Welcome to the Psychofarm podcast. This podcast is for education and entertainment. It certainly is not medical or psychiatric advice, diagnosis, or treatment. Listening does not create a doctor-patient relationship with me or Dr. Fu. If you're a patient, certainly don't change your treatment plan because of something you hear on the show. If you're a clinician, do not use this podcast as a clinical reference or substitute for your own training, judgment, thinking, and up-to-date sources.
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Good morning, Dr. Malzberg.
Good morning, Dr. Fu.
How's it going? Oh, not too bad.
I've got no cutesy little opener today. I feel that the subject matter is sufficiently, what's the word I'm looking for here, dark, disturbing, that we should just jump right in.
Well, I do want to say, so I'm going to pretend that lots of people are listening, not just our normal thousand listeners. So many people have asked me to cover this case with you because for those who don't know, my co-host, Dr. Fu, is, in my opinion, the most perfect person to be discussing this Lindsay Clancy case. He is a forensic psychiatrist. He has very good social takes.
He's got expertise in bipolar and personality disorder. I think you're overselling me at this point. You've done work on filicide cases. So many people from our audience have asked me to talk with you about this case. We always miss the wave of talking about things while they're topical. And I think we probably missed this one, too. But I feel like you just didn't do it because you're a curmudgeon.
Well, I get enough of this at work on one hand. On the other hand, I feel like some of the blame must be shouldered by you, Dr. Malzberg. You must be the least dialed into pop culture person that I'm aware of at this point, Mr. I don't watch the Simpsons for our unpopular not watched Seinfeld video. All right.
All right. Let's let's let's get to let's get to the Lindsay Clancy case. So. OK. Before we jump in, I kind of want to talk about why I think this case is so big, why it's captured the public's attention. I think things that capture the public's attention are stories that activate our repressed emotions. And so much of sports, television, media, it allows us to play out emotions that we have little permission to acknowledge.
And I feel like this case, some of the things that, the repressed emotions that I see coming up, ordinary parental aggression and ambivalence. Our culture is inundated with the idea that motherhood is rainbows and sunshine and a good mother is nurturing, self-sacrificing. Her kids give her all ultimate joy, ultimate meaning. The reality is parenting is full of rage, resentment, fantasies of escape, boredom, regret. I'm also seeing rage at husbands.
I see a lot of hate directed towards the husband of Lindsay Clancy. Lindsay has kind of become a similar. So many women are suffering silently, and I think this case gives them an opportunity to get out some of those emotions. I see rage at doctors. So many people make the incredibly difficult decision to seek help, and then they talk to some practitioner who talks to them for five minutes and throws Zoloft at them.
I see rage at doctors. The way mental health is being treated, our culture now, we're inundated with, I can't do X, Y, Z because I'm depressed. I'm not responsible for this because of some diagnosis.
I'm going to slow you down for a moment there because I think you're bringing up some very good points. Let's summarize. On one hand, you're seeing the anger and frustration that relates to gender roles in society. And parental expectations and lifestyle, let's call it, in the modern age, right? On another column, we're seeing the dissatisfaction with the physical and mental health system of the United States, I think.
I think that's something that everyone, including physicians who themselves are patients, can experience and see quite handily. This comes only a couple years, I think, after the UnitedHealthcare CEO assassination. This is something that's in the public eye that has gotten no progress in terms of being better. And then downstream of that is dissatisfaction with the mental health clinicians themselves. You know, for right or wrong, I think that the status of mental health treatment is not where it should be, maybe for 90% of humanity, where it could be anyway.
And the next one, though, I feel like takes a different bent in a sentence. You're talking about There is another camp. They don't like excusing behaviors for mental health. I've seen avenues of the internet and the public where it seems to be the opposite problem for me. That looking at this case, it's the part where they see her as a monster. There's just no sense of mental conditions as a medical problem or something that can change how people act.
There's just pure, this is a psychopath that we need to lock up. There's that segment of the public as well, right? There's the segment of the public that says women are basically exaggerating and banding up as a group to excuse themselves of any liability. I would say that ultimately, hopefully we get to a place of integration in this episode, as we're often trying to do in this podcast.
There is a middle ground here that I think better resembles reality we can talk about.
Yeah, and the big thing that I'm trying to express with, when these divides happen, people split all, they split. It's all either, you know, it's either she's a monster or she's a victim. She's totally making it up or we completely ignore women's mental health. And I think by doing this split, it allows us to avoid having to tolerate the ambiguity of real life. And it allows us to feel righteous in regards to our feelings when the world is gray and messy.
Yeah.
Well, let's get into it then. The jury is deadlocked, which is actually something I predicted, and you can believe me or not, that's what I predicted in my private forensic discussions with others. It's an unusual law in Massachusetts. It's unlike other not guilty by reason to insanity constructs, which I think is part of why this case even went to trial and why we are talking about it today.
I do feel that in other states, With more rational criteria for not guilty by reason, insanity, we wouldn't be seeing this. How's the Massachusetts ones different? I don't practice in Massachusetts. I'm going to have to say that, but in Massachusetts, they put the burden of proof on the prosecution. Okay. And they put it all in one bundle. You have to decide on the crime itself and also on criminal responsibility from an insanity perspective.
So what the prosecution has to do now is that the prosecution has to prove beyond a reasonable doubt. That is a high bar. Prove beyond a reasonable doubt that the defendant, in this case, Lindsay Clancy, either understood that it was legally or morally wrong. And that she could substantially control her behavior at the time of the offense. Now, here's the problem with the behavioral control element. The behavioral control element, that's a new element.
That was a proposed element from the period that I talked about where they tried to become more progressive with mental health law. I gotta tell you, it is extremely difficult to come up with anything resembling objectivity. Even in a field where objectivity is already scarce, when we talk about the ability to control behavior, we have no scientific test to say who can or cannot control their behavior.
We can basically point at certain facts that we know in medicine, but it's not anywhere as clean cut as the cognitive test of whether someone knows it's wrong or what they're doing. And even that is pretty murky. So it's a very murky set of criteria in Massachusetts. And for some reason, they make it the burden of the prosecution to prove.
Now, I'm glad we're talking about this because the insanity defense, some people think it's like, oh, if you have a mental illness, then you're not responsible for your actions. I asked a few people to see if they had questions regarding this case that we could help talk about. And one person said, isn't she definitionally insane if she kills her children? How could someone kill their children and not be insane?
And I think we're getting to the point that the question isn't does she have a mental illness? The question isn't was she psychotic? The question is could she control her behavior? And that's what's being answered. A good example of that is. A good example of how this is confusing, Jeffrey Dahmer. The question is, is he insane or not? And you look at what he did, and there's not a single person who wouldn't say that he was severely mentally ill.
But that's not the question. The question is, could he control his behavior?
Well, I don't know. I don't know if I would phrase it that way. I know you're getting at something very important there, but I want to break it down more specifically. First, some background. There is definitely a movement of psychiatrists in the 20th century who believed that all criminality is mental illness. Okay, this dates back to the psychoanalysts who were, in my opinion, way too warm and huggy about criminals and thought that criminal behavior could be completely explained.
Bad upbringing, poor little kids getting this and that. I am not of that camp. There are still psychiatrists who act and behave that way. But I think that there is some fundamental aggression and For lack of a better word, evil in humanity that persists. And that's the group that we usually call psychopaths. And there's also people who are repeat offenders, criminals, people who have problems of impulsivity and following rules.
Now, there was that backdrop. So there was a real movement to essentially equate mental illness with With criminality, or rather criminality of mental illness, because that would then lead to treatment. They were very optimistic about the ability to treat people who commit crimes. They still are. This is in the body of people who believe in prison abolition, for example, or the body of people who think that rehabilitation is the goal of criminal punishment, which can be one, but there's also many others.
There is that element. The fact is, some of the laws are written in that fashion. But do we want the laws to be that way? That's a question for society, not for a mental health professional. For us, the mental health professionals, we have to basically break down a different question. So going to Dahmer, in a layperson's Description, he may be, quote, mentally ill or crazy because his behaviors are so far outside of the norm.
But being outside of the norm is not enough to say if someone is mentally ill for a professional, for a psychiatrist. We need to say in what particular way is he outside of the norm? And so it isn't that he can or can't control his behavior. It is, for me, the question, why does he do what he does? Why does Jeffrey Dahmer do what he did? And the answer is because he's a psychopath.
Okay. He has psychopathy and he also has fetishes, sexual fetishes, and that drives him. Versus, let's talk about filicide. OK, when you kill your own children, this is a rare act, relatively speaking, your own children. Unfortunately, the rates of violence against children in the same household who are not related to you are much higher rates of abuse and violence. But when a parent kills their own child, if you look at the studies, pretty much a majority of them did have psychosis.
But what are some other reasons why someone might kill their own children? Well, it could be an accident in a fit of rage. It could be a rational reason. Maybe the child had a terminal illness and they thought they would be better off dead. It could be a selfish rational reason, like trying to collect an insurance policy. And it could also be an impulsive act of rage from a personality problem like narcissistic rage.
But the majority of cases do occur because of some kind of a psychotic condition.
I want to understand how a forensic psychiatrist even goes about differentiating whether someone's underreporting or overreporting symptoms or whether they're genuinely in the aftermath of a psychotic break. To me, there's so many questions there. And I want to hear you talk about the it's really the question of psychosis versus malingering.
Okay, how to detect malingering? That's an interesting question. I think that a good forensic psychiatrist always considers malingering as a possibility. Why? Well, malingering is known to be more common in a forensic context in the sense of some kind of a legal battle, right? Whether it's a criminal matter or a civil matter, people are motivated to portray themselves as either ill when they're not or more ill than they are because it can result in some kind of positive outcome.
So you have to consider these things. And to that end, I think people are generally overemphasizing the importance of patient or evaluee self-report. Yes, a lot of our diagnostic process in psychiatry relies on what a patient or a person tells us about what they went through. But that's not all there is to an exam. An exam includes the mental status exam. And the mental status exam is not just the thing that you write down.
It's everything that you're observing about someone talking to you. It also includes review of known history, beyond what somebody tells you, looking at records, looking at other indicators and other evidence of what has happened in somebody's life across time. Frankly, in most insanity defense or state of mind at the time of the criminal act, Cases, those cases rely more on records because you have things like police interviews.
Often they're recorded these days. There's a video of them being interviewed or even at the time of arrest. You would be shocked how much there is today in terms of video footage. I'm not talking about flock cameras. I'm saying that everyone has a ring doorbell and the police will go nearby and get it. There's a lot of evidence that you can review before you even get to the interview with somebody.
So we want to keep that in mind. And evidence that is from that time of the incident is worth more than any recollection by a person after the fact because memory is fallible. So how do you tell? Well, you have to match what is being told to you to the overall picture. You have to consider the overall picture of what you're seeing. And let's put it this way.
In the Lindsey Clancy case, if someone was trying to malinger entirely from whole cloth a mental illness in order to escape criminal responsibility, It doesn't make sense that they would be repeatedly looking for various different types of outpatient and inpatient care throughout a period of months beforehand. Nobody plans a murder and says, I'm going to get away with this by getting caught red handed. And the way I'm going to get out of it is to be locked in a state hospital indefinitely.
And in order to facilitate that, I'm going to go see a bunch of doctors and psychiatrists and not tell them about my symptoms. You can see that in a case, there is already some background set of information before you evaluate a defendant that tells you what is or is not likely. This is basically Bayes' theorem. We have a pre-evaluation probability of one particular category of what has been happening.
And the evaluation either overturns that assumption based on the available evidence or it confirms it. I don't know if that makes sense. Am I making sense?
Yeah, it does. Now, it's funny. I see forensic psychiatrists often categorize, like you said, like I think Dr. Resnick said there's five types of filicide. We've talked about suicide in a previous podcast and you mentioned that there's, I forget, but six different types of suicidal thoughts. So I guess my understanding here is what you're saying is essentially You categorize the different types of something. So here we categorize the different types of people who end up killing their children.
And then given the evidence, which there's not any one particular thing you're looking at, you're looking at the whole body of evidence, you see which type is the person best fitting into.
Sort of. But the categorization is still after the fact. I think the important thing is that there's a lot here that is not necessarily... The diagnostic practice of psychiatry. You have to be a actual reasonable person who examines the facts And asks the basic human question, why did they do what they did? What kind of person is this and what were their motivations? And this is something that I do see lacking in some forensic experts' reports.
They make an opinion in an almost robotic fashion where they do an evaluation, they get to some diagnosis that they would get as a clinician, and then based on that diagnosis, they basically Skip over the reasoning part and they get to the conclusion, the conclusion of saying or not saying competent or non-competent. But you need to make connection between your conclusion and what you're seeing. And again, the best way to do that is to actually consider the context.
So in the Lindsay Clancy case, I think you need to look at what is the behavior of the person before the offense. Is this a psychopath? Is this someone with a criminal personality? Is there evidence of someone with narcissistic or borderline personality? And the fact is, at least I haven't reviewed this case personally to the degree that a forensic psychiatrist would, I've been kind of keeping away from it, but from what I've read and from what I know from discussions is that this is somebody who had a pretty high functioning job, maintained I'm not talking about TikTok speculation, but no clear evidence of any kind of borderline I don't know if that makes sense, but that's basically what I'm advising.
It definitely does. Now, one thing that always irks me, and I'm sure it irks other people, is it feels like whenever there's one of these cases, there's one forensic psychiatrist on the defense who says it's this, and then there's a forensic psychiatrist on the prosecution who says the exact opposite. I guess my question is, when you're hired, do you ever reach the conclusion that the lawyer doesn't want you to reach?
Does that ever happen?
Well, I do, but I can't say the same for everybody. Since decades ago, I believe there's a publication called something like Forensic Experts or Psychiatric Experts Whores of the Court. There's always been the phenomenon of the hired gun expert. But what you see as the layperson or the jury member, what you see in court, you have to understand, is very filtered. We have an adversarial system in the United States that means you've got one side against the other, which means that each side, their job is to present the strongest possible case that they can because they know that their opposing side is going to present the strongest and most biased possible case that they can.
That's the job of the two sides. And then the finder of fact, either the judge or the jury, their job is to be neutral. So there's no expectation of neutrality on the two sides. And in fact, then if you kind of think about that, it almost is malpractice for them to be neutral instead of a zealous advocate on either side. Right now, how does that play into being an expert?
If you're a neutral and ethical expert, you will come to conclusions that do not help the side that appoints you. But then those conclusions never see the light of day. That's what happens. Generally speaking, if I do a insanity defense evaluation and I tell the defense attorney, hey, doesn't meet the criteria, often I don't even write an insanity report because that would be pointless. It doesn't help the defense.
Instead, they ask me to convert that report into a mitigation report. It's a report that explains why the defendant did what he did and how he's different, basically, from your run-of-the-mill psychopath or criminal. And then they use that report not for insanity plea because they wouldn't meet the criteria, but to bargain for a better deal or to get a lower sentence once they're convicted. So once you get to trial, you've basically found the experts that are most beneficial to your side and you're going to present those.
You're going to show your best evidence on either side. That's why it looks so biased.
Interesting. So there can be theoretically a case that you actually agree with the other point, but it doesn't look that way in the trial.
Yes. Okay. Interesting. And honestly, I wonder if there's a psychological impact of that, even if you are the expert that is going to be fair, neutral, Very good, like a Dr. Resnick, for example. But once you're on the stand, I think that if you're not giving the clearest testimony for your ultimate opinion on the case, you're actually doing a bad job. Because I'm going to say it again, I think everybody involved in the court is actually presenting the strongest argument they can.
And if you're wishy-washy or if you're not showing the clearest parts of your opinion, then you're actually almost hiding the truth from people because each side is basically playing a game of hiding some parts of the truth. So really the work is to highlight the elements of the truth that are most pertinent to one side.
Do you have any other points before I move on to my questions on psychosis?
I guess malingering is not as common as you'd think. Exaggeration of symptoms is probably pretty common, but basically people who are malingering, they tend to be Filtered out by that system. They get some experts in and only the least reputable ones will not notice that this person is malingering and write some kind of opinion. And then when that happens, then for example, the prosecution will read the report and they'll go like, well, this guy is clearly faking it.
And then we'll get me or somebody else in and we'll look at them and go like, well, he's clearly malingering. Right. So that doesn't really fly. It doesn't really go very far. And I think it should be noted that I don't think anyone has said that Lindsay Clancy is malingering, not even the prosecution's experts. Isn't that right? They've casted some doubts on the nature of her symptoms, I think, but they can't medically say that she was malingering.
And the fact is, medically speaking, there are rare cases.
Well, now let me just bombard you. So as I mentioned, I asked a bunch of different people questions that they had about this case. And I'm just going to throw a bunch of them out there at you and kind of see which ones you want to tackle. How do you evaluate the validity of statements? By someone who's just had a trauma versus statements made when they're on medications later on.
If Lindsay was having a delusion or hearing her voice, why wouldn't that stop her from answering the phone when Patrick called? Is it really actually possible to go in and out of psychosis in a day? Then Lindsay called Patrick back quickly and she sounded busy. So how do something like hallucinations or delusions react to something like an interruption?
Yeah, I think a lot of these kinds of questions, generally speaking, come from a more constrained view of psychosis. We have to remember that psychosis is an umbrella term. And we also have to remember that different types of psychosis exist, depending on what So the psychosis that you see in a disorganized schizophrenia is already different than the psychosis that you see in a paranoid schizophrenia. They got rid of the schizophrenia subtypes, but that was a little bit of an error, I think, because they at least showed you how broad the different presentations can be.
And then let's get out of that schizophrenia umbrella. When you get psychosis secondary to a mood disorder, a depressive disorder or bipolar disorder, then the psychosis is quite different. You generally don't see disorganization. You'll find that the DSM, when they talk about psychotic features of a mood condition, don't talk about disorganization. They talk about delusions and hallucinations only. Right. So that right away is what I'm going to point to for the Lindsay Clancy case.
No one is saying that this person has schizophrenia. Right. People are going like, how does this person have organized behaviors? Well, there was no claim. And we don't believe that there is anything that impairs organized behavior in this case. Right. Based on what we know. Now, let's talk
about... Slow that down a little bit. You said there's no claim. How can someone be psychotic and be organized, I guess? Can you explain then what does it mean to be psychotic in that scenario?
Psychosis is basically any kind of syndromic interruption or impairment in your ability to comprehend reality, as the rest of us face it. I know that sounds tautological, and it is. The reason why it is is because it's the best way we have to classify this. There are a lot of different reasons that people can not face reality. There can be psychological reasons like denial. There can be cultural reasons and religious reasons, but then that gets contentious because they think they have reality and we think we have ours.
But when it seems to be from a medical condition, it's because we can reasonably say that because it responds to treatment. The delusions, hallucinations, disorganized behaviors of the psychotic syndromes and the psychotic features of a bipolar disorder respond simply to medication. You don't have to do psychoanalysis. You don't have to do a long-term personality change. You treat that medical condition and the psychosis improves. So without getting too much into the terminology, that's probably what is best meant by a psychotic disorder or psychosis from a psychiatric standpoint.
So I guess when we're talking about her hearing a voice, do people have to act on the voice? Is the voice something that it demands them to kind of do something? Do the voices come and go depending on the scenario? Is she able to suppress the voice? Can you give me an idea of what you see with different cases?
That's the difficult part. It's extremely variable. And I want to highlight something here. In this case, the evidence points to postpartum psychosis. And postpartum psychosis is particularly unique among the psychotic syndromes. I would venture to guess that most psychiatrists have never seen it. And that's the tragedy, I think, in the civil cases against the poor clinicians that have tried to treat Lindsay Clancy. Whether or not they did right or wrong, it's a very unlucky and rare scenario to run into.
I think I only knew this stuff because I had a local slash national expert on perinatal psychiatry and women's mental health in my residency training program that I was able to learn from. And we were a big children and women's hospital on top of being a safety net hospital. So the most difficult psychiatric and maternal cases would come to our hospital. So we had a better chance of running into this basically.
Even so, I never saw postpartum psychosis. I saw a lot of Psychosis during pregnancy, but I never saw postpartum psychosis directly. I've treated it subsequently outside of training, but let me tell you a little story about postpartum psychosis from my co-resident. He did see someone on the floors during consultation liaison who had postpartum psychosis. She looked rock solid normal about 90% of the time. Her husband had no idea that something was wrong with her.
This is years before the Clancy case, okay? And my co-resident, I don't think really saw any deficits with this person either. She just reported depression and insomnia. But then about 40 minutes before visitation time for her family, suddenly she was rummaging through all the drawers and tiny little nooks and crannies of her hospital room looking for her baby, her baby who was with another family member. Okay.
She was absolutely convinced that her baby was hiding in the room somewhere. And then it passed after about 40 minutes. And then she was back to that rock solid normal that you see. There is this strange, very episodic, microepisodic fashion that has been documented in postpartum psychosis. Have I seen it myself? No, but I have heard of it and it is in the literature. So it is probably unique.
And if we think about mechanisms and the science behind it, it may be a completely different, uh, So with Lindsay specifically, what makes you think that she's psychotic?
And I guess what features lead you to thinking that?
Well, I think it's simply that in this case, I don't have my own true opinion, right? I didn't do an evaluation. I didn't review the records myself. I can't have my own opinion as a psychiatrist. I can only rely on the other opinions that have been made into the public, right? If the master, the grandmaster, let's say, of research on filicide and detecting malingering and malingered psychosis, Phil Resnick has an opinion of one kind, unfortunately, I'm going to have to go with him on it.
Okay. Again, this is the guy who basically wrote the book on malingered psychosis and... So I'm sorry to do an argument to authority, but the pretest probability of him being correct is extremely high. Second, as I've already gone over, the facts of the case don't really lean towards another kind of subtype of why someone would kill a family member. The facts of the case don't show different motivations, reasons, or personality type that would explain this behavior.
So unless we come up with some kind of a very complex theory about what happened that may or may not be rooted in reality, parsimony demands that we consider the possibility of psychosis. Third, there's actual evidence from multiple practitioners at this point, it seems like, that they would make a proper Axis-1 diagnosis of a mood disorder or psychotic features. And Lindsay Clancy seems to be still treated medication-wise for this condition.
I don't know if that's enough for most people, but that's pretty much why I'm settling on that end of things.
Well, let's go into Dr. Resnick's testimony. So in his testimony, he argued that it was altruistic filicide and she was driven by a delusion that her children were suffering and that she had to save them. Now, I guess, why do we call that a delusion? Why does a religious belief, I think there's a lot, everyone who is in the Christian religion is going to believe that the kids pass out and go to heaven.
Why would we call that a delusion? Why wouldn't we call that her religious beliefs?
Again, it's a contentious area, but it's an area also filled with misconceptions in my opinion. And I do think that a proper medical definition of delusion demands some kind of tautology. A delusion must be defined medically as a inflexible belief that originates primarily from a psychotic syndrome. OK, that's not very good definition, but I think it must be done. Why? First of all, the traditional erroneous definition of fixed false belief, which, by the way, is not written in most places and not accepted in most places, is not a good definition of delusion because there are many fixed false beliefs that don't come from a psychotic disorder.
OK, sovereign citizens, for example. A variety of niche religious beliefs, anti-vax, sorry. There's so many different beliefs that come from culture, individual learning and error, and religion that many people would be willing to call fixed false beliefs that you can't use that as a definition. The cleanest definition, again, is that you can locate some kind of a medical condition that responds to medical treatment, is not part of the person's baseline belief system, and that the belief is not acquired through normal rational, cultural, or social avenues.
Even if they may resemble it. The classic version that I like to talk about is the paranoid and psychotic guy who thinks that his wife is cheating on him. If he thinks that his wife is cheating on him because he saw a pattern of lights flashing at 3 m. when he was monitoring the neighbor's window and then he knows that the neighbor is surveilling him and that he was trying to let him know that the surveillance cameras hidden all across the house also captured his wife cheating on him.
That's a delusion. It's the product of psychosis. It comes from a process that's not cultural, rational, religious, social. And then it doesn't matter if the man's wife has actually happened to be cheating on him at the time, right? The reality status of that belief doesn't make it a delusion. So in the same way with the Lindsey Clancy case, even if the idea sounds somewhat mundane, even if the idea sounds like something that another religious person could potentially believe, you have to look at what is the power of this belief?
Where did it come from? And is it different than that person's baseline? And if this person had a baseline of believing that she should be dead, And that her children should be dead and would be better off dead. Then why did it take all the way up until that point and so much attempts at treatment to act? Okay, this is a high functioning person, right? She is a nurse, I believe.
She knows a lot of different ways for people to die. Why would she choose the way she did things? It looks irrational compared to the backdrop, right? It's a new type of behavior. Similarly, people who want to say that she's a psychopath or that she just got sick of being a mom or sick of her kids. You know, most people who want to leave their children, they don't get themselves into jail.
They just leave. They just abandon their kids. Right. That's what a rational person does. So the whole context and sequence of events just screams mental illness to me. Mm hmm.
Now, I want to talk a little bit about the voices. So a lot of people are skeptical of Clancy claiming there was an external voice to kill her children. What makes something a voice versus a thought Sometimes I have thoughts and I don't know where they come from. It's not like whether or not I call it a voice. It's also normal for people to have thoughts that are not congruent at all with what they want to do.
Thoughts that go against their value system. People are often disturbed by those thoughts. It doesn't mean they act on those thoughts. What makes us say that this was a command auditory hallucination? What made it so that you had to act on it?
Yeah, I think this is a combination of little hocus pocus from the prosecutors combined with the really wacko not guilty by reason of insanity statute and tradition in Massachusetts. It honestly doesn't matter whether someone heard a voice or not when it comes to not guilty by reason of insanity, because whether or not it's a voice is actually more of a question of does this person have a mental illness that's psychotic in nature or not?
That's really the fundamental question to be asking, not whether or not someone heard a voice. And in other states that have more traditional insanity defense, it's not enough to hear a voice and follow the voice. What you believe at the time has to justify you following that voice in some sense, in a manner that would mean that you didn't understand it was wrong. I'll give you an example.
Even if someone has a diagnosable schizophrenia, And they hear voices telling them to kill random people. That's not enough for insanity defense in the traditional model. Because what if the voice is Satan? Then that's evil. They can understand that evil things are wrong. You have to follow some kind of a baseline morality. If you're fundamentally a psychopath, then it wasn't the voice that was impairing you. It's basically your psychopathy, right?
This is kind of a version of a real case I did. If you go out and follow voices because you think it's going to make you a million dollars and turn you into Satan's top soldier, that's not qualifying for the insanity defense, at least in my area. That's, I think, rational. That's a good construct to follow. If you do have some kind of a thought and it's an overpowering thought and that thought comes from a severe mood episode where you lose the ability to behave in a normal fashion under the Massachusetts system, that could work because they're not concerned about the morality of the thoughts so much as they're concerned about whether you can control yourself.
So Let's get past that nitty gritty for a second. What are the different kinds of voices? Just like psychosis, voices can come from a lot of different mental conditions. It can come from being an ordinary person. Some people simply hear an internal monologue, for example. For some people, that internal monologue is a lot more strong. And persistent than other people. You can also have voices from schizophrenia.
You can have voices from psychotic features of a mood disorder. You can also hear voices that are essentially dissociated of thoughts or even memories in the trauma disorder. There are a lot of different sources to the voices. So I think belaboring the point of was it an external or internal voice or not is basically irrelevant. I think the better question is what was the mental state of the person at the time of the crime and how are they being impaired?
So there was a bunch of different clinicians involved in this care. And there's one camp that's saying that she was she was doctor shopping. There's another camp that was saying essentially she got really fragmented care. The clinicians weren't talking with each other. What do you feel like are the big what are your big takeaways with regards to what we should learn from this case?
It's an unfortunate aspect of how the free market in the United States creates a bunch of different avenues to seek healthcare and that none of the avenues aren't necessarily all that great and it can just worsen the field for everyone. I think there's takeaways both for clinicians and for patients. For patients, the biggest error I see is shopping around as if you're going to different restaurants for healthcare.
Now, if you see a very clear reason why you should not continue seeing the same person, That could be a reason to change, but especially in mental health treatment, emotions and our own relationship baggage naturalistically come into the treatment. This is well known and well demonstrated. So because of that fact, you should try to stick with one therapist or psychiatrist longitudinally. Why? Well, first of all, the ability to gather information about your case and your mental health, that relies on time and repeated observation.
So if you don't stick with one person and they don't observe you repeatedly, that conclusion and therefore the treatment plan can never really be improved and refined. All you do is you get the initial impression with a bunch of different people. And as a consumer, as a patient, you have no clear metric or way to tell if someone's good or not. I think they've done studies and the perception of a clinician by a patient as good or bad actually doesn't track well to their actual clinical expertise and outcomes.
Basically, someone can be a real jerk and they could be a great doctor and someone can be really nice and sweet and you feel like you're really being listened to and it can be a terrible doctor. Of course, I probably have a vested interest in saying that because I see myself as a mean guy who's a pretty decent doctor.
Yeah. And one thing I really want to bring up there, one of the doctors, I think it was one of the inpatient doctors, they essentially, they quote unquote ruled out bipolar because she didn't have hypomania and she didn't have psychosis in her family history. So they ruled out bipolar and they scrapped the bipolar treatment. One thing I want patients to understand is... A doctor can't talk to you for 45 minutes and know with 100% confidence what your diagnoses are.
And you essentially can't rule out conditions by meeting and talking to someone with 45 minutes. A good clinician develops a differential. Has a leading hypothesis as to the diagnoses. And then the other diagnoses are in consideration. And then as you learn more and more about the patient, you either get more evidence for a particular diagnosis. So it goes up or down on the differential. I want to say in so many of my patients' cases, I say, I have to explain, this is what I think is the diagnosis.
I'm considering these things, but the reasons why I'm not making them a primary treatment target right now is because of this evidence. That said, as we get to As I work with you, as I see you over time, it's very possible that my differential is going to change. I think bipolar is a great example because very commonly I'll say, there's this evidence for and against, but right now I think we can still consider treatment just for major depressive disorder.
However, if we see this, this, this, this, then I need to move bipolar up on the differential. I say all this in that a clinician can't talk to you once and just flat out rule out all these conditions. That's not how psychiatry works.
Yeah, a good clinician, their motto should be never say never, right? It's not, you absolutely don't have this. It's that my working theory is currently this, but we're going to continue to screen, monitor, and watch out for XYZ. That's the best approach. And I don't think that's really being done or communicated a lot of the time out in the community. You've seen, and of course there's some psychological reason that some patients do this, but many patients will say, I absolutely do not have this particular diagnosis, and this doctor told me that, and I'm going to hang my hat on that.
That's just not how diagnosis You can't have perfect tests. There are no perfect tests in medicine, even ones where we look directly into the body. So you can't just say, I know this is the case. What you have to do is that you have to stay in the open and honest and long-term evaluation process. Clinician does not seem to be open to reevaluation and continuously reevaluating instead of just asking you about your medications and refilling them, then that could be a better reason to find someone who's more focused on assessment.
The other thing for patients, I would say, is that unfortunately, you got to be honest. The quality of your care depends entirely on honesty because the S. system does not allow for any kind A feasible sharing of records. Even when there are exceptions in the law to say that we should be able to access the past records by putting in a request, you will find medical records departments and other clinicians dragging their feet or even not sending any records at all.
So people who said that the clinicians sort of accessed the records, sure, in a pretend world, but not feasibly in the United States. And until we come up with some kind of a universal system of storage of medical records, which I don't think we're going to get, it's just not possible. And you, the patient, are the only... Single person who can coordinate the care and report everything to everybody.
And yes, I know there are good reasons not to be honest sometimes because of the nature of the system, but it's a garbage in garbage out situation. If you don't tell the truth to the best of your ability, then your treatment plan and the assessment is going to be flawed.
Yeah, I'm so glad you're bringing up. In regards to getting notes, when I worked inpatient residency, I spent so much darn time trying to contact outpatient clinicians. And I would say about 25% of the time, I was actually able to get in touch with them and have them send me my notes. Now that I'm outpatient, I spend so much darn time trying to talk with other outpatient psychiatrists and they don't.
It's incredibly frustrating. Just this last week, I had a therapist. I scheduled two collateral calls and they just skipped both of them. It's It's incredibly frustrating. Now, to your point, with regards to sharing information, when patients send me all their prior notes, it's incredibly helpful for me. And when I say I've had a patient make up a few of the details with bipolar, they're not sure if And they don't want their previous psychiatrist's opinion persuading me one way or another.
What I told that patient was, I hear you, and I'm never going to rely on a past report or a single person provider. Yeah.
Now, that's on the patient side. On the clinician side, I think the things to learn from this, unfortunately, it is to take documentation, assessment and diagnosis and bipolar disorder more seriously. I think there's a disturbing trend in the community that is probably a reaction to the popularity of giving unwarranted bipolar diagnoses about 10, 15 years ago that Kind of writes off the possibility of bipolar too quickly.
It rules out bipolar too quickly. And it also sees bipolar disorders as this very, very specific slice of humanity who presents literally in front of you with mania and hypomania. Okay, it's as if unless this doctor sees mania and hypomania in front of them, the bipolar disorder cannot exist. That's not how you should practice medicine, right? We need to practice medicine with a full, open weighing, a differential diagnosis of what are the possibilities.
And on that end, you also need to recognize the lower grade versions of bipolarity that wouldn't be classified as a bipolar disorder because they still warrant clinical attention and consideration of mood stabilizers and possibly avoidance of SSRIs. Right. This is everything from people with only one to two day duration of mania, hypomania symptoms. This is people with something that sounds and looks like a mixed depression, even if it never meets criteria, DSM criteria, meaning someone who's primarily depressed, but has a lot of agitation and insomnia.
And of course, this includes the people who have prolonged agitation or worsening symptoms and suicidal ideation on SSRIs. Different than the agitation and sleep disturbance that we would see in someone who simply has anxiety, if you see substantially worsening sleep and physiologically improbable sleep, like three, four, five hours in somebody, especially when they don't have a trauma disorder, You really need to start considering the possibility of bipolar and that someone may need augmentation with mood stabilizers.
And I have good news. Next week, we have a podcast coming out with Dr. Phelps talking about hypomania and the bipolar spectrum. But I wanted to use this time now to address a question that someone asked me in regards to what do we make of how... Now, I do not hold out hope that the next DSM is going to be the arbiter of truth and get more accurate.
The problem is something with like bipolar and mood disorders in general, they really exist on a spectrum. And when I think about bipolarity, I don't think of it as a binary. Someone has bipolar one or bipolar two or nothing. It's a spectrum. And the question that I ask is how. How bipolar is this patient? We talked about a negative response to SSRIs. In that podcast next week, Dr.
Phelps calls, whenever a patient has what he calls misadventures of SSRIs, the patient takes an So if you have an SSRI and has a response that's really not typical, severe insomnia, severe anxiety, just a very abnormal reaction to an SSRI, you have to consider bipolarity. It doesn't mean the person necessarily is bipolar 1, doesn't mean they're necessarily bipolar 2, but the degree of bipolarity is going to increase in that.
The amount of bipolarity you think that exists in that patient has to increase.
Yeah, absolutely agree. Real briefly, I think there are three major camps that you see when you see a negative response to SSRI. One is the bipolar or bipolarity patients. Okay, that's a significant portion of them. Another is that the source of the depression is personality disorder or trauma. Okay. And then another is severely anxious patients and somatoform patients. Now, if it's the other two groups other than bipolar, it's a little less dangerous to persist with the SSRI.
But when you persist with SSRI in someone with bipolarity, that's where it becomes more harmful and dangerous. And there are other treatment options. So I do think we've become a little too relaxed in prescribing SSRIs. We think that they work on everything, but really we need to be doing more assessment and formulation. Now, some final points I want to get into before we finish. I think these are the key clinical knowledge takeaways.
Number one, you cannot rely simply on your own clinical experience and DSM diagnostic criteria to teach you about psychopathology. If you really want to learn about psychopathology, you are going to have to do your own reading and get your own clinical experience. You have to read your systematic reviews. You have to read your textbooks. Okay. I don't think the DSM is actually limited. I think people's understanding of the DSM is limited.
They've probably never even read under other specified bipolar disorder where they talk about subthreshold hypomania. And then to that end, if you want to detect bipolar disorder as well, you don't do that by examining the patient's mental state in front of you and simply asking about mania and hypomania. You do that by looking at how recurrent their actual major depressive episodes of neurovegetative symptoms are, when they started, how long they last, and how frequently they occur, and looking at things like family history, life course, and response to different types of medications.
So take a thorough medication history and document it. Take a thorough sleep history and document it. And you guys can listen to our other episodes for some tips on that. You should be advising patients about risk of suicidal ideation and agitation from SSRIs. Again, this is really primarily probably in bipolarity, but it is a risk. And as a field, we should really understand that about 50% of postpartum major depression, not baby blues, not just depression, major depression, is ultimately found to be a bipolar disorder.
Okay. Lithium is extremely important in the treatment, then, postpartum mood. Lithium-initiated postpartum has the strongest evidence for the prevention of postpartum psychosis. And in postpartum psychosis, highly linked to bipolar disorders. Only 25% to 50% in studies of postpartum psychosis have isolated psychosis. The rest, up to 75%, have bipolarity if you examine them longitudinally.
I think that's a great overview. I'm paying attention to time. We're running close to being out of time. I think we jammed a lot in here. I think we both could talk for an hour on postpartum depression, postpartum psychosis on depression. The problems in our field that kind of led to these things. On our lessons, we could probably talk about voices. There's a million things. I guess whether or not we're going to do another episode, people ask questions.
And we're not just saying this to get engagement. Yeah, engagement. I think if people have questions and there is interest in this stuff, we will do another episode. If it's the sort of thing that we're too late to the viral wave, I guess we'll move on to our next clinical point.
But there are important lessons, I think, to be taken from this case. There's a lot of heated emotions all over the map for clinicians and patients, but it's important, I think. It's important in education and for us to get better as a field. Absolutely.
All right. Well, I guess I'll catch you next time.
Until next time.