Dealing with mentally ill citizens on patrol, Part 4
|Part 4 of 4: Mental retardation and organic brain syndromes |
By Dr. Laurence Miller
Previously, we’ve discussed patrol strategies for responding to a wide range of mentally ill citizens. In this final installment of our 4-part series, we’ll deal with syndromes that relate specifically to disorders of the central nervous system. Even though these disorders are “organic,” there is much that patrol officers can do to resolve potential crises involving these individuals.
Mentally retarded subjects
The formal definition of mental retardation is a psychometrically measured IQ below 70. However, there are probably millions of citizens leading productive, satisfying lives with IQs at, or even lower than, that number. More functionally, if a person’s intellectual deficiency interferes with his or her ability to fulfill the normal adult roles and responsibilities of daily life, he or she may be classified as mentally retarded, even without a formal IQ score. Although mental retardation is not a mental illness per se, it may be associated with other kinds of mental disorder, so it is possible to see mood disorders, anxiety disorders, or psychotic disorders coexisting with intellectual deficiency.
Mentally retarded subjects may become involved in the criminal justice system in a number of ways. Their often childlike impulsivity may make them prone to misdemeanor crimes, such as shoplifting or public nuisance. When confused or frightened, they may easily become silent and withdrawn or defensively violent. They are also hardly immune to alcohol and drug abuse, and this may make their behavior even more unpredictable. Ordinarily, they tend to be quite compliant and trusting, and thereby make perfect patsies for other criminals to use as drug couriers or stashers of stolen goods. In criminal trials, mental retardation may be raised as a competency issue or as an exculpatory or mitigating factor; nevertheless, mentally retarded offenders comprise about 5-10% of the convicted prison population.
Identifying and dealing with mentally retarded citizens
Most of the mentally retarded citizens that officers encounter on their street patrols will not be found in the course of committing a crime, but are more likely to be lost and confused. In most cases, a brief conversation will be sufficient to determine that something is not right about this person. Pay attention to missing, excessive, or disheveled clothing or other unusual style of dress. There may be peculiarities in the subject’s gait and movement, as many mentally retarded individuals also have mild-moderate disturbances in motor coordination. The subject’s speech may have a simplistic, childlike quality, it may be characterized by various speech disorders, such as lisps, stutters or variations of volume and pitch, or it may sound relatively normal. When confronted by authorities, such as the police, these subjects are likely to become afraid or confused, or to be overcompliant and dependent.
If it is unclear as to whether the subject is mentally retarded or suffering from some other form of disorder, officers can utilize a few simple curbside tests of cognitive and intellectual functioning. Can the subject identify their name and residence? Can they give coherent directions to where they live or where they’re going? Can they repeat a question in their own words? Can they write their names clearly? Can they recognize coins and make change? Tell time? Use a telephone?
When questioning subjects who may be mentally retarded, keep it simple. Begin with open-ended questions, rather than yes-or-no queries because mentally retarded subjects tend to be overcompliant; they will often answer a question based on what they believe will please the questioner, especially an authority figure like a police officer. However, questions that are not understood are likely to be repeated back to you. In such cases, if necessary, reduce questions to a yes or no. For example:
Officer: Where do you live?”
Subject: Where do I live? Where do I live? In the home.
O: Where’s the home?
S: The home? The home? I dunno, I live in the home. By the school.
O: Is the school in the same building as the home?
S: No, across the street.
O: Do you know which street?”
This may sound frustrating; however, you’re already getting some information that may enable you to track down where this subject resides. For example, how many group homes across the street from a special school can there be in your municipality? Also, don’t overlook the obvious, such as asking for ID or seeing if the subject has some identifying information on his or her person.
If you come across the scene of a crime or other disturbance involving a mentally retarded subject and other people, it may not be immediately clear who is the suspect, victim, witnesses, or bystanders. The mentally retarded subject may be intimidated and be silent while the others do the talking and make their own cases. Be careful to question everyone present very carefully, and document these interviews. If you must arrest the mentally retarded subject, ensure that Miranda rights are understood, for example, ask the suspect to rephrase them in his own words. This might not always be possible. If a mentally retarded suspect has to be criminally detained, all care should be taken not to house him with the general population, where he may be abused. Of course, this will depend on the realities of the situation and available facilities.
Attention Deficit Hyperactivity Disorder (ADHD)
A lifelong difficulty in focusing and sustaining attention on tasks and goals, a tendency toward impulsive action, poor tolerance of frustration, heightened emotional reactivity, a desire for immediate gratification, and poor planning, judgment, and anticipation of consequences are traits that characterize children, adolescents, and adults with attention deficit hyperactivity disorder, or ADHD. To complicate matters, ADHD is typically comorbid with other syndromes, such as conduct disorder, antisocial personality disorder, mood disorders, learning disabilities, and substance abuse, which makes overall adjustment to school and work extremely problematic for these individuals. It is not surprising, then, that many of them become involved in the criminal justice system; in fact, in one study, approximately half of ADHD subjects evaluated in clinics were later identified by law enforcement as delinquents.
Involvement in the criminal justice system may occur in two ways. ADHD subjects may commit crimes such as shoplifting, theft, robbery, assault, drug-related offenses, and traffic violations due to their impulsivity and heightened emotional reactivity. Alternatively, their desire to be liked and accepted, and often poor judgment of social cues, may make them easy chumps for set-ups by other criminals. Indeed, far more ADHD subjects are probably victims of crime than its perpetrators. It is generally believed that for a true criminal career path to develop, ADHD must be combined with conduct disorder that progresses to antisocial personality disorder in adulthood (see Part 3 of this series).
Dealing with the ADHD citizen
ADHD subjects may irritate officers who are trying to question them because they appear distracted and preoccupies and therefore may seem to be disregarding what the officer is saying. This is probably an expression of their difficulty focusing on what’s being said; after all, the hallmark of this syndrome is impaired ability to pay attention. Keep your questions and statements clear, simple, and direct, and repeat as often as necessary. Use calming techniques to deal with the subject’s agitation and emotional outbursts. ADHD subjects may have difficulty with verbal expression, so make use of clear questioning and paraphrasing. They also tend to have poor memories, so what seems to be evasiveness to your questions may actually represent a true problem with remembering what you said or recalling what actually happened. Their sense of both time and direction may also be impaired, so they may have trouble accounting for their whereabouts.
Emotionally, ADHD subjects may have difficulties in two areas. Their need for stimulation may cause them to get bored very easily, in which case they may start to “yes-yes” you just to get the interview over with. At the same time, their poor frustration tolerance may cause them to fly off the handle if they perceive something you do or say as annoying or threatening. All of these problems are exacerbated by increasing fatigue. If your goal is to get as much cooperation and useful information as possible, schedule sufficient breaks in the interview to allow the subject to “recharge his batteries.” Also be alert for coexisting intoxication.
The term dementia refers to an organic brain syndrome that impairs perception, thinking, language, memory, and behavior. As the American population continues to age, police officers can expect to have to deal with an increasing number of such individuals in their daily patrols. The main causes of dementia in the elderly are Alzheimer disease, Parkinson’s disease, and stroke. In younger persons, dementia may occur as the result of AIDS, concussive brain injury, toxic-metabolic and medical syndromes such as kidney or liver disease, or from heavy drug use or overdose.
The difficulty an officer will have in dealing with an organically demented subject is largely determined by how severe the disorder is. Mildly impaired subjects may seem only a bit befuddled and absentminded, while more seriously demented subjects will be unable to communicate or understand you, and will be virtually oblivious to their surroundings, may aimlessly wander, and may become fearful and combative if confined or restrained.
Symptoms of dementia in include disorientation to time (“What day is this? What year are we in?”), place (“What street are we on? Do you know what city we’re in? Where do you live?”), and person (“What’s your name?”). Aphasia is a disturbance of language and can involve the comprehension of speech, the production of speech, or both. Aprosodia is a flattening of the emotional expressiveness of speech. Agnosia is impaired perceptual recognition, and apraxia is a disturbance of complex movement. Other signs and symptoms of dementia include general agitation and sundowing, which is a tendency to become more active and agitated at night. This makes it more likely that these individuals will wander out of their homes at night, especially since the rest of the family may be asleep.
Typically, the behavior of subjects with dementia will be relatively peaceful, albeit confused; however, they may become defensively combative if they feel threatened. Most cases of law enforcement contact with these individuals will involve trespassing, where they simply wander onto private property; theft or shoplifting, where they pick up a store item because they think it’s theirs or just because it’s there; assault related to defensively lashing out when they feel threatened, such as when confronted by an irate shopkeeper; or more rarely, sexual offenses based on inappropriate comments or physical contact with others.
Handling citizens with Dementia
As with mental retardation, don’t overlook the obvious – check for ID. Most nursing home residents have wrist bands. Assess if there is any medical need. Even if not ill or injured, many such subjects may be malnourished or dehydrated because they literally forget to eat or drink. In your interactions with the subject, assess for specific signs or symptoms such as perceptual disturbances, difficulty completing sequences of actions, or language difficulties. If the subject is confused, frightened and agitated, use very basic calming techniques, such as slow even pace of voice, easy body language, and short, simple, reassuring phrases (“It’s okay, we’re going to take you home”). Most of these subjects will be reassured more by the demeanor and tone of what you say than by the content.
Be gently directive – tell and show the subject what you want him to do; most cognitively impaired subjects will display an easy, childlike compliance as they don’t feel threatened. If you can identify where the subject resides, call the facility and offer to transport him or her back there. If not, or if there appears to be any injury or other medical problem, call for paramedic backup or transport to a hospital.
Like dementia, epilepsy is actually a medical-neurological disorder, not a psychiatric disorder per se, and most seizures are fairly unmistakable while they are occurring. However, there are a number of seizure types that produce disturbances primarily in thought, consciousness, and complex behavior; these may not be readily identifiable as manifestation of a medical disorder. In addition, epilepsy may be comorbid with a variety of other medical and mental disorders, including substance abuse, which can exacerbate it.
Epilepsy: Seizure syndrome types
Epileptic seizures are classified into several main subtypes. Grand mal seizures conform to most people’s conceptualization of a seizure: an abrupt whole-body spasm that causes the subject to lose consciousness and fall to the ground, followed by several seconds of whole-body muscular contractions that gradually abate and leave the subject mentally confused and physically exhausted when he regains consciousness. Focal seizures involve only a portion of the body or one side of the body, usually the arm or leg, and are characterized by a few seconds of rapid, involuntary, stereotyped contractions, for which the subject typically remains conscious. In petit mal seizures, more common in children, there is a very brief loss of consciousness for perhaps a few seconds, but no significant disturbance of posture or muscle tone: the individual may be observed to “blink out” for a brief spell. The subject may experience anywhere from a few to several hundred such spells in the course of the day, which can disrupt the continuity of perception, learning, and memory.
The type of epilepsy most often associated with behavioral disturbances leading to trouble with the law is psychomotor epilepsy, also known as temporal lobe epilepsy, or TLE, because the electrophysiological disturbance most commonly originates from the brain’s temporal lobes which contain parts of the limbic system, a region associated with emotion, motivation, and memory. During a temporal lobe seizure, awareness of the person’s surroundings may be severely disturbed, and his behavior may or may not appear to be under his control. The seizure has an abrupt onset and gradual recovery, and can last for several minutes.
Subjects describe all manner of sensory, perceptual, cognitive, and emotional alterations heralding the onset of a TLE seizure, ranging from shapes and colors; strange sounds; sudden fear, sadness, or elation; sudden memories from the past; feelings of great profundity and mystical clarity; religious visions and voices; stomach flutters and other physical sensations. A common TLE experience is deja vu, or false familiarity, the feeling that “I’ve been here before.” A dreamy, partial-consciousness state of disorientation often prevails during the seizure, during which the subject may be nonresponsive or only minimally responsive to others’ questioning or commands. After the seizure passes, the subject may have spotty recall or no memory at all for the event.
The TLE symptoms most likely to get the subject in trouble are collectivedly known as automatisms, which are stereotyped, repetitive actions that, in themselves, are normal in the proper contexts, but occur during the seizure in an inappropriate form or circumstance. These include wandering around; dressing and undressing; sexual and bathroom behavior; picking up and carrying off objects; and approaching others with short, repeated vocalizations. One of my patients had several arrests for indecent exposure for taking off his clothes and walking around a supermarket and up and down the street. Another patient was arrested for gathering up objects in a barbershop while waiting for a haircut.
In between seizures, many TLE patients display what clinicians call an interictal TLE personality, with a characteristic set of symptoms, including emotional intensity; interpersonal clinginess (viscosity); obsessive-compulsive preoccupations and behavior; excessive writing and note-taking (hypergraphia); and sometimes bizarre sexual interests (fetishisms). It is thought that this personality style develops from the frequent and repeated abnormal excitation of the brain’s temporal lobe limbic system by frequent TLE seizures in childhood and adolescence.
Finally, patients with TLE and other forms of epilepsy are likely to be treated with antiseizure medications, many of which have strong sedating, disinhibiting, and cognitively confusing effects of their own. Unsupervised patients can miss doses or take overdoses because of memory problems, or may simply choose to misuse their medication if these are not controlled by a responsible third party.
Epilepsy and violence
There has been a longstanding debate about the relationship of epilepsy in general, and TLE in particular, to violent behavior. It is now generally agreed that, like organic conditions generally, most aggressive activity in TLE is related to defensiveness out of a feeling of fear or to combativeness upon being restrained while in a state of confusion.
In a rare condition called episodic dyscontrol syndrome (EDS), or intermittent explosive disorder (IED), more severe aggressive behavior can appear as a sudden, often unprovoked, “storm-like” outburst, primitive and poorly organized – flailing, spitting, scratching, punching, throwing – and usually directed at the nearest available person or object. The act itself can be quite destructive to furniture, pets, or people who happen to get in the way, but serious injury to bystanders is usually the result of misguided efforts by observers to subdue the subject during an episode. In such cases, the wild thrashing that inflicts the injurious blows probably represents a desperate attempt to escape restraint, rather than a directed assault against a particular individual – although sudden, directed, but usually unsustained, attacks may occur.
More complex, better-organized outbursts are typically short-lived and may be followed by feelings of regret and remorse when the individual becomes aware of what he has done. Murder carried out in such states may be characterized by “overkill,” such as an assailant beating or stabbing his victim dozens or hundreds of times, often in what witnesses describe as a “frenzy.” Such uncontrolled violence is likely to be further fueled by alcohol or drugs. Indeed, EDS can often be triggered by even small amounts of these substances, producing the syndrome of pathological intoxication, which is characterized by uncontrolled violence following seemingly trivial drug or alcohol ingestion (see also above). Although these violent behavioral states have been shown to be associated with distinct electrophysiological brain changes, it is still unclear whether they represent true seizures per se.
Planned, purposeful homicide is almost never a seizure phenomenon, because it requires complex preparation and action sequences that are beyond the mental capability and time frame of a TLE seizure. Even in the case of sudden, impulsive violence, remember that many people simply fly into a rage and commit murder without any particular “brain syndrome” being the cause. Indeed, the medicolegal status of these neurobehavioral syndromes is still being debated, and having any type of medical or mental disorder is not necessarily exculpatory to the commission of a crime.
Handling citizens with Temporal Lobe Epilepsy
As always, safety first – and this applies both to the officer and the citizen. Check for a medical ID bracelet or other identification. Also check for medication containers that may yield clues to what illness is being treated. If this is a true TLE seizure, it will pass in a few minutes. In the meantime, use the minimum amount of restraint necessary to prevent the subject from injuring himself or others. Don’t waste time trying to talk the subject down; it’s unlikely he will comprehend complex verbal interventions – if he hears you at all. Instead, try the “herding” technique: simply stand a few feet in front of, or off to the side of, the subject and gently direct him in the direction you want to go, using slow, easy body language and gestures. Simple, direct instructions may work with some subjects: “This way, it’s okay.” Try not rush or crowd the subject; remember that cases of violence during TLE episodes almost always occur when the subject feels confined or threatened. When the seizure passes, determine if medical treatment is necessary. When in doubt, call for paramedic backup.
Other brain syndromes
Although much rarer, a number of other neurobehavioral syndromes may be encountered during patrol.
Narcolepsy is an organic sleep disorder characterized by poor nighttime sleep and excessive daytime sleepiness. The subject typically experiences vivid, dreamlike hallucinations that occur just when he or she is falling asleep (hypnogogic hallucinations) or waking up (hypnopompic hallucinations), and are associated with sleep paralysis, the transient inability to move while experiencing these “waking dreams.” During the day, the subject may experience sleep attacks, causing him or her to abruptly fall asleep in the middle of whatever he or she is currently doing. These attacks may be associated with cataplexy, which is a sudden loss of muscle tone that causes the subject to abruptly collapse and fall. These episodes can be triggered either by boredom or, conversely, by sudden strong emotion.
A likely scenario for patrol policing involves a driver who becomes excessively drowsy at the wheel and acts like he’s intoxicated, weaving all over the road. When apprehended by police, he becomes frightened and promptly passes out. Of course, true intoxication and many kinds of medical conditions, from a stroke to a diabetic coma, can cause a person to pass out, but in narcolepsy the person will usually awaken after a few minutes with little or no residual symptoms. The most important thing an officer can do in such circumstances is to assure the subject’s safety and call for medical attention.
Beginning in childhood, Tourette syndrome (TS) is characterized by the progressive development of multiple tics, which are rapid, involuntary, coordinated spasms of small muscle groups. Most TS tics are of the motor variety, in which case the subject may appear characteristically “twitchy.” A number of TS patients have vocal tics, which usually consist of throat-clearing, grunts, single syllables, or other simple vocalizations. A smaller proportion of TS patients suffer from coprolalia, in which they utter various kinds of foul language, typically involving sexual or racial epithets, probably because most of these words contain hard consonants emitted with explosive breath – the vocal equivalent of a motor tic. Not surprisingly, these subjects may get into big trouble if they are heard to be uttering “fuck,” “spic,” or “cunt” in a public place.
Of course, people curse each other out for any number of reasons, and most don’t have a brain syndrome. Although an officer needn’t make a formal diagnosis, note if the subject seems to be in control of his utterances, and whether the verbal curses occur in the context of overall twitchy, agitated behavior. Usually, in addition to coprolalia, TS subjects will manifest a number of other vocal and motor tics. If this seems to be the case, and no real harm has been done, escort the subject to a location where his involuntarily obnoxious verbiage is less likely to get him into trouble.
Traumatic brain injury and concussion
Individuals who have suffered a blow to the head may suffer temporary or permanent brain damage producing a postconcussion syndrome. Physical symptoms include headache, dizziness, disturbance of equilibrium and hypersensitivity to light and sound. Cognitive symptoms include attention and concentration, poor short-term memory and, in severe cases, general disorientation and confusion. Emotional-behavioral symptoms include increased irritability and anger, poor frustration tolerance, lack of good judgment, and impulsivity.
The most likely setting for a police officer’s interaction with a brain-injured subject is at the scene of an assault or accident, immediately following the injury. The subject may have difficulty answering the officer’s questions and giving a coherent account of what happened. If the subject was unconscious for any length of time, he will have trouble remembering events when he regains consciousness (anterograde amnesia), as well as for several seconds, minutes, or hours prior to the actual impact, as those memories had not had sufficient time to be consolidated to long-term storage prior to the injurious blow (retrograde amnesia). Some subjects even show a lucid interval, where they will appear relatively normal right after the accident or assault, even give a reasonably coherent account of events, then seem to slip into unconsciousness, from which they emerge with no recollection at all of the preceding interaction with the officer.
Occasionally, officers may encounter subjects with past head injuries who are still showing residual postconcussion effects. These individuals may seem confused and disoriented and may be mistaken for being intoxicated. Or they may well be intoxicated in addition to having a brain injury, in which case the effects exacerbate each other. Treat these subjects as you would any cognitively-impaired citizen: utilize safety precautions, assess for medical need, apply verbal de-escalation strategies, and take appropriate action if necessary.
As I stated in Part 1 of this 4-part series, police officers are already “practical psychologists” because you intuitively understand and utilize much of the information discussed in this series. Hopefully, what I’ve done is provide a little more diagnostic clarity and practical guidance that will make your work with all citizens safer and more effective.
To learn more about these topics:
Disclaimer: This article is for educational purposes only and is not intended to provide specific clinical or legal advice.
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