Guilty by Reason of Insanity: A Psychiatrist Explores the Minds of Killers

by Dorothy Otnow Lewis

Paranoia—the unwarranted sense that one is being threatened, endangered, disrespected—is probably the most common symptom fueling recurrent acts of violence. Jonathan and I have found that this is as true of violent juvenile delinquents as it is of violent adult criminals. This does not mean that most violent people are schizophrenic. As Jonathan and I teach our trainees at Georgetown and Bellevue, paranoia is characteristic of almost any neuropsychiatric disorder: schizophrenia, mania, depression, brain damage, seizures, alcoholism, senility, and more. It can emerge whenever something goes awry in the brain. Paranoia must have strong survival value. Doctors who fail to appreciate this basic psychiatric truth get hurt; some wind up dead.

In Georgia, defense lawyers are not allowed to be present during psychiatric evaluations of inmates.

People who do in family members tend, for the most part, not to be indiscriminately violent.

(1) the temperament to avoid locking horns; (2) the restraint at crucial moments to keep one’s mouth shut; (3) the sensitivity to discern when to break a silence; and (4) the intuition to sense when to end an interview.

interviews are not contests and there can be no bosses. Good interviews are collaborative;

the case of murderers, there are usually numerous psychiatric and neurologic reasons why memory may fluctuate and stories may vary. If Jonathan and I always dismissed memory lapses and contradictions as lies, we would overlook valuable clues to the nature of many violent acts.

many of these families would rather see their children put to death than reveal what had happened behind the closed doors of childhood. What is more, we would find that many of the adolescents themselves preferred death to exposing their abusive parents.

“soft signs”—that is, nonlocalized evidence of some sort of brain damage or dysfunction.

microcephalic. Her head, and therefore her brain, were significantly smaller than they should have been.

a normal EEG did not necessarily mean that a person did not have seizures. In between seizures, even people with grand mal epilepsy might have a normal EEG. If you get three or four EEGs, you stand a better chance of picking up a seizure disorder.

But something seems to happen to these children, or to their doctors, when the children reach about five foot, two inches in height. The very same children that the doctors saw as hyperactive, or brain damaged, or borderline psychotic when they were, say, four foot, nine inches, now look different. Diagnoses change. Schizophrenia, ADHD, and organic dysfunction of one sort or another turn into conduct disorder. (The term conduct disorder is relatively new. Years ago, when Jonathan and I trained, the term for the same set of behaviors was unsocialized aggressive reaction; such is progress.) A look at the children’s charts will reveal in an instant that their symptoms or behaviors have not changed, just their size. They still hallucinate occasionally, or can’t sit still, or feel persecuted. In fact, just about every psychiatric disorder of childhood can manifest itself as a behavior problem. No matter. That is why so many children who arrive at Long Lane with the diagnosis of conduct disorder once suffered from other potentially treatable disorders. Unfortunately, there is no specific treatment for conduct disorder. As time goes on, the diagnostic metamorphosis continues. Adolescence progresses and the children get even bigger. Now age dictates diagnosis. Eighteen is the magic number that transforms the diagnosis of conduct disorder into antisocial personality disorder, or what used to be called sociopathic personality. Once again, nothing much about the patients has changed—...

Doctors are taught to base their diagnoses on patients’ symptoms and signs. Symptoms are the subjective discomfort patients experience and can talk about. Signs are what doctors see for themselves. Doctors don’t mind spending time with small patients or even with big, docile ones. We listen to them. If these patients have trouble talking, we eagerly help them express their thoughts and feelings, describe their pain. Contrariwise, we don’t much care for large, violent patients. That’s understandable. They scare us, especially patients who have already been designated delinquent or criminal. Hence, we don’t spend a whole lot of time helping those patients relax enough to confide their symptoms. The problem with symptoms is that, unlike signs, you can’t see them. Symptoms must be verbalized. Even then, doctors have to be close enough to hear. Because we doctors tend to keep our distance from big, violent patients and minimize the time we spend in their company, their diagnoses often rest on signs, not symptoms.

There are books—diagnostic manuals—that tell doctors how to diagnose. Some psychiatric diagnoses reflect symptoms. Take schizophrenia. To make that diagnosis, the patient tells his doctor that he hears voices, feels persecuted, believes he is controlled by outside forces. Or consider depression. To diagnose depression, doctor and patient must talk with each other at length. The patient tells his doctor he feels sad, doesn’t want to eat or have sex; he says he sleeps badly and sometimes feels the urge to kill himself. We listen carefully. These symptoms, elicited over time, add up to a diagnosis of depression. Then there are diagnoses based on signs—just signs. They reflect what the patient does, not what he thinks, feels, or experiences in his mind. Conduct disorder is such a diagnosis. To make that diagnosis, a child must manifest three or four undesirable behaviors from a list of over a dozen. Thus the child who steals, lies, runs away, or the child who fights, smokes pot, and tortures cats, has a conduct disorder. One hardly needs a diagnostic manual to come to that conclusion. One doesn’t even need to be a doctor. When

the most aggressive delinquents I saw tended to have been the most severely disciplined.

What distinguished these homicidal young children from their less aggressive peers on the ward were signs of neurologic impairment, such as histories of seizures, and households filled with abuse and family violence.

People with soft signs can actually have tiny hemorrhages scattered throughout their brains. The lesions may severely impair functioning; they just can’t be localized.

Several of the murderers Jonathan and I have seen were advised by their ill-paid, ill-motivated attorneys, “Plead guilty and throw yourself on the mercy of the court.” Big mistake. Courts in the South are not noted for their mercy.

find that the claims of children are rarely heeded. Even judges, not to mention police officers, often dismiss what children say.

because different personalities or personality states tend to have different physiologic responses.

Freud had described the way we all tend to repeat or perpetuate the relationships we know. He called it a repetition compulsion.

Secrecy and safety, I have learned, are synonyms to protector personalities.

impulsiveness, labile moods, poor judgment, and paranoia of a prizefighter who has weathered too many rounds. But

When we don’t even believe that something is possible or that it exists, we fail to see it at all.

Ever since the advent of Thorazine and the like, with the slow demise of the state hospital system, prisons have become repositories of disruptive, impoverished, mentally ill men. Psychotic, aggressive men who just a few years ago would have lived out their days muttering quietly to themselves or raising havoc on the back wards of state hospitals now make the rounds of prisons, shelters, and a dwindling assortment of available public psychiatric institutions. About a third of their nights are spent tossing and turning on prison pallets; another third in shelters, on the streets, or “depending on the kindness of strangers”; and another third struggling to keep warm between the thin mattresses and polyester blankets of mental hospitals. Because so many poor, sick men now make their homes in prison cells, their keepers get lots of clinical experience—more, perhaps, than many psychiatric residents. As the guards become increasingly accustomed to this clientele, even their most psychotic charges start to look relatively normal.

In 1983, our own American Bar Association adopted a resolution opposing “in principle, the imposition of capital punishment upon any person for any offense committed while under the age of eighteen.”

“Johnny, you seem to be hearing voices that aren’t there,” I ventured. This is one of the dumber statements psychiatrists are taught to make. Jonathan and I have since dropped it from our repertoire for reasons that will become obvious.

we have seen more than a dozen violent men whose rage could be traced back to early, repeated experiences of being sodomized.

One person committed a murder, another dies for it.

The justice system is less wise and charitable than my children. It has trouble with concepts like maturation and change. The system acts as though a twenty-seven-year-old inmate who has not committed an aggressive act in ten years is just as violent and unthinking as he was at seventeen when he killed someone.

To understand sometimes means to forgive, and these days people aren’t in a very forgiving mood.

At this time it is safe to say that there is no known genetic abnormality associated specifically with violent crime. No particular national or ethnic or racial or religious group has proved itself to be innately and enduringly more violent than another. That is not to say that from time to time one or another group has not tried to so distinguish itself. There is, of course, a normal genetic condition, characteristic of about 50 percent of the human population, that is associated with violent crime: the XY syndrome, or being male. One can’t simply blame male violence on social conditioning. In almost every animal species—bears, chimpanzees, even fish and lizards—males are more aggressive than females. Male hormones, androgens, must have something to do with this phenomenon. If male animals are deprived of androgens at crucial stages in their development, they will not

When we disconnect the pathways between our reptilian brain and our frontal cortex, we no longer have good control of our urges. Accidents and injuries often do just that kind of damage.

diffuse damage to our brains, a common consequence of batterings, tends to make us more irritable and impulsive.

brain concentrations of substances like serotonin are not immutable. They are not simply genetic givens—experience affects them. Certain kinds of stressors can decrease brain serotonin levels and thereby change behavior. For example, if you isolate animals at crucial developmental stages, if you keep them caged all alone, their serotonin drops. What is more, when you then release them and put them in contact with other animals, they are fiercely aggressive. Pain and fear also reduce serotonin levels and promote aggression. That’s how pit bulls are trained to fight. Heat, crowding, discomfort, and upbringing by aggressive members of a species also increase animal aggressiveness.

the most important influence on how we treat others as adults is how we were treated as children.