Masks of Sanity (Part One)

When conducting forensic criminal evaluations, it is crucial to consider the broad context of symptoms and behavior over the course of time in each case. This is essential diagnostic information, and central to detecting the presence of latent character disorders, such as antisocial, narcissistic, or borderline personality.

Personality disorders are defined by the American Psychiatric Association (DSM-IV-TR ) as chronic, culturally deviant patterns of baseline symptoms and behavior that are inflexible, pervasive, enduring, cause impaired social, occupational, or academic functioning, and can be traced back to childhood, adolescence or early adulthood. Despite what numerous expert commentators incorrectly indicate on various television shows covering sensational crimes like the "Craigslist Killer," personality disorders are real mental disorders, and can be both debilitating and dangerous to self and others.

Indeed, some of the ubiquitous evil deeds currently saturating the news, like the so-called Craigslist Killer and the grisly murders of children Caylee Anthony (see my previous posts) and Sandra Cantu, could conceivably be the product of personality disorders. However, without actually evaluating these defendants, this remains merely educated speculation based on what we know about ostensibly similar defendants and particular personality disorders in general.

Philip Markoff

The accused "Craigslist Killer," 23-year-old Philip Markoff, for example, was a high-functioning, engaged-to-be-married, second-year medical student at Boston University prior to being booked for brutally murdering a 26-year-old masseuse and robbing at least one other female victim. He is believed to have possibly been a compulsive gambler, which may have partially motivated his crimes, with police suggesting he had significant recent gambling debts. According to prosecutors, a search of his apartment yielded a semi-automatic handgun matching the murder weapon hidden in a hollowed-out volume of Gray's Anatomy, ammunition, plastic restraints like those used on the victim, duct tape, and, perhaps most incriminating, the murder victim's panties.

Markoff, the son of a well-to-do dentist, has been described by some who know him as cocky or arrogant, suggesting an underlying attitude of self-importance, grandiosity, and possible sense of entitlement. Unlike what might typically be expected of a true antisocial personality, he has no known prior criminal history. Nor, from what we know so far, is there the prior requisite pattern of violent, cruel, destructive, or deceitful behavior beginning before age 15. If he in fact committed these crimes, he would appear to be extremely interpersonally exploitative, selfishly taking advantage of vulnerable victims to achieve his own financial and/or sexual ends, with little or no conscience, empathy, or respect for their feelings or families. Such an individual could, hypothetically, be diagnostically described as manifesting some, if not all, of the hallmarks of both antisocial and narcissistic personality disorder. (See my previous post.)

Melissa Huckaby

In northern California, Melissa Huckaby, a pastor's daughter, is charged with having kidnapped, sexually assaulted, and murdered a 7-year-old little girl whom she had taught in Sunday school, and who was not only a neighbor but a playmate of the defendant's own daughter. Prior to this shocking alleged crime, she was evidently involved in another incident last January in which she disappeared with a different little girl for several hours before returning her to her anxious parents. Alarmed, the parents apparently took their child to the emergency room, where toxicological screening reportedly revealed the presence of a benzodiazepine, a minor tranquilizer. At this point, the source of that medication is a suspicious mystery.

Such atrocious crimes are very rarely committed by women, who are traditionally more likely to kill their own children than someone else's and tend not to be solo sexual predators or pedophiles. Though the police believe she acted alone, the possibility that the defendant is protecting some male accomplice must be ruled out.

Huckaby, now in custody, denies the charges, claiming that her suitcase, in which 7-year-old Sandra Cantu's lifeless body was found, had been recently stolen from her. Huckaby appears to have a long history of serious psychological problems according to those who know her. Just days before being arrested, she reportedly attempted suicide by swallowing several razor blades. She had apparently been arrested last November for burglary and petty theft from a Target store. Her demeanor at that time impressed the judge sufficiently to order a psychological evaluation regarding her competency to stand trial. Huckaby was evidently evaluated by a forensic psychologist or psychiatrist, found competent to stand trial at that time, and accepted a plea deal. But this certainly raises questions as to her state of mind around that period and subsequently. And whether, by her bad behavior, she may have been crying out desperately for help.

There are also reports that Huckaby was a "person of interest" in an arson investigation from 2007, in which the house where she resided at that time sustained deliberate fire damage on two separate occasions. Court documents and interviews with family members show Huckaby had a very chaotic personal life. In 2002, she was granted a restraining order against a boyfriend who had an extensive criminal record and had another restraining order from her previous marriage, according to San Joaquin County court records. She went through a volatile divorce, filed for bankruptcy, and reportedly wrestled constantly with depression and suicidality as she struggled to hold down a steady job and raise a child as a single parent. Any time a defendant such as this has a long-standing history of stormy interpersonal relationships, unstable self-image and mood, labile emotions, impulsivity, recurrent suicidal or self-mutilating behavior, chronic feelings of emptiness, abandonment, depression, hopelessness, anxiety and inappropriate rage, the underlying diagnostic possibility of borderline personality disorder must be considered.

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Causes of personality disorders

What causes these devastating yet deceptive personality disorders? While there is still much debate, I believe, based on my clinical and forensic experience, that narcissistic, borderline, and antisocial personality disorders are closely related (see my previous post), being created primarily by environmental factors like parenting styles, societal influences, and repetitive traumatic experiences during childhood.

Innate temperament also comes into play, as do existential choices made along the way. Much has been asserted, but not yet convincingly proven, about the genetic, neurological, and biochemical influences on bad behavior in general. In certain cases, a neurological anomaly directly and negatively affecting executive functions such as judgment and impulse control can be identified and viewed as being either causal or a prime contributing factor in destructive or violent behavior. But in the vast majority of violent offenders with personality disorders, as in those with other so-called Axis l mental disorders, the role of biology and neurology are not nearly so clear, and, have, in my view, been wildly overstated.

Ticking time bombs

One thing, however, does seem crystal clear: Personality disorders are on the rise. But they are not true insanity. They are—to borrow forensic psychiatrist Hervey Cleckley's (1941) classic description of what he called "psychopathy"—the "mask of sanity." Psychologically speaking, those afflicted with personality disorders tend to appear much healthier than they actually are. But these often consciously camouflaged disorders are also a kind of madness. They can engender potentially dangerous and even deadly states of mind, and occasionally lead to murderous behavior.

Charles Manson, Ted Bundy, Scott Peterson, Susan Smith, and many perpetrators of recent mass killings may merit a primary or secondary diagnosis of some type of personality disorder. (See my previous posts.) Because they are usually not overtly psychotic or blatantly manic, the person suffering from a severe (though not necessarily mild or moderate) narcissistic or antisocial personality disorder is, in some ways, far more frightening, insidious and dangerous to society. Outwardly, they look normal, function fairly well, seem socially adjusted, and can be quite charming. But inwardly, they are deeply disturbed, wounded, manipulative, immature, self-centered, angry people.

These sometimes predatory ticking time bombs often walk undetected among us as best friends, family, lovers, and co-workers until something sets them off—and then, detonation and destruction ensue. (See Part Two.) Such could be the case with murder suspect Philip Markoff, the clean-cut, "all-American" med student who, like the good Dr. Jekyll, may have harbored an evil Mr. Hyde. If we as a society desire to reduce the frequency of these disturbing evil deeds, we need to get much better at understanding, diagnosing, and psychotherapeutically treating these sometimes subtle, well-disguised, potentially life-threatening mental disorders.