Medico-legal aspects of a mixed personality disorder case.
The clinical picture of dissociative disorders starts during childhood, when such persons experience their first academic behaviour issues (skipping classes; assaulting their classmates or even their teachers during classes; possessing white steel; cruelty toward domestic animals; destroying properties and stealing).
Antisocial teenagers violate all moral principles, break all the rules, and they are concerned only with their personal interests. Most of the times, they are cruel with the others, they violate their rights, and they always seem ungrateful (not willing to offer anything in exchange).
Their main purpose is to satisfy their wishes; they are capable of wasting all financial resources for various petty goals. Such persons simply ignore, without embarrassment or compassion, all advice or scolding from others. Their structure outlines an inhuman, cruel, infatuated behaviour, which they maintain stoically and for which they are capable of lying or finding puerile excuses. Such behaviour leads them toward gambling and spending their money on alcohol or drugs. Eventually, they are taken into custody or they end up in prison, but such consequences fail to teach them anything. (3)
Alcohol and substance use intensify their violent behaviour: they commit assaults or even extremely violent acts. Through all these "delinquent qualities", they only manage to get involved in illegal schemes and occupations.
Concerning their romantic relationships, most of the times they fall in love "at first sight" and they get married upon an impulse; later, they threat, fight with, and physically abuse their spouses. Their families have to deal with a heavy burden, and they usually become their enemies, because they repeatedly try to correct their behaviours and to rehabilitate them.
According to ICD-10, diagnostic criteria for Dissocial personality disorder are the following:
Dissocial personality disorder often gets into medical attention because of the patient's gross disparity between behaviour and the prevailing social norms:
a. Callous unconcern for the feelings of others;
b. Marked and persistent irresponsibility and disregard for social obligations, rules, and conventions;
c. Incapacity of maintaining long-term relationships, despite easiness to establish them;
d. Low tolerance to frustration and a low threshold for discharge of aggression, including violence;
e. Behaviour is not readily modifiable by adverse experience, including punishment;
f. Tendency to blame others, or to offer plausible rationalizations for the behaviour bringing the patient into conflict with society.
Irritability is also an associated feature for this disorder. Though not invariably present, behaviour troubles in childhood or adolescence may represent a basis for diagnosis. (1)
Borderline personality disorder is represented by a series of emotional instability characteristics:
a. Self-image is often perturbed and unclear (including sexual preferences);
b. Chronic feelings of emptiness;
c. Intense and unstable interpersonal relationships;
d. Frantic efforts to avoid abandonment;
e. Suicidal and self-mutilative behaviour. (1)
These individuals have a pattern of unstable interpersonal relationships; they are characterized by unstable self-image and severe shifts in their mood and behaviour.
They have a hard time making plan for the future and accomplishing them.
A pathognomonic feature is the fear of abandonment by the significant others; this causes anxiety, anger, and panic, which may entail suicide attempts or self-mutilation acts.
They always have a negative self-image; they manage to make new friends easily and they become attached, but they also get bored rapidly. Because their self-image is constantly unstable, they are always looking for the perfect friend able to fill the emptiness of their frustrations and dissatisfactions. (2)
Concerning their job, they are unable to accomplish their work duties and they get bored with their jobs, as they get bored with other persons. They may become impulsive; they make reckless decisions and they spend great amounts of money on various useless items; they may gamble or abuse substances or alcohol.
Such disharmony usually precipitates; they may easily pass from moderate alcohol consumption to ingesting large and uncontrollable amounts. Alcohol and psychoactive substances may enhance their disharmonic features such as anger, aggressiveness criminal tendencies, which they exacerbate through violent reactions, uncontrolled anger, and offences such as aggravated assault and even murder.
Given their incapacity to express emotional reactions, they often use demonstrative parasuicidal behaviour with numerous attempts, which usually end with self-mutilation acts targeting the chest, neck, abdomen, arms, and forearms. Their intimate relationships are influenced by this amoral and emotionally unstable behaviour; they often assault their partner repeatedly. (2)
GENERAL PRESENTATION OF THE CASE
This case concerns a 34-year-old male, Romanian citizen, admitted twice to the Psychiatry Hospital (one of the admissions was during his teenage years); he was sentenced to life in prison for committing a first-degree murder while he was free and for committing other two murders while he was in prison serving his first sentence. His medical records in prison and his own testimonies reveal a personal pathological history: he was diagnosed with behavioural disorder when he was a teenager, and later with mixed personality disorder (dissocial and borderline).
As for family history, they do not hold any psychiatric relevance; his biological parents raised him. He is currently separated from his partner, with whom he shares four children.
Life and work conditions: during his childhood and adolescence, he lived in a city, with his biological parents and a brother and sister; he is the second child. The family lived in a three-room apartment.
He finished ten grades and a vocational school (within the public education system); he obtained the professional qualification of car mechanic and later, of mason.
The subject has been smoking since he was seven; he currently smokes around ten cigarettes a day and he was a great alcohol and substance user; he was forced to give them up in prison.
He is currently treated with Depakine Chrono (sodium valproate) 1.000 mg/day, Trittico (Trazodonum) 150 mg/day, Haloperidol 1 mg/day, Diazepam 10 mg/day. In his own words concerning medication, "I have been on medication for 15 years and they no longer work"; "diazepam has no more effects on me, it just brings me peace of mind".
Objective clinical exam on devices and systems shows no pathological alterations, while paraclinical examinations show the presence of fatty liver (steatosis).
Concerning psychiatric interview, expression psycho-diagnosis shows a cooperative attitude; he shows no psychomotor agitation; his appearance is groomed (properly washed, clean clothes) and adequate for prison conditions. Mimic and pantomimic have normal ranges; gestures correspond to words; regard is mobile and he keeps eye contact with the examining physician; his voice has normal tone and intensity, while his speech is coherent.
Sensation shows irritability and irascibility, accompanied by low tolerance to minor frustrations; he often acts impulsively and has disputes with the other inmates, which sometimes degenerate in serious verbal and physical assaults. He does not display any attention or memory deficits. The subject talks about psychotic episodes history, with delusional grandiosity ideas: "I thought I was Michael the Brave on the battlefield and I started taking down the walls of my house with a hammer".
Furthermore, he displays sleep disturbances (mixed insomnias).
As for the mental status of this subject, he reported having become addicted to tobacco and alcohol since childhood; the longest he lasted without smoking was five days. During his late teenage years, he started taking psychoactive substances: heroin, cocaine, marijuana, hashish, while he lived in Italy. Moreover, he stated that the only offence he committed while on drugs was a cold steel assault on a Tunisian citizen. In that period, the subject declares having had numerous fights with his wife concerning substance abuse, accompanied by multiple physical and verbal assaults. During the entire period, his relationship with his life partner decreased significantly (due to substance abuse and physical assaults). He left the country and settled in Romania, where he resumed his job in construction.
He states that he was addicted to alcohol and that he had gambling issues since he was 12. He reported having realized his alcohol addiction in the ninth grade, when he would ingest vodka before going to school in the morning (approximately 200 -300 ml/day). "I felt the need to drink 100 ml of vodka before taking the bus to school in the morning". His academic behaviour was influenced by increased use of alcoholic beverages; he was sanctioned by having his conduct grade lowered repeatedly. He also skipped school a lot ("I skipped school for gambling and alcohol") and he assaulted physical and verbally his classmates and his teachers. In his own words, "I don't have a lot of memories from school because I did not attend it much"; "for three years, I was mostly at the pub".
Even since he was a teenager (18 years old), he tried to take his own life using numerous means: taking pills, injecting mice poison, hanging himself, jumping from the fourth level of a building (which miraculously caused only a collarbone fracture), jumping in front of a train, and slashing his wrists. Thus far, he has had around 17 suicide attempts.
Since he was 17, he worked as a baker, while from 27, in the construction field. He managed his own projects alongside his best friend, who ended up among the victims of his pathological behaviour.
Even while he was a child, he reports having mood swings without any apparent reason: he passed very quickly from calmness to restlessness and aggressiveness; he was always tormented by the thought of being rejected by others.
He was impulsive; he got involved in various activities without prior thought or analysis. He would always feel offended and he lived in constant fear of being abandoned by family and friends. He always felt guilty with no reason and he would be tormented daily by the idea that terrible things could happen to him.
His aggressiveness became apparent since that period; his cruelty would often make him kill various domestic animals. He felt good and he liked it when others feared him; he would often attempt to polarize inter-human relationships.
Self-mutilative behaviour began in the same period: he would cut himself on a large portion of his body.
His delinquent behaviour, exacerbated by alcohol and substance abuse, finally got him behind bars (after committing around 41 offences from destruction of property to aggravated assault). Aggravated assaults included head trauma, teeth breaking, and bone fractures. He motivated them by alcohol abuse and jealousy. He stated (with high accuracy) that he committed 31 of his offences using extreme violence and damaging the victims significantly. Eventually, all these crimes led to him committing first-degree murder. For it, he was sentenced to 20 years in prison.
The subject accounted the first offence for which he was sentenced: it occurred while he was with his friend (and work partner) in a locality where they had a project. That particular evening, they went out and had several drinks. Shortly after the first glasses of alcohol, he was involved in a brawl (caused by excessive use of alcohol). Shortly after arriving back home, the subject was attacked by his friend with a knife; he retaliated and hit him twice with an axe in the neck area, once in the lower abdominal region, and at the end, he put a knife in his chest. Investigators found traces of coffee grounds on the victim's face, probably used for humiliating the victim. Afterwards, the subject went to the pub and resumed drinking, and then he went back to town, leaving the body at home.
His own account shows that after ingesting huge amounts of alcohol, he even planned a barbecue with a friend for the next morning; he emotionally blocked any thoughts on the act committed that night. He slept over at some relatives, and the next morning, he confessed the murder to his family and close friends.
He used as pretext for the murder the fact that he had taken a break from psychiatric medication for about five weeks, because "I kept on partying". His criminal impulse will make him state as follows: "when the conflict emerged, I lost control", "I don't care who it is; it may as well be the Prime Minister".
The subject shows no regret or remorse for this murder; his accounts are absolutely impersonal. In a cold, cruel, and impersonal manner, he starts talking about his second sentencing to prison, which occurred while he served his first sentence in the maximum-security prison.
Concerning his second act, he declares that two years prior, while he was incarcerated in a maximum-security facility, alongside six other cellmates (almost all of them recidivists with serious crimes), the atmosphere began changing. This change was caused by the disharmonic personalities expressed by verbal disputes, physical and verbal assaults, behavioural deviations, impulsiveness, and offences, brutal acts, demanding protection fees from each other, and possessing cold steel.
The subject had stopped adhering to psychiatric treatment for approximately one month and a half; when he would have to take the medication, he would find other preoccupations: "I had to charge my phone". This was the subject's motivation and his "payment" for treatment nonadherence. To him, it was more important to have the phone charged than to take the medication and get healthy.
As he declares currently, one morning, he felt psychomotor agitation (caused by sleep disturbances the night before); following a verbal dispute with a cellmate, two inmates attacked him, one with a knife and the other one with a cutter. He fought back and hit one of the victims in the head using a metal chair; the other one he hit multiple times with the cutter. "I exploded; I lost it. I started cutting him and just used the cutter any way I could." The subject was unable to control his anger ("I did not care what happened at that moment"; "I cut his face and neck like 30-40 times; his throttle was slashed, foam was coming out"; "I felt no remorse, nothing"). During his act, he got help from a cellmate, who hit the first victim in the head using the metal chair until "his brains came out".
The subject's account on the massacre and the surgical intervention undergone by the second victim is rakish. "They kept sewing him from 10 in the morning to 1 AM"; "they kept him in an induced coma for two weeks and then they unplugged him". The first victim "died one hour after the fight, while the second after two weeks". The subject talks about his thoughts at the time of the attack, about his anger-fuelled desire to decapitate them both: "I wanted to take their heads off".
Even after these two acts, the subject feels no remorse or regrets for what he did. "The only thing I am sorry for is that I will be locked up here for a long time; that my children will all be grown up when I'm out; that I may not find my parents alive." "In a way I am sorry that they died because they should have lived, to suffer like I do."
He also declares not having taken his medication back then: "I was very sick for a month and a half, when I stopped taking my meds; I couldn't sleep at night". In his mind, this would have driven him to commit those acts.
Upon analyzing this case, it is worth highlighting that pathological personality features emerged during childhood and adolescence. The subject grew up in a balanced family (without physical aggressions), with two parents who finished ten grades and then worked to support the family and to help their children. Despite his upbringing, he followed the rules of his delinquent entourage, including use of alcohol, tobacco, psychoactive substances, followed by the commission of illegal acts. He started smoking when he was seven years old; he began drinking as a child; he was addicted to alcohol as a minor; he committed offences; he had disastrous school records (marked impulsivity and aggressive behaviour toward classmates and teachers). He skipped school; he had low conduct grades; and, finally, he was admitted to a psychiatric centre for minors due to his aggressive behaviour. All of these aspects led to the early diagnosis of mixed personality disorder (antisocial and borderline).
Maybe the military service could have tempered him and correct his attitude using self-discipline, obedience, respect, and volition. However, upon his recruitment, he had a violent (maybe premeditated) reaction toward a military personnel member, who determined that he was not mentally fit for military service.
The subject cannot control his emotions and anger; he committed violent crimes; his history shows 41 aggravated assaults and property destructions. He does not care who he attacks; he simply loses control: "I don't care who it is; it may as well be the Prime Minister". The subject defined his explosive reactions as uncontrollable states: "I see red". He reached extreme aggressiveness.
Social maladjustment throughout his life is accompanied by egocentrism and by a behaviour deviating from social norms; he was sanctioned by competent bodies and he went from crime to crime. Once in prison, it is impossible to control him totally; he does not adhere to treatment and he fails to respect internal laws. He keeps on violating norms and committing offences, including in prison (even atrocities, as seen above).
Most subjects within this category stand out among inmates due to their aggressiveness, visible in the terror they inspire. While free, these severely disharmonic persons fail to control their explosive reactions even in their family: most of the times, they assault family member and they terrorize their own children. While free, they are sociable and they persevere in their projects; they make most decisions based on impulses; they do not consider risks and they are unpredictable. Their explosive reactions may end up in destructive behaviour and violent outbursts targeting strangers. Their jealously may be manifested by extreme impulsivity toward strangers; their tension is uncontrollable and it may even lead to murder. (2)
Considering all the medico-legal aspects of the case, mostly the behavioural issues leading to very serious crimes, psychiatric treatment is mandatory. Nonetheless, while in prison, a person may refuse medication for various reasons; he does not have to provide an actual justification. Hence, psychiatric symptoms may exacerbate and they may entail uncontrollable and explosive manifestations.
Prisons limit very much any physician, in terms of proper therapeutic regimen or adequate therapeutic adherence from the inmate, with the goal of improving his health status significantly. Prison physicians' deal with various medication-hiding strategies from inmates: they hide it in their mouths instead of swallowing it, they sell it to cellmates, or they use it to other ends. There is a high overdosing risk; in many cases, they use medication for suicide attempts and sometimes they succeed. (4)
Concerning the particularities of the case, prognosis is not favourable because he does not adhere to treatment in prison (such behaviour is exacerbated by the specific features of this disorder). His condition is difficult to treat and it would require regular evaluations of his mental state and constant monitoring.
Cozmin MIHAI--M. D., Ph. D. Student, Residency training in Psychiatry, "Grigore T. Popa" University of Medicine and Pharmacy Iasi, Romania
Vasile CHIRITA--M. D., Ph. D., Senior Psychiatrist, Professor, "Socola" Institute of Psychiatry Iasi, Romania
Roxana CHIRITA--M. D., Ph. D., Senior Psychiatrist, Professor, "Socola" Institute of Psychiatry, "Grigore T. Popa" University of Medicine and Pharmacy Iasi, Romania
AKNOLEDGMENT AND DISCLOSURE
This publication benefited from the financial support of the project "Programme of excellence in the multidisciplinary doctoral and post-doctoral research of chronic diseases", contract no. POSDRU/159/1.5/S/133377, beneficiary "Gr. T. Popa" University of Medicine and Pharmacy Iasi, project co-financed from the European Social Fund through the Sectoral Operational Programme Human Resources Development (SOP HRD) 2007-2013.
(1.) ICD 10. Tulburari specifice de personalitate, Editura All, Bucuresti, 1998, pp. 244-246.
(2.) Millon, T., Simonsen, E., Birket-Smith, M., Davis, D. R. Psychopathy-antisocial, criminal and violent behavior. The Guilford Press, New York, London, 2003, pp. 75-101.
(3.) Revenco, M. Tulburari de personalitate, Chisinau, 2015, pp. 42-46, 50-55.
(4.) Daniel, A. E. Preventing suicide in prison. "Journal of the American Academy of Psychiatry and the Law", 2006, pp. 165-175.
M. D., Ph. D., Senior Psychiatrist, Professor
"SOCOLA" INSTITUTE OF PSYCHIATRY
No. 36 Sos. Bucium, zip code 700282, Iasi, Romania
Submission: September, 7th, 2015
Acceptance: October, 30th, 2015
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|Title Annotation:||Case Reports|
|Author:||Mihai, Cozmin; Chirita, Vasile; Chirita, Roxana|
|Publication:||Bulletin of Integrative Psychiatry|
|Article Type:||Case study|
|Date:||Dec 1, 2015|
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