Monday, July 23, 2012

A Psychological Profile of James Holmes: The Joker Killer

In watching and reading the media coverage of The Batman movie killings in Aurora, Colorado, it is frequently stated that the killer’s behaviors are incomprehensible, not understandable, beyond belief, etc. Taken figuratively, I understand what these people are saying since there a very few people who would walk into a crowded movie theater, throw down chemical bombs, shoot and kill 12 people from ages 6 to 51, and wound 58 others. Taken literally, however, I disagree, because there are reasons why people behave the way that they do and those reasons are indeed discoverable.

The first thing I noticed about the alleged killer, James Holmes, that I have not seen anyone discuss yet, is that the school picture of him looks quite awkward. While clean-cut and properly dressed, what stands out from the picture is a vacant stare. Try staring at the picture and making a connection with it. You can’t. The smile also seems forced. In a video of him when he was age 18, note how when he speaks to the audience in front of him, he mostly looks at the presentation screen or at the floor, and when he does look in the audience’s direction, his eyes go out to right, preventing him from properly connecting with them.  He also never seems to directly turn and face the crowd in the clips shown.

The vacant stare, forced smile, and difficulty emotionally connecting with others is consistent with the repeated theme that has emerged in media reports from people who knew him (or knew of him) which is that he was shy, introverted, aloof, socially inept, stubborn, quiet, that he stayed to himself, and was easily forgotten.  This information, combined with other information below, makes me wonder if he has Asperger's syndrome, a condition manifested by qualitative impairment in social interaction and restricted repetitive and stereotyped patterns of behavior, interests and activities.

It seems that Holmes was teased, probably related to his social awkwardness, and that he did not know how to handle it and held his emotions in.  For example, a H.S. classmate said, "He was the kind of person that if you teased him, he would sit there and smile and really not do anything about it."

Many have remarked about his lack of on-line presence, at least under his real name. He apparently does not have a Facebook or Twitter account. Although he had a MySpace page, he either never had any friends or the friends were deleted due to an inactive account. Note how in his MySpace picture that both eyes are closed, apparently at a restaurant,which seems strange. He appears to have had more recent account with the website, Adult Friend Finders, and another profile with This indicates, given the other information that has come out about him, that he was having trouble finding a sexual partner using normal behavioral methods (e.g., introducing himself to someone, dating, etc) and was trying to bypass that by going directly to an exclusive sex dating site and swinger service. By this time, he had dyed his hair orange and was asking “Would you visit me in prison?” In a picture of him on he again seems awkward, with a strange smirk, one eye almost closed, and his head tilted to side. Maybe the sun was shining in his eyes, but all of the pictures seem odd for one reason or another.
Despite stellar grades, Holmes was unable to find a job. One wonders if it was due to his social awkwardness and extreme rigidity and stubbornness that caused him to perform terribly during a computer  programming summer internship. He had been giving off social cues, at least recently, that there was something seriously wrong with him. For example, it was recently discovered that he had a “bizarre, guttural, freakish” sounding answering machine message. It seem like he was struggling to fit into society and recently decided to withdraw from his PhD program. He was trying to pay for college by working part-time at McDonald’s, which obviously is not going to work. Some say he seemed depressed. He would not acknowledge people in his apartment complex who said hello. At some point,  it appears that he had enough. People who decided to shoot members of the public at random can get to that point by being convinced that the world (or a particular society) is the enemy and needs to experience retribution. To someone who thinks this way, there are no more individuals. Each person is simply viewed as a reflection of the society as a whole that the person despises.

In the case of James Holmes, such feelings may have been brewing for some time. It has been said that he always rooted for the bad guys to win and loved to play fantasy role playing computer games.  While there is nothing wrong with that, it seems that Holmes eventually had difficulty detatching fantasy from reality and eventually over-identified with the Joker character, most like Heath Ledger’s award winning version.  The Joker is known to take his anger out against the world through violent means, which sometimes involves using explosive devices and guns in public places. This may account for the dyed hair (although it is strange he did not dye it green) and would account for why he committed this crime during a Batman movie, identified himself as The Joker when police arrived, and is reportedly still carrying out the role in prison.

Note: The comments above are based on early media stories, are preliminary, and partly speculative. Also, I have never evaluated Mr. Holmes.

Related Stories: Cannibal Icepick Killer Luka Magnotta was Not Born Evil
                         A Psychological Profile of Chardon School Shooter, TJ Lane
                         A Psychological Profile of Wade Michael Page: The Sikh Shooter 

Sunday, July 15, 2012

Why I Contributed to New York's Psychology PAC

In advocating for psychology, a quote I have often passed on to colleagues is that “if you are not at the table then you will be on the menu.” This quote has been around since about 2000 as a Washington D.C. political saying. From a professional perspective, being on the menu in psychology is analogous to having something adverse occur to our profession on a state or national level resulting from a legal or regulatory action.

The more I become involved in professional advocacy/lobbying efforts, the more I have realized that being at the table is necessary but not sufficient to avoid being placed on the menu. You must also have strength when you are at the table.

There are four main ways to obtain this strength. One way is having a strong argument – but that is not enough. The strong argument has to deal with an issue that is publicly and politically beneficial for a politician or political appointee to support and ideally should have some type of emotional appeal. The second way is to have friends in powerful places – those who are closest to making the important decisions. An example of this that has nothing to do with psychology draws on my love of cinema. When Paramount chief Bob Evans was making the film “The Italian Job” he needed to film in Turin, Italy, and have the city shut down. He happened to know the most powerful man in the city who had the police and other government officials give Paramount everything they need to make the picture. Evans has remarked how that connection enabled him to do in one day what the President of the United States could not have done in one year.  The third way to obtain strength, at least with politicians, is by making a financial contribution to their political campaigns. This is how you maintain existing political friendships and make new ones.  Lastly, another way to gain strength at the table is to move yourself into a position where you play a major role in the important legal and regulatory decisions that are made.

In an ideal world, strength of argument alone would be enough to allow psychologists to obtain successful professional advocacy results. However, the real world simply does not work that way. We have already seen in New York where state regulators banned the use of psychology technicians and where legislators limited return to play decisions in concussion management to physicians only (thus no longer allowing psychologists with expertise in this area to perform this function). State regulators then followed this up by only naming school nurses as health care professionals who could perform cognitive testing in concussed athletes. Psychologists in New York were caught off guard in the former circumstance but were at the table for the latter. The problem is that we did not have enough strength at the table. Other professions did.

So, what can you do about it? One of the most important things you can do is to make a donation (however small) to PLANY, which is New York’s political action committee (PAC) for psychologists.  The PAC is expressly designed to allow special interest groups access to legislators so we can have a meaningful say in proposed legislation.  Politicians love donations from PACs because they do not need to spend any money soliciting the donation. The larger the PAC, the more influential it is. The PAC becomes larger and more influential with more donations. 

This is where YOU come in, if you are a psychologist reading this. For example, if you want the limited liability company laws (LLC) in New York State amended so that psychologists could be authorized to form LLC partnerships and corporations with physicians on a co-ownership basis, you should donate to PLANY to help get this done. This change is very important because it aligns what we know about best practices and would enable for the first time the creation of corporate partnerships between psychologists and physicians, putting psychology on an equal footing with medicine in our state. With health care reform here, this is something we cannot miss out on.

I want to challenge every psychologist reading this to donate to the psychology PAC in your state, even if it is a small amount.  Doing so would be a great way to help advocate for your profession. To donate to PLANY, please go to this link above for more information.

Thursday, July 12, 2012

The Medical History of Coca-Cola You Never Knew

Long before the modern day Coca-Cola beverage existed that billions of people drink around the world today, there existed a drink known as coca wine. Coca wine was sold in the 1800s alongside many other beverages at the time that contained cocaine. While this may sound shocking to some people today, back then, cocaine was a commonly used medicinal substance and it was not illegal.

For example, see the prior blog entry on the use of cocaine tooth drops.
Coca wine contained 30 grains of Erythroxylum coca per ounce of wine. Erythroxylum coca is one of two species of cultivated coca and is used to make cocaine (a stimulant drug). When wine is combined with cocaine, it creates a substance called cocaethylene. When ingested, it is almost as strong as cocaine.

Below are pictured two images of a coca wine bottle from Metcalf’s Coca Wine (click to enlarge).  As you can read from the back of the bottle, manufacturers of such drinks marketed them based on medical claims, leading consumer to believe that coca wine could cure just about any sign or symptom (i.e., “…a remedy for every malady…”). It was advertising as treating headaches,  anxiety, fatigue, depression, and fever, soothing  the vocal cords, aiding digestion, and more. However, these drinks were also used for pure pleasure seeking purposes.  It was specifically marketed to children, elderly, and people who were in a stage of healing, as you can see written on the back of the second bottle.

Metcalf’s coca wine was not the only one on the market (Vin Mariani was a famous brand in Europe), but it was one of the most popular. The manufacturers claimed that a medium dose of their wine produced a slow and sustained effect different from the excitation caused by any other wines. The dose? Three wineglasses a day! It is because of questionable medical claims such as these and the lack of dose modification for children versus and adults that stricter regulations over pharmaceutical substances later came to pass. It is interesting to note the marketers claiming a benefit of a slow and sustained release because it reminds me of the present day and age when drug companies market slowed release forms of stimulant medications (e.g., Ritalin) to treat children with attention deficit hyperactivity throughout the day.

Metcalf’s coca wine was run by Theodore Metcalf (1812-1894), a pharmacist who ran a widely known pharmaceutical business, selling products all over the world. His store was a mecca for famous people such as Charles Dickens and Oliver Wendell Holmes. Millions of prescriptions were filled by the company, written by some of the greatest physicians of the time. When Metcalf retired, he transferred the store to others. 

Eventually, John Pemberton of Atlanta, created his own version of coca wine, based on the Vin Mariani beverage. He called it Pemberton’s French wine, sold it in a pharmacy, and promoted it as a stimulator of the sexual organs. Once the Prohibition began in 1886, Pemberton replaced the wine in coca wine with sugar syrup and Coca-Cola was born. He marketed it as “the temperance drink” and once again, it is seen in the ad below that it was promoted as a cure for all nervous conditions even though this is obviously not true. Coca-Cola initially contained cocaine. Due to growing concerns about drug addiction in the U.S., cocaine was removed from Coca-Cola  in 1904 (except for trace amounts), but the cola leaf remained.  Now days, there is no cocaine in Coca-Cola at all. Cola wine no longer exists today in legal form but it led to a drink that almost everyone has tasted.

Reference: Mason, B. (1908). The Metcalf Pharmacy in Boston. Bulletin of Pharmacy.  I (XXII), 279-82.

Thursday, July 05, 2012

How New York Fumbled the Ball on Concussion Management

Below is a copy of a letter I sent today to Deputy Commission Ken Slentz at the Office of P-12 Education at the NY State Education Department (SED). The letter concerns opposition to aspects of the Concussion Management and Awareness Act.

The letter also addresses opposition to aspects of the concussion management regulations published by the State Education Department (SED) due to concerns that the safety and well-being of children are being put at risk, despite the best of intentions. The law excludes psychologists with expertise in concussion management and evaluations (e.g., neuropsychologists) from making return to play decisions in children who have suffered concussions. The subsequent regulations do not do enough to recognize the important role that neuropsychologists play in concussion evaluation and management.

If you are as concerned as I am about this issue, parents, students, health care professionals, and others should a) forward this letter to others, b) spread the word via social media and other media sources, and c) contact Senator Kemp Hannon, Assemblywoman Catherine Nolan, and those copied at the end of this letter to voice your opposition and advocate for the amendments to the law and regulations listed below.

Historical background:

Since 7/12/10, the New York State Association of Neuropsychology (NYSAN) and other state and national psychological/neuropsychological organizations have been in contact with multiple sponsors (i.e., Senators Hannon and Stachowski, Assemblypersons Nolan and Benedetto) regarding the Concussion Management and Awareness Act. Through these contacts, we advocated for reverting to the language in an earlier draft of the bill (S07572) that specifically allowed for “a licensed health care provider trained in the evaluation and management of concussions” to make decisions about return to competitive play and physical activity after a known or suspected concussion (mild traumatic brain injury). This would have allowed for our profession to continue in this role, which helps ensure the safety and well-being of children.

Despite our repeated advocacy and educational efforts, the bill states that only physicians are allowed to make return to play decisions after concussion, thus removing part of a psychologist’s scope of practice in New York and creating unnecessary health risks for children (see below). Ironically, the profession (i.e., neuropsychology) that has contributed the most research on understanding the effects of concussions, developed the cognitive assessment tools and symptom checklists now promoted by SED, and led the way in operationally defining a mild traumatic brain injury* is now not legally permitted to pull or return athletes from play in New York after suffering a known or suspected concussion. Meanwhile, physicians whose primary area of expertise is not directly related to neurological functioning (e.g., cardiologists and pulmonologists) are performing cognitive evaluations of such patients and provide return to play clearance.

NYSAN raised the above concerns with the Governor's Office before Governor Cuomo signing the bill into law but the office was non-responsive to our concerns. Senator Hannon (sponsor of the bill) informed me (and others) before the bill was passed that psychologists might be added through an amendment but after the law was passed it is our understanding that there are no such plans at this time. It was suggested to us through Senator Hannon’s and Assemblywoman Nolan’s office that psychologists could have a role in developing the regulations that were published by SED on the practical implementation of the law.

Opposition to Aspects of Current  SED Regulations:

Dr. Dominic Carone served as the New York State neuropsychology representative to SED (by their request) regarding the development of their concussion regulations, but the feedback and edits provided about adding neuropsychology more prominently in the document were essentially ignored and removed. The edits were not intended to change the law regarding who could provide return to play clearance (which we hoped to do with an amendment) but were designed to recognize the important role of neuropsychologists in concussion management and evaluations.

In the final version of the regulations, which were not released to us before they were finalized, new language was added stating that it is a role of school nurses to provide neurocognitive baseline evaluations and similar assessments with concussion patients to aide the physician in understanding the status of the child. This was the only profession specifically singled out to perform these evaluations. While a for-profit test company may provide a certificate to various health care professions to use such tests, this does not equate to the training and education on concussion management and evaluation provided through formal education and professional training in the neurosciences. The most qualified health care providers to provide this service are neuropsychologists due to their formal education and training in cognitive assessment, neurosciences (e.g., neuropathology, neuroanatomy), statistics, emotional pathology, symptom validity assessment, and other factors that are crucial towards interpreting test scores and patient presentations.

While NYSAN agrees with many aspects of the legislation and regulations, we believe that they unintentionally place children at risk of harm due to the problems noted above. As such, Dr. Carone requested that his name be removed as an advisor to these regulations and the request was granted. Neurocognitive evaluations can easily be misinterpreted by those who do not have formal expertise in this area, causing children to be cleared to return to play too early which risks further neurological injury. Another risk, which is rarely discussed in the media but often encountered in clinical circles, is withholding players from most physical activity and/or school for excessive periods of time, resulting in emotional pathology, declining academic performance, over-medication, and development of the sick role.

Action Points:

Our organization strongly recommends an amendment to the state law and regulations to be inclusive of our profession. Legally, this means broadening the language as we originally requested to be consistent with that of so many other states. In terms of regulations, this means specifically recognizing the important role of psychology/neuropsychology in the Concussion Management Team. Please note that neuropsychologists are included on the staff of NHL and NFL teams to aide in making return to play decisions after concussion. In addition, the National Athletic Trainers' Association recommends that a neuropsychologist should ideally be part of the sports-medicine team when evaluating players who have sustained a concussion (Guskiewicz, et al. 2004).Why would New York State not afford children that same layer of safety, protection, and expertise that are afforded to professional athletes?

I have copied Senator Hannon and Assemblywoman Nolan and request a personal meeting (separately or together) to discuss ways to move forwards on an amendment process. I will be happy to discuss this information further and my contact information is listed below.

*Note: Dr. Thomas Kay, a New York neuropsychologist, was the senior contributor of the American Congress of Rehabilitation Medicine’s operational definition of mild traumatic brain injury used throughout the world today. See the attached document for more contributions of neuropsychology. 

Reference: Guskiewicz, et al. (2004). National Athletic Trainers' Association Position Statement: Management of Sport-Related Concussion.  J. Athl Train. 39: 280-297

Dominic A. Carone, Ph.D., ABPP-CN
Diplomate, American Board of Clinical Neuropsychology
NYSAN Past-President

cc: Mr. Ken Slentz, Deputy Commissioner,Office of P-12 Education,NYS Education Department, 2M West EB,89 Washington Avenue,Albany, NY 12234
The Honorable Senator Kemp Hannon, The Capitol Room 420, Albany, NY 12247
The Honorable Assemblywoman Catherine Nolan, 836 Legislative Office Building, Albany, NY 12248
Doug Lentivech, Esq., Deputy Commissioner, Office of the Professions, New York State Education Department, 89 Washington Avenue, Albany, NY, 12234

Sunday, July 01, 2012

How Ripley's Believe It Or Not was Used by Big Tobacco

In the early 1980s, I used to love watching the Ripley’s Believe It or Not TV show with Jack Palance. There were and still are many Ripley’s Believe It or Not books, filled with all sorts of strange images, similar to these pictures on extreme human body parts. I also remember playing a Ripley’s Believe It or Not trivia game at the time, with the purpose being to tell whether or not what was stated on one of the cards was true or not. They also had questions like this on the TV show too.

Ripley began publishing brief panel articles in The New York Globe in 1918 featuring odd news and facts from around the world. In 1929, the famous publisher, William Randolph Hearst, began running these panels in his papers (syndicating them in 17 papers worldwide), increasing their exposure and popularity. In the 1930s, Ripley expanded into radio, short films, and opened a museum. In 1936, he was voted by New York Times readers as the most popular man in America.  As such, his endorsement was highly coveted by advertisers, including the tobacco industry.

Below (click to enlarge) you will see what is actually an advertisement for Old Gold cigarettes (established in 1926) designed to look like one of the Ripley panels. Old Gold is a cigarette brand of Lorillard Tobacco Company. Note their common advertising phrase at the time “Not a Cough In a Carload” features in the ad.

In the ad, the reader is informed about a “public test” of four cigarette brands in which Old Gold is reportedly chosen by otolaryngologists (ear, nose, and throat doctors or ENTs) as the best cigarette, leading to the eye catching headline.

Note that not a single one of the doctors are identifiable in the ad. The person in the dark suit is Ripley. Using ENT’s  was purposely designed to enhance the credibility of the sales pitch. After all, if cigarettes are believed to cause irritability to the nose and throat area, what better doctors to endorse a cigarette purporting not to cause such ill effects. Ripley claims to have run a blind experiment but unlike descriptions of true experiments, the reader is not told how many ENTs tried the cigarettes or what the cigarettes were that they were being compared against.

The ad also claims that there was a “decisive ratio” of 2 to 1 in favor of Old Gold but the reader has no idea if this is truly significant from a statistical perspective. Old Gold received 50% of the votes, two other brands received 25%, and another brand received no votes. To illustrate how misleading these percentages can be, if there were only four ENTs, and two picked Old Gold and one picked two other brands, then 50% liked Old Gold and 25% liked one of the other brands. But if there were only four ENTs in the test, the numbers are misleadingly inflated.

For those interested in learning more about how ENTs were used by the tobacco industry to cover up tobacco’s link to cancer, see this paper (the title says it all): The price paid: manipulation of otolaryngologists by the tobacco industry to obfuscate the emerging truth that smoking causes cancer. Believe it...or not.