So today's panel is Neuroscience in the Courtroom. It's being presented to you by the Stanford Forensic Psychiatry Fellowship Program. My name's Octavio Choi. I'm the founding director of the Forensic Fellowship, and one of our specializations is neuro law. So neuro law is an emerging field that studies the role of neuroscience in courtroom settings. And over the past 20 years, there's been a rise in the use of neuroscience in legal cases, legal scholarship, legislation, marketing, and a lot more. So the graph on the upper right shows you just a number of scholarly articles that are on the topic of neuro law, and you can see this exponential curve in interest. The bottom right curve is a study that calculated how many court cases invoked neuroscience reasoning. And you can see it's a graph going straight up. And the graph on the lower left is quite interesting. It's a number of new bills and legislation across the country that is using neuroscience in its neuroscience language. So neuroscience is making its way into the courts, into scholarship, and in legislation. And one of the reasons for this is because we are in a golden age of neuroscience. The reason there's so much neuroscience in the courts is because there's just so much neuroscience these days. And walking down the hall, you see these neuropsychiatry talks and all these great neuro talks. That's because we are in an incredible age of neuroscience. So when I look at it, there are three different waves. The first wave is a wave of increasingly sophisticated ways to look at brain structure. The second wave was increasingly sophisticated ways to look at brain activity, things like PET scans and fMRI, and most recently, resting state fMRI, which is really unlocking a lot of breakthroughs about the brain. And finally, the third wave is interventions. So these are ways to neuromodulate, things like deep brain stimulation, and most excitingly, noninvasive ways to neuromodulate, things like transcranial magnetic stimulation. And in the future, we're gonna be seeing a lot of focused ultrasound. So the first two waves sort of gave us eyes into the brain and noninvasively look at what's going on in the brain. And the third wave sort of gave us hands and is the basis for the new field of interventional psychiatry. I'm not gonna be talking about interventional psychiatry, although everyone should know about TMS and depression. In research studies, it has induced an 80, eight zero percent remission rate in treatment-resistant depressives. So you should definitely look that up. Okay, the other reason why there's so much neuro law these days is because there's a lot of demand for it in the courtroom. And that's because mental states and capacities are of prime importance in the criminal law. So it comes down to culpability. It's thought that mental states as well as brain capacities play a role in assessing how blameworthy someone should be for any particular offense. And so the idea is that culpability should be proportional to punishment. And this is a key legal principle called proportionality. So proportionality is incorporated in the Eighth Amendment which prohibits cruel and unusual punishments. Cruel and unusual punishments being punishments that are disproportionately harsh. So the idea is just punishment is proportional. It's proportional both to the offense and the offender. So many of you know offenses, criminal offenses are generally defined in terms of an act, the actus reus, as well as the mental state. And the act matters. So shoplifting should be punished a lot less harshly than murder, for instance. But the mental state also very much matters. If you committed homicide purposely, that's very different than doing it knowingly, recklessly, or negligently. And it's thought that what mental state you are in when you commit a particular offense really determines how culpable you should be for that offense. So if you do something on purpose, you should probably be more blamed and have a harsher punishment than if you did something by accident, for instance. And the idea is now that we have ways to look at brain activity, to what extent can we know what someone is thinking based on their brain activity? There's lots of really interesting studies that are trying to extract mens rea from a participant's brain simply by their brain scans. We're not gonna be talking about this completely fascinating area today, unfortunately, but maybe in a future talk. So just punishment is also proportional to the offender, particularly the offender's capacities. So these are capacities like moral reasoning, the capacity to think rationally, the capacity to control your impulses. And many of you will recognize these as prongs of different kinds of insanity defenses. So the idea is that, again, culpability is proportional to capacities. So if you have a mental illness that renders you irrational and incapable of moral reasoning, that should be taken into account in your punishment. But what about if you're very young or very old? What if you have a brain tumor somewhere in your brain? How should the law take into account these sorts of capacities? And now that we have excellent ways to look at brain structure, the idea is to what extent can neuroimaging reveal brain capacities? Which brings us to our three talks today. So today's presentations, you'll be treated to first Shefi Lodi, who is one of our fellows in our forensic psychiatry program. Dr. Lodi also completed a neuropsychiatry fellowship and he's an excellent person to tell you about brain lesions and criminal responsibility in the first talk. That's gonna be followed by Dr. Grace Chaney, who is also a forensic fellow and also completed a child and adolescent fellowship prior to that. So she's in an excellent position to teach you about adolescent neurodevelopment and the law. And finally, last but not least, we have Dr. James Armentrout, who will be the incoming forensic director for our program, talking about a PTSD specialist who will talk about the neurobiology of PTSD in criminal court. And then we'll have, so each talk is designed to be about 20 minutes long. We might have one or two minutes at the end for quick questions that are urgent, but then if you have kind of more complicated questions, save that till the end. We'll have about 15 minutes at the end for a Q&A session. Thank you very much. Now, Dr. Lodi. Thank you. Hi, good afternoon. Let's get started. There are a few slides through the PowerPoint that are interactive. So if you guys can get out your phones, this'll be the Slido. You can either scan the QR code or go to slido.com and put those numbers in. And this'll pop up as we get to the relevant slides again. All right, so my talk today is divided. It's about the complexity of the criminal responsibility and is divided into three portions. First, we're gonna look at the case of Mr. Oft, a case study. And then we're gonna zoom out, talk a little bit about the neural circuitry of criminality and then go back in and apply what we've just learned to the case that we began with. So Mr. Oft, Mr. Oft was a 40-year-old teacher who was found to have been molesting his 13-year-old stepdaughter for several weeks. When he is confronted by this, he admits to it and says the following. The pleasure principle overrode my restraints. So with that in mind, let's go to our first question. And that is, what punishment does he deserve for his actions? For molesting someone and his excuse being that the pleasure principle overrode my restraints. And Jeffrey, do you wanna just go back to the QR code? Sorry, let me go back to the QR code right here. So we've got, oh, and the QR code's up here as well. So we've got kind of a small audience, but overall, I think a lot of people feel that he deserves some time for his actions and possibly rehabilitation as well. You guys are a punitive bunch. All right, so let's go back and find out a little bit more about Mr. Oft. So his excuse, Pledge of Principle, overrode my restraint. Now, some more background about him, Mr. Oft previously was a correctional officer, and he left that career in order to become a schoolteacher. Now, he completed a master's in education, and by all accounts, was a very good schoolteacher. There were no complaints, and he had worked for many years in that same school without any problems. However, two years prior to this incident, things had begun to change for him. His interest in pornography, which dated back to his teenage years, began to increase, and eventually began to increase and started to include child pornography, which is something that he reported he never had an increase in before. He also began frequenting massage parlors, and he would solicit sexual favors from sex workers at these parlors. They went to great lengths to conceal his activities from his family, and they were completely unaware of any changes that were happening to him. Now, it eventually escalated from just downloading the child pornography, and he began making sexual advances towards his prepubescent stepdaughter. Now, it actually went on for several weeks. He was able to conceal it until finally she informed her mother of his behavior, and that led to the further investigation, leading to him being legally removed from the house. He was diagnosed as having pedophilia, and he was prescribed midroxyprogesterone. So with this more background, let me ask a different question. How responsible is Mr. Oft for his actions? What is his responsibility? It looks like most people feel that he shares, he has the bulk of responsibility, if not all the responsibility for his actions. Let's go back and find out maybe some more about Mr. Oft. Now he was given the option by the judge of either going to prison or going to inpatient rehabilitation for sexual addiction. And of course, given this choice, he naturally picked the option of going to inpatient rehabilitation. But something interesting happens. He's in inpatient rehab for sexual addiction, the alternative is jail, and he starts soliciting sexual favors from the staff and the other residents at the facility, and in return is expelled for soliciting sexual favors. So the alternative now is that he has to go to jail. So the day before he's supposed to report to go to this correctional facility, he says I have a headache and I have to go to the ER. So he goes to the ER, and the ER doctor examines the patient and asks him how long has this headache been going on, he says two years, the ER doctor surmises that this headache is not really organic in etiology and decides to discharge the patient and says, you know, nothing I can do for you, you need to go to jail tomorrow. As he's being discharged, the patient says, if I'm discharged, I'm going to kill myself, and if I'm discharged, I'm going to rape my landlady. So now the ER doctor is in a bind and he consults the psychiatrist. So he goes to the psychiatrist, and the psychiatrist decides to admit the patient with a diagnosis of pedophilia not otherwise specified. Now he's on inpatient psychiatry, trying to figure out, you know, what to do with this patient, when the psychiatrist noticed something interesting. He noticed that the patient has an abnormal gait, he's walking strange, and he actually has problems with his balance. So he decides to consult his colleagues in neurology. So the neurologist comes in, and this is an academic center, so it's not just the attending neurologist, there's a resident, there's medical students, it's a whole team of neurologists who come and examine the patient, and they notice several interesting findings on his neuro exams. One, he starts soliciting sexual favors from the female neurology team members while he's being examined. Now keep in mind, he's in this position because of his behavior, he got kicked out of inpatient rehab, and now, as he's trying to avoid jail, he finds himself again soliciting sexual favors from female team members. He also has slow to initial leftward saccades, mild left nasolabial folding, some frontal release signs, wide base gait, and during the course of the evaluation, he urinates on himself and is completely unconcerned and completely unbothered by the fact that he has urinated on himself. So the neurology team gets an MRI, and this is what the MRI shows. Shows this, and this, and this. A very clear orbital frontal tumor, hence the name Mr. OFT, Mr. O-F-T. And this is his performance while asked to draw some interlocking pentagons, draw a clock, write a sentence. This is the best that this man with a master's degree in education is able to perform. So the tumor is resected, and histopathology reveals a hemangioparasitoma. Several days after resection, his gait and bladder control have improved. So now knowing this, let's go back and ask this question again. How much jail time does he deserve for his actions? So what penalty does he deserve for his actions? Let me rephrase that. So interestingly, we're a lot less punitive now. We went from on average thinking 20 years is the best solution for him, to thinking house arrest, maybe one to five years in prison. All right. So let us return. So he goes back to inpatient rehab, and this time he's able to successfully complete the program. Seven months later, he was believed to no longer pose a threat to his stepdaughter, and he actually returns home. Several months later, however, he develops a persistent headache, and his wife discovers that he is again collecting child pornography. Now this time, he gets an MRI, and what's found is that the tumor has regrown. His tumor is back. It is again resected. And now this is his performance. This is two days after resection of the tumor. Now the top is prior to resection of the tumor. The bottom is two days after the tumor is removed. And his behavior at this point has completely resolved, and does not return. Now let's keep this case in mind. I'm gonna zoom out, talk a little bit about the neural circuitry of criminality, and then return to Mr. Oft. Now although pretty rare, some people will exhibit criminal behavior after suffering a brain lesion. Phineas Gage is probably the most famous example of this. Now these cases, although rare, can give us some unique insight into the neurobiological substrate of criminality. So this is, you know, Mr. Oft, he had this lesion in his brain. There's a study done by Dr. Darby and his colleagues, which looked, they did a systematic literature search of all the cases they could find like Mr. Oft. Patients who had a documented temporal relationship between a brain lesion and criminal behavior. And they were able to find 17 cases like this. The most common lesion location was the ventromedial prefrontal cortex, or the orbitofrontal cortex. But not all of them were there. There were, you know, relative variation in where these lesions were. What they did was they took things one step further. Using a connectome database, they looked at where all of the different areas are that these pieces, parts of the brain were connected to. And they looked at a functional connectivity map. And then they looked at all 17 cases and did an overlap superimpose them to find what the commonality was. And this was the lesion network overlap. Now taking this, they then applied their hypothesis to look at other patients. So they looked at 23 cases where there was uncertain temporal association. And they did the exact same thing. And lo and behold, there was a very similar overlap. There was a very similar network that was revealed between those that had a clear temporal relation and those that there wasn't. Now the conclusion from this was that brain lesions associated temporarily with criminal behavior are characterized by a unique pattern of brain connectivity. Basically, there is a certain network in the brain that's common amongst people who have criminal behavior. And that these results can be useful for understating, predicting, and assigning responsibility for criminal acts. Let's talk a little bit more about the area that Mr. Off specifically had his lesion in. This is a paper by Dr. D'Amazio looking at the role of the ventromedial prefrontal cortex. And it's a long paper and I'm just gonna get the highlights of it. They came up with a few key findings. One, patients with lesions in the orbitofrontal cortex show difficulty in making decisions, especially in situations involving risk and reward. Lesions in this area also impair the ability to process emotions, which results in people exhibiting inappropriate social behavior, lack of empathy, difficulty recognizing emotions in others. Almost like an acquired psychopathy type picture. And so they proposed what they call the somatic marker hypothesis. Basically saying that emotional signals are processed in the orbitofrontal cortex and damage to this area can make it difficult to make decisions which have positive or negative values attached to their outcomes. Now with this in mind, let's return to Mr. Off and his statement that he made at the very beginning. The pleasure principle overrode my restraint. This was his justification for his behavior. Now, let's go back and again ask ourselves, knowing what we know now, what penalty does he deserve for his actions? So a lot less than 20, it seems. So there's definitely been a shift in how we view what penalty he deserves for his actions. Now, a few considerations of Mr. Oft. Now, given the relationship between the timing of a tumor growth and his behavior, we can be pretty confident that the tumor played some role in his sexual behavior. Not necessarily causing his sexual impulses, because the VMPFC and the OFC are not really areas of the brain that have been implicated in creating sexual urges, but it is an area that's related to impulse control. And given the timing, we can be pretty sure that the tumor played some role, pretty big role in his sexual behavior. But there's some considerations I'd like the audience to think about, both against and in favor of Mr. Oft. Against him is the fact that we don't actually know whether he lacked the ability to control his sexual behaviors. We just know that he didn't control them. We don't know how strong his pedophilic urges were. We know he clearly had them and he acted on them, but how strong were they? We don't know, and the imaging can't tell us. We do know that he was fully in touch with reality. There was no point where he was psychotic or where he was delusional, where he didn't know what he was doing. And we do know that he understood the moral and legal rules that he was violating, and in fact, he took pretty successful steps to conceal his behavior for quite some time from his wife and others. Now, but in favor of Mr. Oft is we know he had a lesion in an area that has been pretty definitively linked to inappropriate social behavior, lack of empathy, and impaired decision making. We also know that he could not control himself in his treatment program. Now, he had the alternative of going to jail where pedophiles are not treated very well in prison, and even knowing that, he was unable to control himself in his treatment program. And we do know that, again, in the hospital, he couldn't control himself. He was faced, or when he saw a female neurology resident, he was unable to control himself and started making sexual advances. So knowing these against, these considerations against, and in favor of him, I'm gonna ask one more time, how responsible is Mr. Oft for his actions? So we're looking at anywhere from like 20-ish, 20 to 40%. About half of his responsibility, half is kind of outside. We also have a few people who think he's completely responsible for his actions. So I'm going to finish up with the last few slides. Now, Mr. OFT, in this whole case, is a great example of what Dr. Stephen Morris has labeled, what Professor Stephen Morris has labeled as the fundamental psycho-legal error. The belief that discovery of a cause for behavior means that the agent is not responsible for the behavior. In other words, it's conflating the understanding of the neuroscience of an action with being able to assign responsibility for that action. And to put it more simply, it's a criticism of the brain made me do it defense. By the end of the day, all the actions that we take are in the brain. Everything that we do is in the brain. So if simply identifying what's happening in the brain is an excuse for responsibility, then all behavior should be excused. This also can be labeled as the lure of mechanism. In other words, if the brain plays a causal role, then if we know the mechanism, then that mechanism is an excuse. Implication being that the person is not the acting agent, but rather is at the mercy of their brain's anatomy. The question I would have to ask is, how does Mr. Oft substantially differ from pedophiles in general? In his case, really the biggest difference was that what was going on in his brain was visible and it was treatable. We knew what was going on, we knew how to remove it to stop those urges. So is it really the difference simply that we don't know the biology of pedophilia and don't have interventions to treat it? Is that really the difference between Mr. Oft and pedophiles in general? At the end of the day, from a legal standpoint, you know, insanity statutes differ from jurisdiction, but the general template is this. Did he lack capacity to understand the wrongfulness of his actions or to conform his conduct to moral and legal norms? Interestingly enough, one of the neuroscientists who was involved in this case took this to a meeting of the American Academy of the Advancement of Sciences and put it to 14 judges. And unanimously, all 14 judges agreed that he was legally responsible for his pedophilia, that he did not lack capacity and therefore was responsible for his actions. And this was based on the fact that he took steps to conceal it and so on and so forth. I just wanna conclude very quickly with this last slide a few kind of takeaway points is, you know, exploring the role of brain lesions and criminal behavior does give us insights into the neurobiological side of pedophilia. It's also a substrate of criminality. And understanding these mechanisms is crucial and it can help between, but it's important to recognize between simply knowing the mechanism and assessing the person's capacity to comprehend the wrongfulness of their actions. In other words, just because we know what's going on in the brain doesn't necessarily translate one-to-one to what should happen legally. And mechanistic explanations should not lead us to a fundamental psycho-legal error of absolving responsibility entirely. We should have a comprehensive approach to understand and assign responsibility for criminal acts incorporating neuroscience evidence as it comes in. And with that, I'll conclude and I will turn the floor over to my colleague, Dr. Cheney. Thank you. You did mention that he'd never had interest in younger women until the two years, so I question the theory that the tumor did not in any way change his sexual interests or behaviors. That's a good point. So he reported that he never had any interest in child pornography before two years. We're taking him at his face value whether he did or did not. Now in general, the VMPFC is not an area that traditionally we understand as being related to causing sexual urges or sexual impulses, so that is, again, a limit of neuroscience. But yeah, it's his report that he never had any interest in child pornography, but we don't know that for sure. Hello. My name is Grace Cheney, and I'm also a Stanford Forensic Psychiatry Fellow, and I'm here to talk with you about law and the developing brain. I have no disclosures to make. Today I'd like us to review some of the neurodevelopmental changes the brain undergoes as it matures and consider how the Supreme Court has applied these findings to juvenile capital cases. I'd like to encourage you, in the meantime, to reflect on the data and consider how it may or may not influence future policy. While the death penalty can be an upsetting and controversial concept, I raise this topic because I believe we need scientific thinkers, such as yourselves, to share your knowledge with policymakers. The law's differential treatment of children versus adults can be traced back over 2,000 years, but a little over 250 years ago, in the 1760s, the esteemed English justice William Blackstone wrote a now-famous overview of how law was practiced in England, entitled Commentaries on the Laws of England. Blackstone's Rule of Sevens recorded that it was commonly accepted in English law that children under seven years old were by default not held criminally responsible, but above 14 years old, children were held criminally responsible by default. Between the ages of seven to 14, the English law's determination of culpability was more ambiguous and encouraged consideration of the child's ability to appreciate wrongfulness. This, as we've mentioned before, foreshadowed future language around the insanity defense. But in the bigger picture, children as young as seven could be executed. We've changed as a society since that time. What we consider just and fair has evolved, as no sensible person today, I hope, would think it just for a seven-year-old to be executed. While English common law considered late childhood to early adolescence to be a culpability gray zone, in the last 35 years, our justice system has begun to more carefully consider the implications of modern neuroscientific advancements and what they might mean for laws. So what neurodevelopmental processes underpin the change in capabilities Blackstone observed and we see ourselves as children age? Researching studies have given us beautiful visual representations of the way the brain changes with age. In this 2004 study, Gagte and colleagues performed repeated MRIs on 13 patients over approximately eight to 10 years. Notice that cortical maturation generally occurs in a back-to-front directionality, with the frontal lobes maturing last. The immature gray matter, represented in pink, gradually matures over time through pruning, which optimizes the efficiency of neural processing by removing unused or redundant neural connections. Fully pruned gray matter is represented, as you can see, in blue. More recently, and astoundingly, in 2022, Bethlehem and colleagues published a study of over 100,000 aggregated MRIs ranging across the lifespan from participants only 115 days old to 100 years old. This gave us a much more reliable and generalizable data set for how the brain changes with age. Take a look at the red line, which represents gray matter volume. The overall trend we just saw in the previous study can be easily visualized. While gray matter growth velocity peaks very early in life, around half a year, gray matter volume continues to increase through all of early childhood. Gray matter volume reaches its peak around six years of age, represented by the upside-down red triangle, before gradually declining due to pruning as non-relevant circuits are eliminated. White matter volume, on the other hand, is shown in blue. We see peak growth velocity occurs around two and a half years old, represented by the blue circle, but white matter volume doesn't peak until around age 35. White matter accumulation, representing enhanced myelination, suggests improving neural connectivity and efficiency, but we see that this remains incomplete until young adulthood. The terms adolescence and adulthood were originally defined without input from neuroscientific studies such as these. While the person is considered an adult at age 18, as you can see, their brain has not yet fully matured. It's different from that of an adult's. Many child advocates and neuro-legal scholars are questioning if our deepened understanding of these developmental trajectories should change the age of execution. Landmark cases handed down from the U.S. Supreme Court have made some advances to recognize the developmental differences between adults and youth and to protect the rights of juveniles. In 1988, 15-year-old Charles Thomas was convicted of murder and sentenced to death in Oklahoma. His case was appealed up to the Supreme Court of the United States. In the case, the court addressed the constitutionality of the death penalty for juvenile offenders and determined that juveniles under 16 at the time of the crime could not receive a death penalty sentence. The Supreme Court cited an Eighth Amendment argument to support their ruling, using classic evolving standards of decency analysis. Using this concept, they reasoned society's standards of decency had evolved and now considered execution of juvenile offenders under 16 to be cruel and unusual punishment and therefore unconstitutional. They also acknowledged diminished juvenile culpability and increased possibility for reformation and rehabilitation. The court did not utilize neuroscientific findings to support these views. The opinion's reasoning was an appeal largely to common sense. As a result, after appeal, Thompson was sentenced to life in prison with the possibility of parole. 17 years later, Roper v. Simmons revisited the constitutionality of the death penalty for juvenile offenders in a murder committed by then 17-year-old Christopher Simmons. In a 5-4 decision, the Supreme Court of the United States delivered a bright-line rule holding that the Constitution's Eighth and Fourteenth Amendments prohibit capital punishment for juveniles who were under the age of 18 at the time of their offense. The court, again, applied the Eighth Amendment prohibition of cruel and unusual punishment by referencing the evolving standards of decency concept, stating, if the meaning of that amendment had been frozen when it was originally drafted, it would impose no impediment to the execution of a 7-year-old child today. For the first time ever, the Supreme Court used neuroscience to support its reasoning, citing Lewis Steinberg's landmark paper, Less Guilty by Reason of Adolescence, to help make key distinctions between adults and children. Using neuroscience to substantiate and support their argument, the majority opined that youth are less culpable and have better potential for rehabilitation, stating youth are more impulsive and reckless due to their immaturity, more vulnerable to outside influences, such as peer pressure, and emphasized that a juvenile's character is more transient and has a greater possibility for change and, therefore, rehabilitation. So let's take a look at the developmental neuroscience supporting these tenants. Recalling the first study we looked at by Gagte, you will remember that the frontal lobe, which we know controls executive function, such as planning, attention, focus, and inhibitory control, is the last to mature. However, the cortical regions, shown in green, like the frontal lobes, complete maturation after subcortical regions, like the limbic system, shown in red. BJ Casey's limbic imbalance model illustrates the lag in prefrontal maturation, shown in green, compared to limbic development, shown in red. In this model, an unchecked amygdala, an underactive prefrontal cortex, leads to an imbalance in emotional processing and regulation. The car is driving, but the prefrontal cortex brakes haven't been hooked up yet. Because the cortex is the last to develop, adolescent brains have incomplete functional connectivity with the prefrontal cortex. This means that their decision-making is less future-oriented than that of adults. Adolescents are also less likely to identify and consider future consequences of actions. The brain is more attuned to appraisals of immediate gains and rewards than it is long-term consequences. Middle and late adolescents struggle to delay gratification, although it continuously improves from ages 14 to 22 years old. Lawrence Steinberg, who you will recall was cited by the Supreme Court, conducted a study to evaluate if susceptibility to peer influence on risky decision-making varies with age. The experiment was designed such that participants were told to attempt to drive a virtual car as far as they could, until a traffic light turned red and a wall appeared. If the car wasn't stopped soon enough, it crashed. Participants' performance was evaluated as they played the game alone, and then when they played in a group of peers instructed to call out advice. I don't know about you, but that sounds pretty stressful. Steinberg conducted this experiment in groups of adolescents, young adults, and adults. Let's take a look at the outcomes. In the graph, more positive numbers, or the upwards direction on the y-axis, represents riskier driving, whereas more negative numbers represents less risky driving behaviors. As you can see, the adolescents were more likely to engage in risky driving than young adults or adults, but young adults still were also more likely to engage in risky driving, were more likely to engage in risky driving than adults. The difference in risk-taking becomes even more significantly pronounced when we consider performance in group settings. Adolescents and young adults demonstrate significantly increased risk-taking behavior in the presence of peers, whereas adults only demonstrate a small change. While teens acting by themselves are impulsive and reckless, when in the presence of a peer or group, they're even more reckless. This can be explained by heightened reward processing. Studies have shown that youth show increased striatal activity when engaging in risk-taking behaviors when in groups compared to when they are alone. The striatum is a key component of the dopaminergic reward system. The heightened reward processing in adolescents and early adulthood can be understood by striatal hypersensitization during these developmental periods. Although this is developmentally distinct from adults, overall, this is developmentally normative, as it can promote adaptive behaviors, which is healthy exploration and novelty-seeking. Even enhanced risk-taking can be adaptive, as in certain concepts, risk-taking may allow adolescents to explore new interests, skills, or form new friendships. This quick flyover of developmental neuroscience confirms what every parent already knows. It is developmentally normative for youth to be immature, yet how much should the law take this into account? How does it influence our conceptualization of juvenile culpability or their level of responsibility? Societal attitudes have shifted significantly over time. Back in the mid-1700s, society believed it was accountable to hold children as young as seven culpable and, therefore, executable. In 1915, a 14-year-old in Georgia was the youngest person to be executed in the 20th century. In 1988, we had Thompson v. Oklahoma raise the minimum age of execution to 16. In 2005, citing neuroscience, Roper v. Simmons set our current minimum age of capital punishment at 18. But many studies in the literature, and some that we review, suggest that the brain remains demonstrably immature until young adulthood. So what should we consider just in terms of the minimum age of execution? Do the neurodevelopmental curves that we saw help us inform our discussion? Should the minimum age of capital punishment be 20 years old? What about 25 years old? How should our evolving understanding of neuroscience and neurodevelopment be applied to our evolving societal standards of decency? It's a question I continue to monitor, and I'll leave you all to do the same. Thank you for your attention. Going back to the idea of whether pedophiles are culpable because we haven't seen their brain issue yet and we just don't know what it is, if you think about those studies with children who were given marshmallows, is it kind of the same thing, like some 7-year-olds should be executable and have all of this frontal development, but other ones, like we just don't know the differences in their brains yet, why some would take a marshmallow and some wouldn't? I tend to personally agree with what you're saying. I think that the idea I would like to advance here is that, in general, this is the trend that we see, but each individual still needs to be treated as an individual, but most 7-year-olds are so much more, you know, 3-year-olds are much more likely to take the marshmallow than the 7-year-old or the, you know, 30-year-old, et cetera. So putting individuals in terms of, putting individuals in context, I think, is what I'd like us to think about. Does that answer your question? All right. Well, good afternoon. I'm James Armatrout, here to talk about PTSD and some neurobiological correlates in criminal court, and I have no relevant disclosures. So let's start with the case of Mr. M, and this is a fictionalized case based on some elements that you might often see in a criminal proceeding like this one. So Mr. M was around 19 years old. He was with his best friend at a party. They're both sitting on the couch. They're having a good time. Everyone's getting pretty intoxicated, but then at some point, one of the other party goers comes up, and they're a little bit confrontational and belligerent. They say, you know, where's my watch? Somebody took my watch. You took my watch. Pretty soon, Mr. M's friend starts talking back, arguing, no, I didn't take my watch. Get out of here. They exchange some words, and then eventually things start going to slow motion. That person who's intoxicated pulls a gun out. He levels it at Mr. M's best friend, and he pulls the trigger several times. Mr. M bolts. He runs to the corner of the room. He tries to hide under a small table there, but unfortunately, that doesn't do much. The assailant fires several shots at Mr. M, hitting him in his leg, and then piercing his abdomen twice, then leaves. Mr. M is rushed to the hospital. He has emergency surgery. He ends up in the ICU for a while, but he survives. His friend doesn't, and the assailant, it turns out, had his watch in his back pocket the whole time. He was just too intoxicated to remember. So Mr. M goes on to develop PTSD, pretty classic PTSD. He seeks treatment. He takes antidepressants for a while. A friend introduces him to Xanax and cannabis, and he stops taking antidepressants, stops seeking treatment, and carries on with long-term symptoms. And those symptoms include avoiding being around men, avoiding being around situations where he feels he could be shot, and starting to carry a firearm himself, which he brings with him everywhere. Now we fast forward eight years later. Mr. M is with a couple of friends outside of a bar. A fight breaks out. Mr. M doesn't want anything to do with it, but his friends want to go see what's going on. He goes over, he crowds in, and then at one point one of the people who's fighting turns on him. They angrily confront him, they shove him, and as he's falling backwards his ankle explodes in pain, activating that same injury he had from the original incident. He's looking up from the ground like he looked up at his attacker. He's overwhelmed, he's terrified, and then he sees the person looking like they're moving their hand into their clothing. He pulls out the gun he always carries with him, he fires several shots, and the next thing he remembers is running down the street. Later he takes that gun and he throws it into the river. A few days later the police pick him up because he was on camera. It captured the entire exchange. When we think about a case like Mr. M's, it brings us to the question of what kind of role could PTSD play in criminal court? What might an attorney do with the information that Mr. M had PTSD and might that have some link to what he did? There's a really good article written by Omri Berger and a team at UCSF in 2012 that talks about some of the roles PTSD can play in criminal court. We've all heard of the not guilty by reason of insanity defense. In general, used about 1% of felony cases, successful about a quarter of the time. But there are other ways that PTSD and more broadly many different mental disorders can get in to court proceedings. So you could look at unconsciousness, which is a legal term saying that the person was not aware of what they were doing, and we'll get a little bit into that. You could look at self-defense, and that could be either perfect self-defense, which is exculpatory. In other words, you use lethal force because you thought you had to do so in order to preserve your life. Or you could look at imperfect self-defense. And so that's generally something where you're going to be holding the person less culpable for what they did, as in a reasonable person might not have viewed that as imminent threat to their life, but maybe this person who had PTSD or another mental disorder viewed it as a threat to their life, and maybe they could qualify for an imperfect self-defense claim. You could also look at refuting mens rea, or the guilty mind. As you know, you need the guilty mind and the guilty act for many criminal convictions. So someone with PTSD, could it have undermined their ability to form that criminal intent in the moment? And the interesting thing about these three that I just mentioned is if you get a not guilty by reason of insanity finding, you're not guilty by reason of insanity. If you get one of these findings, you could be potentially found just not guilty, or found guilty of a lesser charge. So there's obviously some appeal from a legal sense in invoking one of these defenses. You can also use PTSD as a mitigating circumstance. And testimony has gotten in in Fry and Daubert districts, which are different legal standards for introducing testimony, kind of as a very brief explanation, Fry is basically, it's generally accepted within the field. Daubert is more, it is, the judge is the gatekeeper. It needs to be shown that what you're testifying to came from reliable scientific methods. But PTSD testimony has made it in in a wide range of cases, and the key thing is that you just find a direct and clear connection between the PTSD and the criminal act. So you're not just testifying about the PTSD for the sake of testifying about it, you're finding a clear link between the disorder and what occurred. And I also find this a pretty interesting study to cite, just to talk about a little bit of the controversial nature of some of this. So there was a survey of 238 forensic psychiatrists, all of whom were members of the American Academy of Psychiatry and the Law, published back in 2017. And if you look at how many thought PTSD could even meet the threshold for insanity, now this is not in a particular case like Mr. M's, this is just saying in general I could see this happening. It's about half across different standards. The McNaughton standard is, I'd say, about the closest to the state court standard here, which is basically, did you know the nature and quality of what you were doing, and did you know that it was wrong? But about half of psychiatrists think that that could be met with PTSD, and about half don't. So just something to keep in mind if you're looking at these kinds of cases. 90% believe PTSD could be mitigating. I'm not quite sure about, you know, what the 10% are thinking, but yeah, 90% would be on board with that. And 26% think it could potentially be a basis for finding of incompetence to stand trial. And so, if you're the defense attorney approaching Mr. M's case, what kind of things might you think about, and how might PTSD symptoms link to those particular defenses? So self-defense, you might look at threat sensitivity and misappraisal of threat, a pretty obvious one. Unconsciousness, dissociation. In Mr. M's case, not really applicable. It sounds like he may have had some dissociative amnesia after he started pulling the trigger and when he started remembering running down the road, but he wasn't really dissociated at the time he engaged in the shooting. Not guilty by reason of insanity or mens rea defense. Could really look at symptoms from either of the above categories. And just as a quick aside, what if he claims amnesia? I just mention that because peritraumatic amnesia is pretty common. Probably somewhere about a fifth to a third of people who perpetrate a violent act may have some degree of amnesia for the act itself. And that's usually going to be at the moment of most emotional intensity. So it's usually not, you know, it was eight o'clock, I was getting ready to go to the bar and then it's midnight and I have no idea what happened. It's a little bit more like outlined in Mr. M's case. And what about the link between PTSD and anger? So PTSD and anger are definitely linked. They're definitely correlated. That may do less in terms of a legal defense because often anger is not going to be directly relevant to reducing culpability. And I want to say just a very quick word about reactive versus instrumental violence before we launch into some of the neuroscience. This is taken, sort of borrowed from the VA, but you can see the cat over there is about to engage in reactive violence. So its hair is standing on end, its muscles are tense, it's ready to immediately strike out. The cat on the other side is prepared to do some predatory or instrumental violence. It's cool, it's calm, it's thinking. And PTSD has been linked with reactive violence. So the study there, the Teton et al study, looked specifically at this question, 136 PTSD veterans and found that impulsive aggression was associated with a moderate effect size. Premeditated aggression really wasn't. So thinking about some of the neural correlates of PTSD, this actually goes back a little bit to what we were just talking about with some of the adolescent cases. So you've got the amygdala firing too much, the limbic system overactive, and the frontal lobes basically not putting the brake on sufficiently. In terms of amygdala hyper-responsivity, this is a sampling of some of the research that's out there that I think illustrates some different important components of functioning. And if you're interested, I definitely recommend taking a look at a couple of the review articles I cited here. But one example would be the Rauch et al study. They looked at some PTSD veterans, nine with PTSD, eight who were combat exposed but did not have PTSD. So two different groups. And they showed that fearful faces elicited an exaggerated amygdala response in the PTSD subjects. And interestingly in this study, they said if you look at amygdala reactivity, you can actually correctly categorize people into PTSD and non-PTSD with a 75% sensitivity and 100% specificity based on the data. So pretty cool finding. Relatively smaller sample size but interesting. Bryant et al in another study looked at 15 with PTSD versus 15 matched controls and found greater left amygdala activity in response to fearful stimuli. And interestingly, I think we all know that the amygdala is responding on that very basic level, on kind of a before the conscious processing level. But work has been done looking at that. So for example, in this study, the Matzah et al 2012, they took Chinese ideographs, so basically Chinese symbols that shouldn't really have a particular emotional valence for the people who are viewing them. And they rapidly showed them a fearful face flashed just long enough that it registered but not at the level of consciously thinking about it and processing it. And they found that there was greater amygdala reactivity to the Chinese character after being primed with that negative face. So there's some pre-conscious processing that's happening there. And interestingly, which I think will resonate for those of you who worked with a lot of people with trauma, there is a decreased amygdala response demonstrated in this 2014 study to faces that have positive emotions on them. So kind of sad when you think about it. The amygdala is looking at salience. It's looking at what to pay attention to out in the world. When you've got negative stuff, it's lighting up. It's very active. When you've got positive stuff like, you know, happy child or someone who's expressing joy, it's not telling you to attend to that quite so much. Also, the ACC and MPFC. So this is where, with the frontal lobe, we're looking at kind of the decreased break. The dorsal ACC is involved in cognitive control, error-related processing. The rostral ACC, assessment of salience and emotional information. And in another study with 10 combat veterans with PTSD versus 10 without, they found that in response to combat pictures and sound, there was less activation of the MPFC, decreased ACC activation as well. And another study in 2002 confirmed this with adolescents. So adolescents with PTSD, five of them, versus those without, six of them, didn't show the activation of the ACC during these perception and imagery recollections of traumatic reminders that you would have expected. So potentially not getting the kind of suppression that you might expect. And interestingly, there was a structural study. So a lot of these I've been talking about were functional. This one was actually structural, looking at monozygotic twins who had been exposed to combat and developed PTSD versus other groups. And they found that combat exposed twins who had PTSD had lower gray matter density than the combat unexposed co-twins. So basically, you've got two identical twins. One goes to war, develops PTSD. And when you scan them, the one who went to war and developed PTSD has lower density on their scan. And they also compared that to veterans who had gone to war who were in combat and did not develop PTSD and found that they had higher gray matter density. And they were actually more similar to their twin who was not exposed to combat. So potentially suggesting this may be an acquired sign rather than something like a vulnerability factor. Another interesting study in 2012 actually scanned a bunch of people for a different unrelated study. And then all of those people were exposed to an earthquake. And they managed to track down and scan 42 of them again. And interestingly, they found that if you had a higher gray matter volume in the right ventral ACC before the earthquake, you were less likely to develop PTSD symptoms. They also found that no one developed PTSD in this sample. But those who had more symptoms of PTSD had a greater reduction in gray matter volume in the left orbitofrontal cortex. The insula, just a brief mention that it's highly interconnected with the cortical and limbic structures. And that there have been some studies showing higher anterior insula activity in people with PTSD. And the hippocampus, probably the thing that comes to mind, when I hear about the hippocampus or the London cab drivers who had very impressive hippocampi back in the day before GPS, we remember it's associated with learning and memory. And there's the thought that in PTSD, part of the failure to extinguish learning might be related to deficits in the hippocampus. So when someone was walking around in Fallujah, they could easily be shot at from a tall building. When they're walking around in downtown Palo Alto, that's not a risk, but it's hard for them to suppress that reaction. And there is some evidence from monozygotic twin studies saying that the hippocampal volumes may actually be predisposing rather than a result of the traumatic exposure. But that's a little bit controversial, hasn't really been fully confirmed. SSRI treatment can potentially increase hippocampal volume. And people who don't have PTSD have been exposed to trauma can have smaller hippocampi than people who have not been exposed to trauma. So some kind of mixed data. And I will very briefly mention the triple network model that I think is going to be something to keep an eye on. The triple network model is looking at how different areas of the brain fire together. So looking not just at what does one area in isolation do, but how do these join together and interact. And I don't think it really undermines any of the findings, but kind of expands on them. So there have been some animal studies showing where some of these deficits may come from in a prolonged stress response. That, for instance, you can have increased synaptic connectivity in the prefrontal cortex and the hippocampus and decreased connectivity in the nucleus accumbens and basolateral amygdala. And those may be related to glutamate and monoamine-based pathology. But broadly speaking, the triple network is basically referencing that there's a salience network that modulates between a central executive network and a default mode network. So the default mode network is basically kind of the daydreaming network. And some recently published work suggests that there may be deficits in PTSD. That may be linked to some of the dissociative symptoms, the avoidance, the intrusive thoughts. The central executive network is where you may see some of the loss of top-down regulation and cognitive deficits. And then the salience network is basically activating between one and another and may inappropriately be activating the central executive network and not defaulting to that default mode. And just to mention here, the default mode network includes posterior cingulate cortex, medial prefrontal cortex, and medial temporal lobe, including the hippocampus. So some of the areas we've been talking about. Central executive network anchored in the DLPFC and may be related to that loss of modulation over fear and threat detection. And the salience network likely involves the insula, dorsal anterior cingulate, possibly amygdala. And a brief mention of should functional imaging be routine in forensic evaluations of PTSD. So I've seen some of this data explained in reports in a productive way. I typically haven't seen imaging used in PTSD and I think that what we would be looking for before you can introduce it is can you apply the data to this person sitting in front of you. So do you have enough data to say these are the kind of error rates we would expect. This is the positive predictive value. This is the negative predictive value. I don't think we're quite there yet, but one day we may be. And I think you have to watch the evidence closely because when we arrive there people are going to start introducing it. And basically that may be how it shows up, that it is introduced and the judge accepts it and allows it in. So revisiting Mr. M's case, what ultimately happened, the expert submitted a report talking about the link between his PTSD symptoms and his act. And ultimately that enabled him to reach a plea deal, bumping down to manslaughter and resulting in a far shorter prison term than he might have gotten had he been convicted of outright murder at trial. So that's my time and I think we can open it up to questions. I have a question regarding Dr. Lodi's excellent presentation. I was thinking about the role of empathy as a protective factor against violence. I do violence risk assessments and I was thinking about what you said about the involvement of the orbitofrontal cortex with empathy. What do we know about Mr. Offt's understanding of the impact that his actions were having on his stepdaughter and did his empathy or understanding improve after the tumor was removed? That is a fantastic question. I don't believe we know anything. The case report didn't mention of any comments that he made one way or the other about feeling empathy or if that changed after the section of his tumor. I do think he expressed remorse afterwards if I remember correctly. It's on the case report but nothing specifically about what empathy before or after. I'll just add on that's an excellent question and actually this area the VMPFC which is the medial part of the OFC is one of the key areas that generates the experience of empathy. As Dr. Lodi said, the case study didn't specifically mention the defendant's empathy level but we have little clues like he was very unconcerned that he had urinated on himself for instance so there's sort of a lack of awareness of social cognition which is related to that concept of empathy. Thank you so much for the great presentations. I had a couple questions. First one for Dr. Lodi. I mean when you talk about Morris's fundamental psycho-legal error, not conflating responsibility with causation, external causation at least. I guess, given that, I know Morse also talks how criminal law is in this realm of folk psychology, given that we're not giving up folk psychology anytime soon, I don't think that's possible or even necessarily desirable. Would that not argue for not using any neuroscience in criminal law if we're really operating in that sphere of folk psychology and we care about responsibility and not metaphysics of causation or free will and that stuff, first question. And then second question, more out of curiosity, I know a lot of the presentations mention a lot of structural MRI, functional MRIs. I was wondering if anyone could speak about the admissibility of DTI in cases in recent years, not just with mild TBI, but behavior more generally. You can take that question. Yes, so the first question is about, I'm sorry, can you just, about Stephen Morse's, should we use neuroimaging at all if we just rely on folk psychology? Yeah, exactly. And so folk psychology is basically a fancy term psychologists use for common sense. We all operate with models of how other people are thinking, we all mentalize, we have theory of mind. Folk psychology is basically the use of common sense reasoning for theory of mind. So I would turn that around to you. I mean, the question is, common sense is good, but it's not perfect, right? Common sense can make lots of mistakes, because we don't know, the common sense thing at the very beginning of Dr. Lodi's thing was like, oh, this person should get 20 years in prison, because through my folk psychology lens, he molested his stepdaughter and didn't have any remorse about it, punish him up the wazoo. But isn't it interesting how knowledge of the underlying neuroscience mechanisms change people's internal mechanisms of accountability? So Stephen Morse is one of my mentors, and he's quite skeptic about neuroevidence, but it is undeniable that knowing some of the neuromechanisms changes people's notions of culpability. With regards to DTI imaging, you know, DTI is, I mean, I've been involved in a bunch of cases where people have tried to introduce DTI imaging to show, to demonstrate, for instance, traumatic brain injury, right? So look at this particular circuit that we're looking at, this fasciculus, look how the DTI, so for people who don't know DTI, it's diffusion tensor imaging, it's like a new flavor of MRI that allows us to see axonal connections indirectly. So it's part of how we're developing this connectome map, how brain areas are connected to each other. So the idea with DTI, though, is that it's not routinely used clinically, and that's really a good indication of when something's ready for court, because if something's clinically being used, it generally means that it went through an FDA clearance or approval process that demonstrated safety and efficacy, so that, like, the test has been tested, in a way. So DTI is used, as far as I know, in very narrow circumstances, like neurosurgeons who want to avoid language areas, so they'll do some DTI imaging, and for that, you're not talking about the bundle is too big or too small, you're just talking about presence or absence. The problem with arguments that, oh, this DTI bundle is too big or too small, is that we simply have not imaged enough brains to understand what a normal-sized bundle is, and what the normal variations are, so there's no normative database. Without that, we can't tell whether something's abnormal or not if we simply don't know what's normal. So for those reasons, the lack of a normative database, also DTI is done in a very non-standard way, because, again, it's really not clinically used that much, so, you know, an MRI, a structural MRI, you can get your, it's completely standardized. Every machine is calibrated, there's, like, agencies that check up on it and get penalized if you don't do it, so you can get an MRI in New York, you can have a radiologist in California who's looking at a calibrated monitor that also is very specced and calibrated, so the existence of standards is a huge thing to really understand, really, for something to be reliable in court, the existence of standards really is key, like DNA fingerprinting, for instance, right? Structural MRI. But for fMRI, for DTI, all these things have not, we have not kind of converged on clinical standards yet, because it's so rarely used. David? And just to add a bit to that second question, so I would definitely agree, I think DTI is really not ready for the courtroom yet, but I will say, on cases I've worked on where mild traumatic brain injury was a claim, I've definitely seen it used multiple times, and I have heard of some cases where it got in and seemed to get some attention, so I think it's an evolving area. I think it's probably not ready yet, but if you do these types of cases, it's something to be ready to explain if you think why it's not ready, why you wouldn't rely on it. Hi, thank you so much for these presentations. I am a child and adolescent inferensic psychiatrist in Texas, in many capital murder cases, typically 18, 19, 20 year olds, so talking about brain development, and when I landed here a couple of hours ago, I had a new question from one of the defense attorneys for a gentleman who had PTSD, ADHD, and then was using meth at the time of the crime as well. And so my question is more about the ethics of introducing some of this information in the courtroom and how you do it, because I always am so concerned how to tell the story when we're still saying things like maybe the amygdala is involved here, maybe it's not, and also how we convince a jury, or how we educate a jury, we're not here to commit, but how we educate a jury when there's so much ambiguity in so many of these things. And I think the other thing I worry about is introducing things that would be deemed inadmissible and that carrying weight in the future and other people's testimony, because our science is evolving so quickly. So I wondered if you could talk a little bit about that. Actually, as a young forensic psychiatrist, I'd be much more interested to hear your experiences on how it's been received in the courtroom. What are some of the ways that you've seen these challenges present? I do think it's an interesting and maybe unique, maybe not super unique, but to do it in Texas, and that I do, I'm from Texas, and so I think I'd get asked to do it because I'm seen as a local person there and not an outsider. So, but I feel like things need to be explained, not, I don't mean this just in Texas, I mean everywhere, but very simply, as simply as possible. And so many of these concepts are not simple, and we still have debate amongst ourselves about what is actually happening and that science is evolving so quickly. So I tend to say things more generally than anything was explained here today about what ages the brain develops and what we know and what we don't know. But I worry that I'm not being, that I'm falling into the folk psychology part of it. It was just like, everyone should know this kind of, and not being scientific enough about it sometimes. We've been very successful, and so I guess it's working, but which is why they keep asking me to do it, I guess. But it is, I struggle with that a lot about how I was asking for a case that's going to trial in the coming months. Many of them don't end up going to trial, right? And so after explaining these things, they get settled in some way, and so it's used more for mitigation often. But we do have one going to trial in the next couple of months, which is what this question was about. And I thought, I just don't know that I can adequately explain the answer to this question to a jury. But I think it's a good question, and I think it deserves to be described. I'm just not sure that I can do it adequately. So I asked them, do we want to use pictures? What pictures would be helpful? We debate this, how often should we use images? Is it more confusing to the jury? Is it more overwhelming where they shut down and don't listen at all? What is helpful in this? And so I think that's, at least for me, this is an ongoing discussion over and over, depending on what the presenting factors are. Some of them are much more clear-cut. This one, to me, has lots of ambiguity, and so I fear that the more scientific I get, the more I'm going to have to say I'm not sure that that applies here and cross. And I don't want to say that because it muddles it and decreases the value or validity or strength of my other arguments as well, or my other education. So I don't know if that was helpful or answered your question, but that has been my experience so far, is that I feel confident in explaining the things, but often that allows us to settle and go to mitigation, and I feel more concerned when we're actually in trial, and there's a jury there. You're right about talking and thinking about, should we include images? Should we not include images? We've talked about, there's many studies that support how seductive images can be, that juries think that they understand concepts are more likely. It really influences the way that they respond to the information presented quite significantly. Yeah, I mean, we used to talk about imaging. Imaging can be very persuasive, and it can be very clarifying. I mean, did you find the images I used in my slides to be helpful in understanding? It depends on the image. Like, if the image is full of 8,000 bars and tiny little legends, and that's gonna be very confusing, but if you can't strip it down to its essence and put it in an image, that can be very helpful. You know, one general, I mean, kind of what you're getting at and what you're talking about is the fact that neuroimaging evidence is rarely dispositive. It's like, you can't just say, there's the neuroimage, here's the verdict, right? So, and that's because, actually, brain behavior correlations are quite weak. You know, Dr. Lodi showed you in a case, one of the most convincing cases, that a tumor was causal in some bad behaviors, right? But there's plenty of cases where someone had a tumor and there didn't appear to be any change in their behaviors. So there's a famous case called Herbert Weinstein. He's an ad exec in his 60s who murdered his second wife. You know, no history of violence, no history of imprisonment, wealthy, well-to-do person. And they found an arachnoid cyst in his brain, which led to a very favorable plea bargain to him. But when you look at the literature for arachnoid cysts and what percentage of people with arachnoid cysts have impairments functionally, it's something like, I forget the number, it's like 20%. It's like, it's a pretty low number. So you can't just look at neuroimage and say, now we have our conclusion. So, you know, and this is where Stephen Morse comes in. He says, you know, neuroimaging is just kind of useless because, you know, it's so weak, the brain behavior correlations, and when you care the most, it kind of tells you the least, you know, because of like these kind of close call cases, like mild traumatic brain injury, where there's just a little smidge on the, you know, on the scan. In general, though, I think the way to correctly think about neuroimaging evidence in courts is that it sets up, it makes the general case, but then you as the forensic psychiatrist make the individual case. So this is the group to individual inference problem, where most of the studies that we have, all the studies that we discuss are in groups of 15 vets with PTSD and 15 controls. So on average, we have less activity or more activity on this area, but when you break it all into individuals, there's a lot of overlap. So you can't just say, oh, this brain activation pattern is really high, therefore, you know, the person has PTSD, because frankly, there's a spread in, you know, how active that brain region can be, and there'll be control people who also have just naturally high activation in that area. That's why it's really important, first of all, to have large normative databases, so we know what normal amounts of activation is. But knowing that there is a large spread, and a lot of bio-variability makes it hard to predict just based on the neuroimage. So the neuroimage can make the general argument. Look, this person has a tumor in this part of the brain, it's plausible that since this tumor is in an area that, you know, affects memory or whatnot, the person will have impaired memory. But then to prove it, you as the forensic psychiatrist need to do the rest of your job. Like, let's look at the police records. What about the interview? How do they look in the police interview record? You have to fit, you're making the general case with the neuroimaging, but then you have to make the specific fitting to the specific individual, and it fits or doesn't, so your conclusions will be like, it fits, and it doesn't. If it doesn't fit, then it's like the neuroimaging, you know, it's just a red herring. If it does fit, then you have a really strong argument. So my, the second part of my question was really, I would love to hear your thoughts on the ethics of introducing some of these mindsets kind of before they might be prime time. They might inform, and I think that they would help inform, that they might also confuse, or they might prejudice future juries about, you know, the use of these arguments as well. Yeah, I think it's such a personal question, right? I think it comes down, like, practicing philosophy. For me, I think they're helpful, because as a layperson, I would have liked to understand things in these frameworks, and I think most of us, you know, are kind of adrift, and to have something to anchor onto, and like, start connecting to, like, as you're trying to explain the fine details in the individual, I think would be helpful, but again, I think it's completely individual, but, you know, I think there's, the other side introduces quite a bit of questionable things, like, far more questionable things, like the DTI, you know. I think it doesn't make it right for one to do it on the other side, but individual, I think. One related thought I would have is that probably it shouldn't do a lot of the heavy lifting, you know, kind of like we've been talking about. I think you really make the case with all of the classic things that we look at, and then it might be something that's supporting a conclusion that you're already, you know, defending very well from other vantage points, but I think that's a really interesting point, that if we introduce this evidence, and it gets ruled inadmissible, you know, may that affect down the road, and it's something I haven't thought a ton about, I would say, maybe down the road, you know, when they have a more firm basis for it, it could then overcome any previous ruling that had occurred, and I would say, at least in my experience so far, you know, usually I don't rely very heavily on any of, you know, like the neuroimaging or anything like that, and I've seen cases where these kind of neuroimaging modalities have been rejected, and it doesn't seem to have stopped it. It seems like it keeps getting introduced anyway, and it still gets accepted, you know, on a case-by-case basis. Like the attorneys want it to stay more than it did. Yes. Yeah. I don't think it's ever unethical to tell the truth. I mean, say, this is the state of the studies. Someone with this tumor in this location has a 15% chance of violent outburst. This is what we know, and then, you know, just keep in mind that as the expert, you're not the finder of fact. You're presenting information that the finders of fact, you know, hopefully will find clarifying, and what, you know, if you feel like that information is accurate and clarifying, then there is no ethical barrier. Whether the judge will accept it is a different story, but, you know, just be accurate. Say, you know, I'm often up against really terrible neuroexperts. Neuroexperts that have this super simplistic, oh, this spot here means this behavior there. It's like, we're not puppets on a string. We're these incredibly complicated, you know, organic computers of like a trillion neurons, so really kind of giving the jury the sense of the studies, but also a sense of the complexity, and balancing that, I think, is the expert's job. So I've heard three of you guys talk about how crappy DTI is and all these things, and maybe I'm just showing how ignorant I am, but if you have somebody who's clinically having all these kinds of emotional problems and other kinds of issues, and they're having all this other things clinically that are not explained by their MRI, and they wanna try to say that they have shearing damage, how else are you going to like show that there's any indication of shearing damage? Like, are you saying that it should be only diagnosed clinically, or is there some other better test? Well, I mean, so hopefully if they have, not, I mean, not hopefully if they have brain damage, but hopefully there'll be other ways that it's visible, so like, you know, the CAT scans and the MRIs that are taken acutely after the injury might show, you know, kind of water diffusion problems. You know, there'll be other scans that might show some evidence of cellular damage that could, you know, be used to argue that there is some shearing damage. The problem with DTI is it's not that it's useless, it's just that we don't have enough of a normative definition of DTI. So if you come to me with that patient and say, oh, look, you know, we have all these clinical signs, and now we've done a DTI analysis, and the fasciculus, you know, is, it looks small. You know, my question back to you will be like, well, how do you know that? Like, what's the normal size of the fasciculus? And if you cannot answer that question, that's a real problem, because of biovariability. We're not machines that are all stamped out with exactly the same components. So there's a spread. Some people have thin bundles, some people have fat bundles, and we need to know what the normal range is to bring your kid to a pediatrician, you know, and they measure the kid's head, and they say, oh, your kid's head's too small, or too big, and you go, well, how do you know that? If they said, oh, because we measured five other kids' heads your age, you know, your kid's age, you'd be like, well, is that enough kids to really know whether my kid is too, they have really nice normative growth curves for kids' heads over different ages. We don't have that for DTI, and that's a real problem. So, but for, you know, cases like the neurosurgeon, where they just want to avoid a language area and the wiring, that's just a presence or absence problem. So that's a great use of DTI, because you're not trying to, you know, see what I'm saying? Yeah. But, you know, hopefully if the clinical symptoms are really strong, then, you know, that'll be enough to carry the kid, to make your case. And I've read some expert reports on DTI, too, where they compare one side to the other. Can you comment on that? Yeah, so they often, so I've seen these reports, as well, where they look at the absolute size of the bundle and also the asymmetry. So, and the argument's been, oh, look how asymmetric this is. This is like 9% smaller than the other side. This is, you know, and the machine then has a red asterisk and say, you know, look at this red flag, look at this problem. So, but again, what's the normal degree of asymmetry? We don't know what that is. If we knew what that is, that company that made that, you know, analysis software for the DTI would ask for FDA approval, and the FDA would say, okay, what's your data? Show me, you know, that your test can accurately, you know, differentiate people with TBI without TBI. That's really the problem. There's all these, like, great ideas and the fear, and it makes sense, you have shearing damage, you know, there's gonna be some accidental, you know, injuries, there can be a smaller effect. That's all a great story, that all makes sense, but until you actually test the test, you don't know how valid that is in a court setting. Yeah, yeah, sure. So once you see things using clinically, like right now, I don't think there is a clinic, like if you get a concussion or a TBI, I don't think they, as a standard, run a DTI analysis, you know, that's because it's not useful yet, because we don't have the data to guide people with whatever the DTI machine's spitting out. All right, you guys, thank you so much for your kind attention, staying to the very end. Thank you very much.

neuro law

neuroscience

legal settings

brain imaging

fMRI scans

neuromodulation

culpability

punishment principles

psycho-legal error

juvenile justice

criminal responsibility

PTSD in courts