enforcement related to Tarasoff situations. The objective of this study is to determine the degree to which Florida law enforcement agencies have knowledge, experience, and policies dealing with a serious threat made by a patient. An invitation to participate in a survey was distributed to police departments, sheriffs' offices, and 911 stations using email and traditional paper mail. The response rate was 11 percent (47 of 416) to an emailed questionnaire and 22 percent (82 of 369) to a paper-based follow-up survey. The surveys were completed by 31 percent (129 of 416) of potential respondents. Between 80 and 90 percent of all agencies have policies and procedures on what to do if a warning call from a mental health provider is received, which, for the majority of respondents, was the same policy as if notified about a suicidal individual.

D178N, 129Val and N171S, 129Val genotype in a family with Creutzfeldt-Jakob disease.

BACKGROUND: Fatal familial insomnia (FFI) and genetic Creutzfeldt-Jakob disease (CJD(D178N,)(129V)) are two phenotypes that share a common point mutation at codon 178 of the prion protein gene (PRNP), but differ in their polymorphism at codon 129 of the mutant allele. A mutation at codon 171 of the PRNP gene has been described in a family with a strong psychiatric history without prion disease. METHODS: Clinical and genetic information of a family with CJD was obtained from medical records and family informants. RESULTS: We identified an African-American family with molecular and genetically confirmed CJD(D178N,)(129V) that also carried the N171S, 129V polymorphism and had a strong psychiatric clinical presentation. CONCLUSION: This is a complex family that carries the D178N, 129V and N171S, 129V genotype. This report is the first description of both genotypes occurring within a family with genetic human prion disease.

Prescribing for Women in Corrections.

Prescribing for women in jails and prisons requires special consideration and should be informed by extant evidence. Incarcerated women have higher rates of mental illness than both females in the community and incarcerated men. Medication administration concerns that may disproportionately affect female prisoners include drug-drug interactions with contraceptives, intermittent dosing schedules, and concerns about metabolic side effects. Further, pregnancy, lactation, and menopause may all affect medication choices. Incarcerated women frequently have comorbid mental illness, substance use disorders, and personality disorders. Finally, specific disorders, such as posttraumatic stress disorder, are more common in this population and merit special consideration for recognition and treatment.

Professional Boundaries in Corrections.

Boundary violations occurring in corrections settings require special attention. There is a unique relationship between officers and inmates, governed by policies and procedures as well as ethics in general (e.g., the lack of ability for a person in a controlled environment to consent to a relationship due to power imbalance). Recent high-profile cases between corrections officers and inmates demonstrate the complexities inherent in these relationships. We examine several recent cases and offer analysis of the factors leading to these dangerous encounters. We discuss how a special relationship develops between a corrections employee and an inmate and how that can lead to blackmail, the introduction of contraband to the prison, or other illegal activity. It is easy to state that one should not engage in sexual encounters, but it is harder to discuss and identify feelings that develop in correctional settings, such as transference and counter-transference feelings in a therapeutic relationship. Lessons of professionalism from the doctor-patient relationship parallel the relationships between officers and inmates.

The 1995 Kikwit Ebola outbreak: lessons hospitals and physicians can apply to future viral epidemics.

OBJECTIVE: This article looks at lessons learned from the 1995 Kikwit Ebola outbreak and suggests how modern hospitals should apply these lessons to the next lethal viral epidemic that occurs. METHOD: The 1995 Kikwit Ebola outbreak in the Democratic Republic of the Congo (formally Zaire) is one of the most well studied epidemics to have occurred to date. Many of the lessons learned from identifying, containing and treating that epidemic are applicable to future viral outbreaks, natural disasters and bioterrorist attacks. This is due to Ebola's highly contagious nature and high mortality rate. RESULTS: When an outbreak occurs, it often produces fear in the community and causes the basic practice of medicine to be altered. Changes seen at Kikwit included limited physical examinations, hesitance to give intravenous medications and closure of supporting hospital facilities. The Kikwit Ebola outbreak also provided beneficial psychological insight into how patients, staff and the general community respond to a biological crisis and how this will affect physicians working in an epidemic. CONCLUSIONS: General lessons from the outbreak include the importance of having simple, well-defined triage procedures; staff who are flexible and able to adapt to situations with unknowns; and the need to protect staff physically and emotionally to ensure a sustained effort to provide care.

Involuntary Treatment of Psychosis in Pregnancy.

When a patient with acute psychosis refuses antipsychotic medication despite a clear need for treatment, involuntary medication is often considered. When the patient is both pregnant and acutely unwell, an additional layer of analysis enters the picture. This analysis then also includes the health of the mother and fetus, rights of the mother and fetus, and whose rights take precedence when choosing treatment options in event of a conflict. Antipsychotic agents are frequently the medications prescribed as involuntary treatment. Typical and atypical antipsychotic agents are often used in both emergent and nonemergent situations during pregnancy. Despite a lack of randomized, double-blind, controlled, prospective studies in pregnancy, available data regarding the safety of antipsychotic agents in pregnancy are relatively reassuring. At the same time, the risks of untreated psychosis, for both the mother and the fetus, are not negligible. Such cases merit ethics-related and legal analyses. Forensic psychiatrists involved in such cases need to consider the patient's capacity to make medical decisions and be able to discuss the potential risks, benefits, and alternatives with patients and in court, as part of initiation of involuntary treatment.

A profile of pedophilia: definition, characteristics of offenders, recidivism, treatment outcomes, and forensic issues.

Pedophilia has become a topic of increased interest, awareness, and concern for both the medical community and the public at large. Increased media exposure, new sexual offender disclosure laws, Web sites that list the names and addresses of convicted sexual offenders, politicians taking a 'get tough' stance on sexual offenders, and increased investigations of sexual acts with children have increased public awareness about pedophilia. Because of this increased awareness, it is important for physicians to understand pedophilia, its rate of occurrence, and the characteristics of pedophiles and sexually abused children. In this article, we address research that defines the various types and categories of pedophilia, review available federal data on child molestation and pornography, and briefly discuss the theories on what makes an individual develop a sexual orientation toward children. This article also examines how researchers determine if someone is a pedophile, potential treatments for pedophiles and sexually abused children, the risk of additional sexual offenses, the effect of mandatory reporting laws on both physicians and pedophiles, and limitations of the current pedophilic literature.

Detection of malingered PTSD: an overview of clinical, psychometric, and physiological assessment: where do we stand?

Posttraumatic stress disorder (PTSD) is a condition that can be easily malingered for secondary gain. For this reason, it is important for physicians to understand the phenomenology of true PTSD and indicators that suggest an individual is malingering. This paper reviews the prevalence of PTSD for both the general population and for specific events, such as rape and terrorism, to familiarize evaluators with the frequency of its occurrence. The diagnostic criteria for PTSD, as well as potential ambiguities in the criteria, such as what constitutes an exposure to a traumatic event, are reviewed. Identified risk factors are reviewed as a potential way to help differentiate true cases of PTSD from malingered cases. The question of symptom overreporting as a feature of the disease versus a sign of malingering is discussed. We then examine how the clinician can use the clinical interview (e.g., SIRS, CAPS), psychometric testing, and the patient's physiological responses to detect malingering. Particular attention is paid to research on the MMPI and the subscales of infrequency (F), infrequency-psychopathology (Fp), and infrequency-posttraumatic stress disorder (Fptsd). Research and questions regarding the accuracy of self-report questionnaires, specifically the Mississippi Scale (MSS) and the Personality Assessment Inventory (PAI), are examined. Validity, usability, and cutoff values for other psychometric tests, checklists, and physiological tests are discussed. The review includes a case, which shows how an individual used symptom checklist information to malinger PTSD and the inconsistencies in his story that the evaluator detected. We conclude with a discussion regarding future diagnostic criteria and suggestions for research, including a systematic multifaceted approach to identify malingering.

Commentary: delving further into liability for psychotherapy supervision.

In their article, "Liability and Risk Management in Outpatient Psychotherapy Supervision," Recupero and Rainey discuss some of the difficult matters related to outpatient psychotherapy supervision. We offer this commentary to make observations about their article and to further the discussion of liability and risk management. We believe there is a need to include this type of information in the orientation of supervisors and supervises and to make discussions of liability and risk management a part of outpatient psychotherapy supervision.

Malingering of PTSD: forensic and diagnostic considerations, characteristics of malingerers and clinical presentations.

OBJECTIVE: This paper aims to study the detection of individuals malingering posttraumatic stress disorder (PTSD) in criminal and civil situations. METHOD: A brief history of PTSD and its rise to prominence in legal circles are discussed. The characteristics of individuals who malinger and particularly those who fake PTSD are discussed. Diagnostic dilemmas inherent to the condition, such as the definition of a traumatic exposure, what constitutes a PTSD flashback and the potential for normal symptom exaggeration, are explored. RESULTS: The typical presentation of malingered symptoms is presented to help clinicians detect commonly seen malingering patterns. Suggestions for interview techniques, Minnesota Multiphasic Personality Inventory test values and sources of collateral information to help detect malingering are reviewed. CONCLUSION: The paper concludes with a review of the typical presentations of malingered PTSD symptoms and a reminder that physicians need to distinguish legitimate symptoms from faked or embellished presentations.

Medical and psychiatric casualties caused by conventional and radiological (dirty) bombs.

Bombing is the preferred method of terrorist attack. Unfortunately, the frequency and prevalence of this form of terrorism/criminal act/means of extortion are increasing in the United States. These attacks result in specific physical and psychiatric trauma, and produce both acute and long-term psychiatric sequelae. It will become increasingly important for trauma surgeons, emergency physicians and psychiatrists to be familiar with the special needs and treatment of these patients. This paper reviews the physical and psychiatric consequences of high explosive and radiological (dirty) bombs, and makes recommendations for the psychiatric management of bombing victims.