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Spring 2005 THE FORENSIC EXAMINER 3

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The Forensic Examiner® (ISSN 1084-5569) is published quarterly by The American College of Forensic Examiners International, Inc. (ACFEI). Annual membership for a year in the American College of Forensic Examiners International is $130. Abstracts of articles published in The Forensic Examiner® appear in National Criminal Justice Reference Service, Cambridge Scientific Abstracts, Criminal Justice Abstracts, Gale Group Publishing's InfoTrac Database, e-psyche database and psycINFO database. Periodicals Postage Paid at Springfield, Missouri and additional mailing offices. ©Copyright 2005 by the American College of Forensic Examiners International. All rights reserved. No part of this work can be distributed, or otherwise used without the express permission of the American College of Forensic Examiners International. The views expressed in The Forensic Examiner® are those of the authors and may not reflect the official policies of the American College of Forensic Examiners International.

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4 THE FORENSIC EXAMINER Spring 2005

THE

FORENSIC

EXA MINER

VOLUME 14 • NUMBER 1 The

FORENSICEXAMINER

®

06

®

SPRING 2005

Types of Knee Injuries and How They Occur

CME

By Matthew Donohoe, MA, ATC; Helen Aslanian, BS; and Kenneth Solomon, PhD, PE, DABFE, DABFET, DABLEE, CHS-III

2005 Editorial Advisory Board Jack S. Annon, PhD, FACFEI, DABFE, DABFM, DABPS, DABLEE E. Robert Bertolli, OD, CHS-III, CMI-V David T. Boyd, DBA, CPA, Cr.FA, CMA, CFM John Brick, MA, PhD, DABFE, DABFM, CMI-V Steve Cain, MFS, DABRE, DABFE James H. Carter, MD, FACFEI, DABFE, DABFM Leanne D. Courtney, BSN, MFS, DABFN, DABFE D. Larry Crumbley, PhD, CPA, DABFA, Cr.FA Edmund D. Fenton, Jr., DBA, CPA, CMA, Cr.FA Nicholas J. Giardino, ScD, DABFE Daniel P. Greenfield, MD, MPH, DABFE, DABFM James L. Greenstone, EdD, JD, FACFEI, DABECI, DABFE, DABFM, DABPS, DABLEE, CMI-I, CHS-V Raymond F. Hanbury, Jr., PhD, ABPP, FACFEI, DABPS, DABFE James R. Hanley, III, MD, DABFM Nelson H. Hendler, MD, DABFM Zafar M. Iqbal, PhD, FACFEI, DABFE, DABFM Paul Jerry, PhD, MA, CPsych, DABFC, DAPA Philip I. Kaushall, PhD, DABFE, DABPS Richard L. Levenson, Jr., PsyD, DABFE, DABPS Jonathan J. Lipman, PhD, FACFEI, DABPS, DABFE, DABFM Judith F. Logue, PhD, FACFEI, DABFSW, DABPS, DABFE, DABFM David B. Miller, DDS, FACFEI, DABFE, DABFM, DABFD Sandralee N. Miller, RN, FACFEI, DABFN, DABFE Terrence W. C. O’Shaughnessy, DDS, FACFEI, DABFD, DABFE, DABFM George B. Palermo, MD, FACFEI, DABFE, DABFM Marc A. Rabinoff, EdD, FACFEI, DABFE Don L. Rondeau, MS, CJ, MBA Cert, CHS-V Douglas H. Ruben, PhD, FACFEI, DABFE, DABFM, DABPS William R. Sawyer, PhD, FACFEI, DABFE, DABFM Victoria Schiffler, RN, DABFN Stanley Seidner, PhD, DABFE, DABFET, CHS-III Kandiah Sivakumaran, MS, PE, DABFET Marilyn Stagno, PsyD, DABFE, DABFM, DABPS Gere N. Unger, MD, JD, FACFEI, DABFE, DABFM Ralph Van Atta, PhD, FACFEI, DABPS Raymond E. Webster, PhD, FACFEI, DABFE, DABFM Paul Zikmund, MBA, Cr.FA Publisher: Robert L. O’Block, MDiv, PhD, PsyD, DMin, STD (rloblock@aol.com)

14

The Pseudologia Fantastica Defense in CombatDetermined Post-traumatic Stress Disorder: A Study of the Nature of this Defense and How to Differentiate It from Malingering

By Ralph E. Van Atta, PhD, FACFEI, DABPS

26 31

Prison Gangs: Descriptions and Selected Interventions

By Terri Compton, RN, MSW, and Mike Meacham, PhD, LCSW, DABFSW

A Review of FDR’s Mental Capacity During His Fourth Term and Its Impact on History

By Alen J. Salerian, MD, DABFM, and Gregory H. Salerian, BS

39 44

Financial Statement Fraud: A New Ballgame

By Nicholas Apostolou, DBA, CPA, Cr.FA, DABFA, and D. Larry Crumbley, PhD, CPA, Cr.FA, DABFA

Forensic Application of Palatal Rugae in Dental Identification

By Stuart L. Segelnick, DDS, MSFE, and Leonard Goldstein, DDS, PhD

48

Announcing the Fourth Certified in Homeland Security Conference, Sept. 28-29, 2005, in San Diego

57

Recent Books By ACFEI Members

60

Announcing ACFEI’s 13th National Conference, Sept. 30 - Oct. 1, 2005, in San Diego

FORENSIC CASE PROFILE Uncovering the Mentality of a Serial Rapist

62

Welcome New ACFEI Members

50

ACFEI News

63

Continuing Education (CE) Questions

52

FORENSIC CASE PROFILE Saved by Intelligence...Or Lack Thereof: Mental Retardation & the Death Penalty

66

Falsely Accused

49

Editor: Heather Barbre Blades, MA (editor@acfei.com) Assistant Editor, Senior Writer: Erica B. Simons, BS (erica@acfei.com) Editorial Intern: Leann Long Designed by: Brandon Alms, BFA (brandon@acfei.com)

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Spring 2005 THE FORENSIC EXAMINER 5

CME

This article is approved by the following for continuing education credit: ACFEI provides this continuing education credit for Diplomates.

ACFEI is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. ACFEI designates this educational activity for a maximum of 1 hour in category 1 credit towards the AMA Physicians Recognition Award.

ACFEI is California Board of Registered Nursing Provider 13133.

By Matthew Donohoe, MA, ATC; Helen Aslanian, BS; and Kenneth Solomon, PhD, PE, Post PhD, DABFE, DABFET, DABLEE, CHS-III Key Words: knee injury, knee meniscal tears, knee ligament rupture, knee osteoarthritis, chondromalacia, knee bursitis Abstract The purpose of this article is to distinguish the mechanism of knee injury (e.g., forward fall while foot is trapped, impact of knee on dashboard, chronic injury due to repetitive twisting, etc.) from the type of injury (e.g., torn meniscus, ruptured ACL, bursitis, etc.).

While there are no absolute rules for positively associating each mechanism of injury with a specific type of injury, this article will provide some forensic guidance for those attempting to prove or disprove the relationship between mechanism and injury type.

6 THE FORENSIC EXAMINER Spring 2005

Scope of Paper Before we are able to discuss types of injuries to the knee joint, we must first examine the anatomy of the knee joint and the kinematics that the structures of the knee generate. We will then discuss the relationship of mechanism of injury and the type of injury from an anatomical point of view and by example.

Anatomy of the Knee The knee is the largest joint in the body.9 The femur, tibia, and patella combine to create a complex joint (Figures 1 & 2).

This complex joint is comprised of three articulations: two tibiofemoral articulations (joints between bones or cartilages that are immovable when the bones are directly united) and one patellofemoral articulation.10 The two tibiofemoral joints are created by the condyles (articular prominences of bones) of the femur and plateaus of the tibia. The medial and lateral condyles of the femur roll

Figure 1: Bony anatomy of the knee (anterior view)

Figure 2: Bony anatomy of the knee (posterior view)

Figure 3: Ligaments & cartilage of the knee (anterior view)

and glide across the medial and lateral meniscus (fibrous cartilage within a joint) respectively. In the healthy knee, the roll and glide of the femur produce approximately 140 degrees of flexion and extension. Although flexion and extension are the dominant motions at the tibiofemoral articulations, internal rotation and external rotation are also produced at these articulations. The amount of internal and external rotation is a function of flexion and extension.

Rotation is absent when the knee is in full extension, but there can be up to 30 degrees of internal rotation and 45 degrees of external rotation when the knee is in 90 degrees of flexion.15 The patellofemoral articulation is created by the patella and the femur. The posterior surface of the patella articulates with the trochlear groove of the femur.

The trochlear groove is a U-shaped concavity located between the two condyles of the femur.9 The patella is a sesamoid bone, which is bone that has developed within a tendon. In this case, the tendon that envelopes the patella is the quadriceps tendon. The patella’s primary function is to act as a modified pulley mechanism that changes the direction of the force vector of the quadriceps. This change in the line of pull increases the momentum, and consequently the amount of torque, giving the quadriceps

a mechanical advantage. Another function of the patella is to protect the anterior knee.15 The knee joints contain two C-shaped fibrocartilage structures, medial and lateral menisci, that are attached to the medial and lateral tibial plateaus respectively (Figures 3 & 4). The two menisci help stabilize the joint by deepening the articular surface of the tibia. They also aid in the absorption of shock and the transmission of force by increasing the articular surface area, produce synovial fluid (a source of nutrients and lubrication to the joint), and help prevent the condyles of the femur from articulating directly on the tibial plateaus, which protects against friction wear of the femur and tibia.15 The condyles of the femur and the tibial plateaus are covered with a hyaline cartilage called articular cartilage (Figures 1 & 2). The primary function of articular cartilage is to absorb shock in the joint.19 The articular cartilage does this by absorbing and discharging synovial fluid as pressure changes within the joint.2 The anterior and posterior cruciate ligaments are thick fibrous connective tissue structures that help guide the knee during motion (Figure 4). The anterior cruciate ligament attaches to the tibia at the anterior intercondylar portion of the

tibial plateau; it travels upward and backward and attaches to the femur at the intercondylar fossa (an anatomical pit, groove, or depression). The anterior cruciate ligament prevents excessive anterior translation of the tibia with respect to the femur. The posterior cruciate ligament attaches to the tibia at the posterior proximal tibial shaft and attaches to the femur at the posterior intercondylar fossa. The posterior cruciate ligament prevents excessive posterior translation of the tibia with respect to the femur.2 The medial and lateral collateral ligaments also help guide the knee during motion (Figures 3 & 4). The medial collateral ligament attaches to the tibia at the medial proximal tibial shaft and attaches to the femur at the medial epicondyle (any of several prominences on the outer part of a long bone). The medial collateral ligament helps protect against excessive valgus forces on the knee. The lateral collateral ligament attaches to the proximal head of the fibula and attaches to the femur on the lateral epicondyle. The lateral collateral ligament provides protection from excessive varus forces on the knee.2 The articular capsule of the knee is irregular in that it does not completely envelop the joint like most other synovial joints. It is covered with a synovial

Spring 2005 THE FORENSIC EXAMINER 7

Figure 4: Ligaments & cartilage of the knee (posterior view)

Figure 5: Anterior knee musculature

Figure 6: Tearing of the PCL as a result of falling on a flexed knee*

membrane that produces synovial fluid to lubricate and provide nutrients for the joint structures.15 The knee joint is crossed by 12 muscles that stabilize the joint and produce the anatomical motions of the joint.

These 12 muscles can be divided into three groups: the quadriceps femoris, the hamstring, and the unclassified group.

The quadriceps femoris group is comprised of the rectus femoris, vastus intermedius, vastus lateralis, and the vastus medialis (Figure 5). This muscle group is responsible for knee extension.15 The vastus medialis, however, has an important function in providing a medial force on the patella that counterbalances the lateral components of force generated by the remaining three quadriceps muscles.

The dynamic medio-lateral equilibrium created by the vastus medialis helps to maintain patellar tracking.15 The rectus femoris also assists in hip flexion because the proximal attachment is on the anterior inferior iliac spine.16 The hamstring group is made up of the biceps femoris, semimembranosus, and the semitendinosus. These muscles work together to produce knee flexion and hip extension. The muscles of the hamstring group produce hip extension because they also cross the hip joint and have a proximal attachment on the ischial tuberosity of the pelvis. Only the short head of the biceps femoris does not produce hip extension due to its proximal attachment on the posterior femur.16

The unclassified muscle group contains the sartorius, gracilis, popliteus, gastrocnemius, and plantar muscles.15 These muscles have less influence on the knee than the other two muscle groups. They primarily act on another joint, such as the ankle or the hip, and only assist with flexion, extension, and internal and external rotation of the tibia. The popliteus is the one exception to that statement; its primary function is to initiate internal rotation of the knee and unlock the knee at the onset of knee flexion.6 There are 13 bursae in the knee joint.

A bursa is a sac containing a viscid fluid that helps reduce friction between moving parts. Bursae are usually found over bony prominences and beneath tendons.5 The knee bursae are grouped in three general areas: the anterior bursae, medial bursae, and lateral bursae. The anterior bursae consist of the deep infrapatellar bursa, subcutaneous prepatellar bursa, subcutaneous infrapatellar bursa, and suprapatellar bursa. The medial bursae consist of the bursa between the medial head of the gastrocnemius and the fibrous capsule, the bursa between tendons of the semimembranosus and semitendinosus, bursae deep to the tibial collateral ligament, the bursa superficial to the tibial collateral ligament, and the semimembranosus bursa. The lateral bursae consist of the bursa between the fibular collateral ligament and the tendon of the biceps femoris, the bursa

between the fibular collateral ligament and the tendon of popliteus, the bursa between the lateral head of the gastrocnemius and joint capsule, and the bursa between the tendon of the popliteus and the lateral femoral condyle.14

8 THE FORENSIC EXAMINER Spring 2005

Mechanisms of Knee Injuries Due to the complex nature of the anatomy of the knee, injury to the joint is quite common as a result of both chronic stress and acute insult. This article examines the more common types of knee injuries that occur, describing the mechanisms required to cause these specific injuries. This article also explores how tears occur to the medial and lateral meniscus, anterior cruciate ligament, posterior cruciate ligament, medial cruciate ligament, and lateral cruciate ligament, as well as the causes of arthritic changes, chondromalacia, and bursitis.

Meniscal Tears A tear to the menisci is caused by a combination of compression of the knee joint (such as during weight bearing) in the presence of a rotary force and flexion or extension, or in the absence of synchronous rotation during flexion or extension.2,17 When the knee joint is compressed, the condyles of the femur and the tibial plateaus are brought closer together, which reduces the ability of the menisci to move freely during rotation and flexion or extension. Essentially, a portion of the menisci becomes trapped

Figure 7: Tearing of the medial collateral ligament as a result of a direct valgus force and external rotation*

Figure 8: Tearing of the lateral collateral ligament as a result of a direct varus force and internal rotation*

Medial Collateral Ligament Rupture Ruptures of the medial collateral ligament are caused by a direct valgus force applied to the knee, as well as by an external rotation of the knee joint (Figure 7).2,4 A medial collateral ligament injury is usually more severe than a lateral collateral ligament injury because the medial collateral ligament is part of the joint capsule and is attached to the medial meniscus, while the lateral collateral ligament is not.2,9

and a tear results as a portion of the menisci moves while the trapped portion does not. It is important to note that rotation of the knee joint does not occur in full extension; therefore, a meniscal tear cannot occur in a position of full extension.17 Also, it is very uncommon for both menisci to be torn in a single event. The second meniscal tear is usually the result of a joint that has had a history of internal derangement due to relaxation of either the joint capsule or ligaments and weakened quadriceps musculature.

Anterior Cruciate Ligament Rupture Ruptures of the anterior cruciate ligament can occur due to rotation, abduction, posterior translation of the femur with respect to the tibia, hyperextension, or dislocation of the knee joint. The anterior cruciate ligament is most commonly ruptured during internal rotation of the tibia while the knee is flexed.4 In order to achieve rupture of the anterior cruciate ligament due to abduction, the medial collateral ligament must first be ruptured. When the medial collateral ligament is ruptured due to abduction, the rupture of the anterior cruciate ligament is inevitable.17

Posterior Cruciate Ligament Rupture Posterior cruciate ruptures are created when a posterior force is applied to the head of the tibia while the knee is in flexion.17 Ruptures of the posterior cruciate ligament may also occur during both hyperflexion and hyperextension.

Hyperflexion without coupled posterior translation of the tibia often results in an avulsion of the posterior cruciate ligament from the femur.7 When ruptures of the posterior cruciate ligament occur as a result of hyperextension, first the anterior cruciate ligament is ruptured, followed by injury to the posterior capsule. Then, at 30 degrees of hyperextension, injury to the posterior cruciate ligament occurs; finally, injury to the poplitieal artery occurs at 50 degrees of hyperextension.7 Injury to the posterior cruciate ligament most frequently occurs as a result of motor vehicle accidents and has been referred to as “the dashboard injury.�

During a frontal collision, the occupants of the front seat travel forward and strike their knees on the dashboard. This forces the head of the tibia to move posteriorly and causes the posterior cruciate ligament to rupture.7 Another common means of rupturing the posterior cruciate ligament is falling onto a flexed knee, which also drives the tibia posteriorly, rupturing the posterior cruciate ligament (Figure 6).2

Lateral Collateral Ligament Rupture Ruptures of the lateral collateral ligament are uncommon; however, when they do occur, they are caused by a varus force applied to the knee joint (often coupled with internal rotation of the tibia) (Figure 8) or during complete dislocation of the knee.2,17 Injury to the lateral collateral ligament is rarely an isolated injury and often is concomitant with stretching or rupturing of the lateral popliteal nerve.17 Knee Osteoarthritis Osteoarthritis of the knee is a disease that is characterized by degeneration of the articular cartilage of the joint.

Osteoarthritis is also referred to as osteoarthrosis and degenerative joint disease. The degeneration of articular cartilage leads to a loss of shock absorption, which in turn leads to trabecular micro-fractures. Subsequently, the subchondral bone begins to degenerate and osteophytes form at the joint margin.19,18 The cause of osteoarthritis is not well known; however, risk factors have been established and include age, gender, previous trauma to the joint, and possibly obesity. The prevalence of knee osteoarthritis increases with age because as cartilage ages, it undergoes changes that decrease its ability to withstand compression, putting more stress on the subchondral bone.8,11 Females seem to be more likely to get osteoarthritis than males, but males tend

Spring 2005 THE FORENSIC EXAMINER 9

Table 1: Mechanisms & Types of Knee Injuries Injury

Mechanism of Injury

How the Injury May Occur

Torn Meniscus

combination of compression, rotation and flexion\extension, or absence of synchronous rotation during flexion\extension

twisting knee while walking due to unknowingly stepping in a ground depression

Ruptured ACL

rotation, abduction, posterior translation of the femur, hyperextension or dislocation

twisting knee upon landing after jumping or falling

Ruptured PCL

posterior translation of the tibia, hyperflexion or hyperextension

striking knee on dashboard or falling onto a flexed knee

Ruptured MCL

valgus force applied to the knee or external rotation

lateral side of pedestrian’s knee struck by the bumper of a moving vehicle

Ruptured LCL

varus force applied to the knee or complete dislocation

blow to medial aspect of the knee; often concomitant with other knee injuries

Osteoarthritis

unknown; however, risk factors include age, gender, previous trauma, and possibly obesity

increased age, being female, and being overweight

Chondromalacia

unknown, however it has been postulated that abnormal patellar tracking is a major etiological factor

abnormal patellar tracking secondary to knee injury which disrupts function of the vastus medialis

Bursitis

contact trauma, prolonged kneeling and repeated flexion/extension

striking knee on rigid surface, such as dashboard or ground

to get osteoarthritis at a younger age.1,12 It has been suggested that males get osteoarthritis at a younger age due to the influence of trauma or occupation.12 Any damage to the joint cartilage, no matter how minimal, can lead to osteoarthritis. This is because cartilage has limited healing abilities due to poor vascularity. Once injured, the degeneration process of the joint cartilage begins and is difficult to halt or reverse.19,11 The increased body weight of obese individuals increases the stress placed on the cartilage in the joint and can become a contributing biomechanical factor for knee osteoarthritis.12 Logically, increased loading stress will diminish the capacity for protection of the subchondral bone and injury to these structures is more likely, thus increasing the risk of osteoarthritis.

Knee Chondromalacia Chondromalacia is the softening and deterioration of the articular cartilage on the posterior surface of the patella. The exact cause of chondromalacia is

unknown; however, it has been postulated that abnormal patellar tracking is a major etiological factor.13 Three stages of chondromalacia have been identified.

Stage 1 involves the swelling and softening of the articular cartilage. Stage 2 involves the fissuring of the softened articular cartilage, and stage 3 involves deformation of the surface of the articular cartilage caused by fragmentation.3 Bursitis Bursitis of the knee is the inflammation of one or more of the numerous bursae that surround the knee joint. Bursitis can be acute, chronic, or recurrent.2 Most commonly, the bursae in the anterior group become inflamed. Common mechanisms of knee bursitis include contact trauma, prolonged kneeling, and repeated flexion or extension of the knee.

Summary Although the knee, at first glance, appears to be a relatively simple hinge joint that merely moves in flexion and

10 THE FORENSIC EXAMINER Spring 2005

extension, trauma to the knee can occur in many different manners, some of which are summarized in Table 1. However, in order to damage one of the specific structures of the knee, the mechanism required to injure that structure must be present or injury cannot result.

Meniscal tears require compression, rotation and flexion, or extension. Ruptures of the anterior cruciate ligament occur as a result of rotation, abduction, posterior translation of the femur with respect to the tibia, hyperextension, or dislocation of the knee joint. Ruptures of the posterior cruciate ligament occur as a result of posterior translation of the tibia while the knee is flexed from hyperextension or hyperflexion. The medial collateral ligament will rupture as a result of a valgus force or external rotation. The lateral collateral ligament will rupture as a result of a varus force or complete dislocation of the knee. Bursitis of the knee is often a result of direct impact, prolonged kneeling, or repeated flexion or extension of the knee. While the causes of osteoarthritis and chondromalacia are not known, we do know there are risk factors that increase the likelihood of developing these problems.

The risk factors for osteoarthritis include age, gender, previous trauma, and obesity, while abnormal patellar tracking is the risk factor for chondromalacia.

As can be seen, there is no doubt about the true complexity of the knee joint, the major processes that occur as people walk, sit, stand, run, and jump, and the debilitating injuries that can occur when external and internal forces cause the structures of the knee to exceed their physical limits.

References 1. Altman RD. The classification of osteoarthritis. The Journal of Rheumatology.

1995;Vol. 22;Suppl. 43:42-43.

2. Arnhein DD, Prentice WE. Principles of Athletic Training. 8th ed. St. Louis, MO: Mosby Year Book;1993.

3. Cailliet R. Knee Pain and Disability. 2nd ed.

Philadelphia, PA: FA Davis; 1983.

4. Cross MJ, Chrichton KJ. Clinical Examination of the Injured Knee. Baltimore, MD: Williams

& Wilkins; 1987.

5. Dox IG, Melloni BJ, Eisner GM. The Harper Collins Illustrated Medical Dictionary. New York, NY: HarperCollins; 1993.

6. Enerson OD. 2003. Retrieved from: www.whonamedit.com/synd.csm/2251.html.

7. Fanelli GC. Posterior Cruciate Ligament Injuries: A Practical Guide to Management. New York, NY: Springer-Verlag; 2001.

8. Felson DT, Niamark A, Anderson J, Kazis L, Castilli W, Meenan RF. The prevalence of knee osteoarthritis in the elderly. Arthritis and Rheumatism. 1987;Vol. 30;914-918.

9. Hoppenfeld S. Physical Examination of the Spine and Extremities. East Norwalk, CT: Appleton & Lange; 1976.

10. Kapit W, Elson LM. The Anatomy Coloring Book. 2nd ed. New York, NY: HarperCollins College Publishers; 1993.

11. Martin DF. Pathomechanics of knee osteoarthritis. Medicine and Science in Sports and Exercise. 1994; 26: 1429-1434.

12. Michet CJ. Osteoarthritis. Primary Care.

1993; 20: 815-826.

13. Nicholas J, Hershman E. The Lower Extremity and Spine In Sports Medicine. St. Louis, MO: Mosby-Year Book; 1986.

14. Physiome Project. 2003. Retrieved from: http://www.physiome.org.nz/sites/physiome/anat ml/database/knee/ groups/group_12.html.

15. Rasch PJ. Kinsiology and Applied Anatomy.

7th ed. Philadelphia, PA: Lea & Fehiger.

16. Sieg KW, Adams AP. Illustrated Essentials of Musculoskeletal Anatomy. 2nd ed. Gainesville, FL: Megabooks; 1985.

17. Smilli IS. Injuries of the Knee Joint. UCLA BIOMED WE 870 S641i; 1951.

18. Whiting WC, Zernicke RF. Biomechanics of Musculoskeletal Injury. Champaign, IL; Human Kinetics; 1985.

19. Wilkerson G. Conservative Management of Osteoarthritis (FN: 97-158). Shirley, NY: Biodex Medical Systems; 1997. *Figures 6, 7, and 8 are based on diagrams originally printed in Arnhein DD, Prentice WE. Principles of Athletic Training. 8th ed. St. Louis, MO: Mosby Year Book;1993.

About the Authors Matthew Donohoe, MA, ATC, holds a bachelor’s degree in kinesiology with an emphasis in athletic training, and a master’s degree in physical education with an emphasis in biomechanics and athletic training. He has also been certified as an athletic train-

er by the National Athletic Trainers Association. Donohoe’s studies and professional experience have focused on accident reconstruction, biomechanics, athletic training, and injury rehabilitation.

He has assisted in research projects at San Diego State University’s Biomechanics Lab and has developed and carried out the protocol for research investigations on osteoarthritis knee bracing. Donohoe lectures on biomechanics as it relates to low-speed automobile accidents and daily life activities, and has carried out research on forces generated by sporting activities and activities of daily living.

Currently Donohoe utilizes his knowledge of accident reconstruction, biomechanics, and the mechanics of injury at the Institute of Risk & Safety Analyses to determine the potential for injury in a given accident.

Helen Aslanian, BS, obtained a bachelor’s degree in physics from the University of California, Los Angeles (UCLA) in 2001 and is currently working on a master’s degree in engineering at UCLA. Her experience includes an internship at Boeing’s Electron Dynamics Division, and her professional responsibilities have included assessing and studying products and engineering laboratory processes to create a detailed, web-interface database.

As an undergraduate student at UCLA, Aslanian co-authored and presented papers based on her research on solidstate physics. Her research included laboratory work on, and analysis of, superconducting materials at the National High Magnetic Field Laboratory in Florida. Today Aslanian applies her understanding of a broad range of physics and her background in analysis and problem solving to the field of accident reconstruction at the Institute of Risk & Safety Analyses.

Kenneth Solomon, PhD, DABFE, D A B F E T, DABLEE, CHSIII, obtained a bachelor’s, master’s, and doctorate degree in engineering and a postdoctorate degree in risk benefit assessment from UCLA. He also holds a professional engineering license and holds Diplomates from ACFEI in forensic engineering, forensic technology, law enforcement, and homeland security. Dr. Solomon’s studies are limited primarily to accident reconstruction, biomechanics, and risk-benefit assessment, as demonstrated by his 34 years of independent research; his more than 200 internationally distributed publications, reports, and presentations; the three books he coauthored; and his journal guest-editorships. In December of 1998 and after over 22 years of service, he retired as Senior Scientist with the RAND Corporation. He was on the faculty at the RAND Graduate School for 18 years and has taught as an adjunct faculty member at UCLA, the University of South Carolina, the Naval Post-Graduate School, and George Mason University. Dr. Solomon is a reserve deputy with the Orange County Sheriff ’s Department.

He is also Commissioner of the Policing Commission for the City of Calabasas.

He has published studies on transportation accidents (involving automobiles, trucks, motorcycles, and bicycles), industrial and recreational accidents (involving pressure vessels; rotating machinery; forklifts and cranes; exercise, gym, and recreational equipment; swimming pools; and manufacturing and punch presses), slip-and-fall and trip-and-fall accidents, and the adequacy of warnings.

Dr. Solomon has been a member of ACFEI since 1997.

Earn CE Credit To earn CE credit, complete the exam for this article on page 63 or complete the exam online at www.acfei.com (select “Online CE”).

Spring 2005 THE FORENSIC EXAMINER 11

Take the Certified Medical Investigator®, CMI, course at ACFEI’s 13th National Conference, Sept. 30-Oct. 1, 2005, in San Diego, California.

The Certified Medical Investigator, CMI, designation is an advanced credential that helps confirm to legal authorities that you have experience, education, training, and expertise in conducting medical investigations. It can attest that you have completed the necessary coursework, acquired the advanced specialized knowledge and skills, and passed the required examinations on medical investigation to set you apart as a nationally recognized medical investigator.

About the Certified Medical Investigator, CMI, Training Program The CMI Training Program will educate attendees in the critical areas of forensic investigation, including the importance of recognizing evidence, securing evidence, protecting a forensic scene from contamination, and the legal issues involved in managing evidence and testifying about it.

All forensic professionals will benefit from the CMI course, including those outside the traditional medical professions.

“I would suggest that anyone prosecuting or investigating crimes should consider this course. It makes for a better investigation and expands your knowledge base to understand what can or cannot be determined from the information found. Any forensic scientist, clinician with any connection to law enforcement, or provider of expert testimony should consider this course. Overall, the knowledge is indispensable.” —E. Robert Bertolli, OD, CMI-V, CHS-V

Register now! Call toll free (800) 423-9737, visit www.acfei.com (click “conferences”), or e-mail marianne@acfei.com.

A proctored exam option is also available in your area. For more information call toll free (800) 423-9737. *Conference schedule is subject to change.

12 THE FORENSIC EXAMINER Spring 2005

Become a Certified Forensic Nurse, CFNSM! Take the CFN course at ACFEI’s 13th National Conference, Sept. 30-Oct. 1, 2005, in San Diego, CA

The CFN program is unique from other forensic nurse training programs because, rather than teaching only one specific area of nursing or forensics, it teaches and tests the overall capabilities required of a competent forensic nurse. As a result, the CFN designation helps verify that the Certified Forensic Nurse can conduct a sound forensic engagement, examination, or case that will stand up under the rigorous standards of the U.S. judicial system.

The CFN course covers the following areas related to forensic nursing: I. Forensic Nursing Core II. Forensic Nursing Focus Areas • The History of Forensic Nursing • Homicide • The Forensic Nursing Process • Sexual Assault • Violence and Victimology • Intimate Partner Violence • Injury Identification, Interpretation, and Documentation • Child Maltreatment • Criminalistics and Forensic Science • Legal Nurse Consulting • Nursing and the Law/Legal Interface • Correctional Nursing “All nursing professionals will benefit from this program, including those at the bedside providing direct patient care, those at administrative levels, educators, and nurses working in community-based programs. Every nurse who takes part in the CFN program will benefit and improve his or her practice!” —Jaime Ferrell, BSN, RN, DABFN, CA/CP-SAME, SANE-A, CMI-III, CFN

Register now for this exciting event! Call toll free (800) 423-9737, visit www.acfei.com (click “conferences”), or e-mail marianne@acfei.com.

A proctored exam option is also available in your area. For more information call toll free (800) 423-9737. *Conference schedule is subject to change.

Spring 2005 THE FORENSIC EXAMINER 13

By Ralph E. Van Atta, PhD Abstract This article is approved by the following for continuing education credit: ACFEI provides this continuing education credit for Diplomates.

ACFEI is approved by the American Psychological Association to offer continuing professional education for psychologists. ACFEI maintains responsibility for the program.

ACFEI is recognized by the National Board for Certified Counselors to offer continuing education for National Certified Counselors. We adhere to NBCC Continuing Education Guidelines. Provider #5812.

ACFEI provides this continuing education credit for those Certified in Homeland Security.

ACFEI is an approved provider of the California Board of Behavioral Sciences, approval PCE 1896.

Pseudologia fantastica (PF) refers to the fabrication of events as a defense against the reexperiencing of psychological trauma. This defense involves primary process thinking and may readily be detected as lying by forensic clinicians. Lying in a compensation and pension (C&P) interview places a post-traumatic stress disorder (PTSD) claimant at risk for misdiagnosis as a malingerer. A diagnostic error of this nature is doubly unfortunate since it deprives the claimant of both compensation and the treatment that he or she requires. This research was undertaken with the purpose of reducing the frequency of such diagnostic errors by developing criteria that differentiate PF from malingering. To this end, 144 C&P examinations for PTSD were reviewed to identify cases of malingering and of PTSD with PF. This review detected 11 cases of malingering and 2 cases of PTSD with PF. Both PF cases are presented, and 1 case of malingering is provided for comparison. The profile of the malingerer was marked by poorly substantiated trauma, exaggerated and internally inconsistent combat narratives, and an invalid psychological test profile. These characteristics were present in the profiles of all 11 malingerers. In comparison, the PF cases were marked by exaggerated combat narratives, well-documented combat exposure, and valid psychological test profiles. These profile characteristics are proposed as criteria for differentiating PTSD claimants with PF from those who are malingering.

14 THE FORENSIC EXAMINER Spring 2005

A note from the author: This research was supported by a grant from the Veterans Administration VISN4 Mental Illness Research, Education, and Clinical Center. My research assistant, Jesse F. Menarde of West Virginia University, made significant contributions to this study.

hypothesis is that these claimants suffer too much from the truth to do anything other than confabulate. Their confabulation is a defense referred to in the psychoanalytic tradition as pseudologia fantastica (PF). These individuals are in need of compensation, but because of their pseudologia they are at considerable risk of being mistaken for malingerers; this research was undertaken to minimize these errors.

Key Words: pseudologia fantastica, malingering, PTSD, combat, veterans

In compensation and pension examinations (C&Ps) for combat-determined post-traumatic stress disorder (PTSD), one obvious task for forensic psychologists and psychiatrists is to differentiate truth from falsehood, and to differentiate malingerers from those who have valid claims. Complicating this task is the fact that lying and exaggeration may accompany both valid and false claims.

While it might seem to be in the best interests of individuals with valid claims to tell the truth, they may not do so.

With high financial stakes, some claimants will exaggerate their traumatic exposure and/or inflate the severity of their symptoms.

Much less frequent and less understandable are claimants who relate combat anecdotes that are patently untrue even though they actually experienced significant, potentially traumatic combat exposure. In such cases, one may wonder, “why lie when the truth would do as well?” One

Confabulation functions to defend against pain associated with reexperiencing trauma. It must be understood that “traumatic memory is not narrative.

Rather it is experience that recurs as a full sensory replay of traumatic events in dreams” (Shay, 1994). Lying is hypothesized to serve the individual by protecting him or her from this painful reexperiencing. Pseudologia, literally translated, means false or pretended speaking, while fantastica implies content that is incredible, or dramatic. This term, first used by Deutsch (1922), captures the phenomena of defensive lying in PTSD. Those who utilize PF even though they have valid claims for PTSD are at risk for misdiagnosis, since

some malingerers are also prone to “overplay”. When PF appears in the PTSD syndrome, there is a risk of misdiagnosis even if the clinician thoughtfully follows the DSM-IV TR criteria. DSM-IV TR mentions PF only once, as a symptom of factitious disorder.

C&Ps involve an interplay of dynamic forces seemingly apt to elicit PF. In the C&P, PTSD sufferers must verbalize troubling recollections. In terms of Hullian learning theory, they are in a classic approach-avoidance conflict. To obtain benefits, claimants must describe overwhelming experiences.

Some compromise must be achieved between the desire to approach (to verbalize fully) and the desire to avoid (to say nothing). Compromises other than PF are possible, of course. Caught in this dilemma, PTSD sufferers may speak selectively, exhibit conflict, become defensive and irritable, refuse to go into more detail than necessary, and/or emote with such intensity that they have difficulty talking. A few patients, perhaps a very uncommon few, may exhibit the PF defense.

Consider the case of a World War II (WWII) veteran who claimed to have been at Pearl Harbor in the Hawaiian Islands on December 7, 1941, and to have been in battles for Bataan and Corrigidor in the Philippines Islands, battles that began shortly after the attack on Pearl Harbor. He related that he was

Spring 2005 THE FORENSIC EXAMINER 15

taken prisoner during these battles and was held for the duration of the war, although he made many attempts to escape. Each time he was recaptured, he was placed in a bamboo cage and tattooed to mark him as an escape risk. While stating this, the veteran showed me tattoos on his left inner forearm, each consisting of a column of sets of 3 letters.

Nearly all the sets corresponded to his initials. These initials were oriented toward the veteran rather than the viewer, and I suspected that they had been self-inflicted. In reaction to my interest in these tattoos, the patient (who was right handed) apologized, said he was mistaken, and admitted that he had actually tattooed himself.

The man’s military record showed that he entered service in 1943, well after Pearl Harbor and the fall of Bataan and Corrigidor. He had served in the Philippines Islands Campaign where he was captured and held by the Japanese for approximately 30 days. He met the DSM-IV TR criteria for PTSD, including evidences of hyper-arousal, numbing, and intrusive recollections (both in dream-work and diurnally). So why was the patient lying? He had much documentation to validate his claim of trauma; if he were malingering, he would need only to simulate the symptoms of PTSD. One can only speculate about the nature of his motivation for lying; it seems reasonable to hypothesize that his invention of a pre-1943 military record was intended to distract from the portion of the war during which the trauma actually occurred.

Purpose Individuals such as this elderly veteran pose a diagnostic conundrum and are at considerable risk for misdiagnosis. This study was undertaken

to develop guidelines or criteria for differentiating malingering from PTSD with PF. Hopefully, improvements in differential diagnosis will improve diagnostic accuracy, assure compensation, and ensure appropriate care.

Literature Review Although PF is often used interchangeably with pathological lying, for this article, PF is used in a more specific psychoanalytic sense (Fenichel, 1954). In contrast to pathological lying (Yochelson & Samenow, 1976; Kerns, 1986), PF, in psychoanalytic usage, is not sociopathological in that it is not aimed at criminal objectives. Instead, it is motivated by both extrinsic and intrinsic considerations. It is lying that may deceive others but is intended primarily to be selfdeluding. If one is successful in deluding the other, then the capacity of the lie to delude the self is preserved and strengthened (Fenichel, 1954; Van Atta, 1969).

It was Deutsch (1922) who originally conceived of PF as a trauma-related entity, viewing it as a response to a breakthrough or threatened breakthrough of repressed memories. PF rests along a continuum of representations (or misrepresentations) of reality that reflect an individual’s attempts to adapt to the

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demands of reality. While lying is more likely when there are conflicts between the individual and demands of society (Hartmann, 1958; Van Atta, 1969), PF, as used by Deutsch, involves avoidance of reality as it is known in the individual’s own memory. It is an anxietyreducing response elicited by the potential emergence of an overwhelmingly traumatic memory. PF may reflect the presence of a traumatic disorder rather than a factitious disorder, a sharp contrast to the position taken by the DSMIV TR. Deutsch applied pseudologia to the wishful thinking of an adult female bipolar patient (Deutsch, 1965) to describe shared delusions in 2 families (folie a deux, folie a trois) (Deutsch, 1965), and to imposter behavior of an adolescent with conduct disorder (Deutsch, 1965). In a more contemporary discussion Gabbard noted that “defenses marshaled by the ego in the face of trauma are commonly thought to be primitive or immature. Hence, there is frequently a regression to developmentally earlier modes of dealing with helplessness, vulnerability, fear, and anger” (Gabbard, 2000).

Snyder attributes the commonness of pathological lying in borderline patients (Snyder, 1986) to their need for narcissistic gratification as idealizations of the self. Pathological lying in these patients appeared to be associated with impetuous acting-out behavior. Snyder’s presentation and the examples he provided underscore a need for a clear and explicit definition of PF. In this regard, Kerns (1986), equating PF with pathological lying, defined pseudologia based on limited insight into the lying and its motivation, intact sensorium, intact memory, absence of external motive, and spurious, self-aggrandizing content. Heidrich et al. (1996) described a patient with a cerebellar arachnoid cyst who lied in an apparently pointless and self-aggrandizing way. Heidrich felt the cyst might have contributed to her patient’s PF, emotional instability, and behavioral dis-

turbances. PF involves prelogical thinking, and proneness to this defense may be influenced by some variant of organic brain disease (King & Ford, 1988; Heidrich et al., 1996) or characterological disturbance (Snyder, 1986; Weston & Dalby, 1991; Leung, Lai, Shun, & Lee, 1995). King and Ford (1988) viewed pseudologia as a disorder rather than a defense. Unfortunately, our review of the literature did not yield data about the incidence of PF or its comorbidity with PTSD. Method I conducted an archival study of 144 C&P examinations for PTSD from 1997 to 2002. These cases included 109 Vietnam veterans, 18 WWII veterans, 11 Korean War veterans, 1 Gulf War veteran, 1 Korean Cold War veteran, and 4 veterans who had served in more than 1 of these wars. Within this sample, 10 of the WWII veterans met criteria for PTSD, as did 6 of the Korean War veterans. The Gulf War veteran was dually diagnosed as having both paranoid schizophrenia and PTSD. Two of the 4 patients in the group that had served in more than one war were diagnosed as having PTSD. In the case of the Vietnam veterans, 96 were diagnosed as having PTSD, 3 were indeterminate because of inadequate verification of stressors, and 10 were considered to be malingering.

Because malingering is pejorative and rarely provable, the term is rarely used in C&Ps. Consequently, word-search methodology was used to review the 144 case files for words and phrases suggestive of either the pseudologia defense or malingering. Such words and phrases included the following: PF, rule out PTSD, request verification of stressors, and malingering. These terms were helpful in identifying records of particular interest to this research. Word search methodology in combination with direct visual inspection of the electronic reports was used to identify records that contained obvious exaggeration, a marker for PF.

Findings and Results Using this methodology, 3 cases were identified that showed unusual, obvious exaggeration. One case involved a Korean War veteran who was diagnosed as having alcohol abuse in remission and was considered to be malingering. The second case involved a Korean Cold War veteran diagnosed as having only symptoms of PTSD. As noted above, the third case involved a Gulf War veteran diagnosed with paranoid schizophrenia as well as PTSD. These 3 cases are presented below, with bracketed comments placed strategically for the benefit of readers; precise dates are not provided to protect patient confidentiality.

Case 1: Malingering in a 68-yearold Korean War Veteran Background: This veteran, a disabled African American truck driver, claimed to have PTSD resulting from trauma experienced during the Korean War. His background included desertion by his mother prior to his second birthday and subsequent physical abuse by his father.

When he was 15, his aunt became aware of this abuse and arranged for him to live with her. He seemed to have no residuals from his father’s abuse and

felt fortunate to have been “rescued” by his aunt. He reported no other potentially traumatic experiences and no remarkable medical problems during childhood or adolescence.

Military History: The veteran’s military record established that he was in the Army from October of 1950 until late March of 1954, and that he served in the Korean War. He was awarded the U.N. Medal and a Korean Service Medal for his service. Records did not provide specific details about the time frame in which the man served in the war zone. (This information is sometimes important for corroborating the combat stressors claimed by a veteran.)

He could recall only that he’d departed for Korea in late 1950 and that there was snow on the ground when he arrived. Allowing time for basic and advanced training and travel, he might have arrived in Korea as early as late December, 1950. He was able to remember the particular ordinance unit that he had served in and stated that his job was ammunition handler. He was not able to recall the names of

Spring 2005 THE FORENSIC EXAMINER 17

any of the officers or men with whom he had served. He did recall that his unit had been near the Korean cities of Taegu and Wonju.

[Author comment: Both cities were logical sites for ordnance depots since they were south of the battle lines along major roads and railways in the Republic of Korea; Wonju, farther north but approximately 50 miles south of the 38th parallel, was well behind enemy lines at that time (Halliday & Cumings, 1990). In December of 1950, the situation on the Korean peninsula was highly fluid. The U.S./U.N. forces, which had occupied nearly all of northern Korea, had been forced to retreat and form new battle lines along Korea’s mid-peninsula waistline (Ridgeway, 1967).

Under these circumstances, the man would have experienced great stress from handling and working in the vicinity of high explosives in a war zone. Soldiers assigned to such duties would be aware that the enemy viewed them as a prime—if inaccessible—target. The nature of the Korean War was such that guerrilla activities were possible even though the veteran’s unit would seem to have been in a relatively secure position (Halliday & Cumings, 1988).]

The veteran admitted that

he was disciplined twice while in Korea, once for drunk and disorderly conduct and once for leaving his post and going on a 3-day drinking bout. He based his claim of trauma on several alleged experiences. On one occasion, he said he discovered the body of a little girl lying face up in a drainage ditch. When asked how he reacted, he reported that he told his commanding officer (CO). When asked how he felt at the time, he said that he felt ill afterward. He claims that in recent years he has frequently seen the face of the dead child in water surfaces, such as when he takes a drink of water.

[Author comment: This event, it should be noted, cannot be easily verified and the flashback that he reports—as well as its trigger—is quite unusual.]

He also told of drinking water from a well only to find that it contained the body of a child, saying he felt like “throwing up but couldn’t.” He also reported this to his CO. [Author comment: Troops serving in Korea were cautioned against drinking from local water supplies. It is implausible that a soldier would have hazarded drinking from a well except in a time of dire necessity. In addition, his claim that he reported his discoveries to his CO is suspect. More likely, he would not have had ready access to his CO and so would have reported this to people closer to him in the chain of command, such as his squad leader or sergeant.]

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The veteran stated that he was once on guard duty when confronted by a Korean who tried to shoot him with a .45 caliber semiautomatic pistol. The weapon misfired, and the man wrestled it away from the Korean. As the Korean ran, the veteran shot him with the pistol.

[Author comment: This story lacks plausibility because the veteran, an enlisted man, would have been armed with an M-1 rifle. His training would have led him to use his own weapon rather than try to physically disarm his adversary. Had he obtained the enemy’s weapon, it would not have been ready to fire; the probable cause of its misfire would be a defective round, which would have to be ejected for the weapon to fire.]

This veteran also claimed that he came under enemy sniper fire while climbing a telephone pole to repair a communications line. He returned fire with his rifle and drove the enemy away. [Author comment: There are many problems with this incident. According to records, the vet was not trained in communications. To climb a pole and have both hands free for work, it would have been necessary for him to sling the weapon across his back. Considerable agility would be required to unsling his rifle and fire it accurately while dangling from his safety belt.]

Finally, the veteran shared his experience of “Bed Check Charlie,” an enemy aircraft that would regularly bomb and strafe his area in the twilight hours of the day. He could not remember whether the plane was propeller or jet powered; running, he said, was all that he could remember. After this narrative the veteran spontaneously stated that he had cried many nights wanting to go home.

[Author comment: By the time our claimant arrived in Korea, the U.S. Air Force had destroyed and suppressed nearly all of the North Korean Air Force. Soviet aircraft rarely ventured south of the Yalu River (the border between China and Korea), although they might have occasionally appeared

as far south as Pyongyang (Halliday & Cumings, 1988), more than 70 miles north of the 38th parallel (Gugeler, 1970). American commanders flew without fear of air attack in unarmed aircraft to study the front line situation (Ridgeway, 1967). Army artillery observers operated with impunity from slow-moving light aircraft in search of enemy troop concentrations (Gugler, 1970). Therefore, the man’s report of Bed Check Charlie, a single enemy aircraft that regularly appeared in the predarkness to bomb and strafe as far south as Wonju, may or may not have some basis in reality.]

Post-Military History: After the war, this veteran was employed in a number of jobs for relatively short periods of time (his longest period of employment lasted 8 to 9 years). He admitted that heavy drinking was a significant contributor to his instability in the workplace. He considered himself an alcoholic but denied having received treatment. His only forensic history involved a DUI, although a review of medical history revealed that he had suffered a stab wound to the chest in the early 1970s and had required stitches in his right arm as a result of a fight. Over the years, he developed glaucoma, heart disease, insulin dependent diabetes mellitus, and coronary artery disease. He married and had 10 children; he is quoted as saying that he “got away from” some of these children. He claimed to have 2 Korean sons with whom he maintained correspondence.

This veteran was not treated for PTSD until March of 1999, when he undertook a 6-week rehabilitation program for veterans with PTSD. Although he was diagnosed as having PTSD during this program, there is no record of a thorough evaluation of the alleged trauma.

On admission to the program, he claimed to have a significant sleep problem. However, according to treatment records, his sleep was unremarkable except for restlessness on a single occasion. Subsequent to completing the pro-

gram, he presented at a VA Primary Care Clinic, which prescribed 50mg trazadone @hs, 100mg sertraline qAM. He was taking these medications when he appeared for his examination. Available medical charts showed no history or finding of brain injury or disease.

Mental Status: As an examinee, the veteran seemed a rather pleasant, neatly attired individual. He was mildly obese and of mesomorphic build. His thought processes were productive and relevant, and his affects were appropriate in range and amplitude. He admitted and gave no evidence of auditory or visual hallucinations. He denied suicidal and homicidal ideation. He did show impulsivity, admitting that he had fired his pistol at a male relative during a recent family dispute. He was intolerant of social contact. He had trouble sleeping; this problem was intermittent and marked by problems of onset and interruption. He complained that “different things rush through my mind” after retiring, and that he had senseless bad dreams that he was unable to comprehend. For example, he had dreams of swimming even though he never learned to swim. He also had dreams of war, and had trouble watching war movies. He denied that he was generally nervous but reported having spells of shakiness and shortness of breath on a monthly basis for the past 5 months. He reported these spells to a medical doctor, who told him he needed to relax. He also reported intervals of his chest aching associated with feelings of frustration.

Psychological Test Results: The Personality Assessment Inventory (PAI) is a 344-item objective personality inventory. Psychometrically, the test can be fairly described as producing a highly reliable test profile consisting of 4 validity scales, 11 clinical scales, 4 interpersonal scales, and 3 treatment scales. There are 31 additional subscales, most of them permitting a more refined interpretation of the primary clinical scales.

The pattern of validity scale scores revealed frequent endorsement of test

i t e m s with bizarre and unusual content and minimal endorsement of items that might have made a positive impression. Based upon a statistical configurational analysis, the profile was found to very closely resemble the “fake bad profile.” Inspection of the clinical and subscale profiles revealed that 15 of 49 scales were elevated above the level of 67% of the profiles of the normative group of clinical patients. These validity scale results, while invalidating the PAI results, are consistent with the clinical impression of exaggeration and malingering.

Diagnostic Impressions: Axis I, alcohol abuse in remission. Axis II, none.

Axis III, hypertension, coronary artery disease, insulin dependent diabetes mellitus, and glaucoma. Axis IV, disability.

Axis V, GAF = 60 (reflecting impaired judgment and impulse control).

[Author comment: Exaggeration, a marker for malingering, is also characteristic of PF. Exaggeration is not quite descriptive of this man’s reported war experiences as described above. His claims were illogical and implausible.

His memories are poorly detailed and poorly thought through, perhaps reflecting limited analytic effort and/or ability.

Impairment of analytic ability may reflect diffuse brain dysfunction, common in chronic alcoholism (Parsons, 1996).]

Case 2: Symptoms of PTSD with PF Defense in a Cold War Veteran Background: The examinee was a 46year-old veteran of the Cold War in Korea. He was born in New England, the product of a stable marriage. He was the youngest of four children in a family that was supported by the father, a heavyequipment operator.

The veteran described

Spring 2005 THE FORENSIC EXAMINER 19

his family life as comfortable and harmonious, denying physical, sexual, and/or psychological abuse during his formative years. He related that he was a competent high school student, although he failed to graduate after striking the school’s vice principal. The vice principal, according to the claimant, intimidated boys by painfully gripping them by the trapezius muscle. The claimant reacted to this tactic by punching the vice principal in the face, then leaving school and never returning. Afterward, he obtained stable employment for a defense contractor.

Military History: The veteran stated that he was drafted after “the build-up following the Berlin blockade,” and that he was trained as an MP after completing basic training. He reported being en route to Berlin with 14,000 other troops when the blockade was called off. He was later deployed to confront the Mississippi National Guard and state police during the civil rights crises of the early 1960s. He stated that he was a specialist in the use of chemical and biological weapons and so was personally selected for deployment to confrontations in which tear gas might be used. [Author comment: The Army’s personnel records indicate that this individual was a high school graduate and that he was not drafted but was an enlistee. He served from September of 1961 until February of 1965. The several months of Cold War commonly referred to as the Berlin Blockade occurred in 1949 rather than in 1960, as his remarks suggested. The construction of the Berlin Wall, to which he might have been referring, began in 1961.]

In 1963, the man volunteered for service in Korea and was assigned to an MP company that served in the vicinity of Panmunjom, Korea, also referred to as the Joint

Security Area (JSA). His records show service in Korea for 7 months from 1963-1964. [Author comment: The JSA is a meeting place situated on the border between North and South Korea, where the U.N. Command and the People’s Democratic Republic (PDR) met to resolve truce violations. Within this area, the military presence of each side was numerically limited. American soldiers assigned there were carefully selected on the basis of physique, intellect, and character (Kirkbride, 1994).]

The veteran related that on arrival at his duty station in Korea, he saw 6 body bags containing the remains of Americans killed in an ambush. He said that his duties included patrols in the demilitarized zone (DMZ) and guarding representatives from neutral nations (Sweden and Switzerland). On one occasion, he caught a “sapper” who was working his way under the wire into the neutral nations’ compound. He dragged the sapper through the wire; this was observed by a South Korean sergeant who immediately shot the captive through the head.

[Author comment: The duties described by the patient are consistent with available historical records. However, the casualty rates he reported are at variance with historical data based on military records. Kirkbride reports that

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from 1953 to 1966, 7 Americans were killed in encounters with the enemy (Kirkbride, 1994). Finley (1983) reported that 1 of these occurred in 1966. In addition to inflated casualty rates, the individual’s claim to have caught a sapper attempting to enter the neutral nations’ compound is doubtful. A sapper is a soldier who undermines a military fortification; the veteran’s use of this term implied that the alleged captive was on a military mission. It would have been self-defeating for North Korea to have undertaken a military mission against the neutral nations’ compound.

Further doubt is cast on the claimant’s veracity by his report that the captive was summarily executed. An adversary caught in these circumstances would have been an intelligence prize to be kept alive for interrogation. One wonders, also, at an ROK NCO taking it upon himself to summarily execute a captive, especially since the supposed execution took place within the neutral nations’ compound.]

Our examinee also told of a South Korean major who was boldly kidnapped by the North Koreans and hustled through the JSA into North Korea.

Immediately following this incident, he was told by his superior that an unnamed American general had ordered that he (the claimant) obey the orders of

South Korea’s president. The president then called him (the claimant) with a direct order to assassinate the kidnapped officer. Even though this assignment would mean instant death, he undertook it. However, when he attempted to cross into North Korea’s zone, he was stopped by “truckloads of North Koreans.”

[Author comment: This event is not reported in historical documents. A kidnapping involving the JSA would likely be reported; indeed a similar incident did occur but not during the claimant’s tour of duty. Finally, the notion that the Korean president would give direct orders to an American soldier to commit murder violates the chain of command as well as the principle of deniability.]

The veteran’s medical record shows that he sustained serious injuries (amputation of both feet and a portion of his left hand) as a result of a personnel mine explosion in Korea. These injuries were totally disabling, requiring multiple surgeries and resulting in the termination of his military career. His version of events was that the explosion occurred when he was leading a patrol in the DMZ. Despite his injuries, he said he crawled 30 yards toward his comrades, who then carried him out. He then commented, “They have got it written up as a hunting accident ... the U.N. covered it up.”

He stated that during his tour of duty in Korea, 30 to 40 men were lost from his unit, a fact also covered up by the U.N. [Author comment: The U.N. and U.S. commands were one; the United States was the United Nations in Korea (Bolger, 1991). The interests of the United States/United Nations would have been better served by reporting rather than concealing enemy violations of the truce agreement (Kirkbride, 1994).]

[Author comments: The veteran’s claim to have been conscious immediately after the explosion is confirmed in military records. These include eyewitness accounts and results of the Army’s investigation. These reports state that the claimant triggered a land mine or other explosive device while hunting

with a friend just south of the DMZ. There are 2 direct witness accounts of the incident, one of them provided by the veteran’s hunting companion. His claim to have been leading a patrol at the time of the injury is also brought into question by his assertion that he crawled 30 yards toward his comrades, which would have placed him well in advance of the patrol that he was supposedly leading.]

Post-Military History: After being discharged, the man returned to his premilitary employment working as a letter carrier and attended university, where he completed all but his last semester. He stated that he left college under pressure from his spouse to build a new house.

He obtained employment with a veterans’ organization and became a medical technician at a community hospital. His career progressed in spite of chronic heavy drinking, a series of surgeries, and chronic pain. On a daily basis from his discharge in 1965 until 1988, he drank a “fifth of whiskey everyday.” He completed 2 substance abuse programs before achieving a 3-year period of sobriety. The anniversary of his injury triggered a 4-day drinking bout and his return to treatment in February of 1991.

A battery of neuropsychological tests administered at that time revealed only mild psychomotor slowing and mild attention deficits. These were attributed to fatigue rather than neurological deficits. His MMPI was technically valid. It suggested that he was an angry, suspicious individual with a probable diagnosis of depression secondary to health and medical problems. His score on the MMPI PTSD scale (scale Pk) was well below the range that is characteristic of Vietnam combat veterans.

Mental Status: This veteran was found to be alert, fully oriented, and bright; his mood was tense. Interpersonally, he seemed aloof and distant. He was coldly rational, judgmental, moralistic, and potentially litigious. He admitted that he was easily triggered to violence and cited a number of instances when he

h a d assaulted others. He said that he was not easily startled. His problems of pain were well managed but he reported that his sleep was disturbed. He stated that for a long time he had been having dreams of “being overrun by 300 men in no man’s land.”

He stated that he never slept without a loaded pistol at hand. He was aware of having become cynical, mistrustful, and judgmental of others; he attributed these attitudes to his experiences in Korea.

Memory and other cognitive functions were assessed as intact. He denied psychotic symptoms and suicidality. He admitted having homicidal impulses toward an individual that he held responsible for his daughter’s death in a vehicle accident. No direct report of intrusive recollections of his alleged combat experiences in Korea was elicited in the course of the examination.

Diagnostic Impressions: This patient’s injuries could have provided a solid foundation for a trauma claim.

However, he focused on more dramatic but unverifiable exploits, exploits that were viewed as extremely unlikely to have occurred. Even these incidents were not described by him as productive of diurnal dreams or flashbacks. Thus, he did not meet the DSM-IV TR reexperiencing criteria. He did recurrently describe his supposed cold war experiences and might be said to be preoccupied with them. However he showed no discomfort as he described his experiences; in fact, he seemed to feel rather good during his narration. His pseudologia was not linked specifically to his physical trauma but was recurrently present in his description of his military experience. Further, once his story was complete, he showed no distress or discomfort in the aftermath. This claimant did provide indications of hyperarousal in

Spring 2005 THE FORENSIC EXAMINER 21

the form of his sleep disturbance and explosiveness. He gave evidence of numbing in terms of his coldness and social estrangement. The following diagnoses were established: Axis I, history of alcohol abuse, symptoms of PTSD. Axis II, symptoms of paranoid personality disorder. Axis III, bilateral amputee. Axis IV, recent death in family, physical disability, social isolation. Axis V, global assessment of functioning - 50, reflecting serious symptoms, most notably his homicidal ideation.

Is this a case of PTSD with PF? Clearly, this bright patient was not malingering, as he presented only a partial picture of PTSD. He made no mention of incident-related nightmares and described no diurnal intrusive recollections. His narrative about his military experiences remained stable and resistant to challenge over the course of nearly 10 years.

This stability may reflect the effectiveness of his U.N. cover-up defense. Why lie when the truth would do as well? In his career soldier/warrior mentality, to have been wounded meaninglessly in a hunting accident was not an appropriate conclusion to a military career. To be wounded while leading a patrol, however, would be an enhancing, perhaps even ennobling, conclusion to his career.

Lying was then motivated by a need to defend the self from a narcissistic affront. Note that this man lied and exaggerated about more than the events surrounding his tragic injuries. The generality of his exaggeration suggests an Axis II disturbance and hypothesis of trauma in early development.

Case 3: PTSD with PF in a Gulf War Veteran Background: This case involved a 34-year-old Gulf War veteran who was born in the United States but was

raised in the Hare Krishna faith. He denied being abused but related that discipline within his family and in the Hare Krishna community had been strict, and he felt he had been subjected to emotional deprivation and harsh physical discipline during childhood. Slapping was a common punishment, and at times an offending child would be required to squat with his hands passing behind his knees and covering his eyes.

The man expressed a commitment to the Hare Krishna system of beliefs, although he admitted that he did not always conform to their ways. He described himself as poorly motivated as a student, but he graduated high school.

He worked for 2 years as a laborer before joining the Army because he “needed structure.”

Military Experience: Basic training in the Army was viewed by this veteran as “a cake walk” after the Hare Krishna experience. It was so easy, he said, that he was disciplined for laughing at his sergeants. Advanced training as an Army Ranger was described as tough and demanding, making him the warrior that he had hoped to become.

According to this veteran, he participated as a member of a 4-man reconnaissance team that moved into Iraq just before the Gulf War. He described how his team was “inserted” via helicopter under cover of darkness. VA records showed that he told one staff member that his unit’s companions on the trip were a group of Navy Seals and Special Forces soldiers. In his interview with me, he stated that this same chopper had been used by Special Forces and Navy Seals in a prior operation. He stated that the pilot made false landings to veil their true destination, and described seeing tracer rounds passing both in front and to the rear of their aircraft.

[Author comment: Inconsistencies in the veteran’s story about his association to Navy Seals and Special Forces troops may reflect his desire to be associated with elite warriors. His desire was, then, for us to view him as an elite warrior. His

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combat narrative to this point seems plausible.]

On the ground, the team prepared a camouflaged position. At daybreak, the man realized his team was within 200 yards of an enemy bunker. At times, he observed enemy soldiers. However, they could neither report the enemy position nor request fire support due to a failure of communications equipment. After nightfall, he was able to see bombers overhead and hear and feel their bombs exploding.

[Author comment: It seems a bit surprising that the helicopter’s landing and take-off was not detected by an enemy situated a mere 200 yards away. Perhaps it was detected but not engaged by the enemy soldiers for reasons of their own (poor morale or concealment).]

Prior to the ground attack, according to the claimant, the reconnaissance team was “extracted.” When the attack began, his team followed an armored column that launched a coordinated attack with supporting helicopters, assaulting the very bunker that his team had detected.

He watched with excitement as the bunker exploded and bodies were thrown into the air. As this occurred, he and his buddies exchanged celebratory “high fives” and then went forward for a closer view of the aftermath. He recalls seeing a torso with protruding intestines and another body with its entire left side missing. Looking rather pleased at this point, he stated “it’s tough when you know you’re responsible.”

[Author comments: Through my experience both in the military and as a clinician treating war veterans, this was my first encounter with a report of a battlefield victory celebration. Feelings of relief are understandable, as might be a sense of elation. However, the ground was not secure when this victory celebration supposedly occurred. I was somewhat skeptical of the story. When the man shared his feelings of responsibility and guilt, he appeared pleased to have been responsible; there was no sorrow or suffering that would be typical

of the traumatized. Also, he did not inflict casualties but was a supposed witness to them. Was his victory celebration a fantasy that fulfilled his desire to be a warrior?]

After returning from 6 months of service in the Gulf War, he resumed responsibilities for training reconnaissance teams and as a drill instructor in basic training. Two years later, he returned to civilian life and worked as a laborer and factory worker; he also received training as a masseuse and tried that occupation for a few months. He experienced restlessness and concluded that he just didn’t fit in, then reenlisted.

After 2 years in the Army, he developed what he considered a minor ailment, plantar fascitis, an inflammation of the connective tissues in the sole of the foot.

When he was informed that this was a disabling condition, he stated that he became extremely upset and demanded to see the regulations. [Author comment: That this individual would be upset is not surprising. That he would demand to see the regulations suggests a paranoid orientation.]

Post-Military Experience: Resigned to civilian life, the man attended a large midwestern university hoping to become a lawyer. Shortly after returning from the war, he experienced violent impulses; at college these feelings (which he regarded as “evidence” of PTSD) intensified. One of his professors stated that he could not understand why his class should have difficulty with an assignment that was “high school level.”

The veteran took this as a slight and personally confronted and physically menaced the professor. As further evidence of his PTSD, he explained that he would often sit in his car, watch coeds, and imagine different methods of killing them. These feelings became intense and developed imminence, and, believing them to be war-related, he shared them with his rehabilitation counselors. They felt it best that he withdraw from college. He did so and became a stay-athome dad.

More isolated, his violent impulses did not subside but assumed new directions.

He told of how he was uncomfortable when invited to a family reunion. He attributed his anxiety to the possibility that his uncle, also a veteran and rumored to have PTSD, might attack him. He went to the reunion prepared to defend himself with a carefully selected kitchen fork hidden on his person.

When he and a cousin disagreed over a hunting position, he threatened to kill the cousin. A few weeks prior to the examination, he turned to the VA for help and was hospitalized for 8 days.

Though diagnosed by the treating psychiatrist as having PTSD, it was clear that the veteran was considered an enigma by the treatment team.

Mental Status: This much-decorated veteran seemed to be of bright-normal intellect; his communications were relevant and adequately modulated. He was alert, socially appropriate, and denied impairments of reality contact in the form of hallucinations or delusions. He did exhibit a few oddities of behavior, humming and softly whistling at quiet interludes in the interview. He inquired about a sound screen device (white noise generator) in my office, suggesting that it might be a monitoring or recording device. The interview revealed a very substantial preoccupation with violence, a preoccupation that was odd and bizarre and had little relationship to combat stressors. Since psychoticism had became an issue, I asked the man to complete projective tests, a projective drawing with verbal associations, the Hand Test (HT), and Rorschach’s Test.

My review of his medical records revealed that an MMPI2S (Minnesota Multiphasic Personality Inventory, revised short form) was already on file.

Psychometric Findings: The MMPI2S profile produced by this patient was a valid test profile that was marked by a readiness to endorse pathologically loaded items. The profile was markedly elevated with an overall implication of severe psychopathology, psy-

choticism.

The general configuration of the profile had similarity to the normative PTSD profile (Keane, Malloy, & Fairbank, 1984) but was more heavily weighted in the direction of the more psychotically loaded scales. The general elevation of the profile was sufficiently high, including indices to psychic energy as well as depression, leading us to consider this a profile that might reflect a potential for a psychotic acting-out of depression and despair. The MMPI PTSD Scale, Pk, though not normed for Desert Storm veterans, was within the range that is typical of Vietnam combat veterans. As I have shown elsewhere, the relevance of Pk to combat exposure and to the psychiatric diagnosis of PTSD is questionable (Van Atta, 1999).

In spite of the fact that the veteran had no warning of projective testing, he completed a Draw-A-Person requirement with confidence and spontaneity.

His drawing, a representation of an Iraqi soldier, was accompanied by his explanation that “this is coming to mind first ... an Iraqi soldier [that] ... I see in nightmares or when watching news on TV.” His drawing was generally well integrated with the exception of the absence of eyes.

[Author comment: Confidence and spontaneity are neither expected nor typical from either PTSD patients or from malingerers. It is consistent, though, with the patient’s tendency to pontificate about himself and his experience, a behavior that was puzzling to his inpatient caregivers. Such remarkable confidence may reflect traits such as arrogance and/or narcissism of delusional proportions, sometimes an indicator of paranoid schizophrenia.]

The HT consists of 10 items, each a depiction of a human hand in different poses.

Hands are

Spring 2005 THE FORENSIC EXAMINER 23

organs of contact with the environment, manipulative tools, and so the HT stimuli have potential for eliciting acting-out tendencies. The examinee’s responses were produced without hesitation, with content showing a preoccupation with war, the aftermath of war, and violence.

Some images were contradictory, suggestive of the grandiosity that might be associated with combat hyper-arousal versus feelings of sorrow and guilt in the aftermath of battle. One response and the associative stream associated with it went like this: “I see a fist. The fist of power. Power to the people. My problem will be solved when I come to group [treatment group]. There is hope.

Another hope given like Jesus [gave hope].”

The Rorschach protocol had similarities to the HT in that responses were spontaneous, preoccupied with war, the aftermath of war, and violence. As was also true of the HT, his Rorschach associations were offered without delay and with complete confidence. His ideation was not disorganized but tangentially and peripherally related to the content of the inkblots. He might be said to have shown almost a disdain for reality as represented by the inkblots in favor of his desire to tell his own story of his war experiences. Indices to impaired reality testing and heightened fantasy activity were noted.

With respect to the diagnosis of schizophrenia, subsequent to completion of my C&P, both a CT scan and an EEG were completed. The CT scan was within normal limits, but the EEG interpretation noted abnormal activity in the right frontotemporal region; this finding was speculatively attributed to metabolic or vascular anomaly.

Diagnostic Impressions: The psychological data best

fit a diagnosis of paranoid schizophrenia. Although there was no blatant hallucinatory activity, there were recurrent manifestations of odd and bizarre ideation, impairment of reality testing, and grandiosity with paranoid delusions. These manifestations of paranoid schizophrenia were in the absence of avoidant behaviors and signs of emotional suffering that are often seen in PTSD. The pseudologia that is evident seemed to center on his participation in battle, with the trauma being the attack and the observation of mutilated human remains (which he claims to have reacted to with a “high fives” victory celebration). As has been noted, it is doubtful that this veteran reacted to the events he described as he claimed.

His pseudologia is an aspect of a psychotic reaction to and repudiation of the events that he witnessed, events that were for him tragic and overwhelming.

He was assigned a secondary diagnosis of PTSD on Axis I; this was to recognize that his psychoticism does appear to be reactive to the wartime experience, that his preoccupation with the war experience is pervasive, and that he does meet other criteria, including hyper-arousal, sleep disturbance, intrusive recollections (manifest in his preoccupation, perhaps, but also in his dream work), and avoidance (manifest in the psychotic repudiation of reality).

Summary and Conclusions In this exploratory study, 144 of my C&Ps that focused on the question of PTSD were reviewed. Although confined to a single clinician, a single site, a brief time span, and a small number of cases, the study did succeed in identifying 11 cases of malingering and 2 of PF. These 2 cases and 1 case of malingering were studied for the purpose of determining criteria that might be useful for differentiating malingering from PF. In approaching the credibility tests of combat narratives, we used terms such as exaggeration and plausibility. Exaggeration is to say more than is true; it

24 THE FORENSIC EXAMINER Spring 2005

involves inflation, which logically requires reference to a normative baseline of sorts. Plausibility, a somewhat different test of credibility, emphasizes the degree of reasonableness or the internal consistency of a narrative. An implausible narrative is one that runs counter to the usual, normal, or logical sequence of events. It should be noted that these same credibility tests were applied in the evaluation of the symptoms as well as to combat narratives.

Other baselines included comparisons between the individual narrative and historical records.

From the point of view of developing criteria that would differentiate lying in PTSD with PF from malingering, were there differences in the issues of plausibility and credibility that would separate the malingerer from the 2 PF cases? The malingerer’s narrative was marked by implausibility, not only in terms of his report of combat but also in terms of his clinical symptoms. A thoughtful analysis of his trauma revealed that the sequence of events or context of events were unusual, atypical, or not readily explainable. The fact that the diagnosis of the malingerer was based on not just one but several implausible accounts should be noted. Psychological test profiles provided another very useful baseline. In the case of objective data, malingerers, including those who were not used as exemplars, produced invalid protocols.

In contrast, both cases of PF produced valid objective test profiles.

In summary, this study identified 11 cases of malingering in a sample of 144 psychological evaluations for compensation for combat-determined PTSD. The rate of malingering as detected was thus 7.7%. Two cases involving the PF defense were identified. In both PF cases, personal psychodynamics appeared to be operating that resulted in exaggeration. In both cases, the military records provided clear evidence of a potentially traumatic experience. Both PF cases produced valid MMPI profiles, one consistent with PTSD and the other

not. The case of malingering involved a narrative that included several implausible events, events that were unable to withstand a reasoned analysis. The malingerer’s psychometric profile was invalid and suggestive of malingering.

In this preliminary small-sample study, it is not claimed that we have found criteria that will set PF apart from malingering. However, documented trauma, obvious exaggeration, and valid psychometric profiles versus undocumented trauma, implausible narrative, and invalid psychometric profiles (malingerers) would seem to be differences that are well worth pursuing in future research.

References American Psychiatric Association. (1994).

Diagnostic and Statistical Manual of Mental Disorders-TR. Washington, D.C.: American Psychiatric Association.

Bolger, D. (1991). Scenes from an unfinished war: Low intensity conflict in Korea (1966-1969).

Fort Leavenworth, KA: Combat Studies Institute.

Cumings, B. (1990). The origins of the Korean War, Vol. II. Princeton, NJ: University of Princeton.

Deutsch, H. (1922). Uber die pathologisch leuge (Pseudologia Fantastica). International Journal of Psychoanalysis, 8.

Deutsch, H. (1965). Folie a deux (1937). In H. Deutsch, Neuroses and character types. New York, NY: International University.

Deutsch, H. (1965). Motherhood and sexuality (1933). In H. Deutsch, Neuroses and character types. New York, NY: International University.

Deutsch, H. (1965). The imposter: Contribution to the ego psychology of a type of psychopath. In H. Deutsch, Neuroses and character types. New York, NY: International University.

Fenichel, O. (1954). Economics of pseudologia fantastica. In O. Fenichel, Collected papers of Otto Fenichel. New York, NY: W. W. Norton.

Finley, J. (1983). The US military experience in Korea (1871-1982). In the Vanguard of ROK-US Relations APO San Francisco 96301, Command Historian’s Office, Secretary Joint Chiefs of Staff, USFK/EUSA. Gabbard, G. (2000). Anxiety disorders: Psychodynamic aspects. In B. Sadock & V. Sadock (Eds.), Comprehensive textbook of psychiatry, 7th ed., vol. I. Baltimore, MD: Williams & Wilkins, 1465-1475.

Gugler, R. (1970). Combat actions in Korea.

Washington, D.C.: Office of the Chief of Military History, Department of the Army.

Halliday, J., & Cumings, B. (1988). Korea: The

untold story of war. New York, NY: Pantheon Books.

Hartmann, H. (1958). Ego psychology and the problem of adaptation. Guilford, CT: International Universities Press.

Heidrich, A., et al. (1996). Cerebellar arachnoid cyst in a fire setter: The weight of organic lesions in arson. Journal of Psychiatry and Neuroscience, 3:202-206.

Kerns, L. (1986). Falsifications in the psychiatric history: A differential diagnosis. Psychiatry, 49: 13-17.

Kirkbride, W. (1994). North Korea’’s undeclared war, 1953-. Seoul, Korea: Hollym International.

King, B., & Ford, C. (1988). Pseudologia fantastica. American Journal of Psychiatry, 77: 1-6.

Leung, C., Lai, K., Shum, K., & Lee, G. (1995). Pseudologia fantastica and gender identity disturbance in a Chinese male. Australian and New Zealand Journal of Psychiatry: 321-323.

Parsons, O. (1996). Alcohol abuse and alcoholism. In Adams, R., et al. (Eds.), Neuropsychology for clinical practice. Washington, D.C.: American Psychological Association.

Ridgeway, M.B. (1967). The Korean War. Garden City: Doubleday.

Sharrock, R., & Cresswell, M. (1989).

Pseudologia fantastica: A case study of a man charged with murder. Medical Science Law, 29: 323-328.

Shay, J. (1994). Achilles in Vietnam: Chronic Trauma and the Undoing of Character. New York, NY: Simon & Shuster.

Snyder, S. (1986). Pseudologia fantastica in the borderline patient. American Journal of Psychiatry, 143: 1287-1289.

Sparr, L., & Pankratz, L. (1983). Factitious posttraumatic stress disorder. American Journal of Psychiatry, 140: 1016-1019.

Van Atta, R. (1969). Individual dynamics in deceitful student behavior, unpublished paper presented at the Annual Convention of the American College Personnel Association. (Copies of the paper are available from the author upon request.)

Van Atta, R. (1999). A study of the validity of the MMPI post-traumatic stress disorder scale: Implications for Forensic Clinicians. The Forensic Examiner, 8: 20-23.

Weston, W., & Dalby. J. (1991). A case of pseudologia fantastica and antisocial personality disorder. Canadian Journal of Psychiatry, 36: 612614.

Yochelson, S., & Samenow, S. (1976). Criminal personality. New York, NY: Aronson.

Clinical Assistant Professor in the Department of Behavioral Medicine and Psychiatry of the West Virginia University School of Medicine.

Dr. Van Atta graduated as a distinguished military student in the U.S. Army ROTC program at Ohio State University in 1955. Upon graduation, he served as a Field Artillery Officer in the U.S. Army. His military duties took him to Korea from 1955 to 1957, where he completed a substantial number of surveillance missions along the DMZ. As an Army officer, Dr. Van Atta made his first forays into forensic work, serving as special investigating officer in felony crimes and as trial and defense counsel in Summary Courts Martial. He completed doctoral studies at Ohio State University in 1964. After completing his graduate program, he served as psychologist-professor at the University of Texas (Austin) and at Southern Illinois University-Carbondale before becoming Director and Professor at the University of Wisconsin-Milwaukee, where he established the Department of Psychological Services. In 1978, Dr. Van Atta established a full-time private practice serving on the Panels of Forensic Experts in Wisconsin and appearing on occasion in the Criminal Courts of Cook County Illinois. In 1987, he was honored by the American Society of Clinical Hypnosis for his work on psychophysiological monitoring in hypnotherapy.

Dr. Van Atta is a Diplomate of the American Board Psychological Specialities and a Fellow in the American College of Forensic Examiners International. He has been a member since 1996.

About the Author Ralph E. Van Atta, PhD, is a Clinical Psychologist/Lead Psychologist at the Louis A. Johnson Medical Center Department of Veterans Affairs in Clarksburg, West Virginia. He is also a

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Spring 2005 THE FORENSIC EXAMINER 25

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By Terri Compton, RN, MSW, and Mike Meacham, PhD, LCSW, DABFSW

Key Words:

gangs, prisons, interventions, corrections

ABSTRACT The number of gangs and gang members is increasing just as rapidly in prisons as on the streets. This article provides an overview of the literature, gives basic statistics on incidence, describes the process an inmate generally follows to become a prison gang member, and reviews selected interventions that have been attempted.

We conclude that interventions need to be flexible enough for use under the unique circumstances of each prison and designed with specified and measurable goals so that progress may be effectively measured. We also suggest that communication among prison systems on such programs is important to the development of effective interventions that may be adapted to individual circumstances.

26 THE FORENSIC EXAMINER Spring 2005

lthough gangs have been a problem in many societies throughout history, a new wave of gang activity became a central societal focus in the United States during the 1980s. Gangs have risen to a level of power beyond the control of local or even state authorities, and many experts believe that the problem has international connections.

During the 1920s and 1930s it was discovered that prisons were breeding grounds for gangs, such as those headed

by Dillinger, Floyd, Barrow. Today gangs flourish behind prison walls and grow stronger both in prisons and in the community. The purpose of this article is to give a summary of prison gangs and to suggest interventions that may be helpful. To begin, researchers outside the prison system should be warned: the difficulties in any particular prison are much more complex and dangerous than many outsiders realize. It is necessary to include officials within each particular institution when developing strategies to control gang activity. Furthermore, research focusing on the progress of interventions is necessary for the continued effectiveness of such a program.

The Problem The word “gang” has many meanings and should be defined. To do so, the criteria for a group must first be examined.

Longres (1995) defined a group as a system in which two or more individuals interact and influence one another. These interactions can take place through direct face-to-face contact or through indirect contact transmitted by gang representatives. Longres explained that groups, as systems, are collections of unique individuals who are all interdependent, who must interact with their environment, and who cannot exist without their environment. Each group has an internal structure, with members who define those in the group as “us” and those outside the group as “them.” He further

explained that “every system is a holon; it is a whole – a unit unto itself – and a part of a whole, both at the same time” (Longres, 1995, p. 46). Each group has physical, psychological, and social boundaries that give the group further definition.

Prison gangs meet group criteria and have many common features. Fong et al.

(1996) described several common elements that define a gang: racial and ethnic boundaries, pre-prison gang experience among members, life-long membership, and structured leadership. Gang members often see themselves as political prisoners and therefore may seek to legitimize their actions as political violence against a perceived enemy.

What causes prison gangs to arise? One reason is clear. Within prisons, survival becomes a dominant motivation. Citing other sources, Buentello, Fong, and Vogel (1991) asserted that when prison officials were restrained in their control of inmates, coupled with a lack of support for reforms, the prisoners found themselves in more danger from fellow inmates than before and began to organize self-defense groups.

Another reason for the growth of these gangs is their secretive nature. Many gangs exist undiscovered until a crisis occurs (Fong & Buentello, 1991).

Reforms intended to protect prisoner rights have inadvertently resulted in inhibiting the discovery and control of prison gangs. These reforms were necessary because prior rulings (i.e., Ruffin v. Commonwealth, 1871; Price v. Johnson, 1948) resulted in allowing unfettered treatment of prisoners by officials, which many officials abused. The ruling, which allowed excessive punishment by prison officials, endangered prisoners at the discretion of

individual correctional employees.

Some of these reforms began in the Monroe v. Pape (1961) ruling. In this case, it was ruled that inmates could seek redress for violations of their constitutional rights by prison officials. This decision was expanded in 1964 in the Cooper v. Pate ruling. While these decisions improved many aspects of prison life, they unintentionally undermined prison officials’ authority, which had once served to suppress violence. In many respects, the system became even more dangerous for prisoners as a result (Fong & Vogel, 1995). An example of this process may be found in Ruiz v.

Estelle (1980). This case was brought to court because Texas Department of Corrections officials had been controlling illegal activities through a system known as the “building tender system.” In this system,

Spring 2005 THE FORENSIC EXAMINER 27

trusted prisoners were used to monitor the activities of other inmates, providing intelligence to prison officials on potential or growing problems. Ruiz v. Estelle eliminated this system; as a result, the intelligence provided from this source was lost and prison violence increased.

Even necessary changes meant to equalize prisoner treatment and allow better access to legal and personal contact strengthened gangs and led to increases in prison violence. For example, the elimination of racial segregation, a ruling needed to equalize treatment and conditions for all prisoners (Lee v. Washington, 1968), increased interracial violence.

Intelligence was further inhibited by rulings on mail censorship (Procunier v.

Martinez, 1974). Again, while limiting the arbitrary treatment of prisoners expanded prisoner rights and resulted in better protection from systemic exploitation and cruelty, the unanticipated consequence was that prisons became more dangerous to both prisoners and correctional personnel.

Well-intentioned and necessary court rulings do not completely explain the growth of gangs. At least part of the growth can be attributed to the fact that gangs are well connected to the world outside the prison. Gang members are sent to prisons, where the gangs already exist. This connection supports and protects gang members while they are in prison, and it assists in supporting gang members’ families and associates outside the wall. Cummins (1995) suggested that gangs support members’ families monetarily, that outside gang capital is used to provide new starts in businesses (frequently legitimate), and that frequent contact is maintained. Some state prison systems deny regular access to educational classes for those involved in gangs, so the gangs often provide this education themselves. Inside, gang training assists members in literacy, personal hygiene, enunciation, and other activities. Not all of this training is positive; gang members are also trained in the use of weapons and guerrilla warfare.

What is the extent of this problem? Most data is pro-

vided by individual states. Danitz (1998) cites the following statistics: In Illinois approximately 60% of the prison population belongs to a gang. About 240 street gangs operate in the Florida system. Texas has identified 5,000 gang members and suspects that another 10,000 out of a population of 143,000 are members of gangs. Many older gang members residing in prisons remain powerful leaders in their street gangs. In fact, it is a status symbol among most gang members to have done time in prison. Within the prison, a gang member finds protection and the support cited earlier. For these and numerous other reasons, prison gang membership is increasing.

Not all prison gangs are an extension of gang activity on the street. Buentello, Fong, and Vogel (1991) described some gangs as self-protective and not participating in illegal activities. Other gangs are predatory in nature and resort to contract murder, black marketeering, prostitution, and extortion within the walls. According to Leet, Rush, and Smith (1997), gang members can do anything in prison that they can do on the street. Imprisonment does not pose an excessive undue hardship for many gang members. They can easily get the goods and services they need on the inside.

Fong et al. (1996) described a survey conducted by the American Correctional Association (ACA) of 125 correctional facilities, including prison systems in all 50 states, the Federal Bureau of Prisons (FBOP), and the District of Columbia.

This study revealed that prison gangs existed in 40 prison systems; 1,153 different gangs were identified. The study revealed that Illinois, New Jersey, and California had the largest population of prison gang members. Nearly half of the prisoners in Illinois were affiliated with prison gangs.

It is important to note that many of these statistics are becoming outdated.

Newer data is necessary for more exact knowledge of incidence.

28 THE FORENSIC EXAMINER Spring 2005

Major Prison Gangs and Gang Prevalence Prison gangs continue to be a powerful and destructive force in correctional facilities. The 1993 ACA study revealed that prison gangs were responsible for 20% of the violence toward staff and 40% of the violence directed at other inmates (Fong et al., 1996). Danitz (1998) wrote that over a third of the 143,000 inmates in the Texas prison system are identified gang members, with another 10,000 suspected of being gang members.

Trout (1992) identified five major gangs in the federal prison system: the Aryan Brotherhood, the Mexican Mafia, the Texas Syndicate, the La Nuestra Familia, and the Black Guerrilla Family.

The Aryan Brotherhood originated in California for self-defense and to promote white supremacy. The Aryan Brotherhood has a small membership, but as Trout (1992, p. 620) wrote, “the Aryan Brotherhood has clearly been the most violent prison gang. Its members have been involved in 18% of all homicides in FBOP facilities in the past 10 years.” The Aryan Brotherhood has formed a strong alliance with the Mexican Mafia for protection and control of the prison narcotic business (Leet et al., 1997).

The Mexican Mafia began in the barrios of East Los Angeles; it was developed by street gang members within prisons in the area. Leet et al. (1997) documented that once in prison, the Mexican Mafia prey on African American and Caucasian inmates. Mexican Mafia membership has spread throughout the California prison system, and according to Trout (1992) it is the most active gang in the FBOP. Members of the gang, which has been at war with other Hispanic gangs, can be identified by tattoos of an eagle and a serpent with the letters EME superimposed.

The Black Guerrilla Family is a terrorist group that was organized in San Quentin in the 1960s. Leet et al. (1997) wrote that the Black Guerrilla Family is the smallest—yet strongest and most revolutionary—of the major gangs. They adhere to a Marxist revolutionary movement outside the prison. Black Guerrilla

Family members usually have the insignia of a crossed rifle and sword tattooed on their upper bodies.

La Nuestra Familia was established to protect rural Mexican American prisoners from the Mexican Mafia. According to Leet et al. (1997), the gang also now accepts a few Native Americans and some Caucasians. Rank is achieved according to the number of murders committed, and members consider the gang’s leader as a general with absolute power. La Nuestra members usually have large tattoos of a sombrero superimposed over a bloody dagger (Trout, 1992).

Hispanic Americans from Texas started the Texas Syndicate. It is the oldest and second-largest gang in Texas. It is organized along para-military lines, but their leaders are elected from the entire membership (Fong et al., 1990). These gang members are fiercely loyal and will act in swift retaliation with little regard for their own safety (Leet et al., 1997).

They actively recruit members and now accept Latinos from all Latin-American countries. Their tattoo includes a highly styled “S” superimposed over a “T” (Trout, 1992).

Becoming a Prison Gang Member Buentello et al. (1991) developed a theoretical model of prison gang development. It describes a five-stage process of attitude and behavior change that inmates undergo when they first enter the prison system. In the first stage the prisoner quickly learns how to anticipate and react to violence, how to play by prison rules, and how to relate to administrations, officers, and inmates. In the second stage, the inmate becomes part of a clique. These relationships are based on the need to belong and to survive. Criminal activity is rarely promoted during this stage.

When the cliques become large enough or begin to feel threatened by other groups, prisoners evolve into the third stage, which is the formation of self-protection groups. As the members of the clique develop confidence, leaders devel-

op and begin to exert control over the other group members and over group activities. A good example of this process is the formation of the Texas Syndicate in the California prison system. In this situation, a group of Texas-born inmates banded together when other California inmates threatened them.

The group may then evolve to the fourth stage, the predator group. During this stage, group members are expected to have similar viewpoints and weak members are excluded. Predator groups are willing to participate in illegal activities such as extortion, gambling, prostitution, and violence. The leaders of the group develop the means and power to profit from illegal activities.

Stage five develops as the predator groups become stronger and more feared.

Buentello et al. (1991) described the fifth stage as gang formation. Formal rules and a hierarchy of leadership are developed.

Members are expected to follow all the rules, which include involvement in contract murder, extortion, gambling, drug trafficking, and prostitution. Leadership is often developed along para-military lines. Each member knows his place in the gang and is considered to be a member for life.

Reaction by Officials Most efforts to deal with gang activity have been reactive rather than proactive.

Fong and Buentello (1991, p. 69) wrote that until recently, correctional officials have categorically ignored or minimized the emergence of prison gangs. Their hope was that by refusing to acknowledge their existence, prison gangs would eventually disappear. This, of course, has proven not to be the case. On the contrary, prison gangs have grown to cause a major correctional crisis in America. Still, many correctional officials take a reactive approach to the problem because of their lack of knowledge about prison gangs.

Most gang interventions have focused on street gangs, with little attention given to those in prisons. Correction officials have tried several methods to control the gang population. Fong et al. (1996)

described a programmatic control strategy for controlling prison gangs. It involves the segregation of gang members in a unit separated from the general population and the imposing of disciplinary sanctions, such as isolation, for prison rule violations. This strategy also includes in-state and out-of-state transfers for gang members, security upgrades, and mail and telephone monitoring. Other control strategies include criminal prosecution, protective custody for defected members, and denial of contact visits and furlough privileges.

The Texas Department of Criminal Justice Institutional Division (TDCJ-ID) has instituted several new strategies.

Buentello (1992) wrote of the interventions taken by the TDCJ-ID. These interventions included the development of new in-service and pre-service training and an increase in the number of staff members; additional facilities were also built, and known gang members were placed in administrative segregation. This move helped reduce the tension among general population prisoners and made it more difficult for gang members to recruit and carry out illegal activities.

Buentello (1992) elaborated on another strategy that the TDCJ-ID has found useful. It involves the appointment of a special prosecutor who aggressively addresses in-house violence. The Texas legislature has passed 2 new laws that make it a felony for an inmate to possess a weapon, and if an inmate is convicted of a felony while incarcerated, he or she must serve this sentence consecutively. As a result, gang members have begun to defect and become witnesses for the state.

This creates distrust among gang members and eventually erodes some gangs’ effectiveness.

Another strategy that Buentello (1992, p. 60) described is the designation of gang intelligence officers. These officers help identify gang members in the general population and gather information for the special prosecutor. As a result, more gang members begin to provide information about pending violence to avoid being the subject of further prosecution.

Spring 2005 THE FORENSIC EXAMINER 29

One key management plan is for prison officials to establish communication with outside state and federal law enforcement. This allows the authorities to monitor and disrupt gang activity in the community. Many gang members have been prosecuted at the federal level and have not been sent to state prisons. Buentello explains, “It was a combination of several strategies working together that allowed the department to take the initiative in battling gangs and gang violence.”

These are only some of the strategies being developed. Many more are being tried or considered. Communication and reports on the progress of these programs should prove very useful in the future.

Conclusion In summary, while gangs have always existed in prisons, the modern prison gang is larger, better organized, and receives much more assistance from outside gang members than those of previous times. It appears that the initial reaction—that the problem would pass with time—was one of fruitless hope. Instead, this attitude results in a “free time” during which gangs grow, organize, and arm themselves with capital and weapons.

Often, a crisis level must be achieved or an actual crisis must occur before officials will take any concerted action.

Several interventions have been attempted with some success. It is necessary to communicate these programs to other prison systems and to measure their effectiveness. More research is also needed because of the complexity of the problem. While this article describes the major prison gangs, many more exist.

Some of these are found in particular prisons; some exist solely for survival, while others emerge as a power that exploits fellow inmates and threatens control of the prison.

There are two unique elements in relating to any prison gang. First, there is the unique situation that affects the response of the officials of the particular prison involved. Because of this, intervention must focus on the unique aspects of this system. The hierarchy, budget,

number of employees, and structure of the prison, including its physical structure, are issues that may need to be addressed. Second, there are the unique aspects of each gang and how it affects the general population within a particular prison. Are these gangs formed only for self-defense? Have they moved into illegal marketing or other activities within the prison? How big of a threat are the members of these gangs to the rest of the population? Do these gangs have contacts on the outside? These are some of the issues to be addressed.

Finally, we suggest that any program be operationalized with clearly defined and measurable goals for each aspect of a selected intervention. Some aspects may prove fruitful and be expanded while others may be discarded. The relationship among the aspects of an intervention may also be researched.

Hopefully, by building on the strategies described above as well as other available tactics and combining those with a thorough analysis of progress, effective interventions may be made available for every prison. It is important to communicate the results of these initiatives to other prison systems to enhance progress on a national program that may be adjusted to individual circumstances.

References Buentello, S. (1992). Combating gangs in Texas. Corrections Today, 54: 58-60.

Buentelo, S., Fong, R.S., & Vogel, R.E. (1991). Prison gang development: A theoretical model. The Prison Journal, LXXI: 3-14.

Danitz, T. (1998). The gangs behind bars.

Insight on the News, 54: 34-end.

Cooper v. Pape, 378 U.S. 546 (1964).

Cumins, E. (1995). California Prison Gang Project. Final Project.

Fong, R.S. (1990). The organizational structure of prison gangs: A Texas case study. Federal Probation, 55: 36-43.

Fong, R.S., & Buentello, S. (1991). The detection of prison gang development: An empirical assessment. Federal Probation, 55: 66-69.

Fong, R.S., & Vogel, R.E. (1995). A comparative analysis of prison gang members, security threat group inmates, and general population prisoners in the Texas Department of Corrections. The Journal of Gang Research, 2: 1-12.

Fong, R.S., Vogel, R.E., & Buentello, S.

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(1996). Prison gang dynamics: A research update.

In J.M. Miller & J.P. Rush (eds.), Gangs: A criminal justice approach, pp.105-128. Cincinnati, OH: Andersen Publishing Co. Lee v. Washington, 390 U.S. 333 (1968).

Leet, D.A., Rush, G.E., & Smith, A.M. (1997). Gangs graffiti and violence. Incline Village, NV: Copperhouse Publishing Company.

Longres, J.F. (1995). Human behavior in the social environment. Itasca, IL: F.E. Peacock Publishers, Inc. Monroe v. Pape, 365 U.S. 167 (1961).

Price v. Johnson, 334 U.S. 266 (1948).

Procunier v. Martinez, 416 U.S. 396 (1974).

Ruffin v. Commonwealth, 62 Va. 21 Grat, (1871).

Ruiz v. Estelle, 601, U.S. Court of Appeals for Fifth Circuit (1980).

Ruiz v. Estelle, 503 F. Supp. 1265. United States Court for the Southern District of Texas, Houston Division, (1980).

Trout, C.H. (1992). Taking a look at an old problem. Corrections Today, 54: 62-66.

About the Authors Teri Compton, RN, MSW, is a registered nurse who obtained her master’s of social work in 2000. Compton’s practicum for her degree was in a state prison, where she counseled inmates in group and individual treatment. During her practicum, Compton became interested in prison violence, which led her to conduct research for this article with her coauthor Dr. Mike Meacham.

Mike Meacham, PhD, LCSW, DABFSW, is an associate professor of social work with 6 years experience as a prison therapist. He was the field liaison for Teri Compton’s practicum and continues to supervise students and social workers seeking licensing about corrections and other therapeutic issues. He has developed a graduate course in forensics for social workers that is currently awaiting administrative approval. Dr. Meacham is a Diplomate of the American Board of Forensic Social Workers and has been a member of the American College of Forensic Examiners since 2000.

Earn CE Credit To earn CE credit, complete the exam for this article on page 64 or complete the exam online at www.acfei.com (select “Online CE”).

By Alen J. Salerian, MD, DABFM, and Gregory H. Salerian, BS

Abstract This article reviews Franklin Delano Roosevelt’s (FDR’s) medical problems during the crucial days of World War II. Based on this review, it appears that FDR was unfit for the presidency during his fourth term. FDR’s physicians failed to communicate honestly with the public, which impacted the lives of millions of people around the world.

The mental health of a U.S. president should be a priority due to the president’s potentially catastrophic power. There are new remedies to deal with this issue today. All U.S. presidents should have annual exams to evaluate their mental fitness. These exams

should be focused on executive function, mood, thought content, and reality-based logical thinking.

When completed, they could lead to substantial public benefit.

To assure objectivity, the panel of physicians completing the evaluation should be independent and not in any way affiliated with the U.S. government.

All healthcare professionals must not only respect the privacy of the president, but also consider the welfare of their fellow citizens. The president’s annual mental evaluation results should be shared with the public.

Spring 2005 THE FORENSIC EXAMINER 31

This article is approved by the following for continuing education credit: ACFEI provides this continuing education credit for Diplomates.

ACFEI is approved by the American Psychological Association to offer continuing professional education for psychologists. ACFEI maintains responsibility for the program.

ACFEI is an approved provider of the California Board of Behavioral Sciences, approval PCE 1896.

Key Words: Franklin Delano Roosevelt (FDR), presidential health, mental health, presidents, congestive heart failure, Pulsus alternans, Yalta, 25th Amendment, neuropsychiatric, Soviet, Stalin, executive dysfunction Introduction The U.S. president’s extraordinary power, sometimes daring and brilliant while other times devastating or potentially catastrophic, makes his mental health a global priority. Yet, the current mechanism to deal with presidential disability is flawed. Regular, highly publicized medical examinations are neither objective nor complete because they are conducted by the president’s subordinates, and they do not evaluate the president’s mental health (Salerian, 2002; Ferrell, 1992; Crispell, 1988; Evans, 1992).

The 25th Amendment to the Constitution specifically deals with presidential disability. Although helpful, the 25th Amendment does not address emotional disability, how and when to conduct a psychiatric examination, or how to select a panel of experts (Crispell, 1988; Evans, 1992).

History can help us develop an effective mechanism to deal with presidential incapacitation. This article examines what we can learn from the extraordinary experiences of FDR, Winston Churchill, and three physicians: Lord Moran, Sur-

geon General McIntire, and Commander Bruenn. It analyzes several important questions that have emerged since the death of FDR on April 12, 1945.

• Was FDR mentally fit to be the president of the United States during his fourth term?

• Did FDR’s physicians lie about FDR’s health and mental fitness before his fourth election?

• Did FDR’s feeble health during his fourth term as president, coinciding with the most crucial days of World War II and preceding the surrender of the German army on May 7, 1945, and the atomic bombings of Hiroshima and Nagasaki on August 6 and 9, 1945, impact world history?

• What has changed since FDR’s death, and what steps are necessary to prevent adverse consequences of a potential presidential incapacitation?

FDR’s Physical and Mental Health During His Fourth Term There is a wealth of evidence that FDR’s physical and mental condition during his fourth term was less than optimal.

Medical records, personal observations, and firsthand accounts all illustrate the deteriorating physical and mental capacities of the president during his last years in office.

FDR’s Physical Condition During His Fourth Term Published medical documents reveal that during his fourth presidential term, FDR suffered from hypertension (see Table 1) and congestive heart failure (Bruenn, 1970), conditions commonly associated with hypoxia and cognitive impairment.

His death was attributed to a massive brain hemorrhage, a likely complication of his chronic cardiovascular disease (Bruenn, 1970).

FDR suffered from poorly controlled hypertension dating back to 1937 (Bruenn, 1970). The diagnosis of congestive heart failure secondary to hypertension was made upon the comprehensive medical exam of FDR on March 27, 1944, at Bethesda Naval Hospital (Flem-

32 THE FORENSIC EXAMINER Spring 2005

ing, 2001). Throughout the last 12 months of his presidency, the medical records revealed the presence of exerciseinduced dyspnea, nocturnal cough, and fatigue. Physical examinations revealed generalized edema and an enlarged heart, confirmed by x-rays and a clinical exam, and evidence of poorly controlled hypertension, with repeated measurements of blood pressure ranging as high as 260/150 mmHg to 240/130 mmHg, and 230/120 mmHg (Bruenn, 1970).

FDR died on April 12, 1945. Earlier that day he had complained of a headache then suddenly lost consciousness. According to the death certificate signed by Dr. Howard G. Bruenn, the cause of FDR’s death was brain hemorrhage. An autopsy was not performed (Bruenn, 1970) (see Table 1).

Evidence of Reduced Work Capacity After his comprehensive medical evaluation at Bethesda Naval Hospital in March of 1944, FDR’s physicians limited his work schedule to 4 hours daily. FDR spent 105 days in 1944 and 45 days in 1945 away from the White House recu-

Table 1: History of FDR’s Blood Pressure Date

Blood Pressure

07/30/1935 04/22/1937 11/30/1940 02/27/1941 03/28/1944

136/78 162/98 178/88 188/105 180/104

04/05/1944 04/20/1944 04/28/1944 05/02/1944 06/14/1944 09/11/1944 11/18/1944 11/27/1944 03/29/1945 04/12/1945

218/120 230/126 230/120 240/130 194/96 240/130 210/112 260/150 240/130 300/200

(Source: Bruenn, H. G. Clinical Notes on the Illness and Death of President Franklin D. Roosevelt.)

perating from various medical conditions (Ferrell, 1992; Fleming, 2001).

The Conference at Yalta (an incredibly important historical event discussed later in this article), did not start until the late afternoon and was canceled one day because of FDR’s medical condition (Ferrell, 1992; Bohlen, 1973).

Observations Suggestive of Diminished Mental Capacity Numerous personal observations indicate FDR’s diminished physical and mental capacity during his fourth term (see Table 2).

On August 18, 1944, after having lunch with FDR, Vice President Truman stated, “The President seemed feeble, and when he tried to pour cream into his tea, more went into his saucer than into the cup. He is just going to pieces” (Fleming, 2001).

On December 20, 1944, former vice president Henry Wallace said, “FDR’s mind is not very clear any more” (Fleming, 2001). Charles Bohlen, FDR’s interpreter at Yalta in February of 1945 said, “The President was ill at Yalta” (Bohlen,

1973). That same month, Lord Moran, Churchill’s physician, described FDR as, “looking straight ahead with his mouth open as if he were not taking things in.

To a doctor’s eye, the President appears very ill. I’d give him no more than a few months to live” (Fleming, 2001). In March of 1945, General Lucius Clay said, “I have been talking to a dying man” (Fleming, 2001). In January of 1945, General Murphy, Eisenhower’s chief civilian advisor, stated, “The President is in no condition to offer balanced judgment upon great questions of war” (Fleming, 2001).

Evidence for Possible Impairment of Short-Term Memory Historical evidence suggests that FDR suffered from impaired short-term memory, a deficit that was observed by numerous individuals. For example, on August 24, 1944, when FDR welcomed the president of Iceland, he repeated his welcoming speech twice, unaware of his error (Fleming, 2001). Also, during the same month, Dorothy Thompson, a respected journalist, observed that FDR repeated

the same story at the beginning and the end of their luncheon (Fleming, 2001).

Potential Evidence for Diminished Concentration and Attention Historical records suggest that FDR suffered from diminished concentration and attention, key abilities for a president involved in important discussions and negotiations. An important example of this comes from FDR’s participation in the Yalta Conference.

At Yalta in February 1945, FDR met with Stalin and Churchill at a conference of historical significance. The Crimea Conference (Yalta), which took place from February 4-11, 1945, involved the heads of the governments of the United States, the United Kingdom, and the Union of Soviet Socialist Republics (Dear & Foot, 1995). The discussion at Yalta and the final agreement signed by President Franklin D. Roosevelt, Prime Minister Winston Churchill, and Marshall Joseph Stalin had profound historical consequences, such as the establishment of the United Nations, the rules of voting and procedural matters of the United

Table 2: Observations and public statements of experts, government officers, and foreign diplomats about FDR during the last 18 months of his presidency Who

When and Where Comments and Observations

Dr. Howard Bruenn

March 28,1944

“The President’s condition is God awful. He has congestive heart failure, bronchitis, hypertension, and gallbladder stones” (Bruenn, 1970).

Vice President Harry Truman

Aug. 18, 1944 – Lunch with FDR

“The President seemed feeble and when he tried to pour cream into his tea more went into his saucer than the cup. He is just going to pieces” (Fleming, 2001).

Henry Wallace, former Vice President Dec. 20, 1944

“FDR’s mind is not very clear anymore” (Fleming, 2001).

Charles Bohlen, FDR’s interpreter

Feb. 1945 – Yalta

“The President was ill at Yalta” (Bohlen, 1973).

Prime Minister Winston Churchill

Feb. 1945 – Yalta

“The President had a slender contact with life” (Fleming, 2001; Churchill, 1953).

Lord Moran, Winston Churchill’s physician

Feb. 1945 – Yalta

“Looking straight ahead with his mouth open as if he were not taking things in.

To a doctor’s eye, the President appears very ill. I give him no more than a few months to live” (Moran, 1966).

Harry Hopkins, FDR’s chief advisor Feb. 1945 – Yalta Samuel Rosenman, FDR’s speechwriter

March 1, 1945

“At Yalta, FDR didn’t follow half of what was going on” (Fleming, 2001).

“FDR was wholly irrelevant and some of the things he said almost bordered on ridiculous” (Evans, 2002; Fleming, 2001; Freidel, 1990).

Spring 2005 THE FORENSIC EXAMINER 33

Nations, the terms of surrender and dismemberment of Germany, the terms of German reparation, the creation of a new Poland, and the principles of forming the Polish and other European governments on the premise of democratic elections (Dear & Foot, 1995).

Because of the conference’s political and military significance, the president was expected to review all potentially relevant information to prepare for it.

The evidence shows that FDR was unprepared for the conference and failed to study any of the key documents gathered for his review (Fleming, 2001; Bohlen, 1973). For example, FDR mistakenly thought Japan had forcefully obtained the Kuriles from Russia even though he had been provided with reports stating that Russia obtained the Kuriles through peaceful commercial means (Bohlen, 1973).

In another example of gross failure to pay attention to detail, FDR signed a memorandum authorizing an invitation to Argentina to become a founding member of the United Nations. This was a direct breech of the Yalta agreement, which stated that only those nations that declared war on Germany could be initial members (Bohlen, 1973).

Impairment and Possible Dysfunction in FDR’s Executive Function Executive skills are those mental abilities that govern complex cognitive or behavioral tasks (Coffey et al., 2000). They include drive, the initiation of cognitive activity, sustained motivation to perform tasks, the ability to recognize patterns, the ability to perform sequences, the ability to plan and execute a strategy, the ability to complete a complex cognitive task, and syntheses, which is the ability to appreciate metaphoric meaning and monitor cognitive performance. Of particular importance is an individual’s ability to learn from errors and to self-correct while performing cognitive tasks.

Evidence from several sources suggests that FDR suffered from diminished executive functioning, a deficit that

surely impacted the United States and the world.

Possible Evidence for FDR’s Impaired Drive and Initiative During his fourth term in office, it appears that FDR suffered from lack of drive or initiative, a crucial mental capacity for anyone, but an absolutely essential executive function for a world leader.

For example, FDR’s lack of curiosity in regard to his progressive physical and mental deterioration may have reflected his lack of initiative. Reviewing the reports from Drs. McIntire and Bruenn, who managed FDR’s medical illnesses, it is apparent that FDR was not interested in knowing the nature of his medical problems (Bruenn, 1970; McIntire, 1946). In contrast, when he faced polio and paralysis years earlier, FDR had taken a drastically different approach, tirelessly questioning the experts treating him regarding the nature of his illness, his prognosis, and many minute details of his treatment (Ferrell, 1992). FDR’s lack of curiosity about his illness may reflect his diminished drive and initiative.

Another potential example of FDR’s executive dysfunction and lack of initiative is his total silence on the question of whether to accept Yalta as the location for the meeting with Stalin and Churchill. To FDR’s closest associates, there were logical reasons (such as Stalin’s well-established practice of spying on his associates and adversaries (Fleming, 2001; Persico, 2001), and the fact that their previous meeting was held in Tehran) for him to put political pressure on Stalin to accept a more convenient location for the United States. Yet, FDR failed to register these concerns.

Poor Judgment and Impaired Response Control There are reasons to believe that FDR suffered from poor judgment and impaired response control. Several events from the Yalta conference illustrate this.

For example, at crucial points in the conference FDR rambled on about irrelevant and incoherent recollections of his boy-

34 THE FORENSIC EXAMINER Spring 2005

hood in Germany (Bohlen, 1973). He also made seemingly politically unwise and inappropriate jokes and comments that were inconsistent with his wellproven record of politically and socially mastered communication. Several of FDR’s comments were particularly alarming and suggestive of possible executive dysfunction. For example, FDR asked Stalin to repeat a toast to the execution of 10,000 German prisoners of war (POWs) that the Soviet leader had made in Tehran a year earlier, and he told Stalin that he was thirsty for German blood and would give 6 million American Jews to the Saudi King, Ibn-Saud, as a special gift (Bohlen, 1973). According to history, these statements were inconsistent with his past behavior.

Possible Evidence for Impairment in FDR’s Ability to Learn from Past Events and Process and Synthesize Information Correctly There seems to be a consensus among historians that FDR’s fundamental strategy in dealing with Stalin at Yalta was to charm the Soviet leader and promote a trusting relationship between the two of them in order to persuade Stalin and the Soviets to join the battle against Japan.

The invasion of Japan was crucial for final Japanese surrender to end the war and save American lives (Fleming, 2001; Bohlen, 1973; Persico, 2001). However, this strategy toward Stalin demonstrated obvious flaws in FDR’s logic.

By this time, FDR was well informed of the purges Stalin conducted for his personal political gain, which had exterminated millions of his people and led to the total annihilation of the first parliament (Fleming, 2001; Bohlen, 1973; Persico, 2001). Even without knowing of Stalin’s murderous practices while governing the Soviet Union, surely FDR had a detailed analysis of how Stalin had ordered the Katyn massacre, where 50,000 Polish POWs were murdered (Fleming, 2001; Bohlen, 1973; Dear & Foot, 1995; Persico, 2001). It was extremely unlikely, if not impossible, for FDR to charm and influence a

mass murderer.

There were other reasons to question FDR’s thinking in regard to trying to create a trusting relationship with Stalin in order to accomplish America’s aims. By the time of the conference, Stalin had demonstrated his untrustworthiness by consistently violating the core agreements of the Tehran Agreement signed by the three leaders. According to the Tehran Agreement, all three powers were to cooperate militarily, and the Soviets were to let American fighter jets have access to Russian airfields (Fleming, 2001; Bohlen, 1973; Persico, 2001). Stalin’s pledge of military cooperation was a lie. On a number of occasions he refused to let American strategic bombers take off from the Russian airfields (Fleming, 2001; Bohlen, 1973; Persico, 2001).

Repeated American diplomatic and military protests were to no avail (Fleming, 2001; Bohlen, 1973); the Russians appeared to be indifferent to the projects that were important to the military.

Additionally, in the fall of 1944 the Russians abruptly asked the Americans to vacate the shuttle bombing bases in southwest Russia. Ambassador Harriman and General Deane had been unsuccessful in ensuring Roosevelt’s cooperation in obtaining Siberian bases from which U.S. forces could attack Tokyo (Kuter, 1955).

FDR’s strategy to charm Stalin and his failure to change his strategy despite alarming signs seem to be consistent with his possible executive dysfunction.

Evidence of Impaired Communication Consistent with FDR’s Executive Dysfunction FDR’s March 1, 1945, post-Yalta speech was a portrait of impaired verbal expression, poor grammar and vocabulary, transient disorientation, and poor memory (see Table 3). Dramatically inferior to FDR’s past major speeches, his speech on March 1, 1945, revealed a striking decline in his verbal skills consistent with his impaired executive function (Fleming, 2001; Bohlen, 1973; Freidel, 1990).

Navy Physicians Fail to Disclose FDR’s Health Status FDR’s physicians failed to warn the public and FDR’s family about the true nature of his medical condition and health status. As a result, FDR’s physical and mental decline leading up to his death were unexpected. James Roosevelt, one of FDR’s sons, stated “I never have been reconciled to the fact that father’s physicians did not flatly forbid him to run. None of us was warned that father’s life might be in danger” (Roosevelt, 1959).

Soon after, Dr. Howard Bruenn and a panel of physicians agreed that FDR was suffering from severe hypertension and congestive heart failure, limiting his life expectancy at that time to an average of 18 months (Daley et al., 1943). Despite this, Dr. McIntire, the Navy Surgeon General, repeatedly reassured the public that FDR was okay and that his only problem was a chest cold (McIntire, 1946; Time Magazine, 1944).

The cover-up and misrepresentations about FDR’s health, a disgrace to medicine and politics, were engineered by two Navy physicians: Navy Surgeon General Ross McIntire and Navy Commander Howard Bruenn. Dr. McIntire was consistent in his dishonesty. He repeatedly misrepresentated FDR’s health, wrongly reassuring the world that FDR was in great health before his fourth election and expressing his shock at FDR’s sudden death (McIntire, 1946). In his book several years later, Dr. McIntire once again declared to the world that FDR’s death was unexpected (McIntire, 1946).

Dr. Bruenn’s failure was his silence. His behavior might have been consistent with the behavior of an ordinary physician of his time, as he was under strict orders from Dr. McIntire to remain silent. In addition, Dr. Bruenn realized he faced severe punishments for any public disclosure about FDR’s declining health.

There were several adverse consequences of FDR’s physicians’ failure to inform the public of the serious nature of FDR’s medical disorders: • In November 1944, the voters elect-

ed FDR without the knowledge of his medical condition.

• FDR was not informed of his health condition (Bruenn, 1970; McIntire, 1946); hence, he could not make an informed decision about his political future.

• FDR failed to actively and adequately prepare Vice President Harry Truman for his future presidential duties (Fleming, 2001; Bohlen, 1973; Freidel, 1990).

• At Yalta and afterward, FDR’s executive dysfunction presented a major disadvantage for the United States and Britain (see next section).

FDR’s Executive Dysfunction Is a Major Disadvantage at the Yalta Conference FDR’s failing physical and mental health created a major disadvantage for the United States during the February 1945 Yalta Conference. To start, FDR’s poor decision to have the conference in Yalta, a result of his executive dysfunction, made it easier for Stalin and the People’s Commissariat for Internal Affairs (NKVD) to spy on the American and British delegations, giving them complete access to the top-secret talks that went on between Churchill and Roosevelt (Kern, n.d.). The Soviet espionage was so effective and masterful that Stalin had the opportunity to read the precise translation of all conversations between Churchill and FDR from the evening before (Kern, n.d.). To make matters worse, the decision to hold the conference at Yalta required FDR to make a long journey, a trip that further weakened his already compromised health (Bruenn, 1970).

Because of his poor health and executive dysfunction, FDR failed to study the comprehensive State Department reports (Bohlen, 1973). FDR’s lack of preparation and poor behavior and appearance were observed by the American-British delegation, undermining their confidence in the Commander in Chief (Fleming, 2001; Bohlen, 1973; Weinstein & Vassiliev, 1999).

Spring 2005 THE FORENSIC EXAMINER 35

Table 3: The neuro-psychological evaluation of FDR’s March 1, 1945, speech to Congress after Yalta Symptom

Example: FDR’s speech on March 1, 1945

Correct: A possibly neurologically intact speech by FDR

Slurred speech

Slurred speech

Clear pronunciation of words

Impaired concentration

FDR failed to deliver a clear, articulate speech. On several occasions lost his concentration and had problems following the prepared text.

Clear and organized delivery

Cognitive decline

“Malta”

“Yalta”

“Malta did not concern itself with the Pacific war.”

“At Yalta we made significant progress with the Soviet Union in the pacific war. We reached major agreements involving Japan & China. Soviet Union’s entry to the Pacific War, Soviet Union’s retaking Kurile Islands.”

Japs

Japanese

Prima donnas of this world

Charles DeGaulle

Flawed verbal expression in apparent contrast to previous level of excellence in verbal communication

“If the problems of Arabia I learned were about that whole problem, the [?] problem the Jewish problem by talking with Ibn Saud for five minutes? I could have learned in exchange of two or three dozen letters.”

“My conversation with King Ibn Saud was most helpful. I learned much more about the complexities of the Middle East conflicts from his Excellency that I could have learned from lengthy communications on the same topic.”

Poor vocabulary

“Arabia”

“Middle East”

“That whole problem”

“The religious and ethnic conflicts”

“Ibn Saud”

“King Ibn Saud”

Inappropriate language

Finally, FDR’s executive dysfunction led him to adopt a hopeless strategy at the conference: attempting to charm and appease Stalin. It was senseless to try to charm a mass murderer, and FDR failed to appreciate the fundamental differences between the democratic and totalitarian governments.

At Yalta, only FDR had access to all the crucial information from intelligence, military, and scientific sources to make logical decisions. Not all members of the president’s team had access to all the critical intelligence data from the Office of Secret Service (OSS) or the Manhattan Project (the atomic bomb and ultimate

power that ended the war) (Persico, 2001). In essence, FDR’s executive dysfunction was even more crucial for the final negotiations and outcome at Yalta.

The Impact of FDR’s Compromised Executive Function Upon History It is difficult to measure the impact of FDR’s executive dysfunction upon history. However, we can assume that a neurologically sound, mentally sharp U.S. president would have been much less likely to make the following errors: • During the Yalta Conference, FDR failed to recall that at the Tehran Con-

36 THE FORENSIC EXAMINER Spring 2005

ference in November 1943 he had fought hard and won agreement for the Soviet Union to stay out of Manchuria.

At Yalta, FDR did not offer any opposition to the Soviet takeover of Manchuria (Fleming, 2001; Bohlen, 1973; Freidel, 1990). If this was a strategic move, FDR never explained his reasons to any of his associates.

• FDR failed to realize the Soviet Union had sold the Kuriles to Japan, wrongly assuming that Japan had forcibly taken the Kuriles from the Soviet Union, and agreed to the Soviet occupation of the Kuriles (Fleming, 2001; Bohlen, 1973).

• Because of his executive dysfunction, FDR failed to change his basic strategy of appeasing Stalin, even after Stalin and the Soviets repeatedly violated their pledges. Within weeks of Yalta, where Stalin agreed to free elections in Poland and in most of Eastern Europe, Stalin’s Red Army and the Communist forces forcibly took over the Polish, Romanian, and Bulgarian governments and arranged Russian-style rigged elections (Fleming, 2001; Bohlen, 1973; Freidel, 1990; Weinstein & Vassiliev, 1999). Despite the repeated Soviet violations, FDR continued to provide Stalin and the Soviet Union with massive military aid. Authorized by Congress under the Lend-Lease Act, the American aid during the war totaled $9 billion and included more than 14,000 planes, 400,000 trucks, 1,000,000 telephones, and 4,000,000 pairs of boots (Dear & Foot, 1995; Haynes & Klehr, 2000). Beginning in October 1944 through the secret “Hula” operation, the United States began to supply the Soviet Navy with a flotilla of 30 U.S. frigates, 60 minesweepers, 56 submarine chasers, and 30 large-landing vessels; 15,000 Soviet Naval officers and enlisted men were also trained by the United States (Persico, 2001). Never once, after all the Soviet violations, did FDR cut off or threaten to cut off the massive military aid to the Soviets. It is more than likely that his silence about

the most outrageous Soviet violations contributed to additional Soviet aggressions and was a critical factor in the Communist takeover of the Baltic States and Eastern Europe.

• FDR’s inability to change his basic strategy also led to his rigid stance to not accept the March 1945 surrender of one of Nazi Germany’s key military divisions, which was under the command of General Kesselring. General Eisenhower, Winston Churchill, General Bill Donovan (Chief of OSS) and Allen Dulles (OSS’s Europe Chief ) were all in favor of accepting the surrender (Fleming, 2001; Persico, 2001).

When informed of the secret negotiations between the representatives of the United States and General Kesselring (Operation Sunrise), Stalin protested loudly and angrily, repeatedly questioning FDR’s honesty and integrity.

What FDR did not realize then was that Soviet spies had provided Stalin with the precise communication between General Kesselring and the OSS (Fleming, 2001; Persico, 2001; Haynes & Klehr, 2000). In many ways, this was the perfect crisis to address the issue of integrity and honesty in the FDR-Stalin relationship. FDR’s response was an angry denial mixed with indignation and disappointment.

Before and after Yalta, FDR repeatedly failed to confront the Soviets’ violations of signed agreements (Fleming, 2001; Bohlen, 1973; Persico, 2001).

His failure to confront the Soviets, along with his executive dysfunction, once again invited more aggression and military expansion by the communist forces at the expense of Eastern Europe and the Baltic States.

Discussion Any attempt to study, retrospectively, the health of a world leader in a crucial time in the past naturally faces obstacles of history, political or social bias, and reasonable suspicion of personal or political motives. This study had several major limitations, such as its retrospective

nature, the inclusion of second-hand observations, inclusions of observations by non-medical witnesses, the absence of a comprehensive neurological or psychiatric exam, and the subjective nature of interpreting potential political and military information.

Despite all these obvious limitations, it appears that the collective examination of all the data suggests that FDR’s mental capacity was indeed compromised significantly during his fourth term. Further, there is good reason to believe that FDR’s compromised functioning had a profoundly negative impact on the lives of millions of people around the world.

Sadly, FDR’s physicians deliberately misled the public about FDR’s health. It is difficult to imagine a fourth FDR victory had Dr. McIntire not misrepresentated the reality that FDR was terminally ill before his last election. Indisputably, Dr. McIntire’s and Dr. Bruenn’s loyalty and respect for the privacy of their Commander in Chief is commendable and extraordinary. It is also clear that the realities of that time period, as well as the fact that both doctors were in the Navy and under the command of a national hero at a time of war, created an environment in which it was almost impossible for the doctors to remain objective in the practice of medicine or how they dealt with the media. Yet, any physician who had the privilege to treat the president should have also considered the welfare of the young men who sacrificed their blood and souls in the trenches of faraway lands to serve their country. Did these young men not deserve a Commander in Chief who was not feeble and could thoroughly study important documents before a crucial meeting determining the final outcome of the war? Ethics or no ethics, loyalty or no loyalty, good intentions or bad intentions, the Navy Surgeon General, Dr. McIntire, erred, and his misrepresentations caused immeasurable pain to millions.

What has changed since FDR? The truth remains that a mentally impaired American president may still cause havoc

for the world because the U.S. presidents are not required to have regular psychiatric examinations to evaluate their mental fitness for duty (Salerian, 2002; Ferrell, 1992; Crispell, Kenneth, & Gomez, 1988; Evans, 2002).

Conclusion Before his fourth election, FDR was mentally unfit to be the president of the United States. His ability to lead a nation at war and make sound judgments to defend the interests of the free world was impaired by his chronic hypertension, congestive heart failure, and executive dysfunction.

Before FDR’s fourth election, the Surgeon General lied to the public and falsely reassured the world that FDR was healthy and mentally fit to fulfill the duties of the presidency.

FDR’s impaired mental abilities had a profoundly negative impact on history by prolonging World War II and most likely contributing to the expansion of communist rule over Eastern Europe.

The lessons from FDR’s medical problems and the inadequate methods of dealing with them have offered new opportunities to examine presidential health. All healthcare professionals must respect the welfare of their fellow citizens and seriously consider their ethical responsibilities in balancing the need for the president’s privacy with the potential dangers and adverse consequences for millions of innocent civilians and uniformed men and women.

U.S. presidents, and possibly all government heads, should have yearly exams inclusive of their mental functions.

Although there are enormous challenges involved in establishing such a comprehensive task, hopefully it can be done. At a minimum, the president’s yearly medical exam should evaluate his mental fitness. Several commonly used neurological diagnostic tools to determine cognitive function, such as the Mini-Mental Status examination (Folstein et al., 1975), the Clock-Drawing task (Hadjiistravropoulos, Miller, et al., 1992), the

Spring 2005 THE FORENSIC EXAMINER 37

Montgomery-Asberg Depression Rating Scale (MADRS) (Montgomery & Asberg, 1979), and the Alzheimer’s Disease Assessment Scale (ADAS) (Rosen, Mohs, & Davis, 1984), should be part of the exam. In addition, a direct clinical exam, independently conducted by a qualified panel of forensic psychiatrists, is advisable. Such an examination would evaluate the president’s thought content, judgment, logical thinking, mood, and cognitive ability, but would exclude specific areas such as interpersonal relations, family life, sexual functioning, or psychological issues related the president’s background in order to reduce the potential risk of political exploitation.

Because of their divided loyalties, physicians who work for the president or the government cannot be expected to objectively evaluate and accurately inform the public. Hence, the need for an independent panel of forensic experts to conduct such an examination is obvious.

Hopefully, future presidents will receive better care and hear more honest feedback, and the commander in chief of the United States and his associates will deal with the public honestly.

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Rosen, W. G., Mohs, R. C., & Davis, K. L. (1984). Alzheimer’s disease assessment scale (ADAS): A new rating scale for Alzheimer’s disease. American Journal of Psychiatry, 141, 13561364.

Time Magazine. (1944, October 23). 17.

Tuokko, H., Hadjiistravropoulos, T., Miller, J. A., & Beattie, B. L. (1992, June). The clock test: a sensitive measure to differentiate normal elderly from those with Alzheimer disease. Journal of American Geriatric Soc. 40(6), 579-584.

Weinstein, A., & Vassiliev, A. (1999). The haunted wood: Soviet espionage in America – the Stalin era. New York: Random House.

38 THE FORENSIC EXAMINER Spring 2005

About the Authors Alen J. Salerian, MD, is a psychiatrist and the medical director at Washington Center of Psychiatry in Washington, D.C. He is also a former chief consultant for the F.B.I. and a frequent contributor to national newspapers such as The Washington Post, the Los Angeles Times, and USA Today. Dr. Salerian has authored or co-authored several psychiatric articles in peer-reviewed journals. He has made over 100 appearances on various news shows including CBS's 60 Minutes, 48 Hours, and the BBC's Panorama. He is a regular analyst and commentator on the Washington, D.C., CBS television affiliate WUSA-TV. Dr. Salerian is a Diplomate of the American Board of Forensic Medicine and has been a member of the American College of Forensic Examiners since 1997.

Gregory H. Salerian holds a bachelor’s degree in psychology from the University of Delaware and is currently attaining his master’s degree in clinical social work at the Catholic University of America in Washington, D.C.

From left: Gregory H. Salerian and Dr. Alen J. Salerian

Earn CE Credit To earn CE credit, complete the exam for this article on page 64 or complete the exam online at www.acfei.com (select “Online CE”).

By Nicholas Apostolou, DBA, Cr.FA, DABFA, and D. Larry Crumbley, PhD, CPA, Cr.FA, DABFA This article is approved by the following for continuing education credit: ACFEI provides this continuing education credit for Diplomates.

ACFEI provides this continuing education credit for Certified Forensic Accountants.

Key Words: accounting entries, Sarbanes-Oxley Act, fraud, SAS 99, materiality, walkthroughs, proactive

Abstract Sarbanes-Oxley, SAS 99, and the Public Company Accounting Oversight Board (PCAOB) have not removed pressures on chief financial officers to manipulate accounting statements. PCAOB recommends an auditor perform at least one walkthrough for each major class of transactions. SAS 99 does not require the use of forensic specialists but does recommend brainstorming, increased professional skepticism, and unpredictable audit tests. A proactive fraud approach involves a review of internal controls and the identification of areas most subject to fraud. Certified Forensic Accountants (Cr.FAs) will continue to be in demand to supplement the efforts of internal and external auditors.

Many employees, executives, and investors now realize the stock market’s boom during the 1990s was at least partly stimulated by income smoothing and outright deception. The truth surfaced in October of 2001, when Enron, then the nation’s seventh-largest company, revealed more than $1 billion of accounting errors that stunned investors and launched investigations that continue today.

Since that time, dozens of companies have been prosecuted or investigated for financial fraud. The almost daily revelations of corporate fraud battered the stock market and eroded investors’ confidence in the integrity of our capital markets.

In response, Congress and the regulatory authorities passed legislation and issued regulations intended to raise the standards of corporate accountability, improve the detection and prevention of fraud and abuse, and reassure investors that they have a level playing field.

Persistence of Fraud Although the regulatory environment has definitely stiffened, fraud continues to be pervasive. The Federal Trade Commission reported that its complaint database received over half a million consumer fraud and identity theft complaints in 2003. Consumers reported losses from fraud totaling more than $400 million. Identity theft accounted for 42% of all complaints, up from 40% in 2002. With U.S. gross domestic product totaling in excess of $11 trillion, fraud losses for the economy are estimated to approach $1 trillion.

Disclosures of corporate fraud continue to occur. Royal Dutch/Shell Group was charged with exaggerating its oil and gas reserves, prompting the Securities and Exchange Commission (SEC) to impose a $120 million penalty and requiring a company expenditure of $5 million to improve its internal compliance program.

Executives Are Going to Jail Although Enron was the first of the highly publicized corporate fraud cases in recent years, others quickly followed.

Former Imclone chief executive officer (CEO) Samuel Waksal

Spring 2005 THE FORENSIC EXAMINER 39

pleaded guilty to securities and bank fraud after trying to sell his stock and tipping others before bad news was announced about the firm’s new cancer drug. Adelphia founder and CEO John Rigas and his two sons were charged with defrauding investors of billions of dollars and secretly using company funds to buy condos and make family purchases. Former Tyco chief executive Dennis Kozlowski and Tyco’s former chief financial officer were accused of stealing more than $170 million from Tyco and gaining more than $430 million fraudulently through securities sales. The former Tyco general counsel was charged with falsifying records to hide more than $14 million in loans.

The former controller and three former accounting employees of WorldCom pled guilty to securities fraud.

They were apparently ordered by supervisors to falsify accounting records. The former WorldCom chief financial officer, Scott Sullivan, was charged with orchestrating a scheme to fraudulently cut expenses and inflate profits by more than $11 billion. Merrill Lynch agreed to pay $100 million to settle the New York Attorney General’s charges that stock analysts produced biased recommendations to curry favor with corporate clients. Finally, Rite Aid former chairman and CEO Martin Grass and three other executives of Rite Aid were charged with conspiracy to defraud and making false statements to the SEC. The company restated May 1997-1999 earnings, lowering them by $1.6 billion.

Auditors Highlighted The public interest in corporate corruption and fraud was confirmed by Time magazine’s selection of Cynthia Cooper, Coleen Rowley, and Sherron Watkins as its 2002 Persons of the Year. Cynthia Cooper, former head of the Internal Auditing Department for WorldCom, disclosed a scheme to fraudulently increase profits when she informed its board that the company had covered-up $3.8 billion in losses through the magic of phony bookkeeping. Coleen Rowley is the FBI staff attorney who wrote a memo to FBI Director Robert Mueller describing how the bureau ignored pleas from her Minneapolis, Minnesota, field office that Zacarias Moussaoui, indicted as a co-conspirator in the September 11, 2001, World Trade Center catastrophe, was a man who should be investigated.

Sherron Watkins was the vice president of Enron; she wrote a letter to thenchairman Kenneth Lay in the summer of 2001 warning him that the company’s methods of accounting were improper and characterizing its methods

40 THE FORENSIC EXAMINER Spring 2005

as “an elaborate accounting hoax.”

Corporate Governance The widespread revelations about corporate fraud have renewed governmental and public interest in the topic of corporate governance, particularly because of its importance for the economic health of corporations and society in general.

Corporate governance is the system by which corporations are managed. The corporate governance structure specifies the rights and responsibilities of the different participants in the corporation, such as the board of directors, managers, and shareholders, and spells out the rules and procedures for making decisions on corporate affairs. The admission or investigation of dozens of companies for accounting fraud or other financial misdeeds in recent years resulted in the passage of the Sarbanes-Oxley Act of 2002.

This Act is the most significant legislation affecting corporate governance and securities laws since the passage of the SEC Acts of 1933 and 1934.

Sarbanes-Oxley Act The Sarbanes-Oxley Act set new standards for corporate accountability as well as penalties for corporate wrongdoing. The legislation includes 11 titles ranging from additional responsibilities for audit committees to tougher criminal penalties for white-collar crimes such as securities fraud. Here is a summary of the most important titles: Title I-Public Company Accounting Oversight Board (PCAOB): • Established an independent, nongovernmental board to oversee the audits of public companies to protect the interests of investors and further public confidence in independent audit reports.

• Defines the major responsibilities of the PCAOB. Title III-Corporate Responsibility • Requires audit commit-

The prosecution of many executives who engaged in fraudulent actions, plus the passage of far-reaching legislation improving corporate governance, will hopefully improve the confidence of investors in the integrity of our securities markets as more and more forensic techniques are incorporated into external and internal audits. tees to be independent and undertake specified oversight responsibilities.

• Requires CEOs and CFOs to certify quarterly and annual reports to the SEC, including making representations about the effectiveness of specified controls.

• Requires the SEC to issue rules requiring attorneys in certain roles to report violations of securities laws to the company’s CEO or legal counsel, and if no action is taken, to the company’s audit committee.

Title V-Analyst Conflict of Interest • Requires the SEC to adopt rules to address conflicts of interest that can arise when securities analysts recommend equity securities in research reports and public appearances.

Title VIII-Corporate and Criminal Fraud Accountability • Provides tougher criminal penalties for altering documents, defrauding shareholders, and committing certain other forms of obstruction of justice and securities fraud.

• Protects employees of companies who provide evidence of fraud.

The prosecution of many executives who engaged in fraudulent actions, plus the passage of far-reaching legislation improving corporate governance, will hopefully improve the confidence of investors in the integrity of our securities markets as more and more forensic techniques are incorporated into external and internal audits. Investors should have faith that corporations such as

Enron, WorldCom, and Adelphia are a small minority, and that the vast majority of corporations strive to achieve their goals honestly. If financial statement readers believe that the U.S. economy will grow larger and that corporate earnings will continue to improve, then faith that common stocks should, on average, provide good returns is definitely warranted. Of course, more and more forensic accountants will be needed as internal and external auditors adopt more forensic techniques in their audits.

Public Company Accounting Oversight Board (PCAOB) Although the SEC has had statutory authority to establish accounting principles, for more than 60 years it has looked to the private sector for leadership in establishing and improving accounting standards.

The Sarbanes-Oxley Act changed this relationship with the creation of the PCAOB. The PCAOB is a private sector, non-profit corporation created to oversee the audits of public companies in order to protect the interests of investors and further the public interest in the preparation of informative, fair, and independent audit reports. On April 16, 2003, PCAOB announced plans to begin setting auditing, attestation, quality control, and ethical standards for accounting firms that audit public companies. PCAOB member Daniel Goelzer said that the accounting

firms subject to PCAOB’s oversight should consider the American Institute of Certified Public Accountants (AICPA) and Independence Standards Board (for Professional Auditors) rules to be “written in disappearing ink.”

Prior rules apply for an interim term until they are reviewed and revised by the PCAOB. The once powerful AICPA will become a networking, educational, and social trade association only.

The Sarbanes-Oxley Act created the PCAOB to oversee the audit of public companies that are subject to securities laws. The stated purpose of PCAOB is to protect the interests of investors and further informative, accurate, and independent audit reports. The board is a corporate body operating as a nonprofit corporation under the District of Columbia.

The PCAOB has five full-time members, with two (and only two) members of the board needing to be or have been CPAs. A board member serves for a term of 5 years and can serve no more than two terms. William J. McDonough, former president of the Federal Reserve Bank of New York, was unanimously selected as the first Chairperson of the PCAOB with a $556,000 salary (more than the combined pay of the U.S. President and the head of the SEC). Aside from McDonough, other board members include Daniel L. Goelzer, Kayla J. Gillan, Willis D. Gradison, Jr., and Charles D. Niemeier.

Spring 2005 THE FORENSIC EXAMINER 41

Douglas Carmichael, former professor at Baruch College in New York, was named the chief auditor of the PCAOB. Carmichael said that the AICPA failed to aggressively implement recommendations in the 2000 Public Oversight Board. This report recommended many forensic techniques, calling for more “test of details” instead of relying so heavily on “test of controls.”

According to Carmichael, “auditing firms seem to find ways not to go out to locations and to do less of the type of work that involves actually counting things, observing physical inventory, and doing test counts,” especially when there are multiple locations. Carmichael said that even “when auditors do test transactions, they frequently only sample above a certain dollar amount and are too predictable in their approach” (Frieswick, 2003).

Public accounting firms must register with the PCAOB, and the board is responsible for overhauling auditing standards, inspecting accounting firms, and disciplining bad accountants. The board expects foreign accounting firms to register as required by the SEC. Full inspections of accounting firms began in 2004 on a regular basis, with limited review of the big four auditing firms in 2003. The PCAOB took an active role in the peer review of PricewaterhouseCoopers, which began under the prior peer-review system. The inspections will occur annually for those accounting firms that audit 100 or more public-company clients a year. Firms with fewer clients will be audited every 3 years. The inspection reports will be furnished to the accounting firms, but any potential problems will not be made public if the accounting firm corrects the problems within a year. The PCAOB will issue summary reports highlighting problems and issues discovered without disclosing firm names. The PCAOB can censure, fine, suspend, or bar from prac-

tice registered accounting firms and accountants for violating any provisions of the Sarbanes-Oxely Act. Disciplinary procedures are outlined in Section 105 of the Act. Need for Forensic Accountants The Sarbanes-Oxley Act and the powerful PCAOB will create a huge need for forensic accountants. Forensic accountants may be needed to assist corporations in their quest to ensure compliance with the mandates in Sarbanes-Oxley.

Likewise, public accountants will need to introduce forensic techniques into audits, and they may request help from forensic experts.

Certification of annual and quarterly reports must cover internal controls, disclosure controls, and fraud. There may be a need for a Certified Forensic Officer. The SEC suggests that an entity assign the duties of monitoring internal controls to a specific individual. The SEC also suggests a disclosure committee.

Conclusion The Sarbanes-Oxley Act of 2002 is forcing auditors to view clients’ financial statements skeptically and conduct audits accordingly. Amazingly enough, the word “fraud” was not in any AICPA standard until 1988, and only in 2002 did the AICPA directly state that auditors should not assume that a client’s management is honestly reporting results.

Sarbanes-Oxley places increased pressure on audit firms to detect fraud. Section 404 of Sarbanes-Oxley requires companies to attest to the intended controls they have in place to detect fraud.

Audit firms have indicated that compliance with Section 404 requires the audit firms to spend much more time working with clients to meet this reporting standard.

Demand for forensic accounting spe-

42 THE FORENSIC EXAMINER Spring 2005

cialists will inevitably increase dramatically. PricewaterhouseCoopers is currently implementing a program involving the use of additional procedures performed by fraud specialists at a subset of its audit engagement. Klynveld Peat Marwick Goerdeler has added more than 300 forensic professionals who will take part in some routine audits. These steps are only the beginning of a much greater effort on the part of the accounting profession to reduce the cost of corporate fraud.

About the Authors Nicholas G. Apostolou, DBA, CPA, Cr.FA, is a Diplomate of the American Board of Forensic Accounting and a U.J. LeGrange Professor at Louisiana State University. He is the co-author of a book soon to be published by Barron’s Educational Series Inc., titled Keys to Investing in Common Stocks.

D. Larry Crumbley, PhD, CPA, Cr.FA, is a Diplomate and Executive Advisory Board Member of the American Board of Forensic Accounting. He is a KPMG Endowed Professor at Louisiana State University and is the co-author of Forensic and Investigative Accounting, published by Commerce Clearing House.

Earn CE Credit To earn CE credit, complete the exam for this article on page 65 or complete the exam online at www.acfei.com (select “Online CE”).

Forensic Accountants: Build your credibility, knowledge, skills, prestige, and respect! Advance your career and distinguish yourself from your peers! Earn the prestigious Certified Forensic Accountant, Cr.FA credential*!

Take the Certified Forensic Accountant, Cr.FA, course at ACFEI’s National Conference • September 30-October 1, 2005, at the U.S. Grant Hotel in San Diego, California • The Cr.FA Course is a four-part curriculum program that prepares you for the Cr.FA exam. Part one of the course surveys the general concepts of judicial procedures and evidence applicable to Forensic Accounting, comparing civil procedures to criminal and administrative proceedings and covering alternative dispute resolution, professional responsibility and ethics, admissibility of expert opinions, and potential liability for the forensic accountant. Part two reviews the role of the forensic accountant in

litigation, including consulting engagements, testifying engagements, engagement retention, and types of engagements frequently encountered

by Forensic Accountants. Part three reviews the legal elements of fraud and fraud investigations. Part four of the course reviews the Forensic Accountant’s role in the analysis of damages in litigation, including estimating economic losses in damage calculations and calculating typical damages and damages in special circumstances.

The Cr.FA course teaches accountants to do the following: • Testify as expert witnesses • Write expert reports • Conduct fraud investigations • Assist in civil and criminal investigations • Conduct business valuations • Work with attorneys • Perform legal procedures to build a case *The Cr.FA designation is available only for accountants meeting all of their State Board of Accountancy requirements.

Reserve your spot in this certification course! Call toll free (800) 423-9737, visit www.acfei.com (click “conferences”), or e-mail marianne@acfei.com.

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Conference schedule is subject to change.

Spring 2005 THE FORENSIC EXAMINER 43

This article is approved by the following for continuing education credit:

By Stuart L. Segelnick, DDS, MSFE, and Leonard Goldstein, DDS, PhD

ACFEI provides this continuing education credit for Diplomates.

Key Words: palatal rugae, odontology, dental identification, forensic

ACFEI is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of ACFEI are accepted by AGD for Fellowship/Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry. The current term of approval extends from 11/1/97 to 12/31/06.

Abstract Palatal rugae pattern analysis has been employed successfully in positive human identification. However, reports of the validity of the technique are conflicting. This report explores the viability of the use of palatal rugae in forensic dental identification and discusses the pros and cons of the subject. The level of evidence for the application of palatal rugae in dental identification was found to be insufficient. A well-designed research protocol must be developed to determine if there is a statistical significance in utilizing digital photographs of palatal rugae for forensic dental identification purposes.

44 THE FORENSIC EXAMINER Spring 2005

One of the main focuses of the forensic odontologist (dentist) is human identification. Dental identification can be used as the sole method of identifying a deceased person. Dental identification is based on the comparison of antemortem and postmortem records. The records collected to identify a decedent should be accurate and totally inclusive of objective findings.

Not only should the teeth be assessed, but the findings should come from examining, both clinically and radiographically, the oral cavity and all its structures. Other better-known methods such as DNA analysis and fingerprints are also used alone as means of identification. Some researchers have gone as far as to say: “It is a well established fact that a ruga(e) (an anatomical fold or wrinkle) pattern is as unique to a human as his fingerprints.”1 In the dental identification section of the Manual of Forensic Odontology, an example of a dental identification report states: “Although distorted by the trauma, the rugae pattern of Mr.… was found to match that of John Doe ‘C’.”2 The comparison of the rugae patterns was then graphically shown. The purpose of this article will be to review the literature to determine if there is enough evidence to establish the use of palatal rugae in dental identification.

The palatal rugae are located on the anterior portion of the maxilla (upper jaw) (Figure 1). Anatomically, the rugae consist of around 3 to 7 rigid and oblique ridges that radiate out tangentially from the incisive papilla (a rise in the palatal gingiva immediately anterior to the underlying incisive foramen).3 Histologically, the rugae are stratified squamous (layered scales), mainly parakeratinized epithelium on a connective tissue base, similar to the adjacent tissue of the palate. Embryologically, Thomas4 reported differences in the rugae cores from human embryos of over 20 weeks.

He found the reticulin fiber content to

be very delicate and the fibroblasts to be different in amount and size from the adjacent palatal tissue. Coslet et al.5 reported the clinical removal of palatal rugae is not permanent and that when removed, the rugae returned several months later.

In a case study, Breault et al.6 reported on a single case of a 22-year-old white male. A free gingival graft was placed on the edentulous (toothless) buccal gingiva corresponding to tooth #23. The graft was harvested from the palate and included the palatal rugae. After 2 months, the recipient site displayed prominent ridges and a gingivoplasty was performed. After 9 years, the subject returned for treatment and the palatal rugae had reformed in the graft area.

This study shows that the rugae can be transplanted to different parts of the body. If transferred to other areas of the anterior palate, rugae can easily be confused in identification.

In a case report, Thomas and Van Wyck1 describe the identification of a badly burned body that was found with a set of dentures nearby. These dentures were compared to a set of dentures found in the suspected victim’s house.

Plaster casts of both maxillary dentures were made and the rugae and midpalatal raphe (the seam-like union of the two

lateral halves of the roof of the mouth) were traced on acetate paper and superimposed on photographs of the other models. The lateral and frontal tracings matched well enough to be beyond doubt. Thus, from a subjective view, the author was able to report to the police a match beyond reasonable doubt.

Jacob and Shalla7 designed a study in which they collected data from 14 subjects using dental stone casts. The casts were fabricated from the internal aspect of an existing maxillary denture, the maxillary edentulous arch of the subject (representing a model from the deceased’s dentist), and the internal aspect of a newly constructed maxillary denture.

These casts were then evaluated in 28 trials. The first 14 trials had a single examiner matching 8 casts from the new dentures against 7 randomly chosen existing denture casts. The second 14 trials had a single examiner matching 8 new denture casts to casts of existing dentures and alginate impressions in 2 trials, existing denture casts in 7 trials, and alginate impressions in only 2 trials. The examiner was blinded to the data collection and study design and evaluated each trial of 8 casts based on certain specified matching or nonmatching criteria. The examiner also rated his final decision as equivocal or unequivocal, which was purely subjective. When only rugae were used as the criteria for identification, 79% accuracy with equivocation was demonstrated.

Figure 1: Palatal Rugae

Spring 2005 THE FORENSIC EXAMINER 45

“Dental

identification can be used as the sole method of identifying a deceased person. Dental identification is based on the comparison of antemortem and postmortem records .... Not only should the teeth be assessed, but the findings should come from examining, both clinically and radiographically, the oral cavity and all its structures.�

The authors of the study decided the low level of identification was caused by rugae obliteration in the fabrication of the dentures. This could have occurred during denture adjustment or palatal relief chambers. Also, rugae variation from trauma and disease could explain the missing rugae. Therefore, palatal rugae tracings, derived from dentures, do not give the desired accuracy needed for a forensic dental identification.

In a case report, Gitto et al.8 gives step-by-step instructions on how to add palatal rugae to a complete denture. The added rugae improve speech patterns by incorporating texture into the anterior denture region. Certain patients require a tactile sense to cue or orient their tongue. The addition of rugae to an existing denture takes about 30 minutes. In forensic identification, each human is considered unique, and stable points of singularity are treasured. The forensic dentist should be aware that forgery of rugae patterns could easily be accomplished.

A concern about palatal rugae voiced by many researchers is the possibility of rugae patterns changing with age and other outside influences. Orthodontic movement,9,10 extractions of adjacent teeth,11 cleft palate surgery,12,13 periodontal surgery, and forced eruption of impacted canines are only some of the concerns. In a double blind study, English et al.14 selected 25 orthodontic cases with pretreatment and post treatment dental casts. The casts came from subjects over 14 years of age. The time from pretreatment to post treatment was from 18 to 60 months. One hundred maxil-

lary casts were duplicated from random patients treated at the site. The casts were trimmed so only the rugae were visible. Then the 25 post orthodontic casts were placed within the 100 casts. Seven dentists and 2 dental assistants were chosen as evaluators. Five of the dentists with varying forensic experience in identification were assigned as individual evaluators. Two teams were also formed, with one consisting of the two remaining dentists and the other consisting of the two remaining dental assistants; both teams had no forensic experience.

Each individual or team was given 25 pre-orthodontic dental casts and was asked to compare them to the 125 casts for matches. The time required for the comparison, coupled with the correct percentage, was recorded. Eight investigators correctly matched 100% of the casts and one investigator correctly matched 88%. The use of teams significantly decreased the time needed for correct identification. From this study, it can be observed that palatal rugae can be used for identification purposes. It also demonstrates that changes that occur from orthodontic movement, extractions, aging, and palatal expansion do not modify the rugae enough to hamper identification.

Almeida et al.15 conducted a double blind study of 94 patients enrolled to treat early class-II occlusion. Children 6 to 16 years of age were randomly assigned to three groups: a control group, a headgear group, and a functional-appliance group. Palatal rugae and raphe were traced and recorded with a reflex metrograph, which digitalized

46 THE FORENSIC EXAMINER Spring 2005

Figure 2: Tracing of Palatal Anatomy (A: Incisive Papilla; B: Median Palatine Suture; C: Rugae)

the reference points. Results indicated that the medial rugae were stable (the first medial rugae in particular) and no significant differences were found. However, the lateral rugae showed significant changes.

Bailey et al.16 presented the results of a double-blind study in 57 adult patients.

The maxillary casts of pre- and postorthodontic treatment were examined.

Two groups of patients, an orthodontic extraction group (where two maxillary premolars were extracted) and a nonextraction group, were assessed. Statistically significant changes in rugae were noted only in the extraction group.

Though statistically significant changes occurred, the medial and lateral points of the third rugae were not considered clinically significant and can be used for anatomic reference points in dental cast analysis.

Taken together, these two studies highlight the discrepancy in the stability of the palatal rugae after orthodontic treatment and extractions. Almeida et al.15 purports the first rugae as the most stable, whereas Bailey et al.16 describes the third rugae as the most stable.

These findings present further contradiction to the use of rugae in identification due to possible changes over time and after events.

Few studies using palatal rugae as a means of forensic identification are found in the literature. Most of these studies are case reports or are inadequately designed with small numbers of

subjects. The idea of rugae being unique to an individual but not having exact measurements is a challenging concept. Though promising, there is not enough evidence to allow palatal rugae to be used as a sole means of dental identification.

A research protocol is being developed to attempt to show if there is a statistical significance in utilizing digital photographs of palatal rugae for identification purposes. Palatal rugae will be digitally photographed and placed in a databank similar to that used in digital fingerprint analysis (Figure 2). Identification will be attempted by matching a digital photo of palatal rugae to digital photos in the databank.

References 1. Thomas CJ, van Wyck CW. (1988).

The palatal rugae in an identification. J Forensic Odontostomatol. 1988;6:21-27.

2. Fixott R. The dental identification report. In: Bowers GL, ed. Manual of Forensic Odontology. 3rd ed. Ontario, Canada: Manticore Publishers; 1997.

3. Liebgott. The head by regions. In: The Anatomical Basis of Dentistry.

Philadelphia, PA: B.C. Decker Inc.; 1986; 332-333.

4. Thomas CJ. The prenatal developmental microscopic anatomy of the palatal rugae. J Dent Assoc S Afr. 1984;39:527-533.

5. Coslet JG, Rosenberg ES, Tisat R. The free autogenous gingival graft. Dent Clin North Am. 1980;24:651-682.

6. Breault LG, Fowler EB, Billman MA. Retained free gingival graft rugae: a 9-year case report. J Periodontol.

1999;70:438-440.

7. Jacob RF, Shalla CL. Postmortem identification of the edentulous deceased: denture tissue surface anatomy. J Forensic Sci. 1987;32:698-702.

8. Gitto CA, Esposito SJ, Draper JM. A simple method of adding palatal rugae to a complete denture. J Prosthet Dent.

1999;81:237-239.

9. Peavy Jr. DC, Kendrick GS. The

effects of tooth movement on the palatine rugae. J Prosthet Dent.

1967;18:536-542.

10. Hoggan BR, Sadowsky C. The use of palatal rugae for the assessment of anteroposterior tooth movements. Am J Orthod Dentofacial Orthop.

2001;119:482-488.

11. Abdel-Aziz HM, Sabet NE. Palatal rugae area: a landmark for analysis of pre- and post-orthodontically treated adult Egyptian patients. East Mediterr Health J. 2001;7:60-66.

12. Kratzsch H, Opitz C. Investigations on the palatal rugae pattern in cleft patients. Part I: a morphological analysis. J Orofac Orthop. 2000;61:305-317.

13. Kratzsch H, Opitz C. Investigations on the palatal rugae pattern in cleft patients. Part II: changes in the distances from the palatal rugae to maxillary points. J Orofac Orthop. 2000;61:421431.

14. English WR, Robison SF, Summitt JB, Oesterle LJ, Brannon RB, Morlang WM. Individuality of human palatal rugae. J Forensic Sci. 1988;33:718-726.

15. Almeida MA, Phillips C, Kula K, Tulloch C. Stability of the palatal rugae as landmarks for analysis of dental casts.

Angle Orthod. 1995;65:43-48.

16. Bailey LT, Esmailnejad A, Almeida MA. Stability of the palatal rugae as landmarks for analysis of dental casts in extraction and nonextraction cases.

Angle Orthod. 1996;66:73-78.

About the Authors Leonard B. Goldstein, DDS, PhD, is the medical director of the T M J / Fa c i a l Pain Center at Southside Hospital in Bay Shore, New York. He is the former assistant dean for graduate program development and the program director of the Master of Sci-

ence in forensic examination program at the School of Health Sciences at Touro College. He is also the former chair of the Board of Forensic Dentistry of the American College of Forensic Examiners Institute, and is a member of the American Society of Forensic Odontology and the Suffolk Society of Forensic Dentistry. He holds fellowships in the International College of Dentists and the Academy of General Dentistry.

Stuart L. Segelnick, DDS, MSFE, is a clinical assistant professor in graduate periodontics at New York University’s College of Dentistry, and is a clinical assistant professor in the Division of periodontics at Columbia University School of Dental and Oral Surgery. He is the division chief of periodontics at Brookdale Hospital in Brooklyn, New York, is the section chief of periodontics at Wyckoff Heights Medical Center in Brooklyn, New York, and is attending at New York Hospital of Queens in Flushing, New York. Dr. Segelnick is a member of the Disaster Mortuary Operational Response Team, Region Two, and has a private practice specializing in periodontics in Brooklyn.

He has been a member of the American College of Forensic Examiners International since 1998.

Earn CE Credit To earn CE credit, complete the exam for this article on page 65 or complete the exam online at www.acfei.com (select “Online CE”).

Spring 2005 THE FORENSIC EXAMINER 47

n o i a t l a Confer N 5 0 0 2 enc s ’ S e CH Announcing the Fourth Certified in Homeland Security, CHS, Conference!

September 28-29, 2005 • San Diego, California The fourth Certified in Homeland Security Conference will be held September 28-29, 2005, at the landmark U.S. Grant Hotel in historic downtown San Diego, California.

Attendees will enjoy a variety of homeland security-related presentations and a wealth of networking and educational opportunities.

Earn Advanced Certification in Homeland Security at the CHS National Conference Current CHS-III members may earn their advanced levels of Certification in Homeland Security (CHS-IV and CHS-V) at the CHS National Conference by successfully completing the CHS-IV course: Incident Command Management and Terrorism and the CHSV course: CBRNE Preparedness.

CHS-IV Course: Incident Command Management and Terrorism The Incident Command Management portion of the course will provide an understanding of the differences between a HAZMAT (HMI) incident and an NBC (Nuclear, Biological, and Chemical) incident. It will define and provide an understanding of the importance of incident management and its challenges.

The Terrorism portion of the course will review domestic and international terrorist groups that may engage the United States in WMD-related incidents, covering documented, historical facts and events that have occurred to date. It is designed to present an in-depth analysis of domestic and international terrorism in the world today. Topics to be covered in the course include “lone wolf ” and organized terrorist groups engaged in WMD incidents involving Chemical, Biological, Radiological, Nuclear, and High-Yield Explosives (CBRNE).

CHS-V Course: CBRNE Preparedness This course will review CBRNE in detail, and will also discuss catastrophic events involving CBRNE. In addition, a general overview of CBRNE cases will be provided, including event analysis and medical, physiological, and personnel management considerations.

Space at this conference is limited, so reserve your spot now! Call toll free (800) 423-9737, visit www.acfei.com (click “conferences”), or send an e-mail to marianne@acfei.com.

The U.S. Grant, soon-to-be branded as a Starwood Luxury Collection hotel (www.starwood.com/luxury/), is holding a block of rooms specially priced for the CHS National Conference. Call now and reserve your room at the amazing rate of $169 per night for double occupancy. The cutoff for the guaranteed group rate is Thursday, August 25, 2005. To make your room reservation call (619) 232-3121 and mention the group code: ACFEI.

Space is limited - register now!

Call toll free (800) 423-9737 Qualified individuals may proctor the CHS-IV and CHS-V exams for these courses in their local areas. For more information on this option call Marianne toll free at (800) 423-9737, ext. 220. *Conference schedule is subject to change.

48 THE FORENSIC EXAMINER Spring 2005

ACFEI’s 2005 National Conference September 30 - October 1, 2005 San Diego, California

Save the Date!

ACFEI proudly presents our 13th National Conference September 30 - October 1, 2005 at the U.S. Grant Hotel in San Diego, California

ACFEI's 13th National Conference will be held September 30-October 1, 2005, at the landmark U.S. Grant Hotel located at 326 Broadway in historic downtown San Diego, California.

ACFEI will offer the following courses at the San Diego Conference: • Certified Medical Investigator, CMI • Certified Forensic Nurse, CFN • Certified Forensic Accountant, Cr.FA • Certified Forensic Consultant, CFC ACFEI will also be offering its three Core Courses in Evidence, Law, and Ethics, as well as many general sessions highlighting cutting-edge forensic topics.

The U.S. Grant, soon-to-be branded as a Starwood Luxury Collection hotel (www.starwood.com/luxury/), is holding a block of rooms specially priced for this national meeting. Those members who wait until the last minute to reserve their rooms risk losing the great rates. Space at the hotel is very limited, so don’t delay— reserve your room now! The cut-off for the guaranteed group rate of $169 per night for double occupancy is Thursday, August 25, 2005. To make your room reservation call (619) 232-3121 and mention the group code: ACFEI. *Conference schedule is subject to change.

Register now for this exciting conference and take advantage of our early-early bird rates! Call toll free (800) 423-9737, visit www.acfei.com (click “conferences”), or e-mail marianne@acfei.com.

Spring 2005 THE FORENSIC EXAMINER 49

The American Board for Certification in Homeland Security, ABCHS, Launches the

CHS Veterans Corps ACFEI and the American Board for Certification in Homeland Security (ABCHS) are excited to announce a Nick Bacon, CHS-V new arm of Director of the CHS Veterans the Certified Corps; Chair of the ABCHS in Homeland Security (CHS) program, the new CHS Veterans Corps. The CHS Veterans Corps will provide Veterans a means to join together to channel their patriotic efforts into improving the safety and security of our nation while supplementing and contributing to the CHS Preparation & Response Teams (CHS P&R Teams) based all across the United States.

In a State of the Union Address, President Bush stressed the importance of volunteerism by requesting that every American commit some time to the service of his or her neighbors and the nation. President Bush also stated in his National Strategy for Homeland Security, “We must rally our entire society to overcome a new and very complex challenge.

Homeland Security is a shared responsibility....” The task of protecting our Homeland is a monumental one, and the government cannot meet this enormous challenge alone.

ACFEI and CHS created the CHS Veterans Corps after recognizing the important volunteer role Veterans can play in our nation’s Homeland Security efforts.

There is not a more dedicated, courageous, and patriotic group of Americans capable of fulfilling the President’s request and rising to the challenge of protecting our nation than Veterans. America’s Veterans constitute an indispensable “ready reserve” to contribute to Home-

land Security by virtue of their fervent patriotism and their unique blend of applicable experience, training, knowledge, skill, and education. For our Veterans, it has never been a question of “Should I help?” but “What can I do to help?”

Our nation’s Veterans, representing the Air Force, Army, Marines, Navy, and Coast Guard, have risked their lives in service to their country while serving in World Wars, Korea, Vietnam, the Persian Gulf, and the War on Terrorism.

With more than 25 million Veterans in the United States, these citizens are capable of elevating the protection of our nation, families, and communities to new heights.

Nick Bacon, CHS-V, Chair of the American Board for Certification in Homeland Security (ABCHS), Congressional Medal of Honor Recipient, past President of the Congressional Medal of Honor Society, former Director of the Arkansas Department of Veterans Affairs, and Civilian Aide to the Secretary of the Army, has been selected as the director of this new component of the CHS program. Bacon has a distinguished record of dedicated military and public service, and received an extensive education with the U.S. Military, having attended the First Sergeant Academy, Non-commissioned Officers Academy, Military Police Customs School, and Heavy Weapons Infantry School.

Bacon’s extraordinary background and record of accomplishment in the military, together with his reputation as one of the nation’s leading advocates for veterans affairs, combined with his love of and devotion to his country, make him the ideal person to lead this exciting new patriotic program dedicated to helping make our nation and communities more secure through the volunteer efforts of

50 THE FORENSIC EXAMINER Spring 2005

our Veterans.

The main function of the CHS Veterans Corps is for Veterans to assist and supplement the CHS P&R Teams, which are being developed, positioned, and readied in communities in all 50 states. The purpose of these teams is to bring together Veterans and others with experience in Homeland Security within the same geographical areas. These individuals have a variety of different backgrounds, experiences, training, skills, specializations, and talents that will be invaluable in helping their local communities prevent, prepare for, and respond to incidents of terrorism. These proactive support units will reach out to assist, supplement, and collaborate with all first responder agencies, groups, and organizations to achieve the goal of making their communities as safe as possible.

Many Veterans, by virtue of their experience, training, knowledge, skill, and education, may also qualify for optional Certification in Homeland Security at Levels I, II, or III, or for advanced levels of Certification at Levels IV and V based on the successful completion of in-depth Homeland Security courses and exams. However, Certification in Homeland Security is optional, and is not required for participation in the CHS Veterans Corps.

If you are a Veteran seeking an opportunity to put your skills and experience to work for the good of your country, or if you would like to suggest a Veteran who might be interested in joining the CHS Veterans Corps, call Marianne, Director of Member Services, toll free at (800) 423-9737, ext. 220, or send an e-mail to Marianne@acfei.com.

ACFEI news ACFEI Recognizes Two lished numerous books, articles, and ogist, and was a founding member of Members with Lifetime columns, and has taught at the universi- ACFEI's American Board of Psychologity level and guest lectured on a variety cal Specialties. Dr. Annon has presented Achievement Awards On December 15, 2004, ACFEI recognized two members, Zeph Telpner and Dr. Jack Annon, with Lifetime Achievement Awards.

Zeph Telpner received ACFEI’s Lifetime Achievement Award for his professional contributions to the field of forensic accounting.

Zeph Zeph Telpner worked in the accounting field for more than 40 years, and his accomplishments include numerous forensic engagements as an expert witness and litigation support specialist. He has pub-

of forensic accounting and related topics. Zeph holds a CPA license, is a Certified Forensic Accountant, Cr.FA, and is a Diplomate of the American Board of Forensic Accounting and the American Board of Forensic Examiners. He has been a member of ACFEI since 1997, and has worked tirelessly to promote and expand the field of forensic accounting.

Dr. Jack Annon received ACFEI's Lifetime Achievement Award for his professional contributions to the field of forensic psychology.

Dr. Annon is a forensic Dr. Jack Annon and criminal psychol-

numerous papers and conducted over 500 symposia, seminars, and workshops on a variety of forensic psychology and other topics. Dr. Annon has served on the editorial boards for several professional journals and has authored two books, developed two distance courses on forensic psychology topics, contributed chapters to over a dozen scientific books, and has published numerous papers in scientific and professional journals. Dr. Annon is a Diplomate of the American Board of Forensic Examiners, the American Board of Forensic Medicine, the American Board of Law Enforcement Experts, and the American Board of Psychological Specialties. He has been a member of ACFEI since 1994.

ACFEI Establishes Partnership with Mountain State University ACFEI has established a new collaborative partnership with Mountain State University (MSU). MSU offers undergraduate and graduate degrees through distance learning as well as traditional, classroom-based study programs.

Through this partnership, ACFEI members who enroll in an online MSU degree program, such as a bachelor’s in organizational leadership or a master’s degree in strategic leadership, receive 20% off all tuition and related fees and may be awarded college credit for continuing education (CE) earned through journal learning, courses, and workshops offered at conferences, and other educational opportunities provided by ACFEI that are equivalent to college level learning. Discounts up to 20% are available to spouses of ACFEI members.

Through distance learning, MSU allows working professionals to complete degree programs via the internet or independent study, completing coursework and interacting with instructors and fellow students online from any-

where across the United States or abroad. Master’s degree distance learning programs are available in strategic leadership and interdisciplinary studies.

For more information, call ACFEI’s Continuing Education Coordinator toll free at (800) 423-9737, ext. 125, or send an email to emma@acfei.com. To learn more about MSU, visit www.mountainstate.edu or call (866) 367-6781.

About MSU

Mountain State University offers studies at both the undergraduate and master’s degree levels, with academic programs focusing on high-demand professional fields as well as the humanities and sciences. Founded in 1933, MSU is a notfor-profit independent institution of higher education. The primary campus in Beckley, West Virginia, is surrounded by the natural beauty of the southern West Virginia highlands, home to some of the best outdoor recreation in the United States. A relaxed atmosphere brings together students from the sur-

rounding area with those who come from across the country and around the world. The city of Beckley combines a small-town atmosphere with a surprising number of dining, shopping, and entertainment options. For those who are drawn to more urban pursuits, the state capital of Charleston is only about an hour away, and most major eastern U.S. cities are within a day’s drive.

For more information on Mountain State University (MSU) or one of its many academic programs, please call toll free (866) 367-6781, go online to www.mountainstate.edu, or send an email to gomsu@mountainstate.edu.

Spring 2005 THE FORENSIC EXAMINER 51

By Bruce Gross, PhD, JD, MBA, FACFEI, DABPS, DABFE, DABFM, DAPA In 1979, Johnny Paul Penry was charged with the rape and stabbing murder of a woman who was able to describe her assailant prior to succumbing to her injuries. The investigation quickly led to Penry (then 22 years old), who had recently been released on parole from a prior rape conviction. Shortly after his arrest, Penry gave two statements in which he confessed to the crime.

While Penry was found competent to stand trial, an insanity defense was presented at trial. A psychologist testified that Penry, who had been abused as a child, suffered from organic brain damage (probably caused by brain trauma experienced during birth) and was mildly to moderately mentally retarded with an IQ between 50 and 63, a mental age of 6 years, 6 months, and the social intelligence of a 9- or 10-year-old. The psychologist concluded that Penry, as a result of these cognitive deficits, was unable to learn from experience and had poor impulse control. The prosecution’s

expert testified that Penry was not legally insane and that his behavioral dyscontrol resulted from an antisocial personality disorder.

After Penry been found guilty of capital murder, the sentencing jury was required to decide on three special issues or circumstances: whether the offense was committed deliberately and with the reasonable expectation that death would result, whether Penry posed a continuing threat to society, and whether the killing was unreasonable in response to any provocation by the victim. The defense requested the terms used in the special issues be carefully defined for the jury, and that the jury be given a special instruction allowing for a life sentence without the possibility of parole based on mitigating factors presented during the sentencing hearing; namely, Penry’s history of childhood abuse and mental retardation. The request was denied, and with the jury answering yes to each special issue, Penry was sentenced to death in 1980.

Instructions for Death With the decision of the lower court upheld at all levels of appeal, in 1989 Penry was heard by the United States Supreme Court, resulting in a 5-4 decision on two questions. On the first question, the Court found reversible error on the issue of jury instructions. Case law (see Lockett and Eddings) consistent with the 8th and 14th Amendments prohibits

52 THE FORENSIC EXAMINER Spring 2005

a jury from refusing or being precluded from giving consideration to any relevant evidence offered by the defense as a mitigating basis for a sentence less than death. By law, the sentence given to any defendant must be proportionate to his or her degree of culpability (see Tison v.

Arizona). Therefore, personal factors bearing on culpability (such as mental impairments, emotional problems, or a disadvantaged background) must be considered by the jury during sentencing.

The Supreme Court determined that, as given by the trial court, the instructions did not allow the jury a vehicle to express its reasoned moral response when sentencing Penry. That is, the instructions did not allow or inform the jury to consider and give weight to the mitigating factors that might have led to a lesser sentence. Penry was re-sentenced and was again sentenced to death. In June 2001, Penry was returned to the U.S. Supreme Court, which held that despite the addition of a supplemental instruction given to the second sentencing jury, the instructions were inconsistent with the Court’s holding in Penry I. Cruel and Unusual On the second question raised by Penry, the Supreme Court ruled that when applied to mentally retarded defendants, capital punishment was not per se a violation of the 8th Amendment’s protection against cruel and unusual punishment. Citing the diverse capacities and life experiences of mentally retarded persons, the Court concluded that by definition there are mentally retarded persons who are capable of acting with a level of

culpability associated with or supportive of the death penalty. The Court also noted the absence of a national consensus regarding the execution of persons with mental retardation. At the time, only two states (Maryland and Georgia) banned such sentences.

In 1989, the year Penry I was decided, the American Bar Association publicly opposed the application of the death penalty to persons with mental retardation, describing it as unacceptable in civilized society. By the mid-1990s, only three countries allowed the execution of the mentally retarded: Krygyzstan, Japan, and the United States, with the United States being the only democracy in the world to do so. Between 1989 and 2002, the U.S. federal government and 16 states (Arizona, Arkansas, Colorado, Connecticut, Florida, Indiana, Kansas, Kentucky, Missouri, Nebraska, New Mexico, New York, North Carolina, South Dakota, Tennessee, and Washington), joined Georgia and Maryland by enacting statutes that banned the application of the death penalty to convicted defendants diagnosed with mental retardation.

Realizing a National Consensus In 1996, Daryl Atkins (who had an IQ of 59) was convicted of robbery and murder and was sentenced to death. This death sentence was appealed all the way to the U.S. Supreme Court. In a 6-3 decision handed down in June 2002, the Court reversed its stance in Penry, holding in Atkins v. Virginia that the execution of convicted criminals with mental retardation does, in fact, violate the Eighth Amendment’s ban on cruel and unusual punishment. The Court cited the number of states that had enacted legislation protecting defendants with mental retardation from the death penalty since Penry I, as well as the fact that only five states had subsequently executed offenders with IQs less than 70.

The Court concluded that executing the mentally retarded does not contribute measurably to either the deter-

rent or retributive purposes or effects of sentencing and as such, persons with mental retardation were constitutionally exempted from capital punishment.

Considered a chronic condition, the very diminished capacity resulting from mental retardation that decreases defendants’ moral culpability also decreases their ability to foresee the possible consequences of their actions and control their behavior in response. They are unable to abstract from their mistakes and to learn from experience.

The Court opined that, as a group, the mentally retarded are especially vulnerable to wrongful conviction and execution. Specifically, they are at inherent risk of confessing to crimes they did not commit (being highly suggestible and eager to please), are less able to provide counsel with potentially relevant information requiring abstract reasoning or social intelligence, and generally make unconvincing witnesses. In brief, the very nature and degree of impairment diagnostic of mental retardation jeopardizes due process and the reliability of capital case proceedings. Mentally retarded defendants often know the difference between right and wrong and are regularly found competent to stand trial.

Defining “Mentally Retarded” The Atkins Court did not provide a specific numerical IQ score for qualification as mentally retarded. Instead, the Court delineated attributes considered universal and diagnostic of mental retardation.

These qualifying symptoms or characteristics include sub-average general intellectual functioning, significant impairment in adaptive behavior resulting from the deficits in cognitive functioning, and onset of the impairment or disability at birth or during childhood.

Identifying disabilities include limited and impaired reasoning, judgment, social intelligence, and communication skills, as well as poor impulse control (with their crimes deemed impulsive versus premeditated acts).

As a factor in mitigation, evidence must be presented of the defendant’s mental retardation consistent with the qualifications laid out in Atkins. That evidence can derive from a number of sources and might include historical data, brain scans, and psychological assessment results. While the Court did not provide a numerical standard of retardation, it did refer to the definition found in the diagnostic and statistical manual developed by the American Association of Mental Retardation. A variety of protocols exist for the identification and classification of individuals with limited cognitive functioning and potential, and these are used for different purposes. This leaves open the possibility that one definition might fit or serve a given defendant better than another definition.

An Evolving Standard of Decency Whether by design or oversight, Atkins does not proscribe a discrete category of exclusion and therefore, does not provide foolproof protection consistent with the expressed intention of the Court’s ruling. Using an IQ score from a standardized intelligence test for purposes of qualifying the defendant as mentally retarded raises numerous significant issues of reliability. For example, all standardized psychological assessment instruments have a natural test life of ten years. Over the ten years following the development of a given measure, test scores gradually elevate until the device is re-normed to adjust the mean. A defendant’s score on any given test will vary dependent upon when, in terms of the test’s lifespan, the instrument is administered. A defendant who is truly mentally retarded might score well above the generally accepted cut-off of 70 if the test is given just prior to restandardization, or if an older version of the test is utilized during transition from old to new editions.

Even with a recently normed instrument, there exists a degree of variability

Spring 2005 THE FORENSIC EXAMINER 53

in test scores that may pose an unacceptable risk in the context of a possible death sentence. Beyond test lifespan, a portion of variability can be attributed to when the measure of intelligence is administered in relation to the defendant’s arrest, with tests administered closer to arrest typically resulting in a poorer performance.

Other factors contributing to variability include how and where the test is administered, with detention facilities being less than optimal environments that may work for or against a defendant’s best performance. The standard margin of error for a given test can literally become a matter of life-or-death for defendants who score at or around the classification cut-off. Defendants from different cultures cannot be accurately tested with measures developed in the United States, making it even more difficult to prove retardation.

Recognizing that IQ measures alone cannot determine mental retardation, a showing of significant deficits in adaptive functioning must be made to qualify for exclusion. This raises the question of whether a defendant with an IQ below 70 with either no impairment or insignificant impairment in adaptive behavior meets the Atkins criteria.

Conversely, would a defendant with significant impairments in daily functioning and an IQ of 70 or above be protected by Atkins? Focusing on adaptive behavior suggests that only the defendant’s performance IQ is relevant as a measure of how he or she functions in the world. No matter how he or she is assessed, a defendant might demonstrate certain adaptive functions at or below the mentally retarded level while other functions or overall IQ are above this level. The disparity and question of qualification become highly relevant when the identified low-level functions are the very ones at the nexus of the defendant’s crime.

A diagnosis of mental retardation and qualification under Atkins requires onset of the disability prior to the age of 18.

Yet this seemingly rules out those defendants with significant impairments in cognitive and adaptive functioning resulting from later-onset disturbances or traumas such as developmental disabilities, closed head injury, and Alzheimer’s disease, amongst others.

Exceptions to the Rule Atkins does not limit the etiology of the impairments or clearly define how compromised a defendant’s functioning must be in order to qualify as exempt from the death penalty. This lack of a tight definition allows for the possibility of adding to or expanding the class of defendants protected under Atkins. Potentially, numerous defendants exist who do not meet the diagnostic criteria for mental retardation, yet exhibit all of the attributes and impairments Atkins lays out. Examples of such defendants include those with significant mental illness and a low IQ (but not diagnosed as mentally retarded), those with autism spectrum disorders, and those with fetal alcohol spectrum disorders.

Consistent with prevalence rates in the population at large, approximately 2% of all inmates are mentally retarded. In contrast, anywhere from 14% to 24% of all inmates meet the criteria for fetal alcohol spectrum disorder. Ironically, while it is the leading cause of mental retardation in the United States, the majority of persons with fetal alcohol spectrum disorder have IQs within the normal range, yet demonstrate mild to severe impairments in adaptive functioning. The argument that exceptional defendants should be protected under Atkins is arguable in light of the fact that diagnoses evolve, diagnostic criteria change, and the category of mental retardation might well expand with time (Rieger, 2002).

Atkins established a class of defendants who are constitutionally protected from the death penalty. As the case set an atmosphere of not executing the helpless, the more helpless a defendant

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by peril of cognitive and/or adaptive functioning, the greater the fit with Atkins in both letter and spirit. If, in a capital case, the court does not accept an extension of Atkins based on the defendant’s unique impairments, a request might be made for a jury instruction regarding what specific attributes are characteristic of the exempt class of mentally retarded.

References Atkins v. Virginia, 536 U.S. 304 (2002).

Burd, L., et al. (2004). Fetal alcohol spectrum disorder in the corrections system: Potential screening strategies. International Journal of Fetal Alcohol Syndrome, 1(14):1-10.

Eddings v. Oklahoma, 455 U.S. 104 (1982).

Grossman, H. (Ed.). (1983). Classification in mental retardation. Washington, DC: American Association on Mental Deficiency.

Kerns, K.A., et al. (1997). Cognitive deficits in nonretarded adults with fetal alcohol syndrome. Journal of Learning Disability, 30(6):685-93.

Lockett v. Ohio, 438 U.S. 586 (1978).

Penry v. Lynaugh, 402 U.S. 302 (1989).

Penry v. Johnson, 532 U.S. 782 (2001).

Regier, D.A., et al. (2002). The APA classification of mental disorders: Future perspectives. Psychopathology, 35(2-3):166-70.

Tison v. Arizona, 481 U.S. 137, 149 (1987).

About the Author Bruce Gross, PhD, JD, MBA, FACFEI, DABPS, DABFE, DABFM, DAPA, is a Fellow in the American College of Forensic Examiners (ACFEI) and is an executive advisory board member on the American Board of Forensic Examiners. Dr. Gross is also a Diplomate of the American Board of Forensic Examiners, the American Board of Forensic Medicine, and the American Board Psychological Specialties. He has been a member of ACFEI since 1996. Additionally, Dr. Gross is a Diplomate of the American Psychotherapy Association.

Offer Continuing Medical Education (CME) through your organization by jointly sponsoring an activity with the American College of Forensic Examiners International (ACFEI). By jointly sponsoring activities with ACFEI, a nationally accredited provider of Continuing Medical Education, you can offer Continuing Medical Education to physicians in practice anywhere in the United States.

For more information about how your organization can offer CME by jointly sponsoring an activity with ACFEI, call toll free (800) 4239737 or send an e-mail to cedept@acfei.com.

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Spring 2005 THE FORENSIC EXAMINER 55

In his presentation at the 2004 Certified in Homeland Security National Conference in Washington, D.C., Nick Bacon, CHS-V, Chair of the American Board for Certification in Homeland Security, Congressional Medal of Honor Recipient and Past NICK BACON, CHS-V President of the Congressional Medal Director, Homeland Security Veterans Corps; of Honor Society, former Director of Chair, ABCHS the Arkansas Department of Veterans Affairs, and Civilian Aide to the Secretary of the Army, asked the audience to imagine what could be accomplished by harnessing the incredible collective power, energy, and skills of our Veterans and directing them into efforts to help make our communities and nation more secure.

The American College of Forensic Examiners Institute (ACFEI), the world’s largest forensic membership association, and its Certified in Homeland Security program, the nation’s leading private sector Homeland Security membership organization dedicated to the certification, training, and continuing education of Homeland Security professionals from across the nation, did imagine the enormous contribution that our nation’s Veterans could make to Homeland Security efforts. Accordingly, CHS created the CHS Veterans Corps to provide Veterans a means to channel their efforts into improving the safety and security of our nation.

The main function of the CHS Veterans Corps is to assist the Certified Homeland Security Preparation and Response Teams (CHS P&R Teams)*, which are being developed, positioned, and readied in communities in all 50 states. The purpose of these teams is to bring together Veterans and others with experience in Homeland Security within the same geographical areas. These individuals have a variety of different backgrounds, experiences, training, skills, specializations, and talents that will be invaluable in helping their local communities prevent, prepare for, and respond to incidents of terrorism. These proactive support units will reach out to assist, supplement, and collaborate with all first responder agencies, groups, and organizations to achieve the goal of making their communities as safe as possible. *To be a member of a CHS P&R Team, you must enroll in a Division. Team participation is optional.

For more information or to join the CHS Veterans Corps, call toll free (800) 423-9737 or e-mail homelandsecurity@acfei.com.

Join the CHS Veterans Corps An arm of CHS, the nation’s leading private sector Homeland Security membership organization

Recent Books By ACFEI Members Manhattan Terror by Gerald David Hotopp, MS, CHS-III What would happen if al-Qaida operatives carried out a major terrorist attack in downtown Manhattan on New Year’s Eve? Who would be called to respond to this type of crisis, and how far would New York officials go to save thousands of lives and prevent the destruction of their city? Author Gerald Hotopp explores this all-too-possible scenario in Manhattan Terror, an exciting new suspense novel that entertains while providing a realistic, technically accurate, and in-depth look into the real-life emergency response contingency plans that were established after the terrorist attacks of September 11, 2001.

Using strong dialogue and vivid description, Hotopp carries his readers on a harrowing journey exploring the many levels of emergency response after terrorists seize Grand Central Terminal, taking hundreds of commuter train passengers hostage. The story is told through the point of view of several different characters representing the various types of officials who would be called to action if a terrorist attack of this type really did take place, including mass transit officials and police officers, the FBI, and others. The reader is also given a chilling look into the minds of the terrorists depicted in the story as they coordinate, plan, and carry out their attack.

The key behind Hotopp’s realistic and technical plot line comes from his own life experiences. Hotopp served for over 30 years as a law enforcement officer before becoming Chief of Police for the Metro-North Commuter Railroad Police Department in Midtown Manhattan, headquartered in Grand Central Terminal. In this position, Hotopp was closely

involved in efforts to improve the security of our nation’s transportation systems and the complex emergency preparation and response plans put into place after 9/11. Even with these improved security measures, Hotopp understands how vulnerable the U.S. transportation infrastructure remains to terrorist attack. It was this understanding that inspired Hotopp’s chilling storyline.

This novel will be an exciting and engrossing read for all audiences, but should particularly interest readers involved in any aspect of emergency preparation and response, such as those in the homeland security, law enforcement, and transportation security fields.

Gerald David Hotopp is a member of ACFEI and the Certified in Homeland Security (CHS) program; he is Certified in Homeland Security at Level-III (CHS-III). He is a graduate of the FBI National Academy in Quantico, Virginia, and holds a bachelor’s and a master’s degree in criminal justice.

Narcissistic Evil As Character Pathology, by David Flemmer, PsyD, PhD, DABFC, DAPA In his new book Narcissistic Evil As Character Pathology, Dr. David Flemmer explores the muchdebated issue of evil and narcissistic characteristics in mankind.

In this fascinating text, Dr. Flemmer addresses the fact that the problem of evil as a character pathology is largely ignored or overlooked by modern mental health professionals and the psychoanalytic literature, arguing that the current drive to explain evil acts and tendencies as nothing more than the result of various psychiatric disorders has created a new problem in soci-

ety, as sufficient attempts have not been made to remedy the phenomenon. The author also theorizes that problems in the development of the superego can generate evil tendencies in an individual, arguing that this issue is a major component of the tragic school shootings that have occurred across the United States in recent years.

Dr. Flemmer reviews the work of several renowned figures throughout history, including Freud, Kernberg, Peck, and Goldberg, to compare varying theories on the causes and definition of narcissism and evil. The DSM position on the topic is also examined and debated.

Case examples are used throughout the text to illustrate the wide range of challenges that patients with narcissistic disorder present in the therapeutic setting.

These case vignettes are informative and will provide the reader with a concrete understanding of the author’s point; however, they also serve to make the text a fascinating and highly enjoyable read.

Dr. Flemmer addresses several key issues in his text, including the following: 1.) Too much emphasis is placed on the consequences of early childhood events and environment in the formation of narcissistic evil. 2.) Popular theories about narcissism overestimate the influence of very early developmental stages and underestimate the influences of later life experiences, with emphasis on the Oedipus complex. 3.) Evil as a personal characteristic must no longer be ignored by the psychological community, as the problem will continue to grow and fester in society if those in the mental health professions do not intervene. These points are best illustrated in the author’s own words. The following excerpt from Narcissistic Evil As Character Pathology provides a glimpse into Dr. Flemmer’s writing style and main arguments.

“The problem of evil has not been fully examined in the psychoanalytic literature.

In fact, more often, what appears is a reluctance to tackle the problem. Oftentimes we

Spring 2005 THE FORENSIC EXAMINER 57

Recent Books By ACFEI Members wish that evil could be explained and reduced to a known psychiatric disorder.

This reductionism and psychological denial have not provided meaningful answers and solutions of social problems for the public…

Also, modern psychological theories attempt to cleanse frightening and mysterious behavioral events by rationalizing the irrational. A further example of dysfunctional reasoning that prevents the study of evil is the use of insanity as a legal defense…

Modern psychological theories have not provided a cogent understanding of the “senseless” acts of cruelty and destructiveness that have become commonplace in our society. The general approach in the modern era for understanding malevolence is contained in the assumption that the childhood influences in the formation of character of the people involved are the sole crucial sources of all tragic events.”

This book is highly recommended for all mental health professionals, but spiritual leaders, sociologists, those involved in criminal investigations and law enforcement, and other readers will find it captivating and enlightening as well.

Professionals in the mental health field will especially benefit from the treatment strategies that Dr. Flemmer presents, as well as his review of the problematic factors that often arise in the therapeutic setting involving patients with these complex and troubling issues. This reviewer was especially impressed by Dr. Flemmer’s strong and original stance in his theories and his application of those arguments to the high incidence of seemingly unexplainable evil acts that occur so often in our society today. This is a topic that needs to be addressed more often in the literature and the mental health community. I was also pleasantly surprised at how interesting, enjoyable, and easy-to-comprehend the text was, making it stand out among other works in the field. This is largely due to Dr. Flemmer’s clear, concise, and direct writing style, his skilled use of patient

vignettes and description, and the rarity of his positions in the literature today.

Dr. David Flemmer, a Diplomate in ACFEI and the American Psychotherapy Association (APA), holds doctoral degrees in Christian counseling, child and family psychology, and pastoral psychology. He works as a psychologist with the Montgomery County Public Schools in Maryland, maintains a private clinical practice specializing in forensics, and teaches at John Hopkins University as an adjunct professor.

CISSP Practice Questions, by Michael C. Gregg, MS CISSP Practice Questions is a fantastic study and review tool for Information Technology (IT) professionals preparing to take the challenging CISSP (Certified Information System Security Professional) certification examination. It includes more than 500 practice test questions reflecting those included in the CISSP exam, with detailed answers and rationale provided for each question. Author Michael C. Gregg expertly addresses each of the 10 domains covered in the CISSP exam, including access control; telecommunications and network security; physical security; cryptography; security management; law, investigation, and ethics; operations security; security architecture; application security; and business continuity planning.

This text goes beyond helping readers correctly answer the questions that will be included on the CISSP exam; it also provides an understanding of how and why the questions are asked. This will prepare the reader for the oftentimes

58 THE FORENSIC EXAMINER Spring 2005

confusing and tricky questions that he or she will encounter in the real CISSP exam.

An interactive CD is also included with Gregg’s text. This CD contains each of the sample exam questions covered in the book, as well as innovative features that further aid and challenge the studier, such as multiple test modes (study mode, certification mode, custom mode, and missed-question mode). The CD also automatically presents the sample exam questions randomly, changing the order each time the participant takes a review test. This will help ensure that the reader thoroughly learns and comprehends the CISSP exam material without simply memorizing questions and answers.

Michael C. Gregg is president of Superior Solutions, Inc., a Houston-based security assessment and training firm. He has more than 20 years of experience in the IT field, and holds two associate’s degrees, a bachelor’s degree, and a master’s degree. He is course director and author of Global Knowledge’s Advanced Security Boot Camp, and is a seven-time winner of the Global Knowledge 4.0 Perfect Instructor Award. Gregg has trained IT specialists from numerous leading public and private organizations, including the National Security Agency, Nortel, Motorola, Lucent, Fidelity, Kaiser Medical, Southwestern Bell, and many others. He is a member of ACFEI and the Texas Association for Educational Technology.

Members can have their books reviewed in The Forensic Examiner by sending a review copy to Editor, 2750 E. Sunshine, Springfield MO, 65804

Uncovering the Mentality of a Serial Rapist

By Stanton E. Samenow, PhD

he following is a review of a psychological evaluation I conducted on a 28-year-old man who was arrested after terrorizing a suburban area by attacking and raping young women as they left their offices at night. Edward had been caught when he unwittingly selected a female police decoy as his target.

No one who knew Edward imagined he was capable of committing such heinous acts. His brother characterized him as “honest, quiet, and unassuming,” but said he had “trouble being with people.” Edward was reclusive, a mystery to others, keeping people at a distance so they could never truly know him. When his mother learned of her son’s arrest, she couldn’t believe it. She commented he never expressed feelings about anything, saying “If he had goals, I don't know what they would be,” and that all he seemed capable of doing was sleeping, eating, and working at an undemanding job.

When a person commits a serious crime, it almost always represents the tip of a large iceberg of criminality.

Edward’s criminal activity began at the age of six, when he pilfered small items from stores. As he got older, he had numerous minor infractions. During eighth grade, Edward began spying on his mother as she got dressed and went to the bathroom, eventually sneaking out of his home to peer into neighbors’ windows. Once he began driving, he started stalking women, following them to their homes, and sneaking into ladies’ restrooms. Edward eventually began exposing himself to women, committing more than 50 acts of indecent exposure.

Masturbation accompanied all his voyeuristic and exhibitionistic activities,

T

none of which were discovered.

Finally, Edward began casing out office buildings where he could look into first floor windows to spot attractive women. He described waiting for women who worked late at night, positioning himself behind a door or in a stairwell, then attacking. “I bad complete control,” he stated. If a woman resisted, the challenge was greater.

Edward acknowledged that while in jail he masturbated up to three times a day, fantasizing about the attacks. He thought, “if I could just masturbate enough, it'd kill the urge,” but these fantasies fueled, rather than reduced, his criminal drive. Edward found that fantasy, peeping, exhibitionism, and masturbation were losing some of their voltage.

“I had to move up to something more to get a thrill.” Speaking of missed opportunities, Edward volunteered, “I could have attacked over 50 females in the last four years easily.”

Edward went into endless detail as he confessed to one antisocial act after another, remarking that every “sin is like a cheap thrill.” What was the motivation underlying his disclosures? Undoubtedly he experienced excitement while relating the events, and thought honesty might result in a less severe sentence. Also, he discovered religion while in prison.

Edward hoped not only to minimize his sentence on earth, but also to affect his sentence in the hereafter. He commented, “Prison's the greatest think tank there is. I have a chance of salvation. Life on earth has been hell. I don't want to spend eternity in hell.”

Edward suggested he could help law enforcement officers by “going around with police and spotting potential victims,” stating his detailed knowledge of

60 THE FORENSIC EXAMINER Spring 2005

particular areas “could be put to good use.” Still, Edward refused to provide saliva, blood, and hair samples. During legal proceedings, he was critical of the “overzealous” prosecutor and “the way the women lied on the stand.” He was also scathingly critical of his own attorney, saying he was intimidated by the prosecutor and “failed to do God's will.” Edward felt he “got screwed over;” after being sentenced to 45 years in prison. He told me, “I've lost all respect for the police and prosecutors,” then declared he would file for a reconsideration of his sentence.

In line with most offenders I have interviewed, Edward declared, “I'm not the criminal type. I'm not that violent.”

Yet, after meeting the female prosecutor, Edward told me, “She's the typical type of woman I'd attack—blond, with a dimple, quite attractive.” He also commented about the “nice legs” of the police detective who interviewed him.

The most chilling event occurred during an interview, when Edward heard the click of shoes on concrete, alerting him that a female was approaching even before she came into view. Edward’s posture and demeanor changed suddenly; he sat upright in his chair, orienting himself almost like a bloodhound. He turned his head to stare at the female deputy passing by the window of our interview room.

Obviously, the mentality of a serial rapist remained fully operative.

Stanton E. Samenow is a clinical psychologist specializing in criminal behavior and child custody matters.

He is author of Inside the Criminal Mind, In the Best Interest of the Child, and Straight Talk About Criminals.

Become a Certified Forensic Consultant, CFC, at ACFEI’s 2005 National Conference, Sept. 30-Oct. 1, 2005 in San Diego, CA. adversarial confrontations related to issues such as giving deposition testimony, testifying at trial, and assisting counsel and clients during the opposing expert’s testimony. Participants are challenged so that when confronted with litigation they will be comfortable and competent in their role as forensic consultants.

Upon successful completion of the CFC exam, candidates earn the designation Certified Forensic Consultant, CFC.

The Certified Forensic Consultant, CFC, course is intended to train forensic professionals in the law, both generally and specifically. It educates individuals in the fine points of being competent and knowledgeable forensic consultants in the unique environment of the American judicial system.

The CFC course begins with classroom instruction, followed by interactive role-playing scenarios, including a mock trial, and

The CFC course covers the following areas: • Adhering to professional ethics • Following proper documentation procedures • Writing error-proof reports • Preparing deposition/courtroom testimony • Presenting testimonial evidence and opinions • Preparing/reviewing interrogatories, and assisting counsel in the same • Comporting with jurisdictional rules, including the Federal Rules of Evidence and the Federal Rules of Civil Procedure and Evidence • Preparing a professional resume or curriculum vitae, retainer agreements, contracts, and other documents necessary for your protection • The “business side” of the forensic profession

The CFC course will be offered at ACFEI’s 13th National Conference, September 30-October 1, 2005, in San Diego, California. Register now! Call toll free (800) 423-9737, visit www.acfei.com (click “conferences”), or e-mail marianne@acfei.com. A proctored exam option is also available in your area. For more information call Marianne toll free at (800) 423-9737, ext. 220. *Conference schedule is subject to change.

Spring 2005 THE FORENSIC EXAMINER 61

Due to space limitations, members' academic degrees and professional designations are not listed.

Mark A. Acree Hugo C. Adams Matthew Adesola Adegbite Tunde M. Akinmoladun Chris Amaris Jon D. Asdourian Ben Ashcraft Laura D. Atkins William H. Austin Kitty Austria Charles Sigman Babb Robert W. Babington Gregory A. Bacon Keith A. Badler Jennifer A. Bambeck Richard N. Baril Brian D. Barnhardt Joyce E. Baron Kenneth N. Battin Robert L. Baxter, Jr. Robert Clarence Beady Tammie F. Bell Andy R. Bihain Daniel S. Blankfield Michael Dean Bloxom Barbara R. Bower Frew Marshall S. Bratton Guy Warren Brimmer Kenneth S. Brown Lawrence L. Brown Robert L. Brown Vincent J. Buono, Jr. Charlie Burns James T. Burns, Jr. Karen Ramey Burns Michael R. Burrows Jennifer A.M. Calder Thomas Lyons Carr John R. Caruso Terry L. Casto Andy Chambers Pankaj Chandra Ann Chastain-Homick Roland Rick Church Barbara Biro Citarella Nathaniel Clark J Patrick P Conlon Robert J. Coullahan Robert E. Coulter Jeffrey A. Crouch Andre Gary Croutch Heidi M. Crowder Thomas M. Cunningham Mary E. Czemerynski Anthony P. Daiuto David W. Daniels Albert Y. Davydov Della A. Dean Jan DeMeyere Michael Desalis Raymond L. Douglas Sharon Dowen George E. Dyke Joseph W. Eakle

Judith T. Edwards Maurice O. Edwards John Brent Elliott Burnell Encalade Lynne J. Engelbert Anthony A. Ferrera Jon N. Fessler James V. Fetterman Robert A. Fitton Tracy M. Fortner Perryetta Elizabeth Fortson-Lacy Joseph Fortuna Marc M. Fournier George P. Frambach Jennifer Franklin Kenneth R. Franklin Paul French Steven M. Fruchtman Benjamin H. Gaddy, Jr. John W. Gaissert Brian Dennis Gaon Sabrina H. Gast Donald R. Goedke William S. Grago James P. Graham Lisa E. Graybeal Charles S. Haffenden E. Alexander Hallock Richard J. Hallowell, Jr. Adam L. Hamilton Mark Allen Hammargren Thomas David Harlow Coleen Harris Gresham Oneal Harris, Jr. Katherine T. Hartley Anthony Edward Hartman Ali Hashemian Edwin N. Hatfield Bruce M. Hensel Carole Hilbrandt Martin R. Hill Mary B. Hoffer Tatsuya T. Hofmann Wilma G. Hollingshead Laurence D. Holt Timothy Ray Hughes Michael J. Janow Eric C. Johansen Frank W. Johns John R. Johnson Jay W. Jones Cherie Josefosky Joel B. Junker John F. Kavalick Charles R. Kaylor General Kearney, Jr. Mark Austin Keiser James Thomas Kernen Andrew L. Kidd W. Nim Kidd Jason Kingsley Tina Louise Kinney William J. Kintz Frank R. Kirbyson

Mitchell T. Kitchens Gary M. Klein Alonzo L. Knox Lewis Koh Tammi L. Krebs Pablo Lafitte Katarzyna A. Lankamer Eric A. Latalladi Kenneth E. Latham Janet Lauderdale Dene R. Leonard, III Thea S. Leonard Sylento R. Lewis John B. Linstrom Vincent J. Locurto Enrico Longobardi Clifford M. Lucido Turner A. Luttrell, Jr. Jamie K. Mabery Thomas R. Madigan John W. Magyar, II Cynthia A. Markley Greg J. Marrow Gary Lee Martin Jeremy C. Martin Sharon M. Maslon Keith C. Matthews James L. Mauney Paul E. McAloon William McAuliffe Jim McCabe Jeffrey Michael McClaran Robert A. McDonald Douglas I. McFeeters Valerie Marie McGrew Sandra J. McIntosh Deborah M. McKenna Alexander Kennedy Mclaren James G. McLeod Mary M. McNally Kelly D. McNeese James T. McSherry Kevin A. McVadon Kevin F. Medeiros James D. Medler Peter D. Menk Kevin A. Merchant Scott Miegel, Sr. David Miles Lonna G. Miles Melanie J. Miller Thomas Richard Minick Richard E. Minnigh Ernest P. Miranda Robert J. Mitchell Ralph A. Molinia Isaac D. Montoya Dottie Moody Connie L. Moore Robert J. Muller Charles W. Myers Barry T. Neff Rodger Nogaki Dennis J. Nolan

62 THE FORENSIC EXAMINER Spring 2005

Jon Norwood Brandi L. Odom Hubert E. Odom Timothy J. Odom Shannon M. O’Neill Christa Lea Outlaw Donald L. Palma David K. Panter Pamela Sue Pass Richard P. Payant DaWayne R. Penberthy Virgil Noble Perry Shyrah Perry Xavier D. Peterson Lloyd A. Pethoud, Jr. Wanda L. Pezant Roy L. Pifer William Mack Pitts Ralph Spencer Poore Thomas Prescott Brian S. Quinney Yolanda Bigio Ramos Kimberly Ann Randall Eric E. Ray John Rayeur Lance E. Reeve Jeffrey N. Reich Jeremy Renter Michael R. Richins Janet Helen Riembauer Elizabeth C. Rittinger John E. Ritz Joseph M. Robinson Ralph M. Rodriguez Samuel A. Rosado Jaime Ross William F. Rothenbecker Marc Douglas Rubin Edward J. Ryan Joseph V. Saitta Vladimir Salomatoff, Jr. Richard G. Sanders Sophia L. Santiago Charlotte Sbrega John M. Scales Bradley John Schaufenbuel Steven J. Schlamb William P. Schmel Mary Schultz David M. Scott Maryann Scott Syed Shoaib H Shah Philip Alex Sherer Donald H. Shiles Dana L. Shropshire Robert H. Shullich Robert Paul Simons Richard M. Simpson Rhonda Y. Sims Robert Anthony Sims Michael J. Sircy Robert L. Smith Robert Earl Smith Susan M. Smith

Aleksandar Solomonovic Charles T. Spangler Lisa A. Spencer Susan Spjut Bryan C. Staples Sharon Wallace Stark Clark Staten Raymond C. Steil Andre Stewart Kenneth R. Still Grace S. Sullivan Kay M. Sweeney Gary G. Swindon Rebeca M. Tacy Harold John Tallett James G. Tauber Michael P. Tellekamp Steven A. Templeton Don Noble Tennill Adam C. Thermos Mark F. Theys Carl H. Thomas, Jr. Cherrey Wallace Thoner James S. Thurber Brad A. Tornberg Jesse Torres Frank L. Tosatto Laura J. Tosatto Bryant Garrison Tow Brian R. Usher Ann Elizabeth Van Dyke Brett A. Villarrubia Diane L. Visencio Edward J. Wagner Ashley P. Walker Ronald D. Walker David Brian Ward Thomas D. Weaver Craig Weidele Thomas William Welch Kathy Weller Ricky C. Wesley Albert E. Whale John E. Whitcomb Forrest Alton Wieder Gregory L. Wilder Nena Wiley W. Roy Wilkinson Patrick F. Williams Mark S. Wilson Partick G. Wolcott Steven W. Wood Lewis E. Wood Ned Worcester Hylton B. Wynick Anthony Young Geoffrey W. Young Jeffrey S. Young Joshua T. Ziebell Robert B. Zuest

CE TEST PAGE: SIX TOTAL CREDITS AVAILABLE (WITH THE COMPLETION OF ALL 6 CE TESTS) In order to receive CE credit, each participant is required to do the following: 1.) Read the continuing education article. 2.) Complete the exam by circling the chosen answer for each question. 3.) Complete the evaluation form. 4.) Mail or fax the completed form, along with the $15 payment for each CE exam that you take. If you pass the exam with a grade of 70% or above, a certificate of completion for one continuing education credit will be mailed to you.

Participants who do not pass the exam are notified as such and will have a second opportunity to complete the exam. Any questions, grievances, or comments can be directed to the ACFEI CE Department by phone at (800) 423-9737, faxed to (417) 881-4702, or e-mailed to cedept@acfei.com.

Learning Objectives for “Types of Knee Injuries and How They Occur”

CME

After reading this article, the participant should understand the following: 1.) The anatomy of the knee.

2.) The various anatomical structures of the knee.

3.) The mechanisms required to injure various anatomical structures of the knee.

Article 1: CE Test for “Knee Injuries ...” (See page 6 for article.)

1.) Which of the following bones is not a part of the knee joint?

A. Patella B. Fibula C. Femur D. Tibia

Learning Objectives for “The Pseudologia Fantastica Defense ...”

After reading this article, the participant should be able to do the following: 1.) Define pseudologia fantastica.

2.) Differentiate pseudologia fantastica from malingering in PTSD. 3.) Explain the psychodynamics of pseudologia fantastica in PTSD. 4.) List the characteristics of pseudologia fantastica.

5.) List the characteristics of malingering in PTSD.

Article 2: CE Test for “The Pseudologia Fantastica Defense ...”

(See page 14 for article.)

1.) Pseudologia fantastica as used in this article refers to: A. A rare psychiatric disorder.

B. An uncommon psychiatric disorder.

C. An uncommon defense against reexperiencing.

D. An uncommon sociopathological mechanism.

2.) Which of the following is not one of the cruciate ligaments of the knee?

A. Anterior B. Posterior C. Dorsal D. Medial 3.) Which of the following motions combine to cause a meniscal tear?

A. Compression/Rotation B. Hyperextension/Flexion C. Extension/Rotation D. Plantarflexion/Compression 4.) Which of the following knee injuries has been called “the dashboard injury”?

A. Meniscal tear B. Osteoarthritis C. Lateral collateral rupture D. Posterior cruciate ligament rupture 5.) Which of the following is not considered to be a risk factor for ostearthritis?

A. Age B. High blood pressure C. Gender D. Previous trauma to the joint

2.) Pseudologia fantastica is a stratagem for: A. Deceiving self.

B. Deceiving others.

C. Primarily deceiving others.

D. Primarily deceiving self.

3.) Which one of the following was uncharacteristic of the pseudologia fantastica cases described in this article?

A. Invalid test profiles B. Prominent psychodynamics C. Exaggeration D. Poorly documented trauma 4.) Which one of the following statements is true?

A. Credibility, as assessed in this article, involved elements of exaggeration and plausibility.

B. Implausibility is a credibility assessment based on either internal consistency or external consistency.

C. Exaggeration was not present in the cases of malingering.

5). The rate of malingering detected in the 144 cases reviewed was: A. 6% to 10%.

B. 11% to 15%.

C. 16% to 20%.

D. More than 20%.

Payment Information Evaluation for Article 1: (1-3 rating section) Please circle one (1=Poor 2=Satisfactory 3= Excellent) 1. The author presented material clearly. 1 2 3 2. The stated learning objectives were met. 1 2 3 3. New knowledge or technique was gained. 1 2 3 4. Additional comments:

Evaluation for Article 2: (1-3 rating section) Please circle one (1=Poor 2=Satisfactory 3= Excellent) 1. The author presented material clearly. 1 2 3 2. The stated learning objectives were met. 1 2 3 3. New knowledge or technique was gained. 1 2 3 4. Additional comments:

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State:

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Credit Card # Signature

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Please send the completed form, along with your payment of $15 for each test taken. Fax: (417) 881-4702, or mail the forms to ACFEI Continuing Education, 2750 E. Sunshine, Springfield, MO 65804. If you have questions, please call (417) 881-3818 or toll free at (800) 423-9737.

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Spring 2005 THE FORENSIC EXAMINER 63 Take CE Tests online: www.acfei.com (select ”Online CE“)

CE TEST PAGE: SIX TOTAL CREDITS AVAILABLE (WITH THE COMPLETION OF ALL 6 CE TESTS) Learning Objectives for “Prison Gangs: Descriptions and Selected Interventions”

Learning Objectives for “A Review of FDR’s Mental Capacity During His Fourth Term ...”

After studying this article, the participant should understand the following: 1.) The description of major prison gangs and their distinct characteristics.

2.) The growing prevalence of prison gangs.

3.) The basic laws and rulings that have influenced the growth of prison gangs.

4.) The basic interventions that have been successful in controlling prison gangs.

After studying this article, participants should be able to do the following: 1.) Describe the reasons for presidential medical exams inclusive of neuropsychiatric assessment.

2.) Identify FDR’s symptoms of executive dysfunction during his fourth term.

3.) Describe how FDR’s doctors’ failure to inform the public and the president of FDR’s feeble health impacted history.

4.) Describe steps toward the efficient management of presidential disability and the routine use of neuropsychiatric tools of presidential mental health.

Article 3: CE Test for “Prison Gangs...” (See page 26 for article.)

Article 4: CE Test for “A Review of FDR’s Mental Capacity During His Fourth Term...” (See page 31 for article.)

1.) The most violent prison gang has been the: A. Mexican Mafia.

B. Aryan Brotherhood.

C. Black Guerrilla Family.

D. Texas Syndicate.

2.) A 1993 study of prison gang violence revealed that gangs were responsible for what percentage of violence toward other inmates?

A. 10% B. 20% C. 30% D. 40% 3.) Under which court ruling were inmates granted the right to take legal action against prison officials when their Constitutional rights had been violated?

A. Monroe v. Pape (1961) B. Procunier v. Martinez (1974) C. Ruiz v. Estelle (1980) D. Price v. Johnson (1948) 4.) A strategy that has proven useful in decreasing prison violence is: A. Allowing more inmate control over living areas.

B. Increasing privacy for prison groups.

C. Aggressively prosecuting offenders who commit violent acts.

D. Allowing better communication between gang members in prison and gangs on the street.

5.) Any broad strategy to decrease the danger of prison gangs would need to involve: A. Cooperation with federal, state, and local authorities about gangs outside of prisons.

B. Integrating gang members closely with the general prison population.

C. Hiring ex-gang members to advise prison officials and counsel gang members.

D. Giving gangs opportunities to make some prison decisions.

1.) What was the most likely cause of FDR’s executive dysfunction during his fourth term?

A. Alzheimer’s disease B. Parkinson’s disease C. Long term complications of Polio D. Vascular dementia 2.) FDR’s post-Yalta speech to the joint session of Congress on March 1, 1945, revealed all of the following signs of executive dysfunction except: A. Poor vocabulary and grammar.

B. Obvious intellectual decline compared to previous speeches by FDR. C. Brief episode of confusion, poor concentration.

D. Gross factual errors.

E. Poor initiation.

3.) True or false: There is no evidence that FDR’s poor health had any adverse impact on history.

A. True B. False 4.) True or false: At present, regular presidential medical examinations include systematic evaluations of the president’s intellectual, emotional, and executive abilities.

A. True B. False 5.) During his fourth term, FDR suffered from the following condition(s): A. Paraplegia secondary to Polio or Guillain Barre.

B. Malignant hypertension and congestive heart failure.

C. Vascular dementia.

D. All of the above.

Payment Information Evaluation for Article 3: (1-3 rating section) Please circle one (1=Poor 2=Satisfactory 3= Excellent) 1. The author presented material clearly. 1 2 3 2. The stated learning objectives were met. 1 2 3 3. New knowledge or technique was gained. 1 2 3 4. Additional comments:

Evaluation for Article 4: (1-3 rating section) Please circle one (1=Poor 2=Satisfactory 3= Excellent) 1. The author presented material clearly. 1 2 3 2. The stated learning objectives were met. 1 2 3 3. New knowledge or technique was gained. 1 2 3 4. Additional comments:

Amt: $15 per test

Identifying information: Please print legibly or type the following: Name: Fax Number: Phone Number: Address: City:

State:

Zip:

E-mail:

Statement of completion: I attest to having completed the CE activity.

Credit Card # Signature

Date

Please send the completed form, along with your payment of $15 for each test taken. Fax: (417) 881-4702, or mail the forms to ACFEI Continuing Education, 2750 E. Sunshine, Springfield, MO 65804. If you have questions, please call (417) 881-3818 or toll free at (800) 423-9737.

64 THE FORENSIC EXAMINER Spring 2005 Take CE Tests online: www.acfei.com (select ”Online CE“)

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CE TEST PAGE: SIX TOTAL CREDITS AVAILABLE (WITH THE COMPLETION OF ALL 6 CE TESTS) Learning Objectives for “Financial Statement Fraud: A New Ball Game”

Learning Objectives for “Forensic Application of Palatal Rugae in Dental Identification”

After reading this article, participants should understand that: 1.) Top-side entries may be used by executives to cook books.

2.) SOX, SAS 99, and PCAOB have not removed pressures on CFOs to manipulate accounting numbers.

3.) Ignoring materiality and using walkthroughs, brainstorming, and healthy skepticism may help forensic investigators to deter and detect fraud.

After reading this article, the participant should understand: 1.) The viability of the use of palatal rugae in forensic dental identification.

2.) The pros and cons of utilizing palatal rugae in forensic dental identification.

3.) The structures of palatal rugae.

4.) Potential ways that palatal rugae may change, therefore affecting the use of palatal rugae in forensic dental identification.

Article 5: CE Test for “Financial Statement Fraud: A New Ball Game” (See page 39 for article.)

Article 6: CE Test for “Forensic Application of Palatal Rugae in Dental Identification” (See page 44 for article.)

1.) Which of the following is not a recommendation suggested by SAS 999 to detect material fraud?

A. Brainstorming B. Walkthroughs of major classes of transactions C. Increased emphasis on professional skepticism D. Unpredictable audit tests

1.) Human post-mortem identification can be made utilizing: A. Fingerprints.

B. DNA analysis.

C. Dental identification.

D. All of the above.

2.) Which event occurred earlier in time?

A. The panel on Audit Effectiveness Reports and Recommendations convened.

B. The SAS was released.

C. The PCAOB was established.

D. The Sarbanes-Oxley Act was passed.

3.) Which of the following statements is false?

A. Arthur Andersen was given limited assess to WorldCom’s general ledger.

B. Cynthia Cooper was the director of WorldCom’s internal auditing department.

C. The Sarbanes-Oxley Act created PCAOB. D. Borrowing money temporarily would be an example of a motive for a fraud.

4.) How much does fraud and abuse cost U.S. organizations annually?

A. 8% of annual income B. $500 billion annually C. $4,500 per employee D. All of the above 5.) Which of the following statements is false?

A. SAS 99 mentions the term forensic accounting frequently.

B. SAS 99 recommends that auditors brainstorm.

C. The Panel on Audit Effectiveness suggests the recounting of inventories and unannounced visits to locations.

D. Rationalization is one point of the fraud pyramid.

2.) Palatal rugae are located: A. On the soft palate.

B. On the lateral border of the hard palate.

C. On the anterior portion of the maxilla.

D. On the posterior portion of the maxilla.

3. Some researchers feel that palatal rugae may change due to: A. Orthodontic tooth movement.

B. Tooth extraction.

C. Periodontal surgery.

D. All of the above.

4. In the Baily et al. study: A. Rugae remained stable.

B. The fourth palatal rugae was the most stable.

C. Changes were noted in the extraction group.

D. Changes were noted in the non-extraction group.

5. The literature has: A. Many studies citing the validity of palatal rugae for identification.

B. Few studies using palatal rugae as a means of forensic identification.

C. Convincing evidence to allow palatal rugae as the sole means of dental identification.

D. None of the above.

Payment Information Evaluation for Article 5: (1-3 rating section) Please circle one (1=Poor 2=Satisfactory 3= Excellent) 1. The author presented material clearly. 1 2 3 2. The stated learning objectives were met. 1 2 3 3. New knowledge or technique was gained. 1 2 3 4. Additional comments:

Evaluation for Article 6: (1-3 rating section) Please circle one (1=Poor 2=Satisfactory 3= Excellent) 1. The author presented material clearly. 1 2 3 2. The stated learning objectives were met. 1 2 3 3. New knowledge or technique was gained. 1 2 3 4. Additional comments:

Amt: $15 per test

Identifying information: Please print legibly or type the following: Name: Fax Number: Phone Number: Address: City:

State:

Zip:

E-mail:

Statement of completion: I attest to having completed the CE activity.

Credit Card # Signature

Date

Circle one: check enclosed

Please send the completed form, along with your payment of $15 for each test taken. Fax: (417) 881-4702, or mail the forms to ACFEI Continuing Education, 2750 E. Sunshine, Springfield, MO 65804. If you have questions, please call (417) 881-3818 or toll free at (800) 423-9737.

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Spring 2005 THE FORENSIC EXAMINER 65 Take CE Tests online: www.acfei.com (select ”Online CE“)

Falsely Accused Innocence Project Overturns Wrongful Rape Conviction Through DNA Testing

In December, 43-year-old Brandon Moon of Kansas City, Missouri was declared a free man and was released from prison after serving 17 years of a 75-year sentence for a crime he did not commit. This is his story.

On the morning of April 27, 1987, an armed man in a stocking mask entered the house of a female homemaker.

While threatening to kill her, this man forced the woman into her bedroom and onto her bed, where he raped her before fleeing the scene.

After the attack, the victim put on her son’s robe and drove to a local store for help. She was taken to a hospital, where a rape kit was taken and seminal fluid was collected. This evidence would soon be used to wrongfully convict an innocent man; many years later, it would also be the key that would set the man free.

One day after the attack, the victim helped police create a composite sketch of her attacker. The next day she viewed several photographs and found one that resembled the rapist. The photo she picked out was that of Brandon Moon, a local college student. Police obtained a

warrant and arrested Moon on May 1, 1988. The next day, Moon was placed in a lineup in which all subjects wore hats similar to the one worn by the rapist. The victim again identified Moon out of this lineup. (In a seemingly unfair disadvantage, Moon was the only individual included in both the photo and lineup identification processes.) Two additional women who had been attacked in separate incidences also participated in the lineup and identified Moon as their attacker.

During Moon’s trial, the victim testified that she could identify some of the rapist’s visual characteristics, including his facial structure, build, and hands.

However, she could not remember the color of his eyes or whether he had a moustache. One of the women who had been attacked in a separate incident also testified, identifying Moon as her attacker.

The prosecution used the Texas Department of Public Safety (TDPS) serologist to testify that Moon was a non-secretor, a person whose blood type cannot be determined through bodily fluids such as saliva and semen. Because of this, Moon was among a 15% segment of the population who could have matched the seminal evidence collected in the rape kit.

The defense argued that Moon was misidentified, presenting evidence that he was not the source of any of the hairs recovered from the victim or the scene.

Moon testified that he had been on campus at the time of the crime; his girlfriend testified that she had spoken to him on the phone less than an hour before the rape was committed, and had met him only 15 minutes after the attack occurred. The defense also argued that Moon did not have access to a car at the time and therefore had no way to commit the crime.

Despite this evidence, Moon was convicted and sentenced to 75 years in prison. Following his conviction, Moon maintained his innocence and continuously requested additional testing on the

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evidence. In 1989, he won access to this evidence and submitted it for DNA testing; this test excluded Moon as the contributor of the semen found on the bedspread. Unfortunately, this sample was the only one that provided conclusive results, and the profile obtained from the test was never compared to those of the victim or her husband and son.

In 2001, Texas passed a post-conviction DNA testing statute, and Moon was granted additional testing on the evidence used to convict him. The results of these tests also proved Moon had not been the source of the semen collected in the rape kit. Still, this evidence was not sufficient to reverse Moon’s conviction.

In the fall of 2004, the Innocence Project ran DNA tests proving that the victim’s ex-husband’s sperm matched semen taken from the crime scene. In the original hearing in 1988, the TDPS had mistakenly failed to identify both the victim and her husband as nonsecretors. It was also concluded that the semen on the robe the victim wore after the attack came from an unknown male, not Moon. The Innocence Project used this evidence to argue Moon’s innocence. The court was persuaded, and Moon was declared a free man.

This year Moon was finally able to enjoy Christmas at home with his family. At the time of his arrest, he was studying journalism and political science; he now plans to pursue a career making belt buckles and jewelry, a skill he learned while in prison. He also hopes to build a relationship with his 19-year-old son, who he’s been estranged from since entering prison.

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