Friday, October 22, 2010

What I Learned: Part 2

Continued coverage of the American Academy of Psychiatry and Law (AAPL) conference. For Part 1, click here.

Day Two began with a section on PTSD as a criminal defense in military criminal cases. There was a presentation of a murder case committed by several military personnel in Iraq, followed by a discussion of the uniform code of military justice (UCMJ) rules of criminal procedure. The limitations of PTSD as a diagnosis was discussed, specifically the fact that many symptoms of PTSD overlap with other psychiatric diagnoses and that some people meet symptom criteria for PTSD without ever being exposed to a traumatic event. In 2008, 2.9 million veterans were receiving compensation for PTSD.

In criminal cases, defendants can claim self-defense if they have a reasonable belief that they are in imminent danger of serious bodily injury or death, if the force used in self-defense was reasonable, if the defendant was not the aggressor and if the defendant had no opportunity to retreat. Problems happen when the defendant reasonably believes he is in danger, but there is no objective evidence of imminence. (Eg. battered spouse syndrome and "burning bed" cases: a woman believes she is in danger and pre-meditates violence in self defense.) Soldiers with exposure to traumatic events may base a PTSD defense on a reasonable belief of danger, in the absence of imminence. Although the term "battered soldier syndrome" is not actually used in these military cases, they are clearly drawing an analogy.

As an aside, the UCMJ is interesting in that in courts martial, the military panel (analagous to a jury) decides guilt and also passes sentence. Judges have no role in sentencing. Also, there is no option for bail at the pretrial stage. Defendants have a right to a trial within 120 days, which is not much time to prepare a case for a felony offense.

In a presentation about zolpidem (Ambien) I learned that there were 22 criminal cases at the appellate level in which this medication was used as a defense. Ten were driving cases, seven were violent offenses. Zolpidem has been associated with sleep disordered behavior when combined with an SSRI. There have been 16 cases reports of zolpidem causing improvement in a chronic vegetative state.

There was a fascinating talk about tasers given by a guy from Utah. Apparently tasers have a USB data port that is used to gather stored information about when the taser was used and how many tasing cycles were triggered on a defendant. The presenter collected data from many police departments around the country regarding taser use and the nature of the defendant. He found out that in two-thirds of the cases the taser is never actually fired---merely pointing the taser at a defendant is enough to cause the defendant to surrender. When a taser is used, 82.2% of people required a single cycle. The majority of the cases in which a taser was used was on a defendant who was mentally ill and/or intoxicated. According to 1999 Justice Department data, only 2.1% of arrests actually require the use of a police weapon.

I went to the forensic sciences lecture, which is usually my favorite presentation. The American Academy of Forensic Sciences is a companion organization to AAPL and some of our members are shared between the two organizations. Anyway, this year's presentation was about computer crime. Sadly, it was bad. While the investigator was a good speaker, he didn't say much of anything about the techniques of how computer crime is actually investigated. There was no case presentation. The only crime discussed was online child pornography. The mental health professional talked about child porn users, but made at least three pretty outrageous anti-feminist statements. (Eg. women who made late accusations of child sexual abuse had been 'brainwashed by the feminist movement.') A female forensic psychiatrist audibly blurted out "that's bullshit!" and I could hear the silent dropping of jaws. The most enjoyable part of this talk was when the computer investigator had trouble getting the audience survey system to work.

Lastly, I went to a talk about a survey given to 492 members of the South Carolina bar. 83% of the lawyers said they felt their law school training about mental health law was inadequate. Two-thirds had personal or close experience with mental illness. Judges were the least knowledgable about mental health law compared to public defenders, private attorneys and prosecutors.

Tidbits from the poster session:

  • 27 states have statutes with lifetime restrictions on gun ownership for people with mental illness. Other states have time limited restrictions on ownership, and some allow restoration of full rights contingent on a physician's documentation of recovery.
  • One poster studied inpatient threats in a state hospital over one year. Only one-quarter of the threats were deemed credible by the treatment team, and only one-half of these threats were thought to meet criteria to carry out a Tarasoff warning.
  • There was an interesting review of the Maurice Clemmons case in which public information was used to assess his risk of violence. I blogged about the case here, and provided links to the published clemency materials. Using two violence risk assessment instruments, the poster found Clemmons to be a high risk offender. Easy to say based on his history, but of course the limitation of static risk assessment instruments is that your base risk never lowers. You can get worse, but never better.
  • A national household survey of substance abuse, done annually with tens of thousands of people, showed that 3.8% off all women had used methamphetamine at least twice in the past year. Female meth users were more likely than users of other substances to be involved with the law, but not necessarily for violent offenses.
  • Two states automatically drop misdemeanor charges against incompetent defendants, as required by their statutes.
  • One study found no correlation between a history of childhood sexual abuse and being a perpetrator or victim of inpatient violence.
  • Prisoners over the age of 65 are twice as likely to have at least one chronic medical condition compared to an age-matched sample in free society.
  • Medical students from UCSD who rotate in a jail for their psychiatry experience consistently rate this rotation as their favorite. One quote from the medical student survey stated: "I love jail!"


This is the poster that won my heart. We've discussed this on the blog and we mention it in the book. Now, the "official" word. A poster entitled "Noah's Ark: A Forensic Review of Service Animals in Psychiatric Settings" provided an overview of ADA requirements for service animals in hospitals and clinics. In addition to guide dogs for the blind, other service animal cases involved monkeys, chimpanzees, miniature horses and parrots. Animals may be excluded from operating rooms but not any other general treatment setting. Potential for infection cannot be used to exclude animals, nor can mere concern about safety separate from an actual safety-related incident. Animals have to be able to meet minimal expectations for cleanliness, orderliness, nonaggression and "unnecessary vocalization". The sole determinant of whether an animal is a service animal versus a pet is the patient's declaration: a health care facility cannot demand documentation that an animal is certified or trained as a service animal. Finally, there have been cases of fraudulent service animals: people who put homemade "vests" on their animals and falsely identified them as a service animal. In California this is a crime punishable by six months of incarceration and a thousand dollar fine. I'm not sure how you'd get a vest on a fake service parrot.

So there you have it. I'm bringing my duck to the next session.