What is the Americans with Disabilities Act of 1990?

Introduction

The Americans with Disabilities Act of 1990 or ADA (42 U.S.C. § 12101) is a civil rights law that prohibits discrimination based on disability.

It affords similar protections against discrimination to Americans with disabilities as the Civil Rights Act of 1964, which made discrimination based on race, religion, sex, national origin, and other characteristics illegal, and later sexual orientation. In addition, unlike the Civil Rights Act, the ADA also requires covered employers to provide reasonable accommodations to employees with disabilities, and imposes accessibility requirements on public accommodations.

In 1986, the National Council on Disability had recommended the enactment of an Americans with Disabilities Act (ADA) and drafted the first version of the bill which was introduced in the House and Senate in 1988. The final version of the bill was signed into law on 26 July 1990, by President George H. W. Bush. It was later amended in 2008 and signed by President George W. Bush with changes effective as of 01 January 2009.

Brief History

The ADA has roots in Section 504 of the Rehabilitation Act of 1973.

Drafting

In 1986, the National Council on Disability (NCD), an independent federal agency, issued a report, Towards Independence, in which the Council examined incentives and disincentives in federal laws towards increasing the independence and full integration of people with disabilities into our society. Among the disincentives to independence the Council identified was the existence of large remaining gaps in our nation’s civil rights coverage for people with disabilities. A principal conclusion of the report was to recommend the adoption of comprehensive civil rights legislation, which became the ADA.

The idea of federal legislation enhancing and extending civil rights legislation to millions of Americans with disabilities gained bipartisan support in late 1988 and early 1989. In early 1989 both Congress and the newly inaugurated Bush White House worked separately, then jointly, to write legislation capable of expanding civil rights without imposing undue harm or costs on those already in compliance with existing rules and laws.

Lobbying

Over the years, key activists and advocates played an important role in lobbying members of the US Congress to develop and pass the ADA, including Justin Whitlock Dart Jr., Patrisha Wright and others.

Ms. Wright is known as “the General” for her work in coordinating the campaign to enact the ADA. She is widely considered the main force behind the campaign lobbying for the ADA.

Support and Opposition

Support

About the importance of making employment opportunities inclusive, Shirley Davis, director of global diversity and inclusion at the Society for Human Resource Management, said: “People with disabilities represent a critical talent pool that is underserved and underutilized”.

Opposition from Religious Groups

The debate over the ADA led some religious groups to take opposite positions. The Association of Christian Schools International opposed the ADA in its original form, primarily because the ADA labelled religious institutions “public accommodations” and thus would have required churches to make costly structural changes to ensure access for all. The cost argument advanced by ACSI and others prevailed in keeping religious institutions from being labelled as “public accommodations”.

Church groups such as the National Association of Evangelicals testified against the ADA’s Title I employment provisions on grounds of religious liberty. The NAE believed the regulation of the internal employment of churches was “… an improper intrusion [of] the federal government.”

Opposition from Business Interests

Many members of the business community opposed the Americans with Disabilities Act. Testifying before Congress, Greyhound Bus Lines stated that the act had the potential to “deprive millions of people of affordable intercity public transportation and thousands of rural communities of their only link to the outside world.” The US Chamber of Commerce argued that the costs of the ADA would be “enormous” and have “a disastrous impact on many small businesses struggling to survive.” The National Federation of Independent Businesses, an organization that lobbies for small businesses, called the ADA “a disaster for small business.” Pro-business conservative commentators joined in opposition, writing that the Americans with Disabilities Act was “an expensive headache to millions” that would not necessarily improve the lives of people with disabilities.

“Capitol Crawl”

Shortly before the act was passed, disability rights activists with physical disabilities coalesced in front of the Capitol Building, shed their crutches, wheelchairs, powerchairs and other assistive devices, and immediately proceeded to crawl and pull their bodies up all 100 of the Capitol’s front steps, without warning. As the activists did so, many of them chanted “ADA now”, and “Vote, Now”. Some activists who remained at the bottom of the steps held signs and yelled words of encouragement at the “Capitol Crawlers”. Jennifer Keelan, a second grader with cerebral palsy, was videotaped as she pulled herself up the steps, using mostly her hands and arms, saying “I’ll take all night if I have to.” This direct action is reported to have “inconvenienced” several senators and to have pushed them to approve the act. While there are those who do not attribute much overall importance to this action, the “Capitol Crawl” of 1990 is seen by some present-day disability activists in the United States as a central act for encouraging the ADA into law.

Final Passage

Senator Tom Harkin (D-IA) authored what became the final bill and was its chief sponsor in the Senate. Harkin delivered part of his introduction speech in sign language, saying it was so his deaf brother could understand.

George H. W. Bush, on signing the measure on 26 July 1990, said:

I know there may have been concerns that the ADA may be too vague or too costly, or may lead endlessly to litigation. But I want to reassure you right now that my administration and the United States Congress have carefully crafted this Act. We’ve all been determined to ensure that it gives flexibility, particularly in terms of the timetable of implementation; and we’ve been committed to containing the costs that may be incurred…. Let the shameful wall of exclusion finally come tumbling down.

ADA Amendments Act (2008)

The ADA defines a covered disability as a physical or mental impairment that substantially limits one or more major life activities, a history of having such an impairment, or being regarded as having such an impairment. The Equal Employment Opportunity Commission (EEOC) was charged with interpreting the 1990 law with regard to discrimination in employment. The EEOC developed regulations limiting an individual’s impairment to one that “severely or significantly restricts” a major life activity. The ADAAA directed the EEOC to amend its regulations and replace “severely or significantly” with “substantially limits”, a more lenient standard.

On 25 September 2008, President George W. Bush signed the ADA Amendments Act of 2008 (ADAAA) into law. The amendment broadened the definition of “disability”, thereby extending the ADA’s protections to a greater number of people. The ADAAA also added to the ADA examples of “major life activities” including, but not limited to, “caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working” as well as the operation of several specified major bodily functions. The act overturned a 1999 US Supreme Court case that held that an employee was not disabled if the impairment could be corrected by mitigating measures; it specifically provides that such impairment must be determined without considering such ameliorative measures. It also overturned the court restriction that an impairment that substantially limits one major life activity must also limit others to be considered a disability. In 2008, the United States House Committee on Education and Labour stated that the amendment “makes it absolutely clear that the ADA is intended to provide broad coverage to protect anyone who faces discrimination on the basis of disability.” Thus the ADAAA led to broader coverage of impaired employees.

25th Anniversary (2015)

As of 2015 the ADA had improved access to public services, the built environment (e.g. crosswalks with curb cuts and accessible pedestrian signals), understanding of the abilities of people with disabilities, established a right to equal access to public services and has demonstrated the contributions which people with disabilities can make to the economy. Disparities have remained in employment, earned income, Internet access, transportation, housing, and educational attainment and the disabled remain at a disadvantage with respect to health and health care.

On 20 July 2015, the White House held a reception to celebrate the 25th anniversary of the ADA. The introductory remarks were given by Haben Girma, a deafblind disability rights lawyer and advocate. Among the guests was Alice Wong, a disability rights activist who came via telepresence robot.

Web Content Accessibility Guidelines (2019)

In October 2019, the Supreme Court declined to resolve a circuit split as to whether websites are covered by the ADA. The Court turned down an appeal from Domino’s Pizza and let stand a US 9th Circuit Court of Appeals ruling which held that the Americans With Disabilities Act protects access not just to brick-and-mortar public accommodations, but also to the websites and apps of those businesses.

Disabilities Included

ADA disabilities include both mental and physical medical conditions. A condition does not need to be severe or permanent to be a disability.

Equal Employment Opportunity Commission regulations provide a list of conditions that should easily be concluded to be disabilities: deafness, blindness, an intellectual disability (formerly termed mental retardation), partially or completely missing limbs or mobility impairments requiring the use of a wheelchair, autism, cancer, cerebral palsy, diabetes, epilepsy, attention deficit hyperactivity disorder, Human Immunodeficiency Virus (HIV) infection, multiple sclerosis, muscular dystrophy, major depressive disorder, bipolar disorder, post-traumatic stress disorder, obsessive compulsive disorder, and schizophrenia. Other mental or physical health conditions also may be disabilities, depending on what the individual’s symptoms would be in the absence of “mitigating measures” (medication, therapy, assistive devices, or other means of restoring function), during an “active episode” of the condition (if the condition is episodic).

Certain specific conditions that are widely considered anti-social, or tend to result in illegal activity, such as kleptomania, paedophilia, exhibitionism, voyeurism, etc. are excluded under the definition of “disability” in order to prevent abuse of the statute’s purpose. Additionally, gender identity or orientation is no longer considered a disorder and is also excluded under the definition of “disability”.

Titles

Title I – Employment

The ADA states that a “covered entity” shall not discriminate against “a qualified individual with a disability”. This applies to job application procedures, hiring, advancement and discharge of employees, job training, and other terms, conditions, and privileges of employment. “Covered entities” include employers with 15 or more employees, as well as employment agencies, labour organisations, and joint labour-management committees. There are strict limitations on when a covered entity can ask job applicants or employees disability-related questions or require them to undergo medical examination, and all medical information must be kept confidential.

Prohibited discrimination may include, among other things, firing or refusing to hire someone based on a real or perceived disability, segregation, and harassment based on a disability. Covered entities are also required to provide reasonable accommodations to job applicants and employees with disabilities. A reasonable accommodation is a change in the way things are typically done that the person needs because of a disability, and can include, among other things, special equipment that allows the person to perform the job, scheduling changes, and changes to the way work assignments are chosen or communicated. An employer is not required to provide an accommodation that would involve undue hardship (significant difficulty or expense), and the individual who receives the accommodation must still perform the essential functions of the job and meet the normal performance requirements. An employee or applicant who currently engages in the illegal use of drugs is not considered qualified when a covered entity takes adverse action based on such use.

There are many ways to discriminate against people based on disabilities, including psychological ones. Anyone known to have a history of mental disorders can be considered disabled. Employers with more than 15 employees must take care to treat all employees fairly and with any accommodations needed. Even when an employee is doing a job exceptionally well, she or he is not necessarily no longer disabled; employers must continue to follow all policies for the disabled.

Part of Title I was found unconstitutional by the United States Supreme Court as it pertains to states in the case of Board of Trustees of the University of Alabama v. Garrett as violating the sovereign immunity rights of the several states as specified by the Eleventh Amendment to the United States Constitution. The Court determined that state employees cannot sue their employer for violating ADA rules. State employees can, however, file complaints at the Department of Justice or the Equal Employment Opportunity Commission, who can sue on their behalf.

Title II – Public Entities (and Public Transportation)

Title II prohibits disability discrimination by all public entities at the local level, e.g., school district, municipal, city, or county, and at state level. Public entities must comply with Title II regulations by the US Department of Justice. These regulations cover access to all programmes and services offered by the entity. Access includes physical access described in the ADA Standards for Accessible Design and programmatic access that might be obstructed by discriminatory policies or procedures of the entity.

Title II applies to public transportation provided by public entities through regulations by the US Department of Transportation. It includes the National Railroad Passenger Corporation (Amtrak), along with all other commuter authorities. This section requires the provision of paratransit services by public entities that provide fixed-route services. ADA also sets minimum requirements for space layout in order to facilitate wheelchair securement on public transport.

Title II also applies to all state and local public housing, housing assistance, and housing referrals. The Office of Fair Housing and Equal Opportunity is charged with enforcing this provision.

Title III – Public Accommodations (and Commercial Facilities)

Under Title III, no individual may be discriminated against on the basis of disability with regards to the full and equal enjoyment of the goods, services, facilities, or accommodations of any place of public accommodation by any person who owns, leases, or operates a place of public accommodation. Public accommodations include most places of lodging (such as inns and hotels), recreation, transportation, education, and dining, along with stores, care providers, and places of public displays.

Under Title III of the ADA, all new construction (construction, modification or alterations) after the effective date of the ADA (approximately July 1992) must be fully compliant with the Americans With Disabilities Act Accessibility Guidelines (ADAAG) found in the Code of Federal Regulations at 28 C.F.R., Part 36, Appendix A.

Title III also has applications to existing facilities. One of the definitions of “discrimination” under Title III of the ADA is a “failure to remove” architectural barriers in existing facilities. See 42 U.S.C. § 12182(b)(2)(A)(iv). This means that even facilities that have not been modified or altered in any way after the ADA was passed still have obligations. The standard is whether “removing barriers” (typically defined as bringing a condition into compliance with the ADAAG) is “readily achievable”, defined as “…easily accomplished without much difficulty or expense”.

The statutory definition of “readily achievable” calls for a balancing test between the cost of the proposed “fix” and the wherewithal of the business and/or owners of the business. Thus, what might be “readily achievable” for a sophisticated and financially capable corporation might not be readily achievable for a small or local business.

There are exceptions to this title; many private clubs and religious organizations may not be bound by Title III. With regard to historic properties (those properties that are listed or that are eligible for listing in the National Register of Historic Places, or properties designated as historic under state or local law), those facilities must still comply with the provisions of Title III of the ADA to the “maximum extent feasible” but if following the usual standards would “threaten to destroy the historic significance of a feature of the building” then alternative standards may be used.

Under 2010 revisions of Department of Justice regulations, newly constructed or altered swimming pools, wading pools, and spas must have an accessible means of entrance and exit to pools for disabled people. However, the requirement is conditioned on whether providing access through a fixed lift is “readily achievable”. Other requirements exist, based on pool size, include providing a certain number of accessible means of entry and exit, which are outlined in Section 242 of the standards. However, businesses are free to consider the differences in the application of the rules depending on whether the pool is new or altered, or whether the swimming pool was in existence before the effective date of the new rule. Full compliance may not be required for existing facilities; Section 242 and 1009 of the 2010 Standards outline such exceptions.

Service Animals

The ADA provides explicit coverage for service animals. Guidelines have been developed not only to protect persons with disabilities but also to indemnify businesses from damages related to granting access to service animals on their premises. Businesses are allowed to ask if the animal is a service animal and ask what tasks it is trained to perform, but they are not allowed to ask the service animal to perform the task nor ask for a special ID of the animal. They cannot ask what the person’s disabilities are. A person with a disability cannot be removed from the premises unless either of two things happen: the animal is out of control and its owner cannot get it under control (e.g. a dog barking uncontrollably in a restaurant), or the animal is a direct threat to people’s health and safety. Allergies and fear of animals would not be considered a threat to people’s health and safety, so it would not be a valid reason to deny access to people with service animals. Businesses that prepare or serve food must allow service animals and their owners on the premises even if state or local health laws otherwise prohibit animals on the premises. In this case, businesses that prepare or serve food are not required to provide care or food for service animals, nor do they have to provide a designated area for the service animal to relieve itself. Lastly, people that require service dogs cannot be charged an extra fee for their service dog or be treated unfairly, for example, being isolated from people at a restaurant. People with disabilities cannot be treated as “less than” other customers. However, if a business normally charges for damages caused by the person to property, the customer with a disability will be charged for his/her service animal’s damages to the property.

Auxiliary Aids

The ADA provides explicit coverage for auxiliary aids.

Auxiliary aids and services are items, equipment or services that assist in effective communication between a person who has a hearing, vision or speech disability and a person who does not.

ADA says that a public accommodation shall take those steps that may be necessary to ensure that no individual with a disability is excluded, denied services, segregated or otherwise treated differently than other individuals because of the absence of auxiliary aids and services, unless the public accommodation can demonstrate that taking those steps would fundamentally alter the nature of the goods, services, facilities, privileges, advantages, or accommodations being offered or would result in an undue burden, i.e. significant difficulty or expense. The term “auxiliary aids and services” includes:

  • Qualified interpreters on-site or through video remote interpreting (VRI) services; notetakers; real-time computer-aided transcription services; written materials; exchange of written notes; telephone handset amplifiers; assistive listening devices; assistive listening systems; telephones compatible with hearing aids; closed caption decoders; open and closed captioning, including real-time captioning; voice, text, and video-based telecommunications products and systems, including text telephones (TTYs), videophones, and captioned telephones, or equally effective telecommunications devices; videotext displays; accessible electronic and information technology; or other effective methods of making aurally delivered information available to individuals who are deaf or hard of hearing;
  • Qualified readers; taped texts; audio recordings; Brailled materials and displays; screen reader software; magnification software; optical readers; secondary auditory programmes (SAP); large print materials; accessible electronic and information technology; or other effective methods of making visually delivered materials available to individuals who are blind or have low vision;
  • Acquisition or modification of equipment or devices; and
  • Other similar services and actions.

Captions are considered one type of auxiliary aid. Since the passage of the ADA, the use of captioning has expanded. Entertainment, educational, informational, and training materials are captioned for deaf and hard-of-hearing audiences at the time they are produced and distributed. The Television Decoder Circuitry Act of 1990 requires that all televisions larger than 13 inches sold in the United States after July 1993 have a special built-in decoder that enables viewers to watch closed-captioned programming. The Telecommunications Act of 1996 directs the Federal Communications Commission (FCC) to adopt rules requiring closed captioning of most television programming. The FCC’s rules on closed captioning became effective 01 January 1998.

Title IV – Telecommunications

Title IV of the ADA amended the landmark Communications Act of 1934 primarily by adding section 47 U.S.C. § 225. This section requires that all telecommunications companies in the U.S. take steps to ensure functionally equivalent services for consumers with disabilities, notably those who are deaf or hard of hearing and those with speech impairments. When Title IV took effect in the early 1990s, it led to the installation of public teletypewriter (TTY) machines and other TDD (telecommunications devices for the deaf). Title IV also led to the creation, in all 50 states and the District of Columbia, of what was then called dual-party relay services and now are known as Telecommunications Relay Services (TRS), such as STS relay. Today, many TRS-mediated calls are made over the Internet by consumers who use broadband connections. Some are Video Relay Service (VRS) calls, while others are text calls. In either variation, communication assistants translate between the signed or typed words of a consumer and the spoken words of others. In 2006, according to the Federal Communications Commission (FCC), VRS calls averaged two million minutes a month.

Title V – Miscellaneous Provisions

Title V includes technical provisions. It discusses, for example, the fact that nothing in the ADA amends, overrides or cancels anything in Section 504. Additionally, Title V includes an anti-retaliation or coercion provision. The Technical Assistance Manual for the ADA explains this provision:

III-3.6000 Retaliation or coercion. Individuals who exercise their rights under the ADA, or assist others in exercising their rights, are protected from retaliation. The prohibition against retaliation or coercion applies broadly to any individual or entity that seeks to prevent an individual from exercising his or her rights or to retaliate against him or her for having exercised those rights … Any form of retaliation or coercion, including threats, intimidation, or interference, is prohibited if it is intended to interfere.

Reaction

Criticism

Employment

The ADA has been criticised on the grounds that it decreases the employment rate for people with disabilities and raises the cost of doing business for employers, in large part due to the additional legal risks, which employers avoid by quietly avoiding hiring people with disabilities. Some researchers believe that the law has been ineffectual. Between 1991 (after the enactment of the ADA) and 1995, the employment rate of men with disabilities dropped by 7.8% regardless of age, educational level, or type of disability, with the most affected being young, less-educated and mentally disabled men. Despite the many criticisms, a causal link between the ADA and declining disabled employment over much of the 1990s has not been definitively identified.

In 2001, for men of all working ages and women under 40, Current Population Survey data showed a sharp drop in the employment of disabled workers, leading at least two economists to attribute the cause to the Act. By contrast, a study in 2003 found that while the Act may have led to short term reactions by employers, in the long term, there were either positive or neutral consequences for wages and employment. In 2005 the rate of employment among disabled people increased to 45% of the population of disabled people.

“Professional Plaintiffs”

Since enforcement of the act began in July 1992, it has quickly become a major component of employment law. The ADA allows private plaintiffs to receive only injunctive relief (a court order requiring the public accommodation to remedy violations of the accessibility regulations) and attorneys’ fees, and does not provide monetary rewards to private plaintiffs who sue non-compliant businesses. Unless a state law, such as the California Unruh Civil Rights Act, provides for monetary damages to private plaintiffs, persons with disabilities do not obtain direct financial benefits from suing businesses that violate the ADA.

The attorneys’ fees provision of Title III does provide incentive for lawyers to specialise and engage in serial ADA litigation, but a disabled plaintiff does not obtain a financial reward from attorneys’ fees unless they act as their own attorney, or as mentioned above, a disabled plaintiff resides in a state that provides for minimum compensation and court fees in lawsuits. Moreover, there may be a benefit to these “private attorneys general” who identify and compel the correction of illegal conditions: they may increase the number of public accommodations accessible to persons with disabilities. “Civil rights law depends heavily on private enforcement. Moreover, the inclusion of penalties and damages is the driving force that facilitates voluntary compliance with the ADA.” Courts have noted:

As a result, most ADA suits are brought by a small number of private plaintiffs who view themselves as champions of the disabled. For the ADA to yield its promise of equal access for the disabled, it may indeed be necessary and desirable for committed individuals to bring serial litigation advancing the time when public accommodations will be compliant with the ADA.

However, in states that have enacted laws that allow private individuals to win monetary awards from non-compliant businesses (as of 2008, these include California, Florida, Hawaii, and Illinois), “professional plaintiffs” are typically found. At least one of these plaintiffs in California has been barred by courts from filing lawsuits unless he receives prior court permission. Through the end of fiscal year 1998, 86% of the 106,988 ADA charges filed with and resolved by the Equal Employment Opportunity Commission, were either dropped or investigated and dismissed by EEOC but not without imposing opportunity costs and legal fees on employers.

Case Law

There have been some notable cases regarding the ADA. For example, two major hotel room marketers (Expedia.com and Hotels.com) with their business presence on the Internet were sued because its customers with disabilities could not reserve hotel rooms through their websites without substantial extra efforts that persons without disabilities were not required to perform. These represent a major potential expansion of the ADA in that this, and other similar suits (known as “bricks vs. clicks”), seeks to expand the ADA’s authority to cyberspace, where entities may not have actual physical facilities that are required to comply.

Green v. State of California

Green v. State of California, No. S137770 (Cal. Aug. 23, 2007) was a case in which the majority of the Supreme Court in California was faced with deciding whether the employee suing the state is required to prove he is able to perform “essential” job duties, regardless of whether or not there was “reasonable accommodation,” or if the employer must prove the victim was unable to do so. The court ruled the burden was on the employee, not the employer, and reversed a disputed decision by the courts. Plaintiff attorney David Greenberg brought forth considerations of the concept that, even in the state of California, employers do not have to employ a worker who is unable to perform “essential job functions” with “reasonable accommodation.” Forcing employers to do so “would defy logic and establish a poor public policy in employment matters.”

National Federation of the Blind v. Target Corporation

National Federation of the Blind v. Target Corporation was a case where a major retailer, Target Corp., was sued because their web designers failed to design its website to enable persons with low or no vision to use it.

Board of Trustees of the University of Alabama v. Garrett

Board of Trustees of the University of Alabama v. Garrett was a United States Supreme Court case about Congress’s enforcement powers under the Fourteenth Amendment to the Constitution. It decided that Title I of the Americans with Disabilities Act was unconstitutional insofar as it allowed private citizens to sue states for money damages.

Barden v. The City of Sacramento

Barden v. The City of Sacramento, filed in March 1999, claimed that the City of Sacramento failed to comply with the ADA when, while making public street improvements, it did not bring its sidewalks into compliance with the ADA. Certain issues were resolved in Federal Court. One issue, whether sidewalks were covered by the ADA, was appealed to the 9th Circuit Court of Appeals, which ruled that sidewalks were a “program” under ADA and must be made accessible to persons with disabilities. The ruling was later appealed to the US Supreme Court, which refused to hear the case, letting stand the ruling of the 9th Circuit Court.

Bates v. UPS

Bates v. UPS (begun in 1999) was the first equal opportunity employment class action brought on behalf of Deaf and Hard of Hearing (d/Deaf/HoH) workers throughout the country concerning workplace discrimination. It established legal precedence for d/Deaf/HoH Employees and Customers to be fully covered under the ADA. Key findings included:

  • UPS failed to address communication barriers and to ensure equal conditions and opportunities for deaf employees;
  • Deaf employees were routinely excluded from workplace information, denied opportunities for promotion, and exposed to unsafe conditions due to lack of accommodations by UPS;
  • UPS also lacked a system to alert these employees as to emergencies, such as fires or chemical spills, to ensure that they would safely evacuate their facility; and
  • UPS had no policy to ensure that deaf applicants and employees actually received effective communication in the workplace.

The outcome was that UPS agreed to pay a $5.8 million award and agreed to a comprehensive accommodations programme that was implemented in their facilities throughout the country.

Spector v. Norwegian Cruise Line Ltd

Spector v. Norwegian Cruise Line Ltd was a case that was decided by the United States Supreme Court in 2005. The defendant argued that as a vessel flying the flag of a foreign nation it was exempt from the requirements of the ADA. This argument was accepted by a federal court in Florida and, subsequently, the Fifth Circuit Court of Appeals. However, the US Supreme Court reversed the ruling of the lower courts on the basis that Norwegian Cruise Lines was a business headquartered in the United States whose clients were predominantly Americans and, more importantly, operated out of port facilities throughout the United States.

Olmstead v. L.C.

Not to be confused with Olmstead v. United States, 277 U.S. 438 (1928), a case regarding wiretapping.

Olmstead v. L.C. was a case before the United States Supreme Court in 1999. The two plaintiffs, L.C. and E.W., were institutionalised in Georgia for diagnosed mental retardation and schizophrenia. Clinical assessments by the state determined that the plaintiffs could be appropriately treated in a community setting rather than the state institution. The plaintiffs sued the state of Georgia and the institution for being inappropriately treated and housed in the institutional setting rather than being treated in one of the state’s community-based treatment facilities.

The Supreme Court decided under Title II of the ADA that mental illness is a form of disability and therefore covered under the ADA, and that unjustified institutional isolation of a person with a disability is a form of discrimination because it “…perpetuates unwarranted assumptions that persons so isolated are incapable or unworthy of participating in community life.” The court added, “Confinement in an institution severely diminishes the everyday life activities of individuals, including family relations, social contacts, work options, economic independence, educational advancement, and cultural enrichment.”

Therefore, under Title II no person with a disability can be unjustly excluded from participation in or be denied the benefits of services, programmes or activities of any public entity.

Michigan Paralysed Veterans of America v. The University of Michigan

This was a case filed before The United States District Court for the Eastern District of Michigan Southern Division on behalf of the Michigan Paralysed Veterans of America against University of Michigan – Michigan Stadium claiming that Michigan Stadium violated the Americans with Disabilities Act in its $226-million renovation by failing to add enough seats for disabled fans or accommodate the needs for disabled restrooms, concessions and parking. Additionally, the distribution of the accessible seating was at issue, with nearly all the seats being provided in the end-zone areas. The US Department of Justice assisted in the suit filed by attorney Richard Bernstein of The Law Offices of Sam Bernstein in Farmington Hills, Michigan, which was settled in March 2008. The settlement required the stadium to add 329 wheelchair seats throughout the stadium by 2010, and an additional 135 accessible seats in clubhouses to go along with the existing 88 wheelchair seats. This case was significant because it set a precedent for the uniform distribution of accessible seating and gave the DOJ the opportunity to clarify previously unclear rules. The agreement now is a blueprint for all stadiums and other public facilities regarding accessibility.

Paralysed Veterans of America v. Ellerbe Becket Architects and Engineers

One of the first major ADA lawsuits, Paralysed Veterans of America v. Ellerbe Becket Architects and Engineers (PVA 1996) was focused on the wheelchair accessibility of a stadium project that was still in the design phase, MCI Centre (now known as Capital One Arena) in Washington, D.C. Previous to this case, which was filed only five years after the ADA was passed, the DOJ was unable or unwilling to provide clarification on the distribution requirements for accessible wheelchair locations in large assembly spaces. While Section 4.33.3 of ADAAG makes reference to lines of sight, no specific reference is made to seeing over standing patrons. The MCI Centre, designed by Ellerbe Becket Architects & Engineers, was designed with too few wheelchair and companion seats, and the ones that were included did not provide sight lines that would enable the wheelchair user to view the playing area while the spectators in front of them were standing. This case and another related case established precedent on seat distribution and sight lines issues for ADA enforcement that continues to present day.

Toyota Motor Manufacturing, Kentucky, Inc. v. Williams

Toyota Motor Manufacturing, Kentucky, Inc. v. Williams, was a case in which the Supreme Court interpreted the meaning of the phrase “substantially impairs” as used in the Americans with Disabilities Act. It reversed a Sixth Court of Appeals decision to grant a partial summary judgement in favour of the respondent, Ella Williams, that qualified her inability to perform manual job-related tasks as a disability. The Court held that the “major life activity” definition in evaluating the performance of manual tasks focuses the inquiry on whether Williams was unable to perform a range of tasks central to most people in carrying out the activities of daily living. The issue is not whether Williams was unable to perform her specific job tasks. Therefore, the determination of whether an impairment rises to the level of a disability is not limited to activities in the workplace solely, but rather to manual tasks in life in general. When the Supreme Court applied this standard, it found that the Court of Appeals had incorrectly determined the presence of a disability because it relied solely on her inability to perform specific manual work tasks, which was insufficient in proving the presence of a disability. The Court of Appeals should have taken into account the evidence presented that Williams retained the ability to do personal tasks and household chores, such activities being the nature of tasks most people do in their daily lives, and placed too much emphasis on her job disability. Since the evidence showed that Williams was performing normal daily tasks, it ruled that the Court of Appeals erred when it found that Williams was disabled. This ruling is now, however, no longer good law – it was invalidated by the ADAAA. In fact, Congress explicitly cited Toyota v. Williams in the text of the ADAAA itself as one of its driving influences for passing the ADAAA.

US Airways, Inc. v. Barnett

Decided by the US Supreme Court in 2002, this case held that even requests for accommodation that might seem reasonable on their face, e.g. a transfer to a different position, can be rendered unreasonable because it would require a violation of the company’s seniority system. While the court held that, in general, a violation of a seniority system renders an otherwise reasonable accommodation unreasonable, a plaintiff can present evidence that, despite the seniority system, the accommodation is reasonable in the specific case at hand, e.g. the plaintiff could offer evidence that the seniority system is so often disregarded that another exception would not make a difference.

Importantly, the court held that the defendant need not provide proof that this particular application of the seniority system should prevail, and that, once the defendant showed that the accommodation violated the seniority system, it fell to Barnett to show it was nevertheless reasonable.

In this case, Barnett was a US Airways employee who injured his back, rendering him physically unable to perform his cargo-handling job. Invoking seniority, he transferred to a less-demanding mailroom job, but this position later became open to seniority-based bidding and was bid on by more senior employees. Barnett requested the accommodation of being allowed to stay on in the less-demanding mailroom job. US Airways denied his request, and he lost his job.

The Supreme Court decision invalidated both the approach of the district court, which found that the mere presence and importance of the seniority system was enough to warrant a summary judgment in favour of US Airways, as well as the circuit court’s approach that interpreted ‘reasonable accommodation’ as ‘effective accommodation.’

Access Now v. Southwest Airlines

Access Now v. Southwest Airlines was a case where the District Court decided that the website of Southwest Airlines was not in violation of the Americans with Disabilities Act, because the ADA is concerned with things with a physical existence and thus cannot be applied to cyberspace. Judge Patricia A. Seitz found that the “virtual ticket counter” of the website was a virtual construct, and hence not a “public place of accommodation.” As such, “To expand the ADA to cover ‘virtual’ spaces would be to create new rights without well-defined standards.

Ouellette v. Viacom International Inc.

Ouellette v. Viacom International Inc. followed in Access Now’s footsteps by holding that a mere online presence does not subject a website to the ADA guidelines. Thus Myspace and YouTube were not liable for a dyslexic man’s inability to navigate the site regardless of how impressive the “online theatre” is.

Authors Guild v. HathiTrust

Authors Guild v. HathiTrust was a case in which the District Court decided that the HathiTrust digital library was a transformative, fair use of copyrighted works, making a large number of written text available to those with print disability.

Zamora-Quezada v. HealthTexas Medical Group

Zamora-Quezada v. HealthTexas Medical Group (begun in 1998) was the first time this act was used against HMOs when a novel lawsuit was filed by Texas attorney Robert Provan against five HMOs for their practice of revoking the contracts of doctors treating disabled patients.

Campbell v. General Dynamics Government Systems Corp.

Campbell v. General Dynamics Government Systems Corp. (2005) concerned the enforceability of a mandatory arbitration agreement, contained in a dispute resolution policy linked to an e-mailed company-wide announcement, insofar as it applies to employment discrimination claims brought under the Americans with Disabilities Act.

Tennessee v. Lane

Tennessee v. Lane,[89] 541 U.S. 509 (2004), was a case in the Supreme Court of the United States involving Congress’s enforcement powers under section 5 of the Fourteenth Amendment. George Lane was unable to walk after a 1997 car accident in which he was accused of driving on the wrong side of the road. A woman was killed in the crash, and Lane faced misdemeanour charges of reckless driving. The suit was brought about because he was denied access to appear in criminal court because the courthouse had no elevator, even though the court was willing to carry him up the stairs and then willing to move the hearing to the first floor. He refused, citing he wanted to be treated as any other citizen, and was subsequently charged with failure to appear, after appearing at a previous hearing where he dragged himself up the stairs. The court ruled that Congress did have enough evidence that the disabled were being denied those fundamental rights that are protected by the Due Process clause of the Fourteenth Amendment and had the enforcement powers under section 5 of the Fourteenth Amendment. It further ruled that “reasonable accommodations” mandated by the ADA were not unduly burdensome and disproportionate to the harm.

What is a Neuropsychological Test?

Introduction

Neuropsychological tests are specifically designed tasks that are used to measure a psychological function known to be linked to a particular brain structure or pathway.

Refer to Neuropsychological Assessment.

Tests are used for research into brain function and in a clinical setting for the diagnosis of deficits. They usually involve the systematic administration of clearly defined procedures in a formal environment. Neuropsychological tests are typically administered to a single person working with an examiner in a quiet office environment, free from distractions. As such, it can be argued that neuropsychological tests at times offer an estimate of a person’s peak level of cognitive performance. Neuropsychological tests are a core component of the process of conducting neuropsychological assessment, along with personal, interpersonal and contextual factors.

Most neuropsychological tests in current use are based on traditional psychometric theory. In this model, a person’s raw score on a test is compared to a large general population normative sample, that should ideally be drawn from a comparable population to the person being examined. Normative studies frequently provide data stratified by age, level of education, and/or ethnicity, where such factors have been shown by research to affect performance on a particular test. This allows for a person’s performance to be compared to a suitable control group, and thus provide a fair assessment of their current cognitive function.

According to Larry J. Seidman, the analysis of the wide range of neuropsychological tests can be broken down into four categories. First is an analysis of overall performance, or how well people do from test to test along with how they perform in comparison to the average score. Second is left-right comparisons: how well a person performs on specific tasks that deal with the left and right side of the body. Third is pathognomic signs, or specific test results that directly relate to a distinct disorder. Finally, the last category is differential patterns, which are typically used to diagnose specific diseases or types of damage.

Categories

Most forms of cognition actually involve multiple cognitive functions working in unison, however tests can be organised into broad categories based on the cognitive function which they predominantly assess. Some tests appear under multiple headings as different versions and aspects of tests can be used to assess different functions.

Intelligence

Intelligence testing in a research context is relatively more straightforward than in a clinical context. In research, intelligence is tested and results are generally as obtained, however in a clinical setting intelligence may be impaired so estimates are required for comparison with obtained results. Premorbid estimates can be determined through a number of methods, the most common include: comparison of test results to expected achievement levels based on prior education and occupation and the use of hold tests which are based on cognitive faculties which are generally good indicators of intelligence and thought to be more resistant to cognitive damage, e.g. language.

  • National Adult Reading Test (NART).
  • Wechsler Adult Intelligence Scale (WAIS).
  • Wechsler Intelligence Scale for Children (WISC).
  • Wechsler Preschool and Primary Scale of Intelligence (WPPSI).
  • Wechsler Test of Adult Reading (WTAR).

Memory

Memory is a very broad function which includes several distinct abilities, all of which can be selectively impaired and require individual testing. There is disagreement as to the number of memory systems, depending on the psychological perspective taken. From a clinical perspective, a view of five distinct types of memory, is in most cases sufficient. Semantic memory and episodic memory (collectively called declarative memory or explicit memory); procedural memory and priming or perceptual learning (collectively called non-declarative memory or implicit memory) all four of which are long term memory systems; and working memory or short term memory. Semantic memory is memory for facts, episodic memory is autobiographical memory, procedural memory is memory for the performance of skills, priming is memory facilitated by prior exposure to a stimulus and working memory is a form of short term memory for information manipulation.

  • Benton Visual Retention Test.
  • California Verbal Learning Test.
  • Cambridge Prospective Memory Test (CAMPROMPT).
  • Gollin figure test.
  • Memory Assessment Scales (MAS).
  • Rey Auditory Verbal Learning Test.
  • Rivermead Behavioural Memory Test.
  • Test of Memory and Learning (TOMAL).
  • Mental Attributes Profiling System.
  • Wechsler Memory Scale (WMS).

Language

Language functions include speech, reading and writing, all of which can be selectively impaired.

  • Boston Diagnostic Aphasia Examination.
  • Boston Naming Test.
  • Comprehensive Aphasia Test (CAT).
  • Multilingual Aphasia Examination.

Executive Function

Executive functions is an umbrella term for a various cognitive processes and sub-processes. The executive functions include: problem solving, planning, organisational skills, selective attention, inhibitory control and some aspects of short term memory.

  • Behavioural Assessment of Dysexecutive Syndrome (BADS).
  • CNS Vital Signs (Brief Core Battery).
  • Continuous performance task (CPT).
  • Controlled Oral Word Association Test (COWAT).
  • d2 Test of Attention.
  • Delis-Kaplan Executive Function System (D-KEFS).
  • Digit Vigilance Test.
  • Figural Fluency Test.
  • Halstead Category Test.
  • Hayling and Brixton tests.
  • Kaplan Baycrest Neurocognitive Assessment (KBNA).
  • Kaufman Short Neuropsychological Assessment.
  • Paced Auditory Serial Addition Test (PASAT).
  • Rey-Osterrieth Complex Figure.
  • Ruff Figural Fluency Test.
  • Stroop task.
  • Test of Variables of Attention (T.O.V.A.).
  • Tower of London Test.
  • Trail-Making Test (TMT) or Trails A & B.
  • Wisconsin Card Sorting Test (WCST).
  • Symbol Digit Modalities Test.
  • Test of Everyday Attention (TEA).

Visuospatial

Neuropsychological tests of visuospatial function should cover the areas of visual perception, visual construction and visual integration. Though not their only functions, these tasks are to a large degree carried out by areas of the parietal lobe.

  • Clock Test.
  • Hooper Visual Organisation Task (VOT).
  • Rey-Osterrieth Complex Figure.

Dementia Specific

Dementia testing is often done by way of testing the cognitive functions that are most often impaired by the disease e.g. memory, orientation, language and problem solving. Tests such as these are by no means conclusive of deficits, but may give a good indication as to the presence or severity of dementia.

  • The Alzheimer’s Disease Assessment Scale-Cognitive Subscale (ADAS-Cog).
  • Clinical Dementia Rating.
  • Dementia Rating Scale.

Batteries Assessing Multiple Neuropsychological Functions

There are some test batteries which combine a range of tests to provide an overview of cognitive skills. These are usually good early tests to rule out problems in certain functions and provide an indication of functions which may need to be tested more specifically.

  • Barcelona Neuropsychological Test (BNT).
  • Cambridge Neuropsychological Test Automated Battery (CANTAB).
  • Cognistat (The Neurobehavioral Cognitive Status Examination).
  • Cognitive Assessment Screening Instrument (CASI).
  • Cognitive Function Scanner (CFS).
  • Dean-Woodcock Neuropsychology Assessment System (DWNAS).
  • General Practitioner Assessment Of Cognition (GPCOG).
  • Hooper Visual Organisation Test.
  • Luria-Nebraska Neuropsychological battery.
  • MicroCog.
  • Mini mental state examination (MMSE).
  • NEPSY.
  • Repeatable Battery for the Assessment of Neuropsychological Status.
  • Short Parallel Assessments of Neuropsychological Status (SPANS).
  • CDR Computerised Assessment System.

Automated Computerised Cognitive Tests

Traditional cognitive examinations are mostly paper and pen based. As such most of them are time consuming and require special training to be carried out. Today there is a rapidly growing number of automated computerised cognitive tests emerging, for example Brain on Track, Cogstate, CAMCI, CANTAB. Several of these new tests are shoving promising ability to discriminate between healthy individuals and different cognitive difficulties and/or to monitor cognitive impairment over time. Since these tests are easily administered to large groups of people this is opening up possibilities to, for example, regularly screen portions of the population at risk for cognitive decline and early on give adequate support and treatment.

Benefits of Neuropsychological Testing

The most beneficial factor of neuropsychological assessment is that it provides an accurate diagnosis of the disorder for the patient when it is unclear to the psychologist what exactly the patient has. This allows for accurate treatment later on in the process because treatment is driven by the exact symptoms of the disorder and how a specific patient may react to different treatments. The assessment allows the psychologist and patient to understand the severity of the deficit and to allow better decision-making by both parties. It is also helpful in understanding deteriorating diseases because the patient can be assessed multiple times to see how the disorder is progressing.

What is the Assessment of Suicide Risk?

Introduction

Suicide risk assessment is a process of estimating the likelihood for a person to attempt or die by suicide.

The goal of a thorough risk assessment is to learn about the circumstances of an individual person with regard to suicide, including warning signs, risk factors, and protective factors. Risk for suicide is re-evaluated throughout the course of care to assess the patient’s response to personal situational changes and clinical interventions. Accurate and defensible risk assessment requires a clinician to integrate a clinical judgment with the latest evidence-based practice, although accurate prediction of low base rate events, such as suicide, is inherently difficult and prone to false positives.

The assessment process is ethically complex: the concept of “imminent suicide” (implying the foreseeability of an inherently unpredictable act) is a legal construct in a clinical guise, which can be used to justify the rationing of emergency psychiatric resources or intrusion into patients’ civil liberties. Some experts recommend abandoning suicide risk assessment as it is so inaccurate. In addition suicide risk assessment is often conflated with assessment of self-harm which has little overlap with completed suicide. Instead, it is suggested that the emotional state which has caused the suicidal thoughts, feelings or behaviour should be the focus of assessment with a view to helping the patient rather than reducing the anxiety of clinician who overestimates the risk of suicide and are fearful of litigation. Given the difficulty of suicide prediction, researchers have attempted to improve the state of the art in both suicide and suicidal behaviour prediction using natural language processing and machine learning applied to electronic health records.

Refer to Suicidal Ideation, Suicide Awareness, Suicide Prevention, and Suicide Prevention Contract.

In Practice

There are risks and disadvantages to both over-estimation and under-estimation of suicide risk. Over-sensitivity to risk can have undesirable consequences, including inappropriate deprivation of patients’ rights and squandering of scarce clinical resources. On the other hand, underestimating suicidality as a result of a dismissive attitude or lack of clinical skill jeopardises patient safety and risks clinician liability. Some people may worry that asking about suicidal intentions will make suicide more likely. In reality, regarding that the enquiries are made sympathetically, it does not. Key areas to be assessed include the person’s predisposition to suicidal behaviour; identifiable precipitant or stressors such as job loss, recent death of a loved one and change of residence; the patient’s symptomatic presentation; presence of hopelessness; nature of suicidal thinking; previous suicidal behaviour; impulsivity and self-control; and protective factors.

Suicide risk assessment should distinguish between acute and chronic risk. Acute risk might be raised because of recent changes in the person’s circumstances or mental state, while chronic risk is determined by a diagnosis of a mental illness, and social and demographic factors. Bryan and Rudd (2006) suggest a model in which risk is categorized into one of four categories: Baseline, Acute, Chronic high risk, and Chronic high risk with acute exacerbation. Risk level can be described semantically (in words) e.g. as Non-existent, Mild, Moderate, Severe, or Extreme, and the clinical response can be determined accordingly. Others urge use of numbers to describe level of relative or (preferably) absolute risk of completed suicide.

Scale for Suicide Ideation

The Scale for Suicide Ideation (SSI) was developed in 1979 by Aaron T. Beck, Maria Kovacs, and Arlene Weissman to quantify intensity in suicide ideators. It was developed for use by clinicians during semi-structured interviews. The scale contained 19 items rated on a scale from 0 to 2, allowing scores between 0 and 38. The items could be grouped into three categories: “Active Suicidal Desire, Preparation, and Passive Suicidal Desire.” Initial findings showed promising reliability and validity.

Modified Scale for Suicide Ideation

The Modified Scale for Suicide Ideation (MSSI) was developed by Miller et al., using 13 items from the SSI and 5 new items. The modifications increased both reliability and validity. The scale was also changed to range from 0 to 3, yielding a total score ranging from 0 to 54. Joiner found two factors, Suicidal Desire and Ideation, and Resolved Plans and Preparation. The MSSI was also shown to have higher discrimination between groups of suicide ideators and attempters than the BDI, BHS, PSI, and SPS.

Suicide Intent Scale

The Suicide Intent Scale (SIS) was developed in order to assess the severity of suicide attempts. The scale consists of 15 questions which are scaled from 0-2, which take into account both the logistics of the suicide attempt as well as the intent. The scale has high reliability and validity. Completed suicides ranked higher in the severity of the logistics than attempted suicides (it was impossible to measure intent for the completed suicides), and those with multiple attempts had higher scores than those who only attempted suicide once.

Suicidal Affect Behaviour Cognition Scale

The Suicidal Affect Behaviour Cognition Scale (SABCS) is a six-item self-report measure based on both suicide and psychological theory, developed to assess current suicidality for clinical, screening, and research purposes. Substantial empirical evidence was found, from four independent studies, confirming the importance of assessing suicidal affect, behaviours, and cognition as a single suicidal construct. The SABCS was the first suicide risk measure to be developed through both classical test theory (CTT) and item response theory (IRT) psychometric approaches and to show significant improvements over a highly endorsed comparison measure. The SABCS was shown to have higher internal reliability, and to be a better predictor of both future suicidal behaviours and total suicidality over an existing standard.

Suicide Behaviours Questionnaire

Refer to the Suicide Behaviours Questionnaire-Revised.

The Suicide Behaviours Questionnaire (SBQ) is a self-report measure developed by Linehan in 1981. In 1988 it was transformed from a long questionnaire to a short four questions that can be completed in about 5 minutes. Answers are on a Likert scale that ranges in size for each question, based on data from the original questionnaire. It is designed for adults and results tend to correlate with other measures, such as the SSI. It is popular because it is easy to use as a screening tool, but at only four questions, fails to provide detailed information.

Life Orientation Inventory

The Life Orientation Inventory (LOI) is a self-report measure that comes in both a 30 question and 110 question form. Both forms use a 4-point Likert scale to answer items, which are divided into six sub-scales on the longer form: self-esteem vulnerability, over-investment, overdetermined misery, affective domination, alienation, and suicide tenability. This scale has strong reliability and validity, and has been shown to be able to differentiate between control, depressed, possibly suicidal, and highly suicidal individuals. It also contains 3 validity indices, similar to the MMPI. However, while useful, this inventory is now out of print.

Reasons For Living Inventory

The Reasons For Living Inventory (RFL) is theoretically based, and measures the probability of suicide based on the theory that some factors may mitigate suicidal thoughts. It was developed in 1983 by Linehan and colleagues. and contains 48 items answered on a Likert scale from 1 to 6. The measure is divided into six subscales:

  • Survival and coping beliefs;
  • Responsibility to family;
  • Child concerns;
  • Fear of suicide;
  • Fear of social disproval; and
  • Moral objections.

Scores are reported as an average for the total and each sub-scale. The scale is shown to be fairly reliable and valid, but is still mostly seen in research as compared to clinical use. Other variations of the scale include the College Students Reasons for Living Inventory, and the Brief Reasons for Living Inventory. The college students reasons for living inventory replaced the responsibility to family sub-scale with a responsibility to family and friends sub-scale and that replaced the child concerns sub-scale with a college/future concerns sub-scale. The Brief Reasons for Living Inventory uses only 12 of the items from the RFL. Prolonged stress releases hormones that damage over time the hippocampus. The hippocampus is responsible for storing memories according to context (spatial, emotional and social) as well as activating memories according to context. When the hippocampus is damaged, events will be perceived in the wrong context, or memories with the wrong context might be activated.

Nurses Global Assessment of Suicide Risk

The Nurses Global Assessment of Suicide Risk (NGASR) was developed by Cutcliffe and Barker in 2004 to help novice practitioners with assessment of suicide risk, beyond the option of the current lengthy checklists currently available. It is based on 15 items, with some such as “Evidence of a plan to commit suicide” given a weighting of 3, while others, such as “History of psychosis” are weighted with a 1, giving a maximum total score of 25. Scores of 5 or less are considered low level of risk, 6-8 are intermediate level of risk, 9-11 are high level of risk, and 12 or more are very high level of risk. Each item is supported theoretically by studies that have shown a connection between the item and suicide. However, the validity and reliability of the test as a whole have not yet been empirically tested

Demographic Factors

Within the United States, the suicide rate is 11.3 suicides per 100,000 people within the general population.

Age

In the United States, the peak age for suicide is early adulthood, with a smaller peak of incidence in the elderly. On the other hand, there is no second peak in suicide in black men or women, and a much more muted and earlier-peaking rise in suicide amongst non-Hispanic women than their male counterparts. Older white males are the leading demographic group for suicide within the United States, at 47 deaths per 100,000 individuals for non-Hispanic white men over age 85. For Americans aged 65 and older, the rate is 14.3 per 100,000. Suicide rates are also elevated among teens. For every 100,000 individuals within an age group there are 0.9 suicides in ages 10-14, 6.9 among ages 15-19, and 12.7 among ages 20-24.

Sex

China and São Tomé and Príncipe are the only countries in the world where suicide is more common among women than among men.

In the United States, suicide is around 4.5 times more common in men than in women. US men are 5 times as likely to commit suicide within the 15- to 19-year-old demographic, and 6 times as likely as women to commit suicide within the 20- to 24-year-old demographic. Gelder, Mayou and Geddes reported that women are more likely to commit suicide by taking overdose of drugs than men. Transgender individuals are at particularly high risk. Prolonged stress lasting 3 to 5 years, such clinical depression co-morbid with other conditions, can be a major factor in these cases.

Ethnicity and Culture

In the United States white persons and Native Americans have the highest suicide rates, Black persons have intermediate rates, and Hispanic persons have the lowest rates of suicide. However, Native American males in the 15-24 age group have a dramatically higher suicide rate than any other group. A similar pattern is seen in Australia, where Aboriginal people, especially young Aboriginal men, have a much higher rate of suicide than white Australians, a difference which is attributed to social marginalisation, trans-generational trauma, and high rates of alcoholism. A link may be identified between depression and stress, and suicide.

Sexual Orientation

There is evidence of elevated risk of suicide among non-heterosexual individuals (e.g. homosexual or bisexual individuals), especially among adolescents

Biographical and historical Factors

The literature on this subject consistently shows that a family history of committed suicide in first-degree relatives, adverse childhood experiences (parental loss and emotional, physical and sexual abuse), and adverse life situations (unemployment, isolation and acute psychosocial stressors) are associated with suicide risk.

Recent life events can act as precipitants. Significant interpersonal loss and family instability, such as bereavement, poor relationship with family, domestic partner violence, separation, and divorce have all been identified as risk factors. Financial stress, unemployment, and a drop in socioeconomic status can also be triggers for a suicidal crisis. This is also the case for a range of acute and chronic health problems, such as pain syndromes, or diagnoses of conditions like HIV or cancer.

Mental State

Certain clinical mental state features are predictive of suicide. An affective state of hopelessness, in other words a sense that nothing will ever get better, is a powerful predictive feature. High risk is also associated with a state of severe anger and hostility, or with agitation, anxiety, fearfulness, or apprehension. Research domain criteria symptom burdens, particularly the positive and negative valence domains, are associated with time varying risk of suicide. Specific psychotic symptoms, such as grandiose delusions, delusions of thought insertion and mind reading are thought to indicate a higher likelihood of suicidal behaviour. Command hallucinations are often considered indicative of suicide risk, but the empirical evidence for this is equivocal. Another psychiatric illness that is a high risk of suicide is schizophrenia. The risk is particularly higher in younger patients who have insight into the serious effect the illness is likely to have on their lives.

The primary and necessary mental state Federico Sanchez called idiozimia (from idios “self” and zimia “loss”), followed by suicidal thoughts, hopelessness, loss of will power, hippocampal damage due to stress hormones, and finally either the activation of a suicidal belief system, or in the case of panic or anxiety attacks the switching over to an anger attack, are the converging reasons for a suicide to occur.

Suicidal Ideation

Refer to Suicidal Ideation.

Suicidal ideation refers to the thoughts that a person has about suicide. Assessment of suicidal ideation includes assessment of the extent of preoccupation with thoughts of suicide (for example continuous or specific thoughts), specific plans, and the person’s reasons and motivation to attempt suicide.

Planning

Assessment of suicide risk includes an assessment of the degree of planning, the potential or perceived lethality of the suicide method that the person is considering, and whether the person has access to the means to carry out these plans (such as access to a firearm). A suicide plan may include the following elements:

  • Timing;
  • Availability of method;
  • Setting;
  • Actions made towards carrying out the plan (such as obtaining medicines, poisons, rope or a weapon);
  • Choosing and inspecting a setting; and
  • Rehearsing the plan.

The more detailed and specific the suicide plan, the greater the level of risk. The presence of a suicide note generally suggests more premeditation and greater suicidal intent. The assessment would always include an exploration of the timing and content of any suicide note and a discussion of its meaning with the person who wrote it.

Motivation to Die

Suicide risk assessment includes an assessment of the person’s reasons for wanting to commit suicide. Some are due to overwhelming emotions or others can have a deep philosophical belief. The causes are highly varied.

Other Motivations for Suicide

Suicide is not motivated only by a wish to die. Other motivations for suicide include being motivated to end the suffering psychologically and a person suffering from a terminal illness may intend to commit suicide as a means of managing physical pain and/or their way of dealing with possible future atrophy or death.

Reasons to Live

Balanced against reasons to die are the suicidal person’s reasons to live, and an assessment would include an enquiry into the person’s reasons for living and plans for the future.

Past suicidal Acts

There are people who commit suicide the first time they have suicidal thoughts and there are many who have suicidal thoughts and never commit suicide.

Suicide Risk and Mental Illness

All major mental disorders carry an increased risk of suicide. However, 90% of suicides can be traced to depression, linked either to manic-depression (bipolar), major depression (unipolar), schizophrenia or personality disorders, particularly borderline personality disorder. Comorbidity of mental disorders increases suicide risk, especially anxiety or panic attacks.

Anorexia nervosa has a particularly strong association with suicide: the rate of suicide is forty times greater than the general population. The lifetime risk of suicide was 18% in one study, and in another study 27% of all deaths related to anorexia nervosa were due to suicide.

The long-term suicide rate for people with schizophrenia was estimated to be between 10 and 22% based upon longitudinal studies that extrapolated 10 years of illness for lifetime, but a more recent meta-analysis has estimated that 4.9% of schizophrenics will commit suicide during their lifetimes, usually near the illness onset. Risk factors for suicide among people with schizophrenia include a history of previous suicide attempts, the degree of illness severity, comorbid depression or post-psychotic depression, social isolation, and male gender. The risk is higher for the paranoid subtype of schizophrenia, and is highest in the time immediately after discharge from hospital.

While the lifetime suicide risk for mood disorders in general is around 1%, long-term follow-up studies of people who have been hospitalised for severe depression show a suicide risk of up to 13%. People with severe depression are 20 times more likely and people with bipolar disorder are 15 times more likely to die from suicide than members of the general population. Depressed people with agitation, severe insomnia, anxiety symptoms, and co-morbid anxiety disorders are particularly at-risk. Antidepressants have been linked with suicide as Healy (2009) stated that people on antidepressant have the tendency to commit suicide after 10-14 days of commencement of antidepressant.

People with a diagnosis of a personality disorder, particularly borderline, antisocial or narcissistic personality disorders, are at a high risk of suicide. In this group, elevated suicide risk is associated with younger age, comorbid drug addiction and major mood disorders, a history of childhood sexual abuse, impulsive and antisocial personality traits, and recent reduction of psychiatric care, such as recent discharge from hospital. While some people with personality disorders may make manipulative or contingent suicide threats, the threat is likely to be non-contingent when the person is silent, passive, withdrawn, hopeless, and making few demands.

A history of excessive alcohol use is common among people who commit suicide, and alcohol intoxication at the time of the suicide attempt is a common pattern. Meta analytic research conducted in 2015 indicates that a person with co-occurring alcohol use disorder and major depression is more likely to ideate, attempt, and complete suicide than those with individual disorders.

What is the Suicide Behaviours Questionnaire-Revised?

Introduction

The Suicide Behaviors Questionnaire-Revised (SBQ-R) is a psychological self-report questionnaire designed to identify risk factors for suicide in children and adolescents between ages 13 and 18.

Background

The four-question test is filled out by the child and takes approximately five minutes to complete. The questionnaire has been found to be reliable and valid in recent studies. One study demonstrated that the SBQ-R had high internal consistency with a sample of university students. However, another body of research, which evaluated some of the most commonly used tools for assessing suicidal thoughts and behaviours in college-aged students, found that the SBQ-R and suicide assessment tools in general have very little overlap between them. One of the greatest strengths of the SBQ-R is that, unlike some other tools commonly used for suicidality assessment, it asks about future anticipation of suicidal thoughts or behaviours as well as past and present ones and includes a question about lifetime suicidal ideation, plans to commit suicide, and actual attempts.

Question Breakdown, Scoring, and Interpretation

Each of the four questions addresses a specific risk factor: the first concerns presence of suicidal thoughts and attempts, the second concerns frequency of suicidal thoughts, the third concerns the threat level of suicidal attempts, and the fourth concerns likelihood of future suicidal attempts. The first item has often been used on its own in order to assign individuals to a suicidal and a non-suicidal control group for studies. Each question has an individual scale, and each response corresponds to a certain point value.

Domain Breakdown

A maximum score of 18 is possible on the SBQ-R, and the following responses to the 4 questions correspond to the following point values:

Point ValueQuestion 1 ResponseQuestion 2 ResponseQuestion 3 ResponseQuestion 4 Response
0Never
11Never1No chance at all
22, 3a, or 3bRarely2a or 2bRather unlikely
3Sometimes3a or 3bUnlikely
44a or 4bOftenLikely
5Very oftenRather likely
6Very likely

Interpretation of Subscale Scores

A total score of 7 and higher in the general population and a total score of 8 and higher in patients with psychiatric disorders indicates significant risk of suicidal behaviour.

What is a Suicide Prevention Contract?

Introduction

A suicide prevention contract is a contract that contains an agreement not to attempt/commit suicide.

Refer to Suicidal Ideation, Suicide Awareness, Suicide Prevention, and Assessment of Suicide Risk.

Background

It was historically used by health professionals dealing with depressive clients. Typically, the client was asked to agree to talk with the professional prior to carrying out any decision to commit suicide. Suicide prevention contracts have been shown not to be effective and have risk of harm. Suicide prevention contracts were once a “widely used but overvalued clinical and risk-management technique.” Indeed, it has been argued that such contracts “may in fact increase danger by providing psychiatrists with a false sense of security, thus decreasing their clinical vigilance.” It has also been argued that such contracts can anger or inhibit the client and introduce coercion into therapy.

What is Metapsychology?

Introduction

Metapsychology (Greek: meta ‘beyond, transcending’, and ψυχολογία ‘psychology‘) is that aspect of any psychological theory which refers to the structure of the theory itself (hence the prefix “meta”) rather than to the entity it describes.

The psychology is about the psyche; the metapsychology is about the psychology. The term is used mostly in discourse about psychoanalysis, the psychology developed by Sigmund Freud, which was at its time regarded as a branch of science (with roots in the work of Freud’s scientific mentors and predecessors, especially Helmholtz, Brucke, Charcot, and Janet), or, more recently, as a hermeneutics of understanding (with roots in Freud’s literary sources, especially Sophocles and, to a lesser extent, Goethe and Shakespeare). Interest on the possible scientific status of psychoanalysis has been renewed in the emerging discipline of neuropsychoanalysis, whose major exemplar is Mark Solms. The hermeneutic vision of psychoanalysis is the focus of influential works by Donna Orange.

Freud and the als ob Problem

Psychoanalytic metapsychology is concerned with the fundamental structure and concepts of Freudian theory. Sigmund Freud first used the term on 13 February 1896 in a letter to Wilhelm Fliess, to refer to his addition of unconscious processes to the conscious ones of traditional psychology. On 10 March 1898, he wrote to Fiess: “It seems to me that (German: als ob) the theory of wish fulfilment has brought only the psychological solution and not the biological – or, rather, metapsychical – one. (I am going to ask you seriously, by the way, whether I may use the name metapsychology for my psychology that leads behind consciousness).”

Three years after completing his unpublished Project for a Scientific Psychology, Freud’s optimism had completely vanished. In a letter dated September 22 of that year he told Fliess: “I am not at all in disagreement with you, not at all inclined to leave psychology hanging in the air without an organic basis. But apart from this conviction, I do not know how to go on, neither theoretically nor therapeutically, and therefore must behave as if [als läge] only the psychological were under consideration. Why I cannot fit it together [the organic and the psychological] I have not even begun to fathom”. “When, in his ‘Autobiographical Study’ of 1925, Freud called his metapsychology a ‘speculative superstructure’…the elements of which could be abandoned or changed once proven inadequate, he was, in the terminology of Kant’s Critique of Judgement, proposing a psychology als ob or as if – a heuristic model of mental functioning that did not necessarily correspond with external reality.”

A salient example of Freud’s own metapsychology is his characterisation of psychoanalysis as a “simultaneously closed system, fundamentally unrelated and impervious to the external world and as an open system inherently connected and responsive to environmental influence.

In the 1910s, Freud wrote a series of twelve essays, to be collected as Preliminaries to a Metapsychology. Five of these were published independently under the titles: “Instincts and Their Vicissitudes,” “Repression,” “The Unconscious,” “A Metapsychological Supplement to the Theory of Dreams,” and “Mourning and Melancholia.” The remaining seven remained unpublished, an expression of Freud’s ambivalence about his own attempts to articulate the whole of his vision of psychoanalysis. In 1919 he wrote to Lou Andreas-Salome, “Where is my Metapsychology? In the first place it remains unwritten”. In 1920 he published Beyond the Pleasure Principle, a text with metaphysical ambitions.

Midcentury psychoanalyst David Rapaport defined the term thus: “Books on psychoanalysis usually deal with its clinical theory… there exists, however, a fragmentary—yet consistent—general theory of psychoanalysis, which comprises the premises of the special (clinical) theory, the concepts built on it, and the generalizations derived from it… named metapsychology.”

Freud’s Metapsychology

  • The topographical point of view: the psyche operates at different levels of consciousness – unconscious, preconscious, and conscious.
  • The dynamic point of view: the notion that there are psychological forces which may conflict with one another at work in the psyche.
  • The economic point of view: the psyche contains charges of energy which are transferred from one element of the psyche to another.
  • The structural point of view: the psyche consists of configurations of psychological processes which operate in different ways and reveal different rates of change – the ego, the id, and the superego.
  • The genetic point of view: the origins – or “genesis” – of psychological processes can be found in developmentally previous psychological processes.

Ego psychologist Heinz Hartmann also added ‘the adaptive” point of view’ to Freud’s metapsychology, although Lacan who interpreted metapsychology as the symbolic, the Real, and the imaginary, said “the dimension discovered by analysis is the opposite of anything which progresses through adaptation”

Criticism

Freud’s metapsychology has faced criticism, mainly from ego psychology. Object relations theorists such as Melanie Klein, shifted the focus away from intrapsychic conflicts and towards the dynamics of interpersonal relationships, leading to a unifocal theory of development that focused on the mother-child relationship. Most ego psychologists saw the structural point of view, Freud’s latest metapsychology, as the most important. Some proposed that only the structural point of view be kept in metapsychology, because the topographical point of view made an unnecessary distinction between the unconscious and the preconscious (Arlow & Brenner) and because the economic point of view was viewed as redundant (Gill).

What is a Mental Health Care Navigator?

Introduction

A mental health care navigator is an individual who assists patients and families to find appropriate mental health caregivers, facilities and services. Individuals who are care navigators are often also trained therapists and doctors.

Overview

The need for mental health care navigators arises from the fragmentation of the mental health industry, which can often leave patients with more questions than answers. Care navigators work closely with patients and families through discussion and collaboration to provide information on best options and referrals to healthcare professionals, facilities, and organisations specialising in the patients’ needs. The difference between other mental health professionals and a care navigator is that a care navigator provides information and directs a patient to the best help rather than offering treatment. Still, care navigators may provide diagnosis and treatment planning.

Mental health care navigation is also sometimes provided by self-help books. Lloyd I. Sederer, M.D.’s The Family Guide to Mental Healthcare (W.W. Norton & Company, 2013) is a resource for patients and families searching for guidance in the mental health industry. Publishers Weekly called it a “thoughtful, compassionate, and fact-packed guide for recognizing illness and getting help.” It provides information to patients and families about recognising symptoms of mental illness, how to get diagnosis and how to choose the right therapists and treatments.

Terminology

Many mental health organisations use “navigator” and “navigation” to describe the service of providing guidance through the health care industry. Care navigators are also sometimes referred to as “system navigators.” One type of care navigator is an “educational consultant.”

Models

Models for mental health care navigation can involve many scenarios from a brief consultation to an extended process with follow-up. They offer referrals, assistance with insurance and other financial matters and general support. A highly detailed method of care navigation with long-term follow up was developed in 2011 by San Francisco-based psychiatrist and mental health expert Eli Merritt, M.D. His model involves what he calls the “3 R’s” of mental health care: “Research, Resources, and Referrals.”

It involves four steps:

Assessment & Needs IdentificationIn this preliminary, exploratory phase, care navigators meet with the individual or family seeking help. Patient history and needs are identified. Both the patient and the care navigator think through short- and long-term goals and levels of treatment sought.
Dialogue & Plan FormationThrough discussion and collaboration, both the patient and care navigator brainstorm next steps, establishing a plan that is specific to the patient’s needs.
Care CoordinationAfter information gathering and brainstorming, doctors, therapists, and other mental health options are provided to the patient. Questions of affordability arise, and patients are advised toward the best solutions for their conditions and circumstances.
ContinuityAfter guiding patients to healthcare providers, care navigators maintain communication and continuity with patients, offering assistance with any future obstacles that might arise.

What is a GABA Receptor?

Introduction

The GABA receptors are a class of receptors that respond to the neurotransmitter gamma-aminobutyric acid (GABA), the chief inhibitory compound in the mature vertebrate central nervous system.

There are two classes of GABA receptors: GABAA and GABAB. GABAA receptors are ligand-gated ion channels (also known as ionotropic receptors); whereas GABAB receptors are G protein-coupled receptors, also called metabotropic receptors.

Ligand-Gated Ion Channels

Ionotropic GABA receptors (iGABARs) are ligand-gated ion channel of the GABA receptors class which are activated by gamma-aminobutyric acid (GABA), and include:

  • GABAA receptors.
  • GABAA-ρ receptors.

The GABAB receptor, a G protein-coupled receptor, is the only metabotropic GABA receptor and its mechanism of action differs significantly from the ionotropic receptors. Functionally, in mature organisms, activation of these receptors typically results in neural inhibition, primarily via the influx of chloride ions, although exceptions to this general principle exist, such as during early development. Structurally, iGABARs are pentameric transmembrane ion channels, meaning they are made up of five subunits. Since there are several classes of subunits and a variety of genes encoding many members of these classes, a wide variety of structurally, and therefore functionally, distinct channels of iGABARs is observed.

GABAA Receptor

It has long been recognised that the fast response of neurons to GABA that is stimulated by bicuculline and picrotoxin is due to direct activation of an anion channel. This channel was subsequently termed the GABAA receptor. Fast-responding GABA receptors are members of a family of Cys-loop ligand-gated ion channels. Members of this superfamily, which includes nicotinic acetylcholine receptors, GABAA receptors, glycine and 5-HT3 receptors, possess a characteristic loop formed by a disulfide bond between two cysteine residues.

In ionotropic GABAA receptors, binding of GABA molecules to their binding sites in the extracellular part of the receptor triggers opening of a chloride ion-selective pore. The increased chloride conductance drives the membrane potential towards the reversal potential of the Cl¯ ion which is about -75 mV in neurons, inhibiting the firing of new action potentials. This mechanism is responsible for the sedative effects of GABAA allosteric agonists. In addition, activation of GABA receptors lead to the so-called shunting inhibition, which reduces the excitability of the cell independent of the changes in membrane potential.

There have been numerous reports of excitatory GABAA receptors. According to the excitatory GABA theory, this phenomenon is due to increased intracellular concentration of Cl¯ ions either during development of the nervous system or in certain cell populations. After this period of development, a chloride pump is upregulated and inserted into the cell membrane, pumping Cl− ions into the extracellular space of the tissue. Further openings via GABA binding to the receptor then produce inhibitory responses. Over-excitation of this receptor induces receptor remodelling and the eventual invagination of the GABA receptor. As a result, further GABA binding becomes inhibited and inhibitory postsynaptic potentials are no longer relevant.

However, the excitatory GABA theory has been questioned as potentially being an artefact of experimental conditions, with most data acquired in in-vitro brain slice experiments susceptible to un-physiological milieu such as deficient energy metabolism and neuronal damage. The controversy arose when a number of studies have shown that GABA in neonatal brain slices becomes inhibitory if glucose in perfusate is supplemented with ketone bodies, pyruvate, or lactate, or that the excitatory GABA was an artefact of neuronal damage. Subsequent studies from originators and proponents of the excitatory GABA theory have questioned these results, but the truth remained elusive until the real effects of GABA could be reliably elucidated in intact living brain. Since then, using technology such as in-vivo electrophysiology/imaging and optogenetics, two in-vivo studies have reported the effect of GABA on neonatal brain, and both have shown that GABA is indeed overall inhibitory, with its activation in the developing rodent brain not resulting in network activation, and instead leading to a decrease of activity.

GABA receptors influence neural function by coordinating with glutamatergic processes.

GABAA-ρ Receptor

A subclass of ionotropic GABA receptors, insensitive to typical allosteric modulators of GABAA receptor channels such as benzodiazepines and barbiturates, was designated GABAС receptor. Native responses of the GABAC receptor type occur in retinal bipolar or horizontal cells across vertebrate species.

GABAС receptors are exclusively composed of ρ (rho) subunits that are related to GABAA receptor subunits. Although the term “GABAС receptor” is frequently used, GABAС may be viewed as a variant within the GABAA receptor family. Others have argued that the differences between GABAС and GABAA receptors are large enough to justify maintaining the distinction between these two subclasses of GABA receptors. However, since GABAС receptors are closely related in sequence, structure, and function to GABAA receptors and since other GABAA receptors besides those containing ρ subunits appear to exhibit GABAС pharmacology, the Nomenclature Committee of the IUPHAR has recommended that the GABAС term no longer be used and these ρ receptors should be designated as the ρ subfamily of the GABAA receptors (GABAA-ρ).

G Protein-Coupled Receptors

GABAB Receptor

A subclass of ionotropic GABA receptors, insensitive to typical allosteric modulators of GABAA receptor channels such as benzodiazepines and barbiturates, was designated GABAС receptor. Native responses of the GABAC receptor type occur in retinal bipolar or horizontal cells across vertebrate species.

GABAС receptors are exclusively composed of ρ (rho) subunits that are related to GABAA receptor subunits. Although the term “GABAС receptor” is frequently used, GABAС may be viewed as a variant within the GABAA receptor family. Others have argued that the differences between GABAС and GABAA receptors are large enough to justify maintaining the distinction between these two subclasses of GABA receptors. However, since GABAС receptors are closely related in sequence, structure, and function to GABAA receptors and since other GABAA receptors besides those containing ρ subunits appear to exhibit GABAС pharmacology, the Nomenclature Committee of the IUPHAR has recommended that the GABAС term no longer be used and these ρ receptors should be designated as the ρ subfamily of the GABAA receptors (GABAA-ρ).

GABA Receptor Gene Polymorphisms

Two separate genes on two chromosomes control GABA synthesis – glutamate decarboxylase and alpha-ketoglutarate decarboxylase genes – though not much research has been done to explain this polygenic phenomenon. GABA receptor genes have been studied more in depth, and many have hypothesized about the deleterious effects of polymorphisms in these receptor genes. The most common single nucleotide polymorphisms (SNPs) occurring in GABA receptor genes rho 1, 2, and 3 (GABBR1, GABBR2, and GABBR3) have been more recently explored in literature, in addition to the potential effects of these polymorphisms. However, some research has demonstrated that there is evidence that these polymorphisms caused by single base pair variations may be harmful.

It was discovered that the minor allele of a single nucleotide polymorphism at GABBR1 known as rs1186902 is significantly associated with a later age of onset for migraines, but for the other SNPs, no differences were discovered between genetic and allelic variations in the control vs. migraine participants. Similarly, in a study examining SNPs in rho 1, 2, and 3, and their implication in essential tremor, a nervous system disorder, it was discovered that there were no differences in the frequencies of the allelic variants of polymorphisms for control vs. essential tremor participants. On the other hand, research examining the effect of SNPs in participants with restless leg syndrome found an “association between GABRR3rs832032 polymorphism and the risk for RLS, and a modifier effect of GABRA4 rs2229940 on the age of onset of RLS” – the latter of which is a modifier gene polymorphism. The most common GABA receptor SNPs do not correlate with deleterious health effects in many cases, but do in a few.

One significant example of a deleterious mutation is the major association between several GABA receptor gene polymorphisms and schizophrenia. Because GABA is integral to the release of inhibitory neurotransmitters which produce a calming effect and play a role in reducing anxiety, stress, and fear, it is not surprising that polymorphisms in these genes result in more consequences relating to mental health than to physical health. Of an analysis on 19 SNPs on various GABA receptor genes, five SNPs in the GABBR2 group were found to be significantly associated with schizophrenia, which produce the unexpected haplotype frequencies not found in the studies mentioned previously.

Several studies have verified association between alcohol use disorder and the rs279858 polymorphism on the GABRA2 gene e, and higher negative alcohol effects scores for individuals who were homozygous at six SNPs. Furthermore, a study examining polymorphisms in the GABA receptor beta 2 subunit gene found an association with schizophrenia and bipolar disorder, and examined three SNPs and their effects on disease frequency and treatment dosage. A major finding of this study was that functional psychosis should be conceptualised as a scale of phenotypes rather than distinct categories.

What is Denial (Psychoanalysis)?

Introduction

Denial or abnegation (German: Verneinung) is a psychological defense mechanism postulated by psychoanalyst Sigmund Freud, in which a person is faced with a fact that is too uncomfortable to accept and rejects it instead, insisting that it is not true despite what may be overwhelming evidence.

The subject may use:

  • Simple denial: deny the reality of the unpleasant fact altogether.
  • Minimisation: admit the fact but deny its seriousness (a combination of denial and rationalisation).
  • Projection: admit both the fact and seriousness but deny responsibility by blaming somebody or something else.

Description

The theory of denial was first researched seriously by Anna Freud. She classified denial as a mechanism of the immature mind because it conflicts with the ability to learn from and cope with reality. Where denial occurs in mature minds, it is most often associated with death, dying and rape. More recent research has significantly expanded the scope and utility of the concept. Elisabeth Kübler-Ross used denial as the first of five stages in the psychology of a dying patient, and the idea has been extended to include the reactions of survivors to news of a death.

Many contemporary psychoanalysts treat denial as the first stage of a coping cycle. When an unwelcome change occurs, a trauma of some sort, the first impulse to disbelieve begins the process of coping. That denial, in a healthy mind, slowly rises to greater consciousness. Gradually becoming a subconscious pressure, just beneath the surface of overt awareness, the mechanism of coping then involves repression, while the person accumulates the emotional resources to fully face the trauma. Once faced, the person deals with the trauma in a stage alternately called acceptance or enlightenment, depending on the scope of the issue and the therapist’s school of thought. After this stage, once sufficiently dealt with, or dealt with for the time being, the trauma must sink away from total conscious awareness again. Left out of the conscious mind, the process of sublimation involves a balance of neither quite forgetting nor quite remembering. This allows the trauma to re-emerge in consciousness if it involves an ongoing process such as a protracted illness. Alternately, sublimation may begin the full resolution process, where the trauma finally sinks away into eventual forgetfulness. Occasionally this entire cycle has been referred to in modern parlance as denial, confusing the full cycle with only one stage of it. To further muddy discourse, the terms denial and cycle of denial sometimes get used to refer to an unhealthy, dysfunctional cycle of unresolved coping, particularly with regard to addiction and compulsion.

Unlike some other defence mechanisms postulated by psychoanalytic theory (for instance, repression), the general existence of denial is fairly easy to verify, even for non-specialists. However, denial is one of the most controversial defence mechanisms, since it can be easily used to create unfalsifiable theories: anything the subject says or does that appears to disprove the interpreter’s theory is explained, not as evidence that the interpreter’s theory is wrong, but as the subject’s being “in denial”. However, researchers note that in some cases of corroborated child sexual abuse, the victims sometimes make a series of partial confessions and recantations as they struggle with their own denial and the denial of abusers or family members. Use of denial theory in a legal setting, therefore, is carefully regulated and experts’ credentials verified. “Formulaic guilt” simply by “being a denier” has been castigated by English judges and academics. The main objection is that denial theory is founded on the premise that which the supposed denier is denying the truth. This usurps the judge (and jury) as triers of fact.

Denial is especially characteristic of mania, hypomania, and generally of people with bipolar affective disorder in the manic stage – in this state, one can deny, remarkably a long period of time, the fact that one has fatigue, hunger, negative emotions and problems in general, until one is physically exhausted.

Denial and Disavowal

Freud employs the term Verleugnung (usually translated either as “disavowal” or as “denial”) as distinct from Verneinung (usually translated as “denial” or as “abnegation”). In Verleugnung, the defence consists of denying something that affects the individual and is a way of affirming what he or she is apparently denying. For Freud, Verleugnung is related to psychoses, whereas Verdrängung is a neurotic defense mechanism. Freud broadened his clinical work on disavowal beyond the realm of psychosis. In “Fetishism” (1927), he reported a case of two young men each of whom denied the death of his father. Freud notes that neither of them developed a psychosis, even though “a piece of reality which was undoubtedly important has been disavowed [verleugnet], just as the unwelcome fact of women’s castration is disavowed in fetishists.”

Types

Denial of Fact

In this form of denial, someone avoids a fact by utilising deception. This lying can take the form of an outright falsehood (commission), leaving out certain details to tailor a story (omission), or by falsely agreeing to something (assent). Someone who is in denial of fact is typically using lies to avoid facts they think may be painful to themselves or others.

Denial of Responsibility

This form of denial involves avoiding personal responsibility by:

  • Blaming: a direct statement shifting culpability and may overlap with denial of fact
  • Minimising: an attempt to make the effects or results of an action appear to be less harmful than they may actually be
  • Justifying: when someone takes a choice and attempts to make that choice appear acceptable due to their perception of what is right in a situation
  • Regression: when someone acts in a way unbecoming of their age.

Someone using denial of responsibility is usually attempting to avoid potential harm or pain by shifting attention away from themselves.

Denial of Impact

Denial of impact involves a person’s avoiding thinking about or understanding the harms of their behaviour has caused to self or others, i.e. denial of consequences. Doing this enables that person to avoid feeling a sense of guilt and it can prevent him or her from developing remorse or empathy for others. Denial of impact reduces or eliminates a sense of pain or harm from poor decisions.

Denial of Awareness

This form of denial attempts to divert pain by claiming that the level of awareness was inhibited by some mitigating variable. This is most typically seen in addiction situations where drug or alcohol abuse is a factor, though it also occasionally manifests itself in relation to mental health issues or the pharmaceutical substances used to treat mental health issues. This form of denial may also overlap with denial of responsibility.

What is the Cambridge Neuropsychological Test Automated Battery?

Introduction

The Cambridge Neuropsychological Test Automated Battery (CANTAB), originally developed at the University of Cambridge in the 1980s but now provided in a commercial capacity by Cambridge Cognition, is a computer-based cognitive assessment system consisting of a battery of neuropsychological tests, administered to subjects using a touch screen computer.

Outline

The CANTAB tests were co-invented by Professor Trevor Robbins and Professor Barbara Sahakian.

The 25 tests in CANTAB examine various areas of cognitive function, including:

  • General memory and learning.
  • Working memory and executive function.
  • Visual memory.
  • Attention and reaction time (RT).
  • Semantic/verbal memory.
  • Decision making and response control.

The CANTAB combines the accuracy and rigour of computerised psychological testing whilst retaining the wide range of ability measures demanded of a neuropsychological battery. It is suitable for young and old subjects, and aims to be culture and language independent through the use of non-verbal stimuli in the majority of the tests.

The CANTAB PAL touchscreen test, which assesses visual memory and new learning, received the highest rating of world-leading 4* grade from the Research Excellence Framework (REF) 2014. CANTAB and CANTAB PAL were highlighted in the Medical Schools Council ‘Health of the Nation’ 2015 publication.