Tag Archives: Vince Li

The Brain, Cognition and Illness

By Dr David Laing Dawson

The aware, receiving, perceiving, organizing, planning brain.

Two recent writings got me thinking about this. The first was a comment from Mr. Summerville, in support of the absolute discharge of Mr. Vince Li, that Mr. Li showed “no signs of cognitive impairment”. The second was the raw honesty of Mr. Bowers when he writes that when he took a shotgun upstairs with the intention of killing his grandmother he was “bat shit crazy”.

I suffered one of those nasty strains of flu this winter. At the time it seemed to affect every organ in my body. Including my brain. That is my brain was aware this state of body sickness was impairing some of its functions as well.

I guess it’s tricky. We are aware when our stomachs aren’t working as we would wish them, when our prostates and kidneys are not quite right, when perhaps our livers are acting up, our eyes, our inner and middle ears, our calf muscles are balking. Well, really, it is our brain noticing these things. But when the brain is acting up, not quite functioning smoothly in one of its functions, there is no one left to tell us. That is, no other organ in the body is prepared to tell us that the brain is a little off. “Liver here. Brain, your thinking is off.” or “Brain, your medulla oblongata is a little sluggish this morning. Your perceptions are clouded.”

I have also suffered, by my own count, three depressions of clinical severity so far in my life. Perhaps the cause of these can be traced to my circumstances each time, perhaps my genetics, perhaps to my childhood, probably a combination of genetics and circumstances. But each time it happened I know my brain was impaired, not functioning well, not scanning, perceiving, reviewing, interpreting as it normally does.

You can find a list of the symptoms of “depression” in the DSM and on many a website not to mention TV advertisements for the latest antidepressant. But of course the organ experiencing these symptoms is the same one reading and hearing about them.

It is often family members and close friends who notice first. You are not yourself, they say. Or “the spark has gone from your eyes.” And always when I treat someone for depression and they improve, it is family members who notice the improvement first. The patient tells me they don’t notice any change, though I see his or her eyes are livelier, his face a little less strained, and the corners of his mouth more agile. And the mother or wife points out he came down for dinner, engaged in conversation, laughed at a joke. The brain of the patient hasn’t noticed these changes yet, because… well because its perceptual, interpreting, responding, scanning apparatus is still partially impaired.

Liver illness impairs the functioning of the liver. Mental illness impairs the functioning of the brain, and that can be some or many of its functions. Mental illness is a brain illness.

So let’s go back to Vince Li. His brain was absolutely definitely impaired at the time of his crime. And at this point if he is not terrified of relapsing, and thus wanting help for the rest of his life to keep himself from relapsing, if he does not himself (his brain) understand and want all safeguards in place to keep himself from relapsing, if he thinks he can just change his name and move on, then his brain is still impaired in some of its functions. If this is the case then his perceptual, cognitive, judgmental processes are still impaired.

Contrast that with the Blog written by Mr. Bowers. He has fully recovered from being “bat shit crazy” and he is fully aware he never wants to go there again, and he is fully aware (the perceptual, organizing, planning, monitoring, cognitive processes of his brain are functioning well) that he needs help and vigilance to never go back to that place again.

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More on Vince Li and Absolute Discharge

By Dr David Laing Dawson

Let me give a little background to my previous blog on Vince Li.

I have had many patients over the years (50 years now, actually) who have done well with treatment, who recover, who have insight, who promise to stay on their medication. They are good people. I like them. We become friends. With some it can involve an ongoing dialogue about needing or not needing to stay on medication.

But at some point most of them stop their medication, at least once. Their lives have changed. They have been well for 20 years. They meet a family doc who doesn’t understand why they are still taking Olanzapine. They fall in love. They move. They get ill in some other way. The pharmacy changes hands. Their doctor moves. They come under the influence of one of any number of cults, including Scientology. They read the bullshit of the anti-psychiatry crowd, or the homeopaths. Someone offers them cocaine.

So at some point most of them stop their medication at least once.

With psychotic illness the illness returns, and it always returns in the same way. With some my relationship is good enough that I can cajole them into going back on their medication. With some I have had to spend hours offering it while my patient tries to decide if I am a friend or the devil. With others it means a complete relapse and re-hospitalization.

And in most cases, the only ones hurt by this relapse are my patient and his or her family. That is no small thing though. The social, emotional, vocational, educational, and sense- of-self cost is huge. Often a year or more of progress is lost.

Lack of insight may be a good predictor of human behaviour, but insight itself is not. An equally poor predictor of future behaviour is remorse, or a display of remorse. “Good behaviour, model patient or prisoner” has also little to do with what will happen in a different context five years from now. I will agree, however, that a good support system is a good predictor, but we need that support system in place for 40 years.

We clinicians are further hampered by our natural empathy, our natural sympathy that flows toward anyone nearby. It is not special; it is just human. At least twice a week during commercials I see on the television screen an emaciated fly-covered child. I get up and refill my glass. But should that child and his mother be in the room with me, my response would be quite different. Hence, as I have seen many times with CCRB cases over the years, the staff actually caring for and treating the patient are very poor at predicting future behaviour.

Now, I have not examined Mr. Li. It is possible he had a psychotic episode that will never reoccur. In my 50 years experience I know this to be only possible if the initial psychosis was caused by a brain injury, a stroke, toxic substances, or withdrawal from toxic substances, or very severe acute trauma within the time-frame of the psychosis. But from what I have read Mr. Li developed a schizophrenic illness with hallucinations and the specific delusion that resulted in a very specific horrendous crime.

So, from my 50 years of experience, I would say the people who know Mr. Li, who have spent time with him, are the last people who should be making predictions of future behaviour. Secondly, insight, remorse, promises, even absolute statements of conviction are not good predictors of distant future behaviour.

We know this man, when well, is a very nice man, and could be a good citizen of any community. We also know when ill he is capable of committing a horrendous crime.

Would it not be reasonable to use the tools we have to keep him well for the next 40 plus years? To protect Mr. Li and any future community in which he resides? They are not overly constrictive or intrusive considering the possible consequences of a relapse.

By allowing even a remote chance of a repeated homicide by Mr. Li you are doing everyone else diagnosed with a psychotic illness a great disservice.

The Absolute Discharge for Vince Li was wrong

By Dr David Laing Dawson

Vince Li has been treated now, for his schizophrenia, for 8 years. He has been living in the community and attending classes. The Review Board has given him an “absolute discharge”. He is, we are told, recovered, insightful, remorseful, and willing to take his medication regularly. Thus he is not a threat and qualified for absolute discharge.

He may well remain healthy and compliant with his medication for the rest of his life.

Perhaps the odds are slight that he will stop his medication and become ill again.

But, here are two realities about psychotic illnesses, schizophrenia in particular:It is hard to catch a relapse.

  1. When a patient stops his medication he will feel fine for a while. And when the relapse begins the first thing to become impaired is insight. One can monitor mood, but not one’s own cognitive processes. So very few people with schizophrenia who stop medication and feel good for a while, are then able to detect, on their own, the early signs of cognitive changes. As the illness worsens the prospect of insight lessens. It is the nature of schizophrenia. It affects thinking.
  2. When relapses of psychotic illnesses occur, the original delusion returns, if not exactly word for word, almost word for word. Thus if the original delusion was relatively harmless, in a relapse the patient’s returning delusion will be relatively harmless. “They are listening to my thoughts from the TV so I don’t ever turn it on.” “It is happening again.” But if the original delusion was dangerous: “I must kill to rid the world of the devil”, then when the relapse occurs the person in question will once again become dangerous.

Thus, even if the possibility of a relapse of illness for Mr. Li is small, such a relapse would be far more dangerous than for most people with this illness.

And if this occurs, if Mr. Li relapses and hurts or kills someone else, the cost will be much wider than Mr. Li and his victim. “Let’s talk about it” will certainly not be enough to reduce stigma then.

Such an occurrence will undermine the compassion and civility of the “not criminally responsible” finding.

The average citizen has trouble buying this defense now, for various reasons, especially when the crime is horrifying. If Mr. Li relapses and commits a crime, the community outcry will be very strong. A relapse and repeat by Mr. Li could thus do great harm to all mentally ill in Canada.

This could have been remedied simply: a discharge (though not absolute) that continued a lifetime of monitoring compliance with treatment. Not overly intrusive or restrictive. Simply making sure that Mr. Li continues his treatment, that he continue to take his pills every day or his injections every two weeks.

If Mr. Li stops taking his anti-psychotic medication, one year or ten years from now, the illness will relapse. And the delusions of this illness always return in the same form.