A SHORT FORENSIC TALE

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In which we continue our exploration of the definition of a mental disorder:

DSM-5 (page 20): “A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotional regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning…The diagnosis of a mental disorder should have clinical utility.  It should help clinicians to determine prognosis, treatment plans, and potential treatment outcomes for their patients.”

It would hardly be surprising if the reader finds him/herself wondering what constitutes a clinically significant disturbance.  This looks to be a bit of a tautology in that the area of dysfunction is to indicate a syndrome of disturbance, while the syndrome of disturbance is to indicate the area of dysfunction, all to be determined clinically, that is by a clinician.  Is this about the chicken or about the egg?  Or might this really be about the clinician.  The problem is we don’t know from this definition.  Clinically significant disturbance is determined by the clinician, usually a psychiatrist, just as clinical utility is determined by the clinician as are clinical prognosis, treatment plans, and potential treatment outcomes.  This might give a concerned patient cause to wonder what this is all about anyway, the clinician or the patient?  And what happens if the clinician makes an incorrect determination either through insufficient information, inadequate training or experience, and/or lacking time or interest to consider the cause and nature of the clinician perceived dysfunction.

Is there another way, you might ask?  To that question I respond with a definite maybe, but it first requires the untying of knots.  I’ll blaspheme and say that this definition is both poorly conceived and poorly written.  I will go further and say that a lot of my previous discussions have addressed misconceptions and unanswered questions that an expert writing the DSM would not recognize if all research is generated in an academic setting or even in a clinical setting without a good, solid grounding in the real world.  This seems to be the source of the problem.  There is such a rush to prescribe that the clinician prescribing spends what little time is available looking for symptoms without considering other explanations for what might be causing them.

I recall that, after my internship, I continued working on the Forensic treatment unit at the same hospital in which I had interned.  One of the patients was a man of about 50, relatively short, stocky in build with a blunted affect, although he would smile occasionally and appropriately.  He had a head of gray stubble from a buzz cut, a head that some of the taller patients liked to rub for luck and comfort; and, as he told me, he liked to have his head rubbed by them.  Being new to the situation and to this type of patient, I asked about him and was told by staff that he was delusional.  This assessment wasn’t said once, but many times, although the source of it was never made clear, until eventually I asked, “What makes you say he is delusional?”  “Because he is always saying, when he gets out of here, he is going to go build a house.”  “Really?  That’s enough to make you think he is delusional?”  “Yes. That’s all he talks about is building a house,” and the speaker concluded by insisting, “He doesn’t know how to build a house.”  After a couple of months of hearing the same thing over and over again, I had to ask the patient, “What’s the first thing you do when you build a house?”  “Pour the foundation.”  “Have you ever built a house before?”  “Yes.”  “Do you own property where you can build?” “Yes.”  Well, I thought, this might not be delusional.  So, what must his diagnosis be then?  As I learned, he was a gentle soul, who was arrested and convicted of assault with a deadly weapon after police pulled him over and he got out of the car with a rifle that he was not pointing at anyone.  As he told me, he wasn’t angry at the time and wasn’t threatening.  He just happened to be holding his gun, which he did not intend to use.  He couldn’t even remember why he was holding it.

We might wonder whether his memory of this event was faulty or also a result of delusions.  Except for the fact that the weapon was not concealed and therefore was legal to have in his possession even as he approached officers of the law, this would simply be considered bad judgment.  He might suffer from using bad judgment, and many people do.  Poor judgment many not be impaired judgment and, for this reason, many not necessarily be clinically significant, remembering that impaired judgment is a symptom associated with several psychiatric diagnoses.  Delusions, however, are considered clinical symptoms.  Perhaps for planning his house or for some other reason unknown to me like impaired judgment, he was considered to have delusions and, like everyone else on the ward, he had his medications to take.  I would add that, whether because he was properly medicated or because of his character, he displayed traits that might be considered admirable, perhaps evolved.  For example, his attitude toward his situation was undisturbed and calm.  And his “delusion” of building a house seemed less symptomatic than an appropriate way to encounter a highly stressful living situation on a criminally insane treatment ward.  By planning to build his house, he kept a realistic, well-adjusted hope, something he could look forward to when he would get out.

Fresh out of a doctoral program, I was the least experienced of staff and had all the lack of confidence you would expect from someone working with mentally patients who committed felonies and that the court sent to the hospital for treatment.  Despite this, I learned that the record that would be used to determine whether that patient would be eligible for release was the very same chart that contained this patient’s numerous statements about building a house, statements that were used as the basis of determining whether he continued to be mentally ill, the severity of his symptoms, and to determine the likelihood that he might again take his rifle with him if he were to be stopped by police.

I like to imagine the cops coming to check on him at the house he built with his own hands, only to find him sweeping the threshold and welcome mat.  The man I met would have greeted them.  If they felt comfortable, they might have even enjoyed the calm pleasure of rubbing his head.  He probably wouldn’t have minded and might even have enjoyed the attention.  He used to enjoy it at any rate when he was an inpatient.