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Handbook of Forensic Psychiatric Practice in Capital Cases


Diagnosis allows for the categorisation of mental disorders based upon internationally recognised criteria. Diagnosis will usually be the starting point from which much which is important clinically and legally will flow, including in terms of some likely relevance to legal questions at issue. Psychiatric diagnoses are almost all based on the presence of signs and symptoms, and do not rest on establishing aetiology or pathology. In other words, they are often best viewed as syndromes rather than diseases. Tis can lead to questioning of the validity of the diagnosis in legal settings, where criticism might be levelled at the psychiatrist for making a diagnosis based on what the patient has told them. However, diagnosis relies upon far more than merely what the patient, or defendant, tells the doctor.


Formulation goes beyond diagnosis in that it amounts to offering an ‘understanding’ of the individual’s mental functioning and behaviour, in terms of symptoms but also in terms of ‘psychological mechanisms’.


Process


Te diagnostic process should always incorporate all available information, including collateral information from family and friends when possible. Establishing the presence of symptoms should not be approached with naivety, but with recognition that someone engaged in legal proceedings might seek to fabricate or exaggerate symptoms. Te consistency of symptoms with other reports, any incongruity between the description of symptoms and their apparent manifestation, the reporting of highly unusual or unheard of symptoms, or the over-reporting of symptoms should all be considered. If there is significant concern about the veracity of symptoms reported, then psychological testing can be undertaken to assist in establishing whether malingering or fabrication of symptoms is occurring (see Chapter 5).


Ultimately, however, fabrication is both difficult effectively to achieve and relatively unusual. And what is looked for, as in all medicine, is whether there are enough ‘pieces of the picture in the jigsaw’ to be convincing that ‘the picture is there’. Tis means that the presence of one or more pieces of a particular type can reinforce the likely validity of others. Tis goes beyond the legal analogy of ‘corroborating evidence’, in that there is mutual reinforcement of the likely validity of pieces ‘across the picture’, whilst the presence of pieces that ‘do not fit’ will tend to cast doubt on the picture that is observed.


In psychiatry, and in particular in capital cases, since the values of the assessor can potentially be somewhat determining of decisions about diagnosis, it is important to have insight into one’s values and to recognise that they can influence decision making. Such insight is an important safeguard against bias, alongside a conscious adherence to the pursuit of honesty.


Classification


Diagnosis should be based on one of the two recognised classification systems: Te World Health Organisation’s International Classification of Diseases, 10th Edition (ICD-10) or the American Psychiatric Association’s Diagnostic and Statistical Manual, 4th Edition (DSM-IV). Both of these manuals are periodically revised and new editions of each are expected soon.


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