PTSD and the Forensic Psychiatrist

 
This blog post is aimed at anyone considering a career in forensic psychiatry. Please read this interview in the Ottawa Citizen entitled 'Tough forensic guy' John Bradford opens up about his PTSD'.

I'm going to preface this post by saying that I know the man featured in this interview. He is an extremely accomplished and internationally recognized authority on the evaluation and treatment of sex offenders. To think that we could have lost him is a devastating idea to me. He has always been respected within the forensic community, but I respect him even more after this interview.

In this article Dr. Bradford talks about the recent stress a pretrial evaluation placed upon him when he had to work overtime, under a deadline, to evaluate a sexually sadistic murderer. He was required to watch actual videos of the crimes, to witness the killings and to hear the pleas of the women he knew were doomed. The experience brought back recollections of other serious crimes and cases he had been involved with in the past. In the interview he discusses the effects this had upon him over time and the challenges he faced when he finally needed to get help dealing with it. Getting treatment was particularly difficult for him, both because of his prominence but also because forensic psychiatrists are just supposed to be able to handle this stuff. In his own words:

“It’s complicated,” he says. “In my case it was macho. I’m a top forensic psychiatrist and I saw it as a weakness. I don’t talk about the treatment much because it’s difficult for me but getting to it early is important.”

I understand completely what Dr. Bradford is talking about here. Over the years, forensic psychiatrists end up hearing and seeing information about crimes that are pretty terrible. We see digital photographs of crime scenes, autopsy photographs, surveillance videos of murders, suspect interrogations, phone call tapes, written letters and other pieces of evidence that relate detailed information about violent crimes. A single case can require weeks and hundreds of hours of study with repeated exposure to horrible events.

Even without developing PTSD this can change your view of the world a bit. At times I joke that when I give directions now I don't use street names anymore, I give directions in terms of crime scenes: "Take a left and drive south a few blocks until you get to the church that was the scene of the ice pick murder, then take a right until you get to the samurai sword decapitation..."

Yeah, it makes life a little weird.

There are prohibitions about talking about active cases, for legal reasons, but there are also good clinical reasons why you don't talk about your cases with friends and family. Once you get these images in your head they don't go away, and it's not fair to place them into the heads of other people. I warn my program applicants about this too.

To a certain extent, medical training weeds out people who aren't able to handle this. I think there's a reason why my medical school put anatomy class as the first class on the training agenda. After four months hanging over a formaldehyde soaked body, it took me a while before I could eat chicken again. The muscle fibers and tendons just didn't look the same after anatomy class.

Some people complete forensic training and never touch a forensic case again and never do forensic work. I've often wondered about that, and wondered what we could do ahead of time to help people decide if they're really cut out for the work. Given Dr. Bradford's interview, we should probably also think about what we should be doing to look after the people who stay in the work.

Reforming the Insanity Defense

Over on Peter Earley's blog there is a post entitled "How Fair Is The Insanity Defense" that you should all go over and read. I thought about writing a comment there but quickly released this would require a post of its own, so here it is.


He starts out with a case description of a man with an undoubtedly severe mental illness who either shot or assaulted many people while delusional. In 1992, after a failed attempt at civil commitment, he shot and killed two people. At trial state psychiatrists testified that he knew killing was wrong, even though motivated by delusion---in other words, a legally sane crime by the McNaughten test of insanity (which Mr. Earley describes well, I won't be repetitive here). He was sentenced to death and eventually executed in spite of a recommendation for commutation by the Texas Board of Pardon and Paroles.

Mr. Earley is critical of the McNaughten test and feels that we should rethink the legal definition of insanity. He also advocates to end the use of private forensic experts, a point I'll return to later.

First, I think the public should understand there is a certain logic to when and how a defense attorney decides to file an insanity plea. Mr. Earley is appropriately critical of attorneys who file the plea "when their client is obviously guilty and they don't have any other rational explanation to fall back on." It's true that there is sometimes a hidden agenda for requesting a sanity evaluation: there may be a chance that an evaluation could turn up mitigating information that could be used at sentencing, or as leverage in a plea bargain.

Setting aside the hidden agenda, the fact of the matter is that insanity pleas are filed rarely compared to the overall number of offenses that happen every year. This is particularly true of misdemeanors. That's because an insanity plea, if successful, could lead to the defendant ending up under court or health and mental hygiene supervision for years. A simple guilty plea could get a client out of jail, with or without supervision, in months. The attorney is obligated to act in the stated wishes of his client, and that wish is obviously going to be to get out as soon as possible. Thus, we usually only see insanity pleas filed in very serious, felony cases.

So how rare is it? In Maryland, an insanity plea is filed in fewer than one-half of one percent of all crimes commited in a year, both in Circuit and District Court. Out of all crimes committed in Maryland, only 0.032% end in a successful insanity verdict. This certainly doesn't suggest that the defense is being abused.

Regarding the proposal to use court appointed experts (please see also my previous post on private evaluations):

We're already doing that. Most jurisdictions have individual psychiatrists or psychologists working on behalf of the court, either in a court-affiliated medical clinic or under contract with the state's department of health. As the system usually works, this independent court-appointed evaluator completes an assessment and sends a report with an opinion about sanity back to the judge who ordered the evaluation, with a copy sent to the defense attorney who filed the plea and to the prosecution. (Exact details of who gets the report, when they get it and how it can be used may vary between states. I'm speaking in very general terms here.)

Then and only then will a private expert get involved, mainly because one side or the other won't be happy with the independent expert's opinion. In my experience, this usually takes place when the independent expert thinks a defendant is sane and the defense wants to challenge the report. In Maryland, if the court's expert finds someone insane that opinion is almost never challenged by the prosecution because both sides recognize, and agree, that this person is very very sick. (I think the number is somewhere near 90% agreement on insanity but I don't have the study in front of me.)

In short, the insanity defense is hardly ever used and private forensic expert involvement is even less common than that. Out of a few hundred evaluations done every year in our forensic hospital, only a handful will involve a private opposing expert.

Whether or not the legal test of insanity should be changed is an issue that arises regularly throughout history, most recently in 1984 following the assassination attempt on Ronald Reagan. Then, Congress passed the Insanity Defense Reform Act which changed the test on a Federal level. It excluded any category of mental illness from serving as the basis of an insanity plea unless the diagnosis was a "serious" mental illness. Many states, including Maryland, revised their insanity statutes following the Hinckley verdict. Four states have completely abolished the insanity defense.

And I guess that's the trick when it comes to opening the bag of worms of insanity reform: there's always the chance, particularly given the outrage following the Connecticut shooting, that the defense could be thrown out altogether. And then where would my seriously mentally ill forensic patients be? The Supreme Court recently had the opportunity to hear a case that would have challenged the constitutionality of a state statute barring the defense, but they turned the case down.

OK, that's wraps up my response. I just wanted to provide a little more background and factual information to the topic since it is going to be discussed a lot in the news as certain high profile cases come to trial.

Murder of the Self

Darn you, Blogger. I'm trying to get two presentations done along with lots of other work and there you go, distracting me.

So we have the issue of suicide and criminal law and a discussion of whether it's a crime to kill yourself. Dinah and I just did a presentation about social media and suicide at a local conference on suicide, so the topic is fresh in my mind.

To my knowledge there are no states that still have laws against someone who attempts suicide. In some states, suicide is a common-law crime that could bar recovery in civil cases (and insurance companies don't pay out for the survivors of people who kill themselves).

The complications come up when the suicide attempt puts others at risk. When someone shoots himself and lives, but puts others in danger during the act he could be charged with reckless endangerment or criminal negligence (as well as the associated handgun offenses if applicable). Yes, people have gone to prison for this. Possession of a controlled substance without a prescription, even if possessed for the purpose of suicide, is a crime.

A lay person who forms a suicide pact with someone could be guilty of conspiracy to commit murder (at worst) or aiding and abetting a suicide. Euthanasia, the killing of a terminally ill person, is less of an issue now that we have living wills and advance directives. There is no constitutional right to assisted suicide, by a physician or anyone else, according to two cases decided in the 1990's by the U.S. Supreme Court. Few states allowed physician-assisted suicide, and many have recently passed laws banning it.

Suicide is similar to drug addiction in that both could be considered "status offenses"---it's not a crime to be who you are (someone with suicidal ideation or someone with an addition to drugs), but it could be a crime to possess the materials to express who you are (drugs, a gun, etc) or to carry out some aspects of the behavior (buying the drugs, firing the weapon, etc).

No time to put up specifics about which states and how many of them do what, just an outline of the issues FWIW.

The News is So Depressing Lately

Usually ClinkShrink posts about shooters.  It's really not my area of expertise, but lately I've been struck by how many shootings there have been.  I'm wondering if this is a more common occurrence lately, if it's more publicized, or if I'm just paying more attention.

In the last few weeks, it feels like there is a constant flow of tragedies in the news:
There was the teenager who killed 3 students and wounded two others at a school in Ohio.
A Florida teacher killed the head of his ex-school after being fired .
A gunman walked into a psychiatric hospital in Pittsburgh and killed one person and wounded 6 others.
A U.S. soldier in Afghanistan killed 16 civilians in their homes, including young children.

I suppose the story of the teacher is different in that it was a murder-suicide where the shooter knew the victim and had a motive-- such tragedies do happen often and their news coverage is often limited to local news-- while the other shootings sound to have random, multiple victims, and no obvious motive.  I've actually never heard of a mass shooting in a psychiatric hospital. 

Any thoughts?  Maybe ClinkShrink has some insights.  

Mental Health, Military Style-- Guest Blogger Dr. Jesse Hellman

Today, we're talking about mental health and the military.  But first, I just learned, via Facebook, that today is International Polar Bear Day.  If you have one, hug him tight.  Make sure he's been fed first.


Over on his own blog, Pete Earley, has a post up about a veteran who was about to kill himself with a homemade gun.  He called a Suicide Hotline, the police were sent and the patient was charged with possessing a homemade gun.  It's a good post, worth the read, and Earley brings up issues about mental health emergencies and the legal system that aren't limited to veterans. 


Yesterday, the New York Times had an article about military discharges for a diagnosis of "personality disorder."  The diagnosis is presumed to be a pre-existing one, so once a soldier is diagnosed with a personality disorder, he can be discharged without the usual military benefits.  I know that our guest blogger Dr. Jesse Hellman  has an interest in the topic.  He spent two years as a military psychiatrist, and has attended hearings on the topic, so I asked him to do a quick guest post for us:


Jesse writes:
  The article tells of a 50 year old woman psychologist who enlisted, was sent to Afghanistan, and was involved in a number of incidents, eventually being accused of sexual harassment for remarks she had made. She was sent for psychiatric evaluation and was given the diagnosis of personality order on discharge. There are severe consequences of this diagnosis, which can include loss of future benefits, medical expenses, and more. Was the diagnosis properly considered? Did her commanding officer ask that she be given that diagnosis in order to reduce the huge medical expenses produced by the military?

This is not the first time I had heard of this problem. In the fall, I attended in Washington a meeting of the House Committee for Veteran Affairs. Joshua Kors, a writer who had several pieces in The Nation which addressed this very problem, was testifying along with a soldier who had been discharged as having a personality disorder. The Department of Defense sent several people to testify that there was no abuse of the diagnosis.

One of Mr. Kors's strongest points was the sheer number of personality disorder diagnoses that were being made. It looked like these were occurring at two bases in the United States that processed discharged soldiers: Could it possibly be that this number of applicants slipped through the initial screening process?

My own impressions were mixed. It seemed inconceivable to me that any military commander would directly order physicians to misdiagnose in order to reduce costs to another entity. Vastly too great a risk to him, and to what advantage? On the other hand, the diagnosis as described in the DSM is more severe than the problem warrants: it is possible that many soldiers enlisted thinking the military was for them but then, through various routes, found that life in Afghanistan, under fire, with all the dangers and rigors, was too much. Their attitudes disintegrated. They wanted out. They were poor soldiers who disrupted morale.

To those who understand how to use bureaucracy to effect one's ends, direct orders are not needed. If it takes one hour to examine a soldier and find a given diagnosis, but alternate diagnoses require much more paperwork, repeat examinations, record reviews, etc, and the caseload of the examiner is sufficiently great, is it not predictable that the particular diagnosis that minimizes work will increase in comparison to the alternatives?

So what do you think? There are many issues here worthy of discussion.

Podcast 63: The Bystander Effect

These are the topics we talk about:
The Bystander Effect and why people don't call for help when they see violent crimes.  While we don't talk about the events at Penn State, this was the inspiration for this topic.


From this we go on to talk about legislation that has been proposed to make it a crime for health care workers (including shrinks) to not report child abuse.  As is, there are mandatory reporting laws and licensing implications for those who do not report instances of child abuse.


Finally, we move on to happier techy stuff and discuss Depression Rating Apps.

Roy reviewed iTunes apps with the keyword "depression" which met the following criteria: Medical category; a rating of at least 3 stars, and at least 100 ratings. Five apps came up:

• 3D brain (9600 ratings: not a rating tool but a nice 3D map of the brain)
• Sad Scale Lite (800 ratings: uses a Zung depression rating scale)
• DepressionCheck (700 ratings: uses a 27-item validated screen for depression, bipolar, PTSD, and anxiety)
• Moody Me (600 ratings: an emoticon-based mood diary)
• Health through Breathing: Pranayama (300 ratings: not a rating tool, but a highly-rated meditation tool)

[Disclosure: Roy has consulted for M3, the makers of DepressionCheck.]

This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com. 

Thank you for listening.

Send your questions and comments to: mythreeshrinksATgmailDOTcom, or comment on this post

To review our podcast, please go to iTunes.
To review our book, please go to Amazon.

What I Learned Part III

• More on social media and medicine today. One survey of a surgery department showed half of residents and faculty had public Facebook accounts and a third posted professional information.
• People are using "mindfulness" therapy to treat sex offenders. No studies on efficacy.
• Offenders with bipolar and psychotic disorders are twice as likely to have more than two additional arrests than non- SMI offenders.
• Some criminal defendants try to claim that the government is a corporation, and that they should be tried under contract law rather than criminal law. This is sometimes called a "straw man defense" and may prompt judges to request a competency assessment.
• Defendants who graduate from mental health courts demonstrate improved life circumstnaces with regard to housing, quality of life, symptoms and compliance. Some studies have shown mental health courts to result in improvement for as many as 78% of defendants.
• Court ordered custody evaluators are more likely to recommend paternal custody if the mother is poor or has a history of psychiatric admissions. They are more likely to recommend maternal custody if the father has a history of arrests.
• No suicide prediction tool has a predictive validity greater than 3%.
• Forty percent of patients given opioids for non-cancer pain misuse their meds, 5% become addicted.
• In the UK people with ASPD may be subject to multiagency public protection agreements, sharing information between government agencies.

Coming up tomorrow:
      Correctional risk management and the forensic sciences sampler. Good luck to everyone without power in the snow!

What I Learned Part I

Regular readers know that every year I tweet and blog from the conference of the American Academy of Psychiatry and Law. This group of forensic psychiatrists consists of about 1800 of the country's practitioners. Topics are quite diverse and sometimes rather unusual. It's a lot of fun. Here's just a small smattering of factoids I picked up yesterday:

• The "sovereign citizen" defense can prompt a competency eval, but is not a delusion. The sovereign citizen movement is a recognized subculture of people who believe the government has no jurisdiction over them.
• Of 200 defendants cleared by DNA, one-fourth had confessed to the crime.
• According to FBI uniform crime reports, between 2001 to 2009 2.2% of police murders took place while responding to calls involving a mentally ill person.
• The collection and selling of serial killer memorabilia is also a venue for potential fraud.
• President Peter Ash gave an interesting and useful Presidential address about juvenile violent offenders. Persistent juvenile offenders tend to become more impulsive with age, not less. They commit an average of 30 to 70 previous offenses before they are caught for the index violent offense. They differ from adult violent offenders in that they tend to act in groups rather than alone, they commit impulsive rather than planned violence, and their criminal activities tend to be more diverse than adults. There is a .3 correlation between juvenile psychopathy scores and later adult psychopathy, but this only accounts for ten percent of the variance. Translation: most violent juvenile offenders do not become violent adults. Nobody knows for sure why.
• There was frequent discussion of the hazards and pitfalls of involvement in social media, including discussion about using it to impeach or undermine witness credibility. So far though, when questioned nobody had actually seen this happen to an expert witness. Concern seems to be out of proportion to reality.

HIGHLIGHT OF THE DAY:

My favorite part of this first conference day was the luncheon speech by Pete Earley. Mr. Earley is a former Washington Post report and New York Times bestselling author who's son has a serious mental illness. His book Crazy is required reading in my training program. The book is a description of life inside of one state's broken forensic mental health system. He is passionate and compassionate, and a vigorous and outspoken advocate. The audience was clearly captivated by what he had to say, and at sometimes it was frankly hard not to stand up and shout 'amen'! when he made his points. (Take home quotes for me: "Never give up hope! People get better!" and "A single person can change the system.") I was thrilled to finally meet this very warm man whom I admire. And I'm not just saying this because he wrote a blurb for our book!

SUB-HIGHLIGHT:

I attended a presentation about psychiatrists in the media. The panel presented an interesting categorization of activities: psychiatrist as scientist (presenting and interpreting studies), educator, storyteller, celebrity commentator and curbside therapist. I was surprised and flattered to see the home page of Shrink Rap, and the cover of the book, as an example of "psychiatrist as educator" in the media. I'm glad to see we seem to be accomplishing something helpful.


So that's the first day. You can follow me on Twitter (see the sidebar). If you're here at the conference and want to #OccupyAAPL, drop me a note!

Lessons from Guiteau

Over the last few days I've been reading online discussions and blog posts about the Norwegian spree killer and also reading a book on Google about Charles Guiteau, President Garfield's assassin. I thought it was a bit eerie how similarly the arguments sounded for and against insanity, and how little has changed regarding attitudes toward politically-motivated violence in the last 130 years. I put up a post about the topic over on Clinical Psychiatry News. For more, see Political Violence: A Challenge for Forensic Psychiatrists.

Voices From Within

Tonight CNN will be airing a documentary shot inside the old St. Elizabeth's Hospital, made by patients, about insanity acquittees. This is a very rare opportunity to see the realities of daily life for those found insane and learn more about the insanity defense. For more see the CNN story here.

Budgets, Crime and What Happened to Stephanie

From the New York Times today we have a story entitled, "A Schizophrenic, A Slain Worker, Troubling Questions," a horrible story about a mentally ill man who killed a social worker in his group home. The story highlights the defendant's longstanding history of violence with several assaults in his past. He once fractured his stepfather's skull and his first criminal offense involved slashing and robbing a homeless man. (On another post on this blog Rob wondered why the charges were dismissed in that case; from experience I can tell you it's probably because the victim and only witness was homeless and couldn't be located several months later when the defendant came to trial.) The defendant, Deshawn Chappell, also used drugs while suffering from schizophrenia. Before the murder he reportedly stopped taking his depot neuroleptic and was symptomatic. The news story also suggested that he knew he was committing a crime: he got rid of the body, disposed of the car and changed out of his bloody clothes. Nevertheless, he was sufficiently symptomatic to be found incompetent to stand trial and was committed to a forensic hospital for treatment and restoration. At his competency hearing the victim's family thought that the defendant was malingering his symptoms, while the victim's fiance was distraught enough that he tried to attack Chappell in the courtroom. The point of the Times article appears to be an effort to link the crime to cuts in the Massachusetts mental health budget.

So what do I think about this story? (As Dinah would say, this is a 'Clink' thing.)

About the crime itself I have little to say. There's nothing that out-of-the-ordinary or unusual about this as a forensic case. I have no opinion about his legal sanity since I know nothing other than what's presented in the media (and I've had enough of my own cases covered in the media myself to take what I read with a large grain of salt!). Frankly, these kind of cases happen every day as you could tell by following the Psychiatry and the Law twitter feed.

Why does this story, of all the potential psychotic killer stories, showing up in the New York Times, and why is it showing up now?

Because New York is trying to "beef up" their assisted outpatient treatment law, of course. And the Times has come out in favor of it. They've had other articles in the paper promoting assisted outpatient treatment.

Now, I'm all in favor of advocating for improved mental health services as well as adequate training and reimbursement for well-qualified mental health staff. I just wish they wouldn't feed into the fear and public stereotyping of seriously mentally ill people to do it. That's my first reaction to this piece.

My second reaction is in response to this quote:

"The first time Mr. Chappell secured a state hospital bed — and the treatment that comes with it — was when he ended up behind bars."

And the observation by Chappell's mother:

"In 2007, Mr. Chappell, sentenced to a year in jail but required to serve only three months, ended up at the prison psychiatric hospital. When his mother visited him there, she said, she was heartened to see the effects of an enforced medication regimen. “This was the son I raised,” she said. “He talked about going back to school and getting a college degree.”

I'm going to link back to those quotes the next time I hear somebody comment that "locking people up doesn't do any good." There are some people---fortunately relatively few---who can only be treated in a secure environment because they are just too repetitively assaultive to be treated anywhere else. That's what forensic hospitals and prisons are for.

Shooter Psychology, Part II

Here's an aspect of shooter psychology you don't often hear about. It's from an article written by the mother of Dylan Klebold, one of the Columbine killers. It's hard to imagine how one's child could do something so horrific, harder still to imagine that a shooter could keep his plans so well hidden even from those who knew him best. He was a bright child with few previous problems. Certainly fewer problems than the Tucson shooter and less evidence of mental illness. How did things go wrong?

In her own words:

"Those of us who cared for Dylan felt responsible for his death. We thought, "If I had been a better (mother, father, brother, friend, aunt, uncle, cousin), I would have known this was coming." We perceived his actions to be our failure. I tried to identify a pivotal event in his upbringing that could account for his anger. Had I been too strict? Not strict enough? Had I pushed too hard, or not hard enough? In the days before he died, I had hugged him and told him how much I loved him. I held his scratchy face between my palms and told him that he was a wonderful person and that I was proud of him. Had he felt pressured by this? Did he feel that he could not live up to my expectations?"

It's hard enough being a parent, wondering if you're doing things 'right' or 'good enough', even you're kid isn't a spree killer. The parents of the Tucson shooter are probably asking the same questions.

101 Dalmations (And Chihuahuas…And Cats….And…)

In the New York Times this week we have a story entitled Animal Abuse as Clue to Additional Cruelties. In this article Ian Urbina discusses the problem of people who hoard animals and the connection between animal abuse and violence toward people.

The link between animal cruelty and antisocial behavior is well known and was first studied in the 1960's by a researcher at Washington University by the name of Lee Robins. Dr. Robins followed the outcomes of children referred to a local mental health center for conduct problems, and learned that about one third of them developed antisocial behavior as adults. This is where we get the current conduct disorder criteria for antisocial personality disorder found in DSM-IV: firesetting, theft, running away, truancy and animal cruelty.

States are passing laws to better identify and track people who hoard or abuse animals, with the idea that people who do this are also likely to be abusing or neglect humans in their households. The laws allow for sharing of information between people who investigate domestic violence or child abuse and people who investigate animal neglect cases. Some states are even passing laws to create registries of animal abusers.

Two parts of this story caught my attention: the registry issue and the idea that neglecting an animal becomes a predicate offense for other investigations. Here in Maryland we're big on registries. We have a sex offender registry and child abuse and neglect registry. We have a law requiring child welfare agencies to compare recent birth certificate information to the child abuse registry, to see if any known child abusers are having more kids. Now maybe we should also check to see if they're adopting pets.

The whole idea of registering and tracking people is a bit uncomfortable for me. Registries don't prevent crime but they can prevent people from getting jobs, buying homes and reintegrating into society after they've served their time. Being on a registry (or not being on one) is not truly reflective of the risk that person poses to society. A demented little old lady found with 200 cats in her basement could end up on the Internet, with the implication that she since she has neglected animals she also abuses children. Registries also don't seem to do much for preventing people from getting access to what makes people truly violent: guns and alcohol. Perhaps we should require liquor stores to check registries before any beer transaction. While we're at it, violence is associated with mental illness, untreated mood disorders and personality disorders. Maybe a registry of psychiatric patients?

Please. Enough. I doubt Dr. Robins ever expected this kind of outcome to her work. The purpose of studies like hers was to identify people at risk, for intervention and treatment, not for prosecution and public censure. I think we need to get back to that original idea.

Things We'll Never Know

I've been following the story of Maurice Clemmons, the suspect wanted for the killing of four police officers in Seattle. I don't have any connection to the case, but his story is familiar to me from thousands of inmates like him I've met over the years.

In addition to the media reports, I reviewed the parole and clemency documentation published here.

Here's what strikes me about the case:

Clemmons was a repeat offender who committed new crimes every few months until he turned eighteen. The longest break in his criminal activity was the eleven years that he was in the Arkansas prison system. We don't know what he was involved in before that because juvenile records are generally sealed.

He was already under court supervision when he was convicted of the robbery and theft that sent him to prison in 1990. Even though he was only about eighteen, the judge slammed him: over a hundred consecutive years for what (in Baltimore at least) would have been a ten year sentence, max. When he was first considered for parole, the board would have granted him parole only under one condition (a "firm" condition, as handwritten onto the parole document): that he leave the state. This was not your average offender.

He asked to have his sentence reconsidered, and was granted a reduction by a new judge who noted that she didn't understand why he had been given so much time. (There was no discussion of the reasoning behind this decision other than that the sentence seemed excessive. No discussion of his previous offenses or the nature of the index crimes.) The state's attorney's office opposed his parole each time it came up (then again, that's their job).

When he petitioned Governor Huckabee for a commutation he admitted that he had some initial adjustment problems (he didn't mention what they were, but I could make an educated guess) but added that since his mother died he was determined to turn his life around. He denied any history of alcohol or drug abuse or any history of psychiatric illness or treatment. According the Examiner.com web site, he never required mental health care during the eleven years in prison. When he got out and moved to Washington he was able to run his own landscaping business and get married. A pretty good start, even without therapy.

Prior to killing the police, Clemmons exhibited unusual behavior: claiming to be Jesus, to be able to fly, and forcing his family to undress. To put it modestly, this was a bit of a change for him. He might have been violent and antisocial in the past, but he was never known to be "crazy".

The general public will never know the full story behind the change in his mental state since he was killed by police. Had he survived, he likely would have received a thorough and detailed pretrial psychiatric evaluation for an insanity defense. Only then would we have found out if he really had a psychotic disorder or if he was psychotic due to PCP, Ecstacy or crack cocaine use.

Could any of this have been prevented? I don't know. Maybe, if his sentence hadn't been reduced, both he and the four police officers might be alive today. Then again, maybe he could have been killed (or murdered someone else) in prison. We'll never know.

One Of Us: Physicians Who Kill

"I have already said that if you kill a doctor, all the doctors are instantly on your neck. But what if the man who does the killing is a physician himself? That complicates the situation most damnably..."

---Foursquare: The Story of a Fourfold Life by John Oliver

I've been reading, along with everybody else, the story of the Army major and psychiatrist Dr. Nidal Hasan who killed thirteen people in a spree shooting at Fort Hood yesterday. Let me say first that I've never met Dr. Hasan and know nothing about him; I have no particular information or insights about this offense beyond what I've read in the media.

The CNN article today interviewed two of Dr. Hasan's patients, who both said nothing but glowing things about him and his care. I've blogged about spree killers before ("Shooter Psychology") but this case is different. It got my thinking about the general issue of physicians who kill.

Physician killers are certainly a relative rarity, but they are not unknown. Dr. Jack Kevorkian is probably the most famous here in the United States, but in the United Kingdom there was the case of Dr. Harold Shipman. Dr. Shipman forged the will of, and then killed, several elderly female patients. Then there was Michael Swango, a serial poisoner who killed his patients specifically so that he could take credit for his heroic "resuscitation" efforts. As far back as 1920 Dr. John Oliver wrote about an anonymous psychiatrist colleague who killed another physician and was found legally insane. The quote at the start of this post is from Dr. Oliver's autobiography were he discussed the case. For anyone really fascinated by the topic, I refer you to the book Demon Doctors: Physician Serial Killers. I haven't read it myself so I can't vouch for it; feel free to write in reviews.

But I digress. Getting back to what happened at Fort Hood, the news reports don't indicate anything to suggest that Dr. Hasan was psychotic, motivated by greed or financial gain or out of a need to be a hero. He wasn't an infantryman who had been exposed to combat and who might have been terrified of going back to a traumatic environment. He was educated and presumably in a better financial and social situation than most of the patients he treated, unlike many of my murderer patients who have burned multiple social bridges prior to the killing.

Regardless, a killing by a physician---particularly by a psychiatrist---creates a bizarre aftermath. The military is sending mental health professionals to counsel the victims and witnesses; I'd be willing to bet those military mental health professionals will be required to check their weapons at the door.

Who Is A Criminal?

I'll admit this seems like an odd question with an obvious answer. Most people would say that a criminal is anyone convicted of a crime. However, there is a difference between someone who has merely been convicted of a single crime and someone with a pattern of criminal behavior. Repetitive criminals may be psychopaths or sociopaths. Fictional characters like Hannibal Lechter or Tony Soprano are good examples of sociopathic or psychopathic personalities.

It might be a bit disconcerting to know that people like this actually exist and that they've been around for a long time. In 1837 an English psychiatrist named James Pritchard wrote a book entitled Treatise on Insanity in which he described people who lacked the ability to form attachments to others and who were unable to experience normal human affection or emotions. These individuals had little regard for the feelings or rights of others, however they didn't have the hallucinations or impaired cognitive functioning that was seen in other psychiatric disorders. Dr. Pritchard coined the term 'moral insanity' to describe this disorder, which he felt was a defect in area of the brain responsible for moral reasoning. Around this time the American Journal of Insanity (which later became the American Journal of Psychiatry) published several individual case studies of homicide offenders, all of which were entitled "A Case of Homicidal Insanity". They were all essentially just case descriptions of murderers. The letters to the editor of the journal following these case studies debated the validity of 'moral insanity' as a mental illness. The difficulty was that the term 'insanity' implied that from a legal standpoint the criminal should not be held responsible or punished for his behavior. Eventually the term 'moral insanity' was dropped in favor of the term 'psychopath', a term proposed by a Nineteenth Century German psychiatrist.

More recently, the term 'sociopath' has been used instead of 'psychopath'. This latest change happened because people were getting confused by the 'psycho' part of the psychopathy label---psychopathy doesn't mean that the criminal is psychotic. Actually, neither sociopathy nor psychopathy are actual 'official' psychiatric diagnoses in that they can't be found in the Diagnostic and Statistical Manual (DSM). The DSM uses the term antisocial personality disorder (ASPD). Patients with antisocial personality disorder have difficulty with lying, impulsivity, repeated criminal acts, and impulsivity or irresponsibility. The majority of people with ASPD are not psychopaths. Psychopaths represent a minority of severely disordered people who lack emotional attachments or responsiveness. They are narcissistic and are unable to learn from experience. They lack empathy or remorse and are cold, cruel, callous people. This callousness is what distinguishes psychopathy from antisocial personality disorder.

There are a lot of people with antisocial personality disorder---about 3% of the United States population or nine million people. The exact prevalence of psychopathy may never be known because psychopaths usually only come to the attention of clinicians when they are caught committing crimes or when those around them coerce them into treatment. The most skillful psychopaths may not come to the attention of the law and may function successfully as politicians, religious leaders or heads of large corporations.

A screening tool for psychopathy was developed in the 1980's and has been widely used in research and forensic practice. Scores on the Hare Psychopathy Check List-Revised (PCLR-R) have been found to be useful for predicting violence and criminal recidivism. Psychopaths identified by the PCLR-R are being studied through functional neuroimaging in order to identify the physical basis for the disorder. These studies have shown that in psychopaths the part of the brain responsible for processing emotions works differently than in normal people. They also have different physiologic responses to emotion.

There is a genetic component to both ASPD and psychopathy as shown by adoption and twin studies. One large twin study has shown that for severe psychopaths as much as two-thirds of psychopathy can be attributed to genetics rather than environmental influences. For ASPD, the condition originates in childhood. A study done in the 1960's followed children from a mental health center who were referred for evaluation of their behavior problems. The study found that over fifteen years, one-third of the children with conduct disorder grew up to have antisocial personality disorder.

Can psychopaths be treated?

This is a tough question to answer. Psychopaths don't generally seek treatment voluntarily because they aren't bothered by their condition. They must be coerced into treatment or persuaded to participate by engaging their self-interest. For example, by emphasizing that treatment is a condition of parole and is necessary to stay out of jail or prison. Since psychopaths have difficulty learning from consequences, several treatment attempts may be necessary. The treatment must be designed to have open lines of communication between others involved in the psychopath's life in order to ensure truthfulness. There must be clear, consistent and firm boundaries between the patient and the therapist. Psychopaths with a high risk of violent behavior should only be treated in a secure and structured setting like a correctional facility. Psychopaths and people with ASPD are at increased risk of developing other psychiatric conditions such as mood disorders and substance abuse. Medication may be indicated for treatment of these co-existing conditions.

There is no evidence that psychopathy or ASPD can be cured. The goal of treatment is to minimize the impact of the conditions on others and on the patient. For example, one goal of treatment might be to minimize the risk of accidental injury by teaching the patient to recognize situations that trigger dangerous risk-taking behavior. Violence is another focus of treatment with psychopaths; violent behavior can be managed with administrative disciplinary procedures within the correctional facility or through the use of medication.

Specific treatment goals should be set up collaboratively with the patient so that expectations and treatment parameters are clear. The patient's self-identified treatment goal may also reveal his level of insight. When I asked one of my prisoners what he was working on in therapy, his answer was telling. "The truth," he said. "Telling the truth, it's something I've been working on for a while."

It's a beginning.

What's A Sociopath?

As my fourth and final post for Clink Week here at Shrink Rap, I have been inspired by Roy (again). I was curious about our different reactions to the character Tippi Hedron played in the Alfred Hitchcock movie Marnie. Roy pointed to different aspects of her personality to say that she wasn't a sociopath, so it got me thinking about why I reacted so differently. We've already speculated about whether or not Darth Vader had borderline personality disorder, so lets progress to another Cluster B disorder by talking about Marnie.

First of all, sociopathy per se does not exist in the Diagnostic and Statistical Manual. It was originally conceived in the mid-nineteenth century as "moral insanity", in other words a defect in moral reasoning. Even then there was argument about whether or not this constituted a "real" mental disorder.

Later in the Twentieth Century sociopathy was further refined by Hervey Cleckley's book The Mask of Sanity. His series of case reports of psychopaths formed the basis for Robert Hare's later Hare Psychopathy Checklist, a tool that is in common use in forensic settings. Both of these sources describe several core features of psychopathy:

• a parasitic lifestyle, the ability to control or manipulate others
• superficial charm, glibness, pathological lying
• criminal versatility
• lack of remorse, inability to empathize or lack of regard for impact on others
• shallow or feigned emotions
• early behavior problems, impulsive or unstable adult behavior
  

The descriptions go on and on, but those are some of the main aspects. So, that being said, how does Marnie stack up?

Well, what struck me at first was her level of ease and comfort while committing her crimes. She took her time, observed her workplace surroundings, kept her cool and escaped without breaking a sweat. She readily used aliases and multiple false identities, and her facile lying ability allowed her to quickly gain the confidence of the employers who later became her victims. Many people commented on her confidence, poise, intelligence and charm. She showed no apparent remorse nor did she ever even comment upon the damage her crimes inflicted on others. It's true that she was committing crimes to buy the love of her mother, as Roy suggests, but she showed a startling level of callousness to a young girl in her mother's care who also needed attention. She loved her horse, an attachment that seemed to be her only genuine emotion. Although she agreed to marry Connery, her love for him is closely tied to his willingness to help her as he made restitution for her crimes and took steps to help her avoid prosecution. As far as the impulsive or unstable lifestyle goes, one of the most intense scenes in the movie took place after she shot her horse (her only strong consistent relationship) when it seemed she might shoot Connery as well.

And for the last criteria---the early childhood behavior problems---well, you'll have to watch the movie to find out what that was. Let's just say it's not the behavior of a typical child. (I'm amazed she was so strong for such a little kid!)

So that's why I thought Marnie was a sociopath, for those who are interested in them.

I'm going to let Dinah out from under the floorboards now.

Marnie: A Movie Review

Alfred Hitchock's film "Marnie" is both a romance and a pop psychology study of sociopathy. Sean Connery, playing an amatuer jaguarundi-taming zoologist, traps and marries Tippi Hedron, a compulsive liar and thief who represents the ultimate challenge for him, taming the predatory American female. Hedron is also suffering from erythrophobia (fear of the color red), which drives her sociopathic behavior. Connery feels compelled to cure his wife of the early childhood trauma which lead her in adulthood to commit a series of robberies.

Apart from the questionable wisdom of trying to analyze your wife, his "treatment" tactics are also dubious from my prospective. He attempts to cure his wife through bibliotherapy---titles such as "The Sexual Deviations Of The Female Criminal" and Jung's "The Undiscovered Self", word association and abreaction. Unfortunately, none of this prevents her from shooting her horse, attempting to rob Connery's father, attempting suicide by drowning on her honeymoon and banning her husband from their honeymoon suite.

In true pop psychology form, he ultimately learns that she committed the robberies and used the loot in an attempt to buy the love of her mother. Wow! What a film. Hitchcock takes us from the horseracing track to the brothels of 1960's Baltimore to the estate of Connery's blueblood father. Along the way Hedron reveals clues to her early trauma---she freaks out at any sight of the color red and at the sound of thunder.

Since all criminal behavior is caused by an early childhood trauma, Hedron's secret is of course eventually revealed in a massive regression scene involving Connery and her creepy mother. In the final scene we find her turning gratefully to Connery to say:

"Mark...I won't go to jail for this, will I?"

He answers: "Not after what I have to tell them."

I silently answered: "You may or may not go to prison, Marnie, but you do need a good forensic psychiatrist."

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This is the movie I went to in order to escape my lack of air conditioning this past weekend. Dinah wanted a review, so here it is. It was fun.

I Didn't Hurt Anybody

I am not a happy ClinkShrink right now. I'm a bit hot under the collar. In fact, I'm a bit hot everywhere right now.

I have no air conditioner. I know, I know, I should be used to this by now. I don't have a phone, I don't have a desk, I have to hunt for chairs to sit on every day. I should be used to this.

I am, I'm just not used to this at home.

This isn't something I typically blog about. I generally keep my personal life off the Internet and stick to mainly professional-type topics, but I promise I will make this relevant to psychiatry.

I called up the local heating and air conditioning guy, who took one look and pointed out what was wrong. He saw it immediately, and I can't believe I didn't.

Someone stole my copper freon pipe. It was four or five feet long, leading from the external pump up into the side of my house. It had been clipped off neatly at either end, so neatly I didn't even notice it was gone. I'm told it's going to take four hours of labor (at an hourly rate nearly 50% higher than what I make as a physician) and four gallons of freon (at $60 per gallon) to fix and there is no guarantee it will work. Depending on how long the pipe was gone, both my external compressor and internal unit may be toast. Replacing both units is ridiculously expensive, not to mention time lost from work and loads of inmates who aren't going to get psychiatric care while I'm out.

I'm going to think about this incident the next time I hear someone say drugs should be decriminalized because drug addicts are only hurting themselves. I will think about this the next time a non-violent substance abuser says, "I'm an addict but I never hurt anybody."

Horse hockey.

Like most people who live in big cities, I've been a victim of crime before. I've also had my car window smashed in by someone looking to steal a bag of used spark plugs (long story). Again, metal recycling is used to support drug addiction. (Maybe we need a registry of people selling metal like we do for pawn shops??) Once upon a time, someone even stole the brass doors off of our circuit court house (200 pounds apiece, metal value estimated at a quarter of a million). Drug addicts don't only hurt themselves and the most hardcore addicts need to be picked up involuntarily and taken off the streets to make them stop using.

So anybody who really wants to debate this is welcome to come over to my place this weekend. The forecast is for a hundred degree heat index.

Bring ice.

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For more on the scrap metal theft epidemic, see also:

How hot are metals?

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Note from Dinah: my guest room has a window unit. You're always welcome