Contextual comments on ‘Clinical psychiatry and neuropsychiatry in the forensic context’: This is a ‘special presentation’ of ‘Clinical psychiatry and neuropsychiatry in the forensic context’. This 2-hour series of related lectures consists of a quarter hour introduction and then three half-hour lectures followed by questions. The presenter, Dr Vernon Neppe, MD, PhD, Fellow of the Royal Society (SAf), Distinguished Fellow of the American Psychiatric Association, is an internationally recognized forensic and clinical expert. The author has published and presented on facets of all the three areas and written a forensic book How Attorneys Can Best Utilize Their Medical Expert Witness: A Medical Expert’s Perspective   (Second Edition) Vernon M Neppe. http://www.brainvoyage.com/attorneyadvice.php. 

.  Dr. Neppe is an international expert on the four topics below, both forensically and clinically. He is possibly a world authority on the management and treatment of Tardive Dyskinesia and related conditions, and will discuss the essential details. He is commonly used in head injuries. And he has developed a specialized standardized protocol for evaluating the neuropsychiatric patient clinically and forensically.

There are several key clinical areas to examine in patients with psychiatric disturbances in the medicolegal context. One of the most distressing is handling tardive dyskinesia. Another critical one is the forensic implications of closed and open head injuries, with all its different variants. The appropriate evaluation of forensic patients is important, and this has included a series of structured tests that have been developed at the Pacific Neuropsychiatric Institute over many years.

Tardive Dyskinesia (TD) is an important, sometimes incurable, major medical condition caused by long-term neuroleptic treatment (antipsychotic medications as well as gastro-intestinal medications such as metoclopramide). TD has consequently become possibly the primary drug-induced neuropsychiatric forensic condition. Consequently, civil litigation is a major consideration. Prevention of TD on clinical—for the good of the patient— and medicolegal grounds has become a necessity for all physicians, particularly psychiatrists. Physicians must diminish their civil litigation risks. Several steps for ensuring proper clinical evaluation and management are commonly not performed. The follow-up is complex, and many psychiatrists do not have the expertise themselves and should refer to appropriate experts in movement disorders to assist in the treatment of patients. This management is highly specialized. Moreover, the differential diagnosis must be carefully examined. In evaluation, there are areas of neglect. All patients at risk (i.e. on neuroleptics currently or recently) must be tested regularly: The most effective specific TD scale is the STRAW, developed by Neppe in 1989. This should be performed in conjunction with non-specific tests like the AIMS, Simpson-Angus and possibly SCT Hans evaluations. Videotaping of TD patients is key for monitoring progress in forensic cases, and sometimes clinically. Management requires ongoing interventions to prevent the development of TD and ensure the condition is recognized as soon as practicable. Treatment with pharmacological agents is critical. Amongst these are high-dose buspirone as the most successful treatment, and this appears far more effective, cheaper, and with fewer side-effects than tetrabenazine and likely valbenazine, though they’ve not been compared yet.

Traumatic brain injury (TBI) is very common, ranging from individuals who do not even recognize that they hit their head, to simple concussional injuries, to those who have unrecognized focal abnormalities in their brain, to those who spend days, weeks, months and even years in deep coma. Concussion particularly is a common diagnosis and yet the many varieties of focal brain injury are seldom diagnosed. Management evaluation is different during the acute, compared with the chronic, residual phases. Focal injuries, particularly in the temporal lobes and frontal lobes, are commonly missed, and these can have disastrous clinical and forensic consequences, and yet are commonly helped with appropriate medications (including anticonvulsants and azapirones). Evaluations must be adequate at the time. Patients require proper evaluations and appropriate and detailed testing. This requires particular testing. Evaluation of prior medical records is critical.

Cognitive rehabilitation previously was expensive and lengthy. The advent of computer programs have made management easier and rehabilitation cheaper—this is important medicolegally.

Certain less well-known tests such as the ‘INSET’ (Inventory of Neppe of Symptoms of Epilepsy and the Temporal Lobe) and ‘SOBIN’ (Soft Organic Brain Inventory of Neppe) are very important structured ways of monitoring symptoms clinically and in follow up. Furthermore, specialized techniques like Home Ambulatory Electroencephalography, and neuroradiological evaluations like ‘contrast MRI’, ‘contrast CT’, sometimes SPECT of the head, and occasionally PET scanning, and are beneficial but very costly.

In TBIs, we must consider the roles in civil litigation of specialist plaintiff or defense experts, as there may be contradictions in their roles as treaters and forensic experts. Recently, chronic traumatic encephalopathy (CTE) has become increasingly recognized in football players and other contact sports, and has become a major potential forensic kind of repetitive TBI. There is a need for classification of head injury with its forensic applications. The author has proposed this.

A major basis of litigation is substandard care. Because of the litigious nature of American medical practice, every clinical patient could be a potential forensic case. Treatments are frequently off-label and frequently revisions of management are needed. Clinicians may exhibit substandard care. Therefore, what skills should we apply to evaluate the forensic neuropsychiatric patient and how do we do so? Management within the requisite standard of care may be more easily applied by appropriate evaluation and management. At my institute, we evaluate patients clinically and some forensically, applying standard techniques but recognizing that individual elements must be applied. When patients are at risk, we ensure that all medicolegal elements are taken into account. Clearly previous medical and psychosocial histories are important, with knowledge of comparative norms, and progress over time. We must recognize there are limitations to standardized neuropsychological testing and that may be over-inclusive or not found because each individual is different and baseline data including education, background, and previous exposures to tests must be accounted for. The role of repetitive individualized monitoring over time is important and we apply a series of broad psychiatric and neurological questionnaires: the Diagnostic Screen is a series of 11 detailed questionnaires. The INSET and SOBIN are very valuable. Perspectives about why repeated testing over time might produce different results must be examined. Careful methods of looking at patient malingering, motivation and fatigue are critical. Data must be appropriately correlated, and all records adequately examined. Outside validations by family members, friends, and sometimes law-givers are important.