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.

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.

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.

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.

Clinical assessment of psychotic and mood disorder symptoms for risk of future violence.

This article reviews important components to consider when evaluating the relationship of psychotic and mood disorder symptoms to violence. Particular attention is given to assessing persecutory delusions and command auditory hallucinations. Clinical implications of research findings to evaluating violence risk in psychiatric patients are reviewed.

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.

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.

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.

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.

Fathers who kill their children: an analysis of the literature.

Roughly half of filicidal acts are committed by fathers, though the majority of the literature focuses on maternal filicide. This paper reviews the existing literature on paternal filicide with the goal of identifying characteristics common among these fathers. Fathers who killed their children were, on average, in their mid thirties. The mean age of their victims was five. They may have multiple victims. Sons and daughters were killed in equal numbers. Reasons included death related to abuse, mental illness (including psychosis and depression), and revenge against a spouse. The method often involved wounding violence. Suicide following the act occurred frequently. After being tried for their crimes, filicidal fathers were more frequently incarcerated than hospitalized. Given the range of those capable of this act, mental health professionals must be alert to the possibility of filicide in a variety of fathers. Considering this risk, clinicians should inquire about thoughts of harming children, partners, and themselves.

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.

Psychiatrists' knowledge about maternal filicidal thoughts.

OBJECTIVE: Child murder by mentally ill mothers is an important public health and psychiatric concern. However, the authors' clinical and forensic experience has been that psychiatrists often do not inquire about maternal thoughts of harming their children. This study sought to elucidate the perceptions of psychiatrists and psychiatric residents regarding the frequency of such thoughts, and to clarify whether they inquire specifically about maternal filicidal thoughts. Psychiatrists were expected to underestimate the prevalence maternal thoughts of harming their children. It was hypothesized that psychiatrists often do not ask their patients about these thoughts. METHODS: This study surveyed psychiatrists and psychiatric residents at 2 academic institutions. Respondents were asked whether they routinely query women about motherhood, to estimate the frequency of thoughts of child harm, and whether they inquire about filicidal thoughts in psychotic or suicidal mothers. RESULTS: Two hundred twenty surveys (67%) were returned. Most psychiatrists underestimated the frequency of depressed mothers who experienced thoughts of harming their young children. Almost one half indicated that they do not ask specifically about filicidal ideation but rather ask about general homicidal thoughts only. CONCLUSIONS: Psychiatrists should have further education about the prevalence of filicidal thoughts and more frequently inquire about them.

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.

Child murder by mothers: patterns and prevention.

The tragedy of maternal filicide, or child murder by mothers, has occurred throughout history and throughout the world. This review of the research literature sought to identify common predictors in the general population as well as in correctional and psychiatric samples. Further research is needed to improve identification of children and mothers at risk. Infanticide laws are discussed. Suggestions for prevention are made based on the current literature and the authors' experiences.

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".