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Journal of Developmental and Physical Disabilities, Vol. 13, No. 2, 2001

Two Bankrobbers With “Antisocial” and “Schizoid/ Avoidant” Personality Disorders, Comorbid With Partial Seizures: Temporal Lobe Epilepsy and Limbic Psychotic Trigger Reaction, Respectively1 Anneliese A. Pontius2,3,4

“Diagnostic overshadowing” is illustrated by two cases of unplanned, motiveless bank robbery, initially merely attributed to “antisocoial” or “schizoid/ avoidant” (loner) personality disorder, respectively. Both disorders, however, were comorbid with their potentially unobservable counterparts, with brief partial seizures, supported by both men’s abnormal scalp-EEG’s, their symptomatology with psychosis, and their histories of closed head injury in childhood. Such injuries are known to render particularly the temporo-limbic brain system susceptible to later partial seizure: Mr. A. had temporal lobe epilepsy (TLE) with stereotypic auditory command hallucinations and clouding of consciousness. (His past “antisocial” aggressive behavior might also have reflected TLE-related inter-ictal events.) Mr. B. had the symptomatology proposed as limbic psychotic trigger reaction (LPTR). Mr. B., a social loner, typically ruminated on past intermittent moderate stresses, a specific precondition of seizure kindling, ultimately elicited by a specific stimulus, resembling his past hurts. As is typical for LPTR, Mr. B. had no clouding of consciousness and no amnesia for his atavistically regressive acts, committed with flat affect, nausea, and fleeting delusions of grandeur (being gifted, like Rembrandt). KEY WORDS: antisocial and schizoid/avoidant personality disorders; diagnostic overshadowing; partial temporo-limbic seizures; atavistic regression; criminality; childhood head injury.

1 An

earlier version of this paper had been presented at the 25th Annual Meeting of the American Academy of Psychiatry and the Law, 1994. University, Boston, Massachusetts. 3 Department of Psychiatry, Massachusetts General Hospital, Boston Massachusetts. 4 To whom correspondence should be addressed at Waldschmidt St. 6, 60316 Frankfurt, Germany. 2 Harvard

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INTRODUCTION The present goal is to alert forensic evaluators of potential diagnostic overshadowing (Luiselli, 1998; Reiss and Szyszko, 1983) based on “developmental” (Sturmey, 1998, p. 323) personality disorders. In the terminology of DSM-IV (APA, 1994) this refers to situations in which Axis II disorders (personality disorder or mental retardation) overshadow those of Axis I, herein “psychosis with general medical condition,” partial seizures (DSMIV, 293.81, 293.82; APA, 1994). Such erroneous diagnostic obershadowing can particularly occur when a personality disorder has been traditionally assumed to be readily associated with illegal behaviors, such as antisocial and schizoid/avoidant personalities (loners). The necessity to consider “potentially unobservable counterparts” (Sturmey, 1998) of such personalities is illustrated by two bankrobbers. Both men’s symptomatology occurred with fleeting psychosis, their histories, including closed head injuries in childhood, and their abnormal EEGs were congruent with comorbid partial seizures: Temporal Lobe Epilepsy (TLE) (Table I) and Limbic Psychotic Trigger Reaction (LPTR) (Table I), respectively. TLE includes clouding of consciousness, partial amnesia, and stereotypical auditory command hallucinations; LPTR occurs with preserved consciousness and memory for the atavistically regressive acts, committed with flat affect, with nausea and fleeting delusions of grandeur (being as gifted as Rembrandt). Neuropsychological awareness is particularly necessary because by the time such persons come for forensic evaluation, all seizure symptoms have disappeared, in contrast to various long-lasting conditions, such as schizophrenia, as previously discussed (Pontius, 1981, 1987, 1993, 1996, 1997).

SUBJECTS AND METHODS Two middle-aged college-educated single white men had been incarcerated for the first time in their lives on charges of bank robbery. Mr. A., initially diagnosed with antisocial personality disorder, had previously been charged with repeated moderate aggressive acts. Because of the bizarre nature of the two men’s present “crimes,” they were admitted by court order for extensive neuropsychiatric evaluation (over a period of ca. 3 weeks). The forensic team included a psychiatrist (AAP), neurologist, internist, psychologist, social worker, and radiologist. A scalp-EEG was the only brain test feasable within the setting of a prison

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Table I. Case Vignettes of Two Types of Bank Robberiesa Case 1 (TLE) Mr. A., a single, college-educated White man, age 40, had never worked but was living comfortably on a trust fund. He had a history of several past charges for moderately aggressive acts, suggesting an antisocial personality disorder. Later inquiry detected that he had past histories of closed head injury without loss of consciousness and four prior brief hospitalitzation with the vague diagnoses of “psychotic states.” Further, out of his four scalp-EEG’s two, including his last EEG, had been abnormal “with focal spikes and waves in the right temporal lobe, consistent with temporal lobe epilepsy.” For several years he had been on Dilantin and Tegretal, but had lapsed in taking his medications for ca. 2 months prior to his bank robbery. There was never any drug or alcohol abuse, nor was any of such substances used around the time of the robbery. His mental status examination at the time of admission was unremarkable, except for the events of his “robbery.” He did not remember the essential aspects of his robbery. After his prompt arrest, he falsely confessed a fatal shooting of a bank guard (which was not true). He could recall only some of the events leading up to the robbery: While walking to a family birthday party, he suddenly heard an unfamiliar male voice, commanding repeatedly in a rhythmic, stereotyped voice (stressing the word “rob!”): “rob a bank!, rob a bank!” etc., etc. Mr. A. fell into a rhythmical marching step that brought him into a bank he had never seen before. He did not remember what he did in the bank. Despite his altered state of consciousness, he typically remained capable of routine activities, such as going to the bank. Witnesses stated that he had walked to a female teller, demanding: “Give me all the money, I have a gun” (which was not true). Diagnostic impression: Temporal lobe epilepsy. Case 2 (LPTR) Mr. B. was a single, white, right-handed. college-educated monk in his 50’s, presenting the classical symptoms of a schizoid/avoidant personality disorder. He had grown up in a poor family, and during the Depression his mother had to be “in service.” He strictly observed his vows, including that of poverty. His history included a closed head injury and one hospitalization during his 20s for tuberculosis, of which he was “cured.” Otherwise, Mr. B. had been physically healthy, but had a 25-year history of psychiatric hospitalizations with various diagnoses of “schizophrenia,” “atypical psychosis,” or “psychotic episodes,” including 20 serious suicidal attempts “for no reason” by head banging or hanging. Two had occurred while he was an in-patient following his robbery. He had to be “cut down” from one attempted hanging while in the monastary after a brief loss of consciousness. He had never abused alcohol or drugs and had not used any around the time of the robbery. After admission his scalp-EEG was diffusely abnormal. His mental examination was unremarkable except for a brief lapse in attention and concentration (making there errors during the serial subtraction of 7s from 100). On the day of the robbery, Mr. B. went to confession in town. While in town, he noticed that he had no money in his pocket, whereupon he remembered similar previous money-related esperiences; he “suddenly thought of robbing a bank.” He went into a nearby bank. He remembered that he had written a note on the back of a bank form and had given it to a young female teller: “Please, give me $100, my companions have their guns pointed at you, until I get out of the bank free.” She gave me the money and I walked out into the street to a nearby ‘striptease.’ . . . I felt strange in the stomach, as if I would get nauseaous. . . . I talked a litte bit with some of the girls, cuddled up to them and touched their bare breasts. I told them (and was convinced) that I was as good a painter as (Continued)

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Rembrandt and a better writer than Thomas Merton” (a world-renowned monk-author). (Mr. B. had never published any of his writings nor had he ever sold any of his paintings.) “Then, suddenly (after ca. 20–30 min) the whole day went before me like a replay, and I said to myself ‘what am I doing?’ The change that took place in me was like coming out of a dream, and I look back at it and say ‘how did this ever happen?’ The show on stage had been going on just over my head, and I like woke up and got the idea to go to the police. I was rational again. I left the place and walked to the police station. I was not the same person anymore. I was suddenly changed over. I told the policeman ‘I robbed a bank, and I’m giving myself up.’ He did not believe a word of it and said ‘are you kidding me?’ I told him all the details and finally he found out it was true and I insisted to be arrested.” When asked, whether he would have committed the robbery if a policeman had been standing next to him, Mr. B. was certain that he “would have acted the same way, though I knew it was wrong to rob a bank, it was beyond my control and I never thought of the consequences. It was like an island moving along between two bodies of still water: rationality is on one side and also on the other side, but in the middle there is just chaos. Or, rather, there is rationality behind and after it. It is all around, but not within it . . . I have no control, it takes its course, and afterwards my acts are a curse to me.” Diagnostic impression: Limbic psychotic trigger reaction. a Except

for certain overlapping features, the two men presented with distinct histories and symptoms.

ward. Reports were submitted and psychiatric testimony (by AAP) was given in Court, based on interview techniques recommended for clinicianscientists (Geschwind, 1984). Also applied was a checklist of the 16 inclusion and 13 exclusion criteria specified for LPTR (Pontius, 1997).

RESULTS Partial seizures were suggested by the abnormal EEGs and by the specific symptomatology in Mr. A. (TLE) and in Mr. B. (LPTR), as specified in Table I. These diagnoses were made after an overshadowing by Axis II developmental, that is personality, disorders. Antisocial and schizoid/avoidant types, were assigned as comorbid conditions. Further, also various acute differential diagnoses of Axis I, DSM-IV (APA, 1994) had been ruled out for both TLE and LPTR, as previously detailed (Pontius, 1981, 1987, 1993, 1996, 1997), particularly the recurrent and long-lasting functional (nonorganic) psychoses. Special attention was paid to an exclusion of schizophrenia, which can mimick partial seizures (Weinberger, 1984) and neurological involvement of the limbic system (Weinberger, 1984), for example, partial seizures (Meldrum, 1990).

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DISCUSSION This case presentation is based on the multiaxial system of diagnoses for mental disorders used in DSM-IV “to promote the application of the biopsychosocial model in clinical, educational and research settings” (APA, 1994, pp. 24, 25). Based on the DSM-IV model, the term “diagnostic overshadowing, coined by Reiss and Szyszko (1983), readily translates into situations in which Axis I clinical conditions (here “Psychotic Disorders due to a General Medical Condition,” partial seizures, Nos. 293.81, 293.82) tend to be assumed to be merely an attribute of a long-standing Axis II condition (specified as “personality disorders,” as herein, or “mental retardation,” in other cases), thereby overlooking a comorbid classification, including both Axis I and II conditions. As an illustration, histories are presented of two male college-educated, single, middle-aged men (Table I), incarcerated for bank robbery. Both men’s long-standing antisocial and schizoid/avoidant (loner) personality disorders, respectively, are of the kinds that have been traditionally considered to be commensurate with illegal behaviors (further reinforced by media reports tending to generalize the bizarreness of loners). In view of a detailed history and an abnormal scalp-EEG consistent with Temporal Lobe Epilepsy (TLE) in Mr. A. (Table I), it might retrospectively be suggested that his moderately aggressive behaviors could actually have constituted inter-ictal brain events that can occur between more obvious TLE seizures (Bear, 1987). Mr. B.’s detailed history and diffusely abnormal scalp-EEG findings were consistent with a diagnosis proposed as Limbic Psychotic Trigger Reaction (LPTR), which also includes reciprocally secondary brief frontal lobe system dysfunction (Pontius, 1981, 1987, 1993, 1996, 1997) as shown in Table I. This has been proposed as a partial seizure, elicited by limbic kindling (through intermittently applied, in-themselves harmless electrical, chemical, or experiential (!) stimuli; Goddard, 1967; Goddard and McIntyre, 1986). Social loners are particularly susceptible to such intermittently experienced hurts, because they tend to ruminate on past experiential stresses, instead of sharing them with others and laying them to rest. (It is of further note that in primates, kindled seizures are typically nonconvulsive but “behavioral seizures” (Wada, 1988). On inadvertent human kindling see Heath et al. (1955); Sˇramka et al. (1983). Further, congruent with a diagnosis of partial limbic seizures in both men were their histories of closed head injury in childhood, constituting a potential basis for the much later manifestation of partial seizures in the most

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susceptible temporo-limbic brain region, in which both TLE and LPTR are proposed to be located. Falsely negative, seemingly normal scalp-EEGs are frequent (Devinsky et al., 1988) and do not rule out partial seizures, the diagnosis of which is still mainly based on clinical findings (Geschwind, 1984). The detection of symptoms indicative of seizure activities (Geschwind, 1984) is essential in the forensic determination of perpetrators’ volitional status and of their full appreciation of the “quality” of the act. Both these forensic aspects are impaired during seizures, as previously detailed (Pontius, 1996, 1997). It is essential to note that partial seizures permit routine acts (in TLE) or even rather complex, but atavistically regressive acts (in LPTR). CONCLUSION Forensic evaluators need to be aware of potential diagnostic overshadowing (Reiss and Szyxzko, 1983) when criminal acts are committed by persons with preexisting developmental conditions, such as personality disorders (Axis II of DSM-IV; APA, 1994), particularly disorders traditionally considered to be congruent with illegal behaviors. In case of the two bankrobbers (Table I), their antisocial and schizoid-avoidant (loner) personality disorder, respectively, initially tended to overshadow the unobservable counterparts (Sturmey, 1998) in the form of partial seizures: Temporal Lobe Epilepsy (Bear, 1987) and a proposed Limbic Psychotic Trigger Reaction (Pontius, 1981, 1987, 1993, 1996, 1997, 2000), respectively. In the terminology of DSM-IV (APA, 1994) such situations pertain when Axis II conditions overshadow those of Axis I, here “Psychotic Disorder Due to a General Medical Condition,” partial seizures, Nos 293.81 or 293.82, where criminal acts occurred in association with delusions (Mr. B.) or with hallucinations (Mr. A.), respectively. Thus, evaluators need to check out indicators of various potential preconditions for seizures, including childhood histories of closed head injuries, and symptomatology with sudden onset and cessation, letting symptoms disappear by the time of evaluation. Helpful are also reports by witnesses, who are typically present during seizure-related, that is, motiveless, unplanned acts. REFERENCES American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th edn.) Author, Washington, DC.

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Bear, D. M. (1987). Commentary on A.A. Pontius’ “Psychotic trigger reaction”: Neuropsychiatric and neuro-biological (limbic?) aspects of homicide. Integr. Psychiat. 5: 125–127. Devinsky, I., Kelley, K., Port, R. R., and Theodore, W. H. (1988). Clinical and electroencephalographic features of simple partial seizures. Neurology 38: 1347–1352. Geschwind, N. (1984). Clinician scientists. Science 224: 243. Goddard, G. V. (1967). Development of epileptic seizures through brain stimulation at low intensity. Nature 214: 1020–1021. Goddard, G. V., and McIntyre, D. C. (1986). Some properties of a lasting epileptogenic trace kindled by repeated electrical stimulation of the amygdala in mammals. In Doane, B. K., and Livingston, K. E. (eds.), The Limbic System: Functional Organization and Clinical Disorders Raven, New York, pp. 95–105. Heath, R. G., Monroe, R. R., and Mickle, W. (1955). Stimulation of the amygdalaoid nucleus in a schizophrenic patient. Am. J. Psychiat. 111: 862–863. Luiselli, J. K. (1998). Introduction to the special issue. J. Develop. and Phys. Disab. 10: 315–316. Meldrum, B. S. (1990). Anatomy, physiology, and pathology of epilepsy. Lancet, 336: 228–231. Pontius, A. A. (1981). Stimuli triggering violence in psychosis. J. Forensic Sci. 25: 123–128. Pontius, A. A. (1987). Psychotic trigger reaction: Neuro-psychiatric and neuro-biological (limbic?) aspects of homicide, reflecting on normal action. Integr. Psychiat. 5, 116–139. Pontius, A. A. (1993). Neuroethological aspects of certain limbic seizure-like dysfunction: Exemplified by limbic psychotic trigger reaction (motiveless homicide with intact memory). Integr. Psychiat. 9: 151–167. Pontius, A. A. (1996). Significance of the Limbic Psychotic Trigger Reaction. Bull. Am. Acad. Psychiat. Law 24: 125–134. Pontius, A. A. (1997). Homicide linked to moderate repetitive stresses kindling limbic seizures in 14 cases of limbic psychotic trigger reaction. Aggression Viol. Behav. 2: 125–141. Pontius, A. A. (2000). Comparison between two opposite homicidal syndromes (Syndrome E vs. Limbic Psychotic Trigger Reaction). Aggression Viol. Beh. 5: 423–427. Reiss, S., and Szyszko (1983). Diagnostic overshadowing and professional experience with mentally retarded persons. Am. J. Ment. Retard. 87: 396–402. Sˇramka, M., Sedlak, ´ P., and Nadvorn´ ´ ık, P. (1983). Observation of kindling phenomenon in treatment of pain by stimulation in thalamus. In Sweet, W. H., Abrador, S., and MartinRodriguez, J. (eds.), Neurosurgical treatment in psychiatry Elsevier, New York, pp. 651–654. Sturmey, P. (1998). Classification and diagnossis of psychiatric disorders in persons with developmental disabilities. J. Develop. Phys. Disab. 10: 317–330. Wada, J. A. (1978). The clinical relevance of kindling: Species, brain sites and seizure susceptibility. In Livingston, K. E., and Hornykiewicz, O. (eds.), Limbic Mechanisms, the Continuing Evolution of the Limbic System Concept. Plenum, New York, pp. 369–388. Weinberger, D. R. (1984). Computed tomography (CT) findings in schizophrenia: Speculation on the meaning of it all. J. Psychiat. Res. 18: 477–490.