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IOP seminar probes personality disorders by Heather Woolwine Public Relations The following is the first article in a series of three about the MUSC Institute of Psychiatry’s Day of Discovery: Forensic Psychiatry.   The topic of this year’s Day of Discovery for the Institute of Psychiatry was forensic psychiatry. On May 12, MUSC and other legal and health care professionals gathered to discuss a variety of issues related to forensic psychiatry, from personality disorders and controversies that surround them to catching a person faking mental illness.   John Oldham, M.D., Psychiatry and Behavioral Sciences chairman and professor, began the day with a detailed look at the classification of personality disorders, the biological influences on personality, and how personality disorders might develop through time.   There are three major classifications of personality disorders according to the Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition, dimensionally  defined as odd/eccentric, dramatic/emotional/impulsive, and anxious/fearful types. Of course, any one person can exhibit any of these characteristics, given the circumstances, so just because a behavior is demonstrated doesn’t mean that the person has a disorder. Indeed, an individual must have an enduring pattern of inner experience and behavior that deviates a lot from that person’s culture and can manifest itself through how he thinks about himself, others, and events, and the appropriateness of his emotional response, interpersonal functioning, and impulse control.   In addition, a person with a personality disorder suffers clinically significant distress or social/occupational/functional impairment. The pattern of behavior is ongoing across most situations, can be traced back to adolescence or early adulthood, can’t be blamed on another disorder, and isn’t caused by a substance or medical condition like a head trauma.   Oldham presented a personality style-personality disorder continuum, demonstrating to attendees that basic personality characteristics, when taken too far, become personality disorder characteristics. For example, someone who has a conscientious style could become obsessive-compulsive, or an individual with an adventurous personality might morph into an  antisocial personality disorder. This is not of course to say that these styles automatically lead to disorders, but instead are meant to show how, given the right genetic predispositions and environment, one could evolve into another.   Oldham also spent some time talking about the moving line between Axis I  mental disorders and Axis II personality disorders and the sometimes confusing overlap that occurs within certain dimensions. He then highlighted two impulsive personality disorders in particular; borderline and antisocial.   Borderline personality disorder (BPD) meets all of the general personality disorder criteria, but with the added spin of impulsive behavior, including instability in all kinds of relationships, frantic efforts to avoid real/imagined abandonment, identity disturbances, impulsive in self-damaging areas (i.e. drugs, sex), recurrent suicidal or self-mutilating behavior, marked reactivity of mood, chronic feelings of emptiness, inappropriate and intense anger, and paranoia or dissociative symptoms. Oldham mentioned some evidence suggesting BPD might emerge from the interaction of genetically based traits and environmental situations like severe and persistent childhood abuse. Another study suggested BPD patients suffer neurocognitive deficits in the frontal lobes of the brain. But Oldham offered hope with suggested treatment for these individuals, and said that several types of psychotherapy, along with symptom targeted pharmacotherapy, were effective.   Antisocial personality disorder (ASPD) is most commonly known through the actions of murderers and scores of inmates of the nation’s prison populations. Not to say that all people with this disorder commit violent crime, but these individuals do have a pervasive pattern of disregard for the rights of others and have no worries about violating those rights. This disorder can be traced back to childhood prior to the  age of 15, and a person must have at least three of the following criteria to place in this category: breaking the law repeatedly, conning/lying/deceitful, impulsive, irritable and aggressive (repeated assaults or fights), reckless disregard for own and others’ safety, consistent irresponsibility, and lack of remorse.   All ASPD patients must be at least 18 years old to receive the diagnosis and have evidence of a conduct disorder before age 15. Also, their behavior should not be exclusively a part of schizophrenia or a manic episode. Oldham mentioned a study that found people with ASPD had decreased prefrontal gray matter volume in their brains, as well as decreased autonomic nervous system activity. This could explain low arousal, poor fear-conditioning, a lack of conscience and decision making deficits in these patients. Another study looking at the biology of ASPD patients found increased white matter volume, thickness, length, and functional connectivity in their corpus callosums, thus again suggesting a possible explanation for certain deficits. Malnutrition was also identified as a factor, as it predisposes a person to neurocognitive deficits that may exhibit antisocial and aggressive behavior in children. There are gradations of this disorder, from full-blown ASPD to a series of antisocial traits that may accompany a number of other disorders.   According to Oldham, treatment for ASPD patients is complicated and more often than not ineffective, as successful treatment of these patients relies on the absence of certain characteristics, like conning, lack of remorse, and superficial charm, that are known to be associated with the disorder.   In support of the concept that rehabilitation is difficult for this patient population, Oldham showed the audience some reconviction rates of ASPD patients demonstrating that those with ASPD past a particular threshold have a 75 percent chance of going back to jail. In fact, a study of more than 13,000 prisoners in 28 prisons in a variety of Western countries found 47 percent of the male prison population suffering from ASPD. There seems to be a genetic component to ASPD and studies with twins and preschool age children indicate that early onset hyperactivity ad an inability to inhibit socially inappropriate behavior predicts later asocial behavior in school-age children and thus adult anti-social behavior. Oldham pointed out the numerous associations between people with a type of ASPD and homicide, attempted murder and wounding, arson, kidnapping/abduction, and robbery, firearm offenses, and theft. At the conclusion of his presentation, Oldham related a public case to the audience that he was involved with when he worked as a psychiatrist in New York to illustrate that there is still a huge amount left to learn about treating patients with personality disorders, especially those inclined to manipulate the system. (Case of Albert Fentress) The Case of Albert Fentress Albert Fentress was born in 1941, the oldest of three children, in Brooklyn. His father was a tough man who believed in physical punishment but Fentress had an overall normal childhood.   At 12, he moved with his family to Long Island where he continued in school until becoming one of the top 10 in his high school graduating class. Eventually, Fentress earned his master’s degrees in history and education and became one of the best reputed high school teachers in the area where he lived. He lived alone and was quite a meticulous housekeeper. He appreciated the finer things, as he drove a Cadillac and wore a Rolex watch. He owned a very valuable stamp collection. Although beloved as a teacher, Fentress did not have a romantic relationship or many friends. He actually once described the most depressing point of his life as when his Cadillac was in the shop being fixed. When he was 35, his house was robbed and his stamp collection stolen. Sure that a particular high school student had done it, Fentress lobbied to have him arrested. The student’s school friends found out and soon Fentress’ home was a target for vandalism and harassment. He obtained a gun permit.   After his arrest, Fentress told interviewers that he wrote in his journal a series of events that came to him while he was in a dissociative state and upon waking from it, was so horrified by what he’d written, like it was that of another person, that he burned it immediately. It was this series of events, however, that later took place at Fentress’ home.   While some juveniles were running from police officers in his neighborhood, Fentress invited one boy in and won his trust with a beer. He then gained leverage on the boy, tied him up and tried to sexually assault him. When Fentress was unsuccessful, he castrated the boy, cooked and ate his genitals, then shot him and dragged him upstairs. It is then he claims, that he woke up from what he said was another dissociative fugue. He called a friend, who in turn called the police and Fentress was taken into custody.   Years passed after he was found not guilty by reason of insanity and by the 1990s he was a favorite patient in the New York state forensic facility. He had developed great computer skills and was teaching the other patients and staff. He’d suffered no more episodes. Officially his diagnosis was narcissistic personality disorder, obsessive compulsive disorder and dissociative fugues. The only time that he received antipsychotic medication was in jail prior to his trial.   Because he was an outstanding patient, his treatment team, several psychologists, and several outside consultants suggested he be granted unaccompanied passes into the community. He was already out and about with an escort.   In 1997, John Oldham, M.D., Psychiatry and Behavioral Sciences chairman and professor, who at the time worked in New York, was asked by the state to review Fentress’ records and provide an opinion. Oldham was concerned that Fentress was not on medication and was unsure what could trigger another psychotic episode, “If he couldn’t  handle kids slashing his screens and burning his lawn, then how could he possibly handle the likely public reaction to his release, after he'd been demonized in the media as 'New York's own Hannibal Lector?'”   Fentress then exercised his right to a jury trial for release. Oldham testified as an expert witness of the state, interestingly, in disagreement with recommendations of others within the same state agency. He believed Fentress suffered from malignant narcissism, was not a candidate for release  and was also still potentially dangerous. In a retrial in the appellate court, the state called a witness who testified that when he was a 10-year-old neighbor of Fentress’, he was sexually molested on numerous occasions by Fentress. Fentress had not revealed this information before.   With the last chapter yet  written, Fentress remains in the psychiatric state inpatient facility today. Psychiatry and the Death Penalty Margaret Melikian, MUSC Forensic Psychiatry program director and Psychiatry and Behavioral Sciences assistant professor, and Teresa Norris, Center for Capital Litigation director in Columbia, provided a brief history of capital punishment trends in the United States since 1608 and more recently in the 1970s when two influential cases rewrote state capital punishment statues.   The South performs 80 percent of all executions, and has produced some controversial cases involving the execution of mentally handicapped or retarded inmates. In 2003, the U.S. Supreme Court ruled that mentally retarded criminals could not be executed because it is cruel and unusual punishment, a violation of the Eighth Amendment. However, the court left it up to the states to define mental retardation. South Carolina is currently working on its definition. In 2005, the Court also ruled that it was a violation of the Eighth and 14th Amendment to execute offenders who were under the age of 18 at the time of the crime, and cited “evolving standards of decency that mark the progress of a maturing society.”   But the issues involving mental health and the judicial system are not as easily cut as the Court’s opinions would make it seem. Those involved with capital punishment litigation and mental health professionals now have to discern who among death row inmates qualify for nullification of a death sentence.   Of the 77 men currently on death row in South Carolina, three were juveniles at the time of their crime and as many as 10 have serious allegations of mental retardation. Melikian also presented evidence from several studies demonstrating that a “dangerous” profile of high antisociality and low intelligence was more common in death row inmates and that mental health issues are rampant among dangerous inmates.   For example, of 100 inmates studied by Yarvis in 1990, 38 percent met the antisocial personality disorder criteria, 29 percent had schizophrenia or an affective psychosis, 18 percent met borderline personality disorder criteria, and 9 percent suffered from dysthymic disorder, a chronic mild depression. Melikian offered more studies that followed Yarvis detailing the majority of men in prison for murder or on death row suffered from a variety of mental health issues or medical problems like severe head injuries.   As health care professionals, psychiatrists cannot ethically be involved in deciding someone’s competency to suffer the death penalty (violation of Hippocratic oath), but can offer input for others who would make that decision. Norris offered some recent positions taken on the death penalty by various psychiatric organizations and then discussed four court-ordered psychiatric evaluations in death penalty trials: competency to stand trial, criminal responsibility but legal insanity, guilty but mentally ill (this would send a person to the psychiatric ward of a prison instead of a hospital), and mental retardation. She discussed at length the concept of mitigating circumstances, non-mitigating circumstances, the American Bar Association guidelines for counsel in death penalty cases, and those who make up a death penalty defense team, including the roles of psychiatrists and psychologists as members of that team. Norris closed the presentation with information concerning mental health standards for criminal justice issues, South Carolina’s definition of competence to be executed, and issues with death row inmates who receive medication while incarcerated and how that affects death penalty cases.     Friday, June 3, 2005 Catalyst Online is published weekly, updated as needed and improved from time to time by the MUSC Office of Public Relations for the faculty, employees and students of the Medical University of South Carolina. Catalyst Online editor, Kim Draughn, can be reached at 792-4107 or by email, catalyst@musc.edu. Editorial copy can be submitted to Catalyst Online and to The Catalyst in print by fax, 792-6723, or by email to petersnd@musc.edu or catalyst@musc.edu. To place an ad in The Catalyst hardcopy, call Community Press at 849-1778.