A Guess Isn’t Good Enough for a Jury
If psychiatric damages are suspected, you will need solid information to present to a jury.
Why a Forensic Psychiatrist?
A Forensic Psychiatrist is granted Board-Certification only after receiving extensive training in the application of medical skill in psychiatry applied to legal questions. Psychiatrists without forensic training may miss what’s important in the medico-legal overlap.
Best Representation of Your Client
Cases can, and do, proceed without expert assessment. This decision deprives the triers of fact–and attorneys in a settlement situation–of necessary information to understand damages and value the case.
Evaluate your case in light of reliable information and opinions, not guesses
Call Dr. Adhia: Free Consult
Let’s talk about your case. One Hour No Charge.
DIAGNOSIS AND PROGNOSIS
There is no substitute for diagnosis.
Dr. Adhia evaluates in light of a bigger picture that encompasses events, preexisting conditions, associated physical injuries and malingering (lying for personal gain.)
Objectivity is the cornerstone of Dr. Adhia’s practice. He relies on years of training and experience to determine medical findings founded in hard science and skill.
Dr. Adhia synthesizes a close review of information:
• Medical records
• Doctor reports
• Review of deposition testimony
• Neuropyschological Testing (if brain injury is suspected)
• Clinical Independent Medical Evaluation (IME), face to face with the examinee, if he believes it applicable and will contribute valuable information to his findings.
If Dr. Adhia finds psychiatric damages, he addresses prognosis – efficacy of treatment. Can there be restoration of a psychiatrically injured party to mental health. What treatment is indicated? How much is it likely to cost?
Impact on the family
A psychiatric condition can impact an individual’s family, employment and quality of life when it begins and in the future. For that reason, prognosis informs a network of legal and personal support.
Alarming Trend in Self-Diagnosis
Do you want to rely on Wikipedia to stand up in Court?
Diagnosis by a layperson is a dangerous trend in public thinking, “Armchair Psychology.” Further, a litigant has an emotional investment and may feel urgency to put into words what they believe they are experiencing–even if they don’t understand the words they are using. Emphasis on “belief.” The internet and buzzwords have become go-to terms that suggest anyone is qualified to diagnose a medical condition. Attorneys for plaintiff and defense should be alert when they hear something like this:
“I am depressed”
“I have PTSD”
“I am afraid all the time”
“I don’t remember things like I used to”
“I’m an emotional mess, this has ruined my life”
“Mom had dementia, she could never have changed her Will.”
“He said he was too depressed to leave the house but I heard he was at a party last week.”
“I knew exactly what I was doing. I’m not insane. They’re always saying I lie.”
“She’s crazy. She can’t be trusted to handle responsibility.”
“But for …I wouldn’t have these problems.”
Litigation exists where there’s a cause-and-effect belief. If liability is proven then damages are compensable. What if Psychiatric damages are misunderstood by a non-professional, and thus misrepresented.
A layperson is not qualified to determine if a medical condition is existent or non-existent and the complications that give lie to that simplification. The layperson can be a litigant or an attorney struggling to determine the damages for emotional distress.
Subjective “belief” is not necessarily reality.
Call Dr. Adhia: Free Consult
The antidote to self-diagnosis (or third party diagnosis by a layperson) is real medical knowledge, training and qualifications.
Brain function is complicated. Even a mild “insult” can have a psychiatric impact on the sufferer. (“Insult” is a medical term for injury, e.g., Traumatic Brain Injury/TBI.)
The brain is so complex that sub-specializations like Brain Injury Medicine have developed.
Dr. Adhia developed his interest in Brain Injury Medicine when working on cases where he suspected psychiatric conditions masked or were confused by a brain injury. As a Forensic Psychiatrist, not a neurologist, he decided to pursue Board-Certification in BIM because of his natural interest in the field and desire to conduct forensic evaluations with added skill.
Are Psychiatrists qualified to practice brain injury medicine?
Psychiatrists receive neurological education in medical school and residency. Similarly, neurologists receive some education in psychiatry. They are different disciplines which share study of the brain and its impact on our lives, physical and emotional. And intertwined.
Challenges with Torts
Dr. Adhia finds Forensic conclusions are more robust when the Expert Witness is a doctor with multiple areas of training. Physical injuries are not uncommon in tortious events such as motor vehicle accidents. A physician is qualified to consider all medical information and synthesize it in a forensic opinion. However, medical qualifications and specializations vary.
Physical Injuries and Medical Records
Dr. Adhia’s review of medical records requires a physician’s qualifications Medical records that accompany a physical injury can include hospitalization and treatment notes, radiology, MRIs and CTScans, test results, neurology reports and labwork. A Medical Review Officer has additional qualifications to consider toxicology reports. (Dr. Adhia is a Medical Review Officer.) In addition, deposition testimony from medical experts addressing brain function, whether or not they are qualified to do so, can contain clues helpful to Dr. Adhia’s work.
What if a Forensic Psychiatrist's opinions are limited by a lack of deeper understanding of the brain?
Brain and Mood, Behavior and Mental Performance
A Traumatic Brain Injury (TBI) or Mild Brain Injury (a different diagnosis), can develop into dementia. We have seen this with victims of repeated concussion, athletes in contact sports or victims of persistent physical abuse. A single incident which results in a brain injury may have the same results: assault, an accident, even a fall can result in a brain injury. It may not develop into a permanent condition but any brain injury may accompany changes in behavior and mood, mental performance–clarity of thought, decision-making, even interpretation of “reality.”
Dr. Adhia has treated and evaluated drug use, and the impact of misusing doctor-prescribed and over the counter pharmaceuticals.
Drugs introduce symptoms that impact psychiatric diagnosis.
Pharamaceuticals may interact with illegal substances, or each other, in unexpected ways. Dr. Adhia has been faced with examples in case after case.
Toxic substances can be developed by the body in response to a physical illness, impacting the brain. Pharmacology refers to pharmaceuticals. However, toxic substances need not be ingested to do damage. In a criminal matter described in a case study, an alcoholic’s liver failure and brain injury created a toxic and mentally impaired environment considered by Dr. Adhia as part of his competency evaluation.
In clinical practice, a psychiatrist may prescribe medication as part of a treatment regimen. In fact, the licensing to prescribe is one of several distinctions between a psychiatrist and a psychologist. (Check out “Psychiatrist vs. Psychologist.”)
Drugs as a Weapon
Dr. Adhia’s article “Date Rape Drugs: Weaponized Chemistry” provides an interesting introduction to how drugs manipulate behavior and an overview of what drugs are most often used by perpetrators and how the drugs operate.
“Psychopharmacology is the study of the effects of drugs on the mind and behavior.
There are broad families of medications including:
- Anti-Depressants – for both depression and Anxiety. (e.g., Prozac).
- Anxiolytics – for anxiety. (e.g., Xanax).
- Mood Stabilizers – used in bipolar and for anger (i.e Lithium). Some mood stabilizers are used in epilepsy as well.
- Anti-psychotic – used in schizophrenia and for mood disorders (e.g., Abilify)
- Stimulants – used in ADHD (e.g, Adderall)
There are other categories of medications. Each of the categories above may have subcategories. Illicit substances (not categorized above), would fall into the purview of psychopharmacology.
Experts in psychopharmacology would include psychiatrists and pharmacologists who specialize in psychiatric medications. Psychiatric medications have complicated yet interesting effects on the brain.” — Dr. Adhia
ADDICTION and SUBSTANCE ABUSE
Psychopharmacology is the underpinning of Addiction Medicine. Dr. Adhia has forensically evaluated, opined and treated addicts.
Over the counter or illict (illegal) Drug abuse
Addictive Pain Medications
*The DEA recognizes Dr. Adhia’s qualifications as a physician with special training to prescribe Buprenorphine, in the form of the Buprenorphine Waiver. Learn more about this level of medical standard in prescription of high-risk medications. Better understand the Buprenorphine Waiver.
CRIMINAL / CORRECTIONAL
Correctional / Institutional Standard of Care
Treating the most mentally ill and violent prisoners in the Texas Department of Justice, Dr. Adhia served as a Psychiatrist at the Beauford H. Jester IV Unit Psychiatric Unit and treated death row inmates and those in isolation (Ad. Seg.). He also treated at the Supermax Polunsky Unit. Some psychiatric conditions were associated with imprisonment or may have contributed to committing a violent crime. He also treated unusual psychotic disorders such as schizophrenia, hallucination and delusional disorders. Jester IV is a correctional psychiatric hospital.
A note about competency: Dr. Adhia has conducted dozens of NGRI competency evaluations when relevant in a criminal allegation.
Dr. Adhia has conducted more than 50 evaluations in a criminal setting and is recognized for his skill in correctional psychiatry. He has worked on cases in military court and criminal defense.
In the past year, Dr. Adhia served as an Expert Witness in cases involving use of date rape drugs, homicide (matricide), and sexual assault in civilian and military cases.
Prisons Hospitals Private Care Facilities
Standard of care in a private setting, such as an addiction rehabilitation facility is assessed differently by Dr. Adhia than in an institutional setting. Prisons and hospitals have unique institutional protocols and restrictions on treatment options. For example, a rehab facility may offer Art Therapy; a hospital does not.
TRAUMA, TRAUMATIC EXPERIENCES, DISABILITY AND PTSD
We don’t think of Post-Traumatic Stress Disorder as a Mood Disorder. It is, in the sense that PTSD manifests in the Mood Disorders Depression and Anxiety. It can be chronic (long term) rather than treatable in the short term. In addition to disabling depression or anxiety, PTSD can be accompanied by psychotic features meaning an experience that feels real, in real time, e.g. flashbacks. In his work with victims of human trafficking through Physicians for Human Rights, Dr. Adhia has conducted forensic assessments which, not surprisingly, include PTSD.
If you suspect your client has PTSD
Call Dr. Adhia to discuss if a closer look is necessary for proper diagnosis. Other conditions can appear that mimic PTSD, and PTSD contains elements of other conditions. Misdiagnosis is a danger.
PTSD is relatively uncommon. Treatment can require a long-term regimen including medication and a constellation of treatment approaches.
PTSD is diagnosed by a Psychiatrist. PTSD does not appear randomly. PTSD may derive from an injury or event so severe that it ends up in Court. If the catchall of “emotional distress” proves to be PTSD, a Forensic Psychiatrist is the right Expert to make that call.
DISABLING PSYCHIATRIC TRAUMA AND COLLATERAL FAMILY DAMAGE
Dr. Adhia provides Pro-Bono treatment with Physicians for Human Rights, treating victims of human trafficking and sexual slavery. Human trafficking is a severe relative of kidnapping. Victims isolated from their liberty and family may manifest a range of symptoms and severe psychiatric conditions.
TRAUMA AND RESPONSE TO TRAUMATIC EVENTS
Dr. Adhia’s experience includes forensic assessment of the psychiatric impact of violence committed over an extended period. Victims of elder abuse, for example, may experience manipulation or even violence when a physically incapacitated person is essentially “under house arrest” by family and caregivers.
Response to trauma is experienced differently by each person. Resilience can play a part, as can unusual vulnerability. Vulnerability can include a limited ability to adapt to new circumstances, pain threshold, injuries, brain injuries, Dementia or Alzheimer’s Disease. For example, the mentally impaired elderly person exposed to trauma may be less able to cope.
Debilitating fearfulness of objects and actions associated with the trauma (won’t drive, afraid to sleep, won’t go outside.)
Rejection of Support or Treatment
Reality is a moving target (especially a concern in PTSD)
Suicidal thoughts or actions
A Mood Disorder is a category of illness marked by an unexpected or serious change in mood.
A few of the most familiar types of Mood Disorders are discussed here.
A common type of damages asserted in a civil Complaint are “Emotional Distress.” Emotional Distress sounds broad. However, the nature of “distress” that is “emotional” begs the question: has a Mood Disorder developed in response to the events that have led the matter into Court. Causation is for the trier of fact to determine. The presence of Emotional Distress must be determined by a Forensic Psychiatrist and symptoms begin to tell the story.
What you may think is going on
The layperson, (i.e. the public, a juror, an attorney) may be influenced by popular commentary about what Mood Disorders are common. (“Armchair Psychology” is discussed on this page.) The frequency of a particular Mood Disorder in the population is not the same as the public perception.
DEPRESSION AND ANXIETY
After an injury, Depression and/or Anxiety can develop. This does not mean there is a cause and effect relationship.
Diagnosis is the first step. There may be no clinical depression, for example, though symptoms are reported.
Treatment options can minimize the long term impact on the plaintiff or defendant. Treatment can mitigate damages.
What can make Depression or Anxiety worse?
Pain. In the case of a personal injury, chronic pain can make recovery difficult and depression more disabling.
Preexisting vulnerability to depression or anxiety. An “eggshell psyche” is a medical term for an individual who is at greater risk by virtue of a personality or mental health disorder.
Exascerbating events. An injury, events with strong emotional impact, relationship problems, the death of a loved one. In Wrongful Death cases, watching the death of a loved one is considered by law as a separate category than losing a loved one alone.
BIPOLAR DISORDER I AND II
Dr. Adhia diagnoses and treats Bipolar Disorders. Bipolar Disorders are notoriously difficult to treat, especially with a medication regimen. Notably, once managed, an emotionally turbulent or stressful event such as those that end up in Court, can cause a Bipolar Disorder to again become disabling and resistant to a regimen of treatment that worked previously.
Any stressor, or trauma, can make a pre-existing Bipolar Disorder worse. Examples are motor vehicle accidents, divorce, abuse, sexual assault.
Bipolar Disorder is marked by extreme highs and lows:
Mania (hyperactivity, inability to sleep, speaking fast, thinking unusually fast, rushing through things)
Hypomania (a less severe mania)
Psychiatrically, a Personality Disorder is a diagnostic condition in which the individual’s personality is pathological or medically significant.
The DSM5 1 identifies 10 distinct Personality Disorders. To make a diagnosis, a psychiatrist considers if symptoms meet criteria that meet the diagnostic threshold. He or she relies on clinical evaluation and medical background. Malingering the symptoms is is known to occur. Lastly, criteria and symptoms do not always reflect publicly-held assumptions.
EXAMPLE: IMPLUSE DISORDERS
Dr. Adhia has treated and diagnosed Impulse Disorders. Impulse Disorders are evidenced by a lack of control over emotions and behavior.
EXAMPLE: BORDERLINE PERSONALITY DISORDER.
Borderline Personality Disorder includes a constellation of symptoms. In the med-legal environment, Dr. Adhia is sensitive to all elements, if this is his Diagnosis. A significant feature of this Disorder is impairment of judgment and decision-making.
EXAMPLE: PARANOID PERSONALITY DISORDER.
Misinterpretation of the actions of others through a paranoid lens might lead a person to seek litigation to prove their perceptions are accurate, or punish another for actions which appear to them to be malicious. In some cases, Paranoid Personality Disorder may appear to be malingering (intentional lying.)
PPD is better described as a closely-held belief system that is not based in reality.
1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
What is Malingering?
“Malingering” is intentional lying for personal gain. Common motivations are financial gain, to become enriched as the result of a lawsuit, for example. An attorney or doctor should not assume all malingering is for self-gain. Psychiatric conditions can cause a person to misinterpret or reinvent a closely held belief of what is “true.”
Any clinical examination by a Forensic Psychiatrist includes assessment of malingering. It is an important part of the Fellowship requirement for Board-Certification in Forensic Psychiatry. Detecting Malingering is a feature of fellowship training. A significant proportion of Board Certified Forensic Psychiatrists were “grandfathered” in before completion of a Fellowship was required. Attorneys who retain fellowship-trained Forensic Psychiatrists can be assured they are educated about detection of malingering. Even many years after fellowship, this skill deepens with experience and in med-legal work, it is essential. Dr. Adhia has been assessing malingering for more than 5 years in his forensic practice.
Personality Disorders and Malingering
Malingering: Perception vs. “Reality”
What appears to be malingering can be inconsistent reporting due to other psychiatric conditions. Examples follow.
Paranoid Personality Disorder* which may produce unintentional or non-malicious malingering. A feature is the misinterpretation of the intent of others and their behavior. Such a person may believe they are telling the truth as they say it, but their perception itself is distorted. In that case, malingering is without malicious or greedy intent. However, the Paranoid Personality Disorder can produce a driving need for validation which can only be resolved by a jury or judge. Such an individual is less likely to accept a settlement in lieu of a final judgment of “exoneration.” The malingerer who seeks financial gain, on the other hand, will see settlement negotiations differently.
Factitious Disorder is a Personality Disorder that may appear to be a more self-interested malingering.
Other Factors to Consider:
Brain Injuries can impact a person’s ability to assess reality.
- Amnesia which can be short term, long term, permanent or undefined.
- Psychosis (Schizophrenia, hallucinations)
The most common explanation for malingering is greed, but it is not the only explanation.
*See Diagnostic and Statistical Manual, 5th Ed.
SUICIDE AND SUICIDOLOGY
If you are thinking about suicide or need help, call the National Suicide Hotline.
Reach out. There is help for you.
Considerations: Legal Questions
At-risk. What makes a person at-risk to attempt suicide? Dr. Adhia has treated patients at high risk for Suicide or a Suicide attempt throughout his career. Complicating questions he considers, in addition to events that give rise to litigation or criminal behavior, are medications and pre-existing conditions such as Chronic Depression or Bipolar Disorder.
High-risk behavior. Russian Roulette is an example of high risk behavior. “Death-defying” acts are high-risk. This does not mean the individual wants to commit suicide. For example, they may have an Impulse Disorder.
Self-harm behavior, like “cutting,” can be confused with a suicide attempt. A forensic IME is necessary to make the right diagnosis. Self-harm is not usually associated with suicidal intent, supported by clinical evidence and Dr. Adhia’s experience.
What is Suicidology?
Suicidology is a field of study about suicide. It addresses the nature of suicide and people who are at greatest risk for attempting suicide. In litigation, someone who has attempted suicide may believe it is the result, or fault, of another’s actions and claim for recompense. When a person commits suicide, family members may sue for wrongful death.
Evaluating if a Mood Disorder exists is one piece of the Forensic Psychiatrist’s job in such cases. Certain mood disorders have been found to increase the risk for suicide attempts. Many people believe suicide is always and only associated with severe Depression. This incorrect.
An attempted suicide is sometimes a “cry for help.” It may be a response to overwhelming grief and/or severe depression, for example. That does not mean it is in the inevitable outcome of circumstances giving rise to litigation.
Dr. Adhia assesses individuals who have attempted suicide. He may request an Independent Medical Examination. On the other hand, where there is a completed suicide (death), records, history and observations are essential.
Dr. Adhia notes that in a wrongful death lawsuit, if the cause of death is unclear and the circumstances suggest possible suicide, he is qualified, as a licensed physician, to review an autopsy report and other records to come to forensic conclusions about a person who is no longer alive to tell their own story.
SEVERE MENTAL ILLNESS
BRIEF PSYCHOTIC DISORDER
In 2013 Brief Psychotic Disorder was added to the DSM5. Features of a Psychotic Disorder are present, but the episode lasts less than one month followed by a full recovery. Drug or alcohol use can be a factor in a brief psychotic disorder. Bizarre or unpredictable behavior, even short term amnesia can be due to a Brief Psychotic Disorder.
Dr. Adhia has treated patients in maximum security correctional psychiatric hospital with severe mental illness. These conditions are rare and proper diagnosis is essential.
Individuals who are not hospitalized may still be living life with psychosis of some form. Psychosis can be made worse by drug use, drug interactions, side effects or mixing drugs and alcohol.
A person may experience hallucinations, delusions, or any distortion of their perception without having a psychotic condition.