Commitment Determinations and Definition of Mental Disease
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* Ekaterina Pivovarova
* Debra A. Pinals

## Antisocial Personality Disorder May Constitute a Mental Disease as a Basis for Civil Commitment of Offenders in Federal Court

In *United States v. Beatty*, 642 F.3d 514 (6th Cir. 2011), the United States Court of Appeals for the Sixth Circuit upheld a decision by the U.S. District Court for the Eastern District of Tennessee to recognize antisocial personality disorder (ASPD) as a mental disease for the purposes of conditional release under the civil commitment statute according to Title 18 United States Code Service (18 U.S.C.S.) § 4243 (hospitalization of a person found not guilty by reason of insanity; 1984).

#### Facts of the Case

On February 5, 2002, Danny Lee Beatty stole a truck from a car dealership and drove to a bank where he demanded $200 from a teller while brandishing a knife. After receiving the money, he drove from Knoxville, Tennessee, to Florida in the stolen vehicle. He was apprehended shortly thereafter and was indicted on one count of bank robbery and transporting a stolen vehicle across state lines. He was sent to the Federal Correctional Institution (FCI) Butner, North Carolina, for court-ordered evaluations of his competence to stand trial and criminal responsibility (*U.S. v. Beatty*, 111 F. App'x 820 (6th Cir. 2004); hereafter *Beatty I*). He was identified as presenting with symptoms of multiple Axis I disorders, including psychotic disorder, not otherwise specified (NOS), posttraumatic stress disorder (PTSD), and bipolar I disorder, mixed (in partial remission). The evaluators deemed him to be competent to proceed with trial but not responsible due to “suffering from a severe mental disease or defect, which rendered him unable to appreciate the nature, quality, or wrongfulness of his actions during the alleged offense” (*Beatty I*, p 821). He entered a plea of not guilty by reason of insanity (NGRI), which was unopposed by the government, and was remanded to Federal Medical Center (FMC) Butner for postadjudicative evaluation pursuant to 18 U.S.C.S. § 4243.

Mr. Beatty was ultimately committed and then conditionally released several times pursuant to § 4243(e). His first conditional release occurred from March 2004 through November 2004 and ended when his conditional release was revoked after he acknowledged use of narcotics and failure to comply with treatment programs. He was conditionally released in November 2006, which he again failed because he produced two positive drug tests. The government then sought to modify his supervision conditions but he incurred further violations in 2007 for the use of narcotics, noncompliance with treatment, and stealing $400, resulting in another conditional release revocation.

The court noted that across the numerous criminal and civil commitment proceedings, Mr. Beatty's evaluations had resulted in inconsistent diagnoses. The court cited *Beatty I* explaining: Identifying Mr. Beatty's true diagnoses has been difficult. Over the past seven years he has received numerous psychiatric diagnoses including Obsessive-Compulsive Disorder; Impulse Control Disorder [;] Bipolar Disorder; Manic with Rapid Cycling; Dysthymia [;] Borderline Personality Traits with Narcissistic Features; Antisocial Personality Disorder; and Schizoaffective Disorder [*Beatty I*, p 822, brackets in original].

In May 2009, after the court ordered Mr. Beatty to be conditionally released again, he filed a motion for discharge on unconditional release (2009 U.S. Dist. LEXIS 44636). By then, his diagnosis was further refined only to ASPD, narcissistic personality disorder, and cocaine and marijuana dependence. The government argued that his ASPD, in conjunction with substance dependence, constituted a mental defect and that he should be released conditionally. The court agreed and determined that his previous noncompliance with conditional releases and the combination of personality pathology and substance abuse necessitated supervision of the court and released him under 12 conditions, including substance abuse treatment and abstention from drugs and alcohol.

For the current case, Mr. Beatty appealed the finding of conditional release, citing that his symptoms no longer met the criteria for “mental disease or defect.”

#### Ruling and Reasoning

The appeals court acknowledged that Mr. Beatty's psychiatric history, as reported by FCI Butner, FMC Butner, and FMC Rochester, presented an inconsistent account of his psychiatric diagnoses. However, the findings also appeared to suggest unfailingly the long-standing character pathology, best captured as ASPD, and narcotics dependence. This conclusion was reached by the district court and sustained by the appeals court. Mr. Beatty argued that ASPD is a not mental disease or defect, supported in part by evaluators at FMC Rochester who noted that ASPD is “not typically categorized as a mental disease or defect.”

The appeals court broadly stated that Mr. Beatty failed to prove by clear and convincing evidence that he did not have a mental disease. More specifically, Justice Gibbons, writing a unanimous opinion for the court, explained that the district court could consider any evidence it chose when determining the bases of commitment (i.e., the entirety of Mr. Beatty's record, his history, and all of the reports), as long as there was no egregious error by the judge. In this case, Mr. Beatty's personality pathology and substance abuse supported a chronic risk of future violence, as evidenced in part by his behavior during release under supervision in the community. Furthermore, the defense's reliance on wording in the FMC Rochester report did not accurately reflect the intent of the writers. In fact, the evaluators' use of “typically” suggested that there might be cases when ASPD would meet criteria for mental disease or defect. In addition, the report clearly articulated that, if the court chose to recognize ASPD as a mental disease, then Mr. Beatty would meet the necessary requirements for mental disease, thus indicating that the court could make such a determination. Therefore, he failed to meet the clear and convincing burden that he no longer had a mental disease that would create a substantial risk of harm to others or serious damage to property. Peripherally, the court noted that the terms chronic risk and substantial risk are essentially synonymous, since chronic risk implies frequent recurrences that would therefore create substantial risk. Accordingly, the appeals court upheld the district court's decision that Mr. Beatty failed to meet the criteria for unconditional release.

#### Discussion

In summary, *U.S. v. Beatty* affirms the court's right to classify a personality disorder, specifically ASPD, as meeting the criteria for civil commitment, especially in the context of a complex case with an interplay of personality features, substance use, and historical mental illness and when making a determination about conditional release. This decision does not directly address whether ASPD alone, without substance dependence or other historical mental illness diagnoses, would still constitute a mental disease in conditional release determinations. Given the district court's reliance on, and the appeals court's acknowledgment of, the totality of information about Mr. Beatty's presentation during federal medical center commitments and in the community, one may surmise that additional data (potentially substance abuse and inability to comply with treatment in the context of prior mental illness diagnoses) is essential to meet the mental disease threshold. Of note, this finding is only binding in a limited jurisdiction. More broadly, the court is suggesting a willingness to consider a broad range of psychiatric disorders, including personality disorders, which would not automatically be disqualified from consideration for mental disease or defect.

This case also highlights the important clinical problem of inconsistent diagnostic determinations. Although differences in diagnoses between and within organizations are most likely unavoidable, the diagnostic labels can influence judicial decision-making. In this case, Mr. Beatty's diagnoses ranged from a psychotic disorder (not due to substance use), to obsessive-compulsive disorder (OCD), to narcissistic personality disorder. Identifying what disorder (or category of disorders) best captures such a defendant's symptoms is unquestionably difficult. However, given the reliance on diagnostic labels by the fact finder, the defense, and the prosecution, it is essential to conduct comprehensive evaluations, document known symptomatology, acknowledge missing information, and provide clear rationales for particular diagnoses when given. *U.S. v. Beatty* serves as another reminder of the importance of precision and clarity when conducting court-ordered evaluations.

## Footnotes

*   Disclosures of Financial or Other Potential Conflicts of Interest: None.

*   © 2013 American Academy of Psychiatry and the Law