Stephen A. Diamond Ph.D.

Evil Deeds


Making Sense of the Batman Massacre: Is Suspect's Behavior Motivated by Madness or Manipulation?

Can forensic evaluators really distinguish between malingering and psychosis?

Posted Jul 29, 2012

Commentators, both lay and professional, tend to take two diametrically opposed positions on these alleged developments: Either Mr. Holmes is a malingering (i.e., faking) psychopath or he is suffering from some sort of psychotic symptoms. (See my prior post on such public commentaries.) This is precisely the question forensic psychologists and psychiatrists must attempt now to answer following the conclusion of his competency evaluation, if indeed there is going to be one. Given the circumstances and bizarre nature of the alleged crime, I believe a competency evaluation makes sense in this case. Because it will tell the tale regarding this defendant's current psychiatric condition. His state of mind at the time of the alleged crime will be the subject of any kind of insanity or diminished capacity defense if such a defense is ever invoked. But if the defendant is found currently not competent to stand trial, as in the case of Jared Loughner in Arizona (see my prior post), there will be no trial until such time that Mr. Holmes is deemed by his doctors to be sufficiently competent to comprehend his situation and cooperate rationally with his defense counsel. (See my prior post on forensic psychology.)

Many observers, including those that, since day one, see Holmes as a psychopath (see my prior post on psychopathy), believe he is simulating mental illness for the obvious secondary gain of mitigating his criminal responsibility in this matter. (See my brief appearance on MSNBC's "The Cycle" on the day following the shootings.) Malingering, which can take the form of faking bad or, say, as in the case of Ted (the Unabomber) Kaczynski, faking good (see my prior post), is an ever-present possibility in the practice of forensic psychology and psychiatry. Which is why well-trained forensic evaluators are keenly and constantly on the look out for any signs of such feigning. No mental health professional is beyond the possibility of being fooled by a skilled, clever, determined and manipulative defendant. But, that being said, it is not so easy to fake a mental disorder convincingly enough to totally fool a well-seasoned and astute forensic psychologist or psychiatrist as you may think. (Yet, see my prior post on Casey Anthony's questionable forensic evaluation.) In this sense, the forensic evaluation can become a battle of wits between the malingering defendant and the examining doctor.

Can someone fake psychosis? Psychopaths or sociopaths are notorious for their skillful conning, lying and deceitfulness. They are professional liars and talented con artists. But can they fool a professional forensic psychologist or psychiatrist? They can certainly try. They can deliberately behave bizarrely. Stare off into space. Speak gibberish. Report hearing voices or seeing things that aren't really there. Or to be directly controlled by the CIA, FBI or extraterrestials via implanted devices. They can claim to be Jesus Christ, Krishna, Satan or some famous historical figure. They can insist they do not understand how the legal system functions and that their attorney is part of a grand conspiracy against them. They can try to manipulate testing results. Sometimes successfully.

But psychosis is not diagnosed simply based on what someone says or does. Nor necessarily on how they perform on psychological tests. It is also a matter of how they say it: The paranoid patient, for example, is absolutely and unequivocally convinced that powerful agencies conspire against, influence or directly control him or her. They are genuinely furious, fearful, terrified. Or they truly believe themselves to be possessed by Satan. Or to be Batman or the Joker. Or a member of the Knights Templar. To the seasoned forensic evaluator, there is a qualitative difference between a defendant who is malingering and one who firrmly believes in what is being experienced. Or one who is obviously psychotic but trying to fake good. Someone responding to internal stimuli and detached from outer reality. Who is not in possession of him or herself. And in whom the historical onset and course of the illness conforms closely, if not always exactly, with what we know to be the typical subjective symptoms and objective signs of psychosis. The devil is always in the details. And the details have to be just right to be convincing. That's part of the job. To sort out the truth from the lies. The real from the fake. Of course, if a defendant's developmental history indicates the presence of Antisocial Personality Disorder (psychopathy or sociopathy), the concern and scrutiny regarding possible malingering is magnified greatly. Still, a skilled actor who has done his or her homework can conceivably deceive an inexperienced or incompetent evaluator. But to fool two or more experienced forensic evaluators is far less likely.

Whether Mr. Holmes will be found to be manipulatively malingering mental illness or legitimately psychotic--or suffering from some other medical, neurological or psychiatric condition--remains to be seen. I purposely proffer no diagnosis here. But one of the basic questions raised by this case could eventually have to do with the very nature and definition of the term "psychosis" or "psychotic." And how that differs from, say, psychopathic. And the timing is extremely interesting. Because the highly controversial (see my prior post) revised diagnostic manual of the American Psychiatric Association, the DSM-5, is scheduled for publication next year, and proposed at one point to include a new mental disorder originally called Psychosis Risk Syndrome, but more recently revised to Attenuated Psychosis Syndrome. If it turns out that James Holmes suffered a full-blown psychotic episode in the months prior to the shootings, one which persists at least residually today, and possibly less severe psychotic symptoms prior to that, would he have been a candidate for Attenuated Psychosis Syndrome? And, had he been properly diagnosed as such, could that have possibly prevented this terrible tragedy? (Another related question will be whether Mr. Holmes verbally reported his homicidal ideation or intentions to his psychiatrist at any time. And, if so, why he was not immediately psychiatrically hospitalized, police notified and the potential victims warned.)

Attenuated Psychosis Syndrome is at this time only being recommended for further study in Section III, which is the section of the DSM-5 text in which conditions that require further research will be included. By definition, in this condition, at least one of the following symptoms are present in attenuated form with relatively intact reality testing, but of sufficient severity and/or frequency to warrant clinical attention:

           1.     delusions/delusional ideas

           2.     hallucinations/perceptional abnormalities

           3.     disorganized speech/communication

One of the primary problems with the controversial proposed DSM-V disorder of Attenuated Psychosis Syndrome is, for me, not the diagnostic criteria itself, but rather the still extremely poor comprehension in psychiatry and psychology of the fundamental nature and meaning of psychosis. What is psychosis? What causes it? And who is really at risk for developing it?

It is important to note that psychosis is a broad category of severe mental disorder with a relatively vague definition. One that has evolved over the past century. To say a patient is psychotic is partly a qualitiative description of  the extraordinary and aberrant nature of their symptomatology. But most mental health professionals today would agree that, phenomenologically speaking, psychosis consists of the presence of hallucinations and/or delusions, bizarre behavior, usually (but not always) marked impairment that grossly interferes with social, occupational, academic or basic day-to-day functioning, and extremely poor "reality testing" or a so-called "break with reality." A profound confusion between outer and inner reality. According to DSM-IV-TR, "the narrowest definition of psychotic is restricted to delusions or prominent hallucinations, with the hallucinations occurring in the absence of insight [my emphasis] into their pathological nature." (p. 297) 

However, DSM goes on to note that, while "the term psychotic has historically received a number of different definitions, none of which has achieved universal acceptance. . . A slightly less restrictive definition would also include prominent hallucinations that the individual realizes are hallucinatory experiences." In other words, by this "less restrictive" definition, psychosis can be diagnosed in cases where the hallucinatory phenomena are prominently present even though the patient recognizes the phenomena as hallucinations, i.e., as not objectively real. But this is too broad a definition for my taste, and can cover a multitude of non-pathological perceptual phenomena. Psychosis has also long been associated with "a loss of ego boundaries," which, for some misguided New Age spiritual seekers, is their perceived transcendent goal: the dissolution or death of the ego. Indeed, there are certain transpersonally-oriented psychotherapists who insist that many examples of what would traditionally be diagnosed as psychosis are, in fact, not psychosis at all, but episodes of so-called "spiritual emergence."

The term "psychosis" is generic, in as much as it refers to a handful of more specific severe and debilitating mental disorders. Schizophrenia, one of the most debilitating of all mental disorders, appears consistently in approximately .5 to 1.5% of the population across cultures and is a classic form of psychosis. But there are currently several other kinds of psychotic disorders specified in the DSM-IV-TR, including Schizophreniform Disorder, Schizoaffective Disorder, Brief Psychotic Disorder, Delusional Disorder, Shared Psychotic Disorder, Substance-Induced Psychotic Disorder, and Psychotic Disorder due to a General Medical Condition. In addition, psychosis may be experienced by sufferers of severe Major Depressive Disorder, Bipolar Disorder, Borderline, Paranoid and Schizotypal Personality Disorder. And although most psychotic disorders such as Schizophrenia are devastatingly debilitating, some, like Delusional Disorder or Shared Psychotic Disorder, are far less so as regards daily functioning, including the ability to plan and organize over time a terrorist attack like the ones in Aurora, Arizona or Norway. (See my prior post on Anders Breivik.)

Most mainstream mental health professionals today take (mistakenly, in my estimation) an almost exclusively biological view of psychosis, believing it to be a "broken brain" disease. A genetically inherited neurobiological abnormality. A purely physiological phenomenon. But this is just one medicalized theory of psychosis. Others exist. In fact, there may be somewhat different etiologies for different psychotic disorders. In my book Anger, Madness, and the Daimonic (1996), I present some alternate ways of conceptualizing psychosis (colloquially called "madness") and discuss in depth its correlation with chronically repressed anger or rage.(See my prior posts.)

Another way of psychologically conceptualizing psychosis is that it involves a major distortion of reality due to finding reality as it is unacceptable. From the perspective of depth psychology, psychosis occurs when consciousness and the ego is overtaken or inundated by the unconscious. In Jungian analytical psychology specifically, psychosis can be seen as an extreme and therefore pathological form of introversion, wherein the person withdraws almost completely from the stressful, traumatizing or rejecting and rejected outer world into his or her own inner world. (See, for example, my prior post on Jared Lee Loughner.) Fantasy is fused with reality. Reality with fantasy.

In another of my previous posts, I discuss the phenomenon known as folie a deux (which directly corresponds to the DSM-IV-TR diagnosis of Shared Psychotic Disorder), and how it clearly illustrates the basically psychological rather than biological nature of psychosis in at least some cases. Brief Psychotic Disorder demonstrates the direct relationship between extraordinarily stressful trauma, sudden reactive onset and equally sudden disappearance of psychosis within the span of one month. (See my prior post on the creator of Kony 2012.)

Now, of course, how one conceptualizes psychosis, or any other mental disorder, informs how one goes about trying to treat that disorder. (Three-hundred years ago, psychosis, madness or insanity was widely believed to be the result of demonic possession, for which exorcism was considered the only remedy. In some cultures and theological circles today, psychosis is still seen and treated in this way. See my prior post on the psychology of exorcism.) It also affects the capacity to understand the risks or vulnerabilities in particular individuals for becoming psychotic at some point in their lives. Some people seem more prone to psychosis than others, for reasons still poorly understood. They seem to be predisposed to psychosis or harbor a hidden, underlying, latent psychosis which, under severe stress or trauma, can be triggered.

Having said that, I contend that no one, even the most "normal" among us, is ever fully immune to becoming psychotic. Psychosis is a state of mind that anyone can potentially experience under the right or wrong circumstances. I understand that this is both a provocative and disturbing assertion. We prefer to think of psychosis as something that happens only to other less fortunate, genetically defective folks neurobiologically predisposed or predestined to it. But this is not reality. (See my prior post.) And if this is so, if we all to some extent contain the innate capacity or potentiality for psychosis, transitory or otherwise, does this mean that we all possess the genetic predisposition for it? Or might psychosis, as I would argue, be less of an aberrant biochemical or neurological phenomenon and more of an elaborate psychological defense mechanism and archetypal human reaction to intolerable and unresolvable chronic outer or inner conflict?

Can psychosis be predicted? I think not. But, like the risk of suicidality (or, even less accurately, of violence) it can be imperfectly prognosticated. Who is most at prognostic risk for psychosis? To begin with, based on my own more than three decades of clinical and forensic experience, individuals who have a prior history of psychosis (as with those with a prior history of suicidal behavior or major depression) are probably most at risk for repeated episodes. There are other individuals who, while never having had a psychotic episode, harbor what historically was called a "latent psychosis": an underlying biological or psychological vulnerability or "psychotic core" in the personality that, under intense stress, can become manifest. Such individuals commonly compensate fairly well for this latent psychosis, can function relatively fine, but tend to decompensate under intense psychosocial or intrapsychic pressure.

If, for instance, someone suffers from diagnosable Borderline, Schizotypal, Schizoid or Paranoid Personality Disorder, this tends to make them much more susceptible than others to psychosis under stress. Patients diagnosed with Bipolar Disorder are always at serious risk of experiencing psychotic symptoms during a full-blown manic episode. Abusers of psychoactive substances such as methamphetamine, crack cocaine, and hallucinogens are also highly prone to developing psychotic symptoms. And individuals who are severely depressed can become psychotic, something clinicians refer to as "psychotic depression."

Psychosis can sometimes occur during postpartum depression, and is much more likely in women with prior postpartum mood disorder. (See my prior post on the Andrea Yates case.) The risk of recurrence of psychosis in women giving birth who have previously experienced postpartum psychosis can be as high as 50%. Patients with Dissociative Identity Disorder (formerly multiple personality disorder) and severe Obsessive-Compulsive Disorder are also at increased risk. Severe PTSD may similarly make patients more susceptible to psychosis. Such psychotic states occur  more frequently than most imagine, and are seen every day by psychiatrists and psychologists in private practice, in psychiatric hospitals and clinics, in jails and prisons, and during forensic evaluations of criminal defendants.

Antipsychotic drugs, including the newer "atypical" antipsychotics, can sometimes control psychotic symptoms--for example, enabling a previously grossly psychotic defendant to become competent to stand trial--but many of these symptoms, such as paranoia and thought disorder, residually remain, partially masked by the medication. And just how do these antipsychotic medications work? Well, they are believed by most to, like antidepressants, regulate neurotransmission. But I believe much of their efficacy, such as it is, resides mainly in their potent ability to dampen down what I call the "daimonic," by biochemically suppressing pathological anxiety, anger and rage.

Psychosis can't be statistically predicted based on concordance rates and other risk factors such as having been raised by one or even two psychotic parents. But, while not predictive, these powerful familial influences genetically and/or psychologically certainly can set the stage for psychosis. According to DSM-IV-TR, "the first-degree biological relatives of individuals with Schizophrenia have a risk for Schizophrenia that is about 10 times greater than that of the general population." At the same time, the DSM acknowledges the equally important influence of "environmental factors" in this psychotic disorder though, detrimentally, totally ignoring intrapsychic forces.

While rare in children, schizophrenia first tends to appear in males during late adolescence and early adulthood, and from 25-35 in females.The onset of psychosis is usually slow and insidious. It can sometimes seem to happen precipitously. But, as with all mental disorders, there are always warning signs when a person is veering headlong toward the abyss of psychosis. Social withdrawal. Diminished work or academic functioning. Strange or bizarre behavior. Lack of affect. Poor personal hygiene. Disorganized speech. Uncharacteristic fits of rage. Impulsivity. Sleep disturbance. Religious preoccupation. Paranoia. Command hallucinations. And, sometimes, suicidal and/or homicidal fantasies.

Basically, the DSM-5's proposed research diagnosis of Attenuated Psychosis Syndrome requires the presence of "attenuated" or relatively mild psychotic symptoms like delusions or hallucinations (albeit with generally intact reality testing) to have been present at least once per week for the past month, worsening progressively within the past year, causing some degree of debilitation, subjective discomfort or sufficient concern on the part of others to seek treatment. I would term this dangerous state of mind "incipient psychosis syndrome," and consider the person (adolescent or adult) clearly in need of immediate treatment to try to prevent the psychosis from progressing. Which it tends to do, especially when untreated.

Precisely how Attenuated Psychosis Syndrome differs from the current DSM-IV-TR designation of Psychotic Disorder Not Otherwise Specified is not completely clear to me, except perhaps for the fact that such a patient would not yet be formally diagnosed with a potentially more stigmatizing fully developed psychotic disorder. That's a good thing. And if such a diagnosis were to help bring high risk patients, young or old, to the attention of mental health professionals at this early onset of psychosis, that too would be a good thing. Aggressive early intervention in the psychotic process is absolutely essential. And these early warning signs must be heeded and responded to. I believe that the proper type of prophylactic treatment provided as soon as symptoms start, especially in adolescents and young adults, can make a dramatic difference in the course of this disastrous mental illness. Herein lies the potential value in such a diagnosis. But the truly crucial question is exactly how to treat such a patient. Even if we could accurately prognosticate psychosis, what could be done to prevent it?

From a psychiatric standpoint, the likely answer would be to immediately start them on some antipsychotic medication. This was almost certainly part, perhaps the entire extent, of Mr. Holmes'  supposed treatment by his psychiatrist. But such medications are risky and have serious side-effects, including but not limited to oversedation, significant weight gain and temporary or permanent neurological symptoms. Moreover, they are so limited in efficacy precisely because they address only the symptoms and not the underlying source of the psychosis. It may even be that, in the long-term (and this has also been suspected regarding the chronic use of antidepressant drugs), antipsychotic medications might paradoxically make the patient more rather than less prone to chronic debilitation. If we were able to accurately identify individuals in the earliest stages of psychosis, my own recommendation would be to always include intensive psychotherapy along with medication, either on a residential or out-patient basis. Such profoundly disturbed and vulnerable patients require a form of psychotherapy that carefully and frequently monitors their mental status and can help them to address their underlying traumas and unconscious emotional "demons," especially their chronically dissociated anger and rage. Nothing short of that will provide sufficient assistance. (See my prior post on the importance of psychotherapy.)

What I want to make clear is that the problem with Attenuated Psychosis Syndrome goes way beyond the potential pitfalls of DSM-V's ever-widening diagnostic criteria. It is more deeply rooted in the way psychosis has been medically misunderstood and tragically mistreated in our current mental health system. While antipsychotic drugs may be necessary, they are woefully inadequate. Patients suffering from incipient or chronic psychosis deserve and require much more than psychiatric medication. They need intensive psychotherapeutic intervention informed by and based on a better and deeper understanding of the psychology of psychosis. Not just the biology but the psychology of psychosis.

Psychosis has been part of the human condition from time immemorial. Yet there remains much disagreement about the basic nature and significance of psychosis. For some, like psychiatrist Thomas Szasz for instance, biological mental illness is generally a "myth." Psychosis is not always merely a broken brain producing meaningless symptoms. As Shakespeare rightly remarks regarding Hamlet's seemingly psychotic state, "Though this be madness, yet there is method in it." There is almost always method in madness. Meaning in mental illness. For R.D. Laing, psychosis is the pathological product of society's inescapable "double binds." Some naively see psychosis as a benignly positive transcendent and transformative spiritual experience. While others, including C.G. Jung (see my prior post), Rollo May and myself, understand psychosis to be an extremely perilous yet potentially healing psychological encounter with the unconscious or the daimonic. A dangerous and destructive state of "daimonic possession" potentiating both evil and creativity. A journey through Hades from which most never return. But despite all of our theorizing, the truth is that the phenomenon of psychosis still poses an enigmatic mystery. Yet it is an undeniably and universally real phenomenon. And it unquestionably causes pervasive personal and social suffering.

Psychosis may or may not prove to play a significant part in this particular tragedy. If nothing else positive comes out of this horrific crime, it may serve to stimulate more sophisticated, thoughtful and edifying discussion in the public arena of mental illness and specifically psychosis, something very much needed in our culture and long, long overdue.