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Psychopathy is characterized by diagnostic features such as superficial charm, high intelligence, poor judgment and failure to learn from experience, pathological egocentricity and incapacity for love, lack of remorse or shame, impulsivity, grandiose sense of self-worth, pathological lying, manipulative behavior, poor self-control, promiscuous sexual behavior, juvenile delinquency, and criminal versatility, among others.

 As a consequence of these criteria, the image of the psychopath is that of a cold, heartless, inhuman being. But do all psychopaths show a complete lack of normal emotional capacities and empathy?

Like healthy people, many psychopaths love their parents, spouse, children, and pets in their own way, but they have difficulty in loving and trusting the rest of the world. Furthermore, psychopaths suffer emotionally as a consequence of separation, divorce, death of a beloved person, or dissatisfaction with their own deviant behavior.

Psychopaths can suffer emotional pain for a variety of reasons. As with anyone else, psychopaths have a deep wish to be loved and cared for. This desire remains frequently unfulfilled, however, because it is obviously not easy for another person to get close to someone with such repellent personality characteristics. Psychopaths are at least periodically aware of the effects of their behavior on others and can be genuinely saddened by their inability to control it. The lives of most psychopaths are devoid of a stable social network or warm, close bonds.

The life histories of psychopaths are often characterized by a chaotic family life, lack of parental attention and guidance, parental substance abuse and antisocial behavior, poor relationships, divorce, and adverse neighborhoods.

 These persons may feel that they are prisoners of their own etiological determination and believe that they had, in comparison with normal people, fewer opportunities or advantages in life.

Despite their outward arrogance, psychopaths feel inferior to others and know they are stigmatized by their own behavior. Some psychopaths are superficially adapted to their environment and are even popular, but they feel they must carefully hide their true nature because it will not be acceptable to others. This leaves psychopaths with a difficult choice: adapt and participate in an empty, unreal life, or do not adapt and live a lonely life isolated from the social community. They see the love and friendship others share and feel dejected knowing they will never be part of it.

Psychopaths are known for needing excessive stimulation, but most foolhardy adventures only end in disillusionment because of conflicts with others and unrealistic expectations. Furthermore, many psychopaths are disheartened by their inability to control their sensation-seeking and are repeatedly confronted with their weaknesses. Although they may attempt to change, low fear response and associated inability to learn from experiences lead to repeated negative, frustrating, and depressing confrontations, including trouble with the justice system.

As psychopaths age, they are not able to continue their energy-consuming lifestyle and become burned-out and depressed while they look back on their restless life full of interpersonal discontentment. Their health deteriorates as the effects of their recklessness accumulate.

Social isolation, loneliness, and associated emotional pain in psychopaths may precede violent criminal acts.

 They believe that the whole world is against them and eventually become convinced that they deserve special privileges or rights to satisfy their desires. As psychopathic serial killers Jeffrey Dahmer and Dennis Nilsen expressed, violent psychopaths ultimately reach a point of no return, where they feel they have cut through the last thin connection with the normal world. Subsequently, their sadness and suffering increase, and their crimes become more and more bizarre.

Dahmer and Nilsen have stated that they killed simply for company.

 Both men had no friends and their only social contacts were occasional encounters in homosexual bars. Nilsen watched television and talked for hours with the dead bodies of his victims; Dahmer consumed parts of his victims’ bodies in order to become one with them: he believed that in this way his victims lived further in his body.

For the rest of us, it is unimaginable that these men were so lonely-yet they describe their loneliness and social failures as unbearably painful. Each created his own sadistic universe to avenge his experiences of rejection, abuse, humiliation, neglect, and emotional suffering.

Dahmer and Nilsen claimed that they did not enjoy the killing act itself. Dahmer tried to make zombies of his victims by injecting acid into their brains after he had numbed them with sleeping pills. He wanted complete control over his victims, but when that failed, he killed them. Nilsen felt much more comfortable with dead bodies than with living people-the dead could not leave him. He wrote poems and spoke tender words to the dead bodies, using them as long as possible for company. In other violent psychopaths, a relationship has been found between the intensity of sadness and loneliness and the degree of violence, recklessness, and impulsivity.

Violent psychopaths are at high risk for targeting their aggression toward themselves as much as toward others. A considerable number of psychopaths die a violent death a relatively short time after discharge from forensic psychiatric treatment as a result of their own behavior (for instance, as a consequence of risky driving or involvement in dangerous situations).

 Psychopaths may feel that all life is worthless, including their own.

In the past decade, neurobiological explanations have become available for many of the traits of psychopathy. For example, impulsivity, recklessness/irresponsibility, hostility, and aggressiveness may be determined by abnormal levels of neurochemicals, including monoamine oxidase (MAO), serotonin and 5-hydroxyindoleacetic acid, triiodothyronine, free thyroxine, testosterone, cortisol, adrenocorticotropic hormone, and hormones of the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-gonadal axes.

Other features, such as sensation-seeking and an incapacity to learn from experiences, might be linked to cortical underarousal.

 Sensation-seeking could also be related to low levels of MAO and cortisol and high concentrations of gonadal hormones, as well as reduced prefrontal gray matter volume.9 Many psychopaths can thus be considered, at least to some degree, victims of neurobiologically determined behavioral abnormalities that, in turn, create a fixed gulf between them and the rest of the world.

It may be possible to diminish traits such as sensation-seeking, impulsivity, aggression, and related emotional pain with the help of psychotherapy, psychopharmacotherapy, and/or neurofeedback. Long-term psychotherapy (at least 5 years) seems effective in some categories of psychopaths, in so far as psychopathic personality traits may diminish.

Psychotherapy alone may be insufficient to improve symptoms. Psychopharmacotherapy may help normalize neurobiological functions and related behavior/personality traits.

 Lithium is impressive in treating antisocial, aggressive, and assaultive behavior.

 found that mood stabilizers, such as divalproex, SSRIs, MAOIs, and neuroleptics, have documented efficacy in treating aggression and affective instability in impulsive patients. There have been no controlled studies of psychopharmacotherapy for other core features of psychopathy.

Cortical underarousal and low autonomic activity-reactivity can be substantially reduced with the help of adaptive neurofeedback techniques.

Norman was raised by his aunt; his parents were divorced and neither was capable of or interested in caring for him. As a child and adolescent, he had numerous encounters with law enforcement for joyriding, theft, burglary, fraud, and assault and battery. He was sent to reform school twice. When he was 21, he was convicted of armed robbery and served 1½ years in jail. His only close friend was another violent criminal; he had many short-term relationships with girlfriends. At 29, he killed two strangers in a bar who had insulted him and was sentenced to forensic psychiatric treatment. The diagnosis was psychopathy, according to Hare’s psychopathy checklist.

Norman showed little improvement over the course of 7 years of behavioral psychotherapy and became less and less motivated. The staff of the forensic psychiatric hospital considered him untreatable and intended to stop all treatment attempts. Norman’s lawyer arranged for an examination by a forensic neurologist, who subsequently found that Norman suffered from severe cortical underarousal, serotonin and MAO abnormalities, and concentration problems.

Treatment with D,L-fenfluramine, a serotonin-releasing drug, was started. (Fenfluramine was voluntarily withdrawn from the US market in 1997.) Acute challenge doses (0.2 mg/kg to 0.4 mg/kg) produced significant dose-dependent decreases in impulsive and aggressive responses. After 1 month, an MAOI (pargyline, 10 mg/kg) and psychodynamic psychotherapy were added. Pargyline produced some normalization of his EEG pattern and was titrated to 20 mg/kg over 5 months. Neurofeedback was started after 2 months and continued for 15 months. His EEG pattern gradually normalized, and his capacity for concentration and attention increased.

Norman continued to receive D,L-fenfluramine and psychotherapy for 2 years, at which point he was discharged from forensic treatment. He voluntarily continued psychotherapy for an additional 3 years and, in the 4 years since his release, has not reoffended.

It is extremely important to recognize hidden suffering, loneliness, and lack of self-esteem as risk factors for violent, criminal behavior in psychopaths. Studying the statements of violent criminal psychopaths sheds light on their striking and specific vulnerability and emotional pain. More experimental psychopharmacotherapy, neurofeedback, and combined psychotherapy research is needed to prevent and treat psychopathic behavior.

The current picture of the psychopath is incomplete because emotional suffering and loneliness are ignored. When these aspects are considered, our conception of the psychopath goes beyond the heartless and becomes more human.

This article was originally published in 

 and posted on PsychiatricTimes.com in 2006. Ever since, it has remained one of the best-read articles. We re-publish it here with updates from Dr Martens.

Dr Martens is Chair of the W. Kahn Institute of Theoretical Psychiatry and Neuroscience. He is also Psychiatry Advisor of the European Commission (Leonardo da Vinci) and a member of the Royal College of Psychiatrists.

Mask of Sanity: An Attempt to Clarify Some Issues About the So-Called Psychopathic Personality

 Hare RD, Harpur TJ, Hakstian AR, et al. The revised psychopathy checklist: descriptive statistics, reliability, and factor structure. 

 Martens W. Hidden suffering of the psychopath: new insight on basis of self-reports of psychopaths; 2013. https://www.smashwords.com/books/view/304901. Accessed September 15, 2014.

 Martens WHJ. Antisocial and psychopathic personality disorders: causes, course and remission: a review article. 

 Martens WH, Palermo GB. Loneliness and associated violent antisocial behavior: analysis of the case reports of Jeffrey Dahmer and Dennis Nilsen. 

 Martens WH. Sadism linked to loneliness: psychodynamic dimensions of the sadistic serial killer Jeffrey Dahmer. 

 Black DW, Baumgard CH, Bell SE, Kao C. Death rates in 71 men with antisocial personality disorder: a comparison with general population mortality. 

 Martens WHJ. A new multidimensional model of antisocial personality disorder. 

 Raine A, Lencz T, Bihrle S, et al. Reduced prefrontal gray matter volume and reduced autonomic activity in antisocial personality disorder. 

Psychopathic and Antisocial Personality Disorders: Treatment and Research Issues

 Dolan B. Therapeutic community treatment for severe personality disorders. In: Millon T, Simonsen E, Birket-Smith M, Davis RD, eds.

 Psychopathy: Antisocial, Criminal, and Violent Behaviors

. New York: Guilford Press; 1998:407-438.

 Sanislow CA, McGlashan TH. Treatment outcome of personality disorders. 

 Martens WH. Criminality and moral dysfunctions: neurologic, biochemical and genetic dimensions. 

Psychopharmacology: The Fourth Generation of Progress

 Hollander E. Managing aggressive behavior in patients with obsessive-compulsive disorder and borderline personality disorder. 

 Martens WH. Effects of antisocial or social attitudes on neurobiological functions. 

 Raine A. Autonomic nervous system factors underlying disinhibited, antisocial, and violent behavior. Biosocial perspectives and treatment implications. 

The psychopath has the image of a cold, heartless, inhuman being. But do all psychopaths show a complete lack of normal emotional capacities and empathy?

The Hidden Suffering of the Psychopath

Recent studies provide clinically relevant information related to the course and treatment outcomes of 

. In the longest controlled prospective study of childhood ADHD, 

 (2012) examined clinical and functional outcomes in adulthood. Study participants were boys aged 6 to 12 years (mean age 8.3 years) who had ADHD at the start of the study. The control group consisted of boys without ADHD; 135 men with ADHD in childhood (65.2% of original sample) and 136 men without ADHD (76.4% of original sample) participated in the follow up study. The follow up period was 33 years with a mean age of 41 years.

Study results showed that compared with men without childhood ADHD, men with childhood ADHD had higher rates of ongoing ADHD (22.2% vs 5.1%), antisocial personality disorder (16.3% vs 0%), substance use disorders (14.1% vs 5.1%), and psychiatric hospitalizations (24.4% vs 6.6%). There were no differences between these groups in prevalence of alcohol disorders, mood disorders, and anxiety disorders. Men with childhood ADHD also had lower educational levels (mean 2.5 less years), lower occupational achievement, lower socioeconomic status, lower social functioning, higher divorce rates, more incarcerations, and higher mortality. Based on these long-term outcomes, the investigators emphasize the importance of monitoring and treating children with ADHD. (see 


ADHD has been associated with criminal behavior.

 examined the effects of treatment with ADHD medication on criminality. Information was obtained from the Swedish national registers on 25,656 patients who had a diagnosis of ADHD, their medication treatment and criminal convictions. The rates of criminal behavior were compared when the patients were being treated for ADHD and when these same patients were not being treated for ADHD.

For men with ADHD, there was a 32% reduction in criminality and for women with ADHD there was a 41% reduction in criminality when receiving medication. The rates of criminality were the same whether the ADHD medication was a stimulant or nonstimulant. The authors conclude that medication treatment for ADHD may reduce the risk for criminal behavior in individuals with ADHD.


Cigarette smoking is also associated with ADHD. 

 conducted a study of 154 adolescents with ADHD to determine whether stimulants reduce the risk for cigarette smoking. The comparison groups were a naturalistic sample of ADHD and non-ADHD youth. Cigarette smoking was assessed by a self-report questionnaire that measured smoking behavior and physiological dependence to nicotine. Urine assays for cotinine, a metabolite of nicotine, were obtained for adolescents in the clinical trial. Doses of extended-release methylphenidate were based on clinical response and the mean endpoint dose was 61 mg daily.

The rate of smoking in youths who received stimulant treatment was significantly lower than in the unmedicated ADHD comparison group (7.1% vs 19.6%). The rate of smoking in the stimulant treated adolescents was similar to the comparison group of non-ADHD youth and ADHD youth currently on medication (7.1% vs 8.0% vs 10.9%). The investigators recognize that these positive results are preliminary and recommend a randomized clinical trial.


There is a large evidence base supporting the efficacy of stimulant treatment for children and adolescents with ADHD, however some parents prefer nonmedication treatment for their child. Duric and colleagues

 examined the efficacy of neurofeedback for the treatment of children and adolescents with ADHD. The aim of neurofeedback is to enhance beta and depress theta activity as assessed by EEG.

The researchers randomized 130 youth with ADHD to treatment with methylphenidate, neurofeedback, or neurofeedback plus methylphenidate. The youths in the neurofeedback group had scalp sensors and were given feedback regarding their brain activity to enhance theta and depress beta activity when playing video games or watching films. There were 30 40-minute neurofeedback sesions 3 times a week.

Youths in the medication group received methylphenidate twice a day at doses of approximately 1 mg per kg daily: 91 children (70%) completed treatment. There were no significant differences in demographic factors between subjects who completed treatment and those who dropped out of treatment. The outcome measure was a clinician administered rating scale to assess attention and hyperactivity. All three treatment groups showed significant improvement in inattention and hyperactivity, with the greatest gains for reduction in hyperactivity as per parent report. There were no significant differences among the treatment groups. The authors suggest that neurofeedback be used as alternative therapy for children who do not respond to stimulant treatment.


What factors are involved in parents’ decision to begin medication treatment for a child with ADHD? Coletti and colleagues

 conducted a focus-group study to determine factors that influenced parents’ decision. The study consisted of 27 parents of children aged 5 to 9 years with a diagnosis of ADHD. Parents were given a recommendation for stimulant treatment by a child psychiatrist. The majority of the parents (81.5%) had pursued recommended stimulant treatment.

The factor most related to parents’ decision to initiate stimulant treatment was the belief that stimulant medication was effective and that improvement of the child’s ADHD symptoms would lead to functional improvement such as better social and academic functioning. They also felt that medication might prevent more serious outcomes in the future such as juvenile delinquency. A major barrier to stimulant treatment was the parents’ concern about adverse effects such as tics and reduced appetite. Another concern was that the medication would change the child’s personality.

Some parents wanted to defer medication treatment until nonpharmacological modalities had been tried such as behavior modification or nutrition therapy. Parents had positive perceptions of psychiatrists who were collaborative, provided information about ADHD, and were empathetic. The investigators conclude that parents’ attitudes about stimulant treatment for ADHD needs to be carefully assessed at the initial evaluation in order to address the concerns and to foster adherence to sound clinical treatment recommendations.


What are children’s views of taking stimulants for treatment of their ADHD? Singh

children’s experiences with taking stimulant medication

 for treatment of ADHD. Children, ages 9 to 14 years, who were diagnosed with ADHD and taking stimulant medication were interviewed. They were asked whether they felt like themselves or whether the medication made them feel like a different person (which the investigator termed “a threat to authenticity”). The majority of children denied that the medication made them feel like a different person; rather they believed the medication helped them to behave better. Overall, children were positive about receiving stimulant treatment for ADHD.

This article was originally posted online on 2/3/2014.

Dr Wagner is the Marie B. Gale Centennial Professor and Vice Chair in the Department of Psychiatry and Behavioral Sciences and Director of Child and Adolescent Psychiatry at the University of Texas Medical Branch at Galveston.

1. Klein RG, Mannuzza S, Olazagasti MAR, et al. 

Clinical and functional outcome of childhood attention-deficit/hyperactivity disorder 33 years later

. 2012;69:1295-1303.
2. Lichtenstein P, Halldner L, Zetterqvist J, et al. 

Medication for attention deficit-hyperactivity disorder and criminality

. 2012;367:2006-2014.
3. Hammerness P, Joshi G, Doyle R, et al. 

Do stimulants reduce the risk for cigarette smoking in youth with attention-deficit hyperactivity disorder? A prospective, long-term open-label study of extended-release methylphenidate

. 2013;162:22-27.
4. Duric NS, Assmus J, Gunderson D, Elgen IB. Neurofeedback for the treatment of children and adolescents with ADHD: a randomized and controlled clinical trial using parental reports. 

. 2012;12:107.
5. Coletti DJ, Pappadopulos E, Katsiotas NJ, et al. Parent perspectives on the decision to initiate medication treatment of attention-deficit/hyperactivity disorder. 

.2012;22:226-237.
6. Singh I. Not robots: children’s perspectives on authenticity, moral agency and stimulant drug treatments. 

http://jme.bmj.com/content/early/2012/08/27/medethics-2011-100224.full

What factors are involved in parents’ decision to begin medication treatment for a child with ADHD? An overview of studies that provide clinically relevant information related to the course and treatment outcomes of ADHD in children and adolescents.

Course and Treatment Outcomes of ADHD

Â DiscussionRecent studies provide clinically relevant information related to the course and treatment outcomes of ADHD in children and adolescents.In the longest controlled prospective study of childhood ADHD, Klein and colleagues1 examined clinical and functional outcomes in adulthood. Study participants were boys aged 6 to 12 years (mean age 8.3 years) who had ADHD at the start of the study. The control group consisted of boys without ADHD; 135 men with ADHD in childhood (65.2% of original sample) and 136 men without ADHD (76.4% of original sample) participated in the follow up study. The follow up period was 33 years with a mean age of 41 years.Study results showed that compared with men without childhood ADHD, men with childhood ADHD had higher rates of ongoing ADHD (22.2% vs 5.1%), antisocial personality disorder (16.3% vs 0%), substance use disorders (14.1% vs 5.1%), and psychiatric hospitalizations (24.4% vs 6.6%). There were no differences between these groups in prevalence of alcohol disorders, mood disorders, and anxiety disorders.Men with childhood ADHD also had:Â 
• lower educational levels (mean 2.5 less years)
• lower occupational achievement
• lower socioeconomic status
• lower social functioning
• higher divorce rates
• more incarcerations
• higher mortality lower educational levels (mean 2.5 less years)Based on these long-term outcomes, the investigators emphasize the importance of monitoring and treating children with ADHD.For more information on ADHD, please see "Course and Treatment Outcomes of ADHD," by Karen Dineen Wagner, MD, PhD, on which this infographic is based.

The results of the study featured in this infographic showed that compared with men without childhood ADHD, men with childhood ADHD had higher rates of ongoing issues in adulthood.

Infographic: Men With Versus Men Without ADHD in Childhood

Survived by One: The Life and Mind of a Family Mass Murderer 

by Robert E. Hanlon (with Thomas V. Odle); Carbondale, Illinois: Southern Illinois University Press, 2013

There are many stories written about serial killers and murderers, books that narrate the life course of individuals who commit heinous acts. However, few have been written by murderers explaining their lives first-hand and offering a glimpse into the experiences that bring one to murder. 

Survived by One: The Life and Mind of a Family Mass Murderer

 is a unique endeavor. It combines the psychological expertise of Robert E. Hanlon, PhD, a prominent Chicago-based neuropsychologist, and the raw narration of Thomas Odle, a man serving a life sentence for the murder of his parents, his two brothers, and his sister. Familicide is fairly uncommon, making Odle’s story all the more compelling.

Tom Odle’s journey of self-discovery began when the death sentence was abolished in Illinois in 2003, and all death sentences were commuted to natural life in prison. After 17 years on Illinois Death Row, Odle was handed a new lease on life. With this gift came Tom’s burning questions about himself and a desire to learn who he was and understand what led him to murder. The introspective narrative, which served as a self-exploration for Tom Odle through correspondence with Dr Hanlon, offers readers a rare window into the mind of a killer, exploring his childhood, the details of the murders, and the life that unfolded for him in prison.

The story unfolds with Thomas Odle’s beginning, and is, for the most part, written from his point of view. Dr Hanlon skillfully fills in missing details of Odle’s life with information obtained from collateral sources. Information about the Odle family was also gathered from interviews with Odle’s schoolteacher, principal, former girlfriend, and Yvonne Sexton, a close friend of Odle’s mother. Sexton reportedly stopped by the house and spoke to Tom after he killed his parents and before he proceeded to murder his siblings. The insight offered by those who knew the family well allows the reader a clearer vision of the Odle family dynamics and the interplay of their personalities.

Psychologists and psychiatrists interviewed Tom after the murders and Dr Hanlon describes their findings, quoting them throughout the narrative. Their differing analytic perspectives on Odle’s pathology bring the manuscript to life, shaping the complexity of Tom Odle’s character. Dr Hanlon also injects into the narrative a clear history of the death penalty in Illinois, describing the progression of state law over the years leading up to, and after, Odle’s arrest and conviction for the murders of his family.

Tom Odle paints his life as one filled with the abuse of a sadistic and resentful mother; the frustrations of a silent, passive father; and the jealousy and abuse of sibling rivalry. His writing eloquently conveys his lack of emotional connection to his family, his disdain for laws and rules, and his abuse of drugs and alcohol. His unhealthy sexual relationships with older women contribute to his antisocial personality, which took form at a young age. His young life culminated in the decision to kill his mother, followed by his father, and finally ending with the murders of all three of his siblings.

After his apprehension for the murders and his conviction, Thomas Odle lived the next 17 years of his life awaiting his death. When all death sentences in Illinois were commuted to life in prison, Odle faced a lifetime behind bars. He questioned all that he had been, and hoped to find answers by reaching out to and corresponding with Dr Hanlon, a neuropsychologist who had evaluated him years earlier during his trial. Although a clear reason for why Tom Odle murdered his family may never materialize for him or for us as readers, he does walk us down the path he took toward insight into himself and his past.

Often when we inform people that we are training in forensic psychiatry, their eyes light up and they say, “I want to know what makes people become murderers.” Although this story may not impress a seasoned forensic psychiatrist who has interviewed numerous murderers, it will satisfy the desire of a reader wanting to delve into a killer’s mind. To those curious readers we would recommend this book. 

is a well-written, well-guided, autobiographical narrative of a convicted murderer’s life, before, during, and after the pivotal events that shaped his story.

Dr Bazzi is a Fellow in Forensic Psychiatry at Case Western Reserve University Hospitals in Cleveland, Ohio. Dr Charder is a Fellow in Forensic Psychiatry at SUNY Upstate Medical Center in Syracuse, New York.

There are many stories written about serial killers and murderers, books that narrate the life course of individuals who commit heinous acts. However, few have been written by murderers explaining their lives first-hand.

There has been increasing publicity about the imminent end of the world on December 21, 2012, as possibly posited in the Mayan Calendar. What we do know for sure, is that for all the young children and adults who were killed in Newtown, Connecticut, their world ended a week earlier, on December 14th.

As the play of the same name by Thornton Wilder, Newtown Is Our Town.

The perpetrator must be, in some way, everyman. We must be our brother's keepers. Any field that can contribute to the understanding and prevention of the increasing numbers of attempted and successful mass murders in the United States must work on this for the next weeks, months, and years. Psychiatry is surely one of these.


Amidst all the initial speculation on the reasons for the tragedy, my wife noticed an e-mail from a psychiatrist that struck us as possibly revealing deeper issues, some perhaps indirectly relevant. The subject was “Autism not a Mental Illness.” Autism was one of the initial diagnoses associated with this killer. Beyond such premature diagnostic speculations, the e-mail was reacting to a CNN coverage in which a physician and a reporter discussed that autism may not be an illness, since NIMH was considering autism and other mental conditions as “neurogenerative.” Perhaps, the e-mailer suggested, if autism was not considered to be a mental illness, would that be better because then, if the murderer did not have a mental illness, mental illness could not be blamed for the mass murder.

This argument, though cumbersome, leads us to take a step back and take a bit of a detour. First of all, there are no mental illnesses, at least so far as the terminology goes for the DSM and ICD classifications of mental conditions. This is more important than mere semantics. These conditions are called disorders, not illnesses or diseases. The prime definition of disorders, in my Webster’s dictionary, is “confusion.”

However “disorder” is defined, it causes mental conditions to appear to be different from medical illnesses. It implies that clinicians other than psychiatrists can be expert in the diagnosis and treatment of those disorders. Indeed, that is one of the issues that I was concerned about in the March 2010 blog, “

The DSM Process: More Questions Than Answers

.” The cautionary statement as to who can make a diagnosis reads: “It can be used by a wide range of health and mental health professionals, including psychiatrists and other physicians, psychologists, social workers, nurses occupational and rehabilitation therapists and counselors.”

So much for the medical expertise of psychiatrists in making a diagnosis. As far as I know, that consideration will not change in the upcoming DSM-5.

This is a scenario that is more likely to lead to an inadequate diagnosis or missed diagnosis. Moreover, diagnosis, though necessary for reimbursement, research, and a general sense of what is wrong, should only be the necessary, but not sufficient, step in understanding an individual. Adequate time and analysis is required. As the bio-psycho-social model implies, we have to look far and wide to try to understand anyone. If indeed the perpetrator of the Newtown tragedy fell on the Autism spectrum, how often does a mass murderer have that diagnosis?


As so many have commented, the ease of obtaining automatic weapons can indeed contribute to mass destruction. If someone has untreated mental problems, the risk also increases. Adding guns and knowing how to use them, to someone with apparent mental problems, surely increases the odds of something bad happening.

Any positive reinforcement of gun use, outside of controlled situations such as hunting, may cause more unnecessary harm than benefit. Certainly, we have a lot of positive reinforcement and modeling of a gun culture in our Constitution, our seemingly endless war, and violence in the media. The more impersonal ways of relating on the internet may veer us more toward the social deficits and lack of empathy that is characteristic of the Autism spectrum.


I never used the term evil professionally or personally until I worked in prison part time at the end of my clinical career. For many of the inmates I saw, mental disorders, including substance abuse, seemed to play a significant role in their crimes. Gang involvement, where self-esteem and identity, was enhanced through group process, was another significant factor for many. On a rare occasion, neither a mental disorder, including antisocial personality disorder, nor gang behavior, seemed to be enough of an explanation.

 That is when I began to think more seriously of evil, as did many in the aftermath of this recent tragedy. The Governor of Connecticut claimed that “evil visited this community . . . .” Later he expanded that to mental illness dressed in evil. Perhaps that can be further expanded to mental illness dressed in evil and a holster.


Soon after the tragedy, one of the fathers of a child killed tearfully pleaded for society to learn from what happened in order to prevent future mass murders. Here’s what I think psychiatry can contribute:

• Autism, Asperger, and most every other mental condition worthy of our prime focus should be called diseases, not disorders
• All such diagnoses should be made or certified by a psychiatrist to qualify for medical insurance coverage
• Do not make public diagnoses of anyone not personally examined, per our Goldwater Rule
• This tragedy, following too many others, should spur further study of where criminal behavior ends and psychiatric disease begins, if indeed there is even such a line
• All psychiatrists should spend some clinical time in a correctional institution, either during residency or later for continuing education
• Find better ways to educate the public about the early signs of homicidal risk
• Advocate for a system of safe reporting of those felt to be at- risk for homicidal behavior
• Provide better resources in order to improve early treatment of homicidal ideation
• Convene a representative body of those injured by public violence and loved ones of those murdered, to work on a national Task Force to reduce mass murder
• Advocate for a special anniversary date or holiday, December 14th, to not only remember the Connecticut tragedy or others like it, but also as a way to monitor how we are doing as a nation and a profession in trying to prevent more such tragedies.

http://www.psychiatrictimes.com/blog/couchincrisis/content/article/10168/1850954

What we know for sure is that for all the young children and adults who were killed in Newtown, their world ended a week ago. Soon after the tragedy, one of the fathers of a child killed tearfully pleaded for society to learn from what happened in order to prevent future mass murders. Here, recommendations from a psychiatrist.

Mass Murder and Psychiatry

Sixteen-year-old John and 2 friends go to a club where they get into a verbal argument with 3 members of a rival gang. After receiving a particularly gross insult, John pulls out a handgun and fires 3 shots at one of the gang members. He misses, but one of his shots hits a 15-year-old girl in the head and kills her. John is tried in adult criminal court and is convicted of murder.

Judges and attorneys who deal with such cases have many questions that involve mental health issues. How morally responsible is the adolescent defendant? How likely is he to offend again? How amenable is he to rehabilitation? How will handling this case in a particular way affect other juveniles? Punishment is often seen as having 4 potential purposes: retribution, incapacitation, rehabilitation, and deterrence. Mental health experts potentially have something to say that is relevant to each of these purposes-both at the level of the individual defendant and at the level of developing social policy for handling offending adolescents (

This past June, the US Supreme Court decided the case 

 in which the Court held 5 to 4 that youths younger than 18 years could not be given mandatory life without parole.

This decision does leave open the possibility of a life sentence without parole for a youth, but only after a judge or jury determines that such a sentence is suitable in that particular case.

 decision is the latest in a line of cases going back 25 years in which the Supreme Court has increasingly limited the situations in which minors may receive the most extreme punishments, based largely on a theory of reduced culpability. In 

 the Supreme Court held that it was unconstitutional to impose the death penalty on defendants who were younger than 16 years when they committed their offenses.

 The basic logic was laid out by Justice Stevens, who wrote for the majority in 1988:

. . . the Court has already endorsed the proposition that less culpability should attach to a crime committed by a juvenile than to a comparable crime committed by an adult. The basis for this conclusion is too obvious to require extended explanation. Inexperience, less education, and less intelligence make the teenager less able to evaluate the consequences of his or her conduct while at the same time he or she is much more apt to be motivated by mere emotion or peer pressure than is an adult. The reasons why juveniles are not trusted with the privileges and responsibilities of an adult also explain why their irresponsible conduct is not as morally reprehensible as that of an adult.

 
Mental health issues in punishing adolescents 

In the years since that decision, a good deal of research has put meat on the bones of Justice Stevens' characterization of adolescent behavior and on the neurobiology that underlies it. In the 2005 case 

 the Supreme Court found that the execution of minors was cruel and unusual punishment and thus unconstitutional, basing a reduced culpability analysis on 3 aspects of adolescence: immaturity with impulsivity, vulnerability to adverse environmental factors, and the fact that an adolescent's character is not well formed.

 In 2010, using much of the reasoning of 

 the Court found it unconstitutional to sentence adolescents to life without parole for crimes less than murder.

 In cases involving less serious charges, psychiatric assessments may be used in arguing that a case should be tried in juvenile court-an outcome that usually results in less severe penalties.

Because children are typically considered insufficiently responsible, their cases are not heard in adult court, while adults are legally presumed fully responsible. Adolescents lie somewhere in the middle of this continuum.

A successful insanity defense negates criminal responsibility. Adolescents rarely use an insanity defense, in part because the incidence of psychosis is considerably lower in adolescents than in adults, and in part because youths who are so obviously mentally ill as to qualify for an insanity defense are often not waived to adult court. While it is fairly clear that adolescents overall are less blameworthy than adults, it is often unclear in a particular case how much less blameworthy a particular adolescent is. Psychiatrists may be called on to consult in such cases to assist in determining the adolescent's culpability.

Developmental considerationsof adolescent aggression and impulsivity

One metaphor sometimes used in discussing adolescent aggression is that compared with adults, adolescents have their foot on the gas and have inadequate brakes. The literature reveals a number of key findings about adolescent development that are important to keep in mind when evaluating juvenile offenders for the courts.

For most youths, the onset of serious violence is an adolescent phenomenon, with a peak age of onset at around 16.

 If a person has not acted violently before age 21, the likelihood he or she will ever do so is quite low.

Serious violent offending (defined as aggravated assault, robbery, gang fights, or rape) is surprisingly common in adolescence: the Surgeon General's report on youth violence noted that 30% to 40% of boys and 16% to 32% of girls had committed a serious violent offense by age 17.

For most youths, offending is limited to adolescence. About 80% of adolescent violent offenders stop offending when they reach adulthood, and fewer than half of those who do continue have an adult career of violence that lasts longer than 2 years.

There is little evidence to suggest that one can accurately predict who will go on to offend as an adult and who will not. Some data suggest that delinquents who continue their criminal behavior into adulthood have different developmental patterns: those who persist in criminal activity tend to have a worsening of impulsiveness and ability to suppress their aggression, rather than the improvement that typically comes with maturation.

Serious violence is typically the end of a developmental progression of offenses that begins with low-level offenses (vandalism and shoplifting), progresses to nonconfron-tational offenses (theft), and then to violent offenses (aggravated assault and rape).

 Delinquents do not begin their antisocial activities by shooting someone.

 
Factors to consider in assessing adolescent culpability 

Finally, adolescent crime is different from adult crime. Adolescents typically offend in groups, while adults typically offend alone. Also, adolescent crime tends to be more impulsive than adult crime.

Adolescent culpability is a complex concept. A number of factors should be assessed in evaluating the criminal responsibility of an adolescent offender (

The area that has received the most attention is adolescent immaturity and impulsivity. Cauffman and Steinberg

 found that lower levels of psychosocial maturity correlated with more decisions to commit antisocial acts. Moreover, psychosocial maturity was a more significant predictor than age. Considerable research has further refined our views of components of adolescent judgment; such factors as risk-taking, reward-seeking, impulsivity, and self-regulation have been used to argue for mitigation of adolescent culpability.

Over the past decade, there has also been considerable research on adolescent brain development. The findings are consistent with a biological explanation for the behavioral findings in adolescence and point to an evolving understanding of why adolescents overvalue immediate rewards and lack the impulse control of mature adults.

 These findings show that the limbic system, responsible for emotions, matures before the prefrontal cortex, which is responsible for executive functioning. Furthermore, the tracts between the prefrontal cortex and the limbic system continue to be myelinated through adolescence.

These findings are consistent with the hypothesis that the decrease in impulsivity seen with aging into early adulthood is due to delayed maturation of the prefrontal cortex (the brakes) and its ability to control impulses emanating from the limbic system (the gas). Such findings provide a biological substrate to the argument that adolescents are less mature than adults.

In a particular case, the strongest evidence for impulsivity usually comes from the details of the crime itself. If the crime can be shown to have occurred in the heat of the moment, as in the example given above, impulsivity is clear. If the crime is planned and predatory, the impulsivity argument may not apply. In some cases, historical data from collateral sources (such as reports of persons who know the defendant, previous mental health assessments and treatment, and prior criminal activities) may provide corroborative information regarding the defendant’s impulsivity in other situations.

An adolescent typically has no choice in such matters as what neighborhood to live in; what school to attend; whom to live with; or whether to continue to live in abusive, neglectful, or dangerous circumstances. Also, he is not responsible for the economic circumstances of his family. The Supreme Court has recognized this as a basis for decreased culpability: "[Adolescents'] own vulnerability and comparative lack of control over their immediate surroundings mean juveniles have a greater claim than adults to be forgiven for failing to escape negative influences in their whole environment."

There is strong statistical support linking adolescent crime rates to conditions of socioeconomic deprivation.

Ascertaining the socioeconomic background of a juvenile offender can often be done from collateral sources. Assessing the effect of adverse circumstances on an individual defendant is more complex, but there is nevertheless considerable social science data on the effects of factors such as abuse, neglect, and family disruption that the expert may draw on to help justify his conclusions.

If you want to know how much trouble an adolescent is getting into, ask how much trouble his friends are getting into. Most adolescent offending occurs in groups, and adolescents are especially vulnerable to peer pressure. Gang membership is one of the leading risk factors for predatory violence. Peer group effects are amplified in street subcultures, where it is necessary to appear tough to avoid being seen as weak and therefore vulnerable to attack. Such environments decrease responsibility when the violence, while considered wrong by society, is considered right in the subculture where a youth lives.

The details of the crime, particularly if the crime involved multiple perpetrators, provide evidence as to whether peer group effects were significant. In some cases, there may be characteristics in the defendant’s history that suggest susceptibility to peer pressure as well, such as when an intellectually disabled youth has a history of being easily talked into unwise actions by delinquent peers.

We expect that a 15-year-old adolescent imprisoned for life will not be the same person at age 45; the same is not true for someone convicted as an adult whose personality is likely to remain relatively stable. The fact that personality frequently changes from adolescence to adulthood has repeatedly been cited by the Supreme Court as one of the rea-sons why adolescents have lessened responsibility.

Antisocial personality, by DSM convention, cannot be diagnosed until age 18. Psychopathy (a non-DSM diagnosis, but one used in forensic psychiatry to get at the more inter-nal aspects of antisocial personality, such as exploitativeness and severe deficits in empathy and guilt) is an especially worrisome personality type when seen in adolescents. Nevertheless, psychopathy diagnosed in adolescence is not highly predictive of adult psychopathy: the reported correlation of 

 = 0.31, while significant, is not strong enough to account for enough of the variance to be very useful in sentencing an individual delinquent.

In addition to the clinical interview, a variety of personality tests can be used to buttress conclusions about the defendant's present personality characteristics.

It is well established that among delinquent youths, the rate of mental disorders across the entire range of diagnoses is high.

 Excluding conduct disorders, more than 60% of incarcerated juveniles report at least one disorder, about triple the rate in the general population, and more than 40% report more than one disorder. In most cases, delinquent behavior is not thought to be "caused" by mental illness, but a mental disorder likely magnifies the effects of other factors relevant to reducing culpability through such pathways as further impairing judgment and slowing consolidation of a healthy identity. When an evaluation reveals a mental illness, the youth's amenability to treatment has implications for rehabilitation.

Attitudes toward juvenile offending range from "do the crime, do the time," with its implication for full adult punishment, to "they’re just kids"-a response that elicits more parental feelings of helping offenders not repeat their problematic behavior. Reacting to adolescents as though they are adults brings with it the ready set of attitudes that we apply to adult offenders. If we see adolescents as different from adults, but also as different from children, then we will use, or have to find, a different set of attitudes.

Attorneys often ask experts to testify "about the adolescent brain" in sentencing hearings. Why does such testimony have power? The data showing that adolescents are more impulsive come from studies of behavior, not imaging studies. But the neuroimaging data indicate that the adolescent brain is different, which carries with it an implication that the reactive attitudes that we have toward adults should not apply.

Assessments of partial culpability of adolescents are difficult in individual cases; however, the courts are moving away from mandatory sentencing to individual determinations, even for the most heinous crimes. These individual determinations can frequently be assisted by psychiatrists, because they have an ever-increasing database of behavioral and neurobiological understanding on which to base their opinions.

Assessments of partial culpability of adolescents are difficult in individual cases; however, the courts are moving away from mandatory sentencing to individual determinations, even for the most heinous crimes.

The Adolescent Brain Is Different

Traumatic brain injury (TBI) in children and adolescents (hereafter referred to as children) is a major public health problem. The incidence of TBI in children younger than 15 years is 400 cases per 100,000 each year. Psychiatrists have a crucial role in the management of young persons who have a TBI.

In children with a TBI or other injuries, such as orthopedic injury fractures, there is a high rate of preinjury psychiatric disorders, which may predispose them to being injured. Furthermore, postinjury psychiatric disorders are also common and should be managed.

 It is important for psychiatrists to be knowledgeable about pediatric TBI not only because it is so common but also because understanding the correlates of new-onset disorders might shed light on pathophysiological mechanisms of corresponding psychiatric disorders in children who are not injured.

Pediatric TBI psychiatric research studies have examined new-onset psychiatric disorders in general as well as specific new-onset psychiatric disorders. The rationale for the more general approach (lumping) has been to determine patterns that are common to problematic versus relatively benign psychiatric outcomes. Furthermore, new-onset psychiatric disorders are heterogeneous, and comorbidity is common; thus, only large studies have sufficient power to analyze correlates of specific disorders. The reasoning for investigating more specific psychiatric syndromes or symptoms (splitting) is related to the need to advance understanding in pathophysiology, appropriate diagnosis, and treatment.

What new information does this article provide? 
? This article reviews preinjury and postinjury psychiatric disorders in terms of clinical phenomenology, neuroimaging lesion correlates, and psychopharmacological therapy and psychotherapeutic approaches.

What are the implications for psychiatric practice? 
? The primary implication is a call to practitioners to embrace the challenge of treating children with a TBI, given the concentration of preinjury and postinjury psychopathology in these patients.


The term "novel psychiatric disorders" was coined to facilitate the study of postinjury psychiatric disorders because of the high frequency of preinjury psychiatric disorders in injured children. Novel psychiatric disorders encompass disorders that emerge after injury in children with no preinjury psychiatric disorder and also new disorders that emerge in children with preinjury disorders. For example, a child with preinjury ADHD in whom MDD develops after the injury would be considered to have a novel psychiatric disorder, while a child with preinjury MDD in whom a new episode of depression develops would not be classified as such.

Depending on the postinjury time interval analyzed, the novel psychiatric disorder has been significantly related to severity of the TBI, preinjury family function, intensity of family psychiatric history, socioeconomic status, lifetime preinjury psychiatric disorder of the child, and preinjury adaptive function. Other than severity of the TBI, all these correlates of a novel psychiatric disorder are integral considerations in case formulations conducted by psychiatrists on uninjured patients.

Injury severity is typically classified according to the Glasgow Coma Scale (GCS), which is a measure of responsiveness in the acute postinjury phase. The scale ranges from 15, which represents normal responsiveness, to 3, which indicates complete unresponsiveness in eye opening, verbalization, and motor function. Severe TBI is typically defined as a GCS score of 3 to 8, a score of 9 to 12 suggests moderate TBI, and mild TBI is a score of 13 to 15. Mild TBI is further classified, depending on the presence or absence of brain neuroimaging evidence of intracranial damage, into "complicated mild" TBI and "uncomplicated mild" TBI. Accumulated findings have shown that novel psychiatric disorders occur after severe TBI, moderate or mild TBI, and orthopedic injury fracture controls in 54% to 63%, 10% to 21%, and 4% to 14% of children, respectively.

 summarizes injury/psychosocial correlates for novel psychiatric disorders and 

 summarizes neuroimaging correlates for novel psychiatric disorders. Specific novel psychiatric disorders cover the range of psychiatric disorders that are seen in noninjured children with the notable addition of DSM-IV-TR’s personality change due to traumatic brain injury (PC). PC is critical to recognize and classify correctly because it is generally the most debilitating syndrome that complicates recovery. The name of the syndrome is somewhat misleading because it does not measure personality and is not a personality disorder, but rather it is a syndrome characterized by clinically significant subtypes of affective lability, aggression, disinhibition, apathy, and/or paranoia. Technically, the diagnosis should only be made if symptoms have persisted for at least 1 year. However, the impairing symptoms are evident within days of the TBI after resolution of posttraumatic amnesia.

The affective lability subtype is the most common, and neuroimaging correlates of the syndrome reflect damage to dorsal frontal lobe regions with corresponding failure to regulate affective expression generated by ventral frontal systems.

 As such, PC is associated with dysregulation of other affective states, including anxiety and depression.

Secondary ADHD (SADHD) is the term assigned to novel ADHD. Clinically, there is a predominance of the inattentive type, although all types occur after injury. SADHD is significantly comorbid with PC. There appears to be a confluence of neuroimaging correlates of SADHD and developmental ADHD. However, emerging neuropsychological studies of SADHD versus developmental ADHD are not yet definitive regarding similarity of test performance.

Psychiatrists will recognize other novel psychiatric disorders, such as anxiety disorders, depressive disorders, oppositional defiant disorder (ODD), conduct disorder, and even mania on rare occasions. Caution is required for correct diagnosis because casual counting of symptoms from a list of diagnostic criteria can lead to erroneous conclusions. New-onset irritability may be classified under a diagnosis of PC, major depression, PTSD, or ODD. New-onset concentration difficulties may be part of SADHD, major depression, generalized anxiety disorder, or PTSD. Forgetfulness may be part of SADHD or PTSD, or it may be an isolated symptom (not related to a defined psychiatric disorder) directly related to neurological damage.

An understanding of the context of each symptom and appreciating the cohesiveness of the constellation of symptoms is the path to correct diagnosis. For example, poor concentration that is related to a child being preoccupied with intrusive thoughts of the injury incident and forgetfulness because the child would rather not remember such a traumatic event are more likely to be consistent with PTSD than SADHD, providing that other symptoms of PTSD are also present.

The question of whether all novel psychiatric disorders should be considered to be caused by a general medical condition, ie, TBI in this instance, cannot be definitively answered until children with specific novel psychiatric disorders are compared across many characteristics with uninjured children with corresponding psychiatric diagnoses. Relevant characteristics for comparison of the syndromes are specific symptom frequencies, disorder subtypes if applicable, natural history, neuropsychological profiles, imaging characteristics (eg, regions of interest volumes, microstructural white matter integrity), family history of the psychiatric syndrome, and treatment response.

 
Psychosocial correlates of specific novel psychiatric disorders 

Traumatic brain injury (TBI) in children and adolescents is a major public health problem. Psychiatrists have a crucial role in the management of young persons who have a TBI.

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The Hidden Suffering of the Psychopath

Course and Treatment Outcomes of ADHD

Infographic: Men With Versus Men Without ADHD in Childhood

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Mass Murder and Psychiatry

The Adolescent Brain Is Different

Traumatic Brain Injury in Children and Adolescents

Why Psychiatrists Must Confront Gun-related Violence

Violence in the Media: What Effects on Behavior?

Neuropsychiatric Differences Between Boys and Girls With ADHD