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Delusional Disorder: Treatment and the Restoration of Adjudicative Competence City University of New York (CUNY) CUNY Academic Works All Dissertations, Theses, and Capstone Projects Dissertations, Theses, and Capstone Projects 2-2016 Delusional Disorder: Treatment and the Restoration of Adjudicative Competence Martin Kassen Graduate Center, City University of New York How does access to this work benefit ou?y Let us know! More information about this work at: https://academicworks.cuny.edu/gc_etds/689 Discover additional works at: https://academicworks.cuny.edu This work is made publicly available by the City University of New York (CUNY). Contact: [email protected] Delusional disorder: Treatment and the Restoration of Adjudicative Competence by Martin Kassen A dissertation submitted to the Graduate Faculty in Psychology in partial fulfillment of the requirements of the degree of Doctor of Philosophy, The City University of New York Graduate Center 2016 i © 2016 M. KASSEN All Rights Reserved ii Approval Page This manuscript has been read and accepted for the Graduate Faculty in Psychology in satisfaction of the dissertation requirement for the degree of Doctor of Philosophy. __________________ ____________________________________ Date Dr. Thomas Kucharski Chair of Examining Committee __________________ ____________________________________ Date Dr. Maureen O’Connor Executive Officer Supervisory Committee: Patricia Zapf, Ph.D. Chitra Raghavan, Ph.D. Warren Benton, Ph.D. Maureen Reardon, Ph.D. iii THE CITY UNIVERSITY OF NEW YORK ABSTRACT DELUSIONAL DISORDER: TREATMENT AND THE RESTORATION OF ADJUDICATIVE COMPETENCE by Martin Kassen Advisor: Thomas Kucharski, Ph.D. Delusional disorder has long been recognized in the psychiatric nomenclature, however, low prevalence rates and prevailing clinical views about the seemingly refractory nature of delusional disorder have restricted data on clinical treatment outcomes for this illness. Similar perspectives have been noted in forensic settings where minimal data is available to guide standards of care for incompetent to stand trial (IST) delusional pretrial defendants. Rationale. While the factors explicated in Sell provide guidelines for the involuntary medication of defendants found IST, numerous questions are left unanswered regarding the restorability of pretrial delusional detainees. The proposed study investigated the competency restoration rates of defendants with delusional symptoms and, more broadly, using the Brief Psychiatric Rating Scale (BPRS) assessed how these symptoms impact competency related abilities. Method. Data were gathered from competency restoration reports at a federal medical center. A total of 232 cases were drawn with replacement from a five year span, and then coded for demographic, clinical, and psycholegal variables. Results. Nearly 60% of defendants suffered with one or more iv delusions, and the delusional ideation for those who met the BPRS threshold for a delusional disorder (DD) classification was more pervasive than for those in either the schizophrenia or mood with psychosis subgroups. Defendants in the DD subgroup were also more likely to refuse treatment. The logistic regression model showed adequate overall classification (63.4%) and one static variable, i.e., prior psychiatric treatment, reached statistical significance; indicating that those with such a history were less likely to be restored. Discussion. The high rates of treatment refusal for DD defendants meant that most of these defendants were opined IST after their first statutorily determined competency restoration period, however, this group was no less likely to be opined restorable by forensic examiners given an adequate trial of involuntary treatment with antipsychotic agents. v ACKNOWLEDGEMENTS I wish to thank the following people: All the members of my dissertation committee for their time and instructive feedback. They are Dr. Thomas Kucharski (Chairperson, Professor, John Jay College, CUNY), Dr. Chitra Raghavan (Professor, John Jay College, CUNY), Dr. Patricia Zapf (Professor, John Jay College, CUNY), Dr. Warren Benton (Professor, John Jay College, CUNY), and Dr. Maureen Reardon (Deputy Chief Psychologist, Federal Bureau of Prisons, Butner, NC) Dr. Edward Landis (Chief Psychologist, Federal Bureau of Prisons, Butner, NC) for being so generous with his time and support Dr. Katherine Bracken (Staff Psychologist, Federal Bureau of Prisons, Butner, NC) for her help and thoroughness with the coding process Ms. Kelly Forbes (Health Systems Specialist, Federal Bureau of Prisons, Butner, NC) for providing office space and useful comments. To my family – my inestimable gratitude. In memoriam, Nobomvu Daisy Shange (1929-2013), Uyohlala ukhanya Ma. vi TABLE OF CONTENTS TITLE PAGE........................................................................................................................i COPYRIGHT PAGE...........................................................................................................ii APPROVAL.......................................................................................................................iii ABSTRACT.......................................................................................................................iv ACKNOWLEDGEMENTS................................................................................................vi TABLE OF CONTENTS..................................................................................................vii LIST OF TABLES..............................................................................................................xi LIST OF APPENDICES...................................................................................................xii CHAPTER 1: INTRODUCTION........................................................................................1 CHAPTER II: LITERATURE REVIEW............................................................................5 Nosological Development of Paranoid Disorders………………………………....5 Diagnostic Classification …………………………………………………………7 Epidemiology…………………………………………………………….12 Treatment of Delusional Disorder……………………………………………….12 Psychological Treatment…………………………………………………12 Pharmacotherapy…………………………………………………………14 Competency to Stand Trial………………………………………………………18 Competency Restoration…………………………………………………………24 Restoration Strategies……………………………………………………25 Medication……………………………………………………………….25 Educational Approaches…………………………………………………26 Remediation for Cognitive Disability ……………………………………28 vii Factors Predictive of Restoration………………………………………………...30 Involuntary Medication and Restoration………………………………………...33 Delusional Disorder and Restoration Outcomes…………………………………38 Rationale…………………………………………………………………………40 Research Questions………………………………………………………………43 CHAPTER III: METHOD.................................................................................................45 Sample Demographics…………………………………………………………...45 Procedure………………………………………………………………………...47 Preliminary Case Selection………………………………………………48 Exclusions………………………………………………………………..49 Data Coding……………………………………………………………...50 Interrater Reliability……………………………………………………...50 Statistical Analysis……………………………………………………………….56 Ethical Concerns and Data Protection…………………………………………...57 CHAPTER IV: RESULTS.................................................................................................58 Data Characteristics……………………………………………………………...58 Legal Variables…………………………………………………………………..60 Offense History…………………………………………………………..60 Time Spent in Custody…………………………………………………...60 Length of Stay……………………………………………………………60 CST Related Abilities……………………………………………………………61 Clinical Variables and Delusions………………………………………………...62 Previous Psychiatric Treatment………………………………………….62 viii Comorbid Conditions…………………………………………………….62 Delusions and Clinical Subgroups……………………………………….63 Dimensional Ratings of Delusions………………………………………64 Subgroups and Study Variables………………………………………….66 Treatment………………………………………………………………………...68 Psychotropic Treatment………………………………………………….68 Non-pharmacological Intervention………………………………………68 Treatment Refusal………………………………………………………..68 Involuntary Medication and Sell Requests………………………………69 CST Restoration Outcomes………………………………………………………70 Likelihood of Restorability………………………………………………71 Restored and Non-Restored Defendants…………………………………72 Logistic Regression Analysis…………………………………………….75 CHAPTER V: DISCUSSION............................................................................................78 Prevalence of Delusional Ideation and Salient Demographic Variables..……….78 Delusional Preoccupation and Offense Behavior………………………………..80 Competency Related Abilities and DD Defendants……………………………...81 LOS and Treatment Refusal……………………………………………………...82 Time in Treatment………………………………………………………..82 Treatment Refusal………………………………………………………..83 Psychotic Symptoms and Competency Restoration Outcomes………………….84 Limitations and Strengths………………………………………………………..87 Future Directions………………………………………………………………...89 ix Conclusion……………………………………………………………………….91 APPENDIX A....................................................................................................................92 APPENDIX B....................................................................................................................97 REFERENCES................................................................................................................100 x LIST FIGURES AND OF TABLES Table 1 Historical Overview of the Prognostic Outlook.............................................8 Table 2 CST Restoration Studies…………………………………………………...30
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