Christi Cooper-Lehki, D.O. - West Virginia School of Osteopathic ...

Is My Patient Dangerous?
Christi Cooper-Lehki D.O.
WVSOM Alumni Weekend
24 August 2012
Background
In 2005....
there were 80 murders in West Virginia
nearly 5000 violent crimes
2800 registered sexual offenders
Whereas violence has been associated with brain changes,
sexual crimes have not Cummings 1985, Lewis 1986, Tancredi 1988
Mental illness, including alcohol and drug use are highly
associated with both Pihl 1997
Murder: South Carolina Study Group
Record review of pretrial detainees from 1995
to 2001 (n = 270)
Clinical forensic interview, neurological exam,
psychological testing, MRI scan of brain,
and EEG were performed on all defendants
Finkenbine 1
Frierson 2004
1 May 2007

Alcohol and Drug Use
Alcohol 44%
Cannabis 26%
Cocaine 24%
Other 18%
Any 63%
Mood and Anxiety Disorders
Depression 10%
Manic 1%
PTSD 3%
Generalized Anxiety 1%
Other 16%
Any 33%
Schizophrenia, Dementia, Mental
Retardation
Psychotic 8%
Demented 6%
Mentally retarded 6%
Any 22%
Finkenbine 2
1 May 2007

Head Injury History and
Neurological Examination
head injury with loss of consciousness 29%
neurologic exam abnormal 2%
MRI abnormal 18%
EEG abnormal 15%
Summary: Disorders in Murder
alcohol or drugs 63%
mood or anxiety 33%
psychosis, dementia, retardation 22%
brain injury 29%
Will Any of This Matter to Me?
Finkenbine 3
1 May 2007

Let’s Talk About Sex
Where Does Sex Come From?
The Triune Brain
Paul MacLean
Temporal Lobes and the
Limbic System:
emotions
social behavior
memory
Kluver-Bucy Syndrome ->
hypersexual behavior
Finkenbine 4
Reptilian Brain (brainstem, diencephalon,
basal ganglia)
Limbic System
-> primitive sex response
Limbic system (hippocampus, amygdala)
-> sex desire
Cortex (prefrontal cortex, orbitofrontal cortex)
-> social sex role
1 May 2007

Decision making
Inhibition of automatic activity
Allow adaptive behaviors
Inhibit risky behaviors
The Remarkable Case
of Phineas Gage
Acquired pedophilia
Arch Neurol. 2003 Mar 60(3):437-40
Cortical Function
Cortical Injury
With All This Neuroanatomical Data,
Why Can We Not Find The
Predators?
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1 May 2007

Normal Sexual Behavior
To understand abnormal sexual behavior we
must first understand normal sexual
behavior
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Evolution: Genetics
Normal sexual behavior and sexual deviance both derive
from the evolutionary requisite to procreate- sexual
selection favors more “attractive” organisms who
therefore have more
reproductive success
(we’re here talkin’ about it, cuz
our parents were good at it)
Social Psychology
“Our modern skulls house stone age
minds” Cosmides and Toby
Men prefer younger physically
attractive & sexually faithful mates
Women prefer men with resources,
power, & status
Both prefer intelligence, kindness,
humor, general health & judges
Ridley
1 May 2007

Abnormal Sexual Behavior: Terms
Sex offender
Predator
Paraphilia
Sexual deviance
Molestation
Rape
Finkenbine 7
Kinky
Taboo
Perversion
Disorder
Incest
Contact offending
Psychiatric Language of Sexual
Deviance: DSM-IV-TR
Paraphilias: “recurrent, intense sexually arousing
fantasies, sexual urges, or behaviors involving . . .”
Exhibitionism
Pedophilia
Frotteurism
Fetishism
Sexual masochism
Sexual sadism
Transvestic fetishism
Voyeurism
Social Response to Sexual Deviance
Horatio Alger
Pederasty: Greeks, Alger, Whitman
Molesters pilloried & guillotined
1937: 1 st sexual psychopath law
NAMBLA
1977: “approaches that have failed”
1 May 2007

Recent Response to Sexual
Deviance
1980s: longer sentencing
Media exposure increases public & legislative
attention
Sexually Violent Predator commitment laws:
1. illegal sexual conduct
2. mental disorder
3. risk for future sexually harmful conduct
Hendricks 1997, Crane 2002
West Virginia Response
§ 62-12-2: Probation only after “physical, mental and
psychiatric study and diagnosis which shall include an ongoing
treatment plan”
§ 15-1I-2 “The Child Protection Act of 2006 “
§ 15-12-2Registration: Written notice including physical
characteristics, history of offense & any treatment received
for “the mental abnormality or personality disorder”
Governor’s Sexually Violent Predator
Management Task Force
§62-11E-1: “sexually violent predators
generally have personality disorders and/or
mental abnormalities which are largely
unamenable to existing mental illness
treatment modalities and those conditions
render them likely to engage in sexually
violent behavior”
Finkenbine 8
1 May 2007

Why It Might Matter
Pate v. Robinson, 86 S.Ct. 836, 841 (1966): “It is contradictory to argue that a defendant may be
incompetent, and yet knowingly or intelligently ‘waive’ his right to have the court determine his
capacity to stand trial.”
Drope v. Missouri 96 S.Ct. 896, 980 (1975): “A trial court must be alert to …a change that would
render the accused unable to meet the standards of competence to stand trial.”
State v. Edward Charles L. 183 W. Va. 641 (1990): “Expert psychological testimony is permissible in
cases involving incidents of child sexual abuse and an expert may state an opinion as to whether
the child comports with the psychological and behavioral profile of a child sexual abuse victim”
Haislop v. Edgell 215 W. Va. 88 (2003) allowing expert medical testimony as to whether a person is a
sexually violent offender
WV Rule 702: "If scientific, technical, or other specialized knowledge will assist the trier of fact to
understand the evidence or to determine a fact in issue, a witness qualified as an expert by
knowledge, skill, experience, training, or education may testify thereto in the form of an opinion or
otherwise.“
Attorneys should be aware of benefits of forensic psychiatry’s function
What Will the Evaluation
Provide?
1. Does the defendant have a mental disorder? Do
they meet the “profile”?
2. Are they likely CST, CR, a sexual predator?
3. What is the risk of re-offense?
4. Is the defendant treatable?
5. What are possible mitigating circumstances?
6. Are they faking?
The Role of Mental Health in Law
Competency to stand trial
Insanity
Diminished capacity
Competency to confess
Diversionary recommendations
Flight risk
Dangerousness risk
Sex offender risk
Management and Treatment
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1 May 2007

Mental Health Evaluations
Comprehensive and specific
Record review
Clinical interview
Collateral information
Psychological testing
Physiologic testing
Record Review
Court orders, indictments, determinations, etc
Investigative reports and statements
Photos, videotape, letters
Medical records
Employment records
School records
Diagnostic assessment
Clinical Interview
(Sexual history)
Defendant’s account of the alleged incident(s)
Assessment of malingering
Mental state examination
Finkenbine 10
1 May 2007

Collateral Information
Phone or live interview of:
Victim, victim family
Significant other(s)
Family and friends (inmates)
Interrogators
Other clinicians
Site visit
Psychological Testing
Useful nonspecific tests
MMPI, IQ, Hare Psychopathy Checklist, Millon
Clinical Multiaxial Inventory, diagnostic tests
Useful specific tests
Georgia Court Competency Test, Vermont
Assessment of Sex Offender Risk, Sexual
Violence Risk – 20, MnSOST – R
Physiologic Testing (sex offenders)
Penile plethysmography
Normative data (1994) for pedophilic arousal only
volumetric phallometry: 87% spec 95% sens
circumferential phallometry: 48% 100%
Visual Reaction Time
Similar reliability and validity as with PPG
Polygraphy
Finkenbine 11
1 May 2007

Forensic Reports
Goals should be precise
Limitations disclosed
Provide pertinent information
Offer clear opinions
(Offer recommendations for management)
Overview
Mental illness & brain disease is common in murder defendants
Sexual crimes & disorders are complex, yet specific
West Virginia has procedures for consideration of the impact of
mental illness on unlawful behavior
Forensic psychiatry evaluations may inform attorneys, judges,
juries on relevant matters
Q and A
Finkenbine 12
1 May 2007

References
Discipline and Punish, The Birth of the Prison, Michel Foucault, 1977.
D Strueber et. al. The Violent Brain, Scientific American Mind, 17(6) 2006, 20-27.
Sexual Deviance: Issues and Controversies, Tony Ward, D. Richard Laws, Stephen M. Hudson, 2003.
Psychiatry, Sexual Disoders, Chapter 62, Tasman, Kay, Lieberman
Sexual Offender Treatment: Biopsychosocial Perspectives, Eli Coleman, Michael Miner, 2000.
Children and Young People who Sexually Abuse, Martin Calder, 2005.
Psychosomatics. Neuropsychiatry of Huningtons Disease and other Basal Ganglia Disorders. 41:24-30.
Feb. 2000.
Behavioral Neurobiology and Practical Psychotherapy. Unpublished. Nov. 2004.
Pedophilia. JAMA 288; 219. Nov. 2002.
Proc Biol Sci. 1995 Jun 22;260(1359):245-9.
Epidemiology I
• 60 undergraduate males (1991): nonclinical
setting
– Voyeurism 42%
– Frottage 35%
– Telephone scatologia 8%
– Coersive sexual activity 5%
– Contact with girls under twelve years 3%
– Exhibitionsim 2%
Epidemiology II
• APA Taskforce (1999): 90 programs with
2000 patients seeking treatment
– Pedophiliacs 37%
– Exhibitionists 14%
– Voyeurs 20%
– Fetishists 13%
– Frotteurs 11%
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1 May 2007

Epidemiology III
• 453 pedophiles in treatment (1989)
– 80% of victims were unrelated
– 55% were girls
– Nearly all non-contact (exhibitionism,
voyeurism) molestations involved girls
– Slight majority of contact molestations were
against boys
Treatment
Multidisciplinary approach probably best
clinician, probation officer, community, court
Psychotherapy
Pharmacotherapy
Psychosurgery
Testosterolytic agents
Phenothiazines
SSRI’s
Buspirone
Lithium
Trazadone
Pharmacotherapy
Finkenbine 14
1 May 2007

SSRI Treatment
Not indicated for treatment of paraphilias, but
preliminary studies are supportive of their use
(Bradford, Federoff, Bianchi, Cesnik, Kafka)
Hypothesis along OCD line
Fewer adverse effects, greater familiarity
Sexual effects may be target
APA Task Force on Sexually
Dangerous Offenders
“The potential of SRI’s in the treatment of
paraphilias and sexual offenders is of
enormous significance…Research is
necessary to establish the efficacy of SRI’s
in clinical trials”
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1 May 2007