Mental Illness and Culpability in Iraq

The Washington Post has an interesting article, href="http://www.washingtonpost.com/wp-dyn/content/article/2007/12/01/AR2007120101782.html">'A
Soldier's Officer', about an officer in Iraq who attempted
suicide and endangered other personnel.  The military is
considering putting her on trial for "assault on a superior
commissioned officer, aggravated assault, kidnapping, reckless
endangerment, wrongful discharge of a firearm, communication of a
threat and two attempts of intentional self-injury without intent to
avoid service."



In this post, I will comment on the article and the case as presented
in the article.  The disclaimer is that I don't know the
officer involved, so I can't say anything about her specifically.
 If the article is incomplete or inaccurate, then any analysis
I offer also will be incomplete and inaccurate.  That is
always true with case presentations, by the way.  But even if
the analysis of the case presentation cannot reliably be applied to the
specific case, it can be a useful exercise.

The background is presented as follows:  1st Lt.
Elizabeth Whiteside was an exemplary student and athlete in high
school.  She had some episodes of depression (unspecified type
and severity) in college, but still did very well.  She was a
member of ROTC and received her military commission following
graduation.  



During her first assignment, she received excellent evaluations:

"This superior officer is in the top 10
percent of Officers I have worked with in my 16 years of military
service," wrote her rater, Capt. Joel Grant. She "must be promoted
immediately, ahead of all peers."



Maj. Sandra Hersh, her senior rater, added: "She's a Soldier's Officer.
. . . She is able to get the best from Soldiers and make it look easy."

Her first assignment was at Walter Reed.  Reportedly, she felt
"she was not bearing her full responsibility," so she volunteered for
Iraq.  She became a platoon leader at a detention facility.
 The article describes how stressful it was:

The hours were brutal. Whiteside ate one
meal a day, slept in two four-hour shifts and worked seven days a week.

She continued to receive excellent evaluations.  Evidently,
she was respected by most, whether below, above, or equal to her in
rank.  However, there was conflict between her and a superior
officer.  The article indicates that many others had problems
with that particular superior officer.

As the tensions with the officer
increased, Whiteside said, she began suffering panic attacks. She
stopped sleeping, she said, and started self-medicating with NyQuil and
Benadryl, but decided against seeking help from the mental health
clinic because she feared that the Army would send her home, as it had
recently done with a colonel.

I would be cautious about inferring a causal link between the tension
with the other officer, and the panic attacks.  I would like
to know a lot more about how often she took Benadryl and Nyquil, how
much she took, and what kind of Nyquil it was.  I also would
like to know if she showed any symptoms of sleep deficit.  



At the end of December 2006, Saddam Hussein was taken from the
detention center and hanged.  A riot broke out.  It
was bad.  Lt. Whiteside reportedly handled it well.
 However, after it was over:

At 6:20 p.m. a soldier frantically
approached Maj. Ana Luisa Ramirez, a mental health nurse at the prison,
and said Whiteside was "freaking out" and wanted to see Ramirez. The
nurse found Whiteside sitting on her bed, mumbling and visibly upset.
Ramirez left to get some medication.



Later, she spotted Whiteside in the darkened hallway with her
sweatshirt hood pulled over her head and her hands in her pockets.
Ramirez asked Whiteside to come into her room and noticed what appeared
to be dried blood on her neck and hands. When she tried to take a
closer look, Ramirez said, Whiteside pointed her sidearm, an M9 pistol,
at her and "told me to move away and she locked the door," according to
a statement Ramirez gave to the Army.



Ramirez tried to take Whiteside's gun, but Whiteside pushed her away
and expressed her hatred of the officer she thought was sabotaging her.
She grew more agitated and twice fired into the ceiling.



Nurses in the hallway began yelling, and Whiteside shouted that she
wanted to kill them, the report said. She opened the door and saw armed
soldiers in battle gear coming her way. Slamming the door, she
discharged the weapon once into her stomach.

Lt. Whiteside reported that she has only fragmented memories of the
incident.  This is to be expected, as the gunshot wound
damaged her spleen, liver, and one of her lungs.  The article
indicates that she "was still unconscious when she arrived at Walter
Reed a few days later."  



I would expect that her memory of the incident would be incomplete,
under the circumstances.  



Now, a military prosecutor wants to have her tried.  A
conviction could lead to a life sentence.  Others in the
military disagree:

At the hearing, Wolfe [the prosecutor],
who had already warned Whiteside's lawyer of the risk of using a
"psychobabble" defense, pressed a senior psychiatrist at Walter Reed to
justify his diagnosis.



"I'm not here to play legal games," Col. George Brandt responded
angrily, according to a recording of the hearing. "I am here out of the
genuine concern for a human being that's breaking and that is broken.
She has a severe and significant illness. Let's treat her as a human
being, for Christ's sake!"

Reportedly, she has been diagnosed as having "severe major depressive
disorder," and a "personality disorder." Furthermore, it was reported
that she "was suffering from a disassociation with reality."



Unfortunately, nothing in the article supports any of those diagnostic
statements.  There is nothing there that gives me a reason to
doubt the depression and disassociation with reality.  On the
other hand, there is a lot that casts doubt on the diagnosis of a
personality disorder.



Let's consider that last point.  By definition, a personality
disorder is an enduring set of characteristics, resistant to change,
and is not better accounted for by another diagnosis.
 According to the article, the maladaptive behaviors were not
present prior to the riot, and have not been in evidence over the
course of Lt. Whiteside's recovery.  Instead, what the article
presents is a picture of a strong, resilient person who has superior
social skills.  Not only is this unsupportive
of a diagnosis of a personality disorder, it is entirely inconsistent
with such a diagnosis.  



This brings us to the question: what happened on that day in Iraq?
 We've been given informed of three diagnoses: major
depression, personality disorder, and disassociation from reality.
 Only the first is a real diagnosis; the second is a family of
diagnoses, and the third is a description of a symptom.  None
explains the event.  



There are a lot of depressed people.  Most of them never
attempt suicide.  A personality disorder could explain
something like this, but it could not explain it in the context of an
isolated incident.  In order for a personality disorder
diagnosis to be relevant at all, we would need to see an enduring
pattern of maladaptive behavior.  That simply is not present,
at least so far as the article reveals.  Disassociation from
reality only tells us something about Lt. Whiteside's state of mind at
the time.  It does not tell us how she came to be in that
state of mind.  It also does not explain the event.
 Dissociative episodes generally are not accompanied by events
such as what Lt. Whiteside experienced.  



Clearly, Lt. Whiteside experienced a profound lapse of judgment as well
as disinhibition of behavior.  It is possible that she was
delusional and/or hallucinating.  How could this happen to an
otherwise intact, high-functioning person?



Based upon the information given, I would look first at the sleep
deprivation, then at the Benadryl and Nyquil.  Prolonged
periods of profoundly disturbed sleep can lead to psychosis.
 This is particularly likely if the person is short on REM
sleep.  There are reasons to think this could have been the
case.  Most people get most of their REM sleep in the last 1/3
of the night.  It is easy to attain a state of REM deficiency
with multiple short periods of sleep, as apposed to a single long
period of sleep.  Furthermore, OTC medication such as Benadryl
and Nyquil tend to promote stage 1 and 2 sleep, but suppress stages 3
and 4, as well as REM.  



Occasional use of such things is of no particular concern.
 However, the brain does not do well if this becomes an
uninterrupted pattern.  Most people could not keep going with
the schedule she kept.  Sooner or later they would just fall
asleep and get at least partly caught up on their sleep deficit.
 



The history of depression and panic attacks is not particularly
important here.  Perhaps they indicate that she had some sort
of vulnerability, but such a condition would be neither necessary nor
sufficient to explain the event.



Perhaps she had some other vulnerability, such as slow metabolism of
dextromethorphan (an ingredient in Nyquil).  Such a condition
could have accelerated the process, but again, would be neither
necessary nor sufficient to explain the event.



There is an element of irony here.  Lt. Whiteside clearly was
a driven person possessing a high degree of determination.
 Ordinarily, that would be a good thing.  My
suspicion is that in her situation, she pushed herself beyond a
reasonable limit.  She pushed herself to the point that her
brain could no longer compensate.  The drugs might have helped
at first, but any real benefit would have lasted only a day or two.
 After that, it was just a matter of time before she either
collapsed or developed psychosis.  Or, the preferred outcome,
would be that a superior office would notice that she needed a break,
and send her home.  



This brings us to the really difficult question: Is Lt. Whiteside
guilty of a crime?  



There appears to be no dispute about the events.  The events
themselves would be criminal acts in the absence of some mitigating
factor.  The only available mitigating factor is the insanity
defense.  



Note that, in this context, the term "insanity" is being used in a
technical sense.  The essence of it is this: Was there (A)
something wrong with her brain, AND (B) was that something so severe
that she was either unable to understand the difference between right
and wrong, OR, (C) was she not able to control her actions?



For an insanity defense, criterion A would have to be present, plus
either B or C.  



I realize that we do not have access to the information we would really
need to come to a firm conclusion.  With that understanding,
I'll describe how I would approach the question.  



The A criterion is sometimes referred to as "a substantial disorder of
thought or mood."   The article states that she was given a
diagnosis of "severe major depression."  Taken at face value,
that would qualify as a substantial disorder of mood.  We also
see evidence of a disorder of thought, in that her behavior did not
make any sense.  She fired her gun twice into the ceiling.
 Why?  Presumably it was to make other people go
away, leave her alone, but to what purpose?  There is no
logical framework in which to understand this.  Criterion A is
met.



The article presents little information with which to make a judgment
about criterion B.  We do know that, in general, Lt. Whiteside
was well aware of the distinction between right and wrong.
 But we have no direct information about her capacity to
appreciate and process that distinction at the time of the incident.
 We can make inferences, but they would be weak.



Criterion C is where things get interesting.  Was she able to
control her behavior?  Was she able to take stock of the
situation, decide what she wanted to accomplish, formulate a plan for
how to get it done, then do it in a systematic, goal-directed manner?
 Would she have acted the same way in the absence of a
substantial disorder of mood or thought?  This is a judgment
call, but based solely upon the article, I would say that criterion C
is met.  



This case highlights a number of issues.  Is the military
dealing appropriately with mental illness?  Is their justice
system handling these cases fairly?  Are there any special
considerations in the military system, such that treatment that would
be unfair in a civilian system is proper in a military context?



That last question is the most difficult.  Perhaps in the
military, there are situations in which it is considered proper to
treat one person unfairly, for the greater good of the organization.
 



A few bloggers have weighed in on this.  The most notable that
I have seen is Phil Carter, writing at href="http://inteldump.powerblogs.com/posts/1196608475.shtml">Intel
Dump.  Mr. Carter is an attorney, and a veteran
military police officer.

There is clearly a tension here. On the
one hand, I believe the Army has a compelling need to discipline its
troops, and a compelling need to discipline those who injure themselves
in the line of duty, whether to avoid combat or otherwise. The Army
also has a compelling interest in preventing its officers from locking
other military personnel in rooms and shooting holes in the ceiling.
Such acts are absolutely prejudicial to good order, unit cohesion, and
unit effectiveness, even when they arise out of a person's mental
illness.



However, on the other hand, there is a categorical imperative for the
Army to take care of its own. This is non-negotiable. It is incumbent
upon Army leaders — and the Army as an institution
— to take care of its troops. This is true whether the troops
suffer a traditional combat injury or PTSD — or whether they
suffer from something else.

Clearly the military does have a need to maintain discipline: they all
have guns and lots of bullets and other nasty things.  I vote
for discipline, in that context.  I also agree that the
military has an absolute obligation to take care of its own.
 However, I don't see how convicting Lt. Whiteside would
advance that cause.  Indeed, if it is widely perceived as
unfair, it could have the opposite effect.  



Of course the military should take steps to prevent this kind of thing
from happening again.  The first step is to not have wars.
 The second step is to destigmatize mental illness.
 The third step is to develop a culture in which it is not
only OK to take care of one's mental health, but it is expected.
 The third is to have officers who are more assertive about
ensuring the mental health of their underlings.  The fourth is
to make sure that there are enough personnel to do the job, without
exploiting anyone with excessive work hours.  The fifth is to
educate people about the hazards of sleep deprivation, especially when
combined with REM-suppressing drugs.



Did I mention that we should not have wars?