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.
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.1 Perr2 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, Granacher3 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 of dissociative amnesia. We must acknowledge, however, that there is no such thing as a scientific psychometric test to replace clinical judgment, and this deficit is affirmed clearly in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).4 The DSM is the contemporary gold standard in the broad scientific community with regard to the approach to diagnosis. Results obtained on psychometric testing are not part of diagnostic criteria for any DSM diagnosis. Ultimately, all psychiatric diagnoses are based on a clinical assessment that will take into account a variety of information, such as self-report of symptoms, background, and contextual information, and finally, clinical observations that will permit formulation of a clinical diagnosis based on the dimensional approach put forward in the DSM. As we will see in this series of papers, the DSM is indeed an evolving instrument that is by no means perfect.
The impetus to compile this special section on stress and trauma was to introduce or review notions of dissociative PTSD in various forensic contexts, illustrating the complexity germane to the assessment and treatment of these disorders. In the span of my career as a forensic psychiatrist, I have encountered a few complex legal cases of accused individuals claiming dissociation. I found that critical resources to inform these cases and to allow one to present them in a coherent way before the court were limited and not very helpful.
The first paper in this section, by Bourget, Gagné, and Wood, is a review of general concepts related to dissociation, DSM diagnoses, and forensic implications for assessment in a forensic context. This article emphasizes several difficulties and limitations with regard to assessing individuals involved in civil and criminal proceedings. Some tips and guidelines are offered to assist the expert in the evaluation of claims of dissociation. Two original papers by Tedeschi and Billick deal with PTSD in children, discussing the response to trauma in youth and the evolution of the DSM diagnosis of PTSD in children and adolescents. They address the implications for forensic experts who evaluate youth and provide testimony in court. Regehr and LeBlanc examine the impact of PTSD and acute stress on performance and decision-making in emergency service workers in the context of psychiatric disability.
This collection of papers is intended to provide some useful insights and increase awareness of a phenomenon that has become a focus of concern in many instances, as illustrated throughout the texts. There is much more to this topic that has not been covered in these papers. For instance, the neurobiological processes underlying the development of maladaptive responses to stress, such as dissociation, are still poorly understood. Novel methods of investigating an organ as complex as the brain are still being developed and refined. The current state of knowledge is still too limited to allow pinpointing of the exact mechanisms by which dissociative experiences occur in individuals.
The topic of stress and trauma is broad and most challenging for forensic psychiatry. We hope that this modest contribution will be helpful to forensic psychiatrists when they are asked to perform assessments of individuals claiming dissociation or presenting a clinical picture consistent with dissociation.