What is Haltlose Personality Disorder?

Introduction

Haltlose personality disorder is a personality disorder in which affected individuals possess psychopathic traits built upon short-sighted selfishness and irresponsible hedonism, combined with an inability to anchor one’s identity to a future or past. The symptoms of Haltlose are characterised by a lack of inhibition.

Refer to Hysteroid Dysphoria. Other names have included Willenloser Psychopath, Unstable Psychopath, Unstable Drifter, and Disinhibited Personality.

Described by Emil Kraepelin and Gustav Aschaffenburg in the early twentieth century, and further distinguished by Karl Jaspers, Eugen and Manfred Bleuler, it has been colloquially dubbed psychopathy with an “absence of intent or lack of will”.

With other hyperthymics, Haltlose personalities were considered to make up “the main component of serious crime”, and are studied as one of the strains of psychopathy relevant to criminology as they are “very easily involved in the criminal history” and may become aggressors or homicidal. Their psychopathy is difficult to identify as a shallow sense of conformity is always present. A 2020 characterisation of mental illnesses noted of the Haltlose that “these people constantly need vigilant control, leadership, authoritarian mentor, encouragement and behavior correction” to avoid an idle lifestyle, involvement in antisocial groups, crime and substance abuse. The marked tendencies towards suggestibility are off-set by demonstrations of “abnormal rigidity and intransigence and firmness”.

After discovering a guilty conscience due to some act or omission they have committed, “they then live under constant fear of the consequences of their action or inaction, fear of something bad that might strike them” in stark opposition to their apparent carelessness or hyperthymic temperament, which is itself frequently a subconscious reaction to overwhelming fear. They frequently withdraw from society. Given their tendency to “exaggerate, to embroider their narratives, to picture themselves in ideal situations, to invent stories”, this fear then manifests as being “apt to blame others for their offences, frequently seeking to avoid responsibility for their actions”. They do not hold themselves responsible for their failed life, instead identifying as an ill-treated martyr.

They were characterised as Dégénérés supérieurs, demonstrating normal or heightened intellect but degraded moral standards. Of the ten types of psychopaths defined by Schneider, only the Gemütlose (compassionless) and the Haltlose “had high levels of criminal behavior” without external influence, and thus made up the minority of psychopaths who are “virtually doomed to commit crimes” by virtue only of their own constitution. Frequently changing their determined goals, a haltlose psychopath is “constantly looking for an external hold, it doesn’t really matter whether they join occult or fascist movements”. The ability to moderate external influence was considered one of three characteristics necessary to form an overall personality, thus leaving Haltlose patients without a functional personality of their own. A study of those with haltlose personality disorder concludes “In all of those cases, the result was a continuous social decline that ended in asocial-parasitic existence or an antisocial-criminal life”.

Haltlose has one of the most unfavourable prognoses of psychopathies. To exist safely, such a psychopath requires “a harsh lifestyle” and constant supervision.

Etymology and Criticism

“Haltlos” is a German word that contextually refers to a floundering, aimless, irresponsible lifestyle, and the diagnosis is named “Haltlose” using the feminine variation on the word. They are commonly clinically termed an “unstable psychopath”, which is differentiated from emotionally unstable personality disorder (an alternative name for borderline personality disorder). It was remarked in early studies that England, the United States and northern European countries did not use the same typology, not distinguishing between those psychopaths who were unstable and those who were “Unstable Psychopaths”.

It has been dubbed a part of “German-speaking psychiatry”. The term “Haltlose” is more common in the study of psychiatry, while “Willenlose” is preferred in sociology. Some like Karl Birnbaum prefer the term “Haltlose”, while others like Kurt Schneider prefer “Willenlos” shifting focus off their lack of self-control and opposed to the moralist tones of those like Birnbaum who had described the Haltlose as unable to grasp “important ideal values such as honor and morality, duty and responsibility, as well as material ones such as prosperity and health”. In 1928, Eugen Kahn argued Willenlose was a misnomer, as the patients demonstrated plenty of “will” and simply lacked the ability to translate it into action. Historically, researchers such as Schneider argued that instability is the symptom, whereas lack of volition is the underlying cause. It is not included in the Diagnostic and Statistical Manual of Mental Disorders (DSM), possibly due to a modern belief that the concept of volition is outdated and overshadowed by the concepts of motivation and arousal or drive.

In 1963, Karl Jaspers defined the term as “those who have no willpower at all, the drifters, simply echoing any influence that impinges on them”. However, in 1976, the Government of Canada listed the alternate term “Unstable drifter” in a psychiatric criminology context as a problematic term for which they could not readily offer a French translation in accordance with their bilingualism laws. Similar issues have arisen trying to translate it to other languages, including Turkish. Ultimately the diagnosis was handicapped by the issues of translation, leading to criticism of “the impoverishment of psychiatric vocabulary” that led to declining research and use.

In the early 20th century, Aschaffenburg distanced himself from accusations that the diagnosis was intended to protect criminals from punishment, emphasizing instead that those with Haltlose personality disorder “generally cannot be exculpated”.

Dr. Friedrich Stumpfl cautioned against what he saw as a trend of diagnosing haltlose personality disorder without investigating comorbidities that may be even more pronounced. In condemning the idea of personality disorders generally, Joachim-Ernst Meyer suggested in 1976 that Schneider’s early description of the Haltlose personality disorder, as a lack of determination in aspects of life including parenting, could just as easily be described as an example of a neurosis rather than a psychopathy if studied only by its aetiology rather than its symptoms, and used it as an example of the nature versus nurture debate that surrounded all personality disorders. Critics ceded that the term “Haltlose” remained of value in educational and therapeutic contexts, while suggesting future collaboration between psychiatric research and sociologists would allow further definition.

Recently, it has been criticised as a “diagnosis of convenience [that] avoids all further deliberations about a psychopathic personality”. Dr. DM Svrakic and Dr. M Divac-Jovanovic suggested the ICD-10 explanations of Haltlose, Immature and Psychoneurotic personality disorders appeared “dubious”, and sociologist James Cosgrave found psychiatric use to represent a “fringe figure”. A graduate student at Bochumer Stadt & Studierendenzeitung condemned the historical diagnosis from an LGBT perspective, opining that “incredibly oppressive language” had been used by the psychiatrists studying it such as “pathological femininity”.

It may be that the evolution of test-batteries have minimised diagnoses of Haltlosen, differentiating it from some newer models in psychiatry.

Physiology

Described as bearing a “pronounced heredity burden”, the propensity for Haltlose has also been suggested to be passed only through the maternal genes. Only able to offer “primitive reactions” and “poor and immature judgement”, they are noted to display an absolute lack of purpose in their lives “except for the simple biological need to continue living”.

Gustav von Bergmann, a specialist in internal medicine rather than psychiatry, wrote in 1936 that Haltlose personality disorder was entirely biological rather than fostered through psychological experiences. Indeed, Dr. Hans Luxenburger proposed in 1939 that a toxin in the metabolism, when present with Haltlose personality disorder, might be responsible for asthenic difficulties such as shortness of breath, nausea, and cluster headaches. Dr. E.H. Hughes noted that two-thirds of Huntington’s disease patients had previously been diagnosed as Haltlose or Gemütlose psychopaths.

A study in 1949 of different psychopathies under examination by electroencephalography recordings showed that borderline personalities and haltlose personalities had increased levels of dysrhythmia, whereas other subtypes of psychopathy did not show variation. An individual in 1931 was noted as having initially improved but relapsed “because of encephalitis”. As with other personality disorders, a 1923 article suggests it can also be acquired through encephalitis. In 2006, an Essex warehouse employee who suffered head injuries was awarded £3 million compensation on the basis it had caused him to develop Haltlose personality disorder, seeking out prostitutes and pornography which destroyed his marriage.

Mistakes cannot be fully avoided when placing children under care. even an experienced specialist often cannot distinguish between a blossoming hebephrenia and a Gemutlose or Haltlose personality disorder. Even with weeks of institutional observation, the certainty of our diagnostic aids can remain doubtful…under certain circumstances a doctor will advise medical care even at the risk of learning the patient cannot improve as a result of mental illness and will end up in a madhouse. Kurt Schneider.

Dr. W. Blankenburg posited in 1968 that those with haltlose personality disorder exhibited less categorical orientation than those patients who were simply unstable. By 1962, lobotomy was being tested as a possible means to limit the chaotic thinking of the Haltlose personality.

Kraepelin, in noting “an increased risk of criminal behavior”, estimated that 64% of men and 20% of women with Haltlose descended into alcoholism in the early twentieth century. The frequent intersection between HLPD and alcoholism means modern clinical researchers may use “haltlose” as a grouping when separating subjects by disposition. Research in 1915 noted an increased propensity for lavish spending, and overconsumption of coffee, tea and medication.

One 1954 study suggested female Haltlose patients may experience “manic excitement” during their menses. According to 1949 research, they have a higher rate of homosexuality, and 1939 evidence suggested that masturbation is more prevalent in Haltlose and Gemütlose (compassionless) psychopaths than in other disorders, and Haltlose erethics leave them “usually very sexually excited” and seeking out “atypical, irregular and unusual” debauchery whether in brothels, adultery or destroying marriages.

They demonstrate similarities to hysteroid dysphoria. In 1928, it was proposed that Fantasy prone personality was likely a subset of Haltlose personalities, suffering from maladaptive daydreaming and Absorption.

The eugenicist Verners Kraulis of the University of Latvia noted it was frequently comorbid with Histrionic personality disorder.

Symptoms

According to 1968 research, haltlose personality disorder is frequently comorbid with other mental health diagnoses, and rarely appears isolated on its own. Hans Heinze focused on his belief that Haltlose ultimately stemmed from a sense of inferiority, while Kramer held there was a battling inferiority complex and superiority complex.

The Haltlose were said to have a dynamic instinctual drive to “cling” to others, to avoid a horrible loneliness they fear – but they will always represent a “lurking danger” because they were unable to actually maintain the necessary relationship and were in a class with the “forever abandoned”. According to 1926 research, they view all interaction as a means of winning “indulgence from some people, help from other people”.

One early study indicated that 7.5% of psychopaths were Haltlose, and Kraepelin estimated that his own practice determined fewer than 20% of psychopaths he saw were Haltlose. However more recent studies, after differentiating out newer diagnoses, have suggested that it may be fewer than 1% of psychopaths who are truly Haltlose.

Described in 1922 as both “moody” and “passive”, they quickly switch from over-confidence in victory to sullen defiance.

Their emotional lability means they alternate between projecting an optimistic and competent image claiming they are “destined to do great things”, and a more honest cynicism and depression. Research in 1925 indicates they display “great emotional irritability, which may result in violent loss of temper…and interpret every limitation as an undeserved insult” and have a “pronounced lust for argument”. The symptoms are considered to worsen if patients are granted greater independence “in the home and in their work”.

Their self schema only encompasses the immediate present. They are described as “living in a random location and moment”. A common pitfall in therapy is that they proved in 1917 to be “very superficial, they easily acquire knowledge but do not apply it in any way and soon forget it”.

The essence of these people…playthings of external influences, allowing themselves to be carried away by events like a leaf in the wind! …Impermanence is everything. In one hour, they are happy and excited with the whole world lying open for them in the splendor of the joy of life, but the next hour casts aside this optimism and the future now seems bleak, gray on gray…sympathies and antipathies quickly replace each other, what was worshipped yesterday is burned today, and despite all oaths of eternal loyalty, the best friend is transformed into the deeply-loathed enemy overnight.” Dr. L. Scholz, Anomale Kinder, Berlin, 1919.

Those with HLPD display “a number of endearing qualities, charming with an apparent emotional warmth, but also an enhanced suggestibility and a superficiality of affect”, which can lead to unrealistic optimism. and “wandering through life without ever taking firm root”. They are also noted as “absolutely indifferent to others…likes to live for [their] pleasure today, does not make plans not only for the future but even for tomorrow, studying and working are not for them”. Persons with HLPD typically lack any deep knowledge, and “look for easy life and pleasures”. They have been described as “conquerers with an appearance of emotional warmth”.

Persons with HLPD were noted as struggling with hypochondria in 1907. They also struggle with alcoholism, and identify with antisocial personality disorder.

Kraepelin said they were “apt to take senseless journeys, perhaps even becoming vagabonds”. Kraepelin argued only lifelong wanderlust was tied to Haltlose, whereas Kahn argued that the Haltlose often lost their wanderlust as they aged and preferred to settle into mediocrity. Some make their fortune, but the disappearance of less fortunate travelers is not mentioned by their families who considered them to have been burdensome.

To early twentieth-century researchers, they appeared amiable, well-spoken, self-confident and to be making strong efforts to improve their weaknesses, thus making a misleading first impression and endearing themselves to superiors. The lack of a sense of identity, or internal support, was thought to a lack of resistance to both external and internal impulses in 1927. Their “gradual deterioration in the swamp of neediness and immorality” still does not make a lasting impression on the patients. Thus Haltlose patients who recognize their shortcomings were thought to possibly be overwhelmed by a subconscious fear about participating in the world without restraints in a 1924 account. Similarly, researchers in the early twentieth-century believed that the inauthenticity of their projected self and superficiality of knowledge means that when “someone who is really superior to [them]”, after a period of stiffly asserting themselves hoping to avoid submission, will ultimately and without explanation fully embrace the position of the other.

Pathological lying is closely linked to Haltlose personality disorder, with Arthur Kielholz noting “They lie like children…this activity always remains just a game which never satisfies them and leaves them with a guilty conscious because neither the super ego nor the Id get their due…Since they are offering such a daydream as a gift, they consider themselves entitled to extract some symbolic gift in return through fraud or theft”. Adler maintained “Memory is usually poor and untrustworthy…often they seem to have no realization of the truth”, while Homburger felt they held “no sense of objectivity, no need for truth or consistency”.

According to early accounts, choices are made, often in mirroring others around them, but “do not leave even a passing imprint on the person’s identity”. Thus, they can “behave properly for a while under good leadership”, and are not to be trusted in leadership positions themselves. Gannushkin noted they must be urged, scolded or encouraged “with a stick, as they say”. They demonstrate poor mood control and “react quickly to immediate circumstances” since “mood variation can be extreme and fluctuate wildly”, which led to the denotation “unstable psychopath”.

They have been described as “cold-blooded”, but must be differentiated from dependent personality disorder, as the two can appear similar, due to the artifice of the Haltlose patient, despite having starkly opposing foundations. Persons with Dependent Personality Disorder are defined by a tendency to embarrassment, and submissiveness which are not genuine facets of those with Haltlose even if they mimic such. Haltlose was thus deemed the “more troublesome” personality in 1955.

Childhood Origins, and Later Role of Family

“Whomever is abandoned in youth to the inexorable misery of existence, and at the same time is exposed to all manner of seductions, will find it very difficult to curb their constantly incited desires, and to instead force themselves through to the lofty vantage of moral self-assertion. Kraepelin speaking about the Haltlose, 1915.

It has been proposed that haltlose personality disorder may arise from “traumatization through maternal indolence” or institutionalisation in early life, although without definite conclusion. It may present in childhood simply as a hypomanic reaction to the loss of a parent or incest object. They often display a fear of abandonment that appeared in childhood, a common borderline personality disorder symptom. Male Haltlose personalities may come out of families with a pampering, over-protective and domineering mother with a weak father. Homburger noted the “childhood and youth of the Haltlose are extraordinarily sad”. It is possible, but rare, for Haltlose personalities to develop within healthy family structures.

Gerhardt Nissen referenced the possibility of intrauterine factors in the shaping of anti-social behaviours in Haltlose psychopaths, while noting the concept of psychopathy had been so weakened in modern psychopathology as to be indistinguishable from other conditions. Others have suggested there is a strong heredity correlation, as the parents often also display Haltlose personality disorder, especially the mother. Raising a haltlose child can, in some cases, destroy the family structure by forcing relatives to take opposing positions, provoking disagreement and creating an atmosphere of bitterness and dejection. They have been clinically described as disappointments to their families, and are unable to feel actual love for their parents and are indifferent to the hardships of relatives – since all relationships are seen only as potential means towards acquiring pleasure.

Care must be taken in making Haltlose diagnoses of children, since “the traits of instability of purpose, lack of forethought, suggestibility, egoism and superficiality of affect…are to some extent normal in childhood”. Children with haltlose personality disorder demonstrate a marked milieu dependency, which may be a cause rather than effect of the Haltlose. It is of great importance that only children with Haltlose have peers and friends to surround themselves to try and learn associations and behaviours. They often become sexually active at a young age but delayed sexual maturity, and as adults retain a psychophysical infantilism. Regressive addictions amongst Haltlose psychopaths typically are infantile, and seek to replace the lost “dual union” arising from their parents’ rejection, and later morph into a focus on subjects including vengeance or sado-masochism.

The Russian storybook character Dunno has been noted as an example of a child with Haltlose personality disorder.

The age at which parents or professionals exhibited concern about psychopathy ranged; rarely even at a preschool age. Haltlose children confusingly tend to appear very strong-willed and ambitious, it is only as they age and the lack of perseverance becomes manifest that caretakers become puzzled by their “naughtiness” as it contradicts what had earlier appeared. This arises principally due to their rigid demands for short-term wishes being mistakenly interpreted as having a fixed purpose and persistence. Some patients later shown to be Haltlose, had shown neuropathic traits in childhood such as bedwetting and stuttering. They were also more likely to run away from their home, begin drinking before the socially acceptable age, and were afraid of punishment. Although struggling to make friends in young childhood, they find it easier as they age.

Kraepelin contended the disorder was “based on a biological predisposition” but also affected by factors such as childrearing practises, social position and state of the parental home. His analysis showed that 49% of diagnosed Haltlose had obvious parental issues such as alcoholism or personality disorders. A 1944 study of children produced by incest by Dr. Alfred Aschenbrenner found a high rate of Haltlose personality disorder, which he suggested might be explained as inherited from overly suggestive mothers. It is possible, although difficult, to diagnose from the age of five and presents one of the stronger psychiatric difficulties if present at such young age. It may be possible to prevent social failure “through welfare measures” akin to early intervention. Italian courts stressed mimicry of positive role models as a means to combat Haltlose youth who had fallen afoul of the law.

Schooling

Haltlose can cause educational difficulties, and if parents do not understand the peculiarities of their haltlose child, they may try to through good intentions to force the child into an educational regimen inappropriate for them, which then creates a feeling of isolation in the child which grows into a rebellious tendencies, “which turns out to be disastrous for further development”. Students with Haltlose personalities may prefer the arts over the sciences, since the former does not require a consistent sense of truth and entails less disciplined study. Given their inability to anchor a self-schema and tendency to play-act roles, the theatre and film have great attraction and influence over them.

With proper leadership and controls from teachers, they are able to become “model pupils” in terms of behaviour, although Schneider opined that it was worthless to educate an inability to learn from mistakes prevented actual education, and bemoaned that the late onset of anti-social behaviours kept the Haltlose in school when they might otherwise be removed. Walter Moos believed that Haltlose personality disorder and hyperthymia had shown itself to be contagious in rare cases, wherein classmates developed the same disorder from interaction with patients. Homburger argued for removing a Haltlose child from their family of origin as soon as the disorder was confirmed, to resettle in a rural educational centre.

Adolescence, Young Adulthood and Efforts to Intervene

When required to live independently, they “soon lose interest, become distracted and absent-minded, and commit gross errors and negligence”. Ruth von der Leyen noted that “every care provider, teacher and doctor knows the Haltlose Psychopath from their practice”, and remarked that caring for such a patient was made more difficult because of the need to lecture and intervene to enlist the psychopath’s cooperation in short-term improvements, despite being aware the psychiatric reports have determined such efforts are ultimately useless but should be practised regardless.

The tendency to accumulate debts while seeking pleasure or escaping responsibility is often the attributed cause for their descent into crime, although Kramer noted those who displayed “extreme dexterity, sufficient talent for imagination, and a tendency towards dishonesty” were able to find alternative sources of income without necessarily becoming criminal, although warned that “again and again, their debts have to be paid until the parents no longer can, or want to, do this and leave them to their selves”.

Gannushkin noted “Such people involuntarily evoke sympathy and a desire to help them, but the assistance rendered to them rarely lasts, so it is worth abandoning such people for a short while”. The wasted good intentions resulted in the summary:

“probably the most important function of the psychiatrist when dealing with these patients is to protect their relatives and friends from ruining themselves in hopeless attempts at reclamation. With most of these patients a time comes when the relatives will be best advised…to allow the patient to go to prison, or otherwise suffer unsheltered the consequences of his deeds.”

By contrast, others have advanced the “rather optimistic” belief that “a suitable [spouse]” or similar “strong-willed” relative could drastically improve the outcome of Haltlosen patients. This was echoed by Andrey Yevgenyevich Lichko who, while preferring the term “accentuation of character” to describe the psychopathy rather than “personality disorder”, noted “if they fall into the hands of a person with a strong will, for example a wife or husband, they can they live quite happily…but the guardianship must be permanent.”

Criminology

While some Haltlose have risen to the level of dangerous offenders multiple times over, it is more frequent that they attract attention early from their “vagabond” nature.

Heinrich Schulte, a wartime medical judge and consulting psychiatrist for the military, continued advocating for the sterilization of Haltlose and other “Schwachsinnigen” after the war’s end. In 1979, the Neue Anthropologie publication referred to a need to sterilize those like alcoholics, “who are often Haltlose psychopaths”, from bearing children, to reduce crime.

Although Kraepelin believed those with Haltlose personality disorder represented the antithesis of morality, there is not necessarily a tendency towards deliberate amorality among the demographic despite its frequent criminal violations since they may lack the ability to premeditate. But their demonstrated lack of self-control is “especially manifested in the sphere of morality”.

In 1935, it was estimated that 58% of recidivist criminals were diagnosed with Haltlose personality disorder, higher than any other personality disorder. More recently, Haltlose and Histrionic were the most common personality disorders found in female juvenile delinquents by forensic psychologists in Russia in the year 2000.

Domestic Violence, Incest and Molestation of Children

[Patients resembling Haltlose] as a rule show little insight into the peculiarities of their conduct. They do not understand how they could have done these things, or they blame their relatives, neighbors and so forth”. Dr. Herman Morris Adler, 1917.

Although they enter relationships easily, Andrey Yevgenyevich Lichko contends they are not capable of actual loyalty or selfless love, and sex is treated as a form of entertainment rather than intimacy. They are therefore described as acting as “family tyrants”.

Although they may not qualify as “true” pedophiles, Haltlose personalities demonstrate an increased risk of sexually molesting children, since other potential victims would require the realisation of greater planning, but children are suggestible and easily overwhelmed.

A 1967 German study had suggested over 90% of adult-child incest offenders were diagnosed with Haltlose Personality Disorder. Female patients may also live vicariously through encouraging and directing the sexual lives of their daughters.

Drunk Driving, Hit-and-Run

Some Haltlose personalities are drawn towards dangerous driving habits “as a source of almost hedonist pleasure”. In 1949 the Automobil Revue proposed that additional tests should be necessary for Haltlose personalities to obtain a driver’s license. They have been known to steal cars to joyride at high speeds if they are not otherwise able to find satisfy their urge.

The American Journal of Psychiatry published a study of hit and run drivers in 1941, which showed 40% of drivers who fled the scene of a traffic accident tested positive for haltlose personality disorder. This was consistent with the earlier finding that Haltlose Personalities were among the most likely to attempt to flee if caught in commission of any crime.

Suicidality and Murder-Suicide

Research in the early twentieth century on suicidality among the Haltlose indicated several things: they chafe at the notion of any religion as it introduces unwanted inhibitions, especially against parasuicidal demonstrations; women Haltlose most frequently indicated suicidality was based upon fear of punishment or reproach, as well as the “excitement” of being institutionalised; and although frequently planning or attempting suicide, including through suicide pacts or murder suicide, Haltlose typically do not succeed since they lacked courage and were easily distracted.

Institutionalisation

Haltlose patients respond very well to institutionalization where their influences can be controlled, becoming “model inmates” of sanitariums even within hours of first arriving despite a chaotic life outside of the regimen, “but if you leave them, through good intentions, to their own devices – they don’t last long before collapsing their current state and being seduced back onto the wrong track”. Schneider recommended warning them “through punishing them” as it was the only control on their action. Bleuler said the court system needed to understand such persons were in “urgent need of inhibitions”.

Pyotr Gannushkin noted they joined military service due to peer pressure but given the lack of alcohol and stern, hard work required of them were able to function without their normal impairment. A 1942 study of the Wehrmacht found that only Haltlose and Schizoid were not measurable among soldiers despite their presence in the civilian population. A 1976 Soviet naval study came to similar conclusions.

Roth and Slater concluded “the treatment of such a personality is almost hopeless under the present ordering of society. Any treatment would…present difficulties…beyond the powers of these patients. The prospects of psychotherapy are forlorn and the best that can be obtained will be reached through social control.”

Some researchers suggest their moods and insufficient motivation will lead them to “vague feelings of fear and calamity…turning every little thing into big things, excitement, misinterpreting every harmless word, criticizing everything and commiting hostile acts”, and in some cases they look back with hindsight and regret the injustices they did. However Kramer held that when caught in wrongdoing, “we find them contrite, self-accusing and assuring that they will improve – but on closer inspection it is feigned and not sincere”.

Upon being confronted with their misdeeds, the Haltlose respond “with more or less superficial reasons to excuse them, they claim that their parents treated them incorrectly, that they were the victim of adverse circumstances, seduced by other people and misled. Other Haltlose, especially those with a strong intellect, make up a theoretical schema that would justify their actions.”

Examples

  • Kielholz, Arthur, Internationale Zeitschrift für Psychoanalyse XIX 1933 Heft 4, “Weh’dem der lugt! Beitrag zum problem der pseudologia phantastica”, an article on pathological lying in the Haltlose patients Max Specke, a Swiss charlatan with a penchant for melodramatic flair and Emil Schuldling, a habitual criminal with childhood sexual perversions
  • Story of Robert Wenger, who was diagnosed Haltlose and spent 54 years between institutions and prison for minor crimes until the documentary series Quer exposed his case, leading to an apology from politician Samuel Bhend in 1999.
  • Karl Hager, a habitual criminal diagnosed Haltlose who was frequently jailed for homosexual acts and was ultimately killed in Sachsenhausen concentration camp (in German)
  • Biography of a man diagnosed Haltlose in 1936 (in German)
  • Berlit, Berthold (December 1931). “Erblichkeitsuntersuchungen bei Psychopathen”. Zeitschrift für die gesamte Neurologie und Psychiatrie. 134(1), pp.382-498.
  • Article referencing Hermann Lederman, discharged from the Wehrmacht in 1940 having been diagnosed with Haltlose personality disorder and sent to Wehrmachtgefängnis Torgau
  • Article about Karl Sieger, a chronic drunkard diagnosed with Haltlose personality disorder in 1936 by Dr. Ferdinand Rechberg of Konstanz
  • Thomas Leveritt’s novel “The Exchange-Rate Between Love and Money” contains a character, Frito, who has Haltlose personality disorder.

Book: Dialogical Psychiatry: A Handbook For The Teaching And Practice Of Open Dialogue

Book Title:

Dialogical Psychiatry: A Handbook For The Teaching And Practice Of Open Dialogue.

Author(s): Russell Razzaque.

Year: 2019.

Edition: First (1st).

Publisher: Omni House Books.

Type(s): Paperback and Kindle.

Synopsis:

This book is written for all of those who are searching for a more client driven, compassionate and relational approach to mental health services. Consultant Psychiatrist, Professor Russell Razzaque combines his experience as practitioner, trainer and researcher of Open Dialogue in this accessible guide to a more dialogical psychiatry.

Both thoughtful and eminently practical, this book outlines the operational changes and the cultural shift needed to deliver this promising approach which could fundamentally transform the way mental health services are delivered. If you’ve ever wondered what the future of mental health services can, and hopefully will, look like I encourage you to read this book and be inspired to be part of that change.

Book: Cracked: Why Psychiatry is Doing More Harm Than Good

Book Title:

Cracked: Why Psychiatry is Doing More Harm Than Good.

Author(s): James Davies

Year: 2014.

Edition: First (1st).

Publisher: Icon Books.

Type(s): Hardcover, Paperback, Audiobook, and Kindle.

Synopsis:

Controversial and powerful – a shocking indictment of the pseudo-science at the heart of modern psychiatry.

What is Cross-Cultural Psychiatry?

Introduction

Cross-cultural psychiatry (also known as Ethnopsychiatry or transcultural psychiatry or cultural psychiatry) is a branch of psychiatry concerned with the cultural context of mental disorders and the challenges of addressing ethnic diversity in psychiatric services. It emerged as a coherent field from several strands of work, including surveys of the prevalence and form of disorders in different cultures or countries; the study of migrant populations and ethnic diversity within countries; and analysis of psychiatry itself as a cultural product.

The early literature was associated with colonialism and with observations by asylum psychiatrists or anthropologists who tended to assume the universal applicability of Western psychiatric diagnostic categories. A seminal paper by Arthur Kleinman in 1977 followed by a renewed dialogue between anthropology and psychiatry, is seen as having heralded a “new cross-cultural psychiatry”. However, Kleinman later pointed out that culture often became incorporated in only superficial ways, and that for example 90% of DSM-IV categories are culture-bound to North America and Western Europe, and yet the “culture-bound syndrome” label is only applied to “exotic” conditions outside Euro-American society. Reflecting advances in medical anthropology, DSM-5 replaced the term “culture-bound syndrome” with a set of terms covering cultural concepts of distress: cultural syndromes (which may not be bound to a specific culture but circulate across cultures); cultural idioms of distress (local modes of expressing suffering that may not be syndromes); causal explanations (that attribute symptoms or suffering to specific causal factors rooted in local ontologies); and folk diagnostic categories (which may be part of ethnomedical systems and healing practices).

Definition

Cultural psychiatry looks at whether psychiatric classifications of disorders are appropriate to different cultures or ethnic groups. It often argues that psychiatric illnesses represent social constructs as well as genuine medical conditions, and as such have social uses peculiar to the social groups in which they are created and legitimized. It studies psychiatric classifications in different cultures, whether informal (e.g. category terms used in different languages) or formal (for example the World Health Organisation’s ICD, the American Psychiatric Association’s DSM, or the Chinese Society of Psychiatry’s CCMD). The field has increasingly had to address the process of globalisation. It is said every city has a different culture and that the urban environment, and how people adapt or struggle to adapt to it, can play a crucial role in the onset or worsening of mental illness.

However, some scholars developing an anthropology of mental illness consider that attention to culture is not enough if it is decontextualised from historical events, and history in more general sense. An historical and politically informed perspective can counteract some of the risks related to promoting universalised ‘global mental health’ programmes as well as the increasing hegemony of diagnostic categories such as PTSD (Didier Fassin and Richard Rechtman analyse this issue in their book ‘The Empire of Trauma’). Roberto Beneduce, who devoted many years to research and clinical practice in West Africa (Mali, among the Dogon) and in Italy with migrants, strongly emphasizes this shift. Inspired by the thought of Frantz Fanon, Beneduce points to forms of historical consciousness and selfhood as well as history-related suffering as central dimensions of a ‘critical ethnopsychiatry’ or ‘critical transcultural psychiatry’.

Brief History

As a named field within the larger discipline of psychiatry, cultural psychiatry has a relatively short history. In 1955, a program in transcultural psychiatry was established at McGill University in Montreal by Eric Wittkower from psychiatry and Jacob Fried from the department of anthropology. In 1957, at the International Psychiatric Congress in Zurich, Wittkower organised a meeting that was attended by psychiatrists from 20 countries, including many who became major contributors to the field of cultural psychiatry: Tsung-Yi Lin (Taiwan), Thomas Lambo (Nigeria), Morris Carstairs (Britain), Carlos Alberto Seguin (Peru) and Pow-Meng Yap (Hong Kong). The American Psychiatric Association established a Committee on Transcultural Psychiatry in 1964, followed by the Canadian Psychiatric Association in 1967. H.B.M. Murphy of McGill founded the World Psychiatric Association Section on Transcultural Psychiatry in 1970. By the mid-1970s there were active transcultural psychiatry societies in England, France, Italy and Cuba. There are several scientific journals devoted to cross-cultural issues: Transcultural Psychiatry (est. 1956, originally as Transcultural Psychiatric Research Review, and now the official journal of the WPA Section on Transcultural Psychiatry), Psychopathologie Africaine (1965), Culture Medicine & Psychiatry (1977), Curare (1978), and World Cultural Psychiatry Research Review (2006). The Foundation for Psychocultural Research at UCLA has published an important volume on psychocultural aspects of trauma and most recently the landmark volumes entitled Formative Experiences: the Interaction of Caregiving, Culture, and Developmental Psychobiology edited by Carol Worthman, Paul Plotsky, Daniel Schechter and Constance Cummings. and Re-Visioning Psychiatry: Cultural Phenomenology, Critical Neuroscience, and Global Mental Health edited by Laurence J. Kirmayer, Robert Lemelson and Constance Cummings.

It is argued that a cultural perspective can help psychiatrists become aware of the hidden assumptions and limitations of current psychiatric theory and practice and can identify new approaches appropriate for treating the increasingly diverse populations seen in psychiatric services around the world. The recent revision of the nosology of the American Psychiatric Association, DSM-5, includes a Cultural Formulation Interview that aims to help clinicians contextualise diagnostic assessment. A related approach to cultural assessment involves cultural consultation which works with interpreters and cultural brokers to develop a cultural formulation and treatment plan that can assist clinicians.

Organisations

The main professional organisations devoted to the field are the WPA Section on Transcultural Psychiatry, the Society for the Study of Psychiatry and Culture, and the World Association for Cultural Psychiatry. Many other mental health organisations have interest groups or sections devoted to issues of culture and mental health.

There are active research and training programs in cultural psychiatry at several academic centres around the world, notably the Division of Social and Transcultural Psychiatry at McGill University, Harvard University, the University of Toronto, and University College London. Other organisations are devoted to cross-cultural adaptation of research and clinical methods. In 1993 the Transcultural Psychosocial Organisation (TPO) was founded. The TPO has developed a system of intervention aimed at countries with little or no mental health care. They train local people to become mental health workers, often using people who previously have provided mental health guidance of some kind. The TPO provides training material that is adapted to local culture, language and distinct traumatic events that might have occurred in the region where the organisation is operating. Avoiding Western approaches to mental health, the TPO sets up what becomes a local non-governmental organisation (NGO) that is self-sustainable, as well as economically and politically independent of any state. The TPO projects have been successful in both Uganda and Cambodia.

What is the Biopsychiatry Controversy?

Introduction

The biopsychiatry controversy is a dispute over which viewpoint should predominate and form a basis of psychiatric theory and practice.

The debate is a criticism of a claimed strict biological view of psychiatric thinking. Its critics include disparate groups such as the antipsychiatry movement and some academics.

Overview of Opposition to Biopsychiatry

Biological psychiatry or biopsychiatry aims to investigate determinants of mental disorders devising remedial measures of a primarily somatic nature.

This has been criticised by Alvin Pam for being a “stilted, unidimensional, and mechanistic world-view”, so that subsequent “research in psychiatry has been geared toward discovering which aberrant genetic or neurophysiological factors underlie and cause social deviance”. According to Pam the “blame the body” approach, which typically offers medication for mental distress, shifts the focus from disturbed behaviour in the family to putative biochemical imbalances.

Research Issues

2003 Status in Biopsychiatric Research

Biopsychiatric research has produced reproducible abnormalities of brain structure and function, and a strong genetic component for a number of psychiatric disorders (although the latter has never been shown to be causative, merely correlative). It has also elucidated some of the mechanisms of action of medications that are effective in treating some of these disorders. Still, by their own admission, this research has not progressed to the stage that they can identify clear biomarkers of these disorders.

Research has shown that serious neurobiological disorders such as schizophrenia reveal reproducible abnormalities of brain structure (such as ventricular enlargement) and function. Compelling evidence exists that disorders including schizophrenia, bipolar disorder, and autism to name a few have a strong genetic component. Still, brain science has not advanced to the point where scientists or clinicians can point to readily discernible pathologic lesions or genetic abnormalities that in and of themselves serve as reliable or predictive biomarkers of a given mental disorder or mental disorders as a group. Ultimately, no gross anatomical lesion such as a tumour may ever be found; rather, mental disorders will likely be proven to represent disorders of intercellular communication; or of disrupted neural circuitry. Research already has elucidated some of the mechanisms of action of medications that are effective for depression, schizophrenia, anxiety, attention deficit, and cognitive disorders such as Alzheimer’s disease. These medications clearly exert influence on specific neurotransmitters, naturally occurring brain chemicals that effect, or regulate, communication between neurons in regions of the brain that control mood, complex reasoning, anxiety, and cognition. In 1970, The Nobel Prize was awarded to Julius Axelrod, Ph.D., of the National Institute of Mental Health, for his discovery of how anti-depressant medications regulate the availability of neurotransmitters such as norepinephrine in the synapses, or gaps, between nerve cells. (American Psychiatric Association, Statement on Diagnosis and Treatment of Mental Disorders, 26 September 2003).

Focus on Genetic Factors

Researchers have proposed that most common psychiatric and drug abuse disorders can be traced to a small number of dimensions of genetic risk and reports show significant associations between specific genomic regions and psychiatric disorders. Though, to date only a few genetic lesions have been demonstrated to be mechanistically responsible for psychiatric conditions. For example, one reported finding suggests that in persons diagnosed as schizophrenic as well as in their relatives with chronic psychiatric illnesses, the gene that encodes phosphodiesterase 4B (PDE4B) is disrupted by a balanced translocation.

The reasons for the relative lack of genetic understanding is because the links between genes and mental states defined as abnormal appear highly complex, involve extensive environmental influences and can be mediated in numerous different ways, for example by personality, temperament or life events. Therefore, while twin studies and other research suggests that personality is heritable to some extent, finding the genetic basis for particular personality or temperament traits, and their links to mental health problems, is “at least as hard as the search for genes involved in other complex disorders.” Theodore Lidz and The Gene Illusion argue that biopsychiatrists use genetic terminology in an unscientific way to reinforce their approach. Joseph maintains that biopsychiatrists disproportionately focus on understanding the genetics of those individuals with mental health problems at the expense of addressing the problems of the living in the environments of some extremely abusive families or societies.

Focus on Biochemical Factors

The chemical imbalance hypothesis states that a chemical imbalance within the brain is the main cause of psychiatric conditions and that these conditions can be improved with medication which corrects this imbalance. In that, emotions within a “normal” spectrum reflect a proper balance of neurotransmitter function, but abnormally extreme emotions which are severe enough to impact the daily functioning of patients (as seen in schizophrenia) reflect a profound imbalance. It is the goal of psychiatric intervention, therefore, to regain the homeostasis (via psychopharmacological approaches) that existed prior to the onset of disease.

This conceptual framework has been debated within the scientific community, although no other demonstrably superior hypothesis has emerged. Recently, the biopsychosocial approach to mental illness has been shown to be the most comprehensive and applicable theory in understanding psychiatric disorders. However, there is still much to be discovered in this area of inquiry. As a prime example – while great strides have been made in the field of understanding certain psychiatric disorders (such as schizophrenia) others (such as major depressive disorder) operate via multiple different neurotransmitters and interact in a complex array of systems which are (as yet) not completely understood.

Reductionism

Niall McLaren emphasizes in his books Humanizing Madness and Humanizing Psychiatry that the major problem with psychiatry is that it lacks a unified model of the mind and has become entrapped in a biological reductionist paradigm. The reasons for this biological shift are intuitive as reductionism has been very effective in other fields of science and medicine. However, despite reductionism’s efficacy in explaining the smallest parts of the brain this does not explain the mind, which is where he contends the majority of psychopathology stems from. An example would be that every aspect of a computer can be understood scientifically down to the last atom; however, this does not reveal the program that drives this hardware. He also argues that the widespread acceptance of the reductionist paradigm leads to a lack of openness to self-criticism and therefore halts the very engine of scientific progress. He has proposed his own natural dualist model of the mind, the biocognitive model, which is rooted in the theories of David Chalmers and Alan Turing and does not fall into the dualist’s trap of spiritualism.

Economic Influences on Psychiatric Practice

American Psychiatric Association president Steven S. Sharfstein, M.D. has stated that when the profit motive of pharmaceutical companies and human good are aligned, the results are mutually beneficial for all. In that, “Pharmaceutical companies have developed and brought to market medications that have transformed the lives of millions of psychiatric patients. The proven effectiveness of antidepressant, mood-stabilising, and antipsychotic medications has helped sensitize the public to the reality of mental illness and taught them that treatment works[citation needed]. In this way, Big Pharma has helped reduce stigma associated with psychiatric treatment and with psychiatrists.” However, Sharfstein acknowledged that the goals of individual physicians who deliver direct patient care can be different from the pharmaceutical and medical device industry. Conflicts arising from this disparity raise natural concerns in this regard including:

  • A “broken health care system” that allows “many patients [to be] prescribed the wrong drugs or drugs they don’t need”;
  • “medical education opportunities sponsored by pharmaceutical companies [that] are often biased toward one product or another”;
  • “[d]irect marketing to consumers [that] also leads to increased demand for medications and inflates expectations about the benefits of medications”;
  • “drug companies [paying] physicians to allow company reps to sit in on patient sessions to learn more about care for patients.”

Nevertheless, Sharfstein acknowledged that without pharmaceutical companies developing and producing modern medicines – virtually every medical specialty would have few (if any) treatments for the patients that they care for.

Pharmaceutical Industry Influences in Psychiatry

Studies have shown that promotional marketing by pharmaceutical and other companies has the potential to influence physician decision making. Pharmaceutical manufacturers (and other advocates) would argue that in today’s modern world – physicians simply do not have the time to continually update their knowledge base on the status of the latest research and that by providing educational materials for both physicians and patients, they are providing an educational perspective and that it is up to the individual physician to decide what treatment is best for their patients. The idea of pure promotion (e.g. lavish dinners) is a remnant of bygone era. It has been replaced by educationally-based activities that became the basis for the legal and industry reforms involving physician gifts, influence in graduate medical education, physician disclosure of conflicts of interest, and other promotional activities.

In an essay on the effect of advertisements for marketed anti-depressants there is some evidence that both patients and physicians can be influenced by media advertisements and this has the possibility of increasing the frequency of certain medicines being prescribed over others.

What is the Harvard Review of Psychiatry?

Introduction

The Harvard Review of Psychiatry is a peer-reviewed medical journal covering all aspects of psychiatry.

Background

The Harvard Review of Psychiatry is the authoritative source for scholarly reviews and perspectives on a diverse range of important topics in psychiatry.

Founded by the Harvard Medical School Department of Psychiatry, the journal is peer-reviewed and not industry sponsored. It is the property of the President and Fellows of Harvard College and is affiliated with all of the Departments of Psychiatry at the Harvard teaching hospitals.

Articles encompass all major issues in contemporary psychiatry, including (but not limited to) neuroscience, psychopharmacology, psychotherapy, history of psychiatry, and ethics. In addition to scholarly reviews, perspectives articles, and columns, the journal includes a Clinical Challenge section that presents a case followed by discussion and debate from a panel of experts.

Subscription includes a CME opportunity in each issue.

What is Child and Adolescent Psychiatry?

Introduction

Child and adolescent psychiatry (or paediatric psychiatry) is a branch of psychiatry that focuses on the diagnosis, treatment, and prevention of mental disorders in children, adolescents, and their families.

It investigates the biopsychosocial factors that influence the development and course of psychiatric disorders and treatment responses to various interventions. Child and adolescent psychiatrists primarily use psychotherapy and/or medication to treat mental disorders in the paediatric population.

Brief History

When psychiatrists and paediatricians first began to recognise and discuss childhood psychiatric disorders in the 19th century, they were largely influenced by literary works of the Victorian era. Authors like the Brontë sisters, George Eliot, and Charles Dickens, introduced new ways of thinking about the child mind and the potential influence early childhood experiences could have on child development and the subsequent adult mind. When the Journal of Psychological Medicine and Mental Pathology, the first psychiatric journal in English, was published in 1848, child psychiatry didn’t exist as its own field yet. However, some of the earliest works on the possibility of nervous disorders and “insanity” in children were published in the Journal and several medical writers directly referenced works such as Jane Eyre (1847), Wuthering Heights (1847), Dombey and Son (1848), and David Copperfield (1850), to illustrate this new conceptualisation of the child mind. Until that time, it was generally accepted that children were free from nervous disorders and the “passions” that affected the adult mind.

As early as 1899, the term “child psychiatry” (in French) was used as a subtitle in Manheimer’s monograph Les Troubles Mentaux de l’Enfance. However, the Swiss psychiatrist Moritz Tramer (1882-1963) was probably the first to define the parameters of child psychiatry in terms of diagnosis, treatment, and prognosis within the discipline of medicine, in 1933. In 1934, Tramer founded the Zeitschrift für Kinderpsychiatrie (Journal of Child Psychiatry), which later became Acta Paedopsychiatria. The first academic child psychiatry department in the world was founded in 1930 by Leo Kanner (1894-1981), an Austrian émigré and medical graduate of the University of Berlin, under the direction of Adolf Meyer at the Johns Hopkins Hospital in Baltimore. Kanner was the very first physician to be identified as a child psychiatrist in the US and his textbook, Child Psychiatry (1935), is credited with introducing both the specialty and the term to the anglophone academic community. In 1936, Kanner established the first formal elective course in child psychiatry at the Johns Hopkins Hospital. In 1944 he provided the first clinical description of early infantile autism, otherwise known as Kanner Syndrome.

Maria Montessori together with It:Giuseppe Ferruccio Montesano and Clodomiro Bonfigli, two distinguished child psychiatrists, created in 1901 in Italy the “Lega Nazionale per la Protezione del Fanciullo” (National League for the Protection of Children). She gradually developed her own pedagogic method, initially based on the “intuition that the question of the ‘mentally deficient’ was more pedagogic than medical”. In 1909, Jane Addams and her female colleagues established the Juvenile Psychopathic Institute (JPI) in Chicago, later renamed as the Institute for Juvenile Research (IJR), the world’s first child guidance clinic. Neurologist William Healy, M.D., its first director, was charged with not only studying the delinquent’s biological aspects of brain functioning and IQ, but also the delinquent’s social factors, attitudes, and motivations, thus it was the birthplace of American child psychiatry.

From its establishment in February 1923, the Maudsley Hospital, a South London-based postgraduate teaching and research psychiatric hospital, contained a small children’s department. Similar overall early developments took place in many other countries during the late 1920s and 1930s. In the United States, child and adolescent psychiatry was established as a recognised medical speciality in 1953 with the founding of the American Academy of Child Psychiatry, but was not established as a legitimate, board-certifiable medical speciality until 1959.

The use of medication in the treatment of children also began in the 1930s, when Charles Bradley opened a neuropsychiatric unit and was the first to use amphetamine for brain-damaged and hyperactive children. But it was not until the 1960s that the first NIH grant to study paediatric psychopharmacology was awarded. It went to one of Kanner’s students, Leon Eisenberg, the second director of the division.

The discipline has relatively flourished since the 1980s, in large part, because of contributions made in the 1970s, even if the outcomes for patients have been disappointing at times. It was a decade during which child psychiatry witnessed a major evolution as a result of the work carried out by, Eva Frommer, Douglas Haldane, Michael Rutter, Robin Skynner and Sula Wolff, among others. The first comprehensive population survey of 9- to 11-year-olds, carried out in London and the Isle of Wight, which appeared in 1970, addressed questions that have continued to be of importance for child psychiatry; for example, rates of psychiatric disorders, the role of intellectual development and physical impairment, and specific concern for potential social influences on children’s adjustment. This work was influential, especially since the investigators demonstrated specific continuities of psychopathology over time, and the influence of social and contextual factors in children’s mental health, in their subsequent re-evaluation of the original cohort of children. These studies described the prevalence of ADHD (relatively low as compared to the US), identified the onset and prevalence of depression in mid-adolescence and the frequent co-morbidity with conduct disorder, and explored the relationship between various mental disorders and scholastic achievement.

It was paralleled similarly by work on the epidemiology of autism that was to enormously increase the number of children diagnosed with autism in future years. Although attention had been given in the 1960s and ’70s to the classification of childhood psychiatric disorders, and some issues had then been delineated, such as the distinction between neurotic and conduct disorders, the nomenclature did not parallel the growing clinical knowledge. It was claimed that this situation was altered in the late 1970s with the development of the DSM-III system of classification, although research has shown that this system of classification has problems of validity and reliability. Since then, the DSM-IV and DSM-IVR have altered some of the parsing of psychiatric disorders into “childhood” and “adult” disorders, on the basis that while many psychiatric disorders are not diagnosed until adulthood, they may present in childhood or adolescence (DSM-IV). The American Psychiatric Association’s DSM is now on its fifth edition (DSM-5).

People in the field are sometimes referred to as “neurodevelopmentalists”. As of 2005 there was debate in the field as to whether “neurodevelopmentalist” should be made a new speciality.

In terms of patient outcomes, there is evidence that, in the United Kingdom at least on the 70th anniversary of the NHS, mental health remains a medical “Cinderella” (low priority) and the more so Child and Adolescent Health services which have been through repeated reorganisations and underinvestment all of which leads to disruption and loss of adequate provision.

“Modern neuroscience, genetics, epigenetics, and public health research has presented the tantalizing possibility that it can now be said with relative certainty that much (certainly not all) is understood about why some children struggle and others soar. Although it is an oversimplification, it can now be suggested that it is possible to understand how environmental factors, both negative and positive, influence the genome or epigenome, which in turn influence the structure and function of the brain and thus human thoughts, actions, and behaviors.”

Classification of Disorders

Not an exhaustive list:

  • Developmental disorders:
    • Autism spectrum disorder.
    • Learning disorders.
  • Disorders of attention and behaviour:
    • Attention deficit hyperactivity disorder.
    • Oppositional defiant disorder.
    • Conduct disorder.
  • Psychotic disorders:
    • Childhood schizophrenia.
  • Mood disorders:
    • Major depressive disorder.
    • Bipolar disorder.
    • Persistent Depressive Disorder.
    • Disruptive Mood Dysregulation Disorder.
  • Anxiety disorders:
    • Panic disorder.
    • Phobias.
  • Eating disorders:
    • Anorexia nervosa.
    • Bulimia nervosa.
  • Gender identity disorder:
    • Gender identity disorder in children.

Disorders are often comorbid. For example, an adolescent can be diagnosed with both major depressive disorder and generalised anxiety disorder. The incidence of psychiatric comorbidities during adolescence may vary by race, ethnicity and socioeconomic status, among other variables.

Clinical Practice

Assessment

The psychiatric assessment of a child or adolescent starts with obtaining a psychiatric history by interviewing the young person and their parents or caregivers. The assessment includes a detailed exploration of the current concerns about the child’s emotional or behavioural problems, the child’s physical health and development, history of parental care (including possible abuse and neglect), family relationships and history of parental mental illness. It is regarded as desirable to obtain information from multiple sources (for example both parents, or a parent and a grandparent) as informants may give widely differing accounts of the child’s problems. Collateral information is usually obtained from the child’s school with regards to academic performance, peer relationships, and behaviour in the school environment.

Psychiatric assessment always includes a mental state examination of the child or adolescent which consists of a careful behavioural observation and a first-hand account of the young person’s subjective experiences. The assessment also includes an observation of the interactions within the family, especially the interactions between the child and his/her parents.

The assessment may be supplemented by the use of behaviour or symptom rating scales such as the Achenbach Child Behaviour Checklist or CBCL, the Behavioural Assessment System for Children or BASC, Connors Rating Scales (used for diagnosis of ADHD), Millon Adolescent Clinical Inventory or MACI, and the Strengths and Difficulties Questionnaire or SDQ. These instruments bring a degree of objectivity and consistency to the clinical assessment. More specialised psychometric testing may be carried out by a psychologist, for example using the Wechsler Intelligence Scale for Children, to detect intellectual impairment or other cognitive problems which may be contributing to the child’s difficulties.

Diagnosis and Formulation

The child and adolescent psychiatrist makes a diagnosis based on the pattern of behaviour and emotional symptoms, using a standardized set of diagnostic criteria such as the Diagnostic and Statistical Manual (DSM-IV-TR) or the International Classification of Diseases (ICD-10). While the DSM system is widely used, it may not adequately take into account social, cultural and contextual factors and it has been suggested that an individualized clinical formulation may be more useful. A case formulation is standard practice for child and adolescent psychiatrists and can be defined as a process of integrating and summarising all the relevant factors implicated in the development of the patient’s problem, including biological, psychological, social and cultural perspectives (the “biopsychosocial model”). The applicability of DSM diagnoses have also been questioned with regard to the assessment of very young children: it is argued that very young children are developing too rapidly to be adequately described by a fixed diagnosis, and furthermore that a diagnosis unhelpfully locates the problem within the child when the parent-child relationship is a more appropriate focus of assessment.

The child and adolescent psychiatrist then designs a treatment plan which considers all the components and discusses these recommendations with the child or adolescent and family.

Treatment

Treatment will usually involve one or more of the following elements: behaviour therapy, cognitive behaviour therapy (CBT), problem-solving therapies, psychodynamic therapy, parent training programmes, family therapy, and/or the use of medication. The intervention can also include consultation with paediatricians, primary care physicians or professionals from schools, juvenile courts, social agencies or other community organisations.

In a review of existing meta-analyses and disorders on the four most frequent childhood and adolescent psychiatric disorders (anxiety disorder, depression, ADHD, conduct disorder), only for ADHD was the use of medication (stimulants) considered to be the most efficacious treatment option available. For the remaining three disorders, psychotherapy is recommended as the most effective treatment of choice. A combination of psychological and pharmacological treatments is an important option in ADHD and depressive disorders. Treatments for ADHD and anxiety disorders produce higher effect-sizes than do interventions for depressive and conduct disorders.

Training

In the United States, Child and adolescent psychiatric training requires 4 years of medical school, at least 4 years of approved residency training in medicine, neurology, and general psychiatry with adults, and 2 years of additional specialised training in psychiatric work with children, adolescents, and their families in an accredited residency in child and adolescent psychiatry. Child and adolescent sub-speciality training is similar in other Western countries (such as the UK, New Zealand, and Australia), in that trainees must generally demonstrate competency in general adult psychiatry prior to commencing sub-speciality training.

Certification and Continuing Education

In the US, having completed the child and adolescent psychiatry residency, the child and adolescent psychiatrist is eligible to take the additional certification examination in the subspecialty of child and adolescent psychiatry from the American Board of Psychiatry and Neurology (ABPN) or the American Osteopathic Board of Neurology and Psychiatry (AOBNP). Although the ABPN and AOBNP examinations are not required for practice, they are a further assurance that the child and adolescent psychiatrist with these certifications can be expected to diagnose and treat all psychiatric conditions in patients of any age competently. Training requirements are listed on the web site of The American Academy of Child & Adolescent Psychiatry.

Shortage of Child and Adolescent Psychiatrists in the United States

The demand for child and adolescent psychiatrists continues to far outstrip the supply worldwide. There is also a severe maldistribution of child and adolescent psychiatrists, especially in rural and poor, urban areas where access is significantly reduced. As of 2016, there are 7991 child and adolescent psychiatrists in the United States. A report by the US Bureau of Health Professions (2000) projected a need by the year 2020 for 12,624 child and adolescent psychiatrists, but a supply of only 8,312. In its 1998 report, the Centre for Mental Health Services estimated that 9-13% of 9- to 17-year-olds had serious emotional disturbances, and 5-9% had extreme functional impairments. In 1999, however, the Surgeon General reported that “there is a dearth of child psychiatrists.” Only 20% of emotionally disturbed children and adolescents received any mental health treatment, a small percentage of which was performed by child and adolescent psychiatrists. Furthermore, the US Bureau of Health Professions projects that the demand for child and adolescent psychiatry services will increase by 100% between 1995 and 2020.

Cross-Cultural Considerations

Steady growth in migration of immigrants to higher-income regions and countries has contributed to the growth and interest in cross-cultural psychiatry. Families of immigrants whose child has a psychiatric illness must come to understand the disorder while navigating an unfamiliar health care system.

Criticisms

Subjective Diagnoses

One criticism against psychiatry is that psychiatric diagnoses lack complete “objectivity,” particularly when compared with diagnoses in other medical specialties. However, for several major psychiatric disorders interrater reliability, which shows the degree to which psychiatrists agree on the diagnosis, is generally similar to those in other medical specialties. In 2013, Allen Frances said that “psychiatric diagnosis still relies exclusively on fallible subjective judgements rather than objective biological tests.”

Traditional deficit and disease models of child psychiatry have been criticised as rooted in the medical model which conceptualises adjustment problems in terms of disease states. It is said by these critics that these normative models explicitly characterise problematic behaviour as representing a disorder within the child or young person and these commentators assert that the role of environmental influences on behaviour has become increasingly neglected, leading to a decrease in the popularity of, for example, family therapy. There are criticisms of the medical model approach from within and without the psychiatric profession: it is said to neglect the role of environmental, family, and cultural influences, to discount the psychological meaning of behaviour and symptoms, to promote a view of the “patient” as dependent and needing to be cured or cared for and therefore undermines a sense of personal responsibility for conduct and behaviour, to promote a normative conception based on adaptation to the norms of society (the ill person must adapt to society), and to be based on the shaky foundations of reliance on a classificatory system that has been shown to have problems of validity and reliability.

Prescription of Psychotropic Medications

Since the late 1990s, use of psychiatric medication has become increasingly common for children and adolescents. In 2004 the US Food and Drug Administration (FDA) issued the Black Box Warning on antidepressant prescriptions to alert patients of a research link between use of medication and apparent increased risk of suicidal thoughts, hostility, and agitation in paediatric patients. The most common diagnoses for which children receive psychiatric medication are ADHD, ODD, and conduct disorder.

Some research suggests that children and adolescents are sometimes given antipsychotic drugs as a first-line treatment for mental health problems or behavioural issues other than a psychotic disorder. In the United States, the usage of these drugs in young people has greatly increased since 2000, especially among children from low-income families. More research is needed to specifically assess the efficacy and tolerability of antipsychotic medications in paediatric populations. Because of the risk of metabolic syndrome and cardiovascular events with long-term antipsychotic use, use in paediatric populations is highly scrutinized and recommended in combination with psychotherapy and effective parent-training interventions.

Electroconvulsive Therapy

In 1947, child neuropsychiatrist Lauretta Bender published a study on 98 children aged between four and eleven years old who had been treated in the previous five years with intensive courses of electroconvulsive therapy (ECT). These children received ECT daily for a typical course of approximately twenty treatments. This formed part of an experimental trend amongst a cadre of psychiatrists to explore the therapeutic impact of intensive regimes of ECT, which is also known as either regressive ECT or annihilation therapy. In the 1950s Bender abandoned ECT as a therapeutic practice for the treatment of children. In the same decade the results of her published work on the use of ECT in children was discredited after a study showing that the condition of the children so treated had either not improved or deteriorated. Commenting on his experience as part of Bender’s therapeutic program, Ted Chabasinski said that, “It really made a mess of me … I went from being a shy kid who read a lot to a terrified kid who cried all the time.” Following his treatment, he spent ten years as an inmate of Rockland State Hospital, a psychiatric facility now known as the Rockland Psychiatric Centre.

What is Liaison Psychiatry?

Introduction

Liaison psychiatry, also known as consultative psychiatry or consultation-liaison psychiatry is the branch of psychiatry that specialises in the interface between general medicine/paediatrics and psychiatry, usually taking place in a hospital or medical setting.

The role of the consultation-liaison psychiatrist is to see patients with comorbid medical conditions at the request of the treating medical or surgical consultant or team. Consultation-liaison psychiatry has areas of overlap with other disciplines including psychosomatic medicine, health psychology and neuropsychiatry.

Brief History

The history of liaison psychiatry is partly a history of psychiatry and medicine. Galen was highly influential for over 1500 years in medicine particularly advocating the use of experimentation to advance knowledge. The polymath physician Avicenna produced many insights into medicine but only became influential in Western medicine when William Harvey’s elucidation of the circulatory system forced a re-evaluation of Galen’s work. The French philosopher René Descartes began the dualistic debate on the division between mind and body. Johann Christian August Heinroth is credited with the origination of the term psychosomatic illness. At the beginning of the 19th century Johann Christian Reil created the term psychiatry whilst the polymath Benjamin Rush wrote Diseases of the Mind. The philosopher Spinoza’s concept of conatus, Mesmer’s development of hypnosis together with Charcot’s refinement of this technique influenced Sigmund Freud whose development of psychoanalytic theory was to have a profound impact on the development of liaison psychiatry. Under the guidance of Alan Gregg, psychoanalysis impacted on hospital medicine through figures such as Franz Alexander, Stanley Cobb and Felix Deutsch.

Edward Billings first coined the term “liaison psychiatry.” The publishing of two texts A Handbook of Elementary Psychobiology and Psychiatry, by Billings, and Psychosomatic Medicine, by Edward Weiss and O. Spurgeon English, outlined the theoretical foundations for the developing field. George L. Engel is considered to have been one of the most important figures in the development of liaison psychiatry and coined the term “Biopsychosocial Model” which overcame divisions created by Cartesian Dualism and was to have wider repercussions on psychiatric practice.

United Kingdom

The Faculty of Liaison Psychiatry was established within the Royal College of Psychiatrists in 1997. The European Association for Consultation Liaison Psychiatry and Psychosomatics also produced a set of guidelines for training in Liaison Psychiatry.

A survey for NHS England in 2015 found 133 out of 179 A&E departments could not deliver the minimum core standard for 24/7 liaison psychiatry. 11 hospitals had no liaison psychiatry service, and only 35 delivered at or above the minimum standards. Collectively there was a shortage of 1,270 trained nurses and 230 trained consultants.

United States

The American Psychiatric Association formally recognised C-L psychiatry as a subspecialty in 2004, with its own sub-specialty board exam. The profession debated about the best term for this specialty, finally settling on “Psychosomatic Medicine”.

Scope

Liaison psychiatry usually provides a service to patients in a general medical hospital, either inpatients, outpatients or attenders at the Emergency Department. Referrals are made when the treating medical team has questions about a patient’s mental health, or how that patient’s mental health is affecting their care and treatment. Typical issues include:

  • Patients with medical conditions that cause/exacerbate psychiatric or behavioural problems, such as delirium.
  • Supporting the management of patients with mental disorders who have been admitted for the treatment of medical problems.
  • Assisting with assessment of the capacity of a patient to consent to treatment.
  • Patients who may report physical symptoms as a result of a mental disorder, or patients with medically unexplained physical symptoms.
  • Patients who may not have a psychiatric disorder but are experiencing distress related to their medical problems.
  • Patients who have attempted suicide or self-harm.
  • Assisting with the diagnosis, treatment and functional assessment of people with dementia, including advice on discharge planning or the need for long-term care.

The psychiatric team “liaises” with many other services, including the treating medical team, other mental health services, social services, and community services. There is increasing interest on extending liaison psychiatry to primary care, for the management of long-term medical conditions such as diabetes mellitus.

Effectiveness of Liaison Psychiatry

Consultation-liaison psychiatry helps improve patients’ coping mechanisms, treatment adherence, school/work re-integration and quality of life. An evaluation of the Rapid Assessment, Interface and Discharge (RAID) model of liaison psychiatry – employed at City Hospital, Birmingham – estimated that the service saved between 43 and 64 beds per day through reduced lengths of stay and prevention of readmission. In 2011 the Centre for Mental Health published an economic evaluation of the service, estimating savings of around £3.5 million. This was followed in 2012 by the publication of a report recommending that every NHS hospital should have a liaison psychiatry service as standard.

What is the American Academy of Psychoanalysis and Dynamic Psychiatry?

Introduction

The American Academy of Psychodynamic Psychiatry and Psychoanalysis (AAPDPP)is a scholarly society including psychiatrists interested in all aspects of psychodynamic psychiatry.

Origins

The American Academy of Psychoanalysis was founded in 1956. At that time, the American Psychoanalytic Association, which was the dominant psychoanalytic organisation in North America, set standards for training psychoanalytic candidates at psychoanalytic institutes and certified individual psychoanalysts and institutes as well. The seventy-six Charter members who founded the Academy were concerned that focus on certification associated with a rigid Freudian framework inhibited free and open discourse about basic psychoanalytic concepts. They wanted to establish a forum for open discussion and debate but not an organisation that would certify psychoanalysts or psychoanalytic institutes. The guiding philosophy of this new organisation was expressed by its first President, Janet Rioch:

“The process of communication by forum is of value to encourage honest exchange of scientific opinion and observations; to build upon and expand those basic premises which survive critical scrutiny; to have the courage to discard that which cannot be regarded as scientifically valid in light of our present knowledge.”

Psychoanalysis and Psychiatry

Since the inception of the Academy, great changes have taken place in the practice of psychoanalysis and in the application of depth psychology (from the German term Tiefenpsychologie and commonly termed “psychoanalytic psychology”) to psychiatric symptoms, syndromes and disorders. The Academy changed its name to The American Academy of Psychoanalysis and Dynamic Psychiatry and became an Affiliate organisation of the American Psychiatric Association in 1998. From originally being an organisation of medical psychoanalysts, the Academy became an organisation of psychiatrists interested in all aspects of psychodynamic psychiatry. Psychoanalysis as a treatment technique remains one of its many interests. The membership of The Academy consists of psychiatrists, psychiatric residents, and medical students. Researchers and scholars who are not psychiatrists are welcomed as Scientific Associates.

Psychodynamic Psychiatry

Psychodynamic psychiatry is a new discipline that has emerged from a fusion of psychoanalytic and extra-psychoanalytic psychology, neuroscience and academic psychiatry.

Psychodynamic treatments are based on assessment that is carried out from a developmental perspective. Particular attention is paid to the person’s present and past psychiatric illnesses, experiences of trauma, and family history. The patient’s behaviour is reported both descriptively using established psychiatric diagnostic criteria from the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and from the International Classification of Diseases (ICD). The patient’s behaviour is in addition understood in terms of subjectively constructed narratives.

Psychodynamic psychiatry accepts concepts that are clinically useful and/or scientifically important but discards those that have not stood the test of time. Although it enthusiastically endorses research, it also recognises that much knowledge about normal and abnormal behaviour (however these terms are defined) is based on clinical experience. Thus, for example, the official journal of the American Academy of Psychoanalysis and Dynamic Psychiatry is entitled Psychodynamic Psychiatry and publishes clinical case discussions as well as scholarly reviews and research investigations. As time goes on, psychodynamic psychiatry as a body of knowledge will change as more is learned about the relationships between neuroscience, psychopathology, and individual feelings and behaviour.

All psychodynamic treatments are organised around a therapeutic alliance forged by both participants. They include psychoanalysis, briefer therapies and combinations of therapies including, for example, individual and group psychotherapy, family therapy and/or pharmacotherapy. Psychodynamically oriented treatments may be of any duration from a single meeting to weeks to years. They may take place anywhere the practitioner meets with a patient – not only in the outpatient setting but in inpatient psychiatric services, the emergency ward, and general hospital medical and surgical settings where consultation-liaison psychiatrists use developmental principles and alliance with the patient to render care. In other words, wherever the psychodynamically trained psychiatrist interacts with a patient, the practitioner uses a developmental approach to understand that person and help him or her get better.

Activities

All activities of the Academy foster communication and discussion of psychodynamic concepts as expressed in clinical treatment, research, psychological development and diverse other ways as well. A major priority of The Academy is to teach the principles of psychodynamic psychiatry to medical students, psychiatric residents and other mental health professionals and students. The specific activities include:

  • Annual Meeting Of The Academy The meetings take place immediately prior to the annual meeting of The American Psychiatric Association (APA) and are usually organised around a central theme for example, the meeting in 2013 was focused on the suicidal patient.
    • The meeting in 2016 was focused on play.
  • Symposia and workshops at the American Psychiatric Association and the Institute on Psychiatric Services (IPS)
  • Annual meeting in Italy co-sponsored with OPIFER (Organizzazione Psicoanalisti Italiania Federazione e Registro).
  • Past meetings in Washington DC co-sponsored with the Consortium for Psychoanalytic Research.

Publications and Out-Reach Activities

Psychodynamic Psychiatry (The Journal)

Psychodynamic Psychiatry, the official journal of The American Academy of Psychoanalysis and Dynamic Psychiatry, published by Guilford Press, was created in response to the need for the continued study and teaching of psychodynamic concepts in organised psychiatry. Psychodynamic Psychiatry is the only English-language psychiatric journal exclusively devoted to the study and discussion of these issues.

The central tenet of the journal is that psychodynamic principles are necessary for adequately understanding and treating people with psychiatric symptoms, syndromes and disorders. Its guiding framework is developmental and bio-psycho-social.

The journal publishes review articles, clinical discussions and research. Psychodynamic Psychiatry is edited by Richard C. Friedman MD. The Deputy Editors are Jennifer Downey, MD and Cesar Alfonso, MD.

From 1958 to 1972 the Academy published its proceedings in monograph form under the rubric “Science and Psychoanalysis” edited by Jules Masserman. In 1973 Silvano Arieti became the first editor of the Journal which was entitled Journal of The American Academy of Psychoanalysis. Subsequent Editors- in Chief included Morton Cantor, Jules Bemporad and Douglas Ingram. When Richard C. Friedman became Editor in Chief in 2012, the journal’s name was changed to Psychodynamic Psychiatry.

The Academy Forum

The Academy Forum is a magazine that is published twice yearly and focuses on psychoanalytic and psychodynamically oriented articles about art and culture.

The Academy Newsletter

The Academy Newsletter is published electronically 4 times a year and gives information about the organisation and its members.

Teichner Scholars Programme

The late Victor J Teichner was a former President of the AAPDPP. A grateful patient established a fund making it possible to impart the spirit of Teichner’s creative therapeutic perspective to psychiatric clinicians in training. The Victor J. Teichner Award is made annually to one psychiatric residency programme on the basis of an application to the Award Committee, composed of representatives of the AAPDPP and the AADPRT (American Association of Directors of Psychiatric Residency Training). Its focus is to promote the teaching of psychodynamic principles to psychiatrists-in-training. The Programme Awardee receives a one- to three-day visit from a Visiting Scholar chosen from a list maintained by the AAPDP. The choice of the Visiting Scholar and structure of the visit are made by the Programme. The visit must take place during the academic year beginning 01 July, after the announcement of the Awardee.

What is Forensic Psychiatry?

Introduction

Forensic psychiatry is a subspeciality of psychiatry and is related to criminology. It encompasses the interface between law and psychiatry.

According to the American Academy of Psychiatry and the Law, it is defined as “a subspecialty of psychiatry in which scientific and clinical expertise is applied in legal contexts involving civil, criminal, correctional, regulatory, or legislative matters, and in specialized clinical consultations in areas such as risk assessment or employment.”

A forensic psychiatrist provides services – such as determination of competency to stand trial – to a court of law to facilitate the adjudicative process and provide treatment, such as medications and psychotherapy, to criminals.

Court Work

Forensic psychiatrists work with courts in evaluating an individual’s competency to stand trial, defences based on mental disorders (e.g. the insanity defence), and sentencing recommendations. The two major areas of criminal evaluations in forensic psychiatry are competency to stand trial (CST) and mental state at the time of the offense (MSO).

Competency to Stand Trial

Competency to stand trial (CST) is the competency evaluation to determine that defendants have the mental capacity to understand the charges and assist their attorneys. In the United States, this is seated in the Fifth Amendment to the United States Constitution, which ensures the right to be present at one’s trial, to face one’s accusers, and to have help from an attorney. CST, sometimes referred to as adjudicative competency, serves three purposes: “preserving the dignity of the criminal process, reducing the risk of erroneous convictions, and protecting defendants’ decision-making autonomy”.

In 1960, the Supreme Court of the United States in Dusky v. United States established the standard for federal courts, ruling that “the test must be whether the defendant has sufficient present ability to consult with his attorney with a reasonable degree of rational understanding and a rational as well as factual understanding of proceedings against him.” The evaluations must assess a defendant’s ability to assist their legal counsel, meaning that they understand the legal charges against them, the implications of being a defendant, and the adversarial nature of the proceedings, including the roles played by defence counsel, prosecutors, judges, and the jury. They must be able to communicate relevant information to their attorney, and understand information provided by their attorney. Finally, they must be competent to make important decisions, such as whether or not to accept a plea agreement.

In England, Wales, Scotland, and Ireland, a similar legal concept is that of “fitness to plead”.

As an Expert Witness

Forensic psychiatrists are often called to be expert witnesses in both criminal and civil proceedings. Expert witnesses give their opinions about a specific issue. Often, the psychiatrist will have prepared a detailed report before testifying. The primary duty of the expert witness is to provide an independent opinion to the court. An expert is allowed to testify in court with respect to matters of opinion only when the matters in question are not ordinarily understandable to the finders of fact, be they judge or jury. As such, prominent leaders in the field of forensic psychiatry, from Thomas Gutheil (2009) to Robert Simon and Liza Gold (2010) and Sadoff (2011) have identified teaching as a critical dimension in the role of expert witness. The expert will be asked to form an opinion and to testify about that opinion, but in so doing will explain the basis for that opinion, which will include important concepts, approaches, and methods used in psychiatry.

Mental State Opinion

Mental state opinion (MSO) gives the court an opinion, and only an opinion, as to whether a defendant was able to understand what he/she was doing at the time of the crime. This is worded differently in many states, and has been rejected altogether in some, but in every setting, the intent to do a criminal act and the understanding of the criminal nature of the act bear on the final disposition of the case. Much of forensic psychiatry is guided by significant court rulings or laws that bear on this area which include these three standards:

  • M’Naghten rules: Excuses a defendant who, by virtue of a defect of reason or disease of the mind, does not know the nature and quality of the act, or, if he or she does, does not know that the act is indeed wrong.
  • Durham rule: Excuses a defendant whose conduct is the product of mental disorder.
  • ALI test: Excuses a defendant who, because of a mental disease or defect, lacks substantial capacity to appreciate the criminality (wrongfulness) of his or her conduct or to conform his conduct to the requirements of law.

“Not guilty by reason of insanity” (NGRI) is one potential outcome in this type of trial. Importantly, insanity is a legal and not a medical term. Often, psychiatrists may be testifying for both the defence and the prosecution.

Forensic psychiatrists are also involved in the care of prisoners, both in jails and prisons, and in the care of the mentally ill who have committed criminal acts (such as those who have been found not guilty by reason of insanity).

Risk Management

Many past offenders against other people, and suspected or potential future offenders with mental health problems or an intellectual or developmental disability, are supervised in the community by forensic psychiatric teams made up of a variety of professionals, including psychiatrists, psychologists, nurses, and care workers. These teams have dual responsibilities: to promote both the welfare of their clients and the safety of the public. The aim is not so much to predict as to prevent violence, by means of risk management.

Risk assessment and management is a growth area in the forensic field, with much Canadian academic work being done in Ontario and British Columbia. This began with the attempt to predict the likelihood of a particular kind of offense being repeated, by combining “static” indicators from personal history and offense details in actuarial instruments such as the RRASOR and Static-99, which were shown to be more accurate than unaided professional judgment. More recently, use is being made also of “dynamic” risk factors, such as attitudes, impulsivity, mental state, family and social circumstances, substance use, and the availability and acceptance of support, to make a “structured professional judgment.” The aim of this is to move away from prediction to prevention, by identifying and then managing risk factors. This may entail monitoring, treatment, rehabilitation, supervision, and victim safety planning and depends on the availability of funding and legal powers. These schemes may be based on published assessments such as the HCR-20 (which incorporates 10 Historical, 5 Clinical and 5 Risk Management factors) and the risk of sexual violence protocol from Simon Fraser University, BC.

United Kingdom

In the UK, most forensic psychiatrists work for the National Health Service, in specialist secure units caring for mentally ill offenders (as well as people whose behaviour has made them impossible to manage in other hospitals). These can be either medium secure units (of which there are many throughout the country) or high secure hospitals (also known as special hospitals), of which three are in England and one in Scotland (the State Hospital, Carstairs), the best known of which is Broadmoor Hospital. The other ‘specials’ are Ashworth hospital in Maghull, Liverpool, and Rampton hospital in Nottinghamshire. Also, a number of private-sector medium secure units sell their beds exclusively to the NHS, as not enough secure beds are available in the NHS system.

Forensic psychiatrists often also do prison inreach work, in which they go into prisons and assess and treat people suspected of having mental disorders; much of the day-to-day work of these psychiatrists comprises care of very seriously mentally ill patients, especially those suffering from schizophrenia. Some units also treat people with severe personality disorder or learning disabilities. The areas of assessment for courts are also somewhat different in Britain, because of differing mental health law. Fitness to plead and mental state at the time of the offence are indeed issues given consideration, but the mental state at the time of trial is also a major issue, and this assessment most commonly leads to the use of mental health legislation to detain people in hospitals, as opposed to their getting a prison sentence.

Learning-disabled offenders who are a continuing risk to others may be detained in learning-disability hospitals (or specialised community-based units with a similar regimen, as the hospitals have mostly been closed). This includes those who commit serious crimes of violence, including sexual violence, and fire-setting. They would be cared for by learning disability psychiatrists and registered learning disability nurses. Some psychiatrists doing this work have dual training in learning disability and forensic psychiatry or learning disability and adolescent psychiatry. Some nurses would have training in mental health, also.

Court work (medicolegal work) is generally undertaken as private work by psychiatrists (most often forensic psychiatrists), as well as forensic and clinical psychologists, who usually also work within the NHS. This work is generally funded by the Legal Services Commission (used to be called Legal Aid).

Canada

Criminal Law Framework

In Canada, certain credentialed medical practitioners may, at their discretion, make state-sanctioned investigations into and diagnosis of mental illness. Appropriate use of the DSM-IV-TR is discussed in its section entitled “Use of the DSM-IV-TR in Forensic Settings”.

Concerns have been expressed that the Canadian criminal justice system discriminates based on DSM IV diagnosis within the context of Part XX of the Criminal Code. This part sets out provisions for, among other things, court ordered attempts at “treatment” before individuals receive a trial as described in section 672.58 of the Criminal Code. Also provided for are court ordered “psychiatric assessments”. Critics have also expressed concerns that use of the DSM-IV-TR may conflict with section 2(b) of the Canadian Charter of Rights and Freedoms, which guarantees the fundamental freedom of “thought, belief, opinion, and expression”.

Confidentiality

The position of the Canadian Psychiatric Association holds, “in recent years, serious incursions have been made by governments, powerful commercial interests, law enforcement agencies, and the courts on the rights of persons to their privacy.” It goes on to state, “breaches or potential breaches of confidentiality in the context of therapy seriously jeopardize the quality of the information communicated between patient and psychiatrist and also compromise the mutual trust and confidence necessary for effective therapy to occur.”

An outline of the forensic psychiatric process as it occurs in the province of Ontario is presented in the publication The Forensic Mental Health System In Ontario: An Information Guide published by the Centre for Addiction and Mental Health in Toronto. The Guide states: “Whatever you tell a forensic psychiatrist and the other professionals assessing you is not confidential.” The Guide further states: “The forensic psychiatrist will report to the court using any available information, such as: police and hospital records, information given by your friends, family or co-workers, observations of you in the hospital.” Also according to the Guide: “You have the right to refuse to take part in some or all of the assessment. Sometimes your friends or family members will be asked for information about you. They have the right to refuse to answer questions, too.”

Of note, the emphasis in the guide is on the right to refuse participation. This may seem unusual given that a result of a verdict of “Not Criminally Responsible by reason of Mental Disorder” is often portrayed as desirable to the defence, similar to the insanity defence in the United States. A verdict of “Not Criminally Responsible” is referred to as a “defence” by the Criminal Code. However, the issue of the accused’s mental state can also be raised by the Crown or by the court itself, rather than solely by the defence counsel, differentiating it from many other legal defences.

Treatment/Assessment Conflict

In Ontario, a court-ordered inpatient forensic assessment for criminal responsibility typically involves both treatment and assessment being performed with the accused in the custody of a single multidisciplinary team over a 30- or 60-day period. Concerns have been expressed that an accused may feel compelled on ethical, medical, or legal grounds to divulge information, medical, or otherwise, to assessors in an attempt to allow for and ensure safe and appropriate treatment during that period of custody.

Some Internet references address treatment/assessment conflict as it relates to various justice systems, particularly civil litigation in other jurisdictions. The American Academy Of Psychiatry and the Law states in its ethics guidelines, “when a treatment relationship exists, such as in correctional settings, the usual physician-patient duties apply”, which may be seen as contradiction.

South Africa

In South Africa, patients are referred for observation for a period of 30 days by the courts if questions exist as to CST and MSO. Serious crimes require a panel, which may include two or more psychiatrists. Should the courts find the defendant not criminally responsible, the defendant may become a state patient and be admitted in a forensic psychiatric hospital. They are referred to receive treatment for an indefinite period, but most were back in the community after three years.

Training Standards

Some practitioners of forensic psychiatry have taken extra training in that specific area. In the United States, one-year fellowships are offered in this field to psychiatrists who have completed their general psychiatry training. Such psychiatrists may then be eligible to sit for a board certification examination in forensic psychiatry. In Britain, one is required to complete a three-year subspeciality training in forensic psychiatry, after completing one’s general psychiatry training, before receiving a Certificate of Completion of Training as a forensic psychiatrist. In some countries, general psychiatrists can practice forensic psychiatry, as well. However, other countries, such as Japan, require a specific certification from the government to do this type of work.

References

Gutheil, T.G. (2009) The Psychiatrist as Expert Witness. 2nd Ed. Washington: American Psychiatric Publishing.

Robert, S. & Gold, L. (Eds). (2010) American Psychiatric Textbook of Forensic Psychiatry. Washington: American Psychiatric Publishing.

Sadoff, R.L. (2011). Ethical Issues in Forensic Psychiatry: Minimizing Harm. New Jersey: Wiley-Blackwall.