PRIMARY MENTAL ILLNESS
The Major Psychoses
Mental illness is generally "multifactorial," meaning that genetic as well as environmental factors have interacted to produce the clinical picture we see. In the so-called major psychoses-schizophrenia and manicdepressive psychosis-the genetic factor is of crucial importance. The so-called risks genes for these conditions are going to be present, though in some people the combined effects of these various genes are not enough to make the condition clinically recognizable. This may be because the genetic contribution was not so powerful or because there were other favorable ("modifying," or protective) genetic influences that softened the effects of the abnormal genes. At the moment, our focus is on the primarily genetic forms of mental illness.
Briefly put, the phrase "mental illness" ordinarily refers to conditions where one's reality testing is gravely impaired. By reality testing I am referring to having a good grasp on one's identity and on the natures of the people in one's everyday life. A more subtle aspect of reality testing relates to ideas about what is happening in the world and to estimates about the likelihood of notions about cause and effect. To think, for example, that there is a radio implanted in one's teeth that receives messages from God is so radical a departure from what really could happen that reality testing is seriously hampered. Such a thought is "crazy." To insist that you are the reincarnation of Alexander the Great shows a different kind of impairment in reality testing; in this case, grandiosity has gone overboard: this is a "megalomanic" distortion.
If the abnormality in reality testing is primarily in one's thinking, the condition will usually be called schizophrenia. If the abnormality affects predominantly mood, the condition will be called either mania (the mood is too elevated) or depression (the mood is unrealistically low). These distinctions are not always so clear-cut in real life: intermediate conditions may exist (thought and mood may both be affected). Some less common variants also exist. We have noted earlier that both schizophrenia and mania are associated with a heightened tendency to violence. The shock value of the violence may epitomize our notion of evil. This will be particularly true of schizophrenia, where one's judgment-and the violent crime that judgment may give rise to-may be so incomprehensible or bizarre, so unlike anything we have ever heard of before, that crazy or evil are the first words that come to mind.
One example concerns a woman who took a knife and eviscerated her mother through the genitals-in order to release the "good mother" who lay swallowed up and buried, like Jonah inside the whale-from the "Devil," which in her mind was the mother's visible body. The woman had never committed an act of violence, nor any other crime, before, so the abnormality lay primarily in the "thinking" part of the brain, corresponding for didactic purposes to the orbitofrontal cortex in our model (though what we mean by thought is not confined exclusively to this one area).
There are other, less common conditions, each reminiscent of schizophrenia, where judgment is radically impaired. Each may lead, on the rare occasion, to a similar kind of violence that smacks of the bizarre or the uncanny. One such condition is called delusional disorder, where the distortion in one's sense of reality, though profound, is confined to a comparatively small area of one's total thought. Not only that, but the peculiarity of thought is so cleverly constructed, so "reasonable" sounding-usually involving nefarious plots that might just possibly be true-that other people who hear the person's delusional tale may themselves be persuaded, or may be willing, temporarily at least, to give him the benefit of the doubt. Here is an example:
I once had occasion to interview a woman who was serving a long sentence for killing the man in whose house she lived as a lodger. A highly intelligent and deeply knowledgeable woman, conversant over a wide range of historical and other subjects, she had nevertheless developed (after the birth of her last child) the unshakable conviction that her landlord was secretly plotting to kill her by dropping poison pellets in her breakfast tea. Imagining herself locked in this kill-or-be-killed drama, she shot him to death one morning in the kitchen they shared, then proudly summoned the local police. To her astonishment, rather than celebrating with her this victory over so cunning an adversary, they promptly arrested her for murder. Though grossly delusional about the supposed machinations of the landlord (and certain co-conspirators hidden away in other parts of the country), she was sent to prison, rather than to a forensic hospital. She became the victim, ironically, of her own lucidity and normality on every other topic of conversation. It would have been most instructive to study the patterns of the woman's brain responses during a functional magnetic resonance imaging [fMRI] examination to see which areas of the brain "lit up" when the direction of questioning were shifted from, say, the dynasties of ancient Egypt (which she could discuss with professorial authority) to the execution-style murder of her landlord. Unfortunately, the budgetary constraints of the prison, as the warden informed me, left no surplus for scientific inquiry of that sort, however informative it may have proven.
Asperger's Syndrome
A milder condition within the spectrum of autistic disorders, Asperger's Syndrome is characterized by poor empathy, overly formal speech, and an all-absorbing preoccupation with just one area of interest. The condition is rare (perhaps 1 out of 5,000 children; boys are 3 or 4 times more likely to have the condition than girls); the language and communica tional impairments are not as severe as in autism. Asperger's and autism have a strong genetic component, though there is no known gene or group of genes common to all cases. These conditions used to be grouped with schizophrenia because they involved aberrations of thinking rather than of mood, but they appear to be a separate group.32
There does not seem to be one distinct region of the brain where an abnormality could account for all the features of Asperger's, though some recent research suggests that a brain region called the insula may play an important role.33 The insula, located in the internal area of the temporal lobe, serves a number of functions having to do with speech and also with the recognition of emotions in other people. The amygdala also plays a part, along with the insula, in this capacity for empathy. The cell architecture of the insula consists in part of the so-called mirror cells, which under normal circumstances allow us to imitate the gestures and expressions of others as soon as we see them. Some persons with autistic disorders show a lack of mirror-neuron activity. The problem may not be as simple as this: others have shown that some Asperger patients do not have an across-the-board empathy defect; rather, they have trouble recognizing emotions in other people that correspond to emotions they don't properly recognize in themselves.34
Autistic persons are rarely violent, but in the exceptional case where they commit a violent crime, the outburst will likely be a final act by someone who has been unable to sense what others feel, unable to relate to them in any meaningful way, let alone to form an intimate friendship with anyone. That was certainly the case with the mass murderer on the Virginia Tech campus in 2007.
Seung-Hui Cho had come to the United States from Korea with his family when he was eight. He was already considered "autistic" at that age; he was shy, nearly mute, never initiating a conversation. When he did speak, his speech patterns were strange, which led to his classmates making fun of him, the more so as he refused to participate in ordinary school routines. By the time he was in college, he had become a scowling, disgruntled loner who wrote "plays" of macabre and twisted violence, so disturbing as to frighten his teachers and make his fellow students wonder whether he would become the next "school shooter."35 His behavior in class was bizarre and menacing: he took photos, unbidden, of girls, stalked several girls, and made harassing phone calls. Growing pro gressively more paranoid, he accused the other students of "debauchery," called them "deceitful charlatans."36 His inability to fit in with others led to envy and hatred that grew to such proportions that on April 16, 2007, after writing a note saying that "you made me do this," he shot to death thirty-one students, a teacher, and f
inally himself
The sense of evil in the Cho case stemmed of course from the snuffing out of the lives of the thirty-one students in the prime of life, along with one of their teachers (who had tried to save some of them). We can envision a pathway that led up to the massacre:
Genetic impairment of empathy - Inability to fit in socially -* Envy and hatred - Heightened drive for revenge - Impaired judgment about right and wrong (anterior cingulate) - Insufficient orbitofrontal inhibition -* Implementation of murderous revenge fantasy acted out.
Perhaps there had also been a cultural element interwoven with these other adverse factors: had he remained in his native country, he might not have stood out as much as he did in the new environment. Some students picked on Cho, for example, because of his odd behavior, taunting him (and not even getting the country correct) with "Go back to China!" His age-twenty-three at the time of the murders-was just at the transition point between adolescence and adulthood. Neurophysiologically, the neurons in the frontal lobes, which are not fully coated with myelin until about that age or a little later, may have been a factor as well. As a result, the ability to inhibit destructive drives may not as yet have reached its optimal strength. This kind of neural immaturity was probably a factor in the spree murders of nineteen-year-old Charles Starkweather (mentioned in chapter 5).
Induced Mental Illness
There are several conditions where the tendency to violence has been sparked by factors that are not related to risk genes for schizophrenia, manic-depressive psychosis, delusional disorder, or autistic-spectrum disorders. Either that, or some genetic disadvantage related to one of those conditions is present, but to only a mild degree. The main cause stems from some other source. When obvious psychosis is present (with delusions, hallucinations, bizarre speech, and the like), we can call such conditions "induced mental illness." Here I am using the word induced to mean brought about primarily by causative factors other than the genetic ones directly related to schizophrenia, delusional disorder, manicdepression, or autism. Drug abuse, brain tumors, and serious head injury are examples of conditions that can induce a mental illness. Many practitioners in the mental health field will extend this admittedly vague term-mental illness-to cover certain other conditions that are quite serious (especially as to the risk of violence) but not so disruptive of one's grip on reality as to resemble a full-fledged psychosis. Let us focus here on some of the more prominent examples of this more broadly defined "induced mental illness."
Fetal Alcohol Syndrome
Mothers who abuse alcohol heavily during the early stages of pregnancy may give birth to babies with fetal alcohol syndrome (FAS), though some infants will show less serious signs of damage called fetal alcohol effects (FAE). In the full-blown syndrome, however, a baby may show characteristic facial features: small eye openings, a thin upper lip, and a smoothing of the fold from nose to mouth. But there may also be damage to neurons and brain structures, which may result in eventual memory impairment, attention deficit, impulsive behavior, inadequate cause-andeffect reasoning, delinquent behavior, and inappropriate sexual activity by the teenage years, heightened aggressiveness, and a tendency to drug and alcohol addiction, criminality, and violence. FAS is one of the most common causes of mental retardation.37 The idea of a multifactorial cause is particularly apt in cases of fetal alcohol syndromes: the alcoholic mother may have also passed to her infant risk genes for familial alcoholism. Or the mother may have mated with a man who also abused alcohol or drugs. The mother is more likely than average to be "wild," promiscuous, inattentive to her child, and less competent in her ability to be a mother. As far as the risk for FAS or FAE is concerned, a child born into these circumstances has more than the one strike against him. The following case touches on many of these points.
Richard Clark was born in 1968 out of wedlock to Kathleen Feller, a severe alcoholic. Richard had FAE syndrome. Family life was chaotic. Kathleen later had three quick marriages, before marrying for the fourth time to Bob Smith-an extremely abusive man who used to humiliate Richard by making him do such things as eat a cigar. Richard often stayed home from school so as not to show the scars from the beatings his stepfather gave him. When Richard was fourteen, his mother died while driving drunk. Dropping out of school at that time, he began robbing people and burglarizing homes. At twenty he tried to abduct and rape a girl of four but was intercepted by the mother. By then he was abusing alcohol, marijuana, LSD, cocaine, and methamphetamine-supporting his habits by theft. At twenty-seven he abducted a seven-year-old girl, the daughter of a drinking buddy, raped her and stabbed her to death and then dumped her body in some bushes where it was not discovered for a week. Because the murder occurred in the context of another felony (rape), and because he had stuffed a sock in the girl's mouth, his case was one of aggravated homicide, carrying the possibility of the death penalty (which is what the jury recommended). On the Gradations of Evil scale, Richard would be placed in Category 18, since some torture was involved, for a crime that was primarily sexual. Clark was considered a psychopath at trial, but whether he was a "born" or a "secondary" psychopath (because of his extraordinarily traumatic childhood) is impossible to disentangle.
Drug Abuse
All of the common so-called recreational drugs are capable of causing at least a temporary psychosis. In certain vulnerable persons, chronic abuse of these drugs can induce a lasting mental illness whose characteristics, depending on the drug, may resemble schizophrenia or mania. With the exception of alcohol, all these drugs are illegal. The most important ones for our purposes are marijuana, cocaine, amphetamine compounds (such as methamphetamine), phencyclidine (angel dust or PCP), and lysergic acid diethylamide (LSD). The latter belongs to a group of drugs called hallucinogens because of their ability to provoke hallucinations. Mushrooms of the psilocybin family also have this effect, by means of their metabolism in the body to the hallucinogenic compound psilocin. The other drugs, besides alcohol, can, in sufficient amounts, produce such reactions as well.
As we saw with the Richard Clark case, alcohol, the most readily available of these drugs, can create a vicious circle: the alcoholic mother possibly passed risk genes for alcoholism to her son and certainly exposed him to the (pathological) use of it. Then as he entered his adolescent years, he, too, became alcoholic-and prone to the same loss of inhibitions and self-control that are a regular part of the picture in chronic alcohol abuse. Alcohol's mechanism of action is to suppress the brain's serotonin activity, which ordinarily exerts inhibitory effects. Metaphorically, alcohol takes one's foot off the brake pedal, facilitating behaviors that one might otherwise have kept in check. Chronic abuse of alcohol can also lead to lasting damage of the higher cortical centers, leaving the brain even less able to weigh and measure the possible consequences of an intended action. In susceptible persons, alcohol may induce aggressive, including violent and murderous, behavior, via strong depletion of the brain's serotonin levels.38
Among the 145 serial killers in my study, alcohol abuse was a factor in 61 (42 percent), often serving to remove the last vestiges of self-restraint. This allowed them to do their bloody work without pangs of conscience. Here we can think of the alcohol as functioning as a kind of internal Lady Macbeth, goading her weak-willed husband to go ahead and murder Duncan. Macbeth, still worried about the consequences, asks, "If we should fail?" to which his wife responds: "We fail? But screw your courage to the sticking place, and we'll not fail."39 Before her words loosened his inhibitions, Macbeth reminded himself that his murderous plan could backfire and destroy him: "We still have judgment here, that we but teach bloody instructions, which being taught, return to plague th'inventor." 40
As for the illicit drugs, cocaine and methamphetamine have the effect of "hijacking the brain's reward centers, including a midbrain structure ... the nucleus accumbens."41 The end result is that the drug trumps other sources of pleasure (sex, food), such that the drug becomes the person's only source of pleasure. Thus rewired, the person may be
willing to do literally anything to recapture that intense pleasurable, orgasm-like experience. Under the influence of these drugs, a normally law-abiding person may commit murders-including murders that rise in the public's conscience to the level of evil. Persons who are already psychopathic and chronically disposed to break the law may be driven to serial murder. An example of a previously law-abiding person is Martha Ann Johnson.
Thrice married by age twenty-two, all her marriages were marked by violent quarrels. Her childhood had been marked by beatings, neglect, and poverty. While still in her teens, Martha had a daughter by the first husband; a son by the second; and a son and daughter by the third. The first two children she killed in the hope of bringing Earl Bowen, her third husband, back home after he had left-as though he would feel sorry for her over her "loss" (she staged the murders to appear as sudden infant death [SIDS] cases).42 Martha was sentenced to death in Georgia in 1990, though she was still in prison when I interviewed her in 2007. She had been abusing methamphetamine all during the years of her tumultuous marriages. On the Gradations scale, her acts place her in Category 5: traumatized, desperate persons without marked psychopathic features.
The Anatomy of Evil Page 35