Helen M. Farrell, MD

Dear Dr. Mossman:

I practice in a region with few psychiatrists and very little public transportation. For many patients, coming to my office is inconvenient, expensive, or time-consuming. Sometimes, their emotional problems make it hard for them to travel, and sometimes, bad weather makes travel difficult. I am considering providing remote treatment via Skype. Is this a reasonable idea? What are the risks of using this technology in my practice? — Submitted by “Dr. A”

Diagnosing and treating patients without a face-to-face encounter is not new. Doctors have provided “remote treatment” since shortly after telephones were invented.¹ Until recently, however, forensic psychiatrists advised colleagues not to diagnose patients or start treatment based on phone contact alone.²

The Internet has revolutionized our attitudes about many things. Communication technologies that seemed miraculous a generation ago have become commonplace and have transformed standards for ordinary and “acceptable” human contact. A quick Internet search of “telephone psychotherapy” turns up hundreds of mental health professionals who offer remote treatment services to patients via computers and Web cams.

Physicians in many specialties practice telemedicine, often with the support and encouragement of state governments and third-party payers. To decide whether to include telepsychiatry in your psychiatric practice, you should know:

• what “telemedicine” means and includes
• the possible advantages of offering remote health care
• potential risks and ambiguity about legal matters.

Defining telemedicine

Studies of remote, closed-circuit “telediagnosis” extend back more than 4 decades, closely following mid-20^th century advancements in audio and video relay technologies that made space broadcasts possible.³ Then as now, “telemedicine” simply means conveying health-related information from 1 site to another for diagnostic or treatment purposes.⁴ It’s an adaptation of available technology to deliver care more easily, with the goal of improving patients’ access to care and health status.

Telemedicine usage accelerated as the Internet and related technologies developed. Telemedicine programs in the United States increased by 1,500% from 1993 to 1998.⁴ Telemedicine use has grown 10% annually in recent years and has become a $4 billion per year industry in the United States.⁵ Recently enacted federal legislation is likely to extend health care coverage to 36 million Americans and require coverage of pre-existing conditions. To make these changes affordable, health care delivery will need to exploit new, efficiency-enhancing technologies.⁶

Advantages of telemedicine

State governments and some third-party payers have recognized that telemedicine can overcome geographic and cost barriers to health services and patient education.^5,7-9 Although closed-circuit video transmission has served this purpose for some time, Skype—free software that allows individuals to make video phone calls over the Internet using their computers—is an option that doctors are using to treat patients.^10-12

Research suggests that telepsychiatry may provide huge benefits to medically underserved areas while reducing health care costs.⁴ Telepsychiatry can reduce travel time and expenses for professionals and patients, and it also may lower wait times and “no-show” rates (Table 1).⁴ Telepsychiatry lets patients see caregivers when winter weather makes roads unsafe. It may allow geriatric patients who can no longer drive to access psychiatric care and it lowers health care’s “carbon footprint,” making it “eco-friendly.”¹³

Social media strategies are playing an expanding role in medical education,^14,15 and this probably will help practitioners feel more at ease about incorporating the underlying technologies into work with patients. Increased use of laptops and mobile phones lends itself well to telepsychiatry applications,¹³ and studies have examined the feasibility of psychotherapies delivered via remote communication devices.¹⁶ Smartphone apps are being designed to assist mental health professionals¹⁷ and consumers.¹⁸

Table 1

Potential benefits of telemedicine

Potential pitfalls and drawbacks

Although convenience, access, cost, and fossil fuel savings may favor video-chat doctor visits, telemedicine has downsides, some of which apply specifically to psychiatry. First, no current technology provides psychiatrists with “the rich multidimensional aspects of a person-to-person encounter,”¹⁹ and remote communication may change what patients tell us, how they feel when they tell us things, and how they feel when we respond. Often, an inherent awkwardness affects many forms of Internet communication.²⁰

Also uncertain is whether Skype is compliant with the Health Insurance Portability and Accountability Act and protects doctor-patient privacy well enough to satisfy ethical standards—although it probably is far better than e-mail in this regard. Third-party payers often will not reimburse for telephone calls and may balk at paying for Skype-based therapy, even in states that require insurers to reimburse for telemedicine.

Psychiatrists typically have limited physical contact with patients, but we often check weight and vital signs when we prescribe certain psychotropic medications. Results from home- and drugstore-based blood pressure monitors may not be accurate enough for treatment purposes. Remote communication also reduces the quality of visual information,²⁰ which can be crucial—for example, when good lighting and visual resolution is needed to decide whether a skin rash might be drug-induced.

Telemedicine raises concerns about licensure and meeting adequate standards of care. Medical care usually is deemed to have occurred in the state where the patient is located. For example, only physicians licensed to practice medicine in California are legally permitted to treat patients in California. As is the case with any treatment, care delivered via telemedicine must include appropriate patient examination and diagnosis.²¹

Help and guidance

Despite these potential drawbacks, many state agencies recognize the promise of telemedicine, and have developed networks to promote it (Table 2).^7-9,22,23 These networks have various goals but share a common pattern of establishing infrastructure, policies, and organized results. In the future, states may adopt laws or regulations that address conflicts in malpractice standards and liability coverage, licensing, accreditation, reimbursement, privacy, and data protection policies that now may impede or inhibit use of telepsychiatric services across jurisdictional boundaries. Last year, Ohio produced regulations to guide psychiatrists in prescribing medication remotely without an in-person examination. The University of Hawaii suggested steps that its state legislature might take to help providers predict the potential legal ramifications of telemedicine.⁶

Further help for telepsychiatry practitioners may be found in practice standards and guidelines developed by the American Telemedicine Association.^24,25 These documents gave guidance and support for the practice of telemedicine and for providing appropriate telepsychiatry health services.

Table 2

Telemedicine services available in different states

What should Dr. A do?

In answer to Dr. A’s question, many factors favor including telepsychiatry in her practice. Yet we know little about the accuracy and reliability of psychiatric assessments made solely via Skype or other remote video technology in ordinary practice. Legislation and legal rules about acceptable practices are ambiguous, although in the absence of clear guidance, psychiatrists should assume that all usual professional standards and expectations about adequate care apply to treatment via Skype or other remote communication methods.

Related Resources

• Skype. www.skype.com.
• American Telemedicine Association. www.americantelemed.org.

Dear Dr. Mossman:

I practice in a region with few psychiatrists and very little public transportation. For many patients, coming to my office is inconvenient, expensive, or time-consuming. Sometimes, their emotional problems make it hard for them to travel, and sometimes, bad weather makes travel difficult. I am considering providing remote treatment via Skype. Is this a reasonable idea? What are the risks of using this technology in my practice? — Submitted by “Dr. A”

Diagnosing and treating patients without a face-to-face encounter is not new. Doctors have provided “remote treatment” since shortly after telephones were invented.¹ Until recently, however, forensic psychiatrists advised colleagues not to diagnose patients or start treatment based on phone contact alone.²

The Internet has revolutionized our attitudes about many things. Communication technologies that seemed miraculous a generation ago have become commonplace and have transformed standards for ordinary and “acceptable” human contact. A quick Internet search of “telephone psychotherapy” turns up hundreds of mental health professionals who offer remote treatment services to patients via computers and Web cams.

Physicians in many specialties practice telemedicine, often with the support and encouragement of state governments and third-party payers. To decide whether to include telepsychiatry in your psychiatric practice, you should know:

• what “telemedicine” means and includes
• the possible advantages of offering remote health care
• potential risks and ambiguity about legal matters.

Defining telemedicine

Studies of remote, closed-circuit “telediagnosis” extend back more than 4 decades, closely following mid-20^th century advancements in audio and video relay technologies that made space broadcasts possible.³ Then as now, “telemedicine” simply means conveying health-related information from 1 site to another for diagnostic or treatment purposes.⁴ It’s an adaptation of available technology to deliver care more easily, with the goal of improving patients’ access to care and health status.

Telemedicine usage accelerated as the Internet and related technologies developed. Telemedicine programs in the United States increased by 1,500% from 1993 to 1998.⁴ Telemedicine use has grown 10% annually in recent years and has become a $4 billion per year industry in the United States.⁵ Recently enacted federal legislation is likely to extend health care coverage to 36 million Americans and require coverage of pre-existing conditions. To make these changes affordable, health care delivery will need to exploit new, efficiency-enhancing technologies.⁶

Advantages of telemedicine

State governments and some third-party payers have recognized that telemedicine can overcome geographic and cost barriers to health services and patient education.^5,7-9 Although closed-circuit video transmission has served this purpose for some time, Skype—free software that allows individuals to make video phone calls over the Internet using their computers—is an option that doctors are using to treat patients.^10-12

Research suggests that telepsychiatry may provide huge benefits to medically underserved areas while reducing health care costs.⁴ Telepsychiatry can reduce travel time and expenses for professionals and patients, and it also may lower wait times and “no-show” rates (Table 1).⁴ Telepsychiatry lets patients see caregivers when winter weather makes roads unsafe. It may allow geriatric patients who can no longer drive to access psychiatric care and it lowers health care’s “carbon footprint,” making it “eco-friendly.”¹³

Social media strategies are playing an expanding role in medical education,^14,15 and this probably will help practitioners feel more at ease about incorporating the underlying technologies into work with patients. Increased use of laptops and mobile phones lends itself well to telepsychiatry applications,¹³ and studies have examined the feasibility of psychotherapies delivered via remote communication devices.¹⁶ Smartphone apps are being designed to assist mental health professionals¹⁷ and consumers.¹⁸

Table 1

Potential benefits of telemedicine

Potential pitfalls and drawbacks

Although convenience, access, cost, and fossil fuel savings may favor video-chat doctor visits, telemedicine has downsides, some of which apply specifically to psychiatry. First, no current technology provides psychiatrists with “the rich multidimensional aspects of a person-to-person encounter,”¹⁹ and remote communication may change what patients tell us, how they feel when they tell us things, and how they feel when we respond. Often, an inherent awkwardness affects many forms of Internet communication.²⁰

Also uncertain is whether Skype is compliant with the Health Insurance Portability and Accountability Act and protects doctor-patient privacy well enough to satisfy ethical standards—although it probably is far better than e-mail in this regard. Third-party payers often will not reimburse for telephone calls and may balk at paying for Skype-based therapy, even in states that require insurers to reimburse for telemedicine.

Psychiatrists typically have limited physical contact with patients, but we often check weight and vital signs when we prescribe certain psychotropic medications. Results from home- and drugstore-based blood pressure monitors may not be accurate enough for treatment purposes. Remote communication also reduces the quality of visual information,²⁰ which can be crucial—for example, when good lighting and visual resolution is needed to decide whether a skin rash might be drug-induced.

Telemedicine raises concerns about licensure and meeting adequate standards of care. Medical care usually is deemed to have occurred in the state where the patient is located. For example, only physicians licensed to practice medicine in California are legally permitted to treat patients in California. As is the case with any treatment, care delivered via telemedicine must include appropriate patient examination and diagnosis.²¹

Help and guidance

Despite these potential drawbacks, many state agencies recognize the promise of telemedicine, and have developed networks to promote it (Table 2).^7-9,22,23 These networks have various goals but share a common pattern of establishing infrastructure, policies, and organized results. In the future, states may adopt laws or regulations that address conflicts in malpractice standards and liability coverage, licensing, accreditation, reimbursement, privacy, and data protection policies that now may impede or inhibit use of telepsychiatric services across jurisdictional boundaries. Last year, Ohio produced regulations to guide psychiatrists in prescribing medication remotely without an in-person examination. The University of Hawaii suggested steps that its state legislature might take to help providers predict the potential legal ramifications of telemedicine.⁶

Further help for telepsychiatry practitioners may be found in practice standards and guidelines developed by the American Telemedicine Association.^24,25 These documents gave guidance and support for the practice of telemedicine and for providing appropriate telepsychiatry health services.

Table 2

Telemedicine services available in different states

What should Dr. A do?

In answer to Dr. A’s question, many factors favor including telepsychiatry in her practice. Yet we know little about the accuracy and reliability of psychiatric assessments made solely via Skype or other remote video technology in ordinary practice. Legislation and legal rules about acceptable practices are ambiguous, although in the absence of clear guidance, psychiatrists should assume that all usual professional standards and expectations about adequate care apply to treatment via Skype or other remote communication methods.

Related Resources

• Skype. www.skype.com.
• American Telemedicine Association. www.americantelemed.org.

Dear Dr. Mossman:

I practice in a region with few psychiatrists and very little public transportation. For many patients, coming to my office is inconvenient, expensive, or time-consuming. Sometimes, their emotional problems make it hard for them to travel, and sometimes, bad weather makes travel difficult. I am considering providing remote treatment via Skype. Is this a reasonable idea? What are the risks of using this technology in my practice? — Submitted by “Dr. A”

Diagnosing and treating patients without a face-to-face encounter is not new. Doctors have provided “remote treatment” since shortly after telephones were invented.¹ Until recently, however, forensic psychiatrists advised colleagues not to diagnose patients or start treatment based on phone contact alone.²

The Internet has revolutionized our attitudes about many things. Communication technologies that seemed miraculous a generation ago have become commonplace and have transformed standards for ordinary and “acceptable” human contact. A quick Internet search of “telephone psychotherapy” turns up hundreds of mental health professionals who offer remote treatment services to patients via computers and Web cams.

Physicians in many specialties practice telemedicine, often with the support and encouragement of state governments and third-party payers. To decide whether to include telepsychiatry in your psychiatric practice, you should know:

• what “telemedicine” means and includes
• the possible advantages of offering remote health care
• potential risks and ambiguity about legal matters.

Defining telemedicine

Studies of remote, closed-circuit “telediagnosis” extend back more than 4 decades, closely following mid-20^th century advancements in audio and video relay technologies that made space broadcasts possible.³ Then as now, “telemedicine” simply means conveying health-related information from 1 site to another for diagnostic or treatment purposes.⁴ It’s an adaptation of available technology to deliver care more easily, with the goal of improving patients’ access to care and health status.

Telemedicine usage accelerated as the Internet and related technologies developed. Telemedicine programs in the United States increased by 1,500% from 1993 to 1998.⁴ Telemedicine use has grown 10% annually in recent years and has become a $4 billion per year industry in the United States.⁵ Recently enacted federal legislation is likely to extend health care coverage to 36 million Americans and require coverage of pre-existing conditions. To make these changes affordable, health care delivery will need to exploit new, efficiency-enhancing technologies.⁶

Advantages of telemedicine

State governments and some third-party payers have recognized that telemedicine can overcome geographic and cost barriers to health services and patient education.^5,7-9 Although closed-circuit video transmission has served this purpose for some time, Skype—free software that allows individuals to make video phone calls over the Internet using their computers—is an option that doctors are using to treat patients.^10-12

Research suggests that telepsychiatry may provide huge benefits to medically underserved areas while reducing health care costs.⁴ Telepsychiatry can reduce travel time and expenses for professionals and patients, and it also may lower wait times and “no-show” rates (Table 1).⁴ Telepsychiatry lets patients see caregivers when winter weather makes roads unsafe. It may allow geriatric patients who can no longer drive to access psychiatric care and it lowers health care’s “carbon footprint,” making it “eco-friendly.”¹³

Social media strategies are playing an expanding role in medical education,^14,15 and this probably will help practitioners feel more at ease about incorporating the underlying technologies into work with patients. Increased use of laptops and mobile phones lends itself well to telepsychiatry applications,¹³ and studies have examined the feasibility of psychotherapies delivered via remote communication devices.¹⁶ Smartphone apps are being designed to assist mental health professionals¹⁷ and consumers.¹⁸

Table 1

Potential benefits of telemedicine

Potential pitfalls and drawbacks

Although convenience, access, cost, and fossil fuel savings may favor video-chat doctor visits, telemedicine has downsides, some of which apply specifically to psychiatry. First, no current technology provides psychiatrists with “the rich multidimensional aspects of a person-to-person encounter,”¹⁹ and remote communication may change what patients tell us, how they feel when they tell us things, and how they feel when we respond. Often, an inherent awkwardness affects many forms of Internet communication.²⁰

Also uncertain is whether Skype is compliant with the Health Insurance Portability and Accountability Act and protects doctor-patient privacy well enough to satisfy ethical standards—although it probably is far better than e-mail in this regard. Third-party payers often will not reimburse for telephone calls and may balk at paying for Skype-based therapy, even in states that require insurers to reimburse for telemedicine.

Psychiatrists typically have limited physical contact with patients, but we often check weight and vital signs when we prescribe certain psychotropic medications. Results from home- and drugstore-based blood pressure monitors may not be accurate enough for treatment purposes. Remote communication also reduces the quality of visual information,²⁰ which can be crucial—for example, when good lighting and visual resolution is needed to decide whether a skin rash might be drug-induced.

Telemedicine raises concerns about licensure and meeting adequate standards of care. Medical care usually is deemed to have occurred in the state where the patient is located. For example, only physicians licensed to practice medicine in California are legally permitted to treat patients in California. As is the case with any treatment, care delivered via telemedicine must include appropriate patient examination and diagnosis.²¹

Help and guidance

Despite these potential drawbacks, many state agencies recognize the promise of telemedicine, and have developed networks to promote it (Table 2).^7-9,22,23 These networks have various goals but share a common pattern of establishing infrastructure, policies, and organized results. In the future, states may adopt laws or regulations that address conflicts in malpractice standards and liability coverage, licensing, accreditation, reimbursement, privacy, and data protection policies that now may impede or inhibit use of telepsychiatric services across jurisdictional boundaries. Last year, Ohio produced regulations to guide psychiatrists in prescribing medication remotely without an in-person examination. The University of Hawaii suggested steps that its state legislature might take to help providers predict the potential legal ramifications of telemedicine.⁶

Further help for telepsychiatry practitioners may be found in practice standards and guidelines developed by the American Telemedicine Association.^24,25 These documents gave guidance and support for the practice of telemedicine and for providing appropriate telepsychiatry health services.

Table 2

Telemedicine services available in different states

What should Dr. A do?

In answer to Dr. A’s question, many factors favor including telepsychiatry in her practice. Yet we know little about the accuracy and reliability of psychiatric assessments made solely via Skype or other remote video technology in ordinary practice. Legislation and legal rules about acceptable practices are ambiguous, although in the absence of clear guidance, psychiatrists should assume that all usual professional standards and expectations about adequate care apply to treatment via Skype or other remote communication methods.

Related Resources

• Skype. www.skype.com.
• American Telemedicine Association. www.americantelemed.org.

Formerly called multiple personality disorder, dissociative identity disorder (DID) is a controversial diagnosis that challenges forensic psychiatrists, other mental health clinicians, legal professionals, the media, and the public. DID cases often present in the criminal justice system rather than in the mental health system, and the illness perplexes experts in both professions.

Individuals may commit criminal acts while in a dissociated state. A study that tracked 21 reported DID cases found that 47% of men and 35% of women reported engaging in criminal activity, including 19% of men and 7% of women who committed homicide.¹ Defendants occasionally use DID as a basis for pleading not guilty by reason of insanity (NGRI). Controversy over the DID diagnosis has contributed to debates about the disorder’s role in criminal responsibility.

The DID diagnosis

An American Psychiatric Association Work Group has proposed new diagnostic criteria for DID for DSM-5, which is scheduled to be published in May 2013.² Presently, DID is listed in DSM-IV-TR as an axis I disorder.³ Criteria for DID include the presence of ≥2 distinctive identities or personality states that recurrently take control of an individual’s behavior (Table 1).³ This is accompanied by an inability to recall important personal information to an extent that cannot be explained by ordinary forgetfulness. Patients with DID typically have a primary identity that is passive, dependent, guilty, and depressed, and alternate identities with characteristics that differ from the primary identity, commonly in reported age and gender, vocabulary, general knowledge, or predominant affect.³

Dissociative pathology may result from trauma, comorbid mental illness, or other medical issues, including complex partial seizures. Developmental theorists have proposed that severe sexual, physical, or psychological trauma in childhood predisposes an individual to develop DID.⁴ Theoretically, harm by a trusted caregiver forces a child to split off awareness and memory of the trauma to survive in the relationship. Later these memories and feelings are experienced as a separate personality. Because this process happens repeatedly, the patient develops multiple personalities; each has different memories and performs different functions, which may be helpful or destructive. Later, dissociation becomes a coping mechanism when individuals face stressful situations.⁵

Personality traits that may predispose patients to develop a dissociative disorder include mental absorption, suggestibility, ability to be easily hypnotized, and tendency to fantasize.⁶ Patients with dissociation also may meet criteria for posttraumatic stress disorder, borderline personality disorder, somatoform disorder, eating disorder, or substance use disorders.⁷

Table 1

DSM-IV-TR criteria for dissociative identity disorder

DID and NGRI

An insanity defense is raised in <1% of felony cases, and is successful in only a fraction of those.⁸ A criminal defendant who claims NGRI asserts that he committed the offense and asks the court to find him not culpable because of his mental state when the offense occurred.

The legal approach used by the defense in cases of NGRI due to DID will be determined by the jurisdiction in which the case is tried. The “Alter-in-control” approach considers the key issue as which “alter” (personality) was in control at the time of the offense and whether he or she met the insanity standard, the “Each-alter” approach considers whether each personality met the insanity standard, and the “Host-alter” approach considers whether the dominant or primary personality met the insanity standard.⁹

Legal and mental health professionals are divided on whether DID warrants an acquittal for insanity. The first time DID was recognized as a mental disorder that could excuse criminal responsibility occurred in State v Milligan (1978).¹⁰ The court declared serial rapist Billy Milligan insane due to lack of one integrated personality and therefore not culpable of the crimes he committed. Public outrage was extraordinary. Since this case, most DID defenses have not been successful (Table 2).^10-16

In a 1980 court case,¹¹ a defendant charged with murder pleaded NGRI due to having multiple personalities. The court found that having alter personalities was not necessarily a mental disease that would preclude responsibility for the murder.

In State v Grimsley (1982),¹² the defense used NGRI due to multiple personalities in a drunk driving case. The court ruled that it is immaterial what state of consciousness or personality the defendant was in as long as the personality controlling the behavior was conscious and aware of his or her actions.

In Kirkland v State (1983),¹³ attorneys for a woman who committed a bank robbery asserted an insanity defense based on a psychogenic fugue, which is sudden, unexpected travel away from home accompanied by inability to recall one’s past and confusion about identity or assumption of a new identity.³ The court found that the law adjudges criminal liability according to the person’s state of mind at the time of the act and will not inquire whether an individual possesses other personalities, fugues, or even moods in which he would not have performed the crime.

In State v Jones (1988),¹⁴ the court found the defendant guilty of murdering a woman he met at a bar despite expert testimony that his multiple personalities “paralyzed” him from knowing right from wrong.

More recently, courts have rejected the admissibility of DID evidence, including expert testimony, because the scientific evidence failed to meet reliability standards, and therefore is not ultimately useful to the judge or jury. In State v Greene (1998),¹⁵ the defendant claimed that 1 of his 24 alters was responsible for killing his therapist. The Supreme Court of Washington affirmed that evidence of Mr. Greene’s DID, including expert testimony, was not reliable and not admissible.

Similarly, in State v Lockhart (2000),¹⁶ Mr. Lockhart contested his conviction of first degree sexual assault on the basis that he was not permitted to present evidence of DID to support his insanity defense. The West Virginia Court held that the diagnosis of DID was speculative and therefore did not meet reliability standards for evidence.

Table 2

Using dissociative identity disorder* as a basis for not guilty by reason of insanity

Evaluating DID

Because the courts may ask psychiatrists to provide expert opinion on DID to assist with legal rulings, clinicians must remain vigilant to the possibility of DID as well as to defendants who may malinger multiple personalities to evade punishment. In such situations, factors to consider include the mental status examination, data and history collection, collateral information, criminal background, mental health history, history of abuse, and objective assessment tools.

Extensive field testing has shown that the Structured Clinical Interview for Dissociative Disorders (SCID-D) has good reliability and excellent validity.¹⁷ The SCID-D allows a trained interviewer to assess the severity of 5 dissociative symptoms: amnesia, depersonalization, derealization, identity confusion, and identity alteration.¹⁷ Other tools that may help assess a patient with suspected DID are listed in Table 3.

Patients who commit criminal acts while in a dissociated state may assert a defense of NGRI due to DID, but rarely has this defense been successful. Although a patient may have distinct personalities that control his or her behavior, this condition does not preclude criminal responsibility.

The role of hypnosis in evaluating DID is controversial. The introduction of pseudo-memories and potential for iatrogenic DID may complicate the clinical presentation and subsequent diagnosis.¹⁸

Table 3

Tools for diagnosing dissociative identity disorder

Related Resource

• West S, Noffsinger S. Is this patient not guilty by reason of insanity? Current Psychiatry. 2006;5(8):54-62.

Disclosure

Dr. Farrell reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Formerly called multiple personality disorder, dissociative identity disorder (DID) is a controversial diagnosis that challenges forensic psychiatrists, other mental health clinicians, legal professionals, the media, and the public. DID cases often present in the criminal justice system rather than in the mental health system, and the illness perplexes experts in both professions.

Individuals may commit criminal acts while in a dissociated state. A study that tracked 21 reported DID cases found that 47% of men and 35% of women reported engaging in criminal activity, including 19% of men and 7% of women who committed homicide.¹ Defendants occasionally use DID as a basis for pleading not guilty by reason of insanity (NGRI). Controversy over the DID diagnosis has contributed to debates about the disorder’s role in criminal responsibility.

The DID diagnosis

An American Psychiatric Association Work Group has proposed new diagnostic criteria for DID for DSM-5, which is scheduled to be published in May 2013.² Presently, DID is listed in DSM-IV-TR as an axis I disorder.³ Criteria for DID include the presence of ≥2 distinctive identities or personality states that recurrently take control of an individual’s behavior (Table 1).³ This is accompanied by an inability to recall important personal information to an extent that cannot be explained by ordinary forgetfulness. Patients with DID typically have a primary identity that is passive, dependent, guilty, and depressed, and alternate identities with characteristics that differ from the primary identity, commonly in reported age and gender, vocabulary, general knowledge, or predominant affect.³

Dissociative pathology may result from trauma, comorbid mental illness, or other medical issues, including complex partial seizures. Developmental theorists have proposed that severe sexual, physical, or psychological trauma in childhood predisposes an individual to develop DID.⁴ Theoretically, harm by a trusted caregiver forces a child to split off awareness and memory of the trauma to survive in the relationship. Later these memories and feelings are experienced as a separate personality. Because this process happens repeatedly, the patient develops multiple personalities; each has different memories and performs different functions, which may be helpful or destructive. Later, dissociation becomes a coping mechanism when individuals face stressful situations.⁵

Personality traits that may predispose patients to develop a dissociative disorder include mental absorption, suggestibility, ability to be easily hypnotized, and tendency to fantasize.⁶ Patients with dissociation also may meet criteria for posttraumatic stress disorder, borderline personality disorder, somatoform disorder, eating disorder, or substance use disorders.⁷

Table 1

DSM-IV-TR criteria for dissociative identity disorder

DID and NGRI

An insanity defense is raised in <1% of felony cases, and is successful in only a fraction of those.⁸ A criminal defendant who claims NGRI asserts that he committed the offense and asks the court to find him not culpable because of his mental state when the offense occurred.

The legal approach used by the defense in cases of NGRI due to DID will be determined by the jurisdiction in which the case is tried. The “Alter-in-control” approach considers the key issue as which “alter” (personality) was in control at the time of the offense and whether he or she met the insanity standard, the “Each-alter” approach considers whether each personality met the insanity standard, and the “Host-alter” approach considers whether the dominant or primary personality met the insanity standard.⁹

Legal and mental health professionals are divided on whether DID warrants an acquittal for insanity. The first time DID was recognized as a mental disorder that could excuse criminal responsibility occurred in State v Milligan (1978).¹⁰ The court declared serial rapist Billy Milligan insane due to lack of one integrated personality and therefore not culpable of the crimes he committed. Public outrage was extraordinary. Since this case, most DID defenses have not been successful (Table 2).^10-16

In a 1980 court case,¹¹ a defendant charged with murder pleaded NGRI due to having multiple personalities. The court found that having alter personalities was not necessarily a mental disease that would preclude responsibility for the murder.

In State v Grimsley (1982),¹² the defense used NGRI due to multiple personalities in a drunk driving case. The court ruled that it is immaterial what state of consciousness or personality the defendant was in as long as the personality controlling the behavior was conscious and aware of his or her actions.

In Kirkland v State (1983),¹³ attorneys for a woman who committed a bank robbery asserted an insanity defense based on a psychogenic fugue, which is sudden, unexpected travel away from home accompanied by inability to recall one’s past and confusion about identity or assumption of a new identity.³ The court found that the law adjudges criminal liability according to the person’s state of mind at the time of the act and will not inquire whether an individual possesses other personalities, fugues, or even moods in which he would not have performed the crime.

In State v Jones (1988),¹⁴ the court found the defendant guilty of murdering a woman he met at a bar despite expert testimony that his multiple personalities “paralyzed” him from knowing right from wrong.

More recently, courts have rejected the admissibility of DID evidence, including expert testimony, because the scientific evidence failed to meet reliability standards, and therefore is not ultimately useful to the judge or jury. In State v Greene (1998),¹⁵ the defendant claimed that 1 of his 24 alters was responsible for killing his therapist. The Supreme Court of Washington affirmed that evidence of Mr. Greene’s DID, including expert testimony, was not reliable and not admissible.

Similarly, in State v Lockhart (2000),¹⁶ Mr. Lockhart contested his conviction of first degree sexual assault on the basis that he was not permitted to present evidence of DID to support his insanity defense. The West Virginia Court held that the diagnosis of DID was speculative and therefore did not meet reliability standards for evidence.

Table 2

Using dissociative identity disorder* as a basis for not guilty by reason of insanity

Evaluating DID

Because the courts may ask psychiatrists to provide expert opinion on DID to assist with legal rulings, clinicians must remain vigilant to the possibility of DID as well as to defendants who may malinger multiple personalities to evade punishment. In such situations, factors to consider include the mental status examination, data and history collection, collateral information, criminal background, mental health history, history of abuse, and objective assessment tools.

Extensive field testing has shown that the Structured Clinical Interview for Dissociative Disorders (SCID-D) has good reliability and excellent validity.¹⁷ The SCID-D allows a trained interviewer to assess the severity of 5 dissociative symptoms: amnesia, depersonalization, derealization, identity confusion, and identity alteration.¹⁷ Other tools that may help assess a patient with suspected DID are listed in Table 3.

Patients who commit criminal acts while in a dissociated state may assert a defense of NGRI due to DID, but rarely has this defense been successful. Although a patient may have distinct personalities that control his or her behavior, this condition does not preclude criminal responsibility.

The role of hypnosis in evaluating DID is controversial. The introduction of pseudo-memories and potential for iatrogenic DID may complicate the clinical presentation and subsequent diagnosis.¹⁸

Table 3

Tools for diagnosing dissociative identity disorder

Related Resource

• West S, Noffsinger S. Is this patient not guilty by reason of insanity? Current Psychiatry. 2006;5(8):54-62.

Disclosure

Dr. Farrell reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Formerly called multiple personality disorder, dissociative identity disorder (DID) is a controversial diagnosis that challenges forensic psychiatrists, other mental health clinicians, legal professionals, the media, and the public. DID cases often present in the criminal justice system rather than in the mental health system, and the illness perplexes experts in both professions.

Individuals may commit criminal acts while in a dissociated state. A study that tracked 21 reported DID cases found that 47% of men and 35% of women reported engaging in criminal activity, including 19% of men and 7% of women who committed homicide.¹ Defendants occasionally use DID as a basis for pleading not guilty by reason of insanity (NGRI). Controversy over the DID diagnosis has contributed to debates about the disorder’s role in criminal responsibility.

The DID diagnosis

An American Psychiatric Association Work Group has proposed new diagnostic criteria for DID for DSM-5, which is scheduled to be published in May 2013.² Presently, DID is listed in DSM-IV-TR as an axis I disorder.³ Criteria for DID include the presence of ≥2 distinctive identities or personality states that recurrently take control of an individual’s behavior (Table 1).³ This is accompanied by an inability to recall important personal information to an extent that cannot be explained by ordinary forgetfulness. Patients with DID typically have a primary identity that is passive, dependent, guilty, and depressed, and alternate identities with characteristics that differ from the primary identity, commonly in reported age and gender, vocabulary, general knowledge, or predominant affect.³

Dissociative pathology may result from trauma, comorbid mental illness, or other medical issues, including complex partial seizures. Developmental theorists have proposed that severe sexual, physical, or psychological trauma in childhood predisposes an individual to develop DID.⁴ Theoretically, harm by a trusted caregiver forces a child to split off awareness and memory of the trauma to survive in the relationship. Later these memories and feelings are experienced as a separate personality. Because this process happens repeatedly, the patient develops multiple personalities; each has different memories and performs different functions, which may be helpful or destructive. Later, dissociation becomes a coping mechanism when individuals face stressful situations.⁵

Personality traits that may predispose patients to develop a dissociative disorder include mental absorption, suggestibility, ability to be easily hypnotized, and tendency to fantasize.⁶ Patients with dissociation also may meet criteria for posttraumatic stress disorder, borderline personality disorder, somatoform disorder, eating disorder, or substance use disorders.⁷

Table 1

DSM-IV-TR criteria for dissociative identity disorder

DID and NGRI

An insanity defense is raised in <1% of felony cases, and is successful in only a fraction of those.⁸ A criminal defendant who claims NGRI asserts that he committed the offense and asks the court to find him not culpable because of his mental state when the offense occurred.

The legal approach used by the defense in cases of NGRI due to DID will be determined by the jurisdiction in which the case is tried. The “Alter-in-control” approach considers the key issue as which “alter” (personality) was in control at the time of the offense and whether he or she met the insanity standard, the “Each-alter” approach considers whether each personality met the insanity standard, and the “Host-alter” approach considers whether the dominant or primary personality met the insanity standard.⁹

Legal and mental health professionals are divided on whether DID warrants an acquittal for insanity. The first time DID was recognized as a mental disorder that could excuse criminal responsibility occurred in State v Milligan (1978).¹⁰ The court declared serial rapist Billy Milligan insane due to lack of one integrated personality and therefore not culpable of the crimes he committed. Public outrage was extraordinary. Since this case, most DID defenses have not been successful (Table 2).^10-16

In a 1980 court case,¹¹ a defendant charged with murder pleaded NGRI due to having multiple personalities. The court found that having alter personalities was not necessarily a mental disease that would preclude responsibility for the murder.

In State v Grimsley (1982),¹² the defense used NGRI due to multiple personalities in a drunk driving case. The court ruled that it is immaterial what state of consciousness or personality the defendant was in as long as the personality controlling the behavior was conscious and aware of his or her actions.

In Kirkland v State (1983),¹³ attorneys for a woman who committed a bank robbery asserted an insanity defense based on a psychogenic fugue, which is sudden, unexpected travel away from home accompanied by inability to recall one’s past and confusion about identity or assumption of a new identity.³ The court found that the law adjudges criminal liability according to the person’s state of mind at the time of the act and will not inquire whether an individual possesses other personalities, fugues, or even moods in which he would not have performed the crime.

In State v Jones (1988),¹⁴ the court found the defendant guilty of murdering a woman he met at a bar despite expert testimony that his multiple personalities “paralyzed” him from knowing right from wrong.

More recently, courts have rejected the admissibility of DID evidence, including expert testimony, because the scientific evidence failed to meet reliability standards, and therefore is not ultimately useful to the judge or jury. In State v Greene (1998),¹⁵ the defendant claimed that 1 of his 24 alters was responsible for killing his therapist. The Supreme Court of Washington affirmed that evidence of Mr. Greene’s DID, including expert testimony, was not reliable and not admissible.

Similarly, in State v Lockhart (2000),¹⁶ Mr. Lockhart contested his conviction of first degree sexual assault on the basis that he was not permitted to present evidence of DID to support his insanity defense. The West Virginia Court held that the diagnosis of DID was speculative and therefore did not meet reliability standards for evidence.

Table 2

Using dissociative identity disorder* as a basis for not guilty by reason of insanity

Evaluating DID

Because the courts may ask psychiatrists to provide expert opinion on DID to assist with legal rulings, clinicians must remain vigilant to the possibility of DID as well as to defendants who may malinger multiple personalities to evade punishment. In such situations, factors to consider include the mental status examination, data and history collection, collateral information, criminal background, mental health history, history of abuse, and objective assessment tools.

Extensive field testing has shown that the Structured Clinical Interview for Dissociative Disorders (SCID-D) has good reliability and excellent validity.¹⁷ The SCID-D allows a trained interviewer to assess the severity of 5 dissociative symptoms: amnesia, depersonalization, derealization, identity confusion, and identity alteration.¹⁷ Other tools that may help assess a patient with suspected DID are listed in Table 3.

Patients who commit criminal acts while in a dissociated state may assert a defense of NGRI due to DID, but rarely has this defense been successful. Although a patient may have distinct personalities that control his or her behavior, this condition does not preclude criminal responsibility.

The role of hypnosis in evaluating DID is controversial. The introduction of pseudo-memories and potential for iatrogenic DID may complicate the clinical presentation and subsequent diagnosis.¹⁸

Table 3

Tools for diagnosing dissociative identity disorder

Related Resource

• West S, Noffsinger S. Is this patient not guilty by reason of insanity? Current Psychiatry. 2006;5(8):54-62.

Disclosure

Dr. Farrell reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.