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Anosognosia, Psychopathy, and the Conscience

How people see and understand themselves is likely to have an impact on how they interpret interactions with others. Here, I briefly explore the brain areas implicated in anosognosia, how these areas are also relevant in psychopathy, and why anosognosia is important when considering the crime and the conscience.

ANOSOGNOSIA AND SELF BELIEF

Anosognosia is defined as the impaired ability of patients with neurological disorders to recognize the presence or adequately appreciate the severity of their deficits [1]. Torrey (2012) cites three examples of anosognosic patients; a stroke victim with a paralyzed arm claimed he couldn’t lift it because he had a shirt on; a woman with paralysis in her left arm was asked to raise it, and instead raised her left leg. When this was pointed out to her she responded that some people call it an arm, others a leg, and jokingly inquired as to the difference; the Supreme Court Justice, William Douglas, was paralyzed on his left side. He claimed this was a myth, and was still inviting people to go hiking [2].

NEUROLOGICAL FINDINGS IN ANOSOGNOSIC PATIENTS

Recent research on this phenomenon has identified deficits in the brain of the patients who in all honesty do not recognize that they are in some way impaired. By using fluorodeoxyglucose positron emission tomography (FDG-PET) and single photon emission computed Tomography (SPECT) Perrotin et al. (2015) found that anosognosic Alzheimer’s patients had a disruption in connectivity between the posterior cingulate cortex (PCC) and the orbitofrontal cortex (OFC) [1]. Ries et al. (2007) also implicated a compromised precuneus in anosognosic patients. These midline structures are susceptible to damage in those with Alzheimer’s Disease (AD) and stroke victims. Anosognosia is also experienced by schizophrenic patients; according to Gerretsen et al. (2015), 60% of schizophrenic patients experience moderate to severe illness awareness, and this can lead to medication non-adherence and poor treatment outcomes [4]; they found left hemispheric dominance in the left prefrontal cortex in anosognosic schizophrenic patients and cortical thinning in the temporoparietalocciptal junction (TPO).

There is still much work to be done to determine the mechanistic and functional basis of anosognosia, and to determine the subtleties between illnesses and disorders, but research is starting to identify suspect brain regions. This is useful if anosognosia is questioned in other disorders, because neurological studies exploring the disorder can be explored and legitimate avenues of scientific inquiry explored.

RESEARCH PARALLELS WITH PSYCHOPATHY

A failure to recognize a disorder is also present in those with psychopathy. While anosognosia is yet to be explored thoroughly in those with psychopathy, there are behavioral items on the Psychopathy Checklist (PCL-R) [5] that suggest anosognosia is present; grandiose sense of self-worth, lack of remorse, and failure to accept responsibility. The sense of self-worth and narcissistic traits of the psychopath clearly means that they think very highly of themselves. This negates the idea that the psychopath believes they suffer from a defect or a disorder; at the most they might recognize that most others are different, and perhaps inferior to themselves. If a lack of remorse is experienced, this is an explicit demonstration that they do recognize, at least on an emotional level, the consequences of their bad behavior as being wrong; if they do not believe their behavior is inappropriate, it stands to reason that they believe they behaved appropriately, and thus experience nothing ‘wrong’ about themselves. This aspect of self-belief and self-reflection is also seen in the psychopath’s failure to accept responsibility; if they are always good and right, there is little motivation to make amends.

Based upon this cursory examination of psychopathic behavior, it would seem reasonable to explore the neurological studies of psychopathy and see if there could be some overlap with previous studies on anosognosia, and in fact some of the same compromised brain areas are implicated. Many studies have demonstrated developmental differences in the PFC of the psychopath (for a review, see Umbach et al. (2015) [6]), and the white matter pathways, such as the uncinate fasciculus (UF) connecting to the PFC from the limbic regions [7]. Perrotin et al. [1] hypothesized that Anosognosia can result from a disruption in connectivity in the UF. When exploring connectivity in the frontoparietal network (FPN), Philippi et al. (2015) found reduced connectivity in those with higher scores on the PCL-R, which included the right precuneus. And to further the overlap, Glenn et al. (2009) [8] found that those with who scored high on the interpersonal factors of the PCL-R (manipulative, conning, deceitful), showed reduced activity in the PCC during an fMRI scan when having to make judgments during moral dilemma scenarios.

Anosognosia and psychopathy both demonstrate complex neurological constructs, and it is premature to conclude that the neurological basis for Anosognosia (itself still understood) would tuck neatly into the already known neurological research on the psychopath. However, given the neat juxtaposition of behavioral traits and neurological dysfunction, it is worth bringing psychopathy into discussions of Anosognosia for the following reason. The research on psychopathy is currently deeper and richer than the research on anosognosia, and behavior of the psychopath has been widely observed and studied. If we can reasonably conclude that psychopaths, particularly criminal psychopaths, are also anosognosics, their behavior can be assessed in light of what it means to recognize no disorder or defect within oneself. The parallel is further relevant with psychopathy when considering that a number of those with schizophrenia, and a minority of those with AD, have been known for antisocial, and sometimes criminal, behavior [9, 10].

ANOSOGNOSIA, ANTISOCIAL BEHAVIOR, AND THE CONSCIENCE

Those with schizophrenia and AD also suffer from abuse, but when they have been known to act violently, their behavior and motivations need to be understood. Torrey (2012) has documented extensively the violent acts of those with schizophrenia [2]. There is usually a history of progressively worse episodes of psychosis that can convince the patient that they are receiving supernatural or alien instructions to kill or harm individuals, and more often than not family members. Whether or not the auditory hallucinations slowly convince the patient over time of the necessity for deadly action, or whether the act is impulsive, after the event the patient often remains remorseless and attributes their behavior to necessary and mandated (often divine) reasons. This state of mind is similar to the violent psychopath, who also viewed his violent actions as necessary and fully justified. The problem is never attributed to the self; a disorder or defect is not recognized. While psychopaths are widely regarded as not having a conscience and experience only limited affect, more research is needed on the experience of conscience by schizophrenics, especially understanding the role that psychosis played in circumventing the conscience and providing them with permission to act. It is also crucial to discover how those events are remembered and felt post psychosis, perhaps when the patient has reconvened their medication.

In illnesses and disorders that can be associated with antisocial behavior or aggression, anosognosia could be a partial reason for the event of the behavior. Not recognizing any problems or defects, and thinking that one acted rightly or righteously, will affect personal judgments on the self-evaluation of behavior. This does not provide a fertile ground for remorse or responsibility, and if the behavior was aggressive, the patient could continue to remain dangerous, inflexible to a reasoned and peaceful behavioral change. This makes the search for the neural representation of anosognosia all the more crucial, treatment all the more pressing, and methods of identification all the more necessary.

© Jack Pemment, 2016

 

REFERENCES

  1. Perrotin, A. et al. (2015). Anosognosia in Alzheimer disease: Disconnection between memory and self‐related brain networks. Annals of neurology, 78(3), 477-486
  2. Torrey, E. F. (2012) The Insanity Offense, New York, W. W. Norton and Company
  3. Ries, M. L. et al. (2007). Anosognosia in mild cognitive impairment: relationship to activation of cortical midline structures involved in self-appraisal. Journal of the International Neuropsychological Society, 13(03), 450-461
  4. Gerretsen, P. et al. (2015). Illness denial in schizophrenia spectrum disorders. Human brain mapping, 36(1), 213-225
  5. Hare, R. D. et al. (1990). The revised Psychopathy Checklist: Reliability and factor structure. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 2(3), 338-341
  6. Umbach, R. et al. (2015). Brain imaging research on psychopathy: Implications for punishment, prediction, and treatment in youth and adults. Journal of criminal justice, 43(4), 295-306
  7. Motzkin, J. C. et al. (2011). Reduced prefrontal connectivity in psychopathy. The Journal of Neuroscience, 31(48), 17348-17357
  8. Glenn, A. L. et al. (2009) The Neural Correlates of Moral Decision-Making in Psychopathy. Retrieved from http://repository.upenn.edu/neuroethics_pubs/55
  9. Fazel, S. et al. (2009). Schizophrenia and violence: systematic review and meta-analysis. PLoS Med, 6(8), e1000120
  10. Lopez, O. L. et al. (2003). Psychiatric symptoms vary with the severity of dementia in probable Alzheimer’s disease. The Journal of neuropsychiatry and clinical neurosciences, 15, 346–353

The White Room

A thought experiment, for fun. This is not a trick question and there is no right answer. Please answer and share with your friends and contacts.

Question

You agree to take part in a study. Upon arrival, you are handed a poncho to put on, and given the sole instruction, “Pass through the room.”

You are shown to the door to the room in question, you enter, and the door is closed behind you. The room is well lit, rectangular, perfectly white, and spotless. Opposite you, about 30 feet away, is the exit. To either side of you are two tables, stacked with squeeze bottles full of paint, of all different colors.

Would you pass through the room without touching the paint?

The Treatment Advocacy Center

Treatment Advocacy CenterIf you’re interested to learn how an absence of nationwide mental healthcare assistance contributes in a very real way to violent and aggressive events in the U.S., please check out the website for the Treatment Advocacy Center. This organization was founded by the prominent and distinguished psychiatrist, E. F. Torrey, known for his exhaustive research correlating a decline in therapy (especially outpatient follow-up) with violent crime in the United States.

 

The Treatment Advocacy Center website provides access to a wealth of information and statistics surrounding mental health and crime; you can see how your state measures up against others with the laws they have in place, the population of severe mentally ill persons, an estimate of how many severely ill people are incarcerated, and the ratio of the likelihood of incarceration vs. hospitalization for the severely mentally ill. There is also a database of preventable tragedies, options to become involved, and media to explore surrounding the issues.

 

Torrey’s book, The Insanity Offense, also provides excellent reading on the rise of a national problem, how state governments and politicians have without fail misunderstood (or not cared about) the root of the problem, and how many of the U.S.’s violent crimes stood a chance of being prevented had common sense measures been in place. All too frequently laws have been written that seem to encourage the violent act before any action can be taken (are they a danger to themselves or others?), and enforcing measures that encourage the severely mentally ill to take their medications. Forcing people into institutions and to take their meds has often been viewed as barbaric and an affront to personal liberties, but the severely ill cannot live ‘freely’ unless they are treated (humanely), and neither can their family or friends.

 

Clearly, it is time to acknowledge that mental illness can affect anyone at any time, and sensible, common sense, and compassionate measures need to be put into place.

 

A wonderful resource if you have the time.

No rhyme or reason: The shootings in Kalamazoo, MI

A booking photo of Jason Dalton in Kalamazoo. Photograph: Handout/Reuters

A booking photo of Jason Dalton in Kalamazoo. Photograph: Handout/Reuters

Jason Dalton was recently arrested for the killing of six people, and the wounding of two. The first incident seems to have taken place at about 6pm on Saturday 20th, Feb, near Meadows Townhomes in north-east Kalamazoo, where a woman who was babysitting was shot many times in a parking lot; she is currently in critical condition, but the children were all unharmed. The second incident, also in a parking lot, took place four hours later, where a father and son were gunned down. Fifteen minutes later, there was another shooting at a nearby Cracker Barrel restaurant, where four women were killed in cold blood.

Paul Matyas, Kalamazoo County undersheriff,  told WWMT, “There’s usually a rhyme or reason to it. In this particular case, we’re not finding that. Hopefully when we interview the individual he’ll disclose that to us.”

Even though there doesn’t appear to be a motive – an absence of a link between victims and no known criminal history or affiliation of Dalton, the reason could point to a brain abnormality or mal-development, such as a tumor pressing on the hypothalamus, as was the case with Charles Whitman, the Texas Tower Sniper. This case also reflects, although not to the extent of the meticulous planning involved, the activity of the Washington Sniper, John Allen Muhammed. While there was perhaps an ideological, or radicalized bent to Muhammed’s shootings, they also appeared random at first.

There are biological anomalies that can occur that can make people antisocial; this can happen with frontal lobe dementia and other conditions that result from tissue deterioration in the prefrontal cortex – an area known for controlling impulses and annealing the powerful desires promulgated from the limbic areas. The fact that Dalton was caught driving erratically beforehand as a driver for Uber, also points towards an abnormality in the frontal lobe.

It may turn out that these events were planned and were to justify an ideological end point, or we may find through a brain scan that Dalton has a condition.

The trouble is, we need our killers to have motives, because then we can know we are different from them, and our sense of self can escape unscathed. A lack of motive is unsettling, and diminishes the distance between us and them. This need is probably how ‘evil’ slipped into the world.

 

For more information please see:

The Guardian: Suspect in Kalamazoo shootings that killed six was Uber driver, firm says

 

 

Hervey Cleckley Quote #8

After describing the futile cycle of psychopaths going to prison, to a mental health hospital, and back into society, Cleckley describes the clueless nature of those trying to address those with psychopathic personalities:-

Turning now to penal facilities, now to psychiatric [hospitals], relatives, friends, doctors, lawyers, the community at large, all find they are trying to measure areas in kilowatts or color in inches. Since the fire extinguisher did not particularly help the child’s fever, which has become alarming, we gravely apply a plaster cast.

The Mask of Sanity

Cleckley, Sexuality, and Circumscribed Behavior Disorder

In The Mask of Sanity, Cleckley devotes a chapter to a case about what was termed Circumscribed Behavior Disorder. Cleckley described it thusly:-

When behavior disorder is circumscribed, in a child or in an adult, one sometimes feels that symptomatically the patient resembles a psychopath but that a different sort of personality lies behind the manifestation.

The chapter is included among other chapters that are supposed to stand in contrast to psychopathic personality to help us better understand the psychopath, and includes such cases as the psychoticthe psychoneurotic, and the malingerer. One certainly gets the feel that this is 1940s psychiatry really struggling with classifications and groupings, after all, behavioral permissibility seems to be determined by the cultural and legal zeitgeist, and if something is deemed ‘wrong’ culturally, then psychiatrists automatically look at it as a disease or disorder.

This chapter is particularly striking, however. There is absolutely NOTHING wrong with the ‘patient’ in this case, a young woman who had sought help because she feared social repercussions  because of her deemed promiscuity. The other chapters all describe behavior or symptoms that now have reputable courses for treatment and therapy (mostly), and while it’s easy to attack the work of Cleckley for the obvious 1940s social climate and prejudices, he wrestles with this patient in the same way that Nietzsche struggled to understand women; if he could just lose the product of his time element from his observations and reasoning, the truth, I think, would have blown him away. You feel like he knows something is wrong in the same way that Mr. Anderson feels that something is wrong in the movie ‘The Matrix’ before he becomes Neo.

The young woman in the case ends up in counseling in her mid twenties. She clearly has a strong and curious sex drive, and she is also thoroughly intelligent, a keen social critic when it comes to cultural mores, and very book smart. She had no desire to form any long lasting relationship with a man (something that unfortunately flagged her as psychologically defective – because of course, sex for sex’s sake is clearly ridiculous). Cleckley interprets this as her not caring who she hurts: If men invest in a series of dates, there is some consensual sexual activity, and then she chooses to move on, the hurt the men suffer is obviously her fault and has nothing to do with their emotional immaturity and possessional attitudes.

In two years, she slept with twenty men. Cleckley notes that she easily experienced vaginal orgasm (wonderful that she had to answer those questions because she’s being screened as sexually dysfunctional), and even so, did not want to stay with any one man. After all, as we know, if women are sexually satisfied, what more could they possibly want out of life? There is never any evidence that she cut and run from relationships, or used sex to steal or blackmail from anyone, only that she ever wanted brief sexual encounters. There was also no guilt felt after sex, which is why Cleckley has connected this apparent disorder to psychopathy in the first place.

Later, the young woman finds an intimate and rewarding relationship with a woman who was fifteen years older and was a part of the faculty with her husband at a local college. This older lady was well read, erudite, and felt a reciprocal attraction; they would together listen to symphonies, read Shakespeare out loud together, and drink and chat well into the night. This progressed into nights spent together in the same bed where they had sex. This happened when the husband was away for research.

While the marital infidelity is enough to make one squeamish, the young woman clearly found everything she wanted in a partner. Who doesn’t want an intellectual, thought-provoking, charming, and sexual guru to spend most of their free time with, especially before the dawn of family and work life?  These needs that the young woman experienced would have made her selfish in the sense that she’s trying to figure out the best place for herself in the world, but her culture was against her all the way. In fact, she tells Cleckley how it was okay for little boys to wander off on tree climbing, hiking, or other adventures, but little girls were more restricted, and how boys became airline pilots, surgeons, and generals, but women became wives, and were destined to a life of housework. She fought this all the way and dared to listen to her own drives, dreams, and desires.

While in counseling, Cleckley noted that she was forced to admit that male and female genitalia are better suited to each other and work together to get better “sensual results.” He seems bang on the money – she was forced or defeated to admit something so preposterous. The concluding part to this chapter is disheartening. She’s being made to ‘understand’ that her feelings and drives are mechanisms for avoiding responsibility, in the same way that a child might feign sickness in an effort to avoid school. She is effectively punished for being herself.

I think Cleckley struggled with this case. He knew her observations of 1940s stereotypes were apt, yet her behavior is interpreted heavily by the prevailing morality of the time. One gets the impression that Cleckley’s primary duty for therapy was to encourage cultural assimilation. It wasn’t until 1973 that homosexuality was finally omitted from the American Psychiatric Association’s Diagnostic and Statistical Manual.

There was a disorder here, but it wasn’t Circumscribed Behavior Disorder. It was oppression.

 

Hervey Cleckley Quotes #6

I am not sure there was ever much more need for “psychosis with psychopathic personality” than for “psychosis with red hair” or “neurosis with a Ph.D. degree.” The new nomenclature appears better designed to avoid unnecessary confusions of this sort.

Mask of Sanity