Monday, March 05, 2007

Heads, You Lose

During our last podcast taping Dinah was busy sending email to Roy and Roy was distracted by cookie dough. It's amazing we ever get any of these things done. Anyway, I promised to do a followup blog post on the issue of neurological injuries and criminal culpability in response to Sandra of OmniBrain's question. Here it is.

First of all, in order to be guilty of a crime the state has to prove two things: that you committed the criminal act (also called the actus reus) and that you had a criminal intent or mental state (the mens rea). Both of these elements must be proven beyond a reasonable doubt in order to convict someone of a crime.

Mental state issues come into play when the defendant puts up what's called a 'mens rea' defense---for example, an insanity plea. Another type of mens rea defense is generically called a 'diminished capacity' defense. This just means that there was something about the defendant's thinking that impaired his ability to form a guilty intent, but this 'something' is not so severe as to be considered insanity.

The most common example of a diminished capacity defense is acute substance intoxication. By law this is barred as an insanity defense, but it can reduce mental state culpability to a more serious crime. For example, someone charged with first degree murder could be acquitted of that charge because of intoxication and instead convicted of the less serious offense of manslaughter. Diminished capacity defenses don't generally lead to acquittal, just conviction on a lesser charge. Some states bar the use of diminished capacity completely.

I don't have exact numbers but off the top of my head I can tell you that easily two-thirds of the prisoners I see have a history of some type of head trauma. They do impulsive things and get into accidents. They wreck their motorcycles and their cars. They get into fights and get the...uh...stuffing beat out of them. Outside of the trauma area they also carry the neurologic sequellae of their lifestyles---alcoholic dementia, HIV dementia, sometimes strokes from untreated hypertension. All this is added onto environmental developmental insults like lead poisoning.

OK, so how does brain injury or neurogic impairment relate to criminal prosecution?

My answer is that there's not much of a relationship, although if the injury is severe enough it could fall into the realm of insanity. The fact of the matter is that there's a big leap between what you see on an MRI or on neuropsych testing and a person's actual functional capacity. The more prisoners I see the more I realize you really don't need to have that many functional neurons to get by in life. When it comes to moral reasoning, you need even less. Child development theorists know that social conscience is usually in place by the age of ten. A basic understanding of Miranda rights can be grasped by anyone with a fifth grade reading level. If there's any real question about it the judge can order a competency assessment to determine mental capacity to stand trial.

This is probably more than anyone needed or wanted to know, but here you have it.

Pass the cookie dough.


Dinah said...

Long day and I'm tired. I raced from the gym (where I read People Magazine and now know who all is in rehab) to the grocery store, emergency mission to get Max food. Rushing , I closed the minivan hatch onto my head. Ouch. Please document this, I want legal mitigation for all future crimes.

ClinkShrink said...

Congratulations! You're the only person to comment on this post in the 24 hours it's been up. In return I'll be happy to declare you irresponsible.

NeoNurseChic said...

Oh Dinah - if that gets you off the hook for all future crimes, then surely I'm off the hook for all the drain bamage I've acrued on account of the headaches and subsequent treatment! haha One of my brain CT scans even showed mild volume loss! Oh and the article in which I was a case study is now online early for "Headache" - and it talks all about how I have 9 white matter lesions, and that young female migraineurs are at greater risk for CADASIL. And they were making an association between CADASIL and avascular necrosis - potentially. They weren't saying I have CADASIL - just using my case study to point out potential connections and maybe other factors to consider.

So I think my brain is significantly screwed up enough to be exempt from responsibility for all future crimes! hahaha....

Sorry you bumped your head, though!! I've done that on my parents' jeep (I'm a total klutz), and it hurts!!

Take care!
Carrie :)

Dinah said...

What's CaDASIL>>?

Midwife with a Knife said...

CADASIL is an autosomal dominant cerebral vasculopathy that results in CVAs and dementia at an early age (20's-30's), with death occuring approximately 12 years after the onset of symptoms.

CADASIL stands for:


I had a pregnant pt with it once. She presented with a big midbrain stroke. Sad disease.

NeoNurseChic said...

Yeah - next up for my neurologist is asking if I should be tested for the notch3 gene - since all the signs are there - and I'm sufficiently freaked out now. Thanks a lot, stupid case study. *sigh* Another day in the life......

There has been a rather large push to study CADASIL lately in the headache world as sometimes the only symptom of it is migraine. But MWWAK, I read that the early onset dementia was usually 50s-60s. Onset of strokes and the migraine side of things could be now - which would figure. If the WMLs and my AVN are related - and I've had 2 DVTs in my left arm already, then that's an awful lot of ischemia/clotting considerations...!

I haven't read much on CADASIL - frankly, I don't know if I want to know a thing more. My father has the WMLs as well. It reminds me of finding out you have the Alzheimers gene or something like that. Who wants to know that their life is going to end early and horribly?

My mom read the case study the other day, and I thought she was going to cry.

Sandra said...

Sorry I didn't comment earlier, I hadn't checked your blog this week and nothing was in my referrer logs, strangely. Anyway, thanks for clarifying. One of the reasons I asked is that a popular anti-psychiatry stance [not mine] is that is if a psychiatric illness (say, bipolar or OCD) makes you prone to committing a crime then people would be excused entirely; really, that's not the reality nor is the law likely to change to become so, right?

I've been reading research lately on punding and disinhibited behaviours like compulsive gambling caused by Parkinson's drugs, dopamine agonists. Stuff like a formerly law abiding, conservative person turning into a transvestite pedophiliac sexual deviant, etc. Interesting. Have you seen cases like that?

ClinkShrink said...

You're right, having a psychiatric diagnosis rarely ever excuses one completely from a crime. It sometimes causes judges to be somewhat more lenient than they otherwise would be, but that's about it and I don't think that's likely to change. The fact of the matter is that criminal behavior has more to do with the chemical dependency problems these inmates have than with their psychiatric disorders. Just like the non-mentally ill.

Most folks with paraphilias (sexual deviations) don't suddenly develop them. They can be normal law abiding citizens who accomodate their paraphilias in legal ways until something else intervenes to decrease inhibition (eg. dementia, clinical depression, mania, substance abuse). I don't think I've ever seen a new-onset paraphilia as a result of head trauma, although certain types of head injury can make one disinhibited.

Convoluted enough for you?

Sandra said...

Not convoluted, it's fine. :)

Substance abuse being the main factor makes sense. Violent crimes involving alcohol, and in Vancouver much of the petty crime stems from addicts.

Hypersexuality and paraphilia induced by selegiline in Parkinson's disease was one of the case reports I recently read. A few journal articles don't solidify it of course; I'm sure you're right and disinhibition reveals underlying tendencies, but there does seem to be something to the theory it can be induced.

ClinkShrink said...

Iatrogenic psychiatric disorders are interesting; in the Parkinson's disease case it sounds like the patients may have gotten manic on their meds, which can happen. Typically you'd be more likely to see this with someone given steroids, but it's still pretty rare---I think something like 15% of people given prednisone can get affective side effects.

And by the way Vancouver was a great place to visit---I particularly liked the police museum and the gem and mineral museum. Somewhere early on in the blog I posted I picture I took in the Vancouver police museum of a contraband display.

Sandra said...

Neat, I'll have to check it out. I haven't been to the police museum itself but have shopped in its gift shop. Still have a travel mug. The displays sound interesting. Sharpshooter women, cool. I've met some kickass detectives.

There's a new pathology museum in town, and apparently there's also a "war on drugs" marijuana museum but you have to know someone to find it and get in. I'm guessing the first admission is free, but after that...

Vancouver's a conflicted city for drug issues.