The Mental Status Examination in the Age of the Internet

The Internet in the Forensic Psychiatric Interview

In the forensic psychiatric interview, defensive, manipulative, or uncooperative behavior on the part of the evaluee is common, especially in high-stakes evaluations: those involving denial of disability benefits and subsequent financial ramifications; those determining the extent of damages awarded in tort litigation; and those contributing to outcomes in custody disputes, to name only a few. Obtaining information in the psychiatric interview that the evaluee does not wish to provide can be challenging and often requires some creativity and finesse in conversational strategies. Engaging the evaluee in discussion about his or her hobbies, interests, and day-to-day life is one way to open the conversation. Information and communication technology (ICT) is playing an increasingly important role in individuals’ lives, and it can be a powerful conversational tool in forensic interviews. Asking the evaluee open-ended, exploratory questions about his or her use of the Internet may elicit revealing responses. Table 1contains a list of suggested introductory questions that the examiner might ask during the interview, to assess the evaluee's involvement with the Internet.

Discussion about the evaluee's Internet and computer use can help the psychiatrist to identify areas for further questioning in the MSE, subsequent testing, or collateral research.

Review of Collateral Information

In forensic case formulation, collateral information is often crucial to arriving at an accurate assessment of the evaluee and the circumstances that prompted the evaluation. As evaluees in forensic assessments often have an interest in the outcome of the evaluation, their self-report may be unreliable. Collateral sources of information can help to identify discrepancies between the evaluee's self-report and objective data. The rapid growth of ICT has led to a dramatic increase in the amount of collateral information available to the psychiatrist. Communications that may have been verbal and unrecorded in previous years now are often conducted via e-mail or instant messaging (IM) and are automatically archived as full transcripts. Obtaining digital evidence may require a degree of technical expertise not ordinarily possessed by the average forensic psychiatrist, but the psychiatrist can help to determine when such evidence will be helpful.⁶⁸ When the psychiatrist believes that it would be helpful to review additional electronic evidence not initially provided by the referring agent, the hiring attorney may seek assistance from a specialist to obtain these materials. Employers and Internet service providers (ISPs) typically monitor e-mail and other electronic communications, and associated logs and archives may be available as evidence in trials or investigations.

In addition to acquiring electronic data through discovery and investigations, the forensic psychiatrist may uncover collateral information through independent research on the world-wide web (the web). Neimark and colleagues describe a case in which a Google search on the patient's name produced a news article about a suicide attempt that the patient had not disclosed to his treatment team, leading them to comment, “… a single Internet search, performed in a matter of milliseconds, revealed information that would be vital to determining the patient's ultimate disposition” (Ref. 69, p 1842). In using “the Internet as [a] collateral informant” (Ref. 69, p 1842), the psychiatrist should consider how rare or how common the evaluee's name is. A common name, such as Jane Smith, may have millions of Internet hits that are unrelated to the evaluee; searching through other methods, such as querying the evaluee's e-mail addresses or screen names, may prove helpful. It is also important to remember that the Internet is not a definitive source of factually accurate information. Virtually anyone can post information about someone online. For example, a favored tactic among cyberharassers is to embarrass and intimidate the victim by impersonating her and posting her personal information (e.g., photographs) online, such as in phony erotic personal advertisements. The psychiatrist should consider the credibility or reliability of the source for Internet-based collateral information.

The ubiquitous nature of ICT in young people's lives may lead to troves of socially questionable, even unlawful, behavior being documented online. SNS profiles frequently allude to substance abuse and other risky behavior.⁷⁰ Table 4provides a partial list of the types of materials that the psychiatrist may review or ask an expert to review.

While the volume of this information may seem overwhelming, an important aspect of ICT is the development of tools to help organize materials and navigate electronic sources. In the past, a psychiatrist or investigator may have needed to peruse hundreds of pages in an evaluee's diary to determine whether a crime was premeditated. Today, many “diaries” are archived in computer drives or posted online in the form of blogs, websites, or other electronic documents that can be quickly and efficiently searched through electronic search-and-find tools. When the reason for the evaluation is related to deceptive behavior (for example, an adult who poses as a child online), the evaluation requires a more intensive search for collateral information than would be necessary in a case that did not involve dishonesty (for example, an evaluee who admits to inappropriate Internet use in the workplace).

Assessment of Impairment and Credibility

The forensic psychiatrist may be asked to assess an evaluee's level of impairment from a disability that relates somehow to Internet activities. For example, a victim of cyberharassment may develop severe difficulties in functioning offline, even though the harassment is occurring only online. In such cases, the psychiatrist must be able to evaluate the reasonableness of the victim's response. In a widely reported MySpace cyberbullying case, a 13-year-old girl (Megan Meier) committed suicide when the boy with whom she had formed a romantic attachment online began to subject her to insults and verbal abuse.⁷³ Following Meier's suicide, an investigation revealed that the “boy” with whom she had been conversing online was a fake persona created by a woman who was the mother of one of Meier's classmates. As this case illustrates, cyberbullying or cyberharassment can have a devastating emotional effect on victims. Similar cases have been reported with equally tragic outcomes.^74,75 Cyberharassment has been correlated with depressive symptoms among victims,⁷⁶ and victims often take Internet threats seriously, sometimes altering their behavior out of fear for their personal safety.⁷⁷

An individual's Internet presence may be relevant to disability and fitness-for-duty evaluations in employment legal proceedings.⁷⁸ Employers and schools often consider applicants’ Internet presences in the vetting of candidates for jobs or admissions, and employees may be fired for posting inappropriate material on SNS profiles, blogs, discussion boards, and other websites.⁷⁹ When an individual experiences adverse employment action, such as termination, demotion, or disciplinary actions, subsequent disability evaluations should consider the possibility of secondary gain. When IBM fired an employee for accessing cybersex chats on a company computer during business hours, the employee (a Vietnam veteran) sued, alleging that his inappropriate Internet use arose from his combat-related PTSD and that the employer had terminated him because of his disability.⁸⁰ Although the court dismissed his complaint, the possibility that future editions of the DSM may contain “Internet addiction,”⁸¹ or PIU, as a diagnosable psychiatric disorder raises important legal and ethics-related considerations. Some scholars have speculated that the increasing apparent legitimacy of “Internet addiction” will lead toward protection under the Americans With Disabilities Act.⁸² Forensic psychiatrists may be asked to offer an opinion on whether an individual's PIU indicates a bona fide mental disability.

It is important for the psychiatrist to detect or rule out the likelihood of malingering, which the DSM-IV defines as “… the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs” (Ref. 83, p 683). Today, patients, and even physicians, use publicly available Internet resources, such as search engines and medical websites, as diagnostic aids.⁸⁴ As Swiss researchers have shown, individuals with little or no medical training can reach accurate diagnoses through web research.⁸⁵ In this information age, forensic psychiatrists can expect to encounter evaluees who have researched diagnostic criteria online and who may try to alter their self-presentations accordingly. Dishonesty and deception are common and possibly even normal online. An evaluee who is accustomed to deceptive or manipulative behavior in Internet communications may be more likely to provide inaccurate or distorted information in a forensic evaluation. When assessing credibility, the forensic psychiatrist should consider the evaluee's claims in the context of his behavior.

As Drukteinis notes, “The person's hobbies, recreation, and social interactions can be a rich source of information. A full schedule of personal activities can demonstrate a lack of credible impediment to work” (Ref. 86, p 294). Clinical psychologist Timothy Miller had a patient “who was trying to get on Social Security disability for agoraphobia. He didn't have a mental disorder, he just didn't want to leave ‘EverQuest’ [an online game] or instant messaging.”⁸⁷ High scores on a strategy-type game, for example, may cast doubt on claims of severe impairment of attention and concentration. Similarly, in criminal cases in which a defendant wishes to plead not guilty by reason of insanity (NGRI), evidence of planning (such as “Googling” advice on avoiding detection or prosecution) may suggest premeditated and purposeful behavior.

Additional concerns related to Internet dishonesty may arise when the evaluee's Internet behavior is the reason for the evaluation. In the now-infamous “Alex/Joan case,” a prominent male psychiatrist assumed the online identity of a disabled woman to gain the trust of and have intimate exchanges with women with whom he chatted online.⁸⁸ When his deception and identity were subsequently revealed, many of the women felt betrayed and angry. It is not difficult to see how this type of behavior might raise concerns about fitness for duty among professionals with a fiduciary responsibility toward others. While poor judgment and exploitative behavior on the Internet may have ramifications for professional fitness for duty, such behavior does not necessarily implicate a psychiatric illness that would rise to the level of a disability.

Risk Assessment

Forensic psychiatrists may be asked to evaluate individuals whose Internet activity has raised concerns about dangerousness. For example, in the “Jake Baker” case, which spurred a debate regarding freedom of speech on the web, there was controversy over the appropriate response to a university student's violent fantasies posted to a newsgroup: Baker posted a story to the newsgroup alt.sex.stories in which he graphically described the torture, rape, and murder of a woman who was identified, in the story, as a classmate of Baker's. University officials learned of it—oddly enough, through an attorney in Moscow—and they suspended Baker and began contemplating legal actions. The U.S. government investigated Baker and found much more than just the story posted to the Usenet group. Dozens of emails had been exchanged between him and a person in Canada known as Arthur Gonda, in which the two discussed their shared interests in torture and appeared to be planning violent acts that would be carried out in real life, not just as online fantasies [Ref. 89, p 228].

The forensic psychiatrist may be asked to offer an opinion regarding the likelihood that similar threats or disturbing behavior online represent a true threat of violence or self-harm. During such evaluations, it is important to consider the role that the Internet plays in the evaluee's life: does it provide a forum for harmless relief of stress, or does it exacerbate the evaluee's problems? Persons who struggle with thoughts of violence or self-harm may use the Internet to act out these thoughts without direct bodily harm to themselves or to others.

The use of violent video games and VR simulations could have a desensitizing effect and may reduce normal inhibitions toward aggressive behavior. The military often uses games and simulations for this purpose. The experience of depersonalization and derealization online or in gaming may carry over into an individual's conduct in real life, thereby increasing the risk of violent behavior.⁶³ Block⁹⁰ argues that technology and Internet use played a critical and overlooked role in the lives of the teens who committed mass homicide in the Columbine school shooting tragedy. He notes that leakage and clues to their violent intentions were discovered on the Internet. He places special emphasis on the boys’ use of the Internet as an outlet for their anger and notes that their access had been limited shortly before the school shootings took place. Through online RPGs, the teens had been able to assume roles of power, respect, and belonging, which they lacked in their lives offline. One implication of this case for risk assessment is the importance of considering the role of the Internet in an evaluee's life.

Another implication of the Columbine case is the importance of investigating digital evidence as collateral information when conducting a risk assessment. In the context of evaluations of dangerousness in school settings, Ash writes: Since individuals frequently deny planning predatory violence, other indicators of violent thinking are important. A key concept in these evaluations is ‘leakage‘: fantasies of thinking and planning violence may spill out in identifiable ways. These can include talking about a fascination with weapons and assassinations with peers, diaries or other written communications, drawing, internet chatting on violence-related themes, veiled threats expressed to peers, and so forth [Ref. 91, p 465, emphasis added].

In numerous cases of violent or suicidal behavior reported in the popular press, warning signs were often found on the perpetrator's computer or in Internet records.

Conclusions

An evaluee's Internet use may be relevant to nearly all aspects of a forensic psychiatric evaluation. During the psychiatric interview, open-ended questions about how the evaluee uses the Internet can enhance rapport and lead the forensic psychiatrist to areas that deserve further analysis. During the psychiatric interview, information about an evaluee's use of the Internet can be a valuable conversational tool to encourage candor and self-disclosure, even among less cooperative evaluees. In the MSE, the evaluator may consider inconsistencies between the evaluee's presentation in the psychiatrist's office and his self-presentation or online persona in Internet communications. Numerous psychiatric symptoms may manifest in an individual's relationship to the Internet. The Internet is also useful as a source of collateral material to corroborate, refute, or elaborate on information gathered during the psychiatric interview, particularly for the purposes of assessing credibility, impairment, and risk.

Knowledge about ICT will help to increase opportunities for psychiatrists who serve as consultants to attorneys or courts. Forensic psychiatrists occasionally help attorneys to formulate questions for interrogatories and request materials for production, and, therefore, having an understanding of the ways in which people use the Internet can increase the likelihood of obtaining evidence for a case. Inquiring about evaluees’ Internet use and educating oneself about the ways in which such use may be relevant to a case will increase the psychiatrist's opportunity to gain additional information that will enhance the MSE, the evaluation findings, and the ultimate outcome in the case.

Appendix I