The Measure of Madness:. Katherine Ramsland
was somewhat taken aback when the elegantly dressed, 70-year-old man arrived at my office. While I knew the general facts about the case, I was unprepared for such a soft-spoken, polite defendant. With his gray hair, courtly manner, and easy smile, he actually reminded me of a favorite uncle. It was hard to remember that this reserved old man had strangled his wife and thrown her body out their twelfth floor apartment window.
I felt a rush of discomfort when Mr. Paulson walked into the room. He reached out to shake my hand and I experienced a sense of role reversal. His age and expensive suit made me feel like I was the one about to be evaluated. I wondered if he noticed the shabbiness of my office furniture.
Typically, I might be apprehensive to stay alone with a defendant charged with murder. However, Mr. Paulson’s composure put me at ease. Later, I became more aware of how peculiar his equanimity was in such a situation. His calmness was out of place. Most individuals faced with such serious charges and the distinct possibility of spending the rest of their lives incarcerated would be extremely anxious or depressed. He denied any symptoms of mental illness and I observed none.
We took our seats. At least I was able to maintain enough equilibrium to sit on my side of the desk. I started the interview with the Mini Mental Status Exam (MMSE), a brief screening test of cognitive functioning that takes approximately ten minutes to administer.2 It is widely used in medical and psychiatric settings to test for dementia. The test is composed of a series of questions to assess language skills, memory, and attention. Mr. Paulson passed easily.
Then I asked, as politely as possible, what had led to the killing. There are two big sources of conflict in any marriage: money and sex. Had Mr. Paulson or his wife been spending too much or hiding assets? Was one of them having an affair? He denied any serious financial or marital problems.
“What happened before you attacked her?” I asked.
“We had been arguing,” Mr. Paulson readily admitted.
He then continued to explain dispassionately how, as with so many marital conflicts, theirs had begun as an argument about bills. He was an independent businessman, an importer, and business had been slow recently. While there was no objective reason to fear bankruptcy, he was feeling stressed. Mr. Paulson insisted that they cut their spending but his wife was resistant. They started to argue about a few recent purchases of hers that he considered excessive and unnecessary and then began to argue about the children.
I realized by this point that Mr. Paulson’s typical pattern during their quarrels was to retreat and give in, saying, “O.K. honey, whatever you want.” But this argument was different in important aspects. It escalated and became personal and bitter. He recalled how he tried to end the conflict by retreating; however, his wife blocked his exit, would not let him leave, and, as he pushed to get past her, she attacked him physically, scratching him on the face.
Although Mr. Paulson claimed that he could not recall everything that happened after she scratched him, he did admit that he had became enraged, angrier than he had ever been in his life. He remembered slapping her and, when she continued to scratch him, strangling her to death. He admitted feeling overwhelmed with panic afterwards and throwing her body out the window in a desperate attempt to stage a suicide.
After listening to his story about the argument and how he had strangled his wife, I refocused back to a less emotional part of the evaluation—the psychological testing. I continued with a typical battery of psychological tests, including the Wechsler Adult Intelligence Scale, the Rorschach or “inkblot test,” and the House-Tree-Person drawings.3
In the Rorschach, an individual views ten inkblots and provides responses to the query “What might this be?” The individual’s responses are thought to be important clues to underlying, unconscious thoughts and feelings. Frequently, psychotic individuals can respond with images which do not even conform to the blots. The House-Tree-Person drawings require a person to draw four pictures, one each of a house, a tree, a man, and a woman. Psychologists analyze both the content and the process—how the person completes the drawings, what the person includes (and leaves out), and what parts the person emphasizes. All provide important clues as to a person’s mental state, feelings, and concerns.
Mr. Paulson’s personality testing indicated that, while he had an extremely limited emotional range and a rigid, over-controlled manner, he was not depressed or psychotic. My jaw almost dropped, however, as I watched him draw the female—she was nude! What was even more unexpected was that this nude woman was wearing high-heeled boots.
While artists frequently draw nudes, it was a strange and puzzling drawing for someone of his background. While I did initially consider whether his drawing reflected some unconscious feelings about women, I instead concluded that he, at least during this task, showed poor judgment and self awareness—most intelligent defendants charged with murder would be careful to try to look as normal as possible and draw the female clothed.
Next, I administered the Wechsler Adult Intelligence Test.4 Overall, Mr. Paulson had superior intellectual skills, but the tests revealed some subtle cognitive decline. He had trouble repeating back strings of numbers that I recited to him—a sign of attention problems. The more neuropsychological tests I administered, the more odd discrepancies I found. When I measured his verbal and visual memory skills, his verbal score was in the 45th percentile, but his visual score was in the 99th.
The Purdue Pegboard yielded the most striking results. I instructed Mr. Paulson to place pegs in the holes on the board as quickly as possible, first with his right hand and then with his left. He was right-handed, yet his left, nondominant hand was faster at placing the pegs. This was extremely unusual.
As I watched his right hand fumbling to insert the pegs, I remembered what Dr. Schwartz had said about the symptoms Mr. Paulson had exhibited decades earlier—weakness in the right side of his body and speech difficulties. The left cerebral cortex controls sensations and movement of the right side of the body and vice versa. His slower right hand indicated some dysfunction in the left hemisphere. The speech center is also located in the left hemisphere in most individuals. His history was more evidence of something wrong in his left cerebral hemisphere.
“Mr. Paulson, tell me about your hospitalizations forty years ago,” I said. “What symptoms did you have?”
“It happened when I was twenty-four years old,” he answered. “I started to have terrible headaches and trouble speaking.” He told me he was admitted to a hospital twice but discharged each time after a few days when his symptoms disappeared. His hospitalizations occurred so long ago that sophisticated neurological tests were not yet in existence. There were no MRI (Magnetic Resonance Imagery) or PET (Positron Emission Tomography) scans to take.
Mr. Paulson recalled that the doctors performed a spinal tap. During a spinal tap a needle is placed into the spinal cavity to remove cerebral spinal fluid. The tap can find elevated protein levels, indicating an intracranial (within the brain) bleed. He recalled the doctors telling him he may have suffered some bleeding in his brain.
Mr. Paulson told me that he recovered within a few months with no lingering symptoms. Since he never experienced a recurrence, he paid little attention to what caused the two hospitalizations. Even when new, sophisticated brain scanning tests became available, he never considered going to a physician to investigate.
Looking at Mr. Paulson, I took a deep breath and folded my hands on the table. “Well, we’re all done,” I said. “The good news is you’re not mentally ill. But I do want you to see a neurologist.”
He accepted these results with the same bland expression he had been wearing all day. He shook my hand, thanked me for my time, and walked out. I never saw him again.
I called the defendant’s attorney right away. “There’s definitely something wrong in Mr. Paulson’s brain. I think it’s in his left cerebral hemisphere.”
“What’s the next step?”
“You should get him to a neurologist right away. He needs an MRI,” I said.
After that, Mr. Paulson was referred to a prestigious hospital and evaluated by a team of the most