Prior to beginning this journal, review Chapters 2, 3, and 8 in the textbook, read the article, Allegiance Bias in Statement Reliability Evaluations Is not Eliminated by Falsificatio

9

2Mental Illness and Criminal Behavior

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Learning Outcomes

After reading this chapter, you should be able to

• Define mental illness and distinguish between any mental illness and serious mental illness.

• Describe the subjective nature of psychiatric diagnosis.

• List the mental disorders that are most commonly associated with criminal behavior and describe their symptoms.

• Discuss psychological risk factors for criminal behavior.

• Identify common misperceptions about the association between mental illness and crime.

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10

Section 2.1 Introduction

Introductory Case Study: Jessica Muñoz Ciro Jessica Muñoz Ciro was a pleasant and energetic child who had moved with her mother from South America to the Seattle area when she was a small child. They became U.S. citizens, and Ciro excelled in school. She became a star racquetball player; by the time she was in high school, she was part of the U.S. Junior National Team, winning an individual gold medal at the Inter- national Racquetball Federation Junior World Championships in 2009. Teachers and coaches described Ciro as hardworking, easygoing, and agreeable when given instructions or feedback on her performance. It appeared that Ciro had a bright future—until her behavior took a turn for the worse.

When she was about 16 years old, her mother and stepfather began to notice troubling changes in her mood and personality. Ciro had become withdrawn and excessively temperamental, but her parents attributed her behavior to that of a normal teenage girl going through adolescence.

Ciro began to exhibit signs of mental illness when she showed up at a classmate’s home behav- ing “erratically,” according to the friend’s description. Ciro’s parents rushed over to her friend’s home, but Ciro unexpectedly jumped into her stepdad’s car, sped off, and crashed the car into a tree. She was thrown through the windshield, cutting her face and severely bruising her legs. At the hospital, she was diagnosed with bipolar I disorder.

Unfortunately, this event kicked off many years of struggle for Ciro and her family, with Ciro being hospitalized while trying to find the right combination of medications to stabilize her. Sadly, when her manic episodes were particularly disruptive, Ciro found herself incarcerated in the county jail for petty crimes—an all-too-familiar scenario for many mentally ill individuals in the United States.

As you read this chapter, consider the following questions regarding this case:

1. Do you think Ciro’s symptoms made it easy for medical professionals to determine the reason for her behavior?

2. What is the association between bipolar disorder and criminal behavior? 3. Do you think it is likely that Ciro experienced traumatic experiences in childhood that

made her more vulnerable to developing bipolar disorder? Why or why not?

2.1 Introduction The link between criminal behavior and mental illness has been a focus of investigation for many decades, yet there remain seemingly as many questions as there are answers. Criminal behavior and mental illness have a complex relationship, partly because the link is still being researched, the mental illness classifications are continuously being tweaked, and under- standing and diagnosing mental illnesses is an ongoing process for mental health profession- als. To further explore this complex relationship, we’ll study theories and research from an interdisciplinary perspective to help define mental illness and explore psychological risk fac- tors for criminal behavior.

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11

Section 2.2 Defining Mental Illness

There is a common perception that those who commit crimes must be mentally ill or that mentally ill individuals are prone to violent criminal behavior. We will explore and identify common misconceptions about the association between mental illness and crime.

That being said, some mental illnesses have more risk associations with criminal behav- ior than do others; therefore, we’ll explore relevant mental disorders based on the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) classification system—a system that has been honed over a span of about 100 years.

Exploring these foundations of mental illness is important for understanding how they may or may not lead to criminal behavior and studying the context of crime.

2.2 Defining Mental Illness Mental illness, also referred to as mental disorder, is a medical condition hallmarked by dysfunction in cognition (thinking), affect (emotion), or behavior (APA, 2018). Individuals afflicted with mental disorders often experience co-occurring dysfunction in thinking, emo- tions, and behavior rather than being limited to just one problem area. This can impact one’s ability to overcome adversity (resilience), be productive at work or school, maintain healthy relationships, be a contributing member of society, and adapt to change.

Similar to physiological diseases, psychiatric diseases range in severity from mild to serious. The National Institute of Mental Health (2019) has two major categories for classifying men- tal illness: any mental illness and serious mental illness.

Any Mental Illness Any mental illness (AMI) includes all behavioral, emotional, or mental disorders, ranging from mild to severe impairment. For example, imagine that you occasionally have difficulty falling or staying asleep because you cannot stop dwelling on your sense of uncertainty over everyday events. However, this overthinking interferes with your sleep only a few times per month, and although you feel tired and irritable the next day, most of the time you manage to sleep through the night. Due to this occurring only intermittently, you are likely to seek out remedies other than seeing a doctor, such as changing your diet, exercising, and possibly even introducing an over-the-counter sleep aid. This type of psychological disturbance would likely fall under the mild to moderate range because the functional impairment is limited and manageable with no or minimal intervention.

However, in cases where the sleep disturbance and worry occur more frequently such that daily behavioral, emotional, and mental functioning is disrupted to the point of dysfunction, this may be classified as a mental illness under the moderate to severe range. This is largely due to the fact that greater intervention than in the previous loss of sleep example may be required to restore functioning to normal range. Such interventions may include seeing a physician or psychologist.

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12

Section 2.2 Defining Mental Illness

Figure 2.1: Past year prevalence of any mental illness among U.S. adults, 2016

Nearly one fifth of the adult population in the United States is afflicted with mental illness—a significant proportion.

From “Mental Illness,” by National Institute of Mental Health, 2019 (https://www.nimh.nih.gov/health/statistics/mental -illness.shtml#part_154788).

Sex

18.3

21.7

14.5

22.1 21.1

14.5 15.7

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Overall Female Male 18–25 26–49 50+

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*All other groups are non-Hispanic or Latino **NH/OPI = Native Hawaiian / Other Pacific Islander ***AI/AN = American Indian / Alaskan Native

30

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Race/Ethnicity

The Substance Abuse and Mental Health Services Administration (SAMHSA) and National Institute of Mental Health (2016) estimate that there are approximately 44.7 million adults in the United States suffering from AMI (see Figure 2.1). This represents 18.3% of the overall American adult population.

Regardless of the severity of the dysfunction, any identifiable mental illness or disorder is classified under the AMI category, even if it is also classified as serious mental illness (SMI). In other words, all SMIs are AMIs, but not all AMIs are SMIs.

Serious Mental Illness Serious mental illness (SMI) refers to mental, behavioral, or emotional dysfunction at a significantly impaired level. SMIs include but are not limited to major depressive disorder, bipolar disorder, schizophrenia, substance abuse disorders, or any mental illness that rises

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13

Section 2.2 Defining Mental Illness

Figure 2.2: Past year prevalence of serious mental illness among U.S. adults,

2016

Similar to AMI, the prevalence of SMI was higher among women than men, highest among young adults aged 18–25, and highest among adults reporting two or more races.

From “Mental Illness,” by National Institute of Mental Health, 2019 (https://www.nimh.nih.gov/health/statistics/mental- illness.shtml#part_154788).

to the level of such significantly impaired functioning that the individual may be considered disabled. For example, an individual with major depressive disorder will likely exhibit symp- toms so debilitating that he or she will not be able to function normally without intervention. These types of symptoms may include insomnia or hypersomnia (excessive sleeping), loss of interest in activities that were once enjoyable, a sense of hopelessness, failure to fulfill work obligations, and even planning or attempting to commit suicide (APA, 2013). The significant dysfunction that results, together with the increased risk or likelihood of self-harm, renders this an SMI.

The National Institute of Mental Health (2019) estimates that approximately 10.4 million adults have been diagnosed with SMI. This estimate is based on data gathered and analyzed by SAMHSA. The data in Figure 2.2 show that this group represents 4.2% of the overall popu- lation of adults in the United States, with most being women under age 25 and those who identify as multiracial (i.e., identifying as two or more races/ethnicities).

Sex

4.2

5.3

3.0

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5.3

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1.6 1.9

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Overall Female Male 18–25 26–49 50+

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*All other groups are non-Hispanic or Latino **NH/OPI = Native Hawaiian / Other Pacific Islander ***AI/AN = American Indian / Alaskan Native

8

7

6

5

4

3

2

1

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Race/Ethnicity

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14

Section 2.3 Diagnosing Mental Illness

Spotlight: The History of the DSM In 1917 the American Medico-Psychological Association (now the APA) identified the need to collect data from mental hospitals in order to understand just how many individuals were suf- fering from serious, debilitating mental illness and what their symptoms were.

The attempt to collect objective data actually began in the late 1800s, when the intellectually disabled were classified as “idiots” and the seriously mentally ill were officially referred to as “insane.” The term idiot is now an offensive word not used in formal psychiatric diagnosis, and insanity is no longer a psychological construct but solely a legal one (LaFortune, 2018).

The first DSM, published in 1952, was not nearly the comprehensive volume that it is today—it was heavily focused on mental illness as a dysfunction in personality “reaction” to biological, psychological, and social variables encountered in everyday life. The DSM-2 was similar to the first, but the view of mental disorder began to broaden and shift away from considering it merely a “reaction” to biopsychosocial factors. The DSM-3 was published in 1980 and was a remarkable change from the first two versions, since it was the first to provide a specific list of mental disorders and accompanying diagnostic criteria. In the DSM-4, published in 1994, dis- orders were removed and added, and diagnostic criteria were updated based on the scientific literature in the area. There were more than 1,000 individuals and organizations involved in crafting the DSM-4, and it required a 6-year-long effort to prepare this edition for publication.

By the time the DSM-5 was published in 2013, there was approximately 13 years’ work invested in revising the manual. Several work groups were formed to research and address each of the major diagnostic categories in an effort to ensure that gaps in the relevant scientific literature were addressed and that the revisions were subjected to rigorous review standards prior to publication.

2.3 Diagnosing Mental Illness Accurately assessing clients or patients for mental disorders can be a challenge. The DSM-5 provides an exhaustive list of mental health disorder classifications. It also serves as the pri- mary authority on diagnostic criteria for mental health issues ranging from mild behavioral issues to the most serious mental illnesses. It is used primarily by mental health professionals to assign a diagnosis to clients in order to be eligible to receive payment from health insur- ance companies for services rendered with regard to screening for, and later treating, any identified mental health condition.

Although the work groups and lengthy development time of the DSM-5 suggest that the man- ual is significantly improved over previous editions, there is some skepticism about the reli- ability of mental health diagnoses, given that there is a fair amount of subjectivity in the diag- nostic process. That is, regardless of what the DSM-5 classifies as bona fide mental disorders, what is considered a mental illness is somewhat subjective and often culture bound (Dowrick, 2013). The American Psychiatric Association (APA)—the primary professional organization of psychiatrists in the United States—acknowledged this in the DSM-5 and has emphasized the importance of clinicians becoming culturally competent practitioners so they can recog- nize cultural differences in how mental health issues are viewed, reported, and discussed. See Spotlight: The History of the DSM for a brief overview of the publication’s beginning in 1917 to its most recent version today.

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15

Section 2.3 Diagnosing Mental Illness

Mental Condition Versus Mental Illness Although mental illness is classified as a medical condi- tion by the APA, the challenge in identifying mental disease (mental conditions) as a medical problem lies in the fact that mental illness is not generally diagnosable via the means and methods used to diagnose traditionally accepted and defined disease (physical conditions). That is, there are no conclusive X-rays or lab tests that show mental health con- ditions. However, competent medical professionals will use lab tests, X-rays, MRIs, and other traditional medical testing modalities to rule out any underlying physical disease that may contribute to dysfunction in thinking, behavior, and emotion regulation. When a patient presents with symp- toms that suggest mental dysfunction, it is expected that a competent physician will use laboratory testing to the extent possible to determine whether there are any physical illnesses present that may be the root cause of the observ- able mental disorder.

In the absence of any physical conditions that may account for mental health symptoms, psychologists and psychia- trists diagnose clients or patients using criteria set forth in the DSM published by the APA (2013). See Case Study: Comparing the Cases of Curtis Jacques and Jessica Muñoz Ciro for an example of how some individuals with mental

illnesses have underlying medical conditions that cause impairment in behavior, cognition, or emotions.

Jupiterimages/Thinkstock

While there are no conclusive X-rays or lab tests that show mental illness, medical professionals can use traditional tests such as X-rays and MRIs to rule out underlying physical disease.

Case Study: Comparing the Cases of Curtis Jacques and Jessica Muñoz Ciro

Curtis Jacques’s family began to notice a change in his personality when he was a young adult. Jacques exhibited aggressive and erratic behavior that was highly uncharacteristic of his more typical behavior as a friendly and thoughtful person. When Jacques crashed his truck, he reacted so aggressively toward first responders and hospital personnel that he was involun- tarily committed to a psychiatric hospital. However, doctors later discovered that Jacques had two small cancerous tumors pressing on his brain and that this was causing the disturbing behavioral and emotional changes. There was an underlying physical disease that accounted for the cognitive, behavioral, and affective dysfunction he exhibited.

This is in contrast to Jessica Muñoz Ciro, whom we learned about at the beginning of the chapter. She exhibited changes in temperament and reacted aggressively toward her parents. Although Ciro’s behavior resembles Jacques’s behavior, Ciro had no identifiable physical dis- eases to explain her psychological disturbance. This highlights the importance of performing a battery of laboratory tests to rule out physical disease when symptoms of mental illness are observed.

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16

Section 2.3 Diagnosing Mental Illness

Issues With Diagnosing Unlike medical screening that may include objective tests such as X-rays and blood work to determine the presence of physical disease, psychological assessment relies mostly on the subjective clinical judgment of the licensed practitioner.

Subjectivity The inherent subjectivity in psychiatric diagnoses is a major criticism of psychol- ogy. Objective measures exist that a clini- cian may administer to screen for anxiety, depression, post-traumatic stress disorder (PTSD), intellectual disability, personality disorders, and so on. However, practitio- ners must purchase the measures from the publishers, and most insurance companies will not pay for these types of psychologi- cal evaluation, which average $1,500 each. Even in situations in which objective mea- sures are administered, such as in forensic settings, the scores must be interpreted by the clinician, thereby resulting in a subjec- tive interpretation of the test results.

A more common approach to psychological evaluation is a clinical interview in which the mental health provider delves into the client’s biopsychosocial history and observes present- ing symptoms to render a diagnosis. You may have guessed that a fundamental problem with this approach is that it relies heavily on the client’s self-assessment of his or her own psycho- logical functioning, together with the preconceived expectations and biases of the practitio- ner. This may lead to an ineffective treatment plan for the client. In a courtroom setting the subjective judgment of the practitioner can have dire implications for the accused. That is, an incorrect diagnosis or one that differs from that of the other psychologist hired to evaluate the accused could lead to a lengthy prison sentence or worse, depending on the seriousness of the crime. Therefore, for enhanced precision, it is imperative that practitioners rely heavily on reliable diagnostic criteria, a structured clinical interview, and comprehensive data gath- ering on the client (Aboraya, Rankin, France, El-Missiry, & Collin, 2006).

Inconclusive Test Results Perhaps the biggest barrier to a greater reliability in diagnosing mental illness is the absence of conclusive and objective laboratory testing. There is some promising research to support the idea that certain mental disorders may be identifiable via medical laboratory testing; however, researchers are still working to validate this type of testing for use in diagnosing mental illness.

KatarzynaBialasiewicz/iStock/Getty Images Plus

Psychological assessment relies mostly on the subjective clinical judgment of the licensed practitioner.

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17

Section 2.4 Mental Disorders Commonly Associated With Criminal Behavior

For example, a team of neuroscientists at Cambridge University in England examined whether a blood test might be able to aid in the diagnosis of schizophrenia. The research team, led by Dr. Sabine Bahn (Schwarz et al., 2010), tested a group of 250 schizophrenia patients and compared them to a group of 230 control participants to determine whether the team could identify specific blood biomarkers that were linked exclusively to schizophrenia patients. The team was successful in showing that these blood biomarkers do exist and that by admin- istering the blood test, physicians can predict who will develop schizophrenia long before psychological symptoms such as psychosis manifest themselves. Although the researchers were among the first to test this hypothesis, multiple studies on schizophrenia-related blood biomarkers had already been conducted.

Taking the results of these studies, Bahn and her team conducted a meta-analysis (a statistical analysis that combines the results of multiple studies) to validate their schizophrenia blood test. Due to inconclusive test results, issues still remain with diagnosing mental illness, but the researchers confirmed previous findings and successfully validated the blood biomarker panel, paving the way toward a blood test that could predict the development of schizophre- nia in certain individuals (Chan et al., 2015).

2.4 Mental Disorders Commonly Associated With Criminal Behavior The most commonly diagnosed mental disorders in criminal offenders fall under the catego- ries of schizophrenia spectrum disorders, bipolar disorder, major depressive disorder, and antisocial personality disorder (Large, Ryan, Singh, Paton, & Nielssen, 2011; Peterson, Skeem, Kennealy, Bray, & Zvonkovic, 2014; Skeem, Kennealy, & Louden, 2014; Varshney, Mahapatra, Krishnan, Gupta, & Deb, 2016; Vogel, 2014). In reality, criminal behavior may be attributable to any mental disorder. This is particularly true when a defendant is facing serious criminal charges and mitigating culpability is the goal. For example, in the case of military veterans who commit serious or violent crimes, it is not uncommon to hear a defense attorney assert that the accused suffers from PTSD in an effort to get a reduced sentence. A less common but sensationalized mental disorder sometimes used as a defense in the courtroom is dissociative identity disorder, formerly and more commonly known as multiple personality disorder.

However, it is worth reinforcing that most individuals who are diagnosed with schizophrenia and other disorders that we discuss here do not act violently and do not engage in crimi- nal behavior. In addition, it’s equally important to be reminded that most criminals do not have schizophrenia (or any one particular mental disorder). We are exploring these disorders to shed light on situations in which individuals may commit crimes and how mental illness comes into play.

Let’s begin by taking a closer look at one of the more fascinating groups of mental illnesses: schizophrenia spectrum disorders.

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18

Section 2.4 Mental Disorders Commonly Associated With Criminal Behavior

Schizophrenia Spectrum Disorders Schizophrenia is a chronic and severe mental disorder that affects how an individual behaves, feels, and thinks. It is an SMI most commonly associated with a state of psychosis, or a state in which sufferers experience significant impairment in thoughts and emotions exhibited via hallucinations, disorganized cognition and speech, delusions, flat affect, and even involuntary motor movements or catatonia. Schizophrenia, like many maladies, may present with just some of these symptoms. In fact, on each of the five domains of symptoms discussed in this section, an individual may receive a diagnosis of schizophrenia or other psychotic disorder if two or more of these symptoms are observable and physical disease has been ruled out. Let’s examine briefly the five domains of symptoms typically observed in these types of disorders.

Delusions A delusion is evident when an individual possesses fixed—and generally bizarre— beliefs that persevere even when presented with conflicting evidence. Many people can relate to believing something so strongly that no one is able to change their mind, but delusions are more than being stubborn. Types of delusions include grandiose, ero- tomanic, referential, persecutory, and nihil- istic. Importantly, bizarre delusions tend to be present when individuals are depressed and/or have low self-esteem.

Consider the case of Dave, a homeless man who lived in a tent on the side of a busy highway in his hometown. Dave had been involuntarily committed to a psychiatric hospital and diagnosed with schizophrenia. Dave experienced many symptoms, one of which was the persecutory delusion: He believed that he could not secure a job because his aunt and grand- mother were “working against” him to prevent him from being successful. A persecutory delusion is one in which the individual believes irrationally that people are out to harass, harm, and sabotage him or her (APA, 2013). However, his family was desperate to find ways to help Dave get and stay on his prescribed medications, as well as to help him live as normally as possible. Dave also experienced referential delusions (also known as delusions of refer- ence), as evidenced by his unwavering belief that a popular radio host was sending a special message meant only for him during a radio show.

Dave did not suffer from the other types of delusions, but let’s briefly discuss how each mani- fests itself. Erotomanic delusions refer to a person’s false belief that a celebrity or other famous person is in love with him or her, despite the fact that the delusional individual has never met the celebrity nor had any communication with him or her. (See Spotlight: Notori- ous Individuals With Erotomania for a peek into the cases of now well-known people who suffered from erotomanic delusions.) Nihilistic delusions refer to the erroneous belief that the real world does not exist or that the individual does not exist. This can even apply to the individual’s body parts. Finally, grandiose delusions refer to the false belief that one is wealthier, smarter, and more powerful than others—and perhaps omnipotent and famous— despite evidence to the contrary.

iStockphoto/Thinkstock

Delusions are beliefs that persist even in the face of conflicting evidence. They ten

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