Neurolaw: Taking the Stand on Mental Illness
Melissa Roybal and Salome Ambokadze
Illustrations by: Tori Kim
“All jurors this way!” As you walk down the courthouse hallway, your palms begin to sweat. You, Juror #4, sit down and get ready to hear opening arguments. The sound of the judge's gavel smashing against the podium grabs your attention. After running through a list of the defendant's charges, the judge asks the defense attorney how the defendant pleads. "Not guilty by reason of insanity." The defense attorney's words echo dully throughout the courtroom. “What does ‘guilty by insanity’ even mean? Am I cut out for this?” you wonder, as you begin to grasp what your civic duty truly entails. Let’s take a second to pause and explain what’s going on.
There are a couple of terms that you must understand before we proceed. In most jurisdictions in the United States, defendants have the right to plead not guilty by reason of insanity; this plea indicates that the defendant should not be considered culpable for their actions. The court must determine that the defendant did not fully understand the implications of their actions at the time the crime was committed [1, 2]. The defendant also must be declared “competent” to stand trial and receive the death penalty; in this case, being declared competent means that the defendent is capable of fully understanding the consequences of their actions at the time of the trial [1]. While these terms may seem foreign, putting them into context helps a potential juror understand how to proceed in the following scenarios. In the United States, it is all too common that people who are incompetent to stand trial are declared competent because of misunderstandings surrounding mental illness. Incorporating neuroscience research into the legal system will help people with mental disorders get the treatment that they require, rather than keeping them locked away in prison.
Considering that one day you might be called to be a juror in a case involving mental illness, we ask that you consider the cases of Scott Panetti, Judge Patrick Couwenberg, and Andrea Yates as if you were tasked with deciding their verdicts yourself. As we explain the case at hand, we ask you to make a judgement as a juror. After we explore the neurobiology at play, we ask that you reconsider your original verdict, deciding for yourself what role underlying neuroscience and abnormal psychology might play in the legal assessment of heinous crime.
Scott Panetti: The Man Who Subpoenaed Jesus
When remembering her son Scott Panetti’s childhood, his mother described him as “having something dreadfully wrong.” No one understood what Panetti was really experiencing until he was formally diagnosed with schizophrenia at the age of 20 [1]. Schizophrenia is a psychological disorder characterized by delusions that can interfere with daily life. Along with delusions, someone with schizophrenia may also experience hallucinations, an inability to focus, poor mood, and disorganized thinking. While there were attempts to treat Panetti’s illness, they proved ineffective and his condition worsened [1]. He was hospitalized on multiple occasions due to recurrent threats against his wife and her family [1]. On September 8, 1992, these threats unfortunately became reality. After dressing in camouflage, shaving his head, and gathering a variety of weapons, Panetti went to his in-laws’ house [1]. There, he killed his wife’s parents in front of his immediate family, and later confessed to the police [1].
After being declared competent to stand trial, Panetti fired his lawyers and decided to defend himself [1]. He tried to subpoena over 200 people, including John F. Kennedy and Jesus Christ [1]. During the trial, Panetti referred to himself in the third person and acted erratically [1]. Though his behavior was characteristic of someone who was presently detached from reality, the jury was highly offended and did not interpret Panetti’s actions as a clear sign of mental illness. Even though Panetti was unwell, the judge allowed the trial to proceed normally [1]. This decision reflects a great failure of the judicial system; though it was clear that Panetti was incapable of defending himself, the judge went forward with the prosecution.
Juror, provided with this account of the event, what verdict would you deliver Panetti? Take a second to think. Now, we will explain the neurobiological mechanisms of the illness at hand.
The exact neural correlates of schizophrenia remain a mystery. Different schizophrenic symptoms are defined into subcategories, and many of the symptoms Panetti exhibited would be considered “positive.” Positive symptoms refer to behaviors that “add” experiences or elements to a person’s typical functioning [3]. In schizophrenia, these behaviors typically include delusions, hallucinations, disordered and incoherent thinking, and an inability to correctly assess reality [3]. In Panetti’s case, his inability to assess reality (which resulted in his violent behavior), delusional belief that he could subpoena Jesus or J.F.K., and auditory and visual hallucinations are all examples of positive schizophrenia symptoms. But where do these symptoms come from?
Schizophrenia is thought to primarily affect the relationship between two parts of the brain: the prefrontal cortex and the mesolimbic area [4]. The prefrontal cortex controls decision making, planning, and personality, while the mesolimbic system regulates goal-directed behavior and our reward system [5]. The prefrontal cortex responds to cues, which in turn limits activity in the mesolimbic areas [4]. This process is termed feedback inhibition, and it works like a thermostat: when a room reaches the desired temperature, the thermostat turns off, and when a room drops below the set temperature, the thermostat turns on. Similarly, the brain uses feedback inhibition mechanisms to maintain “desired” functioning. Some researchers believe that this feedback regulation is impaired in schizophrenics, which would explain the relationship between the positive and negative symptoms in the disease’s progression. If scientists had been able to analyze Panetti’s brain, we believe that this dysfunctional feedback mechanism would be found, connecting his atypical behavior to a biological explanation, which may have altered the jury’s verdict.
Symptoms of schizophrenia are also thought to be affected by an excess of dopamine, the “reward neurotransmitter,” in the frontal lobe of the brain [4]. This neural region is responsible for advanced cognitive skills such as planning, abstract thinking, and decision making. But too much dopamine in the frontal lobe can cause hallucinations and delusions characteristic of schizophrenia [3, 4]. This effect can be mimicked by drugs that increase dopamine levels in the brain, such as L-DOPA, cocaine or amphetamine [4]. Scientists do not know why dopamine causes hallucinations and psychotic episodes. However, if we conducted an analysis of the dopamine in Panetti’s brain, we would expect to see greatly increased levels as compared to those of a neurotypical person’s brain.
Unfortunately, at the time of Panetti’s case, no neurobiological evidence was collected. Panetti’s jury found him guilty of capital murder in less than two hours, and he was sentenced to death shortly thereafter [1]. In judicial law, the defendant must also be declared competent for execution, just as they must be declared competent to stand trial [1]. While Panetti was originally declared competent for execution, the Supreme Court reversed the decision after years of debate [1]. Despite this reversal, Panetti remains on death row to this day [1].
Panetti’s case provides us with a drastic, but very important, example of how mental illness and its effects can be seriously misunderstood by judges and jurors in the legal system. Panetti is not at all representative of the entire schizophrenic population, and murder is clearly not a side effect of schizophrenia [5]. However, people with schizophrenia are disproportionately represented in the prison population. Schizophrenia affects less than 1% of the general population; but, the rate of similar serious disorders among prison populations is thought to be as high as 25% [7]. This statistic is alarming, especially considering the fact that most prison facilities cannot offer proper treatment to schizophrenic people. Medical facilities, on the other hand, do have the resources to provide pharmacotherapeutic and behavioral options to reduce violent behavior and recidivism, or the tendency for a convicted criminal to reoffend. The frequent interactions of schizophrenic people with the criminal justice system, as well as Panetti’s complicated trial, point to an urgent need to reform how the system understands and responds to mental illness. Reevaluating the criteria for institutionalization and educating jurors on the seriousness of mental illness could make our legal system far more just. As suggested by the alarming rate of individuals with schizophrenia and similar affective disorders in prisons, it is extremely important to make these neural mechanisms understood by the public. Doing so may completely change a jury's verdict and help more people with schizophrenia get the treatment that they need.
Judge Patrick Couwenberg: Unraveling a Complex Web of Lies
Patrick Couwenberg lived a life of great prestige and adventure. Before attending law school at the University of La Verne, he earned a Purple Heart for being struck by a debilitating barrage of shrapnel in Vietnam [8]. Not one to be tied down, the wounded Couwenberg soon began working as an undercover CIA agent, embarking on dangerous covert missions to Africa and Laos. Couwenberg’s credentials were clearly enough to impress California governor Pete Wilson, who granted him a judicial appointment in 1997. However, investigators quickly realized that Couwenberg's life story was completely fabricated [8]. In 2001, he was removed from office on the basis of generating self misrepresentations in order to become a judge, continuing to make false claims while in office, and deliberately lying to the commission during the course of its investigation [8]. A psychiatrist expert witness concluded that Couwenberg was suffering from pseudologia fantastica. Commonly known as “pathological lying,” this disorder is characterized by storytelling that extensively combines facts with fantasy [8].
Juror, what do you think? Should Couwenberg be jailed for lying, or is there enough evidence to declare him not guilty by reason of insanity?
Whether we care to admit it or not, we all lie. The average person lies as much as once or twice per day [9]. For many individuals, these lies are often minor and relatively inconsequential. However, for people with pseudologia fantastica, lying can become a debilitating mental condition. In fact, we can even trace the roots of pathological lying to specific brain regions and processes [10]. In order to understand Couwenberg’s case, let’s walk through what happens in the brain of a person with pseudologia fantastica.
Pathological liars have more white matter and less grey matter than the average person [11]. White matter acts as the information highway of the brain, bringing activating and inhibitory signals through criss-crossing neuronal “cables” called axons. These extend from the body of one neuron to another, and are the primary method by which neurons communicate. Grey matter makes up the functional lobes of the brain and consists of neuron cell bodies. These structures receive and transmit commands through axons to relevant parts of the body. For example, if you pick up a particularly hot coffee cup, cell bodies in your grey matter will send signals to the hand through white matter so you don’t burn yourself. There are two possible explanations for the excess white matter in the brains of pathological liars: white matter either facilitates verbal processing, or slows down decision-making. Both of these processes could result in the propensity towards deception. In the case of the first hypothesis, excess white matter helps facilitate information processing during deception, which makes sense in the context of increased white matter being associated with superior verbal abilities [11]. In other words, increased white matter allows for these individuals to craft a logical narrative and then believably convey it. Alternatively, an increased volume of prefrontal white matter might prevent the inhibition of neural transmission, halting rational and sensible decision making [11]. Without proper and efficient systems of rational decision making, people may find it easier to lie [11]. However, other processes may also contribute to pseudologia fantastica.
Even minute changes in neural activity can alter deceptive responses, and may help explain the mechanisms at play in pseudologia fantastica [11]. By intentionally inhibiting the prefrontal cortex, scientists have observed a breakdown in reflective thought and guilt [11]. Think back to a time when you were caught lying. Maybe you stole a cookie from the cookie jar and had time to enjoy it in peace. When your parents eventually asked where the cookie went, you thought about how delicious it was, felt no remorse, and promptly created a lie to avoid punishment. This process, which dulls an individual’s sense of morality, is similar to what occurs when prefrontal cortex activity is inhibited. This alteration of neuronal activity facilitates deceptive behavior by bypassing the guilt response, which helps create a lie [11]. Importantly, the act of pathological lying may not be intentional. Impeding morality prevents individuals from recognizing when their actions are harmful to others or themselves.
With all that being said, Juror #4, what’s your decision?
Even though Judge Couwenberg repeatedly gave false testimony under oath, the jurors did not believe that he had any mental condition that excused or mitigated his actions [8]. A three-judge panel reported that the presentation of a symptom such as lying, without any underlying mental disorder diagnosis, is of little legal consequence [8]. While it might be possible to argue that Couwenberg’s lying was uncontrollable, it is unrealistic to expect pathological lying to meet the criteria of insanity in most jurisdictions. Since uncontrollable pathological lying often coexists with ordinary lies for self-benefit, it becomes difficult to differentiate between the two [8]. However, Couwenberg’s case sheds light on the underlying neurobiological dysfunctions associated with pathological lying, which may be more common than you would expect.
Andrea Yates: A Tragic Story of Postpartum Illness
Andrea Yates and her husband were very successful; she was a nurse and he worked for NASA [1]. The couple had five children [1]. However, after the birth of their fourth child, things took a turn for the worse. When Yates attempted suicide and was admitted to a mental hospital, she continued to display suicidal tendencies [1]. Doctors diagnosed Yates with postpartum depression (PPD) with psychosis [1]. In 2000, against doctors’ recommendations, Yates and her husband had their fifth child, Mary [1]. After Mary’s birth, Yates began to show postpartum symptoms again, engaging in self mutilation, child neglect, compulsive biblical study, and falling into catatonic (i.e. rigid body) states [1]. On June 20, 2001, Yates drowned all five of her children while her husband was at work [1]. Yates immediately called the police to confess, explaining that she had done it because she believed that she needed to be punished for being a bad mother [1].
Juror, what would be your verdict?
Yates’s story is an especially intense and heart wrenching one. For readers, it may be difficult to empathize with this mentally ill mother or come to terms with what occurred. The severity of Yates’s postpartum depression is unusual and her actions are not at all representative of all mothers who suffer from postpartum illness [13]. But, to understand what led Yates to commit these murders, let’s explain what may have brought her to this disturbing decision from a neurological lens.
First, let’s consider the major role that hormones play in postpartum disorders. Hormones are chemical messengers that foster communication between the brain and the body; they can also be used to identify certain dysfunctions. Hormones are constantly released to convey all types of messages to the body, like “your stomach is full,” “pump blood faster,” or “it's nighttime, so it's time to get sleepy.” Oxytocin, a hormone associated with attachment and parent-child bonding, may contribute directly to the onset and severity of postpartum depression symptoms. The most affectionate and responsive parents typically have high oxytocin levels [13]. Conversely, low levels of maternal oxytocin are associated with a greater severity of PPD symptoms [14]. Since oxytocin increases maternal responsiveness to a child's crying, low oxytocin levels caused by PPD can hurt the relationship between mother and infant. [16]. Mothers with depression are less likely to engage in face-to-face interactions with their children, such as talking to them, touching them, or smiling [16]. Therefore, the mother may fail to connect with her children, as seen in cases like Yates’s. While oxytocin levels are not responsible for Yates’s behavior, hormone observation may be useful in identifying and treating postpartum disorders.
Oxytocin is not the only biological messenger implicated in the development of postpartum depression. Women with PPD also show increased levels of glutamate in their medial prefrontal cortices [17]. Glutamate is an excitatory neurotransmitter in the brain that activates other surrounding cells, while the medial prefrontal cortex is a brain region responsible for decision making [17]. Increased neural activation caused by excess glutamate may have caused Yates to suffer from severe auditory hallucinations [1]. Some pharmaceuticals have been developed to block glutamate from communicating with other neurons, which improves hallucinatory symptoms in schizophrenic patients; perhaps the same treatment could be used for those with postpartum psychosis [18]. This connection between postpartum psychosis and glutamate may help jurors understand the mechanisms behind Yates’s actions.
While chemical signals are certainly implicated in postpartum depression and psychosis, the physiological anatomy of the brain contributes to this dysfunction as well. In other words, significant physical changes occur in the brains of postpartum depression patients. These changes include disrupted connectivity and reduced activity in both the anterior cingulate cortex and the amygdala [18]. To break it down, the anterior cingulate cortex is involved with empathy, impulse control, emotion, and decision making, while the amygdala is involved with processing fear and emotions. These characteristics relate to how Yates connected with her children, and how irrational fear led her to make an impulsive and dangerous decision [18]. More research is needed on the circuitry of postpartum disorders, but looking at different sections of the brain can help us see that Yates’s actions were not based on her ability to be a good mother, but on imbalances in the brain that resulted in tragic consequences.
All that being said, Juror #4, does this information sway your decision?
The state of Texas charged Yates with five counts of capital murder. During her trial, Yates explained that she wanted to be found guilty and sentenced to death so that she could kill Satan [1]. Despite being in a delusional state, she was tried in a court of law. Fortunately, experts agreed that she met the legal criteria for insanity; four psychiatrists testified that Yates did not know right from wrong when she committed the crime, and the jury ultimately found her “not guilty” [1]. After the trial, Yates was committed to a psychiatric facility indefinitely [1].
Postpartum depression and psychosis are extremely complex disorders that can have drastic implications. While cases of postpartum depression as severe as Yates’s are rare, researchers have found that up to 41% of depressed mothers have had thoughts of harming their children [19]. Yates’s case still leaves us with more questions. Consider the postpartum nature of the disease; does this signify that the symptoms will eventually subside? Medical data has been unable to determine an average duration of PPD, but some women report PPD symptoms as long as five years after giving birth [20]. If there are no lasting symptoms, should patients like Yates remain in mental health institutions or prisons? While we cannot answer these questions, we encourage readers to ponder them and consider the importance of postpartum research and advocacy.
The Final Verdict
By presenting readers with a variety of legal cases, we provide thought experiments that illustrate the importance of neurolaw and why it should continue to be developed as a field. We hope that you will continue to think about the cases we have presented, attempt to answer the questions we have posed, and spread awareness about the issues we have raised. While we are not experts, we would like to propose some possible improvements to the judicial system so that mental health may be adequately taken into consideration. First, educating jurors and judges is essential in trials concerning mentally ill individuals. Panetti’s story, in particular, makes it apparent that the jurors and the judges involved were uneducated about the severity to which mental illness can impact one’s control over, or understanding of, their own actions. Similarly, those who decide the futures of mentally ill defendants must also be aware of how integration into the prison system can be especially harmful for mentally ill people, in a far different way than neurotypical people [21]. Second, mental health experts and social workers should be the primary figures interacting with mentally ill individuals on trial. If police officers must be involved, they should be educated about how to properly respond to those affected by mental illness. In closing, we want to reiterate that these very rare cases are not representative of all people diagnosed with the mental illnesses being discussed. We hope readers will leave with an understanding that the only things separating Panetti, Couwenberg and Yates from us might be a few chemical imbalances and morphological changes in the brain, over which they have no control. Behind shocking and sometimes highly sensationalized cases such as these, there are real people that need help. With a little bit of explanation, the average juror can begin to understand these complex disorders.
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