Competency and Incompetency
Case study: a Medical Condition Changes Competency
“Mr. F was severely inebriated with ammonia from His Failing Liver”
By Sanjay Adhia, M.D.
Mr. F, a retired law enforcement officer with liver failure, was experiencing chronic delirium requiring a Competency to Stand Trial evaluation, which I conducted.
What is Delirium?
Delirium is a serious disturbance in mental abilities that results in confused thinking and reduced awareness of the environment.
Medical Conditions that are not Psychiatric can Cause Delirium
In Mr. F’s case, his Delirium was due to Hepatic Encephalopathy, a condition that results in the loss of brain function when a damaged liver is unable to remove toxins such as ammonia from the blood. Essentially, Mr. F was severely inebriated with ammonia.
The Delirium impaired his ability to understand the charges and consequences of the criminal proceedings, disclose to counsel pertinent facts, engage in a reasoned choice of options, exhibit appropriate courtroom behavior and/or testify. During the interview, the defendant appeared extremely drowsy at times and his mental status exam exhibited marked deficits.
Can he be “cured” of the delirium and restored to full competency?
On the issue of restorability—whether he could be restored to adequate health in order to stand trial—I opined there was no psychiatric treatment that could restore the defendant to competency. He could have potentially regained his competency with a liver transplant. However, he was not medically eligible for a new liver. I opined that he was not restorable in the foreseeable future.
I was scheduled to testify in this case. After reviewing my detailed report with information regarding Hepatic Encephalopathy, the prosecutor agreed to the finding of Incompetency to Stand Trial without a hearing.
Complicated Medical Conditions
This case involved Delirium which is a diagnosis of medical exclusion, essentially a process of elimination requiring a doctor’s training and experience in diagnosis Because of Mr. F’s serious health conditions, my expertise in brain injury medicine and forensic psychiatry allowed me to provide comprehensive assessment and rendering of my opinions on this complicated and interconnected combination of medical conditions. Forensic psychiatrists are physicians and therefore qualified to consider serious medical conditions such as delirium and Hepatic Encephalopathy.
A Forensic Psychologist Is Not Qualified to Opine About Mr. F’s Medical Status
A substantial portion of competency evaluations are performed by a Forensic Psychologist, rather than a Forensic Psychiatrist, who is a physician. Many psychologists are skilled at psychological testing used to determine mental ability. However, when you have a case that involves non-psychological conditions, in this case liver failure, only a physician is qualified to understand extensive medical records with labs and imaging. A psychologist cannot diagnose a medical condition. It would be wise to obtain the services of a Forensic Psychiatrist and possibly other medical specialists. It is not unusual for attorneys to confuse the qualifications of a psychologist vs. a psychiatrist. Retaining the appropriate forensic consultant best serves the interest of the attorney’s client.
At the request of attorneys, I explain in more detail the differences between a psychiatrist and a psychologist.