Posttraumatic Stress Disorder (PTSD), Traumatic Brain Injury, and Criminal Behavior

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Posttraumatic Stress Disorder (PTSD), Traumatic
Brain Injury, and Criminal Behavior

• Rosemary Carr Malone, MD
• CDR, MC, USN
• Adult and Forensic Psychiatrist
• Bureau of Medicine Surgery
• Washington, DC
• 202-762-3010
• Rosemary.Malone_at_med.navy.mil
• March 2012

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• The opinions or assertions presented hereafter
  are the private views of the speaker and should
  not be construed as official or as reflecting the
  views of the Department of Defense, its branches,
  or the Bureau of Medicine and Surgery.

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Background

• PTSD DSM III, 1980 (Soldiers Heart/Civil War
  Shell Shock WWI Combat Fatigue WWII) MIND
  INJURY
• Characterized by the reexperiencing of an
  extremely traumatic event accompanied by symptoms
  of increased arousal and by avoidance of stimuli
  associated with the trauma
• Acute sx lt 3 mos Chronic sx gt/ 3 mos
• Delayed Onset Onset of sx at least 6 mos after
  trauma

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Background (cont.)

• Trauma Combat, Sexual/Physical Assault,
  Robbery, Severe MVA, Kidnapped/Hostage, Terrorist
  Attack, Torture, POW, Natural/Manmade Disasters,
  Life-threatening Illness, Witness Serious
  Injury/Death, Unexpectedly Witnessing Dead
  Body/Body Parts, Learn about Violent
  Assault/Accident/Injury, Learn about Sudden
  Unexpected Death, Learn about Childs
  Life-threatening Illness

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Background (cont.)

• PTSD and TBI caused by explosive blasts are
  considered the signature injuries of OIF/OEF

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PTSD Diagnosis (DSM-IV-TR, 2000)

• Traumatic event
• Reexperiencing (1 symptom)
• Avoidance (3 symptoms)
• Persistent arousal (2 symptoms)
• Begins at least one month after the traumatic
  event (delayed onset begins at least 6 months
  after event)
• Lasts more than one month and causes
  significant distress or impairment

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Traumatic Event

• Experienced, witnessed, or was confronted with
  an event/events that involved actual or
  threatened death or serious injury, or a threat
  to the physical integrity of self or others
• Response involved intense fear, helplessness, or
  horror
• Military Stresses of daily combat Witnessing
  death dismemberment Constant threat of suicide
  bombers (women, children) Insurgents blended in
  with general population

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Reexperiencing the Event

• Intrusive recollections (images/thoughts/
  perceptions)
• Recurrent distressing dreams or nightmares (often
  symbolic, not necessarily of the event)
• Flashbacks alteration of consciousness such
  that the individual believes he/she is again
  experiencing the traumatic event
• Intense psychological distress or physiological
  reactivity when exposed to internal or external
  cues that symbolize/resemble an aspect of the
  traumatic event

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Avoidance Symptoms

• Thoughts/feelings/conversations associated with
  the trauma
• Activities/places/people that arouse
  recollections of the trauma
• Inability to recall an important aspect of the
  trauma
• Markedly diminished interest/participation in
  significant activities
• Feelings of detachment/estrangement from others
• Restricted range of affect (i.e., unable to have
  loving feelings)
• Sense of a foreshortened future (i.e., career,
  marriage, children, normal life span)

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Arousal Symptoms

• Difficulty falling/staying asleep
• Irritability/anger outbursts
• Difficulty concentrating
• Hypervigilance - enhanced state of sensory
  sensitivity, exaggerated to detect threats
• Exaggerated startle response

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PTSD in Criminal Matters

• Severe mental illness is not a robust predictor
  of future violence (which challenges the
  assumption that severe mental illness is a
  foremost cause of violence in society at large)
• People with co-occurring severe mental illness
  and substance abuse/dependence have a higher
  incidence of violence than people with substance
  abuse/dependence alone
• People with severe mental illness report
  histories and environmental stressors associated
  with elevated violence risk

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PTSD in Criminal Matters (cont.)

• In most cases, PTSD does NOT lead to criminal
  behavior
• Symptoms of PTSD can incidentally lead to
  criminal behavior
• Plagued by memories of trauma, have high levels
  of anxiety, fear
• Psychological distress likely to influence mental
  ability to make well-reasoned responses
• Self-medicate with drugs and/or alcohol (cloud
  judgment, cause disinhibition)

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PTSD in Criminal Matters (cont.)

• Symptoms of PTSD can incidentally lead to
  criminal behavior (cont.)
• Emotional numbness
• Can lead trauma survivor to engage in
  sensation-seeking behavior to experience some
  emotion
• May contribute to wrongful or criminal behavior
  because of diminished empathy for the victim,
  difficulties feeling remorse for the act, and/or
  difficulty appreciating the severity and
  consequences of their behavior

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PTSD in Criminal Matters (cont.)

• Symptoms of PTSD can incidentally lead to
  criminal behavior (cont.)
• Some combat veterans also may seek to recreate
  adrenaline rush of combat (US v Tindall)
• Feeling need to be on guard can cause veterans
  to misinterpret benign situations as threatening
  (paranoia) and cause them to respond with
  self-protective behavior that may be aggressive
• Increased baseline psychophysiological arousal
  may lead to violent behavior out of proportion to
  a perceived threat

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PTSD in Criminal Matters (cont.)

• Symptoms of PTSD can incidentally lead to
  criminal behavior (cont.)
• Anger/irritability may lead to more aggressive
  responses
• Common for survivors to feel guilt, which may
  sometimes lead them to commit crimes that will
  likely result in apprehension, punishment,
  serious injury, or death

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PTSD in Criminal Matters (cont.)

• Direct link between particular trauma and a
  specific crime
• Crimes at times literally or symbolically
  recreate important aspects of trauma (State v
  Gregory, MD, 1979 Convicted then overturned on
  appeal)
• Environmental conditions similar to those
  existing at the time of the trauma may induce
  (violent) behavior similar to that exhibited
  during the trauma (People v Wood, IL, 1982
  NGBRI)

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PTSD in Criminal Matters (cont.)

• Direct link between particular trauma and a
  specific crime (cont.)
• Life events immediately preceding the offense can
  realistically or symbolically force the
  individual to face unresolved conflicts related
  to the trauma, which creates a disturbed
  psychological state in which otherwise unlikely
  behaviors emerge (State v Heads, LA, 1981
  Convicted, then overturned on appeal with verdict
  of NGBRI)

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PTSD in Criminal Matters (cont.)

• Direct link between particular trauma and a
  specific crime (cont.)
• Characteristics of crimes directly linked to
  traumatic events
• Often no criminal history
• Unable to offer coherent explanation of the
  behavior
• Difficult to discern any current motivation for
  the crime
• Choice of victim may seem accidental
• Apparently benign situation may result in
  violence
• There may be amnesia surrounding all or part of
  the crime
• May report numerous stressors prior to the crime
  that related psychologically or literally to the
  trauma
• Act may be linked realistically or symbolically
  to the original trauma (individual usually
  unaware of this connection)

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PTSD in Criminal Matters (cont.)

• Defenses
• Lack of mental responsibility (civilian NGBRI)
• West Point Graduate/Former Army CPT Sargent
  Binkley Case Nr. BB619426, Superior Court of
  Santa Clara County, CA, 2009
• Armed robbery of pharmacy for painkillers 2006
• NGBRI due to PTSD (Bosnia, Honduras)
• Impeachment of Witnesses With Caution
• PTSD as a result of event about which they are
  testifying May affect perception/judgment of
  event

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PTSD in Criminal Matters (cont.)

• Sentencing
• Mitigation
• Combat stress must be considered by a jury during
  the penalty phase of a capital case
• Porter v McCollum, USSC, 30 Nov 2009 Our
  Nation has a long tradition of according leniency
  to veterans in recognition of their service,
  especially for those who fought on the front
  lines as Porter did. Moreover, the relevance of
  Porters extensive combat experience is not only
  that he served honorably under extreme hardship
  and gruesome conditions, but also that the jury
  might find mitigating the intense stress and
  mental and emotional toll that combat took on
  Porter.

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PTSD in Criminal Matters (cont.)

• Sentencing (cont.)
• Victim Impact
• Payne v Tennessee, USSC, 1991 Allowing the jury
  to consider evidence of how his crimes affected
  his victims violated the 8th Amendment (Cruel and
  Unusual Punishment)
• Mother daughter killed (stabbed) 3 yo son
  survived (PTSD)
• USSC affirmed Paynes death sentence (6 to 3)
• Jury cannot make the punishment fit the crime if
  it does not know how the crime affected the
  victim/victims family

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PTSD in Criminal Matters (cont.)

• Sentencing (cont.)
• Rising number of panel members are likely to have
  combat experience and are likely familiar with
  PTSD and its effects
• Considerations
• Did the individual receive any treatment?
• What treatment will be available during
  incarceration?
• Litigation process itself produce sx similar to
  PTSD
• Accused may have developed PTSD due to the crime
  they committed (i.e., murder)
• Veterans Court
• First one in Buffalo, NY, 2008, Judge Robert T.
  Russell

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TBI

• TBI Injury to the head from a blunt or
  penetrating object that disrupts the function of
  the brain
• Falls, MVAs, Struck By/Against Objects, Assaults
• Mild (Concussion) Moderate Severe Penetrating
• Evaluation Baseline Automated
  Neuropsychological Assessment Metrics (ANAM),
  Military Acute Concussion Evaluation (MACE),
  Diagnostic Interview, Neuropsychological/Psycholog
  ical Testing

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mTBI

• Mild TBI (mTBI) Concussion (Difficult to dx)
• MRI/CT scans normal
• Brief loss of consciousness (secs to lt 30 mins)
  or a brief period of confusion
• Often managed in theater returned to duty (RTD)
• At risk for changes in work performance,
  disciplinary actions, family distress
• Physical Sx Headaches, Dizziness/Balance,
  Light/Noise Sensitive, Changes in Vision/Hearing,
  Fatigue/Sleep Disturbance

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mTBI (cont.)

• Cognitive sx Forgetful, Poor Concentration,
  Slowed Speech/Thinking/Behavior, Confused, Poor
  Organization/Follow-through
• Behavioral sx Personality Changes Mood Swings
  Apathy Irritability Impulsivity
• At risk for changes in work performance,
  disciplinary actions, family distress
• Sx Headaches, Dizziness/Balance, Light/Noise
  Sensitive, Changes in Vision/Hearing,
  Fatigue/Sleep Disturbance

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TBI (cont.)

• Moderate (Usually clearly recognizable)
• MRI/CT scans may be abnormal
• Unconscious lt 6 hrs
• Typically evacuated out of theater
• Less intensive rehabilitation services
• RTD rates are variable
• At risk for work performance problems,
  disciplinary issues, family distress

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TBI (cont.)

• Severe (Obvious)
• MRI/CT scans typically abnormal
• Associated with gt 6 hrs of coma/more than 7 days
  of amnesia
• Medically evacuated out of theater
• Require intensive rehabilitation
• Unlikely to RTD
• Persistent impairments in function

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TBI (cont.)

• PTSD/mTBI Similar Sxs
• Insomnia/Fatigue Irritability/Anger/Aggression
  Problems Remembering Thinking Personality
  Mood Changes Withdrawal Noise Hypersensitivity
• PTSD/TBI Distinctive Sxs
• mTBI/Concussion Headaches, Dizziness/Balance,
  Reduced Alcohol Tolerance Light Sensitivity
• PTSD Flashbacks/Intrusive Thoughts Increased
  Startle Hypervigilance/Physiological Arousal
  Nightmares

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TBI and Criminal Matters

• mTBI Most recover fully but can take some time
  Associated with job loss, relationship problems,
  substance abuse -gt increased interaction with
  criminal justice system
• May experience increased violence, aggression,
  anger, hostility
• Neurological Impairment Frontal Lobe Damage-gt
  Lack of self-control, poor judgment, violent
  aggressive behavior

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References

• Baker, C Alfonso C. PTSD and Criminal
  Behavior. National Center for PTSD,
  http//ncptsd.va.gov
• Criminal Behavior and PTSD An Analysis.
  National Center for PTSD, US Department of
  Veterans Affairs, http//www.ptsd.va.gov
• Drake, AI. Traumatic Brain Injury and
  Posttraumatic Stress Disorder. Defense and
  Veterans Brain Injury Center, www.dvbic.org
  Defense Center of Excellence, www.dcoe.health.mil
• Elbogen, EB Johnson SC. The Intricate Link
  Between Violence and Mental Disorder Results
  for the National Epidemiologic Survey on Alcohol
  and Related Conditions. Archives of General
  Psychiatry, 2009, 66(2) 152-161
• PTSD in Mental Health Law (PPT) LTC Christopher
  Lange, MD, Program Director, NCC Forensic
  Psychiatry Fellowship
• Seamone, ER. Attorneys as First-Responders
  Recognizing the Destructive Nature of
  Posttraumatic Stress Disorder on the Combat
  Veterans Legal Decision Making Progress.
  Military Law Review, 2009, 202 144-184

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References

• Surprenant, E. Regarding Interim Charge 4
  Monitor the implementation of SB 1940 (81R)
  (which established the veterans court programs in
  Texas) examine the link between combat stress
  disorders of war veterans, including PTSD and
  TBI, at the onset of criminal behavior .
  Presented to the House Criminal Jurisprudence
  Committee and Subcommittee of Defense Veterans
  Affairs, July 13, 2010
• Traumatic Brain Injury Fact Sheet. Proponency
  Office for Rehabilitation and Reintegration, USA,
  www.armymedicine.army.mil/prr/index.html
• Traumatic Brain Injury A Guide for Criminal
  Justice Professionals. Department of Health and
  Human Services, CDC, http//www.cdc.gov
• Traumatic Brain Injury and PTSD. National Center
  for PTSD, US Department of Veterans Affairs,
  http//www.ptsd.va.gov
• Veterans with PTSD in the Justice System.
  National Center for PTSD, US Department of
  Veterans Affairs, http//www.ptsd.va.gov

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Discussion/Questions?