Tag: psychiatrist

Criminal JusticeCriminal LawForensic Psychiatry

Date Rape Drugs: Expert Comments on Unreliable Tests, Harming Prosecutions

A few weeks back, BuzzFeedNews wrote an in-depth article on the unreliability of date rape drug testing and how the tests harm investigations and often prevent prosecutions.

Reading the article angered me. I became frustrated over the additional harm done to victims from a lack of national testing standards. My gut feeling was our lack of national or even statewide standards and capabilities, results in victims being re-victimized after a rape.

As with many other blog posts, it forced me to dig a little deeper and communicate with experts to see who was available to comment on this topic, to continue the discussion. Hopefully, by continuing the discussion we might shine more light on the problem and bring it one step closer to a solution.

Without reliable testing standards, how do we preserve evidence for a future prosecution? Even worse, how do we even know if the victim was drugged? If we do not set a standard, how will medical facilities know which drugs to test for during a DFSA screening? Furthermore, we need a comprehensive testing protocol to determine the standard of care when drug-assisted rape is suspected.

Normally, I provide my “two-cents” on a subject before diving into the Q&A with an expert witness. With this subject, I want to hear directly from the medical professional, and I’m sure the readers feel the same.

Forensic Psychiatry Expert Witness Sanjay Adhia

Dr. Sanjay Adhia is triple-board-certified in psychiatry, brain injury medicine and forensic psychiatry. In addition to forensic/expert witness practice, Dr. Adhia is medical director of PACE Mental Health Clinic in the Houston area.  His forensic practice focuses on the psychiatric impact of personal injury, abuse, competency, violence, and complicating mental illness. Dr. Adhia evaluates and treats psychiatric injury and disability in victims and alleged abusers. Dr. Adhia is among one of the few forensic psychiatrists who is board-certified in Brain Injury Medicine. To learn more about his forensic psychiatry practice, visit: https://www.forensicpsychiatrynow.com/.

Nick: You have written about the issue of date rape drugs in this article  (also found directly on Dr. Adhia’s website: https://www.forensicpsychiatrynow.com/date-rape-drugs) in the past. What are some drugs commonly used in date rape assaults?

Dr. Adhia: Common characteristics of many drugs used in Drug Facilitated Sexual Assaults (DFSAs) include the ability to incapacitate a victim and to cause anterograde amnesia (inability to recall the assault).

There are quite a few drugs commonly used in DFSAs. The most common and readily available drug is alcohol. Sedatives that are used by perpetrators include Ambien. Benzodiazepines, a class of medications used to treat anxiety, are often employed in DFSAs.  They include Valium, Xanax, Ativan and Rohypnol (“Roofies”). Gamma-hydroxybutyrate (GHB), a recreational drug with stimulating and sedating properties, is preferred by some perpetrators as it leaves the body quite rapidly. Ketamine (an anesthetic), Ecstasy (MDMA) and Soma (muscle relaxant) are additional examples of date rape drugs.

Nick: According to the BuzzFeedNews article, there are no national standards with regards to drug testing for date rape drugs. Do you have any recommendations for testing standards?

Dr. Adhia: I would recommend national standards. These standards could establish certification requirements for labs, lab staff and physicians who interpret the tests. For, example there are physicians who are certified to be an MRO (Medical Review Officer). They have expertise in interpreting drug tests.  The standards should include time-specific criteria for the various samples to be tested (blood, urine or hair). There should be a list of drugs that are required to be tested. Recently, I was involved in a case where the sample was destroyed after a year and GHB was not included in the testing battery. The standards should establish reliable methodology and concentration cut-offs for each tested substance. Ideally, there should not be any false-negatives or false-positives. Confounding factors could be considered in national standards.

Nick: In the past, I only ever heard it referred to as “date rape.” I understand it is now called Drug-Facilitated Sexual Assault (DFSA). Is there a national committee working to create standards for addressing DFSA cases?

Dr. Adhia:

A National Protocol for Sexual Assault Medical Forensic Examinations, 2nd Edition was published by the Department of Justice Office of Violence Against Woman. It includes a section on drug and alcohol testing. (Refer to https://www.ncjrs.gov/pdffiles1/ovw/241903.pdf page 107).

Internationally, the United Nations has published “Guidelines for the forensic analysis of drugs facilitating sexual assault and other criminal acts.”

Nick: In your forensic psychiatry practice, how do you go about treating those suffering the aftermath of DFSA? For example, victims often cannot remember the attack, so what approaches are used? With what issues are victims likely to suffer after DFSA (i.e. depression, anxiety)?

Dr. Adhia: Drug-induced amnesia is not protective of PTSD and other disorders that can occur after a DFSA. For example, some of Bill Cosby’s DFSA victims reported symptoms indicative of PTSD in their victim-impact statements. Many of his victims had life-long effects such as a reduced ability to trust men and form relationships, panic attacks, and nightmares. In DFSAs, there can be a sense of shame and self-blame. A victim could be at increased risk for substance abuse or suicide.

The treatment for PTSD and other co-occurring disorders such as depression or anxiety disorders include medications and counselling. Two medications often used in PTSD include anti-depressants and a blood pressure medication that helps reduce the nightmares. Occasionally, mood-stabilizers and anti-psychotic medications are used to target associated symptoms such as irritability.  Counselling includes individual and group psychotherapy.

Nick: Any other comments on concerns you wish to share about this crime…

Dr. Adhia: With increasing awareness, the hope is victims act promptly to preserve evidence for prosecution. Many of these drugs will exit the body in under three days or less. A victim can save his or her urine in a clean and closed container and refrigerate it promptly. A rape kit should be performed as soon as possible. The National Sexual Assault Hotline can be called at 800.656.HOPE to find a medical center for a sexual assault forensic exam with urine and blood testing for drugs.

Prompt treatment of the medical and psychiatric sequelae of DFSA is critical. A victim should be monitored and treated for any drug toxicity. There have been unfortunate cases of overdose such as with Tammy Homolka who choked on her vomit after being drugged with halothane in the course of a DFSA committed by her sister, Karla Homolka and Paul Bernardo. Emergency birth control and STD treatment is often indicated after sexual assaults.

Victims should be evaluated and treated for psychiatric disorders soon after the assault. The hotline number above can be contacted to provide referrals.


 

Again, the National Sexual Assault Hotline phone number is: 800.656.HOPE. The hotline is maintained by RAINN (Rape, Abuse & Incest National Network). They also have live chat options available on their home page: https://www.rainn.org.

 

 

Criminal LawExpert WitnessForensic Psychiatry

Golden State Killer, Part 2: Forensic Psychiatry and the Rapist and Serial Killer

As readers of Part 1 are aware, I’m following this case closely due to the connection to our local community. If you are anything like me, you wonder how someone could allegedly commit so many heinous crimes? Then, after a decade of committing dozens of rapes and multiple murders, the suspect ends his reign of terror (at least as far as we know).

What We Know:

From 1976 to 1986, a violent criminal struck fear throughout the State of California. Twelve murders, 45 or more rapes, and more than 100 hundred residential burglaries are attributed to one man. Authorities have indicated the suspect was meticulous in the planning of his crimes, which started as burglaries and escalated into violent offenses.

The crime spree spanned Northern and Southern California, including Sacramento, San Joaquin, Orange, Ventura, and Contra Costa Counties. The suspect was known by many names, such as Visalia Ransacker, Diamond Knot Killer, Original Night Stalker, East Area Rapist, and more recently the Golden State Killer. It wasn’t until a couple of years ago that DNA evidence connected the dots of all the crimes and detectives realized the crimes were committed by the same individual.

An arrest was made in late April. After using an innovative investigative technique (submitting a DNA profile to a free online ancestry database), detectives identified James Joseph DeAngelo, Jr., a former police officer and mechanic living in Citrus Heights, California.

What Makes Someone Commit Such Crimes?

Violent crimes are difficult for most of us to understand. Certainly we’ve all had emotional moments that could have resulted in a terrible decision had we lost self-control or been otherwise unbalanced. Although I don’t condone violence, I’ll admit reading about crimes where the violent result was understandable. Not acceptable, but understandable. For example, a parent acting violently towards someone who harmed his or her child is the type of violent behavior I can understand.

How do we reconcile vengeful, “loss of control,” or “heat of passion,” violence with violence that seems to be done for pleasure? Why does an offender experience joy from inflicting pain and fear upon a victim? What causes a person to lead a life of rape and murder?

There are so many questions on this topic. Does a lack of understanding make us more fearful? Does the human condition require a rational explanation for irrational acts we cannot fathom?

A little information before we continue:

For this portion of our series on the Golden State Killer, I sought input from a forensic psychiatry expert witness. Part 3 of this series will include input from one or more forensic psychologists.

It is important for readers to understand the difference between psychiatry and psychology. Allow me to differentiate between the two. For any psychologists and psychiatrists reading this post, I apologize for the very simplified descriptions of your professions, but we’ve had lawyers contact us looking for an expert, unaware of the distinction.

A psychiatrist is a medical doctor (MD, DO) capable of prescribing medications to address mental, emotional, and behavioral disorders. They generally focus on diagnosis and treatment. A psychologist is not a medical doctor. Psychology-based doctoral degrees are usually Ph.D or Psy.D. They generally are unable to prescribe medication and focus more on helping patients to effectively cope with mental, emotional, or behavioral disorders via psychotherapy (non-medical treatment). Again, this is an oversimplification of two highly complex professions.

Today, we will be addressing the Golden State Killer with some input from Experts.com member and forensic psychiatry expert, Dr. Stephen M. Raffle.

Stephen M. Raffle, MD – Forensic Psychiatry Expert Witness:

Dr. Stephen Raffle is double board-certified in Psychiatry and Forensic Psychiatry. He has over 40 years of experience as a clinical and forensic psychiatrist offering his expert opinion in federal and state jurisdictions nationwide. Dr. Raffle has conducted over 5,000 psychiatric assessments in his career and was a professor of psychiatry at UCSF Medical Center for 20 years. You can learn more about Dr. Raffle by visiting his website: psychiatristexpertwitness.com.

Nick: Are there common psychological attributes among serial killers?

Dr. Raffle: A common feature is a lack of empathy with victims. Most serial killers ​(with few exceptions) understand they are committing a crime because they take care not to be caught. Antisocial Personality Disorder and Borderline Personality Disorder commonly are present. Sadomasochism is also a common feature. Depending on the shared characteristics of the victims, the serial killer may have problems with impotence, paranoia, or sexual perversions which cannot otherwise be satisfied. Paranoid Schizophrenia is a common psychiatric disorder but not universal. A diagnosis of paranoid schizophrenia, in and of itself, does not necessarily justify a finding of insanity, because “insanity” is a legal construct, not a psychiatric diagnosis.

Nick: If so, what types of psychological attributes are common among serial killers?

Dr. Raffle: Refer to my response in No. 1 above. In addition, the psychiatric disorders, as diagnostic entities, may include:  ​Sadomasochistic Personality Disorder, Necrophilia, Paranoid Schizophrenia, Borderline Personality Disorder, Antisocial Personality Disorder, or other psychotic disorders.

Nick: Does a serial rapist or serial killer experience joy or pleasure from tormenting and harming their victims?

Dr. Raffle: Yes.

Nick: If so, why is it they experience joy or pleasure from inflicting pain or committing murder?

Dr. Raffle: In each instance, the torture is combined with sexual arousal (which is commonly not acknowledged by the perpetrator), leading to an emotional discharge, often overtly sexual in nature​ upon the death of the victim. Following the murder, serial killers have recurrent fantasies about various aspects of the ritual associated with the killing, which brings satisfaction. Over time, the recurrent fantasies become progressively less satisfying, (i.e., “old news”) resulting in a need for new fantasy material. Hence, the serial nature of the murders.

Nick: Can forensic psychiatry explain how one becomes a serial killer? Or, what causes one to become a serial killer?

Dr. Raffle: The prediction of violence in a specific individual is difficult, given the extremely rare occurrence of serial killers. Certain risk factors are identifiable for predisposing an individual to violence; however, the constellation of symptoms, behaviors, life experiences and genetic makeup makes it impossible to identify serial killers before the fact or even to explain how one “becomes a serial killer.” That said, a propensity toward violence most commonly occurs in individuals who have a prior history of violence, premeditated violence, paranoia, a strong impulse for revenge, drug and/or alcohol abuse, Antisocial Personality Disorder, Borderline Personality Disorder, the experience of repeated childhood sexual abuse and/or physical abuse, obsessional thinking, unresolved gender identity issues, sadomasochism, and conflicts about dominance/submission. The causes to become a serial killer commonly include prior sexual fantasies, coupled with torture ending in murder. The shift from fantasy to reality may occur following a personal crisis and need for greater satisfaction than is provided by the fantasy. Once the taboo of murder is breached, the serial killer is freer to convert subsequent emotional needs into murderous actions. Most serial killers have a ritualistic aspect to their killing which reflects their unconscious needs and conflicts, such as killing prostitutes, homosexuals, homeless people, or other such categories. The commonality of the victims usually is based on childhood experiences, parental attitudes, and psychosexual conflicts.

Nick: Are there common childhood development (characteristics or circumstances) issues among serial killers?

Dr. Raffle: The most common childhood development characteristics and circumstances include parental neglect, inconsistent parental behaviors, resulting in excessive, unpredictable punishment​ unrelated to wrongdoing, physical or sexual abuse by a parent or close relative, extreme religious beliefs, isolative behaviors as a child, poor impulse control, conduct disorder during childhood, victimization of various sorts during childhood, to name several.

Nick: News reports indicate the Golden State Killer was active between 1976 and 1986. Is it likely he stopped committing these crimes?

Dr. Raffle: On a probability basis, he didn’t stop committing his crimes after 1986. The nature of his fantasies may have changed over time such that subsequent murders were dissimilar enough from the earlier murders that they don’t share enough commonality to identify him as the perpetrator.

Nick: Is it uncommon for a serial killer to stop committing crimes?

Dr. Raffle: It is common for a serial killer to continue committing crimes.

Nick: Are there items you think the public should know about forensic psychiatry, as it relates to the Golden State Killer, that I have not covered in the above questions?

Dr. Raffle:

a) Serial murder is an extremely uncommon occurrence. It is extremely difficult to prospectively predict a particular person will become a serial killer, irrespective of the forensic psychiatrist’s ability.

b) The ritualistic behaviors of a serial killer do not define insanity or even suggest it​. Serial killers as a group are cunning individuals who seek not to be caught, who do not confess, and who obtain considerable self-satisfaction at the expense of their victims.

c) Serial killers as a group do not understand the intrinsic causes of their behavior and are extremely unlikely to be cured of their obsessional murdering. As the practice of psychiatry now exists, it is unreasonable to expect successful treatment of a serial killer.

d) The FBI Behavioral Studies Unit has interviewed and analyzed all of the serial killers who have been brought to justice. Certain statistical profiles exist which assist law enforcement to “profile” a serial killer based upon the victim type and associated rituals. Roy Hazelwood headed the unit for approximately 20 years and probably knows more about serial murderers than anyone else. His work has been instrumental in creating “profilers.”

e) The psychological makeup of serial killers is different from mass murderers. Serial killers who kill by sniping random people or cars are psychologically more similar to the mass murderer than the serial killer because they usually snipe more than one person during a shooting episode.

f) Contract killers are not serial killers. The mentality of a paid assassin is essentially that of an antisocial ​person who does not empathize with his victims and is therefore comfortable earning his or her living killing others. The obsessional quality or ritualistic behavior of the serial killer is not shared with the assassin. Their only common ground is they have killed more than once. The difference is the assassin is told whom to kill and is paid for it; whereas the serial murderer chooses his victims and engages in other behaviors in addition to a murder which satisfies unconscious needs. Conceptually, as serial murderers go, the assassin is “professional” and the serial murderer is a “hobbyist.”

Stay Tuned:

A huge thank you to Dr. Raffle for his very thorough insight into the mind of the Golden State Killer. Next week we’ll be bringing you more insights on the psychological nature of this perpetrator with input from some of our forensic psychology expert witnesses.