1. 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

2. 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.

3. 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  Delayed Onset: Onset of sx at least 6 mos after trauma

4. 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

5. Background (cont.)  PTSD and TBI caused by explosive blasts are considered the “signature” injuries of OIF/OEF

6. 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

7. 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

8. 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

9. 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)

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

11. 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

12. 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)

13. 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

14. 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

15. 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

16. 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)

17. 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)

18. 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)

19. 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

20. 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.”

21. 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 8 th 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

22. 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

23. 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/Psychological Testing

24. mTBI  Mild TBI (mTBI): Concussion (Difficult to dx) MRI/CT scans normal Brief loss of consciousness (secs to < 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

25. 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

26. TBI (cont.)  Moderate (Usually clearly recognizable) MRI/CT scans may be abnormal Unconscious < 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

27. TBI (cont.)  Severe (Obvious) MRI/CT scans typically abnormal Associated with > 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

28. 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

29. 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

30. References  Baker, C & Alfonso C. PTSD and Criminal Behavior. National Center for PTSD, http://ncptsd.va.govhttp://ncptsd.va.gov  Criminal Behavior and PTSD: An Analysis. National Center for PTSD, US Department of Veterans Affairs, http://www.ptsd.va.govhttp://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.milwww.dvbic.org  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

31. 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.govhttp://www.ptsd.va.gov  Veterans with PTSD in the Justice System. National Center for PTSD, US Department of Veterans Affairs, http://www.ptsd.va.govhttp://www.ptsd.va.gov

32. Discussion/Questions?