Interdisciplinary Review of General, Forensic, Prison and Military Psychiatry and Psychology and the related subjects of Behavior and Law with the occasional notes and comments by Michael Novakhov, M.D. (Mike Nova).
Tuesday, June 18, 2013
My 12 Best Tips on Psychiatric Diagnosis - By Allen Frances, M.D.
We already had a crisis in psychiatric diagnosis before DSM-5. It is a sure sign of excess that 25% of us reportedly qualify for a mental disorder and that 20% are on psychiatric medication. Unless checked, DSM-5 will open the floodgates and may turn current diagnostic inflation into future hyperinflation.
Below are my 12 tips on how best to ensure accurate and safe diagnosis:
(1) The less severe the presentation, the more difficult it is to diagnose. There is no bright line demarcating the very heavily populated boundary between mental disorder and normality. Milder problems often resolve spontaneously with time and without need for diagnosis or treatment.
(2) When in doubt, it is safer and more accurate to underdiagnose. It’s easier to step up to a more severe diagnosis than to step down from it.
(3) Children and teenagers are especially hard to diagnose. They have a short track record, varying rates of maturation, may be using drugs, and are reactive to family and environmental stresses. The initial diagnosis is likely to be unstable and inappropriate.
(4) Mental illness is hard to diagnose in the elderly. Their psychiatric symptoms may be caused by medical and neurological illness and they are prone to drug side effects, interactions, and overdose.
(5) Take the time and make the effort. It takes time to make the right diagnosis—adequate time for each interview and often multiple interviews over time to see how things are evolving. Except for classic presentations, a quick diagnosis is usually the wrong diagnosis.
(6) Get all the information you can. No one source is ever complete. Triangulation of data from multiple information sources leads to a more reliable diagnosis.
(7) Consider previous diagnoses—but don’t blindly believe them. Based on their tenure, incorrect diagnoses tend to have a long half-life and unfortunate staying power. Always do your own careful evaluation of the patient’s entire longitudinal course.
(8) Constantly revisit the diagnosis. This is especially true when someone is not benefiting from a treatment that is based on it. Clinicians can get tunnel vision once they’ve fixed on a diagnosis, become too married to it, and are blinded to contradictory data.
(9) Hippocrates said that knowing the patient is just as important as knowing the disease. Don’t get so caught up in the details of the symptoms that you miss the context in which they occur.
(10) If you hear hoof-beats on Broadway, think horses, not zebras! When in doubt, go with the odds. Exotic diagnoses may be fun to think about—but you almost never see them. Stick with the bread and butter.
(11) Accurate diagnosis can bring great benefits; inaccurate diagnosis can bring disaster.
(12) Remember the other enduring dictum from Hippocrates: First, Do No Harm.
Forensic Psychiatry: Expertise, Treatment and Public Policy — Dedicated to Dr. Thomas G. Gutheil
Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, United States
Available online 28 September 2012
The field of forensic mental health has grown exponentially in the past decades to include forensic psychiatrists and psychologists serving as the primary experts to the court systems. However, many colleagues have chosen to pursue the avenue of serving as forensic experts without obtaining formal training and experience. This article discusses the importance of formal education, training and experience for psychiatrists and psychologists working in forensic settings and the ethical implications that befall those who fail to obtain such credentials. Specific aspects of training and supervised experience are discussed in detail.
There is little knowledge of predictors for involuntary hospitalizations in acute psychiatric units.
The Multi-center study of Acute Psychiatry included all cases of acute consecutive psychiatric admissions in twenty acute psychiatric units in Norway, representing about 75% of the acute psychiatric units during 2005–2006. Data included admission process, rating of Global Assessment of Functioning and Health of the Nation Outcome Scales.
Fifty-six percent were voluntary and 44% involuntary hospitalized. Regression analysis identified contact with police, referral by physicians who did not know the patient, contact with health services within the last 48 h, not living in own apartment or house, high scores for aggression, level of hallucinations and delusions, and contact with an out-of office clinic within the last 48 h and low GAF symptom score as predictors for involuntary hospitalization. Involuntary patients were older, more often male, non-Norwegian, unmarried and had lower level of education. They more often had disability pension or received social benefits, and were more often admitted during evenings and nights, found to have more frequent substance abuse and less often responsible for children and were less frequently motivated for admission. Involuntary patients had less contact with psychiatric services before admission. Most patients were referred because of a deterioration of their psychiatric illness.
Involuntary hospitalization seems to be guided by the severity of psychiatric symptoms and factors “surrounding” the referred patient. Important factors seem to be male gender, substance abuse, contact with own GP, aggressive behavior, and low level of social functioning and lack of motivation. There was a need for assistance by the police in a significant number of cases. This complicated picture offers some important challenges to the organization of primary and psychiatric health services and a need to consider better pathways to care.
aDepartment of Psychology, University of British Columbia Okanagan, Canada
bDepartment of Psychology, University of Saskatchewan, Canada
cRoyal Canadian Mounted Police, Canada
Available online 8 February 2013
High-risk sexual offenders are a complex and heterogeneous group of offenders about whom researchers, clinicians, and law enforcement agencies still know relatively little. In response to the paucity of information that is specifically applicable to high-risk offenders, the present study investigated the potential influence of sexual fantasy, sexual paraphilia, and psychopathy on the offending behaviour of 139 of the highest risk sexual offenders in one province of Canada. The sample included 41 child molesters, 42 rapists, 18 rapist/molesters, 30 mixed offenders, and 6 “other” sexual offenders. Two offenders could not be categorized by type due to insufficient file information. Data analyses revealed significant differences between offender types for a number of criminal history variables including past sexual and nonsexual convictions, number of victims, weapon use, and age of offending onset. Further, there were significant differences between offender types for sexual fantasy themes, paraphilia diagnoses, and levels of psychopathy. For example, results revealed that offenders' sexual fantasies were significantly more likely to correspond with the specific type of index sexual offence that they had committed. Further, offenders scoring high in psychopathy were significantly more likely to have a sadistic paraphilia than offenders with either low or moderate psychopathy scores. Results from the current study provide a refined and informed understanding of sexual offending behaviour with important implications for future research, assessment, and treatment, as well as law enforcement practices when working with high-risk sexual offenders.
Figures and tables from this article:
Table 1. Percentage of each offender type by sexual fantasy theme.
Table 2. Means and standard deviations for number of sexual convictions, number of nonsexual convictions, and number of victims by sexual fantasy theme.
Note. Fantasy themes were available for 95 of 139 offenders; consequently, the ranges across sexual fantasy themes above do not match the overall ranges of sexual and nonsexual convictions and victims when considered separately.
bInstitute of Psychology, Health & Society, University of Liverpool, United Kingdom
Available online 5 February 2013
Psychiatry is characterised by bio-psycho-social approaches and therapies. Thus there should be an interest in comprehensive theoretical models for didactic purposes.
A narrative synthesis of key themes in the current literature on psychiatric aspects of violence was conducted with the aim of integrating biological, psychological and sociological ideas in this area.
Two didactical models are proposed for 1) individual disposition and for 2) acting in specific situations, each including available evidence-based knowledge.
The proposed models may be helpful for a comprehensive understanding of all relevant influencing factors in violent mentally ill people and for didactical purposes.
The Mental Health Act 2001 (MHA 2001) was implemented in November 2006. Since that time, there has been considerable research into its impact, including the impact on service provision, use of coercive practices and the perceptions by key stakeholders. Our objective is to present a summary of research into the MHA 2001 since its implementation in the Irish state in the context of international standards and practice.
We reviewed the literature presented on Medline and Google Scholar, directly assessed relevant journals and sought abstract information from the College of Psychiatry of Ireland.
There has been a small decrease in the rate of involuntary admission since implementation but there has been no change in the representativeness of diagnoses of individuals admitted involuntarily. Mental Health Tribunals were held for 57% of those admitted involuntarily and 46% of service users found that the Mental Health Tribunal made the involuntary admission easier to accept. One year after discharge, 60% of service users reflected that their involuntary admission had been necessary. Professional groups have expressed concerns regarding workload, training time for junior doctors and paperwork.
The MHA 2001 has brought the practice of involuntary admission further into line with international standards. However, five years after the implementation of the Act international guidelines and practice have highlighted areas in need of further reform, including capacity legislation and consideration of advance directives and community treatment orders. Further research is also lacking on caregivers' or family members' perceptions of the MHA 2001.
Mental Health Act;
Figures and tables from this article:
Fig. 1. Flow chart illustrating paper selection for review.CPI: College of Psychiatry of Ireland; IJPM: Irish Journal of Psychological Medicine.1Original research on the topic Oireachtas, 2001, excluding discussion papers and papers addressing learning disability, child and adolescent psychiatry and forensic psychiatry specifically.2, , , , , , , , , , , and .3 and .4Prinsloo & Noonan, 2010.
Table 1. Diagnoses of individuals admitted involuntarily between 2007 and 2010 (, , , and ).