An analysis of competency to stand trial: an integration of case law and clinical knowledge

In the past three decades competency to stand trial has emerged as a central issue in mental health law and forensic psychology. This article combines legal and clinical frameworks for a more integrated understanding of competency to stand trial. The legal framework focuses on Supreme Court decisions beginning with Dusky and reviews several legal theories of competence. The empirical framework is investigated within Grisso's (1986) conceptualization of legal competencies. In addition, the efficacy of specialized forensic assessments is evaluated, including the newly developed MacArthur Structured Assessment of the Competencies of Criminal Defendants (MacSAC-CD). The article concludes with observations of competency as a construct and their implications for forensic practice.

Differences in anxiety between first-time and multiple-time inmates: a multicultural perspective

The present study investigated differences in anxiety symptoms and associated features between 129 first-time and multiple-time male inmates from a large urban jail. Participants were assessed on three separate anxiety measures: the Structured Clinical Interview of DSM-III-R Disorders (SCID) anxiety disorders module, the State Trait Anxiety Inventory, and anxiety scales of the Personality Assessment Inventory (PAI). First-time inmates were found to have more symptom severity for Generalized Anxiety Disorder, especially symptoms related to scanning and vigilance. Both first-time and multiple-time inmates evidenced higher state than trait anxiety, although this pattern did not hold for African Americans. Contrary to previous research, few ethnic differences were found in this incarcerated sample.

Predictors of adolescent psychopathy: oppositional and conduct-disordered symptoms

Psychopathy is an important clinical construct in the evaluation and treatment of adolescent offenders. In this study, predictors of adolescent psychopathy are explored in 81 adolescents from a residential treatment program for dually diagnosed offenders. The number of aggressive conduct disorder symptoms and total rate (number x frequency of symptoms) of deceit/theft symptoms are predictive of adolescent psychopathy. Although age of onset for conduct disorder symptoms is associated with psychopathy, its interpretation appears to be confounded by gender and ethnicity correlates. Unexpectedly, adolescent psychopathy was only modestly associated with institutional infractions. Past research and current findings are summarized with reference to their forensic implications.

Construct validity of psychopathy in a female offender sample: a multitrait-multimethod evaluation

The authors examined the construct of psychopathy as applied to 103 female offenders, using the multitrait-multimethod matrix proposed by D. T. Campbell and D. W. Fiske (1959). Instruments used in the study included the following: (a) Antisocial Scale of the Personality Assessment Inventory (L. C. Morey, 1991); (b) Psychopathy Checklist--Revised (R. D. Hare, 1990); and (c) Antisocial scale of the Personality Disorder Examination (A. W. Loranger, 1988). Criterion-related validity was also evaluated to determine the relationship between psychopathy and staff ratings of aggressive and disruptive behavior within the institution. Results revealed significant convergence and divergence across the instruments supporting the construct of psychopathy in a female offender sample. The measures of psychopathy demonstrated moderate convergence with staff ratings of violence, verbal aggression, manipulativeness, lack of remorse, and noncompliance. It is interesting to note that an exploratory factor analysis of the PCL-R identified a substantially different factor structure for women than has been previously found for male psychopathy.

Active management of labor: does it make a difference?

OBJECTIVE

Our goal was to evaluate whether active management of labor lowers cesarean section rates, shortens the length of labor, and overcomes any negative effects of epidural analgesia on nulliparous labor.

STUDY DESIGN

We randomly assigned 405 low-risk term nulliparous patients to either an active management of labor (n = 200) or our usual care control protocol (n = 205). Patients who were undergoing active management of labor were diagnosed as being in labor on the basis of having painful palpable contractions accompanied by 80% cervical effacement, underwent early amniotomy, and were treated with high-dose oxytocin for failure to progress adequately in labor.

RESULTS

The cesarean section rate in the active management of labor group was lower than that of controls but not significantly so (active management, 7.5%; controls, 11.7%; p = 0.36). The length of labor in the active management group was shortened by 1.7 hours (from 11.4 to 9.7 hours, p = 0.001). Fifty-five percent of patients received epidural analgesics; a reduction in length of labor persisted despite the use of epidural analgesics (active management 11.2 hours vs control 13.3 hours, p = 0.001). A significantly greater proportion of active management patients were delivered by 12 hours compared with controls (75% vs 58%, p = 0.01); this difference also persisted despite the use of epidural analgesics (66% vs 51%, p = 0.03).

CONCLUSIONS

Patients undergoing active management had shortened labors and were more likely to be delivered within 12 hours, differences that persisted despite the use of epidural analgesics. There was a trend toward a reduced rate of cesarean section.

Detecting feigned depression and schizophrenia on the MMPI-2

Increasingly, investigations evaluating the effectiveness of the MMPI-2 in the assessment of malingering employ methodologies whereby research participants are asked to feigned specific disorders rather than just to "fake bad." Yet there is little research addressing the issue of whether different validity scales and indicators work differently in the detection of different feigned disorders. In this study the comparative effectiveness of a number of validity scales and indicators on the MMPI-2 to assess feigned depression and feigned schizophrenia were evaluated. Overall, the validity scales and indicators were better at detecting feigned schizophrenia than they were in detecting feigned depression, attributable, most likely, to closer familiarity with depressive experiences. The validity scales F, Fb, and F(p) best distinguish patients with schizophrenia from participants feigning schizophrenia, and F and Fb best distinguish patients with depression from participants feigning depression.

A pilot study of the Personality Assessment Inventory (PAI) in corrections: assessment of malingering, suicide risk, and aggression in male inmates

Provision of mental health services to correctional populations places considerable demands on clinical staff to provide efficient and effective means to screen patients for severe mental disorders and other emergent conditions that necessitate immediate interventions. Among the highly problematic behaviors found in correctional settings are forms of acting out (e.g., suicide and aggression towards others) and response style (e.g., motivations to malinger). The current study examined the usefulness of the Personality Assessment Inventory (PAI) in assessing problematic behaviors in a corrections-based psychiatric hospital. As evidence of criterion related validity, selected PAI scales were compared to (a) evidence of malingering on the Structured Interview of Reported Symptoms (SIRS), (b) suicidal threats and gestures, and (c) ratings of aggression on the Overt Aggression Scale (OAS). In general, results supported the use of the PAI for the assessment of these problematic behaviors.

Detection of feigned mental disorders on the personality assessment inventory: a discriminant analysis

Psychological assessment with multiscale inventories is largely dependent on the honesty and forthrightness of those persons evaluated. We investigated the effectiveness of the Personality Assessment Inventory (PAI) in detecting participants feigning three specific disorders: schizophrenia, major depression, and generalized anxiety disorder. With a simulation design, we tested the PAI validity scales on 166 naive (undergraduates with minimal preparation) and 80 sophisticated (doctoral psychology students with 1 week preparation) participants. We compared their results to persons with the designated disorders: schizophrenia (n = 45), major depression (n = 136), and generalized anxiety disorder (n = 40). Although moderately effective with naive simulators, the validity scales evidenced only modest positive predictive power with their sophisticated counterparts. Therefore, we performed a two-stage discriminant analysis that yielded a moderately high hit rate (> 80%) that was maintained in the cross-validation sample, irrespective of the feigned disorder or the sophistication of the simulators.

Feigning psychopathology among adolescent offenders: validation of the SIRS, MMPI-A, and SIMS

Clinical decision rules for the assessment of feigning and related response styles have not been systematically investigated in adolescent populations. For instance, evaluations of feigning on the Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A) involve cutting scores extrapolated from adult studies with the MMPI/MMPI-2. Such extrapolations are unwarranted because (a) adolescents perform differently than adults on MMPI/MMPI-2 validity scales and (b) the MMPI-A validity and clinical scales are substantively different than the MMPI/MMPI-2. Given the dearth of adolescent data, this study examined the clinical usefulness of three measures in the assessment of feigning: MMPI-A, Structured Interview of Reported Symptoms (SIRS), and Screening Index of Malingered Symptoms (SIMS). Employing a within-subjects analogue study on 53 dually diagnosed adolescent offenders, we found that commonly used MMPI-A scales (F, F1, and F2) were ineffective, but that F-K > 20 appeared promising. For the SIRS, classification of feigning based on adult criteria yielded moderate positive predictive poser and superb negative predictive power. As a screen, the SIMS proved to be moderately effective in identifying feigned protocols. Finally, two-stage discriminant analysis offered initial support of the incremental validity of a combined SIRS and MMPI-A evaluation of adolescent feigning.

Predicting aggressive and socially disruptive behavior in a maximum security forensic psychiatric hospital

The predictive utility of Hare, Hart, and Cox's Psychopathy Checklist Screening Version (PCL:SV) was assessed utilizing a sample of forensic psychiatric patients from Vernon State Hospital in Vernon, Texas. A sample of 55 patients were interviewed and rated on the PCL:SV. During a six month follow up, occurrences of self-harm (suicide attempts and self mutilation), aggression (verbal abuse and threats, irritability, belligerence, and fighting) escape potential (threats and attempts), and treatment refusal (medication, tests, and physician's appointments) were rated. Separate stepwise multiple regression analyses were performed utilizing patient's age, type of charges, documented history of alcohol/drug abuse and the PCL:SV as predictor variables. Results indicate that the PCL:SV is predictive of aggression and treatment noncompliance.

Syndrome of Type II Polyglandular Autoimmunity Associated with HLA-DR4 in a Large Kindred, Including HLA-DR3/DR4 Heterozygosity in the Probands, Identical Twins with Identical Manifestations

Autoimmune destruction and resultant failure of multiple organ systems constitute an uncommon entity known as type II polyglandular failure. Occasionally, the syndrome is familial, and in the kindreds studied, individual patients have manifested different sets of the associated diseases. We describe a large family in which the presence of HLA-DR4 was associated with development of this syndrome. More commonly, HLA-DR3 has been associated with type II polyglandular failure. The probands are monozygotic twin sisters in whom an identical set of autoimmune diseases occurred in the same order of onset and at approximately the same age. These data suggest that not only do specific factors predispose to this syndrome but also distinct factors determine which individual diseases are expressed.

Serial cardiorespiratory exercise testing in patients with congenital heart disease

Aerobic capacity of patients with different forms of congenital heart disease was serially evaluated in 79 patients and the evolution was correlated with the lesion and the level of daily activity. The patients were divided into six groups: patients with a small ventricular septal defect (VSD) with mini shunt (n = 14), mild pulmonary valve stenosis with gradient < 40 mm Hg (PS) (n = 12), mild to moderate aortic valve stenosis (gradient 36 +/- 17 mmHg) (AS) (n = 12), patients 4.7 +/- 2.1 years after repair of tetralogy of Fallot (PO-TF) (n = 16), patients 2.2 +/- 2.9 years after closure of a high flow/high gradient VSD (PO-VSD) (n = 13), and patients 2.6 +/- 1.7 years after Fontan repair (Fontan-PO) (n = 12). Aerobic capacity was assessed by determination of the ventilatory anaerobic threshold (VAT). VAT reflects the highest aerobic exercise level prior to a disproportionate increase of CO2 and ventilation relative to O2 uptake; it is independent of patient motivation. Data are expressed as percentage of normal O2 uptake at VAT, determined in 234 age/gender matched controls. The habitual level of physical activity was assessed by a standardised questionnaire. Aerobic capacity in all subgroups of patients, even with very mild defects, was at or below the lower limit of normal. Children left unrestricted from physical exercise (VSD, PS, PO-VSD) had no change over the study period. However, aerobic capacity of patients with medically imposed physical restrictions (AS) and significant residual haemodynamic lesions (PO-TF, Fontan) decreased with age.(ABSTRACT TRUNCATED AT 250 WORDS)

Initial validation of the Personality Assessment Inventory-Spanish version with clients from Mexican American communities

Psychological assessment of Hispanic populations are thwarted by the absence of clinical research on comparability of Spanish translations and the stability of their findings. In this study we examined the potential usefulness of the Spanish Personality Assessment Inventory (PAI; Morey, 1991) for Hispanic clients residing in Mexican American communities. We administered the Spanish version on two occasions to 48 monolingual clients and the Spanish and English versions to 21 bilingual clients. Results indicated that the clinical scales had a moderate to good correspondence for Spanish-English (M r = .72) and good test-retest reliability for Spanish-Spanish (M r = .79). Much more variation was observed for the validity scales and the treatment/interpersonal scales. Also more variability was observed in the convergence of elevations across administrations. Because of these mixed results, we discuss the potential usefulness of the PAI clinical scales to screen for major psychopathology.

Determinations of dangerousness in forensic patients: an archival study

The involvement of mental health professionals in determinations of dangerousness is both common and controversial. Among the various contexts for these evaluations, the release of potentially violent forensic patients from maximum security facilities evokes justified concern from involved experts and apprehension to outrage from the immediate community. We sought to examine how conclusions are reached on dangerousness at two sequential stages: clinical recommendations and Manifest Dangerousness Hearings decisions. In an archival study of 245 patients, we found that lack of progress in the institution and physical assaultiveness were the strongest correlates with dangerousness. In contrast, experts and review boards appeared to be relatively less influenced by diagnosis, types of treatment, and sociodemographic variables.

Reliability of subjective estimates of exercise capacity after total repair of tetralogy of Fallot

Sixty-nine patients (age 10 +/- 3.5 years, median 9.7 years) operated on for tetralogy of Fallot, underwent exercise testing 5.1 +/- 2.5 years after total correction. Aerobic capacity was assessed by the ventilatory threshold method. After the exercise test, parents completed a validated standardized questionnaire to evaluate the habitual level of physical activity of their child. They were then asked to place their child into one of three groups, describing their child's activity level, compared to normals (below average, average and above average). In the average and above-average groups, 73% and 65% of the patients were misclassified when compared to objective exercise testing. However, in the below-average group, no misclassifications were found. Subjective estimates of activity level, and consequently exercise tolerance, were poorly associated with objective measurements of exercise performance in these patient groups. Our results question the reliability of self-reported estimates of physical activity level and consequently exercise capacity in children after surgical correction of tetralogy of Fallot.

Detecting malingered and defensive responding on the MMPI-2 in a forensic inpatient sample

The purpose of this study was to examine the effectiveness of the various validity scales and indices on the MMPI-2 to detect malingered (fake-bad), and defensive (fake-good) responding. The entire sample consisted of 165 college students who completed the MMPI-2 under one of three conditions--fake-bad, fake-good, or respond honestly--and 173 forensic inpatients who completed the test as part of a routine evaluation. To detect faking-good and faking-bad, cutting scores for the validity scales and indices were established from the fake-good and fake-bad groups and were compared to the honest and patient groups. Corresponding sensitivity and specificity rates were then determined. Four validity indicators appeared to be moderately effective-at detecting fake-bad profiles: F, F--K, the MMPI-2 version of revised Gough Dissimulation Scale, and Wiener's Obvious-Subtle index, whereas the fake-good indicators were much less effective--only F--K and the Obvious-Subtle index appeared to have moderate utility.

Malingered and Defensive Response Styles on the MMPI-2: An Examination of Validity Scales

The MMPI and more recently the MMPI-2 have been held to be the clinical standard for assessing both fake-good and fake-bad response styles. In a contrasted-groups design, we compared simulators under fake-good (n = 67) and fake-bad (n = 58) instructions to controls (n = 90) and psychiatric patients (n = 95) under standard instructions. For fake-good profiles, we found that F-K < -12 had a hit rate of 80.6% and was partly supported by earlier research (Austin, 1992). For fake-bad profiles, F > 89 and F-K > 7 were the optimum cutting scores with hit rates of 86.2% and 87.0%, respectively. Unfortunately, previous research fails to confirm these cutting scores and leading proponents of the MMPI-2 substantially disagree on what methods to employ. Therefore, we recommend in cases of suspected malingering that the MMPI-2 be used only for screening purposes.

Classification of death in patients under antiarrhythmic treatment

In the evaluation of antiarrhythmic treatment, total mortality and total cardiac mortality are the only endpoints difficult to misclassify. End-stage cardiac failure competes with "suddenness" in many instances of sudden arrhythmic death. This observational study reports on 23 deaths in a group of 129 patients under antiarrhythmic treatment. In the 21 cases of cardiac death, with respect to the notion "sudden arrhythmic death," classification was problematic in 6 patients. According to different interpretations, the number of deaths listed as "sudden" could vary between one and six. A concise description of cause and circumstances of death, is presented.

Coordination of Cl- secretion and contraction by a histamine H2-receptor agonist in guinea pig distal colon

Short-circuit current (Isc) was measured simultaneously with muscle tension recorded in the longitudinal or circumferential axis from strain-gauge transducers sutured to the serosal surface of whole thickness segments of distal colon from guinea pigs. Isc and the amplitude and frequency of small-amplitude phasic contractions were stable for several hours. The histamine H2-receptor agonist dimaprit (5-10 microM) evoked recurrent increases in Isc at a frequency of 0.32-0.37 cycles/min. Associated with each cyclical Isc response was an increase in muscle tension indicative of large-amplitude phasic contractions. Recurrent cycles of Isc and associated large-amplitude phasic contractions were abolished by 10 microM cimetidine. In the presence of dimaprit, severing the neural connections between the myenteric and submucosal plexuses abolished the large-amplitude phasic contractions but not cyclical Isc. The results suggest that coordination of cyclical secretion and large-amplitude contraction during chronic activation of histamine H2 receptors requires intact neural connections between the submucosal and myenteric plexuses. The findings provide potential mechanisms to explain altered motility and ion transport during inflammatory diseases or allergic responses to food antigens.

Feigning specific disorders: a study of the Personality Assessment Inventory (PAI)

The Personality Assessment Inventory (PAI; Morey, 1991) represents an important development in the assessment of psychopathology. We examined the usefulness of the Negative Impression (NIM) scale to detect naive (undergraduates with minimal preparation) and sophisticated (psychology graduate students with 1 week preparation) subjects simulating specific disorders. We found that the NIM cutting score (> 8) was highly effective with feigned schizophrenia, marginally effective with feigned depression, and ineffective with feigned generalized anxiety disorder. Sophistication did not appear to be relevant to successful feigning, although it did allow graduate students to achieve higher clinical elevations in simulating depression.

Feigning schizophrenic disorders on the MMPI-2: detection of coached simulators

The Minnesota Multiphasic Personality Inventory (MMPI) and, more recently, its revised version (the MMPI-2) have represented the "gold standard" in the psychometric assessment of malingering and other response styles. In this study, we provide a stringent test of the MMPI-2 validity indices and their ability to detect feigned schizophrenia in four groups of simulators (n = 72). Simulators were randomly assigned to one of four conditions: (a) coached on symptoms of schizophrenia, (b) coached on strategies for the detection of fakers, (c) coached on both symptoms and strategies, or (d) uncoached. Simulators were compared to subjects responding under an honest condition (n = 13) and a comparison group of schizophrenic inpatients (n = 37). We found knowledge of strategies alone allowed many simulators (i.e., one third or more, depending on the validity indices) to elude detection. In contrast, knowledge of the disorder appeared less useful to simulators in avoiding detection. Coaching on both strategies and symptoms was not as effective as strategies alone. Consistent with previous studies, uncoached simulators were detected with moderately high levels of accuracy.

Screening psychiatric patients for Axis II disorders

This study examined the usefulness of the SCID-PQ on a sample of 82 inpatients as a screening measure for Axis II disorders. The SCID-PQ proved effective (i.e., resulted in a very low false negatives and moderate false positives) in screening for seven of the 11 DSM-III-R personality disorders. Of the four remaining disorders, minor modifications were suggested which resulted in improved classification rates for dependent and schizoid personality disorders.