The limited role of neuroimaging in determining criminal liability: an overview and case report.

OBJECTIVE: Studies indicate there is a substantial biological substrate for psychopathic behavior. Neuroimaging techniques have afforded biomedical sciences a means to investigate further how aberrant brain activity or structure may be correlated with psychopathy and violence. This paper will provide an overview of the literature, and then will explore the role of structural and functional MRI brain imaging in the defense of a young adult male charged with kidnapping and rape. METHOD: Using Pubmed and the keywords "functional neuroimaging," "structural neuroimaging," "psychopathy," "antisocial personality," "sociopathy," "aggression," "impulsivity," and "violence," the authors conduct a review of structural and functional neuroimaging studies involving aggressive, violent, psychopathic or antisocial offenders. We then provide a case report of a defendant, charged with kidnapping and rape, who was found during a forensic evaluation to have abnormal neuroimaging findings. RESULTS: The defendant's counsel was able to present in his client's defense multiple indicators of brain dysfunction and psychiatric illness partially substantiated by brain imaging. CONCLUSIONS: The extent to which neuroimaging findings can be used as exculpatory or mitigating evidence remains the subject of much debate. Neuroimaging is just one piece of evidence the forensic expert relies on in determining the extent of neuropathology and mental illness. As illustrated in the case report, imaging studies most often will serve a mitigating role, affording the courts an opportunity to tailor punishment, provide court-ordered treatment, and potentially decrease recidivism.

Effect of comorbid tics on a clinically meaningful response to 8-week open-label trial of fluoxetine in obsessive compulsive disorder.

Currently, there are limited published data evaluating the effects of tics on serotonin reuptake inhibitor (SRI) monotherapy responses in treating obsessive-compulsive disorder (OCD). One retrospective case-controlled analysis of OCD patients treated with SRI monotherapy showed lesser improvement in OCD symptoms in patients with tics than those without. However, more recently there were preliminary reports of OCD subjects treated with SRI monotherapy which did not demonstrate poorer response in subjects with tics or Tourette's Syndrome (TS). The specific aim of this study was to investigate whether the presence of comorbid chronic tics affected "clinically meaningful improvement" [McDougle, C.J., Goodman, W.K., Leckman, J.F., Barr, L.C., Heninger, G.R., Price, L.H., 1993. The efficacy of fluvoxamine in obsessive-compulsive disorder: effects of comorbid chronic tic disorder. Journal of Clinical Psychopharmacology 13, 354-358] of OCD in an 8-week open-label trial of fluoxetine monotherapy. Seventy-four adult subjects (13 patients with comorbid chronic tics and 61 patients without tics) with a primary DSM-IV OCD diagnosis were treated with up to 40mg fluoxetine for 8 weeks and had at least one post-baseline evaluation. The results indicate that there was a significant response by time in both fluoxetine-with-tic subjects and fluoxetine-without-tic subjects. Additionally, there were 3 (23.0%) OCD subjects with tics who had clinically meaningful improvement versus 16 (26.2%) OCD subjects without tics that demonstrated similar levels of improvement. These findings indicate that OCD patients with or without chronic tic disorders did not have a differential response to an 8-week open-label trial of fluoxetine. Limitations include the relatively low number of tic subjects and the open-label nature of the study. Additional data are needed on how comorbid tics may affect SRI treatment response in OCD.

The motivation behind serial sexual homicide: is it sex, power, and control, or anger?

Controversy exists in the literature and society regarding what motivates serial sexual killers to commit their crimes. Hypotheses range from the seeking of sexual gratification to the achievement of power and control to the expression of anger. The authors provide theoretical, empirical, evolutionary, and physiological support for the argument that serial sexual murderers above all commit their crimes in pursuit of sadistic pleasure. The seeking of power and control over victims is believed to serve the two secondary purposes of heightening sexual arousal and ensuring victim presence for the crime. Anger is not considered a key component of these offenders' motivation due to its inhibitory physiological effect on sexual functioning. On the contrary, criminal investigations into serial sexual killings consistently reveal erotically charged crimes, with sexual motivation expressed either overtly or symbolically. Although anger may be correlated with serial sexual homicide offenders, as it is with criminal offenders in general, it is not causative. The authors further believe serial sexual murderers should be considered sex offenders. A significant proportion of them appear to have paraphilic disorders within the spectrum of sexual sadism. "sexual sadism, homicidal type" is proposed as a diagnostic subtype of sexual sadism applicable to many of these offenders, and a suggested modification of DSM criteria is presented.

Is speeding a form of gambling in adolescents?

Speeding is a major contributor to motor vehicle accidents, which are the leading cause of death in adolescents. This study compares the extent to which adolescents with gambling behavior and substance use reported driving over the posted speed limits ("speeding"). Florida adolescents ages 13-17 (n = 1051) were surveyed, and asked about gambling activities, problems related to gambling, substance use, demographic questions, and speeding. Of the 562 respondents who were drivers, the gender distribution was 52.1% male and 47.9% female. Of those respondents, 76.9% were Caucasian, 6.8% were African American, 10.1% were Hispanic, and 6.1% were Native American/Asian/Other. Simple correlation analysis revealed that self-reported speeding is significantly related to gambling behavior and substance use. When a linear regression model was used, four factors showed the most significant influence on self-reported speeding: past year gambling tendency, age, trouble with the police due to drinking, and tranquilizer usage. Gambling behavior and high-risk speeding (driving ≥ 10 mph over speed limit) also were noted to be positively correlated. Our data indicate a relationship between risky driving, gambling, and other risk-taking behaviors in adolescents, and support the hypothesis that speeding may be a form of gambling behavior in this age group.

Sadistic personality disorder and comorbid mental illness in adolescent psychiatric inpatients.

Sadistic personality disorder (SPD) is a controversial diagnosis proposed in the DSM-III-R, but not included in the DSM-IV. Few studies have focused on this disorder in adolescents. This article describes the results of a study that sought to determine the presence of sadistic personality characteristics in psychiatrically hospitalized adolescents and of comorbid Axis I or personality disorder patterns in those youth with SPD or SPD traits. Fifty-six adolescents were assessed for sadistic and other personality disorders with the Structured Interview for DSM-III-R Personality Disorders-Revised (SIDP-R). Axis I disorders were assessed using the Diagnostic Interview for Children and Adolescents, Adolescent Version (DICA-R-A) and portions of the Schedule for Affective Disorders and Schizophrenia for School Age Children, Epidemiologic (K-SADS-E). The youth were divided into those with SPD and SPD traits, the Sadistic Group (n = 18), and the Nonsadistic Group (n = 38). A significant proportion of the adolescents in this study met full DSM criteria for SPD (14%). The Sadistic Group (32%) had significantly more Axis I and personality pathology than did the Nonsadistic Group. However, all but one in the Sadistic Group met criteria for other personality disorders, confounding the interpretation of these findings and consistent with adult literature studies. Subjects with sadistic personality characteristics were identified in this adolescent inpatient sample, and they had more extensive Axis I and II psychopathology than the comparison group. The validity of this disorder in younger populations requires further study. Future studies should also explore the impact that the mandatory use of the pleasure/gratification criterion has on the validity of the SPD diagnosis and whether the requisite presence of this criterion decreases the overlap currently noted between SPD and other Axis II diagnoses.

The neurocircuitry of obsessive-compulsive disorder and disgust.

Recent evidence from human research has indicated that discrete regions of the brain control different basic emotions. Whether the recognition and formulation of emotions truly stem from compartmentalized systems or arise from a multidimensional framework has yet to be elucidated, however. Disgust is a basic emotion that has been hypothesized to constitute an evolutionary function of contamination and disease avoidance. Disgust involves the appraisal of objects and events for their potential role in contamination, and OCD conceivably involves a dysfunction of this appraisal process. Disgust sensitivity has been shown to be positively correlated with OCD and to significantly predict contamination fear. Likewise, functional imaging studies of OCD patients with contamination concerns demonstrate activation of the same neural regions with disgust-inducing pictures as symptom relevant stimuli. Therefore, the neurocircuits involved in disgust processing may be relevant to OCD and, in particular, the contamination subtype. This review focuses on describing what is known to date concerning the neurocircuitry of disgust, and its relevance to the apparent neurocircuitry of OCD.

A review of the treatment for refractory obsessive-compulsive disorder: from medicine to deep brain stimulation.

This article provides an overview of the etiology, epidemiology, and first-line treatment options for obsessive-compulsive disorder (OCD). The subject of treatment-resistant and treatment-refractory OCD is then discussed, including a definition of these often-debated terms, and the latest treatment options delineated. This includes a review of the latest research concerning the pharmacological agents that have been studied as monotherapy or augmenting agents for the treatment of OCD, the use of experimental medications and procedures, treatment with reversible, minimally invasive procedures, such as vagal nerve stimulation and transcranial magnetic stimulation, invasive but the potentially reversible deep brain stimulation, and irreversible lesioning with ablative psychosurgery. A discussion of the role of psychotherapy in the treatment of OCD is also included.

Cellular localization of thromboxane synthase in ovine spinal cord and hindbrain.

We and others have demonstrated that endogenously-produced prostanoids modify the function of the hypothalamus-pituitary-adrenal (HPA) axis. We have demonstrated that exogenously-administered thromboxane mimetic stimulates ACTH secretion in fetal sheep, and that the endogenous production of thromboxane modifies the HPA response to cardiovascular stress. The purpose of this study was to identify the structures within the fetal and adult ovine medulla and hindbrain which express immunoreactive thromboxane synthase. Using immunohistochemical techniques, we demonstrated thromboxane synthase immunostaining in regions important for cardiovascular afferent signaling (nucleus tractus solitarius, ventrolateral medulla) in both cell bodies and axons. Thromboxane synthase was also apparent in neuroanatomical locations which are consistent with afferent and efferent projections from the cerebellum. We observed staining in the superior cerebellar peduncle in the rostal pons, in the corticopontocerebellar fibers, and in Purkinje cells. The enzyme was found in motor regions, including the dorsal motor nucleus of the vagus nerve, and in the motor neurons of the dorsal column of the spinal cord. In addition to the apparent neuronal staining, there was positive staining in the ventricular ependymal cells. We conclude that, consistent with physiological evidence, thromboxane synthase is present in brain regions which are important for afferent and efferent cardiovascular signaling.