Int J Psychiatry Clin Pract 2014; 18: 215–216. © 2014 Informa Healthcare ISSN 1365-1501 print/ISSN 1471-1788 online. DOI: 10.3109/13651501.2014.894075
SHORT REPORT
Bipolar disorder, testosterone administration, and homicide: A case report
informahealthcare.com/ijpcp
Leo Sher1 & Sean Landers2 1
Icahn School of Medicine at Mount Sinai, and James J. Peters Veterans’ Administration Medical Center, New York, NY, USA and 2Ninth Judicial Circuit, Orlando, FL, USA
Abstract Objective. Homicide is a major public health and social concern in the United States. Studies have found higher rates of psychiatric disorders in homicide offenders than in the general population. The aim of this article is to report and to discuss a case of a patient with bipolar disorder and hypogonadism who murdered his wife shortly after a testosterone injection. Methods. A case study and a review of the relevant literature. Results. Our case study as well as several case reports in the literature suggests that testosterone administration or high testosterone levels may be associated with homicidal behavior. Conclusion. Further studies of the role of testosterone in the neurobiology of violent and homicidal behavior may lead to improvements in the prevention of homicides. Key words: Bipolar disorder, testosterone, homicide (Received 5 December 2013; accepted 31 January 2014)
Introduction Homicide is a major public health and social concern in the United States (Cooper and Smith 2011; Martone et al. 2013; Matejkowski et al. 2008). Approximately 15,000 homicides took place every year over the past decade (Martone et al. 2013). Studies have found higher rates of psychiatric disorders in homicide offenders than in the general population (Martone et al. 2013; Matejkowski et al. 2008; Côté and Hodgins 1992). For example, a study of the inmates in the Indiana state prison system who had been convicted of homicide between 1990 and 2002 showed that about 18% of all homicides are committed by individuals with major depression, bipolar disorder, schizophrenia, and other psychotic illnesses (Matejkowski et al. 2008). This study included only those individuals who committed murder and were sentenced to prison. It did not include individuals with severe psychiatric disorders who were found to be incompetent to stand trial or not guilty by reason of insanity, that is, the real percentage of homicide offenders with severe mental illnesses is probably higher. A study of homicide convicts in Canada reported rates of 12% for schizophrenia, 15% for major depression, and 5% for bipolar disorder (Côté and Hodgins 1992). Studies suggest that schizophrenia, major depression, and bipolar disorder increase the risk of homicide primarily if comorbid substance use disorders are present (Eronen et al. 1996; Palijan et al. 2009; Putkonen et al. 2004). Here, we report a case of a patient with bipolar disorder and polysubstance use disorder who committed a murder after a testosterone injection. Correspondence: Leo Sher, MD, Icahn School of Medicine at Mount Sinai, James J. Peters Veterans’ Administration, Medical Center, 130 West Kingsbridge Road, Bronx, New York, NY 10468, USA. Tel: ⫹ 1-718-584-9000 x 6821. Fax: ⫹ 1-718-741-4703. E-mail: [email protected], [email protected]
Case report Mr. A. was a 42-y.o. man with a long history of bipolar disorder with psychotic features and polysubstance use disorder (including the use of alcohol, marijuana, and lysergic acid diethylamide [LSD]). He had a history of manic and depressive episodes, auditory hallucinations, paranoid delusions, suicidal ideation, aggressive behavior, poor insight, poor adherence to treatment, and multiple psychiatric hospitalizations. Mr. A. had a history of suicidal ideation but not suicide attempts. Over the years, he was treated with different antipsychotics, antidepressants, and mood stabilizers, including lithium. He also had a history of illegal behavior and incarcerations for assaults, burglary, and sexual relationships with teenage girls. Mr. A. also had hypogonadism. The diagnosis of hypogonadism was based on the presence of erectile dysfunction and a low blood testosterone level. In the beginning of 2012, an urologist prescribed testosterone 200 mg IM injections that were supposed to be given every 2 weeks. Mr. A. was getting injections less frequently. He received five injections between January 2012 and May 2012. In mid-April 2012, Mr. A. reported to his therapist that he was experiencing “extreme highs” which he regarded as a side effect of testosterone shot. Eight days before Mr. A. received his 5th testosterone injection in May 2012, his testosterone level was 670 ng/dl (the reference interval: 348–1197 ng/dl). In 2011, Mr. A. married a 25-y.o. woman. There were significant marital problems. Mr. A. and his wife were in marital therapy. In May 2012, about 10 hours after receiving the 5th injection of testosterone Mr. A. hit his wife in the abdominal area which led to an internal bleeding and resulted in her death. At the time of the offense, Mr. A. was also prescribed risperidone, divalproex sodium, trihexyphenidyl, trazodone, and clonazepam.
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Mr. A. admitted to the police to pushing his wife down on the ground and kicking her in the stomach during an argument but said he did not remember the whole episode. Mr. A. told the police hours after his arrest he did not know that he was going to kill her or that she would die and he wanted to hurt himself because of what he did. Mr. A’s wife was found by police deceased in her bed. The autopsy revealed evidence of multiple acute and remote injuries, including multiple contusions to the torso in various stages of healing, healing and acute rib fractures and acute lacerations of the intestinal mesentery and omentum. An accumulation of 1850 ml of thick bloody fluid was present in the abdominal cavity at the time of autopsy. The determined manner of death was homicide. Discussion It is difficult to establish a clear relation between the testosterone administration and the murder in this case. The Adverse Drug Reaction Scale (Naranjo et al. 1981) score is 3 which indicates that the testosterone administration possibly contributed to homicide. There are several case reports in the literature suggesting that testosterone administration or high testosterone levels are associated with homicidal behavior (FoxNews.com 2007; Conacher and Workman 1989; Pope et al. 1996). In 2007, a professional wrestler committed homicide and suicide: he murdered his wife and son in their home before hanging himself (FoxNews.com 2007). At the time of the offense, the testosterone level in his body was very high. Investigators believed that the level found suggested testosterone had been taken shortly before the offense. Another case report described an amateur body builder who beat his common law wife to death while taking steroids (Conacher and Workman 1989). In another case, a 16-year-old boy was convicted of the murder of his 14-year-old girlfriend (Pope et al. 1996). This boy displayed no history of antisocial personality disorder or any criminal record prior to his first use of steroids. After he began taking testosterone and other steroids, he exhibited a remarkable change in personality, became aggressive, and started getting in trouble with the police. In another case, a 19-year old man was convicted of shooting another man a day or two after he had self-administered a testosterone injection, and was likely at the point of peak plasma levels of testosterone (Pope et al. 1996). It has been shown that among prisoners who committed homicide, those who had higher testosterone levels more often knew their victims and planned their murders ahead of time (Dabbs et al. 2001). The authors of this study suggested that their results imply ruthlessness among inmates with higher testosterone concentrations and that homicide more than other violent crimes may bear on issues related to testosterone. Violence toward women may be relatively common among men using steroids (Choi and Pope 1994; Pope et al. 1996). In one study, steroid users reported significantly more fights, verbal aggression, and violence against their wives or girlfriends when they were using steroids as compared with
Int J Psychiatry Clin Pract 2014;18:215–216
periods when they were not taking steroids (Choi and Pope 1994). Our report and other case reports suggest that testosterone administration may play a role in homicidal behavior. Further studies of the role of testosterone in the neurobiology of violent and homicidal behavior may lead to improvements in the prevention of homicides. Key points • • •
Studies have found higher rates of psychiatric disorders in homicide offenders than in the general population. We report and discuss a case of a patient with bipolar disorder and hypogonadism who murdered his wife shortly after a testosterone injection. Testosterone administration or high testosterone levels may be associated with homicidal behavior.
Acknowledgements None. Statement of interest None of the authors reports conflicts of interest. References Choi PY, Pope HG Jr. 1994. Violence toward women and illicit androgenic-anabolic steroid use. Ann Clin Psychiatry 6:21–25. Conacher GN, Workman DG. 1989. Violent crime possibly associated with anabolic steroid use. Am J Psychiatry 146:679. Cooper A, Smith EL. 2011. Homicide Trends in the United States, 1980–2008. Annual Rates for 2009 and 2010. U.S. Department of Justice. Office of Justice Programs. Bureau of Justice Statistics. November 2011, NCJ 236018. http://www.bjs.gov/content/pub/ pdf/htus8008.pdf Côté G, Hodgins S. 1992. The prevalence of major mental disorders among homicide offenders. Int J Law Psychiatry 15:89–99. Dabbs JM, Riad JK, Chance SE. 2001. Testosterone and ruthless homicide. Person Individ Diff 31;599–603. Eronen M, Tiihonen J, Hakola P. 1996. Schizophrenia and homicidal behavior. Schizophr Bull 22:83–89. FoxNews.com (July 17, 2007) Wrestler Chris Benoit used steroid testosterone; son sedated before murders. http://www.foxnews. com/story/2007/07/17/wrestler-chris-benoit-used-steroidtestosterone-son-sedated-before-murders/Accessed: November 5, 2013. Martone CA, Mulvey EP, Yang S, Nemoianu A, Shugarman R, Soliman L. 2013. Psychiatric characteristics of homicide defendants. Am J Psychiatry 170:994–1002. Matejkowski JC, Cullen SW, Solomon PL. 2008. Characteristics of persons with severe mental illness who have been incarcerated for murder. J Am Acad Psychiatry Law 36:74–86. Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, et al. 1981. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 30:239–245. Palijan TZ, Muzinić L, Radeljak S. 2009. Psychiatric comorbidity in forensic psychiatry. Psychiatr Danub 21:429–436. Pope HG Jr, Kouri EM, Powell KF, Campbell C, Katz DL. 1996. Anabolic-androgenic steroid use among 133 prisoners. Compr Psychiatry 37:322–327. Putkonen A, Kotilainen I, Joyal CC, Tiihonen J. 2004. Comorbid personality disorders and substance use disorders of mentally ill homicide offenders: a structured clinical study on dual and triple diagnoses. Schizophr Bull 30:59–72.
Copyright of International Journal of Psychiatry in Clinical Practice is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
SHORT REPORT
Bipolar disorder, testosterone administration, and homicide: A case report
informahealthcare.com/ijpcp
Leo Sher1 & Sean Landers2 1
Icahn School of Medicine at Mount Sinai, and James J. Peters Veterans’ Administration Medical Center, New York, NY, USA and 2Ninth Judicial Circuit, Orlando, FL, USA
Abstract Objective. Homicide is a major public health and social concern in the United States. Studies have found higher rates of psychiatric disorders in homicide offenders than in the general population. The aim of this article is to report and to discuss a case of a patient with bipolar disorder and hypogonadism who murdered his wife shortly after a testosterone injection. Methods. A case study and a review of the relevant literature. Results. Our case study as well as several case reports in the literature suggests that testosterone administration or high testosterone levels may be associated with homicidal behavior. Conclusion. Further studies of the role of testosterone in the neurobiology of violent and homicidal behavior may lead to improvements in the prevention of homicides. Key words: Bipolar disorder, testosterone, homicide (Received 5 December 2013; accepted 31 January 2014)
Introduction Homicide is a major public health and social concern in the United States (Cooper and Smith 2011; Martone et al. 2013; Matejkowski et al. 2008). Approximately 15,000 homicides took place every year over the past decade (Martone et al. 2013). Studies have found higher rates of psychiatric disorders in homicide offenders than in the general population (Martone et al. 2013; Matejkowski et al. 2008; Côté and Hodgins 1992). For example, a study of the inmates in the Indiana state prison system who had been convicted of homicide between 1990 and 2002 showed that about 18% of all homicides are committed by individuals with major depression, bipolar disorder, schizophrenia, and other psychotic illnesses (Matejkowski et al. 2008). This study included only those individuals who committed murder and were sentenced to prison. It did not include individuals with severe psychiatric disorders who were found to be incompetent to stand trial or not guilty by reason of insanity, that is, the real percentage of homicide offenders with severe mental illnesses is probably higher. A study of homicide convicts in Canada reported rates of 12% for schizophrenia, 15% for major depression, and 5% for bipolar disorder (Côté and Hodgins 1992). Studies suggest that schizophrenia, major depression, and bipolar disorder increase the risk of homicide primarily if comorbid substance use disorders are present (Eronen et al. 1996; Palijan et al. 2009; Putkonen et al. 2004). Here, we report a case of a patient with bipolar disorder and polysubstance use disorder who committed a murder after a testosterone injection. Correspondence: Leo Sher, MD, Icahn School of Medicine at Mount Sinai, James J. Peters Veterans’ Administration, Medical Center, 130 West Kingsbridge Road, Bronx, New York, NY 10468, USA. Tel: ⫹ 1-718-584-9000 x 6821. Fax: ⫹ 1-718-741-4703. E-mail: [email protected], [email protected]
Case report Mr. A. was a 42-y.o. man with a long history of bipolar disorder with psychotic features and polysubstance use disorder (including the use of alcohol, marijuana, and lysergic acid diethylamide [LSD]). He had a history of manic and depressive episodes, auditory hallucinations, paranoid delusions, suicidal ideation, aggressive behavior, poor insight, poor adherence to treatment, and multiple psychiatric hospitalizations. Mr. A. had a history of suicidal ideation but not suicide attempts. Over the years, he was treated with different antipsychotics, antidepressants, and mood stabilizers, including lithium. He also had a history of illegal behavior and incarcerations for assaults, burglary, and sexual relationships with teenage girls. Mr. A. also had hypogonadism. The diagnosis of hypogonadism was based on the presence of erectile dysfunction and a low blood testosterone level. In the beginning of 2012, an urologist prescribed testosterone 200 mg IM injections that were supposed to be given every 2 weeks. Mr. A. was getting injections less frequently. He received five injections between January 2012 and May 2012. In mid-April 2012, Mr. A. reported to his therapist that he was experiencing “extreme highs” which he regarded as a side effect of testosterone shot. Eight days before Mr. A. received his 5th testosterone injection in May 2012, his testosterone level was 670 ng/dl (the reference interval: 348–1197 ng/dl). In 2011, Mr. A. married a 25-y.o. woman. There were significant marital problems. Mr. A. and his wife were in marital therapy. In May 2012, about 10 hours after receiving the 5th injection of testosterone Mr. A. hit his wife in the abdominal area which led to an internal bleeding and resulted in her death. At the time of the offense, Mr. A. was also prescribed risperidone, divalproex sodium, trihexyphenidyl, trazodone, and clonazepam.
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Mr. A. admitted to the police to pushing his wife down on the ground and kicking her in the stomach during an argument but said he did not remember the whole episode. Mr. A. told the police hours after his arrest he did not know that he was going to kill her or that she would die and he wanted to hurt himself because of what he did. Mr. A’s wife was found by police deceased in her bed. The autopsy revealed evidence of multiple acute and remote injuries, including multiple contusions to the torso in various stages of healing, healing and acute rib fractures and acute lacerations of the intestinal mesentery and omentum. An accumulation of 1850 ml of thick bloody fluid was present in the abdominal cavity at the time of autopsy. The determined manner of death was homicide. Discussion It is difficult to establish a clear relation between the testosterone administration and the murder in this case. The Adverse Drug Reaction Scale (Naranjo et al. 1981) score is 3 which indicates that the testosterone administration possibly contributed to homicide. There are several case reports in the literature suggesting that testosterone administration or high testosterone levels are associated with homicidal behavior (FoxNews.com 2007; Conacher and Workman 1989; Pope et al. 1996). In 2007, a professional wrestler committed homicide and suicide: he murdered his wife and son in their home before hanging himself (FoxNews.com 2007). At the time of the offense, the testosterone level in his body was very high. Investigators believed that the level found suggested testosterone had been taken shortly before the offense. Another case report described an amateur body builder who beat his common law wife to death while taking steroids (Conacher and Workman 1989). In another case, a 16-year-old boy was convicted of the murder of his 14-year-old girlfriend (Pope et al. 1996). This boy displayed no history of antisocial personality disorder or any criminal record prior to his first use of steroids. After he began taking testosterone and other steroids, he exhibited a remarkable change in personality, became aggressive, and started getting in trouble with the police. In another case, a 19-year old man was convicted of shooting another man a day or two after he had self-administered a testosterone injection, and was likely at the point of peak plasma levels of testosterone (Pope et al. 1996). It has been shown that among prisoners who committed homicide, those who had higher testosterone levels more often knew their victims and planned their murders ahead of time (Dabbs et al. 2001). The authors of this study suggested that their results imply ruthlessness among inmates with higher testosterone concentrations and that homicide more than other violent crimes may bear on issues related to testosterone. Violence toward women may be relatively common among men using steroids (Choi and Pope 1994; Pope et al. 1996). In one study, steroid users reported significantly more fights, verbal aggression, and violence against their wives or girlfriends when they were using steroids as compared with
Int J Psychiatry Clin Pract 2014;18:215–216
periods when they were not taking steroids (Choi and Pope 1994). Our report and other case reports suggest that testosterone administration may play a role in homicidal behavior. Further studies of the role of testosterone in the neurobiology of violent and homicidal behavior may lead to improvements in the prevention of homicides. Key points • • •
Studies have found higher rates of psychiatric disorders in homicide offenders than in the general population. We report and discuss a case of a patient with bipolar disorder and hypogonadism who murdered his wife shortly after a testosterone injection. Testosterone administration or high testosterone levels may be associated with homicidal behavior.
Acknowledgements None. Statement of interest None of the authors reports conflicts of interest. References Choi PY, Pope HG Jr. 1994. Violence toward women and illicit androgenic-anabolic steroid use. Ann Clin Psychiatry 6:21–25. Conacher GN, Workman DG. 1989. Violent crime possibly associated with anabolic steroid use. Am J Psychiatry 146:679. Cooper A, Smith EL. 2011. Homicide Trends in the United States, 1980–2008. Annual Rates for 2009 and 2010. U.S. Department of Justice. Office of Justice Programs. Bureau of Justice Statistics. November 2011, NCJ 236018. http://www.bjs.gov/content/pub/ pdf/htus8008.pdf Côté G, Hodgins S. 1992. The prevalence of major mental disorders among homicide offenders. Int J Law Psychiatry 15:89–99. Dabbs JM, Riad JK, Chance SE. 2001. Testosterone and ruthless homicide. Person Individ Diff 31;599–603. Eronen M, Tiihonen J, Hakola P. 1996. Schizophrenia and homicidal behavior. Schizophr Bull 22:83–89. FoxNews.com (July 17, 2007) Wrestler Chris Benoit used steroid testosterone; son sedated before murders. http://www.foxnews. com/story/2007/07/17/wrestler-chris-benoit-used-steroidtestosterone-son-sedated-before-murders/Accessed: November 5, 2013. Martone CA, Mulvey EP, Yang S, Nemoianu A, Shugarman R, Soliman L. 2013. Psychiatric characteristics of homicide defendants. Am J Psychiatry 170:994–1002. Matejkowski JC, Cullen SW, Solomon PL. 2008. Characteristics of persons with severe mental illness who have been incarcerated for murder. J Am Acad Psychiatry Law 36:74–86. Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, et al. 1981. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 30:239–245. Palijan TZ, Muzinić L, Radeljak S. 2009. Psychiatric comorbidity in forensic psychiatry. Psychiatr Danub 21:429–436. Pope HG Jr, Kouri EM, Powell KF, Campbell C, Katz DL. 1996. Anabolic-androgenic steroid use among 133 prisoners. Compr Psychiatry 37:322–327. Putkonen A, Kotilainen I, Joyal CC, Tiihonen J. 2004. Comorbid personality disorders and substance use disorders of mentally ill homicide offenders: a structured clinical study on dual and triple diagnoses. Schizophr Bull 30:59–72.
Copyright of International Journal of Psychiatry in Clinical Practice is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
