Case study on malingering diagnosis

I was excited when I picked up my mail today to find an advance copy of the latest issue of the Journal of Forensic Psychology Practice, with a long overdue article by me on malingering. As you can probably guess from the title, "Malingering as a Dichotomous Variable: Case Report on an Insanity Defendant," the article evolved out of a forensic case in which I was retained. I testified as an expert witness on the issue of insanity. The article critiques certain practices at an unnamed but easily identifiable state hospital.

Here is the abstract:

Malingering in forensic contexts has garnered increased attention in recent years. As a result, the past two decades have seen the development of more than a half dozen instruments to assess response styles. Although these instruments are gaining unprecedented popularity among forensic practitioners, there is little research on how closely practitioners adhere to the published guidelines for administration or interpretation. This article provides a case study of the use of one popular instrument, the Structured Inventory of Reported Symptoms, in an insanity case. Misinterpretation of the defendant’s scores contributed to the misclassification of malingering, which was used to bolster the government’s case at trial. This case suggests the need for better training and more caution when using instruments to assess response styles in forensic contexts.

No right to competence at SVP trial, court holds

You all know what a "Catch-22" is, right?

In the novel by the same name, that was the military catch that kept any airman from avoiding a combat mission. More broadly, it is a double bind in which a government bureaucracy achieves its goals through circular logic that in reality is both illogical and even immoral at times.

For a perfect, modern-day example, read last week's appellate opinion in the Wisconsin case of Ronald D. Luttrell (available here).

Luttrell is (or at least was) a pretty bad man. Back when he was 29 years old, he raped and killed an 83-year-old woman after breaking into her home. He is now 53 and because his prison term has ended, the state wants to lock him in a hospital so he cannot commit any future crimes.

What the appellate opinion boils down to is this: Luttrell does not have the right to be found competent before being tried as a Sexually Violent Predator. But the opinion is a great example of a Catch-22 because of its circular reasoning, geared not toward justice but toward achieving the state's utilitarian goal of incapacitation.

In the first catch, the court says that Luttrell is not being punished: He is facing civil commitment only to protect the public. Because he is not being punished, criminal protections do not apply. That is despite the fact that SVP "patients" face far more dire consequences than most criminal defendants. Here in California, for example, with one prior "qualifying offense" and an easily demonstrated risk to the public, you can get what amounts to a life sentence at a state hospital.

Second, the court argues, Luttrell must by definition be mentally ill or he could not be civilly committed. That is because, in order to be legal under U.S. Supreme Court holdings, a civil commitment must be based upon a diagnosed "mental abnormality" that makes the person "likely" to commit future sexually violent acts.

This is another great Catch-22. The mental illnesses that most frequently cause incompetence to stand trial are the big ones, like Schizophrenia and Mental Retardation. In SVP cases, people are assigned controversial diagnoses like Pedophilia, "Paraphilia NOS," and Antisocial Personality Disorder (see my previous posts, here and here). These conditions do not scramble the brain such that a person would be legally incompetent.

Competency is not some quirky technicality, by the way. It is a fundamental right in the criminal justice system in most countries. The idea, descended from British common law, is that it is patently unfair to put someone on trial when he is too crazy to defend himself. Not only that, but it makes the government look bad. The requirements for competency are also pretty basic. You need only a rudimentary understanding of your legal situation, and a minimal ability to assist your attorney in preparing a defense.

Contrary to what many people - including some defendants - think, being found incompetent in a criminal case does not necessarily get you off. You go to a state hospital, where you may spend more time incarcerated than if you had pleaded guilty and gone to jail.

However, there are limits. Back in the 1960s, a "feeble-minded" deaf-mute named Theon Jackson was found incompetent and received what amounted to a life sentence for two petty thefts totaling $9. His case triggered reforms that cap how much time a person can be hospitalized for competency restoration treatment. In Wisconsin, for example, a criminal defendant who is not likely to "become competent" within one year must be released from confinement unless he is eligible for the regular kind of civil commitment due to grave disability or dangerousness.

And that is precisely the worry of the Wisconsin court as to Sexually Violent Predators. Although they are dangerous under SVP definitions, most would not meet the criteria for dangerousness under the regular civil commitment laws, which require evidence of a recent act or threat to do serious bodily harm. Luttrell, for example, would not qualify because he committed his crime almost a quarter of a century ago.

But, hey, compared to the innocent children victimized in Operation Wagon Train or the Yearning for Zion raid, it's hard to muster a whole lot of sympathy for a guy who raped and murdered an 83-year-old woman in her own home. Even if it was a long time ago.

Hat tip: Luis Rosell. Photo credit: "Gilbert" (Creative Commons license).

Major ruling on forensic neuropsychology

Flexible wins epic
Battle of the Batteries

The Democrats have Obama versus Clinton. American Idol has the battle of the two Davids. But whoever heard of the battle between the fixed and the flexible batteries?

The New Hampshire Supreme Court, for one. And in that more obscure battle in the field of neuropsychology, the court this week handed a resounding victory to the flexible battery. Although I haven't seen anyone dancing in the streets, it's a victory that forensic psychologists and neuropsychologists should be celebrating.

A bit of background: The "fixed" battery approach involves rigid administration of a fixed set of tests. The most popular such batteries are the Halstead-Reitan and the Luria. The flexible or "Boston Process" approach, in contrast, involves administering a core set of tests, supplemented by extra tests chosen on the basis of specific case factors and hypotheses.

When I was a neuropsychology intern, I was trained in the Boston Process Approach. As it turns out, the overwhelming majority of neuropsychologists in a recent survey - 94% - said they use some type of flexible battery approach. As the New Hampshire Supreme Court pointed out, that makes it the standard of practice in the field.

The case involves the alleged lead poisoning of Shelby Baxter, now 13, when she was a toddler. The civil case against Ms. Baxter's landlord, whom the Baxters claim knew the apartment was contaminated, was dismissed after the trial judge excluded neuropsychological evidence using the Boston Process approach as not scientific. The case will now go forward.

The plaintiffs' neuropsychologist, Barbara Bruno-Golden, Ed.D, had substantial experience with lead-exposed children, and each individual test in her battery was published, tested, and peer reviewed, as befitting reliable science under the legal standard of Daubert and New Hampshire statutory law.

At a 6-day Daubert evidentiary hearing, the defense called controversial neuropsychologist David Faust, Ph.D., who testified that although Dr. Bruno-Golden's approach was generally accepted in clinical practice, it was not so in a forensic setting. The plaintiff's experts, as well as the American Academy of Clinical Neuropsychology in an amicus brief, correctly countered that there is no separate standard for forensic practice.

In its exhaustive and thoroughly reasoned opinion, the Supreme Court soundly rejected Faust's reasoning, issuing a monumental blow to the minority of forensic neuropsychologists who staunchly cling to the fixed battery approach.

"Under the defendants' position, no psychologist who uses a flexible battery would qualify as an expert, even though the flexible battery approach is the prevalent and well-accepted methodology for neuropsychology," the court pointed out. "Therefore, the implication … is that no neuropsychologist, or even psychiatrist or psychologist since, in their view, all combinations of tests need to be validated and reliable, could ever assist a trier of fact in a legal case."

The court held that any weaknesses in Bruno-Golden’s methodology - if indeed such existed - were properly handled through cross-examination and counterbalancing evidence in the adversarial trial process.

The case, Baxter v. Temple, is online here. A news article is here. A blog commentary at Traumatic Brain Injury is here.

Photo credit: 02ma (Creative Commons license)

"Fake Bad Scale": Lawyers advocate exposing in court

When a controversial test is being used against their client, attorneys may weigh the following questions:

• Should I seek an evidentiary hearing (under Frye or Daubert) and try to exclude the test?

• Or, should I let the test come in as evidence, and educate the jury about weaknesses in the underlying science?

This question regularly comes up at Sexually Violent Predator trials, regarding the controversial Static-99 risk assessment tool. Now, it is coming up in civil personal injury trials, regarding the MMPI-2's "Fake Bad Scale" (which I blogged about here back in March).

Increasingly, attorneys are choosing the second option when the science underlying a test is weak. They are openly critiquing the test and its findings, and allowing jurors to form their own conclusions. Yesterday's Lawyers USA features an article on how plaintiffs' attorneys are "turning the tables" on the Fake Bad Scale:

Although plaintiffs' attorneys are unanimous in despising the Fake Bad Scale, there is a mini-debate about whether it is more effective to exclude the test before trial or allow it in and discredit it while cross-examining the defense expert.

"It's a tough call, frankly," said Dorothy Clay Sims, a founding partner of Sims, McCarty, Amat & Stakenborg in Ocala, Fla., who has won three hearings over excluding the test.

"Frye and Daubert hearings are tough, but courts don't seem to like this test, so it's difficult to give up a hearing that you have a good chance of winning," she said. "On the other hand, once the Fake Bad Scale is demystified for the jury, and you pierce through it, they look at the defense doctor and say 'Oh, come on.' "

The article features the case of Sarah Jenkins, a medical receptionist who suffered tissue injuries and cognitive problems after her pick-up truck was hit by a delivery truck. She scored in the faking range on the Fake Bad Scale.

Rather than fighting to exclude the test, experienced trial attorney Dean Heiling made it a centerpiece. He cross-examined the defense expert at length about the test, and through his own expert exposed the controversy in the field about the test's validity.

Most interestingly, he put his client on the stand in rebuttal, and had her go through each test item and her answer with the jury.

Jurors deliberated only three hours before awarding a verdict of $225,749.

The lesson to forensic psychologists: Know your tests, and know their weaknesses.

The full story, by Sylvia Hsieh, is here, although it is only available to subscribers. For more on the controversy over the scale, see my previous post here.

Hat tip: Ken Pope

Scarface idolatry: Evidence of violence?

I was driving past an abandoned gas station where vendors usually sell fresh strawberries and oranges from the back of a pickup truck. This day, the vendors were selling Scarface posters instead. Framed ones, all different poses of the cultural icon.

The sight harkened me back to a young drug trafficker I evaluated. Although he had no known history of violence, federal agents found a Scarface poster along with a loaded handgun in his home. The poster, argued federal prosecutors, showed a propensity for violence.

I don't know how many young drug traffickers hang Scarface posters on their walls, but after last month's appellate decision in U.S. v. Marin I can say that it is not a good idea. Antonio Marin of Massachusetts was caught under very similar circumstances to the young man I evaluated. Charged with possessing a firearm in furtherance of drug trafficking, he said no, he simply had a "casual," innocent interest in guns. At trial, the government rebutted that defense by presenting a Scarface shadow box found in Marin's apartment. The display case contained (among other items) a picture of Al Pacino aiming a machine gun, a replica gun, and a cigar.

An appellate court upheld the use of the Scarface memorabilia against Marin, saying its probative value outweighed its potentially prejudicial impact.

That's where expert testimony might have proven helpful. As I wrote in my report in the similar case, research has established certain factors as correlated with violence. Scarface idolatry, no matter its intuitive appeal, is not one of them. If it was, the crime rate would be much higher: Scarface is one of the most popular DVD's on Amazon, and the Internet has dozens of Scarface-related sites and hundreds of spin-off products, including music tapes, posters, and T-shirts.

Researchers have studied the effects of violent media on aggression for decades, generating hundreds of studies on this topic. Although the debate continues to rage, there is general consensus that no direct link exists between violent cinematic imagery and real-life violence. Watching large amounts of violent movies or TV shows might encourage violence in those already so inclined, but fantasy violence is neither necessary nor sufficient to trigger real-life violence.

Interestingly, the potentially unfair prejudice of Scarface memorabilia was acknowledged in a second case last month, this time when the defense tried to introduce it at a trial.

High school students Jean Pierre Orlewicz and Alexander Letkemann of Michigan were on trial for a gruesome beheading-murder of a 26-year-old man named Daniel Sorensen. To bolster their claim of self defense, the teenagers sought to introduce images from Sorensen's MySpace page of - you guessed it - Scarface.

No can do, the judge ruled. The photos "would tend to move the jury to decide the matter on an improper basis such as inflamed passions and emotions."

Sorensen is not the only murder victim whose MySpace site was scoured for the low-down on his personality and proclivities. Indeed, that is one of the first places police (as well as people like me) will look for uncensored (if sometimes exaggerated) self portrayals when someone gets caught up in a crime. That potential reality is far from the minds of young people as they immerse themselves in the semi-public world of social networking.


Take the case of University of California Berkeley fraternity member Christopher Wootton. He was killed this month in a drunken, late-night brawl. His loyal friends and family insist he was a peaceable guy who must have been trying to defuse the combatants. On his MySpace site just a week earlier, however, he had bragged about grinding another man's face into the pavement during an unrelated drunken fight.

Will this admission be allowed in court, to bolster the 20-year-old murder defendant's contention that he acted in self defense? Only time will tell.

One thing is certain: If either of these young men had a Scarface poster on their wall, we will hear about it on the local news. And then those street-corner vendors might have to go back to selling fruit. So far, no one has tried to link strawberries to violence.

Hat tip: Colin Miller at EvidenceProf

Who will write the next DSM?

Would you believe: Pfizer, Eli Lilly, Wyeth, Merck, AstraZeneca and Bristol-Myers Squibb?

Or, at least, those are some of the BigPharma corporations with whom members of the task force charged with creating the 5th Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders have contracts.

It shouldn't come as a surprise. But it ought to alarm the public, given BigPharma's enormous and growing influence in so many spheres of public life all around the world.

More than half of the experts involved in the previous edition of the psychiatric bible also had monetary relationships with drug makers, according to a Tufts University study. The percentage was up to 100 percent for experts working on certain severe mental illnesses, such as schizophrenia. (The New York Times story on that 2006 research is here.)

A just-published book, The Medicalization of Society: On the Transformation of Human Conditions into Treatable Disorders, has more on this construction of difference as illness. Trends that author Peter Conrad notes include the medicalization of "male" problems such as baldness and sexual impotence, and the pathologizing of children's behavior and appearance (short kids now have idiopathic short stature which requires synthetic human growth hormone).

Another new book, The Rise of Viagra, further documents the pathologizing of sexual variation, including an effort by BigPharma's spin doctors to create public hysteria and a new market for medicines to treat Female Sexual Dysfunction."

Meanwhile, as I've blogged about elsewhere, the sex offender industry is lobbying for new diagnoses to medicalize illegal sexual conduct, including "hebephilia" for men who are sexually attracted to teens, and "Paraphilia Not Otherwise Specified-Nonconsent" for men who rape.

Look for all these, and more, as possible candidates for the new and expanded DSM-V. Each edition of the DSM contains more diagnoses than its predecessor, and each diagnosis is supposedly treatable with meds. DSM-I (1952) listed 106 mental disorders, DSM-II (1968) had 185, DSM-III (1980) had 265, and DSM-IV (1994) has 357. That's an average of about 84 new diagnoses per edition, so the DSM-V should have 440 or more diagnoses.

Hopefully, this week's blog post by New York Times health writer Tara Parker-Pope about the conflict of interest signals that the public will be kept informed.

The consumer watchdog group Integrity in Science, a project of the Center for Science in the Public Interest, is also following the scent of money. See my Amazon book list, Critical Perspectives on Psychiatry, for other books on the DSM and the construction of illness.