Bipolar disorder by proxy proposed for DSM-5

New diagnosis to address "critical clinical need"

Although some scholars warn of dangers posed by the proposed expansions of psychiatric disorders, others say there remains a critical shortage of accurate diagnoses for those who need them. At a forensic psychiatry conference last month, for example, proponents said three new sexual disorders are needed to address an urgent clinical reality.

Incorporation of such broad-brush conditions as "psychosis risk syndrome," "temper dysregulation disorder," and "hebephilia" into the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), due out in 2013, will help address the diagnostic shortfall, the clinical realists say. But more should be done.

To help meet the needs of those few who remain undiagnosed, California psychologist Michael Donner has proposed an umbrella disorder. To qualify for the newly minted Bipolar by Proxy (BPP), patients must meet at least one of the following criteria during the preceding two-year period:

1. A pervasive sense of well being
2. Repetitive episodes of sadness or pleasure while engaging in pleasant or unpleasant activities, typically lasting for the duration of the activity
3. A minimum of one episode of feeling extremely excited or irritated
4. Two or more episodes of crying, or three or more episodes of an urge to cry
5. Engaging in laughing behavior when confronted with something humorous
6. A general willingness to comply with a prescription medication regimen despite having no overt symptoms
7. One or more major medical health insurance reimbursement plans

As a rule-out, the disorder must not occur in the presence of any other previously undiagnosed mental illness. Nor can it be due to the direct physiological effects of exogenous substances (e.g., drugs of abuse or medications).

There may be no need to market a new drug for this condition. The prescription depressant Despondex (see below video) has been on the market for more than a year and targets annoying exuberance, a core symptom of Bipolar by Proxy that often alerts clinicians to conduct a more thorough diagnostic workup.

Although the reliability of the proposed diagnosis has not yet been established through clinical replication studies published in peer-reviewed journals, this should not be a barrier as field trials are being planned in time to make it into the manual just under the wire. The sites for the field trials will be strategically selected to maximize positive findings. Similarly, high inter-rater reliability will be assured through careful selection, training, and certification of raters by the Bipolar By Proxy Promulgation Association. The journal whose editorial board is dominated by that Association is expected to publish the positive findings. The larger question of validity is not thought to be a problem, as many other current and proposed diagnoses lack real-world validity.

Related post:

Despondex: Is psych mania overreaching? (June 22, 2009)

Photo credit: Eva Blue, Creative Commons License, Peaceful Heart Doctor, San Francisco Chinatown

Historical review of false confessions

If you are looking for more information on false confessions but don't want to read an entire book, last month's New York magazine has a nice historical overview. Contributing editor Robert Kolker goes into depth about the science of interrogation tactics and false-confession psychology, and also proposes some solutions. The fascinating piece, anchored around a 1988 murder case in a hamlet in upstate New York, would make a good reading assignment for students.

Don’t miss Frontline's "The Confessions" airing Tuesday

The Norfolk Four sailors are out of prison, but they remain convicted sex offenders with all of the stigma and draconian restrictions that status entails. Now comes what some are calling the best program ever on the subject of why people falsely confess:

Why would four innocent men confess to a brutal crime they didn’t commit? FRONTLINE producer Ofra Bikel (Innocence Lost, An Ordinary Crime) investigates the conviction of four Navy sailors for the rape and murder of a Norfolk, Va., woman in 1997. In interviews with the sailors, Bikel learns of some of the high-pressure police interrogation techniques -- including the threat of the death penalty, sleep deprivation, and intimidation -- that led each of the “Norfolk Four” to confess, despite a lack of evidence linking them to the crime. All four sailors are now out of prison -- one served his sentence and the other three were granted conditional pardons last summer -- but the men were not exonerated as felons or sex offenders. The case raises disturbing questions about the actions of the police and prosecutors, who relied on the sailors’ often contradictory confessions for their convictions, and disregarded DNA evidence that pointed to a lone assailant who would later confess to the crime himself while serving prison time for another rape.

Airing this Tuesday night on PBS, The Confessions is incredibly timely. Two weeks ago, a federal jury convicted the lead homicide detective of extortion for taking bribes from criminals in exchange for favorable treatment in a series of unrelated cases.

But meanwhile, the four sailors from whom he extracted confessions continue to live "in a hellish limbo," writes Virginia journalist Margaret Edds, author of "An Expendable Man: The Near-Execution of Earl Washington Jr."

• In Michigan, Danial Williams wears an electronic ankle bracelet 24 hours a day. He cannot even work in the yard without permission.

• In Texas, Eric Wilson was denied admission to a school for electricians and cannot adopt his wife’s son because of his criminal record.

• In North Carolina, Derek Tice washes windows for a living, his dream of becoming a nurse forever barred.

• In Maryland, Joseph Dick fears taking his parents’ dogs for a walk because a school backs up to their property.

Having blogged about this case since 2007, I am excited to see this show finally airing. Hopefully, it will create enough public pressure to force Virginia's governor to at long last exonerate the four.

So, as a colleague said, "Tape it, burn it, TIVO it, watch it, have your family members watch it, have their friends watch it, have your students watch it, your teenage children watch it, tweet it, Facebook it, blog it."

Bottom line: Don't miss it.

Further resources:

PBS' website on The Confessions is HERE.

My reviews of The Wrong Guys by Tom Wells and Richard Leo are HERE (Amazon) and HERE (California Lawyer magazine).

Prior blog posts on the case:

• Another fascinating disputed confession case (Sept. 24, 2007)

• The Wrong Guys: New book explodes myth that innocent do not confess (Dec. 8, 2008)

Hat tip: Luis

Cheer for rapist or else, appellate court rules

First, she was raped.

Then, she was told she must cheer for her rapist.

Now, a federal appeals court ruling that she had no grounds to protest is putting the tiny town of Silsbee, Texas on the map.

It all started when a group of boys grabbed 16-year-old "H.S." at a post-football game party two years ago, dragged her into a room, locked the door, and proceeded to sexually assault her.

After the assault, H.S. went back to cheerleading at Silsbee High School. But when her rapist sauntered up to the foul line for a free throw, H.S. sat down and turned her back.

"I didn’t want to have to say his name, and I didn’t want to cheer for him," the girl said. "I didn't want to encourage anything he was doing."

The district superintendent, his assistant, and the school principal called her outside and demanded that she cheer for the star athlete, Rakheem Bolton. Either that, or go home. Fans, meanwhile, sat in the bleachers and mocked the crying girl.

As is frequently the case in gang rapes involving athletes and other cultural icons of masculinity, the high school and community rallied around the rapists. H.S. was forced off the squad. In the coming weeks, she and her family underwent a campaign of harassment in the small town of 6,300.

"They were the star athletes, and I was standing up to them," San Francisco Chronicle legal reporter Bob Egelko quotes her as saying.

A panel of three of the most conservatives judges on the Fifth U.S. Circuit of Appeals in New Orleans has denied her claim that her free speech rights were violated. As a "mouthpiece" for the school, she had no right to refuse to cheer for her rapist, they ruled. Indeed, it was she and not the school whose rights were violated:

As a cheerleader … H.S. was contractually required to cheer for the basketball team, whose roster included Bolton…. H.S. served as a mouthpiece through which [the school] could disseminate speech -- namely, support for its athletic teams…. [H.S.'s refusal to cheer] constituted substantial interference with the work of the school because, as a cheerleader, H.S. was at the basketball game for the purpose of cheering, a position she undertook voluntarily.

The girl's lawyer said he will petition for a rehearing in front of the full appeals court.

While the cheerleading aspect of this case is unusual, gang rapes by members of the masculine elite such as athletes, soldiers and fraternity members are common. As I discuss in my theoretical overview of gang rape in Sexuality Research and Social Policy, such assaults serve a variety of functions, including social bonding, the celebration of power, and the public display of heterosexual masculinity through the subordination of women. In other words, group rape of women is a form of cultural theater, in which the victim serves as a mere dramatic prop.

As in this case, the main weapon of these group rapists is alcohol. Also common is for police, prosecutors, judges, school officials and other representatives of the power structure to side with the assailants against the victim.

Here, it appears that H.S. was re-victimized at every stage in the process.

Although Bolton and two alleged co-participants were arrested almost immediately, an initial grand jury declined to indict. Meanwhile, H.S. and her family were told that the rape kit collected that night would not be processed for DNA evidence for more than a year, due to a backlog of cases. The boys were allowed to return to school, and Bolton was allowed back on the basketball team.

When H.S. complained to school officials that students were taunting her in the cafeteria, they told her to keep a low profile and stay out of the cafeteria, according to her court documents.

Eventually, a special prosecutor was appointed. Bolton pleaded guilty to a lesser assault charge and was expelled from the school. He has denied raping H.S., and said it was all a "misunderstanding." The case of codefendant Christian Rountree is still pending.

No matter what the 5th Circuit Court says, it seems outrageous to me that someone can essentially be fired from a job for refusing to cheer for her rapist. But, hey, that's just me.

Bob Egelko's excellent article, explaining the legal landscape of diminishing free speech rights on high school campuses, is HERE. The 5th Circuit ruling is HERE.

Photo: Ultra-conservative jurist Priscilla Owen,
one of three judges who issued the ruling against the cheerleader.

Residency restrictions illegal, Calif judge rules

"Court is not a potted plant"

Breaking news from the Los Angeles Times:

Saying sex offenders are being forced to choose between prison and homelessness, a Los Angeles judge issued an opinion this week blocking enforcement of provisions a state law restricting how close those offenders can live from parks or schools.

Superior Court Judge Peter Espinoza issued the 10-page ruling after four registered sex offenders petitioned the court, arguing that the legislation known as Jessica's Law was unconstitutional.

He said the court had received about 650 habeas corpus petitions raising similar legal issues, and that hundreds more were being prepared....

"The court is not a 'potted plant' and need not sit idly by in the face of immediate, ongoing and significant violations of parolee constitutional rights," Espinoza wrote.

Proposition 83, which is better known as Jessica's Law and was overwhelmingly passed by state voters in 2006, imposes strict residency requirements on sex offenders, including requirements forbidding them from residing within 2,000 feet of any public or private school or park where children regularly gather….

"Rather than protecting public safety, it appears that the sharp rise in homelessness rates in sex offenders on active parole in Los Angeles County actually undermines public safety," wrote Espinoza, who is the supervising judge of the Los Angeles County criminal courts. "The evidence presented suggests that despite lay belief, a sex offender parolee's residential proximity to a school or park where children regularly gather does not bear on the parolee's likelihood to commit a sexual offense against a child." …

New report on parolee recidivism

Meanwhile, California's Department of Corrections has released a new report on recidivism among parolees.

The state's recidivism rates remain among the highest in the United States, the report found, with more than two-thirds of paroled prisoners back behind bars within three years. Younger men and those with shorter sentences had the highest rates.

Almost three in four new imprisonments were for parole violations rather than new crimes, emphasizing the need for alternatives to incarceration for technical violations.

The bright lining is in the recidivism rates of sex offenders, such as those in Los Angeles who cannot find a place to live.

Parolees flagged as sex offenders had lower recidivism rates than other prisoners. And only about 5 percent of those who were sent back to prison had committed a new sex crime. The broad majority were returned for parole violations or non-sexual crimes.

These low sexual recidivism rates are consistent with correctional data from elsewhere in the United States. Unfortunately, as the Los Angeles judge alluded to, thanks to a few rare but highly publicized cases (remember the "black swans"?), the public has not gotten this message.

Judge denies defense expert in capital case

Death penalty cases are expensive.

I spoke with a condemned man on San Quentin Prison's death row who had done the math: The money spent on his trial and appeals could have paid for a year of public education for all of the children in his home town.

The high cost is causing many prosecutors around the United States to think twice before seeking the ultimate penalty. In the Midwestern state of Indiana, for example, capital prosecutions are down in the wake of a state study showing the cost is 10 times more than if the government seeks a sentence of life without parole.

But one crusading prosecutor in Indiana has a more novel solution: Prevent the accused from mounting a defense.

"I feel very strongly about defense death penalty costs," said prosecutor Stan Levco of Vanderburgh County in objecting to a defense request to hire a psychologist.

Astoundingly, the trial judge agreed, and declined the defense request for a psychologist to assist in the defense of Jeffrey Weisheit. The defendant faces trial for murder and arson in the death of his girlfriend's two young daughters. Judge Daniel Moore approved the limited use of a psychologist, just through November, in order to help decide whether Weisheit should plead insane, according to the Evansville (Indiana) Courier and Press.

This puts the defense attorneys in a bind. The standard of practice in capital cases is to hire a team of experts to explore the defendant's life for evidence of mitigating circumstances that can then be presented to the jury. In fact, not to do so may violate a defendant's Constitutional right to effective representation, according to the 2003 case of Wiggins v. Smith.

Expert assistance is even more critical in cases like this one, in which the defendant's mental state may be at issue.

But the financial burden of the trial has been on the public's mind in these cash-strapped times. When a defendant is indigent, as most are, the state public defender pays half of the trial costs, and the other half comes directly from county coffers. According to the state analysis, the average death case in Indiana costs about $450,000; defense attorneys in this case estimate costs may run almost twice that average.

In June, the local paper even ran an opinion poll:

As a taxpayer, are you OK with seeking the death penalty for Jeffrey Weisheit if the estimated cost of approximately $800,000 is used in his defense?

Of the 461 people who voted, 78 percent said "YES." Two-thirds of these thought "there should be a cap on what public defenders can spend on defense.”

Public opinion is hard to ignore.

The prosecutor, meanwhile, says he is so concerned about defense expenses in death penalty cases that he has formed a special prosecutorial committee to study the issue. With such deep concern, it is interesting that he decided to seek the death penalty in the first place. After all, most such efforts are a waste of money. They add years to the process and do not ultimately result in an execution. Between 1990 and 2000, according to the Indiana study, only about one out of six capital prosecutions resulted in a death sentence, and only four of those has led to an actual execution. Indiana currently has 15 prisoners on death row, and six other capital cases pending.

Levco may care about the cost, but I'll bet he cares even more about winning. And he has found an innovative way to improve his odds.

It will be like shooting ducks in a barrel.