Abraham L. Halpern

The proposed diagnosis of hypersexual disorder for inclusion in DSM-5: unnecessary and harmful.

The intent of this Letter is to discuss one of the ‘‘Criteria for Change in the Current Diagnostic Classification’’(as stipulated in the Guidelines for Making Changes to DSM-5) that is lacking in the Sexual and Gender Identity Disorders Work Group’s rationale for its proposed diagnostic category ‘‘Hypersexual Disorder’’(with one of seven possible specifiers: Masturbation, Pornography, Sexual Behavior With Consenting Adults, Cybersex, Telephone Sex, Strip Clubs, or Other) (see Kafka, 2010). The criterion that is lacking in the rationale is: ‘‘A discussion of possible unintended negative effects of its proposed change, if it is made, and a consideration of arguments against making the change should also be included.’’ Let me start by asserting that specifically medicalizing (psychiatrizing)anaberrant sexual activitywhen therealreadyexists a number of DSM diagnoses that more than adequately cover the subject is inimical to the best interests of the persons who experience the‘‘disorder’’and, more important, to society itself. He (almost all‘‘hypersexual’’individuals are male) gets involved with a mental health therapist when he (1) becomes depressed because of any number of reasons (e.g., contracting AIDS,chargedwithacrime,heavilyaddictedtoanarcotic,etc.); (2) seeks help for a compulsive disorder, having frequently failed to resist the urge to engage in sexual activity; (3) is hospitalized for treatment of a psychotic disorder or is in prison for having committed a serious crime (the treatment being sought would be for hypersexual conduct prior to the institutionalization because, obviously, hypersexual activity, at least with the opposite sex, is not ordinarily possible in these settings). A diagnosis of ‘‘Hypersexual Disorder’’ is entirely unnecessary because the criteria for the diagnoses mentioned are correctly met in any particular case. Thus, hypersexually behaving persons are not ‘‘a distinct group of people who need appropriate clinical attention.’’ In otherwords,‘‘HypersexualDisorder’’isnot‘‘sufficiently distinct from other diagnoses to warrant being considered a separate diagnosis.’’It does not contribute to‘‘better conceptualization of diagnoses or to better assessment and treatment.’’ The Work Group’s rationale states: ‘‘There is a significant research-associated need to consolidate an operational definition for such a condition so that research from varying theoretical perspectives can coalesce with a common set of criteria.’’The Work Group also asserts that‘‘A DSM-V-based empirically derived definition should significantly enhance research efforts to explore some of the additional diagnostic validators for which there are no current data.’’ Having had very little involvement in research, I discussed the Work Group’s position with an experienced research psychiatrist at Harvard Medical School. I asked: Can meaningful research be undertaken without varying theoretical perspectives coalescing with a common set of criteria? Can studies (by intelligent, ethical, well-trained, and experienced researchers) to explore some additional diagnostic validators be undertaken without a DSM-5-based empirically derived definition? My consultant found no basis for the Work Group’s assertions that the special conditions are necessary to conduct research on hypersexuality. He emphasized that research that the Work Group deems necessary and important can be undertaken on the basis of hypotheses developed for research on psychological or psychiatric disorders, indeed for research in any field. Although I am not suggesting that hypersexuality is even remotely as serious a problem as some of the sexual disorders described in DSM-IV-TR, I would like to remind the DSM-5 Work Group of the controversies in the American Psychiatric Association (APA) during the Fall and Winter of 1985 when A. L. Halpern (&) Department of Psychiatry, New York Medical College, Valhalla, NY 10595, USA e-mail: ahalpernmd@gmail.com

Pathological Gambling and Criminal Responsibility

There exists significant interdisciplinary support for eliminating the volitional component of the insanity defense. Somewhat in contrast to this trend is the presentation of pathological gambling as a potentially exculpatory condition in criminal trials. The authors discuss three federal appellate court decisions on this attempted inappropriate usage of psychiatric diagnostic nomenclature. All have upheld convictions, and thereby rejected contentions that such an impulse disorder can form the basis for a valid plea of lack of criminal responsibility. It is suggested that the public interest will be served by statutorily making disturbances of behavioral control insufficient to raise a defense of insanity.

Participation by physicians in legal executions in the USA: an update

More than 700 persons have been executed in the USA over the past 25 years. Notwithstanding the codes of ethics of the American Medical Association and the American Psychiatric Association, which prohibit participation in legal executions, physicians have indeed participated in one way or another in most, if not all, of these cases. Given that state laws preclude the disciplining of participating physicians on the grounds that participation in executions is not considered the practice of medicine and that in no instance has a participating physician been disciplined by a medical society, it is our view that nothing less than abolition of capital punishment can bring to an end the unethical participation of physicians in executions.

The American Psychiatric Association Insanity Rule—A Metaphysical Subtlety

The acquittal of John W. Hinckley, Jr., by reason of insanity in June, 1982, although it aroused a public outcry against the exculpatory insanity rule and provoked widespread criticism of the psychiatric profession, did not further the drive for abolition of the insanity defense. On the contrary, the Hinckley verdict served as a stimulus for organizations and individuals that favored retention of the defense to graft the concept onto state and federal laws more firmly than ever before.

The insanity verdict, the psychopath, and post-acquittal confinement

Automatic post-acquittal confinement, an almost inevitable concomitant of a verdict of not guilty or not responsible by reason of insanity has for many acquittees been nothing more than punishment in disguise. Replacement of the insanity defense by statutes that provide for expert witness testimony to show that the defendant lacked the state of mind required as an element of the offense charged, has been found by two state supreme courts to be in accord with constitutional requirements. Procedures can be implemented, with due regard for public safety, so that all offenders, mentally disordered or otherwise, may be dealt with in an ethical, effective and humane manner. The 1992 decision of the Supreme Court of the United States in the case of Foucha v. Louisiana, holding that the Constitution does not permit the continued confinement of a still dangerous, but no longer mentally ill, insanity acquittee, makes it all the more necessary that the insanity defense be abolished and that an offenders mental illness be considered primarily in the context of mitigation, disposition and sentencing, rather than exculpation.

Adjudication of AAPL Ethical Complaints

An issue that was very controversial within AAPL for a long time was the question of adoption of a definition of forensic psychiatry. Prior to 1985 a frequently quoted definition ran as follows: “Forensic psychiatry is the application of psychiatry to legal issues for legal ends.”1 Some members felt that such a definition left our profession open to misuse and to the temptation on the part of forensic psychiatrists to practice in accord with legal, not psychiatric, ethical canons. After a great deal of debate and consultation with a number of senior AAPL members, the following definition was submitted to the American Board of Forensic Psychiatry and subsequently adopted on May 20, 1985: “Forensic psychiatry is a subspecialty of psychiatry in which scientific and clinical expertise is applied to legal issues in legal contexts embracing civil, criminal, correctional or legislative matters; forensic psychiatry should be practiced in accordance with guidelines and ethical principles enunciated by the profession of psychiatry.” Linking the ethical prong to the functional prong in one definition was disturbing to some; but the authors of the definition felt fully vindicated when it was included in AAPL’s Ethical Guidelines for the Practice of Forensic Psychiatry,2 adopted by the membership at the Semiannual Meeting in Chicago on May 10, 1987.3