PROF MAURICE M4 Assignment 2: Diagnostic Case Reports

Schizophrenia and Psychotic Disorders

Individuals with psychotic disorders are characterized by irrational, bizarre beliefs (delusions) and perceptual disturbances (hallucinations). Although these disorders have a relatively low prevalence, they account for a large portion of the costs of mental health care. These disorders start in early adulthood, are relatively chronic, and last an entire normal adult lifetime. Many individuals with schizophrenia are severely impaired and often unable to work or care for themselves. Many of the individuals with schizophrenia are homeless and are entangled in the criminal justice system due to the lack of community resources to treat them. Defendants who are successful with the insanity defense typically have a history of suffering from a severe and persistent mental illness, usually schizophrenia.

As a forensic mental health professional, two major reasons that increase your likelihood of interacting with individuals with schizophrenia are criminal behavior and suicide, as individuals with schizophrenia are at increased risk of both. Individuals with schizophrenia are more likely to commit suicide than individuals with any other diagnosis. As a forensic mental health professional, you should learn about the risk factors for suicide and suicide prevention skills.

Refer to the Webliography section to learn more on suicide prevention.

The issue of severe and persistent mental illness poses important ethical and legal questions. For example, is it ethical and legal to force people to take medications? Many of the antipsychotic medications have unpleasant side effects, some of which can be irreversible, such as tardive dyskinesia. Tardive dyskinesia is an extrapyramidal symptom that involves involuntary movements of the face, mouth, tongue, or jaw. This can cause difficulty in speaking and eating for the patient. Other ethical concerns are involuntary hospitalization and the placement of individuals with severe and persistent mental illness among the general prison population.

Psycholegal Issues

As a forensic health professional, it is important for you to understand the psycholegal issues of competency to stand trial and the insanity defense, both of which involve individuals with psychotic disorders (mental illness).

For example, the Supreme Court has ruled that individuals who cannot understand the punishment that they might receive or the reasons for it cannot be executed. Thus, in the United States, a person with severe mental illness cannot be executed if found incompetent to stand trial. There have been cases of mentally ill individuals on death row who have been found incompetent to be executed (not competent to receive the death penalty). In such instances, the role of the state is to return the person to competency in order for the individual to be executed since it can be assumed that the individual was competent at some time. If the person had been found incompetent, he or she would not have gone to trial. The Supreme Court has ruled that competency is competency regardless of why competency is being considered. Thus, the same standard is applied to competence to stand trial, competence to waive counsel, and competence to be executed. The question is whether an inmate sentenced to death can refuse treatment that would return him or her to competency. Additionally, what is the role of the forensic mental health professional? Should the mental health professional work to return an inmate to competency?

Some of these psycholegal issues have complicated ethical issues that also involve the practitioners' professional and personal values. The practice of forensic mental health has many ethical and legal pitfalls. It is important to continue to seek education and consultation in these areas.

Attention Deficit Hyperactivity Disorder

ADHD, which is no longer referred to just as attention deficit disorder, is a condition of attentional difficulties. Individuals with ADHD are able to pay attention to things around them, but they have a great deal of difficulty discerning what to pay attention to and what not to pay attention to, which results in them paying attention to too many things at once rather than just to relevant stimuli. In other words, people with ADHD are not good at screening out unimportant information around them. For example, a child in a classroom might pay attention to how fast he can twitch his foot for a while without paying attention to what the teacher is saying.

While boys are diagnosed with ADHD at about twice the rate of girls, it is believed that ADHD is underdiagnosed in girls and perhaps overdiagnosed in boys. The challenge with properly diagnosing girls with ADHD is that girls tend to have a predominately inattentive presentation whereas boys tend to have a predominantly hyperactive/impulsive presentation. Essentially, girls with inattentive ADHD go unnoticed because they are not a behavioral problem in the classroom. Conversely, boys with hyperactive/impulsive ADHD are almost impossible not to notice. Although ADHD is usually diagnosed in childhood, it can be diagnosed in adulthood as well.

While ADHD is not in and of itself linked to criminal behavior, the impulsivity aspect of it might be in that individuals with ADHD might have a hard time thinking through the consequences of any illegal behavior. Further, in a correctional setting, individuals with ADHD will likely have difficulty following directions, particularly directions that are given to a group rather than individually or directions with multiple steps.

Aggression in Childhood and Adolescence

As a forensic mental health professional, two disruptive disorders of childhood that you will probably see are oppositional defiant disorder and conduct disorder, due to the aggressive behaviors that are associated with them.

Of the two, oppositional defiant disorder, which is usually diagnosed in children under the age of twelve years, is less severe as it centers on verbal aggression and noncompliance with adults rather than criminal behavior. However, conduct disorder does involve criminal behavior such as physical aggression, theft, vandalism, or truancy. Unlike conduct disorder, which is a criterion for an adult diagnosis of antisocial personality disorder, oppositional defiant disorder is not a criterion for conduct disorder. Similarly, just as conduct disorder does not necessarily lead to antisocial personality disorder, oppositional defiant disorder does not necessarily lead to conduct disorder.

Impulse Control Disorders

The term “impulse control disorder” describes conditions that occur due to an irresistible impulse to engage in the problematic behavior. Intermittent explosive disorder (aggressive outbursts), kleptomania (shoplifting), and pyromania (fire setting) each have in common an irresistible urge to carry out the behavior despite knowledge of the adverse consequences that often result. They each experience excitement and pleasure while contemplating or carrying out the problematic behavior.

Consider the following case example:

Juan is a fourteen-year-old male who lives with his mom and two brothers (aged twelve and sixteen years). Juan is in the eighth grade and does not like school. His mom works two part-time jobs to be able to afford food and rent for her three kids, which means that she is often not at home. Juan has very few friends and was recently kicked off the community soccer team for repeatedly not showing up to practice. His mom cannot drive him to practice, and the two buses that are needed to get there take over an hour. Juan’s older brother recently began smoking, and when Juan was offered a cigarette, he declined. However, he was intrigued by how his brother lit the cigarette, and he secretly took his brother’s matches. The next day, he played a game with the matches by lighting them in his room and dropping them in an empty soda can. A few days later, he burned a paper that was a failed test from a class that he did not like. He was a bit worried that the fire would spread, but he was able to put it out by smothering the burning paper with one of his shirts. He threw the burnt shirt away without anyone knowing and hoped it would not be missed. He found the fire exciting, and he felt powerful that he was able to start it and then put it out. Days later, he lit a small fire in his bedroom that burned some of the wood on the floor. This time, it set off the smoke detector in their apartment and his older brother had to come in to help him put it out. Juan’s mom was not home at the time, and Juan asked his older brother to keep the fire a secret in exchange for him not telling about his older brother’s smoking. His older brother agreed and warned Juan to “not burn the place down.” The following week, Juan lit a fire in a garbage can in a bathroom at school. The fire department was called to extinguish it. It was readily apparent that the fire had been intentionally set. Security cameras in the hallway of the school later identified Juan as the culprit. The next day, Juan was suspended from school, charged with arson, and brought to the local juvenile detention facility. When his mom was notified of his arrest and detention, she was shocked and had no knowledge of any of his fire-setting behavior.

While kleptomania, pyromania, and intermittent explosive disorder are often seen in adolescents, they are not disorders that are exclusive to youth, as adults can have them as well. Further, a diagnosis of any of these three disorders is not a criterion for having them as an adult. In other words, it is possible to develop these disorders in adulthood without having exhibited any such behaviors during adolescence. In adults, intermittent explosive disorder is often referred to as the adult version of “temper tantrums” since the reaction that is displayed in the angry outbursts is quite extreme for a given situation, such as screaming at an employee at a fast-food restaurant because the order was not completed properly.

Pyromaniacs (arsonists) are actually considered among the most dangerous of offenders due to the potential for significant loss of life that fire setting can cause. In fact, the penal system views fire setters as equivalent to mass murderers. Alternatively, kleptomaniacs (shoplifters) are usually not dangerous at all. Additionally, kleptomania is irrespective of social status, which means that a kleptomaniac could be impoverished or wealthy. Many who engage in compulsive theft do not do so out of a need for the items that they take. Often, the items are kept but not used or even sold for profit. They steal simply for the “thrill” of getting away with it. When these individuals are caught, they are often given probation and their prison sentence, if any, is generally brief since they are nondangerous offenders.

Conclusion

Psychotic disorders are the very definition of mental illness. For example, someone with depression, anxiety, or a personality disorder is not considered mentally ill. Rather, the person has a psychological disorder or condition. In other words, someone who only has depression, anxiety, or a personality disorder is not going to have issues with competency to stand trial or insanity if charged with a crime. Only individuals who are mentally ill, typically the severely and persistently mentally ill (SPMI) population, have issues related to competency or insanity. Another important clarification is the distinction between mental illness and intellectual disability (formerly called mental retardation). Someone with an intellectual disability has a low level of intelligence, and, for that reason, he or she may have issues with competency to stand trial or insanity.

However, having an intellectual disability and being mentally ill are not the same. To be diagnosed with an intellectual disability, the individual must be identified as having it sometime during childhood, because an intellectual disability is not a condition that would begin in adulthood unless it occurred due to a significant head injury in adulthood, known as traumatic brain injury (TBI). It is important to know the intellectual disability criteria, as offenders may attempt to feign low levels of intelligence in order to attempt to evade responsibility for their charges. This behavior is known as malingering, and every forensic mental health professional is likely to encounter it at some point in his or her career. In fact, offenders may also attempt to feign mental illness in an attempt to avoid accountability for their charges. In either case, it is essential to detect when malingering is occurring so that offenders are not able to successfully manipulate the criminal justice system.