Knowing Oneself and the Regulation of Behavior

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Recent media coverage of the mass shootings in Gilroy, California, and Dayton, Ohio, led to the inevitable political fallout in which mental illness has once again been targeted as a reason behind motivations of the killers. Advocates for protecting the rights of mentally ill individuals are understandably aggravated when mental illness is presented in this manner, as it perpetuates and increases the stigma of such individuals as being unstable and dangerous. The vast majority of mentally ill individuals are harmless and often vulnerable without appropriate care and compassion. In addition, the impact on a person of their mental illness is not static and often fluctuates. Sometimes the onset is only temporal or mitigated through appropriate therapy and care.

While the motivations for politicians to present mental illness in this manner remain contentious, there is a wealth of medical and psychological literature that reinforces the notion that there are mental illnesses and disorders that have been known to cause an increase in antisocial behavior, or the behavior itself, along with other life factors, is even used as diagnostic criteria for the illness or disorder. Aggression has been noted in patients with schizophrenia (Blanco et al., 2018), frontal lobe dementia (Pivac & Borovečki, 2016), Parkinson’s Disease (Bruno et al., 2016), and those with Bipolar Disorder (Gotavac et al., 2016), Post Traumatic Stress Disorder (Taft, Creech, & Murphy, 2017), Antisocial Personality and Conduct Disorders (Derefinko & Widiger, 2016).

Even though we can list these disorders and illnesses as being associated with aggression, it is crucial to keep in mind, firstly, the majority of patients with the disease or disorder are not aggressive, and secondly, those who do manifest aggression are not always guilty of criminal behavior, let alone serious criminal behavior such as murder.

The etiology of these illnesses and disorders all vary and neurological hypotheses as to why the patient is (or has become) prone to a greater frequency of aggressive behavior will differ. Even when considering the impact of the illness or disorder on the patient’s standard of living, factoring in social and economic conditions, finding a reason for the aggression is complicated. However, there is a symptom of some mental illnesses, anosognosia, which if identified, could be used as a flag to monitor behavior, and even have implications for the legal system. It is my contention that anosognosia, comorbid with an illness or disorder that could increase the frequency of aggressive behavior, is more dangerous to others than when not present.

Anosognosia and Its Ethical and Legal Considerations

The term anosognosia refers to a lack of awareness of having a disorder or disability, from the Greek a–without, nosos–illness, and gnosis–knowledge. It is used in the context of neurological disorders and in relation to the main symptoms/deficits of a condition, including motor, sensory, behavioral, and cognitive alterations (Mograbi & Morris, 2018). Essentially, the anosognosic person does not know, and therefore does not accept, that they have an illness or disorder–and this is symptomatic of the very illness or disorder that they deny, not a result of their own deliberations.

Anosognosia has traditionally been seen in patients with Alzheimer’s Disease (Consentino et al., 2016) or schizophrenia (Gerretsen et al., 2019), but it has recently been identified in bipolar disorder (Acharya & Whitten, 2018), and those who are emotional and personality disordered (Gainotti, 2018). An important point to note is that patients with anosognosia and these illnesses and disorders, will not recognize they have an illness or disorder that could result in heightened levels of aggression, which casts doubt on how they view their own behavior.

The onset of anosognosia in an individual during a period of increased aggressive thoughts or actions presents an ethical dilemma for the immediate family and community. Anosognosia stands as an immediate challenge to the conscience; in fact conscience, from its Latin root, actually means "with knowledge," in contrast to anosognosia, a lack of awareness. An increase in antisocial actions from an individual with anosognosia, could mean the individual is acting with a compromised conscience at best, and without one, at worst.

This has far-reaching legal implications. The severity of the charges leveled against a defendant is mostly based upon the determined level of intent of the defendant when a crime was committed, and this is often mitigated if the court believes the defendant has expressed or is capable of remorse. If the defendant, diagnosed with an illness or disorder associated with a potential increase in antisocial behavior, also has anosognosia, the depth of intent might not be clear, and their capacity for remorse might be diminished. For antisocial behavior, therefore, anosognosia will directly impact considerations within a trial, and decisions by the state that profoundly impact the rest of the defendant’s life.

By contrast, a patient with an awareness of their illness or disease could regulate their life in such a way as to avoid aggressive behavior toward others, especially if they recognize that they are prone to aggressive feelings under certain circumstances. This regulation could involve ensuring the maintenance of drug therapy, isolating oneself during an aggressive "episode," or in a worst-case scenario, simply volunteering to enter into police custody as a precautionary measure. Not recognizing one’s own aggressive behavior removes an important layer of self-regulation.

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For this reason, when anosognosia is identified in individuals with illnesses or diseases that could cause heightened levels of aggression, increased monitoring and ethical discussions and assessments should be a part of the therapy.

© Jack Pemment, 2019