Neurocognitive Disorders in DSM-V: Forensic Perspective

Although determination of diagnosis of cognitive impairments constitutes one of the core objectives of forensic neuropsychological assessment, the diagnostic criteria for cognitive disorders provided by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, American Psychiatric Association 2000) have been of low internal and external validity and limited utility. This paper reviews the evolution of diagnosis of cognitive disorders from current DSM-IV-TR to the proposed DSM-V (American Psychiatric Association 2010). The conceptual framework is tracked, along with the body of literature associated with the DSM-V proposal on Minor and Major Neurocognitive Disorders. The quality of evidence for internal and external validity is reviewed, as well as the fairness and utility of newly proposed diagnoses from both clinical and forensic perspectives. Significant conceptual, evidentiary, psychometric, assessment, and practical questions are raised related to the new classification, and recommendations are offered for improvement to the proposal of the DSM-V Work Group on Neurocognitive Disorders.     

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).     

The DSM-5 Draft: Critique and Recommendations

The series of articles in this special topic on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) draft (American Psychiatric Association 2010), which is preparatory to publication of the DSM-5, deals with issues and disorders and conditions pertinent to the field of psychological injury and law. The articles describe and critique the changes anticipated for the diagnoses of posttraumatic stress disorder, pain disorder, and neurocognitive disorder, in particular. Further, changes suggested in the draft for personality disorder are analyzed with a critical eye. In addition, the articles examine the lack of change for dealing with malingering and the general lack of consideration of group differences such as for race, in areas pertinent to psychological injury and law. This summary of the articles concludes that some of the changes in the DSM-5 draft are premature, and it calls for continued research and evidence-informed bases for recommended changes for the DSM-V.     

DSM-5 and Malingering: a Modest Proposal

The DSM criteria for identifying malingering are reviewed and found to be flawed on both conceptual and practical grounds. Alternative models for diagnosing feigned psychiatric, physical, and neuropsychological symptoms are presented. A number of useful features of these systems are highlighted for potential contributions to modified DSM criteria. It is recommended that the present DSM text on malingering be replaced with feigned psychiatric, physical, or neuropsychological symptoms and suggestions for developing criteria for this condition are made.     

PTSD,Endophenotypes, the RDoC,and the DSM-5

The search for endophenotypes that stand between genetics and disease has been applied to the diagnostic entity of Posttraumatic Stress Disorder (PTSD). Advances are being made in understanding the pathway to disorder in PTSD in terms of brain regions, neuronal networks, stress-related systems (e.g., the hypothalamic–pituitary–adrenal (HPA) axis), and their underlying genetic and neurogenetic bases. The latter are affected by gene–environmental interactions and epigenetic effects, and the environment and context reciprocally interrelate with them, as well. Therefore, a primary focus on (neuro)pathophysiological intermediates in the disease pathway, as appears emphasized in the research domain criteria (RDoC) approach to etiology of psychiatric disorder, and to which the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) subscribes, might detract from a more inclusive biopsychosocial approach that would be more applicable in the case of PTSD. The paper undertakes a comprehensive review of the recent literature in the areas of endophenotypes, neurogenetics, epigenetics, neural networks, HPA axis, neuronal networks, pathways, the PTSD five-factor model, allostasis, and the RDoC criteria for psychiatric diagnosis, and then returns to the topic of endophenotypes. Neuronal networks constitute one integrating area that could help in arriving at an appropriate model of PTSD endophenotype. Pathway analysis provides a rich field for discerning individual differences in PTSD development, more so than the static approach of using DSM-5 symptom criteria. A model of endophenotypes is presented, which considers these factors in relation to PTSD. The paper concludes with implications for the DSM-5, for practice and for court, especially that it would be premature to seek individual biomarkers of PTSD given the current state of knowledge, even if it is burgeoning.     

Forensic Applications of the Miller Forensic Assessment of Symptoms Test (MFAST): Screening for Feigned Disorders in Competency to Stand Trial Evaluations

Forensic evaluations must systematically assess malingering and related response styles. In the criminal forensic domain, competency to stand trial evaluations are the most common referrals. Effective screens for feigned incompetency would be valuable assets for forensic evaluations. This study evaluates the effectiveness of the Miller Forensic Assessment of Symptoms Test (MFAST) as a screen for feigned incompetency. Using a simulation design, the MFAST was tested on jail and competency-restoration samples. Most notably, recommended MFAST cut score (6) was useful for the identification of feigning cases in competency evaluations. Recommendations for forensic practice, including the advantages and disadvantages of systematic screens, are discussed.     

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.     

Posttraumatic Stress Disorder in the DSM-5: Group Difference Commentary

This article provides a commentary on the proposed Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 changes with respect to diagnosing posttraumatic stress disorder (PTSD) in diverse cultural groups in clinical and forensic settings. PTSD is the most common diagnosis in personal injury litigants (Koch et al. 2006). By reviewing the symptoms that have been changed in the DSM-5 draft for PTSD in terms of ethnoracial and minority–cultural factors, this article highlights the lack of data needed in the area and that the DSM project should pay more attention to such factors.     

Symptom Validity Testing in Somatoform and Dissociative Disorders: A Critical Review

When patients present with unusual, atypical, and difficult-to-understand complaints known as dissociative and somatoform disorders or medically unexplained symptoms, clinicians may administer symptom validity tests (SVTs) to determine whether or not the patient exhibits negative response bias. Such tests are especially informative in a context where incentives play a substantial role (e.g., the legal arena). If patients fail SVTs and exhibit negative response bias, how should that bias be interpreted? Some authors have argued that psychological problems (e.g., unconscious conflicts and depression) and circumstances (e.g., a cry for help) may explain such bias. In the current article, we critically review this “psychopathology = superordinate” position. We argue that (1) there is no empirical evidence to suggest that psychological problems may foster SVT failure per se and (2) that the “psychopathology = superordinate” position invites circular argumentation: to clarify the nature of the atypical symptoms, SVTs are administered and a negative response bias is found, which is explained away by the atypical symptoms. Negative response bias allows for only one conclusion: the patient’s self-report of symptoms and life history can no longer be taken at face value.     

Expertise, Counterfactual Thinking, and Fairness Perceptions: A Test of Fairness Theory

While fairness theory (Folger & Cropanzano, 1998, 2001) suggests perceptions of injustice are due to accountability judgments and counterfactual thinking, few studies have examined the influence of contextual variables on counterfactual thinking and the mediating role of counterfactual thought. Further, the few studies that have examined this have resulted in mixed findings, which may be attributable to the methodology used. The present research utilized a unique approach to examine fairness theory: the double-randomized design. Study 1 showed that agent expertise is related to would and should counterfactual strength and the generation of other-attributed counterfactuals (X → M). Study 2 showed that would and should counterfactuals are related to fairness perceptions (M → Y). This study integrates previous research examining fairness theory and highlights the importance of counterfactual thoughts on fairness perceptions when a person’s level of expertise is made salient. Additional implications for research and practice are discussed.     

Limitations of Diagnostic Precision and Predictive Utility in the Individual Case: A Challenge for Forensic Practice

Knowledge of group tendencies may not assist accurate predictions in the individual case. This has importance for forensic decision making and for the assessment tools routinely applied in forensic evaluations. In this article, we applied Monte Carlo methods to examine diagnostic agreement with different levels of inter-rater agreement given the distributional characteristics of PCL-R scores. Diagnostic agreement and score agreement were substantially less than expected. In addition, we examined the confidence intervals associated with individual predictions of violent recidivism. On the basis of empirical findings, statistical theory, and logic, we conclude that predictions of future offending cannot be achieved in the individual case with any degree of confidence. We discuss the problems identified in relation to the PCL-R in terms of the broader relevance to all instruments used in forensic decision making.     

多层螺旋CT与三维重建技术在法医损伤学中的应用

影像学技术发展迅速．已经成为临床诊断、治疗不可或缺的有效工具。利用MSCT与三维重建技术进行虚拟解剖,因为具有非破坏性、可显示特殊部位损伤形态、分析快速且便捷、便于证据保存和出示等特点在法医学尸体解剖中日益凸显优势．在法医损伤学研究及实践鉴定过程中具有较高的应用价值。文章综述了利用MSCT与三维重建技术在锐器伤、钝器伤、高坠伤、交通伤等实践领域的研究成果,并通过实践检案中遇到的典型案例,探讨多层螺旋CT与三维重建技术在法医学损伤鉴定中的应用价值。     

Chronic Pain in the DSM-IV and the DSM-5 Draft: The Pain of It All

The Diagnostic and Statistical Manual, DSM-IV-TR (American Psychiatric Association 2000) includes the diagnosis of pain disorder, and it has been revised in major ways in the DSM-5 draft (American Psychiatric Association 2010). Pain disorder has been relegated as a specifier of the new diagnosis of complex somatic symptom disorder. It cannot be diagnosed prior to 6 months of the pain’s onset. Also, there are still the pejorative connotations with which the disorder is associated. In terms of treatment, it might be more difficult to get treatment plans accepted as a result of the changes, and in terms of the legal arena, it might prove more difficult to have the disorder serve as the basis of action in legal proceedings.