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PubMed2002

[Role of psychiatrists in capital punishment cases : a review].

Many medical organizations have passed resolutions banning participation of psychiatrists in legal executions, such as the Madrid Declaration of World Psychiatric Association. The Criminal Procedure Act of Japan prohibits the execution of the insane. Although the USA and Japan are both among the few so-called developed countries that have a system of capital punishment, many disputes about psychiatrists' participation in death penalty cases have occurred in the US, but few in Japan. This author has reviewed papers addressing this issue. The U.S. Supreme Court decided in Ford v. Wainwright that the execution of an "insane" inmate was not constitutional. The rationale for excluding the mentally incompetent from execution, however, is not completely clear. The most compelling reason is that execution does not satisfy the requirement for "effective retribution," since the insane criminal is not capable of understanding the implications of the death penalty. Nonetheless, there are those who dispute this interpretation and offer other explanations. Psychiatrists may be called upon to assess a criminal's competency for execution. Some find no problem with this practice, while others object to it stating that it conflicts with the ethical tenet to "first do no harm." Those who argue from a middle position insist on assessing competency while recognizing the existence of problems in making such an assessment. Furthermore, there is controversy over which factors exactly constitutes "competency to be executed." Usually, it is thought to be one's capacity to understand the nature of the death penalty and the reasons why the penalty is to be inflicted, but other arguments exist, including the capacity to assist legal counsel in last minute appeals. The question of whether to offer treatment to death row inmates who have been found incompetent to be executed is also under debate. The first position argues that they should "never be treated", because such prisoners would be executed when treatment restores competency. The second, always-treat-position, asserts that psychiatrists are responsible for treating severe mental illness whenever possible. The third, intermediate position, insists upon treatment with several conditions, which entail, for example, respecting the prisoner's autonomy and/or selecting forms of treatment that are unlikely to restore competency. When treatment is given, assessment as to whether competency has been restored is then required. This is still a troublesome issue. The decision in Perry v. Louisiana dealt with the question of whether the state may forcibly treat prisoners incompetent for execution. There were reports about ambivalence and anger among the staff of a psychiatric hospital where an inmate found incompetent for execution was treated. More than a few disputes insist that the ethical dilemma can only be resolved by commuting the sentences of incompetent death row prisoners to life imprisonment. This author further asserts that the secretiveness with which the Ministry of Justice of Japan handles these types of cases should be abolished as soon as possible.

Capital Punishment↗

PubMed2006

Shared psychotic disorder and criminal responsibility: a review and case report of folie à trois.

We present a case of shared psychotic disorder involving three sisters who were successful in establishing an insanity defense on numerous felony charges in the South Carolina criminal court system. Two of the authors of this article were court-appointed examiners in this case. We then present a history of shared psychotic disorder, an overview of the use of this diagnosis in the defense of insanity, and a discussion of the disposition of individuals with "temporary insanity." Finally, we compare shared psychotic disorder, culturally based belief systems, and religious cults, with a focus on their common and contrasting characteristics.

Adult↗

PubMed1990

The trial of Abner Baker, Jr., MD: monomania and McNaughtan rules in antebellum America.

On the third of October 1845, in a small mountain community in Kentucky, Abner Baker, Jr., MD, was executed for the murder of his brother-in-law Daniel Bates. At the trial Baker's attorney argued unsuccessfully that at the time of the crime the accused suffered from monomania, a form of mental disease, and therefore should not be held responsible for the act. The trial bears historical significance by the fact that it took place only a year after the formation of the Association of Medical Superintendents of American Institutions for the Insane, the first professional organization of psychiatrists in the United States, and two years after the McNaughtan ruling in British jurisprudence which molded the insanity plea around the concept of "knowing right from wrong." Because it took place at this particular juncture in the history of both law and medicine, it provides a revealing portrait of how medical and legal concepts on insanity interacted with the indigenous social and political circumstances of antebellum America.

Bipolar Disorder↗

PubMed1989

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).

Criminal Law↗

PubMed1988

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.

Expert Testimony↗

PubMed1997

Automatisms in non common law countries.

The distinction made in the common law tradition between sane and insane automatisms, and in particular the labelling of epileptic automatisms as insane, are legal concepts which surprise and even astonish lawyers of other traditions, whether they work within a civil law system or one with elements both from civil law and common law. It could be useful to those lawyers, doctors and patients struggling for a change in the common law countries to receive comparative material from other countries. Thus, the way automatisms are dealt with in non-common law countries will be discussed with an emphasis on the Norwegian criminal law system. In Norway no distinction is made between sane and insane automatisms and the plea Not Guilty by virtue of epileptic automatism is both available and valid assuming certain conditions are met. No. 44 of the Penal Code states that acts committed while the perpetrator is unconscious are not punishable. Automatisms are regarded as "relative unconsciousness", and thus included under No. 44. Exceptions may be made if the automatism is a result of self-inflicted intoxication following the consumption of alcohol or (illegal) drugs. Also, the role and relevance of experts as well as the law of some other European countries will be briefly discussed.

Automatism↗

PubMed2005

Complex visual hallucinations in the visually impaired: a structured history-taking approach.

OBJECTIVE: To study complex visual hallucinations in visually impaired individuals. METHODS: A prospective comparative study involving structured history taking and cognitive assessment in 48 consecutive visually impaired individuals with best-corrected visual acuity of 20/200 or worse and an age-matched cohort of 48 consecutive patients with visual acuity of 20/40 or better in at least 1 eye. RESULTS: Thirty visually impaired subjects (63%) experienced hallucinations, unrelated to specific ocular pathology. None volunteered the symptom; 2 admitted hallucinations on nonleading questioning and 28 on direct questioning. All displayed insight into the unreality of their hallucinations, although 18 (60%) achieved this after initial deception. Seventeen (57%) expressed concern; 7 (23%) experienced disturbing images. Nineteen (63%) feared being labeled as insane were they to admit to hallucinations, while 10 (33%) were fearful of impending insanity. Sixteen (94%) of 17 concerned patients derived comfort from sympathetic reassurance that their hallucinations did not represent sinister pathology. In contrast, none of the individuals with normal vision experienced any hallucinations (P<.001). Cognition was intact in all groups. CONCLUSIONS: Complex visual hallucinations with insight commonly occur in visually impaired, cognitively intact individuals due to acquired visual impairment and are unrelated to chronological age. Hallucinatory experiences are almost invariably admitted to only on direct questioning, due to fears of being considered insane. Although generally pleasant, hallucinations may cause distress, because of content or implications of the hallucinatory activity. Sympathetic explanation affords significant emotional relief.

Adult↗

PubMed1995

The impact of expertise and sufficient information on psychologists' ability to detect malingering.

Twenty-two forensic diplomates and 22 general clinical psychologists were asked to review a variety of psychological data from one of four cases (two cases of malingering and two cases of legal insanity) to determine whether data suggested malingering or insanity. Of the 44 psychologists who reviewed cases, 86.4% accurately determined whether their protocol was from a malingerer or an insane person. Forensic diplomates and clinical psychologists were equally accurate in their determinations; only three subjects from each group misidentified their case. In spite of their success, confidence levels for both groups were reported as moderate. These results contradict previous studies that have found psychologists to not only be poor detectors of malingering, but also overconfident in their ability to detect it. It is believed that the success of psychologists in this study compared to previous studies was due to improved methodology.

Adult↗

PubMed1986

A historical appraisal of America's experience with "pyromania"--a diagnosis in search of a disorder.

When "pyromania" from 1840-1890 is reviewed, it stands out as a concept that at first found favor in an era of moral insanity and moral treatment. During this period pyromania was variously labeled as a form of monomania, moral insanity, impulsive mania, or instinctive mania. As early as 1850, and clearly after the Civil War, however, controversial arguments regarding the locus of personal responsibilty emerged. Arguments were put forward that there could be diseased brains but not diseased minds. Without the proof of an organic lesion in the brain, fire-setting became an act whose locus rested in the individual's moral fabric, and in this historical context became a nonmedical concern punishable by law. Pyromania, at the hands of those physicians who limited insanity to disorders of the brain, might have received the same fate as other diseases of the mind or will: it could have simply been dismissed. But it lingered. The period 1880-1917 witnessed professional attention directed toward prophylaxis, mental hygiene, and a reorientation of American psychiatry toward an endorsement of psychotherapy (Sicherman, 1980). Attention to pyromania was more quiescent than it had been. The development of psychoanalytic theory which followed allowed for the re-emergence of pyromania as a disease entity. The diagnosis then flourished from 1924 until 1957, with descriptions of it including: an irresistible impulse, a urethra-erotic character trait, an obsession, or a psychosexually based impulse neurosis. The period of 1924-1985 can be viewed as a repetition of the period between 1840-1890 in terms of the evolution of the place of pyromania in the lexicon of psychiatry, of its existence as a disease entity, and of its implications for personal responsibility for destructive acts. Supported at the outset of this later period as a disease, this time grounded in psychoanalytic rather than moral theories of responsibility, it loses favor as the psychobiologic position ascends. And like the preceding period, the conception of pyromania as a specific disorder wanes but never dies, as advocacy for the psychodynamic (replacing moral) approach diminishes but does not disappear. The cyclical nature of pyromania has parallels in cycles of reform in standards of civil commitment (Livermore, Malmquist & Meehl, 1958; Dershowitz, 1974), in the use of physical therapies and medications (Tourney, 1967; Mora, 1974), in treatment of the chronically mentally ill (Deutsch, 1949; Morrissey & Goldman, 1984), and in institutional practices (Treffert, 1967; Morrissey, Goldman & Klerman (1980).(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗

PubMed2006

Clinical and psychometric characterization of depression in mixed mania: a report from the French National Cohort of 1090 manic patients.

BACKGROUND: Despite extensive research recently focused on mixed mania, it is uncertain as how best to define it clinically, psychometrically (which has major bearing on its prevalence), and the methodology needed for future research. This topic is also of historical interest, because Magnan (1890) [Magnan, V., 1890. La Folie Intermittente. G Masson, Paris.] suggested that "combined [mixed] states" linked Falret's "circular insanity" with Baillarger's "dual insanity" (both described in 1854). This work eventually led to the Kraepelinian synthesis of all manic, mixed, and depressive states into the unitary rubric of "manic-depressive insanity (1899/1921). METHOD: EPIMAN-II Thousand" (EPIMAN-II MILLE) is a French national collaborative study, which involved training 317 psychiatrists working in different sites representative of psychiatric practice in France. We recruited 1090 patients hospitalized for acute DSM-IV mania. assessed at index admission by the following measures: the Mania Rating Scale (MRS), the Beigel-Murphy Scale (MSRS), a newly derived checklist of depressive symptoms least contaminated by mania, MADRS for severity of depression, and the SAPS for psychotic features. RESULTS: The rate of mixed mania, as defined by at least 2 depressive symptoms, was 30%. Even with this broad definition, we found significantly higher female representation. This clinical sub-type of mania was characterized by high frequency of past diagnostic errors, particularly those of anxiety and personality disorders. Refined definition of co-exiting depression was obtained from an abbreviated version of the MADRS (6 items), with distinct "emotional-cognitive" symptoms, and "psychomotor inhibition" factors, both of which were separable from an "irritable" factor linked to lability and poor judgment. Mixed mania was psychometrically best identified by a MADRS score of 6 (80% sensitivity, 94% specificity) and validated by a mixed polarity of first episodes, a higher rate of recurrence, psychotic features, and suicide attempts. LIMITATION: Cross-sectional study. CONCLUSIONS: The data deriving from EPIMAN, the largest and only national study ever conducted on mania, provide definitive characterization of the clinical and psychotic structure of mixed mania, which accounts for 1 out of 3 patients who present with mania. This figure is more accurate than higher rates reported in the literature because, in describing "mixity", we eliminated depressive features that could be contaminated by mania. Despite the prominent affective features described herein, the bipolar nature of mixed mania is often missed, with the result that these patients are diagnosed as having anxiety and/or personality disorders. It is of great public health significance for psychiatrists to recognize the bipolar nature of this condition that has been known as a major phase of manic-depressive illness since at least Magnan, a disciple of Falret and Baillarger.

Adolescent↗

PubMed2006

French antecedents of "contemporary" concepts in the American Psychiatric Association's classification of bipolar (mood) disorders.

Although first detailed descriptions of what we today term "bipolar disorders" are generally attributed to E. Kraepelin [Kraepelin, E., 1899 (1976 tr). Manic depressive insanity and paranoia. (reprint of English translation). Arno, New York], a review of French psychiatric literature from Esquirol to the middle of 20th century reveals major clinical contributions to the development of the concept of cyclic mood disorders, their phenomenology and classification as embodied in DSM-IV. The main treatise was published by the Paris psychiatric schools of Salpêtrière, Bicêtre, Charenton, Sainte-Anne and Vanves. Already much before Kraepelin, French authors had described most symptoms and the course of future DSM-IV bipolar, manic, major depressive [Falret, J.-P., 1854. De la folie circulaire ou forme de maladie mentale caracterisée par l'alternative régulière de la manie et de la mélancolie, Bull. Acad. Méd. XIX, 382-400.; Baillarger, J., 1854. Note sur un genre de folie dont les accès sont caractérisés par deux périodes régulières, l'une de dépression, l'autre d'excitation, Bull. Acad. Méd. XIX, 340 et Ann. Méd. Psychol. XII, 369], hypomanic and mixed episodes [Falret, J., 1861. Principes à suivre dans la classification des maladies mentales, Ann. Méd. Psychol. XIX, 145.; Falret, J., 1866, 1867. La folie raisonnante ou folie morale, Ann. Méd. Psychol. XXIV, 382, XXV, 68], as well as - under other names - the characteristics of bipolar II disorder, various specifiers describing mood episode and course of recurrent episodes [Ritti, A., 1883. Traité clinique de la folie à double forme (folie, circulaire, délire à formes alternes). Doin, Paris]. The synthesis of these clinical observations led to Magnan's "intermittent madness" (1893), a precursor of Kraepelin's "manic-depressive psychosis". After 1899, French authors generally adhered to their classification of autonomous depressive disorder (melancholia), as distinct from manic-depressive insanity, thereby foreshadowing (much before the work of such Germanophone authors as Leonhard [Leonhard, K., 1957 (1979 tr). Aufteilung der endogenen Psychosen und ihre differenzierte Atiologie. Berlin: Akademie-Verlag; English transl. by R. Berman, Irvington, New York] and Angst [Angst, J., 1966. Zur Atiologie and Nosologie endogener depressiver Psychosen. Springer: Berlin, Heidelberg, New York]) the DSM-IV dichotomy of depressive (unipolar)/bipolar disorders (UP-BP dichotomy). It is further noteworthy that Falret [Falret, J.-P., 1854. De la folie circulaire ou forme de maladie mentale caracterisée par l'alternative régulière de la manie et de la mélancolie, Bull. Acad. Méd. XIX, 382-400] had hinted at the possibility that short hypomanic episodes at the tail end of depressive episodes in ambulatory patients represented formes frustes of circular insanity, thereby anticipating the latest developments in bipolarity - what today is considered the softer end of the bipolar spectrum. The UP-BP dichotomy and the bipolar spectrum today are the two main competing nosologic conceptual frames for mood disorders in both American and European psychiatry - and world psychiatry at large.

Bipolar Disorder↗

PubMed1997

Myxoedematous madness and grievous bodily harm.

Psychosis is a rare but recognized complication of hypothyroidism (otherwise known as 'myxoedematous madness'). This is the report of a man charged with attempted murder who was found to be suffering from myxoedematous madness. The case illustrates several problems in the law relating to mental disorder and criminal responsibility. He was interviewed in the absence of an appropriate adult and this led to the inadmissibility of the police interviews. However, to have laid the basis for a defence of insanity the ideal evidence would have been what he told the investigating police officers about his state of mind at the material time, under caution and possibly with the assistance of an appropriate adult. As it was, although he was clearly mentally ill at the material time, the insanity defence was not open to him as he did not satisfy the MacNaughton Rules and his mental state did not fulfill the criteria for automatism. By the time he stood trial he was fully recovered from his psychosis and this faced the judge with a difficulty in sentencing him. The case is used to discuss proposed changes to the law concerning insanity.

Journal Article↗

PubMed2004

The frontal cortex and the criminal justice system.

In recent decades, the general trend in the criminal justice system in the USA has been to narrow the range of insanity defences available, with an increasing dependence solely on the M'Naghten rule. This states that innocence by reason of insanity requires that the perpetrator could not understand the nature of their criminal act, or did not know that the act was wrong, by reason of a mental illness. In this essay, I question the appropriateness of this, in light of contemporary neuroscience. Specifically, I focus on the role of the prefrontal cortex (PFC) in cognition, emotional regulation, control of impulsive behaviour and moral reasoning. I review the consequences of PFC damage on these endpoints, the capacity for factors such as alcohol and stress to transiently impair PFC function, and the remarkably late development of the PFC (in which full myelination may not occur until early adulthood). I also consider how individual variation in PFC function and anatomy, within the normative range, covaries with some of these endpoints. This literature is reviewed because of its relevance to issues of criminal insanity; specifically, damage can produce an individual capable of differentiating right from wrong but who, nonetheless, is organically incapable of appropriately regulating their behaviour.

Adult↗

PubMedDate not supplied

Madness and care in the community: a medieval perspective.

Care in the community for insane people today is more a matter of expert provision than communal support. In consequence, although they are no longer confined to hospital, mentally ill people largely remain marginalised in a society that does not have the resources, nor often the inclination, to take responsibility for their care. The experience of insane people in medieval England seems to have been of a different order, as shown by a particularly well documented case dating from 1383. From the late 13th century congenital idiots were protected by law. Care of lunatics, by contrast, was primarily the responsibility of the family. However, where the family could not or was unwilling to provide, provision was made by the crown. Through the instrument of the inquisition, the diagnosis and social circumstances of each case were determined by commissioners in consultation with a local jury and all interested parties, including the subject himself or herself. The best interests of the subject remained a prime concern, and the settlement that was ordained was tried and enforced in law. The process was confined to those with real or personal estate, but it encompassed poor as well as rich and proved, through the close identity of the local community with the process, to be a sophisticated and effective mechanism for maintaining and sustaining insane people. Unlike today, care in the community was a communal activity that ensured a truly public provision for those who could not look after themselves.

Attitude to Health↗

PubMed1998

Social class, ethnicity, and mental illness: the importance of being more than earnest.

This paper revisits a landmark study of the prevalence of mental illness in the state of Massachusetts conducted by Edward Jarvis in the 19th century. Jarvis drew an improper conclusion about the relationship between social class, ethnicity, and insanity, asserting that the Irish foreign-born had a higher prevalence of insanity in each social stratum. A reanalysis of Jarvis' data shows that in both the pauper and independent social classes in Massachusetts, the prevalence of insanity was significantly lower among foreign-born persons than among native-born persons. On the basis of his misperception, Jarvis constructed elaborate etiological theories. These theories made a strong impact on the mental health service policies of his day. The effects of incomplete examination of data on etiological theories and mental health policy in current times are highlighted in this article.

Causality↗

PubMed1991

Perry v. Louisiana: medical ethics on death row--is judicial intervention warranted?

The following note considers the complex case of Perry v. Louisiana, in which the Louisiana Supreme Court ordered an insane defendant on death row to be medicated against his will in order to render him sane, and therefore capable of being executed. In so doing the court pit judicial interests in effecting punishment of certain murderers against the physician's Hippocratic Oath, "first do no harm." In considering this conflict, the note identifies "first do no harm" as a guiding principle, explores the societal values underlying this basic principle, and concludes the judiciary must provide legal support for this medical ethical imperative. Similarly the legal profession must identify its organizing principles, its "first do no harm" proscriptions, and consider the application of those principles in the context of representing the insane. Some of the conflicts confronting the physician in the Perry situation have parallels for the attorney representing an insane client. Should the client be medicated in order to proceed to trial? Is it in the best interests of the client to remain a prisoner of her mental illness rather than to risk the possibility of conviction? How should the attorney address the paradoxical reality that a heavily medicated client may indeed become more lucid without becoming more competent? By publishing this note, the Journal hopes to engender discussion and clarification of the vague and sometimes incoherent guidance offered by the Medical Rules of Professional Responsibility, the Model Code of Professional Conduct, and the Criminal Justice Mental Health Standards for legal work with mentally disturbed clients.

Beneficence↗

PubMed1992

Mentally disordered offenders. Patterns in the relationship between mental disorder and crime.

Five patterns among mentally disordered offenders are distinguished by the relationship between mental disorder, on the one hand, and criminality, on the other. Pattern 1 offenders are those for whom crime is a response to psychotic symptoms, most often delusions or hallucinations. Pattern 2 offenders commit crimes motivated by compulsive desires, such as sex offenses by paraphiles and offenses regarded as evidence of disorders of impulse control. Pattern 3 offenders are those with personality disorder for whom the crime is merely one example of a maladaptive pattern of voluntary and knowing behavior. Pattern 4 offenders have coincidental mental illness that is unrelated to the crime. Pattern 5 offenders are those who become mentally disordered or feign mental disorder as a result of their crimes, such as those who dissociate upon seeing what they have done, those who become depressed in prison, those who become psychotic on death row, and those who malinger mental illness. Although these categories do not determine whether offenders are responsible for their behavior, some unknown proportion of Pattern 1 offenders do meet legal criteria for insanity, depending on the facts of each case and the applicable legal standards. It is arguable whether or not Pattern 2 offenders ever meet legal criteria of insanity. Offenders evidencing only Patterns 3, 4, or 5 are not candidates for an insanity defense.

Adult↗

PubMedDate not supplied

[The problem of the current rights of mental patients facing commitment and regionalization].

Remarkably conceived, the law of 30 June 1838 requires only one actualization. It would be necessary to include some provisions there simply reinforcing the legal protection of the insane interned: procedure of habeas corpus, respect of the rights of defence (free communication with counsel). On the other hand, the rights of the mental patients hospitalized in open department in hospitals devoted to the insanes are singularly forgotten. These patients should profit by the same legal protections as the mental patients of psychiatric private clinics and public hospitals others that the particular hospitals for insanes (art. L. 353-2,3,4, code of public health). Lastly, the legislation on the sector should contain a clause pointing out the respect of the ethical principles and fundamental freedoms of the human person.

Civil Rights↗