Mental defenses and posttraumatic stress disorder: assessment of criminal intent.

Since its formal introduction into psychiatric nomenclature more than a decade ago, the diagnosis of posttraumatic stress disorder (PTSD) has become firmly entrenched in the legal landscape. In part, this is because PTSD seems easy to understand. It is one of only a few mental disorders for which the psychiatric Diagnostic and Statistical Manual (DSM) describes a known cause. Since the diagnosis is usually based on patients' self-report, however, it creates the possibility of distortion aimed at avoidance of criminal punishment, and, as a result, has achieved mixed success as a criminal defense. When providing expert testimony, mental health witnesses must take care to distinguish between mere PTSD and a causal connection between PTSD and the criminal act in question. PTSD has not only been used to abrogate or diminish responsibility, but also to arrange pre-trial plea bargaining agreements or play a role in sentencing determinations. The author explores various uses and potential abuses of PTSD in criminal jurisprudence and offers suggestions regarding retrospective PTSD assessment.

Post-traumatic stress disorder. Does it exist?

Facing the inevitable, psychiatry formally acquired PTSD as a diagnostic entity in 1980. It then discovered that PTSD had a bevy of nasty laylegal relatives (e.g., disability and personal injury claims). In response, psychiatrists have been continuously trying to refine PTSD criteria. There have even been cogent arguments that psychiatrists should take their own forensic medicine and formally address legally relevant behavior in the DSM. In the meantime, prosecutors, defense attorneys, and adjudicators sometimes stretch and pull the DSM-III-R PTSD diagnosis beyond justifiable limits to try to fit square pegs of psychiatric testimony into round holes of legal rules. Ultimately, however, lawyers cannot be blamed for misusing the PTSD diagnosis because only clinicians can make it. Causal diagnosticians may fail to apply the requisite symptomatic criteria or do so only superficially. In their haste to eliminate bogus stress claims, clinicians should not throw out the baby (authentic PTSD) with the bathwater (idiosyncratic "stress" disorders and careless PTSD diagnoses).

Medical ethics, cultural values, and physician participation in lethal injection.

Capital punishment by lethal injection has been discussed in the literature, but there has been no consideration of the sociocultural foundations of the ethical issues related to medical aspects of capital punishment. Lethal injection represents the inappropriate medicalization of a complex social issue whereby medical skills and procedures are used in ways that contradict established medical practice. Although physicians are socialized to their healing role during medical education and training, their behavior is influenced by social and cultural values that both precede and coexist with their professional life. Because of this dynamic interplay between professional and sociocultural values, physicians can neither exempt themselves from societal debate by merely invoking professional ethics, nor can they define their professional role exclusively in terms of societal values that potentially diminish personal and collective professional responsibility. It is essential that physicians have a broad historical perspective on the development of the profession's standards and values in order to deal effectively with present and future complex ethical issues.

Veterans' psychiatric benefits: enter courts and attorneys.

In 1988, the Veterans Judicial Review Act (VJRA) was signed into law, ending more than a century of Congressional measures that kept veterans' benefits claims completely out of the appellate court system. Before this new law, any decision made by the Department of Veterans' Affairs (VA) about a veteran's claim was final, and there was no recourse for independent judgment of an appeal. The legislation modified the existing Board of Veterans Appeals (BVA) to enhance its independence from the Veterans' Administration and established a new Court of Veterans Appeals (CVA) with jurisdiction to review BVA decisions. Veterans' benefits proceedings have not only been insulated from the courts, they also have been undesirable to private attorneys, because since 1864 Congress has prohibited attorneys from charging more than $10 to advocate a VA disability claim. The new law allows attorneys to represent veterans before the CVA and receive appropriate remuneration. In 1991, the number of veterans was estimated at 26,897,000, and VA disability compensation programs spent $9.6 billion. Currently, there are about 2,179,000 veterans receiving service-connected monetary compensation; approximately 13.5 percent (293,200) have a primary psychiatric disability. The CVA is a specialized Article I court that has seven justices and sits in Washington, D.C. In its formative years, the Court has reached decisions that have had an impact on the veterans' psychiatric benefits examination process. Now more than ever, non-VA psychiatrists may be asked to offer probative opinions in veterans' benefits proceedings. The authors review VA psychiatric disability procedures and, using case examples, discuss both precedent decisions involving VA psychiatric claimants and the evolving standards of judicial review.

The effect of house officer rotation on inpatient satisfaction and ward atmosphere: preliminary findings.

Continual rotation of house officers builds discontinuity into the physician-patient relationship in teaching hospitals. This has led to speculation about the problem of residents and interns leaving their patients in the midst of hospital treatment. This article uses prospective data to assess the effect of house officer turnover on levels of patient satisfaction with hospital care and on patient perception of the hospital environment. Two inpatient cohorts defined by whether or not they had undergone a house officer change were matched by age and diagnostic category. Although survey instruments were significantly correlated, there was no significant difference between the two inpatient cohorts overall or on any of the survey subscales. The survey showed good satisfaction with the hospital, doctors, and nurses in both test groups. The authors draw a preliminary conclusion that patient satisfaction with medical care and with the hospital atmosphere remains constant, independent of termination of the doctor-patient relationship. Results from other reports linking patient satisfaction with continuity of care have been mixed. In discussing the limitations of their study, the authors point out that their findings are based on single-site data.

Missed psychiatric appointments: who returns and who stays away.

OBJECTIVE: This study investigated reasons for missed psychiatric appointments, rescheduling of appointments, adverse outcomes, and the association of specific diagnoses and treatments with missed appointments. METHOD: A prospective survey covering all individual outpatient visits to seven mental health clinic psychiatrists was conducted during a 3-month period in 1991. Of the 1,620 scheduled visits, 142 (8.8%) were missed, representing 130 separate patients. For each missed appointment, the psychiatrist involved completed a questionnaire on the type of visit, the patient's DSM-III-R diagnosis, the reason for missing the appointment, the date of patient recontact, and adverse outcome, if any. RESULTS: Of the 142 missed appointments, 71.1% were rescheduled spontaneously by the patients; of these, most (73.3%) were rescheduled within 2 weeks. The remaining missed appointments represented various outcomes, including dropping out of treatment. The most common stated reason for missing an appointment was patient error, such as forgetting, oversleeping, or getting the date wrong. Patients with PTSD and/or substance abuse were significantly more likely than others to miss appointments, and those with major depression were somewhat less likely to do so. CONCLUSIONS: Most patients quickly reschedule missed appointments, and those in more intensive treatments miss fewer appointments. Missed appointments for initial evaluation are not rescheduled most often. Patients in ongoing treatment who do not return may have histories of noncompliance with treatment. The high rate of rescheduling suggests that follow-up of patients who miss appointments should be a clinical decision rather than a routine policy.

Group therapy with WWII ex-POW's: long-term posttraumatic adjustment in a geriatric population.

In this assessment of group therapy with WWII ex-POWs, the small cohort limits generalizations; however, we offer a longitudinal perspective on group process. Posttraumatic suppression and denial of emotions appears to be adaptive for time-limited periods but is not a long-term solution. More lasting changes in self-esteem and social interaction may be partially achieved through a supportive group environment that fosters cognitive synthesis and reorganization.

Disruptive medical patients. Forensically informed decision making.

Patients who disrupt medical care create problems for physicians. The risks are not entirely clinical. Although these patients may compromise sound clinical judgment, some are also litigious and express their dissatisfaction in legal or other forums. It then becomes necessary for treating physicians to be aware of the legal and ethical boundaries of their patient care responsibilities. Some disruptive patients are treated by setting limits, which is usually affirmed by health care agreements. A hospital review board may advise clinicians on these agreements and on the management of disruptive patients. If termination of the physician-patient relationship is considered, physicians must follow proper protocol. We examine these forensic considerations and place them in the context of malpractice. Communication, consultation, and documentation are the key elements in reducing liability.

Recruitment of academic psychiatrists : applicants' decision factors.

To explore factors influencing academic job seekers, the author surveyed 49 applicants for six regular faculty positions at a university and Veterans Affairs (VA) medical center in Oregon. Candidates used active inquiry (40.0%) and advertisements (35.6%) as their pri-mary search methods, applied for an average of 6.75 jobs, expected the search to take 73 months, and confined their search to specific geographical areas (75.5%). In rank order, location, academic position, teaching opportunities, and research opportunities were the most appealing factors; VA hospital setting, fringe benefits, and administrative opportu-nities had the least appeal. Most applicants were moderately satisfied with current jobs and even more satisfied with psychiatry as a career. Related studies are discussed. Three of the six positions were not filled; the author discusses barriers to successfully recruiting academic psychiatrists.

The organization and regulation of voluntary faculty.

A large number of psychiatrists have been, or are currently, unpaid, voluntary, or "clinical" faculty. In 1987-1988, in 127 medical schools, there were approximately 122,000 clinical faculty members, outnumbering regular faculty by approximately two to one. Yet, in contrast to primary faculty, administrative policies (e.g., appointment, reappointment, promotion) regarding clinical faculty are often ill-defined or absent entirely. We discovered in a survey of 8 departments of psychiatry that most departments do not have separate administrative guidelines or policies for these faculty. This article addresses specific mechanisms for determining clinical faculty membership and duties and suggests policies for appointment, reappointment, and promotion. The authors focus on administrative management strategies, such as the creation of a departmental Clinical Faculty Committee and the consideration of quality assurance issues.

Sam Shepard and the dysfunctional American family: therapeutic perspectives.

In depicting dysfunctional families Sam Shepard brought a greater intensity level to family portrayals than had previously been seen in modern American theater. In part, his plays appear to reflect the tumultuous tone of the late 1960s and early 1970s when American society was in flux and when the national uncertainty reached down to the basic unit of society, the family. Yet, despite addressing recently emerging social issues, Shepard's plays also depict universal family conflicts. There have been and always will be compelling forces that threaten domestic cohesiveness. While Shepard's families reflect extremely high levels of disorganization, they also demonstrate scenarios recognizable to all family therapists. They reassert the family's power and its influence on individual development. They also indirectly ask us to reflect on our current clinical practice and research. Family therapists need to continue to pay attention the content issues of family organization as well as therapeutic techniques. Shepard's plays remind therapists to look beyond internal dynamics in order to consider connections and affiliations that integrate families with outside communities. He underscores the importance of knowing the meaning and context of traditional rites of passage within families. Family therapists or other care providers may unwittingly undermine the significance of these family rituals by prescription of "expert" advice.

Posttraumatic stress disorder in tort actions: forensic minefield.

The authors discuss posttraumatic stress disorder (PTSD) as a basis for personal injury litigation. Three case examples raise issues related to: (1) the controversy surrounding expansion of tort liability, (2) the courtroom use of psychiatric nomenclature as represented in the DSM (e.g., PTSD), and (3) ethical concerns regarding psychiatric expert witnesses. Psychiatrists became easy targets when problems related to personal injury "stress" cases developed. A careful analysis, however, demonstrates that the issues are complex and multifaceted. For example, tort liability expansion was primarily instituted to compel a greater provision of liability insurance, not to reward stress claims. The increasing use of psychiatry's DSM in the courtroom has occurred despite explicit precautions against forensic application. Finally, the need for psychiatric expert witnesses has increased because courts have gradually usurped some psychiatric clinical prerogatives and because there has been a trend toward greater consideration of emotional pain and suffering. Although psychiatric expert witnesses have not been beyond reproach, critics have attempted to impeach the entire psychiatric profession for the questionable actions of the minority. The authors provide a detailed analysis of current problems, offer suggestions for improvement, and provide an educational counterpoint to the "hysterical invective" that often greets psychiatric testimony.

Hospital violence reduction among high-risk patients.

We describe the success of one general hospital in reducing violent behavior among a group of repetitively disruptive patients. Following a pilot phase during which violent incidents at the medical center were characterized by location, type, and person responsible, a group of patients at high risk for repeated violence was identified (N = 48). Data were gathered for 1 year before and after the institution of a program designed to reduce violence, primarily in ambulatory care areas, among this group. Outcome assessment included comparison of the number of violent incidents and the number of visits to the medical center during the 12 months before and after the program was started. The number of incidents declined by 91.6%, and visits to the medical center for any reason decreased by 42.2%. The ratio of violent incidents to visits after the program was begun was less than one sixth the rate before the program. Components of the program are described, including staff resistance and management strategies.

Managing violent patient incidents: the role of a behavioral emergency committee.

The Portland (Oregon) Veterans Administration Medical Center acknowledged the problem of dealing with aggressive and disruptive patients by establishing a behavioral emergency committee (BEC). The BEC first introduced a system for tracking disruptive patient incidents and then initiated an electronic flagging system for violence-prone patients that alerts medical center clinical and security personnel when a potentially dangerous patient is present. The committee also coordinates violence control training for medical center personnel. Since the BEC was formed, disruptive behavior among this high-risk patient group has been significantly reduced.

The doctor-patient relationship during medical internship: the evolution of dissatisfaction.

We prospectively examined perceptions of the doctor-patient relationship among interns in two different internal medicine training programs five times during the internship year. All 59 interns in the University of California, Irvine-Long Beach and the Oregon Health Sciences University Medical Programs participated in the study during the 1982-83 internship year. We serially administered a questionnaire that contained four major items: (1) a choice of one of six empirically developed role paradigms of the doctor-patient relationship; (2) a checklist of positive and negative aspects of internship; (3) a measure of level of satisfaction with the decision to become a physician; and (4) a rating list of mood descriptors. The six role paradigms portrayed a variety of positive and negative aspects of the doctor-patient relationship. At the beginning of the year, the interns were quite positive about the doctor-patient relationship and preferentially endorsed collegial models. As the year progressed, they endorsed significantly fewer positive and more negative models (P less than 0.001). Most respondents endorsed two models, one positive: "expert resource (doctor)--active cooperative participant (patient)" and one negative: "clerk, paperwork processor (doctor)--subscriber, seeker of eligibility (patient)." By the end of the year approximately half of the interns endorsed a positive and half a negative model. Interns selecting a negative model of the doctor-patient relationship identified more negative and fewer positive aspects of internship than those selecting a positive model. Specifically, they significantly more often (P less than 0.001) identified too much paper work and coping with difficult patients as negative aspects of internship.(ABSTRACT TRUNCATED AT 250 WORDS)

Military combat, posttraumatic stress disorder, and criminal behavior in Vietnam veterans.

Although data are inconclusive, popular perception has linked military combat, posttraumatic stress disorder (PTSD), and criminal behavior. This paper discusses the multifactorial elements of this association that include both conscious and unconscious parameters of psychologic functioning. Testimony on combat-related PTSD has been presented in the courtroom to support veterans' claims of not guilty by reason of insanity (NGRI) and diminished capacity and for consideration during judicial sentencing. Because there is a known connection between the degree of combat involvement and PTSD, verification through collateral sources of the veteran's report of combat experiences is an important component of forensic assessment. The DSM-III-defined diagnosis of PTSD and the presence of a dissociative state have particular relevance in NGRI determinations. In other aspects of the judicial process demonstration of the absolute presence or absence of PTSD is often irrelevant and should be replaced by efforts to establish plausible links between provable combat experiences and the circumstances of the crime.

Posttraumatic stress disorder as an insanity defense: medicolegal quicksand.

A growing awareness of posttraumatic stress disorder has led to recent use of the disorder as a legal defense against criminal responsibility for both violent and nonviolent crimes. Diagnosis of posttraumatic stress disorder is difficult because the symptoms are mostly subjective, often nonspecific, usually well publicized, and, therefore, relatively easy to imitate. Accurate psychiatric testimony in such cases requires diligent searching for collateral sources of information. The authors argue that the insanity defense is appropriate only in the rare instance that a dissociative episode related to posttraumatic stress disorder directly leads to criminal activity.

The medical management of the paranoid patient.

Patients who are medically ill and distrustful of their care-providers are unfortunately a fact of life for most physicians. Medical management of such patients can be a frustrating experience because their suspiciousness is usually heightened by the stress of medical illness. Most often the patient's mistrust covers profound feelings of personal inadequacy and is a defense against feared passivity. Understanding of basic paranoid thought processes combined with knowledge of practical management techniques will lead to increased confidence and effectiveness when interacting with these difficult patients.

Diagnosis of posttraumatic stress disorder in Viet Nam veterans: preliminary findings.

Sixty-six Viet Nam veterans were evaluated for posttraumatic stress disorder. Several of the DSM-III criteria for the disorder, but no other clinical features, distinguished patients diagnosed as having the disorder from others. The findings tend to validate the DSM-III construct for this disorder.