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| | Paranoia / Delusional Disorder in Law and Psychiatry | | 2005-3-8 23:35:24 2005 Beijing WPA-CSP Workshop Alan A. Stone, M.D. |  The History of Paranoia/Delusional Disorder *
1) Internal causes Kraepelin
Rare subset of
Dementia Praecox
2) Insidious onset
3) Lasting unshakeable Delusional system
4) Clarity in other respects
5) Does not deteriorate
Gaupp Freud
(classic case history) Psychodynamic
Ernst Wagner multiple murderer Explanation of Paranoia
(note Wagners Delusional
system changed)
* This history ignores the French and Scandinavian contributions to the literature.
II.
Psychodynamic Explanations
Paranoid Spectrum
Paranoid Schizophrenia Paraphrenia
Paranoid Paranoia Paranoid
State Personality
Transitions in the Paranoid spectrum caused by stress and other factors.
(Dimensional vs. Categorical)
Nosology
III.
The Move Back Toward Kraepelin in the U.S.A.
Winokur (1977)
Creates the Diagnostic category Delusional Disorder with subtypes
Kendler
Genetic studies indicate Paranoia/Delusional Disorder is distinct from Paranoid Schizophrenia
Munro (Canadian)
Emphasizes somatic subtype (delusions of infestation)
• DSM IIIR, IV and IVR
• Emphasize nonbizarre nature of Delusions to distinguish from schizophrenia
• But "bizarreness may be difficult to judge especially across different cultures" and "an individuals cultural and religious background must be taken into account in evaluating the possible presence of Delusional Disorder"
• Though rare (prevalence .03%) Delusional Disorder (or paranoid spectrum) is common in controversial cases and in forensic psychiatry.
IV. AN ILLUSTRATIVE CASE
1. Sirhan Sirhan assassinated Robert F. Kennedy during his 1968 campaign to be elected President of the U.S.A. Why?
2. Forensic experts for Sirhan and the government (two leading forensic psychiatrists of the time) testify at the trial.
3. Sirhans psychiatrist diagnoses Paranoia (?schizophrenia – paranoid spectrum) and asserts not guilty by reason of insanity.
4. Governments psychiatrist testifies Sirhan is a Palestinian patriot who killed Kennedy because "he was a friend of the Jews".
5. Sirhan in open court agrees with the government psychiatrist and states "I did it for my country (Palestine)."
6. Jury agrees with the government psychiatrist and finds Sirhan guilty. Judge imposes sentence and Sirhan remains in prison to this day.
7. 1973 Palestinian patriots / terrorists take 2 American officials hostage in Sudan and demand Sirhans release. When refused they execute their hostages.
V. IMPORTANT ISSUES ILLUSTRATED BY THE SIRHAN CASE
1. The line between political fanaticism and mental disorder may be difficult to define. "Where in the rainbow do the colors change."
2. Forensic psychiatrists in the U.S.A. testify for one side or the other in the adversarial system of the court room.
3. American law does not rely on the scientific expertise of psychiatry. It relies on its own adversarial system and cross examination by lawyers to get to the truth.
4. American law rejects legal systems in which the court appoints a panel of expert psychiatrists to decide the issue without the intervention of lawyers (as in the former Soviet Union).
5. The profession of forensic psychiatry in America is shaped by the legal system. There is no tradition of leading forensic psychiatrists working in prisons and jails. Their main function is providing expert testimony to courts and to administrative agencies.
6. The ethics of forensic psychiatrists in America primarily focus on their role as providers of expert testimony.
7. In many cases forensic psychiatrists disagree about diagnosis and other matters. This despite the fact that they are well trained, are sworn to tell the truth, and their ethics emphasize honesty.
8. Lawyers will not employ experts whose testimony does not advance their side of the case.
VI. THE POLITICAL COLD WAR CASES INVOLVING THE DIAGNOSIS OF PARANOIA/DELUSIONAL DISORDER: SOVIET DISSIDENT.
1. General Grigorenko: Openly criticizes Soviet government; charged with crimes against the State and arrested. Soviet Unions leading psychiatrists (e.g. Shnezhnevsky) diagnose Kraepelins true paranoia, confined to a special security facility (Serbsky Institute) equivalent to an American institution for the criminally insane or a Chinese Ankang Facility.
2. When does political protest become a symptom?
A. Answer of Soviet psychiatrists at Serbsky: when the person is grandiose, self- important, has fixed ideas, and bad judgment. Grigorenko crossed that line.
B. Answer of Soviet Dissidents: Grigorenko is a great man who had the courage to criticize the corruption in his government and the cult of personality as departures from the principles of Marx and Lenin. His beliefs were widely shared.
C. Answer of psychiatric evaluation in the U.S.A.: no symptoms of Paranoia or Paranoid Spectrum.
VII. THE POLITICAL COLD WAR CASES INVOLVING THE DIAGNOSIS OF PARANOIA/DELUSIONAL DISORDER: AMERICAN DISSIDENT.
1. General Walker openly criticized President Kennedy and his government for being soft on Communism and for forcing integration of black and white races. Charged with crimes against the State and arrested. Americas leading forensic psychiatrists (e.g Guttmacher) reviews material provided by the Attorney General and suggest that Walker is probably a Paranoid and should be confined in a psychiatric hospital for a 40 day evaluation. American newspapers headline "General Walker said to be Mentally Ill."
2. When does political protest become a symptom?
A. Answer of American psychiatrists: when the person is grandiose, self-important, has fixed ideas and bad judgment. Walker crossed that line.
B. Answer of Right Wing Americans: Walker is a great man who had the courage to criticize the Kennedys and assert traditional American values.
C. Walker was released in 1 day not because of the wisdom or ethics of other psychiatrists but because of legal protections.
D. A psychiatrist in his home state of Texas found no symptoms of Paranoia or Paranoid Spectrum Disorder.
E. Walker subsequently ran for governor of Texas but lost.
Note: Neither Shnezhnevsky (U.S.S.R.) nor Guttmacher (U.S.A.) believed they had done anything unethical.
VIII. THE LESSONS OF THE COLD WAR CASES
1. Widely shared beliefs even if repugnant and irrational to a psychiatrist should not be considered sufficient to establish a diagnosis that has legal significance. i.e. justifying involuntary confinement or treatment.
2. The fact that a person initiates or takes part in public political protest even when contrary to self interest should not be considered sufficient to establish a diagnosis that has legal significance.
3. As General Grigorenko reminded me it was one of Americas founding fathers who said "give me liberty or give me death."
4. Soviet and American psychiatrists were in my opinion influenced by their own convictions and by their deference to important government officials.
5. Allegations about political misuse of psychiatry aroused intense reactions in the West all during the Cold War.
6. Robin Munro, a British Human Rights activist, has recently manipulated that same reaction. Although he knows almost nothing about forensic psychiatry or psychiatry in China he is now recognized in Europe and the U.S.A. as the leading authority on the abuses of psychiatry in China.
7. Munro has been honored by the A.P.A. and his work has been the basis of most of the complaints made to the W.P.A. As I have written "it is an account so flawed and misleading that it cannot and should not be relied on as evidence" (Stone 2004).
IX. CULTS/SECTS IN THE U.S.A. (THE BRANCH DAVIDIANS) AND CHINA (THE FALUN GONG)
1. The presidents of both countries (William Clinton and Jiang Zemin) declared the cult/sect leader and his followers criminals and most of the population in America and China agreed.
2. Both in the U.S.A. and China, government force was directed against the cult/sect with unfortunate consequences.
3. The government psychiatrist in America (F.B.I.) diagnosed the leader of the Branch Davidians as moving between Paranoid Personality (Grandiose) Disorder and Antisocial Personality Disorder. These are typical diagnoses given cult leaders in America and I suspect similar diagnoses were given by Chinese psychiatrists to Li Hongxi.
4. My personal opinion is that psychiatric diagnoses do not capture or explain anything important about the personal qualities of charismatic leaders.
5. Although Li Hongxi denies that Falun Gong is a religion it can be described as a millennial movement (end of the world) Chang 2004.
X. A PERSONAL APPRAISAL OF THE BRANCH DAVIDIANS FOLLOWERS OF DAVID KORESH
1. A diverse group drawn from an end of world (Seventh Day Adventist) religion.
2. No evidence of Paranoia Delusional Disorder but shared beliefs of fanatic religious intensity
3. Case examples
A. Mrs. Wayne Martin - her husband and three children died in the fire at Waco. She expects them to be resurrected.
B. Livingston Fagan, a British social worker – he is in a maximum security prison and rejects my offers of assistance. "The only court in which I can be tried is the court of God."
A PERSONAL APPRAISAL OF FALUN GONG COMPLAINTS AND THE REPORTS OF FALUN GONG PRACTITIONERS RE-EXAMINED BY THE C.S.P. (STONE 2002, 2004)
1. The pattern of psychiatric hospitalization varied from province to province. No evidence of a uniform policy.
2. Some Falun Gong complaints indicated several practitioners confined on the same day after a political demonstration. This, if true, raises serious questions.
3. There were highly publicized Falun Gong complaints involving practitioners who had been improperly hospitalized and treated. Some of these proved to be patients with serious mental disorders unrelated to Falun Gong beliefs and verified by standard diagnostic criteria. Many of the complaints of psychiatric mistreatment alleged shock treatment when in fact the patients were receiving acupuncture with direct current an accepted procedure in China (Stone 2002).
4. The C.S.P. also reported Falun Gong practitioners with Qi Gong psychosis. Qi Gong symptoms may or may not be of psychotic proportions.
A. If not psychotic then why forced hospitalization and treatment.
B. Qi Gong symptoms include "paranoid". If evidence of paranoia consists of Falun Gong beliefs then there may be a problem of mistaken diagnosis or misuse of psychiatry.
5. The C.S.P. reports included Falun Gong practitioners diagnosed as psychotic ? Delusional Disorder ? Paranoid Spectrum. The diagnoses were based on the persons belief in and adherence to the practices and teachings of Li Hongxi. (e.g. I have the Falun in my abdomen.)
A. Either the psychiatrist was unfamiliar with Lis teachings.
B. Or the psychiatrist was familiar with Lis teachings but convinced that such beliefs are delusions, that the cult is evil and the anyone who follows them has to be psychotic.
6. Note that many American psychiatrists had the same view of the Branch Davidians. Furthermore Freud asserted that all religions are delusions.
7. Having studies Li Hongxis writings I share the view of those who consider them bizarre and outlandish and think it strange that any reasonable person would believe them. I have the same opinion about the Branch Davidians beliefs.
8. Nonetheless shared beliefs no matter how bizarre (in my opinion) cannot be equated with psychotic delusions and should not be sufficient to justify a diagnosis of Delusional Disorder/Paranoia or Paranoid Schizophrenia.
9. Based on the C.S.P. reports I was able to identify cases of 5A and 5B that suggest mistakes if not misuse of psychiatry.
10. It is my understanding that the C.S.P. has acknowledged instances of mistaken diagnosis and treatment.
11. A radical proposal to remedy mistakes and avoid misuse.
A. Paranoia/Delusional Disorder should not be considered a psychosis for legal purposes.
XI. LESSONS FOR PSYCHIATRY TO BE DRAWN FROM THE CULT/SECT EXPERIENCES IN AMERICA AND CHINA.
1. We have to be familiar with our patients belief systems.
2. We must distinguish between beliefs learned from a charismatic "Authority" and delusions created by the individual as a result of mental derangement.
3. Psychiatrists do nothing ethically wrong when they hypothesize that all Branch Davidians and Falun Gong practitioners are mentally ill in some clinical or theoretical sense.
4. Psychiatrists do risk being unethical when on the basis of such hypotheses and with no other justification they involuntarily confine or treat such patients.
XII. WHAT MORE THAN A DIAGNOSIS OF SERIOUS MENTAL DISORDER SHOULD BE REQUIRED FOR INVOLUNTARY HOSPITALIZATION AND TREATMENT? THE AMERICAN ANSWER.
1. A.P.A. model statute: Serious mental illness (psychosis) with acute deterioration and suffering.
A. Incompetent to make medical decisions
B. Effective treatment available
C. Judge makes a substitute decision for the patient.
XIII. THE AMERICAN LAW AND THE W.P.A. DECLARATION OF MADRID
1. The A.P.A.s model statute may be in conflict with the third provision of the Madrid Declaration "No treatment should be provided against the patients will, unless withholding treatment would endanger the life of the patient and/or those who surround him or her."
2. This provision read narrowly limits involuntary psychiatric treatment to patients who are imminently dangerous to self or others no matter how mentally disturbed they may be.
A. This is a legal formulation not based on medical judgment or tradition.
B. We have had such laws in the United States and the cost to patients and resources is unacceptable.
XIV. The last chapter on Human Rights, Medical Ethics, and Mental Health Law has not been written.
Chinese psychiatry has the opportunity to reexamine the relationship that runs from Human Rights to medical ethics to mental health laws. Hopefully your formulations will recognize the role of families and the needs of mentally ill patients as well as their rights.
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Ministry of Health, (2003) No.013
ICP:No.040657