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.     

Early Intervention with Compensated Lower Back-Injured Workers at Risk for Work Disability: Fixed versus Flexible Approach

Low back pain (LBP), a leading cause of disability, has been linked with profound economic, personal, and social costs (Hills 2006; World Health Organization 2003). This significant effect propels research in identifying modifiable risk factors that protract LBP; these factors can be targeted in early intervention (EI) (Pransky, Journal of Occupational & Environmental Medicine, 49(3):249–251, 2007; Schultz et al., Journal of Occupational Rehabilitation, 17:327–352, 2007, Journal of Occupational Rehabilitation, 18(2), 140–151, 2008; White et al. 2013). This randomized controlled study evaluated the effectiveness of two approaches, fixed versus flexible, in delivering proactive, interdisciplinary EI with 63 workers within a workers' compensation interdisciplinary case management setting (i.e., WorkSafeBC, Canada). Off-work 4 to 10 weeks post-back injury, the workers were also at risk of protracted work disability (N?=?24 at high risk; N?=?39 at moderate risk). Fixed, protocol-driven, interdisciplinary, multimodal, clinical, occupational, and case management-based EI was compared with a flexible, individual need-driven EI with the same modalities as the fixed approach. Results showed a significant narrowing of the outcome gap between the two interventions. High-risk injured workers tended to benefit more from a fixed, protocol-driven approach, as shown in the pilot study (Schultz et al. Journal of Occupational Rehabilitation, 18(2), 140–151, 2008). The results indicated that moderate-risk workers benefitted from a more flexible, need-based, individual, and low-intensity approach as compared with a fixed approach. The flexible approach for moderate-risk workers was also less costly and consumed fewer rehabilitation and health care resources. Recommendations for future research and practice included larger sample sizes, controllability of research interventions, risk for disability-EI matching, and conditions under which a flexible delivery of multimodal EI is more efficacious than a fixed approach, and vice versa.     

Sequential monitoring of burials containing small pig cadavers using ground penetrating radar

Ground-penetrating radar (GPR) was used to monitor 12 pig burials in Florida, each of which contained a small pig cadaver. Six of the cadavers were buried in sand at a depth of 0.50-0.60 m, and the other six were buried in sand at a depth of 1.00-1.10 m to represent deep and shallow burials that are generally encountered in forensic scenarios. Four control excavations with no pig interment were also constructed as blank graves and monitored with GPR. The burials were monitored for durations of either 13 or 21 months, and were then excavated to correlate the decomposition state of the cadaver with the GPR imagery. Overall, this study demonstrated that it may be difficult to detect small cadavers buried in sand soon after they are skeletonized because the area surrounding the body, or the grave, may not provide a strong enough contrasting area to be detected by GPR when compared to that of the surrounding undisturbed soil. Also, depth of burial appears to influence grave detection because bodies that are buried at deeper depths may be detected for a longer period of time due to reduced decomposition rates.     

Coronary artery aneurysms in a young adult

Coronary artery aneurysms are an extremely rare cause of death at any age, but particularly so in young adults. A case is described of a young and previously fit man who died suddenly following thrombosis within one of multiple coronary artery aneurysms. He had had a childhood illness with symptoms consistent with an episode of unrecognized infantile polyarteritis nodosa. It is suggested that many cases of aneurysm of the coronary arteries in young adults, where atherosclerosis has been excluded, may in fact be due to previous polyarteritis, rather than of congenital origin as is usually claimed.