Neuroimaging offers great potential to clinicians and researchers for a host of mental and physical conditions. The use of imaging has been trumpeted for forensic psychiatric and psychological evaluations to allow greater insight into the relationship between the brain and behavior. The results of imaging certainly can be used to inform clinical diagnoses; however, there continue to be limitations in using neuroimaging for insanity cases due to limited scientific backing for how neuroimaging can inform retrospective evaluations of mental state. In making this case, this paper reviews the history of the insanity defense and explains how the use of neuroimaging is not an effective way of improving the reliability of insanity defense evaluations.

Purpose Response style evaluation is a fundamental component of forensic examinations. This retrospective study aims to evaluate how measures of feigning performed with individuals with intellectual disabilities (ID) who were undergoing competency to proceed to trial evaluations. Design/methodology/approach Using a known-groups design (ID vs non-ID) with 145 individuals, 37 individuals met diagnostic criteria for ID. The individuals were administered the Miller Forensic Assessment of Symptoms Test (M-FAST; Miller, 2001), the Inventory Legal Knowledge (ILK; Musick and Otto, 2010), the Evaluation Competency to Stand Trial-Revised, atypical presentation scale (ATP; Rogers et al., 2004b) and the Competence Assessment for Standing Trial-Mental Retardation (Everington and Luckasson, 1992). Findings The total ILK demonstrated differences between groups with a large effect size (Cohen’s d = 1.02). Six items on the ILK had over a 30% difference as a function of group. However, two revised scales from the ILK, the R-ILK-90 and the R-ILK-95 (Rogers et al., 2017), did not demonstrate differences as a function of group membership with small effect sizes (Cohen’s ds = 0.02 and 0.29). The M-FAST total score and ATP scales were not different between groups, although results demonstrated that individuals with ID would be potentially more at risk to for misclassification as feigning on the M-FAST. Research limitations/implications This study has several limitations. It is a retrospective study with a relatively small sample size so additional research is needed to substantiate the results. However, this study highlights the potential for individuals with intellectual disabilities to be disadvantaged when undergoing competency to stand trial evaluations. Practical implications This manuscript shows that individuals with ID are at-risk for being mislabeled as feigning when employing standard measures of response style testing if appropriate cautions are not used. However, revised measures that take into account baseline information of legal knowledge offer a way forward that may prevent false positives with individuals with ID. Social implications The mislabeling of individuals with ID could lead to significant problems, including harsh sentences and unnecessary incarcerations. This manuscript provides real-world data and encourages clinicians to be mindful when evaluation individuals with ID for court-ordered evaluations. Originality/value This manuscript is critical, as it shows that caution is needed when using instruments of feigning with individuals with ID who are undergoing competency evaluations. This has value for clinicians who are tasked with completing these evaluations for the courts.

Relations between representatives of the legal profession and psychiatrists cannot be regarded with much satisfaction by either side?except in so far as satisfaction can be obtained by acid criticism of the other. The fundamental difficulties, though clear, are not always evident to the man in the street and are particularly easy to neglect when involved in the highly sensational atmosphere of a murder trial; this is of course particularly so if the details are horrific or sexual or both and if a plea of insanity is raised in defence. It may therefore be helpful to restate the points at issue. The first point is that lawyers and doctors talk in different terms. This is not quite so simple as to say, in the words of a judge, that one language is forensic and one scientific, for the confusion is made worse confounded by the fact that certain terms are used by the two professions in different senses. Further, it is very easy for discussion to get bogged down in terminological misconception : readers of the Heath trial?just published in the Notable British Trial Series (William Hodges, Glasgow, 1953)?will notice the confusion of "moral defect" and "moral insanity". The second point is that the methods of law and medicine in arriving at the facts of a case are very different. The law holds that the truth will best come to light by allowing opposing counsel to bring forward opposing views, in black or white. To the doctor much is grey, and this is especially so for the psychiatrist who realises that if he is to get a full account of the patient's conduct and motives, he must show the greatest sympathy and tolerance. Because of this and because of the deeper understanding he may thus obtain, he is likely to be (as well as to seem) more sympathetic, either in his consulting room or in court.