Brig. Gen Rhonda Cornum, the recently named head of the, “Comprehensive Soldier Fitness Program”, stated that the violence at Ft. Hood was no more predictable then previous episodes of violence against other soldiers in garrison. I was stationed at Fort Rucker, Alabama in flight surgeon training when then Maj. Cornum, herself a Flight Surgeon, returned from the Gulf War in 1991, one of two females captured in that war. She was taken prisoner when her helicopter was shot down during an attempt to rescue a downed F-16 pilot. After three days of beatings and humiliations, she was released from Iraqi prison. Her resilience and heroism as a prisoner of war convinced many in the Pentagon at the time that women could indeed serve on the front lines. And now, as a general officer, she is an authoritative voice on this violence issue.

But, Maj. Nidal Malik Hasan is not, and was not, just a soldier. Prior to his assault on fellow troops his behavior was disruptive, his performance lacking, fitting the description of what is now called “Disruptive Physician Behavior”, a syndrome that I have written about elsewhere (see http://www.medscape.com/When Behavior Disrupts the Physician-Healer). The function of these physicians deteriorates under stress due to personality structure, mental, and physical disorders. Malik-Hasan, impaired as evidanced by a preoccupation with a precived conflict between his faith and his duty, regardless of the specifics, exhibited disruptive behavior well before his violent rampage. Even Cornum acknowledges “hidden traumas” for soldiers.

What, then, are we to make of her statement that, “…one individual act of murdering tells me (nothing) about the fitness of the 1.1 million people in the force”? It tells us the culture in the military regarding mental health that, if not examined, will allow such catastrophes to happen again. Demographic and situational correlates such as base rate of such instances, age, gender, race, socio-economic status, availability of weapons and victims, job stability, peer relations, and family systems can, and should be considered when a homicidal or violent individual acts (Monahan, 1981; Meloy, 1987a). Even the civil courts now affirm the admissibility of demographic information as “character evidence” in capital cases.

The usual “good order and disipline” in the military may have delayed the wider use of such data concerning the dangerousness of such individuals in the past, but, in a country waging two wars for almost a decade, and, with multiple deployments now the norm, the multitude of situational and individual variables that may precipitate homicidal and violent behavior must be assassed.

Careful study of the pattern, or instance, of target selection in this and other cases of violence against fellow soldiers can make reasonable inferences about the nature of the individual and how they, and others like them, might behave when stressed and confronted with their most primitive and aggressive impulses. In this case, the pattern of target selection seems predictable and, given the size of the potential victim pool (the 1.1 million service members Gen. Cornum mentioned) demands an assessment of any one individual’s dangerousness.

So, if what I say is true, what can we observe about Dr. Malik-Hasan’s behavior and, by inference, his state of mind, on that fateful day? First it is clear that violent and homicidal behavior occur in primitive mental states, in most cases, when individuals are regressed due to stress in individuals who lack mature coping mechanisms. Psychoanalytic theory tells us that three factors are important in determining such states-of-mind of murderers at the time of a killing: First, he perceives important relationships to have failed him, or, feels compelled to right past wrongs previously repressed. Second, he losses touch with reality, misperceiving threats in his environment, and, third he reacts to his experience of internalized aggression. Analysis of these three factors can generate empirical evidence that reflects the state of mind at the time of the murder (Maloy, J.R. 1988). Translating this into predictive data is a bit tricky, but not impossible, and it is this fact that has lead to a movement to identify Disruptive Physician Behavior, find the cause and treat it before the physician, or anyone else suffers. In episodes of violence, the individuals mental picture of important relationships may be inferred by the pattern, or instance, of target selection, and, proactively, but observed relationships with authority figures, subordinates, and colleagues.

In Malik-Hasan’s case, the Army, the community he had defied his parents to join, the caretakers who had given him so much in terms of education, prestige, rank, and social standing, seemed to have failed him. How could this institution fail to recognize the deep personal conflict with which he believed himself to be confronted by? We know he expressed it to superiors; we know he tried to get out; we know his performance suffered; we know he was transferred and ordered to war. And, we know he killed the one’s he was trained to protect. In regard to his ability to test reality, how could he think, after the Army invested so much in him, that they would just let him go? How could he ultimately seem his colleagues as enemies or threats? These errors of mental processing influenced both his motivation and his perceptual-conceptual experience (Meloy, 1985); Reality testing has both distinguishing and evaluating properties. The distinguishing property, a sensory-perceptual task, is most useful in determining the individual’s capacity to separate interoceptive and exteroceptive stimuli, that is, what’s going on inside his head versus what’s going on in the environment.

It is not, as some might think, intuitively obvious that what was going on in Malik-Hasan’s head was more important then what was going on in the environment. Doesn’t everybody think that way? No. In point of fact it is a significant misperception of reality, a break down of the psychodynamic most akin to determining the individual’s ability to distinguish right from wrong. In assessing Malik-Hasan at the time of the alleged violence, there are three possibilities: He did not know, he did not care, or, the thought what he did was right. Third, we must consider his mode of aggression can be classified as either affective (I feel angry) or predatory aggression (Cold and calculating). The two general categories of aggression have distinctive neuro-anatomical pathways and are controlled by different sets of neurotransmitters (Eichelman, Elliott, and Barchas, 1981).

Affective aggression is the result of external or internal threatening stimuli that evoke an intense and patterned activation of the autonomic nervous system, accompanied by threatening vocalizations and attacking or defending postures. If this was present in Malik-Hasan, it has not been reported and, it is my guess, that those around him would have reacted much differently to his overtures had this been evident.

This was not a crime of passion.

It is true that many of the pathways in the brain that control this type of aggression are tied closely to the spinothalamic tract and the periaquaductal gray which closely links affective aggression to pain responses (Eichelman et al., 1981). It is not too much of a stretch to imagine that Malik-Hasan was frightened and in pain. More likely, however, in this case is that Malik-Hasan was in the throws of predatory aggression in humans, which explains the international occurrence of war, is the hallmark of the violent seen in this case. Predatory aggression requires intent, planning, and emotional detachment. Any one act of predatory aggression in a pattern of violent behavior significantly increases the likelihood that a psychopathic character disturbance exists, a problem that is identifiable before manifest violence, if one is inclined to look for it.

So, what could have been done and should be done going forward? The person needs to be talked with, and listened to. Such clinical investigation should focus on the individual’s conceptions of others. Is there sufficient evidence through his reminiscence, evaluation, judgment, and affective responses that he conceptualizes others as three-dimensional, whole, and separate individuals? Or does he reflect, a narcissistic self-absorption, or worse, a callous disregard for the thoughts and feelings of others? Assessment of reality testing through the use of a projective technique like the Rorschach that is dependent upon indices of perceptual distortions (Exner, 1986) is not enough. The interpersonal history is critical to understand the individual’s perspective, his perceptions of others, and his reality testing. The individual’s capacity to suspend empathic regard, to plan and carry out an act that inflicts suffering on another, and to decide that this is the best course of action among all other actions can not exist without telltale signs that can and should be taken note of and accounted for.

It is my experience having assess, treated and returned to productive practice many individuals whose behavior was identified as disruptive, that such a program of identification, intervention, and treatment to, “Conserve the Fighting Strength”, as stated in the motto of my former Regiment, can and should be instituted in the military. Careful analysis of these variables in the military settings should be based upon clinical interviews, a reliable and corroborated history, and psychological testing.

Meloy, J.R. (1988). Violent and Homicidal Behavior in Primitive Mental States.

http://usacac.army.mil/CAC2/cgsc/Events/CSF/images/cornum.jpgJ. Amer. Acad. Psychoanal., 16:381-394

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Crist under fire from GOP
Charlie Crist: statesman or sellout?

All this because of a man-hug for Obama…

Democrats may be lavishing praise on Florida’s Republican governor for enthusiastically supporting the Democrats’ economic stimulus package, but Republicans are questioning whether Crist damaged his future in national politics.

“I don’t think he’s helped any national Republican ambitions he may have by stepping up to the plate and batting for the other team. … There’s a difference between working in a bipartisan way for the common good and switching sides and putting on the other team’s jersey,” said veteran Republican consultant Alex Castellanos. “At the one moment when we’ve finally found our voice and remember who we are as Republicans, Charlie Crist forgets. It’s stunning.”

Story here

Another perspective…

November 13, 2009

Here’s another perspective…
http://stjoenews.net/news/2009/nov/09/fort-hood-shooting-begs-some-answers/?opinion

Here is a copy of an article I wrote on how to interpret changes in physician behavior that are found to be disruptive by those around them. I think you will see that Army Maj. Nidal Malik Hasan exhibited many of them before his rampage:

A physician’s behavior may be defined as disruptive when it ceases to be normative: A disruptive physician can be the surgeon who berates colleagues, residents, and nurses for not performing to his or her standards, and yet constantly violates protocol, arrives early or late for procedures, and disappears at the most inopportune moments.[1] The internist who never uses drugs on the hospital formulary but refuses to serve on the pharmacy committee may be considered disruptive. The pediatrician, a favorite of patients’ families, who never completes paperwork but lets it be known that the blame for a child not getting the care that the family believes is needed lies with the administration, nursing staff, and managed care providers who conspire together to prevent the doctor from practicing good medicine may also be considered disruptive. Such behavior takes its toll. Such disruptive physician behavior can undermine the morale of individual staff members, weaken the effectiveness of the medical team in delivering care to patients, spark lawsuits, make it difficult to hire and retain a good staff, and negatively affect the reputation of the institution as well as that of the entire profession. Results of a new survey show that when physicians exhibit disruptive behavior as this, it fuels the nationwide nursing shortage by affecting on-the-job satisfaction and morale for nurses: “The disruptive physician attempts to manipulate supervisors, staff, and patients. . . .[2]”

The disruptive physician attempts to manipulate supervisors, staff, and patients, often passive-aggressively defying their orders and requests or requiring endless repetition of the same that results in only grudging follow-through. Such physicians will have often “acted out” in some hostile manner. They exhibit verbal hostility, throwing of charts or instruments, hitting desks or computers, or slamming doors. Vague threats against staff, colleagues, and supervisors can also be attributed to such individuals, although these are usually in the form of threats of legal action or administrative action, and not physical harm. Although the physician’s ability to handle the day-to-day job requirements appears satisfactory, he or she often shows poor judgment at work by ignoring established policy or performing tasks at the mere fringes of acceptability. Although the physician is often cordial to coworkers and others, he or she is also volatile and appears overly sensitive, and may even go through periods when he or she does not talk to coworkers because they are irritating.

Contrary to tradition and opinion, such behavior should not be ignored. There are generally agreed upon definitions of disruptive behavior that can be found in the American Medical Association (AMA) Policy H 140.918-Disruptive Physician and in the Joint Commission On Accreditation Of Healthcare Organizations (JCAHO) Medical staff chapter, Physician Health, M.2.6, which will soon demand that all hospitals have well-being committees to handle just such concerns.[3] A 1972 report of the AMA Council on Mental Health defined physician impairment. Certain managed care guidelines broaden the definition of an impaired physician. Along with physicians who are unable, or potentially unable, to practice medicine with reasonable skill and safety is the “disruptive” physician. These physicians may not have identifiable substance abuse or psychiatric disorders, but may still be the subject of action. Even conditions, such as extreme fatigue and emotional distress, can cause impairment, even if only temporarily. Physicians who, because of chemical use, mental or behavioral problems, or physical illness, pose a danger to patients are, by definition, impaired. They may be unsafe to practice medicine, and the danger may be direct or indirect, such as when their interactions with other staff and patients interfere with providing medical care. Clearly, a physician who manifests aberrant behavior that appears to compromise the quality of patient care should be placed under observation. However, what if the behavior is not deemed to present an immediate danger to patient safety? In the past, medical staffs have tolerated a wide range of such behaviors. A set of parameters recognized as a broad standard needed to be identified. The standards needed to be flexible, yet offer guidelines to managers, wellness committees, and boards.

Initially the disruptive physician who attempted to manipulate supervisors, staff, and patients, often passive-aggressively defying their orders and requests or requiring endless repetition of the same with only grudging follow-through, would not have fit any description of impairment. Even physicians who acted out (in the psychiatric sense) in some hostile manner by exhibiting verbal hostility, throwing of charts or instruments, hitting desks or computers, or slamming doors were to be tolerated. Vague threats against staff, colleagues, and supervisors (usually in the form of threats of legal or administrative action) did not fit the pattern. As long as the physician’s ability to handle the day-to-day job requirements appeared satisfactory, ignoring established policy or performing his or her job at the mere fringes of acceptability was to be tolerated. As long as the physician was cordial to coworkers and others, he or she could be volatile and overly sensitive, and even go through periods when he or she does not talk to coworkers because they are irritating. Contrary to tradition and opinion, such behavior should not be ignored. On January 1, 2001, the JCAHO issued new medical staff standards (Joint Commission on Accreditation of Healthcare Organizations [JCAHO] Medical staff chapter, Physician Health, MS.2.6) that require hospitals to implement a nondisciplinary process for the identification and management of matters of individual physician health.[4,5]

The JCAHO has stated that healthcare organizations have an obligation to protect patients from harm, and that they are therefore required to design a process that provides education and prevention of physical, psychiatric, and emotional illness and facilitates confidential diagnosis, treatment, and rehabilitation of potentially impaired physicians. The focus of this process is rehabilitation, rather than discipline, to aid a physician in retaining or regaining optimal professional functioning, consistent with the protection of patients. However, the standards also direct that if, at any time during this process, it is determined that a physician is unable to safely perform according to the privileges that he or she had been granted, the matter is forwarded to medical staff leadership for appropriate corrective action. Such action includes, but is not limited to, strict adherence to any state or federally mandated reporting requirements.

The process design should include:

Education of physicians and other hospital staff about illness and impairment-recognition issues specific to physicians;

Self-referral by a physician;

Referral by others and creation of confidentiality of informants;

Referral of the affected physician to the appropriate professional internal or external resources for evaluation, diagnosis, and treatment of the condition or concern;

Maintenance of the confidentiality of the physician seeking referral or referred for assistance, except as limited by law, ethical obligation, or when the safety of a patient is threatened;

Evaluation of the credibility of a complaint, allegation, or concern;

Monitoring of the affected physician and the safety of patients until the rehabilitation or any disciplinary process is complete and periodically thereafter if required; and

Reporting to the medical staff leadership instances in which a physician is providing unsafe treatment.[4,5]
AMA policy (H-140.918 Disruptive Physician) also provides guidance on how institutions should recognize and respond to disruptive behavior[6]:

(1) Personal conduct, whether verbal or physical, that affects or that potentially may affect patient care negatively constitutes disruptive behavior. (Criticism that is offered in good faith with the aim of improving patient care should not be construed as disruptive behavior).
(2) Each medical staff should develop and adopt bylaw provisions or policies for intervening in situations where a behavior is identified as disruptive and refer such concerns to a medical staff wellness – or equivalent – committee.
(3) Each medical staff should develop and adopt a policy describing the behavior or types of behavior that will prompt intervention.
A channel through which disruptive behavior can be reported and recorded must be provided, and a process to review or verify reports of disruptive behavior must be elaborated. Further, a process to notify a physician whose behavior is suspect that a report has been made and providing him or her with an opportunity to respond to the report are essential. It must be remembered that a single incident may not be sufficient for action, but each individual report may help identify a pattern that requires intervention and so should be recorded, at least for a time. After an intervention, a means of monitoring whether the disruptive conduct improves must be in place.[7] State physician wellness/impairment programs provide many of these services, and many a medical staff has opted to write policies immediately referring suspect behavior to such programs.

This author takes an interdisciplinary and multisourced approach to such work. Comprehensive approaches involve an analysis of biological, psychological, and social questions. The author is also careful to distinguish between involuntary distortion and intentional deception, which is important not only to identify problems but to account for inconsistencies in reports. To arrive at conclusions regarding deception, the author presents testing tools that remove much of the subjectivity that plagues investigations. For example, on occasion neuropsychiatric, neurophysiologic, and imaging studies may be indicated. Most importantly, the following information should be used:

A review of the requested background information (eg, personnel records, medical records, incident reports, or memos);

Psychological testing with assessment instruments (eg, personality, psychopathology, cognitive, or specialized) that are appropriate to the referral question(s);

A comprehensive, face-to-face clinical interview;

Collateral interviews with relevant third parties if deemed necessary by the examiner; and

Referral to, and consultation with, a specialist if deemed necessary by the examiner.
Prior to conducting collateral interviews of third parties, care should be taken to obtain informed consent from the hospital, the physician, and from the third party, as appropriate. This should include, at a minimum, an explanation of the purpose of the interview, how the information will be used, and any limits to confidentiality. Because a large proportion of new-onset disruptive behavior reflects a significant alcohol, drug, or psychiatric problem, a formal fitness-for-duty evaluation by medical and mental health professions should be the standard for interventions of this type. Contrary to the spirit of the “conspiracy of silence” that serves to hide our human frailties, it is confrontation that allows such misery to be identified, as we help to improve the lives of our colleagues, protect the public, and make the medical workplace more tolerable.

In closing, it is important to note that the potential for abuse of the system by those in the power position exists; it goes without saying that protection needs to be in place to protect the rights of the suspect physician, both because of the possibility of misinformation having generated the complaint and in deference to the suspected impairment that may, in principle, diminish the capacity of the individual. Since 1990, with the creation of physician hospital organizations, the advent of managed care and management services organizations, and increased focus on credentialing and peer-review processes in physician health programs, originally designed to help sick physicians get help and avoid discipline, has, on occasion, become inappropriately focused on practice issues that are beyond their purview and that intrude on the medical board’s prerogative to restrict physician practice. This intrusion can be limited by objective clinical guidelines that limit arbitrary and capricious decision making. Commissioning an outside review, assuming that it is objective, offers the best hope for a fair outcome that is not self-serving. Most medical staff bylaws allow that independent committees can be overruled by the Medical Education Collaborative (MEC) and Board of Trustees.[8] To be sure, physicians and hospitals need protection from potentially “troubled” physicians. The goal, however, is to place the burden of proof on the hospital, or the impairment committee, not the physician and to ensure that substantive due process is given to the accused physician and assured by administrative law experts.

When Behavior Disrupts the Physician-Healer

This is a re-post of my interview with The Gezzette about the Ft. Hood Massacre:

Drawing a straight line between secondhand trauma and a military base shooting is easy but could be misguided.
Although Maj. Nidal Hasan, who allegedly killed 13 people and wounded 30 more Thursday afternoon at Fort Hood in Killeen, Texas, worked with combat veterans at Walter Reed Army Medical Center in Washington, D.C., his secondhand exposure to the horrors of war should not yet be treated as a decisive answer to questions surrounding his potential motivations in the shooting, according to mental health experts with military backgrounds.
Terms such as Vicarious Stress Disorder and Compassion Fatigue are used by mental health professionals when discussing their own reactions to patients with Post Traumatic Stress Disorder (PTSD). But their usefulness in explaining the violence allegedly committed by Hasan is unclear.

“It’s a hazard of working in the profession,” said Glenn Schiraldi, a former professor at the University of Maryland who worked at the Defense Department on stress management issues and wrote a book on World War II survivors with strong psychological profiles. “But again, it doesn’t seem to account for this fellow’s behavior.”

“I think it just muddies the water more than clarifies anything,” said Dr. Joseph Molea, a former surgeon in the Army who spent time at Walter Reed and now practices psychotherapy in Florida.

Some psychiatrists report being overwhelmed when dealing with a large caseload of traumatized people such as victims of the Sept. 11, 2001 terrorist attacks, according to Dr. Robert Heinssen, a director at the National Institute of Mental Health in Bethesda and behavioral health officer for the Maryland Army National Guard for the past five years.

“This phenomenon is not uncommon, that people could experience some trauma…hearing these stories retold time and time again,” Heinssen said.

Heinssen and Molea also said they were unaware any research on the topic of how mental health workers in the military deal with the constant exposure to trauma. Such studies have taken place on emergency first responders in civilian settings.
But the same support system for civilian psychologists, who talk to each other about issues facing their patients and how they as professionals can cope, exists for military mental health workers to use.

“A good social support network is really critical in maintaining your resilience for this kind of work,” Heinssen said.

Failure to use that network and not discussing personal issues with ones work, on the other hand, can lead to dangerous consequences.

“If you hold all that stuff in, you’re only taking your own counsel, and when you take that to an extreme, that’s what psychosis is,” Molea said. “Once that line is crossed, anything can make sense.”

Despite reports about how Hasan’s personal background, his state of mind and his beliefs may have influenced his actions, Schiraldi said trying to understand the doctor’s actions based on hindsight and red flags was not necessarily helpful. Molea said Hasan’s work may have merely “fueled the fire” of Hasan’s other problems.

“I don’t know how you could prevent something like this from happening,” said Schiraldi, adding that prevention and equipping military personnel with proper coping skills should be the military’s ultimate objective in such situations.

Soldiers who served overseas and may have previously felt secure at military bases could have that confidence shaken in the short term because of the Fort Hood incident. Heinssen cited the case of people in the Louisiana National Guard who returned home from tours overseas before Hurricane Katrina struck in 2005.

“Hardship, suffering, all that was something that they could handle in Iraq, they understood that was war,” Heinssen said. “…out of nowhere, there was this natural disaster.”

Molea worried about policies that may aim to protect soldiers more carefully after the Fort Hood shootings, such as screening Muslim soldiers or creating a “bunker mentality,” but instead just represent an overreaction and could destabilize military cohesiveness.
He also worried about the lack of a strong psychological screening process for soldiers returning from combat.

“They’re going to have to do some work with troops to regain the sense of safety and stability,” he said.

Still, mental health workers and researchers said they were confident soldiers would not suffer long-term doubts about their safety with comrades and on military installations.

“They’ll get better,” Schiraldi said. “They’ll get over it.”

Mental health experts say reason behind Ft. Hood attack unclear

Here is my interview by the Tampa Tribune about the Ft Hood shooting:

TAMPA – The irony is inescapable: a military psychiatrist, trained to help soldiers deal with internal demons, apparently succumbs to his own and is accused of going on a rampage at a Texas army base.
Investigators say they are determining what motivated Army Maj. Nidal Malik Hasan, a specialist in disaster and preventative psychiatry, to open fire Thursday at Ft. Hood, killing 13 of his fellow soldiers.
Regardless of what prompted the violence, there were signs that Hasan was slipping and needed counseling, former Army surgeon Joseph Molea said.
It is not uncommon for military doctors to feel traumatized after dealing with soldiers’ physical and emotional wounds, said Molea, who now has a private practice in Tampa specializing in addictive medicine and psychotherapy.

“Hearing stories about soldiers’ post-traumatic stress disorder could trigger the same thing in medical professionals,” he said. No violence was done to the doctors or psychiatrists, but the “secondary exposure could case flashbacks and nightmares,” he said.

Hasan’s aunt, Noel Hasan, told The Washington Post that her nephew was affected by seeing injured soldiers for eight years at Walter Reed Army Medical Center in Washington D.C.

“He must have snapped,” Noel Hasan told the Post. “They ignored him.”

Not getting help from the Army, an entity Hasan appeared to have devoted his life to, may have caused resentment and eventually rage, Molea said.
Citing news reports, Molea said additional factors may have caused Hasan to crack.
Hasan had expressed dissatisfaction with the wars in Iraq and Afghanistan and did not want to be deployed. He got at least one poor performance evaluation as an intern at Walter Reed and there have been reports that he was harassed for his Muslim religion and wanted to be discharged.

“The tragedy of it is he was trying to tell people this was coming,” Molea said. “He was making overtures. In retrospect, it will look clearer.”

Doctors who deal with traumatized patients should be monitored more closely and recommended for counseling if they start to exhibit behavior outside of their normal range, Molea said. And soldiers from all specializations should consider treatment not as a sign of weakness but accept it as they would additional training, he said.
It is disparaging that soldiers on the front-line of war zones are identified and treated faster for mental or emotional issues than soldiers at home, Molea said.

“Psychiatrists are deployed in forward areas to deal with soldiers who have problems. They intervene early and are sent back to duty faster,” he said. “It’s ironic that Hasan didn’t get the early intervention that people in battle are afforded these days.”

Information from The Associated Press contributed to this report. Reporter Ray Reyes can be reached at (813) 259-7920.

Watch military psychiatrists closely, former Army doctor says