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negligently. The former two aspects were previously called “specific intent” and the last two “general intent.”
The highest culpability standard is purposely, which means that the person’s conscious object is to engage in such conduct or cause such a result. The second highest is knowingly, that is, the person acts with the awareness of the nature of the conduct or is practically certain that the conduct will cause that result. Recklessly means that, concerning the result of the action, the person consciously disregards a substantial and unjustifiable risk. The disregard of the risk must represent a gross deviation of the standard of conduct that a reasonable person would observe in the actor’s situation. Finally, gross negligence refers to the failure to perceive a substan- tial and unjustifiable risk that the result will occur or that the circumstance exists.
The Insanity Defense Reform Act of 1984, enacted by Congress in 1984 in response to the verdict in the Hinckley trial and codified at Title 18, US Code, Section 17, states that a person accused of a crime can be judged not guilty by rea- son of insanity if “the defendant, as a result of a severe mental disease or defect, was unable to appreciate the nature and quality or the wrongfulness of his act(s).” Under these circumstances, the defendant is declared “not guilty by reason of insanity (NGRI).” Insanity is an affirmative defense and has to be proven by the defendant.
In some jurisdictions, a second prong (volitional) is added, reading: “and/or must not be able to conform his/her conduct to the requirements of the law.”
Case 10a: Assault by a Schizophrenic
In October 2001, Mr. May was brought to a hospital’s emergency room because he had, for no apparent reason, “gone berserk” and attacked a nurse. He was immedi- ately arrested and charged with aggravated assault. Several documents were reviewed, including police statements and hospital and outpatient psychiatric records, prior to examining Mr. May to decide whether or not he was insane at the time of the criminal act.
Mr. May was taken from a city bus for acting strangely, saying the lights on the bus were flickering in a pattern, telling him that there was a bomb on the bus and how to dismantle it. He also is reported to have said that he made a computer when he was 6 years old and was the CEO of multimedia, but could not give the location of his office. Mr. May had not paid the bus fare. He was hospitalized at around 8:00AM. He was “confused, talking nonsense, and seeing something on the wall.”
The medical documents further noted, “Patient not taking medication… refuses labs… diagnostic impression: Psychotic episode.” His responses to questions were inappropriate: “I’m from the ranch in Texas, President Bush’s.” He then began swaying back and forth, staring at the ceiling. He was behaving very aggressively and refused to give consent for hospital treatment. Mr. May was also accusatory, demanding, and fluttering his eyes constantly. At 9:10 AM, he leaped out of a hos- pital bed and attacked a nurse who was going to “check him prior to evaluation.” He was placed in four-point leather restraints (wrists and ankles). Later he explained that the reason for attacking the nurse was because, “She’s part of the plot to end the
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world.” Further investigation led to Osama Bin Laden paraphernalia plastered all over his disheveled apartment.
Later that night Mr. May became calm and cooperative, denying any feelings of agitation. “He cannot remember anything about the assault. Patient is too psychotic to discuss Consent to Inform Family…he is unable to sign form.” The next morning, although still in restraints, he was reading and eating normally. His brother said there was no history of violence or medication. His father explained that he paid for his living arrangements, to keep him off the streets because he did not have a steady job. He was never reportedly in treatment.
His insight and judgment were severely impaired. With a GAF of 30, he described
“9/11” as a stressor. A few days after the assault, he was admitted to a psychiatric hospital, where he was unkempt and behaved in a very guarded and belligerent man- ner. His speech was monotonous; his mood was agitated and labile. He said that people were laughing at him and was found to have delusions of persecution and grandeur. His thinking was often disorganized, and he was not oriented to time. His attention, concentration, insight, and judgment were poor.
Mr. May was eventually transferred to a forensic unit for further care. He was given medications, and his mental state cleared. As he became more cooperative, he admitted to hearing voices from the devil telling him to join “the cult.” He devel- oped a greater insight and was able to recognize he had a mental problem. He became compliant. He soon was no longer hallucinating or delusional and was able to think logically. Mr. May was cleared for discharge with a diagnosis of schizoaf- fective disorder. He was required to stay on medication and follow up with a psychiatrist.
Later, Mr. May attended an outpatient treatment. The psychiatrist mentioned that
“9/11” affected Mr. May, causing him to become seriously preoccupied with terror- ists. He believed the nurse treating him in the hospital was a terrorist, and as a result, he tried to kill her. At that time, his insight was marginal and his judgment was defective. The psychiatrist diagnosed him with schizophrenia, paranoid type.
He was interviewed again a few months later, and although he “seems to be in good shape,” according to the report, with a normal rate of speech and better hygiene, the diagnosis remained the same.
Mr. May showed up promptly to the examination with me. In his late 30s, he had been on psychiatric disability for 9 months. He provided identifying information and current psychiatric medications, which included risperidone (antipsychotic) and Colace (stool softener).
Mr. May said, as he was recounting to me the events of the day of the assault, that on the bus, he had thought there was a bomb, and the only way to disable it was to watch the lights on the bus. “It made perfect sense back then… now it seems per- fectly foolish.” When the police came on the bus to arrest him, he claimed to feel relieved and did not resist. He could not recall if the bus incident happened before or after the hospital. To him, the hospital he was taken to “looked like ground zero…
there were jackhammers… in the street. The noise did not stop bothering me.”
In the hospital Mr. May claimed to have seen “a man with a beard” who reminded him of a terrorist, “the enemy.” He added, “I was tapping my feet and watching the
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lights, as if it were a game of chess… I was looking for black and white players on a chessboard… I didn’t know what they were doing to me.” He said he was afraid of the “man with a beard,” yet cooperative at the same time, providing identifying information. “They were moving me from room to room, again according to the game of chess, and according to the lights… she (the nurse) came in and tapped my arm as if to put in an IV. She was in and out, again according to the rules of chess. I heard people asking my name, then quacking like ducks, gibberish… I thought she was going to poison me… that was when I hit her… a voice told me to punch… I was afraid of the man with a beard. I had to do it to protect me, it was all part of a game of chess… they kept moving me from room to room, it was a game of chess…
the jackhammers in the street… four men restrained me.”
He went on to describe how he was “tortured.” He was asked for a urine sample, but he did not produce any, so “they passed a hot wire in me… twisting… it was the most painful thing I’ve ever had in life… so painful I fell unconscious… I then woke up in a psychiatric hospital… the chess game was over, no more light, no more duck-quacking. I was clearer, no more restraints… I was taking pills.”
In the psychiatric hospital, he said he felt imprisoned, scared, and uncomfort- able. Slowly he realized that people wanted to help him. He did not know why he assaulted the nurse, for he said he had never assaulted anyone before. “I am a very passive man,” he added as he handed me a letter from his father describing dates they could remember about his past psychiatric involvement. In 1996, he was diag- nosed with “bipolar/schizophrenia”, but was not told to seek further counseling. The same happened again in 1999. A few times after that, he went to some sessions at a center, with some help, but interrupted it.
Mr. May described how 6 years ago he was living in California when his car was stolen. He had problems with his job and lost his apartment; he left for the east coast and asked his brother for support. He thought he only needed financial help, not psychiatric help.
He reported having a “good childhood” and rich in experiences and ambition. He claimed to be a very good magician in his youth, but now magic made him nervous.
He said that he had a stable and productive family whom he related well with. “At 8 years old I had a ‘Compu-kit’. The lights blinked according to the way the wires were connected… I can see now how the mind can play tricks on you.”
Before “9/11” he lost his job as a telemarketer. He was studying the Internet since “9/11,” decoding and sending messages to people. He felt distanced from his family and stressed out. He watched the towers collapse and felt very upset that people would do that. “I was frantically decoding messages and sending them everywhere.”
He added that currently, his sleep and appetite were normal and felt comfortable attending psychiatric treatment. Mr. May’s affect was mildly constricted and intense, appropriate to the situation and ideation. His mood, speech, and judgment were unremarkable. There was no formal thought disorder elicited. He denied cur- rent hallucinations and delusions of any type. He denied current or past suicidal ideations. He was oriented to time, person, and place. His ability to recall clearly the events surrounding his assault on the nurse was limited due to the
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psychological turmoil he had been under. Otherwise his memory, attention, and concentration were adequate. His intelligence level appeared average, although no psychometric testing was performed. Mr. May recognized that his insight had been lost the day he assaulted the nurse and that he needed continued psychiatric help to remain stable.
The question for me to address is of Mr. May’s sanity at the time of the act for which he was charged with aggravated assault of a nurse in 2001. The opinion, within a reasonable degree of medical probability, was that on that date, Mr. May was afflicted from an acute decompensation of paranoid schizophrenia.
Manifestations of this mental disease include auditory hallucinations (hear- ing voices), elaborate delusional belief systems (false beliefs about people try- ing to kill him), having a special capacity to decode messages from terrorists, being closely related to President Bush, the hospital being the stage of terrorist attack, hospital personnel being terrorists in disguise (and alternatively chess pieces), and being able to decipher rules and procedures by following lights on the ceiling of a bus and hospital room. His thinking was illogical and secretive, his affect was flattened and inappropriate, and his behavior was erratic and unpredictable.
His delusions were bizarre and included classical paranoid ideas: he thought he was being attacked by a “class” of people and only he knew how to figure them out.
These delusions related to the assumption of his keen intellectual capacity to decode Internet messages and his being a member of President Bush’s staff and family. His auditory hallucinations were of the schizophrenic type. Mr. May’s assault on the nurse is consistent with his perception of being attacked. He had a history of slow but progressive mental decline, lasting over 10 years.
On the day of the assault, it was evident that he was suffering from a psychotic episode and could not comply with any offered treatment or even sign the admission forms. The assault is in response to psychotic symptoms and not due to any use of substances. There is no record of violence in this man.
A psychiatrist confirmed on the day of admission into the hospital that he was suffering from a mental illness that endangered him, others, and/or property. The psychiatrist confirmed that his judgment and capacity to control his behavior and recognize reality were all impaired.
Mr. May’s psychotic behavior fully conformed to his delusions; he did not know the wrongfulness of the act he committed because he truly believed the nurse and other hospital employees were terrorists. He also believed that real people had become chess pieces; among these chess pieces was the nurse, whom he thought was a terrorist instead. He was also receiving specific messages from the lights in the bus and in the hospital rooms he was in.
It is also my opinion that he did not know the wrongfulness of his act, thinking he was acting in self-defense. He acted out of intense fear because of what appeared to him to be a confusing world in which terrorists were killing everybody.
It was not his intention to be violent but to only decode “terrorist” Internet mes- sages and warn other people about their imminent strike. He could not refrain from attacking the nurse because he was convinced that he was the victim of a conspiracy
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in which he was about to be killed by the “terrorist” nurse. Also, he could not stop himself because he felt controlled by voices. Putting all of these pieces together, it is clear that the mind in which Mr. May was operating from did not allow him to act appropriately. In fact, it is likely that the events unfolded due to his psychiatric epi- sode occurring acutely at that time and, furthermore, with the correct treatment, would have been avoided.
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A. M. Goldwaser, E. L. Goldwaser, The Forensic Examination, https://doi.org/10.1007/978-3-030-00163-6_11