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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\u003Cp id=\u0022p-1\u0022\u003EForensic psychiatrists face ethical issues as they balance legal and therapeutic concerns. Accurate assessments of risk are important in many therapeutic situations, including counseling victims of stalking, determining whether juveniles will offend or reoffend, preventing inpatient suicide, and evaluating future dangerousness at sentencing hearings in death penalty cases.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Estalking\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Erisk assessment\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Edeath penalty\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Edetermination of competence\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ejuvenile offenders\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ejuvenile violence\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Einpatient suicide prevention\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eethics\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Edialectical principlism\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Echild \u0026amp; adolescent psychiatry\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Epsychiatry \u0026amp; psychology clinical trials\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\u003Cp id=\u0022p-2\u0022\u003EPractitioners of forensic psychiatry often assess individuals who are involved with the legal system. As such, they may be required to determine those individuals\u2019 past mental states or predict their future behavior.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\u003Ch2 class=\u0022\u0022\u003ERisk Assessment of Stalkers Still in Development\u003C\/h2\u003E\u003Cp id=\u0022p-3\u0022\u003EDebra A. Pinals, MD, University of Massachusetts Medical School, Worcester, Massachusetts, USA, discussed clinical risk management in stalking, noting that women are at a higher lifetime risk of being stalked (8% to 33%) than men (2% to 7%); also at increased risk are mental health professionals, college students, and Native Americans. Typical stalker characteristics include being white, male, and unemployed; lacking relationships or having disturbed relationships; and having a history of criminal behavior, substance abuse, and psychiatric diagnoses.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EThose stalking an ex-intimate are most likely to engage in violence. The majority of those who assaulted victims had made prior threats, and morbid jealousy may be a risk factor. Various risk assessment tools are available or in development (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E).\u003C\/p\u003E\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/16871\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/16871\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16871\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \u003Cp id=\u0022p-5\u0022 class=\u0022first-child\u0022\u003ERisk Assessment Tools\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-6\u0022\u003EThe dilemma of intervention is that anything that is done has the potential to escalate or defuse the stalker\u2019s activity. Victims should convey a single, explicitly clear message that no further contact is desired and then should make no further contact. Victims might consider seeking guidance from law enforcement before acting, although, unfortunately, between 50% and 80% of restraining orders are violated. The victim should have input into actions taken, and the response should be targeted to the individual situation because risk may change over time. If the stalker is the client, therapists should understand their legally required obligations to notify victims at risk.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\u003Ch2 class=\u0022\u0022\u003EAuthentic and Malingered Hallucinations Can Be Differentiated\u003C\/h2\u003E\u003Cp id=\u0022p-7\u0022\u003EPhillip J. Resnick, MD, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA, discussed how to detect malingered hallucinations. The presence of delusions, not hallucinations, is pathognomonic of psychosis; individuals who are not psychotic can hallucinate.\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EMost genuine hallucinations are associated with delusions and gender-based insults. The voices ask questions, are seen as omniscient, but do not see the hallucinator as all-knowing. A voice reported as asking \u201cWhy are you smoking?\u201d is more likely to be genuine than one reported as asking \u201cWhat time is it?\u201d\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EThose experiencing auditory hallucinations usually develop strategies to reduce them, such as seeking company, taking extra antipsychotics, humming, telling voices to go away, sleeping, or praying [Farhall J et al. \u003Cem\u003EClin Psychol Rev.\u003C\/em\u003E 2007]. Being alone, watching television, or listening to the radio, especially news programs, worsens hallucinations, said Dr Resnick.\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EMost visual hallucinations are in color and of normally sized, humanoid forms; a minority are animals or objects. Initial response is often fear, and visual hallucinations are rarely small. Individuals usually remember their first visual hallucinations.\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EThose with suspect auditory hallucinations have no strategies to reduce malevolent voices, saying that they follow all the voices\u2019 commands (commands are obeyed in only one-third of true hallucinations). Voices in malingered auditory hallucinations are reported as always yelling, as vague or mumbling, or only as female or children\u2019s voices; true hallucinations are usually in a normal speaking voice and could be only men\u2019s voices [McCarthy-Jones S, Resnick PJ. \u003Cem\u003EInt J Law Psychiatry.\u003C\/em\u003E 2014]. Malingered visual hallucinations may be reported as being in black and white or otherwise atypical, and the individual will be unable to recall the first one.\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EIn any medicolegal context, clinicians should have a suspicion of malingering. In the case of hallucinations, some evidence-based data can help distinguish the suspect from the genuine.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\u003Ch2 class=\u0022\u0022\u003EPsychiatrists Continue to Play a Role in Death Penalty Issues\u003C\/h2\u003E\u003Cp id=\u0022p-13\u0022\u003ECharles L. Scott, MD, University of California, Davis, Davis, California, USA, discussed how psychiatry contributed to the US Supreme Court decisions stipulating that executing those who were aged \u0026lt;\u200518 years or who were intellectually disabled was cruel and unusual punishment and so violated the Eighth Amendment to the US Constitution. There is no constitutional ban on executing individuals with mental disorders.\u003C\/p\u003E\u003Cp id=\u0022p-14\u0022\u003EThere is no US professional guideline that prohibits psychiatrists from testifying in competence cases of capital defendants. Testimony regarding dangerousness at sentencing is also allowed.\u003C\/p\u003E\u003Cp id=\u0022p-15\u0022\u003EThe US Supreme Court has yet to address the constitutionality of the situation where an individual is psychotic when not medicated but, when treated (even involuntarily), could become competent to be executed. Is it in the best interest of the prisoner to either receive medication, even involuntarily, and cure the psychosis even if it leads to execution or be left untreated and actively psychotic? Dr Scott said that there is no consensus among board-certified psychiatrists on how to handle this situation.\u003C\/p\u003E\u003Cp id=\u0022p-16\u0022\u003EParticipation of psychiatrists in competency, sanity, and sentencing phases of trials involves examining personal ethics related to these forensic duties.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-5\u0022\u003E\u003Ch2 class=\u0022\u0022\u003EDialectical Principlism as a Method of Analyzing and Resolving Complex Ethical Dilemmas\u003C\/h2\u003E\u003Cp id=\u0022p-17\u0022\u003ERobert Weinstock, MD, University of California at Los Angeles, Los Angeles, California, USA, presented a system that he is developing with William Connor Darby, MD, at his institution that analyzes the ethics of situations with conflicting obligations, which they call \u201cdialectical principlism.\u201d The concept deals with the various principles that may arise in a typical situation faced by a psychiatrist and the synthesis of these considerations into a whole.\u003C\/p\u003E\u003Cp id=\u0022p-18\u0022\u003EHe discussed 3 hypothetical situations that a general or forensic psychiatrist might experience: (1) thinking that a patient might reveal committing child abuse, having forgotten his warning that it would have to be reported; (2) having to decide if a patient will be disabled for a year and therefore be a candidate for disability payments; and (3) being asked by an insurance company to agree with its evaluation of a case rather than do an assessment, thereby keeping a source of lucrative referrals.\u003C\/p\u003E\u003Cp id=\u0022p-19\u0022\u003EDr Weinstock presented a balancing process of pros and cons for 2 possible actions for each dilemma, and he explained how using his system could result in different, sometimes opposite conclusions. Therefore, although consideration of the ethics of a situation is frequently called for, it is unclear what dialectical principlism contributes to decision making.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-6\u0022\u003E\u003Ch2 class=\u0022\u0022\u003EImproved Observation Practices Reduce Inpatient Suicide Risk\u003C\/h2\u003E\u003Cp id=\u0022p-20\u0022\u003EPredictors of inpatient suicide have not been identified. Jeffrey S. Janofsky, MD, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA, discussed reducing risk of inpatient suicide in the absence of defined predictors.\u003C\/p\u003E\u003Cp id=\u0022p-21\u0022\u003EInpatient suicide represents 5% to 6% of US suicides a year, mostly by hanging and jumping. Mitigation strategies include initiating structural safeguards, such as installing breakaway shower\/closet rods and safety glass, measures that reduced inpatient suicide rates from an average of 2 every 9 months to 1 every 14 months [Watts BV et al. \u003Cem\u003EArch Gen Psychiatry.\u003C\/em\u003E 2012].\u003C\/p\u003E\u003Cp id=\u0022p-22\u0022\u003EAnother risk mitigation strategy uses procedural safeguards, such as doing a complete mental status evaluation and establishing a good therapeutic relationship. Dr Janofsky noted that a significant number of inpatient suicides occur while patients are on some type of observation status. There are no agreed-on best practices for the observation of psychiatric patients, and observation practices may vary within the same facility across shifts and units.\u003C\/p\u003E\u003Cp id=\u0022p-23\u0022\u003EFailure modes and effects analysis (FMEA) is proactively used to identify and prevent human process errors before they occur by observing the steps in each process that are vulnerable to error. The Institute for Healthcare Improvement tool to aid in FMEA development allows institutions to share their analyses.\u003C\/p\u003E\u003Cp id=\u0022p-24\u0022\u003EIn Dr Janofsky\u2019s hospital, 42 process steps were identified with the help of all inpatient staff, including nursing assistants. Observation of patients was identified as the crucial element in keeping those who were at high risk for suicide safe. Solutions to failure mode causes included development of a patient support sheet that the nurse discusses with observers, as well as an observer feedback form that the observer discusses with the nurse.\u003C\/p\u003E\u003Cp id=\u0022p-25\u0022\u003EOther institutions can identify potential critical process failures. Rather than using an after-the-fact cause analysis, FMEA allows system solutions to prevent errors before harm occurs.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-7\u0022\u003E\u003Ch2 class=\u0022\u0022\u003EProgress Is Being Made in Predicting Juvenile Violence\u003C\/h2\u003E\u003Cp id=\u0022p-26\u0022\u003EDr Scott also discussed how to assess the risk of juvenile violence. Future dangerousness is determined by a combination of risk factors and social context. Early age of onset of involvement with the police predicts a likelihood of continued criminal activity. Conduct disorder is the \u003Cem\u003EDSM-V\u003C\/em\u003E disorder that is the best predictor of juvenile violence; other risk factors include having weapons, gang involvement, substance use, and family conflict and aggression.\u003C\/p\u003E\u003Cp id=\u0022p-27\u0022\u003EAn actuarial risk assessment model\u2014the Youth Level of Service\/Case Management Inventory 2.0\u2014is best suited for use in the juvenile justice system. Other models include structured professional judgment tools that guide clinicians on risk and need for intervention. The structured assessment of violence risk in youth is based on the structured professional judgment model and is one of only a few instruments that includes protective factors along with historical, social\/contextual, and individual\/clinical factors, and it can be administered by a range of professionals.\u003C\/p\u003E\u003Cp id=\u0022p-28\u0022\u003EWhether a child should be assessed as a psychopath is controversial. Some argue that youths should not be given this label, whereas others believe that some children have a high risk for recidivism that should not be ignored. A meta-analysis of 53 studies with \u0026gt;\u200510\u2005000 participants came down on the side of early screening for prediction of recidivism [Asscher JJ et al. \u003Cem\u003EJ Child Psychol Psychiatry.\u003C\/em\u003E 2011].\u003C\/p\u003E\u003Cp id=\u0022p-29\u0022\u003EIt is difficult to predict which students will become homicidal. Dr Scott emphasized that communication of intent prior to attack is important; youths should be educated to tell authorities. Virginia has developed a student threat assessment model; although it needs to be validated via a randomized controlled study comparing alternative approaches, it appears promising, said Dr Scott. Universal school-based programs where everyone receives antibullying and antiviolence training also have a positive effect.\u003C\/p\u003E\u003Cp id=\u0022p-30\u0022\u003EJuvenile and school violence have decreased over the past decade. The use of structured instruments can improve risk assessment and management as they have for adults. Early intervention and matching the intervention to the level of threat are important.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2015 SAGE Publications\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/15\/11\/24.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzlix2\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzlix2\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}