科罗拉多特大枪击案在引起很多人感叹同情和痛恨的同时，大家也实在想不明白为什么James Holmes 会杀这么多人，他是不是精神有问题。这就涉及一个法医精神病鉴定的问题。正好在网上看到一篇用通俗语言对此问题所做的简单介绍，贴在这里供有兴趣的人参考。考虑到有些人可能既不想看英文也不愿意看这么长的文章，我就把文章的意思用中文简单归纳一下。有不够确切的地方，以原文为准。至于James Holmes是不是有精神问题，能不能被判因精神疾患而无罪，这个估计需要最终经过法庭判断，我就不在这里猜测了。

法医精神病鉴定的目的是看嫌疑犯是不是有严重的精神疾患从而不能上庭，以及不需要为自己的行为负法律责任。具体到James Holmes，他没有明确的精神病病史，而且是个受过高等教育的博士生，所以首先要做一些检查看看有没有一些躯体疾病比如脑瘤，或者会不会是什么药物的作用。然后需要有精神科医生做一个详细的问诊检查，包括了解他从小是怎么长大的，以及在检查过程中能不能观察到幻觉或者幻想等等。

一般还需要做那种耗时几个小时的心理学测试，比如明尼苏达多相人格测验。这个明尼苏达多相人格测验很著名，是法医精神病鉴定不可或缺的手段，可以用来看病人是不是在装病。

通常，这种要求因精神病而不服刑的请求很难成功，绝大多数都会失败。道理也很简单，因为陪审团一般不太愿意让一个能够犯下严重罪行的人将来被放出来继续害人。即使经过法医精神病鉴定判定病人最终被判决不需要服刑，通常也会被长期留在精神病院进行治疗，比如，1981年因为喜欢朱迪福斯特而行刺里根总统的John Hinckley, Jr，在华盛顿DC的St Elizabeth's Hospital已经住院30多年了。 


How James Holmes will be evaluated by psychiatrists

James Holmes, the suspect responsible for the worst mass shooting in U.S. history, has begun a legal journey that will include an extensive psychiatric evaluation and may include a plea that he is not criminally responsible for his acts--an "insanity" plea.  As a forensic psychiatrist, I have participated in many such evaluations and then rendered expert testimony about killers in court.

Here's how they work:

First, given the extraordinary change in Holmes' mental status--from brilliant neuroscience Ph.D candidate to a mass killer--all organic (i.e. physical) causes for psychiatric symptoms must be excluded via an extensive medical work-up, including an MRI (to rule out a brain tumor or slow bleed), an EEG (to rule out seizures), a lumbar puncture (to obtain cerebrospinal fluid to rule out a central nervous system infection) and blood work (to rule out toxicity from heavy metals, other physiological abnormalities and any use by Holmes of illicit drugs).  Any medication with which Holmes has recently been treated will be considered for its possible psychiatric side effects.  

Second, a detailed series of psychiatric interviews will be conducted to create a timeline of Holmes' life story--from birth right through any recent stressors--and to attempt to determine how Holmes thinks, feels and communicates.  This will include an analysis of Holmes' personality, as well as a determination of whether he harbors any fixed and false beliefs (delusions)--like being under the control of aliens, being specially selected to save the world, being pursued by the CIA or having thoughts implanted into his head by devices in the walls of his apartment.  Pains will be taken to observe whether he acts as though he is hallucinating--hearing voices or seeing visions or experiencing odd bodily sensations (of, for example, his skin peeling away) in the absence of any stimulus to account for them.

Long, written psychological tests--like the Minnesota Multiphasic Personality Inventory--will likely be used, as well, in order to support or refute data gleaned from the clinical interviews, to gain further insight into Holmes' ways of thinking and feeling and to determine whether he is faking or exaggerating symptoms or, conversely, attempting to cover up symptoms.  The tests and the way they are analyzed have built-in mechanisms to identify those who are trying to seem crazy when they are not--or trying to seem normal when they are not.

The medical work-up, psychiatric interviews and psychological testing will probably both be used first to determine whether Mr. Holmes is competent to stand trial or too burdened by mental illness.  The bar is pretty low.  The issue is whether Holmes knows how a courtroom works (that a judge administrates the proceedings and a jury determines guilt or innocence, that his defense attorney will attempt to establish his innocence and a prosecutor will attempt to establish guilt, that he is the one accused of a crime) and that Holmes can assist his attorney in defending him (rather than being too confused to follow along or too distracted by voices or refusing to speak with his attorney, whom he considers, for example, to be an alien or one of the people sent by the devil to make him renounce God).

The medical and psychiatric evaluation(s) will also form the basis of any "insanity" plea Holmes may put forward.  The questions at the heart of that matter will be whether a major mental illness so impaired Mr. Holmes as to render him unable to tell right from wrong, or if he still knew right from wrong, and whether an illness so impaired him as to render him unable to conform his behavior to the requirements of the law.

While forensic psychiatrists hired by the state and those hired by the accused often disagree whether a defendant suffers from a mental illness that qualifies him or her as not criminally responsible, sometimes they do agree--and, sometimes, the fact that they are in complete agreement even before trial leads to a trial never taking place.  After all, the district attorney in Colorado will need to decide whether to take this case to court or, after receiving information from psychiatrists, whether to agree Holmes should simply have his plea of insanity (if offered) automatically accepted, leading to his hospitalization on a locked psychiatry unit.

It is important to note that while planning a killing is part of the data used to evaluate the mental state of a killer, some people who are psychotic and who kill based on incredibly powerful, unavoidable delusions, do so with a great deal of planning.  If, for example, one were to believe that aliens had invaded the Earth and taken the form of one's family, one might plan for a long time how to do away with them and save the universe.  Yet, the foundation of one's motivation would be a product of mental illness.

Contrary to popular belief, defendants who are found not criminally responsible by virtue of a mental illness generally remain on locked psychiatry units for several decades--or for life.  This has been the case, for example, for John Hinckley, Jr., the man who, in 1981, shot Ronald Reagan to impress actress Jodi Foster.  He has remained an inpatient--with some passes to his family home--at St. Elizabeth's Hospital in Washington, D.C. for more than 30 years.

Holmes' journey through the system is just beginning.  Insanity pleas are notoriously unsuccessful.  The vast, vast majority fail, probably because juries simply don't want to worry over whether a person capable of horrific acts will ever hit the streets.  So, if Holmes should offer such a plea and prevail, it will be because he isn't even close to sane and because the culprit who stole 12 lives and shattered dozens more was mental illness, camouflaged by those accomplices who saw it hobbling a man and did nothing--or too little.

Dr. Keith Ablow is a psychiatrist and member of the Fox News Medical A-Team. Dr. Ablow can be reached at [email protected].

http://www.foxnews.com/health/2012/07/24/how-james-holmes-will-be-evaluated-by-psychiatrists/