Tuesday, June 7, 2011

Accredited Psychiatry and Medicine Medical and Psychiatric Experts


How is an Objective Medical/Psychiatric Opinion Formed?

A medical expert is a physician who has the requisite clinical experience and academic achievement to form an objective medical opinion to a reasonable degree of medical certainty. A forensic psychiatrist is a physician who integrates clinical experience, knowledge of medicine, mental health, and the neurosciences to form an independent, objective opinion. Relevant data are gathered and analyzed as part of a process of alternative hypothesis testing to formulate an expert medical/psychiatric opinion. This expert opinion can be effectively communicated by written report, deposition, or courtroom testimony. The applications of forensic psychiatry are widespread in settings ranging from health care and the workplace to criminal justice and public safety.

Who Can Benefit?

A forensic psychiatrist/medical expert can assist individuals and institutions, plaintiffs and defendants, attorneys, federal agencies, and the courts to evaluate claims ranging from medical and mental health malpractice to disability and sexual harassment. Organizations can also benefit from an expert consultation evaluating the validity and response strategy to employment, supervisory responsibility, or maintenance of health care standards claims. Public safety and criminal justice professionals can also find forensic expert consultation effective in analyzing and preventing threats to security.

Criminalisation in Forensic Psychiatry

Psychiatry, and especially forensic psychiatry influences the criminalising process at many points and this is not always to the benefit of the recipient. The usual view of this activity by psychiatrists is that it is for the benefit of the patient and/or society and indeed there is merit in having a psychiatrist versed in the law and psychiatry assist the patient/court interaction. However this is not a universal view. Foucault had considerable reservations about the use of psychiatry to assist the court and wrote;

" ever since the new penal system - that defined by the great codes of the eighteenth and nineteenth centuries- has been in operation , a general process has led judges to judge something other than crimes; They have been lead in their sentences to do something other than judge ; and the power of judging has been transferred , in part , to other authorities than the judges of the offence. The whole judicial process has taken on extra-judicial elements and personnel. Beneath the increasing leniency of punishment , then, one may map out a displacement of it's point of application ; and through this displacement, a whole new system of truth and a mass of roles hitherto unknown in the exercise of criminal justice, a corpus of knowledge , techniques , scientific discourses informed and becomes entangled with the practice of the power to punish. "

Further on he writes:

" Today , criminal justice functions and justifies itself only by this perpetual reference to something other than itself , by this unceasing reinscription in non-judicial systems . Its fate is to be redefined by knowledge. "

He goes on to make reference to the shadows behind the judges and clearly he has misgivings about this dilution of judicial power. He specifically sees psychiatry as a threat to juridical power;
" Psychiatric expertise, but also in a more general way criminal anthropology and the repetitive discourse of criminology, find one of there precise functions here; by solemnly inscribing offences in the field of objects susceptible of scientific knowledge, they provide the mechanisms of legal punishment with a justifiable hold not only on offences, but on individuals; not on what they do, but also on what they are, will be, may be. The additional factor of the offender's soul , which the legal system has laid hold of , is only apparently explanatory and limitive, and is in fact expansionist. During the 150 or 200 years that Europe has been setting up its new penal systems, the Judges have gradually , by means of a process that goes back very far indeed, taken to judging something other than crimes , namely the 'soul ' of the criminal."

He seems to see psychiatrists as generally having little basic good and an exchange between Dr David Cooper (an anti-psychiatry psychiatrist) and Foucault is a good example of the evident distaste that Foucault has for psychiatry;


" Foucault ; We seem to be seeing two different functions - The medical function of psychiatry , on the one hand , and the strictly repressive function of the police , on the other- coming together at a given moment, in the system we're talking about . But in fact the two functions were only one from the outset. You must have read Castel's book on the birth of the psychiatric order; he shows very well how psychiatry, as it developed in the early nineteenth century was not at all localised in the asylum , with a medical function , and then became generalised and extended to the entire social body. right up to the confusion that we see today- somewhat discreet in France , but much more evident in the Soviet Union. But from the outset, psychiatry has had as its project to be a function of the social order. "

Further on the exchange was;


"D.C.: During the press conference given by Fainberg and Pliuch, I was very struck by Claude Bourdet's question to Victor Fainberg ; why do they use psychiatry in the Soviet Union? When they have the whole police and penitentiary apparatus , which is perfect in itself , and which could take charge of anybody, why use psychiatry ?


"Foucault : There's no answer, except perhaps , that the question is inappropriate. Because it always functioned like that.

"J-P. F.: It was always there...


"Foucault: It was already there,. Once again it is not a question of distortion of the use of psychiatry ; that was its fundamental project.


"D C: The movement in the 1930's toward depsychiatrization in the Soviet Union was reversed by Stalin. The legal prohibition of psychological tests - and lobotomy, around 1936- was then followed by resumption of it , though not as widespread as in the West."

The conversation goes on to discuss the use of psychiatry in Nazi Germany in "scientific euthanasia" , of psychoanalysts who were torture advisors in Argentina, the ideology of pain translating the language of psychiatry to the language of pain, and the fundamental project of psychiatry being "social hygiene " at any cost to the individual freedom and rights.

Many other anti-psychiatrists such as Thomas Szasz saw psychiatry as fundamentally flawed and in the Myth of Mental Illness he wrote; " The introduction of psychiatric considerations into the administration of the criminal law - for example, the insanity plea and verdict, diagnosis of mental incompetence to stand trial and so forth- corrupt the law and victimise the subject on whose behalf they are ostensibly employed."

So during the development of psychiatry voices have been raised expressing concern at its coercive nature and perhaps today it is even more so. A modern definition of the law displays this recognition when it defines law as;

" Analytically it can be pointed out that law is simply one stage in a continuum of disciplinary and normalising discourses , rules of grammar , etiquette and the social, political and moral aspects of collective existence, through to the more explicitly coercive language of psychiatry, therapy , law and religion"

Some psychiatrists do not see themselves as punitive and do not recognise the subtle and insidious effects that they are having perhaps not till long after they have seen the patient. An example of this was a woman who was diagnosed as " mildly schizophrenic " by a very eminent psychiatrist . In fact the woman at the time was 22 years old and passing through a troubled late adolescent crisis which appeared to be eased with Anatensol 1 mg per day for several months.Twenty years later the letter surfaced after she again had problems during the completion of her Degree which had been delayed to have several children . This had the effects of throwing doubt on her whole self and ability to do anything and generally labelled her. Her latter day psychiatrist managed to correct these effects. Had she been involved in a court case a Barrister would have had a meal with this labelling and it would have been quite Criminalising .

On March 31 1978 in the early hours of the morning in Sydney Australia, about three hundred people of Greek background and some of their medical attendants were forcibly detained and removed from their families, then taken to central police headquarters. They were herded into same small cell for many hours , referred to as "Greeks " or worse. The families suffered loss of face in the community ,had their social security benefits removed and had no food unless their families gave them some money but many families simply disowned them . At the police station they were interrogated, finger printed and photographed with the name tag around their neck with the word " Greek " under it. Of the hundreds of people detained 181 people were charged with conspiracy to defraud the commonwealth. The charges related to fraudulent claims for Social Security benefits in Australia.

It was strongly rumoured that these heavy handed and incompetent arrests were triggered off by a psychiatrist informing authorities that some of the people claiming Social Security benefits were not showing the medication in their urine that they were supposed to be taking and that there seemed to
be an excess of Australian Greeks involved in this. In fact no one bothered to enquire about the customs in Greece where it is the usual practice to get an agent to assist these, usually, very poorly educated people to deal with bureaucracy. This agent is paid by the people who he provides the service, however, in Australia we also get people to help in this way but call them Social Workers and they are paid by the Government.

Many of the people arrested commented that they had been treated better by the German Army during the occupation of Greece even when they were suspected of sabotage.

In some cases the commonwealth withdrew the conspiracy proceedings in January 1979 and preferred no other charges. Intermittently over the next three and a half years the conspiracy proceedings against the great majority of the defendants were withdrawn by the Commonwealth.

In January 1984 a Commission of Enquiry by Judge Dame Roma Mitchell, was established to decide compensation. No one was found guilty of anything eventually and the whole exercise cost the Australian tax payer many millions of dollars. The compensation was fixed under the following
headings;

Personal injury Injury to feelings Restriction of liberty Interference with property rights
Injury to reputation Interference with domestic relationships Economic loss
There can be no argument that these people were criminalised in the worst possible manner by the actions of a psychiatrist or other person who felt he was acting in the interests of public social hygiene in the true tradition of psychiatry as described by Foucault.

Other medical specialties do not see themselves as this coercive although they have been seen as paternalistic by others especially the feminist movement. Compared with psychiatry however this is a lesser degree of paternalism , sometimes referred to as " soft paternalism ". Even here though there has been a move against this in society with the patients gaining better control of of their bodies and playing more prominent role in the medical decisions concerning their bodies. This is seen in Sidaway which involved questions of informed consent and Gillick involving questions about duty of care and there was the suggestion that there could be an exemption for social justification or tolerable risk and it could be that a medical assistant would suggest that this is applicable .

More recently Rogers v Whitaker decision has further eroded paternalism by ruling that in future the doctors will not be judged by a body of peers (Bolam Principle) but that the courts will decide what is reasonable. "Essentially , the High Court has thus indicated that the judiciary across Australia ( people who almost always have a background confined to law) from now on is regarding itself as being more competent in architecture then architects, in medicine than doctors , in engineering than engineers and so forth."

However I am putting forward the idea that criminalisation is more than mere paternalism in that it is distinctly more coercive and aggressive. In recent times the worst example has to be the use of the so called" Deep Sleep Therapy " at the Chelmsford Private Hospital which was finally brought to an end in 1979 after a meeting of other doctors which exerted peer pressure and caused nurses at the hospital and the financial backers to exert further pressure to cease this lethal treatment regime. This treatment resulted in the deaths of over 20 people directly and another 20 who died of complications or suicide soon after. " The Report of The Royal Commission Into Deep Sleep Therapy " conducted by Justice J P Slattery. Volume three describes in detail the incarceration of people in Chelmsford Private Hospital in Sydney Australia by psychiatrists and the imposition , without permission , of the drug induced toxic coma known as Deep Sleep Therapy ( DST ). It also covers the main issues and problems under the following headings;
Infections Cyanosis and respiratory problems Incontinence and skin Blood pressure Thrombosis and embolism
Hallucinations Pulse rate Avoiding foot drop Tube feeding Cruelty
Weakness Condition and position Restraints Absconding Secrecy
Effects of drugs Intellectual difficulties

It must be pointed out that every one agrees that the Deep Sleep Doctors were competent as doctors but these DST doctors felt that this medically highly dangerous treatment was reasonable treatment even despite the deaths and even when confronted with a group of peers who strongly opposed it. They still held that it was reasonable to so incarcerate patients and treat them without permission. One could hardly get a more coercive attitude.

Like the Greek Conspiracy case the Deep Sleep Saga has been and is continuing to cost the community millions of dollars as compensation cases continue to tell the appalling horror that the the victims endured, most of whom have been getting almost maximum amounts from the Victims Compensation Tribunal and many will go onto common law claims. Many of the claims revolve around brain damage and the effects of prolonged toxic coma.The damage to Psychiatry's reputation can never be really estimated except to say there have been very severe . Fundamental changes and rather excessive checks and balances have been introduced , in Sydney, to the practice of both Psychiatry and medicine as a whole following the release of the findings of the Royal Commission into Deep Sleep Therapy.

Much of the problem that led to these situations was a certain apathy within psychiatry and perhaps ignorance of the Criminalising effects psychiatrists have. Similar apathy and a numbing effect that the South African Regime had on the doctors there who allowed Steve Biko to be tortured to death with the collusion of the three doctors involved who said after examining him that he was malingering . In South Africa a commission of enquiry said in relation to this matter;

" Failures in the doctors judgement were the result of complex influences including the effects of their own social conditioning, the risk of habituation of the state doctors to degrading conditions, the inroads that apartheid has made to medical practice , the possibility of reprisals if state doctors oppose the wishes of the police ". There was also criticism of the medical organisations for not giving better leadership to doctors to help them to combat hierarchical pressures .

An issue that can often lead to the criminalisation of the mentally ill or even those not mentally ill is when they are labelled by a psychiatrist as " dangerous". There is the widely held belief that mental illness predisposes to violent and dangerous behaviour , and that violent and dangerous behaviour is indicative of mental illness. Dangerousness is a difficult concept which is ill defined, emotional, open to abuse , easily attached and difficult to remove. It has been suggested that maybe the person who give the direction that a person is dangerous is the more dangerous !

One has to distinguish between the legal concept of dangerousness and the medical. The legal concept sees it as stemming from within the individual while the medical views it as " determined by complex interactions between environmental factors and personal variables."

Prediction of dangerousness is very difficult and generally it is felt that mental health professionals over predict dangerousness and that prolonged incarceration is not required for most offender patients. Various methods have been suggested to predict dangerousness and but it seems to come down to subjective assessment and past behaviour predicting future behaviour. The Butler Committee (1975) in recognising the limitations of objective assessment , wondered whether it would be better to rely on the continuing process of management and subjective forms of assessment in which checks on adjustment could constantly be made in the light of the developing pattern shown by the individual concerned.

They also made four recommendations about mentally abnormal offenders. Firstly that a new sentence be introduced for those considered by psychiatrists and others dangerous. Secondly it only apply to serious offences and that they get compulsory treatment if needed . Fourthly that the parole board review these prisoners every two years. It was recognised that the assessment would need to be done by recognised psychiatrists.

Nevertheless there can be few other more Criminalising actions by a psychiatrist than to inform society that a particular person is dangerous thus setting in progress the whole sequence of labelling that a person finds so difficult to rid themselves of. There has been criticism of the use of labels to criminals such as psychopathy, sociopath and antisocial personality disorder which do not do anything to identify the problems these prisoner actually have or understand why they behave this way or help treat them in the long run. It has been suggested by Thomas Szasz that "mental illness is a myth which obscures difficulties located in social relations "

This is somewhat of an overstatement but there is an element of truth in it in that once a psychiatric label is attached to a person they may tend to behave in this expected manner especially if in a prison. Sharyn L Roach Anleu felt that;

" the labelling theorist's main contribution to the study of mental illness is the analysis of the variability of the process of definition and the consequences of being identified as mentally ill. On the other side, mental illness does not involve real symptoms requiring medical treatment, which has become more apparent with the deinstitutionalisation of mental health facilities in most Western societies "

This is a rather naive assertion as there may be a reduction in symptoms when there is the halo effect brought to bear on these patients by deinstitutionalisation but their illness is still present. Once again there is an element of truth is this assertion and the labelling of someone as mentally ill is a significant step in the way society views them and will affect the forces that cause a person to be criminalised.

This bring us to the area of forensic psychiatry which is the most coercive sub-specialty within psychiatry. It would seem however that most people professing to be involved in this area have faced the conflicts that occur between their roles as regards coerciveness and social control and how this conflicts with their role as a member of a nurturing and caring profession. Certainly some compromise is required and exactly where this balance ends up has a lot to do with the persons own attitudes and psychological equanimity and the training they have had. The influence of psychiatrists can be quite pronounced and a court case will often hinge on psychiatric evidence. The qualifications of the expert are often not well tested especially in countries where there is no formal training for forensic psychiatrists or accreditation . In December 1993 the Federal courts in US changed rule 26 concerning expert witnesses in order to reveal

"all publications authored by the witness within the preceding ten years; the compensation to be paid for the study and testimony; and the listing of any other cases in which the witness has testified as an expert at trial or by deposition with in the preceding four years"

This is then available to go to argument in court about the witnesses credibility and is the legal answer to the question of qualifications as well as the guns for hire problem. Another problem area is that court procedure and the rules of evidence are often side-stepped by using experts to introduce evidence that would normally be inadmissible and prejudicial. Yet another problem is that the adversarial system is at odds with the training such experts may have been given and this can distort the evidence. For example an expert witness may wilt under cross examination despite holding correct views thus doing his his evidence a gross disservice . Doctors are just not trained to be advocates.

Further problems are that the constitutional rights of the person may be eroded by an expert ; for example the right to silence . Evidence can be 'crafted' by an expert to fit the case that his side is putting either deliberately or unconsciously. When it comes to the mental defences there's the suggestion that a hidden agenda exists " in which the moral controversies underlying the ascription of responsibility and blame-worthiness are played out through the roles of experts ".

It is not hard to see examples of criminalisation occurring in courts as a result of the activities of psychiatrists. This year a situation occurred when a person who made threats against some doctors at a large hospital and as a result he was charged with assault . However this did not stand up in court and he was subsequently placed under the Mental Health Act and reviewed by the Mental Health Review Tribunal. There was a variation of opinion as to whether he was in fact suffering from any mental illness at all and whether he was dangerous . This man had never been violent and the matter was taken to the appeals court with psychiatrists testifying on both sides of the case. At least there was a supreme court order stopping him from being forced to have medication. The courts were quite shocked that the medication suggested was not going to affect his paranoia in all likelihood , if indeed he had this, and was capable of causing brain damage in the long run. The whole issue seems to have been that the Mental Health Act operates on a lower standard of proof than the criminal courts and thus he was easier to criminalise under this civil standard of proof. If a person is in fact a serious danger to society then the the legally problematic concept of preventative detention will have to be addressed. In the Gary David case in Victoria Australia the legal and political parts of society were forced to address this question. " Theory and consequent action needs to be based on knowledge ; facts cannot be conveniently be changed to conform to theory. An understanding of Gary David's mental state lies in the realm of the discipline of psychiatry. If the knowledge and the insights contributed by psychiatry are discomforting , it is pointless that the realities of that science should change.Fictions should be avoided . By the simple fiction of deeming David to be mentally ill community protection can be ensured and the claims of civil libertarians and the views of adherents of traditional legal theory accommodated. The experience of common law , however , is that the adoption of fictions ultimately give rise to new problems as the internal contradictions of the fiction become apparent. Difficult issues are best faced and faced squarely."

Here the law and society is having problems coming to terms with the Criminalising effects of psychiatry.

Another area where psychiatrists are prominent is in the discourse that has occurred around syndromes and their use in court. These can be quite Criminalising and one of the best examples is the Premenstrual Tension Syndrome (PTS) which has been criticised by feminists for its use in Diminished Responsibility instead of Self Defence. It is a questionable collection of symptoms which cover too diverse a grouping for scientific comfort and there is some doubt as to its aetiology. It does not fit into the widely held belief that it is " due to the hormones " and can occur at various stages in the menstrual cycle. Of course there could turn out to be some biological basis to it and could , for example end up being due to the rate of drop of hormones . However at present and despite numerous attempts there is no unitary aetiological explanation for the various physical and mental disturbances that occur. There have been doctors such as Dr K Dalton in UK who have given evidence which persuaded the English courts that this is a real and convincing condition that warranted a Diminished Responsibility verdict rather than any other even though in some, a provocation defence may well has sufficed. A feminist position is that; " it is theoretically incoherent to treat the legal questions of responsibility, guilt and proper punishment as reducible to any demonstration of biological state. Nothing of judicial relevance can be read off from evidence of the defendant's biological status as a sufferer from premenstrual tension, and there's every reason to resist the reductionism upon which the appeal to premenstrual tension depends. Second there is the consistency in the treatment of male and female defendants....... the general arguments against ' chivalry' are familiar and need no rehearsal here."

Psychiatrists may be asked to give evidence about the defendant's state of mind at the time of the offence and to expand on the reason behind this as regards to the PTS and how this would go to a more lenient treatment especially if there is a cyclical and recurrent story but in fact "cyclical recurrent behaviours are not inherently less reprehensible than others" and they may also be asked to comment of the propensity to crime by these women but again " exceptional propensity to crime is not constituted elsewhere as grounds for special lenience"

The fact that some of these women seem to responds to treatment with hormones is not relevant to culpability or prevention when considering past crimes and what punishment is due. Some might say well this is an example of decriminalisation, in that the Criminalising effects are lessened with psychiatric evidence but one has to remember that there is the question of whether self defence would have been even better and maintained the integrity of women. We all know that a barrister, quite rightly will use anything that is within the rules of evidence to put their case forward. The PMT syndrome also allows the offender to see their behaviour as not due to their free choice and consciously or not convince themselves that the problem is that she is at the mercy of her hormones as well as the issue of learned behaviour where she has learnt to blame her behaviour on her hormones to get the response from society that she wants. By raising a condition to the status of a syndrome although it appears to be scientific there is a deceptive element to it . Another example is the Post Traumatic Stress Disorder widely used at present in the courts to explain a multitude of behaviours especially in the civil courts. " The emerging area of victim's rights has been strengthened and paradoxically divided by PTSD. Yet the newly defined disorder of PTSD has not borne such a heavy forensic burden easily . Indeed the diagnosis poses for psychiatry some of the very problems it supposedly solves for legal purposes, including the illusory objectivity of the causative traumatic event and the expert's dependence upon the victim's subjective and unverifiable reports of symptomatology for the diagnosis ".

Thus it can be seen that there is still a lot of difficulty when a new syndrome appears and the acceptance of this entity.

Previously it was the analytical explanations that the courts swallowed with such unquestioning nativity from the mouths of psychiatrists. Although this has fallen into disrepute by all reasonable psychiatrists, there are still a few who pronounce upon it at the first opportunity. Prostitution , for example would be explained by psychiatrists in terms of excessive penis envy and the need to humiliate the male to keep some control and /or taking revenge for the castration that they perceive has occurred instead of the more realistic need for financial support of their children that criminologists have found to be the main motivation for this occupation. Thus the person is criminalised as an individual and seen to have little hope unless they undergo an analysis to rid themselves of this " medical condition " where as in reality the provision of practical support such as finance and emotional support is in fact what is needed. The usefulness of psychoanalysis in the development of psychiatry cannot be denied but it is its insidious and largely unrecognised function to label and criminalise any behaviour that it turned its mind to that was most objectionable as far as the law is concerned. This may not be seen very much today but it was only 10-20 years ago that to write such a statement would label the author as having some problems with authority figures that stemmed from early development and had to do with the failure to resolve the jealousy experienced in the Oedipus complex and the competition between the authors father and the author for the sexual attachment with the the mother, assuming that the author was a male and if a female then it would be the competition between the mother and the author for the father. The explanations were totally flexible and did not need proof.

These psychoanalytic concepts were accepted into our culture and the law almost without question to explain sex offenders , murder, assault, public disorder,drug offences etc. and psychiatrists were accepted as expert witnesses without much argument by the law.

So is the story all negative? No, psychiatry does have a role to play otherwise it would not still be in there and flourishing. It plays a part at all levels of the criminal justice system and is clearly a great help if used with care. One of the best examples is in the Mental Disability Defences where it can assist the court in coping with these difficult concepts and the handling these merciful excuses for crime. One outstanding problem that has to be overcome is the difference in the technical terms that exist between Psychiatry and the Law. It is for this reason that there is the need for an education across the two disciplines otherwise confusion reigns. There are other areas that are of concern.

Stone (1984) raised a number of issues about the intellectual and ethical boundaries of forensic psychiatry:

"1. Does psychiatry have anything true to say the courts should listen to? (sic )
2. There is a risk that one will go too far and twist the rules of justice and fairness to help the patient.
3. There is the opposite risk, that one will deceive the patient in order to serve justice and fairness.
4. There is the danger that one will prostitute the profession as one is alternatively seduced by the power of the adversarial system and is assaulted by it.
5. there is the need for clear guidelines as to what is proper and ethical."

From this it can be appreciated that psychiatry is walking a very fine line and the personal standards of the person will play a significant role in where the psychiatrist places his or her feet. When the outcome is merely a matter of money as in most civil cases one sees a lessening of the ethical standards with hired guns being quite unethical and mercenary. In the criminal courts the use of the psychiatrist seems more controlled due to the due process being more thorough and the approach to defences such as Insanity, Automatism , Diminished Responsibility, Provocation and Infanticide being more ethically handled or perhaps the standards looked for in expert witnesses by the barristers are higher. In any case it seems the beliefs of the psychiatrists are more genuinely held and perhaps the psychiatrists chosen for these roles are selected for their integrity and demonstrated awareness for , and knowledge of, the law. Most of these psychiatrists are more likely to be aware of the delicate path between Criminalising and decriminalising the client /patient. However it is of some concern that in the lower courts some psychiatrists do not realise that they are on that path and lurch from one side to the other. It would seem logical that there is a need for accreditation of forensic psychiatrists to help overcome these deficiencies and included in this accreditation some study of the law should be required.

Genetic Conditions, Psychiatric Symptoms and Mechanism of Action

Occasional genetic syndromes are often not recognised. Unless one
keeps the possibility in mind they will be missed. The relevance to a
forensic patient, or, for that matter any patient, is obvious, from a
clinical, treatment, and a legal point of view. One such Syndrome was
discussed recently at Reaside Forensic Psychiatric Unit in
Birmingham, UK. The bottom line was that if you suspect such a
syndrome, obtain the opinion of a geneticist as this is a highly
specialised area and investigation needs expert advice. There can be variations on these syndromes with incomplete penetrance
or other genetic mixtures. Scrambler et al described “the wide range
of phenotypes associated with hemizygosity for 22q11, a pattern which
can be found within the family as well as between individuals. The abnormalities found in-patients with monosomy 22q11, including
Velocardiofacial Syndromes (VCF), are consistent with a defect within
the mesenchephalic and cardiac neural crest. The anomalies may occur
alone rather than as part of a syndrome and it is anticipated that a
proportion of patients with isolated features of DiGeorge (DGS) and
Velocardiofacial Syndromes have a deletion gene mutation at 22q11.Most patients with VCFS/DGS have a similar 3-Mb deletion, whereas
some have a nested distal deletion endpoint resulting in a 1.5-Mb
deletion, and a few rare patients have unique deletions. A cohort
of 250 patients was described in 1999 whose clinical findings help to
define the extremely variable phenotype associated with the 22q11.2
deletion and may assist clinicians in providing genetic counseling
and guidelines for clinical management based on these findings.

Such conditions can throw new light on the chemistry of disorders as
described below.

Velocardiofacial Syndrome has the following features:
Mouth Cardiac Facies Eyes Nose
Cleft palate
Velopharyngeal insufficiency
Small open mouth
Pharyngeal hypotonia
Congenital heart septal defect
Ventricular Septal Defect
Tetralogy of Fallot

Medial Displacement of internal carotid arteries

Myopathic Facies
Pierre Robin syndrome
Narrow Palpebral fissure
Almond-shaped palpebral fissures
Small optic discs
Tortuous retinal vessels
Posterior embryotoxon
Cataract
Decreased Nasophayngeal Lymphoid tissue
Prominent tubular nose
Deficient nasal alae
Bulbous nasal tip Nasal voice
Neuropsychiatric Head Somatic GU Lab
Learning disability
Blunt or inappropriate affect
Mental retardation
Psychotic illness
Holoprosencephaly
Microcephaly Minor Auricular anomalies Slender hands and digits

Short stature

Overlapping features of DiGeorge Syndrome

Hypospadias
Neonatal Hypocalcemia
T-lymphocyte dysfunction
Monosomy for a 22q11 region


The Inheritance is autosomal dominant and there is often deletion of chromosome 22q11.

For completion's sake the following is the description of DiGeorge Syndrome, which is not especially relevant to psychiatry. Individuals with the DiGeorge syndrome often have cardiac defects, immune system deficiencies and can be moderately retarded. The cause of the DiGeorge syndrome is a defect in chromosome 22, where one of
the bands in the long arm has been deleted. The deletion can be suspected by looking at the karyotype and can be confirmed by FISH.

COMPT metabolises catecholamines, such as noradrenaline, adrenaline,
and dopamine in soluble and membrane-bound forms but is found
predominantly in the cyctoplasm. Low COMPT activity has been
associated with in women with primary affective disorder

It is conceivable that individuals hemizygous for COMT and carrying a
low metabolising alle on their non-deleted chromosome would be
predisposed to the development of the psychotic features of VCF. This
event could occur via decreased inactivation of catecholamines in the
brain, increased placental transfer of catecholamines, or both. . 23%
of a randomly selected population were classified as low
metabolisers.
so the frequency of the low activity alle(s)
would a considerable proportion of the VCF syndrome group.

Psychopathic Aggression

Constructive Functions of Aggression in Psychopaths


Abstract

Psychopathic aggression may have constructive functions, which might be involved in enhancement of social-emotional and moral development of psychopaths that might lead to improvement or remission. Furthermore, it can contribute to the realization and preservation of self-structure, -esteem, -respect, -knowledge; reality testing; social awareness; a new mental, emotional balance and associated healthier neurobiological functioning; and to obtain useful feedback information from other individuals. More research is needed into a) the hidden motives of aggression, b) the precise etiological routes from the original motives into specific expressions and dimensions of aggressive behavior, c) and different constructive roles, which may be related to aggression in (the different categories) psychopaths in order to develop and provide adequate therapeutic and preventive strategies.

Diagnostic Features

According to the criteria of the fourth edition Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association; DSM-IV, 1994) antisocial personality disorder (ASPD) are characterized by features such as irritability and aggressiveness, impulsivity or failing to planning ahead, social maladjustment, reckless disregard for the safety of self and others, consistent irresponsibility, a lack of guilt or remorse, deceitfulness, pathological egocentricity, and criminality. In the DSM-IV "Associated Features and Disorders" persons with ASPD are described as lacking empathy and they may have an inflated and arrogant self-appraisal, display a glib, superficial charm. These features also apply to psychopathic personality disorder (PPD). Additional diagnostic characteristics of psychopathy, which are not included in the DSM-IV criteria of ASPD are absence of delusions and other signs of irrational thinking; absence of "nervousness' or psychoneurotic manifestation; and incapacity for love; specific loss of insight; unreliability; untruthfulness and insincerity; suicide rarely carried out; sex life impersonal, trivial, and poorly integrated (Cleckely, 1984); a conning/manipulative attitude; a parasitive lifestyle; proneness to boredom/need for stimulation; pathological lying; promiscuous sexual behavior; and grandiose sense of self-worth (Hare, 1998). Today the official term is antisocial personality disorder as defined in the DSM-IV (1994).

Introduction

Freud (1932) wrote, "Aggressiveness is an inherited, independent and instinctive disposition in human being," and, "Civilization tries to put up barriers against the human aggressive instinct." Freud cited Schiller by saying that the greed of love lets the world turn around, and he suggested that the aggressive instinct is subordinated to our self-defence. But, he stated also that the aggressive instinct is in fact a death-instinct that is opposite to the life-giving and pro-social erotic instinct and the society that creates this instinct.
PPD and ASPD are significantly linked to violence (Hicks et al., 2000; Martens, 1997, 1999, 2000), aggression (Edens et al., 2001; Martens, 1997, 1999, 2000), anger and impulsivity (Grisso et al., 2000; Martens, 1997, 1999, 2000; Myers & Monaco, 2000). Violence and aggression in PPD and ASPD correlates with poor health (Johnson, 1990); poor neurobiological functioning (Martens, 2001a); social-emotional learning process deficits (Birnbaum, 1914, Martens, 2003b) verbal and cognitive dysfunctions (mainly in aggressive psychopaths with low intelligence), stress and an inability to internal dialogue (Miller, 1987) and associated lack of modulation of attention, affection, thought and behavior.
Psychopathic and antisocial aggression (which is a diagnostic feature) is intertwined with other psychopathic/antisocial characteristics such as impulsivity, irritability, hostility; lack of remorse and guilt; lack of empathy; irresponsible behavior; sensation seeking; recklessness; irresponsibility; incapacity for love; social-emotional and moral incapacities, - unawareness and/or - immaturity (Martens, 1997, 1999, 2002a, 2002c). Emotional, social and moral impairments might result in lack of empathy, lack of understanding of emotion, social and moral dimensions of life, and an incapacity for social-emotional interactions. Impulsivity contributes to the process of psychopathic/antisocial aggression by means of frequent neurobiological determined irrational, unconscious, sudden stimuli that may lead to aggressive acts (Martens, 2002c). Social, emotional and moral aspects of aggression in ASPD and PPD may also be determined by neurobiological dysfunctions (Martens, 2000, 2002c) such as brain injuries, frontal lesions (Martens, 2000), poor prefrontal functioning (Herpertz & Sass, 2000), frontotemporal dysfunctions (Mychack et al., 2001), cerebrovascular disorders, EEG-abnormalities, low serotonin (5-HT), SCF 5-HIAA (5-hydroxy indoleacetic) (Martens, 2000), genetic factors (Martens, 2000) and a history that is characterized by physical/sexual abuse; chaotic family life; lack of parental guidance; parental divorce, drug abuse, and/or antisocial behavior; adoption; neglect and rejection; poor neighbourhood (Martens, 1997, 2000).
Aggression in ASPD or PPD is frequently considered as a form of unreasonable, impulsive-irritative acting out. However, psychopathic and antisocial aggression may be linked to (hidden) non-aggressive motives and purposes such as efforts to restore a sense of self-esteem, self-confidence; external locus of control; expressions of assertively, reduction of pain and frustrations (Martens, 1997). But, the psychopath is frequently unable to cope with problems and to satisfy his needs in a non-aggressive way. It is clear that the intensity of the aggression in PPD or ASPD is often not in due proportion to the provocation of that moment, if there is any provocation at all. Moreover, the psychosocial origins of their aggression can be mostly found rather in the past than in current frustrating events and/or experiences (Martens, 1997).

Differences Between Psychopathic and Other Forms of Aggression

Moyer (1968) offers us the following useful definition of aggression. He considers aggression as behavior that leads to, or seems to result in damage or destruction of a target entity. According to Daniels et al. (1970), violence or destructive aggression should be understood as (the involvement in) inflict of injuries on other persons and/or dealing with damages of other's properties. From my point of view, it is desirable to make a distinction between aggression (hostile or destructive tendency or behavior) and violence (intense, vehement, passionate, furious, impetuous, vivid actions; which involves a great force). In the rest of my paper I will make this distinction.
In my opinion, the following classification of Moyer (1968) is the most adequate and successful effort to make a subdivision of the range of aggressive and violent behavior: predatory, intermale, frightening, territory, maternal, and instrumental. This wide spectrum of aggressive/violent behavior, however, can be divided in two main categories, namely affective and predatory aggression/violence, which follows different neuroanatomic pathways that were controlled by distinctive sets of neurotransmitters (Eichelman et al., 1981; Meloy, 1988). Psychopaths demonstrated mainly predatory (Martens, 1997, 1999) and instrumental expressions (Martens, 1997, 1999; Woodworth & Porter, 2002) of aggressive/violent behavior, which seem to be most effective in attaining their goals and gratifying their needs. In fact, many violent psychopaths behave like wounded predators and are continuously dangerous because of their life-long pain (Martens, 2002a).

Motives and Intrapsychic Constructive Mechanisms which Underlie Psychopathic Aggression

  • Psychopathic and antisocial aggression/violence might be linked to the following motives and/or intrapsychic constructive mechanisms:

  • Self-defence and/or prevention of depression, psychosis, suicide (Cleckley, 1984; Martens, 1997), loss of self-respect and/or self-confidence (Martens, 1997);

  • Restoration of self-organization, -structure, -confidence and positive self-image after disillusion, frustration, disappointment and/or harmful or threatening actions of others (Martens, 1997, 1999, 2002a); Masters, 1993a, 1993b);

  • An effort to control situations and/or persons as a consequence of a lack of positive coping - and social-emotional skills and/or social isolation (Martens, 1997; Masters, 1993a, 1993b);

  • An attempt to reduce pain from the past and/or today by hitting back. This can be considered as a form of self-liberation (Martens, 1997, 1999; Masters, 1993a, 1993b);

  • A desire not to hide their anger and associated emotions and the need to reject a) rational control and b) a civilized, over-adjusted attitude (Martens, 1997, 1999). The person in question can feel an intense need to acting-out, which may result in enhancement of his or her capacity for a) self-knowledge, b) reality testing, c) using relevant feedback of other people, which may contribute to social-emotional and moral maturation, and associated growth of self- and impulse-control (Martens, 1997, 2001c, 2003c);

  • An intense need to share their emotions with others by means of aggressive/violent acts. It may be an attempt to break through their social isolation (Martens, 1997; Masters, 1993a, 1993b);

  • Self-hate and associated hate of other people and the (unconscious) wish to understand that interactional mechanism of hate and self-hate (Martens, 1997, 1999, 2001b, 2001c);

  • Lack of understanding of and an aversion against the bourgeois and "narrow-minded" norms and values, which are the results of over-adjustment, conformism, fear, and lack of authenticity of normal people. Intelligent psychopaths are fully aware of those serious limitations and weakness of many normal individuals (Martens, 1997; 2003a);

  • Envious attitude towards normal people who experienced healthy upbringing in caring families, and who are able a) to adapt themselves to the rules of society and b) to interact adequately with other people and are able to love others. These normal persons have thus in many respects an advantage over psychopaths. However, psychopathic and antisocial envy of normal individual's life can bring about in some of these patients the wish and motivation for change of their attitude and adjustment to and participation in social life, which in turn might lead to improvement or remission (Martens, 1997);

  • A strong tendency to sensation seeking that is associated with lack of fear and excessive uninhibited drive (Lykken, 1995; Martens, 1997), which may lead to impressive, confronting and painful experiences that evoke self-insight, contemplation, and even remission (Martens, 1997, 2002a).

Self-defence, Obtaining and Maintaining of Self-Structure

Many psychopaths demonstrate violent and/or aggressive forms of self-defence and gratification of needs that might be brought about by deep-rooted frustrations and negative experiences in the past such as being rejected, neglected, abused, and humiliated; a lack of parental attention, warmth, guidance and chaotic and/or violent family life; parental antisocial behavior, - substance abuse and/or - divorce; and a bad and violent neighbourhood (Martens, 1997, 2000). It is quiet understandable that psychopaths, like normal individuals, try to avoid further negative, painful experiences. Antisocial and psychopathic persons did only learn antisocial coping styles and they believe that these are a) most suitable for surviving in a hostile world (Martens, 1997, 1999, 2002a), and therefore b) often unavoidable. Antisocial and psychopathic aggression might be an (unconscious) attempt a) to neutralize or eliminate devastating, harmful external forces, b) to remain or restore their self-respect, -structure, - esteem, -confidence and to "protect" their right to exist, c) to prevent in this way depression, psychosis, suicide, anxiety; and a poor self-organization, -structure and -image. Antisocial and psychopathic personalities demonstrate strong defence against depression and anxiety and they are characterized by an absence of depression and anxiety (Martens, 1997, 2000; Hare, 1998; Cleckley, 1984). Antisocial coping, however, may evoke depressive symptoms (Monnier et al., 2000). Since depression in ASPD and PPD may correlate with remission (Martens, 1997, 1999, 2002a), antisocial coping may contribute indirectly to the process of recovery.

Claims for Respect, Attention and Special Treatment

Many psychopaths realize continuously that their life is determined significantly by bad luck and adverse circumstances (this is discussed before) in comparison with the life of most of the normal people (Martens, 1997, 2002a). For that reason, most psychopaths require extra respect, attention, chances and special treatment of normal people, because they believe that they must be compensated by them for bad luck and negative experiences. Unfortunately, most normal individuals do not feel responsible for the psychopath's misfortune (many of them even do not know or are unaware of it). But, when others reject their claims psychopaths take often what they believe they deserve, if necessary in an aggressive way.
The hidden motives of the psychopaths' claims for respect, special attention and treatment could be linked to their (unconscious) conviction that in this way a) their emotional, social and moral capacities and self-esteem will increase, and b) that real attention, respect will heal the wounds caused by negative experiences in the past. The author speculates, that these claims of psychopaths are not necessarily (mainly) the product of narcissistic arrogance, grandiosity and/or excessive feelings of hate, but sometimes it may be rather the result of awareness of their limitations that could be discontinued by favourable and positive external stimulation.

Envy as Possible Link to Social Adaptation

In persons with ASPD and PPD envy can produce aggression, but in the long run as a result of the frequent imagination of the benefits of normal people's life they can feel the need to adjust themselves to normal social standards and rules. Aggressive envy is sometimes a kind of acting out, that may have positive side effects like a growing wish to transform their hate gradually in a kind of respect for the normal man's capacity to live a social and stable life and to build and maintain adequate and/or harmonious relationships with partner, relatives, friends and neighbors. Some envious psychopaths and antisocial persons believe that the gap between them and normal people is unbridgeable, and their anger and frustration will usually continue. But, individuals with ASPD or PPD who realize that (the benefits of) a normal life is also reachable and desirable for them may become gradually less and less envious (Martens, 1997). Martens (1997, 1999; 2002a) revealed that patients with ASPD or PPD in remission demonstrate gradually less envy of and more respect for normal individuals, and an increased wish and willingness to transform their attitude into a more social direction, although they continued to dislike the overadjusted and fearful attitude of many normal people. Some improved and remitted psychopaths have also learned to see the motives, limitation and adverse effects of their (aggressive) envy, and they became more and more able to convert those envious feelings into more positive and active prosocial emotions and life strategies.

Encounter with the Victim as an Expression of the Wish to Share Emotions, Reality Testing and Avoidance of Loneliness

Healing Effect of Encounter with the Victim

Many patients ASPD or PPD were witnesses to or victims of aggressive/violent acts in the past (Martens, 1997, 2000). The patients' aggression might be linked to his or her experiences as victim or witness in the past. Unfortunately, many of these patients do not make an association between their aggressive/violent acts and their own experiences as victim of aggressive/violent behavior. Nevertheless, during some aggressive/violent acts this link between the psychopath's own suffering from aggression in the past and active aggression/violence may be restored (Martens, 1997, 1999, 2001c, 2002a). The patient can experience an intense wish for constructive and pro-social change and further social-emotional and moral development (which may lead to recovery) as a consequence of a) effective confrontation with the victim or other people's responses, b) and eventually associated shame or remorse (there is an example of a psychopath who experienced deep shame and remorse after that he had killed his victim who wanted to pray first in order to find a solution), c) full awareness of the suffering of and correlated awakening of empathy with their victim, d) realization that not the victim caused his or her suffering but rather other individuals in the past, e) recognition that the victim in not a thing but a human being (the psychopath is not able anymore to devaluate the other person)..

Sharing Emotions with the Victim

Aggressiveness in ASPD and PPD can be an effective strategy to attract (emotional) attention from others, because of the victims fear, intimidation, suffering, and dependence of the aggressor's power. Some antisocial and psychopathic individuals need desperately attention, they even prefer negative attention over an absence of attention. Some psychopaths are inspired to aggressive actions by a deep-rooted need to share emotions with their victims (Martens, 1997). Many normal individuals try to avoid serious contact with patients with ASPD or PPD, and most patients are aware of that and they like to create circumstances in which the victim cannot escape (Martens, 1997). Some aggressive patients with ASPD or PPD have the desire to let their victims suffer in such way, which is comparable to their own intense suffering. In this way they want to share their pain with their victims. By means of such interaction these patients hope (unconsciously) to evoke or to increase the victim's comprehension of the aggressor's emotional and mental condition. However, some aggressive/violent patients with ASPD or PPD become aware of this intrapsychic mechanism, and try to reduce these violent impulses when they realize that the suffering of their victims a) is not identical with their own suffering, b) will not contribute to the victims understanding of the patient's suffering, c) can not provide a solution of their own suffering, d) is not justified because these victims do often not have caused their pain. This might be the road to improvement or remission (Martens, 2002b).

Reality Testing

Psychopathic and antisocial aggression may lead to a) reality testing, and associated b) exploration of their external and internal world. Some persons with ASPD or PPD are able to reveal during their numerous acting outs the real motives and targets of their aggression or violence. They can find out that particular situations and/or persons in the past, rather than current events and/or individuals provoke their anger, frustration and (self-) hate. When these patients become aware of this translocation of hostile emotions from the past into today, they might be able to correct their current impulses and behavior, eventually supported by psychotherapeutic, psychopharmacological, and/or neurofeedback treatment (Martens, 2002a).
There are amazing examples of victims who were able to show their aggressor in an impressive manner their anger, anxiety, gentle emotions, or in contrary a their fearless, strong, gentle and/or elevated attitude (Martens, 1997, 2001c). It is possible that a victim makes clear that his or her emotions and interests are as valuable as that of the aggressor, and/or what the exact reprehensible aspects are of the aggressor's behavior. The victim can become actually the "winner" of this confrontation, when he or she succeeds to make the aggressive psychopathic or antisocial patient aware of the reality of that moment, the unknown dimensions of his or her behavior, and the emotional world of the victim.
Martens (1997, 1999, 2001c) discovered that some aggressive patients with ASPD or PPD in remission are increasingly interested in and capable to utilize feedback provided by their victims or other involved persons. As a result they may become more and more aware of the negative consequences of their behavior. The aggressor might be influenced so much by their victim that they may change their attitude, or show after such violent acts more and more confusion, depression, despair, and associated growing emotional social and moral awareness (Martens, 1997, 1999, 2001c), which may lead to improvement or remission. During agitation therapy in forensic psychiatric settings aggressive antisocial and psychopathic patients may learn in a controlled and structured way (is also a form of reality testing) from their own aggression and the responses of other patients and staff members (Martens, 2001c). As a consequence, the patient may become aware of all unknown dimensions of his or her behavior and personality, and the consequences of his or her aggression. Antisocial and psychopathic patients may experience how their aggression/violence is linked to their emotional, social and moral immaturity and this awareness may awake an intense need for change and maturation (Martens, 2001c). By means of ethics therapy these patients might increase their moral and associated social-emotional awareness and capacities and reality testing, which may form a stable basis for long-lasting change, maturation and reduction of aggressive behavior (Martens, 2001b). This is the first important step to recovery.
Psychopathic or antisocial persons in remission are able to react increasingly mild and gently upon threatening and/or frustrating events and persons, because they realize that they are capable and mature enough:
- not to associate frustrating or threatening incidents and/or individuals constantly with negative events or persons in the past,
-to experience and maintain self-respect, self-structure and their right to exist despite of painful and frustrating experiences,
-to gather positive experiences as a result of their growing social, emotional and moral capacities, which can compensate and/or make it possible to consider negative experiences in the right perspective and/or bring them back to the right proportions.

Psychopathic Violence As a Result of Unbearable loneliness

The major reason for psychopathic violent acts in some serial killers such as Jeffrey Dahmer and Dennis Nilsen was unbearable loneliness and an intense need for human company. When they took strangers home, who were superficial encounters from gay pubs for one-night sex, they sometimes feared so desperately to be left alone again soon that they murdered them. They did not enjoy the act of killing itself, they said, but it was just a necessary evil. Dahmer and Nilsen told that they did not hate their victims (Master, 1993a, 1993b). Nilsen and Dahmer were unable to interact adequately with living human beings and they felt much more comfortable with dead bodies. Their violent behavior was not only an expression of terrible suffering from loneliness, but it was also an attempt to survive. As a consequence of their incapacity to make friends and associated social isolation they felt so worthless and empty that only killing for company could fill up this gap somewhat. In this way they also tried to revive themselves emotionally and socially. Nilsen wrote poems for his dead victims, he talked to them, watched TV with them, admired their beauty, and felt empathy with their unlucky life (Masters, 1993b). Killing for company was away to regain and maintain some control over their life, while their control was lost in other important domains of their life.

The Need for Punishment

Freud (1916) and Reich (1946) wrote that some criminal psychopaths feel unconsciously guilty, and experience relief when they were caught and punished. Psychopathic serial killers like Dennis Nilsen and Jeffrey Dahmer are good examples. They felt indeed relief after arrest and showed a cooperative, communicative and honest attitude towards the police, prison staff and psychiatrists (Masters, 1993a, 1993b). Dennis Nilsen wanted to talk about his crimes so very badly that he even could not wait to make his confessions until they arrived at the police station (Masters, 1993b). This need for punishment and the fact that some persons with ASPD and PPD even orchestrate their own arrest can be considered as a gesture of reconciliation and a sign that they are aware and feel guilty of their deviant behavior. In these cases, the patients' conscience is in conflict with their aggressive and other antisocial impulses, and it is linked to a (growing) wish/need a) to keep control over or b) to eliminate their antisocial and psychopathic features (Martens, 1997, 1999), and/or c) to transform them in social acceptable traits (Martens, 2003c).

Self-hate and Associated Aggression Towards Others

In spite of the arrogant and narcissistic attitudes of patients with ASPD or PPD, their aggression is often grafted onto self-hate, because these patients are aware of their social- emotional limitations, hidden feelings of inferiority, and involuntary expressions of deviant behavior. Many patients with ASPD or PPD wish, at least episodically, to change their personality and behavior in order to avoid excessive interpersonal difficulties and to become a normal person, because they dislike their antisocial attitude (Martens, 1997, 1999, 2002a). But, as a consequence of their neurobiological abnormalities and/or adversive psychosocial factors, they are not capable to realize such difficult and radical transformations on their own (Martens, 1997, 2002a). Aggression towards others is frequently an act of self-destructiveness too, because the mind that produces, prepares and realizes the destruction of others, will be "infected" by those negative thoughts and emotions. Nonetheless, self-hate, and (self-) aggression/violence may have instructive moments. Aggressive/violent behavior will be often coupled with feelings of power and victory, but afterwards as a result of introspection and/or contemplation some patients with ASPD or PPD (who are vulnerable to remission) may experience doubt, depression, shame, and feelings of powerlessness (because of the involuntary, impulsive nature of their behavior) and associated low self-esteem. In fact, in their good moments these patients wish, like normal human beings, to have influence on other persons in a controlled, non-aggressive, positive and social way, and they realize that they need meaningful, intense, affective relationships in which equivalence plays an important role. This awareness can be the start of seeking (neuro)psychiatric and psychotherapeutic help. However, as a result of growing self-knowledge (and insight in their limitations) some patients are able without professional help to obtain gradually more and more control over their destructive impulses and to increase their social, emotional and moral capacities.

Aggression As A Search for a New Balance

Aggression or violence in ASPD or PPD may be a trial to find a new periodical and finally a more profound, long-lasting mental and social-emotional balance and associated healthy neurobiological functioning. Martens (1997) observed that aggressive and violent patients with PPD or ASPD (with and without neurobiological determined aggression/violence) calmed down episodically. The very relaxed condition of psychopaths between episodes of acting out and other restless behavior is characterized by a) a remarkable absence of active neurobiological determination of aggression, violence and impulsivity, and b) stabilized mood as a consequence self-healing psychophysiological (normalization autonomic activity/reactivity) and neurobiological mechanisms (normalization of biochemical correlates of impulsivity and aggression) of the acting out (Martens, 1997, 2001a). Martens (1997, 2001a) hypothesized that remitted and improved psychopaths have learned to anticipate and use this self-healing psychophysiological/ neurobiological mechanisms in order to prevent episodically excessive and aimless aggression. In a further stage they may also learn to recognize, foresee, prepare on and cope adequately with risky situations (Martens, 1997, 2001a, 2002a) by means of a) analysing their own experiences concerning aggression, b) reality testing, c) self-knowledge, d) enhancement of social-emotional and empathic (moral) abilities, and e) growing awareness of the negative consequences of their violent acts.

Case Report of a Violent Sexual Psychopath in Remission

Robin grew up in a working-class family and was the youngest of five sons. His mother was very emotional instable and physical vulnerable, and his father was an aggressive, antisocial, authoritarian man, who required of his sons a Spartan, tough attitude. Robin, however, was a very sensitive, insecure boy who suffered from a serious eye disease. Furthermore, he was crossed-eyed. He felt inferior because he could never fulfill the requires of his dad, and because of his handicap. Only with his mother he developed a strong bond. His father, brothers, and peers rejected him, and as a result he developed gradually a manipulative, histrionic, unreliable, disobedient, aggressive, and ruthless attitude. But, at the same time he was a lonely boy who missed friends and positive attention. He revealed that he felt better when he was cruel to other children who rejected him. It was a way for him to save his honour and to regain his self-esteem, because he had the power to punish those who made of him a cast-out. During his puberty Robin struggled with strong sexual feelings, and he suffered from his incapacity to make social contacts. He made numerous fruitless attempts to get a girl-friend or a boy-friend. At the age of 15 he sexually assaulted a 5-year old girl. After his arrest and during psychiatric examination he demonstrated no sign of guilt or remorse. He said that this was the only way for him to gain sexual experiences. He was sentenced to 1-year juvenile prison. After his discharge he finished secondary school and he had numerous jobs until he was 22 years of age. Since a couple of years he had dubious friends and Robin was aware of it, but bad company was better than loneliness. When he was 22 he sexually assaulted 2 little boys and again he was arrested and was sentenced to 3 years prison. One year after his release he got a relationship with a girl of 17. That relationship gave him for the first time in his life a safe and nice feeling and he believed that he was on his way to become a normal person. He loved her and he gave her many presents. Unfortunately, after a year the girl broke off their relationship. Robin was now 26 years of age. As a consequence of this experience he became very angry and emotional unstable, and he suffered from a very negative self-image. A few weeks later he raped an 18-year old girl, while threatening her with a knife. He was arrested and the forensic psychiatric assessment revealed that he suffered from a psychopathic personality disorder (see diagnostic criteria). He declared that this rape was an unavoidable act, because of his lust, and, moreover, he needed revenge, control and affection.


During his 7 years forensic psychiatric treatment Robins development was remarkable. In the first episode of 2 years he refused all kinds of therapy except labour-, sports-, drama-, and sociotherapy. Because he needed physical affection he played around or have a romp with other fellow-patients or staff members as much as he could. He also demonstrated cross-bordering behavior towards female staff-members of the clinic, and he was deeply emotionally injured when they reprimanded him. He had an attitude of "I get what I a want, because I deserve it." Gradually he formed a bond with his female mentor/sociotherapist. During his 5-th year of residence there was an accident, which was crucial in his development. A fellow-patient made perverse remarks to his female mentor. Robin became so angry that he stabbed this men several times with a knife and raped him. He reported that this man showed him his own perversions and limitations and that it in fact on act of self-punishment, reality testing, self-insight, willing to change and catharsis. After this incidence Robin was replaced to another forensic hospital where he worked hard during psychotherapy to work out this experience and his core problem. He showed gradually a more open mind, and increase of social-emotional and moral capacities, and a decrease of cross-bordering behavior towards women. Furthermore, he seemed in remission, and he did not meet the criteria of psychopathy anymore. After discharge from forensic psychiatric treatment he got a job. Since 12 years he is happily married and has two children. Robin is now 15 years a free man, and he never reoffended.

Discussion

Until now, hardly attention was paid to the constructive functions of psychopathic or antisocial aggression and violence. There exist many non-aggressive motives of aggression and violence in ASPD and PPD such as need for restoration of self-structure, self-esteem, gathering of valuable feedback, finding of a new balance, locus of control and so on.
In order to provide adequate treatment and prevention programs more research is needed into:

  • The distinctions in psychosocial and neurobiological correlates of aggressive behavior manifestations between ASPD/PPD patients with good and poor outcome.

  • The possible impact that ASPD/PPD patients may have on their behavior. When necessary some antisocial and psychopathic patients seem suddenly able to change their violent behavior. For example, an extremely violent psychopathic murderer decided to stop his violent behavior (and succeeded immediately), because otherwise his wife wanted to divorce from him (Martens, 1997).

  • The role that aggression plays in the character and behavior of psychopaths and antisocial persons in remission.

  • Self-reports of patients with ASPD or PPD who transformed their hostile, antisocial attitude into (a more) social attitude.

  • How and when correlate non-aggressive motives precisely with aggressive and violent acts in ASPD and PPD.

  • The differences of constructive functions of aggression and violence between the various categories of psychopaths and antisocial persons, and its implications for treatment and prevention. Martens (1997) found remarkable distinctions between various categories psychopaths such as violent sexual psychopaths, violent non-sexual psychopaths, frauds, fire-setters, and non-criminal psychopaths. For example, fire-setters and violent pedophilic psychopaths behave smooth and over-adjusted, and they demonstrate usually only violent behavior towards their victims during criminal acts, whereas aggressive non-sexual psychopaths and non-criminal psychopaths demonstrate frequently maladjusted and overt aggressive behavior. Most psychopathic frauds, however, do not show physical aggression or violence at all, but demonstrate just manipulative, misleading behavior, blackmail and/or extortion (which could be regarded as non-physical aggression).

  • The precise nature, course, and correlates of psychopathic and antisocial aggression in distinctive categories aggressive patients with ASPD or PPD such as sexual, aggressive non-sexual offenders, firesetters, and frauds.

Dangerous behaviour of mentally disordered individuals in the Community.

Introduction

Richard Harvey from the Royal College of Psychiatrists asked a group of psychiatrists on-line among other things, about community treatment of dangerous offenders. My response prompted Ben Green, Editor of Psychiatry On-Line, to suggest an article on the subject. I am happy to comply. The discussion will focus on the Province of Saskatchewan, Canada because that is where I practise and with which I am most familiar.

Saskatchewan was a world leader in implementing the effective discharge of patients from large asylums. Its move began in 1964 with the establishment of community mental health centres throughout the Province and regulations for the use of approved homes, community psychiatric nurses and facilities for re-integrating the mentally disordered into the community. The Province in 1994 had a new convulsion in Health Services with the establishment of Health Districts each of which is theoretically autonomous for Mental Health. In practice the established Mental Health Centres, associated as they are with general hospital inpatient facilities and larger urban groupings, are still used and their services purchased for needy patients from smaller Districts.

Again, accompanying this move to Districts there have been some changes to the Mental Health Services Act that have given some cause for concern. The current rule is that for a person to be detained involuntarily (certified) in a Mental Health Facility [Psychiatry ward] the following conditions must be met:

The person must be mentally ill
The person must require treatment that will probably improve the illness
The person must refuse that treatment.
The illness must be such that it results in danger to the person or to others or if it continues will result in continuing deterioration in the person's health.

A certificate written by an admitting physician who must practise in the facility, is valid for three days during which a second certificate can be written by a psychiatrist to detain the person for a maximum of three weeks. Many appeal processes are built in as are prohibitions against using any experimental or neurosurgical techniques on a certified patient. For continuing treatment there are several mechanisms now being used:

1. A repeat of the original detention certificate by two doctors one of whom must be a psychiatrist and both of whom must practise in the facility.
2. A Certificate of Incompetency, which allows others to take over limited areas of the patient's life (especially financial).
3. A Community Treatment Order requiring the person to take specific treatment at home or be readmitted involuntarily introduced in 1995.
4. A Dependent Adults' Certificate which can allow up to year at a time of detention introduced in 1994

The last three certificates require appearance before a judge and a judicial ruling.

Saskatchewan has, in addition to its Mental Health Services, a forensic system consisting of a range of services from private psychiatric practitioners to a Regional Psychiatric Centre operated by the Federal Government. There is continual pressure to reduce the length of stay or not admit mentally disordered persons unless their plight is extreme. Long stay and particularly long stay for cognitive impairment is sharply discouraged as is the admission of children to mental health facilities [there are none.]

The dilemma is always where to place an individual who may be dangerous to the community. Should such a person be in hospital ( for treatment of an underlying condition increasing the danger ?) Should they be in prison to provide security for the community and receive whatever "treatment" is needed in a prison centre ? Should they be managed in the community to limit costs and hospital overcrowding? Can this type of behaviour also be seen as a manipulation leading to the protected comfort of hospital or even prison as opposed to the demands and stress of the community ? These questions are the areas discussed in this article.

Despite the repeated urging of researchers, the use of pilot projects and management research is woefully underused. Decisions regarding the whole system are made by industrial managers and based on political expediency instead of by health care professionals and based on patient and family need. We have few test labs for experiments to study the impact of one policy over another. Perhaps it is time for these to be conducted. However, this is for the future. Let us consider the present.

Dangerousness and Mental Disorder

Not all mental disorder is associated with, nor induces dangerous behaviour. Equally, not all dangerous behaviour has a mental disorder at its root (at least as currently defined.) There are perhaps precedents in which suicide has been committed "while the balance of the mind is disturbed" and for while virtually all suicide was seen in this light.
We now recognise altruistic suicide and rational suicide as subtypes where the mind is not disordered. Indeed there are societies that advocate the use of suicide and the "right" to suicide in certain circumstances. In the United States there is a very active debate on whether a person should be charged for assisting someone who wishes to commit suicide but despite laws enacted, juries refuse to convict.

We do not universally recognise altruistic murder nor active euthanasia but do recognise "rational" murder in executions, war and in removing the life support systems in people who are terminally ill. So there are many pitfalls in the legal and ethical definitions of what constitutes the most extreme forms of dangerous behaviour. We have therefore to come to some agreed-upon conclusions about which forms of dangerous behaviour we wish to limit or eliminate in the community. We have to balance safety for the dangerous one and the putative victim with optimal treatment of any underlying mental disorder. And it is certainly true that certain mental disorders associated with fixed and obsessive thinking, impulsivity, hormonal imbalances, substance abuse, fear, depression and suspiciousness or with a constitutional lack of moral development are more likely than average to produce dangerous behaviours. These behaviours are likely by their nature, to be unpredictable.

Dangerous behaviours

The community tends to be scared of certain forms of behaviour more than others. They are worried about personal safety and about behaviours like 'stalking', 'assaultiveness', ' sexual predation', 'kidnapping', 'murderous predation' and 'terrorism' or group threats of assault andmurder. These aggressive invasions of personal space often have mental processes underlying them. They may be perceived by the aggressor as sensible, logical, justified and "right". To the victim they are never any of these things. To the observer they may one or the other depending on circumstances.

Underlying thoughts may be divided into ideas of omnipotence or grandiosity, a false assessment of "justice", suspicion of others planning or plotting against one, or obsessions such as those of erotomania, guilt, revenge, and so on. These thoughts may be accompanied by more dramatic effects such as hallucinations, delusions, illusions, or ideas of being controlled. These are familiar signs of mental disorder as we pass from errant thoughts to rooted obsessions and from internal experience to external actions to try to correct these. As psychiatrists say, there is movement from egosyntonicity to egodystonicity. Ordinarily we exert considerable control over our thoughts and test them against reality constantly. When this facility is compromised or absent, problems arise with more intelligent people more likely to have difficulty because of the range and variety of their thoughts. So should we "lock up"all intelligent people because of the possibility that they might be dangerous at some time ? Of course not.

Beneath the dangerous thoughts lies a layer of hurt or angry feelings. These feelings are seen as the engines of the thoughts, making them persist in the face of rationality. Fears lie beneath suspicions, anger beneath vengeance, misery beneath hopelessness, pain beneath all, loneliness beneath guilt and self blame and hunger beneath the various desires. These desires - sexual satisfaction, food, fluids, air, substances (for the addicted), company and love, religious ecstasy, domination are strong motivators although they must be expressed via feelings and thoughts and be subjected to rational filters before being implemented. And above them all, does the offender WANT to be dangerous or perhaps NEED to be dangerous. This is a question we should perhaps try to answer before passing judgment or sentence.

Managing dangerousness & chronic mental disorder

Currently we try to deal with aggressive individuals by preventing the acceptance of hostile aggressiveness in Society through early education by parents and school teachers. Modern examples of this approach are the attempts to reduce bullying and sibling fighting and the re-training of males to respect and discuss issues with females. These methods are slow but could prove to be effective in the long run. In those places where effective programs are in place it will be years before the results can be measured and even then intervening variables may cause confusion. So again, we are left with a dilemma - should we implement such programs everywhere or to wait for the pilot results, even interim ones ?

Potentially dangerous people may be recognised through their childhood behaviours but the remedies are less obvious. Many more children exhibit the potential than eventually become dangerous but the seeds are sown early in those whose moral development is stunted or absent. This in turn may be biological like attention deficit disorder or learning disability. Some of these early problems Bowlby attributed to maternal deprivation but that has been demonstrated to be reversible by proper foster care. Some are related to attention deficit hyperactivity disorder where again we have treatment assistance available. Some however, of these conduct-disordered children do go on to become conduct-disordered adults with disastrous consequences for the community . Should we have screening programs in place to identify all children with aggressive tendencies and require parents / teachers / therapists to deal effectively with this problem when found?

Applying corrective techniques -usually some form of positive parenting as soon as possible - has been shown to produce good results. This is the form of discipline now favoured, although in Sweden confrontation and angry word exchanges are preferred over the old corporal punishment techniques. But, do we have long term studies that show these methodologies are successful in the long term? Has the dropping of corporal punishment in Sweden resulted in a lessening of dangerousness in the community ? We need to know the answers from these social experiments.

The interesting point is that as aggression increases, the rejection by others increases and the sense of rejection increases, leading to more need for revenge and the cycle continues. Social skills training on a steady and regular basis is called for, with children being involved in as many combinations and permutations as possible of cooperative activity as they learn to work with and for others, reducing the need for aggressiveness from loneliness or frustration.

Working through the family is an attractive option. Mediation, coercion, assistance and support are increasingly available as an extremely expensive option. Canada has also brought in two recent laws to try to curb some of the aggression and predation: - anti-stalking laws are now available to assist women in their need to escape spousal abuse and threats of death or harm should they try to get away. Gun-control legislation is being introduced to try to prevent the large number of domestic aggression incidents and danger from the inappropriate use of guns.

Work continues too on the dangers of exposing of the public and segments of the public in particular to erotically stimulating literature where there is no outlet for the discharge for such heightened desires. Control of imported pornography, especially that using underage children and that demeaning women is increasing and film and video classification allows parents to be selective in their own as well as their childrens' viewing pleasures.

Canada has laws permitting a man to be excluded from the family home if he is abusive and indeed while under suspicion of being abusive. This avoids the need for the woman to leave although even with a restraining order the man may return and cause harm. The restraining orders need to be more effective and be combined with some sort of neighbourhood watch to assist the family settle down without the offender. Public and political solutions continue to be applied. The politicians may in their zeal to correct one problem over-regulate or arbitrarily deny other segments of the population their legitimate rights.

Although an option in Canada for the judges under the Young Offenders Act, parents are rarely held accountable for their children's actions. As a consequence there is a feeling that others are supposed somehow to accept the child's misbehaviour just as the parent has had to do. Is more accountability for parents with support from the community in parent training, discipline techniques and encouragement needed ?

For the aggressive dangerous person attempts are often made before going to Court. Bonds, undertakings to be of good behaviour, promises and contracts and warnings are used in schools and in Society by employers or family members. These mostly seem to be ineffective and rarely prevent the inevitable Court or Emergency Room appearance.

All these methods try to change the person's attitude - to encourage responsibility, increase self-worth, value others, follow the "Golden Rule," "to do unto others as you wish that they would do unto you." The attempts follow a set pattern of demonstration, explanation, recapitulation, examination, practice and progress. These methods often fall short in the first and third areas, especially demonstration, where people are urged to do as I say but NOT as I do. Successful dangerous behaviour is sometimes smiled upon by Society where unsuccessful dangerous behaviour is punished.

To move to the next phase of physically stopping the dangerous person we employ various restraints. We use physical restraint with greater violence offered to combat violence, chains and handcuffs, wounding with weapons, hunting, trapping and caging the dangerous person. We then try to force change by talking AT the person, using drugs to subdue or alter thinking, offering worse threats if the problem continues or using behavioural manipulation to change the person in the desired direction and ultimately removing the threat altogether by judicial execution (not in Canada.) An alternative technique is to change the person by fatigue, malnutrition or drugs until they are in a weakened psychological state and then offering a "way out" through some form of conversion - religious, political or other. These solutions are political mainly and not really for those mentally ill who "cannot help" the way they behave. Are there really any such ?

Thinking these days especially among mental health nurses, social workers and psychologists and physicians questions the role of the unconscious in motivation. The expectation on those who work in mental illness facilities is that the patients (clients) will control themselves and not harm the staff or they will be charged with offences. Substance abuse is met with discharge; violence against staff with discharge and a criminal charge. So these dangerous people are placed back on the street. Those who "slash" themselves to produce a counter pain to their depression and misery inside are not readmitted because the behaviour is reinforced by admission. Meanwhilethe police, seeing a tide of potentially dangerous persons being released onto the streets are calling for more punishment, more jails, They cannot accept bizarre behaviours, the baseless threats and the uncontrolled expressions of emotion. They call for more physical restraint but not necessarily more medication nor chemical restraint.

In the community, recovering alcoholics call for a ban on all psychoactive medication. They extol the virtues of the Twelve Steps even in inappropriate circumstances. They tend to deny the reality of comorbid disorder although there are some ex-addicts who seem to changing their minds at the moment. Another factor in current difficulties is the assertive expectation, supported from a feminist position, that all male physical aggression must be stopped. This limits the placement of an aggressive male back in his community. It also heightens the expectation that someone ( the hospital ?) must be held responsible for aggressive incidents. The expectation that aggression can and should be curbed is as common as the injunction that people should not smoke and probably for the same reasons - that others are affected.

Methods that have been tried where results are uncertain

The Community Treatment Order, law in Saskatchewan now since late 1995, permits a patient to be treated in the community and brought back into hospital if he or she fails to accept the treatment prescribed. It is regretted by most physicians who want a voluntary agreement with their patients for treatment; opposed by many patients who do not want to be "forced" to take medication and looked at askance by medical insurance companies who see legal wrangles ahead in which the prescribing physician will be held accountable for medication errors caused by a patient's self-administration of toxic compounds. In hospital these errors would be detected by nurses and stopped before damage was done. In the community with a non-consenting patient the scene is very different and the physician could be liable for damages.

The CTO requires supervision. This might be by the approved home manager or by a psychiatric home care nurse. One question that arises is how quickly should one return a non-compliant patient to the hospital. In some cases a person with schizophrenia and well established on medication could be left for three or four months before symptom recurrence. A lithium taker for bipolar disorder might go years without another episode. When exactly should a person be returned to hospital and would the order expire before a need demonstrated itself ?

As noted above some dangerous characters are required to live away from the targets of their special interest. In Canada we have one famous case in which a man persists in bothering singing star, Ann Murray. This is erotomania and nothing so far seems to have changed his fixation on her. Prison sentences have been carried out but he resumes his pestering immediately on discharge from jail.,

Canada has developed an anti-stalking law to try to make police action easier in these cases where even with a restraining order the stalker does not stop his behaviour. Of the cases involving stalking of course, the erotomanic is an irritating but less dangerous example than the man who being abandoned by a wife or mate who cannot tolerate his continuing jealousy and violence toward her, threatens to kill her and follows her everywhere. These individuals who threaten are not necessarily physically dangerous but are frightening. Should they be restrained like a serial assaultive male?

For these serial assaulters - people stuck in the mould of having their way, be it never so simple - forms of jail sentence and prolonging the sentence have been used. This process is extremely costly to Society and one would wish another solution. In Canada one possible solution proposed in the Province of Ontario (or course) where the administrators and politicians seem to have had little understanding of mental disorder, is to transfer offenders, identified as "dangerous" to mental health facilities for "treatment." This ignores the fact that they would not be in jail if they could have been treated in the first place and that hospitals are for treatment, not for detention and are much more expensive on the public purse than even prisons.

There is often no absolute requirement that a predatory offender be treated either voluntarily (best) or involuntarily if necessary to stop the behaviour. Lawyers prefer to send a person to jail where they can "do their time" and "pay the price" rather than to hospital for an indeterminate period of treatment. Thus a number of these predators are held in jail with no real attempt to change them. Opportunities are afforded them to practise their art of intimidation on other inmates.

Suppose these individuals were transferred to "hospitals." They are in prison now for at least 15 years before they can even think of parole. They have little to lose and will try manipulation on essentially defenceless mentally disordered persons and the nursing staff. Hospital security personnel who are not trained prison guards with appropriate back-up, will be supposed to control any incidents. At least in Saskatchewan currently we can ensure that a violent person is first detained in a corrections facility and treated there before transfer to a regular hospital for the next phase and prior to discharge there is always the option of returning the prisoner at any time to jail.

Increased security frightens and angers paranoid persons. It decreases the sense of trust that staff try to give to all patients and it turns the hospital into a jail instead of a place of safety, caring and healing. These dangerous people are mostly predators and given a victim population will surely seek their prey close at hand.

Isolation methods can be tried. Interestingly Saskatchewan has tried this too although the results are not to hand. A Healing Circle of First Nations people sentenced a male sexual predator to isolation for two years on a small island away from other people. He accepted the sentence and had served 9 months before a higher Court at the behest of the Crown said that this sentence was too light for his offence and sent him to jail. The Court felt that the sentence was not appropriate for the magnitude of the crime of spousal abuse and the victim agreed.

Part of the problem of dealing with dangerous person is fear for oneself. This type of person has already demonstrated a rejection of the rules by harming others and by treating him or her too lightly one condones and rewards the offence but if one treats the person harshly one confirms the negative opinion they have of Society and the whole situation may well worsen. This is a dilemma from the beginning and right to the end. Religious conversion has been known to succeed where all the coercion and "treatment" has failed. Love may well conquer but who has enough and is willing to risk everything including life for this damaged individual ?

Summary

This has been a discussion of some of the issues involved in the management of dangerous persons in the community from a Canadian and especially Saskatchewan perspective. The problems are fairly universal and solutions, if such there be, may come from anywhere in the world. It is important to retain an open mind and compassion for victims, dangerous offenders and fearful others and to seek to assist all in their pain and anxiety.

Can psychology, the law, social engineering, pharmacology or even love find a way ? What do you think ?