1. COL (Ret) Elspeth Cameron Ritchie MD, MPH

2. Presenter has no interest to disclose. PESG and AMSUS staff have no interest to disclose. This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with AMSUS. PESG, AMSUS, and all accrediting organization do not support or endorse any product or service mentioned in this activity.

3.  Know the DSM-5 definition of PTSD.  Know how PTSD may be used in the courtroom.  Understand how mefloquine may affect criminal behavior.

4. Slide 4  Traumatic experience leads to: Threat of death/serious injury Intense fear, helplessness or horror  Symptoms (3 main types) Reexperiencing the trauma (flashbacks, intrusive thoughts) Numbing & avoidance (social isolation) Physiologic arousal (“fight or flight”)  Which may cause impairment in Social or occupational functioning  Persistence of symptoms mTBI may be associated with PTSD, especially in the context of Blast or other weapons injury

5.  Removes Criterion A-2  Additional criteria  Somatic reactions  Sleep  Depressive symptoms  Anger and irritability Slide 5

6.  Insanity  Diminished Capacity  Coerced/False Confessions  Mitigation

7.  As a result of severe mental disease or defect, the defendant was unable to appreciate the nature and quality or wrongfulness of his conduct

8.  Severe mental disease or defect or intoxication prevented the defendant from forming the requisite mens rea for the charged offense

9.  The circumstances and nature of the interrogation and the defendant’s psychological vulnerabilities may have interfered with the voluntariness and/or truthfulness of statement.

10.  The defendant’s PTSD may not have rendered him insane or negated the culpable mens rea, but it still may have impacted upon his actions such that it should be taken into account at sentencing.

11.  Central theme is that symptoms mislead the defendant into reading a greater degree of threat into a given situation and overreacting in response.  Dissociative flashbacks  Irritability  Hypervigilance

12.  Flashbacks may interfere with reality testing which would interfere with appreciation of the nature and quality and wrongfulness of the defendant’s conduct, thus rendering him insane at the time of the alleged offense.  A defendant in a flashback may misperceive the degree of threat in a given situation and may lead him to erroneously believe that he must act violently in self-defense.

13.  Irritability may impair a defendant’s ability to control his behavior and to act more violently than is warranted by the situation  May negate mens rea or be mitigating

15. Roxanne Laboratories. Mefloquine Hydrochloride. United States Product Insert. June, 2013.

17. Ringqvist Å, Bech P, Glenthøj B, Petersen E: Acute and long-term psychiatric side effects of mefloquine: A Follow-up on Danish adverse event reports. Travel Med. 2015;13(1):80-88.

18. Dow G et al. Mefloquine induces dose-related neurological effects in a rat model. Antimicrob Agents Chemother. 2006 Mar;50(3):1045-53. “…It is also important to point out that the mefloquine- induced brain stem injury revealed by silver staining is permanent in nature….”

19. Acute/Subacute Intoxication Vivid Dreams, Malaise Sleep Disturbance, Nightmares, Personality Change, Disinhibition, “Anxiety, Depression, Restlessness or Confusion”, Mania, Psychosis, Disorientation, Amnesia, Neurological Symptoms Prodrome Time Severity Chronic Neurological Symptoms, Behavioral, Mood, and Cognitive Changes Chronic Toxidrome

20. Ritchie EC, Block J, Nevin RL. Psychiatric Side Effects of Mefloquine: Applications to Forensic Psychiatry. Journal of the American Academy of Psychiatry and the Law. 2013;41(2):224-235; Nevin RL. Mefloquine and Posttraumatic Stress Disorder. In: Ritchie EC, ed. Textbook of Military Medicine. Forensic and Ethical Issues in Military Behavioral Health. Washington, DC: Borden Institute; 2015.

21. If you would like to receive continuing education credit for this activity, please visit: http://AMSUS.cds.pesgce.com