“He’s such a narcissist” – a phrase you’ve most probably heard someone you know say. It is interesting to me how the narcissistic personality has come to symbolise what’s wrong with the modern world. The term has been thrown about a lot more since social media has taken over and it was possibly at its zenith just after Trump was elected. Hot on the lips of so many, but do we really know what it means and how it’s a problem?Read More
After publishing my post on Oscar Pistorius and his psychiatric evaluation last week, I had a few comments regarding the diagnostic process and how it has changed since the arrival of the DSM-5. The DSM (or Diagnostic and Statistical Manual of Mental Disorders), which is now in its fifth edition, is the “bible” of psychiatry and used throughout the world amongst doctors, psychiatrists and psychologists as the “gold standard” classification system for all mental and psychiatric disorders.
The DSM-5 came out last year. I am not even sure if tertiary hospitals like Weskoppies are using it yet because to get funding in South Africa for textbooks etc. can sometimes take months and even years but I thought I would mention it anyway.
Although I really don’t think it will matter much to the OP psychiatric evaluation, I will just briefly outline how the diagnostic process would work differently if the DSM-5 was used instead of the DSM-IV.
I mentioned the DSM-IV’s multi-axial system, which no longer exists in the DSM-5. The latest edition does not use a multi-axial system but instead lists all disorders (previously Axis I, Axis II, and Axis III) together and has replaced Axis IV with “significant psychosocial and contextual features” while removing Axis V (Global Assessment of Functioning or GAF) altogether.
This means that if OP is diagnosed with GAD and NPD, there will not be a distinction in terms of which Axes each diagnosis belongs to as both fall under the one axis with all the other mental and medical diagnoses.
Essentially, I don’t think using one or another diagnostic system is going to make much of a difference to the outcome of the case. The psychiatric team will still conduct the same procedures and a vaierty of other diagnoses will be on offer in addition to GAD, which is what the defence witness referred to.
“Oscar silly question and you’ll get a silly answer”
Almost everybody who is even vaguely interested in his murder trial will have heard by now that Oscar Pistorius (OP) is going to have to undergo a psychiatric evaluation, requested by state prosecutor, Gerrie Nel.
As you will remember, I referred to an article a few weeks ago that explored the possibility that OP has Narcissistic Personality Disorder (NPD). At that stage, the notion that he may have a psychiatric condition such as NPD was simply being tossed around haphazardly by members of the lay public as well as some journalists but since last week the spotlight has been thrust upon the psychiatric community, who are now expected to give formal opinions on his mental state.
Since news broke about this impending psychiatric evaluation, I have had quite a few people ask me to shed light on the process. I am in a privileged position here, you see, because not only am I a psychologist but I also did my internship training at Weskoppies Psychiatric Hospital, which may very well be where OP gets evaluated.
To placate your curiosity, I shall briefly outline what is involved in the state psychiatric evaluation and what some of the potential diagnoses may be.
At Weskoppies, where many high profile criminals such as Advocate Barbie have been evaluated, there are only two questions the psychiatric team made up of psychiatrists, psychologists, occupational therapists, social workers, and nursing staff need to answer.
1) Does the accused have the Capacity to Understand Court Proceedings?
2) Does the accused have a Mental Illness or Mental Defect that reduces his Criminal Responsibility?
Proving either of the above, according to The Criminal Procedures Act, is the only way of using mental illness as a defence.
In OP’s case, no 1 has already been ruled out because the court case would never have gotten to this stage if it were proven that OP’s mental state was so weakened that he couldn’t understand court proceedings. Usually this defence is only used for people who have intellectual disability or severe psychosis rendering them cognitively impaired and therefore unable to comprehend the way the law or the courts work.
This is not Oscar.
So therefore, as the judge already informed us, the 30 day evaluation will be focused around exploring whether OP has a mental illness or mental defect that can be used by the defence to prove that he can’t be held criminally responsible for his behaviour.
What is important to note here, is that the psychiatric team have to determine whether this hypothetical mental illness/defect was present at the time of the shooting.
To this end, each professional in the team has to evaluate OP’s mental state on that fateful night and they will have to look back in time to determine what his mental state was like at the moment of the crime. Their ultimate question will be: At that moment, was Oscar able to distinguish between right and wrong (i.e. was he able to appreciate the wrongfulness of the act) and then if so, was he able to act in accordance with this.
- Conduct lengthy psychiatric interviews in which they will obtain his full life history, his family background, his criminal history, and also importantly his psychiatric history.
- Administer a range of psychological and other tests. These will include personality tests, neuropsychological tests, tests for malingering (the technical term for faking a mental illness) and general cognitive tests that evaluate each and every cognitive process from intelligence to memory. Each test can take between 30min – 3 hrs to complete. It is an extremely rigorous process. To give an example, the MMPI (The Minnesota Multiphasic Personality Inventory) has over 500 items.
- Observe him during every single minute of every procedure. In addition to the formal interviews and tests, OP’s every move will be scrutinized. He will be evaluated on his appearance, attitude, behaviour, mood and cognitions.
- After each member of the team has concluded theses procedures, they will then meet and together they will formulate a diagnosis.
As we know, the defence’s witness, Psychiatrist Merryl Vorster, believes that OP can be diagnosed with Generalized Anxiety Disorder (GAD). This is an Axis 1 diagnosis.
But there are also four other Axes. The team will consider OP’s mental state in terms of these.
The DSM-IV organizes each psychiatric diagnosis into five dimensions (axes) relating to different aspects of disorder or disability:
- Axis I: All psychological diagnostic categories except mental retardation and personality disorder
- Axis II: Personality disorders and mental retardation
- Axis III: General medical condition; acute medical conditions and physical disorders
- Axis IV: Psychosocial and environmental factors contributing to the disorder
- Axis V: Global Assessment of Functioning (GAF score)
Common Axis I disorders include depression, anxiety disorders, bipolar disorder, ADHD, autism spectrum disorders, anorexia nervosa, bulimia nervosa, and schizophrenia.
Common Axis II disorders include personality disorders: paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, histrionic personality disorder, avoidant personality disorder, dependent personality disorder, obsessive-compulsive personality disorder; and intellectual disabilities.
Common Axis III disorders include brain injuries and other medical/physical disorders which may aggravate existing diseases or present symptoms similar to other disorders.
As you can see, personality disorders are recorded on Axis II. In my opinion, it is the Axis II diagnosis that is most interesting to this case. Before, the defence could single out OP’s anxiety to demonstrate how his mental state was weakened on the night of the shooting, but now they have opened pandora’s box because a team of professionals have been mandated to explore his entire personality matrix. The MMPI specifically has scores that relate to each of the personality disorders and so if there is even a hint of one, it will light up the test and together with the clinicians’ clinical impressions, a diagnosis of NPD may very well be on the cards.
In addition, and this is probably the case in the majority of the criminal cases evaluated at Weskoppies, they may also find that he has elements of Antisocial Personality Disorder (APD). When lay people talk about someone being a sociopath or psychopath, the professional talks about a patient having APD. The professionals at Weskoppies have seen their fare share. They therefore know all the tricks. I am confident that the team will not be fooled. Now we just have to wait and see.
Photo from www.theguardian.com
**Please note that the views expressed in this blog are my subjective and biased opinions, and cannot be used as expert testimony for forensic purposes