The Prosecutor, March-April 2008, Volume 38, No. 2

A primer on mental health for prosecutors

2008

Prosecutors are one group in the criminal justice system that deals with mentally ill defendants. But most prosecutors know little about mental health. Here is a primer which discusses terminology and diagnosis.

 

Due to ignorance, fear, shame, or lack of insurance, funding, or programs, the criminal justice system has become one of the largest providers of mental health intervention and treatment in the country. Police officers are often first responders to a mental health crisis, and prisons and jails have become de facto mental health treatment facilities—even judges, probation officers, and parole officers have had to address mental health needs.

Prosecutors are an integral part of this new frontline mental health treatment team and must be aware of mental health issues to properly evaluate and dispose of cases. In this article, you’ll learn the basics of mental health terminology and diagnosis and how to read mental health reports. A second article (to be published in a later issue) will cover treatment and medication. This article is only a primer, and I hope you want to learn more. If so, just head down to your local Barnes & Noble and poke around the psychology or science section, or surf the internet. A reference list is provided at the end of this article.

Brain basics

There are myriad theories about the causes of mental illness. Suffice it to say that we’re born with certain characteristics and shaped by our environments—think of it as nature and nurture rather than nature versus nurture. Chemicals (i.e., neurotransmitters, hormones, etc.) in our bodies impact our moods, thoughts, and actions. For instance, dopamine regulation is a problem for people with ADHD. So, one of the most effective treatments for ADHD is a medication that targets dopamine. Perhaps we were born with the inability to learn past a certain point (mental retardation) or maybe we have an Einsteinian brain. Some of us may be so in-tune with non-verbal communication that we seem psychic. Others have difficulty interpreting and responding to emotions and social cues (a symptom of autistic disorder).
Our brains are use-dependent, which means we form new connections depending on how we use our brains (brain plasticity). For instance, birth to age 3 is a critical time for forming brain connections. That’s why kids exposed to repeat trauma during this time, such as witnessing domestic violence, are at an increased risk for psychological problems.
Age and development are important in evaluation and treatment. Brains of children and juveniles are not developed like adults in areas of reasoning and impulse control. Many of us cringe at the impulsive things that we did as teenagers. Without excusing our behavior, science can now tell us that said behavior might have been due to our immature teenaged brains. The older adult brain is subject to changes related to aging, such as dementia.
Substance abuse is a complicating factor in diagnosis and treatment. Sometimes people self-medicate when they have a mental illness, are under stress, or are exposed to trauma. It doesn’t usually work. For instance, alcohol is a depressant, and it can increase depression symptoms. Methamphetamine abuse can look like the symptoms of a mental health disorder (paranoia, sleeplessness, and agitation). If a history prior to the substance abuse can be obtained, a provisional diagnosis may be made. The best diagnosis is made once a client is detoxed.

Common symptoms and terms

Following are some symptoms and terms that will help prosecutors understand diagnosis and mental health reports:
Anxiety: the overwhelming concern about something bad happening. Unrelenting anxiety can turn into depression.
Appearance: verbal and non-verbal communication, physical appearance, body movement, and demeanor.
Compulsion: the intrusive and disruptive need to “do something.” “I must turn off the light switch three times before I leave the room.”
Cognition: the ability to think and be aware.
Delusion: a strongly held false belief, not accounted for by culture. “When I see a yellow car, that means the FBI is following me.” A bizarre delusion is implausible. The people in the yellow cars are actually from a distant star. A grandiose delusion is one in which a person has an inflated sense of self-worth, position, or power. “I am the best prosecutor in the entire world.” There are delusions in which a person thinks others can hear her thoughts or insert thoughts into her brain.
Dementia: This isn’t usual forgetfulness but rather a progressive symptom often associated with Alzheimer’s disease or old age. A person can lose her memories and control of thoughts, behaviors, or moods. Dementia can be caused by disease, head trauma, or substance ingestion (i.e., inhalant abuse). Delirium is also a change in cognition but occurs briefly and suddenly.
Depressive episode: a period of at least two weeks during which there is either a depressed mood or a loss of interest or pleasure in nearly all activities, plus at least four of these symptoms: changes in appetite or weight, sleep, and psychomotor activity; decreased energy; feelings of worthlessness or guilt; difficulty thinking, concentrating, or making decisions; or recurrent thoughts of death or suicidal ideation.
Executive functioning: higher (frontal lobe) brain functions including reasoning, ordering, analyzing, decision-making, and impulse control.
Environment: We must be culturally competent, which means we consider the norms and values of a person’s culture. We also consider gender, socioeconomic status, family, trauma exposure, religion, age, education, occupation, ethnicity, and life experiences.
Factitious disorders: A person fakes an illness in himself or another because he likes the attention of being sick. An example is Munchausen’s by Proxy, which could be an attention-seeking mother who induces her child to be sick.
Hallucination: a perception of any of the senses that is false. A person with an auditory hallucination may hear a voice that taunts and criticizes her. A visual hallucination is seeing something that isn’t there. These hallucinations are real to the sufferer because his brain tells him it is real.
Intelligence: a measure of mental capacity. There are different types of intelligence (i.e., emotional, social, artistic, spatial, etc.) but generally we consider IQ score, which is usually a measure of verbal, math, general knowledge, and reasoning ability. High intelligence and the presence of a mental illness are not mutually exclusive. For instance, Dr. Kay Redfield Jamison, Ph.D., is a brilliant psychologist who has bi-polar disorder. Her personal experiences make her writings particularly authentic.
Malingering: faking an illness for an external gain, such as a person who pretends to be mentally ill to avoid criminal charges. Collateral information and careful observation are important in discovering malingering. Even mental illness follows patterns, so when people fake it, they tend to overact.
Manic episode: at least one week during which a person displays an abnormally and persistently elevated, expansive or irritable mood, plus at least three of the following: inflated self-esteem or grandiosity, decreased need for sleep, pressure of speech (chatterbox), flight of ideas (can’t stay on one subject), distractibility, increased involvement in goal-directed activities or psycho-motor agitation, and excessive involvement in pleasurable activities with a high potential for painful consequences. For example, this person may make rash, impulsive decisions, such as charge up thousands of dollars in credit card debt or quit her job when she gets mad at a coworker.
Mental Status Exam: an exam that ascertains a person’s emotional, cognitive, and mental condition.
Mood: how a person feels over a long period of time (i.e., sad, happy, indifferent, angry, etc). Affect is the external expression of how a person feels, such as facial expression.
Neurotransmitter/hormones: chemicals that impact our mood, behavior, and cognition.
Obsession: an intrusive, persistent thought or impulse.
Personality Disorder: a shorthand way for mental health workers to describe a set of maladaptive, long-term, and ingrained personality characteristics. There are 11 personality disorders. A person with an Anti-Social Personality Disorder routinely hurts people and doesn’t feel remorse. You may know this person as a sociopath or psychopath. It’s more complicated than that, but you get the idea. The others are: Paranoid (suspicious), Schizoid (detached), Schizotypal (eccentric and odd, not in a good way), Borderline (impulsive, high-maintenance, likes drama), Histrionic (drama queen); Narcissistic (“I am the center of the world and smarter than you”), Avoidant (“Stop looking at me”), Dependent (clingy), Obsessive-Compulsive (“Stop moving my things; I must have them that way”), and Personality Disorder, Not Otherwise Specified (something is wrong but doesn’t meet the criteria for a specific personality disorder).
Psychotic episode: This is a “know when you see it” kind of thing, when a person really loses it. He has active hallucinations or delusions, may babble incoherently, and has generally lost touch with reality. Psychosis can be caused by trauma; an organic brain problem, such as schizophrenia; or substance abuse. We think of psychosis as most associated with schizophrenia, but it occurs with depression and other disorders.
Phobia: an intrusive, persistent fear.
Self-Awareness: how much a person understands how they appear to others. For instance, someone with Narcissistic Personality Disorder might believe he is the smartest man ever. The rest of us just think he’s a jerk. The clinician’s challenge is to help the client understand there is a problem.
Shame: According to social worker Dr. Brene Brown, shame is the debilitating feeling of being “flawed” and “unworthy.” Shame prevents people from getting help and is different from guilt, which is remorse for doing something wrong. Dr. Brown says we can’t shame people into change. Regrettably, I’ve tried it, and it doesn’t work. People do need straight talk, but coupled with compassion, respect, and empathy.
Substance abuse and substance dependence: Substance abuse is the use of a brain-altering substance over a 12-month period that negatively impacts a person’s life but doesn’t dominate it. For example, a person has a good job and an intact family, but after receiving a DWI argues repeatedly with his spouse and friends about his drinking. Substance dependence is more serious. A person needs an increased amount of the substance (she has built up tolerance), and a great deal of time and energy is spent getting it. She can’t stop drinking even though she is facing a felony DWI charge, her husband left her, and she lost her job. This woman knows exactly how many beers are in the refrigerator at any given time.
Suicide: a byproduct of untreated or improperly treated mental illness. Psychologist Dr. Kay Redfield Jamison, who has written extensively about bi-polar disorder and suicide, says that people see suicide as a solution to ending suffering.

Thought content: what dominates a person’s thoughts. For instance, does he have paranoid, persecutory, sad, anxious, desperate, or suspicious thoughts? Does she have any obsessions or phobias? Is he self-absorbed?

 

The DSM-IV

In the early 1950s, mental health professionals agreed to common language and guidelines for defining mental illness and created the DSM, Diagnostic and Statistical Manual of Mental Disorders. We’re on the fourth edition, including revisions, so it’s often called DSM-IV. The DSM is designed for use by trained clinicians; it isn’t a “Cosmo Quiz” to be used by non-clinicians to self-diagnose. Prosecutors can use it as a reference tool in trial for questioning experts.
Diagnosis is primarily done based on evaluating the type, duration, and severity of symptoms. We consider a client’s appearance, affect, mood, cognitive abilities, thought content, and environment. Information is often gained by self-report, which can be unreliable. Clients may be given tests, such as the MMPI (Minnesota Multiphase Personality Inventory, which is designed to identify personality problems) or the Beck Depression Inventory (which measures depression). Collateral information, such as criminal records, medical history, or information from family, friends, or teachers, can be gathered. It is important to identify medical issues that can impact mental health, such as diabetes and thyroid problems.
Major mental health diagnosis includes the following categories:

Mood disorders

Major Depressive Disorder: one or more major depressive episodes that are disruptive in major life areas. Dysthymic Disorder is a low-level depression that lasts for over two years. Bereavement is a normal period (less than two months) of sadness after a major loss, such as the death of a spouse.
Bi-Polar Disorder: alternating or mixed episodes of depression and mania, formerly called “manic-depression.” A person in the manic phase might feel like she is the best in her profession, that no one in the history of her profession has ever been as good. She talks non-stop to everyone, sleeps four hours a night, makes plans and promises she cannot keep, and generally overwhelms everyone around her. During the depressive stage, she feels like the worst of her profession. She feels stupid, worthless, and powerless. She sleeps 16 hours a day and sometimes thinks she should just end her pain by killing herself.
Substance Induced Mood Disorder: a mood disorder caused by a substance, such as alcohol or cocaine. For example, the police respond to a call in which a man is reported to be aggressive, paranoid, and angry. He could be experiencing the impact of cocaine abuse, or he could have a mood disorder. The key is looking at whether the symptoms started before or after the substance abuse.

Psychotic disorders

Schizophrenia: a psychotic disorder that includes positive symptoms (hallucinations, delusions, and disorganized speech) and negative symptoms (severely limited emotional expression, lack of energy, and poverty of speech) that last for more than six months. Schizophreniform Disorder lasts from one to six months. Sometimes people erroneously equate schizophrenia with “multiple personality disorder” (a controversial diagnosis that is now called Disassociative Identity Disorder). The homeless man with the matted hair who talks to an unseen person is an example of a person who may have schizophrenia. Another example is the main character in the movie, A Beautiful Mind.
Schizoaffective Disorder: a combination of schizophrenia and a mood disorder, such as Major Depressive Disorder.

Anxiety disorders

Because we work with crime victims, the most common anxiety disorder we probably see is post traumatic stress disorder (PTSD), which is a reaction to extreme stress or trauma. Symptoms include intrusive thoughts about the traumatic event, loss of concentration, agitation, and depression. A person with PTSD may cope by becoming divorced from her emotions. You can probably think of a crime victim who recounted a horrific incident with no emotion. Other common anxiety disorders include panic disorder, panic attacks, generalized anxiety disorder, phobias, and obsessive-compulsive disorder.

Disorders of childhood

Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD): ODD is an abnormal pattern of defiant, negative, or hostile behavior lasting six months or more. CD is a more severe form of ODD, which includes hurting themselves or others and property destruction.
Mental retardation: an IQ score of 70 or below, impairments in functioning, and onset before age 18.
ADHD: Attention Deficit Hyper-Activity Disorder, formerly known as ADD. People with ADHD have executive functioning problems, such as impulse control, stimulus processing, and ordering (“Should I do this first or that?”). It isn’t that they can’t concentrate on one thing, it is the inability to not pay attention to everything. For instance, a kid with ADHD can’t focus on her test because she can’t ignore the boy next to her who drops his pencil, the person who walks by the door, the ticking of the clock, or the teacher shifting in her chair.
Pervasive Developmental Disorders: disorders that include impairments in verbal and non-verbal communication, social interaction, thinking, and behavior. Examples include autistic disorder and the less restrictive Asperger’s disorder.

Other disorders

Other disorders we might see are substance abuse disorders, personality disorders, malingering, and factitious disorders (all described above), impulse control disorders (i.e., kleptomania, gambling, hair-pulling), and eating and body dysmorphic disorders (anorexia and bulimia).

Reading a mental health report

Armed with this background, you’re ready to read mental health reports. They are written in a standard format with uniform language, codes, qualifiers, and shorthand language.1 The reports are often in a format called a multiaxial assessment report, which contains five areas of evaluation. Sometimes narratives are included with the multiaxial assessment, or the report may be narrative only.
Following are the five axes in the multiaxial assessment:
Axis I: clinical disorders, except mental retardation and personality disorders. This includes mood, psychotic, development, and learning disorders. Common Axis I disorders include depression, bi-polar, schizophrenia, ADHD, and anxiety disorders.
Axis II: mental retardation and personality disorders. Persistent maladaptive personality features can also be noted here. Examples include borderline personality disorder or severe mental retardation.
Axis III: other medical conditions that impact mental health, such as cancer or heart disease.
Axis IV: Psychosocial/environmental issues that impact mental health. i.e. problems with family, support systems, unemployment, domestic violence, housing problems, etc.
Axis V: GAF, Global Assessment of Functioning, a numerical score that gives an indication of the severity of problems and the presence or absence of systems and/or degree of overall functioning. The scale is 1 to 100, with 1 as the worst and 100 the best. The midpoint is 51 because moderate problems start here. Serious problems are captured at 50 and below.

Sample diagnosis

A 24-year-old Hispanic female accountant presents as a voluntary patient in a psychiatric hospital. She has been sleeping 16 hours a day, not taking care of basic hygiene, and feeling hopeless, sad, and overwhelmed.  She was quiet and appeared timid and unsure of herself. Her affect was blunted. She did not display any psychotic symptoms and was oriented to time and place. She reports she was sexually assaulted for several years as a child. She recently left her home because her boyfriend was violent with her. She has used cocaine three times during the past year and has a criminal charge pending for cocaine possession. She has diabetes and was treated in the past for major depression, but she stopped taking her medication because she didn’t like the sexual side effects. She has had thoughts of suicide but no plan, and she reported she hadn’t ever really considered it.

Axis I     296.3x Major Depressive Episode, Recurrent
            309.81 Post Traumatic Stress Disorder, Chronic
            305.60 Cocaine Abuse

Axis II    Deferred

Axis III    Diabetes

Axis IV    Legal problems, facing criminal charges,
Previous sexual abuse, domestic violence

Axis V    GAF: Current 45; highest during past year: 70 

Conclusion

The next article will discuss types of treatment, including types of medication, and treatment providers. I hope this information helps in your work and that you learn more about this topic. In today’s world, all of us need to be more of a “hybrid” professional. Being a clinical social worker in a district attorney’s office, I have had to learn about legal and law enforcement issues to be effective. Similarly, having a greater understanding of mental illness will help you be able to handle today’s issues as prosecutors.

Endnote

1 Qualifiers and shorthand language include: mild, moderate, and severe; in partial or full remission, prior history, recurrent; NOS (Not Otherwise Specified) meets the general criteria, but need more information; Rule-Out: some criteria met, but need more information; Deferred: can’t make a diagnosis on this Axis; V-Codes: areas of clinical focus that do not meet the criteria for another disorder, i.e., relational problems, abuse or neglect, life adjustment problems; With Psychotic Features Disorder includes psychotic features.

Referrals and references

Child Trauma Academy at www.childtraumaacademy.org. Best website for information about how trauma impacts a child’s developing brain and what can be done about it.

NAMI, National Alliance for the Mentally Ill at www.nami.org. A great consumer organization for mental health issues. You can sign up to receive e-mail updates when they have new information.

NIMH, National Institute of Mental Health at www.nimh.gov. Find the latest research on mental health issues.

Public Broadcasting Service at www.pbs.org. Search for “mental illness” or “brain” or related topics. There are many good online free videos.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. Washington, D.C.: APA; 2000.

Andreasen, N. Brave New Brain: Conquering Mental Illness in the Era of the Genome. New York, NY: Oxford University Press; 2001.

Brown B. Women and Shame: Reaching Out, Speaking Truths & Building Connection. Austin, Tex: 3C Press; 2004.

Carter, R. Mapping the Mind. Los Angeles, CA: University of California Press; 1999.

Earley, P. Crazy: A Father’s Search Through America’s Mental Health Madness. New York, NY: G.P. Putnam’s Sons; 2006.

Jamison, K.R. An Unquiet Mind: A Memoir of Moods and Madness. New York, NY: Alfred A. Knopf; 1995.

Jamison, K.R. Night Falls Fast: Understanding Suicide. New York, NY: Random House; 1999.

Johnson, S. Mind Wide Open: Your Brain and the Neuroscience of Everyday Life. New York, NY: Schribner; 2005.

Shorter, E. A History of Psychiatry: From the Era of the Asylum to the Age of Prozac. New York, NY: John Wiley & Sons; 1997.

Siegel, DJ. The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are. New York, NY: Guilford Press; 1999.

Warwick, L and Bolton, L. The Everything Psychology Book: Explore the Human Psyche and Understand Why We Do the Things We Do. Avon, MA: F+W Publications; 2004.

Zimmerman, M. Interview Guide for Evaluating DSM-IV Psychiatric Disorders and the Mental Status Examination. East Greenwich, RI: 1994.