Clinical factors associated with C-reactive protein in chronic spinal cord injury.

STUDY DESIGN: Cross-sectional study. OBJECTIVES: Determine clinical factors associated with plasma C-reactive protein (CRP) in persons with chronic spinal cord injury (SCI). SETTING: Veterans Affairs Medical Center in Boston, MA, USA. METHODS: Participants provided a blood sample, completed a respiratory health questionnaire and underwent dual X-ray absorptiometry (DXA) to assess total and regional body fat. Linear regression models were used to assess cross-sectional associations with plasma CRP. RESULTS: In multivariable models, factors associated with a higher CRP included a greater BMI, urinary catheter use, a respiratory illness in the past week and non-white race. Mean CRP also increased with decreasing mobility (motorized wheelchair >hand-propelled wheelchair >walk with an assistive device >walk independently). Results were similar when adjusting for percentage android, gynoid, trunk or total fat mass in place of BMI. Level and completeness of SCI was not associated with CRP in multivariable models. CONCLUSIONS: Clinical characteristics common in chronic SCI are associated with plasma CRP. These factors are more important than the level and completeness of SCI and some are potentially modifiable.

Paranoids in the legal system. The litigious paranoid and the paranoid criminal.

Paranoid symptomatology involving suspicions, a sense of being wronged and persecuted, along with an implacable will to retaliate against one's enemies, often translates into litigious struggles. Paranoids resort to the judicial arena to act out their own internal psychopathologic needs. Examples are offered of the many ways litigious paranoids may present within the legal system, as well as how interventions by the psychiatrist may be useful. Criminal behavior by paranoids, under the sway of full-blown delusions of various types, is discussed and analyzed. Historical cases are described (Hadfield, M'Naghten), and more contemporary cases are discussed according to diagnostic subtypes. The central importance of paranoid delusions in insanity defense cases and the exculpatory effect of various delusional subtypes are examined.

Dr Rogers' 'insanity detector' and the admissibility of novel scientific evidence.

The R-CRAS (Rogers' Criminal Responsibility Assessment Scales) purports to be a systematic and empirically based approach to evaluations of criminal responsibility. This 'insanity detector' has been heralded as a reliable instrument in the resolution of the psycholegal controversies surrounding the plea of insanity. It is contended that, regardless of its possible scientific merit, most courts will find that the R-CRAS fails to satisfy the Frye test for admissibility of novel scientific evidence (that is, general acceptance by the relevant scientific community). Moreover, it is argued that the R-CRAS's potential for prejudice outweighs its probative value, in that it might unfairly bolster the testimony of the expert witness who relies upon it and might overwhelm the jury because of its 'aura of special reliability and trustworthiness'. Until such time as the R-CRAS does gain widespread acceptance and is shown to be sufficiently reliable to outweigh any potential prejudice (if ever), the author is of the opinion that forensic psychiatrists and psychologists may have to continue to conduct evaluations of criminal responsibility 'the old-fashioned way'. 'Truth does less good in the world than its appearances do harm' --La Rochefoucauld.

The Tarasoff raid: a new extension of the duty to protect.

The authors discuss the general outlines of the Tarasoff duty of psychotherapists to protect potential victims of their violent patients. They describe the flexible range of clinical responses that therapists have utilized, as well as their professional concerns about preserving patient confidentiality (or at least strictly circumscribing the scope of disclosure when confidentiality must be breached). A recent case is reported that illustrates a striking new extension of Tarasoff, involving a police search and seizure of a psychotherapist's confidential treatment records and tapes, in response to a third-party complaint that the records contained evidence of his patients' violent acts and propensities. The implications of this case are that the therapist's discretion in the assessment of his duty to protect, the selection of a proper course of action, and the implementation of specific responses may be taken out of his hands, for all intents and purposes, and expropriated by law and order officials. Moreover, regardless of whatever clinical approach he adopts and whether or not he issues a warning, his attempts to preserve patient confidentiality are bound to prove unsuccessful in any future legal proceedings. Patient communications are likely to lose their confidential status on the grounds that they caused or triggered the Tarasoff warning (or that they should have triggered it). If the patient directed serious threats against the therapist himself, the court may find that, as a consequence, a "genuine therapeutic relationship" ceased to exist and thereafter all patient disclosures were no longer confidential on that basis.(ABSTRACT TRUNCATED AT 250 WORDS)

The Mickey Finn defense: involuntary intoxication and insanity.

The legal context of voluntary and involuntary intoxication is delineated. The author reports a case of involuntary intoxication involving scopolamine toxic psychosis or delirium, in which he testified as a psychiatric expert witness. The specific psychological and physiological symptomatology produced by scopolamine intoxication is outlined. The forensic psychiatrist should be alert to the involuntary intoxication defense in these cases and should familiarize himself with the specific toxicity of scopolamine, in view of the significant increase in the number of incidents in which it is utilized as "knockout" drops in certain jurisdictions.

Medical malpractice in the absence of a doctor-patient relationship: the potential liability of psychiatric examiners in New York State.

In New York, psychiatrists (and all physicians) have a duty, in every circumstance with respect to such functions as they are required to undertake, to conduct themselves and all their examinations in a thorough and proper manner. Especially in a forensic setting, psychiatrists must bear in mind that they have a legal duty to perform a competent examination before they render an opinion. It is well established that malpractice liability does not require the preexistence of a doctor-patient relationship based on an undertaking for the purpose of treatment. The author discusses a long line of cases in New York State which holds that psychiatric examiners are potentially liable in malpractice for any breach of duty with respect to those functions that are undertaken. Failure to conduct a proper, careful, and competent examination may result in liability in a variety of areas: competency examinations, commitment proceedings, workers' compensation claims, and so on. Limitations on such malpractice liability are discussed. Unlike some jurisdictions, New York does not accord judicial immunity to psychiatric examiners.

When doctors divulge: is there a "threat from within" to psychiatric confidentiality?

Psychiatrists, as a profession, have always asserted the central importance of confidentiality. The American Psychiatric Association (APA), in its recently released "Guidelines on Confidentiality," reaffirms this position. In an age of progressive erosion of the traditional psychiatrist-patient confidentiality, the threat to confidentiality is invariably perceived as exogenous, emanating from external sources such as the legal system, third-party payers, and peer review organizations. In rare instances, there appears to be a threat from within, when the psychiatrist (or nonpsychiatrist physician dealing with a psychiatric patient) deliberately chooses to divulge the patient's confidential communications in the absence of any clearcut legal requirement to do so (and against the express wishes of the patient). Four case examples of these unusual breaches of confidentiality are presented. The author concludes that although significant assaults on patient confidentiality are occurring from without, it is quite rare for such violations to come from within the profession itself.

Spying on psychiatrists: surreptitious surveillance of the forensic psychiatric examination by the patient himself.

Lawyers have argued that surveillance of the forensic psychiatric examination is often necessary to protect clients' rights and assure more accurate reporting of the findings. This paper reports a new phenomenon which adds a disconcerting dimension to the current controversy over surveillance of such examinations, namely, surreptitious recording by patient/examinees of their own forensic examination. Their motivations range from psychotic delusions to perceptions that they are acting to protect their legal interests. Neither legal nor ethical code prohibitions in any way serve to bar such conduct. Moral arguments for and against secret recording by patient/examinees are explored, and its relationship to other techniques used to monitor professional practices in the health fields (such as pseudopatient studies) is discussed.

The psychiatrist's guide to right and wrong: Part IV: The insanity defense and the Ultimate Issue Rule.

In the wake of Hinckley, widespread public dissatisfaction with the role of psychiatrists in insanity defense litigation prompted Congress in 1984 to amend the Federal Rules of Evidence to prohibit psychiatric testimony on the ultimate legal issue of whether or not a defendant is insane. APA's Statement on the Insanity Defense served as the ably articulated premise for this evidentiary amendment. APA argued that in going beyond their psychiatric expertise by answering ultimate issue questions as to whether defendants are legally insane, experts are likely to confuse the jury and undermine public confidence in psychiatry. APA also asserted that there was an impermissible logical leap between scientific psychiatric inquiry and moral-legal conclusions on the ultimate issue of insanity. This article reviews the origins, history, and vicissitudes of the Ultimate Issue Rule and analyzes the Statement on the Insanity Defense from both a legal and psychiatric perspective on the issue of whether psychiatrists should answer the ultimate question in insanity cases. The analysis suggests that APA's conclusions are not supported on scientific or evidentiary grounds, but may be warranted as a policy consideration to safeguard the public image of psychiatry.

The psychiatrist's guide to right and wrong: Part II: A systematic analysis of exculpatory delusions.

Although delusions are prima facie evidence of psychosis, their mere presence is not a sufficient condition for exculpation on the grounds of insanity. In most cases, a determination of insanity will depend on the specific content of the delusions and whether, as a result of these delusions, the defendant was unable to know or appreciate the wrongfulness of his or her act. Delusions may be subdivided into four types, according to their content: 1) delusions of being controlled, 2) delusions of grandiosity, 3) delusions of persecution, and 4) delusions of jealousy. An analysis is undertaken of these delusional subtypes in terms of their exculpatory effect within the jurisdictions which follow each of the three respective standards of wrongfulness (i.e., the illegality standard, the subjective moral standard, and the objective moral standard). The criminal law does not recognize a transcendent constancy in the legal insanity status of psychotic individuals whose offense was the result of their delusional ideation. In most such cases, exculpation is based primarily on the specific content of their delusions and how it comports with the law of the jurisdiction specific content of their delusions and how it comports with the law of the jurisdiction in which the act was committed (the lex loci delicti commissi).

The psychiatrist's guide to right and wrong: Part III: Postpartum depression and the "appreciation" of wrongfulness.

Whether or not the psychiatrist testifies on the ultimate issue in insanity defense cases, it is critically important that he familiarize himself with the applicable legal standards and interpretations in order properly to relate his clinical findings to the relevant criteria for insanity and thereby enhance the probative value of his testimony. This is the third in a series of articles which attempts to explicate judicial and statutory standards of insanity and correlate them with the psychiatrist's findings of psychopathology. This article analyzes the Model Penal Code formulation of insanity, with special emphasis on the all important distinction between "know" and "appreciate." This formulation permits the defendant possessed of mere surface knowledge or cognition to be exculpated, requiring that he have a deeper affective appreciation of the legal and moral import of the conduct involved if he is to be held criminally responsible. The Model Penal Code approach more readily lends itself to application as a standard of responsibility in cases involving affective disorders. An important disorder within this group, postpartum depression, is discussed in the context of raising the insanity defense in a case of infanticide.

Consequences of surveillance of the forensic psychiatric examination: an overview.

Lawyers have argued that surveillance of the forensic psychiatric examination (either direct observation by a lawyer or recording of the examination) is necessary under certain circumstances to protect clients' rights and ensure more accurate reporting of the findings. Psychiatrists are concerned that surveillance could disrupt such examinations and impair their validity. The author reviews and extrapolates from available data on the effects of tape recording on clinical examinations and psychotherapy and concludes that the current state of scientific knowledge does not allow confident assessment of whether the perceived need for surveillance outweighs the possible impairment of the validity of forensic psychiatric examinations.

The psychiatrist's guide to right and wrong: judicial standards of wrongfulness since M'Naghten.

In insanity defense litigation, the precise legal definition of wrongfulness is often critically important. References in the M'Naghten Rules to the appropriate standard of wrongfulness were ambiguous, resulting in a divergence of judicial opinion as to whether wrongfulness means legal wrong, subjective moral wrong, or objective moral wrong. This article reviews and analyzes these three judicial standards of wrongfulness in the context of case law from jurisdictions that follow each of the respective standards. The evolution of knowledge of right and wrong tests of criminal responsibility is traced back to its philosophical roots. Most psychiatrists claim no expertise in matters of morality or law. The American Psychiatric Association would bar psychiatric expert testimony on the ultimate issue of insanity, on the grounds that there are "impermissible leaps in logic" when psychiatrists opine on the probable relationship between medical concepts and moral-legal constructs. Whether or not they testify on the ultimate issue, psychiatrists should ascertain the applicable standard of wrongfulness in order to properly relate their findings to the relevant legal criteria for insanity and thereby enhance the probative value of their testimony.

Psychiatrists in the hot seat: discrediting doctors by impeachment of their credibility.

Attacks on the credibility of the psychiatric expert witness are termed impeachment. This article provides an in-depth review of the various impeachment techniques used by lawyers during cross-examination and offers specific suggestions to the psychiatric expert witness on how to prepare for and counter some of these trial ploys. Bolstering and rehabilitation of the expert's credibility are also discussed. Finally, improper use of impeachment tactics is also considered. Excerpts from trial transcripts and court opinions are supplied to illustrate these points. Although impeachment remains a formidable weapon in the lawyer's armamentarium, it is suggested that the well-prepared and experienced psychiatric expert witness will be more than equal to the task.

Litigious paranoids and the legal system: the role of the forensic psychiatrist.

Forensic psychiatrists should be aware of the many ways that paranoid individuals may present within the legal system. Litigious paranoids often utilize the legal system as a vehicle to act out their fantasies and delusional preoccupations. Imaginary grievances, accusations based on delusional ideation, and irrational vindictiveness toward imagined persecutors may find full expression in any number of legal contexts. They can defeat the rational and legitimate objectives of the legal system, enmesh innocent and unsuspecting victims in nightmarish legal entanglements, and subvert the process of justice. The forensic psychiatrist can assist the court by alerting it to the presence of paranoid illness in parties or witnesses and by clarifying what the effects of such psychopathology are and what the most favorable response should be. Three legal contexts wherein paranoid individuals may present within the legal system are discussed: the "hypercompetent" defendant, the paranoid party in a divorce proceeding, and the paranoid complaining witness. Case illustrations are presented for each legal context. Two issues are discussed: the dividing line between paranoid ideation (and its impact on the legal process) and so-called "normal" thinking (and its objective to use the legal process to obtain certain ends); and the degree to which psychiatric opinions in this area should influence the way an individual's case is handled by the legal system. The author concludes that, despite the costs involved, it is preferable that even paranoids have their "day in court."