The DSM-5 and Forensic Relationship Status: It’s Complicated

Psychologists who work in the civil forensic context are tasked with providing legal decision makers with sufficient valid and reliable data to aid them in deciding the penultimate question of whether the claimant has a psychological injury and whether that injury was the direct result of an event that preceded the injury. In May 2013, amidst a barrage of criticism from mental health professionals, the American Psychiatric Association released the long awaited fifth edition of its Diagnostic and Statistical Manual (DSM), oft referred to in legal and non-psychiatric contexts as the gold standard or bible of psychiatric disorders. Previous editions of the DSM have traditionally acknowledged the inadequacy of fit between the DSM and forensic environments. In its most current iteration, DSM-5 framers underscore the DSM’s utility in clinical and research settings, while also highlighting the level of forensic review that occurred in the vetting of DSM-5. Notwithstanding, (a) the vetting among forensic professionals and (b) the framers contention that the diagnostic categories are “concise and explicit,” the DSM-5 diagnostic categories, while perhaps fitting for the educational, clinical, and research contexts, just as its predecessors, are likely to lead to unexpected consequences in forensic contexts. Thus, it is incumbent upon psychologists serving as experts in civil forensic contexts to ensure that their findings are supported by data that are sufficiently reliable and based on sound methodology.     

DSM-5 Neurocognitive Disorders: Validity, Reliability, Fairness, and Utility in Forensic Applications

A previously published paper (Schultz Psychological Injury and Law 3: 271–288, 2010) on forensic considerations regarding neurocognitive disorders within the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5; American Psychiatric Association, 2013) reviewed evidence for internal and external validity, as well as the fairness and utility of the proposed classification. Given recent publication of the DSM-5, in May 2013, the current paper provides an update on this review. It focuses on changes in the final version of the neurocognitive disorders section of the DSM-5 as compared with the earlier proposal in 2010 and raises a range of new conceptual, methodological, and clinical practice issues related to this classification. An examination of forensic neuropsychologists’ diagnostic choices and their associated pitfalls follows. Discussion extends to the unresolved issue of disorder threshold, associated risks of overdiagnosis of mild neurocognitive disorder and underdiagnosis of major neurocognitive disorder, and the absence of a moderately severe disorder classification. Methodological concerns in diagnostic determinations, especially with DSM-5 Criteria A and B, issues associated with subtypes and specifiers, as well as functional assessments of activities of daily living, now embedded in the diagnosis, follow. Subtype omissions and methodological inconsistencies are highlighted.The vulnerability of neuropsychologists and psychiatrists during courtroom testimony on neurocognitive disorders-particularly with conceptual, methodological, and practical issues-will be addressed through clinical and forensic practice recommendations.     

Implications of DSM-5 Personality Traits for Forensic Psychology

One of the major innovations in the DSM-5 involves the introduction of evidence-based, dimensional approaches to diagnostic assessment. One way in which dimensions are being incorporated into the DSM-5 is in the form of a trait system that offers an alternative strategy for the diagnosis of personality disorders. The traits that comprise this system rest on the foundation of decades of quantitative research in personality and clinical psychology. Although they are conceptualized in the DSM-5 as primarily relevant to the diagnosis of personality disorder, emerging evidence suggests that these traits offer an evidence-based framework for organizing psychopathology more generally. For instance, trait approaches provide promising solutions to widely cited problems in clinical and forensic assessment such as diagnostic co-occurrence, heterogeneity, and arbitrary cut-offs. In this paper, rather than focusing specifically on the diagnosis of personality disorder, we review the rapidly emerging literature on the DSM-5 traits with special attention to their application beyond personality disorder diagnosis and their use and implications for forensic psychology.     

DSM-5 proposed diagnostic criteria for sexual paraphilias: tensions between diagnostic validity and forensic utility

In order to prevent sexual crimes, “sexual predator” laws now allow indefinite preventive civil commitment of criminals who have completed their prison sentences but are judged to have a paraphilic mental disorder that makes them likely to commit another crime. Such proceedings can bypass the usual protections of criminal law as long as the basis for incarceration is the attribution of a mental disorder. Thus, the difficult conceptual distinction between deviant sexual desires that are mental disorders versus those that are normal variations in sexual preference (even if they are eccentric, repugnant, or illegal if acted upon) has attained critical forensic significance. Yet, the concept of paraphilic disorders - called “perversions” in earlier times - is inherently fuzzy and controversial and thus open to conceptual abuse for social control purposes. Consequently, the criteria used in diagnosing paraphilic disorders deserve careful scrutiny.The DSM-5 sexual disorders work group is proposing substantial revisions to the paraphilia diagnostic criteria in the DSM-5 nosology. It is claimed that the new criteria provide a reconceptualization that clarifies the distinction between normal variation and paraphilic disorder in a way relevant to forensic settings. In this article, after considering the logic of the concept of a paraphilic disorder, I examine each of the proposed changes to the DSM-5 paraphilia criteria and assess their conceptual validity. I argue that the DSM-5 proposals, while containing a kernel of an advance in distinguishing paraphilias from paraphilic disorders, nonetheless would yield criteria for paraphilic disorders that are conceptually invalid in ways open to serious forensic abuse.     

Ill-Treatment of Pain in the DSM-5

The just-published psychiatric diagnostic manual, the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), American Psychiatric Association (2013), has been lauded by its organizers (e.g., Regier, Kuhl, and Kupfer in World Psychiatry 12, pp. 92–98, 2013), but has been criticized on multiple grounds, as well. Several of its major diagnostic categories concern the area of psychological injury and law (e.g., tort cases involving posttraumatic stress disorder (PTSD), chronic pain, and traumatic brain injury (TBI)). The one for chronic pain seems the one most greatly changed. The approach to chronic pain in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (American Psychiatric Association 2000) and the DSM-5 are compared, leading to an alternative diagnostic criteria list partly based on the changes in the DSM-5. The DSM-5 should be used with caution in forensic assessments. This applies especially to the psychological injury patient, including the pain one, given the high stakes involved and the need for accuracy in assessment based on a reliable and valid diagnostic system. Future iterations of the manual should be improved in both these regards.     

Assessment of Post-Traumatic Stress Disorder: Differences in Standards and Practice between Licensed and Board-Certified Psychologists

The purpose of this study was to examine the current diagnostic standards and assessment practices of psychologists when diagnosing post-traumatic stress disorder (PTSD). A web-based survey was employed to gather information on opinions and assessment practices of psychologists who were either licensed with no board certification, board certified in clinical psychology, or board certified in forensic psychology. Significant differences were found between the three groups of psychologists in frequency of inclusion of Diagnostic and Statistical Manual–Fourth Edition–Text Revision Criterion A, in use of recommended collateral information sources, in use of assessment methods or types of recommended instruments, and in assessing for over-reported PTSD symptoms. Results indicated that board certification status had significant impact on psychologists’ diagnostic standards and assessment practices related to PTSD.     

‘Tolling for the luckless,the abandoned and forsaked’: Therapeutic jurisprudence and international human rights law as applied to prisoners and detainees by forensic psychologists

Objectives. There has been an explosion of interest in therapeutic jurisprudence as both a filter and lens for viewing the extent to which the legal system serves therapeutic or anti‐therapeutic consequences. However, little attention has been paid to the impact of therapeutic jurisprudence on questions of international human rights law and the role of forensic psychologists. The paper aims to provide an intersection between human rights, therapeutic jurisprudence, and forensic psychology. Method. Human rights are based on legal, social, and moral rules. Human rights literature generally considers legal rights but such policy statements do not provide principles to guide forensic psychologists in addressing moral or social rights. Therefore, a framework to guide forensic psychologists is required. Conclusion. As duty‐bearers, forensic psychologists need to address the core values of freedom and well‐being in rights holders (in this instance, prisoners and detainees with a mental illness). The paper proposes that human rights principles can add to the normative base of a therapeutic jurisprudence framework, and in‐turn, therapeutic jurisprudence can assist forensic psychologists to actively address human rights.     

Assessing Cognitive Bias in Forensic Decisions: A Review and Outlook

In recent years, a number of studies have demonstrated that forensic examiners can be biased by task-irrelevant contextual information. However, concerns relating to methodological flaws and ecological validity attenuate how much the current body of knowledge can be applied to real-life operational settings. The current review takes a narrative approach to synthesizing the literature across forensic science. Further, the review considers three main issues: (i) primary research on contextual bias within forensic science; (ii) methodological criticisms of this research; (iii) an alternative perspective that task-irrelevant contextual information does not always lead to error. One suggestion for future research is outlined, which is that studies on contextual bias in forensic decisions should be conducted in collaboration between forensic scientists and cognitive psychologists. Only then can rigorous and ecological valid experiments be created that will be able to assess how task-irrelevant contextual information influences forensic analysis and judgments in operationally valid settings.     

Forensic mental health assessment in France: Recommendations for quality improvement

The quality of forensic mental health assessment has been a growing concern in various countries on both sides of the Atlantic, but the legal systems are not always comparable and some aspects of forensic assessment are specific to a given country. This paper describes the legal context of forensic psychological assessment in France (i.e. pre-trial investigation phase entrusted to a judge, with mental health assessment performed by preselected professionals called “experts” in French), its advantages and its pitfalls. Forensic psychiatric or psychological assessment is often an essential and decisive element in criminal cases, but since a judiciary scandal which was made public in 2005 (the Outreau case) there has been increasing criticism from the public and the legal profession regarding the reliability of clinical conclusions. Several academic studies and a parliamentary report have highlighted various faulty aspects in both the judiciary process and the mental health assessments. The heterogeneity of expert practices in France appears to be mainly related to a lack of consensus on several core notions such as mental health diagnosis or assessment methods, poor working conditions, lack of specialized training, and insufficient familiarity with the Code of Ethics. In this article we describe and analyze the French practice of forensic psychologists and psychiatrists in criminal cases and propose steps that could be taken to improve its quality, such as setting up specialized training courses, enforcing the Code of Ethics for psychologists, and calling for consensus on diagnostic and assessment methods.     

Competing ethical paradigms in forensic psychiatry and forensic psychology: Commentary for a special section of legal and criminological psychology

In her paper Gwen Adshead (2013) identifies the principle of respect for justice as the foundation for ethical practice in forensic psychiatry. This commentary discusses how forensic psychologists have approached a key aspect of the justice principle, the ethical imperative to promote the welfare of the individual client. The approaches of the psychiatric and psychological professions are compared and the role of psychologists as allied health professionals working in the forensic setting considered.     

Clinical presentation of malingerers diagnosed by experienced forensic psychologists

Little is known about the incidence of malingering or the diagnostic criteria for malingering employed by forensic clinical psychologists conducting pretrial evaluations for the criminal justice system. The clinical presentations of 39 criminal defendants diagnosed as malingering psychotic symptoms were contrasted with 25 defendants diagnosed as genuinely psychotic. The incidence of diagnosed malingering was 8% in a series of 314 consecutive evaluations. Malingerers differed from psychotics on 14 of 24 clinical presentation variables, including measures of general presentation, affect, hallucinations, delusions, and formal thought disorder. Results indicate consistent clinical features associated with the diagnosis of malingered psychosis.A summary of this study was presented at the 1988 Annual Convention of the American Psychological Association in Atlanta, Georgia. We very much appreciate the contribution made by the six forensic clinical psychologists at the Michigan Center for Forensic Psychiatry who volunteered to participate in this study.     

The Uncritical Acceptance of Risk Assessment in Forensic Practice

Forensic psychologists are frequently asked to conduct evaluations of risk assessment. While risk assessment has considerable merit, recent applications to forensic psychology raise concerns about whether these evaluations are thorough and balanced. Forensic adult risk-assessment models stress risk factors, and deemphasize or disregard entirely the other side of the equation: protective factors. Mediating and moderating effects must also be considered. Moreover, base-rate estimates may produce erroneous results if applied imprudently to forensic samples without regard to their unstable prevalence rates or the far-reaching effects of settings, referral questions, and evaluation procedures. Psychologists are offered a preliminary list of relevant issues for evaluating the merits of risk assessment in their forensic practices.     

Posttraumatic Stress Disorder in DSM-5: New Criteria,New Measures,and Implications for Assessment

The diagnostic criteria for posttraumatic stress disorder (PTSD) were substantially revised for Diagnostic and Statistical Manual of Mental Disorders—5th edition (DSM-5). This in turn necessitated revision of DSM-correspondent assessment measures of PTSD. We describe the various changes to the PTSD diagnostic criteria and the corresponding changes to National Center for PTSD measures. We also discuss the implications of the new criteria for assessment of trauma exposure and PTSD. Although the DSM-5 version of PTSD departs significantly in some respects from previous versions, we conclude that there is fundamental continuity with the original DSM-III conceptualization of PTSD as a chronic, debilitating mental disorder that develops in response to catastrophic life events.     

Two conjectures about the issue of expert testimony

This article responds to concerns about expert testimony in experimental psychology by conjectur that disagreements about the propriety of the testimony are camouflaged arguments about the strength of psychological knowledge. Differences between proponents and opponents of expert testimony are about the state of psychological knowledge and certainty, rather than about the proper standard for psychologists to use when deciding whether to testify. A second conjecture is stimulated by the assumption that laypersons generally overvalue eyewitness testimony and that expert psychological testimony is a required corrective. The truth of this assumption rests on the debatable assertions that eyewitness identifications, without more, are potent sole determinants of trial outcome, and that lay juries need instruction from experimental psychologists about aspects of human behavior of which the jurors are definitive producers and consumers. One need not resolve these debates in order to understand that psychologists should not rely on the legal community to set the psychologists' standards for expert testimony. And psychologists, in considering their role as courtroom experts, should guard against a self-serving critique of the acumen of lay juries.     

Underlying Dimensions of DSM-5 Posttraumatic Stress Disorder and Major Depressive Disorder Symptoms

This study examined the relationship between the underlying latent factors of major depression symptoms and DSM-5 posttraumatic stress disorder (PTSD) symptoms (American Psychiatric Association, 2013). A nonclinical sample of 266 participants with a trauma history participated in the study. Confirmatory factor analyses were conducted to evaluate the fit of the DSM-5 PTSD model and dysphoria model, as well as a depression model comprised of somatic and nonsomatic factors. The DSM-5 PTSD model demonstrated somewhat better fit over the dysphoria model. Wald tests indicated that PTSD’s negative alterations in cognitions and mood factor was more strongly related to depression’s nonsomatic factor than its somatic factor. This study furthers a nascent line of research examining the relationship between PTSD and depression factors in order to better understand the nature of the high comorbidity rates between the two disorders. Moreover, this study provides an initial analysis of the new DSM-5 diagnostic criteria for PTSD.     

Assaultive behavior in state psychiatric hospitals: differences between forensic and nonforensic patients

Forensic patients are occupying an increasingly large number of beds in state psychiatric hospitals. The presence of these mentally ill offenders has raised concerns about the risk they present to nonforensic patients. This study compared the rate of assaults and factors associated with assaultive behavior among 308 nonforensic patients and two groups of forensic patients including 469 patients found not guilty by reason of insanity and 76 pretrial patients. Consistent with other studies, nonforensic patients had higher rates of assaults than either group of forensic patients. However, being a forensic patient did not affect the odds of assault when controlling for the effects of demographic and clinical variables in a multivariate logistic regression analysis. Factors associated with assaults in each of the three patient groups were identified using multivariate analyses. Implications are presented for treatment of assaultive behavior, mixing of forensic and nonforensic patients within state hospitals, forensic release policies, and future research.     

Statistical Inference and Forensic Evidence: Evaluating a Bullet Lead Match

This experiment tested the ability of undergraduate mock jurors (N=295) to draw appropriate conclusions from statistical data on the diagnostic value of forensic evidence. Jurors read a summary of a homicide trial in which the key evidence was a bullet lead "match" that was either highly diagnostic, non-diagnostic, or of unknown diagnostic value. There was also a control condition in which the forensic "match" was not presented. The results indicate that jurors as a group used the statistics appropriately to distinguish diagnostic from non-diagnostic forensic evidence, giving considerable weight to the former and little or no weight to the latter. However, this effect was attributable to responses of a subset of jurors who expressed confidence in their ability to use statistical data. Jurors who lacked confidence in their statistical ability failed to distinguish highly diagnostic from non-diagnostic forensic evidence; they gave no weight to the forensic evidence regardless of its diagnostic value. Confident jurors also gave more weight to evidence of unknown diagnostic value. Theoretical and legal implications are discussed.     

Accountability and psychiatric disorders: How do forensic psychiatric professionals think?

Swedish penal law does not exculpate on the grounds of diminished accountability; persons judged to suffer from severe mental disorder are sentenced to forensic psychiatric care instead of prison. Re-introduction of accountability as a condition for legal responsibility has been advocated, not least by forensic psychiatric professionals. To investigate how professionals in forensic psychiatry would assess degree of accountability based on psychiatric diagnoses and case vignettes, 30 psychiatrists, 30 psychologists, 45 nurses, and 45 ward attendants from five forensic psychiatric clinics were interviewed. They were asked (i) to judge to which degree (on a dimensional scale from 1 to 5) each of 12 psychiatric diagnoses might affect accountability, (ii) to assess accountability from five case vignettes, and (iii) to list further factors they regarded as relevant for their assessment of accountability. All informants accepted to provide a dimensional assessment of accountability on this basis and consistently found most types of mental disorders to reduce accountability, especially psychotic disorders and dementia. Other factors thought to be relevant were substance abuse, social network, personality traits, social stress, and level of education.     

Pain-Related Symptom Reporting Among Hispanics: Implications for Forensic Psychological Evaluations

Competent forensic psychologists constantly pursue the understanding of cultural differences. The purposes of this paper were to describe and explain the literature regarding the influences of the Hispanic culture on reports of pain-related symptoms and disabilities, and to illustrate ways in which culture-specific factors can impact a forensic psychological evaluation that includes malingering identification. The reviewed literature indicates that, as a group, Hispanics do not consistently differ from other ethnic groups on pain-related symptom reports. However, when examining culture-specific indicators, individuals from a Puerto Rican background and those with high acculturation to the American culture tend to report more pain and psychological distress than non-Hispanic Whites and other Hispanic subgroups. Additionally, language barriers and cultural-structured views of health and illness seem to hinder help-seeking options among the Mexican and less-acculturated Hispanics. Based on these results, we discuss a number of recommendations to make forensic psychological evaluations more sensitive to differences in acculturation and country of heritage. By taking these within-culture characteristics into consideration, the forensic psychologist can most accurately comprehend the meanings associated with the Hispanic client’s pain-related experience.     

Breaking Bad: DSM-5 Description, Criticisms, and Recommendations

The special issue on the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition, American Psychiatric Association, 2013) in the journal Psychological Injury and Law has considered its changes relative to the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision, American Psychiatric Association, 2000) from both a clinical utility and scientific point of view. Although the manual did not undergo wholesale change, the changes to diagnostic categories relevant to the area of psychological injuries (especially posttraumatic stress disorder, mild traumatic brain injury, and chronic pain) present both practical and forensic conundrums, complicating clinical and legal work in the area. The articles in the special issue number nine (including the present one), and involve ones on the major psychological injuries, as well as personality. Separate articles deal with forensics and ethics, with a final one considering forensic psychiatric work using the DSMs. The authors collectively indicate that the DSM-5 is rife with utility and scientific difficulties, although it still might be used in practice and for court in the context of careful, comprehensive assessments and critical analysis. More importantly, ongoing and future research should be considered in revising the DSM-5. Some of the articles review in depth the extant research on their topics and all make recommendations that are useful. The articles include those (in order in the special issue) by: Zoellner et al. (Psychological Injury and Law, 6, 2013); Biehn et al. (Psychological Injury and Law, 6, 2013); Schultz (Psychological Injury and Law, 6, 2013); Young (2013); Hopwood and Sellbom (Psychological Injury and Law, 6, 2013); Thomas (Psychological Injury and Law, 6, 2013); Gordon and Cosgrove (Psychological Injury and Law, 6, 2013); and an opinion piece by Frances and Halon (Psychological Injury and Law, 6, 2013), the chief chair of the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, American Psychiatric Association 1994).