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@med.navy.mil• March 2012

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.

Background PTSD: DSM III, 1980 (Soldier’s 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 < 3 mos; Chronic sx >/= 3 mos Delayed Onset: Onset of sx at least 6 mos

after trauma

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 Child’s Life-threatening Illness

Background (cont.)

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

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

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

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

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)

Arousal Symptoms

Difficulty falling/staying asleep Irritability/anger outbursts Difficulty concentrating Hypervigilance - enhanced state of sensory

sensitivity, exaggerated to detect threats Exaggerated startle response

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

PTSD in Criminal Matters (cont.) In most cases, PTSD does NOT lead to

criminal behavior Symptoms of PTSD can incidentally lead to

criminal behaviorPlagued 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)

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

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

PTSD in Criminal Matters (cont.)

Symptoms of PTSD can incidentally lead to criminal behavior (cont.)Anger/irritability may lead to more aggressive

responsesCommon for survivors to feel guilt, which may

sometimes lead them to commit crimes that will likely result in apprehension, punishment, serious injury, or death

PTSD in Criminal Matters (cont.) Direct link between particular trauma and a

specific crimeCrimes 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)

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)

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)

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 CautionPTSD as a result of event about which they are

testifying: May affect perception/judgment of event

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 Porter’s 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.”

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 Payne’s death sentence (6 to 3)○ Jury cannot make the punishment fit the crime if it

does not know how the crime affected the victim/victim’s family

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

TBI

TBI: Injury to the head from a blunt or penetrating object that disrupts the function of the brainFalls, MVAs, Struck By/Against Objects, AssaultsMild (Concussion); Moderate; Severe; Penetrating

Evaluation: Baseline Automated Neuropsychological Assessment Metrics (ANAM), Military Acute Concussion Evaluation (MACE), Diagnostic Interview, Neuropsychological/Psychological Testing

mTBI Mild TBI (mTBI): Concussion (Difficult to dx)

MRI/CT scans normalBrief loss of consciousness (secs to < 30 mins) or a

brief period of confusionOften managed in theater & returned to duty (RTD)At risk for changes in work performance, disciplinary

actions, & family distressPhysical Sx: Headaches, Dizziness/Balance,

Light/Noise Sensitive, Changes in Vision/Hearing, Fatigue/Sleep Disturbance

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

TBI (cont.) Moderate (Usually clearly

recognizable)MRI/CT scans may be abnormalUnconscious < 6 hrsTypically evacuated out of theaterLess intensive rehabilitation servicesRTD rates are variableAt risk for work performance problems, disciplinary

issues, & family distress

TBI (cont.)

Severe (Obvious)MRI/CT scans typically abnormalAssociated with > 6 hrs of coma/more than 7 days

of amnesiaMedically evacuated out of theaterRequire intensive rehabilitationUnlikely to RTDPersistent impairments in function

TBI (cont.) PTSD/mTBI Similar Sxs

Insomnia/Fatigue; Irritability/Anger/Aggression; Problems Remembering & Thinking; Personality & Mood Changes; Withdrawal; Noise Hypersensitivity

PTSD/TBI Distinctive SxsmTBI/Concussion: Headaches, Dizziness/Balance,

Reduced Alcohol Tolerance; Light SensitivityPTSD: Flashbacks/Intrusive Thoughts; Increased

Startle; Hypervigilance/Physiological Arousal; Nightmares

TBI and Criminal Matters

mTBI: Most recover fully but can take some time; Associated with job loss, relationship problems, substance abuse -> increased interaction with criminal justice system

May experience increased violence, aggression, anger, & hostility

Neurological Impairment: Frontal Lobe Damage-> Lack of self-control, poor judgment, violent & aggressive behavior

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 Veteran’s Legal Decision Making Progress. Military Law Review, 2009, 202: 144-184

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

Discussion/Questions?