Letters

• extreme overvalued belief
• overvalued idea
• obsession
• delusion
• insanity defense
• Perspectives of Psychiatry

Editor:

In response to our article entitled “Extreme Overvalued Beliefs,”¹ Pierre comments that individuals not obviously symptomatic of mental illness would be “best explained” by integrating psychiatric expertise with that of “other disciplines such as psychology, sociology, and political science” (Ref. 2, p 357). Pierre's observation that important areas of an individual's biographical narrative are often missing in psychiatric evaluations highlights psychiatry's current reliance on routine approaches and checklists to conduct evaluations. Failure to recognize and understand limitations in our current diagnostic abilities, coupled with the undesirable consequences of forcing patients into categories that are not truly appropriate, can undermine the usefulness of any diagnostic category.³ Additionally, many diagnostic categories with overlapping signs and symptoms have been notoriously marketed by pharmaceutical companies for profit or abused by forensic consultants opining that individuals do or do not fit criteria for a psychotic mental illness.⁴ Pierre also comments that there is a retributionist quality to extreme overvalued belief. He fails to mention that individuals with clear psychotic mental disorders might also benefit from the application of concise definitions.

The Diagnostic and Statistical Manual of Mental Disorders series produced an important revolution in psychiatry. Reliable definitions were created through data collection and investigative efforts to support them. The most difficult challenge in any guide is separating clinical entities with a similar appearance.⁴ It is easy for examiners to mingle psychosis and personality disorders.^5–6 Checklist diagnoses cost less in time and money while depriving psychiatrists of the ability to know their patients.⁴

We have exposed an important flaw that forensic psychiatrists should pay close attention to: there are three entities (delusion, obsession, and overvalued idea) that once had clear contours but have now become blurred.⁵ Psychiatry's dependence on a “sign and symptom” approach with accompanying automatic remedies can seriously distort the putative causation of mental disorders. This problem could now be approached by equipping psychiatry with a method used at Johns Hopkins University School of Medicine, called the Perspectives of Psychiatry.⁴ This method emphasizes classifying psychiatric disorders by causal processes and generative mechanisms, as opposed to outward appearance. In the Johns Hopkins model, causes of psychiatric disorders derive from four interrelated but separable categories: brain diseases, personality dimensions, motivated behaviors, and life encounters.³

This year the U.S. Supreme Court concluded that “defining the precise relationship between criminal culpability and mental illness involves examining the workings of the brain, the purposes of the criminal law, the ideas of free will and responsibility” (Ref. 7, p 332). Indeed, the justices went on to state that the insanity defense “should be open to revision over time, as new medical knowledge emerges and as legal and moral norms evolve” (Ref. 7, p 332). We now propose a new definition, extreme overvalued belief. It is rooted in rich scholarship for the diagnosis of three interrelated but clearly separable types of rigidly held beliefs.^5–6 We also demonstrate for the first time that these definitions, along with other diagnostic data, can clarify relevant factors in insanity trials.

• © 2020 American Academy of Psychiatry and the Law