Psychiatry & Behavioral Science

Psychiatry & Behavioral Science __ 2018

I1 Elder Abuse: Perception and Knowledge of the Phenomenon by Healthcare Workers From Two Italian Hospitals

Ignazio Grattagliano, PsyD*, University of Bari, Via Mauro Amoruso 68, , Bari 70124, ITALY; Graziamaria Corbi, PhD, via Giovanni Paolo II-Loc Tappino, Campobasso 86100, ITALY; Carlo P. Campobasso, MD, PhD, University of Campania, Dept Experimental Medicine, via Santa Maria di Costantinopoli, 16, Napoli 80138, ITALY; Lidia Scarabaggio, RN, University of Campobasso, Via F. De Sanctis 1, Campobasso 86100, ITALY; Roberto Catanesi, MD, P.za Giulio Cesare, Bari 70124, ITALY; Nicola Ferrara, MD, via Giovanni Paolo II-Loc Tappino, Campobasso 86100, ITALY; Carlo Sabbà, MD, University of Bari, P.za Giulio Cesare, Bari 70124, ITALY; and Giorgio Fiore, MD, University of Bari, Piazza Giulio Cesare, Bari 70124, ITALY

After attending this presentation, attendees will better understand the importance for forensic and healthcare practitioners to recognize early signs of physical, psychological, and emotional abuse on elderly people. This presentation will impact the forensic science community by demonstrating that the absence of early recognition of elder abuse can be a major disadvantage for the community. Background: With a rapidly aging population in countries worldwide, the number of elderly adults vulnerable to abuse, neglect, and exploitation is expected to grow. Hospital personnel usually play a crucial role in identifying mistreatment and making appropriate referrals as they are usually the first people with a medical background to see these victims. Physicians and nurses are also mandatory reporters of elder abuse in accordance with state requirements. Goals: To establish a level of awareness and perception of elder abuse by healthcare workers, to understand if these workers are able to recognize and report elder abuse properly, and to identify the physical elements of abuse and neglect. Methods: The research tool was a survey of 35 questions. Selected questions were chosen from previously validated questionnaires used in other similar published survey studies. Participants were represented by physicians, nurses, and care assistants working in the internal medicine and geriatric services of two different University Hospitals, representative of the Italian public health system in Southern Italy (Cardarelli Hospital of the University of Molise and Policlinico of the University of Bari “Aldo Moro”). Results: The results included 98 of 142 administered questionnaires (69.0% response rate). All data were further analyzed, taking into account age, gender, work experience, and qualifications. For the majority of all personnel, neglect represents a type of abuse; however, approximately 40% of the physicians and 37% of the nurses considered the concept of abuse to be false. The surveyed population was aware that many seniors are victims of abuse and that elder abuse is a form of violation of personal rights, but 46.94% were unsure about the existence of standard procedures for reporting abuse and/or treatment, suggesting low attention paid to the problem and little information provided by institutions on abuse reporting procedures. Regarding whether participants suspected abuse, most nurses (45.7%) and care assistants (68.8%) declared they had never had suspicions of abuse, while 48.7% of physicians stated suspecting abuse on one to three occasions in their lifetime. Only 23.9% of the nurses, 22.4% of the physicians, and 18.8% of the care assistants stated they had witnessed abuse between one and three times in their lives. Surprisingly, in both suspected or witnessed cases, the health care personnel did not take any action and did not report the abuse to public authorities or to adult protective service agencies. Conclusions: The results of the present survey on health care professionals demonstrate that there is still a strong need for education and specific training programs on elder abuse. Reference(s): 1. Corbi G., Grattagliano I., Catanesi R., Ferrara N., Yorston G., Campobasso C.P. (2012). Elderly residents at risk for being victims or offenders. J Am Med Dir Assoc. 13(7), 657-9. 2. Campobasso C.P., Falamingo R., Grattagliano I., Vinci F. (2009). The mummified corpse in a domestic setting. Am J Forensic Med Pathol. 30(3), 307-10. 3. Corbi G.M., Grattagliano I., Ivshina E., Ferrara N., Solimeno Cipriano A., Cmpobasso C.P. Elderly Abuse: Risk Factors And Nursing Role. Intern Emerg Med. 2015 Apr;10(3):297-303. Caregivers, Elder, Abuse

Copyright 2018 by the AAFS. Permission to reprint, publish, or otherwise reproduce such material in any form other than photocopying must be obtained by the AAFS. ______*Presenting Author - 800 - Psychiatry & Behavioral Science __ 2018

I2 Financial-Psychological Crime: The Madoff Case

Ignazio Grattagliano, PsyD, University of Bari, Via Mauro Amoruso 68, , Bari 70124, ITALY; Alessio Ostuni, MD*, Sections of Legal Medicine and Criminology, Policlinico of Bari Italy, Piazza Giulio Cesare 11, Bari 70124, ITALY; Maricla Marrone, MD, P.za Giulio Cesare, 1, Bari 70124, ITALY; Anna Cassano, PsyD, P.za Giulio Cesare, 11, Department of Forensic Psychiatry, Bari 70124, ITALY; Fulvia Carucci, PsyD, Department of Education, Psychology and Communication, Via Crisanzio 42, Bari 70124, ITALY; Michele Di Marcantonio, PsyD, Department of Education, Psychology and Communication, Via Crisanzio 42, Bari 70124, ITALY; Giancarlo Di Vella, MD, PhD, University of Torino, Dept Public Health Sciences, Sezione di Medicina Legale, Corso Galileo Galilei 22, Torino 10126, ITALY; Lucia Tattoli, PhD, Sezione di Medicina Legale, University of Turin - Corso Galileo Galilei, 22, Torino 10126, ITALY; Carlo P. Campobasso, MD, PhD, University of Campania, Dept Experimental Medicine, via Santa Maria di Costantinopoli, 16, Napoli 80138, ITALY; Graziamaria Corbi, PhD, via Giovanni Paolo II-Loc Tappino, Campobasso 86100, ITALY; and Roberto Catanesi, MD, P.za Giulio Cesare, Bari 70124, ITALY

After attending this presentation, attendees will better understand the link between financial fraud and psychopathy. This presentation will impact the forensic science community by exploring the psychological and forensic profiles of victims and perpetrators, with the goal of demonstrating how some individual attributes and characteristics, such as a respectable front, charisma, or strategic presentation of a self-image, are positively correlated with the fraudster profile. In 1920, Charles Ponzi was the first to conduct a large-scale tax fraud scheme. The basis of a Ponzi scheme relies on individuals entrusting a portion of their capital to a subject mediating between the individual and the market, in a process known as financial mediation. The trigger of the scheme is the faith the client has in the intermediary and his superior knowledge in this field. In the fraud mechanism, the perpetrator needs to convince future victims to allow him/her to handle their savings in order to make investments that do not actually exist, promising relatively large returns in a limited period of time. The client/victim, who first obtains financial gains that satisfy his/her expectations, continues to invest and convinces other people to do the same. At the end of 2008, a famous New York broker and ex-president of the National Association of Securities Dealers Automated Quotation (NASDAQ) named Bernard L. Madoff was accused of fraud and was arrested. Madoff succeeded in perpetrating the fraud thanks to his ability to handle first impressions. In other words, he possessed the specific communication trait that can manage the fundamental human tendency to imagine, plan, and regulate social behavior in such a way as to leave a strong impression on others, convincing them of the truth of the self-image presented. In psychological terms, what convinces people to invest in such plans is the fraudster’s ability to exploit people’s weak points, such as greed, trust, and fear. According to Schiller’s theory of the positive feedback investment cycle of large-scale bubbles, when many people believe they will receive good profits, they communicate their belief to other potential investors, making it seem like a mistake to miss out on the investment.1 This triggers phenomena such as familial bias and imitation: the stories and perceptions of the profit to be gained from a given investment make it appear to be affected by a minimum or negligible risk. As persuasion tools, these are even more effective than the fraudster’s own persuasive strategies. In fact, according to Greenspan, the success of the Ponzi scheme was attributable to the human tendency to model actions on those of others, especially when dealing with matters that the client knows little about.2 Typical traits of the victims of these schemes are a limited knowledge of financial matters, little available money, older age, or a low level of education (excluding those affected by mental disease).3 Characteristics of the “fraudster” are being male, between the ages of 35 and 65, an advanced education, “a respectable front” (strictly connected to the self-image presentation strategy), charisma, and a marked ability to handle social relationships.4 One of the most devastating consequences of such schemes is the fraud trauma syndrome that engenders emotions such as rage, pain, anxiety and fear, mistrust of the future, isolation and devastation, as well as symptoms such as insomnia, panic, anxiety attacks, or depression.5 The line between fraud trauma syndrome and post-traumatic stress disorder is becoming less and less clearcut.6 The sense of betrayal of the trust placed in the fraudster provokes a feeling of abuse and violence in the victim. Many victims report that they have even considered committing suicide, or have suffered a worsening of preexisting medical conditions. Similar to victims of rape, victims of fraud tend not to denounce the crime they have suffered due to feelings of guilt induced by the social and legal systems. Reference(s): 1. Robert J.Shiller. Irrational Exuberance. Princeton University Press Princeton, New Jersey. 2005. 2. Greenspan, Stephen. (2009). How Bernard Madoff made off with my money or why even an expert on gullibility can get gulled. Skeptic. Vol. 14, No. 2, 20-25. 3. Tennant D. Why do people risk exposure to Ponzi schemes? Econometric evidence from Jamaica. Journal of International Financial Markets, Institutions & Money. 2011:21(3):328–346. 4. Glodstein D., Glodstein S.L., Fornaro J. Fraud trauma syndrome: The victims of the Bernard Madoff scandal. Journal of Forensic Studies in Accounting & Business. 2010:2(6):1-9. 5. Ganzini L., McFarland B., Bloom J. Victims of Fraud: Comparing Victims of White-Collar and Violent Crime. Bulletin of the American Academy of Psychiatry and the Law. 1990:18(1):55-63. 6. Freshman A. Financial Disaster as a Risk Factor for Posttraumatic Stress Disorder: Internet Survey of Trauma in Victims of the Madoff Ponzi Scheme. Health & Social Work. 2012:37(1):39-48. https://doi.org/10.1093/hsw/hls002. Criminalistic, Financial Fraud, Persuasive Strategies

I3 Sudden Death of a Child: What Could Have Happened in a Family With a Different Socioeconomic Status?

Erica Bacchio, MD*, University of Ferrara, Dept of Legal Medicine, Via Fossato di Mortara, 70, Ferrara 44121, ITALY; Omar Bonato, MD, University of Ferrara, Dept of Legal Medicine, Via Fossato di Mortara, 70, Ferrara 44121, ITALY; Elena Lucenti, MD, University of Ferrara, Dept of Legal Medicine, Via Fossato di Mortara, 70, Ferrara 44121, ITALY; Letizia Alfieri, MD, University of Ferrara, Dept of Legal Medicine, Via Fossato di Mortara, 70, Ferrara 44121, ITALY; Natascha Pascale, MD, Viale Degli Aviatori, Foggia 71100, ITALY; Simone Onti, MD, Unit of Legal Medicine, University of Ferrara, Via Fossato di Mortara 70, Ferrara 44121, ITALY; Stefano Malaguti, MD, via Fossato di Mortara, n70, Ferrara 44121, ITALY; Rosa Maria Gaudio, University of Ferrara, Dept of Legal Medicine, Via Fossato di Mortara, 70, Ferrara 44121, ITALY; and Margherita Neri, MD, PhD, University of Ferrara, Dept of Forensic Pathology, Via Fossato di Mortara 70, Ferrara 44100, ITALY

After attending this presentation, attendees will better understand the importance of the diagnosis of malnutrition and failure to thrive in a child death investigation. This presentation will impact the forensic science community by providing elements to diagnose the exact cause of death in a child neglect or abuse case as well as the legal outcomes which may result. Fatal child starvation is uncommon in Italy, and, according to the National Statistical Data, malnutrition is related to being overweight and morbid obesity. Child abuse and maltreatment are defined as a series of deliberate actions and/or omissions that are conducted by adults (parents, relatives, caretakers), or other children or adolescents, that result in physical or emotional damages or the imminent risk of serious damage or death. Maltreatment/abuse can be expressed as: a failure to provide age-appropriate care, spousal abuse in the child’s presence, psychological maltreatment, physical maltreatment, and sexual abuse. Classifying various forms of child maltreatment is useful for exemplifying goals, but children are usually victims of different types of maltreatments simultaneously. The neglect of a child without appropriate care is an ongoing pattern of inadequate care by parents and caregivers. It includes child neglect, lack of care, inappropriate care at the time, and excessive care. Child neglect is defined as a type of maltreatment related to the failure of parents to provide for the child, which could cause serious damage. The signs of child neglect are a sense of abandonment, refusal, failure to thrive, or other forms of abuse (which may be life threatening). Neglect has received less attention than physical and sexual abuse, probably because it is difficult to identify and often includes other forms of maltreatment. This case study describes a 2-year-old girl who was found dead on the sofa by her mother’s partner. The child was known to social services for suspected abuse after being admitted to the hospital for a fracture of an upper limb and bruises, which the mother reported as an accidental fall. Furthermore, the child was suffering from psychomotor retardation associated with serious self-inflicted injuries with bites, hitting her head against the wall, and pulling out her own hair. Consequently, she was transferred to neuropsychiatry, but the drug therapy (periciazine) administrated by her mother was ineffective. A week before her death, the child was admitted to a pediatric hospital with severe anemia, failure to thrive below the third percentile of growth, and electrolyte imbalance; however, the mother decided to take the child back home, against the advice of doctors. The case had multiple risk factors leading to neglect: the mother’s young age, low socioeconomic status and education, dysfunctional family characteristics (child’s parents were half-siblings, adopted by two different families), the presence of an adult unrelated to the child (mother’s new partner), and parental stress. The case study included the scene investigation, autopsy, toxicology, and police investigation. The external examination was remarkable for multiple limb bruises, bitemarks on her hands and upper limbs, and scratches on the face. The autopsy was negative. There was no chest or head trauma, only the results of the known upper limb fracture. The gross examination of the heart revealed left ventricular hypertrophy and histology exhibited the usual finding of restrictive cardiomyopathy, such as interstitial fibrosis. The toxicological test was positive for a therapeutic range of periciazine. Finally, the cause of death established was cardiac arrest due to restrictive cardiomyopathy, which is known for having a poor prognosis in children. This case met legal challenges due to disagreements regarding the cause of the child’s failure to thrive. In other words, the legal question was whether malnutrition was due to neglect or to cardiomyopathy. In the end, although neglect was not the cause of death, it certainly was related to it. In any case, studies reveal there is poor knowledge of child neglect among medical resources, which leads to a higher rate of sickness and death among these children. This case report illustrates that even in highly suggestive cases of abuse or neglect, it is necessary to refer to the report of the child’s death investigation and pay attention to risk factors in the family context; beginning from the crime scene investigation and medical records to the autopsy and histological findings. Establishing the cause and the manner of death may lead to different legal outcomes in cases that clearly involve child abuse or child neglect. Child Neglect, Cardiomyopathy, Maltreatment

I4 Self-Cutting and Suicide Risk Among Adolescents: The Case of the “Blue-Whales”

Francesco Lupariello, MD*, University of Turin - Legal Medicine Section, Corso Galileo Galilei 22, Torino, ITALY; Serena Maria Curti, MD, Sezione Medicina Legale DSSPP - Univ. TO, C So Galileo Galilei N 22, Torino 10121, ITALY; Elena Coppo, MD, Department of Pediatric Emergency, A.O.U. “Città della Salute e della Scienza,” Turin, ITALY; Sara Simona Racalbuto, PsyD, Department of Pediatric Emergency, Turin, Piazza Polonia 94, Torino 10100, ITALY; Ignazio Grattagliano, PsyD, University of Bari, Via Mauro Amoruso 68, Bari 70124, ITALY; and Giancarlo Di Vella, MD, PhD, University of Torino, Dept Public Health Sciences, Sezione di Medicina Legale, Corso Galileo Galilei 22, Torino 10126, ITALY

After attending this presentation, attendees will understand the importance of training healthcare staff to promptly recognize suicidal risk behaviors among adolescents. This presentation will impact the forensic science community by providing information regarding the media phenomenon known as the “Blue-Whale-Challenge,” which includes self-cutting; this carries a high potential risk of suicide. The Blue-Whale-Challenge is a dangerous internet phenomenon that consists of a series of duties, imposed by an administrator to players who must complete a list of actions involving self-mutilation. The game lasts 50 days, with players usually completing one duty per day, and ends with the suicide of the player.1 The term “Blue-Whale” results from the similarity of suicidal behavior among beached whales. The phenomenon began in 2013, in Russia, on the “VKontakte” social network, with the first case of suicide in 2015. The inventor was a psychology student, expelled from his university. The student said that his purpose was to clean society of people of no value.2 The phenomenon spread among teenagers in Russia, then in other areas, due to the media resonance caused by television broadcasts and newspaper articles that featured information regarding the game. After a wave of panic caused by an article concerning the many suicides related to the Blue-Whale phenomenon in Russia, the inventor was arrested in 2016. Around the world, the phenomenon accounts for many cases, some of which have often turned out to be hoaxes or emulators. In Italy, the first news about the Blue-Whale appeared in June 2016 in a national newspaper, but only in May 2017 did a well-known television program deal with the subject, using reports that did not quote official sources. From that moment on, the police began receiving calls and newspapers published alarming news concerning Blue-Whale incidents, which were often quickly denied. Between May and June 2017, five suspected cases of Blue-Whale have been managed by the officers of the unit. The officers were dedicated to the evaluation of suspected abused children (“Bambi”) of the “Ospedale Infantile Regina Margherita” (Turin). The data collected during the multidisciplinary evaluation of these cases was reported: all patients were female; one case involved a 17-year- old girl, while the other four cases involved 14-year-old girls; all families experienced critical economic, social, or psychological issues; in two cases, the girls’ parents were separated; in one case the father had been sent away from home as he beat his wife and daughter; and the last girl described her father as extremely aggressive and oppressive. During the psychological evaluation, all girls recounted difficulties in integration at school and anxiety. One girl confessed to having purposely taken an excessive dose of alprazolam. In three cases, the medical examiners identified scars related to previous self-cutting. In one case, this activity was recent and the lesions on the forearm were thought to resemble a whale. There was no evidence to sustain an involvement in the Blue-Whale-Challenge or the influences of an administrator in any of these cases, but rather emulative behavior caused by psychological issues. Only one of these girls was hospitalized, while psychological help programs were prescribed for the other girls. Self-harm is the strongest predictor of suicide among young people. Between 40% and 80% of suicide victims had self-harmed in the past.3,4 In particular, longitudinal data indicated that self-cutting is a significant risk factor for complete suicide in children and adolescents.5 Young people who self-harm report that it is difficult to talk about their suicidal feelings and they do not really feel “listened to” when they do.6 Indeed, clinical staff often has a negative attitude toward self-harm and may not possess the ability to deal with it effectively. In this series of cases, there was a strong demand for attention, illustrated through self-cutting and simulation of participation in a life-threatening game. In accordance with the literature, all of these young people experienced negative life events and had difficulties in relationships with families and friends.7 Given these premises, it is crucial that frontline medical staff receive training about self-harm and suicidal behaviors to reduce suicide rates. It has been demonstrated that even short- term training can significantly improve staff attitudes.8 This presentation provides attendees with a better knowledge of behavioral and psychological factors that highly increase the risk of suicide among adolescents. Reference(s): 1. Teen “Suicide Games” Send Shudders Through Russian-Speaking World. RadioFreeEurope/RadioLiberty. Retrieved 2017-06-23. 2. Blue whale challenge administrator pleads guilty to inciting suicide. BBC Newsbeat. 2017-11-05. Retrieved 2017-06-23. 3. Owens D. et al. Fatal and non-fatal repetition of self-harm: Systematic review. Br J Psychiatry. 2002;181:193-9. 4. Hawton K., Houston K., Shepperd R. Suicide in young people. Study of 174 cases, aged under 25 years, based on coroners’ and medical records. Br J Psychiatry. 1999;175:271-6. 5. Hawton K. et al. Repetition of self-harm and suicide following self-harm in children and adolescents: Findings from the multicentre study of self-harm in England. J Child Psychol Psychiatry. 2012;53:1212-19. 6. Mental Health Foundation. Truth hurts—Report of the National Inquiry into Self-Harm among Young People. Mental Health Foundation, 2006. 7. Hawton K., Bergen H., Casey D., et al. Self-harm in England: A tale of three cities. Multicentre study of self-harm. Soc Psychiatry PsychiatrEpidemiol. 2007;42:513-21.8) Botega NJ, Silva SV, Reginato DG, et al. 8. Botega N.J., Silva S.V., Reginato D.G., et al. Maintained attitudinal changes in nursing personnel after a brief training on suicide prevention. Suicide Life Threat Behav. 2007;37:145-53. Self-Cutting, Self-Harm, Suicidal Behaviors Copyright 2018 by the AAFS. Permission to reprint, publish, or otherwise reproduce such material in any form other than photocopying must be obtained by the AAFS. ______*Presenting Author - 803 - Psychiatry & Behavioral Science __ 2018

I5 Acute Stress Disorder (ASD) Symptomatology and Crime in a Nationally Representative Sample of Youth

Joseph Chien, DO*, VA Portland Health Care System, 3710 SW US Veterans Hospital Road, Portland, OR 97239; Bronte T. Pagan, BS, University of New Haven, 300 Boston Post Road, West Haven, CT 06516; Kayla E. Wyant, BA, University of New Haven, 300 Boston Post Road, New Haven, CT 06516; and Kendell L. Coker, PhD, University of New Haven, 300 Boston Post Road, New Haven, CT 06516

After attending this presentation, attendees will appreciate the correlation between ASD symptomatology and criminal behavior in youth and will use this knowledge to implement early interventions for traumatized youth. This presentation will impact the forensic science community by presenting data that will encourage clinicians and policy-makers to pay close attention to symptoms of ASD in youth, as early intervention may help prevent the development of Post-Traumatic Stress Disorder (PTSD) and potentially may deter youth from committing crimes. No previous studies have examined the relationship between ASD and criminal behavior among youth. This study looked at data from the National Comorbidity Survey-Adolescent Supplement (NCS-A). Participants in this survey, which took place between February of 2001 and January of 2003, consisted of 10,148 youths between the ages of 13 and 18 years. Interviews were conducted using computer-assisted personal interviews, computer-assisted telephone interviews, and telephone interviews.1 This study hypothesized that analysis of a nationally representative sample of youths would reveal a relationship between symptoms of ASD and criminal behavior. Since the NCS-A was conducted prior to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), symptoms of PTSD from the DSM-IV were mapped to DSM-5 criteria for ASD. Due to changes in the DSM-5 criteria for ASD, the youths in this study were described as having “ASD symptomatology.” Data were analyzed using the Statistical Package for the Social Sciences (SPSS) to estimate prevalence rates of ASD symptomatology and examine the relationship between ASD and criminal involvement. Youths with ASD symptomology were significantly more likely to report arrest-related crimes than youths without any lifetime diagnosis. Youths with ASD symptomology had 25.4 greater odds of a report arrest for a violent crime when compared to youths who did not meet criteria for any lifetime diagnosis. Additionally, youths with ASD symptomology had 8.3 greater odds to have reported arrest for property crimes and 17.9 greater odds to have reported arrest for “other” crimes compared to youths without any lifetime diagnosis. Youths with ASD symptomology had 11.6 times greater odds of reporting, but not being arrested for, a property crime, 24.2 times greater odds for a violent crime, and 10.9 greater odds for any other crime when compared to youths who did not meet the diagnostic criteria for any DSM-IV lifetime diagnosis. The data presented here provide a more accurate picture of the relationship between ASD and related crime, allowing for prevention and intervention strategies to be potentially developed. Focusing on at-risk youths to provide support and education is crucial. Due to the inevitable nature of certain trauma, intervention strategies must be catered to those youths who are experiencing ASD symptoms. Without addressing youths who are experiencing symptoms of ASD, their conditions may progressively worsen into more severe trauma-related disorders.2,3 The quality of life for these untreated youths decreases severely and serves as an increased risk factor for criminal involvement, suicide, and other comorbid psychiatric disorders. Reference(s): 1. Kessler R.C., Avenevoli S., Costello E.J., Gruber M.J., Heeringa S., Merikangas K.R., Pennell B.E., Sampson N.A., Zaslavsky A.M. Design and field procedures in the US National Comorbidity Survey Replication Adolescent Supplement (NCS-A). International Journal of Methods in Psychiatric Research. 18 (2009), 69-83. 2. Armour C., Elklit A., Shevlin M. The latent structure of acute stress disorder: A posttraumatic stress disorder approach. Psychological Trauma: Theory, Research, Practice, and Policy. 5 (2013), 18-25. 3. Koopman C., Classen C., Spiegel D. Predictors of posttraumatic stress symptoms among survivors of the Oakland/Berkeley, Calif., firestorm. American Journal of Psychiatry. 151 (1994), 888–894. Acute Stress Disorder, Crime, Adolescents

I6 Female-Perpetrated Sexual Abuse on Children: A Five-Year Long Italian Experience

Serena Maria Curti, MD*, Sezione Medicina Legale DSSPP - Univ. TO, C So Galileo Galilei N 22, Torino 10121, ITALY; Francesco Lupariello, MD, University of Turin - Legal Medicine Section, Corso Galileo Galilei 22, Torino, ITALY; Caterina Petetta, MD, Sezione di Medicina Legale DSSPP, C So Galileo Galilei N 22, Torino 10121, ITALY; Anna M. Baldelli, JD, Prosecution Office of the Juvenile Court, Turin, Corso Unione Sovietica, 325, Turin 10135, ITALY; Sara Simona Racalbuto, PsyD, Department of Pediatric Emergency, Turin, Piazza Polonia 94, Torino 10100, ITALY; Elena Coppo, MD, Department of Pediatric Emergency, A.O.U. “Città della Salute e della Scienza,” Turin, ITALY; Ignazio Grattagliano, PsyD, University of Bari, Via Mauro Amoruso 68, Bari 70124, ITALY; and Giancarlo Di Vella, MD, PhD*, University of Torino, Dept Public Health Sciences, Sezione di Medicina Legale, Corso Galileo Galilei 22, Torino 10126, ITALY

After attending this presentation, attendees will better understand the gender-specific features of child sexual abuse perpetrated by women compared with male-perpetrated abuse. This presentation will impact the forensic science community by providing tools to recognize a form of sexual abuse often difficult to identify because of its intrinsic characteristics. In the literature, little attention has been paid to females who sexually abuse as most of the studies focused on male perpetrators.1 The phenomenon has typically been reported as relatively rare with a male-to-female sexual offenders ratio equal to 20:1. Available data indicate that women constitute approximately 5% of all sexual offenders.2 Despite this, female-perpetrated abuse is responsible for a non-negligible number of victims and offenders who need clinical attention. In addition, the phenomenon is certainly underestimated because it is difficult to diagnose females for several reasons: sexual abuse is often perpetrated by women who care for the child during routine daily activities, such as bathing or dressing, so sexual offending is often hidden behind the woman’s caretaking behavior.3 Moreover, in most cases, a strong affective bond between the victim and the offender is created, so that the child does not reveal the abuse. The emerging cases that are reported for investigation appear to be the “tip of the iceberg” with respect to cases that are not reported. Finally, there are usually no clinically detectable lesions because sexual abuse is typically not conducted via violent acts. In order to contribute to the knowledge of this topic, this study reports the data collected from January 2012 to June 2017 in the multidisciplinary unit called “Bambi,” dedicated to the evaluation of suspected abused children, of the “Ospedale Infantile Regina Margherita” (Turin). Among 474 cases of suspected child sexual abuse, in nine cases (1.9%), the potential perpetrator was a woman: one child was male and the others were female. The children were between 3 and 9 years of age (four 4-year-olds, two 5-year-olds, two 9-year-olds, and one 3-year-old). In five cases, the parents of the children were divorced. The perpetrators in two cases were the mothers of the children, in four cases the paternal grandmother, in two cases a female neighbor, and in one case the babysitter. In only one case was the sexual abuse conducted in association with other perpetrators. One of the perpetrators already had a diagnosis of psychiatric disorders (borderline disorder and depression). In all cases, the perpetrators committed the abuse by touching and licking the ano-genital area, and in four cases, by also penetrating the vagina or anus. In one case, the culprit forced the child to watch porn videos. All children, except one, spontaneously described to the medical staff members the abusive actions perpetrated by the offender. More detailed information on the clinical and judicial path of each case will be provided during this presentation. Although it is a common belief that if a female is involved in a sexual abuse, she must have been forcefully coerced by a male partner, the reported cases, in accordance with previous studies, suggest this is often not true.4,5 Considering the unusualness of the phenomenon, although many treatment requirements appear to be similar to those of male sexual offenders, it is crucial that the gender-specific features of the phenomenon be taken into account, rather than attempting to fit female sexual offenders’ treatments to existing male models.1 This presentation provides attendees with additional knowledge regarding female-perpetrated sexual abuse on children in order to understand gender-specific criminal offending patterns and provide an important tool in the development of prevention and rehabilitative strategies. Reference(s): 1. Theresa A. Gannon and Franca Cortoni. Female Sexual Offenders: Theory, Assessment, and Treatment (Chichester: Wiley-Blackwell, 2010). 2. Franca Cortoni, R. Karl Hanson, and Marie-Ève Coache. The recidivism rates of female sexual offenders are low: A meta-analysis. Sexual Abuse: A Journal of Research and Treatment. 2010; 22(4): 387-401, doi: 10.1177/1079063210372142. 3. Christopher J. Ferguson and D. Cricket Meehan. An analysis of females convicted of sex crimes in the State of Florida. Journal of Child Sexual Abuse. 2005;14(1):75-89, doi: 10.1300/J070v14n01_05. 4. Theresa A. Gannon and Mariamne R. Rose. A descriptive model of the offense process for female sexual offenders. Sexual Abuse: A Journal of Research and Treatment. 2008; 20(3): 352-374, doi: 10.1177/1079063208322495. 5. Dominique Simons, Peggy Heil, David Burton et al. Developmental and offense histories of female sexual offenders. (Symposium presented at the 27th Annual Conference for the Treatment of Sexual Abusers Research and Treatment Association. Atlanta, Georgia, 2008). Child Abuse, Female Perpetrators, Sexual Abuse

I7 Sexual Offending and IQ: What Is the Relationship?

R. Gregg Dwyer, MD, EdD*, Medical University of South Carolina, Community & Public Safety Psychiatry Division, 29-C Leinbach Drive, Charleston, SC 29407; and Emily D. Gottfried, PhD*, MUSC, Charleston, SC 29407

The goals of this presentation are to: (1) inform those involved in assessments of persons who have sexually offended of considerations of intellectual functioning as it relates to etiology and, in turn, risk of reoffending; and, (2) provide treatment providers with data on the potential impact of intellectual functioning for treatment planning use. This presentation will impact the forensic science community by improving the ability of evaluators of sexual offending behavior to determine etiology. This presentation will also impact attendees by helping risk and treatment providers to develop treatment plans with likelihoods of successful outcomes. The current proposed presentation will focus on the range of intelligence estimates in a sample of adult men convicted of sexual offenses. Specifically, this presentation will include the data of approximately 1,040 individuals who were serving time for a sexual offense conviction and being assessed for potential civil commitment under the South Carolina Sexually Violent Predator (SVP) Act. A previous meta-analysis of 25,146 adult male sex offenders reported that sexual offenders obtain lower Intelligence Quotient (IQ) scores than non-sexual offenders, but that this difference is likely accounted for by the large proportion of individuals with sex offenses against children in those studies.1 Additionally, a relationship between IQ score and the presence of pedophilic disorder was noted.1 Based on previous research, it was hypothesized that as the offenders’ intellectual functioning (i.e., IQ score) decreased, so did the age of the victims. 2,3 This study hypothesized that offenders with below-average IQ would have younger (i.e., at least pre-adolescent age range) victims than those with average or above-average IQ scores. It was also hypothesized that as IQ score decreased, the report of childhood sexual abuse victimization of the offender would increase. This study hypothesized that the offenders with above-average IQs would be more likely to have no other criminal history beyond the sexual offense(s). Finally, it was predicted that the presence of a pedophilic disorder would be associated with lower IQ scores than of those offenders not meeting diagnostic criteria for pedophilic disorder. Preliminary analyses indicate that IQ scores in this sample ranged from 43 to 164, with a mean IQ score of 91.88 (Standard Deviation (SD)=16.00). Approximately 35% of the sample (n=364) had been diagnosed with at least one mental illness, to include paraphilic disorders (n=25). The sample had an average of 2.17 (SD=2.57) victims and the number of victims ranged in age from 1 to 45 years. This presentation will also address the challenges of providing effective sex offender treatment to offenders with intellectual impairments. Reference(s): 1. Canter J.M., Blanchard J., Robichaud L.K., Christensen, B.K. Quantitative reanalysis of aggregate data on IQ in sex offenders. Psychological Bulletin. 2005: 131(4): 555-568. 2. Kruger T.H.C., Schiffer B. Neurocognitive and personality factors in homo- and heterosexual pedophiles and controls. The Journal of Sexual Medicine. 2011: 8(6): 1650-1659. 3. Lindsay W.R. Research and literature on sex offenders with intellectual and developmental disabilities. Journal of Intellectual Disability Research. 2002: 46(1): 74-85. Sexual Offenders, Intellectual Functioning, Sexually Violent Predators

I8 Do Sex Offenders Secretly Reoffend During Treatment?

Thanh Ly, BSc*, 59 Willwood Crescent, Ottawa, ON K2J 2Z5, CANADA; and J. Paul Fedoroff, MD*, Royal Ottawa Hospital, 1145 Carling Avenue, Ottawa, ON K1Z 7K4, CANADA

The goals of this presentation are to provide insight on: (1) the likelihood of unreported sexual reoffenses occurring during treatment; (2) which sexual reoffenses are more likely to occur; (3) the likelihood of sex offenders disclosing their reoffenses to health care professionals; and, (4) the period sex offenders are more likely to reoffend. This presentation will impact the forensic science community by debunking misconceptions of persons who have committed sexual offenses. Attendees will become more aware of the types of reoffenses that are most likely to be secretly committed by sex offenders. Persons undergoing treatment for problematic sexual behaviors will be given hope that the treatment outcome is usually positive. It was hypothesized that if reoffenses were reported, hands-off reoffenses were more likely to occur than hands-on (contact) reoffenses. The other hypothesis was that the majority of relapses and/or reoffenses would have occurred between six months and one year of treatment, if any were reported. The methodology of this study is unique in the sense that it is virtually untraceable and provides complete anonymity and confidentiality to its participants. An anonymous poll booth was set up in a room where group therapy normally takes place and was located away from cameras and possible prying eyes. Participants were instructed to complete the survey during the break or discreetly during group therapy. They were to go behind the cardboard trifold and had the option of wearing cotton gloves in case of concerns regarding tracing their responses through fingerprint analyses. Participants were also instructed to use the felt-tipped pen provided so all answer sheets would look identically filled and their responses would be untraceable through any form of handwriting analyses. After completing the survey, they were to drop their responses through the slit of a sealed cardboard box. Before starting the survey, a deck of cards was passed out to all participants and they were to choose one card from the deck. The research assistant had a second deck of cards, which was identical to the first deck given to participants. The second deck was shuffled in front of the participants and a card was randomly selected from the deck. The group was told that the participant with the matching card was told not to reveal himself/herself and was also told to complete the survey with false responses and claim that he/she had reoffended. This would provide assurance to participants that if they had disclosed reoffenses, it would be virtually impossible to distinguish their disclosure from the assigned liar’s disclosure. Participants then completed the survey discreetly during group or during the break. Results of the study revealed that the majority of sex offenders did not reoffend while in treatment. When reoffenses did occur and were not reported, the majority of those reoffenses were breaches of conditions. The least likely re-offense to occur, even in secret, were contact offenses that involved sexual touching of a child and/or sexual touching of an adult. Re-offenses were also most likely to occur between the first six months and one year of treatment. Those who had secretly reoffended were also unlikely to disclose their relapses to their doctors. Given that most reoffenses reported were non-sexual breaches, professionals in charge of supervising and/or re-integrating offenders back into the community can improve on preventing breaches. Since pornography-related offenses were the second-most likely to occur, prevention methods may need to be installed to reduce accessibility of illegal pornography. Furthermore, these results inform professionals that treatment can prevent reoffenses, but when reoffenses occur, it is unlikely their patients will disclose those incidents. It also cautions professionals to be vigilant of potential reoffenses during the first six months to one year of treatment. Future research should investigate factors that increase the likelihood of disclosure to health professionals or disclosure of a pending relapse. Sex Offender, Paraphilia, Sexual Reoffenses

I9 The Unfolding Development of Forensic Behavioral Science

John L. Young, MD*, Yale University, 203 Maple Street, New Haven, CT 06511-4048

After attending this presentation, attendees will apply a deeper understanding of the underpinnings of their fields to their work and, as a result, will enjoy more satisfying conversations with colleagues of other disciplines. This presentation will impact the forensic science community by increasing appreciation for gathering and applying sound information — both new and old. The founding of the American Academy of Forensic Sciences (AAFS) marked the commitment of serious professionals in each of the forensic sciences to contribute to the unending progress in the quality of their work. Their intention applied to both the reliability and validity of the methods and procedures to use in each field. In doing so, our founders expected to promote justice and thereby serve not only parties in litigation, but all humanity as well. Regarding the behavioral forensic sciences, it is useful to understand their history as developing over a four-stage course, beginning with a time of genuine, although poorly acknowledged, ignorance. In time, it became difficult to demonstrate that behavioral experts’ opinions offered anything better than random chance; the equivalent of a coin toss. Experiencing the painful impact of even moderately good scientific methodology on their theory-based testimony sufficed for most experts to usher in the second developmental stage. By roughly the early 1970s, working groups from several universities began the publication of statistical scales, based on subjects’ behavioral histories, medical and social histories, and varied additional data yielding estimates of probabilities of future behaviors. Meanwhile, the age of scans, the third developmental stage, was getting underway. In the United Kingdom during the mid-1970s, engineers working for Electronic Music Incorporated (EMI) developed crude planar images of living human subjects’ brains. To do this, they took advantage of technical refinements in the generation and detection of X-rays. Soon enough, these “EMI scans” became valued for their clinical utility. In the forensic arena, their use has demonstrated both the value and the danger of the saying that a picture is worth a thousand words. Having a basic understanding of the workings of the more recent scanning technologies, especially Magnetic Resonance Imaging (MRI), only strengthens this recognition. The final phase, for the present at least, is that of genetics. Here, the behavioral forensic specialist needs to comprehend at least the elementary jargon of the DNA expert and related forensic specialists. Any efforts to do so are soon handsomely repaid. As progress in this fourth stage continues, we may look forward to important conversations among forensic experts as they recognize the many diverse likenesses in their professional DNA. Development, Interdisciplinary, Progress

I10 Application of the Equivocal Death Psychological Autopsy for Investigation: A Case Study

Cinzia Gimelli, PsyD, PhD*, Science & Method, Via Regina Margherita 9/d, Reggio Emilia 42124, ITALY

After attending this presentation, attendees will better understand the role of the Equivocal death Psychological Autopsy (EPA) for investigation. This presentation will impact the forensic science community by discussing the specific technique of EPA as applied during the investigation process in cases registered as a suicide and reinvestigated from the point of view of homicide. Forensic psychological evaluation has contributed significantly as an aid to investigation in many sensitive cases. There are various subfields of forensic psychology and one such technique is that of the psychological autopsy. A psychological autopsy is an extremely important tool to ascertain the mental status of any individual before his or her death; it throws light on various facts that may have been missed during the investigation. An EPA is useful in aiding the investigation process, especially in controversial deaths. The technique of EPA is relatively new in Italy. This particular technique was applied during an investigation for a referred case in which there was a controversy in terms of the investigating agency and the family in deciding between suicide and homicide. Introduction: Forensic psychology deals with the application of principles of human behavior and cognition to the legal, civil, and criminal delivery system. It is also the scientific discipline dealing with the understanding of factors that culminate in the expression of violent and legally unacceptable behavior; this brings the perpetrator of the actions under the focus of law and the need for specialized rehabilitation. A forensic psychologist tries to understand the causes of criminal behavior and tries to establish a link between the crime, crime location, the victim, and the offender; however, forensic psychologists also try to work in areas related to victimology or the victim’s psychology. Forensic psychologists also attempt to understand why a particular victim was chosen, as this aspect throws light on the offenders modus operandi. Similarly, forensic psychologists also perform psychological autopsies in equivocal deaths. Equivocal death analysis is by far the most demanding work. An equivocal death analyst requires extensive information about the victim and circumstances surrounding his or her demise before rendering a knowledgeable opinion of the victim’s personality and behavior. The goal of equivocal death analysis is not to prove the manner of death, but to arrive at an informed opinion as to whether a homicide, a suicide, or an accident most likely occurred. Psychological autopsy is a retrospective psycho-social examination of a descendent to the time of his or her death. It is an extension of victimology that reconstructs the deceased’s psychological state before his or her death. This presentation attempts to portray the importance of the EPA technique in an equivocal death case of a young man whose death was initially registered as a suicide and was reinvestigated as a homicide due to various controversial aspects in the overall case. Case Report: This case has been tested through the method of psychological autopsy. The case involves a 48-year-old male who was found dead (by hanging) by his best friend. The case was initially declared to be a suicide; however, his family insisted that it was a homicide and not a suicide. The case was thus referred for an EPA to better understand the entire case and to check for investigative leads. The EPA was conducted using a detailed study of his personal diary, his postmortem report, and the court petition filed by the family. Information gathered from interviews with key informants by means of direct interviews and past photographs were also utilized as sources of information for this report. The psychological autopsy method entailed reconstructing the biography of the deceased through psychological information gathered from personal documents; police, medical, coroner records, and first-person accounts, either through depositions or interviews with family, friends, coworkers, school associates, and physicians. Results: The results revealed that, with deep psychological investigations, the possibility of homicide cannot be ruled out completely. Conclusions: Psychological autopsy is an important and valuable tool for aiding an investigation. This presentation provides detailed information regarding an individual’s death using various sources and reveals new points that could have been missed during the initial investigation process. This technique is an investigative approach that provides direction in equivocal deaths and attempts to bring justice to the victim. Equivocal Death, Psychological Autopsy, Forensic Psychology

I11 A Review of More Than 20 Parricides and Crime Scene Behaviors: Does It Differentiate Mental Illness, Psychopathy, or Abuse as the Reason for Killing Parents?

Eleanor B. Vo, MD*, OmaDesala Psychiatric Services, 1901 N Olden Avenue Ext, Ste 3A, Ewing, NJ 08618-2111; Kaveh Cyrus Ghaedi, DO*, Rutgers University—Newark, Department Psychiatry, 671 Hoes Lane, D325, Piscataway, NJ 08854; and Wade C. Myers, MD*, Brown University, Dept of Psych & Human Behavior, Forensic Psychiatry Program, 1 Hoppin Street, Ste 204, Providence, RI 02903

The goal of this presentation is to further attendees’ understanding of parricide and crime scene analysis to better understand the motive of the crime. Parricide, while a rare event, has devastating impact on families and others. The crime scene could show details as to the motive of the crime. This presentation will impact the forensic science community by demonstrating how, with further analysis of the crime scene, the motivation could be better extrapolated to improve treatment of cases with mental illness or abuse as compared to psychopathic intentions. Children killing their parents is a rare event that falls into three areas or profiles: (1) children that have mental illness; (2) children that are abused; and, (3) children that are psychopaths. Parricides, while rare, are one of the most sensational crimes that attract the attention of the media, clinicians, and researchers worldwide. Much research has been conducted on the topic of parricide despite only being approximately 1.5% to 2.4% of all homicides yearly. Often research focuses on the offender and the victim’s characteristics to be able to evaluate the crime and motive; however, there is very limited research into the crime scene behaviors. When looking at more than 20 cases of parricide and reviewing the crime scene information from case information in addition to researching data from public records, data has shown that one-third of the children who kill their parents are abused, one-third are mentally ill, and one-third are psychopathic killers. When looking at crime scenes, there is information that can be helpful to both police and mental health providers about the motive of the crime. This study, after observing the patterns of the crime scene, anticipates demonstrating that children who are abused or mentally ill are more likely to cover the body or even stay in the home with their deceased parents’ bodies. Psychopathic offenders will demonstrate less care at the crime scene and not have the empathy to cover or disguise the bodies due to their lack of connection to the parents. Most research has focused on the demographics, motives, social, legal and psychological factors, such as mental health and abuse history. Minimal research of crime scene behaviors in parricide cases have been explored. Crime scene profiles or analyses have been examined when investigating other cases, but not specifically for parricides. When the research has been examined at parricide cases, the focus has been on age and weapons were used, not the basic crime scene information. Often, the basic crime scene details are dismissed, but they can be an invaluable tool for investigators and police in helping to understand the offender of violent crimes. By scrutinizing data from crime reports, publications, and cases, the data on the crime scene can be used to better evaluate the connection of the crime scene data to the reason for the parricide. This concept has not been examined in parricide cases, which could help better understand the events and circumstances that lead an individual to taking their parents’ lives. To examine the components of crime scene behaviors and their implications within parricide, data from adolescent parricides will be presented. This study will present preliminary data concerning parricide offenders and crime scene behaviors, such as the condition of the body when found (covered, face covered, moved, or hidden); the type of attack (blitz, surprise, conned/deceived); the presence of defensive wounds; signs of overkill; and the weapon used. Parricide, Psychopathy, Crime Scene

I12 Narcissism and Violence: Criminological Understanding in a Homicide Case of Complete Decapitation

Ignazio Grattagliano, PsyD*, University of Bari, Via Mauro Amoruso 68, Bari 70124, ITALY; Gabriele Rocca, Via De Toni 12, Genoa, ITALY; Alessandro Bonsignore, MD, PhD, University of Genova, Dept of Legal & Forensic Medicine, Via de Toni 12, Genova, Liguria 16132, ITALY; and Alfredo Verde, PhD, Via De Toni 12, Genoa, ITALY

After attending this presentation, attendees will be able to recognize some of the characteristics of the relationship between narcissism and violence as well as the role of self-conscious emotions, including problems of self-esteem, in the etiology of a homicide case involving complete decapitation. This presentation will impact the forensic science community by demonstrating: (1) how narcissistic behaviors have an important influence on forensic psychiatric evaluation results; and, (2) the need for reliable and more careful attention to both the subject’s history as well as investigation and evaluation results. According to the literature, narcissists tend to become violent when they are confronted with a threat to the self. Nevertheless, the role that provocation plays regarding the personality of the aggressor has not been studied very much from a clinical criminological perspective. In order to better assess the importance of understanding the findings of forensic psychiatric evaluations in such circumstances, this study provides a case of intra- familial homicide in which a nephew shot his uncle with a firearm due to an apparent territorial dispute, after which he completely decapitated the victim and disposed of the head.1 The information acquired during psychiatric investigation revealed a man who was deeply troubled by family conflicts that began in childhood; his relationship with his parents was characterized by deep ambivalence, as well as a lack of stable and well-defined object relations. These elements conditioned the development of thought processes and behavior, which are characterized by intense feelings of inadequacy toward one’s fellow man. The offender coped with these emotions by avoiding social relationships and having the tendency to be highly controlling of the world around him. The subject also exhibited a deeply fragile identity that was brought about by the ambiguity he experienced during his childhood. It was for this reason that he felt empty and “out of place” and sought out idealized figures who would provide him with an apparent sense of stability that would allow him to construct an acceptable ego. Among these figures, one uncle stood out who was a role model for the subject from when he was very young. Later, the uncle became very strict in addition to being an obstacle to the offender’s ability to develop a healthy self-esteem. This uncle also threatened to expropriate a piece of land that was allegedly owned by the nephew. This homicide presents an important paradox: the gap between the obvious horror and high level of destructiveness of the act committed and the apparent banality of the motives and the reason he killed in such a manner. In fact, expert testimony has demonstrated that violent acts directed toward the uncle were neither premeditated nor the result of psychotic elements. On the criminological level, understanding the motive can be found in both the combination of the killer’s personality (depression and narcissism) and the triggers for his violent behavior (the grudge he held against the victim, who was guilty of closing the door on their relationship). This was a source of great humiliation and embarrassment for the perpetrator as he believed this abandonment to be both unjust and unfounded. The ensuing suffering he endured triggered a desire for revenge related to the offenses he endured (the uncle’s unacceptable behavior) and for the latest narcissistic wound that was inflicted. In other words, the key to reading the crime lies in comprehending how the perpetrator’s personality not only developed but was also grafted onto the victim’s.2,3 This homicide has its origins in the distorted relationship between the two subjects, one of whom was convinced to have incurred irreparable damage. The other is merely the projection of the perpetrator’s true enemy, who, in reality, does not exist and is imaginary in nature. In cases such as this one, unlike in serial murders, there is a scapegoat onto which the accumulated anger and aggression may be directed. The victim becomes the unsuspecting symbolic intermediary and symbolic message of the murderer. One wonders about the nature of the relationship between the perpetrator and the victim. What could have motivated such violence in which the nephew (the offender) first shoots a pistol at his uncle and subsequently decapitates him using a machete? Following psychiatric evaluation, the perpetrator was found to have a narcissistic personality. Reference(s): 1. Campobasso C.P., Laviola D., Grattagliano I., Strada L., Dell’Erba A.S. (2015),Undetected patricide: Inaccuracy of cause of death determination without an autopsy. Journal of Forensic and Legal Medicine. 34,67-72. 2. Solarino B., Leonardi S., Grattagliano I., et al. An unusual death of a masochist: Accident or suicide? Forensic Sci Int. 2011; 204:e16-9. 3. Grattagliano I., Greco R., Di Vella G., Corbi G.M., Campobasso C.P., Romanelli M.C., Ostuni A., Petruzzelli N., Brunetti V., Cassibba R., (2015). Parricide, abuse and emotional processes: A review starting from some paradigmatic cases. La Clinica Terapeutica. 166, e47-55. Narcissism, Violence, Decapitation

I13 Holy Crime: Sexual Abuse of Minors by Priests

Ignazio Grattagliano, PsyD, University of Bari, Via Mauro Amoruso 68, Bari 70124, ITALY; Alessio Ostuni, MD*, Sections of Legal Medicine and Criminology, Policlinico of Bari Italy, Piazza Giulio Cesare 11, Bari 70124, ITALY; Maricla Marrone, MD, P.za Giulio Cesare, 1, Bari 70124, ITALY; Anna Cassano, PsyD, P.za Giulio Cesare, 11, Department of Forensic Psychiatry, Bari 70124, ITALY; Annalisa Pasquale, PsyD, Dept of Education, Psychology and Communication, Via Crisanzio 42, Bari 70124, ITALY; Giancarlo Di Vella, MD, PhD, University of Torino, Dept Public Health Sciences, Sezione di Medicina Legale, Corso Galileo Galilei 22, Torino 10126, ITALY; Lucia Tattoli, PhD, Sezione di Medicina Legale, University of Turin - Corso Galileo Galilei, 22, Torino 10126, ITALY; Carlo P. Campobasso, MD, PhD, University of Campania, Dept Experimental Medicine, via Santa Maria di Costantinopoli, 16, Napoli 80138, ITALY; Graziamaria Corbi, PhD, via Giovanni Paolo II-Loc Tappino, Campobasso 86100, ITALY; and Roberto Catanesi, MD, P.za Giulio Cesare, Bari 70124, ITALY

After attending this presentation, attendees will better understand the psychopathic mechanisms underlying a phenomenon that spread in some realms of the Catholic church, namely the sexual abuse of minors. This presentation will impact the forensic science community by serving as an example on which to base a scientific explanation of the phenomenon not only in terms of the victims, but also of the offenders. The John Jay Report of 2004 revealed that in most cases of sexual abuse of minors that came to light concerning the Catholic church in the United States between 1950 and 2002, the episodes involved puberal, preadolescent, and adolescent minors, and so should really be referred to as ephebophilia (offence against minors aged 10 to 17 years). In total, 4,329 priests (accounting for 4.3% of parish priests and 2.5% of priests belonging to religious communities) were accused, on plausible evidence, of the sexual abuse of minors.1 Sexual abuse by priests seems to be a reactive behavior likely generated by insufficient emotional, affective, sexual, and relational maturity; in other words, a compensation mechanism that attempts to fill a void of affection, erotism, and sexuality. The abuse is seen and rationalized as similar to masturbation or pornography so that it does not tarnish the public function of a church minister. The choice of a minor is also due to the fact that satisfaction is thus sought outside the commitment of a relationship. The John Jay College of Criminal Justice reported (referring to 2004) that 64% of the accused priests had abused males only, 22.4% females only, and 3.6% had abused both sexes. This has very often led to attributing the plague of sexual abuse to an increase in the number of homosexual priests.1 In fact, it is sexual immaturity, due to entering a seminary at an early age, and the lack of any sexual education, together with a strong vulnerability to narcissism (in relational terms), that leads the subject to turn his attentions to young people of both sexes. The youths are perceived as psychosexual peers. The sexual choice (mostly male) largely reflects opportunity rather than sexual leanings. It is easier to approach boys and there can be no fear of unwanted pregnancy, as is risked in relations with puberal or postpuberal girls. Finally, some priests conceive of celibacy as the abstention from sexual relations with women. Therefore, they convince themselves that sexual relations with boys do not contravene their vow of celibacy. The boy is seen simply as a means for obtaining pleasure in all safety. Those most likely to suffer abuse by ministers, the victims, are generally young people with some social or physical lack, who are therefore vulnerable. At first, they feel “special” because they have been chosen by the charismatic figure of the priest, but later they develop conflicting, confused feelings during the episodes of abuse, and, finally, they feel betrayed and alienated from the church. Sexual abuse by a priest is a sexual and relational betrayal perpetrated by a Father Confessor of the community — a man the child has learned to trust more than any other since birth. Therefore, it is a psychological shock for the victim, provoked by a violent overstimulation and personal betrayal that triggers the activation of various defense mechanisms. As a result of the sexual abuse, the child loses faith in the world as a relatively safe, foreseeable place, is unable to build a positive, confident self-image, and can no longer trust in relationships with others.2 In order to contain the phenomenon, it is not sufficient for physicians and psychologists to study only the victims; they need to analyze the perpetrators as well and conduct a scientific study of their traits, personalities, and internal operative models. This is not easy, because the institutions and public opinion are ill-equipped to deal with crimes that arouse such strong, aggressive reactions. The expert approaching the study of such phenomena could run into difficulty when faced with feelings and behaviors that test his/her empathic powers and so run the risk of collusion. The adoption of a scientific approach in the attempt to help the perpetrator, too, may interrupt the cycle of violence and thus offer real help for victims, past, present, and future.3 Reference(s): 1. John Jay College Of Criminal Justice. The Nature and Scope of the Problem of Sexual Abuse of Minors by Catholic Priest and Deacons in the United States: A Research Study Conducted by the John Jay College of Criminal Justice. New York: City University of New York, February 2oo4. 2. Grattagliano I., Scardigno R., Casibba R., Mininni G. Holy Crimes: Sexual Abuse by an Imposter Priest. J Child Adolesc Behav. 2015:3(3):1-5. doi:10.4172/2375-4494.1000212. 3. Gartner R.B. Betrayed as Boys: Psychodynamic Treatment of Sexually Abused Men. New York: Guilford Press, 1999:11-42. Children, Sexual Crimes, Priests

I14 Are There Similarities Between Forensic Technician and Sworn Peace Officer Stress?

Selena M. McKay-Davis, MFS*, National University, Forensic Sciences Program, 11255 N Torrey Pines Road, La Jolla, CA 92037; Ismail M. Sebetan, MD, PhD*, National University, Forensic Sciences Program, 11255 N Torrey Pines Road, La Jolla, CA 92037-1011; and Paul Stein, PhD*, National University, Forensic Sciences Program, 11255 N Torrey Pines Road, La Jolla, CA 92037

After attending this presentation, attendees will better understand the physical, psycho-social stress and traumatic experiences endured by forensic technicians and sworn peace officers. Moreover, this survey examined the levels of perceived job-related stress and mental health concerns in forensic technicians and sworn peace officers, both on duty and off duty. This presentation will impact the forensic science community by promoting stress and mental health awareness for forensic technicians who investigate crime scenes and encouraging research into this relatively unexplored area. The results of occupational stress, especially in forensic technicians, has not yet been fully appreciated by law enforcement agencies or human resources departments involved in recruiting and training these professionals. Understanding the lasting impact of occupational stress on forensic technicians will enable law enforcement agencies and their families to proactively train, recognize, and help forensic technicians cope with many job- related stressors. This study hypothesized that sworn peace officers and forensic technicians would report similar levels of overall job stress while on duty and that both occupations would report significant physical and psychological impacts as a result of their crime scene-related occupations. Forensic technicians provide field services at every possible type of crime scene with varying levels of direction and support from sworn peace officers. The primary field services assigned to forensic technicians includes identifying, documenting, collecting, preserving, and conducting preliminary analysis of physical evidence in relation to criminal investigations. They are constantly exposed to the stressful world of violent crime. As a result, forensic technicians can also experience physical and psychological stress, violence, and security vulnerability similar to other law enforcement first responders; however, unlike the latter, there is a lack of research regarding the impact of the stress and danger experienced by forensic technicians on their mental and physical health. This has now been addressed in this study through the development and administration of an anonymous survey that gathered scaled, yes/no, and fill-in-the-blank type choices to 25 basic questions regarding perceived stress, physical danger on and off duty, physical and psychological life impact of job-related duties, preferred stress management networks, and coping strategies. Participants included forensic technicians and sworn peace officers employed at California law enforcement agencies with one or more years of experience processing major crime scenes. Forensic technicians (N=37) and sworn peace officers (N=36) submitted qualifying surveys. The results indicated that perceived on-duty stress was significantly higher (P ≤0.05) for the forensic technicians (M=3.50, Standard Deviation (SD)=.99) compared to the sworn peace officers (M=2.99, SD=.97) based on the scaled (1-5) responses. The off-duty stress rating was higher for forensic technicians than sworn peace officers, but was not statistically significant. It was noted that of the 54 pre-selected stressors common to law enforcement, forensic technicians and sworn peace officers shared 10 of the top 20 ranked stressors. Two-thirds of all stressors were ranked statistically similar between the two occupations. Forensic technicians reported negative job-related impact responses in 14 out of 17 physical and psychological impact categories, whereas sworn peace officers reported negative job-related impacts in only 8 of the categories. Furthermore, forensic technicians and sworn peace officers exhibited statistically similar career-related impacts in 10 of the 17 physical and psychological categories. Perceived danger was experienced less frequently by forensic technicians compared to sworn peace officers, but was not statistically different. Last, both forensic technicians and sworn peace officers reported using friends and family for stress management more frequently, followed by peer support, and ,last, mental health resources. When compared to sworn peace officers, forensic technicians reported lower availability, awareness, and utilization of agency mental health support services, something this study suggests needs to be addressed. The survey responses from this study suggested a similarity of work-related stressors that are shared by both forensic technicians and sworn peace officers; however, it appears that the perceived effects of stress for forensic technicians exceeded that of sworn peace officers. These findings indicate that the initial hypothesis, in part, can be rejected. Forensics, Crime Scene Investigator, Stress

I15 Variation in Genes Affecting Dopamine Turnover, Oxytocin, and Serotonin in Inmate and Student Populations

Elizabeth Chesna, BS*, Sam Houston State University, Dept of Forensic Science, 1003 Bowers Boulevard, Huntsville, TX 77340; Ana I. Blanco, MS, 805 Hackberry Road, #2, San Juan, TX 78589; Charity M. Beherec, MS, Texas DPS, 1404 Lubbock Business Park Boulevard, Ste 200, Lubbock, TX 79403; Gabriella Cansino-Jones, MS, 11350 Four Points Drive, Apt 1121, Austin, TX 78726; Peyton Gandy, MSFS, 2052 Myrtle, Unit 3, Dover, DE 19901; Jessica Wells, PhD, Department of Criminal Justice, 1910 University Drive, Albertsons Library, Boise, ID 83725-1955; Danielle Boisvert, PhD, Department of Criminal Justice and Criminology, 816 17th Street, Huntsville, TX 77340; Todd Armstrong, PhD, Sam Houston State University, College of Criminal Justice, 816 17th Street, Huntsville, TX 77320; Sheree R. Hughes-Stamm, PhD, Sam Houston State University, Dept of Forensic Science, Huntsville, TX 77340; and David A. Gangitano, PhD, Sam Houston State University, 13906 Paradise Valley Drive, Houston, TX 77069

After attending this presentation, attendees will gain knowledge concerning the relationship between Single Nucleotide Polymorphisms (SNPs) associated with genes of oxytocin, serotonin, and dopamine as well as specific behavioral traits. Furthermore, attendees will learn about these genetic differences in an inmate population compared to a student control population. This presentation will impact the forensic science community by demonstrating the genetic influence on aggressive and antisocial behavior. These behaviors have become a major problem as the United States currently has the highest incarceration rate in the world. Moreover, antisocial and aggressive behavior are two of the leading causes of mental health referrals. The strong heritability and environmental issues surrounding criminal activity indicates that a genetic underlying can help explain at least some features related to these behaviors. Behavior is a complex process influenced by both genetics and the environment. Some neurotransmitters have been associated with social behavioral traits, including: Oxytocin (OXT), Serotonin (5-HT), and Dopamine (DA). Certain genes (such as genes of receptors, transporters, and enzymes involved in metabolic pathways of these neurotransmitters) are associated with these neurotransmitters. These genes contain polymorphic sites that can be studied to relate or link them to certain behavioral traits. SNPs are single-base variations found at a specific location on the genome and are considered to be the most abundant type of polymorphism in humans. While some associations between SNPs and behavior have been made, this study analyzes multiple SNPs within the three most common ethnic groups in the United States (Caucasian, Hispanic, and African American) in both inmate and student populations. This study analyzed a total of 17 SNPs: 12 SNPs associated with DA turnover (rs2283739, rs1799836, rs3788862, rs909525, rs979605, rs740603, rs737865, rs739388, rs1611115, rs165599, rs4680, and rs129882), two SNPs associated with the OXT gene (rs877172 and rs4813625), two SNPs related to the serotonin receptor (5HTR2A) (rs6314, and rs6311), and one SNP located within the serotonin transporter gene (5-HTT) (rs25531) using Single-Base Extension (SBE). A student sample set (N=200) and inmate sample set (N=100) were genotyped, and individuals participated in a survey designed to assess 31 behavioral traits. Significant associations were found within the control population for two SNPs associated with OXT and 5-HT: rs6314 and antisocial behavior in Hispanics (p=0.008), and rs877172 and antisocial behavior in Caucasians (p=0.001). Furthermore, statistically significant differences in haplotype frequencies were observed in inmate vs control populations in SNPs associated with dopamine turnover (monoamine oxidase; MAOA). These results indicate that these SNPs play an important role in social behavior, including antisocial behavior. The results of this study provide some evidence that OXT, 5-HT, and enzymes related to DA turnover can influence behavior. It was found that SNPs associated with these neurotransmitters influence antisocial behavior. These behavioral SNPs may be used in early prevention or treatment of psychiatric disorders, which have a large impact the medical field and criminal justice system. Furthermore, understanding the influence of OXT, 5-HT, and DA on behavior may help explain the etiology of aggressive and antisocial behavior. Single Nucleotide Polymorphism, Oxytocin, Dopamine

I16 Phenotypic Characteristicts in Different Groups of Psychopathic Individuals

Donatella La Tegola, PhD*, University of Bari, P.za Giulio Cesare, 11, Bari 70124, ITALY; Alan R. Felthous, MD, Saint Louis University School of Medicine, Forensic Psychiatry Division, 1438 S Grand, St. Louis, MO 63104-1027; Roberto Catanesi, MD, P.za Giulio Cesare, Bari 70124, ITALY; Domenico Montalbò, MD*, p.za G. Cesare, 11, Bari 70124, ITALY; and Felice F. Carabellese, MD, University of Bari, Section of Forensic Psychiatry, p.za G. Cesare, 11, Bari 70124, ITALY

After attending this presentation, attendees will be able to recognize phenotypic characteristics in different groups of psychopathic individuals. This presentation will impact the forensic science community by helping identify any phenotypic gender-specific factors related to psychopathy. Psychopathy in a personality disorder entailing traits and behaviors that have a negative impact on individuals and society. The diagnostic criteria for psychopathy has a long history in psychiatry and overlaps with criteria of other personality disorders, especially antisocial personality disorder and narcissistic personality disorder. These include egocentricity, superficial charm, a grandiose sense of self-worth, the need for stimulation, pathological lying, a manipulative approach to relationships, a lack of remorse and guilt, callousness, a lack of empathy, impulsivity, irresponsibility, and an inclination toward criminal behaviors. The confusion in the use of the term “psychopathic” could be explained by different phenotypic characteristics in different groups of psychopathic individuals and by gender differences. The Psychopathy Checklist-Revised (PCL-R) is one of the most commonly used measures of psychopathy.1 The total score of PCL-R is composed by interpersonal and affective (factor 1) scores and lifestyle scores (factor 2). The current study investigated discrepancies in scoring of PCL-R between a male psychiatric forensic sample, a female psychiatric forensic sample, a female prisoner sample, and female prisoners who had been convicted for Mafia-related crimes. Prior research on psychopathy has primarily focused on the problem in men. Only a few studies have examined whether psychopathy even exists in women, and, if so, how the disorder manifests itself within them. Research on differences between the sexes has suggested that psychopathy is less frequent in women than in men; however, it is debated whether the observed differences in the occurrence of male and female psychopaths reflect actual physical differences in the frequency of psychopathy, or whether those differences reflect factors related to aspects of the diagnostic tools and the terminology used, which surface when these criteria for evaluating psychopathy are applied to women. This study has shown how the psychopathic individuals in the different female samples demonstrated similar phenotypic characteristics. On the contrary, differences between the sample of women and that of men were observed: female sufferers more often seem to demonstrate emotional instability, verbal violence, manipulation of social networks, and, to a lesser degree than male psychopaths, criminal behavior and instrumental violence. The importance of a correct diagnosis of “psychopathy” relates to its potential usefulness with regard to issues such as the choice of treatment strategies, treatment evaluation, risk assessment, and the prediction of future violence. If one assumes that the same research results achieved in studying men are automatically transferable to women, one does risk misjudgments of enormous consequence. For instance, within the field of forensic psychiatry, the diagnosis of psychopathy is often used to justify the length of prison terms. In some countries, indefinite prison terms can be given to criminals with this diagnosis. The diagnosis of psychopathy may also be used to justify patients’ exclusion from treatment programs as well as other punitive measures. Reference(s): 1. Hare, R. D. (2003). Manual for the Revised Psychopathy Checklist. (2nd ed.). Toronto, Ontario, Canada: Multi-Health Systems. Psychopathy, Gender-Specific Factors, Phenotypic Characteristics

I17 The Psychopathic Semantics of Serial Killer Theodore Robert Bundy

Kaveh Cyrus Ghaedi, DO*, 32 Bartle Court, Apt B, Highland Park, NJ 08904; and Ross Crosby, PhD, Neuropsychiatric Research Institute, 120 Eighth Street, S, PO Box 1415, Fargo, ND 58107-1415

The primary objective of this study is to perform an exploratory analysis using quantitative linguistic analysis software, Linguistic Inquiry and Word Count (LIWC), to study how one prototypical psychopathic serial killer used language within various contexts over time. This presentation will impact the forensic science community by providing exposure to a novel and relatively affordable way of gleaning insights into psychopathology by looking at individual differences in language use. Theodore Robert Bundy (1946-1989), or “Ted,” was the quintessential psychopathic serial killer, prototypical of how the clinical construct was extensively detailed qualitatively by psychiatrist Dr. Hervey Cleckley1 and later further refined and quantified by psychologist Dr. Robert Hare.1-3 Psychopathy is a clinical construct loosely characterized by a cluster of severe affective, interpersonal, and behavioral components that include, but are not necessarily limited to, traits such as: superficial charm, egocentrism, glibness, conning/deceptiveness, pathological lying, poor behavioral controls, callous lack of empathy, and/or lack of remorse. Although related, psychopathy is often incorrectly equated with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis of Antisocial Personality Disorder (ASPD), a relatively heterogeneous categorical construct. One of the many characteristics that distinguish psychopaths from non-psychopaths is the way they employ language in unusual ways.4-7 Their words are sometimes perceived as hollow shells devoid of affective content, a phenomenon that Cleckley referred to as “semantic aphasia.”1 Language is the most common and reliable manner to convey our thoughts and emotions so that others can understand us.8 Our words reflect who we are and how we relate to others. Researchers have long studied the semantics of subjects with various psychopathologies to glean more insights into them and their behaviors; however, such endeavors often proved tedious, time consuming, expensive, and often had problematic interrater reliability.9 With the advent of more affordable and powerful computers, we can now empirically and reliably accomplish in seconds or minutes what may have previously taken months or years. One tool that circumvents the aforementioned issues is the LIWC software.9 LIWC (pronounced “Luke”) is a transparent text analysis program developed by psychologist Dr. James Pennebaker and his students at the University of Texas at Austin.9 It counts words and places them in psychologically meaningful categories.10,11 These empirical dimensions have been extensively studied, well validated, and applied to detect meaning in a wide variety of circumstances, such as predicting mild cognitive impairment, detecting deception in written and spoken language, and understanding individual differences between attempters and completers of suicide.12-16 To date, relatively few studies have used LIWC to understand psychopathy, and, as of this writing, no published research has used it to study serial killers. The primary objective of this study is to perform an exploratory analysis using LIWC to study how one prototypical psychopathic serial killer (Bundy) used language within various contexts over time. The dataset includes transcripts of police interrogations, personal correspondence, courtroom testimony, and interviews with the press collected by this study from books, video footage, and original documents from state archives in both Florida and Washington. The goal of this presentation is to introduce attendees to the powerful and affordable potentials of using LIWC in forensic investigations by illustrating how it can reliably relate language patterns to psychopathology. Reference(s): 1. Cleckley, Hervey M. 1976. The Mask of Sanity: An Attempt to Clarify some Issues about the so-Called Psychopathic Personality. 5th ed. St. Louis: Mosby. 2. Hare, Robert D. 1993. Without Conscience: The Disturbing World of the Psychopaths Among Us. New York: Pocket Books. 3. Hare, Robert D., and Craig S. Neumann. 2017. The PCL-R Assessment of Psychopathy: Development, Structural Properties, and New Directions. 4. De Almeida Brites, José. 2016. The Language of Psychopaths: A Systematic Review. Aggression and Violent Behavior. 27 (2016): 50-54. 5. Hare, Robert D., Sherrie E. Williamson, and Timothy J. Harpur. 1988. Psychopathy and Language. 6. Brinkley C.A., Newman J.P., Harpur T.J., and Johnson M. M. 1999. Cohesion in texts produced by psychopathic and nonpsychopathic criminal inmates. Personality and Individual Differences. (26) 873-885. 7. Le, Marina T., Michael Woodworth, Lisa Gillman, Erin Hutton, and Robert D. Hare. 2016. The Linguistic Output of Psychopathic Offenders during a PCL-R Interview. Criminal Justice and Behavior XX. (4): 009385481668342. 8. Tausczik Y.R. and J.W. Pennebaker. 2010. The Psychological Meaning of Words: LIWC and Computerized Text Analysis Methods. Journal of Language and Social Psychology. 29 (1): 24-54. 9. Pennebaker, James W. 2011. The Secret Life of Pronouns: What our Words Say about Us. US ed. New York: Bloomsbury Press. 10. Pennebaker J.W., R.L. Boyd, K. Jordan, and K. Blackburn. 2015. The Development and Psychometric Properties of LIWC2015. Austin, TX: University of Texas at Austin. 11. Pennebaker J.W., Booth R.J., Boyd R.L., and Francis M.E. 2015. Linguistic Inquiry and Word Count: LIWC2015. Austin, TX: Pennebaker Conglomerates.

12. Asgari, Meysam, Jeffrey Kaye, and Hiroko Dodge. 2017. Predicting Mild Cognitive Impairment from Spontaneous Spoken Utterances. Alzheimer’s and Dementia: Translational Research and Clinical Interventions. 3 (2): 219-228. 13. Masip, Jaume, María Bethencourt, Guadalupe Lucas, Miriam Sánchez-San San Segundo, and Carmen Herrero. 2012. Deception Detection from Written Accounts. Scandinavian Journal of Psychology. 53 (2): 103-111. 14. Ali, Mohammed and Timothy Levine. 2008. The Language of Truthful and Deceptive Denials and Confessions. Communication Reports. 21 (September 2014): 82-91. 15. Almela, Ángela, Gema Alcaraz-Mármol, and Pascual Cantos. 2015. Analysing Deception in a Psychopath’s Speech: A Quantitative Approach. DELTA: Documentação De Estudos Em Lingüística Teórica E Aplicada. 31 (2): 559-572. 16. Handelman, Lori D. and David Lester. 2007. The Content of Suicide Notes from Attempters and Completers. Crisis. 28 (2): 102-104. Ted Bundy, Psychopathy, LIWC

I18 The Psychopathological Profile of the Female Serial Killer: From Homicide to Cannibalism — The True Story of the “Soapmaker of Correggio”

Isabella Aquila, MD*, Institute of Legal Medicine, University Magna Graecia of Catanzaro, S Venuta-Medicina Legale, viale Europa, Catanzaro 88100, ITALY; Pietrantonio Ricci, Viale Europa-Località Germaneto, Catanzaro, ITALY; Matteo Antonio Sacco, MD, Chair of Legal Medicine, University of Catanzaro, Viale Europa, Loc Germaneto, Catanzaro 88100, ITALY; Paola Frati, PhD, Dept of Anat Histol Forensic and Orthop Sciences, University of Roma “La Sapienza,” Viale Regina Elena 336, Roma 00161, ITALY; Valerio Riccardo Aquila, Via Dante Alighieri, Crotone, ITALY; and Santo Gratteri, MD*, Viale Europa, Germaneto, Catanzaro 88100, ITALY

After attending this presentation, attendees will better understand the role of the psychopathological profile in female serial killers and, in particular, the role that gratification plays in inducing the serial killer to commit murder. This presentation will impact the forensic science community by highlighting that, for the female serial killer, a psychopathic personality and child sexual abuse are common features. In most cases reported in the literature, serial killers are men. This study sought to analyze cases of female serial killers. A literature review was performed using the Pubmed NCBI search engine with “female serial killer” as the key word. There are few cases in the literature concerning female serial killers. This work seeks to tell the story of a female Italian serial killer. An investigation of the mental processes with the analysis of her memoir, Leonarda Cianciulli, An embittered soul’s confessions, attributed to this serial killer, was performed and the data compared. This study reports the case Leonarda Cianciulli. She was born in 1892, in Mantella, Italy. Her childhood was difficult: “I was a weak child … my parents treated me like a weight … I attempted to hang myself twice ….” She had 17 pregnancies, but only four sons survived. These children became an obsession with her. Cianciulli attended three friends, who were single, middle-aged women. The first victim was Faustina Setti. Leonarda told her she had found a husband for her. Since Faustina was semi-literate, Leonarda volunteered to help her write a letter. The same day, she killed her friend with an ax, then dissected the corpse. She wrote, “I threw the pieces into a pot … I made a lot of pastries … also Giuseppe (her son) and I ate them.” The second victim was Francesca Soavi, who wanted to find an occupation. Cianciulli claimed to have found her a job and convinced her friend to write to her acquaintances regarding her departure. Leonarda rushed the woman with an ax and killed her. The third victim was Virginia Cacioppo, an opera singer who lived in poverty. Leonarda claimed to have found her a job. About her, Cianciulli said, “She ended up in the pot, like the other two ... after a long time on the boil, I was able to make some most acceptable creamy soap. I gave bars to neighbors and acquaintances.” After numerous investigations (victims’ blood and dentures were found in her home), it was considered certain that the woman had committed the crimes. She was sentenced to 30 years in prison and 3 years in a criminal hospital. The woman, in the Aversa mental hospital, said, “I killed … only for mother’s love.” Cianciulli died of cerebral apoplexy in prison. From a psychiatric point of view in serial killing cases, the murders are premeditated, based on obsessions that become an irresistible impulse to kill. The necessary conditions for homicide are the fantasy, the symbolism, the ritualism, and the compulsion. The killer takes with him/her something belonging to the victim. In fact, Cianciulli confessed that she killed the women, destroyed the bodies by boiling them, made soaps, and kept the blood to mix with milk and chocolate to make cookies for her sons, believing this would save them from a mysterious death. Leonarda identified herself with the goddess Thetis, who wanted to give her sons immortality. The victims always have features in common. The perpetrator has a criminal record and prefers victims who are geographically close. According to scientific studies, serial killers are victims of childhood traumas. In these murderers, psychopathological personality disorders, a desire for control, delusions of omnipotence, and sexual motives are common denominators. This historic case is unique for manners; the sexual motive is absent, but it clearly represents a profile of the female serial killer. The feelings of parental abandonment and the sons’ deaths caused frustrations and a desire to control of events. The choice of weapons, such as hatchets or axes, was related to her constitution of being a small woman who needed harmful weapons. The dissection of the bodies was performed for two reasons: to dissolve the traces and to retain fetishes as rituals. Forensic Science, Female Serial Killer, Homicide

I19 Empathy for the Psychopathic Patient

Paulina Riess, MD*, Bronx Lebanon Hospital Center, 1276 Fulton Avenue, Bronx, NY 10456; and Ahmed Albassam, MD*, Bronx Lebanon Hospital Center, 1276 Fulton Avenue, Bronx, NY 10456

The goal of this presentation is to provide a brief review of the literature on this subject, along with the means to cross barriers of negative countertransference when navigating similar cases. This presentation will impact the forensic science community by demonstrating how positive countertransference has been directly correlated to improved patient outcomes, particularly in psychiatry, as the therapeutic alliance remains a central focus in treatment. Literature on this topic is extensive; however, literature on positive countertransference for criminals and psychopaths is scarce. Developing positive countertransference remains challenging for some clinicians when faced with particularly difficult patients. When clinicians are noted to struggle in their supervision to develop positive relationships with patients, supervisors recommend empathizing with such patients as a way of developing positive feelings toward them; however, certain patients, particularly psychopaths, challenge a clinician’s ethics and fundamental beliefs. Hence, developing rapport with such patients remains difficult for many clinicians. Lastly, it is important to differentiate between what is positive countertransference induced by the patient’s attempt to manipulate, appeal, and please the provider versus identification of true and genuine empathy on the provider’s part. The phenomenon of countertransference was first defined publicly by Sigmund Freud in 1910 as being the result of a patient’s influence on the psychiatrist’s unconscious feelings. The concept of countertransference was originally considered a barrier in psychotherapy, whether positive or negative. Freud originally thought it should be identified and rooted out; however, it is now considered very important in the therapy process. Otto Kernberg provided psychiatry with a totalistic way of looking at countertransference. When juxtaposed with Freud’s theory, it encompasses the complete emotional reaction of the therapist toward his patient. Heinrich Racker linked countertransference with empathy. This study would like to implement Racker’s model of countertransference for the purpose of this presentation. Most of the available literature on this topic suggests that empathy for psychopathic patients among psychiatrists is quite rare and only occurs in the context of voyeuristic curiosity or envy of the criminal’s ability to cross social and moral barriers. In this presentation, it is argued that genuine empathy for such patients is possible. Here is described the experience of two residents, both pursuing careers in forensic psychiatry, who provided care for such a patient with concordant rapport. This particular patient had a violent background with severe psychopathic traits; however, both providers were capable of appreciating the patient’s pathology, and identifying his feelings of loss, isolation, illness, and decay. This presentation will also provide a brief review of the literature on this subject, along with the means to cross barriers of negative countertransference when navigating similar cases. Psychopathy, Countertransference, Empathy

I20 How Just Is Manifest Injustice (MI)?: Evaluating the Use of Manifest Justice in the Washington State Juvenile Rehabilitation Administration

Nicole Sussman, MD*, Cambridge Health Alliance, 9 Austin Park, Unit 2, Cambridge, MA 02139; Terry Lee, MD, University of Washington School of Medicine, 2815 Eastlake Avenue, E, Ste 200, Seattle, WA 98102; and Kevin Hallgren, PhD, University of Washington, 1959 NE Pacific Street, Box 356560, Seattle, WA 98195-6560

After attending this presentation, attendees will be able to: (1) appreciate the juvenile justice system’s mission to provide rehabilitation and treatment for youths, as well the existence of policies that support this mission (i.e., MI); (2) recognize the disproportionate minority contact and racial inequality in youth sentencing that exists within the juvenile justice system; (3) understand the circumstances that are contributing to the sentencing disparity identified with the use of MI and the importance of adequate community services for these youths; and, (4) inspire efforts to engage in advocacy for youths and families engaged in the juvenile justice system. This presentation will impact the forensic science community by illuminating ongoing sentencing disparities within the juvenile justice system. The hypotheses generated to explain the findings of this study point to critical system-wide injustices that need to be addressed and better understood. Further research is needed to ensure laws are being used justly across all ethnic and minority groups. Objectives: In the Washington (WA) State Juvenile Code, a provision called Manifest Injustice (MI) allows judges to sentence youths outside of the standard sentencing range guidelines. Racial inequality in juvenile justice sentencing is well established.1 This investigation evaluates how MI is used across racial groups among WA youths involved in the Juvenile Rehabilitation Administration (JRA). It was hypothesized that MI would be used more frequently to decrease sentences of Caucasian youths and to increase sentences of minority youths. Methods: De-identified and aggregated administrative data of the JRA residential population (n=436) was obtained for youths in custody on 1/11/16. The goal was to compare rates of JRA involvement and MI between racial minorities and Caucasian youths. Rate ratios were used to compare the proportions of WA state and JRA-involved minority youths who received MI Down or MI Up/In with Caucasian youths. Results: African American (AA) youths were more than seven times as likely to be involved in the WA Juvenile Justice System than Caucasian youths (RR=7.85, p=<0.0001), while Mixed youths were three times more likely (RR=3.17, p=<0.0001), and Hispanic youths were 40% more likely (RR=1.40, p=0.0131). Although results did not meet statistical significance, there was a trend toward AA and Mixed youths having MI used to decrease their sentence less than Caucasian youths. AA youths were about half as likely to have MI used to increase or intensify their sentence compared to Caucasian youths (RR=0.49, p=.002), whereas Mixed youths were 42% less likely (RR=0.58, p=.04). Conclusions: Finding that Caucasian youths were more likely than AA and Mixed youths to have their sentences increased or intensified was contrary to what was hypothesized. More AA youths reside in the urban and more liberal parts of the state where judges may be more progressive and less likely to use MI to intensify sentences. More diversion programs are available in the urban areas of the state, some target minority youths, and more AA youths are transferred to adult court; all of these actions reduce the likelihood of minority youths receiving sentence intensification. Judges in the rural areas of the state, which are Whiter and have fewer treatment resources, may be using MI to send youths into facilities to access treatment. It is imperative that community behavioral health services are available so youths and families can be justly served. Reference(s): 1. Piquero A. Disproportionate Minority Contact. The Future of Children. (2008): 59-79. Juvenile Justice, Mental Health, Disparities

I21 Potential Effects of Legalized Recreational Cannabis on Youth

Jeramy R. Peters, DO*, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239; and Joseph Chien, DO, VA Portland Health Care System, 3710 SW US Veterans Hospital Road, Portland, OR 97239

After attending this presentation, attendees will appreciate the growing national trend toward legalization of recreational cannabis and understand the potential effects that acceptance of cannabis use and the growing cannabis industry may have on the vulnerable population of children and adolescents. This presentation will impact the forensic science community by increasing awareness of the specific vulnerabilities of children and youths to cannabis products that are transforming due to a changing legal stance toward recreational use. Clinicians will be more aware of changes in Tetrahydrocannabinol (THC) concentration, means of consumption, and packaging that potentially have an impact of pediatric use of cannabis. Clinicians may be better able to counsel their patients on marijuana use and preventing inadvertent consumption of cannabis products by children. Currently, recreational cannabis for adults is legal in eight states and the District of Columbia, and the list is growing.1 This presentation explores current trends in legalization of recreational cannabis, the growing cannabis industry, and changes in THC potency and means of consuming that have resulted from this legal shift; however, a recent report by Han et al. examining data from the National Survey on Drug Use and Health from 2002-2014 found that youth cannabis use has been declining since 2011.2,3 This data is in contradiction to what might be expected with increasing acceptance of cannabis use. As more states begin to legalize recreational marijuana, it remains to be seen if this downward trend in youth cannabis use will continue. This presentation will examine how some of the marketing efforts of the cannabis industry for new forms of cannabis, such as edibles, are being packaged to appear nearly indistinguishable from candy products and may target children or be mistakenly consumed by children. The current trend of legalizing recreational marijuana use may have an adverse effect on the vulnerable youth population. The potential effects of the higher visibility of cannabis products, as well as higher potency products, is also explored in the context of research that suggests that younger populations may be more vulnerable to cognitive impairment and more susceptible to developing psychosis with cannabis use.4 Reference(s): 1. Pierre J.M. Risks of increasingly potent cannabis: The joint effects of potency and frequency. Current Psychiatry. 18 (2017): 15-20. 2. Wilkinson S.T., Yarnell S., Radhakrishnan R., Ball S.A., D’Souza D.C. Marijuana legalization: Impact on physicians and public health. Annual Review of Medicine. 67 (2016): 453-466. 3. Han B., Compton W.M., Jones C.M., Blanco C. Cannabis use and cannabis use disorders among youth in the United States, 2002-2014. Journal of Clinical Psychiatry. (2017): e1-e10. 4. Volkow N.D., Baler R.D., Compton W.M., Weiss S.R.B. Adverse health effects of marijuana use. The New England Journal of Medicine. 370 (2014): 2219-2227. Cannabis, Legalization, Adolescents

I22 Females Who Sexually Offend: Characteristics and Behaviors

Emily D. Gottfried, PhD*, MUSC, Charleston, SC 29407; and R. Gregg Dwyer, MD, EdD*, Medical University of South Carolina, Community & Public Safety Psychiatry Division, 29-C Leinbach Drive, Charleston, SC 29407

The goal of this presentation is to add to the empirical literature on sexual offending by females, given the paucity of such resources available to those involved in assessment, treatment, and prevention. This presentation will impact the forensic science community by increasing empirically based understanding of females who sexually offend, which, in turn, will improve clinicians’ abilities to effectively evaluate clients for diagnosis, treatment, and risk reduction. Female sex offenders are an understudied population and are often regarded as being rare; however, as a recent meta-analysis reported, sex offenses committed by women are more prevalent than it previously appeared.1 Specifically, Cortoni and colleagues reported that although only approximately 2% of sex offenses reported to law enforcement are perpetrated by women, victimization surveys report a much higher (approximately 12%) instance of sexual offending by women.1 This presentation will include data on 13 women who were convicted of sexual offenses and were assessed for civil commitment under the South Carolina Sexually Violent Predator (SVP) Act. The mean age was 32.85 (Standard Deviation (SD)=6.50, range 23-44) at time of assessment. The sample had one to two victims (M=1.23, SD=0.44) each and 30.8% had female-only victims, 61.5% had only male victims, and 7.7% had both female and male victims. The victims’ ages ranged from 3 to 17, with the mean age of the offenders’ youngest victim being 12.54 (SD=4.41). The convictions included Criminal Sexual Conduct with a Minor, Lewd Act on a Child, Criminal Solicitation of a Minor, Promoting Minor Prostitution, and Sexual Exploitation of a Minor. Two of the women had prior convictions for sexual offenses and four had prior convictions for felony offenses. Nine (69.2%) had victims who were unrelated, three (23.1%) had related victims, and one (7.7%) had both related and unrelated victims. None of the women had been diagnosed with a paraphilic disorder. Nearly 70% (n=9) had been diagnosed with a mental illness to include schizophrenia, bipolar disorder, anxiety disorder, substance use disorders, post-traumatic stress disorder, and an unspecified depressive disorder. More than 75% (n=10) reported experiencing childhood sexual abuse. Only one of the women was referred for further review for potential civil commitment under the SVP Act. A comparison with a matched set of male sex offenders will be included, noting similarities and differences, with discussion of likely etiologies of each. Practical application of findings for diagnostic and risk assessments and treatment planning is presented. Next steps in developing this area of limited evidence base are outlined for consideration. Reference(s): 1. Cortoni F., Babchishin K.M., and Rat C. (2017). The proportion of sexual offenders who are female is higher than thought. Criminal Justice and Behavior. 44(2), 145-162. Female Sexual Offenders, Sexually Violent Predators, Women

I23 High-Functioning Autism and Violence Risk

Lindsay Howard, DO, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239; Will Frizzell, MD*, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239; and Joseph Chien, DO, VA Portland Health Care System, 3710 SW US Veterans Hospital Road, Portland, OR 97239

After attending this presentation, attendees will better appreciate how Autism Spectrum Disorder (ASD) may be an underrecognized condition requiring different approaches to the assessment and mitigation of violence risk. Attendees will also gain awareness of special considerations in the assessment and treatment of potentially violent patients with high-functioning autism. This presentation will impact the forensic science community by helping clinicians who routinely assess patients for violence learn to incorporate assessments for autism spectrum disorder (i.e., Autism Spectrum Quotient). Clinicians will learn to utilize recommended strategies for mitigating risk specific to high-functioning autistic individuals. This presentation describes a case of a man admitted to an acute inpatient psychiatry ward with vague symptoms of anxiety and difficulty controlling his anger, and indirectly alluding that he was a threat to harm himself or others. Prior to his admission, he had his first visit with his outpatient psychiatrist, where he reported that he was receiving “ideas” to harm himself and others. The outpatient psychiatrist diagnosed him with likely autism spectrum disorder and recommended he be hospitalized for further assessment. On admission to the inpatient ward, the patient was fixated on themes of government conspiracies and rights to bear arms, making it difficult to obtain a reliable history. He also reported trouble connecting with others, and on further evaluation, reported that he had been diagnosed as being on the autism spectrum as a child. The patient completed the Autism Spectrum Quotient, and scored in the low range of the autism spectrum (formerly Asperger’s Disorder). He was treated with a low dose of risperidone (titrated to 1mg twice daily), which resulted in improved mood and less irritability. He no longer reported thoughts or messages to harm himself or others at the time of discharge, and a course of psychotherapy aimed at improving social skills was recommended. The relationship between high-functioning autism and violence is poorly understood. Media representation of recent mass killers, such as perpetrators of the shootings in Sandy Hook Elementary School, Newtown, CT, in 2012 and Santa Barbara, CA, in 2015, would seem to suggest a link between violence and individuals who appear to be on the autism spectrum. Research to date has not supported this link. Daniel Im reviewed the literature to explore ASD and violence from 1943 to 2014 and found no conclusive evidence of a connection.1 In this review, he did identify some risk factors specific to individuals with ASD that may increase violence risk among these individuals, such as problems with emotional regulation and deficits social-cognitive functioning. This presentation proposes that early identification of ASD may assist in preventing violence by allowing the identification and treatment of these unique risk factors, which otherwise may be missed if the diagnosis is not considered. Assessment and treatment strategies for patients with possible ASD who are at a risk for violence will be discussed. Reference(s): 1. Im D.S. Template to perpetrate: An update on violence in autism spectrum disorder. Harvard Review of Psychiatry. 23 (2016), 14-35. Autism Spectrum Disorder, Violence, Risk Assessment

I24 Factitious Disorder Imposed on Another: A Life-Threatening Italian Case

Sara Simona Racalbuto, PsyD, Department of Pediatric Emergency, Turin, Piazza Polonia 94, Torino 10100, ITALY; Serena Maria Curti, MD*, Sezione Medicina Legale DSSPP - Univ. TO, C So Galileo Galilei N 22, Torino 10121, ITALY; Francesco Lupariello, MD*, University of Turin - Legal Medicine Section, Corso Galileo Galilei 22, Torino, ITALY; Elena Coppo, MD, Department of Pediatric Emergency, A.O.U. “Città della Salute e della Scienza,” Turin, ITALY; and Giancarlo Di Vella, MD, PhD, University of Torino, Dept Public Health Sciences, Sezione di Medicina Legale, Corso Galileo Galilei 22, Torino 10126, ITALY

After attending this presentation, attendees will better understand Factitious Disorder Imposed on Another (FDIA), also termed Munchausen Syndrome by Proxy in some jurisdictions, which should be one of the possible differential diagnoses of recurring health issues in children. This presentation will impact the forensic science community by emphasizing the importance of a multidisciplinary evaluation of suspected somatoform disorders perpetrated by caregivers. FDIA continues to mystify health care professionals, law enforcement officials, and the judicial system.1 Even though the first cases were described in 1977, it remains puzzling as to why a parent would want to induce fictitious symptoms and illnesses onto a child.2 Many professionals do not consider FDIA as a diagnosis because the parent, usually the mother, is extraordinarily able to convince them that she is a “good” mother and wants the best for her child.3 This study reports a severe case of FDIA managed in the multidisciplinary unit dedicated to the evaluation of suspected abused children (“Bambi”) of the “Ospedale Infantile Regina Margherita” in Turin, Italy. After an 11-year-old boy had several prior hospitalizations in multiple other facilities over a period of eight years, he was hospitalized in the Endocrinology Department by his mother. The child was treated for various problems, including Hirsprung Disease and diabetes mellitus type 1 with life-threatening ketoacidosis. He was also subjected to invasive procedures (cystoscopy with bladder neck incision, rectal biopsy, intestinal resection with coloanal anastomosis, and botulin toxin injections). In the consultation processes with the “Bambi” team, the mother and the boy were interviewed separately. The child described himself drawing “Pinocchio” (a notorious character known for being a liar). In interactions with the mother, he always appeared dominant, blackmailing, and manipulative. The mother displayed a facility with medical language, even though she was not a health professional, and strongly identified with the role of therapist. She also displayed tentative and inconsistent parental behaviors and inefficient coping skills. The mother conveyed that she was the only caregiver and refused support from her partner, who had left her and their children a few months earlier. The woman had always cared for sick relatives and showed pride for this role. Her whole life had been focused on the illnesses of others, and she displayed considerable expertise in working with the social workers to obtain economic and other welfare benefits. A discrepancy between the severity of the reported facts and the woman’s emotional state was evident. A careful global assessment of clinical and family history found the heterogeneity of the child’s symptoms and their escalation over time. There was a lack of correlation between the symptoms’ progressions and therapies. There was always a temporal correlation between the stressful life events of the mother (death of her mother, abandonment by her husband) and the subsequent clinical deterioration of the child. Furthermore, when the woman was engaged in taking care of other relatives, the clinical condition of her son improved and his hospitalizations decreased. After a comparison between the “Bambi” unit personnel (pediatrician, medical examiner, psychologist, and trained nurse) and physicians of the Endocrinology Department, the situation was referred to the judicial authority, formulating the hypothesis of FDIA. Thanks to a brief period of intense observation, it was documented that a ketoacidosis crisis had been induced by incongruous insulin delivery by the mother. The subsequent psychiatric evaluation confirmed the mother’s diagnosis. The overall assessment of the case by a multidisciplinary team was fundamental to formulating the proper diagnosis of the mother’s psychological pathology. For many years, the child had been a victim of this particularly subdued form of maltreatment and, upon several occasions, had been subjected to unnecessary life-threatening interventions. In fact, the child’s false symptoms (in particular, the ketoacidosis crises) were an expression of the mother’s need to maintain the only function she had in her life: to be a caregiver. The diagnosis was further complicated by the fact that the child was actually suffering from various diseases, which were overtreated by the mother. This presentation provides attendees with a better knowledge of FDIA. This diagnosis should always be kept in mind when health care professionals evaluate cases of chronic pediatric diseases in the presence of an inappropriate correlation between symptoms and therapeutic efforts.4 Reference(s): 1. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Arlington, 2013. 2. Roy Meadow. Munchausen syndrome by proxy. The hinterland of child abuse. Lancet. 2(1977): 343-5, doi: 10.1016/S0140-6736(77)91497- 0. 3. John Stirling and the Committee on Child Abuse and Neglect. Beyond Munchausen Syndrome by Proxy: Identification and Treatment of Child Abuse in a Medical Setting. Pediatrics. 119 (2007): 1026-1030, doi: 10.1542/peds.2007-0563. 4. Bernard Kahan and Beatrice Crofts Yorker. Munchausen syndrome by proxy: Clinical review and legal issues. Behavioral Science and the Law. 9 (1991): 73-83, doi: 10.1002/bsl.2370090109. Child Abuse, Differential Diagnosis, Munchausen Syndrome By Proxy

I25 Clinical Psychiatry and Neuropsychiatry in the Forensic Context

Vernon M. Neppe, MD, PhD*, Pacific Neuropsychiatric Institute, 6300 Ninth Avenue, NE, Ste 353, Seattle, WA 98115

The goals of this presentation are to: (1) educate mental health professionals in three important medicolegal areas; (2) provide greater understanding of Tardive Dyskinesia (TD) and of Traumatic Brain Injury (TBI); and, (3) demonstrate methods to practice better psychiatry and more properly evaluate patients clinically and forensically. This presentation will provide a greater understanding of clinical psychiatry and neuropsychiatry in the forensic context and consists of lectures on the forensic aspects of TD, TBI, and proper evaluations. This presentation is applicable to all psychiatrists and mental health professionals. This presentation will impact the forensic science community by raising awareness of the need for careful clinical care, prophylaxis, and proper evaluations and will highlight principles generalized to other areas of civil and criminal forensic practice. Psychiatric evaluations include appropriate examination, ongoing assessments, diagnosis, management, prognosis, attributions of proximate causality, and damages. Prior medical histories are critical. Forensic data has an even higher standard emphasizing causality attributions and prognoses. Two key common illustrative medical conditions are: (1) Tardive Dyskinesia (TD) — a complex neuroleptic-prescription-induced, sometimes irreversible, movement disorder. Here, physicians commonly err in management, and the pharmaceutical industry may not properly put “warnings” on drug labels; and, (2) traumatic brain injuries — these could be repeated and catastrophic. Proper acute and chronic care is complex and sometimes additive to previous events. TD is possibly the most well-known but often missed drug-induced neuropsychiatric forensic condition. TD is sometimes incurable and induced by long-term prescription neuroleptic treatment (antipsychotic medications as well as gastro-intestinal medications, such as metoclopramide). Civil litigation against prescribers (physicians, particularly psychiatrists) and the pharmaceutical industry is a common, major consideration. Several steps for ensuring ongoing proper clinical evaluation and management are often neglected, including early detection, appropriate follow-up, including testing, outside specialized expert referral, differential diagnosis, and recognition of patients at risk. Evaluations include an effective specific TD scale (Neppe’s STRAW scale) with other formal examinations (AIMS, Simpson-Angus and possibly SCT Hans). Videotaping monitors progress. Management requires prophylaxis, early recognition, and ongoing interventions. It has been found that off-label, high-dose buspirone treatment (1989- 2017 experience) is extraordinarily successful, efficacious, cost-effective, and safe. This study regards it as far preferable to expensive, tetrabenazine derivatives (e.g., valbenazine), with theoretically significant side-effects and ostensibly incomplete control long-term. Traumatic brain injury (TBI) is very common with variable symptomatology: (1) non-recognition of the blow, but still having subtle changes; (2) concussion is common with several presentations, but sometimes incorrectly labeled; (3) unrecognized, seldom diagnosed yet treatable focal cerebral abnormalities; this includes particularly temporal or frontal lobes dysfunctions and uncommonly, subtle changes; (4) ranges through to prolonged deep coma, where acute lengthy hospitalization and rehabilitation is specialized. Management clearly varies acutely compared with the subacute and chronic residual phases; (5) recently, Chronic Traumatic Encephalopathy (CTE) with repetitive TBI has become increasingly recognized in contact sports and has major potential medicolegal implications; and (6) subtle differences must be recognized. To facilitate, the presentation has classified head injury forensically and clinically. Some management nuggets include: (1) missing the subtle focal injuries can be disastrous in clinical and forensic consequences, and yet can be commonly helped with appropriate, but often unprescribed, medications (including anticonvulsants and azapirones); (2) cognitive rehabilitation (previously expensive and lengthy) has largely been replaced by appropriate computer programs facilitating easier, often effective, management and rehabilitation (important medicolegally); (3) certain less well-known tests, such as the Inventory of Neppe of Symptoms of Epilepsy and the Temporal Lobe (INSET) and Soft Organic Brain Inventory of Neppe (SOBIN) are very important, structured ways of monitoring symptoms clinically and in follow-up; (4) costly, sometimes beneficial, specialized evaluations (e.g., home ambulatory electroencephalography, head Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) with contrast, Positron Emission Tomography (PET) scanning, Single-Photon Emission Computed Tomography (SPECT) scan, and polysomnography amplify diagnoses. Civil litigation may involve contradictory clinician and forensic roles. Testing in Clinical and Forensic Psychiatry and Neuropsychiatry: Every clinical patient could be a potential forensic case, because a major basis of litigation is substandard care. Applying standardized techniques while recognizing individual differences facilitates the appropriate clinical and forensic evaluations. Treatments are sometimes necessarily off-label while repeatedly assessing progress and ongoing management revisions. Clinical and forensic evaluations must include appropriate diagnostic, symptom, and risk assessments. Particularly, medicolegally appropriate data correlations, all pertinent records (medical and psychosocial), and outsider validations by family members, friends, and sometimes law-givers are important. Standardized neuropsychological testing has significant strengths by applying comparative norms. Accounting for baseline data — education, background, and previous test exposures — is essential. Yet, unrecognized testing weaknesses can imply over-inclusiveness and ignore significant individual differences. The clinical neuropsychiatric evaluation with repetitive individualized longitudinal monitoring is essential. Repeated follow-ups, including reviewing critical neglected areas (e.g., subtle malingering, motivation and fatigue), are ideal. These evaluations also require individual clinical tailoring of broad structured psychiatric and neurological questionnaires. The Pacific Neuropsychiatric Institute (PNI) has developed and meaningfully applied many such medicolegal neuropsychiatric screens. These include the detailed “Diagnostic-Screen questionnaires” (“DS-10”), the INSET and SOBIN, plus the BROCAS Screening Cerebral Assessment of Neppe (SCAN) cognitive examination. Tardive Dyskinesia, Traumatic Brain Injury, Evaluations

I26 Contribution of the Psychiatrist in the Evaluation of Fitness for Detention While in Custody in France

Arsene Gambier, MD*, Institut Medico Legal, CHRU Tours, Tours 37044, FRANCE; Camille Rerolle, MD, Service de Medecine Legale, Hopital Trousseau, CHRU Tours, Tours 37000, FRANCE; and Pauline Saint-Martin, MD, PhD, Service de Medecine Legale, Hopital Trousseau, CHRU Tours, Tours 37000, FRANCE

After attending this presentation, attendees will better understand the evaluation of fitness for custodial detention in France, which allows, in some cases, a direct intervention at the police station by a forensic psychiatrist. This presentation will impact the forensic science community by illustrating the in-custody management of mental health issues of a police station in France. Each year in France, several hundred thousand individuals who are suspected of having committed a criminal offence are arrested and retained in custody in a police station. As soon as the measure begins, the individual is allowed several defense rights, including the right to see a defense attorney and the right to have access to medical care at any moment while in the custody. A medical examination can also be solicited by the police officer or by a member of the individual’s family. The physician is always appointed by the police officer. These examinations are performed either by general practitioners or by emergency room doctors, but, in 2011, French forensic medical units were proposed to have a supplementary budget to perform these examinations in the geographic area closest to them. As a result, physicians with forensic training are performing these evaluations in some geographic areas. This report presents the organization of an institute that is located in an area of 600,000 inhabitants. Approximately 1,500 medical evaluations of persons in custody are performed each year. As French medicolegal physicians may have different professional courses, a psychiatrist is working full-time at the unit and is frequently solicited in this context. In general, medical examinations are requested in five circumstances: (1) when the arrestee declares he/she is suffering from a particular disease and requires a specific treatment that needs to be continued during police custody; (2) when recent traumatic lesions need to be treated and recorded; (3) when the arrestee complains of acute symptoms that appeared during police custody; (4) when a mental disorder could lead to an involuntary hospitalization requested by a state representative — this usually concerns individuals whose behavior has disturbed public order; and, (5) when it is imposed by law — for minors, for instance. It should be noted that the individual may still refuse the examination. Intervention of a psychiatrist to evaluate the fitness for detention is of particular interest in two situations, not exclusive from one another: (1) when the individual is suffering from alcohol and/or substance use; and, (2) when the individual needs a mental health assessment. In the first situation, the question of delivering a psychotropic medication may arise, either because the individual requests a substitutive treatment to avoid withdrawal symptoms or because the individual presents symptoms of anxiety or suicidal risk. In the second situation, the psychiatric interview allows determination as to whether or not there is a mental issue that could lead to the deliverance of a specific treatment or an observation in a psychiatric ward. This report suggests that direct evaluation by a psychiatrist in the police station allows better collaboration with the police officers to perform surveillance and administer medication to these individuals. The psychiatric interview also provides a filter before a more complete evaluation in the emergency room (if this is necessary). Forensic Science, Police Custody, Psychiatric Evaluation

I27 Impartiality and Forensic Psychiatry: How Forensic Psychiatry Specialists Consider the Concept of Impartiality

Tony Godet*, Geneva University Hospital, rue G Perret Gentil 4, Geneva 14 1211, SWITZERLAND; and Gérard Niveau, MD, Geneva University Hospital, rue G Perret Gentil 4, Geneva 14 1211, SWITZERLAND

The goal of this presentation is to determine knowledge and representation regarding impartiality and which factors could change this. This presentation will impact the forensic science community by increasing knowledge of the factors that influence impartiality. Introduction: When it comes to justice, an expert psychiatrist has a different role than a therapist. In the first case, the psychiatrist works only when asked by authorities to testify. Impartiality is a priority for the expert psychiatrist.1 This survey was initiated to better understand how forensic psychiatry specialists consider the concept of impartiality and also asks which factors can influence impartiality. Material and Methods: An online survey was created that included a clinical case, some general issues about impartiality, and questions on personal and professional specifications relating to the persons who answered. This survey was sent to psychiatrist members of the World Psychiatrist Association of the European Psychiatric Association and of the American Association of Forensic Psychiatry. Results: One hundred thirty-one psychiatrists from 18 countries (66% from the United States) participated in this survey with a rate of 94.5% answers (103-131 answers by question). The sample consisted of 74% men and 94.5% of graduate psychiatrists. The average age was 53.4 years and the average forensic psychiatry experience was 18.3 years. More than 80% of the sample had an additional forensic psychiatry certification. In the clinical case, personal convictions were identified as a factor that called into question their impartiality in 80% of the cases. Impartiality pertains primarily to ethics and legal topics, according to the survey. The most important factors that influenced personal impartiality were: (1) being the treating psychiatrist of the assessed person in the past (97%); (2) personal past experiences (92%); and, (3) personal convictions (90%). The most frequent factors that strengthened personal impartiality were: (1) forensic psychiatric training (94%); and, (2) professional past experiences (77%). The most important factors that question legal impartiality were: (1) already being the treating psychiatrist of the assessed person in the past (93%); (2) personal convictions (78%); and, (3) already having performed a psychiatric assessment on the person (70%). Comparisons reveal very few differences between answers provided by men and women, the doctor’s age had an influence on the factors questioning legal impartiality, and there were very few differences between the experienced psychiatrists and those who did not have a lot of experience. It was noted that the choice of factors that strengthen and call impartiality into question were influenced by the psychiatrists’ work countries. Finally, the survey compared the different types of forensic psychiatric training. Results reveal that psychiatrists trained in forensic psychiatry within a general psychiatry program feel that personal convictions and being the treating psychiatrist for the assessed person in the past strengthen impartiality. Psychiatrists with additional training in forensic psychiatry consider impartiality more as an ethical notion and that additional training in forensic psychiatry strengthens impartiality. Psychiatrists who were supervised during their assessment consider that the fact that they have already completed a psychiatric assessment affects impartiality — that this could also question it and that professional past experience calls impartiality into question. Conclusion: The psychiatrists sampled have a good knowledge of impartiality. The principal factors they identified as being able to affect, strengthen, and call into question are the same factors mentioned in scientific articles and international recommendations.2 The high participation rate of American psychiatrists could be explained by a large diversity of organizations and the recognition of forensic psychiatry in European countries. As expected, having additional training in forensic psychiatry did not change the perception of impartiality. Moreover, years of experience in forensic psychiatry had a small influence on the answers, whereas psychiatrists older than 65 years of age were most likely to identify some factors that call impartiality into question. Reference(s): 1. ABDA-FILHO. Objectivity and subjectivity in forensic psychiatry. Revista Brasilieira de Psiquiatria. 35 (2013):113-114 2. American Association of Psychiatry and Law. Ethics Guidelines for the Practice of Forensic Psychiatry. Adopted May, 2005. http://www.aapl.org/ethics-guidelines. Impartiality, Forensic Psychiatry, Psychiatric Assessment

I28 Racial Trauma: Its Mental Health Manifestations in Racial Minorities Involved in the Legal System and Incorporating Findings in Forensic Psychiatric Assessments

Donald R. Brown II, MD*, USC Institute of Psychiatry and Law, PO Box 86125, Los Angeles, CA 90086-0125

After attending this presentation, attendees will be able to: (1) understand the concept of “racial trauma”; (2) realize how it could apply specifically to racial minorities involved in the legal system; (3) better understand its psychiatric manifestations; and, (4) value its importance in the forensic psychiatric assessment. This presentation will impact the forensic science community by exposing how racial harassment and discrimination, in its numerous forms, against minorities in American society could lead to emotional and psychiatric manifestations due to traumatic stress. Awareness of this topic will enhance the efficacy of the forensic psychiatrist’s evaluation and treatment plan. In some cases, it may also strengthen the therapeutic alliance between the treating psychiatrist and the client. The information presented is obtained from previously conducted studies and literature that examined the link between cultural competency regarding racial discrimination and the criminal justice system. Additional sources include current events reported by the media that relate to perceived racial injustice. The fact that many members of racial minorities believe there is racial injustice makes it imperative that forensic psychiatric evaluators address and include these issues in their examinations. Researchers have noted that, in recent decades, one area of inquiry that needs increased attention is racial discrimination, specifically as perceived by non-dominant group members (African, Latino, Asian, and Native Americans). Carter and Forsyth define racial discrimination as a “form of avoidant racism, reflected in behaviors, thoughts, and policies that have the effect of maintaining distance or limiting contact between dominant and non-dominant racial group members” and racial harassment as a “form of racism that involves feelings, thoughts, and actions intended to communicate a target’s subordinate status due to membership in a non-dominant racial group.”1 Multiple studies have found that “between 40%-98% of racial minority participants reported that they had experienced racial discrimination.”1 Currently, there are limited resources to assist psychiatrists in appropriately assessing racial trauma. Psychological reactions to racial discrimination often do not fit the specific criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) for posttraumatic stress disorder; however, researchers have documented statistically significant relationships between “perceived experiences with racism” and mental disorders, such as adjustment, stress reaction, mood, and anxiety.1 According to the United States Census Bureau, the 2010 population of Whites (72.4%) far outnumber Black (12.6%) and Latino (16.3%) populations. Yet, in the same year, the national prison population consisted of 38% Black and 22% Latino men and women.2 Race has been used as a political and media tool and, consequently, has engendered fear within the dominant group toward the minority group and vice versa. This has been a contributing factor to the minority groups’ overall distrust of the legal system. The following are some examples: the murder of unarmed Black males by law enforcement in which the perception in the Black community is that justice hasn’t been served, the outcry for the construction of a “wall” between the United States and Mexico with mass deportation of illegal immigrants, or the imposition of a Muslim ban on entry to the United States from Islam-dominant countries. These events have led to severe emotional and psychiatric stress (racial trauma) in these target communities that should be identified. This presentation seeks to: further analyze racial trauma; explore how these reactions to perceived racial injustice could be expressed emotionally, psychologically, cognitively, or behaviorally; and provide a guideline in performing a thorough forensic psychiatric evaluation. In addition, consideration of perceived racial trauma will ultimately lead to enhancing the therapeutic alliance between client and psychiatrist. Reference(s): 1. Robert T. Carter, PhD, and Jessica M. Forsyth, MA, EdM. A Guide to the Forensic Assessment of Race Based Traumatic Stress Reactions. The Journal of the American Academy of Psychiatry and the Law. 37 (2009): 28-40. http://jaapl.org/content/37/1/28.long. 2. Kapoor, Dike, Burns, Carvalho, and Griffith. Cultural Competency in Correctional Mental Health. The International Journal of Law of Psychiatry. 36 (2013): 273-280. doe: 10.1016/j.ijlp.2013.04.016. Racial Trauma, Guideline, Forensic Evaluation

I29 Mental Wellness and Suicide Prevention Programming Among United States Police Agencies

Leslie Ethan Dodson, BA*, Texas Tech University, 6110 36th Street, #14, Lubbock, TX 79407; Megan Thoen, PhD, Texas Tech University, Institute for Forensic Science, 4434 S Loop 289, Lubbock, TX 79414; Brandy Pina-Watson, PhD, Texas Tech University, Dept of Psychological Sciences, Box 42051, Lubbock, TX 79409; and Elizabeth Trejos-Castillo, PhD, Texas Tech University, Human Sciences, Human Development & Family Studies, Box 41230, Lubbock, TX 79409

After attending this presentation, attendees will better understand the availability and use of police officer wellness promotion and suicide prevention programs implemented nationally as well as the perceptions of program effectiveness expressed by employing departments. Attendees will be able to identify and describe various difficulties encountered with, and the need for research within, the area of police mental wellness and suicide prevention. This presentation will impact the forensic science community by discussing perceptions of effectiveness in mental wellness and suicide prevention programming utilized by police departments. Officer suicide is a major issue affecting police: the 2015 President’s Task Force on 21st Century Policing reported on the necessity of research in this area, stating officers were more than twice as likely to die from suicide as from homicide.1 It has been recommended that training and programming should educate officers on emotional strength, and that the provision of relevant resources are essential to reducing officer suicide.2 A dearth of research exists in the area of police mental wellness and suicide prevention, especially regarding wellness programs utilized by police departments. By better understanding the state of police officer wellness promotion, it may be possible to determine the most effective programming for officer wellness and suicide prevention. To date, there has not been a comprehensive list of available programs or an examination of their effectiveness.3 This study is important to law enforcement as mental health issues may negatively impact cognitive abilities, job performance, and the likelihood of post-traumatic stress disorder and suicidal ideation.1,4 This presentation will examine data collected from a national sample of city police departments and sheriff’s offices describing any mental wellness and/or suicide prevention programs implemented. Using the most recent Census of State and Local Law Enforcement Agencies, police departments and sheriff’s offices with more than five full-time, sworn officers were compiled.5 These departments were then stratified into three groups based on the number of full-time, sworn officers: 5-20 (small), 21-100 (medium), and 101+ (large). The ten largest departments, and those recognized for wellness programming by the Destination Zero Program of the National Law Enforcement Officers Memorial Fund, were targeted for sampling.6 Other departments to be sampled were chosen randomly from within these strata. The phone interview, adapted from Kuhns, Maguire, and Leach, asked questions about available programming and perceptions of utilization and effectiveness of those programs.3 Most respondents have been ranking officers with some mental health training or civilian psychologists/counselors employed by the agency. Data collection ended in December 2017. Thirty departments from each stratum (90 total) were targeted, and to date, 13 departments have been interviewed (response rate of 25.5%; 13 respondents out of 51 contacted). Several logistical issues have arisen, most notably, difficulty in making contact with departments. The telephone-based recruitment procedure was chosen to avoid the non-response bias inherent in email or mail-based procedures.7 Nevertheless, difficulties in making contact with the appropriate potential respondents within these departments have occurred (i.e., some departments were unfamiliar with who should be contacted for the request at hand, resulting in the need to contact multiple people from within one agency). Some agencies that declined to participate noted policy against research participation and/or not enough time or officers to respond to the interview; others did not provide a reason for the refusal or never responded to repeated requests for participation. Most respondents willing to participate expressed pride in their department’s programming and had dedicated some effort to mental health issues in police work. Preliminary data indicated peer support groups are the most common programs used; 61.5% of responding departments use them. These programs were considered to be the most highly effective of utilized wellness or suicide prevention programming as well. Some respondents considered peer support programs to be ineffective, citing stigma in asking for help, and thus the programs are being underutilized. Other employed programs identified by departments included employee assistance programs, resiliency training, wellness campaigns/symposia, and use of critical incident response teams. Most agencies recommended peer support programming of all programming utilized. Future directions for research, including further discussion of the methodological and practical implications for generating empirical knowledge, will be addressed. Reference(s): 1. The President's Task Force on 21st Century Policing. Final Report of the President’s Task Force on 21st Century Policing. (Office of Community Oriented Policing Services, 2015). 2. Richard Armitage. Police Suicide: Risk Factors and Intervention Measures. (New York, NY: Routledge, 2017). 3. Joseph B. Kuhns, Edward R. Maguire, and Nancy R. Leach. Health, Safety, and Wellness Program Case Studies in Law Enforcement. (Office of Community Oriented Policing Services, 2015). 4. Judith P. Andersen, Konstantinos Papazoglou, Markku Nyman, Mari Koskelainen, and Harri Gustafsberg. Fostering Resilience among the Police. Journal of Law Enforcement. 5, no. 1 (2015). 5. United States Department of Justice. Census of State and Local Law Enforcement Agencies, 2008. (United States Department of Justice, 2008). 6. Destination Zero. Officer Wellness. The National Law Enforcement Officers Memorial Fund. 2016, http://www.nleomf.org/programs/ destination-zero/wellness/dz-wellness-about.html. 7. Michael G. Maxfield and Babbie, Earl R. Basics of Research Methods for Criminal Justice and Criminology. 4th ed. (Boston: Cengage Learning, 2015), 190. Police, Wellness, Suicide Prevention Copyright 2018 by the AAFS. Permission to reprint, publish, or otherwise reproduce such material in any form other than photocopying must be obtained by the AAFS. ______*Presenting Author - 829 - Psychiatry & Behavioral Science __ 2018

I30 Determining Implicit and Explicit Attitudes of Hiring Non-Violent Ex-Offenders

Cristine S. Kilburn, MA*, University of Central Oklahoma, 400 E Danforth Road, Apt 106, Edmond, OK 73034; and Nora Gayzur, PhD*, University of Central Oklahoma, 100 N University Drive, Box 85, Edmond, OK 73034

After attending this presentation, attendees will better understand the everyday practices of hiring non-violent ex-offenders and the impact of employment opportunities available to those who have been convicted of a non-violent crime as compared to non-offenders. This presentation will impact the forensic science community by explaining reductions in recidivism rates among non-violent ex-offenders (e.g., harsh penalties for drug charges). Offenders who are incarcerated for drug charges are in need of substance abuse treatments instead of imprisonment, while those found not guilty by reason of insanity need treatment for psychological disorders within a secure environment. Both populations have commonalities such as treatment, reintegration back into their community, and productiveness within their society. An integral part of success is gaining employment. The purpose of this study is to examine the implicit and explicit attitudes individuals have toward non-violent ex- offenders and the effect attitudes may have on the hiring process. Implicit and explicit attitudes would have the same impact on hiring decisions and could also aid in understanding discrimination in the hiring process. In 2015, the Bureau of Justice Statistics stated there were approximately 6,741,400 individuals (approximately 2.7%) under some form of correctional supervision (e.g., parole, probation). In 2011, nearly 660,000 people were released from prison. In mid-October 2015, the Federal Bureau of Prisons released another 6,000 offenders to help with the dilemma of population overcrowding and reduced the time served for non-violent offenders with harsh sentencing for some drug-related offenses.1 The drop in numbers has been attributed to lower incarceration rates (down 2.3%), as well as a community supervision decrease (down 1.3%).2 Another reason for the decrease in prison populations was overcrowding in prisons. Attitudes that people have toward ex-offenders have a significant impact on their lives, including social inclusion and employment. Attitudes can be explicit (consciously aware) or implicit (unaware), and each type of attitude may or may not affect behavior in the same way.3,4,5 Wilson, Lindsey, and Schooler demonstrated that explicit and implicit attitudes can have different outcomes on behavior.6 Explicit attitudes have been shown to have a greater influence on well-thought-out decisions. Conversely, implicit attitudes are more difficult to control and monitor; thus, these affect decisions when a person does not know what the response should be. Former President Barack Obama supported a law reform for hiring practices involving ex-offenders. The “Ban the Box Campaign” would ban the criminal information questions from federal employment in the initial hiring stage.7 There are 25 states, (including Oklahoma), and more than 150 counties and cities across the United States that have adopted the “Ban the Box” from the initial job application, which delays background checks until a later stage in the hiring process. The Fair Chance Act protects ex-offenders’ rights to have their employment history based on experience rather than viewed as an ex-offender on the first page of an application. The act provides ex-offenders the same chance as everyone else who is applying for the same position.8 In conclusion, this study could educate employers on the significance of implicit attitudes and their impact. Many people are not aware of how influential these attitudes can be. If they are aware of the impact, they may think more conscientiously about employment decisions. Hopefully, this study will also influence interviewees to request a reason for their employment denial; which is usually offered in the application paperwork. Reference(s): 1. Vega T. (2015). Out of prison and out of work: Jobs out of reach for former inmates. CNNMoney. New York. Retrieved from http://money.cnn.com/2015/10/30/news/economy/former-inmates-unemployed/. 2. Carson E., and Anderson E. Prisoners in 2015. Bureau of Justice Statistics. NCJ, 250374. Web. 2 Feb. 2017. 3. Bargh J.A. (1999). The cognitive monster: The case against the controllability of automatic stereotype effects. In: S. Chaiken & Y. Trope (Eds.), Dual-process theories in social psychology. (pp. 361–382). New York: Guilford Press. 4. Dovidio J.F., and Fazio R.H. (1992). New technologies for the direct and indirect assessment of attitudes. In J. Tanur (Ed.), Questions about survey questions: Meaning, memory, attitudes,and social interaction. (Pp. 204–237). New York: Russell Sage Foundation. 5. Fazio R.H. (1990). Multiple processes by which attitudes guide behavior: The MODE model as an integrative framework. In: M. P. Zanna (Ed.). Advances in experimental social psychology. (Vol. 23, pp. 75–109). Orlando, FL: Academic Press. 6. Wilson T.D., Lindsey S., and Schooler T.Y. (2000). A model of dual attitudes. Psychological Review. 107, 101–126. 7. Kudick K. (2016). Understanding what “ban the box” laws allows and prohibits. The Business National Employment Law Project, Open Society Institute, The Public Welfare Foundation, and The Rosenberg Foundation. (2011). Retrieved from http://www.nelp.org/. Attitudes, Offenders, Employment

I31 A Complex Case of Psychosis and Factitious Disorder

J. Brandon Birath, PhD, Olive View-UCLA Medical Center, 14445 Olive View Drive, Dept of Psychiatry, Sylmar, CA 91342; Stacie Collins, MD*, Olive View-UCLA Medical Center, 14445 Olive View Drive, Sylmar, CA 91342; and Davin Agustines, DO*, Olive View-UCLA Medical Center, 14445 Olive View Drive, Sylmar, CA 91342

The goals of this presentation are to highlight the diagnostic challenges of recognizing factitious disorder and to separate this diagnosis from malingering and psychosis in a clinical setting. This presentation will impact the forensic science community by improving the ability of clinicians to understand and recognize the diagnostic challenges in separating factitious disorder from malingering and psychosis. This presentation will also improve the ability of clinicians to manage this disorder. Factitious disorder is a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) -classified condition characterized by an individual’s intentional deception of medical professionals and others to present themselves or another as ill, injured, or otherwise impaired, motivated by a desire to assume the “sick role.”1 Factitious disorder can pose as a diagnostic challenge, as the patient will often go to great lengths to convince others they are ill, whether by feigning symptoms or by self-inflicting illness or injury, often leading to unnecessary and, in some cases, costly and invasive tests and procedures.2,3 After medical illnesses have been ruled out, factitious disorder may also be confused with other psychiatric disorders, including somatic symptom disorder and conversion disorder (both of which can be distinguished from factitious disorder by the absence of intentional falsification of symptoms) or malingering (characterized by patients feigning symptoms for secondary gain).1 Due to the fact that factitious disorder remains so diagnostically elusive, the exact prevalence is unknown. Studies have suggested that between 0.3% and 1% of patients admitted to general medicine services, who also have had consults placed to psychiatry, may actually have had diagnoses of fictitious disorder.3-5 The majority of patients with factitious disorder present feigning medical conditions, with endocrinologic, dermatologic, and cardiac complaints being the most prevalent.6 Among patients on psychiatric units, studies have estimated between 0.5% and 8% may have diagnoses of factious disorder with a primary psychological complaint.7,8 This occurs most commonly with co-morbid diagnoses of substance use disorder, depression, and cluster B personality traits.6,9-11 There have also been past reports describing factitious disorder patients presenting with primary symptoms of bereavement and post-traumatic stress disorder.12-15 Factitious disorder patients presenting with primary symptoms of psychosis are less common, though there have been sporadically documented case series and reports.16,17 This study presents a diagnostically challenging case of a patient with an unusual presentation of factious disease, with primary presenting symptoms in psychotic and somatic spheres. Reference(s): 1. DSM-5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Publishing, Arlington; 2013. 2. Feldman. The costs of factitious disorders. Psychosomatics. 1994;35(5):506-7. 3. A.J. Sutherland, G.M. Rodin. Factitious disorders in a general hospital setting: Clinical features, and a review of the literature. Psychosomatics. 31 (1990), pp. 392-399. 4. M. Bauer, F. Boegner. Neurological syndromes in factitious disorder. J Nerv Ment Dis. 184 (1996), pp. 281-288. 5. Dahale A.B., Hatti S., Thippeswamy H., Chaturvedi S.K. Factitious disorder-experience at a neuropsychiatric center in southern India. Indian J Psychol Med. 2014:36(1):62-5. 6. Yates G.P., Feldman M.D. Factitious disorder: a systematic review of 455 cases in the professional literature. Gen Hosp Psychiatry. 2016:41:20-8. 7. Bhugra D. Psychiatric Munchausen’s syndrome. Literature review with case reports. Acta Psychiatr Scand. 1988:77(5):497-503. 8. Catalina M.L., Gómez macias V., De cos A. Prevalence of factitious disorder with psychological symptoms in hospitalized patients. Actas Esp Psiquiatr. 2008:36(6):345-9. 9. Carney M.W.P., Brown J.P. Clinical features and motives among 42 artifactual illness patients. Br J Med Psychol. 1983:56:57-63. 10. Ries R.K. DSM-III differential diagnosis of Munchausen’s syndrome. J Nerv Ment Dis. 1980:168:629-632. 11. Kooiman C.G. Neglected phenomena in factitious illness: A case study and review of literature. Compr Psychiatry. 1987:28:499-507. 12. Snowdon J., Solomons R., Druce H. Feigned bereavement: Twelve cases. Br J Psychiatry. 1978:133:15–19. 13. Phillips M.R., Ward N.G., Ries R.K. Factitious mourning: Painless patienthood. Am J Psychiatry. 1983:140:420–5. 14. Sparr L., Pankratz L.D. Factitious posttraumatic stress disorder. Am J Psychiatry. 1983:140(8):1016-9. 15. Lynn E.J., Belza M. Factitious posttraumatic stress disorder: The veteran who never got to Vietnam. Hosp Community Psychiatry. 1984:35(7):697-701. 16. Grover S., Kumar S., Mattoo S.K., Painuly N.P., Bhateja G., Kaur R. Factitious schizophrenia. Indian J Psychiatry. 2005:47(3):169-72. 17. Pope H.G., Jr, Jonas J.M., Jones B. Factitious psychosis: Phenomenology, family history, and long-term outcome of nine patients. Am J Psychiatry. 1982:139:1480–3. Mental Health, Psychosomatics, Malingering

I32 Criminological Analysis of Human Smuggling and Migrant Trafficking Into Italy

Laura Volpini, PhD*, Via Dei Sulpici, 62, Rome 00174, ITALY; and Federica Mondani, EUNAVFORMED Op SOPHIA, Via Guido D’Arezzo 10, Roma 00187, ITALY

After attending this presentation, attendees will understand the identification and criminal characteristics of human traffickers, as well as the organizational structure of trafficking operations into Europe. This presentation will impact the forensic science community by elucidating the findings of a recent study investigating migrant smuggling and human trafficking operations into Europe in an effort to propose empirically based identifiers to assist naval intervention. Furthermore, this presentation will define the role of the forensic and mental health advisor in operations designed to thwart these crimes. With increasing frequency, migrants have been entering Europe. The use of human traffickers is a common method used by migrants to achieve these goals, despite being subjected to dehumanizing treatment and perilous journeys. Previous studies regarding human trafficking have primarily highlighted that the smuggling of migrants is operationalized within a stable, hierarchical, and transnational structure, using non-banking, intermediary, financial circuits called Hawala as payment. These organized crime efforts have been difficult to study because of variable investigative methods. In addition, traffickers make efforts to avoid detection, and migrants, typically instructed to avoid identification photographs, are difficult to identify. The goal of this research study, conducted on behalf of the European Union Naval Force Mediterranean/Operation Sophia (EU NAVFOR MED), was to identify criminological aspects of migrant smuggling and the characteristics of traffickers in order to aid in halting human trafficking in Italy. This study examined a large number of relevant court cases and reviewed national and international literature on the topic with the goal of identifying potential criminal traffickers, from a criminological perspective, during the first moments of migrant survivor rescue. This study found that traffickers are generally male, between 25 and 35 years of age, speak several languages, have good persuasive communication skills, live in shelters, have legal residency paperwork, and are sometimes married. This study also proposes a scientific investigative protocol, based on holistic and systemic methods, to better characterize and study the modus operandi and style of the perpetrators of these crimes. Strategic investigation may be conducted on two levels, direct and indirect, while migrants are detained and recovering from rescue. A direct investigative approach involves the use of digital audio and video recordings of survivor behaviors; these materials are often requested by the judicial authorities. Alternatively, an indirect investigative approach focuses on interviews of survivors, specifically women with minor children, who generally have fewer ties to the traffickers. This method would be managed through the use of behaviorally trained forensic consultants. This study proposes that forensic consultants, used to evaluate these survivors, employ a questionnaire that evaluates the communication methods used by traffickers. The Self-Administered Interviews (SAI) questionnaire was found to be most efficient for this task. In addition, a direct interview to reconstruct the context and the actions of traffickers would be helpful using a Cognitive Interviewing (CI) technique. This technique provides validation for the concerns of migrant survivors and provides investigators with a wealth of information on human traffickers. The use of these investigative methods in a systematic manner will aid in accumulating relevant data regarding this phenomenon. Criminological Analysis, Human Smuggling, Smuggling

I33 Live Streaming Suicide and Murder on Facebook®: Can Someone Be Held Liable?

Chris Chen, MD*, 655 S Hope Street, Unit 1101, Los Angeles, CA 90017

After attending this presentation, attendees will better understand the unique legal considerations related to the live streaming of suicide or murder on the social media site, Facebook®. Attendees will also become familiar with freedom of speech on social media platforms and the associated liability. This presentation will impact the forensic science community by: (1) presenting a review of the current laws regarding the liability of live streaming suicide and murder; and, (2) discussing the possibility of a duty by the social media site and viewers to protect others and prevent harmful acts. Facebook® Live is a service that allows Facebook® users to create and broadcast real-time videos to their followers. It became publicly available in January 2016. Since then, a string of suicides and some murders have been broadcast over Facebook® to a wide audience. These incidents raise questions regarding legal liability related to freedom of speech, trauma inflicted on viewers, and obligations to protect and prevent persons from engaging in harmful behavior. Does Facebook® have a legal responsibility to censor disturbing content, such as live broadcasts of suicide or murder? The first amendment gives Facebook® and its users the right to freedom of speech; however, there are instances when freedom of speech does not protect all content. For example, obscene content (material that offends the sexual morality of its viewers) is federally banned from the internet. Although suicide and murder do not fall under this category, is there another category that would ban such disturbing content? If such videos are not monitored and removed from viewing on Facebook®, can Facebook® observers of these acts of suicide and murder sue the media site for trauma inflicted while watching these videos? There have been cases in which relatives present at the time of death successfully sued for emotional distress after witnessing their family member being killed; however, in these lawsuits, the negligent infliction of emotional distress required that the plaintiff was physically near the scene of the incident. Negligence has been hard to prove and often unsuccessful in cases viewing death from a distance as well as on televised media. After many suicides were live streamed, Facebook® launched tools for viewers to report suicides. Given this ability, would the viewer have a legal obligation to report suicidal behavior? The law traditionally does not impose a general duty on the public to prevent another person from taking his/her own life; however, the case of a “special relationship” (e.g., mental health professional-patient relationship) can give rise to a responsibility where none would otherwise exist. For example, if a psychiatrist were to see a patient live streaming suicidal behavior, then the psychiatrist potentially would have a duty to protect the patient. If it is a murder that is being live streamed, certain states require any person who reasonably believes that he/she has observed the commission of a murder to notify a Peace Officer. Facebook® currently has teams designing artificial intelligence algorithms for identifying users who may be at risk for suicide before it becomes too late. If this algorithm could match or even surpass a physician’s diagnostic abilities, what duties would Facebook® owe to the individuals its algorithm identifies or overlooks? Could Facebook® be found negligent if it does not do enough to prevent suicide? This presentation will review the literature on live streaming suicide and murder with respect to key legal considerations that pertain to liability for viewers and media sites. In addition, possible recommendations toward reducing the incidents of harmful behavior that is live streamed will be provided. Live Streaming, Death, Liability

I34 Do Evidence Submission Forms Expose Latent Print Analysts to Task-Irrelevant Information?

Brett Gardner, PhD*, 205 Douglas Avenue, Apt 2, Charlottesville, VA 22902; Sharon Kelley, PhD, Institute of Law, Psychiatry, and Public Policy, 1230 Cedars Court, Ste 108, Charlottesville, VA 22903; Daniel C. Murrie, PhD, Institute of Law, Psychiatry, & Public Policy, University of Virginia, Box 800660, Charlottesville, VA 22908; and Kellyn Blaisdell, BA, University of Virginia, Institute of Law, Psychiatry, & Public Policy, 1230 Cedars Court, Ste B, Charlottesville, VA 22902

The goals of this presentation are to educate attendees regarding the nature and quantity of potentially biasing, task-irrelevant information routinely requested by crime laboratories before latent print analyses are conducted and to provide insight into appropriate countermeasures. This presentation will impact the forensic science community by providing results of a study examining the type and relevance of information requested by evidence submission forms in laboratories across America. Further, this presentation will apply the recent literature demonstrating contextual effects in forensic sciences to the evidence submission process and offer recommendations for countermeasures. In 2009, the National Academy of Sciences (NAS) released their congressionally mandated Report, Strengthening Forensic Science in the United States: A Path Forward.1 Detailing a variety of problems in the wide-scale practice of forensic science, this influential Report prompted media attention and widespread calls for reform. The concern that forensic science findings may be influenced by contextual effects (i.e., extraneous data and pressures that are unnecessary and potentially biasing to scientific analysis of fingerprints, firearms, DNA, and other evidence) was a primary identified problem. For example, forensic scientists who perform circumscribed procedures such as analyzing latent fingerprints may receive superfluous information regarding the criminal suspect or crime scene details; such contextual information is unnecessary to the task of comparing fingerprints and has the potential to bias the examiner toward a particular finding. Concerns regarding contextual effects are clearly consistent with a rich body of research in cognitive and social psychology.2 Moreover, several seminal studies specifically addressing contextual effects among forensic science procedures recently raised concerns throughout the forensic science community.3-5 Although limited, this growing body of research has substantial implications for policy and justice — many advocates have already urged substantial reforms.6 One of the primary recommendations offered in the NAS Report was to identify sources of bias and develop appropriate “countermeasures.”1 This current study sought to clarify the nature and quantity of potentially task-irrelevant information that is routinely requested before latent print analyses are conducted in forensic laboratories. Moreover, this study seeks to identify explicit requests for potentially biasing information in order to provide insight into appropriate “countermeasures.” In this study, 183 crime laboratories accredited by the American Society of Crime Laboratory Directors – Laboratory Accreditation Board (ASCLD-LAB) for the analysis of latent prints were first identified. An additional 24 laboratories accredited by ANSI-ASQ National Accreditation Board (ANAB) (a unified list of accredited laboratories was not available at the time of data collection) were identified in addition to three other laboratories that were either unaccredited or had recently stopped conducting latent print analyses. This study only identified laboratories accredited in latent print analysis for simplicity, clarity, and due to recent research specifically demonstrating significant contextual effects in latent print analyses.3,7 Each laboratory was asked to provide a blank evidence submission form used in latent print analysis requests. Two weeks after the initial request, a reminder email request was sent to all laboratories that did not respond. All remaining laboratories are now being contacted by telephone to personally request blank evidence submission forms. To date, 76 laboratories responded to this study’s request and the provided submission forms represent at least 105 laboratories across America. The submission forms from 68 laboratories were sufficient to be fully coded. These forms represent at least 97 laboratories in 39 states. Descriptive analyses focus on information requested by submission forms regarding the offense, suspect, victim, and other seemingly task-irrelevant and potentially biasing subjects. For example, approximately 96% of all forms request information regarding the type of offense, whereas only 20% specifically request a police or incident report be provided. Approximately half of all forms request information regarding the suspect’s race and criminal history. Moreover, while some task-irrelevant prompts appear to have practical purposes (e.g., approximately half of the forms request information regarding the location of the offense and most request suspect’s name), others have no overt practical purpose (e.g., victim sex and race). Moreover, approximately 18% of forms request seemingly task-irrelevant information that appears likely to bias latent print analysts (e.g., “Is suspect serious violent felon?”; “Please indicate if item was the probable-cause evidence in your case”). This presentation will provide much more descriptive information regarding the type of task-irrelevant information being requested and exposed to latent print analysts. In conclusion, this presentation will discuss the potential influence of task-irrelevant information currently being requested before latent print analyses are performed. This presentation will also relate current findings to extant literature demonstrating contextual effects in forensic sciences and latent print analysis specifically.3,5,7 Finally, there will be discussion regarding methods of achieving the correct balance of information necessary for latent print analysis (e.g., case management, linear sequential unmasking, Laboratory Information Management Systems (LIMS)) to prevent subconscious bias. Reference(s): 1. National Research Council. Strengthening Forensic Science in the United States: A Path Forward. Washington, DC: National Academies Press, 2009. 2. Saks M.J., Risinger D.M., Rosenthal R., and W.C. Thompson. Context Effects in Forensic Science: A Review and Application of the Science of Science to Crime Laboratory Practice in the United States. Science & Justice. 42, (2003): 77-90.

3. Dror, Itiel E., David Charlton, and Ailsa E. Peron. Contextual Information Renders Experts Vulnerable to Making Erroneous Identifications. Forensic Science International. 156, (2006): 74-78. 4. Dror, Itiel E. et al. Cognitive Issues in Fingerprint Analysis: Inter- and Intra-Expert Consistency and the Effect of a ‘Target’ Comparison. Forensic Science International. 208, (2011): 10-17. 5. Dror, Itiel E. et al. The Impact of Human-Technology Cooperation and Distributed Cognition in Forensic Science: Biasing Effects of AFIS Contextual Information on Human Experts. Journal of Forensic Sciences. 57, (2012): 343-352. 6. Dror, Itiel. et al. Letter to the Editor – Context Management Toolbox: A Linear Sequential Unmasking (LSU) Approach for Minimizing Cognitive Bias in Forensic Decision Making. Journal of Forensic Sciences. 60, (2015): 1111-1112. 7. Stevenage, Sarah V., and Alice Bennett. A biased opinion: Demonstration of cognitive bias on a fingerprint matching task through knowledge of DNA test results. Forensic Science Internationa.l 276, (2017): 93-106. Contextual Effects, Bias, Latent Print Analysis

I35 Jury Instructions on Insanity Acquittal Disposition

Jennifer Piel, MD*, VA Puget Sound, 1660 S Columbian Way, MS-116-MHC, Seattle, WA 98108

The goals of this presentation are to: (1) provide a summary of federal and state laws on jury instructions on insanity acquittal disposition; (2) review the primary reasons for and against jury instructions on what happens to a person acquitted by reason of insanity; and, (3) review the empirical evidence on juror knowledge concerning insanity acquittal disposition. This presentation will impact the forensic science community by reviewing the arguments for and against jury instructions on insanity acquittal disposition and will provide attendees with a review of the empirical research on juror knowledge concerning the consequences of a successful insanity defense. Jurors generally know that persons found guilty of a crime are punished and persons found not guilty are set free. Although jurors may not be aware of sentencing guidelines applied to a particular defendant, they generally have a basic understanding regarding the range of criminal punishments afforded to persons found guilty of a crime and understand that most convicted defendants serve time in jail or prison. Perhaps less obvious to jurors is what happens to defendants who are found Not Guilty by Reason of Insanity (NGRI). Because of uncertainty regarding NGRI disposition, some jurors may believe that criminally insane defendants are set free upon an NGRI verdict or may have unreasonable expectations about the duration of confinement. An important topic concerning the insanity defense is what jurors should be told about the disposition of a defendant acquitted NGRI. In the federal system, jurors are not told about the consequences of an insanity verdict under Shannon v. United States.1 State courts are divided on the issue. This presentation will review the current status of jury instructions — in the federal system and among the states — on the consequences of an NGRI verdict. The most recent legal cases on this topic will be discussed. The role of the jury will also be reviewed. Historically, juries have decided on guilt without knowledge of the consequences to the defendant. In this presentation, principle arguments for and against a jury instruction on NGRI disposition will be reviewed. Some courts address this issue by emphasizing the differences between the role of the jury and that of the judge — that judges are responsible for applying the law and imposing sentences, not the jury.2 Other state courts have held, at least as a matter of policy, that a jury instruction on NGRI disposition is necessary to prevent juror confusion and misguided verdicts. In states that have both NGRI and Guilty but Mentally Ill verdicts, instruction(s) about the verdicts and disposition outcomes are likely to be particularly important to reduce juror confusion. Of particular interest, this presentation will provide a review of the empirical evidence on juror knowledge regarding insanity acquittal disposition. Although the studies are limited in number and scope, they provide relevant information concerning juror knowledge and attitudes about the insanity defense. The weight of the studies confirms juror misunderstanding about a defendant’s disposition upon an insanity acquittal. In one study, a juror commented that he voted for a guilty verdict (in contrast to NGRI) because he “did not want a mad dog released.”3 This comment exemplifies the reason to give an instruction on the consequences to the defendant following acquittal by reason of insanity. Reference(s): 1. Shannon v. United States, 114 S. Ct. 2419 (1994). 2. Piel J. In the Aftermath of State v. Becker: A Review of State and Federal Jury Instructions on Insanity Acquittal Disposition. J Am Acad Psychiatry Law. 2012: 40: 537-546. 3. Morris G.H., Bozzetti L.P., Rusk T.N., et al. Whither thou goest? — An inquiry into jurors’ perceptions of the consequences of a successful insanity defense. San Diego L Rev. 1977: 14:1058–82 Insanity, Jury Instruction, Diisposition

I36 Compassionate Care for the Criminal Courts

Karen B. Rosenbaum, MD*, 49 W 24th Street, Ste 908, New York, NY 10010

The goal of this presentation is to educate defense attorneys, district attorneys, judges, and mental health professionals who work with the criminal court system on the benefits of compassionate care and enhancing empathy in a system that is traditionally adversarial. This presentation will impact the forensic science community by integrating concepts in contemplative science with issues in forensic science. People who are involved with the criminal justice system are under an extreme amount of stress. Defendants are facing possible lengthy incarcerations, defense attorneys are often overworked and underpaid, and judges have an overwhelming number of cases on their docket. Prosecutors are concerned with protecting the community and are not usually as interested in issues pertaining to a suffering individual who has committed a crime. When a defendant is mentally ill and needs treatment to be able to become competent to stand trial, this can delay cases for months and sometimes years. Legal professionals who are not trained in mental illness often have a difficult time understanding how mental illness can affect criminal responsibility and could interfere with someone’s ability to understand their charges and assist in their own defense. Mental health professionals and officers of the court often speak different languages. Issues pertaining to the law are focused on responsibility and blame. Psychiatrists and other clinicians are more concerned with diagnosis and cure and how to help someone out of their suffering. Concepts from Compassionate Care in contemplative science may be helpful in laying common groundwork between mental health professionals and legal professionals that could benefit their own wellbeing as well as their understanding of mentally ill criminal defendants. There are numerous studies on the psychological and neurological health benefits of meditation, yoga and other relaxation techniques that could help educate professionals in the criminal justice system on how to take care of their emotional health in a manner that results in more energy and understanding for another’s suffering. Teaching officers of the court to take time to engage in self-care could help them develop the capacity to better understand and appreciate people who are mentally ill and suffering. Meditating and slowing down at times during the day could also be helpful. Numerous case examples illustrate the need for better understanding of the difficulties mentally ill people face when they are in the criminal justice system. Enhanced empathy does not change the adversarial nature of the court system, but could provide each side with more information in order to better understand each position and the individual’s unique set of circumstances. As a result, they work together to help the defendant/client receive appropriate treatment/rehabilitation. Ultimately, this allows the criminal court system to function in a fairer and more efficient manner. Contemplative, Criminal, Court

I37 The Patient Can Leave: Involuntary Hospitalization of Non-Psychiatric Patients Who Lack the Capacity to Refuse Medical Treatment

Thomas Rodriguez, MD*, LAC+USC Forensic Psychiatry, PO Box 86125, Los Angeles, CA 90033

After attending this presentation, attendees will have gained knowledge of California’s current laws regarding involuntary hospitalization of medically ill patients who do not meet criteria for an involuntary psychiatric hold. This presentation will impact the forensic science community by illuminating the quandary the medical professional may be in when a patient who lacks capacity to refuse treatment chooses to leave the hospital. As most of these cases involve individuals with cognitive impairment, this will become an even greater issue as the proportion of the aged population increases. Generally, there is no legal mechanism to hospitalize medically ill patients against their will unless they are psychiatrically ill, have a legal conservatorship, or have certain contagious diseases. Possible solutions to this dilemma will be discussed. The need for involuntary hospitalization occasionally arises for medically hospitalized patients. Most of these cases pertain to patients with an acute mental illness. In California, if a person is mentally ill and a danger to self and/or others, or gravely disabled (unable to provide food, clothing, or shelter), the patient can be involuntarily hospitalized for psychiatric treatment for a 72-hour period. California law allows for additional periods of involuntary hospitalization of psychiatric patients, if indicated. However, at times there are medically ill patients who do not have a psychiatric illness but may require involuntary hospitalization for medical treatment purposes. An example may be a patient with delirium who lacks the capacity to refuse treatment and wants to leave the hospital. When an individual requires inpatient medical treatment, but lacks the capacity to refuse the treatment, a petition can be filed under California Probate Law. If the court finds that the patient lacks capacity, the court can authorize treatment and appoint an individual to make health care decisions on behalf of the patient for that specific medical problem. It is important to recognize that when this health care decision-making is granted to another, the law does not explicitly grant that individual the authority to involuntarily hospitalize the patient against their will. Consequently, the patient could choose to leave prior to administration of the treatment. Given this situation, staff members at some hospitals are instructed to refrain from physically restraining these patients if they try to leave the hospital. The hospital is in a difficult situation. If they prevent the patient from leaving, they are doing so illegally. If they allow the patient to leave, they are possibly exposing the patient to a serious threat to their physical health. The situation mentioned above presents medical professionals with a significant dilemma. Changes to hospital policy or legislation could provide much needed direction. This presentation will provide a general overview of California statutes related to involuntary psychiatric hospitalization, guardianships, conservatorships, and other protective proceedings. A case example will be used to illustrate the application of these laws and current hospital policies. Involuntary Hospitalization, Capacity, Leaving

I38 Capacity to Consent to Psychiatric Treatment in Ontario, Canada: Perspectives From a Forensic Psychiatry Program

Sebastien S. Prat, MD*, St. Joseph’s Healthcare - McMaster University, Forensic Psychiatry Program, W 5th Campus - 100 W 5th Street, Hamilton, ON L8N 3K7, CANADA; and Joseph Ferencz, MD, St. Joseph’s Healthcare, Forensic Psychiatry Program, 100 W 5th Street, Hamilton, ON L8P 3K7, CANADA

After attending this presentation, attendees will: (1) understand the legal concepts of the capacity to consent to treatment in Ontario, Canada; (2) understand the challenges that clinicians have when someone is refusing psychiatric treatment (including risk of violence); and, (3) be able to discuss ethical aspects of forcing someone to receive psychiatric treatment. This presentation will impact the forensic science community by increasing awareness of a different legal framework and what the impact is on both the patients and the community. Introduction: Pharmacological treatment can be one of the major components of the mental stability of individuals suffering from a psychotic disorder or a bipolar disorder; however, as per the nature of their psychotic or mood symptoms, these patients may lack insight into their condition and refuse to take psychiatric medication. In that situation, these persons may remain acutely psychotic or manic for months and even years if no action is taken to force medication. Most of the legislation authorize but limit the use of forced treatment. The most common method in place is when a Substitute Decision Maker (SDM) is named; in that case, the SDM will make the decision on behalf of the patient as he has the capacity to understand the nature of the mental disorder and the consequences of taking or not taking psychiatric medication. Also, many legislations allow the patient to appeal the decision of the physician who found his/her patient incapable of consenting to treatment. In Canada, each province and territory has developed its own legal framework for consenting to treatment. In Ontario, the legal process is deemed under the Consent and Capacity Act. It appears that the Ontario process has the particularity of not allowing any treatment until the appeal process is extinguished, either because of the patient not having appealed the decision within the allowed time or because no further appeal is possible (the last decision from the Supreme Court of Canada). Some legal procedures may be quick (a few weeks) and some may be extremely long (one or more years), during which time the patient remains acutely unwell. The individuals in favor of such a procedure often argue that each patient should be allowed a freedom of choice. Methods: In the St. Joseph’s Healthcare Forensic Psychiatry Program, patients who have gone the route of appealing the decision of capacity to consent to treatment were identified. Several factors were reviewed, such as how long the process took place, how far the patient appealed the decision, and the change of their mental status before and after receiving treatment (including their risk factor, their aggressive incident, and their access to privileges) Results: Ten patients were identified who appealed their treatment capacity. Only three of them went to the Supreme Court of Canada. The longest appeal was 1.5 years. All had a significant decrease of their aggressive incidents after receiving treatment and were allowed to use off-unit, unaccompanied privileges shortly thereafter. Discussion: The data related to the significant behavioral improvement after receiving treatment was expected; however, obtaining these data may help provide some guidance to enhancing a different legal process and help these patients recover more quickly. It also raises ethical questions and legal issues, notably when these patients are part of the forensic system and their main psychiatric disorder is associated with an offense. All of these points will be detailed in the presentation. Capacity to Consent, Psychiatric Treatment, Forensic Psychiatry