Psychiatry & Psychotherapy Podcast - Identifying Malingering with Dr. Phillip Resnick

Episode Date: December 23, 2022

Malingering is the conscious misrepresentation of psychiatric symptoms for a secondary gain (such as hospitalization, obtaining disability benefits, avoiding criminal responsibility, proceedings or sentencing, or avoiding military service). In today's episode of the podcast, we are joined by Dr. Phillip Resnick and Dr. Alex Scott as we discuss the topic of malingering. By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CME while listening to this podcast? Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is emailed to you in seconds. Dr. Resnick, Dr. Scott, and Dr. Puter have no conflicts of interest to have no conflicts of interest to a announce. All right, welcome back to the podcast. I am joined today with one of the most well-known forensic psychiatrists in the world, Dr. Philip Resnick. He is a professor of psychiatry at

Case Western Reserve University School of Medicine, Cleveland, Ohio. And he has consulted on many of the most high-profile forensic cases. And he has written over 215 professional journal articles and book chapters and contributed to a book that I've enjoyed called The Clinical Assessment of Malingering and Deception. He specializes in Philicide, Insanity to Defense, and Malingering, and I think in this episode I would like to focus on malingering. I'm also joined with Dr. Alex James Scott. He is a forensic Psychiatry Fellow at Case Western University, and I'm excited to have a conversation about forensic psychiatry with you.

I look forward to it. Yeah, so maybe I'll start off with Dr. Resonet. Can you tell us what is malingering and how do you differentiate malingering from something like factitious disorder? Your malingering is the conscious misrepresentation of symptoms or gross exaggeration of symptoms for the specific purpose of some gain, such as getting into a hospital when one is homeless, avoiding military service, or avoiding criminal responsibility. A factitious disorder, there is no assumption about why someone is misrepresenting their symptoms.

And so it may be for some conscious or unconscious game, but there's no, we simply don't know why. Yeah. I want to talk a little, jump into this kind of malingering psychosis. since I know that that's kind of like an area of particular interest for you. And I was thinking about how this is helpful for people who aren't even forensic psychiatrists or psychologist, right? Because I learn more about psychosis from reading this chapter than I had in like so many other books. Because to know what is malingering, you have to know what normal is, right?

And what is, what does someone look like when they're just psychotic? So I'm wondering if maybe, yeah, can you give like a general introduction on malingering psychosis, and then I'll ask you like specific questions? Sure. From the standpoint of an insanity defense is where you would most often have someone malinger psychosis to avoid responsibility. So differentiating what is normal psychotic symptoms from faked symptoms. psychotic symptoms then becomes critical. And before you can even start to do that, as David mentioned, it requires a good understanding of differentiating ordinary psychosis from what are called non-psychotic

hallucinations, for example. And non-psychotic hallucinations, first of all, 10 to 15 percent of the population will have some hallucinatory phenomenon during their lifetime. So it is not at all rare. And that doesn't mean that the person is psychotic, whereas a delusion is pathic-nemonic of psychosis categorically, a hallucination is not. There are many reasons to have non-psychotic hallucinations. One example is women who lose their husband after many years of marriage, between 25 and 35 percent will see or hear their husband in the next six months after the death. So this is just one example of a non-psychotic hallucinations. Okay. And so, so yeah, you kind of talk about how specific,

specifically like an auditory hallucination is unique or what is like a normal or what is it like psychotic auditory hallucination versus a non-psychotic auditory hallucination. Yeah, let me go ahead and add to that. The average age of a non-psychotic hallucination, the onset is age 12, whereas the average age age of a psychotic hallucination is age 21. The age we know that schizophrenia is most likely to occur. And non-psychotic hallucinations tend to be friendly, it may be a parent or some favorable named person, whereas persons with schizophrenia having hallucinations over 80% are more hostile or degrading in their comments, such as you're no good or of a paranoid variety.

So that's just an example of non-psychotic versus psychotic. And one has to know that before you even start to look at how malingered hallucinations differ from genuine hallucinations. Yeah. It seems like the punitive nature of psychotic elucidations, like, drogatory comments that they wouldn't want to tell you. And after reading your book, I read it or this chapter in residency, I started asking patients and all of a sudden, you know, you get content that you wouldn't otherwise get because you ask this specific question, right? Like, do you ever hear, like, for men, I would ask them, do you ever hear hallucinations, like, accusing you that you're gay? And they would get this look on their face of like, oh, no, you know about this or something.

Like, what? Because there's often a lot of fear that they may be gay if they're not gay. Or, you know, the accusatory nature of these things are very sort of stigmatizing to them. or anything on that you want to express? Sure. The most common gender-based insult for a man is some inference that he's gay. So a drill instructor in the military might say, come on, you're acting like women or little girls to insult. And for women, the single most common gender-based insult refers to promiscuous.

being a whore or a slut. So these are things that if a person, if a woman sleeps with more men than she's comfortable with, then her hallucinations may take the form of saying, you're a slut. And a man who may be heterosexual, but have an occasional awareness of attraction toward another man may start hearing voices saying,

you're queer, you're gay. So in other words, the internal concerns come out in the accusatory hallucinations. When I looked at this, you cited a study, and I wonder if that's changed at all in the coming decades from that study being published. Like has the nature of the hallucinations changed? Just like you talk about it and how culturally, you know, if you're in Saudi Arabia, there might be some themes of Muhammad that get wrapped into the delusions or the hallucinations. Like, do you think that there's been a change in the nature of hallucinations over time or

the content of them? Well, first of all, the attitude toward gay people in the United States has had a sea change in the last 40 years so that now TV movies, rather than only having derisive things using gay men as a butt of a joke, now show healthy gay men functioning and attitude toward gay marriage, obviously, has had a marked change. That still doesn't stop some men struggling with whether they're gay, even though they would vote in favor of gay marriage and are very tolerant of others. I think the internal struggle has not changed.

Now, hallucinations vary according to the interest of each individual. So someone who's deeply religious is more likely to have religious hallucinations than someone who is not. So it will follow that individual. Someone who's depressed is likely to have hallucinations saying, you're no good, you're rotten, you ought to kill yourself, you're not worth living as they're struggling with their own depressive feelings. So they will reflect internally what that person is struggling with. Another comment you make is talking about how common delusions are in someone who's truly

psychotic with the hallucinations. So it's very unusual to see someone with pure hallucinations. Can you talk about that? Yes. Well, in some studies, it's 88% of persons with hallucinations will have concurrent delusions. And so when someone comes with pure hallucinations and no paranoia or delusional ideas, one should just have a little higher index of suspicion. It is in proof, but what you're looking for are multiple atypical hallucinations to really raise your index of suspicion, and then one would want to confirm a lingering with psychological testing. Okay.

And then you talk about, as long as we're talking about kind of this idea of delusions being mixed into it, you talk about how it's more likely if they have the delusions that they would act upon their command auditory hallucinations. What have you seen there in particular? Sure. This is consistent across multiple studies that the single greatest risk factor for someone acting on a dangerous command hallucination, would be concurrent delusion. So a common example I'll use in teaching is, if you hear a voice out of the blue that says, kill your mother, your moral fiber would cause you to hesitate. But if you have a concurrent delusion that your mother is an evil wizardess, you're much more likely to act on that command hallucination than if you didn't have that delusion. So it just makes sense. If there's a double distortion of reality, you're more likely to act than if there's only a single hallucination which you may question. And if that person, let's say, in a forensic case, had killed their mother, would they hide the crime in the same way if they had the delusion that their mother was an evil wizardess? Well, no. But generally, if someone believes they're doing what's right, they may call the police and say, I've just killed an evil wizardess.

And they're not trying to hide their crime because they believe they've done what's right. That's a classic valid insanity defense. One exception would be if someone has cap grass syndrome, let's say they believe their brother has been replaced. placed by a demon and they believe that if they kill the demon, their brother will reappear. They go ahead and kill their brother, who they perceive as a demon, and their brother doesn't reappear. Then they may begin to think, uh-oh, maybe I was wrong and realized that they have killed their brother.

Then they might hide the body and act like a criminal. But that's the exception. most people who kill based on a delusion would not try and hide their crime. You know, I want to jump back a little bit earlier in some of your writing here, you talked about how there's been cases where they have pseudopacients being admitted, like in this Rosenhans' 1973 classic study of eight pseudo-patients being admitted, saying they heard very atypical auditory hallucinations, and then immediately upon a mission,

they stopped having any symptoms. And some of them seemed forced to stay or stayed, I'm not sure, nine to 52 days. And it's kind of this question of like, how good are psychiatrists at determining if someone is truly psychotic or not? Can you kind of like share some thoughts on this study and any other studies that come to your mind?

mind with this? Sure. It's a classic study, published in science, a very prestigious journal, and it undermined the kind of the reputation of psychiatry. And again, you are a young man, and I lived through 1973 as a psychiatrist. So when this came out, it was kind of startling. But there are a number of flaws in the study. First of all, all the patients were voluntary, none were involuntary. Secondly, the length of stay in 1973 was three or four weeks as opposed to six or eight days the way it is today. So those lengths of stay look disproportionate compared to today. And they were admitted to state hospitals, not private hospitals, where, again, you had psychiatrists who may not have been, of the strongest caliber and these patients were not asking to leave. And then there is a recent article

by someone who deeply investigated this and found that Rosenhan had actually faked some data and that they were not actually... In other words, they said things actually, which kept... them in the hospital rather than how it appeared in the initial article. So there really are a number of undermining things now. So I don't think it's fair to use that article to conclude that psychiatrists can't make

the distinction. Furthermore, there was no reason to suspect malingering. These were people seeking treatment. There was no criminal or any legal issues going on. So I just don't think it can fairly be used to show that we are not good at this. Whether we are good at it is another question, but I don't think that article is evidence of it. Okay.

Was there any further articles or similar studies that showed something different or showed something similar? Well, it's interesting. If you look at apparent malingering rates. in various medical legal situations, like someone seeking disability, someone seeking workers' comp, someone seeking money after a tort injury. And these various things, based on psychological testing, authors conclude that there's a malignering rate between 8 and 40%, which sounds kind of alarming.

But that's based on studies like an MMPI. And if you actually go back and look at how the MMPI was devised, it was based on clinical judgments about whether someone was malingering. And then those studies conclude that 8 to 40% may be malingering, not are malingering. so that I think there is the appearance of a substantial amount of malingering based on a single psychological test, but the true incidence of malingering is actually not really known. Okay, so that's interesting. So if someone says, well, you need the MMPI because that's the gold standard,

it's like, well, the MMPI was based on the gold standard, which was clinically people trying to judge what was malingering or not, and the MMPI may be picking up suspicion more than actual, you know, malingering. In the cases where we have in my institution potential malingering, it's usually repeat offenders who are looking for something, like a warm place to stay. And I always tell the residents the best way to handle this is to document very clearly incongruent things that are said and build a case over time, right? So we document well, what happened, what they said. And, you know, at some points they say, no, I'm lying. I'm just

needing a place to stay. I want to go now. Document that. And then in subsequent times when they come in, we have a series of documentations. Any thoughts on that? Yes. I certainly would agree with what you're saying. And the people who want to get into the hospital know the magic word. And the magic word is, I'm going to kill myself. Less often, I'm going to kill other people. And there is, there are one or two studies on distinguishing people who malinger suicidality from those who are genuinely suicidal. They have a lot in common. They often are homeless. They often are depressed. They often are desperate, and those things are true in both the real and the fakers.

And the single factor which came out in one study was that the malingerer is more often to make a conditional threat. If I'm not admitted, I'm going to kill myself. And the person who's genuinely suicidal is much, much less likely to make a condition. conditional threat. I'm sure some of my colleagues are thinking, wait, is that true also if kids, for example, adolescents are saying that to parents. Like, if you don't give me my phone back, I will kill myself. Or if you don't, you know, do this.

Like for girls dating a guy or guys dating a girl, it's like, if you don't get back together with me, I'm going to kill myself. Are those conditional threats as well, like kind of in that category or would you consider that different? They are conditional threats by definition. What you're saying is, let me give you a more common example, and that is a adolescent dating, let's say an adolescent male dating a girl of a different religion, and the parents prohibited.

And the son says, you know, if you don't let me date this person, I'm going to. to kill myself. Now that is strategic in the sense of trying to influence the parents. Sometimes threats are called expressive or instrumental. That would be an instrumental threat trying to get the parents to relent, as opposed to an expressive threat where someone is just so upset by some events, they just, you know, shout out a threat to express their emotions. And so an instrumental threat like that, the person may use a razor and actually cut their wrist to bleed, but not deep enough to get a vein or artery to try and, you know, influence their parents to relent.

they may go that far and really spook their parents, but the likelihood they'll actually want to die is not great. However, there's always a possibility of miscalculation. Someone can think they're not taking a lethal dose of Tylenol, but mess up their liver and actually do more damage than they think, for example. Okay. Yeah, Dr. Scott, if you want to jump in, if you have questions, just jump in. Don't think I'm going to, I want you to, you know, if you have things that are kind of things you want to touch on as well as we talk. I have a review article here from the Journal of American Academy of Psychiatry and the Law, the Forensic Journal. It's a few years old, but, you know, reviewing malingered auditory.

hallucinations. And, you know, one thing I want to mention are the some of the psychometric tests that we've been exposed to here in the state hospital system, and this article discusses them. So some of the listeners, you know, might be familiar with the SERS, it's the structured interview report, structured interview for reported symptoms, and the Miller forensic assessment of symptoms test that's called the M-FAST. And those things, you know, can be helpful for administering to patients and seeing if they endorse an exaggerated amount of symptoms or atypical symptoms that wouldn't usually be seen in psychosis. And I found it helpful to work some of those questions, you know, me not administering the test, but work some of those questions into the clinical

interview. So things like, do these voices wake you up from sleep? Are the voices lateralized? Do they come from one side of your head? You know, how severe are they? Is there anything that you can do to diminish them? And then the actual content, you know, what do the voices say to you? Do they question you? It's more atypical that the voices would ask, you know, sort of more vague. questions than not. So yeah, these tests are really helpful and I think if you if you take a look at them just incorporating some of those questions in your clinical interview can help can go a long way and you know sussing this stuff out. Yeah, this is some good points. Let me make a couple of comments about that. With regard to the nature of hallucination

questions, individuals who hallucinate, I'm going to call them voice hearers, they perceive their voices to be omniscient. Therefore, hallucinations are not asking the nature of hallucinations, which ask questions. By the way, one third of persons with hallucinations will report that voices sometimes ask them questions. And the nature of those questions are not information seeking. that is they don't ask about the weather or what time is it. Instead, they're more chastising questions. Why haven't you begun their homework?

So that's a more specific clue about hallucinations. The other comment I would make is that the MFAST is a screening test for malingering. And so you wouldn't want to go into court with that as your final evidence. The SERS developed by Richard Rogers, a structured interview of reported symptoms, takes about 45 minutes to administer and is sometimes considered the gold standard. That is, as other people develop tests for malingering, they're often measured against the SERS. and so if that you can go into court with and use that to support a diagnosis of malingering. I know one thing to you've told us, Dr. Resnick, is malingerers will often try to, or maybe not try, but happen to overstate the presence of symptoms, and that can be a big clue too.

an overwhelming clinical presentation that doesn't seem congruent, you know, with their affect or with their history or maybe they've never been hospitalized and yet they come in with all of these symptoms. That's another important thing to look at. Yeah, I'll just add to that, that naive malingerers overstate their absolutely overstate a very sophisticated Mollinger, it knows to be more subtle. So, for example, we've all encountered people who have a delusion that they're Jesus Christ, but they don't come in costume. So someone who would dress as Jesus would be an example of overplaying their hand. Yeah. One thing that you mentioned that's really helpful is the time course. Like,

how quickly do the auditory hallucinations resolve with Medicaid? And so you say, I think two days is like the average, if they're not psychotically hallucinating, whereas like it would take a good month for antipsychotics to make it less loud and less frequent. And six months for antipsychotic voices to be less frequent, more in control of them. And then the insight took a lot of time. All right. Let me just add to that, that if someone is malingering and they're put on medication and they allege the voices go away completely after two days, that would be very suspicious.

And the study you're referring to is first episode psychosis where, indeed, it takes over 30 days for resolutions of hallucinations and even longer for delusions. So that would certainly be a clue, especially where you have someone for a longer stay, such as in a forensic unit compared to a clinical unit. Are there any cases that you can share about things like this that maybe would kind of help illustrate how cases like this go or how the argument can be helpfully made or, you know, to. get the person the treatment that they need or maybe kind of help find out who like is more psychopathic and not and just kind of trying to abuse the system yeah let me mention first of all they're in the military people have reason to malinger they can malinger because they want to get out of a battle situation or they can malinger let's say they're denied a pass and they want to

but their girlfriend is breaking up with them and they want to, you know, be able to go home and deal with it. So they may allege suicidality to get themselves into a psychiatric hospital or somehow to get discharged from the military by faking some symptoms. And I heard a military psychiatrist lecture on this, and he made a very striking point. And that is, when he does believe someone's malingering, even though technically, malingering is a crime in the military and they can be court-martialed for it, this military psychiatrist said that he will say to the individual who's malingering, look, I know the symptoms you're telling me are not genuine. Tell me what's really going on and maybe I can help you achieve your goal.

And I thought that that was very sophisticated rather than just responding to anger to the suspected malingerer to actually try and assist them in developing some other approach to solve their problem. The one case I want to mention, it's interesting you asked that question because I haven't mentioned this case in my teaching. But many years ago, there was a wealthy individual, and he and his brother developed products for beauty shops. And they had a national, you know, they were earning millions of dollars. And he had a major, and he killed his brother. And I was hired by a...

defense attorney, I evaluated him, and he gave me a clear, non-psychotic reason for killing his brother about some disputes they had in running the business. I told the attorney, I can't help. You know, I just can't help with an insanity defense. The next thing I knew, the defense attorney hired another psychiatrist who at that point the the killer was more sophisticated and made up made up voices and a psychotic reason for killing his brother which I knew categorically was malingered because I had heard a genuine story and then the second psychiatrist just bought it and and was prepared to take testify in the case. So that's a case where I knew it was malingered categorically,

because I had seen him earlier, but I also witnessed another psychiatrist accepting the story. But again, I was tied to attorney-client privilege. I couldn't reveal that I knew it was bogus. But that's just a nice example of where the person got more sophisticated and how they told their story and succeeded in convincing the psychiatrist. Yeah, it's almost like they heard your critique of why he's not psychotic. That helped them come up with a better narrative, you know, which wasn't what you intended, but it was like, yeah, it helped him get off. Are there any other cases that come to your mind that are like,

that were enjoyable for you to partake in or like just stream of consciousness what's coming to your mind as we talk about this maybe well I'll mention that

in federal court someone who commits a crime and is charged in federal court there is what they call upward and downward departures in sentencing in other words

it's a guide for the judge to add, you know, six months or 12 months because of what are called upward departures or reduce the sentence. If someone has mitigating factors, they accept responsibility for the crime and so forth. And there have been a couple of cases now where an individual malingered psychosis, it was discovered as malingering and caused the person to remain in a psychiatric. hospital an extra four months generating, you know, unnecessary cost when they belonged in jail. And the judge actually gave it an upward departure and sentenced them to a longer time in prison.

So it's an example where once malingering is discovered, it's not just okay, now you're facing the consequences, but you are facing consequences because you malingered of extra time. in your sentence. So sometimes I will mention that to an individual that they run the risk of paying a penalty if they don't come clean with me and we get this behind us. Yeah. Yeah, I think the most difficult part about malingering would be malingering the negative symptoms of schizophrenia or malingering the disorganized speech of schizophrenia. Any experience of that, specifically as you're evaluating people? Yes, you're absolutely right about that.

Most people who malinger go for the gusto, the dramatic. So the person malingering PTSD will do a lot of faked reliving experience, whereas the person with genuine PTSD often has a, a blunted affect and a lack of capacity for enjoyment. And so the negative symptoms will not be malingered, but the positive symptoms of psychotic symptoms or dramatic reliving is what the malinger will emphasize. I was just going to add to that.

One of the benefits here in the state hospital system and doing a forensic evaluation is, you know, the nurses are trained to look at behavior of the patients. And like you guys are saying, it can be very common to hear about positive symptoms in an interview, but then perhaps the patient is social, you know, doesn't have any speech latency, calling different people on the phone, you know, not isolating to their room, making their bed, doing nothing bizarre, and having those notes and, you know, documenting a lack of negative symptoms is very important if you do suspect malingering. Right.

I would certainly endorse that. And some psychiatrists on forensic unit are very sophisticated in training their staff of what to look for and what to document in the notes, and then they can go into court with that. Yeah. I always would train my staff to document exactly what they see and try not to put any big words into it. You know, like instead of saying responding to internal stimuli, you know, they write exactly what you're visually seeing, you know, to try to just document data rather than like, you know, having command auditory hallucinations. It's like, okay, what did you actually see? Any thoughts on that or how you coach your staff?

Well, I'd certainly agree, and that's just good nursing notes in general to help diagnosis even separate from malingering. And so I would just endorse what you're saying. I have nothing to add to that. Yeah, one thing that sticks with me when you talk about PTSD malingering is, is how the dreams of someone with PTSD will vary, and it won't be like the same dream over and over again? Can you speak about that and what you've noticed there? Sure.

A person, let's say, let's take a woman who's raped, and that has the highest incidence of PTSD. 80% of women who are raped have PTSD, whereas men in battle only a third will have PTSD. PTSD and persons in a disaster like a flood, only a third will have PTSD. But the personal assault of a rape has the highest incidence. So such a woman may develop PTSD and fear of specific reminders. So if they were raped by a black man, they may feel uneasy just seeing a black man on the

street. and the nature of the dreams might be feeling helpless in various ways. It might not repeat rape itself, but it may feel like they're somehow being tied down and screaming and no one is helping them. Or some other manifestation of helplessness, pain, rather than the rape itself being repeal itself being reversed. repeated, someone who alleges a dream of only the exact same event with no variation would be suspicious of malingering. As someone in the forensic field, do you get called on to evaluate like malingering PTSD, or is that more like the VA and what they're like with service connection? There's like that. It does do the official evaluations and, you know, say whether someone is malignant or not, whether it's 10%, whether it's 80%.

And there are a lot of extreme stories from the military where groups of people who never saw combat, and it's proven in their records, allege PTSD. And so actually something like $7 billion a year goes to veterans with PTSD disability. And some people feel that a certain percentage of that is faked. But the VA overall, I think, tends to, in the face of uncertainty, provide disability. whereas others like insurance companies are much tighter in giving out money and will challenge a suspected malinger to a stronger extent than the government. Right. Alex, anything jumping into your mind that you wanted to bring out in this?

Yeah, you know, I did work in a VA in residency in Ann Arbor. and a lot of, well, in a lot of these cases, I think it's important to look at how engaged the patient is in treatment. You know, are they alleging these things or these service connections and then they're gone, you know, soon after that's secured? Or are they taking the steps, you know, to get into trauma-focused CBT? Are they consistently reporting all these symptoms with different physicians following up with the psychologists? So looking at the patient's level of engagement rather than just hearing their report is really important. I would just add to that there is one study that showed patients with PTSD, like with 40 or 60 percent, would persist in reporting their symptoms.

And once they got 100% disability, a significant percentage then dropped out of treatment, which gives at least the appearance that they were persisting in the appearance of treatment in order to push it up to 100% and then backed away from treatment. Yeah. I mean, I really see that, you know, there are true people that are suffering. And so it's like it's a very different mindset to be a forensic psychiatrist and be judging not just what's best for the person in front of you, but also what's best for society. Can you talk about how that switch occurred in your brain, in your training? And, you know, was that ever difficult? It's a very good point. and that is there's a total shift in ethics.

When one is treating a patient, one is advocating for that patient and doing what's best for the patient. However, in a medical legal context, one is acting as an umpire. And in that role, they don't make the rules. They're just calling the balls and strikes. And in that sense, they're deciding who is ill enough to come into the hospital. They're deciding who is worthy of compensation and so forth, who is worthy of mitigation of the death penalty. And that requires a very different hat where their duty is to the justice system and not to the individual they're evaluating. And sometimes when I lecture about this, I will ask how many in the audience view themselves as forensic as opposed to treating doctors.

And it's almost always over 80 percent are treating doctors, but they somehow are now thrust into this new role. And it's important they realize there's a different set of ethics and a different set of duties. Yeah, I steer pretty clear of the forensic field just because it's so much in my psychology just to be helping the person that comes in. There's like not much in me that wants to, you know, ever try to seek justice, you know, for the larger. I mean, I think, I don't know, I kind of debate what I want to do that at some point in my career. But at least to this point, I have chosen to most. mostly try to not do that. And I wonder if, like, you find there's a different type of person that ends up in the

forensic field, like a different type of personality or a different enjoyment of certain topics. Like, any thoughts on that? Sure. I interview, you know, a lot of candidates for forensic fellowship. And some of the traits that I look for that I think the person will do well is tolerance for scrutiny, a willingness to support your opinion and tolerate cross-examination. So it takes a certain level of confidence and almost feistiness.

You know, the average psychiatrist wants to stay away from the courtroom. They want to be in their own domain of the hospital where they give orders and not having someone challenge them. So, for example, in making a diagnosis, even of major depression, the run-of-the-mill psychiatrist does it on a clinical hunch and doesn't even systematically think, do they meet five or more out of the nine symptoms in the diagnostic manual, whereas a forensic psychiatrist is crossing every T and making sure every diagnosis is, you know, supportable and defensible. So it is a difference. It takes a kind of meticulousness and a willingness to really defend one's opinions. And that is a much, quite a small subset of psychiatrists in general. Yeah. And if I can just jump in, you know, it's it's been such a great year with this fellowship so far because you really do learn a lot of humility about.

taking a good, hard look at what is the truth, you know, what's going on with these people, what can we say about them, and what can't we say about them? What don't we know yet? You know, I've, I loved residency and had a great time, lots of learning, but, you know, I've spent the most time with the DSM this year, really, really digging into what can you prove, what can you not prove? What can you tell the court with a reasonable degree of medical certainty and what can't you comment on? So it's a lot of development of humility and like Dr. Resnick said, really outlining your opinion and reasoning A to Z. Let me give you one example of that, David. There was a case in Albuquerque of a woman who desperately

wanted a baby. And in order to achieve this, she waited outside an OB military clinic, and she found a woman eight and a half months pregnant, took her up to the mountains at gunpoint, and cut the baby out of her abdomen, and presented the baby as her own. She was caught, and the defense was alleging that she had dissociative identity disorder and therefore was not criminally responsible. I was employed by the prosecution and thought she had antisocial personality and that she did not have a DID. And at the time, antisocial personality included promiscuity, which was defined as never having a sustained monogamous relationship for more than a year. And this woman told me in her background that by the age of 15, she was going

into hotel hot tubs and performing oral sex on strangers. So the idea of her being promiscuous was in my mind and I made that diagnosis. A good cross-examiner asked me the question, do you have proof that she was unfaithful in her 18-month marriage, and I didn't. So I had to admit that I could not support that point. That meant I could not support antisocial personality and had to back off that. And so, again, that lack of very careful looking at the exact definitions was, you know, a strong lesson for me that I pass on to my trainees, that it can't just be your general hunch, but actually meticulous examination of each definition.

Very good. Yeah, that's like a very different experience. I had some, yeah, I think there's value, even though, you know, a lot of people who listen aren't forensic psychiatrists, they're never going to be forensic psychiatrists to understand the rigor of how we think about diagnoses. because it really does change and broaden and kind of help us understand what is a psychotic event, like what we talked about. Like, you know, I'll put in the show notes a link to this article and the different, the book that you wrote and the articles that you've written on this and summarize it on my

website. And I think that it's valuable to spend some time kind of learning about like, okay, this is what normal hallucinations are like this is what I'm normal because it kind of gives us a a more clear picture now that being said like there are some psychiatrists like I had one guy recently on here who said look the NIH did this thing they found no difference in genetic markers between bipolar and schizophrenia therefore there is no difference what would you say to someone who kind of is taking that approach like isn't the DSM just a construct like the the DNA markers haven't really shown that to be the case?

I would certainly agree that we are at a very early stage of understanding mental disease. And my guess is that 20 years from now, the DSM will look very different because of more sophisticated brain imaging, DNA, and so forth. So we're just doing the best we can. And again, I lived through, I diagnosed people with the DSM-1, And in DSM-1, the diagnostic criteria for schizophrenia were extremely vague. I recall as a resident, someone had, you know, some funny affect and some, you know, equivocal, paranoid ideas.

And the attending said, you know, how many, how many, so it was like there were 17 of us in the learning room. and the attending said, how many you believe this is schizophrenia and how many in? It was like a nine to eight vote. And a colleague said to me, schizophrenia is the only disease you are elected to. I always remembered that example that the criteria were so vague then. Now, at least with DSM-3, one can argue whether a given belief is a delusion or not. But at least we know you need certain concrete symptoms to make a diagnosis. So it's a marked improvement, but there are going to be further improvements compared to DSM-5.

And just piggybacking on that, as I said, looking more closely into the DSM, I would really encourage, you know, trainees and other people like me early in the career to really take a serious look at all the the unspecified modifiers in DSM you know that's that's what they're there for it's not having enough information to come to a you know a medical diagnosis so you know when these people come into the ER and you've seen them once and they're getting these diagnoses of schizophrenia and bipolar disorder that's that's not doing anyone any favors you know So really look at the unspecified mood disorders, the unspecified substance use disorders, you know, those are great things to use.

To avoid jumping to a diagnosis where the label is tick. Yeah, I completely agree. Yeah, I'm curious, just a sort of side question that's floating in my mind. I saw that you did some work in different high-profile cases, and there's recently a Netflix documentary on Jeffrey Dahmer, wondering if you saw it or heard about it, and if your experience of the case was different than Netflix betrayed it? I did watch the Netflix version, and I don't think it was inaccurate. I know that some families of victims were unhappy with it

because it didn't give enough perspective of the victims and focus. only on Dahmer's mind. But Dahmer was extremely forthcoming and had a very good memory. And so he, you know, as opposed to trying to minimize his psychopathology, he laid it out and acknowledged each killing and the reasons he had in mind for each killing. An insanity defense was raised, and Wisconsin at the time had a fairly liberal insanity defense, but the jury rejected that defense. And if they had accepted it, it would have opened the door for every pedophile saying, I had this attraction and I could not control it.

And the judge actually said in the case that if the jury, had found him insane, he would have overruled it as a matter of law because it would have set such a bad precedent. What was your role in the case? My role in that case was more minor in that I was a consultant to the prosecution. I met with the prosecutor and helped counsel them in this whole insanity issue regarding parapherias. And Dr. Berlin was the one psychiatrist for the defense who was saying that due to necrophilia, he could not control himself. And I pointed out to the prosecution that even someone

who has a powerful drive to have sex with corpses doesn't need to kill people. That individual could go to work in a morgue, they could dig up bodies. There are various ways to satisfy a necrophilic impulse without actually killing people. That's a morbid observation, but astute nonetheless. Oh, gosh. One critique that I heard was that they didn't portray some of just the, his religious sort of, there was some satanic sort of religious stuff that was twisted into it and they didn't really portray it in the Netflix show.

Was that something that you observed or you had heard about in your work in this case or is that not a critique that you would have? No, again, I didn't do a personal examination. So I did review all the material and Park Deeds who worked for the prosecution did a very thing. thorough three-day examination of looking at each criminal act. But there were some very odd beliefs, but they didn't rise to the level of psychosis. And Dr. Berlin didn't allege psychosis. He just alleged the necrophilia he couldn't control. Okay.

Yeah, what advice would you have for someone who is thinking about becoming a forensic psychiatrist? who maybe is a couple years from actually applying? Well, I'd encourage them to take electives where they could rotate through a prison, a jail, or a forensic unit, and even if that meant going away for a month, if that wasn't available nearby. And sometimes people will take initiative, and even though there's no listed forensic elective, They'll create one by going to a jail and asking the psychiatrist to supervise them in that role. Because I think they need to get into it rather than, you know, there's a lot of people who read detective books and they watch law and order and criminal minds.

And it seems exciting. But you should get your hands dirty with it before you want to go into kind of a career mode. With that, what are some of the biggest sort of untruths that are propagated in the media about this field? Well, I think there is the issue of the hired gun where sometimes forensic psychiatrists are portrayed as simply they'll testify to anything that their attorney is paying them to testify for. And I think this does exist, but in a very small degree, and other people simply have different philosophical views as to when someone should be held accountable or not in gray cases. And I don't see them as hired guns. They aren't selling their testimony. They're testifying honestly about how they see cases.

I think the other misperception is that forensic psychiatrists are perceived as testifying in court with great regularity. But as a forensic psychiatrist, I may do 15 to 40 evaluations for every time I go to court. Most of the time, your report is your final product. Okay. Do you see the forensic psychiatrist changing over time or into the future? Well, I think as psychiatry changes and as more scientific methodology comes out like DNA and more sophisticated psychological techniques are developed in assessing people that, you know, forensic psychiatrists have to keep up with.

the science in particular so as the field changes then I think the forensic psychiatrist has to stay with it okay yeah any other pearls you'd like to kind of express as we wrap up our time together and I I really appreciate you coming on and sharing your your wisdom and I'm sure people would love you to continue for a much much longer but I want to appreciate your time here. So yeah, any final like sort of pearls or things either on malingering or just forensic psychiatry in general come into your mind? I think that you've been thorough in bringing things out. But I would just suggest that malingering is something you should not

make by a hunch. And I've been involved in three cases of where psychiatrists were sued for making a misdiagnosis of malingering under defamation of character. And so one should have a solid basis before you use that label and confirm it with psychological testing or actual observation, but not just a hunch and say, I'm a psychiatrist, I can tell these things. Yeah. I concur with that. And I always tell my residents. even when they call me in the middle of the night or on the weekends when I would be on call and they'd be like, I think this person's malingering,

they have this, this, and this reason. And I would be like, don't put malingering in the chart. Don't put it as a diagnosis until we have like a lot of data to support it. So put the expressed concern, right? And then over time, you know, Right. You can put, I suspect, malingering because of A, B, and C, but not make it as a formal diagnosis. Yeah. And you can, yeah, because the formal diagnosis, the chart, and then that gets repeated in future charts, and then if something happens to the person where they get really bad care because of, you know, suspected malingering, then it's like, are you liable potentially? Maybe. What do you think?

Well, it's not even bad care. as I say, there have been lawsuits where someone is not malingering. They're so outraged by that label that they have brought a lawsuit just saying that it is a blur on their reputation, a blight on their reputation, even without getting bad care. So one should not write that down as a formal diagnosis unless you've got very, very clear evidence for it. Okay. Yeah, and Dr. Alex, Scott, any final thoughts or pearls from your experience so far this year that you wanted to make sure we got down? Yeah, you know, I encourage everyone to look into Apple, the forensic organization, if they're interested in forensics. So many, you know, it's not too big of an organization and so many people are willing to mentor.

And there's such a wide variety of things to get into. If you're a careful analytic person that likes to solve puzzles, you know, it's a great field. And you don't have to give up general psychiatry in order to do forensics. You know, you can do a mix of both. So it's really a wonderful career, I think. Let me just add when you mentioned Apple, that's the American Academy of Psychiatry and Law. and the website is AAPL.org.

Nice. Well, we will wrap it up there. Thank you so much for your time. I really appreciate it. And just, yeah, thank you so much. Okay, my pleasure. Thanks.