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.

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.

Credibility and incredibility: the psychiatric examination of the complaining witness.

Psychiatrists are called on to evaluate the credibility (and incredibility) of complaining witnesses in criminal proceedings despite a longstanding controversy about their ability to accurately make such determinations. The author discusses the history of such psychiatric activity from Freud through the Alger Hiss prejury trial, its current status in terms of benefits to the criminal justice system, the legal and social questions it raises (e.g., the competing issue of the complainant's right to privacy), andthe court's restrictions on the psychiatrists. He presents two illustrative case histories.

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.

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.

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.

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."

The psychiatrist's role in retrospective determination of suicide: an uncertain science.

Psychiatrists have made significant contributions to our understanding of the phenomenon of suicide and are generally regarded as experts in all matters relating to suicide. When a legal determination must be made as to whether an individual has died as a result of suicide or by accidental (or any other) means, psychiatrists are often called upon to proffer their expert opinion to assist the courts to resolve the matter. Two case illustrations are presented and analyzed in which psychiatrists were called upon to make such retrospective determinations of suicide. The question is raised as to whether psychiatrists may sometimes exceed the limits of their scientific expertise in making such determinations.

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.