A Criminally Beautiful Mind

What leads people to commit wrongdoing?

By SHEILA R. ALCANTARA, MD

Murder.

Homicide.

Serial killing.

These are the kind of sensational stories that make it to the headlines. So gruesome have they become these days, that one is likely led to doubt whether the perpetrators of these crimes are actually in their “right minds,” if they are humans at all. People so often associate violence with mental illness, that these persons, who are actually sick, just like those suffering from diabetes, stroke or any other similar disease, are looked upon as dangerous, blood-thirsty animals with no control whatsoever of their own faculties.

     But are all violent people insane? Certainly not.  While it is true, and many studies have already affirmed this, that mental illness by itself is a risk factor for violence, let it be said, once and for all, that not all the “insane,” “crazy,” or  “mentally deranged” denizens of this world will harm, steal, or kill out of a whim.

Not all criminals are insane, not all insane are criminals...

"They are being controlled by other people or they cannot antagonize the voices that they are hearing...and they have to follow." -- Dr. Gonzales

     At the National Center for Mental Health (NCMH) in Mandaluyong, 570 of the 4,000 mentally ill under its shelter are housed in a separate Forensic Pavilion. These are the patients confined by virtue of court orders for various crimes ranging from the less serious acts of lasciviousness, malicious mischief, and illegal possession of drugs to the graver cases of homicide, parricide, and murder.

     Dr. Isagani Gonzales, head of the Forensic Psychiatry Service of the NCMH, says that like their patients at the Forensic ward, there are persons who commit crimes because they have a mental disorder that became apparent “when a full investigation or a study of the case was done.”  “They have these delusions that they are the avenger, and other delusions that they have to kill persons so that they can save the world. However, not all criminals suffer from mental disorders.”

     The vast majority of people who commit acts of violence do not suffer from mental disorders. On the other hand, there is that small subgroup of patients, those who have persistent and severe mental illnesses, who are at increased risk of committing violence. The present dictum, therefore, is that any psychotic patient can be potentially violent (psychosis here is defined as loss of reality-testing—with delusions or false beliefs that cannot be dispelled and hallucinations,or things usually seen or heard for which there are no external stimuli).

     Most often, psychosis stems from schizophrenia, but it can also be manifested in other illnesses such as delusional or mood disorders. Hence, while ideally, all inmates at the New Bilibid Prison undergo neuropsychiatric evaluation to determine “kung may sira ba o wala,” the mentally ill patients who hear voices and have these irrational beliefs may only possibly exhibit violence.  

Violence in the Mentally Ill

     The association between violence and mental illness is not a new concept. Even Plato and Aristotle, and the more contemporary Benjamin Franklin, all had something to say on the matter. Since the 1920s, myriad studies have tried to elucidate the connection, most of which concluded that mentally ill people were no more violent than the general population.

     But more recent data presented by the American Psychiatric Association do indicate higher rates of violence in the mentally ill group. 

     Specifically, it was found that psychosis, as well as neurologic impairments, place people at greater risk of turning violent. The Epidemiologic Catchment Area (ECA) study revealed that schizophrenia patients were nearly nine times more likely to have fought with others or hit their partner in the past year, eight times more likely to have hit their child, and almost 22 times more likely to have used a weapon. On the other hand, those with organic brain disorder usually have poor impulse control, making them more likely to commit violence. 

     Shares the forensic expert: “Like, we had two patients. Very impulsive and very violent.  Hiniwalay na namin kasi ilan na ang napatay nilang patients. One of them killed his mother [because] hindi siya binigyan ng pangsigarilyo. It turned out there were abnormal findings on EEG, and there were soft neurologic findings.” 

     The trend also holds true at the NCMH, where schizophrenics top the list of crime offenders, followed by those suffering from mood and seizure disorders. There are also cases of antisocial personality disorder and conduct disorder.

     Meanwhile, pathological family-set-up, where there is physical or sexual abuse, and mental illness in the family, are additional risk factors. Intake of alcohol and drugs, which everyone knows (but fails to acknowledge) to have prominent CNS effects, and mental retardation also make them more likely to be violent.

The Violence Gene, Bad Parents, Wretched Life

     Crime and violence is a phenomenon that civilized society abhors, and for which humanity turns to medical science for explanation. According to Dr. Gonzales, there are three theories that attempt to explain these occurrences.

     First is the Instinctive Theory of Lorenz. One might say that human beings have a violent nature, which perhaps makes it a primal or instinctive trait, one that is universal among all humans. These spontaneous aggressive impulses, however, are usually controlled and channeled to socially acceptable norms, such as sports like boxing or wrestling. When control mechanisms go haywire, as with the presence of disinhibiting factors like mental illness, alcohol and drugs, that’s when the “animal” in you starts to express itself in a million different ways.

     The importance of parents as role models is emphasized in the Learned Theory of Bandura. “During childhood, when a child sees that his father is violent, when he grows up, by observation modeling, aggressive din siya, ” Dr. Gonzales explains. In other words, the child identifies with the parent aggressor, who, in turn, reinforces the violent act.

     Meanwhile, several psychodynamic theories view aggression as an elicited response to external factors. In Dollard’s Frustration-Aggression Theory, feelings of disappointment lead to arousal of an aggressive drive and subsequently, an attack on the source of the frustration. Obviously, there is an interplay between hereditary and environmental influences, and violence—taken in a holistic perspective—can be said to be decidedly multifactorial in origin.

The Voices that Could Kill…

     The conglomeration of all these intrinsic and extrinsic factors, the exact mechanism of which is still not known, leads to violence, and when taken to the extreme, crime. There are probably one million reasons why people “in their right mind” kill other people, and at one point, one may have heard of self-defense, crimes of passion, etc. But taken in the context of a patient who sees and hears things that no one else does, then that is an altogether different matter.

     Dr. Gonzales reiterates that these patients are actually either not treated and thus have severe symptoms, or there may be an exacerbation of symptoms as a result of depression, prostration, or loss of love object. “Usually, they commit these crimes as a reaction to a hallucination, meaning may bumubulung (“Sige, patayain mo yan”) or may delusion na may papatay o papatayin ninyo ako, so uuunahan ko na kayo. Or the one that happened in Valenzuela: he had this delusion that he was God, and that his mother was the seven-headed monster, so pinatay niya.” Violence here occurs as a direct consequence of the illness, and  vice versa.

     Although mental illness can present itself after commission of the crime, Dr.Gonzales emphasizes that this is very rare. Furthermore, the mentally ill can also commit crimes indirectly. For example, as a result of the illness, they become enmeshed in poverty, making them prone to violence, and through coincidental relationship, whereby violence leads to head trauma that in turn predisposes them to even more violence.

     Moreover, Dr. Gonzales shares that awareness of the crime differs from patient to patient. In some, they are aware that they are actually doing it, but cannot seem to control themselves: “They are being controlled by other people or they cannot antagonize the voices that they are hearing…and they have to follow.” A dream-like state is experienced by some, while in others, total blackout. They have no memory at all. 

     When “reality” sets in and consciousness follows, they become depressed. Later on, most patients overcome this depression, but definitely, it is recurrent. Fortunately, they usually don’t reach the point where they commit suicide, and those who actually kill themselves do so only because of severe psychosis or severe depression.

Chasing away the demons...

     For potentially ill persons, crime doesn’t end even when the bodies have already been buried. At the NCMH, these patients are admitted for observation, a period of about a month, during which they also undergo neuropsychiatric testing to determine if they were really mentally ill when they committed their crimes.

     At this time, they are not given behavior-, thought-, or mood-modifying agents that could preclude the correct diagnosis. There are certain exceptions though. Dr. Gonzales cites that “if they are really psychotic or very violent, and you can document it, [then] you can give them medication.” Indeed, psychiatrists, or any doctor for that matter, have to be really sure when they diagnose patients with life-changing disorders such as that of a mental illness. Especially in celebrated cases, they certainly need to be prepared to be in the hot seat in court. 

     Once a psychiatric disorder has been ruled in, patients undergo appropriate drug therapy, as well as non-biologic therapeutic interventions, such as group therapy, supportive therapy, and family therapy. Occupational therapy is also vital in releasing aggression and channeling it to socially acceptable behavior like sports and exercise.

     For some patients, alternative treatment, such as electroconvulsive therapy or ECT (that which zapped John Nash and sent him to feats of uncontrolled repetitive jerks) may be employed, especially in suicidal, homicidal, very aggressive, severely depressed, uncontrolled manic, and paranoid schizophrenic patients. Meanwhile, psychotherapy, which attempts to “heal” by non-biologic paradigms, may play a role in some disorders, but not in schizophrenia.

Aftermath of a crime...

     Once a mentally ill patient has already committed a crime, chances are high that he’s likely to do it again.  Not because of malice, mind you, but these patients’ extreme poor impulse control and low prostration tolerance make them extremely vulnerable to exacerbations that can trigger another violent episode. This is not entirely unpreventable, stresses Dr. Gonzales, and with regular visits to the psychiatrist and compliance to medications, coupled by a supportive and unrestrictive environment, frightful reenactments may just be averted.

     On a grander scale, mental illness must be viewed not just as an incomprehensible menace to society, but as a public health concern… an existent disease that might just affect any member of the family—yours, mine, anyone’s. And while their capacity for violence was dealt with extensively in a hundred words past, it should always be kept in mind that not all mentally ill patients are potentially dangerous.

     In fact, some of them are simply catatonic, seemingly mute, or just plain oblivious to the world around them. It is, therefore, one’s moral duty to assist patients, especially if they are your own, who experience symptoms of mental illness and have them seek consult right away. Lest we forget that the voices and specters that hound them might, but hopefully not, just be our own.