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Much has been written about how to conduct insanity defense evaluations, as well as how to operationalize the legal definitions of insanity. However, the insanity defense has never been categorized by a typology. This article describes a typology of six subtypes of the insanity defense: paranoid self-defense, "but it's mine," erotomanic stalking, deific decree, disorganized, and false report. Knowledge of these subtypes, while not all inclusive, can inform insanity defense evaluations, guide training, and potentially increase the reliability of forensic evaluators' opinions. In addition, such subtypes can generate future research regarding prevalence, interrater reliability, and associated features of the different subtypes.

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Recent research has suggested nationwide increases in the rates of referral for competence to stand trial (CST) evaluations across the United States. Many of these evaluations are for defendants charged only with misdemeanor offenses and for whom diversion programs are most appropriate. The present study was designed to analyze the characteristics of, and re-arrest outcomes for, defendants charged with misdemeanors ordered to undergo CST evaluations in a large metropolitan area. Overall, there was a high base rate of incompetent to stand trial (IST) opinions (over 70% of defendants) in this sample, with the greatest impairments in rational understanding and ability to assist counsel. Defendants opined IST were more likely to have a psychotic disorder, a history of psychiatric hospitalization, and greater abnormalities in thought content relative to their competent counterparts. Of concern, defendants opined IST, and especially those referred for crisis evaluations upon dismissal of the charges, were significantly more likely to be re-arrested than their counterparts. These data support the criminalization hypothesis, suggesting that criminal justice involvement for this subset of defendants inappropriately reflects psychiatric instability, supporting the need for more options for inpatient and outpatient treatment to effectively intervene in this process. Impact StatementDefendants who are charged with low-level offenses and evaluated for competency to stand trial are among the most psychiatrically unstable and severely mentally ill defendants. The increased rates of incompetency findings, higher re-arrest rates for repeat low-level offenses, and recommendations for crisis evaluations provide support for the criminalization of mental illness.

This study examines the use of Psychophysiologic Detection of Deception (Polygraphy) as part of an independent, comprehensive, fitness-for-practice evaluation. It compares the findings for 18 non-randomized polygraph subjects selected from 60 medical professionals referred for assessment between 2007 and 2014 for violating sexual boundaries. Information derived from polygraph examination of fitness-for-practice evaluation subjects was independently rated for seven variables and retrospectively compared with that from subjects who were not polygraphed. Consensus values were used as final ratings associated with each case. In 56% of the 18 polygraphed cases, important new information was uncovered about sexual boundary problems that had not been elicited beforehand by repeated interviews and other standard clinical methods. This rose to 73% among those cases determined to be unfit for practice. Various recommendations were made in each case to improve patient safety and to enhance professionalism through specific education, treatment, support, supervision, monitoring and practice restrictions. Results suggest that the polygraph appears to be a useful component of an independent, comprehensive evaluation for sexual misconduct, as it may provide additional information to better understand what happened and more accurately determine a strategy for possible rehabilitation of the physician.