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 Choose 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–of necessary information to understand damages and value the case, going into trial or settlement discussions.
Evaluate your case in light of reliable information and opinions, not guesses
Call Dr. Adhia: Free Consult
Let’s talk about your case.
DIAGNOSIS AND PROGNOSIS
Emotional Distress, Competency and Other Legal Concepts
There is no substitute for a diagnosis where legal proceedings rest on evidence and associated information, and expert testimony is guided by the standards of Daubert and Frye.
Culpability, Damages and Reasonable Doubt. Emotional Distress damages, for example, must be assessed before compensation is considered by the trier of fact. There is no “emotional distress” diagnosis.
The presence or absence of a condition that causes one to be “emotionally distressed” is established by a physician, not surmised by a layperson obviously.
Competency and Capacity. Similarly, increasingly we are seeing lawsuits reflecting a growing population of seniors. Age and ill health do not always go together. But when they do, questions of Testamentary Capacity or vulnerability to fraud or undue influence, are assessed with an eye to medical conditions, medications, behavior and decision-making.
“Reasonable Medical Certainty.” A Forensic opinion that is issued with Reasonable Medical Certainty requires a close examination of information. Accurate diagnosis of a psychiatric condition, if one exists, is a primary feature.
Malingering and Ruling Out a Diagnosis. In the case of malingering, a diagnosis might be “ruled out” by a Forensic Psychiatrist. In other words, the apparent malingerer may claim a psychiatric condition is present impacting his or her pursuit of damages or criminal defense. The Forensic Psychiatrist evaluates the presence or absence of a diagnosis. One explanation of a claimed psychiatric disorder that is not present is malingering (lying). Read more about Malingering.
Final Word on Daubert/Frye Threshold Diagnosis.
The American Psychiatric Association publishes the Diagnostic and Statistical Manual which identifies criteria for hundreds of psychiatric conditions relied upon by Psychiatrists and Forensic Psychiatrists. It is the professional final word. The DSM5 is updated as research identifies and refines criteria; it is currently in its 5th Edition.
A Forensic Psychiatrist is trained to consider diagnoses in the medico-legal context. Here are a few that may involve a Forensic Psychiatrist:
- Damages in civil litigation, psychiatric factors in behavior, psychiatric outcomes such as response to a trauma, and mitigating psychiatric factors
- Testamentary Capacity
- Psychiatric Disability. Disability insurers, health insurers, the Social Security Administration, VA benefits.
- Fitness for Duty, and added considerations regarding ADA, EEOC and Title VII
- Criminal competency to stand trial
- Treatment plans
- Rehabilitation treatment in the case of brain injuries producing psychiatric symptoms
- Clarification of mental status and state of mind associated with civil or criminal litigation
- Diagnosis or ruling out of dementias / Neurocognitive Disorders in testamentary capacity
- Diagnoses that indicate or do not indicate susceptibility to undue influence
- Decision-making impairment or judgment in entering into a contract such as a revocable Trust, real estate transaction, investment decisions
Dr. Adhia evaluates in light of a bigger picture that encompasses events, preexisting conditions, associated physical injuries and malingering (lying for secondary gain, such as money.) In medicine, and forensic psychiatry is no exception, diagnosis drives understanding, treatment and the jury or judge’s ability to value psychiatric damages.
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 to diagnose or rule out diagnosis. The diagnosis of another expert is also subject to Dr. Adhia’s scrutiny if he does not find it consistent with his own.
Dr. Adhia synthesizes a close review of information:
• Medical records
• Doctor reports
• Review of deposition testimony
• Neuropyschological Testing and Neuroimaging (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.
• Interviewing collateral informants (e.g. spouses, partners, friends who have knowledge of psychiatric conditions, behavior, changes in behavior or other observations relevant to forensic opinion).
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?
Buzzwords vs. Medical Diagnosis
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 from a party:
“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.”
Cause and Effect
Litigation is founded on 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.
Brain Injury and Treatment
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., Concussion, Traumatic Brain Injury/TBI.) Diagnosis is only one feature of treating a patient. It became apparent that specialized training was necessary to help doctors focus on distinct aspects of addressing a brain injury.
Sub-specializations like Brain Injury Medicine (BIM) have developed.
Treatment of Dementia and Alzheimer’s, which are Brain Diseases, is included in “Brain Injury Medicine”
Brain Injury Medicine (upper case) is a Board-Certified subspecialty of Physical Medicine and Rehabilitation; “…disorders encompass a range of medical, physical, cognitive, sensory, and behavioral disorders that result in psychosocial, educational, and vocational consequences.” (American Board of Physical and Medical Rehabilitation.)
The focus of BIM is patient care and recovery for Maximum Medical Improvement (MMI).
Dr. Adhia’s Background
Dr. Adhia developed his interest in Brain Injury Medicine when working on forensic cases where he suspected psychiatric conditions masked or were confused by a brain injury. He decided to pursue Board-Certification in BIM because of his natural interest in the field and desire to treat patients with brain injuries. His BIM expertise enables him to conduct forensic evaluations with added skill.
Dr. Adhia has worked on a number of cases with complications associated with brain injury. In a case study on this site he was asked to assess a man who claimed incompetence to stand trial due to delusions. Dr. Adhia found the delusions were secondary to toxicity in the brain as a result of liver failure. Not all cases are that unusual, but it is one example in which Forensic Psychiatry and an understanding of brain function inspired Dr. Adhia to obtain credentialing in Brain Injury Medicine.
Are Psychiatrists qualified to practice Brain Injury Medicine?
The short answer is that Psychiatrists receive training in brain injuries but not to the greater depth required to be Board-Certified in Brain Injury Medicine.
Psychiatrists and neurologists 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 health and behavior.
Psychiatrists and neurologists do not receive extensive training in the treatment of brain injured patients and rehabilitation, which is the focus of Brain Injury Medicine.
This limits the Psychiatrist or Neurologist’s opinions about prognosis and necessary treatment and other factors that impact monetary damages in a lawsuit.
Dr. Adhia is asked to render expert opinion in cases where both brain injury and psychiatric injury are present. In some cases, a brain injury is not adequately addressed in the opinions of other experts or even treating doctors.
Injuries to the Brain and Forensic Psychiatry: Medical and Legal Records
Dr. Adhia’s review of medical records requires a physician’s qualifications. Medical records 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.
Legal records are also relevant and can contain clues helpful to Dr. Adhia’s work. For example, reviewing the deposition testimony of other medical experts addressing brain function can be revealing inasmuch as they may report medical information not found in other records and worthy of further investigation.
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 (mTBI-concussion), are the most common brain injuries.
TBI 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.”
Causes of TBI or mTBI are physical assault, an accident, a fall, a blow to the head, repeated concussion as we see in athletes in contact sports, or victims of persistent physical abuse. This is not a complete list.
Brain Injury Medicine is described on the site of the ABPMR which partners with the American Board of Psychiatry and Neurology to grant BIM Board-Certification.
Psychiatry and Forensic Psychiatry are different from Brain Injury Medicine.
Any Board-Certification has a high threshold of training, but specialty training differs.
Psychiatry is an independent and primary specialty granted by the American Board of Psychiatry and Neurology (ABPN.) The ABPN also Board-Certifies Neurologists.
Board Examination in Psychiatry follows a 4 year Residency in Psychiatry. If a physician passes their Psychiatry Board-Certification, they are eligible to compete for a limited number of fellowships for further training in the subspecialty of Forensic Psychiatry.
Board-Certification in Forensic Psychiatry is granted after fellowship training, and examination, which Dr. Adhia completed in 2014. A Forensic Psychiatrist must continue to complete a high standard of continuing education including familiarity with case law impacting expert testimony.
Brain Injury Medicine is a subspecialty that arose out of Rehabilitation medicine–treating those recovering from a brain injury, stroke or brain disease. Board Certification is governed by both the ABPN and ABPMR.
What is important to know about the 3 disciplines together?
All three disciplines require study, passing the Board Exam, and a rigorous regimen of continuing education.
Dr. Adhia’s training in Brain Injury Medicine, Psychiatry, and Forensic Psychiatry enable him to identify crossover conditions, symptoms, and treatment, as they apply to matters adjudicated in the Court.
Physical Medicine and Rehabilitation doctors, including specialists in Brain Injury Medicine, are trained in long-term rehabilitation, useful in a forensic/legal setting to determine prognosis and address the costs of treatment, e.g., Monetary Damages, should liability be proven. Dr. Adhia’s training and credentials make him better suited to contribute this information to a trier of fact than someone who does not have this training and qualifications.
PSYCHOPHARMACOLOGY: UNDERSTANDING DRUGS, ADDICTION OR MEDICATION STANDARDS AND INTERACTIONS.
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.
Medical Malpractice and Prescription Medication
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.
ADDICTION and SUBSTANCE ABUSE
Psychopharmacology is the underpinning of Addiction Medicine. Dr. Adhia has forensically evaluated, opined and treated addicts.
Addictive Drugs and Substances (partial list)
- Addictive Pain Medications (Oxycontin, Vicodin)
- Addictive Anxiolytic Medications (Benzodiazepines often used to treat anxiety,e.g. Xanaz, Valium and Clonazepam/Klonopin)
- Opioids (pills, heroin)
- Cannabis (marijuana and chemical variants of THC, also synthetic cannabinoids like k2, spice, kush)
- Synthetics (Bath Salths, N-bomb)
- Hallucinogens (LSD, Psilocybin, PCP)
- Tobacco (cigarettes, cigars, chewing tobacco, E-cigarettes/vaping that contain a nicotine vapor.)
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 treating Bipolar I and II, Impulse and anger regulation related Disorders (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.
Doctors must obtain federal authorization to prescribe medication under the Drug Enforcement Administration. The DEA authorizes clearance to prescribe medications in Schedule levels 1-5 based on the addictive characteristics of a drug.
For example, “Schedule I drugs, substances, or chemicals are defined as drugs with no currently accepted medical use and a high potential for abuse. Some examples of Schedule I drugs are …heroin, lysergic acid diethylamide (LSD), 3,4-methylenedioxymethamphetamine (ecstasy)…” (DEA Drug Scheduling https://www.dea.gov/drug-scheduling)
Schedule V drugs, on the other hand are very different.
“Schedule V drugs, substances, or chemicals are defined as drugs with lower potential for abuse ..antidiarrheal, antitussive, and analgesic purposes. ” (DEA Drug Scheduling https://www.dea.gov/drug-scheduling)
The US Department of Substance Abuse and Mental Health Services Administration issues a further waiver to prescribe the highly addictive substance Buprenorphine.
Dr. Adhia holds the Buprenorphine Waiver and is therefore legally approved to prescribe Buprenorphine if medically indicated.
To prove the presence of drug use in an individual, a toxicology report may be indicated. This is typical in cases involving drug or alcohol abuse–most commonly with a DUI. However, when a victim is drugged, a toxicology report on the victim can reveal more about drug(s) used, and better understand the impact on the victim.
A Medical Review Officer (MRO) receives training to interpret these reports. Dr. Adhia has received Medical Review Officer training and expects certification by early 2020.
CRIMINAL / CORRECTIONAL
Psychiatric Care in Prison
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 Psychiatric Unit, a correctional psychiatric hospital, where he treated incarcerated men, including those in isolation (Ad. Seg.). He also treated at the supermax Polunsky Unit which houses Death Row and other offenders.
Psychiatric conditions were sometimes associated with imprisonment or may have contributed to committing a violent crime, including cellmate murder while imprisoned. Preexisting mental illness was also diagnosed and treated by Dr. Adhia.
Impulse Disorders are disproportionately present in a prison population than the general public. For this reason, an Impulse program was developed and Dr. Adhia served as the primary treating psychiatrist.
Impulse Disorders are not exclusive to criminal behavior.
Dr. Adhia’s patients included those with unusual psychotic disorders such as schizophrenia, with hallucination and delusions.
Suicide and self-injurious behavior was a significant concern in prison and Dr. Adhia treated inmates exhibiting Self Injurious Behavior and those with Suicide Attempts. Self Injurious Behavior could be triggered by personality disorders or psychosis. Self Injurious behavior can include cutting, banging one’s head against a wall or intentionally seeking pain. Dr. Adhia writes further about these issues, as well as malingering, in greater detail on this page..keep reading.
Jail vs. Prison
“Jail” is a correctional facility which is used to describe short-term incarceration at a local law enforcement level and may follow charge with a crime. Dr. Adhia’s experience includes assessment of jailed inmates.
A note about competency: Dr. Adhia has conducted dozens of NGRI competency evaluations when relevant in a criminal allegation. He also worked as a treating psychiatrist on a competency/restoration unit.
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 criminal cases in military court and criminal defense.
TBI and Capital Cases. Dr. Adhia has found TBI to be a factor in some capital cases that resulted in men on death row whom he treated.
A recent capital case
Dr. Adhia consulted in an unusually complex case including a Capital Public Defendant charged with a triple-homicide, and a high profile case of homicide (matricide).
In the past year, Dr. Adhia served as an Expert Witness in cases involving use of date rape drugs, and sexual assault in civilian and military cases.
Standard of Care in Prisons vs. Hospitals, Clinics or Private Care Facilities
Prisons and hospitals in the corrections system have unique institutional protocols and restrictions on treatment options. Keep reading below about Standard of Care in Institutions and facilities which are not in the correctional setting.
MEDICAL-MALPRACTICE. STANDARD OF CARE IN HOSPITALS, PRIVATE PATIENT CARE, IN-PATIENT AND OUT-PATIENT TREATMENT
Examples of medical care facilities and Institutions that must meet Standards of Care
Hospitals and Urgent Care Centers.
Addiction Rehabilitation Treatment centers. Most require patients to live onsite during treatment (In-Patient).
Out-Patient Behavioral Health Clinics. These include psychiatric or psychological treatment clinics for mild or severe mental disorders including psychotherapy with or without medication management. Such clinics may serve a particular community or geographic area. If a unique condition is treated, patients may not live locally.
Assisted Living Facilities where Medical or Nursing Services are provided onsite or on-call.
“Wellness” or Spas that Provide Medical Treatment.
In-Patient Mental Health Treatment Centers. In-patient treatment describes hospitalization or treatment which requires the patient live at the treatment location.
Post-operative recovery in a private clinic.
We see this in some Plastic Surgery “clinics” that advertise recovery facilities that are in a hotel or luxury apartment with nursing and/or medical staff available.
Standard of care in a private facility offering patient care may be subject to different protocols and laws than correctional institutions.
Privately-owned facilities may include:
Addiction and/or Alcohol Recovery Rehabilitation. Those that are “live-in” or inpatient will differ in the services they offer from an outpatient program where patients live outside the facility and visit it for treatment. Privately owned programs may differ from services offered at a public clinic or hospital.
Privately owned surgical centers
Plastic surgery private clinics may promote an experience of luxury and convenience while medical staff credentials and treatment protocols in such facilities might not meet a standard of care. Many such facilities offer a qualified staff, medical oversight, must adhere to state licensing and regulatory agencies and rules. The quality of care can be high. Unfortunately, that is not always the case.
Public Hospitals, Clinics and Treatment Programs
Public, city, county or state hospital, clinic and outpatient treatment is also subject to regulatory oversight.
Rehab and Medical Malpractice, One Example
Legal concerns can arise in a privately owned addiction rehabilitation facility where a patient receives treatment that is not properly supervised by a physician. Treatment of addiction is especially sensitive if side effects from withdrawal create a medical emergency.
In addition, drugs used to treat withdrawal require an appropriately skilled and qualified doctor. Dr. Adhia holds a Buprenorphine Waiver allowing him to treat opioid addiction with this controlled substance.
A hospital usually has strict treatment protocols which, if not followed may impact the standard of care. Both public and private hospitals are subject to licensing and regulations as well as follow best practices in medically ethical treatment.
The Doctor-Patient Relationship. Has Medical-Malpractice been Committed?
The relationship between doctor and patient, whether or not it is psychotherapy, is governed by ethical and legal obligations. Doctors are required to maintain professional “arm’s length” treatment. Crossing the boundary can include developing an emotional or sexual relationship between treater and patient. In general patient care, however, touching not indicated by medical treatment (e.g. hugging) may not withstand scrutiny.
Medical malpractice may not have been committed. Individuals with some psychiatric disorders or personality types may misinterpret what is appropriate treater behavior. Also, professional standards of care are not always understood by patients. What they may think is malpractice in fact is within ethical and legal lines.
I discuss some of the real world medical malpractice cases in which I have been retained in the Medical Lawsuits case study page on this site. Learn More…
TRAUMA, TRAUMATIC EXPERIENCES, DISABILITY AND PTSD
PTSD can be brought up in litigation, as exposure to trauma is required for its diagnosis, in contrast to other disorders.
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. As a damages expert, Dr. Adhia can testify to diagnosis, prognosis and treatment of PTSD.
PTSD 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. The diagnosis of PTSD is not required to proceed with your case. Events can cause other psychiatric disorders that are confused with PTSD including Adjustment Disorder and other trauma-related disorders like Generalized Anxiety and Depression.
Disabling Psychiatric Trauma and Collateral Family Damage
Dr. Adhia provides Pro Bono forensic assessments for Physicians for Human Rights, evaluating victims of human trafficking. 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, including PTSD.
Collateral impact on the family of a PTSD sufferer is common. When Dr. Adhia conducts an evaluation in which PTSD is claimed to be present, he may request a collateral interview with a spouse or partner. PTSD can impact a person’s objectivity and insight into their own experience of life. The observations of a spouse or partner can be invaluable when available.
Military. Much of Dr. Adhia’s early psychiatric training took place in VA hospitals where he treated combat veterans with service-related PTSD. The Defense Base Act addresses compensation to private military contractors and their employees who may develop PTSD from events that take place in combat zones.
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.
Be on the alert for:
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
Misperception of reality during a hallucination.
Suicidal thoughts or actions
MOOD DISORDERS / ANXIETY DISORDERS / EMOTIONAL DISTRESS
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. Note that Anxiety Disorders are not Mood Disorders but a separate diagnostic group of symptoms.
A common type of damages asserted in a civil Complaint is “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.
Anxiety involves excessive worrying and fear. Anxiety disorders include Generalized Anxiety Disorder marked by a general overarching worry even when worrisome situations or events are not present. Other Anxiety Disorders include Panic Disorder, and Social Anxiety Disorder. Anxiety Disorders and Major Depressive Disorder can occur together though they are not the same diagnostically.
Real life examples of how an Anxiety Disorder might appear:
- Job interview causes irrational level of fear (Social Anxiety Disorder).
- Mild confrontation produces a fight or flight level of Panic Disorder.
- Symptoms appear randomly, like a feeling that you can’t breathe.
- Phobias, an extreme irrational fear of things or places.
Anxiety Disorders and their symptoms are described in nearly 100 pages of the DSM5. As a Forensic Psychiatrist, Dr. Adhia is trained to identify and diagnose Anxiety Disorders. In a forensic setting, Dr. Adhia has evaluated malingered Anxiety.
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 MOOD DISORDERS
After an injury, Depression and/or Anxiety can develop. This does not mean there is a cause and effect relationship.
Mood Disorders include Depression and Bipolar Disorders I and II.
PTSD is NOT an Anxiety or Mood Disorder. PTSD is a singular diagnosis although depression and anxiety may be features of the constellation of PTSD symptoms. More about PTSD here.
Diagnosis is the first step. There may be no clinical depression, for example, though symptoms are reported. Misdiagnosis is a serious concern in rendering an Expert opinion and it is not uncommon for Experts to disagree about diagnosis. The diagnostic qualifications, skill and training of an Expert Witness, such as Dr. Adhia, supports his diagnosis.
Treatment options can minimize the long term impact on the plaintiff or defendant. Treatment can mitigate damages. Because many Mood Disorders respond to medication, a Psychiatrist may address medication in rendering a forensic opinion, while a Psychologist is not qualified to prescribe and has limited ability to opine about medication treatment.
What can worsen Depression or Anxiety?
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.
Exacerbating events. An injury, motor vehicle accident, fall, assault, events with strong emotional impact, relationship problems, the death of a loved one. Any of these and more can exacerbate existing conditions or initiate a psychiatric condition like Depression. The law, unlike the clinician’s manual, attributes degrees of severity. In Wrongful Death cases, for example, watching the death of a loved one is considered by law as a separate category than losing a loved one alone. A Board-Certified Forensic Psychiatrist is qualified to address the interface of law and psychiatry.
BIPOLAR DISORDER I AND II
Dr. Adhia diagnoses and treats Bipolar Disorders. Bipolar Disorders are Mood Disorders. They are marked by extreme highs and lows and are notoriously difficult to treat. Relatively recent scientific advances in neuroscience and medicine have produced medications to treat Bipolar Disorders.
A Bipolar Disorder that is being managed with treatment can be derailed. Notably, once managed, an emotionally turbulent or stressful event 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.
Features of Bipolar Disorder. >
Mania (hyperactivity, inability to sleep, speaking fast, thinking unusually fast, rushing through things)
Hypomania (a less severe mania)
Mixed Episode where features of Bipolar Disorder occur in close proximity, swinging between Mania or Hypomania and Depression.
Psychiatrically, a Personality Disorder is a diagnostic condition in which the individual’s personality is pathological or medically significant.
The DSM5 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. Common personality disorders encountered in medico-legal settings is Antisocial Personality Disorder and Borderline Personality Disorder.
Dr. Adhia has treated and diagnosed Impulse Disorders which are not Personality Disorders. Personality Disorders like Borderline Personality Disorder may accompany impulsive behavior. 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.
BPD is marked by self-image issues, difficulty managing emotions and behavior, a pattern of unstable relationships. Often we see self-injurious behavior, anger, impulsivity and impaired interpersonal and occupational functioning. Frequent changes in jobs or inability to get along with co-workers appropriately may accompany BPD. Self-injurious behavior can include cutting one’s self and non-lethal suicide attempts. Self-image and self-injurious behavior may combine to manifest as an eating disorder such as bulemia or intentional starvation to lose weight.
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.
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.
Dr. Adhia is skilled in assessing malingering. In a high profile case involving men who posted on You Tube video of their rape of young girls, Dr. Adhia was asked to evaluate one of the men regarding competency to stand trial. The man suffered a brain injury as a young child which he cited in the competency matter. After two examinations and extensive assessment, Dr. Adhia’s conclusion was that the man was malingering. Read more…
Personality Disorders and Malingering: Diagnostic Concerns
Malingering: Lying vs. Perception vs. Reality
What appears to be malingering can instead be inconsistent statements due to other psychiatric conditions. This might look like lying.
Proper diagnosis is essential.
Malingering is best assessed in conjunction with an Independent Medical Examination (a face to face clinical examination) to evaluate the examinee in light of records, other statements and neuropsychological testing, should it be indicated.
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.
Paranoid Personality Disorder* may produce unintentional or non-malicious report of a distortion of events, feelings and emotional reactions.
PPD 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.
However, 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.
*See DSM5, 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 Major Depressive Disorder (MDD) 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,” or other non-suicidal self injury (NSSI) can be confused with a suicide attempt. A forensic IME is necessary to make the right diagnosis. Self-harm is not always 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.
HALLUCINATIONS AND DELUSIONS AND/OR SEVERE MENTAL ILLNESS
HALLUCINATIONS OR DELUSIONS NOT RELATED TO A SEVERE MENTAL ILLNESS
A Hallucination is a sensory experience that appears real, like hearing voices or seeing people commanding the person to commit a crime. A Delusional Belief is different. It lacks the sensory element. A delusion is a persistent belief held despite evidence to the contrary. “My daughter is poisoning my food” (daughter is living in another country) or “My boss is sabotaging my work” (perhaps positive performance reviews or coworker reports to the contrary are disregarded).
Schizophrenia is not the only reason a hallucination or delusion occurs. In fact, medication side effects and medication interactions are possible culprits. Withdrawal during detox, sleep deprivation and a range of other complicated medical issues can be at play.
I evaluate examinees in light of these possibilities. As a Forensic Psychiatrist, it is essential I consider the possibility of malingering.
My background includes drug addiction (I am an MRO), malingering and I have treated severe mental illness (e.g. Psychosis, Schizophrenia) in the correctional system.
It is important to note that a physician is the best person to determine what is going on when a person appears to be experiencing a hallucination or delusion.
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 a 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.
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.
Behavior we think of as psychopathy is multi-layered. Better understanding of the Psychopath and psychopathic behavior will be addressed separately.