Depression, PTSD, panic disorder, and abuse of alcohol and drugs are more insidious, quieter forms of illness that can cause the same desperation and disability as psychotic disorders.
On October 17, 2010, a 20-year-old Army private deployed to Afghanistan shot and killed a captured Taliban soldier he had arranged to guard.1 After his arrest, he was taken to a psychiatric hospital for evaluation. Controversy ensued: was he a criminal or mentally ill? Was he feigning madness to elude punishment?
On May 24, 2011, a military court at Fort Carson, Colo, accepted a guilty plea to premeditated murder. The media reported this as a deal to a reduced prison term of 12.5 years, instead of possible life imprisonment, with a dishonorable discharge. He continued to carry the diagnoses of schizophrenia and PTSD.
As I read this chilling story, I was reminded of an experience I had 40 years ago as a first-year resident in psychiatry on rotation at a Veterans Administration Hospital in Syracuse, NY.
Syracuse Veterans Hospital, psychiatric unit, circa 1971
I looked like any young resident, wearing my white waist-length coat with stethoscope hanging out from a side pocket and showing signs of exhaustion from too much on-call duty, bad food, coffee, and apprehension about what I was trying to do. I had begun my rotation on a VA psychiatric unit for men with serious mental illness.
Veterans with disabling mental problems often stayed on this unit for many months for rehabilitation and because it also served as a site for those who needed extensive evaluation of their conditions, including those sent by the military. I had 7 men under my care. On the first day, I introduced myself to my patients and tried to instill in each of them some confidence in their new doctor. I knew their stories, at least as they were portrayed in the medical record. The psychiatric illnesses of all these patients-except for one-were familiar to me.
He looked like any gangly, ill-at-ease 19-year-old. Only he was missing a finger on his left hand. Billy seemed passively resigned to being on the psychiatric ward, along with about 50 other men. He had faced a court martial for theft, but because there was considerable suspicion that he was mentally ill, an evaluation was ordered to determine whether his future would be in a psychiatric hospital or a prison. My job was to engage, evaluate, and treat him, with the goal of making recommendations to my supervisors who, in turn, would report to military officials.
The first thing Billy said to me was that he had trouble sleeping. Even a young doctor knows that is usually a plea for sedatives to get high; he was seeking a good-night intoxicant. A combination of sleep medication, a pain killer, and a tranquilizer will give almost anyone a “buzz.” I would meet him halfway. We agreed on evening meds that would help him sleep but with less likelihood of delivering a high or producing abuse and dependence. We also agreed to meet daily to talk about his life and his problems.
Billy had been drafted into the army at 18. We were at war in Vietnam and deferments went to the educated and those who had connections that could enable them to avoid the war and combat-not to poor kids from upstate New York. After basic training, he was deployed to Vietnam and signed up for the “graves detail.” He told me,
Every day at dawn a small patrol of GIs was sent out to recover American bodies. It was awful but because the fields had been heavily patrolled it wasn’t so dangerous from snipers, guerilla ambush, and landmines. There were also dead enemy combatants to be found, and the “graves detail” could put them in body bags, if we wanted. We would get high on dope before we went out on detail. I got really out of it. I took a lot of drugs, like the others, and everything was a haze. Pretty soon we started robbing the bodies. We took things from American troops and sometimes there even was something worth taking from the enemy. We looted watches, rings, money . . . some guys carried all kinds of weird things too. But we got caught. I knew I would be court martialed. That was when I shot my finger off with my service revolver.
Billy intrigued me. He was aloof, preoccupied, highly anxious, and paranoid; sometimes, he heard voices. Was what he did to himself a sane response to insane circumstances? Was he someone feigning madness after having been caught for criminal activity-was he a psychopath (ie, did he have an antisocial personality disorder)? Or had he become psychotic and could not distinguish reality from fantasy? How did his abuse of drugs influence his judgment and behavior? Was there something in Billy’s life and history that would explain his strange behavior, short of the Vietnam hell where he endured danger, drugs, and death at every turn?
A good psychiatric evaluation can generally make the distinction between criminal behavior and mental illness. If the diagnosis is antisocial personality disorder, which is not amenable to psychiatric treatment, it is criminal behavior; if it is determined that the crime was a consequence of a mental illness, then commitment to a psychiatric hospital for treatment follows. Hospitalization lasts until physicians and the court decide the person is no longer a threat to the community-an indeterminate time that could last longer than time spent in prison. It is no wonder that psychopaths typically do not want to be seen as “crazy,” or be sent to a psychiatric hospital for treatment.
Criminal behavior while in a psychotic or drug-induced state needs to be distinguished from antisocial personality behavior. The conclusion of my differential diagnosis on Billy would be used as a basis for whether he would go to prison or receive psychiatric treatment.
Could Billy be malingering? Malingerers are generally not psychopaths (although psychopaths are known to malinger): malingerers do not have a history dating back to adolescence of illegal behaviors and acts of cruelty; their symptoms emerge later when an illness may provide a useful strategy to elude responsibility and elicit special treatment. On the inpatient unit, time would tell. It is really hard to pretend to be mentally ill for days, weeks, or even months. Billy would be under constant surveillance for months-he had no place to hide. As time passed, Billy remained lost in his internal preoccupations, full of fears and fantasies.
After weeks of meeting daily, Billy spoke more freely. I heard about his alcoholic father, a mechanic who could not hold a job, who beat Billy. He beat Billy’s mother, too, sometimes in front of their son. Billy said he had trouble learning to read and could not concentrate. He occasionally skipped school, but if he was caught, his father would beat him, so he usually went to school but daydreamed about war movies or cowboy shows on TV. He failed at school but was moved on from grade to grade. He ultimately graduated but was barely able to read.
Billy had been a loner. He started drinking and smoking cigarettes when he was about 13 and progressed to drinking almost every day, often heavily, by the time he entered the service. He told me that it did not make a difference to him whether he had sex with a girl or a boy or later with a man or a woman. He told me about his daily use of hashish, opium, and anything else he could get once he landed in Vietnam. He blamed his sergeant for talking him into stealing from the bodies.
Finally, he began to tell me about the voices he had started to hear-voices that persecuted and humiliated him. These voices still haunted him, he said, adding that now he had nightly dreams of the fields, full of death, that he had patrolled.
One day, I asked Billy about the day he shot himself.
We were caught because some of the guys were flaunting the loot. I had heard that if you are injured you can get out of going to court, and I sure didn’t want no court martial. I got real high, and it’s all a blur after that. I kind of remember waking up in the field hospital and later in some hospital in Germany. I felt really weird and the voices were really ragging me. Nothing seemed to help.
Billy was always ready to talk with me, although he spent little time with anyone else on the ward. In the dayroom where we met, he always took a seat that allowed him to see everyone coming and going from the ward. I asked him if he wanted to try a medication that might help with the voices and perhaps with his sleep, and he said “. . . sure, will it get me high?” I prescribed the antipsychotic perphenazine. Billy said the medication made the voices “fade” but not go away. He remained aloof and suspicious.
I was becoming convinced that Billy had a mental illness, not antisocial personality disorder. A supervisor suggested I read The Mask of Sanity, a classic text, first published in 1941, by Dr Hervey Cleckley,2 who wrote: “Is it not he himself who is most deeply deceived by his apparent normality?” Cleckley was saying that the psychopath first and foremost deceives himself. It was up to his doctors to answer the diagnostic dilemma of whether he was feigning illness to escape responsibility or whether he was mentally ill-because he himself could not know.
Billy had attracted attention among the university faculty. I was asked to present his case at Grand Rounds: Billy would not be paraded before dozens of professional onlookers, but his story and the questions he presented would be. I worked hard on my presentation and put together as much history as I could muster to stimulate discussion.
Billy did not easily fit within any one diagnostic category because he displayed a combination of traumatic, drug-related, and psychotic features. In fact, many studies today have demonstrated that people with mental illness are more likely to have a comorbid substance use disorder than not, and the converse is just as true: people who abuse drugs and alcohol are more likely to have a mental disorder than not.3,4 However, back in 1971, their astounding co-occurrence was not yet recognized. Nor did we know that unless both disorders are simultaneously effectively treated would there be little chance of recovery from either.
On the day of the Grand Rounds, I put on a fresh, short white coat denoting my novice station among the professors, junior faculty, and senior residents. The long, narrow auditorium in the medical center building had a podium and rows of chairs that could seat about 100. The room was full. The chairman called the Rounds to order and said we had a diagnostic dilemma and that our conclusions would be instrumental to the patient’s future-namely, prison or hospital. It was an era when feelings about the Vietnam War were ablaze. We were seeing the casualties of war mount not just on television but in the wards of our hospitals and local communities.
I told the story of a young man whose shooting off his finger was not the single or simple measure of him or his illness. I recounted Billy’s early cognitive and relationship problems, his victimization by his father, and his progressive use of alcohol dating back to his early adolescence. He had petty antisocial behaviors, such as stealing candy or soda. His sexuality was “undifferentiated” in that it did not matter with whom he was sexually engaged, what mattered was what he called “getting off.” His daytime fantasies were principally aggressive, in which he was the perpetrator of violence; but his dreams repeatedly revealed him to be the victim of others. I emphasized the symptoms of serious mental illness, namely hallucinations and paranoia, and his progressive retreat from the world of others, leaving him isolated and alone.
His self-inflicted gunshot wound was purposeful, even if oiled by an abundance of disinhibiting drugs. It was also, I proposed, an overdetermined act: it was the combined product of his aggressiveness, self-loathing, and a need to punish himself and a strategy to escape a grim and unbearable military fate. That was the psychological beauty and economy, so to speak, of the act: it served many purposes. He was a man fighting for his emotional survival-no hero in the conventional sense, but this was no conventional war and he no conventional soldier (if there is such a person).
I had searched medical history books for a diagnosis I could offer that might befit Billy. I found one, dating back almost a century: constitutional psychopathic inferior, with psychosis. What it conveyed, in an antiquated way, was a person born with a defect of constitution or character that left him disposed to psychopathic behavior (eg, stealing, violating social norms) but who also showed clear and persistent evidence of psychosis. Today Billy would likely carry multiple diagnoses of psychosis (perhaps schizophrenia), a co-occurring substance use disorder, and PTSD.
After I was done with my presentation, the floor erupted with questions and comments. Did I consider that he might have sustained a head injuring from early childhood abuse or concussive blows in Vietnam? asked a professor at the VA who had seen more soldiers returning from Southeast Asia than anyone else. Another asked how could I dismiss the theft and calculated manipulation to avoid punishment that would earmark him as a psychopath. Well, I hadn’t: I tried to put Billy’s behaviors in perspective and the conditions that I thought were the most representative of my patient in rank order.
One of the professors, a well-known social critic of psychiatry, deemed the whole business of searching for a diagnosis a form of cultural delusion we were all swept up in, since, after all, mental illness was a myth. Another asked if we appreciated the discussion that day as an ironic metaphor about “the war”? He said we were discussing a war that had no moral footing so it was not the patient who suffered from antisocial behavior but our country, which was paying the price for its actions in the court of public opinion, at home and abroad.
This was what I loved about psychiatry. The discussion was not only about organs and physiological processes, as it would be in medicine, neurology, or orthopedics; psychiatry was just as at home with psychology, sociology, and ethics as it was with the practice of medicine.
After close to a half hour of lively discussion comprising varied and contradictory ideas, 2 senior professors took control of the discussion. Neither saw Billy as a psychopath. In their view, Billy was mentally ill and had had signs of psychotic illness since late adolescence-a typical time of onset for serious mental illness.
The emotional and physical abuse he received as a child affected his capacity to trust and produced the (now documented) changes to the brain’s anatomy and physiology that trauma can induce. His abuse of alcohol and drugs fueled his antisocial conduct and probably also contributed to brain damage and further prompted the emergence of psychotic symptoms. They recommended that Billy receive treatment through the VA and later from community-based services for what they considered primarily mental disorders and the psychological wounds of war.
The Rounds ended and faculty and students dispersed. I had survived my first professional presentation; more important, I thought I had obtained the support needed to keep Billy in the hospital. I believed he had survived, in his unique way, the psychologically overwhelming circumstances of his life and of Vietnam. He had taken matters into his own hands, so to speak, and then found help in an improbable intern on rotation in a local VA hospital.
As months passed, Billy remained in his shell. I was witnessing the entrenchment of a severe and persistent mental illness. He was more preoccupied with his hallucinations and more guarded and paranoid. There were days he would not leave his room, and when he did, he sat vigilant in the dayroom. Medications did not help much with the paranoia or his withdrawal. He was also showing features of a chronic psychotic illness with apathy and lack of motivation, difficulty in experiencing pleasure, and a blunted expression and feelings. His face seemed frozen, and any luster had dimmed from his eyes. He took little care of his hygiene and appearance. He chain-smoked and harbored a nest of unknown suspicions.
He was not going to be cured any more than someone with a chronic medical illness, such as heart disease, diabetes, or emphysema. He needed long-term treatment and rehabilitation to regain a life-albeit a life with mental illness. In the early 1970s, being mentally ill did not carry the same prospect for recovery as it has in recent years.
Billy would stay in the hospital and in time would be discharged to the community. He was not a menace to society, nor was he a psychopath who deceived himself and exploited others. He was a sick man who needed treatment. In his own way, he knew that and abided by the rules of medical care.
I said goodbye to Billy when my rotation at the VA ended. After almost a year in the hospital, Billy was discharged to live in a group home for people with mental illness. He was at the beginning of a long journey that would test him and his caregivers’ skill and resolve, but he would have a chance to make a life in the community.
Billy taught me more about mental illness than any book or paper I had read or seminar I had attended that year. I had known him for 6 months and saw the way that serious mental illness can fix its grip on a person and not let go. I also saw a will to live and a determination to recover and make a life despite what some would regard as amongst the worst that fate could deliver. In thieving from the dead and maiming himself, Billy may have done something illegal and seemingly incomprehensible-but his just fate was that of a sick man, not an evil one.
Psychotic illnesses represent a small percent of the mental and substance disorders that afflict our soldiers. Nonpsychotic disorders, such as depression, PTSD, panic disorder, and the abuse of alcohol and drugs, are far more common-and infrequently require hospitalization. Depression, PTSD, and panic disorder are more insidious, quieter forms of illness that can cause the same desperation and disability as psychotic disorders. Suicide results from the deadly combination of horrific psychic pain and a conviction that there is no exit; giving up seems almost rational. Suicide among veterans is at the high-est it has been in the almost 3 decades since this type of data has been kept, with more soldiers dying of suicide than in combat.
Veterans with mental and substance use disorders can be helped to recover and rebuild their lives. Many can avoid disability and contribute to society. Veterans-and their families-need our help to overcome the stigma and barriers to care faced by persons with mental illness. Not only is this the law, it is what we owe our veterans, their families, and our communities, as well as all persons with mental illness.
While homicide is exceedingly rare, it is occasionally perpetrated by persons with mental illness. Forensic mental hospitals around the world have patients who have murdered in a psychotic state. The law recognizes that illness, not only badness, can prompt murder. And the law calls for different outcomes for psychotic persons than for psychopathic persons.
Private First Class Lawrence committed murder. There has been no contest about his having a psychotic disorder or whether he understood what he was doing when he planned for and shot his prisoner. The law permitted him to accept a lengthy but not life term of imprisonment. Prisoners are entitled to proper treatment of medical conditions, including mental illnesses. That is what is due Lawrence in the prison to which he will be remanded.
1. Perry T. Army private accused of murder in Afghan prisoner’s death. Los Angeles Times. November 29, 2010. http://articles.latimes.com/2010/nov/29/nation/la-na-soldier-hearing-20101129. Accessed August 29, 2011.
2. Cleckley H. The Mask of Sanity-The Acclaimed Study of the Psychopathic Personality. St Louis: Mosby Press Medical Library; 1982.
3. Sagman D, Tohen M. Comorbidity in bipolar disorder. Psychiatric Times. 2009. http://www.psychiatrictimes.com/bipolar-disorder/content/article/10168/1391541. Accessed August 25, 2011.
4. Pettinati HM, Dundon WD. Comorbid depression and alcohol dependence. Psychiatr Times. 2011;28(6):49-55.