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(PSYCHIATRIC TIMES) - Dr. Charles Sell, a Missouri dentist, has been trapped in the limbo between law and psychiatry for almost a decade. His troubles began with allegedly fraudulent Medicaid billings and related white-collar crimes. But the criminal charges against him subsequently escalated as he quarreled with FBI agents, hurled racial insults and spat at a federal magistrate, and purportedly threatened to kill both a prosecution witness and a federal agent. The unfortunate man has a long history of mental illness and has been diagnosed by both prosecution and defense psychiatrists as suffering from the persecutory type of delusional disorder, which contributed to his unreasonable and belligerent reactions to his legal predicament. Unfortunately, while Sell believed the FBI and the government had been conspiring against him when the first criminal charges were filed in 1997, the intervening years of confinement, maltreatment and legal machinations have only reinforced and intensified these delusions. As of today, federal prosecutors have levied almost 70 criminal counts against him, and recently the St. Louis newspapers reported that he had been the victim of cruel and sadistic harassment by federal prison guards.

Despite its supposed rarity--its prevalence in the United States is estimated to be 0.025% to 0.03%--delusional disorder has played an important role in forensic psychiatry. We believe that German psychiatrist Robert Gaupp's 1938 case history of the infamous multiple murderer Ernst Wagner is the benchmark study in the European literature on paranoia and the insanity defense. Reconsideration of notable U.S. cases (e.g., John Hinckley Jr., Prosenjit Poddar, Sirhan Sirhan on the criminal side and Kenneth Donaldson on the civil side) might highlight the importance of this disorder in the modern U.S. context. Sell is yet another example of a patient with delusional disorder whose case has earned a place in the annals of law and psychiatry.

A Shifting Target

From a clinical perspective, psychiatrists know that it is particularly difficult to establish a therapeutic alliance with patients who suffer from the persecutory form of delusional disorder. Typically, such patients lack insight into their disorder, feel they are the victims of injustice and antagonize even those who would like to help them. As a result, they often prove highly resistant to treatment, and their course once in treatment is often protracted. Although there are no good double-blind studies of efficacy, most psychiatrists now believe that antipsychotic medications are helpful in the treatment of this disorder. In Sell's case, his symptomatic behavior--e.g., literally spitting in the face of the magistrate who was to decide whether he was dangerous enough to require confinement for his competency to stand trial evaluation--seems to have provoked ill will at every level of the criminal justice system and led to years of unproductive confinement.

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