Recently in Mental State Category

Lena Sun reports in the WaPo on the 5th edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, to be released tomorrow. She also discusses the controversies, some of which we have noted on this blog here, here, and here.

Well, at least they dumped the Roman numerals.

Update:  According to the listing at Amazon, the book will actually be available for purchase on May 27.

Allen Frances, chairman of the DSM-IV and a strong critic of the forthcoming DSM-V, has this strong editorial regarding the recent decision by NIMH to abandon the DSM.  Dr. Frances states:

The flat out rejection of DSM-5 by National Institute of Mental Health is a sad moment for mental health and an unsafe one for our patients. The APA and NIMH are both letting us down, failing to be safe custodians for the mental health needs of our country.

DSM-5 certainly deserves rejecting. It offers a reckless hodgepodge of new diagnoses that will misidentify normals and subject them to unnecessary treatment and stigma.

The NIMH director may have hammered the nail in the DSM-5 coffin when he so harshly criticized its lack of validity.

This is misleading and dangerous stuff that is bad for the patients both institutions are meant to serve.

NIMH has gone wrong now in the very same way that DSM-5 has gone wrong in the past -- making impossible to keep promises. The new NIMH research agenda is necessary and highly desirable -- it makes sense to target simpler symptoms rather than complex DSM syndromes, especially since so far we have come up empty. And the new plan will further, and be furthered, by the big, new Obama investment in brain research. But the likely payoff is being wildly oversold. There is no easy solution to what is in fact an almost impossibly complex research problem.

Isaac Newton said it best almost 250 years ago; 'I can calculate the motions of the heavens, but not the madness of men." Figuring out how the universe works is simple stuff compared to figuring out what causes schizophrenia. The ineffable complexity of brain functioning has defeated past DSM hopes and will frustrate even the best NIMH efforts.

Progress in understanding mental disorders will necessarily be slow, retail, and painstaking -- with no grand slam home runs, just occasional singles, no walks, and lots of strikeouts. No sweeping explanations -- no Newtons, or Darwins, or Einsteins.

Experience teaches that there is very little low hanging fruit when you try to translate the results of exciting basic science into meaningful clinical advances. This is true in all of medicine, not just psychiatry. We have been fighting the war on cancer for 40 years and are still losing most of the battles.

Good stuff and it's worth reading the whole thing as they say, but I'd also read Neuroskeptic's always insightful post on the issue.  This may not really be a seismic shift after all and what may replace the DSM at NIMH may be just as bad.  

Last Saturday's neurocriminology essay in the WSJ by Adrian Raine (noted here) gets four thumbs-down in today's letters to the editor.  Chuck Klein of Georgetown, Ohio suggests, "Perhaps we should study the minds of the scientists to learn why they so resist executing these murderers. Might there be something missing in their frontal lobe that negates the practicality of executing killers?"

Meanwhile, in the Books section, Michael Gazzaniga reviews The Anatomy of Violence by, you guessed it, Adrian Raine.  Gazzaniga says Raine's discussion of the science is useful for those not familiar with it, but he is skeptical of the policy leaps.  He recites the history of the pseudoscience of phrenology and of the days when Freudian psychoanalytic theories held sway.  "As psychoanalysts' fairy tales about the nature of human behavior lost influence, their role in the courts began to recede as well." 

In all of these earlier attempts to explain the causes of antisocial behavior and violence, the hope was to provide a scientific explanation for the acts of the defendant--such that, at sentencing, justice could be served. Now our ability to observe what is happening within the brain has much improved, but the question remains how to explain or make use of this in the courts.

Following the links in Steve's post on the DSM-5 led me to this post by Allen Frances.  Neuroskeptic refers to Frances as "the creator of the more reliable DSM-IV."  Frances begins with a process criticism of the way the DSM-5 was created and approved (emphasis added):

This is no way to prepare or to approve a diagnostic system. Psychiatric diagnosis has become too important in selecting treatments, determining eligibility for benefits and services, allocating resources, guiding legal judgments, creating stigma, and influencing personal expectations to be left in the hands of an APA that has proven itself incapable of producing a safe, sound, and widely accepted manual.

New diagnoses in psychiatry are more dangerous than new drugs because they influence whether or not millions of people are placed on drugs -- often by primary care doctors after brief visits. Before their introduction, new diagnoses deserve the same level of attention to safety that we devote to new drugs. APA is not competent to do this.

Diagnoses are also dangerous because of their potential to convince gullible jurors, and sometimes even judges, to let criminals off with less than they actually deserve. 

Thomas Insel, director of the National Institute of Mental Health has announced that the organization will not use the new edition of the Diagnostic and Statistical Manual for Mental Disorders:

In a few weeks, the American Psychiatric Association will release its new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This volume will tweak several current diagnostic categories, from autism spectrum disorders to mood disorders. While many of these changes have been contentious, the final product involves mostly modest alterations of the previous edition, based on new insights emerging from research since 1990 when DSM-IV was published. Sometimes this research recommended new categories (e.g., mood dysregulation disorder) or that previous categories could be dropped (e.g., Asperger's syndrome).

The goal of this new manual, as with all previous editions, is to provide a common language for describing psychopathology. While DSM has been described as a "Bible" for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been "reliability" - each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment. (emphasis added).

But with its reliability also in question, the new DSM5 is turning out to be quite controversial.

The WSJ's Saturday Essay this week is by U. Penn. Professor Adrian Raine on neuroscience and crime.  This is not (and not intended to be) a balanced look at the research with its limitations and criticisms.  Raine is an advocate.

Take the case of Donta Page, who in 1999 robbed a young woman in Denver named Peyton Tuthill, then raped her, slit her throat and killed her by plunging a kitchen knife into her chest. Mr. Page was found guilty of first-degree murder and was a prime candidate for the death penalty.

Working as an expert witness for Mr. Page's defense counsel, I brought him to a lab to assess his brain functioning. Scans revealed a distinct lack of activation in the ventral prefrontal cortex--the brain region that helps to regulate our emotions and control our impulses.

In testifying, I argued for a deep-rooted biosocial explanation for Mr. Page's violence. As his files documented, as a child he suffered from poor nutrition, severe parental neglect, sustained physical and sexual abuse, early head injuries, learning disabilities, poor cognitive functioning and lead exposure. He also had a family history of mental illness. By the age of 18, Mr. Page had been referred for psychological treatment 19 times, but he had never once received treatment. A three-judge panel ultimately decided not to have him executed, accepting our argument that a mix of biological and social factors mitigated Mr. Page's responsibility.

Raine apparently considers this to be a correct result.  It is not, IMHO, unless Page's condition actually rendered him lacking in free will, which I very much doubt.

A more profound understanding of the early biological causes of violence can help us take a more empathetic, understanding and merciful approach toward both the victims of violence and the prisoners themselves. It would be a step forward in a process that should express the highest values of our civilization.

In this passage we see the danger.  Some people slip much too easily from explaining to excusing.  A scientific test that merely shows some factor correlated with a propensity to commit acts of violence should not be regarded as mitigating.  As long as a person has the choice to commit the crime or not, he should be held fully responsible for the choice.  Letting murderers and rapists off easy on weak excuses is most definitely not "the highest values of our civilization."  It is a step on the downward spiral.

A little over a year ago, I wrote about a devastating blow to criminal defense.  The cruelties of the capitalist ruling class had taken down one of the few remaining avenues for defendants to explain why they are forced to act as they do.

When the U.S. Supreme Court makes a new rule of law favoring criminal defendants, it applies to all cases not yet final on direct appeal.  If the rule is one of substance rather than procedure, it applies to cases final on appeal but pending on habeas corpus as well.

How about when a state supreme court corrects a misinterpretation of the law by lower courts, an error that had favored defendants?  Does the defendant have a vested right to the case law as it existed at the time of the crime?

The Ex Post Facto Clause prohibits legislatures from enlarging the definitions of crimes or eliminating defenses retroactively.  For case law, the picture is more muddled.  The case of Bouie v. City of Columbia, during the civil rights struggle, involved a sit-in demonstration that was not a criminal offense at the time of the demonstration, but the state courts expanded the definition of the relevant offense to include it.  The Supreme Court said that violates due process of law.  More recently, in Rogers v. Tennessee, the high court allowed retroactive application of a decision dumping the old rule that a crime is not murder unless the victim dies within a year and a day.

Metrich v. Lancaster, argued today in the high court, involves the Michigan law of diminished capacity. 

I sometimes go after defense lawyers for concocting wacko stories, but I can't this time.  Nope, on this occasion, it was the client himself.

I have been staying miles away from the Jodi Arias trial because there is only so much I can take.  To sum it up very briefly, Ms. Arias does not deny stabbing her boyfriend (or ex-boyfriend, it's not clear which) 27 times, shooting him, and then slitting his throat.  She is claiming "self-defense" and no, that is not a typo.

AP has this story on the Tucson shooter:

Almost everyone who crossed paths with Jared Loughner in the year before he shot former Rep. Gabrielle Giffords described a man who was becoming more unhinged and delusional by the day.

This points to a pretty decent rule of thumb on who is sufficiently out of touch with reality to qualify as not guilty by reason of insanity.  If you need an expert to tell he's crazy, he isn't.

Under the felony-murder rule, a killing occurring during the commission of specified felonies is murder without the need to show intent to kill.  For the most part, this rule just relieves the prosecution of proving intent in cases where the circumstances indicate an intentional killing, but the only witness other than perpetrator(s) is dead, and eliminating him as a witness is often the motive for the killing.  The rule is especially important in multiple perpetrator cases where each says the other did it.

Genuinely accidental killings in the perpetration of a felony are things you see more often on law school exams than in real life.  Yet we do have such a case today from the California Supreme Court, People v. Wilkins, S190713.

A:  Children suffer and lives get ruined.

Psychiatrist E. Fuller Torrey has an op-ed in the WSJ regarding federal funding of mental health treatment.  He notes:
 

It has now become politically correct to claim that this federal program failed because not enough centers were funded and not enough money was spent. In fact, it failed because it did not provide care for the sickest patients released from the state hospitals. When President Ronald Reagan finally block-granted federal CMHC funds to the states in 1981, he was not killing the program. He was disposing of the corpse.

Meantime, during the years CMHCs were funded, Medicaid and Medicare were created and modifications were made to the Supplemental Security Income and Social Security Disability Insurance programs. None of these programs was originally intended to become a major federal support for the mentally ill, but all now fill that role. The federal takeover of the mental-illness treatment system was complete.

Fifty years later, we can see the results of "the open warmth of community concern and capability." Approximately half of the mentally ill individuals discharged from state mental hospitals, many of whom had family support, sought outpatient treatment and have done well. The other half, many of whom lack family support and suffer from the most severe illnesses such as schizophrenia and bipolar disorder, have done poorly.

According to multiple studies summarized by the Treatment Advocacy Center, these untreated mentally ill are responsible for 10% of all homicides (and a higher percentage of the mass killings), constitute 20% of jail and prison inmates and at least 30% of the homeless. Severely mentally ill individuals now inundate hospital emergency rooms and have colonized libraries, parks, train stations and other public spaces. The quality of the lives of these individuals mocks the lofty intentions of the founders of the CMHC program.

In the capital appellate defense playbook, to delay is to win.  If review of a capital case can be dragged out so long that the inmate dies of natural causes, that is a de facto commutation to a life sentence and hence a victory.

A gambit the defense side has been running for a while is to claim that the petitioner/inmate is too crazy to assist his lawyer in the habeas proceeding.  Hence, that proceeding must be stayed indefinitely, while the stay of execution remains in place.  This argument has been accepted in the notorious 9th Circuit and "9th upside down" 6th Circuit.

Today, the Supreme Court unanimously reversed both circuits in Ryan v. Gonzales, No. 10-930, joined with Tibbals v. Carter, No. 11-218.

These two cases present the question whether the incompetence of a state prisoner requires suspension of the prisoner's federal habeas corpus proceedings. We hold that neither 18 U. S. C. §3599 nor 18 U. S. C. §4241 provides such a right and that the Courts of Appeals for the Ninth and Sixth Circuits both erred in holding that district courts must stay federal habeas proceedings when petitioners are adjudged incompetent.

Justice Thomas delivered the opinion of the Court.  There are no separate opinions.