MENTAL HEALTH ISSUES IN CRIMINAL CASES
Mental health issues frequently arise in the context of appeals. They may be present
in the transcripts. Mental health issues may also be lurking in the background, where yoususpect defense counsel could have exploited a defendant’s mental health problems but failedto do so. In either event, you will probably need to read psychological or psychiatric recordsto evaluate potential issues. Few of us are trained in psychology or psychiatry, and it maybe difficult to understand the specialized language which appears in the reports. We willattempt to briefly describe common situations where mental health issues arise on appeal,mention some of the issues which may arise in those contexts, and provide some help inunderstanding the mental health language which may appear in reports relevant to thoseissues. CONTEXTS IN WHICH MENTAL HEALTH ISSUES ARISE
Mental health issues come up in several contexts in criminal cases. Defendant's Competency
Fundamental to our criminal justice system is the principle that no one can be tried
or adjudged to punishment while mentally incompetent. (Pen. Code, § 1367, subd. (a); Patev. Robinson (1966) 383 U.S. 375.) The term “mentally incompetent” means that “as a resultof mental disorder or developmental disability, the defendant is unable to understand thenature of the criminal proceedings or to assist counsel in the conduct of a defense in arational manner.” (Pen. Code, § 1367, subd. (a); Drope v. Missouri (1975) 420 U.S. 162,171; Dusky v. United States (1960) 362 U.S. 402.)
The most common potential issue involving competency is whether the trial court
abused its discretion in refusing or failing to conduct a competency hearing. “If a defendantpresents substantial evidence of his lack of competence and is unable to assist counsel in theconduct of a defense in a rational matter during the legal proceedings, the court must stopthe proceedings and order a hearing on the competence issue. (Pate, supra, 383 U.S. at pp. 384-386; People v. Pennington (1967) 66 Cal.2d 508, 516-517. . . .) In this context,substantial evidence means evidence that raises a reasonable doubt about the defendant’sability to stand trial. (People v. Frye (1998) 18 Cal.4th 894, 951-952 . . . ) Thesubstantiality of the evidence is determined when the competence issue arises at any pointin the proceedings. ([People v.] Welch [(1999)] 20 Cal.4th [701,] 739.) The court’s decisionwhether to grant a competency hearing is reviewed under an abuse of discretion standard. (§ 1368; Welch, supra, 20 Cal.4th at p. 742.)” (People v. Ramos (2004) 34 Cal.4th 494,
507.) Expert testimony is not necessary to raise a doubt. (Pate, supra, 383 U.S. at p. 385,fn. 7.) “[E]vidence of a defendant’s irrational behavior, his demeanor at trial, and any priormedical opinion on competence to stand trial are all relevant in determining whether furtherinquiry is required [and] . . . even one of these factors standing alone may, in somecircumstances, be sufficient. There are, of course, no fixed or immutable signs whichinvariably indicate the need for further inquiry to determine fitness to proceed; the questionis often a difficult one in which a wide range of manifestations and subtle nuances areimplicated.” (Drope, supra, 420 U.S. at p. 180.)
The classic case in California is People v. Stankewitz (1982) 32 Cal.3d 80. In that
case a psychiatrist testified the defendant had paranoid delusions his public defender was incollusion with the prosecutor. If a defendant is so delusional or paranoid that he will nottrust his attorney or tell him the true facts, then he is incompetent. Note that the mistrustmust be delusional, i.e., stemming from a mental disorder. The usual distrust defendantshave for their public defenders does not show the defendant is incompetent.
“Under the applicable substantial evidence test, ‘more is required than mere bizarre
actions [citation] or bizarre statements [citation] or statements of defense counsel thatdefendant is incapable of cooperating in his defense [citation] or psychiatric testimony thatdefendant is immature, dangerous, psychopathic or homicidal or such diagnoses with littlereference to defendant’s ability to assist in his own defense. [Citation.]” (People v. Davis(1995) 10 Cal.4th 463, 527; People v. Koontz (2002) 27 Cal.4th 1041, 1064-1065[competent despite pro per, untenable defense, harmful witness, rambling close]; People v. Rodrigues (1994) 8 Cal.4th 1060, 1109-1112 [insufficient evidence for hearing despite lackof cooperation with counsel, and two experts describing seizures which could have causedbrain damage, and possible drug dementia].)
“Thus, while, the California Supreme Court has repeatedly stated that a competency
hearing is required whenever there is evidence that <raises a reasonable doubt about the defendant's competence to stand trial' [citation], in practice, the court has essentially required that the defendant establish his incompetence before a trial court will be required to hold a competency hearing. In our view, the holdings in these cases appear to have lost sight of the fact that, <[t]he function of the trial court in applying Pate's substantial evidence test is not to determine the ultimate issue: Is the defendant competent to stand trial? It[s] sole function is to decide whether there is any evidence which, assuming its truth, raises a reasonable doubt about the defendant's competency.' [Citation.]” (People v. Harrison (2005) 125 Cal.App.4th 725, 735, DEPUBLISHED.)
If the court has previously considered the competency issue, and has determined a
defendant is competent to stand trial, a new competency hearing is only required if there are
“changed circumstances.” If the defendant merely engages in the same bizarre behaviorwhich initially led the court to consider the competency issue, this is not enough to requirethe court hold another competency hearing. “When, as here, a competency hearing hasalready been held and the defendant was found to be competent to stand trial, a trial courtis not required to conduct a second competency hearing unless ‘it “is presented withsubstantial change of circumstances or with new evidence” ’ that gives rise to a ‘seriousdoubt’ about the validity of the competency finding. [Citation.]” (People v. Marshall (1997)15 Cal.4th 1, 33; accord, People v. Lawley (2002) 27 Cal.4th 102, 136, 139 [despitedefendant being incoherent].)
If the court determines there is a reasonable doubt about competency, the defendant
must be examined by experts and the defendant has the right to a jury trial on the issue ofcompetency. However, the trial is not a criminal proceeding. “Although it arises in thecontext of a criminal trial, a competency hearing is a special proceeding, governed generallyby the rules applicable to civil proceedings. (People v. Skeirik (1991) 229 Cal.App.3d 444,455.) The right to a jury determination of competency is statutory, however, notconstitutional; thus, counsel may effectively waive it without a personal waiver from thedefendant. (People v. Masterson (1994) 8 Cal.4th 965, 969, 972; see § 1369.) A defendantis presumed competent unless the contrary is proven by a preponderance of the evidence. (§ 1369, subd. (f); People v. Medina (1990) 51 Cal.3d 870, 881-886.) On appeal, thereviewing court determines whether substantial evidence, viewed in the light most favorableto the verdict, supports the trial court's finding. (People v. Marshall (1997) 15 Cal.4th 1, 31.)‘Evidence is substantial if it is reasonable, credible and of solid value.’ (Ibid.)” (People v. Lawley (2002) 27 Cal.4th 102, 131.)
Not guilty by reason of insanity
“ ‘ “If a person under an insane delusion as to existing facts, commits and offense in
consequence thereof, is he thereby excused?” To which question the answer must of coursedepend on the nature of the delusion: but, making the . . . assumption . . . that the laboursunder . . . partial delusion only, and is not in other respects insane, we think he must beconsidered in the same situation as to responsibility as if the facts were respect to which thedelusion exists were real. For example, if under the influence of his delusion he supposesanother man to be in the act of attempting to take away his life, and he kills that man, as hesupposes, in self-defence, he would be exempt from punishment. If his delusion was thatthe deceased had inflicted a serious bodily injury to his character and fortune, and he killedhim in revenge for such supposed injury, he would be liable to punishment.’ [Citations.]”(People v. Rittger (1960) 54 Cal.2d 720, 731-732, quoting M'Naghten's Case (1843) 10Clark & Fin. 200, 211 [8 Eng. Rep. 718, 722].)
“ < . . . California courts framed this state's definition of insanity, as a defense in
criminal cases, upon the two-pronged test adopted by the House of Lords in M'Naghten'sCase (1843) 10 Clark & Fin. 200, 210 [8 Eng. Rep. 718, 722]: “[T]o establish a defense onthe ground of insanity, it must be clearly proved that, at the time of the committing the act,the party accused was laboring under such a defect of reason, from disease of the mind, asnot to know the nature and quality of the act he was doing; or, if he did know it, that he didnot know he was doing what was wrong.' [Citations.]” (People v. Kelly (1992) 1 Cal.4th495, 532.)
“ <A person is legally insane when, by reason of mental disease or mental defect he
was incapable of knowing or understanding the nature and quality of his act or incapable ofdistinguishing right from wrong at the time of the commission of the offense. The word“wrong” as used in this instruction is not limited to legal wrong, but properly encompassesmoral wrong as well. Thus, the defendant who is incapable of distinguishing what is morallyright from what is morally wrong is insane, even though he may understand the act isunlawful.' ” (People v. Coddington (2000) 23 Cal.4th 529, 608.)
The “right-wrong” prong is more frequently invoked in cases raising an insanity
defense. It is more unusual that a defendant is so delusional he or she does not evenunderstand the nature of the act committed. (E.g., kills someone while in delusional statebelieving he is killing a Viet Cong enemy who is attacking him.)
In People v. Skinner (1985) 39 Cal.3d 765, the defendant was diagnosed as a paranoid
schizophrenic. He strangled his wife while on leave from a mental hospital. He believedthat the marriage vow "till death do us part" bestowed on him a God-given right to kill hiswife if she had violated or was inclined to violate the marital vows, and that because thevows reflect the direct wishes of God, the killing was morally sanctioned.
Another example is found in People v. Stress (1988) 205 Cal.App.3d 1259, where a
delusional defendant believed he had to kill his wife in order to gain a forum to warnAmericans a conspiracy existed between the professional athletic leagues, the televisionnetworks, the federal government and others to insure that professional athletes were notdrafted for service in the war. In his view, his wife’s death was a necessary sacrifice for thegreater good.
Insanity cannot be based on a diagnosis of an antisocial personality disorder. (Peoplev. Fields (1983) 35 Cal.3d 329, 372.) It cannot be based solely on drug or alcohol use (Pen. Code, § 25.5), but such use can be a partial cause. (People v. Robinson (1999) 72Cal.App.4th 421.)
Lack of specific intent or other requires mental state
There is no longer a defense of diminished capacity, but the defendant can argue a
lack of specific intent or malice aforethought. (People v. Saille (1991) 54 Cal.3d 1103,1116-1117.)
Penal Code “Sections 28 and 29 permit introduction of evidence of mental illness
when relevant to whether a defendant actually formed a mental state that is an element of acharged offense, but do not permit an expert to offer an opinion on whether a defendant hadthe mental capacity to form a specific mental state or whether the defendant actuallyharbored such a mental state.” (People v. Coddington (2000) 23 Cal.4th 529, 582.)
For example, an expert cannot say she or he believes the defendant, due to mental
illness, lacked the capacity to premeditate or deliberate. Nor can an expert say she or hebelieves the defendant did not premeditate or deliberate. But the expert can say thedefendant had a mental illness which would cause the defendant to act impulsively, withoutthinking or considering the consequences of his conduct. Forced medication at trial
The court can force medication in order to make defendant competent only if (1) an
important government interest at stake which is diminished if the defendant will behospitalized for a while, (2) involuntary medication will significantly further the stateinterests in a timely prosecution and fair trial, (3) involuntary medication is necessary tofurther those interests as opposed to contempt or other remedies; and (4) administration ofthe medication is medically appropriate. (Sell v. United States (2003) 539 U.S. 166, 180-183; People v. O'Dell (2005) 126 Cal.App.4th 518, 569-572.) The unjustified forcedadministration of medication could violate the due process right to a fair trial under theFourteenth Amendment. (Riggins v. Nevada (1992) 504 U.S. 127, 137.) [“In extreme cases,the sedationlike effect [of antipsychotic medication] may be severe enough (akinesia) toaffect thought processes. It is clearly possible that such side effects had an impact upon notjust Riggins' outward appearance, but also the content of his testimony on direct or crossexamination, his ability to follow the proceedings, or the substance of his communicationwith counsel.” (internal quotation marks omitted)]
“ ‘[E]vidence about the defendant’s background and character is relevant because of
the belief, long held by this society, that defendants who commit criminal acts that areattributable to a disadvantaged background, or to emotional and mental problems, may be
less culpable than defendants who have no such excuse.’ ” (Penry v. Lynbaugh (1989) 492U.S. 302, 319, quoting California v. Brown (1987) 479 U.S. 538, 545 (conc. opn. ofO’Connor, J.) see also Wiggins v. Smith (2003) 539 U.S. 510, 535; see also Atkins v. Virginia(2002) 536 U.S. 304 [retardation].) “More than any other single factor, mental defect havebeen respected as a reason for leniency in our criminal justice system.” (Caro v. Woodford(9th Cir. 2002) 280 F.3d 1247, 1258, citing 4 William Blackstone, Commentaries *24-*25.)
Conditions of probation
There is little case law in California concerning when the court can order a defendant
to take medication as a condition of probation. Arguably, the factors in Sell would apply. (See United States v. Williams (9th Cir. 2004) 356 F.3d 1045, 1056; cf. Welf. & Inst. Code,§ 5345 et seq.)
Mentally Disordered Offenders
The elements to an MDO commitment are as follows. “First, the prisoner must have
<a severe mental disorder that is not in remission or cannot be kept in remission withouttreatment.' (§ 2962, subd. (a).) Second, the disorder must have been <one of the causes of orwas an aggravating factor in the commission of a crime for which the prisoner was sentencedto prison.' (§ 2962, subd. (b).) Third, the prisoner must have been <in treatment for thesevere mental disorder for 90 days or more within the year prior to the prisoner's parole orrelease.' (§ 2962, subd. (c).) Fourth, before the prisoner's parole or release, the treatingphysician and other specified medical authorities must certify that each of the notedconditions exists, and that by reason of the disorder, the prisoner <represents a substantialdanger of physical harm to others.' (§ 2962, subd. (d)(1).) [¶] The final criterion fortreatment as an MDO under section 2962 is set forth in subdivision (e), [the defendant mustbe in prison after being convicted of a listed offense].” (People v. Anzalone (1999) 19Cal.4th 1074, 1077.)
Sexually Violent Predatory Offenders
To commit someone under the Act, the state must prove “ a person who has been
convicted of a sexually violent offense against two or more victims and  who has adiagnosed mental disorder that  makes the person a danger to the health and safety ofothers in that it is likely that he or she will engage in [predatory] sexually violent criminalbehavior.” (Cooley v. Superior Court (Martinez) (2002) 29 Cal.4th 228, 246, quoting Welf. & Inst. Code, § 6600, subd. (a)(1).)
Mental disorder includes paraphilia (People v. Butler (1998) 68 Cal.App.4th 421,
441-442), pedophilia (People v. Mercer (1999) 70 Cal.App.4th 463, 466), antisocialpersonality disorder. (People v. Burris (2002) 102 Cal.App.4th 1096, 1098-1110; seeKansas v. Crane (2002) 534 U.S. 407, 412 [40-60 percent of prison population sodiagnosed].)
Be alert to hints in the record the defendant is mentally ill and the possibility defense
counsel failed to properly investigate the issue by obtaining medical records and consultingwith experts. An attorney who fails to investigate possible mental health issues, either attrial or sentencing, “deprive[s] himself of the reasonable bases upon which to reach informedtactical and strategic trial decisions.’” (People v. Frierson (1979) 25 Cal.3d 142, 163.)
For example, in People v. Mozingo (1983) 34 Cal.3d 926 the Supreme Court held trial
counsel provided ineffective assistance in failing to investigate an insanity defense eventhough defendant refused to enter an insanity plea and refused to cooperate with anypsychiatrists. Counsel did not bother to investigate mental health issues because thedefendant refused to enter a plea of insanity. The Supreme Court held counsel should have“undertak[en] sufficient investigation of possible defenses to enable counsel to present aninformed report and recommendation to his client.” (Id., at p. 934.)
If you think trial counsel may have failed to adequately investigate mental health
issues at trial or at sentencing, you will have to do the investigation to show counsel’somission was prejudicial. Obtain releases from the client (sample included with thematerials) and get the client’s medical records from prison’s, jails, and any hospitals wherehe received treatment. If you think there is a possible claim of ineffective assistance ofcounsel, you should consider applying for funds to hire a mental health expert who can helpyou decipher the records and render an opinion how they could have helped your client. Asample application for expert funds is included in these materials.
Case Law on the Side-Effects of Antipsychotics
“Psychotropic (or antipsychotic) drugs have become a primary tool of public mental
health professionals for treating serious mental disorders, replacing such earlier measures aslobotomy, insulin shock, and electroshock. In many patients they minimize or eliminatepsychotic symptoms. They <also possess a remarkable potential for undermining individualwill and self-direction, thereby producing a psychological state of unusual receptiveness tothe directions of custodians.' (Keyhea v. Rushen (1986) 178 Cal.App.3d 526, 531, fn. andcitations omitted.) “These include thorazine, prolixin, stelazine, serentil, quide, tindal,compazine, trilafon, repoise, mellaril, tractan, navane, haldol, moban, and vesprin.” (Id. at
p. 531, fn. 1.) “The drugs also, however, have many serious side effects. Reversible sideeffects include akathesia (a distressing urge to move), akinesia (a reduced capacity forspontaneity), pseudo-Parkinsonism (causing retarded muscle movements, masked facialexpression, body rigidity, tremor, and a shuffling gait), and various other complications suchas muscle spasms, blurred vision, dry mouth, sexual dysfunction, drug-induced mentaldisorders, and, on rare occasions, sudden death. A potentially permanent side effect of long-term exposure, for which there is no cure, is tardive diskenesia, a neurological disordermanifested by involuntary, rhythmic, and grotesque movements of the face, mouth, tongue,jaw, and extremities.” (Id. at p. 531; see also Riese v. St. Mary’s Hosp. and Med. Ctr. (1987)209 Cal.App.3d 1303, 1311-1312.)
“Antipsychotic drugs, sometimes called <neuroleptics' or <psychotropic drugs,' are
medications commonly used in treating mental disorders such as schizophrenia.”(Washington v. Harper (1990) 494 U.S. 210, 214.) “The drugs administered to respondentincluded Trialafon, Haldol, Prolixin, Taractan, Loxitane, Mellaril, and Navane.” (Id. at p. 214, fn. 1.) The Supreme Court held:
The purpose of the drugs is to alter the chemical balance in a patient's brain,leading to changes, intended to be beneficial, in his or her cognitive processes. While the therapeutic benefits of antipsychotic drugs are well documented, itis also true that the drugs can have serious, even fatal, side effects. One suchside effect identified by the trial court is acute dystonia, a severe involuntaryspasm of the upper body, tongue, throat, or eyes. The trial court found that itmay be treated and reversed within a few minutes through use of themedication Cogentin. Other side effects include akathesia (motor restlessness,often characterized by an inability to sit still); neuroleptic malignant syndrome(a relatively rare condition which can lead to death from cardiac dysfunction);and tardive dyskinesia, perhaps the most discussed side effect of antipsychoticdrugs. Tardive dyskinesia is a neurological disorder, irreversible in somecases, that is characterized by involuntary, uncontrollable movements ofvarious muscles, especially around the face. The State, respondent, and amicisharply disagree about the frequency with which tardive dyskinesia occurs, itsseverity, and the medical profession's ability to treat, arrest, or reverse thecondition. A fair reading of the evidence, however, suggests that theproportion of patients treated with antipsychotic drugs who exhibit thesymptoms of tardive dyskinesia ranges from 10% to 25%. According to theAmerican Psychiatric Association, studies of the condition indicate that 60%of tardive dyskinesia is mild or minimal in effect, and about 10% may becharacterized as severe.
(Id. at pp. 229-230, citations omitted.)
The California Supreme Court has made similar observations about mental health
No doubt such commonly used drugs, the phenothiazines, have been ofconsiderable benefit to many mentally ill patients. Use of these drugs hasgreatly reduced the number of mentally ill individuals requiringhospitalization, and the frequency and length of hospitalizations. But theyalso have been the cause of considerable side effects. Reversible side effectsinclude akathesia (a distressing urge to move), akinesia (a reduced capacity forspontaneity), pseudo-Parkinsonism (causing retarded muscle movements,masked facial expression, body rigidity, tremor, and a shuffling gait), andvarious other complications such as muscle spasms, blurred vision, dry mouth,sexual dysfunction, and drug-induced mental disorders. A potentiallypermanent side effect of long-term exposure to phenothiazines is tardivedyskinesia, a neurological disorder manifested by involuntary, rhythmic, andgrotesque movements of the face, mouth, tongue, jaw, and extremities, forwhich there is no cure. On rare occasions, use of these drugs has causedsudden death.
Although a new generation of antipsychotic drugs, the so-called
atypicals, have been regarded as being more benign and effective,considerable controversy remains over both their efficacy and the extent andnature of their side effects. Moreover, most atypical antipsychotics aredifficult to administer without a patient's cooperation, because unlike the oldergeneration of medications, the newer drugs are generally not available informs that can be injected. Also, phenothiazines are cheaper than atypicalsand are still the most widely used class of drugs to treat psychosis. The basicconstitutional and common law right to privacy and bodily integrity istherefore especially implicated by the forced administration of medicationswith such potential adverse consequences
(In re Qawi (2004) 32 Cal.4th 1, 14-15, citations omitted.)
Clinical disorder = Problems with perceptions, feelings, or relationships which causes
stress or impairment in everyday functioning.
SCHIZOPHRENIA295.xx Schizophrenia: delusions, hallucinations, or disorganized speech or behavior295.40 Schizophreniform: two such episodes in less than six months295.70 Schizoaffective: schizophrenia with depression or bipolar297.1 Delusional disorder: suffering from a plausible delusion for more than a month298.8 Brief Psychotic Episode: suffering from a delusion for less than a month
depression = at least five of the following: feels depressed, loss of interest, weight loss
or gain, insomnia or hypersomnia, increased or decreased activity, fatigue, guilt or sense ofworthlessness, unable to concentrate or make decisions.
mania = inflated self-esteem or grandiose, decreased sleep, more talkative or
pressured speech, flight of ideas or racing thoughts, distractability, increased activity,increased activities with risks. 296.xx Bipolar I: manic and depressed at least four times within a year296.89 Bipolar II: manic and depressed at least once within a year301.13 Cyclothymic: generally less severe manic phases300.4 Dysthymic: long-term low-grade depression311
Depressive NOS (not otherwise specified)
ANXIETY DISORDERS300.01 Panic attacks300.02 General anxiety: for at least six months300.21 Panic attacks with agoraphobia 300.22 Agoraphobia = fear of crowds300.23 Social phobia = social anxiety settings300.29 Specific phobia = an object triggers panic300.3 Obsessive-compulsive = recurrent thought or activity308.3 Acute stress: for less than a month309.81 Post-Traumatic Stress Syndrome: (A) witnesses or experienced an event concerning(a threat of) great injury or death and with fear, helplessness, or horror; and (B) the traumaticevent is re-experienced by recurrent recollection or dreams, acting or feeling as if it isrecurring, distressed from cues symbolizing the event or trauma; and (C) avoid stimuli of the
trauma; and (D) arousal with insomnia, irratability, hypervigilance, or easily startled.
IMPULSE DISORDERS = failure to resist temptation or impulse which is harmful312.30 Impulse Control NOS312.32 Kleptomania 312.33 PyromaniaV71.01 Antisocial behavior
Dependence, abuse, intoxication, or withdrawalDual diagnosis: substance abuse and another disorder, usually schizophrenia or mood
291, 303 Alcohol292.xx Amphetamine, cannabis, cocaine, hallucinogen, nicotine, opioid, PCP, sedative. 304.80 Polysubstance dependence
SEXUAL DISORDERS302.9 Paraphilia NOS = recurrent and intense fantasies, urges, or behaviors for more thansix months involving nonconsensual sex302.2 Pedophilia
ADJUSTMENT DISORDER309.9 Adjustment disorder NOS: stressors cause distress or functional impairment309.0 with depressed mood309.24 with anxiety309.28 with anxiety and depressed mood309.3 with conduct disturbance = violates rules
300.xx Somatization, conversion, hypochondria: psychosomatic symptoms causing
significant impairment with no apparent advantage to the patient
300.16 Factitious disorder: feigned psychosomatic symptoms with no apparent
V65.2 Malingering: feigned psychosomatic symptoms to gain an apparent advantageV15.81 Noncompliance with treatment
Symptoms arise before the age of 7, symptoms exist at school and at home, and they
314.00 Attention deficit disorder. At least six of the following for more than six
months: not devote close attention to detail, frequent difficulty sustaining attention, does not
seems to listen when spoken to, does not follow instructions or finish tasks, difficultyorganizing tasks, avoids or dislikes tasks involving sustained effort, loses things necessaryto complete tasks, easily distracted, forgetful.
314.01 Attention deficit and hyperactivity disorder. In addition, at least six of the
following: fidgets or squirms in a seat, leaves desk inappropriately in class, runs and climbsexcessively and when inappropriate, difficulty playing quietly, always moving, talksexcessively, blurts out answers before questions are completed, difficulty waiting turns,interrupts.
CONDUCT DISORDER312.8x Conduct disorder: aggressive, harmful, damaging, deceitful or thieving, or seriousviolation of rules. 313.81 Oppositional defiant
MENTAL RETARDATION318.2 Profound retardation: IQ < 25318.1 Severe retardation: IQ 20-40318.0 Moderate retardation: IQ 35-55317
ABUSE OR NEGLECT995.52 victim of child neglect995.53 victim of molestation995.54 victim of child abuse
Personality disorder = A stable, inflexible behavior pattern deviating from cultural
expectations causing a distorted perception of self or others, abnormal range of emotion,impaired and distressed interpersonal functioning, or poor impulse control. They areenduring, inflexible and pervasive, starting in early adulthood.
ECCENTRIC FEATURES (related to schizophrenia or mood disorders)
301.00 Paranoid PD = Pervasive distrust and suspicion, and at least four of the
following: feels exploited, doubts others' loyalties, will not confide in others, reads hiddenmeanings into benign remarks, holds grudges, perceives attacks on reputation, doubts others'fidelity.
301.20 Schizoid PD = Detached and restricted emotion, and at least four of the
following: no desire for close relationships, solitary, no sexual interest, no pleasure fromactivities, no close friends, indifferent to praise or criticism.
301.22 Schizotypal PD = Poor interpersonal skills, distorted perception, eccentric
behavior, no close relationships, and at least five of the following: non-delusional ideas ofreference, odd or magical beliefs, unusual perception, odd thinking and speech, paranoid,constricted affect, odd behavior or appearance, no close friends, social anxiety.
DRAMATIC OR EMOTIONAL FEATURES (related to depression or anxiety)
301.7 Antisocial PD* = Violates other's rights when at least 15 years old, and at
least three of the following: nonconformity to laws or social norms, deceitful, impulsive,irritable and aggressive, disregard of safety, irresponsible at work or with money, lack ofremorse.
301.81 Narcissistic PD* = Needs admiration and lacks empathy, and at least five of
the following: grandiose or sense of superiority, fantasies of power or beauty or ideal love,believes he or she is special and should associate only with high-status people, requiresexcessive admiration, a sense of entitlement, exploitive, lacks empathy, envious of othersand a belief that others are envious, arrogant.
301.83 Borderline PD (borderline depressed or bipolar) = Unstable relationships or
self-image, and at least five of the following: frantic avoidance of abandonment, unstableand intense relationships with idealization and depersonalization of the other person,unstable self-image, impulsive, suicidal and self-mutilating behavior, reactive mood orunstable affect, chronic feeling of emptiness, inappropriate anger, paranoid.
301.50 Histrionic PD = Emotional and attention seeking, and at least five of the
following: a need to be the center of attention, seductive or provocative behavior, shiftingand shallow emotions, physical appearance made to draw attention, impressionistic,theatrical, suggestible, views relationships as more intimate than is realistic.
*Psychopathic in SVP cases (Hare) is a combination of antisocial and narcissistic
ANXIOUS OR FEARFUL FEATURES (related to anxiety disorders)
301.82 Avoidant PD = Inhibited or hypersensitive, and at least four of the following:
avoids interpersonal activity, does not risk being disliked, restraint in intimate relationships,preoccupied with potential criticism, inhibited in new situations, views self as socially inept,reluctance to take risks.
301.6 Dependent PD = Submissive, clingy, in need of being taken care of, and at
least five of the following: indecisive, lets others assume responsibility for major areas one'slife, not disagreeable, lacks initiative, helpless when alone, excessive effort to receivenurture, constant need for relationships, excessive fear of being left to care for oneself alone.
301.4 Obsessive-compulsive PD = Preoccupied with orderliness, perfection, control,
or inflexible and closed, and at least four of the following: irrational preoccupation withdetails or organization, perfectionism thwarts completion of tasks, excessive devotion towork, overly moral, difficulty throwing things out, reluctant to delegate, miserly spending,
MISCELLANEOUS301.9 Personality Disorder NOS301.9 Depressive PD301.9 Passive-aggressive PDV62.89 Borderline retardation: IQ 71-84
General medical conditions (GMC) = Medical problems of the patient. Can include
medication-induced ailments, such as the following:
332.1 Neuroleptic-induced Parkinsonism333.xx other medication induced problems with muscle tone995.2 adverse reaction to medication
Psychosocial and environmental problems (PEP) = The sources of the patient's
psychological stressors or the absence of expected support. Generally, the doctor focuseson the following:
primary support group (family)social environmenteducationoccupation or vocationhousingeconomichealth care accesslegalother stressors
Global Assessment of Functioning (GAF) scale = A scale from 1 to 100 on how well
superior functioning, no psychological symptoms
good functioning in all areas, does not requiring counseling
no more than slight impairment, transient and expected impairment from stressors
some difficulty but generally functions well, occasional counseling helpful
moderate difficulty and interference with functioning, needs counseling
serious impairment and avoidance or panic
major impairment, poor judgment, needs constant supervision, inpatient treatment
unable to function, delusional or impaired reality
unable to function, sometimes a danger to self or others, must commit
persistently nonfunctional, requires long-term commitment
Observations/Mental Status Evaluations
Observations of certain features concerning the patient are frequently recorded in
psychological reports because they might indicate certain disorders.
Inappropriate dress or demeanor might reveal anxiety or disorganized thought. Posture, facial reaction, and grooming can indicate the patient's motivation and self-
Eye contact: wandering eyes might suggest distractability, hallucinations, cognitive
deficits or mania; avoiding eye contact might suggest anxiety, constant eye contact mightsuggest suspicion or paranoia
Orientation (time, place, and purpose) and whether memory is distorted can indicate
Speech: subdued tone can indicate depression or anxiety; hoarse or pressured speech
can indicate mania; monotone can indicate schizophrenia; rising pitch can indicate anxiety;drop in pitch can indicate sadness or depression; excessive modulation can indicate maniaor somatoform disorder.
Thinking: long pauses can indicate depression; short pauses can indicate mania;
varied pauses can indicate schizophrenia; fragmented speech or the use of special terms canindicate schizophrenia.
Insight: full (describes symptoms as a result from a disorder), partial (knows there are
problems but lacks awareness of the disorder), none (denies suffering from mentalproblems).
Judgment = the ability to choose appropriate goals and select socially acceptable
objectives in order to reach the goals. Scores Based on the Bell Curve MEDICATIONS Antipsychotics/Neuroleptics/Psychotropics
Treats schizophrenia (psychosis, delusions); sometimes treats depression, mania,bipolar, anxiety, nausea. Side-effects: extrapyramidal effects (spasms, tardive diskenesia, stiffness ), endocrineeffects (weight gain, diabetes, impotence in men, menstral irregularaties in women),sedation, mental dullness (“Thorazine haze”), muscarinic effects (dry mouth,constipation, blurred vision).
PHENOTHIAZINES (includes TRICYCLICS)chlorpromazine (Thorazine)promazine (Sparine)triflupromazine (Vesprin)acetophphenazine (Tindal)fluphenazine (Prolixin, Decanoate, Permitil, Modecate)perphenazine (Trilafon)prochlorperazine (Compazine)trifluoperazine (Stelazine)mesoridazine (Serentil) thioridazine (Mellaril)butoperazine (Repoise)
Less sedative but harsher extrapyramidal effects.
Less sedative but harsher extrapyramidal effects.
thioxanthene (Navane)flupenthixol (Fluanxol)
Newer drugs generally with less severe side effects.
clozapine (Clozaril) [can reduce the white blood cell count]loxapine (Loxitane, Daxoline)olanzapine (Zyprexa)quetiapine (Seroquel)risperidone (Risperdal) [generally less severe side-effects than other atypicals]ziprasidone (Geodon)aripiprazole (Abilify)
Treats depression, bipolar, dysthymia, anxiety, small doses of tricyclics for migraines. Side effects: tricyclics and tetracyclics have the same effects as antipsychotics.
TRICYCLICSamitriptyline (Elavil, Endep)clomipramine (Anafranil)doxepin (Sinequan, Adapin)imipramine (Tofranil, Janimine)trimipramine (Surmontil, Rhotrimine)amoxapine (Asendin)desipramine (Norpramin, Pertofrane)notriptyline (Aventyl, Pulvules, Pamelor)protriptyline (Vivactil, Triptil)
TETRACYCLICSmaprotroline (Ludiomil)mirtazapine (Remeron)
Also treats nicotine addictionSide effect: greater risk of seizures
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI)
Newer drugs with less side-effects but can increase suicidal and homicidal tendencieswhen the medication is started or ended.
fluoxetine (Prozac)paroxetine (Paxil)sertraline (Zoloft)fluvoxamine (Luvox)citalopram (Celexa)
A wide range of side effects including high blood pressure, reduced performance ofthe kidneys, lower blood flow to the brain and sometimes coma. The drug interactswith a wide variety of medications and foods.
isocarboxazid (Marplan)phenelzine (Nardil)tranylcypromine (Parnate)
Treats anxiety, panic disorders, phobias, insomnia. Side effects: sedation, poor sleeping habits, addiction. Buspirone is not sedating.
BENZODIAZEPINES diazepam (Valium)clonazepam (Klonopin)others (Librium, Ativan, Xanax, Dalmane, Restoril, Halcion)
Beta blockers inhibit the effects of adrenaline (also known as epinephrine). Treats hypertension, angina, arrhythmia, migraines, insomnia, extrapyramidaldisorders, anxiety and panic attacks. Side-effects: potential heart problems, asthma, hypotension, temporary sterility.
propranolol (Inderal)nadolol (Corgard)others
Treats severe anxiety, seizures, Parkinson's, extrapyramidal disorders, mania.
BARBITURATESamobarbital (Amytal)pentobarbital (Nembutal)phenobarbital (Sulfoton)secobarbital (Seconal)
Side effects: interferes with a wide range of drugs.
phenytoin (Dilantin)mephenytoin (Mesantoin)ethotoin (Peganone)fosphenytoin (Cerebyx)
MISCELLANEOUSvalporic acid (Depakote, Valproate)
Side effect: see above. Its benefit is that it is not sedating.
Side effect: higher risk of anemia, bone marrow deficiency.
Side effect: fast heart beat and arrhythmia, ulcers, glaucoma, psychosis in elderly.
trihexphenidyl (Artane)benztropine mesylate (Cogentin)
In addition to allergies, older antihistamines treat nausea, motion sickness, anxiety,extrapyramidal effects and insomnia because of the side-effect of causing drowsiness.
diphenyldramine (Benadryl, Excedrin PM, Nytol)promethazine (Phenegran)hyrdroxyzine (Atarax, Vistaril)
Side effect: Can impairs kidney function, high blood pressure, diabetes. In rare cases,it causes irreversible brain damage. The patient needs constant monitoring becausethe therapeutic dose is close to a toxic level. The concentration of lithium changesbroadly with normal changes in body chemistry throughout the day. Signs of toxicityinclude drowsiness and confusion.
Side effects: Higher risk of liver failure, pancreas failure, ovarian cysts, spina bifidain children.
Side effect: higher risk of anemia, bone marrow deficiency. Stimulants
Treats attention deficit disorder/ hyperactivity, narcolepsy, obesity, dementia, fatigue,depression, psychosis. Side effects: hyperactivity, hypertension, insomnia, addiction, psychosis, depression,thinning of the bone, anxiety, addiction.
amphetamine (Adderall, Benzadrine, Biphetamine)dextroamphetamine (Dexadrine)methamphetamine (Desoxyn)methylphenidate (Ritalin)
Psoriatic arthritis therapy: NSAIDs and traditional DMARDs Ann Rheum Dis doi:10.1136/ard.2004.030783 Updated information and services can be found at: References This article cites 50 articles, 7 of which can be accessed free at: Rapid responses Email alerting Receive free email alerts when new articles cite this article - sign up in the box at the Topic collections Articles