Thursday, October 21, 2010

What I Learned: Part 1

For new readers, it's my tradition to put up posts summarizing tidbits I picked up at the annual American Academy of Psychiatry and Law (AAPL) conference. It's random, it's not explained in detail, but it's stuff I thought was interesting.

The conference started out with a keynote speech by AAPL President Stephen Billick. The title of his talk was "Be True To Psychiatry". His point was that forensic psychiatrists are clinicians first, and that even a forensic evaluation can have therapeutic effects. He cited many examples in his practice in which a criminal or civil evaluation had potential beneficial "side effects" regardless of the forensic opinion. His main point: the forensic psychiatrist's obligation to be neutral and objective does not preclude kindness. A point well taken, and appreciated.

A session on suicide risk assessment gave a very nice illustration of the basic problem inherent in these assessments: even assuming an "ideal" case situation with a "perfect" psychiatrist, a thorough suicide risk assessment would take four hours. Risk assessment is time consuming and inherently will be incomplete. We make the best decisions we can based on the limited data we have at the time. A malpractice defense attorney talked about inpatient suicides: he was shocked when he realized in the course of his practice that many doctors didn't know that most inpatient deaths occured by hanging. They do. About 1500 deaths per year, in fact. Seventy percent of suicide deaths take place in the patient's bedroom, bathroom or closet. One-third happen while the patient is on fifteen minute checks.

There were a few themes to today's conference: conflicts of interest, maintenance of certification, and neuroimaging. The luncheon speaker was the best one I've ever heard at an AAPL conference. Dr. Helen Mayberg has been doing neuroimaging studies for 25 years and was one of the creators of deep brain stimulation. She has testified in several death penalty cases regarding the limitations of inference in imaging, particularly in regard to forensic issues. She was balanced, impartial and scientifically impeccable. Notable quote: "Brain scans have no place in the court room." An afternoon session on "diffusion tensor imaging" and mild traumatic brain injury basically came to the same conclusion, albeit after an astoundingly incomprehensible explanation of "diffusion tensor imaging" technology.

There was a great overview of Munchausen's syndrome by proxy, including a summary of 38 family case studies in which a mother was convicted of MSBP. In this case series a third of the mother's had some health care training and 60% had previously had factitious disorder themselves. Ninety percent of the perpetrators did not admit their abuse even after conviction. Several factors were associated with a worse outcome for the child: reunification with the untreated mother, an absent father, and a history of MSBP abuse lasting over two years. If the child was abused by suffocation or poisoning, about a tenth of them eventually died two years after reunification. Siblings in these cases were also at significant risk of being victims of MSBP.

Another session I attended was a 15 year review of state and Federal case law regarding automatism defenses. An automatism defense is one in which the defendant alleges that a crime was due to some unconscious behavior, like sleepwalking or seizure. Without going into legalisms, I'll just say that states are divided on whether or not automatism is allowed as the basis of an insanity defense. It's clinically and legally complicated so I leave the details for a future blog post if I have the inclination to go into it. If you can't wait, there's a nice concise description here.

Finally, some interesting tidbits from the poster session:

  • There were two posters on forced meds for prisoners. One poster found a significant decrease in infractions and disciplinary problems for prisoners who were ordered to take meds against their will. Another poster found split results: some had fewer infractions, some had more. Infractions may be related to mental illness, but others are due to personality problems and involuntary meds may not touch this.
  • States are developing jail diversion programs for veterans, modeled after diversion programs for the mentally ill.
  • A study of suicides in New York's prison and jail system showed that 2/3rd's of completed suicides had no previous history of suicide attempts.
  • Dr. Paul Federoff and his colleagues had an interesting poster in which they found that increased LH and FSH levels correlated with violent and sexual recidivism. He had another poster session which described a nonprofit program that helped sex offenders transition back into the community. I'm always impressed by the quality of Canadian forensic research.
  • There are 5000 honors killings per year worldwide, and most are committed by fathers or brothers.
  • Mental health providers are not required to report threats against the President except for threats covered by state Tarasoff statutes.
  • Parasomnias sometimes result in violence, but this is rare. Most violence is from random thrashing movements, although there have been rare incidents of parasomnia-associated choking.
So that's it for today. Tomorrow's topics: murder in Iraq, AAPL interfacing with the American Medical Association and the American Psychiatric Association, the forensic sciences sampler (my favorite!! This year the topic is computer crime), and the "Zolpidem defense".

I'll be tweeting throughout the conference. The preliminary program is available here, and I'll consider requests about which sessions to attend.