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Thursday, July 26, 2012

Comments

I'm quite surprised, given the lack of even the usual sort of information (from people who knew him, however vaguely, in school, neighbors growing up or at the apartment in Aurora, etc.) that there has not been more speculation about what is going on with him.

As near as I can tell, there is no information other than resume-level biographical facts. I was startled that he was on a scholarship with a full ride plus a $25K stipend in grad school. But unsure what to make of that.

There's a potential weird paradox in his choice of "rolls." If he selects the roll of an evil villain and then does an evil act, does that suggest he knows right from wrong (and thus is not legally insane under old-fashioned legal tests. I don't know Colorado law...), or that he's living in the unreality of a movie or video game and has no idea? Or both?

Prosecutors will classically use flight to show understanding one has done wrong. James Holmes apparently put his weapons in the car and stood there, still suited up. Waiting for what?

There's of course the likelihood that the document he mailed will have a large impact on an insanity defense.

All of this I've written pretends that the legal standard will decide this case. The reality is that jurors are likely to be very resistant to an insanity defense. It will require a truly brilliant lawyer and story-teller to present Holmes in a way that a juror would begin to try to see him in human terms, or some unusual jurors on the panel who insist on taking seriously what the judge tells them about the insanity defense.

Some lawyers in comments in my blog have dismissed my interest in wondering what is going on with Holmes, saying they are sure he's a sociopath and knows right from wrong, or the like. I'm sure there's probably no understanding of what happened with him, but it's something I find worth puzzling. I suppose a difference I have is that I start with the assumption he's a human being, and wonder what possibly brought this to be.

Sorry to shift the focus from your profession to mine, although it's all in the service of trying to achieve some small level of understanding about this.

NMC,

I was a bit puzzled by the confidence some of the commenters had in describing Holmes as a sociopath/psychopath. He could be, but psychopaths aren't the only people who kill. There are number of pieces here that don't seem consistent with psychopathy, one being psychopaths aren't usually the type to wait around to get caught. And when psychopaths kill numerous people, they are more often serial killers or they break into a home and attack/terrorize the occupants rather than committing indiscriminate mass murder in a public place where they're likely to die or get caught. Usually they have some known history of bad behavior. We haven't heard anything I'm aware of to indicate this is the case with Holmes and Holmes was certainly not the charming variant (not all are). The reports of his oddity/peculiarity, if true, would tend to point toward other personality organizations.

There's some suggestion that Holmes's life was falling apart around him, which can be a trigger for mass murderers of the non-psychopathic variety. There's no basis I can see to rule out a severe personality disorder, possibly with psychotic decompensation (collapsing of his habitual psychological defenses). Another commenter on another post mentioned Asperger's (a neurological condition), which doesn't, in and of itself, predispose to murder, but if it's part of the picture, it might explain some of the descriptions offered by acquaintances, but that's far from a certainty. Should see also: schizotypal and schizoid personality.

So there are still lots of possibilities that would require history, facts and exam to sort it out. I did wonder if there is some record of Holmes with mental health services at the university. The psychiatrist who was the intended recipient of his letter might have seen him as a patient.

Perhaps a premature preference to believe Holmes is a psychopath stems from the simplicity of the explanation--he's just a bad guy--and perhaps for some, it could reduce moral qualms about satisfying a thirst for his blood.

Holmes saw a psychiatrist at CU.

http://news.yahoo.com/blogs/lookout/shooting-suspect-james-holmes-treated-cu-psychiatrist-193517014.html

This doesn't demonstrate that Holmes was actually being treated for schizophrenia. A psychiatrist may describe a specialty area, but still see anyone referred. So, it could be he went to student counseling and was referred for adjunctive medication. Could be he has a history of psychiatric treatment and he went to the psychiatrist immediately after beginning at CU. That would be normal for someone on medication. It still leaves open numerous possibilities, but being on medication and seeing a psychiatrist would make the psychopathic personality even less likely, IMO. Psychopaths don't often seek therapy or psychiatrists except after they've gotten caught in a serious crime and they're in deep trouble.

As if it isn't obvious, this situation is a psychiatrist's or psychologist's absolute worst nightmare. Not to suggest that it has any significance compared with the suffering of the victims and their loved ones, but even if it was completely unforeseeable, I would be devastated and second guessing myself if a patient of mine ever went off the rails and did something like this. It's the kind of thing that would haunt me for life.

One other issue that occurred to me is that Holmes had left school and perhaps discontinued his relationship with his psychiatrist, and ran out of his medication. That could easily precipitate a psychotic episode if he was on antipsychotics.

Let's hope your commenter who speculated that the shooter has an autism-spectrum disorder (Asperger's) is way off the beam. With a diagnosis rate of 1 in every 88 children born in the US since 2008 (according to the CDC) having an ASD, we would all be in deep, deep trouble if this turned out to be true.

This just doesn't sound like autism to me, based on my experience (spending a fair amount of time helping autistic students deal with school districts, and reading a lot of literature because of personal interest).

I have to agree with Dr. X about psychopathy. Would not even have crossed my mind but for ill-informed comments on my blog.

The pleadings about the psych (available on the links Dr. X posted) were pretty interesting for a lawyer. Holmes's lawyer says "We hear in the media they've seized a communication from our client to his pysch. That's privileged. Don't let them look at it." The state says "yeah, we have it, and the media is all wrong." Well, the media was right about the communication and that it was seized.

The interesting questions for a lawyer are these:

1) Patient sets bombs at his home and goes on rampage on Thursday.

2) On Monday, package from patient arrives in his psychiatrists's office.

I'm thinking, privilege or no, such a package arrives in my office at that point, and I'm going to be thinking "time for the bomb squad." And that's (I'm betting) how the cops got summoned. But is that the right answer for a professional with duties of confidentiality? I'm not sure it is?

From the prosecutor's side, the ethical reaction is to send in cops and lawyers who are kept isolated from the team prosecuting Holmes, what federal folks call a "taint team," to make sure everyone is safe without poisoning the prosecutors with privileged information. I'm reading the snotty response from the prosecutors in Colorado to suggest they did nothing so sanitary. They imply the documents are under seal and going to be sent to the court, but I'm reading between the lines to suggest they've read them.

If I were defense counsel, I'd be thinking I was a couple of steps from a motion to recuse the prosecutor. And I'd be thinking that, even if I was right about the legalities of that, I was probably going to lose because of who my client was.

NMC,

Violations of confidentiality for mental health professionals prohibited except:

1. Mandated abuse reporting (children, disabled and seniors).

2. Danger to self or others.

The latter is termed duty to warn/duty to protect. Tarasoff v Regents of the University of the State of California--perhaps the one legal case every American clinical psychologist and psychiatrist can cite by name. We just call it the Tarasoff warning. So not only would it be okay to call the bomb squad, there would be an obligation to do so on the part of the psychiatrist. Even with Tarasoff, only information that is is needed to fulfill the duty to protect can be compromised. The patient's confidentiality is otherwise protected. Law enforcement cannot legally come in and seize records. If I ever found myself in this situation, my first call would be to an intended victim or police and, immediately thereafter, I'd call a psychologist-attorney I know to intervene in the event of any attempt to seize my records. The patient would have a case against me if I revealed anything more than what is necessary to protect the patient and others.

Yes, Aspies and others in autism spectrum are among the most harmless people you'll ever meet. The most damage they will ever do is talk your ear off about their special interest! So I was alarmed that someone would suggest that this ever growing group could be dangerous. I hope that it isn't an opinion that is out there in the media. "Vaccinations programmed them to be killers!" We can look forward to that when they are done with the "he was possessed by a demon" business, I guess. Anything to avoid the real discussion we should be having in this country: easy to get guns, hard get therapy.

As far as being this killer's defense attorney goes, yep, you're gonna lose.

I believe Holmes will be diagnosed a paranoid schizophrenick who does not know right from wrong.Fairly normal life with straight A's in school with only a speeding ticket to tarnish his record and then "bam" a cold blooded killer.Schizophrenia hits young people between the ages of 15 and 25.Some have said he planned this months before so he's not insane but i've read where psychiatrists note that with paranoia one might plan for months to solve a problem.If he thought people were after him (aliens or whatever ) then booby trapping his apartment could have been a defense.The purchase of guns could be used to protect himself against these delusional threats.The stressor of failing the oral exam might have been the trigger that set him off.Looking at his early life with nothing but good and then a sudden desent into maddness makes certainly a strong argument for someone insane.This man snapped into a psychotic episode becoming a sociopath not knowing right from wrong.Brilliant walks a fine line between genius and insanity.

Regarding Asperger's, it's something that can't be ruled out at this point. That doesn't mean it caused the violent behavior. A person can have Asperger's and become manic or delusional or develop any other psychotic symptoms, not because Asperger's causes those conditions, but because they can happen to anyone. The Asperger's could complicate life in an individual otherwise dealing with mental health problems. I think it comes up as a possible premorbid condition for some because public awareness has risen in the last few years, but that leads to overdiagnosis. A few years back, bipolar suddenly became the "it" disorder, then borderline personality, then narcissism, now add Asperger's to the list.

If I were to lean toward a premorbid personality, I'd guess schizotypal, but that is a well-informed person's guess. I'd guess schizotypal because of the characteristic rich, eccentric fantasy life and, when the personality is pathological, there can be movement in and out of temporary psychotic states. That could explain Mr. Holmes' ability to engage in some complex preparation. I should add here, again, that we all have a personality style--a favored pattern of adaptive defenses and coping. One can have a schizotypal style and not be mentally disturbed.

I've seen a great deal of talk about schizophrenia and, while that's a possibility, I've seen nothing to rule out a manic episode yet. Mitigating against schizophrenia is the apparent complexity of Mr. Holmes' planning and execution--'mitigating', not ruled out. But the truth is that when we get into psychoses, things aren't always cut and dried. There are atypical psychoses that can't be nailed down specifically. And we still don't have definitive evidence of psychosis, just a strong suspicion because of the nature of the act. We don't have definitive reports of delusions, hallucinations or thought disorder. Leaping to a diagnosis without a basis for eliminating alternate possibilities is a mistake. Remember, we still know very little about James Holmes. We can raise possibilities, but that's all.

Paul,

That claim of a fine line between genius and madness is a questionable assumption when you're talking about schizophrenia. Persons with any IQ can develop schizophrenia, but the research shows, on average, a premorbid schizophrenic IQ about 1/2 standard deviation lower than mean IQ for the general population. Where a connection between madness and intellect might exist is in mania, which wouldn't be caused by intelligence--anyone could become manic--but a highly intelligent or creative person could be spurred to greater productivity and, perhaps, inventiveness, while in a hypomanic (less than full-blown) state.

Of course, you know more about any of this than I do; it's your business. From what little I've read about Asperger's, it seems that it's a fairly recently identified disorder, and as such may have facets we wouldn't normally think of in an autistic person--the ability/will to do harm to others. However, I would say that one of the hallmarks of Asperger's, it seems, is the inability to plan for the future--either immediate or long-term. Obviously the killer was able to do so with no trouble.

I hope this doesn't seem like a "you know your business better than I do, but here's where you're wrong," sort of comment. Just an add to the chat. I found all your info about the disorder fascinating, especially the idea that one could have mental illness on top of this problem: that's quite a horrifying concept.

Ruth, your comments are always thoughtful and taken in a positive spirit.

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