Questions and Infrequently Found Answers
Informed attorneys are the best attorneys. Dr. Adhia’s answers questions he hears about his areas of expertise when the law intersects with Psychiatry or Psychology and Brain Injury Medicine.
Due Diligence and the Forensic Psychiatrist
How do you know if a Forensic Psychiatrist has good credentials?
As a fellowship-trained Forensic Psychiatrist, I received specialized training to perform medico-legal evaluations. Best practices and professional standards exist to set a high threshold of practice in this area and continuing education required of every Forensic Psychiatrist covers civil as well as criminal considerations in the Forensic evaluation, report of opinions and testimony. You can confirm a doctor’s Board-Certifications with the ABPN and as a matter of due diligence, it is highly recommended.
The American Academy of Psychiatry and the Law, the APA’s Forensic Psychiatry branch (AAPL) sets the well-established gold standard in Forensic Psychiatric practice: AAPL produces Guidelines to Forensic Assessment, Protocols and Ethical standards authored by educators of the highest caliber in the field of Forensic Psychiatry. The continued medical education they and others provide are required of all doctors, however AAPL sets the bar. I am honored to serve on two AAPL Committees: Forensic Neuropsychiatry, and Human Rights and National Security.
Is there a difference between a Board-Certified Forensic Psychiatrist and a general Board-Certified Psychiatrist?
Board-Certification in Forensic Psychiatry by the ABPN reflects a level of medico-legal training, with its unique skillset, a general psychiatrist does not receive. Residency in Psychiatry is focused on diagnosis and treatment of psychiatric disorders. Forensic Psychiatry, on the other hand, adds an additional year of training in a fellowship learning about medico-legal issues like malingering, independent medical evaluations in litigation, criminal behavior, what to look for in a forensic assessment with a degree of training in the interface of psychiatry and law not developed by Psychiatrists not Board-Certified in Forensic Psychiatry. Beware, there are Psychiatrists who claim to be “Forensic Psychiatrists” but do not hold Board-Certification. Whether omission or intentional, attorneys should confirm the credentials of any Expert Witness for accuracy. Once your expert is on the stand is not the time to find out they meant “forensic psychiatrist” in lower case and not actual Board-Certification in Forensic Psychiatry,
How do I know if a Psychologist can do the job as an Expert Witness?
A psychologist has training in treatment of mood disorders, like depression, or life coping mechanisms. They can diagnose some psychological disorders. They may not prescribe medicine or evaluate medical conditions. A psychologist cannot even prescribe an anti-depressant, though they may suspect one will help their patient. The psychologist must turn to a psychiatrist.
A psychiatrist is qualified to interpret lab reports or imaging and can provide medical treatment to patients in a hospital or clinical setting in addition to private practice. A psychologist cannot.
Injuries can be complex and there may be more than one medical factor impacting symptoms. In the case of an accident, it is not uncommon for a person to receive medications to manage symptoms, such as for pain. A psychologist cannot order physical therapy or other rehabilitation treatment. A psychologist, unlike a psychiatrist, is likely unqualified to determine prognosis or competency restoration after medical treatment A psychologist can make a recommendation
Medico-Legal training is almost unheard of among psychologists. In fact, only a tiny percentage of licensed psychologists achieve Board-Certification in Forensic Psychology and are limited in their forensic conclusions.
If your Expert Witness is a Psychiatrist and opposing counsel has retained a Psychologist, qualifications and credentials become especially important to a jury. If a medical condition of any kind is present, the psychologist may even be disqualified from testifying about its impact.
Learn more about the distinction between psychiatrists and psychologist in the article Psychologist vs. Psychiatrist.
Before accepting a case, what does the Forensic Psychiatrist need to know from the attorney?
In my own case, after being contacted by an attorney or other party, I will usually respond with a phone call at no cost. I must determine if there are any conflicts of interest and if my expertise is relevant to the matter.
Conflicts of Interest. A psychiatrist with medico-legal training will know the importance of a conflicts check. A general psychiatrist very likely will not and the attorney will want to walk them through it.
Schedules and Planning. I will ensure there is ample room in my schedule to meet any deadlines. It is helpful to discuss what resources are required for the case.
A Retained Consultant. There are times I may be better suited to assist the attorney as a non-disclosed non-examining consultant which I discuss in my article The Non-Disclosed Consulting Expert: Attorney’s Secret Weapon.
Psychiatry – In Practice
What is PTSD?
PTSD, or Post-Traumatic Stress Disorder, is a psychiatric disorder that can occur in people who have experienced or witnessed a traumatic event such as violence, war, rape or serious accident. Close to 7% of all people in the United States experience PTSD at some point in their life.
A diagnosis of PTSD requires direct or indirect exposure to trauma. This is defined by the DSM-5 as “death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence”. Some refer to this as the “gatekeeper” criterion.
PTSD requires a certain number of symptoms under the following symptom clusters:
1) Intrusive Symptoms – nightmares, flashbacks
2) Persistent Avoidance of traumatic stimuli – either internally or as external reminders
3) Negative Alterations of mood or cognition – negative emotions or beliefs, decreased interest in pleasurable activities, decreased ability to experience positive emotions.
4) Alterations in arousal and reactivity – irritability, reckless behavior, insomnia, hypervigilance.
These symptoms must be present for over a month and cause significant distress or impairment. The symptoms cannot be due to medications, substances or other illness.
PTSD Assessment by a Forensic Psychiatrist
It is my opinion that any diagnosis of PTSD, or ruling out of a diagnosis of PTSD, requires the close review of a trained Forensic Psychiatrist. Medico-legal skill is different from that of a clinical psychiatrist without forensic training.
Brain Injury Medicine
What is Brain Injury Medicine? Do I need a Brain Injury Medicine Expert Witness?
Brain Injury Medicine (BIM) is the study, diagnosis and treatment of a brain injury. Brain injuries can impact how well the brain functions including decision-making or memory. A brain injury can be congenital or might result from a blow to the head. This can be through falling, an accident, being assaulted, or something more complicated like a fall associated with another condition, for example impaired balance associated with drug use. Concussions are called mTBI or “mild traumatic brain injury.” Traumatic Brain Injury is a much more serious condition with longer term, even permanent brain damage.
Acquired (ABI – Acquired Brain Injury) is a response to head impact. Congenital brain injury, for example is called a “non-traumatic brain injury (ABI).
Acquired Brain Injuries include TBI (Traumatic Brain Injury) or non-traumatic brain injuries (often referred to as ABI).
TBI is caused by an external force. Results may include alteration of brain function or other evidence of brain pathology.
Non-traumatic brain injuries can be caused by, for example, lack of oxygen (the most common is a stroke), toxic exposure and pressure from a tumor or another cause.
Brain injuries can cause a range of psychiatric, medical, physical, cognitive (learning, decision-making) and even sensory disorders.
Brain injuries can impact the ability to work, learn and to relate to others. Severe brain injuries can have devastating psychosocial impacts.
Brain Injury Rehabilitation (Recovery) is not a part of the Forensic Psychiatry curriculum. I work at TIRR Hermann, a renowned brain injury rehabilitation center. Treatment and recovery from psychiatric conditions associated with a brain injury is useful in rendering prognosis, a feature of Expert testimony as the Forensic Psychiatrist is a damages expert.
What qualifies a doctor to practice BIM?
The American Board of Psychiatry and Neurology Board-Certifies Psychiatrists and Neurologists in Brain Injury Medicine (BIM), a subspecialty of Physical Medicine and Rehabilitation. The Board-Certification provides a verifiable degree of knowledge in the field to enhance the quality of care of brain-injured individuals above the age of 15.
Physiatrists and Sports Medicine doctors can also be certified in this specialty within their respective board organizations.
Can a brain injury impact criminal behavior?
It is worth noting that about half of all incarcerated individuals have a history of brain injury.
If present at the time of the crime, brain injury could be the mental defect relevant in an Insanity or Criminal Responsibility defense. It could potentially be a factor in both the Cognitive or Volitional prongs.
For example, frontal lobe damage in the brain could be the cause of an Irresistible Impulse.
Brain Injury can also be a factor in Diminished Capacity cases.
Typically, only Forensic Psychiatrists have the training and expertise to examine the nexus between a brain injury and Competency to Stand Trial (CST) or Criminal Responsibility (NGRI). In Civil Litigation, decision-making, even intentionally fraudulent behavior may be linked to a brain injury—or that may be a claim that proves inaccurate on Psychiatric examination
Many states restrict CST and NGRI exams to Forensic Psychiatrists or Forensic Psychologists. Many attorneys are not aware of the local statutory requirements.
Occasionally, it may be helpful to have multiple experts involved in a brain injury case.
Although many Forensic Psychiatrists have some knowledge of brain injury, very few are Board-Certified in Brain Injury Medicine.
I worked on a case in which a perpetrator charged with a heinous crime claimed a brain injury as a child caused him to be incompetent to stand trial. I opined he was malingering and though he did have a minor brain injury, it did not render him incompetent to stand trial. The crime involved rape, social media and a high profile case in Oregon. The man was ultimately convicted. I go into more depth in “A Case Study in Malingering.”
How do you know if a Traumatic Brain Injury (TBI) is changing someone's behavior?
As a psychiatrist, I perform a detailed medical and psychiatric history. If an Independent Medical Examination is an option, I will perform a Mental Status Exam and interview. I may conduct a neurocognitive screen if indicated or I may recommend neuroimaging or forensic neuropsychological assessment to obtain additional objective data. Occasionally, I recommend forming a team with other specialists such as neurologists and physiatrists. For example, often, neuro-endocrine disorders are overlooked and the input from a specialist in this area is a valuable addition to forming and communicating my conclusions as a Forensic Psychiatrist, both in a report and on the stand.