The Relevance of Stress and Trauma to Forensic Psychiatry.

This special section of the Journal of the American Academy of Psychiatry and the Law focuses on stress, trauma, and dissociative experiences in the context of forensic psychiatry. The deleterious effects of stress and traumatic experiences on mental health are well known to mental health professionals. Traumatic experiences of sufficient intensity may cause the development of specific mental health conditions, such as acute stress disorder, posttraumatic stress disorder (PTSD), adjustment disorder, anxiety disorders, and psychotic episodes. Acute stress and traumatic experiences may also be triggers for dissociation. The phenomenon of dissociation in forensic psychiatry is poorly delineated, whether by lack of clear definitions or by gaps in current knowledge. Dissociation may take many forms, and it may be considered either a disorder in itself or the symptom of another disorder. The term is often used broadly, and its relevance in the forensic context is not always clear. Yet, there are numerous instances where, from a forensic psychiatry perspective, dissociative phenomena are important. In the criminal arena, defendants’ claims of having had a dissociative experience at the time of committing a criminal action may give rise to a forensic assessment of criminal responsibility. Forensic psychiatrists have heard of the infamous case of Bianchi, the serial murderer who had convinced a few experts that he had multiple personalities and later admitted that he had faked the disorder. Perr discussed the complexity of a condition such as multiple personality disorder (or dissociative identity disorder) from both clinical and legal perspectives. In the civil arena, dissociation can also raise significant concerns with regard to the presence of PTSD and disability status. Forensic professionals are often called upon to conduct independent assessments of war veterans or other workers who have been exposed to traumatic events. Numerous cases of civil litigation have to do with claims of PTSD following motor vehicle accidents, harassment in the workplace, or maltreatment in childhood, to give only a few examples. The practice of forensic psychiatry requires experts to be knowledgeable in a variety of domains relevant to general psychiatry practice. Yet, many forensic professionals have received little specific training in the area of dissociation beyond the theoretical knowledge acquired through reading or lectures. However, the expertise necessary to assess and treat individuals with dissociative disorders is acquired with supervised training and years of clinical experience with this population. This knowledge is equally important for understanding dissociation and for assessing the validity of claims of dissociation. The task of evaluating these claims has many barriers. Suspicions of malingering are common, whether related to concerns that the defendant in a criminal case is seeking to avoid legal consequences, that a plaintiff wants to obtain a better monetary settlement, or that the individual’s degree of disability is less than portrayed. Claims of dissociation are not always easy to substantiate, owing to the lack of objective measurable evidence and subjectivity of symptoms and experiences reported. In a commentary, Granacher suggested that forensic psychiatrists, without standardized psychometric tests to measure the phenomenon of dissociation, lack the capacity to perform a scientific assessment of a claim Dr. Bourget is a forensic psychiatrist, Integrated Forensic Psychiatric Program, Royal Mental Health Centre, and Associate Professor of Psychiatry, University of Ottawa, Ottawa, Ontario, Canada. Address correspondence to: Dominique Bourget, MD, Royal Ottawa Mental Health Centre, 1145 Carling Avenue, Ottawa, Ontario, K1Z 7K4 Canada. E-mail: [email protected].