Fatal Family Violence and the Dementias

Front matter

Routledge Studies in Criminal Behaviour

FATAL FAMILY VIOLENCE AND THE DEMENTIAS

GRAY MIST KILLINGS

Preface

The sun was setting over the north Norfolk coast of England. Andrew and I were walking toward Cromer. It was a stunningly beautiful late afternoon in August. The beach was practically deserted. We talked as the sun turned slowly orange over the cliffs. Our topics varied. His retirement, his interest in early modern English history, his family, my family, our interest in poetry, and how we spend our days now. The topic of my work came up, and I started to explain this book project. Over the last decade or so, a number of dementia-related family killings have come to my attention in my role as the director of the National Domestic Violence Fatality Review Initiative (NDVFRI), a technical assistance project generously funded since 1999 by grants from the US Department of Justice, Office on Violence Against Women.

Knowing a close and dear family member of mine, Rita May, a pseudonym, had developed dementia, he asked me if Rita May’s dementia contributed to my writing the book. I answered Andrew as best I could by saying that it surely did, but in ways I did not understand. That influence was likely a mélange of the direct, the oblique, the opaque, and the subliminal. Personal experience often informs our work, and in my case, that has turned out to be true. Rita May’s father killed her mother just before VE (Victory Europe) Day. People celebrated VE Day on May 8, 1945. It marked the Allies’ formal acceptance of Germany’s unconditional surrender and thus the official end of World War II. He killed her in their family home. The coroner”s inquest concluded that the death was accidental. He had been cleaning the trigger of a shotgun when it discharged, killing her instantly. He had apparently been under the impression that the gun was not loaded. Rita May, age 12 at the time, was in an upstairs bedroom with her younger sister. She came downstairs to witness the scene, a scene that would haunt her for the rest of her life. Her sister remained upstairs. Some years ago, Rita May’s sister died of complications associated with Parkinson’s disease. Did the shooting somehow contribute to the neurodegeneration the sisters experienced in later life? Rita May’s deterioration over the last few years and my involvement with it suffuse what follows.

The book therefore reflects personal and professional interests. I found it best to tell the story of fatal family violence and the dementias through case studies. The book is a narrative about the bite of dementing illness on a particular cohort of families in three developed democratic societies: the US, UK, and Australia. The subtitle, Gray Mist Killings, intrafamilial killings of or by people with dementia, x Preface reflects my uncertainties about dementing illness, those subject to it, and those involved in what are often deeply troubling lives. In many cases, the profound disruption of social life is disturbing long before the denouement of the homicide.

As we approached Cromer, we picked up the pace. We had been lost in conversation, the vast expanse of sand and sea, and perhaps what Freud called an oceanic feeling, something limitless, unbounded. At the same time, we were also a little anxious about the incoming tide, a metaphor perhaps for our own aging. Among other things, we discussed physicalism, the idea that everything is physical and there is nothing beyond. In the study of the dementias, physicalism manifests as biological determinism.

The pages that follow reflect my personal discomfort with physicalist explanations and biological determinism. My unease with these explanations stems not from the insignificance or irrelevance of physical phenomena for the study of violence and dementing illness. On the contrary, the physical and biological aspects of dementing illness strike me as profoundly important. Clearly, the physical degeneration of the brain and nervous system contributes greatly to the disruption of social life and all of its attendant agony and heartache. However, physicalist explanations do not go far enough, and we run into the problem of what philosopher Joseph Levine calls the explanatory gap. This gap, fissure, or chasm, depending on your view, describes our inability to know how words, smells, sounds, and other subjective experiences, in short, sentience, derive from neuronal activity. As they say on the London underground, we must “mind the gap.” My narrative style and concern with the ash of everyday experience is an attempt to mind the gap, to approach it, rather like a nerve impulse draws near to a synapse.

Many academic journals traffic in quantitative data and empiricism. Yet there is a danger amidst all this garrulous talk of variables that we might lose sight of, downplay, or simply ignore the inconvenient complexities of social life and human interaction. We talk of “controlling for” this context or those social circumstances, of confounding variables, as if these phenomena are mechanical parts of a machine. It is as if social life comprises an endless series of binaries. Such approaches are especially concerning when we are tackling emerging topics such as fatal family violence and the dementias. My reading of the files suggests that human interactions and the sociohistorical contexts within which they take place deeply affect the course of dementing illness. I hope my narration of cases of homicide and the dementias might inform later more scientific analyses of these concerning phenomena.

The pages that follow render problematic false binaries such as the biological and the social, history and society, the physical and the mental, the mind and the body, and remembering and forgetting. The result falls well short of anything definitive. Hopefully the book provides a segue into more comprehensive multidisciplinary studies of the pressing global problem of dementing illness and our responses to it and people like Rita May.

Acknowledgments

Many people involved in reviewing fatal family violence influenced the pages that follow. I want to acknowledge the help and influence of the late Matthew Dale, Joan Eliel, Cynthia Rubenstein, Frank Mullane, Greg Giangobbe, Ray Chaira, Mark Perkovich, and James Rowlands. I also thank all those who spoke with me off the record about the cases I narrate in de-identified form. If those key informants read what follows, they will know who they are and that I am indebted to them. Many thanks to the editorial team at Routledge: Lydia de Cruz, Morwenna Scott, Medha Malaviya, and Sathyasri Kalyanasundaram. My friend, Virgil Hancock, helped enormously by generously providing me with research studies, educating me about psychiatry, and sharing insights about his work spanning three decades with the violently mentally ill. Tori Vnuk furnished expert copyediting and many helpful insights into the material. I thank her greatly. She is a rare talent. My running partner, Jim Novak, listened to much of the manuscript as it unfolded. I thank him. My friendship with Andrew Bush spans six decades. He turned me on to sociology in the first place, and our interactions over the years have fed many of my interests. I thank him from the heart. Mia, Mihai, Kyrie, and James helped in ways I cannot explain. The lives of my mother, Molly, and my sisters, Judy and Jill, permeate the pages. I owe them more than I can put into words. My wife, Kathleen Ferraro, read and critiqued the manuscript and gave insightful feedback. I am indebted to her for so much more than that feedback, especially for the many years of walking in the sacred pine forests of northern Arizona in near silence.

Part 1 Mere Oblivion Seeming Obliviousness

The shabbily dressed man stood at a busy junction in North London. He had dementia. Daily, he held a utensil in his hand, usually a fork. Sometimes energetically, other times calmly, he waved the fork high in the air as vehicles passed. The astute reporter of this behavior noted the man's seeming obliviousness to people who passed by him.' Eventually, the strange man disappeared. The obituaries recalled that he had been a psychoanalyst and a brilliant musicologist. His work sheds light on how Beethoven and Mozart composed their music. Was the man conducting a symphony of traffic? Did the rush of traffic speak to him musically? How did those passersby interpret what he was doing? Was he a mad old man? A dangerous homeless person? Strange episodes like this mirror millions that happen regularly in homes and care facilities across the world. Some are not as benign and harmless as the man directing the traffic.

Spiked Railings

Visiting a cousin in England, I had occasion to walk around a small village that dated from Anglo-Saxon times. Flint, a form of the mineral quartz, peppered the walls of its rounded church tower. A large deciduous tree at the church boundary kept the tower company. Amidst dark green grass, orderly rows of headstones stood at attention. A cobbled path wended its way to the back of the church. A black iron fence with spiked railings separated the church from the quiet street. Weeping willows hung heavy at the edge of the village pond. The pond formed an almost perfect circle. The village had a primary school, a post office, a grocer shop, a pub, and a butcher’s shop. The butcher’s shop sold pheasants, the most popular game quarry in England.

We learn from the UK Domestic Homicide Review (DHR) report that Henry and Gloria Michaels (pseudonyms) had called the village home for half a century.? They bought a house, raised two children, and lived frugally, growing food in their garden. Henry was an avid hunter. Their children described a happy childhood. The couple apparently got along well, reportedly never arguing in front of their children. Later, both children would enjoy successful professional careers. The children remained in the area as adults.

In his late seventies, Henry developed dementia, most likely dementia with Lewy bodies (DLB).* The dementias are not diseases. Rather, they are general terms for the “impaired ability to remember, think, or make decisions” that interferes with everyday life.* Henry had developed what I will refer to throughout as dementing illness.5 The day before he killed Gloria, then age 76, a neighbor intervened when Henry accused her of stealing money. He had wandered over to a neighbor’s house carrying a large amount of cash. Henry told the neighbor he had dementia and was afraid of being robbed. The neighbor called the police. Police arrived. By that time, Gloria had joined Henry. The money Henry was carrying was locked up for safekeeping in the neighbor’s gun cabinet. The officer walked Gloria and Henry home, noting that by then Henry had calmed down.

The next day, Henry used two long kitchen knives to stab Gloria multiple times in the head and neck as she tried to exit their home. A couple, neighbors, saw him standing in the doorway to the house. Gloria was lying on the ground. According to the neighbors, Henry then walked back to the kitchen and came out with two blood-stained knives. Neighbors called the police. Upon arrival, Henry told them, “She won't need an ambulance.” He then proceeded to stab her three more times in the neck. Armed police then arrived. Henry refused to put down the knives. He tried to stab himself in the chest. Henry told them, “She’s dead. Just shoot me.” At one point, he put the knife on Gloria’s neck, and an officer fired a rubber bullet into Henry’s stomach, disabling him.

Police arrested him for murder. Henry was detained in a secure mental health facility. A psychiatrist assessed him as unfit to stand trial. The jury took less than 20 minutes to conclude that Henry killed Gloria. The judge imposed a hospital order under the Mental Health Act, and Henry was again detained in a secure mental health facility.°

Just over four years before the killing, Henry raised concerns about his memory with his general practitioner (GP). The GP arranged for a memory test involving the Test Your Memory (TYM) instrument. Henry scored 42 out of 50, suggesting memory loss.’ The GP ruled out reversible causes of cognitive decline such as a urinary tract infection (UTI) or vitamin B deficiency.’ The couple agreed to monitor Henry’s memory and report back to the physician if symptoms worsened. The initial assessment, therefore, did not rule out a diagnosis of dementia. Within a month, Henry returned to the GP to request medication to help with his memory problems. At this point, the GP referred Henry to the memory clinic for a more detailed workup. Henry reported feeling low and anxious, affective states attributed to his growing loss of physical independence. The memory clinic suggested a diagnosis of mild cognitive impairment (MCI) as a result of anxiety and depression. The clinic’s report advised him to try anti-depressants if his symptoms did not improve over time.

Knowing that Henry had suffered a number of losses over previous years, his GP offered him anti-depressants. These included early retirement and the loss of his role as provider, giving up his motorcycle, and relying on his wife to drive him around. His disabilities required him to give up using his guns and going on hunts. About three years before killing Gloria, a friend of 25 years noticed Henry’s deteriorating memory. Henry had called the friend because he had stripped down his gun and did not know how to put it back together. Given Henry’s experience with guns, putting the gun back together “should have been second nature to him.” Another significant loss involved moving into sheltered housing and leaving the cottage he had helped renovate and the vegetable plot he enjoyed. Additionally, Henry experienced the deaths of his beloved hunting dogs and the loss of various hobbies and activities he enjoyed. Nevertheless, he declined the offer of antidepressants. He was reluctant to discuss personal matters, so his GP did not offer any form of psychological intervention or talking therapies.

Other medical problems followed. Within a month of receiving the MCI diagnosis, Henry visited his GP surgery complaining of double vision.'” He was diagnosed with two cataracts and referred to the neurology department for an MRI brain scan to rule out other possible problems. Within two months, the cataracts were removed. The GP received a letter from the department stating the MRI brain scan was normal. The scan did not, therefore, reveal any brain shrinkage consistent with advancing dementia. A couple of months later, Henry reported reduced mobility due to knee pain. He also told his GP he was having panic attacks and vivid dreams about concentration camps. On waking, Henry often failed to recognize his wife or his surroundings. At times, he experienced hallucinations. When he had nightmares, he disturbed Gloria’s sleep. He also had REM sleep disturbances. Consequently, Henry and Gloria would nap during the day.

The research literature on DLB contains similar case reports of misrecognition of spouses and/or caregivers, sleep deprivation, and violent dreams. Cipriani et al. report a case study involving a patient with DLB who had a rapid eye movement sleep behavior disorder (RBD).'' The man hit his wife on the head and threw objects at her during sleep. They cite other research involving a man who held his wife in a headlock and “attempted to throw her head down toward the foot of the bed.” Upon waking, the man reported a dream where he was making a touchdown. They caution several sleep disorders, especially with patients with dementia, “have a potential for violent behaviors directed to oneself, other individuals or to objects, without awareness of the action and with complete amnesia of the episode on awakening.”

About nine months before the killing, Henry visited the GP surgery in a tearful and anxious state. He reported worsening memory and greater dependence on Gloria. The GP prescribed escitalopram (5 mg) for Henry’s depression. However, within a few weeks, the GP discontinued the antidepressants because their usage corresponded with the increasingly vivid anxiety-provoking dreams and hallucinations. The GP prescribed lorazepam for Henry’s anxiety. The hallucinations and anxiety apparently lessened.

About five months before killing Gloria, Henry complained that his memory was worsening. Over the three-and-a-half years since having the first TYM test, his score has declined from 42 to 36/50. Henry’s GP reported possible Parkinsonian features and hallucinations.'* The GP referred Henry to the specialist dementia diagnostic service, but the consultant for the service first wanted Henry assessed for Parkinson’s disease. '*

The Lewy Body Society (UK) notes the difficulty of diagnosing DLB. The diagnosis requires specialist skills in old-age psychiatry or neurology. Specifically,

If the physical symptoms precede the cognitive symptoms by one year, a diagnosis of Parkinson’s will be made; if the onset of cognitive symptoms precedes or starts at the same time the physical symptoms commence it is considered to be DLB.'*

In Henry’s case, the most likely diagnosis was DLB. Successful treatment apparently relies on an accurate diagnosis.

The assessment concluded that Henry had evidence of cognitive decline, hallucinations and gait disorder (mild Parkinsonism), REM sleep problems, olfactory disturbance!” and arthritis in his left knee. The university consultant arranged an outpatient MRI brain scan and suggested a trial on rivastigmine.'* The communication to the community psychiatric team from the consultant suggesting the use of rivastigmine was delayed for seven weeks, the reasons for which remain unclear. The outpatient MRI brain scan revealed global atrophy (shrinkage) of the brain and a single micro-hemorrhage. The DHR concludes, “Rivastigmine should be given to people with mild to moderate dementia with Lewy Bodies. It is unfortunate that Henry Michaels did not get the opportunity to benefit from this medication prior to the fatal stabbing.”*” Regarding the delay, the DHR notes, “[A]n error in data entry or just an oversight. Prompt receipt of this referral could have sped up the diagnostic process and led to a timelier intervention.”

It lies beyond the scope of this study to weigh the various arguments about the efficacy of using rivastigmine in cases of DLB with Parkinsonian symptoms such as those evident in Michaels. Rather, my interest is to point out the potential significance of the communication breakdown in responding to Henry with this drug intervention. I return to this matter in Chapter 7. Suffice it to say that research evidence in the form of a large (N = 120) randomized, double-blind, placebo-controlled, international study found patients taking rivastigmine had less apathy and anxiety and fewer delusions and hallucinations than controls.” Data addressing how such drug interventions might reduce violence toward self and others appears lacking.

Five days before her death, Gloria accompanied Henry to the GP surgery. Both she and Henry reported being increasingly distressed by Henry’s symptoms including his slow movements and speech and nighttime hallucinations. The GP committed to “chase the mental health team””' and the next day questioned the delay in intervening with Henry. He received the explanation that a routine referral (Henry’s case was not flagged as high-risk) would typically be assessed within two weeks. But time was moving fast in Henry’s case.

As noted earlier, on the day before the killing, Henry turned up at a neighbor’s house with a wad of cash. He was deeply disturbed by the prospect of being robbed and had accused Gloria of trying to steal his money. Neighbors called the police. Gloria went to the neighbor’s house, and the officer and Gloria took him home. The next day, he knifed Gloria to death.

The Michaels DHR found no conclusive evidence of a prior history of intimate partner violence and/or abuse (IPV/A). The report did question whether Gloria would have felt comfortable disclosing any such abuse. At the trial of the facts, the Michaels adult children both told the court that their parents? marriage was a happy one, with no suggestion of domestic violence.” The couple lived in social housing, and the warden call system reported no previous sign of IPV/A. Descriptions of Gloria and Henry comport with their children”s interpretation that there was no IPV/A. One of Henry's friends saw him as “a very gentle person.” The community considered him “blunt but wise . . . fair minded and direct.” Henry wrote poetry. He encouraged Gloria to pursue new interests outside of their home once the children left. Everyone the DHR team interviewed described Gloria as “fiercely independent.”

Based on interviews with family and friends, the DHR team noted the traditional gender roles to which Henry and Gloria appeared to adhere. The reviewers observed that such role adherence is not uncommon among older people in rural communities, “but are now understood to be indicative of a level of coercion and control.” Two examples stood out for reviewers as possible signifiers of Henry’s control or undue influence over Gloria. First, prior to her marriage to Henry, Gloria enjoyed coach holidays with her girlfriends from work. She had one particularly close friend, Barbara, who she knew from school and work. Barbara and Gloria met only once after Gloria married Henry. Apparently, Henry and Barbara did not get along, so Gloria never saw her friend again. Indeed, Barbara died of cancer the year before Henry killed Gloria. Second, Gloria took the bus to her own mother’s funeral because Henry would not have liked her accepting a ride from her brother-in-law.

From the review, Henry emerges as “the dominant one in the couple”s relationship.” However, the report describes Gloria as always maintaining her independence “with her own interests and hobbies.” The couple’s desire to live privately, keeping their doors closed so they would not be overheard by neighbors and eschewing village gossip, “might suggest that the couple had something to hide.” But the DHR notes that both Henry and Gloria grew up in small rural communities and remained keen to preserve their independence from potentially nosy neighbors. The question, which the team could not answer, was whether their privacy involved Henry coercively controlling Gloria. The proposal that keeping their doors closed might spell abuse is interesting and may appear strange to some readers. It may reflect a tendency on the part of some DHR team members to imply abuse existed, thus turning this case into yet another tragedy that speaks to the evils of domestic violence.

During the four years after his initial diagnosis, the couple became increasingly private. Gloria eschewed offers of professional help. Apparently, she hid Henry’s diagnosis of MCI and his worsening health from her sister. Henry tired quickly, so she put the children off visiting because he could not cope. Gloria’s caring responsibilities increased as his disease worsened.” Six weeks before her death, Gloria saw her GP in the surgery without Henry present. The GP encouraged her to accept support in caring for Henry, specifically offering to make a referral to an admiral nurse.” Gloria declined the offer. However, the police officer who was at the house for the call the day before her death wrote,

Gloria is Henry’s only carer and appears to be struggling slightly. She states she is finding it harder to cope. Henry seemed quite upset and frustrated about his dementia. I have suggested Gloria go back to her doctor and ask for help looking after Henry.?

It is possible that the day before her death, Gloria turned a corner and was not only willing to acknowledge her compromised situation but also prepared to seek help. Sadly, her family opined that had she accepted professional help for Henry, “then the fatal stabbing may have been prevented.”?

There is no evidence Henry Michaels had a history of violently abusing Gloria. It appears as if Henry killed Gloria in a state of confusion, perhaps during a dissociative episode, psychotic break, or a state of transitory delirium. We cannot rule out the possibility that Henry killed someone he thought was an imposter, someone who was not his wife but someone who he thought would steal his money, persecute him. Imposter syndrome is sometimes called Capgras syndrome (CS) or misidentification syndrome. At the crime scene, he told responding police as he stood over Gloria, “She won't need an ambulance” and “She”s dead.” Was Henry using the pronoun “she” because he no longer recognized Gloria and thus did not use her name?

Henry Michaels committed what I refer to in this book as a gray mist killing, a killing of or by a person/people with dementia (PWD), usually committed in or around the family home by a family member, usually a spouse/partner. Men commit nearly all gray mist killings and women comprise their principal victims, a fact of considerable analytical import.” The term might also be used to describe the killing of or by a PWD living in a nursing home or specialist care facility. My focus is on fatal family violence, of which Henry and Gloria’s case serves as but one example among a convenience sample of 100 cases.

Existing Research

In the last century or so, researchers have documented a small number of gray mist killings. PWD was the subject of all these reports. It was only much later that caregiving killings also attracted attention. Dr. W. C. Sullivan, Medical Superintendent of Broadmoor Asylum, England’s oldest high-security psychiatric hospital, wrote Crime and Insanity, published in 1924. In a chapter entitled “Crime and Senile Insanity,” readers learn, “In instances where the dementia is profound, the homicidal act may be committed in a sudden impulsive outburst without any antecedent or accompanying evidence of related delusional ideas.””? He narrates two cases, which I now summarize.

H Y, age 78, was a gardener who murdered his wife, 77, and son. He became “enfeebled” in mind a few years before the killing, having delusions about his wife’s sexual behavior with their son. H Y claimed his wife had repeatedly attempted to poison him and “that she had put a ‘cinder,’ specially shaped, into his hash in order to choke him.” He heard voices telling him to kill his wife and son and to commit suicide. Sullivan informs readers H Y “got up one night, in obedience to these voices, split his wife’s head open with an axe, and stabbed the son in his bed.’”*! Upon admission to Broadmoor, he was diagnosed as “demented,” but he was still able to give a lucid account of his murderous acts.*?

In another case, readers learn of E L, a 69-year-old engineer, who attempted to kill his wife and then himself. Sullivan notes that about two years before the crime, “he began to be very querulous and fretful, with signs of failing memory and slowing thought. He also hinted vaguely at suspicions of his food being drugged and of things being stolen from his house.”* Over time, he began to question his wife’s movements. E L started obsessing about her behavior for some months before trying to kill her by slashing her throat with a razor and then cutting himself with it. In the aftermath of the crime, E L reported that the idea to try to kill her came to him “a few moments before he attacked her.”** E L said “he had been brooding over her conduct, and . . . knew she had been misconducting herself with different men for the past two years.”** Sullivan notes E L had no proof of her perceived infidelities.

The so-called delusional jealousy in the cases of H Y and E L appears as part of the psychopathology of dementia.** Such delusions, until recently often seen simply as “false beliefs,” are also present in cases of intimate partner homicide (IPH), where paranoid abusers make unsubstantiated accusations regarding the sexual infidelity of their spouses/partners.*” However, a growing body of phenomenological research seeks to understand delusions above and beyond them being merely “erroneous beliefs.”*

Delusions of infidelity also feature in cases of murder-suicide.” Physician Philip Lecso reports a murder-suicide case perpetrated by a 67-year-old man who killed his live-in partner before taking his own life. Microscopic examination of the man’s brain tissue revealed “a florid number of senile plaques and neurofibrillary tangles in the frontal lobes, left temporal lobe and hippocampus.”*” According to Lesco, these pathological findings confirmed the man’s Alzheimer’s disease (AD). Neighbors reported the man misplacing personal items and accusing his partner of stealing from him. The man’s ex-wife reported significant behavior changes about two years before the killing. Notably, he had trouble adding numbers, became forgetful, and got lost while driving. Investigators found no history of mental illness, violent behavior, or substance abuse. In conclusion, Lecso cautions, “Demented patients are prone to sudden outbursts, and, with their high prevalence of delusional and paranoid ideation, they are at high risk of injuring caregivers and family members.”*!

A case study of a severely demented man who killed his wife has similar themes and more.* Those who knew him described Mr. X, age 78, as overbearing, possessive, and very jealous of his wife but also very dependent upon her. When police arrived at his house in May 1998 after receiving a call from his concerned niece, they found Mr. X confused, disheveled, frail, agitated, and aggressive. Mrs. X was deceased. She had severe head and chest injuries. In follow-up interviews with investigators, Mr. X spoke minimally. His speech was mostly nonsensical and he complained of a buzzing in his ears. Mr. X first had contact with mental health services about 40 years prior to killing his wife. At that time, he was diagnosed with “chronic anxiety state.” He received electroconvulsive therapy and psychotherapy. In 1983, Mr. X cut his throat in a serious attempt at suicide. Once confined to a psychiatric facility, his likely diagnosis included a “chronic neurotic disorder with a more recently superimposed severe dementia of Alzheimer’s type.”* Notably, for our purposes, observations during his post-homicide treatment referenced his agitation and occasional physical violence, mostly directed toward female members of staff and female patients, some of whom he apparently mistook for the wife he had killed. Mr. X was also observed to be domineering and overbearing toward women and, at times, sexually inappropriate. I return to the apparent gendered directionality of anger and hostility in Parts 2 and 3.

Richard-Devantoy and colleagues report a killing similar to the one Henry Michaels committed.“ Mr. A killed his wife at their home by stabbing her multiple times. Prior to the killing, he experienced delusions that his wife was persecuting him. Mr. A's act was apparently unplanned. He had no criminal record, psychiatric disorders, alcohol abuse history, or known dementia. However, in his first neuropsychiatric exam conducted nine months after the homicide, he received a diagnosis of moderate Alzheimer’s disease (AD) with a moderate dysexecutive syndrome. Dysexecutive syndrome, sometimes known as frontal impairment, frontal lobe syndrome, or executive dysfunction, refers to a dysregulation of executive functions in the brain. It is associated with damage to the frontal lobe and typically involves emotional, motivational, behavioral, and cognitive difficulties. It may involve extreme emotional symptoms, including disinhibition of anger, excitement, sadness, or frustration. Richard-Devantoy et al.’s report of Mr. A’s homicide suggests an important role for brain damage in the commission of violence and homicidal behavior.